Hematologic Disorders Flashcards by Kelsey Klipfel

Look at Gas Exchange and Tissue Perfusion
Blood (RBC) oxygen delivery system to body
RBC contain Hemoglobin which exchanges Oxygen and Carbon Dioxide at the cellular level so cells can make ATP and energy
Any interruption of this process creates disease/disorder

Hematologic disorders: direct concepts

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Heme needs iron to transport oxygen
Four molecules of oxygen can attach to one Heme
Globin carries carbon dioxide; carbon dioxide/carbon monoxide more affinity to heme and will kick O2 out - if in a fire - not go off SpO2 because looking at number molecules attached to heme

RBC contain Hemoglobin which exchanges Oxygen and Carbon Dioxide at the cellular level so cells can make ATP and energy

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Anemia
Types of anemia
Symptoms of anemia

Hematologic disorders: RBC disorders

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Shown by Reduction of RBC, Hgb, and/or Hct
Clinical sign – not a specific disease
Classifications look at
Blood loss
Hemolytic - lysis of RBC
Impaired RBC production

Anemia

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Iron-deficiency (microcytic - small blood cell)
Hemolytic - lysis of the blood cells
Megaloblastic (macrocytic - large blood cell)
Aplastic anemia (bone marrow depression)
Chronic disease anemias

Types of anemia

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Due to Blood loss; poor nutrition

Iron-deficiency (microcytic - small blood cell)

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Immune, due to mech. Trauma - broken open the blood cells, sickle cell

Hemolytic - lysis of the blood cells

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Vitamin B12 (Cobalamin) deficiency
Pernicious anemia-lack intrinsic factor
Folic acid deficiency

Megaloblastic (macrocytic - large blood cell)

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Ex: Chronic renal failure - kidneys can no longer produce EPO and stops production of RBC - given Epogen - leading to anemia

Chronic disease anemias

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Fatigue
Dizziness
Fainting - lack oxygen carrying capacity
Low BP - hypotension
Hypovolemia
Heart palpitations - rapid HR
Chest pain due to low O2 delivering capacity
angina/chest pain - due to low O2 delivering capacity
Heart attack - due to low O2 delivering capacity
Muscular weakness
SOB
Persons of color - notice - yellowing in the eyes for anemia

Symptoms of anemia

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Genetic disorder of hemoglobin (HgbS) causing distortion of RBC shape (sickle) in response to decrease O2 - make sickle shape - make C-shaped RBC
Autosomal recessive
Anemia due to abnormal Hgb - cannot carry O2
Vaso-occlusive events - Cs clump together easily
Sickle cells: sticky/fragile; clump together; occlude blood vessels
Leads to anoxia, ischemic infarctions, end-organ damage - looking at PE, MI, stroke; lodging in renal artery = kidney disease

Patho - Hematologic disorders: sickle cell anemia (SCD)

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Cerebral infarts/strokes
Pulmonary infarts/PE
Splenomegaly - blood cells build up in the speen causing it to not work causing autosplenectomy - cause from disease - damage to spleen and organ shrinks and non-functional
Renal infarts
CHF
Bone marrow hyperplasia
Vascular occlusions - ulcers and extremity infartions
Severity varies - depending on what going on
Periodic crises - usually recovers
Precipitating Conditions (triggers):

Clinical Manifestations and Triggers - Hematologic disorders: sickle cell anemia (SCD)

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Hypoxia states - low O2
High altitudes
Dehydration
Venous stasis - blood not moving around; sickle cells can clump together
Physical/emotional stress
Anesthesia
Diff types of Infections
Low or high environmental or body temperatures

Precipitating Conditions (triggers): - Hematologic disorders: sickle cell anemia (SCD)

