REAL EXAM Study guide drill out: MedSurg Hematology

What is anemia?

Blood level is low

Deficiency in the number of erythrocytes, the quality or quality of hemoglobin, and/or volume of packed RBCs (hematocrit)

What happens during anemia?

Decrease of hemoglobin and hematocrit

What are major signs of anemia?

Fatigue — Don’t have enough RBCs

Discoloration — Jaundice (Bilirubin)

What are types of anemia?

Iron Deficiency Anemia — dietary, malabsorption, blood loss, or hemolysis

Thalassemia minor/major — inadequate production of normal hemoglobin

Megaloblastic or Pernicious Anemia — Cobalamin or B-12 deficiency due to impaired DNA synthesis or absorption issues

Anemia or Chronic Disease — associated with underproduction of RBCs (serious chronic illness or medications that suppress immune system) or chronic blood loss (gastritis/bleeding ulcers, hemorrhoids, menstruation, etc.)

Chronic or acute blood loss

Increased RBC Destruction — Hemolysis: ex. Sickle cell, medications, trauma, etc.

Iron Deficiency Anemia

Dietary, malabsorption, blood loss, or hemolysis (destruction of RBCs)

Thalassemia minor/major

Inadequate production of normal hemoglobin

Blood transfusion — Disadvantage

Megaloblastic or Pernicious Anemia

Cobalamin or B-12 deficiency due to impaired DNA synthesis or absorption issues

Anemia of Chronic Disease

Associated with underproduction of RBC’s — serious chronic illness or medications that suppress the immune system

OR

Chronic blood loss (gastritis/bleeding ulcers, hemorrhoids, menstruation, etc.)

Nursing assessment for Integumentary Manifestations

Pallor

Jaundice

Pruritus

Why does pallor (pale skin) occur with anemia?

Decrease of hemoglobin and blood flow to the skin

Why does jaundice (yellowing skin) occur with anemia?

Increase concentration of serum bilirubin

Why does pruritus (itchy skin) occur with anemia?

Increase serum and skin bile salt concentrations

What are the cardiopulmonary manifestations of anemia?

Cardiac output maintained by increasing heart rate and stroke volume due to inadequate O2 in tissues

Clinical Manifestations of Integumentary

Pallor, cyanosis, jaundice

Clinical Manifestations of mucous membranes

Pallor

Clinical Manifestations of Tongue

Shiny, beefy red, smooth, glossitis (inflammation of tongue)

Clinical Manifestations of Eyes

Conjunctival pallor (pale color of inner lining of the lower eyelid), scleral icterus (yellowing of eyes), retinal hemorrhage (bleeding in eyes)

Clinical Manifestations of Cardiopulmonary

Tachycardia, palpitations, angina (chest pain/discomfort), systolic murmur, MI, intermittent claudication (muscle pain, cramping, or weakness in the legs)

Clinical Manifestations of Respiratory

Dyspnea on activity, low SpO2

Clinical Manifestations of Abdomen/GI

Splenomegaly (enlarged spleen), hepatomegaly (enlarged liver), sore mouth/difficulty swallowing

Clinical Manifestations of Neurological

Numbness, ataxia (poor muscle control that causes clumsy movements)

Clinical Manifestations of musculoskeletal

Bone pain

Clinical Manifestations of Constitutional

Weakness, fatigue, sensitivity to cold

Major diagnosis of anemia

Fatigue

Imbalanced nutrition

Ineffective health management

What are the nursing interventions for anemia?

Alternate rest and activity

Prioritize activities: accommodate energy levels, maximize O2 supply

Provide assistance to minimize risk for injury

Evaluate nutritional needs

What are the risk factors for iron deficiency anemia?

Older adults

Poor diet

Menstruating and pregnant women

What are the management priorities for iron deficiency anemia?

Iron rich diet

Iron supplementation (Consider taking with acidic foods)

Discusses patient education for Iron Replacement Therapy

What safety measures needs to be taken with iron deficiency anemia?

Liquid iron should be diluted and ingested through a straw — can stain teeth

Bleeding/bruising precautions

What are the patient and family teachings that need to be done?

