Nursing of Adults with Medical & Surgical Conditions

1. Nursing of Adults with Medical & Surgical Conditions Blood and Lymphatic Disorders

2. Blood and Lymphatic Disorders • Laboratory Tests • RBC (erythrocytes) 4-6 million/cu.mm • Hemoglobin 10-20 gm/100ml • Hematocrit 40-50 percent • WBC 5,000-10,000/mm • Platelets 150,000-400,000/mm

3. Anemia • Definition • Disorder characterized by RBC and hemoglobin and hematocrit levels below normal range • Causes delivery of insufficient amounts of oxygen to tissues and cells

4. Anemia • Types • Blood loss (hemorrhage) • Impaired production of RBC’s (bone marrow depression) • Increased destruction of RBC’s (hemolysis) • Nutritional deficiencies (long term iron deficiency)

5. Signs & Symptoms Anorexia Cardiac dilation Disorientation Dyspepsia Dyspnea Exertional dyspnea Fatigue Headache Insomnia Pallor Palpitation Shortness of breath Systolic murmur Tachycardia Vertigo Anemia

6. Hypovolemic Anemia • Etiology/Pathophysiology • Abnormally low circulating blood volume due to blood loss • 500 ml loss can be tolerated • 1000 ml loss can be severe complications • Severity and signs and symptoms depend on how rapid the blood is lost

7. Hypovolemic Anemia • Signs & Symptoms • Weakness • Stupor • Irritability • Pale, cool, moist skin • Hypotension • Tachycardia (rapid, weak, thready pulse) • Hypothermia • Hemoglobin less than 10 gm/100ml • Hematocrit less than 40 % • H&H may not drop for several hours after blood loss

8. Hypovolemic Anemia • Treatment • Control bleeding • Treat shock • O2, elevate lower extremities, keep warm • Replace fluid • blood transfusion, plasma, dextran, lactaed ringers • Monitor vital signs

9. Pernicious Anemia • Etiology/Pathophysiology • Absence of the intrinsic factor • Intrinsic factor is essential for the absorption of vitamin B12 • Deficiency of vitamin B12 affects growth and maturity of all body cells • RBC’s in the bone marrow don’t mature • RBC membrane ruptures easily • Vitamin B12 is also related to nerve myelination • may cause progressive demyelination and degeneration of nerves and white matter

10. Pernicious Anemia • Signs & Symptoms • Extreme weakness • Dyspnea • Fever • Hypoxia • Weight loss • Jaundice (destruction of RBC’s) • Pallor • GI complaints

11. Pernicious Anemia • Dysphagia • Sore, burning tongue • Smooth and erythematous • Neurological symptoms • tingling of the hands and feet • disorientation • personality changes • behavior problems • partial or total paralysis

12. Pernicious Anemia • Treatment • Vitamin B12 (cyanocobalamin) 1000 units • daily for 1 week • weekly for 1 month • monthly for life • Folic acid supplement • Iron replacement • RBC transfusion • for severe anemia • Diet • high protein, vitamins, and minerals

13. Aplastic Anemia • Etiology/Pathophysiology • Decrease of bone marrow function • RBC production • Primary • congenital • Secondary • viral invasion • medications • chemicals • radiation • chemotherapy

14. Aplastic Anemia • Signs & Symptoms • Pancytopenic • all three major blood elements from the bone marrow are decreased (RBC, WBC, & Platelets) • Repeated infections with high fevers • Fatigue, weakness, malaise • Dyspnea • Palpitations • Bleeding tendencies • petechiae, ecchymossis, bleeding gums, epistaxis, GI & GU bleeds

15. Aplastic Anemia • Treatment • Identify & remove cause • Platelet transfusion for severe thrombocytopenia • Splenectomy for hypersplenism • Hypersplenism can cause destruction of platelets • Steroids and androgens • stimulate bone marrow • Antithymocyte globulin • stimulates bone marrow • Bone marrow transplant

16. Iron Deficiency Anemia • Etiology/Pathophysiology • RBC’s contain decreased levels of hemoglobin • Excessive iron loss • caused by chronic bleeding; intestinal, uterine, gastric

17. Iron Deficiency Anemia • Signs & Symptoms • Pallor • Fatigue • Weakness • Shortness of breath • Angina • S/S of heart failure • Glossitis • Pagophagia (desire to eat ice, clay, starches) • Headache • Paresthesia • Burning tongue

