Nursing Care of Patients With Hematological and Lymphatic Disorders

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

Learning Outcomes

The following learning outcomes are essential for understanding the concepts covered in this chapter pertaining to hematological and lymphatic disorders:

  • Pathophysiology Understanding: Explain the pathophysiology of each hematological and lymphatic disorder discussed.
  • Etiologies and Symptoms: Describe the etiologies and signs and symptoms of each disorder.
  • Diagnostic Identification: Identify tests used to diagnose each disorder.
  • Therapeutic Measures: Describe current therapeutic measures for each disorder.
  • Patient Care Data: List data you should collect when caring for patients with disorders of the hematological or lymphatic systems.
  • Nursing Care Planning: Assist in planning nursing care for patients with hematologic and lymphatic disorders.
  • Intervention Effectiveness: Explain how you will know if your nursing interventions have been effective.
  • Clotting Disorder Precautions: Describe precautions to prevent bleeding in patients with clotting disorders.
  • Infection Prevention: Identify precautions to take to prevent infection in at-risk patients.
  • Splenectomy Care: Identify nursing care and teaching you will provide for patients undergoing a splenectomy.

Chapter Concepts

Key concepts encompass:

  • Cellular Regulation
  • Comfort
  • Infection
  • Safety

Anemia

Anemia is characterized by a deficiency of red blood cells (RBCs), hemoglobin, or both. This results in an impaired ability to carry oxygen to tissues and can arise from:

  • Causes:
      - Impaired production
      - Increased destruction
      - Blood loss
Etiologies

Anemia may be caused by various factors, including:

  • Nutritional deficiencies
  • Hemolysis
  • Hereditary disorders
Signs and Symptoms

Common signs and symptoms include:

  • Pallor
  • Tachycardia
  • Tachypnea
  • Irritability
  • Fatigue
  • Dyspnea
  • Pernicious Anemia: Numb hands or feet, weakness, memory problems
  • Iron Deficiency Anemia: Mouth fissures, glossitis, spoon-shaped nails
Diagnostic Tests

Diagnostic evaluation may consist of:

  • Complete Blood Count (CBC) with microscopic examination
  • Bone marrow analysis
  • Tests to determine the source of bleeding if suspected
Therapeutic Interventions

Interventions aim to:

  • Eliminate the underlying cause
  • Implement dietary changes
  • Administer supplements
  • Provide blood transfusions
Nursing Diagnoses

Common nursing diagnoses associated with anemia include:

  • Decreased Activity Tolerance
  • Imbalanced Nutrition
  • Impaired Oral Mucous Membrane Integrity

Aplastic Anemia

Aplastic anemia involves the bone marrow's inadequate production of blood cells.

  • Causes may include:
      - Congenital factors
      - Exposure to toxins
      - Chemotherapy
Signs and Symptoms

Signs associated with aplastic anemia may include:

  • Weakness
  • Fatigue
  • Pallor
  • Dyspnea
  • Headache
  • Ecchymoses
  • Petechiae
  • Bleeding
  • Infection
  • Possible death
Diagnostic Tests

Diagnostic assessments include:

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

Management strategies focus on:

  • Treating the underlying cause
  • Utilizing colony-stimulating factors
  • Administering steroids
  • Considering bone marrow transplant

Sickle Cell Anemia

Sickle cell anemia is an inherited autosomal recessive disorder leading to abnormal hemoglobin that distorts RBC shape.

Diagnostic Tests

Key diagnostic tests involve:

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

Management approaches may include:

  • Bone marrow transplant
  • Crisis treatment:
      - Antibiotics
      - Hydroxyurea
      - Pain management
      - Transfusions
      - Fluids
      - Oxygen
Signs and Symptoms

Sickle cell anemia can lead to multiple complications, including but not limited to:

  • Brain: Thrombosis, hemorrhage, stroke
  • Eye: Retinal/conjunctival hemorrhage, blindness
  • Heart: Failure
  • Abdominal Organs: Hepatomegaly, gallstones, splenic enlargement/infarction
  • Lungs: Atelectasis, infarction, pneumonia
  • Kidney: Dilute urine, diuresis, hematuria
  • Bones and Joints: Hand and foot syndrome
  • Penis: Priapism
  • Skin: Stasis ulcers
Crisis Prevention

