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Hematology Disorders

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Title: Hematology Disorders


1
Hematology Disorders
  • NUR 2242
  • Lisa G. Smith MSN/ED, RN, CNE
  • 2009/2010

2
Hemotologic system
3
Components of the Hemovascular System
  • Bone marrow -red and yellow
  • Blood and its components
  • Liver -production of prothrombin and clotting
    factors
  • Liver function is critical to formation of
    Vitamin K
  • Spleen- filter, recycling iron, immune response,
    storage of platelets, fetal hematopoesis
  • Lymph system -returns excess interstitial fluid
    to intravascular compartment, no valves
  • superficial and deep nodes

4
Development of blood cells
5
Functions of various blood cells
  • Erythrocytes carry Hgb molecule-carries iron
    protein.
  • Responsible for acid base balance
  • Leukocytes
  • Granulocytes Function Phagocytosis
  • Neutrophils-most common
  • mature neutrophils are segs
  • immature neutrophils are bands.
  • Agranulocytes
  • Lymphocytes B and T cell subtypes
  • Monocytespotent phagocytic, ingestng cells of
    all sizes
  • Thrombocytes platelets

6
Lymph System
  • Consists of
  • Lymph fluid
  • Lymphatic capillaries
  • Lymphatic ducts
  • Lymph nodes

7
Lymph System
  • Lymph fluid
  • Pale yellow interstitial fluid that has diffused
    through capillary walls
  • Circulates through special vasculature
  • Too much interstitial fluid or reduced absorption
    leads to lymphedema
  • May occur as a complication of mastectomy or
    lumpectomy

8
Lymph System
  • Lymph nodes
  • Small clumps of lymphatic tissue found in groups
    along lymph vessels at various sites
  • More than 200 lymph nodes throughout the body
  • Largest concentration of lymph nodes is in the
    abdomen surrounding the GI tract

9
Lymph System
  • Lymph nodes (cont'd)
  • Primary function is filtration of pathogens and
    foreign particles carried by lymph fluid
  • Located both superficially and deep

10
Lymph Nodes
Superficial nodes
11
Lymph node assessment
12
Liver
  • Acts as a filter
  • Produces all the procoagulants essential to
    hemostasis and blood coagulation
  • Stores excess iron
  • Produces hepcidin, a key regulator of iron balance

13
Spleen
  • Located in the upper left quadrant next to kidney
  • Functions can be classified as
  • Hematopoietic Able to produce RBCs during fetal
    development

14
Spleen
  • Functions (cont'd)
  • Filtration
  • Remove old and damaged RBCs from circulation
  • Removes hemoglobin from RBCs and returns iron
    component to the bone marrow for reuse
  • Filters out bacteria, especially encapsulated
    organisms

15
Spleen
  • Functions (cont'd)
  • Immunologic Contains a rich supply of
    lymphocytes, monocytes, and stored
    immunoglobulins
  • Storage Stores RBCs and approximately 30 of
    total mass of platelets

16
Three Principles of Coagulation
  • Vascular response- vasoconstriction and vascular
    spasm
  • Platelet response- occur with collagen exposure,
  • serotonin is released-facilitating coagulation
  • Adhesiveness aggregation occur
  • platelet lipoproteins stimulate plasma clotting
    factors
  • Plasma Clotting Factors
  • - Intrinsic Extrinsic pathways

17
The Clotting cascade
18
Drug Therapy Affecting Clotting Factors
  • Anticoagulant
  • Heparin
  • Low-Molecular Weight Heparins
  • Lovenox (Enoxaparin)
  • Vitamin K antagonists
  • Coumadin (Warfarin)
  • Fibrinolytics
  • Retavase, Eminase, Activase Streptase

19
Subjective Data Assessment
  • Past Health history of blood disorders, anemia
  • Liver or spleen disorders
  • Medications and herbals
  • Surgery (splenectomy, stomach or intestinal),
    wound healing,
  • Prior blood transfusions
  • Activity tolerance
  • Review Table 30-5 for complete health history
    questions

