Test #1 Flashcards
Describe hypotonic vs hypertonic solutions
- Hypotonic solutions have less solutes outside of the cell, so fluids rush into the cell to try and even out the concentration.
- Hypertonic solutions have more solutes outside of the cell, so fluids leave the cell and move to the lower concentration.
What are 3 examples of hypertonic solutions
- 3% NS
- 5% NS
- 5% dextrose in 0.9% saline (D5NS)
- 5% dextrose in 0.45% saline
- 5% dextrose in LR
What are 2 examples of isotonic solutions
- LR
- 0.9% normal saline
What are 3 examples of hypotonic solutions
- 0.45% normal saline
- 2.5% dextrose in water
- 0.33% normal saline
Why would we want to give hypotonic and hypertonic solutions for high and low levels of sodium.
- Hypertonic goes with hyponatremia (pulls sodium back into your vascular system)
- Hypotonic goes with hypernatremia (pushes sodium back into your cells)
What should I remember about D5W
It’s technically an isotonic solution, but the body will metabolize the dextrose, which then turns into a hypotonic solution. (wants dextrose is absorbed, you’re left with just water = hypotonic).
Why would someone receive an isotonic solution
- We want to replace the extracellular fluid (without doing anything to the cells)
Can be caused by blood loss, D/V, dehydration
What is a good way to remember hypotonic
Think of tonic as the as the solution, and the hypo is stating that there is a low amount of solutes in the solution. This means the fluid will want to move to where it’s more concentrated - which is inside the cell. (the solution contains lower concentration of salt or solute than inside the cell)
- They also have a lower osmolality (less concentrated)
When might we give a hypotonic solution
(When there is cellular dehydration - we want water to go into the cells)
- DKA (because there is so much sugar in the blood, water is being pulled out of cells to try and balance, so we want to dilute these)
- Hyperglycemia (because of the reason above)
When do you not want to give a hypotonic solution 3
- Do not give to a patient with increased intercranial pressure, because it can cause fluid to go into the brain and swell. (basically don’t give to someone with a head injury)
- Do not give to burn victims
- Do not give to trauma patients
- Hypovolemia
(we don’t want to deplete their extracellular fluid volume any further)
If I don’t remember the names of the fluids, what’s a good way to determine if a fluid is hypertonic or hypotonic.
Hypertonic fluids will have a higher number like 5% or 10%, while hypotonic fluids will have a lower number like 0.45% (because they’re diluted).
What can hypertonic solutions cause
Fluid overload - because you’re pulling all of the fluid out of your cells and putting it into your vascular system
Why would we give a hypertonic solution
- Hypovolemia (want to move fluid into the blood vessels)
- Cerebral edema (helps to take fluid off of the brain)
What is the difference between crystalloid and colloid solutions
Crystalloids contain small molecules like electrolytes, while colloids contain large proteins and fats.
What are our crystalloid solutions
Our isotonic, hypertonic and hypotonic solutions
What do colloids do
Because of their size, they pull fluid into the blood vessels (these are our volume expanders)
If a patient has 1 liter of blood loss, how much of a crystalloid will they need to replenish that loss
3L (because the crystalloids will also go out into the space, they won’t just stay in the vessel)
What are side effects of LR 4
- Dilutes hemoglobin
- May cause hyperchloremic acidosis (caused by the chloride)
- May cause electrolyte imbalance
- Proinflammatory in large doses
Why do we want to give colloids
Because we want fluid to stay in the vascular system and not leak out (the large molecules in colloids pull and keep fluid in the blood vessels)
Because colloids stay in the blood vessels, how much colloid solution would we need if we lost 1L of blood
We will only need 1L of colloids (it’s in a 1:1 ratio)
What are examples of colloids 5
- 5% albumin (this is the main one)
- 25% albumin
- Dextran 40
- Dextran 70
- Hydroxyethyl starches
Why are colloids not given very often
They’re expensive - so we like to give crystalloids first
Because crystalloids do not stay in the blood vessels, like colloids, what ratio should crystalloids be given in.
3L of crystalloids for every 1L of blood loss.
What is albumin used for
Volume expansion - so it’s used to treat hypovolemia, burns, ascites and hepatic failure.
What is dextran and hydroxyethyl starches used for
These stay in the system for a long time and can be used to treat shock.
What does a low and high osmolarity signify
Low osmolarity - you have excess fluids, so it will show that you have less solutes (because they’ve been diluted).
High osmolarity - you have low fluids, so it is going to show that you have high solutes.
If you have a lot of dehydration in the body, because you’re urinating a lot, in which case your body has high osmolarity, what will be the osmolarity of your urine
It will be low - because you’re urinating so much, that urine is going to be diluted (think in the body and urine are opposites).
Vise versa if you have low osmolarity in your body, because you have so much excess fluid, you’re not peeing a lot, so that urine is going to be concentrated, in which case have a high osmolarity.
What are two indications for hypotonic solutions
- Diabetic ketoacidosis
- Hyperosmolar hyperglycemia
What are three indications for hypertonic solutions
- Severe dehydration
- Severe electrolyte imbalances
What can cause hypovolemia
- GI (diarrhea, vomiting, bleeding)
- Urinary (diuretics)
- Integumentary (burns)
- Hyperglycemia and DKA
- Large wounds and hemorrhage
- Hyperventilation (expending fluid through respiration)
What are signs of hypovolemia
- Hypotension
- Low BP and High HR
- Weak, thready pulses
- Flattened neck veins
- Increased BUN and creatinine
- Falsely increased hematocrit (because it’s going to be concentrated due to the low fluid)
- High urine specific gravity
How would you manage someone with hypovolemia 4
- Treat the underlying cause
- Encourage oral fluids
- Administer replacement fluids
- Monitor I/Os, WT, tissue perfusion and LOC
What drugs can cause hypervolemia
Corticosteroids
What are a few other etiologies that can cause hypervolemia (that I don’t already know) 5
- Cirrhosis and liver failure
- Cancer
- Peripheral vascular disease
- High sodium intake
- Protein malnutrition
What are signs of hypervolemia (a lot)
- Crackles in lungs
- Pitting edema
- SOB
- Weight gain
- Ascities
- Hypertension
- Tachycardia
- Orthopnea
- Decreased O2 sats
- Low serum osmolarity
- Falsely low H&H due to the dilution
What are signs of hypervolemia (a lot)
- Crackles in lungs
- Pitting edema
- SOB
- Weight gain
- Ascites
- Hypertension
- Tachycardia
- Orthopnea
- Decreased O2 sats
- Low serum osmolarity
- Falsely low H&H due to the dilution
What are signs of hypervolemia (a lot)
- Crackles in lungs
- Pitting edema
- SOB
- Weight gain
- Ascites
- Hypertension
- Tachycardia
- Orthopnea
- Decreased O2 sats
- Low serum osmolarity
- Falsely low H&H due to the dilution
When do we never want to give a hypotonic solution
When someone is having cerebral edema (because fluid will rush into the cells and cause them to burst)
When do we use hypertonic solutions 4
When we want to move fluid into the blood vessels
- Water intoxication
- Overuse of hypotonic solutions
- Elevated antidiuretic hormone (ADH)
- Renal failure
If a person has diabetes, where do we not want to put IVs
In their feet (because of the peripheral neuropathy and wound healing problems)
When do we see 14, 16 and 18 gauge catheters used
Trauma, surgery, massive transfusions, rapid administration of large volumes.
