Pn2 Test2 Concept Guide Flashcards
S/s of asthma attack?
Can progress to what?
Wheezing Labored breathing Stridor Use of accessory muscles Distended neck veins
Pneumothorax (abnormal collection of air in the pleural space between the lung and the chest wall.Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath.)
and cardiac/respiratory arrest; intubation
What to do when ones wheezing stops in an asthma attack?
Prepare for emergency trach ! Stat.
It means they have a complete airway obstruction
Meds/Tx for asthma attack
IV fluids Potent systemic bronchodilator Steroids Epinephrine Oxygen Mag sulfate Intubation Tracheotomy
What part of the body does asthma affect ?
Airways
NOT alveoli
Asthma can occur how (2 ways) in the body?
Inflammation obstructing lumens
Airway hyper responsiveness leading to bronchoconstriction
What history nurse should assess with asthma
Symptoms-onset Exposure Prior allergies Smoking Family hx /family allergies
Physical assessment in one with asthma attack
Wheeze Increased respiratory rate Increased cough Use of accessory muscles Barrel chest Long breathing cycle Cyanosis Hypoxemia
Lab assessment to obtain with asthma ?
ABGs
PFT
Pulmonary function tests with asthma
Forced vital capacity
Forced expiratory volume
Peak expiratory flow rate
Goal is to improve what function in one with asthma attack?
Air flow and gas exchange
Self management patient education with asthma
Personal asthma action plan
Drug therapy with asthma ?
Use control drugs daily (LABA long acting)
Reliever drugs (SABA) use to stop attacks
Bronchodilators
Anti-inflammatory agents
Patient education with asthma
Avoid triggers if possible such as smoke, dust , fireplaces , mold, weather changes
Avoid smoking
Teach when to use rescue inhaler vs maintenance inhaler
Proper sleep, reduce stress, relaxation techniques
Wash all bedding with hot water
Monitor peak expiratory flow rates
Avoid food with metabisulfate or MSG
Usually have family hx
How long before should you use a bronchodilator before exercise to prevent bronchospasm
30 min before
What drugs one should avoid that can trigger asthma ?
Aspirin
NSAIDs
Beta blockers
Document patient allergies where
Medical record
SABA teachings
Carry with you at all times
Use before engaging in activity that triggers asthma or during attack
Monitor heart rate- drug increases pulse
Use 5 minutes before any other inhaler
Correct technique
Shake well before using
Albuterol
Levalbuterol (vetoli, proventil)
LABA teachings and meds
Report insomnia, shakiness, tremors , headache, eye pain, palpitations, nausea , and blurry vision - may be due to overdose
Increase fluids -causes dry mouth
Shake well before using
Should never be prescribed as the only drug therapy for asthma
Salmeterol Indacaterol Formoterol Arformoterol Ipratropium Tiotropium (spiriva) Serevent
group of lung diseases that block airflow and make it difficult to breathe.
Emphysema and chronic bronchitis are the most common conditions that make up This condition
Damage to the lungs from it can’t be reversed.
COPD
Chronic obstructive pulmonary disease
Which ABg is the result of COPD ?
Respiratory acidosis because CO2 increases
Copd can result in which conditions?
Hypoxemia - due to no oxygen
Impaired alveoli due to decreased gas exchange
Acidosis- CO2 increases
Respiratory infections
Cardiac failure
Cardiac dysrythmias - due to hypoxia (decreased oxygen perfusion)
What to asses in COPD patient?
Patient history
Activity tolerance
General appearance
Respiratory changes
- limited chest movement with emphysema due to flattened diaphragm
- wheezes inspiration and expiration
Cardiac changes
-signs of Right aided heart failure
Respiratory changes in copd
limited chest movement with emphysema due to flattened diaphragm
wheezes inspiration and expiration
Cardiac changes in COPD
-signs of Right sided heart failure
Management of chronic symptoms of COPD
Improve gas exchange and reduce carbon dioxide retention
O2 sats- 88-90%
Up in chair - for meals
Bipap, intubation for CO2 retention/respiratory failure
Prevent weight loss
Coughing exercises before meals
Small frequent meals, avoid gas producing foods or lots of liquids
Take bronchodilator 30 minutes before eating
Nutrition supplements
Minimize anxiety
Teach to breath through diaphragm and Pursed lip breathing; tripod position
Maintain high protein diet and increase fluids 2-3 L/day to thin mucus
Rest periods, sleep conserve energy
Avoid pollutants
Metered dose inhaler use
Drug therapy for COPD
Beta adrenergic agents (albuterol)
Methylxanthines ex: theophylline
Corticosteroids (prednisone)
NSAIDs
Mucolytics (guaifenesin, tessalon, pearles)
Home care management for copd
Long term use of oxygen -proper use on lowest possible needed
Pulmonary rehab program
Copd self management education
Drug therapy
Manifestations of infections
Breathing techniques; energy conservation
Relaxation therapy
Health care resources for copd patients
Food delivery services
Transportation
Cleaning
Copd-
Use caution with what in these patients?
