JBorrero 10/09

NUR 240

Hematological Stressors

Charting Chuckles1. She has no rigors or shaking chills, but her husband states

she was very hot in bed last night2. Patient has chest pain if she lies on her left side for over a

year.3. On the second day the knee was better, and on the third day

it disappeared.4 . The patient is tearful and crying constantly. She also appears

to be depressed5. The patient has been depressed since she began seeing me

in 19936. Discharge status: Alive but without my permissio7. Healthy appearing decrepit 69-year-old male, mentally alert

but forgetful.8. The patient refused autopsy.9. The patient has no previous history of suicides.10. While in ER, she was examined, x-rated and sent home

Topics

• Anemias resulting in decreased production of RBC’s

Pernicious anemia

Iron deficiency anemia

Folic acid deficiency anemia

Aplastic anemia

• Polycythemia Vera

• Leukemia-CML/CLL

• Blood transfusion procedures and reactions

Anatomy and Physiology Review

• Bone marrow• Blood components Red blood cells (erythrocytes) White blood cells (leukocytes) Thrombocytes (platelets)• Accessory organs of hematopoiesis

Spleen Liver Kidneys

Bone Marrow Hematopoiesis

Erythrocytes

• RBCs are largest proportion of blood cells

• Flexible membrane, no nucleus

• Normal count 4-6 million

• Lifespan 120 days

• Produce Hgb

• Kidneys produce RBC growth factor:erythropoietin

Erythrocyte Depletion

• Iron deficiency anemia

• B12/folic acid deficiency

• Pernicious anemia• Aplastic anemias

• Sickle cell anemia• G6PD• Acute blood loss• Chronic blood loss

Anemia

• Result of a condition in which the function or number of RBCs is inadequate to meet tissue oxygen demands.

• Insufficient function of RBCs: B12, Iron, Folic Acid deficiencies• Reduction in either the number of red blood

cells, the amount of hemoglobin, or the hematocrit

• Clinical sign (not a specific disease); a manifestation of several abnormal conditions

• Tissue hypoxia is the underlying cause of all symptoms accompanying anemia

WBCs or Leukocytes

Involved with inflammation and immunity

Look for “differential” on WBC count

Granulocytes-increase rapidly in presence of infection

1. Monocytes- Macrophages- 1st line of defense

2. Neutrophils- 2nd line of defense

3. Basinophils- help mediate allergic reactions

4. Eosinophils- antiparasitic, limits local inflammation

Lymphocytes

• B-lymphocytes- antibody mediated immunity

• T-lymphocytes- cell mediated immunity

Platelets

• Smallest of blood cells

• Stick to injured blood vessel walls to form platelet plugs

• Perform most of their function by aggregation

• 80% platelets circulate, 20% stored in spleen

Assessment

• Family history and genetic risk

• Personal history

• Diet history

• Socioeconomic status

• HPI

• Physical Exam

• Dx Testing

Physical Assessment

• Skin• Head and neck• Respiratory• Cardiovascular• Renal and urinary• Musculoskeletal• Abdominal• Central nervous system• Psychosocial

Diagnostic Assessment

Tests of cell number and function: – Complete blood count– Reticulocyte count– Differential– Coombs’ test– Serum ferritin, transferrin, and total iron-

binding capacity

Coagulation StudiesBone Marrow aspiration/biopsyCAT Scans

CBC with DifferentialWBC 4.5-11.0

RBC 3.80-5.20

HGB 11.7-15.7

HCT 35.0-47.0%

MCV,MCH, MCHC

Platelets 140K-440K

Neutrophils, Eosinophils, Basophils, Lymphocytes (T&B), Monocytes

Differential

Reticulocytes Count 0.5-2.5% total RBC

Tests Measuring Bleeding and Coagulation

• Bleeding time test

• Prothrombin time (PT)

• International normalized ratio (INR)

• Partial thromboplastin time (PTT)

• Platelet agglutination/aggregation

Bone marrow aspiration and Bx

• Done when other tests show persistent abnormal results

• Results will show bone marrow function

• Aspiration

• Biopsy

Preparation

• Physician’s order• Consent & Vital Signs• Performed at bedside/lab• Procedure takes 5-15 minutes• Provide support/accurate info• Local anesthetic/rapid acting sedative• May feel pressure/pushing/pain• May feel stinging/burning sensation• Site: ileac crest is most common• Sterile precautions

Follow-up Care

• Give client education.

• Cover with pressure dressing; observe for 24 hours.