When do we see 20g catheters
Infusions or blood transfusions
When do we see 22g catheters
Infusions for small veins
When do we see 24g catheters
Infusions for fragile veins
What is phlebitis
Inflammation of the vein
What are the signs of phlebitis
Redness, warmth, discomfort, swelling.
What causes phlebitis 3
- The types of medications, like potassium (this is why we dilute things).
- Maybe a clot is forming
- The catheter is close to the vein
What would you do if you see phlebitis happening
Stop the infusion, remove the catheter
What is infiltration
Infusion of a medication, other than a vesicant (something that destroys the tissues) , that has leaked outside of the vein
What are the signs of infiltration
- Edematous (swelling from fluid)
- Pale, cool skin
- Tight skin
How can we prevent infiltration
- Make sure you’re getting a good blood return when you put in IV
- Make sure you get a good flush
- Secure the IV well
- Try to avoid putting IV in flexion areas
What is extravasation
Vesicant leaking into the tissue causing damage and necrosis
What do you if there is extravasation
- Stop the infusion
- Try to aspirate any drug out that you can
- Then take the catheter out
- Call doctor
- There are some antidotes that you can use
How do we administer an antidote if there is extravasation
You administer the antidote around he site of the extravasation using a 23-25g needle (using a different needle each time)
How can we help avoid mechanical failure
Continue with routine scheduled flushes and dressing changes
What is a midline
Halfway between a central line and an IV
Goes into the upper arm, but doesn’t go all the way to the heart (tip ends around the shoulder - midway to the heart).
Why would we use a midline
When you need to have the IV longer than a regular IV, but you don’t need it as long as a PICC (usually stays in for 1-4 weeks)
- Typically used for short term outpatient antibiotic therapy
Why would we use central lines
- Vesicants like chemotherapy and vasopressors (like epinephrine)
- Administration of TPN
- Outpatient antibiotic infusions
- Dialysis
- Poor peripheral access
Why is it helpful to have medication go straight to the heart in central lines
So it can be pumped out to the rest of the body right away
Where does the end of a central line rest
At the superior vena cava, where the medication can then go straight into the right atrium
What are the three types of centrals
- Centrally inserted catheters
- Peripherally inserted central catheters (PICCs)
- Ports
What are the two types of centrally inserted catheters
- Nontunneled (go through the subclavian or internal jugular vein or femoral vein)
- Tunneled (surgically placed
What do PICCs carry a higher risk of compared to other central lines
Deep vein thrombosis and phlebitis
Can you take a BP on the same arm with a PICC
NO
Why would it be helpful to have a triple lumen
You could use two lumens for incompatible drugs and then the third for blood sampling
Why does a tunneled catheter have less of a risk of infection
It has a dacron cuff, it’s a cuff that is coated in antimicrobial solution that goes on the outside of the catheter
What is non-tunneled typically used for
- Emergent use
- Outpatient
- Dialysis
What is the difference between a groshong and broviac/hickman?
- Groshong is a valve, and does not require the use of heparin (valve prevent backflow)
- Broviac/hickman, does not have a valve and needs heparin (blood will try and backflow and clot off)
What is a trialysis catheter used for
Short term emergency use for dialysis (kidneys are going to be ruined and they are going to die) (these still go straight to the heart, usually placed in the neck)
How many lumens does a trialysis catheter have
3
- Two ports for dialysis and one port for infusion and lab draws
How should ports for dialysis be locked
With a heparin lock and must be withdrawn prior to flushing
What is the advantage of a port
Low risk for infection, but remember that the population is at a high risk of infection.
What type of needle do we use to access a port
A huber needle
How long can a port stay in
6 years
What you put in a central line, what should you get to confirm placement
- Blood return
- An x-ray (you don’t want to accidently put it in the lungs)
- Ok order from physician to use
What are complications of central line
- Infections (this is why all central line procedures and dressing changes are sterile)
- Pneumothorax (collapsed lung) (when the catheter goes into the lungs - you will hear decreased breath sounds)
- Bleeding (usually happens at femoral site - so prefer jugular or subclavian)
Besides the obvious, how can we avoid infections in central lines
- Antiseptic biopatch
- Daily chlorhexidine baths
What are some good tips for a central line dressing change
- Removing the old bandage is a clean procedure (just don’t touch the central line - you will need sterile gloves for this one), - Cleaning and applying a new bandage is a sterile procedure
- Allow chlorhexidine to dry for at least 2 minutes
- Dressing should be changed at least every 7 days
To flush a central line, how much saline should we use
The full 10mLs
When you’re flushing a central line, how should you flush it
With a propelling motion to get any clots out
How should we draw labs from a central line
- Flush with saline syringe, and then with the same syringe withdraw 5-10mLs of blood (using the propelling motion to draw up)
- Remove and discard that syringe
- With a new syringe withdraw specimen
- Once done, flush with 20mLs
How to discontinue a central line
- Position the patient supine and lower the HOB 10-15 degrees if not contraindicated, and have patient turn their head away from the catheter
- Remove dressing, sutures
- Cleanse the site
- Instruct the patient to hold their breath and bear down for about 10 seconds (this helps reduce an air embolism)
- Withdraw the line in one continuous motion
- Apply pressure to the site with a gauze for at least 2-5 minutes
- Patient may need to remain flat for 20 minutes or more
Where does an intraosseous go
Into the bone marrow
Why would we do an intraosseous
Usually do to a trauma - when there is no where else to put a line
Where are the preferred sites of an intraosseous
- Proximal tibia
- Distal tibia
- Proximal humerus
What are complications from an intraosseous
- Bone infection
- Compartment syndrome
What is good to know about nontunneled lines
- They are used in the short-term
- High risk for infection
What are our two long term lines
- Tunneled
- Ports
What do arterial lines allow us to do
Allows for continuous blood pressure monitoring and frequent lab draws
Where can arterial lines be
- Femoral
- Radial
- Brachial
- Axillary
What is interesting about arterial lines and reading the BPs
BPs can be different based on what artery is being used, so we use the MAP, which measures the average pressure (the MAP will be the same no matter what artery you’re using)
What should you compare arterial BPs too?
An automatic or manual BP cuff (you want to spot check with other BP measurements)
What test do they use to pick an artery with good flow? How does it work?
Allen’s test - compress both arteries, the brachial and ulnar, the hand should be white from lack of blood flow, then allow the ulnar artery to flow and we should see the hand flush red. - this tells us that we can use the radial artery, because the ulnar has good blood flow
What are complications of an arterial line
- Occlusion of the radial artery, where one artery has the arterial line and the other is being occluded.
- Bleeding
With arterial lines, what do you want to monitor for besides bleeding
Monitor the extremity below the line for pallor, paresthesia (pins and needles), coolness, in case there is an occlusion
What should we monitor if our patient receives an epidural
- Monitor their dermatomes
- Monitor for hypotension, respiratory depression and bradycardia
Why do we want to avoid giving a patient with an epidural medications that can cause them to bleed?
