Care of Clients with problems

of Tissue Perfussion

JOSEPHINE ENDERIO- CARIASO

AND
PETER JAMES ABAD
Objectives
! Identify risk factors of anemia and clotting disorders;

!Apply principles and appropriate technique in

physical assessment;

! Identify implications of diagnostic test results;

!Analyze pathohysiologic and psychosocial

implications of disease process;

! Formulates individualized nursing care plan

 STUCTURES AND FUNCTION OF
THE HEMATOLOGIC SYSTEM
! BONE MAROW – hematopoiesis (blood cell
production) occurs
yellow marrow
red marrow

▪ BLOOD:
a) TRANSPORTATION: oxygen, nutrients,
hormones and waste
b) REGULATION : fluid, electrolye.,Acid- base
balance
55%plasma; 45% blood cells
! thrombocytes- - platelets (blood
coagulation)
! Erythrocytes – RBC ( O2 transport of
gases; maitain acid-base balance )
! Leokocytes – WBC ( protection from
infection)
! Oxyhemoglobin
! Erythropoiesis- rbc production
(synthesized and released by the
kidney;affected by availability ofnutrients )
! SPLEEN :
1) hematopoietic – produces rbc during
fetal devt
2) Filter-removes old and defective
erythrocytes; reuse of iron
3) Immune – rich supply of phagocytes
and monocytes
4) Storage – 30% platelet
! LYMPH SYSTEM: returns excess
interstitial fluid to the blood

! LIVER :
1) Filter
2) Produces all procoagulants essential
to hemostasis and blood coagulation
Assessment

Nursing Health History

!Personal factors- liver function, presence of

known immunologic or hematologic disorder, drug
use, dietary patterns, and SES.

!Include occupation, hobbies, and location of

residence

Ask about drugs (ie antibiotics, blood thinners)

!
Assessment

Nursing Health History

!Personal factors- liver function, presence of

known immunologic or hematologic disorder, drug
use, dietary patterns, and SES.

!Include occupation, hobbies, and location of

residence

Ask about drugs (ie antibiotics, blood thinners)

!
Assessment
!Assess nutritional status- inc. diet, alcohol
consumption ( adequate supplies of iron , vit B12,
folic acid,protein)

!Assess family history and genetic risk (ie 3-

generation family history, use standard symbols)

!Assess current health problems- excessive bruising/

bleeding, shortness of breath, palpitations, frequent
infection, paresthesias

Assess for easy fatigability. Fatigue is the single

!

most common symptom of anemia

Assessment

Head and Neck assessment- check for

pallor or ulceration in the oral mucosa

Assess texture of the tongue

Inspect for fissures at the corners of the

mouth
Assessment
Physical Assessment

Skin assessment- inspect for pallor or jaundice

!

Assess gums for bleeding

!

Inspect for petechiae and ecchymoses

!

Assess for skin turgor

!
Assessment

Respiratory Assessment- rate, depth of

respiration while at rest and after mild
physical activity

Assess if the patient is fatigued easily

Assess for Dyspnea or orthopnea

Assessment
Cardiovascular Assessment- heaves, distended
neck veins, murmurs, gallops, irregular rhythm,
abn BP

Renal and Urinary Assessment- hematuria

Musculoskeletal- assess ROM of joints and for

swelling, joint pains, motion limitation

Abdominal assessment- palpate for the spleen,

liver, occult blood
Assessment

Central Nervous System- cranial nerve

assessment

Psychosocial assessment- ask about coping

mechanisms, social support, networks,
financial resources
!↓ No of rbc
! ↓Quantity hemoglobin
! ↓Vol Hematocrit

! ↑RBC destruction
! ↓RBC production – Thalassemia IDA
! Acute or chronic blood loss - bleeding
SICKLE CELL DISEASE
! Hemolytic anemia
! Inherited ( sickle hemoglobin gene-
Hbs gene)
! Hypoxia induced change in RBC
! Associated with vascular occlusion
and tissue infarction
! Anemia caused by accelerated
breakdown of abnormal RBC
! Geneticfactor → defective
hemoglobin ( Rigid, crystal C-shaped
configuration )→ sickled RBC adheres
to endothelium→ pile up and plug
vessesl → ischemia → pain, swelling,
fever
! Tachycardia, murmurs, cardiomegaly
! Primary sites of thrombotic occlusion:
spleen lungs, CNS
! Chest pain, dyspnea
Sickle Cell Crisis
! Due to tissue hypoxia and necrosis

