CH 20: Hematologic Disorders Flashcards
two components of blood
Plasma: contains water, solutes, nutrients, and proteins
Blood cells: contains erythrocytes, leukocytes, and thrombocytes
how much blood in average human
There are about 5 to 6 quarts (4.7-5.5L) of blood in the average adult who weighs between 150 and 180 pounds.
thromocytes are responsible for:
clotting
Leukocytes are responsible for:
fighting infection
erythrocytes are responsible for:
carrying oxygen
where do we find iron
Storage in bones
ingestion
transporting
RBC
Recycling
RBC diagnostics
Hemoglobin
Measures gas-carrying capacity of RBC
Female: 12-16 g/dL
Male: 14-18 g/dL
Increased: polycythemia vera, hemoconcentration (dehydration)
Decreased: anemia, blood loss, bone marrow suppression
Hematocrit
Percent of RBCs compared to total blood volume
3x Hgb
Female: 37-47%
Male: 42-52%
Increased: polycythemia vera, hemoconcentration (dehydration)
Decreased: anemia, blood loss, bone marrow suppression
RBC
Number of circulating RBCs
Female: 4.2-5.4 x 106/µL
Male: 4.7-6.1 x 106/µL
Increased: high altitude, polycythemia
Decreased: anemia, blood loss, bone marrow suppression
RBC Morphology
Examines shape and size of RBC
No variation
Aids to determine type of anemia
RBC indices
special indicators that reflect RBC volume, color, and hemoglobin saturation
MCV: 80-95 fL
MCH: 27-31 pg
MCHC: 32-36%
Increased MCV/MCH: pernicious anemia and folic acid deficiencies
Decreased MCV/MCH: iron-deficiency anemia, lead poisoning
Decreased MCHC: iron-deficiency anemia
Erythrocyte sedimentation rate (ESR)
Measures sed rate of RBCs;
<20 mm/hr
Increased: inflammatory process
platelet diagnostic labs
Platelets
Number of circulating platelets
150,000 – 400,000
Increased: polycythemia, thrombocytosis (excessive clotting)
Decreased: thrombocytopenia, suppressed bone marrow, autoimmune disease, splenomegaly; increased risk of bleeding
PT
Assess extrinsic coagulation and response to warfarin therapy
10-15 secs
Prolonged PT: deficiencies in clotting factors, anticoag therapy
Decreased time: vitamin K excess
aPTT
Assess intrinsic coagulation and response to heparin therapy
30-40 secs
Prolonged: insufficiency of clotting factors, presence of heparin, fibrinolysis
INR
Compares PT with control value; measures effectiveness of warfarin
0.8 – 1.1 without warfarin; 2.5 – 3.5 with warfarin
Increased: DIC, cirrhosis, hepatitis, vit K deficiency, salicylate intoxication, supratherapeutic for warfarin therapy
D-dimer
Measures fragment of fibrin that forms b/c of degradation or clot lysis
< 250ng/mL
Increased: hypercoagulable states (PE, DIC)
iron diagnostic labs
Serum iron
Amount of protein-bound iron in circulation
Female: 60-160 mcg/dL
Male: 80-180 mcg/dL
Increased: excess iron, liver disorders, megaloblastic anemia
Decreased: hemorrhage, iron-deficiency anemia
Total iron-binding capacity (TIBC)
Measurement of all proteins that bind or transport iron; indirect measure of transferrin
250-460 mcg/dL
Increased: iron-deficiency anemia
Decreased: anemia, hemorrhage
Serum ferritin
Body iron stores
10-300 ng/mL
Increased: excess iron, liver disorders, megaloblastic anemia
Decreased: hemorrhage, iron-deficiency anemia
Transferrin saturation
Measures available iron for erythropoiesis
Female: 15-50%
Male: 20-50%
Increased: hemolytic and megaloblastic anemia
Decreased: iron-deficiency anemia
Hemoglobin concentration lower than normal; decreased number of RBCs
Deficiency in # of RBCs, quality/quantity of Hgb or Hct
anemia
