Nursing of Adults with

Medical & Surgical Conditions

Blood and Lymphatic

Disorders

Blood and Lymphatic Disorders

Laboratory Tests• RBC (erythrocytes) 4-6 million/cu.mm• Hemoglobin 10-20 gm/100ml• Hematocrit 40-50 percent• WBC 5,000-10,000/mm• Platelets 150,000-400,000/mm

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

Anemia

Types• Blood loss (hemorrhage)

• Impaired production of RBC’s (bone marrow depression)

• Increased destruction of RBC’s (hemolysis)

• Nutritional deficiencies (long term iron deficiency)

Anemia

Signs & Symptoms• Anorexia• Cardiac dilation• Disorientation• Dyspepsia• Dyspnea• Exertional dyspnea• Fatigue• Headache

• Insomnia• Pallor• Palpitation• Shortness of breath• Systolic murmur• Tachycardia• Vertigo

Hypovolemic Anemia

Etiology/Pathophysiology• Abnormally low circulating blood volume due

to blood loss• 500 ml loss can be tolerated• 1000 ml loss can be severe complications• Severity and signs and symptoms depend on

how rapid the blood is lost

Hypovolemic Anemia Signs & Symptoms

• Weakness• Stupor• Irritability• Pale, cool, moist skin• Hypotension• Tachycardia (rapid, weak, thready pulse)

• Hypothermia• Hemoglobin less than 10 gm/100ml• Hematocrit less than 40 %

• H&H may not drop for several hours after blood loss

Hypovolemic Anemia

Treatment• Control bleeding• Treat shock

• O2, elevate lower extremities, keep warm

• Replace fluid• blood transfusion, plasma, dextran, lactaed ringers

• Monitor vital signs

Pernicious Anemia

Etiology/Pathophysiology• Absence of the intrinsic factor• Intrinsic factor is essential for the absorption of

vitamin B12• Deficiency of vitamin B12 affects growth and

maturity of all body cells• RBC’s in the bone marrow don’t mature• RBC membrane ruptures easily

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

degeneration of nerves and white matter

Pernicious Anemia

Signs & Symptoms• Extreme weakness• Dyspnea• Fever• Hypoxia• Weight loss• Jaundice (destruction of RBC’s)

• Pallor• GI complaints

Pernicious Anemia

• 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

Treatment• Vitamin B12 (cyanocobalamin) 1000 units

• daily for 1 week• weekly for 1 month• monthly for life

• Folic acid supplement• Iron replacement• RBC transfusion

• for severe anemia

• Diet• high protein, vitamins, and minerals

Aplastic Anemia

Etiology/Pathophysiology• Decrease of bone marrow function

• RBC production

• Primary• congenital

• Secondary• viral invasion• medications• chemicals• radiation• chemotherapy

Aplastic Anemia

Signs & Symptoms• Pancytopenic

• all three major blood elements from the bone marrow are decreased (RBC, WBC, & Platelets)

• Repeated infections with high fevers• Fatigue, weakness, malaise• Dyspnea• Palpitations• Bleeding tendencies

• petechiae, ecchymossis, bleeding gums, epistaxis, GI & GU bleeds

Aplastic Anemia

Treatment• Identify & remove cause• Platelet transfusion for severe thrombocytopenia• Splenectomy for hypersplenism

• Hypersplenism can cause destruction of platelets

• Steroids and androgens• stimulate bone marrow

• Antithymocyte globulin• stimulates bone marrow

• Bone marrow transplant

Iron Deficiency Anemia

Etiology/Pathophysiology• RBC’s contain decreased levels of hemoglobin• Excessive iron loss

• caused by chronic bleeding; intestinal, uterine, gastric

Iron Deficiency Anemia Signs & Symptoms

• Pallor

• Fatigue

• Weakness

• Shortness of breath

• Angina

• S/S of heart failure

• Glossitis• Pagophagia (desire to eat ice, clay, starches)

• Headache

• Paresthesia

• Burning tongue

Iron Deficiency Anemia Treatment

• Ferrous Sulfate 900 mg daily• Oral or injection (z-tract)

• Ascorbic acid• enhances absorption of iron

• Diet high in iron• Organ meats

– liver, kidney, heart, tongue

• Muscle meats (esp dark meat from poultry)

• Fish

• Eggs

• Green leafy vegetables

• Whole grains

• Dried beans

Sickle Cell Anemia Etiology/Pathophysiology

• Most common genetic disorder in the U.S.

