Hematologic Disorders: Assessment and Management PDF

Hematologic Disorders: Assessment and Hematologic Disorders Management of Patients with Hematologic ANEMIAS Disorders  Normal than norm...

Hematologic Disorders: Assessment and Hematologic Disorders Management of Patients with Hematologic ANEMIAS Disorders  Normal than normal hemoglobin and fewer than normal circulating erythrocytes are signs of an HEMATOLOGIC SYSTEMS underlying disorder  Subsequently, less oxygen reaches the tissues, causing  The blood and the blood forming sites, including the a variety of signs and symptoms bone marrow and the reticuloendothelial system (RES)  It is the most common of all hematologic conditions  Blood – specialized organ that differs from other organs and is prevalent throughout the world in that it exists in a fluid state o Plasma (55%) – fluid portion, contains various CLASSIFICATIONS proteins, such as albumin, globulin, fibrinogen, and other factors necessary for clotting, as  HYPOPROLIFERATIVE ANEMIA – defect in production of well as electrolytes, waste products and RBCs nutrients o Due to iron (microcytic) o Blood cells (45%) o Vitamin B or folate deficiency (megaloblastic  Erythrocyte – red blood cells – characterized by Abnormally large,  Leukocyte – white blood cells nucleated RBCs) (Neutrophil, Monocyte, Eosinophil, o Decreased erythropoietin production (e.g., Basophil, Lymphocyte, lymphocyte from chronic kidney disease) and B lymphocyte) o Cancer/inflammation  Hematopoiesis – ability of body to produce blood cells  HEMOLYTIC ANEMIA – excess destruction of RBCs o Bone marrow – the site of hematopoiesis, r o Due to altered erythropoiesis (sickle cell blood cell formation disease, thalassemia, other o Spleen – is known as the RBC graveyard. RBCs hemoglobinopathies) are destroyed in the spleen o Hypersplenism (hemolysis) o Drug-induced (eg.Chloramphenicol can FUNCTIONS OF BLOOD destroy RBCs) o Autoimmune processes,  Carries oxygen absorbed from the lungs and nutrients o Mechanical heart valves absorbed from the GI tract to the body cells for cellular  May also be due to blood loss – resulting in RBC loss metabolism o Bleeding from gastrointestinal tract, epistaxis  Carries hormones, antibodies, and other substances to (nosebleed), trauma, bleeding from their sites of action or use genitourinary tract (e.g., menorrhagia)  Carries waste product produced by cellular metabolism to the lungs, skin, liver, and kidneys where MANIFESTATIONS they are transformed and eliminated from the body  Depend upon the rapidity of the development of the HEMOSTASIS anemia, duration of the anemia, metabolic requirements of the patient, concurrent problems, and  Balance between blood formation and clotting contaminant features formation  Fatigue, weakness, and malaise o Process of preventing blood loss from intact  Pallor (skin and mucous membranes = conjunctivae, vessels and of stopping bleeding from a oral mucosa) and jaundice severed vessel, which requires adequate  Cardiac and respiratory symptoms numbers of functional platelets  Tongue changes - may be sore and beefy red in  When the endothelial surface of a blood vessel is megaloblastic anemia, and smooth and red with iron injured, several processes occur deficiency anemia o Primary hemostasis – platelets within the  Nail changes - Koilonychia, also known as spoon nails circulation are attracted to the exposed layer  Angular cheilitis - inflammation and fissures in the of collagen at the site of injury, they adhere to corners of the mouth the site of injury, releasing factors stimulate  Pica other platelets to aggregate at the site, forming an unstable platelet plug MEDICAL MANAGEMENT o Secondary hemostasis – based on the type of stimulus, one two clotting pathways is initiated  Correct or control the cause (the intrinsic or extrinsic pathway) and the  Provide transfusion of packed RBCs (NV: 14-16 males; clotting factors within that pathway are >12 females) activated. The end result from either pathway o Secure consent for BT, and recheck that it is the conversion of prothrombin to thrombin crossmatched o Thrombin – necessary for fibrinogen to the o Check for the blood type before giving blood converted into fibrin, the stabilizing protein  Treatment is specific to the type of anemia that anchors the fragile platelet plus to the site o Dietary therapy of injury to prevent further bleeding and o