Disorders Associated with Erythrocytes and Leukocytes PDF

**I. Disorders Associated with Erythrocytes and Leukocytes** - **A. Anemia** - **(1) Etiology:** Characterized by below-normal levels of red blood cells, hemoglobin, and hematocrit, leading to insufficient oxygen delivery to tissues and cells. - **(2) Pathophysiology...

**I. Disorders Associated with Erythrocytes and Leukocytes** - **A. Anemia** - **(1) Etiology:** Characterized by below-normal levels of red blood cells, hemoglobin, and hematocrit, leading to insufficient oxygen delivery to tissues and cells. - **(2) Pathophysiology:** Caused by various factors including: - Loss of red blood cells due to hemorrhage. - Increased destruction of red blood cells (hemolysis). - Impaired production of red blood cells (bone marrow depression or failure). - Nutritional deficiencies, such as long-term iron deficiency. - Loss of oxygen-carrying elements in blood, causing a supply/demand imbalance in vital organs. - Peripheral circulation compensates by shunting blood to vital organs, causing hypoxia in other areas. - **(3) Clinical Manifestations:** - **Common symptoms** due to decreased oxygen-carrying capacity: - Sudden loss of 1/3 of blood volume: hypotension, respiratory distress, altered mental status. - Acute loss (Hgb below 5g/mL): severe hypotension, myocardial infarction, stroke, severe altered mental status, death. - Chronic mild anemia: may be asymptomatic unless detected in lab, general malaise, heart palpitations, shortness of breath on exertion, dizziness/lightheadedness. - **(4) Assessment:** - **Subjective data**: weakness, dyspnea, fatigue, vertigo, sometimes headache and insomnia. - **Objective data**: observing signs and symptoms of shock, bleeding, pallor, monitoring laboratory values. - **(5) Diagnostic Tests:** - Complete blood count (CBC): decreased RBCs, hemoglobin, and hematocrit. - Decreased serum iron, total binding capacity, and serum ferritin levels. - Increased reticulocyte count due to immature RBCs. - Bone marrow biopsy showing abnormalities. - Peripheral blood smears to identify cell shape/color abnormalities. - Decreased vitamin B12 level. - **(6) Medical Management:** - Intervention depends on the cause. - Identify and treat the cause promptly. - Blood transfusions for blood loss and replacement for iron and vitamin B12 deficiencies. - Treatment is often specific to the particular anemia. - **(7) Nursing Interventions and Patient Teaching:** - **Compromised Blood Flow to Tissues:** - Monitor changes in vital signs, cardiac rhythms, Hgb, Hct, RBCs. - Assess baseline arterial blood gases and electrolytes. - Note presence and degree of dyspnea and cyanosis. - **Insufficient Oxygenation:** - Evaluate ability to manage ADLs, assess activity intolerance. - Observe for cyanosis, hypoxia, and hypercapnia. - Maintain bed rest as necessary, monitor SpO2, and administer oxygen as needed. - Teach the relationship between activity and oxygen deficit. - **Inability to Tolerate Activity:** - Plan care to conserve energy after activity periods. - Encourage limiting visitors, phone calls, and unnecessary interruptions. - Assist with ADLs, place articles within easy reach. - Administer oxygen as ordered to relieve dyspnea. - Monitor Hgb and Hct levels. - **B. Jehovah\'s Witnesses** - Opposed to homologous blood transfusions (blood from a blood bank) due to religious beliefs about eternal consequences. - May agree to certain types of autologous blood transfusions (patient\'s own blood taken at an earlier time). - Some may agree to volume expanders. - Often carry a card specifying permitted treatments. - Adults have the right to refuse treatment, but treatment cannot be withheld from a minor child. - **C. Hypovolemic Anemia (Blood Loss Anemia)** - **(1) Etiology/pathophysiology:** - Deficiencies in RBCs and other components due to low circulating blood volume from hemorrhage. - Blood loss of 1000 ml or more in an adult is considered severe; less than 500 ml may be tolerated. - Related to internal or external hemorrhage from surgery, GI bleeding, menorrhagia, trauma, or severe burns. - Decreased blood volume decreases oxygen-carrying