Nursing Interventions and Care of the Patient with Hematologic Problems by NgoRN

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									Nursing Care of the Patient with
    Hematologic Problems

           NURS 400
          Adult Health I

• Hematocrit:
   • Measure of packed cell volume of RBC expressed as a %
   • Women: 38-47%
   • Men: 40-54%
   • Measurement of gas carrying capacity of RBC
   • Men: 13.5-18g/dl
   • Women: 12-16g/dl
   • abnormally low number of neutrophils in the blood
   • < 1500…normal 3000 – 7000mm³
   • Neutrophils, a type of white blood cell, help fight bacterial
     infections. Most abundant WBC
   • Side effects of medication, chemotherapy, viral infections

• Reticulocytes
   • Are young red cells just released from the bone marrow.
     The Retic count tells us how the marrow factory is doing.
   • Immature RBC’s, less than 1%

• Thrombocytopenia
   • Platelet counts are between 150,000-400,000ul
   • low platelets, below 100,000-150,000
   • Bleeding may occur

• ESR Erythrocyte sedimentation rate
   • Indicative of inflammation
   • Increased ESR is common during acute and chronic
     inflammatory reactions
   • Women: 1-20mm
   • Men: 1-15mm

• A deficiency in the number of RBC, quantity of HgB
  and the volume of HCT
• There is an abnormality with the structure or
  function or number of RBC’s
• Anemia is not a disease, it is a manifestation of a
  pathologic process.
   • primary hematological problems
   • secondary to defects in other body systems
• This can lead to hypoxia, a decrease in the oxygen
  carrying capacity of the blood.
• The clinical manifestations anemia are primarily
  caused by the body’s responses to tissue hypoxia.

   Clinical Manifestations of Anemia
• Mild Anemia
  • 10-14 Hgb.
  • Generally asymptomatic, symptoms can occur with disease
    or exertion
• Moderate Anemia
  • Hgb 6-10
  • Cardiopulmonary symptoms may be increased and may be
    associated with rest as well as activity.
  • Palpitations, fatigue, dyspnea, & diaphoresis
• Severe Anemia
  • Hgb less than 6.
  • Symptoms involve many body systems.
  • It is caused by severe tissue hypoxia. Pallor, chronic fatigue,
    chills, ↑ HR, murmurs, can lead to CHF, angina, MI

         Clinical Manifestations with Anemia
• Cardiac effects when Hgb is too low.
    • Ischemia
    • Tissue hypoxia
    • Chronic fatigue
• Sensitivity to cold
    • The blood is shunted to the major organs
•   Pallor – reduced hemoglobin and blood flow to skin
•   Decreased CO leads to Increased HR
•   Murmurs due to lack of blood volume
•   CHF can occur to the increased strain on the heart.
    In severe cases, angina and MI can occur.

       Nursing and Gerontological Considerations
• Anemia is common in older adults
   • Anemia of chronic disease
   • Nutritional deficiencies
• Signs and symptoms unrecognized
   • Attribute them to the normal aging process
   • Common signs and symptoms include: pallor, confusion, ataxia,
     fatigue, worsening angina.
• Nursing Implementation:
   •   Dietary and lifestyle changes
   •   Blood products
   •   Blood transfusions
   •   Drug therapy – Erythropoietin (Procrit, Epogen)
   •   Oxygen therapy

  Nutrients Needed for Erythropoiesis
• Vitamin B12
   • RBC maturation – red meats
• Folic Acid
   • RBC maturation – Green leafy vegetables, liver, meat, fish
     legumes, whole grains
• Iron
   • Hemoglobin synthesis – liver and muscle meats, eggs
• Vitamin B6
   • Hemoglobin synthesis – meats, legumes, potatoes
• Amino Acids
   • Synthesis of nucleoproteins –eggs, meat, milk, poultry, fish
• Vitamin C
   • Aids in iron absorption – citrus fruits, green leafy veggies,
     strawberries, cantaloupe

Anemia’s Related to Decreased Erythrocyte Production
• Iron Deficiency Anemia
   • Found world wide due to poor nutrition
      • Inadequate dietary intake
          • Iron is obtained from food and dietary supplements
          • If you eat 12 mg. of iron per day only 10% is absorbed
      • Malabsorbtion
          • After GI surgery or malabsorbtion syndromes
      • Blood loss
          • Chronic GI bleed scan cause loss of 2-4mls
          • Black stools or melena requires 50 to 75ml of blood from
            UGI tract
      • At risk population:
          •   Pregnancy because of increased iron needs
          •   Pre-menopausal women
          •   Low socioeconomic background
          •   Older adults
          •   Blood loss

