NCTC Med Surg Unit 6
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| What type of cells are lymphocytes and monocytes? | * WBC’s * Norm: 4500-11000 cells/mm3
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| An elevated WBC count can indicate what? | * Infection
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| what is the % of Neutrophils in a normal WBC count | 60%
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| Where are lymphocytes and monocytes produced? | * Bone Marrow * Lymphocytes also produced by the Spleen
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| What 2 cell groups make up lymphocytes? | T cells and B cells
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| What is the purpose of the B cells? | * B cells-when stimulated, produce 2 types of cells: * Plasma cells-antibody factories that produce large amount of immunoglobulin which when released becomes the antibody. * 4 types of Immunoglobulin * Antigen-binding proteins
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| What are the 4 major antibodies produced by B cells? | * IgM-first to be secreted during primary immune response to antigen * IgG-secreted during second immune response-more specific to antigen * IgA-present in mucus and mothers milk * IgE-triggers release of histamine; can create a hypersensitivity reaction
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| IgM | first to be secreted during primary immune response to antigen
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| IgG | secreted during second immune response-more specific to antigen
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| IgA | present in mucus and mothers milk
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| IgE | triggers release of histamine; can create a hypersensitivity reaction
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| * IgE-triggers release of histamine; can create a hypersensitivity reaction | * An immune system disorder * This type of reaction is potentially harmful * There are 4 types of hypersensitivity reactions: Type I, II, III, IV
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| 4 types of hypersensitivity reactions | Type I, II, III, IV
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| Type I | mediated by IgE-reactions to common allergens, i.e., dust, pollen, bee stings, animal dander * Local: edema, pain --Systemic: anaphylaxis
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| Type II | mediated by antibodies-occurs with blood tx or medications
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| Type III | causes tissue damage from precipitation of antibody-antigen rx-autoimmune reactions, occupational diseases or various drugs
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| Type IV | delayed rx-contact dermatitis, measles rash TB skin testing, transplant tissue rejection
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| What are memory B cells? | * remember specific antigens, which triggers plasma cells to react quicker in producing immunoglobulin
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| Innate immunity | always working, starts at birth-it is the inflammatory response and can phagocytize foreign invaders
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| Acquired immunity | occurs when a foreign antigen is introduced into the body
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| active Acquired immunity | Vaccinations
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| passive acquired antibody immunity | Chicken Pox as a child
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| Cell-mediated-T cytokines | attach to defective cells (primarily viruses and cancer) and directly attack them. T cells are a type of lymphocyte
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| HIV is a virus that causes destruction of T cells leading to a decreased immunity. How does this occur? | * HIV copies the RNA into the host T cell’s DNA and then remains hidden until the host cell is activated to mount an immunologic response
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| How is HIV transmitted? | * Sexually Contact with infected body fluids
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| Initial stage: primary HIV infection | may last 4-8 weeks. Pt may have flu like symptoms
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| 2nd stage or Latent stage | may last 2-12 years and have no symptoms
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| when the CD4 count drops below 200 | the pt enters into the final stage and is diagnosed with AIDS. Once this occurs, even if the CD4 count rises again above 200, the pt will still be diagnosed with AIDS.
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| Once the CD4 count drops below 200 | illnesses, known as opportunistic infections, occur. Some of these are pneumocystic pneumonia, TB, and CMV.
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| What are the s/s of the final stage of HIV Infection? | * Fever, night sweats, swollen lymph nodes, and symptoms specific to the infection
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| HIV | Medical care primarily centers on minimizing infection.
