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Flashcards in Hematological system Deck (99):
1

Bone marrow biopsy

coring out an area of bone marrow with a large-bore needle ; iliac crest ( sternum ) ; anesthesia or sedation ; apply pressure; observe ! 24 hrs - bleeding & infection; analgesic ( aspirin free) ; ice packs

2

Bence-Jones Protein

urine test; single sample or 24 hrs urine collection; positive 75 % pts with multiple myeloma + neoplasms affecting bone, blood, lymphatic system

3

Schilling's test

to determine vitamin B12 absorption ; pernicious anemia = Stage 1 abnormal + stage 2 normal ; Malabsorption = both stages abnormal ; NPO ( 8-12) - oral B12 - 1-2 hrs later IM B12 - Eat and drink + 24 hrs urine collection

4

RBC count - Men & Women

M 4.7-6.1
W 4.2-5.4

5

Reticulocyte count

immature RBCs - reflects bone marrow activity

6

Hemoglobin - M & W

M 13.5-18 gm/dL
W 12-16 gm/dL
gas carrying capacity of RBCs ; below 6 gm/dL - severe

7

Hematocrit - M & W - RBCs as %

M 40-54 %
W - 38-47 %

8

WBC differential

5000 - 10000 mm3

9

Platelet count - thrombocytes

150000-400000

10

Coombs test - Direct vs Indirect

1. Direct - used to detect antibodies that are stuck to the surface of red blood cells. These antibodies sometimes destroy red blood cells and cause anemia.
2. Indirect - looks for free-flowing antibodies against certain red blood cells. It is is most often done to determine if you may have a reaction to a blood transfusion.

11

Bilirubin

increased with hemolytic problems; reflects liver function

12

PT

11-12.5 seconds

13

aPTT

30-40 seconds ; therapeutic 1.5-2.5 x control

14

Therapeutic INR

2-3.5

15

Disseminated Intravascular Coagulation - DIC

complication of another disorder : diffuse clotting + hemorrhage
s/s: ecchymosis, petechiae, purpura fulminans

16

Triggers for DIC

1. Massive trauma
2. Shock
3. Sepsis or infection - gram negative; meningococcal
4. Acute promyelocytic leukemia
5. Metastatic cancers
6. Obstetrical emergency
7. Transfusion reaction
8. Severe liver disease

17

DIC - pathophysiology

Underlying disorder - Interleukins and TNF ( tumor necrosis factors) - Systemic activation of coagulation -
1. widespread intravascular fibrin deposition - thrombosis and organ failure
2. consumption of platelets and clotting factors - severe bleeding

18

DIC - complications

1. Renal failure
2. Gangrene
3. PE
4. Hemorrhage
5. CVA
6. ARDS
7. MODS
8. Death

19

DIC - elevated labs

1. PT/INR
2. aPTT
3. FSP ( fibrin split products ); FDP ( fibrin degradation products); D-dimer

20

DIC - decreased labs

1. Platelet count
2. Fibrinogen level

21

Fibrinogen

is a protein produced by the liver. This protein helps stop bleeding by helping blood clots to form

22

DIC: TX

1. Supportive care
2. Blood products - platelets, fresh frozen plasma, cryoprecipitate ( replace fibrinogen)
3. Heparin therapy (prevent more clots)
4. Epsilon-aminocaproic acid ( inhibitor of fibrinolysis) or Activated protein C

23

Activated protein C

enzyme that helps prevent inappropriate clot formation; its activated when it binds to healthy endothelial cells - injured ( sepsis ...) - cannot activate protein C - clots are formed

24

Leukemia - acute or chronic - myelogenous or lymphocytic

1. Increase in immature non-functional WBCs - blasts
2. Decrease in mature, healthy WBCs, RBCs and platelets
3. stem cells - bone marrow problem

25

Philadelphia chromosome - chromosome analysis

1. major feature - CML
2. hallmark ALL

26

Leukemia S/s

1. early - none
2. Fever, generalized bone pain
3. Infections, weigh loss + anorexia
4. S/s of anemia and thrombocytopenia

