medications used in hematologic disorders

what is hematopoiesis?

formation and maturation of blood cells

what is the primary site and other organs involved in hematopoiesis?

1. primary organ: bone marrow

2. other organs: the spleen

what are the three blood cells types and their functions?

1. erythrocytes (RBCs) → transport oxygen from the lungs to tissues and carry carbon dioxide from the tissues to the lungs (reticulocytes are immature RBCs)

2. leukocytes (WBCs) → defend the body against infection and foreign invaders

3. thrombocytes (platelets) → form platelet plugs at sites of vessel injury, releasing clotting factors, help convert fibrinogen to fibrin during coagulation

what are blood products?

components of blood separated into different parts

what is the color of blood in the arteries?

bright red

what is the color of blood in the vein?

dark red

what are packed red blood cells (PRBCs)? when are PRBCs indicated?

concentrated red blood cells used to increase oxygen-carrying capacity and intravascular volume

1. acute hemorrhage

2. symptomatic anemia

3. patients at risk for fluid overload (this will only increase the patient’s overall volume but the most important here is that the fluid overload is significantly impacting their ability to receive oxygen, of which, infusing PRBCs is prioritized)

why are PRBCs preferred over whole blood in patients at risk for fluid overload?

they provide red blood cells with less volume, reducing the risk of fluid overload.

what is anemia?

a deficiency of red blood cells or hemoglobin, resulting in decreased oxygen delivery to tissues

what is fresh frozen plasma (FFP)? what does it contain and its primary use?

1. plasma product used to replace clotting factors

2. it contain plasma with red blood cells and platelets removed, but clotting proteins retains

3. the primary use is to replace clotting factors (e.g., bleeding, coagulopathies)

how is FFP stored and how long is it usable after thawing?

1. it is frozen for up to one year

2. it is usable up to 5 days after thawed

why are platelets given?

to increase platelet count and improve hemostatis

what condition are platelet transfusion commonly used to treat?

thrombocytopenia (low platelet count)

what is the difference between Fresh Frozen Plasma (FFP) and Cryoprecipitate (Cryo)?

FFP:

1. contains ALL clotting factors

2. larger volume

3. used for general coagulation disorders

cryoprecipitate:

1. contains concentrated specific (e.g., fibrinogen, factor VIII, vWF, factor XIII)

2. smaller volume

3. used when fibrinogen or specific factors are low

what is cryoprecipitate (antihemophillic factor, cryo) and how is cryoprecipitate made?

1. FFP is made with a concentrated plasma product rich in specific clotting proteins

2. made from plasma that is frozen → thawed → the solid precipitate is collected

3. contain key clotting factors: fibrinogen, factor VIII, von Willebrand factor, factor XIII

what special considerations should the nurse make for patient who is starting on a blood transfusion?

1. determine the patient’s allergies and previous transfusion reactions if applicable

2. check the patient crossmatch (record with 2 nurses): ABO-group, RH types, client’s name, ID blood band, hospital number, expiration

3. DO NOT warm unless there is a risk of hypothermic responses, if then only by specific blood warming equipment

4. never add any meds to blood product

5. administer within 30 minutes of receiving from the blood bank

6. infuse each unit over 2-4 hours, but NO LONGER than 4 hours

key points:

1. verify client’s ID

2. check the Dr. order

3. check labels on the blood bag and the blood bank transfusion record

4. baseline vitals

5. number 18 or 20 gauge needle

6. normal saline IV solution

7. blood administration set with filter

8. severe reactions most likely first 15 minutes or first 50 cc

9. blood tubing should be changed after 4 hours

what are the four main blood groups?

A, B, AB, and O

what does Rh positive or Rh negative mean?

presence (Rh+) or absence (Rh-) of the Rh (D) antigen on red blood cells

what is cross-matching? what is the purpose of it?

• mixing a sample of donor blood with a sample of recipient blood to check for compatibility

• to detect reactions or agglutination between donor and recipient RBCs

what does agglutination during cross-matching indicate?

incompatibility - blood should NOT be tranfused or very dangerous for blood clots

a patient has A antigens on their red blood cells

1. what antibodies are in their plasma?