• Occurs predominantly in African Americans• 1out of 10 have trait; 1 out of 500 have disease

• An abnormal, crescent shaped RBC• contains hemoglobin S (Hg-S)

• Severe, chronic, incurable condition

• Disease• Homozygous

– has two Hg-S genes; one from each parent

• Trait• Heterozygous

– has one Hg-S gene from one parent and one Hg-A gene from the other parent

Sickle Cell Anemia Signs & Symptoms

• Precipitating Factors• Dehydration

• Change in oxygen tension in the body– infection, overexertion, cold, alcohol, smoking

• Loss of appetite• Irritability• Weakness• Abdominal enlargement

• pooling of blood in the liver, spleen and other organs

• Join and back pain• Edema of extremities

Sickle Cell Anemia

Treatment• No specific treatment

• Alleviate symptoms

• Oxygen• Rest• Fluids

• oral and IV

• Analgesics• Bone marrow transplant

• Experimental

Agranulocytosis

Etiology/Pathophysiology• Severe reduction in the number of granulocytes

(basophils, eosinophils, & neutrophils)• WBC less than 200/mm3

• Medications• analgesics, antibiotics, antiepileptics, antihistamines, antineoplastic agents,

antithyroid drugs, diuretics, phenothiazides, sulfonamides

• Chemotherapy• Radiation• Neoplastic disease• Viral and bacterial infections

Agranulocytosis

Signs & Symptoms• S/S of infection

• fever, chills, headache, fatigue

• Ulcerations of mucous membranes• Bronchial pneumonia• Urinary tract infection

Agranulocytosis

Treatment• Identify and remove cause of bone marrow

depression• Prevent or treat infections• Meticulous handwashing• Strict asepsis

Leukemia

Etiololgy/Pathophysiology• Malignant disorder of the hematopoietic system• Excess leukocytes accumulate in the bone marrow

and lymph nodes• bone marrow produces immature cells

• Cause unknown• Possible causes include genetic, virus, exposure to

radiation, or chemotherapy

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

Leukemia

Signs & Symptoms• Anemia

• pallor, fatigue, malaise

• Thrombocytopenia• petechiae, epistaxis, bruising, occult blood

• Leukopenia• fever, upper resp. infections,

• Enlarged lymph nodes• Splenomegaly

Leukemia

Treatment• Chemotherapy• Radiation• Bone marrow transplant• Medications

• Leukeran

• hydroxyurea

• corticosteroids

• Cytoxan

Thrombocytopenia

Etiology/Pathophysiology• Abnormal hematological condition in which the

number of platelets is reduced below 100,000 mm3

• Decreased production• aplastic anemia, leukemia, tumors, chemotherapy

• Decreased survival• antibody destruction, infection, viral invasion

Thrombocytopenia

Signs & Symptoms• Petechiae• Ecchymoses• Platelets below 100,000

• bleeding mucous membranes

• bleeding internal organs

• Platelets below 20,000• serious bleeding risks

Thrombocytopenia

Treatment• Corticosteriod therapy• Splenectomy• Gamma globulin • Immunosuppressive drugs• Platelet transfusions• Avoid trauma

Hemophilia

Etiology/Pathophysiology• Hereditary coagulation disorder, characterized by a

disturbance of clotting factor• Hemophilia A

• most common• Factor VIII is absent

• Hemophilia B• Deficiency of Factor IX

• X-linked hereditary trait• affects mainly males• females are carriers

Hemophilia

Signs & Symptoms• Internal & external bleeding• Hemarthrosis

• bleeding into the joint; esp knees, ankles, and elbow

• Excessive blood loss from small cuts and dental procedures

Hemophilia

Treatment• Minimize bleeding

• avoid trauma

• Relieve pain• No aspirin

• Transfusions• Factor VIII or IX concentrate

– human-derived products– can be treated to inactivate viruses

• Cryoprecipitate (rich in factor VIII)– human-derived product

• Manufactured factor VIII or IX

von Willebrand’s Disease

Etiology/Pathophysiology• Inherited bleeding disorder characterized by

abnormally slow coagulation of blood and spontaneous episodes of GI bleeding, epistaxis, and gingival bleeding

• Mild deficiency of factor VIII• Common during

• Postpartum• Menorrhagia• Post operative• Post truama

• Similar to hemophilia; not limited to males

von Willebrand’s Disease

Treatment• Cryoprecipitate

• Fibrinogen

• Fresh plasma

• Desmopressin (DDAVP)• Synthetic of the human antiduiuretic hormone, vasopressin

• Causes an increase in factor VIII release from storage sites in the body

• Same nursing interventions as for hemophilia

Disseminated Intravascular Coagulation (DIC)

Etiology/Pathophysiology• Overstimulation of clotting and anticlotting processes

in response to disease or injury• Septicemia• Obstetrical complications• Malignancies• Tissue trauma• Transfusion reaction• Burns• Shock• Snake bites

