Exam 1

Ch. 32
Hematology- platelets (coagulation), RBC (Oxygen) , and WBC ( basophils, Neutrophils Eosinophils,
Monocyte, and Lymphocytes- Immune response)

Hematology Diagnostic
Start with a CBC and coagulation test
CBC- RBC count, Hgb, WBC, and platelets. Coagulation test will tell us PT and PTT
If CBC doesn’t give you what you need more to bone marrow biopsy or aspiration.
Bone marrow aspiration just looks at cells from bone marrow.
Bone Biopsy looks at cells and compensation bone marrow (ex: bone marrow not producing cells
correctly)
Adult takes from iliac crest
Prior to procedureeducate patient about what will happen. Aspiration/ biopsy are sterile procedure. Pt.
need to know we can’t numb or give them medication. Can give them meds for anxiety. Pt will feel sharp
pain, and when needle is advanced.
If you do an aspiration and biopsy do it in TWO DIFFERENT areas of the iliac crest.
After procedure apply pressure to area and put on a dressing. Pain usually subsides after procedure.
Two big complication post procedure: BLEEDING AND INFECTION.
Asses pt. pre-op to see if they have a bleeding issue, platelet and blood count.
Therapeutic approaches:
Splenectomy, stem cell, phlebotomy, apheresis
MOST COMMON- is blood transfusion

Blood donation:
Interview pt. before donation: have to be 18 yr., adequate vital signs and hemoglobin levels, no out of
country in several months.
Different method of blood donation:
1. Standard blood donation center ( American Red Cross)
2. Autologous Donate blood prior to having surgery. Common in Ortho surgery, so during sx.
You get your own blood back if needed.
3. Intraoperative blood Salvage take lost blood from pt. clean it and return it back to patient
**Autologous and intraoperative you are getting your own blood back**
When you are going with standard method of blood donation, the blood must be processed.
o Check for virus like Hep. And HIV
o Type the blood ABO and RH
o Know importance of blood being type. Example if you are A+ you will have different antigens
then someone B+ or AB+.

Blood transfusion:
Prior to blood transfusion ask history! SPECIFICALLY, Cardio, Pulmonary, and Integumentary
system.
Make sure you have an order. Double check that pt. has been crossed and typed
Verify you have a blood consent (Good entire hospital stay).
Have they had a blood transfusion before, did they have a reaction? Are they prego? (worried about Rh
factor)
Do an assessment concentrating on the 3 system? How heart and lung sounds? How skin look?
Educate the pt. Make sure they know before, during, and after.
Tell them S/S to look for: let me know if you start to feel funny, or if something new happens.
Make sure they have at least a 20 gauge IV! Blood to be check by 2 nurses
Nurse has to take vitals before start. NURSES STAYS IN ROOM FIRST 15 MIN. (look for reaction)
After 15 min., get another vitals. Repeat vitals every hour until blood is finished
Blood expires after 4 hours!
Pt. has heart failure hx. and you have to run blood slow. After you hit 4 hour mark, stop blood and toss.
Once blood has been received from blood bank it has to be started in 30 min! If you can’t start
within 30 min. send blood back to blood bank!

Complications during blood donation:

o Febrile Nonhemolytic Reaction- when has reaction to leukocytes WBC that remain in the blood.
Specifically, the antigens on the WBC!!!
Most common
S/S: Chills, fever, anxiety
o Acute Hemolytic Reaction- someone gets the wrong blood type!! Most dangerous it occurs
within sec only takes 10 mL.
S/S: Fever, chills, low back pain, chest pain and dyspnea. Symptoms can worsen-
hypotensive, bronchospasms, kidneys become effective.
o Allergic Reaction- don’t know why this happens. Giving Benadryl usually happens.
S/S: Itching and hives
Not so common:
o Transfusion associated circulatory overload (TACO):
S/S: Hypervolemia as a result of blood being transfused too fast. Usually significant
when pt has cardiac hx.
o Bacterial ContaminationRare, but can occur at any time in the processing of the blood
o Transfusion related lung injury
o Delayed Hemolytic Reaction happens within 14 days after transfusion
What happens if pt. has a reaction to blood transfusion?
o When they have reaction immediately STOP the blood transfusion/ saline and asses patient
vitals. Hang a new bag of saline and fresh tubing. Call the physician let them know what
happened. Also, notify the blood bank and send them the blood and tubing. FINALLY, get blood
and urine samples from pt. to find out why pt. had reaction.
o We can clean blood but its time consuming and expensive. Once pt. has reaction, we have to only
give them clean blood.
 Ch. 33
Erythrocyte disorders-ANEMIA
o Anemia common manifestations-pallor, fatigue, weakness, general feeling of malaise.
Intervention for all anemia’s:
o Managing FatigueLevel of fatigue they have? Can they still perform ADL’s. FATIGUE greatest
impact on the patient’s life.
o Maintain adequate nutrition certain nutrients lacking/malnutrition
 Inadequate intake of certain nutrients can cause anemia. And sometimes
certain anemias can affect adequate nutritional intake
o Activity IntoleranceMay occur with blood loss types of anemia
o Promote adherence with prescribed therapyDon’t just give instructions, determine how the
patient can incorporate the plan. Explain thoroughly, see how it fits their life so they will be
compliant!!
Iron deficiency anemia: MOST COMMON
o Inadequate intake of dietary iron or supply of iron to the bone marrow is insufficient.
o Men caused usually gastric issue. Ulcer IBD
o Women excessive menstruation
o General symptoms we talked about in addition to smooth red tongue, brittle spoon nails,
angular cheilosis (redness and cracking of mouth)
o Treatment: Iron supplements (Ferrous) REMEMBER Take on empty stomach for best
absorption. If it is causing GI problems take w/food just have to take iron supplements longer!
o Educate can turn poop a dark color and can cause constipation. DO NOT TAKE with antiacids or
dairy products!
o Educate on high Iron foods Liver, fortified cereals, spinach, beans, potatoes

***Any pt who has anemia- need to investigate the cause don’t assume!!!***

Aplastic Anemia: Usually asymptomatic until complications occur: A rare disease

caused by a decrease/damage to stem cells in the bone marrow and they can not produce blood cells.
(RBC and Platelets)
Lead to neutropenia and thrombocytopenia
Cause idiopathic or chemical/ toxin (paint Thinner)
Management: Stem cell transplant, Immunosuppressive meds., supportive therapy.

• Most symptoms you see are related to WBC and RBC, then platelets themselves
• CANT FIGURE OUT CAUSE MOST PATIENTS DIE OF INFECTION!!

Folic acid and Vitamin B12 anemia

Folic acid due to lack of folic acids STRICTLY dietary deficiency.
Usually seen in Alcoholics, some Prego women if their dumb asses aren’t taking supplements
Vitamin B12 Usually due to problem of absorption and less dietary. Pt. lack intrinsic factor which is
needed to absorb B12.
Pt. with vitamin B12 deficiency: can develop neurologic symptoms like parathesis. They develop
confusion and difficulty walking/balance.
 BIGGEST CONCERN WITH VITAMIN B12- safety/Fall risk
Treatment Give them what they are lacking. Folate- take supplements. Vit. B12 if its absorption
problem can’t take PO, so they need regular B12 injections.
EDUCATE medication regimen.
Nursing perspective: Look for pt. who are at risk. Like alcoholics and patients who had gastric sx.
B12 deficiency- regular neuro assessments.

Sickle Cell Disease

Genetic disease- when hemoglobin S is inherited from both parents (diagnosis childhood/shorter
lifespan)
Sickle blood cells can not travel properly through vessels and can cause clots!
What can cause RBC to sickle? Dehydration, stress, illness, high altitude (hypoxia), cold temps.
Manifestation: anemia (b/c sickle cells die quicker), thrombi formation, hypoxia, ischemia, high risk for
infections! Manifestation usually only happen in exacerbation
o Acute Vaso-occlusive crisis most common- cz by hypoxia, cold or dehydration. Presenting in
SEVERE PAIN!
*Trapping of RBC’s in the circulation causing hypoxia and ischemia.
o Aplastic Crisisbody kills off all blood cells and you get a rapid drop in hemoglobin.
*Rapid drop in HGB level as a result of the human parvovirus
o Sequestration CrisisOrgan damage as a result of pooling of sickled cells. Occurs typically in
spleen for kids and adults it the LIVER, unless they still have a spleen it will go there!!!
o Other manifestations of sickle cell anemia
 Acute chest syndrome – fever, respiratory distress, and lung infiltrates
 Pulmonary HTN
 Stroke and Reproductive problems

