MEDICAL SURGICAL (MS) LECTURE

HEMATOLOGIC/BLOOD DISORDERS

​
LEUKEMIA
− Commonly targets leukocytes (one of the members of WBC)
− A malignant disorder of hematopoietic system that involves the bone marrow and lymph nodes ​
ᴑ Leukopenia
− Depletion/decreased of WBC
− It doesn’t mean it’s a form of cancer, but it’s a condition where there’s a depletion of WBC
− Common denominator or Leukemia and Leukopenia: Both condition is at risk of infection/ have to
stay away from active form of infection
− Characterized by uncontrolled proliferation of immature WBC’s
o What will happen to WBC?
− There’s still an elevation of WBC
− REMEMBER: This WBC might be abundant in the system but its immature (a lot of blood cells but
immature, are they capable of promoting their function? (We know that WBC will be responsible
for preventing infection) there’s still a chance that they will keep away infection. However, your
body will fail because these are immature cells)
− Cause:
o Genetics
− Can be pass down
o Down syndrome
− Also known as Trisomy 21- there’s an excess chromosome in chromosome 21
− Pediatrics suffering from neurologic and motor impairment
o Radiation
− Exposure of Gamma rays which is found in ultra violet rays, x-ray machines
− Normal individual can only be exposed: twice (2) annually/in a year
− Chemotherapy (radiation) is management for cancer.
− Radiation and Chemo will not only target cancer cells but it also targets normal and healthy living cells (if
these normal cells are targeted then there’s a possibility of mutation meaning it could form a new type of
cancer or malignancy

o Chemotherapy
− No chemo therapy is safe, and 100% sure to cure client
− All cancer medications have a tendency for mutations of cells

− Classified by onset and severity and by precursor cell

ᴑ Acute- AML (Acute Myeloid Leukemia), ALL (Acute Lymphocytic Leukemia)
− “AA - CUTE”: for pediatric individuals or children/these will be evident in pediatric to individual and
commonly seen in children
− Chronic: commonly seen and manifested in adults or elderly individuals
ᴑ Chronic
ᴑ Lymphoid
ᴑ Myeloid

CLINICAL MANIFESTATION OF LEUKEMIA

 − Severe infections (pneumonia, septicemia), ulcerations of mouth and throat
Cause: High numbers of immature or abnormal leukocytes unable to fight and destroy microorganisms
ᴑ “Severe infection”- most likely the px is infected of an opportunistic infection

ᴑ 2 common infection that might be found:

1. Viral infection
2. Fungal infection
ᴑ All microorganism could promote opportunistic infection, but it highly depends of the amount of duration
of exposure from that microorganism
ᴑ Common bacterial infection:

1. TB- commonly targets immunocompromised individuals

ᴑ Septicemia- already a severe form of infection

Notes:

➢ There is no such thing as “severe septicemia” for septicemia itself if severe

− Anemia accompanied by pallor, fatigue, malaise, hypoxia, and hemorrhage (gum bleeding, ecchymoses, petechiae,
retinal hemorrhage
Cause: Rapid proliferating development of leukocytes inhibiting erythrocytes and thrombocytes
ᴑ It doesn’t only target WBC

ᴑ Initially it will target WBC but on the late stage it can target RBC or Platelets

ᴑ It can affect platelets; which causes hemorrhage/bleeding tendency (signs and sx: petechial rashes,
bleeding of gums (avoid brushing of teeth or use soft brittle brush)

− Increased metabolic rate accompanied by weakness, pallor, and weight loss

Cause: Increased leukocyte production requiring large amounts of nutrients, cell destruction increases amount of
metabolic waste

− Head ache disorientation

Cause: Abnormal white cells infiltrating central nervous system

− Enlarged organs (splenomegaly, hepatomegaly, exerting pressure on adjacent organs)

Cause: High numbers of white cells accumulating within liver and spleen causing distention of tissues
 ᴑ 2 x-ray examinations: MRI or CT-scan the client will manifest now signs and sx of splenomegaly or
hepatomegaly) because of increasing amount of dead RBC
ᴑ If you have increasing blood cell destruction there would be an elevation of bilirubin (this blood cells
contains bilirubin)
ᴑ Prone to Arthritis (the client could have signs and sx of hyperuricemia)

