Hematologic Alterations CH 46 (E3)

What is the pathophysiology of iron deficiency anemia?

-Bone marrow lacks iron to produce enough Hgb -O2 carrying capacity of blood is decreased -Leads to S/S of anemia

What should be inspected during the physical exam of a patient with sickle cell anemia?

-Conjunctivae, palms, soles, and skin for pallor -Kkin for lesions or ulcers -Jaundice or scleral icterus -Color and moisture of oral mucosa -Elevated temperature to evaluate infection which can precipitate a sickling crises -Decreased BP -Baseline mental status (stroke)

What diet history factors should be assessed for iron deficiency anemia?

-Cow's milk consumption before 12 months of age -Excessive cow's milk consumption (> 24 oz/day) -Infant consumption of low-iron formula -Lack of iron supplementation after age 6 months in breast-fed infants -Restricted diets

What are the causes of anemia?

-Decreased production and absorption of RBCs -Toxin exposure -Increased destruction -Decreased amount of hemoglobin in RBCs

What should be assessed during the physical exam for the patient with aplastic anemia?

-Ecchymoses -Petechiae -Oral ulcerations -Tachycardia and tachypnea

What medical history factors should be assessed for iron deficiency anemia?

-Excessive weight gain -Chronic infection or inflammation -Chronic or acute blood loss -Use of medication interfering with iron absorption, such as antacids

What should be assessed during the history assessment for the patient with aplastic anemia?

-Exposure history to myelosuppressive medications or radiation therapy -Detailed family, environmental, and infectious disease history -History of epistaxis, gingival oozing, or increased bleeding with menstruation -Headache and fatigue

What should be observed during the physical exam of a child with iron deficiency anemia?

-Fatigue and lethargy -Pallor of the skin, conjunctivae, oral mucosa, palms, and soles -Spooning of the nails -Decreased O2 -Tachycardia -Heart flow murmur -Splenomegaly

What should be assessed during the history assessment for the patient with sickle cell anemia?

-Growth and development -Vaso-occulsive crisis frequency and required treatment -Hospital admissions -Current medication regimen -Immunization and infectious disease -Blood transfusion -Present illness and identified trigger -Pain assessment

In addition to suppression of all blood cells, laboratory and diagnostic testing may reveal what in a patient with aplastic anemia?

-Guaiac positive stool -Blood in the urine -Severe decrease in or the absence of hematopoietic cells on bone marrow aspiration

What should be auscultated during the physical exam of a patient with sickle cell anemia?

-Heart sounds for a murmur -Tachycardia with pain, hyperthermia, or dehydration -Breath sounds

What dietary interventions should be provided for the patient with iron deficiency anemia?

-Iron deficient infants are fed only formula fortified with iron -Breast fed infants should begin iron supplementation around 4-5 months -Encourage breast feeding mothers to increase their dietary intake of iron ->1 year of age limit cow's milk -Encourage iron rich foods

What is the nursing management for a patient with iron deficiency anemia?

-Iron supplements -Blood transfusions -Diet modifications -Teaching -Safety

What should be palpated during the physical exam of a patient with sickle cell anemia?

-Joints for warmth, tenderness, and range of motion -Abdomen for tenderness -Hepatomegaly or splenomegaly

What social history factors should be assessed for iron deficiency anemia?

-Low socioeconomic status -Recent immigration from a developing country

What prenatal and birth history factors should be assessed for iron deficiency anemia?

-Maternal anemia during pregnancy -Poorly controlled diabetes during pregnancy -Prematurity, low birth weight, or multiple birth

What are the labs and diagnostics for sickle cell anemia?

-Newborn screening for SCA -Sickledex -Hgb electrophoresis -Hgb/ Hct lower -Reticulocyte count elevated -Peripheral blood smear showing presence of sickle-shaped cells -Platelet count increased -ESR elevated -Abnormal liver function tests with elevated bilirubin

How can safety be promoted in the patient with iron deficiency anemia?

