Hematology Review

• Exam 1 Review for NR.120.511, Chronic Health Alterations covers Chronic Kidney Disease, BPH/Prostate CA, Hematology & Vascular Disorders, and Chronic Obstructive Pulmonary Disease & Lung CA.
• Clinical judgment model is used with these six functions:
  • Recognize cues: Asking "What matters most?"
  • Analyze cues: Asking "What does it mean?"
  • Prioritize hypotheses: Asking "Where do I start?"
  • Generate solutions: Asking "What can I do?"
  • Take action: Asking "What will I do?"
  • Evaluate outcomes: Asking "Did it help?"

Chronic Kidney Disease (CKD) Recognition

• Recognize the risk factors, lifestyle, disease management, medication compliance, and dietary compliance in clients at risk for CKD.
• Slides dedicated to recognizing each complication are in Module 2 class PDF.

Nursing Management of CKD

• The nursing management of CKD and its complications: fluid overload, hyperkalemia, hypertension, anemia, and dyslipidemia.

Fluid Overload

• Objective Assessment Findings:
  • Weight gain of >2 kg in 24 hours
  • Hypertension with BP > 130/80 mmHg
  • Peripheral edema (pitting or non-pitting)
  • Jugular vein distention (JVD)
  • Pulmonary congestion including crackles/rales in lungs
  • Dyspnea, orthopnea
  • Low SpO2, tachypnea
  • Bounding pulses and increased heart rate
  • Decreased urine output (Oliguria/Anuria)
• Subjective Assessment Findings:
  • Fatigue
  • Shortness of breath
  • Feeling "full" or bloated
  • Headache
  • Restlessness
• Key Lab Values to Look For:
  • Elevated BUN & Creatinine in worsening CKD
  • Decreased GFR (<30 = Severe CKD, <15 = ESRD)
  • Hyperkalemia (>5.3 mEq/L) = Risk of arrhythmias
  • Hyponatremia (Dilutional effect)
  • Hypocalcemia & Hyperphosphatemia (impaired kidney excretion)
  • Decreased Hemoglobin & Hematocrit (Anemia from CKD)
• Diagnostic Tests:
  • Chest X-ray to assess pulmonary edema
  • Echocardiogram to evaluate heart function if needed
  • Urinalysis to check for proteinuria and specific gravity changes
  • Electrocardiogram (ECG) to check hyperkalemia-related arrhythmias
• Prioritization for Fluid Overload:
  • Prioritize fluid overload due to impaired kidney function and sodium retention.
  • Address decreased cardiac output (increased fluid volume and hypertension).
  • Correct electrolyte imbalance (hyperkalemia, hyponatremia).
  • Manage fatigue (anemia and fluid overload).
• Fluid and Oxygenation Management Interventions:
  • Monitor & Restrict Fluid Intake:
    • Daily weight at the same time every day is essential
    • Strict intake & output (I&O) monitoring is a must
    • Fluid restriction to 1,000-1,500 mL/day as ordered should be considered
    • Educate patient on how to spread their fluids evenly throughout the day
• Oxygenation Support & Pulmonary Monitoring:
  • Monitor oxygen saturation (SpO2) & elevate HOB (High Fowler's Position)
  • Administer supplemental oxygen if needed to increase O2 sats
  • Auscultate lung sounds for worsening crackles
• Sodium & Electrolyte Management:
  • Sodium Management for sodium and electrolytes focuses is very important
    • Low-sodium diet (≤2g/day) should be consumed
    • Educate about hidden sodium sources (processed foods, canned soups, deli meats)
  • Electrolyte managment
    • Monitor ECG for signs of hyperkalemia (Peaked T waves, prolonged PR interval)
    • Administer furosemide (Lasix) or Kayexalate (Sodium Polystyrene Sulfonate)
• Dialysis Consideration includes the following:
  • Determine if the patient is in ESRD and symptomatic and if urgent dialysis may be required
  • Assess the need for hemodialysis or peritoneal dialysis
  • Prepare for vascular access evaluation (AV fistula/graft or catheter placement).
  • Troubleshoot vascular access (Peritoneal and Hemodialysis)
• Patient and Family Education for Fluid Overload in CKS centers around the following:
  • Recognizing signs of worsening fluid overload (e.g., weight gain, SOB, swelling)
  • Importance of medication adherence regarding diuretics and antihypertensives
  • Avoiding nephrotoxic substances such as NSAIDs, contrast dye, and certain antibiotics
  • Receiving dietary education and limiting sodium, potassium, and phosphorus
  • Attending dialysis sessions

