Hematology
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HEMATOLOGY. MCC NURSING BY: DIANA BLUM MSN. 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. Anatomy .

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Hematology

HEMATOLOGY

MCC NURSING

BY: DIANA BLUM MSN


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

Anatomy


Hematology

  • 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.

Cell Types (page 1991-94)


Lymphatic system

  • Responsible for removing excess fluid protein and large particles from cells

  • Main functions:

    • fluid balance maintenance

    • Defense

    • Fat absorber

Lymphatic system


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)

Spleen


Hemostasis page 1995

  • Stopping of blood flow

  • 2 phases:

    • Primary

    • Secondary

Hemostasis (page 1995)


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

Anemia (page 2008)


Erythropoiesis

  • Stimulation of RBCs by erythropoietin

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

Erythropoiesis


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

Determination between types


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

Clinical manifestations (pg 2010)


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

Education


Iron deficiency anemia

  • 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 tilcreatinine 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 Renal Disease


Anemia and chronic disease

  • Only inflammation, infection, and malignancy cause

  • It is nonprogressive

  • Develops over 6-8 weeks

  • Many don’t require treatment

Anemia and chronic disease


Aplastic anemia

  • 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


Pernicious 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

Thalassemia


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

Folic Acid Deficiency


Sickle cell anemia

  • 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

  • 4types:

    • 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

Sickle Cell Crisis


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 africanamericans, 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

Glucose -6-Phospate Dehydrogenase Deficiency


Polycythemia vera

  • 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


Autoimmune hemolytic anemia

  • 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 coombsantiglobulin 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

Leukemia


Aml acute 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

AMLAcute Myeloid Leukemia


Hematology

  • 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

CML


Acute lymphocytic leukemia all

  • 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

Acute Lymphocytic LeukemiaALL


Hematology

  • 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

CLL


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%

Hodgkins Disease


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%

Non Hodgkins Lymphoma


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

Multiple Myeloma


Bleeding disorders

Bleeding disorders

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


Thrombocytopenia

  • 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

Immune thrombocytopenic purpura


Hematology

  • Example of drug induced immune mediated thrombocytopenia

  • Rare

  • Related to heparin therapy

  • Tx: observation, assessment, monitor lab values, stop heparin immediately

HIT


Thrombic thrombocytopenic purpura

  • Medical emergency

  • Causes extensive blood clots

  • TX: plasmaphoresis

  • Complication: multi organ FX

  • 95%death rate if not treated

Thrombic Thrombocytopenic Purpura


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

Von Willebrand’s Disease


Hemophilia

  • 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


Hematology

  • Not a disease

  • Triggers: sepsis, trauma, cancer, shock, abruptioplacentae, 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

DIC


Blood typing for transfusion

  • 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 ptblood

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

Blood typing for transfusion


Adminstration on blood

  • 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 birthday

    • Check vitals prior to administration

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

  • Use blood tubing for administration

  • Monitor for blood reactions

  • Monitor vitals continuously during administration

adminstration on blood


Blood reactions

  • 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


Bleeding precautions

  • 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

ANY QUESTIONS???


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