blood disorders summary
TRANSCRIPT
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. , , , Nio C Noveno RN MAN MSN
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An autoimmune disorder Parietal cells are destroyed Atrophy of gastric mucosa
Postgastrectomy
Onset: 50-60 years old Northern European & African American women
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Insidious onset Symptoms appear
several months after Extreme muscle
weakness Sore tongue Numbness &
tingling in the extremities
Edema of the legs Ataxia Dizziness
DOB Headache Fever Blurred vision Tinnitus Jaundice with pallor Poor memory Irritability Loss of bladder &
bowel control
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1. Lack of intrinsic factor • Prevents the absorption of vitamin B12 in the lower
portion of the ileum• Anemia
2. Assessment 2 Pallor2 Beefy red tongue2 Positive Romberg test (loss of balance when eyes
closed) Gastric analysis: no intrinsic factor: (+) Schilling’s test: urine test for B12 absorption
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È lifelong injections of cyanocobalamin (Rubramin PC) or hydroxocabalamin crystalline (Hydroxi Cysti12) 100 μg IM/SC qd x 5-10 days 100 μg IM 2x/week x 1 month 100 μg IM monthly x lifetime
2. Folic acid or folate (Folvite)
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1. Increase dietary consumption of Green leafy vegetables Meat Fish Legumes Whole grains
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Most common type of anemia Affecting premature infants or low birth weight patients Adolescent girls Alcoholics Elderly
Results from the decrease iron in the blood
Diagnostics test Decreased RBC Low Hgb & HCT Low serum iron High total iron binding capacity
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1. Lack of adequate sources of dietary irona. Infant usually has iron reserve for 6 monthsb. Premature infant lacks reservec. Children receiving only milk have no source of
iron
2. Insidious onset: usually diagnosed because of an infection or chronic GI problems
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1. Assessment a. Pallor, weakness, tachycardia, dizzinessb. Slow motor developmentc. Poor muscle toned. Hemoglobin level below normal for age
• general rule: below 11 dl
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Oral iron sources1) Drug: ferrous sulfate (Feosol) - most
absorbable form of iron Ferrous fumarate (Feostat)
3) Adverse effects: N/V; fatalities in children who ingest enteric-coated tablets
5) Drug interactions: • ferrous sulfate binds tetracycline and decreases
absorption• magnesium trisilicate decreases absorption of iron
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Parenteral iron sources Drug:
parenteral iron-dextran injection (Imferon, Infed)
Adverse effects: Tissue staining (use Z tract for
intramuscular injection) Fever Lymphadenopathy N/V Arthralgia Urticaria Severe peripheral vascular
failure Anaphylaxis Secondary
hematochromatosis
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Nursing Considerations: Vitamin C and hydrochloric acid aid absorption Folic acid acts as a coenzyme in the formation of heme
proteins are necessary for the synthesis of hemoglobin ascorbic acid promotes the conversion of folic acid to folinic acid
Oxalates, phosphate, and caffeine decrease absorption [MILK]
Use a straw because some liquid preparations stain teeth Discolors stools
May cause gastric irritation or constipation
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1. Unknown cause [congenital…]2. Secondary
Drug Chloramphenicol (Chloromycetin) Mephenytoin (Mesantoin) Trimethadione (Tridione) Mechlorethamine or nitrogen mustard (Mustargen) Methotrexate (Folex PFS) 6-mercaptopurine or 6-MP (Purinethol) Phenylbutazone (Butazolidin)
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Viral infection Chemicals (benzene or airplane glue) Radiation
Pancytopenia Leukopenia, thrombocytopenia, and decreased
erythrocytes, agranulocytosis
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Symptoms Fatigue Weakness Tachycardia DOB Susceptibilty to infection Petechiae Gingival bleeding Epistaxis
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Therapeutic interventions
3. Identify and eliminate causative agent Bone marrow aspiration
4. Blood transfusions (PRBC, platelets)5. Maintenance of fluid and electrolyte balance6. Corticosteroids and androgens 7. Splenectomy
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Therapeutic interventions
For <45 yo Bone marrow transplant
human leukocyte antigen- (HLA-) matched sibling donor Cyclosporine (Sandimmune) for graft rejection
For >45 yo ATG Cyclosporine
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Therapeutic interventions
Antithymocyte globulin or ATG (Atgam) Suppress the reaction Allow bone marrow recovery
Administration Given through CVP x 7-10 days
Improvement in 3-6 months
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1. Autosomal disorder affecting hemoglobin
3. Defective hemoglobin red blood cells sickle and clump together under
reduced oxygen tension initially fetal hemoglobin prevents sickling
5. Classification1. Sickle cell anemia: homozygous for sickle cell gene
