Presentation on theme: "Hematologic Disorders & Nursing Priorities"— Presentation transcript:
1 Hematologic Disorders & Nursing Priorities Hematology-study of blood and blood forming tissues that includes bone marrow, blood, spleen and lymph systemKeith Rischer RN, MA, CEN
2 Objectives for TodayReview pathophysiology related to hematologic cells and blood forming tissuesInterpret significance of altered hematologic lab valuesReview commonly used medications that alter hematologic functionIdentify the patho, clinical manifestations, diagnostic tests, nursing priorities, and client education in clients with anemia, sickle cell anemia, leukemia, lymphomas, and multiple myeloma.Identify the nursing priorities with blood transfusion and the most common transfusion reactions.
3 Blood Cells Hematopoesis: Red bone marrow The blood forming tissue that produces the 3 major cell components of bloodErythrocytesLeukocytesThrombocytesHematopoesis-blood cell production within bone marrow-produces 100 billion new RBC dailyHOW MANY RBC’S IN DROP OF BLOOD? million in average lab tube 10 billion RBC6 liters of volume=6000cc=60,000 gtts= how many in body?....15,000,000,000,000hemopoietin, produced by the kidney, and is the hormone that regulates the red blood cell productionBone Marrow-soft material that fills central core of bonesRed marrow-actively produces blood cells and found in the flat irregular bones…femur, pelvic, sacrum, sternum, ribs, scapulaBone marrow is stimulated by erythropoetin that influences differentiation of the different blood componentsStem Cell- all components derived from this non-differentiated immature blood cell found in the red marrowWhy are renal failure patients prone to anemia???
4 Erythrocytes Function Normal Life span: 120 days Norms Transport of gases (O2 & CO2)ErythropoesisNormal Life span: 120 daysNormsHgb RBCWomen: g/dl mm3Men: n g/dl mm3HCTWomen: 38-47%Men: 40-54%In order for erythropoesis to occur need certain vital nutrients-IRON, FOLIC ACID, VIT B12 (cobalmin) B vitamins (B2,6)Regulated by cellular O2 requirements and stimulated by hypoxiaWhy do smokers have higher incidence of blood clotting that can contribute to MI or embolic CVA???RBC Comprised of heme (iron compound) and globin (simple protein)Small disc with a bi-concave shape optimal for gas diffusion and can change to a torpedo shape….can squeeze through capilaries that are 1/3 the size of a single RBCHGB is standard to assess adequacy of RBC production in patientHemolysis done in liver, bone marrow and spleen and causes release of….BILIRUBIN. If liver damaged/failure/cirrhosis…JAUNDICE
5 LeukocytesTypesGranulocytes (Also known as polymorphonuclear leukocytes)NeutrophilsEosinophilsBasophilsOne drop of Blood can contain from 7,000 to 25,000 white Blood cellsLeukocytes originate from stem cells within bone marrow5 different types…classified as either granulocytes or agranulocytes or by function as either phagocytes or immunocytes Granulocytes contain granules within the cytoplasm-granules contain enzymes capable of killing micro-organisms and ingested debris during phagocytosisPrimary function is phagocytosis-pacman cellsneutrophil - the first line of defense, 100 billion mature neutrophils are released into the body everyday.Neutrophil-The primary phagocytic cells involved in acute bacterial infection responses…migrate to bacterial invasion source and search and destroy bacterial invaders and then die in 1-2 daysmost common-50-70% of all WBC’s…if >70% consider infectionBands-immature neutrophils-present only with overwhelming sepsis-often referred to LEFT SHIFTEosinophils-2-4% Engulf antigen-antibody complexes formed during an allergic response; defend against parasitic infections.Elevated in allergic responsesBasophils: Cont. granules consisting of heparin, serotonin & histamine which are released during allergic & inflammatory reactions.Basophils-2% or less…function similar to mast cells and are elevated in inflammatory states
6 Leukocytes Normal Blood Count of all WBC: 4,000-11,000/ul Monocytes agranular)Lymphocytes B cells: mediate the humoral immune responseT cells: Mediate cellular immunityNormal Blood Count of all WBC: 4,000-11,000/ulElderly considerationsMonocytes-4-8% -are immature macrophages--Ingest bacteria, dead cells, tissue debris & old or defective RBC’s. When monocytes leave the blood and enter the liver, spleen and lymph nodes they differentiate into macrophages.Lymphocytes-20-40%...are the primary cells of the immune respone-transiently circulate and then reside in lymphoid tissue as mature T cells B cells will see elevated with viral infection as well as immune response>11,000 or <4000 consider infectionGranulocytes may live for hours…T lymphocytes may live for years
