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Ch. 20 - Hematologic Disorders
Test 2
107
Nursing
Undergraduate 4
02/09/2015

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Term
What is thrombocytopenia?
Definition
Low platelet level
Causes:
Bone marrow decreased production
Increased destruction of platelets
Increased consumption of platelets
Term
How is thrombocytopenia treated?
Definition
Management of the underlying cause
Term
At what platelet loss level can there be bleeding/petechiae?
Definition
Platelets <20,000 - 50,000
Term
What can be done for severe thrombocytopenia?
Definition
blood or platelet transfusions
Term
What is used in defense of platelet destruction that is autoimmune?
Definition
Corticosteroids
Term
Where are clotting factors mostly made?
Definition
LIVER
Term
What does a prolonged PT/INR indicate?
Definition
hepatic dysfunction
Term
Does a transfusion of FFP replace the missing clotting factors or just platelets?
Definition
Clotting factors AND platelets
Term
What can FFP transfusion replace?
Definition
Vitamin K dependent coagulation
Term
What clotting factors are created in result of an injury?
Definition
thrombin and fibrin
Term
What can coagulation defects cause?
Definition
bleeding occurs deep within (not on skin surface) causing subq or IM hematomas, hemorrhage into joints.
Term
What does PT test for?
Definition
this blood test measures how long it takes blood to clot and can be used to check for bleeding problems related to warfarin

Extrinsic pathway
Term
What does PTT test for?
Definition
measure time to clot, related to heparin
Term
What reverses coumadin?
Definition
FFP and Vitamin K
Term
What patient education is there with Coumadin?
Definition
-Take at the same time each day
-Avoid drugs/alcohol that interfere with Coumadin
-Keep a diet containing CONSISTENT vitamin K
-Schedule regular follow up visits
-Notify HCP of signs of bleeding
-Notify HCP of any upcoming surgeries
Term
How does Coumadin work cellularly?
Definition
Interferes with prothrombin production, inhibits vitamin K dependent clotting factors. Inhibits thrombin activation, without thrombin fibrinogen can’t be converted to fibrin.
Term
What does heparin do?
Definition
Prevents platelet aggregation - DOES NOT BREAK UP CLOTS.
Term
What reverses Heparin.
Definition
Protamine Sulfate
Term
What pt teaching is involved with Heparin?
Definition
Inform patients why the drug is needed
Report any bleeding
Bleeding precautions
Lab draws to monitor levels
Term
What is used as DVT/PE prophylaxis post hip surgery?
Definition
Rivaroxaban (Xarelto)
Term
What is Rivaroxaban (Xarelto)?
Definition
Factor Xa inhibitor, reduce stroke risk nonvalvular afib
Term
What does Dabigatran (Pradaxa) and Apixaban (Eliquis) do?
Definition
Reduce risk of stroke and thrombosis in patient with nonvalvular afib
Term
What factor do Dabigatran (Pradaxa) and Apixaban (Eliquis) inhibit?
Definition
Specifically inhibit factor Xa and thrombin
Term
What labs are important to monitor with the new oral anticoagulants?
Definition
Partially excreted by kidneys – monitor CrCl
Term
What reverses the NEW oral anticoagulants?
Definition
Reversal - Kcentra
Term
What is Kcentra used for?
Definition
indicated for the urgent reversal of Vitamin K antagonist
Term
What is DIC?
Definition
Disseminated Intravascular Coagulation - clots everywhere.