Diet teaching — foods high in iron and how to maximize absorption

Discuss the need for diagnostic studies to identify the cause

Emphasize compliance with dietary and drug therapy

Patients who require lifelong iron supplementation should be monitored for potential liver problems related to iron storage

What is iron best absorbed as in what environment?

Ferrous sulfate in an acidic environment

When should iron be taken?

An hour before means when duodenal is most acidic

Avoid binding iron with food

What food/vitamin can be taken with iron?

Vitamin C (ascorbic acid) and orange juice enhance iron absorption

Why should people ingest iron through a straw?

Undiluted iron may stain teeth

What can be a substitute for ferrous sulfate?

Ferrous gluconate

How does iron effect stool?

It turns the stool black because of excess iron

What does iron cause? What do they need to be started on?

Causes constipation, so patients should be started on stool softeners and laxatives if needed

What is the primary cause of pernicious anemia?

Absence of intrinsic fluid

This protein is required for the body to absorption B-12 in the intestines

What are other causes of pernicious anemia?

GI surgery

Chronic diseases of GI tract

Excessive alcohol

Smoking

Long-term users of H2-histamine receptor blockers and proton pump inhibitors

Strict vegetarians

What is most commonly caused by pernicious anemia?

Cobalamin deficiency

Which results in poor cobalamin absorption through the GI tract

What are megaloblastic anemias?

A group of disorders caused by impaired DNA synthesis and characterized by the presence of large RBCs

Most common cause of megaloblastic anemia

Cobalamin (vitamin B-12) and/or folic acid deficiencies

Less common causes of megaloblastic anemia

Suppression of DNA synthesis by drugs

Inborn errors of cobalamin and folic acid metabolism

Erythroleukemia — Malignant blood disorder: A proliferation of erythropoietic cells in bone marrow

What is anemia of chronic illness associated with?

Cytokine (interleukin 6) release causing retention of iron in macrophages

Chronic inflammatory process, autoimmune disorder, infectious disorder, (HIV, malaria, hepatitis), malignancy, heart failure

How is anemia of chronic illness different from anemia of other causes?

Reaction aimed at underlying condition

May require blood transfusion

Erythropoietin cautiously

Teach activity modifications

Dietary considerations

What are the causes of acute blood loss?

Trauma

Surgical and surgical complications

What are the concerns related to acute blood loss?

Volume loss and hypovolemic shock

Less sudden loss may compensate with correcting volume loss, but HCT fall is significant

Bleeding ulcer with loss of 750 mL hematemesis over 30 minutes

May have postural hypotension, but normal HGB and HCT, but over next 1-2 days H and H will fall because of intravascular fluid increases (Extravascular to intravascular) and ADH and aldosterone

What are the assessments for anemia from acute blood loss?

Dependent on location of bleeding

Pain from tissue distension, organ displacement and/or nerve compression

Pallor, dusky, cold, clammy skin

Tachycardia, Tachypnea and Hypotension, especially postural

Evidence of slower bleeding

What symptoms are evidence of slower bleeding?

Stools

Urine

Retroperitoneal

Change in heart sounds (muffled)

Diminished lung sounds

Ecchymosis

Abdominal distention

Reduced peripheral pulse strength

Peripheral pallor

What is the adult vascular volume?

Around 5L

Medical management for acute blood loss

Laboratory

Blood bank

Surgical consult

Nursing interventions for acute blood loss

ABC’s

Identify cause — assessment matters

Oxygenation considerations

Volume replacement — need venous access

Common blood products used for replacement

Long term — iron replacement

What are common blood products used for replacement for acute blood loss?

Crystalloid (normal saline, lactated ringers solution)

Packed red blood cells

Plasma for clotting replacement

Platelets

Consider calcium needs

What are the two types of hemolysis?

Intrinsic hemolysis

Extrinsic hemolysis

How does intrinsic hemolysis come from?

Most often hereditary

What is the prototype for anemia from hemolysis?

Sickle cell disease

What needs to be focused on for intrinsic hemolysis?

Preventing dehydration, increased tissue oxygen needs, and infection

Where does extrinsic hemolysis come from?

From physical destruction, antibody reactions, infectious agents and toxin

What is the most important site for RBC destruction?

Spleen

What is polycythemia?

A myeloproliferative disorder that results in the overproduction and presence of increased numbers of RBC’s

What can result from polycythemia?

