NS 470 E2

Complications of hemolytic anemia

1) Jaundice 2) Enlarged spleen / liver 3) Hemoglobin molecules can obstruct renal tubules causing acute tubular necrosis. Watch for signs of AKI(oliguria (<500 ml urine), azotemia (increased urea in blood) Notify provider of jaundice, enlarged spleen and signs of AKI

Blood types

A, B, AB and O. Type O is the universal donor and AB blood is known as the universal recipient. Platelets and plasma do not need a match

Neutropenia

ANC less than 1000 Less than 500 indicates severe neutropenia

Pancytopenia

Decrease of WBC, RBC, Platelets

Normal CBC Results

RBC: (3.8-5.7) male- 4.3-5.7 female-3.8-5.1 hemoglobin: male- 13-17 female- 12-16 hematocrit: male- 39-50% female- 45-47% platelet 150,000-400,000 WBC 5,000-10,000 Reticulocyte count: 0.5%-2.5% Neutrophil: 2500-7000 Pancytopenia: A decreased RBC, WBC, Platelets (S/S include poor tissue perfusion (fatigue/dyspnea), bleeding (petechiae/epistaxis(nosebleed)), infection (septic shock/death)

Absolute Neutrophil Count (ANC)

The percentage and actual number of mature circulating neutrophils; used to measure a patient's risk for infection. The higher the numbers, the greater the resistance to infection.

Other

What is appropriate nurse assignment on the oncology unit? § High acuity patient given to experienced nurse § Chemo patient—must be cared for by oncology certified nurse What is appropriate information to include in a transfer report based on a provided scenario? § What is needed to know? § New vs established patient? What is appropriate delegation of care in clients with alterations in leukocytes? § The nurse needs to assess, evaluate, and teach by themselves (EAT) § CNA: I&O, ADLs, glucose checks, VS § LPN: administer subQ/oral meds; can check blood with RN What is management of chemotherapy side effects/adverse effects such as nutrition related, sterility, and risk of infection and bleeding? § Handwashing! § Sterility: educate the patient on the possibility of harvesting sperm & eggs

Teaching plan for polcythemia ver

a phlebotomy may be needed every 2-3 months (about 500ml) and will be evaluated for complications

Assessment findings of hodgkins lymphomas

a. Age 15-34 b. Risk § Virus § Genetic § Exposure a. Presentation § Large, non-painful lump in neck (cervical) that is movable. Can infiltrate organs and CNS. a. Progresses starting at neck. Treatment depends on this. b. Diagnosis § Excisional biopsy of the lymph node § Reed Sternberg cells are seen § CT of neck, chest, abdomen, pelvis to see lymph nodes above and below diaphragm—this determines the treatment § Above the diaphragm indicates early stages—radiation § Below the diaphragm indicates later stages—chemo § If patient is in remission, then transplant a. Constitutional B symptoms § Indicate a poor prognosis, progression § Weakness, fever, night sweats (drenching), itching, unintentional weight loss >10% normal body weight. b. Complications § Secondary malignancies § Sterility

Platelet transfusion

a. Platelet Transfusion i. When is a platelet transfusion needed: 1. If platelet count is <10,000/uL ii. Laboratory Tests: 1. Assess for secondary hemostasis or coagulation a. PT, PTT, aPPT can all be normal even if platelets are low i. If they are increased- the thrombocytopenia may be r/t DIC b. Platelet Function Assay test i. Screening test that measures both platelet adhesion and aggregation c. Bone marrow biopsy rules out platelet production problems iii. Nursing Considerations: 1. Same as PRBCs transfusion

serum protein electrophoresis (SPEP)

immunoglobulin electrophoresis test that determines the amount of each immunoglobulin in the blood Test used to identify multiple myeloma

Myelodysplastic Syndrome (MDS)

