NAME- Mausam S/o Mhd.

Ibrar
AGE/SEX- 4year/Male
MRD No.- 20195876
DATE OF ADMISSION- 25/09/2019
WARD- 18
ADDRESS- Hatiyonda Thana
DIAGNOSIS- HDL (Hodgkin Lymphoma)

HISTORY TAKING

History of Present Illness: -

The patient was follow-up case ofHDL. Patient was referred case of AIIMS. Patient came to SJH on 19/01/2017. Patient has swelling on both side of the neck
for past 1 year. Patient has repeated history of on and off high-grade fever for 6 months. Patient was suffering from cough and fast breathing from past 1 month.
Patient also complained about yellowish discolouration of eyes from 10 days and pain in both the legs for past 4 days. There was no history of bleeding, rash,
abdominal distension, bladder and bowel distension, swelling.Patient was discharge and took admission on 19/1/2019 with complaint of recurrent fever and fast
breathing from 15 days and discharged on 25/1/2019 and was asked to come back on 1/2/2019 for biopsy.

Patient was admitted to SJH on 2/2/2019 for follow up of HDL. Swelling of the neck progressively increased. Patient has the history of Tachypnoea and febrile
fever for 3 days. No history of Respiratory Distress, Rash, Bleeding from any site.On USG of neck it was ruled out that there was multiple enlarged lymph
nodes.

Past History: -

 Medical history: -
i. Patient has no history of T.B; HTN; Dengue or any other chronic illness.
ii. There is no history of blood transfusion.
 Surgical history: -

No history of previous operation/anaesthesia.

Past History

Antenatal History: G–1, P-1, L–, A-0

Natal History:

Date of Birth –15thFebruary 2015

Mode of Delivery – FTNVD.

Neo-Natal History:

The patient was born on 15thFebruary 2015. She was full term NVD. Patient cried immediately after birth. Vaccine BCG, Hep-B and OPV (zero doses) given to
the patient at the time of birth. The patient is immunized according to her age.

Family history: -

Type of Family: Nuclear

Number of Family Member:3

As informed by patient mother patient family has no surgical history but the patient mother has a medical history of hypothyroidism and bronchial
asthma.The family has no history of any congenital anomaly as per knowledge.

Mr. Rahed Mrs. Afreen

 (PATIENT)

KEYWORDS: -

Female Male Patient

Dietic History: -

The patienteats both vegetarian and non-vegetarian food.

Socioeconomic history

Environment history – The child lives in the rural community with his family. They have their house in Bihar

Ventilation is adequate. Water supply provided by the government. The drainage system is closed. Electricity supply provided by the government.

Head to toe examination

General appearance: General appearanceis fair.

Head: Normal shape and symmetry.

Neck: Range of motion is normal and enlarged lymph nodes are seen in both side of the neck.

Eyes: Normal symmetry of location.

Good distribution of eyelashes.

Ears: Adequate shape and symmetry.

There is no presence of any discharge.

The hearing is adequate.

Nose: Normal shape and location.

 There is no bleeding or discharge present.

Mouth and throat: Light pink colored lips.

Chest: Normal location of ribcage and sternum and normal symmetrical bilateral movements.

Lungs: Biphasic Stridor sound are heard.

Heart: Good symmetry. S1 and S2 sounds are normal

Spine: Movements are normal.

Extremities: Movements of both upper and lower limbs are normal.

ANTHROPOMETRIC MEASUREMENT

 Weight 15 kg
 Height 98 cm
 MUAC 13 cm
 Head circumference 50 cm

VITALS SIGN

DATE PULSE RESPIRATION TEMPRATUREoF

RATE/min RATE/min
11/2/201 140 18 100.4
9
12/2/201 110 20 101.2
9
13/2/201 108 18 102.2
9
14/2/201 110 24 99.8
9
15/2/201 110 20 98.8
9
Medical Management of patient

S NO. NAME OF DRUG DOSE ROUTE- FREQUENCY

1. Pantop 15 mg IV- BD
2. Rantac 15 mg IV-BD
3. Injection Claf 830 mg IV-TDS
4. Injection Paracetamol 65 mg IV-BD
5. N/2 D5% (135 ml) 1:100 KCl 6 hourly IV
6. Nebulization Asthalin 2 hourlr
7. Tablet PDN 10 mg TDS

