Blood Disturbances
PN111
Hematologic System
Involves:
• Blood
• Blood Cells
• Lymph
• Organs involved with blood formation
• Organs involved with blood storage
Review of Blood
Blood is:• sticky, opaque, has a salty metallic taste• can be scarlet in colour (oxy.rich) or dull red
(oxy.poor)• 5 times thicker than water• healthy adults- 5-6 liters 7-10% of body wt• called FLUID TISSUE• solid and liquid components• formed elements suspended in plasma
Plasma
Plasma Proteins:• albumin• fibrinogen• globulins
• osmotic balance• helps maintain H2O• clotting of blood• defences (antibodies)• lipid transport
Bone Marrow
• Site of hematopoiesis
• makes up 4-5% of total body wt, one of the largest organs of the body
• active or red marrow, and , fat or yellow marrow
• with age red is replaced with yellow but can reverse
• assisted in crisis by the spleen and liver
Stem Cells
• Primitive cells that can differentiate into myeloid or lymphoid stem cells
• lymphoid develop into T or B lymphocytes
• myeloid differentiate into erythorcytes, leukocytes or platelets
• See text for chart on stem cell differentiation
Stem Cell differentiation
• Erythropoietin - a hormone produced primarily by the kidney stimulates differentiation
• when kidney detects low 02 as in anemia, it releases erythropoietin which stimulates bone marrow = increased RBC in about 5 days
Bone marrow function
• Erythrocyte production requires iron, vit B12, folic acid, pyridoxine (Vit B6)
• Iron-stored in small intestine as ferritin. When required it binds to transferring and is transported to marrow (6 to 8 hours)
• Iron is lost in feces, bile, blood or intestinal mucousal cells
Red blood cell destruction
• Life span 120 days
• removed from circulation by spleen or liver
• hemoglobin in recycled and some becomes bilirubin and secreted in the bile
• most of iron is recycled, small amts lost in feces
BM aspiration and bx
• Assess the quality and quantity of each type of cell produced in the marrow
• aspirate usually from iliac crest looks like slushy fluid
• biopsy from iliac crest usually looks like a skinny worm
Blood Abnormalities
• Result from problems in the production, function or normal destruction of any type of blood cell.
• We will start with RBC disorders
RBC disorders
• Too few RBC = anemia
• Too many RBC = polycythemia
Anemia
• Lower than normal RBC count and Hgb level
• Anemia is a clinical sign not a diagnosis
• results in diminished amount of O2 to body tissues
• many different kinds of anemia but all fall in one of three categories
3 Categories of Anemia
• Decrease in production of RBC’s (hypoproliferative)
• Excessive destruction of RBC’s (hemolytic)
• Loss of RBC’s(bleeding)
Etiology includes:• genetic, • nutrition deficit, iron deficit• chronic disease
Complications of Anemia
• Congestive heart failure
• parathesias
• confusion
• death
Clinical Manifestations
• Impacted by severity, speed of development, duration, pts metabolic requirements, co-existing disorders or disabilities.
Clinical Manifestations• Dyspnea, chest pain, muscle pain or
cramping
• weakness, fatigue, general malaise
• pallor of the skin, MM including sclera
• jaundice, black stool, coffee emesis
• smooth, red tongue
• beefy red tongue, sore tongue
• angular cheilosis
• brittle ridged concave nails and pica
Gerontologic Considerations
• Most common hematologic condition in elderly due to body’s decreased ability for bone marrow to respond to body’s need
• treat the underlying cause rather than writing it off as an ageing problem
• elderly with concurrent cardiac or pulmonary problem may not be able to tolerate anemia
Diagnostic Evaluation
• Complete hematologic studies
• iron studies
• serum vitamin B12 and folate levels, erythropoietin levels
• bone marrow aspiration and biopsy
• other studies to determine underlying illness/cause
Medical Management
• Correct and control the cause of the anemia
• replace lost or destroyed RBC’s
Nursing assessment
• Health hx, physical exam, review lab values
• hx of symptoms, lifestyle, medications, alcohol use, athletic endeavours
• ? Any loss of bld,
• family hx
• dietary habits
• ?cardiac, neuro, GI functions
Nursing Interventions
• Manage Fatigue
• Monitor and Manage complications
• maintain adequate nutrition
• maintain adequate perfusion
• monitor and manage potential complications
Megaloblastic Anemia
• caused by lack of vit.B12, folic acid
• lack of B12 caused by a problem with the stomach mucous, absence of intrinsic factor, strict vegetarian diet, disease of the ileum or pancreas, gastrectomy
• Lack of folic acid occurs when intake is deficient or requirement increased
• risk groups include those who do not each uncooked veggies or fruit, alcoholics, pregnancy, malabsorptive or small bowel disease
Signs and Symptoms
• Smooth sore tongue
• mild diarrhea
• weakness
• paleness
• confusion
• paresthisis in extremities
• death after several years
Diagnosis:
• shillings test, CBC, serum folate and B12
Treatment for B12 defic:
• B12 orally
• B12 IM if intrinsic factor missing
• counts usually normal in 2 months
• B12 taken for life
Treatment for folic acid defic.
