Download Blood/Lymphatic Disorder

Blood/Lymphatic
Disorder
Chapter 34
White
Christensen
Adam
L. Lehmkuhl, 2009
Blood/Lymphatic
Disorder
• Functions of blood
• Blood-viscous red
– Transports O2 and nutrition
fluid containing RBCs,
to the cells and waste
WBCs, and platelets
products away from the
cells via cardiac and
in fluid called plasma
respiratory systems.
• Slightly alkaline with
– Regulates acid-base
balance, aids in temp
pH 7.35 to 7.45
regulation, and controls
• NaCl concentration
water content
0.9%
– Protects against infection
• 5-6 liters
Blood/Lymphatic
Disorders
• Erythrocytes (RBCs)
– Hgb 14-18 g/dl in males,
12-16 g/dl in females
– Lifespan 120 days
– Produced in red bone
marrow
– Production stimulated by
Erythropoietin
– Hct 42-52% in males, 3747% in females
• Leukocytes (WBCs)
– Unlike RBCs, have a nucleus
– Fight infection and assist in
immunity.
– 5,000-10,000
– Elevated WBC’s indicate
infection, inflammation, tissue
necrosis or leukemia.
– Different kinds of WBCs are
counted and reported as
percentages of the total is
called a differential
– 2 categories- granulocytes and
agranulocytes
– Wright’s stain differentiates
category of WBC
Blood/Lymphatic
Disorders
Granulocytes
– Neutrophils- essential
for phagocytosis
(process of engulfing)
– Immature
polymorphonuclear
leukocytes called
bands are released
into the blood stream
when neutrophils are
depleted and severe
infection occurs
– Eosinophils- play a
role in allergic
reactions and
against certain
parasitic worms
– Basophilsnonspecific
immune response,
release histamine
Blood/Lymphatic
Disorders
Agranulocytes
– Monocytes- function
similarly to neutrophils
through process of
phagocytosis
– Lymphocytes (B & T)-
Blood/Lymphatic
Disorders
• Thrombocytes (platelets)
– Nonnucleated
– Life span of about 10 days.
– Produced in red bone
marrow
– Function in process of
hemostasis (prevention of
blood loss) and in clotting
formation
– Hemostasis
• Vessel spasm
• Platelet plug formation
• Clot formation
• Blood Types
– A, B, AB, and O
– Type O is the universal
donor(no antigens that
bodies can attack)
– Type AB is the universal
recipient
– Rh factor- 85% of humans
carry this factor
• Rh incompatibility seen
most often in pregnancy
causing hemolysis of the
RBCs causing rupture and
loss of cell contents
Complete Blood Count
• The complete blood count
(CBC) is a screening test,
used to diagnose and
manage numerous
diseases. It can reflect
problems with fluid
volume (such as
dehydration) or loss of
blood. It can show
abnormalities in the
production, life span, and
destruction of blood cells.
It can reflect acute or
chronic infection,
allergies, and problems
with clotting.
-
Complete Blood Count
• A CBC requires a small
blood specimen. Blood is
drawn from a vein,
usually from the inside of
the elbow or the back of
the hand.
• Preparation: The skin
should be cleaned with
alcohol or iodine before
the test. The patient
should be seated
comfortably or reclining.
Complete Blood Count
Low numbers of red blood
cells may indicate anemia,
• Blood loss
• Iron deficiency
• Deficiences of vitamin B12 or
folic acid
• Bone marrow failure (for
example, from radiation,
toxin, fibrosis, tumor)
• Erythropoietin deficiency
(secondary to kidney
disease)
• Hemolysis (RBC destruction)
• Leukemia
• Multiple myeloma
Normal values vary with altitude and
gender.
