caring for clients with hematologic and lymphatic disorders

Medical-Surgical Nursing CareThird Edition

CHAPTER

Copyright ©2011 by Pearson Education, Inc.All rights reserved.

Medical-Surgical Nursing Care, Third EditionBurke • Mohn-Brown • Eby

Caring for Clients With Hematologic and Lymphatic Disorders

20



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• Angina• Fatigue• Dyspnea on exertion• Night cramps

• Bone pain• Headache• Dizziness• Dim vision



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



Anemia – Diagnostic Tests

• CBC• Iron levels• Serum ferritin• Sickle cell screening• Hemoglobin electrophoresis• Schilling’s test• Bone marrow aspiration



Anemia – Nursing Implications

• Client Teaching– Types of anemia– Diet– Medications – Genetic counseling– Follow-up appointments– Support groups



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



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




• Self-Care Deficit– Assist with ADL– Rest periods– Concerns about self-care




• Evaluation– Independent ADL– Increased level of activity– Skin and oral mucous membranes– Diet



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



Polycythemia - Treatment

• Reduce blood viscosity and volume• Relieve symptoms• Phlebotomy to keep blood volume within

normal levels• Chemotherapy



Polycythemia – Nursing Care

• Teaching– Hydration– Prevent blood stasis– Elevate legs– Support stockings– Smoking cessation– Report S/S thrombosis



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



Figure 20-5 The multisystem effects of leukemia.



Leukemia – Diagnostic Tests

• CBC with differential and platelet count• Bone marrow



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



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



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




• Imbalanced Nutrition: Less than Body Requirements– Monitor weight– Promote food and fluid intake– Avoid procedures around meals




• 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




• Ineffective Protection– Monitor LOC– Report manifestations of bleeding– Avoid invasive procedures– Apply pressure to puncture sites– Avoid straining with bowel movement




• Anticipatory Grieving– Therapeutic communication– Manage stressful situations– Support groups for the grieving process




• Evaluation– Freedom from infection– Weight– Food intake– Oral mucous membranes– Bleeding– Coping



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



Malignant Lymphoma – Diagnostic Tests

• Chest x-ray• Abdominal CT• Biopsy• Ann Arbor staging system• Cotswold staging classification system



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



Malignant Lymphoma - Treatment

• Chemotherapy– Combination– Remission in more than 75%

• Radiation– Used for both– Combined with chemotherapy



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

• Myeloma cells replace bone marrow, infiltrate bone

• Bone weakened, pathologic fractures• Bone/back pain most common symptoms• Kidney damage



Multiple Myeloma – Diagnostic Tests

• Urine samples• CBC• Bone marrow• Bone x-rays



Multiple Myeloma – Nursing Implications

• Client Teaching – Teach S/S complications– Hospice



Multiple Myeloma - Treatment

• No cure• Relieving symptoms• Death within 2 to 5 years• Treatment

– Chemotherapy, radiation, medications, pain control, blood transfusions



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



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



Neutropenia - Diagnosis

• WBC count• Neutophil count less than 1500 cells/mm3

• May be less than 500 cells/mm3 in agranulocytosis



Neutropenia - Treatment

• Discontinue drugs that may be cause of disorder

• Treat infection• Filgrastim (Neupogen) may be used to

treat disorder



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



Thrombocytopenia – Diagnostic Tests

• CBC, platelet count• Bone marrow• Antinuclear antibodies



Thrombocytopenia – Nursing Implications

• Client Teaching– Continue treatment to maintain remission– Long-term steroid treatment– Splenectomy



Thrombocytopenia - Treatment

• Medications– Steroids– Immunosuppressive drugs

• Platelet transfusions• Plasmapheresis• Surgery:

– Splenectomy



Thrombocytopenia – Nursing Care

• Ineffective Protection– Monitor LOC– Manifestations of bleeding– Avoid invasive procedures– Pressure dressing to puncture sites– Avoid straining at bowel movement



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



Figure 20-8 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



Hemophilia – Diagnostic Tests

• Platelet count• Coagulation studies• Clotting factors



Hemophilia – Nursing Implications

• Client teaching– How to prevent bleeding– Provide medications– Genetic counseling



Hemophilia - Treatment

• Replace clotting factors• Fresh frozen plasma• Cryoprecipitates• Concentrates• DDAVP (desmopressin acetate)



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



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



[Insert Box 20-6 from page 500]



DIC – Tests

• Clotting studies



DIC – Nursing Implications

• Client teaching– Proper foot care– Heparin home therapy– When to contact physician



DIC - Treatment

• Treatment: underlying disease• Medications

– Control bleeding– fresh frozen plasma– Heparin



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




• Acute Pain– Pain scale– Handle gently– Cool compresses to painful joints




• Fear– Verbalize concerns– Answer questions – Coping strategies– Emotional support– Calm environment– Respond to calls for help– Relaxation techniques



Lymphangitis/Lymphedema

• Lymphangitis– Inflammation of lymph vessel

• Lymphedema– Obstructed lymph vessel



Figure 20-9 Severe lymphedema of the lower extremity. (Source: NMSB, Custom Medical Stock Photos, Inc.)



Lymphangitis/LymphedemaNursing Implications

• Client Teaching– Use of pressure devices, elastic stockings– Skin inspection– Skin care– Elevate extremity– Activity, diet, diuretics



Lymphangitis/LymphedemaTreatment

• 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



Lymphangitis/LymphedemaNursing Care

• Implementation– Measure effected extremity– I&O– Daily weights– Sodium restriction



Lymphangitis/LymphedemaNursing Care

• Implementation (continued)– Antiembolic stockings/intermittent pressure

devices– Elevate extremities– Skin care– Protective devices



Infectious Mononucleosis

• Acute infection caused by Epstein–Barr virus

• Benign and self-limiting• Kissing disease



Infectious Mononucleosis - Manifestations

• Headache• Malaise• Fatigue• Fever

• Sore throat• Enlarged and painful

lymph nodes• Enlarged spleen



Infectious Mononucleosis – Diagnostic Tests

• Increased lymphocytes and monocytes• Increased WBC count• Low platelets



Infectious Mononucleosis - Treatment

• Recovery in 2 to 3 weeks• Bed rest• Analgesics

caring for clients with hematologic and lymphatic disorders

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