Hematological system Flashcards
Bone marrow biopsy
coring out an area of bone marrow with a large-bore needle ; iliac crest ( sternum ) ; anesthesia or sedation ; apply pressure; observe ! 24 hrs - bleeding & infection; analgesic ( aspirin free) ; ice packs
Bence-Jones Protein
urine test; single sample or 24 hrs urine collection; positive 75 % pts with multiple myeloma + neoplasms affecting bone, blood, lymphatic system
Schilling’s test
to determine vitamin B12 absorption ; pernicious anemia = Stage 1 abnormal + stage 2 normal ; Malabsorption = both stages abnormal ; NPO ( 8-12) - oral B12 - 1-2 hrs later IM B12 - Eat and drink + 24 hrs urine collection
RBC count - Men & Women
M 4.7-6.1
W 4.2-5.4
Reticulocyte count
immature RBCs - reflects bone marrow activity
Hemoglobin - M & W
M 13.5-18 gm/dL
W 12-16 gm/dL
gas carrying capacity of RBCs ; below 6 gm/dL - severe
Hematocrit - M & W - RBCs as %
M 40-54 %
W - 38-47 %
WBC differential
5000 - 10000 mm3
Platelet count - thrombocytes
150000-400000
Coombs test - Direct vs Indirect
- Direct - used to detect antibodies that are stuck to the surface of red blood cells. These antibodies sometimes destroy red blood cells and cause anemia.
- Indirect - looks for free-flowing antibodies against certain red blood cells. It is is most often done to determine if you may have a reaction to a blood transfusion.
Bilirubin
increased with hemolytic problems; reflects liver function
PT
11-12.5 seconds
aPTT
30-40 seconds ; therapeutic 1.5-2.5 x control
Therapeutic INR
2-3.5
Disseminated Intravascular Coagulation - DIC
complication of another disorder : diffuse clotting + hemorrhage
s/s: ecchymosis, petechiae, purpura fulminans
Triggers for DIC
- Massive trauma
- Shock
- Sepsis or infection - gram negative; meningococcal
- Acute promyelocytic leukemia
- Metastatic cancers
- Obstetrical emergency
- Transfusion reaction
- Severe liver disease
DIC - pathophysiology
Underlying disorder - Interleukins and TNF ( tumor necrosis factors) - Systemic activation of coagulation -
- widespread intravascular fibrin deposition - thrombosis and organ failure
- consumption of platelets and clotting factors - severe bleeding
DIC - complications
- Renal failure
- Gangrene
- PE
- Hemorrhage
- CVA
- ARDS
- MODS
- Death
DIC - elevated labs
- PT/INR
- aPTT
- FSP ( fibrin split products ); FDP ( fibrin degradation products); D-dimer
DIC - decreased labs
- Platelet count
2. Fibrinogen level
Fibrinogen
is a protein produced by the liver. This protein helps stop bleeding by helping blood clots to form
DIC: TX
- Supportive care
- Blood products - platelets, fresh frozen plasma, cryoprecipitate ( replace fibrinogen)
- Heparin therapy (prevent more clots)
- Epsilon-aminocaproic acid ( inhibitor of fibrinolysis) or Activated protein C
Activated protein C
enzyme that helps prevent inappropriate clot formation; its activated when it binds to healthy endothelial cells - injured ( sepsis …) - cannot activate protein C - clots are formed
Leukemia - acute or chronic - myelogenous or lymphocytic
- Increase in immature non-functional WBCs - blasts
- Decrease in mature, healthy WBCs, RBCs and platelets
- stem cells - bone marrow problem
Philadelphia chromosome - chromosome analysis
- major feature - CML
2. hallmark ALL
Leukemia S/s
- early - none
- Fever, generalized bone pain
- Infections, weigh loss + anorexia
- S/s of anemia and thrombocytopenia
“7 plus 3” - cytosine arabinoside + daunorubicin
Tx acute leukemia - severe bone marrow suppression - induction therapy
TX acute leukemia -
SE - Infection + Bleeding
- Induction
2, Consolidation - cure - Maintenance - 2-5 years
Imatinib mesylate (Gleevec) - SE
CML+ Philadelphia chromosome
SE - N/V - take with meal + large glass of water
No grapefruit juice
Muscle cramps - may need Ca
Increase risk for bleeding, diarrhea, rash, fluid retention
Hematopoietic Stem Cell Transplantation - Bone marrow transplant - Indications
- for leukemia patients in remission after induction therapy that have closed matched donor
- lymphoma
- multiple myeloma
- aplastic anemia
- sickle cell disease and many solid tumors
Human leukocyte antigen - HLA
matched stem cells may be obtained from a family member or unrelated donor ( 1 in 5000 ).
