Hematological Nursing Student Notes PDF

NURSN325F NURSING THERAPEUTICS IN GENERAL HEALTH CARE IV NURSING MANAGEMENT OF DISTURBANCES IN HEMATOLOGICAL FUNCTIONS (1) WEEK 1 MS AMY LEUNG 1 LEARNING OUTCOMES Upon successful completion of the topic, students should be able to: 1. Describe th...

NURSN325F NURSING THERAPEUTICS IN GENERAL HEALTH CARE IV NURSING MANAGEMENT OF DISTURBANCES IN HEMATOLOGICAL FUNCTIONS (1) WEEK 1 MS AMY LEUNG 1 LEARNING OUTCOMES Upon successful completion of the topic, students should be able to: 1. Describe the applied anatomy and physiology of the hematological nursing; 2. Identify nursing assessment and common investigations for the hematological nursing and the related care; 3. Describe the definition, etiology, pathophysiology, clinical features, investigations and diagnosis, and the management of common hematological disorders and the related nursing problem and care; 4. Describe the definition, purpose, and technique of blood transfusion and bone marrow transplantation and the related nursing problem and care; 5. Develop integrative nursing care plan for clients with hematological disorders; 6. Describe the basic pharmacological concepts and clinical drug therapy modalities in daily nursing practice and the related nursing considerations for hematological disorders. 2 OVERVIEW  Structure and functions  Assessment  Investigation  Blood transfusion  Splectomy 3 Structure and functions of the hematological system 4 BLOOD ⚫ Exist in a fluid state ⚫ Circulate through the heart, arteries, capillaries, and veins ⚫ Serve as a link between body organs 5  BLOOD Consist of plasma and cellular components Blood Cellular Plasma (55%) component (45%) Erythrocytes Leukocytes (RBC) (WBC) 6 Thrombocytes (Platelets)  BLOOD COMPONENTS Plasma  Water  Proteins  Albumin  Fibrinogen  globulins  Others  Inorganic salts  Urea  Dissolved gases  Hormones  Enzyme 7  BLOOD COMPONENTS Cellular components  RBC  WBC  Platelets  Derived from stem cells in bone marrow by hematopoiesis  Affected by stem cells bone marrow and nutrients e.g. vit B12, iron 8 CHARACTERISTICS OF BLOOD Characteristic Description Color Arterial blood is bright red due to oxygen bound to hemoglobin (Hb) Venous blood is dark red because of lower oxygen content than arterial blood Viscosity 3-4 times more viscous than water Specific gravity 1.046- 1.066 pH Slightly alkaline pH 7.35-7.45 Volume 70-75 ml of blood / kg of body weight (~8%) Average male and female adults have about 5.5 L and 4.5 L of 9 blood respectively FUNCTIONS OF BLOOD  Transportation  Transporting oxygen, carbon dioxide, nutrients, hormones, and metabolic waste products to kidneys and liver  Protection  Transport of cells and substances involved in immune reactions  Clotting  Regulation  Regulating fluid balance, body temperature regulation, and acid base balance 10 TYPES OF BLOOD CELLS 11 TYPES OF BLOOD CELLS Erythrocytes/Red blood cell (RBC)  Major component : Hemoglobin (Hb)  Function: Exchange of oxygen and carbon dioxide between lungs and tissue  Life span : 100-120 days, then destroyed in spleen & liver 12 TYPES OF BLOOD CELLS Leucocytes (White blood cells) / WBC  Function: Protection from bacteria and other foreign substances  Neutrophils – Ingest and destroy microorganisms (phagocytosis)  Eosinophils – Host resistance to helminthic infections  Basophils – Allergic reactions WBC differential counts  Lymphocytes – B-lymphocytes: produce antibodies -- T- lymphocytes : regulate immune response  Monocytes - Phagocytosis 13 TYPES OF BLOOD CELLS Platelets  Function: form platelet plug to stop bleeding and promote thrombin production 14 HEMOSTASIS ⚫ A process that repairs vascular breaks to reduce blood loss from blood vessels while maintaining the flow of blood through the vascular system ⚫ 3 components ◼ Blood vessels ◼ Platelets ◼ Coagulation factors (clotting factors I to XIII) ⚫ 3 phases  