Nursing of Adults with Medical

1
Nursing of Adults with Medical Surgical
Conditions

• Blood and Lymphatic
• Disorders

2
Blood and Lymphatic Disorders

• Laboratory Tests
• RBC (erythrocytes) 4-6 million/cu.mm
• Hemoglobin 10-20 gm/100ml
• Hematocrit 40-50 percent
• WBC 5,000-10,000/mm
• Platelets 150,000-400,000/mm

3
Anemia

• Definition
• Disorder characterized by RBC and hemoglobin and
  hematocrit levels below normal range
• Causes delivery of insufficient amounts of oxygen
  to tissues and cells

4
Anemia

• Types
• Blood loss (hemorrhage)
• Impaired production of RBCs (bone marrow
  depression)
• Increased destruction of RBCs (hemolysis)
• Nutritional deficiencies (long term iron
  deficiency)

5
Anemia

• Signs Symptoms
• Anorexia
• Cardiac dilation
• Disorientation
• Dyspepsia
• Dyspnea
• Exertional dyspnea
• Fatigue
• Headache

• Insomnia
• Pallor
• Palpitation
• Shortness of breath
• Systolic murmur
• Tachycardia
• Vertigo

6
Hypovolemic Anemia

• Etiology/Pathophysiology
• Abnormally low circulating blood volume due to
  blood loss
• 500 ml loss can be tolerated
• 1000 ml loss can be severe complications
• Severity and signs and symptoms depend on how
  rapid the blood is lost

7
Hypovolemic Anemia

• Signs Symptoms
• Weakness
• Stupor
• Irritability
• Pale, cool, moist skin
• Hypotension
• Tachycardia (rapid, weak, thready pulse)
• Hypothermia
• Hemoglobin less than 10 gm/100ml
• Hematocrit less than 40
• HH may not drop for several hours after blood
  loss

8
Hypovolemic Anemia

• Treatment
• Control bleeding
• Treat shock
• O2, elevate lower extremities, keep warm
• Replace fluid
• blood transfusion, plasma, dextran, lactaed
  ringers
• Monitor vital signs

9
Pernicious Anemia

• Etiology/Pathophysiology
• Absence of the intrinsic factor
• Intrinsic factor is essential for the absorption
  of vitamin B12
• Deficiency of vitamin B12 affects growth and
  maturity of all body cells
• RBCs in the bone marrow dont mature
• RBC membrane ruptures easily
• Vitamin B12 is also related to nerve myelination
• may cause progressive demyelination and
  degeneration of nerves and white matter

10
Pernicious Anemia

• Signs Symptoms
• Extreme weakness
• Dyspnea
• Fever
• Hypoxia
• Weight loss
• Jaundice (destruction of RBCs)
• Pallor
• GI complaints

11
Pernicious Anemia

• Dysphagia
• Sore, burning tongue
• Smooth and erythematous
• Neurological symptoms
• tingling of the hands and feet
• disorientation
• personality changes
• behavior problems
• partial or total paralysis

12
Pernicious Anemia

• Treatment
• Vitamin B12 (cyanocobalamin) 1000 units
• daily for 1 week
• weekly for 1 month
• monthly for life
• Folic acid supplement
• Iron replacement
• RBC transfusion
• for severe anemia
• Diet
• high protein, vitamins, and minerals

13
Aplastic Anemia

• Etiology/Pathophysiology
• Decrease of bone marrow function
• RBC production
• Primary
• congenital
• Secondary
• viral invasion
• medications
• chemicals
• radiation
• chemotherapy

14
Aplastic Anemia

• Signs Symptoms
• Pancytopenic
• all three major blood elements from the bone
  marrow are decreased (RBC, WBC, Platelets)
• Repeated infections with high fevers
• Fatigue, weakness, malaise
• Dyspnea
• Palpitations
• Bleeding tendencies
• petechiae, ecchymossis, bleeding gums, epistaxis,
  GI GU bleeds

15
Aplastic Anemia

• Treatment
• Identify remove cause
• Platelet transfusion for severe thrombocytopenia
• Splenectomy for hypersplenism
• Hypersplenism can cause destruction of platelets
• Steroids and androgens
• stimulate bone marrow
• Antithymocyte globulin
• stimulates bone marrow
• Bone marrow transplant

16
Iron Deficiency Anemia

• Etiology/Pathophysiology
• RBCs contain decreased levels of hemoglobin
• Excessive iron loss
• caused by chronic bleeding intestinal, uterine,
  gastric

17
Iron Deficiency Anemia

• Signs Symptoms
• Pallor
• Fatigue
• Weakness
• Shortness of breath
• Angina
• S/S of heart failure
• Glossitis
• Pagophagia (desire to eat ice, clay, starches)
• Headache
• Paresthesia
• Burning tongue

18
Iron Deficiency Anemia

• Treatment
• Ferrous Sulfate 900 mg daily
• Oral or injection (z-tract)
• Ascorbic acid
• enhances absorption of iron
• Diet high in iron
• Organ meats
• liver, kidney, heart, tongue
• Muscle meats (esp dark meat from poultry)
• Fish
• Eggs
• Green leafy vegetables
• Whole grains
• Dried beans