Oxygen - should not exceed 3L due to them retaining too much CO2 which could suppress their respiratory drive (lose of natural stimulus for respiration) instead of elevated CO2
Be careful giving narcotics - could suppress oxygen
Nursing interventions for COPD
Asses for skin breakdown around nose and mouth from oxygen device
Encouraging incentive spirometer deep breathing
Encourage coughing or suction to remove secretions
Monitor vitals and o2
Encourage to quit smoking
High Fowler’s positioning
Small frequent meals
Increase fluids
Oxygen 1-2 L
What does pursed breathing do for the patient?
How to explain to patient ?
Increases oxygen
Breathe like you are blowing out a birthday candle
What does breathing from diaphragm do for copd patients
Makes diaphragm stronger
Makes breathing easier
Decreases energy used due to slowed down breathing rate
Prehypertension range
120-139/ 80-90
Stage 1 hypertension range
140-159/90-99
Stage hypertension 2 range
160 or above/ 100 or above
Desired bp for people over 60
Below 150/90
Desired bp for people younger than 60
Below 140/90
Patient assessment with hypertension
History
Bp both arms and appropriate sized cuff
Secondary disorder
Psychological assessment
Assessment for secondary HTN
Protein and RBC in urine
High BUN and GFR
HTN education
Exercise
Diet - decrease sodium and foods high in fat
Don’t smoke or drink alcohol
Decrease stress
Increase fluids
Co=sv x hr
Bp is product of what
Bp is affected by what
CO
PVR
Risk factors of HTN
Obesity
Smoking
Stress
Family hx
HTN causes to do what to the body?
May result in what
Causes medial hyperplasia (thickening) of arterioles blood flow decreases vital organs are damaged
As arteries thicken blood flow decreases and vital organs are damaged
Which may result in MI, CVA, PVD, CRF
Secondary HTN causes
Renal disease
Primary aldosteronism
Pheochromocytoma
Cushing s syndrome
Medications
Malignant HTN symptoms and results
Morning headaches
Blurred vision
Dyspnea
Kidney failure
LV heart failure
CVA
Tx for HTN
Lifestyle changes
Meds along with lifestyle changes when not responsive
Or combination of both
Ace (prils) can cause cough and high K
ARBs (sartan) good when ace aren’t helping
Beta-adrenergic blockers (lols) for ischemic heart disease, bradycardia
Calcium-channel blockers (ipine)- vasodilation and decrease HR
Diuretics- thiazide, loop, k sparing
A blood clot in a deep vein, usually in the legs.
This condition is serious because blood clots can loosen and lodge in the lungs. (Pulmonary embolism)
Deep vein thrombosis (DVT)
What can DVT be caused from
Surgery Pregnancy Trauma sitting for long periods of time Fracture Heart failure Shock
(Promotes venous restriction and obstructs flow)
S/s of pulmonary embolism
And what to do?
Tachycardia
Crushing chest
- lay them on left side and give oxygen, call code
What percent of hospital deaths start in the calf?
25%
DVT findings?
Swelling at the site
Redness
Tenderness
Do not use homans sign -unreliable
Diagnostic tests for DVT
Venogram dye -ultrasound
IPG-more accurate
D-dimmer
How to prevent DVT
Promote activity after surgery
Elastic stockings
PPDs
Repo q 2 hours
Leg exercises
Anticoagulants
Anticoagulants for clot formation
Heparin
Coumadin
Lovanox
Teachings for heparin
Need to know the PT and INR before admin of IV anticoagulant
Teaching for lovenox
Longer half life than heparin
Can be taught home management
Coumadin teachings
Given for 6 months for DVT and will start low dose 5 days before ending heparin or lovenox
Give vitamin k if excessive bleeding
Watch patient for bleeding, blood in stools, bruising, purple spots under skin
Patient teaching for DVTs
Monitor labs
Alcohol decrease
Use teds or supportive stockings
Avoid inactivity for long periods
Corticosteroid medication for asthma
Serevent
Advair
Cuff bladder width and length for bp should be what circumference ?
Width- 40%
length-80-100%
How many drinks is excessive alcohol intake?
3+ drinks
Headache is most reported s/s upon waking -related to what?
Sleep apnea /HTN
A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs.
It is a sign of fatty deposits and calcium building up in the walls of the arteries (atherosclerosis).
Risk factors include aging, diabetes, and smoking.
Also a risk factor for PAD
involves damage to or blockage in the blood vessels distant from your heart—the peripheral arteries and veins.
