CENTRAL MINDANAO UNIVERSITY

College of Nursing
University Town, Musuan, Maramag, Bukidnon

MATERNAL AND CHILD HEALTH NURSING 2 - RLE

ONLINE ACTIVITY

NAME: NAVARRO, JOHN CLINT P SCORE: ________

SECTION: BSN-2B WARD: PEDIA WARD

CASE STUDY 1: NICOLE

1. Discuss the significance of Nicole’s laboratory findings.

 Adverse effect of chemotherapy is what Nicole’s lab value indicate and
myelosuppression is one common adverse effect of it. Fast-growing
cells like cells with normal function, erythrocytes, leukocytes and
platelets are targets of antineoplastics which results in anemia,
neutropenia, and thrombocytopenia that leads to decrease tissue
perfusion, high risk of infection and high risk of bleeding. Three of the
problems are what Nicole’s laboratory findings exemplify in which, 12-
16 g/dL is the normal hemoglobin for an adolescent girl and 38%-47%
is the normal hematocrit for her age group. Nicole’s values indicate
anemia that occurs when the hematocrit falls below 28%. The normal
count of WBC for Nicole is around 4,100-10,800 cubic millimeter and
neutrophils should value for 58%-67% thus, Nicole indicates having
neutropenia in which her neutrophil count is less than 500 cells per
cubic millimeter. Nicole is at risk for bleeding with her platelet count of
50,000 cells per cubic millimeter and the normal platelet count for 13-
18 year old girls should be 150,000-450,000 per cubic millimeter.
Thrombocytopenia occurs when the platelet counts falls below 50,000
cells per cubic millimeter thus manifests high risk for bleeding.

2. What other assessment data would be helpful for the nurse to have to
prepare Nicole’s care plan.
 Assessment of CVAD for redness, swelling, purulent discharge; pain
 Chest x-ray
 Hem occult of stools
 Urine culture and sensitivity
 Urine for blood
 Urine specific gravity
 Oxygen saturation via pulse oximetry
 Peripheral blood cultures and cultures from CVAD

3. What are the priorities of care for Nicole on admission?

 High risk for bleeding related to platelet count
  Ineffective protection related to neutrophil count
 Risk for ineffective tissue perfusion related to hemoglobin and
hematoctrit values
 Risk for nausea related to effects of chemotherapy on GI mucosa
 Deficient knowledge related to Nicole’s current condition, treatment,
and home care

4. Discuss the common complications (adverse effects) of chemotherapy.

 Most common complication of chemotherapy is myelosuppression
which results from the non-differentiating effects of the agents on fast
multiplying cells both normal and abnormal. This further results in a risk
for neutropenia, thrombocytopenia and anemia. Due to toxcitiy of
antineoplastic to rapidly growing cells, it destroys the hair follicles thus
creating a condition called alopecia. Because of the toxic action on the
epithelium of the GI tract, nausea and vomiting are common thus,
mucositis occurs as a result of the destruction of normal flora in the
upper GI tract and a result of the effect of chemotherapy on rapidly
dividing cells. Impaired hepatic function can be potential as these
agents are detoxified in the liver and are primarily excreted through
renal/urinary system hence contraindicated in the presence of renal
insufficiency. Examples of agent specific that increases the
complications of chemotherapy are the following: Methotrexate which
cause uric acid neuropathy; and Adriamycin which associates
cardiotoxicity. Ifosfamide and cyclophosphamide, an alkylating agents,
carry a high risk for hemorrhagic cystitis.

