blood alterations

• -physical exams
• -preop screening
• -evaulation of acute disease
• -sx of anemia or infection

• -iron deficiency anemia (most often diet induced but can also be assoc. w/ chronic diseases, esp. cancers and renal failure)
• -may cause disorientation and confusion...should be evaulated if there is a mental status change
• -may also cause fatigue, weakness, tachycardia, SOB, stomatitis and glossitis

• -total # of colony-forming b-lymphocytes and the ablility of thesecells to mature into antibody-secreting cells are diminished
• -decline in natural antibodies, decr. antibody responese to antifens, and decr in the amont of time the antibody response is maintained

• -get immunized, esp. flu shots and pneumococcal vaccine
• -avoid ppl w/ viral infections and receive "booster" shots (e.g. tetanus and zoster)

• -thymic activity decr. w/ aging and the # of circulating t-lymphocytes decr.
• -older pt's are more at risk for fungal and bacterial infections, esp. on the skin and mucous memb, in resp tract, and in GI tract

• nonspecific ingestion and phagocytosis of microorganisms and foreign protein
• -55-70%

-shift to the left: incr. # of immature netrophils when bone marrow has been depleted by severe infection ("band" or "stab" cells greater than 8%)

-shift to the right: incr. in # of older mature polymorphonuclear leukocytes (PMNs). indicates relative lack of blood-forming ability and is ommon w/ severe liver dx and advanced pernicious anemia

if you have leukocytosis (low white count) and left shift= worst prognosis than if you have too many WBC (bc your body is trying to "raise the baby soldiers to fight")

• Absolute Neutrophil Count: first line of defense against infection, tells us more about pt's ablility to fight infection
• -WBC x (%neutrophils + %bands) = ANC
• -any # less than 1,000 warrant neutropenic precautions!

• -weak phagocytic action, releases vasoactive amines during allergic reactions
• -active in allergic reactions and parasitic infections (they will be elevated in allergic rxn)
• -act under influence of adreanal cortex

-1-4%

-elevated in allergic response, very active in type 1 hypersensitvity, release histamine

• -manufactured by bone marrow
• -antigen recogintion and phagocytosis of cellular debris
• -the "clean up crew!"
• -when you see eleveated monocytes it is an indication that infection is resolving

• -formed by lymphatic system and bone marrow
• -function in humoral (b-cell antibodies, b for bone marrow) and cell-mediated (t-cell) immune responses to antigens
• -active in chronic bacterial and acute viral infections
• -if lymphocytes elevated suspect viral infection

• -150,000-400,000
• -formed from megakaryocytes (immature platelets) in bone marrow
• -prevent blood loss by sticking together, secreting chemicals, and initiating coagulation pathway

• -a group of malignant disorders involving abnormal overproduction of a specific type of WBC in the bone marrow, usually at an immature stage, which suppresses other mature WBC
• -bone marrow becomes almost totally filled w/ immature and undifferentialted leukocytes or "blast cells"...leukemic cells proliferate rapidly and have a prolonged life span
• -leukemic cells are unable to perform the functions of WBCs, impairing the body's ablility to reduce inflammation, infection, or immune response
• -bc erythrocyte and platelet-producing cells are crowded out, severe anemis, spleomegaly and bleeding results

• -CLL= overproliferation and accumulation of small abnormal mature lymphocytes in the bone marrow, peripheral blood and body tissues
• -abnormal cells are usually B-lymphocytes unable to produce adequate antibodies to produce normal immune function
• -commonly occurs in adults, avg. age 65, slow onset, often found on rotuine exam w/ lab workup
• -vague c/o weakness, malaise, possible anemia, enlarged lymph nodees spleen or liver, leukocytosis and presence of abnormal cells, bone marrow hyperplaisa

• -chemo can cause remission but doesn't cure disease
• -Fludarabine- an antimetabolite that masquerades as nutrinet so cancer goes for that instead, s/e= renal/liver
• -Rituximab- a MAB, target therapy
• -alkylating agents such as chlorambucil w/ or w/o prednisone

-CML= an abnormal proliferation of all of the bone marrow elements, characterized by an incr. # of granulocytes (myeloid line)

• -Philadelphia Chromosome is present in most cases, which is a translocation of chromosome 22 to chrom. 9
• -accounts for 20% of all leukemias, usually found in men over 50
• -causative agents include ionizing radiation and chemical exposure (eg. they were gettin chemo for CLL then got CML)
• -survival generally 3-5 years, cuase of death is infection or hemorrhage