19
Sickle Cell Anemia

• Etiology/Pathophysiology
• Most common genetic disorder in the U.S.
• Occurs predominantly in African Americans
• 1out of 10 have trait 1 out of 500 have disease
• An abnormal, crescent shaped RBC
• contains hemoglobin S (Hg-S)
• Severe, chronic, incurable condition
• Disease
• Homozygous
• has two Hg-S genes one from each parent
• Trait
• Heterozygous
• has one Hg-S gene from one parent and one Hg-A
  gene from the other parent

20
Sickle Cell Anemia

• Signs Symptoms
• Precipitating Factors
• Dehydration
• Change in oxygen tension in the body
• infection, overexertion, cold, alcohol, smoking
• Loss of appetite
• Irritability
• Weakness
• Abdominal enlargement
• pooling of blood in the liver, spleen and other
  organs
• Join and back pain
• Edema of extremities

21
Sickle Cell Anemia

• Treatment
• No specific treatment
• Alleviate symptoms
• Oxygen
• Rest
• Fluids
• oral and IV
• Analgesics
• Bone marrow transplant
• Experimental

22
Agranulocytosis

• Etiology/Pathophysiology
• Severe reduction in the number of granulocytes
  (basophils, eosinophils, neutrophils)
• WBC less than 200/mm3
• Medications
• analgesics, antibiotics, antiepileptics,
  antihistamines, antineoplastic agents,
  antithyroid drugs, diuretics, phenothiazides,
  sulfonamides
• Chemotherapy
• Radiation
• Neoplastic disease
• Viral and bacterial infections

23
Agranulocytosis

• Signs Symptoms
• S/S of infection
• fever, chills, headache, fatigue
• Ulcerations of mucous membranes
• Bronchial pneumonia
• Urinary tract infection

24
Agranulocytosis

• Treatment
• Identify and remove cause of bone marrow
  depression
• Prevent or treat infections
• Meticulous handwashing
• Strict asepsis

25
Leukemia

• Etiololgy/Pathophysiology
• Malignant disorder of the hematopoietic system
• Excess leukocytes accumulate in the bone marrow
  and lymph nodes
• bone marrow produces immature cells
• Cause unknown
• Possible causes include genetic, virus, exposure
  to radiation, or chemotherapy
• Classification
• Acute or Chronic
• Proliferating cells (lymphocytic, monocytic, etc.)

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Leukemia

• Signs Symptoms
• Anemia
• pallor, fatigue, malaise
• Thrombocytopenia
• petechiae, epistaxis, bruising, occult blood
• Leukopenia
• fever, upper resp. infections,
• Enlarged lymph nodes
• Splenomegaly

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Leukemia

• Treatment
• Chemotherapy
• Radiation
• Bone marrow transplant
• Medications
• Leukeran
• hydroxyurea
• corticosteroids
• Cytoxan

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Thrombocytopenia

• Etiology/Pathophysiology
• Abnormal hematological condition in which the
  number of platelets is reduced below 100,000 mm3
• Decreased production
• aplastic anemia, leukemia, tumors, chemotherapy
• Decreased survival
• antibody destruction, infection, viral invasion

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Thrombocytopenia

• Signs Symptoms
• Petechiae
• Ecchymoses
• Platelets below 100,000
• bleeding mucous membranes
• bleeding internal organs
• Platelets below 20,000
• serious bleeding risks

30
Thrombocytopenia

• Treatment
• Corticosteriod therapy
• Splenectomy
• Gamma globulin
• Immunosuppressive drugs
• Platelet transfusions
• Avoid trauma

31
Hemophilia

• Etiology/Pathophysiology
• Hereditary coagulation disorder, characterized by
  a disturbance of clotting factor
• Hemophilia A
• most common
• Factor VIII is absent
• Hemophilia B
• Deficiency of Factor IX
• X-linked hereditary trait
• affects mainly males
• females are carriers

32
Hemophilia

• Signs Symptoms
• Internal external bleeding
• Hemarthrosis
• bleeding into the joint esp knees, ankles, and
  elbow
• Excessive blood loss from small cuts and dental
  procedures

33
Hemophilia

• Treatment
• Minimize bleeding
• avoid trauma
• Relieve pain
• No aspirin
• Transfusions
• Factor VIII or IX concentrate
• human-derived products
• can be treated to inactivate viruses
• Cryoprecipitate (rich in factor VIII)
• human-derived product
• Manufactured factor VIII or IX

34
von Willebrands Disease

• Etiology/Pathophysiology
• Inherited bleeding disorder characterized by
  abnormally slow coagulation of blood and
  spontaneous episodes of GI bleeding, epistaxis,
  and gingival bleeding
• Mild deficiency of factor VIII
• Common during
• Postpartum
• Menorrhagia
• Post operative
• Post truama
• Similar to hemophilia not limited to males

35
von Willebrands Disease

• Treatment
• Cryoprecipitate
• Fibrinogen
• Fresh plasma
• Desmopressin (DDAVP)
• Synthetic of the human antiduiuretic hormone,
  vasopressin
• Causes an increase in factor VIII release from
  storage sites in the body
• Same nursing interventions as for hemophilia

