Nursing Care of Patients With Hematological and Lymphatic Disorders

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

Learning Outcomes

  • Pathophysiology Explanation: Understand the pathophysiology of hematological and lymphatic disorders discussed within the chapter.
  • Etiologies and Symptoms: Describe the etiologies and associated signs and symptoms for each disorder.
  • Diagnostic Tests: Identify tests utilized to diagnose each disorder.
  • Therapeutic Measures: Describe current therapeutic measures for each disorder.
  • Data Collection: List data needed when caring for patients with hematological or lymphatic disorders.
  • Nursing Care Planning: Assist in planning nursing care pertinent to these disorders.
  • Intervention Effectiveness: Explain how to assess if nursing interventions were effective.
  • Clotting Disorder Precautions: Describe precautions to prevent bleeding in patients with clotting disorders.
  • Infection Prevention: Identify precautions for infection prevention in at-risk patients.
  • Splenectomy Care: Identify nursing care and teaching necessary for patients undergoing a splenectomy.

Key Chapter Concepts

  • Cellular Regulation
  • Comfort
  • Infection
  • Safety

Anemia

  • Definition: A deficiency of red blood cells (RBCs), hemoglobin, or both, reducing oxygen-carrying capacity to tissues.
  • Causes: Impaired production, increased destruction, or blood loss.
Etiologies of Anemia
  • Nutritional deficiencies
  • Hemolysis
  • Hereditary disorders
Signs and Symptoms
  • General Symptoms:
      - Pallor
      - Tachycardia
      - Tachypnea
      - Irritability
      - Fatigue
      - Dyspnea
  • Specific Symptoms:
      - Pernicious Anemia: Numbness in hands/feet, weakness, memory issues.
      - Iron Deficiency: Mouth fissures, glossitis, spoon-shaped nails.
Diagnostic Tests
  • Complete blood count (CBC) with microscopic examination
  • Bone marrow analysis
  • Tests to determine bleeding source if applicable
Therapeutic Interventions
  • General Interventions:
      - Elimination of underlying cause
      - Dietary changes
      - Supplements
      - Blood transfusions
Nursing Diagnoses
  • Decreased Activity Tolerance
  • Imbalanced Nutrition
  • Impaired Oral Mucous Membrane Integrity

Aplastic Anemia

  • Definition: Bone marrow fails to produce adequate blood cells.
  • Causes: Congenital factors, toxin exposure, chemotherapy.
Signs and Symptoms
  • Weakness
  • Fatigue
  • Pallor
  • Dyspnea
  • Headache
  • Ecchymoses and petechiae
  • Risk of bleeding and infection
  • Potentially fatal outcomes
Diagnostic Tests
  • CBC
  • Bone marrow biopsy
  • Total iron-binding capacity (TIBC)
  • Serum iron test
Treatment
  • Addressing the cause
  • Colony-stimulating factors
  • Steroids
  • Bone marrow transplant

Sickle Cell Anemia

  • Definition: An inherited autosomal recessive disorder.
Diagnostic Tests
  • Sickledex test
  • Hemoglobin electrophoresis
  • CBC
  • Erythrocyte sedimentation rate (ESR)
Treatment
  • General Treatment: Bone marrow transplant.
  • Crisis Treatment:
      - Antibiotics
      - Hydroxyurea
      - Pain management
      - Transfusions
      - Fluids
      - Oxygen therapy
Signs and Symptoms
  • Brain: Thrombosis, hemorrhage, stroke (brain attack).
  • Eye: Retinal or conjunctival hemorrhage, potential blindness.
  • Heart: Heart failure.
  • Abdominal organs: Hepatomegaly, gallstones, splenic enlargement, splenic infarction.
  • Lungs: Atelectasis, infarction, pneumonia.
  • Kidney: Dilute urine, diuresis, hematuria.
  • Bones/Joints: Hand-foot syndrome.
  • Penis: Priapism.
  • Skin: Stasis ulcers.
Crisis Prevention
  • Avoid risk factors leading to reduced oxygenation, such as cold exposure, infection, and strenuous exercise.
  • Use low-dose penicillin, frequent transfusions, and hydroxyurea for prophylaxis.
Nursing Diagnoses
  • Risk for Ineffective Cerebral/Peripheral Tissue Perfusion
  • Acute Pain
Patient Education
  • Avoid:
      - Tight clothing
      - Strenuous exercise
      - Alcoholic beverages
      - Cold temperatures
      - Smoking
      - Unpressurized aircraft
      - Exposure to infection

Polycythemia

  • Definition: Overabundance of RBCs, with hemoglobin levels >18 mg/dL and hematocrit >55%, resulting in thickened blood.
  • Types: Primary and secondary polycythemia.
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
  • Medications for itching
Patient Education
  • Consume 3 liters of water daily.
  • Avoid restrictive clothing.
  • Elevate feet.
  • Report symptoms of iron deficiency and bleeding.

