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Blood Disorders
| Question | Answer |
|---|---|
| Major Topics Covered | Anemias, Thrombocytopenia, Polycythemia, Neutropenia |
| Health Hx - Past Medical Hx (PMH) | Blood loss/trauma; Liver, endocrince, GI, immune disorders; Exposure to radiation, toxins and infections; travel; Angina, Hx MI; Hx falls |
| Health Hx - Medications/Drugs | Vitamins, iron supplements, Prescription & OTC drugs; Herbal meds; Recreational drugs incl. ETOH & tobacco. |
| Health Hx - Surgeries & Txs | GI & recent surgeries; Prosthetic heart valve replacements; hemodialysis; Radiation & chemotherapy |
| Health Hx - Dietary | Usual dietary pattern; Hx pica |
| Health Hx - Functional (Fx) Health Patterns - Health Perception- Health Management | Family Hx of anemia, malaise |
| Health Hx - Functional (Fx) Health PatternsNutritional-Metabolic | N/V; anorexia; weight loss; dysphagia; dyspepsia; heartburn; night sweats; cold intolerance |
| Health Hx - Functional (Fx) Health PatternsElimination | Hematuria; decreased urinary output; diarrhea; constipation; flatulence; tarry/blood stools |
| Health Hx - Functional (Fx) Health PatternsActivity-exercise | Fatigue; muscle weakenss and decrease strength; cough, hemoptysis; palpitations; dyspnea; shortness of breath with activity |
| Health Hx - Functional (Fx) Health PatternsCognitive-perceptual | HA; abd, chest, bone, tongue pain; paresthesias of feet & hands; disturbances in vision, taste, hearing; vertigo & dizziness; hypersensitivity to cold |
| Health Hx - Functional (Fx) Health PatternsSexual-reproductive | Menorrhagia; metrorrhagia; recent or current pregnancy; erectile dysfunction |
| Physical Findings-General | General lyphadenopathy, fever, lethargy, apathy |
| Physical Findings-Respiratory | tachypnea |
| Physical Findings-Integumentary | Pale skin/mucous membranes, blue, pale white, or icteric sclera; cheilitis; poor skin turgor; brittle, spoon-shaped nails; jaundice; petechiae; ecchymoses; nose or gingival bleeding; poor healing; drya, brittle thinning hair |
| Physical Findings-Cardiovascular | Tachycardia, systolic murmur, dysrhythmias, postural hypotension, increased pulse pressure, bruits (especially carotid), intermittent, claudication, ankle edema |
| Physical Findings-GI | Hepatosplenomegaly; glossitis; beefy red tongue; stomatitis; abd distention; anorexia |
| Physical Findings-Neurologic | HA, roaring in ears, confusion, impaired judgment, irritability, ataxia, unsteady gait, paralysis, loss of vibration sense |
| Laboratory/diagnostic tests | Decrease RBCs, decrease HB; decrease HCT; Increase or decrease reticulocytes, MCV, serum iron, ferritin, folate, or cobalamin; heme (guiac)-positive stools; decrease serum erythropoietin levels; increase or decrease LDH, bilirubin, transferrin |
| Common Tx Modalities-Injury prevention | Activity level, bed devices, call light, safe environment, shower chair, Peds safety helmets; No aspirin-type products for pain, fever; no IMs when clotting decreased; Observation for drug SEs & quick response |
| Common Tx Modalities-Dietary guidelines | Protein foods; Foods for deficiences |
| Common Tx Modalities-Mineral/vitamin supplements | Iron, vitamins, other minerals; Intrinsic factor & Vit B12 deficiency |
| Common Tx Modalities-Blood/blood product transfusions | PRBCs or whole blood; Platelets; Precautions |
| Common Tx Modalities-Stem Cell Transplantations | Precautions |
| Common Tx Modalities-Pharmacological agents | Steroids; Erythropoietin; Vitamin K, protamine sulfate |
| Common Tx Modalities-Surgery | For hemostasis; Therapeutic phlebotomy |
