exam 3 Flashcards
Assessment of hematologic function
Health History:
Prior episodes of bleeding (epistaxis, tooth, gum, hematuria, menorrhagia, hematochezia, gastrointestinal bleeding and/or ulcers)
Prior blood clots, pulmonary emboli, miscarriages
Fatigue and weakness
Dyspnea, particularly dyspnea on exertion, orthopnea, shortness of breath
Prior radiation therapy (especially pelvic irradiation)
Prior chemotherapy
Hobbies/occupational/military exposure history (especially benzene, Agent Orange)
Diet history
Alcohol consumption
Use of herbal supplements
Concurrent medications
Family history/ethnicity
Physical assessment:
Skin:
Gray-tan or bronze skin color (especially genitalia, scars, exposed areas)
Ruddy complexion (face, conjunctiva, hands, feet)
Ecchymoses (i.e., bruises)
Petechiae
Rash
Bleeding (including around vascular lines, tubes)
Conjunctival hemorrhage
Pallor, especially in mucous membranes (including conjunctiva), nail beds, palate
Jaundice in mucous membranes (including conjunctiva), nail beds, palate
Oral cavity:
Petechiae in the buccal mucosa, gingiva, hard palate
Ulceration of oral mucosa
Infection, leukemia
Tongue: Smooth
Beefy red
Enlarged
Angular cheilosis (ulceration at corners of mouth)
Enlarged gums: hyperplasia
Enlarged size, firm and fixed vs. mobile and tender
Respiratory
Increased rate and depth of respirations; adventitious breath sounds
Cardiovascular: Distended neck veins, edema, chest pain on exertion, murmurs, gallops Hypotension (below baseline) Hypertension (above baseline) Severe anemia Polycythemia Genitourinary Hematuria Proteinuria
Musculoskeletal: Rib/sternal tenderness to palpation Back pain; tenderness to palpation over spine, loss of height, kyphosis Pain/swelling in knees, wrists, hands Enlarged spleen Enlarged liver Stool positive for occult blood
Central nervous system:
Cranial nerve dysfunction
Peripheral nerve dysfunction (especially sensory)
Visual changes, headache, alteration in mental status
Gynecologic:
Menorrhagia
Fever, chills, sweats, asthenia
Gerontologic considerations for hematologic function
Bone marrow’s ability to respond to need for blood cells may be decreased
Inability to perform hematopoiesis
More susceptible to myelosuppression effects of medications
hematologic studies
Hematologic Studies- hematopoietic, hemostasis, or reticuloendothelial system (blood and blood disorders)
two most common: CBC & peripheral blood smear
complete blood count (CBC)
RBC: Normal Adult
(female 4.2-5.4 male 4.7-6.1)
Red blood cell indices:
MCV: Normal adult 80-95dL
MCH: Normal adult 27-31pg/cell
MCHC: Normal Adult 32-36%
RDW: Normal Adult 11-14.5 %
Hgb: Normal Adult
(female 12-16 g/dL male 14-18 g/dL)
Hct: Normal Adults
(female 37-47% & Male 42-52%)
WBC: Normal Adults 5000-10,000/mm3 Neutrophils: Normal 50-70% of differential Segments: 38%–71% of total Bands: 0%–10% of total Eosinophils: Normal 0-7% Basophils: Normal 0-2% Lymphocytes: Normal 16-45% Monocytes: Normal 4-10%
Platelet: Normal Adults 150,000-400,000/mm3
Remember:
Hemoglobin – female and male have different numbers, magic number 10 – anemic
Less than 8 – provide blood transfusion
May be less after surgery- but watch the trend before transfusing
1 unit of blood at a time
White count-
Above 10- risk for infection
Focus on 10,000
Platelets-
150-400,000
Below 100- risk for bleeding
Bone marrow aspiration & biopsy
Diagnose and monitor blood cells and marrow diseases, including cancers
Monitor treatment of a disease
Hemochromatosis
Investigate a fever of unknown origin
Assess the quantity and quality cells produced
within the marrow
Nursing Care:
Physician explain procedure
Risks/benefits/alternatives
Informed Consent
Procedure: Skin cleaned using aseptic technique Local anesthesia Hollow core, large bore needle Aspirate marrow from bone (iliac crest or sternum)
Biopsy- iliac crest only
How to take care patient before, during, and after bone marrow aspiration and biopsy
