Hematology

Iron rich foods

• Fruits

• Dark chocolate

• broccoli

• red meat

• legumes

• leafy greens

• whole grains

• tofu

• pumpkin seeds

Vitamin B12 rich foods

• fortified cereals

• Shitake mushrooms

• boiled eggs

• sardines

• chicken

Folate rich foods

• spinach

• broccoli

• lettuce

• peas

• beans

• lentils

• watermelon

• orange juice

• bananas

• lemons

• cereal

• bread

Hematopoiesis

• blood cell formation

Myeloid stem cells:

• RBC, WBC, platelets

Lymphoid stem cells:

• B or T lymphocytes

Erythrocytes

• RBC

Leukocytes

• - WBC

Thrombocytes-

• Platelets 

Plasma

• 90% water, contains plasma proteins and clotting factors

• Red Blood Cells 

• “Feed” the cells of the body

  • • Transport O2 and CO2

  • • Removed by the liver and spleen

  • • Hematocrit

  • • The volume of blood composed of RBC’s.

  • • Hemoglobin

  • • 95% of RBC mass, carries O2

• White Blood Cells 

• “Defend” the cells of the body

• Fight infection

  • Types of Cells:

  • • Neutrophil: prevent or limit bacterial infections

  • • Monocytes: Enter tissue as a macrophage, highly phagocytic (destroy)

  • • Eosinophils: involved in allergic reactions

  • • Basophil: contain histamines

• Platelets

• “Heal” the body

Increased RBC, HCT, HGB:

Polycythemia or erythrocytosis, Chronic anoxia

Decreased RBC, HCT, HGB:

 Anemia or blood loss, bone marrow suppression

Increased WBC

• Infection, inflammation, leukemia

Decreased WBC

• Prolonged infection or bone marrow depression

Increased Serum Fe

• Liver disorders, megaloblastic anemia

Decreased Serum Fe

• Iron-deficiency anemia, hemorrhage

Increased Platelet

• Thrombocytosis

Decreased Platelet

Suppressed bone marrow function, splenomegaly

Increased PT

• Deficiencies in Clotting factor V and VII, oral anticoagulant therapy

Decreased PT

•  Vitamin K excess 

• PTT (aPTT is 25-35 seconds):

• • Monitors response to Heparin, monitors intrinsic pathway clotting factors

• Bone Marrow Aspiration and Biopsy

  • NURSING ACTIONS:

• - Teach about brief pain and pressure

• - Ensure the client avoided anticoagulants before the procedure and that consent is signed

• - Put the patient in a prone or side-lying position

• - Post-procedure, maintain bedrest for 30 min to an hour

• - Check for bleeding every 2 hours for 24 hours

• - Removal of sutures is after 7-10 days

• - Analgesics for pain *not Aspirin

• Potential Complications: Bone marrow aspiration and Biopsy

• Infection at the site

  • - Apply a sterile dressing

  • - Watch for S/S of infection

• Risk for bleeding

• Bedrest for 30-60 min after the test

• Apply pressure at the site, pressure dressing

• Apply ice

• Therapeutic Procedures

• Splenectomy

• Apheresis (Table 28-3)

• Hematopoietic Stem Cell Transplantation

• Phlebotomy

• Types of Blood Donation

• Standard

• Autologous:

  • • Patients own blood, collected 4-6 weeks prior to procedure, give iron supplements, can donate 1 unit per week but not within 72 hours of procedure

• Intraoperative Blood Salvage (Cell Saver)

Autologous Blood donation

• • Patients own blood, collected 4-6 weeks prior to procedure, give iron supplements, can donate 1 unit per week but not within 72 hours of procedure

• Febrile Nonhemolytic transfusion reaction 

• • Chills

• • 1° C elevation temperature (at least)

• • Typically begins within 1 hour of the transfusion

• *Acute Hemolytic Transfusion reaction 

• • Most dangerous

• • Incompatible blood

  • • Fever

  • • Chills

  • • Dyspnea

  • • Low back pain

  • • Nausea

  • • Anxiety

  • • Hypotension

  • • Bronchospasm

  • • Hemoglobinuria

  • • Vascular collapse

• Allergic transfusion reaction 

• • Hives

• • Flushing

• • Wheezing

• • Decreased BP

• • Increased anxiety

• Treatment for transfusion reactions 

• 1. Stop the transfusion

• 2. Begin infusion of NS with new tubing.

