HEMATOLOGY
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Transcript of HEMATOLOGY
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MCC NURSINGBY: DIANA BLUM MSN
HEMATOLOGY
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Anatomy
Blood is a type of connective tissue Transports nutrition Transports oxygen Transports hormones
Immunological aspects also important Critical to body defense Maintains temperature Controls PH Removes toxins Regulates electrolytes
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Hematopoiesis:
Bone Marrow:
Stem Cell:
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Cell Types (page 1991-94)
Plasma: straw colored liquid that suspends blood cells
Leukocyte: warrior cell that fights infection and invasion.
Reticulocyte: immature RBC
WBC: another name for a leukocyte
RBC: gives blood it color. Transports oxygen to cell and co2 to lungs
Erythrocyte: another name for RBC
Platelet: found in plasma. Works with clotting factors to help prevent bleeding.
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Lymphatic system
Responsible for removing excess fluid protein and large particles from cells
Main functions: fluid balance maintenance Defense Fat absorber
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Spleen
Stores 20-40 ml blood Removes old cells Filters and destroys antigens
before they enter system Stores platelets (1/3 of body’s
store)
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Hemostasis (page 1995)
Stopping of blood flow 2 phases:
Primary Secondary
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Anemia (page 2008)
Hemoglobin is low Oxygen is low Not a disease but an underlying
condition 2 types: hypoproliferative and
hemolytic Hypoproliferative: marrow can’t produce
adequate erythrocytes Lack of factors, chemicals, marrow
damage Hemolytic: premature destruction of
erythrocytes. Leads to tissue hypoxia Abnormality like sickle cell, direct injury
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Erythropoiesis
Stimulation of RBCs by erythropoietin
Erythropoietin: hormone produced by kidneys during periods of hypoxia to ensure growing tissues will have sufficient oxygen.
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Determination between types
Based on: Marrow ability to respond to decreased
erythrocytes Manner of maturity for young
erythrocytes The presence or absence of end products
of erythrocyte destruction within the circulation
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Clinical manifestations
(pg 2010)
Rapidity with the anemia has developed
Duration of anemia Metabolic requirements of patient Other disorders
Cardio: tachycardia, hypoxia, MI symptoms
Respiratory: SOB in varying degrees
Neuro: headache, poor concentration, vertigo, irritibility, confusion
Compensation also may occur
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Education
Prioritize activities Plan rest periods Eats healthy foods rich in iron,
vitamins, and proteins Use nutrition supplements as
needed Report palpitations, dizziness,
dyspnea Monitor vitals Monitor edema Monitor neuro status Safety techniques
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Low RBC Low HGB andHCT Low serum Iron level Low ferritin level High TIBC level Results from diet low in iron Results from body not absorbing enough iron from GI tract
Not enough hemoglobin made as result s/s: sore tongue, brittle nails, fatigue, pallor, orthostatic changes (in severe cases) Dx: bone marrow aspiration, lab work Tx: iron supplements, iron rich foods (liver, oysters, red meat, fish, dried fruits,
legumes, dark green veggies, whole grain breads and cereal)---orange juice or other vitamin C product will enhance iron absorption What is the major side effect of IV iron?
Iron Deficiency Anemia
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Anemia and Renal Disease
Pts don’t become severely anemic til creatinine levels exceed 3mg/100ml
Hematocrit decreases Causes:
shorted RBC lifespan Deficiency of erythropoietin Long term hemodialysis
Tx: monitor serum levels of iron, hematocrit, and vitals
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Anemia and chronic disease
Only inflammation, infection, and malignancy cause
It is nonprogressive Develops over 6-8 weeks Many don’t require treatment
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Most cases are idiopathic Infection and pregnancy, medication,
chemicals or radiation can trigger Airplane glue, arsenic, pestisides
Complete failure of the bone marrow Low RBC count Low WBC Low Platelet cts S/S: pallor, fatigue, tachycardia, sob,
hypotension, prolonged/spontaneous bleed, frequent infections, purpura, retinal hemorrhages are common
Tx: transfusion of RBC and Platelet, antibiotics, corticosteroids, bone marrow transplant, ICU setting, monitor for signs and symptoms of infection and bleeding, neutropenic precautions
Aplastic Anemia
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Pt does not absorb vitamin B12 from stomach Higher incidence of gastric cancer
Pt may lack intrinsic factor-essential for b12 absorption
Assess hx: gastrectomy, crohn’s, family history,etc.
