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Hematopoietic System

1. Describe a health history and physical assessment of the hematopoietic and lymphatic system Bone marrow, the soft tissue that fills spaces in the interior of the long bones and spongy bones of the skeleton, manufactures blood cells. Red marrow is primarily found in the ribs, sternum, skull, clavicles, vertebrae, proximal ends of the long bones, and iliac crest. It manufactures blood cells and hemoglobin. Blood consists of cells suspended in the fluid called plasma. Blood cells Erythrocytes (red blood cells)transport oxygen Leukocytes (white blood cells)protect against infection Platelets (thrombocytes)participate in clotting blood Erythrocytes (or RBC) are flexible, anuclear (lacking a nucleus). Production of erythrocytes is called erythopoieses. In the immature state erythroblasts contain a nucleus; the mature erythrocyte has no nucleus. Lymphocytes decrease in number causing a decreased resistance to infection Leukocytes (WBC) perform various protective functions such as engulfing invading microorganisms and cellular debris. Divided in two main categories granulocytes, and agranulocytes. Granulocytes include subgroups Neutrophilsprotect by phagocytosis Basophilsimmediate hypersensitivity and some delayed hypersensitivity reactions. (Capable of phagocytosis) Eosinophils phagocytize foreign material. Platelets: are disk like, non-nucleated cell fragments c a life span of approx. 7.5 days. The platelets release a substance known as glycoprotein IIb/ IIIa which causes the platelets to adhere and form a plug or clot that occludes the injured vessel. Plasma and plasma proteins Plasma is the liquid, or serum, portion of blood Albumin which formed in the liver, and is the most abundant protein in plasma. Globulins are divided into three groups: alpha, beta, and gamma; aka immunoglobulins-prevent or modify some types of infectious diseases. Fibrinogen plays a key role in forming blood clots.

a. Hematopoieticis the manufacture and development of blood cells by the hematopoietic system, which consists of bone marrow and lymph nodes. i. History should include all S&S noted by client, thorough drug hx and dietary hx and occupational hx, recent events, determine when symptoms first appear, inspect skin with particular attention to color (normal, extreme redness, or pallor) temp, ecchymosis or other lesions. Ck for rapid pulse (may indicate reduced erythrocytes or inadequate hemoglobin levels.)

b. Lymphatic systemthymus, spleen, and network of lymphatic vessels that include lymph nodes and lymph --1. Function-- filters and destroys pathogens and removes other potentially harmful substances. 2. Thymus gland is lymphoid tissue in the upper chest that contains undifferentiated stem cells released by bone marrow. 3. Spleen is the largest lymphatic structure 4. Lymph-nodes glandular tissue along the lymphatic network clustered in the axilla, groin, neck, and lg vessels of the thorax and abd. 5. Lymph is fluid c a composition similar to plasma. It flows through the lymphatic system by contraction of the skeletal muscles. Lymph enters each node via the afferent lymph duct and passes through the node, and leaves via the efferent lymph duct. As lymph passes through the node, macrophages attack and engulf foreign substances such as bacteria, viruses, abnormal body cells, and other debris. ii. Through hx.description of S&S, when they began, severity and frequency. iii. Hematopoietic and lymphatic systems it is important to establish: 1. Experiences prolonged bleeding from an obvious injury 2. Has unexplained blood loss, as in the rectal bleeding, nosebleeds,, bleeding gums, or vomiting blood 3. Feels fatigued c normal activities 4. Becomes dizzy or faints 5. Bruises easily 6. Is easily chilled 7. Has frequent infections 8. Feels discomfort in the axilla, groin, or neck 9. Has difficulty swallowing, c localized throat tenderness

10. Has had surgery c lymph node removal or splenectomy, is undergoing tx for cancer, has renal failure---all of which may affect blood cell volume or lymphatic circulation. iv. The nurse obtains a dietary history because compromised nutrition interferes c the production of blood cells and hemoglobin. Obtains drug hx of prescription and non-prescription meds. 1. Pharmacologic consideration** a. Many pharmacologic agents affect the hematopoietic system, causing a decrease if various blood components. Closely monitor pt taking meds that depress the hematopoietic system, particularly thrombocytes and leukocytes, for signs of leukopenia (fever, sore throat, chills) and thrombocytopenia (unusual or easy bleeding, oozing from injection sites, bleeding gums, dark, tarry stools.)the drug epoetin alpha (Epogen, Procrit) can be used to stimulate the production of RBCs. filgrastim (Neupogen), and pelfigrastim (Neulasta) promotes proliferation of neutrophils. v. Check if abnormalities present, if infection when first noticed and its possible cause. Check lymph node enlargement, area of involvement, size, and characteristics. Skin adjacent to the area examined for redness, streaking and swelling. Examine the extremities to determine if they are of similar size, obstruction of the lymphatic circulation can cause unilateral enlargement. Nursing management vi. The nurse collects data to assist dr in dx, and the clients response. vii. When involves a puncture- assess are for excessive bleeding and applies pressure or pressure dressing to site as needed. Monitor VS, contact dr for adverse responses and analyzes and reports test promptly. 2. Identify and describe nursing management for various lab and diagnostic tests used in the diagnosis of hematopoietic and lymphatic systems i. Labs and diagnostics For hematopoietic: Cbc Pt Ptt D-timer test Bone marrow Schilling test Ct Mri Bone scan For lymphatic: Cbc Wbc Differential Lymphangiography Lymph node biopsy Bone scan Ct Mri

