Exam 3 HEME Flashcards
deficiency of erythrocytes (RBCs) reflected by a decreased Hct <4x10^12
anemia
pallor (ears and nailbeds, palmar crease, conjunctiva esp)
fatigue, exercise intolerance, lethargy, orthostatic hypotension
tachycardia, heart murmurs, HR
Bleeding (hematuria, melena, menorrhagia)
Dyspnea
irritability, diff concentrating
cool skin, cold intolerance
assessment with anemic patient
which meds may cause anemia?
salicylates, thiazides, and diuretics
what dietary factors may contribute to anemia?
decreased iron, folate, or Vit B12
when does cardiac output increased to compensate for anemia?
when hgb <7
red meats, organ meats, whole wheat products, spinich, carrots
food high in iron
green veg, liver, citrus fruits
foods high in folic acid
glandular meats, yeast, green lieafy veg, milk and cheese
foods high in vit B12
how do you administer Iron?
use z track method
use air bubble to avoid w/d medication into SC tissue
DONT USE DELTOID
DONT MASSAGE
when do you take iron?
empty stomach one hour before meals or two hours after meals and give vit C to enhance iron absorption
what should you tell patients who take iron?
may turn stool black and may stain skin if given IM (that why we use Ztrack). take liquid iron through a straw and brush teeth afterward to avoid staining teeth
malignant neoplasm of blood forming organs
abnormal overproduction of immature forms of leukocytes and decreased RBC and platelets
leukemia
why does immunosupression occur in leukemia
large number of immature WBC and profound neutropenia
why does hemorrhage occur in leukemia?
thrombocytopenia
how is leukemia diagnosed?
biopsy, bone marrow aspiration, lumbar puncture, and frequent blood counts
type of leukemia where leukocytes are unable to mature
acute myelogenous leukemia: prognosis is poor
type of leukemai characterized by abnormal production of granulocytic cells
Chronic myelogenous leukemia: a biphasic disease with chronic stage of 3 years and acute stage only 2-3 months
hydroxyurea, interferon, imatinib mesylate
tx for chronic myelogenous leukemia
type of leukemia characterized by abnormal leukocytes in blood forming tissue and is the most common cause of childhood cancer
Acute lymphocytic leukemia: prognosis is favorable
type of leukemia characterized by increased production of leukocytes and lymphocytes and porliferation of cells within the bone marrow, spleen and liver. Occurs after age 35
Chronic lymphocytic leukemia
decreased H&H, decreased plt, altered/high WBC
acute myelogenous leukemia
TX: prevent infection, prevent and control bleeding
high protein, high calorie diet, assist with ADL, drug therapy
use immediately after reconstitution avoid vapors in eyes vesicant hydrate well before and during treatment with IV fluids and mannitol monitor hearing and vision
cytophosphamide
leucorvian rescue
leucorvian + methotrexate tp prevent toxic rxn
which chemo drug would you give with alloprinol to increase potency and avoid folic acid?
methoxtrexate
Which chemo drugs may cause cardiomyopathy and turn urine red?
Dactinomycin and Daunorubicin I, Doxorubicin HCl
which chemo meds needs benedryl first?
endothelial growth factor receptor inhibitors: Cetuximab, Panitumumab
which chemo meds are neurotoxic?
Vincristine sulfate nd Vinblastine sulfate (Oncovin and Velban)
which chemo med should you check ANC, give slowly due to pain at site, and assess bone pain after?