Hyperkalemia

• Recognizition of signs of Hyperkalemia and objective Assessments:
  • Heart rate changes (bradycardia, irregular pulse) should be noted
  • Hypotension (if cardiac output decreases) must be looked for
  • ECG Findings are key indicators of hyperkalemia severity:
    • Peaked T waves (early sign)
    • Prolonged PR interval
    • Widened QRS complex (late, life-threatening)
    • Ventricular fibrillation or asystole (cardiac arrest risk)
• Subjective Assessment Findings -- Muscle weakness, fatigue, numbness, or tingling
  • Palpitations, dizziness, chest pain are possible
  • Nausea, vomiting, abdominal cramping are also possible
• Key Lab Values associated to Analyzing Cues of Hyperkalemia:
  • Serum Potassium (K+) > 5.0 mEq/L should be flagged
  • BUN/Creatinine increases (worsening kidney function)
  • GFR < 30 mL/min (CKD progression affecting potassium excretion)
• When Cues Require Urgency:
  • Life-threatening arrhythmias such as ventricular fibrillation or asystole.
  • Cardiac arrest.
• Cardiac Monitors for priority nursing interventions when serum potassium > 5.0.
• Prioritizing: What is MOST Urgent for Hyperkalemia:
  • Decreased Cardiac Output (altered cardiac conduction)
  • Electrolyte Imbalance (Impaired potassium excretion)
  • Ineffective Perfusion (cardiovascular instability)
  • Patient education related to potassium restriction
• Immediate Acations:
  • Stabilize cardiac function (Prevent arrhythmias):
  • Reduce serum potassium levels safely.
  • Prevent further potassium retention (Long-term management)
  • Enhance Potassium Elimination (Definitive Treatment):
    • Sodium Polystyrene Sulfonate (Kayexalate): Binds K+ in gut & excretes in stool.
    • Potassium-wasting Diuretics only if producing urine.
    • Dialysis for Hemodialysis for severe cases or ESRD is an option.
• Patient and Family Education on Hyperkalemia centers itself around: -Dietary Modifications :
  • Follow a low-potassium diet.
  • Avoid potassium-rich medications & NSAIDs and salt-substitutes.
  • Fluid & Dialysis Compliance is also very important.
    • Never skip dialysis appointments.
    • Missing these allow potassium to build up dangerously.
  • Monitor weight everyday between dialysis:
    • A gain of More than 2-3 lb weight gain in 24 hrs = fluid retention risk.
  • Adhere to Fluid Restrictions restrictions as advised by the doctor
  • Follow daily fluid limits to prevent fluid overload and potassium buildup.
  • Monitor urine output and report any significant decrease.
• Management of the remaining Complications of CKD following the same Clinical Judgement Model process:
  • Hypertension - focus Recommendation of BP Levels for CKD and lifestyle Modifications
  • Anemia - focus on why it occur in CKD and Medical and Nursing Managements.
  • Dyslipidemia - focus on Recommended LDL and Triglyceride goals

Key Points for Bening Prostatic Hyperplasia

• Urethral Compression and Urinary Obstruction is a key symotom.
  • Common symptoms include: diminished urine stream, urgency, frequency, nocturia, hesitancy, post-void dribbling, and urinary retention.
• Nursing Management includes:
  • Encouraging fluid intake in an (evenly distributed) way,
  • Monitoring for bladder distension through palpitation,
  • Reduce your intake of caffeine and artifical sweeteners
  • Medications can be used to shrink the prostate and improve urine flow.

Key Points for Prostate Cancer

• Prostate cancer presents as a slow-growing malignancy of the prostate that increases in risk after age 50.
• This cancer can result in metatasis to bones via the bloodstream or lymphatic system
  • The early stages are often asymptomatic
  • Later signs include: painless hematuria, hard nodules on digital rectal exam, weight loss, bone pain, frequent bladder infections.
• Diagnosis is confirmed through a biopsy because PSA screening alone is not a definitive test for cancer.
• Differentiation from BPH is based on symptom presentation, diagnostic imaging, and biopsy findings.

Key Points for Iron-Deficiency Anemia.

• The common cause of causes for Iron-Deficiency Anemia is inadequate dietary iron intake, chronic blood loss (e.g., Gl bleeding, heavy menstruation), and malabsorption.
• Clincial manifestation Fatigue, pallor, weakness, spoon-shaped fingernails, glossitis, pica (craving non-food items), tachycardia.
• Testing for Low hemoglobin (Hgb) and hematocrit (Hct), low serum ferritin, low iron levels, and increased total iron-binding capacity (TIBC).
• Iron supplements (take with vitamin C for absorption), encourage eating iron-rich foods (red meat, leafy greens), and monitor for Gl side effects of iron therapy.

