Test for Anemia (2).pdf

R A nurse develops a fever of 102.4 °F (39.1 °C) prior to beginning a scheduled shift. Which priority action is most appropriate? Take acetaminophen to control the fever and other symptoms. Notify the supervisor that they are unable to work today. Show up to the scheduled shift at work. Wear person...

R A nurse develops a fever of 102.4 °F (39.1 °C) prior to beginning a scheduled shift. Which priority action is most appropriate? Take acetaminophen to control the fever and other symptoms. Notify the supervisor that they are unable to work today. Show up to the scheduled shift at work. Wear personal protective equipment (PPE) at work when caring for clients. In reviewing a client’s chart, the nurse notes a hemoglobin of 7 g/dL with a hematocrit of 21%. Which symptoms are consistent with these lab values? Select all that apply. Pale skin color Dyspnea Bradycardia Hypertension Fatigue The nurse notes a client as having erythrocytosis. Which factors may cause this condition? Select all that apply. Chronic smoking Folate deficiency Excess menses Iron deficiency High altitude The nurse is developing a discharge plan for a client with thrombocytopenia. After receiving treatment, when should the nurse schedule a repeat complete blood count (CBC) to verify that the platelet count has returned to normal? 2 weeks 1 month 2 months 4 months The nurse is making room assignments. Which clients are at high risk for hospital-acquired infection and need a single-occupancy room? Select all that apply. A young adult recovering from aplastic anemia An adult with breast cancer taking tamoxifen An adult with human immunodeficiency virus and a low CD-4 count An older adult with hypertension An older adult with rheumatoid arthritis on adalimumab Blood Administration Julie (pronouns: she/her/hers) had a hysterectomy. During the procedure, she lost a significant amount of blood. She is anemic with a hemoglobin level of 7.2 g/dL. The surgeon has ordered two units of packed red blood cells (PRBC) to be given immediately. The nurse starts to administer the PRBCs at 13:00. At 13:10 Julie displays these clinical findings: T 100.2 °F (37.9 °C), chills, headache, is anxious, and reports generalized muscle pain 7 out of 10 on a pain scale. Question 1 / 2 Which reaction is Julie likely experiencing? Acute intravascular hemolytic Febrile non-hemolytic Anaphylactic Mild allergic Blood Administration Julie (pronouns: she/her/hers) had a hysterectomy. During the procedure, she lost a significant amount of blood. She is anemic with a hemoglobin level of 7.2 g/dL. The surgeon has ordered two units of packed red blood cells (PRBC) to be given immediately. The nurse starts to administer the PRBCs at 13:00. At 13:10 Julie displays these clinical findings: T 100.2 °F (37.9 °C), chills, headache, is anxious, and reports generalized muscle pain 7 out of 10 on a pain scale. Question 2 / 2 What is the priority nursing action? Continue the blood at a lower rate. Stop the blood, change the bag to normal saline, and start infusing. Given an antihistamine orally. Stop the blood, change the tubing and bag to normal saline, and start infusing. Case Study: Janet Janet (pronouns: she/her) is a 64-year-old admitted with shortness of breath and fatigue. Her vital signs: T 97.5 °F (36.4 °C), BP 118/77, P 120, R 20, oxygen saturation 88% on room air. Skin is pale, cool, and dry with normal turgor and capillary refill < 3. Lungs clear in all lobes. Heart is regular, rate and rhythm with no murmur. No edema is present. Prioritizing Hypotheses Select the nursing diagnoses for the client with pancytopenia. Select all that apply. Risk for bleeding Fatigue Risk for shock Impaired gas exchange Hyperthermia Risk for infection Impaired tissue integrity Janet (pronouns: she/her) is a 64-year-old admitted with shortness of breath and fatigue. Her vital signs: T 97.5 °F (36.4 °C), BP 118/77, P 120, R 20, oxygen saturation 88% on room air. Skin is pale, cool, and dry with normal turgor and capillary refill < 3. Lungs clear in all lobes. Heart is regular, rate and rhythm with no murmur. No edema is present. Generating Solutions Based on a client with pancytopenia, which prescriptions does the nurse anticipate being ordered for the client? Select all that apply. Type and cross for 2 units packed red blood cells (PRBC) Neutropenic precautions Continuous pulse oximetry monitoring Oxygen Vital signs once per shift What lab does the nurse anticipate being prescribed to evaluate the needs of a client with a hematologic alteration? Complete blood count B-type natriuretic peptide levels Comprehensive