o MDS is a hematologic disorder of unknown etiology characterized by ineffective blood cell production. § Some of the cells function normally, and others are not effective due to the dysplastic changes. (Some degree of mature cells and some abnormal cells.) § 90% of patients will have anemia. The ineffective cells are responsible for the manifestations of infection and bleeding. § Risk factors for developing MDS are a history of chemotherapy with alkylating agents, radiation therapy treatments and industrial exposures to solvents such as benzene. o The diagnostic evaluation § Usually begins when a CBC evidencing neutropenia, anemia and or thrombocytopenia, in a symptomatic or asymptomatic patient. § A bone marrow biopsy and aspirate analysis is needed for definitive diagnosis and classification of the specific subtype. o Treatment i. Treatment of MDS is supportive care with continued monitoring of the peripheral blood and the bone marrow, transfusion with blood components and antibiotics. ii. In the setting of frequent RBC transfusions, iron chelators are needed to prevent iron overload. The aggressiveness of the disorder determines the treatment recommendations. Less aggressive MDS can be treated with erythropoietin and granulocyte-colony stimulating factors iii. About 1/3 of the cases of MDS are more aggressive in nature. Treatment options include intensive chemotherapy or HSCT. The goal of this type of therapy is to restore normal growth, control and differentiation of the hematopoietic cells, and to reduce the frequency of transformation to acute leukemia. iv. Azacitidine and decitabine are drugs used to treat MDS. Lenalidomide or thalidomide may also be used. Other treatments for MDS include cytarabine, an antimetabolite, with or without antitumor antibiotics, antithymocyte globulin (ATG), and cyclosporine. v. Stem cell transplant is the only way for a cure! o Side Effects i. Side effects include myelosuppression, nausea, vomiting, constipation or diarrhea, renal dysfunction, alopecia and injection side erythema. o Nursing Care/Goal i. Nursing care for the patient with MDS centers on the pancytopenia and anemia. ii. The goal of care is protecting the patient from life-threatening infection and bleeding and maintaining oxygenation and tissue perfusion.

Lab finding for anemia

o Mild: hemoglobin = 10-12 o Moderate: 6-10 § Palpitations, dyspnea, "roaring" in ears o Severe: <6 § Cardiopulmonary symptoms

Plan of care for polycythemia vera and secondary polycythemia

o Nursing and collaborative § Dietary § PT/OT o Pharm: § Phlebotomy (removing blood) · Every other day · 300-500 ml each time · Goal for Hct: o Male: 45% o Female: 42% § Low dose aspirin · Prevent thrombus formation § Myelosuppressive gents · Decrease hypercellularity of bone marrow o Ritxolitinib § Inhibits expression of JAK 2 gene § Allopurinol · Reduce gout attacks from uric acid § Medication to decrease pruritus o Non-pharm: § Hydration · Decrease blood viscosity § Nutrition § Activity/exercise · Early ambulation · Passive and active ROM o Teaching § Stroke education § Reduce risk factors § Medication regimen § When to follow up for repeat CBC and phlebotomy · Once at the goal %, phlebotomies are every 2-3 months o Potential Complications: § Stroke § MI § AKI § Bleeding—monitor § Changes in skin

Assessment findings Non-hodgkins lymphoma

o Older adults—cause is unknown o Autoimmune response/drug therapy, insecticides, pesticides. o Can spread without pattern, unpredictable o Mediastinal (chest) mass or abdominal mass o Constitutional B symptoms: § Indicate a poor prognosis § Weakness, fever, night sweats (drenching), itching, unintentional weight loss >10% normal body weight. § In about 30% of patients a. Treatment/diagnosis § Biopsy lymph node § Bone marrow biopsy § Scans § Lumbar puncture § Rituximab: targets CD20 antigen (binds to cell that has CD20 and lysis). Side effects of Rituximab: hypersensitivity infusion reactions (high BP, low HR, bronchospasms). a. Labs § LDH § Beta 2 microglobulin § If both are elevated, then associated with a poor prognosis

Bone Marrow Biopsy and Aspirations

§ A biopsy is the extraction of a very small amount of tissue, such as bone marrow, to definitively diagnose cell type and to confirm or rule out malignancy. A bone marrow tissue sample is removed by needle aspiration for cytological (histological) examination. § Biopsies are commonly performed with local anesthesia or conscious sedation in an ambulatory setting, intraoperatively, or during endoscopic procedures. § Indications: commonly performed to diagnose causes of blood disorders, such as anemia or thrombocytopenia; to diagnose diseases of the bone marrow, such as leukemia, and infection; or to stage lymphoma or other forms of cancer. § Considerations: § Preoperative: § Nursing Actions § Ensure that the client has provided informed consent. § Place the client in a prone or side-lying position to expose the iliac crest for the procedure. § Client Education: § Explain the procedure to the client. The biopsy site will be anesthetized with a local anesthetic, and the client might feel pressure and brief pain during the aspiration. § Intraoperative: § Nursing Actions § Inform the client that the test will last about 20 min. § Administer a sedative if prescribed. § Older adult clients are at greater risk for complications associated with sedation for biopsy procedures due to chronic illnesses. § The nurse should take an older adult's kidney function into consideration when using analgesics for sedation. § Cleanse the site with an antiseptic solution. § Maintain sterility of equipment and supplies. § Assist the provider with the procedure as needed. § Postoperative: § Nursing Actions § Apply pressure to the biopsy site to control bleeding. § Place a sterile dressing over the biopsy site. § Maintain the client on bed rest for 30 to 60 min. § Monitor for evidence of infection (fever, increased WBCs, pain, and swelling at the site) and bleeding. § Apply ice to the biopsy site to minimize bleeding and bruising. § Post-procedure discomfort is usually relieved by mild analgesics. § Avoid aspirin and other medications that affect clotting. § Client Education § Teach the client to report excessive bleeding and evidence of infection to the provider. § Teach the client to check the biopsy site daily. Keep the dressing clean, dry, and intact. § If sutures are in place, remind the client to return in 7 to 10 days to have them removed. § Complications: § Bleeding: bleeding can occur from the site § Nursing actions: report bleeding to the provider immediately

