efren n. aquino m.d. aug. 4, 2009

Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 1

EFREN N. AQUINO M.D.EFREN N. AQUINO M.D.

Aug. 4, 2009Aug. 4, 2009

Care of the Patient with a Blood

or Lymphatic Disorder – Part 1

Care of the Patient with a Blood

or Lymphatic Disorder – Part 1


Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology

• We live in a hostile and dangerous environment. Each day we are faced with potentially harmful toxins, disease-causing bacteria, viruses, and even cells from our own bodies that have been transformed into cancerous invaders.

Fortunately, we are protected from this staggering variety of biologic enemies by a remarkable set of defense mechanisms.

• These mechanisms involve the circulatory and lymphatic system


Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology

Characteristics of blood Consistency

• 45% blood cells

• 55% blood plasma** pH

• 7.35-7.45 Volume

• 10-12 pints = 5 – 6 Liters


The blood performs three critical functions.The blood performs three critical functions.

• First: transports oxygen and nutrition to the cells and waste products away from the cells, and transports hormones from endocrine glands to tissues and cells.

• Second: regulates the acid-base balance (pH) with buffers, aids with body temperature because of its water contents, and controls the water content of its cells as a result of dissolved sodium ions.

• Third: it protects the body against infection with special cells and prevents blood loss with special clotting mechanisms.


Red blood cells (RBC) Erythrocytes Continuously produced in the red bone

marrow ** Transport oxygen and carbon dioxide

White blood cells (WBC) Leukocytes Body defenses: destruction of bacteria

and viruses called phagocytosis

Thrombocytes (platelets) Initiate blood clotting


Red Blood Cells• Erythrocytes (red blood cells [RBCs]) give

blood its rich color.

• A mature RBC contains cytoplasm and the red pigment hemoglobin (Hgb), a compound in the blood that carries oxygen to the cells from the lungs.

• The normal hemoglobin level is 14 to 18 g/dL for men and 12 to 16 g/dL for women. The average life span of an RBC is 120 days.


Red Blood Cells, cont..• An erythrocyte is the major cellular element of

the circulating blood; its principal function is to transport oxygen and carbon dioxide.

• Erythrocytes are continuously produced in the red bone marrow, principally in the vertebrae, ribs, sternum, and proximal ends of the humerus and femur. (all bones with red bone marrow..ena)


Red Blood Cells, cont..• Erythropoiesis (the process of RBC production)

depends on several factors, among them health conditions of the bone marrow; dietary substances such as iron and copper, plus essential amino acids and certain vitamins like vitamin B12 folic acid, riboflavin (vitamin B2), and pyridoxine (vitamin B6).

• A feedback mechanism is energized when the amount of oxygen delivered to the tissues by RBCs is decreased.


Red Blood Cells, cont..• The decreased oxygen triggers the release of an

enzyme, the renal erythropoietic factor, in the kidneys. Erythropoietin is carried to the bone marrow, where it initiates the development of mature RBCs. The increased number of RBCs allows more oxygen to be delivered to the tissues, and as a result, the signal to increase RBC production is shut off.


Red Blood Cells, cont..• A common laboratory test called the hematocrit

which is a measure of the packed cell volume of red blood cells, expressed as a percentage of the total blood volume

• Normally about 42% to 52% of the blood volume in men and 37% to 47% in women consists of RBCs.


Red Blood Cells, cont..• Hemoglobin is another lab exam which represents

the oxygen carrying capacity of the RBC.

• If hemoglobin falls below the normal level, as it does in anemia, an unhealthy chain reaction begins: less hemoglobin, less oxygen transported to cells, slower breakdown and use of nutrients by cells, less energy produced by cells, decreased cellular function. If one understands the relationship between hemoglobin and energy, one can understand that an anemic person’s complaint will be of feeling “tired all the time”.


White Blood Cells• Unlike erythrocytes, leukocytes (white blood cells

[WBCs]) have nuclei, are colorless, and live from a few days to several years.

• They are primarily involved in body defenses, such as destruction of bacteria and viruses.

• They number 5000 to 10,000 per mm3 of blood.

• Some WBCs can actually leave the bloodstream and move through tissue spaces to fight foreign invaders, such as bacteria.


White Blood Cells, cont..There are two broad categories of white cells:

• granulocytes and

• nongranulocytes.

The three types of granulocytes are:

• neutrophils,

• eosinophils, and

• basophils.

The nongranulocytes include:

• lymphocutes and

• monocytes.


