CHAPTER 26: ASSESSMENT AND vasospastic disorders, and

MANAGEMENT OF PATIENTS WITH congenital malformations

VASCULAR DISORDERS AND PROBLEMS ● Circulatory insufficiency of the
OF PERIPHERAL CIRCULATION extremities

SYSTEMIC AND PULMONARY

VASCULAR SYSTEM CIRCULATION

● Consist of two interdependent systems

○ Right side of the heart pumps
blood through the lungs to the
pulmonary circulation
○ Left side of the heart pumps
blood to all other body tissues
through the systemic
circulation
● Arteries and arterioles
● Capillaries
● Veins and venues
● Lymphatic vessels

FUNCTION OF THE VASCULAR SYSTEM

● Circulatory needs of tissues

● Blood flow
● Blood pressure
● Capillary filtration and reabsorption
● Hemodynamic resistance
● Peripheral vascular regulating
mechanisms
PATHOPHYSIOLOGY OF THE VASCULAR
SYSTEM
● Pump failure
○ Inadequate peripheral blood
flow occurs when the heart’s
pumping action becomes
inefficient
● Alterations in blood and lymphatic
vessels
○ Arteries can become damaged
or obstructed as a result of
atherosclerotic plaque or a
thromboembolus (a blood clot
that may become dislodged
from the vessel where it
originally formed), chemical or
mechanical trauma, infections
or inflammatory processes,
GERONTOLOGIC CONSIDERATION
● Aging produces changes in the walls of
the blood vessels that affect the
transport of oxygen and nutrients to
the tissues
● Changes causes vessels to stiffen and
results
○ Increased peripheral resistance
○ Impaired blood flow
○ Increased left ventricular
workload
ASSESSMENT OF THE VASCULAR SYSTEM
● Health history
○ Intermittent claudication
■ Pain in the calf
■ Less commonly in the
thigh or buttocks
■ caused by narrowing or
blockage in the main
 artery taking blood to the ankle to the systolic BP in
your leg (femoral the arm; it is an objective
artery). indicator of arterial disease
■ This is due to that allows the examiner to
hardening of the quantify the degree of stenosis
arteries ○ ABI is determined by having
(atherosclerosis). the patient in supine position
■ The blockage means for 5 minutes. Then, an
that blood flow in the appropriate sized bp cuff
leg is reduced. (about 10 cm in adults) is
○ “Rest pain” applied to the patients ankle
○ Location of the pain above the malleolus. After
● Physical assessment identifying arterial signals of
○ Skin (cool, pale, pallor, rubor, the posterior tibial and dorsalis
loss of hair, brittle nails, dry or pedis, systolic pressure are
scaling skin, atrophy or obtained in both ankles while
ulceration) listening to the doppler signal
○ Pulses of each artery
○ Used when pulse cannot be
Buerger’s Disease reliably palpated
○ Handheld UTZ device that
detects blood flow, combined
with computation of ankle or
arm pressures
○ Signals are reflected by the
moving blood cells
○ Diagnostic technique helps
characterize the nature of
peripheral vascular disease
● Exercise testing
○ Used to determine how long a
● Vasoconstriction due to smoking patient can walk and to
● Common in males measure the ankle systolic BP
in response to walking
ASSESSING PERIPHERAL PULSE ● Duplex ultrasonography
○ Noninvasive
● Peripheral pulse locations ○ Used to determine the level or
○ Carotid extent venous disease as well
○ Brachial as the chronicity of the disease
○ Radial ○ Patients who undergo
○ Femoral abdominal vascular duplex utz
○ Popliteal should be advised to not eat or
○ Dorsalis pedis drink for at least 6 hours prior
○ Posterior tibial artery to the examination to decrease
bowel gas that can interfere
DIAGNOSTIC EVALUATION with the exam
● Computed tomography scanning
● Doppler ultrasound flow studies (CT scan)
○ Used to determine ankle ○ Provides cross-sectional images
-brachial index (ABI); ABI is of soft tissue and visualizes the
the ratio of the systolic BP in area of volume changes to an