7 Thrombocytes (Platelets) Function:Aid in blood clottingMaintain capillary integrity by working as “plugs” to close any openings in the capillary wall.Normal Blood Count: 150, ,000 mm3First response to clotting cascade is platelet aggregation-work as a plug…WHY GIVE ASA W/CP or AMI???When inactivated are smooth but when activated become entangled
8 Anemia Mild Moderate Severe Hgb 10-14 g/dl Hgb 6-10 g/dl DEFINITION-reduction in the # of RBC, amt of HGB or HCTResult from dietary deficiencies, genetic disorders-bone marrow diseaseGi bleeding most commonMild- asymptomaticPhysical appearance:skin, mucous membranes, lips, nail beds and conjunctivae become paleMod-weakness, fatigue, palpitations, SOB, decreased tol to activity-orthostatic hypotensionThinner blood flows faster through CV system causing hyperdynamic circulatory state that results in increased stroke volume and HRSevere-decr. LOC,dizziness, CP, tachy, SOB…WHY…CO=SVxHR, tachypnea, hypotensive, pallorhypotension & Vasoconstriction diverts blood flow to kidneys activates renin-angiotensin responseWhat lab value will be elevated if kidneys take a hit???Impaired O2 supply to GI system can cause abd pain, N&VBecause RBC’s transport O2, anemias can lead to tissue hypoxia which accounts for many of the clinical manifestations of anemiaWhat are some signs/sx’s of tissue hypoxia?Hypoxia: confusion, SOB,skin pallor- and MM and nailbeds, dizziness, weakness, tachycardia, Decr Hgb and HCTLIFECYCLE CONSIDERATION_ elderly men lose 1 gm HGB because of decreased production of androgens---women do not have this problem
9 Anemia:Causes Macrocytic Pernicious Anemia (B12 deficiency) Folate deficiencyMicrocyticIron deficiency anemiaNormocyticBlood lossSickle cell anemiaNot a specific disease; rather a manifestation of a pathological process. Once identified, determine the cause.Fundamental common pathology is reduced oxygen carrying capacity of the blood resulting in tissue hypoxia
10 Macrocytic Anemia Megaloblastic Anemias: Presence of large RBC’s) Caused by defective DNA synthesisTwo common types:1. Cobalamin (vitamin B12 deficiency)Pernicious anemia =most common cause.2. Folic acid deficiencyPoor nutrition (Anorexia)malabsorption in small bowelETOHHemodialysisPATIENT EDUCATIONMegaloblastic Anemias -when DNA synthesis impaired-defective RBC maturation results… RBC’s are large, abnormal easily destroyed due to fragile membranesProduced by extra large stem cells that mature to unusually large erythrocytesHgb content is normal compared to normal RBCPernicious Anemia- refers to the history of this disease as highly destructive and fatalprotein called intrinsic factor is required for Vit B12 absorption-this is secreted by the parietal cells in the gastric mucousano intrinsic factor secreted due to antibodies directed against parietal cells and or intrinsic factorB12 essential for DNA synthesis of RBCThese defective erythrocytes die prematurely causing anemiaOther causes of cobalmin deficiency are gastrectomy, gastritis, ETOH abuse… and those on LT H2 blockers such as PepcidTakes years to become symptomaticEarly sx vague-but once Hgb decreases to 7-8 becomes symptomatic—weakness, fatigue etc.Will need Vit B12 injections for life—initially weekly then monthly…death as complication now due only to non-complianceFolic acid essential vitamin required for RNA/DNA synthesis in erythrocyteCan only be obtained through diet…400mcg/dayFOLIC ACID deficiency-Folic acid required for DNA synthesis to lead to RBC formationDialysis- folic acid lost during dialysisFoods high in folic acid or supplementation teachingLeafy green veges, liver, citrus fruits, beans, nuts and whole grains
