Study Notes for Chapter 28: Nursing Care of Patients with Hematological and Lymphatic Disorders

Chapter 28: Nursing Care of Patients with Hematological and Lymphatic Disorders

Objectives

• The Learning Objectives for Chapter 28 can be found on the Canvas page under the Heme Module.

Anemia

• Definition: Anemia is the deficiency of red blood cells (RBCs), hemoglobin, or both, leading to a reduced capacity to carry oxygen to tissues.
  • Causes of Anemia:
  • Impaired production of RBCs
  • Increased destruction of RBCs
  • Blood loss

Etiologies

• Nutritional deficiencies
• Hemolysis
• Hereditary disorders

Signs and Symptoms

• Pallor
• Tachycardia
• Tachypnea
• Irritability
• Fatigue
• Dyspnea
• Specific types of anemia:
  • Pernicious anemia: Numb hands or feet, weakness, memory problems.
  • Iron deficiency anemia: Mouth fissures, glossitis, spoon-shaped nails.

Diagnostic Tests

• Complete blood count (CBC) with microscopic examination
• Bone marrow analysis
• Tests to determine the source if bleeding is suspected

Therapeutic Interventions

• Eliminate cause
• Dietary changes
• Supplements (e.g., iron)
• Transfusions

Aplastic Anemia

• Definition: Aplastic anemia occurs when the bone marrow does not produce adequate blood cells.

Causes

• Congenital factors
• Exposure to toxins
• Chemotherapy

Signs and Symptoms

• Weakness
• Fatigue
• Pallor
• Dyspnea
• Headache
• Ecchymoses
• Petechiae
• Bleeding
• Infection
• Potential death

Diagnostic Tests

• CBC
• Bone marrow biopsy
• Total iron-binding capacity (TIBC)
• Serum iron

Treatment

• Treat underlying cause
• Colony-stimulating factors
  • Study Tip: Understand what these treatments are and how they work.
• Steroids
• Bone marrow transplant

Sickle Cell Anemia

• Definition: Sickle cell anemia is an inherited autosomal recessive disorder, also referred to as Sickle Cell Disease.

Diagnostic Tests

• Sickledex test
• Hemoglobin electrophoresis
• CBC
• Erythrocyte sedimentation rate (ESR)

Treatment

• Bone marrow transplant
• Crisis treatment includes:
  • Antibiotics
  • Hydroxyurea
  • Pain management
  • Transfusions
  • Fluids
  • Oxygen

Crisis Prevention

• Avoid risk factors for reduced oxygenation:
  • Exposure to cold
  • Infection
  • Strenuous exercise
• Low-dose penicillin
• Frequent transfusions

Patient Education

• Avoid:
  • Tight clothing
  • Strenuous exercise
  • Alcoholic beverages
  • Cold temperatures
  • Smoking
  • Unpressurized aircraft
  • Exposure to infection

Polycythemia

• Definition: Polycythemia is characterized by an overabundance of RBCs.
  • Laboratory Criteria:
  • Hemoglobin > 18 mg/dL
  • Hematocrit > 55%
• Result: Blood becomes thick.
  • Types:
  • Primary
  • Secondary

Signs and Symptoms

• Hypertension
• Visual changes
• Headache
• Vertigo
• Dizziness
• Tinnitus
• Bleeding
• Chest pain
• Dyspnea
• Dark, flushed skin
• Itching

Therapeutic Interventions

• Phlebotomy
• Low-dose aspirin
• Chemotherapy
• Radiation therapy
• Medication for itching

Patient Education

• Drink 3 liters of water daily
• Avoid restrictive clothing
• Elevate feet
• Report signs and symptoms of iron deficiency
• Report signs and symptoms of bleeding

Disseminated Intravascular Coagulation (DIC)

• Pathophysiology: DIC involves accelerated clotting which leads to depletion of clotting factors and subsequent bleeding.
• Etiology: Major trauma can trigger DIC.

