Chapter 42
Care of Patients with
Hematologic Problems
Marion Kreisel MSN, RN
NU230 Adult Health 2
Fall 2011
Anemia
• Reduction in either the number of red blood cells, the
amount of hemoglobin, or the hematocrit
• Clinical sign (not a specific disease); a manifestation of
several abnormal conditions
Cardiovascular Effects of Anemia
Sickle Cell Disease
• Genetic disorder resulting in chronic anemia, pain,
disability, organ damage, increased risk for
infection, and early death
• Sickle cell disease state and sickle cell trait
Sickle Cell Anemia
Sickle Cell Disease: Pathophysiology
• Main problem of the disorder is formation of abnormal
hemoglobin chains
Sickle Cell Disease (Cont’d)
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Response to local or systemic hypoxia
Sickle cell crisis
Etiology and genetic risk
Incidence/prevalence
Patient assessment
• KNOW ALL SLIDES ABOUT SICKLE CELL
Sickle Cell Disease: Clinical Manifestations
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Cardiovascular changes
Skin changes
Abdominal changes
Renal and urinary changes
Musculoskeletal changes
CNS changes
Sickle Cell Disease: Laboratory Assessment
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Hemoglobin S (HbS)
Number of RBCs with permanent sickling
Hematocrit
Reticulocyte count
Total bilirubin
Total white blood cells
Imaging assessment
Sickle Cell Disease: Interventions
• Pain is the most common problem:
• Drug therapy—48 hours of IV analgesics
• Oral hydration
• Complementary and alternative therapies
Sickle Cell Interventions: Potential for
Sepsis
• Interventions include:
• Prevention and early detection strategies
• Drug therapy
Sickle Cell Disease Interventions: Potential
for Multiple Organ Dysfunction
• Interventions include:
• Hydration
• Oxygen therapy
• Transfusion therapy
Glucose-6-Phosphate Dehydrogenase
(G6PD) Deficiency Anemia
• Most common type of inherited hemolytic anemia
• Effect of exposure to some drugs, benzene and other
toxins
• Screening for this deficiency necessary before donating
blood, because cells deficient in G6PD can be
hazardous
• Hydration
• Osmotic diuretics
• Transfusions
Iron Deficiency Anemia (Microcytic)
• This common type of anemia can result from blood loss,
poor intestinal absorption, or inadequate diet.
• If mild—symptoms of weakness and pallor.
• Evaluate adult patients for abnormal bleeding, especially
from the GI tract.
• Treatment—increasing oral intake of iron from food
sources, oral iron supplements, or IM iron solutions.
Vitamin B12 Deficiency Anemia (Macrocytic)
• Lack of vitamin B12 causes improper DNA synthesis of
RBCs.
• Poor intake of foods containing vitamin B12, small bowel
resection, tapeworm, overgrowth of intestinal bacteria.
Pernicious Anemia
• Anemia resulting from failure to absorb vitamin B12
• Caused by a deficiency of intrinsic factor
• Pt will need B12 Vitamins for the rest of the patient’s
life.
Folic Acid Deficiency Anemia
• Manifestations similar to those of vitamin B12 deficiency,
but nervous system functions remain normal
• Common causes—poor nutrition, malabsorption, and
drugs
Aplastic Anemia
• Deficiency of circulating RBCs because of failure of the
bone marrow to produce these cells
• Injury to the pluripotent stem cell
• Pancytopenia common
• Treatment:
• Blood transfusions
• Immunosuppressive therapy
• Splenectomy
Polycythemia Vera—Cancer of the RBCs
• Disease with a sustained increase in blood hemoglobin
or hematocrit
• Massive production of red blood cells
• Excessive leukocyte production
• Excessive production of platelets
• Treatment:
• Phlebotomy
• Hydration
• Anticoagulants
Myelodysplastic Syndromes
• Group of disorders caused by the formation of abnormal
cells in the bone marrow
• Blood and platelet transfusions
• Erythropoietin
• Chelation therapy
• Drugs for iron overload—deferasirox and deferoxamine
mesylate
Leukemia
• Type of cancer with uncontrolled production of
immature white blood cells in the bone marrow
• Acute or chronic
• Classified by cell type
• Etiology and genetic risk
• Incidence/prevalence
• History
• Assessment
Leukemia: Clinical Manifestations
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Cardiovascular changes
Respiratory changes
Skin changes
Intestinal changes
Central nervous system changes
Miscellaneous changes
Fatigue Need to alternate periods of rest and activity
Leukemia: Laboratory Assessment
• Decreased hemoglobin and hematocrit levels
• Low platelet count
• Abnormal white blood cell count; may be low,
normal, or elevated but is usually quite high
• Bone marrow aspiration and biopsy
• Blood-clotting times
• Chromosome analysis
• Imaging assessment
Leukemia Interventions: Risk for Infections
• Infection is a major cause of death in the patient with
leukemia, and sepsis is a common complication.
