NUR 240
Hematological Stressors
JBorrero 10/09
Charting Chuckles
1.
She has no rigors or shaking chills, but her husband states
she was very hot in bed last night
2. Patient has chest pain if she lies on her left side for over a
year.
3. On the second day the knee was better, and on the third day
it disappeared.
4 . The patient is tearful and crying constantly. She also appears
to be depressed
5. The patient has been depressed since she began seeing me
in 1993
6. Discharge status: Alive but without my permissio
7. Healthy appearing decrepit 69-year-old male, mentally alert
but forgetful.
8. The patient refused autopsy.
9. The patient has no previous history of suicides.
10. While in ER, she was examined, x-rated and sent home
Topics
• Anemias resulting in decreased production of
RBC’s
Pernicious anemia
Iron deficiency anemia
Folic acid deficiency anemia
Aplastic anemia
• Polycythemia Vera
• Leukemia-CML/CLL
• Blood transfusion procedures and reactions
Anatomy and Physiology
Review
• Bone marrow
• Blood components
Red blood cells (erythrocytes)
White blood cells (leukocytes)
Thrombocytes (platelets)
• Accessory organs of hematopoiesis
Spleen
Liver
Kidneys
Bone Marrow Hematopoiesis
Erythrocytes
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RBCs are largest proportion of blood cells
Flexible membrane, no nucleus
Normal count 4-6 million
Lifespan 120 days
Produce Hgb
Kidneys produce RBC growth
factor:erythropoietin
Erythrocyte Depletion
• Iron deficiency
anemia
• B12/folic acid
deficiency
• Pernicious anemia
• Aplastic anemias
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Sickle cell anemia
G6PD
Acute blood loss
Chronic blood loss
Anemia
• Result of a condition in which the function or
number of RBCs is inadequate to meet tissue
oxygen demands.
• Insufficient function of RBCs:
B12, Iron, Folic Acid deficiencies
• Reduction in either the number of red blood
cells, the amount of hemoglobin, or the
hematocrit
• Clinical sign (not a specific disease); a
manifestation of several abnormal conditions
• Tissue hypoxia is the underlying cause of all
symptoms accompanying anemia
WBCs or Leukocytes
Involved with inflammation and immunity
Look for “differential” on WBC count
Granulocytes-increase rapidly in presence of
infection
1. Monocytes- Macrophages- 1st line of defense
2. Neutrophils- 2nd line of defense
3. Basinophils- help mediate allergic reactions
4. Eosinophils- antiparasitic, limits local
inflammation
Lymphocytes
• B-lymphocytes- antibody mediated
immunity
• T-lymphocytes- cell mediated immunity
Platelets
• Smallest of blood cells
• Stick to injured blood vessel walls to form
platelet plugs
• Perform most of their function by
aggregation
• 80% platelets circulate, 20% stored in
spleen
Assessment
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Family history and genetic risk
Personal history
Diet history
Socioeconomic status
HPI
Physical Exam
Dx Testing
Physical Assessment
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Skin
Head and neck
Respiratory
Cardiovascular
Renal and urinary
Musculoskeletal
Abdominal
Central nervous system
Psychosocial
Diagnostic Assessment
Tests of cell number and function:
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Complete blood count
Reticulocyte count
Differential
Coombs’ test
Serum ferritin, transferrin, and total ironbinding capacity
Coagulation Studies
Bone Marrow aspiration/biopsy
CAT Scans
CBC with Differential
WBC
RBC
HGB
HCT
MCV,MCH, MCHC
Platelets
Neutrophils, Eosinophils,
Basophils, Lymphocytes (T&B),
Monocytes
Reticulocytes Count
4.5-11.0
3.80-5.20
11.7-15.7
35.0-47.0%
140K-440K
Differential
0.5-2.5% total
RBC
Tests Measuring Bleeding
and Coagulation
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Bleeding time test
Prothrombin time (PT)
International normalized ratio (INR)
Partial thromboplastin time (PTT)
Platelet agglutination/aggregation
Bone marrow aspiration and Bx
• Done when other tests show persistent
abnormal results
• Results will show bone marrow
function
• Aspiration
• Biopsy
Preparation
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Physician’s order
Consent & Vital Signs
Performed at bedside/lab
Procedure takes 5-15 minutes
Provide support/accurate info
Local anesthetic/rapid acting sedative
May feel pressure/pushing/pain
May feel stinging/burning sensation
Site: ileac crest is most common
Sterile precautions
Follow-up Care
• Give client education.
• Cover with pressure dressing; observe
for 24 hours.
• Administer mild analgesic (ASA free)
• Apply ice pack.
