Assessment of Hematologic Function and Treatment Modalities
Hematologic System
● Has the blood and the blood forming sites including the bone marrow and the
reticuloendothelial system (RES)
● Blood, plasma which is a fluid portion of blood
● Blood cells contain erythrocytes, leukocytes, or thrombocytes and hematopoiesis
● Hematology is the scientific study of the structure and functions of blood in health
and in disease
● Blood is the circulatory fluid of the cardiovascular system which circulating
constantly through a close circuit of tubes
● The bone marrow cells consist of the stem cells, myeloid, erythrocytes or red
blood cells, leukocytes or white blood cells, platelets, lymphoid, lymphocytes and
stroma
Hematopoiesis
● The production of all types of blood cells including formation, development, and
differentiation of blood cells
● Prenatally, hematopoiesis occurs in the yolk sac then in the liver and lastly in the
bone marrow
● In the normal situation, hematopoiesis in adults occurs in the bone marrow and
lymphatic tissues. All types of blood cells are derived from primitive cells that are
pluripotent or they have potential to develop of all types of blood cells
Red Blood Cells (Erythrocytes)
● Carry oxygen throughout the body
● The most numerous blood cell, about 5 million per microliter
● Make up about 40% of our total blood volume, a measure called the hematocrit
White Blood Cells (Leukocytes)
● Has 2 subtypes
○ Granulocytes
■ Eosinophils
■ Basophils
■ Neutrophils
● Bands: left shift
○ Agranulocytes
■ Monocytes
■ Lymphocytes
● T cells and B cells
Platelets (Thrombocytes)
● Are membrane bound cell fragments that are essential for clot formation during
wound healing
● The principle function of platelets is to prevent bleeding
● Thrombopoietin
● Fibrin
Plasma and Plasma Proteins
● Albumin
● Globulins
○ Alpha
○ Beta
○ Gamma
● Impact on fluid balance
Reticuloendothelial System (RES)
● Histiocytes
○ Kupffer cells
○ Peritoneal macrophages
○ Alveolar macrophages
● Spleen
Hemostasis
● The mechanism that leads to cessation of bleeding from a blood vessel
● It is a process that involves multiple interlinked steps
● This cascade culminates into the formation of a plug that closes up the damaged
cite of the blood vessel controlling the bleeding
● It begins with the trauma to the lining of the blood vessel
Assessment of Hematologic Health
● Health history
● Physical assessment
● Diagnostic evaluation
○ Hematologic Studies
○ Bone Marrow Aspiration and Biopsy
Therapeutic Approaches
● Splenectomy
● Apheresis
● Hematopoietic Stem Cell Transplantation (HSCT)
● Phlebotomy
● Blood Component Therapy
● Special Preparations
Blood and Blood Products #1
● Donor Requirements
● Donation Types
○ Directed
○ Standard
○ Autologous
○ Intraoperative Blood Salvage
○ Hemodilution
Blood and Blood Products #2
● Complications of Donation
● Blood Processing
● There are also complications of donation thus we follow blood processing
Transfusion
● Are commonly done in healthcare facilities
● They require pretransfusion assessment and patient education
● Process: PRBC (Packed Red Blood Cells)
● Complications
○ Febrile non-hemolytic reaction
○ Acute hemolytic reaction
○ Allergic reaction
○ Circulatory overload
○ Bacterial contamination
○ Transfusion-related acute lung injury
○ Delayed hemolytic reaction
○ Disease acquisition
○ Long-term transfusion therapy
Nursing Management for Reactions
● If transfusion reaction occurs:
○ Stop
○ Assess
○ Notify primary and implement prescribed treatments. Continue to monitor
○ Return blood
○ Obtain any samples needed
○ Document
Transfusion Alternatives
● These do not require blood transfusion of blood products
● Growth factors
● Erythropoietin
● Granulocyte colony-stimulating factor
● Granulocyte-macrophage colony-stimulating factor
● Thrombopoietin
Hematologic and Immune Function (older adults)
Several factors affect older adults’ hematologic and immune systems. In relation to
hematologic function, anemia is a common disorder among older adults, especially
among those in nursing homes. Although a slight decrease in hemoglobin occurs with
aging, more often the anemia is attributable to an iron deficiency or another illness.
About 40% of adults age 60 or older have iron-deficiency anemia. Assessment should
focus on observation of the color and quality of the skin and nail beds, and address food
choices and food habits. Of a more serious nature, iron deficiency can occur because of
blood loss, and the nurse should ask questions about occurrence of blood in stools.
Diagnostic tests include hemoglobin, hematocrit, complete blood count (CBC), and red
blood cell (RBC) count. The immune system functions to protect the body from bacteria,
viruses, and other microorganisms. Age-related changes to the immune system include
diminished lymphocyte function and antibody immune responses. These changes put
older adults at risk for infections. Vaccines for influenza and pneumonia are given in the
fall and are available in physicians’ offices, public health agencies, and other sites. As
part of the assessment, the nurse should ask about recent and current infections and
access to and use of vaccines to prevent infections. In terms of the symptoms of
infection, it is important to remember that in evaluating vital signs, older adults tend to
have a diminished febrile response to infection. Some nurses are uncomfortable talking
with older adults about sexual activity, prophylaxis, and sexually transmitted disease
(STD), but these questions are an essential part of the health assessment process.
Sexually active older adults, particularly those with more than one partner, are at risk for
STDs. Of particular concern is the lack of STD education (“safe sex”) programs focused
on older adults, specifically HIV education. Human immunodeficiency virus (HIV) is a
human retrovirus that causes acquired immune deficiency syndrome (AIDS). The
disease is spread through parenteral and body fluids. It can be sexually transmitted
through anal, oral, and vaginal intercourse. AIDS is epidemic in the United States, and
the Centers for Disease Control and Prevention reports that 11% of those infected are
50 years of age or older. Older adults may not be tested for HIV because they do not
believe that they are at high risk or they may be unwilling to discuss their risky sexual
behaviors. In terms of assessment, it is important to address the topic of sexual activity
and ask the same questions that would be asked of a younger person. Open-ended
questions are preferable, and it will be more productive to say, “Tell me about your sex
life” rather than simply asking, “Do you have sex?” (Anderson, 2003). Depending on the
status of sexual activity, other questions related to sexual preference and number of
partners should be pursued. Signs and symptoms associated with HIV such as weight
loss, dehydration, ataxic gait, or fatigue may go unnoticed or be attributed to age-related
changes. However, once risk factors are identified, diagnostic testing will confirm a
diagnosis.
Blood and blood product transfusion
Introduction
The transfusion of blood and blood products can be a lifesaving procedure, but it
carries risks. Errors such as the administration of the wrong blood to the wrong patient
can lead to long-term health problems and even death. Extreme caution must be used
when preparing a patient to receive a blood transfusion. Following procedures that
ensure accurate identification of the patient and verification of blood transfusion
components can help to prevent potentially fatal errors.1
Hospital-acquired condition alert: The Centers for Medicare and Medicaid
Services considers blood incompatibility errors a hospital-acquired condition because
they can be reasonably prevented using a variety of best practices. Be sure to follow
evidence-based prevention practices (such as carefully identifying the patient and blood
sample for compatibility testing and participating in a two-person verification process)
before blood or blood product administration to reduce the risk of incompatibility
errors.23
Health care workers should follow their facility's identification and verification
process. In addition, they should not transfuse any blood product that doesn't match the
patient's assigned identification number. Plasma, platelets, and blood derivatives can
also cause serious transfusion reactions and must be administered with care.1
Before administering blood or a blood product, health care professionals should
be familiar with the different types of blood and blood products. (See Transfusing blood
and selected blood products.)
TRANSFUSING BLOOD AND SELECTED BLOOD PRODUCTS
This table describes various blood components, the indications for their use,
compatibility of blood types, and nursing considerations for each blood component.
Blood Component
Red blood
(RBCs)
cells
Concentrate
of
RBCs from whole
blood 4
Indications
● To restore or
maintain
oxygen-carry
ing capacity
in
patients
with
symptomatic
anemia
● To increase
Compatibility
● Group
A
receives A or
O.1
● Group
B
receives B or
O.1
● Group
AB
receives AB,
A, B, or O.1
Nursing
Considerations
● Transfuse
RBCs
through
a
sterile,
pyrogen-free
transfusion
set with an
appropriate
filter.
RBC mass in
patients with
acute
anemia
caused
by
trauma,
surgical
blood loss,
or
chemotherap
y1
● To increase
RBC mass in
patients with
chronic
anemia with
associated
cardiovascul
ar
decompensa
tion1
● Group
O
receives O.1
● Rh-negative
recipients
can receive
only
Rh-negative
RBCs.1
● Rh-positive
recipients
can receive
Rh-positive
or
Rh-negative
RBCs.
● Prime
the
administratio
n set with
normal
saline
solution
if
using
a
Y-type
administratio
n set.
● Ensure that
the
transfusion
is
started
within
the
facility-desig
nated time of
removal from
transfusion
services (for
example, 30
minutes).15
● Start
the
blood
transfusion
at a slow
rate,
as
prescribed,
and increase
the rate as
prescribed if
no signs of a
reaction
occur
to
ensure
completion
of
the
transfusion
within
4
hours.167
● Avoid
administratio
n for anemia
that's
correctable
with nutrition
or
drug
therapy.1
Leukocyte-reduced
RBCs
Concentrate
of
RBCs from whole
blood with white
blood
cells
removed from the
blood component
during
apheresis
collection or by
filtration
of
the
blood product 4
● To restore or
maintain
oxygen-carry
ing capacity
in
symptomatic
anemia
in
patients
at
risk
for
reactions
caused
by
leukocyte
antibodies 1
● To
treat
symptomatic
anemia
in
immunocom
promised
patients
● To increase
RBC mass in
acute
anemia
caused
by
trauma,
surgical
blood loss,
or
chemotherap
y in patients
at risk for
reactions
caused
by
leukocyte
antibodies
● To increase
RBC mass in
chronic
anemia with
● Group
A
receives A or
O.1
● Group
B
receives B or
O.1
● Group
AB
receives AB,
A, B, or O.1
● Group
O
receives O.1
● Rh-positive
recipients
can receive
Rh-positive
or
Rh-negative
RBCs.1
● Rh-negative
recipients
can receive
only
Rh-negative
RBCs.
● Transfuse
the
RBCs
through
a
sterile,
pyrogen-free
transfusion
set with an
appropriate
filter.
● Prime
the
administratio
n set with
normal
saline
solution
if
using
a
Y-type
administratio
n set.
