SN3430 Nursing Therapeutics II Lecture Notes PDF

SN3430 Nursing Therapeutics II Hematopoietic system Blood cells Disorders of red blood cells 6/9/2024 Lily HO Learning objectives Upon the completion of this session, students should be able to: Describe the pro...

SN3430 Nursing Therapeutics II Hematopoietic system Blood cells Disorders of red blood cells 6/9/2024 Lily HO Learning objectives Upon the completion of this session, students should be able to: Describe the process of hematopoiesis, functions of blood cells and growth factors Describe the processes involved in maintaining hemostasis. Differentiate between hypoproliferative and hemolytic anemias, and compare and contrast the physiologic mechanisms, clinical manifestations, diagnostic investigations, medical management, and nursing interventions Discuss the causes, clinical manifestations, diagnostic investigations, medical management, and nursing interventions of polycythaemia Use the nursing process as a framework, discuss the care of patients with anemia and polycythaemia Discuss the indications of diagnostic tests and therapy  Hematopoietic system Blood cells Hematologic system Hematologic system Sites producing Blood blood  Blood (7%-10% of BW, ~5-6L) Plasma Blood cells (55%) (40%-45%) Plasma proteins, WBC Water clotting factors, RBC Platelet other substances (Erythrocyte) (Leukocyte) (Thrombocyte) have granules of enzymes (digest Neutrophil* Basophil* Eosinophil* Monocyte Lymphocyte invading microbes) *Granulocyte Hematopoiesis Complex process of the formation and maturation of blood cells Site: bone marrow In children, most bones contain hematopoietically active marrow In adults, hematopoiesis is confined to axial skeleton, proximal long bones, and skull Hematopoiesis Hematopoiesis & cell differentiation EB, erythroblast MK, megakaryocyte Source: Greer, J. P. et al. (2009). Wintrobe's clinical hematology (12th ed.). Philadelphia: Lippincott Williams & Wilkins. What is erythropoietin? Hormone produced by kidney Blood Decreased O2 delivery Stimulate the differentiation of the primitive myeloid stem cell of Increased the marrow into an erythroblast erythrocyte production Increased Bone erythropoietin marrow production What is thrombopoietin? Hormone is secreted by hepatic parenchymal and endothelial cells bone marrow stromal cells Stimulates production & differentiation of megakaryocytes from myeloid stem cell How to maintain blood in its fluid state? Clot (thrombus) Clot (thrombus) dissolution or formation fibrinolysis  Endothelial Tissue injury Hemostasis membrane injury Intrinsic Extrinsic pathway pathway Hemostasis Activates factors Secondary Prothrombin Primary (Plt) (coagulation factors) Thrombin Fibrinogen Blood vessel constricts → platelets aggregate → form Fibrin (clot) anchors platelet plug to unstable hemostatic plug site of injury Disorders of red blood cells Anaemia Classification of anaemias Underlying disorder? Types Hypoproliferative Hemolytic anemia Bleeding (loss of RBCs) anemia (↓ (↑ destruction of production of RBCs) RBCs) Hypoproliferative anaemias Iron deficiency anemia Vitamin B12 deficiency (megaloblastic) Folate deficiency (megaloblastic) ↓ erythropoietin production (e.g. in renal disease) Cancer /inflammation Hemolytic anemias exposed to low oxygen tension → sickle-shaped Altered erythropoiesis rigid RBCs can adhere to endothelium of small vessels → ↓blood flow to a region Hypersplenism Drug-induced Examples: Autoimmune anaemia Sickle cell anemia (Abnormal hemoglobin, inherited) Mechanical heart valve-related Thalassemia (Abnormal hemoglobin, inherited) Glucose-6-phosphate dehydrogenase deficiency (Enzyme deficiencies, inherited) Autoimmune hemolytic anemia (Antibody-related, acquired) Thalassemia Hereditary disorders associated with 2 major groups defective hemoglobin-chain synthesis Prevalent in the Mediterranean Alpha-thalassemia (α-thal) countries, the Middle East and Asia Beta-thalassemia (β-thal) Characteristics