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Chapter 32
Assessment of Hematologic Function and Treatment Modalities
Hematologic System
The blood and the blood forming sites, including the bone marrow and the reticuloendothelial system
(RES)
Blood
Plasma: fluid portion of blood
Blood cells: erythrocytes, leukocytes, thrombocytes
Hematopoiesis
Bone Marrow
Stem cells
Myeloid
Erythrocytes (RBC)
Leukocytes (WBC)
Platelets
Lymphoid
Lymphocytes
Stroma
Hematopoiesis is the complex process of the formation and maturation of blood cells
Red Blood Cells: Erythrocytes
Types
Hemoglobin
Reticulocytes
Erythropoiesis
Iron stores and metabolism
Vitamin B12 and folic acid
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Destruction
White Blood Cells: Leukocytes
Granulocytes
Eosinophils
Basophils
Neutrophils
Bands: left shift
Agranulocytes
Monocytes
Lymphocytes
T cells and B cells
Platelets: Thrombocytes
Thrombopoietin
Fibrin
Plasma and Plasma Proteins
Albumin
Globulins
Alpha
Beta
Gamma
Impact on fluid balance
The neutrophils are the mature, circulating white blood cells. When a bacterial infection occurs, the
neutrophils will increase in order to phagocytize the bacteria
Reticuloendothelial System
Histiocytes
Kupffer cells
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Peritoneal macrophages
Alveolar macrophages
Spleen
Hemostasis
Assessment of Hematologic Health
Health history (refer to Chart 32-1)
Physical assessment
Diagnostic evaluation
Hematologic studies
Bone marrow aspiration and biopsy
Bone Marrow Aspiration
Therapeutic Approaches
Splenectomy
Apheresis
Hematopoietic stem cell transplantation (HSCT)
Phlebotomy
Blood component therapy
Special preparations
There are a variety of complications and reactions that can occur from a blood transfusion. Depending
on the type will determine the presenting symptoms
Blood and Blood Products #1
Donor requirements
Donation types
Directed
Standard
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Autologous
Intraoperative blood salvage
Hemodilution
Blood and Blood Products #2
Complications of donation
Blood processing
Transfusion
Common settings
Pretransfusion assessment
Patient education
Transfusion Process: PRBC
Transfusion Complications
Febrile nonhemolytic reaction
Acute hemolytic reaction
Allergic reaction
Circulatory overload
Bacterial contamination
Transfusion-related acute lung injury
Delayed hemolytic reaction
Disease acquisition
Long-term transfusion therapy
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Nursing Management for Reactions
Stop
Assess
Notify primary provider and implement prescribed treatments. Continue to monitor
Return blood
Obtain any samples needed
Document
Transfusion Alternatives
Refer to Chart 32-6
Growth factors
Erythropoietin
Granulocyte colony-stimulating factor
Granulocyte-macrophage colony-stimulating factor
Thrombopoietin
Chapter 33 Management of Patients With Nonmalignant Hematologic Disorders
❖ Anemias
Lower than normal hemoglobin and fewer than normal circulating erythrocytes; a sign of an
underlying disorder
❖ Hypoproliferative: defect in production of RBCs
o Caused by iron, vitamin B12, or folate deficiency, decreased erythropoietin production,
cancer
❖ Hemolytic: excess destruction of RBCs
o Caused by altered erythropoiesis, or other causes such as hypersplenism, drug-induced
or autoimmune processes, mechanical heart valves
May also be caused by blood loss
❖ Manifestations
Depends on the rapidity of the development of the anemia, duration of the anemia, metabolic
requirements of the patient, concurrent problems, and concomitant features
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o Fatigue, weakness, malaise
o Pallor or jaundice
o Cardiac and respiratory symptoms
o Tongue changes
o Nail changes
o Angular cheilosis
o Pica
Hypoproliferative anemia results from defective red blood cell production
Diagnostic Testing
o Hemoglobin and hematocrit
o Reticulocyte count
o RBC indices
o Iron studies
o Vitamin B12
o Folate
o Haptoglobin and erythropoietin levels
o Bone marrow aspiration
❖ Medical Management
Correct or control the cause
Transfusion of packed RBCs
Treatment specific to the type of anemia
o Dietary therapy
o Iron or vitamin supplementation: iron, folate, B12
o Transfusions
o Immunosuppressive therapy
o Other
❖ Nursing Process: The Patient With Anemia—Assessment
o Health history and physical exam
