Blood Disturbances

1. Blood Disturbances PN111

2. Hematologic System Involves: • Blood • Blood Cells • Lymph • Organs involved with blood formation • Organs involved with blood storage

3. Review of Blood Blood is: • sticky, opaque, has a salty metallic taste • can be scarlet in colour (oxy.rich) or dull red (oxy.poor) • 5 times thicker than water • healthy adults- 5-6 liters 7-10% of body wt • called FLUID TISSUE • solid and liquid components • formed elements suspended in plasma

4. Plasma Proteins: albumin fibrinogen globulins osmotic balance helps maintain H2O clotting of blood defences (antibodies) lipid transport Plasma

5. Bone Marrow • Site of hematopoiesis • makes up 4-5% of total body wt, one of the largest organs of the body • active or red marrow, and , fat or yellow marrow • with age red is replaced with yellow but can reverse • assisted in crisis by the spleen and liver

6. Stem Cells • Primitive cells that can differentiate into myeloid or lymphoid stem cells • lymphoid develop into T or B lymphocytes • myeloid differentiate into erythorcytes, leukocytes or platelets • See text for chart on stem cell differentiation

7. Stem Cell differentiation • Erythropoietin - a hormone produced primarily by the kidney stimulates differentiation • when kidney detects low 02 as in anemia, it releases erythropoietin which stimulates bone marrow = increased RBC in about 5 days

8. Bone marrow function • Erythrocyte production requires iron, vit B12, folic acid, pyridoxine (Vit B6) • Iron-stored in small intestine as ferritin. When required it binds to transferring and is transported to marrow (6 to 8 hours) • Iron is lost in feces, bile, blood or intestinal mucousal cells

9. Red blood cell destruction • Life span 120 days • removed from circulation by spleen or liver • hemoglobin in recycled and some becomes bilirubin and secreted in the bile • most of iron is recycled, small amts lost in feces

10. BM aspiration and bx • Assess the quality and quantity of each type of cell produced in the marrow • aspirate usually from iliac crest looks like slushy fluid • biopsy from iliac crest usually looks like a skinny worm

11. Blood Abnormalities • Result from problems in the production, function or normal destruction of any type of blood cell. • We will start with RBC disorders

12. RBC disorders • Too few RBC = anemia • Too many RBC = polycythemia

13. Anemia • Lower than normal RBC count and Hgb level • Anemia is a clinical sign not a diagnosis • results in diminished amount of O2 to body tissues • many different kinds of anemia but all fall in one of three categories

14. 3 Categories of Anemia • Decrease in production of RBC’s (hypoproliferative) • Excessive destruction of RBC’s (hemolytic) • Loss of RBC’s(bleeding) Etiology includes: • genetic, • nutrition deficit, iron deficit • chronic disease

15. Complications of Anemia • Congestive heart failure • parathesias • confusion • death

16. Clinical Manifestations • Impacted by severity, speed of development, duration, pts metabolic requirements, co-existing disorders or disabilities.

17. Clinical Manifestations • Dyspnea, chest pain, muscle pain or cramping • weakness, fatigue, general malaise • pallor of the skin, MM including sclera • jaundice, black stool, coffee emesis • smooth, red tongue • beefy red tongue, sore tongue • angular cheilosis • brittle ridged concave nails and pica

18. Gerontologic Considerations • Most common hematologic condition in elderly due to body’s decreased ability for bone marrow to respond to body’s need • treat the underlying cause rather than writing it off as an ageing problem • elderly with concurrent cardiac or pulmonary problem may not be able to tolerate anemia

19. Diagnostic Evaluation • Complete hematologic studies • iron studies • serum vitamin B12 and folate levels, erythropoietin levels • bone marrow aspiration and biopsy • other studies to determine underlying illness/cause

20. Medical Management • Correct and control the cause of the anemia • replace lost or destroyed RBC’s

21. Nursing assessment • Health hx, physical exam, review lab values • hx of symptoms, lifestyle, medications, alcohol use, athletic endeavours • ? Any loss of bld, • family hx • dietary habits • ?cardiac, neuro, GI functions

22. Nursing Interventions • Manage Fatigue • Monitor and Manage complications • maintain adequate nutrition • maintain adequate perfusion • monitor and manage potential complications

23. Megaloblastic Anemia • caused by lack of vit.B12, folic acid • lack of B12 caused by a problem with the stomach mucous, absence of intrinsic factor, strict vegetarian diet, disease of the ileum or pancreas, gastrectomy

24. Lack of folic acid occurs when intake is deficient or requirement increased • risk groups include those who do not each uncooked veggies or fruit, alcoholics, pregnancy, malabsorptive or small bowel disease

25. Signs and Symptoms • Smooth sore tongue • mild diarrhea • weakness • paleness • confusion • paresthisis in extremities • death after several years

26. Diagnosis: • shillings test, CBC, serum folate and B12 Treatment for B12 defic: • B12 orally • B12 IM if intrinsic factor missing • counts usually normal in 2 months • B12 taken for life

