NU 236 Care of the Adult II: Hematologic Disorders

Erythrocytes

red blood cells responsible for oxygen transport

Thrombocytes

platelets responsible for clotting

Leukocytes

white blood cells that fight infection

Anemia

a SYMPTOM that occurs decrease in hemoglobin in the blood due to a decrease in the oxygen carrying capacity of the blood

With anemia, we are primarily concerned about..

oxygenation

Symptoms: Anemia

FATIGUE

SOB on exertion

Pale skin/cold

Tachycardia

Dizziness

Difficulty concentrating

Priority Nursing Interventions: Anemia

Fall and injury prevention r/t weakness/dizziness

Cluster care and promote rest during activities

Monitor vitals, tissue oxygenation, and SpO2

The best lab for anemia is..

hemoglobin (Hgb)

Hemoglobin (Hgb)

blood test that measures the amount of hemoglobin (the protein in red blood cells that carries oxygen) in the blood

Hematocrit (Hct)

percentage of red blood cells in the total volume of blood

MCV, MCH, MCHC

MCV = mean corpuscular volume.

MCH = mean corpuscular hemoglobin. Average weight of hemoglobin in an RBC.

MCHC = measure of the average concentration or percentage of HGB within a RBC.

Normal Hgb

Men: 14-18

Women: 12-16

Normal Hct

35-50%

How is anemia categorized?

the characteristics of the RBC or what caused it

RDW

red cell distribution width

Causes of Anemia

Blood loss

Decreased RBC production

Increased RBC destruction

Anemia r/t Blood Loss: Causes

Occult bleeding (GI)

Acute hemmorhagic d/t trauma

Acute hemorrhagic anemia

rapid loss of large quantity of blood due to trauma, surgical complications, aneurysms, ulcers, or esophageal varices

Symptoms: Acute Hemmorhagic Anemia

Pale

Restless

Tachycardia

Weakness/dizziness

Hypotension

Diaphoresis

(Hypovolemic shock)

Decrease RBC, Hgb, Hct

If blood loss if very rapid, what lab may be normal?

Hct

Treatment: Acute Hemmorhagic Anemia

Treat the bleeding (pressure, cauterize, OR)

Administer O2

Blood transfusions

IV fluids for hypovolemia

Occult Bleeding

blood loss that is not necessarily visible, and may be caused by colonic polyps, carcinoma, menstrual blood loss, ulcers, or hemmorhoids

Iatrogenic causes of occult bleeding

Excessive blood donation/sampling

Dialysis

Occult bleeding symptoms develop _______.

slowly

Treatment: Occult Bleeding

STOP cause

Iron supplementation to treat anemia

Causes of Decreased RBC Production

Iron deficiency anemia

B12 deficiency

Folic acid deficiency

Aplastic anemia

Chronic disease anemia

Who is at risk of anemia caused by decreased RBC production (or deficiencies of nutrients)?

Those in poverty/cannot afford it

Digestion or eating issues

Rapid growth periods

Most common type of anemia

iron deficiency anemia

Iron-deficiency Anemia

microcytic anemia that causes decreased RBC production when iron stores are depleted first, then hemoglobin

2/3 of iron is in _______, while 1/3 is..

hemoglobin, bone marrow, spleen, liver, and muscle

Testing for Anemias r/t Decreased RBC Production (Deficiencies)

Serum ferritin (Iron level)

Total iron-binding capacity (TIBC)

Serum B12

Folate

Erythropoietin

Total iron-binding capacity (TIBC)

measure of blood's capacity to bind iron; low = too much iron high = low iron stores

Lab Findings: Iron-Deficiency Anemia

Decreased H/H

Microcytic, hypochromic cells

Low iron and ferritin

High TIBC

Causes of Iron Deficiency Anemia

Blood loss (GI)

Pregnancy or growth spurt

Dietary insufficient

Common in women, elderly, or poor diet

Treatment: Iron Deficiency Anemia

Increase dietary iron

Iron supplements

Iron-Rich Foods

Lean red meat

Chicken

Turkey

Eggs

Cereal (oatmeal, bran flakes, oat cereal)

Greens

Sweet potatoes

Iron Supplements

Do not take with milk, tea, coffee, or antacids

Take with Vitamin C to increase absorption

May cause black stool, constipation, nausea, metallic taste

Vitamin B12 Deficiency Anemia

anemia caused by lack of vitamin B12 that is hypoproliferative

Symptoms: Vitamin B12 Deficiency Anemia

Neurologic deficits!

Gait issues

Confusion

Pins/needles

Paresthesias

Interventions: Vitamin B12 Deficiency Anemia

SAFETY!

Fall prevention and prevent injury

Dietary Sources of Vitamin B12

Beef

Liver

Seafood (clams/salmon)

Beans

Nuts

Milk

Pernicious Anemia

low B12 despite good dietary intake, due to LACK of intrinsic factor; treated with monthly B12 injections or HIGH dose PO

B12 deficiency is from __________, NOT missing factor and is treated by..

poor dietary intake, treated with diet or PO supplements

Parenteral Vitamin B12

treatment for pernicious anemia and is also available in a nasal spray 1x a week; high mortality rate without treatment

Folic Acid Deficiency

Similar to B12, but NO neuro symptoms

In pregnancy, can cause neural tube defects (spina bifida)

Treatment of Folic Acid Deficiency

Rare due to folic acid in most foods

Folic acid PO daily

Anemia of Chronic Disease (ACD)

second most common anemia and is a diagnosis of exclusion, often related to rheumatoid arthritis, AIDS, infections, COPD, medications, cancer, etc.