metabolic panel Troponin I levels ecognizing Cues: Nursing \ Assessment Which are laboratory markers for anemia? Select all that apply. Red blood cell count Hematocrit Hemoglobin Which nursing diagnosis is the same when comparing anemia to coronary artery disease? Altered tissue perfusion Impaired gas exchange Altered airway clearance Pain The nurse is caring for a client who is hemorrhaging due to being stabbed in the chest with a knife. Which action taken by the nurse is the priority? Administer prescribed ferrous sulfate with vitamin C. Administer prescribed packed red blood cells. Administer prescribed epoetin alpha. Administer prescribed intravenous fluids. Anemia can mimic the signs and symptoms of other serious conditions. Because anemia means less circulating oxygen, any sign of decreased perfusion can be partially or completely exacerbated by the presence of anemia. Treating anemia can include blood transfusions, iron supplementation, folate, vitamin B12 supplementation, or bone marrow stimulation. Generally, it is important to identify a cause in order to properly treat the underlying anemia. In the interim, supportive care can be helpful. This can include oxygen supplementation and volume replacement. Additional lab testing may give more answers as well. For example, there are additional tests to determine thalassemia or sickle cell anemia (both hereditary conditions causing small or deformed red blood cells). Types of Anemia Anemia is defined as the reduced oxygen-carrying capacity of blood. Specifically, the red blood cell count, hemoglobin level, and hematocrit are the three diagnostic tests that identify if someone is anemic. Red blood cells have a 120-day lifespan before they are recycled. Anything affecting that balance (too many are lost or not enough are created) can lead to anemia. Anemia means that on the complete blood count (CBC), the red blood cell (RBC) count, the hemoglobin (Hbg) count, and the hematocrit (HCT%) count are all low. Symptoms, Treatments, and Causes of Anemia Review the common symptoms, treatment, and causes of anemia in this image. When assessing the client, identify signs and symptoms that are cues that indicate the type of anemia. Remember to review medication and family history as some types of anemia can be a side effect of medications while other types can be hereditary. Assessment: Signs • skin color (pale) • skin temperature (cool) Assessment: Symptoms • • • • • fatigue shortness of breath chest discomfort dizziness fast heartbeat Social History • smoking/vaping/e-Cigs • poor dietary intake (anorexia) • vegan (B12 deficiency) Past Medical History • renal disease • trauma • clotting disorders Medications • anti-seizure medications • antipsychotic medications • chemotherapy drugs Prioritizing Hypotheses: Anemia After recognizing and analyzing cues, the following nursing diagnoses could be appropriate for a client with anemia: • Altered perfusion: Less hemoglobin means less oxygen to carry to the targeted tissue. • Impaired gas exchange: Less hemoglobin means less oxygen to collect from the lung and swap with carbon dioxide. • Fatigue: Less oxygen capacity means less energy production through the Kreb's cycle to create ATP within the cells of the body. • Self-neglect: Intentionally or unintentionally not getting enough nutrients, or taking nutrients and then vomiting (i.e., bulimia) . • Imbalanced nutrition: Eating foods that are not high in iron, vitamin B12, or folate (this could occur to some Vegans who may not eat a balanced vegan diet). • Knowledge deficit: As with any disease process, many clients need more education to improve their health literacy. Potential complications which must be considered: • Decisional conflict: Not being able to accept blood or blood products due to a religious belief or cultural understanding. Generating Solutions: Anemia Review possible nursing actions that align with each nursing diagnosis. The intervention varies based on the type of anemia. For example, sickle cell anemia can cause pain and, therefore, pain medicine would be appropriate. Nursing Diagnoses Possible Interventions Altered perfusion • administer prescribed packed red blood cells—add RBCs • administer prescribed volume (IV fluids)—maintain blood pressure • iron supplement—increase iron stores • B12 and folate supplement— increase B12 and folate levels • administer prescribed epoetin alfa—stimulate bone marrow Impaired gas exchange • supplemental oxygen—increase available oxygen Fatigue • frequent rest periods—conserve energy Self-neglect • treat underlying mental health