NS 3205
Study Guide for Final Exam

Chapter 42 Care of Patients with Hematologic Problems
1. Identify the etiologies and clinical manifestations common to all types of anemia. (See Table 42-1 p 870 and Chart 42-1 p 871) Common Cause
Sickle cell disease: autosomal recessive inheritance of two defective gene alleles for hemoglobin synthesis Glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia: X-linked recessive deficiency of enzyme G6PD Autoimmune hemolytic anemia: abnormal immune function in which a person’s immune reactive cells fail to recognize his or her own red blood cells as self cells Iron deficiency anemia: Inadequate iron intake caused by: iron deficient diet, chronic alcoholism, malabsorption syndromes and partial gastrecromy. Rapid metabolic (anabolic) activity caused by: pregnancy, adolescence and infection Vitamine B12 deficiency anemia: dietary deficiency, failure to absorb vitamin b12 from intestinal tract as a result of: partial gastrectomy, pernicious anemia, malabsorption syndromes Folic acide deficiency anemia: dietary deficiency, malabsorption sndromes Drugs: oral contraceptives, anticonvulsants, methotrexate Aplastic anemia: exposure to myelotoxic agents: radiation, benzene, chloramphenicol, alkylating agents, antimetabolites, sulfonamides and insecticides. Viral infection (unproven): Epstein-Barr virus, hepatitis B and cytomegalovirus. Manifestations:

Integumentary manifestation:
-pallor, especially of the ears, the nail beds, the palmar creases, the conjunctivae, and around the Mouth
- Cool to the touch
- Intolerance of cold temperatures
- Nails become brittle and may lose the normal convex shape; over time, mails become concave and figures assume clublike appearance. Cardivascular manifestations:
- Tachycardia at basal activity levels, increasing with activity and during and immediately after meals - Murmurs and gallops heard on auscultation when anemia is severe - Orthostatic hyptension

Respiratory manifestations
- Dyspnea on exertion
- Decreased oxygen saturation levels
Neurologic manifestations
- Increased somnolence and fatigue
- Headache

2. Describe the pathophysiology, etiology, clinical manifestations, and interventions for sickle cell anemia. pp 870 – 875
Pathophysiology: is a genetic disorder that results in chronic anemia, pain disability, organ damage, increased risk for infection and early death. The problem is the formation of abnormal hemoglobin chains. At least 40% of the total hemoglobin is composed of an abnormality of the beta chains, known as hemoglobin S (HbS). HbS is sensitive to changes in the O2 content of the RBC. When RBCs having large amounts of HbS are exposed to decreased O2 condition, the abnormal beta chains contract and pile together within the cell, distorting the shape of RBC. Etiology: sickle cell disease is a genetic disorder with an autosomal recessive pattern of inheritance. The formation of the beta chains of hemoglobin depends on a pair of gene alleles. A mutation in these alleles leads to the formation of HbS instead of HbA. Patient has two HbS genes alleles, one inherited from each parent, because both hemoglobin alleles are S, sickle cell disease is simtimes also abbreviated “SS”. Manifestations: Pain is the most common symptom of SCD crisis. Other manifestation vary with the site of tissue damage. Cardiovascular: high-output HF due to anemia, SOB, gatigue, murmurs at S3 heart sound, Increased jugular-venous pulsation or distention, low BP, slow capillary refill, reduced or absent pulse.

Skin: pallor, cyanosis, color changes at lips, tongue, nail bed, (all due to poor oxygenation from decreased perfusion and anemia), jaundice, sores or ulcers on the lower leg, Abdominal changes: damage to spleen and liver. Kidney and urinary changes, Musculoskeletal changes: joint damage, blood vessel occlusion in Arms and legs, Central nervous system: low grade fever, seizure or stroke Intervention: managing pain is the priority. (Concerns about substance abuse can lead to inadequate pain treatment in these patients); administering O2, pain medication, hydrate the patient with normal saline IV, remove any constrictive clothing, encourage the patient to keep extremities extended to promote venous return, do not raise the knee position of the bed, elevate the HOB no more than 30 degree, keep room temp. above 72 F (warm), avoid taking blood pressure with external cuff. Check circulation in extremities every hr. (P. 874 Chart 42-2)

Managing pain: IV analgesics, morphine and hydromorphone (Dilaudid) are givin IV on a routine scheulde or by infusion pump using PCA. Avoid IM injections because absorption is impaired due to poor perfusion.

Prevent Sepsis: infection control, prevention and early detection strategies are used to protect the patient. Frequent hand-washing. Monitor daily CBC with differential WBC count. Drug therapy.

