Care of Mother and Child At-Risk or with

Problems (Acute and Chronic)- Lecture

STUDENT ACTIVITY SHEET BS NURSING / SECOND YEAR
Session # 22

LESSON TITLE: CARE OF A FAMILY WITH A HIGH-RISK

PRESCHOOLER
LEARNING OUTCOMES: Materials:
At the end of the lesson, the student nurse can: Book, pen, SAS and notebook
1. Define the common classifications of high-risk preschooler
Reference:
and describe common illnesses that occur in these
classifications of preschooler. Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition.
2. Integrate the knowledge of the common classifications of USA: Lippincott Williams and Wilkins
high-risk preschooler and describe common illnesses that occur
in these classifications of preschooler in formulating nursing
care plan in giving quality maternal and child health nursing
care.

LESSON PREVIEW/REVIEW (5 minutes)

MAIN LESSON (50 minutes)

HEALTH PROBLEMS COMMON IN TODDLERS
(Please refer to Health Problems that are Common in Preschoolers-The Leukemias p. 1512, Nephroblastoma p.1524,
Asthma p.1113, Status Asthmaticus p.1116, Urinary Tract Infection p.1303)

LEUKEMIA (p.1512)
Leukemia is the distorted and uncontrolled proliferation of WBC’s and is the most frequently occurring type of cancer in
children
ACUTE LYMPHOCYTIC(LYMPHOBLASTIC) LEUKEMIA (ALL)
 75% of leukemias
 involves lymphoblasts or immature WBC’s
 With rapid proliferation of lymphoblasts, RBC and
platelet production fall and invasion of body
organs by the WBC’s begins
 highest incidence is between 2 to 6 years old
 prognosis in those <1 is not as good as in those
from 2-6 years old
 more common in boys and in white children,
children with Down’s syndrome or Fanconi
syndrome
ASSESSMENT
 1st symptoms: pallor, w-grade fever, lethargy
(symptoms of anemia), petechiae and bleeding
from oral mucous membranes and may bruise
easily because of low platelet count
 As spleen and liver enlarge due to infiltration of
abnormal cells, abdominal pain, vomiting and
anorexia occur
 As abnormal lymphocytes invade the bone
periosteum, bone and Joint point pain
THERAPEUTIC MANAGEMENT
 Up to 95% will have a first remission but if a child
experiences a relapse, chances of long-term
survival are reduced to 70%
 Induction phase of chemotherapy- complete
remission or absence of leukemia cells
 Sanctuary or consolidation phase- preventing
leukemia cells from invading or growing in the
CNS
 3rd, administering delayed intensive therapy
 Maintenance phase-maintaining the original
remission
CHEMOTHERAPY IN CHILDREN
 It involves administration via central venous
catheter or port to prevent irritation of vessel
walls; also they can be clamped or trapped so the
child ca be ambulatory between treatments
 Drugs:
 vincristine,
 prednisone,
 L-asparaginase,

