Hematology - PDF

Hospice and palliative care Palliative care starting to impliment earlier patient doesn't have to be dying to receive palliative care Hospice care they usually have 6 months or less left to live, sometimes they live longer than that and are still approved for this care It can be provided in a hos...

Hospice and palliative care Palliative care starting to impliment earlier patient doesn't have to be dying to receive palliative care Hospice care they usually have 6 months or less left to live, sometimes they live longer than that and are still approved for this care It can be provided in a hospital, at a care center, or at home with hospice it usually means that they aren't going to be cured or pursuing that cure. We can still treat --pain, bronchodilators to help with breathing it just means they are not pursuing that cure. Can be on a morphine drip and we increase for pain level, if respiration can be affected, we don't worry so much about it more about comfort (end of life care) and pain control. We will do a pain aid scale watching for grimacing or moaning Spiritual care, bereavement care for loved ones, S/S of a person\'s body that they are nearing the end of their life they will have less interest in food, drowsier, trouble swallowing, confusion, turn in position speak in a calm quiet voice, liquid form of med or crush pills, if they have trouble swallowing don\'t try to make them eat so they don't aspirate, more sleepy, anxiety, restlessness, mottled skin, mouth dry\'s out, secretions in the back of the throat (Death rattle) heart rate can become fast at first then slow , keep patient warm, circulation decreases they become cold, vision becomes blurry, they see relatives that have passed over, important to use therapeutic communication, hearing is last to go always talk to them, pillows, raise head of the bed, urine starts to decrease and become darker, incontinent of urine and stool Chemo used to treat systemic disease, and used to treat solid tumors and the size, use to shrink tumor before surgery patient would rest for a few weeks then go for surgery, sometimes it is used for after surgery get rid of any malignant cells, can be combined with radiation and surgery, goals can be different for each patient- to cure, control, palliative to reduce S/S, 100% eradication is impossible, before giving it there is a pre chemo checklist that things are within normal limits to give the chemo-VS, making sure there is no temp, blood counts, WBC are low we would hold the chemo it will destroy their CBC even further we would have to hold the chemo and give filgastram or nucogin to get their counts up first and give them time to recover before starting chemo. They have myelosuppression --effects the bone marrow, anemia, neutropenia and thrombocytopenia. regimens and cycle are individualized to each patient. Filgastram will be given 24 hours after chemotherapy Precautions- double gloving and flushing twice, during the time they are getting chemo and 48 hours after, repeated cycles of chemo are needed to destroy cancer, is giving mostly IV, there is oral chemo, intrathecal (through the spine) Radiation has more of a localized effect, chemo has more of a systemic effect it targets rapidly dividing cells, lining of mucus membranes, side effects are due to the destruction of the cells, in the bone marrow there are RBC chemo can make them anemic; WBC are going to be neutropenic more at risk for infection, effect platelets at risk for thrombocytopenia -bleeding risk, N/V diarrhea 24- 48 hours after administration can be delayed up to 1 week, chemo can trigger vomiting can give premedication\'s such as Zofran or lorazepam 1mg , 30 mins before, give small frequent bland meals Alopecia loss of hair- cryotherapy cap to avoid hair loss Mucositis-travels down large intestine, small intestine can even travel to the vagina can be very painful and stomatitis in the mouth Can cause neuropathy, decreased cognitive function, fever, fatigue and Malaise Administration of chemo -- chemo gloves or double gloves, pharmacy makes up the chemotherapy and the prime the line with saline, so we don't have too. When done dispose in a hazardous waste receptacle no other garbage goes in there, they are not cheap Dosage based on the patient\'s total body weight or total body surface area, based on previous response to radiation or chemo, and or organs, we could look at BUN and creatinine, sometime the chemo affects the cardiac so we may look at ejection fraction (depends on the chemo at what we look at) we will look at that with pre chemo checklist If there was an issue last time with the chemo they may reduce the amount given Chemo dosage used to maximize cell death and minimize damage to healthy tissue Extravasation -- leakage of a vesicant some chemo agents are vesicants, can cause necrosis, slothing of the tissue erosion, constantly monitoring IV site, COUNTINUOUSLY monitoring IV, if pain redness or swelling STOP the infusion, pull back on it and discontinue the IV and administer an antidote Hypersensitivity type 1 reaction if it happens will happen in the first 15 mins, premedicate for this to prevent from happening we could give prednisone, Benadryl, Pepcid, Zofran. There are certain ones that will give a certain kind of reaction they could have rash-ericardia, dyspnea, cardiac instability. Sometimes it isn't the first time you give it but the second, we\'ll have standing meds in case that happens. Chemo can be given impatient, outpatient, or at home --orally IV intrathecal, will depend on the agent the dose and the location and extent of the disease Worry about colony stimulating factors- Procrit, epiogen It can cause anorexia, alopecia, gi issues, N/V, avoid pregnancy What does the patient know? Legal issues there are DNR orders, which must be taken care of before it gets to that point. Have this conversation as early as admission. heart stops we don't do CPR Advanced directives -- living will- directions of what you would like health care wise, health care proxy- someone that makes choices for you only if you cannot, durable power of attorney- financial or can be health related, it is important that that is respected despite what the family wants End of life care Palliative- comfort care, get meds, could be on oxygen, Goal is comfort and pain control, supportive care, stress the