3. State the purpose of a bone marrow and Schilling test Bone marrow aspiration- is performed to determine the status of blood-cell formation. In this procedure, the physician applies local anesthesia and removes bone marrow from the posterior iliac crest or sternum. The marrow is examined for the types and percentage of immature and maturing blood cells Schilling test- is used to diagnose pernicious anemia, macrocytic anemia, and malabsorption syndromes. When this test is prescribed, radioactive Vit. B12 is given orally, followed in 1 hour by an injection of nonradioactive B12.

4. Discuss the nursing guidelines for bone marrow aspiration. Nsg. Guidelines 30-1, p 427 - Inform the client of the plan and approximate time for the procedure - Witness the clients signature on consent form and sedation form - Check the clients medical record for history of allergies - Obtain a sterile bone aspiration tray and the type and strength of local anesthetic according to physicians orders - Determine the site from which the physician intends to obtain the sample of marrow - Attach a pulse oximeter to clients finger - Position the client on his back or side to facilitate access to the aspiration site - Cleanse, clip hair, and drape the skin at the test site - Suggest distraction techniques to avoid focusing of pressure or discomfort associated with puncturing the bone that may take approx. 20 mins - Admin. analgesia for significant discomfort - Be prepared to place samples of the aspirate on slides and allow them to dry - Label the biopsy specimen - ***Apply direct pressure followed by a pressure dressing to the site after the needle has been withdrawn*** - Limit clients activity approx. 30 mins after the procedure - Monitor the puncture site frequently for continued bleeding - Report prolonged bleeding - Delay bathing and shower for 24 hrs

5. DO YOURSELF

6. Discuss hypovolemic anemia and iron-deficiency anemia to include assessment findings, medical, and nursing management Anemia- a deficiency of either erythrocytes or hemoglobin Most anemias result from: 1) blood loss, 2) inadequate or abnormal erythrocyte production, or 3) destruction of normally formed RBCs. Hypovolemia- caused by a loss of blood volume, which results in fewer blood cells Heme- the pigmented, iron-containing portion of hemoglobin Assessment Findings: o Severe blood loss is evidenced by signs and symptoms of hypovolemic shock: extreme pallor, tachycardia, hypotension, reduced urine output, and altered consciousness o Symptoms of chronic hypovolemic anemia include pallor, fatigue, chills, postural hypotension, and rapid heart rate and respiratory status o Lab tests to confirm acute or chronic hypovolemic anemia: CBC which demonstrates decreased erythrocytes, increased reticulocytes, and low hemoglobin and hematocrit levels o Treatment: for severe blood loss requires replacement of blood by transfusion or admin of oral, IV, or IM iron to help restore the bodys hemoglobin. Oxygen therapy sometimes is necessary if anemia is serious. Nursing Process o Monitor results of CBC, esp RBC count and hgb and hct levels o Assess V/S every 2-4 hours o Report systolic BP below 90and HR above 100bpm o Monitor I&O accurately each shift or qh o Report urine output <30 to 50mL/hr o In cases of hemorrhage, apply direct pressure o Place in modifies Trendelenburg if hypovolemic shock occurs

Iron deficiency anemia- develops when iron is insufficient to produce hemoglobin. Examples include when 1) heme cannot be recycled because of blood loss, 2)dietary intake of iron is insufficient, 3) absorption of iron from food is inadequate, 4) the need for iron exceeds the reserves. Assessment Findings

o Reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion o HR is usually rapid even at rest o The CBC and hgb, hct, and serum iron levels are decreased o A blood smear reveals erythrocytes that are microcytic (smaller than normal) and hypochromic (lighter in color than normal) Medical Management o Correction of a faulty diet is adding foods high in iron o Oral supplements or parenteral administration of iron is prescribed o Blood transfusion in severe cases Nursing Management o Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid staining teeth o Take iron of an empty stomach unless gastric upset occurs; then take after meals o Avoid taking with antacid o Check with physician about taking iron with over the counter meds o ***Drink orange juice or take other forms of Vit. C with iron to promote absorption*** o Expect iron to color stool dark green or black

7. Describe client and family teaching for the client who takes an oral iron supplement o The nurse focuses on improving the clients nutritional intake of iron. In addition administers oral or parenteral iron supplement and instructs as follows: Dilute liquid preparations of iron c another liquid such as a juice and drink c a straw to avoid staining the teeth Take on empty stomach Avoid taking simultaneously c an antacid; interferes c iron absorption Check c the physicians or pharmacist c combining other prescribed or over the counter medications to determine appropriate absorption of each Drink orange juice and take other forms of vitamin c with iron to promote absorption Expect iron to color stool dark green or black Consult dr if constipation or diarrhea develops Keep meds containing iron out of reach of children. Whom accidental poisoning may be fatal.

