Adult Health II Exam 3
Hematologic Disorders: Concepts
Gas Exchange and Tissue Perfusion
- Blood (RBC) oxygen delivery system -
contain
hemoglobin
- RBC contain Hgb which exchanges oxygen and carbon dioxide at the cellular level
- Heme needs iron to transport oxygen -
- Four molecules of oxygen can attach to heme
- Globin carries carbon dioxide
- Any interruption of this process creates disease/disorder
RBC Disorders
Anemia
- Reduction of RBC, Hgb, and/or Hct
- Clinical sign – not a specific disease
- Classifications – blood loss, hemolytic, impaired RBC production lysis of the blood
Types of Anemia
Is
- Iron-deficiency (microcytic) – blood loss, poor nutrition
plod
mall
a
- Hemolytic – immune, mech, trauma, sickle cell
- Megaloblastic (macrocytic) – vitamin B12 (cobalamin) deficiency, pernicious anemic – lack intrinsic factor,
/largeblo
a
folic acid deficiency
- Aplastic anemia (bone marrow depression)
- Chronic disease anemias (ex: chronic renal failure) Kidney's can't produce erythropoietin
Symptoms
- Eyes – yellowing -
easiest
way for people of color
- Skin – paleness, coldness, yellowing
- Respiratory – shortness of breath
- Muscular – weakness
- Intestinal – changed stool color
- Central – fatigue, dizziness, fainting
- Blood vessels – low blood pressure , hypovolemia
- Heart – palpitations, rapid heart rate, chest pain, angina, heart attack.
- Spleen – enlargement
Sickle Cell Anemia (SCD)
Pathophysiology
- Genetic disorder of hemoglobin causing distortion of RBC shape (sickle) in response to decrease O2
, o Anemia due to abnormal Hgb -
cannot
carry oxygen
o
Vaso-occlusive events: sickle cells – sticky/fragile, clump together, occlude blood vessels; leads
to anoxia, ischemia, infarctions, end-organ damage can cause
pulmonary embolism ,
heart attack stroke
,
Clinical Manifestations
- Severity varies
- Periodic crises -
usually recovers
Precipitating Conditions (triggers)
- Hypoxia states, high altitude, dehydration, venous stasis, physical/emotional stress, anesthesia, infections,
low or high environmental or body temperatures
Medical/Surgical
- Pain management, oxygen, hydration, body positioning, prevent infection, blood transfusion, hydroxyurea
prevent constipation prevent
clumping
if
having severe symptoms or Hgb <
(reduces sickling)
- Teaching – to prevent crisis, manage drugs (women BCP with hydroxyurea), hereditary aspects, emotional
and supportive care
Nursing Diagnosis
- Acute pain, ineffective peripheral tissue perfusion, deficient fluid volume, activity intolerance, decreased
cardiac tissue perfusion, infection, ineffective cerebral tissue perfusion
Nursing Interventions
- Administer oxygen, administer pain medications, do not bend the client to allow for non-constricted blood
flow, check circulation of peripheral extremities, assess for central claudication, keep patient warm, admin
IVF or PO fluids N OT HOT
Anemia
Diagnostics Review
- Complete blood count with differential and RBC indices -
indicates largevs small blood cells
- Reticulocyte count -
how fast RBC are made by bone marrow
- Iron studies
- Coombs test antibodiesonthe surface
-
o a
- Bone marrow aspiration ~
determines if
something in bone marrow is
affecting RBC production
Medical Surgical
- Determine underlying cause
- Iron deficiency
o Mild: oral ferrous sulfate (iron) – vitamin C enhances absorption, take between meals, Hgb
should rise 2g in 4 weeks give with food-hard on stomach
o Severe: IV or IM iron dextran (Z track method)
- Vitamin B – diet, oral supplements, injections
- Blood loss – stop bleeding, transfusions
- Immune – immunosuppressive therapies, transfusions, BM transplant
high risk for infection
- Chronic disease – chronic kidney disease/cancers – erythropoietin (Procrit/epogen) injections
Assessment
- Gather history, diet, meds, menstrual flow, symptoms
