West Coast University NUR 120

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West Coast UniversityNUR 120

• Hematologic System (Blood Disorders)
• Iron Deficiency Anemia
• Pernicious Anemia
• Thrombocytopenia
• Immunologic System (Immune System Disorders)
• HIV/AIDS

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The Hematologic System

• The hematologic system is the
• Blood
• Blood Cells
• Lymph
• And organs involved with blood formation

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Bone Marrow

• Is the blood-forming (hematopoeitic) organ.
• Produces most of the cells of the blood
  including
• RBC erythrocytes
• WBC leukocytes and
• Platelets
• Bone Marrow also is involve in the immune
  responses.

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Bone Marrow

• Releases
• 2.5 billion RBC each day in healthy adult.
• 2.5 billion platelets and
• 1 billion white blood cells per kilogram of body
  weight.
• Fetus blood components are produced in the
  liver and spleen and by the last trimester in the
  bone marrow.

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Bone Marrow

• At birth
• Blood producing marrow is present to every bone.
• Flat bones sternum, skull, pelvis, and shoulder
  girdles contain active blood producing marrow
  throughout life.
• As person age blood producing marrow decreases in
  the long bones and in small and irregularly
  shaped bones.

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Blood Producing Bone Marrow

• 18 years blood production is limited to the
  ends of the long bones
• Adulthood fatty tissue replaces inactive bone
  marrow.

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Blood Producing Bone Marrow

• Process of blood production
• Bone marrow first produces stem cells.
• Stem cells are immature, undifferentiated cells
  that are capable of maturing into any one of
  several types of blood cells RBCs, WBCs, or
  platelets depending on the bodys need. Also
  called pluripotent, multipotent and totipotent.

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Blood Cell Development Cont

• Committed Stem Cell- also called the precursor
  cell or the unipotent stem cell enters
  maturational pathway and then differentiate into
  one cell type.
• Committed stem cell actively divide but require
  the presence of a specific growth factor for
  Maturation and some hormones
• E.g. cytokines.

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Erythropoietin

• Is a growth factor made in the kidneys that is
  specific for RBC.
• RBC growth factor produced in the kidney in same
  amount as RBCs destruction.
• When tissue oxygenation is less than normal
  (hypoxia) the kidney increases the production of
  erythropoietin.
• Synthetic erythropoietin (PROCRIT, EPOGEN, EPO)
  has the same effect on bone marrow as the
  naturally occurring erythropoietin.

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Erythropoiesis

• Erythropoeisis the production of RBC.
• - Process where it involves selective
  maturation of stem cells into mature
  erythrocytes.
• - This process ensures that there is enough
  RBCs for good oxygenation without too many cells
  that could thicken the blood and slow its move.

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Blood Components

• Blood is composed of plasma and cells.
• Plasma part of the bodys extracellular fluid.
  Similar to interstitial fluid.
• Contains several more times protein the
  interstitial fluid.
• E.g. Albumin, Globulins, and Fibrinogen
• Cells RBCs, WBCs, and Platelets.

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Albumin, Globulin and Fibrinogen

• Albumin- Increases the osmotic pressure of the
  blood which prevents plasma from leaking into the
  tissues.
• Globulins - have many function e.g transporting
  other substances and protecting the body against
  infection.
• Fibrinogen is a protein molecule that can be
  activated to form fibrin.
• Fibrin molecules assemble together to form
  structures important in the blood clotting
  process.

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Red Blood Cells (Erythrocytes)

• Largest proportion of the blood cells.
• Mature RBCs has no nucleus and has biconcave disk
  shape.
• Has flexible membrane that allows RBC to change
  shape without breaking as they pass through a
  narrow, winding capillaries.

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Red Blood Cells (Erythrocytes

• Number of RBC varies from person to person
  according to gender, age and general health.
• Normal range 4,200,000 to
• 6, 100,000/mm3.
• Life span 120 days after being released into
  the blood.
• Old cells are trapped and destroyed in the
  tissues, spleen and liver. Some part of destroyed
  RBCs (Iron) are recycled and used to make RBCs.

