Chapter 42: Care of Patients with Hematologic Problems

Question 1

Allogeneic bone marrow transplantation

Answer 1

Transplantation a bone marrow from a sibling

Question 2

Anemia

Answer 2

The clinical sign of an abnormal condition related to a reduction in the number of red blood cells, the amount of hemoglobin, or hematocrit.

Can be the result of dietary problems, genetic disorders, bone marrow disease, or excessive bleeding.

˜Clinical sign (not specific disease); because it occurs with many health problems.
GI bleeding is the most common reason for anemia in adults. Refer to Table 42-1
˜There are many types and causes of anemia. Some are caused by a deficiency in one or more of the components needed to make fully functional RBCs. Such anemias can be caused by deficiencies of iron, vitamin B¹², folic acid, or intrinsic factor.
˜Other causes include a decreased rate of RBC production and increased RBC destruction.

Question 3

Aplastic anemia

Answer 3

Deficiency of circulating red blood cells because of failure of the bone marrow to produce the cells. Usually occurs with leukopenia and thrombocytopenia

Question 4

autocontamination

Answer 4

The occurrence of infection in which the patients own normal flora overgrows and penetrates the internal environment

Question 5

autologous transplant

Answer 5

Bone marrow transplant in which patients receive their own stem cells, which were collected before high dose therapy

Question 6

Blast phase cell

Answer 6

Immature cell that divides

Question 7

Chelation

Answer 7

Referring to a drug or substance that binds or attaches to another substance

Question 8

Cold antibody anemia

Answer 8

A form of immunohemolytic anemia that occurs with complement proteins fixation on immunoglobin M. The arteries in the hands and feet constrict profoundly in response to cold temperatures or stress

Question 9

Crises

Answer 9

In patients with sickle cell disease, periodic episodes of extensive cellular sickling that have a sudden onset and can occur as often as weekly or as seldom as once a year

Question 10

cyroprecipitate

Answer 10

A highly concentrated blood product that is derived from plants that includes clotting factors 8 and 13, von Willebrand factor, and fibrinogen

Question 11

Engraftment

Answer 11

The successful transplantation of cells in the patient’s bone marrow

Question 12

Fresh frozen plasma

Answer 12

Plasma that is frozen right after donation so that clotting factors are preserved

Question 13

glossitis

Answer 13

A smooth, beefy red tongue

Question 14

Hemolytic

Answer 14

Characteristic of destroying red blood cells

Question 15

Hypoplasia

Answer 15

Reduce production of cells

Question 16

Indolent

Answer 16

Slow-growing

Question 17

Leukemia

Answer 17

Cancer with uncontrolled production of immature white blood cells in the bone marrow. The bone marrow becomes overcrowded with immature, nonfunctional cells, and the production of normal blood cells is greatly decreased

Question 18

Lymphoblastic

Answer 18

Abnormal leukemic cells that come from the lymphoid pathways and develop into lymphocytes

Question 19

Macrocytic anemia

Answer 19

A form of vitamin B12 deficiency anemia characterized by abnormally large precursor cells

Question 20

Mitochondria

Answer 20

Within the cytoplasm of cells, the site of production of ATP

Question 21

myelocytic

Answer 21

Pertaining to leukemia in which the abnormal cells come from the myeloid pathways

Question 22

Nephrotoxicity

Answer 22

The disruption of kidney function

Question 23

Neutropenia

Answer 23

Decrease number of leukocytes, especially neutrophils, which causes immunosuppression

Question 24

Pancytopenia

Answer 24

Deficiency of all three cell types red blood cells, white blood cells, and platelet

Question 25

Peripheral blood stem cells

Answer 25

Stem cells that are collected from peripheral blood for transplantation into the patient. Collected by pheresis. Monitor donor closely for catheter clogging & hypocalcemia. Low calcium may cause numbness or tingling, abdominal cramping, or chest pain. Oral calcium supplements may be given.