− Hyperuricemia causing renal pain, obstruction (from stone formation) and infection; a late development is renal
insufficiency with uremia
Cause: Large amounts of uric acid released as a result of destruction of great numbers of leukocytes; in late
stages; abnormal leukocytes infiltrate kidneys
ᴑ Normal level of uric acid: 4-7mg/dl

ᴑ Uric acid is a form of crystal and if you lack fluid in the body then there’s a chance that these crystals
could aggregate and once, they aggregate the px is at risk to develop stone formation. INCREASE
ORAL FLUID INTAKE to dilute increasing uric acid in the body

− Lymphadenopathy (due to cases of infections) and bone pain

Cause: Excessive numbers of white cells accumulating in lymph nodes and bone marrow
ᴑ Myelogenous Leukemia

− Bone involvement, where bone marrow makes too many WBC

− Bone pain; because of bone degeneration or demineralization
ᴑ Lymphocytic Leukemia

− Makes too many lymphocytes (a type of WBC)

− Targets lymphocytes

SIGNS AND SYMPTOMS

− Fatigue (manifestation of decreased in RBC)
− Malaise (relate to fatigue, decreased in O2 supply leading to body weakness, even shortness of breath can be a
manifestation, can suffer from Hypoxia related to depletion of RBC)
− Weight loss (Should be selective to the food that you take; Avoid everything that is raw- contains microorganisms
that has normal micro flora; food should always be properly cooked)
ᴑ Acute Leukemia- Anemia, Bleeding, Symptoms of infection, hepatosplenomegaly, lymphadenopathy

ᴑ Chronic Leukemia- Milder anemia, splenomegaly

Notes:

➢ Patients with leukemia should cook their food properly no raw food
➢ If lymphadenopathy is painful that could be a sign of swelling and infection
➢ If lymphadenopathy is painless that could be an early sign of lymphoma (cancer of lymphatic system)
➢ All cancer is asymptomatic in early stage; they will start to create pain or severe manifestation once you
are in your late stage

➢ If “Acute” it will always be seen in pediatric/ children while Chronic can be seen to adults or elderly
individuals

DIAGNOSIS AND TREATMENT

− Bone marrow examination- Leukemic blast cell
ᴑ Bone marrow examination is identical with Bone marrow aspiration (BMA)
ᴑ BMA- Invasive procedure; Requires consent; This procedure could promote bleeding ALWAYS have to
check for bleeding time of the client to prevent complications during and after BMA
ᴑ Where would be the common site/area of Aspiration: FLAT bones (posterior iliac crest à[most
common], sternum and scapula)
ᴑ Position the client in the unaffected site during the procedure; then position the client on the
affected area after the procedure (to maintain pressure on the area that has been aspirated; pressure
could prevent bleeding tendency; can also put sandbags or icebag to the area)
ᴑ Check the area or aspiration site every 2 hours (any ecchymosis, enlargement, or petechiae on the
area could be a sign of bleeding and must be reported right away)
o As a nurse we should first perform: Apply pressure or ice packs, immobilize area

− Chemotherapy with or without stem cell transplantation

− Allogenic/ Autologous stem cell transplantation (also known as bone marrow transplantation)
ᴑ Allogenic transfusion- coming from family members (compatibility is a big factor)
 ᴑ Autologous- came from you and still will be administered to you

ᴑ Syngeneic transplantation- coming from twins (monozygotic/identical); rare type of transplantation

because not everyone has a twin.
Notes:

➢ Bone marrow examination or BMA, is the diagnostic examination of choice

➢ Bone marrow transplant- it harvests the bone marrow- before surgery it is normal- the harvested bone marrow will
give after chemotherapy

MANAGEMENT
− During an early stage if the client is suffering from anemia
ᴑ Check hemoglobin if its beyond 8-10 transfuse blood
− Blood transfusions (prior to BT properly check the blood type and cross match)
ᴑ Monitor VS
− Monitor if there’s will be an underlying sort of infection
ᴑ Confirm blood compatibility
− Universal donor type O
− Universal recipient A, B
− Have to recheck with another co-worker (blood compatibility)
ᴑ Administer thru filter needle with NSS only because our blood could have consolidate (buo-buong dugo)
on it.
− Prevent coagulation, thrombus in the blood vessels
ᴑ Observe for transfusion reactions (hemolytic, febrile, allergic)

