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

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

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

4. 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.

5. 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.

6. 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

7. 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

8. 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

9. 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

10. 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)

11. 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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

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

20. 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

21. 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

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

23. 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.

24. Pallor From Anemia

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

26. 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

27. 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

28. 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

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

30. 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

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

32. 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.

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

34. 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.

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

36. 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

37. Chronic Skin Ulcers of Sickle Cell

38. 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

39. 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.

40. 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.

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

42. 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)

43. Additional Symptoms

44. Leukemic Infiltrates