OXYGENATION

CARDIOVASCULAR AND
HEMATOLOGIC SYSTEM
By:

Maximin A. Pomperada, RN, MAN

 TERMINOLOGIES
VENTILATION – MOVEMENT OF AIR IN & OUT OF THE
LUNGS

RESPIRATION – EXCHANGE OF GASES : EXTERNAL &

INTERNAL

EXTERNAL – BET. ALVEOLI & PULMONARY CAPILLARIES

INTERNAL – BET. SYSTEMIC CAPILLARIES

PERFUSION – AVAILABILITY & MOVEMENT OF CAPILLARY

BLOOD FOR EXCHANGE OF GASES
 CASE STUDY
 You are the Emergency Room nurse

 A patient came in, 48 y.o.,dyspneic, with

the following vital signs : T= 38C, RR=50,
CR=105, BP=160/110 mmHg
 CASE STUDY
 You noted that the patient is jaundiced,
with bipedal edema, and prefer to sit than
lie down.

 What is your immediate nursing action

even without the doctor’s order?
 CASE STUDY
 What nursing history would you ask ?

 What other nursing assessment would you

do?

 What is your plan for the patient?

 CARDIOVASCULAR SYSTEM
• Review of Anatomy & Physiology
• Assessment : History and Physical
Assessment
• Diagnostics
• Planning
 REVIEW OF ANATOMY AND
PHYSIOLOGY- Heart
 Structures

 Blood Supply – LCA, RCA, veins

 Conductive System –Sino-atrial node

AV node Bundle of His Bundle
branch Purkinje fibers
 HEART
LUNGS

RA LA

RV LV

SYSTEMIC
SYSTEMIC
SYSTEMIC
CIRCULATION
CIRCULATION
CIRCULATION
CONDUCTION PATHWAY

- SA NODE

RA LA
AV NODE-

BUNDLE OF HIS
PURKINJE
RV BUNDLE
BRANCH
LV
PURKINJE
 REVIEW OF ANATOMY AND
PHYSIOLOGY- Heart
 Nervous System Control

– SYMPATHETIC

– PARASYMPATHETIC
 REVIEW OF ANATOMY AND
PHYSIOLOGY- Heart
 Properties of the Heart:
– All or None Principle
– Rhythmicity
– Excitability
– Refractoriness
– Conductivity
– Automaticity
– Extensibility
 REVIEW OF ANATOMY AND
PHYSIOLOGY- Heart
STROKE VOLUME (SV) - amount of blood pumped
out with each contraction
HEART RATE (HR)
CARDIAC OUTPUT (CO)– volume of blood pumped
out per minute
=SV x HR
PRELOAD
AFTERLOAD
 REVIEW OF ANATOMY AND
PHYSIOLOGY – Blood Vessels

 Arteries
 Microcirculation Layers of the Blood
 Veins Vessels:
 Flow Regulation  Intima
– Pressure gradient  Media
– Flow resistance  Adventitia
 Role of Blood vessels
 REVIEW OF ANATOMY AND
PHYSIOLOGY
CIRCULATION
 SYSTEMIC

 PULMONARY

 PORTAL
 PULMONARY CIRCULATION

LUNGS

RA LA

RV LV

SYSTEMIC
SYSTEMIC
SYSTEMIC
CIRCULATION
CIRCULATION
CIRCULATION
 SYSTEMIC CIRCULATION
LUNGS

RA LA

RV LV

SYSTEMIC
SYSTEMIC
SYSTEMIC
CIRCULATION
CIRCULATION
CIRCULATION
HISTORY AND PHYSICAL EXAM
 Check for:
– dyspnea, – abdominal pain and
– jaundice, discomfort,
– edema, – clubbing of fingers,
– hemoptysis, chest pain,
– fatigue, – palpitations
– syncope and
fainting,
– cyanosis,
HISTORY AND PHYSICAL EXAM
 Heart –I P P A  Heart Sounds
– aortic area,  S1- AV valve
closure
– pulmonic area,
 S2 semilunar v.
– tricuspid, closure
– mitral  S3 vent. Gallop
 S4 atrial gallop
 Murmurs
 rubs
HISTORY AND PHYSICAL EXAM
 Blood vessels
– Inspection
 color:pallor, rubor, cyanosis
 circulation of extremities
– Palpation
 edema, pulses
– Auscultation
 bruit
 Diagnostic Assessment
 NonInvasive
 ECG
 Chest Xray

 Dynamic ECG Stress Test

 Radionuclide Studies
 Treadmill Vector
 Venography
 Cardiogram
 UTZ – DOPPLER
 Phonocardiogram
 Pletysmography
 Echocardiogram
 Diagnostic Assessment
Invasive
 Lymphogram
 Cardiac
Catheterization  Bone Marrow
Aspiration:
 Arteriogram – Sternum
– iliac crest
 Angiocardiogram – tibia (infants)

 Venogram
 Diagnostic Assessment
 Blood and Urine
Studies
– lipid profile
– CBC
– serum enzymes:
– Hematocrit
SGOT, SGPT, LDH,
– Clotting time CPK
– PT – VMA
– PTT – Renin Test
– APTT – Schilling’s Test
– ESR
HEMODYNAMICS MONITORING
CVP n= 6 -12 cm water
– Measures:
 cardiac efficiency,
 bld volume,
 peripheral resistance,
 right ventricular pressure
– 0-pt be at mid axillary line, 5 cm below the
sternum
– dc ventilator with reading
– = fluid overload, = hypovolemia
HEMODYNAMICS MONITORING
 Pulmonary
Artery and Pulmonary
Wedge Pressure
– Swan Ganz catheter :
– floated at the right heart,
– measures left side of the heart

