ATI Med-Surg Unit 4 Hematological Systems Flashcards
what does a bone marrow biopsy do?
provides diagnostic info about how the bone marrow is functioning
Describe the process of blood testing
- Preprocedure: use standard precaution in collection/handling blood for specimen colleciton
- Intraprocedure: a. select appropriate vial b. collect sufficient quantity and fill to mark c. properly label specimen and deliver to lab promptly (facility protocol/depends on specimen) d. for coagulation studies, blood will be required to be drawn at specific times and sent to lab immediately so nurse adjusts dose of anticoagulant therapy based on results
- Postprocedure: a. preliminary results within 24-48 hours and final results in 72 hours b. if results out of range, nurse’s responsibility to report results to provider
what is a bone marrow biopsy?
bone marrow sample removed by needle aspiration for cytological/histological examination, can then diagnose cell type and confirm or deny malignancy
what is a bone marrow aspiration for?
to diagnose causes of blood disorders, such as anemia or thrombocytopenia, rule out diseases such as leukemia and other cancer, and for infection
Nursing actions for bone marrow procedure
- preprocedure: ensure that the client has signed informed consent and ***position client in prone or side lying position to expose iliac crest
- > education: explain procedure: biopsy will be anesthetized with local anesthetic and client may feel pressure and brief pain during aspiration - intraprocedure: administer sedative if prescribed, assist provider, if needed apply pressure to biopsy site and place sterile dressing
- postprocedure: monitor for inection and bleeding, apply ice, mild analgesics, avoid aspirin and other clotting meds
- > Education: about bleeding and infection, about checking biopsy site daily (clean, dry, intact), if sutures are in place remind client to return in 7-10 days to have removed
what’s important to note for older client during bone marrow aspiration?
sedatives -> greater risk due to chronic illnesses and renal clearance needs to be considered
what are the big complications of bone marrow aspiration/biopsy?
infection (can occur at aspiration site, monitor site and keep it clean/dry); bleeding
what are the components of blood
packed RBCs, plasma, albumin, clotting factors, prothrombin complex, cryoprecipitate, platelets
what are the transufsion types
- homologous transfusion: from donors
- autologous: client’s blood collected preemptively (elective surgery); only client can use, may donate blood 5 week in advance up to 72 prior to surgery
- > intraoperative blood salvage: loss during surgeries is recycled through a cell-saver maching and transfused intra or postoperatively (orthopedic surgeries, CABG)
what are some indications for blood transfusions and possible corresponding components?
excessive blood loss - whole blood; anemia - packed RBCs, kidney failure - packed RBCs, coagulation factor deficiencies - fresh frozen plasm, thrombocytopenia/platelet dysfunction - platelets
Explain blood types
- big concern is compatability, bloods typed by antigens
A: has A antigens, B antibodies, and compatible with A, O
B: has B antigens, A antibodies, and compatible with B, O
AB: has A and B antigens, no antibodies, compatible with A, B, AB, O
O: has no antigens, A and B antibodies and is only compatible with O
What is a 5th antigen that’s important in blood
D antigen makes the Rh factor positive, Rh-positive given to Rh-negative will cause hemolysis
packed RBCs are prescribed for whom
clients with Hgb of less than 8 g/dL
what needle is standard for administering blood products
20-gauge needle
preprocedure nursing actions for blood transfusion
assess lab values, verify Rx, obtain blood samples for type/crossmatch, initiate large IV access, assess hx, obtain blood products from blood bank (discoloration, excessive bubbles, cloudiness?), confirm client’s identity and exp date, prime, vitals, begin
right before you administer a blood transfusion what’s important to do?
prime set with 0.9% sodium chloride, blood products are infused only with this, NEVER add meds to blood products and then ascertain if filter needed
nursing action after starting blood transfusion
- remain in room for 15-30 minutes (reactions occur usually in first 15 minutes)
Then… - vital signs q1h (neck vein distention)
- older adults - vitals more often, fluid overload
- complete transfusion within 2-4 hr time frame to avoid bacterial growth
Postprocedure nursing actions for blood transfusion
- vitals
- dispose set in biohazard bags
- monitor labs (levels should rise by 1g/dL each unit transfused)
- document
What are the transfusion reactions
- Acute hemolytic
- Febrile
- Mild allergic
- Anaphylactic
What is an acute hemolytic transfusion reaction
immediate
symptoms: chills, fever, low back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria
- can cause cardiovascular collapse, kidney failure, disseminated intravascular coagulation, shock and death
What is a febrile transfusion reaction
30 min - 6 hours after
symptoms: chills, fever, flushing, headache, and anxiety
- use WBC filter, administer antipyretics
mild allergic transfusion reaction
during or up to 24hrs after
symptoms: itching, urticaria, and flushing
- administer antihistamines such as diphenhydramine (Benadryl)
anaphylactic transfusion reaction
immediate
symptoms: wheezing, dyspnea, chest tightness, cyanosis, hypotension
- maintain airway; administer oxygen, IV fluids, antihistamines, corticosteroids and vasopressors
if a transfusion reaction occurs, what do you do?
