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Chapter 7 Care of the Patient with a Blood or Lymphatic Disorder Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Overview of Anatomy and Physiology • Characteristics of blood Consistency • 45% blood cells • 55% blood plasma pH • 7.35 to 7.45 Volume • 10 to 12 pints Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2 Overview of Anatomy and Physiology • Red blood cells (RBCs) Erythrocytes Transport oxygen and carbon dioxide • White blood cells (WBCs) Leukocytes Body defenses: destruction of bacteria and viruses • Thrombocytes (platelets) Initiate blood clotting Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 3 Figure 7-1 (From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.) Human blood cells. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 4 Overview of Anatomy and Physiology • Hemostasis: A body process that arrests the flow of blood and prevents hemorrhage Injury Hemorrhage Grouping platelets Thromboplastin released Converts prothrombin to thrombin Links with fibrinogen Formation of fibrin Traps RBCs and platelets Forms clot Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 5 Figure 7-2 (From Thibodeau, G.A., Patton, K.T. [2007]. The human body in health and disease. [3rd ed.]. St. Louis: Mosby.) Blood clotting. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 6 Overview of Anatomy and Physiology • Blood types (groups) Determined by the presence or absence of specific antigens on the outer surface of the RBC • Type A • Type B • Type AB Universal recipient • Type O Universal donor Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 7 Overview of Anatomy and Physiology • Rh factor Rh antibodies may be located on the surface of the RBC • Rh positive: Antibodies are present • Rh negative: Antibodies are not present Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 8 Overview of Anatomy and Physiology • Lymphatic system Functions • Maintenance of fluid balance • Production of lymphocytes • Absorption and transportation of lipids from the intestine to the bloodstream Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 9 Overview of Anatomy and Physiology • Lymphatic system Lymph and lymph vessels • Lymph is a specialized fluid formed in the tissue spaces transported by way of the lymphatic vessels and reenters the circulatory system Lymphatic tissue • Lymph nodes Act as filters, keeping particulate matter such as bacteria from entering bloodstream Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 10 Overview of Anatomy and Physiology • Lymphatic system (continued) Lymphatic tissue (continued) • Tonsils Produce lymphocytes and antibodies: trap bacteria • Spleen Reservoir for blood; forms lymphocytes, monocytes, and plasma; destroys worn-out RBCs; removes bacteria by phagocytosis • Thymus Immune system before and a few months after birth; atrophies at puberty Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 11 Figure 7-4 (From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.) Principal organs of the lymphatic system. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 12 Disorders of the Hematological and Lymphatic Systems • Diagnostic tests Complete blood count (CBC) Red cell indices Peripheral smear Schilling test Megaloblastic anemia profile Lymphangiography Bone marrow aspiration or biopsy Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 13 Disorders of the Hematological and Lymphatic Systems • Anemia Definition • Disorder characterized by RBC and hemoglobin and hematocrit levels below normal range • Causes delivery of insufficient amounts of oxygen to tissues and cells Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 14 Disorders of the Hematological and Lymphatic Systems • Anemia (continued) Etiology/pathophysiology • Types of anemia Blood loss Impaired production of RBCs Increased destruction of RBCs Nutritional deficiencies Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 15 Disorders of the Hematological and Lymphatic Systems • Anemia (continued) Clinical manifestations/assessment • • • • • • • • Anorexia Dyspepsia Cardiac dilation Disorientation Shortness of breath Dyspnea Fatigue Headache Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 16 Disorders of the Hematological and Lymphatic Systems Anemia (continued) Clinical manifestations/assessment (continued) • • • • • • Insomnia Pallor Palpitation Systolic murmur Tachycardia Vertigo Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 17 Disorders of the Hematological and Lymphatic Systems • Anemia (continued) Medical management • Depends on the cause • Correction of the disease process may correct or lessen the anemic condition • Treatment is often specific to the particular anemia Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 18 Disorders of the Hematological and Lymphatic Systems • Hypovolemic anemia Etiology/pathophysiology • Abnormally low circulating blood volume due to blood loss • 500-mL loss can be tolerated • 1,000-mL loss can cause severe complications • Severity and signs and symptoms depend on how rapid the blood is lost Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 19 Disorders of the Hematological and Lymphatic Systems • Hypovolemic anemia (continued) Clinical manifestations/assessment • • • • • • • • Weakness Stupor; irritability Pale, cool, moist skin Hypotension Tachycardia (rapid, weak, thready pulse) Hypothermia Hemoglobin