Hematologic System

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Hematologic System

• Amanda Hawkins R.N., MSN
• NURS 3277
• Spring, 2008

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Who Am I?

• I produce most the cellular elements of the
• blood. I am involved in some aspects of the
• immune system? Sad but true, my
• functions decrease with age.
• Who am I?

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Who Am I?

• I proudly make up the largest portion of the
  blood cells. If you looked at me under a
  microscope, you would not find a nucleus. But
  that is okay because this makes it easy for me to
  change shape without breaking as I pass in those
  tiny capillaries? I must watch out because
  macrophages will EAT ME!! I love to carry
  oxygenthats my job

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Who Am I?

• I am the smallest formed element of the blood,
  but there are thousands of me. I can adhere to
  any wall and form a plug. I like to hang out
  around the spleen until I am needed. I see a
  good many of my buddies die. I will only live
  1-2 weeks. My formal name is thrombocyte. When
  there is a decrease in me the condition is called
  thrombocytopenia. I increase with hemorrhage.

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Who Am I?

• Without me, one could live but you might have an
  impaired immune function. I store erythrocytes
  and platelets. Remove old and defective
  erythrocytes. I can return to the bone marrow
  iron for reuse. Approximately 30 of platelets
  are stored in me.

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Who Am I?

• I help with erythropoiesis. I produce most of
• the blood clotting factors and prothrombin.
• I can store whole blood.
• Who am I?

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Who Am I?

• I will protect you like a soldier. The enemy
• could be infection or injury. My nick name
• is Luke, for leukocyte. A decrease in me is
• called leukopenia. An increase in me is
• called leukemia.
• Who am I?

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Who Am I?

• I take place in the bone marrow of the skull,
• vertebrae, pelvis, sternum, ribs, and
• proximal epiphysis of long bones.
• Who am I?

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Bone Marrow

• Fills the central core of bones.
• Produces 3 cells RBC, WBC, platelets

• http//www.drstandley.com/images/BoneMarrow.bmp

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Normal RBC Value

• RBC count (million/ul x 10 12/l (SI units)
• Male 4.6 6
• Female 4 5
• MCV size of the RBC
• MCH weight of the hemoglobin in the RBC
• MCHC hemoglobin concentration per unit volume
  of RBCs
• RDW Is the size (width) difference of RBCs

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ErythrocytesRBCs

• Regulated by cellular oxygen requirements.
• Function - is to transport oxygen and carbon
  dioxide.
• Reticulocyte count measures the rate at which new
  RBCs appear in circulation.
• Hemoglobins function is to carry oxygen.

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Altered RBC

• HIGH
• Polycythemia vera
• High altitude
• Cardiovascular Disease
• Chronic Liver Disease
• Dehydration
• Anemias

• LOW
• Hemorrhage
• Leukemia/malignancy
• Pregnancy
• Overhydration
• Anemias

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Normal WBC Value

• WBC count 4500 10,000 ul (mm3)
• mcl (ul) microliter
• mm3 millimeter cubed

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LeukocytesWBCs

• Function - is related to the immune system.
• 3 classes are granulocytes, monocytes,
  lymphocytes
• Granulocytes
• Neutrophils are phagocytic cells involved in
  acute inflammatory responses.
• Eosinophils engulf antigen-antibody complexes
  formed during an allergic response.

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Cont WBCs

• Monocytes
• In tissues, resident macrophages are given
  special names
• Liver Kupffer cells
• Bone osteoclasts
• Lung alveolar macrophages
• Help with immune responses

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Cont WBC

• Lymphocyte subtypes are B cells T cells
• When B cells are stimulated by antigens, they are
  activated to form plasma cells called
  immunoglobulins help with humoral immunity.
• T cell help with cellular immunity against TB,
  contact irritants (poison ivy), cancer,
  parasites, fungi, and organ transplants.

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Altered WBCs

• HIGH
• Acute infections
• Drug influence

• LOW
• Anemia
• Alcoholism
• Drug influence
• Viral infection
• Lupus
• Rheumatoid arthritis

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Cont Altered WBCs

• HIGH
• Drug influence
• Examples - ASA, heparin, digitalis, epinephrine,
  lithium, histamine, antibiotics, ampicilline,
  erythromycin, vancomycin, long acting
  sulfonamindes

• LOW
• Drug influence
• -Examples -Antibiotics, Penicillin's, Tylenol,
  chemotherapy agents, valium, diuretics (lasix),
  Librium, oral hypoglycemic agents, aldomet,
  rifampin

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Platelets

• Aids in blood clotting
• Normal count 150,000 to 400,000 ul
• mcl (ul) microliter

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Altered Platelet Counts

• HIGH
• Malignant disorder
• Polycythemia vera
• Postspleenectomy syndrome
• Rheumatoid arthritis
• Iron deficiency anemia/hemorrhage

• LOW
• Hemorrhage
• Leukemia
• Thrombocytopenia
• Pernicious anemia
• Infection

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Geriatrics WBC

• The total WBC count and differential not usually
  affected by aging.
• During infection minimal elevation in the WBC
  count because there is a diminished bone marrow
  reserve of granulocytes and possible impaired
  stimulation of hematopoiesis.

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Geriatrics Platelets

• Platelets are unaffected by the aging
• process. However, changes in vascular
• integrity from aging can manifest as easy
• bruising.