 Intraarterial Blood Pressure :

– Radial Artery,
– Allen’s Test
 Planning for Health Promotion

Modification of High Risk Factors

Promotion of Circulation

Prevention of Infection
 syphillis,
 staph, strep,
 german measles
Genetic counselling

Role of nutrition
 Modification of High Risk
Factors
dyslipedemia stress

hypertension glucose
intolerance,
smoking
 alcohol abuse
sedentary
lifestyle caffeine

obesity pollution
 Planning for Health
Maintenance & Restoration
– Basic Life Support
– Advanced Life Support

– Client With Cardiac Surgery:

 Closed Heart surgery
 Open Heart Surgery
 Heart Transpant
Closed Heart surgery
– valvutomy

– mitral commisurotomy
 Open Heart surgery (CABG)
COMPLICATIONS :
 DYSRHYTHMIAS  BLEEDING

 THROMBOSIS AND  WOUND INFECTION

PULMONARY
EMBOLISM  RENAL FAILURE

 CARDIOGENIC  ELECTROLYTE
SHOCK IMBALANCE

 POST-OP PSYCHOSIS
 HEART TRANSPLANT
CRITERIA
1. End Stage of Disease
2. Freedom from Chronic Disease
3. Family Support
4. Age < 50 yo
5. No psychological problem

IMPORTANT
1. Immunosuppressant & Steroids – 4 hrs prior
2. Donor-Recipient Compatibility – size, crossmatching
3. Donor Heart – saline solution 4C up to 4 hrs
CARDIOVASCULAR DISTURBANCES
 CORONARY / ISCHEMIC HEART DISEASE
– Arteriosclerotic Heart Disease
– Angina Pectoris
– Coronary Insufficiency
– Myocardial Infarction
 CONGESTIVE HEART FAILURE
 HYPERTENSION
 PERIPHERAL VASCULAR DISEASE
 DISORDERS OF THE BLOOD
 ARTERIOSCLEROTIC HEART DISEASE

Plaque formation and internal thickening

(intima)

Fibrosis and calcification (media)

Narrowing and constriction of coronary arteries

S/sx of ISCHEMIA
 ANGINA PECTORIS

1. STABLE
2. UNSTABLE
3. PRINZMETAL – coronary artery spasm
4. NOCTURNAL
5. DECUBITUS
 ISCHEMIA VS INFARCTION
ISCHEMIA INFARCTION

PAIN SUBSTERNAL SUBSTERNAL

PRESSURE/ HEAVINESS CONSTRICTIVE (+ SX
SQUEEZING OF SHOCK)

DURATION 3-5 MIN > 5 MIN

PRECIPITANTS STRESS/ EXERTION NO

REST RELIEVED NOT RELIEVED

NITROGLYCERINE

CARDIAC TISSUE NO PERMANENT PERMANENT

DAMAGE
 ANGINA PECTORIS
DIAGNOSIS:
Nitro Test 0.4mg

NURSING GOALS:

1. O2 to myocardium

2. O2 demand

3. Prevent future episodes of angina

 O2 to Myocardium:
 Antiplatelets  Nitrates :
RAPID-ACTING :
 Calcium Blockers Nitroglycerine
Nitrostat
AmylNitrate
 Beta blockers
LONG-ACTING:
 Whisky/Brandy ISDN,ISMN,
Nitroglycerine
ointment,
Transdermal,
IV
 O2 Demand

 Limit activities – CBR

 Moderate Exercise

 Sedatives

 Warmth
 Prevent Future Episodes
 DIET – low calorie, low saturated fat

 No tobacco

 Stress Reduction (Anger Management)

 Coronary Insufficiency

IMBALANCE BETWEEN :

 OXYGEN SUPPLY

 OXYGEN DEMAND
 MYOCARDIAL INFARCTION
IRREVERSIBLE CARDIAC DAMAGE FROM OCCLUSION OF 1 OR
MORE CORONARY ARTERY

 REVIEW OF ANATOMY AND PHYSIOLOGY

E.C.G.
Recent M.I. – ST elevation (injury)
T wave inversion (ischemia)
Previous M.I. – Q wave (necrosis / old infarct)

BLOOD STUDIES
Troponin T & I
LDH
CPK MB
 R

P Q T

E.C.G.
 R ST SEGMENT
ELEVATION

S
P Q T

E.C.G.
 R
INVERTED
T - WAVE

T
P Q

E.C.G.
 R Q wave

P T

E.C.G.
 MYOCARDIAL INFARCTION
NURSING CARE
6. No ice or very hot
1. Pain relief – drinks
Morphine ( + 7. Anticoagulants
preload & afterload) 8. ECG and CVP
Demerol causes vomiting monitoring
2. Oxygen 9. Laxatives – Lactulose
3. Inotropics 10. PTCA
4. Beta Blockers 11. Thrombolytic Therapy
BEFORE CELLULAR
5. Antiarrhythmics DEATH, US. 6 HRS AFTER
THE ATTACK
 CARDIAC ARRHYTHMIA
 Review Conduction Pathway