Vasoconstriction/ vessel spasm  Formation of platelet plug  platelet aggregate at the site and adhere to the vessel and to one another  Formation of fibrin clot 15  clotting factors stimulate the formation of fibrin from thrombin by the activation of the intrinsic or extrinsic coagulation pathway 16 17 Structure and functions of the Lymphatic system 18 LYMPHATIC SYSTEM - STRUCTURE ⚫ Lymph tissue located in multiple body systems ⚫ Lymph fluid and collection ducts ⚫ Lymph nodes ◼ Distributed throughout the body ◼ Connected by lymph vessels ◼ Remove foreign material from the lymphatic system before it enter the blood stream ◼ Centers for immune cell proliferation 19 LYMPHATIC SYSTEM - STRUCTURE ⚫ Spleen ◼ Act like a filter ◼ Destroy old and injured RBCs ◼ Contain concentrations of lymphocytes ⚫ Thymus ◼ As a site for the maturation of lymphocytes ⚫ Tonsils and adenoids ◼ Contain immune cells that defense the body against microorganisms 20 LYMPHATIC SYSTEM - FUNCTIONS ⚫ Protect body from antigenic substances ⚫ Remove damaged cells ⚫ Partial barrier to malignant cell maturation ⚫ Maintenance of fluid balance ⚫ Production of lymphocytes ⚫ Production of antibodies ⚫ Ingestion and digestion of other cells or particles by phagocytes ⚫ Absorption of fat and fat-soluble substances ⚫ Manufacture of blood 21 NURSING ASSESSMENT OF HEMATOLOGICAL DISORDERS 22 NURSING ASSESSMENT Patients may have a disruption of the ⚫ Hematological system ⚫ Immune system ⚫ Coagulation system → symptoms and physical examination findings. 23 PAST HISTORY  Past medical problems?  Surgeries?  Ask specifically about partial or total gastrectomy (reduce intrinsic factor production and vitamin B12 absorption)  Any splenic injury or splenectomy  Tendency to bleed (e.g., with dental procedures)  Infectious diseases  Human immunodeficiency virus (HIV) infection  Cancer 24 PAST HISTORY  Present medications  Over-the-counter medications, vitamins, herbals, or nutritional supplements  What else have you taken in the past several months?  e.g. aspirin/aspirin-containing compounds;  non-steroidal anti-inflammatory drugs → interfere with platelet aggregation and cause prolonged bleeding 25 PAST HISTORY  Family history of hematological or malignant disorders  Allergies and allergic reactions, particularly anaphylaxis  Previous blood/blood product transfusion  Occupation/ Exposure to substances (e.g. benzene, pesticides, ionizing radiation)  Social history and lifestyle? Do you use illicit drugs or alcohol? What is your pattern of sexual activity? 26 PHYSICAL ASSESSMENT ⚫ Skin and mucous membranes: ⚫ Any bruises, infections, drainage, or bleeding from wound sites? ⚫ Neurologic ⚫ Any dizziness, tingling or numbness (paresthesia), headache, forgetfulness or confusion, difficulty in walking (disturbance in gait), tiredness (fatigue), or weakness? ⚫ Respiratory ⚫ Shortness of breath, especially on exertion? 27 PHYSICAL ASSESSMENT ⚫ Cardiovascular: ⚫ Chest pain or feelings of funny heartbeats (palpitations)? ⚫ Gastrointestinal ⚫ Any bleeding from gums, abdominal pain, black stools, blood-streaked vomit (emesis), mouth sores, rectal pain, or diarrhea? ⚫ Genitourinary ⚫ Excessive menstrual flow? Any blood in urine or discomfort on urination? 28 CHIEF COMPLAINTS ⚫ Maybe vague; usually fatigue, frequent infections, swollen glands, and bleeding tendencies ⚫ Review the neurologic, respiratory, cardiovascular, gastrointestinal, genitourinary, and integumentary systems ⚫ Decreased blood pressure, tachycardia, and possibly altered level of consciousness → suggest anemia or altered blood clotting 29 CHIEF COMPLAINTS ⚫ Dyspnea; shiny smooth tongue; ataxia; pallor of conjunctivae, nail beds, lips, and oral mucosa → suggest anemia ⚫ Hematuria, tarry stools, petechiae, and bleeding sites → suggest altered blood clotting ⚫ Fever; tachycardia; abnormal breath sounds; delirium; oral