Blood and Lymphatic Disorders

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Blood and Lymphatic Disorders

• By Helen Lucas, B.S.N., M.S.N.
• P.N. Instructor

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Review of Blood Components

• Erythrocytes RBCs carry O2 and CO2
• Thrombocytes Platelets form clots
• Leukocytes WBCs fight infection

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Review of Blood Types

• Type A (type A antigen) contain anti-B antibodies
• Type B (type B antigen) contain anti-A antibodies
• Type AB (type A B antigens) contains no
  antibodies therefore is Universal recipient
• Type O (no antigens) contains Antibodies both A
  B therefore is Universal Donor

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Review Lymphatic System

• Maintenance of fluid balance
• Production of lymphocytes
• Absorption and transportation of lipids from the
  intestine to the blood stream
• Tonsils
• Thymus
• Spleen (stores blood, forms lymphocytes,
  monocytes, and plasma cells, destroy worn out
  Rbc, remove bacteria)

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Anemia

• Insufficient delivery of oxygen to tissue and
  cells
• Usually there is a decrease in
• RBC
• Hemoglobin
• Hematocrit levels
• Increase in RBC destruction

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Common Nursing Diagnoses

• Tissue perfusion, altered cardiovascular, related
  to reduction of cellular components necessary for
  delivery of oxygen to the cells
• Gas exchange, impaired related to RBC,
  hemoglobin, and hematocrit deficit
• Activity intolerance, related to O2 deficit
  secondary to decreased hemoglobin and hematocrit

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Anemia Hypovolemic Anemia

• Due to blood loss
• 1000cc or more can be severe in adult
• Causes
• Surgical procedure
• GI bleed
• Menorrhagia
• Trauma
• Severe burns

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Normal blood volume

• 6000 ml
• Can tolerate 500cc loss
• When around 1000cc serious complications can
  occur (shock)
• Rate of loss affects tolerance. Rapid loss harder
  for body to compensate

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Symptoms similar to hypovolemic shock

• Treatment control bleeding
• Treat for shock
• Replace volume (blood transfusions, plasma or IV
  therapy)

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Pernicious Anemia

• Due to metabolic defect
• Absence of the intrinsic factor
• Intrinsic factor is secreted by the gastric
  mucosa
• Intrinsic factor necessary for absorption of
  Vitamin B 12
• B12 necessary for growth an maturity of all
  cells, including RBCs

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Vitamin B 12 deficiency

• Needed for nerve myelination
• If absent progressive demyelination and
  degeneration of nerves and white matter
• Causes extreme weakness
• Dyspnea, fever, and hypoxia
• Tingling of the hands and feet
• Loss of proprioception

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Skin may become lemon yellow

• Due to excessive destruction of the RBC's
• Causes the bile pigments to increase in the blood
  serum.

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Clinical symptoms

• Extreme weakness, dyspnea, fever, and hypoxia
• Edema of the legs, intermittent constipation and
  diarrhea
• Palpitations
• Sore and beefy red tongue (glossitis), swollen
  gums and dental problems

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Neurological signs

• Paresthesia
• Loss of sense of body position
• Personality and behavior changes
• Depression
• Partial or total paralysis of the spinal cord

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Diagnostic Tests Schilling test
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Gastric Analysis

• Shows decrease or absence of HCL acid
• Gastric acid is low in pernicious anemia.

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Bone Marrow Aspiration

• Shows abnormal RBCs

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Treatment for Pernicious Anemia

• Cyanocobalamin B12 injections
• Given IM
• For life
• Folic acid supplement
• Iron replacements
• Transfusions if anemia severe

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Nursing Diagnosis

• Injury, risk for related to sensory and motor
  losses, alteration in mental status
• Nutrition, altered less than body requirements,
  related to sore mouth and tongue, diarrhea, and
  constipation

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Aplastic Anemia Failure of bone marrow to
produce cells either congenital or secondary to
exposure to viral invasion, meds, chemicals,
radiation, or chemotherapy
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Called Pancytopenia

• red, white and platelets reduced!
• Bone Marrow Biopsy used to assess situation

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Clinical symptoms

• What would you expect?

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Medical treatment

• Give platelets
• Give Neupogen (see pg.322 Christiansen 3rd ed.)
• Splenectomy (may be destroying too many
  platelets)
• Steroids and androgens sometimes stimulate the
  bone marrow
• Antithymocyte globulin may help those not
  candidates for Bone Marrow transplant
• Bone Marrow transplant

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Nursing intervention Discuss

• Activity intolerance, related to inadequate
  tissue oxygenation
• Infection, risk for, related to increased
  susceptibility
• Risk for hemorrhage related to low platelets

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Iron-deficiency anemia

• RBC's contain low levels of hemoglobin

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Common causes

• Excessive iron loss
• Adults chronic bleeding
• Bodys demand for iron greater than absorption
• Infants, young adolescent, and pregnant women
• Malabsorption by diseases such as celiac disease
  and sprue is rare

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Symptoms

• Pallor
• Fatigue
• Weakness
• Shortness of breath

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Assess for-----

• Glossitis
• Pagophagia (the desire to eat ice, clays, or
  starches
• Headache, paresthesia, burning sensation of
  tongue
• (All caused by lack of iron)

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Objective data would include-----

• Pallor
• Tachycardia
• Fingernails fragile, spoon shaped
• Mucous membranes of mouth inflamed (stomatitis)
• Lips red with cracking at the angles

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Diagnostic tests

• CBC
• ? RBC, hemoglobin, hematocrit, serum iron levels

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Medical management

• Ferrous sulfate administered
• Ascorbic acid aids absorption
• Recheck Hct, Hgb in 3 weeks
• Discuss nursing responsibilities in giving iron
• Nutritional recommendations ?

