1. Chapter 33 Assessment and Management of Patients With Hematologic Disorders

2. Question
Is the following statement True or False? Hematopoiesis is the complex process of the formation and maturation of blood cells.

3. Answer
True Hematopoiesis is the complex process of the formation and maturation of blood cells.

4. Hematologic System
The blood and the blood forming sites, including the bone marrow and the reticuloendothelial system
Blood
Plasma
Blood cells
Hematopoiesis

5. Blood Cells* Erythrocyte—RBC Leukocyte—WBC Neutrophil Monocyte
Eosinophil
Basophil
Lymphocyte—T lymphocyte and B lymphocyte
Thrombocyte—platelet

6. Hematopoiesis

7. Hemostasis
Refer to fig. 33-3

8. Question What type of anemia results from red blood cell destruction?
Bleeding
Hemolytic
Hypoproliferative
None of the above

9. Answer
B. Bleeding results from red blood loss. Hemolytic anemia results from red blood cell destruction. Hypoproliferative anemia results from defective red blood cell production.

10. Anemias*
Lower than normal hemoglobin and fewer than normal circulating erythrocytes. A sign of an underlying disorder
Hypoproliferative: defect in production of RBCs
Due to iron, vitamin B12, or folate deficiency, decreased erythropoietin production, cancer
Hemolytic: excess destruction of RBCs
Due to altered erythropoiesis, or other causes such as hypersplenism, drug-induced or autoimmune processes, mechanical heart valves
May also be due to blood loss

11. Manifestations
Depend upon the rapidity of the development of the anemia, duration of the anemia, metabolic requirements of the patient, concurrent problems, and concomitant features
Fatigue, weakness, malaise
Pallor or jaundice
Cardiac and respiratory symptoms
Tongue changes
Nail changes
Angular cheilosis
Pica

12. Medical Management Correct or control the cause
Transfusion of packed RBCs
Treatment specific to the type of anemia
Dietary therapy
Iron or vitamin supplementation—iron, folate, B12
Transfusions
Immunosuppressive therapy
Other

13. Nursing Process: The Care of the Patient with Anemia—Assessment
Health history and physical exam
Laboratory data
Presence of symptoms and impact of those symptoms on patient’s life; fatigue, weakness, malaise, pain
Nutritional assessment
Medications
Cardiac and GI assessment
Blood loss—menses, potential GI loss
Neurologic assessment

14. Nursing Process: The Care of the Patient with Anemia—Diagnoses
Fatigue
Altered nutrition
Altered tissue perfusion
Noncompliance with prescribed therapy

15. Collaborative Problems/Potential Complications
Heart failure
Angina
Paresthesias
Confusion

16. Nursing Process: The Care of the Patient with Anemia—Planning
Major goals include decreased fatigue, attainment or maintenance of adequate nutrition, maintenance of adequate tissue perfusion, compliance with prescribed therapy, and absence of complications.

17. Interventions Balance physical activity, exercise, and rest.
Maintain adequate nutrition.
Patient education to promote compliance with medications and nutrition.
Monitor VS and pulse oximetry, provide supplemental oxygen as needed.
Monitor for potential complications.

18. Leukemia**
Hematopoietic malignancy with unregulated proliferation of leukocytes
Types:
Acute myeloid leukemia (most common, non- lymphocytic anemia)
Chronic myeloid leukemia
Acute lymphocytic leukemia
Chronic lymphocytic leukemia

19. Nursing Process: The Care of the Patient with Leukemia—Assessment
Health history
Assess symptoms of leukemia, and for complications of anemia, infection, and bleeding
Weakness and fatigue
Laboratory tests
Leukocyte count, ANC, hematocrit, platelets, electrolytes, culture reports

20. Nursing Process: The Care of the Patient with Leukemia—Diagnoses
Risk for bleeding
Risk for impaired skin integrity
Impaired gas exchange
Impaired mucous membrane
Imbalanced nutrition
Acute pain
Hyperthermia
Fatigue and activity intolerance
Impaired physical mobility

21. Nursing Process: The Care of the Patient with Leukemia—Diagnoses
Risk for excess fluid volume
Diarrhea
Risk for deficient fluid volume
Self-care deficit
Anxiety
Disturbed body image
Potential for spiritual distress
Grieving diagnoses
Deficient knowledge

22. Collaborative Problems/Potential Complications
Infection
Bleeding
Renal dysfunction
Tumor lysis syndrome
Nutritional depletion
Mucositis
Depression

