N528 Assessment #2 - Hematology Unit

hemolytic anemia

(Resulting from RBC Destruction) (also classified as hyperproliferative) Caused by altered erythropoiesis or direct injury to the erythrocyte - shortened lifespan = their number in the circulation is reduced Altered erythropoiesis (sickle cell disease, thalassemia, other hemoglobinopathies) Hypersplenism (hemolysis) (spleen diseases) Drug-induced anemia Autoimmune anemia Mechanical heart valve-related anemia

Types of coagulation disorders

- Acquired Bleeding Disorders: Liver disease Vitamin K deficiency - Heparin Induced Thrombocytopenia (HIT) -Disseminated intravascular coagulation (DIC) Thrombotic disorders: - TTP Inherited bleeding disorders: -Hemophilia & von Willebrand Disease

How is anemia classified?

- based on MCV: micro-, normo-, or macro-cytic - based on cause: hypoproliferetion, hemolysis, blood loss

What are the s/s of the sickle cell anemia crisis?

-> cell clumping obstruction produces vasooclusive crisis = * Pain abdominal & long bones hand-foot syndrome joint pain *Complications: Infections, stroke, URIs, Leg Ulcers and Splenomegaly * treatment: Hydration, Oxygenation, and pain relive

Nursing Interventions

-Assess vitals and hemodynamic status -Monitor for organ failure or intracranial bleeding -Oliguria, decreased level of consciousness -Monitor lab values -Administer volume IVF, blood products (type and -crossmatched, clotting factors, mass transfusion) -Monitor for complications of blood administration -Protect patient from injury -Prevent increased intracranial pressure (excessive coughing, Valsalva maneuver) -Implement bleeding precautions

What is the ETIOLOGY of anemia normocytic? (Hgb <12 and MCV 80-100fL)

-Blood loss -Sickle cell disease -Hemolysis -Infection -Renal insufficiency -Malignancy -Chronic disease

Hemophilia - Inherited Bleeding Disorders

-Hemorrhages into various parts of the body even with minimal trauma -Most commonly in joints -Adults diagnosed during childhood

What are the causes for coagulation disorders?

-Trauma -Platelet abnormality -Coagulation factor abnormality -Autoimmune disorder

What are some important considerations about hypoproliferative anemia ?

-bone marrow produces an inadequate number of erythrocytes (RBCs) -Low reticulocyte count - Nutritional deficiencies (can be microcytic, normocytic, or macrocytic)

Manifestations of Coagulation Disorder

-spontaneous bleeding gums, epitaxis -Blood oozing from incisions, lacerations, venipuncture, injection sites -Petechiae -Ecchymoses -Hematuria -Tachycardia, hypotension, diaphoresis -Organ failure secondary to micro emboli -Respiratory distress

von Willebrand Disease - Inherited Bleeding Disorders

-vWF deficiency which is necessary for factor VIII activation -Autosomal dominant inheritance

The results of a client's most recent blood work and physical assessment are suggestive of immune thrombocytopenic purpura (ITP). This client should undergo testing for which of the following potential causes? Select all that apply. A. Hepatitis B. Acute kidney injury C. HIV D. Malignant melanoma E. Cholecystitis

A, C

A client has been scheduled for a bone marrow aspiration and admits to the nurse being worried about the pain involved with the procedure. Which statement by the nurse when providing client education would be most accurate? A. "You'll be given painkillers before the test, so there won't likely be any pain." B. "You'll feel some pain when the needle enters your skin, but none during the aspiration." C. "Most people feel some brief, sharp pain when the marrow is aspirated." D. "I'll be there with you, and I'll try to help you keep your mind off the pain."

ANS: C Rationale: Clients typically feel a pressure sensation as the needle is advanced into position. The actual aspiration always causes sharp, brief pain, resulting from the suction exerted as the marrow is aspirated into the syringe; the client should be warned about this. Stating, "I'll try to help you keep your mind off the pain" may increase the client's fears of pain, because this does not help the client know what to expect. Although a local anesthetic agent is administered to the skin, subcutaneous tissue, and periosteum of the bone, it is not possible to anesthetize the bone itself, and the client will most likely experience sharp, brief pain during the actual aspiration. Painkillers are not necessarily given before the test and would not likely block all pain from the aspiration.

A nurse is caring for a client who is undergoing preliminary testing for a hematologic disorder. Which sign or symptom of a hematologic disorder is most common? A. Sudden change in level of consciousness (LOC) B. Recurrent infections C. Anaphylaxis D. Severe fatigue

ANS: D

A client's diagnosis of atrial fibrillation has prompted the primary care provider to prescribe warfarin. When assessing the therapeutic response to this medication, which action by the nurse is the most appropriate? A. Assess for signs of myelosuppression. B. Review the client's platelet level. C. Assess the client's capillary refill time. D. Review the client's international normalized ratio (INR).

