Presentation Transcript

1. Assessment and Management of Patients With Hematologic Disorders

2. Hematologic System • The blood and the blood forming sites, including the bone marrow and
the reticuloendothelial system • Blood • Plasma (fluid portion of blood -55%) • Blood cells •
Hematopoiesis • The body replenishes its supply of blood cells • Primary site is bone marrow
3. Blood Cells • Erythrocyte: RBC • Leukocyte: WBC • Neutrophil • Monocyte • Eosinophil •
Basophil • Lymphocyte: T lymphocyte and B lymphocyte • Thrombocyte: platelet
4. Hematologic Studies • CBC • Peripheral smear • Bone marrow aspiration and biopsy
5. Blood Smear
6. Hemostasis
7. Polycythemia • Increased volume of erythrocytes (HCT >55%M/>50%F) • Primary •
Proliferative disorder - bone marrow is hypercellular • Patients at increased risk for
thromboses and bleeding (due to platelet dysfunction) • Managed usually via phlebotomy •
Secondary • Caused by excessive prodcution of erythropoietin • May be d/t hypoxic stimulus,
neoplasms (epo produced by malignancy)
8. Polycythemia • Manifestations • Hypervolemia and hyperviscosity • Ruddy complexion •
Hypertension • Headache • Dizziness, tinnitus • Signs of embolization • Management •
Phlebotomy - reduce HCT to 45% or less • Hydration • Avoid iron supplementation
9. Neutropenia • Absolute neutrophil count • WBC x %neutrophils • <1500/ ul (severe if <500/ul)
• Predisposed to infection • Neutropenia may mask clasic signs of infection - e.g., even low
grade fever may be of great significance • May progress rapidly to sepsis • Nursing and
collaborative care • Determine cause • Identify offending organism • Institute prophylactic or
therapeutic antibiotic • Administer hematopoetic growth factors • Institute protective
environmental measures • See table 31-22 and 31-23
10. Leukemia • Hematopoietic malignancy with unregulated proliferation of leukocytes • Affect
blood and blood-forming tissues of bone marrow, lymph system, and spleen • Types (see
table 31-24) • Acute myeloid leukemia • Chronic myeloid leukemia • Acute lymphocytic
leukemia • Chronic lymphocytic leukemia
11. Acute Myeloid Leukemia (AML) • Defect in the stem cells that differentiate into all myeloid
cells: monocytes, granulocytes, erythrocytes, and platelets • Most common leukemia in adults
• Affects all ages with peak incidence at age 60 • Abrupt onset • Manifestations: fever and
infection, weakness and fatigue, bleeding tendencies, pain from enlarged liver or spleen,
hyperplasia of gums, and bone pain • Treatment is aggressive chemotherapy: induction
therapy, BMT, and PBSCT
12. Chronic Myeloid Leukemia (CML) • Mutation in myeloid stem cell with uncontrolled
proliferation of cells: excessive neoplastic granulocyts • Stages: chronic phase, blast crisis •
Uncommon in people under 20; incidence increases with age; mean age is 55 to 60 years •
Life expectancy is 3 to 5 years • Manifestations (initially may be asymptomatic): malaise;
anorexia; weight loss; sternal pain; enlarged, tender spleen; enlarged liver • Treatment:
chemotherapy, BMT, and PBSCT, radiation
13. Acute Lymphocytic Leukemia • Uncontrolled proliferation of immature cells from lymphoid
stem cell • Most common in young children • Prognosis is good for children; 80% event-free
after 5 years, but survival drops with increased age • Manifestations: fever, bleeding, anemia,
mouth sores, symptoms of meningeal involvement and liver, spleen, and bone marrow pain •
Treatment: chemotherapy, BMT or PBSCT
14. Chronic Lymphocytic Leukemia • Malignant B lymphocytes, most of which are mature, may
escape apoptosis, resulting in excessive accumulation of cells • Most common form of chronic
leukemia in adults • More common in older adults and affects men more often • Survival varies
from 2 to 14 years depending upon stage
15. Chronic Lymphocytic Leukemia (cont.) • Manifestations: lymphadenopathy, fatigue,
anorexia, hepatomegaly, splenomegaly; in later stages, anemias and thrombocytopenia;; “B
symptoms” include fever, night sweats, and weight loss • Treatment: early stage may require
no treatment, chemotherapy,radiation
16. Chemotherapy • Induction therapy • Nursing implications • Intensification therapy •
