Nursing Management of the Adult Patient with Hematologic and Immunologic Alterations

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Nursing Management of the Adult Patient with
Hematologic and Immunologic Alterations

• Tracy Heberlig, MSN, RN
• NURS 228 Spring, 2007

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Overview

• What is the function of blood?
• Homeostasis
• Life Span
• Short
• Constant need for replacement
• Hematopoiesis

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Plasma

• What is it?
• Why do we need it?
• Components
• Albumin
• Globulins
• Fibrinogen

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Hematological System

• Hematopoeic System
• Bone Marrow
• Where is it located?
• Why do we need it?
• Differentiation
• Myeloid
• Lymphoid

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Erythrocytes (RBCs)

• What is its function?
• Shape
• What is it composed of?
• Production Erythropoeisis
• Destruction

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Leukocytes (WBCs)

• What are the functions?
• Types
• Granulocytes
• Neutrophils
• Eosinophils
• Basophils
• Agranulocytes
• Monocytes
• Lymphocytes

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Thrombocytes (PLTs)

• Not really cells
• What is its function?

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Spleen

• What are the functions?
• Location
• Implications
• Enlarged spleen
• Splenectomy

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Liver

• How is the liver r/t the hematological system?
• Why is it important?
• Liver and Bile connection

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Hemostasis

• Complex Process
• Reaction Cascade
• Series of events
• Intrinsic and Extrinsic factors
• Clotting factors

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Subendothelial matrix
Endothelial cell
Hemostatic plug
Platelets
Fibrin
RBC
WBC
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Fibrinolysis

• Anticoagulant force to stop clotting
• Balance
• Fibrin digestion

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Gerontological Considerations

• Physiological Effects of Aging
• Considerations

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Assessment

• Family History
• Personal History
• Diet
• Current Health Problem(s)
• Physical Assessment

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Physical Assessment

• Dryness
• Itching
• Skin Color
• Petechiae
• Purpura
• Ecchymosis
• Jaundice
• Pallor

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Physical Assessment

• Head and Neck
• Chest
• Back and Extremities
• Lymph Nodes
• CNS

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Physical Assessment

• Respiratory
• Renal
• Abdominal
• Liver (ascites)
• Spleen

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Assessment Findings

• Fatigue
• Fever
• Chills
• Night Sweats
• Fatigue
• Who is at Risk?

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Laboratory Tests

• Complete Blood Count (CBC)
• RBC (4.2 - 5.9 x 1012 cells/L)
• Hgb (Men 13 - 18 g/dL, Women 12 - 16 g/dL)
• Hct (Men 45 - 52, Women 37 - 48)

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CBC 101

• Red Cell Indices
• MCV RBC size (microcytic, normocytic,
  macrocytic)
• MCH Avg. amount of Hgb in avg. RBC
  (hypochromic, normochromic, hyperchromic)
• MCHC Avg. concentration of Hgb in given volume
  of RBCs (calculated from Hgb and Hct)
• RDW How tightly Hgb packed w/in RBC

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CBC 101

• PLTs (150 400,000)
• WBC
• Count (4.3 - 10.8 x 109 cells/L)
• Differentiation ( of different types of WBC)

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Laboratory Tests

• Reticulocyte
• Bone marrow function
• Ferritin, Transferritin
• Total iron binding capacity
• Measures iron levels

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Laboratory Tests

• Bleeding and Coagulation
• Prothrombin Time (PT)
• How long blood takes to clot
• INR
• Eliminates PT errors Normal 0.7 1.8
• Coumadin 2 3
• Partial Thromboplastin Time (PTT)
• Evaluates all clotting factors of intrinsic
  pathway (except PLT)
• Normal 21 35 sec

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Diagnostic Tests

• Bone Marrow Aspiration and Biopsy
• Purpose
• Preparation
• Procedure
• Risks
• Nursing Responsibilities

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Anemia

• Overview
• Classifications
• Hypoproliferative
• Hemolytic
• Bleeding

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Anemia Clinical Manifestations