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Sickle Cell Anemia
Normal
abnormal
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Characteristics

• Common genetic disorder
• Predominantly in African American, Africans and
  Mediterranean populations
• If you are born with this tendency from one
  parent you have Sickle Cell Trait.
• If you are born with this tendency from both
  parents you have Sickle Cell Anemia.

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Pathophysiology

• Hemoglobin S is exposed to a decrease in
  oxygen-----It becomes viscous, the red cells
  become crescent shaped (sickling), rigid, sticky,
  and fragile
• They clump together.
• Circulation in capillaries is impaired.
• The obstruction causes tissue hypoxia

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Crisis

• Sickling
• Thrombi formation
• Vascular occlusion
• Tissue hypoxia
• Infarction

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Symptoms

• Shortened lifespan of the abnormal red cells (10
  to 20 days)Chronic anemia
• Pallor
• Weakness
• Fatigue, irritability
• Jaundice (hemolysis of red cells)
• Severe pain in joints, abdomen
• Swelling of hands and feet
• Fever

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Treatment

• Supplemental iron and blood transfusion
• Adm. Hydroxyurea stimulates the production of
  hemoglobin F (fetal) (decreases the need for
  blood transfusions and painful crises)
• Prophylactic doses of penicillin

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Nursing Care

• During a crisis warm compresses are applied to
  the painful areas.
• Use of blankets (cold aggravates situation)
• Analgesic-antipyretics such as Tylenol are given.
  IV Pain meds also given.
• Oxygen.
• Bedrest is encouraged
• Dehydration and severe pain are two chief reasons
  for hospitalization.

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Prevent exacerbations by

• Avoiding tight clothing that restricts
  circulation
• Avoid strenuous exercise
• Avoid vasoconstricting drugs
• Avoid cold temperatures
• Avoid un pressurized aircraft, high altitudes and
  other hypoxia-provoking conditions

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Genetic counseling

• Prevent future children from having disease.
• Screening of family members.
• Refer to community support groups.

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Polycythemia (erythrocytosis)

• Primary Polycythemia vera
• Caused by excessive bone marrow production of
  erythrocytes, granulocytes and platelets.
• Stem cell abnormality of unknown cause

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Secondary polycythemia

• Caused by hypoxia
• Hypoxia stimulates erythropoietin in the kidneys
• This stimulates production of erythrocytes in the
  bone marrow.
• The body is compensating for low oxygen from high
  altitude, cardiovascular disease, lung disease,
  etc.

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This is a multiorgan system disease?!

• Increase mass of RBCs
• Increase in blood volume
• Increase in blood viscosity (sticky)
• Sluggish circulation leading to infarctions of
  vital organs.

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Symptoms

• Mostly middle age men
• Gradual in onset
• Sensitivity to hot and cold
• Pruritus
• Headaches, vertigo, tinnitus, and blurred vision
• Plethora (skin color ruddy)
• Elevated blood pressure

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Diagnostics

• Blood gases to check oxygenation
• Inc. plasma and red blood cells volume
• Hgb, Hct, reticulocyte and erythrocyte counts
  elevated.

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Treatment

• Repeated phlebotomy decreases blood viscosity
• Repeated when Hct reaches 50
• Drug therapy to suppress bone marrow activity
  (Myleran) and (Hydrea)

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Nursing Responsibilities

• Fluid intake and output
• avoid dehydration which makes blood more viscous
• avoid fluid overload which increases circulatory
  congestion.

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Educate patient

• Nutritional needs (a lot of GI upset)
• Exercise needs (prone to venous stasis and
  clotting)

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Disorders of the Leukocytes
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Agranulocytosis

• Severe reduction in agranulocytes associated with
  adverse medication reaction or toxicity.
• Possibly fatal
• Other causes radiation Rx, neoplastic disease,
  and chemotherapy

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Symptoms of condition

• Fever, chills, headache and fatigue
• Due to infections and inflammatory response

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Medical Focus

• Remove cause responsible for bone marrow
  depression
• Prevent infection
• Transfusions given
• Reverse Isolation (neutropenic precautions)

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Nurses Role

• Infection, risk for related to depressed WBCs
• What measures will protect your patient from
  infection?

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Leukemia

• Malignant disorder causing excess of leukocytes
  in bone marrow and lymph nodes
• Can be genetic in orgin, a virus or exposure to
  radiation or chemotherapy agents toxic to bone
  marrow.

