MS CH. 33 Management of Non-Malignant Blood Disorders

apply pressure to puncture site for a full 10 min

A client with thrombocytopenia has just had a bone marrow aspirate performed to monitor for treatment effectiveness. Which of the following nursing interventions take priority?

6 to 12 months

A health care provider prescribes one tablet of ferrous sulfate daily for a 15-year-old girl who experiences heavy blood flow during her menstrual cycle. The nurse advises the patient and her mother that this over-the-counter preparation must be taken for how many months before stored iron replenishment can occur?

disposing of needles uncapped

A nurse is assigned to a client with acquired immunodeficiency syndrome (AIDS). When handling the client's blood and body fluids, the nurse uses standard precautions, which include:

Invasive procedures

Break in skin integrity leads to increased opportunity for organisms to enter blood system.

Hypogammaglobulinemia

Decreased antibody formation.

Lymphocytopenia; disorders of lymphoid system (chronic lymphocytic leukemia, lymphoma, myeloma)

Decreased cell-mediated and humoral immunity.

Poor dentition; mucositis

Decreased endothelial integrity leads to increased opportunity for organisms to enter blood system.

Liver dysfunction

Decreased synthesis of clotting factors.

staining the teeth

Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid

diagnostics for anemia

H and H, RBC indices, reticulocyte count, iron studies, vitamin B12, folate, haptoglobin, bone marrow aspiration

assess risk of bleeding from activity

ITP nursing management

10,000

ITP patients may also be counseled to refrain from vigorous sexual intercourse when the platelet count is less than

medical alert bracelet

all hemophiliacs should wear one of these

haptoglobin

binds to free hemoglobin released from RBCs

sickle cell

blood is too viscous FLUIDS!!! (and pain meds)

maintain hemodynamic status

major goal of patient with DIC

S shaped

shape of hemoblobin in sickle cell

20,000

when platelet count drops to this level, petechiae can appear, along with bleeding from nose, gums, and excessive menstrual/post dental bleeding

neuroloical

with hemolytic anemias, the most significant complications are of this nature *NEURO EXAM SHOULD BE PERFORMED ON ALL PTS SUSPECTED OF THIS TYPE OF ANEMIA

Xoralto

works directly on factor 5

Deconditioning

Decreased mobility leads to decreased respiratory effort, leading to increased pooling of secretions.

Renal dysfunction

Decreased platelet function.

Nutritional status

Decreased protein stores lead to decreased immune response and anergy.

Increased intracranial pressure

Increased blood pressure leads to rupture of blood vessels.

Duration of neutropenia

Increased duration leads to increased risk of infection.

Poor hygiene

Increased organisms on skin and mucous membranes, including perineum.

Splenomegaly

Increased platelet destruction; spleen traps circulating platelets.

Antibiotic therapy

Increased risk for superinfection, often fungal.

lab values DIC

LOW platelets, elevated PT/aPTT/clot formation(TT) and fibrinolysis, LOW fibrinogen

Sepsis

Mechanism unknown; appears to cause increased platelet consumption.

Dysproteinemia

Protein coats surface of platelet, leading to decreased platelet function; protein causes increased viscosity, which leads to increased stretching of capillaries and thus increased bleeding.

Duration of thrombocytopenia

Risk increases when duration increases (e.g., risk is less when duration is transient after chemotherapy than when duration is permanent with poor marrow production).

Severity of neutropenia

Risk of infection is proportional to severity of neutropenia.

hypoproliferative anemias

generally seen in patients who have had gastric bypass and are not nutritionally supplemented "defect in production of RBCS"

Hemochromacytosis

genetic condition where excess iron is absorbed in the GI tract and deposited in various organs, making them dysfunctional

wet purpura and low platelets

patients admitted with this should have neurological assessment incorporated with routine vitals

medication education anemia

patients need to understand purpose of med, how to take, timing, how to manage side effects

observe themselves for bleeding signs

patients who have bleeding disorders should be educated on this

deconditioning

patients with chronic anemia need to maintain some physical activity to prevent this

paresthesias in LE

patients with megaloblastic anemias usually complain of this (numbness and tingling in bottom of feet)

platelet dysfunction

patients with this should be instructed to avoid any substance that could affect their platelets (OTC meds, alcohol, herbs, nutritional sups)

Severity of thrombocytopenia

Risk increases when platelet count decreases; usually not a significant risk until platelet count is less than 10,000/mm3, or less than 50,000/mm3 when invasive procedure is performed.

