MS CH. 33 Management of Non-Malignant Blood Disorders
apply pressure to puncture site for a full 10 min
A client with thrombocytopenia has just had a bone marrow aspirate performed to monitor for treatment effectiveness. Which of the following nursing interventions take priority?
6 to 12 months
A health care provider prescribes one tablet of ferrous sulfate daily for a 15-year-old girl who experiences heavy blood flow during her menstrual cycle. The nurse advises the patient and her mother that this over-the-counter preparation must be taken for how many months before stored iron replenishment can occur?
disposing of needles uncapped
A nurse is assigned to a client with acquired immunodeficiency syndrome (AIDS). When handling the client's blood and body fluids, the nurse uses standard precautions, which include:
Invasive procedures
Break in skin integrity leads to increased opportunity for organisms to enter blood system.
Hypogammaglobulinemia
Decreased antibody formation.
Lymphocytopenia; disorders of lymphoid system (chronic lymphocytic leukemia, lymphoma, myeloma)
Decreased cell-mediated and humoral immunity.
Poor dentition; mucositis
Decreased endothelial integrity leads to increased opportunity for organisms to enter blood system.
Liver dysfunction
Decreased synthesis of clotting factors.
staining the teeth
Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid
diagnostics for anemia
H and H, RBC indices, reticulocyte count, iron studies, vitamin B12, folate, haptoglobin, bone marrow aspiration
assess risk of bleeding from activity
ITP nursing management
10,000
ITP patients may also be counseled to refrain from vigorous sexual intercourse when the platelet count is less than
medical alert bracelet
all hemophiliacs should wear one of these
haptoglobin
binds to free hemoglobin released from RBCs
sickle cell
blood is too viscous FLUIDS!!! (and pain meds)
maintain hemodynamic status
major goal of patient with DIC
S shaped
shape of hemoblobin in sickle cell
20,000
when platelet count drops to this level, petechiae can appear, along with bleeding from nose, gums, and excessive menstrual/post dental bleeding
neuroloical
with hemolytic anemias, the most significant complications are of this nature *NEURO EXAM SHOULD BE PERFORMED ON ALL PTS SUSPECTED OF THIS TYPE OF ANEMIA
Xoralto
works directly on factor 5
Deconditioning
Decreased mobility leads to decreased respiratory effort, leading to increased pooling of secretions.
Renal dysfunction
Decreased platelet function.
Nutritional status
Decreased protein stores lead to decreased immune response and anergy.
Increased intracranial pressure
Increased blood pressure leads to rupture of blood vessels.
Duration of neutropenia
Increased duration leads to increased risk of infection.
Poor hygiene
Increased organisms on skin and mucous membranes, including perineum.
Splenomegaly
Increased platelet destruction; spleen traps circulating platelets.
Antibiotic therapy
Increased risk for superinfection, often fungal.
lab values DIC
LOW platelets, elevated PT/aPTT/clot formation(TT) and fibrinolysis, LOW fibrinogen
Sepsis
Mechanism unknown; appears to cause increased platelet consumption.
Dysproteinemia
Protein coats surface of platelet, leading to decreased platelet function; protein causes increased viscosity, which leads to increased stretching of capillaries and thus increased bleeding.
Duration of thrombocytopenia
Risk increases when duration increases (e.g., risk is less when duration is transient after chemotherapy than when duration is permanent with poor marrow production).
Severity of neutropenia
Risk of infection is proportional to severity of neutropenia.
hypoproliferative anemias
generally seen in patients who have had gastric bypass and are not nutritionally supplemented "defect in production of RBCS"
Hemochromacytosis
genetic condition where excess iron is absorbed in the GI tract and deposited in various organs, making them dysfunctional
wet purpura and low platelets
patients admitted with this should have neurological assessment incorporated with routine vitals
medication education anemia
patients need to understand purpose of med, how to take, timing, how to manage side effects
observe themselves for bleeding signs
patients who have bleeding disorders should be educated on this
deconditioning
patients with chronic anemia need to maintain some physical activity to prevent this
paresthesias in LE
patients with megaloblastic anemias usually complain of this (numbness and tingling in bottom of feet)
platelet dysfunction
patients with this should be instructed to avoid any substance that could affect their platelets (OTC meds, alcohol, herbs, nutritional sups)
Severity of thrombocytopenia
Risk increases when platelet count decreases; usually not a significant risk until platelet count is less than 10,000/mm3, or less than 50,000/mm3 when invasive procedure is performed.