Pre procedure Nursing management Consent Prone or side-lying position Patient education
Intra procedure Nursing management Sedation Patient education Test will last 20 mins Invasive procedure Education- side lateral position for aspiration Biopsy- use something quiz to get biopsy May see bleeding or drainage from sight for 8-12 hours Feel pressure during procedure, no pain though Outpatient, they will go home Pain meds, any warm redness from sight Pressure dressing Monitor dressing and bleeding
Post procedure Nursing management Control bleeding, Pain/discomfort Patient education Monitor bleeding Monitor S/S of infection Dressing
complications of bone marrow aspiration and biopsy
Hemorrhage Risk factors- coagulopathies myeloproliferative disorders aspirin and warfarin therapy thrombocytopenia Disseminated Intravascular Coagulation liver disease
Infection
Pain
Patient Education
Site may ache 1-2 days
Warm tub baths should be avoided for 24 hours
NSAIDs should be avoided r/t bleeding
Acetaminophen may be used as mild analgesic
Patient support
patho of anemias
Iron deficiency:
hypoproliferative (bone marrow)
When there is little to no iron left to transport to the bone marrow, iron deficient erythropoiesis begins.
Anemias in renal disease:
hypoproliferative (bone marrow)
When your kidneys are damaged, they produce less erythropoietin (EPO), a hormone that signals your bone marrow—the spongy tissue inside most of your bones—to make red blood cells (less RBC made)
Folic acid deficiency:
Folic acid, a B vitamin, is needed for the formation of heme, the pigmented, iron-containing portion of the hemoglobin in red blood cells (erythrocytes). A deficient intake of folic acid impairs the maturation of young red blood cells, which results in anemia
Vitamin B12 deficiency: lack of intrinsic factor
failure of gastric parietal cells to produce sufficient IF (a gastric protein secreted by parietal cells) to permit the absorption of adequate quantities of dietary vitamin B-12.
Resulting from blood loss: trauma, medications, surgery
Hypoproliferative: Iron deficiency anemia Anemia in renal disease Megaloblastic Anemia in chronic disease Aplastic Anemia
Hemolytic:
Sickle Cell Anemia- inherited
Thalassemia’s- inherited
Immune hemolytic anemia’s
Blood loss:
Bleeding
Trauma
manifestations of anemias
Iron deficiency:Smooth, red, sore tongue
Brittle (sometimes spoon shaped) nails
Cracks at the corners of the mouth (Cheilitis)
Hx- multiple pregnancies, GI bleed, and Pica
Anemias in renal disease: Fatigue Increased cardiac output Reduced O2 utilization Decrease concentration and cognitive function
Folic acid deficiency: pale in mucous membranes,
Vitamin B12 deficiency: pernicious anemia- smooth red sore tongue, paresthesia in lower extremities (numbness & tingling)
Resulting from blood loss:
Tachycardia
Tachypnea, SOA
Dizziness
medical management and nursing interventions for anemias
Iron deficiency: Medical Management Identify cause (stool sample, colonoscopy) Inadequate intake of iron Inadequate storage of iron Abnormal loss of iron Prescribe supplements (oral or IV) Nursing Management Food sources – organ meats, meat, beans, leafy green vegetables Administer oral supplement Administer parenteral supplement
Anemias in renal disease: Medical Management Prescribe Epoetin alfa (IV or SQ 3x/week) and supplemental iron Monitor Hgb, Hct, iron and potassium Monitor BP Nursing Management Fatigue Angina Shortness of breath Monitor S/E of Epoetin (helps iron absorb)
Folic acid deficiency: Medical Management Prescribe folic acid (1mg/day) Nursing Management Food sources – liver, green vegetables Administer folic acid (IM or multivitamin)
Vitamin B12 deficiency:
Medical Management
Prescribe vitamin B12 replacement (oral, IM)
Nursing Management
Food sources – fortified soy milk
Administer vitamin B12 (oral when diet-related; monthly IM for pernicious anemia)
