Hematological problems and blood infusions

what is the pathophysiology of anemia?

deficiency in:

• # of erythrocytes

• quantity or quality of hgb

• volume of PRBC (hct)

what hitches a ride with RBC?

oxygen!

if we don’t have enough red blood cells..

decreased oxygen → HYPOXIA into the tissues

if we have a decreased oxygen level..

increased CO2 → hypoxic stage → tissues die

is anemia a disease?

NO → it is a symptom of a bigger problem

etiology of anemia

• decreased erythropoietin (in kidneys and liver)

• decreased iron availability

• iron, folic acid deficiency

how can we have blood loss with anemia?

• can be acute

• trauma

• ruptured aortic aneurysm

GI bleed

can be slow and progressive

why are women commonly anemic?

getting their periods

types of anemia

• iron deficiency anemia

• thalassemia

• megablastic anemia

• anemia of inflammation

• aplastic anemia

• pernicious anemia

what does a patient feel like when coming in with anemia?

extremely tired and pale pallor, decreased energy

labs with anemia

RBC: LOW

Hgb: LOW

Hct: LOW

serum iron: LOW

ferritin: LOW

folate: LOW

cobalmin (B12): LOW

Stool for occult blood: (POS) if GI bleed → look for bloody stool

serum erythropoietin: LOW

bilirubin: HIGH (cannot filter out)

if a woman has heavy periods, what can they take?

iron supplements

what is bilirubin?

dead red blood cells in the bloodstream

what does someone look like with a high bilirubin?

jaundice

grey area of hemoglobin level

6-10

what level of hgb do we usually give blood transfusions?

6-7 (BUT we need to advocate for our patient if they have the symptoms and not the value)

s/s of anemia

• palpations

• exertional dyspnea

• fatigue

• roaring in the ears

• pallor, jaundice

nursing interventions for general anemia

• head to toe

• drug therapy

• iron replacement

• administer blood

• O2 therapy

• IVF

• monitor for shock

• balance rest with activity

• diet

what drugs can we give for anemia

vitamin supplements, vitamin C (helps absorb iron), iron tablet, erythropoetin (shot)

what will a person’s stool look like with iron therapy?

black stool

is erythropoietin a blood product?

NO

what IVF can we give the patient who is anemia/bleeding?

• colloids

• albumin

• hypertonic solution

how often to monitor VS with general anemia?

q4

what does your body do in shock?

• shut down and protect major organs

• shuts down first in the kidneys (decreased UO)

• look at patient and notice cold, clammy, diaphoretic, pale

what does IV iron look like?

dark tea colored

what is a great source of iron in foods ?

liver and organ meats

what is sickle cell anemia?

the RBC are in halfmoon shape → can cause clots → cut off blood supply of area distal to clot

pathophysiology of sickle cell anemia

• abnormal form of hemoglobin in the RBC

• causes irreversible damage to vessels flowing distal to the area

• damage to lungs, kidneys, brain, retina, bones

etiology of sickle cell anemia

• genetic link from BOTH parents

• autosomal recessive disorder

• may have sickle cell trait

where does the pain come from with SCA?

tissues being starved of oxygen

what happens when you get into tissue hypoxia?

start seeing organ death

S/S of SCA

• VARIES

• pain from organ tissue damage

• grayish skin

• jaundice

• prone to gallstones

• fever, swell, tender

• N/V

what will happen to vitals with SCA?

• HR (UP)

• BP (UP)

diagnostic studies for SCA

1. peripheral blood smear (see sickle)

2. hemoglobin electrophoresis (drop blood into separator)

3. Labs

4. Xray

5. MRI

6. venous doppler for DVT

why would we do a venous doppler?

we want to look in the ultrasound for a clot in the deep veins, and observe blood flow (is it good or not?)

nursing interventions for SCA

• O2 therapy for hypoxemia

• monitor resp status

• encourage cough and deep breath, IS

• rest with activity

• DVT prophylaxis

• monitor renal functioning (look at urine)

• IVF (thin blood)

• pain manage

• blood traansfusion

• PT/OT

• long term care

• vaccines

what drug can we give the patient to help with production of hgb in SCA

hydroxyurea (helps with stickiness too)

diet for SCA

supplements and high protein

what should a SCA patient get screened for?

retinopathy (eyes)

what is thrombocytopenia?

low platelets in the blood stream→ bleeding risks

pathophysiology of thrombocytopenia

• reduction of platelets below 150,000

• acute, severe, or prolonged

etiology of thrombo.

• bone marrow disorder: anemia, malignancies, alcohol

• non bone marrow: sepsis, viral, SLE, autoimmune, DIC

S/S of thrombo

• can be asymptomatic

• uncontrolled mucosal or cutaneous bleeding

→ nosebleeds, gingival bleed

• petechiae, pupura

• weakness

• fainting

• dizzy

• tachycardia

• abd pain

• hypotension

• changes in LOC, HA, seizures, coma

what happens if you take too many anti-inflammatories (Motrin, ibuprofen)

can throw self into thrombocytopenia

what can you notice in a hospital that may indicate thombo?

• bruising suddenly

• taking out IV and lots of bleeding

• give injection and won’t stop bleeding

complications for thrombo

• hemorrhage (internal, gradual, external)

• prolonged bleeding at punctures or injections

• death

thrombo labs to look at

• H and P

• bone marrow aspiration and bx (are RBC’s producing or is there a defect?)