Oncology client to be seen first

§ ABCs, threatened vs unthreatened, stable vs unstable, acute vs chronic

Multiple Myeloma

§ Condition where neoplastic plasma cells (body made too many plasma cells), infiltrate the bone marrow and destroy bone § Risk factor: men, over 40 y/o, African American o What is the cause of the bone pain and other symptoms in multiple myeloma? § Malignant plasma cells overproduce and overcrowd the healthy cells in the bone marrow § Causing pancytopenia § These malignant cells produce cytokines that destroy the bones à causing lytic bone lesions § **Bone destruction leads to bone pain** (Reason why pt's seek healthcare) § Ribs/spine/pelvis hurt with movement; x-ray shows lesions § Bone destruction leads to hypercalcemia § Anorexia, coma, seizures o What are the assessment and lab findings? How is multiple myeloma diagnosed? § Bone marrow biopsy § Serum protein electrophoresis- spike in the M protein (igM) § Urine- Bence jones protein is found § CBC- pancytopenia § Labs associated with poor prognosis § Beta-2 microglobulin- increased § Albumin- decreased o What is included in the plan of care (nursing and collaborative, pharmacological and nonpharmacological, client teaching, priorities) for a client with multiple myeloma? § Tx: § Corticosteroids- reduce amount of plasma cells § Targeted therapy-- Lenalidomide § Chemotherapy if disease is progressive § Hydration to flush out kidneys § UO: 1.5-2L/day § Meds: § Bisphosphonates: inhibit bone breakdown § IV furosemide- tx hypercalcemia; causes kidneys to excrete calcium § Allopurinol: decrease hyperuricemia § Analgesics § Radiation to area of bone o What are potential complications of multiple myeloma? § High risk for pathological fractures § b/c bones are so fragile from lesions § Peripheral neuropathy from chemotherapy (risk for injury) § DVT § Constipation- stool softeners o What is the role of bisphosphonates in multiple myeloma? § Inhibit bone breakdown and used for skeletal pain and hypercalcemia o What are the anticipated side effects/adverse reactions with Prednisone therapy? § Slow wound healing, dizziness, n/v, abd pain, bloating o Why is immunotherapy or targeted therapy used in multiple myeloma? § It slows cancer cell growth by killing cancer cells with CD38 (Daratumumab), and enabling immune system to kill myeloma cells

Plan of care for neutropenia

§ Determine the cause § If infection is present · Blood cultures X2 o If they have a central line then take from both central line and IV b/c it could be that the lines infected · Other cultures takes: urine, stool, sputum, & wounds · Give broad spectrum antibiotics within 1 hour of admit o Gram positive, gram negative, fungal, or viral o If they spike a fever while on this then they will start an antifungal o Then they look at the culture results to determine which antibiotic is going to be used · You start with broad spectrum to keep them safe and then once culture results are back, you narrow the antibiotic, so they don't become resistant to brad spectrum antibiotic—given ASAP · Chest X-ray- risk for pneumonia § Interventions: neutropenic precautions (mask/gloves), mask pt when leaving room, no fruits/vegetables, private room, HEPA filter in room § Education for Neutropenic pt's at home: wear mask when in big crowds, no changing cat litter, no gardening, don't drink standing water (~4 hours), call if fever (100.4) · Pts don't stay in hospital for neutropenia unless they have an infection

Notify provider of neutropenia

§ Fever of 100.4 § "I just don't feel right" § Neutropenia without a fever can be managed at home!

Filgrastim

§ Filgrastim- used to prevent neutropenia; b/c it makes more neutrophils § Give before chemo IV/Sub-q § Administer till past nadir to the absolute neutrophil count

Hodgkin's lymphoma

§ Hodgkin's lymphoma is a proliferation of abnormal giant, multinucleated cells, called Reed-Sternberg cells, which are located in lymph nodes. · It occurs most frequently in persons from 15 to 30 years of age and above 50 years of age. · The cause of Hodgkin's lymphoma remains unknown.