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Pain management - opioids (look out for constipation)
Oxygen - caused sickling of cells in first place
Hydration - prevent sticking together and clumping
Body positioning - not bend pts at any pt - bending pts allow cells to clump
Prevent infection
Blood transfusion - esp if pt is having major symp: SOB not tolerable or Hgb less than 7.5
Hydroxyurea (Reduces sickling of cells) - antimetabolite; can increase risk of cancer within infants; make sure not get pregnant
Teaching
Emotional Support
Supportive care

Med-surg - Hematologic disorders: sickle cell anemia (SCD)

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To prevent crisis - staying well hydrated; not go and get into position where lack O2; infected need to come to doc to prevent this
Manage drugs
Women BCP with Hydroxyurea
Heredity aspects

Teaching

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Good
Have disease for rest of live
Lot lose hope

Emotional Support

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Available
Understanding what happening with pt
Lot hospitals have sickle cell clinics that understand these pts

Supportive care

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Acute Pain - cells clotting off and causing ischemic areas; lack tissue perfusion
Ineffective peripheral tissue perfusion
Deficient Fluid volume - give additional fluids
Activity intolerance
Risk for decreased Cardiac tissue perfusion - MI, chest pain
Risk for Infection
Risk for ineffective cerebral Tissue perfusion - stroke

N. diagnosis - Hematologic disorders: sickle cell anemia (SCD)

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Administer oxygen
Administer pain medications
Do not bend the client to allow for non-constricted blood flow
Check circulation of peripheral extremities
Assess for signs of central claudication - chest pain, lack of LOC, suspect PE
Keep patient warm - NOT HOT; no heating pads; warm clothing
Administer IVF or PO fluids

N. interventions - Hematologic disorders: sickle cell anemia (SCD)

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Doing Complete Blood Count with differential and RBC indices (indices good at whether saying large/small RBC)
Reticulocyte Count - look at how fast RBC made by bone marrow
Iron Studies - ferritin iron, transferritin, total iron binding capacity
Coomb’s Test - hemolytic anemia - look at antibodies on surface of RBCs
Bone marrow aspiration - tell us if anything in bone marrow or stimulation of bone marrow that is preventing blood cells from being made

Diagnostics review - Hematologic disorders: anemia

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Red blood cells
Hemoglobin
Hematocrit
RBC indices

Anemia labs

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4.2-6.1
Decreased: anemia/bleeding
Increased: severely dehydrated/PV

Red blood cells

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12-18 g/dL
Decreased: anemia/bleeding/fluid overload
Increased: severely dehydrated; PV

Hemoglobin

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37-52%
Decreased: anemia/bleeding/fluid overload
Increased: severely dehydrated; PV

Hematocrit

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Good look at these to see what is going Relate measurements of RBC, hematocrit, and hemoglobin; provides information on types of anemia

RBC indices

Determine underlying cause Iron deficiency Vitamin B Blood loss Immune Chronic Disease

Med-surg: - Hematologic disorders: anemia

Mild: Oral ferrous sulfate (iron) - give with some food since taste horrible and hard on belly Vitamin C enhances absorption; take between meals Hgb should rise 2 g in 4 weeks Severe: IV or IM iron dextran (IM use the Z track method - not leak back out); IV - esp on initiation - had be on tele and BP checked frequently because high rate rxn

Iron deficiency

Diet changes (high in liver, chicken, beef, tuna, or eggs), oral supplements, injections

Vitamin B

Stop bleeding; transfusions - mass trauma

Blood loss

Immunosuppressive therapies (incredibly high risk for infection - pushing down immune sys so not go into autoimmune state and attack), transfusions, BM transplant

Immune

(Chronic Kidney Disease/cancers) Erythropoietin (Procrit/Epogen) injections - stim EPO

Chronic Disease

Gather history (past of assessment), diet, meds (chemo or something that may drive down blood production), menstrual flow (what like), any symptoms/manifestations Assess for:

Assessment - Hematologic disorders: anemia

Fatigue, pallor, cyanosis, jaundice (good sign of hemolytic anemia - heme outside blood causing skin turn yellow, bleeding, dry skin, Mouth ulcers or fissures, smooth tongue (glossitis) Lymph nodes involvement (infection/cancer), resp. rate and rhythm - low blood volume/inability care O2, tachycardia - low blood volume/inability care O2 VS, O2 sat - not always exactly right - if change CO2 or carbon monoxide poisoning, gen review labs

Assess for:

Activity intolerance Fatigue Any type Altered tissue perfusion Impaired gas exchange - low Hgb Anxiety Impaired comfort Risk for Bleeding Risk for injury Impaired Memory

N. diagnosis - Hematologic disorders: anemia

Apply Oxygen Oral or IM or IV iron Supplements (Vit B, Folic acid) Epoetin (Procrit) SQ weekly - after dialysis session often RBC transfusion (Hemoglobin < 7.5, transfuse higher Hgb if pt extremely symptomatic: not able breathe, confused, lack O2 getting to periphery)

Interdisciplinary interventions - Hematologic disorders: anemia

Energy conservation Good Supportive care - taking care what going on with pt Correction of the anemia EX: Diet changes Teaching pt good self-care

N. interventions - Hematologic disorders: anemia

Loss of cellular regulation; proliferation of RBCs, WBC, Platelets Also known as pan - means all Blood hyper viscous (thick) blood Clinical Manifestations: Complications (thick blood) Medical N. interventions Contact doctor first sign of infection or occlusion Exercise slowly Interdisciplinary N. diagnosis

Hematologic disorders: primary polycythemia vera

Causes Poor oxygenation of tissues due to poor circulation; cell destruction RBC >16.5g/dl; Hgb > 18g/dl; Hct >55%; high K (norm 3.5 -5 mEq/L); high uric acid; high Hgb, Hct, K, uric acid

Blood hyper viscous (thick) blood

Hypertension (beat and push hard to get stuff out into circ - lot pressure in vessels); headaches (thick blood pushed through brain, HTN); dizziness (lack O2); purple/gray color (lack O2); itching, dyspnea

Clinical Manifestations:

Angina/chest pain, claudication (stopping of O2 - clotting areas of body), thromboses; infarctions: MI, intracranial bleeds/CVA - ischemic

Complications (thick blood)

Repeated apheresis 2 to 5 times week - actual bleeding, medications: Hydroxyurea - keep sickle cell shape norm, anticoagulants - thin blood so circ normally

Medical

Prevent clots - give anticoags, wear SCDs, get up and move as much as possible Hydration (3 L day) - 2-4 L qday Stop smoking = causes venous stasus Promote venous return Elevate feet or SCDs worn; esp if have varicose veins - push blood back up Avoid tight clothing Support hose - help muscles of legs push blood up Thrombocytopenia precautions - bleeding precautions - on anticoags; bleeding risk - Use electric razor, soft toothbrush Neutropenic precautions - higher risk for infection

N. interventions

Stop activity at first sign of chest pain (call 911) or dizziness

Exercise slowly

Anticoagulants Chemotherapy - stop overproduction

Interdisciplinary

Ineffective protection Risk for bleeding and infection Risk ineffective tissue perfusion

N. diagnosis

Precancerous state Abnormal cell formation in bone marrow; once out into body and released completely destroyed by body after release; decrease in all blood cell types (aka pancytopenia) 30% risk develop acute leukemia Risk Factors: Diagnosis: Medial Treatment

Hematologic disorders: myelodysplastic syndrome (MDS)

>65 yrs, exposure to chemicals (esp pesticides, benzene), tobacco smoke, chemotherapy/radiation

Risk Factors:

Cytogenetic testing - looks at chromosomes that id’d abnormal Peripheral blood smears - look at cell abnormalities

Diagnosis:

Supportive care Blood/platelet transfusions; Epogen (Procrit) injections Allogeneic hematopoietic stem cell transplant only curative treatment issue for MDS Immunomodulatory agents Medication: immuran