27

"7 plus 3" - cytosine arabinoside + daunorubicin

Tx acute leukemia - severe bone marrow suppression - induction therapy

28

TX acute leukemia -
SE - Infection + Bleeding

1. Induction
2, Consolidation - cure
3. Maintenance - 2-5 years

29

Imatinib mesylate (Gleevec) - SE

CML+ Philadelphia chromosome
SE - N/V - take with meal + large glass of water
No grapefruit juice
Muscle cramps - may need Ca
Increase risk for bleeding, diarrhea, rash, fluid retention

30

Hematopoietic Stem Cell Transplantation - Bone marrow transplant - Indications

1. for leukemia patients in remission after induction therapy that have closed matched donor
2. lymphoma
3. multiple myeloma
4. aplastic anemia
5. sickle cell disease and many solid tumors

31

Human leukocyte antigen - HLA

matched stem cells may be obtained from a family member or unrelated donor ( 1 in 5000 ).

32

Bone marrow transplant and leukemia

Additional chemo with or without whole body radiation is given ( lethal to the bone marrow ) - new cell are given - go to the marrow - if function properly - produce permanent cure
!!! Graft vs Host - immunossupresant for the rest of the life - graft attacks host ; 15 % die

33

Leukemia - Risk

1. any age
2. genetic
3. chemical agents
4. hx of chemo
5. radiation exposure

34

Chemotherapeutic agents - SE

1. hair loss
2. N/V
3. toxicities and interfere with growth of many tissues
4. myelosuppression
5. birth defects and potential sterility

35

Chemotherapy - action

destroy the cells that are rapidly dividing ( malignant) ; any other cells that are reproducing at that time - destroyed as well.

36

Antineoplastic agents

1. Alkylating - interfere with mitosis and cell division usually at any stage of the growth cycle
2. Cytotoxic - "cin-mycin" - antibiotic neoplastics - interfere with DNA and or RNA and protein synthesis
3. Antimetabolites - interfere with biosynthesis - used for solid tumors

37

Lymphoma

1. Solid tumor
2. Abnormal overgrowth of lymphocytes
3. Lymph nodes + spleen problem

38

Reed-Sternberg cells

Hodgkin's lymphoma

39

Hodgkin's lymphoma - Risk

1. young adults and those over age 50 - men
2. genetic
3. viral - Epstain-Barr virus
4. occupational toxins

40

Hodgkin's lymphoma S/s

1. Enlarged cervical lymph nodes - painless
2. fatigue, weakness, tachycardia

41

B symptoms

1. Weigh loss
2. Fever, chills
3. Night sweats
* poorer prognosis
Hodgkin's

42

Hodgkin's lymphoma TX

1. Chemotherapy - ABVD, MOPP
2. Radiation
3. Bone marrow or stem cell support

43

Malignant B or T cells in the lymph tissue

Nonhodgkin's lymphoma
1. older adults
2. aggressive and indolent

44

Nonhodgkin's lymphoma - risk and TX

1. long term immunosuppressive tx;
2. hx of tx for Hodgkin's
3. RA and HIV
TX: CHOP-R chemo ; radiation; bone marrow or stem support

45

Multiple Myeloma

1. Overgrowth of B-lymphocyte plasma cells in the bone marrow - increase
Antibodies - released into blood - increase serum protein levels - clogging blood vessels
Cytokines - increase cancer cell growth rates and destroy bone

46

Multiple Myeloma - Risk

1. Afro-american men after 40 ( 65)
2. Chemical exposure
3. Genetic and viral

47

Multiple Myeloma S/s
Pain, hydration, injury !!!

