chapter 7 care of the patient with a blood or lymphatic disorder mosby items and derived items ©...

Chapter 7Chapter 7

Care of the Patient with a Blood

or Lymphatic Disorder

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.


Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology

• Characteristics of blood Consistency

• 45% blood cells

• 55% blood plasma pH

• 7.35 to 7.45 Volume

• 10 to 12 pints



• Red blood cells (RBCs) Erythrocytes Transport oxygen and carbon dioxide

• White blood cells (WBCs) Leukocytes Body defenses: destruction of bacteria and viruses

• Thrombocytes (platelets) Initiate blood clotting


Figure 7-1Figure 7-1

Human blood cells.

(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)



• Hemostasis: A body process that arrests the flow of blood and prevents hemorrhage Injury Hemorrhage Grouping platelets Thromboplastin released Converts prothrombin to thrombin Links with fibrinogen Formation of fibrin Traps RBCs and platelets Forms clot



Blood clotting.

(From Thibodeau, G.A., Patton, K.T. [2007]. The human body in health and disease. [3rd ed.]. St. Louis: Mosby.)



• Blood types (groups) Determined by the presence or absence of specific

antigens on the outer surface of the RBC• Type A

• Type B

• Type AB Universal recipient

• Type O Universal donor



• Rh factor Rh antibodies may be located on the surface of the

RBC• Rh positive: Antibodies are present

• Rh negative: Antibodies are not present



• Lymphatic system Functions

• Maintenance of fluid balance

• Production of lymphocytes

• Absorption and transportation of lipids from the intestine to the bloodstream



• Lymphatic system Lymph and lymph vessels

• Lymph is a specialized fluid formed in the tissue spaces transported by way of the lymphatic vessels and reenters the circulatory system

Lymphatic tissue• Lymph nodes

Act as filters, keeping particulate matter such as bacteria from entering bloodstream



• Lymphatic system (continued) Lymphatic tissue (continued)

• Tonsils Produce lymphocytes and antibodies: trap bacteria

• Spleen Reservoir for blood; forms lymphocytes, monocytes, and

plasma; destroys worn-out RBCs; removes bacteria by phagocytosis

• Thymus Immune system before and a few months after birth;

atrophies at puberty



Principal organs of the lymphatic system.

(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)


Disorders of the Hematologicaland Lymphatic SystemsDisorders of the Hematologicaland Lymphatic Systems

• Diagnostic tests Complete blood count (CBC) Red cell indices Peripheral smear Schilling test Megaloblastic anemia profile Lymphangiography Bone marrow aspiration or biopsy


• Anemia Definition

• Disorder characterized by RBC and hemoglobin and hematocrit levels below normal range

• Causes delivery of insufficient amounts of oxygen to tissues and cells

Etiology/pathophysiology• Types of anemia

Blood loss Impaired production of RBCs Increased destruction of RBCs Nutritional deficiencies



• Anemia (continued) Clinical manifestations/assessment

• Anorexia

• Dyspepsia

• Cardiac dilation

• Disorientation

• Shortness of breath

• Dyspnea

• Fatigue

• Headache



Anemia (continued) Clinical manifestations/assessment (continued)

• Insomnia

• Pallor

• Palpitation

• Systolic murmur

• Tachycardia

• Vertigo



• Anemia (continued) Medical management

• Depends on the cause

• Correction of the disease process may correct or lessen the anemic condition

• Treatment is often specific to the particular anemia

• Can give PO ferrous sulfate Causes constipation and black stool



• Hypovolemic anemia Etiology/pathophysiology

• Abnormally low circulating blood volume due to blood loss

• 500-mL loss can be tolerated

• 1,000-mL loss can cause severe complications

• Severity and signs and symptoms depend on how rapid the blood is lost



• Hypovolemic anemia (continued) Clinical manifestations/assessment

• Weakness

• Stupor; irritability

• Pale, cool, moist skin

• Hypotension

• Tachycardia (rapid, weak, thready pulse)

• Hypothermia

• Hemoglobin less than 10 g/100 mL

• Hematocrit less than 40%



• Hypovolemic anemia (continued) Medical management/nursing interventions

• Control bleeding

• Treat shock O2, elevate lower extremities, keep warm

• Replace fluid Blood transfusion, plasma, dextran, lactated Ringer’s

• Monitor vital signs



• Pernicious anemia Etiology/pathophysiology

• Absence of the intrinsic factor from stomach

• Intrinsic factor is essential for the absorption of vitamin B12

• Deficiency of vitamin B12 affects growth and maturity of all body cells

• Vitamin B12 is also related to nerve myelination May cause progressive demyelination and degeneration

of nerves and white matter



• Pernicious anemia (continued) Clinical manifestations/assessment

• Extreme weakness

• Dyspnea

• Fever

• Hypoxia

• Weight loss

• Jaundice (destruction of RBCs)