Consolidation therapy • Maintenance therapy
17. Nursing Process—Assessment of the Patient With Leukemia • Health history • Assess for
symptoms of leukemia and complications of anemia, infection, and bleeding • Weakness and
fatigue • See table 31-27 • Laboratory tests • Leukocyte count, ANC, hematocrit, platelets,
electrolytes, and cultures reports
18. Nursing Process—Diagnosis of the Patient With Leukemia • Risk for bleeding • Risk for
impaired skin integrity • Impaired gas exchange • Impaired mucous membrane • Imbalanced
nutrition • Acute pain • Fatigue and activity intolerance • Risk for infection
19. Nursing Process—Diagnosis of the Patient With Leukemia (cont.) • Risk for excess fluid
volume • Diarrhea • Risk for deficient fluid volume • Self-care deficit • Anxiety • Disturbed body
image • Potential for spiritual distress • Grieving diagnoses • Deficient knowledge
20. Collaborative Problems/Potential Complications • Infection • Bleeding • Renal dysfunction
• Tumor lysis syndrome • Nutritional depletion • Mucositis • Depression
21. Nursing Process—Planning the Care of the Patient With Leukemia • Major goals include
absence of complications, attainment and maintenance of adequate nutrition, activity
tolerance, ability for self-care and to cope with the diagnosis and prognosis, positive body
image, and an understanding of the disease process and its treatment
22. Interventions • Reduce risk of infection • Reduce risk of bleeding • Mucositis • Frequent,
gentle oral hygiene • Soft toothbrush, or if counts are low, sponge-tipped applicators • Rinse
only with NS, NS and baking soda, or prescribed solutions • Perineal and rectal care
23. Improving Nutrition • Provide oral care before and after meals • Administer analgesics
before meals • Provide appropriate treatment of nausea • Provide small, frequent feedings
with soft foods that are moderate in temperature • Provide a low-microbial diet • Provide
nutritional supplements
24. Lymphoma • Neoplasm originating in the bone marrow and lymphatic structures resulting in
the proliferation of lymphocytes • Hodgkin’s lymphoma • Non-Hodgkin’s lymphoma
25. Hodgkin’s Disease • Unicentric origin • Reed–Sternberg cell • Suspected viral etiology (EBV);
familial pattern; incidence occurs in early 20s and again after age 50 • Excellent cure rate with
treatment • Manifestations: painless lymph node enlargement; pruritus; B symptoms : fever,
night sweats, and weight loss • Treatment is determined by stage of the disease and may
include chemotherapy and/or radiation therapy
26. Non-Hodgkin's Lymphoma (NHL) • Lymphoid tissues become infiltrated with malignant cells
that spread unpredictably; localized disease is rare • Incidence increases with age; the
average age of onset is 50 to 60 • Prognosis varies with the type of NHL • Diagnosed via
lymph node biopsy and imaging • Treatment is determined by type and stage of disease and
may include interferon, chemotherapy, and/or radiation therapy
27. Multiple Myeloma • Malignant disease of plasma cells in the bone marrow with destruction of
bone • M protein and Bence-Jones protein • Median survival is 3 to 5 years; there is no cure •
Manifestations: insidious onset; bone pain, osteoporosis, fractures, elevated serum protein
hypercalcemia, renal failure, symptoms of anemia, fatigue, weakness, increased serum
 viscosity, and increased risk for bleeding and infection • Treatment may include
chemotherapy, corticosteroids, stem cell transplant, and biphosphonates
28. Multiple Myeloma • Nursing care is relates to bone involvement and sequelae from bone
breakdown • Hypercalcemia • Fractures • Pain • Infection
29. Bleeding Disorders • Thrombocytopenia • Idiopathic thrombocytopenia purpura (ITP) •
Hemophilia • Acquired coagulation disorders: liver disease, anticoagulants, and vitamin K
deficiency • Disseminated intravascular coagulation (DIC) • Bleeding precautions • See
Nursing care plan 31-2, table 31-15
30. Hemophilia • Inherited bleeding disorder, results in deficiency of factor VIII or IX; varying
degrees of disease • Manifested by hemorrhage into various body parts • Medical
