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NURSING CARE OF THE CLIENT/FAMILY WITH A


HEMATOLOGICAL HEALTH DEVIATION
Nursing 304

I. Blood types--presence or absence of A or B antigens on RBC membranes is the


basis of grouping of blood types; everyone has antibodies termed anti-A or anti-B
that react with the A or B antigens; Hemolysis occurs when donor blood does not
match the recipient’s blood.

A. Types
1. Type A--has A antigens and anti-B antibodies; If receives B or AB blood, the
anti-B antibodies will react with the B antigen present in the B blood and
cause agglutination. Can receive type A and type O.
2. Type B--has B antigens and anti-A antibodies; Can receive type B and type O.
3. Type AB--has A and B antigens and no antibodies. Can receive A, B, AB, and
O (universal recipient)
4. Type O--has neither A nor B antigens (no antigens) but anti-A and anti-B
antibodies. (Universal donor but can receive only type O.)

B. Rh Factor--based on a third antigen, (D)


1. Rh positive person has the D antigen and no anti-D antibody
2. Rh negative person does not have the D antigen but if exposed to Rh positive
blood will form the anti-D antibody which will act against the Rh antigens
with future exposures

II. Blood Component Therapy

A. Common Blood Components Administered


1. Whole Blood

2. Packed RBCs

3. Platelets

4. Fresh frozen plasma

5. Cryoprecipitate

6. Albumin

A. Procedure for administration of blood products


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B. Types of Blood Transfusion Reactions

1. Acute Reactions
a. Febrile, non-hemolytic
1. Most common--Not life threatening
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2. Client's antibodies react to WBCs in the donor blood; happens most


often in people who have had previous transfusions and developed
antibodies
3. Chills and fever within 2 hours of start of transfusion
4. Leukocyte poor blood can be used if client known to have this problem
previously; Also, special in-line filters can be used
5. Administer antipyretics if this occurs

b. Acute hemolytic
1. Life-threatening
2. Occurs when donor blood is incompatible with recipient (from errors in
matching and patient identification before giving); Antibodies in
recipient combine with antigens on donor erythrocytes causing
agglutination and hemolysis.
3. Chills, fever, low back pain, nausea, dyspnea, anxiety, blood in urine;
Also, hypotension, bronchospasm and anaphylaxis can occur
4. Must be prevented. Must be recognized quickly and transfusion
stopped. Take down all tubing. Hang new tubing and infuse NS
slowly. Thorough assessment. Notify MD. Obtain required blood and
urine specimens (hemolysis). Document!

c. Allergic
1. Usually because of sensitivity to a plasma protein in the blood
2. Itching, flushing
3. Stop transfusion, infuse NS. Notify MD. Usually antihistamines
(Benadryl) resolve the problem and the blood can be resumed.
4. If severe, blood will not be restarted. Epinephrine and steroids may
be needed.
5. In the future, this client should get antihistamine before transfusion.

d. Circulatory overload
1. Usually happens because client is sensitive to overload, such as in CHF,
or if nurse allows blood to infuse too rapidly.
2. PRBCs better than whole blood unless volume needed.
3. Diuretic may be given after transfusion or between two units.
4. S&S: dyspnea, tachycardia, anxiety, crackles, pink, frothy sputum
5. Nurse should place client upright, feet down. Stop blood. Infuse NS
at KVO rate. Notify MD. May need oxygen, diuretics.
2. Delayed Reactions to Blood Transfusion

a. Delayed hemolytic
1. Usually mild and requires no intervention.
2. Usually will occur within 2 weeks of transfusion--takes this long for
antibodies to get strong enough to do damage to donor blood. Client
usually home by this time and doesn't recognize the problem.
2. Cells are hemolyzed per RES and is gradual
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3. Fever, anemia, increased bilirubin level possible jaundice. Subsequent


transfusions could be acute hemolytic.