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  CNS invasion leads to headache or unsteady gait
 Physical Exam reveals painless, generalized
swelling of lymph nodes (submaxillary or cervical
LN)
 WBC count is markedly elevated but in some,
normal or decreased but composed almost
entirely of immature blast cells
 Platelet count and hematocrit are low, but RBC’s
are normochromic and normocytic
 Bone marrow aspiration is necessary to ID type of
WBC or type of leukemia (if > 29%blast cells
present, leukemia is the diagnosis)
 Bone marrow aspiration is through the iliac crest
because it is less frightening and yields more
marrow
 Radiograph of long bones reveals lesions
 Lumbar puncture reveals evidence of blast cells in
the CSF
DISEASE CLASSIFICATION AND PROGNOSIS
 B-lymphocyte involvement accounts for 85% of
instances of ALL
 15% to 20% have T-lymphocyte cell involvement
ACUTE MYELOID LEUKEMIA
MANAGEMENT
 It involves the over proliferation of granulocytes
neutrophils, basophils and eosinophils)
 Accounts for only 20% in childhood leukemias
 More frequent in late adolescence
 Granulocytes grow so rapidly they are often
forced out into the bloodstream while still in the
blast stage. It results in limited production of RBC
and platelets
ASSESSMENT
 Same symptoms as ALL.
 Susceptible to infection
WILM’S TUMOR/NEPHROBLASTOMA
 Malignant cancer of the kidney; usually
unilateral; encapsulated at the time of
diagnosis
 INCIDENCE: most frequent abdominal tumor
and most common type of renal cancer; 1 :
200,000 to 250,000 children; peak – 3 yrs;
increased incidence among siblings 
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 doxorubicin and
 methotrexate
*****given over a period of about 1 month
Cell destruction due to chemotherapy results in increased
uric acid levels which may destroy glomeruli and leads to
loss of kidney function. To prevent this, allopurinol is
often administered to reduce UA production
 Hydration also helps UA excretion
 Intrathecal administration of drugs may be
included to bypass the blood-brain barrier
MAINTENANCE AND MONITORING
 Standard maintenance therapy includes a
combination of daily 6-mercaptopurine, weekly
methotrexate, vincristine and prednisone, and
intrathecal methotrexate.
 This is continued for 2 to 3 years
 Leucovorin is usually given after methotrexate to
neutralize its action and protect normal cells from
the effect of the drug
 Blood values must be monitored at least monthly
 Children who are free of the disease for 4 years
are considered cured and their maintenance
therapy can be stopped
COMPLICATIONS
 CNS involvement-blindness, hydrocephalus,
recurrent seizures, nuchal rigidity, headache,
irritability
 Renal Involvement- from invasion of leukemia
cells; kidneys enlarge and function impaired