issues—anorexia, bulimia, etc. • dietary teaching—target high iron or vitamin B12/folate foods Knowledge deficit • information on anemia and actions for prevention—teach clients Imbalanced nutrition • suggest dietary changes that target specific deficiencies • measure and monitor deficiencies—increase missing nutrients Pain • administer prescribed pain medication—treat symptoms Pharmacology and Anemia In clients with anemia, specific medications are used to treat the underlying cause. Select each tab to review the types of medications and nursing considerations for each. Vitamins and Minerals If anemia is caused by vitamin deficiency, then the treatment is supplementation. For iron, this may be a course of ferrous sulfate (which needs to be given with vitamin C to ensure good absorption). In the case of vitamin B12 or folate deficiency, injections of B12 (cyanocobalamin) or oral folate supplements are indicated. Because B12 is transported to the terminal ileum by the intrinsic factor for absorption, and the geriatric population and those with malabsorption syndromes have less intrinsic factor, injection is preferred. Erythropoiesis Stimulating Agent This class of medications is used to stimulate the bone marrow to produce more red blood cells. Mostly used in renal insufficiency and failure, this medication stimulates the bone marrow to boost the amount of red blood cells created over time. Blood Transfusion The most comprehensive way to improve anemia is with blood transfusion. However, this carries a lot of risks and is resource intensive. There is a variable and limited supply of donor blood available. Blood must be matched to avoid significant transfusion reactions that could occur. There are some individuals and groups that maintain a religious or cultural belief to not receive a blood transfusion. This can cause an ethical dilemma in a life-threatening situation. Opiates Specific to one type of anemia, sickle cell anemia, opiates are often used due to the pain that this condition can cause. When cells “sickle” in someone who is genetically pre-disposed, the sharp odd-shaped cells cause pain when traveling through tiny blood vessels. Drag and drop the most appropriate medication to administer based on the type of anemia. Pernicious anemia Cyanocobalamin injection Iron deficiency anemia Ferrous sulfate Anemia caused by renal insufficiency Epoetin alfa Symptomatic thalassemia Packed red blood cell transfusion Sickle cell anemia Oxygen therapy Decisional Conflict and Self-Neglect When caring for a client with anemia, the nursing diagnoses of decisional conflict and self-neglect should be considered. Decisional conflict can arise when the treatment of anemia may involve doing something incongruent with a client’s culture or religion. For example, someone who is a member of the Jehovah’s Witnesses cannot accept the transfusion of red blood cells, white blood cells, platelets, or plasma. There are additional religious issues around treatments that may use fetal stem cells. These are cases that need to be discussed with the client and the interprofessional team when they arise. Self-neglect can occur intentionally or unintentionally when someone is not getting enough iron, vitamin B12, or folate. This happens with alcoholism, anorexia, unusual dieting, homelessness, and many other non-medical issues. Other Nursing Considerations There are also other issues to consider with anemia. Select each tab to learn about influencing factors. Age Increased age causes a decrease in the production and circulation of intrinsic factors. This causes pernicious anemia (macrocytic anemia caused by vitamin B12 deficiency). Cyanocobalamin (B12) injections can be common and needed in this age group. Anemia due to medication reaction, bone marrow suppression, or cancer can also be more common in older adults. A new diagnosis of anemia needs a complete workup. Culture Some anemias are more prominent in different cultures. For example, sickle cell anemia is more prominent among African Americans. Thalassemia, another type of anemia, is common in people from Mediterranean countries, Africa, Asia, and the Middle East. Family Dynamics Anemia can cause some changes in family dynamics, especially when it comes to genetic counseling and making decisions about heredity and family planning. Access to Healthcare Those with less access to healthcare may have a higher risk of getting anemia and not getting treatment. Anemia requires periodic blood work and diagnostic testing to determine causes and plan treatment. Without proper available healthcare or insurance, someone may go a long time without