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CHAPTER 9

Hematologic System

Hematologic System

PHYSIOLOGY OF THE BLOOD
A. Functions of the blood. 1. Transports oxygen from the lungs to the tissues and carbon dioxide from the tissues to the lungs. 2. Transports nutrients from intestines to body cells. 3. Transports waste products to kidneys for excretion. Components. 1. Plasma: 90% water; accounts for about half of the total blood volume. 2. Formed elements (cells): account for about half of the total blood volume. a. Erythrocytes (red blood cells [RBCs]). b. Leukocytes (white blood cells [WBCs]). c. Thrombocytes (platelets). Characteristics of plasma. 1. Plasma is clear and straw colored; it does not contain cellular elements. 2. Globulins: Gamma globulins are protein components; their primary function is prevention of infection. 3. Fibrinogen is a necessary element in normal clot formation; produced in the liver. 4. Prothrombin is a necessary element for normal coagulation. a. Produced in the liver. b. Normal production is dependent on availability of adequate vitamin K. Characteristics of erythrocytes (red blood cells). 1. Formed in the red bone marrow; erythropoiesis is the production of red blood cells. 2. Vitamin B12 and folic acid are necessary for the production of normal erythrocytes. 3. Hemoglobin is the primary component of the red blood cell and binds with oxygen. 4. Primary function is transportation of oxygen and carbon dioxide. 5. The fraction of the blood occupied by erythrocytes is called the hematocrit. Characteristics of leukocytes (white blood cells). 1. Function is to protect the body against invading microorganisms. 2. Leukocytosis refers to an overall increase in the number of leukocytes; leukopenia refers to an overall decrease in the number of leukocytes. Characteristics of thrombocytes (platelets). 1. Function: primarily involved with hemostasis. When blood vessel wall is damaged, platelets 2.

B.

G.

adhere to the area and eventually form a platelet plug to decrease bleeding. Thrombocytosis refers to a marked, abnormal increase in the number of thrombocytes; thrombocytopenia refers to a marked, abnormal decrease in the number of thrombocytes. Blood classifi cation. 1. Major blood groups: A, B, AB, and O. 2. Rh factor may be present (positive) or absent (negative). a. Rh factor is present on the red blood cell. b. Rh-positive factor is present in 85% to 95% of the population.

C.

Data Collection
A. Evaluate history. 1. History of disease of bone marrow or organs affecting production of blood. 2. History of treatment that depressed bone marrow activity (especially chemotherapy or radiation therapy). 3. Family history of hematologic problems (inheritance pattern). Bleeding problems occurring during pregnancy, labor and delivery, or immediately after birth in both mother and infant. Presence of disorders, aging, or disease processes other than hematologic disorders (Table 9-1). Evaluate effect hematologic disorder has on client’s lifestyle and activities of daily living (ADLs). 1. How long has client experienced symptoms? 2. What are current activities and metabolic requirements of the client? 3. Presence or absence of bleeding episodes. 4. Ability to control pain. Assess client’s current nutritional status. Evaluate current blood values. Evaluate status of respiratory and cardiovascular systems in maintaining homeostasis.

B. C. D.

D.

E.

E. F. G.

Anemias
✽ Anemia is characterized by a low RBC count and a decrease to below normal in hemoglobin and hematocrit values. The more rapidly an anemia occurs, the more severe the symptoms will be.

F.

