Hemotologic Disorders

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Hemotologic Disorders

• By Diana Blum RN MSN
• Metropolitan Community College

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Functions

• Oxygenation
• Hemostasis (control of bleeding)
• If injury the vessel constricts
• Platelets adheres to injured vessel
• Them the coagulation cascade begins
• Diagnosis of problems can be difficult

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Anatomy

• Bone Marrow
• Liver manufactures clotting factors
• Spleen removes old RBCs from circulation
• Blood transports oxygen from lungs.
• Maintains hemostasis
• About 6 liters in body

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Parts of the Blood

• RBC made in bone marrow
• Transfers oxygen to from lungs to tissues
• Hemoglobin makes the transfer of oxygen and
  carbon dioxide possible
• 120 day life span
• Iron and heme are recycled
• Have proteins called antigens
• 2 major parts are A and B and O
• Rh and Rh-
• PLATELETS made in bone marrow
• Numbered I to XIII
• Form stable fiber matrix over wound

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Parts of the Blood

• Plasma clear straw colored fluid that carries
  red blood cells, platelets, and clotting factors
• Primarily water
• Other components are plasma proteins, albumin,
  and globulins

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Age Related Changes

• The bone marrow becomes less productive
• Hemotologic function is not affected unless
  trauma, a chronic illness, or treatment for cancer

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Nursing Assessment

• Health Hx Chief complaint, Hx of present
  illness
• Past Medical Hx Ca, HIV, liver dx, kidney dx,
  malabsorption dx, transfusions, clots
• Family Hx hemophilia, sickle cell dx
• Review System ask about change in color, skin
  dryness, pruritus(itching), vertigo, confusion,
  pain, headaches (duration, location, intensity),
  mental status changes, bleeding, heart
  palpitations
• Functional assessment occupation, hobbies, self
  concept, activity, exercise, sleep and rest,
  nutrition, relationships, stress, health
  perception
• See page 607

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Physical Exam

• Vs
• Ht
• Wt
• Look for cracking of mouth
• Monitor for SOB
• Look for tachycardia, tachypnea, hypotension
• Look for orthostatic changes, dehydration
• Look for pale skin or jaundice
• Look for bruising (ecchymosis)
• Look for purpura larger than petechiae
• Can be from low platelet count
• From large blood vessels breaking
• Look for petechiae
• (confused with a rash)
• Reddish purple in nature
• Severe coughing can cause

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Blood tests

• Blood cell count
• Hemoglobin
• Hematocrit-approximately 3 times the hemoglobin
• Normal platelet ct is
• PT and PTT measure bleeding time
• Blood typing
• To prepare the client tell them that they will
  feel a small prick

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Procedures

• Bone marrow Bx measures how it is making blood
• Explain the purpose and procedure
• Obtain consent
• No fasting is necessary
• Procedure takes about 30 minutes
• Transfusions see page 612-615

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Blood compatibilities
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Bleeding precautions

• Minimize the of invasive procedure
• Avoid prolonged tourniquet use
• Avoid IM injections
• Instruct the client to use soft bristled tooth
  brush
• No strait edge razor shaving only use electric
  razor
• Avoid NSAIDS

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products

• PRBCs 250-300ml/unit infuse over 2-4 hours
• Platelets 80-60ml/pack usually 4-6 packs are
  pooled for transfusion infuse as quickly as the
  pt tolerates
• FFP 180-270ml/unit infuse in less than 4 hours
• Cryoprecipitate10-15ml/bag usually 10 bags are
  pooled for transfusion infuse in less than 4
  hours (contains factor 1 and 8)

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Blood typing for transfusion

• Universal donor
• Does not contain A, B, or Rh antigens
• Universal recipients
• Blood contains A, B, and RH antigens
• Usually blood banks exactly match the pt blood

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adminstration on blood

• Pt needs 18 or 20 gauge IV needle so cells are
  not lysed (destroyed)
• Prior to administration, blood needs to be
  checked by 2 licensed nurses. Check the
  expiration date, name, medical record number,
  type of blood, blood band id, pt birthday
• Check vitals prior to administration
• blood must be initiated with in 30 minutes of
  arrival from lab to floor
• Use blood tubing for administration
• Monitor for blood reactions
• Monitor vitals continuously during administration

