Chapter 31

Lifestyle modifications and techniques for preventing thromboembolism The increased blood volume and viscosity that are the hallmarks of PV create a significant risk of thromboembolism. A vascular access device is not necessary for the treatment of PV, and a low-iron diet does not resolve the disease. Patients may experience fatigue, but this risk is superseded by that of thromboembolism.

A 63-year-old woman has been diagnosed with polycythemia vera (PV) after undergoing a series of diagnostic tests. When the woman's nurse is providing health education, what subject should the nurse prioritize?

Cryoprecipitate Cryoprecipitate is given to replace fibrinogen and factors V and VII; fresh-frozen plasma is administered to replace other coagulation factors.

A client with disseminated intravascular coagulation (DIC) has a critically low fibrinogen level and is beginning to hemorrhage. To increase the amount of fibrinogen in the body, the nurse anticipates administering which blood product?

B12 The hematologic effects of vitamin B12 deficiency are accompanied by effects on other organ systems, particularly the gastrointestinal tract and nervous system. Patients with pernicious anemia may become confused; more often, they have paresthesias in the extremities (particularly numbness and tingling in the feet and lower legs). They may have difficulty maintaining their balance because of damage to the spinal cord, and they also lose position sense (proprioception).

A patient describes numbness in the arms and hands with a tingling sensation. The patient also frequently stumbles when walking. What vitamin deficiency does the nurse determine may cause some of these symptoms?

Creatinine level of 6 mg/100 mL The degree of anemia in patients with end-stage renal disease varies greatly; however, in general, patients do not become significantly anemic until the serum creatinine level exceeds 3 mg/100 mL.

A patient with end-stage kidney disease (ESKD) has developed anemia. What laboratory finding does the nurse understand to be significant in this stage of anemia?

Pancytopenia Pancytopenia is defined as an abnormal decrease in WBCs, RBCs, and platelets. The condition may be congenital or acquired. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of WBCs in circulation.

Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets?

Reports joint pain less than 3 on a scale of 0 to 10 An expected outcome for a client experiencing a sickle-cell crisis is control of pain.

A pregnant woman is hospitalized as the result of sickle-cell crisis. A finding that indicates the outcome has been achieved for this client is that the client

Intrinsic factor Pernicious anemia develops when a client lacks intrinsic factor, which normally is present in stomach secretions. Intrinsic factor is necessary for absorption of vitamin B. Vitamin B, the extrinsic factor in blood, is required for the maturation of erythrocytes.

An 82-year-old client has pernicious anemia and has been receiving treatment for several years. What is she lacking that results in pernicious anemia?

Megaloblastic A beefy, red, sore tongue is a characteristic indicator of megaloblastic anemia. The nurse should assess for other signs such as fatigue, hypotension, and tachycardia. Safety issues should also be assessed because balance, coordination, and gait are affected.

During a routine assessment of a patient diagnosed with anemia, the nurse observes the patient's beefy red tongue. The nurse is aware that this is a sign of what kind of anemia?

amount and quality of factor VIII In a less serious form of hemophilia A, von Willebrand's disease, the amount and quality of factor VIII is diminished.

Hemophilia A is the most common of the three types of hemophilia. What is diminished in the less serious form of hemophilia A, known as von Willebrand's disease?

Bronzing of the skin Clients with Cooley's anemia exhibit symptoms of severe anemia and a bronzing of the skin which is caused by hemolysis of erythrocytes.

Ralph Meander, an 80-year-old retired chemist, has been diagnosed with Cooley's anemia, a severe form of beta-thalassemia. Which of the following is a symptom of Cooley's anemia?

Hypercalcemia Hypercalcemia may occur when bone destruction occurs due to the disease process

The nurse is currently planning the care of a patient with multiple myeloma who is experiencing bone destruction. When reviewing the patient's most recent blood work, what value would the nurse pay particular attention to?

megaloblasts Megaloblasts are abnormally large erythrocytes

Vitamin B and folic acid deficiencies are characterized by production of abnormally large erythrocytes called

Receive pneumococcal and annual influenza vaccinations Clients with sickle cell anemia must treat infections promptly with appropriate antibiotics; infections, particularly pneumococcal infections, can be serious. These clients should receive pneumococcal and annual influenza vaccinations.

When a nurse is planning discharge teaching for a client admitted with sickle cell crisis, which information should the nurse include in the teaching?

alcoholism intestinal disorders Older adults and clients with alcoholism, intestinal disorders that affect food absorption, malignant disorders, and chronic illnesses often have a folic acid deficiency because of poor nutrition.