You could develop a spinal hematoma, which can lead to permanent paralysis (so make sure you check if they are on blood thinner prior, as they should not receive an epidural)
If a patient has received an epidural, should we administer oral respiratory depressants
NO - this can lead to respiratory depression
Should we ever let an IV bag run dry?
NO - this can allow air to run into the IV
What should a patient never receive if they have an epidural
- Toradol
- Heparin
- Warfarin
- Plavix
- NSAIDS
- Anticoagulants
(unless ordered by the anesthesiologist or until two days after the epidural catheter is pulled)
What can cause a headache if you have an epidural
If your epidural punctures through, and spinal fluid is lost - this causes a change and pressure and can lead to a headache.
What if you miss the epidural space and go into the subarachnoid space
The difference in the amount of medication that you need in each space is different, so a regular dose of medication in the epidural space can actually be an overdose in the subarachnoid space.
What is the difference between an epidural and an intrathecal
An epidural goes into the epidural space, while an intrathecal goes into the subarachnoid space (this space requires much less medication than the epidural space). Plus, medications in the intrathecal space go into the spinal fluid and you can give medications that will cross the blood-brain barrier. Like if you needed to give a specific chemo.
What is interesting about chemotherapy drugs and intrathecal admin
There are only 4 chemotherapy drugs that will work in this space, all others would be fatal.
Can you administer medications in the intrathecal space that have perservatives
NO
What is the ON-Q ball
Way to give localized pain relief, which is helpful for addicts (so they don’t have to take narcotics)
What are risks of the ON-Q Pain relief ball
- Cartilage breakdown
- Cellulitis
- Tissue necrosis
What are antineoplastic agents
Chemotherapy, biologic therapies, targeted agents and hormonal agents
If you are administering chemo, what should be done 6
- A spill kit should be nearby for waste
- You should wear special gloves, gowns and goggles
- Double verification required for some agents
- Monitoring for extravasation or infiltration (why we use a central line most of the time)
- Look for blood return when you’re giving it
- All materials should go into a hazardous waste bin
What are the differences between TPN and PPN 5
- TPN is total nutrition, while PPN is more of a supplement.
- TPN is typically given through a central line, while PPN is peripheral
- PPN is usually two weeks or less, while TPN is more long term
- TPN has more dextrose
- TPN is nutritionally complete (has everything you need)
What are indications for TPN 5
- If a patient is unable to absorb nutrients through the GI tract for 10 days or more
- Debilitating illness lasting longer than 2 weeks
- Loss of 10% or more of pre-illness weight
- Serum albumin below 3.5
- Renal or hepatic failure
What are nursing management things for TPN or PPN 8
- Monitoring blood sugars every 4-6 hours, especially for TPN, because it has a ton of sugar
- Monitor weights, Is and Os
- Monitor labs - electrolytes and albumin.
- Requires a larger filter - 1.2 micron (because you’re using lipids)
- Tubing needs to be changed every 24 hours (so bacteria doesn’t grow because the sugar content is so high)
- If lipids are hung as a secondary they should be administered at the same time each day
- If TPN or PPN must be paused, IV dextrose should be started to prevent hypoglycemia
- There should be a dedicated line for TPN or PPN
What are the two different ways lipids can be administered
- As part of TPN
- As a secondary infusion
What is the purpose of lipids and dextrose
They provide the needed calories for energy so the amino acids can be utilized for wound healing
Who mixes TPN
Pharmacy
What are some considerations with TPN/PPN 3
- Should be stored in the refrigerator and then removed about an hour prior to administering
- Overserve the bag
- Examine the lipid emulsion for “cracks” which would indicate that it has separated and should be returned to the pharmacy
What are some complications of TPN 3
- Infections
- Mechanical (tubing can get clogged, etc)
- Metabolic
What are specific metabolic problems with TPN 5 (these problems usually resolve themselves once they are off TPN)
- Hyper/hypoglycemia (don’t immediately stop TPN, it needs to be titrated down because of the high sugars)
- Prerenal azotemia (build up of protein waste products - which can damage your kidneys)
- Hyperlipidemia
- Hepatic dysfunction
- Refeeding syndrome
What is refeeding syndrome
Life threatening electrolyte imbalances when feeding is restarted after periods of starvation
What are indications for PRBCs
- Anemia
- Blood loss
What are indications for platelets
- Thrombocytopenia
- Cancer treatments when platelets are low (usually less than 20,000)
What are indications for albumin (made from plasma)
- Hypovolemic shock (this is our volume expander - it’s going to keep fluid in the intervascular space)
- Hypoalbuminemia
What are the indications for fresh frozen plasma (FFP)
- Rich in clotting factors (does not have platelets), so it can be given for DIC, hemorrhage, massive transfusion, liver disease, vitamin k deficiency and excess warfarin)
Do we need to infuse FFP slowly?
No, we can usually open FFP wide open and infuse for 30-60 minutes
What is cryoprecipitate
Concentration of all of the clotting factors from plasma (more concentrated then FFP).
What is cryoprecipitate given for
When you are in a more severe need of clotting factors
- Especially VII - Von Willebrand’s disease and Fibrinogen (DIC)
What are alternative therapies to giving blood components
- Erythropoietin (stimulates bone marrow to start producing more RBCs) (can given to cancer patients, kidney disease or anemia)
- Autologous blood donation (own blood)
- Clotting factors
- Fluid Resuscitation (colloids)
- Acceptable to some (albumin, platelets, immunoglobulins - antibodies)
Why is the Rh important
If mom is negative, and baby is positive, then it can cause the mom to create antibodies that will attack that fetus. (get Rhogam)
What is unique about type O
It doesn’t have any antigens
What type of antigens and antibodies does type A have
A antigens and B antibodies
What type of antigens and antibodies does type B have
B antigens and A antibodies
What type of antigens and antibodies does type AB have
AB antigens and no antibodies
What type of antigens and antibodies does type O have
No antigens and AB antibodies
What’s a good way to remember who can receive positive and negative blood
If you have positive blood, like A+, then you can receive blood from O-, O+, A- and A+, however, if you have A-, you can only receive blood from O- and A-.
What type of gauge should you be using for blood
An 18-20g
What color is an 18 and what color is a 20g
18 is green and 20 is pink.
If a patient has had a reaction int he past, what types of blood can we use 2
- Leukoreduced blood (low on WBC - reduces incidence of reactions)
- Irradiated (gets rid of anything else in the blood - used for high risk patients, like if you are immunocompromised, first degree relative, etc)
Which two populations will most always receive pre-medications 2
- Cancer patients
- Patients who have had reactions before
(Tylenol, dexamethasone, etc.)
What fluid do we always use with blood
0.9% NS - nothing else.