2. which blood types can they safely receive?

1. anti-B antibodies

2. can receive A and O

a patient has B antigens on their red blood cells.

• what antibodies are in their plasma?

• which blood types can they safely receive?

1. anti-A antibodies

2. can receive B and O

A patient has A and B antigens on their red blood cells.

• What antibodies are in their plasma?

• Why are they called the “universal recipient”?

• No anti-A or anti-B antibodies

• Can receive A, B, AB, and O

a patient has no A or B antigens on their red blood cells.

• What antibodies are in their plasma?

• Why are they called the “universal donor”?

• Anti-A and anti-B antibodies

• Their RBCs have no antigens, so they won’t trigger agglutination

can an Rh-negative patient receive Rh-positive blood?

❌ No — may develop antibodies and have a transfusion reaction.

what are bleeding disorders also called?

abnormal hemostatis or coagulopathies

what causes bleeding disorders and what some common examples of bleeding disorders?

1. causes by abnormalities in one or more stages of clotting

2. common example: hemophilia, von Willebrand disease, vitamin K deficiency, disseminated intravascular coagulation (DIC)

how is treament for bleeding disorders determined?

by the suspected underlying cause (factor deficiency, platelets, volume, etc)

why are specific blood components preferred over whole blood? however, when is whole blood indicated?

1. they target the exact deficiency and reduce unnecessary fluid overload

2. whole blood is indicated, however, when there are symptomatic anemia with hypovolemia and/or massive hemorrhage

when ware packed red blood celsl (PRBCs) indicated?

1. symptomatic anemia

2. patient is at risk for fluid overload

when is fresh frozen plasma (FFP) indicated?

1. deficiency of coagulation factors

2. examples: DIC, liver disease, massive transfusion protocol (MTP)?

when is cryoprecipitate antihemophilic factor (cryo) indicated)?

1. hemophilia A

2. von Willebrand disease

3. low fibrinogen levels

what should the nurse do if the nurse notice a transfusion reaction?

• STOP Method

• S: stop infusion immediately

• T: turn off blood but keep IV running with NS

• O: obtain vital signs and assess the patient

• P: notify provider and blood bank

• change the IV tubing down to the IV site

• keep the IV open with normal saline

• DO NOT LEAVE THE PATIENT ALONE

what are the signs and symptoms of transfusion reaction?

1. increased heart rate (tachycardia)

2. decreased blood pressure (hypotension) → an increased in heart rate but a decreased in blood pressure are also classic sign of sepsis!!!

3. increased temperature (fever)

4. itching/urticaria/skin rash

5. wheezing/dyspnea/tachypnea

6. anxiety

7. fushing

8. back pain

what is TRALI? what causes it? signs and symptoms? treatment?

an acute lung injury caused by an immune reaction to transfused blood

1. The body recognizes transfused blood as a pathogen and releases inflammatory mediators and histamine into pulmonary vessels

2. signs and symptoms include fever, hypotension, tachycardia, hypoxia (classic signs of sepsis)

3. treatments: supplemental oxygen and supportive care (not diuretics)

Feature	TRALI	TACO
Cause	Immune reaction	Volume overload
BP	Low	High
Treatment	Oxygen	Diuretics

what is TACO? what causes it? signs and symptoms? treatment?

fluid overload caused by excess transfused volume

1. causes by too much volume which overwhelms the heart and circulatory system

2. signs and symptoms: respiratory distress, hypertension, tachycardia, fluid overload (edema, crackles)

3. treatment: diuretics

Feature	TRALI	TACO
Cause	Immune reaction	Volume overload
BP	Low	High
Treatment	Oxygen	Diuretics

what is anemia?

a decrease in functional red blood cells, resulting in reduced oxyfen delivery to tissues

what is aplastic anemia?

failure of the bone marrow to produce red blood cells

what is hemolytic anemia?

premature destruction of red blood cells

what is sickle cell anemia?

a genetic disorder causing abnormal (sickle-shaped) RBCs that break down easily and block blood flow

what causes vitamin B12 deficiency anemia?

lack of vitamin B12, leading to impaired RBC formation

what causes folic acid deficiency anemia?

lack of folate, impairing DNA synthetic and RBC production

what causes iron deficiency anemia?

lack of iron, leading to decreased hemoglobin production, reducing oxygen-carrying capacity

what is polycythemia?

increase in the number of red blood cells

when should oral iron be taken? how should be taken?

