HEMATOLOGIC Assessment 2 N370

A 36-yr-old female patient suspected of having leukemia is scheduled for a bone marrow aspiration. What statement in the patient's health history requires immediate follow-up by the nurse? a)"I had a bad reaction to iodine before and almost died." b)"I am taking an antibiotic to treat a urinary tract infection." c)"I have rheumatoid arthritis and take aspirin for joint pain." d)"I have dialysis for chronic renal failure three times a week."

"I have rheumatoid arthritis and take aspirin for joint pain." Complications of bone marrow aspiration are minimal, but there is a possibility of damaging underlying structures (especially if the sternum site is used). Other complications include hemorrhage (particularly if the patient is thrombocytopenic) and infection (particularly if the patient is leukopenic). The risk of hemorrhage is increased if the patient takes aspirin because it promotes bleeding by inhibiting platelet aggregation. Contrast dye is not used during a bone marrow aspiration. A bone marrow aspiration is not contraindicated in patients who have chronic renal failure (on dialysis) or a urinary tract infection (on an antibiotic).

An anticoagulant such as warfarin coumadin that interferes with prothrombin production will alter the clotting mechanism during: a. platelet aggregation b. activation of thrombin c. release pf tissue thromboplastin d. stimulation of factor activation complex

*Correct answer: b* Rationale: Warfarin inhibits the effective synthesis of vitamin K-dependent clotting factors: II (prothrombin), VII (stable factor), IX (Christmas factor), and X (Stuart-Prower factor) in the extrinsic pathway. Thrombin is not activated, and coagulation is interrupted in the final common pathway of the clotting cascade. Without thrombin activation, fibrinogen is not converted to fibrin, and blood clotting does not occur.

While assessing lymph nodes, the nurse should: a. apple gentle, firm pressure to deep nodes b. palpate the deep cervical and supra clavicular nodes last c. lightly palpate superficial lymph nodes with the pads of the fingers d. use the tips of the second, third, and fourth fingers to apply deep palpation

*Correct answer: c* Rationale: To assess superficial lymph nodes, lightly palpate the nodes, using the pads of your fingers. Then gently roll the skin over the area and concentrates on feeling for possible lymph node enlargement.

Malignant disorders that arise from granulocytiic cells in the bone marrow will have the primary effect of causing: a. risk for hemorrhage b. altered oxygenation c. decreased production of antibodies d. decreased phagocytosis of bacteria

*Correct answer: d* Rationale: The primary function of granulocytes is phagocytosis, a process by which white blood cells (WBCs) ingest or engulf any unwanted organism, such as bacteria, and then digest and kill it. In malignant disorders, these phagocytic cells are often reduced in number and function.

Nursing care for a pt. immediately after a bone marrow biopsy and aspiration includes: a. administering analgesics as neccessary b. preparing to administer blood transfusion c. instructing on need to lie still with sterile pressure dressing intact d. monitoring VS and assessing the site for excess drainage or bleeding

*Correct answers: a, c, d* Rationale: The needle aspiration or biopsy site is covered with a sterile pressure dressing. Monitor the patient's vital signs until stable, and assess the site for excess drainage or bleeding. If bleeding is detected, advise the patient to lie on the side for 30 to 60 minutes to maintain pressure on the site. If the bed is too soft, have the patient lie on a rolled towel to provide additional pressure. Analgesics for postprocedure pain may be administered. Soreness over the puncture site for 3 to 4 days after the procedure is normal.

Aplastic anemia

*Peripheral Blood Pancytopenia- decrease of all 3 blood cells in body* Pt. has neutropenic precautions No invasive procedures (at risk for bleeding) Diagnostic: Bone marrow aspiration to see how well or bad the bone is making blood cells Manifestations: Dyspnea, fatigue, cardio and cerebral response, petechia, nose bleed (epistaxis), ecchymosis Risk for anemia, bleeding, infections-- *septic shock and death* LOW GRADE FEVER 100.4- EMERGENCY Signs and symptoms are more important than lab values

Hematologic physical assessment + Skin

-RBC disorders, patients skin is *pale or pasty or may have a cyanotic tinge in severe anemia* -Erythrocytosis produces small vessel occlusions causing a *purple, mottled appearance in the face* -Chronic anemia (sickle cell), *clubbing of fingers* is seen Indications of bleeding disorders: Decreased platelets or clotting factors resulting in hemorrhage into skin, vascular abnormalities, brik in blood vessel walls from trauma -*Purpura*- small group of conditions characterized by ecchymosis or small hemorrhages in skin and membranes -*Petachiae-small purplish* -*Ecchymoses-bruising* -*Spider nerves- form of telangiectasia* Petachie are more likely to occur where clothing constricts the circulation and blood is accumulated in the skin or mucous membrane

Severe Anemia <6 hgb -Eyes

-Sclera of eyes associated with Jaundice especially in darker skin -Blurred vision due to retinal hemorrhage

Sever Anemia <6 hgb -Cardiovascular

-Tachycardia due to trying to maintain cardiac output -Systolic murmurs and bruits due to the low viscosity of the blood Angina & MI occur if myocardial O2 needs can't be met in serious conditions or if heart disease is already present

Normal Clotting Mechanism

-Vasoconstriction to reduce blood loss -Platelets are activated when exposed to interstitial collagen

Nursing interventions for a patient with severe anemia related to peptic ulcer disease include (select all that apply) A. monitoring stools for guaiac. B. instructions about a high-iron diet. C. taking vital signs every 8 hours. D. teaching self-injection of erythropoietin.

A. monitoring stools for guaiac. B. instructions about a high-iron diet. The stool guaiac test is done to determine whetherthe cause of the iron-deficiency anemia is related to gastrointestinal bleeding. Iron should be increased in the diet. Teach the patient which foods are good sources of iron. If nutrition is already adequate, increasing iron intake by dietary means may not be practical. The patient with iron deficiency related to acute blood loss may require a transfusion of packed red blood cells (RBCs).