Classification based on severity Hypochromia (↓in hemoglobin Thalassemia minor (8.5% content of RBCs) in HK) Extreme microcytosis (smaller- than-normal RBCs) Thalassemia intermedia Destruction of blood elements Thalassemia major (hemolysis) (Cooley’s anemia) Variable degrees of anemia https://www.famplan.org.hk/en/health-info/pregnancy-and-fertility/thalassemia Glucose-6-phosphate Dehydrogenase Deficiency Glucose-6-Phosphate Dehydrogenase: Enzyme which protects RBCs from being damaged 4-5/100 male newborns 3-5/1,000 female newborns Severe infection / exposed to oxidant stress (certain drugs / chemicals) → massive damage of RBCs → acute hemolysis https://www.dh.gov.hk/english/main/main_cgs/files/DH2289E%20G6PD%20English.pdf Immune Hemolytic Anemia Alloimmune hemolytic anemia Hemolytic transfusion reaction Exposure of the RBC to antibodies → Alloantibodies cause immediate destruction of RBCs Autoimmune hemolytic anemias Falsely recognizes own RBCs as foreign & produces antibodies against them Warm-body antibodies vs Cold-body antibodies active at warm temperatures, active at cold temperatures e.g. body temperature Clinical manifestations Iron deficiency anaemia Smooth, sore tongue Fatigue, tiredness, general Brittle & ridged nails malaise Ulceration of corner of mouth Vit B12 deficiency Dyspnea Neurologic manifestations Dizziness Pernicious anemia Tachycardia, palpitations Smooth, sore, red tongue Pale skin Angular cheilitis: scaling of the surface of lips and fissures in the corner of the mouth Jaundice Mild diarrhea Chest pain Extremely pale (esp in the mucous membrane) Weakness Confused Paresthesias (e.g. numbness) Difficulty maintaining balance No symptoms (in chronic) Losing position sense Common investigations CBC (hemoglobin, hematocrit, mean corpuscular volume) Reticulocyte count Iron profile (serum iron level, total iron-binding capacity [TIBC], ferritin) Serum vitamin B12 and folate Bone marrow aspiration and biopsy Source of any blood loss e.g. GIB? Coombs test (direct antiglobulin test): detects antibodies on the surface of RBCs Test Description WBC: White blood cell Total WBC count RBC: Red blood cell Carries hemoglobin HGB: Hemoglobin Delivers O2 through circulation to body tissues and returns CO2 from tissues to lungs HCT: Hematocrit Indicates relative proportions of plasma and RBCs (volume of RBCs/L whole blood) MCV: Mean corpuscular volume Indicates size of RBCs; for differentiating types of anemia ↓:microcytic; ↑: macrocytic MCH: Mean corpuscular hemoglobin MCH=(Hb/RBC) × 10 MCHC: Mean corpuscular hemoglobin Average concentration of Hgb in RBCs concentration RDW: red cell distribution width Measures degree of variation in size of RBCs PLT: Platelet Total number of platelets in circulation MPV: Mean platelet volume Average size of platelets Neutrophils Phagocytosis of bacteria Lymphocytes Integral component of immune system Monocytes Enter tissue as macrophages; phagocytosis of fungus Eosinophils Involved in hypersensitivity reactions (neutralizes histamine); phagocytosis of parasites Basophils Contain histamine; involved in hypersensitivity reactions Management Medications Iron e.g Ferrous Sulphate, Monofer Vitamin B12 e.g. Cyanocobalamin, Mecobalamin Folic acid Erythropoiesis-stimulating agents e.g. Darbepoetin Alfa, Erythropoietin, Methoxy polyethylene glycol-epoetin beta (S/E: ↑BP) Corticosteroids (decrease macrophage’s ability to clear antibody-coated RBCs in immune hemolytic anemia) Immunosuppressive agents e.g. cyclophosphamide (Cytoxan), azathioprine (Imuran) (immune hemolytic anemia) Management Blood transfusion (+ Regular chelation therapy) Treat underlying problem or disease Drug therapy e.g. steroids / immunoglobulins for immune problem Surgery and/or chemotherapy for cancer Treat bleeding problem Splenectomy (immune hemolytic anemia) Bone marrow transplant / hemopoietic stem cell transplantation (HSCT) https://www3.ha.org.hk/hkwc/transplantservice/HSCT-Adult.html