 extremity and the
compartment where change
takes place
● Angiography
○ May be used to confirm the
diagnosis of occlusive arterial
disease when surgery or other
interventions are considered
● Magnetic resonance angiography
○ Performed with MRI
○ Contraindicated in patients with
metal implants
● Contrast phlebography
(venography)
○ Involves injecting a radiopaque
contrast agent to the venous
system
○ If thrombus is present, x-ray
image reveals unfilled segment
of vein
● Lymphoscintigraphy
○ Involves injection of a
radioactively labeled colloid
subcutaneously in the second
interdigital space
○ The extremity is then exercised
to facilitate the uptake of the
colloid by the lymphatic system
ASSESSMENT OF THE PATIENT
WITH PERIPHERAL VASCULAR
PROBLEMS
● Health history
● Medications
● Risk factors
● Signs and symptoms of arterial
insufficiency
● Claudication and rest pain
● Color changes
● Weak or absent pulses
● Skin changes and skin breakdown
❖ Major goals include
➢ Increased arterial blood supply
➢ Decrease in venous congestion
➢ Promotion of vasodilation and
prevention of vascular
compression
➢ Relief of pain
➢ attainment/maintenance of
tissue integrity
➢ Adherence to the self-care
program
IMPROVING PERIPHERAL ARTERIAL
CIRCULATION
● Positioning strategies- body part below
the level of the heart; do not elevate
legs
● Exercise program and activities:
walking, graded isometric exercises
○ Consult primary provider
before engaging in an exercise
routine
● Temperature, effects of heat and cold
● Discourage use of nicotine; can cause
vasoconstriction
● Stress reduction
GOALS IN VASCULAR PROBLEMS
● Vasodilation
● Maintain neutral position
● Do not elevate legs
ARTERIAL DISORDERS
● Arteriosclerosis and atherosclerosis
● Peripheral artery disease
● Upper extremity arterial disease
● Aortoiliac disease
● Aneurysms (thoracic, abdominal,
other)
● Aortic dissection
● Arterial embolism and arterial
thrombosis
● Raynaud’s phenomenon and other
acrosyndrome
PROGRESSION OF ATHEROSCLEROSIS
RISK FACTORS FOR ATHEROSCLEROSIS
AND PAD
● Modifiable
○ Nicotine use
○ Diabetes
○ Hypertension
○ Hyperlipidemia
○ Diet
○ Stress
○ Sedentary lifestyle
○ C-reactive protein
○ Hyperhomocysteinemia
● Nonmodifiable
○ Increasing age
○ Genetics
● Prevention
○ Diet modification and exercise
to reduce blood lipid levels
○ HMG-CoA reductase inhibitor
(statins) as first line therapy in
patients with PAD
● Endovascular Therapy
○ Includes various procedures
that use a puncture or small
incision to place catheters
inside a blood vessel to repair
it
PERIPHERAL ARTERIAL DISEASE (PAD)
● Most common in men
● Most common cause of disability
● Legs are commonly affected
● Hallmark symptom is intermittent
claudication; described as aching,
cramping, or inducing fatigue or
weakness; sensation of coldness or
numbness in the extremities
● Skin and nail changes, ulceration,
gangrene, and muscle atrophy may be
evident
● Examination of peripheral pulses is an
important part of assessing PAD
● Occurs with some degree of exercise or
activity
● Relieved with rest
● Pain is associated with critical ischemia
of the distal extremity and is described
as persistent aching, or boring (rest
pain)
● Ischemic rest pain is usually worse at
night and often wakes the patient
PHARMACOLOGIC THERAPY FOR PAD
● Phosphodiesterase III inhibitor (direct
vasodilator that can inhibit platelet
aggregation)
○ Cilostazol
● Antiplatelet agents (prevent
thromboembolic formation)
○ Aspirin
○ Clopidogrel
● Statins
QUESTION #1
The nurse is teaching a patient
diagnosed with PAD. What should be included
in the teaching plan?
A. Elevate the lower extremities
B. B. exercise is discouraged
C. Keep the lower extremities in a
neutral or dependent position
D. PAD should not cause pain
ANEURYSMS
● Localizee sac or dilation formed at a