176

f. 3. Increased dietary iron intake (see Table 2-2) . or chronic alcoholism. palpitations. evaluate impact of condition on nutritional status. to assess capillary refill. Older adults are losing body hair. D. 2. etc. . tachypnea. Aplastic anemia: characterized by depression of the bone marrow in production of all blood cell types— RBCs. glossitis. cyanosis. most common age at diagnosis is 60 years. weakness. Shortness of breath. and decreased capillary refill are often noted in hematologic disorders. Dilantin). leukemia. cheilitis—three most common findings. a. Tachycardia. 5. nausea. TEST ALERT Identify client’s ability to maintain activities of daily living. Paresthesia in the extremities. a.. Supplemental folic acid. 2. Bleeding problems associated with thrombo- cytopenia. Generally not associated with inadequate dietary intake. 1. Smooth. gastritis. e. General symptoms of anemia. It may be associated with loss of intrinsic factor (gastric resection). Fever. Common goal in treatment of all anemias is to identify the origin and correct the problem. radiation. such as the lips. 3. May occur in pregnancy or with heavy flow during menses. c. Dry skin is a normal aspect of aging and thus becomes an unreliable indicator of skin moisture. Hair distribution Skin moisture and color A. E. Chronic anemia may result in growth retardation in infants and children. Hematopoietic stem cell transplant (see Appendix 9-4). C. postural hypotension. Can result from radiation therapy. General symptoms of anemia. B. 6. Treatment: supplemental iron intake (see Appendix 9-2). Pallor that is not associated with anemia may be noted in older adults. WBCs. Common in adolescents. and jaundice may occur with anemia. dyspnea on exertion. 4. 1. 7. Pigment loss and skin changes along with some yellowing occur with aging. Treatment: injections of vitamin B12 may be required indefinitely. 1. delayed wound healing. May be precipitated by chemotherapeutic agents. Skin dryness. Treatment: a. Pallor. 6. beefy. 7. d. or it may be an autoimmune problem.g. Lack of hair only on lower legs and toes may indicate poor circulation. pallor. weight loss. confusion. Need to use another body area. 6. and anticonvulsant medications (e. Data Collection. because they tend not to go outdoors and get exposed to sunlight. Anorexia. b. and apathy. but often in an even pattern distribution that has occurred slowly over time. May be precipitated by gastric resection. reduced vibratory sense. 3. weakness. Pale skin. 5. 4. Older adults are more prone because of poor dietary iron intake and decreased absorption in the small intestines. Older Adult Changes and Significance Nails are typically thickened and discolored. adapt a diet to meet special needs of the client. Diagnostics: decreased hemoglobin and hematocrit values (Appendix 9-1). 5. occurs in infants whose primary diet is milk. TEST ALERT Evaluate client’s nutritional status. Chronic fatigue. Pernicious anemia: condition characterized by an inability to absorb vitamin B12 (cobalamin). TABLE 9-1 Assessment Area Nail beds (check for capillary refill) CHAPTER 9 Hematologic System 177 AGE-RELATED ASSESSMENT FINDINGS FOR THE HEMATOLOGIC SYSTEM Hematologic System Findings Pallor. b. 2. Iron deficiency anemia: characterized by inadequate intake of dietary iron or excessive loss of iron. Infections associated with neutropenia. Thin or absent hair on trunk and extremities may indicate poor oxygenation and blood supply to area. More common in older adult. red tongue (glossitis). and platelets. 4.

Sickling problem is not apparent until around 6 months of age. Deficiency may occur with increased demands for folic acid: infancy. Maintain adequate hydration. B. characterized by pain. Evaluate for temperature elevations frequently. ischemia. D. Pulmonary – symptoms of pneumonia. Complete nutritional evaluation. F. Predominantly a problem of children and adolescents. 5. (From Zerwekh J. C. History of possible causes. Renal – hematuria. causing ischemia and pain. B. B. Sickle Cell Anemia ✽ Sickle cell anemia is a problem characterized by the sickling effect of the erythrocytes. C. B. 2. A. FIGURE 9-1 Sickle cell anemia crisis. Bleeding in a client with sickle cell anemia produces different symptoms than bleeding in a client who has undergone surgery. 3. 1. and decreased function (hand-foot syndrome). Ingram. Decrease exposure. Evaluate for symptoms of hypoxia (see Chapter 10). Diagnostics (see Appendix 9-1): early diagnosis. B.) 4. The problems from childhood may cause long-term complications as they become adults. Pathologic changes of sickle cell disease result from: 1. A. D. before 3 months of age. v Goal: To decrease body oxygen needs. Data Collection A. Claborn J: Memory notebook of nursing. anorexia. 2. 4. liver failure. visual problems. CNS – stroke. Identify foods high in iron and folic acid (see Chapter 2). v Goal: To help client understand implications of disease and measures to maintain health. May appear ill with malnourishment. Vaso-occlusive crisis: blood flow is impaired by sickled cells. Folic acid deficiency anemia: associated with decreased dietary intake of folic acid. Texas. 6. swelling. Immunosuppressive medications. Discuss importance of continuing medical follow-up. Cycle of occlusion. and pregnancy. A. Observe for leukocytosis. vol 2. helps to minimize complications. Nursing Interventions For all clients with anemia. infection with temperature elevation. May need supplemental oxygen. 1. Provide diversional activities but also provide for adequate rest. Splenomegaly. Nursing Education Consultants. Dehydration. ✔NURSING PRIORITY: Recognize occurrence of a hemorrhage. Extremities . A. Child may be asymptomatic between crises. . Treatment: folic acid injections may be necessary initially. notify health care provider regarding signs of potential complications. Explain side effects of medications. C. and infarction to vascular organs. Assess client’s tolerance to activity. Sequestration crisis: pooling of the blood in the liver and spleen with decreased blood volume. 3. Hypoxia. Conditions precipitating sickling effect (Figure 9-1). Evaluate ability of cardiovascular system to maintain adequate cardiac output. v Goal: To prevent infections. 2007. v Goal: To assess for complications of chronic anemic state. plan and implement nursing care to prevent complications. v Goal: To assist in establishing a diagnosis. hepatomegaly B. 4. acidosis.178 CHAPTER 9 Hematologic System b. D. Kidney damage caused by the congestion of glomerular capillaries and tubular arterioles. B.occlusions in the small distal bones of the hands and the feet. C. 1. ed 3. then oral replacement. A. Increased RBC destruction. an inherited autosomal recessive disorder. 2. A. 3. D. Explain medical regimen. Increased blood viscosity. Caused by alcoholism. 2. C. malabsorption syndromes. adolescence. Abdomen – severe abdominal pain. the increased levels of fetal hemoglobin up to that age prevent serious sickling problems. Increased viscosity eventually precipitates ischemia and tissue necrosis caused by capillary stasis and thrombosis.