Preventive measures include avoiding:

  • Cold exposure
  • Infection risk
  • Strenuous exercise
  • Medication: Low-dose penicillin, frequent transfusions, hydroxyurea
Nursing Diagnoses

Common nursing diagnoses for patients with sickle cell anemia may include:

  • Risk for Ineffective Cerebral/Peripheral Tissue Perfusion
  • Acute Pain
Patient Education

Educating patients about precautionary measures to minimize crises such as:

  • Avoiding tight clothing
  • Avoiding strenuous exercise, alcoholic beverages, cold temperatures, smoking, unpressurized aircraft, and exposure to infection

Polycythemia

Polycythemia is identified by an overabundance of RBCs, with hemoglobin levels exceeding 18 milligrams per deciliter and hematocrit levels above 55%, leading to thickened blood.

Types

Polycythemia can be defined as:

  • Primary: Genetic origin
  • Secondary: Caused by external factors (e.g., hypoxia)
Signs and Symptoms

Typical symptoms may include:

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

Management may include:

  • Therapeutic phlebotomy
  • Low-dose aspirin
  • Chemotherapy or radiation therapy
  • Medication for symptomatic itching
Patient Education

Patients should be educated to:

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

Disseminated Intravascular Coagulation (DIC)

DIC involves accelerated clotting leading to the depletion of clotting factors and subsequent bleeding.

Etiology

DIC can occur due to:

  • Major trauma or other severe stressors
Signs and Symptoms

Common presentations include:

  • Abnormal bleeding (e.g., easy bruising, petechiae)
  • Joint pain
  • Nausea and vomiting
  • Organ system failure
  • Convulsions
  • Shock, coma, or death
Diagnostic Tests

Tests essential for diagnosis consist of:

  • Prothrombin time (PT) and partial thromboplastin time (PTT)
  • Platelet count
  • Hemoglobin level
  • D-dimer level
  • Blood urea nitrogen levels
Therapeutic Interventions

Management focuses on:

  • Correcting the underlying cause
  • Administering blood, fresh frozen plasma, platelets, or cryoprecipitates
Nursing Care

Nursing responsibilities include recognizing and reporting bleeding, avoiding trauma, and teaching patients and their families about care measures.

Immune Thrombocytopenia

This condition involves platelet destruction by the immune system and presents risks for bleeding.

  • Etiology could include:
      - Acute viral illness
      - Drug reactions
      - Immune system dysfunction
Idiopathic Thrombocytopenic Purpura

Symptoms include:

  • Petechiae, ecchymosis, and general bleeding
Diagnostic Tests

Tests may include:

  • A platelet count of less than 20,000/mm3
  • Bleeding time assessment
  • Bone marrow aspiration
Therapeutic Interventions

Treatment approaches may entail:

  • Spontaneous resolution in some cases
  • Steroids
  • Chemotherapy
  • Transfusions
  • Immunoglobulin
  • Vitamin K or splenectomy if necessary
Nursing Care

Focus on:

  • Implementing bleeding precautions
  • Recognizing/reporting bleeding signs
  • Educating patients and families on safety precautions.

Bleeding Precautions

To minimize bleeding risks in patients, recommendations include:

  • Use an electric razor for shaving
  • Use a soft toothbrush
  • Avoid invasive procedures and injections
  • Maintain pressure during blood draws
  • Exercise caution when taking blood pressure measurements
  • Wear appropriate footwear to avoid injuries
  • Avoid medications such as aspirin and NSAIDs that can exacerbate bleeding risks
  • Utilize stool softeners to prevent straining during bowel movements
  • Handle patients gently and advise gentle nose blowing.

Hemophilia

Hemophilia is characterized by missing clotting factors, specifically Factor 8 (Hemophilia A) and Factor 9 (Hemophilia B), predominantly originating from heredity.