Spleen affected for kids liver affected in adults, if they don’t have spleen
B/c spleen does a lot for hematology system
Stem cell transplants are possible and can help cure the patient but not everyone meets the criteria.
Treatments: Hydroxyurea- reduces the formation of sickle cells and decrease crisis. TAKE ON REGULAR
bases. PROBLEM can suppress WBC, so monitor! FOLIC ACID- to help with anemia. Keep patient
hydrated and well oxygenated
Transfusion therapy Give RBC during a crisis Give supportive care for PAIN etc…OPIOIDS
NI: make sure pt. knows what causes crisis. Manage fatigue and infection, help patient cope with long
term disease. Monitor and manage complications.

Leukocyte Disorders
Neutropenia neutrophils being destroyed
 No manifestations until count is so low and signs of infection occur. FIRST SIGN FEVER
o A low neutrophil count (less than 2000/mm3)
o Medical management depends on the cause
o Nursing management is crucial, b/c they can die from result of infection!
 o Neutropenia precaution: Reverse isolation- everyone comes in room must wear
a mask.
o No fresh flowers, fruit, or vegetables!!!!!!!!! B/c of bugs, pesticides and
organism living on the food NOTHING UNCOOKED
o No sick visitors and WASH YO HANDS!!!!!!

Platelet disorders- bleeding disorders

When normal hemostatic mechanisms fail to work it can lead to bleeding or clotting issues
o Bleeding can occur as a result of trauma or spontaneously
o Platelet or coagulation factor issues can cause bleeding anywhere
o Vascular issues can cause localized bleeding
o Bone marrow may secrete more platelets
 Manifestations: Local or internal bleeding or petechiae
 Management includes treating the cause and education
 Pt. that have platelet disorders, Optimum level of platelet is 30,000 or greater
 Normal platelet level 150,000-400,000
Thrombocytopenia: caused by various factors
 Manifestations – Depends on the platelet level- optimum level 30,000 of someone has platelet
disorder. Manifestation happen when in drops lower!
o Platelets >50,000 = typically no bleeding
o Platelets <20,000 = Petechiae and mild to major bleeding
o Platelets <5000 = Spontaneous, potentially fatal, bleeding
 Management: Treat the cause/underlying disease- if its meds stop the meds
Education about bleeding risk
Immune Thrombocytopenic Purpura (ITP)- common in women and children
Autoimmune disorder that destroys the platelet
Manifestation: vary depending on platelet count. USUALLY FOUND ON ACCIDENT
S/S: easy bruising and petechia, movere severe cases has GI & pulmonary bleeding!!!
Medical management: GOAL maintain “SAFE” platelet count (30,000)
• We can transfuse platelets to these patients.
• Don’t transfuse platelets just on platelet count!!! Base it on platelet count and severity of
patients bleeding. (B/c body could just turn around and destroy them)
• MEDS: Some can take immune suppressants and steroids to help lower their risk of destroying
platelets. On steroids short term.
• No contact sports, soft brush teeth, safety razors, avoid aspirin and bleeding meds.
Hemophilia A and B inherited bleeding disorder
Deficiency of factor VIII or IX (CLOTTING FACTOR)
Most common in Men, b/c X chromosome mostly diagnosed in children
o Manifestation: spontaneous hemorrhages occur (usually in joints) but also mucus membranes
and GI tract.
Medical management: ONLY DO WHEN THEY ARE ACTIVELY BLEEDING! Give them the factor they are
lacking
 o Pt that has known hemophilia, can take the factor they are lacking prophylactically. BUT THE
BODY CAN DEVELOP ANTIBODIES ON THIS FACTOR over a period of time. And when you are
badly bleeding the factor never works for you!!! DISCUSS their pro/cons!
o Meds: Analgesic for joint pain
o During active bleeding give cold packs and analgesic
Between bleedings can use warm packs to help with stiffness