Question 26

Pernicious anemia

Answer 26

A form of megaloblastic anemia caused by failure to absorb vitamin B12 because of a deficiency of intrinsic factors needed for intestinal absorption of vitamin B 12

Question 27

pheresis

Answer 27

procedure in which whole-blood is withdrawn from the patient, a blood component is filtered out, and the plasma is returned to the patient

Question 28

plethoric

Answer 28

A flushed appearance of the skin

Question 29

Pluripotent stem cell

Answer 29

The precursor cells involved in the production of red blood cells

Question 30

Polycythemia

Answer 30

In excess of red blood cells, It makes the blood hyperviscous/thicker than normal

Question 31

Polycythemia vera

Answer 31

A disease that involves massive production of red blood cells, leukocytes, and platelets

Question 32

Reed-Sternberg cell

Answer 32

A specific cancer cell type, found in lymph nodes, that is a marker for Hodgkin’s lymphoma

Question 33

resorption

Answer 33

The loss of bone minerals and density. The release of free calcium from phone storage sites directly into the extracellular fluid

Question 34

Stomatitis

Answer 34

Inflammation of the oral mucosa. Painful single or multiple ulcerations that impair the protective lining of the mouth. Often referred to as canker sores

Question 35

syngeneic transplant

Answer 35

bone marrow transplant in which stem cells are taken from the patients own identical sibling

Question 36

thrombocytopenia

Answer 36

reduction in platelets, resulting in increased tendency to bleed

Question 37

thrombosis

Answer 37

the formation of a blood clot within a vessel

Question 38

warm antibody anemia

Answer 38

a form of immunohemolytic anemia (immune system destroys own RBCs for unknown reasons) that occurs with immunoglobulin G antibody excess and may be triggered by drugs, chemicals, or other autoimmune problems

Question 39

Pathophysiology of sickle cell disease

Answer 39

Results in chronic anemia, pain, disability, organ damage, increased risk for infection, and early death. Red blood cells contain at least 40% hemoglobin S which is sensitive to changes in the oxygen content. When there is a decreased oxygen, it distorts the shape of the red blood cell. They become rigid, clumped together, and form masses that block bloodflow. Obstruction leads to further hypoxia which leads to more sickle shaped cells. This leads to ischemia in affected tissues. Leads to progressive organ damage.

Causes include hypoxia, dehydration, infection, venous stasis, pregnancy, alcohol, high-altitude, low temperatures, acidosis, strenuous exercise, and anesthesia

Overtime a sickle cell becomes damaged. The average lifespan is about 12 to 15 days, compared to that of the hundred day lifespan. This causes hemolytic anemia.

Organs most affected are the spleen, liver, heart, kidney, brain, bones, and retina

˜There is a difference in between sickle cell disease state and sickle cell trait, and variation among patients in how severe the disease is and when complications start
˜The main problem in this disorder is the formation of abnormal hemoglobin chains.

Crises: Periodic episodes of extensive cellular sickling. The sudden onset is sudden and as often as weekly or as seldom as once a year. Many patients are in good health much of the time. Crises occur when there is hypoxemia.

Question 40

Risk for sickle cell

Answer 40

Autosomal recessive pattern of inheritance/having a parent with it or being a carrier of it. 70,000 people in the US have it. Most common African Americans.

Sickle cell disease: inherits one from each parent and 80%+ hgbS. Each child will get at least one gene and have sickle cell trait.

Trait: one normal and one abnormal. Manifestations are usually less.

Question 41

Manifestations of sickle cell

Answer 41

Pain is the most common symptom. Jaundicce from red blood cell destruction and release of bilirubin (itching). Heart failure can occur because of anemia. Shortness of breath, fatigue, weakness, murmurs, S3, decreased capillary refill, decreased pulse pressure, priapism, cyanosis, pallor, ulcers on the lower legs, abdominal pain (organ damage of spleen and liver), kidney failure (dilute urine with protein) joint damage, low-grade fever, seizures, stroke manifestations.

Not iron deficient

Question 42

Diagnostic test for sickle cell

Answer 42

Large amount of hemoglobin S seen on electrophoresis, trait <40%. Disease 80-100%
Low hematocrit 20-30%
High reticulocyte count
high bilirubin level
normal iron
high white blood cell from chronic inflammation
X-rays show joint necrosis and changes on the skull
ECG Shows infarcts and tissue damage.