 Review the Basics of Normal ECG

CONDUCTION PATHWAY

- SA NODE

RA LA
AV NODE-

BUNDLE OF HIS
PURKINJE
RV BUNDLE
BRANCH
LV
PURKINJE
 R

P Q T

E.C.G.
 CARDIAC ARRHYTHMIA
 Sinus Tachycardia – P wave precede each QRS
>100 bpm

 Sinus Bradycardia – P wave precede each QRS

<60 bpm

 Atrial Fibrillation: P wave = f waves; QRS = normal

 R

P Q T

E.C.G.
CONDUCTION PATHWAY

- SA NODE

RA LA
AV NODE-

BUNDLE OF HIS
PURKINJE
RV BUNDLE
BRANCH
LV
PURKINJE
 CARDIAC ARRHYTHMIA
 Premature Ventricular Contraction: P wave
normal: early QRS

 Ventricular Tachycardia : 3 or more PVCs

 Asystole – no cardiac activity

 R

P Q T

E.C.G.
CONDUCTION PATHWAY

- SA NODE

RA LA
AV NODE-

BUNDLE OF HIS
PURKINJE
RV BUNDLE
BRANCH
LV
PURKINJE
 CARDIAC ARRHYTHMIA
 Nursing Management
– Oxygen
– Complete Bed Rest
– Cardioversion/ defibrillation
– Administer antiarrhythmics as prescribed:
 Atropine
 Beta blocker- propanolol
 Lidocaine
 Epinephrine
 CONGESTIVE HEART FAILURE
 Review of Anatomy and Physiology
 Backward Failure
 Forward Failure
 Left-Sided
 Right Sided
 Hypermetabolic Failure
 Clinical Manifestations according to:
– Tissue Anoxia
– Pulmonary Hypertension
– Systemic congestion
 C.H.F.
LUNGS
LUNGS

RA LA

RV LVLV

SYSTEMIC
SYSTEMIC
SYSTEMIC
CIRCULATION
CIRCULATION
CIRCULATION
 CONGESTIVE HEART FAILURE
 Review of Anatomy and Physiology
 Backward Failure
 Forward Failure
 Left-Sided
 Right Sided
 Hypermetabolic Failure
 Clinical Manifestations according to:
– Tissue Anoxia
– Pulmonary Hypertension
– Systemic congestion
 CONGESTIVE HEART FAILURE
 Diagnostics
 Nursing Management
– Goals :
1. CARDIAC LOAD
– REST AND SEDATION
2. CARDIAC CONTRACTILITY
– CHRONOTROPICS – DIGITALIS
– Increase in force of contraction
– monitor serum K,
– C/I if HR </= 60 bpm,
– DIGITALIS TOXICITY
 CONGESTIVE HEART FAILURE
3. SODIUM REABSORPTION AND FLUID
RETENTION

-DIURETICS ( Thiazide, Loop, K-sparing)

-measure UO
-weigh patient
-watch for s/sx of electrolyte imbalance
-DIET : Sodium Restricted (0.5gm/day)
 CONGESTIVE HEART FAILURE
4. PREVENTION OF COMPLICATIONS:
– Intractable HF
– Pulmonary edema
– Pulmonary Infarction
– Myocardial Infarction
– Digitalis Toxicity
– Cardiac Arrhythmia
– Pneumonia
 PULMONARY EDEMA
 Emergency!
 Fluid into the alveoli, bronchi & bronchioles

S/SX:
 …of CHF
 Dyspnea
 Cough with pink frothy sputum
 PULMONARY EDEMA
 MANAGEMENT:
– Oxygenation

– Assist in Intubation

– Rotating tourniquet

– Phlebotomy

– CVP monitoring
 HYPERTENSION
 IN SYSTOLIC PRESSURE >140
 IN DIASTOLIC PRESSURE > 90

 CLASSIFICATION :
– PRIMARY
 BENIGN- GRADUAL
 MALIGNANT -ABRUPT ONSET ;SHORT COURSE

– SECONDARY: Renal patho, Adrenal patho, Genetics

 HYPERTENSION
CATEGORY SBP mmHg DBP mmHg

Normal <120 and <180

PreHPN 120-139 or 80-89

HPN, Stage 1 140-159 or 90-99

HPN, Stage 2 >=160 or >=100

 HYPERTENSION
 Assess for Major CVD Risk Factors
 Assess for Identifiable Causes of Hypertension:
– Sleep apnea
– Drug-Induced related
– Chronic Kidney Disease
– Primary Aldosteronism
– Renovascular Disease
– Cushing’s Syndrome/steroid Therapy
– Pheochromocytoma
– Coarctation of the Aorta
 HYPERTENSION
 Diagnostics
 Nursing Care :
– Teach about: modification of Lifestyle, diet,
avoidance of stimulants and coffee

– Administer meds as prescribed:

ANTIHYPERTENSIVES AND DIURETICS

– Hypertensive Crisis : DIAZOXIDE (Hyperstat),

NaNITROPRUSSIDE (Nipride)
 PERIPHERAL VASCULAR DISEASE
ISCHEMIA OF THE PERIPHERAL VESSELS
 Review of Peripheral Vascular Structures
 Signs and Symptoms of Ischemia
– Coldness
– Pallor
– Rubor
– Cyanosis
– Pain ( Intermittent Claudication)
 ISCHEMIA OF THE PERIPHERAL
VESSELS
 Nursing Management
1. Increase Arterial Blood Flow or Venous
return

