Care of Patients w/ Hematologic Disorders

Where are antibodies made from?

The spleen

Blood Overview

• Blood Volume (4-6 L)

• Blood Components: 45%

  • RBC

  • WBC

  • Platelets

• Plasma: 55%

  • Water

  • Proteins

  • Enzymes

  • Antibodies

  • Clotting factors

• pH of Blood

  • 7.35 - 7.45

Red Blood Cells (RBC): AKA Erythrocyte

• Transports O2 on Hgb

• Formation depends on:

  • Stem cells

  • Bone marrow

  • Iron

  • B12

  • Folic acid

  • Protein

  • B6

  • Copper

• Reticulocytes: Immature RBC

RBC Cycle

1. Stimulus: Reduced O2 carrying capacity

2. Kidney releases Erythropoietin

3. Developing erythrocytes in red bone marrow

4. Increased O2 carrying capacity

5. Relieves stimulus

Anticoagulants

• Interfere with steps in blood clotting

• Limit or prevent extension of clots

• Prevent new clots

Plate inhibitors

• Prevent platelets from becoming active & clumping together

Clot Busters

• Thrombolytics: Breaks down proteins (fibrins) that form clots

• Fibrinolytics: Selectively degrade fibrin threads in a formed blood clot

Diagnostic Assessment

Tests of Cell Number & Function

• CBC

• Peripheral Blood Smear

  • We as nurses do not look at this

• Coagulation studies:

  • PT

  • INR

  • aPTT

  • Anti-Za Assay

• Coomb’s test

• Serum ferritin, transferrin, & total iron binding capacity (TIBC)

Diagnostic Assessment Cont.

• Radiographic Exams

• Bone marrow aspiration & biopsy

  • Patient prep

  • Procedure

  • Follow up care

  • Bleeding

  • Bruising

  • Infection Pain

Anemia

Common causes of anemia:

• Decreased RBC production

• Increased RBC destruction

• Chronic RBC loss

Sx similar for all types:

• Tachycardia at rest

• Fatigue

What are the two types of Blood Loss Anemia?

Acute Blood Loss Anemia & Chronic Blood Loss Anemia

Acute Blood Loss Anemia

• Hemorrhage

  • Trauma, surgery, GI bleed

  • Symptomatic if is more than 500mL

Chronic Blood Loss

• Body compensates with gradual loss, bone marrow responds

• Adults

• Women

Treatment For Blood Loss

• Treat underlying cause

• Blood products

• Iron supplements, diet

• Erythropoietin (Epogen, Procrit)

Hemolytic Anemia

• The body is producing ENOUGH RBC, but something is DESTROYING them

• Abnormal breakdown of RBC

• Most common cause:

  • G6PD Enzyme Deficiency

  • G6PD maintains the integrity of RBC

  • Causes RBC to be fragile

• Inherited

• Fever

• Drugs/chemicals

• S/S:

  • Pallor & Jaundice

• Tx:

  • Stop offending agent

  • Hydration

    • Flushes the cellular debris through the kidneys

  • Transfusion (Severe cases)

Immunohemolytic Anemia or Autoimmune Hemolytic Anemia

• Body attacks their own RBC

• Exposure of erythrocyte to antibodies

• May occur with other autoimmune disorders

Autoimmune Hemolytic Anemia Treatment

• Depends on Sx severity

• Steroids (Must taper)

  • Helps stop the body from attacking its own RBC

• Immunosuppressant:

  • Cytoxan (More toxic)

  • Imuran (Less effective)

• Splenectomy

  • Removes the site of destruction

• Plasma exchange therapy

• Transfusion

  • Severe cases but cross-matching can be challenging

Iron Deficiency Anemia

• Most common worldwide

• Definitive Dx by bone marrow aspiration

Iron Deficiency Anemia Etiology

• Bleeding (GI, Menstrual)