Alcohol abuse

Suppressive effect on marrow leads to decreased platelet production and decreased ability to function; decreased liver function results in decreased production of clotting factors.

testing all drainage and excretions for occult and obvious blood

When bleeding disorders are severe, patients who are hospitalized are monitored for bleeding by

platelet count, PT, PTT

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?

vitamin K

antedote for coumadin (warfarin)

protamine sulfate

antedote for heparin

pain, depression, sleep issues

assess for these in a patient with fatigue from anemia

heat

avoid during bleeding episodes because it can make it worse

prophylactic factor replacement

can be very effective in diminishing the morbidity associated with repeated bleeding (HEMOPHILIA). However, this method requires administration of these factors as often as two to three times each week.

nursing goals for anemics

decreased fatigue, attain/maintain nutrition, maintain adequate perfusion, tx compliance, prevent complications

alcohol

discourage this in the patient with anemia as it interferes with absorption of nutrients

hemophilia bleeding

during this, extent of bleeding must be assessment carefully by the nurse

mild confusion

early symptom of megaloblastic anemia

nutritional supps

educate family and ANEMIA patient on the role of these in the proper context

hemolytic aneimas

excessive destruction of RBCs due to altered production, hypersplenism, drug induced, autoimmune, mechanical heart valves

maintains adequate activity level

expected pt outcomes for this goal include baseline vital signs and pulse ox within normal limits

Aplastic anemia

experience all the typical characteristics of anemia (weakness and fatigue). In addition, they have frequent opportunistic infections plus coagulation abnormalities that are manifested by unusual bleeding, small skin hemorrhages called petechiae, and ecchymoses (bruises). The spleen becomes enlarged with an accumulation of the client's blood cells destroyed by lymphocytes that failed to recognize them as normal cells, or with an accumulation of dead transfused blood cells.

11-12.5 seconds

extrinsice pathway normal (PT)

anemia manifestations

fatigue/weakness/malaise, pallor, jaundice, cardiac/respiratory changes, tongue changes, nail changes, pica

0-5

fibrin degredation products (FDP) - fibrinolysis

surgical site, frequent vitals

if hemophiliac has had recent surgery and is bleeding, need to assess this

risk factors, patient education

important nursing roles in preventing and assessment of neutropenia

hypoproliferative anemias

includes iron deficiency, renal disease, inflammation, aplastic, megaloblastic

hemolytic anemias

includes sickle cell, thalassemia, glucose 6 PDH deficiency, immune, hereditary hemochromatosis

coffee and tea

increase gastrointestinal motility and inhibit the absorption of nonheme iron

agular cheilosis

inflammation of the corners of the mouth

chamomile, nettle, alfalfa

instruct hemophiliacs to avoid these which interfere with platelet aggregation

23-35 seconds

intrinsic pathway normal (aPTT)

nursing management bleeding disorders

limit injury, assess for bleeding, prevent bleeding

transfusion or IV fluids

lost blood causing anemia may be replaced with these, depending on symptoms and labs

lymphopenia

lymphocyte count less than 1500

aPTT

maintain this with heparin therapy

PT/INR

maintain this with warfarin (coumadin) therapy

warm baths

many hemophiliacs report these are helpful for relaxation, improving mobility of joints and lessening pain

anemia from HF

may be caused by deficient circulation of blood which stresses the heart

supplemental oxygen

may be needed for anemic patients but is RARELY needed on a long term basis unless there is comorbid pulmonary or heart disease

therapeutic phlebomotomy

medical management for polycythemia if severe

liver

metabolizes and filters/cleans RBCs

fatigue

most common symptom and complication of anemia

0-250

normal D dimer levels (local fibrinolysis)

8-11 seconds

normal clot formation (TT = thrombin time)

170-340

normal fibrinogen levels

headache or vision disturbance

nurse instructions ITP patient to report these as it could indicate increasing ICP (intracranial hemorrhage)

sulfa contining meds

nurse needs to be alert for these in patients with ITP because they can alter platelet function (in addition to aspirin or other NSAIDs)

written emergency plan

nurses should instruct HEMOPHILIA patients and families to have one of these

prioritize activity, establish balance between activity and rest

nursing interventions for fatigue related to anemia

education, fall prevention, safety

nursing management of thrombocytopenia

constipation, valsalva, vigorous flossing, razors, hard toothbrushes, vigorous sexual intercourse

patient with ITP should AVOID THESE

nasal packing

should be avoided in hemophilia patients because bleeding frequently resumes when it is removed

bone mineral density

should be monitored for patients on corticosteroids, may benefit from vitamin D and calcium sups

heart failure

significant complication of anemia is this, due to chronic diminished blood volume causing a compensatory effort to increase CO *ASSESS PTS FOR S/S OF THIS

D dimer

test this to check for pulmonary embolism

avoid injections and suppositories

these should not be used with ITP patients

position and vibration sense, balance issues

this may be DIMINISHED as megaloblastic anemia progresses (later sign)

heparin drip

treat DIC with this

DIC management

treat UNDERLYING CAUSE, correct tissue ischemia, replace fluids and electrolytes, maintain BP, replace coagulation factors, heparin or LMWH

fatigue

very common in ITP - nurse should assess extent and help them manage

oral hygiene

very important in patients with platelet dysfunction so that gingival bleeding can be minimized

5,000

when platelet count drops to this level - spontaneous (potentially fatal) CNS or GI bleeding can occur