Adult nursing Caring for Clients With Hematologic and

Adult nursing Caring for Clients With Hematologic and Lymphatic Disorders

Anemia Hemoglobin concentration or number of circulating RBCs decreased Caused by ◦ Impaired RBC formation ◦ Excessive loss or destruction of RBCs

Anemia - Pathophysiology Reduces the oxygen-carrying capacity of the blood Causes tissue hypoxia Body attempts to restore oxygen delivery

Anemia - Manifestations Pallor Bone pain Angina Headache Fatigue Dizziness Dyspnea on exertion Dim vision Night cramps

Blood Loss Anemia Acute or chronic bleeding Both lead to anemia RBCs normal but reduced in number

Nutritional Anemia Lack of nutrients for RBC formation or development Iron deficiency ◦ Cheilosis (cracks at corners of mouth) ◦ Smooth, sore tongue ◦ Pica Vitamin B 12 ◦ Pernicious anemia ◦ Paresthesias

Nutritional Anemia (continued) Folic acid ◦ ◦ Chronic malnourishment Glossitis Cheilosis Diarrhea

Anemia of Chronic Disease Seen in AIDs, rheumatoid arthritis, inflammatory bowel disease (IBD), chronic hepatitis, chronic renal failure (CRF) Severity depends on the severity of underlying disease Manifestations similar to iron deficiency anemia

Hemolytic Anemias Premature destruction of RBCs Intrinsic or acquired causes Sickle cell disorders ◦ Abnormal Hgb, changes shape ◦ Intense pain, chest, back, joints

Sickle Cell Anemia

Thallassemia Inherited; caused by abnormal Hgb synthesis Liver and spleen enlarged Target cells

Acquired Hemolytic Anemias Damage by outside factors ◦ ◦ Mechanical trauma Antibody reactions Immune responses Drugs, toxins, chemical agents, venoms

Aplastic Anemia Bone marrow fails to produce RBCs Cause unknown Pancytopenia

Myelodysplastic Syndrome Group of stem cell disorders Seen in older adults Anemia, enlarged spleen

Polycythemia Erythrocytosis Abnormally high RBC count, high Hct Blood sticky Secondary form is the most common Develops due to chronic hypoxemia or excess erythropoietin

Polycythemia Vera (continued) Primary type Production of all blood cells increased Cause unknown Insidious onset Gangrene complication

Leukemia Group of malignant disorders of WBCs Greater numbers of WBCs Cause of most unknown Classified by onset and duration: acute or chronic Four types

Leukemia - Pathophysiology Malignant transformation of a single stem cell Cells proliferate slowly, nonfunctional WBCs Bone marrow filled with leukemic cells Leave bone marrow and infiltrate other tissues Death from hemorrhage or infection

Leukemia - Manifestations Anemia Infection Bleeding

The multisystem effects of leukemia

Malignant Lymphoma Cancer of lymph tissue Classified as Hodgkin or non-Hodgkin

Hodgkin Disease Most curable Painless progressive enlargement of one or more lymph nodes Reed-Sternberg cells Cause unknown

Non-Hodgkin Lymphoma More common Multiple lymph nodes involved

Multiple Myeloma cells replace bone marrow, infiltrate bone Bone weakened, pathologic fractures Bone/back pain most common symptoms Kidney damage

Neutropenia Disease of number of circulating neutrophils Usually secondary to infection, hematologic disease, chronic disease, chemotherapy Severe form is called agranulocytosis Can result in impaired WBC formation or increased WBC destruction Protective measures are required

Neutropenia - Manifestations Fatigue Weakness Sore throat Stomatitis Dyphagia Fever Chills

Thrombocytopenia Platelet count less than 100, 000 per m. L Common cause of abnormal bleeding Idiopathic thrombocytopenia purpura most common form ◦ Platelets destroy more rapidly than normal ◦ Autoimmune disorder

