Hematology Flashcards
Concepts of hematologic disorders
GAS EXCHANGE AND TISSUE PERFUSION
RBC = delivers oxygen (hemoglobin)
— heme needs iron to transport oxygen
— four molecules of O2 can attach to heme
Someone with 100% SPO2 reading -> how many molecules are attached to the heme
Anemia
Reduction of RBC, hemoglobin and/or hematocrit
Classifications:
— blood loss
— hemolytic
— impaired RBC production
Types of anemia
Iron-deficiency (microcytic)
— blood loss, poor nutrition
Hemolytic
— immune
— trauma
— sickle cell
Megaloblastic (macrocytic)
— vitamin B12 deficiency
— PERNICIOUS ANEMIA
— folic acid deficiency
Aplastic anemia
— bone marrow suppression
Chronic
— chronic renal failure
— kidneys no longer produce epogen
What are CM of anemia?
— fatigue
— dizziness
— possible fainting
— hypotension
— hypovolemia
— high HR -> dysrhythmias
— chest pain -> low oxygen delivery
— SOB
— yellowing of the eyes in colored persons
Sickle cell anemia
Genetic
RBC in sickle shape (C shape)
— decreased oxygen carrying capacity
— abnormal hemoglobin
— C’s clump together very easily -> occludes blood vessels
— organ damage
— PULM EBOLISM, MI, stroke, kidney disease
Clinical manifestations of sickle cell anemia
— retinopathy
— cardiomegaly
— CHF
— hematuria
— stroke
— pneumonia
— splenomegaly
— ulcers on extremities
— osteomyelitis
Triggers for sickle cell
— HYPOXIA
— high altitudes
— dehydration
— venous stasis
— physical/emotional stress
— anesthesia
— infections
— low or high body temp
Medical surgical tx for sickle cell
— PAIN MANAGMENT
— opioids -> constipation
— hydration to keep cells from clumping
— OXYGEN
— prevent infection
— do not bend over -> RBCs can clump
— blood transfusion (hgb <7.5)
— hydroxyurea -> reduces sickling -> CAN INCREASE CANCER RISK FOR INFANTS (make sure female is not pregnant)
Teaching for sickle cell
— prevent crisis -> STAY HYDRATED; stay oxygenated
— manage drugs -> women on birth control taking hydroxurea
— emotional support -> will have disease for rest of life
Education for hydroxyurea
Do not get pregnant
Risk for infant cancers
Sickle cell nursing dx and interventions
Nursing dx:
— acute pain
— ineffective peripheral tissue perfusion
— deficient fluid volume
— activity intolerance
— risk for decreased cardiac tissue perfusion
— risk for infection
— risk for ineffective cerebral tissue perfusion
Nursing interventions:
— admin OXYGEN
— admin pain medications
— do not bend the client -> restricted blood flow/clumping of sickle RBCs
— check circulation of peripheral extremities
— assess signs of central claudication
— keep pt warm -> NO HEATING PADS
— admin IV fluids and PO fluids
Generalized anemia
— complete blood count with diff and RBC indices
— reticulocyte count
— iron studies
— coomb’s test -> hemolytic anemia / looks for antibodies on surface of RBC
— bone marrow aspiration -> looks to see if there is anything preventing RBC production
Normal range for RBC
What does decreased/increased lab indicate
4.2-6.1
Decreased = anemia or bleeding
Increased = severely dehydrated or PV
Normal range for hemoglobin
12-18
Deceased = anemia, bleeding, fluid overload
Increased = severely dehydrated
Normal range for hematocrit
37-52%
Medical surgical tx for anemia
— determine underlying cause
— iron deficiency -> oral ferrous for mild anemia (take with food - hard on the stomach)
— vitamin C enhances absorption of oral ferrous
Severe: IV or IM dextran
— check BP
— tele monitoring
Vitamin B12
— diet
— oral supplments
Blood loss
— stop bleeding
— mass trauma
Immune
— transfusion
— bone marrow transplant
— immunosuppressive therapies
— HIGH RISK FOR INFECTION
Chronic disease
— procrit/epogen injections to help stimulate erythropoietin
Assessment for anemia
— diet
— meds
CM:
— FATIGUE
— pallor
— cyanosis
— jaundice -> hemolytic anemia
— bleeding
— dry skin
— mouth ulcers or fissures
