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Maternal-Child Nursing Care
Optimizing Outcomes for Mothers, Children, & Families
Chapter 33
Caring for the Child with a
Hematological Condition
Susan Ward
Shelton Hisley
A & P Review
 Blood
 Plasma (albumin, electrolytes, proteins, clotting
factors, fibrinogen, globulins, and circulating
antibodies)
 Cells
 RBCs (transport hemoglobin)
 WBCs (body’s protective system)
 Platelets (hemostasis and vascular repair after injury to a
vessel wall)
Common Hematological
Conditions
Anemia
 Signs and symptoms (initial signs)
 Fatigue, SOB, headache, difficulty concentrating, dizziness, and
pale skin
 Nursing care
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Identify underlying cause
Promote a healthy diet or a vitamin supplement
Administer red blood cells (moderate anemia)
Administer hematopoietic growth factors (specific types of anemia)
Teach family (signs and symptoms, alter daily activities, evaluate
status of anemia)
Iron-Deficiency Anemia
 Signs and symptoms
 Asymptomatic (mild anemia)
 Decreased Hgb and Hct
 Irritability, fatigue, delayed motor
development, SOB, decreased
activity level, and pale skin
 Remember an overweight child
can be diagnosed with irondeficiency anemia.
 Nursing care
 Identify early
 Understand that primary goal is
prevention
 Facilitate nutritional counseling
 Assist with obtaining
recommended iron-fortified formula
and cereal
 See “What to say”—Nutritional
counseling (p. 1074)
 Discuss the Women Infants and
Children (WIC) program
 Administer oral iron supplements
Epistaxis (Nosebleeds)
 Signs and symptoms
 Bleeding from the nose
 Nursing care
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Focus on prevention, family education
Avoid the use of aspirin or NSAIDS
Use a cool mist vaporizer
Use first aid measures to stop bleeding
Sickle Cell Disease (SCD)
 Signs and symptoms
 Result of vaso-occlusion
 Weakness
 Pallor
 Fatigue
 Tissue hypoxia
 Jaundice
 Pain
 Nursing care
 Identify early and treat hypoxic
episodes
 Encourage rest
 Hydrate (1.5 times above normal
calculated requirements)
 Maintain oxygenation (respiratory
assessment)
 Control pain (oral, IV, or PCA)
 Interpret laboratory or
radiographic studies
 Educate family
Beta Thalassemia
 Signs and symptoms
 Enlarged liver and spleen
 Mild jaundice
 Growth retardation
 Moderate to severe anemia
 Bony deformities
 Increased susceptibility to
infection
 Nursing care:
 Understand that the goal is to
prevent hypoxia by providing
blood transfusion therapy
 Promote growth and
development
 Discuss bone marrow transplant
 Educate family (blood transfusion
and chelation treatment, hand
washing, when to seek medical
attention)
 Refer for genetic counseling
Hereditary Spherocytosis (HS)
 Signs and symptoms
 Hyperbilirubinemia
 Splenomegaly
 Negative Comb’s test
 Nursing care
 Give folic acid supplements
 Discuss splenectomy
 Educate family (folic acid supplementation and adhere to prescribed antibiotic
regimen)
 Promote good hand washing
 Instruct parents on temperature taking and when to seek medical attention, evaluate
blood counts and immunizations
 Provide support to help them cope with lifelong illness
Hemophilia
 Signs and symptoms
 Present with bleeding or known family history of bleeding disorders
 Hemarthrosis
 Soft tissue bleeding
 Nursing care
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Initiate prompt treatment of bleeding episodes
Ensure patient safety and prevent complications
For severe hemophilia, administer recombinant factor products
Educate family about proper administration of factor products
von Willebrand’s Disease
 Signs and symptoms
 Epistaxis
 Bleeding from the oral cavity
 Menorrhagia
 Easy bruising
 Nursing care
 Administer Desmopressin
(DDAVP)
 Administer Humate-P and/or
cryoprecipitate or fresh frozen
plasma (FFP)
 Recommend medical alert
 Instruct parents about common
sites of bleeding (nose, gums,
internal, and menses)
 Control bleeding (pressure, ice,
and seek medical attention)
 Avoid the use of aspirin or NSAIDS
