MS2 - Quiz 8 Flashcards Preview

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Flashcards in MS2 - Quiz 8 Deck (20):

INR normal labs

11-12.5 seconds


aPTT normal labs

30-40 seconds


Hgb normal labs

14-18 g/dL (male)
12-16 g/dL (female)


Hct normal labs

42-52% (male)
37-47% (female)


WBC normal



Platelet count normal




27-31 pg



85-95 fL


Reticulocyte count



Transfusion reactions and nursing interventions

If acute reaction occurs:
1. Stop the transfusion
2. Maintain patient IV line with saline solution
3. Notify the blood bank and HCP immediately
4. Recheck identifying tags and numbers
5. Monitor vital signs and urine output
6. Treat symptoms per physician order
7. Save the blood bag and tubing and send them to the blood bank for examination


Thrombocytopenia - definition

Reduction of platelets below 150,000

Acute, severe, or prolonged decreases decreases from this normal range can result in abnormal hemostasis

Can be inherited, acquired via immune, or acquired via nonimmune means -- most are acquired (common cause of acquired is ingestion of certain herbs or drugs)


Thrombocytopenia - S/S

Manifests as prolonged bleeding from minor trauma or spontaneous bleeding without injury

Many are asymptomatic

Bleeding -
Mucosal - epistaxis or gingival bleeding; large bullous hemorrhages may appear on buccal mucosa
Into skin - petechiae, purpura, superficial ecchymoses
Prolonged bleeding after routine procedures


Thrombocytopenia - Complications

Hemorrhage - may be insidious or acute, and internal or external
May occur in any area of the body - incl joints, retina, brain (cerebral hemorrhage may be fatal)

S/S vascular ischemic problems may manifest - subtle confusion, headache, seizure, coma


Thrombocytopenia - Patient education/care

Pt education
- Pts should avoid aspirin and other meds that affect platelet function or production
- Notify HCP when having black/tarry stool, black/bloody vomit sputum or urine; bruising or small red/purple spots, headaches or changes in how well you can see
- Do not blow nose forcefully
- Do not bend down with head lower than waist
- Prevent constipation (fluids, stool softener)
- No piercings or tattoos
- Ask HCP before getting invasive procedures done (including manicure, pedicure, dental cleaning)

Care depends on etiology - removal or tx of underlying cause of disorder sometimes is enough

Acute episode - prevent or control hemorrhage

- ITP - corticosteroids -- high doses of IV immunoglobin and a component of IVIG anti-Rho (if pt does not respond to corticosteroids or splenectomy), splenectomy if does not respond to other tx - usually done lap, 60-70% have complete or partial remission
- Heparin - should be d/c immediately, pt should then be started on direct thrombin inhibitor (e.g., Refludan, Acova, Arixtra) - Warfarin should only be started when platelet count reaches 150,000. Clotting severe - plasmapheresis to clear platelet aggregating IgG from blood. Pts who have had HIT should NEVER be given heparin or low-molecular-weight heparin


Neutropenia - definition

A reduction in neutrophils

The faster the drop and longer the duration, the greater the likelihood of life-threatening infection, sepsis, or death

Can occur from drugs, hematologic disorders, autoimmune disorders, infections, or misc other reasons (such as severe sepsis, bone marrow infiltration, transfusion reaction, etc).

When WBC count is depressed - may not see signs of inflammation, pus formation

Low-grade fever is significant - may indicate infection and lead to septic shock or death if not treated promptly - neutropenic fever (>100.4) and neutrophil count of <500 is medical emergency


Neutropenia - Patient education/care

Pt education:
- Instruct pt and visitors about hand washing and how to avoid infection and to report signs of infection if they occur
- Avoid undercooked meats, uncooked fruits/vegs
- Bathe or shower daily - brush teeth w/soft toothbrush four times daily
- No gardening or cleaning up after pets
- Take temp as directed

- Monitor for s/s of infection and early septic shock
- If infection suspected: Blood cultures should be drawn STAT and antibiotics started within 1 hr
- (If febrile episode occurs - antibiotic therapy initiated immediately before determination of specific causative organism by culture) - usually broad-spectrum via IV
- Iso precuations needed?
- Assess pt for subtle signs of confusion, fatigue
- Screen visitors for infectious diseases


Blood transfusion procedure

- Blood products administered with at least 19-gauge needle, cannula, or catheter
- Verify patency before requesting blood component from blood bank
- Make positive id of donor blood and recipient - many use dual-checking system
- Take vital signs before beginning transfusion - if something like high fever seen, check with HCP before continuing
- Administer blood as soon as its brought - do not refrigerate on nursing unit
- During 1st 15 min or 50 mL, remain with patient - most likely time for reactions to occur
- Rate of infusion should be no more than 2 mL/minute
- Retake vitals after 1st 15 min - rate of infusion determined by pt condition and product being infused
- Observe pt Q30min during procedure and up to 1 HR after - transfusion should not take more than 4 hr, blood should not be unrefrigerated for more than 4 hr- after that should be returned to blood bank


Guidelines for giving blood



Bone marrow bx

- Preferred site for biopsy is posterior iliac crest (ant. iliac crest and sternum are alternative sites - sternum usually only used for aspiration)
- Performed by physician or specially credentialed nurse
- Local anesthesia and sedation may be used to minimize anxiety and pain
- Aspiration - skin cleaned with bactericidal agent
- Skin, SQ tissue, periosteum are infiltrated with local anesthetic
- After a bone marrow aspiration and biopsy, the site must be assessed frequently on the day of the procedure and for several days thereafter. Patients can experience some discomfort or pain and can require a mild analgesic.


Anemia - S/S