Question 43

Nursing diagnoses for sickle cell

Answer 43

acute pain related to poor tissue oxygenation
Chronic pain related to joint destruction
Potential for sepsis
Potential for multiple organ dysfunction and death

Question 44

Nursing interventions for sickle cell

Answer 44

Pain: may require large doses of opioid analgesics. Acute crisis gets 48 hours of IV analgesics, usually morphine or hydromorphone. Orally around the clock after. Avoid IM injections. Taper to oral after relief.

Possible hydroxyurea to increase hemoglobin F, but this could lead to leukemia, birth defects, and suppress bone marrow function.
Hydrate with hypotonic fluids, d5w or d5 1/2 NS 250ml/hr to reach osmolarity of 270-300. Reduce to 125/hr. keep room warm.

sepsis: increased risk cuz of decreased spleen function. Prevention and early detection, daily CBC with diff, Prophylactic penicillin, Yearly flu and pneumonia vaccine. HAND WASH. Mask if URI.

Organ dysfunction: hydration at least 200ml/hr, oxygen, transfusion (careful not to overload with iron). Treat with deferoxamine. Possible HSCT

Question 45

Teaching for sickle cell

Answer 45

Drink 3 to 4 L every day
No alcohol, no smoking
Call Dr. at first signs of illness or infection
Get the flu shot every year, pneumonia vaccine
Avoid extreme hot and cold
avoid unpressurized planes, avoid travel to high-altitudes
Consider genetic counseling and screening
Avoid strenuous activities
Mild, low impact exercise three times a week

Question 46

Glucose 6 Phosphate Dehydrogenase deficiency anemia

Answer 46

Hemolytic anemia. X-linked recessive, 10% of African-Americans. Usually occurs after exposure to medications or severe infection. Anemia and jaundice develop. It is critical that the drug responsible for the reaction is totally removed. Blood from transfusions is screened for this drug. Hydration to prevent renal failure. Possible transfusion. Osmitrol

Question 47

Immunohemolytic anemia

Answer 47

Red blood cells are destroyed in response to trauma, malarial infection common exposure to chemicals or drugs, and an autoimmune reaction. The immune system attacks the person’s own red blood cells. Warm or cold antibody anemia. Warm IgG, cold IgM. Treatment includes steroid therapy to suppress the immune system. If extreme splenectomy or plasma exchange.

Question 48

Iron deficiency anemia

Answer 48

Less than 10ng/mL (normal is 12-300) serum ferritin. RBCs are microcytic. Mild symptoms weak and pale.
Blood loss, or G.I. absorption of iron common inadequate diet. Most common in women, older adults, and poor diet. Should be evaluated for abnormal bleeding. Increase the oral intake of iron from food sources (red meat, organ meat, egg yolks, kidney beans, leafy veg, raisins). For oral, take in between meals. For IM injection use the Z track method (add 0.25 air to syringe), dorsal gluteal only.

˜Iron deficiency anemia is the most common anemia worldwide, especially among women, older adults, and people with poor diets
˜Management of iron deficiency anemia involves increasing the oral intake of iron from food sources (e.g., red meat, organ meat, egg yolks, kidney beans, leafy green vegetable, and raisins).
ØCan use oral supplements for mild cases. Take between meals for better absorption and reduce GI distress
ØSevere cases IV or IM iron solutions. If IM use the Z-track method, Refer to Chart 42-4 Best Practice for Patient Safety and Quality Care

Question 49

Vitamin B12 deficiency anemia

Answer 49

B-12 helps folic acid move into the cell for DNA synthesis. Having a deficiency of B12 reduces DNA synthesis in precursor cells. They undergo improper DNA synthesis and increase in size. Also known as megaloblastic or macrocytic anemia.
From poor intake of b12, including veg diets or lacking dairy. Pernicious has decreased intrinsic factors which decrease absorption of b12.

Manifestations: mild or severe, pale, jaundice, glossitis(smooth beefy red tongue), fatigue, weight loss, paresthesias.

Treatment: increase foods rich in vitamin B12 such as animal proteins, eggs, nuts, dairy, dry beans, citrus fruit, green leafy vegetables. If severe vitamin supplements may be given. B12 and folic acid levels are monitored.

