In childhood cancers and blood disorders, infection is usually what kills, not the disease.
Low neutrophils mean the usual signs of infection may be absent —
fever may be the only sign, and it is an emergency.
🖼️ Sickle cell disease and hemophilia.Swipe it sideways if it is cut off, or tap to open it full size.
🚨 Fever in a neutropenic child
ANC < 500 + fever = emergency
Blood cultures and IV antibiotics within the hour. Do not wait for confirmation.
No rectal temperatures, suppositories or enemas in a neutropenic or thrombocytopenic child.
Condition
Signature
Key nursing point
ALL (commonest childhood cancer)
Pallor, fatigue, bruising, bone pain, fever
Infection precautions; bleeding precautions
Wilms tumor
Firm abdominal mass, often found on diaper change
DO NOT PALPATE the abdomen
Sickle cell
Pain crisis; triggered by hypoxia, dehydration, cold, stress
Hydration + oxygen + analgesia
Hemophilia
Bleeding into joints (hemarthrosis)
Factor replacement; no contact sport, no NSAIDs
ITP
Petechiae, bruising after a viral illness
Bleeding precautions; usually self-limiting
Never palpate a Wilms tumor. Pressure can rupture the capsule and seed cancer cells. Put a sign on the crib.
⭐ Sickle cell crisis — the treatment is the pathophysiology
Cells sickle when they are hypoxic or dehydrated, then jam in small vessels and cause
pain and infarction.
So treatment is simply the reverse: oxygen, aggressive hydration, and pain relief
— opioids are appropriate and often under-given.
Never apply cold to a sickle cell crisis. Cold causes vasoconstriction and worsens sickling. Warmth only.
✅ Hemophilia joint bleed — RICE plus factor
Rest · Ice · Compression · Elevation, and give
the missing factor. Avoid aspirin and NSAIDs; acetaminophen is the safe analgesic.
⭐ High-yield — what the exam actually asks
Show 5 moreHide these 5
Transfusion: consent and baseline vitals first, NS is the only compatible fluid, highest reaction risk is the first 15 minutes, vitals q15 min for the first hour. Fever, chills, back pain, rash, dyspnea or tachycardia → stop immediately.
Iron deficiency: low H/H and RBCs. Give iron on an empty stomach with vitamin C, never with dairy. Warn about dark stools and tooth staining.
Sickle cell: autosomal recessive; symptoms emerge around 6 months as fetal hemoglobin fades. Hemoglobin electrophoresis is definitive. Never restrict fluids, use warm compresses, avoid NSAIDs, O2 when sat drops below 95%, hydroxyurea raises fetal hemoglobin. Stroke is the most serious complication.
Hemophilia: X-linked recessive. A = factor VIII (most common), B = factor IX. PTT is the screening abnormality. Avoid aspirin.
ALL is the most common childhood leukemia, peaking at 2–6 years. Bone marrow biopsy is definitive. Keep flat after LP.
Show 3 moreHide these 3
Wilms tumor: painless abdominal mass with hematuria and hypertension. Do not palpate the abdomen — and post a sign so nobody else does either.
Chemo hits fast-dividing cells: alopecia, mucositis, GI upset, marrow suppression. Neutropenic precautions, no live vaccines, ondansetron plus dexamethasone for nausea.
Brain tumor post-op: HOB slightly up, position off the operative side, seizure precautions. Dexamethasone pre-op for ICP.
📕 From your ATI review book
Covered by ch. 21 (hematologic) · ch. 38–40 (neoplasms).
Leukemia peaks between ages 2 and 5, and risk is higher with trisomy 21. Presentation is often vague — anorexia, headache, fatigue, bruising.
Remission means under 5% blasts in the marrow. Induction aims for exactly that, and intrathecal methotrexate is given prophylactically to protect the CNS.
Bone marrow aspiration: posterior or anterior iliac crest usually; the tibia is used under 18 months. Topical anesthetic 30–60 min before, then supine and flat for 30–60 minutes afterwards to keep pressure on the site.
Lumbar puncture in a neonate: hold the legs and flex the upper back but never flex the neck — it obstructs the airway.
Hemoglobin by age: roughly 10–17 g/dL at 2–6 months, 9.5–14 from 6 months to 6 years, 10–15.5 from 6–18 years. WBC runs higher in the young child: 6,200–17,000 under 2 years.
Epistaxis: sit up, lean forward, and press the nares together for at least 10 minutes.
📚 From your Maternal & Child textbook
Pillitteri, Maternal and Child Health Nursing — ch. 44 (hematologic) · ch. 53 (malignancy).
Hemolytic anemias (cells destroyed): spherocytosis, G6PD, sickle cell, thalassemia, autoimmune. Iron deficiency is a production problem — hypochromic, microcytic, and the commonest in children. Macrocytic anemias come from folate or B12.
After splenectomy the child is vulnerable to pneumococcal infection — check and update vaccination before surgery, and treat any later fever as urgent.
Bleeding disorders are managed by preventing injury without confining the child — chosen activities, safe toys, padding. Aspirin and NSAIDs are avoided.