pneumococcal vaccine is recommended. Peak occurrences: around 4 years of age. especially respiratory tract infections. B. a. claudication (pain in muscles during activity). Hydrea): reduces sickling episodes. prevention of DVT). E. A. then again around 65 years. Favorable prognosis with chemotherapy. Client with sickle cell disease should avoid situations . Chronic myelogenous leukemia (CML). D. 2. Encourage normal growth and developmental activities as tolerated by the child. 1. Blood transfusions and/or exchange transfusions (see Appendix 9-3). Promote respiratory health and tissue oxygenation. B. 3. v Goal: To control pain. Bleeding tendencies caused by decreased platelets. Data Collection A. median age is 60 years. 2. passive range of motion may be beneficial. v Goal: To prevent sickling crisis. Leukemic cells will infiltrate the meninges. Types of leukemia. hypertension. maintain accurate intake and output records. C. D. Acute lymphocytic leukemia (blast or stem cell) (ALL). Complication: stroke secondary to thrombosis. 2. Prevent infection. antibiotics. 1. Analgesics for pain. Daily folic acid supplement. Administer oxygen as indicated. then every 2-3 months). Home Care A. Treatment of crisis. Three primary consequences of leukemia. Adequate hydration. eventual cellular destruction occurs as a result of the infiltration of the leukemic cells into the body tissue. a long-term complication of leukemia. Seek early intervention for symptoms of infection. Inform all significant health care personnel that child should wear medical identification. Polycythemia Vera (Primary) ✽ Polycythemia vera is a chronic disorder characterized by a proliferation of all red marrow cells due to a chromosomal mutation. A. Bed rest. A. B. A. 2. vertigo. tinnitus. Maintain adequate hydration. 1. Peak incidence age 60 to 70 years. Traveling to high-altitude areas. Uncommon before the age of 20 years. Infection associated with neutropenia. Administer appropriate analgesics. A. Surgery: splenectomy. Nursing Interventions v Goal: To prevent sickle cell disease. Leukemia ✽ Leukemia is an uncontrolled proliferation of abnormal white blood cells. coughing. c. C. B. E. 2. Angina. Treatment CHAPTER 9 Hematologic System E. Most common in older adults. Participate in community screening programs and education. pruritus. b. a. B. Acute myelogenous leukemia (AML). Increase fluids with physical activity. 2. Flying in an unpressurized aircraft. 4. Evaluate adequacy of hydration. precipitating increased intracranial pressure. peak incidence age 45 years. C.e. B. report temperature elevations. or pain. hydration. Participating in overly strenuous exercise. C. especially respiratory tract infection. Refer persons who are carriers (autosomal recessive trait) for genetic counseling. Provide good pulmonary hygiene. Thrombophlebitis. Treatment A. b. Anemia from RBC destruction and bleeding. Ruddy complexion (plethora). Clients generally do not require iron because of increased resorption. 3. Maintain rest if movement exacerbates pain. Nursing Interventions v Goal: To help client understand implications of the disease and long-term health care needs (i. B. 1. Myelosuppressive agents. v Goal: To maintain adequate hydration and oxygenation. 3. Oxygen – assists to prevent a crisis in client with respiratory problems. Problems of decreased blood flow. D. 3. Evaluate electrolyte balance. Usually occurs during middle age. D. C. B. Early signs: headache. 3. Phlebotomy (2-3 times per week initially. 5. Assessment of involved area. Allow client to assume a position of comfort. 1. intravenous (IV) fluids may be necessary. that may precipitate hypoxia. Prevention of the sickling problem. Prevent infections. Hydroxyurea (Droxia. 179 A. D. promote adequate oxygenation. 1. Monitor IV fluid administration carefully. C. a.. but it does not reverse a sickling crisis or reduce pain. B.

