Hematologic Disorders Week 5

Basophil

Contains histamine; integral part of hypersensitivity reactions

Eosinophil

Involved in allergic reactions (neutralizes histamine); digests foreign proteins

The patient with SCD is at greater risk for bacterial infection because of

decreased spleen function resulting from anoxic damage

Pernicious anemia (PA) refers to

vitamin B12 deficiency caused by autoantibodies that interfere with vitamin B12 absorption by targeting intrinsic factor (IF), gastric parietal cells, or both. At the time it was described, PA was truly pernicious as it was associated with continuous worsening of symptoms and even death without an available treatment

Causes of vitamin B12 deficiency include

vegan diets or diets lacking dairy products, small bowel resection, chronic diarrhea, diverticula, tapeworm, or overgrowth of intestinal bacteria

Coagulation Disorders

-Autoimmune thrombocytopenic purpura -Heparin induced thrombocytopenia (HIT) -Disseminated intravascular coagulation (DIC)

A client with megaloblastic anemia reports mouth and tongue soreness. What instruction will the nurse give the client regarding eating while managing the client's symptoms?

"Eat small amounts of bland, soft foods frequently."

After teaching a client about taking daily oral iron preparations for a moderate iron deficiency anemia, which statement by the client indicates to the nurse that additional instruction is needed?

"I will call the doctor if my stools turn black."

A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?

"I will receive parenteral vitamin B12 therapy for the rest of my life."

A female client with the beta-thalassemia trait plans to marry a man of Italian ancestry who also has the trait. Which client statement indicates that she understands the teaching provided by the nurse?

"I'll see a genetic counselor before starting a family."

A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor?

Decreased level of erythropoietin

The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions?

Dilute the liquid preparation with another liquid such as juice and drink with a straw.

The nurse is caring for a client with external bleeding. What is the nurse's priority intervention?

Direct pressure

Respiratory manifestations of Anemia

Dyspnea on exertion; decreased oxygen saturation levels

A client with a diagnosis of pernicious anemia comes to the clinic and reports numbness and tingling in the arms and legs. What do these symptoms indicate?

Neurologic involvement

The nurse obtains a unit of blood for the client, Donald D. Smith. The name on the label on the unit of blood reads Donald A. Smith. All the other identifiers are correct. What action should the nurse take?

Refuse to administer the blood

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

Reports joint pain less than 3 on a scale of 0 to 10

Cardiovascular manifestations of anemia

Tachycardia at basal activity levels, increasing with activity and during and immediately after meals; murmurs and gallops heard on auscultation when anemia is severe; orthostatic hypotension

A client is prescribed 325 mg/day of oral ferrous sulfate. What does the nurse include in client teaching?

Take 1 hour before breakfast

A client is seen in the emergency department with severe pain related to a sickle cell crisis. What does the nurse understand is occurring with this client?

Vascular occlusion in small vessels decreasing blood and oxygen to the tissues.

Stage IV HL

Widespread disease; multiple organs, with or without lymph node involvement

RBC (erythrocyte)

carries hemoglobin to provide oxygen to tissues; average lifespan is 120 days

•Laboratory test results often provide the most _______ information about hematologic problems

definitive

Albumin, which is produced by the ________, has the capacity to bind to several substances that are transported in plasma (e.g., certain medications, bilirubin, and some hormones). People with impaired hepatic function may have low concentrations of albumin, with a resultant decrease in osmotic pressure and the development of edema.

liver

A client with sickle cell anemia has a

low hematocrit.

Albumin is particularly important for the

maintenance of fluid balance within the vascular system. Capillary walls are impermeable to albumin, so its presence in the plasma creates an osmotic force that keeps fluid within the vascular space.

•After diagnosis of Hodgkin's Lymphoma, staging is

performed to determine the extent of disease. This process is detailed and must be accurate because the treatment regimen is determined by the extent of disease. •Staging usually includes a history and physical examination, CBC, CMP, kidney and liver function tests, ESR, bone marrow aspiration and biopsy, and CT of the neck, chest, abdomen, and pelvis. •PET scans may be used to assess for disease not detected by CT.

A _________ ________ _________ is made by taking a drop of blood and spreading it over a slide. It can be read by an automated calculator or by a technologist with a microscope. This rapid test provides information on the sizes, shapes, and proportions of different blood cell types within the peripheral blood.

peripheral blood smear

Febrile transfusion reactions occur most often in

the patient with anti-WBC antibodies, which can develop after multiple transfusions, white blood cell transfusions, and platelet transfusions. The patient develops chills, tachycardia, fever, hypotension, and tachypnea. Giving leukocyte-reduced blood or single-donor HLA-matched platelets reduces the risk for this type of reaction. WBC filters may be used to trap WBCs and prevent their infusion into the patient.

Nursing interventions for acute leukemia:

uPharmacological therapy has three phases: -Induction: Intense; consists of combination chemotherapy started at the time of diagnosis. The purpose of this therapy is to achieve a rapid, complete remission of all manifestations of disease; results in severe bone marrow suppression with neutropenia -Consolidation: Consists of another course of either the same drugs used for induction at a different dosage or a different combination of chemotherapy drugs. This treatment occurs early in remission, and its intent is to cure -Maintenance: The purpose is to maintain the remission achieved through induction and consolidation; drugs may be prescribed for months to years after successful induction and consolidation therapies -Recovery of bone marrow function requires at least 2 to 3 weeks, during which the patient must be protected from life-threatening infections. -Hematopoietic stem cell transplantation (HSCT): also known as bone marrow transplantation (BMT), is standard treatment for the patient with leukemia who has a closely matched donor and who is in temporary remission after induction therapy -Before an HSCT, additional chemotherapy with or without total body irradiation is given to purge (condition or clean) the marrow of leukemic cells -These treatments are lethal to the bone marrow, and without replacement of stem cells by transplantation, the patient would die of infection or hemorrhage -After conditioning, new healthy stem cells are given to the patient. The new cells go to the marrow and then begin the process of hematopoiesis, which results in normal, properly functioning blood cells and, ideally, a permanent cure -If the transplanted cells fail to engraft, the patient will die unless another transplant with stem cells is successful. -Prevent infection: Prevention techniques: Observe strict asepsis technique when changing dressings or accessing a line, Reverse isolation and/or private room, Wear a mask with an URI, Hand hygiene, Continually assess -Prevent bleeding- Prevention techniques: Bleeding precautions, Avoid injections, Handle patient gently; use a lift sheet, Measure abdominal girth daily, Continually assess -Reduce fatigue / improve RBC count -Nutrition therapy: to assist the patient to eat enough calories to meet at least basal energy requirements. Collaborate with a dietitian to provide small, frequent meals high in protein and carbohydrates -Blood transfusions: sometimes indicated for the patient with fatigue -Drug therapy with colony-stimulating growth factors may reduce the severity and duration of anemia and neutropenia after intensive chemotherapy -For anemia, erythropoiesis-stimulating agents (ESAs) that boost production of RBCs may be used -Conserve energy: schedule activities appropriately; plan rest times; PT consult -Comfort measures, pain control and improve self-care

Why is staging important for especially for Hodgkin's Lymphoma?

•staging is performed to determine the extent of disease. This process is detailed and must be accurate because the treatment regimen is determined by the extent of disease.

Parents arrive to the clinic with their young child and inform the nurse the child has just been diagnosed with sickle cell disease. The parents ask the nurse how this could have happened and which one of them is the carrier. What is the best response by the nurse?

"The child must inherit two defective genes, one from each parent."

