1. Electrolyte balance assists in regulating water balance, neuromuscular activity, and acid-base balance. The body can actively move electrolytes in and out of cells to maintain electrolyte balance in the right concentrations, which is important for fluid balance between compartments. Imbalanced electrolytes can cause issues like dehydration from exercise or illness. 2. Hyperkalemia, a high level of potassium, can cause lethal cardiac arrhythmias. It is defined as a serum potassium concentration higher than 5.5 mEq/L. Severe electrolyte imbalances can cause problems like coma and can be fatal if untreated. 3. Nursing interventions for a child at risk of infection

1. Electrolyte Balance assist in regulation of water balance and is also essential for
neuromuscular activity and regulation of acid base balance. To enable to achieve
electrolyte balance we have to adjust fluid levels, the body can actively
move electrolytes in or out of cells. Thus, having electrolyte balance in the right
concentrations is important in maintaining fluid balance among the compartments.
Having imbalanced electrolytes causes an electrolyte imbalance, such as: fluid loss from
heavy exercise or physical activity. May cause vomiting and diarrhea, heart failure, kidney
disease, diabetes, and eating disorders. We have to balance it to live a healthy llifestyle.
1. What are the general appearance of a child with alterations in fluid and electrolyte:
a. Skin (2pts) = pale, cyanotic nail beds, dry and poor turgor
b. Cardiovascular (2pts) =pulse rate is weak, thread and poor indication of blood
pressure
c. Respiratory (2 pts) = change in rate, fluid overload and dehydration of hypovolemia
The upper limit may be considerably high in young or premature infants, as high as 6.5
mEq/L. Because hyperkalemia can cause lethal cardiac arrhythmia, it is one of the most
serious electrolyte disturbances. Hyperkalemia is defined as a serum potassium
concentration higher thancan cause respiratory paralysis or cardiac arrest
and can quickly be fatal. Severe electrolyte imbalances can cause serious problems such
as coma,This condition can be fatal if left undiagnosed and untreated.
Nursing Interventions for Hyperkalemia
 Monitor cardiac, respiratory, neuromuscular, renal, and GI status
 Stop IV potassium if running and hold any PO potassium supplements
 Initiate potassium restricted diet and remember foods that are high in potassium
 Remember the word POTASSIUM for food rich in potassium
2. What are the first sign commonly seen in a child with acute lymphocytic leukemia
(ALL)?

2. The most common signs and symptoms of acute lymphoblastic
leukemia in children are:
 Swollen lymph nodes in your neck, armpits, stomach, or groin. Lymph nodes are pea-sized
glands in theseand other areas of your body.
 Shortness of breath
 Pain or fullness in your stomach, which may be becausethe diseasehas made your spleen
bigger
 Fatigue
 Night sweats
 Fever and infections
 Loss of appetite and weight
 Bleeding from the gum
 Bone pain
 Frequent or severe nosebleeds
 Pale skin
 Prevent transfer of microorganism. Perform hand washing prior
giving care, utilize mask and gown when needed, provide a private room, monitor for
any signs and symptoms of infection.
 Prevent oral trauma. Instruct the use of a soft-sponge toothbrush or sponge toothette
or gauze when rinsing the mouth; instruct to avoid foods which are hot, spicy, or high
in ascorbic acid (vitamin C); provide oral hygiene 30 minutes prior or after meals;
instruct to refrain from eating or drinking for 30 minutes after completion of oral
hygiene; and offer moist, soft, bland foods.
 Prevent anxiety. Have the parents to stay with the child or encourage open visitation,
provide a telephone number to call for information; explain all procedures and care
in simple, direct, honest terms and repeat as often as necessary; reinforce physician
information if needed and provide specific information as needed; and provide
consistent nurse assignment with the same personnel; encourage parents to participate
in care.

3.  Prevent injury. Avoid any palpation of abdominal mass; post sign on bed stating
not to palpate preoperatively; assess incision site for redness, swelling, drainage,
intactness, and healing and change dressing when soiled or wet; assess oral
and perineal area; and encourage parents to appropriately dress child based on weather
conditions and to refrain from participating on rough activities or sports.
Interventions Rationales
1. Assess for bleeding from any site and
febrile episodes; Monitor WBC, platelet count,
hematocrit, absolute neutrophil count.
Provides data about frank bleeding or
abnormal blood profiles that contribute
to bleeding induced by bone
marrow suppression and
immunosuppression due to chemotherapy.
2. Perform handwashing prior
giving care, utilize mask and gown when needed,
provide a private room, monitor for any signs and
symptoms of infection.
Prevents transfer of microorganism to a
weakened immune system during
chemotherapy if the absolute neutrophil
count is less than 1,000/cu mm.
3. Provides safety measures such as pad sides of bed,
use soft toothbrush, apply pressure for 5 minutes
after IV administration, avoidance of taking rectal
temperatures or performing unnecessary invasive
procedures.
Avoids bleeding caused by trauma during
the administration of chemotherapy which
changes platelet and clotting factor.
4. Instruct parents and child to avoid exposure to
persons having an upper respiratory infection or
any illness.
Prevents risk for infection in the highly
susceptible child.
5. Advise parents and child to avoid contact sports,
blowing nose hard, and straining at defecation.
Prevents trauma that causes bleeding.
6. Advise parents to report any fever,
behavior changes, headache,
dizziness, fatigue, pallor, slow oozing of blood
from any area, exposure to communicable
diseases.
Signifies an associated abnormal blood
profile complication.

