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What are some uses for a CBC
- -physical exams
- -preop screening
- -evaulation of acute disease
- -sx of anemia or infection
What is a common anemia in older adults? What may it cause?
- -iron deficiency anemia (most often diet induced but can also be assoc. w/ chronic diseases, esp. cancers and renal failure)
- -may cause disorientation and confusion...should be evaulated if there is a mental status change
- -may also cause fatigue, weakness, tachycardia, SOB, stomatitis and glossitis
discuss age-related antibody-mediated immunity
- -total # of colony-forming b-lymphocytes and the ablility of thesecells to mature into antibody-secreting cells are diminished
- -decline in natural antibodies, decr. antibody responese to antifens, and decr in the amont of time the antibody response is maintained
What do we need to teach older adults r/t immunity?
- -get immunized, esp. flu shots and pneumococcal vaccine
- -avoid ppl w/ viral infections and receive "booster" shots (e.g. tetanus and zoster)
discuss age-related factoids r/t cell-mediated immunity
- -thymic activity decr. w/ aging and the # of circulating t-lymphocytes decr.
- -older pt's are more at risk for fungal and bacterial infections, esp. on the skin and mucous memb, in resp tract, and in GI tract
What is the job of neutrophils? what is the norm percentage?
- nonspecific ingestion and phagocytosis of microorganisms and foreign protein
What is a shift to the left? shift to the right?
-shift to the left: incr. # of immature netrophils when bone marrow has been depleted by severe infection ("band" or "stab" cells greater than 8%)
-shift to the right: incr. in # of older mature polymorphonuclear leukocytes (PMNs). indicates relative lack of blood-forming ability and is ommon w/ severe liver dx and advanced pernicious anemia
if you have leukocytosis (low white count) and left shift= worst prognosis than if you have too many WBC (bc your body is trying to "raise the baby soldiers to fight")
- Absolute Neutrophil Count: first line of defense against infection, tells us more about pt's ablility to fight infection
- -WBC x (%neutrophils + %bands) = ANC
- -any # less than 1,000 warrant neutropenic precautions!
what are eosinophils? what is the norm percentage?
- -weak phagocytic action, releases vasoactive amines during allergic reactions
- -active in allergic reactions and parasitic infections (they will be elevated in allergic rxn)
- -act under influence of adreanal cortex
What are basophils? what is the norm percentage?
-elevated in allergic response, very active in type 1 hypersensitvity, release histamine
discuss monocytes? what is the norm percentage?
- -manufactured by bone marrow
- -antigen recogintion and phagocytosis of cellular debris
- -the "clean up crew!"
- -when you see eleveated monocytes it is an indication that infection is resolving
discuss lymphocytes? what is norm percentage?
- -formed by lymphatic system and bone marrow
- -function in humoral (b-cell antibodies, b for bone marrow) and cell-mediated (t-cell) immune responses to antigens
- -active in chronic bacterial and acute viral infections
- -if lymphocytes elevated suspect viral infection
discuss platelets? what is the normal range?
- -formed from megakaryocytes (immature platelets) in bone marrow
- -prevent blood loss by sticking together, secreting chemicals, and initiating coagulation pathway
What is leukemia?
- -a group of malignant disorders involving abnormal overproduction of a specific type of WBC in the bone marrow, usually at an immature stage, which suppresses other mature WBC
- -bone marrow becomes almost totally filled w/ immature and undifferentialted leukocytes or "blast cells"...leukemic cells proliferate rapidly and have a prolonged life span
- -leukemic cells are unable to perform the functions of WBCs, impairing the body's ablility to reduce inflammation, infection, or immune response
- -bc erythrocyte and platelet-producing cells are crowded out, severe anemis, spleomegaly and bleeding results
What is Chronic Lymphocytic Leukemia, CLL?
- -CLL= overproliferation and accumulation of small abnormal mature lymphocytes in the bone marrow, peripheral blood and body tissues
- -abnormal cells are usually B-lymphocytes unable to produce adequate antibodies to produce normal immune function
- -commonly occurs in adults, avg. age 65, slow onset, often found on rotuine exam w/ lab workup
- -vague c/o weakness, malaise, possible anemia, enlarged lymph nodees spleen or liver, leukocytosis and presence of abnormal cells, bone marrow hyperplaisa
What is the tx for Chronic Lymphocytic Leukemia, CLL?
- -chemo can cause remission but doesn't cure disease
- -Fludarabine- an antimetabolite that masquerades as nutrinet so cancer goes for that instead, s/e= renal/liver
- -Rituximab- a MAB, target therapy
- -alkylating agents such as chlorambucil w/ or w/o prednisone
What is Chronic Myelogenous Leukemia, CML?
