CONCEPTS: HEMATOLOGY/CANCER/DERMA

HEMATOPOIESIS
SITE:

Nsg diagnosis:
Low WBC-
High WBC-
High WBC w/ shift to the
left -

Stem cells

Myeloid Lymphoid
Priority:

RBC WBC Platelets Lymphocytes

B-cells T-cells
Priority: (Humoral) (Cell-mediated)

____________

Stem cell

______________
Erythropoietin – (hormone) KIDNEYS

Erythroblasts

Mature into normal RBC thru:

1. Iron - _____ synthesis
2. Vit. B12 + intrinsic factor – absorption site:

3. Folic acid

“If your habits doesn’t work, change it. But don’t change your GOAL.”
RED BLOOD CELL DISORDERS

I. ANEMIA
Vital signs:

Etiologic Categories of Anemia:

A. Hypoproliferative anemia (__RBC production)
1. Iron-deficiency anemia/Microcytic hypochromic anemia
2. Megaloblastic anemia
3. Pernicious anemia
4. Secondary to renal d/o
5. Aplastic anemia – damage to bone marrow due to chemical exposure

B. Hemolytic anemia (__ RBC destruction)

1. Sickle cell anemia

HYPOPROLIFERATIVE ANEMIAS

1. Iron-deficiency Anemia (IDA)

CAUSE:
At RISK:
o Start Fe-Fortified supplemental feedings @ 4-6 mos.
o Iron supplementation for adults

ASSESSMENT:
1. Dyspnea on exertion
2. Activity intolerance
3. Easy fatigability needing more periods of rest.
4. Pallor (palmar) palpebral conjunctiva, nail beds
5. Lethargy
Diagnosis:
1. BMA
2. Serum Ferritin Test –indirectly measures iron stores
CLINICAL CORRELATION:
1. PICA – appetite for non-nutritive substances
2. Angular Cheilosis – sores at the angle of the mouth
3. Koilonychia – spoon shaped nails

MANAGEMENT:
Fe

supplementation for ______ mos.

“If your habits doesn’t work, change it. But don’t change your GOAL.”
 Nursing interventions:
 S/E: Constipation, dark stools
 Decreased absorption with food
especially with milk/dairy, antacids
caffeine and tea
 Increased absorption:
 _________ stomach
 Liquid - stains
 IM injection – stains

2. Megaloblastic Anemia
Causes: Folic acid def. Vitamin B12 def.
1. Poor diet 1. Poor diet
2. Pregnancy 2. Malabsorption:
a) Pernicious anemia

S/S: Paresthesia
Beefy red tongue
Sore tongue
b) Ileal Disease
Crohn’s disease
(Ileum resection)
Diagnosis: Schilling Test – to check the cause of Vit. B12 deficiency
Specimen:

Management:
 For poor diet: food rich in Vit. ____ and ______ acid
 For malabsorption:

3. Aplastic Anemia
Cause: Autoimmune MANAGEMENT:
Toxic chemicals & drugs 1. IMMUNOSUPPRESSANTS
Exposure to radiation
Idiopathic
PRIORITY: 2. STEROIDS
S
W
I
DIAGNOSTIC TESTS: M
 CBC 3. CHEMOTHERAPY
 BMA Cell lysis syndrome
 BMB 4. NEUTROPENIC AND BLEEDING PREC.

“If your habits doesn’t work, change it. But don’t change your GOAL.”
B. HEMOLYTIC ANEMIA
1. Sickle Cell Anemia AUTOSOMAL RECESSIVE
TRAIT

***Both parents should carry

the defective gene for the
child to have sickle cell
anemia

Life span of abnormal cells:

Low oxygen tension causes cells to

Risk Factors:
1. Hereditary Newborn with Sickle Cell
2. Precipitating factors Anemia – No manifestations
- dehydration yet, because they still have
- high altitude Fetal Hgb (HbF) which
- infection keeps oxygen tension high.
- emotional stress
- physical stress
- acidosis
- cold
Manifestations:
1. Anemia
2. Splenomegaly, Jaundice, Hepatomegaly
3. ______ enlargement in children
4. Infection
5. Multi-system failure
6. CHEST Syndrome
7. Cell lysis syndrome