Signs and Symptoms

Patients with hemophilia may experience bleeding in:

  • Joints
  • Muscles
  • Subcutaneous tissue
  • Brain
Diagnostic Tests

Key assessments include:

  • PTT
  • Factor levels
Therapeutic Interventions

Based on individual needs, treatments may involve:

  • Desmopressin (injection or nasal)
  • Infusions of clotting factors
  • Blood transfusions as needed
Nursing Diagnoses

Possible nursing diagnoses are:

  • Acute Pain
  • Risk for Bleeding

Leukemia

Leukemia is a type of blood cancer resulting in an increase in immature white blood cells (WBCs) that hinders the body’s ability to fight infection.

Risk Factors

Includes:

  • Viral infections
  • Genetic predispositions
  • Exposure to radiation or chemotherapy
Types of Leukemia

Common types of leukemia consist of:

  • Acute Lymphocytic Leukemia (ALL)
  • Acute Myelogenous (Myeloblastic) Leukemia (AML)
  • Chronic Lymphocytic Leukemia (CLL)
  • Chronic Myelogenous Leukemia (CML)
Signs and Symptoms

Clinical manifestations may include:

  • Fever
  • Infection
  • Pallor
  • Weakness
  • Tachycardia
  • Palpitations
  • Dyspnea
  • Abdominal pain
  • Malaise
  • Sternal or rib pain
  • CNS changes
  • Bleeding
Diagnostic Tests

Essential tests include:

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

Management options may consist of:

  • Chemotherapy
  • Radiation therapy
  • Stem cell transplantation
  • Biological therapies
Nursing Diagnoses

Potential nursing diagnoses include:

  • Risk for Injury (Infection, Bleeding)
  • Fatigue
  • Impaired Oral Mucous Membrane Integrity

Case Study for SBAR Hand-Off Report

In a clinical setting, a child named Ingrid presented with fatigue, pallor, and easy bruising. During assessment, an enlarged liver and spleen were identified, leading to the need for lumbar puncture to rule out a possible leukemia diagnosis.

SBAR Hand-Off Report
  1. Situation: Ingrid, age 5, displayed symptoms of pallor and fatigue with easy bruising.
  2. Background: Ingrid has had typical childhood illnesses; a lumbar puncture is scheduled.
  3. Analysis: The healthcare provider is considering a leukemic diagnosis. Her mother is not aware of the potential diagnosis.
  4. Recommendation: Ensure protective measures against injury and infection are implemented while awaiting results.

Multiple Myeloma

Multiple myeloma is characterized as cancer of plasma cells in the bone marrow, leading to bone tissue degradation and affecting all blood cell types.

Etiology

The exact etiology remains unknown but may include occupational exposures.

Signs and Symptoms

Patients may present with:

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

Useful diagnostic assessments involve:

  • CBC and blood calcium levels
  • Bone x-rays
  • Urine tests for Bence-Jones proteins
  • Bone marrow biopsy
Therapeutic Interventions

Common management approaches may include:

  • Steroids
  • Chemotherapy
  • Control of hypercalcemia with bisphosphonates
  • Radiation therapy
  • Stem cell transplantation
Nursing Diagnoses

Common diagnoses include:

  • Risk for Injury due to fractures or immobility complications
  • Risk for hypercalcemia

Hodgkin Lymphoma

Hodgkin lymphoma is a type of cancer affecting the lymphatic system characterized by the presence of Reed-Sternberg cells.

Etiology

Possible causes include viral infections, genetic factors, and immune dysfunction.

Signs and Symptoms

Patients typically display:

  • Painless swollen lymph nodes
  • Pruritus
  • Alcohol-induced lymph node pain
  • Fever
  • Dyspnea
  • Night sweats
  • Weight loss
  • Malaise
Late Signs and Symptoms

Include:

  • Edema of the face and neck
  • Airway obstruction
  • Jaundice
  • Nerve pain
  • Various organ involvements (spleen/liver/bone)
Diagnostic Tests

Necessary tests consist of biopsies of lymph nodes, liver, spleen, bone marrow, abdominal CT scan, PET scan, chest x-ray, and CBC.