Peripheral vascular disease
When PVD affects only the arteries and not the veins it is called?
Peripheral arterial disease
Pain that is worse when you elevate your legs, and improves when you dangle your legs over the side of the bed.
PAD
Results in prolonged venous HTN , stretching veins , and damaged valves
Back up of blood causes increased pressure and swelling
Venous insufficiency
Manifestations of venous insufficiency
Reddish brown pigmentation lower legs
Stasis dermatitis, stasis ulcers
Ulcers Difficult to heal
Edema
How to manage s/s with venous insufficiency
Don’t cross legs
Elevate legs /compression
Avoid sitting or standing for long periods
Loose clothes
Drugs , manage ulcers, surgical management
When the heart can not pump blood throughout the body effectively
Heat doesn’t fill with enough blood or pump with enough force
Heart failure
What happens when the heart can not pump enough blood
Compensates by increasing HR which dilates ventricles
Increased HR= decreased cardiac output
PAD risk factors
Men 50+ Postmenopausal women HTN, hyperlipedema Obesity Decreased activity Smoking Diabetes Family hx Stress
Clinical manifestations of PAD
Occurs unilaterally
Skin mottling , ulcerations, Black gangrenous
Muscle atrophy
Shiny skin sparse hair
Thickened nails
6 P’s (seen in affected extremity)
Pulseless Pain-worse at night-crampingfatigue Pallor Paresthesia Paralysis Poikilothermia (coldness)
PAD interventions /tx
Anticoagulants Place extremity in dependent position PTA balloon catheter Laser assisted angioplasty Bypass grafts Amputation
PAD diagnostic
Doppler pulses
ABI
Ultrasound
Treat mill testing
Arterio-angiograms
Diastolic (relaxation) HF
Inability to relax
Causes decrease in ventricular filling
Systolic HF
Inability of the ventricles to contract and pump blood adequately
More common related to aging d/t stiffness of vasculature
Reduced capacity to pump blood into systemic circulation
Decreased CO and stasis or backup of fluid into pulmonary circulation
Left sided HF
Left sided HF causes
HTN
Alcoholism
MI
Coronary artery blockage
Hypothyroidism
Heart infection
Left sided heart failure symptoms
Dyspnea on exertion Orthopnea (sob while laying flat) Cough w pink sputum Crackles , wheezes Cyanosis Heart murmur/gallop Pulmonary edema
Reduced capacity to pump blood into pulmonary circulation
Causes stasis or backup of fluid in venous circulation
Right sided HF
Rt sided HF causes
Pulmonary hypertension, congenital heart disease is, heart valve disease, COPD/chronic lung diseases/cystic fibrosis, left heart failure
Right sided heart failure symptoms
Jugular vein distention, dependent edema in lower extremity, abdominal discomfort, nausea from fluid congestion, irregular heart rate, enlarged liver, weight gain
How to diagnose HF
ECG
ECHO (main test) shows heart enlargement
CXR
Stress tests
MRI
BNP
Cardiac catheterization
HF interventions
Decrease heart workload , Improve cardiac function and symptoms
Decreased fluid and sodium intake
Elevate head of bed and dangle legs
Oh to be a non-breather or mechanical vent
Pulmonary edema= sitting position, high O2, diuretics, intubation
What are diuretics used for?
What to monitor for
HF
HTN
DCM
Dehydration , hyponatremia , hypokalemia
Nitrates used for? Nitr
HF
Do not give if pt has hypotension, tachycardia, bradycardia
Angina
Increase venous capacity
Beta blockers (lol)
HF, HTN, DCM
Decreases HR & BP
Decreases contraction force/workload
Dipine (calcium channel blockers) used for
HF HTN Decreases HR and BP Vasodilators Reduces angina Dilated coronary arteries
Ace inhibitors used for
HF
HTN
DCM
Decreased pressure the heart must overcome to eject blood from the heart by interfering with the renin-angiotensin- aldosterone system
Promotes vasodialation
Digoxin used for?
HF
Cardiac glycoside
Increase hearts contractility
Increases myocardial cell contraction
anticoagulants and anti-platelets used for?
HF HTN DCM Arteriosclerosis Atherosclerosis Thrombophlebitis Heparin, Lovenox , Coumadin, aspirin, plavix Prevent cardiac events Not the primary tx of HF
Vasodilators used for
HF HTN DCM Buergers disease raynauds Isosorbide Decrease BP
Cardiac changes in older adults
Valves degenerate
Natural pacemaker cells decrease in number
LV hypertrophy
Aorta thickens, less flexible
Refers to inflammation of the pericardium
A swelling and irritation of the thin saclike membrane surrounding the heart
Pericarditis
Cause of pericarditis
Unknown
Symptoms of pericarditis
Sharp stabbing chest pain- travel to left shoulder and neck
Pain with inspiration, cough, swallowing
Sudden onset- short duration
SOB, fever orthopnea
Rt sided HF- most common
Fatigue, fever
JVD, high BP
SOB
Pericarditis labs
Elevated WBC ECG T wave elevation Positive BC Leukocytosis
Pericarditis tx
Improve on own
NSAIDs
Surgery
Sitting up and leaning forward relieves pain
What to do if one with pericarditis needs surgery
What Should INR be?