Platelet inhibitors or antiplatelet drugs

- Aspirin, clopidogrel (Plavix), cilostazol (Pletal), Effient, ticagrelor (Brilinta), and ticlopidine (Ticlid), ReoPro, Integrilin, Aggrastat -Prevent either platelet activation or aggregation (clumping)

The hematologic system includes:

- Blood - Blood cells - Lymph - Organs involved with blood formation or blood storage

Indirect thrombin inhibitors

- Heparin, enoxaparin (Lovenox), fondaparinus (Arixtra) -Bind to and increase the activity of antithrombin III, causing thrombin to be indirectly inhibited

Vitamin K antagonists

- Warfarin (Coumadin) - Decrease the synthesis of vitamin K in the intestinal tract, which then reduces the production of vitamin K-dependent clotting factors II, VII, IX, and X

Classification of Leukemia

-Acute: sudden onset of symptoms -Chronic: a slow onset and manifestations that persist for years -Classified by stem cell pathways: -Lymphoid -Myeloid

Nursing interventions for patient's in sickle cell crisis

-Administer oxygen -Administer prescribed pain medication -Hydrate the patient with NS IV and non-caffeinated beverages -Remove any constrictive clothing -Encourage the patient to keep extremities extended to promote venous return -Do not raise the knee position of the bed -Elevate the HOB no more than 30 degrees -Keep room temperature at or above 72 degrees F -Check circulation in extremities every hour

Fibrinolytic drugs

-Alteplase (Activase), reteplase (Retavase), urokinase -Selectively break down fibrin threads present in formed blood clots

Direct thrombin inhibitors

-Argatroban, rivaroxaban (Xarelto), apixaban (Eliquis) -Prevent the conversion of prothrombin (factor X) to its active form, thrombin (factor Xa)

Nursing interventions: for HL

-Assess and manage pancytopenia -Manage nausea & vomiting, constipation or diarrhea -Assess and manage skin problems at site of radiation -Radiation / chemotherapy: -For stages I and II: the treatment is external radiation of involved lymph node regions -With more extensive disease: radiation and combination chemotherapy are used to achieve remission -HSCT is used for advanced or refractory disease -Hodgkin lymphoma is often curable. The nurse should encourage patients to reduce factors that increase the risk of developing second cancers, such as use of tobacco and alcohol and exposure to environmental carcinogens and excessive sunlight. Screening for late effects of treatment is necessary. In addition, the nurse should provide education about relevant self-care strategies and disease management.

During-transfusion nursing responsibilities:

-Check blood for gas bubbles and any unusual color or cloudiness -Verify the blood with another nurse -Administer the blood products with appropriate filtered tubing -Make sure that PRBC transfusion is initiated within 30 minutes after removal of PRBCs from blood bank refrigerator -Use only NS with blood products -Remain with the patient during the first 15-30 minutes of infusion -Infuse the blood product at the prescribed rate -Note that administration time does not exceed 4 hours because of increased risk of bacterial proliferation -Monitor VS and assess the patient for reaction signs •Human error is the most common cause of ABO incompatibility reactions. •The patient's room number is not an acceptable form of identification. •Hemolytic reactions occur most often within the first 50 mL of the infusion.

Nursing interventions: Iron Deficiency Anemia

-Correct the cause if possible -Increase the intake of iron -Red meat, organ meat, egg yolks, kidney beans, leafy green vegetables, and raisins -Manage fatigue -Maintain adequate nutrition -Pharmacological: -Mild: ferrous sulfate PO, ferrous gluconate PO, ferrous fumarate PO -Severe: iron dextran, ferumoxytol IV -Instruct patients to take the iron supplement between meals for better absorption and to reduce GI distress

Signs & symptoms: Polycythemia

-Darkened, purple, cyanotic or flushed facial skin and mucous membranes with distended veins -Intense itching: caused by dilated blood vessels and poor perfusion -Poor perfusion -Hypertension: caused from the thick blood that moves more slowly and places increased demands on the heart -Vascular stasis and thrombosis: In some areas, blood flow may be so slow that stasis occurs. Vascular stasis causes thrombosis within the smaller vessels, occluding them, which leads to tissue hypoxia, anoxia and, later, to infarction and necrosis. Tissues most at risk for this problem are the heart, spleen, and kidneys, although damage can occur in any organ or tissue -Heart, spleen, and kidneys are most at risk -Poor gas exchange with severe hypoxia: Even though the number of RBCs is greatly increased, their oxygen-carrying capacity is impaired, and patients have poor gas exchange with severe hypoxia. Bleeding problems are common because of platelet impairment. -Bleeding

Diagnostics for Leukemia

-Diagnostic labs: CBC, Coagulation studies -Diagnostic tests: Bone marrow aspiration/biopsy •Acute leukemia: usually has decreased hemoglobin and hematocrit levels, a low platelet count, and an abnormal low (possibly normal) or high WBC count •High WBC count consisting of mostly blast cells at diagnosis has a poorer prognosis •Blood clotting times and factors are usually abnormal (prolonged) with acute leukemia. Reduced levels of fibrinogen and other clotting factors are common •The definitive test for leukemia is an examination of cells obtained from bone marrow aspiration and biopsy. The bone marrow is full of leukemic blast phase cells (immature cells that are dividing). The proteins (antigens) on the surfaces of the leukemic cells are "markers" that help diagnose the type of leukemia and may indicate prognosis

Polycythemia Diagnostics

-Diagnostic labs: CBC, Hemoglobin is increased to levels 18g/dL, RBC count is 6million/mm3, Hematocrit is 55% or greater, CMP, Uric acid

Prevention techniques: for sickle cell crises

-Drink at least 3-4L of liquids QD -Avoid alcohol & smoking -Get the flu shot every year & pneumonia shot as needed -Avoid temperature extremes; dress appropriately -Avoid traveling to high altitudes -Avoid strenuous physical activity -Engage in mild, low-impact exercise 3x week -Contact your PCP at the first sign of illness/infection

Acute transfusion reactions:

-Febrile transfusion reactions -Hemolytic transfusion reactions -Allergic transfusion reactions -Transfusion-associated circulatory overload -Bacterial transfusion reactions -Transfusion-related acute lung injury

Types of Anemia

-Hypoproliferative (resulting from defective RBC production) -Bleeding (RBC loss) -Hemolytic (RBC destruction)

Nursing interventions: Vitamin B12 Anemia

-Increase intake of foods rich in vitamin B12 -Animal proteins, fish, eggs, nuts, dairy products, dried beans, citrus fruit, and leafy green vegetables -Pharmacological: -Vitamin B12 deficiency: PO, SL or nasal spray supplements -Pernicious anemia: vitamin B12 injections

Head to toe Manifestations of Leukemia

-Neurologic manifestations: Fatigue, headache, fever, cranial nerve problems, papilledema, seizures, coma -Respiratory manifestations: Dyspnea on exertion, tachypnea, coughing, adventitious breathe sounds -Cardiac manifestations: Tachycardia at basal activity levels, orthostatic hypotension, palpitations, murmurs, bruits, slow capillary refill, hypertension, bounding pulse -Gastrointestinal manifestations: Bleeding gums, weight loss or anorexia, enlarged liver or spleen, nausea, occult blood, constipation -Renal manifestations: Hematuria -Musculoskeletal manifestations: Bone pain or joint swelling/pain -Integumentary manifestations: Petechiae or ecchymoses, pallor, coolness, open infected lesions *Pallor is most evident on the face, around the mouth, and in the nail beds. The conjunctiva of the eye also is pale, as are the creases on the palm of the hand. Petechiae may be present on any area of skin surface, especially the legs and feet*

Clinical manifestations: Sickle Cell Disease

-Neurologic: Pain is the most common manifestation; low grade fever; seizures; stroke -Cardiovascular: Acute chest syndrome, heart failure; SOB; weakness/fatigue; murmurs; S3; jugular-venous pulsation/distention -Skin: Pallor; cyanosis; jaundice; intense itching; lower-leg ulcers -Gastrointestinal: Abdominal pain; enlarged/firm/bumpy liver and spleen on palpation -Genitourinary: Priapism; proteinuria; CKD; reproductive problems -Musculoskeletal: Joint damage; swelling; decreased ROM

