NURS 5031 Study Guide:Disorders of the Hematologic System ("Blood Dyscrasias")
NURS 5031 Study Guide:Disorders of the Hematologic System ("Blood Dyscrasias")
- Assess subjective and objective data (differentiating between normal and abnormal findings) related to the different types of anemias
- General Objective Data
- Morphological classifications
- Normocytic, normochromic
- MCV 80-95 fL (mean corpuscular volume)
- MCH 27-31 pg (mean corpuscular hemoglobin)
- Microcytic, hypochromic
- MCV <80 fL
- MCH <27 pg
- Macrocytic, normochromic
- MCV >95 fL
- MCH >31 pg
- Anemia Severity
- Mild - Hgb 10-12 g/dL or 100-120 g/L
- Exertional dyspnea
- Palpitations
- Moderate - Hgb 6-10 g/dL or 60-100 g/L
- Bounding pulse
- Roaring in the ears
- Severe - Hgb <6 g/dL or 60 g/L
- Transfusions required for severe
- Findings: pale, all systems affected
- Bone pain, because bones are trying to make new cells
- Tachycardia, HF, MI, anorexia, dyspnea at rest
- Insomnia, headaches
- Iron-Deficiency Anemia
- Basically just the same type of objective and subjective symptoms listed above
- Due to iron deficiency, as the name would suggest
- Due to: blood loss, low intake, malabsorption, hemolysis, or pregnancy to name a few
- Chronic Blood Loss Anemia
- A type of iron deficiency anemia, usually due to a GI blood loss like a peptic ulcer - may see black stools
- Could also be menstrual bleeding
- S/Sx
- Pallor - pale
- Glossitis (tongue inflammation)
- Stool blood test
- Endoscopy, colonoscopy, blood labs
- Thalassemia
- Inadequate production of normal Hgb
- All three are thalassemia:
- 1) Reduced RBC production
- Abnormal Hgb synthesis either:
- 2) Alpha globin issues
- 3) Beta globin issues
- Thalassemia Minor S/Sx
- Frequently asymptomatic
- Moderate anemia - typically Microcytosis Hypochromic
- Body adapts - no treatment indicated
- Thalassemia Major S/Sx
- Life-threatening
- Physical and mental growth slows
- Pale and jaundiced
- Splenomegaly, hepatomegaly, cardiomyopathy
- Sx start in childhood
- Treatment
- No specific drug or diet is effective - DO NOT GIVE IRON
- Can give a chelating agent to bind up excess iron
- Stem cell transplant is the only cure, but must weigh risks/benefits
- Splenectomy
- Zinc supplements (b/c zinc decreases w/ chelation therapy)
- Pt pop is at increased risk for blood borne infections due to the frequent blood transfusions required
- Megaloblastic Anemia
- Know its a B12 deficiency, most commonly pernicious anemia
- S/Sx
- Neurological impairments for heat and pain
- Tests and Treatment
- Normal B12 should be 3-16 mg/mL
- Give 1mg B12 daily PO to replace B12, and eat lots of folic acid rich foods
- Anemia of Chronic Disease
- Key here is to treat the underlying disorder
- Chronic inflammation
- Autoimmune or infectious issues (HIV, Hep, Malaria)
- HF
- Malignant diseases
- Frequent bleeding
- Normocytic normochromic RBCs, but just underproduced.
- Either due to short life span or EPO issues
- Treatment
- Can treat with EPO to rectify the initial problem, but really you are going to want to treat the underlying disease
- Aplastic Anemia
- ALL blood cell types are affected
- In addition to the general anemia symptoms, you will also see neutropenia
- Usually due to an autoimmune component
- Assessment:
- Should see hypocellular bone marrow with increased yellow marrow (fat content)
- Mgmt
- Infection risk due to low neutrophils (prevention and education very important!)
- Bleeding mgmt
- Stem cell transplant and immunosuppression (ATG, cyclosporin, or cytoxan)
- Acute Blood Loss Anemia:
- Normal blood volume = 5-6L
- 1000 mL loss = beginning of symptoms like orthostatic hypotension
- 1500 mL loss = maybe some fatigue with rest
- 2000 mL loss = BP problems at rest, thready pulse, clammy skin
- 2500 mL loss = shock, lactic acidosis, death
- Signs and symptoms will tell you more than labs will for this condition specifically!