1. Slow onset
2. Bone pain - triggered by movement
3. Diffuse osteoporosis - pathological fracture
4. Hypercalcemia
5. Increased protein levels may cause renal failure
6. S/s related to anemia, thrombocytopenia + agranulocytopenia

48

Multiple Myeloma - Dx

1. X-ray - Swiss cheese
2. Bence-Jones protein in urine
3. Bone marrow biopsy

49

Multiple Myeloma - TX

1. No cure
2. Chemo, radiation
3. Corticosteroids
4. Biphosphonates - to help prevent bone loss and tx of hypercalcemia
5. Allopurinol - for increased uric acid

50

Colony stimulating factors ( biological response modifiers )

proteins that stimulate or regulate the growth, maturation, and differentiation of bone marrow stem cells; Given subcut or IV

51

Erythropoietin - Stimulating Agents - Erythropoietin ( EPO, Procrit )

glucoprotein produced by the kidney; it stimulates RBCs production in response to hypoxia
* Hgb never exceed 12 g/dl - risk for death

52

Erythropoietin ( EPO, Procrit ) - SE and AR

SE: hypertension, headache, arthralgias (joint pain), weakness, dizziness, thrombosis (clots)
AR: seizures, hyperkalemia, cerebrovasc. accident, MI.

53

Erythropoietin ( EPO, Procrit ) for ...

anemia

54

Granulocyte Colony - Stimulating Factor - Filgrastim (Neupogen)

regulates production of neutrophils within bone marrow

55

Filgrastim (Neupogen) for ...

neutropenia

56

Filgrastim (Neupogen) - SE and AR

SE: N&V, skeletal pain, alopecia, diarrhea, skin rash, anorexia, bone pain
AR: thrombocytopenia, MI

57

Granulocyte Macrophage Colony - Stimulating Factor - Sagramostim ( Leukine )

increase production and functional activity of eosinophils, macrophages, monocytes and neutrophils

58

Sagramostim ( Leukine ) - AR

AR: pleural/pericardial effusion, GI, hemorrhage, dyspnea.

59

Thrombopoietic Growth Factor - Oprelvekin ( Neumega ) - SE

platelet growth factor
Fluid retention
Cardiovascular events
with diuretics - risk for hypokalemia

60

Colony stimulating factors - nursing considerations

1. Keep vial warm
2. Bleeding
3. Admin 24 hrs after chemo
4. Monitor BP and platelet count , CBC
5. Do not shake

61

Aplastic anemia vs Pancytopenia
Risk - congenital, acquired ( radiation, meds), idiopathic

1. decrease of RBCs because of failure of the bone marrow to produce this cells
2. decrease RBCs, WBCs, platelets

62

Aplastic anemia , Pancytopenia S/s :

of anemia, infection, potential bleeding

63

Aplastic anemia , Pancytopenia Tx:

1. Blood transfusions
2. Stem cell transplant
3. Splenectomy
4. Bone marrow stimulants - biological response modifiers - colony stimulating factors

64

B12 - cobalamin

activate enzyme that move folic acid into the cell where DNA synthesis occurs ; stored in liver

65

Vitamin B12 deficiency anemia - macrocytic - types

1. Dietary or due to malabsorption - GI surgery, bowel resection, long term use of H2 ( histamine) blockers
2. Pernicious anemia - lack intrinsic factor - cant absorb B12

66

Pernicious anemia - TX

B12 IM - daily, weekly - Hb normal - for life/ 1 mo ;
Colomist - nasal spray

67

Vitamin B12 deficiency anemia S/s

1. anemia s/s
2. sore tongue, N/V, anorexia, abdominal pain
3. altered thought processes - dementia , neurological/neuromascular deficits ; gastric cancer - some are not reversible

68

Vitamin B12 - foods

meat, eggs, dairy products
* vegans - high folic acid may mask B12 deficiency.

69

Iron supplementation - ferrous sulfate 300 mg = 60 mg elemental iron ; Dose tx - 150-200 mg in 3-4 doses/daily - elemental

Absorbed from duodenum + jejunum
+ OJ or Vitamin C
1 hour before eating ( with food if upset stomach)
Straw for liquid iron - stain teeth
2-3 mo even after Hg normalizes
SE: dark black stools ! constipation
Toxic !!!

70

Iron deficiency anemia - foods

red meats, organ meats, beans + peas, fortified cereals, green leafy veggies + Vitamin C

71

Iron deficiency anemia - Risk !!!