After-transfusion nursing responsibilities:

-Obtain vital signs and breath sounds; compare with baseline measurements. If signs of increased fluid overload present, consider obtaining prescription for diuretic as warranted -Discontinue the infusion and dispose of material properly -Document -Monitor patient for response to and effectiveness of procedure

Nursing interventions: Sickle Cell Disease

-Pain management: Morphine or hydromorphone (Dilaudid) IVP or PCA pump -Hydration: IV and oral routes to help reduce the duration of pain episodes -Oxygenation: To decrease sickling; give nebulizers to prevent dehydration -Hydroxyurea (Droxia): May reduce the number of sickling and pain episodes by stimulating fetal hemoglobin (HbF) production, however, this drug can cause bone marrow suppression and leukemia -Prevent and detect infections early: Patients should receive vaccinations and prompt antibiotic treatment -Transfusion: RBCs can be helpful to increase HbA levels and dilute HbS levels, although they must be prescribed cautiously to prevent iron overload from repeated transfusions -Hematopoietic stem cell transplant: May cure, but limited due to compatibility -Supportive care: Distraction/relaxation techniques, positioning, aroma therapy, warm soaks/compresses, etc.

Integumentary manifestations of Anemia

-Pallor, especially of the ears, nail beds, palmar creases, conjunctivae, and around the mouth; cool to the touch; intolerance of cold temperatures; nails become brittle and concave over time

Compatibility for RBC's

-People develop circulating antibodies against the blood type antigens they did not inherit -A person with type A blood forms antibodies against type B blood -A person with type O blood has not inherited either A or B antigens and will form antibodies against RBCs with either A or B antigens •If RBCs that have an antigen are infused into a recipient who does not share that antigen, the infused blood is recognized by the recipient's antibodies as non-self and the recipient then has a reaction to the transfused products. •Adults who have Rh-positive blood can receive an RBC transfusion from an Rh-negative donor, but Rh-negative adults must not receive Rh-positive blood. •O-negative is universal donor •AB-positive is universal recipient

Nursing interventions: Aplastic Anemia

-Pharmacological: -Immunosuppressive therapy have resulted in partial or complete remissions -Cyclosporine, daclizumab -Corticosteroids are not very useful as immunosuppressive agents in the long term -Splenectomy -Hematopoietic stem cell transplantation with donor cells -Blood transfusions -Neutropenic precautions -Bleeding precautions

Nursing Management/interventions: Autoimmune Thrombocytopenic Purpura

-Prevent bleeding / bleeding precautions -Pharmacological: Immunosuppressive agents for short term therapy, IVIG, Platelet transfusions -Maintaining a safe environment -Surgical management with a splenectomy may be needed for the patient who does not respond to drug therapy, as the spleen is the site of excessive platelet destruction. Results in a sustained normal platelet count approximately 50% of the time, although many patients can maintain a "safe" platelet count of more than 30,000/mm3 after the removal of the spleen. Even those who do respond to splenectomy may have recurrences of severe thrombocytopenia months or years later •Management is often limited to those patients with: Platelet counts lower than 50,000/mm3, Those who are bleeding, Those who are at high risk for bleeding

Nursing interventions for Disseminated Intravascular Coagulation

-Prevention -Identify patients at greatest risk for sepsis and DIC -Practice strict adherence to aseptic technique during invasive procedures and during contact with nonintact skin and mucous membranes -Teach patients and families the early manifestations of infection and when to seek assistance -When sepsis is present and DIC is likely, management focuses on reducing the infection and halting the DIC process -Initiate IV antibiotic therapy ASAP or treat the underlying cause -During the early phase of DIC, anticoagulants (especially heparin or LMWH) are given to limit clotting and prevent the rapid consumption of circulating clotting factors -When DIC has progressed and hemorrhage is the primary problem, clotting factors are given -Improve oxygenation, replace fluids, correct electrolyte imbalances, administer vasopressor medications

Nursing interventions: Folic Acid Anemia

-Prevention is the key -Avoid excessive alcohol use -Consume a diet rich in folic acid and vitamin B12 -Pharmacological: -Folic acid supplements

Hemolytic Anemia

-Sickle cell disease -Aplastic anemia

There are several different approaches to help relieve or attempt to cure hematological disorders such as

-Splenectomy -Apheresis -Hematopoietic stem cell transplant -Therapeutic phlebotomy -Blood transfusions

Nursing interventions for Heparin-Induced Thrombocytopenia

-Stop heparin -Anticoagulation therapy -Direct thrombin inhibitor: Argatroban (Argatroban), lepirudin (Refludan), and bivalirudin (Angiomax) •If the heparin is stopped without providing additional anticoagulation, the patient is at increased risk for developing new thrombi. •Patients need to be aware of their risk for reactivation of the disorder should they be exposed to any amount of heparin within 3 to 4 months after diagnosis. This time frame is thought to be sufficient to remove anti-heparin-platelet antibodies from the circulation by the RES.

Nursing interventions: allergic reaction after blood transfusion

-Stop the transfusion and removing the blood tubing -Notify the Rapid Response Team -Assess the patient -Return the blood and all tubing to the blood bank -If the patient has no other IV access, keep the access and flush with normal saline -Do not flush the contents of the blood transfusion tubing, which would allow more of the reaction-causing blood to enter the patient. -Apply oxygen as needed -Pharmacological: -Diphenhydramine (Benadryl) -Antipyretics

Aging changes the blood components

-The older adult has a decreased blood volume with lower levels of plasma proteins -As bone marrow ages, it produces fewer blood cells -RBC and WBC counts are lower among older adults -Lymphocytes become less reactive to antigens and lose immune function -Antibody levels and responses are lower and slower in older adults -The WBC count does not rise as high in response to infection in older people

Remember the 3 T's for Heparin-Induced Thrombocytopenia

-Thrombocytopenia -Thrombosis or other sequelae -Timing of platelet count fall

Nursing interventions & Education: Polycythemia

-Treat the cause of secondary polycythemia -Increase hydration -Promote venous return to prevent clot formation -Therapeutic phlebotomy -Apheresis (2 to 5 times per week) -Drink at least 3L of liquids QD -Avoid tight or constrictive clothing -Wear support hose or stockings while awake and up -Elevate your feet whenever seated -Take anticoagulants as prescribed -Exercise slowly and only with physician approval -Stop activity at the first sign of chest pain -Use an electric shaver and a soft-bristled toothbrush -Do not floss between your teeth -Contact your health-care provider at the first sign of infection

Nursing interventions: NHL

-Treatment options for patients with NHL vary based on the subtype of the tumor, and staging -Nursing management is similar to Hodgkin's lymphoma but includes organ-specific assessment and management -Radiation / chemotherapy: -Chemotherapy drugs alone or in combination with monoclonal antibodies (e.g., rituximab and alemtuzumab), localized radiation therapy, and/or radiolabeled antibodies -Hematopoietic stem cell transplantation -Supportive care and symptomatic treatment -Many lymphomas can be cured with current treatments. However, as survival rates increase, the incidence of second malignancies, particularly AML or MDS, also increases. Therefore, survivors should be screened regularly for the development of second malignancies. As is true with long-term survivors of Hodgkin lymphoma, survivors of NHL may be faced with managing persistent fatigue, depression, anxiety, cardiac, and pulmonary toxicity.

Pre-transfusion nursing responsibilities:

-Verify the medical prescription -Verify consent -Assess laboratory values -Obtain a type-and-crossmatch -Assess VS, UO, skin color, lung sounds, JVD -Explain procedure and ask hx of previous transfusion reactions -Obtain venous access -THEN obtain blood from the blood bank •Nursing actions during transfusions focus on prevention or early recognition of adverse transfusion reactions. Preparation of the patient for transfusion is critical, and blood product administration procedures must be carefully followed. •Lab values: many institutions have specific guidelines for blood product transfusions (e.g., platelet count <20,000 or hemoglobin <6 g/dL) •Usually a new type-and-crossmatch specimen is required at least every 72 hours.