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| What treatment is available for the pt with HIV? AZT | Nucleoside reverse transcriptase inhibitor-interferes and slows the replication of HIV
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| Crixivan | Protease inhibitor-blocks the protease enzyme so that it can’t make any more HIV proteins
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| Viramune | Non-nucleoside reverse transcriptase inhibitor-interferes with replication inside CD4/T cells
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| Other medical tx for HIV/AIDs pt: | * Balanced diet * Avoid crowded areas * Regular exercise * Avoid illicit drug use Regular dental check-ups
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| What is another name for red blood cells? | Erythrocytes
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| RBC’s | total number of red blood cells found in a cubic mm (mm3) of blood. Norm Men-4.2-5.4 million cells/mm3 Women- 3.6-5.0 million cells/mm3
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| Hemoglobin (Hgb) | indicates the oxygen-carrying capacity of the blood Norm: Men-14.0-17.4 g/dl Women-12.0-16.0 g/dl
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| Hematocrit (Hct) | is the percentage of red blood cells in whole blood Norm: Men-42%-52% Women-36%-48%
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| What is the avg life span of the RBC? | 120 days
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| Calcium ions are necessary in the hematological system for what? | Clotting
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| What is the purpose of the spleen? | * To prevent infection by filtering microorganisms from the blood * Produces lymphocytes * Destroy platelets and old RBC’s
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| What type of white blood cells reside in the spleen? | * Lymphocytes
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| When the spleen malfunctions, it may start removing too many RBC’s and platelets, upsetting the clotting cascade. In this case it may need to be removed. What is this type of surgery called? | * Splenectomy
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| What injection may need to be given preoperatively to correct the clotting deficiencies? | * Vitamin K
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| What complications is the individual without a spleen at risk for? | * Infections-specifically pneumonia * Can be given the pneumococcal vaccine prior to surgery to build own antibodies * Should be vaccinated in the future
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| What interventions are necessary if the post splenectomy patient is lethargic and runs a fever? | * Pt is at risk for a deadly infection
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| Define ecchymosis | * Large areas of bruising or hemorrhaging under the skin
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| What causes clubbing of the fingers? | Long term hypoxia and anemia
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| universal donors? | Donors: O negative
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| Universal recipients? | * Recipients: AB positive
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| What IV solution is used when infusing blood? Why? | * 0.9% saline-can be used to dilute blood if necessary * Any other type of fluid causes clotting
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| Describe the procedure necessary for hanging blood: | * Start IV with an 18 or 20g cath only * 2 nurses at the bedside verify blood with patient ID * Baseline VS * VS q 15 min x4 per protocol * Hang with NS
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| How long can blood hang? | 4 hours
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| * Hemolytic | * Chills, fever, nausea, dyspnea, chest pain, back pain, hypotension
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| Anaphylactic | Itching, swelling, SOB, hypotension
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| Febrile | * Chills, fever
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| * Circulatory overload | * Cough, frothy sputum, crackles, dyspnea, cyanosis, hypotension
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| transfusion reactions | * First nursing intervention * STOP the infusion, keep line open ! * Call the Dr. immediately
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| Aplastic Anemia | * Cause * complete failure of bone marrow * pt’s have extremely low red and white blood cells * Treatment * Epoeiten alfa
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| Autoimmune hemolytic anemia | * bone marrow makes enough RBC’s, but they are destroyed as they are released. * Causes drug reaction certain cancers in newborn- Rh- mother, Rh+ baby * Treatment identify and treat the cause
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| Iron deficiency anemia | Causes a. diet low in iron b. body not absorbing enough iron Treatment a. Iron tablets b. Foods rich in iron
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| Pernicious anemia -Causes | a. unable to absorb Vit B12 due to lack of intrinsic factor produced by the parietal cells of the stomach b. cancer c. gastrectomy
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| Pernicious anemia - s/s | a. Fatigue b. Pallor c. Weakness d. Beefy red tongue
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| Pernicious anemia - Diagnosis tests | a. Schillings test-radioactive Vit B12 used to asses GI absorption of Vit B12
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| Pernicious anemia - treatment | Vit B12 injections-monthly b. Monitor for stomach cancer as this dx carries high risk
