AFAMS Master Lesson Plan (MLP)
Nursing Program
Critical Care-Hematologic
Instructor
Serial/Semester
Location
Start/Finish Time
Date
LESSON OBJECTIVE
Performance: To gain an understanding of Critical Care Hematologic disorders.
Conditions:
The student will be presented a powerpoint presentation by the instructor and will have
all necessary references made available to him/her.
Standard:
1.
Given the five elements of the nursing care process and a scenario of a critical care
patient with a hematological disorder, determine approaches for patient care by
correctly responding to written, oral, and experiential assessment measures
TEACHING POINTS
1. Describe the functions of the hematologic
system
6.
2.
3.
7.
8
4.
5.
Describe the composition of blood
Describe the physiologic effect of neutropenia
on the critically ill patient
Discuss splenomegaly
Differentiate the etiology/pathophysiology,
assessment, diagnosis, medical managment
and nursing interventions for Idiopathic
Thrombocytopenic Purpura and Trombotic
Thrombocytopenic Purpura
Identify the etiology/pathophysiology,
assessment, diagnosis, medical management
and nursing interventions for Disseminated
Intravascular Coagulation
9.
10.
INSTRUCTIONAL STRATEGY
Interactive Lecture
Method:
Instructor
Media:
Classroom
Environment:
OTHER LESSON SPECIFICATIONS
Knowledge Lesson
Type of Lesson:
1/50
Ratio:
Resources:
.
End of Lesson Test: None
Instructional Time: 204
Reference(s):
Click here to enter reference(s).
Minutes
LESSON PLAN APPROVAL
Signature of Standards Officer
Date
AFAMS Master Lesson Plan (MLP)
Nursing Program
Critical Care-Hematologic
INTRODUCTION
Allocated Time:
Review:
5 Minutes
You have had previous anatomy and physiology lectures in your combat medic
training, this lecture will build upon prior instruction.
Objective:
To discuss/describe topics related to the nursing process.
Importance:
Nurses work in various health care settings so it is important to gain an
understanding of this subject as it will apply to your clinical practice.
Fit:
Hematology, also spelled haematology (from the Greek αἷμα haima "blood"
and -λoγία), is the branch of biology physiology, internal medicine, pathology,
clinical laboratory work, and pediatrics that is concerned with the study of
blood, the blood-forming organs, and blood diseases. Hematology includes the
study of etiology, diagnosis, treatment, prognosis, and prevention of blood
diseases. The laboratory work that goes into the study of blood is frequently
performed by a medical technologist. Hematologists physicians also very
frequently do further study in oncology - the medical treatment of cancer.
Blood diseases affect the production of blood and its components, such as
blood cells, hemoglobin, blood proteins, the mechanism of coagulation, etc.
Approach:
You will be presented the subject in lecture format and will be tested using a
written exam at a later date.
Control Statement:
If you have any questions during the lesson please feel free to ask.
BODY
1. Teaching Point: Describe the functions of the hematologic system
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
1. Functions of the Hematological System
a. Respiration
i. RBCs transport oxygen to the tissue
ii. RBCs transport carbon dioxide to the lungs
b. Nutrition
i. return proteins and fats from the GI tract
ii. transport vitamins and minerals
iii. conveyance of necessary electrolytes
c. Excretion
i. waste produces (such as BUN, creatinine)
ii. carry cellular debris to necessary organs to be excreted (i.e., the kidney)
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Critical Care-Hematologic
d. Defense
i. blood is route for first line cellular defense against infection
ii. conveys clotting mechanisms to inhibit bleeding
iii. mode of arrival for healing processes
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Click here to enter the question.