4. 7. Teach and allow for return demonstration
of urine and stool testing for blood using dipstick
and hematest.
Identifies presence of bleeding in the
gastrointestinal or urinary tract.
8. Administer blood transfusion as ordered for severe
blood loss, monitor patency, vital signs, chills,
fever, urticaria, rash,
dyspnea, diaphoresis, headache
during transfusion, and terminate if any of these
changes occur.
Replaces blood loss when symptoms
of anemia appear (dizziness, pallor, fatigue,
increased pulse, and respiration) or when
Hct is less than 20% or platelet count
less than 20,000/cu mm.
7. Make one NCP for a child having a problem with risk for infection related to
decreased
immune function? (10pts)
Cues Nsg.
Diagno
sis
Obje
ctive
s
Intervention Evaluati
on
Subj
ectiv
e
Subje
ctive:“
medy
omahi
na na
kokes
a
dati,p
arang
angda
li
kodap
uan
Risk
for
infecti
on
related
to
compr
omised
immun
e
system
second
ary to
Hepa B
Short
termAft
er 2
hours
of nursi
ng
interve
ntion,p
atient
w ill:
-
Demon
stratedi
fferent
w ays
topreve
ntinfecti
on.Lon
g
termAft
er 3
days
Assess for the presence, existence of, and history of the
common causes of infection (listed above).
These factors represent a break in the body’s normal first line of defense a
Assess for the presence of local infectious processes in the skin
or mucous membranes.
Signs and symptoms include localized swelling, localized redness, pain or te
affected area, palpable heat.
Monitor white blood cell (WBC) count
An increasing WBC count indicates the body’s efforts to combat pathogens
Low: below 4,500
Normal: 4,500 – 11,000
High: more than 11,000
Very low WBC count may indicate a severe risk for infection. In older patien
without an increased WBC count. Additionally, WBC differential may show
infections.
Assess and monitor nutritional status, weight, history of weight
loss, and serum albumin.
Patients with poor nutritional status may be anergic or unable to muster a
pathogens making them susceptible to infection.
.After 2
hours
of nursing
intervention,
short term
goal is
fullymet as
evidenced
by:
Demonstrati
onof
differentway
s
topreventinf
ection
suchas:
monitoredvis
itors
assuggested
by

5. ngsaki
tngay
on.”O
bjectiv
e:-
hepati
tispati
ent-
PR =
57bp
mRisk
of nursi
ng
interve
ntion,p
atient
w ill:
w ill
notacq
uireinfe
ction
For pregnant clients, assess the intactness of amniotic
membranes.
Prolonged rupture of amniotic membranes before delivery puts the mothe
infection.
Investigate the use of medications or treatment modalities that
may cause immunosuppression.
Antineoplastic agents, corticosteroids, and so on, can reduce immunity.
Assess immunization status and history.
People with incomplete immunizations may not have sufficient acquired ac
during history taking when were they last immunized.
Monitor for signs and symptoms of infection. Signs and symptoms of infection vary according to the body area involved.
*Redness, swelling, increased pain, purulent discharge from
incisions, injury, and exit sites of tubes (IV tubings), drains, or
catheters.
These are the classic signs of infection. Any suspicious drainage should be c
determined by pathogens identified.
*Elevated temperature.
A temperature of up to 38º C (100.4º F) 48 hours post-op is usually related
temperature of greater than 37.7º (99.8º F) may indicate infection; very hi
sweating and chills may indicate septicemia.
*Color of respiratory secretions. Yellow or yellow-green sputum is indicative of respiratory infection.
*Appearance of urine. Cloudy, turbid, foul-smelling urine with visible sediment is indicative of urin
healthprovid
er.
Frequentpos
itionchanges
Coveringof
mouthby
thefamilyw h
enever they
cough.
After 3 days
of nursing
intervention,l
ong term
goals
arefully met
as
evidencedby
:
Absence
of infection.
.After 2 hours of nursing intervention,short termgoalis fullymet as evidenced by:
Demonstrationof differentways topreventinfection suchas:
monitoredvisitors assuggestedby healthprovider.
Frequentpositionchanges
Coveringof mouthby thefamilyw heneverthey cough.
After 3 days of nursing intervention,long termgoals arefully met as evidencedby:
Absence of infection.