Hematology & Infectious Disease Anatomy + Physiology Hematology Bone Marrow ● Produces blood cells ○ ○ ○ ○ ● Stem cells Erythrocytes Leukocytes Thrombocytes Immune response ○ Blood components Accessory organs ● Kidneys ○ ● Spleen ○ ○ ○ ● Erythropoietin ■ Stimulates production of erythrocytes Thrombopoietin ■ Controls thrombocyte production 20% of thromobytes stored in the spleen. Breaks down old erythrocytes Liver ○ Clotting factors Blood clotting ● Hemostasis ○ ○ ● ● Triggered by platelet aggregation Two pathways ○ ○ ● Prevent blood loss Maintain perfusion Intrinsic ■ Triggered by changes in the blood Extrinsic ■ Triggered by something occurring outside the blood vessels End result of coagulation = a blood clot….. Hemostasis! Polycythemia Vera What is polycythemia vera? ● ● ● Loss of cellular regulation Excessive number of erythrocytes, leukocytes, and thrombocytes This causes the blood to become hyper viscous ○ ○ ● Hemoglobin > 18 in men and >16.5 in women Hematocrit > 55% The thicker the blood, the more problems with perfusion the patient can have. Assessment ● Skin ○ ● Dark purple, cyanotic appearance CV ○ ○ ○ ○ Distended veins ■ Causes intense itching Hypertension Thrombosis Poor gas exchange ■ Hypoxia Treatment ● Apheresis ○ ○ ○ ● ● Withdrawal of whole blood Removal of the excessive components (erythrocytes) Reinfusion of the plasma back to the patient Anticoagulation Hydration Patient education Drink at least 3 liters of liquids each day. Avoid tight or constrictive clothing. Wear gloves when outdoors in temperatures lower than 50°F (10°C). Contact your primary health care provider at the first sign of infection. Wear support hose or stockings while you are awake and up. Elevate your feet whenever you are seated. Stop activity at the first sign of chest pain. Use an electric shaver. Use a soft-bristle toothbrush to brush your teeth. Do not floss between your teeth. If you are a smoker, strongly consider smoking cessation. NCLEX Question Which priority intervention does the nurse teach the client with polycythemia vera to prevent harm related to injury due to decreased platelet functionality? A. B. C. D. Wear gloves when outside in the cold. Drink 3-4 L of liquid each day. Use an electric shaver Elevate your feet when sitting down. Answer: C A is incorrect. Wear gloves when outside in the cold.” is appropriate education for this patient, but not related to the risk for injury due to decreased platelet function. This educational point is related to the poor perfusion due to hyperviscous blood. B is incorrect. “Drink 3-4 L of liquid each day” is appropriate education for this patient, but not related to the risk for injury due to decreased platelet function. This educational point is related to the poor perfusion due to hyperviscous blood. C is correct. “Use an electric shaver” is an educational point that will help prevent bleeding and decrease the risk of injury due to poor platelet function. D is incorrect. “Elevate your feet when sitting down.” s appropriate education for this patient, but not related to the risk for injury due to decreased platelet function. This educational point is related to the poor perfusion due to hyperviscous blood. Anemia What is anemia? ● ● ● Reduction in the number of erythrocytes Can occur with many different disease processes Several types and causes Iron deficiency anemia Inadequate iron intake caused by: ● ● ● ● ● ● Iron-deficient diet Chronic alcoholism Malabsorption syndromes Partial gastrectomy Rapid metabolic (anabolic) activity caused by: ○ Pregnancy ○ Adolescence ○ Infection Most common! Vitamin B12 deficiency anemia Dietary deficiency Failure to absorb vitamin B12 from intestinal tract as a result of: • Partial gastrectomy • Pernicious anemia • Malabsorption syndromes Aplastic anemia Body stops producing enough new blood cells. Causes include exposure to myelotoxic agents: • Radiation • Benzene • Chloramphenicol • Alkylating agents • Antimetabolites • Sulfonamides • Insecticides Assessment findings ● CV ○ ○ ● Respiratory ○ ○ ● Tachycardia Orthostatic hypotension Dyspnea on exertion Decreased SpO2 Neuro ○ ○ Fatigue Increased need for sleep ● Skin ○ ○ ○ ○ ○ Pallor Cool Mottled Delayed capillary refill Unable to tolerate the cold Treatment ● Depends on the specific type of anemia ○ ○ ○ Iron deficiency anemia → ■ Increased iron in the diet and iron supplements. Vitamin B12 deficiency anemia → ■ Increased B12 in diet and supplements. Aplastic anemia → ■ Depends on cause ■ Discontinue causative drug/exposure if possible ■ Blood transfusions Sickle cell anemia Sickle Cell Anemia A disorder that causes the red blood cells to ‘sickle’ and break down. Autosomal recessive Pathophysiology ● ● ● Autosomal recessive Those with the trait have ‘sickled’ RBCs The sickled cells are not able to carry oxygen like they should ● Due to their shape, they can get caught in vessels and cause obstruction ○ Decreased perfusion Sickle Cell Crisis ● ● ● The decreased blood flow to the tissues leads to hypoxia, ischemia, and infarction. There is severe joint pain Sequestration ○ ○ ○ ● Blood pools Often in the spleen Splenomegaly and tenderness Acute exacerbation can be caused by hypoxia, exercise, high altitude (due to low oxygen), and fever. Assessment ● ● ● ● ● ● Pallor Pain Fatigue Arthralgia Chest pain Respiratory distress Treatment ● IV Fluids ○ ○ ● Blood transfusion ○ ○ ● Provides normal RBCs Helps optimize oxygenation and better perfusion Oxygen ○ ● This helps dilute the blood so that the sickled cells are not so concentrated Provides hydration Increase oxygen to the tissues if the client is hypoxic Medications ○ ○ Pain management - Analgesics often necessary Hydroxyurea ■ Increases production of fetal hemoglobin to reduce crises NCLEX Question You are providing education to your 8 year old client diagnosed with sickle cell anemia. He has had three crisis events this year. Which of the following points do you enforce with him and his parents to help prevent more sickle cell crises? Select all that apply. a. b. c. d. e. Drink lots of water Perform vigorous exercise for 60 minutes a day Avoid flying on airplanes Call the PCP if he becomes febrile. Encourage a diet high in calcium. Answer: A, C, and D A is correct. Hydration is an essential component of preventing a sickle cell crisis, so this is very important education. By drinking lots of water, the boy will increase the volume in his vascular space with fluid, essentially “thinning out” the sickled cells. In other words, they will not be as concentrated anymore. This will help to prevent the sickled cells from snagging on vessels, creating occlusions, and causing a crisis. B is incorrect. While promoting a healthy lifestyle is always important, vigorous exercise is a specific trigger for a sickle cell crisis. This is because during vigorous exercise the tissues have a high demand for oxygen and the sickled cells are unable to deliver a sufficient amount. This results in a crisis. So for this client, 60 minutes of vigorous exercise every day would not be a good recommendation. C is correct. Avoiding flying on airplanes is good education. In airplanes, you are at a very high altitude where there is much less oxygen. This can be a trigger for a sickle cell crisis because it leads to a high oxygen demand state. D is correct. It is important for the parents to know to call the child’s primary care doctor if he is ill with a fever. Because the body demands more oxygen when it is febrile, fevers are a trigger for sickle cell crises, and must be treated promptly. E is incorrect. Encouraging a high calcium diet will not prevent the patient from having sickle cell crises. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Risk potential reduction Reference: Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited. Subject: Pediatrics Lesson: Hematology Disseminated Intravascular Coagulation (DIC) What is DIC? A serious disorder in which the proteins that control blood clotting become overactive. Triggers ● ● ● ● ● Blood transfusion Cancer Pancreatitis Liver disease Severe tissue injury ○ ○ ● Burns Head injury Pregnancy complication Assessment Bleeding Ecchymosis Hematomas Hemoptysis Melena Pallor Hematuria Clotting → Where the clot goes ● Lungs/Heart ○ ○ ○ Chest pain Dyspnea SOB ● Legs ○ ○ ○ ○ ● Pain Redness Warmth Swelling Brain ○ ○ ○ ○ Headache Speech changes Paralysis Dizziness Treatment ● ● ● ● Determine underlying cause and TREAT Administer clotting factors Administer platelets Bleeding precautions NCLEX Question The nurse in the Intensive Care Unit notes bleeding from the client’s transparent dressing over their peripheral intravenous site, gum bleeding, and frank blood in the urine. The client was originally admitted for Sepsis. What should be the nurses immediate next action? a. b. c. d. Assess