Chapters 32-34 Hematologic System Part 1 Med-Surg II

Components of Blood See Figure 16-1 on p. 332.

Products of Erythropoiesis See Figure 16-2 on p. 333.

Factors that May Alter Function of the Hematologic System Genetic disorders Hemorrhage (anemia) Anemia Hemolysis (breakdown of red blood cells) Bone marrow suppression Bone marrow proliferation or abnormality See Box 16-1 on p. 335.

Genetic Hematologic Tendencies African Americans have the highest incidence of sickle cell disease Pernicious anemia is more prevalent among those of Scandinavian descent People of Middle Eastern origin may have a genetic predisposition to thalassemia (a blood disorder passed down through families in which the body makes an abnormal form of hemoglobin resulting in excessive destruction of red blood cells, which leads to anemia.

Preventing Blood Disorders Caution the public about the dangers of exposure to ionizing radiation and harmful chemicals Suggest genetic counseling to those adults who have such a genetic disorder Inform patients about medications that can cause blood disorders and to be alert for signs of excessive bruising or easy bleeding Suggest that CBCs be checked periodically

Clinical Cues Increased numbers of eosinophils often indicate allergy A viral infection prompts the production of additional lymphocytes Bacterial infection stimulates the production of neutrophils, and segmented neutrophils increase

Clinical Cues (cont.) Ongoing bacterial infections cause immature neutrophils to appear in the blood as bands (immature forms of segmented granulocytes) This is referred to as a “shift to the left” A “shift to the right” occurs when there are more mature neutrophils than usual; this occurs with anemia from vitamin B12 or folic acid deficiency

Assessment (Data Collection) Head and neck Color of conjunctiva and sclera of eye Condition of gums and oral mucous membranes; condition of tongue Presence of enlarged cervical lymph nodes

Assessment (Data Collection) (cont.) Skin Color (pale) (check conjunctivae, palms of hands, and roof of the mouth in people with dark skin) Condition of fingernails (brittle, spoon-shaped) Presence of ecchymoses or petechiae Jaundice Nasal or gingival bleeding Hair (dry, brittle, thinning)

Assessment (Data Collection) (cont.) Chest and abdomen Presence of swollen lymph nodes in armpits or groin Rapid respirations; shortness of breath upon exertion Rapid pulse rate at rest Widened pulse pressure (greater distance between systolic and diastolic pressure) Epigastric tenderness Abdominal distention

Assessment (Data Collection) (cont.) Extremities Presence of swollen or painful joints Different lengths of fingers and toes Urine and stool Signs of blood

Nursing Goals Prevent infection Conserve patient’s energy and prevent undue fatigue Correct nutritional deficiencies Provide treatment to halt or slow disease process Control pain or discomfort

Implementation Handle patients with blood dyscrasias gently to prevent bruising and hematomas Take care to apply pressure for 5 to 10 minutes after injections or venipuncture Good skin care is essential, as the skin acts as a protective barrier against infection

Implementation (cont.) Teach about nutrition and medication administration, prevention of infection, and measures to prevent bleeding Pain control is important for the patient with sickle cell anemia in crisis, the hemophiliac with hemarthrosis, and for the advanced leukemia patient

Evaluation Monitor laboratory values for blood counts and determine whether counts are improving to determine if treatment and nursing actions are meeting the patient’s needs Assess for side effects and evaluate how the patient is tolerating the medication or other treatment for the underlying disorder

Evaluation (cont.) Evaluate how closely the patient is following the prescribed treatment plan Determine whether the treatment is effective, and if it is not effective, consult the physician about changing the plan

Evaluation (cont.) When a patient with leukemia is undergoing chemotherapy, evaluate the blood count results to determine that safe levels of leukocytes and platelets are present before administering another dose of a drug that inhibits their production

Common Problems Related to Hematologic System Disorders Excessive bleeding Fatigue Anorexia Pain Infection Bone marrow failure

Anemia Etiology Anemia resulting from blood loss Anemia resulting from a failure in blood cell production Anemia associated with an excessive destruction of red cells

Elder Care Points There is about a 20% incidence of anemia among the elderly, most often due to poor nutrition Shock may develop with smaller blood loss in this group because of decreased vascular tone and impaired cardiac function

Pathophysiology of Iron Deficiency Anemia See Concept Map 17-1 on p. 347.