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Red Blood Cells (Erythrocytes)

• RBCs produce hemoglobin (Hgb).
• The heme part of hemoglobin molecules needs a
  molecule of iron. Only when a heme molecule that
  is complete with iron can it transport up to four
  molecules of OXYGEN.
• The globin portion carries Carbon Dioxide. RBC
  also can buffersand help maintain acid-base
  balance

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Hemoglobin

• Has the ability to combine loosely with oxygen.
• With only a small amount of drop of O2 level in
  the tissues, a greater increase in the transfer
  of O2 from hemoglobin to tissues occurs.
• Transfer of O2 to tissues is called oxygen
  dissociation.

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Substances needed to form Hemoglobin and RBCs

• Iron ( Fe)
• Vitamin B12 ( Cyanocobalamin)
• Folic Acid ( Folate)
• Copper (Ug)
• Pyridoxine ( Vit. B6)
• Cobalt (Co) and
• Nickel
• Lack of these substances can lead to ANEMIA

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White Blood Cells(Leukocytes)

• Performs action critical to inflammation or
  immunity.
• May types of WBCs all have specialized functions.
• Most are formed in the Bone Marrow
• WBCs protect the body from the effect of
  invasions by organisms.

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Neutrophils

• First internal line of defense against invaders
  especially bacteria.
• Destroys invaders through phagocytosis.
• Responsible for continuous, instant, nonspecific
  protection.
• The number of actual mature neutrophils is used
  to measure a clients risk for infection the
  higher the numbers, the greater the resistance
  against infection.

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Macrophages

• They are also known as monocytes when they are
  not mature.
• Move from blood to tissues when they mature.
• Lung alveolar macrophages
• connective tissues- histiocytes
• Brain Microglial cell
• Liver Kupffer cell
• Peritoneum Peritoneal macrophage
• Bone Osteoclast
• Joints Synovial type A cell
• Kidney mesanglial cell.

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Macrophages ( Function)

• Important in immediate inflammatory response.
• Stimulates the longer-lasting immune response of
  the of the anti-body mediated immunity (AMI).
• Phagocytosis
• Repair of injured tissues
• Antigen presenting/processing
• Secretions of cytokines that helps to control the
  immune system.

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Basophils

• Make up 1 of the total circulating WBCs.
• These cells cause the manifestations of
  inflammation.
• Contains vasoactives amines that act on blood
  vessels. Includes heparin, histamine, serotonin,
  kinins, and leukotrienes.
• When release into the blood most of these
  chemicals act on the smooth muscles and blood
  vessel walls.
• Heparin inhibits blood and protein clotting
• Histamine constricts small veins and respiratory
  smooth muscles. Constrictions inhibits blood flow
  and decrease venous return. This results in blood
  collection to capillaries and small arterioles.
• Kinins dilate arterioles and increase capillary
  permeability. Theses actions cause blood plasma
  to leak into interstitial space (vascular leak
  syndrome)

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Eosinophils

• Contains many vasoactive chemicals also. Usually
  make up 1 to 2 of the total WBC count.
• Function- act against infections of parasitic
  larvae.
• Increases in number during an allergic reaction
  because eosinophils degrade the vasoactive
  chemicals released by the other leukocytes.

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Platelets

• They are the smallest of the blood cells.
• Fragments from giant precursor cell in the bone
  marrow known as Megakaryocytes.
• Stick to injured blood vessel walls and form
  platelets plug that can stop the flow of blood
  from the injured site.

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Platelets

• They also produce substances important to
  coagulation.
• Help keep blood vessels intact by beginning
  repair of damage to small blood vessels. They
  perform most of their functions by aggregation
  (clumping).
• Production in the bone marrow is also precisely
  controlled by growth factors (thrombopoieitin).
• After leaving the bone marrow, they are stored in
  the spleen and then released slowly to meet the
  bodys need.
• Normally 80 of platelets circulates and 20
  stored in the spleen.
• Life span 1 2 weeks

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Accessory Organs of Hematopoiesis

• Spleen located under the diaphragm to the left
  of the stomach.
• Composed of three types of tissues white pulp,
  red pulp and marginal pulp.
• These help to balance blood cells production and
  blood cells destruction and assist with immunity.
• The spleen destroys old or imperfect RBCs, breaks
  down the hemoglobin released from destroyed RBCs
  stores platelets and filters antigen.
• Thus after splenectomy, clients are not efficient
  at ridding the body of disease-causing organisms
  and are at greater risk for infection and sepsis.
  