Filgrastim (Neupogen)
What are nursing considerations for Ondansetron HCl (Zofran)?
administer tablets 30 mins prior to choemo and 1-2 hours prior to radiation
dilute IV injection in 50 mL of 5% dextrose or 0.9% NaCl
draw blood sample shortly before administration of an antibiotic
trough
draw blood sample 30 mins to 1 hours after drug adminsitration
peak
Reed Sternberg cell
a generalized painless lymphadenopathy
Hodgkin Disease
how do you determine what stage of Hodgkin disease?
laparotomy
Stage 1 HD:
involvement of a single lymph node region or a single extralymphatic organ or site
stage 2 HD
involvement of two or more lymph nodes on the same side of the diaphragm or localized involvement of an extralymphatic organ or site
stage 3 HD
involvement of lymph node areas on both sides of the diaphragm to localized involvemnt of one extralymphatic organ, the spleen, or both
Stage IV HD
diffuse involvement of one or more extralymphatic organs, with or without lymph node involvement
how do you treat HD?
radiotherapy
chemotherapy
Splenectomy
enlarged lymph nodes (usually cervical), anemia, thrombocytopenia, elevated leukocytes, decreased platelets, fever, increased susceptibility to infections, anorexia, weight loss, malaise, bone pain, night sweats, pruritis, pain in affected lymph node after consuming alcohol
assessment of HD
adeno
glandular tissue
angio
blood vessels
basal cell
epithelium (sun exposed areas)
embryonal
gonads
fibro
fibrous tissue
lympho
lymphoid tissue
melano
pigmented cells of epithelium
myo
muscle tissue
osteo
bone
squamous cell
epithelium
change in bowel and bladder fxn
a sore that does not heal
unusual bleeding or discharge, hematuria, tarry stools, ecchymosis, bleeding mole
thickening or a lump in the breast or elsewhere
indigestion or dysphagia
obvious changes in a wart or mole
nagging cough or hoarseness
f7 warning signs of cancer
what is the only IV fluid compatible with blood products?
normal saline
what do you do if a hemolytic transfusion rxn occurs?
turn off the transfusion take temp send blood being transfused to lab obtain urine sample keep vein patent with NS
What are three interventions for clients with a bleeding tendency?
use a soft toothbrush, avoid salicylates, do not use suppositories
what are two sites to assess for infection in immunocompromised pts?
oral and genitals
List three safety precautions for the administration of antineoplastic chemotherapy
dbl check order with another nurse
check for blood return prior to adminsitration
use a new IV site daily for peripheral chemotherapy
wear gloves when handling the drugs
dispose of waste in special containers
normocytic, normochromic
acute blood loss, hemolysis, CKD, CA
microcytic, hypochromic
iron def anemia, lead poisoning, thalassemia
macrocytic (megaloblastic) normochromic
cobalamin (vit B12) deficiency, folic acid def, liver disease, post splenectomy
What may inhibit iron absorption and thus add to anemia?
antacids, tetracyclines, soft drinks, tea, coffee, calcium, phosphorus, magnesium salts
neutropenic precautions
strict hand hygiene, visitor restrictions, private, positive-pressure room or HEPA
monitor for s/sx of infection
prompt administration (w/in one hour!) of broad spectrum antibiotic at first sign of infection
hematopoietic growth factors (Pegfilgrastim, G-CSF, GM-CSF)
pet your pets, but dont clean up after them-elicit help from family!
fatigue and weakness, HA, mouth sores, anemia, bleeding, fever, infection, sternal tenderness, gingival hyperplasia, min hepatosplenomegaly and lymphadenopathy
AML: most common acute adult leukemia
Fever, bleeding, fatigue, bone/joint pain, CNS manifestations (increasing ICP causes n/v, lethargy)
ALL: most common childhood leukemia
Philadelphia chromosome disease marker which is a translocation of genetic material from chromosomes 9 and 22.