| Common Nsg Dx assoc with Anemia | Activity intolerance; Altered nutrition less than body requirements; Ineffective management of therapeutic regimen; Risk for injury (use ineffective management of therapeutic regime for NIC & NOC) |
| Activity Intolerance-Patient Goals | Participates in normal ADL without abnormal increases in blood pressure and pulse (individualize and quantify). |
| Activity Intolerance-Patient Goals | Reports less weakness and fatigue. |
| Altered Nutrition, less than body requirements-Patient Goals | Maintains dietary intake that provides minimum daily requirements (in hospital usually individualize goal by stating % of food to be consumed). |
| Altered Nutrition, less than body requirements-Patient Goals | Experiences normal blood values of nutrients necessary to prevent anemia. |
| Ineffective Management of Therapeutic Regimen-Patient Goals | Verbalizes knowledge necessary to maintain adequate nutrition and management of medicine regimen (individualize goal--state the specific knowledge necessary; actual objective changes of behavior are preferable to verbalization). |
| Risk for Injuries-Patient Goals | Pt will sustain no (new) injuries during hospitalization. |
| Risk for Injuries-Patient Goals | Pt will identify potential hazards r/t (specific blood disorder) and (specific txs and medicines pt is receiving). |
| Risk for Injuries-Patient Goals | Pt (will verbalize a plan to avoid injury r/t the specific health problem and txs)/(will take specific actions to avoid specific injuries). |
| Activity Intolerance Interventions | Determine pt's physical limitations; Monitor response to activity; Plan activity & rest; Control visits; Limit environmental stimuli; Assist with activities as needed; Assist pt to build endurance. |
| Anemia Definition & Characteristics | Deficient RBCs, Hgb, and/or Hct; NOT a disease process; S/S R/T: Hypoxia, decrease hemoglobin, increase bilirubin. |
| Selected Anemias under Discussion | Iron Deficiency Anemia; Megaloblastic Anemias: Cobalamin deficiency, Folate deficiency; Aplastic Anemia; Hemorrhagic Anemias: Acute, Chronic |
| Classification of Anemias-Anemias are Classified by | Morphology (form), Etiology (cause) |
| Morphology of RBCs | Normocytic, normochromic; Macrocytic, normochromic; Microcytic, hypochromic |
| Etiologies of Anemia | Significance for Nsg Practice |
| Etiologies of Anemia-Relationship to morphology-Normocytic, normochromic | Acute blood loss, hemolysis, chronic kidney disease, chronic disease, cancers, sideroblastic anemia, refractory anemia, diseases of endocrine dysfunction, aplastic anemia, sickle cell anemia, pregnancy |
| Relationship of Etiology to Morphology-Macrocytic, normochromic | B12 deficiency, folic acid deficiency, liver disease, ETOH overuse, postnephrectomy |
| Relationship of Etiology to Microcytic, hypochromic | Iron deficiency anemia, thalasemia, lead poisioning. |
| Etiologic Classifications: Decrease RBC production-Decrease Hgb synthesis | Iron deficiency, thalessemias (decrease Hgb synthesis), sideroblastic anemaias (decrease porphyrin) |
| Etiologic Classifications: Decrease RBC production-Defective DNA synthesis | Cobalmin (B12) deficiency, folic acid deficiency. |
| Etiologic Classifications: Decrease RBC production-Decreased RBC precursors | Aplastic anemia, myeloproliferative (leukemia) & myelodysplasia, chronic diseases or disorders |
| Etiologic Classifications: Decrease RBC production | Chemotherapy |
| Etiologic Classifications: Blood Loss - ACUTE | Trauma, blood vessel rupture |