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Spleen

• Hematopoietic function produces RBC in fetal
  dev.
• Filter function- removes old cells and other
  debris from the blood.
• Immune function contains lymphocytes
  monocytes
• Storage where approximately 30 of platelets
  are stored

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Lymph System

• Function is filtration of bacteria foreign
  particles carried by lymph.
• Complication after surgery
• Example mastectomy is lymph edema

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Lymph Nodes

• Lymph nodes are NOT generally palpable unless
  there is residual enlargement from a previous or
  current infection.
• Tender nodes are usually a result of inflammation
• Hard or fixed nodes suggest malignancy

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Geriatric Considerations on the Hematologic System

• Stem cells maintain their function but
• decrease in number making the elderly
• person more vulnerable to problems with
• clotting, oxygen transport, and fighting
• infection.

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Complete Blood CountCBC

• Pancytopenia the entire CBC is suppressed
• HBG, HCT RBC count are decreased anemia
  hemorrhage
• HBG, HCT RBC count are increased
  polycythemia, volume depletion
• NL Male 13.517 g/dl Female 12-15 g/dl
• Helpful hint - HBG x 3 HCT
• 1 unit of blood raises HBG 1 point

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Cont CBC

• shift to the left the existence of many
  immature cells. When infections are severe, more
  granulocytes are released from the bone marrow as
  a compensatory mechanism. To meet the increased
  demand many young, immature, neutrophils are
  released into circulation.
• Thrombocytopenia platelet count is depressed
  bleeding

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Critical Thinking

• WBC gt 11,000 infection, inflammation, tissue
  injury or death, leukemia, lymphoma
• WBC gt 25,000 certain types of leukemia's
• WBClt 4000 (leukopenia) bone marrow depression,
  severe or chronic illness or leukemia

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Bone Marrow

• Aspiration of bone marrow fluid or tissue through
  a needle.
• Invasive, informed consent, bone marrow tray,
  person from lab assists, betadine, xylocaine,
  done in room, analgesic
• Site used posterior iliac crest, sternum or
  anterior iliac crest
• Painful during the procedure when aspirated
  suction pain
• Band-Aid/sterile dressing over puncture site.
  Watch for bleeding and infection

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Bone Marrow Aspiration

• Pain experienced right now!

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Bone Marrow Aspiration

• Helps determine the cause of the abnormal numbers
  of RBC, WBC or platelets.
• Diagnosis of leukemia and staging of cancers
• Stem cell transplant

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Nursing Care after a Bone Marrow Aspiration

• Cover with sterile dressing/band aid
• Complications bleeding (monitor vital signs and
  apply pressure if this occurs)
• Hemorrhage (thrombocytopenic)
• Infection (leukopenic)

• )

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Lymph Node Biopsy

• Done in surgery. Care must be taken
• because neoplastic cells can be
• disseminated during the biopsy procedure if
• the scalpel passes through tissues
• containing cancerous cells.

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Drugs Affecting Hematologic Function and
Laboratory Values

• Do not memorize but be alert that certain drugs
  can cause anemia, neutropenia, and/or
  thrombocytopenia. Refer to table in your book.

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Common Assessment Abnormalities

• Review common assessment abnormalities
• of the hematologic system. Refer to the
• table in your book.

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Anemia

• Is the reduction below normal in the number of
  RBC, Hbg, Hct which can lead to tissue hypoxia
• Cause blood loss, impaired production,
  destruction of RBCs or iron deficiency
• SS (14 10 Hb) may only have symptoms with
  exercise. (10 6 Hb) has palpitations, dyspnea,
  and fatigue, and lt 6 Hb involves multiple
  systems.
• Below 6 Hb experience many side effects in many
  body systems

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AnemiaNursing Care

• Diet high protein iron, WIC program
• Drug therapy erythropoietin, vitamin
  supplements, iron tablet, oxygen therapy
• Iron p.o. with O.J., I.M. or I.V.
• Nsg Dx Activity intolerance altered nutrition
• Complication Hypoxemia

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AnemiaGerontology Considerations

• Anemia is common in older adults because of their
  poor nutritional intake and decreased iron
  absorption or iron
• Cobalamin (vitamin B12) deficiency may occur in
  more than 20 of the elderly people because of
  pernicious anemia, insufficient dietary intake
  and malabsorption.
• B12 food source red meats, liver

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Iron-Deficiency Anemia

• Cause inadequate diet intake, malabsorption,
  blood loss, or hemolysis.
• Duodenum iron is absorbed
• Side effect of iron absorption is black stools
• Lack of iron in the tissues pallor, glossitis
  (tongue), cheilitis (lips), H/A, paresthesias,
  and burning in the tissues

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Glossitis(Inflammation of the Tongue)
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Treatment for Iron Deficiency Anemia

• Nutrition Iron replacement for months or longer
• Best absorbed in acidic environment, 1 hour
  before meals. Take with O.J. or vitamin C helps
  with absorption
• Undiluted iron (stains teeth) use a straw
• Parenteral (IM Z track IV flush with normal
  saline)
• S.E. heartburn, constipation (may need a stool
  softener or laxative), or black stools

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Iron Poisoning

• It is also one of the most frequent causes of
  poisoning death in children.