E. Nonsteroidal antiinfl ammatory drugs. weight loss. • Perform guaiac tests on stool as necessary. Hematopoietic stem cell transplantation (see Appendix 9-4). and infl uenza immunizations are not recommended to be given to children or adults during immunosuppression. • Avoid overinfl ation of blood pressure cuff or leaving cuff infl ated for prolonged period of time. bruises easily. and bleeding tendencies occurring together. ✦ Use soft toothbrush or no toothbrush. Involve client in evaluating level of activity. ✔NURSING PRIORITY: Identify symptoms of infection and treatment of common infections is a priority in the care of this client. Monitor temperature elevation closely. d. varicella. • Limit number of venipunctures and intramuscular injections. C. 2. B. 4. Use local measures to control bleeding (pressure to area. B. Nursing Interventions v Goal: To prevent infection. • Avoid catheters (urinary and suctioning) when possible. Avoid urinary catheterization if possible. Presence of Philadelphia chromosome in 90% of cases. notify doctor of increase above 100. 1. • Oral hygiene: ✦ Discourage fl ossing. v Goal: To decrease adverse effects of chemotherapy (see Table 2-4). Symptoms are less severe than those in acute stages of disease. Allopurinol (Zyloprim) decreases uric acid levels in clients receiving chemotherapy. lethargy. infl ammation. D. increased irritability. especially oral hygiene and around perianal area. A remission is characterized by absence of leukemic cells and disappearance of all disease symptoms. Complaints of bone and joint pain. F. Maintain adequate hydration. v Goal: To prevent complications of transfusions (see Appendix 9-3). or any condition that causes bleeding. G. may need to use cotton-tipped swabs while gums are friable. administer analgesic before pain becomes severe. and more common in men. B. C.). etc. epistaxis. C. Central nervous system involvement: headache. D. Onset is generally slow. • Avoid aspirin products. especially those with chicken pox. Protect client from exposure to infection. Chronic lymphocytic leukemia (CLL). 3. Frequently asymptomatic. Polio (IPV). may coordinate positioning with administration of analgesics. measles-mumps-rubella. 6. decrease activity when platelet counts are low and anemia is present. E. Treatment A. • Discourage client from vigorous coughing or nose blowing. • Use electric razor for shaving. Hepatomegaly and splenomegaly. 7. Clinical manifestations. Corticosteroids and antineoplastic agents. Assess for evidence of infection: fever. Anorexia. 4. . Evaluate effectiveness of pain relief. B. 2. Medications. • Provide safe environment and prevent injury according to age (padded side rails. Common malignancy of older adults. a. in creased bruising. Data Collection A. ✦ Rinse mouth frequently with mild mouthwash. B. NSAIDs. Meticulous skin care. Do not exercise affected joints. hematuria. v A. lowbacteria diet. rare before age 30. degree of restriction depends on immunosuppression. soft toys. C. Indications: Clients diagnosed with leukemia. often diagnosed in a chronic fatigue work-up. Position carefully. house shoes. cold packs). infection. H. v Goal: To provide pain relief. • Monitor for bleeding episode: nosebleed. Maintain environment conducive to rest. Fatigue. evaluate NSAIDs for bleeding properties. A. clients receiving anticoagulants or thrombolytic medications. confusion. c. b. hemophilia. Anemia. Isolate client from persons with communicable childhood diseases. Encourage adequate protein and calorie intake. • Avoid enemas and suppositories. A. I. cough.5° F (38° C). Petechiae. Restrict strenuous activity. Use acetaminophen rather than aspirin. ✦ Avoid harsh mouthwashes. 1. pain. 5. Goal: To prevent or limit bleeding episodes (Box 9-1).180 CHAPTER 9 Hematologic System BOX 9-1 BLEEDING PRECAUTIONS b. Diagnostics (see Appendix 9-1): bone marrow aspiration to evaluate cell production. • Assess perianal area for fi ssures and bleeding daily.