Complete Blood Count
High numbers of red
blood cells may
indicate:
• Cigarette smoking
• Low oxygen tension in the
blood
• Congenital heart disease
• Cor pulmonale
• Pulmonary fibrosis
• Polycythemia vera
• Dehydration (such as from
severe diarrhea)
• Emphysema
WBC’s
Low numbers of white blood
cells (leukopenia) may
indicate:
• Bone marrow failure (for
example, due to
granuloma (granular
tumor), tumor, or fibrosis)
• Presence of cytotoxic
substance
• Collagen-vascular
diseases (such as lupus
erythematosus)
• Disease of the liver or
spleen
• Radiation exposure
High numbers of white
blood cells
(leukocytosis) may
indicate:
• Infectious diseases
• Inflammatory disease
(such as rheumatoid
arthritis or allergy)
• Leukemia
• Severe emotional or
physical stress
• Tissue damage (for
example, burns)
Blood Transfusions
• Whole blood (^ vol)
• Packed RBC’s
(anemia)
• Platelets (control
bleeding)
• Plasma (clotting d/o’s)
• Cryoprecipate
(fibrinogen
deficiencies)
• Administer within 30
minutes.
• Complete within 4 hours.
• Baseline vs
• 18-19 guage catherter
• 2 nurse check
• Anyreaction immediately
stop infusion..call MD
• N/S to prevent clotting
• Autologous or
homologous
Blood/Lymphatic
Disorders
• Lymphatic systemconsists of lymph
vessels, lymph fluid, and
lymph tissue
• 2 main functions
– Maintenance of fluid
balance (excess fluid from
interstitial space to
circulatory system)
– Production of lymphocytes
to protect body from
infection.
• Lymph nodes– filter impurities from the
lymph and produce
lymphocytes and
macrophages
– Superficial lymph nodes in
neck, axilla and groin can
be palpated, especially
when infected and swollen.
– CA cells can collect,
reproduce and travel
through lymph. Lymph
nodes are biopsied to
detect spread of CA.
Blood/Lymphatic
Disorders
• Tonsils- lymphoid tissue in the
oropharynx
• Spleen- organ located in the
LUQ of the abdomen, contains
lymphatic nodules, stores 350
ml of blood. If needed approx.
200mL can be pumped out
within a minute as needed.
– Removes old RBC’s, platelets
and microorganisms from
blood.
– During infection spleen
enlarges to produce and
release monocytes and
lympthocytes.
• Thymus- located in upper
thorax, develops T
lymphocytes (Tcells).
– Large in infancy and
childhood
– Decreases in size with age
– T cells are actively involved
in immunity.
Blood/Lymphatic
Disorders
• Diagnostic tests
– CBC
– Red cell indices- MCV
(size), MCH (weight),
MCHC (concentration)
– Peripheral smear- most
informative test
– Schilling- measures the
absorption of radioactive
vitamin B12 in diagnosing
pernicious anemia
– Gastric analysis- useful in
determining pernicious
anemia
– Lymphangiographydetects metastatic
involvement of lymph
nodes
– Bone marrow aspiration or
biopsy- most commonly
performed in persons with
marked anemia,
neutropenia, acute
leukemia, and
thrombocytopenia
Blood/Lymphatic
Disorders
• Anemia- disorder
characterized by low
RBC, Hgb, Hct, and
RBC destruction
– Hypovolemic anemia
(blood loss)
• Secondary anemia due
to blood loss
• Control bleeding, tx
shock, replace fluid
volume, O2
– Pernicious anemia
• Absence of intrinsic factor
produced by gastric
mucosa which is needed
for absorption of B12
• Schilling test, serum B12
test, gastric analysis
• Tx is B12 injections (for
life), folic acid
• Pt is highly susceptible to
gastric carcinoma and
should be monitored
closely for symptoms.
Blood/Lymphatic
Disorders
• Aplastic anemia
– Failure of the bone marrow to
produce RBCs
– Patient may have
pancytopenia (low WBC,
RBC,platelets)
– Most cases the cause is
unknown..maybe genetic, or
secondary to viral invasion,
medications, chemicals,
radiation, or chemotherapy
– Bone marrow transplant, if pts
bone marrow fails to respond
to tx.
– Prevent infection, bleeding,
and fatigue
• For transplant the best
candidate is a young pt who
has not had previous infusions.
– Sibling donor under 30 yrs is
higher success
– Immunosupressants are given
to prevent graft rejection.
Blood/Lymphatic
Disorders
• Iron deficiency anemia
– Most common type of
anemia.
