Exam 5 Flashcards
Red Blood Cells
Erythrocytes
Transport oxygen, take away carbon dioxide, produced in red bone marrow
Live about 120 days
White Blood Cells
Leukocytes
Help to fight off pathogens
Characteristics of Blood
45% blood cells (RBCs, WBCs, platelets)
55% blood plasma
pH: 7.35-7.45
Volume: 5-6 L
Hematopoiesis
Process that continuously occurs to replace the blood components
Hemostasis
Balance between clot formation and fibrinolysis
Erythropoiesis
Red blood cell production
Takes about 5 days
Erythropoietin is a hormone that originates in the kidneys
Needs: healthy bone marrow, dietary iron, protein, vitamins
Blood Plasma
Fluid left over after all cells are removed
Blood Serum
If you let the plasma clot and then take away the rest, the serum is left
Does not have fibrinogen or clotting factors
Albumin
Given routinely to expand the volume of the blood
Major component of osmotic pressure of plasma
Reticulocyte
Immature red blood cell
Schistocytes
Irregular fragments of red blood cells
“Helmet Cell”
Polycythemia
Increased RBCs
Occurs with chronic hypoxia (e.g. COPD)
Bone Marrow
Site of hematopoiesis
Stem cells are primitive cells
Myeloid (erythrocytes, leukocytes, platelets)
Lymphoid (T or B lymphocytes)
Stroma
Supportive structures that do not directly produce cells but are there for everything else that needs to be done
Hematological Assessment
Ethnic and family history
Nutritional history
Medications
Symptoms and impact on functional ability
Assess bruising, unexplained bleeding, blood counts
Normal RBC Count
Males: 4.5-6.2 million cells/uL
Females: 4.0-5.5 million cells/uL
Normal Hemoglobin/Hematocrit
Males: 13-18 g/dL and 42-52%
Females: 12-16 g/dL and 35-47%
Normal WBC Count
4.5-11 cells/mm3
Differential: neutrophils, bands, eosinophils, basophils, lymphocytes, monocytes
“Shift to the Left” = increased immature neutrophils
Normal Platelet Count
150,000-450,000 cells/mm3
Bone Marrow Aspiration and Biopsy
Common site is iliac crest
Risk of rebleeding, risk of infection
Anemia
Hemoglobin concentration that is below normal
Not a disease, but a sign of underlying disorder
Most common hematologic condition
Hypoproliferative Anemia
Impaired production of RBCs
Tumor, bone marrow suppression, lack of EPO, long-term iron deficiency, lack of vitamin B12 and folic acid
Hemolytic Anemia
Increased destruction of RBCs
Increased bilirubin and reticulocytes
Sickle cell anemia, toxic chemicals, mechanical heart valves
Severity, Development, Complications of Anemia
Severity depends on how active the patient is; usually don’t show symptoms until less than 8
Slow development may indicate compensation (tachycardia, SOB)
Complications include heart failure, heart attack, paresthesias, confusion/delirium
Medical Management of Anemia
Treatment depends on the cause
Correct or control the cause
Supplementation and foods
Recombinant erythropoietin
Transfusions
Gerontologic Considerations for Anemia
Most common hematologic condition
Decreased mobility, increased depression, increased risk of falling, increased risk for delirium
Manifestations of Anemia
Fatigue, weakness, malaise, pallor
Jaundice
Tongue changes
Brittle, rigid, concave nails
Angular cheilosis
Stomatitis, pica
Cardiac and respiratory symptoms
Pernicious Anemia
Central and peripheral nervous system problems (paresthesia, ataxia) related to vitamin B12 deficiency needed for myelin production
Nursing Interventions for Anemia
Balance rest and activity, assist with ADLs as needed, prevent injuries associated with confusion/dizziness/weakness, encourage slow change of positions, orthostatic hypotension studies, discourage hot baths, turn q2h, try to keep them warm, look at nutrition
Nutrition for Anemia
Iron-Rich Foods (red meats, organ meats, whole wheat products, spinach, carrots)
