Transcript hematologic_and_lymphatic_disorders.ppt

Adult nursing
Caring for Clients With Hematologic
and Lymphatic Disorders
Anemia
Hemoglobin concentration or number of circulating RBCs decreased
Caused by
◦ Impaired RBC formation
◦ Excessive loss or destruction of RBCs
Anemia - Pathophysiology
Reduces the oxygen-carrying capacity of the blood
Causes tissue hypoxia
Body attempts to restore oxygen delivery
Anemia - Manifestations
Pallor
Bone pain
Angina
Headache
Fatigue
Dizziness
Dyspnea on exertion
Dim vision
Night cramps
Blood Loss Anemia
Acute or chronic bleeding
Both lead to anemia
RBCs normal but reduced in number
Nutritional Anemia
Lack of nutrients for RBC formation or development
Iron deficiency
◦ Cheilosis (cracks at corners of mouth)
◦ Smooth, sore tongue
◦ Pica
Vitamin B12
◦ Pernicious anemia
◦ Paresthesias
Nutritional Anemia
(continued)
Folic acid
◦
◦
◦
◦
Chronic malnourishment
Glossitis
Cheilosis
Diarrhea
Anemia of Chronic Disease
Seen in AIDs, rheumatoid arthritis, inflammatory bowel disease (IBD),
chronic hepatitis, chronic renal failure (CRF)
Severity depends on the severity of underlying disease
Manifestations similar to iron deficiency anemia
Hemolytic Anemias
Premature destruction of RBCs
Intrinsic or acquired causes
Sickle cell disorders
◦ Abnormal Hgb, changes shape
◦ Intense pain, chest, back, joints
Sickle Cell Anemia
Thallassemia
Inherited; caused by abnormal Hgb synthesis
Liver and spleen enlarged
Target cells
Acquired Hemolytic Anemias
Damage by outside factors
◦
◦
◦
◦
Mechanical trauma
Antibody reactions
Immune responses
Drugs, toxins, chemical agents, venoms
Aplastic Anemia
Bone marrow fails to produce RBCs
Cause unknown
Pancytopenia
Myelodysplastic Syndrome
Group of stem cell disorders
Seen in older adults
Anemia, enlarged spleen
Polycythemia
Erythrocytosis
Abnormally high RBC count, high Hct
Blood sticky
Secondary form is the most common
Develops due to chronic hypoxemia or excess erythropoietin
Polycythemia Vera
(continued)
Primary type
Production of all blood cells increased
Cause unknown
Insidious onset
Gangrene complication
Leukemia
Group of malignant disorders of WBCs
Greater numbers of WBCs
Cause of most unknown
Classified by onset and duration: acute or chronic
Four types
Leukemia - Pathophysiology
Malignant transformation of a single stem cell
Cells proliferate slowly, nonfunctional WBCs
Bone marrow filled with leukemic cells
Leave bone marrow and infiltrate other tissues
Death from hemorrhage or infection
Leukemia - Manifestations
Anemia
Infection
Bleeding
The multisystem effects of leukemia
Malignant Lymphoma
Cancer of lymph tissue
Classified as Hodgkin or non-Hodgkin
Hodgkin Disease
Most curable
Painless progressive enlargement of one or more lymph nodes
Reed-Sternberg cells
Cause unknown
Non-Hodgkin Lymphoma
More common
Multiple lymph nodes involved
Multiple Myeloma
Myeloma cells replace bone marrow, infiltrate bone
Bone weakened, pathologic fractures
Bone/back pain most common symptoms
Kidney damage
Neutropenia
Disease of number of circulating neutrophils
Usually secondary to infection, hematologic disease, chronic disease,
chemotherapy
Severe form is called agranulocytosis
Can result in impaired WBC formation or increased WBC destruction
Protective measures are required
Neutropenia - Manifestations
Fatigue
Weakness
Sore throat
Stomatitis
Dyphagia
Fever
Chills
Thrombocytopenia
Platelet count less than 100,000 per mL
Common cause of abnormal bleeding
Idiopathic thrombocytopenia purpura most common form
◦ Platelets destroy more rapidly than normal
◦ Autoimmune disorder
Thrombocytopenia
Manifestations
◦
◦
◦
◦
◦
◦
Purpura
Ecchymosis
Petechiae
Epistaxis
Menorrhagia
Hematuria
Hemophilia
Group of hereditary clotting factor deficiencies
Hemophilia A
◦ Most common type
◦ Deficiency in Factor VIII
Hemophilia (continued)
Hemophilia B (Christmas disease)
◦ Less common
◦ Deficiency in Factor IX
Transmitted from mother to son
Sex-linked recessive disorder on X chromosome
The inheritance pattern for hemophilia A and B. Both are X-linked recessive disorders; females
may carry the trait, but only males develop the disorder.