management includes FFP transfusion, recombinant clotting factors, desmopressin (DDAVP) •
Nursing management: control bleeding, patient education aimed at prevention of bleeding
31. Disseminated Intravascular Coagulation • Not a disease but a sign of an underlying
disorder; bleeding/thrombotic disorder • Severity is variable; may be life-threatening • Triggers
may include sepsis, trauma, shock, cancer, abruptio placentae, toxins, and allergic reactions,
malignancies, liver disease • Altered hemostasis mechanism causes massive clotting in
microcirculation; as clotting factors are consumed and lost, bleeding occurs; symptoms are
related to tissue ischemia and bleeding
32. Disseminated Intravascular Coagulation • Manifestations include simultaneous bleeding
and thrombosis; • Pallor, petechiae, purpura, oozing, bleeding, hematomas, cyanosis, tissue
necrosis… • Lab tests - prolonged PT/PTT, elevated d dimer • See table 31-20 • Treatment:
treat underlying cause, correct tissue ischemia, replace fluids and electrolytes, maintain blood
pressure, replace coagulation factors, and use heparin
33. Heparin Induced Thrombocytopenia • Complication of heparin therapy • Higher risk with
prolonged use • Hallmark sign is decline in platelet count, usually after 4-14 days (usually
drops by 50% or more) • Patients at risk for bleeding; also for thrombosis (venous or arterial) •
Treatment includes cessation of heparin, institution of alternative anticoagulation; follow
platelet count
34. Review Heparin, Low Molecular Weight Heparin, and Warfarin therapies • Pharmacology
book
35. Nursing Process—Assessment of the Patient With DIC • Be aware of patients who are at
risk for DIC and assess for signs and symptoms of the condition • Assess for signs and
symptoms and progression of thrombi and bleeding
36. Nursing Process—Diagnosis of the Patient With DIC • Risk for fluid volume deficiency •
Risk for impaired skin integrity • Risk for imbalanced fluid volume • Ineffective tissue perfusion
• Death anxiety
37. Collaborative Problems/Potential Complications • Renal failure • Gangrene • Pulmonary
embolism or hemorrhage • Acute respiratory distress syndrome • Stroke
38. Nursing Process--Planning the Care of the Patient With DIC • Major goals include
maintenance of hemodynamic status, maintenance of intact skin and oral mucosa,
maintenance of fluid balance, maintenance of tissue perfusion, enhanced coping, and
absence of complications
39. Interventions • Assessment and interventions should target potential /actual sites of organ
damage • Monitor and assess carefully for bleeding and thrombosis • Avoid trauma and
procedures that increase the risk of bleeding, including activities that increase intracranial
pressure
40. Blood Transfusion Administration • Review patient history including history of transfusions
and transfusion reactions; note concurrent health problems and obtain baseline assessment
and VS • Perform patient teaching and obtain consent • Equipment: IV (19-20 gauge or
 greater for PRBCs), appropriate tubing, and normal saline solution • Procedure to identify
patient and blood product • Monitoring of patient and VS • Postprocedure care • Nursing
management of adverse reactions
41. Complicationssee table 31-33! • Febrile nonhemolytic reaction • Acute hemolytic reaction •
Allergic reaction (mild or severe) • Circulatory overload • Bacterial contamination •
Transfusion-related acute lung injury • Delayed hemolytic reaction • Disease acquisition •
Complications of long-term transfusion therapy
42. Alternative to blood transfusion • Growth factors • Erythropoietin • Granulocyte-Colony
Stimulating Factor • Granulocyte-Macrophage Colony Stimulating Factor • Thrombopoeitin
43. Peripheral Blood Stem Cell Tranplantation and Bone Marrow Tranplantation • Autologous
stem cell transplantation - uncommon • Donor tranplantation - marrow stem cells or bone
marrow from a donor are transfused • First, patient undergoes intense chemo or radiation to
ablate the patient’s own marrow • Success depends on tissue compatibility and the patient’s
tolerance of the immunosuppression • Nursing management is focused on prevention of
infection and early detection of complication