• 3. Contact MD and Blood Bank.

• 4. Continue to monitor patient; especially VS, cardiac, respiratory, and renal function.

• 5. Return blood and tubing to the blood bank for testing.

Anemia

• Lower than normal hemoglobin

• A sign of an underlying disorder

• Hypo-proliferative Anemia

• ▪Defective RBC production

• • Iron deficiency

• • Vitamin B12 deficiency

• • Folate Deficiency

• Bleeding Anemia 

• ▪RBC loss

• Hemolytic Anemia 

• ▪RBC destruction

• • Altered erythropoiesis:

  • • Sickle Cell

  • • Thalassemia

• • Hypersplenism

  • • Hemolysis

• Iron Deficiency Anemia (IDA)

• • Highest among non- Caucasian Americans of lower-socioeconomic status

• • Can be result of hemorrhage and chronic blood loss

• • Insufficient hemoglobin to transport oxygen

• Clinical manifestations:

  • • Fatigue and pallor

  • • Tachycardia and tachypnea

  • • Fissures, glossitis, and koilonychias (spoon-shaped nails)

  • • Decreased HCT & HGB

  • • Tachypnea & tachycardia

  • • Shortness of breath

  • • Blood loss

  • • Changes in LOC & cognitive impairment

• Nursing Management for iron deficiency anemia

• • Increase dietary iron

• • Increase intake of Vitamin C (aides iron absorption)

• • Iron Supplements:

• • Oral is first choice. Can cause GI upset.

• • IM if severe GI upset with oral.

• • IV – can cause CV side effects, so monitoring vital signs is necessary.

• • If present minimize blood loss

• Vitamin B12 Anemia

• Caused by inadequate intake or malabsorption

  • • Pernicious anemia is a lack of intrinsic factor, so B12 cannot bind, and therefore is not absorbed in the small intestine. (malabsorption)

• Daily intake is essential, because B12 is not stored in the body

• Required for central nervous system function, RBC formation, and synthesis/regulation of DNA

• Cellular metabolism uses b12 for the synthesis of fatty acids and energy production

• Clinical Manifestations:

  • • Neurological deficits

  • • Fatigue & pallor

  • • Tachycardia & tachypnea

  • • Shortness of breath & dizziness

• Nursing management for vitamin B12 anemia 

  • Neurological deficits:

• • Symmetric paresthesia offeet and fingers

• • Coordination and balance problems

• • Lhermitte' s sign – electric shock sensation produced by neck flexion.

• • Confusion

• • Depression

• • Impaired taste – stingingsensation on tongue

• • Impaired balance

• • Mood swings

• • Visual disturbances

• • Tinnitus – ringing in ears

• Actions:

  • Teach dietary choices

  • B12 therapy

  • Assess pain and activity levels due to peripheral neuropathy

• Folic Acid Deficiency

• Folic acid is a synthetic supplement for Folate, which is naturally found in foods.

• Essential for DNA synthesis, cell maturation and replication

• Absorbed in the jejunum of small intestine.

• Deficiency interferes with formation of heme (oxygen carrying portion of blood)

• Nursing Management for folic acid deficiency 

• Clinical Manifestations

  • Fatigue & pallor

  • Tachycardia & tachypnea

  • Dizziness

  • Mood changes

  • Increased bleeding risk

• Neurological complications:

  • Confusion or disorientation

  • Reversible

• Interventions

  • Ensure intake/administer supplements

  • Teach dietary choices

  • Differentiate anemia caused by Folic acid vs. B12

• Sickle Cell Anemia

• Genetic disorder of hemoglobin

• 50% of children born with SCA live to adulthood

• Complications

• Pulmonary infarctions

• Cerebrovascular accidents

• Infection – *leading cause of hospitalization

  • More than 90% of people in the United States with SCD are non-Hispanic Black or African American (Black), and an estimated 3%–9% are Hispanic or Latino.

  • SCD occurs in about 1 out of every 365 Black or African American births and about 1 out of every 16,300 Hispanic American births.

  • About 1 in 13 Black or African American babies is born with sickle cell trait (SCT, inheritance of a sickle cell gene from only one parent).

