Nursing Care of the Patient with Hematologic Problems: Adult Health I

Nursing Care of the Patient with Hematologic Problems

Definitions
Hematocrit:
Measure of packed cell volume of RBC expressed as a %
Women: 38-47%
Men: 40-54%
Hemoglobin
Measurement of gas carrying capacity of RBC
Men: 13.5-18g/dl
Women: 12-16g/dl
Neutropenia
abnormally low number of neutrophils in the blood
< 1500…normal 3000 – 7000mm³
Neutrophils, a type of white blood cell, help fight bacterial infections. Most abundant WBC
Side effects of medication, chemotherapy, viral infections

Reticulocytes
Are young red cells just released from the bone marrow. The Retic count tells us how the marrow factory is doing.
Immature RBC’s, less than 1%
Thrombocytopenia
Platelet counts are between 150,000-400,000ul
low platelets, below 100,000-150,000
Bleeding may occur
ESR Erythrocyte sedimentation rate
Indicative of inflammation
Increased ESR is common during acute and chronic inflammatory reactions
Women: 1-20mm
Men: 1-15mm



Anemias
A deficiency in the number of RBC, quantity of HgB and the volume of HCT
There is an abnormality with the structure or function or number of RBC’s
Anemia is not a disease, it is a manifestation of a pathologic process.
primary hematological problems
secondary to defects in other body systems
This can lead to hypoxia, a decrease in the oxygen carrying capacity of the blood.
The clinical manifestations anemia are primarily caused by the body’s responses to tissue hypoxia.

Clinical Manifestations of Anemia
Mild Anemia
10-14 Hgb.
Generally asymptomatic, symptoms can occur with disease or exertion
Moderate Anemia
Hgb 6-10
Cardiopulmonary symptoms may be increased and may be associated with rest as well as activity.
Palpitations, fatigue, dyspnea, & diaphoresis
Severe Anemia
Hgb less than 6.
Symptoms involve many body systems.
It is caused by severe tissue hypoxia. Pallor, chronic fatigue, chills, ↑ HR, murmurs, can lead to CHF, angina, MI
Cardiac effects when Hgb is too low.
Ischemia
Tissue hypoxia
Chronic fatigue
Sensitivity to cold
The blood is shunted to the major organs
Pallor – reduced hemoglobin and blood flow to skin
Decreased CO leads to Increased HR
Murmurs due to lack of blood volume
CHF can occur to the increased strain on the heart. In severe cases, angina and MI can occur.

Nursing and Gerontological Considerations
Anemia is common in older adults
Anemia of chronic disease
Nutritional deficiencies
Signs and symptoms unrecognized
Attribute them to the normal aging process
Common signs and symptoms include: pallor, confusion, ataxia, fatigue, worsening angina.

Nursing Implementation:
Dietary and lifestyle changes
Blood products
Blood transfusions
Drug therapy – Erythropoietin (Procrit, Epogen)
Oxygen therapy


Nutrients Needed for Erythropoiesis
Vitamin B12
RBC maturation – red meats
Folic Acid
RBC maturation – Green leafy vegetables, liver, meat, fish legumes, whole grains
Iron
Hemoglobin synthesis – liver and muscle meats, eggs
Vitamin B6
Hemoglobin synthesis – meats, legumes, potatoes
Amino Acids
Synthesis of nucleoproteins –eggs, meat, milk, poultry, fish
Vitamin C
Aids in iron absorption – citrus fruits, green leafy veggies, strawberries, cantaloupe

Anemia’s Related to Decreased Erythrocyte Production
Iron Deficiency Anemia
Found world wide due to poor nutrition
Inadequate dietary intake
Iron is obtained from food and dietary supplements
If you eat 12 mg. of iron per day only 10% is absorbed

Malabsorbtion
After GI surgery or malabsorbtion syndromes
Blood loss
Chronic GI bleed scan cause loss of 2-4mls
Black stools or melena requires 50 to 75ml of blood from UGI tract
At risk population:
Pregnancy because of increased iron needs
Pre-menopausal women
Low socioeconomic background
Older adults
Blood loss

Anemia's Related to Decreased Erythrocyte Production
Clinical Manifestations
Asymptomatic early in the disease
Chronic Symptoms:
Pallor – most common
Glossitis – inflammation of the tongue
Cheilitis – lesions of the corners of the lips
Headache, dizziness, parasthesias, DOE, burning sensation of the tongue…..all due to ↓ iron.

Diagnostics
Lab testing
Stool for occult blood
Colonoscopy
Take iron in an acidic environment, with OJ, empty stomach, one hour prior to breakfast. Don’t take with milk, reduces absorption. > fluids to prevent constipation.