anemia types Categorized by morphology (color and size) or physiology (cause)
Hypoproliferative (decreased production)
Blood loss (bleeding)
Hemolysis (destruction of RBCs) - incompatibility
causes of anemia
impaired renal disease
bleeding
blood disorders
lack of iron in diet
medications
competition of minerals for absorption
clinical manifestation of anemia come from:
Depends on severity, coexisting disease, duration of anemia, metabolic requirements of the client, and development of anemia
The more rapidly it develops, the more severe its symptoms
May start to have symptoms when Hgb is 9-141 g/dL
Caused by reduced oxygen-carrying capacity; tissue hypoxia and compensatory mechanisms
clinical manifestations of anemia
weak, fatigue
dizziness
pica (cravings)
numbness and tingling
HA
Confusion
reflex abnormalities
loss of position
spasticity
roaring, rushing ,ringing in ears
pallor
jaundice
impaired wound healing
loss of elasticity
early thinning or greying of hair
palpitations
chest pain
tachy
hypotension
Peripheral edema
murmurs
dyspnea
tachypnea
orthopnea
anorexia
dysphagia
abdominal pain
hepatomegaly
splenomegaly
muscle pain
laboratory data of anemia
Hemoglobin
Hematocrit
Reticulocyte count
RBC indices
–Mean corpuscular volume (MCV)
–Red cell distribution (RDW)
Iron studies
Vitamin B12
Folate
Erythropoietin
Stool for H. Pylori and occult blood
diagnostic data of anemia
Bone marrow aspiration and biopsy - cancer?
Endoscopy - upper GI bleed
Colonoscopy - lower GI bleed
potential nursing problems for anemia
fatigue
ineffective health and management
ineffective tissue perfusion
impaired sensory perception
imbalanced nutrition: less than body requirements
impaired cardiac output
oxygenation
safety
fall prevention
nursing implementation for anemia
Investigate and fix the cause!
Acute therapy
–Supplemental 02
–IVF and/or Blood transfusion (for severe)
–Drug therapy - epogen - renal disease
–Monitor VS and labs
Energy conservation: Balance exercise and rest
Dietary/lifestyle changes
–Iron sources: organ meats, red meats, beans, leafy green veggies, raisins, molasses
–Vitamin C absorbs iron
Interprofessional collaboration
Patients with fatigue
Alternate rest and activity
Prioritize activities
Accommodate energy levels
Maximize O2 supply for vital functions
Provide assistance to minimize risk for injury
Evaluate nutritional needs
Arrange activities to reduce competition for oxygen supply to vital functions, for example avoiding activity immediately after meals.
Collaborate with the dietitian to determine calorie and nutrient needs to meet nutritional requirements.
Provide information and education about nutrition and how to meet patient’s intake of essential nutrients.
Encourage increased intake of foods high in iron.
causes of iron deficiency anemia
Results from blood loss,
poor GI absorption of iron (celiac or gastrectomy),
inadequate diet due to decreased iron,
hemolysis,
dialysis treatment,
alcoholism
s/s of IDA
weakness,
pallor,
fatigue,
glossitis,
cheilitis,
headache,
paresthesia,
burning sensation of the tongue
diagnostics of IDA
Monitor ferritin values,
Hgb and Hct,
RBC,
iron studies,
FOBT,
endoscopy/colonoscopy
drug therapy for IDA
Oral: ferrous sulfate or ferrous gluconate
IM/IV: sodium ferrous gluconate, iron sucrose, iron dextran
Side effects: nausea, constipation, green stools, epigastric discomfort (Oral); hypersensitivity
Nursing considerations
enteric coated do not absorb well - avoid
nursing management of IDA
Identification and treatment of cause
Drug therapy
Nutritional therapy
Examples??
