Hematologic-Oncology

1
Hematologic-Oncology
2
Common Hematologic Disorders in Children

• Iron-Deficiency Anemia
• Sickle Cell Anemia
• Beta-ThalasemiaMajor (Cooleys anemia)
• Hemophilia A
• Von Willebrands Disease
• ITP (Immune Thrombocytopenic Pupura)

3
Common Heme-Oncology Diseases in Children

• Acute Lymphocytic Leukemia
• Hodgkins Disease
• Non-Hodgkins Lymphoma
• Retinoblastoma
• Neuroblastoma
• Nephroblastoma
• Osteogenic Sarcoma
• Ewings Sarcoma

4
Complete Blood Count

• WBC
• RBC
• Hgb
• Hct
• Platelet

5
CBC with Differential

• WBC
• Neutrophils- phagocytosis
• Lymphocytes T and B cell
• Monoocytes phagocytosis, antigen
• Eosophils- allergen
• Basophils-inflammatory
• RBC
• MCV- volume
• MCH
• MCHC
• RCW- width
• Hgb
• Hct
• Platelet
• MPV

6
Other Labs

• PT/PTT
• Sed Rate (ESR)
• Iron
• TIBC (Transferrin)
• Ferritin
• Bilirubin

7
Pediatric Laboratory Normal Values Children age
2-12 Years

• RBC 3.89-4.96
• HgB 10.2-13.4
• Hct 31.7-39.3
• Sed 1-8
• WBC 5,400-11,000

• Platelets 206,000-403,000
• Fe 20-105
• Ferritin 47-110
• TIBC 240-508
• PT 10-11 sec
• PTT 42-54 sec
• Bilirubin- less than 11.7

8
Anemias

• Reduction of
• number of red blood cells
• the quantity of hemoglobin
• the volume of packed red

• Iron-Deficiency Anemia
• Sickle Cell Anemia
• Beta-ThalasemiaMajor (Cooleys anemia

• )

9
Iron Deficiency Anemia
10
Iron-Deficiency Anemia

• A nutrient deficiency of inadequate dietary iron
• The most common hematologic disorder of infancy
  and childhood
• Peaks at 9 months- 2 years, adolescence
• Prevented by use of iron fortified productsn

11
Children at Risk

• low birth weight infants
• infants born to mothers with iron deficiency
  anemia
• infants born with GI defects
• chronic blood loss in older children

12
Pathophysiology

• Dietary Fe is bloodstream binds to transferrin
  (TIBC) and is delivered to RBC in bone
• Marrow, combines with other cells to make Hgb
• Unused dietary Fe is stored in intestinal
  epithelial cells as ferritin

13
History

• Dietary history usually shows abnormally high
  milk intake gt 32 oz day in toddler
• Ask parents specific questions
• Begin the dietary history at the time the child
  awoke yesterday include all activities and
  exactly what the child ate

14
Diagnosis

• Low RBC
• Low HGB
• Mild ( lt 10.2), Moderate (8-9), Severe (lt 7)
• Low HCT
• Low Iron
• High Transferrin (TIBC)
• Low Ferritin

15
Symptoms

• Low Hgblow O2 tissue perfusion
• Hgb of 10.2 or less
• May seem asymptomatic, not noticed by caregiver
• Pallor/Pale mucous membranes (low hgb, not enough
  red color to skin)
• Poor muscle tone, decreased activity
• Fatigue
• Increased HR, RR
• Hgb lt 9
• Above symptoms plus irritability, lack of
  interest in play

16
Nursing Considerations

• Consume Iron-fortified formula
• Limit cows milk to 24-32 oz/day for children gt12
  months
• Increase age-appropriate iron-rich foods and Vit
  C
• May be ordered to take Fe supplements- Ferrous
  Sulfate

17
Nursing Considerations
Iron-Rich Foods Vitamin C Rich Foods
Meats, fish, poultry Orange juice
Vegetables Citrus fruits
Dried fruits Strawberries
Legumes Tomatoes
Enriched grain products Broccoli
Whole grain cereal Leafy Green vegetables
Iron-Fortified Cereal Potatoes
18
Nursing Considerations

• Manage side effects of Ferrous Sulfate
• Nausea,
• Anorexia
• Constipation
• Abdominal distress
• Black stools.
• Give on an empty stomach if possible
• Monitor bowel movements and suggest increased
  fluid and fiber.