1. in the morning on an empty stomach

2. take with vitamin C to increase iron absorption

3. avoid taking iron with diary products which decrease absorption

4. remain upright after taking iron to reduce GI irritate

what stool changes shoud the patient expect with iron therapy?

1. dark green or black stools (normal findings)

2. constipation is a common GI adverse effect that occur after iron

what special instruction is given for liquid iron?

1. drink with a straw

2. brush or rinse mouth afterward to prevent tooth straining

what is the MOA, indications, contraindications, and side effects of hydroxyurea?

1. MOA: boosts fetal hemoglobin (HbF) production to inhibit the sickling of RBCs and reduce blood vessel blockage (prevents sickle cell pain crises because HbF does not sickle, improving RBC flexibility and blood flow)

2. indications: sickle cell anemia crisis prevention

3. contraindications: hypersensitivity, pregnancy

4. side effects: HA, diarrhea, myelosuppression, hair loss, SOB, dark stools

how does sickling affect blood flow?

• sickled RBCs increase blood viscosity and cause microvascular occlusion

• these occlusion causes: hypoxia, thrombosis, tissue and organ infarction, severe pain (pain crises)

what is the MOA, indications, contraindications, and side effects of erythropoietin?

1. MOA: stimulates the bone marrow to produce red blood cells

2. indications: anemia due to chronic kidney disease (decreased natural EPO production), anemia from chemotherapy, anemia in chronic disease

3. contraindications: uncontrolled hypertension, hypersensitivity to the drugs

4. side effects: hypertension, increased risk of thrombosis (blood clots), headache, joint pain

what are the nursing considerations for erythropoietin?

1. monitor blood pressure and Hgb levels

2. do not shake vial

3. monitor iron levels

what is leukopenia?

Decreased white blood cell (WBC) count, increasing infection risk.

what is leukocytosis?

Increased white blood cell count, often due to infection, inflammation, or stress.

what is leukemia?

Cancer of the bone marrow causing uncontrolled production of abnormal white blood cells.

what is lymphoma?

cancer of the lymphatic system, involving lymph nodes and lymphocytes.

what is neutropenia?

Low neutrophil count, resulting in a high risk for infection.

what are granulocyte-colony stimulating factors (G-CSFs)? how do they work (indicated)? what additional effect do G-CSFs have on neutrophil?

1. they are medications that increase neutrophil counts

2. they work my stimulating stem cells in the bone marrow to grow and differentiate into neutrophils (is indicated to trat oe prevent neutropenia, especially after chemotherapy)

3. additional effects: encourage release of neutrophils from bone marrow into the blood, prevent neutrophil death, and improve the neutrophil’s ability to fight infection

4. examples: filgrastim, lenograstim, pegfilgrastism

what is the MOA, indications, contraindications, and side effects of filgrastim (Neuopogen)?

1. MOA: binds to cell surface receptors that stimulate immature neutrophils to divide, differentiate, and mature to increase absolute neutrophil count (ANC); works within 24 hours

2. indication: neutropenia due to chemotherapy, malnutrition, medications

3. contraindications: sickle cell disease, hypersensitivity

4. side effects: bone pain, abdominal pain

what is the common sufix of G-CSFs?

-stim

what are the key nursing consideration for patient on filgrastim?