3. Sickle cell trait: heterozygous for sickle cell gene
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Union of person with sickle cell disease or trait (P1) and person with sickle cell trait (P2)
P1: A A
P2: A s
No sickle cell: AA As: Sickle cell traitNo sickle cell: AA As: Sickle cell trait
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Union of two persons with sickle cell trait
P1: A s
P2: A s
No sickle cell: AA As: Sickle cell traitSickle cell trait: sA ss: Sickle cell anemia
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Sickle cell crisis
Vasoocclusive Splenic sequestration
Aplastic Hyperhemolytic
StrokeChest syndrome
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A. Clinical findings Vasoocclusive crisis (pain episode): most
common and non–life threatening
b. sickled cells obstructing blood vessels, causing occlusion, ischemia, and potential necrosis
d. Symptomsa. Feverb. Acute abdominal pain (visceral hypoxia)c. Hand-foot syndromed. Priapisme. Arthralgia [without an exacerbation of anemia]
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1. Splenic sequestration crisis
b. pooling large quantities of blood in the spleen
c. precipitous drop in blood pressure [shock]d. Acute episode mostly commonly in children
8 months and 5 years of age result in death from anemia & CV collapse
e. Chronic manifestation [functional asplenia]
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Aplastic crisis: diminished red blood cell production
b. triggered by a viral or other infection
d. Profound anemia rapid destruction decreased production
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Hyperhemolytic crisis: increased rate of red blood cell destruction
b. Anemia, jaundice, and reticulcytosis
d. Glucose-6-phosphate dehydrogenase deficiency
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Stroke: sudden and severe complication with no related illnesses
b. Sickled cells block the major blood vessels in the brain
d. Repeat strokes in 60% of children who have experienced previous one
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Chest syndrome: clinically similar to pneumonia
Overwhelming infection Streptococcus pneumoniae
Haemophilus influenzae type B
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A. Therapeutic interventions1. Prevention of sickling phenomenon
a. Adequate oxygenationb. Adequate hydrationc. Administration of hydroxyurea to limit sickling
3. Treatment of crisisa. Restb. Hydration/electrolyte replacementc. Pain managementd. Antibiotic therapye. Blood products
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Hydroxyurea MOA: probable inhibitor of ribonucleotide reductase system
INDICATION: Sickle cell anemia, CML, head & neck, ovarian, colon CA, melanoma, acute leukemia, polycythemia vera, HIV
SE: leukopenia, N/V, rashes, facial erythema,
DOSE: 50-75 mg/kg for WBC counts >100,000 cells/ml 2-30 mg/kg for refractory CML; 1000-1500 mg/day in SD or divided doses
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During crisis provide for:a. Adequate hydration (may need IV therapy):
Avoid dehydration
2) May cause a rapid thrombus formation
4) Fluid intake per body weight 130 to 200 ml per kilogram [2 to 3 oz
per pound]
b. Proper positioning, careful handling
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During crisis cont…:
a. Exercise as tolerated – immobility
promotes thrombus formation respiratory problems
c. Adequate ventilation
e. Control of pain– use narcotics
f. Blood transfusions for severe anemia
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Provide for genetic counselinga. Disorder mostly of blacks / Mediterranean
people
c. If both parents are carriers– 25% chance of producing a child with the
disease
e. Screen young children for the disorder– clinical manifestations usually do not
appear before 6 months of age
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Defect in clotting mechanism of blood
Genetic disorder; X-linked recessive transmission
Usually occurs in males; females are carriers but do not have the disease
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Classification1. Factor VIII deficiency (classic
hemophilia): hemophilia A
3. Factor IX deficiency (Christmas disease): hemophilia B
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Clinical findings1. Prolonged bleeding from any wound
3. Bleeding into the joints (hemarthrosis), resulting in pain, deformity, and retarded growth
5. Intracranial hemorrhage
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1. Severity of bleeding
b. Mild1) Factor VIII activity of 5% to 50%2) Bleeding with severe trauma or surgery
c. Moderate1) Factor VIII activity of 1% to 5%2) Bleeding with trauma
d. Severe1) Factor VIII activity of 1%2) Spontaneous bleeding without trauma
2. Anemia
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Therapeutic interventions
1. Control of bleeding2. Prevention of bleeding with use of factor
replacementa. Drugs that replace deficient coagulation factors
1) Factor VIII concentrate from recombinant DNA2) Factor IX complex contains factors II, VII, IX, X
(concentrated)
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a. Adjunctive measuresr Aminocaproic acid (Amicar): inhibits the