8. Discuss the classification, action, adverse reactions and side effects, and nursing implications for: ferrous sulfate (Feosol), Imferon (Iron dextran), epoetin (Erythropoietic) Ferrous sulfate (Feosol) and Imferon (iron dextran) under same category in Davis. Iron dextran is given by injection only. Classification- antianemic Action: prevention and treatment of iron deficiency. Side effects/adverse reactions: seizures, anaphylaxis, nausea, constipation, diarrhea, epigastric pain, dark stools, hypertension, hypotension, headache, tachycardia, G.I. bleeding Nursing implementations :if given orally can cause staining of the teeth (liquid preparations). Oral preparations are most effectively absorbed if administered one hour before or two hours after males if G.I. irritation occurs administer with meals take tablets and capsules with a full glass of water or juice. Avoid using and assets, coffee, tea, dairy products, eggs, or whole-grain breads with or within one hour after administration of ferrous salts. Iron absorption is decreased by 33% if iron and calcium are given with males if calcium supplementation is needed, calcium carbonate does not decrease absorption of iron salts if supplements are administered between meals. Monitor blood pressure and heart rate frequently following IV administration until stable. Rapid infusion rate may cause hypotension and flushing. Iron dextran monitor hemoglobin, hematocrit, reticulocyte values. epoetin (erythropoietic): classification: antianemics action: Anemia associated with chronic renal failure. Stimulates production of red blood cells. Maintains and may elevate RBCs decreasing the need for transfusions. Adverse reactions\side effects: seizures, headache, CHF, MRI, stroke, thrombotic events, hypertension, transient rashes nursing implications: monitor blood pressure before and during therapy, monitor renal function studies in electrolytes closely. Increases BUN, creatinine, uric acid, phosphorus, and potassium may occur.

9. Discuss sickle cell anemia to include assessment findings, medical, and nursing management - Sickle cell anemia- erythrocytes become sickle or crescent-shaped when oxygen supply in the blood is inadequate. This common genetic disorder is primarily found in African Americans, but also in people from Mediterranean and Middle Eastern countries; currently affects 1 in every 600 African Americans in the US - The person with it suffers from 2 problems: 1) episodes of sickle cell crisis from vascular occlusion, which develops rapidly under hypoxic conditions, and 2) chronic hemolytic anemia - ***Unique manifestations of this disease is acute chest syndrome- a type of pneumonia triggered by decreased hgb and infiltrates in the lungs; characterized by resp. symptoms such as coughing, wheezing, tachypnea, and chest pain*** - Assessment Findings o Juandice caused by hyperbilirubinemia o Gallstones o Chronic leg ulcers from blockage of the small blood vessels of the legs o Priapism (prolonged erection) occurs from delayed emptying of thick blood from the penis o Reduced blood flow leads to localized ischemia, severe pain, and possible tissue infarction if O2 supply is inadequate o Fever, pain, and swelling of one or more joints o CVA, pulmonary infarction, shock, and renal failure Labs- sickle cell screening can be done to detect the presence of abnormal Hbg S. Hbg electrophoresis determines whether the person has sickle cell disease or carries sickle cell trait. Reticulocytes, immature erythrocytes, and prematurely released into the bloodstream in an effort to replace the hemolyzed mature erythrocytes Medical Management o Treat with hydroxyurea (Hydrea, Droxia), an anti-cancer agent, shows evidence that it decreases sickling o Folic acid is prescribed to facilitate the replacement of hemolyzed erythrocytes

Sickle Cell Crisis- A rapidly developing syndrome, affecting various areas of the body, fever, pain, and swelling of one or more joints.

10. Define hemolytic anemia, along with assessment findings and medical and nursing process of this client

a. Hemolytic anemiaconsequence of a widely diverse group of conditions, some acquired, hereditary and idiopathic in which there is chronic mature destruction of erythrocytes. b. Some example of conditions that produce anemia are the use of cardiopulmonary bypass during surgery; arsenic or lead poisoning; invasion of erythrocytes by the malaria parasite; infectious agents; or toxins and exposure to hazardous chemicals and others causes include the production of antibodies that destry erythrocytes. Assessment findings o Symptoms are similar to those associated c hypovolemic anemia:
Increase hr Hypotension Pallor Oliguria Loc Labs Decreased rbc Low h&h

o Severe cases Jaundiced and spleen is enlarged. Is some cases, hemolysis is so extensive it causes shock Med and surgical management o Tx includes removing the cause when possible o Administering corticosteroids o Blood transfusions are often necessary o Splenectomy is performed if the pt fails to respond to tx. Nursing management o Obtain comprehensive health hx to determine cause o Until cause determined provide supportive care to help pt meet basic needs. o After confirmed, implement medical regimen for tx and prepare pt for discharge by teaching measures for self-care, and plan follow up evaluation. 11. DEFINE (End of notes)

