Question

Client Profile

Ashlee is a 4 year old preschooler who lives with her parents and two older siblings in a suburban environment. She attends preschool five mornings a week and enjoys playing with her 5 year old sister and 7 year old brother. She is very active and enjoys playing outside, riding her tricycle, climbing on the family's jungle gym, and playing on the swing set. Her vocabulary consists of approximately 1,500 words and she speaks using four or five word sentences. Her parents are very attentive to their children and spend each weekend doing "family activities". During the week, her parents work, and Ashlee and her siblings stay with their grandmother after school. Their grandmother lives in the same neighborhood. In the evenings, the family eats together and maintains an evening schedule that allows for family play time.

Case Study

During the past 2 months, Ashlee has been less active than usual and has begun taking one or two naps in the afternoon. Her grandmother and parents think she looks pale, reasoning that it is because of her high activity level, until her interest in going outside to play decreases dramatically. When they take her temperature, it is elevated so they administer acetaminophen without effect. At this point they decide to take her to see her pediatrician. Although the health care provider found Ashlee's manifestations consistent with an upper respiratory infection, the pediatrician is concerned and decides to admit Ashlee to the hospital for tests to rule out leukemia.

Questions 1. Her admission vital signs are: Temperature: 38° C (100.4° F) Pulse: 120 beats/minute Respirations: 28 breaths/minute Blood pressure: 100/60 And her admission complete blood count reveals: Hemoglobin: 11 g/dL Hematocrit: 31% Erythrocyte count: 4.6 million Platelet count: 100 (x103 mm3 ) White blood cell count: 23.0 Neutrophils: 16% Lymphocytes: 10% Monocytes: 5% Eosinophils: 1% Basophils: 0.03%

1. Discuss the significance of Ashlee's vital signs and laboratory findings.

2. The tests confirm a diagnosis of acute lymphocytic leukemia. How do you explain this to Ashlee’s parents? They ask you her chances of survival?

3. Identify at least 4 nursing priorities for Ashlee.

4. Discuss the factors that affect Ashlee's prognosis.

5. Ashlee's chemotherapy regimen is started and the oncologist prescribes that she receive ondansetron 2.5 mg IV prior to chemotherapy and the same dose every 4 hours for 24 hours. In addition, she prescribes lorazepam 0.84 mg IV q6h PRN for breakthrough nausea. Discuss these prescriptions including drug classifications, when medications should be administered, special considerations when administering drugs, and safe dosage for Ashlee, who weighs 16.7 kg (36.7 lb).

6. Discuss Ashlee's level of growth and development and how her treatment may impact this.

7. How would you work with Ashlee's parents to help prevent complications associated with her growth and development?

Answer 1

1. Significance of Ashlee's vital signs and laboratory findings:

A. Vital signs: Temperature is high at 100.4 F degrees, which is usually associated with an upper respiratory infection. This could also be due to the suspected leukemia. Pulse is 120 beats/minute, which is normal for a four-year-old. Respirations at 28 breaths/minute is also normal. Blood pressure is 100/60, which is also normal for a 4-year-old.

B. Her admission complete blood count shows hemoglobin at 11 g/dL, which is slightly low. The hematocrit of 31% also shows a slightly decreased value. The hemoglobin and hematocrit values though slightly low from normal values of HB 12.5 and HCT 37% are not of much concern, but alarming. Erythrocyte count is normal at 4.6 million, which is normal. The platelet count of 100 (x103 mm3 ) is low and is quite concerning, which could indicate leukemia. A white blood cell count of 23.0 is elevated and is quite concerning. This could be due to the presence of an infection or leukemia. Neutrophils are low at 16% which is indicative of leukemia. Lymphocytes are low at 10%, which is also indicative of leukemia. Monocytes are normal at 5%. Eosinophils are also normal at 1%. Basophils are low at 0.03%, which is quite concerning and is indicative of leukemia.

All the abnormal lab values, elevated temperature, and increased fatigue point to the need for further testing to confirm leukemia or any other underlying disease process.