Disseminated Intravascular Coagulation (DIC)

  • Pathophysiology: Characterized by accelerated clotting, depletion of clotting factors, and subsequent bleeding.
  • Etiology: Often triggered by major trauma.
Signs and Symptoms
  • Abnormal bleeding
  • Joint pain
  • Nausea and vomiting
  • Organ failure
  • Convulsions
  • Shock, coma, potential death.
Bleeding Indicators
  • Easy bruising, petechiae, ecchymosis
  • Hematuria
  • Black, tarry stools
  • Nose/gum bleeding
  • New-onset joint pain
Diagnostic Tests
  • Prothrombin time (PT), partial thromboplastin time (PTT)
  • Platelet count
  • Hemoglobin
  • D-dimer level
  • Blood urea nitrogen levels
Therapeutic Interventions
  • Correct underlying cause.
  • Administer:
      - Blood products
      - Fresh frozen plasma
      - Platelets
      - Cryoprecipitates
Nursing Considerations
  • Recognize and report any signs of bleeding.
  • Avoid situations that may lead to further trauma.
  • Educate patients and their families about DIC.

Immune Thrombocytopenia

  • Pathophysiology: Destruction of platelets by the immune system, risking potential bleeding.
  • Etiology: May follow viral illnesses, drug reactions, or immune dysfunctions.
Signs and Symptoms
  • Visible bleeding such as petechiae and ecchymosis.
Diagnostic Tests
  • Platelet count <20,000/mm³
  • Bleeding time assessment
  • Bone marrow aspiration
Therapeutic Interventions
  • Often resolves without treatment; may require:
      - Steroids
      - Chemotherapy
      - Transfusions
      - Immunoglobulin
      - Vitamin K
      - Possibly a splenectomy
Nursing Care
  • Implement bleeding precautions.
  • Recognize and report signs of bleeding
  • Teach patient and family safety measures.

Bleeding Precautions

  • Use electric razors and soft toothbrushes.
  • Avoid invasive procedures or injections.
  • Maintain pressure after blood draws.
  • Be cautious during blood pressure measurements.
  • Wear proper footwear.
  • Avoid bumps, bruises, and certain medications (e.g., NSAIDs).

Hemophilia

  • Pathophysiology: Absence of specific clotting factors (Factor 8 for Hemophilia A and Factor 9 for Hemophilia B).
  • Etiology: Genetic inheritance.
Signs and Symptoms
  • Predisposition to bleeding in joints, muscles, subcutaneous tissue, and the brain.
Diagnostic Tests
  • Partial thromboplastin time (PTT)
  • Factor levels testing.
Therapeutic Interventions
  • Common Treatments: Desmopressin (injection or nasal), administration of missing factors, and blood transfusions if necessary.
Nursing Diagnoses
  • Acute Pain
  • Risk for Bleeding

Leukemia

  • Pathophysiology: A form of blood cancer characterized by an increase in immature white blood cells incapable of adequately fighting infections.
  • Risk Factors: Exposure to certain viruses, genetic predisposition, and prior radiation/chemotherapy.
Types of Leukemia
  • Acute lymphocytic leukemia (ALL)
  • Acute myelogenous (myeloblastic) leukemia (AML)
  • Chronic lymphocytic leukemia (CLL)
  • Chronic myelogenous leukemia (CML)
Signs and Symptoms
  • Fever
  • Recurrent infections
  • Pallor
  • Weakness
  • Tachycardia
  • Palpitations and dyspnea
  • Abdominal pain
  • General malaise
  • Pain in the sternal/rib regions
  • Bleeding tendencies
Diagnostic Tests
  • CBC
  • Bone marrow aspiration
  • Lumbar puncture
  • Genetic analysis
Therapeutic Interventions
  • Common Interventions: Chemotherapy, radiation therapy, stem cell transplant, biological therapies.
Nursing Diagnoses
  • Risk for Injury (due to infection and bleeding)
  • Fatigue
  • Impaired Oral Mucous Membrane Integrity

Case Study: SBAR Hand-Off Report

  • Situation: Ingrid, a 5-year-old presenting with pallor, fatigue, and bruising.
  • Background: Recent childhood illnesses; lumbar puncture scheduled to rule out leukemia.
  • Assessment: Examination reveals enlarged liver and spleen.
  • Recommendation: Protect from injury and infection while awaiting results.