Anemia's Related to Decreased Erythrocyte Production
                       Clinical Manifestations

  • Asymptomatic early in the disease
  • Chronic Symptoms:
      • Pallor – most common
      • Glossitis – inflammation of the tongue
      • Cheilitis – lesions of the corners of the lips
      • Headache, dizziness, parasthesias, DOE, burning
        sensation of the tongue…..all due to ↓ iron.
  • Diagnostics
      • Lab testing
      • Stool for occult blood
      • Colonoscopy
      • Take iron in an acidic environment, with OJ, empty
        stomach, one hour prior to breakfast. Don’t take with milk,
        reduces absorption. > fluids to prevent constipation.
  • Treatment
      • Goal: treat underlying cause Foods > in iron = liver, meat,
        eggs, dark green veggies, raisins, prunes, apricots, fortified
        cereals, breads.

Anemia's Related to Decreased Erythrocyte Production

• Drug therapy
   • Oral Iron Replacement – Ferrous Sulfate
   • Iron is best absorbed from the duodenum
       • Enteric coated or SR and not wise choice
   • Dosage should be 150mg to 200mg TID
   • 300mg of ferrous sulfate has 60mg of iron available
   • Best absorbed in an acidic environment
           • Take with OJ, empty stomach, one hour prior to
           • Don’t take with milk, reduces absorption.
           • ↑ fluids to prevent constipation.
   • GI side effects : heartburn, constipation and diarrhea
   • Diet teaching: Foods ↑ in iron: liver, meat, eggs, dark green
     veggies, raisins, prunes, apricots, fortified cereals, breads

                  Nursing Interventions
•   Obtain a history of symptoms, dietary intake and past hx of anemia
•   Possible sources of blood loss
•   Examination for: Tachycardia, pallor DOE, s/s of GI or other bleeding
•   Assess diet for inclusion of Iron rich foods
•   Assess level of fatigue and sleep
•   Assist in scheduling activities and rest patterns
•   Maximize tissue perfusion
     •   A/E for palpitations, chest pain, dizziness and SOB….minimize activities which
         cause these symptoms
     •   Elevate HOB and supplemental Oxygen
•   Education
     •   Proper nutrition
          • Well balanced diet
     •   Teach about Iron supplements
          • Take on empty stomach
          • Epigastric discomfort
          • Stool changes
     •   Follow up lab studies

      Vitamin B12 (Pernicious) Anemia
• Gastric secretion of Intrinisic Factor(IF) is defective
• IF is required for Cobalamin absorption
• Impaired B12 absorption in the small intestine due to lack of IF or
  destruction of the parietal cells.
   • Clinical manifestations: as Anemia- normal levels 200-900ng/L
        • Sore tongue, anorexia, vomiting and abdominal pain
        • Neuromuscular manifestations-parasthesias, weakness
        • Low Hgb
   • Schilling test abnormal test = pernicious anemia
        • Indirect test of IF deficiency
        • Evaluates the ability to absorb vitamin B12
   • Nursing management
        • includes IM B12 1000mg weekly IM or intra-nasally.
        • B12 for the rest of their life due to lack of IF
   • Without vit B12 leads to macrocytic anemia, GI disorders,
      paresthesia, gait problems & death
               Folic Acid Deficiency
• Folic acid is necessary for DNA synthesis leading to
  RBC formation and maturation.
   • Common Causes:
       • Poor nutrition (lack of green vegetables, liver, fruits)
       • Malabsorption syndromes-small bowel disorder
       • Drugs, alcohol and hemodialysis (folic acid is lost).
   • Clinical manifestations are similar to vitamin B 12 deficiency

   • Treatment:
       • Folic Acid replacement: PO 1-5 mg/OD, standard dose is 1mg.
   • Vitamin C helps with development
   • Encourage liver, green veggies, legumes

                       Blood Loss
• Acute Blood Loss
   • Trauma or Blood vessel rupture due to trauma
   • Complications of surgery
   • Diseases that disrupt vascular integrity i.e Shock, the body
     reacts by vasoconstriction.
• 30% blood loss
   • symptoms with exertion only
• 40% blood loss
   • rapid, thready pulse, CO low, clammy skin. Blood is being
     shunted centrally
• 50% Blood loss
   • shock & potential death
• First identify the cause and stop bleeding
• Expand blood volume, pain from organ displacement,
  check blood work, administer albumin, & colloids