lesions; erythema, swelling, tenderness, and drainage of the skin → suggest infection 30 LABORATORY TESTS 31 COMPLETE BLOOD COUNT (CBC)  Numbers or percentages of  RBCs  Hb  WBC  PLT (Platelet) in blood sample 32  COMPLETE BLOOD COUNT (CBC) Red Blood Cell  RBC indices: Hb concentration; diagnosis and classification of anemias  Male 14-16.5 g/dL  Female 12-15 g/dL  MCV: Measure average size or volume of individual RBCs →diagnostic of 33 thalassemia COMPLETE BLOOD COUNT (CBC) WBC  WBC count  Measure the number of WBCs  WBC differential :  number of each type of WBCs  evaluate infection or potential for infection  identify various types 34 of leukemia COMPLETE BLOOD COUNT (CBC) Platelet count  Evaluate platelet production  Assess the severity of thrombocytopenia, which could result in spontaneous bleeding  Decreased production → Prolonged bleeding time; diagnostic of 35 thrombocytopenia  CLOTTING PROFILE  Prothrombin time (PT)  Activated partial thromboplastin time (APTT)  International normalized ratio (INR) 36 CLOTTING PROFILE Prothrombin time (PT)  Measures the time it takes for a clot to form in a blood sample  Determine activity and interaction of clotting factors, prothrombin, and fibrinogen  Help to diagnose clotting disorders  Prolongation of time indicates person receiving anticoagulants or deficiencies of clotting factors.  Normal range is 11-15 seconds 37 CLOTTING PROFILE Activated partial thromboplastin time (APTT)  Evaluate adequacy of factors VIII, IX, XI, XII  Investigate bleeding disorders such as hemophilia  Monitor patients taking an anticlotting drug such as heparin  Prolonged time occurs in severe coagulation problems; therapeutic administration of heparin  Normal range: 24-37 seconds 38 CLOTTING PROFILE International normalized ratio (INR)  An international sensitivity index (ISI) of a normal (control) sample  Measured from PT  Used to determine dosages of oral anticoagulant (Warfarin) drugs  Monitor anticoagulation therapy; improve the effectiveness of the medication  Normal range  Without anticoagulation therapy: 0.8-1.2  Target range in anticoagulant use: 2-3 39 IRON PROFILE  Include levels of serum ferritin, iron, total iron-binding capacity, folate, and vitamin B12  Determine type and severity of anemia  Recent administration of chloramphenicol, hormonal contraceptives, iron supplements, and corticotropin may affect results of serum iron and iron- binding capacity 40 BLOOD SMEAR  Microscopic viewing using appropriate stains, allowing visual analysis of numbers and characteristics of cells  Identify abnormal cells of certain anemias, leukemia, and other disorders 41 Diagnostic evaluation 42 BONE MARROW ASPIRATION (BMA) +/- BIOPSY ⚫ Purposes ◼ Analyze bone marrow for the different types of cells ◼ Monitor the number, appearance, and development of various cell types ◼ Diagnose hemolytic blood disorders, tumors, leukemia, and infectious diseases ◼ Monitor illness and response to treatments (e.g. chemotherapy, marrow 43 transplant) BONE MARROW ASPIRATION (BMA) +/- BIOPSY ⚫ Procedure ◼ Samples are taken from the posterior iliac crests, anterior iliac crests or sternum ◼ Pre-procedure care ◆ Explain the purpose and procedure, puncture site selection, painful sensation, and possible complications ◆ Sign consent form before aspiration ◆ +/- sedation, especially for those BMA with biopsy ◆ Position the client ◆ Posterior iliac crest: prone /side-lying with top knee flexed 44 ◆ Anterior iliac crest: (supine)  BONE MARROW ASPIRATION (BMA) +/- BIOPSY Equipment BMA tray Marrow aspiration needle with stylet Disposable punch biopsy needle with trocar Towels Needles Syringes (different sizes) Local anesthetic (Xylocaine or Lidocaine) Sterile gauze Sterile gloves and drape Skin antiseptic (Betadine) PPE Collection tubes (plain and heparinized) Glass for smear 45 Blade and handle  https://www.youtube.com/watch?v=Ffq4EBD_dB o 46 BONE MARROW ASPIRATION AND BIOPSY Pre-procedure care Nursing action Rationale 1. Explain the procedure to the patient.Tell patient when Allay anxiety and enlist the skin will be marked, antiseptic applied, and needle cooperation. puncture performed. 