20
Assessment Contd
  • Skin and hair
  • Lymph nodes
  • Neuro sensation
  • Joint pain bone pain, abdominal pain
  • Fatigue, SOB
  • Dietary intake habits
  • Elimination changes (amount, color, visible signs
    of blood)
  • Alcohol, cigarettes, other drugs
  • Table 30-7 Assessment Abnormalities

21
Diagnositic Studies
  • Reticulocyte Count
  • 0.5-1.5
  • CBC (Complete Blood Count)
  • Hgb/Hct, RBC, WBC, Platelets
  • Sed Rate nonspecific, any acute or chronic
    inflammatory disease
  • Clotting Factors
  • PT/INR (10-14 sec/)
  • APTT (30-45 sec)
  • ACT Activated Clotting Time (150-180)
  • More accurate than APTT
  • Coombs Test
  • Bone Marrow Aspiration and Biopsy

22
The CBC
  • Red Blood Cell Count
  • Number of circulating RBCs/ml
  • 4.0-6.0 (depending on male or female)
  • Hemoglobin
  • Oxygen carrying capacity of blood
  • Iron and protein complex
  • 12.0-18.0 (F-M)
  • Hematocrit
  • percentage of RBC to total volume of blood
  • 38-54 (F-M)

23
Red Blood Cell Indices
  • MCV (Mean corpuscular Volume)
  • Size of RBCs
  • MCH (Mean Corpuscular Hgb)
  • Average Hgb in RBCs
  • Calculates the weight of the hemoglobin in the
    average RBC
  • MCHC (Mean Corpuscular Hgb
  • Concentration)
  • Average concentration of Hgb in one RBC
  • Determines if cell is hypo or hyperchromic

24
Platelets
  • Necessary for clotting
  • Normal 150,000-450,000
  • lt20,000 can have spontaneous bleeding

25
White Blood Cell Count
  • The WBC is the total number of the five types of
    leukocytes present in blood
  • Normal Value
  • 4,000-11,000
  • Leukocytes combat infection and inflammation
  • Elevated leukocyte count
  • Leukocytosis
  • Decreased count
  • Leukopenia

26
White Blood Cell Count Differential
  • Differential identifies all 5 kinds of leukocytes
  • Granular Leukocytes
  • Neutrophils
  • Eosinophils
  • Basophils
  • Nongranular Leukocytes
  • Lymphocytes
  • Monocytes

27
White Blood Cell Count (cont)
  • Neutrophils respond to tissue damage or infection
  • 0.50-0.70 (50-70) normal range
  • if elevated shows response to bacterial
  • infection
  • - If reduced Neutropenia
  • Elevated Eosinophil count allergies or parasites

28
White Blood Cell Count (cont)
  • Elevated Basophil count allergies or chronic
    inflammation
  • Elevated Lymphocyte count viral or bacterial
    infection
  • Elevated Monocyte count infection or collagen
    disease

29
Differential Review
30
The Older Client
  • Hemoglobin Normal to ?
  • Iron studies ?
  • MCV ? (osmolarity of cell is affected w/ age)
  • MCHC ?
  • WBCs ? response to infection
  • Platelets not affected
  • Clotting studies are affected
  • PTT ?

  • Review Table 30-4

31
Diagnosing Hematological Problems
  • CT Scan
  • MRI
  • PET Scan
  • Lymph Node Biopsy
  • Bone Marrow Biopsy

32
Bone Marrow Aspiration
33
Care of the client having a Bone Marrow Aspiration
  • A bone marrow aspiration provides information on
    bone marrow function including RBC, WBC, and
    platelet function
  • Consent form
  • Explain procedure may be painful
  • Analgesic medication can be given to increase
    patient comfort

34
Bone Marrow (cont)
  • Procedure is sterile
  • Position Patient
  • Site selection Sternum, Iliac crest, Tibia
  • Apply pressure post procedure, assess for
    bleeding
  • A dressing may remain on patient for 24 hours

35
Hematological Problems
  • Fgg

36
Red Blood Cell Disorders
37
Anemia
  • Ggg

38
Anemia
  • Reduction in either
  • Red Blood Cells (RBC),
  • quantity of Hemoglobin,
  • Hematocrit volume of packed RBCs
  • Anemia is a clinical sign, rather than a
    diagnosis, because it is a manifestation of a
    number of abnormal conditions.
  • Signs and symptoms often unrecognized in the
    older adult

