Nursing of Adults with
Medical & Surgical Conditions
Blood and Lymphatic
Disorders
Blood and Lymphatic Disorders
Laboratory Tests• RBC (erythrocytes) 4-6 million/cu.mm• Hemoglobin 10-20 gm/100ml• Hematocrit 40-50 percent• WBC 5,000-10,000/mm• Platelets 150,000-400,000/mm
Anemia
Definition• Disorder characterized by RBC and
hemoglobin and hematocrit levels below normal range
• Causes delivery of insufficient amounts of oxygen to tissues and cells
Anemia
Types• Blood loss (hemorrhage)
• Impaired production of RBC’s (bone marrow depression)
• Increased destruction of RBC’s (hemolysis)
• Nutritional deficiencies (long term iron deficiency)
Anemia
Signs & Symptoms• Anorexia• Cardiac dilation• Disorientation• Dyspepsia• Dyspnea• Exertional dyspnea• Fatigue• Headache
• Insomnia• Pallor• Palpitation• Shortness of breath• Systolic murmur• Tachycardia• Vertigo
Hypovolemic Anemia
Etiology/Pathophysiology• Abnormally low circulating blood volume due
to blood loss• 500 ml loss can be tolerated• 1000 ml loss can be severe complications• Severity and signs and symptoms depend on
how rapid the blood is lost
Hypovolemic Anemia Signs & Symptoms
• Weakness• Stupor• Irritability• Pale, cool, moist skin• Hypotension• Tachycardia (rapid, weak, thready pulse)
• Hypothermia• Hemoglobin less than 10 gm/100ml• Hematocrit less than 40 %
• H&H may not drop for several hours after blood loss
Hypovolemic Anemia
Treatment• Control bleeding• Treat shock
• O2, elevate lower extremities, keep warm
• Replace fluid• blood transfusion, plasma, dextran, lactaed ringers
• Monitor vital signs
Pernicious Anemia
Etiology/Pathophysiology• Absence of the intrinsic factor• Intrinsic factor is essential for the absorption of
vitamin B12• Deficiency of vitamin B12 affects growth and
maturity of all body cells• RBC’s in the bone marrow don’t mature• RBC membrane ruptures easily
• Vitamin B12 is also related to nerve myelination• may cause progressive demyelination and
degeneration of nerves and white matter
Pernicious Anemia
Signs & Symptoms• Extreme weakness• Dyspnea• Fever• Hypoxia• Weight loss• Jaundice (destruction of RBC’s)
• Pallor• GI complaints
Pernicious Anemia
• Dysphagia• Sore, burning tongue
• Smooth and erythematous
• Neurological symptoms• tingling of the hands and feet
• disorientation
• personality changes
• behavior problems
• partial or total paralysis
Pernicious Anemia
Treatment• Vitamin B12 (cyanocobalamin) 1000 units
• daily for 1 week• weekly for 1 month• monthly for life
• Folic acid supplement• Iron replacement• RBC transfusion
• for severe anemia
• Diet• high protein, vitamins, and minerals
Aplastic Anemia
Etiology/Pathophysiology• Decrease of bone marrow function
• RBC production
• Primary• congenital
• Secondary• viral invasion• medications• chemicals• radiation• chemotherapy
Aplastic Anemia
Signs & Symptoms• Pancytopenic
• all three major blood elements from the bone marrow are decreased (RBC, WBC, & Platelets)
• Repeated infections with high fevers• Fatigue, weakness, malaise• Dyspnea• Palpitations• Bleeding tendencies
• petechiae, ecchymossis, bleeding gums, epistaxis, GI & GU bleeds
Aplastic Anemia
Treatment• Identify & remove cause• Platelet transfusion for severe thrombocytopenia• Splenectomy for hypersplenism
• Hypersplenism can cause destruction of platelets
• Steroids and androgens• stimulate bone marrow
• Antithymocyte globulin• stimulates bone marrow
• Bone marrow transplant
Iron Deficiency Anemia
Etiology/Pathophysiology• RBC’s contain decreased levels of hemoglobin• Excessive iron loss
• caused by chronic bleeding; intestinal, uterine, gastric
Iron Deficiency Anemia Signs & Symptoms
• Pallor
• Fatigue
• Weakness
• Shortness of breath
• Angina
• S/S of heart failure
• Glossitis• Pagophagia (desire to eat ice, clay, starches)
• Headache
• Paresthesia
• Burning tongue
Iron Deficiency Anemia Treatment
• Ferrous Sulfate 900 mg daily• Oral or injection (z-tract)
• Ascorbic acid• enhances absorption of iron
• Diet high in iron• Organ meats
– liver, kidney, heart, tongue
• Muscle meats (esp dark meat from poultry)
• Fish
• Eggs
• Green leafy vegetables
• Whole grains
• Dried beans
Sickle Cell Anemia Etiology/Pathophysiology
• Most common genetic disorder in the U.S.
