Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsChapter 33Assessment and Managementof Patients With ...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsQuestionIs the following statement True or False?Hem...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAnswerTrueHematopoiesis is the complex process of th...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsHematologic System• The blood and the blood forming ...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsBlood Cells• Erythrocyte—RBC• Leukocyte—WBC– Neutrop...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsHematopoiesis
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsHemostasisRefer to fig. 33-3
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsQuestionWhat type of anemia results from red blood c...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAnswerBBleeding results from red blood loss. Hemolyt...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAnemias• Lower than normal hemoglobin and fewer than...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsManifestations• Depend upon the rapidity of the deve...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsMedical Management• Correct or control the cause• Tr...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith Anemia—...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith Anemia—...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsCollaborative Problems/PotentialComplications• Heart...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith Anemia—...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsInterventions• Balance physical activity, exercise, ...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsQuestionIs the following statement True or False?Leu...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAnswerFalseLeukocytosis refers to an increased level...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsLeukemia• Hematopoietic malignancy with unregulated ...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAcute Myeloid Leukemia (AML)• Defect in stem cell th...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsChronic Myeloid Leukemia (CML)• Mutation in myeloid ...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAcute Lymphocytic Leukemia• Uncontrolled proliferati...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsChronic Lymphocytic Leukemia• Malignant B lymphocyte...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith Leukemi...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith Leukemi...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith Leukemi...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsCollaborative Problems/PotentialComplications• Infec...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith Leukemi...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsInterventions• Interventions related to risk of infe...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsImproving Nutrition• Oral care before and after meal...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsLymphoma• Neoplasm of lymph origin• Hodgkin’s lympho...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsHodgkin’s Disease• Unicentric origin• Reed–Sternberg...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNon-Hodgkins Lymphoma (NHL)• Lymphoid tissues become...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsQuestionWhat should any elderly patient be evaluated...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAnswerCAny elderly patient whose chief complaint is ...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsMultiple Myeloma• Malignant disease of plasma cells ...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsBleeding Disorders• Primary thrombocythemia• Thrombo...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsQuestionIs the following statement True or False?Dis...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAnswerTrueDisseminated intravascular coagulation is ...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsDIC• Not a disease but a sign of an underlying disor...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith DIC—Ass...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith DIC—Dia...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsCollaborative Problems/PotentialComplications• Renal...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith DIC—Pla...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsInterventions• Assessment and interventions should t...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsTherapies for Blood Disorders• Anticoagulant therapy...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsBlood Transfusion Administration• Review patient his...
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsComplications• Febrile nonhemolytic reaction• Acute ...
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management and assessment of patient with hemaetologic desorder

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management and assessment of patient with hemaetologic desorder

  1. 1. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsChapter 33Assessment and Managementof Patients With HematologicDisorders
  2. 2. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsQuestionIs the following statement True or False?Hematopoiesis is the complex process of the formation andmaturation of blood cells.
  3. 3. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAnswerTrueHematopoiesis is the complex process of the formation andmaturation of blood cells.
  4. 4. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsHematologic System• The blood and the blood forming sites, including the bonemarrow and the reticuloendothelial system• Blood– Plasma– Blood cells• Hematopoiesis
  5. 5. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsBlood Cells• Erythrocyte—RBC• Leukocyte—WBC– Neutrophil– Monocyte– Eosinophil– Basophil– Lymphocyte—T lymphocyte and B lymphocyte• Thrombocyte—platelet
  6. 6. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsHematopoiesis
  7. 7. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsHemostasisRefer to fig. 33-3
  8. 8. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsQuestionWhat type of anemia results from red blood celldestruction?A.BleedingB.HemolyticC.HypoproliferativeD.None of the above
  9. 9. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAnswerBBleeding results from red blood loss. Hemolytic anemiaresults from red blood cell destruction. Hypoproliferativeanemia results from defective red blood cell production.