ANS: D Rationale: The INR and activated partial thromboplastin time serve as useful tools for evaluating a client's clotting ability and monitoring the therapeutic effectiveness of anticoagulant medications. The client's platelet level is not normally used as a short-term indicator of anticoagulation effectiveness. Assessing the client for signs of myelosuppression and assessing capillary refill time do not address the effectiveness of anticoagulants.

Angela Clayton, a 7-year-old girl, was diagnosed with sickle cell disease at birth. She was outside playing in the snow when she developed severe abdominal pain. Her parents immediately took her to the emergency room, suspecting a sickle cell crisis. Describe the nursing process for the patient with sickle cell crisis.

Assessment ·Identify precipitating factors ·Assess pain ·Assess fatigue ·Assess for swelling ·Assess abdomen for pain and tenderness ·Assess cardiopulmonary and neurologic systems ·Assess for infection ·Assess laboratory values: CBC with differential Nursing intervention for the diseases ·Manage pain with analgesics. Aspirin is effective for mild to moderate pain. NSAIDs can be used for moderate pain, but renal function must be monitored. If pain is not controlled with NSAIDs, opioids can be used in combination with NSAIDs or alone. Morphine is the drug of choice ·Support and elevate joints that are swollen ·Administer oxygen ·Implement nonpharmacologic approaches to pain management, such as distraction and relaxation, physiotherapy, and physical therapy ·Reinforce teaching of signs and symptoms of infection. Any fever should be reported to the primary provider. If taking a daily antibiotic, it is important to take it at the same time daily ·Ensure that all immunizations, including the annual influenza, are current ·Manage fatigue by assisting the patient with ADLs ·Balance activity and rest ·Promote adequate sleep ·Maintain hydration and nutrition. Adequate hydration helps to reduce sickling. If unable to take oral fluids, IV fluids will be required ·Provide emotional support to the patient and family ·Educate patient and family on medication and medical management of disease ·Refer the parents to a support group Evaluation ·Control of pain and fatigue ·Absence of infection ·Increased knowledge ·Absence of complication ·Expresses improved sense of control

What is blood loss anemia?

Blood loss anemia is anemia due to excessive bleeding from loss of red blood cells. When this happens, BP decreases which leads to one feeling dizzy. -Leads to a decrease in Hgb and Hct -Decrease in MCV -Increase in reticulocytes: immature RBCs

DIC

Clotting and anticlotting mechanisms occur at the same time. Pt is at risk for internal and external bleeding, as well as dmage to organs resulting from ischemia caused by microclots. Collaborative problems: Kidney injury Gangrene Pulmonary embolism or hemorrhage Acute respiratory distress syndrome Stroke Manifestations of DIC: bleeding from gums/nose (epitaxisis), incisional bleeding, petechiae, hematuria Tachycardia, hypotension, diaphoresis Resp distress Diagnosis is typically made based on laboratory results - FOLLOW TRENDS Med management: treat underlying cause**** = oxygenation, fluid replacement, correcting electrolytes, vasopressors, replace coagulation factors at the same time as heparin infusion or LMWH to prevent VTE

An intensive care nurse is aware of the need to identify clients who may be at risk of developing disseminated intravascular coagulation (DIC). Which ICU client most likely faces the highest risk of DIC? A. A client with extensive burns B. A client who has a diagnosis of acute respiratory distress syndrome C. A client who suffered multiple trauma in a workplace accident D. A client who is being treated for septic shock

D Sepsis is a common cause of DIC. A wide variety of acute illnesses can precipitate DIC, but sepsis is specifically identified as a cause.

A client with a history of atrial fibrillation has contacted the clinic reporting an accidental overdose on prescribed warfarin. The nurse should recognize the possible need for which antidote? A. Intravenous immunoglobulins (IVIG) B. Factor IX C. Vitamin K D. Factor VIII

c Rationale: Vitamin K is given as an antidote for warfarin toxicity. IVIG is a form of immunosuppressive therapy given to treat immune thrombocytopenic purpura and to counteract hemolytic transfusion reaction and neutralizing antibodies (inhibitors) that develop in response to factor replacement therapy in clients with hemophilia. IVIG is not used as an antidote for warfarin toxicity. Factors VIII and IX are clotting factors that are deficient in clients with hemophilia due to a genetic defect; these clients may receive recombinant forms of these factors to treat their condition.