-CML= an abnormal proliferation of all of the bone marrow elements, characterized by an incr. # of granulocytes (myeloid line)
is present in most cases, which is a translocation of chromosome 22 to chrom. 9
- -accounts for 20% of all leukemias, usually found in men over 50
- -causative agents include ionizing radiation and chemical exposure (eg. they were gettin chemo for CLL then got CML)
- -survival generally 3-5 years, cuase of death is infection or hemorrhage
Discuss the 3 phases of CML
- 1) chronic- few blast cells in blood and bone marrow and may be no physical sx of leukemia
- 2) acceleration- more blast cells in bone marrow and fewer normal cells
- 3) blast crisis- more than 30% of cells in the blood or bone marrow are blast cells and may form tumors outside BM or in lymphnodes, may result in death in weeks to months
- -pt. often asymtomatic in early stages, and dx w/ rotuine labs
- -pt is in a hypermetabolic state = fatigue, wt. loss, sweating, heat intolerance, leukocytosis, spleenomegaly. Chromosomal analysis of peripheral blood or BM shows Philadelphia chromosome and elevated leukocytes
What is the CML-specific therapy?
- -imatinib mesylate (Gleevec):
- -targeted specific therapy for CML that is Philadelphis chrom. pos.
- -prevents activation of an enzyme (tyrosine kinase) needed for growth of CML cells
- -usual dose = 400 mg PO daliy
- -toxicities incl. neutropenia, thrombocytopenia, anemia, diarrhea fluid retention/edema, GI upset (take w/ meals!), and muscle cramps (Ca supplements and tonic water (quinine) may help)
-Dasitinib (Sprycel) if unresponsive to Imatinib, but 2nd line of choice d/t many drug interactions
What may be used to manage CML if bone marrow transplant is not feasible?
Interferon alpha (it boost body's immune mechanisms)
What is the purpose of BMT?
-BMT is standard tx to eradicate cancer cells and replace w/ healthy stem cells to begin normal hematopoiesis (formation of blood and componets) . It is the tx of choice to achieve complete cure
What are the 3 types of BMT?
- 1) Allogenic- (donor)- Human Leukocyte Antigen (HLA) matched, at least 4 out of 6...from sibling or donor using bone marrow harvest, peripheral stem cell phereiss or umbilical cord blood
- 2)Autologous-(self)-pt. will get chemo to wipe out bad marrow, then a colony sitmulating booster to boost stem cell count, then reinfused w/ that marrown when disease is in remission
- 3)Singenaic- from an identical twin...ideal!
What are Peripheral Blood Stem Cells, PBSC?
5-6 donations, plasma freezed then spun off, better than BM aspiration bc not as invasive and engraftment only takes 8-12 days (bone marrow takes 12-28)
Discuss the 5 phases of BMT
- 1)screening, complete physical exam and education for donor and receipent
- 2) about 1 liter of bone marrow is aspirated from client donor using multiple large bore needle sites, frozen, and stored for later use
- 3) "conditioning" for pt...lehal doses of chemo and radiation therapy are given over 4-8 days to destroy the malignant cells, the immune system and to make room in the bone marrow for new cells
- 4) transplant- aka day "0"- filtered bone marrow is thawed and infused via a central line
- 5) engraftment- infused marrow cells slowly become part of the clien'ts bone marrow, neutrophil counr incr. and normal hematopoiesis takes place
Approx how long does post-BMT recovery take?
6-12months to recover nearly normal blood cell levels
What are some complications of BMT?
- -nutritional deficiencies
- -failure to engraft...leads to death unless they have another donor
- -Graft-vs-Host disease (GVHD)- 25-50% of all clients
- -immune response of the donated bone marrow- it sees the receipent's tissue as foreign
- -T-lymphocytes in donated marrow attack liver, spleen, GI tract, leading to rashes, desquamation, diarrhea, GI bleed, liver damage
- -prevented w/ corticosteroids, and immunosuppressants
- -Vaso-occlusive disease- liver and blood vessels clot and become inflammed, sx typical of liver enlargement...jaundice, fluid retention...
-mild s/sx that resolve are ok, that means engraftment is working
When is a pt. that received chemo most at r/f infection/when is the Nadir (loweset level of counts)
7-14 days after chemotherapeutic agents
What are the major NANDAS for a pt. w/ adult leukemia?
- -risk for infection
- -altered nutrition, less than body requirements
- -risk for bleeding (postpone invasive diagnostic procedures until platelet count >50,0000)
Discuss colony stimulating factors
colony stimulating factors are biologic response modifiers that stimulate faster recovery of bone marrow after tretment-induced suppression
Disccuss Sagramostim (Leukine)
a colony stimulating factor that works on all granulocytes
Discuss Filgrastim (Neupogen)
- a colony stim. factor that works on neutrophils.
- -can cause bone pain, fever
- -discontinue if ANC >10,000...bc then you don't need it to boost neutrophils anymore!