Management:
H-
O-
P-
P-
E-
Bone marrow transplant

Hydroxyurea – Adult: helps the RBC’s to stay round and flexible

Children: Increases the amount of fetal hemoglobin

Antibiotics

“If your habits doesn’t work, change it. But don’t change your GOAL.”
 Summary of Complications of Sickle Cell Anemia
Organ Physical Findings Symptom
Involved
Spleen Autosplenectomy, increased Abdominal pain; fever, signs
infection (esp. pneumonia, of infection
osteomyelitis)
Lungs Pulmonary infiltrate Chest pain, dyspnea
CNS CVA Weakness (if severe);
learning difficulties (if mild)
Kidney Hematuria, inability to Dehydration
concentrate urine, renal failure
Heart Tachycardia, cardiomegaly, CHF Weakness, fatigue, dyspnea
Bone Widening of medullary spaces Ache; bone pain, especially
and cortical thinning; hips
osteosclerosis; avascular
necrosis
Liver Jaundice & gallstone formation; Abdominal pain
hepatomegaly
Skin & Skin ulcers; poor wound healing Pain
Peripheral
Vasculature
Eye Scarring, hemorrhage, retinal Decreased vision; blindness
detachment
Penis Priapism, impotence Pain, impotence

WHITE BLOOD CELL DISORDERS

I. LEUKEMIA

Cause: idiopathic Classification:

Increase in immature WBC a. Stem cell line involved

b. Time in which symptoms evolve

Classifications of Leukemia
Criteria AML CML ALL CLL

Age Group All, incidence Incidence rises w/ Young children; Older adults,
rises w/ age, age; boy>girl; peak 4 >60y/o
peak 60 y/o median=40-50 y/o y/o
>15 y/o:
uncommon

“If your habits doesn’t work, change it. But don’t change your GOAL.”
CBC
RBC Decreased Varies Decreased Varies
WBC Low (normal Increased Immature Increased
WBC) (>100,000) lymphocytes lymphocytes
Platelets Decreased Varies Decreased Varies

Clinical Insufficient Asymptomatic Immature Lymphadenopathy

manifesta- production of SOB lymphocytes Splenomegaly
tions normal blood Splenomegaly proliferate Hepatomegaly
cells Hepatomegaly CNS involvement “B symptoms”
Splenomegaly Anergy
Hepatomegaly
Survival < 1 year 3-5 years 5 years 14 yrs (early
stage)
2.5 yrs (late
stage)
Common Infection and Infection and Infection, esp. Infection
cause of hemorrhage hemorrhage viral Hemorrhage
death (late)

ACUTE LYMPHOCYTIC LEUKEMIA

 _____________ childhood cancer.
DIAGNOSTIC TESTS: TREATMENT :
1. CBC Chemotherapeutic Agents
1. Vincristine (Oncovin)
N&V
2. BMA IV Extravasation
Constipation
Optic Neuritis
3. BMB 2. Doxorubucin (Adriamycin)
Diarrhea
Alopecia
N&V
3. Cyclophosphamide (Cytoxan)
Hematuria and Cystitis
Alopecia
N&V

“If your habits doesn’t work, change it. But don’t change your GOAL.”
II. MALIGNANT LYMPHOMAS
Hodgkin’s Lymphoma Non-Hodgkin’s Lymphoma
Cause – UNKNOWN Epstein Barr virus Immunosuppression
(HIV/AIDS)
Tumor cells Reed Sternberg cells Malignant B lymphocytes or
metastatic B cells
Onset of symptoms Early (stage ): Late (stage ):
PAINLESS enlarged cervical lymph PAINLESS enlargement of 1 or
node more lymph nodes
“B symptoms”
Late: “B symptoms”
Prognosis
Diagnosis
Treatment
CHEMOTHERAPY / RADIATION THERAPY
REVERSE ISOLATION