o Laboratory data
o Presence of symptoms and impact of those symptoms on patient’s life; fatigue, weakness,
malaise, pain
o Nutritional assessment
o Medications
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o Cardiac and GI assessment
o Blood loss: menses, potential GI loss
o Neurologic assessment
o Pallor From Anemia
❖ Nursing Process: The Care of the Patient With Anemia—Diagnoses
o Fatigue
o Altered nutrition
o Altered tissue perfusion
o Noncompliance with prescribed therapy
❖ Collaborative Problems and Potential Complications #1
o Heart failure
o Angina
o Paresthesias
o Confusion
o Injury related to falls
o Depressed mood
❖ Nursing Process: The Care of the Patient With Anemia—Planning
Major goals include decreased fatigue, attainment or maintenance of adequate nutrition, maintenance
of adequate tissue perfusion, compliance with prescribed therapy, and absence of complications
❖ Nursing Process: The Care of the Patient With Anemia—Interventions
o Balance physical activity, exercise, and rest
o Maintain adequate nutrition
o Maintain adequate perfusion
o Patient education to promote compliance with medications and nutrition
o Monitor VS and pulse oximetry; provide supplemental oxygen as needed
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o Monitor for potential complications
❖ Hypoproliferative Anemias
o Iron deficiency anemia
o Anemia in renal disease
o Anemia of inflammation
o Aplastic anemia
o Megaloblastic anemia
o Folic acid deficiency
o Vitamin B12 deficiency
❖ Hemolytic Anemias
o Sickle cell disease
o Thalassemia
o Glucose-6-phosphate dehydrogenase deficiency
o Immune hemolytic anemia
o Hereditary hemochromatosis
o Others (refer to Chart 33-1)
❖ Nursing Process: The Patient With Sickle Cell Disease—Assessment
o Health history and physical exam
o Pain assessment
o Laboratory data: S-shaped hemoglobin
o Presence of symptoms and impact of those symptoms on patient’s life; swelling, fever, pain
o Sickle cell crisis assessment
o Blood loss: menses, potential GI loss
o Cardiovascular and neurologic assessment
o Chronic Skin Ulcers of Sickle Cell
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❖ Nursing Process: The Patient With Sickle Cell Disease—Diagnoses
o Acute pain and fatigue
o Risk for infection
o Risk for powerlessness
o Deficient knowledge
❖ Collaborative Problems and Potential Complications #2
o Hypoxia, ischemia, infection
o Dehydration
o CVA
o Anemia
o Acute and chronic kidney disease
o Heart failure
o Impotence
o Poor compliance
o Substance abuse
❖ Nursing Process: The Patient With Sickle Cell Disease—Interventions
o Pain management
o Manage fatigue
o Infection prevention
o Promote coping
o Education of disease process
o Monitor for complications
o Polycythemia
o Increased volume of RBCs
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❖ Secondary polycythemia
o Excessive production of erythropoietin from reduced amounts of oxygen, cyanotic heart
disease, nonpathologic conditions or neoplasms
❖ Medical management
o Treatment not needed if condition is mild
o Treat underlying cause
o Therapeutic phlebotomy
❖ Neutropenia
o Decreased production or increased destruction of neutrophils (<2000/mm3)
o Increased risk for infection: monitor closely
o Absolute neutrophil count (ANC)
o Medical management: treatment depends on the cause
o Nursing management: patient education, preventing and managing complications
o Refer to Chart 33-5
❖ Bleeding Disorders #1
Failure of hemostatic mechanisms
❖ Causes
o Trauma
o Platelet abnormality
o Coagulation factor abnormality
❖ Medical management: specific blood products
❖ Nursing management: limit injury, assess for bleeding, bleeding precautions
❖ Bleeding Disorders #2
o Secondary thrombocytosis
o Thrombocytopenia
o Immune thrombocytopenic purpura (ITP)
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o Platelet defects
o Hemophilia
o von Willebrand disease
o Acquired Coagulation Disorders
o Liver disease
o Vitamin K deficiency
o Complications of anticoagulant therapy
o Disseminated intravascular coagulation (DIC)
o Thrombotic disorders
o Hyperhomocysteinemia
o Antithrombin deficiency
o Protein C & S deficiency
o Activated protein C resistance and factor V Leiden mutation
o Acquired thrombophilia
o Malignancy
❖ DIC
Not a disease but a sign of an underlying disorder
Severity is variable; may be life threatening