            Polycythemia Vera
• Overproduction of RBC’s ↑ blood viscosity, volume
• Myeloproliferative disorder – Chromosome mutation
   •   Hgb to 18g/dl, RBC 6 million/mm, HCT > 55%.
   •   Common in patients over 50
   •   Splenomegaly and hepatomegaly – organ engorgement
   •   Headache, ↑BP, vertigo, dizziness, angina
   •   Increased uric acid production – gout
   •   Plethora or ruddy complexion, pruritis
   •   Hemorrhagic phenomenon
         • Nosebleeds, petichiae, thrombus-↑stroke risk
• Treatment: aimed at ↓blood volume and viscosity
   • Phlebotomies to keep Hct < 45%
   • Allopurinol for uric acid
   • Teach S/S of bleeding & clotting, discourage smoking, low sodium
     diet, frequent rest periods
   • Myelosuppressive agents-Hydrea, Alkeran
   • Antiplatelet therapy – ASA
   • Chemotherapy-bone marrow suppression
• Number of platelets is abnormally low
   • Below the normal of 150,000 to 400,000
   • Counts below 50,000 cause prolonged bleeding, below
     20,000 life threatening
   • Platelets help the blood clot
   • Manifests as prolonged bleeding or spontaneous bleeding.
   • Petechiae = micro hemorrhages.
   • Purpura when petechaie are numerous, the resulting reddish
     skin bruise.
   • Ecchymosis larger purplish lesions that are caused by
• Causes: Leukemia, Drugs-ASA, Infection, Lupus
   • Immune thrombocytopenia, patient makes antibiodies
     against their own platelets( survival is 1-3 days).

• Treatment Options:
  • Platelet transfusions
  • Steriod therapy
  • Splenectomy to reduce macrophages which destroy
  • Avoid sharp objects, razors, no contact sports, no IM’s, no
    rectal temps, oral care, no spicy foods.
  • If blood work, hold for 5 minutes or greater
  • Watch for hidden ASA in OTC
  • Periodic check for bleeding times and platelet counts…
  • NO ASA

DIC-Disseminated Intravascular Coagulation

 •   Abnormal response of the clotting cascade
 •   Small blood clots develop throughout the blood stream blocking small
     vessels depleting platelets and clotting factors needed to control
 •   The clotting factors run out & there is excessive bleeding.
 •   Clinical manifestations:
      •   Bleeding -Pallor, petechiae, hematomas, GI bleeding, hematuria, dizziness,
          headache, musculoskeletal changes
      •   Thrombosis- cyanosis, ischemia, pulmonary emboli, resp. distress
 •   Life threatening, mortality is > 80%
 •   Occurs with septic shock.
 •   Bleeding out of every orifice, platelets are destroyed.
 •   PT & PTT is increased, Platelets are decreased.
 •   Medical Management:
      •   Tx underlying cause
      •   Heparin, Xigris
 •   Nursing Management:
      •   Early detection of bleeding

• Reduction in the neutrophils
• Neutrophils play a role in phagocytosis of pathogenic microbes
• Definition: neutrophil count of less than 1,000- 1,500/uL
   • Normal level: 4000-11,000/uL
   • It is not a disease, it is a syndrome that occurs with a variety
     of diseases
   • As a result of chemotherapy
• Patient is predisposed to an infection:
   • Observe for chills, ↑temp, sore throat and cough
   • Abnormal s/s of inflammation
   • Minor infections can lead to sepsis
   • Good mouth care to prevent pneumonia.
   • Protective isolation, private room, limit visitors, handwashing.
   • Normal flora, transmission by hand, food
   • Neupogen – stimulates production of neutrophils

• Acute Lymphocytic (ALL)
  • Most common in children
  • Malignant growth of Lymphoblasts
     • Large numbers of immature white blood cells
     • Proliferate the bone marrow and lose ability to mature

• Chronic Lymphocytic (CLL)
  • Slow growth of lymphoid cells in lymph nodes, failure
    of bone marrow, invasion of malignant cells into the
  • Most age 50 > and men
  • Prognosis poor

