management and assessment of patient with hemaetologic desorder

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 33
Assessment and Management
of Patients With Hematologic
Disorders

Question
Is the following statement True or False?
Hematopoiesis is the complex process of the formation and
maturation of blood cells.

Answer
True
Hematopoiesis is the complex process of the formation and
maturation of blood cells.

Hematologic System
• The blood and the blood forming sites, including the bone
marrow and the reticuloendothelial system
• Blood
– Plasma
– Blood cells
• Hematopoiesis

Blood Cells
• Erythrocyte—RBC
• Leukocyte—WBC
– Neutrophil
– Monocyte
– Eosinophil
– Basophil
– Lymphocyte—T lymphocyte and B lymphocyte
• Thrombocyte—platelet

Hematopoiesis

Hemostasis
Refer to fig. 33-3

Question
What type of anemia results from red blood cell
destruction?
A.Bleeding
B.Hemolytic
C.Hypoproliferative
D.None of the above

Answer
B
Bleeding results from red blood loss. Hemolytic anemia
results from red blood cell destruction. Hypoproliferative
anemia results from defective red blood cell production.

Anemias
• Lower than normal hemoglobin and fewer than normal
circulating erythrocytes. A sign of an underlying disorder
• Hypoproliferative: defect in production of RBCs
– Due to iron, vitamin B12, or folate deficiency,
decreased erythropoietin production, cancer
• Hemolytic: excess destruction of RBCs
– Due to altered erythropoiesis, or other causes such
as hypersplenism, drug-induced or autoimmune
processes, mechanical heart valves
• May also be due to blood loss

Manifestations
• Depend upon the rapidity of the development of the
anemia, duration of the anemia, metabolic requirements
of the patient, concurrent problems, and concomitant
features
• Fatigue, weakness, malaise
• Pallor or jaundice
• Cardiac and respiratory symptoms
• Tongue changes
• Nail changes
• Angular cheilosis
• Pica

Medical Management
• Correct or control the cause
• Transfusion of packed RBCs
• Treatment specific to the type of anemia
– Dietary therapy
– Iron or vitamin supplementation—iron, folate, B12
– Transfusions
– Immunosuppressive therapy
– Other

Nursing Process: The Care of the Patient
with Anemia—Assessment
• Health history and physical exam
• Laboratory data
• Presence of symptoms and impact of those symptoms on
patient’s life; fatigue, weakness, malaise, pain
• Nutritional assessment
• Medications
• Cardiac and GI assessment
• Blood loss—menses, potential GI loss
• Neurologic assessment

with Anemia—Diagnoses
• Fatigue
• Altered nutrition
• Altered tissue perfusion
• Noncompliance with prescribed therapy

Collaborative Problems/Potential
Complications
• Heart failure
• Angina
• Paresthesias
• Confusion

with Anemia—Planning
• Major goals include decreased fatigue, attainment or
maintenance of adequate nutrition, maintenance of
adequate tissue perfusion, compliance with prescribed
therapy, and absence of complications.

Interventions
• Balance physical activity, exercise, and rest.
• Maintain adequate nutrition.
• Patient education to promote compliance with
medications and nutrition.
• Monitor VS and pulse oximetry, provide supplemental
oxygen as needed.
• Monitor for potential complications.

Question
Leukocytosis refers to a decreased level of leukocytes in
the circulation.

Answer
False
Leukocytosis refers to an increased level of leukocytes in
the circulation. Leukopenia refers to a decreased level of
leukocytes in the circulation.

Leukemia
• Hematopoietic malignancy with unregulated proliferation
of leukocytes
• Types:
– Acute myeloid leukemia
– Chronic myeloid leukemia
– Acute lymphocytic leukemia
– Chronic lymphocytic leukemia

Acute Myeloid Leukemia (AML)
• Defect in stem cell that differentiate into all myeloid
cells: monocytes, granulocytes, erythrocytes, and
platelets
• Most common nonlymphocytic leukemia
• Affects all ages with peak incidence at age 60
• Prognosis is variable
• Manifestations: fever and infection, weakness and
fatigue, bleeding tendencies, pain from enlarged liver or
spleen, hyperplasia of gums, bone pain
• Treatment aggressive chemotherapy—induction therapy,
BMT or PBSCT

Chronic Myeloid Leukemia (CML)
• Mutation in myeloid stem cell with uncontrolled
proliferation of cells—Philadelphia chromosome
• Stages: chronic phase, transformational phase, blast
crisis
• Uncommon in people under 20, with increased incidence
with age. Mean age: 55–60
• Life expectancy of 3–5 years
• Manifestations: initially may be asymptomatic, malaise,
anorexia, weight loss, confusion or shortness of breath
due to leukostasis, enlarged tender spleen, or enlarged
liver
• Treatment: imatinib mestylate (Gleevec) blocks signals in
leukemic cells that express BCR-ABL protein;
chemotherapy, BMT or PBSCT

Acute Lymphocytic Leukemia
• Uncontrolled proliferation of immature cells from
lymphoid stem cell
• Most common in young children, boys more often than
girls
• Prognosis is good for children; 80% 5-year event-free
survival, but drops with increased age
• Manifestations: leukemic cell infiltration is more common
with this leukemia, with symptoms of meningeal
involvement and liver, spleen, and bone marrow pain
• Treatment: chemotherapy, imatinib mestylate (if
Philadelphia chromosome positive), BMT or PBSCT,
monoclonal antibody therapy