39
Diagnostics for Anemia
  • CBC
  • TIBC
  • Serum Ferritin
  • Serum Iron

40
Common Causes of Anemia
  • Anemia can result from
  • Heredity
  • Bone marrow disease
  • Bleeding disorders
  • Autoimmune disorders
  • Dietary Deficiencies
  • Colon Cancer is a big cause
  • In older Adults it is due to
  • 1 Chronic disease
  • 2 Dietary deficiency

41
Types of Anemia(Etiologic Classification)
  • Decreased Erythrocyte Production
  • Iron Deficiency Anemia
  • Thalassemia
  • Vitamin B12 Deficiency Anemia (Cobalamin)
  • Folic Acid Deficiency Anemia
  • Aplastic Anemia
  • Increased Erythryrocyte Production
  • Sickle Cell Disease
  • Hemolytic Anemia
  • Blood Loss (acute chronic) Table
    31-1

42
Types of Anemia(Morphologic Classfication)
  • Normal cell size normal color
  • Normocytic Normochromic
  • Aplastic Anemia
  • Sickle Cell Anemia
  • Large cell size with normal color
  • Macrocytic Normochromic
  • Pernicious Anemia ( B-12 anemia)
  • Folic Acid deficiency
  • Small cell size Decreased color
  • Microcytic Hypochromic
  • Iron deficiency anemia
  • Thalassemia Table
    31-2

43
Anemia Review Slide
44
Signs and Symptoms
  • Skin
  • Cardiovascular
  • Pulmonary
  • Neurologic
  • Gastrointestinal
  • Musculoskeletal
  • General
  • Table 31-3

45
Treatment of Anemia
Cause of anemia must be known to provide
appropriate treatment
  • cccc

46
Treatment for Anemia May Include
  • Iron, folate , B12 supplementation
  • Emphasize protein, high heme protein
  • Dark green leafy vegetables, Vitamin C containing
    foods
  • Limit tea, coffee
  • Immunosuppressant's for autoimmune anemias
  • Bone Marrow Transplant Aplastic Anemia
  • Epoetin Generic
  • Epogen trade name
  • Procrit trade name
  • Erythropoietin trade name

47
Blood Transfusion Therapy
48
Blood Products
  • PRBC - ? O2 carrying capacity
  • Indications significant ? HH, ? Blood loss
  • Admin Filter recommended, Give over 2-4 hours
  • Platelets Coagulation components
  • Indications ? platelet count and clotting time
  • Admin Filter recommended, Give over 30 to 2
    hours
  • FFP Fresh Frozen Plasma
  • Action ? clotting factors, H2O electrolytes
  • Indications Replace clotting factors V VIII
  • Admin filter, quickly, but up to 2 hours
  • Cryoprecipitates
  • Action replaces factors VIII XIII,
  • Contains fibrinogen
  • Indications Hemophilia, DIC
  • Admin Administer quickly

49
Blood Transfusion Therapy
  • Supports patient until underlying problem can be
    resolved
  • Used only when necessary
  • Requires a physicians order
  • Signed patient consent
  • Platelets, whole blood, PRBCs, FFP, albumin,
    cryoprecipitates (Table 31-32)
  • Requires at least 20 gauge needle
  • Equipment Special Y tubing set up, NS only.
  • NO Med administration through the same tubing as
    blood products

50
Blood Transfusion (contd)
  • Blood bank types and cross matches
  • Goal of the RN Blood Bank is to prevent
    transfusion reactions
  • Prior to Administration
  • 2 RNs positively ID patient with
  • Blood band
  • Patient identification band
  • Blood product (type and Rh)
  • Unit
  • Expiration date

51
Transfusion Guidelines
  • Obtain baseline V/S prior to infusion
  • Stay with patient for first 15 minutes of
    transfusion
  • Run infusion at 2ml/min during this time
  • Guideline 1 unit PRBCs
  • Transfuse in 2-4 hrs,
  • no longer than 4 hours!!!
  • Can use Y-tubing X2
  • Post tx CBC and VS