5. What nursing actions address the adverse effects associated with

chemotherapy?
a. Myelosuppression
1) Place on Compromised Host precautions.
2) Monitor temperature q 4 hrs during hospitalization
3) Maintain patency of CVAD, monitoring q hourly
4) Use sterile technique for CVAD dressing and line, changes
using approved protocols
5) Monitor laboratory values and report abnormal findings
immediately
6) If reddened area on skin appears, notify the health care provider
immediately
7) Administer antimicrobials and blood products as prescribed
8) Assess oral mucous membranes, nares for bleeding
 9) Monitor platelet count and place bleeding precautions if platelet
counts falls below 50,000
10)Hem occult stools
11)Collaborate with health care provider for prescription for stool
softeners to prevent straining
12)Monitor urine for blood
13)If hematocrit falls below 25%, institute falls precautions
14)Monitor RBC count
15)Assess for S/Sx of anemia
16)Monitor for bleeding
17)Draw labs from CVAD as prescribed
b. Nausea
1) Premedicate child with antiememtics prior to administering
chemotherapy as prescribed.
2) Administer prescribed proton pump inhibitors q 4 hrs for 24 hrs
following chemotherapy
3) Administer lorazepam as prescribed for breakthrough nausea
4) Eliminate offensive odors in environment
c. Alopecia
1) Asses child and parent’s knowledge of alopecia
2) Stress to child that alopecia is temporary and following
chemotherapy, hair will grow back
3) Encourage child and family to express feelings and concerns
4) Actively listen, providing empathetic therapeutic responses to
questions.
5) Provide information concerning local wig retailers if appropriate,
depending on child’s desire.
6) Discuss the use of scarves or turbans as alternatives to wearing
wig.
d. Acute pain associated with mucositis (stomatitis, esophagitis)
1) Assess oral mucous membranes
2) Administer nystatin swish and swallow or swish and spit as
prescribed
3) Assess pain level baseline using appropriate pain assessment
tool
4) Administer morphine sulfate, PCA using both continuous IV
infusion and PCA dosing as prescribed until acute pain
controlled which usually takes 48-72 hours.
5) Assess pain level hourly to evaluate effectiveness of prescribed
analgesic.
6) Encourage intake of cool liquids during the acute phase if
possible
7) If the child has esophagitis, enteral feedings may be required
 e. Vesicant extravasation risk with peripheral IV administration of
chemotherapy
1) Assess IV site for patency and placement prior to administering
chemotherapy
2) Monitor IV site every 15-30 minutes during chemotherapy
infusion
3) Caution the client to inform the nurse immediately if IV site
causes any discomfort or swelling
4) If vesicant extravasation occurs, stop infusion immediately,
remove access, flush site with sterile fluid, notify the health care
provider

6. Nicole is receiving cyclophosphamide intravenously. Discuss this agent

including any nursing interventions necessary specifically related to its
use.
 Cyclophosphamide is an alkylating neoplastic agent that acts by
inhibiting DNA synthesis that works in all phases of the cell cycle;
however, it is most effective in the S cycle and changes the internal
acid-base balance in the cell. To treat acute and chronic leukemia in
children, cyclophosphamide is used as a component of numerous
chemotherapy regimens. Alkylating agents cause myelosuppression,
with their greatest impact on the production of BC especially
neutrophils, resulting in neutropenia. Because of its potential for
extravasation, cyclophosphamide should be administered via CVAD.
As a result of the risk of hemorrhagic cystitis, the rescue agent mesna
should be prescribed and the first dose administered immediately
following the completion of each cyclophosphamide administration.
Mesna rescues the urinary bladder from the effects of
cyclophosphamide. Mesna dosing is continued for 24 hours following
the first dose. The urine should be tested each void for blood as well as
specific gravity. In addition, the hyperhydration prior to and following
administration of the agent is critical. Antiemetics, ondansetron should
be prescribed prior to cyclophosphamide administration in addition to
dexamethasone. Ondansetron dosing should continue q 4 hrs for 24
hrs following cyclophosphamide administration. Lorazepam is the drug
of choice for breakthrough nausea and vomiting. Laboratory values
must be monitored closely at least 24 hrs to detect myelosuppression
and the child should be placed on compromised host precautions.
Alopecia can have potentially harmful effect on the child’s body image,
especially for adolescent girls. Teenage boys have fared better with
alopecia because of the impact of professional sports where the
participants often shave their heads and it is a part of their image.
7. Nicole is diagnosed with a CVAD line infection. Discuss how these
infections occur and why.
 Pathogenic organism growth is the primary source of line infection
because it occurs at the proximal tip of the catheter and is fostered by
fibrin formation thus fibrin provides an excellent media for bacteria
growth. These can prevented through proper flushing of CVAD and
maintaining positive pressure as the proximal end of the catheter. The
greatest risk with CVAD is infection and the risk increases with the
presence of myelosuppression.

8. Nicole’s mother staying with Nicole during her hospitalization and

express concern about Nicole refusing to see her friends and that
Nicole seems “down” since her last chemotherapy. Discuss your
impression about Nicole’s mother statements, considering Nicole’s
level of growth and development.
 Despite Nicole’s alibi for not seeing her friends due to risk of exposure
to infection is true, it would support her level of growth and
development that she is having hard time adapting her condition-
alopecia. Peers, for adolescents, are the essential source of
belongingness and it is significant to them to nurture this belonging.
Girls, at this age group, are very sensitive about how they look
particularly their hair styles thus baldness is not welcome in this very
age. The greatest fear of teenagers is being criticized by others their
age. School is an exact representation to continually make contact with
peers however Nicole feels staying at home than be with them so she
can protect herself from being bashed or shunned by her friends.
Nicole’s mother should suggest things related to her concerns so that
she can realize that true friends accept people as they are. Her mother
could also encourage her to buy wig or wearing scarves or hat to
improve self-esteem in case she is convinced that her friends wont
accept her with her condition. The role of the nurse is to focus on
Nicole’s and her parents perception first.