• Pallor

• GI complaints



• Pernicious anemia (continued) Clinical manifestations/assessment (continued)

• Dysphagia

• Sore, burning tongue Smooth and erythematous

• Neurological symptoms Tingling of the hands and feet Disorientation Personality changes; behavior problems Partial or total paralysis



• Pernicious anemia (continued) Medical management/nursing interventions

• Vitamin B12 (cyanocobalamin) 1,000 units Daily for 1 week Weekly for 1 month Monthly for life

• Folic acid supplement

• Iron replacement

• RBC transfusion

• Diet: high in protein, vitamins, and minerals



• Aplastic anemia Etiology/pathophysiology

• Decrease of bone marrow function

• Primary Congenital

• Secondary Viral invasion Medications Chemicals Radiation; chemotherapy



• Aplastic anemia (continued) Clinical manifestations/assessment

• Pancytopenic

• Repeated infections with high fevers

• Fatigue, weakness, malaise

• Dyspnea

• Palpitations

• Bleeding tendencies



• Aplastic anemia (continued) Medical management/nursing interventions

• Identify and remove cause

• Platelet transfusion for severe thrombocytopenia

• Splenectomy for hypersplenism

• Steroids and androgens

• Antithymocyte globulin

• Bone marrow transplant



• Iron deficiency anemia Etiology/pathophysiology

• RBCs contain decreased levels of hemoglobin

• Insufficient intake of iron

• Excessive iron loss Caused by chronic bleeding—intestinal, uterine, gastric



• Iron deficiency anemia (continued) Clinical manifestations/assessment

• Pallor

• Fatigue; weakness

• Shortness of breath

• Angina; signs and symptoms of heart failure

• Glossitis; burning tongue

• Pagophagia

• Headache

• Paresthesia



• Iron deficiency anemia (continued) Medical management/nursing interventions

• Pharmacological management Ferrous sulfate 900 mg daily

o Oral or injection (Z-track) Ascorbic acid

• Diet high in iron

• What foods are high in iron?



• Sickle cell anemia Etiology/pathophysiology

• An abnormal, crescent-shaped RBC

• Severe, chronic, incurable condition

• Autosomal recessive Disease

o Homozygous Trait

o Heterozygous



• Sickle cell anemia (continued) Clinical manifestations/assessment

• Precipitating factors Dehydration Change in oxygen tension in the body

• Loss of appetite

• Irritability

• Weakness

• Abdominal enlargement

• Joint and back pain

• Edema of extremities



• Sickle cell anemia (continued) Medical management/nursing interventions

• No specific treatment—alleviate symptoms

• Oxygen

• Rest

• Fluids

• Analgesics





• Polycythemia (erythrocytosis) Polycythemia vera

• Characterized by hyperplasia of the bone marrow

• Manifestations Increases in circulating erythrocytes, granulocytes, and

platelets Elevated WBC count

• Diagnostic tests CBC Alkaline phosphatase levels Uric acid levels Histamine levels



• Polycythemia (erythrocytosis) Polycythemia vera

• Medical management/nursing interventions Pharmacological management

o Myelosuppressive agentso Radioactive phosphorus

Reduction of blood viscosity Intake and output Assessment of nutritional status Therapeutic ‘donation’


• Agranulocytosis Etiology/pathophysiology

• Severe reduction in the number of granulocytes

• WBC less than 200/mm3

• Medications

• Chemotherapy **

• Radiation

• Neoplastic disease

• Viral and bacterial infections



• Agranulocytosis (continued) Clinical manifestations/assessment

• Symptoms of infection

• Ulcerations of mucous membranes

• Bronchial pneumonia

• Urinary tract infection Medical management/nursing interventions

• Remove cause of bone marrow depression

• Prevent or treat infections

• Meticulous handwashing

• Strict asepsis



• Leukemia Etiology/pathophysiology

• Malignant disorder of the hematopoietic system

• Excess leukocytes accumulate in the bone marrow and lymph nodes

• Cause unknown

• Classification Acute or chronic Proliferating cells (lymphocytic, monocytic, etc.)



