blood/lymphatic disorder chapter 34

Blood/LymphaticDisorder

Chapter 34

White

Christensen

AdamL. Lehmkuhl, 2009

Blood/LymphaticDisorder

• Blood-viscous red fluid containing RBCs, WBCs, and platelets in fluid called plasma

• Slightly alkaline with pH 7.35 to 7.45

• NaCl concentration 0.9%

• 5-6 liters

• Functions of blood– Transports O2 and nutrition

to the cells and waste products away from the cells via cardiac and respiratory systems.

– Regulates acid-base balance, aids in temp regulation, and controls water content

– Protects against infection

Blood/Lymphatic Disorders

• Erythrocytes (RBCs)– Hgb 14-18 g/dl in males,

12-16 g/dl in females– Lifespan 120 days– Produced in red bone

marrow– Production stimulated by

Erythropoietin– Hct 42-52% in males, 37-

47% in females

• Leukocytes (WBCs)– Unlike RBCs, have a nucleus– Fight infection and assist in

immunity.– 5,000-10,000 – Elevated WBC’s indicate

infection, inflammation, tissue necrosis or leukemia.

– Different kinds of WBCs are counted and reported as percentages of the total is called a differential

– 2 categories- granulocytes and agranulocytes

– Wright’s stain differentiates category of WBC

Blood/LymphaticDisorders

Granulocytes– Neutrophils- essential

for phagocytosis (process of engulfing)

– Immature polymorphonuclear leukocytes called bands are released into the blood stream when neutrophils are depleted and severe infection occurs

– Eosinophils- play a role in allergic reactions and against certain parasitic worms

– Basophils- nonspecific immune response, release histamine


Agranulocytes– Monocytes- function

similarly to neutrophils through process of phagocytosis

– Lymphocytes (B & T)-


• Thrombocytes (platelets)– Nonnucleated– Life span of about 10 days.– Produced in red bone

marrow– Function in process of

hemostasis (prevention of blood loss) and in clotting formation

– Hemostasis• Vessel spasm

• Platelet plug formation

• Clot formation

• Blood Types– A, B, AB, and O– Type O is the universal

donor(no antigens that bodies can attack)

– Type AB is the universal recipient

– Rh factor- 85% of humans carry this factor

• Rh incompatibility seen most often in pregnancy causing hemolysis of the RBCs causing rupture and loss of cell contents

Complete Blood Count -

• The complete blood count (CBC) is a screening test, used to diagnose and manage numerous diseases. It can reflect problems with fluid volume (such as dehydration) or loss of blood. It can show abnormalities in the production, life span, and destruction of blood cells. It can reflect acute or chronic infection, allergies, and problems with clotting.

Complete Blood Count

• A CBC requires a small blood specimen. Blood is drawn from a vein, usually from the inside of the elbow or the back of the hand.

• Preparation: The skin should be cleaned with alcohol or iodine before the test. The patient should be seated comfortably or reclining.

Complete Blood Count Low numbers of red blood

cells may indicate anemia, • Blood loss • Iron deficiency • Deficiences of vitamin B12 or

folic acid • Bone marrow failure (for

example, from radiation, toxin, fibrosis, tumor)

• Erythropoietin deficiency (secondary to kidney disease)

• Hemolysis (RBC destruction) • Leukemia • Multiple myeloma • Over hydration Normal values vary with altitude and

gender.

Complete Blood Count

High numbers of red blood cells may indicate:

• Cigarette smoking • Low oxygen tension in the

blood • Congenital heart disease • Cor pulmonale • Pulmonary fibrosis • Polycythemia vera • Dehydration (such as from

severe diarrhea) • Emphysema

WBC’sLow numbers of white

blood cells (leukopenia) may indicate:

• Bone marrow failure (for example, due to granuloma (granular tumor), tumor, or fibrosis)

• Presence of cytotoxic substance

• Collagen-vascular diseases (such as lupus erythematosus)

• Disease of the liver or spleen

• Radiation exposure

High numbers of white blood cells (leukocytosis) may indicate:

• Infectious diseases • Inflammatory disease

(such as rheumatoid arthritis or allergy)

• Leukemia • Severe emotional or

physical stress • Tissue damage (for

example, burns)

Blood Transfusions

• Whole blood (^ vol)• Packed RBC’s

(anemia)• Platelets (control

bleeding)• Plasma (clotting d/o’s)• Cryoprecipate

(fibrinogen deficiencies)

• Administer within 30 minutes.

• Complete within 4 hours.• Baseline vs• 18-19 guage catherter• 2 nurse check• Anyreaction immediately

stop infusion..call MD• N/S to prevent clotting• Autologous or

homologous


• Lymphatic system- consists of lymph vessels, lymph fluid, and lymph tissue

• 2 main functions– Maintenance of fluid

balance (excess fluid from interstitial space to circulatory system)

– Production of lymphocytes to protect body from infection.

• Lymph nodes- – filter impurities from the

lymph and produce lymphocytes and macrophages

– Superficial lymph nodes in neck, axilla and groin can be palpated, especially when infected and swollen.