- STOP transfusion
- infuse 0.9% sodium chloride with a separate line
- save blood bag and tubing for testing at lab, follow facility protocol
- explain to client why discontinuing
in patients with impaired cardiac function what can occur in a blood transfusion
circulatory overload
manifestations: dyspnea, chest tightness, tachycardia, tachypnea, headache, HTN, jugular-vein distention, peripheral edema, orthopnea, sudden anxiety, and crackles in base of lungs
nursing actions for circulatory overload
o2, vitals, slow infusion rate, administer diuretics
nursing interventions for septic schock during blood transfusion
symptomsL fever, nausea, vomitting, abdominalpain, chills, and hypotension
actions
- maintain airway/administer o2
- antibiotics
- blood culture sample
- vasosupressors like DA to combat vasodilation in late phase
- elevate client’s feet
if disseminated intravascular coagulation (DIC) occurs during blood transfusion, what do you do?
- admin anticoagulants like heparin in early phase
- administer clotting factos/blood products in late phase as clotting factors depleted in after early phase
what’s main concern with anemia
diminished o2 carrying capacity and delivery to tissues/organs, goal is to restore/maintain adequate tissue o2
reasons for anemia
blood loss, hypoproliferative RBC production, hemolytic RBC destruction, deficiency of components like folic acid, iron, erythropoietin, vitamin B12
what’s most common cause of anemia in children, adolescents and pregnant women?
iron-deficiency anemia due to inadequate intake
what’s most common anemia in postmenopausal women and men
iron-deficienncy anemia due to blood loss (eg GI ulcer)
in premenopausal women what’s important to consider?
can get anemia secondary to menorrhagia
what’s important to note for client sthat are iron deficient but have elevated cholesterol elvels?
iron-rich food but not red or organ meats (so iron-fortified cereals, breads, fish and poultry, and dried peas/beans)
what sources are high in folate
spinach, lentils, bananas, and fortified stuff
What are the risk factors for anemia?
- acute/chronic blood loss (trauma, menorrhagia, GI bleeds/ulcers, chemical/radiation, intra postsurgical, hemorrhage)
- increased hemolysis
- inadequate dietary intake or malabsorption
- bone-marrow suppression
What can increase hemolysis?
a) defective Hgb like in sicke-cell disease (RBCs malform with hypoxia and obstruct capillaries)
b) impaired glycolysis: glucose-6-phosphate-dehydrogenase (G6PD) deficiency anemia
c) immune disorder or destruction (transfusion reactions/autoimmune disease)
d) mechanical trauma to RBCs (mechanical heart valve, cardiopulmonary bypass)
what inadequate dietary intakes or malabsorptions can contribute to anemia
1) iron deficiency
2) vitamin B12 deficiency: pernicious anemia is due to deficiency of intrinsic factor produced by gastric mucosa,which is needed for vitamin B12
3) folic acid deficiency
4) pica: persistent eating of substances not normally considered foot like soil/chalk for at least 1 month and may limit nutrition
what are causes of bone-marrow suppression
- exposure to radiation/chemical (insecticides)
- aplastic anemia results in decreased RBCS as well as platelets and WBCs
anemia in older adults
risk for nutrition deficiencies, anemia may be misdiagnosed as depression or debilitation in older adults, GI bleeding is common cause of anemia in older adutls
what are symptoms of anemia
SOB/fatigue, tachycardia and palpitations, dizziness or syncope upon standing/exertion, pallor with pale nail bed and mucous membranes, nail bed deformities, dyspnea, sensitivity to cold
what’s a symptom of vitamin B12 deficiency anemia
smooth, sore, bright-red tongue
what’s symptoms of sickle-cell crisis as relates to anemia
pain/hypoxia
what are lab tests for anemia
CBC
what’s hematocrit
percentage of RBCs in relation to total blood volume
what’s the mean corpuscular volume
MCV = size of red blood cells
what are the different types of MCVs
normocytic - normal size
microcytic - small cells
macrocytic - large cells
what’s the mean corpuscular hemoglobin
MCH = determines amount of Hgb per RBC
what are the results of MCH
normochromic - normal amount of Hgb per cell
hypochromic - decreased Hgb per cell
RBC indices
normal MCV, MCH, MCHC: classification = normocytic, normochromic anemia (causes: acute blood loss, sickle cell disease)
decreased values: classification = microcytic hypochromic anemia (iron-deficiency anemia, anemia of chronic illness, chronic blood loss)
increased MCV: classification = macrocytic anemia (vitamin B12 deficiency, folic acid deficiency)
what is the TIBC
total iron-binding capacity, reflects measurement of serum transferrin, protein that binds with iron and transports it for storage
what is serum ferritin
an indicator of total iron stores in body
what is Hgb electrophoresis
separates normal Hgb from abnormal, detects thalassemia and sickle-cell disease
what does a Schilling test do
measure vitamin B12 absorption with and without intrinsic factor, used to differentiate betweenmalabsorption and pernicious anemia
what is bone-marrow aspiration used to diagnose?