Medial Treatment

Local bleeding - petechiae Easier to control EX: idiopathic thrombocytopenic purpura (ITP) - immune system destroys platelets, thrombotic thrombocytopenic purpura (TTP) - platelets clump abnormally - causing clots - then body runs out

Platelet disorders: - Hematologic disorders: Platelet and clotting disorders

Occurs deeper in body: joint spaces: SQ; deep bleeds difficult to control and often restarts EX: hemophilia, heparin induced thrombocytopenia

Clotting factors disorders - Hematologic disorders: Platelet and clotting disorders

Normal platelets: 150,000-400,000/mm3 Decreased production Increased destruction Increased consumption

Reasons - Hematologic disorders: platelet disorders

Happen because Cancers and treatment - common with chemo; aplastic anemias; toxins; meds; alcohol decreases production

Decreased production

Autoimmune issue Infections; meds; spleen disorder; cancers

Increased destruction

Body make enough but body chewing them up and decreasing them Disseminating intravascular coagulation (DIC) - making microvascular clots and running out of platelets

Increased consumption

Too few Diff levels 40,000-80,000 /mm3: Risk for bleeding with mild trauma <20,000: Risk for spontaneous bleeding <5000/mm3 risk for fatal bleed in CNS or GI hemorrhage - have someone who suddenly becomes confused - worry about bleeding in brain Exemplar Idiopathic Thrombocytopenic Purpura (ITP)

Thrombocytopenia - Hematologic disorders: platelet disorders

Too many Platelet count above normal > 600,000/mm3 HIGH Risk for clotting Exemplar Thrombotic Thrombocytopenic Purpura

Thrombocytosis - Hematologic disorders: platelet disorders

Autoimmune Disorder Patients make antibodies against own platelets; macrophages destroy - chewing up platelets Diagnosis: serial low platelets levels & BM biopsy - BM putting out norm rate but body chewing them up Treatment:

Hematologic disorders: idiopathic thrombocytopenic purpura (ITP)

Triggers: Viral infections thought to trigger condition Most common in women 20-40 yrs

Patients make antibodies against own platelets; macrophages destroy - chewing up platelets

Immunosuppressive drugs (prednisone - INFECTION), platelet transfusion, splenectomy (last resort - destroyed pieces of platelet stored in spleen and going to swell and could rupture)

Treatment:

Platelets to clump together abnormally in capillaries and too few available in circulation Inappropriate clotting but also fails to clot when trauma occurs - not necessary but then when need it not available Tissue becomes ischemic may lead to kidney failure, MI, CVA; untreated fatal in 3 months

Autoimmune disease: - Hematologic disorders: thrombotic thrombocytopenia purpura

Plasmapheresis, fresh frozen plasma to provide platelet aggregation inhibitors; platelet inhibitor drugs

Treatment: - Hematologic disorders: thrombotic thrombocytopenia purpura

X linked recessive trait; Women carrier (50% chance of passing gene to offspring)

Genetic disorder 1 in 10,000 - Hematologic disorders: hemophilia

Type A- factor VIII (8) deficiency (80% of cases) Type B –factor IX (9) deficiency (20% of cases)

Types - Hematologic disorders: hemophilia

Abnormal bleeding to any type of trauma, specifically in the joints Bleed longer than normal Problem forming stable fibrin clot - allow for extensive bleeding

Symptoms: - Hematologic disorders: hemophilia

Complication most common Joint problems from repeated episodes of bleeding Diagnosis PTT prolonged Treatment Replace missing factor with infusion of synthetic factors

Medical management - Hematologic disorders: hemophilia

Minimize trauma and other causes of bleeding Assess for signs and symptoms of bleeding - esp in joints Interdisciplinary

N. management - Hematologic disorders: hemophilia

Thrombocytopenia/bleeding Precautions Risk assessment- Protect patient from injuries - padding side rails; not up by self