52
Transfusion reactions
  • Table 31-33 discusses SS, cause and mananement
  • Acute transfusion reaction
  • Blood incompatability
  • Usually occurs within the first 15 minutes
  • Febrile reaction (Most common)
  • Usually due to leukocyte incompatability
  • Mild allergic reaction
  • Sensitivity to foreign plasma proteins
  • Anaphylaxis
  • Occurs within minutes
  • Circulatory overload too much fluid
  • Sepsis infected product from bacteria
  • Delayed hemolytic reaction
  • 3-14 days, due to destruction of RBCs
  • Incompatibility

53
Risks of Transfusions Include
  • Infection
  • Hepatitis B C, HIV, CMV (blood is not tested
    for CMV)
  • Immunologic
  • you get someone elses antibodies
  • Aged Blood
  • ? mortality rate from transfusions in hospitals
  • Hospitals will give the oldest unit first

54
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55
1 Iron Deficiency Anemia
  • Most common type of anemia
  • 30 of the population
  • Etiology
  • Inadequate iron intake
  • i.e., infants without iron supplementation,
    pregnant women
  • Impaired absorption of iron
  • Usually due to GI surgery
  • Slow persistent blood loss
  • GI or GU i.e., menorrhagia

56
Signs and Symptoms of Iron Deficiency Anemia
  • No symptoms
  • Fatigue
  • Dyspnea on Exertion
  • Pallor most common
  • Tachycardia
  • Weakness
  • Headaches
  • Glossitis
  • (inflammation of the tongue) 2nd most common
  • Cheilitis
  • (inflammation of the lips)
  • Burning sensation of the tongue
  • Smooth, shiny tongue

57
Diagnostics of Iron Deficiency Anemia
  • Hgb/HCT may be decreased
  • Serum iron may be decreased
  • Ferritin levels may be decreased
  • TIBC may be increased
  • Reticulocyte count will be increased after iron
    supplementation

58
Nursing Interventions Iron Deficiency Anemia
  • Dietary Replacement of Iron (Table 31-5)
  • Oral iron replacement
  • FeSo4 300-325 mg po tid after meals
  • Give iron between or 1 hour before meals
  • orange juice enhances absorption
  • Milk and antacids decrease absorption
  • If liquid, give with straw to avoid discoloration
    of teeth
  • Parenteral iron given IM, change needles, 0.5ml
    of air left in syringe, z-track method in outer
    buttocks, not massaged
  • Stool will have a black/green appearance, may
    have false for occult blood

59
2 Thalassemia
  • Inadequate production of
  • Hgb
  • Hemolysis also occurs
  • Seen In ethnic groups from the
  • Mediterranean Sea,
  • equator areas of Africa
  • and Asia
  • Two Types Minor Major
  • Tx Minor None
  • Tx Major blood transfusions
  • from birth, medication,
  • splenectomy
  • Symptoms develop by age of 2

60
3 Cobalamin Deficiency (B- 12 Anemia)
  • Causes
  • Dietary deficiency
  • Hereditary enzymatic defects
  • Pernicious Anemia Most common cause
  • Etiology of Pernicious Anemia
  • Lack of intrinsic factor secreted by gastric
    mucosa, resulting in decreased HCL acid
  • Can occur in Crohns disease, small bowel
    resection, gastrectomy or other diseases causing
    atrophy of gastric mucosa
  • Metformin use

61
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62
Signs and Symptoms of B-12 deficiency
  • Pallor
  • Sore Tongue
  • Fatigue
  • Neurological Changes
  • Paresthesias, Disturbances of Balance and Gait
  • B12 is needed for nerve mylenation
  • Disturbances in memory, confusion
  • Weight Loss

63
Diagnostics of B-12 deficiency
  • Schilling Test--Test for pernicious anemia
  • uses radioactive B12 (cobalamin) to test for GI
    absorption of the B12
  • Lab Tests Low B12, Serum folate
  • If folate is normal and B12 is low Cobalamin
    deficiency
  • Assess for mental changes
  • Gastrosocopy and Biopsy
  • Test other family members
  • Familial tendancy

