Summary NSG 331/431 Exam 4 Study Guide

431 Exam 4 Hematologic and Endocrine
Module 7- Care of the Adult with Hematologic Disorders -Approx. 23 questions

Chapter 13
Chapter 14
-Pgs. 216-230
Chapter 29
Chapter 30
-Pgs. 606-616
622-626
628-630

Anemia (Ch. 29 &30---approx. 2 Qs each type)


Deficiency in the number of erythrocytes (RBCs), the quantity or quality of hemoglobin, and/or
volume of packed RBCs (hematocrit
Etiology
 Primary hematologic problems or develop as a secondary consequence of diseases or
disorders of other body systems
 Commonly d/t blood loss, impaired production of RBCs, or increased destruction of RBCs

Diagnosis
 CBC
 Reticulocyte count
 Peripheral blood smear

(Possible Findings)




Manifestations of Anemia
 Mild (Hgb 10-12)----occur because of underlying disease or as a compensatory response to
exercise
- palpitations
- mild to no fatigue
- exertional dyspnea

,  Moderate (Hgb 6-10)----increase in cardiopulmonary symptoms (at rest and during activity)
- increased palpitations/bounding pulse
- fatigue
- dyspnea
- “roaring in ears”

 Severe (Hbg <6)----impacting multiple body systems
- tachycardia/ increased pulse pressure, angina, HF, MI, intermittent claudication
- ocular issues
- dysphagia/sore mouth/anorexia
- hepato-, splenomegaly
- sensitivity to cold
- weight loss
- lethargy
- pallor/jaundice (d/t hemolysis of RBCs and increase bilirubin)/puritus (d/t hemolysis w/
increase serum and bile salt)
- glossitis/smooth tongue
- bone pain
- tachypnea/orthopnea, dyspnea at rest
- HA/vertigo/irritability/depression/impaired thought process

Nursing Interventions
***GOAL: correcting the cause of anemia
 Blood transfusions
 Drug therapy (erythropoietin, vitamin supplements)
 O2 supplementation
 Dietary & lifestyle changes
 Alternating rest and activity periods (for pts. w/ fatigue)
 Monitor cardiorespiratory response to activity

Gerontologic Considerations
- Modest decline in Hgb of about 1 g/dL in men> 70
- Minimal decline in Hgb of about 0.02 g/dL in women>70
- Anemia is NOT a normal finding in older adults
- May be due to underlying cause
- When no underlying cause identifiedr/t cytokine dysregulation w/ aging
- May go unrecognized in older adult r/t to symptomatic similarities to normal signs of aging

,Pernicious Anemia (cobalamin deficiency (Vit B12) ---typically occurs later in life (around 40-
60 y.o.)
----decrease in RBCs r/t improper intestinal absorption of B12 (from lack of intrinsic factor)
Morphologic Classification: Macrocytic, normochromic (MCV >95, MCH >31)

Etiology
 Parietal cells of gastric mucosa fail to secrete optimal IF due to gastric mucosal atrophy
or autoimmune destruction of parietal cells, decreasing cobalamin absorption in the
distal ileum
 Impaired parietal cells also cause a decreased level of HCL acid in the stomach (an
acidic environment in the stomach is required for secretion of IF)
 Occurs commonly in patients with GI surgery; patients with small bowel resections
involving the ileum; patients with Crohn’s disease, ileitis, celiac disease, diverticula, or
chronic atrophic gastritis---loss of IF-secreting gastric mucosal cells or impaired
absorption of cobalamin in distal ileum
 Can also be due to excessive alcohol or hot tea ingestion, smoking, long term H2 blocker
and PPI use, and strict vegan diets
 Familial predisposition is common


Clinical Manifestations (insidious onset---tales several months for manifestations to develop)
 General anemia manifestations
PLUS….
(Pernicious Anemia Specific Symptoms)
- Sore, red, beefy, and shiny tongue
- Anorexia, N/V, abdominal pain
- Weakness, paresthias of hands/feet, reduced vibratory and position senses, ataxia
- Impaired thought processes ranging from confusion to dementia


Treatments
 Parenteral vitamin B12 (cyanocobalamin, hydroxocobalamin) or intranasal
cyanocobalamin is needed when IF is lacking or if absorption is impaired (dietary intake
is NOT enough) ----W/O patient will die in 1-3 years
-----1000 mcg/day of cobalamin IM for 2 weeks weekly until Hgb normalmonthly
for life
 High-dose oral cobalamin or sublingual cobalamin are options for those in whom Gi
absorption is intact

Nutrition
 Meat, eggs, enriched grain products, milk and dairy foods, fish (esp. salmon)

Education
 Educate on importance of reducing injury from decreased sensitivity to heat and pain
from neurologic impairment
 Neuromuscular complications may not be reversible and physical therapy may be required

, Iron Deficiency Anemia (MOST COMMON)
-----decreased RBC production/decreased hemoglobin synthesis
Morphologic Classification: Microcytic, hypochromic (MCV <80 MCH <27)

Etiology
 Inadequate dietary intake (iron intake requirements higher in menstruating or pregnant
women)
 Malabsorption (d/t GI surgery of duodenum or malabsorption syndromes)
 Blood loss (from GI or GU systems---peptic ulcers, gastritis, esophagitis, diverticula,
hemorrhoids, cancer, menstrual bleeding, postmenopausal bleeding)
---Avg. menstrual blood loss is 45 mL causes loss of 22 mg of iron
---Loss of 50-75 ml in upper GI tract is enough for melena to present
 Hemolysis
 Dialysis

Clinical Manifestations
 In early course, patient may be asymptomatic
 As disease progresses, general manifestations of anemia may develop

(Iron-Deficiency Specific Symptoms)
- Pallor
- Glossitis (inflammation of the tongue)
- Cheilitis (inflammation of the lips)
- HA, paresthesia, burning sensation of tongue


Treatments----treat underlying problem causing iron loss or reduced intake/poor absorption
 Iron replacement
 Nutritional sources of iron
---if nutrition is adeqaute, increasing iron intake by dietary means may not be
enoughoral or parenteral iron supplements
 If iron deficiency is from acute blood losstransfusion of packed RBCs

Medications
 Oral iron (ferrous sulfate or ferrous gluconate)
----150-200 mg daily of elemental iron taken in 3-4 doses (each dose between 50 and 100
mg) ***325 mg tablet of ferrous sulfate contains 65 mg of elemental iron***
---taken an hour before meals w/ vitamin C or orange juice (gastric AE may require taking
w food)
---liquid iron should be diluted and ingested through straw
---stay upright for 30 mins after taking
---black stool is normal---may require stool softeners or laxatives
 IM or IV iron (iron dextran, sodium ferrous gluconate, iron sucrose)
---indicated for malabsorption patients or patients with intolerance to oral iron, or when a
need for iron is greater than the oral limits