CHAPTER 37: CARDIOVASCULAR: BLOOD & LYMPH SYSTEMS
BLOOD:
 Heart pumps 5-6 liters of blood per minute
 Blood plasma consists of
o H20, proteins (albumin), electrolytes, lipids, carbohydrates,
organic and inorganic substances
THE FORMED ELEMENTS IN PLASMA ARE:
 RBC’s, WBC’s and PLATELETS
RBC’S called erythrocytes: 4.5-6.1 million
FUNCTION:
1. Oxygenate body tissue
2. In capillary bed of alveoli
-blood exchanges 02 and C02
3. Hemoglobin is protein in RBC’s that carries 02 & is responsible for
exchange of 02 &C02
4. Hematocrit- 42%-45% (% of RBC’s in blood volume)
WBC’S called leukocytes-n 5,000-10,000
Fight infection & assist with immunity
(Increase in WBC’s indicates Infection, Inflammation, necrosis or Leukemia
 Increase in WBC’s is Leukocytosis
 Decrease in WBC’s is Leukopenia
PLATELETS : known as thrombocytes, active in blood clotting
Prothrombin & Thromoplasin plus Calcium form= Thrombin
Thrombin joins with Fibrinogen to form: Fibrin
Fibrin strands form: clot
BLOOD TYPES:
On the surface of RBC membranes are ANTIGENS
if A antigen is on RBC surface ====TYPE A
if B is on the surface then it is type B
if A+B it is type AB
if no antigens then the blood type is O
Type AB is known as universal recipients
Type O is known as universal donor
RH FACTOR:
Persons who have D-antigen have RH factor---- they are positive +
Have factor means positive
Persons who do not have D-antigen lack RH factor----are said to be
negative
Lack of factor mean--- negative
85% of population and are positive, 15% lack and are negative
RH IncompatibilityNegative mom – positive dad- 85% chance baby will be positive
At birth
Mom with RH- blood is exposed to RH+ blood (baby’s blood is +)
Mom will have anti RH- antibodies may cause problems with next
pregnancy (erythroblastosis fetalis) mental retardation
Mom is given Rhogam to neutralize antibodies
BLOOD TRANSFUSION
Purpose:
1. To replace blood components because of hemorrhage, anemia, clotting
factors or blood deficiencies
2. Before transfusion lab does a cross match
3. Blood should be administered within 30 minutes after being obtained
from the lab
Procedure:
1.
2.
3.
4.
5.
Take baseline vital signs before
Give blood 18 gauge (piggyback the blood with .9%NSS )
2 nurses check blood
Start blood slow, 50cc hour
Take vital signs- observe for reaction(chest pain, dyspnea, decreased bp,
chills, fever (101.4 or higher)
6. No reaction then speed up the rate (50cc-100cc)
7. Take vital signs for one hour
8. Infusion should be complete within 4hour (1 unit is approx 375cc)
Autologous Blood Transfusion
Patient receives own blood (eliminates possibility of reaction or disease
transmission
LYMPATHITIC SYSTEM
Function:
1. Transports excessive fluid from interstitial spaces to circulatory
system
2. Protects body against infectious organisms and also assists with
immunity.
SYMPHATIC SYSTEM CONSITS OF
Lymph fluid & vessels
Lymph nodes can be superficial or deep
Superficial can be palpated( i.e. neck, groin, axillary)
they are easily palpated when infected or swollen
CA cells can enter the lymphatic system and escape into circulation or other
body tissues such as lungs
These CA cells can reproduce and spread to other body parts
LYMPH ORGANS
Spleen- removes old RBC’s, platelets, and microorganisms from blood
during infection it enlarges to release WBC’s to fight infection
Thymus: actively involved in immunity, this organ is large in childhood but
decreases in size
ASSESSMENT OF PATIENT WITH BLOOD DISORDERS:
Subjective data:
1.
2.
3.
4.
5.
Sex, ethic background and race are important
Clients occupation and hobby
Military (exposure to toxic chemicals)
OTC meds- (ASA)
Recent infections, night sweats, bleeding problems, recent
transfusions, past surgeries
6. Neurologic symptoms- numbness, tingling, breathing or vision
problems
7. G.I. ulcers
8. Alcohol consumption
Objective data:
1.
2.
3.
4.
5.
6.
7.
Vital signs, increased temp
Recent weight gain or loss
Lab values
Check lymph nodes (freely movable, firm, & nontender)
Assess skin for bruises, lesions, brittle nails
Urine & stool for OB
Dyspnea, enlarged abdominal, swallowen joints
COMMON DIAGNOSTIC TESTS:
1.