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Foods With Iron

• Beef liver, red meats, fish, poultry, clams, eggs
• Dried fruits. dark green leafy vegetables
• Tofu, Legumes
• Fortified cereals, whole grain, bread, potatoes

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Which of the following food choices made by a
client with anemia best indicates that the
nurses instructions about foods high in iron has
been successful?

• 1. Oranges and grapefruits
• 2. Spinach and broccoli
• 3. Eggs, milk, and milk products
• 4. Liver and muscle meats

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Answer 4

• Liver and muscle meats are excellent sources or
  iron (option 4).
• Citrus fruits such as oranges and grapefruit are
  high in vitamin C (option 1).
• Green leafy vegetables such as spinach and
  broccoli supply the B vitamins (option 2).
• Eggs and milk supply calcium (option 3).

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A client diagnosed with iron deficiency anemia is
taking iron supplements. The nurse should
document which of the following in the teaching
plan to enhance the effect of the medication?

• 1. Include leafy green vegetables in daily diet.
• 2. Include whole-grain bread in daily diet.
• 3. Include raisins in diet three times per week.
• 4. Use adequate sources of vitamin C in diet.

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Answer 4

• Vitamin C helps to enhance the absorption of iron
  supplements as well as dietary iron. Leafy green
  vegetables, whole-grain breads, and raisins are
  high in iron, but would not enhance the
  absorption of the medication.

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A client has been taking iron therapy for
treatment of anemia. To evaluate drug
effectiveness, the nurse reviews which of the
following laboratory test results as the best
verification of iron stores in the body?

• 1. Ferritin level
• 2. Transferrin level
• 3. Hemoglobin and hematocrit
• 4. Complete blood count (CBC)

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Answer 1

• Ferritin levels reflect the visceral stores of
  iron in the body (option 1). Transferrin levels
  reflect how iron is transported in the body
  (option 2). Hemoglobin and hematocrit refer to
  concentration and proportion measures of red
  blood cells (RBCs), but they are not specific to
  body iron store values (option 3). The CBC will
  provide information relative to blood
  concentration of all three cell lines (red,
  white, and platelets) but again it is not
  specific to body iron store values.

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A client has recently started taking ferrous
sulfate (Feosol) 500 mg P.O. TID for anemia.
Which of the following data would indicate to the
home health nurse that the therapy is successful?

• 1. Increased reticulocyte count
• 2. Increased International Normalized Ratio (INR)
• 3. Increased prothrombin time (PT)
• 4. Increased activated partial thromboplastin
  time (APTT)

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Answer 1

• Iron is a mineral found in hemoglobin. The
  reticulocyte counts an indication of the number
  of immature RBCs found circulating in the body.
  An increased reticulocyte count will indicate
  that the bone marrow is functioning and that RBC
  production has been stimulated (option 1).
  Ultimately this will yield an increase in the
  hemoglobin and hematocrit. INR, PT, and APTT
  (options 2,3,4) all refer to coagulation studies
  that are useful in managing anticoagulation
  therapy or the care of clients who have
  coagulation disorders.

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A nurse preparing to administer an intramuscular
IM dose of iron to a client with anemia. Which
of the following precautions should the nurse
take?

• Administer drug utilizing a Z track technique.
• Use a 1 inch, 19 gauge needle.
• Administer drug deep in the deltoid muscle.
• Massage area vigorously after administering the
  iron.

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Answer 1

• When administering an iron preparation
  intramuscularly, it should be given deep in the
  muscle. The site should be in the upper outer
  quadrant of the buttocks utilizing the Z track
  technique (option 1)
• A 22 gauge 2-3 inch needle should be used (option
  2)
• It must be given into the dorsal gluteal muscle
  only (option 3)
• The area should not be massaged after the
  injection (option 4)

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Which of the following statements made by a
client with iron-deficiency anemia indicates the
need for further teaching?

• 1. I should stop taking the medicine if my
  stools turn black.
• 2. I should dilute the liquid iron preparation
  and use a straw when taking it.
• I can prevent the constipation by increasing the
  intake of fluids and fiber.
• I should return to the clinic if my stomach
  upset worsens with this medication.

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Answer 1

• The client taking an oral iron preparation should
  be taught to expect stools to turn black because
  of the excessive iron that is eliminated (option
  1)
• If the oral form is used, it should be placed on
  the back of the tongue with a dropper or be well
  diluted and taken with a straw to avoid staining
  the teeth (option 2)
• Iron can cause constipation, and fluids and fiber
  may prevent its development (option 3)
• If GI symptoms develop, an enteric-coated tablet
  can be prescribed (option 4).

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Cobalamin (Vitamin B 12) Deficiency

• Cause pernicious anemia (most common cause),
  anyone with decrease acid in the stomach
• SS are from tissue hypoxia sore tongue,
  anorexia, N/V, abd. pain, weakness, paresthesias
  of feet hands, weaknesses, impaired thought
  processes
• Diagnostic Schilling test

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When the client with pernicious anemia asked why
vitamin B 12 injections are necessary, the nurse
should provide which of the following responses?

• They contribute to the increased production of
  RBCs after a significant blood loss.
• Vitamin B 12 is needed to prevent the RBCs from
  sickling.
• Your stomach does not produce a substance needed
  for intestinal absorption of Vit B 12.
• Vit B 12 is needed to prevent excessive
  production of RBCs.

