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objective: After four hours of lecture discussion, the level 1V student will be able to: Review the anatomy and physiology of the blood Relate the diagnostic test result to the blood disorder Discuss different blood disorder Develop nursing care plan utilizing nursing process in caring patient with blood disorders
Plasma
- is a straw colored liquid consisting of approximately 90% water and 10
% protein
2. Leukocytes (wbc)
- 4000- 11, 000mm - Granulocytes: a. Neutrophils 40 70% of wbc; active phagocytes; number increases rapidly during short-term or acute infections b. Eosinophils 1- 4% of wbc; kills parasitic worms; increase during allergy attack; might phagocytize antigen-antibody complexes and inactivate some inflammatory chemicals
c. Basophils 0- 1% of wbc
Granules contain histamine ( vasodilator chemicals) which is discharge at sites of inflammation Agranolucytes: a. Lymphocytes- 20 45 % of wbc - Part of immune system; one group (B lymphocytes) produces antibodies; other group (T lymphocytes) involved in graft rejection, fighting tumors and viruses, and activating B lymphocytes -
b. Monocytes 4 8% 0f wbc
- Active phagocytes that become macrophages in the tissues; long-term clean-up; increase in number during chronic infections such as TB
hematocrit
- Is the % of blood cells in a volume of blood - Normal value= 42% - 45% of blood volume
HEMOSTASIS
- Stoppage of blood flow - This response which is fast and localized involves many substances normally present in plasma, as well as some that are released by platelets and injured tissue cells.
PHASES OF HEMOSTASIS
Platelet plug forms sticky and cling to the damage site, Anchored platelets release chemicals that attract more platelets to the site to formed a white thrombus or platelet plug. Vascular spasm occur anchored platelet release serotonin which cause the blood vessel s into spasm resulting to decrease blood loss after clotting can occur Coagulation event occur - release of thromboplastin. Coagulation time = 3 to 6 minutes
BLOOD TYPES
BLOOD GROUP - RBC ANTIGEN
PLASMA ANTIBODIES-
RECEIVED BLOOD
Antigen is a substance that body recognizes as foreign, it stimulates the immune system to release antibodies RH BLOOD GROUP the RBC carry the-Rh antigen
POLYCYTHEMIA Secondary
- Increase RBC and Hgb production - Compensatory response to chronic hypoxia: Hypoxia ->increase Erythropoietin production by the kidneys>stimulation of the bone marrow to increase RBC production
POLYCYTHEMIA VERA/primary
Occurs most frequently in middle age and Jewish men Hyperplasia of the bone marrow Increase RBC (erythrocytosis); increase WBC (leukocytosis); increase platelets (thrombocytosis)
Pathophysiology:
Increase rbc,wbc,platelet -> increase Bld.volume and Viscosity -> thromboembolism and capillary overdistention -> rupture - > hemorrhage ->hypovolemia; Organ infiltration -> hepatomegaly, Spleenomegaly,cerebral hypoxia,arthralgia
Etiology
Unknown
Nursing diagnosis
Ineffective Tissue Perfusion r/t decreased blood circulation Knowledge deficit r/t disease process and treatment Risk for injury r/t dizziness
PATHOLOGY
Reduced O2 carrying capacity of the blood from nutrients deficiencies that disrupts hematopoiesis or hemoglobin synthesis
Etiology:
Decreased dietary intake Decreased iron absorption from GIT Chronic intestinal or uterine blood loss Increased bodily needs for iron such as during growth period and pregnancy
SIGNS AND SYMPTOMS: Pallor Easy fatigability Weakness Anorexia Weight loss Headache/dizziness Brittle hair, nails Syncope Amenorrhea Cold sensitivity Tachycardia Palpitation
Planning
- The patient will relate disease process and treatment
- The patient will have increased circulation - The patient will relate measures to avoid injury
Nursing Intervention
Explain the cause of disease, symptoms, side effect of medication and possible complication, and any procedures to be done Administer O2 as ordered check VS frequently Assess Homan signs and thrombi formation
Positioning patient slowly to prevent dizziness Allow ADL if patient is able Provide HTP : to drink at least 3 L of H2O daily; elevate feet when resting; avoid restrictive clothing; wear support hose; take medication as ordered; report for chest pain, joint pain, fever or activity intolerance etc. Keep appointment for laboratory test and physician checks
Medical/surgical management
Phlebotomy removal of blood from the vein about 350500ml q other day til hct is 40% Radioactive phosphorus and radiation therapy to decrease the production of blood cells in the bone marrow
Pharmacology
Busulfan (Myleran); Chlorambucil (Leukeran); Cylophosphamide (Cytoxan) and mechlorethamine or nitrogen mustard = to decrease bone marrow production Allopurinol (Zyloprim) = to decrease production of uric acid Antihistamine = for pruritus Analgesic
Diet therapy
Increased calories and protein Low in sodium to decrease fluid volume Avoid iron containing food
ANEMIAS
Decreased availability of oxygen to the tissue TYPES of Anemia: 1. Iron deficiency 2. Folate deficiency 3. Aplastic 4. Pernicious
ETIOLOGY
Acute/chronic blood loss Inadequate dietary intake of vitamins/minerals needed for RBC production Decreased RBC production by the bone marrow Increased destruction of RBC Increased demands of vitamins/minerals needed for RBC production
Nursing intervention
Promote rest to reduce O2 demands Render oral care and good skin care Diet: iron rich food
Medical Mgt.