-Provide close observation -Assist with ambulation -Educate the parents on how to protect the child from a fall injury

What are some examples of iron rich foods?

-Red meats -Tuna -Salmon -Eggs -Tofu -Enriched grains -Dried beans and peas -Dried fruits -Leady green vegetables -Iron fortified breakfast cereals

What is the nursing management for a patient with aplastic anemia?

-Safety -Teaching -Blood products -Stem cell transplant -Immunosuppressive therapy -Complications

What is the pathophysiology of sickle cell disease?

-Stress/triggering event leads to RBC sickling -Decreased oxygen carrying capacity -Blood clumps together -Decreased perfusion -Tissue hypoxia -Ischemia -Infarction

What are some teaching points about iron supplement administration?

-Teach how to measure the amount to be administered -Place the liquid behind the teeth -Stool softeners may be necessary to reduce constipation -Increase fluid and fiber intake to avoid constipation

Iron deficiency anemia Hgb: 6 months-<5 years old

<11 g/dL

Iron deficiency anemia Hgb: 5-12 years old

<11.5 g/dL

Iron deficiency anemia ferritin

<15 mcg/L

The mother of a 5-year-old girl brings the child to the clinic for an evaluation. The mother tells the nurse, "She seems to be so tired and irritable lately, and she looks so pale." Further assessment reveals pale conjunctiva and oral mucus membranes. The nurse suspected iron-deficiency anemia. Which additional finding would help provide additional evidence for this suspicion? A) Spooned nails B) Negative splenomegaly C) O2 99% D) Bradycardia

A

The nurse is caring for a child who has just been admitted to the pediatric unit with sickle cell crisis. He is complaining that his right arm and leg hurt. What is the priority nursing intervention? A) Administer pain medication every 3 hours intravenously until pain is controlled. B) Perform passive range of motion of the arm and leg to maintain function. C) Try acetaminophen for pain first, moving up to opioids only if needed. D) Use narcotic analgesics and warm compresses as needed to control the pain.

A

The nurse is reviewing the results of a clotting study for a healthy 6-year-old child. What would the nurse document as a normal prothrombin finding? A) 11.0 to 13.0 seconds B) 16.0 to 18.0 seconds C) 21.0 to 35.0 seconds D) 6.0 to 9.0 seconds

A

When providing care to a child with aplastic anemia, which nursing diagnosis would be the priority? A) Risk for injury B) Imbalanced nutrition, less than body requirements C) Ineffective tissue perfusion D) Impaired gas exchange

A

The nurse is assessing a child with aplastic anemia. What would the nurse expect to assess? SELECT ALL THAT APPLY A) Ecchymoses B) Tachycardia C) Guaiac-positive stool D) Epistaxis E) Severe pain F) Warm, tender joints

A, B, C, D

The nurse is teaching the parents of a child diagnosed with iron-deficiency anemia about ways to increase their child's intake of iron. The parents demonstrate understanding of the teaching when they identify which foods as good choices for the child? SELECT ALL THAT APPLY A) Tuna B) Salmon C) Tofu D) Cow's milk E) Dried fruits

A, B, C, E

Most cases of aplastic anemia are (acquired/inherited).

Acquired

A child is prescribed monthly injections of vitamin B12. When developing the teaching plan for the family, the nurse would focus on which type of anemia? A) Aplastic anemia B) Pernicious anemia C) Folic acid anemia D) Sickle cell anemia

B

A child with suspected sickle cell disease is scheduled for a hemoglobin electrophoresis. When reviewing the child's history, what would the nurse identify as potentially interfering with the accuracy of the results? A) Use of iron supplementation B) Blood transfusion 1 month ago C) Lack of fasting for 12 hours D) History of recent infection

B

A nurse is caring for an infant whose screening test reveals a potential diagnosis of sickle cell disease. Which of the following tests should be performed to distinguish if the infant has the trait or the disease? A) Sickle solubility test B) Hgb electrophoresis C) CBC D) Transcranial doppler

B

A nurse is leading a discussion with a group of new mothers about newborn nutrition and its importance for growth and development. One of the mothers asks, "Doesn't the baby get iron from me before birth?" Which response by the nurse would be most appropriate? A) "You give the baby some iron, but it is not enough to sustain him after birth." B) "Because the baby grows rapidly during the first months, he uses up what you gave him." C) "The iron you give him before birth is different from what he needs once he is born." D) "If the baby didn't use up what you gave him before birth, he excretes it soon after birth."