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Answer 3

• Intrinsic factor is secreted by the gastric
  mucosa to aid in the absorption of Vit B 12.
  Because Vit B 12 activates an enzyme that moves
  folic acid into th cells to contribute to the
  production of RBCs, deficiencies of the
  intrinsic factor results in anemia (option 3).
  Iron deficiency anemia caused by blood loss
  commonly treated with iron supplements (option 1)
  Option 2 is more commonly associated with sickle
  cell anemia, which is treated with Droxia.
  Excessive production of RBCs (polycythemia)
  would be treated with chemotherapy, phlebotomy,
  and anticoagulants (option 4).

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Aplastic Anemiahypoplastic or pancytopenic

• Rare life threatening stem cell disorders.
• Cause congenital or exposure to agents
• All marrow elements RBC, WBC, platelets are
  decreased
• Diagnosis lab values bone marrow
• Poor prognosis
• Tx bone marrow transplant or immunosuppression

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Anemia Caused by Blood Loss

• Look at SS because lab values may not be
  accurate for 2-3 days.
• Pain (localized or referred) bleeding causes
  pain because of tissue distention, organ
  displacement, and nerve compression.
• Complication shock (taught in critical care)

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Patient with Anemia Nursing Diagnosis Activity
intolerance related to weakness and imbalance
between oxygen supply/demand as evidenced by
increased pulse and blood pressure in response to
activity and patient report of weakness

• Goals Participates in normal activities of daily
  living without abnormal increases in blood
  pressure and pulse
• Reports less weakness and fatigue
• Encourage alternate rest and activity periods to
  provide activity without tiring the patient Limit
  number of visitors and interruptions by visitors.
  Limit environmental stimuli to reduce demands
  placed on the patient. Plan activities for
  periods when patient has the most energy. Assist
  with regular physical activities (e.g.,
  ambulation, transfers, personal care). Monitor
  cardio respiratory response to activity (e.g.,
  tachycardia, dyspnea, diaphoresis) to evaluate
  activity intolerance. Determine patients
  physical limitations. Determine what and how much
  activity is required to build endurance.

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Polycythemia

• Increase in RBC (hypervolemia hyperviscosity)
• SS slowed blood flow, (plethora)ruddy complexion
• Tx hold iron therapy, hydration, antiplatelet
  agents (prevent clots), myelosuppressive agents
  (to reduce bone marrow activity), 300 500 mL of
  blood may be removed to keep HCT lt45.

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Thrombocytopeniaprolonged bleeding

• Definition reduction in platelets below the
  normal range 150,000 to 400,000/ul
• Cause inherited or acquired
• SS petechiae, internal bleeding
• Complication hemorrhage
• Treatment- Steroids, IV immunoglobulin,
  splenectomy, platelet transfusion

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Petechiae Versus Purpura

• missinglink.ucsf.edu

dermatology.about.com
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ThrombocytopeniaNursing Care (goal is to stop
the bleeding)

• Risk for altered mucous membrane soft
  toothbrush
• Risk for injury Avoid IM, SQ injections, No ASA
  or ASA products, use electric razor, no straining
• Look for epistaxis, petechiae, ecchymoses,
  hematomas

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Patient with ThrombocytopeniaNursing Diagnosis
Impaired oral mucous membrane related to low
platelet counts and/or effects of pathologic
conditions and treatment as evidenced by oral
bleeding and blood-filled bullae

• Goal Experiences lesion-free oral mucosa without
  bleeding
• Oral Health Restoration Monitor lips, tongue,
  mucous membranes, tonsillar fossae, and gums for
  moisture, color, texture, presence of debris and
  infection using good lighting and a tongue blade
  to provide information for planning
  interventions. Assist the patient to select soft,
  bland, and nonacidic foods to decrease irritation
  of oral mucosa. Use a soft toothbrush for removal
  of dental debris. Use toothettes or disposable
  foam swabs to stimulate and clean cavity with
  minimal trauma to gingiva. Instruct and assist
  patient to perform oral hygiene after eating and
  as often as needed to avoid breakdown of oral
  mucosa. Avoid use of lemon-glycerin swabs to
  prevent excessive drying of the mucosa.

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Do NOT read (senior level)

• Sickle Cell Anemia
• Hemophilia
• Disseminated intravascular coagulation DIC

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New Topic
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WBC/Lymphoid Disorders

• Neutropenia
• Leukemia
• Hodgkins Disease
• Non-Hodgkins Disease

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NeutropeniaReduction in neutrophils

• Cause - Side effect of taking chemotherapy and
  immunosuppressive therapy.
• SS prone to infection but the body does not
  react normally due to decrease in WBC
• Tx protective isolation find the cause

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Protect YOUR patient with Reverse Isolation

• Mask
• Gown
• Gloves
• Limit visitors
• handwashing

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Patient with Neutropenia Nursing Diagnosis Risk
for infection related to decreased neutrophils,
altered response to microbial invasion, and
presence of environmental pathogens