obtaining a diagnosis or treatment. Nursing Outcomes: Anemia Transcript Link When evaluating outcomes, it is important to focus on specific measurable goals to ensure the interventions are effective. Some of these goals may be difficult to measure, so starting with a baseline measurement helps to decide a more specific outcome. For example, someone with anemia may not be able to perform daily activities without having to sleep periodically. If the nurse can measure increased periods of activity between sleep, and/or less sleep time, this may determine an outcome. Review the hematologic alterations below. Drag and drop the anticipated clinical manifestation to the correct box. Erythrocytosis (polycythemia vera) Impaired gas exchange Risk for thromboembolism Erythrocytopenia (anemia) Impaired gas exchange Altered peripheral tissue perfusion Altered cerebral tissue perfusion Risk for shock Risk for unstable blood pressure Fatigue Imbalanced nutrition Leukocytosis Impaired tissue integrity Hyperthermia Risk for shock Leukocytopenia Risk for infection Thrombocytosis Risk for thromboembolism Thrombocytopenia Risk for bleeding Risk for shock Overview of the Hematological System The hematological system is composed of red blood cells, white blood cells, platelets (clotting cells), and other components. Red blood cells are responsible for picking up and delivering oxygen, carbon dioxide, iron, and other nutrients throughout the body. Red blood cells do this job for about 4 months before they are recycled and replaced. White blood cells only last about 20 days in the blood before they are destroyed in the lymphatic system. Many types of different white blood cells make up the immune system. Unlike red blood cells, which maintain a stable population, white blood cells are produced as needed and increase in number when a foreign invader like a virus or bacteria is sensed. Immature white blood cells, called “bands” and “stabs,” are used to signal the presence of a new threat. Other white blood cells are triggered as an allergy response. Platelets are the blood cells responsible for repairing injury. They clump together when damage is present and call for clotting factors to surround them as a temporary barrier. Platelets only live for about nine days before they break down and are replaced and recycled. Red Blood Cells (Erythrocytes) 120 Days Platelets (Thrombocytes) 9 Days White Blood Cells (Leukocytes) 20 Days Blood Cells All blood cells are produced in the bone marrow located in the middle of some of the body’s larger bones. Some hematologic alterations can cause the bone marrow to produce too many or not enough of a specific bone cell. In some cases, bone marrow cannot produce enough of all blood cells, leading to a condition called pancytopenia. This can be caused by damage to the bone marrow due to radiation, chemicals, toxins, or specific medications. This condition can be temporary or permanent. If there are too many blood cells, the suffix –cytosis is used to describe the condition. If there are not enough blood cells, the suffix –penia is used. Review this table for a summary. Cell Type Too Many Not Enough Red blood cells Erythrocytosis Erythrocytopenia White blood cells Leukocytosis Leukocytopenia Platelets Thrombocytosis Thrombocytopenia nemia is measured by looking at three different values: the red blood cell count, hemoglobin, and hematocrit. If one of these three values is below normal, the client has a condition called anemia. This is not a diagnosis; it is a condition caused by an underlying problem. A client can have a normal red blood cell count but a decreased hemoglobin, whereas erythrocytopenia only refers to a low red blood cell count. There are three classifications of anemia, all based on the size of the red blood cell (mean corpuscular volume [MCV]) on the complete blood count (CBC). • Macrocytic anemia—MCV is greater than 100 . • Normocytic anemia—MCV is between 80 and 100 . • Microcytic anemia—MCV is less than 80 . Once identified, the healthcare provider reviews other labs to determine the cause and subsequent treatment. When assessing a client with a hematologic alteration, review and identify history and symptoms that may indicate abnormally high or low levels of blood cell components. Consider other cues in your analysis. Assessment: Symptoms • • • • • • • palpitations symptoms of infection bleeding and/or bruising dizziness or lightheadedness shortness of breath joint pain fatigue or activity intolerance Assessment: Signs Assessment: Signs • • • • • • • skin color enlarged or painful lymph nodes liver enlargement