Folic Acid Sources: green vegetables, liver citrus fruits
Vitamin B12: glandular meats, yeast, green leafy vegetables, milk and cheese
Oral Iron Use
Take iron on an empty stomach
Vitamin C increases absorption
If liquid, use straw and perform oral care
Stools may turn black
IM Iron Use
Z track method, air bubble
Do not use deltoid muscle, do not massage
IV Iron Use
Risk for anaphylaxis; may need test dose
Hypoproliferative Anemia Types
Iron deficiency anemia (most common)
Anemia in renal disease
Anemia of chronic disease
Aplastic anemia (decrease in bone marrow function)
Megaloblastic anemia
Aplastic Anemia
Decrease in bone marrow function
Primary (congenital–30%) and Secondary (infection, medication, chemicals, radiation, chemotherapy, AI)
S/S of Aplastic Anemia
Pancytopenia
Repeated infections related to decreased leukocytes
Fatigue, weakness, malaise
Dyspnea, palpitations
Bleeding tendencies
Treatment of Aplastic Anemia
Identify and remove cause
Reverse isolation, antibiotics
Platelet transfusion due to bleeding
Splenectomy
Immunosuppression (androgens, antithymocyte globulin)
Bone marrow transplant
Nursing Interventions for Aplastic Anemia
Prevent infections
Prevent hemorrhage
Keep warm
IV for hydration
Respiratory support (positioning, oxygen)
Skin care
Rest
Megaloblastic Anemia
Anemia caused by deficiencies of vitamin B12 or folic acid (both necessary for DNA synthesis)
RBCs are abnormally large
Pancytopenia
Vitamin B12 Deficiency Causes
Inadequate diet
Faulty absorption from the GI tract (Crohn’s, ileal resection, bariatric surgery, gastrectomy, PPIs, glucophage)
Absence of intrinsic factor (pernicious anemia, higher rate of gastric cancer)
S/S of Pernicious Anemia
GI (diarrhea, smooth red tongue)
Neurological: paresthesia, loss of proprioception
Vitiligo, premature graying
Treatment of Pernicious Anemia
Vitamin B12
Folic acid supplement
Iron replacement, RBC transfusion
Teach that diet cannot correct this problem, need periodic blood levels drawn
Diet high in protein, vitamins, and minerals
All anemia nursing interventions apply
Hemolytic Anemias
Life of RBC is shortened (increased reticulocytes and indirect bilirubin)
Inherited causes: sickle cell anemia, thalassemia, hereditary hemochromatosis
Acquired causes: immune hemolytic anemia, heart valve hemolysis, hypersplenism
Sickle Cell Anemia Precipitating Factors
Dehydration Overexertion Infection Cold Alcohol Smoking
Signs/Symptoms of Sickle Cell Anemia
Anemia (7-10 hgb always present)
Enlarged bones of the face and skull
Tachycardia, cardiac murmurs, enlarged heart, dysrhythmias, and heart failure
Thrombosis of any organ
Jaundice, PAIN
Complications of Sickle Cell Anemia
Infection, stroke, renal failure, impotence, heart failure, pulmonary hypertension
Vaso-Occlusive Crisis
Vessels are occluded, leads to lack of oxygenation, swelling, abdominal pain, fever
Need oxygen and pain medicine
Aplastic Crisis
Triggered by a viral infection or depletion of folic acid
Anemia worsens
Sequestration
Spleen is full of blood products
Causes problems in the liver and lungs
Fluids, rest, oxygen, pain medication
Acute Chest Syndrome
Respiratory distress, fever, increased RR, coughing/wheezing, infiltrates on the CXR
Need antibiotics
Pulmonary Hyptertension
Often the cause of death related to sickle cell anemia
Symptoms don’t show up clearly until the damage is already done
Damage is irreversible
Present with problems breathing, heart failure, microvascular occlusions throughout the pulmonary system leading to diminished perfusion of the lungs
Treatment of Sickle Cell Anemia
HSTC
Medications (Hydroxyurea, Arginine, pain medication)
Oxygen, rest, fluids
Increased need for folic acid, protein, calcium, vitamins
Education for Sickle Cell Anemia