• Adheres to infection control and protection
  practices. Experiences no signs or symptoms of
  infection Institute standard precautions.
  Institute designated isolation precautions. Wash
  hands before and after each patient care activity
  to prevent transmission of pathogens. Promote
  appropriate nutritional intake to assist natural
  defenses. Ensure aseptic handling of all IV lines
  to reduce risk of introducing infection through
  the skin. Use antimicrobial soap for hand
  washing. Limit number of visitors. Instruct
  visitors to wash hands on entering and leaving
  patients room to prevent the transmission of
  harmful pathogens to patient.
• Infection Protection Provide private room.
  Maintain asepsis for patient at risk. Screen all
  visitors for communicable disease. Monitor for
  systemic and localized signs and symptoms of
  infection. Monitor absolute granulocyte count and
  WBC count and differential results to identify
  signs of and potential for infection Inspect skin
  and mucous membranes for redness, extreme warmth,
  or drainage Instruct patient to take antibiotics
  as prescribed to prevent microbial resistance.
  Eliminate fresh fruits, vegetables, and pepper
  from diet of patients with neutropenia to avoid
  introduction of pathogens. Remove fresh flowers
  and plants from patient areas to avoid
  introduction of pathogens. Report suspected
  infections to infection control personnel in
  order to promptly initiate antibiotic therapy due
  to the rapidly lethal effects of infection. Teach
  patient and family how to avoid infections (e.g.,
  personal hygiene techniques of hand washing, oral
  care, skin hygiene, and pulmonary hygiene). Teach
  patient and family about signs and symptoms of
  infection and when to report them to the health
  care provider.

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Leukemia

• Definition malignant disorder affecting the
  blood and blood-forming tissues of the bone
  marrow, lymph system, and spleen
• Cause genetic environmental
• Acute V/S Chronic

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Signs and Symptoms

• Related to bone marrow failure
• Bone marrow crowding by abnormal cells
• Inadequate production of normal marrow elements
• Predisposed to anemia, thrombocytopenia,
  decreased WBCs

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Acute Myelogenous LeukemiaAML

• Occurs in 85 of adults
• Peak incidence 60 70 year olds
• Onset abrupt and dramatic. Fatigue, H/A, mouth
  sores, hepatosplenomegaly, lymphadenopathy,
  anemia, bleeding, fever, infection sternal
  tenderness
• Diagnostic LOW RBC, HCT, Hb, platelet

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Acute Lymphocytic Leukemia (Senior Level)

• Most common in children, approx 15 in adults.
• SS fever, bleeding, weakness

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Chronic Myelogenous Leukemia orChronic
Granulocytic Leukemia

• A neoplastic disease associated with a chromosome
  abnormality called the Philadelphia chromosome.
• SS malaise, fatigue, anemia, night sweats,
  weight loss, bone pain, splenomegaly, recurrent
  infections
• Prognosis 2 years

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www.meb.uni-bonn.de/cancer.gov/CDR0000257989.html
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Chronic Lymphocytic Leukemia

• Disease of older adults (50 70 years)
• Lymphocytes infiltrate the bone marrow, spleen
  (30 40), and liver (20). Lymph node
  enlargement causing pressure on nerves (pain
  paralysis)
• Petechiae
• Pallor

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• Chronic lymphocytic leukemia is a type of cancer
  in which the bone marrow makes too many
  lymphocytes (a type of white blood cell).
• Chronic lymphocytic leukemia (also called CLL) is
  a blood and bone marrow disease that usually gets
  worse slowly. CLL is the second most common type
  of leukemia in adults. It often occurs during or
  after middle age it rarely occurs in children.
• Normally, the body produces bone marrow stem
  cells (immature cells) that develop into mature
  blood cells. There are 3 types of mature blood
  cells
• Red blood cells that carry oxygen and other
  materials to all tissues of the body.
• White blood cells that fight infection and
  disease.
• Platelets that help prevent bleeding by causing
  blood clots to form.
• In CLL, too many stem cells develop into a type
  of white blood cell called lymphocytes. There are
  3 types of lymphocytes
• B lymphocytes that make antibodies to help fight
  infection.
• T lymphocytes that help B lymphocytes make
  antibodies to fight infection.
• Natural killer cells that attack cancer cells and
  viruses.
• The lymphocytes in CLL are not able to fight
  infection very well. Also, as the amount of
  lymphocytes increases in the blood and bone
  marrow, there is less room for healthy white
  blood cells, red blood cells, and platelets. This
  may result in infection, anemia, and easy
  bleeding.

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Hairy Cell Leukemia

• 2 of the adult population, white males gt 40
  years
• Spleenomegaly abdominal discomfort
• Pancytopenia related to anemia fatigue
  weakness
• Neutropenia fever infections
• Thrombocytopenia bleeding
• Bone Marrow dry tap

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Treatment

• To attain remission destroy leukemic cells in
  the tissues, peripheral blood, and bone marrow
• Intensification or high dose therapy using
  multiple drugs
• Consolidation therapy is started after remission.
  One or more of the same drugs are given to
  eliminate remaining leukemic cells
• Bone marrow transplant

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Bone Marrow Transplant

• Bone marrow is found in a soft fatty tissue
  inside bones where RBC, WBC, and platelets are
  produced and developed.
• Chemotherapy destroys cancer cells and normal
  blood cells
• Bone Marrow Transplant will restore production of
  WBC, RBC, and platelets.
• Donated marrow must match the patients tissue
  type.

