Question

O. M. is a 6-year-old child at a freestanding emergency room. Per the mother, O.M. is complaining of being tired, sleeping at night with several naps in the day, and her appetite is decreasing. The mother reports an uneventful pregnancy and delivery; O.M. has met her milestones, and immunizations are up to date. Her parents and younger brother are healthy. Paternal grandfather died of colorectal cancer in his 70s. She has no medical history and has no medication.  

All vital signs are normal except for an elevated heart rate and she is minimally underweight.

All assessment findings are normal with the exception of:

• Skin pale but warm and dry
• Bruising over the buttocks and left flank
• Noted oral mucous membranes with petechiae
• Mild enlarged, cervical, submaxillary, inguinal nodes
• Presence of hepatosplenomegaly = simultaneous enlargement of both the liver (hepatomegaly) and the spleen (splenomegaly).

Blood work:

Hemoglobin decreased

Hematocrit decreased

RBC count decreased

WBC 13,100/mm3

Neutrophils 58%

WBC differential identifies 11% are blast cells

Platelet count 30,000/mm3

PT/PTT normal

Later results:

Bone marrow aspirate: 94% blast cells, 3% erythroblasts, 3% all other cells.

Reverse Transcriptase – Polymerase Chain Reaction: positive TEL-AMI fusion gene.

No other abnormality.       (acute lymphoblastic leukemia in children)

Chest x-ray: Normal

Lumbar puncture: Cerebral spinal fluid normal

Immunology: positive for cytoplasmic µ heavy chain protein

My question is:

why a chest x-ray and lumbar puncture were necessary.?

What other patient information would you have wanted to have a clearer understanding of the patient?

What educational topics would you address with O.M.s mother (well-being, safety)?

Answer 1

1.yes

Chest x-rays may be done if the doctor suspects a lung infection. They may also be done to look for enlarged lymph nodes in the chest.CXR may show pneumonia, a mediastinal mass or lytic bone lesions.

lumbar puncture-

A lumbar puncture may be done if there's a chance that acute leukaemia has spread to your nervous system.

A needle is inserted into the lower part of your spine to extract a small sample of the fluid that surrounds and protects your spine (cerebrospinal fluid), which is tested for cancer cells.

2. the area they live - any high radiation zones, history of recurrent infections , familial history of blood cancers.

3.

1. Risk for Infection
2. Risk for Deficient Fluid Volume
3. Acute Pain
4. Activity Intolerance
5. Deficient Knowledge.

• Identify actions to prevent/reduce risk of infection.
• Demonstrate techniques, lifestyle changes to promote safe environment, achieve timely healing.
• Prevent chilling. Force fluids, administer tepid sponge bath.
• Encourage frequent turning and deep breathing.
• Handle patient gently. Keep linens dry and wrinkle-free.
• inspect skin for tender, erythematous areas; open wounds. Cleanse skin with antibacterial solutions.
• Inspect oral mucous membranes. Provide good oral hygiene. Use a soft toothbrush, sponge, or swabs for frequent mouthcare.
• Provide thorough skin care by keeping the patient’s skin and perianal area clean, apply mild lotion or creams to keep the skin from drying or cracking.
• Promote good perianal hygiene. Examine perianal area at least daily during acute illness. Provide sitz baths, using Betadine or Hibiclens if indicated.
• Encourage increased intake of foods high in protein and fluids with adequate fiber.
• Place in position of comfort and support joints, extremities with pillows or padding.
• Reposition periodically and assist with gentle ROM exercises.
• Provide comfort measures (massage, cool packs) and psychological support, encouragement, or presence.
• Assist with and provide diversional activities, relaxation techniques.
• Promote good nutrition.
• Weigh daily.
• Encourage fluids of up to 3–4 L/day when oral intake is resumed.
• Provide adequate hydration, and a high-residue diet, stool softners, and mild laxatives. Encourage walking.
• Provide soft diet.
• Encourage patient to keep a diary of daily routines and energy levels, noting activities that increase fatigue.
• Provide quiet environment and uninterrupted rest periods. Encourage rest periods before meals..
• Recommend small, nutritious, high-protein meals and snacks throughout the day..
• Provide psychological support- whole family participation.