– CA cells can collect, reproduce and travel through lymph. Lymph nodes are biopsied to detect spread of CA.


• Tonsils- lymphoid tissue in the oropharynx

• Spleen- organ located in the LUQ of the abdomen, contains lymphatic nodules, stores 350 ml of blood. If needed approx. 200mL can be pumped out within a minute as needed.– Removes old RBC’s, platelets

and microorganisms from blood.

– During infection spleen enlarges to produce and release monocytes and lympthocytes.

• Thymus- located in upper thorax, develops T lymphocytes (Tcells). – Large in infancy and

childhood – Decreases in size with age– T cells are actively involved

in immunity.


• Diagnostic tests– CBC– Red cell indices- MCV

(size), MCH (weight), MCHC (concentration)

– Peripheral smear- most informative test

– Schilling- measures the absorption of radioactive vitamin B12 in diagnosing pernicious anemia

– Gastric analysis- useful in determining pernicious anemia

– Lymphangiography- detects metastatic involvement of lymph nodes

– Bone marrow aspiration or biopsy- most commonly performed in persons with marked anemia, neutropenia, acute leukemia, and thrombocytopenia


• Anemia- disorder characterized by low RBC, Hgb, Hct, and RBC destruction– Hypovolemic anemia

(blood loss)• Secondary anemia due

to blood loss• Control bleeding, tx

shock, replace fluid volume, O2

– Pernicious anemia• Absence of intrinsic factor

produced by gastric mucosa which is needed for absorption of B12

• Schilling test, serum B12 test, gastric analysis

• Tx is B12 injections (for life), folic acid

• Pt is highly susceptible to gastric carcinoma and should be monitored closely for symptoms.


• Aplastic anemia– Failure of the bone marrow to

produce RBCs– Patient may have

pancytopenia (low WBC, RBC,platelets)

– Most cases the cause is unknown..maybe genetic, or secondary to viral invasion, medications, chemicals, radiation, or chemotherapy

– Bone marrow transplant, if pts bone marrow fails to respond to tx.

– Prevent infection, bleeding, and fatigue

• For transplant the best candidate is a young pt who has not had previous infusions.– Sibling donor under 30 yrs is

higher success– Immunosupressants are given

to prevent graft rejection.


• Iron deficiency anemia– Most common type of

anemia.– RBCs contain

decreased Hbg– Most common cause

is chronic intestinal or uterine bleeding

– Low RBC, Hgb, Hct, and serum iron levels

– May have pica, stomatitis, glossitis, and brittle hair if chronic.

• Population with higher incidence are:– Low birth wt infants or premature– Infants– Adolescent girls– Alcoholics– Menstruating women– Pregnancy

Tx is with iron salts such as Ferrous Sulfate

• Ascorbic acid enhances iron absorption• Z track if parenteral• Use straw with liquid• Makes stools green or black• Diet in Fe rich foods

Sickle Cell Anemia

• Sickle cell anemia is caused by an abnormal type of hemoglobin called hemoglobin S.

• Hemoglobin is a protein inside red blood cells that carries oxygen. Hemoglobin S, however, distorts the red blood cells' shape. The fragile, sickle-shaped cells deliver less oxygen to the body's tissues, and can break into pieces that disrupt blood flow.

• Sickle cell anemia is inherited as an autosomal recessive trait. This means it occurs in someone who has inherited the hemoglobin S gene from both parents.

• Sickle cell is the most common genetic D/O in the US particularly in African-Americans,,Asian, India, Mediterranean and Caribbean areas.

Sickle Cell

• 1 in 10 African Americans have the trait, 1 in 500 have the disease

• Dx with Hgb electrophoresis which shows HbS

• Negative means sickle cell trait not sickle cell disease. Individual is asymptomatic but may pass disease to offspring.

• If Hbss (genes) confirmed dz• No specific treatment teach to

avoid sickle cell crisis

• Sickle cell crisis manifestations:– Fever– Severe pain– Loss of blood to various organs

(obstructed vessels)– Areas most affected are joints

(become painful and swollen), bone, brain, lung, liver, kidneys and penis.

• Frequent PVS, assessment, heat to joints, avoid tight clothing and high altitudes.

• Tx symptoms Hydroyurea (pain),folic acid (^RBC production) PCA during crisis, ^HOB, O2 ^ tissue perfusion and offset dyspnea)

SICKLE CELL ANEMIA

Polycythemia• Two types Primary and

Secondary (compensory mech to make more rbcs secondary to hypoxia from smoking, living in high altitude, HF)

• Primary- Jewish men >50 y/o acquired mutation (abnormal DNA) occurs in bone marrow.

• Erythrocytosis in Polycythemia Vera– Hypervolemic, hyperviscous

state (blood is unable to circulate freely)

– Increased plasma, RBC (WBC’s and platelets also increased), Hbg, Hct, low oxygen level on ABG

• Tx is repeated Phlebotomy (350-500mL) to decrease RBC’s, blood viscosity and reduce blood volume.