Massive activation of the coagulation system leading to clot formation. Usage of the clotting factors inappropriately leads to bleeding
Term
What is DIC indicative of?
Definition
Another more serious underlying disorder/disease (trauma, sepsis etc.)
Term
What lab tests are reviewed with DIC?
Definition
Low platelets
Increase in fibrinogen degradation products (FDPs) measured by increased D-Ddimer
Low serum fibrinogen
Prolonged PT, PTT
Term
What is the treatment geared towards for DIC?
Definition
aimed at correcting the underlying cause and
prevent end-organ damage due to microthrombi
Term
What generally causes death in DIC?
Definition
end-organ damage induced
by microvascular thrombosis is responsible for
most of the morbidity and mortality
Term
What are some of the treatments of DIC?
Definition
avoiding hemodilution and allowing permissive hypotension, preventing hypothermia and acidosis (affects fibrin and fibrinogen), evaluating blood component therapy
Term
What are the nursing diagnoses for DIC?
Definition
Impaired skin integrity, ineffective tissue perfusion, risk for fluid volume deficit related to bleeding
Term
What lab values would you expect to see in a patient who is in DIC?
Increased fibrinogen, increased platelets
Decreased fibrinogen, no change in platelets
Decreased fibrinogen, decreased platelets
No change in fibrinogen, decreased platelets
Definition
Decreased fibrinogen, decreased platelets
Term
When assessing a patient who has a diagnosis of thrombocytopenia, the nurse should understand that the patient may present with what sign or symptom of the disease?
Petechiae
Cherry angiomas
Alopecia
Pruritus
Definition
A. Petechiae
Rationale: Petechiae are pinpoint red or purple hemorrhagic spots on the skin that can result from low platelet levels. Alopecia (hair loss), pruritus (itching), and cherry angiomas (benign red spots on the skin surface) are not associated with thrombocytopenia
Term
Is the following statement true or false?
When providing care for a patient who has DIC, the nurse should pay particular attention to the patient’s levels of RBCs, hematocrit, and hemoglobin when reviewing laboratory results.
Definition
False
Rationale: Priority lab results for the patient with DIC are those related to coagulation, such as PT, aPTT and D-dimer.
Term
What is the teaching for people with bleeding disorders?
Definition
Assess themselves frequently for bleeding (skin, gums, nose)
Avoid contact sports
Can do fecal occult testing at home
Term
When receiving whole blood, what is the mixture?
Definition
450ml of blood and 50 ml anticoagulant
Term
When receiving PRBC, what is the mixture?
Definition
Plasma is removed, Hct 70%
Term
What is factor 8 used to treat?
Definition
hemophilia A
Term
What is IVIG used for?
Definition
concentrated IgG, prepared from plasma, used in patients at risk for recurrent bacterial infections, autoimmune disorders.
Term
What are the contraindications for autologous blood donation?
Definition
Acute infection
Chronic disease
Hgb <12.5 g/dL
Hct < 38%
Unstable angina
Acute cardiovascular or cerebrovascular disease
Term
When is a cell saver used?
Definition
Massive trauma
Vascular surgery
Orthopedic surgery
Thoracic surgery
Must be infused within 4 hours of collection
Term
What is directed donation?
Definition
Donating blood or products for a specific person's use
Term
What is autologous?
Definition
Donating your own blood for your own use usually prior to surgery
Term
What are the steps to blood transfusion?
Definition
-Patient must be typed and cross-matched before receiving blood
-When drawn blood band must match label placed on blood tube
-Blood must be double checked with another licensed provider prior to transfusion
-Monitor for transfusion reactions
Term
What are some of the risks associated with blood transfusions?
Definition
chest pain, orthostatic hypotension or tachycardia unresponsive to fluid resuscitation, or congestive heart failure.
Term
What patients have hgb transfused at 7 gm/dl?
Definition
stable patients
Term
What patients have hgb transfused at 8gm/dl?
Definition
postoperative or symptomatic
Term
What are the symptoms of Febrile nonhemolytic transfusion reaction (FNHTR)?
Definition
Increase in temperature 1.8°F
Chills/fever/muscle aches
Term
What are the symptoms of Acute hemolytic reaction?
Definition
causes usually errors in blood component labeling and patient misidentification. Chills, fever, low back pain, hypotension, hematuria, bleeding, anxiety, dyspnea, chest tightness
Term
What are the symptoms of delayed hemolytic rxn?
Definition
fever, anemia, increase bilirubin due to hemolysis of RBCs, gradual and due to a reaction to antibodies, usually mild
Term
What does an allergic rxn to a blood transfusion look like?
Definition
Hives, itching, flushing

