2Blood and Lymph Two of the body’s most important functions are: TransportationProtection-from foreign invadersAchieved through the circulatory and lymph systemsBlood is the primary transportation fluid
3Blood Cells RBC’s, WBC’s, and Platelets Blood cells are made in bone marrowOther structures involved in the blood cell production are:Kidneys (Erythropoietin)Liver (stores iron)Lymph system (breaks down blood cells, produces WBC)
4Red Blood Cell Production (RBC) Erythropoiesis is the process of making red blood cellsStimulated by decreased PO2The kidneys releases ErythropoietinReticulocytes are immature RBC’sIron, folic acid, and Vitamin B12 are needed for RBC productionIron is needed for Hemoglobin production
6Hemoglobin (Hgb) Contained within RBC’s – red pigment Oxygen carrying compound of the RBCNormal ValuesMales g/dLFemales g/dLIncreased: Dehydration, COPD, PolycythemiaDecreased: Anemia, leukemia, Post-hemorrhage
7Hemoglobin Erythrocytes are classified according to: To measure Hgb, RBC’s are broken and Hgb is released and countedHemoglobin content is expressed as normochromic or hypochromic anemiaErythrocytes are classified according to:Size, shape and colorRBCs size is usually expressed as: macrocytic, microcytic, or normocyticAverage life span of an RBC = 120 days
11White Blood CellsHave nuclei, are colorless, live from a few days several yearsPrimarily involved in body defenses such as destruction of bacteria and viruses“Differential” – blood count in which the different kinds of WBCs are counted and reported can discriminate between virus and backteria
12Platelets Also called “thrombocytes Normal Values 150, ,000 cells/microliter – involved with clotting5-9 day life spanIncreased- Polycythemia, granulocytic leukemiaDecreased- Bleeding, thrombocytopenia, Chemotherapy
13Erythrocyte Indices MCV, MCH, MCHC Will help determine type of anemia Iron DeficiencyFolic Acid DeficiencyB12 DeficiencyDefinition of Corpuscular: A living cell
14Mean Corpuscular Volume (MCV) Volume (size) of the RBCHematocrit divided by RBC CountLowRBC = Microcytic (small)Iron Deficiency AnemiaHighRBC = Macrocytic (large)B12Folic Acid Deficiency Anemia
15Mean Corpuscular Hemoglobin (MCH) Weight of hemoglobin in a RBCHemoglobin divided by the total RBC countLowHypochromic (Deficient of hemoglobin)Iron Deficient AnemiaHighHyperchromic- Lab error
16Mean Corpuscular Hemoglobin Concentration (MCHC) Concentration of hemoglobin in the RBCThe hemoglobin is divided by the RBCLowHypochromic (deficient of hemoglobin)Iron Deficiency AnemiaHighHyperchromicLab Error
17Blood Types Genetically determined Determined by the presence or absence of specific antigens on the outer surface of the RBCIn certain blood types, the antigens on the RBC are accompanied by antibodies in the plasma.
18Blood Types O – Good Donor, Bad Receiver Contains A and B antibodies at birthA- Very selective- receives A onlyContains B antibodies at birthB- Very selective- receives B onlyContains A antibodies at birthAB – Good Receiver, Bad DonorDoes not contain A or B antibodies
19Rh Factor Located on the surface of RBCs “positive” = have the factor “negative” = do not have the factorWhen an Rh- person has been exposed toRh+ blood, antibodies develop within 2 weeksNo reaction with this first exposure.
20Rh FactorOn any exposure thereafter, the Antibodies will attack Rh positive blood.“Rh incompatibility” = mother’s antibodies hemolyze the fetal RBCs rupture and loss of contents of cells
21Rh Factor RhoGAM – intramuscular (or IV) injection Action: desensitization antibodiesNext baby’s intrautero development without the potential complications associated with Rh incompatibilityWho (include blood type and Rh factor) will need to receive Rhogam?A women who is Rh Negative and is pregnant (prophylaxis) or has just given birth (baby is Rh positive)
22Rh Factor When is RhoGAM given? 2 injections 1. between 20-28wks pregnancy2. within 72 hrs. post partum
23Who’s the Best?Which blood type (including Rh factor) is the universal donor?O negativeWhich blood type is the universal recipient?AB positive
25LYMPHATIC SYSTEM A subdivision of the cardiovascular system Consists of:Lymph vesselsLymph fluidLymph tissueBasic Functions:Maintenance of fluid balanceProduction of lymphocytesAbsorption and transportation of lipids from intestine to bloodstream
26LYMPHATIC SYSTEMLymph is a specialized fluid formed in the tissue spaces and transported by way of lymphatic vessels to eventually reenter the circulatory system.Lymphatic TissueLymph nodesTonsilsSpleenThymus
27DISORDERS OF THE HEMATOLOGIC AND LYMPHATIC SYSTEMS
28Anemia Characterized by low RBC count, ↓ hematocrit and hemoglobin Look at CBC indices to determine RBC healthAnemia causes delivery of an insufficient supply of oxygen AND nutrients to the cellsLoss of the O2-carrying element in the blood results in a supply/demand imbalance in vital organs.