Von Willebrand DiseaseA common bleeding disorders that affects males and
females
A dominant genetic disease A deficiency of von Willebrand factor
Manifestations: mucosal bleeding
Management: Replace missing factor @ time of bleeding/ prophylactically
DESMOPRESSIN can be used to prevent bleeding
**REMEMBERHemo. is joint bleeding and VON W. is mucosal bleeding**

Disseminated Intravascular Coagulation- sign of underlying condition such as

SEPSIS or MALIGNANCY
Patho: inflammation response trigger coagulation, multiple thrombi are formed. RESULTS tissue
ischemia/bleeding
Manifestation: initially no manifestations except LOW PLT count, the signs of organ dysfunction and
hemorrhage
Mortality rate can exceed 80% in patient with severe DIC
NI: identify patients at risk & monitor labs very closely! PRAY. TREAT the underling cause (sepsis,
electrolyte imbalance), give them back what they are lacking (platelets and oxygen)
Remember: LOW platelet and fibrinogen count
HIGH: PT,PTT,TT,FDP, and D-dimer
Ch.15
Cancer Epidemiology- 2nd leading cause of death in the US (lung, breast, colorectal)

#1 risk factor for cancer Is tobacco

Cancer prevention:
 Primary- vaccinations , stop smoking
 Focused on reducing risks of the disease
 Secondary- mammogram, pap smears, colonoscopy, self checks. Check body to see if developing
any of these
 Focused on screening and early detection
  Tertiary- after being diagnosed- monitoring and preventing relapse. Lifestyle changes after
diagnosis, rehab
 Focused on monitoring for and preventing relapse

Cancer diagnosis: patients with suspected cancer undergo extensive testing to determine presence
and extent of cancer, metastasis and where, function of body tissues.
**Cancer/Tumors are graded 1-4. *know higher the number the worst/aggressive the cancer is!!!**
Staged TMN system:
T looks at tumor and its size
N looks at lymph nodes and see if they are affected
M- looks at metastasis
Cancer prevention: Goals for treatment of cancer include cure, control, or palliation
Surgery- most frequently used can be primary, prophylactic, palliative, or reconstructive
Radiation- can be used along with surgery. (can be used before sx. To shrink tumor)
Chemotherapy: can be used w/sx. Administer of anti-neoplastic meds. To destroy cancer cells
Radiation Toxicity and Nursing Management- usually localized
Common in skin, GI tract lining, and bone marrow
Common toxicities: Skin and hair, stomatitis and mucositis, GI issues, systemic
External radiation main focus asses skin. b/c of break down
Internal radiation- 2 types insertion of radioactive implants and seed implants
For internal implant--Do radiation safety make sure you have signs on door. Limit contact with pt. less
than 30 min, and stay 6 feet away when possible, private room. This is for visitors and nurses! NO
PREGO WOMEN and NO children can come in contact.
Seed implants- let out a small amount of radiation!
Admin of chemo meds- classified according to potential
Non-vesicants: cause little to no irritation to blood vessels
Inflammation: cause some inflammation of vessels and surrounding tissues, but usually not permanent.
Vesicants: MOST CHEMO MEDS! Causes vessel inflammation, tissue damage, and possible necrosis
So prevention and management of extravasation are key: This is what occurs when vesicant med has
leaked into the tissue.
If this happens: 1. STOP INFUSION 2. DO NOT REMOVE CATH. 3. Grab a syringe and pull back in meds
you can get out of skin/cath. 4. Skin maker and circle the area to monitor 5. CALL PHYSICAN
Most common toxicity is GI issues (N/V/ stomatitis and mucositis)
Nursing management: assessing/ managing the effects of chemo. Asses F+E, regular labs and blood
checks. Nutritional and fluid loss. CHECK PATIENCY OF CENTRAL LINES
Treat pain, promote nutrition, address sexuality changes, check blood count WBC THIS IS LEADING CZ OF
DEATH
Oncological Emergencies
1. superior Vena cava syndrome cz by compression of superior vena cava by a tumor. Cause redness
and swelling of everything from upper chest and up! (JVD, facial edema)
2. Spinal cord compression Tumor growing in bone that is compressing the spinal cord.
3. Hypercalcemia most common in bone cancers or hematologic cancer that affect the bone.
4. Acute tumor lysis syndrome Rapidly occurring electrolyte changes due to the destruction of large
tumors.
Ch. 34—more about stupid ass cancer
Leukemia- blood cancer persistent growth of WBC CAUSE UNKOWN
Common feature is an unregulated growth of leukocytes in the bone marrow