B

A nurse is preparing to administer iron dextran IM to a school-age child who has iron deficiency anemia. Which of the following actions by the nurse is appropriate? A) Administer the dose in the deltoid muscle B) Use the Z-track method when administering the dose C) Avoid injecting more than 2 mL with each dose D) Massage the injection site for 1 minute after administering the dose

B

A nurse is providing care to a child with idiopathic thrombocytopenic purpura with a platelet count of 18,000/mm3. Which medication would the nurse most likely expect to be ordered? A) Folic acid B) IV IG C) Dimercaprol D) Deferoxamine

B

After teaching the parents of a child diagnosed with pernicious anemia about the disorder and treatment, the nurse determines that the teaching was successful when the parents state: A) "Our child needs to eat more green leafy vegetables to cure the anemia." B) "Our child will need to have those vitamin shots for life." C) "We will need to plan for a bone marrow transplant soon." D) "Our child might get constipated from the supplement."

B

The nurse is administering meperidine as ordered for pain management for a 10-year-old child in sickle cell crisis. The nurse would be alert for: A) priapism. B) seizures. C) leg ulcers. D) behavioral addiction.

B

The nurse is caring for a 10-year-old child with iron toxicity. What would the nurse expect the healthcare provider to order? A) Succimer B) Deferasirox C) Dimercaprol D) Edentate calcium disodium

B

The nurse is caring for a 12-year-old boy with idiopathic thrombocytopenia. The nurse is providing discharge instructions about home care and safety recommendations to the boy and his parents. Which response indicates a need for further teaching? A) "We should avoid aspirin and drugs like ibuprofen." B) "He can resume participation in football in 2 weeks." C) "Swimming would be a great activity." D) "Our son cannot take any antihistamines."

B

The nurse is caring for a child in sickle cell crisis. To best promote hemodilution, the nurse would expect to administer how much fluid per day intravenously or orally? A) 130 mL/kg of fluids per day B) 150 mL/kg of fluids C) 110 mL/kg of fluids D) 120 mL/kg of fluids per day

B

The nurse is evaluating the laboratory test results of a 7-year-old child with a suspected hematologic disorder. Which finding would cause the nurse to be concerned? A) WBC: 5.6 x 103/mm3 B) RBC: 2.8 x 106/mm3 C) Hgb: 11.4 mg/dL D) Hct: 35%

B

When developing the postoperative plan of care for a child with sickle cell anemia who has undergone a splenectomy, which would the nurse identify as the priority? A) Risk for delayed growth and development B) Risk for infection C) Deficient fluid volume D) Impaired skin integrity

B

What is the peak age for iron deficiency anemia?

Between 12 and 24 months and again during the teenage years

A 5-year-old girl is diagnosed with iron-deficiency anemia and is to receive iron supplements. The child has difficulty swallowing tablets, so a liquid formulation is prescribed. After teaching the parents about administering the iron supplement, which statement indicated the need for additional teaching? A) :She needs to eat foods that are high in fiber, so she doesn't get constipated." B) "We'll try to get her to drink lots of fluids throughout the day." C) "We will place the liquid in front of her gums, just below her teeth." D) "We need to measure the liquid carefully so that we give her the correct amount."