Signs and Symptoms of Severe Anemia Pale skin Shortness of breath Fast heartbeat Dizziness Headache Chest pain Cognitive problems Coldness or numbness in the extremities Loss of appetite Impaired memory See Table 17-2 on p. 348 for specific signs and symptoms within each body system.

Pallor From Anemia

Nursing Management of Anemia Focused assessment Health history Physical assessment Pertinent laboratory values

Expected Outcomes Within 1 month, patient will be able to perform hygiene, dressing, and grooming activities without needing to rest between activities Within 2 months, patient will be able to carry out usual daily activities without shortness of breath or fatigue

Expected Outcomes (cont.) Patient will eat three nutritious meals daily containing sufficient iron, folic acid, vitamin C, and protein Patient will verbalize understanding of dietary and medication regimen within 1 week

Planning Intervention is based upon an understanding of the particular kind of anemia affecting the patient For patients with anemias that interfere with clotting and that tend to cause bleeding episodes, nursing actions are directed toward preventing the episodes For patients with anemia severe enough to cause fatigue, assist with daily living activities and provide planned rest periods

Implementation Nursing functions include Administering blood, iron, vitamin B12, and folic acid Monitoring for desired effects Educating patients about needed dietary adjustments

Elder Care Points Iron supplements should be taken 1 hour before or 2 hours after a meal, as long as they don’t cause GI distress Many elderly people have chronic conditions that require daily medication. Antacids and many other drugs interfere with iron absorption Check all drugs a patient is receiving, in order to determine whether drug interactions might interfere with iron absorption

Pathophysiology of Pernicious Anemia See Concept Map 17-2 on p. 348.

Aplastic Anemia a condition where bone marrow does not produce sufficient new cells to replenish RBC’s Dangers of Toxic Agents All nurses should promote public education about the dangers of toxic agents. It is vitally important that people read and follow the label instructions on all cleaning agents, insecticides, and chemical compounds.

Pathophysiology of Aplastic Anemia See Concept Map 17-3 on p. 352.

Sickle Cell Disease Sickle cell anemia is a disease passed down through families in which red blood cells form an abnormal sickle or crescent shape. Red blood cells carry oxygen to the body and are normally shaped like a disc.

Sickling of Red Blood Cells See Figure 17-2 on p. 353.

Nursing Management Patient teaching Adequate pain relief Avoid high altitudes, vigorous exercise, and iced liquids Maintain adequate fluid intake Refrain from smoking Treat infections promptly Adequate rest Adequate pain relief Monitor intake and output Oxygen therapy

Chronic Skin Ulcers of Sickle Cell

Polycythemia Vera A bone marrow disease that leads to an abnormal increase in the number of blood cells (primarily red blood cells). S/S Dyspnea when lying down, dizziness, excessive bleeding, HA

Polycythemia Vera The goal of treatment is to reduce the thickness of the blood and prevent bleeding and clotting. A method called phlebotomy is used to decrease blood thickness. One unit of blood (about 1 pint) is removed weekly until the hematocrit level is less than 45 (males) or 42 (females). Then therapy is continued as needed. Occasionally, chemotherapy may be given to reduce the number of red blood cells made by the bone marrow. Some patients are advised to take ASA to reduce the risk of blood clots, though it increases the risk for stomach bleeding. Ultraviolet-B light therapy can reduce the severe itching some patients experience.

Leukemia a type of blood cancer that begins in the bone marrow Leukemia leads to an uncontrolled increase in the number of white blood cells. The cancerous cells prevent healthy red cells, platelets, and mature white cells (leukocytes) from being made. Life-threatening symptoms may then develop. The cancer cells spread to the bloodstream and lymph nodes. They can also travel to the brain and spinal cord (the central nervous system) and other parts of the body.

Leukemia Leukemias are divided into two major types: Acute (which progresses quickly) Chronic (which progresses more slowly)

Acute Myeloid Leukemia (AML) Defect in stem cell that differentiate into all myeloid cells: monocytes, granulocytes, erythrocytes, and platelets Most common nonlymphocytic leukemia Affects all ages with peak incidence at age 60 years Prognosis is variable Manifestations: fever and infection, weakness and fatigue, bleeding tendencies, pain from enlarged liver or spleen, hyperplasia of gums, bone pain Treatment aggressive chemotherapy—induction therapy, BMT or PBSCT (Stem Cell)

Additional Symptoms

Leukemic Infiltrates