Week 5: Respiratory And Hematologic Disorders Flashcards
Pco2, pH and Po2 changes in older adults
pH and Pco2 does not change -> Po2 Declines*
Changes in total lung capacity in older adults
Total lung capacity is redistributed..
Residual lung capacity changes in older adults
Increases with diminished inspiration and exploratory muscle strength of the thorax.
Auscultation of Smith bibasilar atelectasis
Is common d/t incomplete lung expansion
Respiratory System: Normal Age-Related Changes
- Lowered efficiency of gas exchange and reduced ability to handle secretions.
- Cilia become less responsive and less effective
- diminished cough reflex and immune response -> high risk for bronchitis and pneumonia
COPD
Characterized by persistent and irreversible obstruction of airflow into the lungs.
COPD includes
Emphysema and chronic bronchitis
What is the gold standard for diagnosis of COPD?
Spirometry
What causes COPD?
Caused by inhalation of toxins or pollutants earlier in life such a dust, chemicals and especially tobacco smoke, either directly or indirectly.
Chronic bronchitis is caused by
A combination of thickened and I talked bronchial walls, hypertrophy of mucous glands, smooth muscle constriction and excess mucous production which can cause lumen compromise.
COPD symptoms may not appear until
50% of lung function has been irretrievable lost.
Most common symptoms of COPD include
Wheezing, cough, dyspnea on exertion and increased phlegm production.
Later signs of COPD include:
- Prolonged expiration
- Barrel chest
- Hyper-resonance
- Fingernail clubbing
- Pursed lip breathing
- Air trapping
- Pale lips or nail beds
- Use of accessory muscles
COPD Complications include
- Exacerbation and remission in symptoms
- Pneumonia
- COPD hospitalizations and death
What can signal an emergent COPD exacerbation?
- Spirometry results of less than 150 mL
- Worsening orthopnea
- Paroxysmal nocturnal dyspnea
- Respiration’s >30 per minute
Asthma
An inflammatory airway disease closely linked to allergies and viral or bacterial infections.
What can cause asthma?
- Influenced by genetics, environment, and lifestyle.
- After susceptible person is exposed to an antigen, a cascade reaction occurs, which have effects on airway smooth muscle and mucus secretion but also recruits monocytes, lymphocytes, neutrophils and eosinophils into the cells lining the airways.
- Repeated exposure potentiates the person’s inflammatory response or desensitizes him or her to the antigen, making them more susceptible.
What are signs and symptoms of asthma?
May be less obvious in older adults
- Wheezing
- Dyspnea on exertion
- SOB
- Nonproductive cough
- Chest tightness
Symptoms of asthma are usually worse when?
Worse at night or in the early morning hours but may being anytime following exposure.
Complications of Asthma include
- Death
- Thickening of airway wall and peri-bronchial fibrosis
- Higher risk for lower respiratory infections including pneumonia and prolonged associated debility, than those without.
Hematology: Normal Age-Related Changes
- Reduction in total body water = decreased blood volume
- Decreased speed with which RBCs are produced in response to stress or illness = slower response to blood loss and anemia.
- Most WBC’s stay the same, but WBCs important to immunity (neutrophils) decrease in their number and ability to fight bacteria = decreased ability to resist infection.
What are hematological disorders in older adults?
RBCs: Anemia
WBCs: Immune, Neutropenia, Leukemia
Platelets: Thrombocytopenia
Hematopoietic Stem Cells
Are the stem cells that give rise to blood cells through the process of haematopoiesis.
An aging hematopoietic system can lead to
Decline in reserve capacity and decline in formation of blood.
Anemia
Deficiency in the number of RBCs
Hemoglobin levels that indicate anemia
- Females: <12
- Males: <13
Hematocrit values that indicates anemia
Females: <36%
Males: <41%
WHO Definition of anemia
The condition when the number of red blood cells is insufficient to meet the physiological needs.
What is the leading cause of anemia?
Iron deficiency and malnutrition (folate and/or vitamin B12 deficiency)
Is anemia a normal part of aging?
Not a normal part of aging.
Difference in Hgb among African-Americans and Caucasians
African American hemoglobin is 0.5-1.0 g/dL lower than Caucasians
Normocytic normochromic anemia
- Blood loss
- Chronic Diseases
- Sideroblastic anemia
- Sickle cell anemia
Micro grid Hypochromic Anemia
-Hemoglobin synthesis : Iron, B6, copper, lead
Macrocyclic (Megaloblastic) Normochromic
DNA synthesis: Vitamin B12 (Cobalamin, Folic Acid)
What patient history should you get in a patient with anemia?
- Is the patient bleeding?
- Past medical history of anemia, family history?
- Alcohol, nutritional questions
- Liver or renal disease
- Ethnicity
- Environmental/work toxins (i.e lead)
Anemia: Lab Results
- RBC, Hgb, Hct
- Mean Corpuscular Volume
- Reticulocyte Count
Mean Corpuscular Volume
Tells you more about the size of the RBCs
Low MCV
Small RBC microcytic (iron deficiency anemia)
High MCV
Large RBC macrocytic (Vitamin B12 or folate deficiency)
Reticulocyte count
Measures how fast RBCs called Reticulocyte a (immature RBCs) are made by the bone marrow and released.