Triggers may include sepsis, trauma, shock, cancer, abruptio placentae, toxins, and allergic
reactions
Altered hemostasis mechanism causes massive clotting in microcirculation. As clotting factors
are consumed, bleeding occurs. Symptoms are related to tissue ischemia and bleeding
❖ Laboratory tests
❖ Treatment: treat underlying cause, correct tissue ischemia, replace fluids and electrolytes,
maintain blood pressure, replace coagulation factors, use heparin or LMWH
❖ Pathophysiology of DIC
❖ Nursing Process: The Care of the Patient With DIC—Assessment
o Be aware of patients who are at risk for DIC and assess for signs and symptoms of the
condition
o Assess for signs and symptoms and progression of thrombi and bleeding
o Common Lab Values of DIC
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❖ Nursing Process: The Care of the Patient With DIC—Diagnoses
o Risk for fluid volume deficiency
o Risk for impaired skin integrity
o Risk for imbalanced fluid volume
o Ineffective tissue perfusion
o Risk for injury
o Death anxiety
❖ Collaborative Problems and Potential Complications #3
o Kidney injury
o Gangrene
o Pulmonary embolism or hemorrhage
o Acute respiratory distress syndrome
o Stroke
❖ Nursing Process: The Care of the Patient With DIC—Planning
o Major goals may include maintenance of hemodynamic status, maintenance of intact skin and
oral mucosa, maintenance of fluid balance, maintenance of tissue perfusion, enhanced coping,
and absence of complications
❖ Nursing Process: The Care of the Patient With DIC—Interventions
o Assessment and interventions should target potential sites of organ damage
o Monitor and assess carefully
o Avoid trauma and procedures that increase the risk of bleeding, including activities that would
increase intracranial pressure
o Pharmacology and Coagulation
o Unfractionated heparin therapy
o Thrombosis prevention
o Maintain therapeutic aPTT
o Heparin-induced thrombocytopenia
o Low--molecular-weight heparin therapy
o Warfarin (Coumadin) therapy
o Impact of vitamin K
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o INR
❖ Dabigatran (Pradaxa), rivaroxaban (Xeralto), apixiban (Eliquis), endoxaban (Savaysa), Aspirin
Chapter 34 Management of Patients With Hematologic Neoplasms
❖ Hematopoietic Malignancies
Hematopoietic malignancy originates in the hematopoietic stem cell, the myeloid, or the
lymphoid stem cell
❖ Clonal stem cell disorders occur when the control mechanism fails and “indolent” clone cells
may evolve to more aggressive clone cells
❖ Classification by Cells Involved
❖ Leukemia: Proliferation of particular cell type:
o Granulocytes
o Lymphocytes
o Infrequently erythrocytes or megakaryocytes
❖ Lymphoma: Neoplasms of lymphoid tissue, usually derived from B lymphocyte
❖ Multiple myeloma: Malignancy of the most mature form of B lymphocyte—the plasma cell
❖ Leukemia
Hematopoietic malignancy with unregulated proliferation of leukocytes
❖ Types
o Acute myeloid leukemia
o Chronic myeloid leukemia
o Acute lymphocytic leukemia
o Chronic lymphocytic leukemia
These are four types of leukemia. Each caries a different treatment and prognosis
❖ Acute Myeloid Leukemia (AML) #1
o Defect in stem cell that differentiate into all myeloid cells: monocytes, granulocytes,
erythrocytes, and platelets
o Most common nonlymphocytic leukemia
o Affects all ages with peak incidence at age 67 years
o Prognosis is highly variable
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o Manifestations: fever and infection, weakness and fatigue, bleeding tendencies, pain from
enlarged liver or spleen, hyperplasia of gums, bone pain
❖ Acute Myeloid Leukemia (AML) #2
❖ Treatment:
o Aggressive chemotherapy—induction therapy,
o Hematopoietic stem cell transplantation (HSCT)
❖ Supportive care
o May be the only option
o Antimicrobial therapy and transfusions
o Death occurs within months
❖ Chronic Myeloid Leukemia (CML)
o Mutation in myeloid stem cell with uncontrolled proliferation of cells—Philadelphia
chromosome
o Stages: chronic phase, transformational phase, blast crisis
o Uncommon in people younger than age 20 years, with increased incidence with age; mean age:
64 years
o Manifestations: initially may be asymptomatic, malaise, anorexia, weight loss, confusion or
shortness of breath caused by leukostasis, enlarged tender spleen, or enlarged liver