⚠️ Exam traps
Warm compresses in sickle cell (correct) vs cold (worsens sickling).
Aspirin is contraindicated in hemophilia and generally in peds — but it is the treatment in Kawasaki (week 9). The two turn up in the same exam.
Reticulocytes rise in crisis. That is expected, not alarming.
🧠 Mind maps 4
One per disorder, built from the structure of your ATI chapter.
Hematologic Disorders
🎯 Who gets it
Epistaxis: nose picking or rubbing tearing the fragile vascular mucosa, low humidity, allergic rhinitis, upper respiratory infection, blunt injury, nasal foreign body
Epistaxis from medications affecting clotting or underlying disease — von Willebrand disease, hemophilia, idiopathic thrombocytopenic purpura, leukemia
Iron deficiency: prematurity with low iron stores, excessive cow's milk in toddlers (milk lacks iron and displaces iron-rich solids), malabsorption, poor dietary iron
Iron deficiency from blood loss — GERD and pyloric stenosis in infants, GI polyps and colitis in older children, menorrhagia in adolescents
👀 What you see
Epistaxis: active bleeding from the nose, restlessness, agitation
Iron deficiency anemia: tachycardia, pallor, brittle spoon-shaped nails, fatigue, irritability, muscle weakness, systolic murmur, pica for ice, dirt, or paper
Sickle cell: family history, reports of pain, shortness of breath, fatigue, pallor and pale mucous membranes, jaundice, cool hands and feet, dizziness, headache
Vaso-occlusive crisis from dehydration and low oxygen: severe pain in bones, joints, and abdomen, swollen joints, hands, and feet, hematuria, obstructive jaundice, visual disturbance
🧪 What confirms it
CBC with decreased RBC count, hemoglobin, and hematocrit; hemoglobin values vary by age
RBC indices decreased, showing microcytic hypochromic cells — MCV is average cell size, MCH average cell weight, MCHC hemoglobin relative to cell size
Reticulocyte count may be decreased, reflecting marrow red cell production
Total iron binding capacity elevated; transferrin saturation of 10% indicates anemia
🩺 What you do
Epistaxis: stay calm, sit the child up with the head tilted slightly forward to prevent swallowing or aspirating blood
Pinch the lower nose between thumb and forefinger for at least 10 min while the child breathes through the mouth
If bleeding persists, place ice over the nasal bridge
Iron: supplement preterm and low-birth-weight infants, and full-term infants by 4-6 months; use iron-fortified formula and add high-iron and vitamin C foods when solids start
💊 Drugs
Oral iron supplements — expect tarry green stools when the dose is adequate, brush teeth after a dose to prevent staining, give through a straw, and pair with vitamin C sources
IV ferrous sulfate for severe anemia is a very painful infusion requiring close monitoring
DDAVP, a synthetic vasopressin, raises plasma factor VIII — effective for mild but not severe hemophilia A, ineffective in hemophilia B, and can be given before dental or surgical procedures
💬 What you teach
For recurrent nosebleeds sit up and lean slightly forward so blood does not run down the throat; bleeding usually stops within 10 min
Report any signs of bleeding promptly
Monthly transfusions are usually given after a stroke to prevent recurrence
⚠️ What goes wrong
Developmental delay — assess functioning, improve nutrition, refer to developmental services, support the family
Stroke from sickled cells occluding vessels — report abnormal behavior, weakness or inability to move a limb, slurred speech, visual changes, vomiting, severe headache
Acute chest syndrome, common in adolescents and potentially fatal: fever of 38.5 C (101.3 F) or above with chest, back, or abdominal pain, cough, dyspnea, tachypnea, wheezing, retractions, falling oxygen saturation, and raised pneumonia risk
Infection risk from a shrinking spleen, especially Streptococcus pneumoniae and H. influenzae, with risk of septicemia
Read left to right: who gets it → what you see → what confirms it → what you do → what goes wrong. Cover a column and rebuild it out loud.
Organ Neoplasms
🎯 Who gets it
Wilms tumor: 90% have no identified risk factor; 10% have a family history or a rare congenital syndrome
Neuroblastoma: male sex and family history, with no known environmental risk factors
👀 What you see
Wilms tumor: painless, firm, nontender abdominal swelling or mass, usually discovered by a caregiver during bathing or dressing
Never palpate the abdomen when an abdominal tumor is suspected, and handle or bathe the child with extreme care to avoid trauma to the tumor
Assess coping and support for child and family, screen for developmental delay, and track height and weight
Teach and support the family about diagnostic testing, treatment plan, ongoing therapy, and prognosis
Monitor for infection and give antibiotics as prescribed; keep skin clean and dry and provide oral hygiene
💬 What you teach
Do not wash off the skin markings outlining radiation fields
Wash marked skin with lukewarm water using hands rather than a washcloth, pat dry, and avoid hot or cold water
Avoid soaps, creams, lotions, and powders unless prescribed
⚠️ What goes wrong
Metastasis, kidney failure, and pancytopenia with anemia, neutropenia, and thrombocytopenia
Read left to right: who gets it → what you see → what confirms it → what you do → what goes wrong. Cover a column and rebuild it out loud.