Prevent multiple organ dysfunction: Prevent heart and lung damage is priority, prevent VOEs (vaso- occlusive episode that caused damage to the pulmonary system), and promotion of O2, hydration, transfusion with RBCs,

3. Compare and contrast the pathophysiology, etiology, clinical manifestations, and interventions for iron deficiency, vitamin B12 deficiency, and folic acid deficiency anemias. pp 876 – 878

Iron Deficiency anemia
It is the most common anemia worldwide, especially among woman, older adults and people with poor diet. Patho: the iron stores are depleted first, followed by the hemoglobin stores, as a result, RBCs are smaller and the patient has mild s/s of anemia including weakness and pallor, reduced exercise tolerance. Patient should be evaluated for abnormal bleeding especially from GI tract. S/S: Mild symptoms of anemia, including weakness, pallor, fatigue, reduced exercise tolerance and fissures at the corners of the mouth. Intervention: increasing the ...

-1 -11 -2 -21 -28 -3 -45 -48 -5 -6 -7.45 -892 000/mm 02 1 10 100 100.4 102 10mmhg 11 12 13 136 14 15 16 17 18 19 2 20 20/min 21 22 23 24 28 3 30 3205 35 36 39 4 40 42 45 48 5 50s 512 513 515 517 519 520 521 522 523 524 525 526 527 529 530 531 537 538 540 6 60s 7 7.35 72 8 810 870 871 874 875 876 878 880 885 889 892 895 897 9 90 96 abbrevi abdomin abg abnorm about24 absenc absent absorb absorpt abstain abus accid achiev acid acid-bas acidosi acquir activ actual acut addit adequ administ admit adolesc adren adult affect age age-group agent aha air airway alcohol aldosteron alert alkalosi alkyl allel allergi alon along also although ambul aminoglycosid among amount anabol anaerob analges anemia angina anim antibacteri antibiot antibodi anticonvuls antidiuret antimetabolit antivir anuria anxieti aplast appear appetit appli appoint appropri area arm around arriv arteri ask aslo assess associ assum atelectasi atherosclerosi atrial attent auscult autoantibodi autoimmun autosom av avoid b b-lymphocyt b.c b/c b12 bacteri bacteria balanc barr barrier basal base baselin basic bean beats/min becom bed beefi begin behavior benzen beta beyond beyong blacken blanch blanket bleed blister block blood bodi bone bortexomib bowel bp brain breast breath brittl brought bruis burn caffein calcul call calori cancer cannot capac capillari car cardiac cardiogen cardiovascular cardivascular care casu catecholamin catheret cathet caus cbc cell cellular center central cephalosporin chain chang chapter charcoal chart check chemic chemo chemotherapi chest chloramphenicol chronic circul circulatori classif clean client clinic close closur clot cloth clublik coagul cold collabor colloid colon/rectal color combat combin comfort common compar comparison compensatori complet complex complic compos concav concern condit confus conjunctiva conscious constrict contac contact contain content continu contracept contract contrast control convex cool copd core corner correct corticosteroid cortisol count countinu cours cover cramp creas creatinin crisi critic crohn crust crystalloid cuff cure curl current cviral cyanosi cytokin cytomegalovirus daili dairi damag danger date day dead death decreas deep deep-parti deeper defect defici degre dehydr dehydrogenas deliv depart depend deplet depress depth dermi describ destroy destruct detect determin develop devic diabet diagnos diagnosi diarrhea diastol die diet dietari differ differenti difficult dilaudid direct disabl discomfort diseas disord disrupt distent distinguish distort distribut diverticula divid divis dna donor dose drainag drench dress dri drug due duski dysfunct dyspnea dysrhythmia ear earli easier easili edema effect egg ekg electr electrolyt elev emerg emot encourag end enhanc enough ensur enter entir environ environment enzym epidermi episod epstein epstein-barr equip eschar especi establish estim etiolog evalu even everi exact exam examin excess exercis exert experienc explain explan explos expos exposur extend extens extern extra extra-nod extrem f face factor fail failur fascia faster fat fatigu feel feet femal ferrous fever fewer fibril figur final find fire first fissur flame flat flow fluid folic follow follow-up food form format fractur frequent full full-thick fume function fungal g6pd gallop garment gastrecromi gastrectomi gastrointestin gatigu gene general genet gi given givin glossiti glucos go good grade graft gram gram-neg greas great greater green group growth guid guidelin gum ha half hand hand-wash happi hard hba hbs hco3 head head-to-to headach heal health healthi heard heart heat heighest help hematolog hematopoiesi hemoglobin hemolyt hemorrhag hepat herp hf hg high high-output hint hip hob hodgkin hogkin