, - Assess for fatigue, pallor, cyanosis, jaundice, bleeding, dry skin, mouth ulcers or fissures, smooth tongue
hemolytic anemia
(glossitis), lymph nodes, respiratory rate and rhythm, tachycardia, VS, O2 sat, review labs
infection or cancer
Nursing Diagnosis
- Activity intolerance, fatigue, altered tissue perfusion, impaired gas exchange, anxiety, impaired comfort, risk
for bleeding, risk for injury, impaired memory
Interdisciplinary Interventions
- Oxygen, oral or IM iron, supplements (Vit B, folic acid), Epoetin (Procrit) SQ weekly, RBC transfusion (Hgb
< 7.5)
Nursing Interventions
- Energy conservation, supportive care, correction of the anemia (diet changes), teaching self-care
Anemia Labs
Test Significance Ref. Range
Red blood cell (RBC) F: 4.2-5.4
Decreased: anemia or bleeding
M: 4.7-6.1
High: severely dehydrated or PV
Hemoglobin (Hgb) F: 12-16
Decreased: anemia, bleeding, fluid
overload M: 14-18
High: Severely dehydrated or PV
Hematocrit (Hct) - % of packed RBCs F: 37-47% Decreased: anemia, bleeding, or fluid
in total blood volume, use to M: 42-52% overload
determine if Hgb is high or low due to High: severely dehydrated or PV
hydration status
RBC indices – relate measurements of RBC, hematocrit, and hemoglobin; provides information on types of anemia
Primary Polycythemia Vera
Pathophysiology
- Loss of cellular regulation; proliferation of RBCs, WBC, Platelets
- Blood hyper viscous (thick) blood
o Poor oxygenation of tissues; cell destruction
poor circulation
o RBC > 16.5g/dL, Hgb > 18g/dL, Hct > 55%, high K, high uric acid (2.7-8.5mg/dL)
Clinical Manifestations
- Hypertension, headaches, dizziness, purple/gray color, itching, dyspnea
Complications (thick blood)
- Angina, claudication, thromboses, infarctions, MI, intracranial bleeds/CVA
Medical
- Repeated apheresis 2-5 times a week, medications, Hydroxyurea, anticoagulants -
thin blood so it can circulate
normally
Nursing Interventions
- Prevent clots, hydration (3L/day), stop smoking, promote venous return, elevate feet, avoid tight clothing,
will cause venostasis
support hose, thrombocytopenia precautions, use electric razor and soft tissue, neutropenic precautions
because they are on
anticoagulants
- Contact doctor first sign of infection or occlusion
- Exercise slowly – stop activity at first sign of chest pain or dizziness
- Interdisciplinary – anticoagulants, chemotherapy -
to thin down or stop overproduction
Nursing Diagnosis
- Ineffective protection, risk for bleeding, risk for ineffective tissue perfusion
Hematologic Disorders: Concepts
Gas Exchange and Tissue Perfusion
- Blood (RBC) oxygen delivery system -
contain
hemoglobin
- RBC contain Hgb which exchanges oxygen and carbon dioxide at the cellular level
- Heme needs iron to transport oxygen -
- Four molecules of oxygen can attach to heme
- Globin carries carbon dioxide
- Any interruption of this process creates disease/disorder
RBC Disorders
Anemia
- Reduction of RBC, Hgb, and/or Hct
- Clinical sign – not a specific disease
- Classifications – blood loss, hemolytic, impaired RBC production lysis of the blood
Types of Anemia
Is
- Iron-deficiency (microcytic) – blood loss, poor nutrition
plod
mall
a
- Hemolytic – immune, mech, trauma, sickle cell
- Megaloblastic (macrocytic) – vitamin B12 (cobalamin) deficiency, pernicious anemic – lack intrinsic factor,
/largeblo
a
folic acid deficiency
- Aplastic anemia (bone marrow depression)
- Chronic disease anemias (ex: chronic renal failure) Kidney's can't produce erythropoietin
Symptoms
- Eyes – yellowing -
easiest
way for people of color
- Skin – paleness, coldness, yellowing
- Respiratory – shortness of breath
- Muscular – weakness
- Intestinal – changed stool color
- Central – fatigue, dizziness, fainting
- Blood vessels – low blood pressure , hypovolemia
- Heart – palpitations, rapid heart rate, chest pain, angina, heart attack.