o Iron supplement: oral FeSO4; parenteral Imferon o Oral should be given pc to prevent GI irritation o Oral liquid iron to be administered with straw to prevent permanent staining of the teeth o Vit. C increase iron absorption o Do not administer with milk, antacid these will inhibit absorption o Inferon: Z-track to prevent staining of the skin o Do not massage site injection to prevent leakage of medication to subcu. layer o Iron salt change color of stool to dark green or black o Oxygen therapy o Blood transfusion
Poor dietary intake Eat Uncooked fruits and vegetables Alcoholism Chronic malnutrition Pregnancy
Assessment Cracked lips, smooth, sore tongue and mild dirrhea Same as pernicious anemia Bone marrow analysis reveals hyperplasia Poikilocytosis(abnormally-shaped RBC) Extreme paleness, especially in mucous membrane Confusion, paresthesia in extremeties, lose of maintaining balance Lose of position sense (proprioception Mild jaundice, vilitigo, pemature of graying skin (+)Schilling test MANAGEMENT: Well balance diet, assess ambulation, gait and stability Folic acid 1mg/day; instruct to avoid extreme hot or cold
Pathophysiology
Decreased Intrinsic factor production by the parietal cells of the stomach ->decreased Vit, B12 absorption ->decreased RBC production -> decrease DNA synthesis in maturing RBC -> impairment of cell integrity
Diagnostic test
Schillings test most definitive diagnostic test - Oral radioactive Vit 12 is administered - IM nonradioactive Vit 12. To push the radioactive Vit 12 into the urine - Collect 24 hours urine specimen - Decreased excretion of Vit 12 in the urine indicates (+)
Assessment
Beefy red, inflamed tongue ( most characteristic manifestation) Achlorhydria( absence of free Hcl acid in the gastric juice Tingling, numbness Lack of balance, uncoordinated movement Confusion Paralysis Depression, psychosis Jaundice
Collaborative MGT
Vit 12 im: daily for 7 days; weekly for 10 weeks; monthly lifetime 100mg/Mos. Hydrochloric acid p.o. for 1 week Iron therapy Blood transfusion as needed Physical examination every 6 months
Aplastic anemia
- Hypoplasia of the bone marrow - Fat replaces bone marrow - Pancytopenia drop in the # of RBC: anemia, leukopenia,thrombocytopenia ETIOLOGY: cause unknown - Congenital Medications Infection - Acquired heavy metals Hepatitis - Idiopathic
Diagnostic test
Bone marrow aspiration/biopsy
Adult: posterior iliac crest the most common site Prone position during the procedure Brief, sharp pain is normally experienced as bone marrow is aspirated Child: Tibia most common site Side-lying position during the procedure Apply pressure at the puncture site to prevent bleeding
Medical treatment
- ATG (Atgam) antihymocyte globulin an Immunosuppressive therapy to suppress the rxn causing the aplastic anemia and allow the bone marrow to recover - Given OD through CVC for 7 to 10 days - Transfusion of plt. and Packed RBC
Surgical tx
BM transplant Cyclosporine (sandimmune) an immnunosuppressant is given for BMT to decrease the graft rejection
Pharmacological tx
Antibiotic for infection Steroids and Androgen used to stimulate the bone marrow
MEDICAL MGT.
BT- blood transfusion Erythrocytapheresis a procedure that removes abnormal RBCS and replaces a healthy one
Surgical tx
Splenectomy to stop destruction of RBC Pharmacological: - Corticosteroids to decrease the autoimmune response - Folic acid to increase the production of RBC
SICKLE CELL Disease/INHERITED HYMOLYTIC ANEMIA Genetic disorder caused by recessive genes Has an abnormal Hb. S instead of Hb A in the RBC The person with one S gene (HbsA) has sickle cell trait The person with two S genes (Hbss) has sickle cell disease
Diagnostic Procedure
Sickledex or sickle cell test
- A screening test to infant to diagnose sickle cell disease - If Hb S is present, a Hb electrophoresis is done to distinguish between sickle trait and sickle cell disease - If the Hb electrophoresis test is negative, the client has the sickle cell trait and not sickle cell disease.