• Avoid contact sports or any activity
that might result in trauma to the area.
NCLEX TIME
• After a bone marrow aspiration, the nurse
questions which post procedure order?
• A.Administer aspirin for pain
• B.Apply ice packs to the puncture site.
• C.Administer acetaminophen for
discomfort.
• D.Maintain sandbag on puncture site until
bleeding stops
NCLEX TIME
In reviewing laboratory data in a client, the
nurse recognizes which hematologic
change associated with aging?
• A.Decreased red blood cells
• B.Decreased platelets
• C.Increased hemoglobin
• D.Increased white blood cells
Goals of tx for anemias
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Enhance tissue perfusion
Minimize O2 demand
Maintain CO
Prevent hypovolemia
Minimize complications of therapy
Iron Deficiency Anemia
• This common type of anemia can result
from blood loss, poor intestinal
absorption, or inadequate diet.
• Evaluate adult clients for abnormal
bleeding.
• Supplemental iron is the treatment.
• Microcytic- RBC cell size is smaller
than normal
Vitamin B12 Deficiency Anemia
Pernicious Anemia
• Anemia is caused by inhibiting folic acid
transport and reducing DNA synthesis in
precursor cells.
• B12 transports Folic Acid into RBC precursor
cell
• Pernicious anemia is anemia caused by failure
to absorb vitamin B12 by lack of intrinsic factor
Etiology:
Vitamin B12 deficiency is a result of poor intake
of foods containing vitamin B12. OR
Intrinsic Factor deficiency
Vitamin B12 Deficiency
Anemia
S&S- paresthesias, loss of coordination,
smooth, beefy, sore, bright red tongue
weight loss and fatigue, pallor
DX test: Schilling Test-24hr urine
Tx:
Pernicious Anemia: Vitamin B12
(Cyanocobalamin) injections
Poor dietary intake: Increase intake of
liver/organ meats, dried beans. Citrus
fruits, eggs , green leafy vegetables
Folic Acid Deficiency Anemia
• Can cause megaloblastic anemia
• Manifestations similar to those of
vitamin B12 deficiency, but nervous
system functions remain normal
Folic Acid Deficiency Anemia
• Caused by:
– Poor nutrition and chronic alcohol abuse
– Malabsorption syndromes, such as
Crohn’s disease
– Drugs, including anticonvulsants and oral
contraceptives, that slow or prevent
absorption of folic acid
– Tx- Folic Acid
Nursing Interventions for B12 and
Folic Acid Deficiency Anemias
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Assess VS, labs, pulse ox
Provide care for oral mucous membranes
Administer B12 IM, Folic Acid
Teach about disease process and selfinjection
• Pace activities
• Eliminate alcohol intake
• Diet modification
Aplastic Anemia
• Deficiency of circulating erythrocytes
• Injury to the hematopoietic precursor cell
• Usually leukopenic and thrombopenic as
well: PANCYTOPENIC
ETIOLOGY: chronic toxic exposure, viral,
50% idiopathic
CLINICAL MANIFESTATIONS:
Medical Management
• Immunosuppressive tx
• Splenectomy
• Bone marrow transplant
Anemias from Blood Loss
• ACUTE
• Severed blood
vessels due to trauma
• Rupture of aneurysm
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• Tx
• Tx
CHRONIC
Peptic ulcers
Excessive menses
Bleeding hemorrhoids
Polycythemia Vera
• Malignant disease with a sustained
increase in blood hemoglobin
• Massive production of red blood cells
• Excessive leukocyte production
• Excessive production of platelets
• Blood viscosity and blood volume
increased
• Severe congestion of all tissues and
organs
Etiology
• Usually unknown (idiopathic)
• Sometimes caused by other conditions
such as COPD, high altitudes, heart failure
• Bone marrow produces more RBCs to
prevent hypoxia
Clinical Manifestations
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Hypertension
Epistaxis, Ecchymosis, Hemorrhage
Complications of MI, CVA
Headaches
Red, dark, flushed hands & skin
Splenomegaly and Hepatomegaly
Intense itching
Distended superficial veins
Treatment
• Phlebotomy- keep Hct<45
• Myelosuppressive agents- suppress bone
marrow
• Radiation tx
• Hydration
• Promote venous return
• Encourage oral fluids
• Encourage ambulation
• Anticoagulation therapy
Leukemia
• Type of cancer with uncontrolled
production of immature white blood cells
in the bone marrow
• Invade and destroy bone marrow
• Metastasize to liver, spleen, lymph
nodes, testes and brain
• Acute or chronic
• Classified by cell type- lymphocytic vs.