2. Give analgesic 30 mins before procedure. Minimize pain, discomfort, and anxiety during procedure. 3. Position the client: Expose desired site. Posterior iliac crest — prone (if patient cannot tolerate prone position, assist patient to side-lying position with top knee flexed) Anterior iliac crest — supine (if patient is very 47 obese) BONE MARROW ASPIRATION AND BIOPSY Performance phase (nurse assists) 1. The posterior iliac crest is located and marked. The iliac crest provides a large marrow cavity at the posterior superior iliac spine away from nearby abdominal organs. 2. The skin area is prepared and draped.The marked area is Tell the patient to expect a infiltrated with local anesthetic through the skin and needle prick followed by a subcutaneous tissue to the periosteum of the bone. burning sensation. The periosteum is the region of greatest sensitivity. 3. A small incision may be made. The biopsy needle is large and a small incision facilitates 48 insertion. BONE MARROW ASPIRATION AND BIOPSY Performance phase (nurse assists) 4. The marrow aspiration needle, with stylet in place, is There is usually decreased introduced through the incision.The needle is advanced resistance when the bone and rotated by using firm and steady pressure.When the marrow cavity is entered. The needle is felt to enter the outer cortex of the bone actual aspiration may cause marrow cavity, the stylet is removed and the syringe is brief pain and the patient attached. Negative pressure is applied and a small should be forewarned. volume of blood and marrow is aspirated. 5. A biopsy is taken by using a special needle (disposable Bone marrow appears rusty- punch biopsy needle with trocar) → rotate with constant red and normally has a thick pressure at the same site → remove trocar → move and fluid-like consistency. deeper into the bone marrow → insert spoon and needle → rotate without pressure (cut the biopsy) → remove out → put specimen into bottle and send to the 49 laboratory immediately. BONE MARROW ASPIRATION AND BIOPSY 6. After removal of needle, apply pressure and dressing to Prevent bleeding from site. puncture site. Dressing keeps site clean and dry until healed. 50 BONE MARROW ASPIRATION (BMA) +/- BIOPSY ◼ Post-procedure care ◆Apply sterile dressing and direct pressure for 10 minutes in order to control bleeding and reduce hematoma and pain ◆Use pressure dressing and sandbag ◆Observe the site frequently on the day of the procedure and teach the patient to observe for several days ◆pain usually lasts for 2-3 days, if there is persistence or increase in pain, bleeding, hematoma, or discharge → consult doctor immediately 51 ◆Administer analgesics as prescribed LYMPH NODE BIOPSY ⚫ Surgical excision or needle aspiration of a superficial lymph node in the cervical, supraclavicular, axillary, or inguinal region ⚫ Purpose: ⚫ determine the cause of lymph node enlargement ⚫ distinguish between benign and malignant lymph node tumors 52 ⚫ stage metastatic carcinoma LYMPH NODE BIOPSY ⚫ Local anesthetic is usually given ⚫ Specimen is placed in normal saline or 10% formaldehyde solution for transportation to the laboratory for cytologic and histologic evaluation 53 BLOOD PRODUCT TRANSFUSION 54  BLOOD COMPATIBILITY ⚫ Antigens ◼ Surface membrane of RBC is characterized by antigens ◼ Two antigenic systems (ABO and Rh) require routine prospective matching before the transfusion ◼ ABO blood group system is clinically the most significant 55 BLOOD COMPATIBILITY ⚫ Antibodies ◼ In serum ◼ The five classes of immunoglobulin (Ig) are determined by differences in their heavy chains: IgG, IgA, IgM, IgD, and IgE ◼ The interaction of antibodies and antigens triggers immune response ◼ Antibodies against the A and B antigens are large IgM molecules. When they interact with and coat the A and B antigens on the RBC surface, the antibody/RBC complexes clump together (agglutinate) ◼ → large antibody/RBC complexes also become trapped in capillaries, where they may cause thrombotic complications to vital organs, and in the reticuloendothelial system, where they are removed from circulation by the spleen. They also cause RBC lysis. 