12. Discuss leukemia o Leukemiaany malignant blood disorder in which proliferation of leukocytes, usually in an immature form, is unregulated. There often is an accompanying decrease in production of erythrocytes and platelets. The cause of leukemia is unknown. Exposure to toxic chemicals, radiation, viruses, and certain drugs are known to precipitate the disorder. And in some cases genetic correlation.

o Although the increase in leukocytes is rampant, there is many more immature than mature cells. Cause their immaturity leukocytes are ineffective at fighting infections. Pt eventually develops severe anemia and reduction in platelets leads to bleeding. 13. Differentiate acute myelogenous leukemia, chronic myelogenous leukemia, acute and chronic lymphocytic leukemia and their age of onset. Table 33-3 pg 439 Type Acute lymphocytic (ALL) Cellular Characteristics immature lymphocytes Normal or granulocytes erythrocytes platelets Same as above, but erythrocyte and platelet counts may be normal or low. in all myeloid formed cells: monocytes, granulocytes, erythrocytes, and platelets Same as above, but greater number of normal cells than in acute form. Age of onset Younger than 5; uncommon after 15. 70-75% of child leukemia Older than 40; most common type in adults survival rate 7-8 years Occurs in all age ranges

Chronic lymphocytic (CLL)

Acute myelogenous (AML)

Chronic myelogenous (CML)

Older than 20, but incidence increases c age; genetic link in 90-95% of cases.

14. Describe clinical manifestations, treatment and nursing process to include the care plan for the client with leukemia Assessment findings o Infections, fatigue from anemia and easy bruising are all hallmarks of leukemia o Fever, spleen and lymph node enlargement, and internal or external bleeding. o Common bleeding sites Nose, mouth, and GI tract Leukocyte count is low, normal or high but the # of normal leukocytes is decreased. Consequently the number of erythrocytes and platelets decreases as well Medical management o Drug therapy is primary weapon for arresting leukemia o Using one or a combo of antineopastic drugs; type depending on form of leukemia. Tx most successful in young pts.

o Erythrocyte and platelet transfusions necessary to treat anemia and decreased platelets o Antibiotics given when secondary infections develop o Bone marrow transplantation and stem cell transplantation have increased survival for some clients. o Toxic drugs or radiation are administered before transplantation. This renders the client extremely susceptible to infection. Nursing process o Look for cluster of symptoms that includes weakness and fatigue, frequent infections, nosebleeds, or other prolonged bleeding events and joint pain. Other symptoms of leukocyte infiltration of the CNS such as headache and confusion o Examine the body for bruising, palpate the abdomen for enlargement and tenderness of liver and spleen, and review lab test results.

Risk for infection: r/t compromised immunity Expected outcomes: client will be free of infection AEB: normal temperature and no signs of an infectious disorder o Implement neutropenic percautions o Ensure that any staff, family member, or visitor who is ill temporarily discontinues direct contact c the client. o Monitor tem at least once per shift and continually assess for signs of infection such as swelling and tenderness.

Hemorrhage: ( platelet) Expected outcomes: the nurse will monitor for hemorrhage: if bleeding is detected the nurse will manage and minimize it. o Monitory the platelet count o Inspect skin for signs of bruising and petechiae; report melena, hematuria, or epistaxis (nosebleeds.) o Handle pt gently when assisting c care and encourage use of electric razors o Apply prolonged pressure to needle sites or other sources of external bleeding. o Implement physician orders for transfusion of blood and platelets.

Activity intolerance: r/t hypoxia Expected outcomes: client will 1. Tolerate essential activity AEB a HR below 100 bpm and 2. Have a RR less than 28 breaths/minute

o o o o

Limit nonessential activities Distribute essential tasks over a long period Provide periods of rest Administer supplemental oxygen during periods of rapid breathing or tachycardia

Risk for disturbed body image: r/t hair loss secondary to chemo Expected outcomes: client will cope c hair loss and changing body image o Provide opportunity for client to express feelings about hair loss and changing body image; offer suggestions such as scarves, turbans, baseball caps, or wigs. o Head coverings may increase self-esteem and foster more interactions c others.

Anxiety and fear: r/t unfamiliar experiences and unknown prognosis Expected outcomes: anxiety and fear will be relieved AEB the clients report of emotional comfort. o Acknowledge your awareness of the clients anxieties and fears: open communication o Encourage the client to talk about the disorder and potential and actual effects o Explain the plan of care and all treatment procedures o Give encouragement and emotional support and foster hope without implying unrealistic expectations. o Teach how to manage their disease and treatment regimen.

