Hematology Refresh (NR324)

Page 1

• Hematology Refresh
• NR324

Page 2

ANEMIA

Symptoms

• Tiredness
• Cold hands
• Dizziness
• Fast heartbeat
• Pain in bones
• Pale skin

TREATMENT

• Treat the cause
• Vitamins and supplements

COMMON CAUSES

• Diet
• Medication
• Iron deficiency
• Vitamin deficiency
• Chronic diseases
• Bone marrow diseases
• Hemolytic anemia
• Sickle cell anemia
• Blood transfusion
• Bone marrow transplant

Page 3

Prioritizing Hypotheses: Anemia

After recognizing and analyzing cues, the following nursing diagnoses could be appropriate for a client with anemia:

• Altered perfusion: Less hemoglobin means less oxygen to carry to the targeted tissue.
• Impaired gas exchange: Less hemoglobin means less oxygen to collect from the lung and swap with carbon dioxide.
• Fatigue: Less oxygen capacity means less energy production through the Kreb’s cycle to create ATP within the cells of the body.
• Self-neglect: Intentionally or unintentionally not getting enough nutrients, or taking nutrients and then vomiting (i.e., bulimia).
• Imbalanced nutrition: Eating foods that are not high in iron, vitamin B12, or folate (this could occur to some Vegans who may not eat a balanced vegan diet).
• Knowledge deficit: As with any disease process, many clients need more education to improve their health literacy.

Page 4

Nursing Diagnoses

• Altered perfusion
• Impaired gas exchange
• Fatigue
• Self-neglect
• Knowledge deficit
• Imbalanced nutrition
• Pain

Possible Interventions

• administer prescribed packed red blood cells — add RBCs
• administer prescribed volume (IV fluids) — maintain blood pressure
• iron supplement — increase iron stores
• B12 and folate supplement — increase B12 and folate levels
• administer prescribed epoetin alfa — stimulate bone marrow
• supplemental oxygen — increase available oxygen
• frequent rest periods — conserve energy
• treat underlying mental health issues (anorexia, bulimia, etc.)
• dietary teaching — target high iron or vitamin B12/folate foods
• information on anemia and actions for prevention — teach clients
• suggest dietary changes that target specific deficiencies
• measure and monitor deficiencies — increase missing nutrients
• administer prescribed pain medication — treat symptoms

Anemia: Collaborative Interventions

• [Collaborative interventions are implemented with the care team to address underlying causes and prevent recurrence; specifics align with listed interventions above.]

Page 5

Anemia: Treatment

• Ferrous Sulfate — iron deficiency anemia
• Vitamin B12 (cyanocobalamin) injections — B12 deficiency anemia
• Epoetin alfa (erythropoiesis-stimulating agent) — anemia associated with renal insufficiency
• Blood transfusion — used when risk outweighs benefit in severe anemia; Quickly resolves anemia
• Opiates — pain management in Sickle Cell anemia

Page 6

Sickle Cell Disease: Sickle Cell Crisis

• Acute exacerbation of RBC sickling causes vaso-occlusive crisis
• Symptoms: Severe, painful
• Pathophysiology: Severe capillary hypoxia eventually leads to tissue necrosis
• Complications: Shock is the life-threatening complication from hypoxia and hypovolemia

Page 7

Sickle Cell Disease: Treatment

• Hospitalized patients in Sickle Cell Crisis
  • Apply O2 to treat hypoxia and prevent further sickling
  • Assess and treat for infection and acute chest syndrome
  • Rest
  • VTE prophylaxis
  • IV fluids
  • Transfusion therapy if necessary
  • Pain management
  • Hydroxyurea: anti-sickling agent
  • Cure: Stem-cell transplant

Page 8

Aplastic Anemia

• Bone marrow is lacking and hypocellular
• Pancytopenia
• Low WBC
• Low RBC
• Low Platelet
• Rare, but can be very severe

Nursing to:

• Initiate bleeding precautions
• Initiate neutropenic precautions or strict handwashing to prevent infection
• Encourage rest periods due to anemia and potential poor perfusion/fatigue

Page 9

Polycythemia

• Pathophysiology
  • \text{RBC} > 6.1\quad\text{(males)}\quad\text{or}\quad \text{RBC} > 5.4\quad\text{(females)}
• Primary polycythemia: Polycythemia vera — blood cancer
• Secondary polycythemia: due to chronic hypoxia
• Increased blood viscosity and volume
• Manifestations: Related to hypervolemia and clotting
• Treatment: therapeutic phlebotomy, hydration, aspirin
• Complications: Thrombosis