myelocytic
• Patients are vulnerable to infection and
anemia
Etiology
Exact cause is unknown
Risk factors:
ionizing radiation
exposure to certain chemicals and
drugs
genetic factors
immunologic factors
treatment for other types of cancer
Classification of Leukemia
• Acute- can die in days to 6mos without
appropriate tx
Acute Lymphocytic Leukemia
Acute Myelogenous Leukemia
• Chronic- gradual onset, can live 5 years or
more without tx
Chronic Lymphocytic Leukemia
Chronic Myelogenous Leukemia
Clinical Manifestations
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Neuro
CV
Resp
MS
GI
GU
Integumentary
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Signs of bleeding
Signs of anemia
Lymphadenopathy
CBC abnormal
Signs of infection
Definitive Test
Examination of cells obtained from bone
marrow aspiration and biopsy
Nursing Diagnoses
Risk for Injury
Alteration in
oral mucus
membranes
Alteration in
nutrition, less
Grieving
Nausea
Bleeding
Fatigue
Risk for infection Acute or
chronic Pain
Risk for Infections
• Infection is a major cause of death in
the client with leukemia, and sepsis is a
common complication.
• Cross-contamination
GOAL: prevent, treat and control
infection
Infection Prevention
• “Minimal bacteria diet” without
uncooked foods
• Monitoring of daily laboratory results
• Assessment of vital signs
• Skin care, respiratory care
• Prevent and manage stomatitis
• Teach pt to care for CVAD
Protective Isolation
• Frequent handwashing
• Private room
• HEPA filtration or laminar airflow
system
• Mask for visitor with upper respiratory
infection
• Institute precautions for pt with low
platelet count
Treatment for Leukemia:
Chemotherapy
Intensive/combo at time of dx.
Goal: Remission
SIDE EFFECTS:
Bone marrow suppression
N/V/D
Alopecia
Stomatitis
Kidney/liver/cardiac toxicity
Leukemia Treatment
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Radiation tx
Antibiotics, anti-virals, anti-fungal agents
Interferon/ Interlukin
Neupogen
Epogen, Procrit,
Diet tx
PRBC- leukocyte depleted transfusion
Patient education
Emotional support
Side Effects of RT/CT
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Drug induced pancytopenia
Severe N&V
Skin problems at site of RT
Impaired hepatic function
Permanent sterility for males with RT to
pelvic area
• Secondary Ca development
Bone Marrow Transplantation
• Standard treatment for leukemia
• Before procedure, CT and total body
irradiation
• Purges present marrow of the leukemic
cells
• After conditioning, new, healthy
marrow given to the client toward a
cure
Types of BMT
• Allogeneic
• Syngeneic
• Autologous
Complications of BMT
1.Failure to engraft
2.Graft vs host disease (GVHD)
3.Bleeding / Infection
4.Fatigue
5.Venocclusive disease
Blood Transfusions
Types of Blood Products
• Red blood cell
• Platelet transfusions
• Plasma transfusions: fresh frozen
plasma
• Cryoprecipitate
• Granulocyte (white cell) transfusions
*Review typing/crossmatching
*Review ABO Compatibilities
Blood Products:
Transfusion Therapy
Pretransfusion responsibilities to prevent
adverse transfusion reactions:
– Verify prescription.
– Test donor’s and recipient’s blood for
compatibility.
– Examine blood bag for identification.
– Check expiration date.
– Inspect blood for discoloration, gas
bubbles, or cloudiness.
Nursing Interventions
• Explain procedure
• Get signed consent
• Start transfusion within 30 minutes of
arrival from blood bank
• IV access: What size angiocath?
• Y tubing, filter and which fluid?
• Check blood with another RN
• Obtain Vital Signs
• Teach patient to report any untoward
symptoms
• Premedicate if necessary
Transfusion Responsibilities
• Provide client education.
• Assess vital signs.
• Begin transfusion slowly and stay with
client first 15 to 30 minutes.
• Ask client to report unusual sensations
such as chills, shortness of breath, hives, or
itching.
• If reaction occurs: STOP TRANSFUSION
• Change tubing, call MD, call blood bank. Get
urine/blood samples. Send blood bag to lab
Transfusion Reactions
• Clients can develop any of the
following transfusion reactions:
– Hemolytic
– Allergic
– Febrile
– Bacterial
– Circulatory overload
Autologous Blood
Transfusion
• Collection and infusion of client’s own
blood
• Eliminates compatibility problems;
reduces risk for transmission of
bloodborne disease
• Preoperative autologous blood donation
• Intraoperative autologous transfusion
• Postoperative blood salvage