| Etiologic Classifications: Blood Loss - CHRONIC | Gastritis, menstrual flow, hemorrhoids |
| Etiologic Classifications: Increase RBC Destruction - INTRINSIC | Abnormal Hgb (Hb S), enzyme deficiency (G6PD), membrane abnormalities (paroxysmal nocturnal hemoglobinuria, hereditary spherocytosis) |
| Etiologic Classifications: Increase RBC Destruction - EXTRINSIC | Physical trama (prosthetic heart valves, extracorporeal circulation), Antibodies (isoimmune & autoimmune), infectious agents, medications, & toxins (malaria) |
| Factors Contributing to Anemia Development - HEREDITY | Hemophilia, Sickle Cell, thalassemia |
| Factors Contributing to Anemia Development - NUTRITION | Iron, protein, vitamins: folic acid, B6, B12, C (overdose danger) |
| Factors Contributing to Anemia Development - SOCIOCULTURAL/ECONOMIC FACTORS | Especially health care access & nutrition |
| Factors Contributing to Anemia Development - DISEASE PROCESSES | Liver, spleen, kidney, GI conditions; immunological & genetic conditions; txs associated with diseases |
| Factors Contributing to Anemia Development - AGE | Immune & organ function, hormones, disease susceptibility, metabolism |
| Factors Contributing to Anemia Development - TRAUMA/AGE | Blood loss, altered organ function (splenectomy, nephrectomy) |
| Factors Contributing to Anemia Development - MEDICATIONS | Altered immune, bone marrow, organ function; direct effect on blood cells; absorption/use of nutrients |
| Clinical Manifestations of Anemia by Severity and Body System - SEVERITY - MILD | Hb 10-14g/dL |
| Clinical Manifestations of Anemia by Severity and Body System - SEVERITY - MODERATE | Hb 6-10g/dL |
| Clinical Manifestations of Anemia by Severity and Body System - SEVERITY - SEVERE | Hb <6g/dL |
| Clinical Manifestations of Anemia by Severity and Body System - INTEGUMENTARY - MILD | None |
| Clinical Manifestations of Anemia by Severity and Body System - INTEGUMENTARY - MODERATE | None |
| Clinical Manifestations of Anemia by Severity and Body System - INTEGUMENTARY - SEVERE | Pallor, jaundice, "pruritis" |
| Clinical Manifestations of Anemia by Severity and Body System - EYES - MILD | None |
| Clinical Manifestations of Anemia by Severity and Body System - EYES - MODERATE | None |
| Clinical Manifestations of Anemia by Severity and Body System - EYES - SEVERE | Icteric conjunctiva & sclera, retinal hemorrhage, blurred vision |
| Clinical Manifestations of Anemia by Severity and Body System - MOUTH - MILD | None |
| Clinical Manifestations of Anemia by Severity and Body System - MOUTH - MODERATE | None |
| Clinical Manifestations of Anemia by Severity and Body System - MOUTH - SEVERE | Glossitis, smooth tongue |
| Clinical Manifestations of Anemia by Severity and Body System - CARDIOVASCULAR - MILD | Palpitations |
| Clinical Manifestations of Anemia by Severity and Body System - CARDIOVASCULAR - MILD | Palpitations |
| Clinical Manifestations of Anemia by Severity and Body System - CARDIOVASCULAR - MODERATE | Increased palpitations, "bounding pulse" |
| Clinical Manifestations of Anemia by Severity and Body System - CARDIOVASCULAR - SEVERE | Tahycardia, increased pulse pressure, systolic murmurs, intermittent claudication, angine, HF, MI |
| Clinical Manifestations of Anemia by Severity and Body System - PULMONARY - MILD | Exertional dyspnea |
| Clinical Manifestations of Anemia by Severity and Body System - PULMONARY - MODERATE | Dyspnea |
| Clinical Manifestations of Anemia by Severity and Body System - PULMONARY - SEVERE | Tachypnea, orthopnea, dyspnea at rest. |
| Clinical Manifestations of Anemia by Severity and Body System - NEUROLOGIC - MILD | None |