HEMATOLOGY

TEST RESULTS
Hemoglobin 9.3 g/dl
MCV 81 µm3
MCH 25.4pg
MCHC 31.3 g/dl
RDWcv 20 %
RDWsd 58 µm3
RBC count 3.68 * 106 / mm3
HCT 29.8%
MPV 7.6 µm3
PCT 0.529%
WBC 4.5* 103/ mm3
PLT 429 103/ mm3
SERUM ELECTROLYTES
Sodium 135meq/L
Potassium 4.5 meq/L
Calcium 6.8
Phosphorus 5.0
S.LDH 1115 U/L

KFT

 Urea 15
 Creatinine 0.1

LFT

 Total bilirubin 0.4

 SGOT 34
 SGPT 16
 ALP 383

Coagulation Profile

 P.T 14.0 seconds

 A.P.P.T 40.5 seconds
 INR 1.27 seconds

BIOPSY REPORT

Multiple enlargedlymph nodes with maintained fatty hilum are seen in bilateral level 5th ,2nd , and 3rd locationlongest is 1.2 cm in SAD . Bilateral Intra Jugular
Vein appear mildly compressed because of main effect. However shows normal colour flow.
 HODGKIN LYMPHOMA

Hodgkin’s disease (HD) is a malignant disorder of lymphoreticular system. a lymphoreticular neoplasm primarily of B cell lineage involving lymph nodes and
the lymphatic system has unique molecular, histologic, immune phenotypic and clinical features. Hodgkin’s disease occurs in 5 to 7 per 1,00,000 population.
The incidence is highest in late childhood and early adulthood (15-35 years). It is very uncommon under 5 years of age and almost never seen under 2 years of
age. In asian population, HD is common even at younger ages.

The WHO classification of Hodgkin lymphoma recognizes two major subtypes:

(i) Nodular lymphocytic-predominant Hodgkin lymphoma (NLPHL),
(ii) Classical Hodgkin lymphoma.

(i) Nodular lymphocytic-predominant Hodgkin lymphoma (NLPHL),

NLPHL is most common in males younger than 10 years. Patients with NLPHL generally present with localized, non-bulky disease. Almost all patients are
asymptomatic.

(ii) Classical Hodgkin lymphoma.

The hallmark of classic Hodgkin lymphoma is the Reed-Sternberg cell. This is a binucleated or multinucleated giant cell that is often characterized by a
bilobed nucleus, with two large nucleoli, giving an owl’s eye appearance to the cells.

Who's most at risk?

While the cause of the initial mutation that triggers Hodgkin lymphoma is unknown, a number of factors can increase your risk of developing the condition.
These include:
  having a medical condition that weakens immune system, such as HIV
 having medical treatment that weakens immune system – for example, taking medication to suppress immune system after an organ transplant
 being previously exposed to the Epstein-Barr virus (EBV) – a common virus that causes glandular fever
 having previously had non-Hodgkin lymphoma, possibly because of treatment with chemotherapy or radiotherapy
 being very overweight (obese) – this may be more of a risk factor in women than men

Hodgkin lymphoma isn't infectious and isn't thought to run in families. Although risk is increased if a first-degree relative (parent, sibling or child) has had
lymphoma, it's not clear if this is because of an inherited genetic fault or lifestyle factors.

Hodgkin lymphoma can occur at any age, although most cases are diagnosed in people in their early 20s or 70s. The condition is slightly more common in men
than women.

CLINICAL MANIFESTATIONS

 Lymphadenopathy, usually in the cervical, supraclavicular, and mediastinal areas; mediastinal presentation common in adolescents and young adults;
significant mediastinal adenopathy may cause cough, dyspnea, or superior vena cava syndrome
 Painless, movable lymph nodes in tissues surrounding involved area
 Unexplained fever
 Weight loss
 Drenching night sweats
 Malaise
 Painless cervical or supraclavicular lymphadenopathy

STAGES OF HODGKIN LYMPHOMA

STAGES DESCRIPTION
I Involvement of single lymph node region (I) or of single
extra-lymphatic or site (IE) by direct extension
II Involvement of two or more lymph node regions on the
same side of diaphragm or localized involvement of an
extra-lymphatic organ or site and of one or more lymph
node regions on the same side of the diaphragm
III1 Involvement of lymph node regions on both sides of the
diaphragm Abdominal disease is limited to the upper
abdomen (i.e. spleen, splenic hilar nodes, celiac nodes,
 porta hepatitis nodes)
III2 Involvement of lymph node regions on both side of the
diaphragm Abdominal disease includes paraaortic,
mesenteric, and iliac involvement with or without
disease in the upper abdomen.
IV Disseminated involvement of one or more
Extra lymphatic organs or tissues with or without
associated lymph node disease.