Chronic Lymphocytic Leukemia
• Malignant B lymphocytes, most of which are mature, may
escape apoptosis, resulting in excessive accumulation of
cells
• Most common form of leukemia
• More common in older adults, effects men more often
• Survival varies from 2 to 14 years depending upon stage
• Manifestations: lymphadenopathy, hepatomegaly,
splenomegaly; in later stages anemias and
thrombocytopenia; autoimmune complications with RES
destroying RBCs and platelets may occur, B symptoms
include fever, sweats, weight loss
• Treatment: early stage may require no treatment,
chemotherapy, monoclonal antibody therapy

with Leukemia—Assessment
• Health history
• Assess symptoms of leukemia, and for complications of
anemia, infection, and bleeding
– Weakness and fatigue
• Laboratory tests
– Leukocyte count, ANC, hematocrit, platelets,
electrolytes, culture reports

with Leukemia—Diagnoses
• Risk for bleeding
• Risk for impaired skin integrity
• Impaired gas exchange
• Impaired mucous membrane
• Imbalanced nutrition
• Acute pain
• Hyperthermia
• Fatigue and activity intolerance
• Impaired physical mobility

with Leukemia—Diagnoses
• 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

Complications
• Infection
• Bleeding
• Renal dysfunction
• Tumor lysis syndrome
• Nutritional depletion
• Mucositis
• Depression

with Leukemia- Planning
• Major goals may 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.

Interventions
• Interventions related to risk of infection and 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

Improving Nutrition
• Oral care before and after meals
• Administer analgesics before meals
• Appropriate treatment of nausea
• Small, frequent feedings
• Soft foods that are moderate in temperature
• Low-microbial diet
• Nutritional supplements

Lymphoma
• Neoplasm of lymph origin
• Hodgkin’s lymphoma
• Non-Hodgkin’s lymphoma

Hodgkin’s Disease
• Unicentric origin
• Reed–Sternberg cells
• Suspected viral etiology, familial pattern, incidence early
20s and again after age 50
• Excellent cure rate with treatment
• Manifestations: painless lymph node enlargement,
pruritis; B symptoms: fever, sweats, weight loss
• Treatment is determined by stage of the disease and may
include chemotherapy and/or radiation therapy

Non-Hodgkin's Lymphoma (NHL)
• Lymphoid tissues become infiltrated with malignant cells,
spread is unpredictable and localized disease is rare.
• Incidence increases with age, with average age being 50
to 60.
• Prognosis varies with type of NHL.
• Treatment is determined by type and stage of disease,
and may include interferon, chemotherapy, and/or
radiation therapy.

Question
What should any elderly patient be evaluated for whose
chief complaint is back pain and has an elevated total
protein level?
A.Anemia
B.Leukemia
C.Multiple myeloma
D.Non-Hodgkin’s lymphoma

Answer
C
Any elderly patient whose chief complaint is back pain and
has an elevated total protein level should be evaluated
for possible myeloma.

Multiple Myeloma
• Malignant disease of plasma cells in the bone marrow
with destruction of bone
• M protein and Bence–Jones protein
• Median survival 3 to 5 years, no cure
• Manifestations: bone pain, osteoporosis, fractures,
elevated serum protein hypocalcaemia, renal damage
renal failure, symptoms of anemia, fatigue, weakness,
increased serum viscosity, and increased risk for bleeding
and infection
• Treatment may include chemotherapy, corticosteroids,
radiation therapy, biphosphonates

Bleeding Disorders
• Primary thrombocythemia
• Thrombocytopenia
• Idiopathic thrombocytopenia purpura (ITP)
• Hemophilia
• Acquired coagulation disorders: liver disease,
anticoagulants, vitamin K deficiency
• Disseminated intravascular coagulation (DIC)
• Bleeding precautions

Question
Disseminated intravascular coagulation is not a disease but
a sign of an underlying condition.

Answer
True
Disseminated intravascular coagulation is not a disease but
a sign of an underlying condition.

DIC
• Not a disease but a sign of an underlying disorder.
• Severity is variable; may be life-threatening.
• Triggers may include sepsis, trauma, shock cancer
abrupto placenta, toxins, and allergic reactions.
• Altered hemostasis mechanism causes massive clotting in
microcirculation. As clotting factors are consumed,
bleeding occurs. Symptoms are related to tissue ischemia
and bleeding.
• Laboratory tests.
• Treatment: treat underlying cause, correct tissue
ischemia, replace fluids and electrolytes, maintain blood
pressure, replace coagulation factors, use heparin.

with DIC—Assessment
• Be aware of patient 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.

with DIC—Diagnoses
• Risk for fluid volume deficient
• Risk for impaired skin integrity
• Risk for imbalanced fluid volume
• Ineffective tissue perfusion
• Death anxiety

Complications
• Renal failure
• Gangrene
• Pulmonary embolism or hemorrhage
• Acute respiratory distress syndrome
• Stroke

with DIC—Planning
• Major goals may 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.

Interventions
• Assessment and interventions should target potential
sites of organ damage.
• Monitor and assess carefully
• Avoid trauma and procedures which increase risk of
bleeding, including activities which would increase
intracranial pressure.

Therapies for Blood Disorders
• Anticoagulant therapy
• Splenectomy
• Therapeutic apheresis
• Therapeutic phlebotomy
• Blood component therapy

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 (20-gauge or greater for PRBCs) and
appropriate tubing, normal saline solution
• Procedure to identify patient and blood product
• Monitoring of patient and VS
• Post procedure care
• Nursing management of adverse reactions

Complications
• Febrile nonhemolytic reaction
• Acute hemolytic reaction
• Allergic reaction
• Circulatory overload
• Bacterial contamination
• Transfusion related acute lung injury
• Delayed hemolytic reaction
• Disease acquisition
• Complications of long-term transfusion therapy

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