2. Promote Vasodilation

3. Prevent and Treat Vascular Occlusion

Increase Arterial Blood Flow or
Venous return
Proper positioning

Exercise
 Short walks
 Buerger Allen Routine
 Oscillating Bed
 Circoelectric Bed
 Buerger Allen Routine
1. FEET UP , 3 MIN

2. SIT ON BED & DO FOOT EXERCISE,3 MIN

3. LIE DOWN 5 MIN

Increase Arterial Blood Flow or
Venous return
Patient education

 Decrease wieght

 Avoid prolonged standing

 Never wear constricting garments

 Never cross legs

 Promote Vasodilation
– Warmth

– No nicotine

– Vasodilators : papaverine HCl, vasodilan

– Moderate alcohol

– sympathectomy
Prevent and Treat Vascular
Occlusion
- avoid prolonged bedrest

-increase fluids

-proper positions

-anticoagulant therapy & fibrinolytics

Heparin - APTT- Protamine SO4
Dicumarol- PT - Vit K
 ARTERIAL DISEASE
 ARTERIOSCLEROSIS OBLITERANS –
LATE STAGE OF ATHEROSCLEROSIS WITH PARTIAL OR COMPLETE
OCCLUSION BY ATHEROMA WITH THROMBOSIS

 RAYNAUD’S DISEASE – PERIODIC SPASM OF THE

ARTERIES

 ANEURYSMS – LOCALIZED OR DIFFUSED ARTERIAL

DILATION

 EMBOLUS/THROMBUS
 VENOUS DISEASE
 THROMBOPHLEBITIS –
– INFLAMMATION OF THE VEIN WITH CLOT FORMATION
– HOMAN’S SIGN

 PHLEBOTHROMBOSIS
– CLOTS WITHOUT INFLAMMATION

 VARICOSE VEINS
– TRENDELENBERG’S TEST – NORMAL VEIN FILLS FROM BELOW
 DISEASE OF ARTERIES AND
VEINS
 BUERGER’S DSE / Thromboangitis
Obliterans
– RECURRING INFLAMMATION OF ARTERIES & VEINS
– SMOKING
– INTERMITTENT CLAUDICATION

 A-V FISTULA
– ABN COMMUNICATION BETWEEN A. & V.
– TRAUMATIC/ CONGENITAL
– BRUIT
 NURSING CARE OF PATIENTS
WITH AMPUTATION
1. Control Bleeding – Bandage
2. Prevent Edema – elevate 1st 24 hrs
3. Relieving Phantom Limb Pain – hypnosis,
destruction
4. Assume Body Alignment – Prone 30 min
2x a day to prevent flexion contracture ;
AKA –HIP FLEXION AND ABDUCTION, EXTERNAL ROTATION
BKA – KNEE FLEXION
 NURSING CARE OF PATIENTS
WITH AMPUTATION
 Trochanter roll against the hip along the
outer side to prevent outward rotation

5. Preparing for Locomotion

– Stump care : wash with soap and water only
– Exercise : quad setting, isometric
– Crutch walking : weight- palms, stairs :
GOOD LEG FIRST TO HEAVEN; BAD LEG FIRST TO HELL
 The acute nursing management of a
client with CHF will include all of the
following goals except:

a. Increase in cardiac output

b. Elevation in renal blood flow
c. Reduction in the heart’s workload
d. Decrease in myocardial contractility
 REVIEW OF ANATOMY AND
PHYSIOLOGY – Blood and
Lymphatics
 Composition of the blood
 RBC, WBC, Platelets, Plasma
 RBC
 normal erythropoeisis requires : pyridoxine, Vit B12,
folic acid, protein, copper, cobalt;
 HEMOBGLOBIN : Iron; Oxygen transport; Acid-base
buffer
 WBC
 granulocytes –neutrophils, eosinophils, basophils
 agaranulocytes –lymphocytes (T,B), monocytes
 Plasma
 albumin, water, clotting factors, antibodies
 REVIEW OF ANATOMY AND
PHYSIOLOGY – Blood and Lymphatics
 Role of the Bone Marrow
– Production of all blood components
 Major Roles of the Blood
– homeostasis
– transport of nutrients and electrolytes
– distribute hormones and electrolytes
 Major Role of Lymphatics
– brings back blood to the circulation
– immune antibody production
HEMATOLOGIC DISTURBANCES
 DISORDERS OF THE BLOOD
– RBC :IDA, PERNICIOUS ANEMIA, APLASTIC ANEMIA,
HEMOLYTIC ANEMIA, POLYCYTHEMIA VERA
– WBC and Plasma Cell : LEUKEMIA, MULTIPLE MYELOMA
– Lymph Nodes and Spleen : LYMPHOMA, INFECTIOUS
MONONUCLEOSIS, SPLENIC RUPTURE, HYPERSPLENISM
– Hemorrhagic Disorders : PURPURA
– Altered Coagulation : HEMOPHILIA,
HYPOPROTHROMBINEMIA, D.I.C.
HEMATOLOGIC DISTURBANCES
RBC :
 IDA
 PERNICIOUS ANEMIA
 APLASTIC ANEMIA
 HEMOLYTIC ANEMIA
 POLYCYTHEMIA VERA
 NUTRITIONAL ANEMIA

 IRON DEFICIENCY ANEMIA

 PERNICIOUS ANEMIA
 IRON DEFICIENCY ANEMIA
 Composition of the blood
 RBC, WBC, Platelets, Plasma
 RBC
 normal erythropoeisis requires : pyridoxine, Vit B12, folic acid,
protein, copper, cobalt;