• Integumentary
• Cardiovascular
• Respiratory
• Neurological
• Complications
• Management

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Hypoproliferative Anemias

• Iron Deficiency Anemia
• Most common type
• Causes
• Who is at risk?
• Relationship between Hgb and Fe

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Iron Deficiency Anemia

• Clinical Manifestations
• Cheilosis
• Koilonychia
• Glossitis
• Pica
• Assessment/Dx Findings
• Medical Management

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Iron Deficiency Anemia

• Nursing Management
• Preventive education
• Nutritional counseling

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Iron Deficiency Anemia

• Medication Education / Management
• Oral supplement (ferrous sulfate)
• IV supplement (iron dextran)

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Aplastic Anemia

• Decreased, Damaged Marrow Stem Cells
• Marrow Replace w/ Fat
• Pancytopenia
• Results?
• Diagnosis
• Bone Marrow Aspiration

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Aplastic Anemia

• Treatments
• BMT or PBSCT
• Immunosuppressive therapy
• Supportive
• PRBCs
• PLTs

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Megaloblastic Anemias

• Vitamin B12 and/or Folic Acid Deficiencies
• Why are these important?
• Deficiencies result in
• Pernicious Anemia
• Intrinsic Factor

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Megaloblastic Anemias

• Clinical Manifestations
• Assessment / Dx Findings
• Schilling test
• Medical Management
• Folic acid
• B12 replacement
• Alert!
• Transfusions generally not used!

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Megaloblastic Anemias

• Nursing Interventions

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Polycythemia

• Too many cells in the blood
• Polycythemia Vera
• Primary polycythemia
• Laboratory findings
• Clinical manifestations
• Assessment / Dx findings

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Polycythemia Vera

• Complications
• Medical Management
• Phlebotomy
• Hydration
• Avoid tight clothing
• LE elevation
• Nursing Management

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Polycythemia Vera

• Nursing Management

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Hematologic System

• Most common nursing diagnoses?
• Interventions for these?
• Outcomes

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Activity Intolerance
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How do these pictures relate?
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Leukopenia - Neutropenia

• Absolute Neutrophil Count (ANC)
• ANC Total WBC Count x ( neutrophils bands)
• 100
• Significance
• Neutropenic Precaution

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Leukemia

• Leukocytosis
• What is it?
• Classification
• Acute or Chronic
• Unknown Etiology
• Prevalence

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Leukemia

• Varied Signs and Symptoms
• Risk Factors
• Survival Rates

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AML

• Defect in stem cells that differentiate into
  myeloid cells
• Most common nonlymphocytic leukemia
• Signs and Symptoms
• Assessment / Dx findings
• Complications
• Management

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CML

• Mutation in myeloid stem cell
• Normal cells and Blast cells
• Chromosomal defect
• Prevalence
• Signs and Symptoms
• Management

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ALL

• Uncontrolled proliferation of immature lymphoid
  stem cells (lymphoblasts)
• Prevalence
• Signs and Symptoms
• Medical Management

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CLL

• Malignant clone of B lymphocytes
• Prevalence
• Most common form of leukemia in US and Europe
• Signs and Symptoms
• Complications
• Medical Management

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Leukemia

• Treatment
• Radiation
• Chemotherapy
• BMT
• Biological Therapy
• Care focused on remission

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Leukemia

• BMT
• Closely matched donor
• Siblings, Unrelated, Umbilical cord blood
• Bone marrow suppression (before BMT)
• Transfused via central line
• New, healthy engrafted marrow begins
  hematopoiesis
• Complications
• Infection, Thrombocytopenia, Graft failure

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BMT

• Nursing Interventions
• Infection control
• Frequent handwashing
• Strict asepsis
• Protective isolation
• Frequent assessment

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Acute Leukemia

• Nursing Assessment
• Subjective Assessment
• Objective Assessment

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Acute Leukemia

• What are the major nursing diagnoses and
  collaborative problems?