III. MULTIPLE MYELOMA

Proliferation of B cells (plasma cells) and
tumors within the bones
Risk factors: elderly, African american
Metastasis: Diagnosis:
______
1. Serum protein electrophoresis

Bone loss (Ca leak) 2. Urine protein electrophoresis

Brittle bones Hypercalcemia 3. CBC

4. Bone marrow biopsy

Assessment: weakness Management:

B
1. Increase oral fluids to
prevent renal calculi

“If your habits doesn’t work, change it. But don’t change your GOAL.”
 BLEEDING DISORDERS
Hemostasis - Process of preventing blood loss from intact vessels and of
stopping bleeding from a severed vessel

Idiopathic Thrombocytopenic HEMOPHILIA

Purpura X-linked, recessive autosomal trait
(ITP) Classification:
Hemophilia A
-Autoimmune- Hemophilia B
Signs and Early:
symptoms Petechiae,ecchymosis,bruises
Early: Reluctance of patient to move the
Late: body part
Platelet count=
Hemoptysis,melena,epistaxis, Late: Evident bleeding
heavy menses Instability of joint

WOF:
NI:
Management Bleeding precaution Bleeding precaution
Blood transfusion: Platelets Blood transfusion:
Fresh frozen plasma (FFP)
Factor concentrate
NEUTROPENIA AND BLEEDING PRECAUTIONS:
Implementing Neutropenia Precautions
1. Thorough hand washing
2. Isolation
3. No fresh flowers (stagnant water)
4. Change water in containers every shift
5. Clean room daily
6. Low microbial diet
7. Maintain skin integrity
8. Provide total body and oral hygiene
9. Maintain meticulous IV site care
Implementing Bleeding Precautions
1. Avoid anti-platelet medications
2. Avoid invasive procedures
3. Avoid constipation
4. No flossing of teeth, no commercial mouthwashes
5. Soft-bristled toothbrush only
6. Toothettes for mouth care if platelets <10,000, if gums bleed
7. Discourage vigorous coughing/blowing of nose
8. Electric razor only. Trim nails by filing, no cutting.
9. Pad side rails of bed

“If your habits doesn’t work, change it. But don’t change your GOAL.”
 LATEX ALLERGY
- Hypersensitivity to the proteins in the natural rubber latex or the various
chemicals used in the manufacturing process of the latex

Risk factors:
1.
2. Frequent exposure to latex:

3.
Ex. of tropical fruits: avocado, banana, chest nuts, fig, kiwi, mango, papaya,
passion fruit, pineapple, strawberries, watermelon
4. History of allergic skin disorder:

SCREENING TESTS:
1. Breast self-exam (BSE)
Timing: Pre-menopausal -

Menopause -

Palpation:
Inspection: asymmetry, painless lump, discharge

Radical Mastectomy - breast tissue + lymph nodes + chest muscles

Modified Radical Mastectomy - breast tissue + lymph nodes
Simple Mastectomy - breast tissue
Lumpectomy - tumor + surrounding tissue

2. Mammography
Timing:
Pre: Avoid using –cream, powder, lotion, deodorant
Expect:
Radiation exposure =

3. Testicular self-exam (TSE)

Timing:
Warning sign: __________, pea-sized lump
Testicular CA high risk: Cryptorchidism
Management: Orchiopexy – to bring the testicle in the scrotum

4. Digital rectal exam

Timing:
Warning sign: Stony-hard prostate
Normal: boggy, tender (feels like the tip of the nose)

“If your habits doesn’t work, change it. But don’t change your GOAL.”
 RADIOACTIVE
RADIATION THERAPY PATIENT EXCRETA

TELETHERAPY
(EXTERNAL/BEAM RADIATION)
_____________________________________
BRACHYTHERAPY
(INTERNAL RADIATION)
SEALED
-IMPLANTS
-SEEDS

Focus:
Nsg care:
L
B
C

UNSEALED
-IV
-ORAL

PRINCIPLES OF BRACHYTHERAPY (INTERNAL)