Risk factors: exposure to radiation and chemicals, viral infections

Two classifications:
o Acute VS. Chronic: Acute- abrupt onset and progress quickly WBC are immature and are called
BLAST CELLS chronic- longer to develop and progresses slowly. Leukocytes are fully mature.
o Lymphoid vs Myeloid- Myeloid- effects all cells EXCEPT lymphocytes
Lymphoid- effects only lymphocytes
TYPES OF LEUKEMIA

Acute Myeloid Chronic myeloid Acute lymphocytic Chronic Lymphocytic

leukemia (AML) leukemia (CML) leukemia (ALL) leukemia (CLL)
Defect in stem cells Mutation in myeloid Uncontrol growth of Caused by a malignant
that produce myeloid cells, producing large immature lymphocytes clone of B lymphocytes
cells. amount of blast cells. ACUTE immature WBC Large accumulation of
fully matured cells
Collect in the lungs and
brain

45 yrs & over CML results from a YOUNG CHILDREN A common malignancy
=common. The chromosomal of older adults, avg age
younger the better translocation VERY RESPONSIVE to 70’s
survival. Overall goal BCR-ABL gene tx. Some familial
remission Bottom of preposition and
chromosome swap Although these pt. are Vietnam war
RARE IN CHILDREN, at high risk of getting Autoimmune
usually 65 older another cancer (OVER complications are
50) common
Manifestation: Manifestation: widely Manifestations: caused Manifestations:
Develop with out vary. by overgrowth of Asymptomatic- find it
warning result from Asymptomatic-25% immature cells in bone on accident
decrease production of Vague- marrow OR the cells ENLARGE lymph nodes
blood cells. fatigue/weakness infiltration other “b” symptoms
Fever/ weakness to INCREEAES WBC organs!!! (spleen, liver,
bruise and bleeding Enlarge liver & spleen bone) s/s headache,
Patients can also have frequent V, confusion
large liver and spleen
Diagnoses: CBC, bone Management: ONLY LEUKEMIA LIKES to hang out in
marrow biopsy- BEST medication called WHERE CELLS INVADE liver and spleen
TEST! HALLMARK tyrosine kinase CNS!!!!
excess of BLAST CELLS inhibitors is primary tx. WATCH FOR
Imatinib mesylate INFECITION
(Gleevec)-stop growth Goal: obtain complete Watch and wait
2 stages of chemo: of excessive WBC. remission without approach for some
1. Induction Given at convential excess toxicity to the patients.
 therapy: dose watch for toxicity body. Treat by stage and
AGGRESSIVE TRY MEDS BEFORE TX based on genetic symptoms
admission. Aim STEM CELL markers & risk factors Whats pt. functional
is to kill all TRANSPLANT of patient: status?
cells. Nursing Interv. *Intrathecal Chemo
(complete 1 Treat like chronic dz. *Complex Chemo- PRIMARY meds are
round then let Educate pt, to follow schedule immunotherapeutic
pt count tx. Regimen *Corticosteroids antibody combined
return) Regular blood testing Once remission has with chemo drugs!!
2. Consolidation Side effects w been achieved:
therapy: after /meds(fatigue, itching, *Special genetic testing
induction headache) *Consolidation tx.
therapy, 1 *Watch blood levels
more round of
chemo is done. If CNS is affected
Stem cell transplant: intrathecal cath placed
meet all qualifications, and chemo injected
use radiation and into spinal space
chemo 1st.
Myelodysplastic syndrome (MDS)- usually seen in older adults
A group of disorders in which the myeloid stem cells in the bone marrow undergo dysplasia (cell changes
shape and develops abnormally.)
o Most commonly affecting the RBC’s
****MDS HAS POTENTIAL TO EVOLVE INTO AML**** their chances to
recover LOW
Manifestation: Vary, 80-90% will have anemia
Diagnosis: CBC and bone marrow biopsy
INFECTION RATES ARE HIGH
IRON OVERLOAD IS ONE OF THE BIGGST ISSUES for these patients!
Requires frequent chelation therapy- give pt. medication that binds to access Iron in body. Typically
long term tx. That causes GI issue like diarrhea and cramping. Take these meds on empty stomach.
Overtime increase dosage!!! REMEMBER is excreted through urine so MONITOR THEIR KIDNEYS!!
Nursing Management focused on:
o Extensive education about infection risk, monitoring of labs
o The chronic nature of the disease and risk of progression to AML
o Education about chelation therapy
***Most treatment is symptom management- treated like a chronic illness, chemo hasn’t been
shown to be affected**