Hemophilia - Manifestations
Hemorrhages into body tissues
Disseminated Intravascular
Coagulation (DIC)
Simultaneous blood clotting and hemorrhage
Intrinsic and/or extrinsic clotting cascades activated
Widespread clotting of small vessels
Clotting factors depleted; leads to bleeding
DIC - Manifestations
Bleeding most obvious
Tachycardia, hypotension
Mottling
Abdominal distention
Decreased LOC
Lymphangitis/Lymphedema
Lymphangitis
◦ Inflammation of lymph vessel
Lymphedema
◦ Obstructed lymph vessel
Severe lymphedema of the lower extremity. (Source: NMSB, Custom Medical Stock Photos, Inc.)
Infectious Mononucleosis
Acute infection caused by Epstein–Barr virus
Benign and self-limiting
Kissing disease
Infectious Mononucleosis Manifestations
Headache
Sore throat
Fatigue
Enlarged and painful
lymph nodes
Fever
Enlarged spleen
Anemia – Diagnostic Tests
CBC
Iron levels
Serum ferritin
Sickle cell screening
Hemoglobin electrophoresis
Schilling’s test
Bone marrow aspiration
Leukemia – Diagnostic Tests
CBC with differential and platelet count
Bone marrow
Multiple Myeloma – Diagnostic
Tests
Urine samples
CBC
Bone marrow
Bone x-rays
Neutropenia - Diagnosis
WBC count
Neutophil count less than 1500 cells/mm3
May be less than 500 cells/mm3 in agranulocytosis
Thrombocytopenia – Diagnostic
Tests
CBC, platelet count
Bone marrow
Antinuclear antibodies
Hemophilia – Diagnostic Tests
Platelet count
Coagulation studies
Clotting factors
DIC – Tests
Clotting studies
Infectious Mononucleosis –
Diagnostic Tests
Increased lymphocytes and monocytes
Increased WBC count
Low platelets
Malignant Lymphoma – Diagnostic
Tests
Chest x-ray
Abdominal CT
Biopsy
Ann Arbor staging system
Cotswold staging classification system
Anemia – Nursing Implications
Client Teaching
◦
◦
◦
◦
◦
◦
Types of anemia
Diet
Medications
Genetic counseling
Follow-up appointments
Support groups
Leukemia – Nursing Implications
Client Teaching
◦
◦
◦
◦
◦
◦
◦
Diagnosis, treatment, bone marrow, complications
Cancer as a chronic illness
Balance activity with rest
Maintain weight and nutrition
Hydration
Prevent infection
Oral hygiene
Leukemia – Nursing Implications
(continued)
Client Teaching (continued)
◦
◦
◦
◦
◦
Avoid crowds, sick people
Avoid immunizations
Reduce risk of bleeding or injury
Avoid OTC medications that can cause bleeding
Refer to social services, support groups, home health
Malignant Lymphoma – Nursing
Implications
Client teaching
◦
◦
◦
◦
◦
◦
◦
Treatment and effects of treatment
Skin care
New symptoms
Complementary pain management strategies
Rest and exercise
Diet
American Cancer Society referral
Multiple Myeloma – Nursing
Implications
Client Teaching
◦ Teach S/S complications
◦ Hospice
Thrombocytopenia – Nursing
Implications
Client Teaching
◦ Continue treatment to maintain remission
◦ Long-term steroid treatment
◦ Splenectomy
Hemophilia – Nursing Implications
Client teaching
◦ How to prevent bleeding
◦ Provide medications
◦ Genetic counseling
DIC – Nursing Implications
Client teaching
◦ Proper foot care
◦ Heparin home therapy
◦ When to contact physician
Lymphangitis/Lymphedema
Nursing Implications
Client Teaching
◦
◦
◦
◦
◦
Use of pressure devices, elastic stockings
Skin inspection
Skin care
Elevate extremity
Activity, diet, diuretics
Anemia - Treatment
Medications