Blood Neoplasms
🎯 Who gets it
Leukemia is the most common childhood cancer
Male sex assigned at birth
Non-Hispanic white or Hispanic children
Family history of leukemia
👀 What you see
Vague early complaints of anorexia, headache, and fatigue
Low-grade fever, pallor, listlessness
Increased bruising and petechiae
Enlarged liver, spleen, lymph nodes, and joints; enlarged kidneys and testicles
🧪 What confirms it
CBC showing anemia, thrombocytopenia, and neutropenia
Leukemic blasts (immature white cells) on CBC and blood smear
Bone marrow aspiration or biopsy is the definitive test, showing abundant immature leukemic blast cells and protein markers identifying the leukemia type
Cerebrospinal fluid analysis by lumbar puncture determines CNS involvement
🩺 What you do
Bone marrow aspiration: assist the provider, conscious sedation with a general anesthetic, and position by access site — posterior or anterior iliac crest most often, or the tibia under 18 months because the iliac crest is immature
After marrow aspiration apply pressure then a pressure dressing, watch the site for bleeding, use ice packs to limit bleeding, keep the child supine on bed rest for 30-60 min, and give mild analgesics as ordered
Lumbar puncture: have the child empty the bladder, apply topical anesthetic 30-60 min before, monitor if conscious sedation is used
Position side-lying with head flexed and knees drawn to the chest, use distraction, and assist with the sterile procedure
💊 Drugs
Chemotherapy agents are selected by leukemia type, age, and whether leukemic cells are in the cerebrospinal fluid; common agents include vincristine and doxorubicin
Agents must be given through a central line or port
Corticosteroids treat certain cancers and reduce treatment adverse effects
Intrathecal methotrexate is given prophylactically to prevent CNS involvement
💬 What you teach
Steroids cause moon face along with skin and mood changes
Notify the treatment team immediately for fever
Watch for infection, skin breakdown, and nutritional deficiency, and maintain good hygiene
⚠️ What goes wrong
Infection from myelosuppression — private room with adequate airflow to reduce airborne pathogens
Restrict visitors and staff with active illness and enforce strict hand hygiene
Assess potential infection sites such as oral ulcers and open cuts and monitor temperature
Give antibiotics once the source is identified through chest radiograph and blood, stool, urine, and nasopharyngeal cultures
Read left to right: who gets it → what you see → what confirms it → what you do → what goes wrong. Cover a column and rebuild it out loud.
Bone and Soft Tissue Cancers
🎯 Who gets it
Osteosarcoma peaks during adolescence, overlapping growth spurts, and is more common in males
Ewing sarcoma occurs before age 20 and is more common in Caucasian children
Rhabdomyosarcoma occurs at any age but most often under 6 years, and is more common in the Black population
👀 What you see
Osteosarcoma: pain that worsens with activity, swelling over the site, palpable lump
Ewing sarcoma: swelling and discomfort over the site, pain worse at night and with activity, difficulty walking on the affected leg, fever
Rhabdomyosarcoma findings depend on location and may include bulging eyes, ear pain, painful elimination, and vomiting
Tumor compression causes local pain, but retroperitoneal tumors may be painless until they obstruct an organ
🧪 What confirms it
CBC and routine tests help exclude infection, iron deficiency anemia, and other causes
Lactate dehydrogenase is a known prognostic factor in Ewing sarcoma
X-ray, CT, or MRI of the primary site
Tissue biopsy of the tumor under anesthesia to confirm presence and tissue type
🩺 What you do
Explain diagnosis and treatment in developmentally appropriate language without overwhelming the child
Allow the child several days to prepare emotionally for surgery and chemotherapy
Provide emotional support for child and family, and explain the possibility of sterilization to adolescents and caregivers when relevant
Surgical biopsy: routine preoperative and postoperative care, adequate pain relief, and wound monitoring for infection
💊 Drugs
Osteosarcoma chemotherapy uses single agents or combinations before and after surgery: cisplatin, doxorubicin, bleomycin, cyclophosphamide, ifosfamide, etoposide, and high-dose methotrexate with leucovorin rescue
Ewing sarcoma: cyclophosphamide, doxorubicin, and vincristine alternating with etoposide and ifosfamide
Give antiemetics before treatment to control nausea and vomiting
💬 What you teach
Adhere to the full course of therapy and understand postprocedure and postoperative care
Preoperative chemotherapy causes effects such as hair loss
A temporary prosthesis may be fitted immediately after amputation
⚠️ What goes wrong
Skin desquamation, either dry or moist, leaving permanent hyperpigmentation and sometimes injuring deeper structures — check the site for infection, shield it from further irritation, dress in loose clothing, keep it out of sun and temperature extremes, and keep follow-up appointments
Myelosuppression eliminates normal blood cells along with cancer cells, causing infection from low leukocytes, hemorrhage from low platelets, and anemia from low red cells
Myelosuppression care: evaluate labs, restrict infected visitors and staff, avoid live-virus vaccines, provide adequate protein and calories, avoid rectal temperatures, and prevent injury from bleeding and anemia
Teach families to recognize complications at home and prevent injury from infection or bleeding
Read left to right: who gets it → what you see → what confirms it → what you do → what goes wrong. Cover a column and rebuild it out loud.