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Liver

• Main production site for prothrombin and most of
  the blood clotting factors.
• Proper liver function and bile production are
  critical to the formation of Vitamin K in the
• intestinal tract.
• Vitamin K is essential for producing blotting
  factors VII, IX, and X. Large quantities of whole
  blood and blood cells can be stored in liver.
• Also converts bilirubin to bile and stores iron
  within the protein ferritin.
• Small amount of erythropoeitin are also produced
  in the liver.

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Assessments of the Hematopoeitic System/Functions

• Health History base on Gordons Functional Health
  Pattern
• Activity Exercise Pattern questions guide
• Ask on energy level in comparison of last year.
• How rested after a typical night sleep.
• Any experiences of dizziness or light headedness
• Is the heart seems to pound?
• How much exercise do you get? How often? What
  type?
• Do you feel you have enough energy to do what you
  want or need to do?

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Assessments of the Hematopoeitic System/Functions

• Family History and Genetic Risk- Bleeding
  Disorders e.g. Hemophilia
• Personal History e.g. liver function, known
  immunologic or hematologic disorder, and current
  drug use? Check all drugs pt is taking in the
  past 3 weeks/
• Ask about use of ATBs.(prolonged use can lead to
  clotting problems or bone marrow depression.
• Diet History
• Socioeconomic Status
• Current Health Problems

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Physical Assessment

• Skin Assessment- Inspect color of the skin, nail
  beds.
• Note People with darker skin pallor and
  cyanosis easily detected in the oral mucous
  membrane and the conjunctivae of the eye while
  jaundice is in the roof of the mouth.
• Head and neck assessment lymph nodes ,
  symmetrical, light palpation.
• Respiratory Assessment
• Cardiovascular Assessment
• Renal and Urinary Assessment
• Musculoskeletal Assessment paresthesias of
  lower extremity
• Abdominal Assessment
• CNS assessment
• Psychosocial Assessment

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Common Assessment Abnormalities

• Skin pallor, jaundice, cyanosis, leg ulcers
  (malleoli), purpura (ecchymosis- decrease Plts),
  peticchia (pinpoint bleeding),hematoma.
• Eyes- yellow sclera, pallor (conjunctiva).
• Nose epistaxis low Platelet Ct.
• Mouth pallor, gingival/mucosa ulceration.
• Lymph Nodes- enlarge, tender to touch.
• Heart and Chest tachycardia, gt100 bpm,
  palpitation.
• Orthostasis,
  Hypertension ( initial reaction of anemia).
• Abdominal Hepatomegaly, Splenomegaly
• Nervous System Paresthesis of feet and hand,
  low B12 or Folate. Weakness low Hgb.
• Musculoskeletal Pain in pelvis, ribs, spine,
  sternum
• Joint swelling hemophilia, sickle cell
  anemia.

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Hematologic Changes Associated with Aging

• As bone marrow ages, it produces fewer blood
  cells. Total RBC and WBC are lower in older
  adults.
• Platelets count do not appear to change with age.
  
• Antibody levels and responses are lower in older
  adults.

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Hematologic Changes Associated with Aging

• Changes the cellular and plasma component of
  blood.
• Several factors causes decrease blood volume in
  older adults and tend to have lower levels of
  plasma proteins and decreased plasma osmotic
  pressure ( decreased intake of dietary protein)
  which also causes some loss of blood volume into
  the interstitial space.

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Hematologic Changes Associated with Aging

• Lymphocytes become less reactive to antigen and
  have a loss of immune function.
• WBC count does not rise as high in response to
  infections in older people and younger people.
• Hemoglobin levels also change with age.
  Hemoglobin levels in men and women fall after
  middle age. Iron deficient diets may play in a
  role in this reduction.

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Iron Deficiency Anemia/Pernicious

• Anemia is an abnormally low amount of
  circulating red blood cells (RBCs ), hemoglobin
  concentration, or both.
• Iron Deficiency Anemia is the most common
  anemia. Lack of Iron (Fe) that promotes formation
  of Hgb.
• Pernicious Anemia due to deficiency of
  intrinsic factor produced by gastric mucosa which
  is necessary for absorption of Vit B 12.