Macrocytic Anemia

-Vitamin B12 deficiency anemia -Folic acid deficiency anemia

Diagnostic tests: hematologic

-X-rays -CT scans -Nuclear medicine scan with radioactive isotope -Bone marrow aspiration and biopsy

Polycythemia:

-a malignant and progressive condition where the number of RBCs in the blood is greater than normal; the blood of a patient with polycythemia is hyperviscous (thicker than normal blood) -Three hallmarks signs: -Massive production of RBCs -Excessive leukocyte production -Excessive production of platelets Primary polycythemia: also called polycythemia vera, is a proliferative disorder of malignancy Secondary polycythemia: is caused by excessive production of erythropoietin; may occur in response to a reduced amount of oxygen, which acts as a hypoxic stimulus, as in heavy cigarette smoking, obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD), or cyanotic heart disease, or with conditions such as living at a high altitude or exposure to low levels of carbon monoxide

Hodgkin's Lymphoma

-cancer usually starts in a single lymph node or a single chain of nodes. These nodes contain a specific cancer cell type, the Reed-Sternberg cell -Often spreads predictably from one group of lymph nodes to the next, unlike non-Hodgkin's lymphoma -Peaks in two different age-groups: (1) teens and young adults, and (2) adults in their 50s and 60s •Hodgkin lymphoma is a relatively rare malignancy that has a high cure rate. •The 5-year survival rate is 90% for more limited disease (stage I or II), and 65% for those with more extensive disease (stage IV). •Reed-Sternberg cell. Reed-Sternberg cells are large, abnormal lymphocytes that may contain more than one nucleus. -Large, firm but painless lymph node or nodes -Most common assessment finding -Mediastinal mass may be seen on xray -Constitutional manifestations ("B symptoms") include: Fevers (>101.5° F [>38.6° C]); heavy night sweats; unplanned weight loss (>10% of normal body weight)

Non-Hodgkin's Lymphoma

-includes all lymphoid cancers that do not have the Reed-Sternberg cell. There are over 60 subtypes of NHL divided into either indolent or aggressive lymphomas -Generally spreads through the lymphatic system in a less orderly fashion than Hodgkin's lymphoma -Lymph nodes from multiple sites may be infiltrated, as may sites outside the lymphoid system -The incidence increases with each decade of life; the median age at diagnosis is 66 years •NHL is the sixth most common type of cancer diagnosed in the United States; incidence rates have almost doubled in the past 35 years. •The overall survival rate is 69% at 5 years, and 59% at 10 years. -Signs & symptoms: Lymphadenopathy, Painless swelling of the cervical, axillary, inguinal, and femoral nodes most common, Tumor spreading elsewhere:, GI tract, skin, bone marrow, sinuses, thyroid, central nervous system, Constitutional manifestations ("B symptoms") are seen about 1/3 of the time •The diagnosis of NHL is made only after the biopsy of an involved lymph node is reviewed by a hematopathologist. •Classification of NHL is more complicated than that for Hodgkin's lymphoma and is based on the World Health Organization (WHO) classification system. •In addition, lactate dehydrogenase (LDH) levels and beta-2 microglobulin levels are also evaluated to measure tumor growth rates and calculate prognosis. •High LDH levels and high beta-2 microglobulin levels are associated with a poorer prognosis.

Sickle Cell Disease (hemolytic anemia)

-is a genetic disorder that results in chronic anemia, pain, disability, organ damage, increased risk for infection, and early death -The average life span of an RBC containing 40% or more of HbS is about 10 to 20 days, causing hemolytic anemia -The patient with SCD has periodic episodes of extensive cellular sickling, called crises -Sickle cell trait: occurs when one normal gene allele and one abnormal gene allele for hemoglobin are inherited and only half of the hemoglobin chains are abnormal -The patient has only mild manifestations of the disease when precipitating conditions are present because less than 40% of the hemoglobin is abnormal

Vaso-occlusive event (VOE):

-results from entrapment of erythrocytes and leukocytes in the microcirculation, causing tissue hypoxia, inflammation, and necrosis due to inadequate blood flow to a specific region of tissue or organ (Sickle Cell Disease) -leads to further tissue hypoxia (reduced oxygen supply) and more sickle-shaped cells, which then leads to more blood vessel obstruction and ischemia in the affected tissues -Repeated episodes of ischemia cause progressive organ damage from anoxia and infarction -Organs begin to have small infarcted areas and scar tissue formation, and eventually organ failure results -Tissues most often affected are: Spleen, Liver, Heart, Kidney, Brain, Joints & bones, Retina

A client with idiopathic thrombocytopenic purpura (ITP) is admitted to an acute care facility. The nurse monitors the client's platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below what number?

10,000/?l.

A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. The new graduate knows that the greatest likelihood of an acute hemolytic reaction would occur when giving:

A-positive blood to an A-negative client.

A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?

Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels

Pain in Sickle Cell Disease

Acute pain episodes have a sudden onset, usually involving the chest, back, abdomen, and extremities. Complications of SCD can cause severe, chronic pain, requiring large doses of opioid analgesics •Concerns about substance abuse can lead to inadequate pain treatment in these patients. Opioid addiction is rare, occurring in only 2% to 5% of patients with SCD •Avoid "as needed" (PRN) schedules because they do not provide adequate relief. •Addicted patients in acute pain crisis still need opioids.

The nurse is talking with the parents of a toddler who was diagnosed with hemophilia A. What instruction should the nurse give to the parents?

Administer factor VIII intravenously at the first sign of bleeding

A client is hospitalized 3 days prior to a total hip arthroplasty and reports a high level of pain with ambulation. The client has been taking warfarin at home, which is now discontinued. To prevent the formation of blood clots, which action should the nurse take?

Administer the prescribed enoxaparin (Lovenox).

Splenectomy:

An enlarged spleen may be the site of excessive destruction of blood cells. In addition, some patients with grossly enlarged spleens develop severe thrombocytopenia as a result of platelets being sequestered in the spleen. Splenectomy removes the "trap," and platelet counts may normalize over time. There is a high risk of acute lethal infections after splenectomy, so patients should be vaccinated for pneumonia before undergoing splenectomy •After splenectomy, the patient is at increased risk for infection because the spleen performs many protective immune functions, especially antibody generation

A client in end-stage renal disease is prescribed epoetin alfa and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, what is the priority action taken by the nurse?

Assesses the hemoglobin level

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?

B12

When teaching a client with iron deficiency anemia about appropriate food choices, the nurse encourages the client to increase the dietary intake of which foods?

Beans, dried fruits, and leafy, green vegetables

A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply.

Blood loss Abnormal erythrocyte production Destruction of normally formed red blood cells

Which is a symptom of hemochromatosis?

Bronzing of the skin

The nurse is educating a client about iron supplements. The nurse teaches that what vitamin enhances the absorption of iron?

C

A client with multiple myeloma reports pain along the spinal column. The client is prescribed naproxen (Aleve) and oxycodone. Prior to administering these medications, the nurse

Checks the client's BUN and creatinine

Sickle Cell Disease Diagnostics

Diagnostic labs: Electrophoresis to determine percent of HbS, CBC, Reticulocyte count, Total bilirubin Diagnostic tests: X-rays, Ultrasound, ECG, CT, PET, MRI •The hematocrit of patients with SCD is low (between 20% and 30%) because of RBC shortened life span and RBC destruction. This value decreases even more during crises or during stress (aplastic crisis). The reticulocyte count is high, indicating anemia of long duration. The total bilirubin level may be high because damaged RBCs release iron and bilirubin. The total white blood cell (WBC) count is usually high in patients with SCD due to chronic inflammation from tissue hypoxia/ischemia. •X-rays of joints may show necrosis and destruction. Ultrasonography, CT, positron emission tomography (PET), and MRI may show soft-tissue and organ changes from poor perfusion and chronic inflammation

The nurse is educating a patient with iron deficiency anemia about food sources high in iron and how to enhance the absorption of iron when eating these foods. What can the nurse inform the client would enhance the absorption?