DIAGNOSIS

1. Complete blood count—diagnostic (anemia may indicate advanced disease)

2. Erythrocyte sedimentation rate (ESR)—may be elevated at diagnosis
3. Serum copper, iron, calcium, and alkaline phosphatase levels—also may be elevated at diagnosis
4. Liver and renal function tests—to assess organ involvement
5. Urinalysis—to determine renal involvement
6. Chest radiographic study—to determine mediastinal or hilar node involvement
7. Computed tomography—to evaluate mediastinal, pulmonary, and abdominal disease
8. Gallium and/or positron emission tomography (PET) scan to determine the extent of involvement
9. Excisional lymph node biopsy—essential to diagnosis and staging
10. Bone marrow biopsy if patient has stage 3 or 4 disease according to imaging studies

TREATMENT

Treatment of HD in paediatric population is different in certain respects from adults. Devising the ideal therapeutic approach for children with HD is
complicated by their increased risk for late adverse effects. Treatment modalities have varied from total nodal radiation therapy to chemotherapy to
combination of chemotherapy and radiotherapy with significant improvement in survival rate throughout the last three decades. All children generally receive
combination chemotherapy as initial treatment.

In particular, radiation therapy can cause profound musculoskeletal growth retardation and increase the risk for cardiovascular disease and secondary solid
malignancies in children.

Further complicating the treatment of children are gender-specific differences in chemotherapy- induced gonadal injury. The desire to cure young children with
minimal side effects has stimulated attempts to reduce the intensity of chemotherapy (particularly alkylating agents) and radiation dose or volume.

In general, the use of combined chemotherapy with radiation broadens the spectrum of potential toxicities, while reducing the severity of individual drug
related or radiation-related toxicities. Current approaches use chemotherapy alone with or without low-dose involved-field radiation therapy (LD-IFRT). The
volume of radiation and the intensity/duration of chemotherapy are determined by prognostic factors at presentation, including presence of constitutional
symptoms, disease stage, and bulk.

NURSING MANAGEMENT

NURSING ASSESSMENT
1. Assess child’s physiologic status.
a. Signs and symptoms of Hodgkin’s disease
b. Involvement of other body systems (e.g., respiratory, gastrointestinal)
c. Adverse effects of treatment
2. Assess family’s psychosocial needs.
a. Knowledge and education level
b. Body image
c. Family structure
d. Family stressors
e. Coping mechanisms
f. Support systems
3. Assess child’s developmental level.
4. Assess family’s ability to manage home care.