• 3 crisis types 

• 1. Acute vaso-occlusive crisis

• 2. Aplastic Crisis

• 3. Sequestration crisis

• SCA – Clinical manifestations

• Pallor, fatigue, SOB

• Pain and swelling due to vaso-occlusion

• Pain usually occurs in joints, bones, chest, and abdomen

• Ischemic organ damage

• Delayed wound healing

• Increased risk of infections, particularly respiratory

• Hand-foot syndrome

•  Jaundice

• Sickle Cell Anemia Management

• During a crisis:

  • • Oxygen therapy

  • • Aggressive hydration with oral and parenteral fluids.

  • • Analgesia – opiates

  • Exchange blood transfusion

  • Peripheral stem cell transplantation

  • Emotional support

• Teaching:

  • • Infection control

  • • Avoid cold temperatures, tight clothing

  • • Avoid high altitudes

  • • Avoid dehydration and overexertion

• Aplastic Anemia

• Damage to bone marrow resulting in a reduction of all blood cells

• Result of diseases or

• treatments for diseases

• Decrease RBC

  • • Fatigue, SOB, tachycardia, pallor, dizziness

• Decreased WBC

  • • Increased infection

• Thrombocytopenia

  • • Nosebleed, bruising, bleeding gums

• Aplastic Anemia – Nursing Management

• Provide O2

• Administer blood products

• Bleeding precautions

• Fall precautions

• Teaching:

  • • Avoid infection

  • • Monitor temperature

  • • Avoid risky activities

• Polycythemia Vera

• Increase in RBC production

• Either a genetic tendency or a response to hypoxia

• Disease is slow to progress

• Hyperviscocity makes it difficult for the heart to pump, leads to

• hypoxia

• Clinical Manifestations:

  • SOB

  • Pruritis, especially after a warm bath

  • Flushing of the face

  • Splenomegaly

• Polycythemia Vera – Nursing management

• Treatment

  • • Therapeutic phlebotomy

• Complications:

  • • Hyperviscocity leads to increase risk of thrombus.

  • • Most deaths occur from a heart attack or stroke

  • • If an injury occurs, there may be hemorrhaging due to a lack of platelets

• Actions:

  • • Increase fluid intake

  • • Removal of a unit of blood weekly until Hct is <45%, then as needed.

  • • Routine CBC’s

  • • Increase rest

  • • Elevate lower extremities

  • • Avoid tight clothing and extreme temperatures

• Thrombocytopenia

• Platelets below normal range (<150,000)

• Decreased because of decreased production or platelet destruction.

• Heparin Induced Thrombocytopenia (HIT)

• Hemorrhagic conditions with thrombocytopenia:

  • • Hemophilia

  • • Von Willebrand Disease

• Disseminated Intravascular Coagulation

• Heparin Induced Thrombocytopenia

• Occurs 5-14 days after first administration

• Antibodies form against the “foreign” heparin, leads to blood clots and a reduction of platelets

• Treatment

  • • Stop use of Heparin

  • • DO NOT use Warfarin or platelet transfusions

  • • Lepirudin and Argatroban are the only anticoagulants approved for treatment

• Disseminated Intravascular Coagulation (DIC)

• Abnormal blood clotting

• Two stages:

  • • Stage 1: Overactive clotting, all platelets and clotting factors are used, creating thrombi throughout the body.

  • • Stage 2: Spontaneous bleeding from every orifice due to no platelets/clotting factors

• Disseminated Intravascular Coagulation (DIC) causes and treatment

• Causes

  • • Cancer, Sepsis, Pregnancy/Delivery, Injury, Blood transfusion reaction

• Treatment:

  • • Stage 1: Anticoagulants

  • • Stage 2: Plasma and platelet transfusions, O2 , fibrinogen to replace clotting factors

• Bleeding Precautions

• 1. Soft toothbrush, no flossing

• 2. Electric razors

• 3. Shoes or slippers when out of bed

• 4. Clutter free environment

• 5. Use stool softener daily (Ex: Docusate)

• 6. Avoid rectal thermometer, suppositories, enemas, vaginal douches

• 7. Avoid sexual intercourse if platelet count <50,000

• 8. Do not blow nose

• 9. Apply direct pressure and/or ice to lacerations for at least 5 minutes

• 10. IM injections, arterial sticks, and peripheral blood draws should be minimized

• Leukemia 

• “Blood cancer”

• Bone marrow disorder leading to uncontrollable, immature WBC production, known as leukemic/blast cells

• Bone marrow, spleen, and lymph tissue congests with blast cells.

