Summary

16.1 Anemias

• Anemia is a deficiency of red blood cells (RBCs) or hemoglobin (Hb). It impairs the blood’s oxygen-carrying capacity. Clinical signs and symptoms of anemia include fatigue, weakness, pale skin, and shortness of breath. Pathophysiology of anemia includes nutritional deficiencies, chronic diseases, genetic factors, and chronic bleeding.
• Diagnostics and laboratory values include a variety of blood tests and a physical examination to identify manifestations of the disorder and diagnose the cause. The main diagnostic is a hemogram, a detailed analysis of a blood sample that examines not only the quantity of RBCs, WBCs, and platelets but also their size and color and the percentage of iron in them.
• Nursing care for patients with anemia involves regular monitoring of vital signs and review of hematology laboratory tests. Management of symptoms includes helping the patient conserve energy effectively. Medication administration includes nutritional supplements and erythropoietin as ordered. Blood products may also be administered when necessary. Patient education is provided on diet, lifestyle modifications, and adherence to medications. Nurses also provide emotional support by providing resources and acknowledging the patient’s fatigue.
• To evaluate the effectiveness of nursing interventions, the desired goal must first be identified and then compared with the outcomes. The following are a few examples of outcomes the nurse would evaluate for a patient with anemia: assessing vital signs to determine if ranges are met, assessing the patient for continued syncope or altered consciousness, and identifying if there has been an improvement in overall symptoms.
• The medical therapies that apply to the care of the patient with anemia include medication administration, such as iron supplements. In severe cases, blood transfusions may be necessary.

16.2 Hereditary Disorders

• Pathology of hematological disorders includes genetics, and hereditary disorders such as sickle cell anemia (SCA) and thalassemia are common in ethnic and racial groups, such as the those of African, Mediterranean, Middle Eastern, or South Asian descent (sickle cell anemia) or Mediterranean, Asian, or African descent (thalassemia).
• Identification of these disorders includes specific diagnostic testing, such as bone marrow aspiration, complete blood cell (CBC) count, total bilirubin test, genetic testing, hemoglobin solubility test, hemoglobin electrophoresis, peripheral blood smear, and reticulocyte count.
• Nursing care is directed if the patient is experiencing an acute exacerbation or through prevention. Acute interventions include hydration, pain control, or, if required, transfusion. Chronic management may be medications, iron chelation therapy, or bone marrow transplantation.
• The efficacy of nursing care is measured by symptom control during an exacerbation, normalization of laboratory test results toward target goals (clinically driven), and prevention of complications.
• Medical treatments for patients with hereditary hematological disorders include medication administration, blood transfusions, and iron chelation therapy.
• Emphasize infection prevention measures like vaccinations and proper hygiene, given the greater susceptibility to infection associated with some hematologic disorders.

16.3 Polycythemia

• Polycythemia is an abnormal increase in the number of red blood cells in the bloodstream.
• The two types of polycythemias are primary polycythemia (polycythemia vera), which is caused by a gene mutation, and secondary polycythemia, which is caused by an external factor triggering an increase in EPO production.
• Clinical manifestations include headache, dizziness, fatigue, pruritus, and jaundice.
• Diagnosis is based on CBC count, genetic testing, and, in some cases, bone marrow biopsy.
• Treatment includes therapeutic phlebotomy, myelosuppressive medications, aspirin, anticoagulants, and JAK2 inhibitors.
• Lifestyle measures include smoking cessation, adequate hydration, and regular exercise and nutrition to support normal RBC production.
• Nursing actions include medication administration, patient education, identification of complications, collaborative care, and monitoring of laboratory tests.

16.4 Thrombocytopenia

• Thrombocytopenia is a hematologic disorder with the hallmark feature of decreased platelet count, which increases the risk of bleeding.
• The causes of thrombocytopenia include immune-mediated destruction, decreased platelet production, and increased consumption of platelets.
• Nursing actions for patients with thrombocytopenia include frequent monitoring of vital signs and assessing any signs of bleeding. Monitoring laboratory results of platelet counts is crucial to awareness of trends of improvement or decline.
• Patient education must include bleeding precautions, such as using a soft toothbrush, and injury prevention. Patients must be taught to notify their provider of any increase in bleeding.
• Medical treatments include corticosteroids and immunosuppressive drugs for immune-related thrombocytopenia. Intravenous immunoglobulin (IVIG) and thrombopoietin receptor agonists stimulate platelet production. Splenectomy is a last resort for chronic ITP resistant to other treatments. Platelet transfusions can be given to immediately increase platelet counts in the acute care setting. Plasmapheresis may be used to remove antibodies in HIT.

16.5 Neutropenia

• Neutropenia refers to abnormally low levels of neutrophils, a type of white blood cell that is critical to fighting bacterial and fungal infections.
• Neutropenia can be caused by chemotherapy, radiation, certain medications, bone marrow disorders, infections, autoimmune diseases, and congenital genetic mutations.
• Nursing interventions include infection prevention, assessment, and monitoring; patient education; and management of neutropenic precautions.
• Medical treatments for neutropenia include antibiotics targeting the offending pathogen, adjustment of medications that may be causing neutropenia, bone marrow stimulants, granulocyte colony-stimulating factor, bone marrow or stem cell transplantation, monitoring of laboratory test results, and overall infection control.

16.6 Thrombotic Disorder

• Two common thrombotic disorders are deep vein thrombosis (DVT) and pulmonary embolism (PE).
• A thrombotic disorder creates a blockage in a blood vessel, threatening adequate oxygen delivery to tissues.
• The pathology of thrombotic disorders includes hypoxemia and tissue hypoxia.
• Classic symptoms of DVT include redness and warmth of the affected limb, as well as pain or tenderness.
• Classic key symptoms of a PE include tachypnea, redness of sputum, difficulty breathing, especially on exertion, disorientation, and anxiety due to lack of oxygen to the brain.
• Nursing actions include completing a thorough medical history and physical exam, stabilizing breathing, notifying the provider of changes, monitoring vital signs, preparing the patient for diagnostic studies, and administering anticoagulant medications as ordered.
• Medical treatment is focused on identification of the thrombus and use of anticoagulants.

16.7 Blood Products and Transfusion Principles

• Blood typing is a necessary safety procedure because the antigen response differs among blood types.
• Examples of blood products include PRBCs, plasma, FFP, cryoprecipitate, and proteins, such as albumin, which can each be given separately depending on the patient’s specific need.
• A type and crossmatch of blood ensures the recipient of a blood donation receives the correct ABO match and as well as the least possible risk of adverse reactions.
• There could be cultural considerations that spill into the ethical and legal protections when administering blood products. Informed processes are in place to respect these.
• Nursing assessments of the patient’s tolerance of administered blood products are required before, during, and after administration and are critical to ensure the safe administration of blood.
• Blood transfusion reactions can be caused by improper handling and storage of blood products, incompatibility, contamination, and fluid overload.
• Safe transfusion is a priority in patient care.