| Clinical Manifestations of Anemia by Severity and Body System - NEUROLOGIC - MODERATE | "Roaring in the ears" |
| Clinical Manifestations of Anemia by Severity and Body System - NEUROLOGIC - SEVERE | Headache, vertigo, irritability, depression, impaired thought processes |
| Clinical Manifestations of Anemia by Severity and Body System - GI - MILD | None |
| Clinical Manifestations of Anemia by Severity and Body System - GI - MODERATE | None |
| Clinical Manifestations of Anemia by Severity and Body System - GI - SEVERE | Anorexia, hepatomegaly, splenomegaly, difficulty swallowing, sore mouth |
| Clinical Manifestations of Anemia by Severity and Body System - MUSCULOSKELETAL - MILD | None |
| Clinical Manifestations of Anemia by Severity and Body System - MUSCULOSKELETAL - MODERATE | None |
| Clinical Manifestations of Anemia by Severity and Body System - MUSCULOSKELETAL - SEVERE | Bone pain |
| Clinical Manifestations of Anemia by Severity and Body System - GENERAL - MILD | None |
| Clinical Manifestations of Anemia by Severity and Body System - GENERAL - MODERATE | Fatigue |
| Clinical Manifestations of Anemia by Severity and Body System - GENERAL - SEVERE | Sensitivity to cold, weight loss, lethargy |
| Definition of Iron Deficiency Anemia | Microcytic, hypochromic anemia caused by inadequate supplies of iron needed to synthesize hemoglobin. |
| Characteristics of Iron Deficiency Anemia | Pallor, fatigue, & weakness. |
| Pathophysiology of Anemia | Tissue hypoxia results from deficient functioning hemoglobin. Hemoglobin cannot bind to oxygen without iron. |
| Labs: Iron Deficiency Anemia - DECREASED | Hb/Hct, MCV, Serum Fe, Ferritin |
| Labs: Iron Deficiency Anemia - DECREASED OR NORMAL | Transferrin, Bili. |
| Labs: Iron Deficiency Anemia - NORMAL OR SLIGHT DECREASE OR INCREASE | Reticulocytes |
| Labs: Iron Deficiency Anemia - INCREASED | TIBC (Total Iron Binding Capacity) |
| Iron Deficiency Anemia Treatment - ORDER OF PREFERENCE | Fe rich diet, Oral supplements, Parenteral routes |
| Iron Deficiency Anemia Treatment - NURSING CONSIDERATIONS | Ferrous iron best absorbed; Irritating staining to tissue; Allergic reactions parenterally |
| Definition & Characteristics of Megaloblastic Anemias | Anemias resulting from impaired DNA synthesis |
| Definition & Characteristics of Megaloblastic Anemias | Causes large, defective RBCs that are fragile |
| Definition & Characteristics of Megaloblastic Anemias | Cobalamin & Folate Deficiency are most common causes. |
| Labs: Megaloblastic Anemias - DECREASED | Hb/Hct |
| Labs: Megaloblastic Anemias - DECREASED OR NORMAL | Reticulocytes |
| Labs: Megaloblastic Anemias - NORMAL | TIBC |
| Labs: Megaloblastic Anemias - NORMAL OR SLIGHT INCREASE | Bilirubin |
| Labs: Megaloblastic Anemias - NORMAL OR INCREASED | Serum Fe |
| Labs: Megaloblastic Anemias - SLIGHT INCREASE | Transferrin |
| Labs: Megaloblastic Anemias - INCREASED | MCV, Ferritin |
| Cobalamin Absorption - B12 | Absorbed indistal ileum only in presence of IF |
| Cobalamin Absorption - IF | Secreted by gastric parietal cells in acidic environment |
| Diagnostic Tests for Cobalamin Levels | Folic acid & cobalamin levels; Schilling's test with radioactive cobalamin (with or without B12); Gastroscopy with Bx for stomach Ca; Serum methylmalonic acid (MMA); Serum homocysteine |
| Cobalamin Absorption | Antibodies may destroy cells causing pernicious anemia, especially in elderly & African Americans |
| Cobalamin Absorption | Gastrectomy, chronic atrophic gastritis, H2 blockers, decreased IF secretion |
