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Adult Health II > Hematologic Deficits > Flashcards

Hematologic Deficits Flashcards

1
Q

Assessment

A
  • Symptom analysis- quality, severity
  • Past history- bleeding history, major illnesses
  • Family history- many are hereditary
  • Psychosocial history- job, hobbies, nutrition
  • Physical examination- each system
  • Labs and other tests
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2
Q

Tests

A
  • CBC (varies from men to women)
  • RBC = 4.2 - 6 million/mm2
  • —-Polycythemia, dehydration
  • Hgb = 12 - 18 g/dl
  • Hct = 37 - 50% (% in whole blood)
  • Blood loss, shock, dehydration, anemia
  • WBC = 4,000 - 9,000/mm2
  • —-Infection, leukemia, anemia, stress response
  • Platelets = 150,000 - 450,000/mm2
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3
Q

Other Blood Tests

A
  • Anemia – Iron, Iron binding, Ferritin, Folate, B12, Schilling test (B12 absorption)
  • Coagulation
  • -Platelets, PT, PTT, Thrombin time, Fibrinogen level
  • -PT used to measure what drug?
  • -PTT used to measure what drug?
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4
Q

Bone Marrow Biopsy

A
  • For blood dyscrasias
  • Number, size, shape of RBC, WBC and platelet precursors
  • Site is posterior iliac crest or sternum
  • No pre-procedure prep needed
  • Requires consent form (invasive)
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5
Q

Bone Marrow Procedure

A
  • Lateral decubitus position, betadine prep
  • Local anesthesia, small incision with scalpel
  • Needle with obturator inserted into bone with back and forth pressure
  • Aspiration done first – very painful
  • Marrow biopsy last – looks violent
  • Mild pain meds may be needed
  • Pressure on site until bleeding stops
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6
Q

Know what position you have the patient get into for Bone marrow biopsy and aspiration

A

Look in book

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7
Q

Blood Cells

A

-Erythrocytes
-Leukocytes
neutrophils, basophils, eosinophils, monocytes, and lymphocytes
-Platelets
-Bone marrow produces all the blood cells and platelets

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8
Q

Stem Cell Theory

A
  • Pluripotential stem cells divide into myelocyte stem cell line and lymphoid stem cell line
  • Myelocyte stem cell line differentiates into precursor cells for erythrocytes, leukocytes and platelets
  • A myelocyte stem cell population is maintained within the marrow
  • Lymph cells leave the marrow
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9
Q

Hematopoiesis

A
  • Many things can go wrong along the way to the production of individual cells
  • Examining cells under microscope can help identify a problem
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10
Q

Dietary Substances needed for Erythropoiesis

A
  • Vitamin B12
  • Folic Acid
  • Iron
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11
Q

Vitamin B12

A
  • Found only in animal products
  • Necessary for the action of folic acid
  • Absorption of Vitamin B12 by the intestines requires presence of a protein called “intrinsic factor” secreted by parietal cells of stomach
  • Vitamin B12 also required for normal myelin formation in the nervous system
  • Lack of Vitamin B12 results in pernicious anemia.
  • —Another form of megaloblastic anemia (macrocytic)
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12
Q

Folic Acid

A

-Vitamin found in green leafy vegetables, yeast, liver
-Essential for the formation of the nucleotide base thymine.
-Therefore any rapidly proliferating tissue such as bone marrow affected by low dietary folic acid.
-Lack of folic acid results in maturation failure anemia - also known as megaloblastic anemia
-Appearance of large, immature RBC’s
What else results from folic acid deficiency?

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13
Q

Iron

A
  • Source-ferritin, the storage form of iron
  • Ferritin is iron combined with protein apoferritin
  • Ferritin stored in the liver until needed
  • Transported to bone marrow via another transporter protein called transferrin
  • Iron moves into bone marrow cells
  • While transferrin is recycled
  • Lack of iron results in microcytic anemia - small erythrocytes
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14
Q

Anemia- Dec. RBCS

A
  • Blood loss (chronic or acute)
  • Destruction of RBC’s
  • Poor RBC production
  • –RBC production requires:
  • —-Precursors cells
  • —-Adequate iron
  • —-B12 & folic acid
  • —-Pyridoxine (Vitamin B6)
  • —-Copper
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15
Q