b. Infection from blood transfusions


1. Hepatitis B and C
2. HIV
3. Malaria
4. Syphilis

c. Iron overload
1. Occurs with clients who get frequent transfusions
2. Can cause severe organ damage
3. Requires iron chelation therapy

d. Graft-versus-host disease

III. Assessment of the hematological system


A. Nursing assessment

B. Diagnostic studies
1. Lab Tests
a. CBC
1. CBC with diff--RBC, Platelets, and WBCs with the different types ID'd
2. Peripheral blood smear --sizes and shapes of cells identified
b. ESR--erythrocyte sedimentation rate; indicates inflammation
c. Clotting Studies
d. Iron studies
e. Blood typing and Rh factor
f. Bence Jones protein--random urine specimen (negative normal, positive
usually means multiple myeloma)
2. Radiologic Tests
a. Lymphangiography (dye)
b. Scans (Bone Scan, Liver/Spleen Scan)

3. Biopsies
a. Bone Marrow aspiration and biopsy

b. Lymph Node aspiration and biopsy


1. Local anesthetic
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2. Small dressing afterwards

IV. RBCs: Normal ___________________________


A. Main function is that they have hemoglobin that transports oxygen
The more rapid onset, the more severe symptoms; the more chronic, the less
severe

B. Low RBCs

1. Overall S&S with low RBCs (There are some specific S&S particular
to different anemias)

2. General Management and Nursing Care for low RBCs--aimed at


correcting underlying problem if possible and controlling symptoms

3. Anemias --anemia is a not a disease but a manifestation of a pathology;

a. Blood Loss Anemias

b. Hypoproliferative Anemias--Decreased erythropoiesis (will see


low reticulocyte count; RBCs live a normal life, but there are too few
of them)

1. Lack of stimulation

2. Lack of factors needed to make RBCs


a. Iron deficiency
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Specific symptoms of Iron deficiency anemia:

Care specific to Iron Deficiency Anemia:

b. Vitamin B 12 deficiency--also called Megaloblastic (large


cell) anemia, Cobalamin deficiency (and Pernicious anemia
when the only problem is lack of Intrinsic Factor)

Specific symptoms of Vitamin B12 deficiency: May take


years to manifest due to fairly large stores of B12 in the body

Diagnostic test specific for Vitamin B12 deficiency:


Schilling Test--receives oral dose of radioactive Vitamin
B12. If absorbed, there will be radioactivity in the urine
within the 24 hour urine test, and you know the small
intestine is not the problem. If no radioactivity in urine,
not sure if problem is intestine or stomach. So, the test
is repeated with intrinsic factor added to the oral
radioactive B12. If the urine has radioactivity, it means
that true pernicious anemia is the problem.

Specific Nursing Care for Vitamin B12 deficiency:


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c. Folic Acid Deficiency--also Megaloblastic

Specific symptoms of Folic Acid Deficiency:

Diagnostic test specific for Folic Acid Deficiency:


Measuring folate within the RBC

Specific Nursing Care for Folic Acid Deficiency:


Diet, Folic acid supplements , oral care

c. Anemia from Bone marrow damage or suppression--


meds, chemicals, cancer
1. Aplastic anemia/Pancytopenia

2. Myelodysplastic Syndromes (MDS)


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a. Abnormal development of cells; Most common is RBCs


being macrocytic (large), but the WBCs and platelets can
also be affected. Many of the cells die before leaving the
bone marrow, and even those released have reduced ability
to do what they are supposed to do. Most of these cases
turn into acute myeloid leukemia (AML)
b. Most often due to age, but can occur secondary to chemical
exposure or chemotherapy.
c. S&S like pancytopenia
d. Dx test reveals macrocytic red cells

e. Treatment of Myelodysplastic Syndromes


1.
2.
3.
4.

3. Hemolytic Anemias--RBC destruction


Erythrocytes are destroyed for whatever reason; hypoxia develops and
signals the kidney to release erythropoietin, so the bone marrow
marrow is stimulated to make more RBCS and they get released
prematurely as reticulocytes. As this continues, jaundice occurs.

a. Symptom specific to hemolytic anemias

b. Many forms but we will focus on Sickle Cell Anemia.


1. Hereditary. Inheritance of sickle hemoglobin gene (HbS)
which causes hemoglobin to be defective. When oxygen
levels are low, the S hemoglobin loses its round, flexible shape
and become rigid and sickle-shaped. They get caught in small
vessels and restrict or stop blood flow to tissue or an organ.
With ischemia and infarction, pain, swelling and fever occurs.
Exposure to cold can cause vasoconstriction and lead to the
same problem.
With restored oxygen tension, the sickled cells "unsickle".
Repeated episodes damage RBC membranes and they die.
This client's RBCs only live about 30 to 40 days.