How fast can a rapid transfuser infuse blood
As fast at 750mls/minute
When giving blood, how long should we be in the room, monitoring the patient
For the first 15 minutes
After infusing blood, what should you do with their IV site
Flush with NS
How often should tubing be changed
Every two units or every four hours
What if you can’t infuse both bags in 2 hours
Then change the tubing in-between
What is a acute hemolytic reaction
ABO incompatibility
What are symptoms of ABO incompatibility
- Fever/chills
- Low back pain
- Flushing
- Tachycardia/tachypnea
- Hypotension
- Vascular collapse
- Hemoglobinuria/dark urine
- Shock/cardiac arrest
- Death
(symptoms usually occur within the first 15 minutes)
What do we do if we suspect an acute hemolytic reaction
- Stop the transfusion
- Run the saline (to help maintain their blood volume - with a new line)
- May need to give diuretics to maintain urine output
- Retype and cross
What is a delayed hemolytic reaction
Less severe reaction than acute hemolytic
What is some info on a delayed hemolytic reaction
- Occurs usually 5-10 days after
- No acute treatment is usually necessary
- Usually from the antibodies, where your body is not compatible with those antibodies
What is a febrile nonhemolytic reaction
When the recipient is really sensitive to the donor’s WBCs, platelets or plasma proteins
What are the symptoms of a febrile nonhemolytic reaction
- Sudden fever, chills, headache, anxiety, vomiting, muscle pain
What should we do if there is a febrile nonhemolytic reaction
- Give an antipyretic (to reduce their fever)
- Give leuko-reduced or irradiated products going forward
If the patient is having a mild allergic reaction, what should we do
The provider may have us premedicate with an antihistamine or steroid and then restart the transfusion
What are signs of anaphylaxis 5
- Hypotension
- Cyanosis
- Bronchospasm
- Shock
- Cardiac arrest
What are other complications 4
- Electrolyte imbalances (hyperkalemia & hypercalcemia)
- Sepsis (contaminated blood)
- Hypothermia (why we warm our blood)
- Fluid overload (can give diuretics, split up units so you can give it slowly)
What are signs of a fluid overload
- Cough
- Dyspnea
- Pulmonary congestion
- Adventitious breath sounds
- Headache
- Hypertension
- Tachycardia
- Distended neck veins
How can 1 unit of RBC impact your H and H
1 unit can increase hemoglobin by 1g or Hct by 3%
What are normal levels of hemoglobin
Females: 12-16
Males: 13-18
What are normal values of hematocrit
Females: 36-48%
Males: 39-54%
What is plasma made up of
Water, proteins, electrolytes, gases, nutrients (glucose, amino acids, lipids), and waste
What 3 elements make up blood cells
- RBCs
- WBCs
- Platelets
What are immature blood cells known as
Blasts
What regulates RBCs
Erythropoietin (produced by the kidneys) - these stimulate RBC production. If you have low oxygen, your body will produce more erythropoietin to stimulate RBC growth.
What is an immature RBC
Reticulocyte
What in hemoglobin carries oxygen
Each heme group on a hemoglobin molecule has one iron atom that can bind to one oxygen molecule
What is a typical RBC count
Males: 4.6-6
Females: 4-5
What is a typical reticulocyte count
0.5-1.5% of total RBCs
is a typical erythrocyte sedimentation rate (ESR) (test to see how fast your RBCs settle - faster they settle, more of a sign that you have inflammation in your body)
0-42 mm/hour depending on age and gender
What happens to our ability to create cells as we age
Aging lead to decreased bone marrow mass, which leads to a decrease in the ability of the body to make cells, which can lead to issues clotting, transporting oxygen, or fighting off oxygen, anemia.
What are typical symptoms of anemia
- Fatigue
- High HR
- SOB
- Possible headache
- Cold hands and feet
- Pallor
What is iron deficiency anemia
Where your body doesn’t have enough iron to form hemoglobin
What can cause iron deficiency anemia
- Chronic blood loss
- Medication
- Malabsorption (something is wrong with your GI, where you aren’t absorbing)
What are clinical manifestations
- Tachycardia
- Fatigue
- Tachypnea and SOB
- Pica (eating things that are not usually considered food - like eating dirt)
- Koilonychias (spoon nails from lack of oxygen)
- Glossitis (inflammation of the tongue)
- Pallor
- Cold hands and feet
How can iron deficiency anemia be diagnosed
Labs: H and H, RBCs, reticulocyte count, iron, ferritin, transferrin, TIBC, stool exam for occult blood
(low levels of H and H , RBCs and iron)
What are treatments for iron deficiency anemia
- Eat foods rich in iron (animal meet, beans, leafy greens, eggs, seafood)
- Increase vitamin C intake (fruits, broccoli)
- Iron supplementation (like ferrous sulfate)
- Limit blood loss
If someone is needing to take iron supplements, what should they take with them
Vitamin C to increase absorption
Why do we need vitamin B12
The body needs B12 to make RBCs
What can cause vitamin B12 deficiency
- Vegetarian/vegan diet
- Pernicious anemia
- Anything that alters the digestive system (crohn’s/celiac, alcoholism, drugs, GI surgery, etc)
Can our body make vitamin B12
No - we consume it from animal products or supplements
What are symptoms of vitamin B12
- Beefy tongue
- N/V
- Weakness
- Yellowish skin
- Weight loss
- Neurological symptoms
- Vision problems
- Numbness/tingling
- Depression
(important for physical, neurological and psychological functions)
What are symptoms of vitamin B12
- Beefy tongue
- N/V
- Weakness
- Yellowish skin
- Weight loss
- Neurological symptoms
- Vision problems
- Numbness/tingling
- Depression
How can we diagnosis Vitamin B12 deficiency
- CBC
- Vitamin B12 level
What is the treatment
B12 medication (usually cyanocobalamin)
How can you prevent Vitamin B12 deficiency
- Consume animal products
- If vegan, take supplements
- Avoid alcohol
What is Pernicious Anemia
An autoimmune disorder, where you do not create enough intrinsic factor, which is needed for the absorption of vitamin B12.
Why is B12 necessary
It is necessary for RBC production and to create myelin sheaths
What labs are we looking at for Pernicious Anemia 5
- CBC
- B12 levels
- Methylmalonic acid (MMA)
- Intrinsic factor levels
- Homocysteine (look at antibodies)
What are clinical manifestations of Pernicious Anemia
- Neurological issues (altered mental status, depression, etc)
- Visual disturbances
- Signs and symptoms of low RBCs (tachycardia, tachypnea, SOB)
How can we prevent Pernicious Anemia
- Adequate nutritional intake
- Supplementation
If you have Pernicious Anemia, what should you not receive in surgery
Nitrous oxide - it can worsen the anemia (it inactivates B12)
Why do we need folic acid
It’s necessary to make RBCs
What can cause Folic Acid Deficiency
- Inadequate intake
- Malabsorption (crohn’s, celiac disease, alcoholism, certain medications)
- Chronic Dialysis
What are manifestations of Folic Acid Deficiency
(Similar to other anemias)
- Tachypnea
- SOB
- Tachycardia
- Fatigue
- Dizziness
How do we diagnosis Folic Acid Deficiency
- CBC may show a decrease in hemoglobin
- Homocystein levels may be elevated
- RBC folate level
What foods are high in folic acid
- Fortified breads, cereals and rices.