— smooth tongue
— lymph node involvement -> infection/cancer
— tachycardia -> low blood volume
— VS -> O2 saturation (carbon dioxide/monoxide poisoning the SPO2 will not be accurate)
Nursing dx for anemia
— activity intolerance
— fatigue
— altered tissue perfusion
— impaired gas exchange
— anxiety
— impaired comfort
— risk for bleeding
— risk for injury
— impaired memory
Interdisciplinary interventions and nursing interventions for anemia
— oxygen
— oral or IM iron
— supplments -> VITAMIN B, FOLIC ACID
— epoetin SQ weekly
— RBC transfusion for hgb <7.5
Nursing interventions:
— energy conservation
— supportive care
— correct anemia -> diet changes
— teaching self care
Level of hemoglobin that indicates need for blood transfusion
<7.5
Primary polycythemia Vera
Loss of cellular regulation
— RBCs, WBC and platelet
— blood will become viscous (THICK) -> poor oxygenation
— HIGH HEMOGLOBIN AND HEMATOCRIT
Hyperkalemia, high hct + hgb, high uric acid
CM and complications of polycythemia Vera
CM:
— HTN
— headache
— dizziness
— itching
— dyspnea
— purple/gray color
Complications:
— angina
— claudication -> stopping of oxygen/clotting
— thromboses
— infarctions -> MI, CVA
— intracranial bleeds/CVA FROM HTN
Medical tx:
— ANTICOAGULANTS
Nursing interventions for primary polycythemia Vera
— prevent clots = get up and ambulate as frequently as possible
— HYDRATION -> 3L/day
— stop smoking
— promote venous return
— elevate feet to prevent pooling in lower extremities
— avoid tight clothing
— support hose
— thrombocytopenia precautions -> bleeding precautions
— use electric razor, soft toothbrush (anticoagulants)
— neutropenic precautions -> higher risk for infection
Primary polycythemia Vera education
— contact doctor first sign of infection or occlusion
— exercise slowly
— stop activity at first sign of chest pain or dizziness (possible MI)
— interdisciplinary -> anticoagulants, chemotherapy to thin down/stop overproduction
Nursing dx PPV
Ineffective protection
Risk for bleeding
Risk for ineffective tissue perfusion
Myelodysplastic syndrome (MDS)
PRECANCEROUS STATE
— abnormal cell formation in bone marrow
— destroyed by body after release; decrease in all blood cell types
— Pancytopenia
— 30% develop leukemia
Risk factors:
— >65 age
— exposure to chemicals
— tobacco smoke
— chemo/radiation
Diagnostics for myelodysplastic syndrome
— cytogenetic testing -> looks at chromosomes that are identified as abnormal
— peripheral blood smears -> cell abnormalities
Medical tx:
— supportive care
— blood/platelet transfusion
— epogen injections
Platelet disorders
— local bleeding-petichiae
— easier to control
— Idiopathic thrombocytopenic purpura -> immune system destroys platelets
— Thrombotic thrombocytopenic purpura -> platelets clump together and forms clots
Clotting disorders
— occurs deeper in the body
— bleeding in joint spaces; SQ
— deeps bleeds difficult to control and often restarts
— hemophilia
— heparin-induced thrombocytopenia
Reasons for platelet disorders
Decreased production
— cancers and tx
— aplastic anemia
— toxins; meds, alcohol
Increased destruction
— autoimmune
— infections, meds, spleen disorder, cancers
Increased consumption
— disseminating intravascular coagulation - body is running out of platelets
Normal platelet count
150,000-400,000
Thrombocytopenia
TOO FEW PLATELETS
— 40,000-80,000 platelets
— risk for bleeding with mild trauma
<20,000 risk for spontaneous bleed
<5,000 risk for fatal bleed in CNS or GI hemorrhage
Idiopathic thrombocytopenic purpura
Thrombocytosis
TOO MUCH PLATELET
— platelets >60,000
— risk for clotting
Thrombotic thrombocytopenic purpura
Idiopathic thrombocytopenic purpura
Autoimmune disorder
— patients makes antibodies against own platelets
— macrophages destroy
Viral infections thought to trigger condition
Most common in women 20-40
Dx: serial law platelets and bone marrow biopsy