weak point in the wall of the artery
● Classified by ts shape or form
● Most common forms of aneurysm are
saccular and fusiform
○ Saccular aneurysm projects
from only one side of the
vessel
 ○ When an entire arterial
segment becomes dilated, a
fusiform aneurysm develops
THORACIC AORTIC ANEURYSM
● 70% cases are caused by
atherosclerosis
● Occur most frequently in ages 50 and
70 years old
● Thoracic area is the most common site
of dissecting aneurysm
CLINICAL MANIFESTATION
● Depends how rapidly the aneurysm
dilates and how the pulsating mass
affects surrounding intra-thoracic
structures
● Some are asymptomatic
● Pain is the most prominent symptom;
usually constant and boring; may occur
when the patient is supine
● Other symptoms: dyspnea, dysphagia,
aphonia, cough
ASSESSMENT AND DIAGNOSTIC
FINDINGS
● Superficial veins of the neck, chest, or
arms become dilated
● Diagnosis includes x-ray, CT scan,
MRA, or TEE
MEDICAL MANAGEMENT
● Control BP
● Correct risk factors
● Beta blockers have been the mainstay
treatment
● The systolic is maintained at
approximately 90to 120 mmHg in
order to maintain a mean arterial
pressure of 65 to 75 mmHg;
hydralazine is used for this purpose
RAYNAUD’S PHENOMENON
❖ Intermittent arterial vasoocclusion,
usually of the fingertips or toes.
● Raynaud's disease: primary or
idiopathic
● Raynaud's syndrome:
associated with other
underlying diseases such as
scleroderma.
❖ Manifestation: sudden vasoconstriction
results in color
changes,numbness,tingling and
burning pain.
❖ Episodes brought on by a trigger such
as cold or stress
❖ Occurs most frequently in young
women.
❖ Protect from cold and other triggers.
❖ Avoid injury to hands or fingers.
VENOUS DISORDERS
❖ Venous thromboembolism (VTE)
condition
● DVT and PE
❖ Chronic venous insufficiency
postthrombotic syndrome
❖ Leg ulcers
❖ Varicose Veins
Venous Thromboembolism
❖ Pathophysiology
❖ Risk factors
❖ Endothelial damage
 ● Venous stasis ❖ Assess nutrition
● altered coagulation
❖ Manifestations
● Deep veins
● Superficial veins
❖ Preventive measures MEDICAL MANAGEMENT OF PATIENTS
● Early ambulation and leg WITH LEG ULCER
exercises
● Graduated compression ❖ Anti-Infective therapy depends on the
stockings infecting agent
● Intermittent pneumatic ❖ Oral antibiotics are usually prescribed
compression devices ❖ Compression therapy
● Subcutaneous heparin or ❖ Débridement of wound (debridement:
LMWH removal of dead tissue)
● Lifestyle changes ❖ Dressings
- Weight loss ❖ Other
- Smoking cessation
- Regular exercise NURSING INTERVENTIONS FOR THE
PATIENT WITH LEG ULCER
QUESTION #2
Which patient is at highest risk for venous ❖ Restoring skin integrity
thromboembolism? ● Cleansing wound; positioning;
A. A 50-year-old postoperative patient avoiding trauma; avoid heat
B. A 25-year-old patient with a central venous sources
catheter in place to treat septicemia ❖ Improving physical mobility
CA 71-year-old otherwise healthy older adult ● Physical activity initially
D. A pregnant 30-year-old woman due in 2 restricted to promote
weeks healing:gradual progression of
activity
B. A 25-year-old patient with a central venous ● Activity to promote blood flow;
catheter in place to treat septicemia encourage patient to move
Rationale: Some risk factors for venous about in bed and exercise
thromboembolism Include but are not limited upper extremities
to age older than 65 years, patients ● Diversional activities
undergoing surgery, central venous catheter ● Analgesic agents before
placement, septicemia, and pregnancy, The scheduled activities
client in this question with two risk factors is ❖ Promoting adequate nutrition
the 25-year-old with a central venous catheter ● Protein; Vitamins C and A;
in place to treat septicemia. All other patients Iron, Zinc
only have one risk factor.
VARICOSE VEINS