56 BLOOD TYPE 57 BLOOD COMPATIBILITY ⚫ Rhesus (Rh) system  Include C, D, and E antigens  Negative sign after AOB indicate Rh(D) antigen –ve  Most people are Rh +ve ( with Rh D antigen)  For Rh(D)-negative people, they do not develop RhD antibodies without specific exposure  For Rh(D)-negative people , during transfusion of RhD+ve blood or feto-maternal hemorrhage during pregnancy and delivery (with baby have Rh +ve blood ) → Develop RhD antibodies (alloimmunization) 58 BLOOD COMPATIBILITY  The Rh(D) antibodies can complicate future transfusions and pregnancies  For the Rh(D)-ve person, exposure to Rh +ve blood should be avoided by the use of Rh(D)-negative blood products  In the case of Rh-ve mother and Rh+ve fetus, prophylaxis for exposure to D uses Rho(D) immunoglobulin (RhoGAM), which will prevent Rh(D) antibodies formation 59 SUMMARY OF ABO BLOOD GROUPING Blood type Antigen in Antibody in Incompatible Compatible RBCs plasma donor blood donor blood A A Anti-B B and AB A and O B B Anti-A A and AB B and O AB A and B - - All blood groups O - Anti-A and All blood O anti-B groups Rh +ve Rh(D) - - Rh –ve & Rh +ve 60 Rh -ve - - Rh +ve Rh –ve blood 61 62 TYPES OF BLOOD PRODUCTS  Whole Blood  Packed Red Blood Cells  Platelet concentrate  Fresh Frozen Plasma  Cryoprecipitate 63 TYPES OF BLOOD PRODUCTS ⚫ Whole blood ◼ Prevention or resolution of hypovolemic shock and anemia 64 TYPES OF BLOOD PRODUCTS ⚫ Packed Red Blood Cells ◼ Volume: 250-400 ml/unit ◼ Resolution of symptoms of anemia ◼ 1 unit of RBC should increase Hb by 1 g/dL in a non-bleeding adult 65 TYPES OF BLOOD PRODUCTS ⚫ Platelet concentrate ◼ Prevention or resolution of bleeding due to thrombocytopenia or platelet dysfunction ◼ Obtained by centrifuging multiple units of whole blood ◼ Infuse at the rate prescribed (usually at full rate) ◼ Complete within 20 to 60 minutes, depending on total volume 66 TYPES OF BLOOD PRODUCTS ⚫ Fresh Frozen Plasma ◼ Contain 91% water, 7% protein (globulin, antibodies, and clotting factors), and 2% carbohydrates ◼ Freeze within 8 hours of collection, preserve all clotting factors ◼ Unfreeze before transfusion ◼ Reassess by monitoring coagulation function (e.g. PT, APTT) 67 TYPES OF BLOOD PRODUCTS ⚫ Cryoprecipitate ◼ Contain factor VIII (anti-hemophilic factor), fibrinogen, and factor XIII 68 69 PREPARATION ⚫ Doctor’s order for transfusion (blood component, volume, and rate of infusion) 70 PREPARATION ⚫ Informed consent and client teaching; risks and alternatives 71 PREPARATION ⚫ Blood product screening ◼ Serologic testing ◆ Type & screen : ABO group and Rh type: Determine the presence of A, B, and D antigens on the surface of the patient's RBCs ◆ Cross match (compatibility test): Detect agglutination of donor RBCs caused by antibodies in the patient's serum ◼ Screening for infectious diseases ◆ Hepatitis B and C ◆ HIV ◆ Cytomegalovirus (CMV), especially for impaired immune function (e.g. bone marrow and organ transplant recipients, premature babies) ◆ Syphilis ◆ Bacteria 72 ◆ Others: Variant Creutzfeldt-Jacob disease PREPARATION  Patient assessment  Take baseline vital signs  Explain the procedure to the client and the reasons for it.  Assess the client’s understanding of the blood transfusions procedure  Assist the client into comfortable position. Ensure the relevant extremity is well supported.  Inspect the IV infusion site and access port for patency or abnormalities. 