64
Interventions for Pernicious Anemia
  • Treat underlying disorder
  • An Increase in dietary intake of foods rich in
    B12, meat, legumes
  • Does not help if Intrinsic Factor is missing
  • Still educate on proper nutrition
  • Vitamin B12 injections required for pernicious
    anemia (Cyanocobalamin)
  • Endoscopy every 5 years to rule out gastric
    carcinoma (high risk for Gastric Ca)

65
4 Folic Acid Deficiency
  • Etiology
  • Poor nutrition
  • Lack of Dk. Green Leafy Veg., citrus, beans,
    nuts, grains
  • Malabsorbtion syndromes, i.e., Crohns disease
  • Medications, i.e., oral contraceptives,
    anti-seizure medications (Dilantin,
    Phenobarbital), methotrexate
  • Alcohol abuse, Anorexia
  • Hemodialysis (folic acid is lost during dialysis)

66
Signs /Symptoms Tx. of Folic Acid Deficiency
  • Smooth, red, beefy tongue
  • No neurological symptoms (different from
    Cobalamin
  • Pallor
  • Fatigue
  • Serum folate is low, Cobalamin is normal (another
    difference between the two)
  • Treatment
  • Correct underlying cause
  • Dietary supplementation (See Table 31-5)
  • Folic Acid (1mg./day)

67
5 Aplastic Anemia
  • A deficiency of all cells
  • RBCs, WBCs, Platelets, and hypocellular bone
    marrow
  • Can be related to
  • Congenital
  • Viral and bacterial infections (hepatitis)
  • Medications (antimicrobials, antiseizure)
  • Chemicals (benzene, insecticides, arsenic,
    alcohol)
  • radiation/chemo
  • 70 of all cases are idiopathic

68
Signs and Symptoms of Aplastic Anemia
  • Repeated infections
  • Fever
  • Fatigue
  • Dyspnea
  • Bleeding Tendencies (Petechiae, ecchymosis,
    epistaxis)

69
Diagnostics of Aplastic Anemia
  • Lab studies
  • Hemoglobin, WBCs, Platelets are usually
    decreased
  • Known as Normocytic, Normochromic Anemia
  • Decreased reticulocytes
  • Increased serum iron secondary to erythropoiesis
    (formation of RBC) suppression
  • Bone Marrow Aspriation will show decreased RBC
    with an increase in fat content (called a dry
    tap)

70
Aplastic Anemia Treatment
  • Adults lt45 years of age Bone Marrow Transplant
  • Best Results in a patient with no prior history
    of blood transfusion
  • Adults gt45 years of age treatment of choice is
    immunosuppression therapy with either ATG or
    cyclosporine

71
6 Sickle Cell Disease
  • Abnormal hgb (Hb S), which causes the RBC to
    become stiff and elongate in response to ? oxygen
  • Most common genetic disorder in the United States
  • Predominent in African Americans, as well as in
    Mediterranean, Caribbean, South S. America,
    Arab East Indian descents
  • Types
  • Sickle Cell Anemia most severe
  • Sickle Cell-Thalassemia
  • Sicle Cell - HbC
  • Sickle Cell Trait

72
Genetic Expression of Sickle Cell Anemia
  • Both parents carrying trait
  • One parent only carrying trait

73
Sickle Cell
74
Sickle Cell Crisis
  • During a crisis, sickling of RBCs occurs,
    resulting in occlusion and ischemia in distal
    blood vessels
  • Triggers
  • Viral or Bacterial infections
  • High altitudes
  • Stress
  • Surgery
  • Blood Loss
  • Dehydration

75
Sickled Cells
  • Cells become sickle shaped,
  • rigid and clump together
  • Leads to tissue
  • necrosis/infarction
  • Progressive organ damage
  • Cells do return to normal
  • shape when O2 levels are
  • restored
  • Over time-cell membranes
  • become damaged? more
  • cells become permanently
  • sickled.

