Hematology
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| Alterations in the hematoligic system | Disorders of erythrocytes (RBCs), platelets,leukocytes (WBCs),coagulation
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| Anemia | A deficiency in the
Number of erythrocytes
(red blood cells [RBCs])
Quantity of hemoglobin
Volume of packed RBCs (hematocrit)
Not a specific disease
Manifestation of a pathologic process
Identified and classified by laboratory diagnosis
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| Anemia General Symptoms of Anemia Integumentary Manifestations | Pallor
↓ Hemoglobin
↓ Blood flow to the skin
Jaundice
↑ Concentration of serum bilirubin
Pruritus
↑ Serum and skin bile salt concentrations
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| Anemia General Symptoms of Anemia Cardiopulmonary Manifestations | Tachycardia
Tachypnea
Fatigability
Dyspnea
Orthopnea
Orthostatic hypotension
MI
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| Anemia General Symptoms of Anemia Neurological manifestations | Inability to concentrate
Vertigo
Irritability
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| Anemia General Symptoms of Anemia GI Manifestations | Anorexia
Abdominal pain
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| Diagnostic findings | Mild = Hb 10 to 14 g/dl
May exist without symptoms
Possible symptoms
Palpitations, dyspnea, diaphoresis
Moderate = Hb 6 to 10 g/dl
Increased cardiopulmonary symptoms
Experienced at rest or during activity
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| Diagnostic findings | Severe = Hb <6 g/dl
Involve multiple body systems
Integument
Eyes
Mouth
Cardiovascular
Pulmonary
Neurologic
Gastrointestinal (GI)
Musculoskeletal
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| Iron-Deficiency Anemia | One of the most common chronic hematologic disorders
Iron is present in all RBCs as heme in hemoglobin and in a stored form, ferritin
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| Iron-Deficiency Anemia Etiology | Inadequate dietary intake
5% to 10% of ingested iron is absorbed
Malabsorption
Blood loss
Hemolysis
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| Iron-Deficiency Anemia Diagnostic Studies | Laboratory findings
Hb, Hct, MCV, MCH, MCHC, reticulocytes, serum iron, TIBC, bilirubin, platelets
Stool guaiac test
Endoscopy
Colonoscopy
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| Iron-Deficiency Anemia Collaborative Care | Goal is to treat the underlying disease
Increased intake of iron
Nutritional therapy
Oral or occasional parenteral iron supplements
Transfusion of packed RBCs
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| Iron-Deficiency Anemia Nursing Management | At-risk groups
Premenopausal women
Pregnant women
Persons from low socioeconomic backgrounds
Older adults
Individuals experiencing blood loss
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| Megaloblastic Anemias | Classification
Cobalamin (vitamin B12) deficiency
Folic acid deficiency
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| Cobalamin Deficiency Etiology | Absence of intrinsic factor (IF)
Acid environment required for IF secretion
GI surgery
Long-term users of H2-histamine receptor blockers
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| Cobalamin Deficiency Clinical Manifestations | General symptoms of anemia
Sore tongue
Anorexia
Nausea
Vomiting
Abdominal pain
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| Cobalamin Deficiency Diagnostic Studies | Normal serum folate levels and decreased cobalamin levels suggest megaloblastic anemia due to cobalamin deficiency
Schilling test
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| Cobalamin Deficiency Collaborative Care | Parenteral administration of cobalamin
Increase in dietary cobalamin does not correct the anemia
Still important to emphasize adequate dietary intake
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| Cobalamin Deficiency Nursing Management | Familial disposition
Early detection and treatment can lead to reversal of symptoms
Ensure that injuries are not sustained because of the patient’s diminished sensations to heat and pain
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| Folic Acid Deficiency | Common causes
Poor nutrition
Malabsorption syndromes
Drugs
Alcohol abuse and anorexia
Lost during hemodialysis
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| Folic Acid Deficiency Clinical manifestations are similar to those of cobalamin deficiency | Insidious onset
Absence of neurologic problems
Treated by replacement therapy
Encourage patient to eat foods with large amounts of folic acid