CBC thrombo trends

• WBC: normal

• Hgb: LOW

• Hct: LOW

• RBC: LOW

• platelets: LOW

bilirubin lab value for thrombo

normal

PT/PTT are what?

our clotting times, how long it take the sample to clot, ability to perform clots

what will happen to PT/PTT

• elevated

• it is going to take longer to clot

what is a d-dimer?

determines if you have a clotting disorder problem,

what will happen to D-dimer level?

within normal limits

how to manage a patient with thrombo

• treat underlying cause

• if the anticoagulant medications have not been helping, STOP the meds

• avoid drugs that affect the platelets

• platelet transfusion (this is a blood product)

health promotion for thrombo

• no OTC meds (ASA, NSAIDS)

• find out what causes nose bleeds, bruising

• look for any signs of thrombo in cancer patients

what are the thrombo precautions?

• electric razors only

• soft bristle toothbrush

• no tampons

• no needle sticks

nursing intetventions for thrombo

• head to toe assessment

• bleeding precautions

• avoid injections

• monitor labs

for a nose bleed, how long should we ice pack the bridge of the nose?

5-10 minutes, and put head FORWARD

should we give blood thinners with DVT prophylaxis for thrombo?

NO (we can still do SCD and ROM)

how many mL’s soak a women’s pad?

50 mL → they should be counting these pads → may need to stop periods

patient teaching for thrombo

• understand iron in stool is formed, blood is thinner and sticky

• investigate bruises, headache, how well the person can see

• do not blow nose forcefully

• no vigorous activities, or lifting (increases pressure)

• do not bend all the way down (dizzy)

• do not strain when trying to poop

• no tweezing eyebrows or tattoos

what is leukemia?

decrease in the white blood cells

pathophysiology of leukemia

• bone marrow failure

• cells infiltrate outside the bone marrow

• CNS, testes, liver, spleen, joints

• person has low RBC count

presentation of someone with leukemia?

very sickly looking

etiology of leukemia

• no one cause

• genetics, environment, chemicals, chemo, virus, immunologic deficiency

s/s of leukemia

• weight loss

• fever

• frequent infections

• SOB

• weakness

• fatigue

• loss of appetite

• swollen lymph nodes

• large spleen

• petechaie and patches

what will the leukemia patient’s WBC look like when they have an infection

LOW

diagnostic testing for leukemia

• bone marrow biopsy

• lumbar puncture (C position)

• CT scan

• PET scan

• labs

what is complete remission?

no diagnosis of leukemia

what is minimal residual?

they still have leukemia, but no detection of problems with the WBC

what is partial residual?

still have the cancer, but the person lacks the s/s

what is molecular residual?

tests see nothing going on

what therapies might someone with leukema have?

• chemo

• drug therapy

• radiation therapy

• symptom manage

• bone marrow stem cell transplant

what drugs do we give someone with leukemia?

steroids → to fight off infections and decrease inflammation

nursing interventions for leukemia

• head to toe

• emotional support

• monitor for DIC

• administer drugs safely

• administer antiemetics

• IVF

• central venous lines only

• rest with activity

• self-care

monitor for what when patient is bone marrow supressed?

• anemia

• thrombocytopenia

• neutropenia

• platelet deficiency

neutropenic precautions for bone marrow supression?

No fresh fruit or fresh flowers

types of blood products

• packed red blood cells (anemia)

• platelets (clot disorder)

• plasma (clot and protein def)

• albumin (pulls fluid to bloodstream)

• prothrombin (hemophilia)

• factor VIII (severe bleeding)

who can group A receive from?

A, O

who can group B get it from?

B, O

who can AB receive from?

A, B, AB, O

who can O receive from?

only O

AB+ is considered?

the universal recipient

what is O- considered?

universal donor

what happens after you receive an order for blood?

• check order

• check patient allergies

• check if they had previous transfusion → check for reactions

• check labs

• OBTAIN CONSENT (we as nurses can do this)

• patient teaching

what organ function do we need to check for administering blood?

kidneys → we need to make sure the kidneys can function and handle the thick blood

what does it mean for someone to get typed and crosses?

• draw patient’s blood and find out what their blood type is (type)

• check to see the units available in the hospital for that pt (cross)

• these are only good for 2-3 days

• put specific band on patient and it does not come off until it expires

what IVF do we always hang with blood?

0.9% NS

what two meds can we premedicate the patient with before blood?

1. acetaminophen (fever)

2. benedryl (allergic reaction)

what should we teach the patient about the blood transfusion?

• they can get an infection

• they are getting it through the IV

• how long the transfusion will last

• if they start to feel any different, let the nurse know

what side effects can you get from the transfusion?

chills, headache, flushing, fever, chest pains, tachycardia, nausea

how often should we change out blood tubing?

• new set of tubing with each unit of blood

• OR every 4 hours

what is the maximum amount of time to run 1 unit of blood

4 hours

because the blood is thick, what could happen to the patient?

they can go into fluid overload → watch closely

if we are giving more than 1 unit, what should we have an order for?

20 mg furosemide → we need to diaphorase and shift the fluid

can any other medications be infused while the blood is infusing?

NO

if we have an atb running and we need to give blood, what do we do?

start another line, do not stop the med

what if the antibiotic is a 30 minute infusion?

let it run, (window of 1 hr before and after)

what if we have two ports on a picc line, or 3 ports on a central line?

we can have IV fluids or antibiotics running in one, blood in the other

what if you cannot start another IV line?

ask someone else, find expert, maybe picc line