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Causes of Anemia

• Blood Loss
• Inadequate RBC production
• Increase RBC destruction
• Insufficient or defective hemoglobin

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Common Risk Factor for Anemia

• Acute or Chronic Blood loss menorrhagia, GI
• 
  ulcers/bleed
• Increased Hemolysis defective hemoglobin
  (sickle
• 
  cell), impaired glycolysis (G6PD- Glucose
  6phosphate dehydrogenase) deficiency anemia,
  transfusion reaction, autoimmune diseases.
• Mechanical Trauma to RBCs mechanical heart
  valve, cardiopulmonary bypass.

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Common Risk Factor for Anemia

• Dietary Insufficiency Iron Deficiency
• - Vit. B
  12 deficiency
• - Folic
  Acid Deficiency
• - Pica or
  persistent eating of substances not normally
  considered food (non-nutritive value ) for at
  least 1 month.
• Bone Marrow Suppression exposure to
• radiation or
  chemicals.
• Aplastic anemia
  results in
• decreased
  number of red blood
• cells as well
  as decreased platelets and
• WBC.

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Diagnostic Procedures for Anemia

• Lab Assessment
• 1. CBC (Complete Blood Count)
• RBC major carrier of Hgb in the blood
• Hgb- transport O2 and Co2 to and from
  the cells
• and can be used as index of oxygen
  carrying
• capacity of the blood.
• Hematocrit (Hct) percentage of RBCs in
  relation
• to the total blood volume.
• Platelets important for clcot
  formation

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RBC indices to determine type and cause of most
anemias

• Mean Corpuscular Volume (MCV) size of red blood
  cell Normocytic, microcytic, macrocytic.
• Mean Corpuscular Hemoglobin (MCH) to determine
  the amount of hemoglobin per RBC.
• Normochromic normal amt. of Hgb per cell,
• Hypochromic decreased amt. of Hgb per cell.
• Mean Corpuscular Hgb Concentration (MCHC) to
  indicate Hgb amt. relative to the size of the
  cell.
• In Iron deficiency anemia there is decreased
  MCV, MCH, MCHC and classified as microcytic,
  hypochromic anemia.
• In pernicious anemia there is increased MCV and
  classified as macrocytic anemia.

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Diagnostic Studies/Procedures for Anemia

• 2. Iron Studies
• Total Iron Binding Capacities (TIBC)
  reflects an indirect measurement of serum
  transference.
• Serum Ferritin is indicator of total body
  iron stores.
• Serum Iron measures the amt. or iron in the
  blood.
• Low serum iron and elevated TIBC indicates
  iron deficiency anemia

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Diagnostic Studies/Procedures for Anemia

• Hemoglobin Electrophoresis separates normal Hbg
  from abnormal. Use to detect thalassemia and
  sickle cell disease.
• Schillings Test measures Vit. B12 absorption
  with and without intrinsic factor. It is used to
  differentiate between malabsorption and
  pernicious anemia.
• Procedure in a form of handouts.
• Bone Marrow Examination diagnoses aplastic
  anemia(failure of bone marrow to produce RBC as
  well as WBCs and platelets).

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Nursing Care after Bone Marrow Aspiration

• Apply pressure to the site for 5 to 10 minutes
• Assess V/S frequently.
• Apply pressure dressing.
• Monitor for signs of bleeding and infection for
  24 hours.
• Pt. going for Bone Marrow aspiration is
  position based on area where they will obtain the
  sample. Either prone or side lying.
• Local anesthesia to the site of aspiration is
  given and pt. is mildly sedated.

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Nursing Assessment for Anemia.

• Pallor especially in the ear and nail beds,
  palmar
• crease and conjunctiva.
• Fatigue exercise intolerance, lethargy,
  orthostatic
• hypotension.
• Tachycardia
• Heart murmurs
• Heart failure
• Signs of bleeding- hematuria, melena,
  menorrhagia.
• Dyspnea
• Irritability difficulty concentrating
• Cool skin, cold intolerance.

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Iron Deficiency Anemia

• What Causes Iron Deficiency Anemia?
• Poor absorption of iron by the body (Vitamin C
  aides in iron absorption)
• Inadequate daily intake of iron
• Pregnancy
• Growth spurts or blood loss due to heavy period
  or internal bleeding.
• Anemia develops slowly after the normal stores of
  iron have been depleted in the body and in the
  bone marrow.
• Women, in general, have smaller stores of iron
  than men. Women also lose iron more frequently
  than men because of the blood loss during
  menstruation.