Iron or vitamin supplementation: iron folate, permit the injured vessel or site to heal vitamin B12  If some effects are present: anti- allergy and paracetamol o BMT (Blood Marrow Transplant) or PBSCT (Peripheral Blood Stem Cell Transplant) 1 ʚїɞ  o Immunosuppressive therapy – treatment that  Manifestations: fever and infection, weakness and lowers the activity of the body’s immune fatigue, bleeding tendencies, pain from enlarged liver system or spleen, hyperplasia of gums, and bone pain o Others  Treatment is aggressive chemotherapy, induction therapy, BMT (bone marrow transplant), and PBSCT NURSING PROCESS (peripheral blood stem cell transplant) ASSESSMENT CHRONIC MYELOID LEUKEMIA (CML)  Health history and physical exam  Mutation in myeloid stem cells with uncontrolled  Laboratory data proliferation of cells: Philadelphia chromosome (forms  Presence of symptoms and impact of those symptoms when chromosome 9 and chromosome 22 break and on the patient’s life: fatigue, weakness, malaise, pain exchange parts)  Nutritional assessment  Stages: chronic phase, transformational phase, blast  Medications crisis  Cardia and GI assessments  Uncommon in people under 20; incidence increase  Blood loss: menses and potential GI loss with age; mean age is 55 to 60 years  Neurologic assessment  Life expectancy is 3-5 years  Manifestations (initially may be asymptomatic): DIAGNOSIS malaise, anorexia, weight loss, confusion, or shortness of breath due to leukostasis (characterized by an  Fatigue extremely elevated blast cell count and symptoms of  Altered nutrition decreased tissue perfusion), enlarged, tender spleen,  Altered tissue perfusion enlarged liver  Noncompliance with prescribed therapy  Treatment: Imatinib Mesylase [works by slowing or COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS stopping the growth] (Gleeve) blocks signals in leukemic cells that express BCR-ABL protein,  Heart failure chemotherapy, BMT and PBSCT  Angina  Paresthesia – absence of feeling ACUTE LYMPHOCYTIC LEUKEMIA (ALL)  Confusion  Uncontrolled proliferation of immature cells from PLANNING lymphoid stem cell  Common in young children, boys more other than girls Major goals include:  Prognosis is good for children: 80% event free after 5 years, but survival drops with increased age  Decreased fatigue  Manifestations: leukemic cell infiltration is more  Attainment or maintenance of adequate nutrition common with this leukemia with symptoms of  Maintenance of adequate tissue perfusion meningeal involvement and liver, spleen and bone  Compliance with prescribed therapy - ferrous sulfate marrow pain (black poop / teeth staining)  Treatment: chemotherapy, imatinib mesylase (if  Absence of complications Philadelphia chromosome positive), BMT, or PBSCT, and monoclonal antibody therapy INTERVENTIONS o Brudzinski’s sign – reflexive flexion of the knees and hips following passive neck flexion  Balance physical activity, exercise, and rest  Maintain adequate nutrition CHRONIC LYMPHOCYTIC LEUKEMIA (CLL)  Provide patient education to promote compliance with medications and nutrition  Malignant B lymphocytes, most which are mature, may  Monitor vital signs and pulse oximetry and provide escape apoptosis (type of cell death in which a series supplemental oxygen as needed of molecular steps in a cell to its death), resulting in  Monitor for potential complications excessive accumulation of cells  Most common form of leukemia LEUKEMIA  More common in older adults and affects men more often  Hematopoietic malignancy with unregulated  Survival varies from 2-14 years depending upon stage proliferation of leukocytes  Manifestation: lymphadenopathy, hepatomegaly,  AML and CML - cancer of bone marrow; ALL and CLL - splenomegaly cancer of lymph nodes o In later stages: anemia and  Types thrombocytopenia – autoimmune o Acute myeloid leukemia complications with antibodies destroying o Chronic myeloid leukemia RBCs and platelets may occur; symptoms o Acute lymphocytic leukemia include fever, sweats, and weight loss o Chronic lymphocytic leukemia  Treatment: early stage may require no treatment, ACUTE MYELOID LEUKEMIA (AML) chemotherapy, or monoclonal antibody therapy  Defect in the stem cells that differentiate into all NURSING PROCESS myeloid cells, monocytes, granulocytes, erythrocytes, ASSESSMENT and platelets  Most common non-lymphocytic leukemia  Health history  Affects all ages