Chapter 30: Hematologic System

What are the ranges for normal, abnormal, and severe Neutrophil counts?

Normal: 2200-7700 cells/uL Abnormal: <1,000 cells/uL Severe: <500 cells/uL

How do you calculate ANC?

ANC= Total WBC X Percentage of Neutrophils

This is the most commonly acquired thrombocytopenia, where the spleen recognizes antibody covered platelets as foreign.

ITP

Discuss the Diagnostic studies used to identify TTP:

-The diagnosis of TTP is a presumed diagnosis by HCP -Identifying the pentad of clinical manifestations -ADAMTS13 testing may not always diagnose -LDH levels increase -altered RBC morphology: *Spherocytes (completely hemoglobinated RBCs) *Schistocytes (fragment cells) *Pronounced reticulocytes = TTP Dx slicing of RBCs

What diagnostic studies are used to identify Neutropenia?

1. ANC 2. WBC count 3. Bone marrow aspiration/biopsy 4. Peripheral Blood Smear (to assess for immature/banded WBCs) 5. H&H, Reticulocyte count, and platelet counts 6. CXR 7. Cultures: sputum, nose throat, blood, urine, stool and obvious lesions

After a nurse discontinues the heparin therapy in a patient diagnosed with HIT, what other therapies may the nurse implement?

1. Direct Thrombin Inhibitors (Refludan) and Indirect Thrombin Inhibitors- to maintain anti-coagulation 2. Warfarin (Coumadin) once platelet counts are at 150,000 3. Plasmapheresis- if severe clotting is occurring 4. Protamine sulfate- to interrupt circulating heparin 5. Thrombolytic agents (clot busting/ tPA) or surgery- to remove clots

What is the inter-professional care for a patient diagnosed with TTP?

1. Identify and treat the cause of TTP (e.g. infection) 2. Plasmapheresis- reduces vWf 3. Corticosteroids 4. Rituximab- decreases level of inhibitory ADAMTS13 IgG antibodies 5. Immunosuppressants 6. Splenectomy if refractory to plasma exchange or immunosuppressants

If the nurse cannot avoid giving a subcutaneous injection to a patient with thrombocytopenia, how long must the nurse hold pressure to the injection site?

10-15 minutes

A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1 mL equals 10 drops. How many drops will the nurse infuse?

21 gtt/min 20.8 > 21 drops

HIT patients develop thrombocytopenia _____ days after heparin therapy.

5-10 days

An ANC of ______ is indicative of Neutropenia?

<1,000 cells/microL

TTP is caused by the deficient supply of the enzyme ______. _________ breaks down the clotting factor, vWf. Without _______ there is an accumulation of vWf on the platelets causing them to aggregate.

ADAMTS13

A patient with neutropenia has just been admitted to the floor. As the nurse, which actions will you implement, select all that apply. A. Place immunocompromised patient in a room with patient diagnosed with infectious disease B. Private, HEPA filtered room C. Place patient on neutropenic precautions D. Strict handwashing by visitors and staff E. Use prophylactic antibiotics/antifungals and stool softeners F. Bed rest and limited activities to promote health G. Advise the patient eat fruits and vegetables that are thoroughly washed and cooked H. Discharge education to include avoiding cleaning pet excrement and gardening

B, C, D, E, G, H

The nurse notes a physician's order written at 10:00 AM for two units of packed red blood cells to be administered to a patient who is anemic as a result of chronic blood loss. If the transfusion is picked up at 11:30 AM, the nurse should plan to hang the unit no later than what time? A.11:45 AM B. 12:00 noon C. 12:30 PM D. 3:30 PM

B. 12:00 noon Rationale: The nurse must hang the unit of packed red blood cells within 30 minutes of signing them out from the blood bank.

The nurse is taking report for a neutropenic patient who has a fever of >100.4 F and ANC of <500. What are the first actions the nurse must do?