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| Sickle cell anemia | * normal number of RBC’s but they’re sickle shaped
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| * Polycythemia vera | too many RBC’s
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| Define anemia | * Decreased circulating RBC’s
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| What nutritional deficiencies contribute to anemia? | iron folic acid B12
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| Which foods are rich in iron? | * Liver, red meats * Raisins * Dark, red fruits and juices such as cherry or cranberry * dark green, leafy veggies * iron enriched cereals
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| iron tablets side effects expected | * C/O black stools * Constipation * Mild nausea
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| Why is it necessary to Z track an Iron injection? | * to prevent tissue damage at the site, and discoloration of the skin
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| What is the trade name for an iron injection? | Imferon
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| What is the purpose of an Epogen injection? Generic name? | * increase production of RBC’s * erythropoietin
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| Lists at least 1 nursing diagnosis appropriate for anemia. | Activity intolerance R/T tissue hypoxia and dyspnea
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| What is polycythemia vera? | * too many RBC’s --s/s are HA, dizziness, ringing in ears, blurred vision
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| What type of treatment is common for polycythemia vera? | * treatment is a therapeutic phlebotomy: one unit of blood removed regularly (this blood is not suitable for donation)
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| Which lab tests help confirm that the tx for polycythemia verais effective? | monitor Hct
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| Describe the process that leads to sickle cell anemia (pathology). | * RBC’s become sickle shaped which causes rupture, clumping, congestion and clogging of capillary blood flow - Leads to tissue hypoxia and pain
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| Name the factors that can cause a sickle cell crisis | * pneumonia-hypoxia * diabetic acidosis * dehydration * exposure to cold severe infection
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| What is the most immediate treatment for a sickle cell crisis | * O2 * Sedatives and analgesia for pain Blood tx to replace cells
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| What can you do to help relieve joint painassociated with sickle cell crisis? | * warm compresses increases circulation and vasodilation * cover with blanket * keep room warm to prevent vasoconstriction and impaired circulation
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| What teaching will a sickle cell pt require? | * To prevent crisis: * Maintain hydration: 4-6 L/day * Avoid smoking, alcohol, high altitudes * Genetic counseling * Offer info RT resources: Sickle Cell Disease Assoc. of America
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| What does the word Leukemia mean? | * white blood
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| Define Leukemia. | * cancer of the WBC’s where bone marrow over-produces immature WBC’s * pt is unable to fight infection
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| What type of test is used to diagnose leukemia? | CBC-if abnormal, then bone marrow biopsy
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| What is the site of choice for a bone marrow biopsy? | iliac crest
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| Describe the procedure for a Bone Marrow Biopsy and post procedure interventions: | * sterile procedure * local anesthetic, & often, conscious sedation * Jamshedi needle inserted into bone marrow, fluid aspirated * Pressure drsg applied for 2h * Observe for bleeding * VS q 15 min
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| What are the 2 types of leukemia? | * Myelogenous and lymphocytic * Can be acute or chronic
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| * Chronic leukemia | * WBC increases over months or years * usually in adults * Each of the chronic types also have an acute form * s/s for final stage: fever and abnormal bleeding
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| Types of Acute Leukemias: | * Acute Lymphocytic Leukemia (ALL) –occurs most often in kids * Acute Myelogenous Leukemia (AML) – usually occurs in adults * WBC’s skyrocket over days, crowding out RBC’s and plts
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| What are the s/s of acute leukemia? | * infection and fever, with night sweats * s/s of decreased RBC’s-fatigue, paleness, tachycardia * decreased platelets-petechiae or purpura, epistaxis, gingival bleeding, melena, meorrhagia
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| Describe the nursing care that would be important for a pt with leukemia? | * prevent infection * if pt has thrombocytopenia-avoid needle sticks * treat N/V with meds: Zofran, assess for dehydration, avoid foods pt doesn’t like, no fluids with meals * anorexia-small frequent meals, frequent oral hygiene, monitor weight
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| What are some of the SE or complications of chemo? | * neutropenia-decreased WBC’s * stomatitis-mouth infection * bone marrow suppression-decreased red and white blood cells causes anemia and inability to fight infection
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| What blood test is done weekly to monitor for bone marrow suppression? | CBC