with peak incidence at age 60  Assess for symptoms of leukemia and complications of  Prognosis variable anemia, infection and bleeding 2 ʚїɞ  o Weakness and fatigue  Prescribed solution – used betadine o Pallor, SOB, possible edema gargle  Laboratory tests o Perineal and rectal care o Leukocyte count, ANC (measures the number  Applicable during sexual intercourse of neutrophil), hematocrit, platelets, electrolytes, and culture reports IMPROVING NUTRITION DIAGNOSIS  Provide oral care before and after care  Administer analgesic before meal for faster absorption  Risk for bleeding – low platelet  Provide appropriate treatment of nausea  Risk for impaired skin integrity – presence of bruise  Provide small, frequent feeding with soft foods that are  Impaired gas exchange – supply of RBC = lack of moderate in temperature oxygen in the blood  Provide a low-microbial diet (unprocessed food)  Impaired mucous membrane o Fresh milk is better than milkshake (processed  Imbalance nutrition – chemotherapy causes nausea and with preservatives) and vomiting  Provide nutritional supplement  Acute pain o Because of decreased immune system  Hyperthermia  Fatigue and activity intolerance – low supply of RBC = LYMPHOMA lack of oxygen in the blood  Impaired physical mobility – low supply of RBC = lack of  Neoplasm of lymph origin oxygen in the blood o Beginning of cancer  Risk for excess fluid volume  Hodgkin’s lymphoma  Diarrhea  Non-Hodgkin’s lymphoma  Risk of deficient fluid volume – chemotherapy causes HODGKIN’S DISEASE nausea and vomiting  Self-care deficit – presence of bruise  Unicentric of origin  Anxiety – presence of bruise o Single center of origin  Disturbed body image – presence of bruise  Reed-Sternberg cell  Potential for spiritual distress o Large, abnormal lymphocytes that may  Grieving diagnoses contain more than one nucleus  Deficient knowledge  Excellent cure rate  Suspected viral etiology: familial pattern, incidence COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS occurs in early 20s and again after age of 50  Infection – low WBC count  Excellent are rate with treatment  Bleeding – low platelet count  Manifestation: painless lymph nodes enlargement,  Renal dysfunction pruritus, and symptoms such as fever, sweats and  Tumor lysis syndrome (cancer cells) weight loss  Nutritional depletion  Treatment is determined by stage of the disease and  Mucositis – inflammation of the mouth : easy to bleed may include chemotherapy and/or radiation therapy o Instruct the patient to not brush too much or  Cancer of the immune system that develop new/ brush once a day abnormal B cells (WBC that provide antibodies)  Depression NONHODGKIN’S DISEASE PLANNING: GOALS  Lymphoid tissues become infiltrated with malignant cell  Absence of complications – be compassionate to all that spread unpredictably, localized disease is rare CA patients o Problems with lymphoid tissues, invade by  Attainment and maintenance of adequate nutrition malignant cells  Activity tolerance – they are not allowed to be tired,  Incidence increases with age: the average age of but are advised to move around, suggest activities with onset is 50-60 less oxygen demand  Prognosis varies with the type  Ability for self-care and to cope with the diagnosis and  Treatment is determined by type and stage of disease prognosis – suggest counseling and may include immunotherapy, chemotherapy  Positive body image – counseling as well “everything and/or radiation therapy happens for a reason” MULTIPLE MYELOMA  An understanding of the disease process and its treatment  Malignant disease of plasma cells in the bone marrow with destruction of bone ; cancer of the bone marrow = INTERVENTIONS brittle bones  Interventions related to risk of infection and bleeding  M protein and Bence-Jones protein  Mucositis  Median survival is 3-5 years, there is no cure o Frequent, gentle oral hygiene  Treatment may include chemotherapy, corticosteroids, o Soft toothbrush or if counts are low, sponge- radiation therapy, and bisphosphonates tipped applications  Manifestations: bone pain, osteoporosis, fractures,  If hard toothbrush is only available, elevated serum protein, hypocalcemia, renal damage, soak the brush in hot water renal failure, symptoms of anemia, fatigue, weakness, o Rinse only with normal saline, NS, and baking increased serum viscosity, and increased risk for soda, or prescribed