3. Initially. Lymphoma is the fifth most common type of cancer in the U. B. 3. Apply cold pack to promote vasoconstriction. Spontaneous hematuria Hematoma. C. Primarily affects males. during. C. Physical therapy after the acute phase. Encourage active range of motion so child will limit movement based on pain tolerance. The disease is most often recognized during the toddler stage. F. Evaluate for shortness of breath. Hemarthrosis: bleeding into joint cavities. Symptoms are highly variable. Hemophilia is a sex-linked recessive disorders. F. Immobilize and elevate the joints involved. Correct technique for venipuncture. Females are carriers. Observe for signs of internal bleeding: tarry stools. Treatment: chemotherapy and radiation. A. D. Preventive dental care. given IV push over 5-10 minutes. v Goal: To decrease adverse effects of chemotherapy and radiation therapy (see Table 2-4). Maintain pain relief during physical therapy. E. . Indications for use. D. bone marrow. It spreads malignant cells unpredictably. v Goal: To recognize and treat bleeding episodes. B. 2. 1. Manage pain and effects of therapy. A. Common metastatic sites are the spleen. Petechiae are uncommon. Maintain good pulmonary hygiene. Treatment may be carried out at home. liver. E. or mediastinal lymph nodes. generally around age 9 to 12 years. B. C. Non-Hodgkin’s lymphoma: a neoplastic growth that originates in the lymphoid tissue. Disease is spread by extension along the lymphatic system. infiltrating the lymphoid tissue. v Goal: To prevent infection (see “ v Goal: To prevent infection” in Leukemia section above). Instruct client to avoid contact sports. night sweats. Fever. axillary. Regular exercise and physical therapy to promote muscle strength around joints and decrease bleeding episodes. A. slurred speech. Assess ability of cardiovascular system to maintain cardiac output. Hemophilia ✽ Hemophilia is a defect in the clotting mechanism. because platelet count is normal. D. Treatment A. 1. Lymphomas CHAPTER 9 Hematologic System C. E. depending on where the disease has spread. Do not perform passive range of motion on affected joints. 2. Administer clotting factors before. C. Desmopressin (DDAVP. Apply pressure to the area. G. and lungs. Make environment as safe as possible without hampering motor development. B. Data Collection A. Maintain normal weight. D. increased weight causes increased strain on the joints. E. Maintain hydration and nutrition. B. headache. C. malaise. Treatment: chemotherapy and radiation. Decrease risk for injury. D. Avoid any aspirin compounds. A. and prevent oral infections. A. Increased incidence in immunosuppressed clients.. but encourage noncontact sports (e. Intracranial hemorrhage may be fatal. 181 ✽ Characterized by malignant neoplasms originating in the bone marrow and lymphocytes. B. Hodgkin’s disease: characterized by painless enlarge- ment of lymph nodes with progression to involve the liver and spleen. A. Weight loss and fatigue are associated with a poor prognosis. This is the most curable of the lymphomas. B. v Goal: To prepare client and family to administer clotting factors intravenously at home. Factor VIII concentrate: must be reconstituted with sterile water immediately before administration. painless enlargement of cervical. Encourage child to learn self-administration. F. swimming). Decrease body needs for oxygen. given IV or intranasal. 1. 5. Administer clotting factors in a timely manner. C. B. 2. Nursing Interventions v Goal: To prevent spontaneous bleeding episodes (see Box 9-1). 4. Persistent or prolonged bleeding that occurs from minor trauma/insults.S. Stimate): synthetic vaso- pressin used to treat mild cases. 2. inguinal. no weight bearing until swelling has resolved. and after invasive medical procedures. maintain in semi- Fowler’s position. 1.g. 3. Increased incidence in clients with immuno- deficiency or autoimmune conditions who have used immunosuppressant medications. Nursing Interventions v Goal: To maintain physiologic equilibrium. Elevate joint and immobilize during acute bleeding episode. v Goal: To prevent permanent joint degeneration.