quality of life, dignified death Hospice care 6 months or left to live, or a cureless illness, developmental stage, for terminally ill patient and families can be provided in the home and in the hospital, or hospice center Principles of hospice death must be accepted, total care is best managed by disciplinary team, bereavement care must be provided to the family Reflect on your own values concerning death and illness if you\'re not comfortable you\'re not going to want to have that conversation, other resources- case managers, other staff Deliver and interpret info- state the facts Best time for patient to talk may be the least convenient to you, not most optimal time to talk but stop whatever you are doing and listen, do whatever is needed to help the patient feel calm- music could be one Want to be fully present during communication, sometimes they aren't ready to have those convos must respect that Resist the impulse to fill empty space sometimes being quiet is beneficial for someone who is crying, allow time to reflect and respond, avoid distraction and impulse to give advice, ask questions --open ended questions, clarifications, keep cultural sensitivity on mind Kubler\'s ross stages of dying -- acceptance, anger, denial, depression, bargaining --can happen in any order Signs of death -- urinary output decrease, weak, confusion, restlessness, impaired vision and hearing last thing to go, death rattle, chans stokes breathing, decrease temp control ad mottled skin Encourage family to speak to the patient Hematology System consists of blood and where its produce-where hematopoiesis occurs blood cell formation happens, bone marrow is found in the pelvis the ribs, the vertebrae, the sternum Consists of red marrow separated by yellow marrow which is a fat If there is disease of the marrow the liver or spleen can take over blood cell production- extra medullary hematopoiesis Reticula endothelial system known as the mono nuclear phagocyte system consists of specialized macrophages monocytes that are release form the marrow, and they spend 24 hours in circulation than enter the bodies tissues --help defend against foreign Blood is composed of plasma, proteins, electrolytes, nutrients, waste products and nutrients. There are cellular components the erythrocytes RBCs, WBC are neutrophils, thrombocytes are your platelets. Blood plasma is the fluid portion of the blood, proteins in blood consist of albumin, globulin, fibrinogen and there is about 5-6 liters of blood din the body Stem cells are in the bone marrow they divide and produce specific stem cells, myeloid stem cell and lymphatic that are you B/T lymphocytes Myeloid stem cells develop into erythroblast, Cary oblast, myeloblast, Mono blast they differentiate into different things like erythrocytes, thrombocytes, through different types of WBC Stem cell transplants can turn into different types of cells to help with deficiencies, stem cells are immature cells, and they can turn into myeloid cells and lymphoid cells The stroma is the tissue of the marrow and that is yellow marrow that is not involved in hematopoiesis, it also has fibroblast, osteoblast, osteoclast and endo cells, it does produce the colony stimulating factors needed for blood production it\'s within the bone marrow (nucogen can cause bone pain) Erythrocytes- RBC biconcave flexible thin membrane allowing for gas to diffuse across, has a large surface area that helps with absorption and oxygen molecules, job is to transport oxygen between the lungs and tissues, life span is 120 days Hemoglobin is a mature erythrocyte that contains iron, the o2 binds with hemoglobin in the lungs then goes through arteriole circulation, oxygen gives the blood the bright red color, when the o2 disassociates from the hemoglobin and the tissue that\'s where it becomes darker Reticulocyte is an immature RBC, it only is released if there is bleeding or in some disease state For normal erythrocyte production the body needs iron, b12, b6, folate, protein, RBC average id 120 days and is removed by the liver and spleen Differentiation of the primitive stem cell into erythroblast is stimulated by erythropoietin (produced by the kidney) if a patient has kidney disease, they also have anemia Iron is important, B12 is absorbed in the small intestine with the help of the intrinsic factor WBC normal 4,5-11,1 helps to protect against infection and tissue injury, divide into granulocytes --ecenophils, basil Fils, neutrophils and band cells and agranulocytes mono cytes and lymphocytes --T/B/natural killer cells Granulocytes have granules in the cytoplasm, major function is phagocytosis, acinophils with hypersensitivity reactions are phagocytes of parasites, basil Fils produce and store histamine, neutrophils usually are first to arrive to the site of infection and then are short lived, band cells immature cells that have an elongated nucleus-increased number indicated an infection and is called a left shift can happen if the pt has an infection Agranulocytes- mom cytes are largest leukocyte, produced by the bone marrow produced in the tissue to remove Debrie Lymphocytes major components of immune system, T kills foreign cells, responsible for delayed allergic reaction, can destroy tumor cells, can reject foreign material B can develop into plasma cells and produce antibodies can help identify foreign bacteria Natural killer cells are potent killers of virus\'s in cancer cells they secrete chemical messengers and call on B/T lymphocytes Platelets when injury occurs platelets collect at the site and are activated, adhere to the site of injury and activated to form a clot to stop the bleeding, life span 7-10days and are involved on hemostasis, platelets are the bases for coagulation, hemostasis is the process of preventing blood loss from impact vessels and stopping bleeding from severed vessels Primary hemostasis is where the severed blood vessel constricts circulating platelets arrive in site to form an unstable plug these platelets release factors to attract other platelets to the site to form the plug Secondary hemostasis one of two clotting pathways are initiated-intrinsic or extrinsic either pathway will activate clotting factors a series of events will happen prothrombin to thrombin, fibrinogen to convert to fibrin, fibrin helps to anchor and reinforce that blood Recording 8- 24:38