◦ Depends on type and cause
◦ Iron replacement
◦ Vitamin B12
◦ Folic acid
◦ Hydroxyurea
◦ Immunosuppressive therapy or androgens
Anemia – Treatment
(continued)
Dietary Considerations
◦ Iron that is readily absorbed
◦ Iron sources
Blood Transfusions
◦ Replace RBCs
◦ Whole blood or packed RBCs
Polycythemia - Treatment
Reduce blood viscosity and volume
Relieve symptoms
Phlebotomy to keep blood volume within normal levels
Chemotherapy
Leukemia - Treatment
Chemotherapy
◦ Destroy leukemic cells
◦ Produce remission
◦ Achieve remission, cure, relieve symptoms
Radiation therapy
◦ Shrink lymph nodes
Biologic therapy
◦ Interferons, interleukins
◦ Colony-stimulating factors
Leukemia – Treatment
(continued)
Bone marrow transplantation
◦ Allogenic
◦ Eliminate leukemic cells
◦ Donor marrow transfused
◦ Autologous
◦ Own bone marrow withdrawn, treated, frozen, reinfused later
Leukemia – Treatment
(continued)
Stem cell transplant
◦ Donor treated with colony-stimulating factors to increase concentration of
stem cells in blood
◦ Blood removed from donor, given to patient
Malignant Lymphoma - Treatment
Chemotherapy
◦ Combination
◦ Remission in more than 75%
Radiation
◦ Used for both
◦ Combined with chemotherapy
Areas of radiation for total nodal radiation therapy.
Multiple Myeloma Treatment
No cure
Relieving symptoms
Death within 2 to 5 years
Treatment
◦ Chemotherapy, radiation, medications, pain control, blood transfusions
Neutropenia - Treatment
Discontinue drugs that may be cause of disorder
Treat infection
Filgrastim (Neupogen) may be used to treat disorder
Thrombocytopenia - Treatment
Medications
◦ Steroids
◦ Immunosuppressive drugs
Platelet transfusions
Plasmapheresis
Surgery:
◦ Splenectomy
Hemophilia - Treatment
Replace clotting factors
Fresh frozen plasma
Cryoprecipitates
Concentrates
DDAVP (desmopressin acetate)
DIC - Treatment
Treatment: underlying disease
Medications
◦ Control bleeding
◦ fresh frozen plasma
◦ Heparin
Lymphangitis/Lymphedema
Treatment
Relieve edema, maintain skin integrity, prevent/treat infection
Lymphangitis
◦ Moist heat, elevate, immobilize, skin/wound care, antibiotics
Lymphedema
◦ Elevate, elastic stockings, skin care, bed rest, sodium restriction
Infectious Mononucleosis Treatment
Recovery in 2 to 3 weeks
Bed rest
Analgesics
Anemia – Nursing Care
Assessment
Activity Intolerance
◦
◦
◦
◦
Vital signs
Rest periods
Energy conservation
Smoking cessation
Anemia – Nursing Care
(continued)
Impaired Oral Mucous Membranes
◦
◦
◦
◦
◦
◦
◦
◦
Assess lips and tongue
Mouthwash
Frequent oral hygiene
Avoid alcohol-based mouthwashes
Petroleum jelly for lips
Avoid spicy foods
Encourage soft bland foods
Small high-protein balanced meals each day
Anemia – Nursing Care
(continued)
Self-Care Deficit
◦ Assist with ADL
◦ Rest periods
◦ Concerns about self-care
Anemia – Nursing Care
(continued)
Evaluation
◦
◦
◦
◦
Independent ADL
Increased level of activity
Skin and oral mucous membranes
Diet
Polycythemia – Nursing Care
Teaching
◦
◦
◦
◦
◦
◦
Hydration
Prevent blood stasis
Elevate legs
Support stockings
Smoking cessation
Report S/S thrombosis
Leukemia – Nursing Care
Assessment
◦ Recognize manifestations
Leukemia – Nursing Care
(continued)
Risk for Infection
◦
◦
◦
◦
◦
◦
Infection precautions
Avoid invasive procedures
