Assessment and Management Chapter 33
Blood Cells -- Overview
• The hematologic system is composed of what three parts? • Identify the cellular components of blood. • What substances constitute the fluid portion of blood? • Identify the processes that must be in balance for hemostasis. • Define hematopoiesis.
• What is important to know about RBCs?
– What is the principle component of mature RBCs? – What is the function of that component? – What hormone is important to the production of RBCs? – What other substances are required for normal erythrocyte production? – What are normal lab values?
• What is important to know about WBCs?
– What is overall primary function? – What are the two general categories? – Identify cells within each category. – What is the primary function of the differentiated cells? – Bands are less mature granulocytes. What does an increase in bands indicate? – What are normal lab values?
• What is important to know about platelets?
– They technically are not cells, what are they? – What hormone partially regulates their production? – What is their essential role? – What are normal lab values? – What is the collaborative problem associated with thrombocytosis?
• Initiated by triggering event • Landslide effect • Two pathways
– Intrinsic (slower) – Extrinsic (faster)
• Clotting factors are activated sequentially • Regardless of triggering event the outcome is formation of a fibrin clot and coagulation
More on Hemostasis
• What has to happen once the coagulation cascade has achieved the formation of the clot and the vessel injury has healed?
• How will this process be accomplished?
• What lab test will identify the end result of this process?
Hematologic Assessment: Lab Profile
• • • • • • • CBC Peripheral blood smear Hemoglobin Hematocrit Mean cell volume Mean cell hemoglobin Mean cell hemoglobin concentration • Reticulocyte count • Total iron binding capacity • Serum haptoglobin • • • • • • • • • Iron Serum ferritin Platelet count Hg electrophoresis Direct Coombs Indirect Coombs Bleeding time Euglobin lysis time Fibrin degredation products
• Identify the diagnostic tests associated with bone marrow evaluation. • What is the purpose of these diagnostic tests? • Identify the most prevalent sites used. • Identify important pre-procedure nursing responsibilities. • What are two hazards of these procedures? • Identify post-procedure nursing responsibilities.
TYPE CAUSE Autosomal recessive inheritance of two defective genes for hemoglobin synthesis X-linked recessive inherited deficiency of the enzyme glucose-6phosphate dehydrogenase Abnormal immune function; immune reactive cells fail to recognize own blood cells as self cells Inadequate iron intake (iron deficient diet, chronic alcoholism, malabsorption syndromes, partial gastrectomy); Or rapid metabolic activity (pregnancy, adolescence, infection)
Sickle Cell Disease G6PD Deficiency Autoimmune Hemolytic Iron Deficiency
TYPE CAUSE Dietary deficiency Failure to absorb vitamin B12 from intestinal tract (partial gastrectomy, pernicious anemia) Dietary deficiency Malabsorption syndromes Drugs (Oral contraceptives, anticonvulsants, methotrexate) Exposure to myelotoxic agents (radiation, benzene, chloromycetin, alkylating agents, antimetabolities, sulfonamides, insecticides) Viral Infections [unproven] (Epstein-Barr virus, hepatitis B, cytomegalovirus)
Vitamin B12 Deficiency Folic Acid Deficiency Aplastic Anemia
• Identify manifestations specific to the following body systems.
– Integumentary – Cardiovascular – Respiratory – Neurologic
What will the severity of symptoms depend upon?
Care of Anemia
• What is the most important treatment consideration? • Review the Nursing Process: The Patient with Anemia, p. 1047 -1049
• Define leukopenia. • Identify which two cell types are predominantly involved. • The patient who is leukpenic is at increase risk of what complication? • What is the ANC? How is it determined? • How will leukopenia be treated?
