1. Medical-Surgical Nursing: Concepts & Practice
3rd edition
Chapter 16
Care of Patients with Hematologic Disorders
Copyright © 2017, Elsevier Inc. All rights reserved.

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

3. Older Adult Care Points
There is about a 20% incidence of anemia among older adults, most often caused by poor nutrition.
Shock may develop with smaller blood loss in this group because of decreased vascular tone and impaired cardiac function.

4. Anemia Pathophysiology Signs and symptoms Diagnosis Treatment
Clinical Cues  
If your patient has had gastric bypass surgery or a gastrectomy, there is a risk of pernicious anemia because there will be a decrease of available intrinsic factor. Observe for signs of pernicious anemia in the patient.
Patients who take medications over a long period of time that suppress gastric acid secretion (histamine2 inhibitors, proton pump inhibitors) must be watched for signs of pernicious anemia. Supplementation with vitamin B12 injections or sublingual vitamin B12 may help avoid this problem.

6. Pathophysiology of Iron Deficiency Anemia
See Concept Map 16-1 on p. 344.

7. Signs and Symptoms of Severe Anemia
General
Eyes
Skin
Cardiovascular
Respiratory
Gastrointestinal
Musculoskeletal
Neurologic
See Table 16-2 on p. 345 for specific signs and symptoms within each body system.

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

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

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

11. Planning
Intervention is based on 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 activities of daily living and provide planned rest periods.

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

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

14. Pathophysiology of Pernicious Anemia
See Concept Map 16-2 on p

15. Aplastic Anemia Diagnosis Treatment Health promotion
Dangers of Toxic Agents
All nurses should promote public education about the dangers of toxic agents. It is vital that people read and follow the label instructions on all cleaning agents, insecticides, and chemical compounds.

16. Pathophysiology of Aplastic Anemia
See Concept Map 16-3 on p. 349.

17. Sickle Cell Disease Etiology Pathophysiology Signs and symptoms
Diagnosis
Treatment

18. Sickling of Red Blood Cells
See Figure 16-2 on p. 351.
From Ignatavicius DD, Workman ML: Medical-surgical nursing:
patient-centered collaborative care, ed. 7, Philadelphia, 2012,
Elsevier Saunders.

19. 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

20. Polycythemia Vera Cause Signs and symptoms Treatment
Phlebotomy, antineoplastic agents, and radiation therapy
Increased fluid intake
Aspirin

21. Leukemia Etiology Pathophysiology Signs and symptoms Diagnosis
Treatment

22. Older Adult Care Points
Patients older than the age of 65 years require reduced doses of chemotherapeutic drugs (to prevent toxicity) because they have decreased kidney and liver function, and the drugs are not metabolized as quickly as in younger people.

23. Causes of Clinical Signs of Leukemia
Severe infections
Symptoms of anemia
Enlarged spleen, liver, and lymph nodes
Weakness, pallor, and weight loss caused by an elevated metabolic rate
Renal pain, urinary stones and obstruction to flow of urine, and urinary tract infection
Headache, disorientation, and other central nervous system symptoms 
See Table 16-5 on p. 353.

24. Nursing Management Potential for infection Abnormal bleeding Anemia
Nutritional alteration with severe anorexia and weight loss
Increased levels of uric acid in the urine and blood (due to chemotherapy)
Psychosocial problems related to the effects of the disease as well as the prescribed treatment

25. Thrombocytopenia Causes Nursing care Prevention of bleeding
Close observation for signs of spontaneous bleeding and quick intervention
Invasive procedures only when essential
Avoid activities that might induce bleeding.

27. Safety Alert: Prevent Bleeding
For a patient with a low platelet count, whenever venipuncture is performed, an injection is administered, or an intravenous catheter or needle is discontinued, pressure over the site must be maintained for 10 minutes to prevent continuous oozing.

28. Ecchymoses of the Hand from Thrombocytopenia
See Figure 16-4 on p. 357.
From Lewis SL, Heitkemper MM, Dirksen SR, et al: Medical-surgical nursing: assessment and management of clinical problems, ed. 7, St. Louis, 2007, Mosby.