Testicular Invasion- leukemic cells in the testes
will not be destroyed by chemotherapy therefore
irradiation is done leading to sterility
 Bone Marrow aspiration and Biopsy; cells are
typed to determine prognosis (M1 to M6)
 1 to 2 months of Cytarabine and anthracycline
(daunorubicin) to achieve full remission
 During maintenance phase, additional
chemotherapeutic agents like cyclophosphamide
and 6-thioguanine are used usually for 6 to 9
months
 Remission is difficult to achieve and is often brief
 Bone Marrow transplantation is recommended
STAGE DESCRIPTION
I Tumor confined to 1 kidney and
completely removed surgically
II Tumor extending beyond the kidney but
completely removed surgically
III Regional spread of the disease beyond
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 evidence of genetic inheritance
ASSESSMENT
 discovered early in life (6 mos to 5 yrs), although it
arises from an embryonic structure present before
birth
 Nephroblastomas distort the kidney so that the
tumor is felt as a firm, nontender abdominal
mass (sometimes mistaken as hard stool by
the parents)
 Fathers often discover the tumor when they toss
their child in the air and catch him or her by the
abdomen, and feel the mass.
 Parents sometimes feel that the tumor grew
overnight.
 It may manifest with hematuria and low-grade
fever
 Hypertension may occur due to excessive rennin
production
 Anemic due to lack of erythropoietin formation by
the diseased kidney
 CT scan reveals the tumor and points of
metastasis
 GFR, BUN tests are done to assess the kidney
before the surgery
 DO NOT palpate the child’s abdomen because
handling appears to aid metastasis
 Place a sign reading “No abdominal palpation”
over the child’s crib
ASTHMA
 Immediate hypersensitivity (Type I) response
and is the most common chronic illness in children
 It tends to occur initially before 5 years of age
 The condition may be intermittent, with
symptom-free periods, or chronic, with continuous
symptoms
 It tends to occur in children with atopy or those
hypersensitive to allergens.
 Mast cells release histamine and leukotrienes that THERAPEUTIC MANAGEMENT
result in diffuse obstructive and restrictive airway
disease because of a triad of inflammation,
bronchoconstriction and increased mucus
production
 Most are sensitive to: pollens, molds, house dust,
cigarette smoke, cold weather, irritating odors like
turpentine or smog
 Increased incidence in cold weather though some
may experience the symptoms all year long
 Aspirin can be a trigger
MECHANISM OF THE DISEASE
 Bronchospasm, inflammation of bronchial mucosa
and increased bronchial secretions all act to
reduce the airway lumen, leading to respiratory
distress
 Bronchial constriction is due to stimulation of
parasympathetic nervous system which initiates
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the kidney with residual abdominal
disease postoperatively
IV Metastases to lung, liver, bone, distant
lymph nodes, or other distant sites
V Bilateral disease
TREATMENT
1. Nephrectomy
2. Chemotherapy
3. Radiation therapy
4. Thoracotomy
PROGNOSIS: better prognosis if no metastasis and with
younger age of the child; among all childhood cancers,
highest survival rates
HISTORY
 Include history of the attack, and ask parents to
describe the home environment
PHYSICAL ASSESSMENT
 Auscultate for wheezing
 Cyanosis and eosinophilia may be present
 Pulmonary function studies
3 goals:
 avoidance of allergen by environmental control,
 skin testing and
 hypo sensitization to identified allergens, and
relief of symptoms by pharmacologic agents
 Cough suppressants are contraindicated to
prevent accumulation and formation of thick
mucus plugs
 Inhaled anti-inflammatory corticosteroid such as
fluticasone (Flovent) daily
 Long-acting bronchodilator at bedtime in addition
to inhaled anti-inflammatory daily corticosteroid
 For severe and persistent asthma, combination of
oral and inhaled corticosteroid daily
 Short-acting beta-2 agonist bronchodilator
such as albuterol or terbutaline to use if an attack
should begin
 Cromolyn sodium is a mast cell stabilizer is
given by a nebulizer or metered-dose inhaler to
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 smooth muscle constriction prevent bronchoconstriction and prevent
 Inflammation and mucus production occurs symptoms (not effective once symptoms have
because of mast cell activation to release begun)
leukotrienes, histamine and prostaglandins  Leukotriene receptor antagonists such as
montelukast (Kastair, Singulair) for prophylaxis
ASSESSMENT and chronic treatment of asthma in children over
 After exposure to an allergen or trigger, an 6yo. Not effective in an attack.
episode begins with a dry cough, often at night  Encourage drinking of fluids during attack to
and bronchoconstriction begins prevent dehydration but avoid milk ad milk
 Since bronchiole lumen are larger on inspiration products because they thicken the mucus
than on expiration, there is little difficulty in
inhaling. They later on develop difficulty exhaling
due to the narrow lumen and more so as mucus is
produced causing plugging
 This causes the typical dyspnea and wheezing
(sound caused by air forcibly pushed past
obstructed bronchioles) heard primarily upon
expiration
 If the child coughs up mucus, it is usually white
and has the shape of the bronchi from which it
was dislodged.
 Cyanosis, clubbing of fingers (for chronic cases)
 Tripod position to ease breathing
STATUS ASTHMATICUS

 It occurs when children fail to respond to medications during an attack

 It is an extreme emergency because a child may die of heart failure due to a combination of exhaustion,
atelectasis and acidosis from bronchial plugging
 It is managed by Oxygen therapy, continuous nebulizing with beta-2 antagonist, IV corticosteroids and careful
monitoring
URINARY TRACT INFECTION
 It occurs more often in females as an ascending MANAGEMENT
infection from the perineum because the urethra is  Antibiotic therapy. Make sure to instruct the
shorter in girls parents to complete the regimen to prevent
 Most are caused by gram-negative rods (usually recurrence
E. coli)  Increase fluid intake to flush out the organisms
 Girls should be taught to wipe from the front to  Cranberry juice to acidify the urine
back after voiding and defecating to avoid  Repeat clean-catch sample is obtained after 72
contaminating the urethra hours of antibiotic therapy to assess effectiveness
 Minimize use of feminine hygiene sprays, bubble of treatment
baths and hot tubs
 Encourage voiding after sexual intercourse

SYMPTOMS
 pain on urination,
 frequency,
 burning
 hematuria, l
 low-grade fever,
 mild abdominal pain,
 enuresis
**Urine for culture is obtained by a clean-catch technique

CHECK FOR UNDERSTANDING (30 minutes)

