Nurs 498 hematology

Pharmacological and Nursing Management for Chronic Hematologic and Endocrine Disorders

• Nursing 498 Winter 2025

Learning Objectives

• Identify safe, effective nursing management of pharmacotherapeutic regimes for individuals across lifespans and families experiencing chronic hematological disorders
• Select and prioritize nursing interventions to create a nursing care plan for a client experiencing chronic hematological disorders
• Build collaborative approaches to support self-management and effective coping for individuals across the lifespan and families experiencing chronic hematological disorders.

Drugs for Anemias

• Iron Therapy
• Cyanocobalamin
• Folate

Important Lab Values for Anemia

• Hemoglobin/hematocrit indicates the overall health of red blood cells
• Reticulocytes (young RBCs) offer insight into bone marrow activity
• Iron is an essential component of hemoglobin
• Transferrin helps evaluate iron metabolism and storage
• Ferritin evaluates iron metabolism and storage
• Bilirubin assesses RBC breakdown
• Folate is essential for RBC formation and maturation

Anemia General Management

• Identification and treatment of the underlying cause
• Drug Therapy
• Nutritional Therapy
• Transfusion of packed RBC's, potentially with 0.9% NS IV

Drugs for Anemias: Iron Therapy

• Oral iron is prescribed for mild-moderate iron deficiency anemia
• Mechanism: Increases iron stores
• Adverse Effects: Abdominal pain, constipation, and dark stools
• Drug Interactions: Antacids and calcium decrease absorption; may decrease serum concentration of levothyroxine
• Nursing Considerations: Administer on an empty stomach
• Vitamin C enhances/facilitates absorption and helps manage GI side effects
• IV Iron (Iron Sucrose/Venofer) for severe iron deficiency anemia or when oral therapy is not feasible
• Directly replenishes iron levels
• Adverse Effects: Hypotension, anaphylaxis (rare)
• Avoid with oral iron and use caution with ACE inhibitors due to potential severe allergic reactions
• Monitor IV site to prevent extravasation, reduce infusion rate for hypotension
• Observe for hypersensitivity reactions, especially at the start of administration
• Discontinue infusion and adhere to parenteral monograph guidelines

Drugs for Anemias: Vitamin B12 and Folic Acid

• Indicated for Vitamin B12 deficiency anemia, folate deficiency anemia, pernicious anemia, megaloblastic anemia.
• Examples: Cyanocobalamin (B12), Folic Acid
• Nursing Considerations: B12 IM injection for pernicious anemia (lifelong therapy). Supplementation is required in pregnancy & alcohol use disorder

Vitamin B12 and Folic Acid Drug Details

• Cyanocobalamin (B12 - IM, oral) treats pernicious anemia and B12 deficiency by restoring B12
• Adverse effect: Headache
• Injection is recommended for pernicious anemia and is a lifelong therapy
• Folic Acid is used for folate deficiency, pregnancy and replaces folate for DNA synthesis and RBC maturation
• Rare adverse effects
• Methotrexate, anticonvulsants (phenytoin, valproate), and sulfa drugs can lower folate levels
• Folic acid is essential in pregnancy & if there is alcohol use disorder

Hematopoietic Agents

• Includes Erythropoiesis-Stimulating Agents (ESAs) and Myelosuppressive Agents

Hematopoietic Agents: ESAs

• Erythropoiesis-Stimulating Agents (ESAS) used for chemotherapy-induced anemia and CKD anemia
• Examples: Epoetin Alfa (Epogen, Procrit), Darbepoetin Alfa (Aranesp)
• Monitor BP and Hgb aiming for 100-110 g/L
• Iron levels must be sufficient for ESAs to work

ESAs Drug Details

• Epoetin Alfa and Darbepoetin Alfa treat chemotherapy-induced anemia and CKD anemia by stimulating RBC production
• Adverse effects: HTN and thrombosis
• ACEI & ARBs may diminish the effects of ESAs; Hormone therapy (androgens) influence drug interactions
• Monitor BP, Hgb (goal 100-110 g/L)
• Adequate iron levels required
• Increased clot risk with high-dose use

