Download cardio unit 3

DISORDERS OF THE
HEMATOPOETIC SYSTEM
Student Learning Goals
At the completion of this unit, the student will be able to:

List the components of the hematologic system and
describe their role in oxygenation and hemostasis.

Identify data to be collected when assessing a patient
with a disorder of the hematologic and/or immune
system.

Describe tests and procedures used to diagnose
disorders of the hematologic/immune system, and
nursing considerations for each.

Describe nursing care for patients undergoing common
therapeutic measures for disorders of the hematologic
system, including blood transfusion.

Differentiate between iron deficiency anemia,
pernicious anemia, aplastic anemia, and sickle cell
anemia according to pathophysiology, symptoms,
treatment, and nursing management.
Student Learning Goals


Define the major aspects of diagnosis, treatment and
nursing management of the patient with Leukemia,
Hodgkin's disease, Non-Hodgkin’s Lymphoma and
Multiple Myeloma.
Define and describe the differences between the
following bleeding disorders:
–
–
–
–

Thrombocytopenia
ITP/TTP
Hemophilia
DIC
Assist in planning nursing care for a patient with a
disorder of the hematologic/Immune system.
– Risk for Injury with Low RBCs
– Risk for Injury from Bleeding
– Risk for Injury from Infecction

Define, spell correctly and pronounce all words on Unit
III Word List.
Structures and Components
of the Hematologic System
– Bone marrow
– Liver
– Spleen
– Blood
– Red blood cells (erythrocytes)
– Platelets (thrombocytes)
– Clotting factors
– Plasma
Age-Related Changes
Bone marrow becomes less productive
 Hematologic function not affected unless
a person is unusually stressed with
trauma, a chronic illness, or treatment
for cancer
 In conditions necessitating a higher
production of blood cells, bone marrow
usually responds to the increased
demand, given time

Diagnostic Tests and
Procedures

Blood tests
– Red blood cell count
– Hemoglobin (Hb or Hgb)
– Hematocrit (Hct)
– Platelet counts

Bone marrow biopsy
Important Lab Values

RBC
– 4.5 – 5 million/cubic mm

Hemoglobin
– Male:
13.5 – 18 Gm / 100 ml
– Female:
12.1 – 16 Gm / 100 ml

Platelets (Thrombocytes)
– 150,000 – 400,000 per microliter
Learning Goal Reflection

List the components of the hematologic
system and describe their role in
oxygenation and hemostasis.
Bone Marrow Aspirated from:
Posterior Iliac Crest (most
common)
Anterior Iliac
Tibia
Sternum
What is Nursing care before, during
and after?
Learning Goal Reflection

Describe tests and procedures used to
diagnose disorders of the
hematologic/immune system, and nursing
considerations for each.
 Type
/ Cross Match
 Recipient and donor must be of same
Type (ABO) & Rh Factor
– What is Rh factor and why do we care
– Universal Donor?
– Universal Recipient?
 Is
donor blood safe?






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Hung on separate IV line
Normal Saline (0.9% Sodium Chloride) only!
Special filter to IV line that screens clots
Larger bore IV catheter – 20 gauge minimum
Must be hung ASAP – timing important
Requires 2 licensed people at bedside
Get baseline vitals
Stay with pt. for 10-20 mins after blood started
Monitor vitals
Document procedure
Blood Product Transfusion

Reactions to blood transfusions
– Four main types
 Hemolytic
 Anaphylactic
 Febrile
 Circulatory overload
– Symptoms
 Back or chest pain, fever, chills, decreased blood
pressure, urticaria, wheezing, dyspnea, or
coughing during the transfusion
Blood Product Transfusion

Reactions to blood transfusions
– Interventions
 Stop transfusion immediately; keep intravenous
line open with normal saline
 Immediately notify physician, nursing supervisor,
blood bank
 Be prepared to administer oxygen, epinephrine,
Solu-Cortef, furosemide (Lasix), antipyretics as
prescribed by physician
 Save the unused portion of the blood bag for the
blood bank
 Be prepared to collect blood and urine samples
from the patient for evaluation
Learning Goal Reflection

Describe nursing care for patients
undergoing common therapeutic measures
for disorders of the hematologic system,
including blood transfusion.
Too many RBC’s
- Polycythemia Vera
Too few RBC’s
- Anemia
 What
is Anemia:
– Disease / Symptom
– Condition of low red blood cells (RBC) or
low hemoglobin (HgB)
Anemia Symptoms & Diagnosis

Symptoms:
– Pallor / hypersensitive to cold – why?
– Extreme Fatigue – why?
– Tachycardia – why?
– SOB – why?

