Hematologic Problems - Chapter 40 (2)
The nurse is teaching a client about induction therapy for acute leukemia. Which client statement indicates a need for additional education?
"After this therapy, I will not need to have any more." Induction therapy is not a cure for leukemia, it is a treatment; therefore, the client needs more education to understand this. Because of infection risk, clients with leukemia should avoid people with a cold or flu. Induction therapy will most likely cause the client with leukemia to lose his or her hair. The goal of induction therapy is to force leukemia into remission.
The nurse is providing teaching for a client who follows a lacto-ovo vegetarian diet. Which statement by the nurse is most appropriate regarding a sufficient intake of vitamin B12?
"Egg yolks contain a high amount of vitamin B12." Vitamin B12 is found in animal protein, eggs, and dairy products. Telling the client to change his or her beliefs about consuming meat is dictatorial and not supportive. Dairy products contain vitamin B12; therefore, absorption is not inhibited. Salmon contains omega-3 fatty acids, which may prevent heart disease, but not vitamin B12 deficiency.
A client with thrombocytopenia is being discharged. What information does the nurse incorporate into the teaching plan for this client?
"Use a soft-bristled toothbrush." Using a soft-bristled toothbrush reduces the risk for bleeding in the client with thrombocytopenia. Avoiding large crowds reduces the risk for infection, but is not specific to the client with thrombocytopenia. Increased fluid intake reduces the risk for dehydration, but is not specific to the client with thrombocytopenia. Elevating extremities reduces the risk for dependent edema, but is not specific to the client with thrombocytopenia.
A client recently diagnosed with polycythemia vera (PV) has a serum hemoglobin of 20 g/dL, elevated leukocytes and platelets, a purplish flushed appearance, and reports intense itching. A family member asks the nurse if the client will get better. How does the nurse respond?
"With aggressive management, people can live for over 10 years." PV is a type of cancer of the red blood cells. With aggressive treatment, clients can live for 10-15 years. Without treatment, most clients die within 2 years. PV is not a temporary condition and requires aggressive treatment.
The nurse is counseling a 65-year-old client diagnosed with a myelodysplastic syndrome who has severe pancytopenia and a high number of blast cells. The client wants to know if this will eventually cause cancer. How does the nurse respond?
"You have a high risk for developing cancer." Myelodysplastic syndrome is not cancer, but is considered pre-cancer. This client has severe pancytopenia and a high number of blast cells, making the cancer risk high. The client does not have an intermediate or low risk of developing cancer.
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bone marrow aspiration
-MD uses a thin needle to remove small amounts of liquid bone marrow, usually from a spot in the illiac crest.
febrile reaction
-anti-wbc antibodies this is common with multiple transfusions already taken place -chills, tachycardia,fever,hypotension
sickle cell information
-clumped masses of sickled cells can block blood flow, known as a vaso-occlusive event. -voe leads to hypoxia, and more sickle shaped cells -repeated episodes of ischemia cause progressive organ damage from anorxia and infarction -repeated voes can cause damage to tissue and organs -10/20 day life span
PV information
-dark, purple or cyanotic skin, flsuhed, disteined veins, itching caused by dilated blood vessels, poor perfusion is common -hypertension -thrombosis risk, rapid turnover of cell life -even though the number of rbcs is increased, their oxygen carrying capacity is impaired, and patients have poor gas exchange -bleeding problems are common because of platelet impairment -increase is cell debris adding to general sludging of the blood, uric acid and potassium, gout and hyperkalemia common
preparing for self management
-drink at least 3l of liquids daily -avoid tight clothing -wear gloves if its cold out -contact hcp if infection is suspected -electric shaver, soft bristled brush, dont floss
sickle cell disease
-genetic disorder that results in chronic anemia, pain, disability, organ damage, increased risk for infections, and early death
polycythemia vera
-greater than normal RBCs -temporary or permanent -treatment includes: phlebotomy, hydration, anticoagulants
anemia is
-insufficient supply of healthy RBC's common causes: nutritional. hereditary, bone marrow disease, hemorrhage, pregnancy
4 types of anemias
-iron deficiency -vitamin b12 deficiency -folic acid deficient -aplastic
chronic lymphocytic leukemia
-more common in older adults -survival rate is 2-14 years malignant B lymphocytes s/s include: B symptoms, swollen lymph nodes treatment: chemotherapy
iron deficient anemia
-most common causes: insufficient dietary intake of iron, blood loss, impaired absorption of iron -meds and guidelines: "consult lilley"
acute myeloid leukemia
-most common adult onset leukemia -peak incidence is age 60 -prognosis is variable -s/s include fever, infection, fatigue, bleeding, bone pain treatment: chemo induction therapy, bone marrow transfer if applicable -supportive treatment: blood transfusion and antibiotics