• Occurs predominantly in African Americans• 1out of 10 have trait; 1 out of 500 have disease
• An abnormal, crescent shaped RBC• contains hemoglobin S (Hg-S)
• Severe, chronic, incurable condition
• Disease• Homozygous
– has two Hg-S genes; one from each parent
• Trait• Heterozygous
– has one Hg-S gene from one parent and one Hg-A gene from the other parent
Sickle Cell Anemia Signs & Symptoms
• Precipitating Factors• Dehydration
• Change in oxygen tension in the body– infection, overexertion, cold, alcohol, smoking
• Loss of appetite• Irritability• Weakness• Abdominal enlargement
• pooling of blood in the liver, spleen and other organs
• Join and back pain• Edema of extremities
Sickle Cell Anemia
Treatment• No specific treatment
• Alleviate symptoms
• Oxygen• Rest• Fluids
• oral and IV
• Analgesics• Bone marrow transplant
• Experimental
Agranulocytosis
Etiology/Pathophysiology• Severe reduction in the number of granulocytes
(basophils, eosinophils, & neutrophils)• WBC less than 200/mm3
• Medications• analgesics, antibiotics, antiepileptics, antihistamines, antineoplastic agents,
antithyroid drugs, diuretics, phenothiazides, sulfonamides
• Chemotherapy• Radiation• Neoplastic disease• Viral and bacterial infections
Agranulocytosis
Signs & Symptoms• S/S of infection
• fever, chills, headache, fatigue
• Ulcerations of mucous membranes• Bronchial pneumonia• Urinary tract infection
Agranulocytosis
Treatment• Identify and remove cause of bone marrow
depression• Prevent or treat infections• Meticulous handwashing• Strict asepsis
Leukemia
Etiololgy/Pathophysiology• Malignant disorder of the hematopoietic system• Excess leukocytes accumulate in the bone marrow
and lymph nodes• bone marrow produces immature cells
• Cause unknown• Possible causes include genetic, virus, exposure to
radiation, or chemotherapy
• Classification• Acute or Chronic• Proliferating cells (lymphocytic, monocytic, etc.)
Leukemia
Signs & Symptoms• Anemia
• pallor, fatigue, malaise
• Thrombocytopenia• petechiae, epistaxis, bruising, occult blood
• Leukopenia• fever, upper resp. infections,
• Enlarged lymph nodes• Splenomegaly
Leukemia
Treatment• Chemotherapy• Radiation• Bone marrow transplant• Medications
• Leukeran
• hydroxyurea
• corticosteroids
• Cytoxan
Thrombocytopenia
Etiology/Pathophysiology• Abnormal hematological condition in which the
number of platelets is reduced below 100,000 mm3
• Decreased production• aplastic anemia, leukemia, tumors, chemotherapy
• Decreased survival• antibody destruction, infection, viral invasion
Thrombocytopenia
Signs & Symptoms• Petechiae• Ecchymoses• Platelets below 100,000
• bleeding mucous membranes
• bleeding internal organs
• Platelets below 20,000• serious bleeding risks
Thrombocytopenia
Treatment• Corticosteriod therapy• Splenectomy• Gamma globulin • Immunosuppressive drugs• Platelet transfusions• Avoid trauma
Hemophilia
Etiology/Pathophysiology• Hereditary coagulation disorder, characterized by a
disturbance of clotting factor• Hemophilia A
• most common• Factor VIII is absent
• Hemophilia B• Deficiency of Factor IX
• X-linked hereditary trait• affects mainly males• females are carriers
Hemophilia
Signs & Symptoms• Internal & external bleeding• Hemarthrosis
• bleeding into the joint; esp knees, ankles, and elbow
• Excessive blood loss from small cuts and dental procedures
Hemophilia
Treatment• Minimize bleeding
• avoid trauma
• Relieve pain• No aspirin
• Transfusions• Factor VIII or IX concentrate
– human-derived products– can be treated to inactivate viruses
• Cryoprecipitate (rich in factor VIII)– human-derived product
• Manufactured factor VIII or IX
von Willebrand’s Disease
Etiology/Pathophysiology• Inherited bleeding disorder characterized by
abnormally slow coagulation of blood and spontaneous episodes of GI bleeding, epistaxis, and gingival bleeding
• Mild deficiency of factor VIII• Common during
• Postpartum• Menorrhagia• Post operative• Post truama
• Similar to hemophilia; not limited to males
von Willebrand’s Disease
Treatment• Cryoprecipitate
• Fibrinogen
• Fresh plasma
• Desmopressin (DDAVP)• Synthetic of the human antiduiuretic hormone, vasopressin
• Causes an increase in factor VIII release from storage sites in the body
• Same nursing interventions as for hemophilia
Disseminated Intravascular Coagulation (DIC)