🎥 Lecture recordings 2
Tap a card to open that recording in Google Drive. The same list lives in the lecture library.
ATI Active Learning Template — System DisorderHematologic Disorders
Filled from ATI chapter 21, row by row from that chapter’s own sections — 12 of 12 rows have content.
🧭 What it isAlterations in Health (Diagnosis) · Health Promotion & Disease Prevention
Alterations in Health (Diagnosis)
Covers epistaxis, iron deficiency anemia, sickle cell disease, hemophilia, and von Willebrand disease. Nosebleeds are common and brief in childhood and rarely an emergency, though frightening for families. Iron deficiency anemia is the most common anemia worldwide and the most preventable mineral disorder, since hemoglobin production requires iron. Sickle cell disease is a group of autosomal recessive disorders in which abnormal hemoglobin S replaces normal hemoglobin A; sickle cell anemia is the homozygous and most common form. Sickling raises blood viscosity, obstructs flow, and causes tissue hypoxia, ischemia, pain, and accelerated red cell destruction, usually not apparent until later in infancy. Children with sickle cell trait carry the gene without symptoms. Hemophilia is a group of X-linked recessive clotting factor deficiencies — hemophilia A (factor VIII, classic, 80% of cases) and hemophilia B (factor IX, Christmas disease). Von Willebrand disease is an inherited lack of von Willebrand factor so platelets cannot aggregate.
Health Promotion & Disease Prevention
From this module — built from the notes above on this page, not a section of the ATI chapter.
Iron deficiency: limit cow’s milk to about 16–24 oz daily after 12 months — excess milk displaces iron-rich food and irritates the gut.
Iron-rich weaning foods from 6 months; vitamin C alongside to aid absorption.
Sickle cell disease: hydration, avoid extremes of temperature, altitude and exhaustion; penicillin prophylaxis and full vaccination.
Hemophilia: avoid contact sport; no IM injections where a subcutaneous route exists; no aspirin or NSAIDs.
Newborn screening detects sickle cell disease before the first crisis — make sure the result was followed up.
👀 How it shows upAssessment — Risk Factors · Assessment — Expected Findings
Assessment — Risk Factors
Epistaxis: nose picking or rubbing tearing the fragile vascular mucosa, low humidity, allergic rhinitis, upper respiratory infection, blunt injury, nasal foreign body
Epistaxis from medications affecting clotting or underlying disease — von Willebrand disease, hemophilia, idiopathic thrombocytopenic purpura, leukemia
Iron deficiency: prematurity with low iron stores, excessive cow's milk in toddlers (milk lacks iron and displaces iron-rich solids), malabsorption, poor dietary iron
Iron deficiency from blood loss — GERD and pyloric stenosis in infants, GI polyps and colitis in older children, menorrhagia in adolescents
Adolescents also at risk from poor diet, rapid growth, strenuous activity, and obesity
Sickle cell anemia mainly affects African Americans; other forms of sickle cell disease affect people of Mediterranean, Indian, or Middle Eastern descent
Hemophilia severity depends on the percentage of clotting factor present — mild disease can have up to 40% of normal factor VIII
Assessment — Expected Findings
Epistaxis: active bleeding from the nose, restlessness, agitation
Iron deficiency anemia: tachycardia, pallor, brittle spoon-shaped nails, fatigue, irritability, muscle weakness, systolic murmur, pica for ice, dirt, or paper
Sickle cell: family history, reports of pain, shortness of breath, fatigue, pallor and pale mucous membranes, jaundice, cool hands and feet, dizziness, headache
Vaso-occlusive crisis from dehydration and low oxygen: severe pain in bones, joints, and abdomen, swollen joints, hands, and feet, hematuria, obstructive jaundice, visual disturbance
Chronic sickle cell effects: repeated respiratory infection, osteomyelitis, blindness from retinal detachment, systolic murmurs, enuresis and renal failure, hepatomegaly with cirrhosis, seizures, skeletal deformity, and avascular necrosis of the hip or shoulder
Sequestration crisis: blood pools in the spleen (splenomegaly) and sometimes liver, dropping circulating volume toward hypovolemia and shock — irritability, tachycardia, pallor, decreased urine output, tachypnea, cool extremities, thready pulse, hypotension
Aplastic crisis: severe anemia from temporarily suppressed red cell production, usually triggered by a viral infection
Hyperhemolytic crisis: accelerated red cell destruction with anemia, jaundice, reticulocytosis
🧪 How it is confirmedLaboratory Tests · Diagnostic Procedures
Laboratory Tests
CBC with decreased RBC count, hemoglobin, and hematocrit; hemoglobin values vary by age
RBC indices decreased, showing microcytic hypochromic cells — MCV is average cell size, MCH average cell weight, MCHC hemoglobin relative to cell size
Reticulocyte count may be decreased, reflecting marrow red cell production
Total iron binding capacity elevated; transferrin saturation of 10% indicates anemia
Stool guaiac for occult blood
Diagnostic Procedures
Hemoglobin electrophoresis distinguishes sickle cell disease from sickle cell trait