Eating calf's liver with a glass of orange juice

A thin client is prescribed iron dextran intramuscularly. What is most important action taken by the nurse when administering this medication?

Employs the Z-track technique

Monocyte

Enters tissue as macrophage; highly phagocytic, especially against fungus; immune surveillance

The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia?

Erythrocytes that are microcytic and hypochromic

Neutrophil

Essential in preventing or limiting bacterial infection via phagocytosis

WBC (leukocyte)

Fights infection

A patient with End Stage Kidney Disease 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?

Hemoglobin level

Neurologic manifestations of Anemia

Increased somnolence and fatigue; headache

A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is most appropriate for this client?

Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit

A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?

Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI

The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the health care provider. What type of anemia is the nurse concerned the co-worker may have?

Iron deficiency anemia

The nurse is performing an assessment for a client with anemia admitted to the hospital to have blood transfusions administered. Why would the nurse need to include a nutritional assessment for this patient?

It may indicate deficiencies in essential nutrients.

Which iron-rich foods should a nurse encourage an anemic client requiring iron therapy to eat?

Lamb and peaches

Stage I HL

Localized disease; single lymph node region or single organ

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?

Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential

A client with a diagnosis of pernicious anemia comes to the clinic complaining of numbness and tingling in his arms and legs. What do these symptoms indicate?

Neurologic involvement

The nurse is caring for an older adult client who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine where the blood loss is coming from, what intervention can the nurse provide?

Observe stools for blood.

A nurse is caring for a client with iron deficiency anemia. Which food or beverage will the nurse suggest to the client to eat or drink when taking supplemental iron?

Orange juice

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

Osteoporosis

A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?

Pallor, tachycardia, and a sore tongue

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

Pernicious anemia

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

Platelet count, prothrombin time, and partial thromboplastin time

T lymphocyte

Responsible for cell-mediated immunity; recognizes material as foreign (surveillance system)

The nurse is preparing the patient for a test to determine the cause of vitamin B12 deficiency. The patient will receive a small oral dose of radioactive vitamin B12 followed by a large parenteral dose of nonradioactive vitamin B12. What test is the patient being prepared for?

Schilling test

Complications in Sickle Cell Disease

Spleen: decreased Phagocytic function of macrophages Lungs: Infection CNS: Infarction Kidney: Damage to renal medulla Heart: anemia Bone: infarction of bone Liver: hemolysis Skin and periph. vaculature: Skin ulcers Eye: Infarction Penis: vascular thrombosis

•Complementary therapy agents, such as _______ and _________, inhibit platelet activity too

St. John's wort; Ginkgo biloba

A client with chronic anemia has received multiple transfusions. Which client action would the nurse be concerned about relative to the client's condition?

Takes over-the-counter iron supplements

A client is treated for anemia. What is the nurse's best understanding about the correlation between anemia and the client's iron stores?

There is a strong correlation between iron stores and hemoglobin levels.

Which of the following is accurate regarding the use of corticosteroids for immune hemolytic anemia? Select all that apply.

They decrease the macrophages ability to clear the antibody-coated RBCs. If the hemoglobin returns to normal, the corticosteroid dose can be lowered.

After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/mm3. What term should the nurse use to describe this low platelet count?

Thrombocytopenia

Stage III HL

Two or more lymph node regions along and below the diaphragm

Stage II HL

Two or more lymph node regions on the same side of the diaphragm

During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy interfering with synthesis of which vitamin?

Vitamin K

Packed Red Blood Cells (PRBC's)

Volume: 200-250ml Infusion time: 2-4hrs Indications: Anemia hemoglobin <6g/dl, depending on symptoms

Washed Red Blood Cells (WBC-poor PRBC's)

Volume: 200ml Infusion Time: 2-4hrs Indications: History of allergic transfusion reactions. Hematopoietic stem cell patients

Fresh Frozen Plasma

Volume: 200ml Infusion time: 15-30min Indications: Deficiency in plasma coagulation factors. Prothrombin or partial thromboplastin time 1.5 times normal

Single Donor Platelets

Volume: 200ml Infusion time: 30min Indications: history of febrile or allergic reactions

White blood cells (WBC's)

Volume: 400ml Infusion time: 1hr Indications: Sepsis, neutropenic infection not responding to antibiotic therapy

Pooled Platelets

Volume: about 300ml Infusion time: 15-30min Indications: thrombocytopenia, platelet count of <20,000. Patients who are actively bleeding with a platelet count <50,000

A young client is diagnosed with a mild form of hemophilia and is experiencing bleeding in the joints with pain. In preparing the client for discharge, what instructions should the nurse provide?

Wear a medical identification bracelet.

A nurse cares for clients with hematological disorders and notes that women are diagnosed with hemochromatosis at a much lower rate than men. What is the primary reason for this?

Women lose iron through menstrual cycles

Circulatory overload (aka TACO) can occur when

a blood product is infused too quickly, especially in an older adult. This is most common with whole-blood transfusions or when the patient receives multiple packed RBC transfusions. Manifestations include: hypertension, bounding pulse, distended jugular veins, dyspnea, restlessness, and confusion. You can both manage and prevent this complication by monitoring intake and output, infusing blood products more slowly, and giving diuretics.

Macrocytic: Folic Acid Deficiency Anemia

a decrease in RBCs due to low folate, causing macrocytic anemia -Signs & symptoms: Fatigue, Mouth sores, Tongue swelling, Weakness, Pallor, Gray hair, Irritable -Causes: Poor nutrition: especially a diet lacking green leafy vegetables, liver, yeast, citrus fruits, dried beans, and nuts, is the most common cause. Malabsorption syndromes: such as Crohn's disease, are the second most common cause. Drugs: anticonvulsants and oral contraceptives can contribute to folic acid deficiency and anemia

Chronic myeloid leukemia (CML):

arises from a mutation in the myeloid stem cell; normal myeloid cells continue to be produced, but there is a pathologic increase in the production of forms of blast cells -The average age at diagnosis is 64; it rarely occurs in children -Signs & symptoms: May be asymptomatic, Shortness of breath or slightly confused due to decreased perfusion from leukostasis, Enlarged tender spleen or liver, Insidious symptoms of malaise, anorexia, weight loss -accounts for 10% to 15% of all leukemias -Because of marked advances in treatment, patients diagnosed with CML in the chronic phase have an overall median life expectancy nearly equal to that of the general population.

Why would you assess family history in a elderly patient being assessed for hematologic conditions?

because many disorders affecting blood and blood clotting are inherited. Ask whether anyone in the family has had hemophilia, sickle cell disease/trait, frequent nosebleeds, postpartum hemorrhages, excessive bleeding after tooth extractions, or heavy bruising after mild trauma.

Apheresis is a Greek word meaning "separation." In therapeutic apheresis (or pheresis),

blood is taken from the patient and passed through a centrifuge, where a specific component is separated from the blood and removed. The remaining blood is then returned to the patient.

