hematologic problems

Care of Clients with Care of Clients with Hematologic DiseasesHematologic Diseases

Earl Francis R. Sumile, RNEarl Francis R. Sumile, RN

Instructor, College of NursingInstructor, College of Nursing

University of Santo TomasUniversity of Santo Tomas

Care of Clients with Hematologic Care of Clients with Hematologic DiseasesDiseases

Blood – transports cellular requirements and Blood – transports cellular requirements and products from one part of the body to another; products from one part of the body to another; composed of plasma (55%) and cellular composed of plasma (55%) and cellular component (45%)component (45%) slightly alkaline (ph 7.35-7.4)slightly alkaline (ph 7.35-7.4) 5-6 liters or 70-75 ml/kg BW (average volume)5-6 liters or 70-75 ml/kg BW (average volume)

Pulmonary circulation = 1300 ccPulmonary circulation = 1300 cc arterial (400cc) + capillary (60cc) + venous (840cc)arterial (400cc) + capillary (60cc) + venous (840cc)

Systemic circulation = 3000 ccSystemic circulation = 3000 cc arterial (550cc) + capillary (300cc) + venous (2150cc)arterial (550cc) + capillary (300cc) + venous (2150cc)

Care of Clients with Care of Clients with Hematologic DiseasesHematologic Diseases

Hematopoiesis – blood cell production; done in Hematopoiesis – blood cell production; done in the bone marrow (red), pelvis, sternum, ribs, the bone marrow (red), pelvis, sternum, ribs, epiphysis of long bonesepiphysis of long bones

Erythropoiesis – red blood cell production in the Erythropoiesis – red blood cell production in the liver in utero (2 to 5 months old) then in bone liver in utero (2 to 5 months old) then in bone marrow.marrow. needs iron, protein, pyridoxine (B6), cyanocobalamine needs iron, protein, pyridoxine (B6), cyanocobalamine

(B12), folic acid, and copper(B12), folic acid, and copper Reticuloendothilial System – mononuclear Reticuloendothilial System – mononuclear

phagocyte system or macrophage (spleen, liver, phagocyte system or macrophage (spleen, liver, lymphatic system, lungs)lymphatic system, lungs)


Nursing Assessment:Nursing Assessment: Pallor – conjunctivaPallor – conjunctiva Jaundice (hemolytic) – sclera; palms of Jaundice (hemolytic) – sclera; palms of

hands; soles of feethands; soles of feet Signs of bleeding such as petechiae, Signs of bleeding such as petechiae,

ecchymosis, hematoma, epistaxisecchymosis, hematoma, epistaxis Lymph nodes enlargementLymph nodes enlargement Limited joint range of motionLimited joint range of motion Splenomegaly or hepatomegalySplenomegaly or hepatomegaly

Care of Clients with Hematologic Care of Clients with Hematologic DiseasesDiseases Physical Assessment:Physical Assessment:

• Auscultate – heart murmur, bruitsAuscultate – heart murmur, bruits• Inspect – above assessmentInspect – above assessment• Palpate – lymph nodes, location, size, bone Palpate – lymph nodes, location, size, bone

tendernesstenderness• Percuss for ling excursion, splenomegaly, Percuss for ling excursion, splenomegaly,

hepatomegalyhepatomegaly• Evaluate joint ROM asnd tendernessEvaluate joint ROM asnd tenderness


Diagnostic Assessment:Diagnostic Assessment: Blood Blood

CBC with differential CBC with differential a. Hemoglobin – Males13-16 gm/dla. Hemoglobin – Males13-16 gm/dl

- Females 12-14 gm/dl- Females 12-14 gm/dlb. Hematocrit – Males 42-50%b. Hematocrit – Males 42-50%

- Females 40-48%- Females 40-48%c. RBC – N=Males 4,600,000 – 6,200,000 per cu.mmc. RBC – N=Males 4,600,000 – 6,200,000 per cu.mm