Page 10

Thrombocytopenia

• Pathophysiology
  • Platelet count < 150{,}000
• Manifestations: Bleeding
• Complications: Severe bleeding; Hypovolemic shock

Page 11

Nursing care for a patient with thrombocytopenia

• Avoid aspirin or other medications that affect platelet function or promote bleeding
• Assess for symptoms of bleeding
• Notify provider if severe symptoms of bleeding
• Prevent or control bleeding
• NO IM injections
• Apply pressure to needle sticks for 10 minutes
• Potential platelet transfusion

Page 12

Leukopenia and Neutropenia

• Leukopenia: WBC < 5{,}000
• Neutropenia: ANC < 1.0
• High risk for infection!
• Initiate neutropenic precautions for neutropenia
• Cook all fruits and vegetables and meat
• Providers and visitors must wash hands with soap and water, wear a mask
• Patient to wear a mask outside the room
• No fresh flowers
• Private room
• Report any fever or signs of illness to provider

Page 13

Blood administration

• Please thoroughly review the blood administration handout in files
• Pre-Administration Checks
• Blood Administration Reference
• Physicians order to transfuse
  • Type and Crossmatch
  • Blood consent
  • Patient identified
  • Patient's blood band
  • 2-RN verification
  • Obtain baseline vital signs
• Administer pre-medications 30-60 min prior to administration if ordered

Transfusion

• Begin transfusion — Slowly
• RN to remain with patient for first 15 minutes
• Vital signs 15 minutes after transfusion start
• May increase flow rate to meet infusion needs
• Vital signs 1 hour after transfusion start
• Vital signs 2 hours after transfusion start
• Vital signs 3 hours after transfusion start
• Vital signs when infusion is complete

Supplies

• 0.9% Normal Saline
• Patent IV (ideally 20G or larger)
• Blood infusion set-up
• IV infusion pump
• Y-tubing
• Continue to monitor for a potential transfusion reaction or fluid volume overload

Blood Product options

• Packed red blood cells (PRBCs)
• Platelets
• Fresh Frozen Plasma

Blood Transfusion Reactions

• 1. Priority: Immediately STOP the transfusion
• Transfusion Times: 2-4 hours recommended, except in emergency
  • 15-30 minutes
  • 30-60 minutes
• 2. Hang 0.9% NS with new tubing, maintain patent IV
• 3. Notify blood bank and provider
• 4. Save blood unit and tubing, place in biohazard bag and return to blood bank
• 5. Collect urine and blood samples per policy as part of transfusion reaction workup

Remember transfusion reactions are most likely to occur in the first 15-30 minutes but can occur hours to days after transfusion. Always be alert and report changes to the provider.

Page 14

Blood transfusion Reactions

Blood Transfusion Reaction Types

• Acute Hemolytic Reaction
• Febrile
• Mild Allergic Reaction
• Anaphylaxis
• Circulatory overload
• Sepsis
• TRALI

Symptoms

• Acute Hemolytic: Back or flank pain, fever, chills, tachycardia, SOB, hypotension, hemoglobinuria, jaundice, AKI, shock, death
• Febrile: Fever (or 1°C increase in temp), chills, rigors, headache, vomiting
• Mild Allergic: Flushing, itching, pruritis, urticaria
• Anaphylaxis: Wheezing, dyspnea, cyanosis, hypotension, shock, urticaria, possible cardiac arrest
• Circulatory overload: Cough, dyspnea, pulmonary congestion, crackles or wheezing, headache, hypertension, JVD
• Sepsis: High fever, chills, hypotension, or shock
• TRALI: Dyspnea, hypoxemia, respiratory failure, fever, chills

Nursing Action and Management

• Monitor I&O and VS
• Hemodialysis if severe
• Administer acetaminophen
• Consider leukocyte reduced transfusion in the future
• Administer antihistamine and corticosteroids
• Administer epinephrine, antihistamine, and corticosteroids
• Sit patient upright
• Apply O2
• Chest x-ray
• Administer diuretic
• Blood cultures, IV antibiotics, IV fluids, vasopressors
• Administer O2, corticosteroids, diuretics, CPR or ventilation as needed