A nurse is planning the care of a client with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. Which nursing diagnosis should the nurse prioritize in the client's plan of care? A. Risk for disuse syndrome related to ineffective peripheral circulation B. Functional urinary incontinence related to urethral occlusion C. Ineffective tissue perfusion related to thrombosis D. Ineffective thermoregulation related to hypothalamic dysfunction

c Rationale: There are multiple potential complications of sickle cell disease and sickle cell crises. Central among these, however, is the risk of thrombosis and consequent lack of tissue perfusion

An adult client has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely to apply to this client's health status? A. Risk for deficient fluid volume related to impaired erythropoiesis B. Risk for infection related to tissue hypoxia C. Acute pain related to uncontrolled hemolysis D. Fatigue related to decreased oxygen-carrying capacity

d Rationale: Fatigue is the major assessment finding common to all forms of anemia. Anemia does not normally result in acute pain or fluid deficit. The client may have an increased risk of infection due to impaired immune function, but fatigue is more likely.

When teaching a client with sickle cell disease about strategies to prevent crises, what measures should the nurse recommend? A. Using prophylactic antibiotics and performing meticulous hygiene B. Maximizing physical activity and taking OTC iron supplements C. Limiting psychosocial stress and eating a high-protein diet D. Avoiding cold temperatures and ensuring sufficient hydration

d Rationale: Keeping warm and providing adequate hydration can be effective in diminishing the occurrence and severity of attacks. Hygiene, antibiotics, and high protein intake do not prevent crises. Maximizing activity may exacerbate pain and be unrealistic.

What does hypoproliferation mean?

decreased number of erythrocytes is associated with hypoprofliferation (decreased production)

What is the cause of iron deficiency anemia?

dietary lack of iron or chronic bleeding (like a bleeding ulcer), leading to microcytic and hypochromic red blood cells. Common in infants, older adults, and young adult women due to pregnancy and menses Low serum iron and elevated TIBC Skin problems: brittle hair and nails, smooth tongue, sores in corners of mouth Pica: weird cravings like ice and clay Treatment: iron supplementation (PO or IV), iron rich foods (organ meats, beans, leafy green veggies, raisins, molasses) w/ Vit C foods to increase absorption - PO iron to be taken on an empty stomach.

What does hemolysis mean?

hemolysis (increased destruction)

treatment of iron deficiency anemia

iron supplementation (PO or IV), iron rich foods (organ meats, beans, leafy green veggies, raisins, molasses) w/ Vit C foods to increase absorption - PO iron to be taken on an empty stomach.

What is the nursing management for coagulation disorder?

limit injury, assess for bleeding, bleeding precautions

Acquired bleeding disorders

Liver disease - coagulation factors are synthesized in the liver (all but factor VIII), prolonged PT, will need FFP, PRBs, and platelets - OFTEN Vit K is needed for synthesis of many coagulation factors - seen in malnourished patients, antibiotic use (due to intestinal flora that produces vit k), PO (at birth) or SQ admin of Vit K.

Folic Acid deficiency

Macrocytic, megaloblastic anemia; Folic acid is a water soluble b complex vitamin, it is needed for the production of new RBCs. Seen with alcoholism (mal nourishment), liver disease, pregnancy (erythrocyte production is increased), malabsorption (Chron's disease)

Vit B12 Deficiency Anemia

Macrocytic, pernicious anemia, inability to absorb vit b12 Insufficient vitamin B12 dietary intake or intrinsic factor destruction by autoantibodies (doesn't allow proper absorption of vit. B12); leading to macrocytic anemia Deficiencies cause abnormally large immature RBC with flimsy membranes- macrotytic cells and megaloblasts Contributing factors: atrophy of the gastric mucosa/hypochlorhydria (underproduction of hydrochloric acid by the stomach), total gastrectomy (lack of intrinsic factor decreases intestinal vit b12 absorption), and malnutrition RBC will have a decreased life span (weeks rather than months) because of the weak membrane Bilirubin levels can increase Manifestations: nervous system involvement (numbness, tingling of extremities = parasthesia), hypoxemia, pallor, jaundice, glossitis(sore, red tongue) , poor balance Med management: Cyanocobalamin 1000mcg IM Schilling test determines whether the body absorbs vit B12 normally (very rarely peformred)

Idiopathic or immune thrombocytopenic purpura (ITP)

Caused by an idiopathic isolated event, autoimmune disorders, viral infections (hep C), some drugs (cephalosporins, sulfonamides, and Lasix) Platelet production is normal, but the lifespan is short due to antiplatelet antibodies Med management: corticosteroids, immunosuppressants... can even lead to a splenectomy if pt does not respond to med management Treat when platelets are less than 30,000/mm3 Risk factors: female sex (20-50 years) Secondary conditions (medications, viruses [HIV, hep c]) Autoimmune disorders Recent virus (children)

HIT (heparin induced thrombocytopenia)

Complication of anticoagulant therapy. Immunity-mediated clotting disorder that causes unexplained low blood platelet counts as a result of treatment with heparin Risk factors: Female sex Duration: Receiving heparin longer than 1 week Surgery: Especially if cardiopulmonary bypass is used Exposure to unfractionated heparin LMWH (lovenox) Postsurgical thromboprophylaxis Bovine (cow) more likely to cause HIT than vs porcine (pig) heparin Platelet's drop by 50% from baseline over a period of 1-3 days, after successful management, the autoantibodies typically disappear in 2-3 months. Pt may be transitioned to argatroban IV.