A client has a history of seizures and presents with severe fatigue, frequent headaches, and a sore, beefy-red tongue. What could be causing the client's current condition? Select all that apply.

Gradually taper the dose and frequency of medication. For a patient with thrombocytopenia, he or she gradually tapers the dose and frequency of steroid medication before discontinuing it to avoid adrenal insufficiency or crisis.

A patient has been diagnosed with thrombocytopenia. What are the primary nursing interventions while instituting corticosteroid therapy in this patient?

Megaloblastic anemia Strict vegetarians are at risk for megaloblastic anemias, which are characterized by the presence of abnormally large, nucleated RBCs, if they do not supplement their diet with vitamin B12.

The nurse is assessing a patient who is a strict vegetarian. What type of anemia is the nurse aware that this patient is at risk for?

Osteoporosis Hypertension, osteoporosis, muscle wasting, and truncal obesity are all adverse effects of long-term corticosteroid therapy; however, osteoporosis commonly causes compression fractures of the spine. Hypertension, muscle wasting, and truncal obesity aren't likely to cause severe back pain

A client diagnosed with systemic lupus erythematosus comes to the emergency department with severe back pain. She reports that she first felt pain after manually opening her garage door and that she is taking prednisone daily. What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain?

Aplastic anemia Aplastic anemia can be congenital or acquired, but most cases are idiopathic. It can be triggered by infection. The manifestations of aplastic anemia are symptoms of anemia, purpura (bruising), retinal hemorrhages, significant neutropenia, and thrombocytopenia. Other lymphadenopathies and splenomegaly sometimes occur.

A client is brought to the ED reporting fatigue, large amounts of bruising on the extremities, and abdominal pain localized in the left upper quadrant. A health history reveals the xlient has been treated for a sore throat three times in the past 2 months. Laboratory tests indicate severe anemia, significant neutropenia, and thrombocytopenia. Based on the symptoms, what could be the client's diagnosis?

Never exceed the recommended dosages of analgesics. Dress warmly in cold temperatures. While participating in physical exercise, wear constrictive clothing to support circulation. Avoid extremes of heat and cold. Wear warm clothes outside in cold weather and inside of air-conditioned rooms. Do not swim in cold water. Be cautious at high altitudes; extra oxygen may be needed. Avoid vigorous physical exercise and leg positions or clothing that cause vasoconstriction. Especially avoid exceeding the recommended dosage of narcotic analgesics and avoid self-medicating with illegal substances.

A client is hospitalized with sickle cell anemia and the nurse is preparing a teaching plan to review with the client and the client's family. Which interventions should be included? Select all that apply.

Pallor of the mucous membranes Palpitations Tachypnea Dizziness Anemia would be associated with all the correct symptoms, as well as hypotension and tachycardia.

A person who becomes gradually anemic can adjust to reduced levels of hemoglobin over time. However, as the hemoglobin count drops below 8 g/dL, the nurse needs to assess for the following indicators of serious complications. Select all that apply.

Megaloblastic anemia Strict vegetarians are at risk for megaloblastic anemias, which are characterized by the presence of abnormally large, nucleated RBCs, if they do not supplement their diet with vitamin B12.

The nurse is assessing a patient who is a strict vegetarian. What type of anemia is the nurse aware that this patient is at risk for?

agranulocytosis Agranulocytosis refers specifically to a decreased production of granulocytes, neutrophils, basophils, and eosinophils. The most common cause of agranulocytosis is toxicity from drugs such as sulfonamides, chloramphenicol (Chloromycetin), antineoplastics, and some psychotropic medications.

A nurse is caring for a client who developed toxicity after long-term treatment with sulfasalazine for Crohn's disease. The client is experiencing fatigue, fever, chills, and headache and is at risk to develop opportunistic infections. Which condition has the client most likely developed?

Neutrophil count of 50% Laboratory values consistent with a diagnosis of aplastic anemia would be a hemoglobin less than 9 g/dL, significant neutropenia and thrombocytopenia, and a reduced erythrocyte count.

A nurse practitioner suspects that a patient may have aplastic anemia based on clinical manifestations and assessment. Which one of the following lab results would be consistent with this diagnosis?

