Hematologic Problems: Anemia, Sickle Cell Disease, Leukemia, and More

1. Chapter 42 Care of Patients with Hematologic Problems Marion Kreisel MSN, RN NU230 Adult Health 2 Fall 2011

2. Anemia • Reduction in either the number of red blood cells, the amount of hemoglobin, or the hematocrit • Clinical sign (not a specific disease); a manifestation of several abnormal conditions

3. Cardiovascular Effects of Anemia

4. Sickle Cell Disease • Genetic disorder resulting in chronic anemia, pain, disability, organ damage, increased risk for infection, and early death • Sickle cell disease state and sickle cell trait

5. Sickle Cell Anemia

6. Sickle Cell Disease: Pathophysiology • Main problem of the disorder is formation of abnormal hemoglobin chains

7. Sickle Cell Disease (Cont’d) • Response to local or systemic hypoxia • Sickle cell crisis • Etiology and genetic risk • Incidence/prevalence • Patient assessment • KNOW ALL SLIDES ABOUT SICKLE CELL

8. Sickle Cell Disease: Clinical Manifestations • Cardiovascular changes • Skin changes • Abdominal changes • Renal and urinary changes • Musculoskeletal changes • CNS changes

9. Sickle Cell Disease: Laboratory Assessment • Hemoglobin S (HbS) • Number of RBCs with permanent sickling • Hematocrit • Reticulocyte count • Total bilirubin • Total white blood cells • Imaging assessment

10. Sickle Cell Disease: Interventions • Pain is the most common problem: • Drug therapy—48 hours of IV analgesics • Oral hydration • Complementary and alternative therapies

11. Sickle Cell Interventions: Potential for Sepsis • Interventions include: • Prevention and early detection strategies • Drug therapy

12. Sickle Cell Disease Interventions: Potential for Multiple Organ Dysfunction • Interventions include: • Hydration • Oxygen therapy • Transfusion therapy

13. Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency Anemia • Most common type of inherited hemolytic anemia • Effect of exposure to some drugs, benzene and other toxins • Screening for this deficiency necessary before donating blood, because cells deficient in G6PD can be hazardous • Hydration • Osmotic diuretics • Transfusions

14. Iron Deficiency Anemia (Microcytic) • This common type of anemia can result from blood loss, poor intestinal absorption, or inadequate diet. • If mild—symptoms of weakness and pallor. • Evaluate adult patients for abnormal bleeding, especially from the GI tract. • Treatment—increasing oral intake of iron from food sources, oral iron supplements, or IM iron solutions.

15. Vitamin B12 Deficiency Anemia (Macrocytic) • Lack of vitamin B12 causes improper DNA synthesis of RBCs. • Poor intake of foods containing vitamin B12, small bowel resection, tapeworm, overgrowth of intestinal bacteria.

16. Pernicious Anemia • Anemia resulting from failure to absorb vitamin B12 • Caused by a deficiency of intrinsic factor • Pt will need B12 Vitamins for the rest of the patient’s life.

17. Folic Acid Deficiency Anemia • Manifestations similar to those of vitamin B12 deficiency, but nervous system functions remain normal • Common causes—poor nutrition, malabsorption, and drugs

18. Aplastic Anemia • Deficiency of circulating RBCs because of failure of the bone marrow to produce these cells • Injury to the pluripotent stem cell • Pancytopenia common • Treatment: • Blood transfusions • Immunosuppressive therapy • Splenectomy

19. Polycythemia Vera—Cancer of the RBCs • Disease with a sustained increase in blood hemoglobin or hematocrit • Massive production of red blood cells • Excessive leukocyte production • Excessive production of platelets • Treatment: • Phlebotomy • Hydration • Anticoagulants

20. Myelodysplastic Syndromes • Group of disorders caused by the formation of abnormal cells in the bone marrow • Blood and platelet transfusions • Erythropoietin • Chelation therapy • Drugs for iron overload—deferasirox and deferoxamine mesylate

21. Leukemia • Type of cancer with uncontrolled production of immature white blood cells in the bone marrow • Acute or chronic • Classified by cell type • Etiology and genetic risk • Incidence/prevalence • History • Assessment

22. Leukemia: Clinical Manifestations • Cardiovascular changes • Respiratory changes • Skin changes • Intestinal changes • Central nervous system changes • Miscellaneous changes • Fatigue Need to alternate periods of rest and activity

23. Leukemia: Laboratory Assessment • Decreased hemoglobin and hematocrit levels • Low platelet count • Abnormal white blood cell count; may be low, normal, or elevated but is usually quite high • Bone marrow aspiration and biopsy • Blood-clotting times • Chromosome analysis • Imaging assessment

24. Leukemia Interventions: Risk for Infections • Infection is a major cause of death in the patient with leukemia, and sepsis is a common complication. • Autocontamination • Cross-contamination • Drug therapy • Hematopoietic stem cell transplantation