• 1) chronic- few blast cells in blood and bone marrow and may be no physical sx of leukemia
• 2) acceleration- more blast cells in bone marrow and fewer normal cells
• 3) blast crisis- more than 30% of cells in the blood or bone marrow are blast cells and may form tumors outside BM or in lymphnodes, may result in death in weeks to months

• -pt. often asymtomatic in early stages, and dx w/ rotuine labs
• -pt is in a hypermetabolic state = fatigue, wt. loss, sweating, heat intolerance, leukocytosis, spleenomegaly. Chromosomal analysis of peripheral blood or BM shows Philadelphia chromosome and elevated leukocytes

• -imatinib mesylate (Gleevec):
• -targeted specific therapy for CML that is Philadelphis chrom. pos.
• -prevents activation of an enzyme (tyrosine kinase) needed for growth of CML cells
• -usual dose = 400 mg PO daliy
• -toxicities incl. neutropenia, thrombocytopenia, anemia, diarrhea fluid retention/edema, GI upset (take w/ meals!), and muscle cramps (Ca supplements and tonic water (quinine) may help)

-Dasitinib (Sprycel) if unresponsive to Imatinib, but 2nd line of choice d/t many drug interactions

Interferon alpha (it boost body's immune mechanisms)

-BMT is standard tx to eradicate cancer cells and replace w/ healthy stem cells to begin normal hematopoiesis (formation of blood and componets) . It is the tx of choice to achieve complete cure

• 1) Allogenic- (donor)- Human Leukocyte Antigen (HLA) matched, at least 4 out of 6...from sibling or donor using bone marrow harvest, peripheral stem cell phereiss or umbilical cord blood
• 2)Autologous-(self)-pt. will get chemo to wipe out bad marrow, then a colony sitmulating booster to boost stem cell count, then reinfused w/ that marrown when disease is in remission
• 3)Singenaic- from an identical twin...ideal!

5-6 donations, plasma freezed then spun off, better than BM aspiration bc not as invasive and engraftment only takes 8-12 days (bone marrow takes 12-28)

• 1)screening, complete physical exam and education for donor and receipent
• 2) about 1 liter of bone marrow is aspirated from client donor using multiple large bore needle sites, frozen, and stored for later use
• 3) "conditioning" for pt...lehal doses of chemo and radiation therapy are given over 4-8 days to destroy the malignant cells, the immune system and to make room in the bone marrow for new cells
• 4) transplant- aka day "0"- filtered bone marrow is thawed and infused via a central line
• 5) engraftment- infused marrow cells slowly become part of the clien'ts bone marrow, neutrophil counr incr. and normal hematopoiesis takes place

6-12months to recover nearly normal blood cell levels

• -pancytopenia
• -nutritional deficiencies
• -failure to engraft...leads to death unless they have another donor
• -Graft-vs-Host disease (GVHD)- 25-50% of all clients
• -immune response of the donated bone marrow- it sees the receipent's tissue as foreign
• -T-lymphocytes in donated marrow attack liver, spleen, GI tract, leading to rashes, desquamation, diarrhea, GI bleed, liver damage
• -prevented w/ corticosteroids, and immunosuppressants
• -Vaso-occlusive disease- liver and blood vessels clot and become inflammed, sx typical of liver enlargement...jaundice, fluid retention...

-mild s/sx that resolve are ok, that means engraftment is working

7-14 days after chemotherapeutic agents

• -risk for infection
• -altered nutrition, less than body requirements
• -risk for bleeding (postpone invasive diagnostic procedures until platelet count >50,0000)

colony stimulating factors are biologic response modifiers that stimulate faster recovery of bone marrow after tretment-induced suppression

a colony stimulating factor that works on all granulocytes

• a colony stim. factor that works on neutrophils.
• -can cause bone pain, fever
• -discontinue if ANC >10,000...bc then you don't need it to boost neutrophils anymore!