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| Anemia of Chronic Disease | Underproduction of RBCs
Mild shortening of RBC survival
Causes
End-stage renal disease
Primary factor: ↓ Erythropoietin
Chronic liver disease
Chronic inflammation
Malignant tumors
Chronic endocrine diseases
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| Anemia of diagnostic findings | ↑ Serum ferritin
↑ Iron stores
Normal folate and cobalamin levels
Treating underlying cause is best
Rarely blood transfusions
Erythropoietin therapy
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| Chronic Blood Loss | Reduced iron stores
Bleeding ulcer
Hemorrhoids
Menstrual and postmenopausal blood loss
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| Chronic Blood Loss Management | Identify source
Stop bleeding
Possible use of supplemental iron
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| Acute Blood Loss | Result of sudden hemorrhage
Trauma
Complications of surgery
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| Acute Blood Loss Clinical Manifestations | Tissue hypoxia
Tachycardia
Tachypnea
Bone pain
Internal hemorrhage
Tissue distention, organ displacement, nerve compression
Pain
Retroperitoneal bleeding
Numbness
Pain in the lower extremities
Shock is the major complication
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| Diagnostic Studies | Laboratory data do not adequately assess RBC problems for 2 to 3 days
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| Collaborative Care | Replacing blood volume to prevent shock
Identifying the source of the hemorrhage
Stopping blood loss
Correcting RBC loss
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| Aplastic Anemia | Rare
Damage or decrease in the# of stem cells in bone marrow
Congenital
Chromosomal alteration
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| Aplastic Anemia | Acquired
Caused by exposure to benzene &benzene derivatives(air plane glue),radiation, infections,pregnancy
Results in neurtopenia& thrombocytopenia
Unknown etiology in 50% of the cases
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| Aplastic Anemia Clinical Manifestations | Symptoms of anemia
Infection
Purpura
Lymphadenopathies
Splenomegaly
Retinal hemorrhages
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| Aplastic Anemia Diagnostic findings | Decreased RBCs, WBCs and platelets
Decreased reticulocyte count (immature RBCs)
Bone marrow examination
Decrease activity of bone marrow/no cell activity
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| Aplastic Anemia Collaborative Care | Remove the cause
Treat symptoms
Transfusions
RBCs
Platelets
Bone marrow transplant/peripheral stem cell transplant
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| Anemia Nursing Diagnoses | Activity intolerance
Imbalanced nutrition: Less than body requirements
Ineffective therapeutic regimen management
Potential complication: Hypoxemia
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| Anemia Nursing Management | Goals
Maintain adequate oxygenation
Assume normal activities of daily living
Maintain adequate nutrition
Develop no complications related to anemia
Monitor labs
Monitor oxygenation status
Monitor for signs of bleeding
Pace activities to avoid fati
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| Anemia Nursing Implementation | Blood or blood product transfusions
Drug therapy
Oxygen therapy
Patient teaching
Nutrition intake
Plan frequent rest periods
Compliance with drug therapy
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| Polycythemia | Excessive production of RBCs as well as platelets and leukocytes
Increased blood viscosity
Congestion of blood in tissues
Liver
Spleen
Evolves to Acute Myelocytic Leukemia (AML)
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| Polycythemia Clinical manifestations | Headaches
Dizziness
Parasthesias
Visual disturbances
Hypertension
Thrombophlebitis
Joint pain
Hepatosplenomegaly
Ruddy complexion
Angina
Pruritis
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| Polycythemia Diagnostic findings | Increased RBCs
Increased Hgb & Hct
Increased uric acid levels (due to increased RBC destruction)
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| Polycythemia Collaborative Care | Phlebotomy
Myelosuppressive therapy
Pain relief
Monitor for organ failure
Kidneys
Heart
Cerebral perfusion
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| Polycythemia Nursing Management | Pain management
Monitor for organ failure
Monitor for altered nutrition (less than body requirements)
Monitor for complications post phlebotomy
Orthostatic hypotension
Tachycardia
Decreased LOC
Chest pain
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| Thrombocytopenia | Reduction of platelets below 150,000/ul