PRBC transfusion
Emphasize compliance
Interprofessional collaboration
Verify therapeutic effect; manage side effects
treatment for IDA
increasing iron via food (red meat, organ meat, beets, dried beans, cream of wheat, iron-fortified cereals, egg yolks, dark leafy green vegetables, raisins);
ferrous sulfate PO (take b/w meals, stool color changes, constipation), IV, IM (Z-track, can stain skin)
administration considerations for iron
Iron is best absorbed as ferrous sulfate (Fe2+) in an acidic environment. For this reason and to avoid binding the iron with food, iron should be taken about an hour before meals, when the duodenal mucosa is most acidic. Taking iron with vitamin C (ascorbic acid) or orange juice, which contains ascorbic acid enhances iron absorption.
Undiluted liquid iron may stain teeth, thus the reason for ingesting it through a straw.
side effects of ferrous sulfate
Many individuals who need supplemental iron cannot tolerate ferrous sulfate because of the effects of the sulfate base. However, ferrous gluconate may be an acceptable substitute.
All patients need to be told that iron will cause their stools to become black because excess iron is excreted in the GI tract.
Because iron causes constipation, patients should be started on stool softeners and laxatives, if needed, when started on iron.
An iron-dextran complex (INFeD) contains 50 mg/mL of elemental iron in 2 mL. Sodium ferrous gluconate and iron sucrose are alternatives and may provide less risk of life-threatening anaphylaxis.
Because IM iron solutions may stain the skin, separate needles should be used for withdrawing the solution and for injecting the medication. A Z-track injection technique should be used.
teaching for administration of iron
Diet teaching
Supplemental iron
Discuss diagnostic studies
Emphasize compliance
Iron therapy for 2 to 3 months after Hgb levels return to normal
low platelet levels
Thrombocytopenia
thrombocytopenia results from:
Decreased production of platelets in bone marrow
Increased destruction of platelets
Increased consumption of platelets
s/s of thrombocytopenia
<20,000 Petechiae, bleeding (nasal, gingival, menstrual, etc.)
<10,000 CNS or GI hemorrhage possible
dx of thrombocytopenia
Platelet counts, bone marrow aspiration and biopsy, tests for causes
goal for thrombocytopenia
identify and treat cause
medical management of thrombocytopenia
Remove offending agent (PCN, sulfa drugs, vanc, cephalsporins, dig, salicylates, famotidine, etc.)
Chemotherapy induced: transfuse platelets if <10,000/mm3
If there is platelet destruction, avoid platelet transfusion!
Nursing Management
–Bleeding precautions
what is Immune Thrombocytopenia Purpura
Decreased platelet counts due to antibody-mediated platelet destruction and impaired platelet production due to antiplatelet antibodies produced by B cells
Low platelets and low thrombopoietin
s/s of ITP
Easy bruising, heavy menses, petechiae (dry purpura)
Bleeding from mucosal surfaces and pulmonary system (wet purpura)
medical and nursing management of ITP
We do not give platelets
Treatment initiated with severe or life-threatening bleeding, platelets <10,000, or increased risk factors for bleeding
Goal increase platelets to 30-50K; not curative
Removal causal agents
Steroids
Intravenous immunoglobulin
Rituximab depletes B cells that produce platelet-destroying autoantibodies
Thrombopoietin receptor agonists (romiplostim and eltrombopag)
Splenectomy removes mechanism for platelet destruction
NO PLATELET TRANSFUSIONS!
