Download N308 Care of the Adult with Hematopoietic stressors

N308 Care of the Adult with
Hematopoietic stressors
Zelne Zamora DNP, RN
Blood Production Problems
(Quantity Problems)
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UNDERPRODUCTION
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OVERPRODUCTION
IMPAIRED PRODUCTION
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• Hypoproliferative
• Microcytic (RBCs small)
• Macrocytic (RBCs large)
• Hypochromic (↓Hemoglobin)
• Hyperchromic (↑Hemoglobin)
Circulation - Patho
Circulation
Circulation - Purpose
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Movement of
nutrients and
medications
Oxygenation
Homeostasis
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Fluid balance
Acid-base balance
Blood Cells
Blood Cells
Plasma
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Plasma proteins
Clotting factors
Other substances:
nutrients, enzymes
Waste products
Gases
Albumin
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Maintains fluid balance
Binds substances to
transfer in plasma, i.e.,
meds
Maintains osmotic forces
ANEMIA
A client without sufficient red blood cells is said to
be anemic.
Normal Red Blood Cell Count
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4.0 – 5.4 million u/L
Males are often
slightly higher than
females
Testing for CBC
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Non-fasting
Can take blood sample from vein, artery
or capillary
Do not use vein where I. V. is located
Do not massage area (heel stick, or fingers)
• False low
 If tourniquet on too long, remove, wait, then try again
 False high
Hemoglobin & Hematocrit
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Hemoglobin
Normal Adult
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12-17 gm/dl
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Hematocrit
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36-51% of whole blood
volume
Is generally 3X the
hemoglobin value
Mean Corpuscular Hemoglobin
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Amount of hemoglobin in an average red
blood cell.
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Normal MCH level is between 26 and 33
picograms (one trillionth of a gram) of
hemoglobin per red blood cell.
MCV and RDW
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MCV – Mean Corpuscular Volume
Average amount of space occupied by
each red blood cell.
The normal MCV level = between 78 and
98 cubic micrometers (abbreviated um3)
RDW – Red cell Distribution Width:
Differences in sizes of the cells
Normal RDW = variation of 11%-14.5%
Common Cause:
Hemorrhagic Blood Loss
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Menstruation
Childbirth
Gastro-intestinal
Trauma
Abnormal cell
morphology, i.e.,
hemophilia
Common Cause:
Poor Nutrition
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Inadequate intake of
nutrients
Inadequate
absorption of
nutrients (iron, folic
acid, Vit. B12)
Anemia
Iron Deficiency Anemia
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Microcytic,
hypochromic
disorder
s/s Iron Deficiency
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Early: fatigue, weakness, pale skin
Late: dyspnea, chest pain, muscle pain,
cramping
Iron Deficiency
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Most common type of
anemia
Health history may be
significant if client has GI
bleeds, multiple
pregnancies, and pica
(eating items without
nutritional value or non-food
items)
Diagnostics
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Hgb
Hct
Reticuloctye count
indices
MCV
RDW
Too much iron in the body
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Hemochromatosis
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Genetic
Iron absorbed from GI
tract
Common in
Caucasian descent
Hemochromatosis
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Serial screening tests – alpha fetal proteins
Serum iron studies
Genetic counseling
Tx: removal of blood
Iron Studies
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Serum iron level
TIBC
% saturation
Ferritin
Differentiation of iron
amounts in different
areas of the body
Vitamin B12 Deficiency
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Pernicious anemia
Macrocytic
normochromic
Lack of intrinsic factor
Cheilosis, smooth sore
tongue, neurological
problems
Schilling Test
Schilling Test
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The Schilling test is performed to
evaluate Vitamin B12 absorption.
Excretion of 8 to 40% of the radioactive
Vitamin B12 within 24-hours is normal.
The Schilling test is most commonly
used to evaluate patients for pernicious
anemia.