• Acute Myelogenous Leukemia (AML).
  • Make to many immature myeloblasts infiltrate organs
  • Normal cells turn in to granulocytes (WBC)… leukemia
    blast cells don’t
  • Most common adult (15-39) leukemia, exact cause is
  • Prognosis generally poor
• Chronic Myelocytic Leukemia (CML)
  • Slow abnormal growth of granulocytes
     • Chromosomal abnormality called Philadelphia
  • Affect age 50 >, more males than females
  • Prognosis generally poor, worse if Ph chromosome
 Leukemia Signs & Symptoms
•Eccymoses                   •Tachycardia
•Petechiae                   •Orthostatic hypotension
•Open infected lesions       •Palpitations
•Pallor                      •DOE
•Bleeding gums               •Fatigue
•Anorexia                    •Headahce
•Weight loss                 •Fever
•Enlarged liver and spleen   •Bone pain
•Hematuria                   •Joint swelling

     Leukemia Treatment
• Chemotherapy
• Bone Marrow Transplantation

Leukemia Nursing Interventions

•   Infection prevention
•   Injury prevention
•   Energy conservation
•   Blood replacement therapy
•   Psychosocial support
•   Home care education related to care of: CVC,
    diet, infection prevention, bleeding risk

                    Hodgkins & Non Hodgkins
• Hodgkin’s disease
   • Malignant disorder of unknown cause
   • Reed sternberg cells invade lymph nodes
       • Gigantic atypical tumor cell which multiplies and replaces
         normal cells.
       • Painless superficial adenopathy or enlarged lymph nodes
       • Fever, night sweats, weight loss
• Non Hodgkin’s Lymphoma
   • Malignancies of the lymphoid tissue
   • Abnormal lymphocytes invade lymph nodes organs bone
     marrow and blood.
   • Symptoms are the same
• Treatment
   • Outpatient chemo & radiation
   • High risk for infection, as survival rate increases
   • Risk of secondary malignancy increases
• Administration of blood or blood components
• Need #20 or larger IV line
• Establish IV access before getting blood from blood
• Check ABO compatibility
• Inspect blood for abnormalities
• Check pt ID
• Stay with pt during first 15min of transfusion
• Monitor vs per protocol
• Monitor for s/s adverse reactions
• PRBCs – give over 2h-4h (but not more than 4h)
• FFP, Platelets- run in as quickly as possible

• ABO Incompatibility
  • 4 types of blood- A, B, AB, O
    • A carries A antigen, B carries B antigen, AB
      carries A&B antigens, O has no antigens
  • O- universal donor
  • AB+ universal recipient
  • Rh factor
    - absent
    + present
  • Blood testing is done to determine

 Transfusion Complications

• Febrile non-hemolytic reaction
  • Temp rise 1°C or greater during infusion
  • Tx with antipyrectics
  • Consider use of leuko depleted blood for future
• Acute hemolytic reaction
  • Life threatening
  • Cause- ABO incompatibility
  • s/s- fever, chills, back pain, nausea, chest
    tightness, dyspnea, anxiety
  • Stop blood immediately and start transfusion
    reaction protocol
  Transfusion Complications

• Allergic reaction
   • Cause- rx to proteins in blood
   • s/s- pruritis, hives (mild), to bronchospasm,
     laryngeal edema, shock (life threatening)
   • Tx- antihistamines, steroids, epinephrine
• Circulatory Overload
   • Cause- too rapid infusion in vulnerable individual
   • s/s- dyspnea, tachycardia, anxiety, frothy pink
     sputum, crackles, JVD
   • Tx- give blood slowly, diuretics, O2, morphine if
     dyspnea severe

  Transfusion Complications
• Bacterial Contamination
   • s/s- fever, chills, hypotension
   • Tx- prevention is key; stop transfusion, broad-
     spectrum abt
• Disease Acquisition
   • Hep B, Hep C, CMV, HIV, Creutzfeldt-Jakob
• Complication r/t Long-term Transfusions
   • Infection, sensitization to donor antigens, iron

      Practice Questions

During physical exam of a patient with
 thrombocytopenia, the nurse would
 expect to find:
 a. sternal tenderness
 b. petechiae and purpura
 c. jaundiced sclera and skin
 d. tender, enlarged lymph nodes

       Practice Questions
A nursing diagnosis that is appropriate for
  patients with moderate to severe anemia of
  any etiology is:
  a. impaired skin integrity r/t edema and
  b. disturbed body image r/t changes in
  appearance and body function
  c. imbalanced nutrition: less than body
  requirements r/t lack of knowledge of
  adequate nutrition
  d. activity intolerance r/t decrease hgb and
  imbalance between O2 supply and demand
       Practice Questions

The major method of preventing infection in the
  patient with neutropenia is use of:
  a. HEPA room filtration
  b. prophylactic antibiotics
  c. diet that eliminates fresh fruit and
  d. strict handwashing by all persons in
  contact with the patient


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