| Cobalamin Absorption | Small bowel resection, Crohn's disease, ileitis, small bowel diverticulosis decrease ileal absorption |
| Cobalamin Absorption | Parenteral (IM, intranasal) cobalamin must be given for life if deficient IF or ileal absorption |
| Folacin Deficiency Risk Factors | Poor nutrition; Malabsorption syndrome; Drugs decreasing absorption or metabolism of folate; Alcohol & anorexia; Hemodialysis |
| Neurological Manifestations of Megaloblastic Anemias | Folacin deficiency does not cause neurological problems |
| Neurological Manifestations of Megaloblastic Anemias | Excessive intake of folic acid blocks anemai but not prevent neurological changes of B12 deficiency which may be permanent |
| Neurological Manifestations of Megaloblastic Anemias | Neuro problems are risk fx for injuries |
| Definition & Characteristics of Aplastic Anemia | Pancytopenia, hypocellular bone marrow; Variable presentation; Low incidence; Immune based destruction of bone marrow cells |
| Labs: Aplastic Anemias - DECREASED | Hb/Hct, Reticulocytes |
| Labs: Aplastic Anemias - NORMAL | Transferrin, Ferritin, Bilirubin |
| Labs: Aplastic Anemias - NORMAL OR SLIGHT INCREASE | MCV |
| Labs: Aplastic Anemias - NORMAL OR INCREASED | Serum Fe, TIBC |
| Aplastic Anemia Etiology - CONGENITAL | (30%) |
| Aplastic Anemia Etiology - ACQUIRED | Ionizing radiation; Chemical agents or medications; Viral or bacterial infections |
| Aplastic Anemia Etiology - IDIOPATHIC | 70% of acquired aplasctic anemias) |
| Aplastic Anemia Diagnostic Studies | CBC; Bone marrow bx: Hypocellular, yellow marrow replacement of hematopoietic stem cells |
| Aplastic Anemia Management | Identification & avoidance of causative factors |
| Aplastic Anemia Management - MILD CASES | Erythropoietin, blood transfusions |
| Aplastic Anemia Management - SEVERE CASES | Supportive care, prevention of bleeding/infection |
| Treatment for Aplastic Anemia with Poor Prognosis | Hematopoietic stem cell transplant (HSCT) |
| Treatment for Aplastic Anemia with Poor Prognosis | Immunosupressive therapy: Cyclosporine or cylophosphamide; Antithymocyte globulin (ATG)(horse serum with antibodies against human T-cells) |
| Definition & Characteristics of Anemia Caused by Acute Blood Loss - Stage 1 | Hypovolemia with normal Hct/Hb, possible hypovolemic shock |
| Definition & Characteristics of Anemia Caused by Acute Blood Loss - Stage 2 | Normal blood volumce, decreased Hct/Hb |
| Labs: Acute Blood Loss - DECREASED | Hb/Hct |
| Labs: Acute Blood Loss - DECREASED OR NORMAL | MCV |
| Labs: Acute Blood Loss - NORMAL | Serum Fe, TIBC, Transferrin, Ferritin, Bilirubin |
| Labs: Acute Blood Loss - NORMAL OR INCREASED | Reticulocytes |
| Management of Anemia caused by Acute Blood Loss - Pain assessment | Pain may indicate tissue distention, organ displacement or nerve compression from internal hemorrhage; Pain and numbness may be referred to extremity due to nerve compression |
| Management of Anemia caused by Acute Blood Loss | Careful quantification of post-op blood loss |
| Management of Anemia caused by Acute Blood Loss | Fluid replacement |
| Management of Anemia caused by Acute Blood Loss | PRBC administration |
| Management of Anemia caused by Acute Blood Loss | Hemorrhage identification & stasis |
| Management of Anemia caused by Acute Blood Loss | Parenteral iron supplementation |
| Characteristics of Anemia caused by Chronic Blood Loss | Similar to Fe deficency anemia |
| Management of Anemia caused by Chronic Blood Loss | Identification and stasis of source of blood loss; Suplementary Fe administration |
| Labs: Chronic Blood Loss - DECREASED | Hb/Hct, MCV, Serum Fe, TIBC |