characterized by a chronic stable phase followed by an aggressive BLASTIC phase (only a few months to live once blastic phase hits)
no symptoms early in disease, fatigue, weakness, sternal tenderness, weight loss, joint pain, bone pain, massive splenomegaly, increase in sweating
CML
characterized by the production and accumulation of functionally inactive but long-lived, small, mature appearing lymphocytes
no symptoms frequently, detection of disease often during exam for unrelated condition
chronic fatigue, anorexia, splenomegaly, lymphadenopathy, hepatomegaly, fever, night sweats, weight loss, frequent infections
CLL: most common leukemia in adults
sim to non hodgkins lymphoma–>richter’s syndrome
B symptoms
fever, night sweats, weight loss
ABVD regimen
for Hodgkins lymphoma
Adriamycin (doxorubicin), Bleomycin, Vinblastine, dacarbazine
BEACOPP
for advanced stage hodgkins lymphoma
bleomycin, etoposide, adriamycim, cyclophosphamide, Oncovin (vincristine), procarbazine, prednisone
nursing mgmt multiple myeloma
adequate hydration to decrease complications r/t hypercalcemia (due to bone involvement of multiple myeloma)
allopurinol may be given to prevent renal damage once chemo has been initiated
high risk for fractures-be careful when moving pt
nursing care for anemia, thrombocytopenia, and neutropenia may be appropriate
less danger of fluid overload
used for severe or symptomatic anemia, acute blood loss
packed RBCs
in general, one unit of packed RBCs can be expected to increase Hgb by 1g/dL or Hct by 30%
autotransfusion, stcokpiling or rare donors for patients with alloantibodies. Infrequently used bc filters remove most WBCs
Frozen RBC (can be stored for 10 years) but use within 24 hours of thawing
bleeding caused by thrombocytopenia, may be contraindicated in thrombotic thrombocytopenic purpura and heparin induced thrombocytopenia except in life threatening hemorrhage
can be kept at room temp for 1-5 days
expected increase is 10,000uL/U
Platelets
bleeding caused by deficiency in clotting factors (DIC, hemorrhage, massive transfusion, liver disease, vit K def, excess warfarin)
Fresh Frozen Plasma
may be stored for 1 year
use w/in 2 hours of thawing
hypovolemic shock, hypoalbuminemia
heat treated adn does not transmit viruses!
Albumin (can be stored for 5 years)
25g/100mL is osmotically equal to 500mL plasma
what size needle do you use for blood?
19
18-16 if rapid transfusion
smaller needles can be used for platelets, clotting factors, and albumin
Why cant you use dextrose solutions or LR for administering blood?
they will cause RBC hemolysis
what should you do BEFORE requesting the blood component from blood bank?
check patency first!
Nursing considerations for blood products
use within 30 mins or return to blood bank
stay with patient first 15 mins or first 50 mL
take vitals before administration-if fever-call HCP to make sure you can give blood product
initial rate of infusion should not exceed 2mL/min
PRBCs should not be infused quickly unless an emergency crisis as rapid infusion of cold blood may chill patient if so, use a blood warmer
fresh frozen plasma and platelets may be infused over 15-30mins
retake vitals after first 15 mins
observe patient q30mins during administration and up to 1 hour after
transfusion time should not exceed 4 hours due to potential of bacterial growth in blood while hanging
what to do in an acute transfusion rxn?
stop transfusion
maintain a patent IV line with NS
notify blood bank and HCP immediately
recheck id tags and #s
monitor VS and urine output
treat symptoms per physician orders
save the blood bag and tubing and send them to the blood bank for examination
complete transfusion rxn reports
collect required blood and urine specimens at intervals stipulated by hospital policy to evaluate for hemolysis
document on transfusion rxn form and pt chart
ABO incompatible blood
acute hemolytic rxn
chills, fever, low back pain, flushing, tachycardia, dyspnea, tachypnea, hypotension, vascular collapse, hemoglobinuria, acute jaundice, dark urine, bleeding, AKI, shock, cardiac arrest, death
type II cytotoxic hypersensitivity rxn
what causes a febrile transfusion rxn?