This can result in impairment in blood circulation due to the viscosity of the blood as well as hypervolemia

What are the symptoms of polycythemia?

Viscous blood due to high RBC count

Vertigo, headache, tinnitus, visual disturbances

Generalized pruritus — exacerbated by hot bath — due to histamine release from increase number of basophils

Angina, heart failure, intermittent claudication, thrombophlebitis

What are the nursing interventions for polycythemia?

Phlebotomy — for acute exacerbations

Monitor I & O to prevent overload and dehydration

Myelosuppressive agents (suppress bone marrow function) — give as directed and teach patient about potential side effects

Assess nutritional status and provide appropriate teaching

Activities and medications to decrease thrombus formation

Supportive care

What is aplastic anemia?

A condition that occurs when the body stops producing enough new blood cells

How does aplastic anemia affect the body?

It leaves the body fatigued and more prone to infections and uncontrolled bleeding

What are the clinical manifestations for aplastic anemia?

Fatigue

Shortness of breath

Rapid or irregular heart rate

Pale skin

Frequent or prolonged infections

Unexplained or easy bruising

Nosebleeds and bleeding gums

Prolonged bleeding from cuts

Skin rash

Dizziness

Headache

What is the most common cause of aplastic anemia?

The immune system attacking stem cells in the bone marrow

What are other factors that can injure the bone marrow and affect blood cell production?

Radiation and chemotherapy treatments

Exposure to toxic chemicals

Use of certain prescription drugs — such as chloramphenicol

Autoimmune disorders, certain blood diseases, and serious infection

A viral infection

Pregnancy

What are prevention tactics for aplastic anemia?

There’s no prevention for most cases of aplastic anemia

Avoiding exposure to insecticides

Herbicides

Organic solvents

Paint removers

Other toxic chemicals might lower the risk of the disease

What is normal hemostasis?

Involves the vascular endothelium, platelets, and coagulation factors

They function together to stop hemorrhage and repair vascular injury

Disruption of any component may result in bleeding or thrombotic

What is thrombocytopenia?

A reduction of platelets

Result of thrombocytopenia

Abnormal hemostasis

Prolonged or spontaneous bleeding

What is thrombocytopenia commonly from?

Ingestion of high doses of certain drugs (chemotherapy, etc)

What is the range of thrombocytopenia?

Below 150,000/microliters

What are acquired problems that arise from a reduction in platelet count?

Immune Thrombocytopenic Purpura (ITP)

Thrombotic Thrombocytopenic Purpura (TTP)

Heparin Induced Thrombocytopenia (HIT)

What are laboratory findings for thrombocytopenia?

Low platelet count <150 K

Prolonged bleeding from trauma or injury at platelet counts < 50 K

Spontaneous, life-threatening hemorrhage at platelet counts < 20 K

Assessment for Thrombocytopenia

Epistaxis, gingival bleeding, petechiae, purpura, superficial ecchymoses

Prolonged bleeding after routine procedures

Weakness, tachycardia, dizziness, abdominal pain, hypotension

Hemorrhage insidious, acute or severe — joints, retina, cerebral

Nursing assessment for thrombocytopenia

Vital signs — Check for fever, tachycardia, and hypotension

Question carefully about any overt or covert

Do a complete medication assessment including OTC medications

Question more thoroughly these symptoms:

Pain

Stool cool

Bleeding gums

Changes in menses

Vomiting blood

Easy bruising

Headaches

Bloody urination

Nursing interventions for thrombocytopenia

Prompt follow-up evidence of bleeding tendency — prolonged nose bleed, petechiae; “Minor” bleeding may be only visible sign of internal bleeding

Monitor medications that may affect platelet counts — discourage use of OTC meds especially aspirin and aspirin containing medications

Monitor blood counts and coagulation studies — D-dimer, PT, aPTT

Monitor menstrual bleeding

Prevent injury:

Avoid injections, use smallest gauge possible, apply direct pressure after injections and venipunctures for 5-10 minutes

Use of ice packs

Assess ability to self-ambulate — keep “traffic pattern” clear, call light available

Soft bristle toothbrush

Avoid intramuscular injections

What is considered Heparin Induced Thrombocytopenia?