Staging

Staging of Hodgkin lymphoma includes:

  • Stage I: Involvement of a single lymph node or site.
  • Stage II: Involvement of multiple nodes on one side of the diaphragm.
  • Stage III: Involvement of nodes or organs on both sides of the diaphragm.
  • Stage IV: Presenting as widely disseminated disease in organs or tissues.
Therapeutic Interventions

Management strategies may involve:

  • Chemotherapy
  • Radiation therapy
Nursing Diagnoses

Common nursing diagnoses include:

  • Activity Intolerance
  • Risk for Infection
  • Support for long-term sequelae and symptom control

Non-Hodgkin Lymphoma

Non-Hodgkin lymphoma arises from B and T cells, distinguished by the absence of Reed-Sternberg cells.

Etiology

Possible etiological factors include some viruses, Helicobacter pylori exposure, immune dysfunction, and occupational hazards.

Signs and Symptoms

Typical symptoms reflect painless lymph node enlargement, similar to Hodgkin lymphoma symptoms, but with faster progression.

Diagnostic Tests

Testing may include biopsies of lymph nodes, tonsils, bone marrow, liver, bone scans, CT scans, chest x-rays, MRI, PET scans, and CBC.

Therapeutic Interventions

Management may require:

  • Chemotherapy
  • Radiation therapy
  • Stem cell transplant
  • Targeted therapies
  • Immunotherapies
Nursing Care

Nursing care measures are largely similar to those for Hodgkin lymphoma.

Comparison of Lymphomas

  • Hodgkin Lymphoma:
      - Less common, typically affecting individuals in their 20s to 30s as well as those over 55
      - Presence of Reed-Sternberg cells
      - Generally favorable prognosis
      - Symptoms can include pain after alcohol consumption.
  • Non-Hodgkin Lymphoma:
      - More common, predominantly affecting those over 60
      - Characterized by the absence of Reed-Sternberg cells
      - Generally poorer prognosis.

Splenectomy

Splenectomy refers to the surgical removal of the spleen which can be partial or total, and performed either open or laparoscopic.

Preoperative Care

Preoperative measures should include:

  • Establishing baseline labs and vital signs
  • Administering blood transfusions if necessary
  • Administering vitamin K
  • Instructing patient on coughing and deep-breathing exercises.
Postoperative Care

Post-surgery considerations include monitoring for:

  • Bleeding
  • Vital signs
  • Managing pain with narcotics
  • Encouraging coughing, deep breathing, and ambulation.
Complications

Complications that may arise include:

  • Infection
  • Overwhelming postsplenectomy infection (OPSI)
  • Pneumonia
  • Atelectasis

Case Study With Concept Map (Justin)

Justin is a college student with sickle cell disease presenting with pain after exercise, potentially indicating the onset of a sickle cell crisis. Nursing management includes assessing how he can reduce crisis frequency and manage his symptoms effectively during acute episodes.

Activity: Concept Mapping
  • Identify relationships between concepts affecting Justin’s condition, including:
      - Comfort: Pain and swelling after exercise
      - Safety: Risk for joint/organs damage
      - Infection: Increased crisis risk due to infections
      - Cellular Regulation: Impact of sickled cells on circulation.

Review Questions

  1. A patient is admitted with a low hemoglobin and hematocrit. Which type of anemia requires recommendations to avoid strenuous exercise and cold temperatures?
       - Correct Answer: Sickle Cell Anemia
  2. Which disease processes should be included in a care plan for patients at risk for hemorrhage?
       - Correct Answer: Idiopathic thrombocytopenic purpura, Hemolytic anemia, Disseminated intravascular coagulation, Aplastic anemia, Multiple myeloma
  3. Which patient is at highest risk for spontaneous pathological fractures?
       - Correct Answer: Multiple Myeloma
  4. When caring for a patient with leukemia, which finding is most crucial to monitor?
       - Correct Answer: Temperature
  5. Which patient should be taught about the possibility of an overwhelming infection?
       - Correct Answer: Post-splenectomy patient