● Ensure that
the
transfusion
is
started
within
the
facility-desig
nated time of
removal from
transfusion
services (for
example, 30
minutes).5
● Start
the
blood
transfusion
at a slow
rate,
as
prescribed,
and increase
the rate as
associated
cardiovascul
ar
decompensa
tion
in
patients
at
risk
for
reactions
caused
by
leukocyte
antibodies
Platelets
Concentrate
of
platelets separated
from whole blood or
blood obtained by
apheresis or pooled
from
multiple
donors
● To control for
bleeding that
results from
decreased
circulating
platelets or
malfunctioni
ng platelets1
● To increase
prescribed if
no signs of a
reaction
occur
to
ensure
completion
of
the
transfusion
within
4
hours.17
● RBCs
can
be collected
in
special
multiple-bag
units so that
the patient
can receive
a
small
volume
of
blood
multiple
times from
the
same
donor.
● Avoid
administerin
g for anemia
that's
correctable
with nutrition
or
drug
therapy.1
● Donor
plasma
should
be
ABO-compat
ible with the
recipient's
RBCs when
large
volumes are
● Transfuse
through
a
sterile,
pyrogen-free
transfusion
set with an
appropriate
filter. (Don't
use
a
Plasma
Noncellular portion
of
blood
that's
separated
and
frozen
after
donation
and
contains
coagulation factors
and other proteins
platelet
count
in
patients who
require
an
invasive
procedure
● To prevent
bleeding in
patients with
a low platelet
count
given
to
adults.
● Rh-negative
recipients
should
receive
Rh-negative
platelets
when
possible,
especially
women
going
through
childbirth.
microaggreg
ate filter.)1 A
leukocyte-re
duction filter
may
be
necessary if
leukocyte-re
duced
platelets
aren't
available.
● Transfusion
may proceed
as quickly as
tolerated but
must
take
less than 4
hours.
● Patients who
don't benefit
from
transfusion
with
non–human
leukocyte
antigen
(HLA)
platelets
may benefit
from
HLA
platelets.
● To
temporarily
reverse the
effects
of
warfarin1
● For plasma
exchange
(especially in
patients with
thrombotic
● Group
A
receives A or
AB.
● Group
B
receives B or
AB.
● Group
AB
receives AB.
● Group
O
receives O,
● Transfuse
through
a
sterile,
pyrogen-free
transfusion
set with an
appropriate
filter.
● Infuse
immediately
thrombocyto
penia)1
For patients
with
factor
deficiency if
concentrate
is
unavailable1
For patients
with
abnormal
coagulation
test results
before
invasive
procedures1
For patients
with
liver
disease with
protein
synthetic
defect1
For patients
with
dilutional
coagulopath
y1
For patients
with
consumptive
coagulopath
y1
A, B, or AB.
● Rh matching
isn't
required.
after
thawing.
● Administratio
n is usually
over 30 to 60
minutes.1
● For patients
with
factor
deficiency
when
factor-specifi
c
concentrate
is
unavailable1
● ABO
compatibility
isn't
required, but
it's
preferred.1
● Rh matching
isn't
● Transfuse
through
a
sterile,
pyrogen-free
transfusion
set with an
appropriate
filter.
● Infuse
●
●
●
●
●
Cryoprecipitate
Also known as
cryoprecipitated
antihemophilic
factor, noncellular
blood component
that's prepared by
thawing
fresh
frozen
plasma,
recovering
the
insoluble
precipitate,
and
then refreezing the
precipitate within 1
hour of collection;
contains
concentrated levels
of fibrinogen, factor
VIII, von Willebrand
factor, factor XIII,
and fibronectin4
● For patients
with
hypofibrinog
enemia1
● For patients
with
dysfibrinoge
nemia1
● For patients
with
von
Willebrand
disease1
● For patients
with
fibronectin
deficiency
required.
immediately
after
thawing.
● May
be
administered
through
a
small-gauge
IV catheter.
● Administratio
n is usually
over 15 to 30
minutes.1
Equipment
●
●
●
●
●
●
●
●
●
●
●
●
Blood or blood product administration set
IV pole
Gloves
Blood or blood product
Preservative-free normal saline solution
3-mL syringe
Antiseptic pad (chlorhexidine-based, povidone-iodine, or alcohol)
Disinfectant pad
Stethoscope
Vital signs monitoring equipment
Blood request form
Optional: prescribed premedications, 250 mL of normal saline solution, IV
catheter equipment (should include 18G to 24G catheters),6 electronic infusion
device indicated for blood transfusion use,6 blood warming device and
administration set, mask, protective eyewear, gown, pulse oximeter, venipuncture
equipment, labels
Straight line and Y-type blood administration sets contain a standard 170- to
260-micron blood filter designed to eliminate blood clots and cellular debris that occur
during blood storage.6 Sometimes, however, a specialized blood filter is required.1 (See
Specialized blood filters.)
SPECIALIZED BLOOD FILTERS
When deemed medically necessary, specialized filters are used to transfuse blood
and blood products.6
Filter type
Considerations
Microaggregate filter
● Eliminates debris as small as 20
microns
● Not
warranted
for
routine
transfusion therapy16
● Not appropriate for granulocyte
infusions1
● May be indicated for use with
extracorporeal
membrane
oxygenation circuits, preparation of
intraoperative
blood
recovery
collections, or infusion of wound
drainage collections1
Leukocyte-reduction filter
● Reduces the number of leukocytes
by 99.9% in red blood cell and
platelet units
● May be used to reduce the risk of
transfusion complications if a
prestorage
leukocyte-reduced
blood unit isn't available16
● Requires close adherence to the
manufacturer's instructions for
use1
Preparation of Equipment
Inspect all equipment and supplies. If a product is expired, is defective, or has
compromised integrity, remove it from patient use, label it as expired or defective, and
report the expiration or defect as directed by your facility.
Avoid obtaining the blood or blood product until you're ready to begin the
transfusion. Prepare the equipment when you're ready to start the infusion. If the patient
has a history of adverse reactions, administer premedication, as prescribed, following
safe medication administration practices.891011 To ensure effectiveness, administer
oral medication 30 minutes before starting the transfusion. If IV medication is
prescribed, administer it immediately before starting the transfusion.1
Implementation
● Verify the practitioner's order. Confirm that the order addresses the indication for
transfusion, the preparation of the product, and administration requirements
(including the start time and rate of infusion).112 Confirm that the order and the
medical record are labeled with the patient's first and last name and unique
identification number.6
● Unless the transfusion is an emergency, confirm that informed consent has been
obtained and that the signed consent form is in the patient's medical record
before initiating the transfusion.1314151617
● Review the patient's medication regimen. Certain medications, such as antifungal
agents and chemotherapy, might not be recommended during blood
transfusion.1 Consult with the patient's practitioner, if necessary.
● Ensure that a blood sample was obtained for compatibility testing. If not, collect
one. (See the "Venipuncture" procedure.) Blood samples must be collected within
3 days of red blood cell (RBC) transfusion if the patient has been pregnant within
the preceding 3 months, has been transfused within the preceding 3 months, or
has an uncertain or unavailable patient history.1
● Make sure that transfusion services receives a blood request form that contains
the patient's first and last name, an identification number that's unique to the
patient, the prescribed blood component and amount ordered, and the name of
the responsible practitioner. (A computer-transmitted request is acceptable if it
contains the required information.) Additional information, such as the patient's
age, sex, diagnosis, transfusion history, pregnancy history, and special blood
component or service needs as well as the date and time of blood sample
collection for compatibility testing may be helpful in resolving problems should
they occur.1
● Gather and prepare the necessary equipment and supplies.
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
Perform hand hygiene.1819202122232425
Confirm the patient's identity using at least two patient identifiers.126
Provide privacy.27282930
Verify that the patient's religious beliefs don't prohibit blood transfusion therapy.1
Explain the procedure to the patient and family (if appropriate) according to their
individual communication and learning needs to increase their understanding,
allay their fears, and enhance cooperation.31
Perform hand hygiene.1819202122232425
Put on gloves to comply with standard precautions.223233343536
Ensure that the patient has adequate venous access with an appropriately sized
catheter (for short peripheral catheters, 20G to 24G based on vein size and
patient preference; 18G to 20G if rapid transfusion is required).6 Verify patency
by aspirating for blood return.637 Insert an IV catheter, if necessary. (See the "IV
catheter insertion" procedure.) A central venous catheter is also an acceptable
option for blood transfusion.16
Remove and discard your gloves.323438
Perform hand hygiene.1819202122232425
Obtain the patient's vital signs immediately before initiating the transfusion to
serve as baselines for comparison.16
Assess the patient's breath and heart sounds, skin color, and current laboratory
test results, such as hemoglobin level and hematocrit. Identify any conditions that
may increase the risk of a transfusion reaction, such as fever, heart failure,
kidney disease, and risk of fluid volume excess.56
Question the patient about the presence of signs and symptoms that may later
be mistaken for signs and symptoms of a transfusion reaction, such as chills,
itching, rash, hematuria, muscle aches, and difficulty breathing.1
Assist the patient to the bathroom, if necessary, before beginning the
transfusion.1
Help the patient assume a comfortable position either in a chair or bed. Providing
patient comfort before the transfusion helps reduce the number of manipulations
of the blood and tubing during the course of the procedure.1
If the patient is in bed, raise the bed to waist level before providing care to
prevent caregiver back strain.39
Offer the patient diversional activities, such as reading materials, television,
radio, and games, to allay anxiety during the transfusion.1
Perform hand hygiene.1819202122232425
Obtain the blood or blood product from transfusion services. When receiving the
blood or blood product from the transfusion services representative, verify the
patient's two independent identifiers; ABO group and Rh type; the donor
identification number, ABO group, and (if required) Rh type; interpretation of
●
●
●
●
●
●
crossmatch tests (if required); special transfusion requirements (if applicable);
the expiration date and time (if applicable); and the date and time of blood issue.
Wear gloves or transport the blood product units in a container that prevents
direct contact with the blood unit bag.134
Remove and discard your gloves, if worn for transport.3438
Perform hand hygiene.1819202122232425
Put on gloves and, as needed, other personal protective equipment to comply
with standard precautions.223233343536
Use a two-person verification process in the presence of the patient to match the
blood or blood product with the practitioner's order and the patient to the blood
product.640 One of the people conducting the verification must be qualified to
administer the blood or blood product and is usually a registered nurse. The
second person conducting the verification must be qualified to participate in the
process, as determined by your facility.40 Each employee must independently
compare the information, as follows:1
● Compare the name and identification number on the patient's wristband
with those on the blood bag label.
● Check the blood bag identification number, ABO blood group, Rh
compatibility, and interpretation of compatibility testing.
● Compare the patient's transfusion services identification number with the
number on the blood bag.1
Check the expiration date on the blood bag, and observe for leaks, abnormal
color, clots, excessive air or bubbling, and unusual odor.16Return expired or
abnormal blood to transfusion services.1
After checking all of the identifying information, sign the transfusion form to
indicate that the identification was correct and that you're the person starting the
transfusion; other items that may be included on the transfusion form include the
name and volume of the blood product, the blood product's identification number,
and the date and time of the transfusion.1
Clinical alert: Leave all identification attached to the blood or blood product bag
attached until you've terminated the transfusion.1
● If your facility uses bar-code technology, use it as directed by your facility.