Thrombocytopenia Manifestations ◦ ◦ ◦ Purpura Ecchymosis Petechiae Epistaxis Menorrhagia Hematuria

Hemophilia Group of hereditary clotting factor deficiencies Hemophilia A ◦ Most common type ◦ Deficiency in Factor VIII

Hemophilia (continued) Hemophilia B (Christmas disease) ◦ Less common ◦ Deficiency in Factor IX Transmitted from mother to son Sex-linked recessive disorder on X chromosome

The inheritance pattern for hemophilia A and B. Both are X-linked recessive disorders; females may carry the trait, but only males develop the disorder.

Hemophilia - Manifestations Hemorrhages into body tissues

Disseminated Intravascular Coagulation (DIC) Simultaneous blood clotting and hemorrhage Intrinsic and/or extrinsic clotting cascades activated Widespread clotting of small vessels Clotting factors depleted; leads to bleeding

DIC - Manifestations Bleeding most obvious Tachycardia, hypotension Mottling Abdominal distention Decreased LOC

Lymphangitis/Lymphedema Lymphangitis ◦ Inflammation of lymph vessel Lymphedema ◦ Obstructed lymph vessel

Severe lymphedema of the lower extremity. (Source: NMSB, Custom Medical Stock Photos, Inc. )

Infectious Mononucleosis Acute infection caused by Epstein–Barr virus Benign and self-limiting Kissing disease

Infectious Mononucleosis Manifestations Headache Sore throat Fatigue Enlarged and painful lymph nodes Fever Enlarged spleen

Anemia – Diagnostic Tests CBC Iron levels Serum ferritin Sickle cell screening Hemoglobin electrophoresis Schilling’s test Bone marrow aspiration

Leukemia – Diagnostic Tests CBC with differential and platelet count Bone marrow

Multiple Myeloma – Diagnostic Tests Urine samples CBC Bone marrow Bone x-rays

Neutropenia - Diagnosis WBC count Neutophil count less than 1500 cells/mm 3 May be less than 500 cells/mm 3 in agranulocytosis

Thrombocytopenia – Diagnostic Tests CBC, platelet count Bone marrow Antinuclear antibodies

Hemophilia – Diagnostic Tests Platelet count Coagulation studies Clotting factors

DIC – Tests Clotting studies

Infectious Mononucleosis – Diagnostic Tests Increased lymphocytes and monocytes Increased WBC count Low platelets

Malignant Lymphoma – Diagnostic Tests Chest x-ray Abdominal CT Biopsy Ann Arbor staging system Cotswold staging classification system

Anemia – Nursing Implications Client Teaching ◦ ◦ ◦ Types of anemia Diet Medications Genetic counseling Follow-up appointments Support groups

Leukemia – Nursing Implications Client Teaching ◦ ◦ ◦ ◦ Diagnosis, treatment, bone marrow, complications Cancer as a chronic illness Balance activity with rest Maintain weight and nutrition Hydration Prevent infection Oral hygiene

Leukemia – Nursing Implications (continued) Client Teaching (continued) ◦ ◦ ◦ Avoid crowds, sick people Avoid immunizations Reduce risk of bleeding or injury Avoid OTC medications that can cause bleeding Refer to social services, support groups, home health

Malignant Lymphoma – Nursing Implications Client teaching ◦ ◦ ◦ ◦ Treatment and effects of treatment Skin care New symptoms Complementary pain management strategies Rest and exercise Diet American Cancer Society referral

Multiple Myeloma – Nursing Implications Client Teaching ◦ Teach S/S complications ◦ Hospice

Thrombocytopenia – Nursing Implications Client Teaching ◦ Continue treatment to maintain remission ◦ Long-term steroid treatment ◦ Splenectomy

Hemophilia – Nursing Implications Client teaching ◦ How to prevent bleeding ◦ Provide medications ◦ Genetic counseling