Idiopathic
Thrombocytopenia Purpura (ITP)
 Signs and symptoms
 After a recent viral infection
 Petechiae
 Bruising
 Mucocutaneous bleeding
 Epitaxis
 Menorrhagia (adolescent)
 Nursing care
 Administer steroids, Intravenous
Immune Gamma Globulin (IVIG), or
Anti-D antibody (WhinRho®)
 Restrict activities
 Instruct parents on how to manage a
bleeding episode
 Avoid aspirin, injections, tampons,
nothing via the rectum
 Teach family to report signs and
symptoms of bleeding
 Encourage child to wear a medical
alert bracelet
Disseminated
Intravascular Coagulation (DIC)
 Signs and symptoms
 Excessive bleeding from orifices
 Petechia, purpura, and hypotension
 Multi-organ failure
 Nursing care
 Identify the underlying cause
 Monitor for signs of hemorrhage,
bleeding petechiae, cutaneous oozing,
dyspnea, lethargy, pallor, increased
heart rate, decreased blood pressure,
headache, dizziness, muscle
weakness, restlessness, and internal
bleeding
 Do not disturb clots, use pressure and
ice to control bleeding
 Obtain laboratory tests and administer
blood and factor products
 Inform family about plan of care and
course of treatment
Aplastic Anemia
 Signs and symptoms
 Pancytopenia
 Anemia, pallor, dizziness, and
fatigue
 Petechia, epistaxis
 Increased susceptibility to
infections and oral ulcerations
 Nursing care
 Remove causative agent
 Administer antithymocyte globulin
(ATG) and high-dose cyclosporine
(Neoral®, Gengraf®)
 Administer hematopoietic growth
factors
 Discuss hematopoietic stem cell
transplant (HSCT)
 Support and educate family
Note: Traditional s/s of infection
are not evident (swelling, pus, and
redness)
Neutropenia
 Signs and symptoms
 Lymphadenopathy, organomegaly,
pallor, bruising, petechia
 Absolute neutrophil count (ANC)
 Total number of white blood cells
multiplied by the percentage of
neutrophils (segs and bands)
 Nursing care
 Evaluate etiology
 Understand that treatment ranges from
supportive measures to administration
of colony-stimulating factors (GCSF
[Neupogen ®]) to bone marrow
transplant
 Monitor for infections (broad-spectrum
antibiotic)
 Inform about bone marrow transplant
procedure
 Educate family (hand washing, taking
temperature, oral hygiene, skin care,
keep away from other sick children)
 See Critical Nursing Action—The
Neutropenic Child (p. 1089)
Blood Transfusion Therapy
 Reasons for transfusion
 Hematological illness
 Oncological illness
 Chronic conditions
Blood Transfusion Therapy
 Nurse responsibilities
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Be knowledgeable about blood transfusion
Review the plan of care with the family
Explain in detail the indications and process
Obtain blood consent
 Jehovah Witnesses
 Obtain the required blood samples
 Administer based on policy and procedures
The Administration of Blood
 Strict observance to the institutional policy
regarding the administration of blood
products cannot be stressed enough.
 The accuracy of patient verification is a
critical nursing action that can help prevent
a transfusion reaction.
Transfusion Reactions
 Most transfusion reactions occur during the initiation of a
transfusion, but a reaction can occur at any time during
this process. These reactions can vary from a mild
reaction, such as mild fever, to the most severe
complication of death.
 Children who have received multiple transfusions are at
higher risk for developing a transfusion reaction.
Febrile Reaction
 Child develops a fever greater than 1.8˚F from the baseline
temperature
 Occurs on initiation of the transfusion, but has been known to occur
up to 12 hours posttransfusion
 Signs and symptoms—fever and chills, which then may progress to
more serious complications such as tachycardia, tachypnea, and
hypotension
 Nursing care—premedicating with acetaminophen (children’s
Tylenol) can sometimes prevent this type of reaction. Monitor the
child’s temperature to recognize febrile reactions early and prevent
progression. Stop the transfusion, monitor vital signs closely, and
notify the physician.