SHIELD:

TIME:

DISTANCE:
Room:
Utensils:

PRINCIPLES OF TELETHERAPY (EXTERNAL)

Nursing Diagnosis: Impaired skin integrity

Health Education:
1. Gently wash the IRRADIATED area with warm water and mild soap.
2. Take care not to remove the markings
3. Pat-dry the irradiated area; DO NOT RUB!
4. Avoid constrictive clothing / materials
5. Keep off the sunlight / heat exposure

“If your habits doesn’t work, change it. But don’t change your GOAL.”
 LARYNGECTOMY
Type Swallowing Voice Airway NGT

Hoarseness
PARTIAL Normal Intact Initially, to prevent
NI: contamination of the
suture line
Permanent loss of
TOTAL Normal voice Permanent
Tracheostomy/Stoma
NI:

Stoma care: 1. Avoid any debris from entering stoma

a) Cover stoma
b) No powder, aerosols, tissue, swimming
2. Keep stoma moist

DECUBITUS ULCERS

Risk factors: Malnutrition, Immobility, Infection, Excessive skin moisture, Advancing

age, Equipment (cast/traction)‫‏‬

STAGES
1. Stage I – “IMPENDING” erythema that can be relieved w/in 24 hours.
N/I : Turning
Nutrition - ___ CHON, ___ Albumin, ___Hydration
2. Stage II – “EPIDERMAL BREAKAGE”
* Blisters, Abrasion
* Eschar – Y_____ / W____
* Epidermis ( ) Drainage
N/I : Cover the wound + Stage 1
3. Stage III - __ Risk for Infection ( Dermis and SQ )
* Shallow crater
* ( ) Drainage ;
* Eschar – Y_____ / W____
N/I : ANTIBIOTICS + STAGE II
4. Stage IV – ( ) Drainage
* Eschar – B____
N/I : DEBRIDEMENT / SURGERY + Stage III
ANALGESICS – 30 mins before DEBRIDEMENT / SURGERY

“If your habits doesn’t work, change it. But don’t change your GOAL.”
 SYSTEMIC LUPUS ERYTHEMATOSUS
CRITERIA IN DIAGNOSING SLE
CAUSE:
1. Malar (over the cheeks of the face)
ASSESSMENT: "butterfly" rash
Chest pain when taking a deep 2. Discoid skin rash (patchy redness with
breath hyperpigmentation and hypopigmentation
Fatigue that can cause scarring)
Fever 3. Photosensitivity
Hair loss 4. Mucous membrane ulcers
Mouth sores 5. Arthritis
Photosensitivity 6. Pleuritis or pericarditis
Skin rash 7. Kidney abnormalities (lupus nephritis
Friction rub or pleural friction 8. Brain irritation (manifested by
MANAGEMENT
SEIZURES and PSYCHOSIS, "lupus
1. Corticosteroids cerebritis")
9. Blood-count abnormalities:
2. NSAIDs AVOID Diclofenac (Voltaren) 10. Immunologic Disorder
11. Anti- Nuclear Antibody
Indomethacin (Indocin)

3.Hydroxychloroquine – Relief of rashes

PSORIASIS

Causes: Stress, trauma, infection, and changes in climate

Problem: chronic skin inflammation involving keratin synthesis

Treatment:
1. Tar preparations
2. Calamine lotion
3.PUVA – Psoralen plus UV light

S/Sx: patches on the scalp, elbows, knees, and sacral regions

LYME’S DISEASE
Risk factors: campers, children (summer camp)
Causative agent:
Vector:
Health teaching:
______ sleeved shirt
______ pants, inserted into socks
______ colored
______ shoes

“If your habits doesn’t work, change it. But don’t change your GOAL.”
 MALIGNANT MELANOMA
- most common cause of skin cancer – may
lead to death
- poor prognosis even with treatment

Risk factors:
Exposure to UV light, family history, elderly,
Caucasian, chronic friction to skin, exposure to
irritating chemicals

NI: Avoid
SPF of atleast
____-brimmed hats

POINTS TO REMEMBER:

II. POLYCYTHEMIA
- increased volume of RBCs

Polycythemia Vera Secondary Polycythemia

Cause Idiopathic In response to chronic
Proliferation of myeloid stem Hypoxia
cells (Smoking, COPD)
Diagnosis CBC – Increase RBC, WBC, CBC – Increase RBC
Platelets

Assessment EARLY (for both): Facial flushing(Ruddy complexion)

Increase Blood volume =High BP (headache, dizziness)
Increase Blood viscosity = SOB/DOB, thrombus/clot formation
(claudication, DVT, MI, CVA)

LATE: Pruritus, Gout

Management 1.Therapeutic Phlebotomy 1.Therapeutic Phlebotomy

2. Avoid Iron rich food and
supplements
3. Small frequent feedings
4. Avoid hot and spicy food
5. For pruritus: give calamine
lotion or cocoa butter
2. Avoid Iron rich food and
supplements
3. Small frequent feedings
4. Avoid hot and spicy food

*Phlebotomy: Removal of excessive RBC’s (500ml/session) done once a week

“If your habits doesn’t work, change it. But don’t change your GOAL.”
 CANCERS (RISK FACTORS)

LUNG CANCER
1. Radon gas exposure (cement)
2. Smoking
3. Pollutants

BREAST CANCER
1. Prolonged exposure to hormone (Estrogen)
2. Early menarche
3. Late menopause
4. Null parity – also a risk factor for Ovarian CA
5. First child post 35 y/o
6. Genetic mutations – BRCA1 and BRCA2
7. High fat diet
8. Obesity
9. Caucasian (American women)

CERVICAL CANCER
1. SEXUALLY ACTIVE BELOW THE AGE OF 18
2. INFECTED WITH HUMAN PAPILLOMA VIRUS
3. MULTIPLE SEX PARTNERS
4. ORAL CONTRACEPTIVE USAGE
5. HEAVY SMOKER
6. AFRICAN AMERICAN

TESTICULAR CANCER
15-40 y.o.
S/Sx
1. Painless testicular swelling
2. Dragging and pulling sensation
3. Palpable lymphadenopathy, abdominal masses
4. Gynecomastia

BLADDER CANCER
 Cigarette smoking
 Industrial chemicals
 Exposure to radiation

PROSTATE CANCER
 ABNORMAL: Hard prostate, localized and diffused
 NORMAL: tender and boggy prostate

“If your habits doesn’t work, change it. But don’t change your GOAL.”
PANCREATIC CANCER URINE COLLECTION (INFANT)
• Male, african american
• Smoking, toxins 1. Wash the genital.
• Diet: high fat, red meat 2. Open the urine collection
bag (wee bag) and place it on
• History: pancreatitis, DM
the infant.
•
3. Diaper the infant.
4. Check the baby frequently
COLORECTAL CANCER and remove the bag after the
• Male, african american infant has urinated.
• Increasing age, obese
• Alcohol, smoking
• Diet: high fat & protein, low fiber
• History: CA, polyps, IBS, gastrectomy

WHAT TO DO IN TRANSFUSION REACTION. HERPES ZOSTER VIRUS

(Shingles)
1. Stop the transfusion / infusion.  INFECTION CONTROL
2. Run NSS at KVO (keep vein open) rate.  Painful, unilateral
3. Assess the patient. vesicular rashes
4. Notify the physician.  Acyclovir within 72 hours
5. Bring back the blood products to the  Corticosteroid
blood bank.
 Calamine lotion
6. Document.

TRACHEOSTOMY CARE

1. Hand hygiene.
2. Provide privacy.
3. Prepare the client and equipments needed.
4. Suction the tracheostomy tube, if necessary.
5. Clean the inner cannula.
6. Clean the incision site and tube flange.
7. Apply a sterile dressing.
8. Change tracheostomy ties.
9. Tape and pad the tie knot.
10. Check the tightness of ties.
11. Document.

“If your habits doesn’t work, change it. But don’t change your GOAL.”