RBCs

WBCs

Platelets

• Certian conditions like kideny disease or medical tx like chemotherapy can cause hemotological failure, in which inadequate cells are produced.

• When adequate blood cells are not produced (RBSs,WBCs, platelets)
• Can happen with kidney disease, or medical treatments like chemotherary
• Body cannot meet O2 demands, coagulate blood and/or fight infection, depending on which cells are low

• Condition where not enough O2 is delivered to tissues
• There are many cuases of anemia, all ultimately affecting the RBC and it's ability to carry oxygen 
• Sometimes bc low hemoglobin
• Can result from blood loss, excess RBC destruction, inadequate RBC production, nutrient deficiencies

Low neutrophil count

Neutrophils are major line of defense

Low neutrophils mean less abililty to fight infection

Can be caused by chemotherapy or even cancer itself

Chemo induced major reason chemo is delayed or discontinued

Treated with CSF drug to promote WBC production

low platelet count

treated by operlvekin

1.        filgrastim (Neupogen)

2.        pegfilgrastim (Neulasta)

3.         sargramostin (Leukine) 

                                                               i.      Treats neutropenia

                                                              ii.      glycoproteins that act on blood cells to simulate proliferation, differentiation, maturation of WBCs.

                                                            iii.      Used to prevent infection when chemo-induced neutropenia

                                                            iv.      Bone marrow transplant (BMT) neutropenia

                                                             v.      Production of stem cells for harverst before BMT

                                                            vi.      Neutropenia in those susceptible to chronic infection

                                                          vii.      fligrastim and pegfilgrastim are used between chemo treatments

                                                         viii.      sargramostim used after BMT, leukemia induction chemo and to stim stem cells for harvest

1.        Bone pain

2.        hypertension

3.        N/V

4.        Alopecia

5.        Hypersensitivity/allergic rxn

Colony Stimulating Factors

Promote WBC proliferation

Used to treat neutropenia

                                                               i.      hypersensivity not only to drug but components of drug

                                                              ii.      Still being studied for use in kids

                                                               i.      hypothyroidism

                                                              ii.      preg cat C and lactation

                                                            iii.      Pegfilgrastin can cause sickle cell crisis in those with disease

                                                            iv.      Hypersensitivity reactinos treated with antihistamines, steroid and bronchodilators to maintain use

                                                             v.      Can actually stimulate cancer cell growth in those tumors that respond to growth factors

                                                               i.      With lithium, can increase neutrophils even higher

Neumega

stimulates thrombopoiesis to prevent and treat low platelet counts

Decreases need for platelet transfusions

Used furing chemo induced thrombocytopenia

                                                               i.      General

1.        fluid retention/peripheral edema

2.        dypnea

3.        sncope

4.        fever

5.        allergic reactions

                                                              ii.      Cardiovascular

1.        Tachycardis

2.        palpations

3.        a fib

4.        arrythmias resulting in stroke and pulm edema

5.        capillary leak syndrome

                                                               i.      pts on chemo that is extremely myelosuppresive

                                                              ii.      lactation

                                                            iii.      safety in children not established

                                                            iv.      If caused an anaphylactic-like reaction in pt

                                                               i.      renal failure

                                                              ii.      heart failure

                                                            iii.      atrial arrythmias

                                                            iv.      preg cat C

                                                               i.      with ifosfamide given for cancer chemo à severe hypoklemia

lack of secretion by gastric mucosa of intrinsic factor needed for formation of RBCs and B12 absorption

Must be dxed and txed ASAP bc if goes more than 3 months may result in degenerative lesions of spinal cord

·         used to stimulate/regulate productions of erythrocytes; are glycoproteins

·         Chronic kidney disease (CKD) reduces kidney production of erythropoietin to stim RBC production

·         Cancer treatments reduce bone marrows ability to produce RBCs

·         Includes:

1.        epoein alfa (Epogen, Procrit)

2.        darbepoetin alfa (Aranesp)

3.        methocy polyethylene (epoeitin beta) (Mircera)

epoitin alfa

darbepoitin alfa

methoxy polyethylene- epoitin beta

erythropoiesis stimulating agents

• epoitin alfa (Epogen, Procrit)
• darbepoeitin alfa (Aranesp)
• methoxy polyethylene - epoitin beta (Micera)

                                                               i.      like natural erythropoietin to stim ERYTHROPOIESIS

                                                              ii.      Used for

1.        chronic kidney disease (CKD)

2.        chemotherapy

3.        zidovudine (AZT) therapy for HIV

4.        postsurg blood replacement in place of allogenic transfusions

5.        decrease need for blood transfusions

                                                               i.      Well tolerated when used to maintain hemoglobin no higher than 12g/dL

                                                              ii.      Hypertension

                                                            iii.      Headache

                                                            iv.      N/V, diarrhea

                                                             v.      Rashes

                                                            vi.      Fatigue

                                                          vii.      Athralgia

                                                         viii.      Skin reaction at injection site

                                                               i.      uncontrolled hypertension

                                                              ii.      those needing emergency transfusions

                                                            iii.      hypersensitivity to human albumin

                                                            iv.      darbepoeitin contraindicated in those allergic to drug

Polycythemia may develop (too many RBCs) if not closely monitored and can cause death, CV or thromboembolitic events, or cancer progression

