Chapter 28 Nursing Care of Patients with Hematologic

Chapter 28 Nursing Care of Patients with Hematologic and Lymphatic Disorders

Anemia � Deficiency Both of Red Blood Cells, Hemoglobin, or ◦ Impaired Production ◦ Increased Destruction ◦ Blood Loss � Reduced Capacity to Carry Oxygen to Tissues

Etiologies � Dietary Deficiencies � Hemolysis � Hereditary Disorders

Signs and Symptoms � Pallor � Tachycardia � Tachypnea � Irritability � Fatigue � Dyspnea

Signs and Symptoms (cont’d) � Pernicious Anemia ◦ Numb Hands or Feet ◦ Sore Tongue � Iron Deficiency ◦ Mouth Fissures ◦ Glossitis ◦ Spoon-shaped Nails

Diagnosis � CBC with Microscopic Examination � Bone Marrow Analysis � Tests to Determine Source of Bleeding

Therapeutic Interventions � Eliminate Cause � Dietary Changes � Supplements � Transfusions

Nursing Diagnoses � Activity Intolerance � Imbalanced Nutrition � Risk for Injury � Impaired Oral Mucous Membranes

Aplastic Anemia � Bone Marrow Does not Produce Adequate RBCs � Causes ◦ Congenital ◦ Exposure to Toxins ◦ Chemotherapy

Signs and Symptoms Weakness Fatigue Pallor Dyspnea Headache Ecchymoses Petechiae Frank Bleeding Infection Death

Aplastic Anemia (cont’d) Diagnosis ◦ ◦ CBC Bone Marrow Biopsy TIBC Serum Iron Treatment ◦ Treat Cause ◦ Colony Stimulating Factors ◦ Steroids ◦ Bone Marrow Transplant

Sickle Cell Anemia Inherited Autosomal Recessive Disorder

Sickle Cell Anemia (cont’d) Diagnosis ◦ Sickledex Test ◦ Hemoglobin Electrophoresis ◦ CBC ◦ ESR Crisis Treatment ◦ ◦ ◦ Antibiotics Pain Management Transfusions Fluids Oxygen

Signs and Symptoms

Crisis Prevention � Avoid Risk of Reduced Oxygenation ◦ Exposure to Cold ◦ Infection ◦ Strenuous Exercise � Low Dose Penicillin � Frequent Transfusions � Hydroxyurea

Nursing Diagnoses � Risk for Ineffective Tissue Perfusion � Acute Pain

Patient Education � Avoid ◦ ◦ ◦ ◦ Tight Clothing Strenuous Exercise Alcoholic Beverages Cold Temperatures Smoking Unpressurized Aircraft Exposure to Infection

Polycythemia � Overabundance of Red Cells � Hemoglobin >18 mg/d. L � Hematocrit >55% � Blood Becomes Thick ◦ Primary ◦ Secondary

Signs and Symptoms Hypertension Visual Changes Headache Vertigo Dizziness Tinnitus Bleeding Chest Pain Dyspnea Dark, Flushed Skin Itching

Therapeutic Interventions � Phlebotomy � Low Dose Aspirin � Chemotherapy � Radiation Therapy

Patient Education � Drink 3 Liters of Water Daily � Avoid Restrictive Clothing � Elevate Feet � Report Signs and Symptoms of Iron Deficiency � Report Signs and Symptoms of Bleeding

Disseminated Intravascular Coagulation � Pathophysiology ◦ Accelerated Clotting ◦ Clotting Factors Depleted ◦ Bleeding � Etiology ◦ Major Trauma

Signs and Symptoms � Abnormal � Joint Bleeding Pain � Nausea and Vomiting � Organ System Failure � Convulsions � Shock, Coma � Death

Bleeding: Signs and Symptoms � Easy Bruising � Petechiae � Blood in Urine � Black Tarry Stools � Bleeding from Nose or Gums � New Onset of Painful Joints

Hemorrhage Into Skin

Diagnostic Tests � PT, PTT � Platelet Count � Hbg � Hemoglobin, Creatinine

Therapeutic Interventions � Correct Underlying Cause � Administer ◦ ◦ Blood FFP Platelets Cryoprecipitates

Nursing Care � Recognize and Report Bleeding � Avoid Trauma and Further Bleeding � Teach Patient and Family

Idiopathic Thrombocytopenic Purpura � Pathophysiology ◦ Platelet Destruction by Immune System ◦ Risk for Bleeding � Etiology ◦ Acute Viral Illness ◦ Drug Reaction ◦ Immune System Dysfunction

Signs and Symptoms Bleeding ◦ Petechiae ◦ Ecchymoses ◦ Bleeding

Diagnosis � Platelet Count � Bleeding Time � Bone Marrow Aspiration

Therapeutic Interventions � Steroids � Chemotherapy � Transfusions � Vitamin K � Chemotherapy � Splenectomy

Nursing Care � Bleeding Precautions � Recognize and Report Signs and Symptoms Bleeding � Teach Patient and Family

Bleeding Precautions � Use Electric Razor � Use Soft Toothbrush � Avoid Invasive Procedures, Injections � Maintain Pressure if Blood Draw Essential � Wear Shoes or Slippers

Bleeding Precautions (cont’d) � Avoid Bumps and Bruises � Avoid Aspirin and Nsaids � Administer Stool Softener � Handle Patient Gently � Gentle Nose Blowing