2.
3.
4.
5.
list on pg 779
PPT
PT
Hgb
Hct
WBC’s
RBC’s DISORDERS:
Anemeia manifest with decreased RBC’s and low Hgb
Causes:
1. Decreased RBC’s
2. Increase in destruction of RBC’s
3. Blood loss
Iron deficiency anemia - body does not have enough FE to synthesize Hgb
Causes:
1. Decreased dietary intake
2. Decreased FE absorption
3. Increase demand for FE (ie: pregnancy)
Seen most frequently:
1.
2.
3.
4.
Premature infants
Adolescent girl
Alcoholic
Elderly
S/S:
1. Fatigue
2. Loss of appetite
3. Decreased to concentrate
4. Pallor
Chronic anemia S/S:
1. Tachy
2. Exertional dyspnea
3. Hypotension
4. Dysphagia
5. Stomatits
6. Brittle nails
DIAGNOSTIC TESTS:
1.
2.
3.
4.
5.
Decreased RBC’s
Low Hgb
Low Hct
Low serum FE
High FE bending capacity (TIBC)
PHARMACOLOGICAL:
1. Oral FE preparations (i.e.Feosol ) (don’t give FEwith milk: Milk
decreases FE absorption)
2. Take thru straw- stains teeth
3. Parenteral route of admisinstrion should be given Z track
DIET:
1. Foods rich in FE (red meats, raisins, fish, apricots, dark green veggies,
dried beans, eggs)
2. Diet high in vitamin C assess vital signs in absorption of FE
3. FE supplements
Activity:
Frequent Rest Periods
APLASTIC ANEMIA- when there is no known cause is known to be congenital:
1.
2.
3.
4.
Pancytopenia- def in any of the blood cell elements
Decreased RBC’s
Decreased WBC’s
Decreased platelets
SECONDARY APLASTIC ANEMIA
Causes: exposure to viruses, chemicals (ie benzene glue), radiation and
certain meds, (ie antineoplastics)
S/S:
1. Fatigue, weakness, tachy, dyspnea, increased susceptibility to infection,
petchial, gingival bleeding and epistaxis
DIAGNOSTIC:
Bone marrow aspiration
MEDICAL MANAGEMENT:
1. Immunosuppressants
2. Transfusion RBC’s and platelets
SURGICAL MANAGEMENT:
1. Bone marrow transplant from HLA
2. Immunosuppressant : cyclosporine (sandimmine) to decrease graft
rejection
Pharmacological
1. Infection treated with antibodies
2. Steroids
3. Androgens
PERNICIOUS ANEMIA
Autoimmune disease that effects the parietal cells of the gastric mucosa
that secretes a protein intrinsic factor that is essential for the proper absorption
of vitamin B 12
Without secretion of intrinsic factor vitamin B 12 cannot be absorbed
Incidence:
1. Seen most often in patients who have had gastrectomy
2. Female African Americans
3. Patients should be monitored closely for gastric carcinomas
Diagnostic Tests
1. Schelleny
2. Gastric analysis
S/S
1. Has insidious onset
2. Extreme weakness
3. Sore tongue
4. Numbness and tingling of extremities
5. Edema of legs
6. Atoxia
7. Dizziness
8. Dyspnea
9. H/A
10.Fever
11.Blurred vision
12.Tinnitus
13.Poor memory ect.
Pharmacological:
1. Tropical anesthias (oral discomfort)
2. Cyanocobalamin (vit B 12) given IM daily for two weeks then weekly
until Hct returns to normal
 Then monthly for the rest of their lives.
VITAMIN B 12- cannot be given orally b/c it cannot be absorbed without the
intrinsic factor
3. Folic acid (folate)
4. Diet high in folic acid: green leafy veggies, meat, fish, legumes and
whole grains
5. FE is usually not prescribed
ACQUIRED HEMOLYTIC ANEMIA:
Hemolytic anemias- causes hemolysis or destruction of RBC’s --- release of
FE and Hemoglobin
Cause:
1.
2.
3.
4.
5.
6.
