Hematologic System, Oncologic Disorders

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• Hematologic System, Oncologic Disorders Anemias

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Hematology

• Study of blood and blood forming tissues
• Key components of hematologic system are
• Blood
• Blood forming tissues
• Bone marrow
• Spleen
• Lymph system

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What Does Blood Do?

• Transportation
• Oxygen
• Nutrients
• Hormones
• Waste Products
• Regulation
• Fluid, electrolyte
• Acid-Base balance
• Protection
• Coagulation
• Fight Infections

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Components of Blood

• Plasma
• 55
• Blood Cells
• 45
• Three types
• Erythrocytes/RBCs
• Leukocytes/WBCs
• Thrombocytes/Platelets

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Erythrocytes/Red Blood Cells

• Composed of hemoglobin
• Erythropoiesis
• RBC production
• Stimulated by hypoxia
• Controlled by erythropoietin
• Hormone synthesized in kidney
• Hemolysis
• destruction of RBCs
• Releases bilirubin into blood stream
• Normal lifespan of RBC 120 days

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Leukocytes/White Blood Cells

• 5 types
• Basophils
• Eosinophils
• Neutrophils
• Monocytes
• Lymphocytes

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Types and Functions of Leukocytes
TYPE
CELL FUNCTION
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Thrombocytes/Platelets

• Must be present for clotting to occur
• Involved in hemostasis

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Normal Clotting Mechanisms

• Hemostasis
• Goal Minimizing blood loss when injured
• Vascular Response
• vasoconstriction
• Platelet response
• Activated during injury
• Form clumps (agglutination)
• Plasma Clotting Factors
• Factors I XIII
• Intrinsic pathway
• Extrinsic pathway

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Anticoagulation

• Elements that interfere with blood clotting
• Countermechanism to blood clottingkeeps blood
  liquid and able to flow

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Development of Blood Cells
Fig. 29-1
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Structures of the Hematologic System

• Bone Marrow
• Liver
• Lymph System

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Bone Marrow

• Bone Marrow
• Soft substance in core of bones
• Blood cell production (Hematopoiesis)
• RBCs
• WBCs
• Platelets

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Liver

• Located in upper right quadrant
• Receives 24 of the cardiac output (1500 ml of
  blood each minute)
• Liver has many functions
• Hematologic functions
• Liver synthesis plasma proteins including
  clotting factors and albumin
• Liver clears damaged and non-functioning
  RBCs/erythrocytes from circulation

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Spleen

• Located in upper L quadrant of abdomen
• Functions
• Hematopoietic function
• Produces fetal RBCs
• Filter function
• Filter and reuse certain cells
• Immune function
• Lymphocytes, monocytes
• Storage function
• 30 platelets stored in spleen

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Effects of Aging on the Hematologic System

• CBC Studies
• ? Hemoglobin (Hb or Hgb)
• ? response to infection (WBC)
• Plateletsno change
• Clotting Studies
• ? PTT

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Assessment of the Hematologic System

• Subjective Data
• Important Health Information
• Past health history
• Medications
• Surgery or other treatments

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Assessment of the Hematologic System (cont.)

• Functional Health Patterns
• Health perception health management
• Nutritional metabolic
• Elimination
• Activity exercise
• Sleep rest
• Cognitive perceptual
• Self-perception self-concept
• Role relationship
• Sexuality reproductive
• Coping stress tolerance
• Value belief

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Assessment ofthe Hematologic System (cont.)

• Objective Data
• Physical Examination
• Skin
• Eyes
• Mouth
• Lymph Nodes
• Heart and Chest
• Abdomen
• Nervous System
• Musculoskeletal System

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Diagnostic Studies of the Hematologic System
Complete Blood Count (CBC)

• WBCs
• Normal 4,000 -11,000 µ/l
• Associated with infection, inflammation, tissue
  injury or death
• Leukopenia-- ? WBC
• Neutropenia -- ? neutrophil count
• RBC
• ? 4.5 5.5 x 106/l
• ? 4.0 5.0 x 106/l
• Hematocrit (Hct)
• The hematocrit is the percent of whole blood that
  is composed of red blood cells. The hematocrit is
  a measure of both the number of red blood cells
  and the size of red blood cells.