spleen enlargement nail changes jaundice joint swelling Hematologic Testing The main hematologic test done to evaluate blood cell counts is the complete blood count (CBC). The most important values to review are the hemoglobin and hematocrit (H & H), the white blood cell count (WBC), and the platelet count (PLT). These values will show if a client’s cells are too low, too high, or within the normal range. These values, along with assessment findings, can identify problems or potential risks for problems. Cell Type Red cells Too Many • Impaired gas exchange • Risk for thromboembolism Not Enough • Impaired gas exchange • Altered peripheral tissue perfusion • Altered cerebral tissue perfusion • Risk for shock • Risk for unstable blood pressure • Fatigue • Imbalanced nutrition White cells • Impaired tissue integrity • Hyperthermia • Risk for shock • Risk for infection Platelets • Risk for thromboembolism • Risk for bleeding • Risk for shock Generating a Plan: Red Blood Cells Too few red blood cells, called erythrocytopenia (anemia), can be caused by many different problems. • The body is not producing enough red blood cells, which can be caused by iron deficiency, aplastic anemia, certain medications, or folic acid deficiency. • The body is destroying/recycling the cells faster than it is creating them, which can be caused by antibodies against RBCs, infectious agents, disseminated intravascular coagulopathy, or widespread cancer. • Acute or chronic blood loss is caused by blood vessel rupture, trauma, gastritis, or menstrual flow. Red blood cells Nursing Diagnoses • Impaired gas exchange • Altered peripheral tissue perfusion • Altered cerebral tissue perfusion • Risk for shock • Risk for unstable blood pressure • Fatigue • Imbalanced nutrition Nursing Actions • • • • • • Administer oxygen as prescribed . Administer blood/fluids as prescribed . Treat iron deficiency as prescribed . Treat B12 or folate deficiency as prescribed . Monitor for signs of shock . Monitor for signs of hypoxia . Too many red blood cells, called erythrocytosis, can be caused by lung disease, high altitude, smoking, or anything that causes the body to compensate by creating more red blood cells to carry oxygen. The danger is thromboembolism. Here are some nursing diagnoses and actions to consider. Nursing Diagnoses • Impaired gas exchange • Risk for thromboembolism Nursing Actions • Administer oxygen as prescribed . • Administer anticoagulants as prescribed . • Monitor for symptoms of thromboembolism . Generating a Plan: White Blood Cells Not enough white blood cells, called leukocytopenia, can be caused by many different problems. Either the body is not producing enough, which can be caused by bone marrow suppression due to toxins, chemicals, bone marrow dysfunction, or a virus or autoimmune condition may be limiting the immune system from producing additional white cells. Here is a nursing diagnosis and actions to consider. White cell Nursing Diagnoses • Risk for infection Nursing Actions • • • • • • Monitor for signs of infection . Maintain good hand hygiene. Clean potentially contaminated surfaces . Personal protective equipment as needed . Administer medication as prescribed . Implement neutropenic precautions. Too many white blood cells, called leukocytosis, can be caused by infection, stress, or abnormal white blood cell creation. Sometimes, too many white cells is a sign of blood cancer (leukemia). The main danger is shock. Here are some nursing diagnoses and actions to consider. Nursing Diagnoses • Impaired tissue integrity • Hyperthermia • Risk for shock Nursing Actions • • • • • Monitor for signs of infection . Treat symptoms of infection (fever) . Monitor blood pressure for signs of shock . Administer antibiotics as prescribed . Administer antivirals as prescribed . Generating a Plan: Platelets Not enough platelets, called thrombocytopenia, can be caused by many different problems. Either the body is not producing enough, which can be caused by bone marrow suppression due to toxins, chemicals, bone marrow dysfunction, or a virus or autoimmune condition may be limiting the liver from releasing platelets into circulation. Here are some nursing diagnoses and corresponding actions to consider when there are not enough platelets. Platelet Nursing Diagnoses • Risk for bleeding • Risk for shock Nursing Actions • Monitor for signs of bleeding/bruising . • Administer platelets or blood as prescribed . • Implement bleeding precautions. Too many platelets, called thrombocytosis, can be caused by infection. The main danger is the increased risk of thromboembolism. Here