Hematopoietic Agents: Myelosuppressive Agents

• Myelosuppressive Therapy reduces overproduction of RBCs and used for Sickle Cell Disease (SCD), polycythemia vera (PV), some leukemias
• Prevents sickling in SCD and reduces RBC production in PV
• Monitor CBC for risk of myelosuppression and infection
• Teratogenic-contraception required
• Takes weeks to work

JAK2 Inhibitors

• Used in bone marrow disorders or when hydroxyurea is ineffective for treating PV
• Example: Ruxolitinib (Jakafi)
• Monitor WBCs for infection risk
• Monitor CBC for bone marrow suppression

Myelosuppressive Agents Drug Details

• Hydroxyurea is used for sickle cell disease, polycythemia vera, and chronic myeloid leukemia by reducing sickling in SCD and suppressing RBC production in PV
• Adverse effects: Myelosuppression and infection risk
• Drug Interactions: Increased toxicity with myelosuppressive agents (e.g., chemotherapy)
• Monitor CBC, infection prevention, and teratogenic effects; use contraception
• Ruxolitinib is for polycythemia vera, which is resistant to hydroxyurea, so it reduces abnormal RBC production
• Adverse effects: Myelosuppression and infection risk
• Drug Interactions; Immunosuppressants increase infection risk, CYP3A4 inhibitors (ketoconazole) increase drug levels
• Monitor WBCs & CBC, assess for anemia, thrombocytopenia, and infection

Hemostatic Drugs

• Clotting Factor Replacement
• Desmopressin (DDAVP)
• Antifibrinolytics

Hemostatic Drugs: Clotting Factor Replacement

• Indicated for factor deficiencies, bleeding prevention.
• Examples: Factor VIII → Hemophilia A, von Willebrand disease; Factor IX → Hemophilia B
• Adverse Effects: Infusion reactions (rash, fever), headache
• Nursing Considerations: Monitor for inhibitor development (antibodies); Infusion reactions are possible

Desmopressin (DDAVP)

• Indicated for mild Hemophilia A and Von Willebrand Disease
• Adverse Effects: Hyponatremia
• Drug Interactions: Carbamazepine, NSAIDs, lithium, demeclocycline, loop diuretics, glucocorticoids
• Monitor sodium levels, fluid intake, and urine output
• Educate on fluid restriction to prevent water retention
• Monitor BP and pulse during infusion

Hemostatic Drugs: Antifibrinolytics

• Antifibrinolytics prevent clot breakdown
• Indicated for mucosal bleeding, menorrhagia, and dental procedures in bleeding disorders
• Examples: Tranexamic Acid (TXA), Aminocaproic Acid
• Adverse Effects: Abdominal pain, headache, back pain, seizures, thrombosis, hypersensitivity reactions (rare)
• Increased clot risk if used with estrogen-based contraceptives
• Monitor for signs of hypersensitivity, seizure activity, or thrombosis

Clinical Application

• Managing:
  • Iron Deficiency Anemia
  • Sickle Cell Disease
  • CKD Anemia
  • Polycythemia Vera
  • Hemophilia

Iron Deficiency Anemia Management

• First-line treatment: Oral iron therapy using ferrous sulfate or ferrous gluconate
• IV Iron: For malabsorption, severe anemia, or CKD is addressed by Iron Sucrose
• Transfusion is for severe symptomatic anemia (Hgb <70 g/L) or acute blood loss requiring urgent correction
• Take oral iron with Vitamin C for better absorption
• Avoid calcium & antacids
• Monitor for GI side effects (constipation, nausea, black stools); encourage hydration & fiber intake
• Monitor IV iron for hypotension and anaphylaxis risk

Sickle Cell Therapy Management

• Managed with both preventive and acute treatments to reduce complications, enhance quality of life, and alleviate pain crises
• First-line treatment: Hydroxyurea
• L-glutamine reduces oxidative stress and prevents RBC damage and used if the patient cannot tolerate hydroxyurea
• Crizanlizumab is a monoclonal antibody that reduces cell adhesion to prevent vaso-occlusive crises and given IV infusion monthly
• Hematopoietic Stem Cell Transplant (HSCT) is the only cure

