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7 Hematologic Function UNIT Hematologic 7 Function Case Study PREVENTING INFECTION IN THE PATIENT WITH LEUKEMIA A 47-year-old patient is admitted to an inpatient oncology unit with a new diagnosis of acute myeloid leukemia (AML). She presented to the outpatient office of her primary provider with complaints of flu-like symptoms for the past four weeks, which have worsened over the past three days to now include weakness and dyspnea on exertion. Laboratory tests and a bone marrow biopsy confirmed the diagnosis of AML. The patient is scheduled to begin chemotherapy and a central venous catheter will be placed prior to treatment initiation. Prevention of infection is vital in patients with leukemia. Often patients with AML will not exhibit typical signs of infection such as elevated fever. Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this content is prohibited. LWBK1592-CH32_p900-924.indd 900 7/25/17 5:13 PM QSEN Competency Focus: Evidence-Based Practice (EBP) The complexities inherent in today’s health care system challenges nurses to demonstrate integration of specific inter- disciplinary core competencies. These competencies are aimed at ensuring the delivery of safe, quality patient care (Institute of Medicine, 2003). The Quality and Safety Education for Nurses project (QSEN, 2017; Cronenwett, Sherwood, Barnsteiner, et al., 2007) provides a framework for the knowledge, skills, and attitudes (KSA) required for nurses to demonstrate competency in these key areas, which include patient-centered care, interdisciplinary teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. Evidence-Based Practice Definition: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. SELECTED PRE-LICENSURE KSAs APPLICATION AND REFLECTION Knowledge Explain the role of evidence in determining best clinical What is the strength of the evidence for strategies aimed practice. at preventing infection in patients with AML? Identify the pathophysiologic relationships between the disease process in AML, the susceptibility to infection, and the atypical signs and symptoms of infection in patients with leukemias. Skills Locate evidence reports related to clinical practice What strategies would you use to search for and then topics and guidelines. identify appropriate evidence for decreasing rates of infection in patients with AML? What resources might you mobilize to provide education for this patient on the best strategies to prevent infection? What signs and symptoms should she monitor and report to her primary provider? Attitudes Value the need for continuous improvement in clinical Reflect on your attitudes toward patients with diseases practice based on new knowledge. susceptible to infection. Do you tend to think that infection is inevitable in patients with a cancer diagnosis? Cronenwett, L., Sherwood, G., Barnsteiner, J., et al. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122–131. Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press. QSEN Institute. (2017). QSEN competencies: Definitions and pre-licensure KSAs. Retrieved on 3/1/2017 at: www.qsen.org/competencies/ pre-licensure-ksas 901 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this content is prohibited. LWBK1592-CH32_p900-924.indd 901 7/25/17 5:13 PM Assessment of Hematologic Function and Treatment 32 Modalities LEARNING OBJECTIVES On completion of this chapter, the learner will be able to: 3 Specify the proper techniques utilized to perform a com- prehensive physical assessment of hematologic function. 1 Describe hematopoiesis and the processes involved in 4 Explain the diagnostic tests and related nursing implica- maintaining hemostasis. tions used to evaluate hematologic function. 2 Discuss the significance of the health history to the 5 Identify therapies for blood disorders, including nursing assessment of hematologic health. implications for the administration of blood components. GLOSSARY anemia: decreased red blood cell (RBC) count myeloid: pertaining to nonlymphoid blood cells that differen- band cell: slightly immature neutrophil tiate into RBCs, platelets, macrophages, mast cells, and blast cell: primitive white blood cell (WBC) various WBCs cytokines: proteins produced by leukocytes that are vital to reg- myelopoiesis: formation and maturation of cells derived ulation of hematopoiesis, apoptosis, and immune responses from myeloid stem cell differentiation: development of functions and characteris- natural killer (NK) cells: immune cells that accumulate in tics that are different from those of the parent stem cell lymphoid tissue that are potent killers of virus-infected erythrocyte: a cellular component of blood involved in