MCC NURSINGBY: DIANA BLUM MSN

HEMATOLOGY

Anatomy

Blood is a type of connective tissue Transports nutrition Transports oxygen Transports hormones

Immunological aspects also important Critical to body defense Maintains temperature Controls PH Removes toxins Regulates electrolytes

Hematopoiesis:

Bone Marrow:

Stem Cell:

Cell Types (page 1991-94)

Plasma: straw colored liquid that suspends blood cells

Leukocyte: warrior cell that fights infection and invasion.

Reticulocyte: immature RBC

WBC: another name for a leukocyte

RBC: gives blood it color. Transports oxygen to cell and co2 to lungs

Erythrocyte: another name for RBC

Platelet: found in plasma. Works with clotting factors to help prevent bleeding.

Lymphatic system

Responsible for removing excess fluid protein and large particles from cells

Main functions: fluid balance maintenance Defense Fat absorber

Spleen

Stores 20-40 ml blood Removes old cells Filters and destroys antigens

before they enter system Stores platelets (1/3 of body’s

store)

Hemostasis (page 1995)

Stopping of blood flow 2 phases:

Primary Secondary

Anemia (page 2008)

Hemoglobin is low Oxygen is low Not a disease but an underlying

condition 2 types: hypoproliferative and

hemolytic Hypoproliferative: marrow can’t produce

adequate erythrocytes Lack of factors, chemicals, marrow

damage Hemolytic: premature destruction of

erythrocytes. Leads to tissue hypoxia Abnormality like sickle cell, direct injury

Erythropoiesis

Stimulation of RBCs by erythropoietin

Erythropoietin: hormone produced by kidneys during periods of hypoxia to ensure growing tissues will have sufficient oxygen.

Determination between types

Based on: Marrow ability to respond to decreased

erythrocytes Manner of maturity for young

erythrocytes The presence or absence of end products

of erythrocyte destruction within the circulation

Clinical manifestations

(pg 2010)

Rapidity with the anemia has developed

Duration of anemia Metabolic requirements of patient Other disorders

Cardio: tachycardia, hypoxia, MI symptoms

Respiratory: SOB in varying degrees

Neuro: headache, poor concentration, vertigo, irritibility, confusion

Compensation also may occur

Education

Prioritize activities Plan rest periods Eats healthy foods rich in iron,

vitamins, and proteins Use nutrition supplements as

needed Report palpitations, dizziness,

dyspnea Monitor vitals Monitor edema Monitor neuro status Safety techniques

Low RBC Low HGB andHCT Low serum Iron level Low ferritin level High TIBC level Results from diet low in iron Results from body not absorbing enough iron from GI tract

Not enough hemoglobin made as result s/s: sore tongue, brittle nails, fatigue, pallor, orthostatic changes (in severe cases) Dx: bone marrow aspiration, lab work Tx: iron supplements, iron rich foods (liver, oysters, red meat, fish, dried fruits,

legumes, dark green veggies, whole grain breads and cereal)---orange juice or other vitamin C product will enhance iron absorption What is the major side effect of IV iron?

Iron Deficiency Anemia

Anemia and Renal Disease

Pts don’t become severely anemic til creatinine levels exceed 3mg/100ml

Hematocrit decreases Causes:

shorted RBC lifespan Deficiency of erythropoietin Long term hemodialysis

Tx: monitor serum levels of iron, hematocrit, and vitals

Anemia and chronic disease

Only inflammation, infection, and malignancy cause

It is nonprogressive Develops over 6-8 weeks Many don’t require treatment

Most cases are idiopathic Infection and pregnancy,

medication, chemicals or radiation can trigger Airplane glue, arsenic, pestisides

Complete failure of the bone marrow

Low RBC count Low WBC Low Platelet cts S/S: pallor, fatigue, tachycardia, sob,

hypotension, prolonged/spontaneous bleed, frequent infections, purpura, retinal hemorrhages are common

Tx: transfusion of RBC and Platelet, antibiotics, corticosteroids, bone marrow transplant, ICU setting, monitor for signs and symptoms of infection and bleeding, neutropenic precautions

Aplastic Anemia

Pt does not absorb vitamin B12 from stomach Higher incidence of gastric cancer

Pt may lack intrinsic factor-essential for b12 absorption

Assess hx: gastrectomy, crohn’s, family history,etc.

s/s: weakness, sore tongue, numbness of hand and feet

Tx: B12 injections monthly, endoscopy q1-2 years---if untreated can develop heart failure and lead to death Monitor oral cavity, and skin. Monitor for

jaundice, monitor gait, provide small frequent bland diet

Dx: Obtain shilling test

Pernicious Anemia

Thalassemia Most frequent in SE Asian, African,

and Mediterranean descent

Folic Acid Deficiency

Folate is in green leafy veggies and liver

Alcohol increases need for folic acid

S/S same as pernicious anemia except no neuro symptoms

Dx: folate level Tx: replacements

RBCs normally disc shaped In sickle cell they are sickle shaped Easily rupture Obstruct blood flow Genetic in nature Most common in African