Bone marrow transplant and leukemia
Additional chemo with or without whole body radiation is given ( lethal to the bone marrow ) - new cell are given - go to the marrow - if function properly - produce permanent cure
!!! Graft vs Host - immunossupresant for the rest of the life - graft attacks host ; 15 % die
Leukemia - Risk
- any age
- genetic
- chemical agents
- hx of chemo
- radiation exposure
Chemotherapeutic agents - SE
- hair loss
- N/V
- toxicities and interfere with growth of many tissues
- myelosuppression
- birth defects and potential sterility
Chemotherapy - action
destroy the cells that are rapidly dividing ( malignant) ; any other cells that are reproducing at that time - destroyed as well.
Antineoplastic agents
- Alkylating - interfere with mitosis and cell division usually at any stage of the growth cycle
- Cytotoxic - “cin-mycin” - antibiotic neoplastics - interfere with DNA and or RNA and protein synthesis
- Antimetabolites - interfere with biosynthesis - used for solid tumors
Lymphoma
- Solid tumor
- Abnormal overgrowth of lymphocytes
- Lymph nodes + spleen problem
Reed-Sternberg cells
Hodgkin’s lymphoma
Hodgkin’s lymphoma - Risk
- young adults and those over age 50 - men
- genetic
- viral - Epstain-Barr virus
- occupational toxins
Hodgkin’s lymphoma S/s
- Enlarged cervical lymph nodes - painless
2. fatigue, weakness, tachycardia
B symptoms
- Weigh loss
- Fever, chills
- Night sweats
* poorer prognosis
Hodgkin’s
Hodgkin’s lymphoma TX
- Chemotherapy - ABVD, MOPP
- Radiation
- Bone marrow or stem cell support
Malignant B or T cells in the lymph tissue
Nonhodgkin’s lymphoma
- older adults
- aggressive and indolent
Nonhodgkin’s lymphoma - risk and TX
- long term immunosuppressive tx;
- hx of tx for Hodgkin’s
- RA and HIV
TX: CHOP-R chemo ; radiation; bone marrow or stem support
Multiple Myeloma
- Overgrowth of B-lymphocyte plasma cells in the bone marrow - increase
Antibodies - released into blood - increase serum protein levels - clogging blood vessels
Cytokines - increase cancer cell growth rates and destroy bone
Multiple Myeloma - Risk
- Afro-american men after 40 ( 65)
- Chemical exposure
- Genetic and viral
Multiple Myeloma S/s
Pain, hydration, injury !!!