Educate re: pernicious anemia - lifelong treatment, risk of gastric cancer
Resulting from blood loss: Medical Management Identify cause Stop the bleeding Prescribe blood transfusion Prescribe iron supplements Nursing Management Monitor for bleeding Administer blood Administer iron supplement
assessment and diagnosis of anemia
Time to develop anemia Duration of the anemia Physical Assessment Metabolic requirements of the patient Other disorders/diseases present in the patient Family history
Iron Deficiency Anemia
Labs: low iron, ferritin levels, decreased MCV, increased RDW
Bone marrow aspiration
Occult blood stool sample
Megaloblastic Anemias Labs: increased MCV, increased RDW Bone marrow analysis Vitamin B12 level Folic acid level
Polycythemia
Causes:
Polycythemia Vera (PV): myeloid stem cell mechanisms out of control
Secondary polycythemia: Excessive production of erythropoietin
“thick blood”
Manifestation: HA, angina, dyspnea, claudication, blurred vision, pruritus
Risk for thrombosis and MI
Treatment: Phlebotomy (~ 500mL 1-2 times per week) Chemotherapy Antihistamines and Interferon alfa-2b for pruritus Allopurinol for gout attacks
Nursing Considerations: Educate patient of risk factors for thrombolytic complications Reduce risk of DVT Avoid iron supplements Tepid baths
Neutropenia
Causes: Decreased production of neutrophils Aplastic anemia (medications or toxins) Chemotherapy Radiation therapy Metastatic cancer Ineffective granulocytopoiesis Megaloblastic anemia Increased destruction of neutrophils Bacterial infection viral disease Immunologic disorders (SLE) Medication induced
Assessment
Neutrophil count < 2000/mm3
Routine CBC with differential
Treatment:
Treat underlying disease
Nursing: Assessment, prevention, and management of infection Educate r/t risk of infection Educate of s/s infection reverse isolation
thrombocytopenia
Causes:
Decreased platelet production
Increased platelet destruction
Increased platelet consumption
Assessment
Bleeding Precautions for platelets < 50,000
Risk of bleeding if platelets < 20,000
Bleeding and petechiae
Excessive bleeding after surgery or dental extraction
excessive menstrual bleeding
Spontaneous bleeding if platelets < 5,000
Treatment:
Prepare to administer FFP, PRBCs, Platelets, Vitamin K
Monitor lab work
Treat underlying disease
Nursing: Bleeding precaution Promote safety Educate r/t risk of hemorrhage Educate of s/s bleeding
difference between cellular and humoral immune response
Humoral:
B-cell quantification with monoclonal antibody
In vivo immunoglobulin synthesis with T-cell subsets
Specific antibody response
Total serum globulins and individual immunoglobulins (electrophoresis, immunoelectrophoresis, single radial immunodiffusion, nephelometry, & isohemagglutinin techniques
Cellular:
Total lymphocyte count
T-cell and T-cell-subset quantification with monoclonal antibody
Delayed hypersensitivity test
Cytokine production
Lymphocyte response to mitogens, antigens, and allogenic cells
Helper and suppressor T-cell functions
Humoral immunity secretes antibodies to fight against antigens, whereas cell-mediated immunity secretes cytokines and no antibodies to attack the pathogens
humoral immunity responses, B Cells produce antibodies after being activated by free antigens present in body fluids. In cell-mediated immunity responses, T cells attack infected body cells that display the antigens of pathogens on their surface.
Humoral immunity is also called antibody-mediated immunity. With assistance from helper T cells, B cells will differentiate into plasma B cells that can produce antibodies against a specific antigen. The humoral immune system deals with antigens from pathogens that are freely circulating, or outside the infected cells. Antibodies produced by the B cells will bind to antigens, neutralizing them, or causing lysis (dissolution or destruction of cells by a lysin) or phagocytosis.