Anemia Vitamin B-12 (Pernicious Anemia)

• Cause: The cause of Pernicious Anemia is the Lack of intrinsic factor (pernicious anemia), inadequate dietary intake (vegans), and malabsorption (gastric surgery, Crohn's disease).
• Clinical Manifestations can be Fatigue, pallor, glossitis, and neurological symptoms (paresthesia, balance issues, cognitive changes).
• The medical team will run Diagnostics: checkingLow Hgb and Hct, macrocytic RBCs, and low serum B12 levels.
• The doctor will prescribe Lifelong B12 injections for pernicious anemia and oral B12 for dietary deficiencies.
• The nurse should encourage eating B12-rich foods (ie meat, eggs, dairy)

Folate Deficiency Anemia.

• This is most likely caused via Poor dietary intake, alcoholism, pregnancy, and certain medications (methotrexate, anticonvulsants).
• Clinical Manifestations fatigue, such as Fatigue, pallor, glossitis, mood changes, dizziness, no neurological symptoms (differentiates from B12 deficiency). You should ensure there are Low Hgb and Hct, macrocytic RBCs, and low serum folate, .
• The nurse should administer Folate supplements and encourage to eat folate-rich foods (leafy greens, legumes, citrus fruits).

Key Points for Anemia of Chronic Disease

• The key cause of Anemia of Chronic Disease is inflammation which causes (CKD, autoimmune diseases,infections, malignancies) leading to impaired RBC production.
• Pay close attention to fatigue, pallor, weakness, symptoms related to underlying chronic illness.
• Diagnostic testing for low Hgb and Hct, normal or low iron levels, normal to high ferritin, and low TIBC.
• Management of this case will focus on treating underlying condition through erythropoiesis-stimulating agents, with epoetin alfa for CKD patients, and monitor iron levels.

Key Notes on Sickle Cell Disease

• This is a genetic disorder that cases abnormal hemoglobin and is leading to RBC sickling and vaso-occlusive crises.
• Common symptoms include: Severe pain crises, anemia, jaundice, splenomegaly, increased risk of infections, delayed growth, and stroke risk
• Interventions involve Hydration, oxygen, pain management (opioids, NSAIDs), hydroxyurea, blood transfusions, and infection prevention (vaccinations, antibiotics)
• A key step in treamtent is identification triggers for Sickle Cell Crisis and educate patient and family on the impact.

Points to consider in Thrombocytopenia treatment

• Cause: Thrombocytopenia is typically due to Decreased platelet production (e.g., bone marrow disorders, leukemia, chemotherapy.
• Clinical Manifestations: Easy bruising, petechiae, purpura, prolonged bleeding from minor cuts or procedures, tarry stools, hematuria, epistaxis (nosebleeds), gum bleeding, fatigue and weakness if associated with anemia. There will be an Increased risk of spontaneous bleeding if platelet count is critically low
• Diagnostics: checking for w platelet count (< 150,000/μL; severe if < 20,000/μL) Management: Avoid invasive procedures and IM injections. Monitor for signs of bleeding, use soft toothbrush and electric razors. The Nurse should also implement fall precautions and avoid contact sports

Blood Transfusion

• A key step during a transfusion is the Pre-Transfusion Preparation
• The nurse should Verify physician order and assess indications for Transfusion
• The nurse obtain informed consent from the patient, and make sure to Ensure a valid type and screen is available.
• The nurse should gather the necessary equipment: blood tubing with filter, normal saline (NS), infusion pump.
• The nurse should Perform a full set of baseline vitals before starting transfusion.
• The nurse should Educate the patient on possible transfusion reactions.
• At least two nurses must verify the correct blood product, patient identification, blood type, and expiration date prior to the transfusion.
• During Transfusion: The nurse should start the transfusion slowly and stay with the patient to monitor
  • Monitor vital signs at 15 minutes, 30 minutes, hourly, and until the end
  • Once determined safe the rate can increase
  • Ensure the infusion is completed within 4 hours to reduce the risk of bacterial contamination.
  • Do not mix blood products with lactated Ringers or dextrose
  • the fluid should only normal saline (NS) as it is compatible.
• Post–Transfusion Care: The nurse should Flush IV line with normal saline while documenting transfusion
  • Monitor for delayed reactions
  • Reassess VS and patient response.
  • Dispose of bag and tubing per facility protocol.
  • Document: Patient tolerance, start and end time, allergies, reactions, and interventions

Blood Transfusion: Recognizing and Managing Transfusion Reactions:

• Febrile Reaction: Fever and chills mean you stop transfusion, and administer antipyretics.
• Hemolytic Reaction (life-threatening): Flank pain, hypotension, dark urine, chest pain indicates you must stop the transfusion immediately, call provider, keep IV open with NS, monitor vitals closely.
• Allergic Reaction: Rash, itching, and dyspnea. The Nurse should sTop transfusion, administer antihistamines, may need pre-medication with diphenhydramine.
• Circulatory Overload: Dyspnea, hypertension, and crackles in lungs means you reduce infusion rate or give diuretics as advised.

