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Hematologic System

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Title: Hematologic System


1
Hematologic System
  • Amanda Hawkins R.N., MSN
  • NURS 3277
  • Spring, 2008

2
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?

3
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

4
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.

5
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.

6
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?

7
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?

8
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?

9
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10
Bone Marrow
  • Fills the central core of bones.
  • Produces 3 cells RBC, WBC, platelets
  • http//www.drstandley.com/images/BoneMarrow.bmp

11
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

12
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.

13
Altered RBC
  • HIGH
  • Polycythemia vera
  • High altitude
  • Cardiovascular Disease
  • Chronic Liver Disease
  • Dehydration
  • Anemias
  • LOW
  • Hemorrhage
  • Leukemia/malignancy
  • Pregnancy
  • Overhydration
  • Anemias

14
Normal WBC Value
  • WBC count 4500 10,000 ul (mm3)
  • mcl (ul) microliter
  • mm3 millimeter cubed

15
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.

16
Cont WBCs
  • Monocytes
  • In tissues, resident macrophages are given
    special names
  • Liver Kupffer cells
  • Bone osteoclasts
  • Lung alveolar macrophages
  • Help with immune responses

17
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.

18
Altered WBCs
  • HIGH
  • Acute infections
  • Drug influence
  • LOW
  • Anemia
  • Alcoholism
  • Drug influence
  • Viral infection
  • Lupus
  • Rheumatoid arthritis

19
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

20
Platelets
  • Aids in blood clotting
  • Normal count 150,000 to 400,000 ul
  • mcl (ul) microliter

21
Altered Platelet Counts
  • HIGH
  • Malignant disorder
  • Polycythemia vera
  • Postspleenectomy syndrome
  • Rheumatoid arthritis
  • Iron deficiency anemia/hemorrhage
  • LOW
  • Hemorrhage
  • Leukemia
  • Thrombocytopenia
  • Pernicious anemia
  • Infection

22
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.

23
Geriatrics Platelets
  • Platelets are unaffected by the aging
  • process. However, changes in vascular
  • integrity from aging can manifest as easy
  • bruising.

24
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

25
Lymph System
  • Function is filtration of bacteria foreign
    particles carried by lymph.
  • Complication after surgery
  • Example mastectomy is lymph edema

26
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

27
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.

28
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

29
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

30
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

31
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

32
Bone Marrow Aspiration
  • Pain experienced right now!

33
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

34
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)
  • )

35
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.

36
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37
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.

38
Common Assessment Abnormalities
  • Review common assessment abnormalities
  • of the hematologic system. Refer to the
  • table in your book.

39
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

40
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

41
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

42
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

43
Glossitis(Inflammation of the Tongue)
44
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

45
Iron Poisoning
  • It is also one of the most frequent causes of
    poisoning death in children.

46
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

47
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

48
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).

49
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.

50
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.

51
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)

52
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.

53
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)

54
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.

55
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.

56
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)

57
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.

58
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).

59
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

60
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.

61
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).

62
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

63
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)

64
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.

65
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.

66
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

67
Petechiae Versus Purpura
  • missinglink.ucsf.edu

dermatology.about.com
68
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

69
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.

70
Do NOT read (senior level)
  • Sickle Cell Anemia
  • Hemophilia
  • Disseminated intravascular coagulation DIC

71
New Topic
72
WBC/Lymphoid Disorders
  • Neutropenia
  • Leukemia
  • Hodgkins Disease
  • Non-Hodgkins Disease

73
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

74
Protect YOUR patient with Reverse Isolation
  • Mask
  • Gown
  • Gloves
  • Limit visitors
  • handwashing

75
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.

76
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

77
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

78
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79
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

80
Acute Lymphocytic Leukemia (Senior Level)
  • Most common in children, approx 15 in adults.
  • SS fever, bleeding, weakness

81
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

82
www.meb.uni-bonn.de/cancer.gov/CDR0000257989.html
83
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

84
  • 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.

85
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

86
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

87
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.

88
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.

89
Complication of Bone Marrow Transplant
  • Graft versus host disease
  • Relapse of leukemia

90
Complications
  • Veno-Occlusive Disease
  • Mucositis
  • Infection
  • Graft-versus-host disease (GVHD)
  • Graft versus tumor effect

91
Nursing Care
  • Fear death
  • Isolation loneliness
  • Chemotherapy certified
  • Side effects from chemotherapy
  • Nutritional support
  • Support groups, American Cancer Society,
    Meals-on-Wheels, spiritual support

92
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

96
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

97
Nursing Care Treatment of Hodgkins Disease
  • Care for the immunosuppressed
  • Manage pancytopenia
  • Psychosocial considerations
  • Radiation
  • Chemotherapy (combination of drugs)
  • Bone marrow
  • Stem Cell Transplant

98
Hodgkins versus NON Hodgkins
  • www.cancerbacup.org.uk

www.about-blood-disorders.com
99
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

102
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.

104
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

109
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.

112
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

120
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

123
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

124
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

126
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.

129
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.

138
  • 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

139
Answer B
  • Corticosteroids may cause hyperglycemia,
    especially in clients with diabetes. All the
    other options are correct for all clients.

140
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

141
  • 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

157
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

159
Answer B
  • To reduce the number of pathogens the patient is
    exposed.

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  • The End !
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