• Myelosuppressive agents- Myleran, hydroxyurea, and radioactive phosphorous (to decrease RBC production)

• Low Na+ diet (decrease blood vol and avoid Fe rich foods

POLYCYTHEMIA VERA

Leukemia

• Malignant D/O with excess WBCs in marrow and lymph nodes

• Pt constantly fighting infections and has fever and chills.

• Enlarged lymph nodes, anemia, thrombocytopenia (bleeding, bruising), low or very high WBCs

• Hepatosplenomegaly, lymphadenopathy, bone pain (WBC;s crowding cells in bone marrow), oral lesions

• Bone marrow bx shows immature WBCs

• Bleeding common monitor platlets

• Tx is chemo + radiation (destroys CA cells and good cells), bone marrow transplant

• Prevent infection (high risk), and chronic pain

• Most common cause of death is viral or fungal PNA.

• Acute lymphocytic leukemia (ALL) <15 yo more rapid onset than Acute myeloid leukemia (AML).

• R/f infection and bleeding• Teach: Hand washing to

visitors, pt hygiene use antimicrobial soaps, electric razor, antiemetics, stool softener, monitor for hematuria or cloudy urine.

LEUKEMIA

LEUKEMIA CELLS

Agranulocytosis

• Severe reduction in granulocytes (basophils, eosinophils, and neutrophils)

• Leukopenia• Med reaction or toxicity,

cancer, chemotherapy or radiation

• Differential below normal• Tx is to alleviate cause

and to prevent infection

• Meticulous handwashing, monitor: VS, WBC, lung sounds.

• Strict aseptic technique, visitors screened, reverse isolation may be implemented.

Coagulation Disorders

• Disseminated Intravascular Coagulation

• Hemophilia

• Thrombocytopenia

Hemophilia

• Inherited blood clotting d/o from lack of certain clotting factors– Hemophilia A most common– Hereditary, x linked, affects

mostly males, females carry genes

– Disturbance in clotting factors– Dx Factors VIII and IX,

prolonged PTT– Tx transfusions, replacement

of factor VIII and IX (cryoprecipitate)

• Willebrand’s Disease- mild deficiency of factor VIII

• 3 classifications– Mild– Moderate– Severe

• Can bleed out from trauma or bleed spontaneously.

• Spontaneous ecchymosis from GI or GU tracts

HEMOPHILIA A

Disseminated Intravascular Coagulation (DIC)

• Acquired Hemorrhagic syndrome of the clotting cascade and over stimulation of the clotting process.

• DIC a condition of alternating clotting and hemorrhaging.– Coagulopathy resulting from

the overstimulation of clotting and anticlotting processes in response to disease or injury

– Dx prolonged clotting coagulation profile, marked thrombocytopenia, deficits in factor V and VIII

– Tx cryoprecipitate, heparin, fibrinolytics, transfusion

– Primary dz stimulates the clotting mechanism , causes mini microthrombi to develop. The body’s fibronolytic process attempts top break clots thus causing hemorrhaging.

Thrombocytopenia

• Platelets reduced below 100,000– Drug induced, infection or

idiopathic

• Risk for bleeding– Prevent trauma (0 falls) or

infection – Petechiae (small skin

hemorrhages) and ecchymosis (bruising).

– Monitor for internal bleeding

• Tx corticosteroids and splenectomy (last resort..spleen is where platelet destruction occurs), platelet transfusions or apheresis (removal of unwanted componenets), IV gamma globulin or immunosuppressive drugs

THROMBOCYTOPENIA

Lymph Disorders

• Hodkins Lymphoma

• Non-Hodkins Lymphoma


• Malignant Lymphoma– Cancer of lymphoid tissue– Painless, enlarged lymph

nodes, fever, wt loss, anemia, pruritus, and prone to infection

– Bone scan may reveal fxs from bone mets, CT scan, node bx

– Tx chemo and radiation– Supportive care,

interventions similar to Hodgkins Lymphoma

• Hodgkins Lymphoma– Cancer of the lymphoid

tissue– Males, bimodal – Biopsy of lymphoid tissue

shows Reed Sternberg Cells.

– Tx dependent on stage– Tx chemo and radiation– Nursing care according to

stage– Comfort measures focus

on skin integrity• Soothing baths with

antipruritic medications (e.g. puritis).

CHILD WITH HODGKIN’S

Plasma Cell Disorder

• Myeloma

Multiple Myeloma

• Malignant neoplastic immunodeficiency disease of the bone marrow

• Plasma cell tumor• Disruption of production

of RBC, WBC, and platelets due to overproduction of plasma cells

• Bone destruction with release of calcium and phosphorous from bones

• Hyperuricemia with high Pro leads to renal failure– Pain relief, prevent infection

and bone injury, chemo, and hydration

• Encourage 3-4 Lof H2O to minimize complications of excessive Ca in the blood and urine.

• Exercise to preveny bone demineralization

• Monitor for hypercalciumia

MYELOMA

BENCE JONES PROTEIN CAST IN URINE

MONOCLONAL PROTEIN

blood/lymphatic disorder chapter 34

Documents

loss of blood

blood stream

destruction of blood

complete blood count

small blood specimen

complete blood counta

red bone marrowfunction

red bone marrowproduction