Multiple Myeloma

  • Pathophysiology: Cancer that affects plasma cells in the bone marrow, characterized by bone tissue destruction and systemic organ invasion impacting blood cell types.
  • Etiology: Unknown; potential links to occupational exposures.
Signs and Symptoms
  • Bone pain
  • Joint swelling
  • Fever
  • General malaise
  • Spinal cord compression
  • Pathological fractures
  • Hypercalcemia
  • Increased infection risk
Diagnostic Tests
  • CBC and calcium blood levels
  • Bone x-rays
  • Urine analysis for Bence-Jones proteins
  • Bone marrow biopsy
Therapeutic Interventions
  • Common Treatments: Use of steroids, chemotherapy, management of hypercalcemia with biphosphonates, radiation, and potential stem cell transplantation.
Nursing Diagnoses
  • Risk for Injury (from fractures and immobility)
  • Risk of hypercalcemia complications

Hodgkin Lymphoma

  • Pathophysiology: Cancer originating in the lymphatic system, identifiable by the presence of Reed-Sternberg cells.
  • Etiology: Often associated with viral infections, genetic factors, and immune dysfunction.
Signs and Symptoms
  • Painless swollen lymph nodes
  • Pruritus
  • Pain induced by alcohol consumption
  • Fever, dyspnea, night sweats, weight loss, malaise.
  • Advanced features include facial edema, airway obstruction, jaundice, nerve pain, and organ involvement (liver/spleen).
Diagnostic Tests
  • Lymph node biopsy, liver/spleen/and bone marrow biopsy
  • CT/PET scans, chest x-rays, bone scans, lymphangiography, CBC.
Staging of Disease
  • Stage I: Single lymph node/site
  • Stage II: Multiple nodes on the same diaphragm side
  • Stage III: Nodes/organs on both sides
  • Stage IV: Disseminated disease in many tissues/organs.
Therapeutic Interventions
  • Primary Treatments: Chemotherapy, radiation therapy.
Nursing Diagnoses
  • Activity Intolerance
  • Risk for Infection

Non-Hodgkin Lymphoma

  • Pathophysiology: Arises from B and T cells, lacking Reed-Sternberg cells.
  • Etiology: Associated with viral infections, Helicobacter pylori, immune dysfunctions, and certain occupational exposures.
Signs and Symptoms
  • Painless enlarged lymph nodes
  • Symptoms similar to Hodgkin lymphoma but with faster progression.
Diagnostic Tests
  • Lymph node biopsy, bone scans, CT/MRI, chest x-rays, PET scans, CBC, and liver function studies.
Therapeutic Interventions
  • Common Treatments: Chemotherapy, radiation therapy, stem cell transplants, targeted therapies, and immunotherapies.
Nursing Care
  • Similar protocols as for Hodgkin lymphoma.

Comparison of Lymphomas

  • Hodgkin Lymphoma:
      - Less prevalent
      - Common in ages 20-30 and above 55
      - Presence of Reed-Sternberg cells
      - Typically favorable prognosis
      - Alcohol-induced pain

  • Non-Hodgkin Lymphoma:
      - More common
      - Typically occurs in individuals older than 60
      - Absence of Reed-Sternberg cells
      - Tends to have a poorer prognosis

Splenectomy

  • Definition: Surgical removal of the spleen, either partially or fully, using open or laparoscopic techniques.
Preoperative Care
  • Establishing baseline labs and vital signs.
  • Blood transfusion if necessary.
  • Administration of Vitamin K.
  • Preparation for coughing and deep breathing exercises post-surgery.
Postoperative Care
  • Carefully monitor for bleeding and vital signs.
  • Administer pain management.
  • Encourage respiratory activities and mobility.
Complications
  • Potential for bleeding, pneumonia, atelectasis, infections, and overwhelming postsplenectomy infection (OPSI).

Case Study: Justin with Sickle Cell Disease

  • Justin is a 5-year-old with sickle cell anemia presenting with significant pain and swelling after weight training. He has a history of sickle cell crises and hospitalization for pneumonia.
  • Assessment indicates presence of sickled cells, necessitating IV fluids and pain relief.
Nursing Management Considerations
  • Emphasize strategies for reducing sickle crisis frequency and managing symptoms, incorporating healthy lifestyle choices.
  • Collaboration in developing a comprehensive care plan using concept mapping to identify interrelated nursing interventions and patient cues.

Review Questions

  1. Anemia and Exercise Precautions: Correct Answer: Sickle cell anemia
  2. Plan of Care for Hemorrhage Risk: Correct Answers: All processes listed (Idiopathic thrombocytopenic purpura, Hemolytic anemia, DIC, Aplastic anemia, Multiple myeloma)
  3. Risk for Pathological Fractures: Correct Answer: Multiple myeloma
  4. Monitoring in Leukemia: Correct Answer: Temperature
  5. Complications in Overwhelming Infection: Correct Answer: Post-splenectomy patient