Black, Hawks and Keene Instructors Manual for Medical-Surgical Nursing 6/e

Chapter 75: Management of Clients with Hematologic Disorders

Critical Points to Emphasize

Include the following elements in discussion about the anemias: Etiology, classification, and risk factors Clinical manifestations and laboratory findings Medical management: alleviate or control the cause, relieve manifestations, prevent complications Nursing management: focused on nursing diagnoses of Activity Intolerance, Altered Tissue Perfusion, Altered Nutrition: Less Than Body Requirements, and Risk for Ineffective Management of Therapeutic Regimen Nursing assessment and management of the client receiving blood transfusions Include the following elements in discussion about multiple myeloma: Pathophysiology Clinical manifestations and diagnostic findings Medical management: suppress the bone marrow and reduce serum calcium levels Include the following elements in discussion about idiopathic thrombocytopenic purpura: Clinical manifestations Medical management: medication therapy and plasmapheresis Nursing management: focused on reduction of risk for bleeding Include the following elements in discussion about the hemophilias: Classification and etiology Clinical manifestations Medical management: stop topical bleeding, replace missing blood clotting factors, and prevent complications related to bleeding

Copyright 2001. W. B. Saunders Company. All Rights Reserved.

Black, Hawks and Keene Instructors Manual for Medical-Surgical Nursing 6/e
Chapter 75: Management of Clients with Hematologic Disorders

Nursing management: focused on reduction of risk for bleeding Facilitating Student Learning

Classroom Review Activities Assign students to review content on normal erythrocyte structure, function, and life span in an anatomy-physiology textbook. Assign students to review the hemostatic mechanism and the structure and function of leukocytes and plasma cells. Ask students to review diagnostic studies associated with hematologic disorders. Assign students to review an anatomy and physiology textbook on blood group systems. Class Assignments Supply students with a case study of a client with anemia. Ask students to identify the subjective and objective manifestations and the type of anemia. Provide students with the manifestations listed below; ask them to provide the pathophysiologic bases for each. Palpitations Sensitivity to cold Dizziness Fatigue Angina pectoris Congestive heart failure Ask students to develop a discharge plan for a person with an erythrocyte disorder that considers the following: drugs, diet, safety measures, hygiene, and comfort measures.

Copyright 2001. W. B. Saunders Company. All Rights Reserved.

Black, Hawks and Keene Instructors Manual for Medical-Surgical Nursing 6/e
Chapter 75: Management of Clients with Hematologic Disorders

Supply students with a case study of a client experiencing a hemolytic reaction. Have students identify the subjective and objective manifestations of the reaction. Have students select a hematologic disorder that they want to study in more depth. Assign students to find two journal articles that address the disorder (one of the articles should be a nursing research study). Ask the students to share findings with the class. Lecture/Discussion Start this portion of study by asking the students to describe normal erythrocyte structure, function, and life span. Ask them to provide the normal values for red blood cell count, hemoglobin, hematocrit, and reticulocyte count. Review the diagnostic tests used to determine abnormal erythrocyte structure, function, and life span. Before presenting the types of anemia in depth, you should begin by discussing the common pathologic changes that exist among the various anemias. Emphasize the common manifestations that exist among the anemias. Also include the medical management of anemias, including oxygen therapy, blood transfusions, drug therapy, and diet therapy. Obtain slides that depict the structural changes in erythrocytes that occur in selected disorders. Discuss the major drug groups used to treat erythrocyte disorders. Select one drug that typifies each group and discuss this drug in depth. Discuss disorders that cause overproduction of red blood cells. Emphasize the pathology produced by excessive circulating red blood cells. Start this portion of study by asking the students to describe normal leukocyte structure, function, and life span. Ask them to provide you with the normal values for white blood cell count and differential count. Review the hemostatic mechanism.

Copyright 2001. W. B. Saunders Company. All Rights Reserved.

