3. 2. Goal: reduce workload of heart to conserve energy.
      1. Position: infant seat, semi - Fowler’s to promote maximum expansion of the lungs.
      2. Provide pacifier to promote psychological rest.
      3. Organize nursing care to provide periods of uninterrupted rest.
      4. Adjust physical activity according to child’s condition, capabilities to conserve energy.
      5. Provide diversion, as tolerated, to meet developmental needs yet conserve energy.
      6. Avoid extremes of temperature to avoid the stress of hypothermia/hyperthermia, which will increase the body’s demand for oxygen.
      7. Administer diuretics (Lasix), per physician’s order, to eliminate excess fluids, which increase the heart’s workload.
   3. Goal: provide for adequate nutrition.
      1. Offer low - sodium formula (Lonalac) to minimize fluid retention.
      2. Discourage foods with high or added sodium to minimize fluid retention.
      3. I&O, daily/weekly weights, and monitor for rate of growth.
      4. Limit PO feedings to 20 min to avoid overtiring infant. Supplement PO feeding with gavage feeding (prn with physician’s order) to meet fluid and caloric needs.
      5. Encourage foods high in potassium (prevent hypokalemia) and high in iron (prevent anemia).
   4. Goal: prevent infection.
      1. Standard precautions to prevent infection.
      2. Use good hand - washing technique.
      3. Limit contact with staff/visitors (especially children) with infections.
      4. Monitor for early symptoms and signs of infection; report stat.
   5. Goal: meet teaching needs of patient, family.
      1. Explain diagnostic procedures: blood tests, x - rays, urine, ECG, echocardiogram, cardiac catheterization.
      2. Explain condition/treatment/prognosis.
      3. Review dietary restrictions, medications.
      4. Discuss how to adjust realistically to life with congenital heart disease, activity restrictions, etc.
4. Evaluation/outcome criteria:
   1. Child’s level of oxygenation is maintained, as evidenced by pink color in nailbeds and mucous membranes (for both light - and dark - skinned children) and ease in respiratory effort.
   2. Energy is conserved, thus reducing the heart’s workload as evidenced by vital signs within normal limits.
   3. The child’s fluid and caloric requirements are met, allowing for physical growth to occur at normal or near - normal rate.
   4. The family (and child, when old enough) verbalize their understanding of the type of CHD, its treatment and prognosis.
   5. The family and child demonstrate adequate coping mechanisms to deal with CHD.

Disorders of the Blood

1. Leukemia
   1. Introduction: Known as “cancer of the blood,” leukemia is the most common form of childhood cancer, with an incidence of 4/100,000. Acute leukemia is basically a malignant proliferation of white blood cell (WBC) precursors triggered by an unknown cause and affecting all blood - forming organs and systems throughout the body. The onset is typically insidious, and the disease is most common in preschoolers (age 2 - 6 year old), occurring more frequently in boys.
   2. Assessment:
      1. Major problem - leukopenia: decreased WBC/ increased blasts (overproduction of immature, poorly functioning white blood cells).
      2. Bone marrow dysfunction results in:
         1. Neutropenia: multiple prolonged infections.
         2. Anemia: pallor, weakness, irritability, shortness of breath.
         3. Thrombocytopenia: bleeding tendencies (petechiae, epistaxis, bruising).
      3. Infiltration of reticuloendothelial system (RES): hepatosplenomegaly, abdominal pain, lymphadenopathy.
      4. Leukemic invasion of CNS: increased intracranial pressure/leukemic meningitis.
      5. Leukemic invasion of bone: pain, pathological fractures, hemarthrosis.
   3. Analysis/nursing diagnosis:
      1. Risk for infection related to neutropenia.
      2. Risk for injury related to thrombocytopenia.
      3. Altered nutrition, less than body requirements, related to loss of appetite, vomiting, mouth ulcers.
      4. Pain related to disease process and treatments (e.g., hemarthrosis, bone pain, bone marrow aspiration).
      5. Activity intolerance related to infection and anemia.
      6. Self - esteem disturbance related to disease process and treatments (e.g., loss of hair with chemotherapy, moon face with prednisone).
      7. Anticipatory grieving related to life - threatening illness.
      8. Knowledge deficit related to diagnosis, treatment, prognosis.
   4. Nursing care plan/implementation:
      1. Goal: maintain infection - free state.
         1. Standard precautions to prevent infection
         2. Use good hand - washing technique.
         3. Ongoing evaluation of sites for potential infection, e.g., gums.
         4. Provide meticulous oral hygiene.
         5. Keep record of vital signs, especially temperature.
         6. Provide good skin care.
         7. Screen staff and visitors (especially children) - restrict anyone with infection.
         8. Protective isolation/reverse isolation to minimize exposure to potentially lifethreatening infection.
         9. Discharge planning: return to school, but isolate from chickenpox or known communicable diseases.