Blood/Lymphatic Disorder Chapter 34

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Blood/LymphaticDisorderChapter 34

• White
• Christensen
• Adam

L. Lehmkuhl, 2009
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Blood/LymphaticDisorder

• Blood-viscous red fluid containing RBCs, WBCs,
  and platelets in fluid called plasma
• Slightly alkaline with pH 7.35 to 7.45
• NaCl concentration 0.9
• 5-6 liters

• Functions of blood
• Transports O2 and nutrition to the cells and
  waste products away from the cells via cardiac
  and respiratory systems.
• Regulates acid-base balance, aids in temp
  regulation, and controls water content
• Protects against infection

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Blood/Lymphatic Disorders

• Leukocytes (WBCs)
• Unlike RBCs, have a nucleus
• Fight infection and assist in immunity.
• 5,000-10,000
• Elevated WBCs indicate infection, inflammation,
  tissue necrosis or leukemia.
• Different kinds of WBCs are counted and reported
  as percentages of the total is called a
  differential
• 2 categories- granulocytes and agranulocytes
• Wrights stain differentiates category of WBC

• Erythrocytes (RBCs)
• Hgb 14-18 g/dl in males, 12-16 g/dl in females
• Lifespan 120 days
• Produced in red bone marrow
• Production stimulated by Erythropoietin
• Hct 42-52 in males, 37-47 in females

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Blood/LymphaticDisorders

• Granulocytes
• Neutrophils- essential for phagocytosis (process
  of engulfing)
• Immature polymorphonuclear leukocytes called
  bands are released into the blood stream when
  neutrophils are depleted and severe infection
  occurs

• Eosinophils- play a role in allergic reactions
  and against certain parasitic worms
• Basophils- nonspecific immune response, release
  histamine

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Blood/LymphaticDisorders

• Agranulocytes
• Monocytes- function similarly to neutrophils
  through process of phagocytosis
• Lymphocytes (B T)-

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Blood/LymphaticDisorders

• Thrombocytes (platelets)
• Nonnucleated
• Life span of about 10 days.
• Produced in red bone marrow
• Function in process of hemostasis (prevention of
  blood loss) and in clotting formation
• Hemostasis
• Vessel spasm
• Platelet plug formation
• Clot formation

• Blood Types
• A, B, AB, and O
• Type O is the universal donor(no antigens that
  bodies can attack)
• Type AB is the universal recipient
• Rh factor- 85 of humans carry this factor
• Rh incompatibility seen most often in pregnancy
  causing hemolysis of the RBCs causing rupture and
  loss of cell contents

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Complete Blood Count -

• The complete blood count (CBC) is a screening
  test, used to diagnose and manage numerous
  diseases. It can reflect problems with fluid
  volume (such as dehydration) or loss of blood. It
  can show abnormalities in the production, life
  span, and destruction of blood cells. It can
  reflect acute or chronic infection, allergies,
  and problems with clotting.

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Complete Blood Count

• A CBC requires a small blood specimen. Blood is
  drawn from a vein, usually from the inside of the
  elbow or the back of the hand.
• Preparation The skin should be cleaned with
  alcohol or iodine before the test. The patient
  should be seated comfortably or reclining.

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Complete Blood Count

• Low numbers of red blood cells may indicate
  anemia,
• Blood loss
• Iron deficiency
• Deficiences of vitamin B12 or folic acid
• Bone marrow failure (for example, from radiation,
  toxin, fibrosis, tumor)
• Erythropoietin deficiency (secondary to kidney
  disease)
• Hemolysis (RBC destruction)
• Leukemia
• Multiple myeloma
• Over hydration

Normal values vary with altitude and gender.
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Complete Blood Count

• High numbers of red blood cells may indicate
• Cigarette smoking
• Low oxygen tension in the blood
• Congenital heart disease
• Cor pulmonale
• Pulmonary fibrosis
• Polycythemia vera
• Dehydration (such as from severe diarrhea)
• Emphysema

