Hematology

Assessment and Management of Patients With Hematologic Disorders
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following statement True or False? Hematopoiesis is the complex process of the formation and maturation of blood cells.
Answer
True Hematopoiesis is the complex process of the formation and maturation of blood cells.
Hematologic System
The blood and the blood forming sites, including the bone marrow and the reticuloendothelial system Blood
Plasma
Blood cells Hematopoiesis
Blood Cells
ErythrocyteRBC LeukocyteWBC Neutrophil Monocyte Eosinophil Basophil LymphocyteT lymphocyte and B lymphocyte Thrombocyteplatelet
Hematopoiesis
Hemostasis
Refer to fig. 33-3
Question
What type of anemia results from red blood cell destruction? A.Bleeding
B.Hemolytic
C.Hypoproliferative D.None of the above
Answer
B Bleeding results from red blood loss. Hemolytic anemia results from red blood cell destruction. Hypoproliferative anemia results from defective red blood cell production.
Anemias
Lower than normal hemoglobin and fewer than normal circulating erythrocytes. A sign of an underlying disorder Hypoproliferative: defect in production of RBCs Due to iron, vitamin B12, or folate deficiency, decreased erythropoietin production, cancer Hemolytic: excess destruction of RBCs
Due to altered erythropoiesis, or other causes such as hypersplenism, drug-induced or autoimmune processes, mechanical heart valves
May also be due to blood loss
Manifestations
Depend upon the rapidity of the development of the anemia, duration of the anemia, metabolic requirements of the patient, concurrent problems Fatigue, weakness, malaise Pallor or jaundice Cardiac and respiratory symptoms
Tongue changes
Nail changes Angular cheilosis
Pica
Medical Management
Correct or control the cause Transfusion of packed RBCs Treatment specific to the type of anemia Dietary therapy Iron or vitamin supplementationiron, folate, B12 Transfusions Immunosuppressive therapy Other
Nursing Process: The Care of the Patient with AnemiaAssessment

Health history and physical exam
Laboratory data
Presence of symptoms and impact of those symptoms on patients life; fatigue, weakness, malaise, pain Nutritional assessment Medications Cardiac and GI assessment
Blood lossmenses, potential GI loss

Neurologic assessment
Nursing Process: The Care of the Patient with AnemiaDiagnoses

Fatigue Altered nutrition Altered tissue perfusion Noncompliance with prescribed therapy
Collaborative Problems/Potential Complications

Heart failure Angina Paresthesias Confusion
Nursing Process: The Care of the Patient with AnemiaPlanning

Major goals include 1. decreased fatigue,
2. attaining or maintaining adequate nutrition,

3. maintaining adequate tissue perfusion, 4. complying with prescribed therapy, and 5. the absence of complications.
Interventions Balance physical activity, exercise, and rest. Maintain adequate nutrition.
Patient education to promote compliance with medications and nutrition.

Monitor VS and pulse oximetry, provide supplemental oxygen as needed. Monitor for potential complications.
Question
Is the following statement True or False? Leukocytosis refers to a decreased level of leukocytes in the circulation.
Answer
False Leukocytosis refers to an increased level of leukocytes in the circulation. Leukopenia refers to a decreased level of leukocytes in the circulation.
Leukemia
Hematopoietic malignancy with unregulated proliferation of leukocytes Types:
Acute myeloid leukemia

Chronic myeloid leukemia Acute lymphocytic leukemia
Chronic lymphocytic leukemia
Acute Myeloid Leukemia (AML)

Defect in stem cell that differentiate into all myeloid cells: monocytes, granulocytes, erythrocytes, and platelets
Most common nonlymphocytic leukemia Affects all ages with peak incidence at age 67 Prognosis is variable and wide range Manifestations: fever and infection , weakness and fatigue, bleeding tendencies, pain from enlarged liver or spleen, hyperplasia of gums, bone pain Treatment aggressive chemotherapyinduction therapy, BMT or PBSCT
Chronic Myeloid Leukemia (CML)

Mutation in myeloid stem cell with uncontrolled proliferation of cells
Chromosome 22 (Philadelphia chromosome) has a section of DNA missing
Stages:
1. chronic phase, life expectancy >5 yrs 2. transformational phase
3. blast crisis (acute phase), survival less than 6 mths

Uncommon in people under 20, with increased incidence with age. Mean age 67
Chronic Myeloid Leukemia (CML)

Manifestations Initially may be asymptomatic 1
Confusion or shortness of breath 2

Enlarged, tender spleen, or enlarged liver Malaise, anorexia, weight loss,
Treatment
Imatinib mestylate (Gleevec) 3 Chemotherapy, BMT or PBSCT
Acute Lymphocytic Leukemia (ALL)

Uncontrolled proliferation of immature cells (lymphoblasts) from lymphoid stem cell Most common in young children, boys more often than girls, 4 yrs old is peak Prognosis is good for children, but diminishes with age
Acute Lymphocytic Leukemia (ALL)