Cellular immunity occurs inside infected cells and is mediated by T lymphocytes. The pathogen’s antigens are expressed on the cell surface or on an antigen-presenting cell. Helper T cells release cytokines that help activated T cells bind to the infected cells’ MHC-antigen complex and differentiate the T cell into a cytotoxic T cell. The infected cell then undergoes lysis.
body’s general allergic reactions and the stages of the allergic response
Allergic reaction:
Manifestation of tissue injury resulting from interaction between antigen & antibody
Body encounters allergens that are types of antigens
Body’s defenses recognize antigens as foreign
Series of events occurs in an attempt to render the invaders harmless, destroy them, and remove them from the body
Allergen triggers the B cell to make IgE antibody, which attaches to the mast cell. When that allergen reappears, it binds to the IgE and triggers the mast cell to release its chemicals.
Primary: Histamine Eosinophil chemotactic factor of anaphylaxis Platelet-activating factor Prostaglandins
Secondary:
Leukotrienes
Bradykinin
Serotonin
Environment (dust, pollen, mold, animal hair, etc.)
Food- nuts, seafood, eggs, peas, beans, milk
Proteins- foreign serum, vaccines
Latex
Medications- penicillin, sulfonamides, local anesthetics, salicylates
Inset bites/ stings
hypersensitivity
Abnormal heightened reaction to a stimulus of any kind Types of hypersensitivity reactions: 1 = Allergic Anaphylaxis and Atopy 2 = antiBody 3 = immune Complex 4 = Delayed
Type I- IgE mediated
Immediate onset (minutes): ingestion, inhalation, injection, or direct contact
IgE formation-histamine and leukotriene release
Manifestations: erythema, edema, pruritus, contraction of bronchial smooth muscle, increased mucous secretion
Example: Anaphylaxis, environmental (pollens)/ food allergy, insect stings, allergic conjunctivitis, allergic rhinitis (hay fever), atopic dermatitis (eczema), allergic asthma, hereditary angioedema, eosinophilia, urticaria (hives), maybe latex allergy
Type II-Antibody mediated
Fast onset (minutes – hours)
Cytotoxic reaction-antigen attach to cell- IgG, IgM, Macrophages attack antigen and self-cells; destroy (lyse) them (cellular lysis)
Cellular destruction by three mechanisms: (i) phagocytosis, (ii) complement-dependent cytotoxicity (CDC), and (iii) antibody-dependent cellular cytotoxicity (ADCC).
Example: Medication reactions (S/E), autoimmune blood transfusion hemolytic reactions, hemolytic disease, and hemolytic anemia, Good Pasture Syndrome, myasthenia gravis
Type III- Immune Complex mediated
Onset hours-days
Immune Complex –(Neutrophils, IgG, IgM)-deposited in small blood vessels of the skin (vasculitic), joints, kidneys (nephritis), lungs (extrinsic allergic alveolitis), systemic (serum sickness)
Vascular permeability, inflammation, fever, joint pain, rash, lymphadenopathy, hypotension, shock
Example: Systemic Lupus Erythematosus, serum sickness, Rheumatoid Arthritis, glomerulonephritis
Type IV- Delayed Type
Onset Delayed (24-72 hours after exposure)
Due to infectious agents, such as mycobacteria, protozoa and fungi
Sensitized T cells and macrophages – release lysosomes
Manifestations: edema, erythema, pruritus, ischemia, inflammation, and tissue damage
Example: Latex allergy (can turn into Type I), TB test and TB, contact dermatitis (latex, poison ivy), multiple sclerosis, transplant rejection
Assessment of Patients with Allergic Disorders
History, manifestations, & comprehensive allergy history
Diagnostic tests:
CBC: eosinophil count
Total serum IgE
Skin tests: prick, scratch, and intradermal
Two types of reactions: atopic and nonatopic
Atopic: (mediated by IgE)
Asthma, allergic rhinitis, atopic dermatitis
Familial
Nonatopic:
Lack genetic component
Latex
Anaphylaxis
Immediate release of IgE-mediated chemicals that produce a life-threatening reaction
Mild, moderate, and severe systemic reactions
Symptoms (Sudden onset. Progress in severity over minutes to hours.) Flushing Urticaria Angioedema Hypotension Bronchoconstriction
Causes
Foods
Peanuts, tree nuts (e.g., walnuts, pecans, cashews, almonds), shellfish (e.g., shrimp, lobster, crab), fish, milk, eggs, soy, wheat
Medications
Antibiotics, especially penicillin and sulfa antibiotics, allopurinol, radiocontrast agents, anesthetic agents (lidocaine, procaine), vaccines, hormones (insulin, vasopressin, adrenocorticotropic hormone), aspirin, nonsteroidal anti-inflammatory drugs
Other Pharmaceutical/Biologic Agents
Animal serums (tetanus antitoxin, snake venom antitoxin, rabies antitoxin), antigens used in skin testing
Insect Stings
Bees, wasps, hornets, yellow jackets, ants (including fire ants)
Latex
Medical and nonmedical products containing latex
prevention and management of allergic reactions/anaphylaxis
prevention:
Avoid potential allergens
If avoidance is impossible, get an epinephrine autoinjector.