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Iron Deficiency Anemia

• Signs and Symptoms specific for Iron Deficiency
  Anemia
• Pale skin color (Pallor)
• Fatigue
• Irritability
• Dizziness
• Weakness
• Shortness of breath
• Sore tongue (smooth sore bright red tongue)
• Brittle nails
• Decreased appetite (especially in children)
• Headache - frontal.
• The tests are Red blood cell measures 4 x 10 (12
  power), hemocrit (below 36, NV m 40-54 ml/dl,
  w 37 -47 ml/dl, and hemoglobin( below 10 g/dl)
  NV- m 13-18 g/dl, w 12.0 16.0 g/dl. Size of
  red blood cells (microcytic), serum iron level
  (low), and iron binding capacity in the blood
  (elevated).

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Iron Deficiency Anemia

• Treatment of Iron Deficiency Anemia
• Ferrous salts of iron are absorbed much more
  readily and are generally preferred.
• Commonly available oral preparations
• Ferrous Sulfate, Ferrous Gluconate and
  Ferrous Fumarate (Hemocyte). All three forms are
  well absorbed. Ferrous sulfate is the least
  expensive and most commonly used oral iron
  supplement.
• For iron replacement therapy, a dosage equivalent
  to 150 to 200 mg of elemental iron per day is
  recommended.
• Ferrous sulfate, 325 mg of three times a day,
  will provide the necessary elemental iron for
  replacement therapy.
• Hematocrit levels should show improvement within
  one to two months of initiation of therapy.
• Take with meals if GI side effects occurs.
• Give with Vit. C for better Iron absorption
• D0 not take with 2 hours of milk or antacids.
• Stools will be black.
• May cause constipation. Increase fluid intake and
  foods high in fiber.
• Use of straw for liquid iron to prevent teeth
  staining.

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Treatment of Iron Deficiency Anemia

• Injectable iron dextran, containing 50 mg of iron
  per mL, is supplied in a 2-mL single-dose vial.
• Adverse reactions include headache, dyspnea,
  flushing, nausea and vomiting, fever,
  hypotension, seizures, urticaria, anaphylaxis.

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Pernicious Anemia

• Body stores of vitamin B12 are adequate for up to
  five years.
• Symptoms are attributable primarily to anemia,
  although Glossitis, Jaundice, and Splenomegaly
  may be present. Vitamin B12 deficiency may cause
• Decreased vibratory and positional sense
• Ataxia
• Paresthesias and
• Confusion.
• Treatment of Vitamin B 12 Deficiency Anemia.
  Intramuscular, oral or intranasal preparations
  are available for B 12 replacement.
• In patients with severe vitamin B12 deficiency,
  daily IM injections of 1,000 mcg of
  cyanocobalamin.

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.Pernicious Anemia

• Can not be prevented if due to lack of intrinsic
  factor. .
• Some develop pernicious anemia due not getting
  enough Vitamin B12 in their diets.
• Eating foods high in vitamin B12 can help prevent
  low vitamin B12 levels.
• Good food sources of vitamin B12 include Meats
  such as beef, liver (glandular meats), and
  poultry, Fish and Shellfish, yeast, Egg and Dairy
  products, such as milk, yogurt, and cheese,
  cereals and other fortified foods that have
  vitamin B12 added, Vitamin B12 also is found in
  multivitamins and in B-complex vitamin
  supplements.
• Supplements for people at risk for vitamin B12
  deficiency, such as strict vegetarians or people
  who have had stomach surgery is needed.
• Older adults may have trouble absorbing vitamin
  B12.