White Blood Cells, cont..• A differential white blood cell count is an

examination in which the different kind of WBCs are counted and reported as percentages of the total examined.

• Neutrophils are the primary phagocytic cells involved in acute inflammatory response. A mature neutrophil is called a segmental neutrophil or “seg” because the nucleus is segmented into two to five lobes connected by strands. They also release lysozyme, an enzyme that destroys certain bacteria.

• Normal value: 60-70%


White Blood Cells, cont..• Neutrophils: Because neutrophils respond in

proportion to the severity of the infection, an overwhelming infection may deplete marrow reserves. When this happens, the marrow releases immature polymorphonuclear leukocytes (“polys”), called bands, which are immature neutrophils that are in the final stages of development.

• When the band count exceeds 8% of the total number of WBC’s, the marrow has used up its reserve. The presence of excess bands in the peripheral bloods is called a shift to the left (i.e., a shift toward immature cells) and indicates severe infection.


Eosinophils are WBCs that play a role in allergic reactions and are effective against certain parasitic worms. Normal value = 1- 4 %

Basophils are WBCs that are essential to the nonspecific immune response to inflammation because of their role in releasing histamine (vasodilator) during tissue damage or invasion. Basophils have cytoplasmic granules that contain heparin, serotonin, and histamine, If a basophil is stimulated by an antigen or by tissue injury, it will respond by releasing substances within the granules. This is part of the response seen in allergic and inflammatory reactions. Normal value of basophils are 0.5% to 1%.


Monocytes are WBCs that function similarly to neutrophils; they circulate in the bloodstream and move into tissue, where they engulf foreign antigens and cell debris. Monocytes are the second type of WBC to arrive at the scene of an injury. They are useful in removing dead bacterial infections. Normal values of monocytes are 2% to 6%.


The lymphocytes are WBCs that are responsible for antibody formation, a special protein that combats foreign invaders, or antigens. They set up the antigen-antibody process, which protects the body.

• There are two groups of lymphocytes: B cells and T cells. The function of the B cells is to search out, identify, and bind with specific antigens. T cells, when exposed to an antigen, divide rapidly and produce large numbers of new T cells that are sensitized to that antigen. They work together with the B cells to destroy the foreign antigen. Normal values of lymphocytes are 20% to 40%.


RBC with Hemoglobin / HematodritRBC with Hemoglobin / Hematodrit

RBC

Hgb

Hct

Males: 4.7-6.1million/mm3

Females: 4.2-5.4 million/mm3

Males: 14-18 g/dL

Females: 12-16 g/dL

Males: 42%-52%

Females: 37%-47%


Normal WBC results

done with differential countTotal white cell count 5,000-10,000/mm3

• Neutrophils 60 - 70%.

• Lymphocytes 20 - 40%.

• Monocytes 2 - 6%.

• Eosinophils 1- 4%.

• Basophils 0.5 - 1%.

• Bands 0 - 3%.


Thrombocytes, or platelets, are the smallest cells in the blood. They are circular cell fragments, which do not contain nuclei. They have a life span of 5 to 9 days and number 150,000 to 400,000 per mm3 of blood. They are produced in the red bone marrow and function in the process of hemostasis (the prevention of blood loss). They assist in clotting formation, which seals off a break in the continuity of the walls of the blood vessels.


Human blood cells.

(Thibodeau, G.A., Patton, K.T.

[2003]. Anatomy and physiology. [5th

ed.]. St. Louis: Mosby.)


Hemostasis: A body process that arrests the flow of blood and prevents hemorrhage by the following actions: Vessel spasm Platelet plug formation and Clot formation


Hemostasis: Injury Hemorrhage Grouping platelets Thromboplastin released Converts prothrombin to thrombin Links with fibrinogen Formation of fibrin Trap RBCs and platelets Forms clot


Figure 7-2Figure 7-2 Blood clotting.


Blood types (groups) Determined by the presence or

absence of specific antigens on the outer surface of the RBC

• Type A• Type B• Type AB

Universal recipient

• Type O Universal donor


Rh factor Rh antibodies may be located on

the surface of the RBC• Rh positive: antibodies are present• Rh negative: antibodies are not present

Erythroblastosis Fetalis


Erythroblastosis fetalis is hemolytic anemia in the fetus or neonate caused by transplacental transmission of maternal antibodies to fetal RBCs.

• Erythroblastosis fetalis classically results from Rh0(D) incompatibility, which may develop when a woman with Rh-negative blood is impregnated by a man with Rh-positive blood and conceives a fetus with Rh-positive blood.