 HEMOBGLOBIN : IRON; Oxygen transport; Acid-

base buffer
 WBC
 granulocytes –neutrophils, eosinophils, basophils
 agaranulocytes –lymphocytes (T,B), monocytes
 Plasma
 albumin, water, clotting factors, antibodies
 IRON DEFICIENCY ANEMIA
 HEMOGLOBIN LEVEL FALLS BELOW NORMAL

CAUSES:
1. Poor intake if iron rich foods
2. Poor absorption & utilization of iron from
foods
3. Acute / chronic blood loss
 Poor intake if iron rich foods

 increased requirement :
– infants after 6 mos,
– children & adolescents
– women of reproductive age
– pregnant & nursing women
 Erroneous food practices
 Respiratory & GI conditions
 Substandard living condition
 IRON DEFICIENCY ANEMIA
CAUSES:
1. Poor intake if iron rich foods
2. Poor absorption & utilization of iron from
foods
3. Acute / chronic blood loss
Poor absorption & utilization of iron
from foods
 Form of Iron-
hemosiderin: from animal food
more readily absorbed than
from plants (nonheme iron)

 Effects of other foods

– inhibit absorption of iron:
tea, unpolished rice, veges: bulaklak ng kalabasa,
sampalok, mustasa
Poor absorption & utilization of iron
from foods
 Host factors :

– poor iron absorption in:

 severe protein-energy malnutrition &
repeated diarrhea
 Infections
 Delibitating disease
 IRON DEFICIENCY ANEMIA
CAUSES:

1. Poor intake if iron rich foods

2. Poor absorption & utilization of iron from
foods
3. Acute / Chronic blood loss
 Acute / Chronic blood loss
 Acute hemorrhage
 Chronic or repeated Blood loss:
– WHIPWORM
 0.005 ML OF BLOOD PER WORM PER DAY
– HOOKWORM
 0.2 ML OF BLOOD PER WORM PER DAY
– SCHISTOSOMIASIS
– MALARIA
– PEPTIC ULCER
– EXCESSIVE MENSTRUAL FLOW
 IRON DEFICIENCY ANEMIA
CLINICAL FEATURES:
 Asymptomatic
– inability to respond to increased iron demand
 Normal Hgb levels but with s/sx :
– lack of energy, fatiguability, reduced power and
concentration
 Severe anemia :
– difficulty in breathing,
– palpitation,
– headache,
– faintness
– loss of appetite
 IRON DEFICIENCY ANEMIA
ASSESSMENT:
Lab:
DECREASED HEMOGLOBIN & HEMATOCRIT LEVEL
MICROCYTIC, HYPOCHROMIC RBC
DECREASED RETICULOCYTE COUNT

Clinical Method
HISTORY
CLINICAL EXAMINATION - PALLOR
 IRON DEFICIENCY ANEMIA
TREATMENT:
IRON ADMINISTRATION:
 ORAL
– ADULT : 100-120 mg/day
– INFANTS AND CHILDREN : 3mg/kg/day
 PARENTERAL IRON DEXTRAN
– IM :250 MG FOR EACH gm% LOWER THAN THE
NORMAL VALUE
– IV: 100-300 mg in 500ml SALINE SOLUTION
 ORAL IRON ADMINISTRATION
ABSORPTION :
 GREATEST DURING THE FIRST MONTH OF TX,
AND DECREASES WHEN IRON STORES ARE INCREASING
 EMPTY STOMACH: GOOD ABSORPTION, MORE G.I. S/E
 ADMINISTER DURING OR PC
 ASCORBIC ACID
 BETTER ABSORBED IN FERROUS THAN IN FERRIC
FORM
 FERROUS SULFATE IS THE CHEAPEST AND READILY
ABSORBABLE FORM
 DOSE: CALCULATE THE ELEMENTAL IRON
– FERROUS SULFATE HAS 36.74% ELEMENTAL IRON
 ORAL IRON ADMINISTRATION
DURATION:
 2 MOS, ANEMIA IS ALREADY ALLEVIATED
 5 MOS, FOR IRON STORES
 PREGNANT : 24TH WK TO TERM

SIDE EFFECTS:
 CONSTIPATION/DIARRHEA
 NAUSEA
 EPIGASTRIC PAIN / HEART BURN
 PARENTERAL IRON
ADMINISTRATION
INDICATIONS:
 SEVERE DEFICIENCY
 ORAL PREPARATIONS FAIL
 CONDITION DO NOT PERMIT ORAL
ADMINISTRATION

ABSORPTION:
 RAPID

THERAPEUTIC RESPONSE
 SAME WITH ORAL
 PARENTERAL IRON
ADMINISTRATION
ADVANTAGE:
 S/E ARE AVOIDED
 PROBLEMS WITH ABSORPTION IS
AVOIDED