– RBCs contain
decreased Hbg
– Most common cause
is chronic intestinal or
uterine bleeding
– Low RBC, Hgb, Hct,
and serum iron levels
– May have pica,
stomatitis, glossitis,
and brittle hair if
chronic.
• Population with higher
incidence are:
– Low birth wt infants or
premature
– Infants
– Adolescent girls
– Alcoholics
– Menstruating women
– Pregnancy
Tx is with iron salts such as
Ferrous Sulfate
• Ascorbic acid enhances iron
absorption
• Z track if parenteral
• Use straw with liquid
• Makes stools green or black
• Diet in Fe rich foods
Sickle Cell Anemia
• Sickle cell anemia is
caused by an abnormal
type of hemoglobin called
hemoglobin S.
• Hemoglobin is a protein
inside red blood cells that
carries oxygen.
Hemoglobin S, however,
distorts the red blood
cells' shape. The fragile,
sickle-shaped cells
deliver less oxygen to the
body's tissues, and can
break into pieces that
disrupt blood flow.
• Sickle cell anemia is
inherited as an autosomal
recessive trait. This
means it occurs in
someone who has
inherited the hemoglobin
S gene from both
parents.
• Sickle cell is the most
common genetic D/O in
the US particularly in
African-Americans,,Asian,
India, Mediterranean and
Caribbean areas.
Sickle Cell
• 1 in 10 African Americans have
the trait, 1 in 500 have the
disease
• Dx with Hgb electrophoresis
which shows HbS
• Negative means sickle cell trait
not sickle cell disease.
Individual is asymptomatic but
may pass disease to offspring.
• If Hbss (genes) confirmed dz
• No specific treatment teach to
avoid sickle cell crisis
• Sickle cell crisis
manifestations:
– Fever
– Severe pain
– Loss of blood to various
organs (obstructed vessels)
– Areas most affected are joints
(become painful and swollen),
bone, brain, lung, liver,
kidneys and penis.
• Frequent PVS, assessment,
heat to joints, avoid tight
clothing and high altitudes.
• Tx symptoms Hydroyurea
(pain),folic acid (^RBC
production) PCA during crisis,
^HOB, O2 ^ tissue perfusion
and offset dyspnea)
SICKLE CELL ANEMIA
Polycythemia
• Two types Primary and
Secondary (compensory
mech to make more rbcs
secondary to hypoxia
from smoking, living in
high altitude, HF)
• Primary- Jewish men >50
y/o acquired mutation
(abnormal DNA) occurs in
bone marrow.
• Erythrocytosis in
Polycythemia Vera
– Hypervolemic,
hyperviscous state (blood
is unable to circulate freely)
– Increased plasma, RBC
(WBC’s and platelets also
increased), Hbg, Hct, low
oxygen level on ABG
• Tx is repeated
Phlebotomy (350-500mL)
to decrease RBC’s, blood
viscosity and reduce
blood volume.
• Myelosuppressive
agents- Myleran,
hydroxyurea, and
radioactive phosphorous
(to decrease RBC
production)
• Low Na+ diet (decrease
blood vol and avoid Fe
rich foods
POLYCYTHEMIA VERA
Leukemia
• Malignant D/O with excess
WBCs in marrow and lymph
nodes
• Pt constantly fighting infections
and has fever and chills.
• Enlarged lymph nodes,
anemia, thrombocytopenia
(bleeding, bruising), low or
very high WBCs
• Hepatosplenomegaly,
lymphadenopathy, bone pain
(WBC;s crowding cells in bone
marrow), oral lesions
• Bone marrow bx shows
immature WBCs
• Bleeding common monitor
platlets
• Tx is chemo + radiation
(destroys CA cells and good
cells), bone marrow transplant
• Prevent infection (high risk),
and chronic pain
• Most common cause of death
is viral or fungal PNA.
• Acute lymphocytic leukemia
(ALL) <15 yo more rapid
onset than Acute myeloid
leukemia (AML).
• R/f infection and bleeding
• Teach: Hand washing to
visitors, pt hygiene use
antimicrobial soaps, electric
razor, antiemetics, stool
softener, monitor for
hematuria or cloudy urine.