● Prime the blood administration set according to the manufacturer's instructions. If
you're using a Y-type set, prime the tubing with normal saline solution (as shown
below) as ordered. When using a straight set, prime the administration set tubing
with the prescribed blood product.1
Clinical alert: Never mix medications with blood or blood products.6 If the patient
requires IV medications during transfusion, start a separate IV line for the administration
of blood products so that the patient can simultaneously receive the therapeutic benefits
of the blood product and the medication. Other IV solutions (with the exception of
Plasma-Lyte 148) aren't compatible with blood products, so you shouldn't administer
them through the same IV line.1
● If you're using a blood warming device or an electronic infusion device, insert the
tubing into the device and operate the device according to the manufacturer's
instructions for use.16 (See Blood warmers.)
EQUIPMENT
BLOOD WARMERS
Blood warming devices may be used to prevent hypothermia that can result from
rapid infusion of large volumes of refrigerated blood.1 Various types of blood and fluid
warmers are available.
The ideal blood and fluid warmer should be capable of safely delivering fluids and
blood products at normothermia at both high and low flow rates and must be tested
and approved for use with blood components.1 The blood and fluid warmer should be
equipped with a visible temperature gauge and an audible alarm system.41 No matter
what type of device is available at your facility, follow the manufacturer's instructions
for use.
A blood warmer may be indicated for use in:
●
●
●
●
plasma exchange transfusion
surgery
trauma
cold agglutinin disease.141
● Perform a vigorous mechanical scrub of the vascular access device hub for at
least 5 seconds using an antiseptic pad. Allow it to dry completely.4243
● Trace the blood administration set tubing from the patient to its point of origin
before beginning the transfusion to make sure that you're connecting the tubing
to the correct port and then attach it to the venous access device.3744 Route the
tubing in a standardized direction if the patient has other tubing and catheters
having different purposes. If multiple IV lines will be used, label the tubing at both
the distal (near the patient connection) and proximal (near the source container)
ends to reduce the risk of misconnection.4445
● Start the blood transfusion at a slow rate for the first 15 minutes, and increase
the rate as prescribed if no signs of a reaction occur to ensure completion of the
transfusion within 4 hours.167
● Remain near the patient during the first 15 minutes to monitor for signs and
symptoms of a transfusion reaction because, if a major incompatibility exists or a
severe allergic reaction such as anaphylaxis occurs, signs and symptoms usually
appear before transfusion of the first 50 mL of the unit.6
● If a reaction occurs, stop the transfusion immediately and notify transfusion
services and the patient's practitioner.16 (See the "Blood and blood product
transfusion reaction management" procedure.)
● Assess the patient's respiratory status (including breath sounds and, if indicated,
oxygen saturation level), skin appearance, and urine output.46
● If no evidence of a transfusion reaction occurs within the first 15 minutes of the
transfusion, increase the infusion rate to the prescribed rate.6
● Before leaving the room, instruct the patient and family (if applicable) to report
anything unusual immediately.1
● Observe the patient periodically during the transfusion to identify early signs and
symptoms of a possible transfusion reaction.1 Monitor vital signs during the
transfusion (as shown below), as directed by your facility and as the patient's
condition warrants.
● Closely monitor the flow rate and inspect the IV insertion site for signs of
infiltration. If you observe signs of infiltration, immediately stop the transfusion,
disconnect the administration set, and aspirate fluid from the catheter using a
small syringe. Remove the catheter and estimate the volume of fluid infiltrated.
Notify the practitioner and insert a new IV catheter in a different location to
prevent an interruption in transfusion therapy.47
● Remove and discard your gloves and, if worn, other personal protective
equipment.323438
● Perform hand hygiene.1819202122232425
● At the completion of blood product administration, obtain the patient's vital signs
and compare them with baseline measurements to detect signs of a possible
transfusion reaction.1
● If you must administer additional units, repeat the procedure. Follow
manufacturer's instructions regarding changing of transfusion administration set
and filters.1648
● If no additional units are prescribed, perform hand hygiene,1819202122232425
put on gloves,323334 and reconnect the original IV fluid, saline lock the catheter,
or discontinue the IV infusion, as prescribed.549
● Return the bed to the lowest position, if applicable, to prevent falls and maintain
the patient's safety.50
● Discard used infusion supplies in an appropriate container, and discard the blood
bag, tubing, and filter in an appropriate hazardous waste container.323438
● Clean and disinfect your stethoscope using a disinfectant pad.5152
● Remove and discard your gloves.323438
● Perform hand hygiene.18192021232425
● Continue to assess and monitor the patient for signs and symptoms of a delayed
transfusion reaction for 4 to 6 hours after the transfusion.6 If the patient isn't
under direct observation after the transfusion (for example, if the patient receives
a transfusion as an outpatient), provide patient teaching about the signs and
symptoms of a delayed transfusion reaction and the importance of reporting
them.16
● Document the procedure.53545556
Special Considerations
● Use of automated identification technology, such as bar-coding, radio frequency
identification devices, and biometric scanning, is acceptable if permitted by your
facility to improve the identification system.640
● If necessary, using sterile technique, change the blood or blood product
administration set and filter according to the manufacturer's instructions. Change
it immediately if you suspect contamination or if the integrity of the product or
system becomes compromised.48
● Be aware that a donor unit of blood can be split if a patient might not be able to
tolerate the fluid volume of an entire unit at one time. Individual portions of the
unit can be released for administration while the remainder is safely stored.16
Consult with transfusion services if unit splitting is necessary.
● Note that the U.S. Food and Drug Administration has approved the compatibility
of Plasma-Lyte 148 with blood products; you may administer it before or after the
infusion of blood through the same administration set (for example, as priming
solution), add it to or infuse it concurrently with blood products, and use it as a
diluent in the transfusion of RBCs.1
● For rapid blood replacement, consider using a manual pressure cuff. Always
follow the manufacturer's instructions for use. Externally applied compression
devices should be equipped with a pressure gauge, totally encase the blood bag,
and exert uniform pressure against all parts of the blood bag. Don't use a blood
pressure cuff because it can't deliver uniform pressure.6
● If the blood bag empties before the next one arrives, administer normal saline
solution slowly to keep the vein patent. If you're using a Y-type administration set,
close the blood-line clamp, open the clamp to the normal saline solution, and let
it infuse slowly until the new unit of blood arrives. Decrease the flow rate or
clamp the line before attaching the new unit of blood.
● Blood products must be infused within 4 hours of removal from the transfusion
services refrigerator.167 If any blood product remains after 4 hours, discontinue
the infusion and discard the remaining product as directed.
● Many organized religions don't prohibit the use of blood products by their
members when a medical need arises; however, Jehovah's Witnesses and
Christian Scientists include teachings that prohibit transfusion therapy (although
some believers of these and other faiths accept some blood components).
Provide the opportunity for all patients to discuss their beliefs regarding blood
transfusion.1
● Be aware that whole blood is rarely used. It may be used on rare occasions to
restore blood volume from hemorrhage or in an exchange transfusion.
● The Joint Commission issued a sentinel event alert related to managing risk
during transition to new International Organization for Standardization tubing
standards that were designed to prevent dangerous tubing misconnections,
which can lead to serious patient injury and death. During the transition, make
sure to trace each tubing and catheter from the patient to its point of origin before
connecting or reconnecting any device or infusion, at any care transition (such as
to a new setting or service), and as part of the handoff process; route tubes and
catheters having different purposes in different, standardized directions. Label
tubing at both the distal and proximal ends when the patient has different access
sites or several bags hanging, use tubing and equipment only as intended, and
store medications for different delivery routes in separate location.45
● The Joint Commission considers a blood incompatibility error a sentinel event. A
sentinel event is an unexpected occurrence involving death or serious physical or
psychological injury or the risk thereof. Sentinel events require immediate
investigation and response. Follow your facility's process for reporting a
suspected blood incompatibility error.57
Patient Teaching
Because blood transfusion reactions can occur after a transfusion is complete, teach
the patient and family (if applicable) about signs and symptoms of a transfusion
reaction. Tell them to be alert to the possibility of a delayed reaction, and advise them to
report signs and symptoms promptly to the practitioner. (See Teaching about blood and
blood product transfusion.)
PATIENT TEACHING
TEACHING ABOUT BLOOD AND BLOOD PRODUCT TRANSFUSION
When developing a teaching plan, set objectives based on the information you
gathered during your assessment. Set criteria for evaluating whether your objectives
were met. Make sure that your teaching plan contains content that's directly related to
your objectives and covers the following information.1
Sequence of events
●
●
●
●
●
Reasons for the transfusion
Performance of compatibility testing
IV catheter insertion, if an appropriately sized catheter isn't already in place
Premedication administration, as needed and prescribed
Monitoring of vital signs and other parameters before, during, and after the
transfusion
● Activity limitations during the transfusion
● Expectations after the transfusion
Benefits of the transfusion
● Improved oxygen-carrying capacity of red blood cells (RBCs), for example, if
RBCs are prescribed for treatment of symptomatic anemia
● Provision of coagulation factors to prevent or control bleeding
Risks associated with the transfusion
●
●
●
●
Immunologic complications, such as hemolytic and nonhemolytic reactions
Transmission of infectious disease
Fluid overload and subsequent pulmonary edema
Sepsis
Signs and symptoms of complications associated with the transfusion
●
●
●
●
●
●
●
●
●
●
Vague, uneasy feeling
Onset of pain (especially at the IV site, back, or chest)
Chills
Flushing
Fever
Nausea
Dizziness
Rash
Itching
Dark or red urine
Complications
Despite improvements in crossmatching precautions, transfusion reactions can still
occur during a transfusion or within 96 hours after a transfusion. Transfusion reactions
typically stem from a major antigen-antibody reaction. Monitor the patient closely for
signs and symptoms, especially if the patient can't report the symptoms. A transfusion
reaction requires prompt nursing action to prevent further complications and possibly
death.
Unlike a transfusion reaction, an infectious disease transmitted during a transfusion may
go undetected until days, weeks, or even months later, when the disease produces
signs and symptoms. Measures to prevent disease transmission include laboratory
testing of blood products and careful screening of potential donors—neither of which is
guaranteed. Hepatitis C accounts for most posttransfusion hepatitis cases. The tests
that detect hepatitis B and hepatitis C can produce false-negative results and may allow
some hepatitis cases to go undetected. The risk of transmitting human
immunodeficiency virus during transfusion is rare. Blood products are rigorously tested
using highly sensitive testing.5859 Many transfusion services also screen blood for
cytomegalovirus (CMV); blood contaminated with CMV is especially dangerous for an
immunosuppressed, seronegative patient. Transfusion services also test blood for
syphilis, but refrigerating blood virtually eliminates the risk of transfusion-related
syphilis. Transfusion services also screen blood for human T-lymphotropic viruses types
I and II and for the mosquito-borne diseases West Nile virus and Zika virus, which can
be transmitted through blood transfusion; however, cases are rare.58
Transfusion-associated circulatory overload, transfusion-related acute lung injury, and
hemolytic, allergic, febrile, and pyogenic reactions can result from any transfusion.
