Chapter 41 & 42 : Interventions for Clients with Hematologic Problems (RBC Disorders,

WBC Disorders, Platelet & Coagulation Problems)

Anemia
▪ Reduction in either the number of red blood cells, the amount of hemoglobin, or the hematocrit
▪ Clinical sign (not a specific disease); a manifestation of several abnormal conditions
Question:  a nurse interviews an older fm pt who is complaining of fatigue, SOB and headaches,
What ? should the nurse ask first to collect more data about cause of S/S?
1.  Do you have a hx of CVD
2. Can you tell me about your diet?
3. Have you been feeling depressed lately
4. What meds do you routinely take?
Answer: B
 
The pt is complaining of increased fatigue, bleeding gums, and chills. Whats most app initial
nursing intervention?
1. Call Dr
2. Review Labs analysis for S/S of bone marrow suppression  
3. Review lab analysis for s/s of infection
4. Admin prescribed antibiotics to manage pt current infection
Answer: B
 Concern:
▪ Why is client Anemic????
▪ Problem with production
▪ Nutrition
▪ Bone Marrow
▪ Problem with loss
▪ GI tract (bleeding of gut)
▪ Trauma
▪ Problem with destruction
▪ Spleen
l  What will be the consequences of Anemia?
 
Iron Deficiency Anemia
▪ This common type of anemia can result from blood loss, poor intestinal absorption, or
inadequate diet. 
▪ Evaluate adult clients for abnormal bleeding.
▪ Supplemental iron is the treatment.
▪ Side effects:
▪ FOODS    high in Fe (Iron)
▪ Women more at risk b/c of monthly period
 Vitamin B12 Deficiency Anemia
▪ Anemia is caused by inhibiting folic acid transport and reducing DNA synthesis in precursor
cells.
▪ Medication interactions (Metformin & PPIs, H2 Receptor blockers)
▪ Malabsorption (GI-failure to produce intrinsic factor, failure to absorb nutrients)
▪ Poor intake of foods containing vitamin B12.
▪ Vitamin B12 deficiency is a result of poor intake of foods containing vitamin B12.
▪ What are this high B12. foods? Clam, Oysters, Mussels, liver, caviar, octopus, fish, crab,
lobster, beef, lamb, cheese, eggs, fortified cereals, yogurt, luncheon meat
▪ Old ppl get this, ppl with lapband or Gastric bypass;
 Pernicious anemia is anemia caused by failure to absorb vitamin B12 and lack of intrinsic factor;
clients often exhibit paresthesia, smooth tongue.
▪ in addition to s/s anemia
▪ Dx test: Schilling’s test (inject small radioactive amt of B12 and measure its activity
▪ Tx: admin B12 – oral, intranasal, IM;
▪ Alternate nostrals b/c its an irritant to nasal mucosa
▪ Case Ex:  45 yr old man presented with dizziness.  Usual tests include
audiometry, EEG and MRI all normal.  In course an evaluation for
gastritis it was det. That he was infected with H-pylori.  B12 level check
and they gave him B12.
Loss pipilli (beefy red smooth tongue) Get Cheilitis (Cuts in corners of mouth)
 
Folic Acid Deficiency Anemia – caused by inhibiting folic acid transport and reducing DNA
synthesis in precursor cells
▪ Can cause megaloblastic (large RBC) anemia
▪ Manifestations similar to those of vitamin B12 deficiency, but nervous system functions
remain normal
▪ Folic acid (prevent neurotube defects)
▪ Caused by:
▪ Poor nutrition and chronic alcohol abuse
▪ Malabsorption syndromes, such as Crohn’s disease
▪ Drugs, including anticonvulsants and oral contraceptives, that slow or prevent absorption of
folic acid
▪ Tx: folic acid
Question:  What is priority nursing intervention in care of older pt with hx of bowel disease and
pernicious anemia?
1.  encouraging diet high in it B – cant absorb it so this is wrong
2.  Preventing falls
3.  Turning pt every 2 hr
4. Monitoring I & O
Answer: B
Question:  23 yr old AA with sickle cell had emergent open reduction and internal fixation of his
right femur after car crash.  Whats initial postop priority? 
1.  Hydration due to the sickle cell disease
2.  Treating pain
3.  Titrating oxygen to Sp02 > 95 (keep 90 or better)
4.  Examin surgical incision for infection
Answer: A - Main prob of disorder is formation of abnormal hbg, clumps and clots
 
Polycythemia Vera
▪ Disease with a sustained increase in blood hemoglobin & massive production of red blood
cells; Bone marrow excess but decrease WBC And platelets;
▪ Hyperviscosity (viscosity of blood very thick due to excess hbg) to thick to flow; 
▪ Heart: HTN, HF, clots (blood so thick);
▪ Often have Hgb > 17 gms hct > 50;
▪ Excessive leukocyte production
▪ Excessive production of platelets
▪ Rx: Phlebotomy (donation of blood) & Increased hydration
▪ Anticoagulants are part of therapy due to hyperviscosity and ↑↑↑ risk of clotting
 Leukemia
▪ Type of cancer with uncontrolled production of immature white blood cells in the bone marrow
▪ Acute or chronic
▪ Classified by cell type (myeloid or lymphoid) = Chronic Myeloid Leukemia, Acute Leukositic
Leukemia
▪ Risk factors: ionizing radiation (savannah river radiation), exposure to certain chemicals and
drugs, bone marrow hypoplasia, genetic factors, immunologic factors, environmental
factors
▪ Clinical Manifestations
▪ Cardiovascular: heart rate is increased (anemia) blood pressure is decreased.
▪ Respiratory rate increases.
▪ Petechiae- little purple dots;
▪ Skin grows pale (anemia) and cool to the touch.
▪ Intestinal manifestations include weight loss, nausea, and anorexia.
l   Central nervous system disturbances include headache.
 