sudden chills and fever, HA, flushing, anxiety, vomiting, muscle pain
leukocyte incompatibility
avoid this in patients who have received five or more transfusions as they may have developed circulating antibodies, by using addt’l filters in the tubing to leukocyte deplete RBCs and platelets
generally, tylenol and benedryl 30 mins prior to transfusion will avoid this rxn
consider leukocyte poor blood products such as filtered, washed, or frozen
result from recipient’s sensitivity to plasma proteins in donors blood
flushing, itching, urticaria
cyanosis, bronchospasm, shock, cardiac arrest
allergic rxn
give antihistamine before
EPI and corticosteriods after to treat a sever rxn
cough, dypnea, pulmonary congestion, HA, HTN, tachycardia, distended neck veins
circulatory overload
adjust transfusion rate and volume
place pt upright with feet in dependent postion
rapid onset of chills, high fever, vomiting, diarrhea, marked hypotension or shock
sepsis rxn
obtain culture of pts blood and send bag with remaining blood and tubing to blood bank for further study
treat septicemia with antibiotics, IV fluids, vasopressors
fever, hypotension, tachypnea, dyspnea, decreased o2 sat, frothy sputum
transfusion related acute lung injury rxn (TRALI)
provide o2 and administer corticosteriods
initiate CPR if needed and provide ventilatory and BP support if needed
provide leukocyte reduced products and id donors who are implicated in TRALI rxns and do not allow them to donate
what is a potential complication of hyperviscosity polycythemia?
thrombosis
a disease process stimulates coagulation processes with resultant thrombosis as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage
DIC
Priority nursing actions when caring for a hospitalized patient with new-onset temp of 102.2F and severe neutropenia include (select all that apply):
a. administer the prescribed antibiotic STAT
b. draw peripheral and central line blood cultures
c. ongoing monitoring of VS for signs of septic shock
d. taking a full set of vitals and notifying physician right away
e. administering transfusions of WBCs treated to decrease immunogenicity
abcd
The nurse is aware that a major difference between Hodgkins lymphoma and non-Hodgkins lymphoma is:
a. Hodgkin’s lymphoma occurs only in young adults
b. Hodgkin’s lymphoma is considered potentially curable
c. non-Hodgkin’s lymphoma can manifest in many organs
d. non-Hodgkin’s lymphoma is treated only with radiation therapy
c. non-Hodgkin’s lymphoma can manifest in many organs
A patient with multiple myeloma becomes confused and lethargic. The nurse would expect that these clinical manifestations may be explained by diagnostic results that indicate:
a. hyperkalemia
b. hyperuricemia
c. hypercalcemia
d. CNA myeloma
c. hypercalcemia
When reviewing the patient’s hematologic lab values after a splenectomy, the nurse would expect to find
a. leukopenia
b. RBC abnormalities
c. decreased hemoglobin
d. increased platelet count
d. increased platelet count
Complications of transfusions that can be decreased by the use of leukocyte depletion or reduction of RBC transfusions are
a. chills and hemolysis
b. leukostasis and neutrophilia
c. fluid overload and pulmonary edema
d. transmission of cytomegalovirus and fever
d. transmission of cytomegalovirus and fever
nursing considerations for thrombocytopenia
risk for spontaneous bleeding
avoid invasive procedures
avoid activities that place them at risk for bleeding or injury (including excessive straining-avoid constipation!!)