❖ Prevention
● Avoid activities that cause venous
ASSESSMENT FOR THE PATIENT WITH LEG stasis (wearing socks that are too
ULCER tight at the top or that leave marks
on the skin, crossing the legs at
History of the condition the thighs, and sitting or standing
❖ Assess pain, peripheral pulses, edema for long periods)
❖ Treatment depends on the type of ulcer ● Elevate the legs 3 to 6 inches
❖ Assess for presence of infection higher than heart level
 ● Encourage to walk 30 minutes
each day if there are no
contraindications
● Wear graduated compression
stockings
● Overweight patients should be
encouraged to begin weight
reduction plans
LYMPHATIC DISORDERS
❖ Lymphangitis: inflammation or
Infection of lymphatic channels the
❖ Lymphadenitis: inflammation or
infection of the lymph nodes
❖ Lymphedema: tissue swelling related
to obstruction of lymphatic flow
● Primary: congenital
● Secondary: acquired
obstruction
Question #3
Which of the following is an effective
strategy used to promote lymphatic
drainage and prevent edema In clients
with lymphedema?
A. Antibiotic therapy for 14 days
B. Constant elevation of the affected
extremity
C. Application of heat therapy twice per
day
D. Daily exposure to the sun
B. Constant elevation of the affected
extremity
Rationale: Constant elevation of the
affected extremity and observation for
complications are essential. After
surgery, antibiotics may be prescribed
for 3 to 7 days. The patient is
Instructed to avoid the application of
heating pads or exposure to sun to
prevent burns or trauma to the area.
CELLULITIS
❖ S&S: localized swelling or redness,
fever, chills, sweating
❖ Treat with oral or IV antibiotics based
on severity
❖ Nursing Interventions
● Elevate affected area 3 to 6
inches above heart level
● Warm, moist packs to site
every 2 to 4 hours
● Educate regarding prevention
of recurrence
● Reinforce education about skin
and foot care
CHAPTER 28: ASSESSMENT OF
HEMATOLOGIC FUNCTION AND
TREATMENT MODALITIES
HEMATOLOGIC SYSTEM
❖ The blood and the blood-forming sites,
including the c bone marrow and the
reticuloendothelial system (RES)
❖ Blood
● Plasma: fluid portion of blood
● Blood cells: erythrocytes,
leukocytes, thrombocytes
❖ Hematopoiesis: complex process of the
formation and maturation of the blood
cells (RBCs)
Question #1
Is the following statement true or false?
Hematopoiesis is the complex process of the
formation and maturation of blood cells.
Red Blood Cells: Erythrocytes
❖ Types-Figure 28-2
● Hemoglobin- iron containing
protein of RBCs;delivers
oxygen to tissue
● Reticulocytes- slightly
immature RBCs, usually only
1% of total circulating RBCs
❖ Erythropoiesis - process of formation of
RBCs
❖ Iron stores and metabolism Vitamin B
and folic acid
❖ Destruction
White Blood Cells: Leukocytes
❖ Granulocytes (granulated WBC)
 ● Eosinophils:Involved in allergic Monocytes
reactions (neutralizes Eosinophils
histamine);digests foreign
proteins.
● Basophils:Involved in allergic RETICULOENDOTHELIAL SYSTEM
reactions (neutralizes
histamine); digests foreign
proteins. ❖ Histiocytes
● Neutrophils:Essential in ● Kupffer cells: a phagocytic cell
preventing or limiting bacterial which forms the lining of the
infection via phagocytosis. sinusoids of the liver and is
Bands: left shift
involved in the breakdown of
red blood cells
❖ Agranulocytes
● Peritoneal macrophages: major
● Monocytes:Enters tissue as
cell type of peritoneal cells that
macrophage, highly phagocytic
participate in multiple aspects
,especially against fungus;
of innate and acquired
immune surveillance
immunity in the peritoneal
● Lymphocytes: Integral
cavity.
component of immune system.
● Alveolar macrophages:also
- T cells and B cells
known as dust cells are a type
of white blood cells.
Platelets: Thrombocytes
❖ Spleen
❖ Thrombopoietin:
❖ Fibrin:filamentous protein; basis of
➔ NOTE: Macrophages give rise to tissue
thrombus and clot
histiocytes phagocytic cells that are
present in loose connective
Plasma and Plasma Proteins
tissue.These include Kupffer cells of the
❖ Albumin
liver, peritoneal tissue macrophages,
❖ Globulins
alveolar macrophages, and other
● Alpha
components of the RES.
● Beta
➔ NOTE: The spleen is the site of activity
● Gamma
for most macrophages. Most of the
❖ Impact on fluid balance
spleen (75%) is made of red pulp.