− Hemolytic reaction: initial manifestation for this is low back pain; elevation of uric acid
− Febrile reaction: manifestation is hyperthermia
− Allergic reaction: manifestation is rashes; worst possible effect of allergic reaction is anaphylaxis- the
client will have bronchoconstriction leading to closure of airway, DOB; most alarming is ABSENCE OF
BREATH SOUNDS

Notes:

➢ Administer antihistamine prior in giving any blood product- to prevent allergic reaction
Ex: diphenhydramine (Benadryl)

➢ Weren’t able to prevent allergic reaction, client progress in anaphylactic shock

Best medication: Epinephrine

− Platelet transfusions
ᴑ If the client has bleeding tendency, then administer platelet transfusion, to prevent hemorrhage
− WBC transfusions
ᴑ Transfusion for those individual whose WBC is abnormally low
ᴑ And if they have increasing WBC that’s more even immature; best administer WBC
Notes:

➢ If the client is already suffering from blood internal bleeding, then administer the whole blood (you don’t know
where blood loss is coming from; because when you bleed, you are liberating all blood components)

➢ If you know what type of blood component you are losing then administer the specific product (WBC, RBC,
Platelets)

NURSING MANAGEMENT
− Monitor for infection (It’s not just an infection, it is an opportunistic type of infection; VIRAL or FUNGAL infection)
ᴑ Private room
− Make sure it is POSITIVE PRESSURE ROOM- wind from the room of the client going out to the door;
meaning if the nurse opens the door all microorganisms that is with the nurse will flush out because of
the increasing pressure inside the room
− Never share with other clients; for the px is leukemic or immunocompromised
ᴑ No flowers, plants, fresh fruits

− No raw products, as much as possible you have to cook the product to avoid micro flora or any
microorganism that might go to the system of the client leading to life threating complications or sepsis
ᴑ Avoid infected persons
 − Avoid crowded areas because we are not sure if all of these people are clear from microorganisms;
asymptomatic individuals
ᴑ Handwashing

− Important parameters of handwashing: running water, antimicrobial soap, duration, and friction applied
to the hands
− There’s no difference in using brush and using your hands in handwashing stated by the WHO it still
prevents infection
− Prevent bleeding
− Prevent or manage stomatitis- oral care
ᴑ Avoid irritants in the mouth like elixirs (product that contains alcohol) for it can irritate and promote
xerostomia (dryness of the mouth) and breakage of skin, which is a risk for infection
ᴑ No. 1 barrier against infection à intact skin or mucous membrane
− Conserve the patient’s energy
ᴑ Plan an activity that is safe for the client because the client has easy fatiguability
− Provide emotional support

Notes:

➢ LEUKEMIA: Initially it will be the WBC that’s infected, but in the end part of the disorder, it will cause depletion and
immaturity of all blood cells meaning px is risk for anemia, thrombocytopenia, risk for infection

➢ Ideal precautions for these px:

Immunocompromised: Neutropenic precaution

➢ Cancer is not just traumatic to the client its also traumatic for the family members (burn out in terms of
caregiving)

PREVENTION
− History taking
− Avoid radiation or any form of carcinogen
− Avoid stress

ANEMIA
2 MAIN TYPES OF ANEMIA

1. QUANTITAVE ANEMIA
− RBC falls below for 4 million cells per microlitre (cells/mcL)
o Normal RBC: 4-6 million cells/mcL
− Amount of cells
2. QUALITATIVE ANEMIA
− Maturity of the RBC
− If there’s a nucleus
− The only cell in the body that has no nucleus is the RBC; why? It gives way for maturation of the hemoglobin,
nucleus is going out for Hemoglobin synthesis

Notes:

➢ Normal level of RBC: 4-6 million cells per microlitre (cells/mcL)

IRON DEFICIENCY ANEMIA
− Commonly seen in female individuals
− Iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in RBC’s
o Iron is mainly responsible for hemoglobin synthesis (oxygen capacity of the blood)
o If there’s no hemoglobin no oxygen
o No gas exchange; meaning there would be cases of hypoxia- main manifestation of anemia
− Commonly results from HAMM
o Hemorrhage
o Anorexia (dietary problems)
 − Psychological problem
− Other psych. problem: PICA- eating inedible food (clay, paste, mud)
o Menstruation