You correctly identify which descriptions as characteristic of anemia of chronic disease (select all that apply) A. normocytic. B. normochromic. C. microcytic. D. hypochromic. E. proliferative.

A. normocytic. B. normochromic. Anemia of chronic disease, also called anemia of inflammation, is associated with an underproduction of RBCs and mild shortening of RBC survival. The RBCs are usually normocytic, normochromic, and hypoproliferative. The anemia is usually mild, but it can be more severe.

Priority nursing actions when caring for a hospitalized patient with new-onset temperature of 102.2° F and severe neutropenia include (select all that apply) A. administering the prescribed antibiotic STAT. B. drawing peripheral and central line blood cultures. C. ongoing monitoring of the patient's vital signs for septic shock. D. taking a full set of vital signs and notifying the physician immediately.

ALL answers are correct. Early identification of an infective organism is a priority, and samples for cultures should be obtained from various sites. In the febrile, neutropenic patient, antibiotics should be started immediately (within 1 hour). Cultures of the nose, throat, sputum, urine, stool, obvious lesions, and the blood may be indicated. Ongoing febrile episodes or a change in the patient's assessment (or vital signs) requires a call to the physician to order additional cultures, diagnostic tests, and antimicrobial therapies.

The thrombocytopenic patient has had a bone marrow biopsy taken from the posterior iliac crest. What nursing care is the priority for this patient after this procedure? a)Position the patient prone. b)Apply a pressure dressing. c)Administer analgesic for pain. d)Return metal objects to the patient.

Apply a pressure dressing. The sterile pressure dressing is applied after a bone marrow biopsy to ensure hemostasis. If bleeding is present, the patient will lie on the site and may need a rolled towel for additional pressure, thus this patient will not be in the prone position. The analgesic should have been administered preprocedure. Metal objects would be removed for an MRI, not a bone marrow biopsy.

When assessing a patient's nutritional-metabolic pattern related to hematologic health, what should the nurse do? a)Inspect the skin for petechiae. b)Ask the patient about joint pain. c)Assess for vitamin C deficiency. d)Determine if the patient can perform activities of daily living.

Assess for vitamin C deficiency. Any changes in the skin's texture or color should be explored when assessing the patient's nutritional-metabolic pattern related to hematologic health. The presence of petechiae or ecchymotic areas could be indicative of hematologic deficiencies related to poor nutritional intake or related causes. The other options are not specific to the nutritional-metabolic pattern related to hematologic health.

You are caring for a patient with a diagnosis of iron-deficiency anemia. Which clinical manifestations are you most likely to observe when assessing this patient? A. Convex nails, bright red gums, and alopecia B. Brittle nails; smooth, shiny tongue; and cheilosis C. Tenting of the skin, sunken eyes, and complaints of diarrhea D. Pale pink tongue; dull, brittle hair; and blue mucous membranes

B. Brittle nails; smooth, shiny tongue; and cheilosis Specific clinical manifestations may be related to iron-deficiency anemia. Pallor is the most common finding, and glossitis (inflammation of the tongue) is the second most common; another finding is cheilitis (inflammation of the lips). The patient may report headache, paresthesias, and a burning sensation of the tongue, all of which are caused by lack of iron in the tissues.

The nursing student asks the clinical instructor to explain why clinical symptoms are more important than laboratory values when the patient has experienced blood loss. The instructor correctly recognizes that A. nurses should focus on clinical symptoms because those are the parameters of nursing practice. B. blood values are often normal or even high because fluid shifts have not occurred and laboratory values are falsely high. C. laboratory values are used to supplement nursing assessments. D. laboratory findings are often falsely low in the early period of blood loss.

B. blood values are often normal or even high because fluid shifts have not occurred and laboratory values are falsely high. It is essential to understand that the clinical signs and symptoms the patient is experiencing are more important than the laboratory values. For example, an adult with a bleeding peptic ulcer who had a 750-mL hematemesis (15% of a normal total blood volume) within the past 30 minutes may have postural hypotension but have normal hemoglobin and hematocrit values. Over the ensuing 36 to 48 hours, most of the blood volume deficit will be replaced by the movement of fluid from the extravascular into the intravascular space. Only at these later times will the hemoglobin and hematocrit values reflect the blood loss.

When obtaining assessment data from a patient with a microcytic, hypochromic anemia, you question the patient about A. folic acid intake. B. dietary intake of iron. C. a history of gastric surgery. D. a history of sickle cell anemia.

B. dietary intake of iron. Iron deficiency anemia is a type of microcytic, hypochromic anemia.

When caring for a patient with metastatic cancer, you note a hemoglobin level of 8.7 g/dL and hematocrit of 26%. You place highest priority on initiating interventions that can reduce A. thirst. B. fatigue. C. headache. D. abdominal pain.

B. fatigue. The patient with a low hemoglobin level and hematocrit is anemic and is most likely to experience fatigue. Fatigue develops because of the lowered oxygen-carrying capacity that leads to reduced tissue oxygenation with which to carry out cellular functions.

Hematopoiesis

Blood cell production that occurs within the bone marrow which responds to increased demands for various types of blood cells by increasing production via *negative feedback system* Example: When hypoxia occurs, erythropoietin is secreted by the kidney and liver which then circulate to the bone marrow and cause differentiation of pro erythroblasts in the bone marrow

When providing teaching for the patient with iron-deficiency anemia who has been prescribed iron supplements, you should include taking the iron with which beverage? A. Milk B. Ginger ale C. Orange juice D. Water

C. Orange juice Taking iron with vitamin C (ascorbic acid) or orange juice, which contains ascorbic acid, also enhances iron absorption. Milk may interfere with iron absorption. Ginger ale and water do not facilitate iron absorption.