Which type of cells increase in number when

the patient is exposed to a bacterial Infection?
HEMOSTASIS
A. Erythrocyte
B. Eosinophil
❖ Assessment of Hematologic Health
C. Neutrophil
❖ Health history (refer to Chart 28-1)
D. Thrombocyte
❖ Physical assessment (refer to Table
E. Monocyte
28-2)
❖ Diagnostic evaluation
C.Neutrophil
❖ Hematologic studies
Rationale: The neutrophils are the mature,
❖ Bone marrow aspiration and biopsy
circulating white blood cells. When a bacterial
infection occurs, the neutrophils will increase in
Bone Marrow Aspiration
order to phagocytize the bacteria.
REMEMBER: Never Let Monkeys Eat Bananas
Neutrophils Basophils
Lymphocytes
 ➢ Correct administration
techniques per agency’s
policies and procedures
➢ Refer to Charts 28-3 and 28-4
Type Universal Universal
Recipient Donor

A B AB O

Anti-B Anti-A Neither Both A, B

A B A,B,O O

Transfusion Complications
❖ Febrile nonhemolytic reaction
Therapeutic Approaches ❖ Acute hemolytic reaction
❖ Splenectomy ❖ Allergic reaction
❖ Apheresis (refer to Table 28-3) ❖ transfusion-associated circulatory
❖ Hematopoietic stem cell overload
transplantation (HSCT) ❖ Bacterial contamination
❖ Phlebotomy ❖ Transfusion-related acute lung injury
❖ Blood component therapy ❖ Delayed hemolytic reaction
❖ Special preparations ❖ Disease acquisition — Chart 28-6
Question #3 ❖ Long-term transfusion therapy
Is the following statement true or false? Nursing Management Of Transfusion
Reactions
Petechiae are pinpoint hemorrhagic lesions ❖ Stop
often seen on a patient with thrombocytopenia. ❖ Assess
Answer: True ❖ Notify primary provider and Implement
Rationale: A thrombocyte is a cellular prescribed treatments. Continue to
component of blood involved in blood monitor.
coagulation. Thrombocytopenia can often ❖ Return blood
include petechiae, pinpoint hemorrhagic lesions ❖ Obtain any samples needed
often more prominent on the trunk or anterior ❖ document
aspects of the lower extremities. Transfusion Alternatives
❖ Refer to Chart 28-7
Blood and Blood Products ❖ Growth factors
❖ Donor requirements ❖ Erythropoietin
❖ Donation types-Refer to Table 28-4 ❖ Granulocyte colony-stimulating factor
➢ Directed ❖ Thrombopoietin
➢ Standard
➢ Autologous CHAPTER 29: MANAGEMENT OF PATIENTS
➢ Intraoperative blood salvages WITH NONMALIGNANT HEMATOLOGIC
➢ hemodilution DISORDERS
❖ Complications of donation
❖ Blood processing ANEMIA
Transfusion
❖ Common settings ❖ Lower than normal hemoglobin and
❖ Pretransfusion assessment fewer than normal circulating
❖ Patient education erythrocytes; a sign of an underlying
❖ Transfusion process disorder
 ❖ Hypoproliferative: defect in production
of erythrocytes (RBCs)
➢ Caused by iron, vitamin B12,
or folate deficiency, decreased
erythropoietin production,
cancer, bone marrow damage
❖ Hemolytic: excess destruction of
erythrocytes (RBCs)
➢ Caused by altered
erythropoiesis, or directed
injury to the erythrocyte
➢ Refer to Chart 29-1 and Table
29-1
Manifestations of Anemias
❖ Depends on the rapidity of the
development of the anemia, duration
of the anemia, metabolic requirements
of the patient, concurrent problems,
and contaminant features
❖ Fatigue, weakness, malaise
❖ Pallor or jaundice
❖ Cardiac, GI, neurologic and respiratory
symptoms
❖ Tongue changes
❖ Nail changes
❖ Angular cheilitis
❖ Pica (eating of things that are not
edible)
Question #1
What type of anemia results from red blood
cell destruction?
A. Iron deficiency
B. Hemolytic
C. Hypoproliferative
D. None of the above
Answer: B. Hemolytic
Rationale: Hemolytic anemia results from red
blood cell destruction. In hemolytic anemias,
premature destruction of erythrocytes results
in the liberation of hemoglobin from the
erythrocytes into the plasma. The bilirubin
concentration rises, and increased erythrocyte
destruction leads to tissue hypoxia, which in
turn stimulates erythropietin production,
reflected in an increased reticulocyte count.
Diagnostic Testing for Anemia
❖ Hemoglobin and hematocrit
❖ Reticulocyte count
❖ RBC indices
❖ Iron studies
❖ Vitamin B12
❖ Folate
❖ Haptoglobin and erythropoietin levels
❖ Bone marrow aspiration
Medical Management Of Anemias
❖ Correct or control the cause
❖ Transfusion of packed RBCs
❖ Treatment specific to type of anemia
➢ Dietary therapy
➢ Iron or vitamin
supplementation: iron, folate,
B12
➢ Transfusions
➢ Immunosuppresive therapy
➢ other
Hemolytic Anemias
❖ Sickle cell disease
❖ Thalassemia
❖ Glucose-6-phosphate
dehydrogenasedeficiency
❖ Immune hemolytic anemia
❖ Hereditary hemochromatosis