capacity. - Sudden reduction in total blood volume can lead to hypovolemic shock. - **(2) Clinical Manifestations:** - Restlessness, subtle rise in respiratory rate. - Weakness, stupor, irritability, pale, cool, moist skin. - Shock occurs with deprivation of oxygen/nutrients to organs, causing vasoconstriction in noncritical organs. - Decreased blood volume leading to tachycardia and hypotension. - Clinical signs and symptoms are more important than lab values. - Internal hemorrhage may cause pain due to tissue distention, organ displacement, and nerve compression. - Decreased RBC, hemoglobin, and hematocrit may not be evident until several days after severe blood loss. - Severity of signs and symptoms correlates with severity of blood loss. - **(3) Assessment:** - **Subjective data:** thirst, weakness, irritability, and restlessness. - **Objective data:** hypotension, rapid/weak/thready pulse, increased respiration, cool/clammy skin with pallor, oliguria, mental disorientation, and physical collapse. - **(4) Diagnostic Tests:** - Loss of RBCs may not be reflected in lab data initially, with values appearing normal or high for 2-3 days. - Once plasma is replaced, RBC mass is less concentrated; RBC, hemoglobin, and hematocrit levels are severely decreased, often to half the normal values. - **(5) Medical Management:** - Controlling hemorrhage by stopping blood loss and treating for shock. - Replacing volume with IV saline (2L bolus in severe depletion). - Packed RBCs if hemoglobin is below 7g/dL. - Platelets, fresh frozen plasma (FFP), and cryoprecipitate to control hemorrhage. - One unit of packed RBCs should increase hemoglobin by 1g/dL or Hct by 3%. - Supplemental iron may be needed. - Provide oxygen therapy. - **(6) Nursing Interventions and Patient Teaching:** - Monitor blood and fluid restoration and identify blood loss sites to control bleeding. - Take vital signs frequently. - Prevent injury to restless and disoriented patients. - Measure I&O, watching for oliguria caused by decreased renal perfusion. - If hemorrhage is chronic, teach patient to monitor bleeding amounts and report to MD. - **D. Pernicious Anemia** - **(1) Etiology/pathophysiology:** - Metabolic defect resulting from the absence of intrinsic factor secreted by the gastric mucosa. - Atrophy or partial gastrectomy in the stomach\'s parietal walls prevents intrinsic factor production. - Progressive, megaloblastic, macrocytic anemia primarily affecting older adults. - Intrinsic factor is essential for Vitamin B12 absorption. - Without intrinsic factor, systemic absorption of B12 in the ileum is prevented. - Vitamin B12 is needed for: - Growth and maturation of all body cells, including RBCs in the marrow. - Erythrocyte membrane stability, lack thereof leads to easy rupture. - Nerve myelination; its absence leads to progressive demyelination and nerve degeneration. - **(2) Clinical manifestations:** - Fever, extreme weakness, dyspnea, and hypoxia. - Weight loss, slight icterus (jaundice) with pallor due to increased RBC destruction. - Edema of legs, intermittent constipation and diarrhea. - **(3) Assessment:** - **Subjective data:** palpitations, nausea, flatulence, dysphagia, indigestion, weakness, and difficulty swallowing, tingling of hands and feet, and impaired proprioception. - **Objective data:** smooth and erythematous tongue, infection of teeth and gums, cerebral signs (mental disorientation, personality changes, behavior problems), severe neurological impairments including paralysis due to spinal cord nerve fiber destruction. - **(4) Diagnostic tests:** - CBC (decreased Hgb & Hct), reticulocyte count to show bone marrow activity, mean corpuscular volume (MCV) measures RBC size, typically larger in pernicious anemia. - Serum megaloblastic anemic profile showing decreased serum levels of vitamin B12, serum methylmalonic acid, and homocysteine. - Bone marrow aspiration reveals abnormal RBC development. - Gastric analysis to determine the cause of B12 deficiency. - **(5) Medical management:** - Drug therapy: Vitamin B12 replacement therapy (Cyanocobalamin IM injections) given daily for two weeks, then weekly