  10. 10. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAnemias• Lower than normal hemoglobin and fewer than normalcirculating erythrocytes. A sign of an underlying disorder• Hypoproliferative: defect in production of RBCs– Due to iron, vitamin B12, or folate deficiency,decreased erythropoietin production, cancer• Hemolytic: excess destruction of RBCs– Due to altered erythropoiesis, or other causes suchas hypersplenism, drug-induced or autoimmuneprocesses, mechanical heart valves• May also be due to blood loss
  11. 11. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsManifestations• Depend upon the rapidity of the development of theanemia, duration of the anemia, metabolic requirementsof the patient, concurrent problems, and concomitantfeatures• Fatigue, weakness, malaise• Pallor or jaundice• Cardiac and respiratory symptoms• Tongue changes• Nail changes• Angular cheilosis• Pica
  12. 12. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsMedical Management• Correct or control the cause• Transfusion of packed RBCs• Treatment specific to the type of anemia– Dietary therapy– Iron or vitamin supplementation—iron, folate, B12– Transfusions– Immunosuppressive therapy– Other
  13. 13. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith Anemia—Assessment• Health history and physical exam• Laboratory data• Presence of symptoms and impact of those symptoms onpatient’s life; fatigue, weakness, malaise, pain• Nutritional assessment• Medications• Cardiac and GI assessment• Blood loss—menses, potential GI loss• Neurologic assessment
  14. 14. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith Anemia—Diagnoses• Fatigue• Altered nutrition• Altered tissue perfusion• Noncompliance with prescribed therapy
  15. 15. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsCollaborative Problems/PotentialComplications• Heart failure• Angina• Paresthesias• Confusion
  16. 16. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith Anemia—Planning• Major goals include decreased fatigue, attainment ormaintenance of adequate nutrition, maintenance ofadequate tissue perfusion, compliance with prescribedtherapy, and absence of complications.
  17. 17. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsInterventions• Balance physical activity, exercise, and rest.• Maintain adequate nutrition.• Patient education to promote compliance withmedications and nutrition.• Monitor VS and pulse oximetry, provide supplementaloxygen as needed.• Monitor for potential complications.
  18. 18. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsQuestionIs the following statement True or False?Leukocytosis refers to a decreased level of leukocytes inthe circulation.
  19. 19. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAnswerFalseLeukocytosis refers to an increased level of leukocytes inthe circulation. Leukopenia refers to a decreased level ofleukocytes in the circulation.
  20. 20. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsLeukemia• Hematopoietic malignancy with unregulated proliferationof leukocytes• Types:– Acute myeloid leukemia– Chronic myeloid leukemia– Acute lymphocytic leukemia– Chronic lymphocytic leukemia
  21. 21. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAcute Myeloid Leukemia (AML)• Defect in stem cell that differentiate into all myeloidcells: monocytes, granulocytes, erythrocytes, andplatelets• Most common nonlymphocytic leukemia• Affects all ages with peak incidence at age 60• Prognosis is variable• Manifestations: fever and infection, weakness andfatigue, bleeding tendencies, pain from enlarged liver orspleen, hyperplasia of gums, bone pain• Treatment aggressive chemotherapy—induction therapy,BMT or PBSCT
  22. 22. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsChronic Myeloid Leukemia (CML)• Mutation in myeloid stem cell with uncontrolledproliferation of cells—Philadelphia chromosome• Stages: chronic phase, transformational phase, blastcrisis• Uncommon in people under 20, with increased incidencewith age. Mean age: 55–60• Life expectancy of 3–5 years• Manifestations: initially may be asymptomatic, malaise,anorexia, weight loss, confusion or shortness of breathdue to leukostasis, enlarged tender spleen, or enlargedliver• Treatment: imatinib mestylate (Gleevec) blocks signals inleukemic cells that express BCR-ABL protein;chemotherapy, BMT or PBSCT
