Altered Hematologic Function PDF

Altered Hematologic Function  Content Anemia Polycythemia Vera Myelodysplastic Syndrome Leukemia, Multiple Myeloma, Lymphoma Tumor Lysis Syndrome Idiopathic Thrombocytopenic Purpura Normal Ranges  WBC Differential Neutrophil Nonspecific ingesti...

Altered Hematologic Function  Content Anemia Polycythemia Vera Myelodysplastic Syndrome Leukemia, Multiple Myeloma, Lymphoma Tumor Lysis Syndrome Idiopathic Thrombocytopenic Purpura Normal Ranges  WBC Differential Neutrophil Nonspecific ingestion and phagocytosis Matures into macrophage, migrates into tissue Monocyte On site ingestion and phagocytosis of Macrophage microorganisms Weak phagocytic action; release vasoactive Eosinophil substances that induce allergic reactions Releases histamine and heparin Basophil  Immunity Responds to foreign cells and proteins B-lymphocyte Enhances immune activity through the secretion of cytokines T- lymphocyte Secretes immunoglobulins (antibodies) in response to the presence of antigens Plasma cell Selectively attacks and destroys non-self cells, including grafts, and transplanted organs Cytotoxic T-cell Non-selectively attacks mutated and malignant cells; also attacks grafts and transplanted organs Natural killer cell Bone Marrow Bx Informed consent Sterile technique Local anesthetic first Iliac Crest Pressure and pain when the bx is obtained  Anemia: According to Cell Size Microcytic Iron Deficiency – most common anemia Normocytic Aplastic Anemia (Bone marrow failure) Hemolytic Anemia: (auto-immune) Macrocytic Folate deficiency B12 deficiency Pernicious anemia  Polycythemia Vera Problem: overproduction bone marrow Different than secondary polycythemia Increased viscosity > clotting Monitor: K+, Uric acid levels Tx: hydration, anti-coagulants, phlebotomy w/ apheresis JAK-2 Mutation.  Myelodysplastic Syndrome Not cancer, may be pre-cancerous Pancytopenia Know all nursing interventions for thrombocytopenia, leukopenia, anemia  Leukemia Acute or Chronic Myelocytic vs Sudden onset vs slow Lymphocytic onset Pathway ALL = AML = CLL = CML =  Blasts = baby cells Overproduction of dysfunctional, immature WBCs (blasts) They crowd the bone marrow and interfere w/ normal production of RBCs and platelets Infection is major cause of death  Philadelphia Chromosome *ALL* Most common childhood leukemia CML  Lymphoma: Cancer of the lymphatic system PAINLESS Lymph node enlargement Night sweats 1.. Hodgkin’s Lymphoma (+) Reed Sternberg Cell 2. Non-Hodgkin’s Lymphoma Sub-categorized as B-cell or T-cell  Multiple Myeloma Problem: Overproduction of dysfunctional, cancerous plasma cells Interferes w/ normal RBC, WBC and platelet production Anatomy review: plasma cells important because they produce antibodies. (+) Bence Jones Protein in the urine is consistent w/ multiple myeloma Abnormal plasma cells remove calcium from the bone causing ‘soft spots’ in the bones, increasing the risk for fracture and bone pain  Tumor Lysis Syndrome Associated w/ Chemo Bone Marrow Transplant = Stem Cell Transplant Harvesting from the Donor  Case Study 1 A 43-year-old female developed a rash on her neck and chest approximately 6 weeks ago. The rash became generalized, spreading to her head, abdomen, and arms and was accompanied by joint pain and back pain. She reports three episodes of epistaxis in 1 day that occurred one week ago. Over the past week, her gums are bleeding and and she is severely fatigued. She sought medical attention as her symptoms got progressively worse  CBC Results White blood cells (WBCs) 39,000/mm3 Neutrophils 4% Monocytes 64% Blasts 17% Hemoglobin (Hgb) 10.4g/dL Hematocrit (Hct) 28.7% Platelets 49,000/mm3  In view of her lab results, and she was directly admitted to the oncology unit for diagnostic evaluation. Bone marrow biopsy showed hyper-cellular marrow with collections of monoblasts (immature monocytes). The final diagnosis was acute myeloblastic leukemia (AML)  What was the purpose of the bone marrow biopsy? What are the nurse’s priority post-biopsy?  The patient is to begin induction therapy with cytarabine (as a continuous infusion for 7 days and idarubicin intravenous (IV) push for 3 days. (7 plus 3 regime) She is scheduled in for placement of a triple- lumen subclavian Hickman catheter (a central catheter that is tunneled)  Stages of Chemotherapy 1. Induction 2. Consolidation 3. Maintenance  Considering the admission data, what potential problem will the nurse be alert for when the patient returns to the unit after central venous catheter insertion? The oncology nurse must be alert to side effects related to specific chemotherapeutic agents. There are several unique adverse effects associated with cytarabine and idarubicin (7 plus 3 regime) *Keep in mind that all chemotherapeutic agents cause varying degrees of immunocompromise  Adverse and Toxic Effects: 7 plus 3 Regime cytarabine: Peripheral neuropathy, pulmonary edema, hepatotoxicity, renal failure, conjunctivitis idarubicin: Myocardial toxicity → CHF List nursing interventions related to these potential adverse effects: 1. Monitor labs: _______________ 2. Assess: __________________ 3. Monitor and assess volume status: _______________  On the fifth day of continuous infusion of cytarabine, the unlicensed assistive personnel (UAP) reports the following vital signs to you: Vital Signs Blood pressure (BP) 110/54mm Hg Heart rate 115 beats/min Respiratory rate 26 breaths/min Temperature 101.6° F Nursing actions? ________________ ________________  Oncologist Orders Blood cultures now × 2 (different sites) Repeat CBC Stat Urine culture Acetaminophen (Tylenol) suppository 650mg q4- 6h prn gentamicin 60mg intravenous piggyback (IVPB) q8h Notify physician for temp over 100.0° F Would you question any of these orders?  