until hematocrit is normal and then monthly for life, intranasal B12 available. - Folic acid and iron supplements. - Blood transfusions for severe anemia. - CBC monitoring every 3-6 months. - **(6) Nursing interventions and patient teaching:** - Symptomatic approach depending on disease stage. - Monitor vital signs every 4 hours, keep patient warm. - Perform frequent mouth care. - Diet should be high in protein, vitamins, and minerals (red meat, dairy, and eggs) to increase B12 intake. - Prevent injury, lower stress, assist with ADLs and encourage rest periods. - Teach/assess understanding of medication and dietary regimen, chronic nature of the problem, and importance of B12 in diet. - **E. Aplastic Anemia** - **(1) Etiology/pathophysiology:** - Bone marrow failure to produce enough RBCs. - Causes: autoimmune disorders, inherited conditions, certain medications, infections (hepatitis, Epstein-Barr virus, HIV), pregnancy, radiation, toxic chemicals (pesticides, arsenic, benzene), unknown causes. - Patients are usually pancytopenic (low RBCs, platelets, and WBCs). - **(2) Clinical manifestations:** - Repeated infections that can be severe or flu-like due to decreased WBCs. - Fatigue, dyspnea, dizziness with standing, headaches, and cool/pale skin due to decreased RBCs. - Epistaxis, bleeding gums, petechiae, and blood in stool due to decreased platelets. - **(3) Assessment:** - **Subjective data:** history of chemical exposure, level of fatigue. - **Objective data:** pallor, signs of infection, bleeding tendencies, dyspnea, tachycardia. - **(4) Diagnostic tests:** - CBC shows low levels of all blood cells. - Reticulocyte count may show decreased levels. - Bone marrow aspiration and biopsy, showing pancytopenia. - **(5) Medical management:** - Identify and remove the cause. - Avoid blood transfusions if possible to minimize risks. - Platelet transfusions (HLA typed) for serious bleeding. - Splenectomy may be required for thrombocytopenia. - Drug therapy: Immunosuppressive therapy with anti-thymocyte globulin and cyclosporine for patients not candidates for bone marrow/stem cell transplant, GM-CSF. - Bone marrow and stem cell transplant is the therapy of choice for patients under 45 with matched donor. - Bone marrow transplant process: establish a pathogen-free environment, monitor for fever/infection, collect donor marrow via multiple marrow aspirations, then freeze until use. - After chemotherapy/radiation, the patient receives donated marrow via IV. The marrow flows into the bone marrow to manufacture new blood cells and restore the patient\'s marrow. - Medications support graft acceptance. - **(6) Nursing interventions and patient teaching:** - Proper observation and care after bone marrow study. - Monitor/prevent infections: strict aseptic techniques, prevent skin/mucous membrane breakdown, avoid IM injections/rectal medications, teach signs/symptoms of infection. - Use protective devices to prevent skin breakdown. - Monitor/prevent bleeding: observe for signs of bleeding, avoid trauma, monitor occult/gross bleeding, teach signs/symptoms of bleeding. - Prevent fatigue and teach balance between rest and activity. - **F. Iron Deficiency Anemia** - **(1) Etiology/pathophysiology:** - RBCs have decreased hemoglobin levels. - Causes: excessive iron loss, chronic intestinal blood loss, gastric/duodenal ulcers, esophageal varices, hiatal hernia, colonic diverticula, tumors, menstruation/pregnancies, increased iron demand, malabsorption of iron, subtotal gastrectomy and poor diet. - **(2) Clinical manifestations:** - Pallor (most common finding), glossitis, fatigue, weakness, shortness of breath, and other symptoms from previously discussed anemias. - **(3) Assessment:** - **Subjective data:** GI symptoms (glossitis, pagophagia), headache, paresthesia, burning tongue. - **Objective data:** pallor, tachycardia, fragile spoon-shaped fingernails, stomatitis, erythemic lips with cracking. - **(4) Diagnostic tests:** - CBC: decreased RBC, hemoglobin, and hematocrit. - Decreased serum iron levels. - **(5) Medical management:** - Drug therapy: Ferrous sulfate (oral or injection), Vitamin C to enhance iron