include pruritus, urticaria, and headache, if previous reaction can be pretreated with antihistamines and corticosteriods
Term
What do you do if a patient has a blood reaction?
Definition
-Stop transfusion/notify DR
-Change IV tubing
-Treat the present symptoms (O2, fluids, epi.)
-Recheck crossmatch record with unit
Term
What do you do for a hemolytic rxn?
Definition
-Obtain 2 blood samples distal to infusion site
-Obtain first Ua test for hemoglobinuria
-Monitor fluid/electrolyte balance
-Evaluate serum calcium levels
Term
How fast can we give blood components?
Definition
PRBCs over 1-2 hours
Term
How fast is blood transfused in a non-emergent situation?
Definition
begin infusion slowly at no more than 5 ml/minute to allow for recognition of an acute adverse reaction
Term
When can the infusion rate of PRBC be increased?
Definition
After 15 minutes, the remainder of the blood can be infused to adults at a rate of 60-80 ml per hour
Term
What is the preferred time frame of a blood transfusion?
Definition
Complete the transfusion within two hours unless the patient cannot tolerate the expansion of the intravascular volume. The infusion time should not exceed 4 hours
Term
Should platelets be infused slowly?
Definition
NO!!!

Platelets, plasma and cryoprecipitate generally are transfused at a rate of 10 ml per minute. In order for a patient to receive maximum benefit platelets need to be transfused rapidly to get control of bleeding.
Term
How should platelets be stored and handled?
Definition
Platelets should be stored at room temperature no more than 5 days. Gently rotate bag to prevent clumping, use tubing with filter (not blood tubing), NOT ABO/Rh compatibility but HLA lymphocyte
Term
When is a spleenectomy done?
Definition
May be removed due to severe trauma, ITP, autoimmune hemolytic anemia
Term
What does an enlarged spleen cause?
Definition
Enlarged spleen causes excessive destruction of RBCs and thrombocytopenia
Term
What effect does spleenectomy have on circulating platelets at first?
Definition
initially a high number of plts enter the circulation
Term
What does a spleenectomy put the pt at risk for?
Definition
Infection
Term
What is therapeutic apheresis?
Definition
Blood is taken from the patient and passed through a centrifuge to remove a specific component
Term
What is Therapeutic phlebotomy?
Definition
USED IN POLYCYTHEMIA VERA!