less than 10 g/100 mL Hematocrit less than 40% Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 20 Disorders of the Hematological and Lymphatic Systems • Hypovolemic anemia (continued) Medical management/nursing interventions • Control bleeding • Treat shock O2, elevate lower extremities, keep warm • Replace fluid Blood transfusion, plasma, dextran, lactated Ringer’s • Monitor vital signs Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 21 Disorders of the Hematological and Lymphatic Systems • Pernicious anemia Etiology/pathophysiology • Absence of the intrinsic factor • Intrinsic factor is essential for the absorption of vitamin B12 • Deficiency of vitamin B12 affects growth and maturity of all body cells • Vitamin B12 is also related to nerve myelination May cause progressive demyelination and degeneration of nerves and white matter Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 22 Disorders of the Hematological and Lymphatic Systems • Pernicious anemia (continued) Clinical manifestations/assessment • • • • • • • • Extreme weakness Dyspnea Fever Hypoxia Weight loss Jaundice (destruction of RBCs) Pallor GI complaints Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 23 Disorders of the Hematological and Lymphatic Systems • Pernicious anemia (continued) Clinical manifestations/assessment (continued) • Dysphagia • Sore, burning tongue Smooth and erythematous • Neurological symptoms Tingling of the hands and feet Disorientation Personality changes; behavior problems Partial or total paralysis Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 24 Disorders of the Hematological and Lymphatic Systems • Pernicious anemia (continued) Medical management/nursing interventions • Vitamin B12 (cyanocobalamin) 1,000 units • • • • Daily for 1 week Weekly for 1 month Monthly for life Folic acid supplement Iron replacement RBC transfusion Diet: high in protein, vitamins, and minerals Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 25 Disorders of the Hematological and Lymphatic Systems • Aplastic anemia Etiology/pathophysiology • Decrease of bone marrow function • Primary Congenital • Secondary Viral invasion Medications Chemicals Radiation; chemotherapy Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 26 Disorders of the Hematological and Lymphatic Systems • Aplastic anemia (continued) Clinical manifestations/assessment • • • • • • Pancytopenic Repeated infections with high fevers Fatigue, weakness, malaise Dyspnea Palpitations Bleeding tendencies Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 27 Disorders of the Hematological and Lymphatic Systems • Aplastic anemia (continued) Medical management/nursing interventions • • • • • • Identify and remove cause Platelet transfusion for severe thrombocytopenia Splenectomy for hypersplenism Steroids and androgens Antithymocyte globulin Bone marrow transplant Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 28 Disorders of the Hematological and Lymphatic Systems • Iron deficiency anemia Etiology/pathophysiology • RBCs contain decreased levels of hemoglobin • Excessive iron loss Caused by chronic bleeding—intestinal, uterine, gastric Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 29 Disorders of the Hematological and Lymphatic Systems • Iron deficiency anemia (continued) Clinical manifestations/assessment • • • • • • • • Pallor Fatigue; weakness Shortness of breath Angina; signs and symptoms of heart failure Glossitis; burning tongue Pagophagia Headache Paresthesia Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 30 Disorders of the Hematological and Lymphatic Systems • Iron deficiency anemia (continued) Medical management/nursing interventions • Pharmacological management Ferrous sulfate 900 mg daily o Oral or injection (Z-track) Ascorbic acid • Diet high in iron Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 31 Disorders of the Hematological and Lymphatic Systems • Sickle cell anemia Etiology/pathophysiology • An abnormal, crescent-shaped RBC • Severe, chronic, incurable condition • Disease Homozygous • Trait Heterozygous Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 32 Disorders of the Hematological and Lymphatic Systems • Sickle cell anemia (continued) Clinical manifestations/assessment • Precipitating factors • • • • • • Dehydration Change in oxygen tension in the body Loss of appetite Irritability Weakness Abdominal enlargement Joint and back pain Edema of extremities Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 33 Disorders of the Hematological and Lymphatic Systems • Sickle cell anemia (continued) Medical management/nursing interventions • • • • • • No specific treatment—alleviate symptoms Oxygen Rest Fluids Analgesics Bone marrow transplant Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 34 Disorders of the Hematological and Lymphatic Systems • Polycythemia (erythrocytosis) Polycythemia vera • Characterized by hyperplasia of the bone marrow • Manifestations Increases in circulating erythrocytes, granulocytes, and platelets Elevated WBC count • Diagnostic tests CBC Alkaline phosphatase levels Uric acid levels Histamine levels Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 35 Disorders of the Hematological and Lymphatic Systems • Polycythemia (erythrocytosis) Polycythemia vera • Medical management/nursing interventions Pharmacological management o Myelosuppressive agents o Radioactive phosphorus Reduction