Nursing Management
Nursing Interventions for thrombocytopenia/bleeding
process of DIC
Massive amount of tiny clots form failure of coagulation bleeding
Life-threatening, 80% mortality rate
causes of DIC
Sepsis,
trauma,
cancer,
shock,
abruptio placentae,
toxins,
allergic reactions,
extensive burns,
severe TBI,
hemolytic processes,
postop damage,
SLE
s/s of DIC
Bleed from mucous membranes, venipuncture sites, GI tract, urinary tract
Overall can depend on the organ involved
Can lead to organ dysfunction and infarctions
dx of DIC
Platlets (low),
fibrinogen,
d-dimers,
PT,
PTT,
thrombin time
clinical manifestations of DIC
decreased temp and sensations
pain
cyanosis
ischemia
gangrene
petechiae
bleeding gums
wound oozing
decrease pulse
capillary filling time greater than 3 sec
tachy
hypoxia
dyspnea
decreased breath sounds
tachypnea
ARDS
heartburn
hematemesis
melana
distended abd
increased abd girth
decreased urine
increase CR and BUN
hematuria
decreased alertness and orientation
decreased response
anxiety, restless, decreased mentation
nursing interventions for patients with thrombocytopenia (19-2)
avoid aspirin/NSAIDS
herbal meds?
no IM
no indwelling cath
no rectal route
stool softeners and laxatives
smallest possible needles
apply pressure to venipuncture site for 5 min
soft-bristled tooth brush
no restrictive clothing
lubricate lips
avoid suctioning
not coughing or blowing nose
no electric razor
pad side rails
prevent falls
no contact sports
avoid sexual intercourse
hematast secreation of occult blood
control bleeding with thrombocytopenia
direct pressure
manual pressure
epistaxis - position high fowlers with body forward and mouth open
hemostatic agents
notify HCP for longer than 10 min
administer platelet, plasma, PRBC
lab value changes with DIC
low platelet count
high PT
high PTT
high TT
low fibrinogen
high D-dimer
high FDP and FSP
euglobulin clot lysis 1 hour of less
goals for treating DIC
Diagnose quickly
Stabilization
Treat underlying cause
Control thrombi and bleeding
Correct secondary effects of tissue ischemia
–Improving oxygenation
–Replacing fluids
–Correcting electrolyte imbalances
–Vasopressor med admin
blood product support for DIC
Platelets if <50K
FFP if bleeding and prolonged PT/PTT
Cryoprecipitate if fibrinogen <1.5 g/L
tx of DIC
blood products
Heparin with clinically evident thromboemboli in large vessel (benefit outweighs risk)
–Monitor for bleeding
Oxygenation
Volume replacement
nursing management for DIC
Astute assessment & prompt admin of therapies
–Assess for s/s of bleeding or thrombi
–Administer appropriate blood products & anticoags
Avoid things that can cause bleeding
Implement bleeding precautions
–Low pressure with suction
Maintain fluid balance
Maintain acid–base balance, oxygenation
Fall and safety precautions
Maintain skin integrity
Implement psychosocial support
blood transfusion process
Transfusions of whole blood or components of whole blood
Blood components include packed RBCs, fresh frozen plasma, albumin, clotting factors, cryoprecipitate, and platelets.
Can be used for a variety of disorders
Temporary; doesn’t fix the cause!
Used when anemia causes disability/death or when bleeding is life-threatening
Autologous transfusion
Done in infusion centers, acute care, MD offices, clinics, etc.
Various nursing responsibilities
blood type A antigen A: antibody produced and type of transfusion
antibody B
can receive A or O
blood type B antigen B:antibody produced and type of transfusion
antibody A
can receive B or O
blood type AB antigen AB:antibody produced and type of transfusion
none
can receive A, B, or O
blood type O no antigens: antibody produced and type of transfusion
antibodies A and B
can receive only O
universal donor
RH transfusion
Rh positive can get (-) and (+); Rh negative can get only (-)
PRBC transfusions
given to replace blood lost from trauma or surgery, Hgb <7-8, or symptomatic anemia;
More component specific
Should raise Hgb by 1 and Hct by 3%
platelet transfusions
Prevents bleeding
Given for low platelet counts, active bleeding, scheduled for invasive procedure
Should increase platelets by 30K
plasma transfusions - FFP
Given to replace blood volume and clotting factors (DIC, liver disease, hemorrhage), emergency reversal of elevated PT/INR
cryoprecipitate transfusion
Given for fibrinogen <1.5, hemophilia A, von Willebrand disease, DIC
albumin transfusion
Volume expansion when crystalloids not adequate
Moves water from extravascular to intravascular to maintain intravascular volume and prevent shock
For hypovolemic shock, after large-volume paracentesis, low albumin
pre-transfusion responsibilities
Review agency policy and procedures
Be aware of cultural concerns
Assess lab values and obtain blood for type and crossmatch per policy
Physical assessment & patient history
Consent
Verify order/prescription for type of blood, # of units, flow rate, & parameters
Assess vitals signs (15 min before), urine output, respiratory status, fluid status, skin color, and hx of transfusion reactions
At least 18-20 gauge FUNCTIONAL IV access
Gather equipment such as
Patient Education
Gather blood from the lab; Inspect blood for discoloration, gas bubbles, cloudiness
Patient identification and verification of order with another RN
given with blood transfusion
Don’t use D5, LR or anything other than NS because it causes RBC hemolysis. Do not give any additvies or meds in the same tubing of blood!