29Anemia Causes Hemorrhage Impaired production of RBC’s Increased destruction of RBC’s (hemolysis)Nutritional deficiencies
30Diagnostic Tests: Coombs’ Test Hemoglobin Electrophoresis Schilling SickledexTIBCGastric Analysis
31Coombs TestDirect Antiglobulin test – identifies autoantibodies against RBCsCoombs + = autoimmune hemolytic anemia, hemolytic disease of the newborn, lymphomas, LE, mycoplasma infection, and infectious mononucleosis
32General Signs and Symptoms of Anemia Big fiveDOEChest painPalpitations(Tachycardia)Dizziness (Vertigo)PallorAnorexiaDisorientationDyspepsiaFatigueHeadacheInsominia
33Hypovolemic ShockMay be caused by severe dehydration or extreme blood lossMay require 1000 mL loss before severe s/sInitial s/s:ThirstWeaknessRestlessnessLater s/sHypotensionTachycardia and weak, thready pulsePallor and cold, clammy skinOliguriaDisorientationProstration
34Hypovolemic Shock H&H will not decrease until ~6-8 hours Treatment If bleeding source obvious: direct pressureIf not, intervention ASAPIV fluids (Isotonic/Volume expanders: NS)O2O negative blood transfusionPlateletsPlasmaFactor 7
35Nursing Interventions Monitor blood and fluid restorationIdentify blood loss sites to control bleedingVS frequentlyI/O – particularly careful monitoring of urine outputPatient teaching
36Pernicious AnemiaCaused by autoimmune disease: There is an absence of glycoprotein intrinsic factor that is usually secreted by the stomach and assists with the absorption of Vitamin B12.Without this factor, Vitamin B12 is unavailable for the maturation of the Red Blood Cell Production.
37Signs and Symptoms Subjective Objective Palpitations Nausea Flatulence IndigestionSoreness and burning of the tongueTingling of the hands and feetImpaired proprioceptionObjectiveSmooth and erythematous tongueGum infectionMental disorientationPersonality changesBehavior problemsSevere neurological impair from destroyed Spinal Cord Tracts
38Diagnostic Tests Gastric Analysis – determine pH Schilling test Subject will get two doses of vitamin B-12 (cobalamin). The first dose is taken by mouth. The second dose is radioactive and is given as a shot 2-6 hours later. Urine is tested for radioactive B12Reveals malabsorption of Vit B12Serum Megaloblastic Anemia Profile (serum level of B12) soon to replace Schilling testWill reveal serum levels of Vit B12 + moreGastric Analysis – determine pH
39Medical Management Medication B 12 injectionsFolic acid supplementIron replacementTransfused with Packed RBC if severe anemiaCBC every 3-6 months
40Iron-deficiency Anemia Plenty of RBC, normal H &H sometimes, but hypochromicCausesDietUsually chronic bleedingBody’s demand exceeds its absorptionPregnancyInfantsYoung adolescentsMalabsorption of iron as in celiac disease or sprueSubtotal gastrectomy because iron needs an acid environment to be absorbed.
41Iron Deficiency Anemia Signs and SymptomsSore, Swollen TongueCracks in the side of the mouthBrittle nailsIncreased frequency of infectionsPICA- Ice, dirt, paint etc.Restless Leg Syndrome
42Iron Deficiency Anemia Medical ManagementBecause less than 10% of iron is absorbed in the duodenum, high doses of Iron supplement are neededAdditional Vitamin C has shown to enhance iron absorptionSee p. 277 Box 7-2 for food sources of nutrients needed for Erythropoiesis
43Z-trackBecause some patients cannot tolerate oral preparations of iron, Iron can be given IV or IM. The z-track method of giving iron dextran is preferred to prevent staining
44Sickle Cell Anemia EMcrit.org Genetic --Recessive homozygousPredominately found in the African and African-American PopulationFirst crisis usually occurs at weeks of agePathophysiology: After the hemoglobin molecules give up their oxygen, some of them may cluster together and form long, rod-like structures.
