Hematology Lecture Notes PDF

HEMATOLOGY Inge Luce, MSN/Ed, RN-C, NRP Hematologic System Blood, blood cells, lymph, organs involved in blood formation and blood storage. Blood consists of plasma and cells The primary roles of the hematologic system are to: CIRCULATE oxygen, nutrients, hormones, and m...

HEMATOLOGY Inge Luce, MSN/Ed, RN-C, NRP Hematologic System Blood, blood cells, lymph, organs involved in blood formation and blood storage. Blood consists of plasma and cells The primary roles of the hematologic system are to: CIRCULATE oxygen, nutrients, hormones, and metabolic wastes PROTECT against invasion of pathogens MAINTAIN coagulation, fluid and acid- base balance, body temperature  HEMATOPOIESIS Hematopoiesis Bone marrow, PLURIPOTENT stem cells RBCs CARRY OXYGEN and help with clot formation ANEMIA- low RBCs= HYPOXIA WBCs FIGHT INFECTION, part of the immune and inflammatory response LEUKOPENIA- low WBCs= INFECTION PLATELETS AGGREGATE/CLUMP together to CLOT THROMBOCYTOPENIA- low platelets= BLEEDING Accessory Organs of Blood Formation SPLEEN LIVER Made of vascular and lymph The liver produces clotting factors tissues Prothrombin The spleen stores WBCs, RBCs, and PT = time for blood to clot, elevated in Platelets. therapeutic oral anticoagulant therapy like warfarin (Coumadin) Blood filters through the spleen Aids in vitamin K synthesis and old cells are destroyed The reversal agent for warfarin Removal of the spleen increases (Coumadin) the risk of infection and sepsis Stores large amounts of blood and iron (long term) People with liver problems have CLOTTING and BLEEDING problems Where do we check for jaundice? The SCLERA can be yellowed for reasons other than hyperbilirubinemi a Follow up by checking: PALATE PALMS SKIN Stages of Hemostasis Damage to the vessel Causes spasms, restricts flow Platelet plug formation PLT, vWF, fibrin, blood cells Coagulation/clot formation Clotting cascade = fibrin mesh Clot retraction/growth factors Edges of wound are pulled together New cell growth is stimulated Clot dissolution Fibrinolysis ANTICLOTTING FORCES Hematological Assessment History Present Illness (OPQRSTU) Past medical history (SAMPLE, surgical and family hx) Nutrition Physical Exam Skin / HEENT Respiratory Cardiovascular GU MS GI Neuro Labs RBC 4.2-5.14 Hgb 12-18 Hct 38-49 WBC 5-10 Labs PLT 150-450 PT 10-13 seconds HEPARIN COUMADIN Coumadin aPTT INR 0.8-1.1 reg Protamine PT/INR 2.0-3.5 if on Coumadin Vit K PTT 21-35 seconds Heparin  Other Diagnostic tests Bone marrow aspiration Posterior superior iliac crest is the most common site Local anesthetic is used Apply pressure for 5-10 minutes after needle removal. After procedure monitor for bleeding, treat pain Teach patient to watch for s/s of infection Age related changes Bone mass and intracellular fluids decrease with age Decreased blood volume and liver function Decreased albumin Decreased hematopoiesis and iron binding Anemia Increased risk of infection Increased risk of bleeding Care of patients with hematologic problems Prevent hypoxia, infection, and bleeding LACK OF INGREDIENTS (MISSING BUILDING BLOCKS) MICROCYTIC (Small cells) IRON deficiency GI Bleeding (#1 cause) MACROCYTIC (Large cells) VITAMIN B deficiency Dietary Pernicious anemia (intrinsic factor) FOLIC ACID deficiency Dietary BONE MARROW DISEASE / APLASTIC ANEMIA PANCYTOPENIA- too few of ALL types of blood cells ANEMIA- too few RBCs Pallor, fatigue, dyspnea, activity intolerance LEUKOPENIA- too few WBCs Frequent infections (ARF INFECTION!) THROMBOCYTOPENIA- too few PLT Petechiae, bleeding gums, hematuria (ARF BLEEDING!) NURSING CARE FOCUSES ON