1.        hypertension

2.        heart disease

3.        HF

4.        hx seizures

5.        pregnancy and lactation preg cat C

Very common

50% pregnant women

20% all women

Deficiency from reduced RBCs from menstruation, poor absorption or lack of iron in diet

ferrous

iron dextra

iron sucrose

sodium ferric gluconate complex

                                                               i.      elevates iron to replenich hemoglobin and depleted iron stores

                                                              ii.      Usually oral, and absorpbed best on empty stomach

                                                            iii.      Needed during pregnancy and lactation bc diet is rarely sufficient

Parenteral is given when cannot take oral or GI intolerance

                                                               i.      GI

1.        GI irritation

2.        N/V

3.        C/D

4.        Dark/black stool

                                                              ii.      General

1.        Headache

2.        Backache

3.        Allegic reactions

                                                            iii.      When given parenterally IM, can cause soreness, inflam, sterile abcesses at IM site; may discolor skin brown

                                                            iv.      IV admin may cuase phlebitis at injection site

                                                               i.      hemochromatsis

                                                              ii.      hemolytic anemia

                                                               i.      hypersensitivity to aspirin bc these pts may be sensitive to tartrazine or sulfite content in some iron preparations

                                                              ii.      Parenteral only given when oral is contraindicated

                                                               i.      antibiotics à decreased absorb antibiotic

                                                              ii.      levothyroxine for hypothyroidism à decreased absorb levothyroxine

                                                            iii.      levodopa, methyldopa à decreased effect of antiparkinson’s meds

                                                            iv.      ascorbic acid (vit C) à increases absorption of iron

folic acid

leucovorin (Wellcovorin)

a.         

                                                               i.      treats megaloblastic anemias caused by low folic acid

                                                              ii.      decresased risk for neural tube defects if taken before pregnancy and beginning of pregnancy

1.        anencephaly

2.        spina bifida

3.        menigocele

                                                            iii.      Oral supplements first choice; if unable, can use leucovorin which is a derivative of folic acid (I assue leucovorin is parenteral then

                                                            iv.      Leucovorin is more commonly used to diminish hemotological effects of methotrexate (cancer treatment); it “rescues”noraml cells from destruction caused by methotrexate

1.        method of admin leucovoring with methotrexate called FOLINIC ACID RESCUE or LEUCOVORIN RESCUE

                                                               i.      few

                                                              ii.      rarely parenteral admin may cause allergic reaction

                                                               i.      pernicious anemia or other anemias where vit B12 is deficient

                                                               i.      Even though recommended for pregnancy, still use cautiously and within guidelines .4mg/day during pregnanct and .26mg/day lactation

                                                               i.      with sulfasalazine à increased floate deficiency signs

                                                              ii.      with hydantoins for seizure à increased seizure activity

vitimin B12

essential for cell reproduction, growth, manufacture of myelin and blood cells

                 produced by stomach cells needed for absorption of vit B12 in intestine
Intrinsic factor deficiency results in abnormally formed erythrocytes; this is called MACROCYTIC ANEMIA

                                                               i.      B12 deficiencies from

1.        veganism

2.        gastrectomy or gastric resectino

3.        intestinal diseases like uncerative colitis or sprue

4.        gastric cancer

5.        congenital decrease in gastric cells that secrete intrinsic factor

6.        Used to perform the Schilling Test, which is used to diagnose pernicious anemia

                                                              ii.      NURSING ALERT – pernicious anemia must be dxed and txed ASAP bc if goes more than 3 months may result in degenerative lesions of spinal cord

                                                            iii.      Dietary cause of low B12 is rare bc in meat, dairy, eggs and body stores it

                                                               i.      mild diarrhea

                                                              ii.      itching

                                                            iii.      marked increase in RBC production

                                                            iv.      acne

                                                             v.      peripheral vascular thrombosis

                                                            vi.      HF

                                                          vii.      pulmonary edema

                                                               i.      those allergic to B12

                                                               i.      Preg cat A oral, and preg cat C parenterally

                                                              ii.      pulmonary disease

                                                            iii.      anemia

                                                               i.      alcohol à decreases absorption oral B12

                                                              ii.      neomycin à decreased absorption oral B12

                                                            iii.      colchicine à decreased absorption oral B12

                                                               i.      Health hx

                                                              ii.      sxs anemia, bleeding or infections

                                                            iii.      Review labs, can indicate severeity, type, cause; for cancer tx blood counts used to titrate doses