Blood cultures must be drawn from 2 sites STAT and IV antibiotics started within 1 hour. (e.g. 1 peripheral site and 1 central line)

When preparing to administer an ordered blood transfusion, which IV solution does the nurse use when priming the blood tubing? A. Lactated Ringer's B. 5% dextrose in water C. 0.9% sodium chloride D. 0.45% sodium chloride

C. 0.9% sodium chloride

The nurse is assigned to care for several patients on a medical unit. Which patient should the nurse check on first? A. A 60-yr-old patient with a blood pressure of 92/64 mm Hg and hemoglobin of 9.8 g/dL B. A 50-yr-old patient with a respiratory rate of 26 breaths/minute and an elevated D-dimer C. A 40-yr-old patient with a temperature of 100.8 F (38.2 C) and a neutrophil count of 256/µL Correct D. A 30-yr-old patient with a pulse of 112 beats/min and a white blood cell count of 14,000/µL

C. A 40-yr-old patient with a temperature of 100.8 F (38.2 C) and a neutrophil count of 256/µL Rationale: A low-grade fever greater than 100.4°F (38°C) in a patient with a neutrophil count below 500/µL is a medical emergency and may indicate an infection. An infection in a neutropenic patient could lead to septic shock and possible death if not treated immediately.

What are some clinical manifestations and complications of HIT?

Clinical manifestations may include vascular infarcts that result in skin necrosis, stroke and end organ damage (kidneys). Symptoms of bleeding are rare (plt. count rarely drops below 20,000). Major complications of HIT are venous and arterial thromboses (e.g. DVT and PE).

What are some clinical manifestations of thrombocytopenia?

Many patients may be asymptomatic, but the most common symptom is mucosal or cutaneous bleeding. Others may include: - epitaxis, gingival bleeding - large bullous hemorrhages on buccal mucosa -petechiae, purpura, ecchymoses - tenderness -prolonged bleeding post IM -weakness, fainting, dizziness, tachycardia, abdominal pain, hypotension

A patient comes into the ER complaining of night sweats, a cough and sore throat. Upon examination, the nurse notes that the patient has ulcerative lesions on the buccal mucosa and crackle sounds in lungs bilaterally. These are clinical manifestations of:

Neutropenia

Which lab test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? A. Platelet count B. Reticulocyte count C. Total lymphocyte count D. Absolute Neutrophil count

D. Absolute Neutrophil count Rationale: Filgrastim increases the neutrophil count and function in neutropenic patients.

Which lab result will the nurse expect to show a decreased value if a patient develops HIT? A. Prothrombin time B. Erythrocyte count C. Fibrinogen degradation products D. Activated partial thromboplastin time (aPTT)

D. Activated partial thromboplastin time (aPTT) Rationale: Platelet aggregation in HIT causes neutralization of heparin, so the aPTT time will be shorter, and more heparin will be needed to maintain therapeutic levels. The other data will not be affected.

A patient with leukemia is admitted for severe hypovolemia after prolonged diarrhea has a platelet count of 43,000/µL. It is most important for the nurse to take which action? A. Insert two 18-gauge IV catheters. B. Administer prescribed enoxaparin. C. Monitor the patient's temperature every 2 hours. D. Check stools for presence of frank or occult blood.

D. Check stools for presence of frank or occult blood. Rationale: A platelet count below 150,000/µL indicates thrombocytopenia. Prolonged bleeding from trauma or injury does not usually occur until the platelet counts are below 50,000/µL. Bleeding precautions (e.g., check all secretions for frank and occult blood) are indicated for patients with thrombocytopenia. Injections (including IVs) should be avoided; however, when needed for critical fluids and medications, IV access should be provided through the smallest bore devices that are feasible. Enoxaparin, an anticoagulant administered subcutaneously, is contraindicated in patients with thrombocytopenia. Monitoring temperature would be indicated in a patient with leukopenia.