- Slow onset
- Bone pain - triggered by movement
- Diffuse osteoporosis - pathological fracture
- Hypercalcemia
- Increased protein levels may cause renal failure
- S/s related to anemia, thrombocytopenia + agranulocytopenia
Multiple Myeloma - Dx
- X-ray - Swiss cheese
- Bence-Jones protein in urine
- Bone marrow biopsy
Multiple Myeloma - TX
- No cure
- Chemo, radiation
- Corticosteroids
- Biphosphonates - to help prevent bone loss and tx of hypercalcemia
- Allopurinol - for increased uric acid
Colony stimulating factors ( biological response modifiers )
proteins that stimulate or regulate the growth, maturation, and differentiation of bone marrow stem cells; Given subcut or IV
Erythropoietin - Stimulating Agents - Erythropoietin ( EPO, Procrit )
glucoprotein produced by the kidney; it stimulates RBCs production in response to hypoxia
* Hgb never exceed 12 g/dl - risk for death
Erythropoietin ( EPO, Procrit ) - SE and AR
SE: hypertension, headache, arthralgias (joint pain), weakness, dizziness, thrombosis (clots)
AR: seizures, hyperkalemia, cerebrovasc. accident, MI.
Erythropoietin ( EPO, Procrit ) for …
anemia
Granulocyte Colony - Stimulating Factor - Filgrastim (Neupogen)
regulates production of neutrophils within bone marrow
Filgrastim (Neupogen) for …
neutropenia
Filgrastim (Neupogen) - SE and AR
SE: N&V, skeletal pain, alopecia, diarrhea, skin rash, anorexia, bone pain
AR: thrombocytopenia, MI
Granulocyte Macrophage Colony - Stimulating Factor - Sagramostim ( Leukine )
increase production and functional activity of eosinophils, macrophages, monocytes and neutrophils
Sagramostim ( Leukine ) - AR
AR: pleural/pericardial effusion, GI, hemorrhage, dyspnea.
Thrombopoietic Growth Factor - Oprelvekin ( Neumega ) - SE
platelet growth factor
Fluid retention
Cardiovascular events
with diuretics - risk for hypokalemia
Colony stimulating factors - nursing considerations
- Keep vial warm
- Bleeding
- Admin 24 hrs after chemo
- Monitor BP and platelet count , CBC
- Do not shake
Aplastic anemia vs Pancytopenia
Risk - congenital, acquired ( radiation, meds), idiopathic
- decrease of RBCs because of failure of the bone marrow to produce this cells
- decrease RBCs, WBCs, platelets
Aplastic anemia , Pancytopenia S/s :
of anemia, infection, potential bleeding
Aplastic anemia , Pancytopenia Tx:
- Blood transfusions
- Stem cell transplant
- Splenectomy
- Bone marrow stimulants - biological response modifiers - colony stimulating factors
B12 - cobalamin
activate enzyme that move folic acid into the cell where DNA synthesis occurs ; stored in liver
Vitamin B12 deficiency anemia - macrocytic - types
- Dietary or due to malabsorption - GI surgery, bowel resection, long term use of H2 ( histamine) blockers
- Pernicious anemia - lack intrinsic factor - cant absorb B12
Pernicious anemia - TX
B12 IM - daily, weekly - Hb normal - for life/ 1 mo ;
Colomist - nasal spray
Vitamin B12 deficiency anemia S/s
- anemia s/s
- sore tongue, N/V, anorexia, abdominal pain
- altered thought processes - dementia , neurological/neuromascular deficits ; gastric cancer - some are not reversible
Vitamin B12 - foods
meat, eggs, dairy products
* vegans - high folic acid may mask B12 deficiency.
Iron supplementation - ferrous sulfate 300 mg = 60 mg elemental iron ; Dose tx - 150-200 mg in 3-4 doses/daily - elemental
Absorbed from duodenum + jejunum \+ OJ or Vitamin C 1 hour before eating ( with food if upset stomach) Straw for liquid iron - stain teeth 2-3 mo even after Hg normalizes SE: dark black stools ! constipation Toxic !!!
Iron deficiency anemia - foods
red meats, organ meats, beans + peas, fortified cereals, green leafy veggies + Vitamin C
Iron deficiency anemia - Risk !!!