Repeat Bloodwork (on Chemo) WBCs 1,200/mm3 Neutrophils 5% Lymphocytes 65% Blasts 5% Bands 0% Hgb 6.8g/dL Hct 21.3% Platelets 17,000/mm  Based on this bloodwork what blood products do you expect to be ordered? _____________________________  Based on this bloodwork, what medications are indicated? _________________________  On day 14, a bone marrow biopsy shows complete remission. With continued blood product support and antibiotic coverage, her marrow recovers, and she is discharged from the hospital. Bone marrow transplant is the recommended course of treatment. HLA (human lymphocyte antigen) typing has been performed on all four of her siblings. Her oldest brother is a perfect HLA match and has agreed to donate bone marrow (stem cells). The plan is to readmit the patient to the bone marrow transplant unit within the next few weeks. What will the bone marrow bx show if it indicates complete remission?  The Process: Bone Marrow Transplant 1. The patient will receive myeloablative therapy consisting of high-dose chemotherapy (wipe-out therapy) 2. The patient’s brother will be taken to the operating room (OR), where bone marrow will be harvested from both of his iliac crests. 3. This marrow will then be infused into the patient via the central venous catheter. The bone marrow will engraft into the patient's marrow  Nursing Priorities 1. INFECTION!!!!!!! 2. BLEEDING!!!!! 3. Organ rejection, Graft vs Host Disease: Immunosuppressant Therapy to prevent ~cyclosporine ~corticosteroids ~methotrexate *1st sign of graft vs host disease is rash  Case Study 2 H.J. is a 46-year-old man diagnosed with non- Hodgkin lymphoma 4 months ago. He finished receiving his third round of six chemotherapy courses a few days earlier. He presented to his oncologist's office today with complaints of malaise, muscle weakness, night sweats and palpitations. He had splenomegaly on examination. A computed tomography (CT) scan of the abdomen showed metastatic disease in the liver and spleen. He is admitted to the hospital with Lymphatic System  Labs: CBC White blood cells (WBCs) 1,500/mm3 Neutrophils 66% Lymphocytes 16% Monocytes 15% Eosinophils 5% Hemoglobin (Hgb) 8.3g/dL Hematocrit (Hct) 23.6% Platelets 21,000/mm3  Labs: Metabolic Panel Na 136 mmol/L K ↑6.1 mmol/L Cl 97 mmol/L CO2 28 mmol/L Glucose 98 mg/dL BUN ↑54 mg/dL Creatinine ↑2.7 mg/dL Ca ↓6.3 units/L Total protein ↓5.4 g/dL Albumin ↓2.8 g/dL Phosphorus ↑14.5 mg/dL (NL 2.5-4.5) Uric acid ↑↑23.7mg/dL (NL ~5) Aspartate transaminase (AST) ↑254 units/L Alanine transaminase (ALT) ↑74 units/L  Based on these values, what common oncologic emergency is H.J. experiencing? ___________________________________________ Which of his laboratory results confirm this diagnosis? 1. _________________ 2. _________________ Remember: This needs to be 3. _________________ treated as an emergency 4._________________ What clinical manifestations do you expect?  Cardiac: ________________________  Renal: __________________________  Neuromuscular: ___________________  Signs hypocalcemia: 1)__________________2)_______________  Joints: (S&S of gout) ____________________  Orders IV 0.9% saline at 150mL/hr furosemide (Lasix) 40mg IV now then every 6 hours 100 mEq sodium bicarbonate in the first liter of IV fluid allopurinol 500mg orally twice daily sodium polystyrene (Kayexalate) 15g orally every 6 hours Aluminum hydroxide (Amphojel) two caps orally with meals  Administer aggressive IV therapy (0.9 NS) combined w/ furosemide (Lasix) is given to increase the excretion of both uric acid and potassium sodium bicarbonate, IV: excretes uric acid, prevents renal failure from uric acid deposits in the kidneys. allopurinol prevents the formation of uric acid sodium polystyrene (Kayexalate) reduces potassium levels Phosphate-binding agents, such as aluminum hydroxide (Amphojel), help eliminate excess phosphorus.  Tumor Lysis Syndrome (TLS) What major complication is this patient at risk for associated w/ TLS and why? _______________________________ Identify three signs and symptoms of this complication you will assess for in H.J? 1._______________ 2._______________ 3. _______________ After administration of the sodium polystyrene (Kayexalate), it is important for you to monitor H.J.'s: a. Level of consciousness b. Urine output c. Bowel sounds d. Peripheral pulses  Idiopathic Thrombocytopenic Purpura Auto-immune Risk for bleeding! (of course) Precautions? Treatment?  Clinical Markers Reed Sternberg Chromosome < _______________ Philadelphia Chromosome < _____________, _______________ Bence Jones Protein (urine) < ________________