Hematology/Oncology

Question 1

What could cause disturbances in the hematologic system?

Answer 1

Decreased number of cells during hematopoiesis (the production & development of blood cells, normally in the bone marrow)

Over production of normal or abnormal cells during erythropoiesis (formation of red blood cells)

Clotting defects

Disorders of the spleen

Aging results in lower blood volume and plasma proteins; the total RBC and WBC level lower, antigen/antibody responses are lower and slower

Question 2

What could cause disturbances in the lymphatic system?

Answer 2

Enlargement and swelling of soft tissues, usually caused by infection, inflammation, neoplasm, or obstruction

Question 3

What is the most prevalent anemia world wide?

Answer 3

Iron deficiency anemia

Question 4

What are some lab findings we see in iron deficiency anemia?

Answer 4

Chronic, microcytic, hypochromic anemia (cells are small and pale)

Without iron there is decreased production of hemoglobin

Levels of hemoglobin usually lower than 10 and RBC 3-4 million

Hematocrit <47 in males and <42 in females

Mean Corpuscular hemoglobin <27 (measures concentration of hemoglobin in a volume of PRBC, low in microcytic anemia, normal in normocytic anemia and high in macrocytic anemia). How pale or dark cells are.

Serum iron levels as low as 10 (normal is 50-170)

Iron binding capacity increased (nothing to bind to)

Ferritin level (form that iron is stored in body) is decreased

Question 5

What would we assess for with a patient that has iron deficiency anemia?

Answer 5

Assess for underlying cause (GI bleeding etc) and address the cause

Question 6

What are some Hematinic agents we would use to increase iron level?

Answer 6

Chromygen, Ferrous sulfate, Ferrous gluconate, Iron Dextran, and ascorbic acid to increase absorption

Question 7

What are some ways we could assist the patient manage Iron deficiency anemia?

Answer 7

Provide safe environment; assist with ambulation if dizzy

Allow for frequent rest periods

Frequent oral hygiene with saline mouth washes and lubricate lips. May even need viscous Lidocaine to swish and spit out

Administer medication as ordered

Give iron with orange juice or ascorbic acid but not milk, if iron liquid give through a straw to prevent discoloration of teeth. Best if given before or between meals. Do not give with milk or antacids

IV route has high rate of anaphylaxis.

If IM give Z-track as will stain the skin.

Observe stools as iron may cause constipation; black stools

Soft foods high in iron

If severe anemia, may need supplemental oxygen

Question 8

Which anemia has an unknown cause and that may be hereditary?

Answer 8

Pernicious Anemia

Question 9

What population do we tend to see more with Pernicious Anemia?

Answer 9

Men and women over age 50 and blue eyed people of Scandinavian origin

Question 10

When do we use the Schilling test?

Answer 10

specific for Pernicious anemia, radioactive tagged vitamin B12 is not absorbed in the stomach & if ↓ 10% of tagged B12 is excreted in the urine = positive test for presence of pernicious anemia; not used very often anymore.

Question 11

What are some manifestations of Pernicious anemia?

Answer 11

Pallor & jaundice, waxy, fatigue, weakness, dyspnea

Glossitis (smooth beefy red tongue), gingivitis, indigestion, epigastric pain. Loss of appetite, diarrhea, constipation, weight loss

Tachycardia, wide pulse pressure, palpitations

Peripheral neurological changes with tingling, numbness and paresthesias to hands and feet

If untreated neurological symptoms worsen with loss of vibratory sense, ataxia, spasticity, and disturbances in bowel and bladder function. Depression, paranoia, poor memory with impaired judgment; delirium may follow.

Eventually there may be splenomegaly and hepatomegaly, organ failure, neuro degeneration or infection and eventual death

Question 12

What replacement therapy is needed for Pernicious anemia?

Answer 12

Life long B12 (cyanocobalamin) replacement therapy, given IM. Begin with 2-3 times weekly for 10 doses and then 200 mg monthly or 100 mg every two weeks

Question 13

What safety precautions should we advise patients with Pernicious Anemia to take?