Out patient on prophylactic antibiotic
INR normal 1-2 but should be 2-3
If above 7 monitor for bleeding
Mechanical valves -
Valve leaflets become stiff and opening narrows
Rumbling , murmur
Results from Rheumatic carditis (thickening by fibrosis and calcification)
Mitral stenosis
Valve doesn’t close completely
High pitched murmur
Mitral regurgitation
Leaflets enlarge and fall into left atrium
Chest pain; systolic click
Mitral valve prolapse
Aorta opening narrows from artheroscleroais
Harsh murmur
Most common valve dysfunction in the US and is caused by wear and tear
Aortic stenosis
Blood backs up into LV and LV hypertrophies
Blowing murmur
Valve leafs do most close properly during diastole
Aortic regurgitation
Mechanical valve treatments
NSAIDs Corticosteroids Antibiotics Monitor for change in symptoms Monitor cardiac tamponade
Compression of the heart caused by fluid collecting in the sac surrounding the heart.
This puts pressure on the heart and keeps it from filling properly. The result is a dramatic drop in blood pressure that can be fatal.
Cardiac tamponade
Cardiac tamponade manifestations s/s
JVD with clear lungs
Muffled heart sounds
Altered mental status; anxiety; restlessness
Treatment for Cardiac tamponade
Hemodynamic monitoring for decreased CO
Pulses paradoxus- widens pulse pressure
Pericardiocentesis
Pericardial window - removal of part of pericardium to allow drainage
Pericardiectomy- removal of part of pericardium that is encasing the heart
condition caused by excess fluid in the lungs.
Pulmonary edema
Pulmonary Edema signs and symptoms
Crackles in the lungs
Dyspnea at rest
Disorientation or confusion
Tachycardia
Hypertension /hypotension
Reduced urinary output
Cough with frothy pink sputum
Premature ventricular contractions and other dysthymias
Anxiety
Restlessness
Lethargy
Pulmonary edema prevention/management
High Fowler’s position
Oxygen therapy; Cpap
Diuretics
IV morphine
I&O and vitals
Diet
Weight monitoring
Activity
Stick to tx plan and understanding of the illness
Amount of blood pumped from the left ventricle per minute
Cardiac output
Heart rate x stroke volume =
Cardiac output
What is the mean arterial pressure with in the heart
MAP
Must maintain at least 60mm hg to perfume vital organs and coronaries
average pressure in a patient’s arteries during one cardiac cycle. It is considered a better indicator of perfusion to vital organs than systolic blood pressure
Pressure the heart has to pump against to move blood forward
(Resistance the left ventricle must overcome to circulate blood )
Increased in hypertension and vasoconstriction
Increase of this - increases cardiac workload
Afterload
Volume of the blood in ventricles at end of diastole (ends diastole pressure) - like blowing up balloon
Increased in hypervolemia
Regurgitation of cardiac valves
Preload
An acquired or hereditary disease of heart muscle,
Heart chambers become enlarged and makes it hard for the heart to deliver blood to the body, and can lead to heart failure.
Cardiomyopathy
Cardiomyopathy stems from which HF side?
S/s?
Starts from Lt can lead to Rt
Edema in legs
SOB
Afib
DOE
Syncope(fainting)
Decrease activity tolerance
Management of cardiomyopathy
Meds:
Diuretics
Vasodilation agents
Digoxin
Toxin exposure avoidance
Alcohol avoidance
Strenuous exercise prohibited
Surgical intervention:
Depends on type -
Cardiac Defibrillator (Incase of sudden MI)
Ventriculomyomectomy - remove part of septum
Percutaneous alcohol ablation -inject alcohol into heart to create infarct
Heart transplant
cardiomyopathy
o Most common type?
o Both ventricles are dilated, LV usually worse
Viral, HIV , Lyme disease
Dilated cardiomyopathy
cardiomyopathy-
Hypertrophied walls and/or septum, decreases SV & CO
o High incidence of fatal arrhythmias
o Restrictive cardiomyopathy
o Rarest; assoc. with sarcoidosis, amyloidosis
o Stiff ventricles that restrict filling during diastole
Leading cause with athletes
Swelling -thickened
Hypertrophic cardiomyopathy
cardiomyopathy-
o Replacement of cardiac tissue with fibrous, fatty tissue
Arrhythmogenic right ventricular cardiomyopathy
Reduction in either the number of RBCs, amount of hemoglobin, or hematocrit and decreases oxygen in blood
Anemia
First cause of anemia
Second
Third
Blood loss
Decreased RBC/renal disease/bone marrow
Rbc distruction - sickle cell anemia
Increased risk for anemia:
iron deficiency from poor nutrition
menorrhagia (heavy period bleeding) from menstrual,
sickle cell anemia,
trauma from excessive bleeding,
lack of erythropoietin from renal disease,
immunosuppression- from leukemia or lymphoma and medication therapy that depresses bone marrow activity.