Click here to enter the answer.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
2. Teaching Point: Describe the composition of blood
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
2. Composition of Blood
a. Cellular Components
i. Red Blood Cells (RBCs): 5 million cells/mm3
ii. White Blood Cells (WBCs): 5000-10,000 cells/m3
1. Granulocytes
2. Neutrophils: 50-70%
3. Eosinophils: 1-5%
4. Basophils: 0.05-1%
5. Monocytes (+ macrophages): 1-8%
6. Lymphocytes: 20-40%
7. B lymphocytes
8. T lymphocytes
iii. Platelets (thrombocytes)
1. 150,000-400,000 cells/mm3
iv. Plasma
1. 55% of blood
2. Water (92%)
3. Protein (7%)
4. Albumin and other plasma proteins
v. Immunoglobulins (alpha, beta and gamma)
1. Clotting Factors
vi. Other
1. Respiratory gases
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Critical Care-Hematologic
2. Metabolites
3. Enzymes
4. Hormones
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Click here to enter the question.
Click here to enter the answer.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
3. Teaching Point: Describe the physiologic effect of neutropenia on the critically ill patient
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
3. Neutropenia
a. Absolute Neutrophil Count (ANC) of <1000 cells/ml
i. Significant Risk of Infection when ANC < 500 cells/ml occurs as a result of
decreased production or excess destruction of neutrophils
b. Etiologies
i. extremes in age
ii. malnutrition
iii. irradiation/chemical (benzene)
iv. drugs
1. ETOH, chemotherapy, antibiotics, etc.
v. stress
vi. surgery
c. Immune Impairment & Increased Infections
i. renal failure, AIDS, anemia, DM, leukemia
d. Infections
i. typhoid, hepatitis, measles, influenza, malaria, VRE, disseminated TB, etc.
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Click here to enter the question.
Click here to enter the answer.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
3
AFAMS Master Lesson Plan (MLP)
Nursing Program
Critical Care-Hematologic
4. Teaching Point: Discuss splenomegaly
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
4. Splenomegaly
a. Fever; flushed, warm skin
b. Tachycardia
c. Chills
d. Cough
e. Change in sputum color
f. Ulcerative mouth lesions
g. Sore throat; dysphagia
h. Difficulty/burning on urination
i. Fatigue; malaise; joint pain
j. Patient Management
k. Identify Risk Factors
l. Enhance Generation of Cells
i. granulocytes, macrophages, or both
m. Therapies to Stimulate Immune System
i. bone marrow growth factors (Neupogen)
ii. also known as colony-stimulating factors
n. Decrease Risk for Infection
i. decrease exposure to exogenous organisms
ii. decrease number of normal endogenous organisms
iii. avoid indwelling catheters
iv. meticulous care of all lines
v. frequent oral and skin care
vi. consistent use of standard precautions
o. Early Detection of Infections
p. Appropriate Use of Antibiotics
i. prophylactics may be ordered for prevention
q. Adequate Nutrition
i. high protein, high caloric diet essential
ii. enteral feeding may be warranted
r. Patient Participation in Care
i. establish patient readiness/ability to learn
s. Assist Patient with Verbalization of Fears
i. anxiety-producing information at patient comfort level
t. Encourage Patient to Participate in ADLs
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Critical Care-Hematologic
u. Nursing Diagnosis
i. risk for infection related to neutropenia
ii. Signs/Symptoms
1. Fever; flushed, warm skin
2. Tachycardia
3. Chills
4. Cough
5. Change in sputum color
6. Ulcerative mouth lesions
7. Sore throat; dysphagia
8. Difficulty/burning on urination
9. Fatigue; malaise; joint pain
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Click here to enter the question.