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Nursing Diagnosis - Anemia

• Activity Intolerance
• Anxiety
• Ineffective tissue perfusion
• Fatigue
• Self-Care Deficit
• Risk for Infection

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Nursing Plans and Interventions

• Instruct client to alternate periods of activity
  with periods of rest.
• Teach client about diet
• Food selection and preparation to maximize
  intake of
• A. Iron rich food e.g. red meats, organ
  meats, whole wheat and whole wheat products,
  spinach, carrots.
• B. Folic Acid sources e.g. green vegetables,
  liver, citrus fruits for Folic Acid
  Anemia/Deficiency.
• C. Vit. B 12 rich foods.
• Instruct in need for Vitamin Supplements

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Vitamin Supplements

• Give Iron preparation with meals to
  prevent/decrease GI irritation.
• Administration of Iron
• Dos Use Z-Track technique of administration
• Use air bubble to avoid
  withdrawing medication
• into subcutaneous tissue.
• Donts Do not use deltoid muscle.
• Do not massage injection site.
• Administer B12 and Folic acid orally except to
  client with pernicious anemia who should receive
  parenterally.
• If parenteral Iron is required, use Z-track
  method for administration to prevent staining the
  skin.

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Complications and Nursing Implications

• Monitor client for s/s of hypoxemia.
• - dyspnea, decreased O2 saturation, central
  cyanosis.
• - administer oxygen therapy. Monitor SaO2.
• - Administer blood transfusion as ordered.
• Blood Transfusion lead to an immediate
  improvement in blood cell counts and client sign
  and symptoms.
• Use only saline to flush IV tubing or to run
  with blood. Never add medications to blood
  product.
• Two RNs should simultaneously check the
  physicians prescription, the clients identity,
  and the blood bag label.

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Complications and Nursing Implications

• Assess neurologic status of client with
  macrocytic anemias.
• Vit. B 12 is essential for neurologic
  function. Administer supplements.
• Notify the physician in any changes in
  mentation.
• GI Bleeding is a most common cause of anemia in
  older adults.
• Anemia maybe misdiagnosed as depression or
  debilitation.

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Thrombocytopenia

• Thrombocytopenia - is any disorder in which there
  are not enough platelets. Platelets are cells in
  the blood that help blood to clot. This condition
  is sometimes associated with abnormal bleeding.
• Reduction of platelets below 150,000/ul.
• Acute, severe, or prolonged decreases from this
  normal rannge can result in abnormal hemostasis
  that manifest as prolonged bleeding from minor
  trauma to spontaneous bleeding w/o injury.
• Symptoms
• Bruising
• Nosebleeds or bleeding in the mouth
• Rash (pinpoint red spots called petechiae)
• Mild thrombocytopenia can occur without symptoms.

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Causes

• Can be inherited (Wiscott-Aldrich Syndrome ) or
• Acquired autoimmune diseases, increased
  platelets consumption, splenomegaly, marrow
  supression and bone marrow failure.
• Is often divided into three major causes of low
  platelets
• 1. Low production of platelets in the bone
  marrow
• 2. Increased breakdown of platelets in the
• bloodstream (called intravascular)
• 3. Increased breakdown of platelets in the
  spleen or
• liver (called extravascular).

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Disorders that involve low production in the
bone marrow include

• Aplastic anemia
• Cancer in the bone marrow
• Infections in the bone marrow (very rare)
• Myelodysplasia
• Use of certain drugs may also lead to a low
  production of platelets in the bone marrow,
  although this is rare

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Causes and Risk Factors

• Acquired thrombocytopenia may result from the use
  of certain drugs, such as quinine, quinidine,
  rifampin, heparin, nonsteroidal anti-inflammatory
  agents, histamine blockers, most chemotherapeutic
  agents, allopurinol and alcohol.
• Common causes of decreased platelet production
• 1. marrow aplasia (when the marrow is not
  developing naturally)
• 2. fibrosis (an abnormal formation) or
  infiltration with malignant cells.

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Drugs that cause drug-induced thrombocytopenia

• Diabetes drugs taken by mouth (hypoglycemic
  agents)
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Penicillin
• Quinidine
• Quinine
• Ranitidine
• Some drugs used to treat arthritis conditions
• Sulfonamides
• Diuretics - Thiazides

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Common causes of decreased platelet production

• Occur transiently after a viral infection (such
  as Epstein-Barr) or infectious mononucleosis.
• Idiopathic thrombocytopenic purpura (ITP), an
  autoimmune disorder.
• - Cause is unknown. When reach spleen this
  platelets were recognize as foreign and are
  destroyed by macrophages.
• Thrombotic thrombocytopenic purpura (TTP), which
  is an uncommon disorder associated with anemia.
• - Characterized by hemolytic anemia,
  neurologic abnormalities , fever in absence of
  infection and renal abnormalities.