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Diagnostic Studies of the Hematologic System
Complete Blood Count (CBC) Contd

• Platelet count
• Normal 150,000- 400,000
• Thrombocytopenia-? platelet count
• Spontaneous hemorrhage likely when count is below
  20,000
• Pancytopenia
• Decrease in number of RBCs, WBCs, and platelets

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Diagnostic Studies of the Hematologic System

• Radiologic Studies
• CT/MRI of lymph tissues
• Biopsies
• Bone Marrow examination
• Lymph node biopsies

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Anemia

• Anemia is a reduction in the number of RBCs, the
  quantity of hemoglobin, or the volume of RBCs
• Because the main function of RBCs is oxygenation,
  anemia results in varying degrees of hypoxia

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Anemia

• Prevalent conditions
• Blood loss
• Decreased production of erythrocytes
• Increased destruction of erythrocytes
• Signs Symptoms
• Same as hypoxia

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Nursing Management Anemia

• Nursing Assessmentsee tables 30-3 30-4
• Nursing Diagnoses
• Planning
• Nursing Implementation

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Nursing Actions for a Patient who is Anemic or
Suffered Blood Loss

• Administer oxygen as prescribed
• Administer blood products as prescribed
• Administer erythropoietin as prescribed
• Allow for rest between periods of activity
• Elevate the pts head on pillows during episodes
  of shortness of breath
• Provide extra blankets if the pt feels cool
• Teach the pt/family about underlying
  pathophysiology and how to manage the symptoms of
  anemia

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Anemia Caused by Decreased Erythrocyte Production

• Iron Deficiency Anemia
• Thalassemia
• Megablastic Anemia

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Iron-Deficiency Anemia

• Etiology
• Inadequate dietary intake
• Found in 30 of the worlds population
• Malabsorption
• Absorbed in duodenum
• GI surgery
• Blood loss
• 2 mls blood contain 1mg iron
• GI, GU losses
• Hemolysis

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Iron-Deficiency Anemia

• Clinical Manifestations
• See table 30-3
• Most common pallor
• Second most common inflammation of the tongue
  (glossistis)
• Cheilitisinflammation/fissures of lips
• Sensitivity to cold
• Weakness and fatigue
• Diagnostic Studies
• CBC
• Iron studies
• Endoscopy/Colonscopy

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Iron-Deficiency Anemia

• Collaborative Care
• Treatment of underlying disease/problem
• Replacing iron
• Food sources cited in table 30-5
• Drug Therapy
• Iron replacement
• Oral iron
• considerations pg 711
• Feosol, DexFerrum, etc
• Absorbed best in acidic environemtn
• GI effects
• Parenteral iron
• IM or IV
• Less desirable than PO

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Iron-Deficiency AnemiaNursing Management

• Assess cardiovascular respiratory status
• Monitor vital signs
• Recognizing s/s bleeding
• Monitor stool, urine and emesis for occult blood
• Diet teachingfoods rich in iron
• Provide periods of rest
• Supplemental iron
• Discuss diagnostic studies
• Emphasize compliance
• Iron therapy for 2-3 months after the hemoglobin
  levels return to normal

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Thalassemia

• Etiology
• Autosomal recessive genetic disorder of
  inadequate production of normal hemoglobin
• Found in Mediterranean ethnic groups
• Clinical Manifestations
• Asymptomatic ? major retardation ? life
  threatening
• Splenomegaly, hepatomegaly

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ThalassemiaCollaborative Care

• No specific drug or diet are effective in
  treating thalassemia
• Thalassemia minor
• Body adapts to ? Hgb
• Thalassemia major
• Blood transfusions with IV deferoxamine

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Megaloblastic Anemias

• Characterized by large RBCs which are fragile and
  easily destroyed
• Common forms of megaloblastic anemia
• Cobalamin deficiency
• Folic acid deficiency