Client and family teaching


Home medications: explain dosing and schedule because compliance is essential to treat disease successfully. The nurse includes the following points in teaching plan: o Have frequent examinations of blood and sometimes of bone marrow, necessary to monitor the results of therapy. o Take precautions to avoid physical injury o Avoid exposure to people who have infections o Seek medical care promptly if excessive bleeding or symptoms of illness or infection o Obtain sufficient rest and eat an adequate diet to prevent secondary infections o When feeling well, continue usual activities unless Dr. instructs otherwise o If sores in mouth occur, contact Dr. a.s.a.p.! Do not self-treat them. o Contact Dr. immediately about any of the following: severe nausea c prolonged vomiting, severe diarrhea, fever, chills, excessive bleeding, or bruising, coughing, chest pain, cloudy urine, rash,

o o

blood in stool or urine, severe headache, extreme fatigue, increased respiratory rate or difficulty breathing and rapid pulse rate. Follow Dr. recommendation to monitory temp and wt Keep all clinic or office appointments

15. Discuss the classification, action, adverse reactions and side effects, and nursing implications for: busulfan (Myleran), methotrexate (MTX), chlorambucil (Leukeran), vincristine (Oncovin), melphalan (Alkeran), cyclophosphamide (Cytoxan), allopurinol (Zyloprim) busulfan (Mylenran) classification anti-neoplastics action: death of rapidly growing cells, especially malignant ones. Adverse reactions/side effects: seizures, cerebral damage/coma, anxiety, confusion, depression, dizziness, headache, weakness, epistaxis, pharyngitis, pulmonary fibrosis, hypotension, tachycardia, thrombosis, chest pain, bone marrow depression. Nursing implementations: monitor for bone marrow depression. Assess for bleeding, bruising, petechiae, guaiac stools, urine, and avoid IM injections and taking rectal temperatures. Apply pressure to venipuncture sites for at least 10 min. Assess for signs of infection during neutropenia. Anemia may occur. Monitor for increased fatigue, dyspnea, and orthostatic hypotension. Monitor I and Os. Monitor for pulmonary fibrosis. Administer the same time every day. Administer on empty stomach to decrease nausea and vomiting. Chlorambucil (Leukeran) classification anti-neoplastics, immunosuppressant's action: management of chronic lymphocytic leukemia, malignant lymphoma, and Hodgkin's disease adverse reactions/side effects: leukopenia, pulmonary fibrosis, nausea, vomiting, alopecia, dermatitis, hyperuricemia Melphalan (Alkeran)

Classification: Antineoplastics Action: death of rapidly replicating cells, particularly malignant ones. Also have immunosuppressive properties. Adverse reactions/side effects: leukopenia, thrombocytopenia, diarrhea, hepatitis, nausea, vomiting, pulmonary fibrosis, hyperuricemia nursing implications: avoid IM injections and taking rectal temperature. Apply pressure to venipuncture sites for 10 min. Anemia may occur. Assess for bleeding (bleeding gums, bruising, petechiae, quaiac stools, urine, and emesis). Wear gloves, gown, and mask while handling medication(IV). If solution context skin or mucosal, immediately wash skin or mucosa with soap and water. Maybe ordered in divided doses or as a single daily dose(PO). Allopurinol (Zyloprim) Classification: anti-gout agent, anti-hyperuricemics Action: lowering of serum uric acid levels adverse reactions/side effects: rash (discontinue drug at first sign of rash), hypotension, flushing, hypertension, bradycardia, heart failure, drowsiness, diarrhea, nausea, vomiting, renal failure nursing implementations: decreased kidney function can cause drug accumulation and toxic effects. In sure that patient maintains adequate fluid intake to minimize risk of kidney stone formation. May be administered after milk or with meals to minimize gastric irritation; give with plenty of fluid. Methotrexate (MTX) Classification: antineoplastics, antiheumatics, immunosuppressant Action: death of rapidly replicating cells, particularly malignant ones and immunosuppression. Interferes with folic acid metabolism. Adverse reactions/side effects: pulmonary fibrosis, dizziness, drowsiness, headache, blurred vision, nausea, aplastic anemia, leukopenia, thrombocytopenia nursing implications: monitor for bone marrow depression. Assess for bleeding and avoid IM injections and taking rectal temperatures if platelet count is low. Apply pressure to venipuncture sites for 10 min. Wear gloves, gown, and mask while handling medication. Monitor intake and output ratios and daily weights. Vincristine (Oncovin) Classification: antineoplastics

Action: death of rapidly replicating cells, particularly malignant ones. Has immunosuppressive properties. Adverse reactions/side effects: nausea, vomiting, alopecia, phlebitis (IV site), agitation, insomnia nursing implications: monitor blood pressure, pulse, and respiratory rate during therapy. Monitor neurologic status. Monitor intake and output ratios and daily weight. Wear gloves, gown, and mask while handling medication. Cyclophosphamide (Cytoxan) Classification: antineoplastics, immunosuppressive Action: death of rapidly replicating cells, particularly malignant ones. Also has immunosuppressive action and smaller doses. Adverse reactions/side effects: pulmonary fibrosis, myocardial fibrosis, hemorrhage cystitis, hypotension, anorexia, nausea, vomiting, leukopenia, thrombocytopenia nursing implementations: monitor blood pressure pulse respiratory rate and temperature frequently during administration to reduce risk of hemorrhage cystitis fluid intake should be at least 3000 mL per day for adults and 1000 to 2000 mL per day for children. Monitor for bone marrow depression. Assess for bleeding. Encourage patient to drink 2000 to 3000 mL/day to promote excretion of uric acid. Administer medication on empty stomach.