— shows bone marrow is putting out normal rate
— body is chewing it up (platelets)
Tx:
— immunosuppressive drugs (prednisone)
— platelet transfusion
— splenectomy -> last resort
Thrombotic thrombocytopenic purpura
Autoimmune disease
— platelets clump together abnormally in capillaries and too few available in circulation
— clotting occurs but also fails to clot when trauma occurs
— tissue becomes ischemic -> kidney failure, MI, CVA
— FATAL IN 3 MO. IF NOT TREATED
Tx:
— plasmaphoresis
— fresh frozen plasma to provide platelet aggregation inhibitors
— platelet inhibitor drugs
Hemophilia
Genetic disorder
— chance of giving disorder to offspring
— women carrier
Types:
A = factor 8 (VIII)
— 80%
B = factor 9 (IX)
— 20%
Symptoms:
— abnormal bleeding to any trauma, specifically joints
— bleeding longer than normal
— problem forming stable fibrin clot -> allows for extensive bleeding
PT range
11-12.5
Warfarin therapy
Liver failure
INR range
0.8-1.1
PTT range
60-70 seconds
Heparin therapy
Medical and nursing management of hemophilia
Complications most common -> joint problems from repeated episodes of bleeding
Dx -> prolonged PTT
Tx -> replace missing factor with infusion of synthetic factors
Nursing management of hemophilia
Minimize trauma and other causes of bleeding
— thrombocytopenia precautions
— risk assessment -> protect pt from injury
Assess s/s bleeding
Prepare to admin platelet infusion for counts below 10,000
— replace missing clotting factors with transfusion of synthetic factors
— educate patient and family -> risk for bleeding
Cancers of the blood
— leukemia
— lymphoma
— multiple myeloma
Leukemia
Uncontrolled NORMAL cell production
— cancer occurs in stem cells of bone marrow -> overcrowded with nonfunctional cells
Overproduction of blasts cells -> immature WBC
Exact cause unknown
— genetic and environmental factors involved
— 50% of pt have abnormal chromosomes
Normal cell production decreased results in:
— Pancytopenia
— neutropenia
— anemia
— thrombocytopenia
— infiltration of tissue/organs
Acute leukemia
Sudden onset of abono al blood cells
Chronic leukemia
Abnormal cells replicate slowly
How is leukemia classified
By cell type
— lymphoid cells: lymphocytic
— myeloid cells: myelogenous
Types of leukemia
Acute lymphocytic leukemia
— most common type in young children
Acute myelogenous leukemia
— most common type in adults
Chronic lymphocytic leukemia
— most common chronic adult leukemia
Chronic myelogenous leukemia
— asymptomatic for years enforce entering fast growth phase
Leukemia risk factors
— prior exposure to chemo or ionizing radiation
— bone marrow hypoplasia (slow growth)
— genetic -> Down syndrome
— immune deficiency
— virus
Definitive test for leukemia
Bone marrow biopsy
Leukemia dx
Abnormal WBC
— high blast cells -> poor prognosis
— low hgb + hct
— low platelet
Chromosome analysis
X-ray, CAT scan, MRI
Clinical manifestations of leukemia
Systemic:
— weight loss
— fever
— frequent infections
Psychological:
— fatigue
— loss of appetite
— SOB
— weakness (lack of oxygen)
— pain/tenderness in bones/joints
— lymph node swelling
— spleen/liver enlargement
Skin:
— night sweats
— easy bleeding and bruising
— purplish patches or spots
Nursing interventions for bone marrow aspiration
— provide info to pt about blood cells and production
Nursing:
— prone or side lying position
— sedatives
— needle and incision will be made
Follow-up care:
— control bleeding
— inspection of site q2 hr
— pain control
Medical tx of leukemia
Induction therapy
— started as soon as dx confirmed
— hospitalized 2-3 wk in protective isolation
S/S:
— severe bone marrow suppression
— alopecia
— n/v
— stomatitis
— organ toxicity
Consolidation therapy: once recovered
— repeat drugs or bone marrow transplant
Maintenance:
— months and years to maintain remission
What are the two main types of lymphomas?
