Nursing Assessment Hematologic System Chapter 30 Copyright 2014

Nursing Assessment Hematologic System Chapter 30 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Assessment of Hematologic System • Subjective Data • Past health history • Demographic data • Current and past individual and family history • Past and current use of medications, herbs, and supplements • Surgical history • Review of systems using functional health patterns Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Assessment of Hematologic System • Subjective Data • Past health history • Previous hematologic problems such as anemia, bleeding disorders, or blood diseases • Disorders, injuries, or transplants involving the liver, kidney, or spleen • Alcohol or IV drug use Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Assessment of Hematologic System • Subjective Data • Medications • Thorough assessment is important for identifying all substances that can potentially influence hematologic health including • Disruption of clotting processes • Bone marrow depression • Secondary malignancies • Bleeding problems Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Assessment of Hematologic System • Subjective Data • Surgery or other treatments • Splenectomy, tumor removal, prosthetic heart valve placement, excision of the duodenum, partial or total gastrectomy, gastric bypass, and ileal resection are significant. • History of bleeding and wound healing • Previous blood transfusions Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study i. Stockphoto/Thinkstock • B. C. is a 76 -year-old female who presents to the hematology clinic where you work. • She is complaining of an increase in fatigue over the past 3 months that is “not any better after a decent night’s rest. ” Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 6

Case Study i. Stockphoto/Thinkstock • Her daughter adds that her mother has “nearly fallen” twice in the past week while just walking around in her house. • Her primary doctor referred her for further evaluation of her complaints. • What do you do first? Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 7

Assessment of Hematologic System • Subjective Data: Functional Health Patterns • Health Perception–Health Management Pattern • Usual and present state of health • Demographic data • Family history and genetically linked disorders • High-risk behaviors Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Assessment of Hematologic System • Subjective Data: Functional Health Patterns • Nutritional-Metabolic Pattern • Weight, dietary pattern, history of cardiac or pulmonary diseases • Changes in skin texture or color and presence of petechiae or ecchymotic areas • Characteristics of lumps in neck, armpits, or groin Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Assessment of Hematologic System • Subjective Data: Functional Health Patterns • Elimination Pattern • Bleeding is significant. • Activity-Exercise Pattern • Weakness or ability to perform ADLs are important. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Assessment of Hematologic System • Subjective Data: Functional Health Patterns • Sleep-Rest Pattern • Fatigue not relieved by sleep should be evaluated. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Assessment of Hematologic System • Subjective Data: Functional Health Patterns • Cognitive-Perceptual Pattern • Arthralgia or aching bones • Hemarthrosis • Paresthesias, numbness, tingling • Changes in vision, hearing, taste, or mental status Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Assessment of Hematologic System • Subjective Data: Functional Health Patterns • Self-Perception–Self-Concept Pattern • Impact on function and appearance • Role-Relationship Pattern • Exposure to radiation or chemicals • Military history • Impact on usual roles and responsibilities Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Assessment of Hematologic System • Subjective Data: Functional Health Patterns • Sexuality-Reproductive Pattern • Menstrual history, impotence, or high-risk sexual behaviors Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Assessment of Hematologic System • Subjective Data: Functional Health Patterns • Coping–Stress Tolerance Pattern • Impact on ability to perform ADLs • Value-Belief Pattern • Conflicts with transfusions or transplants Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study • B. C. tells you she has had to ask her i. Stockphoto/Thinkstock daughter for help with grocery shopping, laundry, and cleaning lately. • She said she stopped taking baths as she was afraid of not being able to get out of the bathtub. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 16

Case Study i. Stockphoto/Thinkstock • She explains there is a family reunion planned in a nearby state next month and that is the most important reason she is here. • She is concerned she wouldn’t be able to make the trip the way she feels. • What are some questions you might want to ask both the mother and daughter in this case? Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 17

Assessment of Hematologic System • Objective Data • Physical Examination • Diagnosis of hematologic disorders often requires considering presenting symptoms in context of broader clinical assessment findings and risk factors. • Of particular importance are examination of the skin, lymph nodes, spleen, and liver. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Assessment of Hematologic System Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Assessment of Hematologic System • Objective Data • Physical Examination • Palpation of liver or spleen • An enlarged liver is noted by measuring the number of finger-breadths it extends below the rib cage border. • Spleen is usually quite difficult to palpate. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Assessment of Hematologic System • Objective Data • Physical Examination • Skin assessment • • Systematic head-to-toe order Petechiae Ecchymoses Spider nevus Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study i. Stockphoto/Thinkstock • B. C. answers all your questions about her health and history. • Later in the interview, her daughter interjects, “My mom has always gone to ‘quacks. ’ She has a whole bunch of pills I found in the kitchen drawer. ” • Why should you specifically ask B. C. to get a complete list of her “medications”? Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 22

Diagnostic Studies of Hematologic System • Laboratory Studies • Complete blood count • RBCs, WBCs, and platelets • Peripheral smear • Morphology of blood cells • Pancytopenia • Suppression of the entire CBC Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies of Hematologic System • Laboratory Studies • Red blood cells • Total RBC count alone not always diagnostic • Hemoglobin value (Hgb) • Hematocrit value (Hct) • RBC indices • Erythrocyte sedimentation rate (ESR/Sed rate) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies of Hematologic System • Laboratory Studies • White blood cells • Total WBC count • Leukopenia • Differential count • % of each type of leukocyte • Neutropenia Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies of Hematologic System • Laboratory Studies • Platelet count • Number of platelets/µL of blood • Thrombocytopenia • Danger of spontaneous hemorrhage • Thrombocytosis • Danger of excessive clotting Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study i. Stockphoto/Thinkstock The nurse practitioner orders blood work for B. C. While reviewing the results of her complete blood count (CBC), which finding would be of greatest concern to the nurse? a. Hemoglobin of 11. 4 g/d. L b. Platelet count of 80, 000/μL c. White cell count of 4500/μL d. Red cell count of 4. 5 × 106/μL Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 27

Diagnostic Studies of Hematologic System Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies of Hematologic System • Laboratory Studies • Blood typing and Rh factor • Blood group antigens • • • Rh system based on a third antigen, D Rh+ have antigen D. Rh- do not. Coombs test determines Rh status. Significant with transfusions and during childbirth Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies of Hematologic System • Laboratory Studies • Iron metabolism • Serum iron • Total iron-binding capacity (TIBC) • Serum ferritin • Transferrin saturation Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies of Hematologic System • Radiologic Studies • Computed tomography (CT) • Magnetic resonance imaging (MRI) • Biopsies • Bone marrow examination • Lymph node biopsy Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies of Hematologic System Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Diagnostic Studies of Hematologic System • Biopsies • Lymph node biopsy • Molecular cytogenetics and gene analysis • From bone marrow and lymph node biopsy samples • Fluorescent in situ hybridization (FISH) • Spectral karyotyping (SKY) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study i. Stockphoto/Thinkstock B. C is diagnosed with thrombocytopenia. To evaluate the effectiveness of her treatment, the nurse plans to monitor the a. platelet count. b. prothrombin time. c. partial thromboplastin time. d. international normalized ratio (INR). Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 34