! Acute Chest Syndrome

! rapidly falling hemoglobin level,
tachycardia, fever, chest infiltrates in
the CXR
NURSING DIAGNOSIS
Acute Pain r/t poor tissue oxygenation

Chronic Pain r/t joint destruction

Potential for Sepsis

Potential for Multiple Organ Dysfunction

and Death
 Interventions

Pain
 to reduce metabolic needs

support and elevbate affected
! Analgesics
! Relaxation techniques
! Support and elevate acutely affected joint
! Prevent and manage infection
! Promote coping skills
! Monitor and prevent potential complications
– avoid cold temperatures that can cause
vasoconstriction. Provide adequate
hydration
! Maintain Fluid and electrolyte balance to
reduce blood viscosity
Thalassemia
! Normal Hemoglobin has 4 globin chains
! ↓production of hemoglobin due to
abnormal hemoglobin synthesis
! Reduced production or no production of 1
of the globin chains that make up
hemoglobin
! Thalassemia Minor – 1 thalasesemic and
1 normal gene
! Thalassemia Major – 2 thalassemic genes
Assessment
! Skin:pale, jaundiced
! Splenomegaly and hepatomegaly
Nursing management
! Administer BT
! Monitor transfusions
! Instruct about treatments
! strenghten client and family support
system
G6PD Deficiency
! GLUCOSE – 6 PHOSPHATE
DEHYDROGNASE
! Lack of RBC enzyme → RBC damange
when meatbolic needs of RBC ↑
! Group of X-linked familial hemo;ytic
mutations of the genes
! Hemolysis occurs due to oxidative stress
generated by either infection or exposure
to certain drugs
! More common amomg males of
mediterranean or african descent
Assessment
! Jaundice
! Headache
! Easy fatigability
! dizziness
Nursing management
! Provideperiods of rest
! Adequate hydration
! Administer treatments and medications
Iron Deficiency Anemia
Management

Management is geared towards increasing

intake of iron from food sources.

Iron supplements

Iron solutions
Vitamin B12 Deficiency Anemia
Management
If due to dietary deficiency-
goal is to increase intake
of foods rich in Vit. B12,
supplements

If due to deficiency of
intrinsic factor- undergo
Shilling test

If positive- Vitamin B12

injections
Folic Acid Deficiency Anemia
Management

Prevention is aimed at
identifying at-risk
persons.

Management is geared
towards increasing
intake of food rich in
folic acid or folic acid
replacement therapy.
Aplastic Anemia
Management

Blood transfusion is the management.

Splenectomy may be needed in patients with

enlarged spleen.

Hematopoietic stem cell transplant.

POLYCYTHEMIA VERA
! ↑VOLUME OF RBC

! ↑HEMATOCRIT LEVEL more than

55%
! proliferative disorder where myeloid
stem cells become uncontrolled
! Neoplastic disorder where there is↑in 3
types of blood cells
! Skin is pruritic due to histamine release
! Spenomegaly in primary PN only
! Headacxhe, tinnitus
! Dizziness; blurred vision
! Angina, dyspnea
! Laboratory:
! ↑WBC and Plateletss
! RBC mass↑
Management

Phlebotomy

Increased hydration and promotion of

venous return

Aspirin therapy may be indicated.

Platelet Disorders

Autoimmune Thrombocytopenic Purpura

Thrombotic Thrombocytopenic Purpura

Management

Drug therapy

Platelet transfusions

Maintaining a safe environment

Surgical Management
Clotting Factor Disorders

Hemophilia
! Sex-linked, genetic disorder; recessive
disorder- mother carrier – genetic
deffect transmitted to 59% 0f sons and
50% daughters are carriers
! Hemophilia A _ deficiency in Factor
VIII
! Hemophilia B- ( Christmas
disease)Deficiency in factor IX
Management

Factor VIII cryoprecipitate

Transfusion Therapy
Types of Transfusions
! RBC Transfusion

! Platelet Transfusion

! Plasma Transfusion

! Cryoprecipitate Transfusion

! Granulocyte Transfusion
RBC Transfusion
Platelet Transfusion
!Given to patients with platelet count >10,000 mm^3,
with thrombocytopenia or those scheduled for
invasive procedure

!Platelets are fragile and must be infused

immediately.

! Use platelet transfusion set, not BT set.