                                                            iv.      Vital signs for baseline

                                                             v.      General appearance, ADLs; fatigue, SOB, sore tongue, headache, pallor

                                                            vi.      Allergy hx for admin of iron dextran bc given w caution significatn allergues or asthma; also for dectran need weight and hmglbn level to calc dose

                                                               i.      vitals daily; more if very ill

                                                              ii.      Monitor adverse reaction and report to PCP before next dose due; immediately report severe reactions

                                                            iii.      Assess for relief of sxs (less fatigue, SOB, sore tongue,headache, pallor, etc);some pts days

                                                            iv.      Review  ongoing labs

                                                             v.      monitor for signs bleeding, infections with CSFs first few days bc takes a while to increase blood counts

                                                            vi.      For oral iron, inform of stool color changes

                                                          vii.      If diarrhea of constipation, notify PCP

                                                         viii.      If parenteral iron dextran, inform of soreness at site and check sites daily for inflam, swelling, abcess formation

                                                               i.       

1.        if pt has HTN, monitor BP closely.  Report any rise 20mmHg or more in sys or dias to PCP

2.        Hematocrit usually checked before each dose given

3.        Is given 3Xweek IV or subcut

4.        If pt on dialysis, is given in venous access line

5.        Mix gently, do not over agitate, can denature glycoprotein

6.        Unused of dose, discard

7.        NURSING ALERT – report any increase of hematocrit of 4 points within 2 wekk period, bc worsening HTN assoc with increases hematocrit; to decrease hematocrit, epoetin alfa does is decreased or d/ced

1.        Preferably given bt meals with water, by may cannot tolerate and may need food

2.        Milk and antacids interfere with absorption, do not take with these things

3.        If taking other drugs, check with pharm about this

4.        Iron dextran given IM or IV; before, a small test dose is given to monitor for allergic reaction for at least 1 hour

a.        epinephrine must be near incase of severe anaphylactic reaction

5.        NURSING ALERT – parenteral iron may result in fatal anaphylactic reaction, so resport any of these:

a.        dyspnea

b.       urticaria

c.        rashes

d.       itching

e.        fever

6.        After test, give IM buttocks using Z-track to prevent leakage; using a “larege-bore needle”

1.        given IM weekly; parenteral bc ineffective orally (bc no intrinsic factor in stomach)

2.        Once stable, monthly injections may be needed for life

3.        Also available intranasal for maintenance therapy

M/M

Fatigue rt dilutional anemia caused by fluid retention from admin of CSF

1.        CSF drugs may cause fluid retention

2.        Explaint to pt cause of fatigue and teach energy-saving skills

M/M 

Imbalanced nutrition: Less than body requirements rt lack of iron, folic acid, B12 in diet

1.        Recommend balanced diet emphasizing foods high in iron, folic acid or B12; if vegetarian, may need dietician to provide menus

2.        Monitor food intake, if poor, consult dietician maybe

3.        Can have smaller portions more frew

4.        Provide pleasant atmosphere and give ample time to eat

5.        Discuss problem with PCP

1.        instruct to increase fluid to 10-12 glasses a day, high fiber, exercise

2.        Notify if persists, may need stool-softener

                                                               i.      admined up to 3 times a week, and may need many labs; go to appointments

                                                              ii.      strict compliance with HTN regimen needed during ep alfa

                                                            iii.      May experience dizziness, headache ,fatigue, joint pain, N/V or diarrhea; report these reactions

                                                            iv.      Leikine was temp w/drawn bc reports of fainting.  If pt heard this, explain the formula has changes and is now safe

                                                             v.      If injecting at home, dispose of needle properly

a.         

                                                               i.      take with water on empty stomach; can take with food if can’t tolerate

                                                              ii.      Do not take with antacids, tetracyclines, penicillamine or fluroquinolones (2 hours before or after iron) without PCP approval

                                                            iii.      May cause consipation and dark stool; can even cause diarrhea; if these things severe, contact PCP

                                                            iv.      Mix liquid iron with juice and use straw to prevent teeth staining

                                                             v.      If have true iron deficieny, don’t self-treat without PCP, must understand cause and therapy should be under consult of PCP

                                                            vi.      Periodic tests willl determine effectiveness of iron therapy

                                                               i.      avoid multivitamin preparations unless approved

                                                              ii.      follow diet recommended bc need drug and diet to correct deficiency

                                                               i.      For megaloblastic anemia, adhere to diet prescribed

                                                              ii.      May require high protein consumption and can be expensive, talk to PCP about this (why?)

                                                               i.      for a nutriotional deficiency, fix diet – eat meat, seafood, eggs, dairy (theses are all non-vegan)

                                                              ii.      For pernicious anemia – may req lifetime therapy.  Eat diet high in above, avoid infections and report signs of infection to PCP bc may need higher dose

                                                            iii.      Adhere to tx reg and keep all appointments

                                                            iv.      Will probably be given monthly for life (once at maintenance)

                                                             v.      sometimes can self-admin by parenteral or intranasal and instruction needed