aplastic anemia (failure of bone marrow to produce blood factors)
what iron supplement is only given for severe anemia?
parenteral iron dextran (remember to use Z-track)
client education for iron-deficient anemia
instruct to have Hgb checked in 4-6 weeks, vitamin C may increase oral iron absorption, take iron supplements between meals to increase absorption
what is erythropoietin
epoetin alfa (Epogen, Procrit): hematopoietic growth factor to increase RBC production
- monitor for increased BP, monitor Hgb and Hct twice a week, monitor for cardiovascular event if Hgb increases too rapidly (greater than 1g/dL in 2 weeks)
what is used for pernicious anemia
vitamin B12 supplementation (cyanocobalamin)
- B12 converts folate to active form (needed to create DNA)
- can be given orally bu if deficiency due to lack of intrinsic factor from parietal cells of stomach or etc, must be admin parenterally or intranasally to be absorbed (MUST be continued for rest of patient’s life, done on a monthly basis)
what can large doses of folate do?
- mask vitamin B12 deficiency
2. turn urine dark yellow
what’s a complicaiton of anemia
heart failure as increased demand on heart to provide O2 to tissues (tachycardia, palpitations)
nursing actions for heart failure as complication of anemia
- admin O2 and monitor O2 sat
- monitor cardiac rhythm
- obtain daily weight
- admin blood transfusion prescribed
- admin cardiac meds as prescribed (diuretics, antidysrhytmics)
- admin antianemia meds as prescribed
coagulatin disorders overview
- occur seconday to alteration in platelet/clotting factos
- coagulopathy - condition affecting abilty to coagulate
name the coagulation disorders
- idiopathic thrombocytopenia (ITP): autoimmune disorder where lifespan of platelets decreased by antiplatelet antibodies although platelet production normal (severe hemorrhages with lacerations)
- disseminated intravascular coagulation (DIC) - life-threatening coagulopathy where clotting/anticlotting occurs simultaneously -> risk for internal and external bleeding, as well as ischemia by microclots
risk factors for ITP/DIC
ITP: female (20-40), autoimmune disorder, recent virus (children only)
DIC: septicemia, cardiopulmonary arrest, hemorrhage
Symptoms of coagulopathy
- bleeding from gums/epistaxis
- oozing, trickling or flow of blood from incision
- petechiae and ecchymoses
- bleeding from venipuncture, injection sites,, or slight traumas
- tachycard, hypotension, and diaphoresis
- organ failure secondary to microemboli
lab tests of coagulopathy
Hemoglobin (decreased with both)
platelets (decreased with both)
fibrinogen decreased wtih DIC
DIC: increased prothrombin time, increased partial thromboplastin time, increased fibrin split, increased D-dimer
- for both do blood typing and crossmatch
nursing care for DIC
- assessing and corercting underlying cause (sepsis, hemorrhage), then focus to prevent organ damage from microemboli and replacing clotting components
- monitor for signs of microemboli (cyanotic nail beds, pain)
nursing care for DIC and ITP
- take vitals and assess hemodynamic status
- signs of organ failure or intracranial bleed (oliguria, decreased LoC)
- monitor lab values for clotting factors
- admin fluid volume replacement
- transfuse blood, platelets, and clotting products
- mointor for complications from admin of blood products
- avoid NSAIDs
- admin O2
- protect from injury
- instruct client to avoid Valsalva maneuver (could cause cerebral hemorrhage)
- implement bleeding precautions (avoid needles)
Meds for coagulopathy
ITP - corticosteroids and immunosuppressants
DIC - anticoagulants (heparin) : may be used to decrease microclots from forming and using up clotting factors
surgical interventions for coagulopathies
ITP - splenectomy