- Beans
- Orange juice
- Spinach
What is sickle cell anemia
An autosomal recessive genetic disorder - that changes the size and shape of the RBC
Is there a cure for sickle cell anemia
No
What are signs and symptoms of sickle cell anemia
- Tachycardia
- Tachypnea
- Pain (periodic, chest, abdomen, and joints)
- Decreased hemoglobin
- Increased bilirubin
- Fatigue
- SOB
- Pallor
What can sickle cell anemia cause in the body
- Higher risk for infections
- Delayed puberty
- Growth and developmental delays
- Hand-foot syndrome (swelling and redness because of necrosis to the tissues)
- Death due to organ damage
What are treatments for sickle cell anemia
- Pain management (because blood is clotting due to the sickle cell shape causing swelling and pain)
- Hydration
- Oxygen (because you’re not getting good perfusion)
- Blood transfusions are a temporary fix (not used often)
- Stem cell transplant is an option
What organ can sickle cell anemia damage
The spleen can become enlarged, because these sickle cells do not have a long life span, so the amount of dead RBCs increases and the spleen is responsible for getting rid of this waste (basically becomes overworked)
Even though we can’t cure sickle cell anemia, what medication can we give to help RBCs not turn into the sickle cell shape
Hydroxyurea (can’t take if pregnant - causes birth defects)
How does sickle cell anemia impact your bones
They grow larger to try and produce more RBCs, but these causes them to become hallow and weak.
How does sickle cell anemia impact your bones
They grow larger to try and produce more RBCs, but these causes them to become hallow and weak.
How does sickle cell anemia impact your bones
They grow larger to try and produce more RBCs, but these causes them to become hallow and weak
What can trigger a sickle cell anemia crisis
Hypoxia caused by:
- Exercise
- Stress
- High altitudes
- Illness
- Temperature extremes
- Dehydration
What are signs of sickle cell anemia crisis
- Fatigue
- SOB
- Pain (joints, bones, chest, abdomen)
- Fever
- Impaired circulation
- Venous stasis
- Infarctions (CVAs, long term organ damage)
What does aplastic anemia cause
Pancytopenia which is the decrease production of all cell types
(basically your bone marrow isn’t making any of your cells)
What causes aplastic anemia
- Autoimmune
- Acquired (idiopathic, from medications, chemo, radiation, toxins, viruses)
- Inherited (rare)
How do we diagnosis
We will see low numbers for all cells on CBC or we could do a bone marrow biopsy
What are signs of aplastic anemia
- Easily bruising, because you’re low on all of your cells
- SOB
(anemia symptoms)
What are treatment options for aplastic anemia
- Stem cell transplants
- immunosuppressants (if autoimmune)
- Address the cause
- Blood transfusions
What two precautions should a person be on if they have aplastic anemia
Neutropenic (infection) and thrombocytopenic precautions (bleeding)
THESE PEOPLE WILL BLEED TO DEATH AND THEY CAN ALSO GET AN INFECTION THAT THEY CANNOT FIGHT OFF BECAUSE THEIR WBCS ARE LOW
What is thalassemia
Inherited autosomal recessive disorder, where there is not enough hemoglobin, which decreases RBC production (basically making abnormal hemoglobin)
What are treatments of thalassemia
- Blood exchange transfusions
- Stem cell transplants
- Folate
What are symptoms of thalassemia
- Jaundice (from the hemolysis of RBCs)
- Splenomegaly (from the spleen trying to remove the damaged RBCs)
- Hepatomegaly (liver enlargement from iron deposition)
What are the two types of thalassemia
Major - which is life threatening
Minor - which may be asymptomatic
What is hemolytic anemia
Premature destruction of RBCs can be inherited or acquired (like from lupus, rumetoid arthritis, mechanical heart valves, reaction to blood transfusion, from chemo)
Why is jaundice caused when RBCs are destroyed
Because the byproduct is bilirubin (liver is unable to get this processed and out of the body fast enough)
How can we diagnosis hemolytic anemia
- Decrease in RBCs
- Increase in reticulocytes (baby RBCs)
- Increase in bilirubin
What tx would we give for hemolytic anemia
(depends on the cause)
- Blood transfusions
- Corticosteroids (if from an autoimmune response)
- Immunosuppressives
- IVIG
- Surgery to remove spleen (if severe)
What should you do if someone has hemolytic anemia
- Watch kidney function (body is trying to excrete all of these RBCs) (might cause kidney failure)
- Watch CBC, increase bilirubin
- Hemoglobin and iron in your urine
- Bone marrow biopsy
What are symptoms of hemolytic anemia
- Jaundice (also dark urine from jaundice)
- Fever
- Weakness
- Fatigue
- Dizziness
- Confusion
What is important to remember about labs for someone with acute blood loss anemia
Their H and H will look elevated at first, because their volume has decreased, but overtime it will also decrease.
If someone has low BP from blood loss anemia what can we give to help increase BP
Vasopressors like epinephrine
With blood loss anemia, how long does it take your body to start making RBCs or if you give erythropoietin
2-5 days
What type of supplements should you take if you have chronic blood los anemia
Iron supplements
What is hemochromatosis
Too much iron in your body and your body has no natural way to get rid of iron, so it stores it in your liver, heart, pancreas and damage these organs.
What are the two types of hemochromatosis
Primary - genetic
Secondary - from thalassemia, liver disease, post blood transfusion problems
What are the symptoms of hemochromatosis
- First asymptomatic
- Then joint pain, weakness, weight loss, stomach pain
- Later: iron deposits in organs cause heart failure, fibrosis of the liver (liver cancer, cirrhosis), diabetes (from damage to the pancreas) and impotence (ovaries, testicals)
What are the treatments of hemochromatosis 3
- Phlebotomy (blood letting - take off 500mls of blood at intervals)
- Avoid iron (no supplements, no iron cookware, no iron rich foods, no uncooked seafood)
- Avoid things that are going to help you absorb iron like orange juice (vitamin C things)
What is primary polycythemia
Overproduction of all cells, but mostly RBCs
What can primary polycythemia lead too
Leads to an increase hyperviscosity (thicker) and hypervolemia (more blood)
- this causes overclotting, which can lead to organ damage
What causes primary polycythemia
Genetic mutation (not inherited)
Is secondary polycythemia caused by a genetic disorder? What are the causes?
No, it’s caused by an underlying problem like:
1. Hypoxia driven - where you have low oxygen, which causes your erythropoietin to stimulate your bone marrow to make more RBCs (more than what you need) (caused by COPD, high altitude, cardiovascular disease etc.)
2. Hypoxia independent - could be a tumor or medication that stimulates erythropoietin production by the kidneys
How can we resolve both causes of polycythemia
Increase oxygen so body is not stimulated to make more RBCs
What are symptoms of polycythemia
- Headache
- Vision disturbances
- Tinnitus
- HTN
- Red hands and feet
- Ruptured vessels from overdistention causing nosebleeds
- Petechiae
- Bruising
- GI bleed
What labs will we see for polycythemia
- Increase in H and H
- Increase in RBCs
- Increase in platelets and WBCs
What are our treatments for polycythemia 4
- Phlebotomy
- Myelosuppression (inhibits expression of mutation in primary)
- Hydroxyurea
- Aspirin (keep the blood from clotting)
What is a thrombocyte
Platelet - used to stop bleeding.
Stored in the spleen.
