Week 6 Remediation

THROMBOCYTOPENIA

Excessive destruction of platelets; causes: infections, medications, immune disorders, portal hypertension; treatment: removal or treatment of underlying cause, blood and/or platelet transfusions; nursing considerations: monitor for internal and external bleeding, use humidifier or nasal saline spray to prevent drying nasal passages, administer stool softeners; client education: bleeding precautions (use soft toothbrush, electric razor), avoid contact sports, dental floss, ASA, NSAIDs, feverfew, ginger, ginkgo, garlic, kava, and corticosteroids, and contact health care provider if there is head or abdominal trauma, inform every health care provider of bleeding potential, wear closed heel and toe shoes and socks.

HEMOPHILIA

Hereditary bleeding disorder caused by deficiency of a clotting factor, hemophilia A, which is deficiency of factor VIII, is most common; indications include prolonged internal or external bleeding, easy bruising, joint pain with bleeding, pallor; nursing interventions include assess for internal bleeding; recognize and control all bleeding; administer analgesics for joint pain (not aspirin; acetaminophen/Tylenol acceptable); avoid IM injections; administer factor replacement therapy as ordered; during bleeding episodes maintain bed rest with joint elevation, immobilization, ice or cold packs; instruct in active range of motion after bleeding episodes; decrease risk of injury; teach to avoid contact sport, engage in activities such as swimming, golf; assist child and family with coping with chronic disease and altered lifestyle.

LEUKEMIA

Cancer of blood forming tissues of bone marrow, spleen, lymph nodes; abnormal uncontrolled destructive proliferation of one type of white cell and its precursors; immature cells are overproduced faster than needed by the body; as older blood cells are depleted, these newer, more immature cells are not able to replace and function as the older mature cells did; predisposing factors: viruses, ioning radiation, genetic predisposition, absorption of chemicals (benzene, pyridine, aniline dyes); signs and symptoms: mouth and throat ulcerations, pneumonia, septicemia, anemia, thrombocytopenia, leukocytosis, erythropenia, fatigue, lethargy, bone and joint pain, bleeding gums, ecchymosis, petechiae, retinal hemorrhage, weakness, pallor, weight loss, hepatomegaly, splenomegaly, headache, disorientation, altered leukocyte count (15,000-5000/mm3) convulsions, infections; diagnosis: bone marrow aspiration (informed consent required to do bone marrow aspiration, bone marrow aspirated from sternum and/or iliac crest, done under local anesthetic, afterwards apply sterile dressing with pressure to puncture site to prevent bleeding, complication: bleeding, osteomyelitis); classification: acute- rapid onset, progresses to fatal termination within days to months, more common in children and young adults; chronic – gradual onset with slower more protracted course, more common between 24 and 60 years; nursing care: monitor for bleeding and infections, good oral care, high calorie and protein and vitamin diet, frequent feedings of soft easy-to-eat foods, antiemetics, neutropenic precautions, strict handwashing, prevent development of decubitus, administer blood transfusions, administer chemotherapy agents and medications related to therapy, monitor for side effects of chemotherapy (nausea, vomiting, diarrhea, stomatitis, alopecia, skin reactions, bone marrow depression); client education: preventive measures for bleeding and infections, avoid crowd or persons with know infections.

DISSEMINATED INTRAVASCULAR COAGULATION/DIC

Pathological form of coagulation that involves both bleeding and thrombosis; predicated by septic shock, fat emboli, infection, trauma, cancer, abruptio placenta, retained expired fetus, toxins; DIC is sign of underlying disease; indications include bleeding from surgical or invasive procedures, bleeding gums, petechiae, ecchymoses, expistaxis, tachycardia, hypotension; nursing considerations include assess for bleeding, assess for indications of shock, monitor PT, PTT, platelet count, fibrinogen levels, clotting times, avoid injections if possible, apply pressure to bleeding sites, administer blood components.

Rh (D) IMMUNE GLOBULIN

Kaplan overview

Hormone and synthetic substitute, immune globulin; use: promote lysis of fetal Rh-positive red blood cells (RBCs) circulating in maternal bloodstream before Rh-negative mother develops her own antibodies to them; thereby prevents isoimmunization, which otherwise could result in hemolytic disease of the newborn (erythroblastosis fetalis), affecting subsequent pregnancies; administered whenever maternal and fetal blood intermingling possible (if mother is Rh-negative, father is Rh-positive) suchas amniocentesis or other trauma, fetomaternal hemorrhage, full term delivery, miscarriage, abortion, ectopic pregnancy; side effects: injection site discomfort, low fever, lethargy, myalgia; nursing consideration: immediately after delivery send sample of cord blood of infant to lab for crossmatch and typing and do dot administer Rh(D) immune globulin until results return, administer within 72 hours after deliver, ensure that mother understands reason Rh(D) immune globulin is given.

Essential nursing care

Therapeutic class: concentrated immune globulin

Acton: suppresses maternal response to Rh-positive blood

Indications

In pregnant women with isoimmunization, or Rh incompatibility: mother is Rh-positive but fetus is Rh-negative.
In pregnant woman with Rh sensitization: anti-D antibody titer of 1:16 or greater as measured by amniocentesis
In Rh-negative woman after abortion, ectopic pregnancy, delivery of Rh-positive infant, accidental transfusion of Rh-positive blood, amniocentesis, abruption placentae, abdominal trauma
In cases of Rh-incompatibility, if bleeding injury caused fetal blood to come into contact with maternal blood

Nursing Implication/Care

Assess all pregnant woman for possible Rh incompatibility
Test woman and infants within 72 hours after delivery for Rh incompatibility
Expect to administer Rh(D) intramuscular in indicated cases
Check patient history for allergies to immunoglobulins, blood, and blood products
Explain purpose and procedure of RhoGAM administration to patient
As ordered, assist with administration of RhoGAM to Rh-negative woman, prophylactically at 28 weeks’ gestation, or within 72 hours after abortion or delivery
RhoGAM must be cross-matched to specific patient. Check vitals identification numbers with another nurse; sign triplicate form that comes with RhoGAM; attach top copy of form to patient’s chart. Send other copies along with empty RhoGAM vial to laboratory or blood bank
Give patient card indicating Rh-negative status; instruct her to carry it with her pr keep it in a convenient location
Assess muscle sites for appropriateness: deltoid preferably; if patient is thin or dose is large, use ventrogluteal or gluteal site
Before infusion, obtain baseline fetal heart rate by electronic monitoring
After infusion, observe patient for uterine contractions and fluid leakage from puncture site
Monitor fetal heart rate for tachycardia or bradycardia
Document administration and patient’s reaction
In cases of isoimmunization
Prepare patient for planned delivery, usually 2 to 4 weeks before term (depending on results of serologic tests, amniocentesis, maternal history)
Assist with labor induction between 34th and 38th week, as indicated
During labor, monitor fetus electronically
Determine fetal acid-base balance through capillary blood scalp sample
Fetal distress necessitates emergency cesarean delivery

Expected outcomes

Patient expresses understanding of need for RhoGAM
Patient tolerates injection without adverse effects
No Rh incompatibility develops between Rh-negative mother and Rh-positive fetus
Fetus does not develop hemolytic disease
Fetus is delivered without incident