• Group of malignant disorders involving abnormal overproduction of a specific WBC type
– Usually at an immature state – In the bone marrow
• May be acute or chronic • Categorized by the specific maturational pathway from which the abnormal cell arose
– Lymphocytic/lymphoblastic – Myelocytic/myelogenous
Leukemia: Basic Physiology
• Malignant transformation of the stem cells causing an abnormal proliferation of a specific type of leukocyte • Proliferation shuts down normal bone marrow production • Results in anemia, thrombocytopenia, and leukopenia of the unaffected WBC types
• INFECTION and HEMORRHAGE are the causes of death • Etiology: many genetic and environmental factors. . . Involving gene damage to the cells
– May be viral pathogenesis – Can be secondary to bone marrow damage from radiation
• Lab assessment
– Decreased H&H – Decreased platelets – Altered WBC (low, normal, elevated: usually 20,000 to 100,000 – Bone marrow aspiration/biopsy identifies types
• Drug therapy
– Intensive combination chemotherapy – Major side effects: bone marrow depression
• Increases vulnerability to infection • Antibiotics, antifungals, antivirals
• Bone marrow transplantation (BMT) • Peripheral Blood Stem Cell Transplant (PBSCT)
• Malignancies characterized by a proliferation of committed lymphocytes rather than stem cell precursors • Solid tumors- particularly affecting lymph nodes and spleen • Types
– Hodgkin’s – Non-Hodgkin’s
– Peaks in mid to late 20’s – And > 50 (males affected more in > 50)
– Probably viral or chemical – Usually originates in a single or chain of nodes – Reed-Sternberg cells (characteristic marker)
• Assessment: enlarged painless node or nodes, fever, malaise, night sweats
• Diagnosis: Biopsy reveals R-S cells • Staging: crucial– treatment is based on extent of disease • Prognosis: one of most curable forms of cancer • Treatment
– Stage 1-2: extensive radiation – More extensive: radiation with aggressive multiagent chemotherapy – Nursing management focuses on side effects
• Cancers of the lymph tissue that are not Hodgkin’s • Most occur in older adults • Causes unknown
– Suspect viral, radiation, chemical
– Dependent on cell type – Ranges from excellent to poor
• Treatment and nursing care similar to Hodgkin’s lymphoma
• What is thrombocytopenia? • What can it result from?
Autoimmune Thrombocytopenic Purpura
• Cause- autoimmune • Patho- body makes an anti-platelet antibody that destroys platelets • What manifestations would you expect? • Diagnosis: platelet count < 20,000 • Collaborative care
– – – – – Identify cause if possible and treat Provide safe environment Immunosuppressants IVIG Splenectomy
Thrombotic Thrombocytopenic Purpura
• Rare • Platelets clump
– Clinical picture similar to DIC
• Cause: suspect autoimmune • Treatment:
– Immunosuppressants – Plasma exchange – Platelet aggregation inhibitors
Clotting Factor Disorders
• Most are congenitally transmitted gene abnormalities of one clotting factor
– Hemophilia A & B – von Willebrand’s
Disseminated Intravascular Coagulation
• An acquired disorder • Triggers: sepsis, trauma, cancer, shock, abruptio
placenta, toxins, allergic reactions
• Patho– thrombi form in microcirculation consuming all platelets and clotting factors – Fibrinolytic system triggered to release fibrin degredation products (potent anticoagulants) further bleeding
• Characterized by:
– Low platelet and fibrinogen levels – Prolonged PT, aPTT, thrombin time – Elevated D-dimer
• Clinical manifestations:
– Bleeding from mucous membranes, venipuncture sites, GI and urinary tracts
– – – – Most important: identify and treat cause Correct secondary effects of tissue hypoxia Replace depleted coagulation factors Heparin infusions (controvesial)
• Blood component that is removed from a door and transfused to benefit a recipient. • Components may be transfused individually or collectively. • Pretransfusion responsibilities:
– Review and understand agency policies and procedures – Review physicians order – Evaluate clinical condition of patient and lab values
• Normal saline is solution of choice • Must determine that blood components to be administered are correct
– Must check components with another RN
• Transfusion responsibilities
– Measure and record vital signs– initially and at specified intervals – Initiate infusion slowly and observe for signs of reaction
• Hemolytic Transfusion Reaction
– Caused by blood type or Rh incompatibility – May range from mild to life threatening – Clinical signs: fever, chills, low back pain, nause, chest tightness, dyspnea, anxiety – Onset: may be immediate or may not occur until subsequent transfusion
How would you ensure that this does not occur?
• Allergic Transfusion Reaction
– Most often in those with h/o allergies – Clinical signs: urticaria, itching, flushing, bronchospams, and occasionally anaphylaxis – Onset- during or up to 24 hours after transfusion
What pharmacologic intervention may prevent future reactions?
• Febrile Transfusion Reaction
– Occurs commonly with those with anti-WBC antibodies – Clinical signs– chills, muscle stiffness, tachycardia, fever, hypotension, tachypnea
How will the transfusion procedure be adapted to prevent febrile reactions?
• Bacterial Transfusion Reactions
– Seen after transfusion of contaminated blood or blood products – Clinical signs-- fever, chills, hypotension – Onset is rapid
What interventions are essential to preventing a bacterial transfusion reaction.
• Circulatory Overload
– In what patient population would you anticipate this reaction? – Most common with whole blood transfusions or with multiple transfusions – What clinical signs would you expect?
When Transfusion Reaction Occurs
• • • • • • • STOP THE TRANSFUSION Maintain 0.9% NS at KVO rate Notify physician Document according to agency policy/protocol Teat symptoms per physician order Monitor VS Collect specimens (blood, urine) and send to lab with transfusion administration set • Thoroughly document