Idiopathic Thrombocytopenic Purpura (ITP)

§ Is a coagulopathy that is an autoimmune disorder in which the life span of platelets is decreased by antiplatelet antibodies although platelet production is normal. This can result in severe hemorrhage following a cesarean birth or lacerations. § Risk Factors: § Female (ages 20-30 years) § Autoimmune disorder § Recent virus (children only) § Expected Findings: § Unusual spontaneous bleeding from the gums and nose (epistaxis) § Oozing, trickling, or flow of blood form incisions or lacerations § Petechiae and ecchymoses § Hematuria § Excessive bleeding from venipuncture, injection sites or slight traumas § Tachycardia, hypotension, and diaphoresis § Organ failure secondary to microemboli § Respiratory distress § Laboratory tests: § Hemoglobin (decreased with DIC and ITP): male, 14 to 18 g/dL; female, 12 to 16 g/dL § Platelet levels (thrombocytopenia; decreased with DIC, HIT, and ITP): 140,000 to 400,000 mm3 § Fibrinogen levels (decreased with DIC): 60 to 100 mg/dL § Prothrombin time (increased with DIC): 11.0 to 12.5 seconds § Partial thromboplastin (increased with DIC): aPTT, 30 to 40 seconds; PTT, 60 to 70 seconds § Thrombin time (increased with DIC): 8 to 11 seconds § Fibrin split product levels/fibrin degradation products (increased with DIC): less than 10 mcg/mL § D-dimer (increased with DIC): less than 0.4 mcg/mL § Blood typing and cross- match § Nursing Actions (all the same for DIC, HIT, and ITP) § Regularly assess vital signs and hemodynamic status. § Monitor for signs of organ failure or intracranial bleed (oliguria, decreased level of consciousness). § Monitor laboratory values for clotting factors. § Administer fluid volume replacement. § Transfuse blood, platelets, and other clotting products. § Monitor for complications from administration of blood and blood products. § Avoid use of NSAIDs. § Administer supplemental oxygen. § Provide protection from injury. § Instruct client to avoid Valsalva maneuver (could cause cerebral hemorrhage). § Implement bleeding precautions (avoid use of needles). § Medications: § Corticosteroids § Immunosuppressants § Therapeutic Procedures: § Splenectomy can be performed if the client does not respond to other medical interventions

Acute and Chronic Leukemia

§ Leukemias are cancers of white blood cells or of cells that develop into white blood cells. The bone marrow makes abnormal, malignant leukocytes that are dysfunctional and don't die like normal leukocytes. o They can crowd out normal leukocytes, erythrocytes and thrombocytes in the bone marrow. They invade and destroy bone marrow, and they can metastasize to the liver, spleen, lymph nodes, testes, and brain. o Blast cells o Leukemia is fatal if untreated. Leukemia can be classified based on acute versus chronic disease, referring to the cell maturity and nature of the disease, and on the type of WBC affected, myelogenous or lymphocytic in origin. o S/S: bone marrow suppression, CNS symptoms, bone pain, splenomegaly o Risks: virus, previous exposure to chemo/radiation o Dx: bone marrow biopsy, lumbar puncture, CT scan o Pts are most likely to die from infection o Oncology emergencies: tumor lysis syndrome (Labs: increased phosphorous, hypocalcemia, hyperkalemia, increased uric acid—give allopurinol), DIC, leukostasis—WBCs are so thick that it causes the blood to be slow moving—at risk for clots o GI, cardiac, pulmonary, liver, kidney and neurologic issues o Fatigue is a long term complication; may need to be in hospital for ~6 weeks, psychosocial issues o Overall goals: prevent infection, monitor for bleeding, maximize functional abilities, encourage them to discuss fears/anxieties, what keeps the conversation going?, education, possibility for stem cell transplant Phases: o Induction: attempt to bring about a remission—absence of all findings of leukemic cells including less than 5% blasts o Intensification/Consolidation: high dose chemo; can be given immediately after induction o Consolidation is started after remission o Maintenance: to prevent relapse—keep body free of leukemic cells § Acute · Undifferentiated · Rapid · Aggressive · Fatal if not treated · Bone marrow failure (cells crowd it out) · Pancytopenia · Abnormal WBC count o At risk § Chemo/radiation § Genetics § Viruses · Diagnosis o Bone marrow biopsy o CT (if splenomegaly is present) o LP (if in the spinal cord) · Care o Chemotherapy § Chronic · Well differentiated · Slow growing · Types o Chronic Lymphocytic Leukemia (CLL) § Most common § Over age 50 § Malignant B-lymphocytes § Not as aggressive § Lymphocytosis § Lymphadenopathy (enlarged lymph nodes) § Splenomegaly § Treatment · Watch and wait · Supportive care · Treat the anemia, thrombocytopenia, neutropenia · Control or prevent bleeding/infection (these are complications), leukostasis, chemo side effects o Chronic Myelocytic Leukemia (CML) § Makes up 20% of adult chronic leukemia § Philadelphia chromosome § Three disease phases 1. Chronic phase: slow, mild symptoms 2. Accelerated phase: spleen enlargement, fever, night sweats, unexpected weight loss, 10-30% blasts if did bone marrow biopsy in this phase 3. Blast phase: will go to this phase in 6-12 months (blast crisis is aggressive). >30% blasts. CML transforms into AML § Treatment: Imatinib—first line therapy · Targets Philadelphia Chromosome · Gets patient into remission o Chronic Leukemia assessment findings: § frequent infections § poor wound healing § anemia § thrombocytopenia § splenomegaly § hepatomegaly § lymphadenopathy § bone pain § meningeal irritations § oral lesions o Chronic Leukemia lab findings: § WBC high, low, or normal. § Decreased hemoglobin, hematocrit, and platelets. § CT and Lumbar Puncture can detect leukemic cells outside of the blood and bone marrow. o Chronic Leukemia complications: § tumor lysis syndrome § DIC § Leukostasis (risk for clots) § life threatening bone marrow suppression § infection, leukopheresis

