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Care of Clients with Problems In Oxygenation, Fluids and Electrolytes, Metabolism and Endocrine (NCM103) Patients With Hematologic

Alterations: Erythrocytes


The Blood

Makes 7 10% of Total Body Weight (TBW) (F) 4 5 L; (M) 5 6 L pH: 7.35 7.45 Specific Gravity: 1.048 1.066 Functions as a: o Link To the different organ systems o Transporter / carrier Oxygen and nutrients, CO2, Glucose o Controller IF you lose blood homeostasis o Defender To foreign activities

Topics Discussed Here Are: 1. Anatomy and Physiology Of Blood 2. Anemia Iron Deficiency Anemia Megaloblastic Anemia Folic Acid Deficiency Anemia Pernicious Anemia (Vit B12) Hemolytic Anemia Aplastic Anemia 3. Polycythemia


Liquid part of the blood; yellow in color Transporter medium for nutrients, wastes, hormones, electrolytes, gases Plasma is: o 30% - 96% H2O o 2% other small molecular substances o 6.5% to 8% Protein Albumin NORMAL VALUES: Prevents colloidal osmotic pressure Hemoglobin: Male: 13 18 gm/dL Big protein molecules Female: 12 16 gm/dL Remains in the interstitial space Regulates blood volume preventing Hematocrit: the occurrence of edema Male: 42 52% Female: 35 47% Prevents the shifting of water Serum Globulin Red Blood Cell: Alpha, Beta, Gamma Male: 4.6 6.2x1012 / L Female: 4.2 5.4x1012 / L For clotting factors Fibrinogen, Prothrombin, Plasminogen Iron: 50 160 ug/dL For clotting factors

Plasma 55% of Total Blood Leukocytes and Platelets < 1% Erythrocytes 45% of total Blood

Cellular Components
Red Blood Cells, White Blood Cells, Platelets

Folic: 2.5 20 ug/ml


The Red Blood Cells

Erythrocytes (RBC) o R Roles CO2 + H2O = H2CO3 o B Buffering (Carbonic Anhydrase) (Carbonic Acid) o C Carry Hemoglobin Catalyzes CO2 and H2O RBC Characteristics o Shape Biconcave disk Deformed in any shape Lifespan of 120 days

Production of RBC Where??

o o o o o o Tibia (Shaft) 20 Y/o Femur (Shaft) 25 y/o Rib 70 y/o Sternum 70 y/o Vertebra 70 y/o Ilium 70 y/o

RBC Production o Requirements for RBC Production Precursor Cells Proper microenvironment Iron, Vit. B12, Folic Acid, Protein, Pyridoxine and Copper RBC Differentiation o Reticulocytes = Body is attempting to compensate


RBC Regulation o Tissue Oxygenation: (PPALL) Poor Blood Flow Pulmonary Disease Anemia Low Hemoglobin Low Blood Volume

Erythropoietin - 90% Kidney - 10% Liver

RBC Maturation o 2 Important Vitamins 1. Folic Acid Green leafy vegetables 2. Vitamin B12 Meat ONLY! Formation of Hemoglobin

Required as an essential building block of DNA

Nuclear Maturation and Division Iron Cycle o Absorbs and stored in the duodenum o Forms of iron in body 4 5 grams of Fe 65% Hmg 15 35% ferritin (Stored iron in liver) 4% Myoglobin (muscles) 19% variations heme compounds needed for intracellular oxidation 0.1% transferrin o After RBC death, Fe is being phagocytized by the Spleen o Fe is being reused


Alterations of Erythrocyte Function Anemia

Clinical condition, decreased in hemoglobin content or Red Cell mass that impairs oxygen transport Classification based on morphology 1. Normocytic / Normochromic 2. Microcytic / Hypochromic 3. Macrocytic / Normochromic Etiology of Anemia Inadequate RBC Production Premature / excessive RBC destruction Blood loss Deficits in nutrition Hereditary factors Chronic disease Types of Anemia Nutritional Anemia Iron Deficiency Anemia (IDA) Vit B12 Deficiency Anemia Folic Acid Anemia Hemolytic Anemia Sickle Cell Anemia Thalasemia Glucose-6-Phosphate Dehydrogenase (G6PD) Bone Marrow Depression Anemia Aplastic Anemia

Iron Deficiency Anemia (IDA)

Below normal total body iron (50 160 ug/dL) Inadequate hmg production for body requirements Etiology: (5 Is) 1. Increased Blood loss 2. Insufficient dietary iron intake 3. Impaired GIT absorption 4. Increased Iron Requirements 5. Infection Laboratory Findings Microcytic Hypochromic RBC Hmg LOWER than Hct Serum iron concentration Total iron binding capacity Serum ferritin Reticulocyte Assessment Findings (FE-KAP) Fatigue Low O2 Capacity in tissues (common) Exercise Tolerance Decreased Koilonychia Nails become brittle and spoon-shaped Angular cheilitis Mouth ulcerations, lesions in oral mucosa Pica, Pallor Pica Feeling of deficiency of something so you crave Pallor Pale