What is the normal value of platelets
150,000-400,000
What is thrombocytopenia
Low platletes, less than 150,000
What can cause thrombocytopenia
- Decreased platelet production (caused by liver disease or myelosuppression)
- Increased platelet destruction (immunologic thrombocytopenic purpura (ITP) or Heparin induced thrombocytopenia (HIT)
- Platelet sequestration (platelets become trapped in the spleen)
- Acute blood loss
What are signs of thrombocytopenia
(signs that blood is not clotting)
- Easy or excessive bruising (purpura)
- Petechiae, usually on the lower legs
- Prolonged bleeding from cuts
- Bleeding from gums or nose
- Blood in urine or stools
- Unusually heavy menstrual flows
- Fatigue
- Enlarged spleen
- Hemorrhage (Major complication)
At what platelet count do bleeding and trauma really become an issue for thrombocytopenia
At or below 50,000
What if the patient’s platelets drop down to 20,000
They are at risk for spontaneous bleeding - in which case, they would need a blood transfusion
What if platelets drop below 10,000, but the patient is now showing any signs of bleeding
Still transfuse.
What is some nursing management for someone with thrombocytopenia
- Bleeding precautions (protect from injury)
- Soft bristled toothbrush
- Use electric razors
- No flossing
- No aspirin
- Gentle blowing nose
- Avoid constipation
- Avoid invasive procedures
- Might administer a corticosteroid to help boost platelet counts
- Plasma exchange (get rid of your old plasma for new plasma)
What is Immunologic Thrombocytopenic Purpura
- Rare autoimmune condition
- Occurs when immune system attacks your platelets
- Most commonly seen in children after a viral infection (they can overcome)
- Adults - it can develop and be chronic (can be caused by certain medications or infections, or pregnancies, etc)
What is a sign of Immunologic Thrombocytopenic Purpura
Purpura (those red pinpoints)
What labs are we going to look at for someone with Immunologic Thrombocytopenic Purpura
- Monitor their CBC looking at the platelets, bleeding time, platelet antibodies
What are treatments for Immunologic Thrombocytopenic Purpura
- Steroids (reduces rate of platelet destructions)
- IVIG (has antibodies that help stop platelet destruction - works faster than steroids)
- Septectomy
- Avoiding anti-platelet drugs
What is hemophilia and Von Willebrand disease
Hereditary condition caused by inadequate clotting factors
- Hemophilia lack clotting factors 8 and 9
- Von Willebrand lack of von willebrands factor
What is the difference between hemophilia A and Hemophilia B
- Hemophilia A is a lack of clotting factor 8, while hemophilia B is lack of clotting factor 9
Where do we see a lot of bleeding for hemophilia and Von Willebrand disease
In their joints, which causes a lot of pain
How can we diagnosis hemophilia and Von Willebrand disease
- Check clotting factors 8, 9 or von willebrand factor
- Checking bleeding times (will be longer)
What is a normal range for PTT and INR
- PTT 25-35 seconds
- INR less than 1 second
What is the tx for hemophilia and Von Willebrand disease
Replace their missing clotting factor
What is Disseminated Intravascular Coagulation
There is some big event, like a trauma, sepsis, tumors, snake bites or complication of pregnancy, where your body uses up all of your clotting factors, which leads to low clotting factors and platelets
(basically run out of clotting factors and platelets, because they were all used up from the big event)
What are signs of Disseminated Intravascular Coagulation
(we’ll see signs of both clotting (thrombosis) and bleeding)
- Thrombosis related (cyanosis or ischemia of fingers, nose and ears, cerebral hemorrhage)
- Bleeding (petechiae, purpura, ecchymoses, internal bleeding)
What labs do we see for Disseminated Intravascular Coagulation
- Increased PT and aPTT
- Decrease in platelets
- Decrease in fibrinogen
- Increase in D-dimer
What are treatments of Disseminated Intravascular Coagulation
- Give clotting factors (like platelets, cryoprecipitate or FFP)
- Replace volume lost
What is the biggest clotting factor that we would give first for Disseminated Intravascular Coagulation
Cryoprecipitate and FFP (these both have clotting factors)
What is happening in Heparin-induced Thrombocytopenia
Heparin and platelets bind creating this PF4 factor, your body recognizes this as foreign and starts to attack those platelets, which then causes your body to form these big clots, which can lead to PEs, VTEs, MI, CVAs
What labs are we looking at for Heparin-induced Thrombocytopenia
- Platelets
- PF4 antibody levels
What is the treatment for Heparin-induced Thrombocytopenia
- Stop heparin (once you get rid of the cause, it should stop happening)
- Use a different anticoagulant, like warfarin
- Don’t transfuse platelets (more platelets will just make it worse)
- Monitor for thromboses (ex - necrosis of toes)
When should a patient go on bleeding precautions
When platelets are below 150,000
What is another name for WBCs
Leukocytes
Where are WBCs made
Bone marrow and a little in the spleen
Where are WBCs stored
In your lymph tissues
What are the neutrophils
These are the “first responders” (first line of defense. Alive for 6-8 hours. They eat the bad things , die because they have such a short lifespan, and then turn into pus.
What are immature neutrophils called, what about mature?
Bands, segs
What is shift to the left
When you have more immature neutrophils (bands), this shows that your body is trying to fight off something, and has needed to make a lot of neutrophils
What are lymphocytes 3
- T cells and B cells
- Create antibodies
- Found in the lymph
What are monocytes 3
- Have a long lifespan
- Become macrophages and eat up bacteria
- Responsible for innate immunity
What are basophils 2
- Secrete histamine
- Responsible for allergic responses
What are eosinophils
- Kill parasites and cancer
What is the normal WBC cound
4500-11,000
What is our innate immunity
It’s our natural immune response - first responder to kill (skin, mucous membranes, stomach acids)
Which WBCs are phagocytes (where they consume and destroy invading materials) 4
- Natural killer cells
- Neutrophils
- Monocytes
- Macrophages
What is our humoral and cell-mediated immunity
Our adaptive (specific) immunity - where the body now recognizes antigens and produces antibodies to them
How long does it take your adaptive immunity to respond
Days rather than hours, like with your innate immunity
Which cells are the key components of our adaptive immunity
T cells and B cells
What are immunoglobulins known as
Antibodies
What are the 4 different types of hypersensitivity reactions
- Mediated hypersensitivity - classic anaphylactic symptoms like when you have allergies, pollen, animal dander.
- Mediated cytotoxic response - healthy cells are dying in response to the antigen. Examples - can cause thrombocytopenia, immune hemolytic anemia, autoimmune things like graves disease or hypothyroidism.
- Immune complex reaction - where antibodies form complexes in tissues and causes a serious of reactions that lead to tissue damage (caused by a response to drugs, bites, etc).
- Cell mediated hypersensitivity - where the T cells that control the hypersensitivity (usually from things like an exposure to poison ivy, etc. - things that have a delayed response)
What is neutropenia
Severe decrease in our neutrophils
What is a normal neutrophil range
2200-7700
At what range do your neutrophils fall that you are considered to have neutropenia
Below 1000
How do we calculate the amount of neutrophils
We use the absolute neutrophil count (ANC) , which is your WBCs x % of neutrophils
What if your ANC falls below 1,000? What if it’s at 500? What if it’s less than 100?