19
Nursing Considerations

• Monitor development, sleep, and activity/fatigue
  patterns
• Monitor hemoglobin to measure effectiveness of
  therapy
• Instruct families to keep Ferrous Sulfate locked
  and out of reach of children poisoning is a
  serious risk

20
Sickle Cell Anemia
21
Sickle Cell Anemia

• Autosomal recessive disorder
• Seen in African Americans
• Characterized by abnormal hemoglobin (HbS)
• Clinical manifestations caused by obstructions
  due to the sickled RBCs and destruction of
  sickled and normal RBCs

22
Sickle Cell Anemia

• Can be diagnosed in-utero
• Symptoms may not appear until 6 months of age
• Mortality rate children lt 3 years old is 35

23
Signs and Symptoms

• Pallor
• Fatigue
• SOB
• Irritability
• Jaundice

24
Diagnosis

• Moderately low Hcb and Hct
• Normal Iron, TIBC, Ferritin
• Elevated Billirubin

25
3 Complications of Sickle Cell Anemia

1. Vaso-Occlusive Crisis
2. Acute Chest Syndrome
3. Splenic Sequestration

26
Vaso-occlusive crisis

• Severe, sudden onset of sickling where many new
  sickled cells pool in a vessel and cause pain and
  tissue hypoxia
• Caused by infection, dehydration, anxiety, cold
• Most common from hypoxia secondary to rapidly
  destroyed RBC
• Lasts for hours to weeks

27
(No Transcript)
28
Vaso-occlusive Crisis

• Early Signs
• fever
• tachycardia
• pallor
• Late Signs
• abdominal pain
• back pain
• extremity pain

• First Crisis in infants
• Dactylitis (hand foot syndrome)
• swelling of hands and feet
• joints may be warm swollen

29
Management

• Pain relief
• Prevent/Treat occulsions
• Adequate oxygenation

30
Pain

• Assess pain every 1-2h or more frequently
• Use pain scale appropriate for age
• Non-pharmacological pain methods
• AROUND THE CLOCK PAIN MEDS
• Tylenol for mild pain
• Narcotics for mod-severe pain

31
Hydration

• Prevents and treats occlusion
• Push PO fluids
• IV hydration 1.5 to 2 times normal rate
• Risk for fluid overload
• Listen for crackles

32
Treat Sickling-Oxygenation

• Administer oxygen
• Maintain saturation of 95 or higher
• Semi-fowlers position

33
Acute Chest Syndrome

• Sickle contents break off
• Bilateral pulmonary involvement
• Causes chest infection, embolism

34
Nursing Considerations

• Symptoms
• Chest pain
• Fever
• Cough
• Wheeze
• Tachypnea

• Analgesics
• Oxygen
• Hydration
• Incentive spirometry
• Antibiotics
• PRBC

35
Splenic Sequestration

• Sickled cells block the spleen
• Blood pools in spleen and/or liver and enlarges
• Pooled blood leads to a decrease in circulating
  volume
• Can lead to hypovolemic shock

36
Nursing Considerations

• Symptoms
• Irritability
• Pale
• Tachycardia
• Pain to LUQ
• Enlarged Spleen

• Life Threatening- get child to ED a.s.a.p.!
• PRBC
• Remove spleen

37
Post-Splenectomy

• Risk for Infection r/t Chronic Immunosuppression
• Administer PCN everyday
• Up-to-date vaccines
• Educate parents
• Signs of infection respiratory distress
• possible triggers
• treat pain immediately
• adequate fluids

38
Beta-ThalasemiaMajor

• (Cooleys Anemia)

39
Beta-ThalasemiaMajor (Cooleys anemia)

• Hereditary anemia due to abnormal synthesis of
  hemoglobin
• Life long disorder
• Mediterranean descent
• Life threatening symptoms

40
Diagnosis

• Low RBCs
• Extremely low Hgb lt 5
• Increased serum iron

41
Symptoms

• Facial anomalies
• Frontal bossing (prominent and protruding
  forehead)
• Maxillary prominence
• Wide-set eyes with a flattened nose
• Bronze skin color (Greenish yellow skin tone)
• Growth and maturation retardation

42
Management

• RBC transfusions q 2-4 weeks
• Iron Chelation therapy
• Desferal (deferoxamine) SQ
• Splenectomy
• Cure isbone marrow stem cell transplant
• Estimated 70 do not find a suitable donor