INFECTION CONTROL, INJURY PREVENTION, AND BLOOD TRANSFUSIONS GENETIC / AUTOIMMUNE DISORDERS SICKLE CELL DISEASE >40% HbS Dehydration and hypoxia Cells sickle, clump in joints and small vessels, organs JOINT PAIN Destroyed by spleen G6PD deficiency Sex-linked enzyme deficiency Cell walls degrade rapidly, rupture JAUNDICE HEMOLYTIC ANEMIA Destruction of RBCs (immune system, trauma, medical devices) ANEMIA TREATMENT Erythropoietin Stimulates production of new RBCs from bone marrow Iron Required for oxygen carrying Can stain teeth, will cause dark tarry stools Vitamin B12 Required for RBC synthesis. PO/SL/IN gel for B12 deficiency SQ/IM for Pernicious anemia (no intrinsic factor to absorb PO route) Folic Acid Required for production of DNA and RNA Also essential for fetal development and prevention of neural tube defects ANEMIA **safe medication concern** Folic acid may mask s/s of pernicious anemia Always diagnose problem before starting treatment Iron administration in pediatrics Administer with vitamin C, mix with water or juice, use a straw Give with food if upsets stomach (not with dairy/calcium) Place where child cannot reach (avoid overdose) Iron overdose is the most common cause of pediatric poisoning death reported in the US. Metabolic acidosis, shock, seizures, death Hematopoietic growth factors Erythropoietic drugs Decrease duration of chemo induced Epoetin alpha anemia, neutropenia, and Darbepoetin alpha thrombocytopenia Colony-stimulating factors Enable higher doses of chemo to be Filgrastim given Pegfilgrastim Sargramostim Decrease bone marrow recovery time after transplant or radiation therapy Platelet-promoting drugs Oprelvekin Stimulate Immune System to fight Romiplostim off “bad” cells Hematopoietic drugs Common adverse effects CV: edema GI: anorexa, n/v/d Integuementary: Rash, alopecia Respiratory: cough, dyspnea, sore throat Other: fever, blood dyscrasias, headache, bone pain Epogen can cause hypertension as RBCs increase oncotic pulling pressure and draw more fluid into the intravascular space Giving Epogen to a patient with a Hgb of 12 or higher can cause AMI/CVA Hemopoietic drugs Contraindications Known allergy, myeloid cells in marrow (normal labs) Infection (filgrastim) Elevated Hgb (Epogen) Interactions Colony-stimulating factors and myelosuppressive drugs Cancel each other out if given within 24 hours Polycythemia Too many RBCs Treatment Blood is too thick (increased viscosity) Therapeutic phlebotomy Cells are malformed, cannot carry O2 Apheresis well Hydration, promote venous return, Small vessels get plugged up anticoagulants, stop smoking, stay Clots form (thrombosis) warm Leads to Hypoxia, Anoxia, Infarct, Necrosis Heart, spleen, and kidneys are at greatest risk  Abundance of Decreased RBCs and immature, ineffective Platelets as well WBCs in the marrow Avoid skin injuries Leukopenia- frequent Leukemia – Avoid rectal temps or infections suppositories, can cause abscess and sepsis Cancer of Anemia- pallor, WBCs fatigue, dyspnea, decreased activity Cluster care to prevent increased fatigue and shortness of breath tolerance Thrombocytopenia- Monitor CBC to watch for Petechiae, bleeding decrease in H&H gums, hematuria Leukemia treatment Chemotherapy Radiation Bone marrow transplant Stomatitis, oral pain Fatigue- conserve energy Pain management, observe for Provide mouth care, gently Skin care- lotion to irritated bleeding, infection Soft, bland foods skin An increase in just WBCs may Hydration mean infection Will increase pancytopenia An increase in WBCs, RBCs, Watch for bleeding, infection, and Platelets means fatigue, dyspnea ENGRAFTING!!! WIN! CARE