Test: pernicious anemia is tested using the shilling test. Measures the amount of radioactive vitamin B12 in the urine. Injections are given weekly and then monthly for the rest of their life.

smooth beefy red tongue indicates b12 deficiency

Question 50

Folic acid deficiency anemia

Answer 50

Same as B12 deficiency without the paresthesia. Causes include poor nutrition, malabsorption, and drugs. Crohn’s disease, chronic alcohol abuse, anticonvulsants and oral contraceptives
Lacking Food: gl veg, liver, yeast, citrus, dried beans, nuts.
Treated with scheduled folic acid replacement and vitamin b12 foods.

Question 51

Aplastic anemia

Answer 51

Deficiency of circulating red blood cells because of the failure of the bone marrow to produce them. Caused by injury to the immature precursor cell. Usually occurs with leukopenia and thrombocytopenia. Pancytopenia is a deficiency in all three cell types and is common.

Acquired: long term toxic agents, ionizing radiation, infection. 50% unknown.

Manifestations: bone marrow failure, poor oxygenation, weakness, pallor, petechiae, ecchymosis,

Treatment: blood transfusions when disability or when bleeding is life-threatening. Immunosuppressive therapy, chemotherapy, splenectomy to stop destroying normal cells, hematopoietic stem cell transplant can cure it.

Question 52

Polycythemia vera

Answer 52

Increase in hemoglobin to 18 g/dL, the red blood cell count of 6 million, hematocrit 55% or greater. The cancer of the red blood cells. Massive production of red blood cells, excessive leukocyte production, excessive production of platelets.

Manifestations: dark, flushed appearance of the skin and mucous membranes. May be cyanotic or purplish. Intense itching (dilated bv and poor o2). Hypertension (increased blood viscosity). Distended veins. Thrombosis. Poor oxygenation with severe hypoxia. Bleeding problems cuz platelet impairment.

The red blood cells have a shorter life span, rapid turnover increasing the amount of debris leading to uric acid and hyperkalemia

Malignant disease that increases in severity. death within two years if untreated. Phlebotomy increases the lifespan. Increase hydration. Anticoagulants or aspirin.

Teaching: increased fluids 3L, avoid constrictive clothing, wear gloves in cold weather, take anticoagulants, wear support stockings, elevate feet, decrease bleeding by being careful, call if infection, exercise slowly if advised. Stop if chest pain. Soft brush, electric razor, no flossing.

Question 53

Myelodysplastic syndromes MDSs

Answer 53

caused from formation of abnormal cells in the bone marrow. pts have Anemia, neutropenia, thrombocytopenia. Most common in the elderly. Usually develop acute leukemia.

Risk factors include age, chemical exposures, smoke, radiation, chemotherapy.

Diagnosis is made with cytogenic testing of the bone marrow and examining the chromosomes. Peripheral blood smears assess the level

Treatment includes supportive care such as blood transfusions for anemia and platelet transfusions for severe thrombocytopenia. Erythropoietin may be given. May lead to iron overload and organ damage. Chelation may be needed to remove iron. Ferritin >2500

Question 54

Pathophysiology of leukemia

Answer 54

Uncontrolled production of immature white blood cells in the bone marrow. Maybe acute or chronic. Cancer occurs in the stem cells or early precursor cells causing excessive growth. These cells are abnormal. The excessive production stops normal production of red blood cells, platelets, and leukocytes. This leads to anemia, thrombocytopenia, and leukopenia. Increases in abnormal white blood cells cannot provide infection protection. The patient will die of infection or hemorrhage without treatment.

Question 55

Risk for leukemia

Answer 55

Ionizing radiation (atomic bomb, nuclear accident), chemical exposure (can damage DNA), drugs, bone marrow hypoplasia (Fanconis anemia & melody spastic syndrome), genetic factors (DS, Bloom syndrome, klinefelter, fanconis, identical sibling), immunologic factors (deficiency), environmental factors.