43
Nursing Considerations

• Observe for complications of transfusion- iron
  overload
• Supporting the child and family in dealing with a
  chronic life-threatening illness
• Monitor Growth and Development
• Refer the family for genetic counseling

44
Compare and Contrast
Iron Deficiency Sickle Cell Thalasemia
Low RBCs Low HCT Low Hgb Low iron Low ferritin High TIBC Low RBCs Low HCT Mod low Hgb Normal iron Normal ferritin Normal TIBC Inc Bilirubin Low RBCs Low HCT Very low Hgb Increased iron Normal ferritin Normal TIBC
45
Bleeding Disorders
46
Clotting

• Host of factors
• Platelets aggregation at site of injury
• Tested by coagulation time (PT/PTT)

47
Types of Bleeding Disorders

• Hemophilia A
• Von Willebrands Disease
• ITP (Immune Thrombocytopenic Pupura)

48
Hemophilia A
49
Hemophilia A

• Hereditary blood coagulation deficiency (factor
  8)
• Ability to clot is slower
• X-linked recessive (white, males)

50
If Suspected ask about

• Recent traumas and measures used to stop bleeding
• Length of time pressure was applied before
  bleeding subsided
• Whether swelling increased after surface bleeding
  subsided
• Whether swelling and stiffness occurred without
  apparent trauma

51
Diagnosis

• Above History
• Suspected by Labs
• Platelet level Normal
• PTT Prolonged (elevated number) gt 60
• Confirmed by genetic testing for missing factor

52
Symptoms

• Vary according to concentration of factor 8
• Soft tissue bleeding and painful hemorrhage into
  joints
• Severe bleeding may occur in GI tract, peritoneum
  or CNS

53
Management of Bleeding

• Acute therapy
• Acute bleeding stopped by IV administration of
  factor 8
• Pressure to laceration
• Prophylactic therapy
• PO factor 8 replacement on a regular schedule if
  frequently symptomatic (prior to surgery, dental
  work)

54
Parental Education

• Primary Goal is Injury Prevention
• Promote oral hygiene, up to date immunizations
• No aspirin
• Avoid activities that induce bleeding
• Provide activities for normal GD
• Administration of factor replacement prn

55
Von Willebrands Disease
56
Von Willebrands Disease

• Most commonly inherited bleeding disorder,
  autosomal dominant (Males and Females)
• Lacks production of VWF
• Platelets are normal in number
• Inability of platelets to aggregate
• Varying degrees of disease
• VWF is deficient to defective

57
Diagnosis

• Platelets is normal
• PT/PTT is normal
• Confirmed by genetic testing for VWF

58
Signs Symptoms

• Can be so mild that disease is undiagnosed
• Bleeding from gums
• Epitaxis
• Prolonged bleeding from cuts
• Excessive bleeding following surgery

59
Management

• Primary Goal Injury Prevention
• Prophylactic therapy
• Replace dysfunctional factor in blood when
  bleeding with DDAVP

60
ITP (Immune Thrombocytopenic Pupura)
61
ITP

• Autoimmune disorder (antiplatelet antibody) or
  cause is unknown (idiopathic)
• Occurs most commonly at age 2-4 years
• Reduction in and destruction of platelets
• Typically seen 2 weeks after a febrile, viral
  illness

62
Signs and Symptoms

• Excessive bruising and petechiae
• Epitaxis
• Bleeding into joints
• Tourniquet test shows many petechiae after
  inflation of BP cuff

63
Diagnosis

• Platelets lt 150 (Marked thrombocytopenia)
• PT and PTT is Normal

64
Management

• PLT transfusion (only a temporary solution)
• Injury Prevention
• Avoid when possible
• administering intramuscular injections
• aspirin, aspirin-containing products, and
  nonsteroidal antiinflammatory medications (e.g.,
  ibuprofen)
• taking temperatures rectally

65
Compare and Contrast
Hemophilia A VWF ITP
Normal Platelets Elevated PT/PTT Normal Platelets Normal PT/PTT Very Low Platelets Normal PT/PTT
66
Oncology
67
Oncology

• Cancer in adults
• abnormal cell is transformed by genetic mutation
  of its DNA
• usually as a result from exposure to a tetragon
• Cancer in children
• usually arises from chromosomal abnormalities,
  genetic mutations and proliferation of embryonic
  cells

68
Oncology Treatment

• Surgical intervention
• Removing the entire cancerous tumor
• Most ideal and frequently used treatment method