risk for bleeding is significant if platelet count is less than 50,000
when do you give platelet transfusion
when platelet count <20,000
skin care in radiation treatment area
cleanse gently w mild soap
apply moisturizer or cream (non-medicated, no perfume) OTC hydrocortisone cream 1% may relieve itching
rinse area with saline solution and expose area to air often
avoid sun
avoid tight clothes, abrasive fabrics, nongentle detergents
avoid temp extremes
no swimming in salt water or chlorinated pools
electric razor to shave if necessary
myeloid cell recovery after bone marrow transplant
SE n/v/d, fever, chills, myalgia, HA, fatigue
GM-CSF (Leukine)
chemo induced neutropenia
SE bone pain, n/v
G-CSF
Filgrastim-Neupogen), pedfilgrastim-Neulasta
anemia of chronic cancer (Epogen, Procrit epoetin alpha)
anemia r/t chemo (Aranesp darbepoetin alpha)
SE HTN, thrombosis, HA
erythropoietin
Thrombocytopenia r/t chemo
SE fluid retention, peripheral edema, dyspnea, tachycardia, nausea, mouth sores
Interleukin 11 (platelet growth factor) Neumega
Trends in the incidence and death rates of cancer include the fact that
a. lung cancer is the most common type of cancer in men
b. a higher percentage of women than men have lung cancer
c. breast cancer is the leading cause of cancer deaths in women
d. african americas have a higher death rate from cancer than whites
d. african americans have a higher death rate from cancer than whites
what cellular features of cancer cells distinguish them from normal cells? (select all that apply)
a. cells lack contact inhibition
b. cells return to a previous undifferentiated state
c. oncogenes maintain normal cellular expression
d. proliferation occurs when there is a need for more cells
e. new proteins characteristic of embryonic stage emerge on cell membrane
abe
- a. cells lack contact inhibition
- b. cells return to a previous undifferentiated state
c. oncogenes maintain normal cellular expression
d. proliferation occurs when there is a need for more cells - e. new proteins characteristic of embryonic stage emerge on cell membrane
The goals of cancer treatment are based on the principle that
a. surgery is the single most effective treatment for cancer
b. initial treatment is always directed toward cure
c. a combination of treatment modalities is effective for controlling many cancers
d. although cancer cure is rare, quality of life can be increased with treatment modalities.
d. although cancer cure is rare, quality of life can be increased with treatment modalities.
what is the most effective method of administering a chemotherapeutic agent that is a vesicant
use a central venous access device
a patient undergoing brachytherapy must be told
that radioactive precautions are required during nursing care
What do you do if your patient complains of being cold and begins to shiver while you are infusing Rituxan?
stop the infusion and administer NS
rule of threes
HgbX3=Hct
HctX3=RBC
Hgb normal value
M 14-18
F12-16
Hct normal
37-52%
RBC normal
4.2-5.4
platelets
150-400
WBC
5-10
What do neutrophils fight?
bacteria
normal 55-70%
pancytopenia
decrease in WBC, RBC, platelets
PTT
60-70 sec
Heparin
PT/INR
11-12.5 sec
Warfarin
Med management for hemophilia
FFP, recombinant clotting factors, desmopressin (DDVAP)
simultaneous bleeding and thrombosis
pallor, petechiae, purpura, oozing, severe bleeding, hematomas, cyanosis, ischemia
DIC
what are hemostatic agents?
thromboplastin, surgiseal, collagen, alginate (wet it)
how do you correct a hemolytic transfusion rxn?
dopamine, cystalloids (NS), osmotic diuresis (removed lysed cells), FFP, cryo, maybe platelets
How do you treat hemochromatosis?
IV deferoxamine
glossitis
iron deficiency anemia-assume due to blood loss until proven otherwise
dextran
Iron replacement-never in arm; use z track to avoid skin staining with 20 gauge; monitor closely for 30 mins
beefy, sore tongue
pernicious anemia (vit B12) deficiency
megaloblastic
crohns, h2 receptor blocker use, ETOH abuse
chelitis
folic acid def anemia
*take iron supplements with vit C and avoid calcium containing foods for two hours
SE joint, muscle, and/or bone pain, fever, cough, soreness of mouth
may cause certain cancers to grow faster
concomitant VTE prophylaxis
Epoetin (epogen, Procrit)
What is important to know if pt undergoes a spleenectomy?
increased risk of infeciton–>vaccinate!!!
complete bone marrow failure
pancytopenia
falconi’s
aplastic anemia
fatigue, SOB, activity intolerance, infection, purpura
aplastic anemia clinical manifestations
left shoulder or rib cage pain, ARDS, alveolar hemorrhage, hemoptysis, sickle cell crisis
filgrastin (Neupogen)
when do you calculate ANC (absolute neutrophil count)?
when pt has a low WBC
if less than 1000, hold chemo
why do we do bone marrow transplants (BMT) and peripheral blood stem cell transplant (PBSCT)?