45Sickle Cell AnemiaA sickle cell is an abnormal, crescent-shaped RBC containing hemoglobin S (a defective hemoglobin molecule)Sickle Cell crisis – an episode of acute “sickling” of RBCs which causes occlusion and ischemia in distal blood vesselsSickling clumping or aggregation of these misshapen RBCs which lodge in small vessels
46Health maintenance for patients with sickle cell disease starts with early diagnosis, preferably in the newborn period and includes penicillin prophylaxis, vaccination against pneumococcus bacteria and folic acid supplementation.Pulmonary Hypertension
47Sickle Cell Maintenance Health maintenance for patients with sickle cell diseaseStarts with early diagnosis, preferably in the newborn periodVaccination against pneumococcus bacteria (infections are a major complication of Sickle-Cell anemia)Folic acid supplementationPrevention of infection and dehydration
48Medical Management Supportive Pain is biggest problem Rehydration PCA pump is indicatedLong-term MS therapy with breakthrough pain medsRehydrationPacked cells for anemia but clients have problems with iron overloadProbable treatment/cure is stem cell transplant
49Aplastic Anemia aka Hypoplastic Anemia Congenital Aplastic Anemia is caused by a chromosomal alterationAcquired Aplastic Anemia related to chemical exposures.Cause of 70% of acquired aplastic anemias remains unknown (idiopathic)
50Aplastic Anemia People are pancytopenic when: Reduced or absent red blood cellsReduced or absent white blood cellsReduced or absent platelets
51Aplastic Anemia Signs/Symptoms: Pallor Bleeding tendencies Dyspnea PalpitationsRepeated infection with high feversFatigue, weaknessGeneral malaise
52Diagnostic Tests Diagnostic tests Bone Marrow Aspiration Hypoplastic or aplastic fatty depositsCBC may show normocytic and normochromic blood cells
53Medical Management Need to know cause! Blood transfusion with caution (need to preserve immune system for bone marrow transplant)Spleenectomy if spleen is enlargedSteroids and/or androgens used to stimulate bone marrowImmunosuppressive therapy or cyclosporine
54Bone Marrow Transplant Involves taking cells that are normally found in the bone marrow (stem cells), filtering those cells, and giving them back either to the patient or to another person.The goal of BMT is to transfuse healthy bone marrow cells into a person after their own unhealthy bone marrow has been eliminated.Stem cells, when transplanted, find their way to the recipient's marrow and begin to differentiate and produce all types of blood cells that are needed by the body.
55Polycythemia Abnormal ↑ in RBC’s Two types Primary Secondary Myeloproliferative disease: overproduction by the bone marrowRelated to a Stem Cell abnormalityIncreased WBC, RBC and plateletsSecondaryUsually related to chronic hypoxia – a physiologic response to compensate for hypoxia Increased RBCChronic hypoxia maybe d/t: pulmonary disease, CV disease, high altitude, tissue hypoxia
56Polycythemia Vera Signs and Symptoms: ↑ blood volume and viscosity HTN, angina, HF, thrombophlebitisVenous distentionGI bleedingHepatomegaly and splenomegaly from organ engorgement
57Polycythemia Vera Diagnostic Tests: H and H (Plasma and RBC volume ↑) Reticulocyte and Erythrocyte countsPlatelets and RBC’sBone Marrow exam
59Polycythemia Vera Medical Management Repeated plebotomy Myelosuppressive agentsAllopurinol for goutTrue Chronic Disease requires lifetime treatmentPopulation can be non-compliant until very illDeath by thrombosis
61Agranulocytosis Severe reduction of Granulocytes Basophils Eosinophils NeutrophilsLow WBC count (leukopenia)Usually caused by medication and/or toxic substances(includes herbal substances!)
