Med Surg: Class 2

Class 2

Med Surg

 

Hematology

 

  • Reticulocyte – the precursor cell to RBC
  • Neutrophil levels are the main indicator of infection
    • band cells are the immature version of neutrophils
  • Basophil levels are the main indicator of allergic reaction

 

  • Erythropoietin stimulates rbc production, and the kidneys do this if hypoxia is present.
  • RBC life span is 120 days
    • production of RBC needs, iron copper and b vitamins
    • a reticulocyte count will show you if the body is reacting to anemia, if it is reacting there will be an elevated reticulocyte count.
  • WBC range – 5,000 – 10,000
    • granulocytes – strong phagocytes
      • -phils
      • left shift in neutrophils means that there are more band cells than “segs” (segmented neutrophils, mature)
    • agranulocytes –
      • -cytes
  • ANC – absolute neutrophil count (1500 – 8,00)
    • “segs” and bands combined
    • if this number is low the patient is compromised and will not be able to fight infection well.
  • Bone marrow aspiration (big ass needle grinding out a bone sample)
    • taking bone cells to be able to look at the mat the microscopic level
    • helps diagnose heme diseases
    • may need pain meds and/or conscious sedation.
    • educate the patient and family on the procedure
    • check the leukocyte count to prevent bleeding.
    • the bone sample is usually in the anterior iliac crest.
  • hematologic s/s
    • fatigue, decreased activity tolerance, pain with sickle cell.
    • bleeding may occur in, gums, bladder, nose ect.
    • Hgb 13.5 -17.5 for men and 12-15.5 for women.
  • Nursing care plan (ADPIE)
    • Assessment
    • Diagnosis
    • Planning
    • Implementation
    • Evaluation
    • Were the goals met? if not reassess and start fresh.

 

  • Assessment
    • look for multiple organ involvement
    • changes in BP, tachycardia, dyspnea
    • jaundice? for hemolytic anemia
    • lymphadenopathy (enlargement of the lymph nodes)
    • petechiae from thrombocytopenia
    • ecchymosis (bruising)
    • signs of bleeding

 

  • prevention of anemia
    • Nutritional consult
    • education on s/s: fatigue, HR changes, bleeding signs.
  • treating anemia
    • give blood
    • find and treat cause
  • types of anemia
    • Decreased production
      • Hgb (iron)
      • DNA synthesis (cobalamin)
      • bone marrow suppression
    • blood loss
    • hemolysis
      • sickle cell disease (intrinsik)
      • antibodies (extrinsic)
  • labs for diagnosis
    • Hgb (12-14)
    • Hct (40-50%)
    • MCV (normocytic, micro, or macro)
    • Retic count (immature RBC)
    • TIBC (total iron binding capacity)
    • Transferrin
    • Ferritin (iron stores)
    • Total bilirubin

 

  • s/s come from the decreased oxygenation, from low RBC or low volume and RBC
    • the s/s are more pronounced if the anemic changes occur quickly
  • TACO – transfusion associated cardiac overload
  • special populations that may have higher Hgb levels
    • high altitude people, smokers, athletes
    • african americans have 0.5 – 1.0 g/dL

 

types of anemia

 

  • Iron-deficiency anemia
    • hypochromic, microcytic
    • from poor nutrition, or chronic blood loss
    • s/s unique to I-D anemia: spoon shaped nails, no jaundice,
    • Low serum Ferritin, increased TIBC, low serum iron concentration
      • Ferritin is the best test  
    • look for hx of chronic bleeding
    • give the person IRON PO or IM (PO is preferred if they can tolerate it)
    • foods high in iron: leafy greens, red meats, liver, fortified grains.
  • Megaloblastic anemia
    • Megaloblastic (macrocytic)
    • impaired DNA synthesis
    • usually from deficiency in folate or B12
    • drugs such as phenytoin, and Methotrexate can cause folate anemia
    • alcohol abuse, and anorexia are risk factors
  • Anemia of chronic disease
    • under production of RBC
    • from renal, or liver dx. as well as tumors, inflammation and endocrine disorders
  • Aplastic anemia
    • decrease of all blood types
    • from hypocellular bone marrow
    • this can arise from anything that damages the bone marrow: chemotherapy, anorexia (rarely), parvovirus.
    • 75% fatal
    • bone marrow transplantation can help as well and long term steroids (immunosuppression)
  • Hemolytic anemia
    • destruction of hemoglobin
    • RBC life span of <100 days
    • hereditary
      • Spherocytosis – hereditary, spherical small RBCs
      • sickle cell – hereditary, comes with pain
      • thalassemia major – malformation of the hemoglobin,  
    • acquired
      • Coombs
      • thrombotic thrombocytopenic purpura
      • Hemolytic uremic syndrome
      • malaria
    • Jaundice
      • normal bilirubin level is about 1.5
      • the destroyed RBCs cause bili to rise
      • direct = conjugated = processed (bilirubin)
      • Indirect = unconjugated = unprocessed

 

Too much RBC production

  • Polycythemia
    • polycythemia vera – chromosomal mutation
    • secondary is caused by hypoxemia   
    • the issue is hyper viscosity, this can clog up the small vessels in the eye brain, and heart.
    • splenomegaly in 90% on pt’s due to the larger amount of cells that need to be broken down after life span over.
  • Neutropenia
    • low neutrophil count
    • also there are granulocytopenia, and  leukocytopenia)
    • get them in protective isolation room
    • limit outside contact
    • get cultures then give the antibiotics if necessary
  • Thrombocytopenia
    • low platelets
    • caused by: sepsis, folate or b12 deficiency, can be autoimmune
    • protect from bleeding
    • will not give platelets unless severe
    • high platelet count is thrombocytosis
      • myeloproliferative disease
      • chronic iron deficiency
      • inflammatory, infectious or neoplastic disorders  
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