NR- 324 Exam 2 Hematology

Neutropenia precautions

- HAND HYGIENE (Pt and ppl around them) - Shower daily - Brush teeth BID w/ soft toothbrush - Check Pt temp q4 hr - >100.4F, signal alarm → blood cultures and antibiotics - Avoid sick ppl - Do not clean up after pets - No gardening / contact w/ dirt - Wear mask when going out - avoid most fresh fruits and veggies (except those w/ thick skin; Oranges, Bananas, Avocado; can be peeled and washed) - Avoid uncooked foods (no sushi, med rare meat, runny eggs) - Avoid crowds

Sickle cell anemia crisis

-Cell clumping: Obstruction produces vasoocclusive crisis ↓↓↓↓↓↓ Abdominal & Long Bones Pain, Hand foot syndrome, Joint Pain -Complications: infections, stroke, URIs, Leg ulcers, splenomegaly -Treatment: HOPe - Hydration, Oxygen, Pain relief, Education

s/s of a Febrile reaction

-Chills -Fever -HA -Flushing -Tachycardia -↑ Anxiety

Nursing management of Anemia

-Correcting the cause of anemia is ultimate goal (treat UNDERLYING CAUSE) -Blood / blood product transfusion -Meds -Volume replacement -O2 -Prevent Falls -Educate on dietary and lifestyle changes -Schedule rest

3 Main classifications/causes of Anemia

-Decreased RBC Production -Blood Loss -Increased RBC Destruction (Hemolytic anemias)

Causes of neutropenia

-Drug induced -hematologic disorders -Autoimmune disorders -Infections -Others (sepsis, nutritional deficiencies, etc.)

Blood transfusion reactions types (3)

-Febrile reaction -Hemolytic Transfusion reaction -Allergic Reaction (mild / severe)

s/s of mild allergic reaction to blood

-Hives -Pruritis Facial flushing

s/s of Hemolytic Transfusion reaction

-Low back pain -Hypotension -Tachycardia -Fever & chills -chest pain -Tachypnea -Hemoglobinuria -May have immediate onset

Manifestations of thrombocytopenia

-Many Pts asymptomatic -Bleeding Precautions -Most common = Bleeding, usually mucosal (epistaxis, gingival bleeding, large bullous hemorrhages may appear on buccal mucosa) -Bleeding into skin (petechiae, purpura, superficial ecchymoses)

blood administration

-Need consent -Determine Pt's allergies & previous transfusion reactions -Check crossmatch record with 2 Nurses: ABO, RH, Pt Name, Id blood band, Hospital #, Expiration date - Administer blood w/in 30 min of receiving -may be premedicated w/ antihistamine and hydrocortisone to ↓ possibility of reaction -Take baseline VS before beginning -Remain w/ patient for first 15 min! recheck VS after 15", -Never add any meds to blood -Do NOT warm unless risk of Hypothermic response THEN only by specific blood warming equipment -Infuse each unit over 2-4 hours but NO LONGER than 4 hours

Patient teaching: Thrombocytopenia

-Notify HCP of s/s of bleeding (black tarry stools, hematemisis, hematuria, bruising) -Ask HCP about restrictions in normal activities, -Do not blow nose forcefully; gently pat -do not bend down w/ head lower than waist -Drink plenty of fluids (prevent constipation) -No enemas, suppository, rectal thermometer -Electric razor only -No pluck hair -No tattoo/piercings -Avoid meds that can prolong bleeding -Use soft toothbrush -Women keep track of pads/day. no tampons -ask HCP before any invasive procedure (dental cleaning, mani/pedicure)

Manifestations of Neutropenia

-Pt is predisposed to infection w/ opportunistic pathogens and nonpathogenic organisms -absent pus formation cuz WBC are main component of pus -Low-grade fever is of great significance cuz it may indicate infection and lead to septic shock -Sore throat and dysphagia -Ulcerative lesions of pharyngeal and buccal mucosa -diarrhea -rectal tenderness -vaginal itching and tenderness -SOB -nonproductive cough

nursing implications r/t Hemolytic reaction

-STOP transfusion -Obtain 2 blood samples distal to infusion site -Obtain Urinalysis first → test for hemoglobinuria -Monitor fluid/electrolyte balance -Evaluate serum calcium levels

s/s of severe allergic reaction to blood

-Severe shortness of breath -Bronchospasm -Anxiety

Nursing implications for Blood transfusion Reactions

-Stop transfusion and notify HCP -Change IV tubing -Treat symptoms if present → O2 fluids, epinephrine as ordered, -Recheck crossmatch record w/ unit For Hemolytic Reactions: Obtain 2 blood samples distal to infusion site, Obtain first UA→test for hemoglobinuria, Monitor fluid/electrolyte balance, Evaluate serum calcium levels

Nurse management of Thrombocytopenia

-Treat Underlying Cause -Goal is to prevent / control hemorrhage -Use small gauge needles for SubQ shots -Avoid IM inj -Count sanitary napkins during menses to detect excess blood loss -Closely monitor platelet count, coagulation, Hgb, Hct -Teach to avoid causative agents when possible