16. Define multiple myeloma and discuss nursing management Multiple myeloma is a malignancy involving plasma cells which are B-lymphocyte cells in bone marrow. The nurse assesses for pain, signs of infection, excessive fatigue, bleeding, thrombus formation, and changes in the quantity or quality of urine production, administers analgesics, provides up to 4000 mL of fluid to prevent renal damage, documents and reports signs of calculus formation is the kidneys, ureters, or bladder. Safety is paramount because any injury, no matter how slight, can result in a fracture.

17. DEFINE (End of notes)

18. Discuss thrombocytopenia as to assessment findings, and medical management Thrombocytopenia is a lower than normal number of platelets or thrombocytes.

Purura, small hemorrhages in the skin, mucous membranes, or subcutaneous tissues, bleeding from other parts of the body, such as nose, oral mucous membraine, and the GI tract. Internal hemorrhage. Diagnosis is based on symptoms, a low platelet count and abnormal bleeding and clotting times. The cause is eliminated. Corticosteroids provide symptomatic relief until the platelet count returns to normal. Transfusions of platelets or whole blood are given. Splenectomy is necessary to stop destruction of platelets in the spleen. Removal of the spleen results in a rise in the platelet count and relief of symptoms.

19. Define hemophilia along with medical management Hemophilia is a disorder involving an absence or reduction of a clotting factor. The three types of hemophilia are hemophilia A, B, and C. Persistent oozing and sometimes severe bleeding, bleeding in joints eventually damages the joints. Diagnosis is based on the history, and lab tests such as coagulant factor assay, which shows deficiency of factors VIII, IX, or XI. Treatment includes transfusions of fresh blood, frozen plasma, factor VIII concentrate, and anti-inhibitor coagulant complex for hemophilia A, factor IX concentrate for hemophilia B, factor XI for hemophilia C, and the application of thrombin or fibrin to the bleeding area. Aminocaproic acid (Amicar) that helps to hold a clot in place once it has formed direct pressure over the bleeding site, and cold compresses or ice packs.

20. Describe nursing management of an adult with hemophilia, along with client and family teaching The nurse obtains a health history, including current symptoms and treatment for bleeding disorder, questions about when the last episode occurred, its location, duration, and what treatment if any where necessary. The nurse assesses the joints and mobility and inspects the skin for purpura or hemorrhagic areas. Before taking a BP, ask if the use of a blood pressure cuff has ever produced bleeding under the skin or in the arm joints. Take the temperature tympanically to avoid oral or rectal injuries, check the urine and stools for signs of bleeding. Overall care includes preventing trauma, managing and minimizing bleeding episodes, reducing pain or discomfort, conserving energy, and helping the client learn ways to prevent further bleeding episodes.

Eliminate aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), because these drugs can increase bleeding tendencies. Avoid activities that can result in injury. Wear a Medic Alert bracelet and inform the dentist and others, when appropriate, of the condition. Notify the physician promptly if pain, discomfort, or obvious bleeding from the nose or rectum, in vomitus, or elsewhere occurs. Bleeding in internal organs or structures initially produces only vague symptoms. Use a soft toothbrush and rinse the mouth with warm water between and after meals. Support painful joints on pillows.

21. Review the difference between whole blood, packed cells, blood products, and plasma expanders Whole blood and packed cells probably are the most commonly administered colloid solutions. One unit of whole blood contains approximately 475 mL of blood cells and plasma, with 60 to 70 mL of preservative and anti-coagulant added. Packed cells have most of the plasma (fluid) removed for clients who need cellular replacements but do not need additional fluid. Blood products, components extracted from blood. Blood products are administered to clients who need specific blood substances but not all the fluid and cellular components in whole blood. Plasma expanders are nonblood solutions, such as dextran 40 (Rheomacrodex) and hetastarch (Hespan), that pull fluid into vascular space. They are used as an economical and virus-free substitute for blood and blood products when treating clients with hypovolemic shock.

22. Review the different types of blood products (Table 13-3, p 130) Blood product platelets description Disk-shaped cellular fragments that Promote coagulation of blood Types of WBCs, serum without Purpose for administration Restores or improves the ability to Control bleeding.

Granulocytes Plasma

Blood cells. Types of WBCs Serum without blood cells Plasma protein

Albumin

Cryoprecipitate Mixture of clotting factors

Improves the ability to overcome Infection. Replaces clotting factors or increases Intravascular fluid volume by increasing colloidal osmotic pressure. Pulls third spaced fluid by increasing colloidal osmotic pressure. Treats blood clotting disorders such as hemophilia.