Non-Hodkin's Lymphoma

§ Non-Hodgkin's lymphomas (NHLs) all involve lymphocytes, primarily B-, T-, or natural killer (NK) cell in origin. § B-cell lymphomas constitute about 88% of all NHLs. · NHL is more common than HL. § NHL spreads in an unpredictable manner and patients typically have widely disseminated disease at the time of diagnosis. § The cause of NHL is usually unknown.

PRBC transfusion

§ Nursing Actions: § Explain the procedure to the client. § Assess vital signs and the client's temperature prior to transfusion. § Remain with the client during the initial 15 to 30 min of the transfusion and give 50ml of blood. Most severe reactions occur within this time frame. § Assess laboratory values (e.g., platelet count less than 20,000 and hemoglobin less than 6 g/dL). § Verify the prescription for a specific blood product. § Obtain consent for procedure if required. § Obtain blood samples for compatibility determination, such as type and cross- match. § Assess for a history of blood-transfusion reactions. § Initiate large-bore IV access. An 18- or 20-gauge needle is standard for administering blood products § Obtain blood products from the blood bank. Inspect the blood for discoloration, excessive bubbles, or cloudiness. § Prior to transfusion, two RNs must identify the correct blood product and client by looking at the hospital identification number (noted on the blood product) and the number identified on the client's identification band to make sure the numbers match. § The nurse completing the blood product verification must be one of the nurses who administers the blood product. § Prime the blood administration set with 0.9% sodium chloride only. Never add medications to blood products. Y-tubing with a filter is used to transfuse blood. § Begin the transfusion and use a blood warmer if indicated. Initiate the transfusion within 30 min of obtaining the blood product to reduce the risk of bacterial growth. § Older Adults: § No larger than a 19-gauge needle is used. § Assess kidney function, fluid status, and circulation prior to blood product administration. Older adult clients are at an increased risk for fluid overload. § Use blood products that are less than 1 week old. § Delegation: VS, can retrieve blood products § Expected lab results: § Hemoglobin: for each unit of PRBCs the Hgb is expected to increase by 1g/dL § Hematocrit: for each unit of PRBCs the Hct is expected to increase by 3%

Circulatory overload

§ Onset: Can occur any time during the transfusion § Findings § Results from a transfusion rate that is too rapid for the client. Older adult clients or those who have a preexisting increased circulatory volume are at an increased risk. § Findings include crackles, dyspnea, cough, anxiety, jugular vein distention, and tachycardia. Manifestations can progress to pulmonary edema. § Nursing Actions § Slow or stop the transfusion depending on the severity of manifestations. § Position the client upright with feet lower than the level of the heart. § Administer oxygen, diuretics, and morphine as prescribed.

Febrile reaction to blood transfusion

§ Onset: Commonly occurs within 2 hr of starting the transfusion § Findings § Results from the development of anti-WBC antibodies. Can be seen when the client has received multiple transfusions. § Findings include chills, increase of 1° F (0.5° C) or greater from the pre-transfusion temperature, hypotension, and tachycardia. § Nursing Actions § Stop the transfusion and administer antipyretics. § Leukocyte reduced blood product or a leukocyte filter to prevent § Initiate an infusion of 0.9% sodium chloride using new tubing.