This picture shows large, dense, oversized, red
blood cells (RBCs) that are seen in megaloblastic
anemia.
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Cobalamin (Vitamin B12) Deficiency

• Cobalamin Deficiency--formerly known as
  pernicious anemia
• Vitamin B12 (cobalamin) is an important
  water-soluble vitamin.
• Intrinsic factor (IF) is required for cobalamin
  absorption
• Causes of cobalamin deficiency
• Gastric mucosa not secreting IF
• GI surgery ?loss of IF-secreting gastric mucosal
  cells
• Long-term use of H2-histamine receptor blockers
• Nutritional deficiency
• Hereditary defects of cobalamine utilization

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Cobalamin (Vitamin B12) Deficiency

• Clinical manifestations
• General symptoms of anemia
• Sore tongue
• Anorexia
• Weakness
• Parathesias of the feet and hands
• Altered thought processes
• Confusion ? dementia

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Cobalamin Deficiency Diagnostic Studies

• RBCs appear large
• Abnormal shapes
• Structure contributes to erythrocyte destruction
• Schilling Test

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Cobalamin Deficiency

• Collaborative Care
• Parenteral administration of cobalamin
• ? Dietary cobalamin does not correct the anemia
• Still important to emphasize adequate dietary
  intake
• Intranasal form of cyanocobalamin (Nascobal) is
  available
• High dose oral cobalamin and SL cobalamin can use
  be used

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Cobalamin Deficiency

• Nursing Management
• Familial disposition
• Early detection and treatment can lead to
  reversal of symptoms
• Potential for Injury d/t patients diminished
  sensations to heat and pain
• Compliance with medication regime
• Ongoing evaluation of GI and neuro status
• Evaluate patient for gastric carcinoma frequently

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Folic Acid Deficiency

• Folic Acid Deficiency also causes megablastic
  anemia (RBCs that are large and fewer in number)
• Folic Acid required for RBC formation and
  maturation
• Causes
• Poor dietary intake
• Malabsorption syndromes
• Drugs that inhibit absorption
• Alcohol abuse
• Hemodialysis

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Folic Acid Deficiency

• Clinical manifestations are similar to those of
  cobalamin deficiency
• Insidious onset
• Absence of neurologic problems
• Treated by folate replacement therapy
• Encourage patient to eat foods with large amounts
  of folic acid
• Leafy green vegetables
• Liver
• Mushrooms
• Oatmeal
• Peanut butter
• Red beans

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Anemia of Chronic Disease

• Underproduction of RBCs, shortening of RBC
  survival
• 2nd most common cause of anemia (after iron
  deficiency anemia
• Generally develops after 1-2 months of sustained
  disease
• Causes
• Impaired renal function
• Chronic, inflammatory, infectious or malignant
  disease
• Chronic liver disease
• Folic acid deficiencies
• Splenomegaly
• Hepatitis

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Aplastic Anemia

• Characterized by Pancytopenia
• ? of all blood cell types
• RBCs
• White blood cells (WBCs)
• Platelets
• Hypocellular bone marrow
• Etiology
• Congenital
• Chromosomal alterations
• Acquired
• Results from exposure to ionizing radiation,
  chemical agents, viral and bacterial infections

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Aplastic Anemia

• Etiology
• Low incidence
• Affecting 4 of every 1 million persons
• Manageable with erythropoietin or blood
  transfusion
• Can be a critical condition
• Hemorrhage
• Sepsis

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Aplastic Anemia

• Clinical Manifestations
• Gradual development
• Symptoms caused by suppression of any or all bone
  marrow elements
• General manifestations of anemia
• Fatigue
• Dyspnea
• Pale skin
• Frequent or prolonged infections
• Unexplained or easy bruising
• Nosebleed and bleeding gums
• Prolonged bleeding from cuts
• Dizziness
• headache

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Aplastic Anemia

• Diagnosis
• Blood tests
• CBC
• Bone marrow biopsy

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Aplastic Anemia

• Treatment
• Identifying cause
• Blood transfusions
• Antibiotics
• Immunosuppressants (neoral, sandimmune)
• Corticosteroids (Medrol, solu-medrol)
• Bone marrow stimulants
• Filgrastim (Neupogen)
• Epoetin alfa (Epogen, Procrit)
• Bone marrow transplantation

