1. Hematologic Problems
Klecka, Spring 2016

2. Learning Outcomes (Anemia)
Describe and classify anemia's
Understand the nursing management for specific anemia’s
Incorporate medical pharmacology into the nursing management of anemia

3. Anemia Classification
A deficiency in the
Number of erythrocytes (red blood cells [RBCs])
Quantity of hemoglobin
Volume of packed RBCs (hematocrit)
Diverse causes such as
Blood loss
Impaired production of erythrocytes
Increased destruction of erythrocytes

4. Clinical Manifestations
Caused by the body’s response to tissue hypoxia
Hemoglobin (Hb) levels are used to determine the severity of anemia.
Remember norms (Hemoglobin Normal Range)
Female: g/dl
Male: g/dl

5. Types of Anemia Iron-Deficiency Anemia Thalassemia
Megaloblastic Anemias
Chronic Anemia
Aplastic Anemia
Acute/chronic Blood Loss Anemia
Hemolytic Anemias
4:32 min

6. Integumentary Manifestations
Pallor
↓ Hemoglobin
↓ Blood flow to the skin
Jaundice
↑ Concentration of serum bilirubin
Pruritus
↑ Serum and skin bile salt concentrations

7. Cardiopulmonary Manifestations
Additional attempts by the heart and lungs to provide adequate O2 to the tissues
Cardiac output maintained by increasing the heart rate and stroke volume
HR X SV = CO

8. Anemia: Nursing Assessment
Subjective Data
Important health information
Past health history
Medications
Surgery or other treatments
Dietary history
At-risk groups
Premenopausal women
Pregnant women
Persons from low socioeconomic backgrounds
Older adults
Individuals experiencing blood loss

9. Anemia: Nursing Assessment
Subjective Data
Functional health patterns
Health perception–health management
Nutritional-metabolic
Elimination
Activity-exercise
Cognitive-perceptual
Sexuality-reproductive

10. Anemia: Nursing Assessment
Objective Data
General
Integumentary
Respiratory
Cardiovascular
Gastrointestinal
Neurologic

11. Anemia: Nursing Diagnoses
Fatigue
Altered nutrition: Less than body requirements
Ineffective self-health management

12. Anemia: Nursing Management
Goals
Assume normal activities of daily living.
Maintain adequate nutrition.
Develop no complications related to anemia

13. Anemia: Nursing Implementation
Blood or blood product transfusions
Drug therapy
Volume replacement
Dietary and lifestyle changes

14. Anemia: Nursing Implementation
Oxygen therapy
Patient teaching
Nutrition intake
Compliance with safety precautions to prevent falls and injury

15. Iron Deficiency Anemia
One of the most common chronic hematologic disorders
Iron is present in all RBCs as heme in hemoglobin and in a stored form.
Heme accounts for two thirds of the body’s iron.

16. Iron-Deficiency Anemia Collaborative Care
Goal is to treat the underlying disease.
Increased intake of iron
Nutritional therapy
Oral or occasional parenteral iron supplements
Transfusion of packed RBCs

17. Iron Supplementation Pharmacological
Single drug or as part of a multivitamin preparation
Oral iron preparations are available as ferrous salts (ferrous fumarate, ferrous gluconate, ferrous sulfate)
Parenteral
iron dextran
ferric gluconate (Ferrlecit)
iron sucrose (Venofer)
Most common cause of pediatric poisoning deaths
Causes nausea, vomiting, diarrhea, constipation, stomach cramps, and pain
Causes black, tarry stools
Liquid oral preparations may stain teeth
Injectable forms may stain skin and cause pain upon injection
Dextran rarely used now b/cause of anaphylactic side effects, replaced by newer products
Ferric gluconate and iron sucrose
Used for patients with chronic renal disease and iron-deficiency anemia
Less risk of anaphylaxis
Hypotension is the most common adverse effect and is related to infusion rate

18. Iron Deficiency: Nursing Management
Diet teaching
Supplemental iron
Discuss diagnostic studies.
Emphasize compliance.
Iron therapy for 2 to 3 months after hemoglobin levels return to normal

19. Megaloblastic Anemias
Group of disorders caused by impaired DNA synthesis
Characterized by the presence of large RBCs (megaloblasts)
Easily destroyed because of fragile cell membrane
Majority result from deficiency in
Cobalamin (vitamin B12)
Folic acid
Folic Acid
Water-soluble, B-complex vitamin
Essential for erythropoiesis
Primary uses
Folic acid deficiency
During pregnancy to prevent neural tube defects
Malabsorption syndromes are the most common cause of deficiency

20. Cobalamin Deficiency Intrinsic factor (IF)
Protein secreted by the parietal cells of the gastric mucosa
IF is required for cobalamin absorption in the small intestine.
Causes Pernicious Anemia
Pernicious Anemics may need IF to absorb B12 without IF oral supplementation of B12 will be futile. These patients will need Parenteral cyanocobalamin or Intranasal (CaloMist)
See anemia care plan and include safety precaustions for decreased sensitivity to heat, protect for burns.