❖ Others (refer to Chart 29-1)
Hypoproliferative Anemias
❖ Iron deficiency anemia
❖ Anemia in renal disease
❖ Anemia of inflammation
❖ Aplastic anemia
❖ Megaloblastic anemia
➢ Folic acid deficiency
➢ Vitamin B12 deficiency
Neutropenia
❖ Decreased production or increaed
destruction of neutrophils
(<2000/mm3)
❖ Incrased risk for infection: monitor
closely
❖ Absolute neutrophil count (ANC)
❖ Medical management: tretament
depends on the cause
❖ Nursing management: patient
education, preventing and managing
complications
❖ Refer to Charts 29-5 and 29-7
Lymphopenia
❖ Lymphocyte count less than 1500/mm3
❖ Causes
➢ Exposure to radiation
➢ Long-term use of
corticosteroids
 ➢ Infections
➢ Neoplasms
➢ Alcohol abuse
Polycythemia
❖ Increased volume of RBCs
❖ Secondary polycythemia
➢ Excessive production of
erythropoietin from reduced
amounts of oxygen, cyanotic
heart disease, nonpathologic
conditions or neoplasms
❖ Medical management
➢ Treatment not needed if
condition is mild
➢ Treat underlying cause
➢ Therapeutic phlebotomy
Question #2
Is the following statement true or false?
Polycythemia is a form of anemia.
Answer: False
Rationale: Polycythemia is caused by
excessive production of erythropoietin.
Examples of conditions causing polycythemia
include smoking, obstructive sleep apnea,
chronic obstructive pulmonary disease, severe
heart disease, living at high altitudes or
exposure to low levels of carbon monoxide.
Secondary polycythemia can result from
neoplasms that stimulate erythropoietin
production.
Bleeding Disorders #1
❖ Failure of hemostatic mechanisms
❖ Causes
➢ Trauma
➢ Platelet abnormality
➢ Coagulation factor abnormality
❖ Medical management:
➢ Specific blood products
❖ Nursing management:
➢ Limit injury
➢ Assess for bleeding
➢ Bleeding precautions
Bleeding Disorders #2
❖ Secondary thrombocytosis
❖ Thrombocytopenia
❖ Immune thrombocytopenic purpura
(ITP)
❖ Platelet defects- refer to chart 29-9
❖ Hemophilia
❖ Von willebrand disease
❖ Refer to chart 29-6 and 29-8 table
Pl29-3
Assessment of the Patient with Anemia
❖ Health history and physical exam
❖ Laboratory data
❖ Presence of symptoms and impact of
those symptoms on patients life;
fatigue, weakness, malaise and pain
❖ Nutritional assessment
❖ Medications
❖ Cardiac and GI assessment
❖ Blood loss: menses, potential GI loss
❖ Neurologic assessment
Collaborative Problems and Potential
Complications of the Patient with Anemia
❖ Heart failure
❖ Angina
❖ Paresthesias
❖ Confusion
❖ Injury related to falls
❖ Depressed mood
Planning and Goals for the Patients with
Anemia
❖ Major goals include decreased fatigue,
attainment or maintenance of
adequate tissue perfusion, compliance
with prescribed therapy, and absence
of complications
Interventions for the Patient with Anemia
❖ Balance physical activities, exercise,
and rest
❖ Maintain adequate nutrition
❖ Maintain adequate perfusion
❖ Patient education to promote
compliance with medications and
nutrition
❖ Monitor VS and pulse oximetry
(95-100); provide supplemental
oxygen (1-2 L) as needed
❖ Monitor for potential complications
Assessment of the Patient with Sickle Cell
Disease (DEPRANOCYTOSIS)
❖ Health history and physical exam
❖ Pain assessment
❖ Laboratory data: S-shaped
hemoglobin
❖ Presence of symptoms and impact of
those symptoms on patients life;
swelling, fever, pain
❖ Sickle cell crisis assessment
❖ Blood loss: menses, potential GI loss
❖ Cardiovascular and neurologic
assessment
● Adequate tissue perfusion
- O2 stat
Chronic Skin Ulcers of Sickle Cell
Collaborative Problems and Potential
Complications of the Patients with Sickle
Cell Disease
❖ Hypoxia, ischemia, infection
❖ Dehydration
❖ Cerebral vascular accident (CVA)
❖ Anemia
❖ Acute and chronic kidney disease
❖ Heart failure
❖ Impotence
❖ Poor compliance
❖ Substance abuse
Interventions for the Patient with Sickle
Cell Disease
❖ Pain management
❖ Manage fatigue
❖ Infection prevention
❖ Promote coping
❖ Education of disease process
❖ Monitor of complications
❖ Refer to chart 29-4
Hemophilia
❖ Hereditary bleeding disorder caused by
a lack of coagulation factors
❖ 2 major forms of hemophilia-
hemophilia a or classic
❖ Hemophilia a: deficiency of factor
vili, most common common type,
incidence is 1 in 10,000 males
❖ Hemophilia b or Christmas disease:
deficiency of factor ix, incidence is 1
in 100,000 males
Hemophilia
❖ Early in the twentieth century, survival
was normally to 11 years, by the
1970s it rose to 68 years median
survival. Infection with HIV from factor