Signs of Anemia include
- Extreme Fatigue
- Heart palpitations
- Loss of appetite
- Loss of concentration
- Tachycardia
- Tachypnea
- Orthostatic hypotension
- Pallor, jaundice, priority’s
- Murmur, chest pain
- Koilonychia or “spoon nails”
Signs of Anemia include
- Splenomegaly, lymphadenopathy
- Petechiae, ecchymosis
- Atrophy of tongue papillae
- Angular chelitis (red, swollen patches in the corners of the mouth)
- Hemoccult + stool
Signs and symptoms of anemia may go unrecognized or mistaken for
Normal age changes.
Symptoms of Anemia include
- Fatigue
- Pallor, confusion, ataxia
- Worsening angina, CHF
- Decreased O2 delivery
- Hypovolemia if acute loss
- Exertional dyspnea, palpitations, lightheaded ness
- PICA
- Pagophagia (eating ice)
Severe anemia symptoms include
Heart failure and angina
Iron Deficiency Anemia
- One of the most common anemia’s but not the most common in older adults.
- Microcytic normocromic.
Foods and medications that can inhibit the absorption of iron include:
- Eggs
- Cocoa, coffee, black tea
- High oxalate foods (spinach, kale, beets, nuts, chocolate, tea, wheat bran, rhubarb, strawberries)
- Herbs such as oregano, basil and parsley
- High calcium foods (milk, yogurt, cheese, sardines, canned salmon tofu, broccoli, almonds, figs, turnip greens and rhubarb)
Contributing factors for iron deficiency anemia include
Heart failure and vitamin A deficit.
The definitive treat for iron deficiency anemia includes
Serum ferritin (measures amount of stored iron. Low serum ferritin is diagnostic of iron deficiency (<12 ug/L)
Management of Iron Deficiency Anemia
- Assess to determine and eliminate cause
- Iron Replacement therapy
Iron Replacement Therapy
-Iron supplement:
A. oral ferrous sulfate (with vitamin C or orange juice), ferrous gluconate.
B. IV iron-dextran complex, parental iron
C. IM: Use Z track injection technique.
Folate and Cobalamin Deficiency
- Megaloblastic anemia (macrocytic normochromic)
- Causes ineffective erythrpoiesis.
Cobalamin Deficiency
- Malnutrition
- Pernicious anemia
- Gastrectomy
- Chronic alcoholism
Folic acid deficiency
- Alcohol abuse
- Anorexia
- Drugs (Methotrexate, anti-seizure)
- Malabsorption
What test is used to check for vitamin B12 deficiency?
Schilling Test for B12 Deficiency - parietal cell antibody or intrinsic factory antibody.
Management of Vitamin B12 deficiency and pernicious anemia
Vitamin B12 injection or nasal
Management for folic acid deficiency
- Folate supplement 1 mg daily average dose
- Foods high in folate e.g dark green vegetables
Anemia of Chronic Diseases
Associated with inflammation, autoimmune infectious disease (malaria, HIV, hepatitis), heart failure, renal disease and cancer.
Causes of Anemia of Chronic Diseases
- Reduction of RBC life span
- Suppress production of erythropoietin
- Ineffective bone marrow response to erythropoietin
What hemoglobin values can indicate the need for blood Transfusion?
- Hgb <10 (CAD)
- Hgb <8 (All patients)
Immune Response and Aging
- Aging associated with increased incidence of infectious diseases (influenza and herpes zoster)
- Higher incidence of bacterial infections (TB, pneumococcal pneumonia)
- Greater morbidity/mortality and hospitalization
How is humoral immunity affected by aging?
- Natural serum antibodies decline with aging.
- Decline in immunoglobulin (function as antibodies) production
- Health status influences outcome of antibody response
Leukemia
- A group of malignant disorders affecting the blood and blood-forming tissues of bone marrow, lymphatic system and spleen.
- Fatal if untreated.
- Accumulation of dysfunctional cells d/t loss of regulation in cell division.
Acute Myeloid Leukemia
Most common in elderly population
Coagulation and Aging
- Old age is a hypercoagulable state
- Thrombotic conditions increase with age because of the increasing plasma fibrinogen and clotting factors.
Types of thrombocytopenia include
- Idiopathic thrombocytopenic purpura
- Thrombotic thrombocytopenic purpura
- Heparin induced thrombocytopenia
- Heparin-induced thrombosis syndrome
Idiopathic Thrombocytopenic Purpura
Most common
Low levels of platelets due to immune system cells produce antibodies against platelets
Thrombotic thrombocytopenic purpura
Rare in which blood clots form in small blood vessels resulting in low platelet count.
Heparin-induced thrombocytopenia
Development of thrombocytopenia due to heparin
Heparin-induced thrombosis syndrome
Immune-mediated adverse reaction to heparin
Diagnostic Studies for Thrombocytopenia
- CBC
- PT/PTT (check whether blood is clotting properly)
- Blood smear (check the appearance of platelets)
- Bone marrow aspiration or biopsy (check if bone marrow is healthy)
- Ultrasound of spleen
Treatment for Thrombocytopenia
- Blood or platelet transfusions
- Steroids such as prednisone (may slow platelet destruction)
- No anti-platelet medications
- Splenectomy if medications are not effective (mostly done for those who have ITP)
Platelets below 150,000/uL
Abnormal platelet count
Platelets below 50,000/uL
Bleeding with minimal trauma and prolonged bleeding.
Bleeding precaution
No IM medications
Platelets below 20,000/uL
Spontaneous bleeding: life threatening
Nursing management for platelets below 20,000/uL
- Monitor neuro sign and consciousness
- Absolute bed rest
- No IM medications (if blood work, hold at least 5 minutes)
- Oral care but no toothbrush, no spicy food
- No rectal temperature.