Diagnosis
–
–
–
–
Eval of RBC and HgB
Further lab studies to determine type of anemia
Schillings Test
Bone Marrow Biopsy
 Blood
Loss
 Aplastic
 Autoimmune Hemolytic
 Iron Deficiency
 Pernicious
 Sickle Cell
Results from complete failure of bone
marrow
Will see Pancytopenia
decrease in:
- RBC
- WBC
- Platelets
Aplastic Anemia

Causes:
– Many Unknown
– Toxic Chemicals
 Look at work history
– Drugs
 Good history and previous drug use
– Radiation
 Exposure?

Additional S & S:
– Frequent Infections – why?
– Prolonged or spontaneous bleeding – why?
Treatment of Aplastic Anemia
 ID
and Treat Cause
 Transfusions
 Antibiotics
 Corticosteroids
 Bone Marrow Transplant (BMT)
 Neutropenic Precautions
 Any others?
Autoimmune Hemolytic
Anemia
 Blood
cells destroyed once they are
released into circulation
– See jaundice with destruction of RBC’s
 Causes:
– Infections, drug reactions, certain
cancers
 Treatment:
– ID cause; transfusions; corticosteroids
Iron Deficiency Anemia
Results from diet low in iron or poor
absorption of iron
Treatment:
– Iron Supplements
 How to administer
 Side Effects
– Incorporating Iron rich foods into diet
 What foods are iron rich?
Pernicious Anemia

Results when a person does not absorb
B12 from stomach
– B12 needed for iron absorption, RBC
maturation and protection of nerve
fibers
 Additional
S&S:
– Weakness
– Sore Tongue
– Numbness of hands and feet
 B-12
injections IM or SC
-cyanocobalamin
how to administer?
 Given
q 4 weeks for lifetime
Genetic blood disease
 Sickle-shaped RBC’s
 Crescent shaped, rigid, and inflexible
 Shape change d/t presence of abnormal
hemoglobin S – reduced O2 carrying capacity


Sickle Cells:
– Are Destroyed easier:
- live only 6-20 days
- normal is 120 days
– Tend to jam capillaries and decreased blood flow
Sickle Cell Anemia
Almost exclusive to AF/AM
 Autosomal recessive gene

– a person must inherit the gene from both the mother
and the father to actually have the disease
8% of AF AM carry genetic trait
 Sickle cell trait
- have 25 – 50% HGB S (AS)
 Sickle cell disease
- have >80% HGB S (SS)

Sickle Cell Anemia
 Lab
studies
– CBC shows Anemia
– Sickle cell test or Sickledex
– HGB electrophoresis
 Signs and Symptoms:
– Fatigue
– Jaundice (Splenomegaly)
– Cardiomegaly / Tachycardia
Occurs when sickled cells become stuck in
a larger blood vessel
- Obstructing Blood Flow
- Causing Severe Pain- Why?
 Crisis Triggers:

–
–
–
–
–
Dehydration
Infection
Overexertion
Cold Weather Changes
Excess ETOH / Smoking
Sickle Cell Disease
 Severe
Pain
–Pain location varies depending on
where circulation is blocked
 Complications:
–Thrombus
–Infection
No Cure
 Symptomatic during crisis
 IV Fluids
 Pain Medication
 Oxygen
 Antibiotics
 Blood Transfusions
 Hydroxyurea

Sickle Cell Nursing Diagnosis
and Interventions
 Acute
Pain
 Anxiety
 Risk for Injury
 Fluid
Volume Deficit
 Ineffective Therapeutic Regimen
- Patient Teaching
Learning Goal Reflection

Differentiate between iron deficiency
anemia, pernicious anemia, aplastic
anemia, and sickle cell anemia according
to pathophysiology, symptoms, treatment,
and nursing management.
Coagulation Disorders
Thrombocytopenia

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Too few platelets circulating in the blood
Why?
– Not enough platelets being made in bone marrow
– Too many platelets are being destroyed in
circulation
Major cause for bone suppression:
– chemotherapy
– radiation therapy
 Causes for platelets being either destroyed or
consumed are:

– idiopathic thrombocytopenic purpura (ITP)
– thrombotic thrombocytopenic purpura (TTP)
Thrombocytopenia

Symtoms:
– petechiae and purpura
– gingival bleeding
– epistaxis (nosebleeds)
– any other unusual or prolonged bleeding

Treatment:
– treat or stop the causative factor
– What is Neupogen?
 When would it be used?
Idiopathic Thrombocytopenic
Purpura (ITP)
IgG mistakenly helps destroy patient’s platelets
 Drugs that induce ITP: sulfonamides, thiazide
diuretics, chlorpropamide, quinidine, and gold.
 Patients with HIV are at increased risk for
developing ITP
 Treatment:

–
–
–
–
steroids
intravenous immune globulin (IVIG)
Splenectomy – maybe/Why?
Immunosuppressive therapy with cytotoxic drugs
Thrombotic Thrombocytopenic
Purpura (TTP)

Exaggerated immunologic response to blood
vessel injury
– results in extensive clot formation and decreased
blood flow to the site

Patients critically ill
– develop fever, thrombocytopenia, hemolytic anemia,
renal impairment, and neurologic symptoms

Treatment
– plasmapheresis
– steroids, antiplatelet agents (e.g., aspirin,
dipyridamole), splenectomy, or all three
Nursing Care w/
Bleeding Disorders

See Box 32-4 pg. 612
– Prevent Injury – ideas?
– Check for S/S bleeding – ideas?
– Safety Measures – ideas?
Disseminated Intravascular
Coagulation (DIC)
A hypercoagulable state
 Overstimulation of normal coagulation
cascade

– simultaneous thrombosis and hemorrhage

Always secondary to another pathologic
process:
– overwhelming sepsis, shock, major trauma,
crush injuries, burns, cancer, acute tumor
lysis syndrome, or obstetric complications
(abruptio placentae, fetal demise)
D.I.C. cont’d
Coagulation occurs at so many sites
 Eventually all available platelets and
clotting factors are depleted
 Uncontrolled hemorrhage results
 Blood tests that help diagnose DIC
include:

– prothrombin time, partial thromboplastin
time, fibrinogen, thrombin time, fibrin split
products level, and D-dimers
D.I.C. cont’d

Treatment
– Blood component replacement therapy
?
– Heparin to interrupt the DIC cycle and allow
the body to replenish platelets and clotting
factors
 Controversial

Nursing care?
– Box 32-4 – is there a theme?
HEMOPHILIA

Genetic disease: affected person lacks some
blood clotting factors normally found in plasma
– X-linked recessive genetic condition
– Women inherit and pass on to son
– From grandfather to grandson through mother


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Blood slow to coagulate
Platelets OK
Clotting intrinsic factor affected
 Hemophilia A - Factor VIII
 Hemophilia B – Factor IX
Hemophilia

Signs and symptoms
– Uncontrollable bleeding is the hallmark of
hemophilia
 Occurs after trauma; however, also
spontaneously for no clear reason
 Commonly, bleeding occurs into the joints,
causing swelling and severe pain
 Also can occur into the skin; from the mouth,
gums, and lips; and from the gastrointestinal
tract
 Prolonged oozing from minor injuries
Hemophilia cont’d

Medical diagnosis
– Measuring factors VIII and IX in the blood
– Partial thromboplastin time

Medical treatment
– No cure; treatment is symptomatic
– Physician prescribes transfusions of fresh frozen
plasma or cryoprecipitate, or both
– Red blood cell transfusions
– Intravenous morphine
– Physicians try quickly to transition from IV opioids
to oral opioids to nonopioid pain relievers as crisis
resolves
Hemophilia cont’d

Assessment
– For bleeding and pain; note what measures
have stopped the bleeding and relieved pain
in the past
– Monitor vital signs and urine output

Interventions
– Risk for Injury
– Acute Pain
– Ineffective Therapeutic Regimen
Management
Learning Goal Reflection

Define and describe the differences
between the following bleeding disorders:
– Thrombocytopenia
– ITP/TTP
– Hemophilia
– DIC
Let’s look at the WBC
Aka: Leukocytes
 4,500 – 10,000 per microliter
 5 Major types

– Each combats different microorganisms

Identify and destroy foreign antigens and
proteins by ingesting them
– This process destroys the WBC
– Short life span
Malignant disease
 Cancer of the white blood cells:
– bone marrow produces too many immature
white blood cells
Immature white blood cells leave patient
at great risk for life-threatening infections
 Overabundance of immature WBC’s

– Results in decreased RBC’s and Platelets
Leukemia
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Most common CA in childhood
Also affects adults
Fatal without treatment
Types of Leukemia
–Myelogenous
–Lymphocytic