Americans Sickle cell is recessive (inherit from

mom and dad) http://www.youtube.com/watch?v

=R4-c3hUhhyc

Sickle cell anemia

Sickle Cell Crisis

4 types: sickle crisis: most common---obstructive aplasic crisis---from infection from

parvovirus Hyperhemolytic---massive rbc destruction sequestrian crisis---result from other organs

pooling sickled cells Spleen is most common Also in liver and lungs

S/S: tachycardia, fever, decreased HGB, infiltrates on chest x-ray

Pulomary HTN is a symptom that is not usually detected until damage is irreversible

Monitor x-rays, CT scan, Echo, HGB level Tx: treat symptoms, Bone marrow transplant,

transfusions, Hydroxyurea, Arginine http://

www.youtube.com/watch?v=qe59ar-GZmg

Glucose -6-Phospate

Dehydrogenase Deficiency

This is a deficiency in the gene that is essential for membrane stability

Hemolysis only occurs with stressful situations

Mostly affects african americans, greek or italian decent as well as asians and jewish origins

Inherited on x chromosome S/S: asymptomatic, or jaundice,

pallor, hemoglobinuria Dx: serum G-6-PD Tx: stop offending med,

transfusion, educate about meds to avoid, instruct to wear medic alert bracelet

Too many RBCs produced Blood more viscous

s/s: headache, dizziness, ringing in the ears, blurred vision, ruddy complexion, HTN, pruritis, gout problems, burning fingers and toes

DX: o2 sat, CBC with DIFF Complications: CVA, MI, BLEED

issues Tx: hydroxyurea, interferon, plavix,

ASA Treat symptoms Teach pt: don’t cross legs, quit

smoking, stay active, minimal alcohol, avoid excess iron

TX: phlebotomize blood

Polycythemia Vera

Enough RBCs made but they are destroyed once they are released into circulation

Causes: infection, drug reaction, cancer

s/s: pallor, fatigue, tachycardia, sob, hypotension, jaundice, high bilirubin levels

Positive direct coombs antiglobulin test

Tx: blood transfusions, corticosteroids, spleenectomy

Recovery in few days to weeks

Autoimmune Hemolytic

Anemia

Leukemia

Defect in the WBC stem cell Abnormal reproductions Unknown cause, may be from

chemical or radiation exposure Symptom onset is abrupt http://

www.youtube.com/watch?v=FJOYAaygQFE

AMLAcute Myeloid Leukemia

Defective stem cell Incidence rises with age 60+ Prognosis variable Younger pts may survive 5 years S/S: fever, infection, weakness,

fatigue, bleed tendency, pain Dx: no warning, CBC Complications: bleeding

(petechiae, ecchymosis), infection, DIC

TX: chemo, transfusions, infection treatment, growth factor agents, bone marrow transplant, palliative care

CML

Uncommon in pts under 20 Life expectancy 3-5 years s/s: asymptomatic, dyspnea, mild

confusion, enlarged liver, wt loss, anorexia

Tx: tyrosine kinase inhibitor, avoid antacids and grapefruit juice, interferon, cytosine, leukopheresis, bone marrow transplant, Gleevac

Acute Lymphocytic

LeukemiaALL

Most common in young kids 4-14 Uncommon s/s: decreased cbc counts, pain,

enlarged liver, enlarged spleen, headache, vomiting

Tx: bone marrow transplant, chemo, corticosteroids

Complications: infection

CLL

Common in older adults Most common form in US and

Europe More frequent in men s/s: asymptomatic,

lymphadenopathy, pain, hepatomegaly, spleenomegaly, anemia, fevers, drenching sweats, wt loss, infections

Tx: treat symptoms, chemo, monoclonal antibodies

Hodgkins Disease

Characterized by reed- sternberg cells in the lymph nodes

Highest occurance is in 20s and50s Men are more likely than women

to have Tx: radiation, chemo, bone marrow

transplant, stem cell transplant Survival rates vary 5 yr survival rate is 82%

Non Hodgkins Lymphoma

6th most common type of cancer and cancer death in US Avg age of dx is 60

Stages Low grade Intermediate grade High grade

The higher the grade the more aggressive

Tx: chemo, radiation, bone marrow transplant, stem cell transplant

5 year survival rate is 52%

Multiple Myeloma

Cancer of the plasma cells Most common over the age of 60 No known cause

Genetics and radiation exposure play a part

s/s: bone pain, hyperuricemia (kidneys), anemia, hypercalcemia, fractures, spinal cord compression, renal failure