D. Analgesics for pain. E. B. Treatment A. C.182 CHAPTER 9 Hematologic System Disorders of the Spleen ✽ The spleen is affected by many disorders that can result in splenomegaly (enlarged spleen). Correction of the underlying problem. Encourage ventilation of feelings regarding critical illness of family member. Teach about lifelong risk for infection following splenectomy. Hypotension leading to shock. extensive tissue damage. Hypersplenism: splenomegaly with peripheral cyto- penias (anemia. Prolonged bleeding from multiple body areas. A. thrombocytopenia). Encourage ventilation of feelings regarding critical illness of family member. Provide emotional support and encourage visiting as intensive care policies and client’s condition allow. thereby precipitating a bleeding disorder. Nursing Interventions v Goal: To identify the problem early (splenomegaly. Be available to family members during visiting time. infection. ✔NURSING PRIORITY: Apply RICE to the affected joints: rest. Assess and support all vital systems. It is not a disease but a result of underlying conditions. abdominal distention. B. B. B. Data Collection A. ice. elevation. Nursing Interventions v Goal: To identify the problem early and to decrease potential adverse effects. shock. ecchymosis on skin and mucous membranes are noted. C. leukopenia. compression. Multiple organ dysfunction syndrome. v Goal: To help the client’s family understand the implications of the disease and demonstrate appropriate coping behaviors. Nursing measures to prevent bleeding episodes in hypersplenism (see Box 9-1). Splenic rupture from trauma or inadvertent tearing during other surgical procedures. Treatment A. Splenectomy. C. hypersplenism. sepsis. Thorough assessment of bleeding problems in clients severely compromised by other problems (shock and sepsis). immunologic deficiencies. hypersplenism. The spleen usually contains 20 to 40 mL of blood and does not serve as a reservoir for blood volume or red blood cells. fresh frozen plasma transfusions. C. or splenic rupture (emergency surgery). B. A. Be available to family members during visiting time. Assess and support all vital systems D. Provide emotional support and encourage visiting as intensive care policies and client’s condition allow. . Thorough assessment of spleen problem and man- agement to address issues of splenomegaly (pain). C. Platelets. burns. B. C. or splenic rupture) and to decrease potential adverse effects. shock. A. Data Collection A. Pain due to splenomegaly. C. Monitor for complications following surgery—hem- orrhage. B. A. fever. Disseminated Intravascular Coagulation ✽ Disseminated intravascular coagulation is a secondary coagulation disorder involving widespread clotting in the small vessels. Caused by hemolytic processes. leading to consumption of clotting factors. v Goal: To help the client’s family to understand the implications of the problem and demonstrate appropriate coping behavior. D. encourage vaccination for pneumococcus. Nursing measures to prevent bleeding episodes (see Box 9-1). Petechiae.

____ 2  Plan all nursing activities early in morning to pre- vent fatigue. A client is admitted with thrombocytopenia. 2 Discourage flossing and encourage use of a soft toothbrush. What will the nurse implement to address this problem? 1 Contact precautions. What is important to include in the nursing care? 1 Evaluate daily lab values to determine clotting fac- tors. 2 Apply pressure at the site. 4 Apply warm packs to joints to prevent further bleeding. What is the best nursing action? 1 Put an ice bag on the finger. What is the best nursing care regarding joint mobility and activity? 1 Encourage walking around the unit every 2 hours. 4 Petechiae and tachycardia. 4 Decreased bowel sounds. 3 Provide increased availability of iron. A client is being treated with epoetin alfa (Epogen). 6. 2 Joint pain and bleeding. CHAPTER 9 Hematologic System 183 Study Questions Hematologic System 1. 3 Monitor for bleeding tendencies. 11. 3. 3 A 2-year-old child with a high milk intake. What nursing interventions would be important in the care of a client who has severe aplastic anemia? Select all that apply: ____ 1  Maintain warm environment. ____ 5  Encourage activity. 10. ____ 6  Evaluate respiratory response when ambulating. 3 Nausea and fever. 3 Apply pressure at the brachial artery. 2. or peel vegetables and fruits. 4 Keep the joints immobilized and maintain bed rest. call physician’s office if oral temperature is greater than 101˚ F. 2 A client with a history of peptic ulcer disease. 4 A teenager in a sickle cell crisis. A client has developed aplastic anemia. 12. What health problem in the client’s past would be associated with this condition? 1 Hemorrhage and shock after surgery. 2 Avoid active virus vaccinations. 8. The nurse is caring for a client with a hemoglobin level of 8. 2 Gently move each leg through active range-of- motion exercises. 2 Increase fluid intake. 4 History of stomach resection and loss of intrinsic factor. what is impor- tant for the nurse to discuss with the parents? 1 Maintain good hydration status. 3 Nausea and vomiting. The nurse is assessing a client who has been admitted for treatment of his leukemia. ____ 3  Evaluate client for tachycardia. 5. 3 Treatment of high temperature. 4 Increase intake of high-calorie foods. 7. 4 Assess for bradycardia and fever. 3 Encourage increased intake of iron-rich foods. A child is recovering from a sickle cell crisis. What nursing observation should be reported immediately? 1 Swelling and bleeding into knees. An older client is being discharged after diagnosis and treatment for leukemia. 2 Increased bruising. 13. The nurse would expect to find which symptoms in a client who has hemophilia? 1 Muscle pain and vomiting. 4 Increase production of red blood cells. A child has a severe laceration on his finger that is bleeding profusely. bleeding joints. 4 Catheterize the client to determine renal bleeding. What would the nurse anticipate to be a priority concern for nursing care? 1 Pain management. 9. . He is experiencing bleeding into his knees. A 10-year-old client is admitted in a sickle cell crisis. Which client would the nurse identify as being at in- creased risk for development of an iron-deficiency anemia? 1 An older client receiving radiation therapy weekly. 4 Prepare an injection of vitamin K. What will be important to discuss with this client regarding home care? 1 Maintain a diet that is low in protein and high in carbohydrates. The nurse is caring for an older client with leukemia. 2 Enhance the effectiveness of the chemotherapy medications. cook. To pro- mote health in this child after discharge. 4 Bleeding precautions. 3 Avoid contact with peers. 2 Swollen. 3 Cold packs to the joints. 2 Poor dietary intake of iron and folic acid. 3 Treatment for a pulmonary malignancy. keep warm. The nurse would explain to the client that the purpose of the medication is to: 1 Decrease the availability of prothrombin to decrease bleeding episodes. A client has been placed on bleeding precautions. 3 Always thoroughly wash. 3 Place warm packs on the joints to promote mobility. especially ambulating 3 times a day. 2 It is important to regularly check temperature. 4. ____ 4  Encourage diet that is high in iron and vitamin K. 14. 2 Assess for tachycardia. What are important nursing measures? 1 Increase fluids and ambulate 3 times a day. 4 Oral temperature of 101˚ F.2 gm/dl.

