Hematologic Problems Klecka, Spring 2016.

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Presentation transcript:

Hematologic Problems Klecka, Spring 2016

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

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

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: 12-16 g/dl Male: 13-17 g/dl

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

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

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.

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

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.

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)

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

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

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

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.

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.

Other Red Blood Cell Disorders

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.

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.

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.

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)