23. Review the nursing management of a client receiving a blood transfusion Blood contains cells and is generally infused through a 16 to 20- gauge (preferably an 18gauge) catheter. Blood is administered through Y- administration tubing. This tubing contains two branches: one for blood and one for isotonic (normal) saline, above a filter. The normal saline infuses before and after the blood infuses, or during the infusion if a transfusion reaction occurs. Before blood is administered, it must be examined to make sure the donor and recipient blood types are compatible. Blood is typed according to the ABO system. Four blood types: A to A and O B to B and O AB to A, B, AB and O O+ to O+, and OO- to A,B, AB, O+, and 0-

Rh factor was discovered in rhesus monkeys and have additional protein on their blood cells. Each client that needs a blood transfusion has an additional identification bracelet that is attached when the laboratory draws a sample of blood for typing and cross matching. Before a blood transfusion is initiated, two nurses must check the identifying numbers on the bracelet to confirm that they match the numbers on the unit of blood from the blood bank.

24. Discuss Complications of Blood Transfusions.

Table 13 5 Complications of Blood Transfusion A transfusion reaction is an untoward event at the time the blood is being administered. One of the most life-threatening transfusion reactions is an incompatibility reaction that occurs when the donor and recipient blood types are incorrectly matched. In this instance, the recipient antibodies destroy the donor cells. Although incompatibility reaction occurs once in approximately 25,000 blood transfusions, it accounts for more than 50% of reported transfusion related deaths. An acute incompatibility reaction occurs within minutes of infusing the donor blood. Because serious transfusion reactions generally occur within first 5 to 15 min. of the infusion, many healthcare agencies require the nurse remains with and monitors the client during this critical time. Clients are instructed to call for assistance if they feel unusual while receiving the infusion of blood. In cases of a suspected transfusion reaction, it is appropriate to stop the infusion of blood in infused a solution of normal saline while continuing to assess the client. Complication Incompatibility Reaction Signs and Symptoms hypotension, rapid pulse rate, difficulty breathing, back pain, flushing Causes mismatch between donor and recipient blood groups Actions Stop the infusion of blood infused the saline at a rapid rate call for assistance administer oxygen raise the feet higher than the head be prepared to administer emergency drugs send first urine specimen to laboratory save the blood and tubing stop the blood infusion start the saline check the vital signs report findings Stop the infusion of blood start the saline report findings save the blood and tubing

Febrile reaction

fever, shaking chills, headache, rapid pulse, muscle aches

allergy to foreign proteins in the donated blood

Septic reaction

fever, chills, hypotension

infusion of blood that contains microorganisms

Allergic reaction

rash, itching, flushing, stable vital signs

minor sensitivity to substances in the donor blood

Moderate chilling

no fever or other symptoms

infusion of cold blood

Circulatory overload

hypertension, difficulty breathing, moist breath sounds, bounding pulse

large volume or rapid rate of infusion; inadequate cardiac or kidney function

Hypocalcemia (low calcium)

Tingling of fingers, hypotension, muscle cramps, convulsions

Multiple blood transfusions containing anticalcium agents

HIV and hepatitis B virus transmission

Opportunistic infections; elevated antibody titers, abnormal blood cell counts or liver enzyme levels

Blood collected from infected donors the past screening examinations

slow the rate of infusion assess the client report findings be prepared to give an antihistamine continue the infusion cover and make the client comfortable reduce the rate of infusion elevate the head give oxygen report findings be prepared to give diuretic Stop the blood infusion start saline be prepared to give antidotes, calcium chloride Encourage autologous (self) blood collection of possible

25. Define lymphedema, to include nursing management. Lymphedema and is an accumulation of lymphatic fluid that results from impaired lymph circulation. Primary lymphedema I usually is congenitally acquired, although manifestations usually don't appear until adolescence or early adulthood. This disorder causing lymphedema and leads to an accumulation of length containing a large percentage of protein within lymphatic vessels. Nursing management: The nurse inspects and measures the affected area to assess the extent of enlargement and assess the condition of the skin. He or she encourages the client to move and exercise the affected arm

or leg to enhance the flow of lymph from the congested area. The nurse instructs the client elevate edematous extremities when sitting and teaches how to apply and use elastic garments and mechanical devices. Extensive emotional support is necessary when the edema is severe. The clients self-esteem often is decreased, which can lead to social withdraw. The nurse supports the client self- image by suggesting certain styles of clothing that can still abnormal enlargement of an arm or leg.