Implement Bleeding Precautions when

-using anticoagulants -Liver disease is present -Platelets ↓ 150,000 -Hemophilia present -Using thrombolytics

A nurse is assessing a patient who has neutropenia and is receiving filgrastim. Which of the following assessments is an expected adverse reaction of filgrastim? 1.Assess for bone pain 2.Assess for right lower quadrant pain 3.Auscultate for crackles in the bases of the lungs 4.Auscultate the chest to listen for a heart murmur

1

Your patient has a platelet count of 87,000/mm3. The nurse concludes the patient understands instructions to avoid potential complications when the patient says to do which of the following? 1. Avoid aspirin and aspirin (salicylate) containing products. 2. Monitor fever every 4 hours. 3. Allow for rest periods to avoid fatigue 4. Brush and floss teeth daily to prevent infection

1 -low platelet = Bleeding precautions, Aspirin ↑ bleeding = contraindicated for this PT

Blood tests for hematology

CBC Coagulation: PT/INR, PTT

Platelets think

Coagulation -Lack of = Thrombocytopenia

Normal hemoglobin

Female: 11.7 - 16.0 g/dL Male 13.2 - 17.3 g/dL

Normal RBC

Female: 3.8-5.1 Male: 4.3-5.7

Normal Hematocrit

Female: 35-47% Male: 30-50%

Treatment of Sickle Cell: HOPE

Hydration Oxygenation Pain relief Education: ↓amount of crises, ↓ infections, ↑ Vaccines; S/s of infections

WBC think

Infection protection -Lack of = Leukopenia

cause of hemolytic reaction

Infusion of ABO-incompatible whole blood, RBCs, or components. Antibodies in the Pt's plasma attach to antigens on transfused RBCs, causing RBC destruction

Causes of Thrombocytopenia

Inheritied (Fanconi syndrome [pancytopenia], Hereditary thrombocytopenia) Acquired -Immune (Immune thrombocytopenia purpura [ITP], Neonatal alloimmune thrombocytopenia) -Nonimmune (thrombotic thrombocytopenia purpura [TTP], DIC, Heparin-induced tpia [HIT], Splenomegaly or splenic sequestration; heamangiomas, abnormal cardiac valves, intraaortic balloon pumps; Drug-induced marrow suppression, Chemo, Viral/Bacterial infection, Alcoholis, BMS, Myelodysplastic syndrome) -Drugs and Hebal products (thiazide, NSAIDs, Antibiotics, antiinfectives, analgesics,

Define Eccymoses

Larger purplish lesions caused by hemorrhage -may be flat or raised -Pain and tenderness are sometimes present

Bone marrow think

Malignant Predisposition -Lack of = Leukemia/Lymphoma

Manifestations of Sickle cell

May have chronic health probs d/t organ tissue hypoxia and damage Manifestations during episode: -Pallor, dark skin may have grayish cast -Jaundice -Gallstones -Pain d/t ischemia -Fever -Swelling -Tenderness -Tachypnea -HTN -N&V

RBC think

Oxygen transportation Lack of = Anemia

Tests included in CBC

RBC Hemoglobin Hematocrit Platelet WBC Neutrophil

Bleeding Precautions (RANDI)

Razor Electric Aspirin NONE Needles, small gauge Decrease needle sticks Injury - protect from

Cause of severe allergic reaction to blood

Sensitivity to donor plasma proteins. Infusions of IgA proteins to IgA-deficient recipient who has developed IgA antibody

cause of mild allergic reaction to blood

Sensitivity to foreign plasma proteins -More common in Pts w/ a Hx of allergies

cause of Febrile reaction

Sensitization to donor WBCs (most common), Platelets, or Plasma proteins

Leukemia treatment

Stem cell transplant Radiation Chemotherapy

define Leukemia

The general term used to describe a group of malignant disorders affecting the blood and blood-forming tissues of the bone marrow, lymph system, and spleen -Cancer of blood forming tissue in bone marrow

define Anemia

a deficiency in the number of erythrocytes, the quantity of hemaglobin, and/or the volume of packed RBCs (hematocrit) -not a disease, a clinical finding that arises from many causes

A nurse is planning care for a client who has Hgb 7.5g/dL and Hct 21.5%. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Provide assistance with ambulation. B. Monitor oxygen saturation. C. Weigh the client weekly. D. Obtain stool specimen for occult blood. E. Schedule daily rest periods.

a, b, d, e The nurse should assist the client when ambulating to prevent a fall because the client who has anemia can experience dizziness. The nurse should monitor O2 saturation when the client has anemia due to decreased O2 carrying capacity of the blood. The nurse should obtain the client's stool to test for occult blood, which can identify a possible cause of anemia caused by GI bleed. The nurse should schedule the client to rest throughout the day because clients with anemia can experience fatigue.