Removal of a certain amount of blood under controlled conditions

Can lead to iron deficiency
Term
What is HIT?
Definition
Immune-mediated, occurring 4-10 days after exposure to heparin, with life-threatening thrombotic complications.
Term
What are the symptoms of HIT?
Definition
skin lesions at injection sites, or acute systemic reactions (chills, fever, chest pain, dyspnea) after an IV bolus
Term
What are the characteristics of HIT?
Definition
-A decrease in baseline platelet count of over 50%
-Venous thromboembolism (DVT, PE) are the most common complications
-Large vessel venous or arterial thrombosis with thrombocytopenia
Term
How is HIT treated?
Definition
Stop all heparin products including any heparin flushes
Draw labs, key to recognition is platelet count
Begin on alternate anticoagulation
Term
What is important to note about HIT alternative anticoagulant therapy?
Definition
-Warfarin alone can cause microthrombosis
-Give direct thrombin inhibitor (DTI)
-Argatroban and bivalirudin both
approved for use
Term
Which laboratory information will the nurse monitor to detect heparin-induced thrombocytopenia (HIT) in a patient who is receiving a continuous heparin infusion?
Prothrombin time (PT)
Erythrocyte count
Fibrinogen degradation products
Activated partial thromboplastin time (aPTT)
Definition
Activated partial thromboplastin time (aPTT)
Platelet aggregation in HIT causes neutralization of heparin, so that the aPTT time will be shorter and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.
Term
What are the causes of anemia?
Definition
Iron deficiency
Suppression of erythropoietin
Trauma
Phlebotomy
Coagulopathies
Adverse effects or reactions to meds
Hemolysis or suppression of erythropoietin
Stress induced GI bleeding
Term
What are the 3 drugs most often identified as causing drug-induced hemolytic anemia?
Definition
piperacillin, cefotetan, and ceftriaxone
Term
What drugs suppress release of erythropoietin in some patients?
Definition
angiotensin-converting enzyme inhibitors (Lisinopril)and angiotensin-receptor blockers (Losartan) (for treatment of high blood pressure), calcium channel blockers (Nifedipine), theophylline, and β-adrenergic blockers (metaprolol)
Term
What does anemia result from?
Definition
Loss of RBCs
Reduction in production of RBCs
Increased destruction of RBCs
Shorter life span of RBCs
Term
What are the strategies to conserve blood loss in phlebotomy?
Definition
Using pediatric tubes
Reduce daily blood draws
Closed loop system to return blood ordinarily wasted back to the patient
Continuous and noninvasive hemoglobin monitoring by pulse co-oximetry
Term
Why is phlebotomy a problem in ICU patients?
Definition
Diagnostic phlebotomy can result in a mean daily loss of up to 70 mL of blood per day in an ICU patient
Term
What is TRALI?
Definition
Transfusion Related Acute Lung Injury
Term
What are the risk factors for TRALI?
Definition
age, illness severity, time on cardiopulmonary bypass
Term
What signs should you monitor for with TRALI?
Definition
Monitor for signs of respiratory distress (cough, dyspnea)
Term
S/S of TRALI?
Definition
Pulmonary edema
Hypoxemia
Respiratory distress
Radiographic evidence of new bilateral pulmonary infiltrates (white lung)
Fever, tachycardia, cyanosis, hypotension, frothy sputum
Term
When can TRALI happen?
Definition
minutes to 6 hours after transfusion:
Term
What is administered in patient's with a history of TRALI?
Definition
Administer leukocyte-reduced PRBC
Term
What blood products are TRALI associated with mostly?
Definition
whole blood, PRBCs, FFP and platelets
Term
What is TACO?
Definition
Transfusion Associated Circulatory Overload
Unable to compensate for rapid or high-volume infusions of blood products
Term
Who is at risk for TACO?
Definition
CHF
Renal failure
Respiratory failure
Left ventricular dysfunction
Term
What are the S/S of TACO?
Definition
Crackles/rales, dyspnea, orthopnea, wheezing, elevated jugular venous pressure, cyanosis, tachypnea, hypertension, S3 heart sound, a rapid increase in blood pressure, and distended neck veins.
Term
What is the difference between TACO and TRALI?
Definition
HYPERTENSION = TACO
HYPOTENSION = TRALI

The pulmonary edema in TACO is cardiogenic. BNP will be elevated so you can tell the difference.
Term
How is TACO treated?
Definition
Diuretics
Term
What is TRIM?
Definition
Transfusion Related Immunomodulation

Can develop postoperative bacterial infections in additions to other nosocomial infections. WBCs may play the most important role
Term
What can you not delegate?
Definition
Planning
Assessment
Collaboration
Evaluation
Teaching

Planning such as care plans, can not delegate primary or initial assessments. Can’t delegate consults or collaboration with other departments.
Term
What is the most important clotting factor?
Definition
10A! Where the intrinsic and extrinsic pathways meet
Term
What factor do most anticoagulants effect?
Definition
Factor 10 (a)
Term
What is the intrinsic pathway's job?
Definition
amplifies cascade, when a factor is activated it has an “a” behind its number. Factor Xa turns prothrombin to thrombin
Term
What is the extrinsic pathway's job?
Definition
cascade occurs when there is tissue damage which releases tissue factor
Term
What triggers the extrinsic system?
Definition
Tissue damage
Term
What system STARTS the clotting cascade?
Definition
Extrinsic
Term
What system ENDS the clotting cascade?
Definition
Intrinsic
Term
Which pathway is a PT test associated with?
Definition
Extrinsic pathway
Term
Which pathway is a PTT test associated with?
Definition
Intrinsic pathway
Term
If DIC is suspected and your pt has a low platelet count, what test should be performed next?
Definition
Fibrinogen Degradation Products
Term
What does D-Dimer test for?
Definition
Inflammation of any kind
Term
What is the best way to raise your hematocrit?
Definition
PRBC with plasma removed
Term
When would you not give heparin?
Definition
-Allergic
-Had already had HIT(T)
Term
What causes the TRIM rxn?
Definition
BECAUSE OF LEUKOCYTES OR ANTIGENS
BLOOD GIVEN FROM MOTHER WHO HAS HAD A CHILD IS GREATER CHANCE OF RXN
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