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What causes leukemia?
What happens in the marrow and lymph nodes?
What happens as a result?
- Not known; but maybe genetics or hx chemo or radiation
- too many leukocytes in bone marrow and LNs
- immature cells go into bloodstream, infiltrate and damage bone marrow, lymph, spleen, CNS, organs, everywhere
How many types of leukemia are there?
What does myelogenous mean?
- Acute: lymphocytic (ALL), Myelogenous (AML)
- Chronic (CLL), (CML)
- Myleogenous- refers to nonlymphocytic groups of WBCells, granulocytes, monocytes, platelets
Leukemia- how does the bone marrow fail?
What are they predisposed to?
- -Overcrowding of weird cells and not enough normal ones/abnormal WBC production
- -splenomegaly, lymphadenopathy, hepatomegaly, bone pain, meningeal irritation, oral lesions, bleeding, petechiae
- -Predisposed to anemia, thrombocytopenia
What are the diagnostic tests?
- WBCs- low, high or way high
- anemia, thrombocytopenia,
- biopsy of bone marrow (immature leukocytes)
- CXR- may show nodal involvement, bone and lung changes
- lymph node biopsy- immature cells in excess
Leukemia- management besides controlling sx, pain control, and emo care?
- Eradication- chemo, radiation, marrow xplant
- Prev of inf- watch for sx- neutropenic prec (leukopenia can be fatal)
- Thrombocytopenia- prev, watch for bleeding
Leukemia- what's the prognosis
in kids with chemo?
- 4-6 months
- chemo helps kids
- - ALymphocyticL 5 year survival rate 50%
- -AMyelogenousL remission can be 75%
- -CLymphocyticL is variable early stages 10-12 years, late stages 18 months
- Adults w AML, 5 year remission in 25%
What can cause coagulation disorders?
- vessel damage or inedequacy
- platelet or clotting factor malfunction
- liver disease (impairs clotting mechs)
What are clinical manifestations to assess of coagulation disorders?
itching, petechiae, epistaxis, gingival bleeding, hypovolemia, tension (and bleeding), pale, cold clammy skin, tachycardis, GI bleed, ABD pain, internal bleeding, CNS affected due to hypotension, H&P including recent trauma, exposure to tox, meds, radiation
dx/coag disorders- what tests are done?
How is it managed/interventions?
- CBC (spec platelet count, Hgb, HCT), coag profile, liver profile, BMarrow studied
- Try and treat underlying cause (med induced?), xfusion of blood or blood products, treat stuff like hypotension, prevent trauma
Thrombocytopenia- what is it?
What is ITP/Immune thrombocytopenic purpura?
low # circ platelets or a change in their function. Less than floor; 150,000 mm3
- ITP- most common cause of acquired- autoimmune.
- plts coated in antibodies, function normally. ABs make plts look foreign to spleen, macrophages destroy them
What meds can induce thrombocytopenia and how long until the plt count returns to normal?
Heparin, penicillins, aspirin, oral hypglycemics, digoxin, sulfonamides, furosemide, thiazide, NSAIDS
What tests dx thromocytopenia?
what are s/sx?
CBC (platelet), peripheral blood smear, bleeding time, bone marrow biopsy to rule out anemia
recent viral infections may cause it petechiae and bruising, bleeding risk, mucous membranes, old puncture sites, less than 5000 mm3 can cause spontaneous bleed
What are mgmt and interventions for thrombocytopenia?
ITP: IV Ig; corticosteroid and or immunosuppressants, splenectomy (80% benefit), xfusion of platelets if active bleeding (otherwise if platelets less than 20,000), plasmapheresis, be careful, limit sticks
What is Hemophilia A? What is Hemophilia B?
- 85% of H/factor 8 missing (prothrombin to thrombin)
- Factor 9 is missing (plasma protein)
Internal, external bleeding. Larger ecchymotic areas, bleeding into joint space- hallmark of the disease, knees, ankles, elbow, painful, edema, fever
Hemophilia, dx tests?
Mgmt and interventions?
coag times, abnormal PTT, check for factor 8 and 9 def
- prev bleeding, pain relief, admin of factor 8 and 9, cryoprecipitate (8), factors pooled from 1000s of donors, now engineered factors avail. No ASA or aspirin at home, transfuse prior to surgery.
- Other than HIV, prognosis good
von Willebrand's Disease
Common with? etc
- genetic, men and women
- mild factor 8 def, slow coag time. Common post partum, menorrhagia, post surg, trauma
spontaneous GI bleeds
- Cryo, FFP, Factor 8
- DDAVP-desmopressin (vasopressin) release factor 8
Disseminated Intravascular coag (DIC)
How does it cause problems?
What happens in small vessels?
What happens to clotting factors?
very bad. overstim of clotting process, xfusion reactions, shock, septicemia, desease or injury, obstetric complications
widespread clots for within them
clotting factors are depleted- bleeding, clotting, bleeding
bleeding- anywhere, dyspnea, diaphoresis, mottled extremities
elevated D-Dimer (reveals the breakdown of fibrin, degree of fibrinolysis), coag profile, platelets, factor profile
- fix underlying cause, admin blood products and factors
- maybe heparin- stops form of microemboli, inhibits thrombin act, still controversial
- protect pt from potential (even oral care)
- prognosis varies
What is it?
Review on own: clin manifestations, assessment, dx tests, mgmt, interventions, prog, drugs
inadequate tissue perfusion
dec in fluid volume shock
hypersensitivity reaction shock
sx hypovolemic shock
restlessness, anxiety, disorientation, syncope, often dec urine output,
cool and clammy skin, thready pulse + tach combined w reduced bp, cold, moist, pale, or cyanotic skin
post op shock interventions
O2, raise pt legs above h level, increase IV fl unless contra, notify anesthesia person and surgeion, provide meds as ordered, continue to assess pt and respond to interventions
- modified trendelenburg
- warm and dry
- IV fluids
- blood/blood products
- no pain meds
how often post op inc spiretrom?
Post surg, check on pt (VS) q______
No pillow under head until__________
Either position_______or at a_________
Report any _________ emesis immediately
- 4h q15, 4h q30, 4h q1h, then q4h etc
- fully conscious
- on side, 45deg angle
- red or coffee ground
Evisceration, what to do
cover wound w warm sterile moistened sterile towel. Place in fowler's pos w knees slightly flexed, reassure, tell her surg will be req, prep pt for surgery, sterile tech precedures
opioids w mixed ag and antag act
precipitating causes of dic
Hodgkin’s Disease vNon-Hodgkin’s Disease
- Untreated less than 5 years
- Stage I-II is 90% curable
- Peripheral blood studies – anemia
- Bone scan
- Increased WBC
- Abnormal ESR (Erythrocyte Sedimentation rate)
- CXR reveal a mediastinal mass
- CT scan & biopsy – organ & nodal involvement
- Bone marrow biopsy stages
- Presence of Reed-Sternberg cells!