Treatment: ACD

Treat underlying disorder

Epoetin

Aplastic Anemia

presence of anemia, leukopenia, and thrombocytopenia (pancytopenia) that occurs due to damage to stem cells or bone marrow and is congenital or acquired

Pancytopenia

deficiency of all types of blood cells

Symptoms: Aplastic Anemia

Pallor/fatigue

Infections

Bleeding

Nursing Interventions: Aplastic Anemia

Protect from infection (neutropenic precautions)

Bleeding precautions

Frequent rest for anemia

Treatments: Aplastic Anemia

Blood transfusions

Splenectomy

Bone marrow transplant

Causes of Anemia due to Increased RBC Production

Sickle Cell Anemia

Incompatible blood

Spleen issues

Sickle Cell Anemia

chronic hereditary disorder of abnormal hemoglobin producing crescent-shaped erythrocytes and hemolysis

Sickle Cell is the ONLY _________ anemia. When?

painful; during sickle cell crisis

Interventions: Sickle Cell Crisis

O2

Hydration (dehydration can cause crisis)

Monitor for complications

Medicate for pain

Polycythemia

excess of red blood cells, causing increased viscosity and volume

Nursing Priorities: Anemia

Help with fatigue/SOB and encourage rest

Monitor HR/BP and admin blood

Safety interventions to prevent falls

Assess nutritional status and diet and educate regarding RDA of calories, vitamins, proteins, etc.

Avoid overcooking veggies

Universal Interventions: Anemia

O2 admin

Blood transfusion and volume replacement

Diet high in iron (meat, eggs, legumes, dried fruit)

Medications (iron, folic acid, B12, Epoeitin)

Thrombocytopenia

platelet count under 150,000; critical under 50,000

Causes: Thrombocytopenia

Malignancy

Infection'

Meds

Autoimmunes

Interventions: Thrombocytopenia

Treat underlying cause

Assess for bleeding

Bleeding precautions

Transfusion (

Bleeding precautions

Electric razor

No aspirin

Avoid needles/injections and if needed use small gauge

Limit needlesticks

Protect injury

Observe for bleeding, bruising, nosebleeds, etc.

Hemophilia

inherited bleeding disorder due to a deficiency in factor VIII or IX, causing abnormal bleeding with trauma and impaired formation of clots

Heparin-induced thrombocytopenia (HIT)

antibody immune reaction causing clots, often on days 5-7; life-threatening and suspected if platelet count is >50% or more from baseline or if a thrombus forms on heparin

Treatment: HIT

d/c heparin ASAP

Disseminated Intravascular Coagulation (DIC)

sign of an underlying cause that is an EMERGENCY, causes massive amounts of tiny clots to circulate and is treated by addressing underlying cause/transfusions

Coagulation studies

PT

INR

PTT

aPTT

D-Dimer

Fibrinogen

Bleeding time

Blood Component Therapies

Packed red blood cells

Factor VIII concentrate

Intravenous immunoglobulin (IVIG)

Blood Transfusions

introduction of blood products into a patient's circulation to restore blood volume to normal levels

Complications: Transfusions

Febrile nonhemolytic transfusion reaction (FNHTR)

Acute hemolytic reaction

Delayed hemolytic reaction

Allergic reaction

Circulatory overload

Bacterial contamination

Administering Blood

Obtain vital signs before and during administering blood products

Stay with the client for AT LEAST 15 minutes after starting blood product with an 18-20G IV

Close monitoring

Never leave blood product out of the blood bank for more than 30 minutes

Meticulous double-checks of patient ID and blood product prior to administration

Admin MAX time 4 hours

Careful communication and documentation

Platelet Transfusion

Indicated with platelets

Plasma Transfusion

given to replace blood volume or FFP for clotting disorders/active bleeding, donor matching is NOT required

White Blood Cells

Agranulocytes

Granulocytes

Neutrophils

Eosinophils

allergic reactions and parasites, decrease with steroid level rise

Basophils

healing process, decrease with steroid level rise

Absolute Neutrophil Count (ANC)

estimate of body's ability to fight infection and is helpful with neutropenia, as patients with neutropenia cannot often show classic infection signs

Neutropenia

a decreased number of neutrophils (

Neutropenic Precautions (Compromised Host Precautions)

Standard precautions

Strict, rigorous handwashing

Private room

Gown and gloves

NO visitors with infection/URI

Keep equipment (BP, steth, etc.) in room

Clean room daily

Monitor VS q4h and note MINOR temp elevations

Avoid indwelling catheters

NO fresh flowers

NO raw fruits and veggies

NO potted plants

Oral care

Bone Marrow Aspiration and Biopsy

removal of living bone marrow tissue, usually taken from the sternum or iliac crest, for microscopic examination to assess how blood cells are formed and the quantity/quality of each cell produced

Leukemia

cancer of the white blood cells; HUGE risk for infection and is classified on where it is and the maturity of the WBC

Treatments: Leukemia

Chemo

Radiation

Stem cell trasnplant

CAR-T

Priority Interventions for Leukemia

INFECTION PREVENTION!

Hand washing

Lymphoma

cancer of the lymphatic system

Hodgkin's Lymphoma

characterized by the presence of Reed-Sternberg cells in the lymph nodes and often occurs between 15-35 and 55-75; often starts with a firm and painless enlargement of a lymph node on the side of the neck and can spread

Treatment: Hodgkin's Lymphoma

radiation, chemotherapy, stem cell transplant

Multiple myeloma

cancer cells infiltrate the bone marrow and destroy bone, causing bone pain and high risk for pathologic fractures

Pathologic fractures

occurs when a weakened bone breaks under normal strain; caution when moving and ambulating patient

Stem Cell Transplant

procedure to replace damaged bone marrow.

Stem Cell Transplant: Complications

Infection

Graft vs. host disease

Progression of disease

Rejection

CAD/HF/Hyperlipidemia

Secondary malignancies

Lung disease