Which findings do you expect to find for a patient with acute loss of blood? A. Weakness, lethargy, and warm, dry skin B. Restlessness, hyperthermia, and bradycardia C. Tachycardia, hypotension, and cool, clammy skin D. Widened pulse pressure, anxiety, and hypoventilation

C. Tachycardia, hypotension, and cool, clammy skin Tachycardia, hypotension, and cool, clammy skin can be found in a person who has had an acute loss of blood. These are manifestations of hypovolemic shock. A person with a bleeding peptic ulcer who had a 750-mL hematemesis (15% of a normal total blood volume) within the past 30 minutes may have postural hypotension. Because blood is shunted to major organs, the skin in the periphery is cool to the touch. Tachycardia is the body's attempt to maintain adequate cardiac output.

Lymph

Carries fluids from the interstitial spaces to the blood as well as returns any excess interstitial fluids to the blood which is important in preventing edema aka lymphedema. Lymphedema occurs as a complication of mastectomy or lumpectomy due to and obstruction of lymph flow form the removal of lymph nodes. Superficial lymph nodes can be palpated but evaluation of the deep nodes requires radiologic examination. *Nontender consistently swellen lymph nodes may be signs of malignancy, such as Hodgkins or non Hodgkins lymphoma* *Enlarged, tender nodes are associated with an acute infection*

Complications of transfusions that can be decreased by the use of leukocyte depletion or reduction for red blood cells are A. chills and hemolysis. B. leukostasis and neutrophilia. C. fluid overload and pulmonary edema. D. transmission of cytomegalovirus and fever.

D. transmission of cytomegalovirus and fever. Infectious viruses, HIV, human herpesvirus agents transmitted by blood transfusion include hepatitis B and C type 6 (HSV-6), Epstein-Barr virus (EBV), human T-cell leukemia virus, type 1 (HTLV-1), cytomegalovirus (CMV), and malaria. Leukocyte-reduced blood products drastically reduce the risk of blood transfusion-associated viral infections, including CMV

The nurse is providing care for older adults on a subacute, geriatric medical unit. What effect does aging have on hematologic function of older adults? a)Thrombocytosis b)Decreased hemoglobin c)Decreased WBC count d)Decreased blood volume

Decreased hemoglobin Older adults frequently experience decreased hemoglobin levels as a result of changes in erythropoiesis. Decreased blood volume, decreased WBCs, and alterations in platelet number are not considered to be normal, age-related hematologic changes.

Iron is absorbed most in the...

Duodenum and upper jejunum (only 5-10% of ingested iron is absorbed) *Iron is obtained from food and dietary supplements. It accounts for 2/3 of rbc in out body, the other 1/3 is stored. If stored iron is not replaced, Hgb production is reduced*

The nurse is reviewing the objective data from the table below of a patient with suspected allergies. Which assessment finding does the nurse know indicates allergies?Tab 1Tab 2Tab 3Physical examinationLaboratory resultsMedicationsDry coughPale skinNeutrophils: 60%Eosinophils: 10%Basophils: 1%Lymphocytes: 20%Monocytes: 6%Acetaminophen 1000 mg every 12 hoursLevothyroxine (Synthroid) 125 mcg each day a)Dry cough b)Eosinophil result c)Lymphocyte result d)Acetaminophen use

Eosinophil result Eosinophils are granulocytes that phagocytize antigen-antibody complexes formed during an allergic response. The normal eosinophil count is 2% to 4% of all white blood cells. The dry cough, lymphocyte result, and acetaminophen use do not indicate allergies.

Liver

Functions as a filter, produces all procoagulants that are needed to hemostasis and stores iron that is in excess of tissue needs which can occur w frequent blood transfusion or disease that cause iron overload. Hepcidin is a key regulator of iron balance made by the liver. It does so by being stimulated by iron overload and inflammation which then it inhibits the release of stored iron from enterocytes. Thus when iron is deficient the hepatocytes produce less hepcidin.

When assessing laboratory values on a patient admitted with septicemia, what does the nurse expect to find? a)Increased platelets b)Decreased red blood cells c)Decreased erythrocyte sedimentation rate (ESR) d)Increased bands in the white blood cell (WBC) differential

Increased bands in the white blood cell (WBC) differential When infections are severe, such as in septicemia, more granulocytes are released from the bone marrow as a compensatory mechanism. To meet the increased demand, many young, immature polymorphonuclear neutrophils (bands) are released into circulation. WBCs are usually reported in order of maturity (initially with the less mature forms on the left side of a written report). Hence, the term "shift to the left" is used to denote an increase in the number of bands. Thrombocytosis occurs with inflammation and some malignant disorders. Decreased red blood cells indicate anemia. Decreased ESR is not indicative of septicemia.

Results of a patient's most recent blood work indicate an elevated neutrophil level. The nurse recognizes that this diagnostic finding most likely suggests which problem? a)Infection b)Hypoxemia c)Acute thrombotic event d)Risk of hypocoagulation

Infection An increase in the neutrophil count most commonly occurs in response to infection or inflammation. Hypoxemia and coagulation do not directly affect neutrophil production.

Thrombocytes (platelets)

Initiates clotting process by producing a platelet plug

Hemostasis

Used to describe the arrest of bleeding. 1) *Vascular injury and sub endothelial exposure* -when a blood vessel is injured, an immediate local vasoconstrictive response occurs. Vasoconstriction reduces the leakage of blood from the vessel not only by restricting the vessel size but by pressing the endothelial surfaces together. The platelet response and plasma clotting factors are triggered by endothelial injury and the release of thromboxane A2 2)*Platelet adhesion* *Stickiness -The loss of endothelial cells exposes adhesive glycoproteins such as collagen and von willebrand factor to which platelets adhere to. 3)*Platelet activation* -The interaction above causes platelets to undergo an activation response which leads to changes in platelet shape. The platelets then have the ability to bind adhesive proteins. ADP also recruits and activates other platelets. 4)*Platelet aggregation*

The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse should expect to note which sign or symptom in the client as a result of the anemia? a. Bradycardia b. Muscle cramps c. Increased respiratory rate d. Shortness of breath with activity

d. Shortness of breath with activity The client with anemia is likely to experience shortness of breath and complain of fatigue because of the decreased ability of the blood to carry oxygen to the tissues to meet metabolic demands. The client is likely to have tachycardia, not bradycardia, as a result of efforts by the body to compensate for the effects of anemia.