Sickle solubility test as a screen
Transcranial Doppler assesses intracranial blood flow and stroke risk, performed annually in children 2-16 years with sickle cell disease
DNA testing detects the classic hemophilia trait in females
🩺 What you doNursing Care · Medications · Therapeutic Procedures
Nursing Care
Epistaxis: stay calm, sit the child up with the head tilted slightly forward to prevent swallowing or aspirating blood
Pinch the lower nose between thumb and forefinger for at least 10 min while the child breathes through the mouth
If bleeding persists, place ice over the nasal bridge
Iron: supplement preterm and low-birth-weight infants, and full-term infants by 4-6 months; use iron-fortified formula and add high-iron and vitamin C foods when solids start
Sickle cell pain: interprofessional approach, acetaminophen or ibuprofen for mild to moderate pain and opioids for severe pain
Give analgesics on a schedule rather than PRN to stay ahead of pain, orally as immediate or sustained release, or IV for severe pain, with PCA when appropriate
Apply warm packs to painful joints
Bleeding disorders in the hospital: use subcutaneous rather than intramuscular injections when possible, avoid unnecessary skin punctures, use surgical aseptic technique, and prefer venipuncture over finger or heel sticks
Medications
Oral iron supplements — expect tarry green stools when the dose is adequate, brush teeth after a dose to prevent staining, give through a straw, and pair with vitamin C sources
IV ferrous sulfate for severe anemia is a very painful infusion requiring close monitoring
DDAVP, a synthetic vasopressin, raises plasma factor VIII — effective for mild but not severe hemophilia A, ineffective in hemophilia B, and can be given before dental or surgical procedures
Factor VIII concentrate, pooled plasma, and recombinant products by IV infusion to prevent and treat hemorrhage
Therapeutic Procedures
Packed RBC transfusion for severe anemia, with supplemental oxygen for severe hypoxia
Exchange transfusion replaces sickled cells with normal cells
Hematopoietic stem cell transplant is the only permanent cure for sickle cell disease but carries high neurologic risk
💬 Around the patientClient Education · Interprofessional Care
Client Education
For recurrent nosebleeds sit up and lean slightly forward so blood does not run down the throat; bleeding usually stops within 10 min
Report any signs of bleeding promptly
Monthly transfusions are usually given after a stroke to prevent recurrence
Acute chest syndrome may require transfusion and prescribed antibiotics
Interprofessional Care
Hematologist, pediatrician, orthopedist, nurse practitioner, nurse, school nurse, physical therapist, and social worker
⚠️ What goes wrongComplications
Complications
Developmental delay — assess functioning, improve nutrition, refer to developmental services, support the family
Stroke from sickled cells occluding vessels — report abnormal behavior, weakness or inability to move a limb, slurred speech, visual changes, vomiting, severe headache
Acute chest syndrome, common in adolescents and potentially fatal: fever of 38.5 C (101.3 F) or above with chest, back, or abdominal pain, cough, dyspnea, tachypnea, wheezing, retractions, falling oxygen saturation, and raised pneumonia risk
Infection risk from a shrinking spleen, especially Streptococcus pneumoniae and H. influenzae, with risk of septicemia
Other sickle cell complications: kidney scarring, reduced visual acuity, priapism in males
Uncontrolled bleeding causing intracranial hemorrhage or airway obstruction from bleeding into mouth, neck, or chest
Bleeding care: monitor vital signs for impending shock, control bleeding, give factor replacement for bleeding episodes or hemarthrosis, transfuse as prescribed, and perform neurologic assessment for intracranial bleed
📋 Organ Neoplasms6 parts
ATI Active Learning Template — System DisorderOrgan Neoplasms
Filled from ATI chapter 38, row by row from that chapter’s own sections — 12 of 12 rows have content.
🧭 What it isAlterations in Health (Diagnosis) · Health Promotion & Disease Prevention
Alterations in Health (Diagnosis)
Childhood cancer is rarer than adult cancer and demands both competence and compassion, with individualized support for child and family. Wilms tumor (nephroblastoma) is a malignancy of the kidney or abdomen, usually unilateral with 5-7% bilateral, and two-thirds of cases occur before age 5. Neuroblastoma arises in the adrenal gland, retroperitoneal sympathetic chain, head, neck, pelvis, or chest, and is almost always found in children under 5 years.
Health Promotion & Disease Prevention
From this module — built from the notes above on this page, not a section of the ATI chapter.
Abdominal masses in children are frequently found by a parent during bathing — teach that any is reported.
Do not palpate a known or suspected Wilms tumor — palpation can rupture the capsule and seed the tumor. Sign the crib.
Children with associated syndromes are enrolled in surveillance programs.
Protect renal function lifelong after nephrectomy: hydration, avoid nephrotoxic drugs, and contact-sport advice.