26. DEFINE (End of notes)

27. Define infectious mononucleosis including, assessment findings, medical and nursing management in the adult client. Infectious mononucleosis is a viral disease that affects lymphoid tissues such as the tonsils and spleen. It can also involve other organs such as the brain, meninges, and liver. Pathophysiology and Etiology: the Epstein-Barr virus causes infectious mononucleosis. This contagious disorder spread by direct contact with saliva and pharyngeal secretions from an infected person. It is transmitted by kissing; oral spraying during coughing, talking, or sneezing; or sharing food, cigarettes, or other items containing oral secretions. The incubation period can be as long as 30 to 50 days. The virus most commonly affects young adults, especially those in close living quarters, such as the armed service housing in college dormitories. Assessment Findings: fatigue, fever, sore throat, headache, and cervical lymph node enlargement typically occur. The tonsils ooze white or greenish- gray exudates. Pharyngeal swelling can compromise swallowing and breathing. Some clients develop a faint red rash on their hands or abdomen. The liver and spleen become enlarged. The symptoms persist for several weeks. Medical Management: the infection usually is self-limiting. Bed rest, analgesic, and antipyretic therapy, and increase fluid intake are recommended. Corticosteroid therapy is prescribed of complications such as hepatic involvement occur. If a bacterial infection such as sinusitis or streptococcal pharyngitis accompanies mononucleosis an antibiotic is prescribed. Nursing Management: the nurse inspects the client's throat for the extent of inflammation or edema. He or she gently palpated the lymph nodes to detect swelling and encourages fluids. Soft, bland foods and cool liquids are best for clients with ulcerations of the oral mucosa. The nurse advises the client to rest as much as possible. If the client expresses concern over prolongs time off from work or school, the nurse listens and helps the client cope with the anxiety. He or she advises the client to withhold donating blood for at least six months after recovering from illness.

28. Review the classification, action, adverse reactions and side effects, and nursing implications for: dexamethasone (Decadron). Dexamethasone (Decadron) Classification: corticosteroid Action: regulate immune response; control inflammatory response side effects/adverse reactions: euphoria, insomnia, gastrointestinal irritation, increased appetite, weight gain, hyperglycemia nursing implementations taper doses when discontinuing; abrupt discontinuation may lead to acute adrenal insufficiency. Give doses in the morning with food. Monitor blood sugar levels, assess for peripheral edema

29. DEFINE (End of notes) 30. Discuss assessment findings, medical and nursing process including the nursing process for the client with Hodgkins disease Assessment Findings: Early: painless enlargement of 1 or more lymph nodes, marked weight loss, anorexia, fatigue. Weakness, chills, fever, marked anemia, thrombocytopenia bleeding, decreases resistance to infection, resp. infections, staph skin infections, pruritus Medical Management: - Radiation - Corticosteroids - Antineoplastic Rx - Antibiotics - Transfusions Nursing Process:

31. NOT AN OBJECTIVE 32. DO YOURSELF

33. Monitor response to medicines, treatments, and procedures in the client with a hematopoietic disorder

34. Recall normal values of hematocrit, RBC, WBC, and platelets Hct: Male 42-52 Female: 37-47 Hgb: Male 14-18 Female 12-16 RBC: Male 4.7-6.1 Female 4.2-5.4 WBC: 5000-10000 Platelets: 150,000-400,000 DEFINE Intracellular- water located within cells Interstitial- water located between cells Intravascular-water located in the plasma (serum) portion of blood Fluid imbalance-is general term used describing any of several conditions in which the bodys water is not in the proper volume or location Petechial- tiny reddish hemorrhagic spots on the skin and mucous membranes. Coagulopathy- bleeding disorders that involve platelets or clotting factors. Hodgkins-a malignancy that produces enlargement of lymphoid tissue spleen, liver, bone marrow, and lungs. Lymphoma- a group of cancers that affect the lymphatic system. Infectious mononucleosis- viral disease that affects lymphoid tissues such as tonsils and spleen. Lymphadenitis- condition of inflammation of lymph nodes. Lymphangitis- inflammation of the lymphatic vessels Lymphedema- an accumulation of lymphatic fluids results from impaired lymph circulation. Anemia- a deficiency of either erythrocytes or hemoglobin. Hypovolemic anemia-caused by loss of blood volume which results in fewer blood cells. Sickle cell anemia- erythrocytes become sickle or crescent shaped when oxygen supply in blood is inadequate. Hemolytic anemia- consequences of a widely diverse, group of conditions, some acquired, some hereditary, some idiopathic, chronic premature destruction of erythrocytes. Pernicious anemia- develops when pt lacks intrinsic factor. it is necessary for absorption of vitamin b12 Folic acid deficiency- causes anemia characterized by immature erythrocytes. Polycythemia Vera- characterized by a greater than normal number of erythrocytes.

Multiple myeloma- a malignancy involving plasma cells, which are b- lymphocyte, cells in bone marrow. Leukopenia-is generalized reduction in all WBCs Agranulocytosis-refers specifically to a decrease production of granulocytes including neutrophils, basophils, and eosinophils. Pancytopenia- refers to condition such as aplastic anemia in which numbers of all marrow produced blood cells are reduced. Aplastic anemia-is more than just a deficiency of erythrocytes Hemophilia- disorder involving an absence or reduction of clotting factor Non-Hodgkins lymphoma- is a group of 30 sub-classifications of malignant diseases that originate in lymph glands and other lymphoid tissues.