• Leukemia (continued) Clinical manifestations/assessment

• Anemia• Thrombocytopenia; leukopenia• Enlarged lymph nodes• Splenomegaly

Medical management/nursing interventions• Pharmacological management

Leukeran Hydroxyurea Corticosteroids Cytoxan

• Chemotherapy; radiation• Bone marrow transplant



• Thrombocytopenia Etiology/pathophysiology

• Condition in which the number of platelets is reduced below 100,000/mm3; may be due to decreased production or decreased survival of the platelets

Clinical manifestations/assessment• Petechiae

• Ecchymoses

• Platelets below 100,000/mm3

• Bleeding from mucous membranes



• Thrombocytopenia (continued) Medical management/nursing interventions

• Pharmacological management Corticosteroid therapy Gamma globulin Immunosuppressive therapy

• Splenectomy

• Platelet transfusions

• Avoid trauma



• Hemophilia Etiology/pathophysiology

• Hereditary coagulation disorder, characterized by a disturbance of clotting factor

• Hemophilia A; hemophilia B

• X-linked hereditary trait Clinical manifestations/assessment

• Internal and external bleeding

• Hemarthrosis

• Excessive blood loss from small cuts and dental procedures



• Hemophilia (continued) Medical management/nursing interventions

• Minimize bleeding—avoid trauma

• Relieve pain—no aspirin

• Transfusions Factor VIII or IX concentrate Cryoprecipitate (rich in factor VIII) Manufactured factor VIII or IX



• von Willebrand’s disease Etiology/pathophysiology

• Inherited bleeding disorder characterized by abnormally slow coagulation of blood; mild deficiency of factor VIII

• Similar to hemophilia; not limited to males Clinical manifestations/assessment

• Spontaneous episodes of GI bleeding Epistaxis Gingival bleeding



• von Willebrand’s disease (continued) Medical management/nursing interventions

• Pharmacological management Desmopressin (DDAVP)

• Cryoprecipitate

• Fibrinogen

• Fresh plasma

• Minimize bleeding—avoid trauma

• Relieve pain—no aspirin



• Disseminated intravascular coagulation Etiology/pathophysiology

• Overstimulation of clotting and anticlotting processes in response to disease or injury

Clinical manifestations/assessment• Bleeding; hemoptysis

• Dyspnea

• Diaphoresis

• Cold, mottled digits

• Purpura on the chest and abdomen

• Petechiae



• Disseminated intravascular coagulation (continued) Medical management/nursing interventions

• Pharmacological management Heparin—considered somewhat controversial

• Treat underlying cause

• Cryoprecipitate

• Protect from bleeding and trauma



• Multiple myeloma Etiology/pathophysiology

• Malignant neoplastic immunodeficiency disease of the bone marrow

Clinical manifestations/assessment• Bone pain; pathological fractures

• Infection

• Anemia; bleeding

• Hypercalcemia

• Renal failure



• Multiple myeloma (continued) Medical management/nursing interventions

• Symptomatic; not curable

• Pharmacological management Corticosteroids Analgesics

• Radiation

• Chemotherapy

• IV fluids



• Lymphangitis Etiology/pathophysiology

• Inflammation of one or more lymphatic vessels

• Usually occurs from acute streptococcal or staphylococcal infection in an extremity

Clinical manifestations/assessment • Fine red streaks from the affected area

• Edema

• Chills; fever

• Local pain

• Headache; myalgia



• Lymphangitis (continued) Medical management/nursing interventions

• Penicillin

• Moist heat

• Elevate extremity



• Lymphedema Etiology/pathophysiology

• Primary or secondary disorder

• Accumulation of lymph in the soft tissue Clinical manifestations/assessment

• Massive edema and tightness of affected extremity

• Pain



• Lymphedema (continued) Medical management/nursing interventions

• Pharmacological management Diuretics Antibiotics

• Compression pump

• Elastic stocking or sleeve

• Restricted sodium diet

• Avoid constrictive clothing

• Meticulous skin care



• Hodgkin’s disease Etiology/pathophysiology

• Inflammatory or infectious process that develops into a neoplasm

• Affects males twice as frequently as females

• Reed-Sternberg cells



• Hodgkin’s disease (continued) Clinical manifestations/assessment

• Enlargement of cervical lymph nodes

• Anorexia

• Weight loss

• Pruritus

• Low-grade fever

• Night sweats

• Anemia

• Leukocytosis



• Hodgkin’s disease (continued) Medical management/nursing interventions

• Stage I or II (localized) Radiation

• Stage III or IV (generalized) Chemotherapy Combination




Nodal involvement by stage in Hodgkin’s disease (based on modified Ann

Arbor Staging System).

(From Belcher, A.E. [1992]. Blood disorders, Mosby’s clinical nursing series. St. Louis: Mosby.)