Folic Acid Deficiency
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Macrocytic,
normochromic
Malnutrition
Alcoholics
Serum folate levels
Birth defects
Folic Acid (B9)
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Malabsorption
Antibiotics:
ampicillin,
tetracycline
Estrogen
Symptoms similar to
B12
Aplastic Anemia
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Rare
Congenital or acquired
Commonly idiopathic
Caused by infections or
pregnancy
Chemical agents
Aplastic Anemia
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Decreased in all cells:
Hgb, RBCs, WBCs,
platelets
Medication related
(toxicity) or chemical
related
Do bone marrow aspiration
Aplastic Anemia - Tx
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Tx: hematopoietic stem cell
transplant
Immunosuppressive therapy
to prevent lymphocytes from
destroying stem cells
Transfusions of RBCs and
platelets
Aplastic Anemia - Nursing
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Safety!
s/s Infection and
bleeding
Monitor side effects of
therapy
Drugs and Anemia
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AZT(Zidovudine)
Phenytoin
Methotrexate
G6PD deficiency
Chronic Illness
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Renal disease
Rheumatoid arthritis
Cancer
Kidney Dysfunction Patients
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Likely to be anemic
Under produce
erythropoietin
Uremia: bone
marrow less likely to
respond to the
erythropoietin that is
produced
Hemolysis
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(erythrocyte destruction)
Hereditary Spherocytosis
Heavy metals (lead, copper)
Malaria
Prosthetic heart valves
Vasculitis
Malignant hypertension
Sepsis
Chemical poisoning
Autoimmune diseases
Pregnant women have ↓ RBCs
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Dilutional
Fluid retention
dilutes RBCs
If RBCs are TOO HIGH you have
polycythemia
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Sluggish flow
↑ clotting
Tissue hypoxia
High altitude
Polycythemia VERA
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Overproduction of
ALL blood cell types
Blood removal is the
treatment
Bone marrow
suppression drugs
Other causes of ↑ RBCs
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Dehydration
Smoking
Drugs
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Gentamycin
Methyldopa
Types of Anemia
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Hemolytic
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Nutritional
• Thalassemia
• Sickle cell
• Spherocytosis
• Iron deficiency
• Folic Acid
• Vitamin B12
Types of Anemia
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Production
Impairment
• Aplastic
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Bone Marrow
suppression
• Cancer therapy
Thrombocytopenia
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Not enough platelets
Coagulation
problems
Bleeding
Thrombocytopenia
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Manual examination
of peripheral smear
Nursing: safety of
patient: shaving,
toothbrush,
medications
Primary Immune or Autoimmune
Thrombocytopenic Purpura (ITP)
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Acute vs. chronic
1-6 weeks post viral
illness
Self-limiting
Dx: exclusion of other
causes of
thrombocytopenia
DIC is Triggered by?
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Sepsis
Trauma
Cancer
Shock
Toxins
Allergic Reactions
Emergency situation
NURSING CARE FOR DIC
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Maintain optimal oxygenation
Manage fluid replacement
Monitor electrolyte imbalances
Administer vasopressor meds as
ordered
Protect from falls/injury
Provide emotional reassurance
Clotting tests
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Prothrombin time (PT)
International Normalized
Ratio (INR)
Clotting tests
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Partial prothromboplastin time (PTT)
Bone Marrow Biopsies:
Blood Transfusions:
Nursing Responsibilities
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Verify, Verify, Verify with 2
nurses!
• Patient identification (name,
record #, B.D.)
• Correct blood type, blood
unit, exp. date
• Set up I.V. access with
saline
• Answer patient questions
Hang blood, use blood tubing
with filter
Blood Transfusion Reactions:
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Febrile Non-hemolytic – most common
Acute hemolytic – most dangerous
Allergic reaction
Circulatory overload
Blood Transfusion Reactions:
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Bacterial contamination
TRALI – transfusion related acute lung injury –
potentially fatal
Delayed hemolytic reaction
Disease acquisition
Blood Transfusions:
Nursing Responsibilities
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Monitor Vital signs frequently
Unit to hang < 4 hours, note
patient condition to regulate
flow.
TRANSFUSION REACTION!
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Stop the blood
Have someone call M.D.
Raise the head of the
bed
Apply 02
TRANSFUSION REACTION!
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Hang new saline bag
and tubing
Monitor urine for
amount/blood
Frequent VS