Assessment of hematologic disorders (PHYSICAL ASSESSMENT (NOSE Epistaxis,…
Assessment of hematologic disorders
Do you have any difficulty performing daily activities because of a lack of energy?*
Do you smoke cigarettes or drink alcohol, street drugs?
Family history of blood problems?
Unusual bleeding or bruising
Night sweats or cold intolerance
Blood in stools
Blood in urine
SOB with rest or activity
Feel rested after sleep
Job exposure to chemicals
Women: assess menstural cycle
Religious views about blood products and anything that might prohibit certain treatments
Bence Jones protein= Negative finding is considered normal. = Acquire random urine specimen.
Liver and spleen scan
Radioactive isotope is injected IV. Images from the radioactive emissions are used to evaluate the structure of spleen and liver. Patient is not a source of radioactivity.
No specific nursing responsibilities.
Same procedure as for the spleen scan except used for evaluating the structure of the bones.
Patient needs to lie still during the imaging. Patient may be asked to drink 4-6 glasses of water and then void before the imaging (to see pelvic bones).
Positron emission tomography (PET)
A nuclear tracer substance is injected and is taken up by metabolically active cells. The follow-up scan shows different-colored tissues based on the metabolic rate. “Hot spots” reflect increased glucose consumption that is typical of tumors. A valuable diagnostic tool to detect active malignancy because it highlights areas with increased metabolism. PET or CT scanning may also be used.
IV access is required for injection of the tracer substance. Patients should have nothing by mouth, except water and medications, for at least 4 hr before the test. IV solutions containing glucose may be held. Patients who are glucose intolerant or diabetic may need adjustments in their medications. Bowel preparation may also be needed, depending on the area being studied.
Computed tomography (CT)
Noninvasive radiologic examination using computer-assisted x-ray evaluates the lymph nodes. Contrast medium often is used in abdominal studies of liver or spleen. Spiral (helical) CT scans are used to evaluate lymph nodes.
Investigate iodine sensitivity if contrast medium used.
Liver, spleen, or abdominal ultrasound
Noninvasive probe is lubricated and slid across the abdomen to detect the density and borders of the abdominal organs. Can detect irregular borders, masses, vascular structure, and biliary tree.
Patients must be comfortable lying flat and having the probe compress the abdomen.
Magnetic resonance imaging (MRI)
Noninvasive procedure produces sensitive images of soft tissue without using contrast media. No ionizing radiation is required. Technique is used to evaluate spleen, liver, and lymph nodes.
Instruct patient to remove all metal objects and ask about any history of surgical insertion of staples, plates, or other metal appliances. Inform patient of need to lie still in small chamber.
X-rays done as a bone survey to detect lytic lesions associated with multiple myeloma. Bone scans do not identify lesions in this condition because there is no uptake of radioactive isotopes due to lack of blood supply.
No specific nursing responsibilities.
Molecular, Cytogenetic, and Gene Analysis Studies
Fluorescence in situ hybridization (FISH)
Comparative genomic hybridization (CGH)
Spectral karyotyping (SKY)
Tests are performed on malignant cells, either peripheral blood (e.g., leukemia) or biopsy specimen (bone marrow, lymph node) to assess genetic or chromosomal abnormalities of cancer cells. May be useful in confirming diagnosis and determining treatment modalities and prognosis.
No specific nursing responsibilities. Explain purpose of testing to patient.
Technique involves removal of bone marrow through a locally anesthetized site to evaluate the status of the blood-forming tissue. It is used to diagnose multiple myeloma, all types of leukemia, and some lymphomas and to stage some solid tumors (e.g., breast cancer). It is also done to assess efficacy of leukemia therapy.
Explain procedure to patient. Obtain signed consent form. Ensure that a time-out* is done before procedure. Consider pre-procedure analgesic administration to enhance patient comfort and cooperation. Apply pressure dressing after procedure. Assess biopsy site for bleeding.
Lymph node biopsy
Purpose is to obtain lymph tissue for histologic examination to determine diagnosis and therapy.
Explain procedure to patient. Obtain signed consent form. Use sterile technique in dressing changes after procedure.
Performed in the operating room or procedure area using either local or general anesthesia. An incision is made, and the lymph node and surrounding tissue are dissected (excised) whenever possible.
Apply direct pressure to the area after the biopsy procedure to achieve hemostasis. Observe site for bleeding and monitor vital signs, especially if the platelet count is low. The sterile dressing should be changed as ordered, and the wound should be inspected for healing and infection.
Closed (needle) or fine needle
Performed by a physician at the bedside or in an outpatient area. An extremely small needle is used to reduce the risk of tracking malignant cells through normal subcutaneous tissue.
Blurred vision, diplopia, visual field cuts
Gingival and mucous membrane changes
HEART AND CHEST
Altered blood pressure
Low O2 saturation
Paresthesias of feet and hands; ataxia
Headache, nuchal rigidity
CBC w/ Differential
Activated clotting time (ACT)=70-120 sec
Activated partial thromboplastin time (aPTT)=25-35 sec
Antithrombin=21-30 mg/dL (210-300mg/L) or 80%-120% of standard
Bleeding time =2-7 min
Capillary fragility test (tourniquet test, Rumpel-Leede test)=No petechiae or negative
Clot retraction= Begins in 1 hr. Maximum by 24 hr
D-dimer= <250 ng/mL (<250 mcg/L)
Fibrin split products (FSPs), or fibrin degradation products (FDPs)= <10 mcg/mL (<10 mg/L)
Fibrinogen= 200-400mg/dL (2-4 g/L)
International normalized ratio (INR)=2-3
Platelet count= 150,000-400,000/µL
Prothrombin time (PT)= 11-16 sec
Thrombin time= 17-23 sec
Miscellaneous Blood Studies
Total: 0.2-1.2 mg/dL (3.0-21.0 µmol/L)
Direct: 0.1-0.3 mg/dL (1.7-5.1 µmol/L)
Indirect: 0.1-1.0 mg/dL (1.7-17.0 µmol/L)
Coombs test= Negative
• Direct =Detection of antibodies that are attached to RBCs.= Negative
• Indirect= Detection of antibodies in serum.= Negative
Cobalamin (vitamin B12)= 200-835 pg/mL (148-616 pmol/L)
Erythropoietin= 5-30 mU/mL (5-30 U/L)
Erythrocyte sedimentation rate (ESR)= <30 mm/hr (some gender variation) Ferritin=10-250 ng/mL (10-250 mcg/L) Folic acid (folate)= 3-16 ng/mL (7-36 nmol/L) Hemoglobin (Hgb) electrophoresis= Normal; Hb A1: >95%; Hb A2: 1.5-3.7%; Hb F: <2%; Hb S: 0%;
Homocysteine= Male: 5.2-12.9 µmol/L; Female: 3.7-10.4 µmol/L
• Serum iron= 50-175mcg/dL (9-31.3µmol/L)
• Total iron-binding capacity= 250-425 mcg/dL (45-76 µmol/L)
Methylmalonic acid (MMA)= <0.2 µmol/L (<2.4 mcg/dL)
Reticulocyte count= 0.5%-1.5% of RBC count (0.005-0.015 of RBC count)
Serum protein electrophoresis (SPEP)= Normal banding pattern of albumin and globulins. Increase in any protein (“protein spike”) is abnormal.
Transferrin= 190-380 mg/dL (1.9-3.8 g/L)
Transferrin saturation (%)= 15%-50%