1. Premenopausal + pregnant women
2. Children
3. Lower socioeconomic background
4. Older adults
5. Blood loss - GI

72

Koilonychia

spoon nails - chronic anemia

73

Iron deficiency anemia - S/s

1. Fatigue + activity intolerance
2. Pallor
3. Glossitis and burning of tongue, chelitis ( mouth)
4. Headache
5. Paresthesias
6. Bleeding - menstrual bleeding , melena (black tarry stool)

74

Iron deficiency anemia - Dx

1. Decreased - Hh/Hct , ferritin test ( free iron in the plasma)
2. Increased - transferrin ( transports iron ) & total iron binding capacity
Microcytic cells

75

MCV - mean corpuscular volume

average size of RBCs - normocytic, microcytic, macrocytic

76

MCHC - mean corpuscular Hgb concentration

average concentration of Hgb in RBC - normochromic ( RBCs normal color ) & hypochromic ( RBCs pale color )

77

MCH - mean corpuscular Hgb

average weight of Hgb

78

Agranulocytosis vs leukopenia vs neutropenia vs granulocytopenia

low count of neutrophils (granulocytes) vs WBC vs neutrophils (largest) vs granulocytes

79

Actual neutrophil count (ANC)- normal

greater than 2000

80

Thrombocytopenia - types (platelets live 8-10 days)

1. ITP - Immune Thrombocytopenia Purpura (platelets destroyed by spleen)
2. Heparin-Induced thrombocytopenia - most common
* severe < 20 000 - bleed spontaneously

81

Thrombocytopenia S/s

1. Bleeding
2. Petechiae, purpura, ecchymosis

82

Persantine
Plavix
Aspirin
Trental

Antiplatelets

83

Glycoprotein inhibitor; prevent platelet activation and thrombus formation with recent MI, CVA ... ; IV route; SE: dyspepsia , dizziness, pain at injection site, hypotension, bradycardia ; hematuria, tarry stools, bruising.

Abciximab (Reopro)

84

Polycythemia

Increase of RBCs - increase blood viscosity + volume

85

Primary Polycythemia Vera (PV)

cancer of RBCs - massive production of RBCs , excessive leukocyte production and excessive production of platelets - can develop acute myelogenous leukemia

86

Secondary PV

due to chronic hypoxia - COPD, chronic heart conditions, high attitudes

87

PV - pathophysiology

Increase in number of cells - abnormal RBCs - shorter life span - rapid turnover - increase amount of cell debris ( cells die) - uric acid + potassium - gout and hyperkalemia ; Oxygen-carrying capacity is impaired - hypoxia; Bleeding.

88

Plethora

ruddy (flushed) complexion - polycythemia

89

PV - S/s

1. Hypertension
2. Headache + vertigo
3. Tinnitus + visual problems
4. Plethora
5. Thrombosis
6. Hepatomegaly + splenomegaly - abdom. stomach pain
7. Pruritus , bleeding

90

PV - TX

1. Prevent/ treat hypoxia
2. Phlebotomy - 500 ml of blood 1-2/week
3. Myelosuppresive agents - Busulfan or hydroxyurea
4. maintain hydration - over - volume overload ; under - increased blood viscosity

91

PV + nutrition

encourage small, frequent meals rather than three big meals

92

Hemolytic anemia : causes

1. Trauma
2. Mechanical heart valves
3. Hemodialysis
4.Cardiopulmonary bypass
5. Toxins, infection, blood transfusion, drugs, autoimmune disorder

93

Hemolytic anemia - S/s

jaundice + renal damage

94

Hemolytic anemia - Tx

remove/limit cause; splenectomy; corticosteroids; blood transfusions

95

G6PD deficiency anemia (X-linked enzyme) black male

not anemic until a stressor causes hemolytic response - hemolytic crisis

96

G6PD deficiency anemia - stressors

1. Infection
2. Antimalarial agents
3. Nitofurantoin
4. NSAIDs
5. Fava beans (lima)
6. Moth balls

97

G6PD deficiency anemia - S/s

1. worsening of s/s of anemia
2. red, red-brown, tea colored urine
3. decreased urinary output - renal failure

98

G6PD deficiency anemia - Tx

Eliminate/treat cause
Transfusion
Hydration
Genetic counseling + newborn screening

99

ITP - idiopathic thrombocytopenia purpura - tx

Corticosteroids, splenectomy, immunosuppresive therapies, platelet transfusion