- Below 1,000: neutropenia
- Between 500-1,000 = moderate
- Less than 100 = profound/severe
What are the two different types of neutropenia
- Primary, which is caused by a genetic mutation
- Secondary, which is acquired - could be from a medication, treatment or underlying problem
Why would you have neutropenia
- You could have premature neutrophil destruction, which can be from:
1. Hypersensitivity to a medication
2. Autoimmune disorder
3. Splenomegaly (enlarged spleen traps neutrophils and destroys them) - You could have decreased neutrophil production, which can be from:
1. Injury to your bone marrow
2. Overcrowding from malignant cells (like blood cancers, where you have so many cancerous cells, that new ones don’t have enough room to be made).
3. Bone marrow suppression (chemo, immunosuppression drugs, radiation)
4. Severe deficiencies (like vitamin B12, folate - we need these to make neutropenic cells), infections (HIV, sepsis) and medications (like steroids)
If someone has neutropenia, how might they respond if they have an infection
- May have a lack of response, because they don’t have many neutropenias to start a response
- Lack pus
- Maybe only a slight fever
- Can develop sepsis without you noticing - so watch their vitals, looking for tachycardia, tachypneic .
- Swollen painful gums, mouth ulcers
For a neutropenic patient, what temperature is considered very high and should be considered an emergency
Anything greater than 100.4
How should we manage neutropenia 3
- Find the cause (you can do this through a bone marrow biopsy, discontinuing a medication that is causing the neutropenia)
- Initiate neutropenic precautions
- Monitor temperature closely (at least every 2-4hrs)!!
What medication can we give to help stimulate the bone marrow to make WBCs, specifically neutrophils
- Granulocyte-colony stimulating factor drug (G-CSF) known as filgrastim or Neupogen
Who often receives filgrastim (Neupogen)
- Cancer patients so they can continue treatment by having their WBC up.
What are adverse effects of Filgrastim (Neupogen)
Bone pain (from the stimulation in your bone marrow), fever, fatigue
When should you not give Filgrastim (Neupogen)
Within 24 hours before or after chemo (the chemo will just kill the Filgrastim, so it’s pointless)
What are some neutropenic precautions that I maybe don’t know
- Wash all fruits and vegetables well
- Avoid fruits that cannot be washed easily like raspberries or blackberries
- Avoid sick people, small children and pets
- No live plants or cut flowers
- Have a private room
- Avoid rectal temperatures, suppositories and enemas, where bacteria can be introduced from rectal trauma.
- The patient should shower often so their own flora does not make them sick
What is the number one neutropenic precaution
HANDWASHING by both patient and visitors
What is myelodysplastic syndrome (MDS)
Group of disorders where the bone marrow does not produce enough normal, healthy cells (produces abnormal cells instead)
What might cause MDS
Exact cause is unknown, but it might be caused by the following:
- Exposure to certain drugs and chemicals (like chemo)
- Chromosomal abnormality
- Rare cases are genetic
Why is MDS bad
It can progress to acute myelogenous leukemia (AML)
What are symptoms of MDS
- Infection
- Bleeding
- Low platelet count
How can we diagnosis MDS
- Look at a CBC
- Bone marrow biopsy will offer a definitive diagnosis
How can we manage a patient with MDS
- Might need transfusions with iron chelators (to prevent iron overload)
- Bone marrow biopsies for monitoring
- Antibiotic therapy
- Erythropoietin, filgrastim and thrombopoietin (because they’re low on all of their cells)
- Intensive chemo (to kill the abnormal cells)
- Medications to restore normal growth of bone marrow like Vidaza and Dacogen
- Implement appropriate precautions
What two things do they do during a bone marrow biopsy
- Needle aspiration and a punch biopsy
myelosuppression
Suppression in the bone marrow
What are some nursing considerations for administering a bone biopsy 5
- Make sure the patient is educated by the doctor
- Make sure the doctor has consent
- Assess risk for bleeding
- Help patient into the prone or side lying position
- Encourage deep breathing
What should you do after a bone marrow biopsy 3
- Apply pressure to the area for at least 5-10minutes
- Cover site with a sterile dressing
- If bleeding occurs, have patient lie on the puncture site
What should you educate the patient on after a bone marrow biopsy 3
- Keep dressing in place for 24 hours (if starting to get soaked, apply a new one over the top without removing the old)
- Report to the provider if bleeding soaks dressing or continues for over 24 hours
- May need to take Tylenol (don’t take anything that can thin your blood like NSAIDs or aspirin)
What is the difference between MDS and aplastic anemia
MDS is where the bone marrow does not produce enough healthy cells (abnormal cells are produced) versus aplastic anemia, the body is just not producing enough cells in general
What is leukemia
Cancer affecting the blood, where there is an accumulation of dysfunctional cells due to loss of regulation in cell division (like cancer, this is an uncontrolled growth of immature WBCs)
Is there a single cause of leukemia
No, like with most cancers it can be a combination of genetic and environmental factors (remember how leukemia can be a secondary disease from chemo (like you have chemo from breast cancer, but then this chemo causes you to have leukemia))
Why is it an issue to have a proliferation of immature WBCs (leukemia)
Because these immature cells crowd out all of the normal, good cells.
How do we classify the 4 different types of leukemia
Based on whether their acute or chronic, and whether they are made of myeloid cells (basophils, eosinophils, neutrophils, monocytes, platelets, erythrocytes), or lymphoid cells (B cells, T cells, NK cells) (basically classified as acute or chronic and then what type of cell is involved)
What are the 4 different types of leukemia
- Acute lymphocytic leukemia (ALL)
- Acute myelogenous leukemia (AML)
- Chronic myelogenous leukemia (CML)
- Chronic lymphocytic leukemia (CLL)
What is the most common leukemia
Acute Myelogenous Leukemia (AML)
What is Acute Myelogenous Leukemia (AML)
Leukemia that starts in the bone marrow but then moves to the blood, lymph nodes, liver, spleen and central nervous system.
- Develops from myeloblasts (so any of the WBCs other than the T, B and NK cells)
What does Acute Myelogenous Leukemia (AML) cause
Hyperplasia of the bone marrow
What is Acute Lymphocytic Leukemia (ALL)
- Comes from immature lymphocytes, mostly B cells.
- Starts in the bone marrow and invades the blood, then can spread to other parts of the body like lymphnodes, liver, spleen, central nervous system and testicals.
What are symptoms of Acute Lymphocytic Leukemia (ALL)
- Can appear abruptly like fever and bleeding.
- Can be insidious, where there is progressive weakness, fatigue, bone and/or joint pain, bleeding.
- CNS symptoms can be seen
What is happening with Chronic Myelogenous Leukemia (CML)
Excessive neoplastic development of all of the WBCs except the lymphocytes
What is the hallmark for Chronic Myelogenous Leukemia (CML)
- Most patients will have the Philadelphia chromosome (abnormality on that chromosome)
How can Chronic Myelogenous Leukemia (CML) kill you
These cancer cells will build up in your bone marrow, spill out into your blood and infiltrate your liver and spleen (this all happens pretty slowly). Then, it can suddenly turn acute and aggressive, which can make it hard to treat.
What is Chronic Lymphocytic Leukemia (CLL)
- Affects older adults (so treatment options are limited)
- B cells are involved
- Builds up slowly, then it can start invading the lymphnodes, liver and spleen.