Females 4,200,000 – 5,400,000 per cu.mmFemales 4,200,000 – 5,400,000 per cu.mm

Diagnostic AssessmentDiagnostic Assessment

BloodBloodd. WBC – N=5,000 – 10,000 cu.mmd. WBC – N=5,000 – 10,000 cu.mm*neutrophils – N=60-70%*neutrophils – N=60-70% *eosinophils – N=1-4%*eosinophils – N=1-4%

*basophils – N=0–0.5%*basophils – N=0–0.5%*monocytes – N=2-6%*monocytes – N=2-6%*lymphocytes – N=20-30%*lymphocytes – N=20-30%

e. Platelets – N=200,000-350,000 per cu.mme. Platelets – N=200,000-350,000 per cu.mm


Coagulation studiesCoagulation studies• PT Prothrombin time N= 11-18 secsPT Prothrombin time N= 11-18 secs• PTT Partial Thromboplastin Time – N =50 PTT Partial Thromboplastin Time – N =50

to 80 secondsto 80 seconds• Clotting Time – N= 5 to 10 minutesClotting Time – N= 5 to 10 minutes• Bleeding Time – N=30 sec – 6 minutesBleeding Time – N=30 sec – 6 minutes


Blood chemistries – patients fasts for 6 to 8 hoursBlood chemistries – patients fasts for 6 to 8 hours a. Blood Urea Nitrogen (BUN) – N=10-20mgs/dla. Blood Urea Nitrogen (BUN) – N=10-20mgs/dl b. Creatinine – N=0.7-1.4mgs/dlb. Creatinine – N=0.7-1.4mgs/dl c. Uric acid – N= 2.5-8.0 mg/dl c. Uric acid – N= 2.5-8.0 mg/dl d. Cholesterol – N=150-300 mg/dld. Cholesterol – N=150-300 mg/dl e. Bilirubin – Total N=0.1-1.0 mg/dle. Bilirubin – Total N=0.1-1.0 mg/dl

• direct (N=0.1-0.2mg/dl)direct (N=0.1-0.2mg/dl)• indirect (N=0.1-0.8mg/dl)indirect (N=0.1-0.8mg/dl)


Miscellaneous Miscellaneous a. ESR – N=0 to 20 mm/hra. ESR – N=0 to 20 mm/hrb. Coomb’s test – indirect blood from mom, direct b. Coomb’s test – indirect blood from mom, direct blood from baby’s cordblood from baby’s cordc. Schillings test – Vit.B12 in the gastro-intestinal c. Schillings test – Vit.B12 in the gastro-intestinal systemsystem

prep NPO x 8 hours prep NPO x 8 hours radioactive Vit.B12 given POradioactive Vit.B12 given POVit.B12 nonradioactive given IMVit.B12 nonradioactive given IM2 hours after urine collection for radioactive2 hours after urine collection for radioactiveVit.B12; N = 15-40% of oral dose excretedVit.B12; N = 15-40% of oral dose excreted


Urine and Stool Urine and Stool UrinalysisUrinalysis Hematest Hematest Hemoccult – prep; -no dark colored food x 24 hours prior to Hemoccult – prep; -no dark colored food x 24 hours prior to

testtest Radiologic Radiologic

CXRCXR ScanScan LymphangiographyLymphangiography

Bone Marrow aspiration and biopsyBone Marrow aspiration and biopsy Preferred site – iliac crest, sternum or tibiaPreferred site – iliac crest, sternum or tibia Before: Before: consent, position exposing the siteconsent, position exposing the site After:After: pressure to site x5miuntes pressure to site x5miuntes