solution bleeding and infection 3 ʚїɞ  BLEEDING DISORDERS  Maintenance of tissue perfusion – pressure injury: turn the patient side to side  Primary thrombocythemia  Enhance coping o A disease in which your bone marrow makes  Absence of complication too many platelets  Thrombocytopenia INTERVENTION o Very low platelet level  Idiopathic thrombocytopenia purpura (ITP)  Assessment and intervention should target potential o Antibodies attacks the platelet sites of organ damage o Purpura = purple color of bruise  Monitor and assess carefully  Hemophilia – excessive bleeding even for small cuts  Avoid trauma and procedures that increase the risk of o Rare, genetic blood disorder that happens bleeding, including activities that increase intracranial when the blood doesn’t clot and make the pressure bleeding slow or stop o Limit sneezing and coughing by reducing the o Risk for shock allergens  Acquired coagulation disorders – liver disease, anticoagulants, and vitamin K deficiency THERAPIES FOR BLOOD DISORDERS  Disseminated intravascular coagulation (DIC) BLOOD TRANSFUSION ADMINISTRATION  Bleeding precautions  Procedure to identify patient and blood product DISSEMINATED INTRAVASCULAR COAGULATION (DIC)  Monitoring of patient and VS  Not a disease but a sign of an underlying disorder  Post procedure care  Severity is variable, may be life-threatening  Nursing management of adverse reactions  Triggers: sepsis, trauma, shock, cancer, abruptio o Review patient history including history of placentae, toxins, and allergic reactions transfusions and transfusion reactions; note  Altered hemostasis mechanism causes massive clotting concurrent health problems and obtain in microcirculation: as clotting factors are consumed baseline assessment and vital signs (q15 1st and increase bleeding occurs. Symptoms are related to hour / q30 2nd hour / q1 3rd and 4th hour); tissue ischemia and bleeding the first 15 minutes is crucial  Laboratory tests o Perform patient teaching and obtain consent;  Treatment: treat underlying cause, correct tissue recheck serial number with medtech, then ischemia, replace fluids and electrolytes, maintain again with doctor blood pressure, replace coagulation factors and use o 20-25 minutes of obtaining blood from blood heparin bank, it must be hook; bag cannot be broken in any way NURSING PROCESS  250 mL of blood is administered for 4- 6 hours only, not after because it will ASSESSMENT spoil; it can be placed in an ice chest  Be aware of patients who are at risk for DIC and assess o Equipment IV (20 gauge or greater PRBCS) for signs and symptoms of the condition appropriate tubing and NS solution (NS -  Assess for signs and symptoms and progression of green) thombi and bleeding  18 gauge doesn’t last for 4 bags because of clotting and phlebitis DIAGNOSIS  Blood warmer - tube 37°C for blood too cold because it clots;  Risk for fluid volume deficiency o Always assess patient for fever or any  Risk for impaired skin integrity complications; If complications occur STOP  Risk for imbalanced fluid volume and wait a minute. Remove blood transfusion  Ineffective tissue perfusion – decreased oxygen supply tube, connect PNSS patayin MedTech and to the tissue create an incident report  Death anxiety COMPLICATIONS COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS  Febrile nonhemolytic reaction  Renal failure  Acute hemolytic reaction  Gangrene – decreased oxygen supply for healing  Allergic reaction  Pulmonary embolism or hemorrhage  Circulatory overload - first and most avoided  Acute respiratory distress syndrome o Happens when blood is fast dripped  Stroke  Transfusion-related acute lung injury o Microthrombi formation = small vessels that  Bacterial contamination - change BT set per transfusion pop form small clots, collect and becomes a bag (usually 4 bags) bigger clot, travels and causes  Delayed hemolytic reaction thromboembolism (May occlude blood flow  Disease acquisition - prone to HIV causing O2 reduction)  Complications of long-term transfusion therapy PLANING: MAJOR GOALS Viral and Bacterial: Ear Infections  Maintenance of hemodynamic status  Maintenance of intact skin and oral mucosa  There are 3 pathways for pathogens to enter the ear  Maintenance of fluid imbalance o Through the eustachian (auditory) tube, from the throat & nasopharynx 4 ʚїɞ  o o From the external ear Via the blood or lymph Rheumatic Disorders  Usually, bacteria are trapped in the middle ear when bacterial infection in the throat ad nasopharynx causes RHEUMATIC DISEASE the eustachian tube to close.  