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Bone Marrow Transplant Types

• Depending on the type of cancer treatment and
  other factors, one patient may receive a
  different type of bone marrow transplant than
  another patient
• Bone Marrow Transplant Autologous
• Bone Marrow Transplant Allogeneic
• Bone Marrow Transplant Syngeneic
• Each cancer patient who receives a bone marrow
  transplant will receive the type that most
  appropriately fits his or her situation. An
  autologous bone marrow transplant uses a
  patient's own bone marrow that will be extracted
  before chemotherapy takes place. The allogeneic
  bone marrow transplant uses bone marrow donated
  by another person. The most rare type of bone
  marrow transplant is the syngeneic bone marrow
  transplant. This last type is when the bone
  marrow of an identical twin is used for the bone
  marrow transplant.

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Complication of Bone Marrow Transplant

• Graft versus host disease
• Relapse of leukemia

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Complications

• Veno-Occlusive Disease
• Mucositis
• Infection
• Graft-versus-host disease (GVHD)
• Graft versus tumor effect

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Nursing Care

• Fear death
• Isolation loneliness
• Chemotherapy certified
• Side effects from chemotherapy
• Nutritional support
• Support groups, American Cancer Society,
  Meals-on-Wheels, spiritual support

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Lymphomas

• Malignant neoplasm's originating in the bone
  marrow and lymphatic structures resulting in the
  proliferation of lymphocytes.
• Types
• Hodgkins Disease
• non-Hodgkins Disease

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Hodgkins Disease

• Proliferation of abnormal giant, multinucleated
  cells, called Reed-Sternberg cells located in
  the lymph nodes.
• Occurs most often 15 35 year olds and gt50 yrs.
  Men more than women.
• Cause genetic, Epstein Barr virus, or exposure
  to occupational toxins

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Signs Symptoms of Hodgkins Disease

• Enlargement of lymph nodes non painful movable
• Fatigue, weakness,, chills, tachycardia, fever,
  night sweats, weight loss
• Alcohol ingestion pain

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Diagnostics of Hodgkins Disease

• Blood analysis microcytic hypochromic anemia,
  leukocytosis, increased platelet count
• Lymph node biopsy shows Reed-Sternberg cells
• Bone Marrow biopsy
• X-rays (CT MRIs) helps with defining sites of
  the disease

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Nursing Care Treatment of Hodgkins Disease

• Care for the immunosuppressed
• Manage pancytopenia
• Psychosocial considerations
• Radiation
• Chemotherapy (combination of drugs)
• Bone marrow
• Stem Cell Transplant

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Hodgkins versus NON Hodgkins

• www.cancerbacup.org.uk

www.about-blood-disorders.com
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Non-Hodgkins LymphomaBurkitts Lymphoma,
reticulum cell sarcoma, or lymphosarcoma

• Affects all ages
• All lymphocytes arrested in various stages of
  development
• Painless lymph node enlargement and unpredictable
  spread
• Usually well disseminated when it is diagnosed

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Diagnostics

• Blood is usually normal
• Lymph node biopsy establishes the cell type and
  pattern
• Staging same as for Hodgkins

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Treatment for non-Hodgkins Disease

• Radiation
• Chemotherapy
• Bone marrow transplant

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Radiation Therapy

• Radiation therapy is the use of high-energy
  x-rays to destroy cancer cells. When radiation
  therapy is given for Hodgkin disease, it usually
  involves a focused beam of radiation, given from
  a machine outside the body. This is known as
  external beam radiation. Radiation therapy is
  often given after 3 or 4 courses of chemotherapy.
  
• Radiation therapy can produce some serious side
  effects including damage to nearby healthy
  tissue. Other problems can include skin changes
  similar to sunburn, tiredness, upset stomach, and
  diarrhea. There can be long-term side effects as
  well, such as an increased chance of getting
  another cancer later in life. To reduce the risk
  of side effects, doctors are careful to give the
  exact dose needed and to aim the beam so that it
  hits only the cancer.
• As more patients have been able to live longer,
  doctors have seen more long-term problems from
  radiation. For this reason, they are slowly
  moving away from using radiation, or at least
  limiting the dose.

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Blood or Bone Marrow Stem Cell Transplant

• Sometimes Hodgkin disease does not respond
  completely to standard treatment or the disease
  comes back later. In these cases, the next step
  might be very high doses of chemotherapy followed
  by blood-forming stem cell transplant.
• In one approach, blood-forming stem cells from
  the patients own blood (or, less often, bone
  marrow) are removed, frozen, and stored. Then
  very high doses of chemotherapy (with or without
  radiation therapy) are given in order to kill the
  cancer. These high doses will destroy bone
  marrow, too. When that happens, the body wont be
  able to make new blood cells. Therefore, after
  the treatment, the stored stem cells are thawed
  and given back to the patient through a vein. The
  cells enter the bloodstream and return to the
  bone, replacing the marrow and making new red and
  white blood cells.
• The short-term side effects from stem cell
  transplants are about the same as those from
  other forms of chemotherapy, although they may be
  more severe because of the higher doses used.