Minimize trauma and other causes of bleeding

Prepare to administer platelet transfusions for counts below < 10,000 mm3 Replace missing clotting factors with infusion of synthetic factors Educate patient and family: risk for bleeding and how reduce risk for trauma

Interdisciplinary

PT INR PTT

Clotting time

Ref range: 11-12.5 sec Significance: prolonged: warfarin therapy; clotting factor deficient; liver failure Most stacked with INR Looks at clotting factors II, V, VII, X WARFARIN THERAPY; LIVER FAILURE

Ref range: 0.8-1.1 Significance: standard measure for PT WARFARIN THERAPY; LIVER FAILURE Most stacked with PT

INR

Ref range: 60-70 sec Significance: prolonged: heparin therapy; clotting factor deficient (hemophilia); autoimmune: ab attack clotting factors HEPARIN THERAPY; HEMOPHILIA; AUTOIMMUNE DISORDERS Looks at clotting factors II, V, VIII, IX, XI, XII

PTT

Leukemia Lymphoma Multiple myeloma

Hematologic disorders: cancers of the blood

Uncontrolled cell production Cancer occurs in stem cells of bone marrow; overcrowded with nonfunctional blood cells - lot of them but not functional Overproduction of blasts cells (immature WBC - called blasts) Exact cause unknown; many/may be genetic and enviornmental factors involved 50% of pts have abnormal chromosomes Normal cell production decreased result in: Infiltration tissues/organs Norm cell production increased Classifications Type Risk factors Diagnosis CM Diagnosis: bone marrow aspiration - for leukemia Medical treatment

Leukemia

Pancytopenia Neutropenia Anemia Thrombocytopenia

Normal cell production decreased result in:

Acute: Sudden onset abnormal blood cells Chronic: Abnormal cells replicate slowly Classified by Cell type Lymphoid cells: Lymphocytic Myeloid cells: Myelogenous

Classifications

Acute Lymphocytic Leukemia (ALL) Most common type in young children Acute Myelogenous Leukemia (AML) Most common type of in all adults Chronic Lymphocytic Leukemia (CLL) Most common chronic adult leukemia Chronic Myelogenous Leukemia (CML) Asymptomatic for years before entering a fast growth phase

Type

Prior exposure chemotherapy or ionizing radiation - previous cancer Bone marrow hypoplasia/slow growth Genetic factors (Down syndrome) Immune deficiency Virus

Risk factors

CBC Abnormal WBC count; High blast cells show poorer prognosis Low Hgb & Hct and platelets Bone Marrow Biopsy Definitive test Chromosome analysis - diff things on chromosome that can lead to pt having leukemia Other x-rays, CAT scans, MRI

Diagnosis

Weight loss Fever Frequent infections - no control over cells any longer SOB - low cell production Muscular weakness bone/joint pain Fatigue Loss of appetite spleen/liver enlargement - both/one - r/t engulfment of diff cells that need to be destroyed/cleaned Swelling with lymph nodes Skin: night sweats, easy bruising/bleeding, puplish patches/spots

Provides information to pt about what expect with procedure; blood cells and production Nursing: Teach patient what to expect Position Sedative provided Local anesthetic injected - both needle and incision made Follow-up Care Look at area incised - no more bleeding Control bleeding Inspect site every 2 hours Pain control BM provide info about blood cells and production

Diagnosis: bone marrow aspiration - for leukemia

Induction Therapy Intense chemotherapy started as soon as diagnosis confirmed Hospitalized 2-3 weeks in protective isolation - drive down and suppress bone marrow SE: Severe bone marrow suppression, alopecia N&V, stomatitis, can cause organ toxicity - kill fast growing cells Recovered: Consolidation Therapy: Repeat drugs or Bone Marrow Transplant Maintenance therapy: Months and years to maintain remission

Medical treatment

Cancer of lymphocytes Two main types: Many subtypes of both Hodgkin’s lymphoma Non-Hodgkin’s Lymphoma