Wear medical identification which lists allergens.
Management:
Oxygen as needed
Epinephrine (1:1000 dilution) IM preferred (See Chart 37-3, pg. 1067)
Manage airway (bronchodilators, corticosteroids)
Adjuncts: antihistamines & corticosteroids
IV fluids (NS), volume expanders, vasopressors
Transfer to ED
Watch for delayed reaction 4-8 hours after initial allergic reaction
Rheumatic Disease
Encompass autoimmune, degenerative, inflammatory, & systemic conditions
Affect the joints, muscles, and soft tissues
Problems caused by rheumatic diseases include:
Limitations in mobility and activities of daily living
Pain and fatigue
Altered self-image
Sleep disturbances
Systemic effects that can lead to organ failure and death
Commonly manifest the clinical features of arthritis (inflammation of a joint) & pain
Marked by periods of remission and exacerbation
Classifications:
Monoarticular or polyarticular
Inflammatory or noninflammatory
Three distinct characteristics: Inflammation: Autoimmunity: hallmark of rheumatologic disease Degeneration Manifestations: Secondary process to inflammation Pain Joint swelling Limited movement Stiffness Weakness Fatigue
Nursing Process: The Care of the Patient with a Rheumatic Disorder
Assessment:
Current and past symptoms: fatigue, weakness, pain, stiffness, fever, or anorexia
Effects of symptoms on the patient’s lifestyle and self-image
Psychological and mental status, social support system, comply with treatment regimen, and manage self-care
Pain:
Provide comfort measures
Administer anti-inflammatory analgesic
Fatigue:
Explain energy conserving techniques
Facilitate development of activity/rest schedule
Impaired physical mobility:
Assess for need of PT/OT
Encourage independence in mobility
Self-care deficit:
Assist in identifying self-care deficits
Provide assistive devices
Consult with community agencies
Disturbed body image:
Assist to identify elements of control over disease
Encourage verbalization of feelings
Ineffective coping:
Identify areas of life affected by disease
Develop plan for managing symptoms and enlisting support of family and friends to promote daily function
Complications secondary to medications:
Perform periodic clinical assessment and laboratory evaluation
Provide education about correct self-administration, potential side effects, and importance of monitoring
Counsel regarding methods to reduce side effects and manage symptoms
Administer medications in modified doses as prescribed if complications occur
Rheumatoid Arthritis
usually affects joints symmetrically, may initially begin in a couple of joints only, and most frequently attacks the wrists, hands, elbows, shoulders, knees, and ankles
Manifestation:
Symmetric joint
Pain, Swelling, Warmth, Erythema
Morning stiffness
Testing: ESR, CRP: elevated RBC decreased ANA positive Arthrocentesis shows cloudy, milky, dark yellow fluid
Treatment:
NSAIDs, COX-2 inhibitors, disease-modifying antirheumatic drugs (DMARDs)
Systemic Lupus Erythematosus (SLE)
SLE is an autoimmune disorder wherein immune complexes form and deposit in the basement membranes of capillaries, causing manifestations in the skin, joints, serous membranes, renal, hematologic and neurologic systems.