Coagulation disturbances, citrate intoxication, hyperkalemia, acid-base imbalance,
ammonia intoxication, hypothermia, and loss of 2,3-diphosphoglycerate can result from
massive transfusion.
Documentation
Record the date and time of the transfusion; confirmation that informed consent was
obtained; the indications for the transfusion; any premedications administered; the
donor identification number; the type and amount of transfusion product transfused; the
amount of normal saline solution infused; the patient's vital signs before, during (if
required), and after the transfusion; your check of all identification data; and the
patient's response. Document any transfusion reaction, the name of the practitioner
notified, time of notification, interventions performed, and the patient's response to those
interventions. Document teaching provided to the patient and family (if applicable), their
understanding of that teaching, and any need for follow-up teaching.1 (See
Documenting blood transfusions.)
DOCUMENTING BLOOD TRANSFUSIONS
After matching the patient's name, medical record number, blood group (or type), and
Rh factor (the patient's and the donor's); the crossmatch data; and the transfusion
services identification number with the label on the blood bag, you'll need to clearly
document that you did so. The blood or blood product must be identified and
documented properly by two health care professionals as well unless one-person
verification accompanied by automated identification technology is permitted in your
facility.
On the transfusion record, document:
●
●
●
●
●
●
●
●
date and time the transfusion was started and completed
name of the health care professional who verified the information
type and gauge of the catheter
total amount of the transfusion
patient's vital signs before, during, and after the transfusion
any infusion device used
flow rate
any blood warming device used.
If the patient received autologous blood, document in the intake and output records:
● amount of autologous blood retrieved
● amount reinfused
● laboratory data during and after the autotransfusion
● patient's pretransfusion and posttransfusion vital signs.
Pay particular attention to the patient's:
● coagulation profile
● hemoglobin level, hematocrit, arterial blood gas values, and calcium level
● tolerance of the procedure, especially fluid status.
Management of Patients with Non-malignant Hematologic Disorders
Anemias
● Fewer than normal hemoglobin and fewer than normal circulating erythrocytes
● This is a sign of an underlying disorder
● May also be caused by blood loss
● Can either be
○ Hypoproliferative
■ Defect in the production of red blood cells caused by iron, vitamin
B12, or folic deficiency, or decreased erythropoietin production, or
cancer
○ Hemolytic
■ Has an excess destruction of red blood cells caused by altered
erythropoiesis or other causes such as hypersplenism,
drug-induced or autoimmune processes, or mechanical heart
valves
● Manifestations
○ Depends on the rapidity of the development of the anemia, duration of the
anemia, metabolic requirements of the patient, concurrent problems, and
concomitant features
○ Fatigue
○ Weakness
○ Malaise
○ Pallor
○ Jaundice
○ Cardiac and respiratory symptoms
○ Tongue changes
○ Nail changes
○ Angularculosis
○ Pica
● Diagnostic Testing
○ Consists of hemoglobin and hematocrit counts, reticulocyte count, RBC
indices, iron studies, vitamin B12, folate, haptoglobin, erythropoietin
levels, bone marrow aspiration
● Medical Management
○ Correct or control the cause
○ Transfusion of packed RBCs
○ Treatment specific to the type of anemia
■ Dietary therapy
■ Iron or vitamin supplementation
■ Transfusions
■ Immunosuppressive therapy
■ Others
● ASSESSMENT
○ Health history and physical exam
○ Laboratory data
○ Presence of symptoms and impact of those symptoms on patient’s life;
fatigue, weakness, malaise, pain
○ Nutritional assessment
○ Medications
○ Cardiac and GI assessment
○ Blood loss: menses, potential GI loss
○ Neurologic assessment
○ Pallor from Anemia
● DIAGNOSES
○ Fatigue
○ Altered nutrition
○ Altered tissue perfusion
○ Noncompliance with prescribed therapy
● Collaborative problems and potential complications
○ Heart failure
○ Angina
○ Paresthesia
○ Confusion
○ Injury related to falls
○ Depressed mood
● Planning
○ Major goals include
■ Decreased fatigue
■ Attainment or maintenance of adequate nutrition
■ Maintenance of adequate tissue perfusion
■ Compliance with prescribed therapy
■ Absence of complications
● Interventions
○ Balance physical activity, exercise, and rest
○ Maintain adequate nutrition
○ Maintain adequate perfusion
○ Patient education to promote compliance with medications and nutrition
○ Monitor vital signs and pulse oximetry; provide supplemental oxygen as
needed
○ Monitor for potential complications
Hypoproliferative Anemias
● Iron Deficiency Anemia
● Anemia in renal disease
● Anemia of inflammation
● Aplastic anemia
● Megaloblastic anemia
○ Folic acid deficiency
○ Vitamin B12 deficiency
Hemolytic Anemias
● Sickle Cell Disease
● Thalassemia
● Glucose-6-phosphate dehydrogenase deficiency
● Immune hemolytic anemia
● Hereditary hemochromatosis
Sickle Cell Disease
● Assessment
○ health history and physical exam
○ Pain assessment
○ Laboratory data
■ S shaped hemoglobin
○ Presence of symptoms and impact of those symptoms on patient’s life like
swelling, fever, pain
Sickle Cell Crisis
● Assessment
○ Blood loss
■ Menses
■ Potential GI loss
○ Cardiovascular and neurologic assessment
● Chronic skin ulcers of sickle cell
● Diagnoses
○ Acute pain and fatigue
○ Risk for infection
○ Risk for powerlessness
○ Deficient knowledge
● Collaborative problems and potential complications
○ 1, 2, or more of the following
■ Hypoxia, ischemia, infection
■ Dehydration
■ CVA
■ Anemia
■ Acute and chronic kidney disease
■ Heart failure
■ Impotence
■ Poor compliance
■ Substance abuse
● Interventions
○ Pain management
○ Manage fatigue
○ Infection prevention
○ Promote coping
○ Education of disease process
○ Monitor for complications
Polycythemia
● Increased volume of red blood cells
● Secondary polycythemia
○ Excessive production of erythropoietin from reduced amounts of oxygen,
cyanotic disease or non pathologic conditions or neoplasms
● Medical management
○ Focuses on the treatment not needed if condition is mild thus retreat the
underlying cause
○ Therapeutic phlebotomy is also used or given
Neutropenia
● Decreased production or increased destruction of neutrophils (<2000/mm3)
● Increased risk for infection monitor closely
● Absolute neutrophil count (ANC)
● Medical management
○ Treatment depends on the cause
● Nursing management
○ Patient education, preventing and managing complications
Bleeding Disorders
● Failure of hemostatic mechanisms
● Causes
○ Trauma
○ Platelet abnormality
○ Coagulation factor abnormality
● Medical management
○ Specific blood products
● Nursing management
○ Limit injury, assess for bleeding, bleeding precautions
● Secondary thrombocytosis
● Thrombocytopenia
● Immune thrombocytopenic purpura (ITP)
● Platelet defects
● Hemophilia
● Von Willebrand disease
Acquired Coagulation Disorders
● Disseminated Intravascular Coagulation (DIC)
○ Not a disease but a sign of an underlying disorder
○ Severity is variable but this may be life-threatening
○ Triggers may include sepsis, trauma, shock, cancer, abruptio placenta,
toxins, and allergic reactions
○ Altered hemostatic mechanism causes massive clotting in microcirculation
as clotting factors are consumed, bleeding occurs
○ Pathophysiology
■ Involves abnormal excessive generation of thrombin, fibrin in the
circulating blood
■ During the process, increase platelet aggregation and coagulation
factor consumption occur
■ DIC that evolves slowly ex. Over weeks or months causes primarily
venous thrombotic and embolic manifestation
■ DIC that evolves rapidly over hours and days causes primarily
bleeding
■ Severe rapidly evolving DIC is diagnosed by demonstrating
thrombocytopenia or an elevated partial thromboplastin time and
prothrombin time, increase levels of plasma D dymers and a
decreasing plasma fibrinogen level
○ Symptoms
■ Related to tissue ischemia and bleeding
○ Laboratory test
○
○
○
○
○
■ Retrieve the underlying cause
Correct tissue ischemia or replace fluids and electrolytes
Maintain blood pressure and replace coagulation factors
Treatment
■ Correction of the cause and replacement of platelets or coagulation
factors
■ Fibrinogen to control severe bleeding
■ Heparin
● Used as therapy or prophylaxis in patients with slowly
evolving DIC who have venous thromboembolism
Assessment
■ Assess for signs and symptoms and progression of thrombi and
bleeding
Common lab values of DIC
Laboratory Values Commonly Found in Disseminated Intravascular
Coagulation
Test
Function
Evaluated
Normal
Range
Changes in
DIC
●
●
●
●
●
●
●
●
●
●
○ Diagnoses
■ Risk for fluid volume deficiency
■ Risk for impaired skin integrity
■ Risk for imbalance fluid volume
■ Ineffective tissue perfusion
■ Risk for injury
■ Death anxiety
○ Collaborative problems and potential Complications
■ Kidney injury
■ Gangrene
■ Pulmonary embolism or hemorrhage
■ Acute respiratory distress syndrome (ARDS)
■ Stroke
○ Planning
■ Major goals
● Maintenance of hemodynamic status or intact skin and oral
mucosa
● Maintenance of fluid balance and tissue perfusion
● Enhanced coping
● Absence of complications
○ Interventions
■ Assessment and interventions should target potential sites of organ
damage
■ Monitor and assess carefully
■ Avoid trauma and procedures that increase the risk of bleeding,
including activities that would increase intracranial pressure
Liver disease
Vitamin K deficiency
Complications of anticoagulant therapy
Thrombotic disorders
Hyperhomocysteinemia
Antithrombin deficiency
Protein C and S deficiency
Activated protein C resistance and factor V Leiden mutation
Acquired thrombophilia
Malignancy
Hematologic Disorders
White Blood Cells Disorders
● High WBC Count
● Low WBC Count
● Reactive increase in number - “philias”
○ Neutrophilia
■ Bacterial sepsis
■ Increase in the neutrophil count above 7.5x109
■ Causes
● Bacterial infections
○ Pyogenic infections
● Inflammation and tissue necrosis
○ Cardiac infarction
○ Trauma
○ vasculitis
● Metabolic disorders
○ Uremia
○ Eclampsia
○ Gout
● Neoplasms or cancer cells
○ CA
○ Lymphoma
○ Melanoma
● Acute hemorrhage or hemolysis
● Corticosteroid therapy
● Myeloproliferative diseases
○ CML
○ Lymphocytosis
■ Viral, immune
○ Eosinophilia
■ Allergy and parasites
■ Caused by allergic disorders: bronchial asthma, urticaria, food
hypersensitivity such as
● Skin disease