S/s of anemia
The quicker the onset the more serious the condition.
Slowly becoming anemic may adapt to low hemoglobin levels:
common symptoms fatigue, weakness, skin pallor, tachycardia, shortness of breath. – severe may need to consider cardiovascular implications- heart pump faster in attempt to make up for low oxygen. Most common found in active adults, who will show a sign of anemia.
Tests for anemia
➢ Tests: hemoglobin, hematocrit, RBC indices , reticulocyte count, iron studies, Mcv- size of RBCs serum vitamin B12 are looked over.
Later CBC and erythropoietin and bone marrow are considered
Anemia ➢ Planning and Treatment:
What can occur from it and interventions
Arrhythmias can occur from anemic condition, as well as Hypovolemic shock when anemia continues to deteriorate-
interventions:
giving oxygen;
blood and blood products,
fluid and monitoring are all important steps to consider.
What to asses in anemia patients ?
o Assessment ➢ Risk for infection, risk for bleeding s/s: ➢ Cardiovascular changes ➢ Respiratory changes ➢ Intestinal changes ➢ Central nervous system changes o Laboratory assessment ▪ The definitive test for leukemia is an examination of cells obtained from bone marrow aspiration and biopsy
: type of anemia that occurs hemolysis outside RBC
o Genetic, Burns, radiation, drugs, toxins, autoimmune disease, transfusion reactions and bacterial infections can all cause.
o Enlarged spleen from removing damages RBCs.
Liver is pushed to it limits and can increase bilirubin levels and jaundice!
Most sever bone marrow can fracture, patient having deoxygenating and skin pallor, tachycardia and hypotension.
Hemolytic Anemia’s
Autosomal Recessive defect and a type of hemolytic anemia, causing synthesis of an abnormal form of hemoglobin within the red blood cells. Common in African descent, from parent to offspring- giving 50 percent chance of transmitting the gene to child.
**Deoxygenation is the most important variable!
Sickle Cell Anemia
Sickle cell findings
fatigue, pallor, jaundice, irritability- occluded circulation
Sickle cell anemia tests
➢ Tests:
Hematological test and essential and family history- presence of Hgbs in the blood.
Tx of sickle cell
➢ Treatment:
IV fluids for dehydration,
antibiotic therapy, and
bone marrow transplants,
splenectomy.
Medication for sickle cell
Oxygen as it effect oxygenation, Antisickling agents like urea, cyanate are given.
Folic acid supplements must be given to meet RBC production-
blood transfusion are often needed.
: loss of iron becomes inadequate for RBC production- common in elderly, Increase dietary intake & absorption
Most common type
Iron Anemia
Folic Acid Deficiency Anemia
Found in who
Diet?
Normally in green leafy vegetables, fruits, and cereals.
Found in drug abusers, elderly and alcoholics. Poor nutrition, malabsorption, drugs, etoh
Tx for anemia
RBC infusion Folic acid -green leafy veggies vit b12 Iron replacement (meat) O2 Hemodynamic and cardiac monitoring Erythropoietin -hormone by kidney that produces bone marrow (when then produce blood cells)
lack of intake or malabsorption, higher if cognitive disability, Smooth, beefy red tongue, paresthesias, jaundice, wt loss. Increase dietary intake, supplements, B12 injections
Vitamin B12 Anemia:
- Deficiency of RBC’s due to impaired cellular regulation of bone marrow
And injury to pre-cursor cells
Due to bone marrow damage
Aplastic anemia
the body’s immune system stops red blood cells from forming or causes them to clump together.
Treated with Immunosuppressant, steroids, splenectomy
Immunohemolytic anemia-
• Is an inherited disease whereby hemoglobin synthesis is missing either the alpha or beta chain of the hemoglobin molecule. Resulting in hemoglobin production being deficient and weak, hypochromic RBCs are formed and labeled target cells (bull eye appearance).
blood disorder involving less than normal amounts of an oxygen-carrying protein and fewer RBC than normal.
If children get this young, rarely live to adulthood, most common in Asians from China, Philippines and Thailand.
Thalassemia
What causes Thalassemia
Four genes causes alpha chain formation, with either one, two, three, or all four may cause the thalassemia conditions.