gathered from pools of donors
decreased the life expectancy to 49
years in the 1980s, life expectancy is
improving because of tests now
available for HIV and hepatitis, better
screening of donors, and heat
treatment of some products.
Hemophilia (Medical Management)
❖ Before 1986, HIV infections from factor
transfusion gathered from many
donors was common. Factor safety has
been increased with heat and chemical
treatment of factor concentrates, and
recombinant DNA technologies for
making factor that does not use
donors.
❖ The body can produce inhibitors to
factors vili and ix, making these
treatments less effective. One strategy
is to suppress the immune system to
show this response.
Hemophilia ( Assessment)
❖ Skin bruising or ecchymoses
❖ Neurologic manifestations such as
pain, lack of sensation in a limb,
paralysis
❖ Musculoskeletal manifestation-
such as joint swelling from bleeding
internally (hemarthrosis); may have
deformities of joints, causing mobility
problems
Hemophilia (Diagnostic Tests)
 ❖ Diagnostic tests- blood tests for
intrinsic factor vili, ix, xi, or xii
deficiency
❖ Coagulation tests: partial
thromboplastin time may be prolonged,
others may be normal because the
extrinsic system is not involved.
Hemophilia (Nursing Intervention)
❖ Assess the client history and physical,
family, or personal history excessive or
delayed bleeding from minor skin
trauma, dental extractors, or
hematuria.
❖ Acute intervention focus is to stop
bleeding.
❖ Administer coagulation factor;
concentrate on time and for long
enough time.
❖ Encourage bed rest for joint or major
muscle bleed.
❖ Administer prescribed drugs for pain.
❖ Prevent airway compromise
❖ Assess for intracranial bleeding provide
referral to genetic counseling,
psychosocial counseling, and support.
❖ Instruct the client and family regarding
prevention and early signs of bleeding,
home administration of factors, pain
management and rehabilitation
considerations.
❖ Instruct the client to wear a medic
alert bracelet, participate in noncontact
sports, and avoid injury from tools in
the home.
Von Willebrand’s Disease
❖ Hereditary bleeding disorder caused by
the deficiency of the Von Willebrand
coagulation protein (VWF) and platelet
dysfunction; most common type of
bleeding disorder (1 in 100), can range
from mild to serve
❖ Autosomal dominant; occurs in both
sexes
❖ Assessment same as hemophilia
Von Willebrand’s Disease
❖ Diagnostic tests- Bleeding time;
prolonged due to dysfuntional
platelets; reduction in factor will
❖ Medical management
Desmopressin acetate(DDAVP)-given
Intravenously or as a nasal spray
Increases factor will and VWF
concentration; decreases bleeding time
But the effect is short-live;useful to
control bleeding from a dental
procedure or surgery
❖ Nursing interventions- same as
hemophilia
Acquired Coagulation Disorders
❖ Liver disease
❖ Vitamin K deficiency
❖ Complications of anticoagulant therapy
❖ Disseminated intravascular
coagulation(DID)
❖ Thrombotic disorders
❖ Hyperhomocysteinemia
❖ Antithrombin deficiency
❖ Protein C & S deficiency
❖ Activated protein C resistance and
factor V Leiden mutation
❖ Acquired thrombophilia
❖ Malignancy
Disseminated Intravascular Coagulation
❖ Not a disease but a sign of underlying
disorder
❖ Severity is variable; may be life
threatening
❖ Triggers may include sepsis, trauma,
shock, cancer, abruptio placentae,
toxins and allergic reactions
❖ Altered hemostasis mechanism causes
massive clotting in microcirculation. As
clotting factors are consumed, bleeding
occurs. Symptoms are related to tissue
ischemia and bleeding
❖ Laboratory tests
❖ Treatment; treat underlying
cause,correct tissue ischemia, replace
fluids and electrolytes, maintain blood
pressure, replace coagulation factors ,
use heparin or LMWH
Assessment of the Patient with DIC
 ● Be aware of patients who at risk for
DIC and assess for signs and
symptoms of the condition
● Asses for signs and symptoms and
progressions of thrombia and bleeding
Collaborative Problems and Potential
Complications of the Patient with DIC
❖ Kidney injury
❖ Gangrene
❖ Pulmonary embolism or hemorrhage
❖ Acute respiratory distress syndrome
❖ Stroke
❖ infection, trauma , etc)
❖ Heparin and antithrombin III (AT III)
to prevent
❖ Treat thrombosis 3)
Epsilon-aminocaproic acid (AMICAR) to
inhibit fibrinolysis
Question number 3
Is the following statement true or false?
Disseminated intravascular coagulation is
caused by alteration of normal hemostatic
mechanisms.
Answer to Question number 3