• 4 major types:

  • • Acute Myeloid Leukemia (AML)

  • • Chronic Myeloid Leukemia (CML)

  • • Acute Lymphoblastic Leukemia (ALL)

  • • Chronic Lymphocytic Leukemia (CLL)

• Leukemia Clinical Manifestations

• Swollen, painful lymph glands in neck, axillae, groin and left upper abdominal quadrant (spleen location)

• Increased risk of infection due to neutropenia

• Decrease in RBC’s and platelets due to blast congestion in bone marrow

  • • Present with symptoms of anemia and thrombocytopenia

• Can present with flu like symptoms, but many times  asymptomatic

• Treatment:

  • • Chemotherapy and radiation

  • • Bone marrow transplant

• Emergency Situations

  • • Leukostasis

  • • Tumor Lysis Syndrome

Leukostasis

• WBC count >100,000

• Excessive immature WBC

• Congestion and organ dysfunction

• Mainly in brain, lungs, kidney

• Increased risk of bleeding, stroke, dyspnea

• Treatment:

  • • Immediate chemotherapy

  • • Leukapheresis – removal of WBC

• Tumor Lysis Syndrome

• treatment

• Leads to hyperuricemia, hyperkalemia, hyperphosphatemia

• Risk for heart block and tachypnea; renal failure

• Treatment:

  • • Large volume IV fluid administration with diuretics.

  • •Allopurinol for hyperuricemia

  • • Dialysis

• Complications of Leukemia Treatment

• Myelosuppression: suppression of bone marrow activity

  • • Neutropenia:

    • High risk of infection

    • Neutropenic precautions if neutrophil count Is less than 1,000 (Box 34. 2)

  • • Thrombocytopenia – bleeding precautions (Box 34.1)

• Lymph Disorders 

• Malignant neoplasms originating in the bone marrow and lymphatic system.

• HODGKINS LYMPHOMA

• Reed-Sternberg (RS-H) cells

• Associated with Epstein-Barr Virus and being a 1st degree relative of someone with Hodgkins

• Higher survival rate than NHL

• Specific manifestations:

  • • Generalized pruritis

  • • Alcohol-induced pain

• Goal of treatment is cure

• NON-HODGKINS LYMPHOMA (NHL)

• All other lymphomas that do not have RS-H cells

• Associated with Auto-immune disorders and organ transplants

• HIV/AIDS, Chlamydia, and Heliobacter pylori increases risk

• Evolve mainly from B and T lymphocytes

• Goal of treatment is remission

• Malignant Lymphoma

• Clinical Manifestations

  • • Painless swelling of the lymph nodes in neck, underarm, and groin.

  • • Low grade fever for no reason

  • • Night sweats

  • • Unexplained weight loss of 10%

  • • Fatigue

• Treatment:

  • • Chemotherapy and radiation therapy

  • • Surgical removal of the tumors

  • • Emergency Situations

  • • Superior Vena Cava Syndrome

  • • Spinal Cord Compression

  • • Tumor Lysis Syndrome

• Superior Vena Cava (SVC) Syndrome

• Tumor compression of the SVC, causing reduced return of blood flow to the heart and venous congestion.

• Dyspnea is most common, edema of the upper body

• Treatment:

  • • Immediate chemotherapy

  • • Corticosteroids

  • • SVC stent

• Spinal cord compression

• Tumor compression of spinal cord.

• Symptoms depend on level of compression

• Treatment:

  • • Radiation therapy

  • • Corticosteroids

• Multiple Myeloma

• Incurable B-cell malignancy of plasma

• Plasma cells create immunoglobulins, which are used in infection control

• Malignant plasma cells produce an abnormal antibody: M protein

• M protein can cause tumors, bone destruction, kidney damage, and impaired immune function

• Risk factors

  • • Herbicides, insecticides, petroleum, heavy metals, plastics, and radiation

  • • African Americans

  • • Males

  • • Over age 45

• Multiple Myeloma

  • 4 classic clinical manifestations

• • hyperCalcemia

• • Renal dysfunction

• • Anemia

• • Bone destruction

Multiple Myeloma

• Treatment

• • No cure

• • Chemotherapy

• • Bisphosphanates (Ex. Alendronate)

• • Encourage fluid intake

RBC’s

• “Feed” the body

WBC’s

• “Defend” the body

Platelets

• “Heal” the body