s/s: weakness, sore tongue, numbness of hand and feet
Tx: B12 injections monthly, endoscopy q1-2 years---if untreated can develop heart failure and lead to death Monitor oral cavity, and skin. Monitor for
jaundice, monitor gait, provide small frequent bland diet
Dx: Obtain shilling test
Pernicious Anemia
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Thalassemia Most frequent in SE Asian, African, and Mediterranean descent
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Folic Acid Deficiency
Folate is in green leafy veggies and liver
Alcohol increases need for folic acid
S/S same as pernicious anemia except no neuro symptoms
Dx: folate level Tx: replacements
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RBCs normally disc shaped In sickle cell they are sickle shaped Easily rupture Obstruct blood flow Genetic in nature Most common in African
Americans Sickle cell is recessive (inherit from
mom and dad) http://www.youtube.com/watch?v
=R4-c3hUhhyc
Sickle cell anemia
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Sickle Cell Crisis
4 types: sickle crisis: most common---obstructive aplasic crisis---from infection from
parvovirus Hyperhemolytic---massive rbc destruction sequestrian crisis---result from other organs
pooling sickled cells Spleen is most common Also in liver and lungs
S/S: tachycardia, fever, decreased HGB, infiltrates on chest x-ray
Pulomary HTN is a symptom that is not usually detected until damage is irreversible
Monitor x-rays, CT scan, Echo, HGB level Tx: treat symptoms, Bone marrow transplant,
transfusions, Hydroxyurea, Arginine http://
www.youtube.com/watch?v=qe59ar-GZmg
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Glucose -6-Phospate
Dehydrogenase Deficiency
This is a deficiency in the gene that is essential for membrane stability
Hemolysis only occurs with stressful situations
Mostly affects african americans, greek or italian decent as well as asians and jewish origins
Inherited on x chromosome S/S: asymptomatic, or jaundice,
pallor, hemoglobinuria Dx: serum G-6-PD Tx: stop offending med,
transfusion, educate about meds to avoid, instruct to wear medic alert bracelet
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Too many RBCs produced Blood more viscous
s/s: headache, dizziness, ringing in the ears, blurred vision, ruddy complexion, HTN, pruritis, gout problems, burning fingers and toes
DX: o2 sat, CBC with DIFF Complications: CVA, MI, BLEED
issues Tx: hydroxyurea, interferon, plavix,
ASA Treat symptoms Teach pt: don’t cross legs, quit
smoking, stay active, minimal alcohol, avoid excess iron
TX: phlebotomize blood
Polycythemia Vera
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Enough RBCs made but they are destroyed once they are released into circulation
Causes: infection, drug reaction, cancer
s/s: pallor, fatigue, tachycardia, sob, hypotension, jaundice, high bilirubin levels
Positive direct coombs antiglobulin test
Tx: blood transfusions, corticosteroids, spleenectomy
Recovery in few days to weeks
Autoimmune Hemolytic
Anemia
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Leukemia
Defect in the WBC stem cell Abnormal reproductions Unknown cause, may be from
chemical or radiation exposure Symptom onset is abrupt http://
www.youtube.com/watch?v=FJOYAaygQFE
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AMLAcute Myeloid Leukemia
Defective stem cell Incidence rises with age 60+ Prognosis variable Younger pts may survive 5 years S/S: fever, infection, weakness,
fatigue, bleed tendency, pain Dx: no warning, CBC Complications: bleeding
(petechiae, ecchymosis), infection, DIC
TX: chemo, transfusions, infection treatment, growth factor agents, bone marrow transplant, palliative care
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CML
Uncommon in pts under 20 Life expectancy 3-5 years s/s: asymptomatic, dyspnea, mild
confusion, enlarged liver, wt loss, anorexia
Tx: tyrosine kinase inhibitor, avoid antacids and grapefruit juice, interferon, cytosine, leukopheresis, bone marrow transplant, Gleevac
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Acute Lymphocytic
LeukemiaALL
Most common in young kids 4-14 Uncommon s/s: decreased cbc counts, pain,
enlarged liver, enlarged spleen, headache, vomiting
Tx: bone marrow transplant, chemo, corticosteroids
Complications: infection
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CLL
Common in older adults Most common form in US and
Europe More frequent in men s/s: asymptomatic,
lymphadenopathy, pain, hepatomegaly, spleenomegaly, anemia, fevers, drenching sweats, wt loss, infections
Tx: treat symptoms, chemo, monoclonal antibodies
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Hodgkins Disease
Characterized by reed- sternberg cells in the lymph nodes
Highest occurance is in 20s and50s Men are more likely than women
to have Tx: radiation, chemo, bone marrow
transplant, stem cell transplant Survival rates vary 5 yr survival rate is 82%
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Non Hodgkins Lymphoma
6th most common type of cancer and cancer death in US Avg age of dx is 60
Stages Low grade Intermediate grade High grade
The higher the grade the more aggressive
Tx: chemo, radiation, bone marrow transplant, stem cell transplant
5 year survival rate is 52%
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Multiple Myeloma