Further divided by how rapidly they progress:
Acute
Chronic
Diagnosis of Leukemia
–Presenting Symptoms
 Pancytopenia sx.
–CBC w/ differential
 Most useful initial test
 Shows increased and immature
leukocytes
–Bone Marrow Biopsy
 To identify specific type
 Affects
Granulocytes:
– Eosinophils
 detoxify foreign proteins in allergic reactions &
fights parasites
– Basophils
 inflammatory response
– Neutrophils
 fight bacterial infections, most numerous WBC
 Easily destroyed, rapidly replaced
 Affects
Agranulocytes
–Lymphocytes
 form antibodies
 immune response
–Monocytes
 Largest WBC
 Macrophages in tissues
 Live longer than neutrophils
 ALL – Acute Lymphocytic Leukemia
– Most frequently affects children
– 2 – 6 years most frequent age
– With tx. Generally good prognosis
 AML – Acute Myelogenous Leukemia
– Most common in adults
– With tx, generally poor prognosis
Symptoms of Acute Leukemia
– Sx of Neutropenia
 Fevers and night sweats
– Sx of Anemia
 Fatigue, paleness, tachycardia, and tachypnea
– Sx of Thrombocytopenia
 Petechiae or purpura, epistaxis, gingival bleeding,
melena, or menorrhagia
– Weight loss and swollen lymph nodes
– Bone Pain
 Chemo
 Antibiotics
 Colony
Stimulating Factors
 Bone Marrow Transplant (BMT)
 Peripheral Blood Stem Cell Transplant
(PBST)
 CLL
- Chronic Lymphocytic Leukemia
 CML - Chronic Myelogenous Leukemia
– Occur most often in adults
– WBC counts slowly increase over years
– Usually controlled with oral chemo
 Gleevec
– Life expectancy
 2 – 10 years

Symptoms and Diagnosis same as for
Acute but slow onset
– What are the Sx?
– How is it diagnosed?

Treatment
– Oral Chemo
– Antibiotics
– Interferon
– BMT/PBST
Leukemia - Nursing
Diagnosis/Intervention
 Risk
for Injury
– Infection/Thrombocytopenia/Anemia
 Fatigue
 Impaired
Oral Mucous Membrane
 Imbalanced Nutrition less than body
requirements
 Anxiety
 Ineffective Self Help Management
 Cancer
of the lymph system
 1st sx often enlarged lymph nodes
 Higher incidence in men
 Etiology unknown
 2 Types:
–Hodgkin’s Disease
–Non-Hodgkin’s Lymphoma


Most common in 20’s and 50’s
More common in men

Symptoms:
– Painless enlargement of lymph nodes
– Persistent fatigue
– Generalized pruritis
– Chills, fever that come and go
– Soaking Night Sweats
– Anorexia and Unexplained Weight Loss
– Pain r/t pressure from enlarged lymph nodes

Diagnosis
– Lymph node biopsy
Reed-Sternberg cell
– Bone Marrow Biopsy
– CT
 Detect large nodes and metastasis
– Gallium Scan
 Radioactive tracer to malignant lymph
tissue

Treatment depends on:
– The type of Hodgkin lymphoma
– The stage (where the disease has spread)
– Whether the tumor is more than 4 inches (10
cm) wide
– Age and other medical issues
– Other factors, including weight loss, night
sweats, and fever

Treatment includes:
– Radiation Therapy
– Chemotherapy
– Combination of 2
– PBST

Nursing Care:
– Coping w/ SE of radiation
– Chemo SE
– Infection Prevention
Group of lymphatic neoplasms
 More common than Hodgkin’s
 Non-Hodgkin lymphomas begin when a
type of white blood cell, called a T cell or
B cell, becomes abnormal.

– he cell divides again and again, making more
and more abnormal cells.
Symptoms/Diagnosis/Treatment
Same as Hodgkin’s except:
no pruritis
no Reed-Sternberg cell

Cancer of plasma cells in bone marrow
– Plasma cell is type of WBC

High levels of immunoglobulins
– Plasma proteins

Bones weaken
– As cells grow and break down bone

Pancytopenia
– What is this?

Diagnosis:
– X-ray
– Bone marrow biopsy
– Serum Protein Electrophoresis
 Measures immunoglobulins
– 24 hour urine protein electrophoresis
– Look at:
 BUN/Creatinine
 Calcium Level
 Protein Levels

Common symptoms may include:
– Bone pain, often in the back or ribs
– Broken bones
– Weakness or fatigue
– Weight loss
– Repeated infections
– Frequent infections and fevers
– Feeling very thirsty
– Frequent urination
 Management:
– No cure
– Radiation / Chemo
– BMT
– Nursing Care:
 Maintaining Hydration
 Pain management
 Activity / Nutrition
 Decrease infections
 Risk
for Injury
 Acute Pain
 Ineffective Therapeutic Regimen
–Pt Teaching Plan
Learning Goal Reflection

Define the major aspects of diagnosis,
treatment and nursing management of the
patient with:
– Leukemia
– Hodgkin's disease
– Non-Hodgkin’s Lymphoma
– Multiple Myeloma.
Final (Conceptual) Learning Goal

Assist in planning nursing care for a
patient with a disorder of the
hematologic/Immune system.
– Risk for Injury with Low RBCs
– Risk for Injury from Bleeding
– Risk for Injury from Infecction