Even person who only has the trait can have


some symptoms in extreme situations of hypoxia and FVD.
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2. Diagnostic testing for Sickle Cell Anemia:


a. Low hematocrit and sickled cells on smear
b. Confirmed by hemoglobin electrophoresis which identifies
the hemoglobin S

3. Symptoms specific to Sickle Cell Anemia

4. Management of sickle cell anemia--goals are to


prevent effects of anemia and avoid crises
a.
b.

c. Hydroxyurea (chemotherapy)--decreases formation of


sickled cells, but has many negatives (WBC suppression,
secondary malignancy, birth defects if birth control not
practiced)
d.
e.
f.
g.
h.
i.
j.

5. Management of sickle cell crisis


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C. High RBCs: Polycythemia

1. Overall S&S of high RBCs

2. General Management and Nursing Care of High RBCs


a.

b.

c.

d.

3. Polycythemia Vera or Primary Polycythemia-Bone marrow &


spleen have excessive hematopoiesis

a. All myeloid cells increased, but mostly RBCs, thus Hgb and Hct are
elevated
b. Eventually bone marrow "burns out" and becomes fibrotic
c. Dx by CBC, enlarged spleen, and S&S
d. Can end up in Acute Myeloid Leukemia (AML)
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4. Secondary Polycythemia

V. WBCs: Main function is that they protect body against infection and tissue
injury; Normal is 5,000 - 10,000

A. A&P of WBCs

1. Leukocytes from Myeloid cells

a. Granulocytes—60 0 70% of leukocytes are these


1. Immature granulocytes are called bands “Shift to the left”

2. Mature granulocytes are called Segs

3. Types of granulocytes
a. Neutrophils—segmented neutrophils (Segs)
important for phagocytosis

b. Eosinophils—function in hypersensitivity reactions to


neutralize histamine

c. Basophils—Produce and store histamine and other


substances involved in hypersensitivity reactions

b. Monocytes
1. Only about 5% of total leukocytes but are the largest
2. Are 2nd to arrive at site of inflammation and continue phagocytosis
as macrophages
3. Produces in bone marrow, circulate briefly and then become
macrophages in various body tissues such as spleen (main site),
liver, lungs, and lymph nodes
Macrophages are the Reticuloendothelial System (RES)

2. Leukocytes from Lymphoid cells


a. Produce substances that aid in attacking foreign material
b. 30 – 45% of leukocytes are lymphocytes but only about 1% circulating in
blood. They migrate through the lymphatics and blood vessels to
lymphoid tissues all over the body. As they go, they mature into either
B or T Lymphocytes.
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1. B Lymphocytes
a. Produced in bone marrow
b. Can differentiate into plasma cells which produce
immunoglobulins or antibodies which are proteins that destroy
foreign material—humoral immunity
2. T Lymphocytes (also called CD4 Count)
a. Produced in bone marrow but migrate to and mature in the
thymus
b. Responsible for delayed allergic reactions, destruction of tumor
cells, and transplant rejection

B. Low WBCs:
1. Terminology
a. Leukopenia

b. Neutropenia

c. Granulocytopenia (Agranulocytosis)

2. Overall S&S with low WBCs

3. General Medical and Nursing Care for low WBCs


NEUTROPENIC PRECAUTIONS (see cancer notes)

C. High WBCs: Leukocytosis


1. Leukemias--proliferations of WBCs in bone marrow--classified
according to whether from lymphoid or myeloid stem cells;
Genetic? Viruses? Most deaths due to infection

a. Myeloid
1. Acute Myeloid Leukemia-AML
a. Proliferation of all myeloid cells
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b. Usually poor prognosis


c. S&S b/c of all cells abnormal (anemia, infection, bleeding)
d. Tx: Supportive care (antibiotics, blood, etc)
Chemo, Allogenic bone marrow transplant

2. Chronic Myeloid Leukemia-CML


a. Proliferation of all myeloid cells, but there are also normal cells
b. Usually older people get this & are asymptomatic for years,
but with progression symptoms begin (bone pain, fever, wt
loss)
c. Tx: Treated symptomatically at first, then as it becomes more
acute, chemo is stepped up more aggressively, Supportive
care, Bone marrow transplant before becomes acute

b. Lymphoid
1. Acute Lymphocytic Leukemia-ALL
a. Proliferation from lymphoid stem cell
b. Usually occurs in very young children
c. Most survive about 5 years with treatment
d. Immature lymphocytes proliferate & crowd out production of
other cells: S&S are of decreased RBCs, platetlets, and
increased immature white cells; Also bone pain common
e. Tx: chemo, radiation, allogenic bone marrow transplant