  23. 23. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAcute Lymphocytic Leukemia• Uncontrolled proliferation of immature cells fromlymphoid stem cell• Most common in young children, boys more often thangirls• Prognosis is good for children; 80% 5-year event-freesurvival, but drops with increased age• Manifestations: leukemic cell infiltration is more commonwith this leukemia, with symptoms of meningealinvolvement and liver, spleen, and bone marrow pain• Treatment: chemotherapy, imatinib mestylate (ifPhiladelphia chromosome positive), BMT or PBSCT,monoclonal antibody therapy
  24. 24. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsChronic Lymphocytic Leukemia• Malignant B lymphocytes, most of which are mature, mayescape apoptosis, resulting in excessive accumulation ofcells• Most common form of leukemia• More common in older adults, effects men more often• Survival varies from 2 to 14 years depending upon stage• Manifestations: lymphadenopathy, hepatomegaly,splenomegaly; in later stages anemias andthrombocytopenia; autoimmune complications with RESdestroying RBCs and platelets may occur, B symptomsinclude fever, sweats, weight loss• Treatment: early stage may require no treatment,chemotherapy, monoclonal antibody therapy
  25. 25. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith Leukemia—Assessment• Health history• Assess symptoms of leukemia, and for complications ofanemia, infection, and bleeding– Weakness and fatigue• Laboratory tests– Leukocyte count, ANC, hematocrit, platelets,electrolytes, culture reports
  26. 26. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith Leukemia—Diagnoses• Risk for bleeding• Risk for impaired skin integrity• Impaired gas exchange• Impaired mucous membrane• Imbalanced nutrition• Acute pain• Hyperthermia• Fatigue and activity intolerance• Impaired physical mobility
  27. 27. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith Leukemia—Diagnoses• Risk for excess fluid volume• Diarrhea• Risk for deficient fluid volume• Self-care deficit• Anxiety• Disturbed body image• Potential for spiritual distress• Grieving diagnoses• Deficient knowledge
  28. 28. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsCollaborative Problems/PotentialComplications• Infection• Bleeding• Renal dysfunction• Tumor lysis syndrome• Nutritional depletion• Mucositis• Depression
  29. 29. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith Leukemia- Planning• Major goals may include absence of complications,attainment and maintenance of adequate nutrition,activity tolerance, ability for self-care and to cope withthe diagnosis and prognosis, positive body image, and anunderstanding of the disease process and its treatment.
  30. 30. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsInterventions• Interventions related to risk of infection and bleeding• Mucositis– Frequent, gentle oral hygiene– Soft toothbrush, or if counts are low, sponge-tippedapplicators– Rinse only with NS, NS and baking soda, orprescribed solutions– Perineal and rectal care
  31. 31. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsImproving Nutrition• Oral care before and after meals• Administer analgesics before meals• Appropriate treatment of nausea• Small, frequent feedings• Soft foods that are moderate in temperature• Low-microbial diet• Nutritional supplements
  32. 32. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsLymphoma• Neoplasm of lymph origin• Hodgkin’s lymphoma• Non-Hodgkin’s lymphoma
  33. 33. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsHodgkin’s Disease• Unicentric origin• Reed–Sternberg cells• Suspected viral etiology, familial pattern, incidence early20s and again after age 50• Excellent cure rate with treatment• Manifestations: painless lymph node enlargement,pruritis; B symptoms: fever, sweats, weight loss• Treatment is determined by stage of the disease and mayinclude chemotherapy and/or radiation therapy
  34. 34. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNon-Hodgkins Lymphoma (NHL)• Lymphoid tissues become infiltrated with malignant cells,spread is unpredictable and localized disease is rare.• Incidence increases with age, with average age being 50to 60.• Prognosis varies with type of NHL.• Treatment is determined by type and stage of disease,and may include interferon, chemotherapy, and/orradiation therapy.