A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education? A. Take the iron with dairy products to enhance absorption. B. Increase the intake of vitamin E to enhance absorption. C. Iron will cause the stools to darken in color. D. Limit foods high in fiber due to the risk for diarrhea.

c Rationale: The nurse will inform the client that iron will cause the stools to become dark in color. Iron should be taken on an empty stomach, as its absorption is affected by food, especially dairy products. Clients should be instructed to increase their intake of vitamin C to enhance iron absorption. Foods high in fiber should be consumed to minimize problems with constipation, a common side effect associated with iron therapy.

What is anemia microcytic? (Hgb <12 and MCV<80fL)

Serum iron and ferritin low, TIBC elevated= Iron deficiency anemia Serum iron normal or elevated, ferritin normal or elevated, TIBC normal, Hgb electrophoresis Normal in alpha abnormal in Beta= Thalassemias Serum iron normal or decreased, ferritin normal or elevated TIBC normal or decreased Hgb electrophoresis normal = Chronic disease

sign/symptom of iron deficiency anemia

Skin problems: brittle hair and nails, smooth tongue, sores in corners of mouth Pica: weird cravings like ice and clay

What happens with sickle cell?

The long, rigid cells can adhere to the walls of small blood vessels, accumulate, and decrease blood flow to the tissues and organs in that region. When blood flow is severely reduced, ischemia or infarction can cause severe pain, swelling, and fever referred to as a sickle cell crisis. Type of hemolytic anemia Contributing factors: stress, dehydration, hypoxia, high altitudes, and infections may precipitate a crisis by enhancing sickling Collaborative Problems Hypoxia, ischemia, infection Dehydration CVA Anemia Acute and chronic kidney disease Heart failure Impotence Poor compliance Substance abuse Nursing Interventions Pain management Manage fatigue Infection prevention Promote coping Education of disease process Monitor for complications

What is associated with macrocytic anemia? Hbg <12 and MCV >100

b12 low, HC elevated , serum folate low, MMA elevated= Vitan B12 deficiency b12 low, HC elevated , serum folate low, MMA normal = Folate deficiency IF b12 and folate is normal, = Can be of origin: Alcoholism bone narrow disorders hypothyroidism Liver disorder Medication (CHEMOTHERAPY, ANTIVIRALS)

William Smith, a 76-year-old man, was admitted to the hospital with anemia. The primary provider informs Mr. Smith that it is necessary to perform a bone marrow aspiration to assess the formation of the blood cells. The primary provider explains the procedure to the patient, including the risks, benefits, and alternatives. An informed consent is obtained. How should the nurse prepare the patient for the procedure? What instructions should the nurse provide to the patient after the procedure?

The nurse should ensure that informed consent has been obtained. The patient will be positioned on his side since the primary provider will use the iliac crest to obtain the bone marrow specimen. The nurse will explain to the patient that he will feel a pinch when the local anesthetic is administered. As the bone marrow aspiration needle is advanced into the bone, he will feel pressure. The actual aspiration will cause a sharp pain that will quickly be relieved. Taking deep breaths will help to relieve the discomfort. If the patient is very anxious, an antianxiety medication may be ordered. After the procedure, the puncture site is covered with a sterile dressing and direct pressure is applied. The patient may be instructed to lie on the procedure side so that pressure is on the iliac crest. The patient is informed that his hip may ache for a few days. Relief measures may include a warm tub bath or a mild analgesic agent. Aspirin products should be avoided.

TTP (thrombotic thrombocytopenic purpura)

Thrombocytopenia = low platelet level, Thrombotic disorder = platelets clump together - insufficient quantity in circulation (inappropriate clotting) Med management: antiplatelet medications (aspirin) and immunosuppressive therapy decreases the intensity of complications •"Thrombotic" refers to the blood clots that form. •"Thrombocytopenic" means the blood has a lower-than-normal platelet count. •"Purpura" refers to purple bruises caused by bleeding under your skin.

Aplastic Anemia

a normocytic-normochromic type of anemia characterized by the failure of bone marrow to produce red blood cells, exposure to radiation or chemicals (insecticides or solvents)