Patho-hematologic Disorder

Care of Clients with Hematologic Diseases Andrew D. Beluso, RN

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)

 The reticuloendothelial system (RES),

part of the immune system, consists of the phagocytic cells located in reticular connective tissue, primarily monocytes and macrophages. These cells accumulate in lymph nodes and the spleen. The Kupffer cells of the liver and tissue histiocytes are also part of the RES.

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  Three broad categories

1. Loss of RBC- occurs with bleeding 2. Decreased RBC production 3. Increased RBC destruction

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

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