62Agranulocytosis Signs and Symptoms: Fever and chills Headache and fatigueInfectionsUlceration of the mucous membranesPneumonia and UTIs
63Medical Management Need to know the cause Transfusion of Packed RBC G-CSF (filgrastim or Neupogen)Neutropenic precautions (Reverse Isolation)Death by Infection
64Nursing Interventions A patient with a compromised WBC system is highly susceptible to life-threatening infections.List nursing interventions directed toward protecting the patient from potential sources of infection.
65Leukemia Malignancy involving the hematopoetic system. Characterized by rapidly developing white cells that overwhelm the bone marrow, lymph system, spleen and liverComplications include infiltration and damage to organs as well as the central nervous systemIncreased susceptibility to infections
66Leukemia Four Major Types: Acute lymphocytic leukemia (ALL) Acute Myelogenous leukemia (AML)Chronic Myelogenous leukemia (CML)Chronic Lymphocytic leukemia (CLL)
67Leukemia S/SX Irrelevant complaints at first Petechiae/Ecchymosis MalaiseFatigueIrritabilityPetechiae/EcchymosisMucous membrane bleedingBone painMeningial irritationEnlarged lymph nodes
68Leukemia Diagnostic Tests WBC ↓, ↑, or excessively ↑ Bone Marrow Bx. CXRLymph Node Bx.LP, CT scan
69Medical ManagementChemotherapy – interrupt cell growth at multiple points in the cell cycleBone marrow transplant and stem cell therapyDeath by infection, hemorrhage and/or Graft-Verses-Host Disease if BMT treatedMore to follow in Oncolgy Nursing
70Nursing Interventions Prevention of InfectionPatient educationPain ControlPsycho-social support for coping
72Disorders of Coagulation Release of blood from the vascular sys. results from:trauma or vessel damagevessel inadequacydisturbance of the function of platelets or clotting factors, or liver disease ( impairment of clotting mechanism)Disorders can be congenital, acquired, or 2nd to disease or medication toxicity
73Thrombocytopenia “Who Ate my Platelets?” Idiopathic Thrombocytopenia (auto-immune disease)Aplastic anemiaLeukemiaTumorsChemotherapyDrugsAlcoholInfections/Sepsis
74Thrombocytopenia Platelets < 150,000 (nml = 150,000-400,000/mmᶟ) S/SXPetechiae and eccymosis on the skinFrank BleedingLow Platelet count on CBCWith extremely low platelet counts, fatal central nervous system or gastrointestinal hemorrhage can occur
75Thrombocytopenia Management Corticosteroid therapy Splenectomy if neededIVIGImmunosuppresive drug therapyPlatelets to increase count to 20,000PlasmapheresisPlasmapheresis involves selective removal of the patient's plasma, which is then replaced by albumin solution.Time time needed to complete a treatment usually ranges from 1 1/2 - 3 hours.
76Hemophilia Disease of the royal family (don’t marry your cousin!) X-linked hereditary traitHemophilia
77Hemophilia Clinical Manifestations: Diagnostic Tests Internal or external hemorrhage with large ecchymoses into tissueHemarthrosis = bleeding into a jointSwelling, fever, painDiagnostic TestsBlood work for Factors VIII or IXabsent or deficient
78Medical ManagementReplacement therapy—giving or replacing the clotting factor that’s too low or missing.Most common: antihemophilic factor VIII is missingHemophilia B is missing factor IXCheck out the National Hemophilia Society website-www.hemophilia.org
79Hemophilia Crisis Usually involves trauma After an IM injectionUsually involves traumaIce and elevate above heartApply pressure to bleedingImmobilization of limbPain ManagementCan be treated with cryoprecipitate (FFP)Medic alert bracelet should be worn at all times
80HIV and Hemophilia Usually associated with infusions prior to 1984 Heat inactivation of the virus has significantly reduced the client’s exposure to HIV
81vonWillebrand’s Disease Mild form of HemophiliaS/SxSlow coagulation of blood (as opposed to none)Spontaneous GI BleedsEpistaxisGingival BleedingCommon occurrences: post partum, menorrhagia, post op
82vonWillebrand’s Disease Medical Management:Usually treated with Cyroprecipitate (containing Factor VIII)FibrinogenFresh plasmaDesmopressin (DDAVP): Synthetic ADH (vasopressin)
83Disseminated Intravascular Coagulation A disorder in which the proteins that control blood clotting become abnormally active Small blood clots form in blood vesselsPlasma clotting factors are depleted during widespread clotting within small vessels bleeding disorder and thrombosis.Primary disorder initiates a generalized intravascular clotting
85Medical Management Supportive in nature Heparin therapy to calm the hypercoagulopathyLab tests confirm dxSerum fibrinogen - low(PT) - high(PTT) - highPlatelets: depressedD-Dimer(fibrin breakdown): elevated
86Multiple MyelomaA malignant neoplastic immunodeficiency disease of the bone marrowNeoplastic plasma cells infiltrate the bone marrow destruction of osseous tissue, esp. flat bones pain, fractures, and skeletal deformities“Monoclonal Protein” – the specific immunoglobulin produced by the myeloma cells
87Disrupts erythrocyte, platelet and leukocyte production Electrolyte disturbance from release of Calcium and Phosphorus from deteriorating bone cellsGradual onset so it slips right by practitionersCould present itself as a spinal fracture with cord compression
88Signs and Symptoms Bone pain Fatigue Feeling ill Fever Night sweats Weight loss is not common in the early stages.