  35. 35. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsQuestionWhat should any elderly patient be evaluated for whosechief complaint is back pain and has an elevated totalprotein level?A.AnemiaB.LeukemiaC.Multiple myelomaD.Non-Hodgkin’s lymphoma
  36. 36. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAnswerCAny elderly patient whose chief complaint is back pain andhas an elevated total protein level should be evaluatedfor possible myeloma.
  37. 37. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsMultiple Myeloma• Malignant disease of plasma cells in the bone marrowwith destruction of bone• M protein and Bence–Jones protein• Median survival 3 to 5 years, no cure• Manifestations: bone pain, osteoporosis, fractures,elevated serum protein hypocalcaemia, renal damagerenal failure, symptoms of anemia, fatigue, weakness,increased serum viscosity, and increased risk for bleedingand infection• Treatment may include chemotherapy, corticosteroids,radiation therapy, biphosphonates
  38. 38. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsBleeding Disorders• Primary thrombocythemia• Thrombocytopenia• Idiopathic thrombocytopenia purpura (ITP)• Hemophilia• Acquired coagulation disorders: liver disease,anticoagulants, vitamin K deficiency• Disseminated intravascular coagulation (DIC)• Bleeding precautions
  39. 39. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsQuestionIs the following statement True or False?Disseminated intravascular coagulation is not a disease buta sign of an underlying condition.
  40. 40. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsAnswerTrueDisseminated intravascular coagulation is not a disease buta sign of an underlying condition.
  41. 41. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsDIC• Not a disease but a sign of an underlying disorder.• Severity is variable; may be life-threatening.• Triggers may include sepsis, trauma, shock cancerabrupto placenta, toxins, and allergic reactions.• Altered hemostasis mechanism causes massive clotting inmicrocirculation. As clotting factors are consumed,bleeding occurs. Symptoms are related to tissue ischemiaand bleeding.• Laboratory tests.• Treatment: treat underlying cause, correct tissueischemia, replace fluids and electrolytes, maintain bloodpressure, replace coagulation factors, use heparin.
  42. 42. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith DIC—Assessment• Be aware of patient who are at risk for DIC and assessfor signs and symptoms of the condition.• Assess for signs and symptoms and progression ofthrombi and bleeding.
  43. 43. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith DIC—Diagnoses• Risk for fluid volume deficient• Risk for impaired skin integrity• Risk for imbalanced fluid volume• Ineffective tissue perfusion• Death anxiety
  44. 44. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsCollaborative Problems/PotentialComplications• Renal failure• Gangrene• Pulmonary embolism or hemorrhage• Acute respiratory distress syndrome• Stroke
  45. 45. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsNursing Process: The Care of the Patientwith DIC—Planning• Major goals may include maintenance of hemodynamicstatus, maintenance of intact skin and oral mucosa,maintenance of fluid balance, maintenance of tissueperfusion, enhanced coping, and absence ofcomplications.
  46. 46. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsInterventions• Assessment and interventions should target potentialsites of organ damage.• Monitor and assess carefully• Avoid trauma and procedures which increase risk ofbleeding, including activities which would increaseintracranial pressure.
  47. 47. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsTherapies for Blood Disorders• Anticoagulant therapy• Splenectomy• Therapeutic apheresis• Therapeutic phlebotomy• Blood component therapy
  48. 48. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsBlood Transfusion Administration• Review patient history including history of transfusionsand transfusion reactions; note concurrent healthproblems and obtain baseline assessment and VS• Perform patient teaching and obtain consent• Equipment: IV (20-gauge or greater for PRBCs) andappropriate tubing, normal saline solution• Procedure to identify patient and blood product• Monitoring of patient and VS• Post procedure care• Nursing management of adverse reactions
  49. 49. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsComplications• Febrile nonhemolytic reaction• Acute hemolytic reaction• Allergic reaction• Circulatory overload• Bacterial contamination• Transfusion related acute lung injury• Delayed hemolytic reaction• Disease acquisition• Complications of long-term transfusion therapy

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