Remissions and exacerbations of Manifestations: Fatigue Myalgia /arthralgia Photosensitivity/rash Neurologic/behavioral changes Pericarditis/ pleuritis Renal disease Oral ulcers Erythrocyte Sedimentation Rate (ESR), Antinuclear Antibody (ANA), creatinine elevated CBC-anemia or thrombocytopenia weight loss
Treatment- Multiple Medications Corticosteroids (topical and oral) NSAIDs Glucocorticoids Immunosuppressive agents
Nursing Consideration
Fatigue. Impaired skin integrity. Body image disturbance
Avoid exposure to sun & UV light
Diet to prevent HTN, atherosclerosis
gout
Monosodium urate crystals deposit in joints; Tophi
swollen and inflamed joints, masses of uric acid (tophi), uric acid crystals
Manifestations:
Acute pain, redness, swelling, warmth of affected joint
Triggers: Alcohol, trauma, diet, medications, stress, illness
food to avoid:
fatty fish, shell fish, red meat, eggs, caffeine, white flour, yeast, alcohol, leafy green veggies, cake, pastries, sugars
Testing: polarized light microcopy pf synovial fluid, Serum uric Acid level
Treatment Xanthine oxidase inhibitor (Allopurinol) Uricosuric agents (Probenecide) NSAIDs Colchicine
Nursing Care: Rest joint Apply ice Avoid aspirin, stress, ETOH, trauma, food high in purines Drink plenty of fluids
fibromyalgia
Manifestations
Chronic pain, Diffuse musculoskeletal achiness, Morning stiffness, Fatigue, Sleep disturbances, Functional impairment, Weight gain, Mood disturbances, Chemical sensitivity, dysmenorrhea,
Dx by manifestations
Widespread pain index (WPI)
& symptom severity score
Symptoms present for at least
3 months
No other disorder to explain
the pain
Treatment NSAIDs TCA (Amitriptyline, Nortriptyline) Muscle relaxants (Cyclobenzaprine) AEDs (Gabapentin, Pregabalin) Antidepressants
Nursing Care
Exercise
Cognitive therapy
Medication regimen
Management of Patients with Oncologic Disorders
Treatment Goals
Cure- complete eradication of malignant disease
Control- prolonged survival and containment of cancer cell growth
Palliation- relief of symptoms associated with the disease and improvement of quality of life
Treatment Approaches
Surgery- diagnostic surgery (biopsy), treatment, prophylactic surgery, palliative surgery, reconstructive surgery
Radiation
Chemotherapy
Preop care:
Emotional support. Education (consistent information)
RN is patient advocate & liaison
Post-op care:
Complications (dehiscence, fluid/electrolyte imbalances, organ dysfunction)
Wound care, pain management, activity, nutrition & medication teaching
Surgery combined w/radiation & chemotherapy
post-op complications:
Infection & impaired wound healing & development of VTE
Altered pulmonary & renal function
Discharge: Community resources (American Cancer Society)
radiation therapy
Treatment Goals
Cure- Thyroid carcinomas, cancers of the cervix
Control- reduce tumor size to facilitate surgical resection
Prophylactically- prevent spread of the primary cancer to a distance area
Palliative- relieve the symptoms of metastatic disease
Administration
Teletherapy- external-beam radiation e.g. EBRT (GammaKnife)
Brachytherapy- internal radiation implantation (vagina, abdomen, pleura, breast, prostate)- LDR (low dose), HDR (high dose)
Toxicity Early, systemic, late effects Altered skin integrity Alterations in oral mucosa Affect QOL, overall health
Side Effects- localized
Alopecia, Erythema, Desquamation, Potentially Ulceration, Hyperpigmentation
Stomatitis, Xerostomia, change in or loss of taste
Mucositis, anorexia, nausea, vomiting, and diarrhea
Anemia, Leukopenia, Thrombocytopenia
Radiation precautions- Time, Distance, & Shielding private room w/notice on door staff wear dosimeter badges no pregnant staff members assigned no children or pregnant visitors limit visits to 30 min. daily stay 6 feet away If internal implant dislodged: Pick up w/metal forceps. Place in lead-lined container Contact radiation safety officer & go to occupational health
Protect skin and oral mucosa
Avoid ointment, lotion, powder on treated area
Gently cleanse with mild soap using fingertips instead of washcloth
Do not remove temporary skin markings
Electric razors only
Avoid constrictive clothing
Avoid sun exposure, health lamps, head pads, ice packs
Gentle oral hygiene