polycythemia vera
-number of RBCs in the blood is greater than normal. -hyperviscous (thicker than normal) -hemoglobin levels 18g/dl, rbc count of 6million, hematocrit 55% or greater
HL information
-one of the most treatable types of cancer -stages 1,2 = radiation of involved nodes
physical assessment and clinical manifestations of sickle cell
-pain is the most common manifestation of a SCD crisis -high risk for heart failure -peripheral pulses, temp, capillary refill, heart rate rapid but blood pressure dropping/average -priapism (prolonged erection due to vascular engorgment) -pallor, cyanotic, lips, tounge, jaundice from rbc destruction -ulcers on lower legs -spleen and liver changes in the abdomin, may feel firm or large -chronic kidney disease may occur from the anoxic damage to nephrons, protein in urine? little to no output? -joints may be damage from hypoxic episodes, necrotic degeneration, areas of swelling? color difference? move all joints? -seizures or a stroke? -hemotocrit low, 20-30% because of shortened rbc life -bilirubin levels high -elevated wbc is commonfrom chronic inflammation caused by hypoxia and ischemia -x-ray of joints may show necrosis and destruction
chronic myeloid leukemia
-philadelphia chromosome bcr-abl gene tyrosine kinase protein 3 stages treatment: gleeven or sprycel, chemotherapy, BMT
crisis event
-sudden onset and can occur as often as weekly or seldom such as once a year -hypoxemia a cause of this usually
Which client does the nurse consider at risk for folic acid deficiency anemia?
Client with Chrohn's disease Malabsorption syndromes, such as Chrohn's disease, are the second most common cause of folic acid deficiency anemia. Other risk factors include poor nutrition and the use of anticonvulsants or oral contraceptives. Those with an increased need for folic acid are at additional high risk. Heart failure and basal cell skin cancer are not included in these risks. Clients with fractures may require additional calcium, not folic acid.
question information
Clients with sickle cell anemia who have decreased oxygen conditions develop vasoocclusive crisis, causing reduction in oxygen supply and furthering development of sickled cells and organ damage. The nurse must encourage oral fluids and administer parenteral fluids to restore tissue perfusion.
A client who has undergone bone marrow transplantation 21 days prior is receiving growth factors. The client's blood test reveals mixed chimerism with a greater percentage of donor cells than 1 week prior. How does the nurse interpret this result?
Engraftment appears to be successful. Clients who undergo bone marrow transplantation can expect engraftment to occur 12-28 days after the transplant. Progressive chimerism (presence of donor cells) indicates engraftment; graft failure would be indicated by regressive chimerism. It is not necessarily expected for the client to have 100% donor cells this early after transplant and there is no indication for increasing growth factor.
The nurse is caring for a client with sickle cell disease (SCD). Which action is most effective in reducing the potential for sepsis in this client?
Frequent and thorough handwashing Prevention and early detection strategies are used to protect the client in sickle cell crisis from infection. Frequent and thorough handwashing is of the utmost importance. Drug therapy is a major defense against infections that develop in the client with sickle cell disease, but is not the most effective way that the nurse can reduce the potential for sepsis. Continually assessing the client for infection and monitoring the daily complete blood count (CBC) with differential white blood cell (WBC) count is early detection, not prevention. Taking vital signs every 4 hours will help with early detection of infection, but is not prevention.
Which assessment finding is consistent with polycythemia vera (PV)?
Increased hematocrit PV is a disease with a sustained increase in hemoglobin levels to =18 g/dL, a red blood cell (RBC) count of 6 million/mm3, or a hematocrit =55%. PV is a cancer of the RBCs that has three major hallmarks—massive production of RBCs, excessive leukocyte production, and excessive production of platelets. The client's facial skin and mucous membranes have a dark, flushed appearance because the blood in these tissues is poorly oxygenated. Even though the number of RBCs is greatly increased, their oxygen-carrying capacity is impaired, and clients have poor oxygenation.
A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding which potential problem takes priority in the client's nursing care plan?
Infection The main objective in caring for a newly diagnosed client with leukemia is protection from infection. Fluid overload, hemorrhage, and hypoxia are not priority problems for the client with leukemia.
The nurse is caring for a client who is in sickle cell crisis. What action does the nurse perform first?
Provide pain medications as needed. Analgesics are needed to treat sickle cell pain. Warm soaks or compresses can help reduce pain perception. Cool compresses do not help the client in sickle cell crisis. Birth control is not the priority for this client. Increasing iron in the diet is not pertinent for the client in sickle cell crisis.