Manifestations
Immature lymphocytes proliferate in the marrow1

Large liver or spleen and bone pain Headache, vomiting 2
Treatment - complex
Chemotherapy Corticosteroids
imatinib mestylate (if Philadelphia chromosome positive)

BMT or PBSCT
Chronic Lymphocytic Leukemia (CLL)

Common among older adults , ave. age 72 Results form malignant B lymphocytes 1
May escape apoptosis 2, resulting in excessive accumulation of cells

Survival varies from 3-15 years Lymphadenopathy Hepatomegaly Splenomegaly In later stages anemia and thrombocytopenia Autoimmune complications occur 1
Chronic Lymphocytic Leukemia (CLL)

Manifestations
Some pts asymptomaic 1

Lymphadenopathy 2 Splenomegaly
Some develop B symptoms 3

Infections are common Treatment
early stage may require no treatment 4

Chemotherapy given with monoclonal antibody therapy 5
Nursing Process: The Care of the Patient with LeukemiaAssessment

Health history Assess symptoms of leukemia, and for complications of anemia, infection, and bleeding
Weakness and fatigue

Laboratory tests CXR, Leukocyte count, ANC, hematocrit, platelets (may be very low)1 electrolytes, culture reports
Nursing Process: The Care of the Patient with LeukemiaDiagnoses

Risk for bleeding and infection Risk for impaired skin integrity
Impaired gas exchange

Impaired mucous membrane Imbalanced nutrition Acute pain Hyperthermia Fatigue and activity intolerance Impaired physical mobility
Nursing Process: The Care of the Patient with LeukemiaDiagnoses

Risk for excess fluid volume Diarrhea Risk for deficient fluid volume
Self-care deficit
Anxiety Disturbed body image Potential for spiritual distress Grieving diagnoses Deficient knowledge

Infection Bleeding Renal dysfunction
Tumor lysis syndrome

Nutritional depletion Mucositis
Depression
Nursing Process: The Care of the Patient with Leukemia- Planning

Major goals absence of complications Attaining and maintaining adequate nutrition Activity tolerance Ability for self-care Ability to cope with diagnosis and prognosis Positive body image Understanding disease process and its treatment.
Interventions
Interventions related to risk of infection and bleeding Mucositis Frequent, gentle oral hygiene Soft toothbrush, or if counts are low, sponge-tipped applicators Rinse only with NS, NS and baking soda, or prescribed solutions Perineal and rectal care
Improving Nutrition
Oral care before and after meals Administer analgesics before meals Appropriate treatment of nausea Small, frequent feedings Soft foods that are moderate in temperature Low-microbial diet Nutritional supplements
Lymphoma
Neoplasms of lymph origin Hodgkins lymphoma Non-Hodgkins lymphoma
Hodgkin Lymphoma
Relatively rare More men than women, Two peaks 20s and 50s, familial pattern
Unicentric origin, malignant cell is ReedSternberg cell1

Excellent cure rate with treatment Cause is unknown thought to be viral
Hodgkin Lymphoma
Manifestations
Painless, firm lymph node enlargement on one side of neck

Pruritis B symptoms Sed rate (ESR erythrocyte sedimentation rate) Treatment Determined by stage of the disease May include chemotherapy and/or radiation therapy
Hodgkins Lymphoma Nursing Management

Encourage patient to reduce other factors that increase the risk of developing second cancers
1. Tobacco use
2. Alcohol use 3. Exposure to carcinogens
4. Exposure to sunlight
Screening for effects of treatment Provide education regarding self care strategies Provide education regarding disease management
Non-Hodgkin Lymphoma (NHL)

Lymphoid tissues infiltrated with malignant cells Spread is unpredictable Incidence increases with age, with average age 67 Incidence increases with autoimmune disorders Prognosis varies
Non-Hodgkin Lymphoma (NHL)

Manifestations Symptoms are variable Lymphadenopathy most common 1 Symptoms may be absent or minor until diagnosed at later stage (III or IV) when symptomatic B symptoms
Treatment
Determined by type and stage of disease 2 May include interferon, chemotherapy, and/or radiation therapy.
Non-Hodgkin's Lymphoma (NHL)

Diagnostic Findings Staging based on data from CT and PET scans, bone marrow biopsies, sometimes cerebrospinal fluid
Stage based on site of disease and its spread to other sites
Question
What should any elderly patient be evaluated for whose chief complaint is back pain and has an elevated total protein level? A. Anemia B. Leukemia C. Multiple myeloma D. Non-Hodgkins lymphoma
Answer
C Any elderly patient whose chief complaint is back pain and has an elevated total protein level should be evaluated for possible myeloma.
Multiple Myeloma
Malignant disease of plasma cells in the bone marrow with destruction of bone
Prognosis based on markers 1. Serum albumin
2. Serum beta2 microglobulin
Multiple Myeloma
Manifestations Bone pain (back or ribs) Osteoporosis & spinal fractures
Hypercalcemia 1
Renal failure Anemia 2, so fatigue , weakness
Reduced leukocytes and platelets 3