absorption. - Food sources rich in iron: fish, meat, poultry, eggs, green leafy vegetables, whole grains, and dry beans. - **(6) Nursing interventions and patient teaching:** - Patient interview to identify the cause of anemia. - Drug therapy: iron replacement as ordered, teach medication regimen. - Stress importance of not stopping/omitting medications, educate on side effects (GI upset, constipation/diarrhea, green/black stools, staining of teeth). - Iron best absorbed in acidic environment and an hour before meals. Take with orange juice or vitamin C and do not administer with antacids. - If dose missed, continue with schedule; do not double a dose. Iron may interfere with oral antibiotic absorption. Check for constipation or diarrhea and record stool. - Iron is toxic; and caution must be taken to store iron out of reach of children. - Educate on nutritional needs to prevent anemia (organ meats, white beans, leafy vegetables, raisins, molasses, dry fruits, and egg yolk). - Assist to plan for rest periods when fatigue is present. - **G. Sickle Cell Anemia** - **(1) Etiology/pathophysiology:** - Most common genetic disorder in the U.S., predominantly in African/Eastern Mediterranean populations. - Sickle cell is abnormal, crescent-shaped RBC containing hemoglobin S (Hg-S). - Normal hemoglobin is hemoglobin A (Hg-A). Anemia occurs in people homozygous for Hg-S. - Sickle trait is the heterozygous form with both Hg-S and Hg-A. Those with the trait do not have signs or symptoms, but risk passing it to their children. - Sickle cell crisis: an episode of acute sickling that causes occlusion and ischemia in distal blood vessels. - Triggers include: stress, dehydration, infection, overexertion, weather changes, alcohol intake, and smoking. - Sickling leads to clumping in small vessels, causing tissue hypoxia, ischemia, pain, and edema due to inflammation. - **(2) Clinical manifestations:** - Usually asymptomatic for the first 10-12 weeks of life. - Typical patient is anemic but asymptomatic except during painful episodes. - Infections are a major complication (pneumonia, meningitis, influenza, hepatitis). - Abdominal enlargement, jaundice, joint and back pain, edema of extremities, multisystem failure, and retinal damage. - **(3) Assessment:** - **Subjective data:** assess knowledge/feelings about the disease, known triggers, fatigue, and severe pain. - **Objective data:** abdominal enlargement, jaundice, edema of extremities, increased respirations, hypoxia, cough, and signs of hemorrhage. - **(4) Diagnostic tests:** - Hemoglobin electrophoresis shows \>80% hemoglobin as Hg-S. - Stained blood smear shows anemia. - CBC: decreased hematocrit and hemoglobin, WBCs increased with infection. - Skeletal x-rays and MRI. - **(5) Medical management:** - No specific treatment, mainly supportive care to alleviate symptoms. - Drug therapy: oxygen, analgesics (opioid/non-opioid), antibiotics, immunizations, rest and IV fluids, blood transfusions (cautiously), folic acid. - Hematopoietic stem cell transplantation (HSCT) is the only therapy that can cure selected patients. - **(6) Nursing interventions and patient teaching:** - Monitor fluid and electrolyte balance, maintain hydration, prevent volume overload. - Monitor and maintain pain control: analgesics on a fixed schedule, PCA, warmth, and proper positioning. - Genetic counseling as indicated. - Teach/assess patient understanding of avoiding triggers, preventing infections, maintaining adequate volume, regular exercise/ROM, and medication/dietary regimen. - **H. Polycythemia Vera** - **(1) Etiology/pathophysiology:** - Primary: overgrowth of bone marrow causing increased erythrocytes, granulocytes, basophils, and platelets. Develops gradually and is chronic, diagnosed at an average age of 60, and more frequent in men. - Secondary: caused by hypoxia, stimulating erythropoietin in the kidneys which then stimulates erythrocyte production. May result from high altitude, pulmonary disease, cardiovascular disease, or tissue hypoxia. A physiologic response, not pathologic. - Multi-organ system involvement due to hypervolemia and hyperviscosity predisposing to