Allergic reaction to blood transfusion

§ Onset: During or up to 24 hr after transfusion § Findings § Results from a sensitivity reaction to a component of the transfused blood products. § Findings are usually mild and include itching, urticaria, and flushing. § The client can develop an anaphylactic transfusion reaction resulting in bronchospasm, laryngeal edema, and shock. § Mild Reaction Nursing Actions § Stop the transfusion. § Initiate an infusion of 0.9% sodium chloride using new tubing § Administer an antihistamine, such as diphenhydramine. § If the provider prescribes to restart the transfusion, do so slowly. § Anaphylactic Reaction Nursing Actions § Stop the transfusion. § Administer epinephrine, oxygen, or CPR if indicated. § Remove the blood tubing from the client's IV access. § Initiate an infusion of 0.9% sodium chloride using new tubing.

acute hemolytic reaction

§ Onset: Immediate or can manifest during subsequent transfusions § Findings § Results from a transfusion of blood products that are incompatible with the client's blood type or Rh factor. Can occur following the transfusion of as few as 10 mL of a blood product. § Can be mild or life-threatening, resulting in disseminated intravascular coagulation (DIC) or circulatory collapse. § Findings include chills, fever, low-back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and an impending sense of doom. § Occurs within first 15 min § Nursing Actions § Stop the transfusion. § Remove the blood tubing from the IV access. § Avoid infusing further blood products into the circulatory system. § Initiate an infusion of 0.9% sodium chloride using new tubing. § Monitor vital signs and fluid status. Send the blood bag and administration set to the lab for testing.

TRALI

§ Onset: Occur 1-6hrs after transfusion § Reaction between transfused antileukocyte antibodies and recipient's leukocytes, causing pulmonary inflammation and capillary leak § Findings § Findings include fever, chills, hypotension, tachypnea, frothy sputum, dyspnea, hypoxemia, respiratory failure. Non-cardiogenic pulmonary edema § Leading cause of transfusion-related deaths § Nursing Actions § Stop infusion § Draw blood for arterial blood gases and HLA or antileukocyte antibodies. Obtain chest x-ray STAT. § Provide O2 and administer corticosteroids (diuretics of no value) as ordered. § Initiate CPR if needed and provide ventilatory and BP support if needed. § Prevention: Provide leukocyte-reduced products. Identify donors who are implicated in TRALI reactions and do not allow them to donate § Leukocyte filter § Leukocyte removal filters are used to reduce complications associated with transfused WBC that are contained in units of RBCs and platelets.

Splenectomy

§ Role: the spleen plays an important part in the body`s defense (immune) system. § It destroys bacteria to help fight infection; and helps remove old RBCs from circulation. § Reasons for removal: § Ruptured/ enlarged spleen § Blood disorders § Idiopathic thrombocytopenia purpura § Polycythemia vera § Thalassemia § Only performed after other treatments have failed to reduce the symptoms of these disorders § Cancer § Chronic lymphocytic leukemia (CLL) § Hodgkin`s lymphoma § Non-Hodgkin`s lymphoma § Infection § Severe infection or an abscess in the spleen § Cyst or tumor § Nursing Considerations § Pre-operative: ? § Post-operative: ? § Long-term risk of infection

Thrombocytopenia

§ Secondary to disease and/or treatment; greatly increases the client's risk for bleeding. § The greatest risk is at platelet counts less than 50,000/mm3, and spontaneous bleeding can occur at less than 20,000/mm3. § Nursing Considerations: § Monitor for petechiae, ecchymosis, bleeding of the gums, nosebleeds, and occult or frank blood in stools, urine, or vomitus. § Institute bleeding precautions. § Avoid IVs and injections. § Apply pressure for approximately 10 min after blood is obtained. § Handle client gently and avoid trauma. § Administer thrombopoietic medications such as oprelvekin to stimulate platelet production § Monitor platelet count and be prepared to administer platelets if the count falls below 10,000/mm3. § Client Education: § Instruct the client and family how to manage active bleeding. § Instruct the client about measures to prevent bleeding (use electric razor and soft-bristled toothbrush, avoid blowing nose vigorously, ensure that dentures fit appropriately). § Instruct the client to avoid the use of NSAIDs. § Teach the client to prevent injury when ambulating (wear closed-toes shoes, remove tripping hazards in the home) and apply cold if injury occurs. § Call HCP: § If they have black tarry or bloody bowel movements; black or bloody vomit, sputum or urine; bruising or small red and purple spots on the skin; bleeding from the mouth or anywhere in the body; headache; changes in vision; difficulty talking; sudden weakness of an arm or leg; or confusion.