Which nursing intervention is effective in helping promote peripheral perfusion in a client who has sickle cell disease?
Remove constrictive clothing. To help prevent damage to peripheral tissues, the nurse should remove constrictive clothing from the client in sickle cell crisis. The head of the bed should be no higher than 30 degrees and the legs should not be elevated, especially with pillows under the knees. The room should be kept warm at a temperature of 72° F or higher.
The complete blood count results for a client with acute myelogenous leukemia shows a platelet count of 40,000/mm3. What does the nurse counsel this client to do?
Report any abdominal distention immediately. Clients with platelet counts of <50,000/mm3 are at extreme risk for bleeding. Abdominal distention may represent internal hemorrhage and should be reported immediately. Clients should be instructed to apply ice to areas of trauma, to brush teeth carefully with a sponge or soft-bristled toothbrush, and to wear hard-soled shoes to protect their feet.
A client with leukemia is admitted to the hospital with a temperature of 97.8° F (36.6° C). Later that evening, the client's temperature is 99.0° F (37.2° C). Which action by the nurse is correct?
Report the temperature increase to the provider. Any client receiving chemotherapy for leukemia who has a temperature rise of just 1° F (0.5° C) above baseline is considered to have an infection until it has been proven otherwise. The provider should be notified immediately. Antipyretics are used later if a temperature elevation is uncomfortable. Because infection can be life-threatening for these clients, just providing comfort measures is not enough.
A client who is receiving a blood transfusion suddenly exclaims to the nurse, "I don't feel right!" What does the nurse do next?
Stop the transfusion. The client may be experiencing a transfusion reaction; the nurse should stop the transfusion immediately. Calling the Rapid Response Team or obtaining vital signs is not the first thing that should be done. The nurse should not slow the infusion rate, but should stop it altogether.
question information
The client with leukemia typically has symptoms related to thrombocytopenia such as bruising or bleeding. Additionally, anemia causing pallor, lethargy, headaches, fatigue, and dyspnea on exertion is also present. Frequent colds or illnesses result from excessive but immature white blood cells. Weight loss occurs from the increased metabolism of leukemic cells. Hematuria (blood in the urine) is an assessment finding of leukemia. Hypertension is often idiopathic or secondary to kidney failure or shock; it is not an assessment finding for leukemia.
The nurse is transfusing a unit of whole blood to a client when the health care provider requests the following: "Furosemide (Lasix) 20 mg IV push." What does the nurse do?
Wait until the transfusion has been completed to administer furosemide. Completing the transfusion before administering furosemide is the best course of action in this scenario. Drugs are not to be administered with infusing blood products; they can interact with the blood, causing risks for the client. Stopping the infusing blood to administer the drug and then restarting it is also not the best decision. Changing the admission route is not a nursing decision.
leukemia
a cancer with uncontrolled production of immature wbcs called blast cells in the bone marrow. -overcrowded marrow with immature, nonfunctional cells and production of normal cells is effected -these overgrown cells are abnormal, useless, leads to anemia, thrombocytopenia, and leukopenia.
pernicious anemia
a decrease in red blood cells because the body can't absorb b12 properly
lymphoma
abnormal overgrowth of lymphocytes primarily tumors of the lymphatic system
4 types of leukemias
acute myelogenous (aml) acute lymphocytic (all) chronic mylenogenous (cml) chronic lymphocytic (cll)
non hodgkins lymphoma
all other cancers originating from lymphoid tissue -causes unknown: viral infection? radiation? autoimmune disorders and toxic chemicals -incidence increases with age, 50-60 is the average
assessment for HL
assessment finding is a large painless lymph node." staging is extensive to determine the extent of the disease -history, cbc, kidney and liver functions, ESR, bone marrow aspiration/biopsy, CT scan of body parts
signs and symptoms of leukemia
bleeding petechiae / ecchymosis fatigue/weakness fever enlarged spleen/liver anorexia bone pain
hemolytic transfusion reaction
blood type / rh incompatibility
hodgkin's lymphoma
cancer that can effect any age group especially: 50-60s and young adults -cause is unknown, viruses might be a link -usually starts in a single lymph node, these nodes contain a specific cancer cell types, the reed sternberg cell, a marker for HL. -predictable spread from lymph nodes to the next, unlike NHL.