infarctions. - **(2) Clinical manifestations:** - Increased blood volume and viscosity. - Excess WBCs and platelets. - Increase in blood clots (DVT, pulmonary embolism, MI). - Venous distention and platelet dysfunction (esophageal varices, epistaxis, GI bleeding, and petechiae). - Hepatomegaly and splenomegaly. - **(3) Assessment:** - **Subjective data:** sensitivity to hot and cold, pruritus, headaches, vertigo, tinnitus, blurred vision, and painful burning of hands/feet. - **Objective data:** eczema and dermatological changes, hypertension, left ventricular hypertrophy, and angina. - **(4) Diagnostic tests:** - CBC: elevated Hgb and Hct, elevated RBCs and WBCs, elevated platelets. - Elevated reticulocyte count. - Bone marrow biopsy. - Increased BMR. - Splenomegaly found in primary polycythemia, not in secondary. - **(5) Medical management:** - Directed at decreasing blood volume and viscosity and bone marrow activity. - Repeated phlebotomy to maintain hematocrit between 45 and 48%. - Drug therapy: Myelosuppressive agents (busulfan, hydroxyurea, melphalan), radioactive phosphorous. - **(6) Nursing interventions and patient teaching:** - Secondary polycythemia: Maintain adequate oxygenation, control pulmonary disease and avoid high altitudes. - Polycythemia vera: Monitor fluid balance, strict I&Os, prevent dehydration/fluid overload. - Teach/assess understanding of medication and nutritional status. - Monitor/prevent thrombus formation (ambulation/ROM exercises), teach patient signs/symptoms. - Teach/assess maintenance of adequate volume status and importance of compliance with the medical/nutritional regimen. - **I. Agranulocytosis** - **(1) Etiology/pathophysiology:** - Potentially fatal condition characterized by severe reduction in granulocytes (basophils, eosinophils, neutrophils). - Low white blood count (leukopenia) and absolute neutrophil count (neutropenia). - Bone marrow suppression reduces WBC production; therefore, protection against foreign invaders is ineffective. - Fatality results from severe bacterial infections. - **(2) Common causes:** - Adverse medication reaction or toxicity, neoplastic disease, chemotherapy/radiation, viral/bacterial infections, heredity. - **(3) Clinical manifestations:** - Fever, chills, headache, fatigue, ulcerations of mucous membranes, bronchial pneumonia, and urinary tract infections in later stages. - **(4) Assessment:** - **Subjective:** extreme fatigue, all medications are considered as possible causes. - **Objective:** fever over 100.6°F, erythema and pain from ulcerations, crackles and rhonchi due to exudates. - **(5) Diagnosis:** - WBC with differential shows decreased WBCs in all categories. - Bone marrow biopsy shows suppressed activity. - Culture ulcerations to identify possible infectious organisms. - **(6) Medical management:** - Alleviate bone marrow depression and prevent/treat infections. - Treat infections based on organism and drug sensitivity to avoid resistant organisms. - Institute neutropenic precautions. - Transfusions of packed red blood cells. - Treat neutropenic patients with G-CSF (Neupogen). - **(7) Nursing interventions:** - Protect against infection: monitor closely, meticulous handwashing/asepsis, observe for signs of infection, enforce neutropenic precautions. - Prevent visitors/staff with infections from having contact, avoid fresh flowers and raw foods. - Monitor mucous membranes for ulcerations. - Provide high-protein, high-calorie diet, encourage fluids for hydration. - **(8) Patient teaching:** - Teach/assess understanding of signs/symptoms of infection. - Explain the need to avoid crowds, people with infectious diseases, and cold or hot environments. - Teach/assess understanding of medication and dietary regimen. - Discuss the importance of not stopping medications and the need for a soft, bland diet high in protein, vitamins, and calories. - Encourage balance between rest and activity to prevent fatigue. - **J. Leukemia** - **(1) Etiology/pathophysiology:** - Malignant disorder of the hematopoietic system where excess leukocytes accumulate in bone marrow and lymph nodes. - Causes are unknown but attributed to: genetic