000-400. and bone marrow depression. 3. Feeling of pressure when bone marrow is entered. Values reflect the volume of RBCs found in 100 ml of whole blood. CLINICAL AND NURSING IMPLICATIONS 1. Answers and rationales to these questions are in the section at the end of the book titled Chapter Study Questions: Answers and Rationales. 3 Position the client supine and check the blood pres- sure. and platelets). 2 He will need to take the medication with milk. 2. resulting in hemo. 1. 2. pain occurs as marrow is being withdrawn. chromosomal abnormalities). Analgesics as indicated. Low levels in anemias. 2 Hold the client’s head back and put ice on the nose. False-positive result can occur for up to 4 months after a transfusion of RBCs that are positive for the trait. COMPLETE BLOOD COUNT Platelets RBC count Hemoglobin 150. Appendix 9-1 TEST Bone marrow aspiration or biopsy HEMATOLOGIC DIAGNOSTICS NORMAL All formed cell elements within normal range (erythrocytes. d. White blood cells are an important component in the body’s defense against infection.. 1.184 CHAPTER 9 Hematologic System 16. Routine screening test for sickle cell trait or disorder. 1. Components of the RBC responsible for oxygen transport.000/mm3 Child (2 years): 6000-17. Decreased platelets (thrombocytopenia) associated with bleeding. Apply pressure to site 5 to 10 minutes or longer if client is thrombocytopenic. Observe for bleeding at site. 3 He should decrease his intake of leafy. 4 It will be important for him to have weekly lab studies to evaluate the medication. b. After test: a. c. 1. as well as analgesics or conscious sedation. Elevated levels (leukocytosis) are associated with infection. 3. Decreased in clients with bone marrow depression and anemias. does not distinguish between them.000/mm3 4. 2. Client preparation: a. 4 Encourage clear liquids and observe for nausea. absence. chronic and acute blood loss. Local anesthetic is used. or ratio of cells characteristic of a suspected disease (e. False-negative result in infants less than 3 months. 1. 1. hematopoiesis pathology. bone marrow depression 3. Monitor for infection. 2.000/mm3 . What is the first nursing action? 1 Apply pressure to the nose and have the client lean forward.0 million/mm3 Female: 16 g/dl Male: 14-18 g/dl Newborn: 14-20 g/dl Female: 37%-47% Male: 40%-54% Newborn: 52%-62% Hematocrit WBC count Adults: 5000-10. green veg- etables that are high in vitamin K. Sickle cell test (SICKLEDEX) No hemoglobin S present. Decreased in anemias. 3. Evaluates presence. A client has been diagnosed with pernicious anemia. An effective indicator of hydration status. Preferable site is posterior iliac crest. e. A client is experiencing a problem with epistaxis. 2. 4. concentration.g. 15.0-6. What will the nurse discuss with the client regarding the vitamin B12 he will be prescribed when he is discharged? 1 He will need to have monthly injections of vitamin B12. leukocytes. Decreased levels (leukopenia) are associated with diseases of the blood and bone marrow depression. Bed rest for approximately 30 min afterward. An increase in hematocrit may be indicative of a decrease in fluid volume. b.