Chronic anemia Cardiomegaly Fatigue Jaundice Chronic leg ulcer Tachypnea priapism
Dyspnea Arrhythmias Fever Severe pain Loss of bld supply Joint pain, swollen and tender
Medical management
Antibiotics Genetic Counselling Large amount of oral and IV fluid Pharmalogical: - Folic acid OD to assist in the production of RBC - Cetiedel citrate antisickling effect by changing the RBC membrane. - Trental (Pentoxifylline) reduces blood viscosity, increase RBC flexibility, lengthens the time between sickle cell crises - Blood transfusion during crisis - Patient-Controlled Analgesia with morphine during crisis
Nursing management
Ineffective Tissue Perfusion r/t decreased # of RBC and decreased oxygenation as evidenced by dyspnea, tingling sensation and numbness of LE
Administer IV as ordered Offer 8 to 10 glasses of H20/day Monitor for symptoms of obstructed vessels such as: pain, leg ulceration, abdominal tenderness, dyspnea, confusion and blurred vision Administered Blood. product as ordered Close monitoring for possible BT RXN Elevate head; administer O2 as ordered
Alteration in comfort: Pain r/t occlusion of small vessels by sickled cells as evidenced by---
Assess the severity, location and type of pain Monitor analgesic administration by PCA pump Support joints and LE with pillows Keep bed linens off knees and ankles with a bed cradle
Activity Intolerance r/t imbalance between O2 supply and demand as E/B weakness, fatigue, tingling and numbness
Assist with ADL Teach the importance of alternating periods of rest with activity
Survival: 5 7 yrs.
Pathophysiology
- Proliferation of Immature WBCS---- Immune system
compromised state-- production of RBCs and Platelets Hypertrophy of the Bone marrow (bone pain) organ Infiltration: hepatomegaly; Splenomegaly;renal insufficiency; hyperuricemia; arthralgia; Increase ICP (meningeal infiltration)
COLLABORATIVE MANAGEMENT MEDICAL MGT: Chemotherapy Bone marrow transplantation Blood transfusion NURSING INTERVENTION: PROTECT FROM INFECTION: Reverse isolation/protective isolation; Practice asepsis; Limit visitors; Do not allow people with infection to visit; Avoid fresh fruits/fresh flowers in the unit; Avoid raw foods PREVENT TRAUMA and BLEEDING: minimize parenteral injection, use small needle, apply pressure at injection site for 5 mins.,support/handle body parts gently,use soft-bristled toothbrush/soft swab, use electric razors, do not administer ASA CONSERVE ENERGY/O2 SUPPLY: adequate rest, Oxygen therapy
Decreased platelets
--- Bleeding
ALL
Vincristine(oncovin) Prenisone(deltasone) 6-mercaptopurine or 6-MP(purinethol) Methotrexate daunorubicin Hcl(cerubidine) cytarabine or era-C(cytosar-U) 6-thioquanine(thioguanine) Doxorubicin Hcl(Adriamycin) Chlorambucil(Leukeran), COP(cytoxan,oncovin,prednisone
BUSULFAN(MYLERAN), HYDROXYUREA(HYDREA)
AML
CLL
CML
DAT(daunorubicin,ara-C, thioguanine
AGRANULOCYTOSIS
DESCRIPTION - severely reduced number of granulocytes:basophils,
eosinophils, neutrophils Etiology: medication toxicity, neoplastic disease, chemotherapy, radiation therapy, bacterial and viral infection
Signs & symptoms:
headache Chills Fever fatigue mucous membrane ulceration of the nose, mouth, pharynx, vagina, and rectum WBC and neutrophils is low
Collaborative Mgt.
Culture and sensitivity if fever occur and ulceration Blood transfusion to provide mature leukocytes Filgrastin (Neopogen)- a human granulocyte colony stimulating factors Protective isolation Antibiotic specific for cultured microorganism Soft bland diet high in calories, protein and vitamins
Nursing intervention
Infection control:
Follow aseptic technique in any procedures Environment must be kept very clean Should avoid crowds Avoid hot and cold temperature Client reports any signs or symptoms of infection Adequate amount of fluids Monitor wbc Provide rest between activities
COAGULATION DISORDERS:
DIC(DISSEMINATED INTRAVASCULAR COAGULATION) - A syndrome and not a disease - Occurs due to primary disease process or condition like: burns, acute leukemia, metastatic cancer, polycythemia vera, pheochromocytoma, shock, acute infection, septic abortion, abruptio placenta, BT rxn. and trauma - A condition of alternating clotting and hemorrhaging
Pathophysiology
- Primary
disease stimulation of clotting mechanism -- microthrombi formation process and Fibrinolysis Depletion of clotting factors and Bleeding Obstruction of circulation tendency leads to organ and tissue necrosis. In bleeding - hemorrhage.