If all 4 are defective, the result is labeled alpha thalassemia major and is fatal, most commonly in utero.
Findings of Thalassemia
➢ Findings: mild to moderate anemia, bone marrow hyperplasia, bronze skin coloring-
more serious results in heart failure, liver and spleen dysfunction from increased RBC destruction, sever anemia, and fractures to long bones, ribs .
- form of anemia caused by genetic defect in RBC metabolism.
Contracted most commonly from medication that caused inflammatory disorder.
It is more common in males as it is on the X chromosome, usually Mediterranean or African people.
A condition causing red blood cells to break down in response to certain medications, infections, or other stressors.
Glucose- 6- Phosphate Dehydrogenase Anemia
G6PD
Aka - hemolytic anemia
➢ Findings of
Glucose- 6- Phosphate Dehydrogenase Anemia :
Aka hemolytic anemia
will normally have normal hemoglobin levels, but certain medication cause hemolytic effects-
jaundice, skin pallor, hemoglobinuria (in urine).
Tests for Glucose- 6- Phosphate Dehydrogenase Anemia :
Aka- hemolytic anemia
➢ Test: screening test, Heinz bodies may be identified, as well as hemoglbinuria.
Medications that will heighten effects of Glucose- 6- Phosphate Dehydrogenase Anemia :
Aka hemolytic anemia
Vitamin K, Thiazide diuretics, Sulfonamides, oral hypoglycemic, antimalarial drugs, and Nitrofurantoin.
is the MOST COMMON HEMOLYTIC DISORDER.
There is no abnormality of the hemoglobin and it is found in 1-5000.
Autosomal dominant disorder- abnormality of the erythrocyte membrane, and prematurely destroyed in the spleen.
Aka
Hereditary Spherocytosis
Also known as congenital hemolytic anemia and
Hereditary Spherocytosis findings
Findings:
starts in utero or early infancy exhibits anemia and hyperbilirubinema, higher severity so does jaundice appearance.
Gallstones develop young, and Aplastic crises are the most serious complication.
Hereditary Spherocytosis tests
➢ Test: family history, blood smear, no single test to identify.
➢ Hematological changes in older adults
➢ Decrease in blood volume with lower levels of plasma proteins
➢ Bone marrow produces fewer blood cells
➢ RBC, WBC counts lower
➢ Lymphocytes less reaction to antigens, lose immune function
➢ Hemoglobin levels fall after middle-age
FINDINGS IN HEMATOLOGIC DISORDERS NORMAL CHANGES IN THE OLDER ADULT SIGNIFICANCE/ALTERNATIVES
Nail Beds (for Capillary Refill) Pallor or cyanosis may indicate a hematologic disorder.
Thickened or discolored nails
Hair Distribution Thin or absent hair on the trunk or extremities may indicate poor PERFUSION to a particular area.
Progressive loss of body hair is a normal facet of aging. A relatively even pattern of hair loss that has occurred over an extended period is not significant.
Older adults also have decreased pubic hair as a result of age-related hormone changes.
Skin Moisture Skin dryness may indicate any of a number of hematologic disorders.
Skin dryness is a normal result of aging.
Skin moisture is not usually a reliable indicator of an underlying pathologic condition in the older adult.
Skin Color Skin color changes, especially pallor and jaundice, are associated with some hematologic disorders.
Pigment loss and skin yellowing are common changes associated with aging.
Pallor in an older adult may not be a reliable indicator of anemia. Laboratory testing is required.
Yellow-tinged skin in an older adult may not be a reliable indicator of increased serum bilirubin levels. Laboratory testing is required.
➢ Blood transfusion therapy
Pretransfusion:
Interventions
- Verify order with another RN
- Obtain consent, educate patient
- Test donor’s/recipient’s blood for compatibility
- Determine IV access
- Obtain blood product from lab
- Verify patient’s identity with another RN
- Examine blood bag label, attached tag, and requisition slip for ABO and Rh compatibility with the patient with another RN
- Check expiration date with another RN
- Inspect blood for discoloration, gas bubbles, cloudiness
Blood transfusion
• During transfusion?
Nursing interventions
- Provide patient education re: reaction symptoms
- Assess vital signs immediately before starting infusion
- Begin transfusion slowly, stay with patient first 15 minutes
- Ask patient to report unusual sensations (for example, chills, shortness of breath, chest or back pain, hives, itching)
- Administer blood product per protocol
- Assess for hyperkalemia
Older adult receiving transfusion?