Answer 13

Safety consideration due to neurological manifestations (assist with ambulation, adjust hot water heater, no heating pads or hot water bottles, bed cradle to keep pressure off extremities, avoid people with infection)

Question 14

What are some management we need to tell our Aplastic Anemia patients of?

Answer 14

Corticosteroids to stimulate granulocyte production

Bone marrow transplant

Antibiotics for infection

Androgens to stimulate bone marrow

Removal of causative agent

Blood transfusion, FFP, Platelets

Bed rest with oxygen

Stool softeners

Bleeding precautions (soft tooth brush, electric razor)

Avoid injections

Monitor for bleeding, infection, change in V/S, LOC

Reverse isolation when WBCs low

No raw food, cooked food only

Question 15

Which anemia can lead to renal failure?

Answer 15

Hemolytic and Sickle cell anemia

Question 16

What would trigger a hemolytic crisis?

Answer 16

For chronic cases, a physiological or emotional stress

Question 17

What symptoms would we see for a patient in an acute hemolytic crisis?

Answer 17

there are severe chills, fever, headache, back pain, abdomen and joint pain, splenomegaly, hepatomegaly, lymphadenopathy and reduced urinary output

Question 18

What is the management of hemolytic anemia?

Answer 18

Splenectomy if steroids fail to arrest RBC destruction by the spleen

Corticosteroids to suppress extracorpusuclar factors such as inflammation

Diuretics to prevent tubular necrosis

Folic acid replacement

Remove causative factors

Maintain fluid and electrolyte balance (hydration)

Maintain renal function, using sodium bicarbonate or lactate to alkalize the blood to prevent overload and failure

Blood transfusion

Strict I&O and monitor BUN and Creatinine.

Bed rest and oxygen

Question 19

What population group is most affected by Thallassemia?

Answer 19

Autosomal dominant inherited disorder most frequently affecting people of Mediterranean (beta form) or Southern Chinese or Asian ancestry (alpha or milder form)

Question 20

What are the three types of Thallassemia?

Answer 20

major (Cooley’s anemia), intermedia, and minor (mild)

Question 21

What is one of the biggest manifestations of Thallassemia?

Answer 21

Greatly elevated urine, serum, and fecal Bilirubin

Question 22

What population group is most affected by Sickle Cell Anemia?

Answer 22

Prevalent in tropical Africa and in those of African descent, those from the Mediterranean, Puerto Rico, Turkey, India and Middle East may also be affected

Question 23

What is the most common X linked genetic disease in the US?

Answer 23

Hemophilia. Sons of men who are hemophiliacs are normal where as daughters are 100% obligatory carriers.

Sons of women who are carriers have a 50% chance of being hemophilic and daughters have a 50% chance of being carriers

Question 24

Who would need to follow this management: No surgery; any procedure even dental cleaning with extreme care

Avoid ASA and IM injections

Hepatitis B immunizations

FFP during episodes of bleeding

Cryoprecipitate to replace factor VIII or Factor IX concentrate

Immunosuppressive, DDAVP or Amicar to treat developing antibody inhibitors against a specific coagulation factor

Safety at all times

No contact sports

Ice to painful joints and splinting or casting

Monitor for hematuria, melena, change in LOC

Bed rest during episode of bleeding

Those who received plasma in the early 1980s were infected with HIV

and Genetic counseling?

Answer 24

Hemophiliacs

Question 25

What population develops Polycythemia vera?

Answer 25

develops in middle age, particularly in Jewish men, is an overproduction of RBCs and thrombocytes by the bone marrow. Results in increased blood viscosity, blood volume, and congestion of tissues and organs

Question 26

What is some of the management needed for Polycythemia?

Answer 26

Splenectomy if splenomegaly resistant to treatment

Chemotherapeutic agents to induce myelosuppresion in some forms of polycythemia vera

Allopurinol for hyperuricemia

Analgesics for joint pain

Phlebotomy or removal of 500-2000cc of blood or until hematocrit is 45%, this reduces RBC mass. May be needed every 2-3 months to prevent circulatory overload

Exercise to promote circulation

Avoid smoking

Vasodilators

Low sodium diet to prevent further fluid retention

In secondary polycythemia treat underlying cause

In relative polycythemia, fluid and electrolyte replacement

Question 27

How is AIDS diagnosed?

