N 308 Care of the Adult with Hematopoietic

N 308 Care of the Adult with Hematopoietic stressors

Blood Production Problems (Quantity Problems) l UNDERPRODUCTION l OVERPRODUCTION IMPAIRED PRODUCTION l • Hypoproliferative • Microcytic (RBCs small) • Macrocytic (RBCs large) • Hypochromic (↓Hemoglobin) • Hyperchromic (↑Hemoglobin)

Circulation - Patho

Circulation

Circulation - Purpose l l l Movement of nutrients and medications Oxygenation Homeostasis • • Fluid balance Acid-base balance

Blood Cells

Blood Cells

Plasma l l l Plasma proteins Clotting factors Other substances: nutrients, enzymes Waste products Gases

Albumin l l l Maintains fluid balance Binds substances to transfer in plasma, i. e. , meds Maintains osmotic forces

ANEMIA A client without sufficient red blood cells is said to be anemic.

Normal Red Blood Cell Count l l 4. 0 – 5. 4 million u/L Males are often slightly higher than females

Testing for CBC l l ü Non-fasting Can take blood sample from vein, artery or capillary Do not use vein where I. V. is located Do not massage area (heel stick, or fingers) • False low If tourniquet on too long, remove, wait, then try again üFalse high

Hemoglobin & Hematocrit l l Hemoglobin Normal Adult • l 12 -17 gm/dl l Hematocrit • 36 -51% of whole blood volume Is generally 3 X the hemoglobin value

Mean Corpuscular Hemoglobin l Amount of hemoglobin in an average red blood cell. l Normal MCH level is between 26 and 33 picograms (one trillionth of a gram) of hemoglobin per red blood cell.

MCV and RDW l l MCV – Mean Corpuscular Volume Average amount of space occupied by each red blood cell. The normal MCV level = between 78 and 98 cubic micrometers (abbreviated um 3) RDW – Red cell Distribution Width: Differences in sizes of the cells Normal RDW = variation of 11%-14. 5%

Common Cause: Hemorrhagic Blood Loss l l l Menstruation Childbirth Gastro-intestinal Trauma Abnormal cell morphology, i. e. , hemophilia

Common Cause: Poor Nutrition l l Inadequate intake of nutrients Inadequate absorption of nutrients (iron, folic acid, Vit. B 12)

Anemia

Iron Deficiency Anemia l Microcytic, hypochromic disorder

s/s Iron Deficiency l l Early: fatigue, weakness, pale skin Late: dyspnea, chest pain, muscle pain, cramping

Diagnostics l l l Hgb Hct Reticuloctye count indices MCV RDW

Too much iron in the body l l Hemochromatosis • • Genetic Iron absorbed from GI tract Common in Caucasian descent

Hemochromatosis l l Serial screening tests – alpha fetal proteins Serum iron studies Genetic counseling Tx: removal of blood

Iron Studies l l l Serum iron level TIBC % saturation Ferritin Differentiation of iron amounts in different areas of the body

Vitamin B 12 Deficiency l l l Pernicious anemia Macrocytic normochromic Lack of intrinsic factor Cheilosis, smooth sore tongue, neurological problems Schilling Test

Schilling Test l l l The Schilling test is performed to evaluate Vitamin B 12 absorption. Excretion of 8 to 40% of the radioactive Vitamin B 12 within 24 -hours is normal. The Schilling test is most commonly used to evaluate patients for pernicious anemia.

Folic Acid Deficiency l l l Macrocytic, normochromic Malnutrition Alcoholics Serum folate levels Birth defects

Folic Acid (B 9) l l Malabsorption Antibiotics: ampicillin, tetracycline Estrogen Symptoms similar to B 12

Drugs and Anemia l l AZT(Zidovudine) Phenytoin Methotrexate G 6 PD deficiency

Chronic Illness l l l Renal disease Rheumatoid arthritis Cancer

Kidney Dysfunction Patients l l l Likely to be anemic Under produce erythropoietin Uremia: bone marrow less likely to respond to the erythropoietin that is produced

Hemolysis l l l l l (erythrocyte destruction) Hereditary Spherocytosis Heavy metals (lead, copper) Malaria Prosthetic heart valves Vasculitis Malignant hypertension Sepsis Chemical poisoning Autoimmune diseases

Pregnant women have ↓ RBCs l l Dilutional Fluid retention dilutes RBCs

If RBCs are TOO HIGH you have polycythemia l l Sluggish flow ↑ clotting Tissue hypoxia High altitude

Polycythemia VERA l l l Overproduction of ALL blood cell types Blood removal is the treatment Bone marrow suppression drugs

Other causes of ↑ RBCs l l l Dehydration Smoking Drugs • • Gentamycin Methyldopa

Types of Anemia l Hemolytic l Nutritional • Thalassemia • Sickle cell • Spherocytosis • Iron deficiency • Folic Acid • Vitamin B 12

Types of Anemia l Production Impairment • Aplastic l Bone Marrow suppression • Cancer therapy

Thrombocytopenia l l l Not enough platelets Coagulation problems Bleeding

Thrombocytopenia l l Manual examination of peripheral smear Nursing: safety of patient: shaving, toothbrush, medications

Idiopathic Thrombocytopenic Purpura (ITP) l l Acute vs. chronic 1 -6 weeks post viral illness Self-limiting Dx: exclusion of other causes of thrombocytopenia

DIC is Triggered by? l l l l Sepsis Trauma Cancer Shock Toxins Allergic Reactions Emergency situation

NURSING CARE FOR DIC l l l Maintain optimal oxygenation Manage fluid replacement Monitor electrolyte imbalances Administer vasopressor meds as ordered Protect from falls/injury Provide emotional reassurance

Clotting tests l l Prothrombin time (PT) International Normalized Ratio (INR)

Clotting tests l Partial prothrombin time (PTT)

Bone Marrow Biopsies:

Blood Transfusions: Nursing Responsibilities l l Verify, Verify with 2 nurses! • Patient identification (name, record #, B. D. ) • Correct blood type, blood unit, exp. date • Set up I. V. access with saline • Answer patient questions Hang blood, use blood tubing with filter

Blood Transfusion Reactions: l l Febrile Non-hemolytic – most common Acute hemolytic – most dangerous Allergic reaction Circulatory overload

Blood Transfusion Reactions: l l Bacterial contamination TRALI – transfusion related acute lung injury – potentially fatal Delayed hemolytic reaction Disease acquisition

Blood Transfusions: Nursing Responsibilities l l Monitor Vital signs frequently Unit to hang < 4 hours, note patient condition to regulate flow.

TRANSFUSION REACTION! l l Stop the blood Have someone call M. D. Raise the head of the bed Apply 02

TRANSFUSION REACTION! l l l Hang new saline bag and tubing Monitor urine for amount/blood Frequent VS