Nursing Implications of the Hematological System
Review of A&P:
Hematological System: Relating to blood or to hematology (the study of blood and blood-forming organs). Components of the blood are:
Red Blood Cells (RBCs): Erythropoiesis (RBC production) is primarily a function of the bone marrow and as part of the normal aging process decreases with age. The main function of RBCs is to transport oxygen carrying hemoglobin. They also are involved in transporting carbon dioxide (in the form of sodium bicarbonate) and serve as an acid-base buffer for whole blood. It is estimated that the life span of an RBC is 120 days and RBC destruction occurs at the same rate as RBC production. Normal lab values for RBCs range from 4.2-5.4 million/mm3 in men and 3.6-5.0 million/mm3 in women. Red cell indices measure the size and hemoglobin content of the RBCs and are diagnostic in determining the type of anemia. The RBC indices are MCH (mean red cell hemoglobin), MCHC (mean red cell hemoglobin concentration), and MCV (mean red cell volume).
Platelets are found in circulating blood and in the spleen. The life span of a platelet is approximately 10 days. The major function of platelets is to maintain hemostasis and coagulation (a series of reactions that lead to the formation of a platelet and clot where there is damage or injury). Platelets also release thromboplastin which is necessary for the conversion of prothrombin to thrombin, the first step in the coagulation mechanism. A normal platelet count ranges from 150,000-400,000 mm3.
The following are the main screening test used to diagnose suspected coagulation disorders:
General signs and symptoms associated with disorders of the hematological system include pallor of the skin, tachycardia, tachypnea, history of palpitations, fatigue/weakness, SOB, dyspnea, night cramps, headache, dizziness, bleeding, bruising, recurrent infections, jaundice, and irritability.
Specific symptoms include:
· Brittle spoon like nails, smooth/sore tongue; iron deficiency anemia (IDA)
· Craving for unusual substances such as clay or starch; IDA
· Cheilosis (cracks in the corners of the mouth), proprioception (difficulty identifying one’s position in space); vitamin B12 deficiency anemia
· Plethora (ruddy, red color of the face, hands, feet and mucous membranes); polycythemia
· RBC sickling (RBCs become crescent shaped); sickle cell anemia
Nursing Diagnosis: common nursing diagnosis associated with hematological disorders includes:
· Activity Intolerance related to weakness and malaise
· Acute Blood Loss related to decreased platelets
· Fatigue related to disease process
· Hypoxemia related to decreased hemoglobin
· Imbalanced Nutrition: Less than Body Requirements related to poor nutritional intake
· Impaired Oral Mucous Membranes related to low platelet count, treatment of disease
· Ineffective Protection related to decreased platelets, immunosuppression
· Pain related to affects of altered blood flow in distal extremities
· Risk for Infection related to immunosuppression
· Risk for Injury related to low platelet count
Nursing Interventions: Nursing care will include on-going assessment of color, peripheral pulses, capillary refill, lab values and VS. Care planning should address measures to prevent injury and/or infection; following standard precautions, no IM/rectal medications if platelets are low, limiting visitation for neutropenic patients, use of soft bristle toothbrush and electric razors. Other strategies will include transfusion support (if need) and administration of prescribed medication. Frequently patients with hematological disorders are prescribed various medications to assist in managing the disease and its symptoms. Medication management is an important role of the nurse and includes monitoring for side effects, teaching side effects, being familiar with the prescribed medications and their interactions with other drugs, administration, and lab values affected by medications administered (i.e.: growth factors to increase neutrophil count, platelet count, and erythropoiesis).
For patients that are anemic, nursing considerations will focus on specific dietary needs, energy conservation and administration of vitamin B12 supplements (IDA). Nurses can provide information on sources of iron; meat, green leafy vegetables, beans, molasses, and raisins. Measures for maintaining oral health include avoiding alcohol based mouthwashes (drying to the mouth), lubricating lips, rinsing mouth with saline or saltwater frequently, and encourage avoidance of foods that are irritating to the oral cavity (spicy, acidic, hot).
The nursing goals for the patient experiencing a sickle cell crisis will focus on oxygenation, assessment and management of pain, administration of blood, fluids (oral, IV), and monitoring for complications such as thrombosis, CVA, renal dysfunction, priapism, acute chest syndrome (fever, chest pain, cough and dyspnea). Patient teaching will include prevention strategies to avoid a sickle cell crisis and will include adequate hydration, avoiding high altitudes, cold, overexertion, and reducing stress.