Diagnosis: radiographs, serum and urine protein electrophoresis, bone marrow biopsy

No known cure Tx: chemo and radiation to treat symptoms,

vertebroplasty, antiemetics, pain management

Bleeding disorders

http://www.mhhe.com/biosci/esp/2002_general/Esp/folder_structure/tr/m1/s7/trm1s7_3.htm

Too few platelets Causes: cancer treatment

Too many platelets being destroyed Causes: idiopathic thrombocytopenic

purpura, thrombic thrombocytopenic purpura

Dx: bone marrow bx, CBC s/s: petechiae, purpura, gingival

bleed, epistaxis, prolonged bleeding

Tx: transfusions, spleenectomy, chemo, stop med that is causing, stop ETOH, treat infection

Thrombocytopenia

Immune thrombocytopenic

purpura

Most common among kids and young girls

Usually 1-6 wks after viral infection Cause unknown, h. pylori may play

role s/s: asymptomatic, low platelet

count, petechiae, hemoptysis Dx: bone marrow bx, platelet ct Tx: stop med, immune globulin,

chemo, prednisone, spleenectomy Nsg: assess lifestyle, teach

symptoms, avoid constipation, avoid valsalva, avoid teeth flossing, use only electric razors, use only soft bristled tooth brush, monitor for osteoporosis

HIT

Example of drug induced immune mediated thrombocytopenia

Rare Related to heparin therapy Tx: observation, assessment,

monitor lab values, stop heparin immediately

Thrombic Thrombocytopenic

Purpura

Medical emergency Causes extensive blood clots TX: plasmaphoresis Complication: multi organ FX 95%death rate if not treated

Von Willebrand’s Disease

Most common inherited bleeding disorder

1-2% international population s/s: Mucosal and cutaneous

bleeding, porlonged bleed times

Tx: DDAVP, FFP, Cryoprecipitate, bleed precautions

Genetic Lack of blood clotting factor 1-2 cases per 20,000 persons Types

A: factor VIII is missing-higher incidence B: factor IX is missing

Trait is carried on x chromosome Rare for women to have s/s: uncontrolled bleed especially in joints, skin, GI tract Tx: no cure. Transfusions, pain treatment (IV morphine is

common)..monitor for addiction to opiods. http://

www.youtube.com/watch?NR=1&feature=endscreen&v=pVHbMuBK8CI

Hemophilia

DIC

Not a disease Triggers: sepsis, trauma, cancer,

shock, abruptio placentae, allergic reactions

Life threatening condition Initially coag time is normal S/S: are manifested in organs with

either clots or bleeding. Bleeding from all orifaces(tear ducts, gums, IV sites, rectum, urethra, etc.)

Dx: PT, PTT, D-Dimer Tx: treat the cause, replace fluids,

o2, fix electrolyte imbalances, administering vasopressors are vital, cryoprecipitate to replace factor 5 and 7, FFP, heparin

http://www.youtube.com/watch?v=kNSwGUqaVgs

Universal donor= O Does not contain A, B, or Rh antigens

Universal recipients= AB+ Blood contains A, B, and RH antigens

Usually blood banks exactly match the pt blood

http://www.youtube.com/watch?v=G_-9_CF02qI

Blood typing for transfusion

Pt needs 18 or 20 gauge IV needle so cells are not lysed (destroyed)

Prior to administration, blood needs to be checked by 2 licensed nurses. Check the expiration date, name, medical record number, type of blood, blood band id, pt birthdayCheck vitals prior to administration

**blood must be initiated with in 30 minutes of arrival from lab to floor

Use blood tubing for administrationMonitor for blood reactionsMonitor vitals continuously during administration

adminstration on blood

Hemolytic: fever, chills, nausea, dyspnea, chest pain, back pain, hypotension Antigen/antibody rx to transfusion Happens shortly after initiation Tx: stop the transfusion, call md, supportive therapy to maintain HR and BP

Anaphylactic: urticartia, wheezing, dyspnea, hypotension Type 1 hypersensitivity rx to plasma proteins Occurs within 30 minutes of initiation Tx: stop transfusion, call md, be ready for epi and steroids

Febrile: fever, chills Recipients antibodies rx to donor leukocyte Occurs within 30-90minutes of initiation Tx: stop infusion, call md

Circulatory overload: cough, frothy sputum, cyanosis, decreased BP cardio system is unable to manage the additional fluid load Occurs anytime during transfusion and up to several hours after completion Tx: stop infusion, call for help, be prepared for code, be prepared to administer oxygen and Lasix

Blood reactions

Minimize the # of invasive procedure

Avoid prolonged tourniquet use Avoid IM injections Instruct the client to use soft

bristled tooth brush No strait edge razor shaving only

use electric razor Avoid NSAIDS

Bleeding precautions

ANY QUESTIONS???