DISADVANTAGE:
 COSTLY
 TOXICITY IS POSSIBLE
 ALLERGIC REACTION
 PARENTERAL IRON
ADMINISTRATION
PRECAUTION:
 GIVEN UNDER CLOSE SUPERVISION BY
PHYSICIAN
 Z-TRACK METHOD
 TISSUE STAINING & IRRITATION
 IRON TOXICITY
 VERY RARE IN ORAL
 SIDEROSIS
– HEMOSIDERIN IN TISSUES
 HEMOCHROMATOSIS
– END POINT OF SIDEROSIS,
– DAMAGE TO LIVER AND PANCREAS
 PREVENTION:
– ADMIN IN DIVIDED DOSES
– KEEP OUT OF CHILDREN’S REACH
MEASURES TO MINIMIZE IRON
REQUIREMENTS
 PARASITE CONTROL
– ADMINISTER MEDS FOR PARASITISM
– MINIMIZE RISK OF REINFESTATION:
 REGULAR DEWORMING – EVERY 4-6 MOS
 FOOTWEAR
 PROPER USE OF LATRINE
 FAMILY PLANNING
– DECREASE THE # OF PREGNANCIES AND
DELIVERIES
– IUD – INCREASED MENSTRUAL LOSSES
 POST-DELIVERY MEASURES
– LATCH ON – OXYTOCIN RELEASE
– CUT THE CORD AFTER PULSATION STOPS
 MEASURES TO DIRECTLY
AUGMENT IRON STORES
 SUPLEMENTATION
– PREGNANT 24 WKS TO TERM
– NURSING MOTHERS
– MALNOURISHED INFANTS & PRESCHOOLERS
– PRETERM INFANTS

 FORTIFICATION

 EDUCATION
Burger King guest
 PERNICIOUS ANEMIA
REVIEW OF ANATOMY & PHYSIOLOGY :
STOMACH
 Stores and mixes food with gastric juices & mucus
producing chemical & mechanical changes in the bolus
of food
 Sphincters: cardiac and pyloric
 Divisions: fundus, body, antrum
 Secretions:
– Pepsinogen : by chief cells
– HCl: by parietal cells
– Intrinsic factor : by parietal cells
– mucoid
 PERNICIOUS ANEMIA
 Composition of the blood
 RBC, WBC, Platelets, Plasma
 RBC
 normal erythropoeisis requires : pyridoxine,
Vitamin B12, folic acid, protein, copper, cobalt;
 HEMOBGLOBIN : Iron; Oxygen transport; Acid-base buffer
 WBC
 granulocytes –neutrophils, eosinophils, basophils
 agaranulocytes –lymphocytes (T,B), monocytes
 Plasma
 albumin, water, clotting factors, antibodies
 PERNICIOUS ANEMIA
No INTRINSIC FACTOR

VIT B 12 cannot be absorbed

Alteration in DNA synthesis needed for cell division

Delayed cellular division, altered nuclear pattern

MEGALOBLAST

Ineffective erythropoeisis : increased

serum bilirubin & urobilinogen excretion
 PERNICIOUS ANEMIA
OTHER TISSUES AFFECTED BY VIT B12
DEFICIENCY:

 MOUTH
 STOMACH
 VAGINA
 MYELIN SHEATH
 PERNICIOUS ANEMIA
S/SX:
 WEAKNESS, FATIGUE, PALLOR, JAUNDICE
 SORE MOUTH, SMOOTH BEEFY TONGUE
 ATROPHY OF THE GASTRIC MUCOSA
 PERIPHERAL NERVE DEGENERATION :
TINGLING, NUMBNESS OF HANDS AND
FEET
 LOSS OF COORDINATION, +ROMBERG’S
 PERNICIOUS ANEMIA
DIAGNOSIS:

 PERIPHERAL SMEAR : MACROCYTIC CELLS

 (+) ROMBERG’S
 GASTRIC ANALYSIS
– (diagnex blue test) – ACHLORHYDRIA from
thinning of mucosa – HCl is also produced by parietal
cells of the stomach
 SCHILLING’S TEST – B12 IN 24 HRS URINE
SPEC
 SCHILLING’S TEST
 DEFINITIVE TEST FOR PERNICIOUS ANEMIA

 DETECT LACK OF INTRINSIC FACTOR

 MEASURES ABSORPTION OF RADIOACTIVE VIT

B12 BOTH BEFORE & AFTER PARENTERAL ADMINISTRATION OF
INTRINSIC FACTOR

 FASTING CLIENT IS GIVEN RADIOACTIVE VIT B12 BY

MOUTH AND NONRADIOACTIVE VIT B12 IM
 SCHILLING’S TEST
 24-48 HR URINE OBTAINED & TESTED FOR VIT
B 12

 AFTER 1 WK, FASTING CLIENT IS GIVEN

RADIOACTIVE VIT B 12 ORALLY WITH
PARENTERAL HUMAN INTRINSIC FACTOR

 URINE TEST IS REPEATED

 PERNICIOUS ANEMIA
MANAGEMENT:
 NO CURE; VIT B12 IM FOR LIFE

 DIET: MEAT & DAIRY

 HCL :
– 1ST WK;
– DILUTE WITH WATER;
– ADMINISTER WITH STRAW

 AVOID SEASONED FOODS

 PERNICIOUS ANEMIA
MANAGEMENT:

 MOUTH CARE: SOFT TOOTHBRUSH

 AVOID HEATING PADS – DECREASE IN SENSATION

 AFTER 2-3 DAYS TX, INCREASE IN RETICULOCYTE

COUNT

 REHAB & PT FOR NEURODEFICITS

 APLASTIC ANEMIA
DEPRESSION OF ALL BLOOD FORMING ELEMENTS FROM
BONE MARROW DESTRUCTION

 IDIOPATHIC

 SECONDARY
 APLASTIC ANEMIA
CAUSE:

 ANTINEOPLASTIC DRUGS & RADIATION

 IMMUNOSUPPRESIVE DRUGS
 CHLORAMPHENICOL
 SULFONAMIDES
 TOXIC SUBSTANCES: BENZENE ,DDT, THIAZIDE,
DIURETICS GOLD
 APLASTIC ANEMIA

ASSESSMENT:

 S/SX OF ANEMIA
 INCREASED SUSCEPTIBILITY TO
INFECTION
 BLEEDING TENDENCIES & HEMORRHAGE
 APLASTIC ANEMIA
LAB:
 NORMOCYTIC ANEMIA
 GRANULOCYTOPENIA
 THROMBOCYTOPENIA

BONE MARROW BIOPSY:

 FATTY
 VERY FEW DEVELOPING CELLS
 HEMOLYTIC ANEMIA
EXCESSIVE RBC DESTRUCTION
CAUSES:

 ACQUIRED  CONGENITAL
– SNAKE VENOM – HEREDITARY
– BURNS SPHEROCYTOSIS
– BT – G6PD DEFICIENCY
INCOMPATIBILITY – THALASSEMIA
– MALARIA – SICKLE CELL
– TOXOPLASMOSIS
 POLYCYTHEMIA
 INCREASE IN CIRCULATING BLOOD CELLS IN THE
BLOOD DUE TO BONE MARROW OVERGROWTH

FORMS:
 POLYCYTHEMIA VERA
 SECONDARY POLYCYTHEMIA
 RELATIVE POLYCYTHEMIA
 POLYCYTHEMIA
ASSESSMENT:
 RUDDY COMPLEXION
 HYPERTENSION
 SYMPTOMS OF CHF
 THROMBUS FORMATION
 BLEEDING
 HEPATOSPLENOMEGALY
 GOUT
PHLEBOTOMY
 CLINICAL CARE OF PATIENTS
WITH ANEMIA
 REST
 SKIN CARE
– DECUBITUS ULCER FROM CELL HYPOXIA
 DIET
– 6 SMALL EASILY DIGESTIBLE MEALS
– NO HOT & SPICY FOODS
 MOUTH CARE
 TRANSFUSION NOT A ROUTINE
 OXYGEN
 CLINICAL CARE OF PATIENTS
WITH ANEMIA
 PROTECTION FROM INJURY
– BURNS and CHILLING

 ISLOLATION BY:
– REVERSE ISOLATION
– LIFE ISLAND- BED ENCLOSED IN PLASTIC CANOPY
– LAMIANR AIRFLOW LIMIT – UNIT WITH
MICROFILTER
HEMATOLOGIC DISTURBANCES
 WBC and Plasma Cell :

 LEUKEMIA

 MULTIPLE MYELOMA
 LEUKEMIA
 FATAL NEOPLASTIC DISEASE THAT INVOLVES THE
BLOOD FORMING TISSUES OF THE:
– BONE MARROW
– SPLEEN
– LYMPH NODES
 UNCONTROLLED & DESTRUCTIVE
PROLIFERATION OF ONE TYPE OF WBC &
ITS PRECURSORS
 LEUKEMIA
INFILTRATE: TYPES:
– LIVER
 MYELOGENOUS
– SKIN

– KIDNEYS
 LYMPHOCYTIC

– LYMPH TISSUES
 LEUKEMIA
S/SX:
– ANEMIA
– THROMBOCYTOPENIA
– INFECTION
– PETECHIAE
– HEPATOSPLENOMEGALY & LYMPH NODE
ENLARGEMENT
– ARTHRALGIA & BONE PAIN FROM EXPANSION
OF BM
 LEUKEMIA
LAB:
 INCREASED WBC
 ANEMIA
 THROMBOCYTOPENIA
 INCREASE ALKALINE PHOSPHATASE
– OSTEOBLASTIC ACTIVITY

 BONE MARROW BIOPSY

 LEUKEMIA – NURSING CARE

 PROVIDE ADEQUATE REST INCREASED

METABOLIC RATE FROM OVERPRODUCTION OF
LEUKOCYTES

 PAIN CONTROL ASA, CODEINE, DEMEROL

 ADEQUATE FOOD & FLUID INTAKE

HIGH CALORIE DIET VITAMIN SUPPLEMENTS 3-4 L OF
FLUID PER DAY
 LEUKEMIA – NURSING CARE
 MOUTH CARE H2O2 LEMON & GLYCERINE

 PREVENT INFECTION PROTECT PATIENT

FROM HIS OWN FLORA – NEOMYCIN

 CHEMOTHERAPY
GOAL- INDUCTION OF COMPLETE REMISSION
TOLERABLE LEVEL OF TOXICITY – CRITERION FOR LIMITATION
OF INDUCTION PHASE
 MULTIPLE MYELOMA
 MOST COMMON NEOPLASTIC DISORDER OF THE
PLASMA CELL
 BONE MARROW MALIGNANCY

 REVIEW OF PLASMA CELL AND ITS PRODUCTS

 S/SX:
– BACK PAIN,
– FATIGUE, WEIGHT LOSS,
– OSTEOPOROSIS
– HYPERCALCEMIA
 MULTIPLE MYELOMA
 LABS:
– BLOOD: DECREASED WBC, HGB & PLATELET;
INCREASED SERUM INMMUNEGLOBULINS