• Monitor ANC / WBC count
  → Goal is to raise neutrophils, but avoid excessive leukocytosis

• Assess for bone pain (very common)
  → Caused by bone marrow stimulation

• Monitor for signs of infection
  → Fever, sore throat, chills (especially early in therapy)

• Watch for splenic enlargement or rupture (rare but serious)
  → Left upper abdominal pain or shoulder pain = report immediately

• Do NOT give within 24 hours of chemotherapy
  → Can worsen bone marrow toxicity

• Monitor respiratory status
  → Rare risk of acute respiratory distress syndrome (ARDS)

56. Von Willebrand disease affects:

• A. Platelet adhesion

• B. RBC production

• C. WBC function

• D. Iron absorption

• A. Platelet adhesion

57. Hemophilia A is caused by deficiency of:

• A. Factor V

• B. Factor VIII

• C. Factor IX

• D. Fibrinogen

• B. Factor VIII

58. Best IV solution for blood transfusion compatibility:

• A. D5W

• B. Lactated Ringer’s

• C. Normal saline

• D. Half-normal saline

• C. Normal saline

59. Why is LR incompatible with blood?

• A. Calcium causes clotting

• B. Sodium causes hemolysis

• C. Potassium destroys RBCs

• D. pH imbalance

• A. Calcium causes clotting

60. Priority teaching for patients receiving hematologic therapy:

• A. Increase sodium intake

• B. Monitor for bleeding and infection

• C. Avoid all exercise

• D. Limit fluids

For patients on hematologic therapy, B. Monitor for bleeding and infection is the priority teaching, as treatments often lower blood counts (neutropenia and thrombocytopenia), increasing risks for infection and hemorrhage, while other options are generally incorrect or context-dependent. 

Why B is correct:

• Neutropenia: Many therapies suppress white blood cells, leading to low neutrophils (neutropenia) and a high risk of serious infections.

• Thrombocytopenia: Treatments can also reduce platelets (thrombocytopenia), impairing clotting and increasing the risk of bleeding (bruising, petechiae, prolonged bleeding).

• Patient Education: Teaching patients to recognize signs of infection (fever, chills, cough) and bleeding (easy bruising, blood in urine/stool, nosebleeds) and to report them immediately is crucial for timely intervention and preventing life-threatening complications. 

Why other options are incorrect:

• A. Increase sodium intake: Not a universal recommendation; fluid/electrolyte balance needs monitoring, but increasing sodium isn't a primary goal and could be harmful if fluid retention is present.

• C. Avoid all exercise: Inappropriate; gentle, regular exercise is often encouraged for overall health and to combat fatigue, though heavy lifting or high-risk activities might be temporarily restricted.

• D. Limit fluids: Not always correct; patients might need increased fluids to prevent dehydration or help with medication excretion, though fluid balance must be managed based on specific therapy and lab results

61. Which lab value should be monitored in a patient receiving erythropoietin?

• A. Platelet count

• B. Hemoglobin and hematocrit

• C. INR

• D. Potassium

• B. Hemoglobin and hematocrit

62. Which patient is most likely to receive erythropoietin?

• A. Acute trauma patient

• B. Patient with chronic kidney disease

• C. Patient with iron overload

• D. Patient with leukemia

• The correct option is ✅ B. Patient with chronic kidney disease.

  Explanation

  • Mechanism: The kidneys are the primary source of natural erythropoietin (EPO), a hormone that stimulates the bone marrow to produce red blood cells.

  • Clinical Need: In chronic kidney disease (CKD), the kidneys become unable to produce sufficient EPO, leading to chronic anemia.

  • Standard Treatment: Synthetic erythropoietin (epoetin alfa) is a standard, FDA-approved treatment specifically indicated to manage anemia in CKD patients to reduce the need for blood transfusions. It is most commonly used when hemoglobin levels fall below 10 g/dL. 

  Why other options are incorrect

  • ❌ A. Acute trauma patient: Acute trauma typically involves sudden, massive blood loss that requires immediate replacement with blood transfusions (fluids and red cells) to stabilize volume and oxygen delivery. While EPO is sometimes studied for long-term recovery in trauma, it is not the primary or most likely treatment for the acute phase.

  • ❌ C. Patient with iron overload: EPO therapy actually requires adequate iron stores to be effective. Iron overload is a complication often caused by frequent blood transfusions; while EPO might be used to reduce the need for those transfusions, it is not a treatment for the overload itself.

