Week 8- Chronic Hematology and Endocrinology Interventions

Hemoglobin/hematocrit lab looks for overall

health of RBCs

Reticulocytes lab

young RBCs (looks for bone marrow activity)

Iron lab

essential for hemoglobin and oxygen binding

Transferrin lab

evaluates iron binding capacity, metabolism, and storage

Ferritin lab

evaluates iron storage in the body

Bilirubin lab

assesses rate of RBC breakdown

Folate lab

measures component essential for RBC formation and maturation

4 general anemia management strategies

identify/treat underlying cause, drug therapy, nutritional therapy, and RBC transfusions/or NS

Nutritional therapy for patients with anemia should be focused on a diet high in

vitamin B12, iron, and folic acid

Packed RBC transfusions are indicated when a patients hemoglobin level falls below ____ or they are ____

70, symptomatic

Drugs for anemias include

iron therapy, cyanocobalamin (vitamin B12), and folic acid

Patients on iron supplements should be encouraged to take them ____ and with ___

on an empty stomach, vitamin C/orange juice

Common side affect of iron is

constipation

In order to limit constipation on iron supplements, we can encourage patients to

drink water, increase their movement, and increase fibre intake

Enteric coated iron is

ineffective (iron is absorbed in the deuodenum and small intestine, so enteric coating is pointless)

Vitamin B12 injections are commonly indicated for what time of anemia?

pernicous anemia

Folic acid is essential for

RBC production

Hematopoietic agents help stimulate bone marrow to

make cells or stop making cells

Erythropoiesis-stimulating agents (ESAs) have a high risk of serious

cardiovascular events (MI, stroke, thromboembolism)

ESAs risk for cardiovascular events is increased when patients hemoglobin levels rise > ____ or when there is a rapid rise of hemoglobin >____ over ___ weeks

110 g/L, 10 g/L, 2 weeks

Target hemoglobin for patients on ESAs is

100-110g/L

When patients are receiving lots of blood products (including clotting factor replacements for hemophilia) they are at an increased risk of developing

antibodies

When patients are on desmopressin (synthetic ADH) for hemophilia, it is important that we monitor for signs of

hyponatremia (caused by too much water reabsorption)

First lime therapy for iron deficiency anemia is

oral iron therapy (ferrous sulfate, ferrous gluconate)

IV iron is used for

malabsorption, severe anemia, or CKD (iron sucrose)

Transfusions are used for

severe symptomatic anemia or acute blood loss

Patients who are on iron supplements should avoid taking them with

calcium and antacids (reduce absorption)

Educate patients for GI side effects of iron such as

constipation, nausea, and black stools

IV iron has a risk for ___ and ____

anaphylaxis and hypotension

Sickle cell disease is managed with both preventative and acute treatments to reduce ____, enhance ___, and alleviate ___

complications, quality of life, pain crises

First line treatment for sickle cell disease is

hydroxyurea (myelosuppressive therapy)

The only cure for sickle cell disease is

hematopoietic stem cell transplant (HSCT)

3 main priorities for management of sickle cell crisis

pain control, hydration, and oxygen therapy

Other priorities for sickle cell crisis are

blood transfusions and priapism treatment (if indicated)

Sickle cell crisis moderate-severe pain control

opioids (morphine, hydromorphone)

Sickle cell crisis mild-moderate pain control

NSAIDs (avoid in renal impairment)

Sickle cell crisis pain non-pharmacologic therapies

heat therapy and relaxation tecniques

Sickle cell crisis hydration is important to

increase RBC flexibility and decrease sickling

Sickle cell crisis hydration first step is

IV fluids

If there is a severe sickle cell crisis, it may be indicated to perform a

RBC exchange transfusion (take sickled RBC cells out of body and replace with new packed RBCs)

Blood transfusions for sickle cell crisis are used for _____, _____, and _____

acute chest syndrome, stroke prevention, severe anemia

Treatment for priapism includes

IV fluids, analgesics, vasodilators, and aspiration if severe (if lasting over 4 hrs)

Chronic kidney disease (CKD) leads to reduced

erythropoietin

Decreased levels of erythropoietin in CKD leads to

anemia

Treatment for anemia in CKD is focused on correcting ____ and ____ while minimizing complications such as ___ and ____

low RBC production, iron deficiency, HTN, thrombosis

Erythropoiesis-stimulating agents (ESAs) stimulate the

bone marrow to increase RBC production

ESAs have a slower onset compared to

blood transfusions (2-6 weeks)

If patients with CKD are on ESAs, we must monitor ___, ____, and _____ regularly

BP (risk for hypertension due to too many RBCs), hemoglobin (do not go >110 or >10 from baseline over 2 wks), iron stores

ESAs are only effective if the body has enough

iron stores (monitor iron levels)