○ psoriasis
● Parasitic infestations
○ Amoebiasis, ascariasis, hookworm, filariasis
● Decreased number - “penias”
○ Neutropenia
■ Decreased production because of
● Infiltrative marrow disorders
○ Tumors, granulomatous disease, etc
● Exposure to drugs
○ Cytotoxic drugs, chemotherapy
■ Accelerated removal or destruction of neutrophils
● Immunologically mediated injury to neutrophils
● Associated with immunologic disorders
○ Ex. SLE
○ Ex. Felty’s syndrome
■ Combination
of
rheumatoid
arthritis,
splenomegaly, neutropenia
■ Hypersplenism
● Excessive destruction occurs secondary
to enlargement of the spleen usually
associated with increased destruction of
RBC and platelets as well
■ Medical Management
● Stop medication if drug induced neutropenia
● Use of growth factors like granulocyte/macrophage,
colony-stimulating factor can be effective in increasing
neutrophil production when the cause of the neutropenia is
decreased production
● Laboratory tests
○ Lymphopenia
■ Causes
● Primary
○ Immunodeficiency diseases
● Secondary
○ Influenza, Tb, Malaria, HIV
○ Whipples disease
■ Rare, relapsing, slowly progressing infectious
systemic illness characterized by fever of
unknown origin, polyarthralgias, and chronic
diarrhea
○ severe right side heart failure
● Drugs
○ Radiotherapy
○ Corticosteroids
○ cytotoxic drugs
● Neoplastic Conditions
○ Metastatic CA
○ Advanced Hodgkin’s disease/Hodkin’s lymphoma
■ Cancer that begins in cells of the immune
system
● Nutritional/metabolic
○ B12/folate deficiency
○ uremia
● Others
○ SLE
○ Aplastic anemia
○ Sarcoidosis
■ Involves inflammation that produces tiny lumps
of cells in various organs in the body
○ Eosinopenia
○ Pancytopenia
○ Drugs
○ Viral infections
○ Radiation
○ Chemotherapy
● Classification
○ 2 broad categories
■ Leukocytosis (proliferative disorders)
● Increase in numbers of leukocytes
● The proliferations of WBC can be reactive or neoplastic
■ Leukopenia
● Decreased number of leukocytes
● Reduction in the number of total WBC
● Could be due to
○ Neutropenia
○ Lymphopenia
○ both
● Granulocytosis
○ Neutrophilia may be accompanied by fever due to the release of leukocyte
pyrogens
● Lymphocytosis
○ The increase in the number or proportion of lymphocytes in the blood
usually detected when the routine blood count is routinely obtained
○ Causes
■ Most often viral infection
■ Chronic inflammation
■ Marked lymphocytosis with activated lymphocytes
● Seen in infectious mononucleosis (EBV)
● Monocytosis
○ Causes include
■ Chronic bacterial infections
● Bacterial endocarditis
● Malaria
● Tb
● Typhoid
■ Chronic inflammation
● SLE
● RA
● Ulcerative colitis
● Sarcoidosis
○ Involving inflammation that produces tiny lumps of
cells in various organs in your body
■ Malignant
● AML
● CA
● Hodgkins disease
■ Others
● Post-splenectomy
● Chronic neutropenia
● Basophilia
○ Occurs in CML (Myeloproliferative disorders)
Malignancies of Leukocytes
● Leukemia
○ It is the malignant proliferation of the WBC, with the presence of the
immature forms in the peripheral circulation
○ Causes
■ Genetics
■ More in male than in female and white people there have high
recurrence
■ Risk factors
● Exposure to large amounts of high-energy radiation
● Exposure to electromagnetic fields
○ A type of low energy radiation that comes from power
lines and electric appliances
○ Types
■ Acute vs Chronic
● Acute
○ The abnormal blood cells are blasts that remain very
immature that cannot carry out their normal functions
○ The number of blasts increase rapidly and the
disease worsens quickly
● Chronic
○ The abnormal blood cells may gradually collect in
various parts of the body
○ Some blast cells are present but in general these cells
are more mature and can carry out some of their
normal functions
○ The number of blasts increases less rapidly than in
acute leukemia, thus it worsens gradually
■ Lymphoid vs Myeloid
● Lymphoid
○ When lymphoid cells are involved we call it
lymphocytic leukemia
○ Acute lymphocytic Leukemia (ALL)
■ Most common type in young children
■ Affects adults, especially those age 65 and
older
● Myeloid
○ When myeloid cells are involved we call it myeloid
leukemia
○ Acute Myeloid Leukemia (AML)
■ Abnormal WBC that accumulate in the bone
marrow and interfere with the production of
normal blood cells
■ Characterized by the rapid growth of abnormal
WBC
■ Occurs in both adults and children
■ This type of leukemia is sometimes called
acute non-lymphocytic leukemia (ANLL)
○ Chronic Myeloid Leukemia
■ Often associated with great enlargement of the
spleen
■ Condition characterized by an increased
proliferation of all myeloid cell lines
■ Greatest incidence at age of 40-60 years
■ Has insidious onset affecting older populations
or those 60 years and above may be relatively
asymptomatic over a number of years
■ Proliferation
and
accumulation
of
mature-appearing
lymphocytes
in
the
circulation and in the lymphoid organs of the
body
○ Medical Management
■ 3 phases
● Induction phase
○ Intensive course of the chemotherapy to induce
complete remission
● Consolidation phase
○ Modified course of intensive chemotherapy to
eradicate any remaining disease
● Maintenance phase
○ Small doses given every 3-4 weeks to allow client to
live a normal life
■ Acute Leukemia
● Chemotherapy
● Tumor lysis syndrome
○ Rapid destruction of a large number of WBCs
● Radiation therapy
○ Adjunct to chemotherapy
● Targeted therapy
○ Targeted only to tumor cells and spare normal cells
thereby decreasing associated toxicities
■ Chronic Myelogenous Leukemia
● Stem cell transplantation
● Chemotherapy
● Single agent chemotherapy
■ Chronic Lymphocytic Leukemia
● Chemotherapy
○ Nursing Management
■ Prevent infection
■ Prevent bleeding by
● Providing soft toothbrush, avoid flossing and commercial
mouthwash containing alcohol
● Instruct to avoid blowing or picking the nose, straining at
bowel movements, douching or using tampons or using
razors
● Do not give IM or SC injections
● Do not insert rectal suppositories
● Do not give medications containing aspirin
● Avoid urinary catheters whenever possible
● Avoid mucosal trauma during suctioning
● Remove all potential hazards and sharp instruments in the
environment
● Turn patient to sides to prevent bed sores
● Avoid over-inflation of blood pressure cuff and rotate cuff to
different sites
● Use only paper tape and avoid strong adhesives
● Myeloma
○ It is the malignant proliferation of the plasma cells, the immunoglobulin
producing cells
● Multiple Myeloma
○ Monoclonal gammopathy
■ The presence in the blood of a large quantity of 1 antibody or
protein
■ Malignancy of plasma B-cells characterized by infiltration of cells
and secretion of monoclonal paraprotein
■ Etiology
● Neoplastic proliferation of plasma B cells
■ Risk factors
● Familial tendency
● Ionizing radiation
● Occupational chemical exposure
■ Incidence 4 in 100,000 people
■ Men and black 2x as often
■ Management
● No cure thus we only aim at only intervention of treatment of
complications
● The doctor can also suppress bone marrow through
chemotherapy and reduce serum cancer levels by
corticosteroids and hydration
● Treat complications with antiemetics and bone pain
management
Bone marrow aspiration and biopsy (Advanced practice)
Introduction
Bone marrow is the major site of blood cell formation. Obtaining a bone marrow
specimen enables evaluation of overall blood composition, blood elements,
precursor cells, and abnormal or malignant cells. A specimen is also used to help
determine the prognosis of blood diseases and cancer.1 A practitioner may
obtain a bone marrow specimen by needle aspiration or biopsy from the posterior
superior iliac crest. (See Obtaining a bone marrow specimen.)12 The sternum and
anterior iliac crest are rarely used because they pose an excessive risk of
damage to underlying tissues, including the heart.2
Bone marrow aspiration and biopsy can help diagnose leukemia, multiple
myeloma, anemia, and other blood disorders. The procedures can also help
assess bone marrow cellularity as well as cell morphology and maturation.123
During aspiration, the practitioner inserts a needle into the marrow cavity of the
bone and removes semifluid cells. During a biopsy, the practitioner removes a
small, solid core of marrow tissue through the needle. A biopsy specimen shows
not only the bone marrow architecture but also the cellularity.12 Bone marrow
aspiration and biopsy are contraindicated in patients with severe bleeding
disorders.2
OBTAINING A BONE MARROW SPECIMEN
The illustration below shows the removal of bone marrow from the posterior
iliac crest.
Bone marrow aspiration and biopsy are both painful procedures and, depending
on the patient's condition, may require administration of a sedative, pain
medication, or moderate sedation.2 Other nonpharmacologic methods of
reducing pain during bone marrow aspiration and biopsy include thorough
preprocedure patient teaching about expectations, use of a device that allows for
specimen collection with minimal manipulation, and music therapy.4
Equipment
● Bone marrow aspiration or biopsy tray, which includes:
● Sterile gauze or cotton balls
● Sterile forceps
● Sterile scalpel
● Sterile skin marker
● Antiseptic solution (chlorhexidine-based preparation)
● Two sterile fenestrated drapes
●
●
●
●
●
●
●
●
●
●
●
●
● 4″ × 4″ (10- × 10-cm) gauze pads
● 2″ × 2″ (5- × 5-cm) gauze pads
● 20-mL syringes
● 22G 1″ (2.5-cm) or 2″ (5-cm) needle
● Specimen containers with appropriate fixative agent
● Bone marrow aspiration or biopsy needle
● Specimen tubes
● Glass slides and cover slips
● Sterile labels
● Adhesive tape
● Sterile nonadherent dressing
● 26G or 27G ½″ (1.3-cm) to ⅝″ (1.6-cm) needle
● Sterile gloves
Sterile gown
Cap
Mask and goggles or mask with face shield
Vital signs monitoring equipment
Pulse oximeter and probe
1% or 2% lidocaine injection solution
Heparin 100 units/mL
Ethylenediaminetetraacetic acid (EDTA) sterile solution (15 mg/mL)
Labels
Laboratory biohazard transport bag
Antibiotic ointment
Optional: emergency equipment (code cart with emergency medications,
defibrillator, handheld resuscitation bag with mask, intubation equipment),
prescribed sedative, prescribed pain medication, prescribed moderate
sedation medication, IV insertion equipment, cardiac monitoring
equipment, bone biopsy drill
Most of the equipment above is available in a sterile, prepackaged tray.
Familiarize yourself with your facility's tray, and obtain any additional necessary
equipment.
Preparation of Equipment
If the patient is receiving moderate sedation, make sure that emergency
equipment is functioning properly and readily available.