• Non-Hodgkin’s lymphoma Etiology and pathology

• A group of malignant neoplasms

• Characterized as a neoplasm of the immune system

• Cause is unknown

• Tumors usually start in lymph nodes and spread to lymphoid tissue in the spleen, liver, GI tract, and bone marrow


• Non-Hodgkin’s lymphoma (continued) Clinical manifestations/assessment

• Painless, enlarged cervical lymph nodes

• Fever; susceptibility to infection

• Weight loss; anorexia

• Anemia

• Pruritus

• Fatigue

• Malaise




• Non-Hodgkin’s lymphoma (continued) Diagnostic tests

• Bone scan

• CBC

• ESR

• Coombs’ test

• Chest roentgenogram

• CT scan

• Gallium scan

• Biopsies


• Non-Hodgkin’s lymphoma (continued) Medical management/nursing interventions

• Accurate staging of the disease is crucial to determine treatment regimen

• Radiation

• Chemotherapy


• Tumor necrosis factor (TNF)



Nursing ProcessNursing Process

• Nursing diagnoses Infection, risk for Injury (trauma) risk for (bleeding, falls) Fatigue Knowledge, deficient Pain, acute and chronic Tissue perfusion, ineffective Gas exchange, impaired Activity intolerance Coping, ineffective Skin integrity, impaired

Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 62

Antineoplastic Medications

Adverse Reactions Dose-dependent GI: nausea, vomiting, diarrhea, and anorexia Bone marrow depression System-specific toxicity Alopecia Drug-specific: consult manufacturer’s

guidelines

63Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antineoplastic Medications

Nursing Implications and Patient Teaching Patient and Family Teaching

Chemotherapy/product education Adverse effects When to report symptoms to the health care provider Nutrition Signs of dehydration Hair loss Support groups


Anticoagulants

Two Categories Coumarin and indandione derivatives

• Limit the formation of blood coagulation factors II, VII, IX, and X in the liver by interfering with vitamin K

Heparin sodium• Increases the action of antithrombin III

(heparin cofactor) on several other coagulation factors to slow new clot development


Anticoagulants (cont.)

Action and Uses Prevent new thrombus formation Stop existing thrombi from growing in size Prophylactic: postsurgery involving the heart or

circulatory system Patients with heart valve disease, some

dysrhythmias, and receiving hemodialysis Patients on prolonged bed rest or with a history

of thrombus formation



Adverse Reactions Warfarin (Coumadin): alopecia, rash, urticaria,

cramping, diarrhea, intestinal obstruction, nausea, paralytic ileus, vomiting, excessive uterine bleeding, hemorrhage, leukopenia, fever

Heparin sodium: hypertension, headache, hematoma, conjunctivitis, tearing of eyes, rhinitis, hemorrhage, thrombocytopenia, dyspnea, chills, fevers, alopecia, persistent or prolonged erection, hypersensitivity



Drug InteractionsNursing Implications and Patient Teaching Calculation procedure of heparin is critical Monitoring blood values

Coumadin = prothrombin time (PT); therapeutic is 1.5 to 2.5 × normal or an INR of 2.0 to 3.0

Heparin = activated partial thromboplastin time (aPPT); therapeutic is 2.5 to 3 × the control value


Protamine Sulfate

Action Strong, alkaline protein that neutralizes effects of

heparin Results immediate, last 2 hours or moreUses Treatment of heparin overdose After surgical procedure where heparin was usedAdverse Reactions


Thrombolytic Agents

Action Convert plasminogen to the enzyme plasmin,

which breaks down fibrin clots, fibrinogen, and other plasma proteins anywhere in the body

Uses Acute myocardial infarctions Acute pulmonary emboli Acute ischemic stroke Acute arterial occlusion


Antiplatelet Agents

Action Inhibit platelet aggregation (clumping) Reduce thrombus formation

Uses Salicylic acid (aspirin)

Reduces incidence of myocardial infarction-related deaths in men over 50

Drug of choice in ischemic stroke


Antiplatelet Agents (cont.)

Uses (cont.) Dipyridamole (Persantine), ticlopidine (Ticlid),

clopidogrel (Plavix) Myocardial prophylaxis for men Adjunctive therapy with thrombolytics to prevent an

infarction or stroke Abciximab (ReoPro), anagrelide (Agrylin)

During cardiac catheterization and cardiac procedures


Question ?

Which is the anticoagulant of choice when an immediate effect is needed?

1. Warfarin2. Plavix (clopidogrel bisulfate)3. Heparin4. Aspirin


chapter 7 care of the patient with a blood or lymphatic disorder mosby items and derived items ©...

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heparin cofactor

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