2. Chronic Lymphocytic Leukemia-CLL


a. B Lymphocytes mature but are in excess and accumulate in the
bone marrow, circulation, lymph nodes, liver, spleen, and other
organs causing pain
b. Most common in US and Europe
c. Usually over age 60
d. S&S of anemia & thrombocytopenia once they are crowded out
Also can get "B" symptoms:
fever, drenching night sweats, wt loss
In this case, they have defective humoral and
cell-mediated immunity so infections common
e. Tx: Not necessary when asymptomatic, but once with
symtpoms may get chemo, steroids, immunoglobulins

Nursing Care of Leukemias:

2. Malignant Lymphomas--cancer of lymphoid cells

a. Hodgkin's Lymphoma
1. Rare malignancy, easily cured in early stages; extends
through lymphatic system
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2. Dx: Excessional lymph node biopsy with presence of


Reed Sternberg cell (giant tumor cell); then must be
"staged" (to determine the extent of the disease)

3. S&S of Hodgkin’s Lymphoma

b. Non-Hodgkin's Lymphoma
1. Dx:

2. S&S

Nursing Care of Both Lymphomas:

3. Multiple Myeloma
a. Malignancy of the plasma cell (mature form of lymphocyte)
b. Remember plasma cells secrete immunoglobulin which is
necessary for antibody production

c. Diagnosed by:

d. S&S of multiple myeloma

e. Treatment of multiple myeloma

VI. Platelets
A. Main function is control of bleeding

B. Normal value is 150,000 - 400,000


C. Low Platelets: Thrombocytopenia
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1. Overall S&S with low platelets

2. General Medical Care for low platelets

3. Bleeding Precautions (see cancer notes)

4. Thombocytopenia
a. Caused by:
1.
2.
3.

b. Petechiae

c. Hemorrhage

d.

e.

f. Managed by treating underlying problem

5. Idiopathic Thrombocytopenic Purpura (ITP)


a. Various causes

b. DX:

c. Treatment
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d. Nursing care:

6. Primary Thrombocythemia (platelets > 600,000 but poor


function, thus bleeding occurs)
7. Disseminated Intravascular Coagulopathy (DIC)

D. High platelets--many acquired and hereditary causes


1. Terminology
a. Thrombotic disorders/thrombophilia--tendency to make clots --
can be venous or arterial

b. Secondary Thrombocytosis--Is a response to some other problem


and usually & significant S&S, and resolves once underlying
cause fixed

2. Overall S&S with high platelets--thrombotic episodes

3. General Medical and Nursing Care with High Platelets


a. Medical Management:
1. Heparin therapy

2. Low-Molecular-Weight-Heparin Therapy (LMWH) Lovenox

3. Coumadin therapy

b. Nursing Care of Thrombotic Disorders


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STEM CELLS IN BONE MARROW

MYELOID CELLS LYMPHOID CELLS

ERYTHROCYTES THROMBOCYTES
RBCs Platelets

NK cells
B LYMPHOCYTES Can attack T LYMPHOCYTES
Mature in bone marrow any target Mature in thymus
LEUKOCYTES Humoral Immunity Cell Mediated I
Immunity
WBCs

Memory cells Memory cells


Acquired Immunity Acquired
immunity

PLASMA CELLS Regulator


GRANULOCYTES MONOCYTES Make Antibodies T cells Effector T cells
Large #s Small #s
Bands--babies Macrophages--RES IgM 1st formed
2nd Response IgG 2nd formed
Most #s
IgE Releases Helper T Suppressor T
histamine "ON" "OFF"
IgA Mucosal Promotes Shuts off &
NEUTROPHILS IgD ????? proliferation limits T helper
Segs--mature of B Lymphs and B cells
Phagocytic BASOPHILS and T cytotoxic
1st response Release histamine and
heparin in allergic response

T cytotoxic
EOSINOPHILS Killer cells
Neutralize histamine; defend against parasites