Inspect all equipment and supplies. If a product is expired, is defective, or has
compromised integrity, remove it from patient use, label it as expired or defective,
and report the expiration or defect as directed by your facility.
Implementation
● Check the patient's medical record for a history of allergies to the local
anesthetic and to pain and sedation medications and for contraindications
(such as a severe bleeding disorder).
● Gather and prepare the necessary equipment and supplies.
● Obtain the assistance of a nurse or another practitioner competent to
assist with the procedure.
● Perform hand hygiene.5678910
● Confirm the patient's identity using at least two patient identifiers.11
● Provide privacy.12131415
● Explain the procedure to the patient and family (if appropriate) according to
their individual communication and learning needs to increase their
understanding, allay their fears, and enhance cooperation. Answer any
questions they may have.16171819
● Tell the patient which bone you'll obtain the sample from.
● Explain that you'll administer a local anesthetic but that the patient
will still feel a heavy pressure during insertion of the biopsy or
aspiration needle as well as a brief pulling sensation. Tell the patient
that you may make a small incision to avoid tearing the skin.
● Encourage the patient to verbalize any discomfort or anxiety during
the procedure.
● If the patient has osteoporosis, explain that the needle pressure may
be minimal and that you may need to use a drill.
● Inform the patient that the procedure normally takes about 20
minutes and that you may need more than one marrow specimen.
● If required by your facility, obtain informed consent and place the signed
consent form in the patient's medical record.16171819
● Assess the patient for an increased risk of bleeding. Review the results of
coagulation studies and the complete blood count as indicated.2
● Conduct a preprocedure verification to make sure that all relevant
documentation, information, and equipment are available and correctly
identified to the patient's identifiers.2021
● If appropriate, make sure that the aspiration or biopsy site has been
marked as directed by your facility.22
● If the patient will receive moderate sedation, ensure that the patient has
adequate IV access.
● Ensure that the patient is connected to a cardiac monitor if moderate
sedation will be used. Make sure that alarm limits are set appropriately for
the patient's current condition and that alarms are turned on, functioning
properly, and audible to staff.2324
● Assess the patient's vital signs and oxygen saturation level by pulse
oximetry to provide baselines to monitor for changes during and after the
procedure.225
● Screen for and assess the patient's pain using facility-defined criteria that
are consistent with the patient's age, condition, and ability to
understand.26
● Raise the bed to waist level before providing care to prevent caregiver back
strain.27
● Put on a cap and a mask and goggles or a mask with face shield.22829
● Perform hand hygiene.5678910
● Put on a sterile gown and sterile gloves.22829
● Have your assistant prepare the sterile field, open the prepackaged tray,
and prepare the supplies. Prepare specimen collection syringes by
following facility standards and guidelines for using EDTA and heparin in
syringes and tubes.2
● Make sure that all medications, medication containers, and other solutions
on and off the sterile field are labeled.3031
● Have your assistant administer a sedative, pain medication, or moderate
sedation as ordered following safe medication administration
practices.123233343536
● Have your assistant position the patient based on the selected puncture
site. Instruct the patient to remain as still as possible during the procedure.
(See Preferred site for bone marrow aspiration and biopsy.)
PREFERRED SITE FOR BONE MARROW ASPIRATION AND BIOPSY
The iliac crest is the only site that allows safe performance of aspiration or
biopsy in an adult.23 The posterior superior iliac crest (shown below) is the
preferred site for aspiration or biopsy because using this site decreases the risk
of pain and increases accessibility, and the site isn't near any vital organs or
vessels. The patient should be placed in the lateral position with one leg flexed
or in the prone position.2 For a patient who can't lie prone or when the posterior
iliac crest is unapproachable or unavailable because of infection, injury, or
morbid obesity, the anterior iliac crest is an alternative;23 however, it isn't
generally preferred because of its dense cortical layer, which makes obtaining
specimens more difficult, necessitates smaller specimens, and increases the
risk of pain.
● Conduct a time-out immediately before starting the procedure to perform a
final assessment that the correct patient, site, positioning, and procedure
are identified and, as applicable, all relevant information and necessary
equipment are available during and after the procedure.37
● Using sterile forceps and sterile gauze or cotton balls, clean the puncture
site with antiseptic solution (chlorhexidine-based preparation) using sterile
technique. Allow it to air dry.2
● Cover the area with sterile drapes to comply with full barrier precautions.2
● To anesthetize the site, use a 26G or 27G ½″ to ⅝″ (1.3- to 1.6-cm) needle to
inject a small amount of 1% or 2% lidocaine solution intradermally, creating
a wheal. This helps decrease the discomfort of local anesthesia.2
● To anesthetize the tissue down to the periosteum, use a larger 22G 1″ to 2″
(2.5- to 5-cm) needle to inject 5 to 15 mL of 1% to 2% lidocaine solution in a
peppering fashion.2 Withdraw the needle from the periosteum after each
injection. Anesthetize an area about 1¼" (3 cm) in diameter to
accommodate adjustments in needle placement.2
● Monitor the patient's vital signs and oxygen saturation and pain levels
throughout the procedure.225
Bone marrow aspiration
● Advance the bone marrow aspiration needle by applying an even,
downward force with the palm or heel of the hand while twisting the needle
back and forth slightly. Lodge it firmly in the bone cortex and stabilize the
needle with the thumb and forefinger of your other hand.2 When the needle
reaches the marrow cavity or medulla, you'll feel a "giving" or crackling
sensation.2 If the patient feels sharp pain instead of pressure when the
needle first touches the bone, the needle has most likely been inserted
outside the anesthetized area. In this case, withdraw the needle slightly and
move it to the anesthetized area.
● Remove the inner cannula stylet, attach the 20-mL syringe primed with
EDTA to the needle, and aspirate the required specimen (usually 3 to 5
mL).2
● Hand the specimen to your assistant to place a small portion of it on a
glass slide to verify the presence of spicules.2 Have your assistant place
the remainder of the specimen in the appropriate tubes for clot sections or
molecular studies.
● Attach the 20-mL syringe of heparin to the needle and aspirate any
additional specimens needed. Have your assistant place them in the
appropriate tubes.2
● Ensure that all collected specimen tubes are inverted several times to mix
the contents thoroughly and prevent clotting.2
● Gently remove the needle with a twisting and pulling motion. Apply
pressure to the aspiration site with a sterile gauze pad for 5 minutes or
until bleeding has stopped.2
● Label the specimens in the presence of the patient with the date and the
patient's name and identification number to prevent mislabeling.20
Bone marrow biopsy
● Use a scalpel to make a small (⅛" [3-mm]) stab incision in the patient's skin
to accommodate the bone marrow needle. This technique allows for
smooth needle entry, avoids pushing skin into the bone marrow, helps
avoid unnecessary skin tearing, and helps reduce the risk of infection.2
● Insert the biopsy needle and advance it steadily until it reaches the
periosteum. Direct the biopsy needle into the bone by alternately rotating
the inner needle clockwise and counterclockwise.2
● Remove the stylet, replace the cap on the needle, and gently advance the
needle ¾" (2 cm) with a firm, rotating motion.2
● Rotate the manual needle 360 degrees in each direction several times with
the needle cap on to create a vacuum to retain the bone core specimen in
the needle.2
● Back the needle out of the bone, muscle, and skin gently and firmly. Apply
pressure to the biopsy site with a gauze pad for 5 minutes to control
bleeding.2
● Label the specimen in the presence of the patient with the date and the
patient's name and identification number to prevent mislabeling.20
● Hand the specimen to your assistant to expel onto a glass slide, onto a
nonadherent dressing, or into a specimen container.2
Completing the procedure
●
●
●
●
●
●
●
●
●
●
●
Clean the area with antiseptic solution.2
Apply antibiotic ointment to the site.2
Apply a sterile pressure dressing using adhesive tape and gauze.2
Instruct the patient to remain in a supine position for 15 minutes to
maintain pressure on the aspiration or biopsy site.2
Discard used supplies in appropriate receptacles.38
Assist the patient into a comfortable position.
Return the bed to the lowest position to prevent falls and maintain patient
safety.39
Place all specimens in a biohazard transport bag and send the bag
immediately to the laboratory.38
Remove and discard your gloves and other personal protective
equipment.38
Perform hand hygiene.5678910
Continue to assess the patient until fully awake.2Note that the sedative's
duration of action may extend beyond the time needed to complete the
procedure.
● Reassess and respond to the patient's pain by evaluating the response to
treatment and progress toward pain management goals. Assess for
adverse reactions and risk factors for adverse events that may result from
treatment.26
● Perform hand hygiene.5678910
● Document the procedure.40
Special Considerations
● Faulty needle placement may yield too small a sample. If you don't obtain a
specimen, withdraw the needle from the bone (but not from the overlying
soft tissue), replace the stylet, and insert the needle into a second site in
the anesthetized field.
● The Joint Commission issued a sentinel event alert concerning medical
device alarm safety because alarm-related events have been associated
with permanent loss of function or death. Among the major contributing
factors were improper alarm settings, alarm settings turned off
inappropriately, and alarm signals not audible to staff. Make sure alarm
limits are set appropriately and that alarms are turned on, functioning
properly, and audible to staff. Follow facility guidelines for preventing alarm
fatigue.
● If the patient received a sedative, monitor the patient closely.2
● Don't collect bone marrow specimens from irradiated areas because
radiation may have altered or destroyed the marrow.41
● Apply ice to the site, as needed, to reduce discomfort and the risk of
bleeding.2
Patient Teaching
Instruct the patient to leave the sterile pressure dressing in place for 24 hours.2 If
the patient received a sedative, provide instruction about safety concerns and
driving restrictions.2 Advise the patient to avoid strenuous activity, tub baths, hot
tubs, swimming pools, and whirlpool baths for 48 hours after the procedure to
allow the biopsy site adequate time to heal. Tell the patient to expect mild to
moderate discomfort at the site for 24 to 48 hours. Instruct the patient to take
analgesics as needed but to avoid aspirin and nonsteroidal anti-inflammatory
drugs for 24 hours to minimize the risk of bleeding from the site.2 Tell the patient
that an ice pack may decrease pain and prevent hematoma formation.2 Instruct
the patient to call if bleeding or fever occurs after discharge.
Complications
Bleeding and infection are potentially life-threatening complications of aspiration
and biopsy at any site. Complications of bone marrow aspiration and biopsy are
uncommon but include hematoma, retroperitoneal bleeding, local infection, and
nerve damage.2
Documentation
Document the date and time of the procedure, the location of the aspiration or
biopsy site, and the patient's tolerance of the procedure. Note the amount and
color of aspirated or biopsied marrow, ordered laboratory tests, and time you
sent the specimen to the laboratory. Record the patient's vital signs, oxygen
saturation level, pain level, and level of consciousness. Note cardiac arrhythmias
or other complications that occurred during the procedure, and document the
type of dressing applied. Document teaching provided to the patient and family (if
applicable), their understanding of that teaching, and any need for follow-up
teaching.
