Chapter 82
Blood and Lymph Disorders
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Hematology
• Hematology
– The specialty concerned with the hematologic and
lymphatic systems
• Hematologist
– Physicians educated in hematology
• Oncologist
– Treats blood and lymph disorders
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Blood Types
• Type A
• Type B
• Type AB—Universal recipient
• Type O—Universal donor
• Rh factor: D antigen (D factor)
– Rh-positive (Rh+)
– Rh-negative (Rh–)
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ABO Blood Typing
• Indirect Coombs’ test-dectects Rh antigens-is the
positive for antigen D/or Rh-RhoGAM
• Direct Coombs’ test-dectect Rh factors attached RBC
– Type and screen test• Type and crossmatch test
• It is extremely important that the client receive blood
that matches his or her own body’s antigens and
antibodies.
• The wrong type of blood could easily be fatal.
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Nursing considerations:
• Patient’s blood type
• Antigen D positive or negative
• Temperature
• Vital signs
• Monitor transfusion reaction- page 1363
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Complete Blood Count
• Red blood cell count-measures the number of red
blood cells
– Hgb-amt of in rbc-ability to carry O2 to cells –HCT
_%RBC- 3x of Hgb-MCH, MCHCand the MCV-used
diagnosis type of anemia
• White blood cell count and differential
– Leukocytosis or leukopenia
– Leukocytosis
• Platelet count-aka megakaryocytes)8-12 days destroys
– Hemostasis-blood clotting
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Coagulation Studies
•
•
•
Prothrombin time-actual time it takes for blood to clot-measure warfarin <12 sec
–
PT, Pro Time, PT Ratio/INR-fixed standard-
–
Vitamin K usually works 12-24 hour
–
If warfarin is therapeutic then the PT us usually-1.5 2 times the normal
–
Nursing care guideline-things to avoid bullets
Partial thromboplastin time-measure the clot formation
–
PTT and APTT PTT- normal 60-90 seconds ; Aptt-25-27 seconds – Used for
heparin therapy therapeutic 1.5-2.5 normal
–
Antidote for Heparin Protamine sulfate=100 units of heparin
Bleeding time- screen platelet disorders /aka can they stop bleeding –normal bleeding
time 3-8 minutes
–
Aspirin tolerance test, a Duke bleeding time, an Ivy bleeding time, or a modified
Ivy test
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Question
Is the following statement true or false?
Successful anticoagulation therapies require a shortened
time for either the PT or the PTT/APTT.
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Answer
False
When a client is on anticoagulation therapy, a “normal”
laboratory value may indicate too little warfarin
(Coumadin) or heparin.
Successful anticoagulation therapies require a prolonged
time for either the PT (Coumadin) or the PTT/APTT
(heparin).
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Other Hematologic Studies
• Erythrocyte sedimentation rate-measures how fast the
rbc settle to bottom lab tube in one hour > indicates
inflammation
• Blood culture- before give antibiotics, if patient has a
fever; usually from 2 sites and 15 min
• Bone marrow aspiration and biopsy-evaluates number
size and shape of WBC, RBC and platelets- helpful
diagnosis
• Lymph node biopsy-diagnosis or stage of tumor
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Common Treatments
• Transfusions of colloid solutions- expanders are <.9%
–
Fluid in the extracellular dept and they bring that fluid in the
intracellular/ circulation aka blood stream
–
Macrodex ie….=expander ; erythropoietin ask Epogen stimulates RBC
• Transfusions of blood and blood products
–
Blood transfusion, allogeneic transfusion HGB is less than 8 usually
transfuse
• Blood donation
• Autologous blood donations, perioperative blood infusions,
directed blood donations
• Blood products
• Adults have 8-10 pints children approx. ½ of an adult
• Blood administration- ist 15min/ first 50mm blood
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Common Treatments (cont’d)
• Blood products
– Packed RBCs-decrease in volume
– Platelet concentrates- stop bleeding
– Fresh frozen plasma (FFP)- clotting factors
– Serum albumin-expanders
– Cryoprecipitates
– Plasmapheresis or apheresis- separate toxins
– Immunoglobulins (Ig)-IgD - Rhogam
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Question
Is the followings statement true or false?
A blood transfusion cannot transmit hepatitis.
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Answer
False
Even though it is rare, a blood transfusion can transmit
blood-borne diseases, such as hepatitis.
Tests and procedures for screening blood and selecting
blood donors have improved the safety of blood
transfusions.