1. 2. Correction of underlying cause Treatment through diet and supplemental iron preparations (Vitamin C)

Supportive Management for Patients with Anemia

Meet patients nutritional needs - Small frequent meals - Oral lesions Soft, cool, bland foods - Dyspepsia Eliminate spicy foods, milk and dairy products - Anorexic and irritable Give preferred food, accompany during meals


Fatigue - Adequate rest periods - Proper scheduling of activities Prepare patient for diagnostic testing - Schedule all tests to avoid disrupting patient meal, sleep and visiting hours - Finish first life activities before doing heavy ones Prevent complications - Observe for signs of bleeding - Monitor transfusions - Warn patient to change position slowly to minimize dizziness induced by cerebral hypoxia Set limitations on acts - Assess level of tolerance on acts - Frequent rest periods - Pace activities

Nursing Responsibilities in Iron Preparation

Assess for use of drugs that can interact with Iron Administer with ORANGE JUICE Administer 1 hour AC or 2 hours PC Do not give with MILK and ANTACIDS Give with straw For liquid preparations Monitor for Iron toxicity - Loss of appetite, fatigue, weight loss, HA, bronze/gray hue to the skin, dizziness, nausea, SOB Monitor Hmg and Reticulocyte count Stools may be dark green fluids and fibers to prevent constipation

Injecting Iron Solutions

Use Z-Track technique in the buttocks To prevent staining skin Pinch and twist Apply pressure, dont massage! WOF: Dizziness, HA, Thrombophlebitis in the IV site Regular check-up and blood studies

Megaloblastic Anemia
Characterized by the production and peripheral proliferation of large, immature and dysfunctional RBCs Macrocytic Anemia

Vitamin B12 Deficiency (Pernicious) Anemia Folic Acid Deficiency Anemia

Folic Acid Deficiency Anemia (FAD-Anemia)

Causes: (ABCDEF) - Alcohol Abuse - Bacteria - Cooking excessively - Diet, Drug Therapy (Anticonvulsants) - E(i)nfants (limited storage capacity) - Folic acid requirement increased Folic Acid Administration: - Assess the use of other drugs - Do not mix with other drugs in the same syringe (if IV form) - Monitor for hypersensitivity - Urine may become darker yellow - Excess alcohol intake may folic acid requirements


Pernicious Anemia
Causes: (VAAGGGO) - Vitamin B12 Deficient in diet (no meat) - Auto-immune reaction Body attacking on B12 (Intrinsic factor) To be absorbed in the ileum for RBC production - Alcoholics - Gastric atrophy - Gastrectomy (no IF) - Gastritis, chronic - Older individuals Assessment Findings - Beefy red tongue - General S/Sx of anemia Weakness, Smooth Sore Tongue, Diarrhea - Paresthesia Abnormal sensation Tingling sensation in the fingertips - Impaired coordination and position sense - Confusion and behavioral change Laboratory Findings - Serum Folate Levels - Serum Vit B12 - Schillings Test Measure of excretion of orally administered radionuclide labeled B12 Urine Samples are collected Stage 1: Patient is given radionuclide labeled Vit B12 to drink or to eat IM is given at around the same time (temporary saturate B12 receptors in liver without normal B12) Normal result at least 5% radiolabeled Vit B12 in urine over 1st 24hrs Pernicious anemia less than 5% radiolabeled Vit B12 Stage 2: If abnormal, test is repeated with additional oral IF Normal urine collection = lack IF or pernicious anemia Low Result = abnormal intestinal absorption Result: No trace in urine (+) PERNICIOUS ANEMIA To absorb Vit B12, give IF After giving IF > Trace seen > (+)

Vitamin B12 Administration o Cyanocobalamine (oral, IV, IM) o Do not expose crystalline injection to light o Assess for other drugs o Administer parenteral doses IM or Deep SQ to local irritation o A burning sensation with injection is temporary o No to alcohol o Monitor Hmg, RBC, Reticulocyte count and K levels o Medication is taken for life Special Considerations o Monitor PR (Heart PUMPS!) o Compliance with lifelong Vit B12 o Diet, Plan activities (Fatigue) o Good Oral Hygiene (Angular Cheilitis) CNS complications


Hemolytic Anemia (Sickle Cell Anemia)

Results from excessive destruction of RBC - RBC Hgb Sickle Cell Anemia Abnormal Shape of RBCs Severe, chronic, incurable, hemolytic anemia resulting from an inherited defective hmg molecule Painful, episodic crisis Autosomal recessive genetic

NC + C = 0% Chance! C + C = 25% Chance! With disease + C = 50% Chance!