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Disorders that involve the breakdown of
platelets include

• Disseminated Intravascular Coagulation (DIC)
• Disseminated intravascular coagulation
  (DIC) is a serious disorder in which the proteins
  that control blood clotting become abnormally
  active.
• Drug-induced nonimmune thrombocytopenia
• Drug-induced thrombocytopenia occurs when
  certain drugs or medications destroy platelets or
  interfere with the body's ability to make enough
  of them.
• Drug-induced immune thrombocytopenia
• If a medicine prevents your bone marrow from
  making enough platelets, the condition is called
  drug-induced nonimmune thrombocytopenia.
  Chemotherapy drugs and a seizure medication
  called valproic acid may lead to this problem.
• Hypersplenism
• Immune thrombocytopenic purpura (ITP)
• Thrombotic thrombocytopenic purpura

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Symptoms of Thrombocytopenia

• Sudden onset of petechiae and ecchymoses from
  bleeding into mucous membranes or on the skin.
• Malaise, fatigue and general weakness (with or
  without accompanying blood loss).
• Adults may have large, blood-filled bullae in the
  mouth.
• If the platelet count is between 30,000 and
  50,000/mm3, bruising with minor trauma may be
  expected.
• If it is between 15,000 and 30,000/mm3,
  spontaneous bruising will occur. Ave. 20,000/mm3.
  life treathening hemorrhages.

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Diagnostic Studies

• Platelet count decreased, any reduction below
  150,000 u/l.
• Platelet transfusion is recommended when count
  is below 10,000 u/l unless client is actively
  bleeding.
• Lab test to assess secondary bleeding
• - Prothrombin time
• - activated Partial Thromboplastin Time.
• If PT/aPTT are elevated this may indicate DIC.

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PT/INR and aPTT

• PT/PTT are laboratory tests that measure the
  clotting time (how long it takes blood to clot.)
• PT/PTT are blood tests and INR is a ratio
  calculated from the PT.
• Prothrombin, or factor II, is one of several
  clotting factors produced by the liver. This test
  measures the integrity of the extrinsic and
  common pathways of coagulation.
• The prothrombin time (PT) measures the clotting
  time from the activation of factor VII through
  the formation of the fibrin clot. Adequate
  amounts of vitamin K are needed to produce
  prothrombin. Warfarin (Coumadin) is sometimes
  prescribed as a "blood thinner" because it is an
  effective vitamin K antagonist (blocks the
  formation of vitamin K).
• The reference range for prothrombin time is
  usually around 1215 seconds
• The normal range for the INR is 0.81.2

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PT/INR and aPTT

• The activated partial thromboplastin time (PTT)
  measures the function of several other clotting
  factors, found in the intrinsic and common blood
  clotting pathways.
• It measures the clotting time from the activation
  of factor XII through the formation of the fibrin
  clot. PTT prolongations are caused by factor
  deficiencies (factors VIII, IX, XI, and/or XII),
  or inhibitors (most commonly, heparin).
• Heparin prevents clotting by blocking certain
  factors in the intrinsic pathway.
• The greater the PT/PTT values, the longer it
  takes the blood to clot. HIGH PT/PTT risk for
  BLEEDING. LOW PT/PTT risk for blood clots/
  stroke.

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INR

• The INR stands for International Normalized
  Ratio.
• The INR is calculated from the PT and is intended
  to allow valid comparisons of results regardless
  of the type of PT reagent used among different
  laboratories (INR patient PT / mean normal
  PT).
• The INR is a method of standardizing the PT for
  coumadin anticoagulation.
• Before the INR, different labs using different
  reagents had different controls and widely
  differing PT value ranges. An INR of 1 means
  the blood clots "normally" for that pt. The
  greater the INR, the longer it takes the blood to
  clot.

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INR

• The warfarin (Coumadin) dosage for people being
  treated to prevent the formation of blood clots
  is usually adjusted so that the prothrombin time
  is about 1.5 to 2.5 times the normal value (or
  INR values 2 to 3).
• A patient may take warfarin to anticoagulate for
  atrial fibrillation (target INR around 2.5) or
  for a mechanical heart valve (target INR 3).
• An INR of 3 means the blood takes about three
  times as long to clot compared with the normal
  value for that pt.