• Also known as Hemolytic disease of the fetus and newborn, HDN, HDFN.


Lymphatic systemThe lymphatic system is a subdivision of the

cardiovascular system. It consists of lymphatic vessels, the lymph fluid, and the lymph tissue.

Functions• Maintenance of fluid balance

• Production of lymphocytes

• Absorption and transportation of lipids from the intestine to the bloodstream


Lymphatic system Lymph and lymph vessels

• Lymph is a specialized fluid formed in the tissue spaces transported by way of the lymphatic vessels and reenters the circulatory system

Lymphatic tissues

• Lymph nodes

• Tonsils

• Spleen

• Thymus


Lymphatic tissues• Lymph nodes

Act as filters, keeping particulate matter such as bacteria from entering bloodstream

Produce lymphocytes

• Tonsils Produce lymphocytes and

antibodies: trap bacteria


Lymphatic tissue (continued)• Spleen

Reservoir for blood; Stores about 500 ml of blood that can be released in emergencies**; forms lymphocytes, monocytes, and plasma; destroys worn-out RBCs; removes bacteria by phagocytosis

• Thymus Immune system before and a few

months after birth; atrophies at puberty


Principal organs of

the lymphatic

system.

(From Thibodeau, G.A., Patton, K.T. [2003].

Anatomy and physiology. [5th ed.]. St. Louis:

Mosby.)


Disorders of the Hematological and Lymphatic Systems


• Diagnostic tests Complete blood count (CBC) Red cell indices Peripheral smear Schilling test: pernicious anemia** Megaloblastic anemia profile Lymphangiography Bone marrow aspiration or biopsy


• Diagnostic testsComplete blood count (CBC) The complete blood count (CBC) is an

important part of routine screening and hospital admission. It involves several tests, each of which assesses the three major cells formed in the bone marrow.

A CBC includes red and white cell counts, hematocrit and hemoglobin levels, erythrocyte indices, differential white cell count, and examination of the peripheral blood cells


Red Cell Indices: Erythrocyte indices are measurements of the

size and hemoglobin content of red blood cells.

Mean Corpuscular volume (MCV).

Mean corpuscular hemoglobin (MCH)

Mean corpuscular hemoglobin concentration (MCHC)


Peripheral Smear• A peripheral smear often accompanies the

differential WBC count and permits examination of the size, shape, and structure of individual RBCs and platelets. All three hematological cell lines (RBCs, WBCs, platelets) can be examined. When adequately prepared and examined microscopically by an experienced technologist, a smear of peripheral blood is the most informative of all hematological tests.


Schilling Test and Megaloblastic Anemia Profile

• The Schilling test is a laboratory blood test for diagnosing pernicious anemiapernicious anemia. The test measures the absorption of radioactive vitamin B12, before and after parenteral injection of the intrinsic factor, by examination of the urinary excretion of vitamin B12.

• Normal findings are excretion of 8% to 40% of radioactive vitamin B12 within 24 hours.


Gastric Analysis

• Gastric analysis is an older test in determining pernicious anemia. In pernicious anemia the gastric secretions are minimal and the pH remains elevated, even after injection of histamine.


Radiologic Studies• Radiologic studies for the hematological

system involve primarily the use of computed tomography (CT) or magnetic resonance imaging (MRI) for evaluating the spleen, liver, and lymph nodes. In the past, lymphangiography with the use of contrast dye was a common procedure to evaluate deep lymph nodes. CT is now the preferred method (Lewis et al, 2004).


Bone Marrow Aspiration or Biopsy• When the diagnosis is not clearly

established by peripheral blood smears or when further information is needed, bone marrow aspiration or biopsy is specific for establishing the dianosis and for treatment response.

• The most common site for this procedure is the posterior iliac crest, although the sternum can also be used; however, the sternum is generally used only for aspiration.


Bone Marrow Aspiration or Biopsy• Bone marrow aspiration is most commonly

performed in people with marked anemia, neutropenia, acute leukemia, and thrombocytopenia.

• Although complications of bone marrow aspiration are minimal, there is a possibility of penetrating the bone and underlying structures. This hazard is greatest in aspiration procedure involving the sternum.


Lymphangiography• Lymphangiography is a radiologic

examination used to detect metastatic involvement of the lymph nodes. Contrast medium is injected into a lymphatic vessel of the foot or hand, followed by radiological visualization of the lymphatic system.

• This examination is being replaced by CT scanning.