A patient in the ER complains of back pain and difficulty breathing 15 minutes after a transfusion of PRBC's is started. The nurse's first action should be to: A. Administer oxygen therapy at a high flow rate B. Obtain a urine specimen to send to the lab C. Notify the HCP about the symptoms D. Disconnect the transfusion and infuse normal saline

D. Disconnect the transfusion and infuse normal saline Rationale: Patient's symptoms indicate acute hemolytic reaction caused by transfusion. First action is to disconnect the transfusion

What is the treatment temporarily used for TTP until the patient can receive plasmapheresis?

Fresh frozen plasma

Diagnostic study specifically for HIT:

PF4 heparin complex assay - Suspected HIT if platelets fall more than 50% or below 150,000

This treatment is contraindicated in patients with TTP:

Platelet transfusions

What is the gold standard treatment for TTP?

Therapeutic plasma exchange (plasmapheresis)

The nurse is caring for a patient who is to receive a transfusion of two units of packed red blood cells. After obtaining the first unit from the blood bank, the nurse would ask which health team member in the nurses' station to assist in checking the unit before administration? A. Unit secretary B. A physician's assistant C. Another registered nurse D. An unlicensed assistive personnel

C. Another Registered Nurse

The nurse is caring for a patient with microcytic, hypochromic anemia. What teaching should the nurse provide that would be beneficial to the patient? A. Take enteric-coated iron with each meal. B. Take cobalamin with green leafy vegetables. C. Take the iron with orange juice one hour before meals. D. Decrease the intake of the antiseizure medications to improve.

C. Take the iron with orange juice one hour before meals.

The nurse receives a physician's order to transfuse fresh frozen plasma to a patient with acute blood loss. Which procedure is most appropriate for infusing this blood product? A. Infuse the fresh frozen plasma as rapidly as the patient will tolerate. B. Hang the fresh frozen plasma as a piggyback to the primary IV solution. C. Infuse the fresh frozen plasma as a piggyback to a primary solution of normal saline. D. Hang the fresh frozen plasma as a piggyback to a new bag of primary IV solution without KCl.

A. Infuse the fresh frozen plasma as rapidly as the patient will tolerate. Rationale: The fresh frozen plasma should be administered as rapidly as possible and should be used within 24 hours of thawing to avoid a decrease in factors V and VIII. Fresh frozen plasma is infused using any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion.

A patient with cancer is having chemotherapy treatments and has now developed neutropenia. What care should the nurse expect to provide and teach the patient about (select all that apply.)? A. Strict hand washing B. Daily nasal swabs for culture C. Monitor temperature every hour. D. Daily skin care and oral hygiene E. Encourage eating all foods to increase nutrients. F. Private room with a high-efficiency particulate air (HEPA) filter

A. Strict hand washing D. Daily skin care and oral hygiene F. Private room with a high-efficiency particulate air (HEPA) filter

An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000 during chemotherapy is to: A. Check all stools for occult blood B. Encourage fluids to 3000 mL/day C. Provide oral hygiene every 2 hours D. Check the temperature every 4 hours

A. Check all stools for occult blood Rationale: Because patient is at risk for spontaneous bleeding, check stool for blood

Before beginning a transfusion of packed red blood cells (PRBCs), which action by the nurse would be of highest priority to avoid an error during this procedure? A. Check the identifying information on the unit of blood against the patient's ID bracelet. B. Select new primary IV tubing primed with lactated Ringer's solution to use for the transfusion. C. Remain with the patient for 60 minutes after beginning the transfusion to watch for signs of a transfusion reaction. D. Add the blood transfusion as a secondary line to the existing IV and use the IV controller to maintain correct flow.