origins, viruses, exposure to radiation or chemotherapeutic agents. - Bone marrow is replaced by rapidly developing white cells. - Abnormal concentrations of immature cells in circulation. - Infiltration damages bone marrow, spleen, lymph nodes, and other organs, leading to hepatomegaly, splenomegaly, lymphadenopathy, bone pain, meningeal irritation, and oral lesions. - Elevated leukocyte production but cells are immature and cannot prevent infection. - **(2) Classification:** - Classified by whether it is acute or chronic, and the type of blood cell involved. - Acute lymphocytic leukemia (ALL): affects lymphoid cells, grows rapidly, seen in male children under 5 and adults over 50. - Acute myelogenous leukemia (AML): affects myeloid cells, grows rapidly, seen in children and adults, more seen in adults. - Chronic lymphocytic leukemia (CLL): affects lymphoid cells (lymphocytes, often B cells), grows slowly, rare in children/young adults, more likely to be diagnosed in 70s. - Chronic Myeloid Leukemia (CML): affects myeloid cells (not lymphocytes), typically starts slow growing and affects older adults. - **(3) Clinical manifestations:** - Anemia (pallor, fatigue, malaise, decreased activity tolerance). - Thrombocytopenia (petechiae, epistaxis, easy bruising, occult blood in urine/stool). - Leukopenia (fever, URI, UTI). - Enlarged lymph nodes and painless splenomegaly. - **(4) Diagnostic tests:** - CBC (low, elevated, or severely elevated WBCs). - Bone marrow biopsy (immature leukocytes). - Lymph node biopsy (excessive blasts). - Chest radiograph (mediastinal lymph nodes, lung involvement, and/or bone changes). - Peripheral smear (immature WBCs). - CT/Lumbar puncture (leukemic cells outside of the blood and bone marrow). - **(5) Assessment:** - **Subjective:** pain in bones/joints, fatigue, malaise, irritability, bleeding abnormalities, and increased activity intolerance. - **Objective:** presence of infection, occult blood, petechiae, ecchymosis, and bleeding of mucous membranes. - **(6) Diagnostic Tests:** - CBC checking WBC, RBC and platelets. - Bone marrow biopsy shows immature leukocytes. - Lymph node biopsy reveals excessive blasts. - Chest radiograph shows mediastinal lymph node and lung involvement and bone changes. - Peripheral smear along with bone marrow biopsy are primary methods of diagnosing/classifying leukemia. - CT / Lumbar puncture determine the presence of leukemic cells outside of blood and bone marrow. - **(7) Medical management:** - Goal is to achieve remission or control symptoms. - Treatment aims to eradicate leukemia with chemotherapy or bone marrow transplant. - Multiple medications may be administered, LVNs treat side effects (nausea, vomiting, itching, etc.) but do not administer chemo. - Acute leukemia: Combination of chemotherapeutic drugs and total body radiation, bone marrow transplant after remission, autologous transplant (patient\'s bone marrow is removed, irradiated, and reinfused), or allogenic transplant from a donor, stem cell transplant. - Chronic leukemia: Occurs in adults, drug therapy (chlorambucil, hydroxyurea, corticosteroids, cyclophosphamide), irradiation of lymph nodes is palliative, not curative, blood transfusions for severe anemia. - **(7) Nursing interventions:** - Prevention of infection: neutropenic precautions, patient teaching on avoiding infectious agents, frequent observation. - Prevention of hemorrhage: monitor CBC, protect from trauma. - Pain control: non-pharmacological measures and analgesics. - Support coping mechanisms with a multidisciplinary approach and community support groups, develop a positive nurse-patient-family relationship. - Obtain knowledge of chemotherapeutic and prophylactic drugs (mechanism, side effects, treatment of side effects). - **(8) Patient teaching:** - Teach/assess signs/symptoms of infection and avoiding infected individuals. - Teach/assess understanding of medication/dietary regimen, importance of completing antibiotics, a balanced, high calorie/protein/vitamin diet, and soft bland foods. - Explain all procedures and interventions to patient/family. 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