Hematologic Problems

Care of Clients with Hematologic Diseases Earl Francis R. Sumile, RN Instructor, College of Nursing University of Santo Tomas

Care of Clients with Hematologic Diseases 

Blood – transports cellular requirements and products from one part of the body to another; composed of plasma (55%) and cellular component (45%)  

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Pulmonary circulation = 1300 cc 

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slightly alkaline (ph 7.35-7.4) 5-6 liters or 70-75 ml/kg BW (average volume) arterial (400cc) + capillary (60cc) + venous (840cc)

Systemic circulation = 3000 cc 

arterial (550cc) + capillary (300cc) + venous (2150cc)

Care of Clients with Hematologic Diseases 

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Hematopoiesis – blood cell production; done in the bone marrow (red), pelvis, sternum, ribs, epiphysis of long bones Erythropoiesis – red blood cell production in the liver in utero (2 to 5 months old) then in bone marrow. 

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needs iron, protein, pyridoxine (B6), cyanocobalamine (B12), folic acid, and copper

Reticuloendothilial System – mononuclear phagocyte system or macrophage (spleen, liver, lymphatic system, lungs)

Care of Clients with Hematologic Diseases  Nursing Assessment:  

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Pallor – conjunctiva Jaundice (hemolytic) – sclera; palms of hands; soles of feet Signs of bleeding such as petechiae, ecchymosis, hematoma, epistaxis Lymph nodes enlargement Limited joint range of motion Splenomegaly or hepatomegaly

Care of Clients with Hematologic Diseases 

Physical Assessment:

• Auscultate – heart murmur, bruits • Inspect – above assessment • Palpate – lymph nodes, location, size, bone tenderness • Percuss for ling excursion, splenomegaly, hepatomegaly • Evaluate joint ROM asnd tenderness

Care of Clients with Hematologic Diseases  

Diagnostic Assessment: Blood  CBC with differential a. Hemoglobin – Males13-16 gm/dl - Females 12-14 gm/dl b. Hematocrit – Males 42-50% - Females 40-48% c. RBC – N=Males 4,600,000 – 6,200,000 per cu.mm Females 4,200,000 – 5,400,000 per cu.mm

Diagnostic Assessment 

Blood d. WBC – N=5,000 – 10,000 cu.mm *neutrophils – N=60-70% *eosinophils – N=1-4% *basophils – N=0–0.5% *monocytes – N=2-6% *lymphocytes – N=20-30% e. Platelets – N=200,000-350,000 per cu.mm

Diagnostic Assessment 

Coagulation studies • PT Prothrombin time N= 11-18 secs • PTT Partial Thromboplastin Time – N =50 to 80 seconds • Clotting Time – N= 5 to 10 minutes • Bleeding Time – N=30 sec – 6 minutes

Diagnostic Assessment Blood chemistries – patients fasts for 6 to 8 hours  a. Blood Urea Nitrogen (BUN) – N=10-20mgs/dl  b. Creatinine – N=0.7-1.4mgs/dl  c. Uric acid – N= 2.5-8.0 mg/dl  d. Cholesterol – N=150-300 mg/dl  e. Bilirubin – Total N=0.1-1.0 mg/dl • direct (N=0.1-0.2mg/dl) • indirect (N=0.1-0.8mg/dl)

Diagnostic Assessment Miscellaneous a. ESR – N=0 to 20 mm/hr b. Coomb’s test – indirect blood from mom, direct blood from baby’s cord c. Schillings test – Vit.B12 in the gastro-intestinal system prep NPO x 8 hours radioactive Vit.B12 given PO Vit.B12 nonradioactive given IM 2 hours after urine collection for radioactive Vit.B12; N = 15-40% of oral dose excreted

Diagnostic Assessment Urine and Stool

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Urinalysis Hematest Hemoccult – prep; -no dark colored food x 24 hours prior to test

Radiologic

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CXR Scan Lymphangiography

Bone Marrow aspiration and biopsy

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Preferred site – iliac crest, sternum or tibia Before: consent, position exposing the site After: pressure to site x5miuntes

Erythrocyte Disorders 

Anemia – reduction below normal level in number of erythrocytes, quantity of hemoglobin and volume of packed RBC’s.  