89Multiple MyelomaPhysically, patients are pale with diffuse bone tenderness, especially around the sternum (breastbone) and pelvis (hips).Pathologic fractures (fractures caused by tumors) occur frequently.The spine is the most common location for a pathological fracture. It can also happen in the ribs and pelvis.
90Diagnostics Radiographic skeletal studies Bone marrow aspiration Labs Pancytopenia (low cells)HypercalcemiaHyperuricemiaElevated creatinineUrinalysisHigh protein
91Multiple Myeloma Medical Management Supportive Radiation and chemotherapy to reduce or impede tumor growthHypercalcemia tx.Pain management
93Hodgkin’s Disease Enlargement of lymphoid tissue Affects men 2:1 Look! It’s Math!’m so happy!Enlargement of lymphoid tissueAffects men 2:1Bimodal peak (2 separate populations)Early 20-30Late 60-70Accounts for <1% of all cancer casesDifferentiated by Lymphocyte cytology, Reed-Sternberg cell
94Hodgkin’s LymphomaHodgkin's disease may occur in a single lymph node, a group of lymph nodes, or, sometimes, in other parts of the lymphatic system such as the bone marrow and spleen.This type of cancer tends to spread in a fairly orderly way from one group of lymph nodes to the next group.
95Hodgkin’s Lymphoma Risk factors associated with this disease: Age/Sex -- Hodgkin's disease occurs most often in people between 15 and 34 and in people over the age of 55. It is more common in men than in women.Family History -- Brothers and sisters of those with Hodgkin's disease have a higher-than-average chance of developing this disease.Viruses – Epstein-Barr virus is an infectious agent that may be associated with an increased chance of getting Hodgkin's disease.
96Hodgkin’s Lymphoma Signs/Symptoms A painless swelling in the lymph nodes in the neck, underarm, or groinUnexplained recurrent feversNight sweatsUnexplained weight lossItchy skin
97Hodgkin’s Lymphoma Diagnostic studies CBC: elevated WBCESRX-raysCTMRIPresence of Reed-SternbergcellReed-Sternberg cell: characterized by mirror image nuclei
98Medical Management Radiation against localized tumors Chemotherapy for early and late stagesCandidates for Neupogen because of suppressed neutrophil productionHigh risk for secondary malignancies especially leukemia
99Non-Hodgkins Lymphoma Absence of the Reed-Sternberg CellUsually described as “all other lymphomas”More likely to spread beyond the lymph nodesComprised of approximately 10 different subtypes and 20 different disease entitiesThese subtypes are grouped into 3 biologic states- low grade, intermediate grade, and high grade lymphomas
101Non-Hodgkins Lymphoma Diagnostic Tests:AnemiaIncreased plateletsLeukocytosis(increased and abnormal WBCs)ESR-elevatedHypercalcemia and elevated Alkaline PhosphatasePositive Coombs testChest XrayCT scan
102Non-Hodgkins Lymphoma Medical ManagementTherapy is determined by several factors:biologic state of the lymphomastage of lymphomapresence or absence of symptoms (e.g., weight loss, night sweats, organ dysfunction)overall general health of the patientChemo and radiation
103Non-Hodgkin’s Lymphoma Nursing InterventionsSupportive care during radiation and chemoObservation for complicationsPatient educationParticipate in care planning