76
Signs and Symptoms of Sickle Cell Disease
  • Patient usually asymptomatic first year of life
    (Due to fetal Hgb)
  • Fatigue
  • Pallor
  • Pain back, chest, abdomen, extremities
  • Jaundice
  • Cholelithiasis
  • Painful swelling of hands and feet
  • Priapism

77
Diagnostics of Sickle Cell Disease
  • Genetic Testing
  • Hgb electrophoresis less expensive
  • Sickling screening test less expensive
  • DNA testing very expensive
  • Decreased Hgb
  • Decreased Hct
  • Increased WBC due to infection
  • Increase in Reticulocytes

78
Best Practice for the Client with Sickle Cell
disease
  • Oxygen
  • Pain Management under tx. Is a problem
  • PCA break-through pain medication
  • Rest
  • Fluid Electrolyte Replacement
  • Treat Infections
  • Prophylactic therapy w/ Penicillin
  • Regular Flu Pneumonia vaccines
  • Transfusions (Occasionally)
  • Avoid Triggers
  • Hydroxyurea - drug induces HbF formation

79
7 Hemolytic Anemia
  • The rate of destruction of RBCs exceeds
    production
  • Two Types
  • Intrinsic defects within the RBC itself
  • Abnormal Hgb, enzyme deficiency (G6PD), cell
    membrane defect
  • Extrinsic Acquired Most Common
  • The RBC is normal, but damage to the RBC occurs
    externally
  • from toxins
  • mechanical injury from mechanical heart valves
  • Hemodialysis
  • S/S general symptoms of anemia, jaundice
  • Focus is to maintain renal function
  • Accumulation of Hgb from hemolyzed RBC obstructs
    the kidney tubules
  • Nursing Care provide for periods of rest
  • Corticosteroids
  • Blood products
  • Spleenectomy

80
Blood Loss
  • Acute
  • Sudden hemorrhage from trauma, surgery
  • Concerns
  • Hypovolemic shock from loss of volume
  • If blood loss is gradual plasma volume
    increases but Hypoxia occurs due to ? circulating
    RBCs
  • Management
  • Replace Blood Volume
  • Identify the source
  • IV fluids Lactated Ringers, Albumin
  • PRBC transfusion
  • Supplemental Iron

81
Blood Loss
  • Chronic
  • Occurs over time as seen in
  • Bleeding ulcers, hemorrhoids, menstruation
  • Effect
  • Depletion of iron
  • Management
  • Find the source
  • Stop the bleeding
  • Supplemental iron

82
Polycythemia Vera
  • Primary Polycythemia increase in RBCs
  • Hyperviscosity, hypervolemia
  • Not preventable
  • If left untreated, will be fatal
  • Etiology
  • Chromosomal mutation
  • Diagnostics show
  • An increase in Hgb
  • An increase in RBC count
  • An increase in Hct
  • An increase in WBC
  • An increase in platelets
  • Elevated uric acid, Cobalamin and histamine
  • Splenomegaly

83
Polycythemia
84
Signs and Symptoms of Polycythemia Vera
  • HTN
  • Flushed appearance of hands and face
  • (Plethora)
  • Fatigue
  • Headache
  • Painful joints
  • CHF/Chest pain
  • Distention of superficial veins
  • Thrombopheblitis

85
Treatment of Polycythemia Vera
  • Phlebotomy
  • Nursing Interventions
  • Adequate hydration (3 l/day)
  • Maintain fluid balance
  • Too much circulatory overload
  • Too little ? viscosity
  • Increase calories and protein
  • Promote activity to prevent thrombus
  • Prognosis is usually poor
  • High risk for stroke due to thrombosis

86
Coagulation Disorders
87
Normal Platelet Response
88
Platelet Disorder ? Thrombocytopenia
  • Reduction of platelts below 150,000 mcl
  • Can be inherited or acquired
  • Acquired
  • Immune Thrombocytopenia Purpura (ITP)
  • Autoimmune response, spleen destroys the
    platelets
  • Acute or Chronic
  • Thrombotic Thrombocytopenic Purpura (TTP)
  • Agglutination of platelets causing mini thrombi
  • Bleeding clotting occur simultaneously
  • Uncommon, cause unknown
  • Heparin-Induced Thrombocytopenia (HIT), also
    called (HITT- Thrombosis syndrome)