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Blood reactions

• Hemolytic fever, chills, nausea, dyspnea, chest
  pain, back pain, hypotension
• Antigen/antibody rx to transfusion
• Happens shortly after initiation
• Tx stop the transfusion, call md, supportive
  therapy to maintain HR and BP
• Anaphylactic urticartia, wheezing, dyspnea,
  hypotension
• Type 1 hypersensitivity rx to plasma proteins
• Occurs within 30 minutes of initiation
• Tx stop transfusion, call md, be ready for epi
  and steroids
• Febrile fever, chills
• Recipients antibodies rx to donor leukocyte
• Occurs within 30-90minutes of initiation
• Tx stop infusion, call md
• Circulatory overload cough, frothy sputum,
  cyanosis, decreased BP
• cardio system is unable to manage the additional
  fluid load
• Occurs anytime during transfusion and up to
  several hours after completion
• Tx stop infusion, call for help, be prepared for
  code, be prepared to administer oxygen and Lasix

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FFP Transfusion administration

• Start IV of NS using at least 24 gauge needle
• Platelets are smaller so a smaller needle can be
  used
• Check just like you check blood
• Prior to administration check vs
• Continue to check vs during administration
• Run platelets through blood tubing with a filter
• Infuse as fast as the pt can tolerate
• Monitor for rx
• See page 614

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Colony Stimulating Factors

• Naturally occuring hormones that stimulate bone
  marrow to produce more blood cells
• Ferrous sulfate iron replacement
• Iron dextran iron replacement
• Vitamin B12 Vitamin B12 replacement
• Hydroxyurea prevention of sickle cell crisis
• Epogen stimulates the bone marrow to produce
  more RBCs
• Used frequently with hemodialysis
• Used for anemia secondary to HIV or cancer
• See page 614

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Polycythemia Vera

• Too many RBCs produced
• Blood more viscous
• s/s headache, dizziness, ringing in the ears,
  blurred vision, ruddy complexion
• Tx

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Aplastic Anemia

• Complete failure of the bone marrow
• Low RBC count
• Low WBC
• Low Platelet cts
• S/S pallor, fatigue, tachycardia, sob,
  hypotension, prolonged/spontaneous bleed,
  frequent infections
• Tx transfusion of RBC and Platelet, antibiotics,
  corticosteroids, bone marrow transplant, ICU
  setting

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Autoimmune Hemolytic Anemia

• Enough RBCs made but they are destroyed once they
  are released into circulation
• Causes infection, drug reaction, cancer
• s/s pallor, fatigue, tachycardia, sob,
  hypotension, jaundice, high bilirubin levels
• Postive direct coombs antiglobulin test
• Tx blood transfusions, corticosteroids
• Recovery in few days to weeks

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Iron Deficiency Anemia

• Low RBC
• Low HGB andHCT
• Low serum Iron level
• Low ferritin level
• High TIBC level
• Results from diet low in iron
• Results from body not absorbing enough iron from
  GI tract
• Not enough hemoglobin made as result
• s/s fatigue, pallor, orthostatic changes (in
  severe cases)
• Tx iron supplements, iron rich foods

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Pernicious Anemia

• Pt does not absorb vitamin B12 from stomach
• Pt may lack intrinsic factor-essential for b12
  absorption
• Assess hx gastrectomy,
• s/s weakness, sore tongue, numbness of hand and
  feet
• Tx B12 injections monthly

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Sickle cell anemia

• RBCs normally disc shaped
• In sickle cell they are sickle shaped
• Easily rupture
• Obstruct blood flow
• Genetic in nature
• Most common in African Americans
• Sickle cell is recessive (inherit from mom and
  dad)

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Thrombocytopenia

• Too few platelets
• Causes cancer treatment
• Too many platelets being destroyed
• Causes idiopathic thrombocytopenic purpura,
  thrombic thrombocytopenic purpura (chptr 32)
• s/s petechiae, purpura, gingival bleed,
  epistaxis, prolonged bleeding

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Hemophilia

• Genetic
• Lack of blood clotting factor
• 1-2 cases per 20,000 persons
• Types
• A factor VIII is missing-higher incidence
• B factor IX is missing
• Trait is carried on x chromosome
• Rare for women to have
• s/s uncontrolled bleed especially in joints,
  skin, GI tract
• Tx no cure. Transfusions, pain treatment (IV
  morphine is common)..monitor for addiction to
  opiods.

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Nrsg diagnosis

• Risk for injury r/t bleed. Goal cessation of
  bleeding aeb no visual signs of bleeding and
  stable vs
• Acute pain r/t bleeding into closed
  spaces(creating pressure on nerves. Goal pain
  relief aeb patient states pain is relieved and
  appears to be in relaxed manner.
• Ineffective therapeutic regimen management r/t
  lack of knowledge about dx process and self
  care. Goal effective management of condition
  aeb patient accurately describes condition and
  demonstrates self care measures.

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THE END