1
Chapter 32
Assessment of Hematologic Function and Treatment Modalities
Hematologic System
The blood and the blood forming sites, including the bone marrow and the
reticuloendothelial system
(RES)
Blood
Plasma: fluid portion of blood
Blood cells: erythrocytes, leukocytes, thrombocytes
Hematopoiesis
Bone Marrow
Stem cells
Myeloid
Erythrocytes (RBC)
Leukocytes (WBC)
Platelets
Lymphoid
Lymphocytes
Stroma
Hematopoiesis is the complex process of the formation and maturation of blood
cells
Red Blood Cells: Erythrocytes
Types
Hemoglobin
Reticulocytes
Erythropoiesis
Iron stores and metabolism
Vitamin B12 and folic acid
2
Destruction
White Blood Cells: Leukocytes
Granulocytes
Eosinophils
Basophils
Neutrophils
Bands: left shift
Agranulocytes
Monocytes
Lymphocytes
T cells and B cells
Platelets: Thrombocytes
Thrombopoietin
Fibrin
Plasma and Plasma Proteins
Albumin
Globulins
Alpha
Beta
Gamma
Impact on fluid balance
The neutrophils are the mature, circulating white blood cells. When a bacterial
infection occurs, the
neutrophils will increase in order to phagocytize the bacteria
Reticuloendothelial System
Histiocytes
Kupffer cells
3
Peritoneal macrophages
Alveolar macrophages
Spleen
Hemostasis
Assessment of Hematologic Health
Health history (refer to Chart 32-1)
Physical assessment
Diagnostic evaluation
Hematologic studies
Bone marrow aspiration and biopsy
Bone Marrow Aspiration
Therapeutic Approaches
Splenectomy
Apheresis
Hematopoietic stem cell transplantation (HSCT)
Phlebotomy
Blood component therapy
Special preparations
There are a variety of complications and reactions that can occur from a blood
transfusion. Depending
on the type will determine the presenting symptoms
Blood and Blood Products #1
Donor requirements
Donation types
Directed
Standard
4
Autologous
Intraoperative blood salvage
Hemodilution
Blood and Blood Products #2
Complications of donation
Blood processing
Transfusion
Common settings
Pretransfusion assessment
Patient education
Transfusion Process: PRBC
Transfusion Complications
Febrile nonhemolytic reaction
Acute hemolytic reaction
Allergic reaction
Circulatory overload
Bacterial contamination
Transfusion-related acute lung injury
Delayed hemolytic reaction
Disease acquisition
Long-term transfusion therapy
5
Nursing Management for Reactions
Stop
Assess
Notify primary provider and implement prescribed treatments. Continue to
monitor
Return blood
Obtain any samples needed
Document
Transfusion Alternatives
Refer to Chart 32-6
Growth factors
Erythropoietin
Granulocyte colony-stimulating factor
Granulocyte-macrophage colony-stimulating factor
Thrombopoietin
Chapter 33 Management of Patients With Nonmalignant Hematologic Disorders
❖ Anemias
Lower than normal hemoglobin and fewer than normal circulating erythrocytes; a
sign of an
underlying disorder
❖ Hypoproliferative: defect in production of RBCs
o Caused by iron, vitamin B12, or folate deficiency, decreased erythropoietin
production,
cancer
❖ Hemolytic: excess destruction of RBCs
o Caused by altered erythropoiesis, or other causes such as hypersplenism,
drug-induced
or autoimmune processes, mechanical heart valves
May also be caused by blood loss
❖ Manifestations
Depends on the rapidity of the development of the anemia, duration of the
anemia, metabolic
requirements of the patient, concurrent problems, and concomitant features
6
o Fatigue, weakness, malaise
o Pallor or jaundice
o Cardiac and respiratory symptoms
o Tongue changes
o Nail changes
o Angular cheilosis
o Pica
Hypoproliferative anemia results from defective red blood cell production
Diagnostic Testing
o Hemoglobin and hematocrit
o Reticulocyte count
o RBC indices
o Iron studies
o Vitamin B12
o Folate
o Haptoglobin and erythropoietin levels
o Bone marrow aspiration
❖ Medical Management
Correct or control the cause
Transfusion of packed RBCs
Treatment specific to the type of anemia
o Dietary therapy
o Iron or vitamin supplementation: iron, folate, B12
o Transfusions
o Immunosuppressive therapy
o Other
❖ Nursing Process: The Patient With Anemia—Assessment
o Health history and physical exam
o Laboratory data
o Presence of symptoms and impact of those symptoms on patient’s life; fatigue,
weakness,
malaise, pain
o Nutritional assessment
o Medications
7
o Cardiac and GI assessment
o Blood loss: menses, potential GI loss
o Neurologic assessment
o Pallor From Anemia
❖ Nursing Process: The Care of the Patient With Anemia—Diagnoses
o Fatigue
o Altered nutrition
o Altered tissue perfusion
o Noncompliance with prescribed therapy
❖ Collaborative Problems and Potential Complications #1
o Heart failure
o Angina
o Paresthesias
o Confusion
o Injury related to falls
o Depressed mood
❖ Nursing Process: The Care of the Patient With Anemia—Planning
Major goals include decreased fatigue, attainment or maintenance of adequate
nutrition, maintenance
of adequate tissue perfusion, compliance with prescribed therapy, and absence of
complications
❖ Nursing Process: The Care of the Patient With Anemia—Interventions
o Balance physical activity, exercise, and rest
o Maintain adequate nutrition
o Maintain adequate perfusion
o Patient education to promote compliance with medications and nutrition
o Monitor VS and pulse oximetry; provide supplemental oxygen as needed
8
o Monitor for potential complications
❖ Hypoproliferative Anemias
o Iron deficiency anemia
o Anemia in renal disease
o Anemia of inflammation
o Aplastic anemia
o Megaloblastic anemia
o Folic acid deficiency
o Vitamin B12 deficiency
❖ Hemolytic Anemias
o Sickle cell disease
o Thalassemia
o Glucose-6-phosphate dehydrogenase deficiency
o Immune hemolytic anemia
o Hereditary hemochromatosis
o Others (refer to Chart 33-1)
❖ Nursing Process: The Patient With Sickle Cell Disease—Assessment
o Health history and physical exam
o Pain assessment
o Laboratory data: S-shaped hemoglobin
o Presence of symptoms and impact of those symptoms on patient’s life;
swelling, fever, pain
o Sickle cell crisis assessment
o Blood loss: menses, potential GI loss
o Cardiovascular and neurologic assessment
o Chronic Skin Ulcers of Sickle Cell
9
❖ Nursing Process: The Patient With Sickle Cell Disease—Diagnoses
o Acute pain and fatigue
o Risk for infection
o Risk for powerlessness
o Deficient knowledge
❖ Collaborative Problems and Potential Complications #2
o Hypoxia, ischemia, infection
o Dehydration
o CVA
o Anemia
o Acute and chronic kidney disease
o Heart failure
o Impotence
o Poor compliance
o Substance abuse
❖ Nursing Process: The Patient With Sickle Cell Disease—Interventions
o Pain management
o Manage fatigue
o Infection prevention
o Promote coping
o Education of disease process
o Monitor for complications
o Polycythemia
o Increased volume of RBCs
10
❖ Secondary polycythemia
o Excessive production of erythropoietin from reduced amounts of oxygen,
cyanotic heart
disease, nonpathologic conditions or neoplasms
❖ Medical management
o Treatment not needed if condition is mild
o Treat underlying cause
o Therapeutic phlebotomy
❖ Neutropenia
o Decreased production or increased destruction of neutrophils (<2000/mm3
)
o Increased risk for infection: monitor closely
o Absolute neutrophil count (ANC)
o Medical management: treatment depends on the cause
o Nursing management: patient education, preventing and managing
complications
o Refer to Chart 33-5
❖ Bleeding Disorders #1
Failure of hemostatic mechanisms
❖ Causes
o Trauma
o Platelet abnormality
o Coagulation factor abnormality
❖ Medical management: specific blood products
❖ Nursing management: limit injury, assess for bleeding, bleeding precautions
❖ Bleeding Disorders #2
o Secondary thrombocytosis
o Thrombocytopenia
o Immune thrombocytopenic purpura (ITP)
11
o Platelet defects
o Hemophilia
o von Willebrand disease
o Acquired Coagulation Disorders
o Liver disease
o Vitamin K deficiency
o Complications of anticoagulant therapy
o Disseminated intravascular coagulation (DIC)
o Thrombotic disorders
o Hyperhomocysteinemia
o Antithrombin deficiency
o Protein C & S deficiency
o Activated protein C resistance and factor V Leiden mutation
o Acquired thrombophilia
o Malignancy
❖ DIC
Not a disease but a sign of an underlying disorder
Severity is variable; may be life threatening
Triggers may include sepsis, trauma, shock, cancer, abruptio placentae, toxins,
and allergic
reactions
Altered hemostasis mechanism causes massive clotting in microcirculation. As
clotting factors
are consumed, bleeding occurs. Symptoms are related to tissue ischemia and
bleeding
❖ Laboratory tests
❖ Treatment: treat underlying cause, correct tissue ischemia, replace fluids and
electrolytes,
maintain blood pressure, replace coagulation factors, use heparin or LMWH
❖ Pathophysiology of DIC
❖ Nursing Process: The Care of the Patient With DIC—Assessment
o Be aware of patients who are at risk for DIC and assess for signs and
symptoms of the
condition
o Assess for signs and symptoms and progression of thrombi and bleeding
o Common Lab Values of DIC
12
❖ Nursing Process: The Care of the Patient With DIC—Diagnoses
o Risk for fluid volume deficiency
o Risk for impaired skin integrity
o Risk for imbalanced fluid volume
o Ineffective tissue perfusion
o Risk for injury
o Death anxiety
❖ Collaborative Problems and Potential Complications #3
o Kidney injury
o Gangrene
o Pulmonary embolism or hemorrhage
o Acute respiratory distress syndrome
o Stroke
❖ Nursing Process: The Care of the Patient With DIC—Planning
o Major goals may include maintenance of hemodynamic status, maintenance of
intact skin and
oral mucosa, maintenance of fluid balance, maintenance of tissue perfusion,
enhanced coping,
and absence of complications
❖ Nursing Process: The Care of the Patient With DIC—Interventions
o Assessment and interventions should target potential sites of organ damage
o Monitor and assess carefully
o Avoid trauma and procedures that increase the risk of bleeding, including
activities that would
increase intracranial pressure
o Pharmacology and Coagulation
o Unfractionated heparin therapy
o Thrombosis prevention
o Maintain therapeutic aPTT
o Heparin-induced thrombocytopenia
o Low--molecular-weight heparin therapy
o Warfarin (Coumadin) therapy
o Impact of vitamin K
13
o INR
❖ Dabigatran (Pradaxa), rivaroxaban (Xeralto), apixiban (Eliquis), endoxaban
(Savaysa), Aspirin
Chapter 34 Management of Patients With Hematologic Neoplasms
❖ Hematopoietic Malignancies