the and cancer cells transport of oxygen and carbon dioxide (synonym: red neutrophil: fully mature WBC capable of phagocytosis; pri- blood cell) mary defense against bacterial infection erythropoiesis: process of the formation of RBCs nucleated RBC: immature form of RBC; portion of nucleus erythropoietin: hormone produced primarily by the kidney; remains within the RBC necessary for erythropoiesis oxyhemoglobin: combined form of oxygen and hemoglo- fibrin: filamentous protein; basis of thrombus and blood clot bin; found in arterial blood fibrinogen: protein converted into fibrin to form thrombus phagocytosis: process of cellular ingestion and digestion of and clot foreign bodies fibrinolysis: process of breakdown of fibrin clot plasma: liquid portion of blood granulocyte: granulated WBC (i.e., neutrophil, eosinophil, plasminogen: protein converted to plasmin to dissolve basophil); sometimes used synonymously with neutrophil thrombi and clots hematocrit: percentage of total blood volume consisting of platelet: a cellular component of blood involved in blood RBCs coagulation (synonym: thrombocyte) hematopoiesis: complex process of the formation and red blood cell (RBC): a cellular component of blood maturation of blood cells involved in the transport of oxygen and carbon dioxide hemoglobin: iron-containing protein of RBCs; delivers oxy- (synonym: erythrocyte) gen to tissues reticulocytes: slightly immature RBCs, usually only 1% of hemostasis: intricate balance between clot formation and total circulating RBCs clot dissolution reticuloendothelial system: complex system of cells histiocytes: cells present in all loose connective tissue, throughout the body capable of phagocytosis capable of phagocytosis serum: portion of blood remaining after coagulation occurs leukocyte: one of several cellular components of blood stem cell: primitive cell, capable of self-replication and dif- involved in defense of the body; subtypes include neu- ferentiation into myeloid or lymphoid stem cell trophils, eosinophils, basophils, monocytes, and lympho- stroma: component of the bone marrow not directly related cytes (synonym: white blood cell) to hematopoiesis but serves important supportive roles in leukopenia: less-than-normal amount of WBCs in circulation this process lymphocyte: form of WBC involved in immune functions thrombocyte: a cellular component of blood involved in lymphoid: pertaining to lymphocytes blood coagulation (synonym: platelet) macrophage: reticuloendothelial cells capable of white blood cell (WBC): one of several cellular compo- phagocytosis nents of blood involved in defense of the body; subtypes monocyte: large WBC that becomes a macrophage when it include neutrophils, eosinophils, basophils, monocytes, leaves the circulation and moves into body tissues and lymphocytes (synonym: leukocyte) 902 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this content is prohibited. LWBK1592-CH32_p900-924.indd 902 7/25/17 5:13 PM CHAPTER 32 Assessment of Hematologic Function and Treatment Modalities 903 Unlike many other body systems, the hematologic system normally make up 40% to 45% of the blood volume. Because encompasses the entire human body. Patients with hemato- most blood cells have a short lifespan, the need for the body logic disorders often have significant abnormalities in blood to replenish its supply of cells is continuous; this process is tests but few or no symptoms. Therefore, the nurse must have termed hematopoiesis. The primary site for hematopoiesis a good understanding of the pathophysiology of the patient’s is the bone marrow. During embryonic development and in condition and the ability to make a thorough assessment other conditions, the liver and spleen may also be involved. that relies heavily on the interpretation of laboratory tests. Under normal conditions, the adult bone marrow pro- It is equally important for the nurse to anticipate potential duces about 175 billion erythrocytes, 70 billion neutrophils patient needs and to target nursing interventions accordingly. (a mature type of WBC), and 175 billion platelets each day. Because it is so important to the understanding of most hema- When the body needs more blood cells, as in infection (when tologic diseases, a basic appreciation of blood cells and bone neutrophils are needed to fight the invading pathogen) or marrow function is necessary. in bleeding (when more RBCs are required), the marrow increases its production of the cells required. Thus, under normal conditions, the marrow responds to increased demand Anatomic and Physiologic Overview and releases adequate numbers of cells into the circulation. The hematologic
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