o Treatment: imatinib mesylate (Gleevec) blocks signals in leukemic cells that express BCR-ABL
protein; chemotherapy, HSCT
❖ Acute Lymphocytic Leukemia (ALL)
o Uncontrolled proliferation of immature cells from lymphoid stem cell
o Most common in young children, boys more often than girls, peak age 4 years old
o Prognosis is good for children; 85% for 3-year event-free survival but drops with increased age
<45% adults
o Manifestations: Pain from enlarged liver/spleen, bone, CNS; headache and vomiting
o Treatment: chemotherapy, HSCT, monoclonal antibody therapy, corticosteroids
o Lymphadenopathy
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❖ Chronic Lymphocytic Leukemia (CLL)
o Common malignancy of older adults, and the most prevalent type of adult leukemia, mean: 72
years old
o Derived from a malignant clone of B lymphocytes
o Survival varies from 2 to 14 years depending on stage
o Manifestations: “B symptoms,” a constellation of symptoms including fevers, drenching sweats
(especially at night), and unintentional weight loss
o Treatment: early stage “watch and wait”, chemotherapy, monoclonal antibody therapy, IVIG for
recurrent infections, and HSCT
❖ Nursing Process: The Care of the Patient With Leukemia—Assessment
o Health history
o Assess symptoms of leukemia and for complications
o Anemia, infection, and bleeding
o Weakness and fatigue
o Laboratory tests
o Leukocyte count, ANC, hematocrit, platelets, creatinine and electrolyte levels, and
coagulation and hepatic function tests
o Cultures as needed
❖ Nursing Process: The Care of the Patient With Leukemia—Diagnoses
o Risk for infection and/or bleeding
o Impaired oral mucous membrane
o Imbalanced nutrition and fluid volume
o Acute pain
o Fatigue and activity intolerance
o Risk for imbalanced fluid volume
o Self-care deficits due to fatigue
o Anxiety
o Risk for spiritual distress and knowledge deficit
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❖ Collaborative Problems and Potential Complications
o Infection
o Bleeding/DIC
o Renal dysfunction
o Tumor lysis syndrome
❖ Nursing Process: The Care of the Patient With Leukemia—Planning
Major goals may include:
o Absence of complications and pain
o Attainment and maintenance of adequate nutrition
o Activity tolerance
o Ability to provide self-care and to cope with the diagnosis and prognosis
o Positive body image
o Understanding of the disease process and its treatment
❖ Nursing Process: The Care of the Patient With Leukemia—Interventions #1
o Interventions related to risk of infection and bleeding
o Mucositis
o Frequent, gentle oral hygiene
o Soft toothbrush or if counts are low, sponge-tipped applicators
o Rinse only with NS, NS and baking soda, or prescribed solutions
o Perineal and rectal care
❖ Nursing Process: The Care of the Patient With Leukemia—Interventions #2
o Improve nutritional intake
o Oral care before and after meals
o Administer analgesics before meals
o Appropriate treatment of nausea
o Small, frequent feedings
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o Soft foods that are moderate in temperature
o Low-microbial diet
o Nutritional supplements
❖ Nursing Process: The Care of the Patient With Leukemia—Interventions #3
o Easing pain and discomfort
o Acetaminophen (Tylenol) for fever and myalgias
o Cool water sponging
o Frequent bedding changes
o Gentle massage
o Relaxation techniques
o Decreasing fatigue and activity intolerance
o Balance activity and rest
o Nursing Process: The Care of the Patient With Leukemia—Interventions
#4
o Maintaining fluid and electrolyte balance
o Intake and output, daily weights
o Assess for dehydration and overload
o Laboratory studies including electrolytes, blood urea nitrogen,
creatinine, and hematocrit
o Replacement as necessary
o Improve self-care, self-esteem, anxiety, and grief with empathetic listening and
realistic reassurance
❖ Myelodysplastic Syndromes (MDS)
o Disorder of the myeloid stem cell
o May be asymptomatic or present with fatigue or illness
o Diagnosed with CBC or bone marrow biopsy
o Occurs in older adult: mean 65 to 70 years old
o Only cure is with HCST
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o Other treatment: blood transfusion, bone marrow–stimulating agents, immunosuppressive
therapy in some, chelation therapy, and myeloid growth factors
❖ Myeloproliferative Neoplasms
o Polycythemia vera
o Essential thrombocythemia