The nurse should remember the following teaching and administration points when giving iron:

•Administer iron preparations with orange juice to enhance absorption. •If giving an iron elixir, it should be administered through a straw to prevent staining the teeth. •When administering iron IM, it should be given through the IM Z track method to avoid stain of skin. •Instruct the patient that her stools might be dark green or black when taking iron preparations. •When administering IM or IV, monitor closely for anaphylaxis. •Client education should focus on drug administration and side effects. •The client should be instructed to increase dietary iron intake (good sources of iron include egg yolk; green, leafy vegetables; iron-fortified cereals; peanut butter; raisins; molasses; beans; oatmeal; dried fruit; and organ meats). •Enteric coated or sustained release capsules are DOC because they will release iron farther into the GI tract which is absorbed better for the duodenum and jejunum. BUT they are counterproductive and expensive. • Daily dosage is 150-200 mg of iron which is ingested in 3-4 doses about 50-100 mg a dose. • Iron is best absorbed as ferrous sulfate in an acidic environment. For this reason and to avoid binding in iron with food, *iron should be taken an hour before meals* when duodenal mucosa is most acidic. •If pt. can not handle side effects associated with ferrous sulfate (heartburn, constipation, diarrhea) iron supplement could be adjusted or replaced with ferrous gluconate. •Constipation is the most common, if so patient should be started on stool softener and laxatives. •Iron therapy takes 2-3 months for Hgb levels to return to normal •Pt. that need life long iron therapy should be monitored for *potential liver problems rt iron storage* monitor for BUNs

The symptoms of iron deficiency anemia are the same as general anemia. There are a few symptoms for severe, prolonged anemia that are different (included here):

•Brittle nails •Cheilosis (ulcers in the corner of the mouth) •Sore tongue •Koilonchyia (concave or spoon-shaped fingernails) •Pica (craving to eat unusual substances such as clay or starch)

CBC & Pap smear

Pap smears are used to look at the morphology (shape and appearance) of the blood cells which when combing this and CBC, assists with the diagnosis.

Liver

Responsible for synthesis of coagulation factors, albumin and also to remove non functioning erythrocytes

You are taking care of a male pt. who has the following labs from his CBC: WBC 6.5, Hgb 13.4, Hct 40%, platelets 50. What are you most concerned about? a. pt. is neutropenic b. pt. has an infection c. pt. is at risk for bleeding d. pt. is at risk for falls due to his anemia

*Correct answer: b* Rationale: The patient complete blood cell count (CBC) has normal parameters except for the platelet count, which is below normal.

The nurse is planning health promotion teaching for a group of healthy older adults in a residential community. Which statement accurately describes expected hematologic effects of aging? a)"Platelet production increases with age and leads to easy bruising." b)"Anemia is common with aging because iron absorption is impaired." c)"Older adults with infections may have only a mild white blood cell count elevation." d)"Older adults often have poor immune function with a decreased number of lymphocytes"

"Older adults with infections may have only a mild white blood cell count elevation." During an infection, the older adult may have only a minimal elevation in the total white blood cell count and may not have a fever. Presentation of infection can initially be nonspecific with disorientation, anorexia, and weakness. Platelets are unaffected by the aging process. However, changes in vascular integrity from aging can manifest as easy bruising. Iron absorption is not impaired in the older patient, but adequate nutritional intake of iron may be decreased. The total white blood cell count and differential are generally not affected by aging. However, a decrease in humoral antibody response and decrease in T-cell function may occur.

When reviewing lab results of an older pt. with an infection, the nurse would expect to find: a. minimal leukocytosis b. decreased platelet count c. increased hemoglobin and hct levels d. decreased erythrocyte sedimentation rate (ESR)

*Correct answer: a* Rationale: During an infection, an older adult may have only a minimal elevation in the total WBC count. This laboratory finding suggests a diminished bone marrow reserve of granulocytes in older adults and reflects possible impaired stimulation of hematopoiesis.

Significant info obtained from pts health history that relates to the hematologic system includes: a. jaundice b. bladder surgery c. early menapause d. multiple pregnancies

*Correct answer: a* Rationale: Jaundice is a common symptom that occurs with hematologic abnormalities. Jaundice is related to an accumulation of bile pigment that is caused by rapid or excessive hemolysis or liver damage.

An individual who lives at a high altitude may normally have an increased Hgb and RBC count because: a. high altitudes cause vascular fluid loss, leading to hemo- concentration b. hypoxia caused by decreased atmospheric O2 stimulates erythropoiesis c. the function of spleen in removing old rbcs is impaired at high altitudes d. impaired production of leukocytes and platelets lead to proportionally high rbc count

*Correct answer: b* Rationale: Normal physiologic increases in the red blood cell (RBC) count occur at high altitudes. At high altitudes, less atmospheric weight pushes air into the lungs; the partial pressure of O2 is thereby decreased, which causes hypoxia. Erythropoiesis is stimulated by hypoxia and controlled by erythropoietin, a glycoprotein growth factor synthesized and released by the kidneys. Erythropoietin stimulates the bone marrow to increase erythrocyte production.

If a lymph node is palpated, what is a normal finding? a. hard, fixed nodes b. firm, mobile nodes c. enlarged, tender nodes d. hard, nontender nodes

*Correct answer: b* Rationale: Ordinarily, lymph nodes are not palpable in adults. If a node is palpable, it should be small (0.5 to 1 cm), mobile, firm, and nontender to be considered a normal finding.