Answer 27

Initial stage asymptomatic but will have HIV antibodies detected by protein electrophoresis

Positive ELISA that then must be confirmed by Western blot

AIDS diagnosis

CD4 count less than 200/microliter (indicates very low immune status)

HIV viral load determines level of disease in the body, used to monitor progression and treatment effectiveness

Indicator condition manifested (PCP pneumonia, Kaposi sarcoma, CMV, invasive cervical cancer, candidiasis, TB, etc.)

Question 28

What level of IgG would warrant immunoglobulin infusion?

Answer 28

Less than 300mg/dl

Question 29

What disease is characterized by the earliest sign of painless lymphadenopathy in one side of the neck?

Answer 29

Malignant lymphomas

Question 30

What disease is characterized by “Reed-Sternberg” cells?

Answer 30

Hodgkin’s Disease

Question 31

What is the prognosis for patients with Hodgkin’s Disease?

Answer 31

Prognosis if untreated is about 5 years and those with stage I or II have a 95% cure rate, while those with stages III and IV have a poor prognosis

Question 32

What are some primary prevention tools to use for Cancer prevention?

Answer 32

education of community about risks, known carcinogens & dietary & lifestyle changes. Medications such as tamoxifen for breast cancer

Question 33

What are some primary prevention tools to use for Cancer prevention?

Answer 33

genetic screening & risk evaluation; race, cultural influences, level of education, age, knowledge & attitudes about cancer, etc.

Examples of screening is mammography, pap smear, stool for OB, screening colonoscopy, testicular self exam, prostate exam, breast self exam)

Question 34

What are some management steps for patients undergoing Radiation?

Answer 34

-Radiation therapy (external beam)

Skin manifestations may occur

Assess skin condition (dryness, tautness, erythema, desquamation, telangiectasis; at times even blisters)

Apply bland cream or oil to site only if ordered; usually even if ordered are avoided for at least 2 hours prior to therapy.

Bath with mild soap and lukewarm water, no powder

Protect skin from sunlight, heat, trauma, constricting clothing, heat

Radiation to the head will cause hair loss

-GI (radiation enteritis with atrophy intestinal villa) and Diet

Antiemetics as needed for nausea and vomiting

Gluten, protein, lactose free with adequate fluids

May require IV fluids and in severe cases TPN

Antidiarrheal agents

Weigh weekly

-Mucous Membrane Damage

Good oral hygiene due to possible change or loss of taste and soreness of mouth

Avoid alcohol mouth washes, and spicy foods

-Systemic

Protect from injury and infection

Observe for signs of bleeding

Sedatives for pain

Question 35

Cancer management: what kind of meds do we see for chemotherapy patients?

Answer 35

N/V is most common side effect & usually persists for 24 hours.

Antiemetics, such as Zofran (ondansetron) used.

Delayed N/V & diarrhea may occur 3-5 days after treatment along with stomatitis or mucositis.

Oncologists now use marinol, phenothiazines, sedatives, corticosteroids & histamines along with the chemo to diminish side effects. Certain chemo agents, such as daunorubicin & doxorubicin are known to cause irreversible cumulative cardiac toxicities

Question 36

How long after a bone marrow transplant does “engraftment” occur?

Answer 36

2-3 weeks to take place/new marrow becomes functional

Question 37

What are patients at a high risk for prior to engraftment?

Answer 37

Infection, sepsis, bleeding, and Venous Occlusive Disease (VOD) which is from high-dose chemo that can lead to liver failure

Question 38

What are some oncological emergencies?

Answer 38

Hypercalcemia, Super vena cava syndrome, Tumor lysis syndrome, organ toxicities, spinal cord compressions, Neutropenic entercolitis, and Hemorrhagic cystitis