Report evidence of infection
Monitor vital signs
Report lab values
Explain precautions and restrictions
Leukemia – Nursing Care
(continued)
Imbalanced Nutrition: Less than Body Requirements
◦ Monitor weight
◦ Promote food and fluid intake
◦ Avoid procedures around meals
Leukemia – Nursing Care
(continued)
Impaired Oral Mucous Membranes
◦
◦
◦
◦
◦
Assess mouth
1:1 solution saline/peroxide as mouthwash
Soft-bristle toothbrush
Medications for infection, pain
Avoid alcohol-based mouth washes
Leukemia – Nursing Care
(continued)
Ineffective Protection
◦
◦
◦
◦
◦
Monitor LOC
Report manifestations of bleeding
Avoid invasive procedures
Apply pressure to puncture sites
Avoid straining with bowel movement
Leukemia – Nursing Care
(continued)
Anticipatory Grieving
◦ Therapeutic communication
◦ Manage stressful situations
◦ Support groups for the grieving process
Leukemia – Nursing Care
(continued)
Evaluation
◦
◦
◦
◦
◦
◦
Freedom from infection
Weight
Food intake
Oral mucous membranes
Bleeding
Coping
Malignant Lymphoma – Nursing
Care
Risk for Impaired Skin Integrity
◦ Measures to reduce itching
Nausea
◦ Antiemetics
◦ Measures to relieve/reduce nausea
Malignant Lymphoma – Nursing
Care (continued)
Fatigue
◦
◦
◦
◦
◦
◦
Assess malaise
Encourage talking about disease
Quiet activities
Rest periods
High-carbohydrate diet
Fluids
Malignant Lymphoma – Nursing
Care (continued)
Disturbed Body Image
◦
◦
◦
◦
◦
Body image assessment
Objective signs of altered body image
Coping with alopecia
Effects of illness on sexuality
Support groups
Multiple Myeloma – Nursing
Care
Chronic Pain
◦
◦
◦
◦
◦
Assess pain
Positioning, support with pillows
Use of analgesics
Nonpharmacology pain control
Rest periods
Multiple Myeloma – Nursing
Care (continued)
Impaired Physical Mobility
◦
◦
◦
◦
Reposition
Change positions every 2 hours
Trapeze
Safety measures
Thrombocytopenia – Nursing
Care
Ineffective Protection
◦
◦
◦
◦
◦
Monitor LOC
Manifestations of bleeding
Avoid invasive procedures
Pressure dressing to puncture sites
Avoid straining at bowel movement
Hemophilia – Nursing Care
Risk for Injury
◦
◦
◦
◦
Signs of bleeding
Stop bleeding with pressure, ice
No IM injections
Safety measures
Hemophilia – Nursing Care
Risk for Ineffective Therapeutic Regimen Management
◦ Assess knowledge/reinforce teaching
◦ Emotional support
◦ Opportunities to learn/practice administration clotting factors
DIC – Nursing Care
Ineffective Tissue Perfusion
◦
◦
◦
◦
Assess pulses
Turn every 2 hours
No knee crossing
Minimize tape use
DIC – Nursing Care
(continued)
Impaired Gas Exchange
◦
◦
◦
◦
◦
◦
O2 saturation levels
ABGs
Oxygen
Fowler’s/semi-Fowler’s position
Bed rest
Deep breathing and coughing
DIC – Nursing Care
(continued)
Acute Pain
◦ Pain scale
◦ Handle gently
◦ Cool compresses to painful joints
DIC – Nursing Care
(continued)
Fear
◦
◦
◦
◦
◦
◦
◦
Verbalize concerns
Answer questions
Coping strategies
Emotional support
Calm environment
Respond to calls for help
Relaxation techniques
Lymphangitis/Lymphedema
Nursing Care
Implementation
◦
◦
◦
◦
Measure effected extremity
I&O
Daily weights
Sodium restriction
Lymphangitis/Lymphedema
Nursing Care
Implementation (continued)
◦
◦
◦
◦
Antiembolic stockings/intermittent pressure devices
Elevate extremities
Skin care
Protective devices