enzyme that destroys formed fibrin and increases fibrinogen activity in clot formation
o Fibrinogen: maintains plasma fibrinogen levels required for clotting materials
t Thrombin: supplies physiologic levels of natural material at superficial bleeding sites to control bleeding
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Aminocaproic acid (Amicar)MOA: inhibits fibrinolysis via inhibition of TPA substances
INDICATION: excessive bleeding
SE: low BP & HR, dizziness, HA, fatigue, rash, GI disturbance, low platelet function
DOSE: 5 g IV or PO (1st h) followed by 1-1.25 g/h IV or PO
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Planning/Implementation1. Instruct the child and parents in the
treatment of bleedinga. Immobilization of the areab. Compression of the areac. Elevation of the body partd. Application of cool compresses
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1. Provide for appropriate activity2. Select safe toys and inform parents to safe-
proof house3. Avoid use of aspirin or ibuprofen4. Control joint pain5. Provide counseling6. Encourage parents to treat the child as
normally as possible
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A. Etiology and pathophysiology
2. Results in a decreased number of leukocytes
4. Thought to arise from physical agents heavy metals and cytotoxic drugs
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A. Clinical findings
2. Subjective
a. Fatigue b. Malaise
b Objective a. High fever b. Necrotic ulcers of
mucosa c. Rapid weak pulse
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A. Therapeutic interventions
2. Removal of causative agent
4. Transfusions
6. Antibiotics
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A. Planning/Implementation1. Prevent infection and observe for signs
of infection2. Provide careful oral hygiene3. Provide for bed rest4. Encourage diet consisting of high
nutrient density foods that are rich in vitamins and minerals
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A. Etiology and pathophysiology
2. Appears to result from the production of an antiplatelet antibody, which coats the surface of platelets
4. Coated platelets are then easily destroyed by phagocytic leukocytes
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A. Clinical findings 1. Subjective
b. History of epistaxis
d. History of gum bleeding
2. Objective
b. Low platelet count
d. Ecchymotis
f. Hemorrhagic petechiae
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A. Medical interventions
2. Corticosteroids
4. Immunosuppressive agents
6. Splenectomy
8. Platelet transfusions
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B Planning/Implementation 1. Prevent injury and bruises2. Encourage client to adhere to medical
regimen 3. Teach the side effects of medications,
particularly proneness to infection 4. Provide postoperative care related to
splenectomy
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A. Etiology and pathophysiology
2. Incidence highest in children ages 3 to 4• declines until age 35 [there is a steady
increase]3. Exposure to certain toxic substances
• radiation increases the incidence4. An uncontrolled proliferation of white blood
cells 5. Classified according to the type of white
blood cell affected
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Acute lymphocytic leukemia (ALL)
2) Primarily occurs in children
4) Most favorable prognosis with chemotherapy
6) Results from abnormal leukocytes in blood-forming tissue
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Acute myelogenous leukemia (AML)
2) Occurs throughout life cycle
4) Prognosis is poor with or without chemotherapy
6) Results from inability of leukocytes to mature
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Chronic myelogenous leukemia (CML)
2) Occurs after the second decade
4) Prognosis is poor
6) Results from abnormal production of granulocytic cells
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Chronic lymphocytic leukemia (CLL)
2) Occurs after age 35 years
4) Life expectancy: 4 to 5 years
6) Results from increased production of leukocytes and lymphocytes
• proliferation of cells within the bone marrow, spleen, and liver
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A. Clinical findings
1. Subjectivea. Malaiseb. Bone pain
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1. Objectivea. Anemiab. Thrombocytopeniac. Elevated leukocytesd. Decreased plateletse. Petechiaef. Gingival bleeding
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A. Therapeutic interventions1. Chemotherapy2. Transfusions of whole blood or blood fractions3. Analgesics4. Bone marrow transplant5. Radiation to areas of lymphocytic infiltration
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A. Planning/Implementation1. Discuss the importance of follow-up care with the
client and family2. Provide emotional support for the client and
family3. Provide specific nursing care related to particular
chemotherapeutic therapy, transfusion, or diagnostic tests
4. Provide a safe injury-free environment5. Use appropriate infection control techniques6. Pace care to avoid fatigue and assist client as
necessary
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Th a n k y o u !Nio C. Noveno, RN, MAN, MSN