- replace diseased marrow with healthy marrow (leukemia, aplastic anemia, and sickle cell anemia)
- regenerate new immune system to fight cancer not killed by chemo or radiation
- rescue-replace the bone marrow and restore function after high dose chemo/radiation
what med will boost stem cell release?
plerixafor (Mozobil) SQ
n/v/d, HA, fatigue, joint pain, spleen enlargement or rupture
s/s spleen rupture
pain left shoulder or under left rib cage
monocytes, granulocytes, erythrocytes, and platelet
myeloid cells
(AML)-defect in the stem cells that differentiate into all myeloid cells
most common leukemia in adults
neoplasms in lymphoid tissue
HL and NHL
CLL (chronic lymphocytic leukemia) and ALL (Acute lymphocytic leukemia)
too many lymphocytes (t cells and B cells, but mostly an overproliferation of b cells, esp in CLL)
malignant disease of plasma cells in the bone marrow with destruction of bone
(elevated proteins, bone marrow biospy shows >10% plasma cells, CRAB)
multiple myeloma
most pts are >70 yo
How do you manage multiple myeloma?
chemo, radiation, plasmapheresis, corticosteriods (Decadron), stem cell transplant
biophosphonates-sit up for 30 mins after taking; dont lift >10lbs
hypercalcemia (increase fluids, cranberry j)
treat pain w NSAIDs or opioids
neutropenic precautions
aimed at achieving a rapid, complete remission of all manifestations of the disease
Induction therapy (chemo)
administered early in remission with the aim of curing
consolidation therapy (chemo)
maintenance therapy may be prescribed for month or years following successful induction and consolidation therapy. The aim is to maintain _______
remission (chemo)
anemic and fatigued pt will get
packed RBCs
pt with <20,000 platelets will get
platelet transfusion
patient with multiple myeloma is at risk for
pathological fractures. provide skeletal support during moving, turning and ambulating and provide a hazard-free environment (promote fluids to combat hypercalcemia!!)
lymphocytes
NK cells, T cells, and B cells
a malignant proliferation of plasma cells within the bone
multiple myeloma
the abnormal plasma cells invade the bone marrow and destroy bone and also invade liver, spleen and lymph nodes
Bence Jones protein
abnormal protein found in blood and urine that is produced by the abnormal plasma cells in multiple myeloma
causes decreased production of immunoglobulin and antibodies and increased levels of uric acid and calcium, which can lead to kidney failure
multiple myeloma
urinalysis shows Bence Jones proteinuria and elevated total serum protein level
multiple myeloma
administer biphosphonates as prescribed to slow bone damage and reduce pain and risk of fractures
multiple myeloma
- sepsis and DIC
- SIADH
- Spinal cord compression
- hypercalcemia
- superior vena cava syndrome
- Tumor lysis syndrome
oncological EMERGENCIES
what indicates superior vena cava syndrome?
prepare client for high-dose radiation therapy to the mediastinal area, and possible surgery to insert a metal stent in the vena cava
blockage of blood flow in the venous system of head, neck and upper trunk which may manifest as facial puffiness
Stokes’ sign is tightness of collar
morning puffy face
seizures, coma, and eventually death may occur when sodium measures how low?
110mEq/L
early signs are fatigue, anorexia, nausea, vomiting constipation, and polyuria
more serious signs: severe muscle weakness, diminished deep tendon reflexes, paralytic ileus, dehydration, and changes to ECG
hypercalcemia
large quantities of tumor cells are destroyed rapidly and intracellular components such as potassium and uric acid are released into the bloodstream faster than the body can eliminate them.