Autoimmune reaction
Radiation
Blood transfusion
Chemicals (lead)
Meds (penicillin, methyldopa, gantrisin)
A substance produced by bacterium (clostridium)
S/S
1. Jaundice
2. Palpatations
3. Hypotension
4. Dyspnea
5. Back and joint pain
DIAGNOSIS TESTS
1. Decrease in Hgb and Hct, increase in LDH
MEDICAL
1. Remove cause
2. Blood transfusion
3. Erythocylopheresis (a procedure that removes abnormal RBC’s
and replace them with healthy RBC’s
SURGICAL
1. Splenectomy (will stop destruction of RBC’s b/c spleen is to destroy
RBC’s
PHARMACOLOGICAL
1. Corticosteroids- decrease autoimmune response
2. Folic Acid- increase in production of RBC’s
SICKLE CELL ANEMIA:
Genetic disorder which there is abnormal Hgb S rather than Hemoglobin A
in the RBC’s
Condition occurs most frequently in Africa-American. It also occurs in
persons from Asia Minor, India, Mediterranean, and Caribbean areas.
SITUATIONS THAT PRECIPATATE SICKLE CELL ANEMIA ARE:
1.
2.
3.
4.
5.
Dehydration
Fatigue
Infection
Emotional stress
Alcohol consumption
When 02 is compromised the RBC’s become sickled.
(cresent shaped) obstructed capillaries and larger vessels
S/s
1.
2.
3.
4.
5.
Fatigue
Jaundice
Chronic leg ulcers
Tachypnea
Dyspnea
SICKLE CELL CRISIS: fever, pain, blood loss to various organs, (requires immediate
intervention)
MEDICAL MANAGEMENT:
1.
2.
3.
4.
Infections are treated with antibodies
Encourage fluids and IV therapy (3-5 liters a day)
Skin graft if leg ulcer
Genetic counseling
PHARMACOLOGICAL:
1.
2.
3.
4.
Folic Acid (daily)
Cetided citrate (has antisickling effect)
Trental
PCA pump with morphine
POLYCYTHEMEA: 2 TYPES
1.
2.
3.
4.
Increase production of RBC’s
Usually WBC’s and platelets also increased
Occurs in middle age Jewish men
Etiology unknown
S/s
1. H/A
2. Epistaxis
3. Dizziness
4. Tennitis
5. Blurred vision
6. Fatigue
7. Weakness
8. Prutitis
9. External dyspnea
10. Angina
11.Increase pulse
12.Increase bp
13.Lips become reddish purple
14.Bruise easily
15.Susceptible to thrombic formation
16.Hyperurciema (increase destruction of RBC’s, Hgt>18,Hct >55%)
MEDICAL:
1. Phlebotomy-Is the usual Rx. ( removal of blood from vein 350-500cc)
qod
2. Radioactive phosphorous
3. Radiation therapy
PHARMOCOLOGICAL:
1. Antineoplastic drugs (to decrease bone marrow production)
A. Mylean B. Cytoxan C. Mustargen
2. Allopurinol (decrease production of uric acid)
3. Antihistamines (pruituis)
DIET:
1. High calorie
2. High protein intake
3. Low NA intake
4. AVOID FE containing foods
ACTIVITY
1. Regular periods of rest
WHITE BLOOD CELL DISORDERS
LEUKEMIA :
Is a malignancy of blood-forming tissues in which the bone marrow
produces immature WBC’s --- crowding out of other cells in bone marrow, causing
decreased production of RBC’s and Platelets--- anemia and bleeding disorders
There are 2 classifications (acute and chronic)
ACUTE: (2types)
1. AML- acute myelocytic leukemia
2. ALL- acute lymphocytic leukemia
CHRONIC: (2types)
1. CMI- chronic myeloctic
2. CLL- chronic lymphocytic leukemia
ETIOLOGY of AML
1. There is a connection with survivors of Japanese A bomb and exposure
to radiation
2. Rheumatoid Arthritis that are treated with drugs that suppress the
immunes system
3. CA treated with cytoxic drugs and radiation
S/s of leukemia
1. Persistent infections with fever and chills
2. S/S of anemia
1. Fatigue
2. Pallor
3. Malaise
4. Tachy
5. Tachypnea
3. Bleeding, tenderness, and client will experience bruising, epistaxis,
gingival bleeding and increased menstrual bleeding
4. Weight loss, night sweats, swollen lymph nodes
5. H/A visual disturbances
6. Bone pain
ACUTE LEUKEMIA (ALL)
1.
2.
3.
4.
5.
6.