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Symptoms

• Same as anemia, thrombocytopenia and leukopenia
• Enlarged lymph nodes
• Painless splenomegaly

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Diagnostics

• WBC is low, elevated or excessively elevated
• Bone marrow biopsy shows immature leukocytes
• Chest X-ray mediastinal node and lung
  involvement
• Bone changes

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Medical treatment

• chemotherapy or bone marrow transplants for
  acute leukemia in young
• For Chronic leukemia in adults
• Monitor for drug toxicity.
• Meds Leukeran, hydroxyurea, Corticosteroids,
  Cytoxan
• Irradiation of lymph nodes
• Blood transfusions

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Coagulation Disorders
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Platelet disorders

• Thrombocytopenia abn. Low count of platelets
• Most common cause is increased destruction of
  platelets called thrombocytopenic purpura
• Drug induced or idiopathic(cause unknown)

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Symptoms

• Petechiae and ecchymoses on the skin
• Below 100,000/mm3 risk fro bleeding from mucous
  membranes and in cutaneous sites and internal
  organs increase
• Below 20,000/mm3 serious bleeding occurs

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Assessment

• Hx of recent viral infections
• Medications in current use
• Extent of alcohol ingestion
• Observe for bruising, epistaxis, gingival
  bleeding
• Signs of increase intracranial pressure caused by
  cerebral hemorrhage

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Medical Management

• Corticosteroid therapy and splenectomy
• Immunosuppressive drugs or gamma globulin?
• Transfusions with platelet concentrates
• Apheresis (removes antibodies produced by the
  autoimmune process)

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Nursing Care

• Meticulous asepsis and gentle handling of the
  patient
• Monitor transfusions for reactions and effects on
  patients condition.
• Treat pain related to hemorrhage

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Patient education

• Avoid trauma or infection
• Use stool softeners
• High fiber diet to prevent constipation
• Check for presence of blood
• Soft toothbrush
• Blow nose gently
• Notify Dr. of signs of bleeding

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Clotting Factor Defects

• Hemophilia
• Hereditary coagulation disorder
• Hemophilia A 85, Factor VIII deficiency
• Hemophilia B (Christmas disease) Factor IX
  deficiency
• Females carriers, males primarily have disease
• High risk for HIV positive because of treatment
  with cryoprecipitate concentrates

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Clinical manifestations

• Hemarthrosis bleeding in joints, usually knees,
  ankles, elbow
• Pain, edema, erythema and fever, small cuts can
  prove fatal

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Von Willebrands disease

• Similar inherited with low Factor VIII
• Affecting women during postpartum periods, as
  menorrhagia and after surgery or trauma
• Treated with cryoprecipitate containing factor
  VIII, fibrinogen or fresh plasma
• Desmopressin (DDAVP) stimulates increase in
  release of factor VIII from storage sites

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DIC Disseminated intravascular coagulation

• Overstimulation of clotting and anti clotting
  processes in response to disease, injury or
  septicemia
• See box 9-3 pg 328 precipitating causes
• Widespread clotting within small vessels,
  followed by bleeding disorder and thrombosis

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Plasma Cell Disorder

• Multiple myeloma
• Malignant neoplastic immunodeficiency disease of
  the bone marrow
• Tumor causes pain, fractures and skeletal
  deformities.
• Person experiences recurrent bacterial
  infections.
• Increased susceptibility to infection follows
  disturbances of antibody formation by abnormal
  plasma cells

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Progression----

• Development of bone marrow tumors
• Bone destruction with metastasis into lymph
  nodes, liver, spleen, and kidneys
• Involves ribs, spine and pelvis
• Bone pain increases with movement

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Treatment

• Not curable
• Pain relief by radiation and chemo
• Antineoplastic drugs to depress bone marrow
• Prevention of infection
• Prevent bone injury
• Maintain hydration
• Emotional and spiritual needs

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Lymphatic disorders

• Lymphangitis infectious process
• Treat with antibiotics, bed rest, moist warm
  soaks, elevate

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Lymphedema

• Accumulation of lymph in soft issue
• Edema caused by obstruction, or increase in the
  amount of lymph or removal of channels and nodes
• Can be hereditary
• Massive edema, tightness causes pressure
• and pain
• Promote lymph drainage (elevate, compression
  hose)
• No cure

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Malignant lymphoma

• Neoplastic disorder of lymphoid tissue
• Possibly due to virus
• Cause unknown includes non-Hodgkins lymphoma
• Painless, enlarged lymph nodes in the cervical
  area
• Fever, weight loss, anemia, pruritus,
  susceptibility to infection
• Nursing care is supportive.

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Hodgkins Disease

• Malignant painless, progressive enlargement of
  lymphoid tissue
• Immune disorder
• Increase in Reed-Sternberg cells replacing normal
  cells.
• Anorexia, weight loss, and extreme pruritus
• Low-grade fever, night sweats, anemia,
  leukocytosis

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Treatment

• Stages I and II Radiation therapy
• Chemotherapy for stages III and IV

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Nursing Care

• Comfort measure focus on skin integrity
• Soothing baths
• Fever and perspiration controlled with meds.
• Linen changes
• Assist the patient who is impatient and anxious