| Labs: Chronic Blood Loss - DECREASED OR NORMAL | Bilirubin |
| Labs: Chronic Blood Loss - NORMAL | Transferrin, Ferritin |
| Labs: Chronic Blood Loss - NORMAL OR INCREASED | RETICULOCYTES |
| Anemia Treatment Modalities - PRIMARY PREVENTION | GOAL: Maintain optimal health; Screening (blood disorders, hereditary, kidney, liver, hereditary disorders); Teaching (nutrition, pathophysiology, medications); Collaboration (genetic counseling, medical, dietary referrals) |
| Anemia Treatment Modalities - SECONDARY PREVENTION (see NCP) | GOAL: Retain optimal health |
| Anemia Treatment Modalities - TERTIARY PREVENTION | GOAL: Attain optimal health; Monitor pt's health state (including lab exams); Teach reportable s/s, adaptations & precautions; Medication teaching: purpose, administration instructions, medications to avoid, S/Es; Other (see primary prevention) |
| Thrombocytopenia Causes - HEREDITARY | Rare |
| Thrombocytopenia Causes - ACQUIRED IMMUNE | Immune thrombocytopenic purpura (ITP_ - platelets coated antibodies |
| Thrombocytopenia Causes - NONIMMUNE SHORTENED CIRCULATION | Thrombotic thrombocytopenic purpura; Heparin-induced thrombocytopenia; Splenomegaly/Splenic Sequestration |
| Thrombocytopenia Causes - TURBULENT BLOOD FLOW | Hemangiomas, Abnormal Cardiac Vavles, Intra-aortic balloon pumps |
| Thrombocytopenia Causes - DECREASED PLATELET PRODUCTION | Food, drugs, herbs, chemotherapy; Infections; Neoplasms; Aplastic Anemia; Radiation; Other |
| Thrombocytopenia: S/S | Petechiae, purpura, ecchymoses |
| Thrombocytopenia: S/S | Epistaxis, bucal bullous hemorrhages |
| Thrombocytopenia: S/S | Weakness, fainting, dizziness, swelling, tachycardia, pain, hypotension |
| Thrombocytopenia: S/S | Subtle confusion/personality change, headache, seizures, coma |
| Thrombocytopenia: Major Complications | Anemia, severe hemorrhage, hypovolemic shock |
| Thrombocytopenia: Major Complications | Thrombosis, infarct, stroke, organ/joint/muscle destruction |
| Thrombocytopenia: Major Complications | Brain death or death |
| Thrombocytopenia: NSG Dx | Impaired oral mucous membrane; Risk for injury; Ineffective management of therapeutic regimen |
| Thrombocytopenia: Collaborative Care - MAJOR GOALS | Treat thrombocytopeni; Prevent complications |
| Thrombocytopenia: Collaborative Care - PRIMARY/SECONDARY/TERTIARY Nsg Goals | See anemia |
| Thrombocytopenia: Collaborative Care, Interventions - GENERAL | Identify precipitating agent & avoid; Avoid injuries; Monitor pt status, document, collaborate; Teach conditions to report, safety measures |
| Thrombocytopenia: Collaborative Care, Interventions - IMMUNE THROMBOCYTOPENIC PURPURA | In sequence: 1) prednisone PO, 2) MethylPREDNISolone IV, 3) splenectomy, 4) immunosuppresive therapy; Other: immunoglobulin IV, Danazol (androgen), aminocaproic acid (Amicar) [antifibrinolytic] |
| Thrombocytopenia: Collaborative Care, Interventions - IMMUNE THROBOCYTOPENIC PURPURA - AVOID | Aspirin, platelet transfusion (w/o HLA matching; diphenydramine, hydrocortisone premed) |
| Thrombocytopenia: Collaborative Care, Interventions - Heparin-induced thrombocytopenia and thrombosis syndrome - FIRST STEP | D/C heparin, avoid platelet transfusions |
| Thrombocytopenia: Collaborative Care, Interventions - Heparin-induced thrombocytopenia and thrombosis syndrome - SECOND STEP | Begin direct thrombin inhibitor (lepirudin or argatroban), fondaparinux (Xa inhibitor), or Coumadin if platelets =/> 100k/mcl |
| Thrombocytopenia: Collaborative Care, Interventions - Heparin-induced thrombocytopenia and thrombosis syndrome - THIRD STEP | Thrombectomy, plasmapharesis to clear IgG, protamine sulfate |