Nursing assessment Health history (e.g. extent and symptoms, family history) Physical examination (e.g. tongue, skin, mucous membranes) Nutritional assessment (e.g. iron, alcohol) Cardiac assessment (e.g. tachycardia, palpitations, dyspnea) Gastrointestinal assessment (e.g. coffee ground vomiting, melena) Neurologic examination (e.g. poor coordination, confusion) Excessive menstrual flow in females What are the common problems in patients with anaemia? Activity intolerance related to weakness, fatigue, and general malaise Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients Ineffective tissue perfusion related to inadequate blood volume or hematocrit Noncompliance with prescribed therapy Nursing interventions Managing fatigue Prioritize activities Establish a balance between activity & rest Maintain some physical activity and exercise (to prevent deconditioning caused by inactivity) Maintaining safety Fall prevention (gait, stability, position sense, coordination) Injury (sensation esp excessive heat & cold) Nursing interventions Maintaining adequate nutrition Iron: meat, fish, seafood, dark green vegetables, dried beans, nuts Folate: green leafy vegetables, beans etc Vitamin B12: meat, fish, egg, milk Vitamin C: kiwifruit, orange Bland, soft food for patients with mouth & tongue soreness Source: https://www.fhs.gov.hk/english/health_info/woman/30069.html Nursing interventions Maintaining adequate perfusion Promoting compliance with IVF / blood transfusions (based prescribed therapy on symptoms and laboratory Developing ways to incorporate findings) therapeutic plan e.g. Ferrous Oxygen prn Sulphate Vital sign monitoring Iron is best absorbed on empty stomach (1 hour before or 2 hours Withhold medications e.g. after meal) antihypertensive agents Vitamin B12 injections even no symptoms Nursing interventions (G6PD Deficiency) Educate patients to avoid triggering factors Certain antipyretics Antibiotics e.g. Nitrofurantoin, Nalidixic acid, Sulfamethoxazole Antimalarials e.g. Primaquine Antispasmodics e.g. Phenazopyridine Certain Chinese herbal medicines e.g. Flos Lonicerae (Jin Yin Hua) Broad beans & their products Naphthalene-containing mothballs & products https://www.dh.gov.hk/english/main/main_cgs/files/DH2289E%20G6PD%20English.pdf Disorders of red blood cells Polycythemia Polycythaemia Polycythaemia (↑ volume of RBCs,↑Haematocrit) Primary Secondary (Polycythaemia vera) Secondary polycythemia Management ↓O2 (hypoxic Treat underlying causes stimulus) / neoplasms Therapeutic phlebotomy Excessive production of erythropoietin Primary polycythaemia Proliferative disorder Complications Myeloid stem cells escape Stroke / heart attack (↑ risk normal control mechanism for thromboses) Bone marrow: hypercellular Bleeding (dysfunctional (RBC [predominant], WBC, platelets) platelet ↑) & may become fibrotic Spleen: resume production of blood cells & enlarge Clinical manifestations Ruddy complexion Angina Splenomegaly Claudication ↑blood viscosity Headache Dyspnoea Dizziness Thrombophlebitis Tinnitus Generalized pruritus ↑blood vol Fatigue Paresthesias blurred vision Diagnostic findings ↑RBC mass Enlarged spleen Normal O2 saturation level Management Phlebotomy (removing whole blood from a vein) Avoid iron supplements, multivitamin supplements Chemotherapeutic agents (e.g. hydroxyurea) Nursing interventions Education Signs and symptoms of thrombosis Avoid aspirin and aspirin-containing medications Minimizing alcohol Bathing in tepid or cool water with cocoa butter–based lotions and bath products Bone marrow aspiration & biopsy Bone marrow aspiration and biopsy Aspiration: assess cellular morphology Risks Biopsy: assess structure and cellularity of bone marrow Persistent bleeding, haematoma Infection Aims Assess how blood cells are formed Wound pain Assess quantity & quality of each type of cell produced Allergic reaction to lidocaine within the marrow Document infection or tumor within the marrow