Nursing interventions
Consider chronic diseases • Monitor for fluid overload • Transfuse slower • Decrease chance of overload • Decrease chance of infiltration • Space units apart
• Post Transfusion
Nursing interventions
- Post Transfusion
- Vital Signs
- Flush access site until clear
- Red bag blood bag & tubing
- Nursing Note/Complete documentation
- Follow up on lab values
—
• given to replace cells lost from trauma or surgery
RBC transfusions
—given for low platelet counts, active bleeding, scheduled for invasive procedure
Platelet transfusions
—given to replace blood volume and clotting factors
Plasma transfusions
Transfusion —-given (rarely) to neutropenic patients
Granulocyte (WBC) transfusions
Acute transfusion reactions
• Febrile • Hemolytic • Allergic • Bacterial • Circulatory overload Transfusion-associated graft-versus-host disease (GVHD
shape into sickle shape, cells die early, shortage of RBC which results in anemia, blocks blood flow which causes pain=crisis
➢ sickle cell disease
Sickle cell s/s
s/s:
➢ Hypoxia, dehydration, infection, venous stasis, pregnancy, etoh, high altitudes, fever, acidosis, strenuous exercise, emotional stress, anesthesia
What to asses in sickle cell disease
o Pain is the most common SCD symptom o Cardiovascular changes o Respiratory changes o Skin changes o Abdominal changes o Kidney and urinary changes o Musculoskeletal changes o Central nervous system changes
: blocks blood flow which causes pain=crisis, pain can last from hours to days. Pain is usually in back, legs, knees, chest, arms, stomach. (sharp, throbbing, dull, stabbing)
Sickle cell crisis
Priorities of care in sickle cell
o priorities of care
o Manage pain
o Drug therapy (opioids, hydroxyurea)
o Hydration (decreases sickling)
o Oxygen (hypoxia is main cause of sickling)
o Prevent sepsis/infection
o Continual assessment
o Prevention & early detection strategy
o Drug therapy
o Care coordination & transition management
Red blood cell (RBC) count
Male range ?
Female range?
Increased and decreased levels mean what?
Females: 4.2-5.4 million/
Males: 4.7-6.1 million/
Decreased levels indicate possible anemia or hemorrhage.
Increased levels indicate possible chronic hypoxia or polycythemia vera.
➢ Hemoglobin (Hgb)
Ranges?
Females: 12-16 g/ Same as for RBC. Males: 14-18 g
Hematocrit (Hct)
Ranges
Females: 37%-47% volume fraction Same as for RBC. Males: 42%-52%
Mean corpuscular hemoglobin concentration (MCHC)
Increased ?
Decreased?
32-36 g/dL or 32%-36% Same as reference range
Increased levels may indicate spherocytosis or anemia.
Decreased levels may indicate iron deficiency anemia or a hemoglobinopathy.
Mean corpuscular volume (MCV)
Ranges
Increased ?
Decreased?
80-95 fL Same as reference range
Increased levels indicate macrocytic cells, possible anemia
. Decreased levels indicate microcytic cells, possible iron deficiency anemia.
Mean corpuscular hemoglobin (MCH) 27-31 pg Same as reference range Same as for MCV.
Y
White blood cell (WBC) count
Increased ?
Decreased?
5000-10,000/mm3 5.0-10.0 × 109 cells/L
Increased levels are associated with infection, inflammation, autoimmune disorders, and leukemia.
Decreased levels may indicate prolonged infection or bone marrow suppression.
Reticulocyte count
Increased ?
Decreased?
0.5%-2.0% of RBCs Same as reference range
Increased levels may indicate chronic blood loss.
Decreased levels indicate possible inadequate RBC production
Total iron-binding capacity
Increased ?
Decreased?
(TIBC) 250-460 mcg/dL 45-82 mcmol/L
Increased levels indicate iron deficiency.
Decreased levels may indicate anemia, hemorrhage, hemolysis.
Iron (Fe)
Females:
Increased ?
Decreased?
60-160 mcg/dL
Increased levels indicate iron excess, liver disorders, hemochromatosis, megaloblastic anemia.
Decreased levels indicate possible iron deficiency anemia, hemorrhage.
Males: 80-180 mcg/dL
Serum ferritin Females:
Female: 10-150 ng/mL
Same as for iron.
Males: 12-300 ng/mL
Platelet count
Increased
Decreased
150,000-400,000/mm
Increased levels may indicate polycythemia vera (too many red blood cells) or malignancy.
Decreased levels may indicate bone marrow suppression, autoimmune disease, hypersplenism.
Hemoglobin electrophoresis Hgb A1:
Variations indicate hemoglobinopathies.
Direct and indirect Coombs’ test Positive or negative findings indicate antibodies to RBCs
It is abnormal And means your body will fight against the RBCs
Positive
International normalized ratio (INR)
Increase and decrease means?
0.8-1.1
times the control value Same as reference range Increased values indicate longer clotting times. This is desirable for anticoagulation therapy with warfarin.