Allergic Reaction
 Occurs during a transfusion in which the child has had a
previous exposure to a particular allergen in the blood
product
 Signs and symptoms—rash, hives, pruritus, swelling of
the lips, wheezing, and anxiety
 Nursing care—stop the transfusion immediately, monitor
vital signs closely, and notify the physician. The
administration of an antihistamine such as
diphenhydramine (Benadryl) resolves an allergic
response.
Circulatory Overload
 Occurs when the infusion is given too rapidly or an excessive
quantity of blood is given
 Signs and symptoms—dry cough, dyspnea, rales, distended neck
veins, hypertension/hypotension, bradycardia/tachycardia, clammy
skin, and cyanosis of the extremities
 Nursing care—accurate verification of physician orders, doublechecking the volume to be infused, and the use of an intravenous
pump. If any of the signs and symptoms are identified, the nurse
must immediately stop the transfusion, monitor vital signs closely,
place the child upright with feet in a dependent position to increase
venous resistance, notify physician, and prepare emergency care.
Acute Hemolytic Transfusion Reaction
 Occurs when the donor RBCs and the recipient plasma are incompatible and
there is an ABO mismatch. Acute hemolytic transfusion reactions occur upon
initiation after exposure to a small amount of blood.
 Signs and symptoms—fever, shaking chills, pain at the intravenous site,
tightness of the chest, difficulty breathing, impending sense of doom, pallor,
jaundice, nausea/vomiting, red or black urine, flank pain, and progressive
signs of shock such as tachycardia and hypotension
 Nursing care—stop the transfusion, monitor vital signs closely, start a normal
saline infusion, verify patient identification, notify the physician, and prepare
emergency care. Other nursing responsibilities include obtaining blood and
urine samples and sending them to the laboratory to analyze for the
presence of hemoglobin, which indicates intravascular hemolysis. Insert a
urinary catheter to monitor the child’s output more accurately.
Bacterial Contamination
 Occurs during the initiation of the infusion
 Guidelines from the AABB (2004) require strict adherence to the
completion of all transfusions in 4 hours or less to prevent this from
happening.
 Signs and symptoms—shaking chills, fever, vomiting, diffuse erythema,
and the onset of hypotension that may progress to shock. In severe
cases, hemoglobinuria, actual renal failure, and DIC may develop.
 Nursing care—stop the transfusion immediately, monitor vital signs
closely, start a normal saline infusion, notify the physician, and prepare
emergency care. Nursing responsibilities also include obtaining blood
samples for culture and sensitivity and sending the blood product with
tubing to the blood bank also to be cultured.
Bone Marrow Transplantation
 Hematopoietic stem cell transplant (HSCT)
 Bone marrow transplantation (BMT)
Bone Marrow Transplantation
 Preparative regimen
 Administration of “near lethal” doses of chemotherapy and/or
radiation
 Three types of hematopoietic stem cell transplants
(HSCT)
 Autologous transplant (child’s own donor of stem cells)
 Allogeneic transplant (matched compatible donor, usually a sibling)
 Syngeneic (identical sibling)
Bone Marrow Transplantation
 Complications
 Acute and chronic graft versus host disease
(GVHD)
 Infection
 Immunosuppression
 Organ dysfunction
 Psyosocial impact
Apheresis
 The process of apheresis is the selective removal
of a specific blood component from a donor or
child while re-transfusing the remaining
components.
 Blood is removed from the child, pumped through
a special cell separator in the apheresis machine
that removes the specific desire component by
centrifugal force, and then is returned to the
patient.
Thrombosis
 Risk factors
 Prolonged immobility
 Disease states, obesity,
medications, hereditary
factors
 Major surgery or trauma
 Complications
 Stroke
 Deep vein thrombosis
 Pulmonary emboli
 Signs and symptoms
 Lungs—SOB, lightheaded,
and increased heart rate
 Kidney—blood in the urine
 Skin—hemorrhagic spots
 Artery or extremity—cold,
pale, blue, and absent pulse
Thrombosis
 Nursing care
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Thoroughly assess risk factors
Apply compression stockings
Use an intermittent pneumatic compression device
Perform passive range of motion
Administer low–molecular-weight heparin
Promote early ambulation
Administer heparin in some cases