9. Nicole tells the nurse that her mouth and throat are so sore she cannot
drink or eat anything. Discuss your impression about Nicole’s
complaints and the appropriate nursing actions to help Nicole.
 Nicole’s sore mouth and throat probably represent mucositis, a very
painful condition which results from the destruction of the normal oral
flora by chemotherapy. Through collaboration of health care provider
for prescription of medications which includes nystatin swish and spit
for stomatitis or swish and swallow for esophagitis and IV morphine
sulfate both continuous infusion and PCA dosing, have proven its
efficacy in treating mucositis. IV fluids can be maintained as a means
to her hydration until her pain is controlled at which time cool liquids
 should be offered. Supplements to be included in her therapeutic
regimen are high protein and high carbohydrate drinks except for citrus
fruits because of their acid content that is irritating to the sensitive and
injured mucous membranes of the mouth and esophagus.

10. Nicole is prescribed intravenous antibiotic therapy to treat her line

infection. The health care provider prescribes gentamicin sulfate 100mg
IV q8h, vancomycin hydrochloride 500mg IV every 6 hours, and cefoxitin
sodium 1g IV every 6 hours. Nicole weighs 40kg (88 lbs.) Discuss these
agents and if the doses prescribed are safe for Nicole.
 Gentamycin sulfate is an aminoglycoside which acts as an
antimicrobial by inhibiting protein synthesis in the bacterial cell wall.
This causes the cell to die . The adverse effect specific to this
classification is ototoxicity. Vancomycin hydrochloride is classified as a
miscellaneous antimicrobial or tricyclic glycopeptide that is highly
potent antimicrobial used to treat many gram-positive infection that are
not responsive to other less toxic agents. The most serious
complication specific to this agent is renal failure. Cefoxitin sodium is a
second-generation cephalosporin that acts on gram-positive and some
gram-negative bacteria by interfering with cell wall synthesis. The most
serious adverse effect of cephalosporin is allergic or sensitivity reaction
that can lead to anaphylaxis. All of Nicole’s dosages are safe.

11. The pharmacy schedules Nicole’s antibiotic therapy as follows:

Gentamicin 2400h 0600h 1200h 1800h
Vancomycin 0200h 0800h 1400h 2200h
Cefoxitin 2400h 0600h 1200h 1800h

Discuss this schedule and what alterations the nurse should make, if
any.
 This schedule is possible; however, changing the cefoxitin schedule to
0100-0700-1300-1900 would eliminate the overlap of drug
administration. Nurses must realize that time of administration for
medications is part of the seven rights of medication administration-
Right time. Some nurses do not want to use this schedule because of
the 0700 dose being at the time of morning change of shifts, and on
units where nurses work 12 hour shifts, it affects both shift times;
however, nurses should first consider what is best for the client. In
most health facilities, a 30-minute window for administration is policy
(drugs can be administered 30 minutes prior to or after the scheduled
time) so if the aforementioned schedule cannot be changed, the nurse
should administer the cefoxitin sodium before the gentamicin because
it infuses in 15 minutes versus the 30-minute administration time for
 gentamicin; thus both could be administered within the 30-minute
window.

12. Calculate the rates of administration via a volumetric intravenous

infusion pump for the following:
a. Gentamicin hydrochloride: 500 mg in 250 ml of 0.9% normal saline
b. Cefoxitin sodium: 1 g in 50ml of 5% dextrose in water to infuse
over 15 minutes.

A.

Time = Time
Volume Volume

30 minutes = 60 minutes
100mL. X

X= (60 minutes) (100 mL)

30 minutes
X= 200mg/hr – hourly rate for gentamicin

B.

15 minutes = 60 minutes
50 mL. X

X= (50 mL) (60 mins)

15mins
X= 200 mg/hr – hourly rate for cefoxitin
CASE STUDY 2: JEROD

1. Discuss the reason for Jerod being delivered by caesarean section.

 The decision to deliver Jerod by caesarean section was made to
protect the integrity of the myelomeningocele from the stress of labor
and a vaginal delivery. If he was delivered vaginally, the passage
through the tight birth canal would compromise the integrity of the
myelomeningocele, resulting in potential exposure of the sac contents
to the vaginal canal and the air. This would increase the risk of
infection and further compromise the contents of the sac, leading to
additional neurological deficits for Jerod.