| Thrombocytopenia Educational Needs | S/S to report for early intervention; Interventions to reduce risk of injury/complications; SEE LEWIS p 707 Table 31-15 |
| Polycythemia: Definitions | Increased RBCs, increased Hb, hyperviscosity, hypervolemia |
| Polycthemia: Definitions - POLYCTHEMIA VERA | Chromosomal abnormality |
| Polychtemia: Definitions - SECONDARY POLYCYTHEMIA | Hypoxia, Nonhypoxic (EPO-producing neoplasm) |
| Polycythemia S/S - r/t hyperviscosity & hypervolemia | Htn, HA, vertigo, dizziness, tinnitus, visual disturbances, paresthesias, erythomelalgia, angina, heart failure, intermittent claudication, thrombophlebitis, embolization, impaired blood flow, circulatory stasis, thrombosis, tissue hypoxia, plethora |
| Polycythemia S/S - r/t platelet dysfunction or vessel distention & rupture (bleeding) | Petechiae, ecchymoses, epistaxis, GI bleeding, acute catastrophic hemorrhage, heaptomegaly, splenomegaly, satiety & fullness of stomach, hyperuricemia, gout |
| Polycythemia S/S - r/t increased basophils & histamine release | Generalized pruritis |
| Polycythemia: Dx studies - Polycythemia VERA | Increased Hb/RBC, microcytosis; decreased or N EPO; Increased WC, basophilia; increased platelets & platelet dysfunction; increased leukocyte alkaline phosphatase, uric acid & cobalamin levels; increased histamine, bone marrow |
| Polycythemia: Dx studies Polycythemia VERA Bx | Hypercellularity of WBCs, RBCs, & platelets; splenomegaly (90% of PV cases) |
| Polycythemia: Dx studies Secondary polycythemia | Increased Hb/RBC, (possible) microcytosis; increased EPO levels; s/s, lab values consistent with respiratory or renal disease |
| Polycythemia Nsg Dx: PCs | Potential Complication (PC) [similar to risk problem, but requires high degree of collaboration] - PC: heart failure, PC: hemorrhage, PC: stroke |
| Polycythemia: Nsg Dx | Pain r/t gout (or tissue hypoxia), risk for injury |
| Polycythemia: Major Tx - Nursing | Decreased risk & related factors for complications; Monitor & report defining characteristics of P/Cs ASAP |
| Polycythemia: Major Tx - Medical | Decreased blood volume, viscosity, & bone marrow hyperactivity; Treat exacerbating conditions & prevent or treat complications |
| Polycythemia: Interventions | Phlebotomy, maintain appropriate fluid balance, maintain adequate oxygenation, maintain adequate nutrition, prevent thrombus development by leg exercises and early ambulation, monitor for complications & pts health status |
| Polycythemia: Interventions - MEDICATION ADMINISTRATION | Busulfan, hydroxyurea, melphalan (Alkeran), radioactive phosphorous [myelosuppresion]; paroxetine (Paxil), aspirin [erythromelalgia-paroxysmal peripheral dilation of peripheral blood vessels]; interferon alpha [intractabl pruritis] |
| Polycythemia: Interventions - MEDICATION ADMINISTRATION | Anagrelide (Agrylin) [decreased platelet count & agregation]; allopurinol [gout] |
| Polycythemia: Health Promotion Strategies/Medication Teaching | Teach pts to weigh advantages & disadvantages of taking aspirin and other OTHC meds that cause a high incidence of platelet |
| Polycythemia: Health Promotion Strategies/Medication Teaching | Teach pts to report drug specific s/s that they are having a drug reaction |
| Neutropenia: Definition | Reduction in neutrophils from normal levels; Note: since most granulocytes are neutrophils, granulocytopenia & neutropenia are often used interchangeably |
| Neutropenia: Causes | Iatrogenic (drug induced) causes are most common |