of blood viscosity Intake and output Assessment of nutritional status Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 36 Disorders of the Hematological and Lymphatic Systems • Agranulocytosis Etiology/pathophysiology • • • • • • • Severe reduction in the number of granulocytes WBC less than 200/mm3 Medications Chemotherapy Radiation Neoplastic disease Viral and bacterial infections Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 37 Disorders of the Hematological and Lymphatic Systems • Agranulocytosis (continued) Clinical manifestations/assessment • • • • Symptoms of infection Ulcerations of mucous membranes Bronchial pneumonia Urinary tract infection Medical management/nursing interventions • • • • Remove cause of bone marrow depression Prevent or treat infections Meticulous handwashing Strict asepsis Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 38 Disorders of the Hematological and Lymphatic Systems • Leukemia Etiology/pathophysiology • Malignant disorder of the hematopoietic system • Excess leukocytes accumulate in the bone marrow and lymph nodes • Cause unknown • Classification Acute or chronic Proliferating cells (lymphocytic, monocytic, etc.) Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 39 Disorders of the Hematological and Lymphatic Systems • Leukemia (continued) Clinical manifestations/assessment • Anemia • Thrombocytopenia; leukopenia • Enlarged lymph nodes • Splenomegaly Medical management/nursing interventions • Pharmacological management Leukeran Hydroxyurea Corticosteroids Cytoxan • Chemotherapy; radiation • Bone marrow transplant Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 40 Disorders of the Hematological and Lymphatic Systems • Thrombocytopenia Etiology/pathophysiology • Condition in which the number of platelets is reduced below 100,000/mm3; may be due to decreased production or decreased survival Clinical manifestations/assessment • • • • Petechiae Ecchymoses Platelets below 100,000/mm3 Bleeding from mucous membranes Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 41 Disorders of the Hematological and Lymphatic Systems • Thrombocytopenia (continued) Medical management/nursing interventions • Pharmacological management Corticosteroid therapy Gamma globulin Immunosuppressive therapy • Splenectomy • Platelet transfusions • Avoid trauma Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 42 Disorders of the Hematological and Lymphatic Systems • Hemophilia Etiology/pathophysiology • Hereditary coagulation disorder, characterized by a disturbance of clotting factor • Hemophilia A; hemophilia B • X-linked hereditary trait Clinical manifestations/assessment • Internal and external bleeding • Hemarthrosis • Excessive blood loss from small cuts and dental procedures Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 43 Disorders of the Hematological and Lymphatic Systems • Hemophilia (continued) Medical management/nursing interventions • Minimize bleeding—avoid trauma • Relieve pain—no aspirin • Transfusions Factor VIII or IX concentrate Cryoprecipitate (rich in factor VIII) Manufactured factor VIII or IX Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 44 Disorders of the Hematological and Lymphatic Systems • von Willebrand’s disease Etiology/pathophysiology • Inherited bleeding disorder characterized by abnormally slow coagulation of blood; mild deficiency of factor VIII • Similar to hemophilia; not limited to males Clinical manifestations/assessment • Spontaneous episodes of GI bleeding Epistaxis Gingival bleeding Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 45 Disorders of the Hematological and Lymphatic Systems • von Willebrand’s disease (continued) Medical management/nursing interventions • Pharmacological management • • • • • Desmopressin (DDAVP) Cryoprecipitate Fibrinogen Fresh plasma Minimize bleeding—avoid trauma Relieve pain—no aspirin Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 46 Disorders of the Hematological and Lymphatic Systems • Disseminated intravascular coagulation Etiology/pathophysiology • Overstimulation of clotting and anticlotting processes in response to disease or injury Clinical manifestations/assessment • • • • • • Bleeding; hemoptysis Dyspnea Diaphoresis Cold, mottled digits Purpura on the chest and abdomen Petechiae Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 47 Disorders of the Hematological and Lymphatic Systems • Disseminated intravascular coagulation (continued) Medical management/nursing interventions • Pharmacological management Heparin—considered somewhat controversial • Treat underlying cause • Cryoprecipitate • Protect from bleeding and trauma Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 48 Disorders of the Hematological and Lymphatic Systems • Multiple myeloma Etiology/pathophysiology • Malignant neoplastic immunodeficiency disease of the bone marrow Clinical manifestations/assessment • • • • • Bone pain; pathological fractures Infection Anemia; bleeding Hypercalcemia Renal failure Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 49 Disorders of the Hematological and Lymphatic Systems • Multiple myeloma (continued) Medical management/nursing interventions • Symptomatic; not curable • Pharmacological management Corticosteroids Analgesics • Radiation • Chemotherapy • IV fluids Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 50 Disorders of the Hematological and Lymphatic Systems • Lymphangitis Etiology/pathophysiology • Inflammation of one or more lymphatic vessels • Usually occurs from acute streptococcal or staphylococcal infection in an extremity Clinical manifestations/assessment • • • • • Fine red streaks from the affected area Edema Chills; fever Local pain Headache; myalgia Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 51 Disorders of the Hematological and Lymphatic Systems • Lymphangitis (continued) Medical management/nursing interventions • Penicillin • Moist heat • Elevate extremity Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 52 Disorders of the Hematological and Lymphatic Systems • Lymphedema Etiology/pathophysiology • Primary or secondary disorder • Accumulation of lymph in the soft tissue Clinical manifestations/assessment • Massive edema and tightness of affected extremity • Pain Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 53 Disorders of the Hematological and Lymphatic Systems • Lymphedema (continued) Medical management/nursing interventions • Pharmacological management • • • • • Diuretics Antibiotics Compression pump Elastic stocking or sleeve Restricted sodium diet Avoid constrictive clothing Meticulous skin care Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 54 Disorders of the Hematological and Lymphatic Systems • Hodgkin’s disease Etiology/pathophysiology • Inflammatory or infectious process that develops into a neoplasm • Affects males twice as frequently as females • Reed-Sternberg cells Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 55 Disorders of the Hematological and Lymphatic Systems • Hodgkin’s disease (continued) Clinical manifestations/assessment • • • • • • • • Enlargement of cervical lymph nodes Anorexia Weight loss Pruritus Low-grade fever Night sweats Anemia Leukocytosis Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 56 Disorders of the Hematological and Lymphatic Systems • Hodgkin’s disease (continued) Medical management/nursing interventions • Stage I or II (localized) Radiation • Stage III or IV (generalized) Chemotherapy Combination Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 57 Figure 7-5 (From Belcher, A.E. [1992]. Blood disorders, Mosby’s clinical nursing series. St. Louis: Mosby.) Nodal involvement by stage in Hodgkin’s disease (based on modified Ann Arbor Staging System). Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 58 Disorders of the Hematological and Lymphatic Systems • Non-Hodgkin’s lymphoma Etiology and pathology • • • • A group of malignant neoplasms Characterized as a neoplasm of the immune system Cause is unknown Tumors usually start in lymph nodes and spread to lymphoid tissue in the spleen, liver, GI tract, and bone marrow Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 59 Disorders of the Hematological and Lymphatic Systems • Non-Hodgkin’s lymphoma (continued) Clinical manifestations/assessment • • • • • • • Painless, enlarged cervical lymph nodes Fever; susceptibility to infection Weight loss; anorexia Anemia Pruritus Fatigue Malaise Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 60 Disorders of the Hematological and Lymphatic Systems • Non-Hodgkin’s lymphoma (continued) Diagnostic tests • • • • • • • • Bone scan CBC ESR Coombs’ test Chest roentgenogram CT scan Gallium scan Biopsies Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 61 Disorders of the Hematological and Lymphatic Systems • Non-Hodgkin’s lymphoma (continued) Medical management/nursing interventions • Accurate staging of the disease is crucial to determine treatment regimen • Radiation • Chemotherapy • Bone marrow transplant • Tumor necrosis factor (TNF) Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 62 Nursing Process • Nursing diagnoses Infection, risk for Injury (trauma) risk for (bleeding, falls) Fatigue Knowledge, deficient Pain, acute and chronic Tissue perfusion, ineffective Gas exchange, impaired Activity intolerance Coping, ineffective Skin integrity, impaired Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 63 Slide 63 Chapter 14 Antineoplastic Medications Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 64 Chapter 14 Lesson 14.1 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 65 Learning Objectives List the types of drugs used to treat neoplastic disease or cancer Identify the major adverse reactions associated with antineoplastic agents Develop a teaching plan for a patient taking an antineoplastic drug Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 66 Overview Neoplasms Metastasis Malignancy Chemotherapeutic agents Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 67 Antineoplastic Medications Action and Uses Alkylating agents interfere with cell division Antibiotic preparations not used as antiinfectives Antimetabolites affect cell metabolism Action of male and female hormones on cancer unclear Mitotic inhibitors interfere with cell division Miscellaneous agents Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 68 Antineoplastic Medications (cont.) Adverse Reactions Dose-dependent GI: nausea, vomiting, diarrhea, and anorexia Bone marrow depression System-specific toxicity Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 69 Antineoplastic Medications (cont.) Drug Interactions Drug-specific: consult manufacturer’s guidelines Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 70 Antineoplastic Medications (cont.) Nursing Implications and Patient Teaching Assessment Diagnosis Planning Implementation Evaluation Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 71 Antineoplastic Medications (cont.) Nursing Implications and Patient Teaching (cont.) Patient and Family Teaching Chemotherapy/product education Adverse effects When to report symptoms to the health care provider Nutrition Signs of dehydration Hair loss Support groups Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 72 Question 1 In which of the following areas of the body are the cells not as rapidly dividing and growing as other areas? 