• Administer mild analgesic (ASA free)

• Apply ice pack.

• Avoid contact sports or any activity that might result in trauma to the area.

NCLEX TIME

• After a bone marrow aspiration, the nurse questions which post procedure order?

• A.Administer aspirin for pain

• B.Apply ice packs to the puncture site.

• C.Administer acetaminophen for discomfort.

• D.Maintain sandbag on puncture site until bleeding stops

NCLEX TIME

In reviewing laboratory data in a client, the nurse recognizes which hematologic change associated with aging?

• A.Decreased red blood cells

• B.Decreased platelets

• C.Increased hemoglobin

• D.Increased white blood cells

Goals of tx for anemias

• Enhance tissue perfusion

• Minimize O2 demand

• Maintain CO

• Prevent hypovolemia

• Minimize complications of therapy

Iron Deficiency Anemia

• This common type of anemia can result from blood loss, poor intestinal absorption, or inadequate diet.

• Evaluate adult clients for abnormal bleeding.

• Supplemental iron is the treatment.

• Microcytic- RBC cell size is smaller than normal

Vitamin B12 Deficiency AnemiaPernicious Anemia

• Anemia is caused by inhibiting folic acid transport and reducing DNA synthesis in precursor cells.

• B12 transports Folic Acid into RBC precursor cell

• Pernicious anemia is anemia caused by failure to absorb vitamin B12 by lack of intrinsic factor

Etiology:Vitamin B12 deficiency is a result of poor intake

of foods containing vitamin B12. ORIntrinsic Factor deficiency

Vitamin B12 Deficiency Anemia

S&S- paresthesias, loss of coordination, smooth, beefy, sore, bright red tongue

weight loss and fatigue, pallorDX test: Schilling Test-24hr urineTx: Pernicious Anemia: Vitamin B12

(Cyanocobalamin) injections Poor dietary intake: Increase intake of

liver/organ meats, dried beans. Citrus fruits, eggs , green leafy vegetables

Folic Acid Deficiency Anemia

• Can cause megaloblastic anemia

• Manifestations similar to those of vitamin B12 deficiency, but nervous system functions remain normal

Folic Acid Deficiency Anemia

• Caused by:– Poor nutrition and chronic alcohol abuse – Malabsorption syndromes, such as

Crohn’s disease– Drugs, including anticonvulsants and oral

contraceptives, that slow or prevent absorption of folic acid

– Tx- Folic Acid

Nursing Interventions for B12 and Folic Acid Deficiency Anemias

• Assess VS, labs, pulse ox

• Provide care for oral mucous membranes

• Administer B12 IM, Folic Acid

• Teach about disease process and self-injection

• Pace activities

• Eliminate alcohol intake

• Diet modification

Aplastic Anemia

• Deficiency of circulating erythrocytes

• Injury to the hematopoietic precursor cell

• Usually leukopenic and thrombopenic as well: PANCYTOPENIC

ETIOLOGY: chronic toxic exposure, viral, 50% idiopathic

CLINICAL MANIFESTATIONS:

Medical Management

• Immunosuppressive tx

• Splenectomy

• Bone marrow transplant

Anemias from Blood Loss

• ACUTE• Severed blood

vessels due to trauma• Rupture of aneurysm

• Tx

• CHRONIC• Peptic ulcers• Excessive menses• Bleeding hemorrhoids

• Tx

Polycythemia Vera• Malignant disease with a sustained

increase in blood hemoglobin

• Massive production of red blood cells

• Excessive leukocyte production

• Excessive production of platelets

• Blood viscosity and blood volume increased

• Severe congestion of all tissues and organs

Etiology

• Usually unknown (idiopathic)

• Sometimes caused by other conditions such as COPD, high altitudes, heart failure

• Bone marrow produces more RBCs to prevent hypoxia

Clinical Manifestations

• Hypertension

• Epistaxis, Ecchymosis, Hemorrhage

• Complications of MI, CVA

• Headaches

• Red, dark, flushed hands & skin

• Splenomegaly and Hepatomegaly

• Intense itching

• Distended superficial veins

Treatment

• Phlebotomy- keep Hct<45• Myelosuppressive agents- suppress bone

marrow• Radiation tx• Hydration• Promote venous return• Encourage oral fluids• Encourage ambulation• Anticoagulation therapy