Key Points for Peripheral Arterial Disease

• With PAD the underlying cause is Atherosclerosis which leads to narrowed arteries and reduced blood flow to limbs.
• Pts can complain intermittient claudication where pain with walking is relieved by rest.
• Other symptoms include Cold extremities with weak or absent pulses, delayed wound healing, risk of gangrene and Shiny, hairless skin.
• Treatments include Encouraging smoking cessation and regular/monitored excise to promote circulation. The monitor with attention especially lipid levels and blood pressure levels.
• The nurse shoudl administer meds such as antiplatelet therapy (aspirin. The nurse should make sure Administer antiplatelet therapy via aspirin or clopidogrel.
• Pt education shoyld emphasize daily foot inspections, avoid extreme temperatures and the patient wear proper footwear.

Key Points for Peripheral Vascular Disease

• The primary cause of Peripheral Vascular Diase is venoust insufficiency due to weakened/damaged veins
• Common symptoms include Leg swelling, or edema, achining pain relieved with elevation, varicose veins, and brownish skin discolations due to chronic venous stasis. Venous ulcers and Warm extremities with normal pules.
• Nursing Management:
  • Encourage leg elevation to reduce swelling when avoid prolonger standing or stittiing, and applying compressions stocking to improve venous circulation, while monioring for pain warth and redness. Educate Pts to prevent clotting
  • Education: Pt need to promote movement and hydration to prevent clot Pt need movement and hydration to prevent clotting and adhere to life style changes

Key Points for Chronic Venous Insufficiency

• Common causes that trigger Chronic Venous Insufficiency is if Dysfunction venours valves is leading to poor blood return to the heart, or chronic venous hypertension due to prolonged standing, obesity, pregnancy, or DVT.
• The primary symptom is Leg swelling/edema that worsens throughout the day, combined with brownish skin discoloration due to blood pooling..
• Further symptoms include warm skin, heavy legs, and venous status ulcers.
• Some nursing interventios include: Encourage leg elevation above heart level, encourage compression therapy and ambulatoin while monitoring for sores & wounds.
• A key education point for patients is proper skin care (moisturizine to prevent cracking and avoiding heat.

Revisit COPD and applying Clinical Judgement Model

• Recognize:
• Assess for shortness of breath, accessory muscle use, tachypnea, wheezing, and prolonged expiratory phase.
• Identify signs of chronic hypoxia clubbing, that leads to cyanosis, barrel chest, pursed-lip breathing.
• Monitor changes inSputum production & increase inRR.
• Look for decrease ofSPO2 or if tachycardia is visible
• ABG: resp acidosis with high PaCO2 and low PaO2.
• Social / enviro risk factors

Analyzing COPD

• Determine if there is exacerbation due to increased sputum leading to increase resp fatigue
• Identify issues of02/ vent,
• Early & late signs of respiratory distress Confusion/cyanosis
• Consider current symptoms/infection

Prioritizing COPD

• 02 88-92%
• Prevent over ox - suppress hypoxic dive.
• Risk of respiratory failure with increased PaCO2. Different/ New complications/ pneumonia
• Assess complications/therapy/steroid side effects.

Generating Solutions for COPD

• High fowlers is a good option
• 02 needs to be 1-2 l & monitor ABG.
• Bronch/ alubuterol. quick relief
• Steroids- reduce inflammation
• Breathing tech.

Key Points for Lung Cancer

• Recognize a persistent cough, Hemoptysis and Dyspnea.
• Assess for weight loss with fatigue.
• Look for Hoarseness and wheezing due to airway compressio
• History of smoking, second-hand smoke, and occupational exposure (asbestos, radon).
• Analyzing Cues
• Differatate symptoms and is lung cancer, COPD exacerbation, and pneumonia.
• Assess for metastasis
• Social determinant of health .

Steps to Navigate Questions

• The first step is to focus on the given data
• Then, Base your answer on the info provide & NOT the dx Focus on strategic workds is this a pos/Neg query

The 5 Test Taking strategies include the following tips:

• Avoid immunizations and annual flu vaccines Rationale: Sickle cell patients are at high risk for infections due to functional asplenia (damaged or absent spleen function). Why this should not be included in the teaching: Vaccinations, including the annual flu shot, pneumococcal, and meningococcal vaccines, are essential to prevent life-threatening infections. Proper teaching: Encourage routine immunizations and flu shots to prevent infections, which can trigger a sickle cell crisis.

Test your knowledge of hematological disorders and their clinical manifestations. See how well you understand anemia, thrombocytopenia and peripheral artery disease! These questions will assess your understanding of diagnosis and management strategies.