the client’s hemoglobin and hematocrit level Check the client’s oxygen saturation. Apply pressure to the intravenous site. Call the physician Answer: D Choice D is correct. The client is manifesting signs of Disseminated Intravascular Coagulation (DIC). This is a critical complication that often happens in the intensive care unit and usually is secondary to other serious etiologies such as Sepsis. In this condition, the clotting system is activated significantly and leads to the consumption of platelets and clotting factors. DIC can manifest with either bleeding or clotting complications. Thrombocytopenia (low platelet count), coagulopathy (increased prothrombin time, increased partial thromboplastin time, decreased fibrinogen), and hemolysis are hallmarks of DIC. In the absence of any significant bleeding, transfusing platelets or clotting factors may fuel the thrombotic process in DIC. Therefore, Platelets, cryoprecipitate, and Fresh Frozen Plasma are not routinely injected in DIC unless there is significant bleeding. The client is bleeding from multiple sites. The nurse must call the physician first to initiate medical interventions, which may include ordering labs to confirm DIC, transfusing platelets, or infusing clotting factors. Choice A is incorrect. DIC is a consumption coagulopathy and also causes intravascular hemolysis. Intravascular small clots (microthrombi) form due to activation of the coagulation pathway in DIC. Red blood cells may rub against these thrombi leading to hemolysis. Fragmented red blood cells (schistocytes) can be seen in DIC due to this hemolysis. Hemolysis causes a drop in hemoglobin and hematocrit (Anemia). The nurse should undoubtedly check the client's Hemoglobin and Hematocrit levels; however, the nurse needs to notify the physician right away since the client is showing bleeding signs of DIC. Choice B is incorrect. Assessing the client’s oxygen saturation may also be performed later. The client is not in apparent respiratory distress based on the information presented. Hypoxia is not the cause of his bleeding complications. DIC should be suspected in this bleeding, septic clientand the nurse must notify the physician immediately since urgent intervention is needed Choice C is incorrect. The client is bleeding from multiple sites. The application of pressure to the intravenous site alone will not help stop the bleeding from other websites. DIC is a consumption coagulopathy. All the clotting factors and platelets are being used up in the clotting process. Therefore, the bleeding complications of DIC would necessitate platelets and clotting factor infusion. Anatomy + Physiology The Immune System Definitions ● Immunity ○ ● Inflammation ○ ○ ● “Protection from illness or disease maintained by the body’s physiological defense mechanisms” “Normal tissue response to cellular injury, allergy, or invasion by pathogens” Nonspecific Infection ○ ○ “The invasion of pathogens into the body that multiply and cause disease or illness” Trigger inflammation Antigens vs. Antibodies Infections ● Communicable ○ ● ● Healthcare Acquired Infections (HAIs) Transmitted from person to person ■ Influenza ■ Pertussis ■ Mumps ■ Rhinovirus ■ Adenovirus ■ Meningitis ■ Streptococcus Aureus ○ ○ ○ CAUTIs CLABSIs SSIs Non-communicable ○ NOT transmitted from person to person ■ Peritonitis ■ Endocarditis ● Infections requiring contact precautions: ○ MRSA ○ VRE ○ Noroviruses ○ Rotavirus ○ Conjunctivitis ○ Diphtheria (cutaneous) ○ Herpes Simplex virus ○ Human Metapneumovirus ○ Pediculosis (lice) ○ Scabies ○ Poliomyelitis ○ Staphylococcus aureus ● ● Infections requiring droplet precautions: ○ Influenza ○ Pertussis ○ Mumps ○ Rhinovirus ○ Adenovirus ○ Meningitis ○ Streptococcus Aureus ○ Rubella ○ Haemophilus influenzae type B ■ Epiglottitis ○ Parvovirus ○ Diphtheria (pharyngeal) Infections requiring airborne precautions: ○ Tuberculosis ○ Rubeola virus (Measles) ○ Varicella virus (Chickenpox) ○ Varicella zoster ○ SARS ○ Smallpox Sepsis What is sepsis? ● A systemic inflammatory reaction to an infection. Pathophysiology Assessment ● Elevated lactic acid ○ ○ ● ● ● ● ● ● Indicates body has switched to anaerobic metabolism Tissues are not getting sufficient oxygen Metabolic acidosis Leukocytosis Hypotension Tachypnea Tachycardia Febrile Treatment ● Blood cultures first ● ● ● Broad spectrum IV abx within one hour IV fluids Vasopressors