Hodgkin’s lymphoma
— teens and adults in 50s-60s
Nonhodgkin’s lymphoma
— all other lymphomas
— over 60 types
— older adult men
Hodgkin’s lymphoma
Starts in single lymph node in neck, underarm, or chest
— proceeds in orderly fashion to next
— fatigue, anorexia, SOB
— sweats, fever, itching, weight loss
— pain in node areas after alcohol intake
Risk factors and tx of Hodgkin’s lymphoma
Risk factors:
— viral infections
— chemical exposure
Tx:
— external radiation and chemo
— CURABLE
Non-Hodgkin’s lymphoma
CHRONIC/NOT CURABLE
— lymphadenopathy in multiple sites
— spreads to other organs by the time of dx
Risk factors:
— autoimmune
— immunosuppressive disorders -> HIV
— chemicals
Tx:
— chemo/monoclonal antibodies
— radiation
— not curable
Multiple myeloma
Overgrowth of plasma cells
— plasma cells overproduce gamma globulin (gammopathy)
— excess antibodies in blood CLOG BLOOD VESSELS of KIDNEY and other organs -> infects the organs
Produces excess cytokines
— increase cancer growth rate and destroy bone
Dx testing:
— serum electrophoresis test detects monoclonal immunoglobulin (high levels of calcium)
— bone marrow -> greater than 10% infiltrated plasma cells
— X-ray -> osteolytic bone lesions
Early s/s of multiple myeloma
— fatigue
— anemia
— easy bruising
— bone pain
— infections
Late s/s of multiple myeloma
— bone factures
— kidney dysfunction
— HTN
— RARE: hypercalcemia, hyper viscosity syndrome
Leads to progressive bone destruction, bleeding, kidney failure, immunosuppression and death
Treatment and nursing interventions of multiple myeloma
Tx:
— chemo agents
— bone marrow transplant
— INCURABLE
Nursing:
— care of immunocompromised patient
— pain control
Nursing care for leukemia, lymphoma and multiple myeloma
INFECTION PROTECTION
— prophylactic drugs -> antiviral, antibiotic, anti fungal
— neutropenic precautions
— monitor labs daily
— monitor for early manifestations of infection
— hygiene/skin care
THROMBOCYTOPENIC PRECAUTIONS (bleeding precautions)
— energy conservation
— teach self care -> avoid large crowds
— psychosocial support
Neutropenic precautions
Infection protection
— avoid crows, children, ill people
— wear mask
— hand hygiene
— good personal hygiene, mouth care
— avoid constipation
— shave with electric razor
— do not handle feces
— NO FRESH FLOWERS OR GARDENING
— no invasive procedures
— no sexual relations
— no fresh fruits/veggies, raw meat, eggs, cheese
— assess temperature
Thrombocytopenic precautions
Bleeding precautions
— assess for s/s of bleeding -> bruises/nose/gums/urine/stool/severe headache
— avoid IM/SQ/IV or invasive procedures
— NO ASPIRIN/NSAID
— soft toothbrush
— no flossing/dental procedures
— no razor blades -> electric
— stool softeners to prevent straining
— hold pressure for 5 min on venipuncture sites
— teach s/s of bleeding
— avoid situations where falls may occur