− Menorrhagia (heavy bleeding)

o Normal blood loss in one menstrual cycle: 80 ml
o Malabsorption syndrome

− Problem in absorbing nutrients in intestines

ASSESSMENT
− Early cases of anemia are asymptomatic, seems normal but if you place the px in the big crowd the px will get
nauseous because of lack of oxygen
− Mild cases usually asymptomatic
− Pallor, Irritability (consult hematologist for medications to promote maturation of the RBC)
− Weakness and Fatigue may also have dyspnea
− Palpitation, dizziness and cold sensitivity
o Palpitations is a compensatory mechanism of the body meaning when the body detect that you have low
O2 then it increases the contraction of the heart- palpitations

Early manifestation:
− Fatigability
− Restlessness
− Agitation
− Tachycardia (synonymous to palpitations)
− Shortness of breath
Late manifestation of hypoxia: 3C’S
− Cyanosis
− Clubbing of fingers (because nails are trying to compensate)
− Chest retractions (use of accessory muscles)

Notes:

➢ Early manifestation nothing to worry about; However, if it is late manifestation then it is alarming
➢ Early manifestation management: administer green leafy vegetables, iron supplements
➢ Late manifestation management: the doctor will administer BT (packed RBC)
LABORATORY FINDINGS
− Serum iron is decreased
− RBC’s small
o Hypochromic (less color) and Microcytic type of anemia
o Small and colorless RBC’s
− Hgb markedly decreased
Hemoglobin/Hgb:
Normal level: Female: 12-14grams; Male: 14-16grams

Hematocrit/Hct: Hgb x 3
Normal level: Female: 36-42%; Male: 42-48%
o Anything less than this could be decreased in concentration of the blood to your plasma; low RBC

Notes:

➢ If your hgb decreases then possible for anemia

➢ Concentration of blood cells to your plasma, meaning if your RBC is decreased then there’s a decreased
concentration, then low hematocrit \

➢ Hallmark Manifestation for Iron Deficiency Anemia: Angular Cheilosis (dry of side of the lips) and sometimes
associated with Plummer Vinson syndrome (group of signs and symptoms relating to GIT; stomatitis etc.)
MANAGEMENT
− Determine possible sources of bleeding
o Internal bleeding is hard to treat than external
o Ask If the px has gastric upset, it can be an early sign of GIT bleeding because blood vessels in our GIT
are very small. We also have peristaltic movement (kiskisan; wave like motion) could promote bleeding
and trauma
− Increased iron intake or administer as prescribed
o Iron is best administered with Vitamin c (look for food sources rich in Vit C)
Notes:

➢ If the blood is immature then these cells can easily erupt meaning high chance of jaundice

A. Oral Iron preparations: route of choice (if client can tolerate this route)
Health teachings (iron intake): “IRONS”
− Intake with vitamin C
− Remind client that there will be gastric upset
− Observe stool changes (dark tarry)
o It could be a normal manifestation; however, if the px has abdominal pain then that requires
for further analysis
o For that could be a sign of bleeding; if the px has abdominal pain

o Guaiac test: to determine bleeding that is hidden, microscopic level

Blue if there’s a positive blood in the stool
− No PO solution
o For it can promote staining of the teeth (use of straw)
− Straw
o In administrating iron sol
o Iron containing products such as red meat (high in iron and uric acid- sometimes manifest
gouty arthritis) and green leafy vegetables

PERNICIOUS ANEMIA
− A form of qualitative anemia (maturity of RBC)
− Chronic progressive, macrocytic anemia caused by a deficiency of intrinsic factor
o Macrocytic anemia or megaloblastic anemia
o Big cells but does not mean that they are mature cells

− Lack of intrinsic factor is caused by gastric mucosal atrophy (possibly due to heredity, prolonged in iron deficiency, or
an autoimmune disorder), can also result in client who have had a total gastrectomy if vitamin B12 not administered
o Pernicious anemia is due to losing the ability to absorb B12 or lack of intrinsic factor in the stomach and
NOT due to insufficiency in vitamin B12 (cyanocobalamine) itself
o Stress could promote autoimmunity

o Billroth 1 and Billroth 2 (current terms for gastric surgery)

Notes:

➢ Billroth 1: Gastroduodenostomy (removal of portion of stomach, remaining part of stomach is anastomosed with
duodenal area)

➢ Billroth 2: Gastrojejunostomy (anastomose the remaining parts of stomach to the jejunum)

➢ If the stomach is removed, the ability to produce intrinsic factor will be gone, thus losing the ability to absorb vit
B12.