89
Causes of Abnormal Platelet Function
  • Digoxin
  • Thiazide diruetics
  • Alcohol
  • Estrogen
  • Chemo
  • NSAIDs
  • Penicillins, cephalosporins
  • ASA, Heparin
  • Spices ginger, cumin, tumeric, cloves
  • Vitamins C E

90
Thrombocytopenia
  • Signs and Symptoms
  • Bleeding from mucosa or cuts
  • Ecchymosis
  • Petechiae
  • Decreased platelet count, lt150,000 mcl
  • Treatment based on type
  • Find the cause
  • Steroids - TTP
  • Splenectomy Autoimmune (ITP TTP)
  • D/C offending medications, such as ASA or Heparin
  • HITT

91
HITTWhat is it?
  • Heparin-Induced Thrombocytopenia and Thrombosis
    syndrome
  • Heparin use
  • Type I (mild) Type II (severe)
  • Antibodies develop causing-immune response
  • Platelet aggregation occurs
  • Thrombus formation reduction of platelets
  • at the same time

92
HITTDiagnosis
  • Drop in platelet count
  • 50 or less of patients baseline
  • Asymptomatic or have bleeding tendencies
  • Purpura
  • Petehiae
  • Internal
  • Thrombosis development
  • Positive antibody test

93
HITWhen to expect it?
  • Anytime the patient is on Heparin for
    anticoagulation - examples
  • Pulmonary embolus
  • Evolving stroke
  • Deep Vein Thrombosis (DVT)
  • Open heart surgery
  • Renal dialysis
  • Acute onset of A-fib

94
HITTreatment
  • Notify the physician
  • Discontinuation of Heparin
  • All sources Drips,
  • Sub Q (Heparin and Lovenox)
  • Flushes
  • Alternative medication options
  • Direct Thrombin Inhibitor (DTI)
  • Lepirudin (Refludan)
  • Argatroban
  • Bivalirudin

95
HITNursing Considerations
  • Monitor platelet count
  • Watch for signs of thrombosis
  • Sign - No Heparin products
  • Heparin allergy band
  • Educate the patient on
  • HIT-related thrombosis
  • Heparin allergy alert

96
HITThe Consequences
  • DVT
  • Pulmonary embolus
  • Cerebral thrombosis
  • Myocardial infarction
  • Amputation
  • Multi-organ failure
  • Death

97
Hemophilia
  • Sex linked recessive disorder
  • (X chromosome)
  • Hem A -- missing Factor VIII
  • Hem B -- missing Christmas Factor -(Factor IX)
  • Symptoms are similar for both types
  • Bleeding prolonged and delayed
  • Page 707
  • Von Willerbrand is a related disorder
  • Treatment Replace the missing factors
  • Factors have short half-life, requires regular
    transfusions

98
Disseminated Intravascular Coagulation (DIC)
  • Bleeding Disorder due to over stimulation of
    normal coagulation process
  • Abnormal response to clotting
  • Clotting and Hemorrhage occur simultaneously
  • Ischemia and Infarction Occur
  • Acute, Sub Acute or Chronic
  • Occurs secondary to
  • Septic Shock, Tissue Trauma, Burns, Malignancies,
    Pregnancy, Lupus, Sickle Cell, Transplants,
    Massive blood transfusions, prolonged CABG
    surgery
  • Refer to table 31-19

99
Where DIC begins..
  • Endothelial integrity is compromised..

Endothelium
  • Tissue Factor is released from damaged cells
  • Ischemia/necrosis
  • Surgical manipulation
  • Crushing injury

100
Pathophysiologic Paradox
  • DIC

Thrombosis in the presence of hemorrhage
101
Clinical Manifestations
  • Rapid development of hemorrhage epistaxis,
    hemoptysis oozing from venipuncture/IV sites,
    surgical wounds, bleeding of sclera
  • Hemorrhagic lesions purpura, petechiae,
    hematoma
  • GI bleeding
  • GU bleeding
  • S/S of ischemic tissue necrosis R/T thrombosis

