Hematological Flashcards
Nephroblastoma
✓ Nephroblastoma is a tumor affecting the kidney(s).
✓ The average age at diagnosis is three years in children with single kidney disease.
✓ It is slightly younger for those with bilateral involvement.
Nephroblastoma nursing care involves
✓ Frequent blood pressure monitoring because this tumor may induce renin-related hypertension
✓ Avoid any activities that may cause palpation of the abdomen
✓ Gastrointestinal assessment as obstruction may consequently occur (absent bowel sounds, abdominal distention should be reported)
✓ Assessment of hemorrhage (tachycardia and hypotension)
Enalapril is an ACE inhibitor used to lower blood pressure. Since clients with nephroblastoma are hypertensive due to increased renin levels, this medication is commonly prescribed to decrease their blood pressure. Any ACE inhibitor reduces blood pressure by inhibiting the formation of angiotensin II in the renin-angiotensin-aldosterone system (RAAS), so they are an excellent choice for treating hypertension caused by nephroblastoma. While ACE-I’s may be nephrotoxic, this is still the recommended treatment and is therapeutic as long as the creatinine levels are monitored closely.
Drugs of the Hematologic System
Prevent clotting
● Anticoagulants
○ Heparin
○ LMWH
○ Antiplatelet drugs
■ ASA
■ Clopidogrel
Break up a clot
● Thrombolytics
Blood products
Anticoagulants
● Heparins
○ Heparin
○ Low Molecular weight heparin
● Antiplatelet drugs
○ Clopidogrel
○ Aspirin
● Warfarin
● Factor Xa inhibitors
○ Apixaban (Eliquis)
○ Fondaparinux (Arixtra)
○ Rivaroxaban (Xarelto)
Heparin works by?
● Classification: Indirect Thrombin Inhibitor
○ Anticoagulant!
● How it works
○ Thrombin → converts fibrinogen to fibrin → Fibrin forms clots!
○ Antithrombin III inhibits thrombin
○ Heparin ENHANCES antithrombin III
○ This stops thrombin from being activated, which therefore prevents clots from forming
● This is the intrinsic coagulation pathway
End result? SLOWS DOWN CLOTTING.
Heparin info
Basic Information
● Uses
○ To prevent blood clots
■ Strokes
■ Chronic a-fib
■ Post-operatively
● Titration
○ Clients on a heparin drip have aPTT levels drawn q4-6 hours to titrate the drip
■ Normal aPTT: 30-40 seconds
■ Therapeutic aPTT: 1.5-2x normal
Important Nursing Considerations
● Biggest side effect to monitor for = bleeding!
○ Hematuria - Pink tinged urine
○ Hematemesis - bloody vomitus
○ Bruising
○ Downtrending H&H
● Antidote = protamine sulfate
HIIT
Heparin Induced Thrombocytopenia and Thrombosis (HITT)
● Complication of Heparin therapy
● Usually occurs 5-10 days after heparin exposure
● Suspect in any client on heparin who has an unexplained platelet drop
● Clinical manifestations:
○ Skin lesions at heparin injection sites
○ Chills
○ Fever
○ Dyspnea
○ Chest pain
● Complications - clotting!
○ DVT
○ PE
● Treatment
○ Discontinue ALL heparin and start a different anticoagulant!
Low Molecular Weight Heparin
Names: Enoxaparin
Indication: DVT prophylaxis
Action: Contain an active anticoagulant fraction of heparin - enhances antithrombin III,
which stops thrombin from being activated, which therefore prevents clots from forming
Nursing Considerations:
● Always given SC
● Porcine derived, may have cultural or religious implications
● No need for anticoagulation tests/monitoring, dose is based on body size
○ DO monitor platelets… HITT
● Only anticoagulant that CAN be used in pregnancy
Warfarin
Therapeutic class: Anticoagulant
Indication: venous thrombosis, pulmonary embolism, A-fib
Action: disrupts liver synthesis of Vitamin K-dependent clotting factors
Nursing Considerations:
● Monitor for bleeding
● Monitor PT and INR
○ PT
■ Normal: 10-12 seconds
○ INR
■ Normal: 0.9-1.2
■ Therapeutic INR: 2-3x
● Antidote: Vitamin K
● Contraindicated during pregnancy
make sure no medication contraindications
Antiplatelet anticoagulants
Names: Aspirin, clopidogrel, ticlopidine
Indication: Ischemic disease prevention: MI, CVA, DCT, PE….
Action: Inhibit platelet aggregation
Nursing Considerations:
● ASA is used in 325 mg or less a day to reduce ischemic disease
● SE: headache, vomiting, rash, diarrhea, dizziness
● Discontinue 5-7 days before surgery!
Fibrinolytics/Thrombolytics
Names: Urokinase, streptokinase, alteplase (tissue plasminogen activator: tPA)
Indication: Established clot: PE, ischemic stroke
Action: Enzyme converts plasminogen to plasmin -plasmin destroys the clot!
Nursing Considerations:
● Must be given ASAP to have good effects (door to tPA time - 60 min!)
○ Also can be considered if within 4.5 hours of “last known well”
● Adverse Effects: Hemorrhage
○ Don’t give with other anticoagulants or antiplatelets if you can help it
● Mild allergic reactions common - give antihistamines or corticosteroids
Blood Administration
● Blood is administered as a medication… so follow the same
“rights”!
● Checked by 2 RNs to ensure compatibility and correct order
○ Client should have an active Type & Screen to determine compatibility
● Blood should be administered with special blood tubing that has
a filter with a larger gauge IV
○ Normal saline is the approved compatible IV fluid to infuse with/after blood
● Ensure vital signs are taken before, during, and after infusion per
hospital policy
○ Baseline vitals are crucial to determine if your client is having a reaction!!
● Closely monitor client for the first 30 minutes, which is the most
likely time a reaction could occur
Transfusion Reactions
● If a reaction is suspected, first STOP the infusion!
● Remove the tubing with the blood and flush the IV only if it is the only IV
access
○ Blood product and all tubing should be returned to lab/blood bank
● Follow hospital policy to initiate the Rapid Response team
● Prepare to administer diphenhydramine and oxygen (if needed) and treat the
client’s symptoms