• colony stim. factor that works on erythrocytes
• -can cause vascular access thrombosis, myalgias, arthralgias

• a colony stim. factor that works on platelets
• -can cause fever, rash, HA, edema

• malignancies characterized by a proliferation of committed lymphocytes rather that stem cell precursors. Usually originates in a sigle lymph node or chain. Lymphoid tissue undergoes malignant transformation, initiating an inflammatory process
• -incidence higher in young adults, cure rate more than 80%

enlarged, painless lymph nodes, fever, malaise, night sweats, wt. loss (10% or more), pruritis

-may be r/t ionizing radiation, viral infection, autoimmune disorders, exposure to toxic chemicals

• -Reed-Sternberg cell is a specific marker on lymph node bx (cell marker that differentiates it from non-hodgkins)
• -chest and abd. CT identify abnormal or enlarged lymph nodes
• -Lymphangiography (x-ray of lymph nodes afer injection of contrast medium inito lymphatic vessels) defines extent of lymph node involvement

• bx of distant lymphnodes, CT of thorax and abd., stafing laparotomy...how many nodes involved? one or both sides of diaphragm? Presence of constitutional s/sx?
• ...the lower the stage the better

radiation therapy alone in stage 1 and 2 w/o mediastinal node envolvement, if dx advance total nodal radiation possible

-single agent chemo for older adults or those who have had heavy radiation therapy w/ myelosuppression and unable to tolerate combo tx

• -combination chemotherapy: ABVD
• Adriamycin. s/e: cardiomyapathy
• Bleomycin. s/e: respiratory complications/ARDS
• Vinblastine. s/e: alopecia
• Dacarbazine
• every 14 days for 4 cycles, then radiation
• -adverse rxns also: N/V

• -nursing care for drug-induced pancytopenia
• -counseling for males that irradiation of abd-pelvic region will result in sterility, possible sperm-banking prior to tx
• -possibility of secondary malignancies, like other leukemias d/t high doeses of chemo

• -malignant proliferation of plasma cells (which are the mature cells of the b-lymphocyte and they are ineffective
• -disrupts normal BM function and invades adjacent bone
• -plasma cells have limited ability to make antibodies
• -sx: bone pain, fractures, fatige, wt. loss, repeated infections
• -diagnosis: elevated Ca, bone x-rays, M-protein in blood sample (monoclonal protein-"m" for multiple myelomia), BM bx has myelomia cells present
• -tx is chemo and biophosphonates to incr. bone density, hydration and possibly lasix or calcitonin to reduce serum Ca

• -used for sepsis, and neutropenic infections not responsive to AB
• -can cause antibody/antigen rxns! risk often outweighs benefit
• -volume: 430 ml of plasma, give over 45-60 min, physician may need to be present

• -total # of platelets greatly diminished, but platelet production in marrow is normal. person has antiplatelet antibody that allows platlets to be destroyed in the spleen
• -s/sx: ecchymosis, mucosal bleeding, sx of anemia if blood loss, possible neuro impaiment if brain bleed
• -DX: decr. platelet count, antiplatelet antibodies in peripheral blood, irreg. # of megakaryocytes in bone marrow, incr. MPV indicating a normal reactive BM
• -TX: immune suppressants (cortiosteroids, azathioprine), low doses of chemo alkylating agent (e.g. cyclophosphamide) and antimiotic agents (e.g. vinca alkaloids), platelet transfusions if plt. count <20,000

• -contain trace RBC and WBC, may be admin w/ a leukocyte filter
• -1 bag/10kg body weight. 1 bag will incr. platelet count 5,000-10,000
• -infuse w/ smaller filter and shorter tubing, over about 15 min for each unit (platelets are fragile)
• -single donor (200 ml) vs pooled donor (300 ml) platelets

• -Nursing assessment priorities for transfusion rxns:
• -hemolytic, watch for overwhelming change in VS
• -alleric
• -febrile, grether than 1 degree C from baseline, uaually manageable w/ tylenol
• -bacterial from contaminated blood
• -circulatory overload
• -transfusion associated graft vs host disease...a later rxn you may see skin peeling, rashes, GI sx

• -rare disorder, platelets clump together in the capillaries and too few are left in the circulation...can result in infarcts, MI, stroke
• -pt has inappropriate clottin, and failure to clot w/ trauma
• -thought to be autoimmune rxn to the endothelium of blood vessels
• -Tx: plasmapheresis, infusionof fresh frozen plasma for aggregation inhibitors, immunosuppressants, anti-platelet clumping drugs (asprin), antitumor antibiotic (plicamycin)
• -no lab marker exists to dx TTP