• Malabsorption

• Inadequate iron intake/ absorption

• Chronic alcoholism

• Partial gastrectomy

• Pregnancy

• Adolescence

• Infection

Iron Deficiency Anemia Sx/Manifestations

• Chronic Bleeding

• Alterations in the tongue

• Brittle nails

• Cheilosis

  • Cracks on the sides of the mouth

• Pica

  • Unusual craving

• Fatigue

• Exercise intolerance

• Tachycardia

Iron Deficiency Anemia Tx

• Treat underlying cause

• Preventative Education

• Nutrition Counseling

• Iron Supplements

  • IV

  • PO

Vitamin B12 Deficiency: Pernicious Anemia

• Failure to absorb B12

• Lack of Intrinsic Factor

  • Intrinsic factor is what allows it to absorb B12

Clinical Manifestations of Vit. B12 Deficiency

• Pallor, Slight Jaundice

• Sore beefy red tongue

• Diarrhea

• Neurologic S/S (B12 needed for nerve function)

  • Paresthesia

  • Proprioception

  • Balance difficulty

  • Cognitive dysfunction

Vit. B12 Deficiency Anemia Tx

• If true Vit. B12 deficiency:

  • Increase PO dietary intake of B12 enriched foods

• If Vit. B12 Pernicious Anemia:

  • Vit. B12 injections

Folic Acid Deficiency Anemia

Common Causes:

• Malabsorption

  • Crohn’s Disease

  • Chemotherapy

  • Celiac Sprue (Celiac Disease)

  • Chronic Alcohol Abuse

• Increased need:

  • Pregnancy

  • Rapid growth

• Chronic Malnourishment:

  • Elderly

  • Alcoholics

Folic Acid Deficiency Anemia Clinical Manifestations

• Pallor, SOB, Fatigue

• Red smooth beefy tongue

• Cheilosis

• Diarrhea

• No neurologic symptoms

Folic Acid Deficiency Anemia Tx

• Folic Acid Supplement

• Increase intake of green leafy vegetables, fruits, meats, & cereals

Aplastic Anemia

Pathology:

• Bone marrow fails to produce blood cells (RBC, WBC, or Platelets):

  • Pancytopenia

  • Dec. RBCS

  • Dec. WBC

  • Dec. Platelets

• Stem cells injured:

  • # of stem cells decreased

Aplastic Anemia Diagnosis

• CBC

• Bone Marrow Biopsy

  • Very few to no cells, often replaced with fat)

Aplastic Anemia Treatment

• Blood transfusions

• Avoid offending agent

• Immunosuppressive therapy

• Splenectomy (Controversial)

• Stem cell Transplant

  • Cost

  • Availability

  • Complications

Polycythemia

• Primarily a cancer in the blood

• Increase number of RBC’s (Above normal)

  • Inc. in RBC, WBC, & platelets

• Congestion like traffic (Stagnant)

• Leads to clotting

• Blood is hyperviscous

  • Inc. Hematocrit (55% in males, 50% in females)

  • Not like dehydration (Related to overproduction of RBC)

Polycythemia Vera (PV)

• Excessive production of Erythropoietin

• Increases in RBCs, WBC, & platelets

Polycythemia Vera (PV) Treatment

• Repeat Phlebotomy (2-5 time per week)

  • First line

  • Draws blood

  • Prevents clotting

• Pheresis

  • Withdrawal of whole blood & removal of RBCs

• Inc. Hydration

  • Flushes out the kidneys

  • Flushes the cellular debris

  • Usually paired with phlebotomy

• Prevent clot formation

• Think about bleeding

Polycythemia Vera (PV) Clinical Manifestations

• Looks like someone not getting perfused

• Skin & mucous membranes have a plethoric appearance

  • Purplish or cyanotic

• Intense itching

  • Dec. perfusion

  • Dilated vessels

• Superficial veins visibly distended

  • Appearance similar to fluid overload

• Hypertension

• Inc. risk of blood clots

• Rapid turnover

  • Immature cells banging into each other & breaking down

  • Inc. cell debris

  • Inc. Potassium