− Usually occurs in men and women over age 50, with an increase in blue eyed persons. (more common to Western
people)
o As we grow old, there is an increased incidence of parietal cells degeneration; Parietal cells produce
intrinsic factor of stomach and are responsible for the following:

▪ acidity of stomach (hydrochloric acid)

▪ absorption of vit B12 or cyanocobalamin
ASSESSMENT
 − Anemia, weakness, pallor, dyspnea, palpitations, fatigue
o IDA is microcytic while Pernicious anemia is macrocytic
− GI symptoms:
o sore mouth,
o smooth, beefy, red tongue (hallmark manifestation)
o weight loss
o constipation or diarrhea
o jaundice
▪ because RBC is immature and there is a tendency that RBC will be destroyed and the by-product
of this is bilirubin which is yellow in pigment)
− CNS symptoms (a hallmark manifestation too)
o only type of anemia that has neurologic manifestation because vit B12 promotes maturation of brain cells
o Pediatric s/sx: Mental retardation (or now called as Intellectual disability), Failure to thrive,
Developmental delays
o Adults s/sx: Paresthesia, numbness of extremities, psychosis
LAB TESTS:
− Erythrocyte decreased (they are immature and easy to die)
o 80-120 days à lifespan of RBCs
− Gastric analysis: decreased free hydrochloric acid (Hypochloridriaà less HCl acid)
o If stomach is removed, parietal cells are also removed
o Achlorhydria à absence of hydrochloric acid

− Positive schilling test (one of the recommended diagnostic exam)

1. Measure absorption of radioactive vitamin B12 both before and after parenteral administration of intrinsic
factor.
• Client is in NPO status for 8-12 hours
• After 8-12 hours, px will be instructed to drink synthetic vit B12
• After drinking synthetic vit B12, normally vit B12 should be absorbed in the stomach because of the
presence of intrinsic factor. However, if the px has loss of HCl acid and intrinsic factor, vit B12 will not
be absorbed and will be excreted to the stool or urine.
• Increased vit B in the urine
à Positive Schilling test (vit B12 should not be seen in the urine)

2. Definitive test for pernicious anemia.

3. Used to detect lack of intrinsic factor
4. Fasting client is given radioactive vitamin B12 by mouth and nonradioactive vitamin B12 to saturate tissue
binding sites and to permit some excretion of radioactive vit B12 in the urine, if it is absorbed.

5. 24–48-hour urine collection is obtained; client is encouraged to drink fluids

• First voided urine will be DISCARDED.
6. If indicated, a second stage Schilling test will be performed 1 week after first stage. Fasting client is given
radioactive vit B12 combined with human intrinsic factor and the test will be repeated.
INTERVENTIONS:
− Provide a nutritious diet high in iron, protein, and vitamins (fish, meat, milk/milk products, and eggs)
− Avoid highly seasoned, coarse, or very hot foods if client has mouth sores
− Provide mouth care before and after meals using a soft toothbrush and non-irritating rinses
− Patient teaching (importance of life long vitamin B12 therapy)
Notes:

➢ If the problem is total absence of vit B12 and giving of green leafy vegetables are useless because of absence
of intrinsic factor, the patient will be instructed by the MD that he/she will receive lifetime injection of vit B12 via
deep IM, administered every month.