69
Oncology Treatment

• Chemotherapy
• destroy tumor cells by cause cell death
• normal cells that have rapid growth are also
  affected, such as hair growth
• toxic side effects

70
Oncology Treatment

• Radiation therapy
• Least preferred treatment in children
• Interrupt cellular growth by breaking the DNA
  stands, leading to cell death

71
Types of Cancer in Children

• Small percentage Carcinoma (opposed to large
  percentage in adults)
• Mostly Leukemia
• Followed by Lymphoma
• The rest is solid or soft tissue tumors

72
Clinical Manifestations

• Differ based on type of cancer
• Many symptoms are similar to common childhood
  illnesses
• Symptoms may be in site other than the cancer
• delay in diagnosis
• Often diagnosis made when cancer is advanced

73
Common Clinical Manifestations

• Pain
• Anemia
• Anorexia, weight loss
• Infections
• Bruising
• Neurological symptoms
• Palpable mass

74
Psychosocial Concerns

• Parents in disbelief
• Health child suddenly becomes ill
• Potentially life-threatening
• Treatment decisions, can last months-years
• Travel for treatment, heavy financial
  responsibilities
• Effects of siblings

75
Effects on Child

• Infants- unaware of diagnosis
• Toddlers- aware they do not feel well
• Preschoolers-beginning understanding of illness,
  not cancer
• School-age-understand cancer, benefit from
  talking about it
• Adolescents-mature understanding, benefits from
  other adolescents with cancer

76
General Nursing Considerations

• Provide optimal nutrition- high metabolic rate of
  cancer depletes stores
• Ensure adequate hydration-ice pops, jello
• Manage pain
• Promote growth and development
• Prevent Infection (next slide)

77
Risk for infection r/t Immunosuppressed state.

• Monitor vital signs q4h
• Instruct parents how to measure temp at home
• Proper handwashing
• Inspect childs skin for breakdown
• Inspect childs mouth for ulcers
• Teach child and parents meticulous oral hygiene
• No live virus administration

78
Leukemia
79
Leukemia

• Broad term describing a group of malignant
  diseases
• Normal bone marrow is replaced by abnormal
  immature cells
• Develops from a variety of agents thought to
  increase risk (virus, toxins, drugs) combined
  with genetics

80
Acute Lymphocytic Leukemia

• Occurs in childrenlt 15 years old (peak 2-6 years
  old)
• Distorted and uncontrolled proliferation of
  immature WBCs (lymphoblasts)
• Causes decreased RBCs, platelets, and mature
  WBCs production
• Invasion of body organs by rapidly increasing
  lymphoblasts

81
Signs and Symptoms

• CBC Changes

• Physical Exam

• Fever
• Bone or joint pain
• Bruising
• Lymphadenopathy
• Hepatosplenomegaly

• Decreased RBCs
• Decreased PLTs
• Very high WBC

82
Diagnosis

• Signs symptoms
• CBC changes
• Confirmed with bone marrow aspiration (gt 25 of
  lymphoblast cells present)

83
Management

• High dose chemotherapy administered for 2-3 years
• Returns blast cells in bone marrow to less than
  5
• Physical assessment findings are normal

84
Tumor Lysis Syndrome

• Metabolic emergency
• Lysis (dissolving or decomposing) of tumor cells
• Rapid release of their contents into the blood

85
Tumor lysis syndrome

• Rapid cell destruction releases high levels of
• uric acid
• potassium
• phosphates
• Uric acid overloads the kidneys
• Leads to cardiac arrhythmias and renal failure

86
Nursing Considerations

• Children receiving chemotherapy monitor for
• Hyperuricemia
• Hyperkalemia
• Hyperphosphatemia
• Hypocalcemia

87
Nursing Considerations

• Administer vigorous hydration (24 times rate for
  maintenance fluid)
• Administer allopurinol or urate oxidase
  (rasburicase)
• Reduce conversion of metabolic by-products to
  uric acid

88
Soft Tissue Tumors

• Hodgkin's
• Non Hodgkin's
• Retinoblastoma

89
Lymphomas

• A malignancy that arises from the lymphoid system
  
• Two types
• Hodgkins
• Non Hodgkins

90
Hodgkins Lymphoma
91
Hodgkins Lymphoma

• Neoplasm of the lymph tissue
• Affects adolescents to late 20s
• Males gt females
• Etiology unknown- infectious agent likely