1. 2. 3. 4. Gastrointestinal tract Bone marrow Lung tissue Hair follicles Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 73 Question 2 Another name for a chemotherapeutic agent is a(n) _____ agent. 1. 2. 3. 4. Metabolic Antineoplastic Metastatic Neoplastic Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 74 Question 3 Which of the following alkylating agents is administered as a wafer that is inserted into a cavity after surgery? 1. 2. 3. 4. Gliadel Leukeran Mustargen Platinol-AQ Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 75 Chapter 20 Hematologic Products Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 76 Chapter 20 Lesson 20.1 Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 77 Learning Objectives Describe the influence of anticoagulants on blood clotting Develop a teaching plan for patients taking anticoagulants on a long-term basis Identify drugs that act in the formation, repair, or function of red blood cells Identify at least three adverse reactions associated with hematologic products. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 78 Anticoagulants Two Categories Coumarin and indandione derivatives • Limit the formation of blood coagulation factors II, VII, IX, and X in the liver by interfering with vitamin K Heparin sodium • Increases the action of antithrombin III (heparin cofactor) on several other coagulation factors to slow new clot development Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 79 Anticoagulants (cont.) Action and Uses Prevent new thrombus formation Stop existing thrombi from growing in size Prophylactic: postsurgery involving the heart or circulatory system Patients with heart valve disease, some dysrhythmias, and receiving hemodialysis Patients on prolonged bed rest or with a history of thrombus formation Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 80 Anticoagulants (cont.) Adverse Reactions Warfarin (Coumadin): alopecia, rash, urticaria, cramping, diarrhea, intestinal obstruction, nausea, paralytic ileus, vomiting, excessive uterine bleeding, hemorrhage, leukopenia, fever Heparin sodium: hypertension, headache, hematoma, conjunctivitis, tearing of eyes, rhinitis, hemorrhage, thrombocytopenia, dyspnea, chills, fevers, alopecia, persistent or prolonged erection, hypersensitivity Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 81 Anticoagulants (cont.) Drug Interactions Nursing Implications and Patient Teaching Calculation procedure of heparin is critical Monitoring blood values Coumadin = prothrombin time (PT); therapeutic is 1.5 to 2.5 × normal or an INR of 2.0 to 3.0 Heparin = activated partial thromboplastin time (aPPT); therapeutic is 2.5 to 3 × the control value Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 82 Anticoagulants (cont.) Nursing Process Assessment Diagnosis Planning Implementation Evaluation Patient and Family Teaching Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 83 Protamine Sulfate Action Strong, alkaline protein that neutralizes effects of heparin Results immediate, last 2 hours or more Uses Treatment of heparin overdose After surgical procedure where heparin was used Adverse Reactions Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 84 Thrombolytic Agents Action Convert plasminogen to the enzyme plasmin, which breaks down fibrin clots, fibrinogen, and other plasma proteins Uses Acute myocardial infarctions Acute pulmonary emboli Acute ischemic stroke Acute arterial occlusion Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 85 Antiplatelet Agents Action Inhibit platelet aggregation (clumping) Reduce thrombus formation Uses Salicylic acid (aspirin) Reduces incidence of myocardial infarction-related deaths in men over 50 Drug of choice in ischemic stroke Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 86 Antiplatelet Agents (cont.) Uses (cont.) Dipyridamole (Persantine), ticlopidine (Ticlid), clopidogrel (Plavix) Myocardial prophylaxis for men Adjunctive therapy with thrombolytics to prevent an infarction or stroke Abciximab (ReoPro), anagrelide (Agrylin) During cardiac catheterization and cardiac procedures Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 87 Question 1 Cellular damage first results in the formation of: 1. 2. 3. 4. Prothrombin. Thrombin. Thromboplastin. Fibrinogen. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 88 Question 2 Which is true about emboli? 1. 2. 3. 4. Emboli are not life threatening. The function of heparin is to dissolve existing blood clots that may form emboli. Emboli can only travel to nearby blood vessels. An embolism can cause stroke or death. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 89 Question 3 Which is the anticoagulant of choice when an immediate effect is needed? 1. 2. 3. 4. Warfarin Plavix (clopidogrel bisulfate) Heparin Aspirin Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 90