during transfusion responsibilities
Assess vital signs immediately before starting infusion
Verify - Double check labels with another licensed provider; check ID, compare data
Begin - Begin transfusion slowly, stay with patient first 15 minutes once the blood enters the client; adjust rate per protocol
Ask - Ask patient to report unusual sensations (for example,chills, shortness of breath, hives, itching)
Administer - Administer blood product per protocol and within 30 minutes of getting it
Assess - Assess VS and patient 15 min after initiation and every hour until complete; assess for hyperkalemia
Don’t infuse - Don’t infuse anything else during transfusion; don’t add anything to the blood bag
Notify - Notify HCP of s/s of reaction
Complete - Complete PRBC within 4 hours; FFP and platelets are transfused rapidly
what were doing after transfusion
Take vitals and compare to baseline
Discontinue infusion
Dispose properly
Document
Monitor adverse & therapeutic effects
acute transfusion reaction – febrile
S/S: temp increase (> 100.4 or 1C increase); chills, headache, chest pain, headache, vomiting; accounts for 90% of reactions; fever typically 2 hours after start, not fatal
* Tx: stop transfusion (don’t restart without order), administer antipyretics before and/or during
acute transfusion reaction – hemolytic
occurs with infusion of incompatible blood; antibodies develop
S/S: fever, chills, chest tightness, hypotension, flank pain, vascular collapse, tachycardia/pnea, anxiety, hematuria/dark urine, jaundice, bleeding, DIC, AKI
Tx: Stop transfusion, notify HCP, infuse NS in new tubing, send to lab, treat shock, draw labs and urine, catheter strict I&O; prevent _ check blood type and bag before; updated cross-match
acute transfusion reactions – allergic
sensitivity reaction to a component of the transfused blood
s/s of anaphylaxis; can occur up to 24 hours later
* Tx: mild stop transfusion (don’t restart if in distress), NS in new tubing, antihistamine;
if provider says to restart start slowly. Severe stop transfusion, Rapid response, 02,
epi, CPR, NS, antihistamines
acute transfusion reactions – bacterial/sepsis
from contaminated blood
S/S: Wheezing, dyspnea, hypotension, chills, high fever, vomiting, and shock.
Tx: stop transfusion, send blood cultures, NS in new tubing, broad-spectrum ABX, pressors; admin in 4 hours to prevent
acute transfusion reactions – circulatory overload
infusing too fast
s/s of fluid volume overload;
Tx: diuretics b/w transfusions, infusing slowly, 02, upright position with feet lower than heart, CXR, morphine; reduce IVF during transfusion
what to do for a transfusion reaction
Stop the transfusion and remove blood tubing
Flush access with normal saline, but don’t flush blood
Assess the patient
Notify blood bank and HCP; rapid response team if applicable
Recheck identifying tags and numbers
Monitor VS and U/O
Treat symptoms per HCP order
–02
–Fluid resuscitation
–Hemodynamic monitoring
–Antipyretics
–Antibiotics
–Vasopressors
Return components of bag, labels, and tubing to lab (urine specimen)
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