29. Multiple Myeloma Etiology and pathophysiology
Signs, symptoms, and diagnosis
Treatment

30. Nursing Management
Provide supportive care for the many complications of the disease and treatment.
Encourage adequate hydration with an intake of 3 to 5 L of fluid a day to minimize problems from hypercalcemia.
Assess and manage pain—acetaminophen and nonsteroidal anti-inflammatory drugs and narcotic analgesics.
Carefully move the patient because of the potential for fractures.

31. Assignment Considerations
When enlisting a nursing assistant to help with positioning, moving, or toileting the patient, remind the person that the patient is very prone to bruising, bleeding, or fractures as the case may be.
Do not assign ambulation of a patient with multiple myeloma to assistive personnel; any slight bump or twist of the body may cause a fracture.

32. Hemophilia Etiology Pathophysiology Signs and symptoms
Diagnosis and treatment

34. Safety Alert: Avoid Taking Aspirin
Aspirin must never be taken by patients with hemophilia because aspirin increases the bleeding problems.
Patients must read the labels on every over-the-counter preparation to be certain that drug products do not contain aspirin or acetylsalicylic acid.

35. Nursing Management Administer the necessary clotting factors.
Elevate the injured body part.
Apply cold packs.
Control pain.
Observe for further bleeding.
Provide psychological support for the patient and family.
Encourage genetic counseling for family members, if this counseling has not occurred previously.

36. Aspiration of the Knee to Relieve Hemarthrosis
See Figure 16-5 on p. 359.
From Roberts JR, Hedges JS: Clinical procedures in emergency medicine, ed. 5, Philadelphia, 2009, Saunders.

37. Disseminated Intravascular Coagulation
Etiology
Diagnosis
Treatment
Nursing management
Be alert to the possibility of DIC when a patient has predisposing conditions.
Early detection of external bleeding
Monitoring sensorium and vital signs for indications of internal bleeding

38. Management of Hematologic Disorders
Leukapheresis
Biologic response modifiers: colony-stimulating factor therapy
Bone marrow and stem cell transplantation

39. Legal and Ethical Considerations
The patient must have signed a consent form to receive a blood transfusion.
If the patient is unable to sign, the condition is life threatening, and no family member is reachable, the physician may make the decision to transfuse the patient.

40. Check the LPN/LVN Role
Some states have expanded their LPN practice act to include the administration of blood products.
Check your nurse practice act to see if that procedure is within legal practice in your state.

41. Older Adult Care Points
Vessels in older adults are fragile.
A 22-gauge cannula may be used for transfusion to older adults rather than an 18-gauge cannula.
Blood products should be transfused more slowly to allow the older person’s body time to adjust to the added fluid.
Careful assessment for fluid overload during and after the transfusion is essential. Signs of fluid overload are rapid bounding pulse, hypertension, and visibly swollen veins.

42. Signs and Symptoms of a Transfusion Reaction
Chills
Fever
Shortness of breath
Itching or rash
Apprehension
Sense of impending doom
Headache
Pain in the low back or chest
Tachycardia
Tachypnea
Hypotension
Hemoglobinuria (hemoglobin in the urine)
Shock

44. Cultural Considerations
Most people willing to donate bone marrow are white.
There is a 30% to 40% chance of a human leukocyte antigen (HLA) match for a white patient and donor marrow.

45. Cultural Considerations (Cont.)
Far fewer African Americans have signed up at the bone marrow registry, and the chance for an HLA match for an African American patient is less than 20%.
Efforts are being made to encourage African Americans to become bone marrow donors.

46. Acute Transfusion Reactions
Acute hemolytic reaction
Febrile, nonhemolytic reaction (most common)
Mild allergic reaction
Anaphylactic and severe allergic reaction
Circulatory overload
Sepsis
See Table 16-7 on p. 362.

47. Management of Hematologic Disorders
Oxygen therapy
Iron therapy
Vitamin B12 therapy
Splenectomy
Severe trauma to and rupture of the spleen
Splenomegaly caused by rapid destruction of blood cells
Splenomegaly from blood disorders, such as leukemia

48. Community Care Support groups
Home care: parenteral medications, including chemotherapy
Patient teaching
Coordination of care