Medical Surgical Review Handout- Hematology/Oncology 2016

Transcription

1 Medical Surgical Review Handout- Hematology/Oncology 2016 Overview Blood circulates in the cardiovascular system o Carries oxygen to the cells o Carries waste away from the cells Functions of blood o Transportation: O2, CO2, leukocytes, water, electrolytes, hormones, enzymes, o Hemostasis: process of which stops bleeding o Immune system transportation o Response system for inflammation due to injury o Temperature regulation Components in the blood o Red Blood Cells (RBC): cells that carry oxygen within the system Hemoglobin: oxygen carrying pigment of the RBC. It is the best measurement of the oxygen carrying capacity Hematocrit: measure the packed RBC s volume Rule of Threes: HGB x 3 < HCT = dehydration HGB x 3 > HCT = fluid overload o White Blood Cells (WBC): part of the immune system Defenders in the body against infectious diseases and foreign matter All are generated in the bone marrow o Platelets (Plt): key component in hemostasis Polycythemia Vera Disorder of the myeloid stem cells that causes elevated levels of RBCs, WBCs, and platelets in the circulating blood o Early stages: hematocrit is elevated o Later stages: bone marrow becomes fibrotic, which results in the decrease production of cells and the spleen resumes its embryonic functions of hematopoises and enlarges Sign and symptoms o Ruddy complexion and splenomegaly o Increased blood volume or increased blood viscosity cause headache, dizziness, tinnitus, fatigue, paresthesias, blurred vision, angina, claudication, dyspnea, thrombophlebitis, and hypertension

2 o Pruritus, gout, and burning in the fingers and toes o Complications include stroke, myocardial infarction (MI), thrombotic events, and bleeding due to dysfunctional platelets Diagnosis o Lab: hematocrit (can exceed 60%), leukocyte elevation, platelet elevated, uric acid elevated o Reduction of blood cell mass o Therapeutic phlebotomy o Can replace volume out with IVF or no replacement o Goal is to keep hematocrit less than 45% o Drug therapies including chemotherapy can be used to suppress the bone marrow Nursing interventions o Assess for thrombotic complications (DVT, MI or stroke) o Control pruritis with warm and cool baths along with antihistamines, as ordered o Educate family about disease process and how to prevent complications o Provide emotional support Sickle Cell Anemia Vasoocclusive process which is a genetically inherited abnormality of hemoglobin. The vasooclusion results in a painful episodes and can lead to organ system complications and life long disabilities. Often can be a rapid development of sickling cells that cause clogging of capillaries. Cyclical disease process of hemostasis, local hypoxia, deoxygentation, and more sickling of cells. Results in the patient having severe pain and can also result in severe organ damage, fevers and death. Clinical Manifestations/Complications o Pain o Acute Chest Syndrome: defined as a new infiltrate seen on chest xray associated with fever and respiratory symptoms (cough, sputum production, dyspnea, or hypoxia) o Pulmonary Hypertension: damage to the small vessel in the lungs, which then makes it difficult for the heart to pump blood through the lungs o Splenic crisis: sickled cells become trapped within the spleen causing the spleen to grow large and increasing anemia

3 o Gallstones: created after red blood cells die and release hemoglobin. The hemoglobin then is broken down into bilirubin, which can increase the cause of gallstones to occur. o Infections: individuals are more at risk to develop infections and have a more difficult time fighting infection. Initiation of treatment is key o Stroke: a possibility of having the blood vessel damaged or blocked by sickled cells or having the blood vessel burst in the brain. o Organ failure: rare but it is does occur. Often with at least two major organs failing (liver, lungs or kidney) and can occur after a unusually severe painful crisis Medical Management o Pain Management: including morphine, hydromorphone, fentanyl, and toradol. Often given on a continuous basis. PCAs can be utilized. Patients should be on a long acting pain medication. In addition to having a breakthrough pain regime. o Hydration: IV fluids along with PO intake are encouraged for this population o Oxygen: Oxygen should be worn during all sickle cell crisis to help with pain. o of infection: CBC, Blood and urine cultures, antibiotic therapy o Bedrest o Joint Support o Hydroxyurea can be utilized to reduce the production of red blood cells from the marrow Heparin Induced Thrombocytopenia (HIT) Life threatening disorder that follows the exposure to unfractionated or low molecular weight heparin. It is caused by antibodies that are created against heparin-platelet factor 4 complexes. Often occurs 5-10 days after the exposure to heparin Diagnostic tests include: Heparin antibody test, tests to include IgG, IgA, IgM antibodies Signs and Symptoms o Platelet count < 150 o Skin Necrosis o MI or stroke is possible