18. Iron Deficiency Anemia • Treatment • Ferrous Sulfate 900 mg daily • Oral or injection (z-tract) • Ascorbic acid • enhances absorption of iron • Diet high in iron • Organ meats • liver, kidney, heart, tongue • Muscle meats (esp dark meat from poultry) • Fish • Eggs • Green leafy vegetables • Whole grains • Dried beans

19. Sickle Cell Anemia • Etiology/Pathophysiology • Most common genetic disorder in the U.S. • Occurs predominantly in African Americans • 1out of 10 have trait; 1 out of 500 have disease • An abnormal, crescent shaped RBC • contains hemoglobin S (Hg-S) • Severe, chronic, incurable condition • Disease • Homozygous • has two Hg-S genes; one from each parent • Trait • Heterozygous • has one Hg-S gene from one parent and one Hg-A gene from the other parent

20. Sickle Cell Anemia • Signs & Symptoms • Precipitating Factors • Dehydration • Change in oxygen tension in the body • infection, overexertion, cold, alcohol, smoking • Loss of appetite • Irritability • Weakness • Abdominal enlargement • pooling of blood in the liver, spleen and other organs • Join and back pain • Edema of extremities

21. Sickle Cell Anemia • Treatment • No specific treatment • Alleviate symptoms • Oxygen • Rest • Fluids • oral and IV • Analgesics • Bone marrow transplant • Experimental

22. Agranulocytosis • Etiology/Pathophysiology • Severe reduction in the number of granulocytes (basophils, eosinophils, & neutrophils) • WBC less than 200/mm3 • Medications • analgesics, antibiotics, antiepileptics, antihistamines, antineoplastic agents, antithyroid drugs, diuretics, phenothiazides, sulfonamides • Chemotherapy • Radiation • Neoplastic disease • Viral and bacterial infections

23. Agranulocytosis • Signs & Symptoms • S/S of infection • fever, chills, headache, fatigue • Ulcerations of mucous membranes • Bronchial pneumonia • Urinary tract infection

24. Agranulocytosis • Treatment • Identify and remove cause of bone marrow depression • Prevent or treat infections • Meticulous handwashing • Strict asepsis

25. Leukemia • Etiololgy/Pathophysiology • Malignant disorder of the hematopoietic system • Excess leukocytes accumulate in the bone marrow and lymph nodes • bone marrow produces immature cells • Cause unknown • Possible causes include genetic, virus, exposure to radiation, or chemotherapy • Classification • Acute or Chronic • Proliferating cells (lymphocytic, monocytic, etc.)

26. Leukemia • Signs & Symptoms • Anemia • pallor, fatigue, malaise • Thrombocytopenia • petechiae, epistaxis, bruising, occult blood • Leukopenia • fever, upper resp. infections, • Enlarged lymph nodes • Splenomegaly

27. Leukemia • Treatment • Chemotherapy • Radiation • Bone marrow transplant • Medications • Leukeran • hydroxyurea • corticosteroids • Cytoxan

28. Thrombocytopenia • Etiology/Pathophysiology • Abnormal hematological condition in which the number of platelets is reduced below 100,000 mm3 • Decreased production • aplastic anemia, leukemia, tumors, chemotherapy • Decreased survival • antibody destruction, infection, viral invasion

29. Thrombocytopenia • Signs & Symptoms • Petechiae • Ecchymoses • Platelets below 100,000 • bleeding mucous membranes • bleeding internal organs • Platelets below 20,000 • serious bleeding risks

30. Thrombocytopenia • Treatment • Corticosteriod therapy • Splenectomy • Gamma globulin • Immunosuppressive drugs • Platelet transfusions • Avoid trauma

31. Hemophilia • Etiology/Pathophysiology • Hereditary coagulation disorder, characterized by a disturbance of clotting factor • Hemophilia A • most common • Factor VIII is absent • Hemophilia B • Deficiency of Factor IX • X-linked hereditary trait • affects mainly males • females are carriers

32. Hemophilia • Signs & Symptoms • Internal & external bleeding • Hemarthrosis • bleeding into the joint; esp knees, ankles, and elbow • Excessive blood loss from small cuts and dental procedures