A nurse is teaching a client who has a new prescription for ferrous sulfate (Feosol). What should be included in the teaching? A. Stools will be dark red in color. B. Take with a glass of milk if gastrointestinal distress occurs. C. Foods high in vitamin C will promote absorption. D. Take for 14 days.

c

define Thrombocytopenia

deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and slow blood clotting after injury. -Platelet count below 150,000

Neutropenia is defined as ANC

less than 1000

Manifestations of leukemia

r/t probs caused by bone marrow failure and the formation of leukemic infiltrates -Predisposed to anemia, thrombocytopenia, ↓ # of functional WBCs (makes broken WBC that accumulate and don't die) -Leukemic cells infiltrate organs → lead to Splenomegaly, Hepatomegaly, lymphadenopathy (swollen lymph nodes), bone pain, meningeal irritation, and oral lesions -night sweats -Freq UTI/ infections -weight loss -unexplained fever -chloromas (solid masses d/t collections of leuk cells) -leukostasis (↑ leuk white count can cause blood to thicken and block circulatory pathways

manifestations of Anemia

reflect hypoxia -Fatigue -Tachycardia -Tachypnea -Restlessness -Irritability -Dyspnea

define petechiae

small, flat, pinpoint, red or reddish brown microhemorrage

Manifestations of severe anemia

symptoms are constant (at rest & during activity) -Daily tasks are difficult to complete. Mental abilities are impaired. Emotional changes. Headache, Noticeable pallor, tachycardia, angina. Tachypnea, orthopnea, Sensitivity to cold. Dyspnea at rest. -Int: Pallor, jaundice, pruritis -Eyes: icteric conjunctiva & sclera, retinal hemorrhage, blurred vision -Mouth: glossitis, smooth tongue -CV: Tachy, ↑Pulse pressure, systolic murmurs, int. claudication, angina, HF, MI -Pulm: Tachypnea, Orthopnea, dyspnea @ rest -Neuro: HA, vertigo, irritability, depression, impaired thought processes GI: anorexia, hepatomegaly, splenomegaly, difficulty swallowing, sore mouth -Bone pain -Sensitivity to cold, Weight loss Lethargy

define purpura

when petechiae are numerous, resulting reddish skin bruise

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse expect if an allergic transfusion reaction is suspected? (Select all that apply.) 1.Stop the transfusion 2.Monitor for hypertension 3.Maintain an IV infusion with 0.9% sodium chloride 4.Position the client in an upright position with the feet lower than the heart 5.Administer diphenhydramine

1, 3, 5 The nurse should immediately stop the infusion if an allergic transfusion reaction is suspected. The nurse should administer 0.9%sodium chloride solution through new IV tubing The nurse should administer an antihistamine, such asdiphenhydramine, if an allergic transfusion reaction is suspected.

Normal platelet count

150,000 - 450,000 <150,000 = thrombocytopenia

The nurse is preparing a teaching plan for a client with sickle cell disease about ways to prevent crisis episodes. Which of the following should be emphasized to prevent crisis? 1.Eat nutritious foods that are high in iron 2.Seek treatment for infections as soon as possible 3.Take adequate amounts of supplemental vitamins 4.Avoid any type of physical activity

2

A patient is to receive epoetin (Epogen) injections. Which laboratory result should the nurse assess before giving the injection. 1.Hemoglobin concentration 2.Partial thromboplastin time 3.Prothrombin time 4.Hematocrit

4

Normal WBC count

4,000 - 11,000

Normal neutrophil count

50 - 70 % or 2200 - 7700 cells

A nurse is providing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should be included in the teaching? (Select all that apply). A. "You will need a monthly injection of vitamin B12 for the rest of your life." B. "Using the nasal spray form of vitamin B12 on a daily basis may be an option." C. "An oral supplement of vitamin B12 taken on a daily basis may be an option." D. "You should increase your intake of animal proteins, legumes, and dairy products to increase vitamin B12 in your diet." E. "Add soy fortified with vitamin B12 to your diet to decrease the risk of pernicious anemia."

A, B The client who had a gastrectomy will require injections of vitamin B12 for the rest of his life due to lack of intrinsic factor being produced by the parietal cells of the stomach. Cyanocobalamin nasal spray used daily is an option.

classification of Leukemia

Acute VS. Chronic -based on cell maturity & nature of disease -acute: proliferation of immature cells -chronic: mature forms of WBC w/ more gradual onset

define Neutropenia

An abnormal drop in blood neutrophil count -May be d/t drugs, infections, blood disorders, cancer, or birth defects

Symptoms of Leukemia (ANT)

Anemia ↓ Hgb Neutropenia - risk of infection Thrombocytopenia - bleeding

When a client with thrombocytopenia reports experiencing a severe headache the nurse should interpret these findings may indicate which of the following? A. Sinus congestion B. Cerebral bleeding C. Migraine headache D. Stress of the disease

B

Diagnostic test for hematology

Bone marrow Biopsy

What guides the plan of care for leukemia?

Bone marrow biopsy