Sickle Cell Crisis Management

• Pain management through:
  • Opioids (morphine, hydromorphone), is for moderate-severe pain
  • NSAIDs are for mild-moderate pain with renal impairment consideration
  • Non-pharmacologic options include heat therapy and relaxation techniques
• Hydration
  • IV fluids to improve RBC flexibility
  • Prevents sickling & vascular occlusion
• Oxygen therapy
• Blood transfusions
  • RBC exchange transfusion if severe crisis
  • Used for acute chest syndrome, stroke prevention, severe anemia
• Priapism treatment

Chronic Kidney Disease Anemia Management

• CKD leads to reduced erythropoietin (EPO) production, which causes anemia
• Treatment aims to correct low RBC production and iron deficiency
• Minimize complications like hypertension and thrombosis -Erythropoiesis-Stimulating Agents (ESAs):
  • Stimulates bone marrow to increase RBC production
  • Has a slower onset than blood transfusions (2-6 weeks)
• Monitor BP regularly for hypertension:
• Do not increase Hgb to >110 g/L to avoid thrombosis (DVT, PE, stroke)
• Monitor iron levels, as ESAs are only effective if iron stores are sufficient

Polycythemia Vera Management

• Polycythemia Vera (PV) is a myeloproliferative disorder
• Causes overproduction of RBCs, WBCs, and platelets
• Increases the risk of thrombosis (DVT, PE, stroke)
• Focuses on reducing RBC overproduction and preventing blood clots
• First-Line: Phlebotomy (Mainstay of Treatment)
• High Risk Patients: Myelosuppressive Therapy
  • Hydroxyurea reduces RBC production in bone marrow
  • Ruxolitinib (JAK2 inhibitor) is used in hydroxyurea-resistant PV
• Adjuvant Therapy:
  • Low-dose aspirin (for thrombosis prevention)
  • Encourage hydration & mobility to prevent clots

Hemophilia Management

• Hemophilia is a genetic bleeding disorder
• Deficiency of clotting factors are needed for blood clot formation. Treatment focuses on management
• On factor replacement, bleeding prevention, and emergency management
• First-Line: Clotting Factor Replacement Therapy
• Adjunctive Therapies:
  • Desmopressin (DDAVP) is for mild Hemophilia A and stimulates release of stored Factor VIII and not effective for Hemophilia B
  • Tranexamic Acid (TXA) is for mucosal bleeding (e.g., nosebleeds, dental procedures)
  • Antifibrinolytic prevents clot breakdown
• Avoid NSAIDs & aspirin (Use acetaminophen for pain relief)
• Implement bleeding prevention strategies

Hemophilia Emergency Management

• Intracranial Hemorrhage (ICH):
  • Presents with severe headache, nausea/vomiting, vision changes, seizures, and altered LOC
  • Immediate management includes giving factor immediately, calling rapid response, and sending the patient for STAT CT scan
• Gastrointestinal Bleeding (GI Bleed):
  • Characterized by black/tarry stools, hematemesis, abdominal pain, and pallor
  • Immediate management involves administering factor and IV fluids, monitor vitals, prepares for endoscopy
• Joint Bleed (Hemarthrosis):
  • Symptoms include joint swelling, warmth, stiffness, and severe pain
  • Immediate management involves administering factor, immobilizing the joint, applying ice, and managing pain
• Retroperitoneal Bleeding:
  • Presents with severe back/flank pain, hypotension, and abdominal distension
  • Administer factor and IV fluids, and monitor for shock
• Major Trauma or Surgery:
  • Active uncontrolled bleeding, hypotension, and tachycardia indicate the severity
  • Administer factor, blood transfusion if needed, and prepare for surgery

Pharmacological and Nursing Management for Endocrine Disorders

• Nursing 498 Winter 2025

Learning Objectives for Endocrine Disorders

• Identify safe and effective nursing management of pharmacotherapeutic regimes for individuals with chronic endocrine conditions
• Select and prioritize nursing actions to create a care plan for a patient with endocrine disorders
• Build collaborative approaches to support self-management and coping for individuals and families dealing with chronic endocrine conditions

Chronic Endocrine Conditions

• Diabetes Mellitus
• Diabetes Insipidus
• SIADH
• Hypo/Hyperthyroidism
• Cushing's Syndrome
• Adrenal Insufficiency