👀 How it shows upAssessment — Risk Factors · Assessment — Expected Findings
Assessment — Risk Factors
Wilms tumor: 90% have no identified risk factor; 10% have a family history or a rare congenital syndrome
Neuroblastoma: male sex and family history, with no known environmental risk factors
Assessment — Expected Findings
Wilms tumor: painless, firm, nontender abdominal swelling or mass, usually discovered by a caregiver during bathing or dressing
Inferior venacavogram to rule out vena cava involvement
Skeletal survey; skull, neck, chest, abdominal, and bone CT
Bone marrow aspiration to rule out metastasis
Metaiodobenzylguanidine scan to define bone, marrow, and soft tissue involvement
🩺 What you doNursing Care · Medications · Therapeutic Procedures
Nursing Care
Never palpate the abdomen when an abdominal tumor is suspected, and handle or bathe the child with extreme care to avoid trauma to the tumor
Assess coping and support for child and family, screen for developmental delay, and track height and weight
Teach and support the family about diagnostic testing, treatment plan, ongoing therapy, and prognosis
Monitor for infection and give antibiotics as prescribed; keep skin clean and dry and provide oral hygiene
Provide age-appropriate diversional activity, listen to the child's concerns, and avoid false reassurance
Wear lead aprons when radiation is in use
Bone marrow suppression: monitor and report vital signs, especially temperature above 37.8 C (100 F), and watch for lung congestion, redness, swelling, and pain at IV sites, mouth lesions, and wound changes
Give prescribed antimicrobials, antivirals, and antifungals, shield the child from infection sources, screen visitors and staff, avoid crowds during chemotherapy, and withhold fresh fruits and vegetables
Avoid invasive procedures such as injections, rectal temperatures, and catheters, and hold pressure on puncture sites for 5 min
Medications
From this module — built from the notes above on this page, not a section of the ATI chapter.
Chemotherapy regimens are protocol-driven; doses are calculated on body surface area and double-checked.
Antiemetics scheduled rather than as needed — anticipatory nausea is hard to reverse once established.
Growth factors to shorten neutropenia; prophylactic antimicrobials per protocol.
Watch specific toxicities: anthracycline cardiotoxicity, vincristine neuropathy and constipation, cisplatin ototoxicity and nephrotoxicity.
Chemotherapy is handled with cytotoxic precautions, including body fluids for the period specified.
Therapeutic Procedures
Wilms tumor treatment varies by stage and histology — surgical removal of the tumor and kidney soon after diagnosis
Preoperative chemotherapy or radiation when both kidneys are involved, to shrink tumors and possibly preserve one kidney
Postoperative radiation and/or chemotherapy for large tumors, metastasis, recurrence, or residual disease; agents include dactinomycin and vincristine
Neuroblastoma treatment varies by stage — surgical removal, with chemotherapy and/or radiation for metastasis and residual disease
A long-term central venous access device or PICC is often placed for chemotherapy
💬 Around the patientClient Education · Interprofessional Care
Client Education
Do not wash off the skin markings outlining radiation fields
Wash marked skin with lukewarm water using hands rather than a washcloth, pat dry, and avoid hot or cold water
Avoid soaps, creams, lotions, and powders unless prescribed
Wear loose cotton clothing and protect the area from sun with a hat and long sleeves
Seek care for blistering, weeping, or red tender skin
Interprofessional Care
Social services for access to medications and durable medical equipment
Dietitian to build a diet plan
⚠️ What goes wrongComplications
Complications
Metastasis, kidney failure, and pancytopenia with anemia, neutropenia, and thrombocytopenia
📋 Blood Neoplasms6 parts
ATI Active Learning Template — System DisorderBlood Neoplasms
Filled from ATI chapter 39, row by row from that chapter’s own sections — 12 of 12 rows have content.
🧭 What it isAlterations in Health (Diagnosis) · Health Promotion & Disease Prevention
Alterations in Health (Diagnosis)
Leukemia is a group of malignancies of the bone marrow and lymphatic system with peak childhood onset between 2 and 5 years, classified by the type of white cell that becomes neoplastic. Production of immature white cells (leukoblasts) surges and these cells infiltrate organs and tissues. Marrow infiltration crowds out normal production, so red cells fall causing anemia, mature white cells fall causing neutropenia and infection risk, and platelets fall causing bleeding risk.
Health Promotion & Disease Prevention
From this module — built from the notes above on this page, not a section of the ATI chapter.
There is no screening and little that is preventable — say so, because parents look for a cause they could have avoided.
Prevention is aimed at treatment complications: infection, bleeding and late effects.
No live vaccines during chemotherapy or for the period afterwards specified by oncology.
Vaccinate household contacts, including influenza, to protect the child.
Teach that fever in a neutropenic child is an emergency and goes straight to hospital.