A. Check the identifying information on the unit of blood against the patient's ID bracelet. Rationale: The patient's identifying information (name, date of birth, medical record number) on the ID bracelet should exactly match the information on the blood bank tag that has been placed on the unit of blood. If any information does not match, the transfusions should not be hung because of possible error and risk to the patient. The transfusion is hung on blood transfusion tubing, not a secondary line, and cannot be hung with lactated Ringer's solution because it will cause RBC hemolysis. Usually, the patient will need continuous monitoring for 15 minutes after the transfusion is started, as this is the time most transfusion reactions occur. Then the patient should be monitored every 30 to 60 minutes during the administration.

A patient with ITP has an order for a platelet transfusion. Which information indicates that the nurse should consult with the HCP before obtaining and administering platelets? A. Platelet count is 42,000 B. Petechiae are present on chest C. BP is 94/56 D. Blood is oozing from the venipuncture site

A. Platelet count is 42,000 Rationale: Platelet transfusions are not usually indicated until the platelet count is below 10,000-20,000, unless the patient is actively bleeding.

Before starting a transfusion of packed red blood cells for an older anemic patient, the nurse would arrange for a peer to monitor his or her other assigned patients for how many minutes when the nurse begins the transfusion? A. 5 B. 15 C. 30 D. 60

B. 15 Rationale: As part of standard procedure, the nurse remains with the patient for the first 15 minutes after starting a blood transfusion. Patients who are likely to have a transfusion reaction will more often exhibit signs within the first 15 minutes that the blood is infusing. Monitoring during the transfusion will be every 30 to 60 minutes.

After receiving report for several patient with neutropenia, which patient should the nurse assess first? A. 56 y.o. with frequent explosive diarrhea B. 33 y.o. with a fever of 100.8 F C. 66 y.o. who has white pharyngeal lesions D. 23 y.o. who is complaining of severe fatigue

B. 33 y.o. with a fever of 100.8 F Rationale: indicates infection and can quickly lead to sepsis

The nurse is caring for a patient with a diagnosis of immune thrombocytopenic purpura (ITP). What is a priority nursing action in the care of this patient? A. Administration of packed red blood cells B. Administration of oral or IV corticosteroids C. Administration of clotting factors VIII and IX D. Maintenance of reverse isolation and application of standard precautions

B. Administration of oral or IV corticosteroids Rationale: Common treatment modalities for ITP include corticosteroid therapy to suppress the phagocytic response of splenic macrophages. Blood transfusions, administration of clotting factors, and reverse isolation are not interventions that are indicated in the care of patients with ITP. Standard precautions are used with all patients.

Which intervention will be included in the nursing care plan for a patient with ITP? A. Assign patient to private room B. Avoid IM injections C. Use rinses rather than a soft toothbrush for oral care D. Restrict activity to passive and active ROM

B. Avoid IM injections Rationale: Avoid because of risk for bleeding.

A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the: A. Platelet count B. Bleeding time C. Thrombin time D. Prothrombin time

B. Bleeding time Rationale: Bleeding time is affected in vWd

Which action will the admitting nurse include in the care plan for a patient who has neutropenia? A. Avoid intramuscular injections B. Check temperature every 4 hours C. Omit fruits and vegetables from the diet D. Place a "No Visitors" sign on the door

B. Check temperature every 4 hours Rationale: Earliest sign of infection in a neutropenic patient is elevation in temperature.

A patient who has been receiving IV heparin infusion and oral warfarin for a DVT is diagnosed with heparin-induced thrombocytopenia. When the platelet level drops to 110,00/microL, which action will the nurse include in the plan of care? A. Prepare for platelet transfusion B. Discontinue the heparin infusion C. Administer prescribed warfarin D. Use LMWH

B. Discontinue the heparin infusion Rationale: All heparin is DC when HIT is diagnosed. Patient should never be given LMWH or heparin. Warfarin not usually given until platelet count has returned to 150K. Platelet count does not drop low enough in HIT for a transfusion, more platelets can cause risk for thrombosis.