11 Microcytic Anemia: Iron Deficiency Abnormal-small erythrocytes…decr. HgbMost common anemiaManifestationsPallorGlossitisfatigueDietary sourcesPatient educationMost common anemia in world30% worlds population have this problem….malnutrition. In US 5-10%Most susceptible-children, malnourished, women in reproductive years…WHY?Men need 10 mg daily…women 18mg…pregnant women 30mgPatho-daily blood loss of 2-4cc/daily enough to cause or inadequate dietary of ironBody is able to recycle majority of iron from destroyed RBC-blood loss destroys this balanceOnly 1 mg of every mg ingested is absorbed in duodenum…translates to 5-10 % absorptionIron-supplements if needed-l Ferrous Gluconate 325mg-65mg is elemental iron onlyNursing: Teach your patient about dietary sources of Fe, along with how to properly take Fe supplements.Requires acidic environment to promote absorption-therefore take on empty stomachTake with Vit C also enhance absorptionLifespan ConsiderationElderly – anemia is commonly unrecognized and/or untreated…mental confusion, memory loss, disorientation may be anemia relatedNursing Assessment - thorough history-taking, gathering subjective/objective dataFe supplements teaching….black stools…why? Constipation, take 1 hour before meals…why? Vit C in cooridination will increase absorptionPT EDUCATION-What ? Could be asked of any elderly pt. that would help identify possible undiagnosed anemia (check most recent CBC)Any change in level of activity or energy?Any SOB at rest or with exertion?Assess dietRisky patients-premenopausal-pregnat women, poverty, elderlyEducation- diet, meds and when to take, need to take iron for 2-3 months after hgb returns to normal to replenish storesPLAY GAME
12 Normocytic Anemia: Etiology Blood LossAcuteChronicExtrinsic (acquired) hemolytic anemias – (damage to RBCs due to external factors)Physical factorsAcute-what will change first in acute bleed…HR, BP or bothWhat are positive orthostatic BP findings?Body can compensate for low hgb if slow bleed or chronic anemiaTx-replace lost volume with crystaloid such as NS cc til responds with stabilization in VS. 2-4 liters not uncommon in emergency…what is the potential problem…can NS carry O2-definitive tx-get T&C and transfuse PRBC’s?Remember: Signs and symptoms are valuable indicators of blood loss. Rx: *Replace blood volume*Oxygen*ID source of hemorrhage*RBCs as neededChronic-Geriatric men-common to become anemic as they age.(hemorrhoids, heavy menses). Rx: ID source and stop bleeding, Fe supplements.UGI Bleed: black, tarry stools….Why?Damage due to exertion of extreme force on the RBC’sPhysical-dialysis, heart-lung bypass machine w/CABG, prosthetic heart valves…even seen with severe atherosclerosis (DM)
13 ED Case Study88 yr women w/dk tarry stools last 5 days. c/o weakness, nausea.Pale, cool-initial VS /30….2 hours later /49Wbc 9.8, hgb 6.9 (was weeks ago), hct 21.5, plt 176, INR 4.8 (was weeks ago)Nursing priorities
14 Sickle Cell Anemia Patho Sickle Cell Crisis Nsg Management Pain controlHydrationPatient EducationTx infectionPsychosocialSickle cell-inherited recessive genetic trait-results in abnormal form of hgb on the RBC that elongates and stiffens in response to low O2 levels…fatal most ofetn in mid adulthood due to renal and pulmonary failureA family of genetic disorders affecting African-Americans predominantly. Systemic: RBCs form a sickle shape=clog capillaries resulting in hypoxia of tissuesDominant in African Americans-1:400 births, Hispanic 1:Sickling episodes triggered by low oxygentension in the blood-caused by infection, stress, dehydration and high altitudes….sickled cells cannot pass easily through capillaries and cause micro vascular acclusion which leads to further hypoxia… can last for hours to daysAvg lifespanRBC 120 days-sickle days…leads to disposition to chronic anemia…hypoxia…sickle cell crisisSx-severe pain-high doses narcs-one ED pt received up to Dilaudid 16 mg IM in one visit-this is equal to almost 100mg Morphine!Concerns for drug seeking existSickle cell crisis-vasoocclusive crisis-impaired blood flow—cellular hypoxia—leads to thrombus development—furthur tissue ischemia—increased painPain in back, chest, abd and extremities most commonHeart failure, kidney failure due to increased blood viscosity and lack of O2, CVA common complications as well as infection susceptibility because spleen becomes unable to phagocytize foreign substances as it becomes infarcted and dysfunctional by the age of 2-4 yearsAre usually asymptomatic but are consistently anemicHow to assess African American??? Pallor of mucous membranesNursing Management -O2 to treat hypoxia…Pain control with large doses of Narcotics…IV hydration…Education –understanding of disease process, maintain fluid intake, treat any infection promptly, avoid high altitudes..psychosocial support due to chronic pain/depression refer as needed