Red blood cells

*Erythrocytes (RBC)* *Main function:* transportation of both O2 and CO2. *Erythrocytes are composed of:* hemoglobins which is a *complex protein iron compound* that consists of heme (iron compund) and globin (simple protein) *Erythropoiesis:* As RBCs circulate through capillaries surrounding alveoli within the lung, O2 attaches to iron which is then reffered to as oxyhemoglobin which is responsible for giving blood its bright red color. As RBCs flow to body tissues, O2 detaches from hemoglobin and diffuses from the capillary into the tissue cells. CO2 diffuses from tissue cells and into the capillary, attaching to the globin portion of hemoglobin and then transports to lungs for removal. *Regulated by:* cellular o2 requirements and general metabolic activity. Erythropoiesis is stimulated by hypoxia and controlled by erythropoietin (glycoprotein growth factor synthesized and released by the kidneys) which then stimulates the bone marrow to increase erythrocyte production. *Erythrocytes life span is 120 days* Erythrocyte productioon is also affected by endocrine hormones such as corticosteroids, testosterone and thyroxine (ex: hypothyroidism associated with anemia) When evaluating the rate and adequacy of erythrocyte production, assess the number of reticulocytes (immature erythrocytes) *Reticulocyte is an immature erythrocyte*

Primary symptom of a hematologic disorder

*Fatigue!* Others: apathy, malaise, dyspnea, palpitations, arthralgia (joint pain), paresthesias, numbness and tingling Arthralgia may indicate an autoimmune disorder such as rheumatoid arthritis or may be caused by gout secondary to increased uric acid production as a result of a hematologic malignancy or hemolytic anemia Hemathrosis (blood in join) occurs in patients with bleeding disorders and are painful

Severe Anemia <6 hgb -Integumentary Manifestations

*Jaundice & sclera of eyes* when hemolysis of RBC results in an increased concentration of serum bilirubin *Pallor* from reduced amounts of hemoglobin and reduced blood flow to skin *Pruritus* bc of increased serum and skin bile salt concentrations

Iron deficiency anemia *diagnostic tests*

*Labs:* -CBC -Stool guaiac to see if blood is in stool *Endoscopy* *Colonoscopy*

White blood cells

*Leukocytes* originate from the bone marrow and reside in the thymus or secondary lymphoid tissues (spleen, lymph nodes, peyer patches) Appears white when separated from the RBCs Granulocytes include *Neutrophils-primary phagocytic cells involved in inflammatory response*, basophils, eosinophils. The Primary function of granulocytes is phagocytosis (process which WBCs engulf any unwanted organism and digest and kill it) An increase in neutrophils is the common diagnostic indicator of an infection or tissue injury Eosinophils 0-4%- engulf antigen antibody complexes formed during an allergic response. An elevation in these levels indicate neoplastic disorders such as Hodgkins lymphoma, and other skin diseases. Basophils 2%- contain heparine and histamine. If a basophil is stimulated by an antigen or tissue injury, it responds by releasing substances and inflammatory reactions. Basophils act similarly to mast cells but mast cells reside in connective tissues.

Neutropenic precautions

*Minimize risk of life threatening infections w white blood cell count less than 2000* -HAND HYGIENE! -Avoid staff and visitors w illness -Protective gowns, gloves, mask -Avoidance of invasive procedures -Avoidance of fresh fruit, vegetables, raw meat, egg and flowers -Meticulous skin care -Assessment of mouth for stomatitis, ulcers, white patches (soft tooth brushes should be used and avoid alcoholic based mouth wash!) -HEPA room with high filtering system to eliminate and reduce pathogens

Anemia

*Most common blood disorder of infancy, childhood and geriatric population* First thing done with suspected anemic patient: Find cause!!! Deficiency in the number of erythrocytes (rbc), quantity or quality of hemoglobin, and hematocrits. Because rbc transport O2, erythrocyte disorders can lead to *hypoxia* Diagnostic test: CBC and peripheral blood smear. Once it is identified, further investigations are done to determine cause. *Anemia symptoms: Most common -Pallor -Glossitis -Chelitis (swelling of tongue) Also: -HA -Paresthesia -Burning sensation of tongue *Hemoglobin levels are used to determine severity of anemia*

Iron deficiency anemia

*Most common nutritional disorder in the world.* Occurs in young people with poor diets and women in reproductive years. It develops as a result of: 1) Inadequate dietary intake 2) Malabsorption of iron that occurs after GI surgery such as removal or bypass of duodenum or malabsorption syndromes that occur of the duodenum in which iron is altered or destroyed 3) Blood loss 4) Hemolysis *Pallor is the most common, first findings* *Glossitis (inflammation of tongue) is the second* *Cheilitis (inflammation of lip) *HA* *Paresthesia* *Burning sensation of tongue* All of these are caused by lack of iron in tissues!

Platelet count

*N: 150,000-400,000* Counts below 100,000- thrombocytopenia where bleeding occurs Counts below 10,000- hemorrhage occurs Thrombocytosis- disorder that occurs with inflammation and leads to excessive platelets which puts patient at risk for excessive clotting

WBC Count

*N: 4,000-11,000* Elevation >11,000- infection, inflammation, tissue injury/death, malignancies (leukemia, lymphoma) Elevation >25,000- indicate types of leukemia Decrease <4,000- *leukopenia* is associated with bone marrow depression or severe chronic illness Differential count- measures the % of each type of leukocyte which determines the cause of illness. When infections are severe, more granulocytes are released from bone marrow as a compensatory mech. To meet the increased demand, many immature neutrophils (bands) are released into circulation. These are termed *Shift to the Left* The differential count is considered significant bc it is possible for total WBC to remain normal despite marked change in leukocytes. *Neutropenia* is a condition when the bone marrow does not produce enough neutrophils and ANC is less then less than 1,000 cells. Neutropenia is a result from a number of disease processes such as leukemia, or bone marrow suppression and puts pt. at high risk of infection and death from sepsis.