25. Bone Marrow Transplantation

26. Hodgkin’s Lymphoma • Cancer that starts in a single lymph node or a single chain of nodes • Marker—Reed-Sternberg cell • Large, painless lymph node, usually in the neck, becomes painful when alcohol ingested; fever, drenching night sweats, and unexplained weight loss • Staging • Ann Arbor Staging Criteria

27. Hodgkin’s Lymphoma: Interventions • One of the most treatable types of cancer • External radiation • Chemotherapy • Combination radiation and chemotherapy

28. Non-Hodgkin’s Lymphoma • All lymphoid cancers that do not have the Reed-Sternberg cell • More than 12 types of non-Hodgkin’s lymphoma

29. Non-Hodgkin’s Lymphoma: Collaborative Care • Chemotherapy • Monoclonal antibodies • Localized radiation therapy • Radiolabeled antibodies • Hematopoietic stem cell transplantation • Vaccine therapy • Proteasome inhibitors

30. Multiple Myeloma • White blood cell cancer that involves a more mature lymphocyte called a plasma cell • Assessment • Interventions: • Chemotherapy • Autologous stem cell transplant • Analgesics • Alternative approaches for pain management • Bisphosphonates

31. Autoimmune Thrombocytopenic Purpura • Also called idiopathic thrombocytopenic purpura (ITP). • Total number of circulating platelets is greatly reduced even though production in the bone marrow is normal. • Patients make an antibody directed against the surface of their own platelets. • Normal count 150,000-400,000/mm3 • Treatment is reserved for patients whose count is below 50, 0/mm3, those who are bleeding, and those who are at high risk for bleeding. • Transfusions are not done regularly b/c pt destroys them as if they were his/her own and back to ground zero.

32. Thrombocytopenia

33. Hemophilia (Cont’d)

34. Hemophilia: Collaborative Care • Monitor for excessive bleeding from minor cuts, bruises, or abrasions. • Joint and muscle hemorrhages can lead to disabling long-term problems. • Tendency to bruise easily. • Prolonged and potentially fatal hemorrhage after surgery.

35. Transfusion Therapy • Pretransfusion responsibilities to prevent adverse transfusion reactions: • Verify prescription. • Test donor’s and recipient’s blood for compatibility. • Examine blood bag for identification. • Check expiration date. • Inspect blood for discoloration, gas bubbles, or cloudiness.

36. Transfusion Responsibilities • Provide patient education. • Assess vital signs. • Begin transfusion slowly, and stay with patient first 15 to 30 minutes. • Ask patient to report unusual sensations such as chills, shortness of breath, hives, or itching. • Administer blood product per protocol. • Assess for hyperkalemia.

37. Transfusions

38. Blood Grouping

39. Types of Transfusions • Red blood cell • Platelet • Plasma—fresh frozen plasma • Cryoprecipitate • Granulocyte (white cell)

40. Transfusion Reactions • Febrile transfusion reactions • Hemolytic transfusion reactions • Allergic transfusion reactions • Bacterial transfusion reactions • Circulatory overload • Transfusion-associated graft-versus-host disease

41. Autologous Blood Transfusion • Collection and infusion of patient’s own blood • Eliminates compatibility problems; reduces risk for transmission of bloodborne disease • Types: • Preoperative • Acute normovolemic hemodilution • Intraoperative autologous transfusion • Postoperative blood salvage

42. NCLEX TIME

43. Question 1 What type of transfusion reaction would the patient who received multiple transfusions over the course of his cancer treatment most likely experience? • Febrile • Bacterial • Allergic • Hemolytic

44. Question 2 How many people in the United States are estimated to have sickle cell disease? • 30,000 • 50,000 • 70,000 • 100,000

45. Question 3 A 23-year-old African-American male with a history of sickle cell disease had an emergent open reduction and internal fixation of his right femur after a car crash. What is the initial postoperative nursing priority? • Ensuring adequate IV hydration • Treating the patient’s pain • Titrating oxygen to an Spo2 >95% • Examining the surgical incision for signs and symptoms of infection

46. Question 4 A patient with glucose-6-phosphate dehydrogenase deficiency anemia is admitted with increasing fatigue, malaise, and jaundice. What priority question should the nurse ask the patient during the admission assessment? • “When was your last hemolytic anemia crisis?” • “How much fluid have you been able to drink in the past 24 hours?” • “Have you taken any over-the-counter medications in the past week?” • “Have you had a fever in the past 24 to 48 hours?”

47. Question 5 What is a priority nursing intervention in the care of an older patient with a history of diverticular disease and pernicious anemia? • Encouraging a diet high in vitamin B12 • Preventing falls • Turning the patient every 2 hours • Monitoring intake and output