Increases with age >50

Question 56

Types of leukemia

Answer 56

AML acute myelogenous leukemia: most common adult onset,

ALL acute lymphocytic leukemia, most common in children, Philadelphia chromosome abnormality is normally seen in adults

CML Chronic myelogenous leukemia, occurs most often above 50. Philadelphia chromosome.
Chronic
Accelerate
Blast aggressive

CLL Chronic lymphocytic leukemia - over 50, usually hereditary,

Question 57

Manifestation of acute leukemia

Answer 57

Ecchymoses, Petechiae, infected lesions, palor, cyanosis, bleeding gums, anorexia, enlarged liver and spleen, hematuria, tachycardia, orthostatic hypotension, palpitations, dyspnea, fatigue, headache, fever, bone pain, joint swelling and pain. Decreased alertness and attention. Murmurs, Bruits, Respiratory rate increases because of anemia. Constipation, reduced bowel sounds. Papillaedema. Wt loss.

Cardiovascular from tissue perfusion. Respiratory from tissue oxygenation. Skin changes from tissue perfusion. Intestinal changes due to increased bleeding. Central nervous system changes.

Question 58

Testing for leukemia

Answer 58

CBC with diff will show a low hemoglobin and hematocrit, low platelets, abnormal white blood cell count. Definitive test is a bone marrow aspiration and biopsy. They will be full of leukemic blasts phase cells. Blood clotting time, Chromosome analysis, x-rays to see if this infiltrated the lung or resorption by the bone.

Question 59

Interventions for leukemia

Answer 59

Prevent infection. An increase of .5 temperature could indicate infection. Common sites skin, resp, and GI. Treat or prevent with antibiotics and antifungals if fever >4-7 days.

Three phases of drug therapy.
Induction therapy: chemotherapy 7 plus 3 (two types) intent is complete remission from manifestations. Leads to severe bone marrow suppression. Recovery 2-3 weeks. Side effects include nausea and vomiting, diarrhea, alopecia, stomatitis, kidney toxicity, liver toxicity, cardiac toxicity

Consolidation therapy: Another dose of chemotherapy drugs given early in remission, it’s intent is to cure.

Maintenance therapy: used for ALL and APL. Milder doses are given orally for 2 to 5 years.

Chronic Leukemia: Gleevec Prevents the activation of an enzyme needed for growth of CML cells. Interferon is also used. Must have the Philadelphia chromosome to work.

CLL is incurable

Acyclovir is given at the start of chemotherapy. Antivirals have serious side effects such as ototoxicity and nephrotoxicity

Handwashing, masks, aseptic technique, no standing water, no denture cups, no humidifiers, minimal bacteria diet, no pepper, monitor daily CBC with diff. Inspect the mouth listen to the lungs every eight hours, assess urine.. Daily bathing, turn every hour, pulmonary hygiene every 2 to 4 hours

Question 60

Hematopoietic Stem cell Transplant

Answer 60

Bone marrow transplant
Before the transplant chemotherapy and possibly total body irradiation are given to purge the bone marrow of leukemic cells. These treatments are lethal to the bone marrow and without replacement of stem cells by transplantation, the patient will die of infection or hemorrhage.
Consists of five phases: obtainment, conditioning regimen, transplantation, engraftment, and posttransplantation recovery

Question 61

Bone marrow donor

Answer 61

It removed about 500 to 1000 mL of marrow from the iliac crest. Monitor for fluid loss, assess for complications of anesthesia, and manage pain. Hydrate with saline infusions before and after. Occasionally they may need a red blood cell transfusion. Assess the harvest sites frequently.

Peripheral blood stem cell requires three phases: mobilization, collection by pheresis, and re-infusion. They are stem cells that are circulating with in the blood. Growth factors are given to the patient to increased numbers. We go through 125 for recess, each lasting 2 to 4 hours. The cells are frozen and stored. Pheresis complications include catheter clotting and hypocalcemia. Low calcium causes numbness or tingling in the fingers and toes, abdominal or muscle cramping, or chest pain. Oral calcium supplements may be given. Monitor vitals and hypotension from fluid loss.

Cord blood involves obtaining stem cells from umbilical cord blood of newborns. They are obtained via a simple draw from the placenta afterbirth before the placenta detaches. 40-150 mL of blood from the umbilical vein. They can last for years in liquid nitrogen.