73 IMPLEMENTATION ⚫ Check the whole procedure with another Registered Nurse, preferably nurse in charge of the ward. ⚫ Check doctor’s orders (progress sheet, blood product prescription form (may be IV fluid chart), and matched transfusion record) for the type and units of blood products that will be given ⚫ Check the blood bag for expiry date, leakage, bubbles, cloudiness, dark color, or black sediment (indication of bacterial invasion) 74 IMPLEMENTATION → Go to the bedside of patient  Check client’s identity (name, HKID and hospital number) against the matched transfusion record, blood bag and bracelet  Ask client about allergy history, report any previous blood reactions and ask the patient about the blood group  Take baseline vital signs at start of transfusion 75  IMPLEMENTATION  Start infusion with normal saline and appropriate blood tubing (blood giving set +/- pump set)  Start blood within 30 minutes from time it is removed from refrigerator  Start transfusion slowly, observe vital signs and signs of transfusion reaction during the first 15 minutes.  After initial slow rate, infuse at a rate according to doctor’s prescription 76 IMPLEMENTATION  Do not allow duration of blood transfusion to exceed 4 hours  Maintain aseptic technique during procedure  Maintain close monitoring during the whole process (e.g. vital signs, adverse effect)  Health education and documentation 77 TRANSFUSION REACTIONS 1. Febrile Nonhemolytic reaction 2. Hemolytic Reaction or incompatibility reaction 3. Allergic reaction 4. Circulatory overload 5. Bacterial contamination 78 TRANSFUSION REACTIONS Febrile Nonhemolytic reaction  Caused by antibodies to donor leukocytes that remain in the unit of blood or blood component.  More frequent in patients who have had previous transfusion  Signs and symptoms: fever begins within 2 hours after transfusion begun 79 TRANSFUSION REACTIONS Hemolytic Reaction or incompatibility reaction  Most dangerous, life threatening  When the type of transfusion reaction occurs when the donor blood is incompatible with that of recipient  Signs and symptoms: fever, chills, hypotension, chest tightness, dyspnea (increase HR and RR), blood stain urine 80 TRANSFUSION REACTIONS Allergic reaction Simple allergic reaction  A sensitive reaction to a plasma protein within the blood component being transfused.  Signs and symptoms: urticarial (skin rash), itching, and flushing Anaphylactic reaction  Anaphylactic reactions occur in those with immunoglobulin A (IgA) deficiencies and have IgA antibodies in their plasma.  The recipient’s anti-IgA antibodies can react with the IgA antibodies in the donor blood.  Signs and symptoms: flushed skin, itching, swelling, difficulty breathing, wheezing blue lips, low blood pressure 81 TRANSFUSION REACTIONS Circulatory overload  If too much blood is infused too quickly, hypervolemia can occur  Signs and symptoms: Dyspnea, orthopnea, tachycardia, increase BP, jugular vein distention 82 TRANSFUSION REACTIONS Bacterial contamination  Administration of contaminated products during procurement or processing.  Signs & symptoms: fever, chills and hypotentsion.  Symptoms may not occur until the transfusion is complete. 83 TRANSFUSION REACTIONS Nursing interventions for transfusion reactions  Stop transfusion immediately  Notify the doctor  Change new tubing as soon as possible and keep vein open with slow IVF (NS)  Monitor vital signs every 15 minutes until stable +/- signs of progressive allergic reaction and shock 84 TRANSFUSION REACTIONS Nursing interventions for transfusion reactions  Maintain patent airway and adequate ventilation (administer oxygen +/- intubation), position to semi/Fowler position  Obtain order and administer antihistamine, diuretic, broad-spectrum antibiotic (draw blood cultures prior), and hydrocortisone as prescribed 85 TRANSFUSION REACTIONS Nursing interventions for transfusion reactions  Notify blood bank that a suspected transfusion reaction has occurred.  