NURSING DIAGNOSES
1. Impaired Tissue integrity,
2. Anxiety
3. Fluid volumeDeficient
4. Imbalanced Nutrition: less than body requirements,
5. Impaired Oral mucous membrane,
6. Pain
7. Fatigue
8. Delayed Growth and development,
9. Therapeutic regimen management, Ineffective
10. Disturbed Body image,
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS
Incision was Impaired tissue integrity To monitor site of Monitor site of impaired Systematic inspection can Integrity of the skin
made for the related to the surgical impaired tissue tissue integrity at least once identify impending problems was maintained
biopsy. incisionas evidenced by integrity. daily for colour changes, early.
incision done for biopsy. redness, swelling, warmth,
pain, or other signs of Skin wounds may be covered
To provide tissue care infection. with wet or dry dressings,
as needed. Tissue care provided as topical creams or lubricants,
needed. hydrocolloid dressings (e.g.,
DuoDerm) or vapor-
permeable membrane
dressings such as Tegaderm.
To maintain sterility The dressing replaces the
during the wound Keep sterile dressing protective function of the
care. technique during the wound injured tissue during the
To administer care. healing process.
antibiotics as ordered. Antibiotics administered as Sterility will decrease the
ordered. risk of infection.
Do not position Wound infections may be
patient on site of Patient of the patient was managed well and more
impaired tissue kept properly. efficiently with topical
integrity. agents, although intravenous
antibiotics may be indicated.
This is to avoid adverse
effects of external
mechanical forces (pressure,
friction, and shear).
Risk of infection related to To promote hand Promote good hand Protect patient from source Risk of infection
ASSESSMENT NURSING DIAGNOSIS
biopsy as evidenced by
increased WBC level.
Mother Imbalanced nutrition less
verbalized that than body requirement
patient is losing related to the disease
weight. condition as evidenced by
Objective data poor weight gain.
Weight 15 kg
Subjective data Hyperthermia related to
Mother infection as evidence by
verbalized patient temperature 102° Forally,
is suffering from loss of appetite, weakness,
fever. and dehydration.
Objective data
Vitals monitored
PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS
hygiene movements. washing procedure by staff of infection. decreased by
and family member. Limit potential sources of promoting hygiene
To promote personal Emphasize personal infection.
hygiene of the patient. hygiene.
It is used to treat infection or
To administer Administer antibiotic as given prophylactically.
antibiotics. prescribed. Temperature elevation may
To monitor Vitals. Monitor temperature. occur.
To maintain body Ascertain healthy body Experts like a dietician can Body weight will be
weight. weight for age and height. determine nitrogen balance maintained.
Refer to a dietitian for as a measure of the
complete nutrition nutritional status of the
assessment and methods for patient. A negative nitrogen
nutritional support. balance may mean protein
malnutrition. The dietician
can also determine the
To provide a pleasant patient’s daily requirements
environment. of specific nutrients to
Provide a pleasant promote sufficient nutritional
To provide small environment. intake.
meals A pleasing atmosphere helps
Consider six small nutrient- in decreasing stress and is
dense meals instead of three more favourable to eating.
larger meals daily to lessen Eating small, frequent meals
the feeling of fullness. lessens the feeling of fullness
and decreases the stimulus to
vomit.
To check the Assessed the general Cooling too quickly may Body temperature is
temperature of the condition of patient. cause shivering, which 1020 F. Respiration
patient. Monitor the vital signs of increases the use of energy 20 breath/min.
the patient. calories and increases the Pulse 100 beats/
metabolic rate to produce min.
To give tepid Provide tepid sponging by heat. Tepid sponge bath
sponging. using tap water with cotton is given to patient.
cloths to baby for 15 Antipyretic medications Patient will
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS
Temp 102oF minutes at least. lower body temperature by maintain normal
Administration blocking the synthesis of body temperature as
antipyretic Give Injection PCM (65 prostaglandins that act in the evidenced by vital
medication. mg) as prescribed by the hypothalamus. signs within normal
physician. limits.
Body temperature is
99oF.
Subjective data Sleep pattern disturbance. Discourage long Diversional therapies given Sleeping during odd hours Patient sleep pattern
Mother related to decreased physical periods of sleep to avoid sleeping during can lead to lack of sleep at will be maintained
verbalized there activity, fear, anxiety, during the day day time. night time.
is decrease in inability to assume
sleep timing usual sleep position, frequent Discourage intake of Educated mother regarding
assessments or treatments, foods and fluids high the dietary habits which
Objective data unfamiliar environment, and in caffeine (e.g. should be improved. L-tryptophan is a component
Patient appeared discomfort resulting from Chocolate, coffee, tea, of milk which promotes
dull. current illness/injury. colas) in the evening. Encourage patient to take sleep
milk
Allow client to
continue usual sleep A proper routine can lead to
practices (e.g. proper sleep pateern
Position; time; Advised mother to follow
presleep routines such daily routine.
as reading, watching
television, listening to
music, and
meditating) whenever
possible

Satisfy basic needs

such as comfort and
warmth before sleep.
Reduce A warm; pleasant; well
environmental ventilated environment
distractions. Ensure given to the patient while
good room ventilation sleeping.
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS
Level of Knowledge deficit related to To educate parents or Assess the level of Facilitates planning of Parents or caregiver
understanding. the disease condition as caregiver related to understanding of the preoperative teaching knowledge will
evidenced by frequent the disease condition patient’s parents or program, identifies content increase
questioning caregivers. needs.
Review specific pathology Provides knowledge base
and anticipated surgical from which patient can make
procedure. Verify that informed therapy choices and
appropriate consent has consent for procedure, and
been signed. presents opportunity to
clarify misconceptions.
Use resources teaching Specifically, designed
materials as available. materials can facilitate the
patients learning.
Discuss individual
postoperative pain Increases likelihood of
management plan. Identify successful pain management.
misconceptions patient Some patients may expect to
parents or care givers may be pain-free
have and provide or fear becoming addicted to
appropriate information. narcotic agents.
Mother asking Anxiety related to surgical To decrease the Provide preoperative Can provide reassurance and Anxiety level of
frequent question. procedure and future anxiety of the education including visit alleviate patient’s care giver parents will
wellbeing of the patient caregivers by with or personnel before anxiety, as well as provide decrease.
resolving their doubts surgery when possible. information for formulating
Discuss anticipated things intraoperative care.
that may concern patient Acknowledges that foreign
mask, lights, BP cuff, environment may be
electrodes, etc. frightening, alleviates
associated fears.
Validate source of fear. Identification of specific fear
Provide accurate factual helps patient deal
information. realistically with it. Patient
may have misinterpreted
preoperative information or
have misinformation
 ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTIONS
regarding surgery. Fears
regarding previous
experiences of self or family
may be resolved.