Black, Hawks and Keene Instructors Manual for Medical-Surgical Nursing 6/e
Chapter 75: Management of Clients with Hematologic Disorders

As with the erythrocyte and leukocyte disorders, concentrate on the commonalties among the disorders of platelets and clotting factors. Since many conditions can precipitate disseminated intravascular coagulation (DIC), more time should be spent discussing this condition. Sickle-cell anemia and hemophilias are probably discussed in material on nursing of children. Stress the impact of these conditions on the adult. Group Activities Divide the class into small groups. Ask students to discuss how the following factors might cause anemia: vitamin B12 deficiency, intrinsic factor deficiency, radiation therapy, severed blood vessels due to trauma, iron deficiency, lead poisoning. Divide the class into small groups. Ask students to discuss how the following diagnostic tests confirm erythrocyte disorders: erythrocyte indices, urobilinogen test, Schillings test, gastric secretion analysis, serum folate level, bone marrow examination. Divide the class into four groups. Provide each group with a case study on one of the following: agranulocytosis, multiple myeloma, idiopathic thrombocytopenia purpura, and hemophilia A. Ask students to identify the clinical manifestations found in the case study. Have them discuss etiologies, pathophysiology, diagnostic tests, and clinical interventions for each disorder. Divide the class into small groups. Ask each group to develop a learning/teaching guide for one of the following: Potential for infection due to low granulocyte count Potential for bleeding due to thrombocytopenia Ask students to consider how these guidelines would be altered for a client in each of the developmental stages. Clinical Skills Laboratory Role-play teaching a client to self-administer vitamin B12 injections.
Copyright 2001. W. B. Saunders Company. All Rights Reserved. 4

Black, Hawks and Keene Instructors Manual for Medical-Surgical Nursing 6/e
Chapter 75: Management of Clients with Hematologic Disorders

Demonstrate bone marrow aspiration procedure. Demonstrate Z-track or air lock injection technique. Discuss blood transfusions. Discuss informed consent, pretransfusion testing, and blood bank regulations. Demonstrate blood infusion equipment and devices. Discuss monitoring the client and nursing management of transfusion reactions. Clinical Site Activities Assign students to assess an client with a major hematologic disorder. Based on their assessed data, have the students develop a comprehensive plan of care. Ask students to provide the rationale for specific nursing interventions included on the care plan. Assign students to develop drug cards that include pharmacologic action, expected physiologic response, side effects, usual dosage, route of administration, and nursing implications for selected chemotherapeutic agents. Assign students to determine if community resources related to erythrocyte disorders exist; for instance, sickle cell anemia screening. Assign students to visit the hospitals blood bank. Ask the technician in charge of the blood bank to describe the procedures used for blood storage and blood typing and cross-matching. Clinical Conference Activities Ask students to share their assessment findings; have the conference group discuss the significance of these findings. Ask students to identify the diagnostic studies that confirmed the existence of a hematologic disorder in their client. Invite the dietitian to conference; ask the person to give examples of meals with higher-thannormal amounts of protein, iron, vitamins, and minerals.

Copyright 2001. W. B. Saunders Company. All Rights Reserved.

Black, Hawks and Keene Instructors Manual for Medical-Surgical Nursing 6/e
Chapter 75: Management of Clients with Hematologic Disorders

Discuss the relationship among erythrocyte disorders, activities, and metabolic needs. Ask the students to discuss how nurses can intervene to reduce oxygen requirements of the client with an erythrocyte disorder. Ask students to discuss their observational experience (see Clinical Site Activities). Ask students to identify one nursing diagnosis and two nursing interventions specific to one of the clients receiving chemotherapy. Ask students to provide the purpose, normal values, and finding interpretation for the following laboratory studies used to diagnose hemorrhagic disorders: bleeding time, prothrombin time, platelet count, partial thromboplastin time, clotting time, Rumple-Leeds test Assign students to review institutional policies for ordering, handling, and administering blood and blood products. Discuss these policies and their impact on nursing care.

Copyright 2001. W. B. Saunders Company. All Rights Reserved.