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| What are the most common sites of infection for the patient with neutropenia? | * lungs-pneumonia * blood-septicemia * skin * urinary tract * GI tract
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| What s/s may occur with neutropenia? | * fever may be the only sign of infection, because the inflammatory response is gone due to decreased WBC’s
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| Why is it important to protect the patient with leukemia form infection? | Decreased WBC count will decrease the patient’s ability to fight infection
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| What precautions and treatment are necessary for the pt with thrombocytopenia? | * minimize invasive procedures * avoid IM injections-apply pressure for 5-10 min * administer platelets as ordered * avoid damage to rectal mucosa * use soft bristle tooth brush * watch for meds that interfere with plt production
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| * idiopathic thrombocytopenia purpura | * autoimmune disorder * IgG mistakenly attacks plts. Meds can cause ITP * Pt’s with HIV at risk
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| thrombolytic thrombocytopenia purpura | * exaggerated response of the body to vessel injury which leads to extensive clot formation
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| What is DIC? | * Disseminated intravascular coagulation * hypercoagulable state where you have an over stimulation of the coag cascade which leads to simultaneous thrombosis and hemorrhage
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| DIC: treat primary illness or cause | * Early treatment-Heparin to anticoags blood-stops the system from using up all of the clotting factors * Can give Vit K to prevent the lysis of fibrin and promote clotting
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| What is Hemophilia ? | * Genetic disease * Carried on X chromosome as a recessive trait, passed from mothers to sons * person lacks clotting factors * A- missing factor VIII * Most common * B- missing factor IX
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| What are the s/s of hemophilia? | * uncontrollable bleeding – either by trauma or spontaneous bleeding * severe pain in joints due to bleeding and swelling * can bleed to death
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| Describe the medical treatment necessary for Hemophilia | * no cure * Treatment: replace missing factors * A-factor VIII found in FFP and cryoprecipitate * B-factor IX found in FFP * PRBC’s to replace blood loss * IV morphine for pain relief
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| What other immune disorders can affect patients? | * Systemic Lupus Erythematosus * autoimmune disorder in which the body loses the ability to recognize itself * mounts an immune response against itself and causes damage to organs * most common in women, 3X more common in African Americans
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| What are S/S of SLE? | * periods of remission alternating with symptom exacerbation * fatigue and malaise * anorexia and nausea * Fever * weight loss * musculoskeletal symptoms, joint pain * classic rash across bridge of nose and cheeks, called butterfly rash
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| How is SLE diagnosed? | * positive ANA (antinuclear antibody)-makes dx more likely * primarily dx is based on s/s must have 4 of the following-classic rash, photosensitivity, oral ulcers, arthritis, organ involvement, hematologic disorder, immune system disorder
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| How is SLE treated? | no cure b. prevent organ damage c. maintain quality of life d. take anti-inflammatory drugs e. antimalarials and corticosteroids f. Cytotoxic agents if other meds ineffective, or organ damage occurs
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| Hodgkin’s Lymphoma | * cancer of the lymph system characterized by Reed-Sterling cells in the lymph nodes * lymph nodes enlarge in chest and neck-may cause stridor * treatment consists of radiation and chemo * bone marrow or stem cell transplant * survival rate 81%
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| Non-Hodgkin’s Lymphoma | * cancer of the lymph system * treatment consists of radiation and chemo-possibly treat bone marrow or peripheral stem cell transplant * overall survival rate 51%
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| Multiple Myeloma | * cancer of plasma cells in the bone marrow * abnormally high levels immunoglobulin * bone pain from fx or bone destruction which causes hypercalcemia, hyperuricemia and anemia * drink plenty of fluids * twice as common in African Americans
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| What is transplant rejection & how is it prevented? | * treated with Cyclosporine or Prograf * must take for the rest of their life * depresses risk of rejection, but also depresses the pt’s immune system increasing risk of infx. * rationale for tissue matching, donor to recipient
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| Primary functions of the hematologic system: | * Oxygenation * Hemostasis * Control of bleeding
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| Structures & components of the hematologic system: | * Bone marrow * Spongy center produces RBC’s & platelets * Becomes less productive with aging * Liver * Manufactures clotting factors * Clears old or damaged RBC’s * Spleen * Also removes old RBC’s from circulation
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| RBC’s AKA Erythrocytes | * Life cycle of RBC: 120 days * 45% of blood
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| Platelets AKA Thrombocytes | * Life span: 7.5- 10 days * less than 1% of blood