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Blood Transfusion Reactions
• General
• Integumentary system
• Nervous system
• Cardiovascular system
• Respiratory system
• Gastrointestinal system
• Urinary system
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Hemopoietic Stem Cell Transplantation
• Bone marrow transplantation (BMT)
• Hematopoietic stem cell transplantation (HSCT)
• Stem cells
– Derived and developed from bone marrow,
umbilical cord blood amniotic fluid, and peripheral
blood stem cells (PBSC)
• Sources for bone marrow
– Autologous, syngeneic, allogeneic
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Nursing Process
• Data collection
• Planning and implementation
• Evaluation
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Red Blood Cell Disorders
• Polycythemia-means too many RBC
• Anemias- low than normal hgb or rbc
–
Iron-deficiency anemia-loss iron-iron aministration
–
Hemolytic anemia-destruction of RBC-tx steroids/splenectomy
–
Acute hemorrhagic anemia-trauma rapid loss
–
Chronic hemorrhagic anemia-peptic ulcer
–
Pernicious anemia-lack intrinsic factor to absorb B12
–
Aplastic anemia- failed or undeveloped bone marrow-causes-TX stem
cell-nursing considerations
• Thalassemia- deficient and damaged change HGB- may start infancy
–
Fever, enlarged spleen and failure to thrive
–
Transfusions ; PRBC
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Sickle Cell disease
• Genetic disease in the Hgb gene
• Trait –asymptotic
• Anemia –hypoxia and damage to RBC
• Symptoms
–
pain, abd, jaundice
– TX- antibiotics, folic acid, blood, o2, fluids, pain
management
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Anemias
• Symptoms box 82-1
Diagnose: CBC, HCT, HGB
• Causes
drops <8 blood
• Dietary, iron, b12 folic acid
• Cancer
• Congenital
• Infection
• Chronic bleeding
• Spleen issue
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Polycythemia
• Relative-low
vascular volume in
comparison to RBCviscosity
• Absolute-cause bone
marrow, o2 low,
cancer
– Primary-increase in
RBC
– SECONDARYincrease in
erythropoietin
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Symptoms
• HCT>55%, HTN, HA, Vertigo, enlarge spleen
• Treatment: Phlebotomy
• Hypoxia, fluids
• Signs dehydration, poor skin turgor pale mucus
membranes
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White Blood Cell Disorders
• Neutropenia and agranulocytosis- acquired/ congenital
–
Neutropenia-decease neutrophil
–
Agranulocytosis
–
S?S respiratory infections, fever, HA
–
TX: remove agent/ CSF
• Leukemia- pg 1369 TX transplants
–
Acute lymphoid leukemia (ALL) or chronic lymphoid leukemia
(CLL)
–
Acute myeloid leukemia (AML) or chronic myeloid leukemia
(CML)
–
bruising Fever, fatigue , lack appetite , night sweat and SOA
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Question
Is the followings statement true or false?
A nurse can use a pulse oximeter to reflect the number
of RBCs.
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Answer
False
The pulse oximeter reflects the ability of the RBC to
carry hemoglobin, that is, its oxygen-carrying capacity.
The pulse oximeter does not reflect the number of RBCs.
Thus, in an individual with anemia, the client may have
symptoms of hypoxia, such as dyspnea, but the pulse
oximeter might read normal.
The readings of a pulse oximeter may not truly coincide
with the severity of dyspneic symptoms.
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Platelets and Clotting Disorders
• Thrombocythemia-overproduction of platelets >600000
• Hemorrhage and vas-occlusion Nursing considerations signs and
symptoms of bleeding TX: ASA
• Thrombocytopenia-low Platelets<50.000
–
Idiopathic thrombocytopenia purpura (ITP)-s/s- bruising, headache,
bleeding
• Disseminated intravascular coagulation-cotting in the microvascular system
s/s: bleeding, PTT increase, Nursing consideration: fluids, shock, CVA, MI:
treatment: Heparin,O2, caused
• Hemophilia- sex linked disorder due to lack of clotting factor-8/ Signs:nose
bleeds , CVA, MI, Bleeding TX: clotting factor
• Von Willebrand disease-lack of factor required for platelet adhesion
Diagnosis >apt, Signs: bleed more TX: factor 8
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Signs of Internal Bleeding
• Restlessness
• Rapid pulse and a drop in blood pressure
• Unusual pallor, headache
• Signs of a cerebrovascular accident
• Joint pain and swelling
• Hematuria, hematemesis
• Blood in the stool
• Shock
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Signs of External Bleeding
• Purpura (bruising)—with or without known injury
• Petechiae (small hemorrhagic spots)
• Epistaxis (nosebleed)
• Bleeding from the gums, mouth, or tooth extraction
• Thrombocytopenia (low platelet counts)
• Menorrhagia (excessive menses)
• Death
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Lymphatic System Disorders
• Hodgkin’s lymphoma– All include small vessels, lymphatic and bone
marrow- change in B cells reed-sternberg cells –
infection-diagnosis- biopsy –S/s- painless lymph
nodes, fever fatigue,-TX radiation, chemo, stem
cells
• Non-Hodgkin’s lymphoma-over growth WBC- risk
factors –h. pylori
• Multiple myeloma- cancer of bone marrow- risk –male
black person’s Signs: high calcium/ fractures
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Question
Is the following statement true or false?
An older African American male client with the signs and
symptoms of back pain with movement, hypercalcemia,
and fractures should be tested for multiple myeloma.
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Answer
True
Typical multiple myeloma includes pathologic fractures
and hypercalcemia with skeletal deformities. Bone pain
of the back and ribs are commonly found with bone
fractures. Infections include pneumonia and
pyelonephritis. Fatigue, confusion, and weakness owing
to anemia or hypercalcemia may occur.
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End of Presentation
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