Thrombotic Thrombocytopenic Purpura (ITP)

§ Uncommon disease and is the result of a deficiency of an enzyme necessary for breaking down von Willebrand's clotting factor (vWF) into normal size. This enzyme deficiency, ADAMTS13, leads to increased clotting, which decreases available platelets. The enhanced aggregation of platelets form microthrombi and they are deposited in the arterioles and capillaries. This disease is a medical emergency and is almost always associated with hemolytic-uremic syndrome (HUS). § Expected Findings: § Neurological abnormalities § Weakness, confusion, fatigue, seizures, and/or coma, abdominal pain, n/v/d, and arrythmias caused by myocardial damage § Can be the result of § Drug toxicities (chemotherapy, cyclosporin, contraceptive, valcyclovir, clopidogrel) § Pregnancy/ preeclampsia § Autoimmune disorders (lupus, scleroderma) § Diagnosis: § Labs: § CBC with platelets, LDH, PT, PTT, fibrinogen § Fragmented RBCs: Schistocytes § ADAMTS 13 activity levels § Nursing Actions: § Prevent infection § Encourage fluid intake (2-3L/day) § Hand hygiene § Soft- bristled toothbrush and stool softeners to protect mucous membranes § If infection occurs: take antibiotics as prescribed § Prevent bleeding § Including herbal/ aspirin, OTC medications § Prevent injury or trauma § Treatment: § Treat underlying cause or remove the causative agent § Plasmapheresis: done daily until the platelet count returns to normal and hemolysis has stopped. § If plasmapheresis is not effective then Rituximab may be used § Pharmacological Management § Corticosteroids § Immunosuppressive therapy § Splenectomy- if no other treatment has been effective § Contraindication: Platelet transfusion as it leads to increase platelets furthering the disease process § If this disease is untreated, irreversible renal failure and death will result

Lymphomas

§ cancers of lymphocytes and the lymph nodes, originating in the bone marrow. · Two major types of lymphoma o Hodgkin's lymphoma (HL) o non-Hodgkin's lymphoma (NHL).

Plan of care for anemia

· Assess pt knowledge · Fall risk! · Help with ADLs · Lifestyle: o Diet o Smoking cessation o No alcohol o Occupational safety · Medications

Assessment and lab findings of hemolytic anemia

· Assessment findings: o Jaundice o Pruritus § Bilirubin increased due to the breakdown of cells · Labs: o **Low H&H, high bilirubin** o Decreased CBC o Increased electrolytes due to AKI o Increased bilirubin o Increased creatinine and BUN o Increased reticulocytes

AE of erythropoietin

· Cardiac arrest · HTN · HF · MI/stroke—monitor EKG

What occurs in aplastic anemia

· Decreased production of erythrocytes (RBCs), WBCs, and Platelets from an autoimmune response o Can be idiopathic (cause is unknown) or acquired

What happens in hemolytic anemia

· Destruction of red blood cells (hemolysis) faster than RBCs can be produced o Can be from physical destruction § Prosthetic valves § Atherosclerosic vessels o Infectious agents § Mycoplasma ammonia o Mismatched blood

Assessment finding of neutropenia

· Fever may be their only sign of infection!!! 100.4!! § Neutropenia is an absolute neutrophil count of less than 1,000 o What are assessment and lab findings in a client with neutropenia? § s/s: Fever (100.4), sore throat, drainage from wounds, signs of UTI, vaginal itching · s/s of pneumonia (SOB/cough) · Classic s/s of infection are often not seen b/c they don't have wbcs to cause purulent drainage/mucus · They may be so immunocompromised they don't even spike a fever · "I just don't feel well" § Infection comes from their own normal flora § Mucus membranes are entry points for infection § Since they don't have the ability to fight off infection they can quickly go from minor infection to sepsis

Assessment finding of Anemia

· Generalized tissue hypoxia o Angina o Fatigue o Dyspnea o Night cramps o Dizziness/syncope o Headache · Compensatory—tachycardia, dyspnea, increased RR, systolic murmur, orthostatic hypotension

Assessment and lab findings of polycythemia

· HTN o Headache o Dizziness o Vertigo o Visual disturbances · HF o Angina, dyspnea, tachycardia · Ruddy (reddish complexion) o Plethora · Thrombophlebitis phenomena · Hemorrhagic phenomena o Blood vessel rupture from overdistension or inadequate platelet function · Labs: o Bone marrow biopsy to detect o Hyperuricemia o Increased RBC, hgb, WBCs, and platelets o Erythropoietin is low or normal o Increased leukocyte alkaline phosphatase (LAP) § Enzyme produced by normal mature neutrophils

What is polycythemia and secondary polycythemia?

· Increased RBCs, WBCs, and platelets · Primary: genetic mutation of the JAK 2 gene o Not preventative · Secondary: hypoxia driven o High altitudes o COPD o Smoking/occupational exposure Malignant tumors

Complications of Aplastic anemia

· Infection—elevated temp · Bleeding—hypotension, tachycardia · Impaired perfusion—cold skin

Disseminated Intravascular Coagulation (DIC)