DIC – Nursing Implications Client teaching ◦ Proper foot care ◦ Heparin home therapy ◦ When to contact physician

Lymphangitis/Lymphedema Nursing Implications Client Teaching ◦ ◦ ◦ Use of pressure devices, elastic stockings Skin inspection Skin care Elevate extremity Activity, diet, diuretics

Anemia - Treatment Medications ◦ Depends on type and cause ◦ ◦ ◦ Iron replacement Vitamin B 12 Folic acid Hydroxyurea Immunosuppressive therapy or androgens

Anemia – Treatment (continued) Dietary Considerations ◦ Iron that is readily absorbed ◦ Iron sources Blood Transfusions ◦ Replace RBCs ◦ Whole blood or packed RBCs

Polycythemia - Treatment Reduce blood viscosity and volume Relieve symptoms Phlebotomy to keep blood volume within normal levels Chemotherapy

Leukemia - Treatment Chemotherapy ◦ Destroy leukemic cells ◦ Produce remission ◦ Achieve remission, cure, relieve symptoms Radiation therapy ◦ Shrink lymph nodes Biologic therapy ◦ Interferons, interleukins ◦ Colony-stimulating factors

Leukemia – Treatment (continued) Bone marrow transplantation ◦ Allogenic ◦ Eliminate leukemic cells ◦ Donor marrow transfused ◦ Autologous ◦ Own bone marrow withdrawn, treated, frozen, reinfused later

Leukemia – Treatment (continued) Stem cell transplant ◦ Donor treated with colony-stimulating factors to increase concentration of stem cells in blood ◦ Blood removed from donor, given to patient

Malignant Lymphoma - Treatment Chemotherapy ◦ Combination ◦ Remission in more than 75% Radiation ◦ Used for both ◦ Combined with chemotherapy

Areas of radiation for total nodal radiation therapy.

Multiple Myeloma Treatment No cure Relieving symptoms Death within 2 to 5 years Treatment ◦ Chemotherapy, radiation, medications, pain control, blood transfusions

Neutropenia - Treatment Discontinue drugs that may be cause of disorder Treat infection Filgrastim (Neupogen) may be used to treat disorder

Thrombocytopenia - Treatment Medications ◦ Steroids ◦ Immunosuppressive drugs Platelet transfusions Plasmapheresis Surgery: ◦ Splenectomy

Hemophilia - Treatment Replace clotting factors Fresh frozen plasma Cryoprecipitates Concentrates DDAVP (desmopressin acetate)

DIC - Treatment: underlying disease Medications ◦ Control bleeding ◦ fresh frozen plasma ◦ Heparin

Lymphangitis/Lymphedema Treatment Relieve edema, maintain skin integrity, prevent/treat infection Lymphangitis ◦ Moist heat, elevate, immobilize, skin/wound care, antibiotics Lymphedema ◦ Elevate, elastic stockings, skin care, bed rest, sodium restriction

Infectious Mononucleosis Treatment Recovery in 2 to 3 weeks Bed rest Analgesics

Anemia – Nursing Care Assessment Activity Intolerance ◦ ◦ Vital signs Rest periods Energy conservation Smoking cessation

Anemia – Nursing Care (continued) Impaired Oral Mucous Membranes ◦ ◦ ◦ ◦ Assess lips and tongue Mouthwash Frequent oral hygiene Avoid alcohol-based mouthwashes Petroleum jelly for lips Avoid spicy foods Encourage soft bland foods Small high-protein balanced meals each day

Anemia – Nursing Care (continued) Self-Care Deficit ◦ Assist with ADL ◦ Rest periods ◦ Concerns about self-care

Anemia – Nursing Care (continued) Evaluation ◦ ◦ Independent ADL Increased level of activity Skin and oral mucous membranes Diet

Polycythemia – Nursing Care Teaching ◦ ◦ ◦ Hydration Prevent blood stasis Elevate legs Support stockings Smoking cessation Report S/S thrombosis