Click here to enter the answer.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
5. Teaching Point: Differentiate the etiology/pathophysiology, assessment, diagnosis, medical
managment and nursing interventions for Idiopathic Thrombocytopenic Purpura and Trombotic
Thrombocytopenic Purpura
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
5. Thrombocytopenia
a. Causes
i. Bone Marrow Suppression  Decreased Platelet Production
ii. Aplastic anemia
iii. Burns
iv. Chemotherapy
v. Radiation
b. Interference with Platelet Production
i. Alcohol
ii. Histamine-2 blockers
iii. Hormones
iv. Thiazide diuretics
c. Platelet Destruction artificial heart valves cardiopulmonary bypass machine
i. heparin
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Critical Care-Hematologic
ii. infection
iii. sulfonamides
iv. Septra/Bactrim
v. transfusions
d. Immune Response Against Platelets
i. Idiopathic Thrombocytopenic Purpura
ii. Thrombotic Thrombocytopenic Purpura
iii. Mononucleosis
iv. Vaccinations
e. Interference with Platelet Function
i. catecholamines
1. DM
2. SLE (systemic lupus erythematosus)
3. Thyrotoxicosis (Grave’s disease)
4. uremia
5. medications
a. Aminoglycosides, NSAIDS, Dextran, Diazepam, Digitoxin, Loop
diuretics, Phenytoin, Salicylates, Tricyclic antidepressants, Vitamin
E
6. ITP
a. Thrombocytopenia without evidence of toxic exposure
i. absence of disease associated with decreased platelets
b. Immunological Mechanism Involving IgG Antiplatelet Antibodies
i. platelets removed by spleen from circulation
ii. acute and chronic from have been identified
iii. exhibit normal production with decreased platelet survival without splenomegaly
c. Acute
i. most common cause of thrombocytopenia without anemia or neutropenia
ii. 95% of Patients are Children between 2 and 6 years of age
iii. history of recent viral illness
iv. 85% Complete Recovery Rate with Rare Recurrence
d. Chronic
i. adults 20-40 years of age (usually)
e. Gradual Onset
i. many remissions and exacerbations
f. Exacerbations
i. often correlate with cyclic metabolic changes
g. Forerunner of Other Autoimmune Dis.
i. SLE, lymphoma, autoimmune hemolytic anemia
ii. 25-30% of Chronic ITP Patients have SLE
h. Other as a complication of many systemic disorders
i. Signs and Symptoms are Indistinguishable
j. Diseases Include
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Critical Care-Hematologic
i. Lymphoma
ii. SLE
iii. Infectious mononucleosis
iv. Thyrotoxicosis
v. Severe infection
k. Clinical Manifestations
i. petechiae, purpura and ecchymosis
ii. oozing from mucous membranes
iii. Platelet Count <150,000/ul
iv. Spontaneous Hemorrhage <20,000/ul
v. Fatal Hemorrhage Risk if <10,000/ul
l. Medical Management
i. Platelet Transfusions
ii. Attempt to Maintain Single Donor
1. decrease exposure to multiple antigens
2. fever/allergic reactions- multiple transfusions
iii. Corticosteroids
iv. IV IgG
v. Plasmapheresis
vi. Splenectomy
vii. Monitor CBC- report values <50,000/ul
viii. Monitor for Bleeding
1. esp. mucous membranes
ix. Recognize/Limit Interventions
1. that can deplete or shorten life of platelets
2. medications, fever, high metabolic activity
7. Thrombotic Thrombocytopenic Purpura
a. More Common in Females
b. Middle to Late Adulthood
i. peak incidence in the 40s
c. Rarely Seen in Infants and the Elderly
d. Clinical Manifestations
i. Thrombocytopenia
ii. Low Red Blood Cell Count
iii. Neurological Abnormalities
iv. Petechiae, Purpura and Ecchymosis
v. Oozing from Mucous Membranes
vi. Fever, Weakness, Fatigue
vii. Pallor, Shortness of Breath
viii. LOC, Headache, Confusion, Speech Changes
e. Medical Management
i. Medical Management
ii. Plasmapheresis with Plasma Exchange
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Critical Care-Hematologic
iii. Nursing Interventions
1. same as with ITP
2. monitor end organ function closely
3. i.e. uop, ABG, neuro status
iv. Report changes in end organ function
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Click here to enter the question.