Etiology/Pathophysiology• Overstimulation of clotting and anticlotting processes
in response to disease or injury• Septicemia• Obstetrical complications• Malignancies• Tissue trauma• Transfusion reaction• Burns• Shock• Snake bites
Disseminated Intravascular Coagulation (DIC)
• Primary disorder initiates generalized intravascular clotting, which overtimulates fibrinolytic mechanisms
• The hypercoagulability is followed by a deficiency in clotting factors with subsequent hypocoagulability and hemorrhaging
Disseminated Intravascular Coagulation (DIC)
Signs & Symptoms• Bleeding
• Mucous membranes
• Venipuncture sites
• Surgical sites
• GI & GU tracts
• All orifices
• Dyspnea• Hemoptysis• Diaphoresis• Cold, mottled digits• Purpura on the chest and abdomen• Petechiae
Disseminated Intravascular Coagulation (DIC)
Treatment• Treat underlying cause• Cryoprecipitate• Heparin• Protect from bleeding and trauma
Multiple Myeloma
Etiology/Pathophysiology• Malignant neoplastic immunodeficiency
disease of the bone marrow• Tumor, composed of plasma cells, destroys
osseous tissue• Bone marrow becomes overcrowded and
unable to produce erythrocytes, platelets, and leukocytes
• Onset is gradual and insidious
Multiple Myeloma Signs & Symptoms
• Bone pain• Ribs, spine, and pelvis
• Pathological fractures• Infection• Anemia• Bleeding• Hypercalcemia
• Calcium and phosphorus drain from bones
• Renal failure• Myeloma protein causes kidney damage• Destruction of cells causes hyperuricemia
Multiple Myeloma Treatment
• Symptomatic; not curable• Radiation• Chemotherapy
• Alkeran
• Cytoxan
• Leukeran
• Carmustin
• Vincristine
• Adriamycin
• Dexamethasone
• Corticosteroids• IV fluids
Lymphangitis
Etiology/Pathophysiology• Inflammation of one or more lymphatic vessels• Usually occurs from acute streptococcal or
staphylococcal infection in an extremity
Lymphangitis
Signs & Symptoms• Fine red streaks from the affected area in the
groin or axilla• Edema• Chills• Fever• Local pain• Headache • Myalgia
Lymphangitis
Treatment• Penicillin• Hot, moist heat• Elevate extremity
Lymphedema
Etiology/Pathophysiology• Primary or secondary disorder • Accumulation of lymph in the soft tissue
• Obstruction
• Increase in amount of lymph
• Removal of lymph channels and nodes
Lymphedema
Signs & Symptoms• Massive edema and
tightness of affected extremity
• Pain
Treatment• Diuretics• Antibiotics• Compression pump• Elastic stocking or sleeve• Restricted sodium diet• Avoid constrictive clothing• Meticulous skin care
Lymphedema
Malignant Lymphoma
Etiology/Pathophysiology• Non-Hodgkin’s Lymphoma• Neoplastic disorder of lymphoid tissue• Tumors usually start in lymph nodes and spread
to lymphoid tissue in the spleen, liver, GI tract, and bone marrow
Malignant Lymphoma Signs & Symptoms
• Painless, enlarged cervical lymph nodes • Fever• Weight loss• Anemia• Pruritus• Susceptiblity to infection• Complications
• Pleural effusion, bone fractures, and paralysis
• Fatigue• Malaise• Anorexia
Malignant Lymphoma Treatment
• Accurate staging of the disease is crucial to determine treatment regimen• Radiation
• Initial treatment when localized
• Chemotherapy• Cytoxan, Oncovin adriamycin bleomycin, methotrexate• Treatment when not localized
• Bone marrow transplant• Tumor necrosis factor (TNF)
• Direct cell toxicity• Stimulates bone marrow
Hodgkin’s Disease
Etilology/Pathophysiology Inflammatory or infectious process that develops into a neoplasm Affects males twice as frequently as females Reed-Sternberg cells Large, abnormal, multinucleated cells in the lymphatic system replace the normal cells
Signs & Symptoms Enlargement of cervical lymph nodes Anorexia Weight loss Pruritus Low-grade fever Night sweats Anemia Leukocytosis
Hodgkin’s Disease
Etilology/Pathophysiology• Inflammatory or infectious process that
develops into a neoplasm• Affects males twice as frequently as females• Reed-Sternberg cells
• Large, abnormal, multinucleated cells in the lymphatic system replace the normal cells
Hodgkin’s Disease Signs & Symptoms
• Enlargement of cervical lymph nodes• Anorexia• Weight loss• Pruritus• Low-grade fever• Night sweats• Anemia• Leukocytosis
• Increased WBC
Hodgkin’s Disease
Treatment• Depends on the staging process
• Chart on page 280
• Stage I or II (localized)• Radiation
• Stage III or IV (generalized)• Chemotherapy
• Combination