o Primary myelofibrosis
❖ Polycythemia Vera
o Proliferative disorder of the myeloid stem cells
o Median age 65 and survival 14 to 24 years
o Symptoms include ruddy complexion, splenomegaly, high blood pressure, generalized pruritis,
and erythromelalgia
o Diagnosis: elevated hemoglobin or hematocrit and the presence of an acquired mutation in the
JAK2 gene
o Risks include thrombosis complications (CVA, MI) and bleeding from dysfunctional platelets
o Polycythemia Vera Treatment
o Phlebotomy (500 mL or once or twice a week)
o Chemotherapeutic agents to suppress marrow function
o Aggressive management of atherosclerosis
o Allopurinol to prevent gout
o Aspirin for pain
o Platelet aggregation inhibitors
o Interferon
❖ Essential Thrombocythemia
o Also called primary thrombocythemia
o Stem cell disorder within the bone marrow
o Cause is unknown, affects women more than men, median age 65 to 70 years old
o Symptoms usually occur from vascular occlusion, headaches, enlarged spleen, and hemorrhage
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o Treatment based on risk for developing thrombosis or hemorrhage, and the presence of
symptoms
o Table 34-2
❖ Primary Myelofibrosis
o Chronic myeloproliferative disorder within the stem cell
o Disease of older adults 65 to 70 years; survival rate 2 to 10 years
o Pancytopenia is common
o Symptoms include enlarged spleen, fatigue, pruritus, bone pain, weight loss, infection, bleeding,
and cachexia
o Treatment based on reducing the burden of the disease (by decreasing symptoms and
splenomegaly) and improving blood count. Splenectomy may be used to control significant
problems
o Primary Myelofibrosis Treatment
o Treatment based on reducing the burden of the disease and improving blood counts:
o Blood transfusions and erythroid stimulating agents for anemia
o HSCT useful in younger people, only current therapy to reduce fibrosis of marrow
o Splenectomy may be used to control significant problems
❖ Lymphoma
o Neoplasm of lymphoid origin
o Usually start in lymph nodes but can involve lymphoid tissue in the spleen, GI tract, liver, or
bone marrow
o Refer to Figure 35-1
o Classified according to degree of cell differentiation and origin of predominant malignant cell
o Two major categories:
o Hodgkin lymphoma
o Non-Hodgkin lymphoma
❖ Hodgkin Disease
o Relatively rare malignancy that has a high cure rate
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o Suspected viral etiology, familial pattern, incidence in early 20s and again after the age of 50
years; more common in men
o Unicentric; initiates in a single node
o Reed--Sternberg cell (Fig. 34-7)
o Manifestations: painless lymph node enlargement; pruritus; B symptoms: fever, sweats, weight
loss
o Treatment is determined by stage of the disease and may include chemotherapy, radiation
therapy, or both, and HSCT for advanced disease
❖ Non-Hodgkin Lymphoma (NHL)
o Lymphoid tissues become infiltrated with malignant cells; spread is unpredictable and localized
disease is rare
o Increases with age, with average age being 66 years
o Increased in autoimmune, prior treatment for cancer, organ transplant, viral infections,
exposure to pesticides
o Manifestation: lymphadenopathy, B symptoms, and symptoms associated with lymphomatous
masses
o Treatment is determined by type and stage of disease and may include interferon,
chemotherapy, radiation therapy, and HSCT
❖ Multiple Myeloma
o Malignant disease of the most mature form of B lymphocyte—the plasma cell
o Incidence increases with age; median 70 years old; 5 year survival rate; no cure
o Manifestations: bone pain reported in 80%, mostly back and ribs; osteoporosis and fractures
related to bone destruction; hypercalcemia, renal impairment and failure, anemia
o Treatment may include HSCT, chemotherapy, corticosteroids, radiation therapy,
o New drugs being used: immunomodulatory drugs (IMiDs), thalidomide analogs, monoclonal
antibody
o Multiple Myeloma Treatment
o Treatment may include:
o Auto HSCT
o Chemotherapy and radiation
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o Corticosteroid
❖ New drugs being used:
o Immunomodulatory drugs (IMiDs)
o Thalidomide analogs
o Monoclonal antibody
❖ Multiple myeloma
Any older adult patient whose chief complaint is back pain and who has an elevated total protein level
should be evaluated for possible myeloma