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




Normal values• Hemoglobin = 14 – 18 gm/dl**

• Hematocrit = 40 – 52 %


Anemia (continued) Etiology/pathophysiology

• Causes of anemia Blood loss Impaired production of RBCs Increased destruction of RBCs Nutritional deficiencies


Clinical manifestations/assessmentClinical manifestations/assessment

• Anorexia• Dyspepsia • Cardiac

dilation• Disorientation• Shortness of

breath• Dyspnea• Fatigue• Headache

• Insomnia• Pallor• Palpitation• Systolic

murmur• Tachycardia• Vertigo


Anemia (continued) Medical management

• Depends on the cause

• Correction of the disease process may correct or lessen the anemic condition

• Treatment is often specific to the particular anemia


Hypovolemic anemia Etiology/pathophysiology

• Abnormally low circulating blood volume due to blood loss

• 500 ml loss can be tolerated

• 1000 ml loss can cause severe complications

• Severity and signs and symptoms depend on how rapid the blood is lost


Hypovolemic anemia (continued) Clinical manifestations/assessment

• Weakness• Stupor; irritability• Pale, cool, moist skin• Hypotension• Tachycardia (rapid, weak, thready

pulse)• Hypothermia• Hemoglobin less than 10 g/100 ml• Hematocrit less than 40%


Hypovolemic anemia (continued) Medical management/nursing

interventions

• Control bleeding

• Treat shock O2, elevate lower extremities, keep

warm

• Replace fluid Blood transfusion, plasma,

dextran, lactated Ringer’s

• Monitor vital signs


Cultural and Ethnic Considerations• Jehovah’s Witness Opposition to Blood

Transfusion

• There are so many implications for the nurse who provides culturally appropriate nursing interventions to a Jehovah’s Witness.

• The paramount concern for the nurse is that Jehovah’s Witnesses are opposed to homologous blood transfusion (blood obtained from a blood bank or through donations). Jehovah’s Witnesses believe that if they receive blood products, there are eternal consequences.


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

• Vitamin B12 is also related to nerve myelination May cause progressive

demyelination and degeneration of nerves and white matter


Pernicious anemia• Intrinsic factor is a glycoprotein produced

by the parietal cells of the stomach. It is necessary for the absorption of vitamin B12 later on in the terminal ileum.

• The intrinsic factor is an enzyme-like unidentified substance secreted by the stomach. It is present in the gastric juice as well as in the gastric mucous membrane.


Pernicious anemia• In pernicious anemia, an autoimmune

disease, autoantibodies directed against intrinsic factor or parietal cells themselves lead to an intrinsic factor deficiency, malabsorption of vitamin B12, and subsequent megaloblastic anemia.


Pernicious anemia (continued) Clinical manifestations/assessment

• Extreme weakness

• Dyspnea

• Fever

• Hypoxia

• Weight loss

• Jaundice (destruction of RBCs)

• Pallor

• GI complaints


Pernicious anemia (continued) Clinical manifestations/assessment

(continued)• 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 (continued) Medical management/nursing

interventions• Vitamin B12 (cyanocobalamin) 1000

units Daily for 1 week Weekly for 1 month Monthly for life

• Folic acid supplement• Iron replacement• RBC transfusion• Diet: high in protein, vitamins, and

minerals


Aplastic anemia Etiology/pathophysiology

• Decrease of bone marrow function**

• Primary Congenital

• Secondary Viral invasion Medications Chemicals Radiation; chemotherapy


Aplastic anemia (continued) Clinical manifestations/assessment

• Pancytopenic

• Repeated infections with high fevers

• Fatigue, weakness, malaise

• Dyspnea

• Palpitations

• Bleeding tendencies


Aplastic anemia (continued) Medical management/nursing

interventions

• Identify and remove cause

• Platelet transfusion for severe thrombocytopenia

• Splenectomy for hypersplenism

• Steroids and androgens

• Antithymocyte globulin

• Bone marrow transplant


Iron deficiency anemia Etiology/pathophysiology

• RBCs contain decreased levels of hemoglobin**

• Hemoglobin level is markedly reduced

• Excessive iron loss Caused by chronic bleeding—

intestinal, uterine, gastric


Iron deficiency anemia (continued) Clinical manifestations/assessment

• Pallor• Fatigue; weakness• Shortness of breath• Angina; signs and symptoms of heart

failure• Glossitis; burning tongue• Pagophagia: desire to eat ice, clay or

starches• Headache• Paresthesia


Iron deficiency anemia (continued) Medical management/nursing

interventions

• Ferrous sulfate 900 mg daily Oral or injection (Z-track) Causes black stool

• Ascorbic acid

• Diet high in iron

( Dark green leafy vegetables and organ meat)**

• Blood product given is packed RBC**


Sickle cell anemia Etiology/pathophysiology

• An abnormal, crescent-shaped RBC

• Severe, chronic, incurable condition• Sickle cell crisis is an episode of acute

“sickling” of erythrocytes, which causes occlusion and ischemia in distal blood vessels. Sickling indicates a clumping or aggregation of these mishappen RBCs, which lodge in small vessels.