Click here to enter the answer.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
6. Teaching Point: Identify the etiology/pathophysiology, assessment, diagnosis, medical management
and nursing interventions for Disseminated Intravascular Coagulation
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
8. DIC
a. Etiology/Pathophysiology
i. Serious Disorder of Hemostasis
1. microsvascular coagulation
2. depletion of clotting factors and hemorrhage
ii. Mortality Rate of 80 - 90%
iii. Acute, Chronic and Subacute Forms
iv. Acute DIC
1. develops rapidly
2. most serious form of acquired coagulopathy
v. Chronic DIC
1. most often caused by malignancy
2. also from renal, liver or metabolic disease
vi. Subacute DIC
1. no clinical signs or symptoms
2. laboratory abnormalities
b. Normal Hemostasis
i. Vessel Spasm
1. contraction of blood vessel immediately after damage to control the loss of
blood
2. effect lasts for about 30 minutes
ii. Platelet Plug
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Critical Care-Hematologic
1. platelets activated (become sticky), clump together, adhere to damaged blood
vessel
2. controls blood loss if vessel break is small
c. Clotting cascade
i. Damaged Blood Vessels/Tissues
1. elease substances that activate clotting cascade
ii. Intrinsic and Extrinsic Pathways
1. both end in final common pathway
iii. Prothrombin is Converted to Thrombin
iv. Thrombin Degrades Fibrinogen into Fibrin
v. Fibrin Threads are Relatively Insoluble
1. maintain the stability of a clot
vi. Fibrin Enmeshes with the Platelet Plug
vii. Serum is Released, Clot is Stable
viii. Fibrinolysis
1. breakdown of clot
ix. Tissue Plasminogen Activator (t-PA)
1. present in lining of all blood vessels
2. released after clot formation
3. converts plasminogen into plasmin
x. Plasmin Dissolves Fibrin/Clot
1. perfusion through blood vessel reestablished
xi. Normal Clotting Cascade Overstimulated
1. massive tissue destruction
2. damage to endothelial cells
xii. Thrombin Produced
xiii. Fibrin Produced
xiv. Clotting Factors Consumed
xv. Fibrin Strands in Microvasculature
xvi. Clotting in Microvasculature
1. causes organ ischemia and necrosis
2. skin, lungs, kidneys especially damaged
3. thrombophlebitis, PE, CVA, GI bleeding, renal failure  thrombosis
xvii. RBCs Damaged
1. schistocytes
a. lost ability to carry oxygen
xviii. Clotting Cascade Stimulated Fibrinolysis Stimulated
1. degrade clot once stable-reestablish perfusion
xix. Fibrinolysis
1. breakdown of fibrin
2. release of fibrin degradation products
xx. Fibrin Degradation Products
1. potent anticoagulants that interfere with thrombin, fibrin and platelet activity
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Critical Care-Hematologic
xxi. Consumption of Clotting Factors
1. at sites where a clot is not needed
2. leads to body depletion
3. results in an inability to form clots as needed
xxii. Assessment/Clinical Manifestations
xxiii. Recognition of Risk Factors
xxiv. Microvascular Thrombosis Develops
1. organ ischemia and necrosis
2. mental status changes
xxv. Angina
xxvi. Hypoxemia
xxvii. Decreased Urine Output
xxviii. Nonspecific Hepatitis
xxix. Depletion of Clotting Factors & Clot Lysis
1. excessive bleeding
2. occult blood
3. gingival bleeding, petechiae, ecchymoses
xxx. Overt Bleeding from Three Unrelated Sites
1. must consider bleeding in unseen spaces
a. i.e. peritoneum and retroperitoneal space
xxxi. May Exhibit Signs/Symptoms of Shock
xxxii. Increased d-dimer
xxxiii. byproducts of fibrin breakdown
xxxiv. FSPs/FDPs
1. byproducts of fibrin breakdown
2. non-specific to identify clot lysis
xxxv. Increased Coagulation Times
xxxvi. Decreased Antithrombin III
1. substance that binds with heparin
2. decreased ATIII increases likelihood of clots
d. Medical Management
i. Goals
ii. Identify/Treat Underlying Cause
iii. DIC is a secondary process
1. stop the abnormal coagulation
2. control the bleeding
iv. Correct Hypotension, Hypoxemia, acidosis
v. Intubate & Mechanically Ventilate prn
vi. Volume Replacement - NS or LR