Hemophilia � Pathophysiology ◦ Missing Clotting Factors �A—Factor VIII �B—Factor IX � Etiology ◦ Heredity

Signs and Symptoms � Bleeding ◦ ◦ Joints Muscles Subcutaneous Tissue Brain

Diagnosis � PTT � Factor Levels

Therapeutic Interventions � Desmopressin � Clotting Factors ◦ Factor VIII ◦ Factor IX � Blood Transfusion

Nursing Diagnoses � Pain � Ineffective Protection � Risk for Ineffective Self Health Management

Leukemia � Pathophysiology ◦ Increase in Immature WBCs ◦ Unable to Fight Infection � Risk Factors ◦ Viruses ◦ Genetic Factors ◦ Radiation/Chemotherapy

Types of Leukemia � Acute Lymphocytic Leukemia � Acute Myelogenous Leukemia � Chronic Lymphocytic Leukemia � Chronic Myelogenous Leukemia

Signs and Symptoms Fever Infection Pallor Weakness Tachycardia Palpitations Dyspnea Abdominal Pain Malaise Sternal/Rib Pain CNS Changes Bleeding

Diagnosis � CBC � Bone Marrow Aspiration � Lumbar Puncture � Genetic Analysis

Therapeutic Interventions � Chemotherapy � Radiation Therapy � Bone Marrow Transplant � Peripheral Blood Stem Cell Transplant

Nursing Diagnoses � Risk for Injury: Infection, Bleeding � Fatigue � Impaired Oral Mucous Membranes � Knowledge Deficit � Anxiety

Multiple Myeloma � Pathophysiology ◦ Cancer of Plasma Cells in Bone Marrow ◦ Tumors Devour Bone Tissue ◦ Organ Invasion � Etiology ◦ Unknown ◦ Occupational Exposures

Signs and Symptoms � Bone � Fever Pain � Malaise � Spinal Cord Compression � Pathological Fractures � Hypercalcemia � Infection

Diagnosis CBC, Blood Calcium Bone X-Rays Urine for Bence Jones Protein Bone Marrow Biopsy

Therapeutic Interventions � Steroids � Chemotherapy � Control of Serum Calcium � Radiation � Stem Cell Transplantation � IV Pamidronate (Aredia)

Nursing Diagnoses � Risk for Infection � Risk for Injury ◦ Fracture ◦ Complications of Immobility ◦ Hypercalcemia

Hodgkin’s Disease � Cancer of Lymph System ◦ Presence of Reed-Sternberg Cells � Etiology ◦ Viral ◦ Genetic ◦ Immune Dysfunction

Signs and Symptoms � Painless � Pruritis � Pain Swollen Lymph Node Induced by Alcohol � Fever � Night Sweats � Weight Loss � Malaise

Late Signs and Symptoms � Edema of Face and Neck � Jaundice � Nerve Pain � Retroperitoneal Node Involvement � Spleen, Liver, and Bone Involvement

Diagnosis Biopsy ◦ Lymph Node ◦ Liver and Spleen ◦ Bone Marrow CT, Chest X-Ray Lung Bone Scan Lymphangiography CBC

Staging � Stage I: Single Lymph Node or Site � Stage II: Two or More Nodes on Same Side of Diaphragm � Stage III: Nodes on Both Sides of Diaphragm � Stage IV: Widely Disseminated Disease in Organs or Tissues

Therapeutic Interventions � Chemotherapy � Radiation Therapy

Nursing Diagnoses � Impaired Comfort � Activity Intolerance � Risk for Infection � Risk for Ineffective Coping

Non-Hodgkin’s Lymphomas � Lymphoma Arising from B Cells and T Cells � Absence of Reed-Sternberg Cells � Etiology ◦ ◦ Some Viruses H Pylori Immune Dysfunction Occupational Exposures

Signs and Symptoms � Painless Lymph Nodes � Enlarged Tonsils and Adenoids � Other Signs and Symptoms Similar to Hodgkin’s Disease

Diagnosis Biopsy ◦ ◦ ◦ Lymph Nodes Tonsils Bone Marrow Liver Other Bone Scan CT, Chest X-ray, IVP MRI, PET Scan Lymphangiography CBC Liver Function Studies Serum Calcium

Therapeutic Interventions � Chemotherapy � Monoclonal Antibodies � Interferon Therapy � Radiation Therapy � Stem Cell Transplant

Nursing Diagnoses � Activity Intolerance � Risk for Infection � Risk for Ineffective Coping

Comparison of Lymphomas Hodgkin’s ◦ ◦ ◦ Less Common Age 15 to 40 and >55 Reed-Sternberg Cells Younger Good Prognosis Alcohol-induced Pain Non-Hodgkin’s ◦ More Common ◦ Usually >Age 50 ◦ Absence of Reed. Sternberg Cells ◦ Poorer Prognosis

Splenectomy Surgical Removal of the Spleen

Preoperative Care � Baseline Labs � Blood Transfusion if Necessary � Vitamin K � Baseline Vital Signs � Teach Coughing and Deep Breathing

Postoperative Care � Monitor for Bleeding � Monitor Vital Signs � Administer Narcotics for Pain � Encourage to Cough and Deep Breathe and Ambulate

Complications of Splenectomy � Bleeding � Pneumonia � Atelectasis � Infection � OPSI