- Explain the nursing and interprofessional management of Sickle Cell Anemia and emergent complications
- Sickle cell anemia Etiology/Pathophysiology
- Presence of abnormal Hgb in RBC (Hemoglobin S)
- Homozygous for Hgb S, inherited autosomal recessive disorder
- Incurable and often fatal by middle age
- Hemoglobin S is sensitive to changes in O2 content, hypoxia causes cells to assume sickle shape and clump together, obstructing capillary blood flow.
- Circulating sickled cells are hemolyzed by the spleen causing anemia
- Sickle cell emergencies
- Sickle cell crisis
- Acute exacerbation of sickling causes vaso-occlusive crisis
- Hypoxia leads to tissue necrosis
- Shock is a result of severe O2 depletion and reduction of fluid volume
- Acute chest syndrome
- Pulmonary complications that include pneumonia, tissue infarction, and fat embolism
- Fever chest pain, dyspnea, cough
- Leads to multiple serious complications
- Sickle Cell Complications
- Infections
- Major cause of morbidity and mortality
- Spleen function becomes compromised due to sickle RBCs (spleen becomes small)
- Pneumococcal pneumonia most common
- Severe infections can cause aplastic crisis and result in shutdown of RBC production
- Pain
- Often pain tolerant
- Under treatment is major problem
- Require continuous and breakthrough analgesia with morphine and hydromorphone.
- Sickle Cell Manifestations
- Pain from tissue hypoxia
- Pallor of mucous membranes
- Jaundice from hemolysis
- Sickle Cell Nursing/Interprofessional management
- O2 for hypoxia to control sickling
- Promote rest with DVT prophylaxis
- Administration of fluids and electrolytes
- Pain management
- Encourage consumption of high-calorie, high-protein diet, with folic acid supplementation
- Understand nursing priorities when caring for a patient undergoing a hematopoietic stem cell transplant[a]
- Basic principle = conditioning
- Two functions of the conditioning regimen
- 1) Myeloreduction
- Make space in the marrow by highly toxic drugs like Cytoxan, Busulfan, or Melphalan
- Total body irradiation (NOT LOCAL)
- 2) Immunosuppression
- Anti-thymocyte Globulin
- Cytoxan, or other strange drgus
- Irradiation
- What are we worried about?
- Risk of bleeding and infection due to the reduction in myelocytes + immunosuppression regiment
- HLA Matching
- Just know that bone marrow transplants must be HLA matched due to the “extreme polymorphism” in those genes
- 25% chance that a sibling will match, and it’s not useful to test non-sibling relatives or neighbors because there is such a low chance of there being a match - must use a database of donors
- Describe the nursing management of the patient receiving transfusions of blood and blood components. Note potential complications of blood transfusions, safety considerations, and nursing management of complications.
