Nurs 209 Patho Leukemia, Anemia, Dic

Front 1

Leukemia Defined

Back 1

A group of malignant disorder affected the blood & blood-forming tissues of the bone marrow, lymph & spleen.

It results in an accumulation of dysfunctional cells b/c of a loss of regulation in cell division

Front 2

Leukemia:
Etiology/Pathophysiology

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Most leukemias result from a combination of factors, including genetic and environmental influences. Chromosomal changes,

Chemical agents, chemotherapeutic agents, viruses, radiation, and immunologic deficiencies have all been associated with the development of leukemia in susceptible hosts.

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Acute Leukemia

Back 3

characterized by the clonal proliferation of immature hematopoietic cells

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Chronic Leukemia

Back 4

more mature forms of the WBC and disease onset is more gradual

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AML
Acute Myelogenous Leukemia

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*Serious infections & abnormal bleeding from the onset of the disease.
*uncontrolled proliferation of myeloblasts, the precursors of granulocytes
*hyperplasia of bone marrow
*60-70 yrs

Front 6

ALL
Acute Lymphocytic Leukemia

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*Immature lymphocytes proliferate in the bone marrow
*B-cell origin
*S/S: fever, bleeding, weakness, fatigue, bone/joint pain, meningitis
*<14 yrs

Front 7

CML
Chronic Myelogenous Leukemia

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*excessive development of mature neoplastic granulocytes in the bone marrow which infiltrate the liver & spleen
*Philadelphia chromosome
*Chronic stable phase followed by acute phase (Blastic phase)
*25-60 yrs

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CLL
Chronic Lymphocytic Leuemia

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*pronduction & accumulation of functionally inactive but long-lived, small mature-appearing lymphocytes which infiltrate bone marrow, spleen & liver
*B cells
*S/S: lymphandenopathy, Richter's syndrome, pressure on nerves from enlarged lymph nodes: pain/paralysis
*50-70 yrs

Front 9

Hairy Cell Leukemia

Back 9

*Chronic disease of lymphoproliferation w/ B lymphocytes which infiltrates the bone marrow & spleen
*S/S: splenomegaly, pancytopenia, infection, vasculitis
* >40 yrs male

Front 10

Leukemia
Clinical Manifestations:
Problems caused by bone marrow failure

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1. bone marrow overcrowding by abnormal cells
2. inadequate production of normal marrow elements
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Pt predisposed to anemia, thromboyctopenia & decreased # & function of WBC's

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Leukemia
Diagnostic Studies

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*blood evaluation
*bone marrow examination *morphologic, histochemical, immunologic, & cytogenic) to ID subtypes
*Lumbar punction
*CT
*Chromosomal abnormalities

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Leukemia
Treatment

Back 12

Cytotoxic Chemotherapy

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Cytotoxic Chemotherapy:
Stage 1

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induction therapy:
*bring about a remission
*seeks to destroy leukemic cells in the tissues, peripheral blood & bone marrow
NI: neutorpenia, thrombocytopenia, anemia, psychosocial support

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Cytotoxic Chemotherapy:
Stage 2

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Intensification therapy:
*high dose therapy

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Cytotoxic Chemotherapy:
Stage 2
Consolidation therapy

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*started after remission
*eliminate remaining leukemic cells that may not be clinically or pathologically evident

Front 16

Cytotoxic Chemotherapy:
Stage 2
Maintenance therapy

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*lower doses of induction drugs given every 3-4 weeks
*keeps the body free of leukemic cells

Front 17

Leukemia
Combination Therapy

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1. decrease drug resistance
2. minimize drug toxicity by using multiple drugs w/ varying toxicities
3. interrupt cell growth at multiple points in cell cycle

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Hematopoietic Stem Cell Transplantation (HSCT)

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totally eliminate leukemic cells from the body using combinations of chemotherapy w/ or w/o total body irradiation

Front 19

Complications w/ HSCT

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*graft vs. host disease
*relapse of leukemia
*infection

Front 20

Leukemia Planning

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(1) understand and cooperate with the treatment plan,
(2) experience minimal side effects and complications associated with both the disease and its treatment, (3) feel hopeful and supported during the periods of treatment, relapse, or remission

Front 21

Leukemia NI

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*understand type of leukemia, prognosis & treatment plan
*assess for potential S/S of depression
*manage side effects
*know about drugs

Front 22

Leukemia Evaluation

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(1) cope effectively with diagnosis, treatment regimen, and prognosis; (2) attain and maintain adequate nutrition;
(3) experience no complications related to the disease or its treatment;
(4) feel comfortable and supported throughout treatment.