More Food Issues

A

-Iron- organ meat, poultry, fish, green leafy veggies, fortified cereals and grains
-B12 - needed to produce blood cells and maintain nervous system- meat, eggs, dairy (animal products)
-Folic Acid- prevents nerve birth defects. -Folic acid is also essential for RBC production Enriched grains, green leafy veggies, papaya, strawberries
Pyridoxine- banana, carrots, nuts, beans, meat, poultry, fish
Copper- breads, cereals, dried fruits, liver, beans – DON’T OVERCOOK

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16
Q

Pathophysiology of Anemia

A
  • Impaired oxygen transport
  • Body compensates
  • –Distribute O2 to vital tissues
  • –Increase cardiac output (rate, stroke volume)
  • –Increase RBS production
  • Symptoms occur when compensation fails to keep up
  • Hemoglobin in blood, myoglobin in muscle
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17
Q

Multi-System Effects of Anemia

A
  • Neurologic- H/A, fainting, paresthesias
  • Respiratory- dyspnea,  rate
  • Cardiovascular- tachy, CHF, palpitations
  • Gastrointestinal- N&V, splenomegaly
  • Urinary- hematuria
  • Musculoskeletal- night cramps, fractures
  • Integumentary- jaundice, petecchiae, spoon shaped nails, red beefy tongue, leg ulcers
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18
Q

Nursing Diagnoses- Anemias

A
  • Altered tissue perfusion- vitals, skin temp, pulse ox, cyanosis, keep warm
  • Altered nutrition- protein, iron, vitamins
  • –Liver, oysters, kidney beans, greens, grains
  • Risk for falls- monitor activity tolerance
  • Activity intolerance- plan activities
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19
Q

Treatment of Anemias

A
  • Find and treat cause
  • –Replace minerals
  • –Nutritional support
  • Find source of bleeding
  • Blood transfusion
  • System support
  • –Oxygen
  • –IV fluids
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20
Q

Iron Deficency Anemia

A

-Poor absorption or excessive loss of iron

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21
Q

Pernicous Anemia

A

-Poor absorption of vitamin B12 due to absence of intrinsic factor- leads to low H&H, GI problems (gas), neuro symptoms

22
Q

Aplastic Anemia

A
  • Bone marrow without erythroid, myeloid, megakaryiocytic (platelet) cell lines
  • X-rays, some antibiotics, chemo
  • Requires transfusions until bone marrow produces cells again
23
Q

Hemolytic Anemia

A
  • As RBCS are destroyed, kidneys are taxed to get rid of cell byproducts and often renal failure ensues
  • Bone marrow can’t keep up with RBC loss
24
Q

Thalassemia

A

-Genetic disorder leading to inadequate hemoglobin production

25
Q

Sickle cell disease

A
  • cells sickle in low oxygenation
  • chronic anemia, painful joints
  • Crisis induced by stress, cold temps, infection, hypoxia
26
Q

Polycythemia Vera

A
  • Over production of erythrocytes, leukocytes, platelets due to stem cell stimulation
  • Hematocrit over 55 (37-50 is normal)
  • Thick blood, large blood volume, organ congestion
  • Red complexion, dizziness, headache, visual disturbances, painful joints
27
Q

Polycythemia Treatment

A
  • Phlebotomy, myelosupressive drugs, radiation therapy
  • Primary- uncommon disorder of increased RBC production
  • Secondary- response to elevated erythropoetin levels- from living in high altitude, smoking, COPD
28
Q

Aplastic Anemia

A
  • Reduced bone marrow function – all three cell lines
  • Cause poorly understood
  • Genetic failure
  • Or trauma to stem cells (radiation, chemotherapeutic agents, antimicrobial, anticonvulsant and anti-inflammatory drugs implicated)
29
Q

Symptoms of Aplastic Anemia

A
  • Weakness, dyspnea, headaches common
  • Impaired immune function and bleeding seen
  • Bone marrow transplant - helpful in extreme cases
  • Discontinued use of causative agent helpful
  • Prognosis depends on degree of damage to bone marrow
30
Q

Sickle Cell Trait and Disease

A
  • Inherited disorders characterized by structural defects of hemoglobin
  • Individuals with sickle cell trait are asymptomatic unless the patient suffers an hypoxic episode
  • Disease results in abnormal shape of the RBC’s when exposed to low pO2 levels.
31
Q