tumor lysis syndrome
tumor lysis syndrome can indicate that cancer treatment is destroying tumor cells, however, if left untreated ______
it can cause severe tissue damage and death
encourage hydration
administer diuretics to increase urine flow
allopurinol will help excrete purines
IV infusion of glucose and insulin to treat hyperkalemia
prepare pt for dialysis if hyperkalemia and hyperuricemia persist
fluid restriction, increased sodium, and meds antagonistic to ADH
SIADH treatment
shortened T segment and widened T wave
hypercalcemia
withhold antineoplastic meds when the neutrophil count is
<1800 clls/mm^3
may cause hemorrhage cystitis–encourage fluids
cyclophosphamide and ifosfamide (Ifex)
may cause alopecia, stomatitis, hyperuricemia, photosensitivity, hepatotoxicity, and hematological, GI, and skin toxicity
methotrexate
may cause hyperuricemia and hepatotoxicity
mercaptopurine
may cause alopecia, stomatitis, diarrhea, phototoxicity, cerebellar dysfunction (dizzness, weakness, ataxia)
fluorouracil
neurotoxic
vincristine (numbness and tingling in the fingers and toes, constipation, paralytic ileus
orthostatic hypotension
administer this med slowly over 30-60 mins and monitor BP during infusion
etoposide
what is the first clinical sign indicating peripheral neuropathy? (Vincristine)
depressed achilles tendon reflex
tamoxifen may increase
calcium, cholesterol, and triglyceride levels
increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, and deep bone or flank pain
hypercalcemia
dexrazoxane (zinecard)
may be given with Doxorubicin to reduce cardiomyopathy
extravasion
redness and swelling with slowed infusion stop infusion call HCP apply ice or heat antidote
platelets
thrombocytes
etiology of a platelet disorder may be due to
bone marrow, increased platelet consumption, or destruction of platelets.
CBC, Chem panel (sodium, potassium, chloride, BUN/Cr, Glu, CO2), Liver enzymes, coag panels
labs you always want to look at
primary thrombocythemia
overproduction of platelets (a stem cell disorder within the bone marrow) levels are consistently 600,000. Platelet size may be abnormal. May lead to embolus or DVT, stroke or MI; GI is most common site of bleeding
immune thrombocytopenic purpura (ITP)
autoimmune blood disorder
- most common autoimmune blood disorder affecting all ages
- may appear after 1-6 wks after a viral illness
- the body is destroying its own platelets and simultaneously impairing further production-unknown cause; may give IVIG (Intravenous Immunoglobulin), splenectomy is possible !platelet transfusions are ineffective!!
causes of platelet defects
may be caused by ASA, NSAIDs, and ESRD, CABG and meds
Von Willebrand’s Disease
most common inherited bleeding disorder
-a deficiency, dysfunction, or absence of von Willebrand Factor (vWF) which is necessary for factor VII activity and is essential for platelet adhesion at site of injury
DIC
primary culprit is sepsis; progressive decrease in platelets may be all that we see to clue us in on pending DIC
necessary for abdominal trauma, may be necessary in the presence of hemolytic anemia and ITP
splenectomy
blood is taken from the patient, passed through a centrifuge where a specific component is separtated from the blood, the blood is returned to the patient
therapeutic apheresis
elevated Hct’s (Polcythemia) or excessive iron absorption (hemochromatosis)
Therapeutic phlebotomy
Growth factors –
stimulate bone marrow production
Erythropoietin-
Epoen, Procrit. Stimulates erythropoiesis
Granulocyte-colony stimulating factor (G-CSF) Neupogen;
Neupogen: stimulates differentiation of myeloid cells
Granulocyte-macrophage stimulating factor (GM-CSF)
stimulates myelopoiesis
Thrombopoietin –
for proliferation of megakaryocytes and subsequent platelet formation
Autologous donation
patient’s own blood is collected for future use. 4-6 weeks for preoperative donations. 1 unit per week. Pat may receive Epogen and iron suplements
Intraoperative blood salvage
salvaged during a surgery
Hemodilution
CABG for avoid damage to RBC’s on the bypass machine
one unit of platelets will increase the count by
7000-10000 for a single donor.