36
Disseminated Intravascular Coagulation (DIC)

• Etiology/Pathophysiology
• Overstimulation of clotting and anticlotting
  processes in response to disease or injury
• Septicemia
• Obstetrical complications
• Malignancies
• Tissue trauma
• Transfusion reaction
• Burns
• Shock
• Snake bites

37
Disseminated Intravascular Coagulation (DIC)

• Primary disorder initiates generalized
  intravascular clotting, which overtimulates
  fibrinolytic mechanisms
• The hypercoagulability is followed by a
  deficiency in clotting factors with subsequent
  hypocoagulability and hemorrhaging

38
Disseminated Intravascular Coagulation (DIC)

• Signs Symptoms
• Bleeding
• Mucous membranes
• Venipuncture sites
• Surgical sites
• GI GU tracts
• All orifices
• Dyspnea
• Hemoptysis
• Diaphoresis
• Cold, mottled digits
• Purpura on the chest and abdomen
• Petechiae

39
Disseminated Intravascular Coagulation (DIC)

• Treatment
• Treat underlying cause
• Cryoprecipitate
• Heparin
• Protect from bleeding and trauma

40
Multiple Myeloma

• Etiology/Pathophysiology
• Malignant neoplastic immunodeficiency disease of
  the bone marrow
• Tumor, composed of plasma cells, destroys osseous
  tissue
• Bone marrow becomes overcrowded and unable to
  produce erythrocytes, platelets, and leukocytes
• Onset is gradual and insidious

41
Multiple Myeloma

• Signs Symptoms
• Bone pain
• Ribs, spine, and pelvis
• Pathological fractures
• Infection
• Anemia
• Bleeding
• Hypercalcemia
• Calcium and phosphorus drain from bones
• Renal failure
• Myeloma protein causes kidney damage
• Destruction of cells causes hyperuricemia

42
Multiple Myeloma

• Treatment
• Symptomatic not curable
• Radiation
• Chemotherapy
• Alkeran
• Cytoxan
• Leukeran
• Carmustin
• Vincristine
• Adriamycin
• Dexamethasone
• Corticosteroids
• IV fluids

43
Lymphangitis

• Etiology/Pathophysiology
• Inflammation of one or more lymphatic vessels
• Usually occurs from acute streptococcal or
  staphylococcal infection in an extremity

44
Lymphangitis

• Signs Symptoms
• Fine red streaks from the affected area in the
  groin or axilla
• Edema
• Chills
• Fever
• Local pain
• Headache
• Myalgia

45
Lymphangitis

• Treatment
• Penicillin
• Hot, moist heat
• Elevate extremity

46
Lymphedema

• Etiology/Pathophysiology
• Primary or secondary disorder
• Accumulation of lymph in the soft tissue
• Obstruction
• Increase in amount of lymph
• Removal of lymph channels and nodes

47
Lymphedema

• Signs Symptoms
• Massive edema and tightness of affected extremity
• Pain

48
Lymphedema

• Treatment
• Diuretics
• Antibiotics
• Compression pump
• Elastic stocking or sleeve
• Restricted sodium diet
• Avoid constrictive clothing
• Meticulous skin care

49
Malignant Lymphoma

• Etiology/Pathophysiology
• Non-Hodgkins Lymphoma
• Neoplastic disorder of lymphoid tissue
• Tumors usually start in lymph nodes and spread to
  lymphoid tissue in the spleen, liver, GI tract,
  and bone marrow

50
Malignant Lymphoma

• Signs Symptoms
• Painless, enlarged cervical lymph nodes
• Fever
• Weight loss
• Anemia
• Pruritus
• Susceptiblity to infection
• Complications
• Pleural effusion, bone fractures, and paralysis
• Fatigue
• Malaise
• Anorexia

51
Malignant Lymphoma

• Treatment
• Accurate staging of the disease is crucial to
  determine treatment regimen
• Radiation
• Initial treatment when localized
• Chemotherapy
• Cytoxan, Oncovin adriamycin bleomycin,
  methotrexate
• Treatment when not localized
• Bone marrow transplant
• Tumor necrosis factor (TNF)
• Direct cell toxicity
• Stimulates bone marrow
• Hodgkins Disease
• Etilology/Pathophysiology
• Inflammatory or infectious process that develops
  into a neoplasm
• Affects males twice as frequently as females

52
Hodgkins Disease

• Etilology/Pathophysiology
• Inflammatory or infectious process that develops
  into a neoplasm
• Affects males twice as frequently as females
• Reed-Sternberg cells
• Large, abnormal, multinucleated cells in the
  lymphatic system replace the normal cells

53
Hodgkins Disease

• Signs Symptoms
• Enlargement of cervical lymph nodes
• Anorexia
• Weight loss
• Pruritus
• Low-grade fever
• Night sweats
• Anemia
• Leukocytosis
• Increased WBC

54
Hodgkins Disease

• Treatment
• Depends on the staging process
• Chart on page 280
• Stage I or II (localized)
• Radiation
• Stage III or IV (generalized)
• Chemotherapy
• Combination