33. Hemophilia • Treatment • Minimize bleeding • avoid trauma • Relieve pain • No aspirin • Transfusions • Factor VIII or IX concentrate • human-derived products • can be treated to inactivate viruses • Cryoprecipitate (rich in factor VIII) • human-derived product • Manufactured factor VIII or IX

34. von Willebrand’s Disease • Etiology/Pathophysiology • Inherited bleeding disorder characterized by abnormally slow coagulation of blood and spontaneous episodes of GI bleeding, epistaxis, and gingival bleeding • Mild deficiency of factor VIII • Common during • Postpartum • Menorrhagia • Post operative • Post truama • Similar to hemophilia; not limited to males

35. von Willebrand’s Disease • Treatment • Cryoprecipitate • Fibrinogen • Fresh plasma • Desmopressin (DDAVP) • Synthetic of the human antiduiuretic hormone, vasopressin • Causes an increase in factor VIII release from storage sites in the body • Same nursing interventions as for hemophilia

36. Disseminated Intravascular Coagulation (DIC) • Etiology/Pathophysiology • Overstimulation of clotting and anticlotting processes in response to disease or injury • Septicemia • Obstetrical complications • Malignancies • Tissue trauma • Transfusion reaction • Burns • Shock • Snake bites

37. Disseminated Intravascular Coagulation (DIC) • Primary disorder initiates generalized intravascular clotting, which overtimulates fibrinolytic mechanisms • The hypercoagulability is followed by a deficiency in clotting factors with subsequent hypocoagulability and hemorrhaging

38. Disseminated Intravascular Coagulation (DIC) • Signs & Symptoms • Bleeding • Mucous membranes • Venipuncture sites • Surgical sites • GI & GU tracts • All orifices • Dyspnea • Hemoptysis • Diaphoresis • Cold, mottled digits • Purpura on the chest and abdomen • Petechiae

39. Disseminated Intravascular Coagulation (DIC) • Treatment • Treat underlying cause • Cryoprecipitate • Heparin • Protect from bleeding and trauma

40. Multiple Myeloma • Etiology/Pathophysiology • Malignant neoplastic immunodeficiency disease of the bone marrow • Tumor, composed of plasma cells, destroys osseous tissue • Bone marrow becomes overcrowded and unable to produce erythrocytes, platelets, and leukocytes • Onset is gradual and insidious

41. Multiple Myeloma • Signs & Symptoms • Bone pain • Ribs, spine, and pelvis • Pathological fractures • Infection • Anemia • Bleeding • Hypercalcemia • Calcium and phosphorus drain from bones • Renal failure • Myeloma protein causes kidney damage • Destruction of cells causes hyperuricemia

42. Multiple Myeloma • Treatment • Symptomatic; not curable • Radiation • Chemotherapy • Alkeran • Cytoxan • Leukeran • Carmustin • Vincristine • Adriamycin • Dexamethasone • Corticosteroids • IV fluids

43. Lymphangitis • Etiology/Pathophysiology • Inflammation of one or more lymphatic vessels • Usually occurs from acute streptococcal or staphylococcal infection in an extremity

44. Lymphangitis • Signs & Symptoms • Fine red streaks from the affected area in the groin or axilla • Edema • Chills • Fever • Local pain • Headache • Myalgia

45. Lymphangitis • Treatment • Penicillin • Hot, moist heat • Elevate extremity

46. Lymphedema • Etiology/Pathophysiology • Primary or secondary disorder • Accumulation of lymph in the soft tissue • Obstruction • Increase in amount of lymph • Removal of lymph channels and nodes

47. Lymphedema • Signs & Symptoms • Massive edema and tightness of affected extremity • Pain

48. Lymphedema • Treatment • Diuretics • Antibiotics • Compression pump • Elastic stocking or sleeve • Restricted sodium diet • Avoid constrictive clothing • Meticulous skin care

49. Malignant Lymphoma • Etiology/Pathophysiology • Non-Hodgkin’s Lymphoma • Neoplastic disorder of lymphoid tissue • Tumors usually start in lymph nodes and spread to lymphoid tissue in the spleen, liver, GI tract, and bone marrow

50. Malignant Lymphoma • Signs & Symptoms • Painless, enlarged cervical lymph nodes • Fever • Weight loss • Anemia • Pruritus • Susceptiblity to infection • Complications • Pleural effusion, bone fractures, and paralysis • Fatigue • Malaise • Anorexia