home hormon hose hospit hospital-acquir hot hour hous hr hrs human hx hydrat hydromorphon hyper hyper-metabol hyperglycemia hyperparathyroid hypocalcemia hypoplasia hypovolem hypoxia hyptens ice ideal identifi ileus im imag imbal immatur immedi immun immunolog immunomodul immunosuppress impair import improv inadequ incis includ increas increment indic indoor induc induct industri infarct infect inflamm inflammatori inform infus ingest inhal inherit initi inject injur injuri injuruesl insecticid insert instead insuffici insulin intak integumentari intens interpret interstiti intervent intestin intoler intra intra-or intraderm intrins invers involv ioniz iron irradi irrit itp iv ivf jaundic joint jugular jugular-ven keep kidney knee know known lactic larg laryng last late lead leafi least leather leav left leg lenalidomid less lethal leukem leukemia leukemia/lymphoma leukopenia level lical life life-threaten lighten like limit line link lip liquid littl liver local longer look lose loss lost low low-intens lower lung lymph lymphocyt lymphoid lymphoma macrolid made mail main maintain major make malabsorpt male manag mani manifest map marrow match materi matur may mayb meal mean measur meat mechan medic medical/nursing men menstrual mental meq/l meta metabol method methotrex mg/dl mi middl midlin mild minim minor minut mm mmhg mobil moder moist moistur monitor monoclon morphin mouth move movement much mucosa multipl murmur muscl musculoskelet must mutat myeloma myelotox myocardi nail narrow nasal need negat nerv nervous neurolog new nhl night nine nitroglycerin nodal node non non-hodgkin non-palp non-progress non-vit normal nose noseble note notifi novel npo ns number nurs nut nutrit o2 object obstruct obtain obvious occlus occur often old older one onset open oper oral organ orthostat output overestim overgrowth overproduc overt oxgen oxgen-car oxygen p pac pac02 pack paco2 pacu pad pain painless pair pallor palmar palpabl paralyt parent paresthesia part partial partial-thick particl patenc patent patho patholog pathophysiolog patient pattern pca penicillin peopl per perform perfus period peristalsi perman pernici person ph pharyng phase phosphat physic pigment pile pink place plasma platelet pneumonia poor posit possibl posterior postop pp preburn precursor pregnanc prematur prepar present pressur prevent previous primari priorit prioriti problem process produc product progress prolong promot proper prophylaxi prostat prosthet protect protein provid pruritus psycholog psychosoci pts ptsd pulmonari puls pulsat pump purg purs pursed-lip q question quinolon radiat radioact rais raisin rapid rate rational rbc rbcs reabsorpt reach reactiv receiv recess recogn recoveri rectal recurr red reduc reduct reed reed-sternberg refil refractori regimen regrow regular rehabilit relief remain remiss remobil remov reperfus replac repopul requir resect respir respiratori respons rest restless restor result resuscit return revers revlimid rich right rise risk room routin rr rule s/s s3 safe safeti salin satur save say scar scd scheuld seat secret secur see segment seizur self self-imag self-manag sensat sensit sepsi septic serious serosanguin serum sever sexual shallow shape shift shock short sickl sign similar simtim sinus site situat skelet skin slight slough slow slowli small smaller smoke smooth sndrome sob sodium sometim somnol soon sore sound sourc space span specif spleen splenectomi splint spread ss st stabl stage stale standard start status steam stem step steril sternberg steroid stimul store strategi stress stressor stroke studi sublingu subsid substanc success sudden suffici sulfat sulfonamid superfici superficial-parti superficial-thick superh supplement suppli support sure surfac surgeri surgic suspect sustain sutur sweat swollen sympathet symptom syndrom synthesi system systol t-cell tabl tablet tachycardia take taken talk tapeworm tar tbsa teach team ted teen tell temp temperatur temporari temporarili tend tendenc tendon test tetanus thatn therapi thick third third-degre thirst though threaten thrombocytopenia thrombolyt thrombophleb thyroid time tissu toe togeth toilet toler tongu total totl touch toxic toxoid trace track tract transfus transplant trauma trauma-induc treatabl treatment trigger tumor two type ulcer un un-measur uncertain unconsci uncontrol under undergo unexplain unhealthi unknown unproven unstabl upper urin urinari use usual v.s vancomycin vari vascular vaso veget venous ventil ventricular vessel viral virus vital vitamin vitm voe voic volum wake walker warm wash wave wbc wbcs weak weight whisper white widespread within without woman women worldwid wors would wound x x-link year yeast yolk young