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WBCs

• Low numbers of white blood cells (leukopenia) may
  indicate
• Bone marrow failure (for example, due to
  granuloma (granular tumor), tumor, or fibrosis)
• Presence of cytotoxic substance
• Collagen-vascular diseases (such as lupus
  erythematosus)
• Disease of the liver or spleen
• Radiation exposure

• High numbers of white blood cells (leukocytosis)
  may indicate
• Infectious diseases
• Inflammatory disease (such as rheumatoid
  arthritis or allergy)
• Leukemia
• Severe emotional or physical stress
• Tissue damage (for example, burns)

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Blood Transfusions

• Whole blood ( vol)
• Packed RBCs (anemia)
• Platelets (control bleeding)
• Plasma (clotting d/os)
• Cryoprecipate (fibrinogen deficiencies)

• Administer within 30 minutes.
• Complete within 4 hours.
• Baseline vs
• 18-19 guage catherter
• 2 nurse check
• Anyreaction immediately stop infusion..call MD
• N/S to prevent clotting
• Autologous or homologous

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Blood/LymphaticDisorders

• Lymphatic system- consists of lymph vessels,
  lymph fluid, and lymph tissue
• 2 main functions
• Maintenance of fluid balance (excess fluid from
  interstitial space to circulatory system)
• Production of lymphocytes to protect body from
  infection.

• Lymph nodes-
• filter impurities from the lymph and produce
  lymphocytes and macrophages
• Superficial lymph nodes in neck, axilla and groin
  can be palpated, especially when infected and
  swollen.
• CA cells can collect, reproduce and travel
  through lymph. Lymph nodes are biopsied to
  detect spread of CA.

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Blood/LymphaticDisorders

• Tonsils- lymphoid tissue in the oropharynx
• Spleen- organ located in the LUQ of the abdomen,
  contains lymphatic nodules, stores 350 ml of
  blood. If needed approx. 200mL can be pumped out
  within a minute as needed.
• Removes old RBCs, platelets and microorganisms
  from blood.
• During infection spleen enlarges to produce and
  release monocytes and lympthocytes.

• Thymus- located in upper thorax, develops T
  lymphocytes (Tcells).
• Large in infancy and childhood
• Decreases in size with age
• T cells are actively involved in immunity.

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Blood/LymphaticDisorders

• Diagnostic tests
• CBC
• Red cell indices- MCV (size), MCH (weight), MCHC
  (concentration)
• Peripheral smear- most informative test
• Schilling- measures the absorption of radioactive
  vitamin B12 in diagnosing pernicious anemia

• Gastric analysis- useful in determining
  pernicious anemia
• Lymphangiography- detects metastatic involvement
  of lymph nodes
• Bone marrow aspiration or biopsy- most commonly
  performed in persons with marked anemia,
  neutropenia, acute leukemia, and thrombocytopenia

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Blood/LymphaticDisorders

• Anemia- disorder characterized by low RBC, Hgb,
  Hct, and RBC destruction
• Hypovolemic anemia (blood loss)
• Secondary anemia due to blood loss
• Control bleeding, tx shock, replace fluid volume,
  O2

• Pernicious anemia
• Absence of intrinsic factor produced by gastric
  mucosa which is needed for absorption of B12
• Schilling test, serum B12 test, gastric analysis
• Tx is B12 injections (for life), folic acid
• Pt is highly susceptible to gastric carcinoma and
  should be monitored closely for symptoms.

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Blood/LymphaticDisorders

• Aplastic anemia
• Failure of the bone marrow to produce RBCs
• Patient may have pancytopenia (low WBC,
  RBC,platelets)
• Most cases the cause is unknown..maybe genetic,
  or secondary to viral invasion, medications,
  chemicals, radiation, or chemotherapy
• Bone marrow transplant, if pts bone marrow fails
  to respond to tx.
• Prevent infection, bleeding, and fatigue

• For transplant the best candidate is a young pt
  who has not had previous infusions.
• Sibling donor under 30 yrs is higher success
• Immunosupressants are given to prevent graft
  rejection.