Laboratory Assessment
▪ Decreased hemoglobin and hematocrit levels
▪ Low platelet count
▪ ‘Blasts’ (very, very immature WBC) cant fight infection (may have UTI, pneumonia or simple
skin cut infection)
▪ Actue is premature WBC; more common in child and older adult; (child acute is curable with
chemo and radiation but older adults its not respondable as well)
▪ Abnormal white blood cell count, may be low, normal or elevated; is usually quite high in
chronic leukemia (chronic can usually live unless a clot was formed somewhere
important)
▪ Poorer prognosis: client with high white blood cell count at diagnosis
▪ Laboratory Assessment
l   Definitive test: examination of cells obtained from bone marrow aspiration and biopsy
 
Risk for Infections
▪ Infection is a major cause of death in the client with leukemia, and sepsis is a common
complication.
▪ Autocontamination (infected from ones self)
▪ Cross-contamination
▪ Neutopenic – minimal bacteria diet without uncooked food no fresh flowers
▪ Freq handwashing
▪ Priate room
▪ HEPA filtration of laminar airflow system
▪ Mask for anyone coming in
▪ Cranial radiation – meds wont cross brain barrier; RADIATION TO GONADS – STERILE!
 Bone Marrow Transplantation
▪ Standard treatment for leukemia (drain marrow – take donor marrow and its infused in a vein
and the marrow goes to the bone and hopefully the pt makes own WBC, platelets)
STERILE environment!!  Air flow room, no entrance w/out garb b./c they have no bone
marrow!!  Undergo anasesthia (booty hurtin)
▪ Purges present marrow of the leukemic cells
▪ After conditioning, new, healthy marrow given to the client toward a cure
▪ Sources of stem cells
▪ Conditioning regimen
▪ Transplantation
▪ Risk for Injury
▪ Nadir: period of greatest bone marrow suppression
▪ Bleeding precautions
▪ Fatigue
▪ Interventions:
▪ Diet therapy
▪ Blood replacement therapy
▪ Drug therapy
▪ Energy conservation
Hodgkin’s Lymphoma
▪ Cancer that starts in a single lymph node or a single chain of nodes
▪ Good prognosis (if Stage 1 or 2)
▪ Marker: Reed-Sternberg cell (better type of marker)
▪ Large, painless lymph node usually in the neck; fever, malaise, night sweats
▪ One of the most curable cancers (if they are not mobile, hard, irregular,
▪ Treatment: external radiation alone or with combination chemotherapy
Non-Hodgkin’s Lymphoma
▪ All lymphoid cancers that do not have the Reed-Sternberg cell
▪ More than 12 types of non-Hodgkin’s lymphoma
▪ Low-grade lymphomas less responsive to treatment; cures are rare
▪ Treatment: radiation therapy and multiagent chemotherapy,
▪ Doesn’t respond as well to tx
 Multiple Myeloma
▪ Cancer of the B lymphocyte  that  is more mature lymphocyte than either leukemia or
lymphoma. A plasma cell disorder
▪ Uncommon cancer & is not curable
▪ Manifestations: fatigue, easy bruising, bone pain/fractures, hypercalcemia, hypertension,
increased infection/ pneumonia and fluid imbalance, renal failure
▪ Treatment: chemotherapy (curable only with bonemarrow transplant)
▪ Bense Jones Protein (when present that is diagnostic for multiple Myeloma) when tx is
undergone and there is none of this protein then they are under  remission;
▪ Destroys bone and bone marrow!  High risk for Hypercalcemia; Bones are extremely fragile!! 
Question: The pt was transition from IV heparin therapy to oral warfarin.  Therapeutic anticoag
on pt is best assessed by?
1.  PTT time of 24.3
2. PT time of 18 sec
3. C.   INR ratio of 2.5  Goal on warfarin therapy is usually to maintain pt INR between 2.0
– 3.0 regardless of actual PT in seconds.  DON’T TAKE FOODS HIGH IN VIT K ;
this is the antidote
4. Bleeding time of 5 min
 Autoimmune Thrombocytopenic Purpura   AT RISK FOR BLEEDING : LOW PLATELETS!!
▪ Large ecchymosis or petechial rash on arms, legs, upper chest, and neck
▪ Diagnosed by decreased platelet count and large numbers of megakaryocytes in the bone
marrow
▪ Interventions include:
▪ Therapy to prevent bleeding
▪ Drug therapy to suppress immune function
▪ Blood replacement therapy
▪ Splenectomy
 Thrombotic Thrombocytopenic Purpura
▪ Rare disorder; platelets clump together abnormally in the capillaries and too few platelets
remain in circulation
▪ Inappropriate clotting, yet blood fails to clot properly when trauma occurs
▪ Plasma pheresis, infusion of FFP
▪ Aspirin, alprostadil, plicamycin
▪ Immunosuppressive therapy
 DIC       
▪ Disseminated Intravascular Coagulapathy
▪ Client has both clotting and bleeding 
Hemophilia  - sex links (usually males)
▪ Hemophilia A is deficiency of factor VIII and accounts for 80% of cases.
▪ Hemophilia B (Christmas disease) is deficiency of factor IX and accounts for 20% of cases.
▪ For hemophilia A with blood transfusion and factor VIII therapy, survival time has increased
greatly.
Lack of Clotting factors (manufactured in liver)