Leukemia – Nursing Care Assessment ◦ Recognize manifestations

Leukemia – Nursing Care (continued) Risk for Infection ◦ ◦ ◦ Infection precautions Avoid invasive procedures Report evidence of infection Monitor vital signs Report lab values Explain precautions and restrictions

Leukemia – Nursing Care (continued) Imbalanced Nutrition: Less than Body Requirements ◦ Monitor weight ◦ Promote food and fluid intake ◦ Avoid procedures around meals

Leukemia – Nursing Care (continued) Impaired Oral Mucous Membranes ◦ ◦ ◦ Assess mouth 1: 1 solution saline/peroxide as mouthwash Soft-bristle toothbrush Medications for infection, pain Avoid alcohol-based mouth washes

Leukemia – Nursing Care (continued) Ineffective Protection ◦ ◦ ◦ Monitor LOC Report manifestations of bleeding Avoid invasive procedures Apply pressure to puncture sites Avoid straining with bowel movement

Leukemia – Nursing Care (continued) Anticipatory Grieving ◦ Therapeutic communication ◦ Manage stressful situations ◦ Support groups for the grieving process

Leukemia – Nursing Care (continued) Evaluation ◦ ◦ ◦ Freedom from infection Weight Food intake Oral mucous membranes Bleeding Coping

Malignant Lymphoma – Nursing Care Risk for Impaired Skin Integrity ◦ Measures to reduce itching Nausea ◦ Antiemetics ◦ Measures to relieve/reduce nausea

Malignant Lymphoma – Nursing Care (continued) Fatigue ◦ ◦ ◦ Assess malaise Encourage talking about disease Quiet activities Rest periods High-carbohydrate diet Fluids

Malignant Lymphoma – Nursing Care (continued) Disturbed Body Image ◦ ◦ ◦ Body image assessment Objective signs of altered body image Coping with alopecia Effects of illness on sexuality Support groups

Multiple Myeloma – Nursing Care Chronic Pain ◦ ◦ ◦ Assess pain Positioning, support with pillows Use of analgesics Nonpharmacology pain control Rest periods

Multiple Myeloma – Nursing Care (continued) Impaired Physical Mobility ◦ ◦ Reposition Change positions every 2 hours Trapeze Safety measures

Thrombocytopenia – Nursing Care Ineffective Protection ◦ ◦ ◦ Monitor LOC Manifestations of bleeding Avoid invasive procedures Pressure dressing to puncture sites Avoid straining at bowel movement

Hemophilia – Nursing Care Risk for Injury ◦ ◦ Signs of bleeding Stop bleeding with pressure, ice No IM injections Safety measures

Hemophilia – Nursing Care Risk for Ineffective Therapeutic Regimen Management ◦ Assess knowledge/reinforce teaching ◦ Emotional support ◦ Opportunities to learn/practice administration clotting factors

DIC – Nursing Care Ineffective Tissue Perfusion ◦ ◦ Assess pulses Turn every 2 hours No knee crossing Minimize tape use

DIC – Nursing Care (continued) Impaired Gas Exchange ◦ ◦ ◦ O 2 saturation levels ABGs Oxygen Fowler’s/semi-Fowler’s position Bed rest Deep breathing and coughing

DIC – Nursing Care (continued) Acute Pain ◦ Pain scale ◦ Handle gently ◦ Cool compresses to painful joints

DIC – Nursing Care (continued) Fear ◦ ◦ ◦ ◦ Verbalize concerns Answer questions Coping strategies Emotional support Calm environment Respond to calls for help Relaxation techniques

Lymphangitis/Lymphedema Nursing Care Implementation ◦ ◦ Measure effected extremity I&O Daily weights Sodium restriction

Lymphangitis/Lymphedema Nursing Care Implementation (continued) ◦ ◦ Antiembolic stockings/intermittent pressure devices Elevate extremities Skin care Protective devices