vii. Blood Volume Expanders, as ordered
viii. Blood Products
1. replace platelet deficiency & clotting factors
2. treat hemorrhage
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Critical Care-Hematologic
ix. Platelets for Consumptive Thrombocytopenia
x. FFP
1. clotting factor replacement
xi. Cryoprecipitate
1. fibrinogen and Factor VIII replacement
xii. RBCs
1. hemorrhage replacement
a. to maintain oxygen carrying capacity
xiii. Medications
1. Heparin
a. potent thrombin inhibitor
b. prevents thrombus formation
c. blocks process that initiates DIC
d. may increase the risk of bleeding
i. use in controversial
e. administered in low-dose, i.e. 500u/hr
2. Vitamin K
i. critical to the production of clotting factors
ii. may be administered SQ or IV
3. Antithrombin III
a. inhibits thrombin
b. enhances action of heparin
c. ATIII Deficit  No Response to Heparin
d. due to above relationship
e. may shorten course of DIC,increase survival
f. must infuse slowly due to risk for hypotension
4. Aminocaproic Acid
a. inhibits fibrinolysis
b. interferes with plasmin activity
c. given with heparin to prevent lysis of existing clots
e. Nursing Interventions
i. Goals
1. Recognize/Prevent Thrombotic and Hemorrhagic Events
2. Identify Patients at Risk
3. Continuous Assessment
4. Pain Management
5. Administer Medications as Ordered
6. Monitor Lab Values
7. Control Bleeding
a. avoid invasive procedures, as able
b. Avoid Dressing Changes
c. reinforce- avoid disrupting an unstable clot
f. Diagnosis
11
AFAMS Master Lesson Plan (MLP)
Nursing Program
Critical Care-Hematologic
i. History and Physical
1. include identification of risk factors
ii. Clinical Presentation
1. abs
iii. Thrombocytopenia
1. decreased fibrinogen
2. increased FDP/FSP
3. fibrin degradation products/fibrin split products
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Click here to enter the question.
Click here to enter the answer.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
END OF LESSON TEST
Allocated Time:
Instructions:
Test Questions or
Performance
Expected:
Test Key:
0 Minutes
You will be tested on this subject at a later date.
You will be expected to review and study the material taught in this session in
order to pass the associated written test. If you have difficulty with the material
please see me so we can review together.
None.
CONCLUSION
Allocated Time:
Summary:
5 Minutes
Review and re-emphasize the difficult Teaching Points below.
1.
2.
3.
4.
5.
6.
7.
8
9.
10.
12
Describe the functions of the hematologic system
Describe the composition of blood
Describe the physiologic effect of neutropenia on the critically ill
patient
Discuss splenomegaly
Differentiate the etiology/pathophysiology, assessment, diagnosis,
medical managment and nursing interventions for Idiopathic
Thrombocytopenic Purpura and Trombotic Thrombocytopenic
Purpura
Identify the etiology/pathophysiology, assessment, diagnosis, medical
management and nursing interventions for Disseminated Intravascular
Coagulation
AFAMS Master Lesson Plan (MLP)
Nursing Program
Critical Care-Hematologic
Closing Statement:
Nurses work in various health care settings so it is important to gain an
understanding of this subject as it will apply to your clinical practice.
Re-motivating
Statement:
Hematology, also spelled haematology (from the Greek αἷμα haima "blood"
and -λoγία), is the branch of biology physiology, internal medicine, pathology,
clinical laboratory work, and pediatrics that is concerned with the study of
blood, the blood-forming organs, and blood diseases. Hematology includes the
study of etiology, diagnosis, treatment, prognosis, and prevention of blood
diseases. The laboratory work that goes into the study of blood is frequently
performed by a medical technologist. Hematologists physicians also very
frequently do further study in oncology - the medical treatment of cancer.
Blood diseases affect the production of blood and its components, such as
blood cells, hemoglobin, blood proteins, the mechanism of coagulation, etc.
13