Question

Scenario: Alex is a 6 year old boy who arrives to his primary care office with a 3-day temperature of 102-103F axillary and L leg pain.  Today he started with red pinpoint rash and has been unusually sleep.  Alex is up-to-date on his vaccines.   His vitals today are RR 28

HR 120    T102.5F     BP 90/60   O298% on room air.  Weight 21.8 kg    Height 3.5 feet

the NP finds that Alex has not only cervical lymphadenopathy but also enlarged lymph nodes in the axillae and groin. Yet, Alex is not complaining of a sore throat, headache, ear pain, or trouble urinating.  UA, rapid strep, and rapid flu test are all negative.  Alex hasn’t had any recent injury to his leg.  The NP draws blood to run a CBC and comprehensive metabolic panel.  

The CBC shows a WBC 42,000 (very high)  RBC  (normal)  Hbg 10 (low)  Hct 31% (low)  Platelets 90,000 (low)  Neutrophils-bands – (high)  Neutrophils-segmented (low)  Lymphoblasts at 38% (very high).    The NP admits Alex to the local children’s hospital and orders an oncology consult for suspected leukemia.

1. What in the above scenario could lead to a diagnosis of leukemia?

2.  What additional tests would you expect to be done in hospital?

3. What pain scale would you use for Alex?

4.  Who else in the hospital could you ask to help prepare Alex for the various tests and procedures?  

5. List one nursing diagnosis with interventions & goals.

6. Would advance directives be appropriate here?  Why or why not?

Answer 1

1. He has signs of leukaemia

• red pinpoint rash
• cervical lymphadenopathy and enlarged lymph nodes in the axilla and groin
• Fever
• will have lower than normal counts of red blood cells and platelets, and higher than normal counts of white blood cells. Here WBC is very high and platelets low

2.He may need to do following tests

• Bone marrow biopsy
• Doctor may order a chest X-ray, CT scan, or magnetic resonance imaging (MRI) scan if have symptoms that indicate a complication of the leukemia.
• A lumbar puncture may be ordered to see if the cancer had spread to the spinal fluid surrounding the brain and spinal cord.

3.The FACES® Pain Rating Scale-Revised uses facial expressions to help young children rate their pain on the 0-10 scale. The faces show how much something can hurt. The face on the far left (0) shows no pain. The faces show more and more pain as the number go up. A 10 scale means the pain is very intense. Patients are asked to point to the face that shows how much they hurt right now.

4.Paediatric nurse can help child for preparing for the test

5.Risk for infection related to decreased primary and secondary responses

Goals: Minimize complications and resolve if possible. Maximize the normal blood cells and minimize the abnormal cells.

Nursing interventions:

• Place in a private room. Limit visitors as indicated. Prohibit live plants or flowers. Restrict fresh fruits and make sure they are properly washed or peeled. Coordinate patient care so that leukemic patient doesn’t come in contact with staff who also care for patients with infections or infectious diseases.
• Require good hand washing protocol for all personnel and visitors.
• Closely monitor temperature. Note correlation between temperature elevations and chemotherapy treatments. Observe for fever associated with tachycardia, hypotension, subtle mental changes.
• Prevent chilling. Force fluids, administer tepid sponge bath
• Inspect skin for tender, erythematous areas; open wounds. Cleanse skin with antibacterial solutions.
• Encourage increased intake of foods high in protein and fluids with adequate fiber.
• Limit invasive procedures (venipuncture and injections) as possible.

6.Advance directives are legal documents about health care choices for anyone 18 years of age or older, with or without a medical condition. In them, you can write your plans and make your wishes known if you are not able to speak for yourself. These documents can be updated or withdrawn at any time.

Here the child is 6 year old .So that he doesn’t need advanced directi