Question 62

Conditioning phase of a bone marrow transplant

Answer 62

Wipes out the patient’s own bone marrow. It’s a higher dose of chemotherapy and radiation to rid the person of cancer cells. Normally 5 to 10 days. Total body irradiation. This can be extremely dangerous and lower doses can be used but it increases your risk for graft versus host disease. Rocket type countdown. T-5 thru T4 is high dose chemo to kill own bone marrow and leukemia cells. T3-t1 is total body irradiation

Side effects include nausea and vomiting, mucositis, capillary leak syndrome, diarrhea, and bone marrow suppression

Late effects are common even 3 to 10 years after transplantation include venoocclusive disease, skin toxicities, cataracts, lung fibrosis, secondary cancers, cardiomyopathy, endocrine complications, neurologic complication
Day T-0 is the day they receive cells.

Question 63

Transplantation phase of a bone marrow transplant

Answer 63

Day t-0 Frozen marrow, stem cells, umbilical cord cells are thawed, infused through central catheter just like a blood transfusion. Do not use filtered tubing because cells can get caught in the filter.
Side effects include fever, hypertension,. Prevent these with acetaminophen, hydrocortisone, and Benadryl before transfusion. You may need antihypertensive or diuretics. Patient may have red urine because of red blood cells breakage.

Question 64

Engraftment phase of bone marrow transplant

Answer 64

The donated cells find their way to the bone marrow sites. Engraftment is the successful take of the transplanted cells in the patient’s bone marrow. It takes 8 to 12 days for peripheral blood stem cells and 12 to 28 days for bone marrow. Growth factors may be given. When it occurs, WBC, RBC, and platelet counts rise

Question 65

Complications from a bone marrow transplant

Answer 65

life-threatening include infection and bleeding (as long as platelets are under 50,000). Failure to engraft, development of graft versus host disease, venoocclusive disease.

Failure to engraft is most with allogenic. The patient will die unless another transplant with stem cells is successful.

Graft versus host disease is mostly in allogenic transplant. The donated Marrow recognizes the patient cells as a foreign and starts to attack against them. Usually in the skin, intestinal tract and liver. Use drugs to suppress the immune function such a cyclosporine or methotrexate, corticosteroids.

VOD is blockage of liver blood vessels by clotting and inflammation/phlebitis. Jaundice, pain RUQ, ascites, wt gain, liver enlargement. Treatment is supportive.

Question 66

Care of the central venous catheter

Answer 66

Flush with saline once a day, change the leur-lok on catheter lumen weekly. Change the dressing every other day. Clean there is site with alcohol and iodine. Apply antibacterial ointment ever with a dry sterile quaze or transparent dressing. Always tape catheter. Report signs of infection or a break in the catheter

Question 67

Lymphoma

Answer 67

Cancers of the lymphoid tissue. Overgrowth of the lymphocyte. it is cancer of the commitment lymphocyte rather than the stem cell precursor. They are solid tumors not cellular suspensions.

Question 68

Hodgkin’s lymphoma

Answer 68

Peaks in the teens and young adult, and also in adults in their 50s and 60s. Could possibly be caused by viral infections (Epstein bar, HTLV, HIV) and exposure to chemical agents. Cancer starts in a single lymph node and includes the Reed-Sternberg cell. It spreads from one group to the next in orderly fashion.

Manifestations: large but painless lymph nodes. Sometimes pain in the node is brought on by ingestion of alcohol. The B symptoms include: fever, night sweats, weight loss. Usually have no symptoms.

Diagnosis is established with the biopsy. It is then classified and staged. 1a=1 node 1b=with symptoms IIa 2 nodes, IIB with symptoms IIIa nodes on both sides of diaphragm IIIb with symptoms IIIc also in spleen IV many areas, including non node tissue and organs

One most treatable cancers. Involvess radiation and chemotherapy. Management focuses on side effects. This includes pancytopenia, increased risk for infection, anemia, and bleeding. Nausea and vomiting, skin problems, constipation or diarrhea, decreased liver function, sterility for males, Or secondary cancer development

Question 69

Non-Hodgkins Lymphoma

Answer 69

Includes all lymphoid cancers that do not have the Reed-Sternberg cell. There are 12 subtypes. More common in men, white, and older adults. It is associated with autoimmune conditions such as sjorgen, celiac, RA, sle, and immune supression. Genetics, chemicals

The most common extranodal sites are the G.I. tract, skin, bone marrow, sinuses, thyroid, central nervous system. Enlarged painless lymph nodes may be the only symptom. Diagnosis is made after a biopsy.