• Diet = 1mg of folic acid daily
• IM folic acid for malabsorptive disease
• orally
• stopped when hgb returns to normal except for alcoholics who continue while alcohol is used
Nursing Care:
• Skin care especially with incontinence, paralysis
• mouth care• accurate urine tests• educate re: monthly injections (compliance)• educate re: ongoing medical assessment
especially for increased risk of stomach CA
Nursing Interventions
• Manage Fatigue
• Monitor and Manage complications
• maintain adequate nutrition
• maintain adequate perfusion
• monitor and manage potential complications
Hemmorragic Anemia
• Sudden loss of blood resulting in decreased RBC
• hemorrhage
signs and symptoms:
• you tell me
treatment:
• replace blood loss
Aplastic Anemia• Decrease in RBC as a result of a decrease
in precursor cells (marrow stem cells) in bone marrow - replaced with fat
• can be congenital, acquired or idiopathic• can be caused by certain infections,
radiation, chemicals (benzene), anti-tumor agents (nitrogen mustard), toxic material (arsenic), meds (anti-convulsants, anti-inflamatory's, gold compounds)
Signs and Symptoms
• Gradual weakness, pallor, SOBOE, sometimes fever, adenopathy
• purpura, retinal hemorrhages
• repeated throat infections with possible lymphadenopathy and splenomegally
Dx:
• CBC, bone marrow and biopsy
Treatment
• bone marrow (stem cell) transplant
• immunosuppressants
• support therapy - transfusion
• frequent CBC
Nursing Care• Assess re:hypoxia, bleeding, infection
• oral hygiene, no break in skin or mucous membrane
• preserve energy of pt.
• if low platelets, avoid trauma of IM or SC
• stool softeners to prevent straining
• if using potentially toxic medications, monitor blood work
Hemolytic Anemia
• Shortened life span of RBC or destruction of RBC
• bone marrow tries to compensate by producing RBC’s 3 times the normal rate
• can be caused by infection or toxic chemicals, mismatched blood trans, disorder of the immune system, Hodgkins, liver disease
Dx, and Tx• Reticulocyte count (elevated)
• bilirubin increased
• haptoglobin decreased (binding protein for free Hgb)
treatment:
• in severe cases - hospitalization
• blood transfusion
• removal of spleen
• detection and tx of cause
Nursing Care
• Bed rest to conserve energy
• avoid IM’s
• frequent mouth care
• 02 support
• increased protein diet
• stool softener
• skin care
Sickle Cell Anemia
• Severe hemolytic anemia because of a defective Hgb molecule
• genetic defect of a single amino acid necessary for hemoglobin
• RBC becomes deformed in venous circ.when exposed to low O2
• RBC takes on sickle shape and becomes lodged in small vessels-slows circulation to area and causes ischemia and pain
Sickle Cell Anemia
• Sickle cell has a short life span 15-25 days
• at risk: 1 in 375 African American, Mediterraneans, Carribeans, South and Central American heritage, Arab and East Indian ancestry
Signs and Symptoms• In crisis - severe pain, fever, swelling in
arms, legs and abdomen
• anemia
• jaundice in sclera
• progressive renal damage
• In childhood - larger bones in face and skull due to bone marrow expansion
• enlarged heart, tachy, damage to any organ
• increased blood viscosity
Diagnosis
• Hgb and hematocrit levels, blood smear,
• electrophoresis because the sickling will occur even if the pt has sickle cell trait or sickle cell anemia and this test will tell the difference
Treatment
• Diagnose early in children, genetic counselling
• 1st crisis may be at age 1 - 2
• average life span 40 years
• blood transfusion, bone marrow transplant
• new drugs to prolong RBC life span (side effects)
Nursing Care
• Pt.teaching re: avoiding infections
• avoiding high altitudes
• increased folic acid (where can we get this?)
• In a crisis, ++ fluids, analgesia, monitor blood transfusions.
• Maximize pts. Knowledge base
Potential complications
• Leg ulcers
• priaprism leading to impotence
• chronic pain and substance abuse
Iron Deficiency Anemia
• A form of anemia where the RBC contain less Hgb.
• Usually due to an inadequate supply of iron or due to loss of blood
• RBC may be described as microcytic or hypochromic, what does this mean?
Signs and Symptoms
• Low energy
• pallor of skin or mucous membranes
• fatigue, poor appetite
• smooth, sore tongue, brittle nails, angular cheilosis, pica
• Hgb lower than hematocrit and RBC count
• low serum iron, ferritin low
Evaluation
• Bone marrow aspiration
• lab work: ferritin, blood count, serum iron levels, total iron binding capacity (high)
Treatment
• Search for cause, treat cause
• test stools for occult bld
• iron preparations
Pharmacology
Vitamin B12:
• body can store 4 to 5 mg of B12 so it may take 2 to 5 years for a deficiency to be detected after intrinsic factor is no longer released.
• Minimum daily requirement is 1 to 2 micrograms
B12
• Usual therapeutic dose is 30 - 50 ug/day times 5 days then 100 to 200 ug monthly.
• Cyanocobalamin
• can be p.o or parenteral. Not given po.for pernicious anemia Why?
• IM or deep sc.
• Avoid alcohol, may need intrinsic factor or folic acid, What is the underlying cause?
Folic Acid• For anemias related to folic acid defic.
• Not stored in great quantities in the body
• require 1mg/day
• drug interference from oral contraceptives, aspirin, phenytoin
• dietary sources: liver, broccoli, dried beans, lentils, peas, spinach, beets
• Routes: po, IM, SC, IV
• may turn urine dark yellow/green
Iron (Fe)
• For anemia related to iron deficiency
• taken up by cells in duodenum/upper jejunum
• ferritin binds with the iron and once saturated the remaining iron is discarded in stool
• iron is transferred as needed to plasma proteins by binding with transferrin.
Iron
• The iron then goes to the bone marrow where it is incorporated into Hgb.
• Side effects: GI upset
• Overdose: 4 stages, may lead to coma or death.
• Drug interactions:
• Antidote: DESFERAL
Fe
• Take iron supplements an hour before meals. If GI upset, take with meals and after symptoms subside resume before meals.
• Stool colour changes to green or black
• brush teeth and floss, take liquid with a straw
• avoid antacids or dairy
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