Final Exam SG
3130
HEME
Bone Marrow examination
- Aspiration and Biopsy - similar invasive procedures. Used when other tests show
persistent abnormal results
- As an adjunct to peripheral blood smear - if diagnosis is not clear – sets cells apart from
each other
- MD order and informed consent are required for both! May be performed at bedside,
exam room or lab
- Bone Marrow Aspiration – fluid is soft and semi-fluid and can be removed by needle
aspiration; cells and fluid are suctioned from the bone marrow
- Bone Marrow Biopsy – solid tissues and cells are obtained by coring out an area of bone
marrow with a large bore needle
- Patient PREP:
o Emotional support – Lots of emotional support with these procedures. WHY?
Stay with patient/allow family member to stay; thorough explanation – let them
know what to expect
o Heavy sensation of pressure and pushing while the needle is being inserted;
Hear a crunching sound or feel a scraping sensation as needle punctures the bone
o Brief sensation of painful pulling will be experienced as bone marrow is being
aspirated by mild suction in the syringe
o If biopsy is performed, may feel more pressure and discomfort as needle is
rotated into the bone
- Most common site – posterior iliac crest – anterior iliac crest and sternum can also be
used – sternum only for aspiration
- Local anesthetic, midazolam (Versed) or lorazepam (Ativan)
- Sterile precautions are observed – sterile dsg. Over site after procedure
- External pressure until hemostasis is ensured – pressure dressing or sand bags may be
used – may lie on biopsied side for 30-60 minutes to maintain pressure
- Follow up care
- Dressing for 24 hours – observe for bleeding/infection – have patient inspect site every
1-2 hours for 24 hours – ice packs to decrease bruising and provide comfort
- Mild analgesic – aspirin free
Anemia
- Reduction in number of RBCs, quantity of HgB, or volume of RBCs
- Main function of RBCs – oxygenation/ PERFUSION
o anemia results in varying degrees of hypoxia
- Prevalent conditions
o Blood loss
o Decreased production of erythrocytes
o Increased destruction of erythrocytes
- Signs & Symptoms
o Same as hypoxia
- Objective Data
, o Integumentary
Pallor – ears, nail beds, palmer creases, conjunctiva, around mouth
Intolerance of cold temperatures
Nails become brittle and lose the normal convex shape; overtime, fingers
assume clublike appearance
o GI
Beefy red tongue, stomatitis, abd distention, anorexia
o Cardiovascular
Tachycardia at basal activity levels, increasing with activity and during &
after meals
Murmurs/gallops when anemia is severe
Orthostatic hypotension
o Respiratory
Dyspnea on exertion
Decreased O2 Sat
o Neurologic
Increased somnolence and fatigue
Headache
- Nursing Management
o Diagnosis: Fatigue, Nutrition (Less)
o Planning:
Resume ADLs without increase in BP/pulse, increase endurance, maintain
adequate nutrition, normal blood values, no complications r/t anemia,
verbalizes knowledge of nutrition/medication mgt
Iron Deficiency Anemia:
o Downeys Notes: Basic problem – decrease in iron supply for developing RBCs –
one of the most common hematologic disorders
o Major source of chronic blood loss is from GI and GU systems
o With iron def anemia, the iron stores are depleted first, followed by HgB -- as a
result, RBCs are small (Microcytic) and mild manifestations of anemia are seen
-- weakness/pallor
o Hemolysis - the rupture or destruction of red blood cells.
o Most susceptible – very young, poor diets, women in reproductive years
o 1mg of iron is lost daily through feces, sweat and urine
o Etiology
Inadequate dietary intake
30% of the
world’s population
Malabsorption
Absorbed in duodenum
GI surgery
Blood loss
2 ml blood contain 1mg iron
GI, GU losses
Hemolysis
, o Clinical Manifestations
Pallor - Most common
Inflammation of the tongue (glossitis) – 2nd most common
WEAKNESS/FATIGUE
Cheilitiis…inflammation/fissures of lips
Sensitivity to cold
Paresthesis, HA, burning sensation of the tongue
o Diagnostic Studies
CBC
Iron studies
Endoscopy
- Downey’s Notes:
o Gradual development - adaptation with few clinical signs
o Mild
o Fatigue, weakness and exertional dyspnea, pallor
o Severe
o nails become brittle/spoon shaped (concave), longitudinal ridges
o Papillae of tongue atrophy, tongue is smooth, shiny, bright red
o Corners of the mouth - cracked, reddened, painful (cheilosis)
o DX
o ↓serum iron, ↑ serum iron-binding capacity (TIBC), ↓ ferritin level or absent iron
stores in bone marrow.
- Collaborative Care
o Treatment of underlying disease/problem – evaluate for abnormal bleeding;
correct the cause
- Drug Therapy - Iron replacement
o Oral iron – Chart 33-3
Ferosol, DexFerrum, etc
Absorbed best in acidic environment
Irritating GI effects, constipation
o Parenteral iron – Chart 33-2
IM or IV
Less desirable than PO
- Downey’s Notes
o Increase the oral intake of iron from common food sources – green leafy vegs,
liver, whole grain, potatoes
o Ferrous sulfate - replace iron stores; Hgb to rise 2g/dL in 4 weeks
o irritating to GI tract - after meals, with OJ or vitamin C - improves absorption.
o stools - black or tarry; symptoms of diarrhea or nausea should be reported.
o constipation - major side effect - stool softener
o Do not take within 2 hours of milk or antacids
o Take one hour before meals
o Use a straw with liquid iron to avoid staining of the teeth
o Administer parental iron using Z-track method
, o Vitamin C supplements to improve absorption
Management
- Poor diet is rarely the sole cause of iron deficiency anemia - usually a contributing factor.
- Teaching is the major nursing intervention, especially with a newly diagnosed patient
- Energy conservation
- Identify people at increased risk – premenopausal women, pregnant women, low
socioeconomic backgrounds, older adults, persons experiencing blood loss
- Assess cardiovascular & respiratory status
- Monitor vital signs
- Recognizing s/s bleeding
- Monitor stool, urine and emesis for occult blood
- Diet teaching—foods rich in iron
- Provide periods of rest
- Supplemental iron
- Discuss diagnostic studies
- Emphasize compliance
- Iron therapy for 2-3 months after the hemoglobin levels return to normal
Thalassemia
- Etiology
o Autosomal recessive genetic disorder of inadequate production of normal HgB
o Found in Mediterranean ethnic groups
- Clinical Manifestations
o Asymptomatic à major retardation à life threatening
o Splenomegaly, hepatomegaly
- Collaborative care
o No specific drug or diet are effective in treating thalassemia
- Thalassemia minor
o Body adapts to ↓ Hgb
- Thalassemia major
o Blood transfusions along with IV deferoxamine
- DN: Group of diseases involving inadequate production of normal HgB, therefore
decreased erthrocyte production
- Absent or reduced globulin chain – Alpha/Beta chain -- Hgb beta (B) chain is most
often affected (B-thalassemia)
- Thalassemia minor – a person who is heterozygous has one normal and one thalassemic
gene - mild anemia (usually asymptomatic). No therapy required
- Thalassemia major (also called Cooley’s anemia) – homozygous person has two
thalassemic genes - severe anemia
o RBC vulnerable to injury/die early
o Cardiomegaly, splenomegaly, jaundice – from hemolysis is prominent
o Developmental delays – growth failure begins between 10-12 years; Death
usually occurs during the young adult years 17-30 years of age
- Common treatment - blood transfusion therapy, chelating agents, supportive dare
for anemia/HF.
- BMT - considered in children < 5 years old