| Neutropenia: Causes - MAJOR CATEGORIES OF CAUSES | Drug induced; Hematological disorders; Autoimmune disorders; Infections; Miscellaneous (See Lewis, p 714, table 31-21) |
| Neutropenia: Causes - MISCELLNEOUS CAUSES INCLUDE | Severe sepsis; Bone marrow infiltration; Hypersplenism; Nutritional deficiencies; Transfusion reaction; Hemodialysis |
| Neutropenia: s/s - DECREASED IMMUNE RESPONSE M/B | No decreased pus, s/s inflammation (incl. low-grade fever only), atopic skn tests; Severe infectins with normal flora candida, staph aureus) or opportunistic infectious agents (TB, Pneumocystis jiroveci, cytomegalovirus [CMV]) |
| Neutropenia: s/s - DECREASED IMMUNE RESPONSE M/B | H-Z & herpes simplex reactivization with severe, wide-spread infection |
| Neutropenia: s/s - POINT OF ENTRY LESIONS M/B | Sore throat, dysphagia, pharyngeal & buccal ulcers, diarrhea, rectal tenderness, vaginal itching or discharge, SOB, nonproductive cough, minor pain |
| Neutropenia: s/s | Precipitous progression of minor s/s to fever, chills, sepsis, septic shock, & death |
| Neutropenia: s/s | "Opportunistic" tumors |
| Neutropenia: Dx Tests - PERIPHERAL WBC (with diff) | Absolute neutropenia of 500-1,000/mcl moderate risk for infection; Absolute neutropenia of <500mcl severe risk for infection |
| Neutropenia: Dx Tests - BONE MARROW Bx WITH ASPIRATION | For cellularity & cell morphology |
| Neutropenia: Dx Tests - CULTURE & SENSITIVITY (C&S) | Blood, (induced) sputum, spinal fluid, stool, urine; Genital, throat, wound swabs |
| Neutropenia: Dx Tests | Stool for ova & parasites (O&P); Bronchoscopy with brush bx; Tissue bx for tumors |
| Neutropenia: Dx Tests | Fungus cultures; TB smears or cultures; Skin tests with controls |
| Neutropenia: Nursing Dx - PRIMARY NSG DX | Risk for infection (See Lewis, p716 for NIC, NOC & goals) |
| Neutropenia: Nursing Dx - SECONDARY NSG DX | Fatigue, social isolation, depression |
| Neutropenia: Protective Practices - Monitor for s/s infection & sepsis - STAGE 1 | "Warm", "reversible", stage: subtle personality change, irritability, change in LOC or orientation, "picking at butterflies"; increased HR, bounding pulse, cardiac output, BP usually normal or slightly decreased; skin warm/hot, flushed |
| Neutropenia: Protective Practices - Monitor for s/s infection & sepsis - STAGE 1 | Increased temp; increased RR, SOB; increased urinary output |
| Neutropenia: Protective Practices - Monitor for s/s infection & sepsis - STAGE 2 | "Cold", "irreversible", "fatal" stage; Cardiac, temp, urine output reverse, classic shock s/s |
| Neutropenia: Protective Practices | Follow CDC guidelines for neutropenic pts: Wash hands before, during, and after; Segregate neutropenic pts from infectious pts--institute protective isolation |
| Neutropenia: Collaborative Management Goals | Establishing cause for neutropenia; Dx'ing infectious agent, instituting prophylactic empiric, or therapeutic antibiotic tx |
| Neutropenia: Collaborative Management Goals: INCREASED NEUTROPHILS | Administer granulocyte colony-stimulating factor (G-CSF) & granulocyte-macrophage colony-stimulating factor (GM-CSF) |
| Neutropenia: Collaborative Management Goals: PREVENT INFECTIONS | Restrict visitors appropriately, HEPA filters, etc. |
| Neutropenia: Collaborative Goals: MAINTAIN ADEQUATE NUTRITION | Collaborate with dietician re: n/v, diarrhea, dysphagia due to throat infections |
| Neutropenia: Teaching | See Lewis p.715, Table 31-23; Note: These same teaching guidelines should be applied to planning non-teaching nursing interventions for neutropenic pts. |
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