Hemolytic transfusion reactions are caused by

blood type or Rh incompatibility. When blood containing antigens different from the patient's own antigens is infused, antigen-antibody complexes are formed in his or her blood. These complexes destroy the transfused cells and start inflammatory responses in the blood vessel walls and organs. The reaction may be mild, with fever and chills, or life threatening, with disseminated intravascular coagulation (DIC) and circulatory collapse. Other manifestations include apprehension, headache, chest pain, low back pain, tachycardia, tachypnea, hypotension, hemoglobinuria, and a sense of impending doom. The onset of a hemolytic reaction may be immediate or may not occur until subsequent units have been transfused

•Reticulocyte count is helpful in determining ______ _____ _______. A reticulocyte is an immature RBC that still has its nucleus. An elevated reticulocyte count indicates that RBCs are being produced and released by the bone marrow before they mature. Normally only about 2% of circulating RBCs are reticulocytes. An elevated reticulocyte count is desirable in an anemic patient or after hemorrhage because this indicates that the bone marrow is responding to a decrease in the total RBC level. An elevated reticulocyte count without a precipitating cause usually indicates health problems, such as polycythemia vera (a malignant condition in which the bone marrow overproduces RBCs).

bone marrow function

Microcytic: Iron Deficiency Anemia

caused from decreased iron supply for the developing RBCs making the RBCs small (microcytic) Causes: -Blood loss -Poor GI absorption of iron -Inadequate iron intake •the most common anemia worldwide, especially among women, older adults, and people with poor diets •Any adult with iron deficiency should be evaluated for abnormal bleeding, especially from the GI tract Signs & symptoms: -Weakness -Pallor -Fatigue -Reduced exercise tolerance -Fissures in the corners of the mouth -Brittle and ridged nails -Pica Diagnostic labs: Low Hgb and Hct, Low MCV, Low serum iron (Fe), Low serum ferritin (less than 10 ng/mL (normal range is 12 to 300 ng/mL)), High transferrin or TIBC, Low iron saturation, Fecal occult blood Diagnostic tests: Barium enema, Barium swallow, Endoscopy

Aplastic anemia:

deficiency of circulating RBCs because of failure of the bone marrow to produce these cells. It is caused by an injury to the immature precursor cell for red blood cells -Usually occurs with leukopenia and thrombocytopenia, a condition known as pancytopenia -Signs & symptoms: Feeling tired and out of breath after only a little exercise, fatigue, pallor; The tendency to bruise and bleed easily; Bleeding that won't stop; Infections and an associated fever •caused by the destruction of blood-forming stem cells in your bone marrow. These stem cells normally develop into three types of blood cells: red blood cells, white blood cells and platelets. The symptoms of aplastic anemia vary depending on how severe it is and how low blood counts are -Symptoms of aplastic anemia vary depending on how severe it is and how low blood counts are •Causes: Long-term exposure to toxic agents, Ionizing radiation, Infection, Idiopathic, Hereditary •Diagnostics: •CBC: reveals pancytopenia with a neutrophil count <1500/μL, Hbg <10 g/dL, and platelets < 50,000/μL •Bone marrow aspirate: shows an extremely hypoplastic or even aplastic (very few to no cells) marrow replaced with fat

Transfusion-related acute lung injury (TRALI) is a life-threatening event that occurs most often when

donor blood contains antibodies against the recipient's neutrophil antigens, HLA, or both. Common manifestations are a rapid onset of dyspnea and hypoxia within 6 hours of the transfusion.

Blood transfusions: It is more appropriate, economical, and practical to separate a unit of whole blood into its primary components.... ...and transfuse what is actually needed.

erythrocytes, platelets, and plasma

With aging, _____ ______ replaces active bone marrow and only a small portion of the remaining marrow continues to produce blood in older adults

fatty tissue

In adults, cell-producing marrow is present only in

flat bones (sternum, skull, pelvic and shoulder girdles) and the ends of long bones

Platelet (thrombocyte)

fragment of megakaryocyte; provides basis of coagulation to occur; maintains hemostasis; average lifespan is 10 days

Bone marrow aspiration or biopsy, which are similar invasive procedures, helps evaluate the patient's ________ ________ when other tests show abnormal findings that indicate a possible problem in blood cell production or maturation. Results provide information about bone marrow function, including the production of all blood cells and platelets

hematologic status

Mature erythrocytes consist primarily of

hemoglobin, which contains iron and makes up 95% of the cell mass. Mature erythrocytes have no nuclei, and they have many fewer metabolic enzymes than do most other cells. The presence of a large amount of hemoglobin enables the red cell to perform its principal function, which is the transport of oxygen between the lungs and tissues. •Occasionally, the marrow releases slightly immature forms of erythrocytes, called reticulocytes, into the circulation. This occurs as a normal response to an increased demand for erythrocytes (as in bleeding) or in some disease states.

Bacterial transfusion reactions occur from

infusion of contaminated blood products, especially those contaminated with a gram-negative organism. Manifestations include tachycardia, hypotension, fever, chills, and shock. The onset of a bacterial transfusion reaction is rapid.

Lymphocyte

integral component of immune system

Microcytic Anemia

iron deficiency

•Serum ferritin, transferrin, and the total iron-binding capacity (TIBC) tests measure iron levels. Abnormal levels of iron and TIBC occur with problems such as _____ _______ ______.

iron deficiency anemia

Chronic lymphocytic leukemia (CLL):

is a common malignancy of older adults that is typically derived from a malignant clone of B lymphocytes -The average age at diagnosis is 72 years -Signs & symptoms: Many patients are asymptomatic and diagnosed incidentally, Enlarged lymph nodes (sometimes painful), Splenomegaly, Fevers, night sweats, unintentional weight loss •The most prevalent type of adult leukemia in the Western world •While many patients will have a normal life expectancy, others will have a very short life expectancy due to the aggressive nature of the disease •The decision to initiate therapy is based on disease stage, manifestations, and disease activity; as treatment can cause remissions but does not cure the disease •Life-threatening infections are particularly common with advanced disease, and account for 50% to 60% of all deaths in this patient population

Red Blood Cell Disorders: Anemia

is a condition in which the hemoglobin concentration is lower than normal; it reflects the presence of fewer than the normal number of erythrocytes (i.e., RBCs) within the circulation. As a result, the amount of oxygen delivered to body tissues is also diminished Can result from: -Dietary problems / deficiency -Genetic disorders -Bone marrow disease -Excessive bleeding -Decreased RBC production or increased RBC destruction •It is not a specific disease, because it occurs with many health problems •GI bleeding is the most common reason for anemia in adults •Despite the many causes, manifestations and the nursing care needed are similar for all types of anemia

Autoimmune thrombocytopenic purpura also called immune or idiopathic thrombocytopenic purpura (ITP):

is an autoimmune disorder characterized by a destruction of normal platelets by an unknown stimulus -Signs & symptoms: Ecchymosis, Petechial rash on arms, legs, upper chest, and/or neck, Mucosal bleeding, Anemia, Intracranial hemorrhage -The trigger for the production of autoantibodies is unknown, but viral infection is suspected. •ITP is most common among young children and women between the ages of 20 and 50 years; and among people who have other autoimmune disorders •Manifestations of ITP are at first seen in the skin and mucous membranes •Diagnostics: ITP is diagnosed by a low platelet count and increased megakaryocytes in the bone marrow, Antiplatelet antibodies may be detected

Heparin-Induced Thrombocytopenia

is an immune-mediated drug reaction that causes a drop in the platelet count after heparin treatment -A ~ 50% decline in platelet count is a hallmark sign that typically occurs after 5 to 10 days of heparin therapy -Risk factors: Heparin use > 4 days, Exposure to unfractionated heparin, Post-surgical thromboprophylaxis, Being female •The occurrence is increasing because of the increased use of heparin. HIT may occur in as many as 5% of patients receiving heparin. •Neither the dose nor the route of administration (IV vs. subcutaneous) is a risk. •Affected patients are at increased risk for thrombosis, either venous, arterial, or both, and the thrombosis can range from DVT to ACS or stroke, or to ischemic damage to an extremity, necessitating amputation. -Signs & symptoms: Venous thromboembolism (VTE), Bleeding, Skin necrosis