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Aplastic Anemia

• Nursing Management
• Preventing complications from infection and
  hemorrhage
• Prognosis is poor if untreated
• 75 fatal

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Anemia Caused By Blood Loss

• Acute Blood Loss
• Chronic Blood Loss

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Acute Blood Loss

• Result of sudden hemorrhage
• Trauma, surgery, vascular disruption
• Manifestations
• d/t attempts to maintain adequate blood volume
  and meet oxygen requirements
• Table 30-10 details manifestations of Acute Blood
  Loss
• Collaborative Care
• Replacing blood volume
• Identifying source of hemorrhage
• Stopping blood loss

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Chronic Blood Loss

• Sources/Symptoms
• Similar to iron deficiency anemia
• GI bleeding, hemorrhoids, menstrual blood loss
• Diagnostic Studies
• Identifying source
• Stopping bleeding
• Collaborative Care
• Supplemental iron administration

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Anemia caused by Increased Erythrocyte Destruction

• Hemolytic Anemia
• Sickle Cell disease (peds)
• Acquired Hemolytic Anemia
• Hemochromatosis
• Polycythemia

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Hemolytic Anemia

• Destruction or hemolysis of RBCs at a rate that
  exceeds production
• Third major cause of anemia
• Intrinsic hemolytic anemia
• Abnormal hemoglobin
• Enzyme deficiencies
• RBC membrane abnormalities
• Extrinsic hemolytic anemia
• Normal RBCs
• Damaged by external factors
• Liver
• Spleen
• Toxins
• Mechanical injury (heart valves)

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Sequence of Events in Hemolysis
Fig. 30-1
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Acquired Hemolytic Anemia

• Causes
• Medications
• Infections
• Manifestations
• S/S of anemia
• Complications
• Accumulation of hemoglobin molecules can obstruct
  renal tubules ? Tubular necrosis
• Treatment
• Eliminating the causative agent

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Potential Nursing Dx for Patients with Anemia

• Activity Intolerance r/t weakness, malaise m/b
  difficulty tolerating ?d activity
• Imbalance nutrition less than body requirements
  r/t poor intake, anorexia, etc. m/b wt loss, ?
  serum albumin, ? iron levels, vitamin
  deficiencies, below ideal body wt.
• Ineffective therapeutic regimen management r/t
  lack of knowledge about nutrition/medications
  etc. m/b ineffective lifestyle/diet/medication
  adjustments
• Collaborative Problem Hypoxemia r/t ?hemoglobin

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Hemochromatosis

• Iron overload disease
• Over absorption and storage of iron causing
  damage especially to liver, heart and pancreas

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Polycythemia

• Polycythemia is a condition in which there is a
  net increase in the total number of red blood
  cells
• Overproduction of red blood cells may be due to
• a primary process in the bone marrow (a so-called
  myeloproliferative syndrome)
• or it may be a reaction to chronically low oxygen
  levels or
• malignancy

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Polycythemia

• Complications
• ?d viscosity of blood
• ? hemorrhage and thrombosis
• Treatment
• Phlebotomy
• Myelosupressive agents

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Problems of Hemostasis

• Thrombocytopenia
• Inherited clotting disorders (peds)
• Disseminated intravascular coagulation (DIC)

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Thrombocytopenia

• Disorder of decreased platelets
• platelet count below 150,000
• Causes
• Low production of platelets
• Increased breakdown of platelets
• Symptoms
• Bruising
• Nosebleeds
• Petechiae (pinpoint microhemorrhages)

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Thrombocytopenia

• Types of Thrombocytopenia
• Immune Thrombocytopenic Purpura
• Abnormal destruction of circulating platelets
• Autoimmune disorder
• Destroyed in hosts spleen by macrophages
• Thrombotic Thrombocytopenic Purpura
• ?d agglutination of platelets that from
  microthrombi

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Heparin-Induced Thrombocytopenia (HIT)