Collaborative Mgt.
Lab. Test D DIMER test measures a fibrin split product that is released when a clot breaks Treatment of primary disease. Ex. Infection antibiotic,CA chemotherapy Whole blood or blood products to normalize clotting factor levels Platelets and Packed RBC Cryoprecipitate or fresh-frozen plasma to nomalize clotting factor levels Heparin to prevent the formation of more microthrombi Aminocaproic acid (Amicar) to stop bleeding it inhibit the fibrinolytic process **Fibrinolysis is the process of breaking fibrin apart
Nursing Intervention
Assess previous condition such infection, trauma, CA, Monitor I&O closely and record Monitor color, VS, peripheral pulses, neurological checks If abdominal bleeding is suspected measure abdominal girth every 4 hours Assess surgical wounds, all body orifices for bleeding Assess presence of pulmonary edema, hypotension tachycardia, confusion restlessness, convulsion and coma
Hemophilia
Is an inherited bleeding disorder in which there is a lack of clotting factors - The trait is carried on the recessive X chromsome a mother is asymptomatic but can pass the trait to the son who manifest the symptoms TYPES: 1. HEMOPHILIA A lacking of clotting factorsVIII 2. HEMOPHILIA B (CHRISTMAS DISEASE) lacking of factor IX -
COLLABORATIVE MGT.
LAB. Test Partial thromboplastin time(PTT) result is prolonged Diagnosed by deficient or absent blood level of factors VIII or IX
TX:
administration of clotting factors VIII & IX Hemophilia A fresh frozen plasma and cryoprecipitate that has factor VIII Hemophilia B - fresh frozen plasma that contain factor IX
Pharmacological
Desmopressin acetate (DDAVP) Aminocaproic Acid (Amicar) ** To decrease fibrinolytic process
Nursing Intervention
Deficient knowledge r/t disease process: Discuss ways to improve the safety of the clients home environment Advise not to take ASA Encourage to use electric razor and soft-bristled toothbrush Refer to genetic counselling Encourage client to wear Medic-Alert bacelet
Alteration in Comfort Pain r/t inflammation/swelling of tissue and joints Assess for bruising, swelling and joint discomfort Apply ice and pressure to bleeding site Immobilize with a supportive device Administer analgesic as ordered Risk for Injury r/t altered clotting factors: Transfuse clotting factors as ordered Encourage to avoid activities that may cause harm Post emergency medical # for future need. Prevent injuries: wear gloves, long-sleeved clothing when doing household chores, participate in noncontact sport and activities
Thrombocytopenia
- Is a decreased in the number of platelet in the blood - The decrease may R/T:
aplastic anemia tumors, leukemia and chemotherapy Infection or viral illnesses Increased platelet destruction as in DIC or thrombocytopenic purpura that is either drug induced or idiopathic( occurring without cause)
Nursing intervention
Activity should be undertaken to prevent trauma Assess level of pain on pain scale and coping ability Monitor VS, neuro andmental status Assess skin and excretions for signs of bleeding Handle very carefully in all nursing procedures Teach to use razor for shaving, soft bristles toothbrush, wear slippers at all time. Do not take ASA. Eat high fiver diet, blow nose very gently
Test questions Identification: Identify the ff: write the correct answer.
1. 2. 3. Sickledex or Hb.Electrophoresis - are the diagnostic test for sickle cell anemia Anemia decreased number of RBCs and low Hb and hct level DIC is not a disease but a syndrome that occurs because of a clients having a primary disease or condition 4. Hemophilia is a recessive X chromosome inherited bleeding disorder in which the client is lacking clotting factors 5. Severe hemophilia one of the classification of hemophilia wherein the level factor is less than1% of normal 6. Agranulocytosis a severely reduced number of granulocytes(basophil, eosinophils, and neutrophils 7. Leukemia a malignancy of blood forming tissues in which the bone marrow produces increased numbers of immature WBC 8. Phlebotomy one of the treatment of polycytemia which is the removal of blood from a vein 9. Polycythemia is a disease in which there is an increased production of RBC 10. Iron deficiency Anemia - the most common type of anemia and occurs when the body does not have enough iron to synthesize functional Hb.
Enumeration