27. Treatment for folic acid defic. • Diet = 1mg of folic acid daily • IM folic acid for malabsorptive disease • orally • stopped when hgb returns to normal except for alcoholics who continue while alcohol is used

28. Nursing Care: • Skin care especially with incontinence, paralysis • mouth care • accurate urine tests • educate re: monthly injections (compliance) • educate re: ongoing medical assessment especially for increased risk of stomach CA

29. Nursing Interventions • Manage Fatigue • Monitor and Manage complications • maintain adequate nutrition • maintain adequate perfusion • monitor and manage potential complications

30. Hemmorragic Anemia • Sudden loss of blood resulting in decreased RBC • hemorrhage signs and symptoms: • you tell me treatment: • replace blood loss

31. Aplastic Anemia • Decrease in RBC as a result of a decrease in precursor cells (marrow stem cells) in bone marrow - replaced with fat • can be congenital, acquired or idiopathic • can be caused by certain infections, radiation, chemicals (benzene), anti-tumor agents (nitrogen mustard), toxic material (arsenic), meds (anti-convulsants, anti-inflamatory's, gold compounds)

32. Signs and Symptoms • Gradual weakness, pallor, SOBOE, sometimes fever, adenopathy • purpura, retinal hemorrhages • repeated throat infections with possible lymphadenopathy and splenomegally Dx: • CBC, bone marrow and biopsy

33. Treatment • bone marrow (stem cell) transplant • immunosuppressants • support therapy - transfusion • frequent CBC

34. Nursing Care • Assess re:hypoxia, bleeding, infection • oral hygiene, no break in skin or mucous membrane • preserve energy of pt. • if low platelets, avoid trauma of IM or SC • stool softeners to prevent straining • if using potentially toxic medications, monitor blood work

35. Hemolytic Anemia • Shortened life span of RBC or destruction of RBC • bone marrow tries to compensate by producing RBC’s 3 times the normal rate • can be caused by infection or toxic chemicals, mismatched blood trans, disorder of the immune system, Hodgkins, liver disease

36. Dx, and Tx • Reticulocyte count (elevated) • bilirubin increased • haptoglobin decreased (binding protein for free Hgb) treatment: • in severe cases - hospitalization • blood transfusion • removal of spleen • detection and tx of cause

37. Nursing Care • Bed rest to conserve energy • avoid IM’s • frequent mouth care • 02 support • increased protein diet • stool softener • skin care

38. Sickle Cell Anemia • Severe hemolytic anemia because of a defective Hgb molecule • genetic defect of a single amino acid necessary for hemoglobin • RBC becomes deformed in venous circ.when exposed to low O2 • RBC takes on sickle shape and becomes lodged in small vessels-slows circulation to area and causes ischemia and pain

39. Sickle Cell Anemia • Sickle cell has a short life span 15-25 days • at risk: 1 in 375 African American, Mediterraneans, Carribeans, South and Central American heritage, Arab and East Indian ancestry

40. Signs and Symptoms • In crisis - severe pain, fever, swelling in arms, legs and abdomen • anemia • jaundice in sclera • progressive renal damage • In childhood - larger bones in face and skull due to bone marrow expansion • enlarged heart, tachy, damage to any organ • increased blood viscosity

41. Diagnosis • Hgb and hematocrit levels, blood smear, • electrophoresis because the sickling will occur even if the pt has sickle cell trait or sickle cell anemia and this test will tell the difference

42. Treatment • Diagnose early in children, genetic counselling • 1st crisis may be at age 1 - 2 • average life span 40 years • blood transfusion, bone marrow transplant • new drugs to prolong RBC life span (side effects)

43. Nursing Care • Pt.teaching re: avoiding infections • avoiding high altitudes • increased folic acid (where can we get this?) • In a crisis, ++ fluids, analgesia, monitor blood transfusions. • Maximize pts. Knowledge base

44. Potential complications • Leg ulcers • priaprism leading to impotence • chronic pain and substance abuse

45. Iron Deficiency Anemia • A form of anemia where the RBC contain less Hgb. • Usually due to an inadequate supply of iron or due to loss of blood • RBC may be described as microcytic or hypochromic, what does this mean?

46. Signs and Symptoms • Low energy • pallor of skin or mucous membranes • fatigue, poor appetite • smooth, sore tongue, brittle nails, angular cheilosis, pica • Hgb lower than hematocrit and RBC count • low serum iron, ferritin low

47. Evaluation • Bone marrow aspiration • lab work: ferritin, blood count, serum iron levels, total iron binding capacity (high)

48. Treatment • Search for cause, treat cause • test stools for occult bld • iron preparations

49. Pharmacology Vitamin B12: • body can store 4 to 5 mg of B12 so it may take 2 to 5 years for a deficiency to be detected after intrinsic factor is no longer released. • Minimum daily requirement is 1 to 2 micrograms

50. B12 • Usual therapeutic dose is 30 - 50 ug/day times 5 days then 100 to 200 ug monthly. • Cyanocobalamin • can be p.o or parenteral. Not given po.for pernicious anemia Why? • IM or deep sc. • Avoid alcohol, may need intrinsic factor or folic acid, What is the underlying cause?