lymphoma
cancers of the lymphoid tissues with abnormal overgrowth of lymphocytes -cancer of committed lymphocytes rather than stem cell precursors as with leukemia -solid tumors in lymphoid tissues and scattered through the body, especially the lymph nodes and spleen, rather than in the bone marrow
folic acid deficiency anemia
causes are: dietary, malabsorption, medications, chronic alcoholism
transfusion additional information
check expiration date, inspect for discoloration or gases, cloudiness, indicators of bacteria -remain with the patient 15-30 minutes -monitor v/s every hour
autologous blood transfusion
collection and infusion of your own blood -eliminates compatibility problems -reduces risk for transmission of blood -borne disease
autologous blood transfusions
collection and infusion of your own blood. -eliminates compatibility issues and reduces the risk for transmitting bloodborne diseases -collecting whole blood from a patient, dividing it into components, and storing it for later use -can be stored up to 40 days and frozen up to 10 years -overload and bacteria reactions can still occur
diagnostics include
complete blood count bone marrow examination
goes back to normal when
condition is removed, o2 goes back to normal and tissues become well perfused again
aplastic anemia
deficiency of circulating rbcs because of failure of the bone marrow to produce these cells exposure to myelotoxic agents: radiation, benzene, chloramphenicol, alkyating agents, antimetabolites, sulfonamides, insecticides vital infections: EBV, hep B, cytomegalovirus
lab assessment
definitive test for leukemia is examination of the cells from bone marrow aspiration and biopsy
folic acid deficiency anemia
dietary deficiency, malabsorption syndromes drugs also: oral contraceptives, anticonvulsants, methotrexate -anemia possible, lack of green leafy veggies, liver, yeast, citrus fruits, dried beans and nuts -crohns disease (malabsorption)
vitamin b12 deficiency anemia
dietary deficiency/failure to absorb b12 from intestinal tract: partial gastrectomy, pernicious anemia, malabsorption syndromes -failure to activate the enzyme that moves folic acid into rbc cells so that cell division is altered -vegan diets, tape worm
anemia can be caused by
dietary problems, genetic disorders, bone marrow disease, or excessive bleeding. -gi bleeding is the most common reason for anemia in adults
anemia management
early identification for those at risk dietary modification supplements and medications blood transfusion (done for STAT needs)
bone marrow aspiration/biopsy
extraction of a small amount of tissue, such as bone marrow for the diagnosis of blood disorders, such as anemia or thrombocytopenia; and bone marrow diseases such as leukemia, infection or to stage lymphoma
transfusion reactions include
febrile transfusion reaction hemolytic transfusion reaction allergic transfusion reaction bacterial transfusion reaction circulatory overload
acute transfusion reactions
febrile, hemolytic, allergic, bacterial reactions, circulatory overload
"B symptoms"
fever greater than 101.5, heavy night sweats, unplanned weight loss
etiology and genetic risk
genetic disorder with an autosomal recessive trait -need to have both recessive genes present -can be only be a carrier which has mild effects
factors associated with leukemia
genetics exposure to ionizing radiation/chemicals congenital abnormalities
physical assessment and clinical manifestations
heart rate increased blood pressure decreased wbc count elevated, blood is viscious, bounding pulse pallor, coolness, face, around mouth and nail beds -weight loss, nausea, anorexia
conditions that cause sickling include
hypoxia, dehydration, infection, venous stasis, pregnancy, alcohol consumption, high altitudes, low or high body temps, acidosis, strenuous exercise, emotional stress, anesthesia
care of someone with this
if left untreated you will die within 2 years -apheresis= withdrawal of whole blood and removal of some of the blood components, in this case rbcs
iron deficiency anemia
inadequate iron intake caused by: iron deficient diet, chronic alcoholism, malabsorption syndromes, partial gastrectomy rapid metabolic activity: pregnancy, adolescence, infection -fatigue, weakness, microcytic cells, oral intake of iron (red meats, egg yolks, kidney beans, leafy green veggies) -between meals for better absorption
non-hodgkin's lymphoma (NHL)
includes all lymphoid cancers that do not have the reed-sternberg cell. -over 60 subtypes of this disease -less orderly fashion than HL in spreading -classification is tougher with this -divided into either indolent (slow) or aggressive lymphomas. -this is an umbrella term for everything involving the lymphoid but without that reed-sternberg cell
sickle cell disease (anemia)
increased RBC destruction because of the poor shape/function of the RBC -genetic disorder -sickle shaped RBCs -painful episodes are common
platelet function and leukemia
is reduced with leukemia, interfering with clotting. bruise easy? nosebleeds, menstrual flow, bleeding from the gums, rectal bleeding, hematuria
history
labs will only show the presence of S cells, nothing else -previous crisis? severity and management? -manifestations of infections? -food you ate? temperatures? drugs taken, exercise, trauma, stress, airplane travel, alcohol, sleep and rest patterns?