Sickle cell anemia Etiology/pathophysiology

• Seen in 1:500 of African Americans**

• 1 in 12 African Americans — have sickle cell trait, which means they carry a single gene for the disease, but do not have the disease itself.


Clinical manifestations/assessment• Precipitating factors

Dehydration Change in oxygen tension in the

body

• Loss of appetite

• Irritability

• Weakness

• Abdominal enlargement

• Joint and back pain

• Edema of extremities


Sickle cell anemia (continued) Medical management/nursing

interventions

• No specific treatment—alleviate symptoms

• Oxygen

• Rest

• Fluids

• Analgesics



POLYCYTHEMIA VERA or (PV) is a chronic blood disorder marked by an abnormal increase in three types of blood cells produced by bone marrow; red blood cells (RBCs), white blood cells (WBCs), and platelets. PV is called a myeloproliferative disorder, which means that the bone marrow is producing too many cells too quickly.

Increase in RBC, hemoglobin and hematocrit results in hyperviscosity.**


• Most of the symptoms of PV are related to the increased volume of the patient's blood and its greater thickness (high viscosity).

• The first line of treatment for patients with PV is Phlebotomy. Phlebotomy is the withdrawal of blood from a vein.

• Phlebotomy is used to bring down the ratio of red blood cells to fluid volume (the hematocrit) in the patient's blood to a level below 45%.


• In most cases the doctor will withdraw about 500 mL of blood (about 15 fluid ounces) once or twice a week until the hematocrit is low enough. Phlebotomy is considered the best course of treatment for patients younger than 60 and for women of childbearing age. Its drawback is that patients remain at some risk for either thrombosis or hemorrhage.


• END OF PART 1


Agranulocytosis Etiology/pathophysiology

• Severe reduction in the number of granulocytes

• WBC less than 200/mm3

• Neutrophil count is markedly reduced**

• Medications

• Chemotherapy

• Radiation

• Neoplastic disease

• Viral and bacterial infections


Agranulocytosis (continued) Clinical manifestations/assessment

• Symptoms of infection

• Ulcerations of mucous membranes

• Bronchial pneumonia

• Urinary tract infection Medical management/nursing interventions

• Remove cause of bone marrow depression

• Prevent or treat infections**

• Meticulous handwashing

• Strict asepsis


Leukemia Etiology/pathophysiology

• Malignant disorder of the hematopoietic system

• Excess leukocytes accumulate in the bone marrow and lymph nodes

• Cause unknown• Classification

Acute or chronic Proliferating cells (lymphocytic,

monocytic, etc.)


Clinical manifestations/assessment• Anemia• Thrombocytopenia; leukopenia• Enlarged lymph nodes• Splenomegaly

Medical management/nursing interventions• Chemotherapy; radiation• Bone marrow transplant• Medications: Leukeran, hydroxyurea,

corticosteroids, Cytoxan• Nursing Diagnosis is Ineffective coping and Nursing Diagnosis is Ineffective coping and

chronic pain**chronic pain**


Thrombocytopenia Etiology/pathophysiology

• Condition in which the number of platelets is reduced below 100,000/mm3; may be due to decreased production or decreased survival

Clinical manifestations/assessment• Petechiae• Ecchymoses• Platelets below 100,000/mm3

• Bleeding from mucous membranes


Thrombocytopenia (continued) Medical management/nursing interventions

• Corticosteriod therapy

• Splenectomy

• Gamma globulin

• Immunosuppressive drugs

• Platelet transfusions

• Avoid trauma and falling **

• Institute bleeding precautions**


Hemophilia Etiology/pathophysiology

• Hereditary coagulation disorder, characterized by a disturbance of clotting factor