Classification per WHO. bcell or tcell lymphoma.

B symptoms.
Treatment includes chemotherapy, radiation, antibiotics, stem cell transplants, vaccine therapy, protease inhibitors. Care is the same as Hodgkin’s lymphoma

Question 70

Multiple myeloma

Answer 70

A white blood cell cancer. Overgrowth of the B lymphocytes plasma cells. They overproduce antibiotics. There are fewer functioning RBCs, WBCs, and platelets produce. They produce excess cytokines and increase cancer cell growth rates and destroy bone. There also released into the blood causing clogging vessels in the kidney and other organs. It is higher in men and higher in blacks, >65. Possible risk factors include radiation, chemical exposure, an infection with herpes eight.

Manifestations include no symptoms or fatigue, anemia, bone pain, pathological fractures, recurrent bacterial infections, renal dysfunction. Rarely they have hypercalcemia and hyperviscosity

Diagnosis is made by x-ray findings of bone thinning areas that resemble Swiss cheese. Immunoglobulin levels, electrophoresis of plasma proteins, and the presence of Bence Jones protein. Bone marrow biopsy is performed. Abnormal chromosomes 11 predicts longer survival, absence of chromosome 13 is a poor diagnosis.

Interventions: chemotherapy, autologous bone marrow transplant. It is incurable. Pain management, biophosphonates for bone disease.

Question 71

Autoimmune thrombocytopenic Purpura

Idiopathic thrombocytopenia purpura ITP

Answer 71

The number of circulating platelets is reduced even though production is normal. Patients make an antibody against the surface of their own platelets making them more likely to be destroyed by macrophages. Autoimmune disorder more common among women between 20 and 40.

Manifestations: ecchymosis, petechiae on the arms, legs, upper chest, neck. Mucosal bleeding, Anemia. Rarely an intracranial bleed.
Diagnosed by decreased platelet count and large numbers of megakeratocytes in the bone marrow.
Interventions: decrease risk for bleeding. Immunosuppression therapy. Platelet transfusions if under 20,000. Splenectomy if no response to drug therapy.

Question 72

Thrombotic thrombocytopenic purpura

Answer 72

Platelets clump together in the capillaries and too few platelets remain in circulation. There’s inappropriate clotting, yet the blood fails to clot when trauma occurs. Probably autoimmune disorder. Tissues become ischemic leading to kidney failure, myocardial infarction, and stroke. Death in 3 months is untreated

Treatment consists of plasmapheresis and infusion of ff plasma. Provide platelet aggregation inhibitors. Drugs that inhibit platelet clumping such as aspirin. Immunosuppressive therapy may also help

Question 73

Hemophilia

Answer 73

A: deficiency of clotting factor VIII. 80%
B: Deficiency of clotting factor IX-Christmas disease. 20%
Most the time it is an x-linked recessive trait women: (sons will get it, daughters carrier)
Men: sons none, daughters carrier.

Patient has abnormal bleeding in response to any trauma. They will bleed for a longer amount of time because they cannot clot. They can form the platelet plug but not the fibrin clot.

Manifestations: excessive bleeding from minor cuts, bruises, or abrasions. Joint and muscle hemorrhages that can be disabling(especially of hip and knee). Bruise easily. Potentially fatal hemorrhage after surgery. DJD is common.

Treatment: scheduled infusions of factor VIII cyroprecipitate. Expensive

Prolonged PTT, but normal PT

Question 74

Pre-transfusion responsibilities

Answer 74

A type and match requires at least 45 minutes from the lab and is usually renewed at least every 72 hours. Obtain consent.

Assess lab values
Verify that prescription. Includes type of product, volume, and transfusion time, and other considerations.
Vital sign, urine output, skin color, history of transfusion
Central catheter or at least a 18-20 gauge needle. NS used, filter tubing.
Blood should be transfused with in four hours of removal from fridge
Verify with another nurse the name, number, blood compatibility, and expiration time

Question 75

Transfusion responsibilities

Answer 75

Take vitals and temp.
Administer blood using appropriate filter tubing
If dilution is necessary, only use saline
Remain with the patient during the first 15 to 30 minutes.
Infuse at the prescribed rate. Watch for fluid overload. Usually 1 unit in 2 hours
Monitor vitals: Take after 15 minutes and every hour

Tell the patient to report chills, shortness of breath, hives, or itching. Hyperkalemia may occur.