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Blood/LymphaticDisorders

• Population with higher incidence are
• Low birth wt infants or premature
• Infants
• Adolescent girls
• Alcoholics
• Menstruating women
• Pregnancy
• Tx is with iron salts such as Ferrous Sulfate
• Ascorbic acid enhances iron absorption
• Z track if parenteral
• Use straw with liquid
• Makes stools green or black
• Diet in Fe rich foods

• Iron deficiency anemia
• Most common type of anemia.
• RBCs contain decreased Hbg
• Most common cause is chronic intestinal or
  uterine bleeding
• Low RBC, Hgb, Hct, and serum iron levels
• May have pica, stomatitis, glossitis, and brittle
  hair if chronic.

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Sickle Cell Anemia

• Sickle cell anemia is caused by an abnormal type
  of hemoglobin called hemoglobin S.
• Hemoglobin is a protein inside red blood cells
  that carries oxygen. Hemoglobin S, however,
  distorts the red blood cells' shape. The fragile,
  sickle-shaped cells deliver less oxygen to the
  body's tissues, and can break into pieces that
  disrupt blood flow.

• Sickle cell anemia is inherited as an autosomal
  recessive trait. This means it occurs in someone
  who has inherited the hemoglobin S gene from both
  parents.
• Sickle cell is the most common genetic D/O in the
  US particularly in African-Americans,,Asian,
  India, Mediterranean and Caribbean areas.

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Sickle Cell

• 1 in 10 African Americans have the trait, 1 in
  500 have the disease
• Dx with Hgb electrophoresis which shows HbS
• Negative means sickle cell trait not sickle cell
  disease. Individual is asymptomatic but may pass
  disease to offspring.
• If Hbss (genes) confirmed dz
• No specific treatment teach to avoid sickle cell
  crisis

• Sickle cell crisis manifestations
• Fever
• Severe pain
• Loss of blood to various organs (obstructed
  vessels)
• Areas most affected are joints (become painful
  and swollen), bone, brain, lung, liver, kidneys
  and penis.
• Frequent PVS, assessment, heat to joints, avoid
  tight clothing and high altitudes.
• Tx symptoms Hydroyurea (pain),folic acid (RBC
  production) PCA during crisis, HOB, O2 tissue
  perfusion and offset dyspnea)

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SICKLE CELL ANEMIA
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Polycythemia

• Two types Primary and Secondary (compensory mech
  to make more rbcs secondary to hypoxia from
  smoking, living in high altitude, HF)
• Primary- Jewish men gt50 y/o acquired mutation
  (abnormal DNA) occurs in bone marrow.
• Erythrocytosis in Polycythemia Vera
• Hypervolemic, hyperviscous state (blood is unable
  to circulate freely)
• Increased plasma, RBC (WBCs and platelets also
  increased), Hbg, Hct, low oxygen level on ABG

• Tx is repeated Phlebotomy (350-500mL) to decrease
  RBCs, blood viscosity and reduce blood volume.
• Myelosuppressive agents- Myleran, hydroxyurea,
  and radioactive phosphorous (to decrease RBC
  production)
• Low Na diet (decrease blood vol and avoid Fe
  rich foods

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POLYCYTHEMIA VERA
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Leukemia

• Malignant D/O with excess WBCs in marrow and
  lymph nodes
• Pt constantly fighting infections and has fever
  and chills.
• Enlarged lymph nodes, anemia, thrombocytopenia
  (bleeding, bruising), low or very high WBCs
• Hepatosplenomegaly, lymphadenopathy, bone pain
  (WBCs crowding cells in bone marrow), oral
  lesions
• Bone marrow bx shows immature WBCs
• Bleeding common monitor platlets

• Tx is chemo radiation (destroys CA cells and
  good cells), bone marrow transplant
• Prevent infection (high risk), and chronic pain
• Most common cause of death is viral or fungal
  PNA.
• Acute lymphocytic leukemia (ALL) lt15 yo more
  rapid onset than Acute myeloid leukemia (AML).
• R/f infection and bleeding
• Teach Hand washing to visitors, pt hygiene use
  antimicrobial soaps, electric razor, antiemetics,
  stool softener, monitor for hematuria or cloudy
  urine.