102
Thrombi formation in glomerulus
103
Hemorrhagic purpura
104
Diagnosis
  • PT, APTT increased times
  • Platelets lt100,000
  • Specialized testing
  • FDPs
  • D-dimer test
  • by-product of the break down of fibrin within a
    clot

105
DIC (cont)
  • Treatment
  • Controversial, depends on underlying cause
  • Platelets corrects thrombocytopenia
  • Cryoprecipitate replaces Factor VIII
  • FFP replaces all factors except platelets
  • Heparin treat thrombosis
  • Vitamin K Folic Acid
  • Treat ischemic pain
  • Maintain skin integrity

106
Identify and Treat Cause
Cardiovascular and Ventilatory support
Homeostatic support Replacement Therapy
107
White Blood Cell Disorders
108
Leukemia
  • General term accumulation of dysfunctional
    cells affecting blood, lymph, bone marrow
    spleen
  • Production of normal blood cells is reduced
  • 2nd most prominent blood cancer today
  • Originates in the stem cell
  • Etiology
  • Unknown but could have combination of genetic and
    environmental exposures

109
Leukemia (cont)
  • Classified (4 types) according to
  • type of cell involved
  • and
  • acute (2) or chronic (2)
  • Diagnostics of leukemia
  • Lab studies
  • Leukopenia or elevated abnormal WBC
  • Low RBCs
  • Thrombocytopenia or ? in platelet count
  • Bone marrow aspiration biospsy
  • CXR

110
Microscope View
Acute Lymphocytic leukemia
Normal Blood Smear
111
Signs and Symptoms of Leukemia
  • Varied
  • Fatigue and weakness
  • Fever
  • Bleeding tendencies, ecchymosis
  • Paleness
  • Anorexia and weight loss
  • Potential for infections
  • white patches in mouth in some types
  • Joint and/or bone pain
  • Possible CNS involvement

112
Treatment of Leukemia
  • Some types are not curable
  • But remission and control is feasible
  • Avoid crowds
  • Avoid raw foods, undercooked meats
  • Use hot water for all eating utensils, plates
  • Wash toothbrush in dishwasher daily or bleach and
    H2O
  • Wash moist body areas 2X/day w/ antimicrobial
  • Depends on type of leukemia
  • Chemotherapy
  • Antibiotics/antivirals
  • Bone Marrow Transplant

113
Nursing Interventions in the Client with Leukemia
  • Private room/isolation
  • Strict Hand washing
  • Strict aseptic technique for all dressing changes
  • Pain management
  • Limit visitors
  • Institute bleeding precautions if client has
    thrombocytopenia
  • No flowers
  • Observe for any signs of infection

114
Lymphomas
  • General term for cancers originating in the
    lymphatic system
  • Two Types
  • Hodgkin
  • Non-Hodgkin
  • Side Note
  • Mantle Cell Lymphoma (MCL)
  • Ground Zero Fire Fighters
  • Represents 6 of all NHL cases
  • (Leukemia Lymphoma Society)
  • Most prominent blood cancer today

115
Hodgkins Lymphoma
  • Presence of Reed-Sternberg cell in the lymph
    nodes
  • Giant multinucleated cell
  • Signs and Symptoms
  • Nodes are movable and non-tender (unless pressing
    against a nerve)
  • Fatigue, Weight loss, Fever, Night Sweats
  • Pain at node site with ingestion of alcohol

116
Diagnostics/Treatment
  • Reed-Sternberg cells from lymph node biopsy
  • Disease is staged
  • May be localized or diffuse-advanced stage
  • Treated with radiation, chemotherapy, supportive
    care
  • Radiation can cure 95 if stage I or II
  • Combination therapy is used if it is resistant
  • Prognosis is better than other forms of CA

117
Reed-Sternberg Cell
118
Non-Hodgkins Lymphoma
  • All other lymph malignancies that do not contain
    the Reed-Sternberg cells, more diverse,
    originating from lymphoid tissues
  • No hallmark feature
  • More common than Hodgkins
  • SS
  • Painless lymph node enlargement
  • Can start outside of the lymph node
  • By the time it is diagnosed, it is usually
    widespread
  • Treated with radiation, chemotherapy, and
    supportive care
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