Planning and Goals for the Patient with True

DIC
❖ Major goals may include maintenance
of hemodynamic status, maintenance
of intact skin and oral mucosa,
maintenance of fluid balance,
maintenance of tissue perfusion,
enhanced coping, and absence of
complications
Interventions for the Patient with DIC
❖ Assessment and interventions should
target potential sites of organ damage
❖ Monitor and assess carefully
❖ Avoid trauma and procedures that
increase the risk of bleeding, including
activities that would increase
Rationale; Normal hemostatic mechanisms are
altered in DIC. The inflammatory response
generated by the underlying disease initiates
the process of inflammation and coagulation
within the vasculature. Normal anticoagulation
pathways are impaired and fibrinolysis is
suppressed allowing small clots to form. As
platelets and clotting factors are consumed by
the microthrombi, coagulation falls, leading to
excessive clotting and bleeding.

Interventions for the Patient with DIC

❖ Acute DIC is a medical emergency and
the nurse should do everything
possible to facilitate procedures for
appropriate testing
❖ Ongoing assessment for external and
internal bleeding
❖ Minimize damage to tissues to prevent
new sites of bleeding
❖ Administer blood products,
cryoprecipitate, and fresh frozen
plasma promptly and safely
❖ Instruct the client about the entity of
DIC and the rationale for seemingly
paradoxical therapies.

Medical Management for the Patient with

DIC
❖ Treat underlying cause- (malignancy,

OTHER INFORMATION MENTIONED IN
THE LECTURE
● Venous Assessment
○ Pulse
○ Capillary blood refill (should
be 1-3 secs)
● Smoking promotes vasoconstriction
● Left ventricle supply oxygenated
blood
● There is hardening and narrowing
happening in intermittent
claudication
● Raynaud’s Phenomenon
○ Blood insufficiency in the
psalm and hands
○ Common in females
○ Remember Elsa from Frozen.
Where does her ice power
come from? In the hands.
● Stroke has no first aid. Once you see
early signs of stroke, immediately
bring the patient to the nearest
hospital
● Gangrene means tissue death
● The hallmark sign of PAD is
intermittent claudication
● Debridement means removal of
tissue
● Pressure ulcer medications
○ Calmoseptine for rashes or
redness; it is a
lotion/ointment
○ Mupirocin
(Bactroban/Bactifree- for
open wounds
○ Bazot powder- powerful
medication
● You can donate blood after 90 days
or 3 months
● There are 13 clotting factors
● Neutrophil increases when there is a
bacterial infection
● Liver has the capability to regenerate
● You can only donate 450mL of blood
● If BT is prohibited to patient d/t
religion, provide options such as
plasma expanders
● There are 2 types of anemia:
hypoproliferative and hemolytic
● You should take iron with vitamin c
on an empty stomach to increase
absorption. You may take it with
orange juice
● In a child, use straw when giving
iron because it can cause teeth
staining
● Other name of sickle cell disease is
drepanocytosis; there is a decrease
in globin which is responsible for a
cells shape;painful
● Goal in sickle cell disease is
adequate tissue perfusion by oxygen
supplementation
● Normal lifespan of a cell is 120 days.
But in sickle cell disease, cell last for
only 7-10 days
CLOTTING FACTORS
FACTOR I: Fibrinogen
FACTOR II: Prothrombin
FACTOR III: Tissue thromboplastin
FACTOR IV: Calcium ions
FACTOR V: Labile factor
FACTOR VII: Stable factor
FACTOR VIII: Antihemophilic factor
FACTOR IX: Christmas factor
FACTOR X: Stuart-Prower factor
FACTOR XI: Plasma thromboplastin antecedent
FACTOR XII: Hageman factor (contact factor)
FACTOR XIII: Fibrin stabilizing factor