92
Signs and Symptoms

• Begins as a single painless enlarged cervical
  node
• Spreads predictably to nonnodal sites
• spleen, liver, bone, marrow, lungs, mediastinum

93
Signs and Symptoms

• As cancer progresses
• Unexplained weight loss
• Unexplained fevers
• Night sweats

94
Diagnosis and Treatment

• Diagnosis
• Biopsy of enlarged lymph node
• Treatment
• Chemotherapy
• Radiation-low doses, higher if physiologically
  mature
• Good Prognosis-single origin

95
Non-Hodgkins Lymphoma
96
Non-Hodgkins Lymphoma

• Aggressive neoplasm of many lymph nodes
• No single origin
• Rapid in onset
• Affects younger children ages 5-15
• Males gt females
• Cause unknown-infectious agent likely

97
Signs and Symptoms

• Multiple enlarged painless lymph nodes
• Acute abdominal and chest pain, constipation,
  cramping
• Anorexia, weight loss

98
Signs and Symptoms

• As cancer progresses
• CNS symptoms,
• Headache
• Nausea
• Vomiting
• Mediastinal mass
• Petichaie
• Bruising
• Bone pain

99
Diagnosis and Treament

• Diagnosis
• Biopsy from bone marrow or lymph node
• Treatment
• Aggressive multi-agent chemo for 2 years
• Risk for tumor lysis syndrome
• May need crainal radiation

100
Compare and Contrast
Hodgkins Non Hodgkins
MalesgtFemales Late adolescent-20s Single origin of cervical gland Good Prognosis Males gt females Ages 5-15 No single origin wide-spread involvement Aggressive treatment- may have poorer progrosis
101
Retinoblastoma
102
Retinoblastoma

• Malignant tumor of retina
• Immature retinal cells become malignant
• Affects children 6 weeks of age to preschool age
• May be unilateral or bilateral

103
Signs and Symptoms

• Absent red reflex
• Whitish glow to pupil
• Strabismus
• Eye pain

104
Treatment

• Small retinoblastoma
• Cryosurgery
• Partial vision
• Large retinoblastoma and/or metastases brain/ 2nd
  eye
• Chemo
• Radiation
• Enucleation
• Eye prosthesis

105
Solid Tumors

• Neuroblastoma
• Nephroblastoma
• Osteoscaroma
• Ewings Sarcoma

106
Neuroblastoma
107
Neuroblastoma

• Solid tumor usually in abdomen
• Affects infants to pre-school age children
• Cancer cells arise from sympathetic nervous
  system called crest cells
• Embryologic cells of adrenal glands
• Etiology unknown

108
Signs and Symptoms

• Depend on
• extent of disease
• location of tumor
• 65 of neuroblastomas
• protuberant, firm, irregular abdominal mass that
  crosses midline

109
Signs and Symptoms

• impaired ROM and mobility
• pain limping
• respiratory symptoms
• Management
• depends on the presence and extent of metastasis

110
Nephroblastoma
111
Nephroblastoma

• Malignant tumor of the kidneys
• Peak age 3-4 years
• Girls gt boys
• Cause is unknown

112
Nephroblastoma

• Parents usually notice a large, mobile abdominal
  mass while bathing or the diaper doesnt fit
  anymore
• Grows extremely quickly, in a matter of days

113
Other Signs Symptoms

• Hematuria
• Hypertension
• Abdominal pain
• Fatigue
• Anemia
• Fever

114
Staging 1 through 5

• tumor confined to the kidney and completely
  removed surgically
• tumor extending beyond the kidney but completely
  removed surgically
• regional spread of disease beyond the kidney with
  residual abdominal disease postoperatively
• metastases to lung (primary site), liver, bone,
  distant lymph nodes
• bilateral disease

115
Treatment

• DO NOT PALPATE ABDOMEN
• can rupture the tumor and cause spreading of
  cancerous cells
• State 1 and 2
• Nephrectomy
• Chemotherapy
• Stage 3-5
• Nephrectomy
• Radiation
• Chemotherapy

116
Bone Cancers
117
Osteosarcoma
118
Osteosarcoma

• Bone cancer from osteoblasts
• Affects adolescents
• Attributed to extremity injury or growth spurt
• 40-50 occur at distal femur and knee

119
Signs and symptoms

• Progressive pain at site of tumor
• Palpable mass swelling
• Limping
• Limited range of motion
• Pathological fractures