Cancer of the plasma cells Most common over the age of 60 No known cause
Genetics and radiation exposure play a part s/s: bone pain, hyperuricemia (kidneys), anemia,
hypercalcemia, fractures, spinal cord compression, renal failure
Diagnosis: radiographs, serum and urine protein electrophoresis, bone marrow biopsy
No known cure Tx: chemo and radiation to treat symptoms,
vertebroplasty, antiemetics, pain management
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Bleeding disorders
http://www.mhhe.com/biosci/esp/2002_general/Esp/folder_structure/tr/m1/s7/trm1s7_3.htm
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Too few platelets Causes: cancer treatment
Too many platelets being destroyed Causes: idiopathic thrombocytopenic
purpura, thrombic thrombocytopenic purpura
Dx: bone marrow bx, CBC s/s: petechiae, purpura, gingival
bleed, epistaxis, prolonged bleeding
Tx: transfusions, spleenectomy, chemo, stop med that is causing, stop ETOH, treat infection
Thrombocytopenia
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Immune thrombocytopenic
purpura
Most common among kids and young girls
Usually 1-6 wks after viral infection Cause unknown, h. pylori may play
role s/s: asymptomatic, low platelet
count, petechiae, hemoptysis Dx: bone marrow bx, platelet ct Tx: stop med, immune globulin,
chemo, prednisone, spleenectomy Nsg: assess lifestyle, teach
symptoms, avoid constipation, avoid valsalva, avoid teeth flossing, use only electric razors, use only soft bristled tooth brush, monitor for osteoporosis
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HIT
Example of drug induced immune mediated thrombocytopenia
Rare Related to heparin therapy Tx: observation, assessment,
monitor lab values, stop heparin immediately
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Thrombic Thrombocytopenic
Purpura
Medical emergency Causes extensive blood clots TX: plasmaphoresis Complication: multi organ FX 95%death rate if not treated
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Von Willebrand’s Disease
Most common inherited bleeding disorder
1-2% international population s/s: Mucosal and cutaneous
bleeding, porlonged bleed times
Tx: DDAVP, FFP, Cryoprecipitate, bleed precautions
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Genetic Lack of blood clotting factor 1-2 cases per 20,000 persons Types
A: factor VIII is missing-higher incidence B: factor IX is missing
Trait is carried on x chromosome Rare for women to have s/s: uncontrolled bleed especially in joints, skin, GI tract Tx: no cure. Transfusions, pain treatment (IV morphine is common)..monitor
for addiction to opiods. http://www.youtube.com/watch?NR=1&feature=endscreen&v=pVHbMuBK8CI
Hemophilia
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DIC
Not a disease Triggers: sepsis, trauma, cancer,
shock, abruptio placentae, allergic reactions
Life threatening condition Initially coag time is normal S/S: are manifested in organs with
either clots or bleeding. Bleeding from all orifaces(tear ducts, gums, IV sites, rectum, urethra, etc.)
Dx: PT, PTT, D-Dimer Tx: treat the cause, replace fluids,
o2, fix electrolyte imbalances, administering vasopressors are vital, cryoprecipitate to replace factor 5 and 7, FFP, heparin
http://www.youtube.com/watch?v=kNSwGUqaVgs
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Universal donor= O Does not contain A, B, or Rh antigens
Universal recipients= AB+ Blood contains A, B, and RH antigens
Usually blood banks exactly match the pt blood
http://www.youtube.com/watch?v=G_-9_CF02qI
Blood typing for transfusion
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Pt needs 18 or 20 gauge IV needle so cells are not lysed (destroyed)
Prior to administration, blood needs to be checked by 2 licensed nurses. Check the expiration date, name, medical record number, type of blood, blood band id, pt birthdayCheck vitals prior to administration
**blood must be initiated with in 30 minutes of arrival from lab to floor
Use blood tubing for administrationMonitor for blood reactionsMonitor vitals continuously during administration
adminstration on blood
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Hemolytic: fever, chills, nausea, dyspnea, chest pain, back pain, hypotension Antigen/antibody rx to transfusion Happens shortly after initiation Tx: stop the transfusion, call md, supportive therapy to maintain HR and BP
Anaphylactic: urticartia, wheezing, dyspnea, hypotension Type 1 hypersensitivity rx to plasma proteins Occurs within 30 minutes of initiation Tx: stop transfusion, call md, be ready for epi and steroids
Febrile: fever, chills Recipients antibodies rx to donor leukocyte Occurs within 30-90minutes of initiation Tx: stop infusion, call md
Circulatory overload: cough, frothy sputum, cyanosis, decreased BP cardio system is unable to manage the additional fluid load Occurs anytime during transfusion and up to several hours after completion Tx: stop infusion, call for help, be prepared for code, be prepared to administer oxygen and Lasix
Blood reactions
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Minimize the # of invasive procedure
Avoid prolonged tourniquet use Avoid IM injections Instruct the client to use soft
bristled tooth brush No strait edge razor shaving only
use electric razor Avoid NSAIDS
Bleeding precautions
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ANY QUESTIONS???