Front 23

Anemia Defined

Back 23

A deficiency in the number of RBC's, the quantity of hbg and/or the volume of packed RBC's

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Causes of Anemia

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*blood loss- GI bleed, colon cancer, trama
*impaired production of RBC's- low iron, B12, folate, erythropoietin or iron availability
*increased destruction of RBC's- sickle cell, medication, incompatible blood, trama

Front 25

Anemia
Grouped by:

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Morphologic (cellular characteristic)

Etiologic (underlying cause)

Front 26

Anemia
Decreased Erythrocyte Production
Decreased Hemoglobin Synthesis

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*Iron deficiency
*Thalassemias
*Sideroblastic anemia

Front 27

Anemia
Defective DNA Synthesis

Back 27

*Cobalamin (B12) deficiency
*Folic acid deficiency

Front 28

Anemia
Increased Erythrocyte Destruction

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*Sickle cell (abnormal hemoglobin
*G6PD (enzyme deficiency)
*Membrane abnormalities

Front 29

Anemia
Nursing Diagnosis

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*Activity Intolerance
*Altered Nutrition: < body requirements
*Ineffective management of therapeutic regimen

Front 30

Anemia
Planning

Back 30

(1) assume normal activities of daily living,
(2) maintain adequate nutrition,
(3) develop no complications related to anemia.

Front 31

Anemia
Implementation

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*Correcting the cause of the anemia
*blood product transfusions
*drug therapy/volume replacement
*O2 therapy
*dietary/lifestyle changes

Front 32

Anemia
Gerontologic S/S

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pallor, confusion, ataxia, fatigue, worsening angina, HF

Front 33

Causes of decreased RBC Production

Back 33

(1) decreased hemoglobin synthesis may lead to iron-deficiency anemia, thalassemia, and sideroblastic anemia;
(2) defective DNA synthesis in RBCs (e.g., cobalamin [vitamin B12] deficiency, folic acid deficiency) may lead to megaloblastic anemias; and
(3) diminished availability of erythrocyte precursors may result in aplastic anemia and anemia of chronic disease

Front 34

Iron Deficiency Anemia
(Decreased Erythrocyte Production)

Back 34

* very young, poor diets, reproductive women
* dietary intake, absorption, blood loss, or hemolysis
S/S: peptic ulcer, gastritis, esophagitis, diverticuli, hemorrhoids, neoplasia, menstrual bleeding, pallor, glossitis, cheilitis, headache, paresthesia, burning sensation of the tongue

Front 35

Iron Deficiency Anemia
Diagnostic Studies
(Decreased Erythrocyte Production)

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*Endoscopy, colonoscopy, bone marrow biopsy
* low: hb/Hct, MCV, reticulocytes, serum iron, transferrin, ferritin, bilirubin
* high TIBC

Front 36

Iron Deficiency Anemia
Collaborative Care/ NI
(Decreased Erythrocyte Production)

Back 36

*treat underlying disease causing low iron
*replace iron
*teach iron rich foods
*transfusion of packed RBC's

Front 37

Iron Deficiency Anemia
Info on Oral Iron Supplement
(Decreased Erythrocyte Production)

Back 37

1. absorbed best in duodenum no enteric coated
2. 150-200 mg daily
3. absorbed best as ferrous sulfate in acidic environment 1 hr before meals
4. Undiluted liquid iron could stain teeth
5. side effects: heartburn, constipation & diarrhea

Front 38

Iron Deficiency Anemia
Info on Parenteral Iron
(Decreased Erythrocyte Production)

Back 38

* IM or IV
* IM may stain the skin:
Use separate needles for drawing/admin
Z track
Should not be massaged

Front 39

Anemia: Thalassemia Defined
(Decreased Erythrocyte Production)

Back 39

A group of diseases that have an autosomal recessive genetic basis involving inadequate production of normal hemoglobin

Front 40

Anemia: Thalassemia
(Decreased Erythrocyte Production)

Back 40

absent or reduced globulin protein
Alpha or beta chains

a homozygous person has 2 thalassemic genes, causing a sever condition known as thalassemia major

Front 41

Anemia: Thalassemia
Clinical Manifestations
(Decreased Erythrocyte Production)

Back 41

Life threatening disease in which physical/mental growth is often retarded
Pale, splenomegaly, hepatomegaly, jaundice, chronic bone marrow hyperlasia, expansion of bone marrow space.