Treatment
Goal: treat underlying cause Foods > in iron = liver, meat, eggs, dark green veggies, raisins, prunes, apricots, fortified cereals, breads.
Anemia's Related to Decreased Erythrocyte Production

Drug therapy
Oral Iron Replacement – Ferrous Sulfate
Iron is best absorbed from the duodenum
Enteric coated or SR and not wise choice
Dosage should be 150mg to 200mg TID
300mg of ferrous sulfate has 60mg of iron available
Best absorbed in an acidic environment
Take with OJ, empty stomach, one hour prior to breakfast.
Don’t take with milk, reduces absorption.
↑ fluids to prevent constipation.
GI side effects : heartburn, constipation and diarrhea
Diet teaching: Foods ↑ in iron: liver, meat, eggs, dark green veggies, raisins, prunes, apricots, fortified cereals, breads

Nursing Interventions
Obtain a history of symptoms, dietary intake and past hx of anemia
Possible sources of blood loss
Examination for: Tachycardia, pallor DOE, s/s of GI or other bleeding
Assess diet for inclusion of Iron rich foods
Assess level of fatigue and sleep
Assist in scheduling activities and rest patterns
Maximize tissue perfusion
Assess /Evaluate for palpitations, chest pain, dizziness and SOB….minimize activities which cause these symptoms
Elevate HOB and supplemental Oxygen

Education
Proper nutrition
Well balanced diet
Teach about Iron supplements
Take on empty stomach
Epigastric discomfort
Stool changes
Follow up lab studies

Vitamin B12 (Pernicious) Anemia
Gastric secretion of Intrinisic Factor(IF) is defective
IF is required for Cobalamin absorption
Impaired B12 absorption in the small intestine due to lack of IF or destruction of the parietal cells.

Clinical manifestations: as Anemia- normal levels 200-900ng/L
Sore tongue, anorexia, vomiting and abdominal pain
Neuromuscular manifestations-parasthesias, weakness
Low Hgb
Schilling test abnormal test = pernicious anemia
Indirect test of IF deficiency
Evaluates the ability to absorb vitamin B12

Nursing management
includes IM B12 1000mg weekly IM or intra-nasally.
B12 for the rest of their life due to lack of IF
Without vit B12 leads to macrocytic anemia, GI disorders, paresthesia, gait problems & death

Folic Acid Deficiency
Folic acid is necessary for DNA synthesis leading to RBC formation and maturation.
Common Causes:
Poor nutrition (lack of green vegetables, liver, fruits)
Malabsorption syndromes-small bowel disorder
Drugs, alcohol and hemodialysis (folic acid is lost).
Clinical manifestations are similar to vitamin B 12 deficiency

Treatment:
Folic Acid replacement: PO 1-5 mg/OD, standard dose is 1mg.
Vitamin C helps with development
Encourage liver, green veggies, legumes


Blood Loss
Acute Blood Loss
Trauma or Blood vessel rupture due to trauma

Complications of surgery
Diseases that disrupt vascular integrity i.e Shock, the body reacts by vasoconstriction.
30% blood loss
symptoms with exertion only
40% blood loss
rapid, thready pulse, CO low, clammy skin. Blood is being shunted centrally
50% Blood loss
shock & potential death
First identify the cause and stop bleeding
Expand blood volume, pain from organ displacement, check blood work, administer albumin, & colloids

Polycythemia Vera
Overproduction of RBC’s ↑ blood viscosity, volume
Myeloproliferative disorder – Chromosome mutation
Hgb to 18g/dl, RBC 6 million/mm, HCT > 55%.
Common in patients over 50
Splenomegaly and hepatomegaly – organ engorgement
Headache, ↑BP, vertigo, dizziness, angina
Increased uric acid production – gout
Plethora or ruddy complexion, pruritis
Hemorrhagic phenomenon
Nosebleeds, petichiae, thrombus-↑stroke risk

Treatment: aimed at ↓blood volume and viscosity
Phlebotomies to keep Hct < 45%
Allopurinol for uric acid
Teach S/S of bleeding & clotting, discourage smoking, low sodium diet, frequent rest periods
Myelosuppressive agents-Hydrea, Alkeran
Antiplatelet therapy – ASA
Chemotherapy-bone marrow suppression

Thrombocytopenia
Number of platelets is abnormally low
Below the normal of 150,000 to 400,000
Counts below 50,000 cause prolonged bleeding, below 20,000 life threatening
Platelets help the blood clot
Manifests as prolonged bleeding or spontaneous bleeding.
Petechiae = micro hemorrhages.
Purpura when petechaie are numerous, the resulting reddish skin bruise.
Ecchymosis larger purplish lesions that are caused by hemorrhage
Causes: Leukemia, Drugs-ASA, Infection, Lupus
Immune thrombocytopenia, patient makes antibiodies against their own platelets( survival is 1-3 days).

Thrombocytopenia Treatment Options:
Platelet transfusions
Steriod therapy
Splenectomy to reduce macrophages which destroy platelets.
Avoid sharp objects, razors, no contact sports, no IM’s, no rectal temps, oral care, no spicy foods.
If blood work, hold for 5 minutes or greater
Watch for hidden ASA in OTC
Periodic check for bleeding times and platelet counts…
NO ASA

DIC-Disseminated Intravascular Coagulation
Abnormal response of the clotting cascade
Small blood clots develop throughout the blood stream blocking small vessels depleting platelets and clotting factors needed to control bleeding
The clotting factors run out & there is excessive bleeding.