Lymphoma

Hodgkin's lymphoma (HL) Teens and adults in 50-60s Non-Hodgkin's lymphoma (NHL) All other lymphomas (over 60 types) Older adult men Variety lymph nodes affected

Two main types:

Starts in single lymph node in neck underarm or chest Proceeds in orderly fashion to next lymph node Fatigue, anorexia, short of breath “B” symptoms: sweats, fever, itching, weight loss Pain in lymph node areas after alcohol intake

Signs/Symptoms - Hodgkin’s lymphoma

Viral infections; chemical exposure

Risk Factors: - Hodgkin’s lymphoma

External radiation and Chemotherapy Curable

Treatment - Hodgkin’s lymphoma

Lymphadenopathy in multiple sites - swelling of lymph nodes in multiple sides Spread to other organs at time of diagnosis most time

Symptoms: - Non-Hodgkin’s Lymphoma

Autoimmune disease and immunosuppressive disorders, viruses (HIV, EBV - ebstein barr), chemicals

Risk factors: - Non-Hodgkin’s Lymphoma

Chemotherapy/monoclonal antibodies; radiation Chronic disease/not curable

Treat: - Non-Hodgkin’s Lymphoma

Overgrowth of plasma cells (PC) PC overproduce gamma globulin (gammopathy) - excess in antibodies in blood clog blood vessels of kidneys and other organs - clog in blood vessels and infect organ Produce excess cytokines - increase cancer growth rate and destroy bone - destroy higher level of calcium Diagnostic tests - serum electrophoresis test detects monoclonal immunoglobulin; bone marrow biopsy: greater than 10% infiltrated plasma cells; X-ray: osteolytic bone lesions CM Treatment Nursing

Multiple myeloma

Early signs Fatigue Anemia Easy bruising Bone pain Infections Later Bone fractures Kidney dysfunction due to cells going in and infection HTN Rare: hypercalcemia, hyperviscosity syndrome - can happen - Leads to progressive bone destruction, bleeding, kidney failure, immunosuppression, and death

Chemotherapy agents Bone marrow transplant Incurable

Treatment

Care of immunocompromised patient Pain control

Nursing

Infection protection Thrombocytopenic precautions - bleeding Energy conservation Teach good self care Stay out crowds or to HCP if look like have an infeciton Good Psychosocial support

Hematologic disorders: nursing care for leukemia, lymphoma, and multiple myeloma

Prophylactic Drugs: antiviral, antibiotic, antifungals Neutropenic precautions Monitor labs daily Monitor for early manifestations of infection Good Hygiene/skin care

Infection protection

Teach risk/signs of infection/how to prevent - how reduce risk Avoid crowd, children/ill people/wear mask Hand hygiene/good personal hygiene/mouth care Avoid constipation/shaving with blade –use electric shaver Do not handle feces (clean cat litter/bird cage/dog, etc.) No fresh flowers or plants/No gardening - dirt harbors infective process Non invasive procedures - unless not helped No sexual relations Discuss food safety (No fresh fruits/vegetables/raw meat/eggs/some cheeses) Pt should have thermometer and know how to use it Who to notify and when (report temp greater than or equal to 100.5 degrees F, chills, signs of illness or infection) Weekly labs Administer growth factor as directed to stim neutrophil regeneration

Hematologic disorders: neutropenic precautions

Risk for injury: Risk factors: abnormal clotting Assess for S/S of bleedin - Bruises/nose/gums/blood in urine/blood in stool/severe headaches Avoid IM/SQ/IV or invasive procedures No aspirin/NSAID Soft toothbrush; no flossing or dental procedures No razor blades-use Electric razor Stool softeners & laxatives to prevent straining Hold pressure for 5 min. on venipuncture sites Teach signs of bleeding; when to notify doctor - signs hematoma, joint bleeding Provide Safe environment: Avoid situations where falls may occur

Hematologic disorders: thrombocyptopenic precautions

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Hematologic Disorders Flashcards

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