Sickle Cell Disease

A
  • When reoxygenated, cells may assume normal shape
  • After several cycles, cells become permanently sickled
  • What happens to sickled cells?
  • —Bilirubin levels?
32
Q

Coagulation Disorders: Idiopathic Thrombocytopenia Purpura

A
  • Idiopathic (immune) thrombocytopenia purpura
  • Platelets below 100,000 (150,000-450,000)
  • Below 20,000 can cause spontaneous bleeding
  • Prolonged bleeding time
    • antibody screening (immune disorder)
  •  megacaryocytes – precursors to platelets
  • Cerebral hemorrhage, nose/GI bleed, nerve pain, paralysis
  • Treat with steroids, plasmapheresis, platelets, splenectomy, because spleen is site of platelet destruction and antibody production
33
Q

Nursing for Coagulation Disorders

A
  • Ineffective protection
  • Vitals, skin, oral mucosa, blood in urine/stool, bleeding from puncture sites, bruising from B/P
  • Neuro changes- H/A, change in LOC
  • No rectal temps or rectal meds
  • Limit catheterization
  • Limit IM’s, blood draws or use small bore needle
  • Electric razor
34
Q

Nursing Continued

A
  • Impaired oral mucosa
  • Discomfort when eating
  • Assess for wounds/bleeding
  • Soft-bristle toothbrush, toothette
  • Rinse with saline q 2-4 hrs
  • Apply vasoline to lips
  • No mouthwash- alcohol
  • No hot, spicy, or crusty foods
35
Q

Blood Transfusion

A
  • Replacing blood provides healthy cells for O2 transport (or platelets or plasma cells)
  • Venous access, NS, 20 gauge or larger
  • Type and crossmatch
  • Confirm with 2 RN’s (not LPN)
  • -ABO
  • -Rh factor
  • -TXM number (red arm band)
  • -Patient name
  • -Hospital number
  • -Expiration date of blood product
36
Q

Process of Transfusion

A
  • Start IV (assure current IV is patent)
  • Use blood tubing and NS- filter
  • Confirm with 2 RN’s
  • Baseline vitals
  • Must start the blood within 30 min of leaving blood bank
  • Start blood, infuse over 2 hrs (125ml/hr)
  • First 10-15 minutes is most critical, RN stays in room
  • Vitals q 15 min X2, q 30 min
  • Never hang blood for more than 4 hours
37
Q

Tranfusion Reaction

A

-Allergic- foreign proteins
Flushing, itching
-Febrile- sensitive to WBC, platelets or plasma proteins
Fever, sudden chills, H/A, muscle pain
-Acute hemolytic (rare)- ABO incompatibility
Chills, fever, low back pain, ↑ HR, ↑ RR, vascular collapse, Renal failure, shock, death
-Anaphylactic (very rare)- antigen/antibody reaction
Anxiety, itching, wheezing, cardiac arrest
* Reaction increases with multiple transfusions, immunosuppression, multi-system failure

38
Q

Nursing Care for Suspected Transfusion Reaction

A
  • Stop blood, run NS IV @ KVO
  • Best to get all new tubing
  • Continue to monitor vitals
  • Listen to lung sounds, neuro assessment, assess pain
  • Document carefully, specifically
  • Notify Lab (send blood bag and tubing)
  • Notify physician
39
Q

Disseminated Intravascular Coagulation (DIC)

A
  • Fibrin deposits in arterioles and capillaries – widespread clotting
  • Hemorrhage from kidneys, brain, other organs leading to activation of clotting factors
  • SEEM IN OPPOSITION
40
Q

Causes of DIC

A
  • Shock
  • Sepsis *
  • Cirrhosis
  • Glomerulonephritis
  • Transfusion reaction
  • Severe trauma
  • Heat stroke
  • Abruptio placentae
  • Acute leukemia’s
  • Prostate cancer
  • Bronchogenic cancer
  • Transplant rejection
41
Q

Pathophysiology of DIC

A
  • Very complex syndrome
  • Almost always a secondary event from activation of one of the coagulation pathways
  • Underlying pathology creates a triggering event: Either-
  • – endothelial tissue injury (Extrinsic)
  • –blood vessel injury (Intrinsic)
42
Q

DIC CONT:

A
  • Thrombosis-brief period of hypercoagulability
  • Coagulation cascade is initiated, causing widespread fibrin formation
  • Microthrombi are deposited throughout he microcirculatory
  • Fibrin deposits result in tissue ischemia, hypoxia, necrosis
  • Leads to multi organ dysfunction
43
Q

DIC CONT:

A
  • Fibrinolysis-period of hypocoagulability (the hemorrhagic phase)
  • Activates the complement system
  • Byproducts of fibrinolysis (fibrin/fibrin degradation products) further enhance bleeding by interfering with platelet aggregation, fibrin polymerization, & thrombin activity
  • Leads to Hemorrhage
44
Q

Pathologic Pathway:

A
  • Extrinsic (endothelial)
  • -Shock or trauma
  • -Infections ( gram positive and gram negative sepsis, aspergillosis)
  • -Obstetric complications (eclampsia, placenta abruptio, fetal death syndrome)
  • -Malignancies: APML, AML, cancers of the lung, colon, breast, prostate)
45
Q

Pathologic Pathway:

A
  • Intrinsic (blood vessel)
  • -Infectious vasculitis (certain viral infections, rocky mountain spotted fever)
  • -Vascular disorders
  • -Intravascular hemolysis (hemolytic transfusion reactions)
  • -Miscellaneous: snakebite, pancreatitis, liver disease
  • -Vascular surgery
46
Q

Signs and symptoms

A

Most common sign of DIC is bleeding

  • manifested by ecchymosis,petechiae,and purpura
  • bleeding from multiple sites either oozing or frank bleeding
  • cool and or mottled extremities may be noted
  • dyspnea and chest pain if pleura and pericardium involvement
  • hematuria
47
Q

Management of DIC

A
  • Correct precipitating problem- sepsis, etc
  • Reverse pathologic clotting (heparin, other coagulation inhibitors) *Usually the first step, and somewhat controversial
  • Control bleeding (Fresh Frozen Plasma, platelets, factor V, factor VIII)
  • Plasma contains all of the clotting factors, but no red cells, no white cells and no platelets
  • Plasma (250 ML) is frozen 8 hrs after collection so that all cells remain healthy
  • Plasma can reverse effects of coumadin
  • Blood transfusions- usually packed cells
48
Q

Nursing Issues with DIC

A
  • Skin, sub-Q bleeding
  • INC. resp rate, hemoptysis, rales in bases
  • INC.heart rate, hypotension
  • GI bleeding, GU bleeding
  • Bleeding from IV sites
  • Neuro changed: vision, dizziness, headache irritability, mental status changes
  • Avoid injections, turn carefully, no rectal temps or rectal meds
  • Provide emotional support – this is really scary.
49
Q

Final Exam

A

Review the last two lectures in detail. There are about 45 questions from those two lectures.
It would be helpful to review previous exams. Exact questions will not be used on the final but similar concepts will be seen on the final.
You might want to review the assigned NCLEX questions that you have been reviewing in your clinical groups. There will be some familiar questions from there on the final.
Review DKA and HHNS. Know the causes, and how they are generally treated.

50
Q

Final Exam

A

Review head injury, brain hemorrhage, and increased ICP. Review the differences in symptoms with the various brain bleeds, and nursing interventions for increased ICP.
Know lab values: hemoglobin, hematocrit, WBC, platelets, calcium
Be able to identify symptoms of hyper and hypothyroidism, hyper and hypoparathyroidism, and hyper and hypo adrenal function, including Grave’s, Cushing’s, and Addison’s diseases.
Review Diabetes Insipitus, and inappropriate ADH- be able to identify symptoms and possible causes.

51
Q

Final Exam

A

Review pheochromocytoma.
Differentiate between right and left heart failure, to include symptoms and treatments (including medications).
Review valve disease and rheumatic fever, and know symptoms. Don’t concentrate on murmurs in detail, but understand what happens with the various valve disorders.
Review EKG interpretation. Know how to measure a strip to evaluate it. Know the major treatments for the life-threatening rhythms: V-fib, V-tach, bradycardia.

52
Q

Final Exam

A

Be able to interpret ABG’s.
Review osteoporosis, osteoarthritis, and Systemic Lupus.
Know the rule of nines.
Know symptoms of chronic and acute renal failure.
Review symptoms of ARDS, use of chest tubes, tension pneumothorax
I did not give you EVERY concept, but these are the major ones.

Adult Health II (7 decks)

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