Tell client stool may be black and iron may cause constipation. 2. cheese. IV. PO Ferrous gluconate (Fergon. Observe bleeding precautions. IV route recommended if oral route is not acceptable. 3. subQ. GI. Anaphylactic reaction can occur. may give with meals if GI upset occurs. IM GI irritation Nausea Constipation Toxic reactions: Fever Urticaria 1. 1. 3. IV 1. 4. milk. IM should be avoided because of pain and tissue discoloration. Appendix 9-2 MEDICATIONS CHAPTER 9 Hematologic System HEMATOLOGIC MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONS 185 Iron Preparations Replacement Ferrous fumarate (Feostat. GI upset. If given IM. 2. Fer-In-Sol): PO Iron dextran injection (InFeD. intravenously. however. rash IV not recommended because of hypersensitivity reactions IM/IV preparations may be used if on oral tetracycline. and antacids inhibit oral iron absorption. subcutaneously. by mouth (orally). FEM Iron): IM. PO. Gastrointestinal. test dose should be given. 4. use Z-track method to prevent tissue staining. Iron preparations inhibit oral tetracycline absorption. Liquid preparations should be diluted and given through a straw to prevent staining of the teeth. . Vitamin K Necessary for normal prothrombin activity Vitamin K: phytonadione (AquaMEPHYTON): PO. Ferralet): PO Ferrous sulfate (Feosol. IM. PO and subQ most common routes. Absorbed better on empty stomach. 2. intramuscularly. Span 77. 3. Eggs. 5. Antidote for Coumadin. IM. SQ. Dexferrum): IV.

sense of impending doom 4. antihistamines may be given before starting the transfusion. Severe shortness of breath. Change the IV tubing. If client has a history of allergic reactions. maintain IV access. Stop transfusion immediately and notify RN or physician. Apprehension. Keep client covered and warm during transfusion. 4. TEST ALERT: Monitor the administration of blood or blood products. Hypotension. 3. Notify the RN if the client’s temperature is above 101˚ F or increases more than 2˚ F. Check vital signs every hour during and 1 hour after transfusion. 3. tachypnea 3. Transfusion with leukocyte-poor RBCs or frozen washed packed cells may prevent this reaction in clients susceptible to fever. chills. Anticipate blood samples to be drawn by the lab. flushing 5. Stop transfusion until status of reaction can be determined. Low back pain 2. 2. 1. • Baseline vital signs must be obtained immediately before starting the infusion. bronchospasm Febrile Reaction 1. do not allow blood in the tubing to infuse into the client. Increased anxiety NURSING MANAGEMENT 1. Headache. • Blood deteriorates rapidly after exposure to room temperature. • When blood is brought to the client care unit from the blood bank. Obtain first-voided urine specimen to test for blood in the urine. Chest pain 6. 1. TRANSFUSION REACTIONS TYPE OF TRANSFUSION REACTION Hemolytic Transfusion Reaction 1. Urticaria (hives) 2. Muscle stiffness/pain 4. • Never add any medication to blood products or to the infusion line of a blood product. the transfusion may be resumed. tachycardia. Pruritus 3. . or if any other vital signs have changed significantly from previous readings. 4. treatment with diuretics is initiated to promote diuresis. Monitor for reaction. Most common reaction. Stop the transfusion until status of reaction can be determined. it should be started immediately. depending on the condition of the client. • Determine if the client has a history of allergy. Facial flushing 4. 2. • The client is most likely to experience a reaction during the first 50 ml of blood infused (approximately the first 15 minutes). • The usual rate of infusion in an adult is 1 unit of blood over 3 to 4 hours. Chills and fever 2. Fever. flushing 3. The RN should set the initial rate. With suspected renal involvement. specifically a previous reaction to transfused blood. Onset is immediate Allergic Reaction 1. if symptoms are mild and transient.186 CHAPTER 9 Hematologic System Appendix 9-3 GUIDELINES FOR MONITORING BLOOD TRANSFUSIONS General Nursing Implications • The practical nurse should be familiar with the Nurse Practice Act of the individual state and hospital policies regarding the administration of blood and blood products. Dyspnea 7. 5. Blood should never be stored in a unit refrigerator or allowed to sit at room temperature. 2. Blood should not hang longer than 4 hours.

Severe thrombocytopenia resulting in bleeding problems. Care of the immunosuppressed client (see Chapter 2). leukemia. Appendix 9-4 anemias.) complications 1. . and platelets. 3. * Includes bone marrow transplant and stem cell transplant. usually 2 to 5 weeks after transplantation. Bacterial. nursing implications 1. 3. 2. procedure CHAPTER 9 Hematologic System HEMATOPOIETIC STEM CELL TRANSPLANT* 187 v Goal: To restore hematologic and immunologic function in clients with immunologic deficiencies. 2. or fungal infection from immunosuppressed state. Successful engraftment is indicated by formation of erythrocytes. approximately 400 to 800 mL of bone marrow or harvested stem cells are processed and transfused into the client. Rejection of the transplant. Preparation of the client for immunosuppression with chemotherapy and radiation therapy. leukocytes. viral. congenital or acquired In the adult client. (See Appendix 9-1 for care of donor client for bone marrow aspiration.

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