Encourage genetic testing, avoid high altitudes, avoid dehydration and extreme temperatures, avoid iced liquids and vigorous exercise
Pregnant women are at high risk for complications
Thalassemias
Group of hereditary anemia
Defective synthesis of hemoglobin which leads to hemolysis of the blood
Treatment of Thalassemias
Blood transfusions
Bone marrow transplantation
Splenectomy
Encourage genetic counseling, prompt medical treatment for infections
Immune Hemolytic Anemia
Exposure to antibodies
Caused by hemolytic transfusion reaction, dysfunctional immune system
S/S of Immune Hemolytic Anemia
Depends on severity of anemia
Fatigue, dizziness, organs swelling, lymphadenopathy, jaundice
Treatment of Immune Hemolytic Anemia
Remove any identified cause
Corticosteroids, splenectomy, immunosuppressive drugs (last ditch effort)
Hypovolemic Anemia
Caused by losing blood
Severity depends on how much blood is lost
S/S of Hypovolemic Anemia
Thirst, weakness, irritability and restlessness, stupor, mental disorientation, physical collapse, pale clammy skin, decreased temperature, urine output decreased
Low BP, increased RR, increased HR, increased pain
Treatment of Hypovolemic Anemia
Elevate lower extremities, oxygen, replace fluid loss, give albumin or dextran or LR, encourage iron
Keep track of intake and output; minimum of 30mL/hour of urine output
Blood Transfusions
Type and Cross match; 2 nurses must double check your numbers
Whole blood: 450mL
Packed RBCs: 300-350mL, concentrated hematocrit
Platelets: 50-70mL
Plasma: helps treat shock and has coagulation factors, 200mL
Albumin helps to get blood pressures up
Polycythemia
Too many red blood cells, blood volume increases
Primary/polycythemia vera: malignancy problem
Secondary: hypoxia-driven polycythemia
Pathophysiology of Polycythemia Vera
Hyperplasia in the bone marrow; increase in circulating erythrocytes, granulocytes, and platelets
Increased risk for infections because of increased immature circulating granulocytes
Increased risk of infarctions due to sluggish circulation
Multi-organ system problem
S/S of Polycythemia Vera
Ruddy appearance, increased BP, problems with angina/chest pain/heart failure, extra clot formation, thrombophlebitis, venous distention, bleeding problems, esophageal varices, nosebleeds, GI bleeds, petechiae, hepatomegaly and splenomegaly, itching, headache, ringing in the ears, painful burning of hands and feet
Diagnostic Tests for Polycythemia Vera
Elevated
CBC, alkaline phosphate levels, uric acid levels, histamine levels
Treatment of Polycythemia Vera
Phlebotomy (1-2 times a week every week for years, 500mL-2L of blood)
Medications: chemotherapy, interferon alpha 2-b, low-dose aspirin, allopurinol
Avoid smoking and high altitudes, avoid foods high in iron
Pathophysiology of Agranulocytosis
Acute problem, potentially fatal blood disorder characterized by profound neutropenia (<2000/mm3)
Caused by chemotherapy, drug toxicities/hypersensitivities, radiation, hereditary components, viral/bacterial infections
Neutropenia
Fever would be a significant response
Treatment depends on the cause
Remove the cause of the bone marrow suppression
Prevent or treat infections
NEUPOGEN GIVEN SUBQ OR IV
Failure in Platelet Production
Localized bleeding, petechiae
Failure in Coagulation Factor
Bleeding deeper in the body
External bleeding diminished slowly
Bleeding Precautions
Avoid aspirin and aspirin-containing products, as well as alcohol
No suppositories, enemas, or tampons
Prevent constipation, vigorous sexual intercourse, anal sex, contact sports, and aggressive manual labor
Use electric razor for shaving and a soft toothbrush
Secondary Thrombocytosis
Increased platelet production
Platelet function is normal