- Premenopausal + pregnant women
- Children
- Lower socioeconomic background
- Older adults
- Blood loss - GI
Koilonychia
spoon nails - chronic anemia
Iron deficiency anemia - S/s
- Fatigue + activity intolerance
- Pallor
- Glossitis and burning of tongue, chelitis ( mouth)
- Headache
- Paresthesias
- Bleeding - menstrual bleeding , melena (black tarry stool)
Iron deficiency anemia - Dx
- Decreased - Hh/Hct , ferritin test ( free iron in the plasma)
- Increased - transferrin ( transports iron ) & total iron binding capacity
Microcytic cells
MCV - mean corpuscular volume
average size of RBCs - normocytic, microcytic, macrocytic
MCHC - mean corpuscular Hgb concentration
average concentration of Hgb in RBC - normochromic ( RBCs normal color ) & hypochromic ( RBCs pale color )
MCH - mean corpuscular Hgb
average weight of Hgb
Agranulocytosis vs leukopenia vs neutropenia vs granulocytopenia
low count of neutrophils (granulocytes) vs WBC vs neutrophils (largest) vs granulocytes
Actual neutrophil count (ANC)- normal
greater than 2000
Thrombocytopenia - types (platelets live 8-10 days)
- ITP - Immune Thrombocytopenia Purpura (platelets destroyed by spleen)
- Heparin-Induced thrombocytopenia - most common
* severe < 20 000 - bleed spontaneously
Thrombocytopenia S/s
- Bleeding
2. Petechiae, purpura, ecchymosis
Persantine
Plavix
Aspirin
Trental
Antiplatelets
Glycoprotein inhibitor; prevent platelet activation and thrombus formation with recent MI, CVA … ; IV route; SE: dyspepsia , dizziness, pain at injection site, hypotension, bradycardia ; hematuria, tarry stools, bruising.
Abciximab (Reopro)
Polycythemia
Increase of RBCs - increase blood viscosity + volume
Primary Polycythemia Vera (PV)
cancer of RBCs - massive production of RBCs , excessive leukocyte production and excessive production of platelets - can develop acute myelogenous leukemia
Secondary PV
due to chronic hypoxia - COPD, chronic heart conditions, high attitudes
PV - pathophysiology
Increase in number of cells - abnormal RBCs - shorter life span - rapid turnover - increase amount of cell debris ( cells die) - uric acid + potassium - gout and hyperkalemia ; Oxygen-carrying capacity is impaired - hypoxia; Bleeding.
Plethora
ruddy (flushed) complexion - polycythemia
PV - S/s
- Hypertension
- Headache + vertigo
- Tinnitus + visual problems
- Plethora
- Thrombosis
- Hepatomegaly + splenomegaly - abdom. stomach pain
- Pruritus , bleeding
PV - TX
- Prevent/ treat hypoxia
- Phlebotomy - 500 ml of blood 1-2/week
- Myelosuppresive agents - Busulfan or hydroxyurea
- maintain hydration - over - volume overload ; under - increased blood viscosity
PV + nutrition
encourage small, frequent meals rather than three big meals
Hemolytic anemia : causes
- Trauma
- Mechanical heart valves
- Hemodialysis
- Cardiopulmonary bypass
- Toxins, infection, blood transfusion, drugs, autoimmune disorder
Hemolytic anemia - S/s
jaundice + renal damage
Hemolytic anemia - Tx
remove/limit cause; splenectomy; corticosteroids; blood transfusions
G6PD deficiency anemia (X-linked enzyme) black male
not anemic until a stressor causes hemolytic response - hemolytic crisis
G6PD deficiency anemia - stressors
- Infection
- Antimalarial agents
- Nitofurantoin
- NSAIDs
- Fava beans (lima)
- Moth balls
G6PD deficiency anemia - S/s
- worsening of s/s of anemia
- red, red-brown, tea colored urine
- decreased urinary output - renal failure
G6PD deficiency anemia - Tx
Eliminate/treat cause
Transfusion
Hydration
Genetic counseling + newborn screening
ITP - idiopathic thrombocytopenia purpura - tx
Corticosteroids, splenectomy, immunosuppresive therapies, platelet transfusion