Diabetes Mellitus Management Review

• Type 1 Diabetes: lifelong insulin therapy focused on optimizing insulin dosing, preventing hypoglycemia, and adjusting for lifestyle factors
• Type 2 Diabetes: medication adjustments are needed over time as insulin resistance and beta-cell dysfunction progresses
• First-line therapy: Metformin if there are no contraindications
• Additional therapies: GLP-1 receptor agonists, SGLT2 inhibitors, sulfonylureas, or insulin
• Lifestyle changes play a major role, like weight loss, diet modifications, and physical activity

Insulins: Review

• Rapid-Acting:
  • Examples: Aspart (NovoRapid), Lispro (Humalog), Glulisine (Apidra)
  • Onset: 10-15 min
  • Peak: 60-90 min
  • Duration: 3.5-5 hrs
  • Indications: Mealtime insulin, postprandial glucose control
  • Adverse Effects: Hypoglycemia, weight gain
  • Take right before meals, used in sliding scale insulin (SSI)
• Short-Acting:
  • Examples: Regular insulin (Humulin R, Novolin R)
  • Onset: 30 min-1 hr
  • Peak: 2-3 hrs
  • Duration: 5-8 hrs
  • Indications: IV insulin for DKA, hyperkalemia, mealtime insulin
  • Adverse Effects: Hypoglycemia, lipodystrophy
  • Can be given IV, Take 30-45 min before meals
• Intermediate-Acting:
• Examples: NPH (Humulin N, Novolin N)
• Onset: 2-4 hrs
• Peak: 4-10 hrs
• Duration: 12-18 hrs
• Indications: Basal insulin, taken twice daily
• Adverse Effects: Unpredictable peak -> Risk of hypoglycemia
• Roll vial before administration, not used IV
• Long-Acting:
  • Examples: Glargine (Lantus, Basaglar), Detemir (Levemir)
  • Onset: 1-2 hrs
  • Peak: No peak
  • Duration: 24 hrs
  • Indications: Basal insulin (once daily dosing)
  • Adverse Effects: Lower risk of hypoglycemia
  • Do not mix with other insulins
• Ultra Long-Acting:
  • Examples: Degludec (Tresiba)
  • Onset: 1 hr
  • Peak: No peak
  • Duration: >42 hrs
  • Indications: Basal insulin(once daily, more flexible dosing)
  • Adverse Effects: Less nocturnal hypoglycemia
  • Can be taken at different times each day
• Risk of hypoglycemia ↑ w/ beta-blockers, sulfonylureas, alcohol
• Insulin is less effective corticosteroids, diuretics, sympathomimetics

Oral & Non-Insulin Antidiabetic Agents: Review

• Biguanides:

  • Examples: Metformin (Glucophage)
  • Mechanism: Decreases hepatic glucose production and increases insulin sensitivity.
  • Adverse Effects: GI upset, lactic acidosis (rare)

• Drug Interactions: Hold before contrast dye procedures (AKI risk)

• Nursing Considerations: Take with food, avoid in renal dysfunction (eGFR <30)

• Sulfonylureas

  • Examples: Gliclazide, Glimepiride and Glyburide
  • Mechanism: Stimulates insulin releases from the pancreas
  • Adverse Effects: Hypoglycemia and Weight Gain
  • Drug Interactions: Risk increased with Beta Blockers and NSAIDS
  • Nursing Considerations: Take with food, monitor for hypoglycemia.

• DPP-4 Inhibitors

  • Examples: Sitagliptin, Linagliptin
  • Mechanism: Increases incretin hormones that stimulate insulin and decrease glucagon
  • Adverse Effects: Pancreatitis and Joint Pain
  • Drug Interactions: May enhance digoxin levels
  • Nursing Considerations: Monitor of Pancreatitis symptoms, abdominal pain, nausea

• SGLT2 Inhibitors

  • Examples: Empagliflozin, Canagliflozin, Dapagliflozin
  • ↑ glucose excretion in urine
  • Adverse Effects: UTI, yeast infections, dehydration, DK A risk

• Drug Interactions: ↑ Risk with diuretics, hypotension, dehydration

• Nursing Considerations: Monitor Renal Function and Encourage Hydration.