Polycythemia vera

myeloproliferative disordwe causing overproduction of RBCs, WBCs, and platelets

Polycythemia vera increases patients risk for

thrombosis (DVT, PE, stroke)

Treatment for polycythemia vera focuses on reducing ___ and preventing ___

RBC overproduction, blood clots

First line therapy for polycythemia vera is

phlebotomy

Phlebotomy

removing blood from the body

Patients who are high risk with polycythemia vera may be put on

myelosuppressive therapy (hydroxyurea)

If patient is resistant to hydroxyurea, patient can be put on

ruxolitinib (JAK2 inhibitor)

Hydroxyurea reduces

RBC production in the bone marrow

Adjuvant therapies for polycythemia vera include

low dose aspirin, encouraging hydration, and frequent mobility to prevent clots

Hemophilia treatment focuses on ____ replacement, ____ prevention, and ______ management

factor, bleeding, emergency

First line therapy for hemophilia is

clotting factor replacement therapy

Adjunctive therapies for hemophilia include

desmopressin and tranexamic acid

Desmopressin is used for hemophilia

A (NOT effective for hemophilia B)

Desmopressin stimulates the release of stored

factor VIII

Tranexamic (antifibrinolytic) acid is used for prevention of

mucosal bleeding (ex. nosebleeds, dental procedures)

Tranexamic acid (antifibrinolytic) prevents the

breakdown of clots

____ and ____ should be avoided in patients with hemophilia due to increased risk of bleeding

NSAIDs, aspirin

Patients with hemophilia should be educated on bleeding

prevention strategies

Hemophilia emergencies include

intracranial hemorrhage, GI bleed, joint bleed (COMMON), retroperitoneal bleeding, and major trauma/surgery

Intracranial hemorrhage signs and symptoms

severe headache, N/V, vision changes, seizures, and altered LOC

GI bleed signs and symptoms

black/tarry stools, hematemesis, abdominal pain, and pallor

Joint bleed signs and symptoms

joint swelling, warmth, stiffness, and severe pain

Retroperitoneal bleeding signs and symptoms

severe back/flank pain, hypotension, and abdominal distention

Major trauma/surgery signs and symptoms

active uncontrolled bleeding, hypotension, and tachycardia

Immediate management for all hemophilia emergencies is

administer factor replacement

Immediate management for joint bleed

give factor replacement, immobilize joint, apply ice, and pain management

Other management for other types of hemophilia emergencies

administer IV fluids (GI bleed/retroperitoneal bleed), rapid response/head CT (intracranial hemorrhage), and monitor for shock

Diabetes insipidus (DI) is caused by deficient ____ or kidney _____

antidiuretic hormone, resistance to ADH

Central DI

lack of ADH production from the hypothalmus/pituitary damage

Nephrogenic DI

kidneys do not respond to ADH

DI common symptoms

severe polyuria, polydipsia, dehydration (hypotension/tachycardia/dry mucous membranes), and dilue urine

Goals of therapy for DI include restoring ____, preventing ____, correcting ____, and reducing ___

fluid balance, dehydration, underlying cause, excessive urination

Central DI treatment

desmopressin

Nephrogenic DI treatment

thiazide diuretics (hydrochlorothiazide) and NSAIDs (indomethacin)

Thiazide diuretics and NSAIDs reduce

urine output by altering kidney response

Patient with DI should adjust

fluid intake to ensure adequate hydration

When giving desmopressin, what is the most important lab to monitor?

sodium

Desmopressin has a high risk for

hyponatremia

Desmopressin is preferred over vasopressin as it has lowered ____ and longer ____

side effects, duration

Other nursing management for DI is

strict I/O monitoring, daily weights, monitor sodium/urine specific gravity/osmolarity, monitor for hypotension/hypertension, monitor for excessive thirst/urination/confusion

Syndrome of inappropriate antidiuretic hormone is caused by excessive

secretion of antidiuretic hormone

SIADH leads to fluid ____, dilutional ___, and low ____

retention, hyponatremia, serum osmolarity

Causes of SIADH

CNS disorders, malignancies, medications, and pulmonary disorders

What medications can cause SIADH?

SSRIs, opioids, antipsychotics, carbamazepine, NSAIDs, and some chemotherapy agents

Symptoms of SIADH include symptoms of

fluid overload (weight gain, low urine output, HTN, tachycardia)

Hyponatremia neurologic symptoms

confusion, seizures, and lethargy

In SIADH, urine concentration will be ____ and blood osmolarity will be _____

high, low

Major discrepancy for SIADH manifestations is that there will be no

peripheral edema (cerebral edema will kill them before signs of peripheral edema)

Goal of therapy for SIADH is correct ____ and promote ____

hyponatremia, free water excretion/prevent dehydration

First line treatment for SIADH is

fluid restriction (<1L/day)

Medications for SIADH include

vasopressin receptor antagonists (tovaptan and conivaptan)