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Nursing Responsibilities for Lab Studies

• Nurse needs to closely monitor platelet count and
  other anticoagulation therapy.
• Nurse need to monitor hematocrit and hemoglobin
  levels.

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Nursing Assessment

• Subjective Data important health information
• past health
  history
• medications
  
• Functional Health Patterns
• health perceptions health management Family
  history of bleeding problems, malaise.
• nutritional-metabolic bleeding gingiva,
  coffee-ground or bloody vomitus, easy bruising.
• Activity exercises fatigue, weakness, fainting,
  epistaxis, hemoptysis, dyspnea.
• Cognitive-perceptual pain and tenderness in
  bleeding areas, headache.
• Sexuality-reproductive menorrhagia, metrorrhagia

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Nursing Assessment

• Objective Data
• General Fever, lethargy
• Integumentary petecchia, ecchymosis, purpura
• GI Splenomegaly, abdominal distention,
  guiac-positive stools.
• Possible findings
• Platelet countlt 150,000/ul prolonged bleeding
  time,
• dec. hemoglobin and hematocrit normal or elev.
  Megakaryocytes in bone marrow examination.

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Tests diagnosis

• Complete blood count (CBC) shows low number of
  platelets.
• Blood clotting studies (PTT and PT) are normal.
• Other tests that may help diagnose this condition
  include
• Bone marrow aspiration or biopsy
• Platelet associated antibodies
• Complications
• Severe bleeding (hemorrhage) is the main
  complication. This can include
• Bleeding in the brain (intracranial hemorrhage)
• Gastrointestinal bleeding (vomiting blood or
  blood in the stools)
• When to contact a healthcare provider
• Call a healthcare provider if unexplained
  bleeding or bruising is noted.

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Collaborative Care Thrombocytopenia

• TTP

• ITP

• Plasmaparesis (plasma exchange)
• High dose prednisone
• Splenectomy
• Dextran
• Chemotherapy e.g. vincristine, vinblastin
• Immunosuppressives.

• Corticosteroids
• Platelets transfusions
• Splenectomy
• IV immunoglobulin
• Danazol
• Anti-Rho (D)
• Immunosuppressives.
• e.g. cytoxan, Imuran, Rituxan

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Collaborative Care Thrombocytopenia

• Heparin-Induced Thrombocytopenia

• Decrease Platelet Production

• Direct thrombin inhibitor e.g. lepirudin
• Indirect thrombin inhibitor
• e.g. arixtra
• Plasmapheresis (plasma exchange)
• Protamine Sulfate
• Coumadin
• Thrombolytic agents

• Identification and treatment of cause.
• Corticosteroids
• Platelet transfusions
• Oprelvekin (Neumega)

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Treatments

• Removal of the offending agents should correct
  the condition.
• Corticosteroids may be used to increase platelet
  production.
• Lithium carbonate or folate may also be used to
  stimulate the bone marrow production of
  platelets.
• Platelet transfusions may be used to stop
  episodic abnormal bleeding caused by a low
  platelet count.

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Patient Teaching Thrombocytopenia

• Notify HCP for any manifestations of bleeding.
• Ask HCP for restriction for in normal activities.
  E.g. vigorous exercises. Sturdy shoes or slippers
  for walking.
• Do not blow nose forcefully. Place head up and
  apply firm pressure on the nostrils and bridge of
  the nose.
• Do not bend down with your head lower than your
  waist.
• Prevent constipation by drinking plenty of fluids
  and do not strain when having BM.
• Shave only with electric razor. Do not use
  blade.
• Do not pluck eyebrows or other body hair.

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Patient Teaching Thrombocytopenia

• Do not puncture skin, e.g. getting tattoos or
  body piercing .
• Avoid using any medications that can prolonged
  clotting such as aspirin. Be careful also with
  herbs with same effects.
• Use soft bristle tothbrush to prevent injuring
  the gums. Flossing is also usually safeif it is
  done gently using the tape floss.
• Do not use alcohol -based mouthwashes as they can
  dry gums and increase bleeding.
• Women who are menstruating should keep tract of
  the number of pads that are used per day.
• Ask HCP before you have any invasive procedures
  done such as dental cleaning, manicure, or
  pedicure.