Increased number means thinner blood
Decreased values indicate hypercoagulation and increased risk for venous thromboembolic events. (Clotting )
Prothrombin time (PT)
Increase ?
Decrease? Means what
11-12.5 sec 85%-100% Same as reference range
Increased time indicates possible deficiency of clotting factors V and VII.
Decreased time may indicate vitamin K excess.
Pallor and cyanosis are more easily detected in adults with darker skin by examining the ???
Jaundice can be seen more where??
Petechiae may be visible only ??
Bruises can be seen as darker areas of skin and palpated as??
Ask the patient about pain when skin surfaces are touched lightly or palpated. (
Chapter 24 provides tips for assessing darker skin.)
oral mucous membranes and the conjunctiva of the eye.
On the roof of the mouth
on the palms of the hands or the soles of the feet.
slight swellings or irregular skin surfaces.
Verify that a patient having a bone marrow aspiration or biopsy has signed a/an??
informed consent statement.
Risk factors for those with hematologic disorders
Age-elderly
Gender -female
Drug use, anticoagulants, NSAIDS, illicit
Iron and protein deficiency
Poor- Healthy foods are more spendy
Family hx of clotting disorders
Currents health issues
• Do not palpate the of any patient suspected of having a hematologic problem.
QSEN: Safety
splenic area
• Maintain pressure over a venipuncture site for at least how long to prevent excessive bleeding.
QSEN: Safety
5 min
Patient with hematologic disorders should eat a diet high in what?
Instruct patients about the importance of eating a diet with adequate amounts of foods that are good sources of
iron, folic acid, and vitamin B12.
• The most common symptom of a hematologic problem is ?•
Fatigue
Both clotting forces and anticlotting forces are needed to maintain adequate what??
Perfusion
Use the ? rather than nail beds to assess capillary refill on older adults.
Lip
• Rely on ?? rather than skin color changes in older adults to assess anemia or jaundice.
Lab results
- Assess the patient’s endurance in performing ADLs.
- Teach patients and family members about what to expect during procedures to assess hematologic function,
including restrictions, drugs, and follow-up care.
Yes
Apply what? to the needle site after a bone marrow aspiration or biopsy.
Ice pack
Check the needle insertion site at least every 2 hours after a bone marrow aspiration or biopsy.
If the patient is going home, teach the patient and family how to assess the site for bleeding and when to seek help.
QSEN: Patient-Centered Care •
Instruct patients to avoid ??
activities that may traumatize the site after a bone marrow aspiration or biopsy.
• In collaboration with who? help the patient incorporate healthy eating behaviors to lower cholesterol and saturated fats and increase :
? What ??
Teach patients to engage in how long/type of exercise?? to lower blood pressure and LDL-C levels.
Dietitian
fresh fruits, vegetables, and fiber in the diet. For overweight patients, assist in a weight-reduction plan•
40 minutes of moderate-to-vigorous physical activity three or four times a week
?? occurs when fatty plaques occlude arteries and prevent adequate PERFUSION to vital body tissues
. • Monitor what labs?
atherosclerosis
total cholesterol, HDL-C, and LDL-C levels to assess patient risk for atherosclerosis.
• Teach patients taking any of the statins …
in Table 36-5
to report any adverse effects,
including ??? to their primary health care provider.
Monitor the patient’s ??? carefully.
Monitor muscle cramping
Monitor liver enzymes
Monitor for ??? levels when patients are taking thiazide or loop diuretics
Why?
decreased serum potassium
hypokalemia could cause life-threatening cardiac dysrhythmias (
see Chart 36-1).
??? is the most common type of peripheral vascular problem.
Deep vein thrombosis (DVT)
Teach foot care for patients with PVD as outlined in Chart 36-6.
Yes
Monitor for indications of aneurysm rupture:
What are the s/s?
diaphoresis, nausea, vomiting, pallor, hypotension, tachycardia, severe pain, decreased level of consciousness.
• Varicose veins can cause severe pain and reflux requiring the three Es:
elastic compression hose
exercise
elevation.
Ace inhibitors and arbs (prils and sartins) decrease afterload or preload of hf and arbs
Decrease afterload (pressure it takes to expel blood through vessel)
First line Tx for preload hf
Diet, then diuretics ..morphine?
average pressure in a patient’s arteries during one cardiac cycle. It is considered a better indicator of perfusion to vital organs than systolic blood pressure
MAP
Mean arterial pressure
Tx for anemia?
oxygen
pain relievers
oral and intravenous fluids-to reduce pain and prevent blood transfusions
folic acid supplements and antibiotics.
When DVT symptoms are present, they include??
• Be aware that DVT can lead to ?
swelling, redness, localized pain, and warmth.
pulmonary embolism, a life-threatening emergency!
Clinical Judgment