- Nursing management for transfusions:
- Complete baseline physical assessment
- Check IV line (appropriate needle, catheter, patency)
- Double check patient identification and blood product with another RN
- Adjust infusion rate according to patient needs, order, and agency policy
- Assess patient for signs of transfusion reactions
- Take vitals as directed
- Evaluate therapeutic effect (improvement in CBC, increased BP, decreased bleeding)
- Monitor for signs of circulatory overload (shortness of breath)
- Complications of transfusions:
- Transfusion reactions: mild to life-threatening, can be acute or delayed, includes acute hemolytic reaction, allergic reactions, circulatory overload reactions, sepsis, delayed hemolytic reaction, hepatitis B and C, iron overload
- Safety considerations:
- Do not use solution other than 0.9% saline for giving blood because they will cause RBC hemolysis
- Do not give any additives, including medications, in the same tubing as the blood unless you first clear the tubing with saline
- Do not be complacent
- Make sure provider has discussed risks, benefits, and alternative with the patient
- Make positive identification of blood product and recipient (often dual checking system in place)
- Take vitals, if abnormal call provider to determine if blood should be given
- Start within 30 minutes of receiving blood (or return to blood bank for storage)
- Stay with patient for first 15min to look for adverse reactions
- Continue to observe during and up to 1 hour after infusion
- Transfusion should not take more than 4 hours due to increased risk for bacterial growth in the product once it is unrefrigerated
- Nursing management of complications:
- Stop the transfusion
- Maintain patent IV line with saline solution
- Notify blood bank and provider immediately
- Recheck ID tags and numbers
- Monitor vitals and urine output
- Treat symptoms per provider’s orders
- Send blood bag and tubing to blood bank for examination
- Collect required blood and urine specimens to evaluate for hemolysis
- Document transfusion reaction
- Know what supplements are appropriate and their common routes of administration for the different types of anemia
- Iron supplements
- DO NOT GIVE IRON FOR THALASSEMIA (condition with too much iron)
- DO give iron for iron deficiency anemia or chronic blood loss anemia
- Oral
- Inexpensive and convenient
- Take between meals for maximum absorption
- Vitamin C increases absorption (orange juice)
- Do not take with milk or antacids
- Parenteral
- Given IM or IV
- IM may stain skin
- One of the only IM injections given z-track
- Indicated for malabsorption, oral iron intolerance, need for iron beyond normal limits, poor patient compliance
- Side effects include black stools, heartburn, constipation, and foul aftertaste
- Liquid iron stains teeth so it should be taken through a straw and teeth should be brushed after
- Erythropoietin: epoetin alfa
- GIVE EPO FOR ANEMIA OF CHRONIC DISEASE
- Used to increase production of RBC
- Monitor Hgb and Hct twice per week
- Vitamin B12 supplements
- Give for Megaloblastic/Pernicious anemia
- Oral
- given if deficiency is due to inadequate dietary intake
- Parenteral
- Given due to lack of intrinsic factor (pernicious anemia) being produced by the parietal cells in the stomach or malabsorption syndrome
- Lifelong treatment if patient has pernicious anemia
- Also given intranasally
- Folic Acid supplements
- Give for sickle cell anemia
- Oral/parenteral
- Large doses of folic acid can mask vitamin B12 deficiency and turn urine dark yellow
- Know the pathophysiology of deep vein thrombosis and preventative strategies in the immobilized patient. Consider complications of these therapies, particularly nurse administered anticoagulants, and interventions to manage these complications.
- DVT
- Formation of a clot in deep vein
- Type of VTE
- Veins most susceptible
- Pelvic area, lower leg, hip
- Risk factors (Virchow’s Triad)
- Stasis of venous circulation
- Immobilized, varicose veins, surgery, traveling for long hours without moving, late pregnancy, obesity, heart failure, A-fib
- Hypercoagulability (increased clotting)
- Cancer, severe illness, dehydration, estrogen, heparin induced (HIT), pp period
- Endothelial damage
- IV drug usage, indwelling device (CVC, IV line, heart valve), medications, trauma or injury to a vessel (surgery)
- Manifestations
- Redness, swelling, very warm, look different than other extremity
- Homan’s sign -> positive sign is pain when the foot is dorsiflexed.
- Nursing interventions for patient with DVT
- Elevate affected extremity above heart level
- Ensure bedrest
- Pharmacological measures
- Anticoagulants (prevent clots from getting bigger and new clots from forming)
- Heparin (indirect thrombin inhibitors)
- Fast onset; given IV or subQ
- Monitor aPTT
- Warfarin (Vit K antagonist)
- Given PO
- Slow onset
- Monitor PT/INR
- Warm/moist compress to affected extremity
- Monitor for s/sx of pulmonary embolism
- Compression stockings
- Preventing DVT in immobilized patient
- Pneumatic compression devices; need to fit properly
- Wear all times in bed
- Ambulate and get out of bed when possible!
- Leg and feet exercises several times a day
- Apply compression stockings per MD order
- Prophylactic anticoagulant, typically subQ lovenox
- Complication: heparin-induced thrombocytopenia. Immediately + permanently stop heparin therapy and flushes, note in medical record, start on direct thrombin inhibitor
- Complications of DVT
- Dislodgement of clot
- Pulmonary embolism
- s/sx include SOB, decreased O2 sats, tachycardia, chest pain, anxiety