Immune thrombocytopenic purpura (ITP)
Most common acquired form
Autoimmune – platelets destroyed in the spleen
Thrombotic thrombocytopenic purpura
Uncommon
Cause: unknown
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| Thrombocytopenia |
Heparin Induced Thrombocytopenia an Thrombosis Syndrome (HITTS)
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| Thrombocytopenia Clinical manifestations | Epistaxis(nose bleed)
Gingival bleeding
Petechiae
Purpura
Ecchymosis
Internal bleeding
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| Thrombocytopenia Complications | Hemorrhage
Cerebral hemorrhage fatal
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| Thrombocytopenia Collaborative Care | Stop bleeding
Replace coagulation factors
Blood & blood product transfusion
Plasmaphoresis
Treat underlying cause
Splenectomy
Medications
Corticosteriods
Imuran
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| Thrombocytopenia Safety | Bleeding precautions
Avoid IM injections
Avoid rectal manipulation
Prevent constipation
Apply direct pressure to venipuncture sites
Avoid anticoagulants,anti-platelet medications
Use soft tooth brush
Avoid dental floss
Use electric razor
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| Thrombocytopenia Safety | Bedrest(platelet count < 20,000/mm3)
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| Thrombocytopenia Nursing Management | Pain management
Hemarthrosis
Fluids & Electrolytes
Maintain hydration status (IV/PO) – blood loss leads to decreased circulating volume
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| Thrombocytopenia Nursing Management | Nutrition
Promote erythropoiesis –
Folic acid, B12 - RBC maturation
Iron, B6 - Hgb synthesis
Vitamin C - converts folic acid to active form, Fe absorption
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| Focus Assessment/Complications Cardiovascular | Hypovolemia/Hypovolemic Shock: VS changes; S/S low cardiac output/decreased perfusion manifested in the following body systems:
Integument
Respiratory
Neuro
Renal
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| Focus Assessment/Complications | Integument: petechiae/ecchymosis
Hematological: prolonged bleeding w/ invasive procedures; occult blood
Gastrointestinal: splenomegaly; abdominal pain & distention
Neuro: CVA - cerebral bleed; retinal bleed
Musculoskeletal: hemarthrosis
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| Neutropenia | Decrease in neutrophil count as a result of decreased production or increased destruction
Increased risk for infection
Not a disease but a syndrome
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| Neutropenia Etiology | Nutritional deficiencies
Folic acid
Cobalamin
Medication induced
Chemotherapeutic agents
Autoimmune disorders
Infections
Sepsis
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| Neutropenia Clinical Manifestations | Low WBC
Low grade fever
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| Neutropenia Complication | Infection
Sepsis
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| Neutropenia Diagnostic Findings | WBC; < 4000/ul
Absolute Neutrophil
< 1000 - 1500/ul presence of neutropenia
500 - 1000/ul moderate risk for infection
< 500/ul severe risk for infection
Bone marrow examination
Determine the cause
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| Neutropenia Collaborative Care | Prevention of infection
Hand washing
Private room if possible
Medications
Antibiotics
Analgesics
Antipyretics
G-CSF (Neupogen)
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| Neutropenia Nursing Management Fluids & Electrolytes | Adequate intake to prevent dehydration & possible urinary tract infection; up to 3-4L daily
Monitor I&O
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| Neutropenia Nursing Management Nutrition | Low microbial
High nutritional value
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| Neutropenia Nursing Management Safety | Avoid exposure/risk for infection
Strict hand washing
Avoid invasive procedures
Pulmonary hygiene (IS, TCDB)
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| Neutropenia Nursing Management Discharge teaching | Meticulous personal hygiene
Avoid crowds
Avoid persons known to have a cold or other contagious illness
Avoid swimming in lakes and crowded pools
Keep home free of dust/dirt
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| Leukemia | A group of malignant disorders affecting the blood and blood-forming tissues of
Bone marrow
Lymph system
Spleen
Occurs in all age groups
Fatal if untreated
Progressive
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| Leukemia Etiology | Type of white blood cell involved (WBC)