23. Interventions Interventions related to risk of infection and bleeding
Mucositis
Frequent, gentle oral hygiene
Soft toothbrush, or if counts are low, sponge-tipped applicators
Rinse only with NS, NS and baking soda, or prescribed solutions
Perineal and rectal care

24. Improving Nutrition Oral care before and after meals
Administer analgesics before meals
Appropriate treatment of nausea
Small, frequent feedings
Soft foods that are moderate in temperature
Low-microbial diet
Nutritional supplements

25. Lymphoma Neoplasm of lymph origin Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma

26. Non-Hodgkin's Lymphoma
Hodgkin’s Disease
Non-Hodgkin's Lymphoma
Lymphoid tissues become infiltrated with malignant cells, spread is unpredictable and localized disease is rare.
Incidence increases with age, with average age being 50 to 60.
Prognosis varies with type of NHL.
Treatment is determined by type and stage of disease, and may include interferon, chemotherapy, and/or radiation therapy.
Unicentric origin
Reed–Sternberg cells
Suspected viral etiology, familial pattern, incidence early 20s and again after age 50
Excellent cure rate with treatment
Manifestations: painless lymph node enlargement, pruritis; B symptoms: fever, sweats, weight loss
Treatment is determined by stage of the disease and may include chemotherapy and/or radiation therapy

27. Question
What should any elderly patient be evaluated for whose chief complaint is back pain and has an elevated total protein level?
Anemia
Leukemia
Multiple myeloma
Non-Hodgkin’s lymphoma

28. Answer
C Any elderly patient whose chief complaint is back pain and has an elevated total protein level should be evaluated for possible myeloma.

29. Bleeding Disorders Primary thrombocythemia Thrombocytopenia
Idiopathic thrombocytopenia purpura (ITP)
Hemophilia
Acquired coagulation disorders: liver disease, anticoagulants, vitamin K deficiency
Disseminated intravascular coagulation (DIC)
Bleeding precautions

30. Question
Is the following statement True or False? Disseminated intravascular coagulation is not a disease but a sign of an underlying condition.

31. Answer
True Disseminated intravascular coagulation is not a disease but a sign of an underlying condition.

32. DIC *** Not a disease but a sign of an underlying disorder.
Severity is variable; may be life-threatening.
Triggers may include sepsis, trauma, shock cancer abrupto placenta, toxins, and allergic reactions.
Altered hemostasis mechanism causes massive clotting in microcirculation. As clotting factors are consumed, bleeding occurs. Symptoms are related to tissue ischemia and bleeding.
Laboratory tests.
Treatment: treat underlying cause, correct tissue ischemia, replace fluids and electrolytes, maintain blood pressure, replace coagulation factors, use heparin.

33. Nursing Process: The Care of the Patient with DIC—Assessment
Be aware of patient who are at risk for DIC and assess for signs and symptoms of the condition.
Assess for signs and symptoms and progression of thrombi and bleeding.

34. Nursing Process: The Care of the Patient with DIC—Diagnoses
Risk for fluid volume deficient
Risk for impaired skin integrity
Risk for imbalanced fluid volume
Ineffective tissue perfusion
Death anxiety

35. Collaborative Problems/Potential Complications
Renal failure
Gangrene
Pulmonary embolism or hemorrhage
Acute respiratory distress syndrome
Stroke

36. Nursing Process: The Care of the Patient with DIC—Planning
Major goals may include maintenance of hemodynamic status, maintenance of intact skin and oral mucosa, maintenance of fluid balance, maintenance of tissue perfusion, enhanced coping, and absence of complications.

37. Interventions
Assessment and interventions should target potential sites of organ damage.
Monitor and assess carefully
Avoid trauma and procedures which increase risk of bleeding, including activities which would increase intracranial pressure.

38. Therapies for Blood Disorders
Anticoagulant therapy
Splenectomy
Therapeutic apheresis
Therapeutic phlebotomy
Blood component therapy

39. Blood Transfusion Administration**
Review patient history including history of transfusions and transfusion reactions; note concurrent health problems and obtain baseline assessment and VS
Perform patient teaching and obtain consent
Equipment: IV (20-gauge or greater for PRBCs) and appropriate tubing, normal saline solution
Procedure to identify patient and blood product
Monitoring of patient and VS
Post procedure care
Nursing management of adverse reactions

40. Blood Administration Videos
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41. Complications Febrile nonhemolytic reaction Acute hemolytic reaction
Allergic reaction
Circulatory overload
Bacterial contamination
Transfusion related acute lung injury
Delayed hemolytic reaction
Disease acquisition
Complications of long-term transfusion therapy