👀 How it shows upAssessment — Risk Factors · Assessment — Expected Findings
Assessment — Risk Factors
Leukemia is the most common childhood cancer
Male sex assigned at birth
Non-Hispanic white or Hispanic children
Family history of leukemia
Trisomy 21 (Down syndrome)
Assessment — Expected Findings
Vague early complaints of anorexia, headache, and fatigue
Low-grade fever, pallor, listlessness
Increased bruising and petechiae
Enlarged liver, spleen, lymph nodes, and joints; enlarged kidneys and testicles
Abdominal, leg, and joint pain, plus headache
Vomiting and anorexia, unsteady gait
Signs of increased intracranial pressure
🧪 How it is confirmedLaboratory Tests · Diagnostic Procedures
Laboratory Tests
CBC showing anemia, thrombocytopenia, and neutropenia
Leukemic blasts (immature white cells) on CBC and blood smear
Diagnostic Procedures
Bone marrow aspiration or biopsy is the definitive test, showing abundant immature leukemic blast cells and protein markers identifying the leukemia type
Cerebrospinal fluid analysis by lumbar puncture determines CNS involvement
🩺 What you doNursing Care · Medications · Therapeutic Procedures
Nursing Care
Bone marrow aspiration: assist the provider, conscious sedation with a general anesthetic, and position by access site — posterior or anterior iliac crest most often, or the tibia under 18 months because the iliac crest is immature
After marrow aspiration apply pressure then a pressure dressing, watch the site for bleeding, use ice packs to limit bleeding, keep the child supine on bed rest for 30-60 min, and give mild analgesics as ordered
Lumbar puncture: have the child empty the bladder, apply topical anesthetic 30-60 min before, monitor if conscious sedation is used
Position side-lying with head flexed and knees drawn to the chest, use distraction, and assist with the sterile procedure
After lumbar puncture apply pressure and an elastic bandage, label and deliver specimens, keep the bed flat with the child lying flat at least 30 min, and monitor for hematoma, bleeding, and infection
Medications
Chemotherapy agents are selected by leukemia type, age, and whether leukemic cells are in the cerebrospinal fluid; common agents include vincristine and doxorubicin
Agents must be given through a central line or port
Corticosteroids treat certain cancers and reduce treatment adverse effects
Intrathecal methotrexate is given prophylactically to prevent CNS involvement
Therapy proceeds in phases, starting with induction/remission therapy
The goal is complete remission with fewer than 5% blast cells
Therapeutic Procedures
Hematopoietic stem cell transplant is indicated for AML during the first remission and for ALL after a second remission; allogeneic transplant uses stem cells donated by another person
💬 Around the patientClient Education · Interprofessional Care
Client Education
Steroids cause moon face along with skin and mood changes
Notify the treatment team immediately for fever
Watch for infection, skin breakdown, and nutritional deficiency, and maintain good hygiene
Avoid people with infectious diseases
Learn to give medications, provide nutrition at home, and use vascular access devices correctly
Follow bleeding precautions and know how to manage active bleeding
Perform meticulous oral care with a soft toothbrush and no astringent mouthwash to prevent gingival bleeding
Interprofessional Care
Provide information about support services for child and family
⚠️ What goes wrongComplications
Complications
Infection from myelosuppression — private room with adequate airflow to reduce airborne pathogens
Restrict visitors and staff with active illness and enforce strict hand hygiene
Assess potential infection sites such as oral ulcers and open cuts and monitor temperature
Give antibiotics once the source is identified through chest radiograph and blood, stool, urine, and nasopharyngeal cultures
Encourage adequate protein and calories, monitor absolute neutrophil count, and use aseptic technique for all procedures
ATI Active Learning Template — System DisorderBone and Soft Tissue Cancers
Filled from ATI chapter 40, row by row from that chapter’s own sections — 12 of 12 rows have content.
🧭 What it isAlterations in Health (Diagnosis) · Health Promotion & Disease Prevention
Alterations in Health (Diagnosis)
Bone malignancies can arise from any tissue that participates in bone growth — osteoid matrix, cartilage, and blood vessels. Osteosarcoma typically starts in the metaphysis of a long bone, most often the femur. Soft tissue malignancies begin in undifferentiated cells of muscle, tendon, connective or fibrous tissue, or blood and lymph vessels, and can appear anywhere. Pelvic or near-pelvic irradiation in childhood can cause sterility and later secondary cancers.
Health Promotion & Disease Prevention
From this module — built from the notes above on this page, not a section of the ATI chapter.
No screening exists; awareness of the presentation is what shortens the delay.
Persistent bone pain, especially at night, or a limp with no injury, needs imaging — it is too often attributed to growing pains or sport.
A mass that is enlarging, firm and painless deserves the same urgency as a painful one.
Survivors need lifelong follow-up for second cancers and treatment late effects.