!Take VS before transfusion, q15 mins thereafter until

completion.

! Diphenhydramine and acetaminophen- dec reaction

Plasma Transfusion
! In the form of fresh frozen plasma (FFP)

! Freezing preserves the clotting factors

! Infuse FFP immediately after thawing

!ABO compatibility is required for transfusion

of plasma products

! Infuse as rapidly as the patient can tolerate

Cryoprecipitate Transfusions
!Contains Factor VIII, XIII, von Willebrand's
factor and fibrinogen

! Usually given at a volume of 10-15 ml/unit

Usually given as IV push for 3 mins, but

!

maybe infused

!Individualized dosages and should be ABO

compatible.
Granulocyte Transfusions

!Surfaces of WBCs contain antigen that may

react with the patient (weighing of benefits)

! Strict protocol for WBC transfusions

Nursing Responsibilities
Before Infusion

!Assess laboratory values

!Verify medical order

!Assess the patient's vital signs, urine output,

skin color, and history of transfusion reactions

!Obtain venous access. Usually gauge 18-20

needle
!Obtain blood product from the blood bank.

!With another RN, verify the patient by name

and number, check blood compatibility, and

note expiration time
!Transfuse immediately
Nursing Responsibilities

During Transfusion

!Administer the blood product using the

appropriate filtered tubing
!If the blood product needs to be diluted, use

only NSS
!Remain with the patient during the first 15 to

30 minutes of the infusion

!Infused the blood product at the prescribed

rate
!Monitor vital signs
Nursing Responsibilities

After Transfusion

!When the transfusion is completed,

discontinue infusion and dispose of the bag
and tubing properly

! Document.
Transfusion Reactions

Febrile Transfusion Reactions: most often in

patients with anti-WBC antibodies.
Presents with chills, tachycardia, fever,
hypotension and tachypnea.

Hemolytic Transfusion Reactions: cause by

blood type or Rh-incompatibility. Presents
with fever, chills, or DIC. May also include
apprehension, headache, chest pain, low
back pain, tachycardia, tachypnea,
hypotension, a sense of impending doom.
Transfusion Reactions
Allergic Transfusion Reaction: usually seen in
patients with history of allergy. Presents with
urticaria, itching, bronchospasm, or
anaphylaxis.

Bacterial transfusion reaction: infusion of

contaminated blood products.

Circulatory overload: if infused too quickly.

Presents with HPN, bounding pulse,
distended jugular vein, dyspnea,
restlessness, confusion
Management of Transfusion Reactions
!Stop transfusion immediately
!Change administration set and KVO with NSS

!Give antipyretic or antihistamine if febrile or

allergic reaction is suspected. When symptoms

subside, reinfuse blood. Stop when symptoms
recur.
!Check all labels, forms, and patient

identification to determine if patient received the

correct blood unit.
!Send remaining blood with intact blood tubing

to the blood back immediately with filled-up

transfusion reaction form
Management of Transfusion Reactions

!Closely monitor patient and his/her vital

signs
!Observe color of urine especially first voided

specimen. Monitor urine output.

!Consider referral to appropriate specialties

for severe adverse reaction.

Autologous Blood Donation
!Process whereby the blood donor is also the
recipient. This is the safest blood to give to
the patient.

!Criteria: There is no age or weight limit. Hgb

should be above 110 mg/dl and Hct should
be above 33%.

! Donation can be done every 4-7 days.

Apheresis
!Technique where the donor/patient is
connected to a cell separator equipment to
remove one or more components from his/
her blood and return the remaining blood
components back to the donor/patient

!Indications: collection of cellular/blood

components (ie platelets, granulocytes, red
cells and plasma); therapeutic apheresis
 References
Ignatavicius, DD, Workman, ML. (2010). Medical-
Surgical Nursing: Patient-centered Collaborative
Care. St. Louis, Missouri: Saunders Elsevier
Lewis, Heitkemper, Dirksen (2004) 6th edition
Medical – Surgical Nursimg: Assessment and
Management of Clinical Problems
Smeltzer,S Bare, Brenda (1996). Brunner and
Suddarth’s Medical-Surgical Nursing. Lippincott

Martinez-Ona, N et al (2010). Blood Transfusion

Medicine and PGH Blood Bank. Manila: PGH
Blood Bank
 activity
! Identify1 possible nursing diagnosis
for any of the Problems discusses and
idetify possible nursing interventions