120
Management

• Remove tumor, prevent spread of disease
• Combination of surgery chemo
• Amputation my be necessary
• Limb salvage operation

121
Nursing care Post-Op

• Comfort
• Infection
• Potential hemorrhage
• Phantom limb pain
• Prosthesis
• Changes in body image and functioning

122
Ewings Sarcoma
123
Ewings Sarcoma

• Highly malignant tumor in bone marrow
• Can present in any bone
• Spreads longitudinally through bone
• Affects older children and young adolescents

124
Signs and Symptoms

• Intermittent pain attributed to injury
• Swelling at tumor site
• Pain becomes constant
• Progresses into
• Weight loss
• Fever
• Increased sed rate
• Metastases is usually present at time of dx
  (lungs, bone, CNS, lymph nodes)

125
Treatment

• Surgery
• Multi agent chemo
• Risk for tumor lysis syndrome
• Radiation

126
Compare and Contrast
Osteogenic scaroma Ewings Sarcoma
Affects long bones Older adolescents Intermittent pain Palpable mass swelling Limping, progressive limited range of motion Pathological fractures Metastases not as likely Surgery and chemo Affects any bone School-age and adolescents Intermittent pain becomes constant Swelling at tumor site Progresses into systemic symptoms Metastases likely Aggressive treatment
127
Care of the Chronically Ill Child
128
Chronically Ill ChildNursing Diagnosis

• Fear
• Death Anxiety
• Anticipatory Grieving
• Hopelessness

129
Goals for Care of the Chronically Ill Child

• Goals for the child
• Achieve and maintain normalization
• Obtain the highest level of health and function
  possible
• Goals for the family
• Remain intact
• Achieve and maintain normalization
• Maximize function throughout the illness

130
Nursing Care for Children with Chronic
Conditions and Their Families

• Attend to the needs of the family system
• Revise goals frequently to meet the childs
  changing developmental needs
• Listen carefully to the child's perception of the
  condition

131
Nursing Care for the Dying Child and the Childs
Family

• Be available to assist both child and family
• Avoid imposing personal beliefs and expectations
• Provide time and attention to the dying child
• Recognize the need to talk about illness and
  death
• Provide adequate pain control, oral care,
  privacy, and information about the signs of
  imminent death
• After death, allow family members as much time as
  they desire with the child

132
Practice Questions!
133

• A child is being admitted to the unit with
  thalassemia major (Cooleys anemia). In preparing
  client assignments, the charge nurse wants to
  assign a nurse to this child who can
• Teach dietary sources of iron
• Administer blood infusions
• Work with a dying child
• Monitor the child for bleeding tendencies

134

• A 14-year-old boy with sickle cell anemia is
  admitted with severe pain in his abdomen and
  legs. He asks why the doctor ordered oxygen when
  he is not having any breathing problems. The
  nurse states the therapeutic action of O2 is
• Prevent further sickling
• Prevent respiratory complications
• Increase O2 capacity of RBCs
• Decrease the potential for infection

135

• A 10-year old in the ER has a CBC results that
  include a Hgb of 8, and Hct of 24. The nurse
  determines that based on the lab results which
  nursing action has a high priority?
• Promotion of skin integrity
• Promotion of hydration
• Promotion of nutrition
• Conserving energy

136

• A 17-year old is being admitted for an amputation
  related to a bone tumor. The nurse is developing
  a nursing care plan and determines the most
  appropriate age related diagnosis is
• Risk for disuse syndrome
• Disturbed body image
• Self-care deficit
• Activity related intolerance

137
The nurse is reviewing the lab work on a child
admitted for fatigue

• WBC 7,200
• RBC3.01
• Hgb 9.1
• Hct 29.3
• Platelets 371,000

• Iron 64
• Ferritin 70
• Transferrin 250
• Bilirubin 18.2
• PTT 45 seconds

138

• After analyzing the results, the nurse suspects
  the child may have
• 1. Fe Deficiency Anemia
• 2. Cooleys Anemia
• 3. Sickle Cell Anemia
• 4. Aplastic Anemia

139

• The nurse is admitting a child for a swollen
  elbow. The history indicated multiple bruising.
  Which of the following laboratory results
  heightens the nurses suspicion for Hemophilia?
• 1. Hbg 12,000
• 2. WBC 9,000
• 3. Platelets 356,000
• 4. PTT 73 seconds