Sickling Process
Exposure to low O2

Triggers: Stress (Anxiety, etc) Infections Cold Environment Physical exercise Acidosis, Altitudes (high) Dehydration

Defective Hmg

Sickle Cells

Signs and Symptoms o Severe anemia Pallor, weakness, tachycardia o Hyperbilirubinemia Jaundice o Splenomegaly o Vascular occlusions Pain, ulcers, infarcts, tissue death

Fragile and Sticky

Impede circulation

Short lifespan of RBCs ANEMIA

Tissue hypoxia


Diagnostics - Hb Electrophoresis Diagnostic test - DNA screening (neonates) - X-ray - Abdominal UTZ - Transcranial CT-Scan

Sickle Cell Crisis o Occurs when client experiences O2 resulting in the enlargement of rigid sickleshaped cells Vaso-occlusive crises/pain crises Aplastic crisis Infection with human parovirus Hyperhemolytic crises Sequestration crises


Supportive Management: Acute Pain Assess PQRST Monitor effectiveness of analgesia Monitor I&O When dehydrated = O2 Apply heat to joints as ordered Provide rest periods Administer fluids Oral fluid intake Drugs: (MAN) Morphine Acetaminophen NSAIDS Other Pharmacological Management Hydroxyurea Sodium cromoglycate Folic acid supplement Fe supplement Blood transfusion Penicillin prophylaxis (Prevent infection) Pneumococcal vaccination (Prevent infection) Readiness for Enhanced Self-Care Client Education Explain nature of disease Adherence to treatment regimen, follow up Routine CBC count Genetic counseling Alert young women with sickle cell anemia that pregnancy carries a high-risk for them Explain complications and how to prevent crises

Aplastic Anemia (Bone Marrow Depression)

Primary condition of bone marrow stem cells Bone marrow fails to produce all three types of blood cell - Pancytopenia All blood components are low! Anemia No RBC Infection No WBC Bleeding No Platelet Etiology - 50% Idiopathic - Chemical damage: benzene, arsenic, Chloramphenicol, chemotherapeutic drugs - Viral infections: mononucleosis, Hep C, HIV - Exposure to radiation Clinical Manifestations - Anemia - Leukopenia = Low levels, recurrent/multiple infections - Thrombocytopenia = Petechiae, tendency to bleed excessively Management: - Eliminate any identifiable cause - Explain patient condition - Educate public about hazards of toxic agents - Prevent infection - Prevent bleeding - Prevent falls - Continue normal lifestyle with appropriate restrictions


Bone Marrow Transplant (BMT) - 3 Categories Autologous From Patient Syngeneic Transplant taken from identical twin Allogenic Transplant from an HLA-matched sibling or an unrelated HLA matching donor HLA = Human leukocyte antigen; match required to prevent rejection - Steps (Hindi naman ata important tooo) Conditioning Pre-treatment of bone marrow transplant recipient with high doses of chemotherapy +/- total body irradiation to destroy malignancy Bone Marrow Harvesting Needle is inserted into pelvis Bone marrow is collected from the donor under general anesthetic, 500 1200 mL of bone marrow from pelvis Processing Removal of red cells and to concentrate the mononuclear cells Transplantation Processed donor cells are injected into the recipient where they find their way to the bone marrow and attach Most critical days: First 100 days (post-transplantation) Before Transplantation: o Patient understanding o Procedure o Treatment protocol to be used o Venous access During Transplantation o Monitor VS o Maintain sterility o WOF: Complications After implementation: o Monitor VS o Administer meds o Provide good oral care o Meticulous skin care o Observe nursing care - Antithymocyte Globulin (ATG) Immunosuppressive agent Selectively destroys T-lymphocytes Gamma globulin from rabbits/horses that have been immunized against human thymocytes Indication: Aplastic anemia, transplant rejection WHY T CELLS? They attack the bone marrow

Erythrocytosis Excessive of RBCs Hct higher than 55% Can be Primary, Secondary, or Relative

Secondary Polycythemia
Something that is normal Physiologic disease (Physiologic Polycythemia) Occurs as a response to an elevated erythropoietin levels


Compensatory response to hypoxia

Relative Polycythemia
Not due to excess RBC production Fluid DEFICIT RBC count is normal but fluid loss increases cell concentration Corrected by rehydration

Primary Polycythemia / Polycythemia Vera / Erythremia (PV)

No Hmg formation Below normal total body iron Inadequate Hmg production for body requirements Clinical Features - Blood Flow Head ache Dizziness Sensory deficits (vision, hearing) Chest pain - Viscosity HTN Thromboses (Major cause of M/M) SOB, especially when lying flat Splenomegaly - Venous stasis Phletora: Ruddy appearance to face, especially nose Clubbing of fingers Dusky appearance to lips and Nursing Care: mucous membranes - Health Teaching: Dangers of smoking ( Viscosity) Adequate hydration Prevent blood stasis Report signs of thrombosis and bleeding Monitor hct and blood counts Management - Periodic Phlebotomy Removal of certain amount of blood (300 500 mL) Goal: Blood volume Make client non-deficient (no RBC production) Special considerations: Before: o Explain Procedure o WOF: Tachycardia, clamminess, vertigo o VS o Keep patient supine After: o WOF: S/Sx of Iron deficiency, bleeding o Advice ambulation o Oral fluid intake o VS o Monitor blood counts o Ambulates slowly