2. Discuss the significance of Jerod’s clinical manifestations.

 Classic manifestations of hydrocephalus include bulging fontanels, a
high-pitched cry, and an enlarged head circumference compared to the
chest circumference. A neonate’s fontanels should be flat; bulging
indicates increased intracranial pressure. The head circumference of a
normal neonate is within 2.5 cm (1in.) of the chest circumference;
Jerod’s is 6 cm (2.4in) larger than his chest. This further indicates
increased intracranial pressure. The sac-like projection in his lumbar
region is consistent with spina bifida. Transillumination is a noninvasive
procedure of shining a flashlight beam on the lateral aspect of the sac
to determine whether the sac is filled with just fluid or if the sac
contains solid contents which indicates a myelomeningocele. An
ultrasound provides definitive differentiation, however, Jerod’s vital
signs are within normal limits for a neonate. Unlike in adults, vital sign
indicators of increased intracranial pressure are not present in
neonates until the pressure exceeds the accommodation of the flexible
cranial sutures and the fontanels.

3. What is hydrocephalus?
 Hydrocephalus is an excess of CSF in the ventricles or the
subarachnoid space. In the infant whose cranial sutures are not firmly
knitted , this excess fluid causes enlargement of the skull. If fluid can
reach the spinal cord, the disorder is called communicating
hydrocephalus or extraventricular hydrocephalus. Hydrocephalus is
also classified regarding whether it occurs at birth or from an incident
later in life. The cause of congenital hydrocephalus is unknown,
although, maternal infection such as toxoplasmosis or infant meningitis
may be factors.

4. What is myelomeningocele and how is it related to hydrocephalus?

  The spinal cord and the meninges protrude through the vertebrae the
same as with meningocele. The difference is that the spinal cord ends
at the point, so motor and sensory function is absent beyond this point.
Because this results in lower motor neuron damage, the child will have
flaccidity and lack of sensation of the lower extremities and loss of
bowel and bladder control. Infants’ legs are lax, and they do not move
them; urine and stools continually dribble because of lack of sphincter
control. Children often have accompanying talipes disorders and
developmental hip dysplasia. Hydrocephalus accompanies
myelomeningocele in as many as 80% of infants because of the lack of
an adequate subarachnoid membrane for CSF absorption; the higher
the myelomeningocele occurs kn the cord, the more likely it is that
hydrocephalus will accompany it. It is generally difficult to tell from
visual appearance whether the disorder is myelomeningocele or the
simpler meningocele. A CT or ultrasound scan or MRI will reveal this.

5. Discuss the incidence and etiology of Hydrocephalus and

myelomeningocele.
 Hydrocephalus affects approximately 1 in every 500 children, the
majority occurring prenatally. The cause of hydrocephalus is not
completely understood, but has been associated with genetic
inheritance, complications of preterm birth, prenatal maternal infection,
prenatal infection or injury Childhood tumors , or subarachnoid
hemorrhage. According to National Information Center for Children and
Youth with Disabilities, "Approximately 40% of all Americans may have
spina bifida occulta, but because they experience little or no symptoms,
very few of them ever know that they have it." The other two types of
spina bifida, meningocele and myelomeningocele, are known
collectively as "spina bifida manifesta," and occur in approximately one
out of every 1,000 births . Of these infants born with "spina bifida
manifesta,” about 4% have the meningocele form, while about 96%
have meningocele form. The exact cause of myelomeningocele is not
known; However, evidence indicates the genetic predisposition,
maternal folic acid deficiency during pregnancy, and viral  infections
are strongly associated with the development of spina bifida.

6. Discuss the complications associated with Jerod’s myelomeningocele.

 Myelomeningoceles can cause life-threatening infections in the
neonate if the sac loses its integrity prior to surgical closure. In
addition, myelomeningocele leads to neurological defects similar to a
spinal cord injury including neurogenic bladder and bowel, weakness of
the lower extremities, and paralysis when located in the lumbar region.
Defects in the thoracic level above and many  cause preterm or
neonatal death. Because the central nervous system develops early
 including all of its components, hydrocephalus most commonly occurs
in conjunction with neural tube defects. Latex allergies are common in
these children as a result need for daily intermittent urinary
catheterization.