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| Clotting Factors | * Numbered I – XIII * Includes fibrinogen (factor I) * Thrombin (factor II)
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| Plasma | * Clear, straw-colored fluid carries blood cells, etc * Primarily water. Also contains proteins, albumin & globulins * makes 55%of blood
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| * Upon injury to blood vessel: | * The blood vessel constricts * Platelets adhere to it * Coagulation cascade is initiated * Forms scab
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| Bone Marrow Biopsy | * Evaluates production of blood cells & plts * Obtain consent * Posterior iliac crest site of choice, using Jamshidi needle * Usually requires local + conscious sedation & monitoring * Pressure dressing applied X 2hrs
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| Platelets - lab values | 150,000 - 450,000
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| RBC - lab values | 4-6 million
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| WBC - lab values | 5000 - 10000
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| T - Lymphocytes - lab values | 60% - 80%
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| B - Lymphocytes - lab values | 10% - 20%
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| Risk for injury RT Anemia | * O2 as Rx * Blood products * Meds: hematopoietic growth factor erythropoietin (epogen) * Alternate rest & activity * Elevate HOB * Keep warm * Teaching
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| * PRBCs | * Adm for symptomatic low H&H * 250-300 ml/unit over 2-4 hours per unit * 4 hrs max
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| * Platelets | * Adm as quick as tolerated for bleeding due to low plts * 60-80 ml/pack, usually 4-6 packs pooled
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| * FFP | * Adm for clotting deficiencies, hemophilia, Coumadin reversal, & w/massive RBC transfusions * 180-270 ml/unit adm in < 4 hours * Cryoprecipitate (factors I & VIII) * Adm for hemophilia A, DIC * 10-15 ml/bag; 10 bags pooled, adm in < 4 hours
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| Adm PRBC transfusion | * Start 18-20G IV of NS; use approp tubing with filter * Start within 30 mins from blood bank * Take baseline VS; stay w/pt X 15 mins
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| Platelet transfusions | * Interventions same as PRBC transfusions no filters * May use 24G IV
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| * Scandinavians | Higher risk of pernicious anemia
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| Immunologic Disorders | Recognizes, isolates & destroys pathogens
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| * Lymph, lymphatics, & lymph nodes | * Collects left over plasma & returns it to venous system * WBC’s also travel thru lymph system * Filters out microorganisms
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| Cytokines | hormones secreted by cells to signal other cells
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| Leukocytes - * 5 major types: | * neutrophils, lymphocytes, eosinophils, basophils, & monocytes * ID & destroy foreign antigens by ingesting them * This process also destroys the WBC * Pus formed if used old WBC’s build up faster than macrophages can get rid of them
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| * Neutrophils | * Fight bacteria; most numerous: 60% of WBC’s
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| Monocytes | * Circulate in bloodstream X1day, then enter tissue * Called macrophages once in tissue, can live months/years
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| * Eosinophils | * Combat parasites; aid in allergic & inflammatory response
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| Basophils | * Release histamine, a vasodilator, when IgE ID’s foreign antigen; this brings large # of WBC’s to area for combat
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| Lymphocytes | * B cells produce plasma cells (antibody factories: IgM, IgG, IgA, IgE) * T cells: T helper & T cytotoxic; can directly destroy invaders
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| Innate immunity | * Present at birth & operational at all times Includes: anatomic/physiological barriers, inflammation & phagocytosis
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| * Acquired immunity | * Active only when needed; attacks specifically * Includes: antibody-mediated immunity, cell-mediated immunity
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| Tolerance | * Immune system recognizes itself
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| Goldenseal | Must be avoided by organ transplant recipients
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| Nursing Interventions for the Immune compromised pt: | Private room Teach everyone (pt & visitors) to wash hands * Avoid invasive techs; remove tubes ASAP; use ASEPTIC tech; use designated stethoscope & thermometer * Diet: NO fresh fruit or veggies,milk products NO live plants, NO humidifiers in room
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| Apheresis | done to collect pt’s stem cells, then these are given back to pt post chemo or radiation
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| * Bone marrow | * Spongy center produces RBC’s & platelets * Becomes less productive with aging
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| Liver | Manufactures clotting factors Clears old or damaged RBC’s
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| Spleen | Also removes old RBC’s from circulation
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