Send the blood container and tubing to the blood bank for repeat typing and culture.  Obtain urine specimen to detect hemoglobin in the urine. +/- insert Foley catheter for accurate input and output measurement.  Documents the reaction according to the hospital policy. If hemolytic transfusion reaction, need to report in Advance Incident Reporting System (AIRS) (For HA hospital) 86 Therapeutic approach to hematololgic disorders 87 SPLENECTOMY ⚫ Surgical removal of spleen ⚫ Reasons ◼ Trauma ◼ Hemolytic or malignant disorders with accompanying splenomegaly ⚫ Laparoscopic technique 88 89 SPLENECTOMY Preoperative nursing care ◼ General preoperative nursing interventions ◼ Stabilization of pre-existing condition ◆ For trauma: Volume replacement with IV fluids, evacuation of stomach contents via nasogastric tube to prevent aspiration, urinary catheterization to monitor urine output, assessment for pneumothorax or hemothorax +/- chest drain placement ◆ For hemolytic or malignant disorders with accompanying thrombocytopenia: Coagulation studies, administration of coagulation factors (e.g. vitamin K, fresh frozen plasma (FFP), cryoprecipitate), platelet and red cell transfusions ◆ Preoperative pulmonary evaluation and teaching (chest physiotherapy) ◆ Vaccination (e.g. pneumococcus, haemophilus influenzae type B, meningococcus) (at least 290 weeks prior) SPLENECTOMY Postoperative nursing care ◼ General postoperative nursing care ◼ Prevention of respiratory complications ◆ Hypoventilation and limited diaphragmatic movement ◆ Atelectasis ◆ Pneumonia ◆ Left pleural effusion ◼ Monitor for hemorrhage ◼ Pharmacologic deep vein thrombosis prophylaxis 91 SPLENECTOMY Postoperative nursing care ◼ Administer analgesics and observe for adverse effects ◼ Monitor for fever ◆ Mild and transient fever is expected ◆ Persistent fever may indicate subphrenic abscess or hematoma ◼ Monitor daily platelet count ◆ Thrombocytosis (elevation of platelet count) may appear a few days after splenectomy and may persist during first 2 weeks 92 SPLENECTOMY Potential complications ◼ Pancreatitis and fistula formation ◼ Hemorrhage ◼ Atelectasis and pneumonia 93 SPLENECTOMY Possible nursing diagnoses ◼ Ineffective breathing pattern ◼ Risk for deficient fluid volume ◼ Risk for infection ◼ Acute pain 94 SPLENECTOMY Nursing interventions ◼ Maintain effective breathing ◆Assess breath sounds and report absent, diminished, or adventitious sounds ◆Assist with aggressive chest physiotherapy and incentive spirometry ◆Encourage early and progressive mobilization 95 SPLENECTOMY Nursing interventions ◼ Monitor for hemorrhage ◆Monitor vital signs frequently ◆Measure abdominal girth and report abdominal distention ◆Assess for pain and report increasing pain ◆Prepare patient for surgical re-exploration if bleeding is suspected 96 SPLENECTOMY Nursing interventions ◼ Avoid thromboembolic complications ◆ Monitor platelet count daily and report abnormal result promptly ◆ Administer deep vein thrombosis prophylaxis ◆ Assess for possible thromboembolism ◆ Assess skin color, temperature, and pulses ◆ Advise patient to report chest pain, shortness of breath, pain, or weakness ◆ Report signs of thromboembolism immediately 97 SPLENECTOMY Nursing interventions ◼ Prevent infection ◆Assess wound condition, use aseptic technique for dressing, teach patient to report signs of infections, plan for postsplenectomy immunizations, and use prophylactic antibiotics ◼ Relieve pain ◆Administer analgesics and observe for adverse effects ◆Use non-pharmacologic methods 98 REFERENCES All figures without citation are subjected copy right terms with commercial and other licenses  Hinkle, J. L., Cheever, K. H. & Overbaugh, K.J. (2022). Brunner & Suddarth’s textbook of medical-surgical nursing (15th ed.). Lippincott Williams & Wilkins. 99