Folic acid deficiency Anemia caused by a deficiency of folic acid cause bone marrow and peripheral blood changes. The erythrocytes that are produced are abnormally large and are called megaloblastic red cells. Other cells derived from the myeloid stem cell are also abnormal. A bone marrow analysis reveals hyperplasia (abnormal increase in the number of cells). Pancytopenia (a decrease in all myeloid stem cell-derived cells) can develop. In advanced stages of disease, the hemoglobin value may be as low as 4-5 g/dL, the leukocyte count 2,000-3,000/mm3, and the platelet count less than 50,000/mm3. Cells that are released into the circulation are often abnormally shaped. The neutrophils are hypersegmented. The platelets may be abnormally large. The erythrocytes are abnormally shaped.

A client was admitted to the hospital with the following laboratory values: hemoglobin 5 g/dL, leukocyte count 2000/mm3, and a platelet count of 48,000/mm3; abnormally shaped erythrocytes and hypersegmented neutrophils were seen. The platelets appear abnormally large. A bone marrow biopsy was competed and revealed hyperplasia. Based on this information, the nurse determines that client most likely has which diagnosis?

Platelet destruction and impaired platelet production resulting from an autoimmune process Although the precise cause of ITP remains unknown, the platelet count is decreased by a combination of autoantibody-mediated platelet destruction and impaired platelet production secondary to autoantibody effects on the megakaryocyte. Viruses, impaired liver function, and inappropriate platelet aggregation are not dimensions of the etiology of ITP

A patient with a diagnosis of immune thrombocytopenic purpura (ITP) is currently receiving IVIG for the treatment of her health condition. The nurse who is providing this patient's care is aware that ITP is a consequence of:

Pancytopenia Pancytopenia is defined as an abnormal decrease in WBCs, RBCs, and platelets. The condition may be congenital or acquired.

Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets?

Start an intravenous line with dextrose 5% in 0.25 normal saline Adequate hydration is important during a painful sickling episode. Oral hydration is acceptable if the patient can maintain adequate fluid intake; IV hydration with dextrose 5% in water (D5W) or dextrose 5% in 0.25 normal saline solution (3 L/m2/24 h) may be required for a sickle crisis. Supplemental oxygen may also be needed.

A patient with sickle cell disease comes to the emergency department complaining of severe pain in the back, right hip, and right arm. What intervention is important for the nurse to provide?

Hemoglobin level When using recombinant erythropoietin, the hemoglobin must be checked at least monthly (more frequently until a maintenance dose is established) and the dose titrated to ensure the hemoglobin level does not exceed 12 g/dL.

A patient with ESRD is taking recombinant erythropoietin for the treatment of anemia. What laboratory study does the nurse understand will have to be assessed at least monthly related to this medication?

Risk The nurse should calculate the ANC using this formula: ANC = [(% Neutrophils + % Bands)/100] X total white blood cell count. For this client, the ANC = [(15 + 1)/100] X 4500. So [16/100] X 4500 = .16 X 4500 = 720. A score of 999 to 500 indicates a risk for infection.

A nurse is caring for a client with the following laboratory values: white blood cell count (WBC) 4,500/mm3, neutrophils 15%, and bands 1%. Based on the client's absolute neutrophil count (ANC), what is the client's risk of infection?

Pernicious anemia A deficiency of vitamin B 12 can occur in several ways. Inadequate dietary intake is rare but can develop in strict vegans (who consume no meat or dairy products). Faulty absorption from the GI tract is a more common cause. This occurs in conditions such as Crohn's disease, or after ileal resection or gastrectomy.

A patient had gastric bypass surgery 3 years ago and now, experiencing fatigue, visits the clinic to determine the cause. The patient takes pantoprazole (Protonix) for the treatment of frequent heartburn. What type of anemia is this patient at risk for?

Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential Clients with neutropenia often do not exhibit classic signs of infection. Fever is the most common indicator of infection, yet it is not always present. No definite symptoms of neutropenia appear until the client develops an infection. A routine CBC with differential can reveal neutropenia before the onset of infection

A nursing instructor is evaluating a student caring for a neutropenic client. The instructor concludes that the nursing student demonstrates accurate knowledge of neutropenia based on which intervention?

Pernicious anemia A deficiency of vitamin B 12 can occur in several ways. Inadequate dietary intake is rare but can develop in strict vegans (who consume no meat or dairy products). Faulty absorption from the GI tract is a more common cause. This occurs in conditions such as Crohn's disease, or after ileal resection or gastrectomy.

A patient had gastric bypass surgery 3 years ago and now, experiencing fatigue, visits the clinic to determine the cause. The patient takes pantoprazole (Protonix) for the treatment of frequent heartburn. What type of anemia is this patient at risk for?