➢ For severe case of hypoxia, blood products will also be given

SICKLE-CELL ANEMIA
− “Sickled” or crescent shaped cells
 o Normal appearance should be biconcave

− Qualitative type of anemia

− Most common inherited disease among black Americans acc to literature
− HgbS (abnormal hemoglobin), which has reduced oxygen carrying capacity, replaces all or part of the hemoglobin in
the RBS’s.
o Bone marrow continuously produces immature cells that are still sickle in shape

o Stress and infection can promote sickled cells

− Life span is 6-20 days (for sickle-cell anemia) causing hemolytic anemiaà increase bilirubin & uric acid
o RBC can die right after the 20 day or even in between the 15 day
th th

− Death often occurs in early adulthood due to occlusion or infection.

o Very poor prognosis (anticipated recovery) if not improved by blood transfusion
ASSESSMENT
VASO-OCCLUSIVE CRISIS:
− Most common type of crisis caused by stasis of blood with clumping of the cells in the microcirculation, ischemia
(tissue enlargement), and infarction (necrosis)
o Immature, sickled RBC could clog the arterioles and venules

o If px’s hands are cold to touch means decrease of blood supply in the area (blood promotes warmth)

o Blood will be hyper viscous during this crisis so there is a possibility for HPN

o Pallor on the affected area

o Hand and foot syndrome - Decreased sensation on the affected area; hallmark manifestation of vaso-
occlusive crisis
− Dilution of blood by increasing oral fluid intake so the nursing priority is hydration over pain
− S/sx: Fever, pain, and tissue enlargement;
SPLENIC SEQUESTRATION:
− Storage of dead RBCsà spleen or liver
− Early manifestation is enlargement of spleen (splenomegaly)
− Life threatening crisis caused by the pooling of blood in the spleen (internal bleeding due to rupture of spleen
caused by deep palpation and strenuous activities)
− S/sx: Profound anemia, hypovolemia, & shock
Health instructions:

❖ Avoid palpating the abdomen of the client or the affected area at the left upper quadrant.
❖ Avoid tight clothing.
❖ Avoid contact sports or strenuous activities
APLASTIC CRISIS
− Aplastic crisis is same with aplastic anemia but they are different in terms of aggravating or causative factors
− Caused by the diminished production and increased destruction of RBCs, triggered by viral infection or the
depletion of folic acid
o All organs in the body, even the bone marrow, when over used, napapagod din yan HAYS

− In aplastic crisis, all blood components are low

o Pancytopenia (general term when all blood components are low):
▪ Anemia (low RBC),
▪ Leukopenia (low WBC),
▪ Thrombocytopenia (low platelets, at risk for bleeding as well)

− S/sx: Profound anemia and pallor, infection, bleeding tendency

− Frequent infection especially with H. influenzae (bacterial)
− Infants may have Dactylitis (hand-foot syndrome) symmetrical painful soft tissue swelling in the hands and feet in
the absence of trauma.
o But hand-foot syndrome is most significant in vaso-occlusive crisis
INTERVENTIONS:
− Administer oxygen and blood transfusion as prescribed to increase tissue perfusion
− Maintain adequate hydration (this is the priority or first action)
− Avoid tight clothing that could impair circulation
− Keep wounds clean and dry
 − Provide bed rest to decrease energy expenditure and oxygen use (especially if px is suffering from anemia and
hypoxia)
− Encourage patient to eat foods high in calories, CHON, with folic acid supplementation
Medications:

❖ Analgesics: acetaminophen, meperidine, morphine (avoid aspirin as it enhances acidosis, which promotes sickling)
❖ Avoid anticoagulants (sludging is not due to clotting)
o No problem with platelets kaya not due to clotting but clumping of immature RBCs
❖ Antibiotics (during episodes of Aplastic crisis due to opportunistic infections)

− Avoid activities that requires so much energy

− Keep arms and legs from becoming cold
o Encourage use of blanket because warmth can promote vasodilation, which can help the blood to flow
more properly
− Decrease emotional stress
− Provide good skin care, especially to legs
o If there is ulceration then there is vaso-occlusive crisis because the first target are distal parts of the body

COMBINED MEDICAL & NURSING INTERVENTIONS: “HHOPIA”

Hydration – first thing to administer if the px can tolerate
Hydroxyurea – a chemotherapeutic product that can prevent sickling of cells.
• Remember that chemotherapeutic products can depress immune system in the long run
Oxygen – after ensuring that the client is properly hydrated
Pain relievers – best to administer Morphine because Meperidine can promote sickling of cells
IV Fluids & BT – if oral hydration is not tolerated
• If the px only has sickle-cell anemia with no complicationsà packed RBC
• If the px has splenic sequestration or aplastic crisis à whole blood
• Blood typing & crossmatching is a must as always
Antibiotics