• HIT
• Associated with administration of heparin
• Develops when the body develops an antibody, or
  allergy to heparin
• Heparin (paradoxically) causes thrombosis
• Immune mediated response that casues intense
  platelet activation and relaese of
  procoaggulation particles.
• Clinical features
• Thrombocytopenia
• Possible thrombosis after heparin therapy
• Can be triggered by any type, route or amount of
  heparin

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Thrombocytopenia

• Diagnostic Studies
• Platelet count
• Prothrombin Time (PT)
• Activated Partial Thromboplastin Time (aPTT)
• Hgb/Hct
• Treatment
• Based on cause
• Corticosteroids
• Plasmaphoresis
• Splenectomy
• Platelet transfusion

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Nursing Management Thrombocytopenia

• NCP 30-2 pg 725
• Nursing Assessment
• Nursing Diagnoses
• Planning
• Nursing Implementation
• Health Promotion
• Acute Intervention
• Ambulatory and Home Care
• Evaluation

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Neutropenia

• Abnormally low number of neutrophil granulocytes
  (type of WBC)
• Neutrophil make up 50-70 of circulating WBCs and
  are the primary defense against infection
• Susceptible to bacterial infections

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Neutropenia

• Diagnostic Studies
• WBC Count
• lt4,000 Total WBCs Leukopenia
• Neutrophil count 1,000-1,500 moderate risk for
  infection
• Neutrophil count lt 500 severe risk for
  infection
• Bone Marrow aspirations Biopsies
• Spleen and liver function test

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Neutropenia

• Nursing and Collaborative Care
• ID cause
• ID organism of infection
• Antibiotic therapy
• Hematopoietic growth factors
• Neupogen
• Neulasta
• Protective isolation measures

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Leukemia

• Leukemia is the general term used to describe
  four different disease-types called
• Acute Myelogenous Leukemia (AML)
• Acute Lymphocytic Leukemia (ALL)
• Chronic Myelogenous Leukemia (CML)
• Chronic Lymphocytic Leukemia (CLL)
• The four types of leukemia each begin in a cell
  in the bone marrow. The cell undergoes a leukemic
  change and multiplies into many cells. The
  leukemia cells grow and survive better than
  normal cells and, over time, they crowd out
  normal cells.

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Leukemia

• Clinical Manifestations
• Tiredness or no energy
• Shortness of breath during physical activity
• Pale skin
• Mild fever or night sweats
• Slow healing of cuts and excess bleeding
• Black-and-blue marks (bruises) for no clear
  reason
• Pinhead-size red spots under the skin
• Aches in bones or joints (for example, knees,
  hips or shoulders)
• Low white cell counts, especially monocytes or
  neutrophils.

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Leukemia

• Often thought of as a childhood disease
• The number of adults affected with leukemia is 10
  times that of children

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Leukemia

• Diagnostic Studies
• To diagnose and classify
• Peripheral blood evaluation
• Bone marrow evaluation
• To identify cell subtype and stage
• Morphologic, histochemical, immunologic, and
  cytogenic methods

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Leukemia

• Goal is to attain remission
• Chemotherapeutic treatment
• Gleevac-used to treat CML
• Combination chemotherapy
• Mainstay treatment
• 3 purposes
• ? drug resistance
• ? drug toxicity to the patient by using multiple
  drugs with varying toxicities
• Interrupt cell growth at multiple points in the
  cell cycle

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Leukemia

• Bone Marrow and Stem Cell Transplantation
• Goal
• Totally eliminate leukemic cells from the body
  using combinations of chemotherapy with or
  without total body irradiation

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Nursing Management Leukemia

• Nursing Assessment
• Nursing Diagnoses
• Planning
• Nursing Implementation
• Acute Intervention
• Ambulatory and Home Care
• Evaluation

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Nursing Management

• Overall goals
• Understand and cooperate with the treatment plan
• Experience minimal side effects and complications
  of disease and treatment
• Feel hopeful and supported during the periods of
  treatment, relapse, and remission

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Nursing Management

• Many physical and psychological needs
• Evokes great fear
• Family also needs help
• Balance demanding technical needs with a
  humanistic, caring approach