one unit of PRBC’s will raise the Hg by ___ and HCT by ___
raise Hg by 1 g and Hct by 3%
what is the infusion rate for the first 15 mins of a blood transfusion?
no faster than 5mL/min and STAY in the room for the first 15 mins!! If asymptomatic, increase the flow rate and continue to monitor closely
signs of circulatory overload
dyspnea, orthopnea, tachycardia, and sudden anxiety
signs of sepsis
fever, chills, hypotension
sign of febrile rxn
1 degree increase in temp in the febrile range during or shortly after a transfusion
signs of an allergic rxn
hives and itching during transfusion
Acute hemolytic reaction –
most dangerous and potentially life-threatening. Occurs when transfusion and patient’s blood are incompatible. Most rapid that can occur with only 10 ml’s of transfusion is ABO compatibility. Labeling and patient misidentification are the primary culprits.
Delayed hemolytic reaction –
occurs within 14 days; S/s fever, anemia, increased bilirubin and possibly jaundice. Mild requires no intervention.
Primary thrombocythemia –
stem cell disorders = increased platelet production
Secondary thrombocytosis –
increased platelet production as a reaction to a disorder or condition
Von Willebrand
is the most common inherited blood disorder and is characterized by an increased tendency to blled from mucous membranes. Management is to replace deficient protein and minimize post-operative bleeding
-causes platelets to adhere to damaged endothelium; the von Willebrand factor protein also serves as a carrier protein for factor VIII
Disseminated intravascular coagulopathy (DIC) –
micro clots form and clotting factors are used up. Prognosis depends on medical management of underlying cause.
situations that cause sickling
fever, dehydration, emotional or physical stress
primary treatment for hemophilia
replace the missing clotting factor, give agents to relieve pain or corticosteriods
prevention organ damage from too much iron, chelation therapy with either
Exjade or deferoxamine (Desferal)
DIC treatment
administer anticoags during early phase, administer cryoprecipitated clotting factors when DIC progresses and hemorrhage is the primary problem
abruptio placentae, amniotic fluid embolism, gestational hypertension, intrauterine fetal death, liver disease, sepsis
predisposing conditions for DIC
polycythemia
production and presence of increased RBCs (hyperviscosity and hypervolemia) (secondary can be caused by hypoxia)–> control chronic pulmonary disease, no smoking, avoid high altitudes
thrombocytopenia
low platelets
caused by
(Inherited) Fanconi Syndrome (pancytopenia)
Hereditary thrombocytopenia
(Acquired-Immune) Immune thrombocytopenic purpura (ITP)
Neonatal alloimmune thrombocytopenia
(Acquired Nonimmune): Thrombotic thrombocytopenic purpura (TTP), DIC, HIT, Splenomegaly/splenic sequestration, drug induced marrow suppression, chemo, viral infection, bacterial infection, alcoholism, bone marrow supression, etc
observe for early signs of thrombocytopenia
in patients receiving chemo
leukopenia
decrease in total WBC count
granulocytopenia
decrease of granulocytes (phagocytize pathogens so think increased risk of infection)
neutropenia
=ANC<1000; normal is 4000-11,000; reduction in neutrophils; the largest constituency of granulocytes is neutrophils; the faster the drop and the longer duration of neutropenia will increase likelihood of developing infection, sepsis, and death.
the most common cause of neutropenia
is iatrogenic, resulting from widespread use of chemotherapy and immunosuppressive therapy in the treatment of malignancies and autoimmune diseases
neutropenic fever (>100.4) and a neutrophil count <500
is a medical emergency as it could lead quickly to septic shock
iron patient teachings
Iron preparations can be very irritating to the stomach and are best taken between meals. Because iron supplements may be associated with constipation, the client should increase fluids and fiber in the diet to counteract this side effect of therapy. Iron preparations should be taken with a substance that is high in vitamin C to increase its absorption. The tablet is swallowed whole and not chewed.