Disseminated Intravascular Coagulation

is not an actual disease but a sign of an underlying condition May be triggered by: Sepsis, trauma, cancer, shock, abruptio placentae, toxins, allergic reactions, and other conditions -The vast majority (two thirds) of cases are initiated by an infection or malignancy -Extensive, abnormal clotting occurs throughout the small blood vessels of patients with DIC. Clots block blood vessels and decrease blood flow to major body organs and result in organ dysfunction (i.e. pain, stroke-like manifestations, dyspnea, tachycardia, reduced kidney function, and bowel necrosis). This widespread clotting depletes the existing clotting factors and platelets. As this happens, extensive bleeding occurs •Bleeding from many sites is the most common problem and ranges from minimal to fatal hemorrhage. •The clinical manifestations of DIC are primarily reflected in compromised organ function or failure. •The bleeding is characterized by low platelet and fibrinogen levels; prolonged PT, aPTT, and thrombin time; and elevated fibrin degradation products and D-dimers. DIC is a life-threatening problem with a high mortality rate even when proper therapies are instituted •Signs & symptoms: Bleeding from mucous membranes, venipuncture sites, GI/GU tracts, etc., Minimal to profuse hemorrhage for all orifices, Developing multi-organ dysfunction à failure due to clots, Especially in kidneys, lungs, neurological system •Diagnostics: Drop in platelet count, an elevation in fibrin degradation products and D-dimer, an increase in PT and aPTT, and a low fibrinogen level

Allergic transfusion reactions (anaphylactic transfusion reactions) are most often seen in patients with

other allergies. They may have urticaria, itching, bronchospasm, or anaphylaxis. Onset usually occurs during or up to 24 hours after the transfusion. Patients with an allergy history can be given leukocyte-reduced or washed RBCs in which the WBCs, plasma, and immunoglobulin A have been removed, reducing the possibility of an allergic reaction.

The hematologic system is important for what two functions?

oxygenation (gas exchange) and tissue perfusion because the blood is the oxygen delivery system

Eosinophils are important in the phagocytosis of

parasites

Anticoagulant drugs

prevent new clots from forming and limit or prevent extension of formed clots, they do not break down existing clots. Many patients refer to these drugs as "blood thinners" although they do not change blood thickness (viscosity)

In general, the more _______ an anemia develops, the more severe its symptoms. An otherwise healthy person can often tolerate as much as a 50% gradual reduction in hemoglobin (e.g., over months) without pronounced symptoms or significant incapacity, whereas the rapid loss of as little as 30% (e.g., over minutes) may precipitate profound vascular collapse in the same person. A person who has become gradually anemic, with hemoglobin levels between 9 and 11 g/dL, usually has fewer or no symptoms other than slight tachycardia on exertion and possibly fatigue.

rapidly

B lymphocyte

responsible for humoral immunity; many mature into plasma cells to form antibodies

Acute myeloid leukemia (AML):

results from a defect in the hematopoietic stem cell that differentiates into all myeloid cells: monocytes, granulocytes, (i.e. neutrophils, basophils, eosinophils), erythrocytes, and platelets -More common after age 45 and a peak incidence at age 67 -Signs & symptoms: Symptoms typically occur over a period of a few weeks, Fever and infection, Weakness, fatigue, DOE, pallor, Petechiae, ecchymoses, bleeding tendencies, Enlarged painful spleen or liver, bone pain •AML is the most common non-lymphocytic leukemia. •AML: 5-year survival rates of 56% for those under age 45, 39% for those aged 45 to 54, 27% for those aged 55 to 64, 11% for those between 65 and 74 years old, and less than 2% for those over age 75. Despite these poor statistics, cure is possible for some individuals, either with stem cell transplant or with chemotherapy. •Death usually is due to infection or bleeding.

Acute lymphocytic leukemia (ALL):

results from an uncontrolled proliferation of immature cells (lymphoblasts) derived from the lymphoid stem cell -ALL is most common in young children, with boys affected more often than girls; the peak incidence is 4 years of age -After 15 years of age, it is relatively uncommon, until age 50 when the incidence again rises -Signs & symptoms: Leukemic cell infiltration into other organs are more common with ALL than with other forms of leukemia à pain from an enlarged liver or spleen and bone pain, Cranial nerve palsies, headaches, vomiting with meningeal involvement, Involvement of testes and breasts -very responsive to treatment; complete remission or response rates are approximately 85% for adults. Increasing age appears to be associated with diminished survival; the 5-year event-free survival rate is more than 85% for children, whereas the 3-year event-free survival rate drops to less than 45% for adults

Macrocytic: Vitamin B12 Deficiency Anemia

results in failure to activate the enzyme that moves folic acid into precursor RBCs so that cell division and growth into functional RBCs can occur -These precursor cells then undergo improper DNA synthesis and increase in size, therefore they are called macrocytic or megaloblastic -Pernicious anemia results from failure to absorb vitamin B12 caused by a deficiency of intrinsic factor (a substance normally secreted by the gastric mucosa), which is needed for intestinal absorption of vitamin B12 Signs & symptoms: Pallor, Jaundice, Glossitis, Confusion or other mental problems, Parasthesias, Fatigue, Weight loss, Poor balance•Glossitis a smooth, beefy-red tongue, Mental problems like depression, memory loss, or behavioral changes can also occur, Low levels of B12 have been linked to mood and brain disorders like depression and dementia -Any nerve damage that happened due to the deficiency could be permanent. This can occur over time, as vitamin B12 is an important contributor to the metabolic pathway that produces the fatty substance myelin. Myelin surrounds your nerves as a form of protection and insulation. Without B12, myelin is produced differently, and your nervous system isn't able to function properly

Plasma cell

secretes immunoglobulin (antibody); most mature form of B lymphocyte

Hematopoietic stem cell transplantation (HSCT) (AKA bone marrow transplant [BMT]) is a therapeutic modality that offers the possibility of cure for some patients with hematologic disorders such as

severe aplastic anemia, some forms of leukemia, and thalassemia. It can also provide longer remission from disease even when cure is not possible, such as in multiple myeloma. Hematopoietic stem cells may be transplanted from either allogeneic or autologous donors. •BMT: can also be used for lymphoma, multiple myeloma, aplastic anemia, sickle cell disease, and many solid tumors.

In polycythemia, Because the actual number of cells in the blood is greatly increased and the cells are not completely normal, cell life spans are

shorter. The shorter life spans and increased cell production cause a rapid turnover of circulating blood cells. This rapid turnover increases the amount of cell debris (released when cells die) in the blood, adding to the general "sludging" of the blood •This debris includes uric acid and potassium, which cause the manifestations of gout and hyperkalemia (elevated serum potassium level) •If left untreated, few people with PV live longer than 2 years after diagnosis

About 1 in 13 African Americans are carriers of one _______ ______ gene allele

sickle cell

Therapeutic phlebotomy is

the removal of a certain amount of blood under controlled conditions. Patients with elevated hematocrits (e.g., those with polycythemia vera) or excessive iron absorption (e.g., hemochromatosis) can usually be managed by periodically removing 1 unit (about 500 mL) of whole blood.

With leukemia, cancer most often occurs in

the stem cells or early precursor leukocyte cells, causing excessive growth of a specific type of immature leukocyte. In some chronic leukemias, the cancerous cells may be more mature. These cells are abnormal, and their excessive production in the bone marrow stops normal bone marrow production, leading to anemia, thrombocytopenia, and leukopenia. •Often the number of immature, abnormal WBCs ("blasts") in the blood is greatly elevated, and these cells cannot provide infection protection

Why would you assess socioeconomic status and for drug use in a elderly patient being assessed for hematologic conditions?