· Is a life-threatening coagulopathy in which clotting and anticlotting mechanisms occur at the same time. So there is accelerated micro-clotting within the vessels using up all the clotting factors, causing uncontrollable bleeding. o What are the assessment and lab findings (increased vs decreased) in DIC? § Decreased = Hemoglobin, Platelets, & Fibrinogen § Increased = D-dimer, PT/INR, PTT, & Fibrin Split Products (FSP) o What are fibrin split products? § Have anticoagulation properties and breakdown fibrin so they interfere with clotting, leading to inability to stabilize fibrin, so bleeding is increased o How is DIC diagnosed? § By the decreased plasma fibrinogen and the increased coagulation factors (PT/PTT & D-dimers) o What assessment findings would indicate worsening in the condition of client with DIC? § Thrombi s/s- cyanosis, paralytic ileus, & kidney damage § Bleeding s/s- GI bleed, oozing blood from venipuncture sites, & hematuria o What is included in the plan of care (nursing and collaborative, pharmacological and nonpharmacological) for a client with DIC? § Initially- assessing and correcting underlying causes (sepsis/hemorrhage/mis-matched blood, malignancy, burns) § Then goal is to prevent organ damage and replacing bloods clotting components o What is the role of Heparin in DIC? § Heparin is used to decrease micro-clots from forming and using up the clotting factor o Why is plasma given in DIC? § If there is significant bleeding, prolonged PT/PTT § It replaces all clotting factors except platelets and is a source of antithrombin III o What are potential complications of DIC? § Bleeding/clotting of major organs, AKI, gangrene, bleeding in brain, and GI bleed o What is the priority care in a client with DIC? § Remove and TX underlying cause, stabilize pt w/ oxygenation, fluid replacement, control clotting/bleeding, and provide blood product support.

Heparin-induced thrombocytopenia (HIT)

· Is an immunity mediated clotting disorder that causes unexplained low blood platelet count as a result of treatment with heparin § Suspect HIT if... § Platelet count falls more than 50% or under 150,000 after administration or within 5-10 days after admin o What are the assessment and lab findings (increased vs decreased) in HIT? How is HIT diagnosed? § Platelet levels= decreased o What is included in the plan of care (nursing and collaborative, pharmacological and nonpharmacological) for a client with HIT? § Stop Heparin § Administer thrombin inhibitors § Direct- Fondaparinux § Indirect- Lepidine § If clotting is very severe - can remove antibody or give protamine sulfate to inhibit heparin § DO NOT give platelets (enhances thrombolytic events) § Interventions: Implement bleeding precautions, Monitor clotting factors, and Avoid use of NSAIDs o What are potential complications of HIT? § Venous/Arterial Thrombosis § DVT § Pulmonary Emboli o What is the antidote for Heparin? § Protamine Sulfate o When can warfarin be used in a client with HIT? § Warfarin should only be started when platelet count has reached 150,000 o What is the antidote for warfarin? § Vitamin K

Teaching plan for Aplastic anemia

· Monitor for infection · Educate on when to call HCP · Prevent injury and bleeding · Educate for medication therapy · Healthy lifestyle

Plan of care for hemolytic anemia

· Plan of care: o Prevent infections o Prevent hemorrhage o Pharm: § Remove cause § Immunosuppressants · Corticosteroids · Rituximab · Eculizumab § Packed RBC transfusion § Last resort · Splenectomy o Non-pharm: § Hydration § Electrolyte replacement o Teaching: § Monitor for infection § When to call HCP § Prevent injury and bleeding § Educate for medication therapy § Healthy lifestyle o Complications: § Bleeding § Hemolytic crisis · Kidney filters broken cells which causes an obstruction of clot of the kidney tubules o Causes AKI § Treatment: hydration and electrolyte replacement

Plan of care for aplastic anemia

· Prevent infections · Prevent hemorrhages · Hematopoietic stem cell transplant o 1st treatment for under 55 y/o · Immunosuppressive therapy o ATG o Cyclosporine o Cyclophosphamide o Corticosteroids o Alemtuzumab § Attaches and kills WBCs; believed to be responsible for destruction of cells in the bone marrow o Eltromopaq § Receptor agonist or bone marrow stimulant § For those not responding to other treatments o O2 o Blood transfusion o Antibiotics NON-PHARM??

Possible causes of Anemia

· Renal disease or chronic inflammation · Adverse effects of certain medication or OTC herbal supplements · Ethnicity disparities o African Americans are more likely to be anemic · Blood loss/trauma · Chemo/drugs · Prosthetic valve-hemolyzes RBCs when processing though · Infectious disease or HIV · Exposure to chemicals

Room assignment for aplastic anemia

· Room with another pt with aplastic anemia · Someone who doesn't have an infection

What is a WBC differential count?

• Shift to the left: percentage of neutrophils is greater than 60% • Seen in infections • increased number of bands (baby neutrophils) • Shift to the right: percentage of neutrophils is smaller • Bone marrow not making neutrophils • body is so overwhelmed with infection measure of the percentage of different types of white blood cells present in the blood