15 Thrombocytopenia Reduction of platelets below normal range Normal = 150, ,000 mm3Etiology:Immune Thrombocytopenic Purpura (ITP)HeparinBone marrow suppressionCritical values50,000 or less- risk of bleeding<20,000 spontaneous life threatening hemorrhages (brain bleed)<10,000 transfusions recommendedMost cases are acquired by dz processes such as spleenmegaly, bone marrow suppression (chemo or infectious) or HEPARINImmune Thrombocytopenic Purpura (ITP): Abnormal destruction of circulating platelets by the spleen - caused by an autoimmune reaction –platelets coated with antibodies—spleen sees as foreign and destroyed—Normal life of platelets 8-10 days---ITP 1-3 daysHeparin induced thrombocytopenia -platelets decrease due to immune response to Heparin…Tx-stop heparin and use alternative anticoagulants such as argatroban or lepirudinAny pt on Heparin IV or subq routinely monitored for platelet decreases-watch closely!Bone marrow suppression-chemo most commonVery important #’s:50,000 or less- risk of bleeding<20,000 spontaneous life threatening hemorrhages (brain bleed)<10,000 transfusions recommended
16 Clinical Manifestations PetechiaePurpuraEcchymosisBleedingPurpura (Reddish skin bruise)Ecchymosis (Flat, raised, occ. painful)Prolonged bleeding and internal bleeding*Bleeding can be insidious or acute; external or internal – What are some general symptoms the nurse would be monitoring for?VS changes with routine VS to watch for….what will you look for? Why?Don’t forget neuro changes-decreased LOC, confusion, dizziness
17 Nursing Management If acute care-Peripheral IV established No ASA products for pain controlPrevent/control acute bleedingPlatelet transfusions-assess for reactionSteroids-pt. teachingEducation-signs of bleedingNsg care-make sure has at least 20 gu.-preferably 18 guage available and in place. Assess patency IV….what will you assess each shift?Why no ASA?Steroid education?...take with food-immunosuppressive-watch closely for signs of infection and avoid those with known infection…must be tapered and not suddenly stopped or can cause life threatening adrenal crisis (anorexia, nausea, weakness, SOB)What will you teach how to know if internal bleeding-this is also same teaching you will do with Coumadin
18 Blood Product Administration Minimum 22 g.(blue hub) IV-prefer 20g.(pink) or 18g. (green)Blood tubing with filter-use NS to prime/flushValidate pt., type of blood product, expiration date, blood tag #VS before, 15” after initiation, end of eachInfuse PRBC’s over 2 hours (appx 300cc/unit)Refer to p.73190% hemolytic transfusion reactions-worst life threatening due to giving blood product to wrong ptAsses closely first 15-30” infuse at rate no more than 125cc/hrTransfusion reaction—… …People older than 65 use 43% of all donated Blood. The demand for Blood and Blood products will increase as the population ages. 25% of all Blood products are used to treat cancer patients. One out of every ten people entering a hospital requires Blood. The average liver transplant patient needs 40 units of red Blood cells, 30 units of platelets, 20 bags of Cryoprecipitate, and 25 units of fresh frozen plasma. heart surgery uses, on average, the red Blood cells and platelets provided by from six Blood unit donations. People who have been in car accidents and suffered massive Blood loss can need transfusions of 50 units or more of red Blood cells. The average bone marrow transplant requires the platelets from about 120 donations, and the red Blood cells from about 20 Blood unit donations.
19 Complications Blood Products Circulatory OverloadAcute Hemolytic ReactionChills, fever, flushing, tachycardia, SOB, hypotension, acute renal failure, shock, cardiac arrest, deathFebrile-Nonhemolytic ReactionSudden onset of chills, fever, temp elevation >1 degree C. headache, anxietyMild Allergic ReactionFlushing, urticaria, hivesWho is at risk?...how can you minimize this potential problem?Hemolytic-due to incompatible blood-antibodies of pt. attaching to incompatible antibodies of unitFebrile-most common-due to sensitization to donor WBC’s, platelets or plasma proteinsMild allergic due to sensitivity to plasma proteins
20 Nursing Responsibilities STOP transfusionMaintain IV site-disconnect from IV and flush with NSNotify blood bank/MDRecheck IDMonitor VSTreat sx per MD ordersSave bag and tubing-send to blood bank