👀 How it shows upAssessment — Risk Factors · Assessment — Expected Findings
Assessment — Risk Factors
Osteosarcoma peaks during adolescence, overlapping growth spurts, and is more common in males
Ewing sarcoma occurs before age 20 and is more common in Caucasian children
Rhabdomyosarcoma occurs at any age but most often under 6 years, and is more common in the Black population
Assessment — Expected Findings
Osteosarcoma: pain that worsens with activity, swelling over the site, palpable lump
Ewing sarcoma: swelling and discomfort over the site, pain worse at night and with activity, difficulty walking on the affected leg, fever
Rhabdomyosarcoma findings depend on location and may include bulging eyes, ear pain, painful elimination, and vomiting
Tumor compression causes local pain, but retroperitoneal tumors may be painless until they obstruct an organ
Orbital rhabdomyosarcoma: unilateral proptosis, eye pain, tearing
Nasopharyngeal: stuffy nose, pain, nasal obstruction, epistaxis, palpable neck nodes, and a visible mass late
🧪 How it is confirmedLaboratory Tests · Diagnostic Procedures
Laboratory Tests
CBC and routine tests help exclude infection, iron deficiency anemia, and other causes
Lactate dehydrogenase is a known prognostic factor in Ewing sarcoma
Diagnostic Procedures
X-ray, CT, or MRI of the primary site
Tissue biopsy of the tumor under anesthesia to confirm presence and tissue type
Chest CT, bone scans, and bone marrow biopsy to evaluate metastasis
🩺 What you doNursing Care · Medications · Therapeutic Procedures
Nursing Care
Explain diagnosis and treatment in developmentally appropriate language without overwhelming the child
Allow the child several days to prepare emotionally for surgery and chemotherapy
Provide emotional support for child and family, and explain the possibility of sterilization to adolescents and caregivers when relevant
Surgical biopsy: routine preoperative and postoperative care, adequate pain relief, and wound monitoring for infection
Limb salvage: give preoperative chemotherapy, manage adverse effects, provide routine postoperative care, and offer emotional support
Assess for phantom limb pain after amputation and medicate appropriately
Watch labs for complications — elevated WBC and fever signal infection, blood in urine or stool with bruising and petechiae signal hemorrhage, and fatigue with falling hemoglobin and hematocrit signals anemia
Infection prevention: private room, restrict staff and visitors with infections, promote frequent hand hygiene, and give no live-virus vaccines during immunosuppression
Radiation therapy: help with positioning and monitor for adverse effects
Medications
Osteosarcoma chemotherapy uses single agents or combinations before and after surgery: cisplatin, doxorubicin, bleomycin, cyclophosphamide, ifosfamide, etoposide, and high-dose methotrexate with leucovorin rescue
Ewing sarcoma: cyclophosphamide, doxorubicin, and vincristine alternating with etoposide and ifosfamide
Give antiemetics before treatment to control nausea and vomiting
Therapeutic Procedures
Localized radiation therapy combined with chemotherapy and surgery
Limb salvage: chemotherapy to shrink the tumor, then removal of tumor and affected bone with total bone and joint replacement
Limb amputation for bone cancer, with chemotherapy before and after surgery
💬 Around the patientClient Education · Interprofessional Care
Client Education
Adhere to the full course of therapy and understand postprocedure and postoperative care
Preoperative chemotherapy causes effects such as hair loss
A temporary prosthesis may be fitted immediately after amputation
Cooperate with postoperative physical therapy
Anger and other emotions after amputation and chemotherapy are normal grief reactions
Watch for infection, skin breakdown, and nutritional deficiency, keep good hygiene, use vascular access devices correctly, and follow bleeding precautions
Interprofessional Care
Physical and occupational therapy referrals starting in the hospital and continuing after discharge
Mental health counseling and referrals to help the child return to school and physical activity
Support groups for older children and adolescents with cancer or amputation
⚠️ What goes wrongComplications
Complications
Skin desquamation, either dry or moist, leaving permanent hyperpigmentation and sometimes injuring deeper structures — check the site for infection, shield it from further irritation, dress in loose clothing, keep it out of sun and temperature extremes, and keep follow-up appointments
Myelosuppression eliminates normal blood cells along with cancer cells, causing infection from low leukocytes, hemorrhage from low platelets, and anemia from low red cells
Myelosuppression care: evaluate labs, restrict infected visitors and staff, avoid live-virus vaccines, provide adequate protein and calories, avoid rectal temperatures, and prevent injury from bleeding and anemia
Teach families to recognize complications at home and prevent injury from infection or bleeding
📝 Notes & key concepts
The lines from this module that carry a number, a dose or an absolute rule — the ones that decide questions. Everything else is on the cards above.
Transfusion: consent and baseline vitals first, NS is the only compatible fluid, highest reaction risk is the first 15 minutes, vitals q15 min for the first hour. Fever, chills, back pain, rash, dyspnea or tachycardia → stop immediately.
Iron deficiency: low H/H and RBCs. Give iron on an empty stomach with vitamin C, never with dairy. Warn about dark stools and tooth staining.
Sickle cell: autosomal recessive; symptoms emerge around 6 months as fetal hemoglobin fades. Hemoglobin electrophoresis is definitive. Never restrict fluids, use warm compresses, avoid NSAIDs, O2 when sat drops below 95%, hydroxyurea raises fetal hemoglobin. Stroke is the most serious complication.
ALL is the most common childhood leukemia, peaking at 2–6 years. Bone marrow biopsy is definitive. Keep flat after LP.
Wilms tumor: painless abdominal mass with hematuria and hypertension. Do not palpate the abdomen — and post a sign so nobody else does either.
🎯 Module quiz
Questions for this module. They also feed the Mega Quiz.