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Nursing Diagnosis with Cancer

• Risk for infection related to depressed body
  defenses
• Risk for injury (hemorrhage) related to
  interference with cell proliferation
• Risk for fluid volume deficit related to nausea
  and vomiting
• Altered nutrition less than body requirements
  related to loss of appetite

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• Impaired skin integrity related to administration
  of chemotherapy agents, radiotherapy, immobility
• Impaired physical mobility related to
  neuromuscular impairment
• Body image disturbance related to loss of hair,
  moon face, debilitation
• Pain - Fear - Grieving - Altered family
  processes

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All About Blood
108
Blood Typing Rh Factor

• Blood types A, B, AB, and O
• Checked by type and cross match
• Rh positive or negative
• Checked by Coombs test
• ABO incompatibilities and hemolytic reactions can
  occur if given the wrong blood type.
• Know procedure for blood administration

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Guidelines to Donate Blood

• Health history (illnesses, diseases, surgeries,
  drugs, immunizations)
• Vital signs
• Weight
• Venous access without skin lesions

• Has not donated blood or plasma within the last
  8 weeks
• Hemoglobin 12 g/dl females 12.5 males
• Hematocrit 36 females 38 males

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Most Common Blood Types

• O 38
• A 34
• B 9
• O- 7

• A- 6
• AB 3
• B- 2
• AB- 1

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Compatibility Testing

• Physician orders type and cross match _______
  units. Infuse _____ units.
• Blood bank personnel draws blood and places
  bracelet on arm. (DO NOT REMOVE).
• Blood bank responsible for testing.

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Common Reasons the Physician Orders Blood

• Operative blood loss MORE than 1200 mL
• Acute bleeding (more than 30)
• Hgb less than 8 to 10 mg/dL
• Symptomatic anemia (angina, syncope, CHF, TIAs,
  dyspnea, tachycardia)

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Testing of Donor Blood

• Test to see
• if the donor is A, B, or O
• RH negative or positive
• Test for RBC antibodies (most check for this)

• Transmissible disease (Hepatitis B C, HIV,
  human herpes virus type 6, Epstein-Barr virus,
  human T cell leukemia, sytomegalovirus, malaria,
  Syphilis, West Nile Virus)

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Blood Transfusion

• 18 to 20 gauge (safely via 23 gauge)
• PICC lines are not recommended
• Only normal saline
• Informed consent/blood letter
• Proper identification, 2 nurses to check
• R.N. stay with patient for first 15 minutes
• (follow protocol for vital signs, drop factor 10)

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• Usual time 1 ½ to 2 hours. Never hang blood over
  4 hours (Never play catch up)
• Y type tubing with a microaggregate filter
  (filters out particulate)
• Never give medications in this line

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RN must do Before transfusion

• Take Vital signs
• Assess neurological status
• Assess lungs and kidney function
• Review lab data
• Pre-medicate with diuretics, antihistamines, or
  antipyretics (with order)
• Hand hygiene wear gloves
• Blood transfusion record (hospital specific)

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Nursing Tips

• 1 unit of RBCs should raise the hemoglobin level
  approximately 1 g/dL and the hematocrit 3.
• Credit 250 mL or 300 mL on the graphic sheet for
  IV intake.
• If the patient requires medication or solution IV
  while receiving blood, start a second IV.
• Blood bag (hospital specific)

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• Pressure bag (increases the flow)
• Electronic monitoring device
• Must administer blood within 30 minutes in
  obtaining from blood bank.
• DO NOT place in refrigerators on unit

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Blood Transfusion Reaction

• Follow hospital protocol
• Acute hemolytic reactions
• Febrile reactions
• Mild allergic reactions
• Circulatory overload
• Sepsis
• Massive blood transfusion reaction
• Infection

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Nursing Intervention(s) with Blood Transfusion
Reaction

• Stop the transfusion, infuse saline
• Monitor vital signs urinary output
• Recheck ID tags numbers
• Notify blood bank physician
• Send blood bag tubing back to the blood bank
• Collect blood and urine specimens as ordered
• Document on blood form and nursing notes

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Drugs that may be used in a reaction

• Acute hemolytic Diuretics Ex. Lasix
• Febrile reactions Antipyretics Ex. Tylenol
• Mild allergic Antihistamines or Corticosteroid
• Anaphylactic Epinephrine
• Circulatory overload sit up, diuretics oxygen

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Autologous Blood

• Perfect match! (Blood bank can label
  incorrectly)
• Provides an option for patients who find
  homologous (volunteers) transfusion unacceptable
  on religious grounds
• Contains more viable RBCs and increases the
  oxygen-carrying capacity of hemoglobin.
• 42 day shelf life

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• Donate weekly, must be at least 72 hours (prefer
  1 week) BEFORE the operation.
• Often put on oral iron supplements to replenish
  bone marrow reserves
• Must have physician approval

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Auto transfusion or Autologous blood

• Removing whole blood from the patient and then
  transfusing that blood back into them.
• Stored up to 3 years (frozen)
• Autologous - Usually done for elective surgery
• Auto transfusion collection devices attached to
  drains following chest or orthopedic devices and
  then filtered and reinfused in the patient

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Cultural Awareness and Blood Transfusion

• Jehovahs Witness
• Only if life threatening situations will the
  court override a religious belief of a parent for
  a minor.