The blood bank notifies the nurse that the two units of blood ordered for a patient is ready for pick up. Which action should the nurse take to prevent an adverse effect during this procedure? A. Immediately pick up both units of blood from the blood bank. B. Infuse the blood slowly for the first 15 minutes of the transfusion. C. Regulate the flow rate so that each unit takes at least 4 hours to transfuse. D. Set up the Y-tubing of the blood set with dextrose in water as the flush solution.

B. Infuse the blood slowly for the first 15 minutes of the transfusion. Rationale: Because a transfusion reaction is more likely to occur at the beginning of a transfusion, the nurse should initially infuse the blood at a rate no faster than 2 mL/min and remain with the patient for the first 15 minutes after hanging 1 unit of blood. Only 1 unit of blood can be picked up at a time, it must be infused within 4 hours, and it cannot be hung with dextrose.

The nurse is planning to administer a transfusion of packed red blood cells to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to UAP? A. Verify the patient ID according to hospital policy B. Obtain the temperature, blood pressure, and pulse before the transfusion C. Double-check the product numbers on the PRBC's with the patient ID band D. Monitor the patient for SOB or chest pain during the transfusion

B. Obtain the temperature, blood pressure, and pulse before the transfusion

A patient with an acute peptic ulcer and major blood loss requires an immediate transfusion with packed red blood cells. Which task is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? A. Confirm the IV solution is 0.9% saline. B. Obtain the vital signs before the transfusion is initiated. C. Monitor the patient for shortness of breath and back pain. D. Double check the patient identity and verify the blood product.

B. Obtain the vital signs before the transfusion is initiated.

A patient who has acute myelogenous leukemia develops an ANC of 850/microL while receiving outpatient chemo. Which action by the outpatient clinic nurse is most appropriate? A. Discuss the need for hospital admission to treat neutropenia B. Teach the patient to administer filgrastim (Neupogen) injections C. Plan to discontinue the chemotherapy until the neutropenia resolves D. Order a HEPA filter for the patient's home

B. Teach the patient to administer filgrastim (Neupogen) injections Rationale: The patient may be taught to self-administer Neupogen. Although chemo may be stopped with severe neutropenia (<500/microL), administration of Neupogen usually allows chemotherapy to continue.

Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the HCP? A. The platelet count is 52,000 B. The patient is difficult to arouse C. There are purpura on the oral mucosa D. There are large bruises on the patient's back

B. The patient is difficult to arouse Rationale: Patient may indicate a cerebral hemorrhage

Which patient requires the most rapid assessment and care by the ER nurse? A. The patient with hemochromatosis who reports abdominal pain B. The patient with neutropenia who has a temperature of 101.8F C. The patient with thrombocytopenia who has oozing gums after a tooth extraction D. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours

B. The patient with neutropenia who has a temperature of 101.8F Rationale: Neutropenic patient is assumed to have an infection and is at risk for rapidly developing sepsis

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? A. Give the PRN diphenhydramine B. Send a urine specimen to the lab C. Administer PRN acetaminophen D. Draw blood for a new type and crossmatch

C. Administer PRN acetaminophen Rationale: The patient's clinical manifestations are consistent with a febrile, non-hemolytic transfusion reaction. Urine specimen is needed for acute hemolytic reaction.

Which action for a patient with neutropenia is appropriate for the nurse to delegate to the LVN/LPN? A. Assessing the patient for S/S of infection B. Teaching the patient the purpose of neutropenic precautions C. Administering subcutaneous filgrastim injection D. Developing discharge teaching plan for the patient and family

C. Administering subcutaneous filgrastim injection

What is the major complication of thrombocytopenia, and where can it occur?

Hemorrhage that can occur anywhere in the body (joints, retina, brain)

This is a rare and uncommon condition in which bleeding and clotting occurs simultaneously:

TTP

What are the clinical manifestations of TTP?

The Classic Pentad: 1. Microangiopathic hemolytic anemia 2. Thrombocytopenia 3. Severe neurologic findings (fluctuating altered mental status) 4. Fever 5. Acute renal failure