Contraindication Indications Severe bleeding disorders Diagnosis of leukaemia & other blood diseases Investigation of unexplained enlargement of lymph nodes, Leaflet spleen or liver, unexplained fever and infection https://www3.ha.org.hk/hkwc/ppi/InfoPam/docs/med/med_23.pdf Evaluation of blood composition, blood elements, precursor cells, and malignant cells Video Evaluation of effects of treatment https://www-jove-com.ezproxy.lb.polyu.edu.hk/v/56386/comprehensive-protocol- to-sample-process-bone-marrow-for-measuring (1:06) Bone marrow aspiration and biopsy Aspiration and biopsy are usually done as a posterior iliac crest single procedure by doctors. Skin over posterior iliac crest is cleaned and anesthetized, then it is punctured. Biopsy requires adequate bone depth, sample is usually taken from posterior iliac crest (or, less commonly, anterior). A bone marrow needle is inserted into the marrow. Aspiration of blood with syringe. Biopsy taken after aspiration with twisting and gentle rocking motion. Source: https://lymphoma-action.org.uk/about-lymphoma-tests-diagnosis-and-staging/bone-marrow-biopsy What are the nursing roles before, during and after bone marrow aspiration and biopsy? Blood & blood component therapy What is blood transfusion? Blood transfusion: infusion of whole blood or a blood component into the patient’s venous circulation Indication Blood transfusion is given when one of the following blood components decrease to a level that compromise a patient’s health Red blood cells Platelets Coagulation factors ABO & Rh blood groups Blood type Red cell antigens Serum antibodies Rh (Rhesus) factor / D antigen A A Anti-B B B Anti-A Positive Negative AB A, B None O None Anti-A, Anti-B Chinese: 1 in 370 Caucasians: 1 in 7 Storage temperature & shelf life Blood Component Indication Storage Shelf Life Temperature Whole Blood Significant bleeding (> 25% blood 2–6oC 28–35 days volume lost) Packed red blood cells Anaemia, massive bleeding 2–6oC 42 days Platelet Concentrates Thrombocytopenia, platelet 20–24oC under 5 days dysfunction continuous agitation Fresh Frozen Plasma Coagulation factor deficiency Below –30oC 365 days (provide coagulation factors) https://www5.ha.org.hk/rcbts/blood-treatment?lang=en Transfusion complications Causes Signs & symptoms Febrile, nonhemolytic reaction Caused by antibodies to donor WBCs Chills, fever (begins within 2 hours after present. commencement of transfusion) Acute hemolytic reaction Incompatible transfusion Fever, chills, low back pain, nausea, chest tightness, dyspnea, anxiety, hemoglobinuria, hypotension, bronchospasm, vascular collapse Allergic reaction Sensitivity reaction to plasma protein Urticaria, itching, flushing Circulatory overload Blood infuses too quickly, Dyspnea, orthopnea, tachycardia, sudden hypervolemia anxiety Bacterial contamination Administration of contaminated Fever, chills, hypotension products Transfusion-related acute lung Antibodies in blood component Fever, chills, acute respiratory distress, bilateral injury stimulate recipient’s WBCs, which pulmonary infiltrates aggregates and occlude the microvasculature within the lungs Delayed hemolytic reaction Antibody has been increased to the Fever, anemia, increased bilirubin level, (within 14 days after transfusion) extent that a reaction can occur decreased or absent haptoglobin, possibly jaundice Diseases transmitted by blood Problems in donor screening and transfusion (HIV, hep B, hep C) blood testing Iron overload Complications of long-term transfusion therapy Acquire more iron →iron toxicity Treatment: Desferrioxamine References Bunn, H., & Aster, J. (2017). Pathophysiology of blood disorders (2nd ed.). New York: McGraw-Hill Medical. Hinkle, J. L., Cheever, K. H., & Overbaugh, K. (2022). Brunner & Suddarth’s textbook of medical-surgical nursing (15th ed.). Philadelphia: Wolters Kluwer. Nettina, S. M. (2019). Lippincott manual of nursing practice (11th ed.). Philadelphia: Wolters Kluwer.