Acute lymphocytic leukemia (ALL)
Acute myelogenous leukemia (AML)
Also called acute nonlymphoblastic leukemia (ANLL)
Chronic myelogenous leukemia (CML)
Chronic lymphocytic leukemia (CLL)
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| Leukemia Clinical Manifestations | Relate to problems caused by
Bone marrow failure
Overcrowding by abnormal cells
Inadequate production of normal marrow elements
Anemia, thrombocytopenia, neutropenia
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| Leukemia Clinical Manifestations | Relate to problems caused by
Leukemic cells infiltrate patient’s organs
Splenomegaly
Hepatomegaly
Lymphadenopathy
Bone pain
Seizures (meningeal irritation)
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| Leukemia Diagnostic Studies | Peripheral blood evaluation
Bone marrow evaluation (definitive diagnosis)
Diagnose and classify
Identify cell subtype and stage
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| Leukemia Collaborative Care | Goal is to attain remission/disease control
Chemotherapy regimen
Radiation
Bone marrow and stem cell transplantation
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| Bone Marrow and Stem Cell Transplantation | Eliminate leukemic cells from patient’s body
Replaced with those of an HLA-matched
Sibling
Volunteer
Identical twin
Patient’s own stem cells removed before
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| Bone Marrow and Stem Cell Transplantation Nursing Management | Assess for signs and symptoms of disease progression,infection,bleeding,Provide nutrition,Prevent fatigue,Promote safety
Observe for side effects of tx
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| Bone Marrow and Stem Cell Transplantation Nursing Management | Patient empowered by knowledge of the disease& tx can have a more positive outlook& improved quality of life
Nurses face special challenges when meeting the intense psychosocial needs of a patient with leukemia
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| Hemophilia | Hereditary coagulation disorder
Sex-linked recessive disorder
Von Willebrand’s disease
Hemophilia A (most common)
Hemophilia B
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| Hemophilia Diagnostic Findings | Assays for factors VIII, IX and vWF
PTT is prolonged due to the intrinsic pathway problem
Normal platelets and PT
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| Hemophilia Clinical manifestations | Persistent and prolonged bleeding from injuries
Delay of onset of bleeding
Subcutaneous echymosis and subcutaneous hematomas
Gingival bleeding
GI bleeding
Hematuria
Hemarthrosis
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| Hemophilia Collaborative Care | Replace the deficient coagulation factor
Supportive treatment of symptoms
Control bleeding
Management complications
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| Hemophilia Nursing Management | Supportive care
Assess for symptoms; pain, bleeding
Bleeding precautions
Patient education
Genetic counseling
National hemophilia foundation
Medical alert bracelet
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| Disseminated intravascular coagulation /coagulopathy (DIC) | Imbalance between coagulation and anticoagulation
Caused by sepsis, anoxia, burns, multiple trauma, amniotic fluid embolus, snake bites, metabolic acidosis, hypotension
80% mortality rate
Net effect is hemorrhage
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| DIC Diagnostic Findings | Prolonged PT
Prolonged PTT
Prolonged thrombin time
Decreased fibrinogen
Decreased platelets
Elevated FDP/fibrin split products
Elevated D-dimer
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| DIC Clinical Manifestations | Related to the cause
Purpura
Ecchymoses
Bleeding from various sites with pain and clinical manifestations associated with bleeding
Hypotension
Shock
Death
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| DIC Collaborative Care | Treat cause
Symptom management
Administer blood products
Replace clotting factors
Fresh frozen plasma (FFP)
Cryoprecipitate
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| DIC Nursing Management | Assess for hemorrhage
Implement bleeding precautions
Monitor for signs of fluid overload (transfusions)
Assess for signs of renal failure
Assess for signs of respiratory failure
Supportive care
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| Complex protein-iron compound that binds with oxygen and carbon dioxide | Hemoglobin
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| Process by which WBCs engulf and kill organisms | Phagocytosis
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