Erythrocyte DisordersErythrocyte Disorders

Anemia – reduction below normal level in Anemia – reduction below normal level in number of erythrocytes, quantity of hemoglobin number of erythrocytes, quantity of hemoglobin and volume of packed RBC’s.and volume of packed RBC’s. Basic underlying Basic underlying – tissue hypoxia– tissue hypoxia Signs and Symptoms Signs and Symptoms – depends upon severity and – depends upon severity and

chronicity and age.chronicity and age.• a. Mild – hemoglobin 10-14 gms; asymptomatic; palpitations, a. Mild – hemoglobin 10-14 gms; asymptomatic; palpitations,

dyspnea and diaphoresis following strenuous exertion.dyspnea and diaphoresis following strenuous exertion.• b. Moderate – increased palpitations, dyspnea, and b. Moderate – increased palpitations, dyspnea, and

diaphoresis; fatigue at rest or during activity.diaphoresis; fatigue at rest or during activity.• c. Severe – pale and exhausted all the time, sever c. Severe – pale and exhausted all the time, sever

palpitations, sensitivity to cold, loss of appetite, profound palpitations, sensitivity to cold, loss of appetite, profound weakness, angina.weakness, angina.

AnemiaAnemia

Iron Deficiency AnemiaIron Deficiency AnemiaCauses:Causes:

Inadequate absorption – increased Inadequate absorption – increased requirement requirement

Inadequate intake of iron rich foods Inadequate intake of iron rich foods Physiologic need – more in children and Physiologic need – more in children and

pregnant women pregnant women Physiologic loss – menstruationPhysiologic loss – menstruation Blood loss – trauma, GI bleeding Blood loss – trauma, GI bleeding

Iron Deficiency AnemiaIron Deficiency Anemia

Signs and Symptoms:Signs and Symptoms: Palpitations, dizziness, easy fatigability Palpitations, dizziness, easy fatigability Cold sensitivity, pallorCold sensitivity, pallor Brittle nails, and hairBrittle nails, and hair Plummer-vinsons syndrome – soreness and Plummer-vinsons syndrome – soreness and

inflammation of mouth and tongue (stomatitis inflammation of mouth and tongue (stomatitis and glossitis)and glossitis)

Iron Deficiency AnemiaIron Deficiency Anemia

Nursing management:Nursing management:*Oral iron – route of choice; given after meals; liquid iron *Oral iron – route of choice; given after meals; liquid iron intake with straw because it stains; mixed with 1 glass intake with straw because it stains; mixed with 1 glass cold H2O, best absorbed with Vitamin C; stool becomes cold H2O, best absorbed with Vitamin C; stool becomes tarry and constipation may occur. tarry and constipation may occur. *Parenteral – avoid tissue staining by using separate *Parenteral – avoid tissue staining by using separate aspiration injection needles; Z-tract method and deep IM; aspiration injection needles; Z-tract method and deep IM; do not massage but encourage ambulation. do not massage but encourage ambulation. *Dietary – increased in iron and roughage *Dietary – increased in iron and roughage *Blood transfusion*Blood transfusion

AnemiaAnemia

Pernicious anemia – Vitamin B12 Pernicious anemia – Vitamin B12 (cyanocobalamine) deficiency of intrinsic factor (cyanocobalamine) deficiency of intrinsic factor in the gastric mucosa which is necessary for in the gastric mucosa which is necessary for absorption of Vit.B12.absorption of Vit.B12.

Signs and Symptoms:Signs and Symptoms: Hemolytic jaundice – macrolytic hypochromic Hemolytic jaundice – macrolytic hypochromic Tingling sensations, paresthesias Tingling sensations, paresthesias Beefy red tongueBeefy red tongue Deficiency or absence of hydrochloric acid in the Deficiency or absence of hydrochloric acid in the

stomach stomach

Pernicious anemiaPernicious anemia

Nursing management:Nursing management: Drug therapy – Vit B12 injections (monthly) for Drug therapy – Vit B12 injections (monthly) for

lifelife Folic acid – reverses anemia, decreases Folic acid – reverses anemia, decreases

neurological symptomsneurological symptoms Transfusion therapyTransfusion therapy

Diagnostic assessment:Diagnostic assessment: Schilling’s testSchilling’s test Gastric analysisGastric analysis

AnemiaAnemia

Aplastic anemia – depressed bone Aplastic anemia – depressed bone marrow activity secondary to marrow activity secondary to antineoplastics, radiation, insecticide, antineoplastics, radiation, insecticide, drugs and chemical toxins.drugs and chemical toxins.