Basic underlying – tissue hypoxia Signs and Symptoms – depends upon severity and chronicity and age. • a. Mild – hemoglobin 10-14 gms; asymptomatic; palpitations, dyspnea and diaphoresis following strenuous exertion. • b. Moderate – increased palpitations, dyspnea, and diaphoresis; fatigue at rest or during activity. • c. Severe – pale and exhausted all the time, sever palpitations, sensitivity to cold, loss of appetite, profound weakness, angina.

Anemia 

Iron Deficiency Anemia Causes: 

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Inadequate absorption – increased requirement Inadequate intake of iron rich foods Physiologic need – more in children and pregnant women Physiologic loss – menstruation Blood loss – trauma, GI bleeding

Iron Deficiency Anemia 

Signs and Symptoms:  Palpitations, dizziness, easy fatigability  Cold sensitivity, pallor  Brittle nails, and hair  Plummer-vinsons syndrome – soreness and inflammation of mouth and tongue (stomatitis and glossitis)

Iron Deficiency Anemia 

Nursing management: *Oral iron – route of choice; given after meals; liquid iron intake with straw because it stains; mixed with 1 glass cold H2O, best absorbed with Vitamin C; stool becomes tarry and constipation may occur. *Parenteral – avoid tissue staining by using separate aspiration injection needles; Z-tract method and deep IM; do not massage but encourage ambulation. *Dietary – increased in iron and roughage *Blood transfusion

Anemia Pernicious anemia – Vitamin B12 (cyanocobalamine) deficiency of intrinsic factor in the gastric mucosa which is necessary for absorption of Vit.B12. Signs and Symptoms:

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Hemolytic jaundice – macrolytic hypochromic Tingling sensations, paresthesias Beefy red tongue Deficiency or absence of hydrochloric acid in the stomach

Pernicious anemia  Nursing management: 

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Drug therapy – Vit B12 injections (monthly) for life Folic acid – reverses anemia, decreases neurological symptoms Transfusion therapy

 Diagnostic assessment:  

Schilling’s test Gastric analysis

Anemia 

Aplastic anemia – depressed bone marrow activity secondary to antineoplastics, radiation, insecticide, drugs and chemical toxins. Laboratory Assessment: pancytopenia   

Erythrocytopenia Leukocytopenia Thrombocytopenia

Aplastic anemia  Nursing management:     

Blood transfusion Prevent and treat infections Bone marrow transplant Drug – corticosteroids; estrogen Identify and withdraw offending agent

Leukocyte Disorders  Leukemia – most common of childhood

(3-5 y/o) cancer; abnormal proliferation of WBC in blast form. Predisposing factors:   

Radiation Survivors of Hiroshima Benzol, aniline dyes

Leukemia  Types of Leukemia:

*Acute lymphocytic leukemia (ALL) • 80-85%of childhood leukemia • 95% chance of obtaining remission with diagnostic assessment • 75% chance of surviving over 5 years

*Acute non-lymphocytic anemia (ANLL) • • •

granulocytic and monocytic 60-80% will obtain remission with treatment 30-40% cure rate

Leukemia 

Signs and Symptoms:      

Anemia – weakness, pallor, dyspnea Petechiae, spontaneous bleeding Infection, - fever, malaise Enlarged lymph nodes, liver and spleen Abdominal pain, weight loss, anorexia Bone pain due to expansion of marrow

Leukemia Nursing management: *Supportive therapy – rest, blood transfusion, prevent infection, promote nutrition, oral hygiene, skin care *Drug therapy – antileukemia – oncovin, prednisone, methotrexate (2-3 yrs.) *Radiation *Bone marrow transplant

Leukocyte Disorders  Lymphoma – lymphatic tissue

(lymphocytes) 

a. Hodgkin’s – malignant neoplasms of lymphatic tissue originating in lymph nodes proliferating to spleen and liver • Signs and Symptoms – enlarged nontender nodes, Reed Sternberg cells, pruritus Management – chemotherapy, radiation

Lymphoma b. NonHodgkins – tumor originating in lymphatic tissue characterized by diffuse, undifferentiated cell; prognosis is poorer than Hodgkin’s. Management: • • •

*chemotherapy *radiotherapy and *surgery for diagnosis and staging