21. Cobalamin Deficiency Clinical Manifestations
Neuromuscular manifestations
Weakness
Paresthesias of the feet and hands
↓ Vibratory and position senses
Ataxia
Muscle weakness
Impaired thought processes

22. Folic Acid Deficiency Common causes Dietary deficiency
Malabsorption syndromes
Drugs
Increased requirement
Alcohol abuse and anorexia
Loss during hemodialysis
Also a cause of megaloblastic anemia
Folic acid is required for DNA synthesis.
RBC formation and maturation
Clinical manifestations are similar to those of cobalamin deficiency.
Insidious onset
Absence of neurologic problems
Treated by replacement therapy
Encourage patient to eat foods with large amounts of folic acid.

23. Anemia of Chronic Disease
Review
Conditions/Meds that would effect Erythropoietin production
Underproduction of RBCs
Mild shortening of RBC survival (normal RBC life 120 days)
Monitor for therapeutic responses
Improved nutritional status
Increased weight, activity tolerance, well-being
Absence of fatigue
Monitor for adverse effects
Treat underlying cause Meds (chemo agents causing anemia) Renal disease reducing erythropoietin secretion
r/o other anemias (patient will have high serum ferritin, normal b12, normal folate)

24. Immunomodulators (IMs)
Include drugs from several classes
Immunosuppressants
Immunizing drugs
Biologic response modifiers (BRMs)
Hematopoietic drugs
Immunomodulating drugs
Medications that therapeutically alter a patient’s immune response to malignant tumor cells
Drugs that modify the body’s own immune response so that it can destroy various viruses and cancerous cells

25. Acute Blood Loss Nursing management Assess for cause
Volume Replacement
Cause
Body’s attempt to maintain adequate blood volume and O2
Pain
Internal hemorrhage
Tissue distention, organ displacement, nerve compression
Pain (cont'd)
Retroperitoneal bleeding
Numbness
Pain in the lower extremities
Shock is the major complication

26. Chronic Blood Loss Reduced iron stores Bleeding ulcer Hemorrhoids
Menstrual and postmenopausal blood loss
Management
Identify source.
Stop bleeding.
Use supplemental iron if needed.

27. Pair and Share #1 1. A history of jaundice and black tarry stools.
At an outpatient clinic, a 78-year-old woman is found to have a Hb of 8.7 g/dL (87 g/L) and a Hct of 35%. Based on the most common cause of these findings in the older adult, the nurse collects information regarding:
1. A history of jaundice and black tarry stools.
2. A 3-day diet recall of the foods the patient has eaten.
3. Any drugs that have depressed the function of the bone marrow.
4. A history of any chronic diseases such as cancer or renal disease.
Answer: 4
Rationale: A common cause of anemia in the older adult population is co-morbid conditions such as cancer or renal disease.

28. Answer: 4
4. A history of any chronic diseases such as cancer or renal disease
Rationale: A common cause of anemia in the older adult population is co-morbid conditions such as cancer or renal disease.

29. Other Red Blood Cell Disorders

30. Thrombocytopenia Reduction of Platelets below 150,000
(ITP) Immune Thrombocytopenic Purpura
Syndrome of abnormal destruction of circulating platelets. The body sees platelts as a forign substance (they are coated with antibodies) Platelets life cycle is shortned (normal platelet life is 8-10 days)..These patients are at risk for bleeding. Measures to avoid bleeding are taken. Medications are given po or IV rather than IM. See care plan 31-2.

31. Hemophilia
Hemophilia is a genetic disorder caused by defective or deficient coagulation factor. Hemophilia A is the most common, almost exclusively in men.
Slow, persistant prolonged bleeding from minor trauma or cuts. They have adequate platelets BUT prolonged PTT (Partial thromboplastin time) Because of a deficency in intrensic clotting system.

32. Hemophilia
Acute hemarthrosis of the knee is a common complication of hemophilia. Ice, immobilize, Administer replacement factors, pain meds..except not asprin. After the bleed range of motion exercise can be performed to prevent stiffining of the joint. Weight bearing exercise is contraindicated until swelling has subsided. Expected outcomes are similar for thoses in the NCP for thrombocytopenia. Safety and injury prevention teaching is the main focus of long term nursing management for these patients. Also, teaching to seek medical attention at the first sign of swelling or pain of a muscle or joint. Von Willebrand disease is a related disorder in which bleeding time is prolonged secondary to a lack of the Von Willebrand coagulation protein.

33. Bone Marrow Biopsy
Bone Marrow Aspiration . Hematopoietic Stem Cell Transplant. Autologous (patients own)or allogeneic(matched donor) stem cells are reinfused (IV) after chemo agents have cleared the system so as to not destroy the new stem cells. (after this procedure, can be outpatient, a patient will experience pain for up to a week and is treated with mild analgesics)