Disseminated Intravascular Coagulation (DIC)

• Primary disorder initiates generalized intravascular clotting, which overtimulates fibrinolytic mechanisms

• The hypercoagulability is followed by a deficiency in clotting factors with subsequent hypocoagulability and hemorrhaging

Disseminated Intravascular Coagulation (DIC)

Signs & Symptoms• Bleeding

• Mucous membranes

• Venipuncture sites

• Surgical sites

• GI & GU tracts

• All orifices

• Dyspnea• Hemoptysis• Diaphoresis• Cold, mottled digits• Purpura on the chest and abdomen• Petechiae

Disseminated Intravascular Coagulation (DIC)

Treatment• Treat underlying cause• Cryoprecipitate• Heparin• Protect from bleeding and trauma

Multiple Myeloma

Etiology/Pathophysiology• Malignant neoplastic immunodeficiency

disease of the bone marrow• Tumor, composed of plasma cells, destroys

osseous tissue• Bone marrow becomes overcrowded and

unable to produce erythrocytes, platelets, and leukocytes

• Onset is gradual and insidious

Multiple Myeloma Signs & Symptoms

• Bone pain• Ribs, spine, and pelvis

• Pathological fractures• Infection• Anemia• Bleeding• Hypercalcemia

• Calcium and phosphorus drain from bones

• Renal failure• Myeloma protein causes kidney damage• Destruction of cells causes hyperuricemia

Multiple Myeloma Treatment

• Symptomatic; not curable• Radiation• Chemotherapy

• Alkeran

• Cytoxan

• Leukeran

• Carmustin

• Vincristine

• Adriamycin

• Dexamethasone

• Corticosteroids• IV fluids

Lymphangitis

Etiology/Pathophysiology• Inflammation of one or more lymphatic vessels• Usually occurs from acute streptococcal or

staphylococcal infection in an extremity

Lymphangitis

Signs & Symptoms• Fine red streaks from the affected area in the

groin or axilla• Edema• Chills• Fever• Local pain• Headache • Myalgia

Lymphangitis

Treatment• Penicillin• Hot, moist heat• Elevate extremity

Lymphedema

Etiology/Pathophysiology• Primary or secondary disorder • Accumulation of lymph in the soft tissue

• Obstruction

• Increase in amount of lymph

• Removal of lymph channels and nodes

Lymphedema

Signs & Symptoms• Massive edema and

tightness of affected extremity

• Pain

Treatment• Diuretics• Antibiotics• Compression pump• Elastic stocking or sleeve• Restricted sodium diet• Avoid constrictive clothing• Meticulous skin care

Lymphedema

Malignant Lymphoma

Etiology/Pathophysiology• Non-Hodgkin’s Lymphoma• Neoplastic disorder of lymphoid tissue• Tumors usually start in lymph nodes and spread

to lymphoid tissue in the spleen, liver, GI tract, and bone marrow

Malignant Lymphoma Signs & Symptoms

• Painless, enlarged cervical lymph nodes • Fever• Weight loss• Anemia• Pruritus• Susceptiblity to infection• Complications

• Pleural effusion, bone fractures, and paralysis

• Fatigue• Malaise• Anorexia

Malignant Lymphoma Treatment

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

• Initial treatment when localized

• Chemotherapy• Cytoxan, Oncovin adriamycin bleomycin, methotrexate• Treatment when not localized

• Bone marrow transplant• Tumor necrosis factor (TNF)

• Direct cell toxicity• Stimulates bone marrow

Hodgkin’s Disease

Etilology/Pathophysiology Inflammatory or infectious process that develops into a neoplasm Affects males twice as frequently as females Reed-Sternberg cells Large, abnormal, multinucleated cells in the lymphatic system replace the normal cells

Signs & Symptoms Enlargement of cervical lymph nodes Anorexia Weight loss Pruritus Low-grade fever Night sweats Anemia Leukocytosis

Hodgkin’s Disease

Etilology/Pathophysiology• Inflammatory or infectious process that

develops into a neoplasm• Affects males twice as frequently as females• Reed-Sternberg cells

• Large, abnormal, multinucleated cells in the lymphatic system replace the normal cells

Hodgkin’s Disease Signs & Symptoms

• Enlargement of cervical lymph nodes• Anorexia• Weight loss• Pruritus• Low-grade fever• Night sweats• Anemia• Leukocytosis

• Increased WBC

Hodgkin’s Disease

Treatment• Depends on the staging process

• Chart on page 280

• Stage I or II (localized)• Radiation

• Stage III or IV (generalized)• Chemotherapy

• Combination