Treatment Chemotherapy, corticosteroids, radiation therapy, BMT or PBSCT, biphosphonates (strenghten the bone)
Bleeding Disorders
Disseminated Intravascular Coagulation (DIC) Primary Thrombocythemia Thrombocytopenia Idiopathic Thrombocytopenia Purpura (ITP)
Hemophilia
Acquired Coagulation disorders: liver disease, anticoagulants, vitamin K deficiency Bleeding precautions
Question
Is the following statement True or False? Disseminated intravascular coagulation is not a disease but a sign of an underlying condition.
Answer
True Disseminated intravascular coagulation is not a disease but a sign of an underlying condition.
DIC
Severity is variable; may be life-threatening -80% mortality rate
Triggers may include sepsis, trauma, shock, cancer, abruptio placenta, toxins, and allergic reactions.
Hemostasic mechanism is altered causing massive clotting. As clotting factors are consumed, bleeding occurs. Symptoms are related to tissue ischemia and bleeding. 1 Laboratory tests. Treatment: treat underlying cause, correct tissue ischemia, replace fluids and electrolytes, maintain blood pressure, replace coagulation factors, use heparin.
DIC
Manifestations Organ failure (or compromised function) Low platelet and fibrinogen levels 1
Prolonged PT, PTT, INR

Elevated D Dimer Bleeding from minimal to hemorrhage from all orifices and sites 2 Management Treat underlying cause
Correct secondary effects
Nursing Process: The Care of the Patient with DICAssessment

Be aware of patient who are at risk for DIC and assess for signs and symptoms of the condition. Assess for signs and symptoms and progression of thrombi and bleeding.
Nursing Process: The Care of the Patient with DICDiagnoses

Risk for fluid volume deficient Risk for impaired skin integrity Risk for imbalanced fluid volume Ineffective tissue perfusion Death anxiety

Renal failure Gangrene Pulmonary embolism or hemorrhage Acute respiratory distress syndrome Stroke
Nursing Process: The Care of the Patient with DICPlanning

Major goals maintenance of hemodynamic status, maintenance of intact skin and oral mucosa, maintenance of fluid balance, maintenance of tissue perfusion, enhanced coping, and absence of complications.
Interventions
Assessment and interventions should target potential sites of organ damage. Monitor and assess carefully
Avoid trauma and procedures which increase risk of bleeding, including activities which would increase intracranial pressure.
Therapies for Blood Disorders

Anticoagulant therapy Splenectomy Therapeutic apheresis Therapeutic phlebotomy Blood component therapy *** see handout
Complications of Transfusions
Febrile nonhemolytic reaction Acute hemolytic reaction Allergic reaction Circulatory overload Bacterial contamination Transfusion related acute lung injury Delayed hemolytic reaction Disease acquisition Complications of long-term transfusion therapy

Hematology

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Assessment and Management of Patients With Hematologic Disorders

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient with AnemiaAssessment

Blood lossmenses, potential GI loss

Nursing Process: The Care of the Patient with AnemiaDiagnoses

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Collaborative Problems/Potential Complications

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient with AnemiaPlanning

2. attaining or maintaining adequate nutrition,

Patient education to promote compliance with medications and nutrition.

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Acute myeloid leukemia

Chronic lymphocytic leukemia

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Acute Myeloid Leukemia (AML)

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chronic Myeloid Leukemia (CML)

3. blast crisis (acute phase), survival less than 6 mths

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chronic Myeloid Leukemia (CML)

Confusion or shortness of breath 2

Acute Lymphocytic Leukemia (ALL)

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Acute Lymphocytic Leukemia (ALL)

Immature lymphocytes proliferate in the marrow1

imatinib mestylate (if Philadelphia chromosome positive)

Chronic Lymphocytic Leukemia (CLL)

May escape apoptosis 2, resulting in excessive accumulation of cells

Chronic Lymphocytic Leukemia (CLL)

Some pts asymptomaic 1

Some develop B symptoms 3

early stage may require no treatment 4

Nursing Process: The Care of the Patient with LeukemiaAssessment

Weakness and fatigue

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient with LeukemiaDiagnoses

Impaired gas exchange

Nursing Process: The Care of the Patient with LeukemiaDiagnoses

Collaborative Problems/Potential Complications

Tumor lysis syndrome

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nursing Process: The Care of the Patient with Leukemia- Planning

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Unicentric origin, malignant cell is ReedSternberg cell1

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Painless, firm lymph node enlargement on one side of neck

Hodgkins Lymphoma Nursing Management

Non-Hodgkin Lymphoma (NHL)

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Non-Hodgkin Lymphoma (NHL)

Non-Hodgkin's Lymphoma (NHL)

Stage based on site of disease and its spread to other sites