• Autocontamination
• Cross-contamination
• Drug therapy
• Hematopoietic stem cell transplantation
Bone Marrow Transplantation
Hodgkin’s Lymphoma
• Cancer that starts in a single lymph node or a single
chain of nodes
• Marker—Reed-Sternberg cell
• Large, painless lymph node, usually in the neck,
becomes painful when alcohol ingested; fever, drenching
night sweats, and unexplained weight loss
• Staging
• Ann Arbor Staging Criteria
Hodgkin’s Lymphoma: Interventions
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One of the most treatable types of cancer
External radiation
Chemotherapy
Combination radiation and chemotherapy
Non-Hodgkin’s Lymphoma
• All lymphoid cancers that do not have the ReedSternberg cell
• More than 12 types of non-Hodgkin’s lymphoma
Non-Hodgkin’s Lymphoma: Collaborative
Care
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Chemotherapy
Monoclonal antibodies
Localized radiation therapy
Radiolabeled antibodies
Hematopoietic stem cell transplantation
Vaccine therapy
Proteasome inhibitors
Multiple Myeloma
• White blood cell cancer that involves a more mature
lymphocyte called a plasma cell
• Assessment
• Interventions:
• Chemotherapy
• Autologous stem cell transplant
• Analgesics
• Alternative approaches for pain management
• Bisphosphonates
Autoimmune Thrombocytopenic Purpura
• Also called idiopathic thrombocytopenic purpura (ITP).
• Total number of circulating platelets is greatly reduced
even though production in the bone marrow is normal.
• Patients make an antibody directed against the surface
of their own platelets.
• Normal count 150,000-400,000/mm3
• Treatment is reserved for patients whose count is
below 50, 0/mm3, those who are bleeding, and those
who are at high risk for bleeding.
• Transfusions are not done regularly b/c pt destroys them
as if they were his/her own and back to ground zero.
Thrombocytopenia
Hemophilia (Cont’d)
Hemophilia: Collaborative Care
• Monitor for excessive bleeding from minor cuts, bruises,
or abrasions.
• Joint and muscle hemorrhages can lead to disabling
long-term problems.
• Tendency to bruise easily.
• Prolonged and potentially fatal hemorrhage after
surgery.
Transfusion Therapy
• Pretransfusion responsibilities to prevent adverse
transfusion reactions:
• Verify prescription.
• Test donor’s and recipient’s blood for compatibility.
• Examine blood bag for identification.
• Check expiration date.
• Inspect blood for discoloration, gas bubbles, or
cloudiness.
Transfusion Responsibilities
• Provide patient education.
• Assess vital signs.
• Begin transfusion slowly, and stay with patient first 15 to
30 minutes.
• Ask patient to report unusual sensations such as chills,
shortness of breath, hives, or itching.
• Administer blood product per protocol.
• Assess for hyperkalemia.
Transfusions
Blood Grouping
Types of Transfusions
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Red blood cell
Platelet
Plasma—fresh frozen plasma
Cryoprecipitate
Granulocyte (white cell)
Transfusion Reactions
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Febrile transfusion reactions
Hemolytic transfusion reactions
Allergic transfusion reactions
Bacterial transfusion reactions
Circulatory overload
Transfusion-associated graft-versus-host disease
Autologous Blood Transfusion
• Collection and infusion of patient’s own blood
• Eliminates compatibility problems; reduces risk for
transmission of bloodborne disease
• Types:
• Preoperative
• Acute normovolemic hemodilution
• Intraoperative autologous transfusion
• Postoperative blood salvage
NCLEX
TIME
Question 1
What type of transfusion reaction would the patient who
received multiple transfusions over the course of his
cancer treatment most likely experience?
A.
B.
C.
D.
Febrile
Bacterial
Allergic
Hemolytic
Question 2
How many people in the United States are estimated to
have sickle cell disease?
A.
B.
C.
D.
30,000
50,000
70,000
100,000
Question 3
A 23-year-old African-American male with a history of sickle cell
disease had an emergent open reduction and internal fixation of his
right femur after a car crash. What is the initial postoperative
nursing priority?
A.
B.
C.
D.
Ensuring adequate IV hydration
Treating the patient’s pain
Titrating oxygen to an Spo2 >95%
Examining the surgical incision for signs and symptoms of infection
Question 4
A patient with glucose-6-phosphate dehydrogenase deficiency
anemia is admitted with increasing fatigue, malaise, and jaundice.
What priority question should the nurse ask the patient during the
admission assessment?
A. “When was your last hemolytic anemia crisis?”
B. “How much fluid have you been able to drink in the past 24 hours?”
C. “Have you taken any over-the-counter medications in the past
week?”
D. “Have you had a fever in the past 24 to 48 hours?”
Question 5
What is a priority nursing intervention in the care of an
older patient with a history of diverticular disease and
pernicious anemia?
A.
B.
C.
D.
Encouraging a diet high in vitamin B12
Preventing falls
Turning the patient every 2 hours
Monitoring intake and output