Front 42

Anemia: Thalassemia
Collaborative Care
(Decreased Erythrocyte Production)

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* no specific drug/diet therapies
* blood transfusions
* zinc supplementation
* increased incidence of Hep C
* Pulm disease & hypertension

Front 43

Megaloblastic Anemia Defined

Back 43

A group of disorders caused by impaired DNA synthesis & characterized by the presence of large RBC's
B12 or Folic Acid Deficiencies

Front 44

Cobalamin (B12) Deficiency
(Megaloblastic Anemia)

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gastric mucosa is not secreting IF b/c of antibodies being directed against the gastric parietal cells and/or IF itself
Other causes: gastrectomy, gastritis, nutritional deficiency, chronic alcoholism, hereditary enzymatic defects of cobalamin utilization

Front 45

Cobalamin (B12) Deficiency
Etiology
(Megaloblastic Anemia)

Back 45

cobalamin deficiency results from the loss of IF-secreting gastric mucosal cells or impaired absorption of cobalamin in the distal ileum.
Pernicious anemia is caused by an absence of IF, from either gastric mucosal atrophy or autoimmune destruction of parietal cellsPernicious anemia is caused by an absence of IF, from either gastric mucosal atrophy or autoimmune destruction of parietal cells.
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Front 46

Cobalamin (B12) Deficiency
Clinical Manifestations
(Megaloblastic Anemia)

Back 46

sore tongue, anorexia, n/v, abdominal pain, weakness, paresthesia of feet/hands, ataxia, muscle weakness, impaired thought processes

Front 47

Cobalamin (B12) Deficiency
Diagnostic Studies
(Megaloblastic Anemia)

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*RBC's appear large/abnormal shapes
* RBC destruction
* serum cobalamin levels reduced
*gastroscopy/biopsy of gastric mucosa
*Shilling test
* serum methylmalonic acid
* serum homocysteine

Front 48

Cobalamin (B12) Deficiency
Collaborative Care
(Megaloblastic Anemia)

Back 48

* adequate dietary intake
* parenteral/intranasal admin of cobalamin

Front 49

Folic Acid Deficiency
Causes
(Megaloblastic Anemia)

Back 49

1. poor nutrition
2. malabsorption syndromes
3. drugs that impede absorption & use of folic acid
4. alcohol abuse & anorexia
5. hemodialysis patients

Front 50

Folic Acid Deficiency
S/S
(Megaloblastic Anemia)

Back 50

dyspepsia, smooth beefy red tongue
lack of neuro involvement differentiates folate deficiency from B12 deficiency

Front 51

Folic Acid Deficiency
Management/ NI
(Megaloblastic Anemia)

Back 51

* ensure injuries are not sustained
* ensure good pt compliance w/ treatement

Front 52

Aplastic Anemia Defined

Back 52

is a disease in which the patient has peripheral blood pancytopenia (decrease of all blood cell types—RBCs, white blood cells [WBCs], and platelets) and hypocellular bone marrow.

Front 53

Aplastic Anemia
Etiology

Back 53

* Chromosomal alterations
* exposure to ionizing radiation, chemical agents, viral/bacterial infections or idiopathic

Front 54

Aplastic Anemia
Clinical Manifestations

Back 54

fatigue, dsypnea, thrombocytopenia

Front 55

Aplastic Anemia
Diagnostic Studies

Back 55

* Low: Hb/Hct, reticulocytes
* high: MCV, serum iron, TIBC
* bone marrow biopsy, aspiration, pathologic examination

Front 56

Aplastic Anemia
Collaborative

Back 56

HSCT, ATG

Front 57

HELLP

Back 57

* Hemolysis
* Elevated
* Liver Enzymes
* Low
* Platelets

Front 58

What is HELLP Syndrome

Back 58

Serious complication of preeclampsia

Front 59

HELLP Etiology

Back 59

*circulating RBCs are destroyed as they navigate thru constricted vessels
*vasospasms lower blood flow to liver
*platelets aggregate @ the site and fibrin network is setup = decrease in circulating platelets

Front 60

HELLP
Collaborative/ NI

Back 60

* transfusion of fresh-frozen plasma/ platelets
* delivery of baby
* continuous maternal-fetal monitoring
* measurement of central venous pressure
* pulmonary arterial wedge pressure
* monitor fluid status (edema)

Front 61

Neutropenia Defined

Back 61

Occurs when an absolute neutrophil count is less than 1000 microliters in infants younger than 1 year of age and 1500 micrioliters for those older than 1 year

Front 62

Neutropenia
Grade 1, 2, 3, 4

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Grade 1: < 2000
Grade 2: < 1500
Grade 3: < 1000
Grade 4: < 500

Front 63

Neutropenia
S/S

Back 63

lymphandenopathy, organomegaly, pallow, bruising, petechia, underlying infection, fever

Front 64

Neutropenia
Diagnostic Factors

Back 64

* meticulous history & physical exam
* CBC w/ differential (ANC)
* Peripheral smear
* high MCV
* normal B12

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Neutropenia
NI

Back 65

* supportive measures
* admin of colony stimulating factors
* bone marrow transplant
* admin GCSF
* monitoring for infections