4 o Venous gangrene of the limbs o Anaphylactic reaction after a bolus of Heparin o Discontinuation of all heparin products o Coumadin will also be discontinued o Anticoagulation should be completed with Argatroban Idiopathic thrombocytopenic purpura (ITP) Condition in which there is a reduction of production of platelets and increased destruction of platelets by the body. The cause is unknown. Often it is a diagnosis after many others are ruled out including systemic lupus, antiphospholipid syndrome, chronic lymphocytic leukemia Within the CBC, all other counts are normal except for platelets. Clinical Manifestations/ Complications o Purpura: bruises o Epitaxis o Petechiae: small, flat, pinpoint red purpura o Ecchymosis: large purplish lesions. Can be raised or flat or painful due to hemorrhage o Hemorrhage o Spleenectomy: often will help increase the platelet count in half of all patients o Corticosteroids: helps suppress the immune system o Plasmapheresis: can filter antibodies out of the system o IVIG: high dose a gamma globulin, an immune factor Nursing Interventions o Safety is key for this patient population o Assessment of any bleeding Disseminated intravascular coagulation (DIC) Serious blood coagulation disorder that arises as a complication of accelerated blood clotting. o Often secondary to other diseases

5 Occurs by the suppression of the fibrinolytic system and then the development of small clots in the microcirculation, which then consumes up the clotting factors and causes excessive bleeding. o Tissue hypoxia can occur along with multiple organ failure. o Mortality rates can be up to 80% Causes: o Septicemia, cancer, blood transfusions reactions, cirrhosis, trauma, infectious states, and obstetric complications Acute development occurs with septicemia Chronic forms occur with cancer Signs and symptoms include: o Abnormal bleeding (often appearing as oozing, petechiae, ecchymosis, hematomas, GI bleeding, and bleeding from wounds or IV sites Hemorrhage can occur also in the form of hematuria, cranial, peritoneal or pericardial bleeding o Thrombotic events Obstruction of blood flow to organs Dyspnea, oliguria, muscle pain, lastly shock Diagnosis: o PT and PTT increased o Thrombin time increased o Platelet count decreased o Fibrinogen reduced o Fibrin degradation products (FDP) elevated o Thrombocytopenia o D-dimer test Management of DIC o Treat the underlying cause o Supportive therapies Heparin Thought to help with the development of clots Recombinant activated protein C Inhibits thrombin but not tested within DIC Vitamin K Enhances factor production Recombinant activated factor VIIa Reflects reduced hemorrhage in trauma patients High doses it attaches to activated platelets, enhancing production of a fibrin clot resistant to fibrinolysis Nursing Management o Early recognition is key to having improved patient outcomes o Avoid additional types of trauma to minimize bleeding, protect patient from injury, avoid dislodging clots o Apply pressure to puncture sites until bleeding stops o Monitor vital signs

6 Lymphoma Administer IVF, as needed Administer blood products, as needed and ordered o Closely monitor intake and output o Monitor for tissue ischemia and failure o Provide emotional support to patient and family Non Hodgkin s Lymphoma o Diverse group of blood cancers o Range from indolent to very aggressive forms o Cancer arises from lymphocytes and originates in the lymphatic system The lymphatic system is part of the immune system and helps fight infection It filters out bacteria and other waste o Signs and symptoms Weight loss Night sweats Fever o Chemotherapy Radiation Stem cell transplant Hodgkin s Lymphoma o Also a cancer of the lymphatic system o Compromises the body s ability to fight infection o Large advances in the treatment have allowed for a full recovery within this subset of lymphoma Multiple Myeloma Cancer of the plasma cell, which is a type of WBC and responsible for producing antibodies Abnormal plasma cells accumulate in the bone marrow and interfere with normal cell production Signs and Symptoms: o Fatigue o Pain o Pathological fractures o Labs: decrease RBC, decrease in WBC, decrease in plt, increase Calcium (due to bone leisons) Diagnosis o Blood tests: protein electrophoresis o Bone marrow biopsy

7 o Xrays and skeletal survey for bone lesions o Chemotherapy o Interferon o Bone Marrow transplant o Plasmaphoresis o Calcium management There is no cure for multiple myeloma Leukemia Cancer of the bone marrow or blood Defined as an abnormal increase of immature WBC also known as blasts. The overproduction of immature WBC take up the space and crowd out the normal cells that are functioning within the marrow o Crowds out the platelets and affect the clotting process Signs and Symptoms o Bleeding: petechiae, bruising, frank bleeding o Additional symptoms: fatigue, weight loss, bone pain, infection o Labs: Low RBC, High WBC Diagnosis: o Bone marrow biopsy Acute leukemia o Rapidly developing o Must be treated immediately o Cells are spilling out of the marrow into the bloodstream and affect organs o Subsets: Acute lymphocytic (ALL): most common childhood leukemia Acute Myelogenous (AML) Chronic leukemia: o Excessive build up of relatively mature but still abnormal WBC o Often is monitored for some time and then decided whether or not to treat o Subsets: Chronic Lymphocytic (CLL) Chronic Myelogenous (CML)