OF THE IMMUNOSUPPRESSED PATIENT NO Raw fruits/veggies Standing water (>15 minutes) Crowds / sick visitors Fresh plants/flowers Rectal temps or suppositories A TEMPERATURE ELEVATION OF EVEN 1 DEGREE ABOVE BASELINE SHOULD BE CONSIDERED AN INFECTION UNTIL PROVEN OTHERWISE  PANCYTOPENIA- too few of all cells in Due to bone marrow dysfunction blood Pallor, fatigue, dyspnea. Chronic hypoxia will ANEMIA- too few lead to clubbing RBCs EPOIETIN ALPHA- Epogen, Procrit Myelodysplasti c Syndromes Frequent infections Neutropenia- low neutrophils, increased risk LEUKOPENIA- too for infection few WBCs NEUTROPHIL STIMULATORS- Neupogen, Leukine THROMBOCYTOPENI Increased risk for bleeding, avoid A- too few unnecessary VP, monitor H&H thrombocytes PLATELET STIMULATORS- Neumega, Nplate (platelets) (for ITP) CARE OF THE PATIENT WITH THROMBOCYTOPENIA BLEEDING PRECAUTIONS Soft bristle toothbrush Electric razor Stool softener Clutter-free environment No rectal temps or suppositories Avoid intercourse Avoid blowing nose Avoid injections and non- essential blood draws This Photo by Unknown Author is licensed under CC BY-SA Thrombocyte disorders (clotting problems) Autoimmune Thrombotic Thrombocytopenic Thrombocytopenic Purpura Purpura (TTP) (ITP) Increased destruction by Over abundance of clumping spleen leads to too few available Immunosuppression, platelet platelets in circulation transfusion only for life In times of trauma, the body threatening bleed. cannot protect itself Safety, splenectomy may be Aspirin can be used to necessary- MONITOR FOR decrease improper clotting POST OP BLEEDING! Clotting factor disorders Heparin Induced Hemophilia Thrombocytopenia (HIT) IgG Immune response after use Genetic deficiency of a clotting of heparin, stimulates the factor. clotting cascade Bleeding is slow to stop, even Causes VTE/DVT and PEs from minor cuts Direct thrombin inhibitor like For children, avoiding injury is argatroban or Angiomax important (bivalirudin) IM injections, immunizations are Monitor for bleeding OK. HEMOPHILIA TEACHING Avoid injury Gentle hygiene Wear ID bracelet Good nutrition Teach patient and parents how to assess for bleeding Epistaxis Hematomas Hemarthroses GI bleeding Post surgical bleed If they have rescue medications at home, like desmopressin, teach about use HEMOPHILIA TREATMENT Treatment Bleeding/injury Administer missing factor Antifibrinolytics (hemostatic drugs) Amicar and Cyklokapron help prevent breakdown of clot Desmopressin increases platelet aggregation and clot formation Hemarthrosis RICE Pain Acetaminophen, steroids, and opiates AVOID NSAIDS (including ASA) because they further impair platelet aggregation Lymphomas- Cancer of the Lymph Nodes HODGKINS (HAS R-S NON-HODGKINS (NO R-S cells) cells) Lymph nodes- usually upper Metastasis is common, spread is body, spread in predictable disorganized patterns Same signs and symptoms Swollen, painless nodes Both: Biopsy nodes, stage Weight loss, Night sweats progression Persistent fever and malaise Both: Chemo, radiation, surgery. Prognosis is better for HL than NHL Cough, dyspnea, Chest pain Both: Risk factors: HIV and Recurrent infections, Pruritis immunosuppression Splenomegaly Multiple Myeloma- cancer of the plasma cells (B-lymphocytes) Overabundance of abnormal Cancer invades Pathological Hypercalcemia plasma cells the bone fractures can cause AKI crowd marrow Pancytopenia ve due to lack of Forms painful space h ie Anemia tumors p y : a y ac t r a o The hemo mn but n Leukopenia Thrombocytopenia C i ssio m re tive s h rink o cura iation t Pushes calcium into the blood d t Ra mors agemen stream tu m an in Pa