Usually seen in children between 2 and 6 yrs old
Rapid onset
If untreated client have median survival time (4-6months)
Good prognosis with chemotherapy ( 90% remission)
If adults (50-70% remission)
High risk of ALL occurs in pts with Down’s syndrome
ACUTE MYLOCYTIC LEUKEMIA:
1. Occurs frequently in adolescence and 55+
2. Median survival time if untreated 2-3 months
3. With chemo 50-70% remission
With median survival time 2-3yrs
MEDICAL SURGICAL MANAGEMENT : Good handwashing Important
MEDICAL
DIAGNOSTIC:
1. CBC
2. Bone marrow biopsy
3. Lumbar puncture
4. Xray, MRI, or CTscan
SURGICAL:
1. Bone marrow transplants (must have compatible donor)
2. Chemo (high doses)
3. Radiation
1. High doses of chemo and radiation are given prior to transplant to
destroy WBC’s and bone marrow cells
PHARMACOLOGICAL- antineoplastic drugs: IV or within spinal cord: b/c chemo
does not cross blood-brain barrier
1.
2.
3.
4.
5.
6.
7.
8.
Oncovin
Deltasone
Purithol
Methotrexate
Ditasone
Radiation
Blood transfusion
Antibiotics
DIET: Bland, High protein, high carbs
Avoid
1. Extreme hot or cold foods
2. Alcohol
ACTIVITY
Frequent rest periods
CHRONIC LEUKEMIA
1. Occurs in adults 50-70 yrs old
2. Higher in men then women
3. Clients Rx with chemo have life expectancy of 2-10 yrs
4. Prognosis depends on severity of disease
5. WBC’s 20,00-100,000
CML- chronic myelocytic leukemia:
1. Occurs in patients 35-50yrs old
2. Higher in men
3. WBC’s 15,000-500,000
MEDICAL
DIAGNOSTIC- CBC and Bone marrow biopsy
SURGICAL
Bone marrow transplant
PHARMACOLOGICAL
1. CLL>>>>>Chemo- (Leukaran, cytoxin, oncovin, prednisone)
2. CML>>>>>Chemo- (Myleran, Hydrea, DAT)
3. Interferon- (increases survival time)
DIET:
High protein, high carbs, high vitamins, bland non-irritating diet. AVOID
alcohol
ACTIVITY
1. Conserve energy
AGRANULOCYTOSIS:
Severely reduced # of granulocytes
CAUSE: Adverse reaction to meds or med toxicity from:
A. Butazolidine, chloromycetin, penicillin, cephalosporins, dilantin,
antihistamines, oncovin, prolixin, thorazine and sparine
B. Chemo, radiation, bacterial and viral infection
S/S
1. H/A- fever, chills, fatigue, ulcerations of mucous membranes of nose,
mouth, pharynx, vagina and rectum
2. WBC’s decreased
MEDICAL Rx: symptomatic
1. Rx infection
2. Blood cultures
PHARMACOLOGICAL
1. Antibiotic
DIET: soft, bland, high calorie, high protein, high vitamins
ACTIVITY: alter periods of activity with periods of rest
COAGULATION DISORDERS: very serious and potentially FATAL disease
DIC: Disseminated Intravascular Coagulation: A syndrome that occurs b/c of a
primary disease process or condition where there is alternating clotting and
hemorrhaging
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
Burns
Acute leukemia
Mets CA
Polycythemia
Pheochromocytoma
Shock
Acute infection
Septic abortion
Abruptio placenta
Blood transfusion reaction
Trauma
The condition stimulates the clotting mechanism causing very small clots to form --the body’s fibrinolytic process to stop the clotting—hemorrhage
(Small clots block the arterioles and Capillaries…That stimulates the body’s
fibrinolytic process that stops the clotting and leads to hemorrhaging)
S/S
1. Purpura
2. Bleeding tendencies
3. Renal impairment (decreased output)—renal insufficiency
MEDICAL MANAGEMENT
1.
2.
3.
4.
Increased PT &PTT and increase Thrombin time
Decrease in fibrinogens and platelets
Symptomatic: (treat primary condition)
Administer whole blood or blood products- platelets and packed red
blood cells
5. Cryoprecipitate of fresh- frozen plasma is given
PHARMACOLOGICAL:
1. Heparin (Rx. Is controversial)
2. Amicar
HEMOPHILIA:
Appox: 18,000 people have
 Inherited bleeding disorder where there is lack of clotting factors
 The hemophilia tract is carried on the recessive X chromosome (ie
mother is asymptomatic-can carry and pass trait to son)
2types
 Hemophilia A- Lacks clotting factor 8
 Hemophilia B- Lacks clotting factor 9
3 classifications
1. Severe: factor level (<1% is normal)
2. Moderate: Factor level (1%-5% is normal)
3. Mild :
factor level 40% is normal
S/S
1.