An immune-mediated response resulting in premature platelet destruction and platelet-fibrin thrombus formation

Manifestations of Heparin Induced Thrombocytopenia

Dyspnea

Bruising

Hypertension

Anxiety

Interprofessional Care for Heparin Induced Thrombocytopenia

Permanently stop all heparin including heparin flushes

Start the patient on a direct thrombin inhibitor

Start warfarin (Coumadin) when platelet count reaches 150,000/microliter

For severe clotting:

Plasmapheresis to clear platelet-aggregating IgG from the blood

Protamine sulfate to interrupt circulating heparin

Thrombolytic agents to treat thromboembolic events

Surgery to remove clots

When must heparin be discontinued?

When HIT is first recognized

How should you maintain anticoagulation when heparin is discontinued?

The patient should be started on a direct thrombin inhibitor, such as lepirudin (Refludan) or argatroban (Acova)

When should Coumadin be started?

When the platelet count has reached 150,000/microliter

People who have heparin induced thrombocytopenia should never be given what?

Heparin or low-molecular-weight heparin

What are the risk factors of thromboembolism (Deep vein thrombosis - DVT)?

Venous stasis

Endothelial damage

Hypercoagulability of blood

What are the nursing processes for DVT?

Assessment

Analysis

Planning

Implementation

Evaluation

Management Priorities

Safety

Patient and family teaching

Psycho-social/Spiritual Considerations

What are ways to prevent Deep Vein Thrombosis?

Graduated Compression Stockings

Early and Aggressive Mobilization

SQ Heparin/Lovenox

What are the diagnostics and labs that you should look out for with Deep Vein Thrombosis?

Hematocrit and Hemoglobin

Platelet count

D-dimer

Coagulation Studies: INR, aPTT, Activated Clotting Time (ACT), Anti-factor Xa

*Link each of these labs with medications. Which lab would you follow based on what med the patient was prescribed?

Medical treatment for DVT

Medication Therapy:

Heparin gtt with a bridge to Coumadin

Other long-term anti-coagulants

Catheter-guided admin of thrombolytic drugs (tPA)

Surgical intervention for DVT

Venous Thrombectomy

IVC Filter Placement

Nursing management for Acute DVT

Prevention is first! But if that doesn’t:

Manage pain

Follow labs

Administer medications

Nursing management for Chronic DVT

Dietary and medication teaching

Lifestyle teaching — smoking, weight management, oral contraception, mobility

Nursing care for Heparin protocol

Monitor labs and make prompt changes as described in order set

Monitor for complications of thromboembolism — Shortness of breath, angina, and change of mental status are most significant/life threatening

Prevention is key! — Venous Thromboembolism (VTE) is a major hospital associated risk

What is Neutropenia?

When a person has a low level of neutrophils

Where are neutrophils made?

Bone marrow

What are the signs and symptoms of neutropenia?

A fever

Chills or sweating

Sore throat, sores in the mouth, or a toothache

Abdominal pain

Pain near the anus

Pain or burning when urinating, or urinating often

Diarrhea or sores around the anus

A cough or shortness of breath

Any redness, swelling, or pain — especially around a cut, wound, or catheter

Unusual vaginal discharge or itching

What are the causes of neutropenia?

Some types of chemotherapy

Cancers that will affect bone marrow directly — Leukemia, lymphoma, and multiple myeloma

Cancers that spread

Radiation therapy — To body or to bones in the pelvis, legs, chest, or abdomen

Vitamin deficiencies, most commonly vitamin B12, folate, and copper deficiency

Sepsis — an infection of the bloodstream

Pearson syndrome

Certain infections — Including Hepatitis A, B, and C, HIV/AIDS, malaria, tuberculosis, dengue fever, and Lyme disease

Hypersplenism or enlarged spleen

Neutropenia Lab Values

Between 2.0 and 7.5 × 10^9/litre — Not neutropenic

Less than 2.0 and 10^9/litre — Neutropenic

Less than 0.5 × 10^9/litre — Severely neutropenic

Nursing interventions for Neutropenia

Educate patient on infection prevention strategies, including meticulous hand hygiene, avoiding crows, and maintaining a clean living environment

Emphasize the importance of promptly reporting any signs of infection

The nurse should place the patient in a private room and institute neutropenic precautions (REVERSE ISOLATION)

Administer medications as ordered