is a nursing diagnosis and corresponding actions to consider when there are too many platelets. Nursing Diagnoses • Risk for thromboembolism Nursing Actions • Monitor for signs of thromboembolism . • Administer fluids as prescribed. • Administer anticoagulants as prescribed . Infection Control and Disease Prevention In some cases, white blood cell counts can be so low that opportunistic bacteria or parasites can cause altered tissue integrity by invading organs and tissue, causing infection. The most common instances of this include clients who are taking chemotherapy medications or clients who have an immune deficiency syndrome. Infection control and disease prevention can mean life or death to these clients. Utilizing basic control procedures like hand washing, mask or gown wearing, and maintaining clean surfaces are some of the many interventions nurses use to ensure no increased infection or new infection. Sometimes clients will be placed in neutropenic precautions for their protection. This includes a cart placed outside their room, disposable utensils and equipment, and notification signs warning visitors of needed actions to take in preventing illness for the client. Nursing Care A professional nurse who has signs or symptoms of infection should not work in client care settings until they are able to get treatment or the signs or symptoms resolve. Taking Action: Blood Products For clients with low red blood cells or platelet counts, the nurse may be asked to administer blood or blood products. Administering blood products can be a significant risk to the client. It is important to follow these general guidelines when performing this nursing action: • Ensure that the blood type and all identifying information match between the blood product and the client. • Verify with another nurse (most hospitals require two signatures) . • Collect baseline vital signs and additional vital signs frequently, especially when starting the infusion. • Monitor the client closely for the first 15 minutes, looking for a potential transfusion reaction. • If a reaction occurs, stop the administration, disconnect the tubing, contact the healthcare provider, and follow hospital policy for transfusion reactions. Outcomes: Nursing Evaluation Reviewing outcomes is essential to ensure that nursing interventions are effective and to continue to plan further client needs while continuing to recognize and update cues and generate further actions. Here are some basic evaluation criteria the nurse can use to verify improvement and plan further action. Improvement of Anemia (low red blood cell count) • • • • • increased red blood cell count on complete blood count (CBC) improved oxygen saturation increased blood pressure decreased pulse improved fatigue Improvement of Leukocytopenia (low white blood cell count) • absence of signs or symptoms of infection • increased white blood cell count Improvement of Leukocytosis (high white blood cell count) • decreased fever • decreased white blood cell count • stable blood pressure Improvement of Thrombocytopenia (low platelet count) • absence of signs or symptoms of infection • increased platelet count Improvement of Thrombocytosis (high platelet count) • absence of signs or symptoms of thromboembolism • decreased platelet count • WBC (White Blood Cell count): 4.5-5.5 White blood cells are a part of the immune system and are responsible for fighting infections. • • • • • • • • • • • • • • • • • • • • • • RBC (Red Blood Cell count): 4,500-11,000 Red blood cells carry oxygen from the lungs to the rest of the body and return carbon dioxide to the lungs for exhalation. Hemoglobin (HGB): Females: 12-16 g/dL Males: 13-18 g/dL Hemoglobin is a protein in red blood cells that carries oxygen. Hematocrit (HCT): Females: 36-48% Males: 39-54% Hematocrit is the proportion of blood that is cellular, expressed as a percentage. Platelets: 150,000-450,000/μL Platelets are involved in blood clotting and help to stop bleeding. PT (Prothrombin Time): 10-13 seconds PT measures the time it takes for blood to clot. It is often used to monitor the effectiveness of anticoagulant medications. PTT (Partial Thromboplastin Time): 25-35 seconds PTT also measures the time it takes for blood to clot and is used to monitor certain clotting factors. APTT (Activated Partial Thromboplastin Time): 30-40 seconds Similar to PTT, APTT is a test that measures the time it takes for blood to clot. INR (International Normalized Ratio): <1 second (no warfarin) 2-3 seconds (on warfarin) INR is used to monitor the effects of anticoagulant therapy, particularly with warfarin.