Neutropenia

*Reduction in neutrophils (ANC- >1000 cells, Normal range- 2200 to 7700, Severe- >500 cells)* The faster the drop and longer duration patient is neutropenic, the greater risk of life threatening infection, sepsis and death! (Patient 60 yo or older, existing infection, in a hospital setting, have diabetes or other co morbid conditions are higher at risk) *NADIR- from chemo & immunosuppression therapy* is the most common cause of neutropenia *Low grade fever >100.4* in neutropenic pt. is of great significance because it indicates infection and septic shock which leads to death, *thus needs to be treated immediately! TOP PRIORITY* *1. Blood cultures should be drawn stat (2 or 1 from peripheral & 1 from venous)* *2. Antibiotics are started w/in 1 hour* Symptoms associated w infection to watch for in neutropenic patient: -sore throat/unproductive cough -dysphagia/SOB -ulcerative lesions of pharynx or buccal mucosa -diarrhea -rectal tender -vaginal itch *Report symptoms immediately*

Anemia Nursing intervention

*To stabilize acute anemia* -blood transfusions -drug therapy (erythropoietin, vitamin supps) -RBC replacement -O2 therapy *Correct physiologic status deficits (e.g., chemotherapy-induced anemia) as priority items* *Encourage alternating rest and activity periods to provide activity without tiring the patient* *Monitor cardiorespiratory response to activity (e.g., tachycardia, dysrhythmias, dyspnea, diaphoresis, pallor, respiratory rate) to evaluate activity intolerance* *Arrange physical activities (e.g., avoid activity immediately after meals) to reduce competition for O2 supply to vital body functions* *Assist with regular physical activities (e.g., ambulation, transfers, turning, personal care) to minimize fatigue and risk of injury from falls* *Instruct patient about nutritional needs (i.e., encourage increased intake of protein, iron, vitamin C) to provide nutrients needed for maximum iron absorption and hemoglobin production*

RBC count

*Total* Female: 3.8-5.1 Male: 4.3-5.7 *Hematocrit (Hct) measurent of packed cell volume of RBCs expressed as a % of the total blood volume* Female: 35%-47% Male: 39%-50% *Hemoglobin (Hgb) measurement of gas carrying capacity of RBC* Female: 11.7-15.5 Male: 13.2-17.3

Iron supplement

-Best given enteric coated (digested in dejunum) -Could stain teeth and cause dark stools (normal!) -Ztrack! -Drink with OJ because acidic environment helps with absorbency (not milk!) -Take an hour before meals if no stomach SE

Hematologic Diagnostic Studies

-CBC (cell types) -Erythrocyte Sedimentation Rate (ESR) *indicates inflammatory response* -Blood typing and RH factor (ABO, Rh-/+) -Iron metabolism (TIBC, Transferrin)

Radiologic Studies

-CT (computed tomagraphy) -MRI -PET -Liver, spleen, or abdominal ultrasound -Skeletal x-rays

Sever Anemia <6 hgb -Mouth

-Glossitis -Smooth tongue

The patient has anemia and has had laboratory tests done to diagnose the cause. Which results does the nurse know indicates a lack of nutrients needed to produce new red blood cells (RBCs) (select all that apply.)? Select all that apply. a)Increased homocysteine b)Decreased reticulocyte count c)Decreased cobalamin (vitamin B12) d)Increased methylmalonic acid (MMA) e)Elevated erythrocyte sedimentation rate (ESR)

-Increased homocysteine -Decreased cobalamin (vitamin B12) -Increased methylmalonic acid (MMA) Increased homocysteine and MMA along with decreased cobalamin (vitamin B12) indicate cobalamin deficiency, which is a nutrient needed for RBC production. Decreased reticulocytes indicate low bone marrow activity in producing RBCs, not available nutrients. Elevated ESR is related to an increased inflammatory process, not anemia.

A 30-yr-old patient has undergone a splenectomy as a result of injuries sustained in a motor vehicle accident. Which phenomena are likely to result from the absence of the patient's spleen (select all that apply.)? Select all that apply. a)Impaired fibrinolysis b)Increased platelet levels c)Increased eosinophil levels d)Fatigue and cold intolerance e)Impaired immunologic function

-Increased platelet levels -Impaired immunologic function Splenectomy can result in increased platelet levels and impaired immunologic function as a consequence of the loss of storage and immunologic functions of the spleen. Fibrinolysis, fatigue, and cold intolerance are less likely to result from the loss of the spleen since coagulation and oxygenation are not primary responsibilities of the spleen

Iron deficiency *management*

-Infants get formula and cereal with iron added *Don't give fresh cows milk under 12 mo old* -Adults & kids need iron fortified foods -Oral iron supplement -Provide rest (space activities) -Assist with ADLs -Monitor for constipation -Education needed rt nutrition and meds

Hematologic System Physical Examination

-Lymph node assessment -Palpitation of liver & spleen -Skin assessment

Elderly changes on the hematologic system

-decrease in bone marrow mass and cellularity & increase in bone marrow fat -although the older adult is still capable of maintaining adequate blood cell levels, the reserve capacity leaves the older adult more vulnerable to possible problems with clotting, transporting O2, and fighting infection especially during periods of increased demand thus results in a diminished ability of an older adult to compensate for an acute or chronic illness -hemoglobin levels begin to decrease due to total serum iron are all decreased thus iron deficiency is responsible for the low hemoglobin levels but before diagnosing iron deficiency anemia; assess for GI bleed to rule it out -during an infection, older adults may have only a minimal elevation in total WBC count due to the lab findings suggesting a diminished bone marrow reserve of granulocytes which reflect the possible impaired stimulation of hematopoiesis -changes in vascular integrity rt aging can manifest as easy bruising -platelet levels are unaffected but functionally may have increased adhesiveness