Clinical manifestations:
Bleeding -Pallor, petechiae, hematomas, GI bleeding, hematuria, dizziness, headache, musculoskeletal changes
Thrombosis- cyanosis, ischemia, pulmonary emboli, resp. distress
Life threatening, mortality is > 80%
Occurs with septic shock.
Bleeding out of every orifice, platelets are destroyed.
PT & PTT is increased, Platelets are decreased.

Medical Management:
Tx underlying cause
Heparin, Xigris

Nursing Management:
Early detection of bleeding

Neutropenia
Reduction in the neutrophils
Neutrophils play a role in phagocytosis of pathogenic microbes
Definition: neutrophil count of less than 1,000- 1,500/uL
Normal level: 4000-11,000/uL
It is not a disease, it is a syndrome that occurs with a variety of diseases
As a result of chemotherapy
Patient is predisposed to an infection:
Observe for chills, ↑temp, sore throat and cough
Abnormal s/s of inflammation
Minor infections can lead to sepsis
Good mouth care to prevent pneumonia.
Protective isolation, private room, limit visitors, handwashing.
Normal flora, transmission by hand, food
Neupogen – stimulates production of neutrophils

Leukemias
Acute Lymphocytic (ALL)
Most common in children
Malignant growth of Lymphoblasts
Large numbers of immature white blood cells
Proliferate the bone marrow and lose ability to mature
Chronic Lymphocytic (CLL)
Slow growth of lymphoid cells in lymph nodes, failure of bone marrow, invasion of malignant cells into the organs
Most age 50 > and men
Prognosis poor

Leukemias
Acute Myelogenous Leukemia (AML).
Make to many immature myeloblasts infiltrate organs
Normal cells turn in to granulocytes (WBC)… leukemia blast cells don’t
Most common adult (15-39) leukemia, exact cause is unknown
Prognosis generally poor

Chronic Myelocytic Leukemia (CML)
Slow abnormal growth of granulocytes
Chromosomal abnormality called Philadelphia chromosome.
Affect age 50 >, more males than females
Prognosis generally poor, worse if Ph chromosome present

Leukemia Signs & Symptoms
Eccymoses
Petechiae
Open infected lesions
Pallor
Bleeding gums
Anorexia
Weight loss
Enlarged liver and spleen
Hematuria

Leukemia Treatment
Chemotherapy
Bone Marrow Transplantation
Leukemia Nursing Interventions
Infection prevention
Injury prevention
Energy conservation
Blood replacement therapy
Psychosocial support
Home care education related to care of: CVC, diet, infection prevention, bleeding risk

Hodgkins & Non Hodgkins

Hodgkin’s disease
Malignant disorder of unknown cause
Reed sternberg cells invade lymph nodes
Gigantic atypical tumor cell which multiplies and replaces normal cells.
Painless superficial adenopathy or enlarged lymph nodes
Fever, night sweats, weight loss

Non Hodgkin’s Lymphoma
Malignancies of the lymphoid tissue
Abnormal lymphocytes invade lymph nodes organs bone marrow and blood.

Symptoms are the same
Treatment
Outpatient chemo & radiation
High risk for infection, as survival rate increases
Risk of secondary malignancy increases

Transfusions
Administration of blood or blood components
Need #20 or larger IV line
Establish IV access before getting blood from blood bank!
Check ABO compatibility
Inspect blood for abnormalities
Check pt ID
Stay with pt during first 15min of transfusion

Monitor vs per protocol
Monitor for s/s adverse reactions
PRBCs – give over 2h-4h (but not more than 4h)
FFP, Platelets- run in as quickly as possible

Transfusions
ABO Incompatibility
4 types of blood- A, B, AB, O
A carries A antigen, B carries B antigen, AB carries A&B antigens, O has no antigens
O- universal donor
AB+ universal recipient
Rh factor
- absent
+ present
Blood testing is done to determine compatibility

Transfusion Complications
Febrile non-hemolytic reaction
Temp rise 1°C or greater during infusion
Tx with antipyrectics
Consider use of leuko depleted blood for future transfusions

Acute hemolytic reaction
Life threatening
Cause- ABO incompatibility
s/s- fever, chills, back pain, nausea, chest tightness, dyspnea, anxiety
Stop blood immediately and start transfusion reaction protocol

Transfusion Complications
Allergic reaction
Cause- rx to proteins in blood
s/s- pruritis, hives (mild), to bronchospasm, laryngeal edema, shock (life threatening)
Tx- antihistamines, steroids, epinephrine
Circulatory Overload
Cause- too rapid infusion in vulnerable individual
s/s- dyspnea, tachycardia, anxiety, frothy pink sputum, crackles, JVD
Tx- give blood slowly, diuretics, O2, morphine if dyspnea severe

Transfusion Complications
Bacterial Contamination
s/s- fever, chills, hypotension
Tx- prevention is key; stop transfusion, broad-spectrum abt

Disease Acquisition
Hep B, Hep C, CMV, HIV, Creutzfeldt-Jakob Disease

Complication r/t Long-term Transfusions
Infection, sensitization to donor antigens, iron overload