  • ❌ D. Patient with leukemia: While EPO can be used to treat anemia caused by chemotherapy in some cancers, it is generally avoided or used with extreme caution in myeloid malignancies like certain leukemias because it could potentially stimulate the growth of the cancer cells themselves. 

63. A patient with sickle cell anemia experiences pain primarily due to:

• A. Low platelet count

• B. Hemoglobin deficiency

• C. Vaso-occlusion

• D. Iron deficiency

• C. Vaso-occlusion

64. Which medication is commonly used to stimulate white blood cell production after chemotherapy?

• A. Erythropoietin

• B. Filgrastim

• C. Iron dextran

• D. Warfarin

• B. Filgrastim

65. Which finding indicates effectiveness of filgrastim therapy?

• A. Increased hemoglobin

• B. Increased neutrophil count

• C. Decreased INR

• D. Increased platelet count

• B. Increased neutrophil count

66. A patient with von Willebrand disease is at increased risk for:

• A. Thrombosis

• B. Infection

• C. Bleeding

• D. Iron overload

• C. Bleeding - because the disease have to do with platelet adhesion problem

67. Which product is most appropriate for a patient with hemophilia A?

• A. Platelets

• B. Fresh frozen plasma

• C. Cryoprecipitate

• D. Whole blood

• C. Cryoprecipitate - because hemophilia A is lacking clotting factors (especially factor VIII)

68. Which transfusion product is given to correct clotting factor deficiencies?

• A. PRBCs

• B. Platelets

• C. Fresh frozen plasma

• D. Normal saline

• C. Fresh frozen plasm

69. A patient receiving a transfusion develops fever and chills. The nurse should first:

• A. Administer acetaminophen

• B. Stop the transfusion

• C. Slow the infusion rate

• D. Draw blood cultures

• B. Stop the transfusion

70. Which symptom differentiates TRALI from TACO?

• A. Hypertension

• B. Pulmonary edema

• C. Fever

• D. Hypotension

• D. Hypotension (classic symptoms of sepsis while TACO is fluid overload so definitely hypertension)

71. TACO is more likely in patients with:

• A. Liver disease

• B. Renal or heart failure

• C. Diabetes

• D. Obesity

• B. Renal or heart failure

72. Which assessment is most important during a blood transfusion?

• A. Pain level

• B. Lung sounds

• C. Bowel sounds

• D. Skin turgor

• B. Lung sounds

73. Iron supplements should be taught to be taken:

• A. With milk

• B. With antacids

• C. On an empty stomach if tolerated

• D. At bedtime only

• C. On an empty stomach if tolerated and with vitamin C

74. A common side effect of oral iron therapy is:

• A. Diarrhea

• B. Black, tarry stools

• C. Hypoglycemia

• D. Bruising

• B. Black, tarry stools

75. Which patient teaching is appropriate for iron deficiency anemia?

• A. Increase calcium intake

• B. Avoid vitamin C

• C. Eat iron-rich foods

• D. Limit protein

• . Eat iron-rich foods

76. Which IV fluid is compatible with blood products?

• A. D5W

• B. Lactated Ringer’s

• C. Normal saline

• D. 0.45% saline

• C. Normal saline

77. Calcium in Lactated Ringer’s is problematic because it:

• A. Causes hemolysis

• B. Promotes clotting in blood tubing

• C. Alters blood pH

• D. Increases potassium

• B. Promotes clotting in blood tubing

78. Which medication neutralizes the effects of excessive anticoagulation?

• A. Protamine sulfate

• B. Naloxone

• C. Vitamin K

• D. Filgrastim

• C. Vitamin K

79. A priority nursing goal for a patient with a hematologic disorder is to:

• A. Prevent infection and bleeding

• B. Maintain strict bed rest

• C. Restrict fluids

• D. Increase calorie intake

• A. Prevent infection and bleeding

80. Which outcome best indicates effective hematologic therapy?

• A. Patient reports no fatigue

• B. Laboratory values move toward normal

• C. Patient gains weight

• D. No medication side effects

• B. Laboratory values move toward normal