What are symptoms of Chronic Lymphocytic Leukemia (CLL)
- Pain, paralysis from pressure on nerves caused by enlarged lymph nodes
- Mediastinal node enlargement (this node is right by your sternum) can lead to pulmonary issues
What are general manifestations of leukemia
- Overcrowding by abnormal cells in the bone marrow, this interferes with the bone marrow being able to make normal cells
- This leads to patients getting anemia, thrombocytopenia, Neutropenia (because not enough cells are being made)
- These cancer cells do not die and just continue to thrive
What can leukemic cells cause
- Splenomegaly
- Hepatomegaly
- Lymphadenopathy
- Bone pain
- Meningeal irritation
- Oral lesions
- Solid masses (chloromas)
What is a common complication of leukemia
Leukostasis - caused by high leukemic WBC count in the peripheral blood (greater than 100,000) which leads to blood thickening (causes clotting and blocks pathways)
How can we diagnosis and classify the different types of leukemias
- Peripheral blood evaluation
- Bone marrow exam
- Lumbar puncture
- PET/CT scan
What are other diagnostic findings of leukemias
- WBC count may be normal or abnormal
- Anemia
- Decreased H and H
- Thrombocytopenia
- Philadelphia chromosome
- Hypercellular bone marrow aspirate or biopsy
How are patients with leukemia going to present
- Frequent infections, because they don’t have a normal immune system
- Fever
- Lymphadenopathy
- Pallor
- Jaundice
- Petechiae
- Ecchymoses
- CV - tachycardia, systolic murmurs
- GI - oral lesions or bleeding, herpes or cold sores, hepatomegaly, splenomegaly
- Seizures, disorientation, confusion
- Muscle wasting and bone or joint pain
What is lymphoma
Cancer originating in the bone marrow and lymphatic system, which is from the proliferation of lymphocytes
What are the two major types of lymphoma
Hodgkin’s lymphoma and non-Hodgkin’s lymphoma
What is Hodgkin’s Lymphoma
Proliferation of abnormal, giant, multinucleated cells called Reed-Sternberg cells, which proliferate in the lymph nodes
What is the biggest difference between leukemia and lymphomas
Leukemias grow in bone marrow and then move into blood, while lymphomas also start in the bone marrow but move into the lymph nodes
What is interesting about Hodgkin’s Lymphoma
It has a bimodal age-specific incidence, where you’re at risk between the ages of 15-30, and then between the ages of 55 and up.
Even though the cause of Hodgkin’s Lymphoma is unknown, what could possibly cause it 4
- Epstein-Barr virus
- Genetic predisposition
- Exposure with toxins
- HIV
What are the manifestations of Hodgkin’s Lymphoma 3
- Enlargement of their lymph nodes
- They are moveable and nontender
- Only painful if they are pushing on a nerve
What are symptoms of Hodgkin’s Lymphoma
- Weight loss
- Fatigue and weakness
- Fever and chills
- Tachycardia
- Night sweats
- Alcohol-induced pain at the site of the disease
- Generalized pruritus without lesions
- Mediastinal node enlargement can cause cough, dyspnea, stridor or dysphagia
What are the B symptoms of Hodgkin’s Lymphoma 3
Set of symptoms that correlated with a poor prognosis
- Fever greater than 100.4
- Drenching night sweats
- Weight loss exceeding 10% in 6 months
In advanced cases, what are the signs of Hodgkin’s Lymphoma 3
- Hepatomegaly
- Splenomegaly
- Anemia
What is Non-Hodgkin’s Lymphoma
- Broad group of cancers affecting all ages
- Affects the B, T, NK, histiocytic and dendritic cells
- Over 75 types
How do we categorize Non-Hodgkin’s Lymphomas
- Level of differentiation (maturity)
- Cell of origin
- Rate of cellular proliferation
- Immunophenotype (cell surface markers)
- Clinical features
We don’t know the cause of Non-Hodgkin’s Lymphoma, but what might cause them? 4
Chromosomal translocations
Infections
Environmental factors
Immunodeficiency states
Secondary cancer after being exposed to chemo
Who do we more commonly see have non-hodgkins lymphoma
People who have:
Inherited immunodeficiency syndromes
Have used immunosuppressive agents
Received chemotherapy or radiation
Are there hallmark features of non-hodgkins lymphoma
No, all involve lymphocytes arrested in various stages of development.
What is the primary manifestation of Non-Hodgkin’s Lymphoma
Enlarged lymph nodes (disease is usually widespread at this point)
Will these enlarged lymph nodes always be the same size
No, they can wax and wane
What is helpful about diagnosing Non-Hodgkin’s Lymphoma
Can do more tests because of the enlarged lymph nodes
What is multiple myeloma
Cancerous plasma cells proliferate in the bone marrow, where these plasma cells make monoclonal antibodies that are ineffective and even destroy our bones.
What are manifestations of Multiple Myeloma
- Pain in the bones, including the pelvis, spine and ribs
- Osteoporosis develops
- Osteolytic lesions on the skull, vertebrae, long bones and ribs
- Vertebral collapse (compression of your spinal cord)
- Pathological fractures
- Hypercalcemia from bones being destroyed
- Serum hyperviscosity leading to organ dysfunction (clotting)
What lab results would we see for Multiple Myeloma
- M protein in blood and urine
- Pancytopenia (low RBCs, WBCs and platelets)
- Hypercalcemia
- Bence Jones protein in urine (this is a hallmark of this disease)
- High serum creatinine (from the kidney damage due to high levels of proteins in the urine)
What is good pt teaching for someone with Multiple Myeloma
Increase fluid intake to help your kidneys excrete the increase in protein to keep it from building up.
What can cause severe splenomegaly
- Mononucleosis
- CML
- Thalassemia Major
(where cells get caught up in the spleen)
What are causes of mild splenomegaly
Heart failure and lupus
What are symptoms of Splenomegaly
- Upper left quadrant pain, which can radiate to the left shoulder and back.
- Palpable spleen (you shouldn’t be able to palpate your spleen)
- Loss of appetite or early fullness (encroaching on your stomach)
- Symptoms of anemia (weakness and fatigue, more colds and infections, more bleeding and bruising).
What labs would we see for Splenomegaly 3
- Reduced RBCs
- Howell-Jolly bodies
- Pocked or pitted erythrocytes
What are the risks of a splenectomy
- Increase in circulating RBCs, WBCs and platelets (dump all of these cells into the bloodstream that it has been housing) - this can lead to thrombosis
What are some considerations for someone with an enlarged spleen
- The spleen can interfere with the movement of the diaphragm
- Implement precautions for neutropenic, thrombocytopenic and anemia
- Monitor for signs of hemorrhage or shock following a splenectomy (you have a high risk of bleeding after it is removed)
- Encourage vaccinations following a splenectomy due to altered immunity (you have an increased risk for pneumococcus pneumonia - because you don’t have your spleen helping you fight infections anymore)
What are Age Related Changes of the Immune System
Immune system function declines with age
Thymus gland begins to atrophy in adulthood
T-cell differentiation decreases
Macrophages are slower to respond
Immune system has more trouble determining self from non-self
Less effective at identifying cancer cells
IgA and IgG production increases (increase in allergies)
How does malnutrition lead to immunocompromise
Altered function of B & T cells
May lead to sepsis
How does stress and trauma lead to an altered immune system
Cortisol suppresses the immune system
Increased glucose levels
Trauma predisposes a patient to immunocompromise