•Ask about alcohol consumption because chronic alcoholism causes nutrition deficiencies and impairs the liver, both of which reduce blood clotting. •Ask about personal resources, such as finances and social support. A person with a low income may have a diet deficient in iron and protein because foods containing these substances are more expensive.

Specific assessments for sickle cell disease crises

•Ask about previous crises, what led to the crises, severity, and usual management. Explore recent contact with ill people and activities to determine what caused the current crisis. Ask about manifestations of infection. Review all activities and events during the past 24 hours, including food and fluid intake, exposure to temperature extremes, drugs taken, exercise, trauma, stress, recent airplane travel, and ingestion of alcohol or other recreational drugs. •Skin changes: examine the lips, tongue, nail beds, conjunctivae, palms, and soles of the feet at least every 8 hours for subtle color changes. With cyanosis, the lips and tongue are gray and the palms, soles, conjunctivae, and nail beds have a bluish tinge. Jaundice results from RBC destruction and release of bilirubin. •To assess for jaundice in patients with darker skin, inspect the roof of the mouth for a yellow appearance. Examine the sclera closest to the cornea to assess jaundice more accurately

Common findings to assess for in a hematologic head to toe assessment

•Assess the whole body because blood problems may reduce oxygen delivery and tissue perfusion to all systems •Petechiae are pinpoint hemorrhagic lesions in the skin •Pernicious anemia: A bright red, smooth tongue, mouth ulcers •Iron deficiency anemia: Inflammation or soreness of your tongue •Assess the conjunctiva of the eye when assessing a dark-skinned patient for pallor •assess for jaundice in patients with darker skin, inspect the roof of the mouth for a yellow appearance. Examine the sclera closest to the cornea to assess jaundice more accurately

Risk Factors for Leukemia

•Ionizing radiation •Viral infection •Exposure to chemicals / drugs •Genetic factors •There is an increased incidence of the disease among patients with genetic conditions such as Down syndrome, Bloom syndrome, Klinefelter syndrome, and Fanconi's anemia. Immune deficiencies may promote the development of leukemia •Immunologic factors •Environmental factors

It is usually possible to determine whether the presence of anemia in a given patient is caused by destruction or by inadequate production of erythrocytes on the basis of the following factors:

•The bone marrow's ability to respond to decreased erythrocytes (as evidenced by an increased reticulocyte count in the circulating blood) •The degree to which young erythrocytes proliferate in the bone marrow and the manner in which they mature (as observed on bone marrow aspirate) •The presence or absence of end products of erythrocyte destruction within the circulation (e.g., increased bilirubin level, decreased haptoglobin level)

Leukemia

•is a neoplastic proliferation of a particular cell type (granulocytes, lymphocytes, or infrequently erythrocytes or megakaryocytes). The defect originates in the hematopoietic stem cell, the myeloid, or the lymphoid stem cell. Lymphomas are neoplasms of lymphoid tissue, usually derived from B lymphocytes. -is cancer with uncontrolled production of immature WBCs ("blast" cells) in the bone marrow; as a result, the bone marrow becomes overcrowded with immature, nonfunctional cells and production of normal blood cells is greatly decreased

The serum ferritin test measures the amount of _____ ____ present in the plasma, which represents 1% of the total body iron stores. Therefore the serum ferritin level provides a means to assess total iron stores. People with serum ferritin levels within 10 g of the normal range for their gender have adequate iron stores; people with levels 10 g or more lower than the normal range have inadequate iron stores and have difficulty recovering from any blood loss.

free iron

Many substances are needed to form hemoglobin and RBCs, including... A lack of any of these substances can lead to anemia, which results in unmet tissue oxygen needs because of a reduction in the number or function of RBCs.

iron, vitamin B12, folic acid, copper, pyridoxine, cobalt, and nickel.

Transferrin is a protein that __________ dietary iron from the intestines to cell storage sites. Measuring the amount of iron that can be bound to serum transferrin indirectly determines whether an adequate amount of transferrin is present. This test is the total iron-binding capacity (TIBC) test. Normally, only about 30% of the transferrin is bound to iron in the blood. TIBC increases when a person is deficient in serum iron and stored iron levels. Such a value indicates that an adequate amount of transferrin is present but less than 30% of it is bound to serum iron.

transports

in a Older Adult why would you assess their medical history, including their medication history and nutritional status?

•Liver function, the presence of known immunologic or hematologic disorders, current drug use, dietary patterns, and socioeconomic status are important to assess. Because the liver makes clotting factors, ask about manifestations that may indicate liver problems, such as jaundice, anemia, and gallstones. •Ask about lymph nodes swelling, excessive bruising or bleeding, fatigue, shortness of breath on exertion, palpitations, frequent infections, fevers, recent weight loss, headaches, or paresthesias •Ask the patient about use of blood "thinners" and NSAIDs, which change blood clotting activity. Such drugs include anticoagulants, fibrinolytics, and platelet inhibitors. •Obtain a nutritional history and assess the use of prescription and over-the-counter medications, as well as herbal supplements, are important to note, because several conditions can result from nutritional deficiencies, or from the use of certain herbs or medications.

Diagnostic labs: hematologic

-CBC -Iron studies (serum ferritin, transferrin, TIBC) -Peripheral blood smear -Reticulocyte count -Coagulation studies (PT, INR, PTT)

Hair and skin changes in the older adult are:

-Pallor or cyanosis may indicate a hematologic disorder: While thickened or discolored nails make viewing color of nail beds impossible in the elderly (Use another body area, such as the lip, to assess central capillary refill) -Thin or absent hair on the trunk or extremities may indicate poor circulation to a particular area: While progressive loss of body hair is a normal facet of aging (Know that a relatively even pattern of hair loss that has occurred over an extended period is not significant) -Skin dryness may indicate any of a number of hematologic disorders: While skin dryness is a normal result of aging -Skin color changes, especially pallor and jaundice, are associated with some hematologic disorders: While pigment loss and skin yellowing are common changes associated with aging (Pallor in an older adult may not be a reliable indicator of anemia. Laboratory testing is required. Yellow-tinged skin in an older adult may not be a reliable indicator of increased serum bilirubin levels. Laboratory testing is required.)

What would be included in a physical assessment for hematologic patient?

-Skin: assess for pallor, jaundice, petechiae, ecchymosis, hair patterns, etc. -HEENT: assess for pernicious anemia and iron deficiency anemia, scleral jaundice, etc. -Neurologic: assess for cranial nerve dysfunction, sensory dysfunction, cognition, etc. -Respiratory: assess for rate and depth of respirations after mild activity, SOB at rest, etc. -Cardiac: assess for pulse grade, distended neck veins, edema, low BP, etc. -GI: assess for splenomegaly, hepatomegaly, occult blood, etc. -GU: assess for hematuria, proteins in urine, etc. -Musculoskeletal: assess for any bone tenderness (esp. ribs and sternum)

The CBC can measure other features of the RBCs such as...

The mean corpuscular volume (MCV) measures the average volume or size of individual RBCs and is useful for classifying anemias. When the MCV is elevated, the cell is larger than normal (macrocytic), as seen in megaloblastic anemias. When the MCV is decreased, the cell is smaller than normal (microcytic), as seen in iron deficiency anemia. The mean corpuscular hemoglobin (MCH) is the average amount of hemoglobin by weight in a single RBC. The mean corpuscular hemoglobin concentration (MCHC) measures the average amount of hemoglobin by percentage in a single RBC. When the MCHC is decreased, the cell has a hemoglobin deficiency and is hypochromic (a lighter color), as in iron deficiency anemia. These three tests can help determine possible causes of low RBC counts that are not related to blood loss

A patient is taking prednisone 60 mg per day for the treatment of an acute exacerbation of Crohn's disease. The patient has developed lymphopenia with a lymphocyte count of less than 1,500 mm3. What should the nurse monitor the client for?

The onset of a bacterial infection