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LEUKEMIA
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LEUKEMIA CELLS
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Agranulocytosis

• Severe reduction in granulocytes (basophils,
  eosinophils, and neutrophils)
• Leukopenia
• Med reaction or toxicity, cancer, chemotherapy or
  radiation
• Differential below normal
• Tx is to alleviate cause and to prevent infection

• Meticulous handwashing, monitor VS, WBC, lung
  sounds.
• Strict aseptic technique, visitors screened,
  reverse isolation may be implemented.

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Coagulation Disorders

• Disseminated Intravascular Coagulation
• Hemophilia
• Thrombocytopenia

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Hemophilia

• Inherited blood clotting d/o from lack of certain
  clotting factors
• Hemophilia A most common
• Hereditary, x linked, affects mostly males,
  females carry genes
• Disturbance in clotting factors
• Dx Factors VIII and IX, prolonged PTT
• Tx transfusions, replacement of factor VIII and
  IX (cryoprecipitate)
• Willebrands Disease- mild deficiency of factor
  VIII

• 3 classifications
• Mild
• Moderate
• Severe
• Can bleed out from trauma or bleed spontaneously.
• Spontaneous ecchymosis from GI or GU tracts

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HEMOPHILIA A
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Disseminated Intravascular Coagulation (DIC)

• Acquired Hemorrhagic syndrome of the clotting
  cascade and over stimulation of the clotting
  process.
• DIC a condition of alternating clotting and
  hemorrhaging.
• Coagulopathy resulting from the overstimulation
  of clotting and anticlotting processes in
  response to disease or injury
• Dx prolonged clotting coagulation profile, marked
  thrombocytopenia, deficits in factor V and VIII
• Tx cryoprecipitate, heparin, fibrinolytics,
  transfusion

• Primary dz stimulates the clotting mechanism ,
  causes mini microthrombi to develop. The bodys
  fibronolytic process attempts top break clots
  thus causing hemorrhaging.

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Thrombocytopenia

• Platelets reduced below 100,000
• Drug induced, infection or idiopathic
• Risk for bleeding
• Prevent trauma (0 falls) or infection
• Petechiae (small skin hemorrhages) and ecchymosis
  (bruising).
• Monitor for internal bleeding

• Tx corticosteroids and splenectomy (last
  resort..spleen is where platelet destruction
  occurs), platelet transfusions or apheresis
  (removal of unwanted componenets), IV gamma
  globulin or immunosuppressive drugs

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THROMBOCYTOPENIA
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Lymph Disorders

• Hodkins Lymphoma
• Non-Hodkins Lymphoma

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Blood/LymphaticDisorders

• Malignant Lymphoma
• Cancer of lymphoid tissue
• Painless, enlarged lymph nodes, fever, wt loss,
  anemia, pruritus, and prone to infection
• Bone scan may reveal fxs from bone mets, CT scan,
  node bx
• Tx chemo and radiation
• Supportive care, interventions similar to
  Hodgkins Lymphoma

• Hodgkins Lymphoma
• Cancer of the lymphoid tissue
• Males, bimodal
• Biopsy of lymphoid tissue shows Reed Sternberg
  Cells.
• Tx dependent on stage
• Tx chemo and radiation
• Nursing care according to stage
• Comfort measures focus on skin integrity
• Soothing baths with antipruritic medications
  (e.g. puritis).

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CHILD WITH HODGKINS
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Plasma Cell Disorder

• Myeloma

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Multiple Myeloma

• Malignant neoplastic immunodeficiency disease of
  the bone marrow
• Plasma cell tumor
• Disruption of production of RBC, WBC, and
  platelets due to overproduction of plasma cells
• Bone destruction with release of calcium and
  phosphorous from bones

• Hyperuricemia with high Pro leads to renal
  failure
• Pain relief, prevent infection and bone injury,
  chemo, and hydration
• Encourage 3-4 Lof H2O to minimize complications
  of excessive Ca in the blood and urine.
• Exercise to preveny bone demineralization
• Monitor for hypercalciumia

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MYELOMA
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BENCE JONES PROTEIN CAST IN URINE
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MONOCLONAL PROTEIN