Laboratory Assessment: Laboratory Assessment: pancytopeniapancytopenia ErythrocytopeniaErythrocytopenia Leukocytopenia Leukocytopenia Thrombocytopenia Thrombocytopenia

Aplastic anemiaAplastic anemia

Nursing management:Nursing management: Blood transfusionBlood transfusion Prevent and treat infections Prevent and treat infections Bone marrow transplant Bone marrow transplant Drug – corticosteroids; estrogenDrug – corticosteroids; estrogen Identify and withdraw offending agentIdentify and withdraw offending agent

Leukocyte DisordersLeukocyte Disorders

Leukemia – most common of childhood (3-Leukemia – most common of childhood (3-5 y/o) cancer; abnormal proliferation of 5 y/o) cancer; abnormal proliferation of WBC in blast form.WBC in blast form.

Predisposing factors:Predisposing factors: Radiation Radiation Survivors of HiroshimaSurvivors of Hiroshima Benzol, aniline dyesBenzol, aniline dyes

LeukemiaLeukemia

Types of Leukemia:Types of Leukemia:*Acute lymphocytic leukemia (ALL)*Acute lymphocytic leukemia (ALL)

• 80-85%of childhood leukemia 80-85%of childhood leukemia • 95% chance of obtaining remission with diagnostic 95% chance of obtaining remission with diagnostic

assessment assessment • 75% chance of surviving over 5 years75% chance of surviving over 5 years

*Acute non-lymphocytic anemia (ANLL)*Acute non-lymphocytic anemia (ANLL)• granulocytic and monocyticgranulocytic and monocytic• 60-80% will obtain remission with treatment 60-80% will obtain remission with treatment • 30-40% cure rate30-40% cure rate

LeukemiaLeukemia Signs and Symptoms:Signs and Symptoms:

Anemia – weakness, pallor, dyspneaAnemia – weakness, pallor, dyspnea Petechiae, spontaneous bleeding Petechiae, spontaneous bleeding Infection, - fever, malaiseInfection, - fever, malaise Enlarged lymph nodes, liver and spleenEnlarged lymph nodes, liver and spleen Abdominal pain, weight loss, anorexiaAbdominal pain, weight loss, anorexia Bone pain due to expansion of marrowBone pain due to expansion of marrow

LeukemiaLeukemia

Nursing management:Nursing management:*Supportive therapy – rest, blood transfusion, prevent *Supportive therapy – rest, blood transfusion, prevent infection, promote nutrition, oral hygiene, skin careinfection, promote nutrition, oral hygiene, skin care*Drug therapy – antileukemia – oncovin, prednisone, *Drug therapy – antileukemia – oncovin, prednisone, methotrexate (2-3 yrs.)methotrexate (2-3 yrs.)*Radiation*Radiation*Bone marrow transplant*Bone marrow transplant

Leukocyte DisordersLeukocyte Disorders

Lymphoma – lymphatic tissue Lymphoma – lymphatic tissue (lymphocytes)(lymphocytes) a. Hodgkin’s – malignant neoplasms of a. Hodgkin’s – malignant neoplasms of

lymphatic tissue originating in lymph nodes lymphatic tissue originating in lymph nodes proliferating to spleen and liver proliferating to spleen and liver • Signs and Symptoms Signs and Symptoms – enlarged nontender nodes, – enlarged nontender nodes,

Reed Sternberg cells, pruritus Management – Reed Sternberg cells, pruritus Management – chemotherapy, radiationchemotherapy, radiation

LymphomaLymphoma

b. NonHodgkins – tumor originating in b. NonHodgkins – tumor originating in lymphatic tissue characterized by diffuse, lymphatic tissue characterized by diffuse, undifferentiated cell; prognosis is poorer undifferentiated cell; prognosis is poorer than Hodgkin’s.than Hodgkin’s.

Management:Management:• *chemotherapy*chemotherapy• *radiotherapy and *radiotherapy and • *surgery for diagnosis and staging *surgery for diagnosis and staging

hematologic problems

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