vitamin b12 deficiency
lacks intrinsic factor b12 so it isn't being absorbed properly, poor absorption -shilling test -treatment includes: dietary, b12 injections,
white blood cell disorders
leukemia lymphoma
infection and leukemia
major cause of death in the patient with leukemia because the white blood cells are immature and don't function well -most common causes of infection are skin, respiratory tract, and intestinal tract
three major hallmarks of polycythemia vera
massive production of rbcs excessive leukocyte production excessive platelets
chronic lymphocytic leukemia (CLL)
most common chronic leukemia in adults often after age 50 genetic predisposition -survival can be 10+ years with early diagnosis
acute myelogenous leukemia (AML)
most common in adults has 8 subtypes
acute promyelocytic leukemia (APL)
most curable type of leukemia
allergic transfusion reactions
most often seen in patients with an allergy
The nurse is assessing a newly admitted client with thrombocytopenia. Which factor needs immediate intervention?
nosebleed The client with thrombocytopenia has a high risk for bleeding. The nosebleed should be attended to immediately. The client's report of pain, decreased urine output, and increased temperature are not the highest priority.
infection and sickle cell
occurances can be high due to decreased spleen function from anoxic damage -prevention and protection is important -handwashing, assess for infection, hydration, oxygen is given during a crisis -transfusion can be given to increase hba levels, although it can also cause iron overload -work on reducing crisis because remission is rare
circulatory overload
occurs when a blood product is being infused too quickly, especially in older people
bone marrow biopsy
often taken at the same time of aspiration. this is the removal of a small piece of bone tissue and the enclosed marrow.
clinical manifestations of anemia
pallor fatigue cold to touch spoon shaped fingers tachycardia weakness palpitations hypotension headache
thrombocytopenia
platelet numbers below that eneded for blood clotting
rhogam sensitivity
positive person can get negative blood, but a negative person should not get positive blood
transfusion responsibilities
provide patient education assess vital signs begin transfusion slowly and stay with the patient for the first 15-30 minutes -ask the patient to report unusual sensations such as chills, SOB, itching -administer the blood product slowly, usually protocol -assess for hyperkalemia
hodgkins lymphoma
r/f include: chronic immunosuppressive therapy, veterans and EBV -unicentric origin (single node) -reed-sternberg cell -s/s painless enlarged lymph nodes on neck, B symptoms
aplastic anemia
rare type of anemia -deficiency in circulating RBCs -chronic exposure to a toxic -agents/congenital -accompanied by decreased leukocytes / platelets
anemia
reduction in either the number of circulating RBCs, the amount of hemoglobin, or the hematrocrit (percentage of packed RBCs per deciliter of blood)
hodgkins lymphoma treatment
staging chemo radiation diagnosis: lymph node biopsy; presence of reed sternberg cells
acute lymphocyte leukemia
uncontrolled proliferation of lymphoblasts from the lymphoid stem cell -most common in children -treatment includes: chemo, methotrexate, bone marrow transplant
transfusion therapy
verify the prescription, test the donor and recipient for compatibility -examine the blood bag for i.d, check expiration date, any discoloration? gas? bubbles? or cloudiness
more s/s of leukemia
weakness and fatigue, headaches, behavior changes, alertness decreased, attention span, muscle weakness, loss of appetite, weight loss
transfusion therapy best practice therapy
1. assess lab values rationale: specific guidelines for blood product trans. 2. verify the medical prescription rat: legally, prescription is required for a trans. type, dose, and transfusion time. 3. assess pt v/s, urine output, skin color, history rat: can this patient tolerate an infusion right now 4.obtain venous access. at least 19 gauge usually rat: easier for cells to flow with occluding 5. obtain blood product from bank. transfuse asap. rat: should be done within 4 hours of removal from fridge 6. with another nurse: verify rat: human error is most common cause of ABO incomp. 7. administer blood product using appro. tubing rat:filters are needed to remove aggregates and possible contaminants 8: dilute blood products with normal saline rat: hemolysis can occur with any other IV solution 9. remain with the patient during 15-30 minutes rationale: if something is going to happen, within 50mL 10. run at prescribed rate, monitor v/s rat: overload is possible, changes in v/s may be a reaction
acute lymphocytic leukemia (ALL)
10% of adult onset leukemias often Philadelphia chromosome positive
chronic myelogenous leukemia (CML)
20% of adult leukemias -over the age of 50 -3 phases: chronic, accelerated, and blast