• Hemophilia A; hemophilia B• X-linked hereditary trait: seen in males

Clinical manifestations/assessment• Internal and external bleeding. Petechiae

and ecchymoses are seen.• Hemarthrosis• Excessive blood loss from small cuts and

dental procedures


Hemophilia (continued) Medical management/nursing

interventions

• Minimize bleeding—avoid trauma

• Relieve pain—no aspirin

• Transfusions Factor VIII or IX concentrate Cryoprecipitate (rich in factor VIII) Manufactured factor VIII or IX


Disseminated intravascular coagulation Etiology/pathophysiology

• An acquired hemorrhagic syndrome with overstimulation of clotting and anticlotting processes in response to disease or injury**

Clinical manifestations/assessment• Bleeding; hemoptysis

• Dyspnea

• Diaphoresis

• Cold, mottled digits

• Purpura on the chest and abdomen

• Petechiae


Disseminated intravascular coagulation (continued) Medical management/nursing

interventions

• Treat underlying cause

• Cryoprecipitate

• Heparin

• Protect from bleeding and trauma


Multiple myeloma Etiology/pathophysiology

• Malignant neoplastic immunodeficiency disease of the bone marrow

Clinical manifestations/assessment

• Bone pain; pathological fractures

• Infection

• Anemia; bleeding

• Hypercalcemia**

• Renal failure


Multiple myeloma (continued) Medical management/nursing

interventions

• Symptomatic; not curable

• Radiation

• Chemotherapy

• Corticosteroids

• IV fluids

• Maintain fluid intake of 3-4 liters/day to dilute calcium load**


Malignant lymphoma (continued) 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 (continued) Clinical manifestations/assessment

• Painless, enlarged cervical lymph nodes

• Fever; susceptibility to infection

• Weight loss; anorexia

• Anemia

• Pruritus

• Fatigue

• Malaise


Malignant lymphoma (continued) Medical management/nursing

interventions

• Accurate staging of the disease is crucial to determine treatment regimen

• Radiation

• Chemotherapy


• Tumor necrosis factor (TNF)


Hodgkin’s disease Etiology/pathophysiology

• Inflammatory or infectious process that develops into a neoplasm

• Affects males twice as frequently as females

• Reed-Sternberg cells** Abnormal cells noted


Hodgkin’s disease (continued) Clinical manifestations/assessment

• Enlargement of cervical lymph nodes• Anorexia• Weight loss• Pruritus: relieved with soothing bath and

antipruritic medications**• Low-grade fever• Night sweats• Anemia• Leukocytosis


Hodgkin’s disease (continued) Medical management/nursing

interventions

• Stage I or II (localized) Radiation

• Stage III or IV (generalized) Chemotherapy Combination


Figure 7-5Figure 7-5

Nodal involvement by

stage in Hodgkin’s

disease (based on modified Ann Arbor

Staging

System).


Nursing Process

• Nursing diagnoses Infection, risk for Injury (trauma) risk for (bleeding, falls) Fatigue Knowledge, deficient Pain, acute and chronic Tissue perfusion, ineffective Gas exchange, impaired Activity intolerance Coping, ineffective Skin integrity, impaired


• DONE!!


von Willebrand’s disease Etiology/pathophysiology

• Inherited bleeding disorder characterized by abnormally slow coagulation of blood; mild deficiency of factor VIII

• Similar to hemophilia; not limited to males

Clinical manifestations/assessment• Spontaneous episodes of

GI bleeding Epistaxis Gingival bleeding


von Willebrand’s disease (continued) Medical management/nursing

interventions

• Cryoprecipitate

• Fibrinogen

• Fresh plasma

• Desmopressin (DDAVP)

• Minimize bleeding—avoid trauma

• Relieve pain—no aspirin


Lymphangitis Etiology/pathophysiology

• Inflammation of one or more lymphatic vessels

• Usually occurs from acute streptococcal or staphylococcal infection in an extremity

Clinical manifestations/assessment • Fine red streaks from the affected area• Edema• Chills; fever• Local pain• Headache; myalgia


Lymphangitis (continued) Medical management/nursing

interventions

• Penicillin

• Moist heat

• Elevate extremity


Lymphedema Etiology/pathophysiology

• Primary or secondary disorder

• Accumulation of lymph in the soft tissue Clinical manifestations/assessment

• Massive edema and tightness of affected extremity

• Pain


Lymphedema (continued) Medical management/nursing

interventions

• Diuretics

• Antibiotics

• Compression pump

• Elastic stocking or sleeve

• Restricted sodium diet

• Avoid constrictive clothing

• Meticulous skin care

efren n. aquino m.d. aug. 4, 2009

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