Reactive Increase: infection, chronic inflammatory disorders, iron deficiency, malignant disease, acute hemorrhage, and splenectomy
Thrombocytopenia
Decreased thrombocyte production, aplastic anemia, leukemia
Increased destruction: immune thrombocytopenic purpura
Increased consumption: disseminated intravascular coagulation
S/S include petechiae/purpura, ecchymosis
Watch for CNS bleeds, epistaxis, spontaneous GI bleeds
Treatment of Thrombocytopenia
Treat the underlying cause
Platelet transfusions
Splenectomy: often not an option
Bleeding precautions
Immune Thrombocytopenic Purpura
Body destroys the platelets
Pharmacological management includes corticosteroids, gamma globulin, and immunosuppressive therapy
Splenectomy is helpful 50% of the time
Platelet Defects
Number of platelets normal, but do not function well
ASA: inhibits platelet function (7-10d)
NSAID: inhibits platelet function (4d)
End Stage Renal Disease: metabolic products produced affect platelet function
Pathophysiology of Hemophilia
Lack of clotting factors
Genetically induced
Hemophilia A: factor VIII deficiency
Hemophilia B: factor IX deficiency
Common in boys
S/S of Hemophilia
Chronic, crippling pain
Internal and external bleeding
Hemiarthrosis: ankylosis
Excessive blood loss from small cuts and dental procedures
Treatment of Hemophilia
Minimize bleeding and avoid trauma
Relieve pain (NO ASPIRIN)
Transfusions (Factor VIII or IX concentrate, Cryoprecipitate, manufactured factor VIII or IX)
Pathophysiology of Von Willebrand’s Disease
Disorder of coagulation; slow coagulation, spontaneous bleeds
Deficiency in Factor VIII
Common in girls
S/S of Von Willebrand’s Disease
Bleeding tends to be mucosal
Acquired Coagulation Disorders
Liver disease
Vitamin K deficiency
Complication of Anticoagulant Therapy: vitamin K antidote for Warfarin toxicity, protamine sulfate for Heparin toxicity
Acquired Coagulation Disorders
Liver disease
Vitamin K deficiency
Complication of Anticoagulant Therapy: vitamin K antidote for Warfarin toxicity, protamine sulfate for Heparin toxicity
Pathophysiology of DIC
Overstimulation of clotting and anti-clotting processes at the same time
S/S of DIC
Compromised organ function
Bleeding, hemoptysis, dyspnea, diaphoresis, cold mottled digits, purpura, petechiae
Lab Values with DIC
Low platelets and fibrinogen
Prolonged PT, aPTT and thrombin time
Elevated fibrin degradation products and D-dimer
Chronic Myeloid Leukemia
Mutation in myeloid stem cell
Uncontrolled proliferation of cells
May be asymptomatic
May be cured with stem cell transplant
Pathophysiology of Leukemia
Malignant disorder of the lymph nodes and the bone marrow
Excessive immature leukocytes that accumulate in the bone marrow and lymph nodes
Lead to problems with anemia (decreased RBCs), bleeding (decreased platelets), infection (immature WBCs)
Diagnosis based on blood count, bone marrow biopsy, CXR
Acute Myeloid Leukemia
Develops without warning over a period of weeks
S/S from insufficient production of normal blood cells
Lymphadenopathy or splenomegaly rare
Immature blast cells on marrow biopsy
Bleeding and infection are major causes of death
High mortality, can happen in young people
Chronic Myeloid Leukemia
Mutation in myeloid stem cell
Uncontrolled proliferation of cells
May be asymptomatic
May be cured with stem cell transplant
Thrombocytopenia, death in less than 5 years
Acute Lymphocytic Leukemia
Results from uncontrolled proliferation of immature cells (lymphoblasts)
Common in young children
Very responsive to treatment
50% cure rate
Chronic Lymphocytic Leukemia
Common in older adults
Most common form of leukemia in the US
S/S include lymphocytosis, enlarged lymph nodes, splenomegaly
B symptoms (fever, drenching sweat especially at night, unintentional weight loss, life-threatening infections common as disease advances)