Neutropenic nursing roles

-determine the type of isolation precaution that needs to be initiated -assess pt. for S&S of infection (fatigue or confusion) -screen visitor for infectious disease -communicate w dietary ti eliminate undercooked meats from pt. diet -instruct pt and visitors handwashing -teach pt. & caregiver how to avoid infection (skin care, oral hygiene) -If pt. is outpatient, teach about S&S and to report to HCP if occur

Medications and supplements that interfere with our blood cells

-herbs interfere with clotting -chemotherapy (cancer) and antiretroviral (HIV) cause bone marrow depression -coumadin could be a risk for bleeding problems

Clinical manifestations in older adults

-pallor -confusion -ataxia -fatigue -worsening of cardiovascular and resp. problems Signs of anemia go on being overlooked because they may be mistaken for normal aging changes

Iron deficiency *collaborative care*

1) Identify underlying cause and treat 2) Iron supplements 3) Nutritional therapy 4) Transfusion of PRBCs (symptomatic way)

Causes of anemia

1) deficient nutrients 2) decreased erythropoietin 3) decreased iron 4) blood loss 5) increased RBC destruction- hemolysis, sickle cell, incompatible blood, trauma

Normal blood volume range levels

150-180 lb patients- 4.7 to 5.5 (5-6 quarts) -Plasma makes up 55% of blood -Blood cells (RBC, WBC, platelets) make up 45% blood

A nurse is assessing an adult client's endurance in performing ADLs. What question does the nurse ask the client? 1."Can you prepare your own meals?" 2."Has your weight changed by 5 pounds or more this year?" 3."How is your energy level-compared with last year?" 4."What medications do you take daily, weekly, monthly?"

3. This question from Gordon's Functional Health Pattern Assessment is an activity exercise question that correctly assesses endurance compared with self-assessment in the past. It is most likely to provide data about the client's ability and endurance with ADLs. The client may never have been able to prepare his or her own meals. This question does not really address endurance.

In a severely anemic patient, you expect to find A. dyspnea and tachycardia. B. cyanosis and pulmonary edema. C. cardiomegaly and pulmonary fibrosis. D. ventricular dysrhythmias and wheezing.

A. dyspnea and tachycardia. Patients with severe anemia (hemoglobin <6 g/dL) exhibit the following cardiovascular and pulmonary manifestations: tachycardia, increased pulse pressure, systolic murmurs, intermittent claudication, angina, heart failure, myocardial infarction; tachypnea, orthopnea, dyspnea at rest.

Radiation + hematologic problems

A person exposed to radiation or chemicals has a higher incidence of certain hematologic problems. Ask patients about a history of being in the military because many Vietnam war veterans were exposed to a *dioxin-containing defoliant (agent orange)* which has been linked with leukemia and lymphoma.

By definition, neutropenia occurs when the white blood cell (WBC) count drops below? A. 4000/μL B. 3000/μL C. 2000/μL D. 1000/μL

A. 4000/μL

Which patient is most likely to experience anemia caused by increased destruction of RBCs? A. An African American man who has a diagnosis of sickle cell disease B. A 59-year-old man whose alcoholism has precipitated folic acid deficiency C. A 30-year-old woman with a history of "heavy periods" accompanied by anemia D. A 3-year-old child whose impaired growth and development is attributable to thalassemia

A. An African American man who has a diagnosis of sickle cell disease The cause of sickle cell anemia involves increased hemolysis. Thalassemias and folic acid deficiencies decrease erythropoiesis, whereas the anemia related to menstruation is a direct result of blood loss.

You receive a physician's order to transfuse fresh frozen plasma to a patient suffering from an 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. Hand 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. The fresh frozen plasma should be administered as rapidly as possible and should be used within 2 hours of thawing. 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.

Alcohol + hematologic problems

Alcohol is a caustic agent to the GI mucosa and can cause damage that results in GI bleed, esophageal varices, and frequent vitamin deficiencies. Alcohol also exerts a damaging effect on platelet function and the liver where clotting factors are produced.

The nurse is caring for a 36-yr-old male patient receiving phenytoin (Dilantin) to treat seizures resulting from his traumatic brain injury as a teenager. It is most important for the nurse to observe for which hematologic adverse effect of this medication? a)Anemia b)Leukemia c)Polycythemia d)Thrombocytosis

Anemia Hematologic adverse effects of phenytoin include anemia, thrombocytopenia, leukopenia, granulocytopenia, agranulocytosis, and pancytopenia.

Mild anemia manifestations

Hgb: 10-14 May exist without causing symptoms but can include palpitations, dyspnea, and diaphoresis

Moderate anemia manifestations

Hgb: 6-10 Increased palpitations, dyspnea, roaring in ears, fatigue

Severe anemia manifestations

Hgb: >6 has many manisfestations involving multiple body systems (pulmonary edema) Cardiopulmonary symptoms are increased: heart murmurs, CHF, acute MI, cardiomegaly, client may experience them while resting or with activity

Foods high in Iron

Liver Muscle meats Dried fruit Legumes Dark green leafy vegetables Whole grain Enriched bread and cereals Beans

Parenteral iron is only administered if...

Malabsorption is occuring

The nurse is providing care to a pt. after a bone biopsy. Which action should the nurse take a part of aftercare for this procedure? a. monitor VS per day b. keep area in a dependent position c. administer IM opioid analgesics d. monitor the site for swelling, bleeding, or hematoma formation

Monitor the site for swelling, bleeding or hematoma formation Rationale: Nursing care after a bone biopsy includes monitoring the site for swelling, bleeding, or hematoma formation. The VS are monitored every 4 hours for 24 hours. The biopsy site is elevated for 24 hours to reduce edema. A dependent position would increase the risk for bleeding. The pt. usually requires mild analgesics for more severe pain would usually indicate complications that are arising. The nurse should advise pt. that mild to moderate discomfort is normal after a bone biopsy.