Alcohol abuse
Suppressive effect on marrow leads to decreased platelet production and decreased ability to function; decreased liver function results in decreased production of clotting factors.
testing all drainage and excretions for occult and obvious blood
When bleeding disorders are severe, patients who are hospitalized are monitored for bleeding by
platelet count, PT, PTT
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?
vitamin K
antedote for coumadin (warfarin)
protamine sulfate
antedote for heparin
pain, depression, sleep issues
assess for these in a patient with fatigue from anemia
heat
avoid during bleeding episodes because it can make it worse
prophylactic factor replacement
can be very effective in diminishing the morbidity associated with repeated bleeding (HEMOPHILIA). However, this method requires administration of these factors as often as two to three times each week.
nursing goals for anemics
decreased fatigue, attain/maintain nutrition, maintain adequate perfusion, tx compliance, prevent complications
alcohol
discourage this in the patient with anemia as it interferes with absorption of nutrients
hemophilia bleeding
during this, extent of bleeding must be assessment carefully by the nurse
mild confusion
early symptom of megaloblastic anemia
nutritional supps
educate family and ANEMIA patient on the role of these in the proper context
hemolytic aneimas
excessive destruction of RBCs due to altered production, hypersplenism, drug induced, autoimmune, mechanical heart valves
maintains adequate activity level
expected pt outcomes for this goal include baseline vital signs and pulse ox within normal limits
Aplastic anemia
experience all the typical characteristics of anemia (weakness and fatigue). In addition, they have frequent opportunistic infections plus coagulation abnormalities that are manifested by unusual bleeding, small skin hemorrhages called petechiae, and ecchymoses (bruises). The spleen becomes enlarged with an accumulation of the client's blood cells destroyed by lymphocytes that failed to recognize them as normal cells, or with an accumulation of dead transfused blood cells.
11-12.5 seconds
extrinsice pathway normal (PT)
anemia manifestations
fatigue/weakness/malaise, pallor, jaundice, cardiac/respiratory changes, tongue changes, nail changes, pica
0-5
fibrin degredation products (FDP) - fibrinolysis
surgical site, frequent vitals
if hemophiliac has had recent surgery and is bleeding, need to assess this
risk factors, patient education
important nursing roles in preventing and assessment of neutropenia
hypoproliferative anemias
includes iron deficiency, renal disease, inflammation, aplastic, megaloblastic
hemolytic anemias
includes sickle cell, thalassemia, glucose 6 PDH deficiency, immune, hereditary hemochromatosis
coffee and tea
increase gastrointestinal motility and inhibit the absorption of nonheme iron
agular cheilosis
inflammation of the corners of the mouth
chamomile, nettle, alfalfa
instruct hemophiliacs to avoid these which interfere with platelet aggregation
23-35 seconds
intrinsic pathway normal (aPTT)
nursing management bleeding disorders
limit injury, assess for bleeding, prevent bleeding
transfusion or IV fluids
lost blood causing anemia may be replaced with these, depending on symptoms and labs
lymphopenia
lymphocyte count less than 1500
aPTT
maintain this with heparin therapy
PT/INR
maintain this with warfarin (coumadin) therapy
warm baths
many hemophiliacs report these are helpful for relaxation, improving mobility of joints and lessening pain
anemia from HF
may be caused by deficient circulation of blood which stresses the heart
supplemental oxygen
may be needed for anemic patients but is RARELY needed on a long term basis unless there is comorbid pulmonary or heart disease
therapeutic phlebomotomy
medical management for polycythemia if severe
liver
metabolizes and filters/cleans RBCs
fatigue
most common symptom and complication of anemia
0-250
normal D dimer levels (local fibrinolysis)
8-11 seconds
normal clot formation (TT = thrombin time)
170-340
normal fibrinogen levels
headache or vision disturbance
nurse instructions ITP patient to report these as it could indicate increasing ICP (intracranial hemorrhage)
sulfa contining meds
nurse needs to be alert for these in patients with ITP because they can alter platelet function (in addition to aspirin or other NSAIDs)
written emergency plan
nurses should instruct HEMOPHILIA patients and families to have one of these
prioritize activity, establish balance between activity and rest
nursing interventions for fatigue related to anemia
education, fall prevention, safety
nursing management of thrombocytopenia
constipation, valsalva, vigorous flossing, razors, hard toothbrushes, vigorous sexual intercourse
patient with ITP should AVOID THESE
nasal packing
should be avoided in hemophilia patients because bleeding frequently resumes when it is removed
bone mineral density
should be monitored for patients on corticosteroids, may benefit from vitamin D and calcium sups
heart failure
significant complication of anemia is this, due to chronic diminished blood volume causing a compensatory effort to increase CO *ASSESS PTS FOR S/S OF THIS
D dimer
test this to check for pulmonary embolism
avoid injections and suppositories
these should not be used with ITP patients
position and vibration sense, balance issues
this may be DIMINISHED as megaloblastic anemia progresses (later sign)
heparin drip
treat DIC with this
DIC management
treat UNDERLYING CAUSE, correct tissue ischemia, replace fluids and electrolytes, maintain BP, replace coagulation factors, heparin or LMWH
fatigue
very common in ITP - nurse should assess extent and help them manage
oral hygiene
very important in patients with platelet dysfunction so that gingival bleeding can be minimized
5,000
when platelet count drops to this level - spontaneous (potentially fatal) CNS or GI bleeding can occur