- Spleen – enlargement
Sickle Cell Anemia (SCD)
Pathophysiology
- Genetic disorder of hemoglobin causing distortion of RBC shape (sickle) in response to decrease O2
, o Anemia due to abnormal Hgb -
cannot
carry oxygen
o
Vaso-occlusive events: sickle cells – sticky/fragile, clump together, occlude blood vessels; leads
to anoxia, ischemia, infarctions, end-organ damage can cause
pulmonary embolism ,
heart attack stroke
,
Clinical Manifestations
- Severity varies
- Periodic crises -
usually recovers
Precipitating Conditions (triggers)
- Hypoxia states, high altitude, dehydration, venous stasis, physical/emotional stress, anesthesia, infections,
low or high environmental or body temperatures
Medical/Surgical
- Pain management, oxygen, hydration, body positioning, prevent infection, blood transfusion, hydroxyurea
prevent constipation prevent
clumping
if
having severe symptoms or Hgb <
(reduces sickling)
- Teaching – to prevent crisis, manage drugs (women BCP with hydroxyurea), hereditary aspects, emotional
and supportive care
Nursing Diagnosis
- Acute pain, ineffective peripheral tissue perfusion, deficient fluid volume, activity intolerance, decreased
cardiac tissue perfusion, infection, ineffective cerebral tissue perfusion
Nursing Interventions
- Administer oxygen, administer pain medications, do not bend the client to allow for non-constricted blood
flow, check circulation of peripheral extremities, assess for central claudication, keep patient warm, admin
IVF or PO fluids N OT HOT
Anemia
Diagnostics Review
- Complete blood count with differential and RBC indices -
indicates largevs small blood cells
- Reticulocyte count -
how fast RBC are made by bone marrow
- Iron studies
- Coombs test antibodiesonthe surface
-
o a
- Bone marrow aspiration ~
determines if
something in bone marrow is
affecting RBC production
Medical Surgical
- Determine underlying cause
- Iron deficiency
o Mild: oral ferrous sulfate (iron) – vitamin C enhances absorption, take between meals, Hgb
should rise 2g in 4 weeks give with food-hard on stomach
o Severe: IV or IM iron dextran (Z track method)
- Vitamin B – diet, oral supplements, injections
- Blood loss – stop bleeding, transfusions
- Immune – immunosuppressive therapies, transfusions, BM transplant
high risk for infection
- Chronic disease – chronic kidney disease/cancers – erythropoietin (Procrit/epogen) injections
Assessment
- Gather history, diet, meds, menstrual flow, symptoms
, - Assess for fatigue, pallor, cyanosis, jaundice, bleeding, dry skin, mouth ulcers or fissures, smooth tongue
hemolytic anemia
(glossitis), lymph nodes, respiratory rate and rhythm, tachycardia, VS, O2 sat, review labs
infection or cancer
Nursing Diagnosis
- Activity intolerance, fatigue, altered tissue perfusion, impaired gas exchange, anxiety, impaired comfort, risk
for bleeding, risk for injury, impaired memory
Interdisciplinary Interventions
- Oxygen, oral or IM iron, supplements (Vit B, folic acid), Epoetin (Procrit) SQ weekly, RBC transfusion (Hgb
< 7.5)
Nursing Interventions
- Energy conservation, supportive care, correction of the anemia (diet changes), teaching self-care
Anemia Labs
Test Significance Ref. Range
Red blood cell (RBC) F: 4.2-5.4
Decreased: anemia or bleeding
M: 4.7-6.1
High: severely dehydrated or PV
Hemoglobin (Hgb) F: 12-16
Decreased: anemia, bleeding, fluid
overload M: 14-18
High: Severely dehydrated or PV
Hematocrit (Hct) - % of packed RBCs F: 37-47% Decreased: anemia, bleeding, or fluid
in total blood volume, use to M: 42-52% overload
determine if Hgb is high or low due to High: severely dehydrated or PV
hydration status
RBC indices – relate measurements of RBC, hematocrit, and hemoglobin; provides information on types of anemia
Primary Polycythemia Vera
Pathophysiology
- Loss of cellular regulation; proliferation of RBCs, WBC, Platelets
- Blood hyper viscous (thick) blood
o Poor oxygenation of tissues; cell destruction
poor circulation
o RBC > 16.5g/dL, Hgb > 18g/dL, Hct > 55%, high K, high uric acid (2.7-8.5mg/dL)
Clinical Manifestations
- Hypertension, headaches, dizziness, purple/gray color, itching, dyspnea
Complications (thick blood)
- Angina, claudication, thromboses, infarctions, MI, intracranial bleeds/CVA
Medical
- Repeated apheresis 2-5 times a week, medications, Hydroxyurea, anticoagulants -
thin blood so it can circulate
normally
Nursing Interventions
- Prevent clots, hydration (3L/day), stop smoking, promote venous return, elevate feet, avoid tight clothing,
will cause venostasis
support hose, thrombocytopenia precautions, use electric razor and soft tissue, neutropenic precautions
because they are on
anticoagulants
- Contact doctor first sign of infection or occlusion
- Exercise slowly – stop activity at first sign of chest pain or dizziness
- Interdisciplinary – anticoagulants, chemotherapy -
to thin down or stop overproduction
Nursing Diagnosis
- Ineffective protection, risk for bleeding, risk for ineffective tissue perfusion