Leukemia • Type of cancer with uncontrolled

production of immature white blood cells in the bone marrow

• Invade and destroy bone marrow• Metastasize to liver, spleen, lymph

nodes, testes and brain• Acute or chronic• Classified by cell type- lymphocytic vs.myelocytic • Patients are vulnerable to infection and

anemia

Etiology

Exact cause is unknown

Risk factors:

ionizing radiation

exposure to certain chemicals and drugs

genetic factors

immunologic factors

treatment for other types of cancer

Classification of Leukemia

• Acute- can die in days to 6mos without appropriate tx

Acute Lymphocytic Leukemia

Acute Myelogenous Leukemia

• Chronic- gradual onset, can live 5 years or more without tx

Chronic Lymphocytic Leukemia

Chronic Myelogenous Leukemia

Clinical Manifestations

• Neuro• CV• Resp• MS• GI• GU• Integumentary

• Signs of bleeding• Signs of anemia• Lymphadenopathy• CBC abnormal• Signs of infection

Definitive Test

Examination of cells obtained from bone marrow aspiration and biopsy

Nursing Diagnoses

Risk for Injury Alteration in

oral mucus membranes

Alteration in nutrition, less

Grieving Nausea Bleeding

Fatigue Risk for infection Acute or chronic Pain

Risk for Infections

• Infection is a major cause of death in the client with leukemia, and sepsis is a common complication.

• Cross-contamination

GOAL: prevent, treat and control infection

Infection Prevention

• “Minimal bacteria diet” without uncooked foods

• Monitoring of daily laboratory results

• Assessment of vital signs

• Skin care, respiratory care

• Prevent and manage stomatitis

• Teach pt to care for CVAD

Protective Isolation• Frequent handwashing

• Private room

• HEPA filtration or laminar airflow system

• Mask for visitor with upper respiratory infection

• Institute precautions for pt with low platelet count

Treatment for Leukemia:Chemotherapy

Intensive/combo at time of dx.Goal: RemissionSIDE EFFECTS: Bone marrow suppression N/V/D Alopecia Stomatitis Kidney/liver/cardiac toxicity

Leukemia Treatment

• Radiation tx• Antibiotics, anti-virals, anti-fungal agents• Interferon/ Interlukin• Neupogen• Epogen, Procrit,• Diet tx• PRBC- leukocyte depleted transfusion• Patient education• Emotional support

Side Effects of RT/CT

• Drug induced pancytopenia

• Severe N&V

• Skin problems at site of RT

• Impaired hepatic function

• Permanent sterility for males with RT to pelvic area

• Secondary Ca development

Bone Marrow Transplantation

• Standard treatment for leukemia

• Before procedure, CT and total body irradiation

• Purges present marrow of the leukemic cells

• After conditioning, new, healthy marrow given to the client toward a cure

Types of BMT

• Allogeneic

• Syngeneic

• Autologous

Complications of BMT

1.Failure to engraft2.Graft vs host disease (GVHD)3.Bleeding / Infection4.Fatigue5.Venocclusive disease

Blood TransfusionsTypes of Blood Products

• Red blood cell• Platelet transfusions• Plasma transfusions: fresh frozen plasma• Cryoprecipitate• Granulocyte (white cell) transfusions

*Review typing/crossmatching

*Review ABO Compatibilities

Blood Products:Transfusion Therapy

Pretransfusion responsibilities to prevent adverse transfusion reactions:– Verify prescription.– Test donor’s and recipient’s blood for

compatibility.– Examine blood bag for identification.– Check expiration date.– Inspect blood for discoloration, gas

bubbles, or cloudiness.

Nursing Interventions• Explain procedure• Get signed consent• Start transfusion within 30 minutes of

arrival from blood bank• IV access: What size angiocath?• Y tubing, filter and which fluid?• Check blood with another RN• Obtain Vital Signs• Teach patient to report any untoward

symptoms• Premedicate if necessary

Transfusion Responsibilities • Provide client education.

• Assess vital signs.

• Begin transfusion slowly and stay with client first 15 to 30 minutes.

• Ask client to report unusual sensations such as chills, shortness of breath, hives, or itching.

• If reaction occurs: STOP TRANSFUSION

• Change tubing, call MD, call blood bank. Get urine/blood samples. Send blood bag to lab

Transfusion Reactions

• Clients can develop any of the following transfusion reactions:– Hemolytic – Allergic– Febrile – Bacterial– Circulatory overload

Autologous Blood Transfusion

• Collection and infusion of client’s own blood

• Eliminates compatibility problems; reduces risk for transmission of bloodborne disease

• Preoperative autologous blood donation

• Intraoperative autologous transfusion

• Postoperative blood salvage