Hematopoietic malignancy originates in the hematopoietic stem cell, the myeloid,
or the
lymphoid stem cell
❖ Clonal stem cell disorders occur when the control mechanism fails and
“indolent” clone cells
may evolve to more aggressive clone cells
❖ Classification by Cells Involved
❖ Leukemia: Proliferation of particular cell type:
o Granulocytes
o Lymphocytes
o Infrequently erythrocytes or megakaryocytes
❖ Lymphoma: Neoplasms of lymphoid tissue, usually derived from B lymphocyte
❖ Multiple myeloma: Malignancy of the most mature form of B lymphocyte—the
plasma cell
❖ Leukemia
Hematopoietic malignancy with unregulated proliferation of leukocytes
❖ Types
o Acute myeloid leukemia
o Chronic myeloid leukemia
o Acute lymphocytic leukemia
o Chronic lymphocytic leukemia
These are four types of leukemia. Each caries a different treatment and prognosis
❖ Acute Myeloid Leukemia (AML) #1
o Defect in stem cell that differentiate into all myeloid cells: monocytes,
granulocytes,
erythrocytes, and platelets
o Most common nonlymphocytic leukemia
o Affects all ages with peak incidence at age 67 years
o Prognosis is highly variable
14
o Manifestations: fever and infection, weakness and fatigue, bleeding tendencies,
pain from
enlarged liver or spleen, hyperplasia of gums, bone pain
❖ Acute Myeloid Leukemia (AML) #2
❖ Treatment:
o Aggressive chemotherapy—induction therapy,
o Hematopoietic stem cell transplantation (HSCT)
❖ Supportive care
o May be the only option
o Antimicrobial therapy and transfusions
o Death occurs within months
❖ Chronic Myeloid Leukemia (CML)
o Mutation in myeloid stem cell with uncontrolled proliferation of
cells—Philadelphia
chromosome
o Stages: chronic phase, transformational phase, blast crisis
o Uncommon in people younger than age 20 years, with increased incidence with
age; mean age:
64 years
o Manifestations: initially may be asymptomatic, malaise, anorexia, weight loss,
confusion or
shortness of breath caused by leukostasis, enlarged tender spleen, or enlarged
liver
o Treatment: imatinib mesylate (Gleevec) blocks signals in leukemic cells that
express BCR-ABL
protein; chemotherapy, HSCT
❖ Acute Lymphocytic Leukemia (ALL)
o Uncontrolled proliferation of immature cells from lymphoid stem cell
o Most common in young children, boys more often than girls, peak age 4 years
old
o Prognosis is good for children; 85% for 3-year event-free survival but drops
with increased age
<45% adults
o Manifestations: Pain from enlarged liver/spleen, bone, CNS; headache and
vomiting
o Treatment: chemotherapy, HSCT, monoclonal antibody therapy, corticosteroids
o Lymphadenopathy
15
❖ Chronic Lymphocytic Leukemia (CLL)
o Common malignancy of older adults, and the most prevalent type of adult
leukemia, mean: 72
years old
o Derived from a malignant clone of B lymphocytes
o Survival varies from 2 to 14 years depending on stage
o Manifestations: “B symptoms,” a constellation of symptoms including fevers,
drenching sweats
(especially at night), and unintentional weight loss
o Treatment: early stage “watch and wait”, chemotherapy, monoclonal antibody
therapy, IVIG for
recurrent infections, and HSCT
❖ Nursing Process: The Care of the Patient With Leukemia—Assessment
o Health history
o Assess symptoms of leukemia and for complications
o Anemia, infection, and bleeding
o Weakness and fatigue
o Laboratory tests
o Leukocyte count, ANC, hematocrit, platelets, creatinine and electrolyte levels,
and
coagulation and hepatic function tests
o Cultures as needed
❖ Nursing Process: The Care of the Patient With Leukemia—Diagnoses
o Risk for infection and/or bleeding
o Impaired oral mucous membrane
o Imbalanced nutrition and fluid volume
o Acute pain
o Fatigue and activity intolerance
o Risk for imbalanced fluid volume
o Self-care deficits due to fatigue
o Anxiety
o Risk for spiritual distress and knowledge deficit
16
❖ Collaborative Problems and Potential Complications
o Infection
o Bleeding/DIC
o Renal dysfunction
o Tumor lysis syndrome
❖ Nursing Process: The Care of the Patient With Leukemia—Planning
Major goals may include:
o Absence of complications and pain
o Attainment and maintenance of adequate nutrition
o Activity tolerance
o Ability to provide self-care and to cope with the diagnosis and prognosis
o Positive body image
o Understanding of the disease process and its treatment
❖ Nursing Process: The Care of the Patient With Leukemia—Interventions #1
o Interventions related to risk of infection and bleeding
o Mucositis
o Frequent, gentle oral hygiene
o Soft toothbrush or if counts are low, sponge-tipped applicators
o Rinse only with NS, NS and baking soda, or prescribed solutions
o Perineal and rectal care
❖ Nursing Process: The Care of the Patient With Leukemia—Interventions #2
o Improve nutritional intake
o Oral care before and after meals
o Administer analgesics before meals
o Appropriate treatment of nausea
o Small, frequent feedings
17
o Soft foods that are moderate in temperature
o Low-microbial diet
o Nutritional supplements
❖ Nursing Process: The Care of the Patient With Leukemia—Interventions #3
o Easing pain and discomfort
o Acetaminophen (Tylenol) for fever and myalgias
o Cool water sponging
o Frequent bedding changes
o Gentle massage
o Relaxation techniques
o Decreasing fatigue and activity intolerance
o Balance activity and rest
o Nursing Process: The Care of the Patient With Leukemia—Interventions
#4
o Maintaining fluid and electrolyte balance
o Intake and output, daily weights
o Assess for dehydration and overload
o Laboratory studies including electrolytes, blood urea nitrogen,
creatinine, and hematocrit
o Replacement as necessary
o Improve self-care, self-esteem, anxiety, and grief with empathetic listening and
realistic reassurance
❖ Myelodysplastic Syndromes (MDS)
o Disorder of the myeloid stem cell
o May be asymptomatic or present with fatigue or illness
o Diagnosed with CBC or bone marrow biopsy
o Occurs in older adult: mean 65 to 70 years old
o Only cure is with HCST
18
o Other treatment: blood transfusion, bone marrow–stimulating agents,
immunosuppressive
therapy in some, chelation therapy, and myeloid growth factors
❖ Myeloproliferative Neoplasms
o Polycythemia vera
o Essential thrombocythemia
o Primary myelofibrosis
❖ Polycythemia Vera
o Proliferative disorder of the myeloid stem cells
o Median age 65 and survival 14 to 24 years
o Symptoms include ruddy complexion, splenomegaly, high blood pressure,
generalized pruritis,
and erythromelalgia
o Diagnosis: elevated hemoglobin or hematocrit and the presence of an acquired
mutation in the
JAK2 gene
o Risks include thrombosis complications (CVA, MI) and bleeding from
dysfunctional platelets
o Polycythemia Vera Treatment
o Phlebotomy (500 mL or once or twice a week)
o Chemotherapeutic agents to suppress marrow function
o Aggressive management of atherosclerosis
o Allopurinol to prevent gout
o Aspirin for pain
o Platelet aggregation inhibitors
o Interferon
❖ Essential Thrombocythemia
o Also called primary thrombocythemia
o Stem cell disorder within the bone marrow
o Cause is unknown, affects women more than men, median age 65 to 70 years
old
o Symptoms usually occur from vascular occlusion, headaches, enlarged spleen,
and hemorrhage
19
o Treatment based on risk for developing thrombosis or hemorrhage, and the
presence of
symptoms
o Table 34-2
❖ Primary Myelofibrosis
o Chronic myeloproliferative disorder within the stem cell
o Disease of older adults 65 to 70 years; survival rate 2 to 10 years
o Pancytopenia is common
o Symptoms include enlarged spleen, fatigue, pruritus, bone pain, weight loss,
infection, bleeding,
and cachexia
o Treatment based on reducing the burden of the disease (by decreasing
symptoms and
splenomegaly) and improving blood count. Splenectomy may be used to control
significant
problems
o Primary Myelofibrosis Treatment
o Treatment based on reducing the burden of the disease and improving blood
counts:
o Blood transfusions and erythroid stimulating agents for anemia
o HSCT useful in younger people, only current therapy to reduce fibrosis of
marrow
o Splenectomy may be used to control significant problems
❖ Lymphoma
o Neoplasm of lymphoid origin
o Usually start in lymph nodes but can involve lymphoid tissue in the spleen, GI
tract, liver, or
bone marrow
o Refer to Figure 35-1
o Classified according to degree of cell differentiation and origin of predominant
malignant cell
o Two major categories:
o Hodgkin lymphoma
o Non-Hodgkin lymphoma
❖ Hodgkin Disease
o Relatively rare malignancy that has a high cure rate
20
o Suspected viral etiology, familial pattern, incidence in early 20s and again after
the age of 50
years; more common in men
o Unicentric; initiates in a single node
o Reed--Sternberg cell (Fig. 34-7)
o Manifestations: painless lymph node enlargement; pruritus; B symptoms: fever,
sweats, weight
loss
o Treatment is determined by stage of the disease and may include
chemotherapy, radiation
therapy, or both, and HSCT for advanced disease
❖ Non-Hodgkin Lymphoma (NHL)
o Lymphoid tissues become infiltrated with malignant cells; spread is
unpredictable and localized
disease is rare
o Increases with age, with average age being 66 years
o Increased in autoimmune, prior treatment for cancer, organ transplant, viral
infections,
exposure to pesticides
o Manifestation: lymphadenopathy, B symptoms, and symptoms associated with
lymphomatous
masses
o Treatment is determined by type and stage of disease and may include
interferon,
chemotherapy, radiation therapy, and HSCT
❖ Multiple Myeloma
o Malignant disease of the most mature form of B lymphocyte—the plasma cell
o Incidence increases with age; median 70 years old; 5 year survival rate; no cure
o Manifestations: bone pain reported in 80%, mostly back and ribs; osteoporosis
and fractures
related to bone destruction; hypercalcemia, renal impairment and failure, anemia
o Treatment may include HSCT, chemotherapy, corticosteroids, radiation therapy,
o New drugs being used: immunomodulatory drugs (IMiDs), thalidomide analogs,
monoclonal
antibody
o Multiple Myeloma Treatment
o Treatment may include:
o Auto HSCT
o Chemotherapy and radiation
21
o Corticosteroid
❖ New drugs being used:
o Immunomodulatory drugs (IMiDs)
o Thalidomide analogs
o Monoclonal antibody
❖ Multiple myeloma
Any older adult patient whose chief complaint is back pain and who has an
elevated total protein level
should be evaluated for possible myeloma