2.
3.
4.
Severe bleeding with trauma
Spontaneous ecchymoses & bleeding from mouth, GI and Urinary tracts
Hemarthrosis- bleeding into joints (pain, swelling, redness and fever)
Intracranial hemorrhage (most common cause of death)
MEDICAL MANAGEMENT
1. Administer clotting factors that pt lacks
2. Administer fresh frozen plasma
3. Keep pt safe (helmet)
PHARMACOLOGICAL
Desmopressin acelate (DDAVP) to decrease fibrinolytic process
THROMBOCYTOPENIA: decrease in # of platelets
CAUSE:
1. Aplastic anemia, tumors, leukemia, and chemo
2. Decrease in platelet destruction either drug induced or idiopathic
3. Decrease in platelet survival as in infection or viral disease
S/S
1. Petchiae
2. Echymosis
3.
4.
5.
6.
Bleeding from mucus membranes
Bleeding from internal organs
Platelet ct decreased
Hgb, hct decreased
MEDICAL MANAGEMENT
1. Transfuse platelets
2. Apheresis (removal of unwanted componenets)
SURGICAL
1. Spleenectomy
Pharmacalogical: Immunosuppressant, gamma globulin and vitamin K
DIET: high fiber
LYMPH DISORDERS: Lymphatic system
1. Transports excess fluid from interstitial spaces
2. Protects body against infection
LYMPHOMA- A tumor of the lymphatic system
HODGKINS DISEASE
CAUSE: unknown, maybe correlated with mono, associated with virus Epstein Barr
INCiDENCE:
1. High in adolescent and young adults
S/S
1. Painless swelling in lymph nodes (neck and groin)
2. High temp- night sweats, weight loss
DIAGNOTIC:
1. Biopsy (Reed-Sternberg cells isolated)
2. CBC, platelet count, bone marrow aspiration, chest xray, CAT scan,
Lymphangiogram
MEDICAL MANAGEMENT
1. Stage disease (using staging system to determine progression in body)
Chart P. 1138-39
2. Rx: chemo and radiaton
SURGICAL:
1. Laparotomy if liver and spleen involved
PHARMACOLOGICAL
1.
2.
3.
4.
Antiemetic (zofran) during radiation therapy
Analgesics for esophagitis
Combination of chemos given thru central line
Allopurinol (prevent uric acid renal stones)
DIET- high caloric, protein, fluid (2500cc a day)
ACTIVITY: rest periods
NON-HODGKINS LYMPHOMA- cause B is seen as pt ages, T is seen in skin ca
1. More common then hodgkins
2. 5th most common cause of CA in US
3. 5yr survival rate 63%/ 10 yr survival rate = 51%
DIAGNOSTIC
1. Lymph node biopsy (no Reed Sternberg cells on biopsy)
2. Stage disease (to determine progression)
S/S
1. Enlarged tonsils and adenoids
2. Enlarged lymph nodes (ie groin, axillary and inguinal)
3. Fever, night sweats, weight loss, excessive, tiredness, indigestion, abd
pain, loss of appetite, bone pain
4.
PHARMACOLOGICAL Rx: various chemo protocols or combination of chemo
PLASMA CELL DISORDERS:
MULTIPLE MYELOMA- plasma cells in bone marrow become malignant and crowd
out normal cell production destroy normal bone tissue – pain—cause is
unknown—normal production of antibodies is changed—highly susceptible to
infection
S/S
1.
2.
3.
4.
Bone pain (1st sign)
Long bones ache, joints swollen and tender
Low grade fever
Malaise
DIAGNOSTIC:
1.
2.
3.
4.
Bone marrow biopsy (shows large # of immature plasma cells)
Xrays
Bence Jones protein found in urine
Hypercalcemia, hyperurcemia, anemia, hypercalciuria
MEDICAL MANAGEMENT
1. Symptomatic Rx
2. Radiation and chemo
SURGICAL
1. Laminectomy ( if vertebrae collapse)
2. Surgery (if renal calculi)
PHARMACOLOGIAL:
1. Steroids
2. Prednisone
3. Antineoplastics: (Cytoxan, Alkeran, Leukeran)
DIET:
1. Small frequent meals (6 small)
2. Increased fluid intake (3-4 liters a day)
ACTIVITY
1. Keep ambulatory
2. If bedridden turn often