NURSING INTERVENTIONS
Staging Procedure
1. Provide preprocedural education to child and family
2. Prepare child for clinical staging procedures with age-appropriate approach .
3. Assist and support child in collection of laboratory specimens.
4. Provide instruction, support, and family crisis intervention.

RADIATION AND CHEMOTHERAPY PHASE

1. Provide sedation for radiation treatments if needed.
2. Monitor cardiorespiratory status during treatments.
3. Prepare for treatment-induced emergencies.
a. Metabolic disturbances, though Hodgkin’s disease is generally low risk for tumour lysis syndrome
b. Hematologic disturbances, such as febrile neutropenia, severe anemia
c. Space-occupying tumours, specifically superior vena cava syndrome
4. Assess for signs of extravasation of chemotherapeutic agents.
a. Edema, erythema, pain at infusion site
b. Tissue sloughing
5. Monitor for signs and symptoms of infection.
6. Assess skin integrity.
7. Minimize side effects of radiotherapy and c hemotherapy.
a. Bone marrow suppression
b. Nausea and vomiting
c. Anorexia and weight loss
d. Oral mucositis
e. Pain
8. Provide ongoing emotional support to child and family.
9. Refer to child life specialist to assist with continued coping strategies.
10. Provide ongoing education about treatment and follow-up care, medications—both chemotherapy and supportive care medications.
11. Refer family to social services for support and resource utilization.
12. If school age, refer to hospital or homebound teacher or obtain lessons for teaching.

DISCHARGE PLANNING AND HOME CARE

1. Signs of infection and guidelines on when to seek medicalattention

2. Care of child’s central venous access device, including sitecare, dressing change, flushing, and emergency care
3. Medication administration (provide written information);review side effects and indications for medications
4. Adherence to treatment regimen and medical appointments,as well as future late effects follow-up
5. Proper nutrition for optimal weight gain and healthmaintenance
6. School attendance and/or activity restrictions
7. Potential behavioural changes in child and/or siblings
8. Stress importance of oral hygiene; discuss dental care andappointments while on therapy
9. Assess transportation needs
10. Provide and review staff phone numbers; that is, who tocontact with questions, and who to contact foremergencies

CLIENT OUTCOMES
1. Child and family will demonstrate ability to cope withlife-threatening illness.
2. Infectious complications will be minimized.
3. Child and family will understand home care, currenttreatment plan, and long-term follow-up needs.

PROGNOSTIC FACTORS IN HODGKIN LYMPHOMA

Several factors influence the success and choice of therapy. Pre-treatment factors associated with an adverse
outcome include advanced stage of disease, presence of B symptoms, bulky disease, extranodal extension, male sex, and elevated erythrocyte sedimentation
rate. These factors are interrelated in the sense that disease stage, bulk, and biologic aggressiveness are frequently co-dependent. There is some controversy as
to whether histology is an important prognostic factor. The rapidity of response to initial cycles of chemotherapy based on PET is also prognostically important
and is being usedto determine subsequent therapy.

BIBLIOGRAPHY
1. https://www.nhs.uk/conditions/hodgkin-lymphoma/treatment/
2. Indian Academy of Pediatric Sixth Edition Published by Jaypee Brothers Medical Publishers (P) LTD
3. OP Ghai, Vinod K Paul, Arvind Bagga, CBS Publishers, Seventh Edition ,Ghai essential of Pediatric Nursing
4. Betz, Sowden , Mosby Pediatric Nursing Reference . Mosby Elsevier , 6th Edition