 RADIOLOGY
– DIFFUSE BONE LESIONS

 DIAGNOSIS: BENCE-JONES PROTEIN GLOBULIN

IN THE URINE
HEMATOLOGIC DISTURBANCES
 Lymph Nodes and Spleen :
– LYMPHOMA

– INFECTIOUS MONONUCLEOSIS

– SPLENIC RUPTURE

– HYPERSPLENISM
 LYMPHOMA
 HODGKIN’S & NON HODGKIN’S DISEASE

 LYMPHOSARCOMA

 BURKITT’S LYMPHOMA
 HODGKIN’S DISEASE
 MALIGNANT NEOPLASM OF THE LYMPHOID TISSUE

 ENLARGEMENT OF THE LYMPH NODES

 NIGHT SWEATS

 BODY MALAISE

 WEIGHT LOSS

 REED-STERNBERG CELLS IN LYMPHNODE BIOPSY

 NONHODGKIN’S DISEASE

 MALIGNANT NEOPLASM OF THE LYMPHOID TISSUE

 ENLARGEMENT OF THE LYMPH NODES

 MORE FATAL & DIFFICULT TO CONTROL

 UNDIFFERENTIATED CELLS IN LYMPH NODE BIOPSY

INFECTIOUS MONONUCLEOSIS
AKA: GLANDULAR / KISSING DSE

S/SX:
 PAINFUL ENLARGEMENT - LYMPHNODES

 LYMPHOCYTOSIS

 FEVER
INFECTIOUS MONONUCLEOSIS
CAUSE: EPSTEIN-BARR VIRUS

CONTACT: KISSING

DIAGNOSIS: PAUL-BUNNEL HETEROPHIL

TEST

COMPLICATION: SPLENIC RUPTURE

 SPLENECTOMY
INDICATIONS:

 RUPTURE OF THE SPLEEN FROM TRAUMA,

INFECTIOUS MONONUCLEOSIS

 HYPERSPLENISM – EXCESSIVE SPLENIC DAMAGE

OF CELLULAR BLOOD COMPONENTS
 SPLENECTOMY
NURSING CARE:
PREOP
 PNEUMOCOCCAL VACCINE

POSTOP
 MONITOR FOR BLEEDING & SHOCK
 FEVER WITHOUT INFECTION IS COMMON
 PROPHYLACTIC ANTIBIOTIC
Hemorrhagic Disorders : PURPURA
EXTRAVASATION OF SMALL AMTS OF BLOOD INTO THE TISSUES AND
MUCUS MEMBRANE

 VASCULAR PURPURA
CAUSES :
1. HEREDITY
2. ALLERGY (HENOCH-SCHONLEIN)
3. DRUGS (TOXIC PURPURA)
4. POOR NUTRITION
5. INFECTION
6. HPN
 THROMBOCYTOPENIC PURPURA
Disorders of Altered Coagulation
–HEMOPHILIA

–HYPOPROTHROMBINEMIA

–D.I.C.
 HEMOPHILIA

Deficit in one of the clotting factors

A – Factor VIII

B- Factor IX

C- Factor XI
 HEMOPHILIA
S/SX:
– PROLONGED BLEEDING AFTER MINOR INJURY:
 CUTTING OF CORD
 CIRCUMCISION
 IMMUNIZATION
– HEMARTHROSIS
– PERIPHERAL NEUROPATHY – BLEEDING NEAR
PERIPHERAL NERVES

LAB:
PROLONGED PTT
NORMAL PLT CT
ANEMIA
 HYPOPROTHROMBINEMIA

 LIVER FAILURE

 BLEEDING EPISODES

 VITAMIN K
 D.I.C.
2 CONFLICTING SETS OF
MANIFESTATIONS:

 DIFFUSE FIBRIN DEPOSITION WITHIN

ARTERIOLES AND CAPILLARIES
THROUGHOUT THE BODY

 BLEEDING INTO THE KIDNEYS, BRAIN,

ADRENAL, HEART AND OTHER ORGANS
 D.I.C.
DIFFUSE FIBRIN DEPOSITION WIHIN
ARTERIOLES AND CAPILLARIES

WIDESPREAD CLOTTING

DEPLETION OF CLOTTING FACTORS

 D.I.C.
CAUSE: ASSESMENT:
 UNKNOWN  PETECHIAE,
ECCHYMOSIS
 CRITICAL ILLNESS:
 PROLONGED BLEEDING
– TOXEMIA OF
 ARF
PREGNANCY
 CONVULSIONS
– CANCER
 COMA
– SURGICAL PROBLEMS
– HEMOLYTIC DSE LAB:
 FIBRIN SPLIT PRODUCTS
 A.I.D.S.
 Severe deficit in cellular immune functions
 HIV virus- infects T helper cells
 Transmission
 Antiretroviral drugs
 Assessment: •Laboratory :
– Flulike s/sx
– Hypoxemia from pulm infection •ELISA
– Progressive weight loss •Western Blot
– Temp elevations; night sweats •Anemia
•Leukopenia
– Neurologic dyfxn
•thrombocytopenia
– Opportunistic infections
 A.I.D.S.
NURSING INTERVENTION:
 Administer meds
 Monitor resp, neurologic, F & E balance
 Monitor nutritional intake
 Inspect oral cavity for ulcerations
 Observe s/sx of infection
 Severe leukopenia – neutropenic precaution
 Blood & body fluid precaution
 Emotional support
 The nurse should understand that a
heparin order for a client with DIC is
given to:

a. Prevent clot formation

b. Increase blood flow to target organs
c. Increase clot formation
d. Decrease blood flow to target organs