Question 76

Transfusion considerations for the older adult

Answer 76

Use no larger than a 19 gauge needle. Use blood less than one week old. Take vital signs every 15 minutes throughout. Overload symptoms include a rapid bounding pulse, hypertension, swollen superficial veins. Take 2 to 4 hours for each unit of blood. Avoid concurrent fluid administration. Allow two hours after one unit of blood before giving the next.
Reaction: Rapid thready pulse, hypotension, cyanosis,.

Administer slower taking 2 to 4 hours for each unit of blood. Allow two hours between units.

Question 77

Red blood cell transfusions

Answer 77

Result of trauma or surgery, problems that destroyed red blood cells. They are supplied in 250 mL bags.

For patient who are hypoxemic and have a hemoglobin of less than eight. Compatibility is determined by the ABO system antigens and RH antigens.

Question 78

Platelet transfusions

Answer 78

For patients with platelet count under 10,000 or those with thrombocytopenia who are actively bleeding are going to have surgery. They are usually pooled from 10 donors and do not have to have the same blood type. If patients are going to have a stem cell transplant, they will come from a single donor. They must be infused immediately within 15 to 30 minutes. Smaller filter and shorter tubing are used. Patient may be given Benadryl and Tylenol to reduce chances of a reaction. Patient may become febrile and have rigors, but they are not a true reaction

Question 79

Plasma transfusions

Answer 79

Blood type must match. Usually fresh frozen plasma. It is given immediately after thawing to patients actively bleeding with a PTT time greater than 1.5x normal. Infused with in 30 to 60 minutes or as rapid as patient can tolerate. Y or straight filter tubing.

Question 80

Cryoprecipitate transfusions

Answer 80

For patients with clotting factor disorders. Includes factor eight, 13, vonWillebrand factor, and fibrinogen. Usually 10 to 15 mL given IV push in three minutes. Should be ABO compatible

Question 81

Granulocyte/white blood cell transfusion

Answer 81

For neutropenic patients with infections. There’s a lot of controversy because white blood cells have several antigens and could cause transfusion reaction. They are given in 400 mL of plasma over 45 to 60 minutes. The physician should be in the unit, vitals every 15 minutes. Amphotericin B should not be given within six hours.

Question 82

Transfusion reactions

Answer 82

Febrile: chills, tachycardia, fever, hypotension, tachypnea. Usually from white blood cells

Hemolytic: Caused by blood type or Rh incompatibility. Fever and chills, disseminated intravascular coagulation, circulatory collapse, apprehension, headache, chest pain, low back pain, tachycardia, tachypnea, hypotension, Hemoglobinuria, impending doom

Allergic: uticaria, itchy, bronchospasm, anaphylaxis. Up to 24 hrs after

Bacterial: from contaminated products. tachycardia, hypotension, fever, chills, shock. Rapid onset.

Circulatory overload: hypertension, bounding pulse, distended jugular veins, dyspnea, restlessness, confusion. Give slow or use diuretic.

Graft versus host disease: Occurring within 1 to 2 weeks, thrombocytopenia, anorexia, nausea and vomiting, chronic hepatitis, weight-loss, recurrent infections. Usually fatal

Question 83

Key features of anemia

Answer 83

Pallor of the ears, nails, palmar creases, conjunctiva, and around the mouth. Cool to the touch. Intolerant of cold. Nails become brittle concave. Tachycardia increasing during activity. Murmurs gallops if severe. Orthostatic hypotension. Dyspnea on exertion. Decreased oxygen levels. Increased fatigue. Headache.

Question 85

Blood type

Answer 85

Positive can get - or +
A can get A or O
B can get B or O
AB can get all of them
O can get on,y O

Question 86

Nursing diagnosis for leukemia

Answer 86

Risk for infection. Risk for injury related to thrombocytopenia. Fatigue related to decreased oxygenation and increased energy demands. Additional problems include impaired skin integrity, impaired oral mucous membranes, self-care deficit, imbalanced nutrition, death anxiety, powerlessness, interrupted family processes, ineffective role performance, deficient diversional activity