Discuss Epoetin alfa (Epogen Procrit); Darbapoetin alfa (Aranesp)
- colony stim. factor that works on erythrocytes
- -can cause vascular access thrombosis, myalgias, arthralgias
Discuss Oprelvekin (Neumega)
- a colony stim. factor that works on platelets
- -can cause fever, rash, HA, edema
Define Hodgkins Lymphoma
- malignancies characterized by a proliferation of committed lymphocytes rather that stem cell precursors. Usually originates in a sigle lymph node or chain. Lymphoid tissue undergoes malignant transformation, initiating an inflammatory process
- -incidence higher in young adults, cure rate more than 80%
What are the s/sx of HL?...What may HL be r/t?
enlarged, painless lymph nodes, fever, malaise, night sweats, wt. loss (10% or more), pruritis
-may be r/t ionizing radiation, viral infection, autoimmune disorders, exposure to toxic chemicals
How is HL diagnosed?
- -Reed-Sternberg cell is a specific marker on lymph node bx (cell marker that differentiates it from non-hodgkins)
- -chest and abd. CT identify abnormal or enlarged lymph nodes
- -Lymphangiography (x-ray of lymph nodes afer injection of contrast medium inito lymphatic vessels) defines extent of lymph node involvement
Discuss staging of HL
- bx of distant lymphnodes, CT of thorax and abd., stafing laparotomy...how many nodes involved? one or both sides of diaphragm? Presence of constitutional s/sx?
- ...the lower the stage the better
Discuss tx for HL
radiation therapy alone in stage 1 and 2 w/o mediastinal node envolvement, if dx advance total nodal radiation possible
-single agent chemo for older adults or those who have had heavy radiation therapy w/ myelosuppression and unable to tolerate combo tx
- -combination chemotherapy: ABVD
- Adriamycin. s/e: cardiomyapathy
- Bleomycin. s/e: respiratory complications/ARDS
- Vinblastine. s/e: alopecia
- every 14 days for 4 cycles, then radiation
- -adverse rxns also: N/V
Discuss HL more
- -nursing care for drug-induced pancytopenia
- -counseling for males that irradiation of abd-pelvic region will result in sterility, possible sperm-banking prior to tx
- -possibility of secondary malignancies, like other leukemias d/t high doeses of chemo
Define multiple myelomia
- -malignant proliferation of plasma cells (which are the mature cells of the b-lymphocyte and they are ineffective
- -disrupts normal BM function and invades adjacent bone
- -plasma cells have limited ability to make antibodies
- -sx: bone pain, fractures, fatige, wt. loss, repeated infections
- -diagnosis: elevated Ca, bone x-rays, M-protein in blood sample (monoclonal protein-"m" for multiple myelomia), BM bx has myelomia cells present
- -tx is chemo and biophosphonates to incr. bone density, hydration and possibly lasix or calcitonin to reduce serum Ca
Discuss WBC transfusions
- -used for sepsis, and neutropenic infections not responsive to AB
- -can cause antibody/antigen rxns! risk often outweighs benefit
- -volume: 430 ml of plasma, give over 45-60 min, physician may need to be present
Define Autoimmune thrombocytopenia purpura (ITP), what are the s/sx and how is it diagnosed, tx?
- -total # of platelets greatly diminished, but platelet production in marrow is normal. person has antiplatelet antibody that allows platlets to be destroyed in the spleen
- -s/sx: ecchymosis, mucosal bleeding, sx of anemia if blood loss, possible neuro impaiment if brain bleed
- -DX: decr. platelet count, antiplatelet antibodies in peripheral blood, irreg. # of megakaryocytes in bone marrow, incr. MPV indicating a normal reactive BM
- -TX: immune suppressants (cortiosteroids, azathioprine), low doses of chemo alkylating agent (e.g. cyclophosphamide) and antimiotic agents (e.g. vinca alkaloids), platelet transfusions if plt. count <20,000
Discuss platelet transfusions
- -contain trace RBC and WBC, may be admin w/ a leukocyte filter
- -1 bag/10kg body weight. 1 bag will incr. platelet count 5,000-10,000
- -infuse w/ smaller filter and shorter tubing, over about 15 min for each unit (platelets are fragile)
- -single donor (200 ml) vs pooled donor (300 ml) platelets
- -Nursing assessment priorities for transfusion rxns: -hemolytic, watch for overwhelming change in VS
- -febrile, grether than 1 degree C from baseline, uaually manageable w/ tylenol
- -bacterial from contaminated blood
- -circulatory overload
- -transfusion associated graft vs host disease...a later rxn you may see skin peeling, rashes, GI sx
Discuss Thrombotic Throbocytopenic Purpura (TTP)
- -rare disorder, platelets clump together in the capillaries and too few are left in the circulation...can result in infarcts, MI, stroke
- -pt has inappropriate clottin, and failure to clot w/ trauma
- -thought to be autoimmune rxn to the endothelium of blood vessels
- -Tx: plasmapheresis, infusionof fresh frozen plasma for aggregation inhibitors, immunosuppressants, anti-platelet clumping drugs (asprin), antitumor antibiotic (plicamycin)
- -no lab marker exists to dx TTP