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Platelets

• One platelet concentrate should raise the
  recipients platelet count 5000 to 10,000. The
  usual dose is 6 to 10 U random.
• Administer 1 U in 5 10 minutes
• Y tubing with Normal Saline
• 16 20 gauge IV catheter

130
Triple Lumen

• Treat each port as separate
• Incompatible medications
• Clotted ports

131
Critical Thinking QuestionsPair and Share
132

• When assessing a client with a hemoglobin of 8
  g/dL, which lab value indicates that the client
  is experiencing normal changes associated with a
  transfusion of 1 unit of packed red blood cells?
• A. hemoglobin 7 g/dL
• B. hematocrit 27
• C. type and cross match was positive
• D. red blood cells 5.0 x 10 6/ul

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Answer B Assessment

• Rationale 1 unit of PRBC should raise the
  hemoglobin level approximately 1 g/dL and the
  hematocrit 3. The hemoglobin level of 7
  indicates the client has dropped one point
  (loosing blood which would be an abnormal
  change). Type and cross match is prior to
  administration for blood type. RBC levels
  typically correlate with the H H and this value
  is a normal. The value of 8 is not normal.

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• While caring for a neutropenic client, the nurse
  is about to change the dressing on the central
  line and perform a heparin flush to one port.
  The nurse would prepare to gather the following
  equipment Select all that apply
• A. 3 cc syringe
• B. 5 cc syringe
• C. 10 cc syringe
• D. gown
• E. mask

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Answer D Planning

• To care for the neutropenic patient, the patient
  is on reverse isolation (gloves, gown, and mask)
  but the nurse will also need sterile gloves and
  10 cc syringe to perform central line site care
  and flush. Heparins flush is 10 100 units/mL.

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• In caring for a client with suspected graft
  versus host disease, the nurse should be alert
  for which complication?
• A. maculopapular rash
• B. constipation
• C. dry, pale skin
• D. numbness of extremities

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Answer A Assessment

• Maculopapular rash, jaundice, diarrhea, and
  severe abdominal pain are some of the classic
  symptoms of graft versus host disease.

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• The nurse is administering the drug
  methylprednisolone (Solu-Medrol), a side effect
  specific for a diabetic client who is scheduled
  for a bone marrow transplant could be
• A. moon face
• B. hyperglycemia
• C. depression
• D. ecchymosis

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Answer B

• Corticosteroids may cause hyperglycemia,
  especially in clients with diabetes. All the
  other options are correct for all clients.

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The physician orders 1 unit of PRBC to infuse
over 3 hours. How many drops per minute? Round
to a whole number

• Hint PRBC 250mL

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• Answer 13.888 14 gtts per minute

142

• Home care instructions for a patient being
  discharged with thrombocytopenia include. Select
  all that apply
• A. no aspirin products
• B. use electric razor
• C. no driving for 24 hours
• D. eat only fruits and vegetables
• E. do not operate heavy machinery

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• Answer A, B, E

144
For approximately thirty minutes after the bone
marrow biopsy the nurse should plan to

• A. add heat to the site
• B. keep the head of bed elevated 30 degrees
• C. maintain bed rest
• D. administer Phenergan as ordered

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Correct Answer C

• You can add ice packs. Heat would vasodilate and
  could cause bleeding
• HOB does not matter
• You need bed rest for 30 1 hour
• no Phenergan (should not be nauseated)

146
Which plan would best prevent an infection in a
patient with neutropenia

• A. Contact isolation
• B. Protective/reverse isolation
• C. Wearing gloves for all procedures
• D. Sterile gloving with procedures

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Answer B

• The nurse should limit the number of exposing
  pathogens to the neutrogenic patient.

148
Which nursing action will best infuse the blood
ordered

• A. hang in the proximal port that is taped and
  marked clotted.
• B. piggyback in the 18 gage line with the
  Heparin drip
• C. hang in the 20 gauge line with the D5W.
• D. hang in the distal port infusing with Normal
  Saline.

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Answer D

• The other sites were not compatible with blood or
  clotted.

150
In assessing the following patients, who is the
most likely to fall

• A. 40 year old post surgical patient sitting
• OOB in chair
• B. 18 year old scheduled for a bone
• marrow biopsy
• C. 65 year old medicated for pain
• D. 80 year old receiving blood

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Answer C
152
Which is priority teaching at the time of
discharge for an anemic patient?

• A. No fresh fruits or vegetables
• B. Increase foods with iron
• C. Limit sodium in the diet
• D. Restrict fluids to 500 mL per day

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Answer B
154
On admission your patient is having fatigue,
headache, chills, B/P 128/84, pulse 110,
temperature 102.7. Your priority nursing action
is to administer

• A. Dulcolax suppository
• B. Phenergan 50 mg p.o.
• C. Aspirin 50 mg p.o.
• D. Tylenol suppository

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Answer D
156
Which documentation would be most appropriate to
assess fluid volume deficit.

• A. intake and output
• B. weekly weight
• C. vital signs
• D. hemocult stools

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Answer A
158
Included in the discharge instructions for a
Lymphoma patient on chemotherapy and radiation,
would be

• A. no high calorie foods or candy
• B. no alcohol, fresh vegetables or flowers
• C. no greasy foods, high fat foods, or dairy
  products.
• D. no medium -rare cooked meat or pork

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Answer B

• To reduce the number of pathogens the patient is
  exposed.

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• The End !