7. What are the priorities of care for Jerod on admission?

a. a.Ineffective ceberal tissue perfusion related to increased intracranial
pressure
b. Risk for impaired skin integrity related to fragility of myelomeningocele sac
c. Risk for injury,neurological alterations,related to spinal cord injury
meningocele sac,invasive line's and surgical placement of sunt
d. Risk for impaired parent parent/infant attachmaent related to jerod's being in
critical care environment.
e. Risk for impaired parent/infant attachment related to Jerod's being in critical
care environment.
f. Impaired urinary and bowel enlimination related to interference of nerve
stimulation.
g. Deficient knowledge related to Jerod's condition,treatement,and home care
and breastfeeding.

8. How should the nurse therapeutically respond to Jerod's mother?

 Jerod can be breastfed. Prior to surgery, the nurse can assist Joanna in
positioning Jerod on his side facing her breast, taking care not to apply any
pressure to Jerod's back in the vicinity of the myelomeningocele. This position
can be used postoperatively following Jerod's surgical repair and closure  of
the myelomeningocele. Joanna should be taught to use a breast pump to
express the breast milk  can be stored in the refrigerator and breastfeeding.
the nurse should encourage Joanna about breastfeeding and her option until
normal breastfeeding can continue.

9. Discuss the priority nursing interventions when caring for Jerod’s

myelomeningocele prior to surgery.
 The priority goal for the nurse is to maintain the integrity of the sac until
surgery. This is accomplished by placing Jerod in a side-lying position and
providing care to the sac according to the health care provider's prescription.
Sac care may involve leaving the sac open to the air, applying a sterile gauze
dressing, a transparent dressing , or wet-to-dry dressing using sterile normal
saline. Iodine substances and alcohol are very drying  and should not be used
on the sac. Monitoring urinary and bowel output is necessary catheterization
may be prescribe to prevent bladder infections due to urinary stasis and to
prevent bladder injury related to bladder distension.
 10. Jerod's myelomeningocele  is surgically repaired and the shunt is
placed for his hydrocephalus. Discuss the two  types repaired and a shunts
used to treat hydrocephalus and which is the most common.
 Ventriculoperitoneal shunts (VP shunts) are the most common types of
drainage shunts used in children with CSF and causing it to be absorbed
through the peritoneal wall into  systemic circulation and excreted by the
kidneys. The shunts is flexible tube beginning in the ventricle and ending in
the peritoneal cavity. The atrioventricular shunts (AV shunts) are much less
common and are usually inserted in response to complication of the VP
shunts. The AV shunts drains the ventricle(s) of the brain into the atrium of the
hearth to be absorbed into the blood and pumped into systemic circulation by
the left cardiac ventricle. The excess fluid them circulated systemically and
excreted through the kidneys.

11. Discuss the complications that may occur in a child with VP shunt and an
AV shunt.
 The most common complications associated with VP shunt are malfunction of
the shunt and infection. Malfunction or obstruction of the shunt will lead to
increased intracranial pressure. Infection in the shunt can lead to central
nervous system infections that can lead to death. And AV shunt can produce
the same complications as a VP shunt, but with the additional life threatening
complication of cardiac dysrhythmias associated with the cardiac end of the
shunt coming in contact with myocardium and stimulating dysfunctional
contractions.
12.Discuss the teaching priorities for Jerod’s parents prior to his discharge
from the hospital to home.
a. Assess the understanding Joanna and Jim have about Jerod’s
condition and surgical treatment.
b. Demonstrate infant care including intermittent catheterization for Jerod
and allow sufficient opportunities for them to return the demonstration,
evaluating their ability and providing encouragement.
c. Demonstrate ROM exercises for Jerod, as prescribed, allowing for
return demonstration.
d. Discuss s/sx of increased intracranial pressure, stressing the
importance of reporting these immediately to Jerod’s physician.
e. Discuss skin care as prescribed
f. Following collaboration with health care provider, discuss referral
information including home health, National Hydrocephalus
Foundation, and Social Services and phone numbers
g. Discuss s/sx infection, ensuring parents know how to take Jerod’s
temperature and importance of reporting temperature elevation to the
health care provider.
h. Discuss specific discharge information prescribed by the health care
provider including the importance of follow-up care.
i. Allow sufficient time for Joanna and Jim to ask questions, ensuring
these are addressed by the appropriate health care professionals.
j. Document teaching and Joanna and Jim’s responses including
evaluation of their abilities to provide care demonstrated.