Hematologic physical assessment + Lymph Nodes

Nurse should lightly palpate the nodes symmetrically using the pads of the fingers which then should gently roll the skin over the area and concentrate on feeling for enlargement in superficial nodes. Deep nodes are assessed via radiology. Sequence: 1)Start at head and neck 2)Next, palpate axillary and pectoral 3)Then, examine epitrochlear e nodes 4)Lastly, inguinal lymph nodes found in groin Note: location, size (cm), degree of fixation (movable, fixed), tenderness and texture. N: lymph nodes are not palpable, if so it should be small (0.5-1 cm), mobile, firm and nontender. AN: tender, hard, fixed or enlarged. Tender nodes are usually a result of inflammation; where as hard or fixed nodes indicate malignancy.

Plasma

Plasma proteins (albumin, globulin, fibrinogen) are produced by the liver except antibodies (immunoglobulin) are produced by plasma cells. *Albumin is a protein that helps maintain oncotic pressure in the blood*

In assessing the patient, which abnormal finding should the nurse relate to hemostasis abnormalities? a)Purpura b)Pruritus c)Weakness d)Pale conjunctiva

Purpura Purpura may occur when platelets or clotting factors are decreased and bleeding into the skin occurs. Pruritus is not related to hemostasis but to hematologic cancers (e.g., lymphomas, leukemias) or increased bilirubin. Weakness and pale conjunctiva are not related to hemostasis unless a lot of bleeding leads to anemia with low hemoglobin level.

A 62-yr-old male patient with disseminated intravascular coagulation (DIC) after urosepsis has a platelet count of 48,000/μL. The nurse should assess the patient for which abnormality? a)Pallor b)Purpura c)Pruritus d)Palpitation

Purpura The normal range for a platelet count is 150,000 to 400,000/μL. Purpura is caused by decreased platelets or clotting factors, resulting in small hemorrhages into the skin or mucous membranes. Pallor is decreased or absent coloration in the conjunctiva or skin. Pruritus is an intense itching sensation. Palpitation is a sensation of feeling the heart beat, flutter, or pound in the chest.

Spleen

Removes damaged erythrocytes from circulation A person who has had a splenectomy has higher circulating levels of platelets than a person who has a spleen.

If we lose a lot of blood fast, biggest problem would be..

Shock S&S: -low BP -tachycardia -dysphagia -skin cool & clammy -weak Not important to get Hgb and Hct because labs will not show until 4-6 hours later

Cigarettes + hematologic problems

Smoking increases LDL cholesterol and levels of CO2 leading to hypoxia and altering the anticoagulant properties of the endothelium. Smoking increases platelet reactivity, plasma fibrinogen, hematocrit, and blood viscosity

The nurse collects a nutritional history from a 22-yr-old woman who is planning to conceive a child in the next year. Which foods reported by the woman would indicate that her diet is high in folate and iron? a)Crab, fish, and tuna b)Milk, cheese, and yogurt c)Spinach, beans, and liver d)White rice, potatoes, and pasta

Spinach, beans, and liver Normal intake of iron and folic acid is necessary for the development of red blood cells, and normal levels before conception and in early pregnancy are particularly important for normal fetal development. Foods high in both folic acid and iron include liver, red meat, egg yolks, turkey or chicken giblets, beans, lentils, chick peas, soybeans, spinach, and collard greens. In addition, enriched cereals, pasta, and breads are also high in both folic acid and iron (check the labels).

Bone Marrow

Stem cells originate, mature and are released into the blood

Bone marrow biopsy

Technique involves removal of bone marrow through a locally anesthetized site to evaluate status of blood forming tissue. The exam may involve aspiration only or aspiration with biopsy.It is used to diagnose and monitor multiple myelomas, gives a full evaluation of hematopoiesis. *Done by a physician or specialized nurse* *Preferred site- posterior iliac crest* *10 mL syringe aspirates 0.2-5 mL of fluid marrow* *Nurse responsibilities* *Before:* Explain procedure, obtain signed consent form, ensure that a TIME OUT us done before procedure. Analagesic administration may be done for comfort. *After:* Apply sterile pressure dressing after procedure. Assess site for bleeding and apply pressure as needed to ensure hemostasis. Assess VS until stable. If pt. is bleeding, have pt. lie on dependent side (opp. side of procedure) for 30-60 mins to maintain pressure on site. If bed it too soft, have pt. lie on rolled towel to provide extra pressure. Assure soreness over site for 3-4 days is normal.

Iron Deficiency

The management of iron deficiency anemia is conservative. The cause of the anemia is explored. The healthcare provider will focus on determining the source of the blood loss. A stool specimen for occult blood and endoscopic exam might be ordered to rule out these common GI sources of bleeding. A thorough menstrual history is obtained from female patients with anemia to determine whether blood loss might be the source of the anemia. The treatment for iron deficiency anemia includes treating the underlying cause of the anemia, medications for iron replacement, client education, and administration of blood transfusions in severe cases of depletion. The drugs used during therapy include ferrous sulfate (Feosol) and iron dextran injection (Imferon).

Thrombin

The most powerful and common enzyme in the coagulation process

A blood type and cross-match has been ordered for a male patient who is experiencing an upper gastrointestinal bleed. The results of the blood work indicate that the patient has type A blood. Which description explains what this means? a)The patient can be transfused with type AB blood. b)The patient may only receive a type A transfusion. c)The patient has A antigens on his red blood cells (RBCs). d)Antibodies are present on the surface of the patient's RBCs.

The patient has A antigens on his red blood cells (RBCs). An individual with type A blood has A antigens, not A antibodies, on his RBCs. An AB transfusion would result in agglutination, but he may be transfused with either type A or type O blood.

Pancytopenia

When the entire CBC count is supressed and there is a decrease in number of RBCs, WBCs, and platelets.