Signs and Symptoms

• Abnormal bleeding
• Joint pain
• Nausea and vomiting
• Organ system failure
• Convulsions
• Shock, coma, and potentially death

Bleeding Signs and Symptoms

• Easy bruising
• Petechiae
• Ecchymosis
• Blood in urine
• Black, tarry stools
• Bleeding from nose or gums
• New onset of painful joints

Diagnostic Tests

• Prothrombin time (PT) and partial thromboplastin time (PTT)
• Platelet count
• Hemoglobin
• D-dimer
• Fibrinogen
• Blood urea nitrogen

Therapeutic Interventions

• Correct underlying cause
• Administer:
  • Blood products
  • Fresh frozen plasma
  • Platelets

Nursing Care

• Recognize and report any signs of bleeding
• Avoid trauma and further bleeding
• Teach patient and family about DIC

Group Work on DIC

• Scenario: You are a student nurse with a 32-year-old female patient Postpartum Day 1 following a placental abruption that led to severe postpartum hemorrhage and DIC. You should:
  • Look at her labs and interpret them.

Most Recent Labs (DIC Patient)

Hemophilia

• Pathophysiology: Characterized by missing clotting factors:
  • Hemophilia A: Deficiency of Factor 8 (VIII)
  • Hemophilia B: Deficiency of Factor 9 (IX)
• Etiology: Primarily hereditary.

Signs and Symptoms

• Bleeding may occur in:
  • Joints
  • Muscles
  • Subcutaneous tissues
  • Brain
• Important Note: Bleeding may not be immediately evident!

Leukemia

• Pathophysiology: Blood cancer characterized by an increase in immature white blood cells (WBCs), which are unable to effectively fight infections.
• Risk Factors: Include viral infections, genetic factors, and radiation/chemotherapy exposure.

Signs and Symptoms

• Fever
• Infections
• Pallor
• Weakness
• Tachycardia
• Palpitations
• Dyspnea
• Abdominal pain
• Malaise
• Sternal/rib pain
• Central nervous system changes
• Bleeding

Diagnostic Tests

• CBC
• Bone marrow aspiration
• Lumbar puncture
• Genetic analysis

Therapeutic Interventions

• Chemotherapy
• Radiation therapy
• Stem cell transplant
• Biological therapies

Multiple Myeloma

• Pathophysiology: A cancer of plasma cells in the bone marrow leading to the degradation of bone tissue, organ invasion, and impact on all blood cell types.
• Etiology: Often unknown, but may involve occupational exposures.

Signs and Symptoms

• Bone pain
• Joint swelling
• Fever
• Malaise
• Spinal cord compression
• Pathological fractures
• Hypercalcemia
• Infection

Therapeutic Interventions

• Steroids
• Chemotherapy
• Control of serum calcium (e.g., push fluids!)
• Radiation
• Stem cell transplantation

Activity: Cue Recognition 28.1

• Scenario: Caring for a patient with multiple myeloma who has fallen in the bathroom:
  • Action Steps:
  • Call for help and check briefly for injuries.
  • Do not move the patient until injury has been ruled out.

Rationale

• Patients with multiple myeloma have fragile bones; a fall could easily result in a fracture or may have already occurred due to a fracture. Ensuring safety through careful assessment is critical.

Hodgkin Lymphoma

• Definition: Cancer of the lymph system characterized by the presence of Reed-Sternberg cells.
• Etiology: Viral infections, genetic predispositions, immune dysfunction.

Signs and Symptoms

• Painless swollen lymph node
• Pruritis
• Alcohol-induced pain
• Fever
• Dyspnea
• Night sweats
• Weight loss
• Malaise

Late Signs and Symptoms

• Edema of the face and neck
• Airway obstruction
• Jaundice
• Nerve pain
• Retroperitoneal node involvement
• Involvement of spleen, liver, and bone.

Non-Hodgkin Lymphoma

• Definition: Lymphoma that arises from B cells and T cells, characterized by the absence of Reed-Sternberg cells.
• Etiology: May include certain viruses, Helicobacter pylori, immune dysfunction, and occupational exposures.

Signs and Symptoms

• Painless enlarged lymph nodes
• Other signs are similar to Hodgkin Disease but progress more rapidly.

Comparison of Lymphomas

• Hodgkin Lymphoma:

  • Less common
  • Affects ages 20s to 30s and > 55
  • Presence of Reed-Sternberg cells
  • Generally better prognosis
  • Exhibits alcohol-induced pain

• Non-Hodgkin Lymphoma:

  • More common
  • Typically affects > 60 years of age
  • Absence of Reed-Sternberg cells
  • Generally poorer prognosis

Group Work on Lymphangiography

• Task: Create a patient handout regarding the procedure of Lymphangiography, detailing:
  • Mechanisms of the test
  • Preparation requirements
  • Aftercare instructions.