C

A child with hemophilia fell while riding his bicycle. He was wearing a helmet and did not lose consciousness. He has a mild abrasion on his knee that is not oozing. He is complaining of abdominal pain. What is the priority nursing assessment? A) Perform neurologic checks. B) Assess ability to void frequently. C) Carefully assess his abdomen. D) Examine his knee frequently.

C

A nurse is conducting a physical examination of a 5-year-old with suspected iron-deficiency anemia. How would the nurse evaluate for changes in neurologic functioning? A) "Open your mouth so I can look inside your cheeks and lips." B) "Do you have any bruises on your feet or shins?" C) "Will you show me how you walk across the room?" D) "Let me see the palms of your hands and soles of your feet."

C

A nurse is preparing a teaching plan for a child with hemophilia and parents. Which would the nurse be least likely to include to manage a bleeding episode? A) Administer factor VIII replacement. B) Apply direct pressure to the area. C) Apply heat to the site of bleeding. D) Elevate the injured area such as a leg or arm.

C

A group of students are reviewing the effects of sickle cell anemia on the various parts of the body. The students demonstrate a need for additional study when they identify what as an effect? A) Pulmonary hypertension B) Cholelithiasis C) Chest syndrome D) High urine specific gravity

D

A nurse is providing teaching to the parent of a child who has a new prescription for liquid oral iron supplements. Which of the following statements by the parents indicates an understanding of the teaching? A) "I should take my child to the ED if his stools become dark." B) "My child should avoid eating citrus fruits while taking the supplements." C) "I should give the iron with milk to help prevent an upset stomach." D) "My child should take the supplement through a straw."

D

The nurse is caring for a 10-year-old child with hemophilia. The child asks the nurse for suggestions about appropriate physical activities. Which activity would the nurse most likely recommend? A) Soccer B) Wrestling C) Football D) Baseball

D

The nurse is caring for a 2-year-old boy with hemophilia. His parents are upset by the possibility that he will become infected with hepatitis or HIV from the clotting factor replacement therapy. Which response by the nurse would be most appropriate? A) "Parents commonly fear the worst; however, the factor will help your child lead a normal life." B) "There are risks with any treatment including using blood products, but these are very minor." C) "Although factor replacement is expensive, there's more financial strain from missing work if he has a bleeding episode." D) "Since dry hear treatment of the factor began in 1986, there have been no reports of the virus transmission."

D

The nurse is caring for a 3-year-old child with suspected iron-deficiency anemia. Which test would the nurse expect to be ordered to confirm the diagnosis? A) Reticulocyte count B) Iron test C) Hemoglobin electrophoresis D) Serum ferritin

D

The nurse is caring for a child who has been admitted for a sickle cell crises. What would the nurse do first to provide adequate pain management? A) Administer a NSAID as ordered B) Use guided imagery and therapeutic touch C) Administer meperidine as ordered D) Initiate pain assessment with a standardized pain scale

D

The nurse is providing family education for the prevention or early recognition of vaso-occlusive events in sickle cell anemia. Which response by a family member indicates a need for further teaching? A) "We must watch for unusual headache, loss of feeling, or sudden weakness." B) "We must be compliant with vaccinations and prophylactic penicillin." C) "We need to seek medical attention for abdominal pain." D) "We should call the healthcare provider for any fever over 100°F (37.8°C)."

D

Iron Deficiency Anemia

Deficient amount of iron to produce Hgb

Aplastic anemia

Failure of the bone marrow to produce cells

T/F: Meperidine is okay to use for pain management during a sickle cell crises.

False

Adult hemoglobin

Hgb A

Fetal hemoglobin

Hgb F

Hemoglobinopathies

Hgb molecules are abnormal in structure and/or function

Anemia

RBC, Hgb, and Hct level is lower than the age appropriate minimum normal value

Sickle Cell Disease

RBCs carry a less effective type of Hgb

Hgb SS

Sickle cell disease

Hgb AS

Sickle cell trait

T/F: For appropriate growth to occur in adolescence, increased amounts of iron must be consumed and absorbed.

True