Remission in 70% of people
Treatment of Leukemia
Leukeran, Hydroxyurea, Corticosteroids, Cytoxan
Chemotherapy, radiation
Bone marrow transplant
Lymphomas
Neoplasms of cells of lymphoid origin
Hodgkins or Non-Hodgkins
Hodgkin’s Lymphoma
Reed-Sternberg cells
S/S include enlargement of cervical lymph nodes, anorexia, weight loss, pruritus, low-grade fever, night sweats, anemia, leukocytosis
Later: all organs susceptible to invasion of tumor cells, splenomegaly, bone pain
Treatment of Hodgkin’s Lymphoma
Goal is to cure
Chemotherapy with radiation
Most are cured or have a long remission
Risk of second cancer elevated by 26%, most of which are leukemia (82%)
Non-Hodgkin’s Lymphoma
No Reed Sternberg cells
S/S include enlarged cervical lymph nodes, fever, susceptibility to infection and bleeding, night sweats, weight loss, anorexia, cachexia, anemia, pruritus, fatigue, malaise, facial swelling
Diagnosis of Multiple Myeloma
BENCE JONES PROTEIN
S/S of Multiple Myeloma
Bone pain, pathological fractures
Infection, weight loss
Anemia, bleeding
Hypercalcemia, renal failure
Pathophysiology of Multiple Myeloma
Malignancy
Excessive number of abnormal plasma cells invade the bone marrow, which leads to tumor formation, destruction of the bone, invasion of the lymph nodes, spleen, and liver
Treatment of Multiple Myeloma
Symptomatic; not curable
Corticosteroids, analgesics
Radiation, chemotherapy
IV fluids
S/S of Multiple Myeloma
Bone pain, pathological fractures
Infection, weight loss
Anemia, bleeding
Hypercalcemia (lethargic, weak, confused, depressed), renal failure
Nurses should encourage fluids to flush out the kidneys
Common Symptoms of Leukemia
Weight loss, fever, frequent infections
Easy SOB, weakness, pain or tenderness in bones/joints
Fatigue, loss of appetite, swelling of lymph nodes, splenomegaly/hepatomegaly, night sweats, easy bleeding and bruising, purplish patches/spots
Blood Transfusions
Type and cross match
Whole Blood
450mL
Packed RBCs
Last for 42 days, spin off of the plasma
300-350mL
Platelets
Last for 5 days
Taken from different people and put together
50-70mL
Fresh Frozen Plasma
Can last for up to a year
200-250mL
Cryoprecipitate
Corrects fibrinogen deficiencies
About 20mL
Albumin
Does not have to go through a filter
Increases blood volume in the vascular system
Different volumes
Dextran
Reduces blood viscosity
Used to prevent clotting
Type AB
Universal recipient
Type O
Universal donor
Nursing Care for Blood Transfusions
Need a permit and baseline vital signs
Licensed person collects from lab and checks info
RN and one other licensed nurse checks before transfusion
18 gauge needle and 0.9 NS
Given over 4 hours
Transfusion Complications
Circulatory overload
Febrile reaction
Allergic reaction
Hemolytic reaction
Circulatory Overload
Difficulty breathing, cyanosis, pink frothy sputum, distended neck veins, full bounding pulses
Stop the transfusion, call the doctor
Febrile Reaction
See temperature elevation
Most common transfusion complication
Stop transfusion, start a normal saline line, call the doctor, take more vital signs
Allergic Reaction
Starts within 30 minutes
Laryngeal edema, hives
Stop the transfusion, call the doctor, start a saline line, take vital signs, give an antihistamine
Hemolytic Reaction
Blood is incompatible; most dangerous
Occurs within 10 minutes
Burning along the vein, itching, fever, chills, nausea, chest pain, red urine, vascular collapse
Stop the infusion and call the doctor, monitor vital signs, give oxygen
Tips for Blood Transfusions
Never give meds through a blood line
All blood products must be administered using filtered transfusion administration set except for albumin
Nurse needs to make sure consent is signed