You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed

Multiple Choice

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1. It occurs more often in females as an ascending infection from the perineum because the urethra is shorter in
girls:
A. Status Asthmaticus
B. Urinary Tract Infection
C. Asthma
D. Acute Allergic Reaction
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________

2. It tends to occur in children with atopy or those hypersensitive to allergens of inflammation,

bronchoconstriction and increased mucus production:
A. Status Asthmaticus
B. Urinary Tract Infection
C. Asthma
D. Acute Allergic Reaction
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________

3. It occurs when children fail to respond to medications during an attack with an extreme emergency because a
child may die of heart failure due to a combination of exhaustion, atelectasis and acidosis from bronchial
plugging:
A. Status Asthmaticus
B. Urinary Tract Infection
C. Asthma
D. Acute Allergic Reaction
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________

4. Malignant cancer of the kidney; usually unilateral; encapsulated at the time of diagnosis:
A. Acute Myeloid Leukemia
B. Nephroblastoma
C. Acute Lymphocytic Leukemia
D. Asthma
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________

5. It involves lymphoblasts or immature WBC’s with rapid proliferation of lymphoblasts, RBC and platelet
production fall and invasion of body organs by the WBC’s begins:
A. Acute Myeloid Leukemia
B. Nephroblastoma
C. Acute Lymphocytic Leukemia
D. Asthma
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________

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6. It involves the over proliferation of granulocytes and more frequent in late adolescence.
A. Acute Myeloid Leukemia
B. Nephroblastoma
C. Acute Lymphocytic Leukemia
D. Asthma
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________

7. A complication of Acute Lymphocytic Leukemia wherein the leukemic cells in the testes will not be destroyed
by chemotherapy therefore irradiation is done leading to sterility:
A. CNS involvement
B. Renal Involvement
C. Testicular Invasion
D. Wilm’s Tumor
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________

8. A complication of Acute Lymphocytic Leukemia wherein blindness, hydrocephalus, recurrent seizures, nuchal
rigidity, headache, irritability:
A. CNS involvement
B. Renal Involvement
C. Testicular Invasion
D. Wilm’s Tumor
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________

9. A complication of Acute Lymphocytic Leukemia wherein from invasion of leukemia cells the kidneys enlarge
and function impaired
A. CNS involvement
B. Renal Involvement
C. Testicular Invasion
D. Wilm’s Tumor
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________

10. The following are goals in managing asthma, EXCEPT:

A. Avoidance of allergen by environmental control,
B. Skin testing
C. Hypo-sensitization to identified allergens
D. Increase fluid intake to flush out the organisms
E. Relief of symptoms by pharmacologic agents
ANSWER: ________
RATIO:__________________________________________________________________________________________
_________________________________________________________________________________________________
______________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________

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 RATIO:_______________________________________________________________________________________
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2. ANSWER: ________
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RATIO:_______________________________________________________________________________________
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RATIO:_______________________________________________________________________________________
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5. ANSWER: ________
RATIO:_______________________________________________________________________________________
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6. ANSWER: ________
RATIO:_______________________________________________________________________________________
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RATIO:_______________________________________________________________________________________
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RATIO:_______________________________________________________________________________________
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9. ANSWER: ________
RATIO:_______________________________________________________________________________________
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10. ANSWER: ________
RATIO:_______________________________________________________________________________________
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LESSON WRAP-UP (5 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.
PERIOD 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
PERIOD 2
17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
PERIOD 3
32 33 34 35 36 37 38 39 40 41 42 43 44 45 46

AL STRATEGY: MINUTE PAPER

1. You will use index cards or half-sheets of paper to provide written feedback to the following questions:
a. What was the most useful or the most meaningful thing you have learned this session?
b. What question(s) do you have as we end this session?
2. Pass the responses to your instructor before you leave.

(For next session, review Common Health Problems in School Aged Children-Diabetes Mellitus p.1359,
Rheumatic Fever p. 1161, Juvenile Arthritis p. 1454, Common Parasitic Infection p.1225, Impetigo p.1216 .)

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