LEUKEMIA
LEUKEMIA CELLS
Agranulocytosis
• Severe reduction in
granulocytes (basophils,
eosinophils, and
neutrophils)
• Leukopenia
• Med reaction or toxicity,
cancer, chemotherapy or
radiation
• Differential below normal
• Tx is to alleviate cause
and to prevent infection
• Meticulous
handwashing,
monitor: VS, WBC,
lung sounds.
• Strict aseptic
technique, visitors
screened, reverse
isolation may be
implemented.
Coagulation Disorders
• Disseminated Intravascular Coagulation
• Hemophilia
• Thrombocytopenia
Hemophilia
• Inherited blood clotting d/o
from lack of certain clotting
factors
– Hemophilia A most common
– Hereditary, x linked, affects
mostly males, females carry
genes
– Disturbance in clotting factors
– Dx Factors VIII and IX,
prolonged PTT
– Tx transfusions, replacement
of factor VIII and IX
(cryoprecipitate)
• Willebrand’s Disease- mild
deficiency of factor VIII
• 3 classifications
– Mild
– Moderate
– Severe
• Can bleed out from trauma or
bleed spontaneously.
• Spontaneous ecchymosis
from GI or GU tracts
HEMOPHILIA A
Disseminated Intravascular
Coagulation (DIC)
• Acquired Hemorrhagic
syndrome of the clotting
cascade and over stimulation
of the clotting process.
• DIC a condition of alternating
clotting and hemorrhaging.
– Coagulopathy resulting from
the overstimulation of clotting
and anticlotting processes in
response to disease or injury
– Dx prolonged clotting
coagulation profile, marked
thrombocytopenia, deficits in
factor V and VIII
– Tx cryoprecipitate, heparin,
fibrinolytics, transfusion
– Primary dz stimulates
the clotting
mechanism , causes
mini microthrombi to
develop. The body’s
fibronolytic process
attempts top break
clots thus causing
hemorrhaging.
Thrombocytopenia
• Platelets reduced below
100,000
– Drug induced, infection or
idiopathic
• Risk for bleeding
– Prevent trauma (0 falls) or
infection
– Petechiae (small skin
hemorrhages) and
ecchymosis (bruising).
– Monitor for internal
bleeding
• Tx corticosteroids and
splenectomy (last
resort..spleen is where
platelet destruction
occurs), platelet
transfusions or apheresis
(removal of unwanted
componenets), IV gamma
globulin or
immunosuppressive
drugs
THROMBOCYTOPENIA
Lymph Disorders
• Hodkins Lymphoma
• Non-Hodkins Lymphoma
Blood/Lymphatic
Disorders
• Malignant Lymphoma
– Cancer of lymphoid tissue
– Painless, enlarged lymph
nodes, fever, wt loss,
anemia, pruritus, and prone
to infection
– Bone scan may reveal fxs
from bone mets, CT scan,
node bx
– Tx chemo and radiation
– Supportive care,
interventions similar to
Hodgkins Lymphoma
• Hodgkins Lymphoma
– Cancer of the lymphoid
tissue
– Males, bimodal
– Biopsy of lymphoid tissue
shows Reed Sternberg
Cells.
– Tx dependent on stage
– Tx chemo and radiation
– Nursing care according to
stage
– Comfort measures focus
on skin integrity
• Soothing baths with
antipruritic medications
(e.g. puritis).
CHILD WITH HODGKIN’S
Plasma Cell Disorder
• Myeloma
Multiple Myeloma
• Malignant neoplastic
immunodeficiency
disease of the bone
marrow
• Plasma cell tumor
• Disruption of production
of RBC, WBC, and
platelets due to
overproduction of plasma
cells
• Bone destruction with
release of calcium and
phosphorous from bones
• Hyperuricemia with high
Pro leads to renal failure
– Pain relief, prevent infection
and bone injury, chemo, and
hydration
• Encourage 3-4 Lof H2O
to minimize complications
of excessive Ca in the
blood and urine.
• Exercise to preveny bone
demineralization
• Monitor for
hypercalciumia
MYELOMA
BENCE JONES PROTEIN CAST
IN URINE
MONOCLONAL PROTEIN