• GLP-1 Receptor Agonists

  • Examples: Liraglutide, Semaglutide, Dulaglutide.
  • Mechanism: Increases insulin secretion, decreases gastric emptying
  • Adverse Effects: Nausea, Pancreatitis, Thyroid, Tumour, Risk!
  • Drug Interactions: Avoid in patients with Thyroid Cancer history.
  • Nursing Considerations: Subcutaneous Injection and Monitor for Pancreatitis

Diabetes Mellitus: Chronic Management

• Prevent acute complications:
  • Type 1 Diabetes: Hypoglycemia, Diabetic Ketoacidosis (DKA)
  • Type 2 Diabetes: Hypoglycemia, Hyperosmolar Hyperglycemic State (HHS)
• Prevent or delay long-term complications:
  • Microvascular: Retinopathy, Nephropathy, Neuropathy
  • Macrovascular: Cardiovascular disease (MI, stroke), Peripheral Arterial Disease
• Maintain strict control of blood sugar levels reduces the long-term effects of diabetes

Diabetes Management: Nursing Considerations

• Routinely reinforce glucose monitoring
• Assess medication adherence and the side effects
• Encourage lifestyle modifications of weight loss, dietary changes and exercise
• Prevent hypoglycemia and educate the patient
• Regular Screenings Needed.

Diabetes Insipidus

• Is a disorder caused by deficient antidiuretic hormone
• ADH or kidney resistance to ADH, leading to excessive urination:
  • polyuria -intense Thirst types of DI:
• Lack of ADH production caused from damages.
  :kidneys not responding to ADH (genetic, medication-induced, chronic kidney disease)
• -polyuria *4-20 L -Excessive Thirst
• -hypotension
• Dehydration: Tachycardia. Dilute urine: low urine osmolality & specific gravity <1.005.

DI management

• Restore Fluid- Prevent Dehydration

• Correct Cause If needed

• Reduce Excressive Urination

• Desmporessin: ADH Replacement.

• Thiazide Diuretics. Reduce Urine Output - Kidneys need to respond

• Ensure Adequate Hydration

Pharmacologic Treatment of Diabetes

• Increase water reabsorption for the ADH

Pharmacologic Treatment

• Sodium Levels and fluid dose
• Monitor urine output.

Monitoring

• BP and signs of dehydration need monitoring.

Nursing Management for DI

• I&Os and weights
• serum levels need monitoring
• osmolality.gravitity.
• Vital Signs
• Excess thrist = Headaches.

DIADH: Excessive Secretion

• excessive fluid intake

Management

• Weight gain and low urinary output
• Fluid restriction

Vasopressin

• promote water release

Loop

• increase the body's water release

DIADH Nursing managaement

• Levels need close monitor
• Strict IOs, and dialy weights

Hypo-Thyroidism: T3/T4 deficienty

• Immune systen destruction - T3/T4 Hormones

Symptoms

• Fatigue
• Cold Intelorance
• constipation = brittle hair

HYPO - Management

• Restor hormones and Thyroid
• Prevent Myxedema coma: cardiovascular risk, depression, infertility) Dietary Consderations
• Increase activity levels

##PHARM managementT4

• empty stomach: calcium, iron, levels check.

HYPER

t3 t4 production causes increase in metabolic functions

Symptoms Weight loss

• increased appetite
• Heat intolerance Sweatin
• Bulging Eyes

Treatment

Reduce Hormone replacement

• Autoimmune system needs adress

Pharmacotherapy

• Monitor wBC;s/ Signs of Infection
• Avoid foods and meds with iodine
• Medication adherence

Cushings syndrome

Occurs from exposure to high cortisol levels for long amount of time

symptoms truncal obesity moonface/ buffalo bump increased infectio risk increased acne

Nursing Considerations

• Reduce Sodium levels/ Hypertension
• Decrease Blood pressure and risk with Infection

Insufficency: decrease In

Low Cortisol and Alodesterome levels

• Fatigue
• Hypotension
• Bronze Tone = only present in primary

Treatment - Monitor Bp, check sodium/levels increase sodium intake and intake of liquids