Polycythemia Vera- a proliferative disorder of the myeloid cells, RBCs are

predominant
Over time spleen enlarges and starts to participate in erythropoiesis.
Diagnosis: Elevated HGB and Presence of a mutated gene
Manifestations result from: Increased blood volume Increased blood viscosity
Complications: Thrombosis and bleeding, red compaction, pt. complain of dyspnea, puritis or itching.
(biggest things pt. complain of)
Treatment: (rest of life) therapy based on patient and risk of thrombi, THERAPEUTIC PHELBOTOMY is
primary treatment!! Make sure pt.are active and wear TED hose. (reduce risk for clots)
P.t have to go on a weekly/biweekly basis to thin blood, remove blood about 500mL!!!!
Goal is to keep the HCT less than 45!! Pt. usually has it over 60!
If pt have cardiac issue and polycythemia= big risk for MI

FOR GOD SAKE MANAGE FATIGUE!!

TX: manage pruitisus- itching/burning gets worse when water touches it. Only thing that helps is SSRI
and UV therapy

Hodgkin- HIGH CURE RATE

R/F: genetics (1st degree) MEN high risk, age 15-35 and after 60, virus Epstein BARR (MONO, Herpes)
Management: Goal is to cure, tx based on stage all pt. get a small dose of CHEMO and radiation to
affected lymph nodes. SECONDAY MALIGNANCES ARE COMMMON

Non-Hodgkin- DOESN’T STAY IN LYMPH NODE low cure rate AVERAGE AGE OVER 60
Risk factors: immunosuppression, autoimmune disorders, prior cancer or prior organ transplant
Treatment: usually consist of chemo, radiation, and intrathecal chemo (if in CNS)

Multiple Myeloma malignant disorder of plasma cells (fully mature B lymphocyte)

Average age 70 ONLY RISK FACTOR IS VIETNAM WAR
Multiple myeloma likes to INVADE THE BONES!!! When entered they active cells and make lytic
lesions (circle holes in bone)
Normal plasma cells are mature B lymphocytes that release antibodies that help you fight infection
In this case the cells are malignant, so these cells produce non-function antibodies called M proteins!
THERE IS NO CURE
Tx: immunomodulatory drugs, protease inhibitors, corticosteroids (help with bone pain)
Managing Complications: Radiation Therapy- can strengthen bones
Bisphosphonates- strengthen bones (used in osteoporosis a lot as well
PAIN MANAGEMENT, NO HEAVY LIFTING, SAFETY, PREVENT BONE FRACTURES! Weight bearing
exercise
Chapter 35
Innate/Natural what your born with 1st line of defense
Wbc, inflamm response and physical and chemical barriers
Adaptive/acquired developed after birth
Have a specific response to a foreign antigen (pathogen)
Can be from immunizations, or exposure to the disease
Inflammatory response: 1st response when body gets injured
Vasodilation, increase cap. Permeability (vessels leak), and leukocytes come to site, systemic response
Cellular/ tissue level you see: redness, heat, swelling, pain, tenderness
Two types of immunity:
 Humoral immunity- immunity by B-cells that produce antibodies to attack
 Cellular immunity- T-cells either directly attack or produce CYTOKINES to directly attack
Chapter 36