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Nursing Management

• Ongoing care is necessary to monitor for signs
  and symptoms of disease control or relapse
• Teach patient and significant other
• Diligence in disease management
• Need for follow-up care
• When to seek medical attention

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Lymphoma

• Malignant neoplasms originating in the bone
  marrow and lymphatic structures
• Result in the proliferation of lymphocytes
• Two major types
• Hodgkins disease
• Non-Hodgkins lymphoma

80
Myelodysplastic Syndrome

• Etiology and Pathophysiology
• Unknown etiology
• Results in change of quantity and quality of bone
  marrow elements
• Clinical Manifestations
• Infection
• Bleeding
• d/t ineffective granulocytes or platelets
• Diagnostic Studies
• Bone marrow aspiration

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Blood Component Therapy

• Administration Procedure
• Large bore needle
• 19 gauge or higher
• Blood Tubing
• Y type
• Microaggregate filter
• Isotonic Solution
• Normal Saline
• Strict Identification process

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Blood Component Therapy

• Red Blood Cell Transfusions
• One unit contains
• 200 ml red blood cells
• 100 ml storage solution
• 30 ml plasma
• Must be ABO/Rh compatible
• In dire emergencies O- can be used
• Do not provide viable platelets nor do they
  contain significant amounts of coagulation
  factors

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Blood Component Therapy

• Red Blood Cell Transfusions
• Indications
• Pts with symptomatic anemia who are not treatable
  with specific therapy such as iron, vitamin B12,
  folic acid or Erythropoietin
• Therapeutic Effect
• In 70 kg adult, each unit should increase
  hematocrit by 3-4

84
Blood Component Therapy

• Platelets
• Platelet concentrate contains
• Platelets concentrated by centrifuging whole
  units of blood
• 60 ml plasma
• Small numbers of RBCs and WBCs
• Pooled platelets
• Up to 8 units of platelets from separate donors
  can be pooled into single bag for transfusion
• Expire 4 hours after pooling

85
Blood Component Therapy

• Platelets
• Platelet Phoresis
• Collected from a single donor. Equivalent to 4
  pooled units
• Contains 200-400ml of plasma
• Expire 4 hours after processing for release
• Indications
• Prevent bleeding d/t thrombocytopenia
• Bleeding
• Abnormal platelet function

86
Blood Component Therapy

• Fresh Frozen Plasma (FFP)
• One unit of FFP is plasma taken from one unit of
  whole blood
• FFP contains all coagulation factors
• One unit 250 ml
• Must be ABO compatible, Rh factor is not
  considered
• Thawed plasma may be transfuse for 5 days after
  thawing
• Indications
• Documented coagulation factor deficiencies (r/t
  liver disease, Warfarin, DIC)
• Active bleeding

87
Blood Component Therapy

• Cryoprecipitate (Cryo)
• Prepared from plasma and contains fibrinogen
• 1 bag contains
• 350 mg Fibrinogen
• Pooled 6 bags or 2100 mg Fibrinogen
• Indications
• Bleeding
• Immediately prior to invasive procedures

88
Blood Component Therapy

• Blood Transfusion Reactions
• Acute Transfusion Reactions
• Acute hemolytic reactions
• d/t antibodies in ABO antigen system
• May cause acute renal failure, DIC
• Treatment fluids, diuresis, support for
  bleeding
• Most errors are clerical or d/t patient
  misidentification
• Febrile reactions
• D/t sensitization on cell components (usually
  leukocytes)
• Treatment leukocyte depleted RBCs

89
Blood Component Therapy (cont.)

• Allergic reactions
• Most common
• D/t proteins on donors plasma
• Treatment pretransfusin treatment with
  antihistamines or steroids
• Circulatory overload
• Sepsis
• Delayed Transfusion Reactions
• Autotransfusion

90

• In Class Project

91
Present to Class

• Demographics
• Clinical Manifestations
• Treatment
• Nursing Management
• 2-3 Possible Nursing Diagnoses
• Prevention/Client Teaching