Autoimmune and inflammatory diseases that cause o Accumulation of pus immune system to attack the joints, muscles, bones and o Treatment: augmentin drops organs  The result is an anaerobic condition the middle ear,  Also called arthritis. Rheumatic diseases include more allowing obligate and facultative anaerobes to than 100 different disorders proliferate and cause pressure on the tympanic  They primarily affect the joints, but also muscles, bones, membrane (eardrum) ligament, tendons, and cartilage  Swollen, lymphoid (adenoid) tissues, viral infections, and allergies may also close the eustachian tube, CLASSIFICATIONS especially in young children  Infection of the middle ear is known as otitis media,  MONOARTICULAR (affects one joint OR POLYARTICULAR whereas infection of the outer ear canal is known as (affects many joints at the same time) otitis externa  Inflammatory or non-inflammatory o Can performed ear irrigation RHEUMATOID ARTHRITIS VIRAL AND BACTERIAL EAR INFECTION  A chronic, progressive and disabling autoimmune OTITUS EXTERNA, EXTERNAL OTITIS, EARL CANAL INFECTION, disease SWIMMER’S EAR  Causes inflammation, swelling and pain in and around the joints and can affect other body organs  Infection of the ear with itching, pain, a malodorous  RA usually affects the hands and feet first, but it can discharge, tenderness, redness, swelling, and impaired occur in any joint hearing o Most common during the summer swimming season o Trapped water in external ear canal can lead to wet, softened skin, which is more easily infected by bacteria or fungi  Otitis externa is often referred to as “swimmer’s ear” because it often results from swimming in water contaminated with pseudomonas aeruginosa  Etiologic agent: escheria coli, pseudomonas aeruginosa, proteus vulgaris, staphylococcus aureus rarely by a fungus, such as aspergillus  Reservoirs and mode of transmission: contaminated swimming pod water, sometimes indigenous microflora, article inserted in ear canal for cleaning out debris and wax OTITIS MEDIA, MIDDLE EAR INFECTION NURSING PROCESS  Often develops as a complication of the common cold  Persistent and severe earache, bulging of the eardrum ASSESSMENT (tympanic membrane), nausea, vomiting, diarrhea,  Ask history (especially the diet) and fever in young children  Ask BUA (blood uric acid) test  May lead to rupture of the eardrum, bloody discharge, o Febuxostat 40-80mg/tab, give for 7 days, and then pus from the ear once a day  Reservoirs and mode of transmission: probably not  Can lower the uric acid levels communicable  Patient in pain, if prescribed by the physician  Etiologic agent may be caused by bacteria or viruses o Colchicine 800 mg/tab, give only 4 tablets o Three most common bacterial causes  2 tabs now (note for the time), after  Streptococcus pneumoniae (gram 1 hour take the 3rd tablet, after an positive diplococcus) hour take the 4th tablet  Haemophilus influenzae (gram  Take note that it can affect the negative bacillus kidney  Moraxella catarrhalis (gram negative diplococcus) CLINICAL MANIFESTATION o Less common bacterial causes  Streptococcus pyogenes  Stiff joints  Staphylococcus aureus  Fatigue o Viral causes include  Pain or achiness in more than 1 joint  Measles virus  Swelling in more than one joint  Parainfluenza virus  Symmetrical joint involvement  Respiratory syncytial virus (RSV)  General feeling of being unwell  Low-grade fever  Appetite loss  Weight loss  Weakness 5 ʚїɞ   Joint deformity  Causes pain, weakness and  Limited movement dysfunction  Loss of function and mobility o Muscle atrophy – wasting or thinning of  Unsteadiness when walking muscle mass  Increase bone bacteria can be ADDITIONAL NOTES treated using the medications for TB  Increase infection in bone  Ask the patient what part the pain is specifically  Laboratory test: erythrocyte located sedimentation rate (ESR) test o “Saan po yung pain, saang parte ng kamay o paa partikular na masakit?”  In the assessment, ask patient for trauma, observe the patient; Instruct the patient to dangle legs  Uric acid in the blood is normal, but is a worry when elevated (BUA = 1.6 - 6 mg/dL; NV depends on hospitals) o Ex: 4 mg/dl with reports of joint pain = abnormal (normal if without symptoms or