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Lymphoma

• Hodgkins Disease
• No Benign Form
• Painless progressive enlargement of lymph nodes
• Reed-Sternberg Cells
• Malignant B lymphocyte

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Hodgkins Disease

• Prevalence
• Symptoms
• Diagnosis
• Treatment
• Management

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Multiple Myeloma

• Malignant Disease of Plasma Cells
• Cancer of Bone Marrow
• Myeloma Cells
• Collect in bone marrow and in the hard, outer
  part of bones
• Can form tumors plasmocytomas

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Multiple Myeloma

• Increased Myeloma Cell Production
• Damage and weaken bones
• Bone pain limits movement
• Associated With
• Hypercalcemia (Why?)
• Anemia
• Renal damage

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Multiple Myeloma

• Symptoms Dependent on How Advanced Disease Is
• Early asymptomatic
• Symptoms Advanced
• Bone pain (back or ribs) N/V
• Fractures Constipation
• Weakness and Fatigue Dysuria
• Weight loss Numbness in LEs
• Repeated infections

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Multiple Myeloma

• Risk Factors
• Diagnosis
• Medical Management

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Multiple Myeloma

• Complications
• Pathologic fractures
• Fluid overload
• Infection

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Multiple Myeloma

• Nursing Interventions
• Activity and exercise
• Adequate hydration
• Monitor renal function
• Prevention of infection
• Chart 33-8, p. 879
• Pneumovax and flu vaccines
• Pain medications

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Bleeding Disorders

• Platelets
• Thrombocytopenia
• Coagulation
• Hemophilia A / B
• von Willebrands disease
• Acquired
• Vitamin K deficiency
• DIC

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Bleeding Disorders

• S/S dependent upon defect
• Coagulation factors
• Thrombocythemia - gt 600,000
• Thrombocytopenia lt 150,000
• Clinical Manifestations
• Diagnostic Tests

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Thrombocytopenia

• Low PLT Count
• Decreased production
• Increased destruction
• Increased consumption
• Manifestations
• lt 50,000/mm3
• lt 20,000/mm3
• lt 5,000/mm3

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Thrombocytopenia

• Assessment and Dx Findings
• Medical Management

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Idiopathic Thrombocytopenic Purpura

• ITP
• Autoimmune Thrombocytopenic Purpura
• Production of antibody against PLT antigen
• PLTs destroyed by phagocytic lymphocytes
• Clinical Manifestations
• PLT lt 20,000/mm3

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ITP

• Medical Management
• Corticosteroids
• Immunosuppressants - Imuran
• Immunoglobulins - IVIG
• PLT transfusion, Plasmapheresis
• Splenectomy

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ITP

• Nursing Management
• Lifestyle assessment
• Recent history
• Restrictions
• Education

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Hemophilia

• Inherited bleeding disorders
• Hemophilia A
• Hemophilia B
• von Willebrands Disease
• Clinical Manifestations
• Laboratory Findings

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Hemophilia

• Medical Management
• Factor concentrates
• Cryoprecipitate
• DDAVP
• Nursing Interventions
• Education
• Prevention

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Acquired Coagulation Disorders

• Liver Disease
• Vitamin K Deficiency
• Disseminated Intravascular Coagulation (DIC)

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DIC

• Disorder of Clotting Cascade
• Pathophysiology
• Hypercoagulable
• Clotting factor and PLT depletion
• Clot lysis
• Hemorrhage
• Causes
• Sepsis (gram-neg) Transfusion reaction
• Recent surgery Severe liver disease
• LD complication

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DIC

• Laboratory Findings
• Low PLT, fibrinogen
• Prolonged PTT, PT, thrombin time
• Elevated d-dimer

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DIC

• Medical Management
• Treat the underlying cause
• Correct secondary effects
• Control bleeding
• Heparin use Contraversial
• Interrupts thrombosis process

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Blood Component Therapy

• Delegation and Collaboration
• Reasons for Administration
• Products
• Whole blood
• PRBCs / Washed PRBCs
• Plasma / FFP
• PLTs
• Cryoprecipitates
• Albumin