Hematologic & Vascular Function

Question 1

What does bone marrow make?

Answer 1

RBC
WBC
Platelets

Question 2

Normal Platelet Count

Answer 2

150-400 x 10^9/L

Question 3

Causes of Decreased Platelets

Answer 3

decreased production

increased destruction

Question 4

Thrombocytopenia: S/Sx

Answer 4

• petechiae
• jaundice
• nose bleed
• bleeding from gums
• blood in urine/stool
• unusual heavy menstrual flows
• fatigue
• enlarged spleen

Question 5

Thrombocytopenia: Dx

Answer 5

CBC:

• platelet count
• RBC
• H&H

Question 6

Thrombocytopenia: Interventions

Answer 6

• bleeding precautions
• basic nursing skills
• specific preventions

Question 7

HIT

Answer 7

occurs w/in days of starting heparin

platelet counts drop below 100

Question 8

HIT: Tx

Answer 8

-stop heparin
-give alternate thrombin inhibitor like:
argatroban
-rivaxaban (xarelto)
-dabigatran (pradaxa)
-bivalirudin (angiomax)
-give protamine sulfate if necessary
-platelet transfusion

Question 9

ITP

Answer 9

platelets become coated w/ antibodies

body sees them as foreign and spleen destroys them

platelet survive 1-3 days

acute: resolves on it’s own
chronic: corticosteroids, immunoglobulins, splenectomy

Question 10

Thrombocytic Thrombocytopenia Purpura

Answer 10

unsure of cause

medical emergency

s/sx = thrombocytopenia, anemia, neuro symptoms, fever

tx = FFP, plasmapheresis, antiplatelets, corticosteroids, chemo

Question 11

Anemia: Caues

Answer 11

Decreased RBC production:

• decreased iron from liver
• decreased nutrients from GI tract
• decreased erythropoietin from kidney

Direct Blood Loss

Increased RBC Destruction/Hemolysis

• sickle cell disease
• meds
• incompatible blood (transfusions)
• trauma (cardiopulmonary bypass machine)

Question 12

Anemia: S/Sx

Answer 12

mild anemia (Hgb 10-12):

• exertional dyspnea
• palpitations

moderate anemia (Hgb 6-10):

• palpitations
• dyspnea
• “roaring in the ears”
• fatigue

severe anemia (Hgb < 6):

• pallor, jaundice, pruritus
• smooth tongue
• tachycardia
• angina, HF, MI
• orthopnea
• dyspnea at rest
• bone pain
• sensitivity to cold, weight loss, lethargy

Question 13

Anemia: Tx

Answer 13

• replacing blood volume to prevent shock
• identifying source of bleeding and stopping
• supplemental iron (PO or IV)
• meds: erythropoietin (for those with kidney dysfunction)
• O2
• dietary and lifestyle changes
• alternate rest and activities

Question 14

DIC: Causes

Answer 14

sepsis
surgery
trauma
cancer
complications from pregnancy/childbirth

Question 15

DIC: Dx

Answer 15

lab testing

• platelet count
• PT/INR
• aPTT
• fibrin split products (clots mad and broken down forms FSP and indicates widespread dissolving clots)
• D-dimer

*elevated FSP and D-dimer are highly predictive of DIC

Question 16

DIC: Tx

Answer 16

• prevention
• find cause and tx
• replacement of clotting factors (packed RBCs, FFP, Platelets, Cryoprecipitate)
• anticoagulants (when thrombosis predominates - heparin, thrombin inhibitors)

Question 17

Cryoprecipitate

Answer 17

FFP + platelets

Question 18

PAD

Answer 18

thickening of artery walls

likely to have coronary artery disease

RF: smoking, hyperlipidemia, diabetes, HTN, family hx, obesity, stress

Question 19

PAD: S/Sx

Answer 19

• affects lower extremities
• intermittent claudication
• paresthesia
• shiny, taut, hairless lower extremities
• diminished or absent pulses
• pallor in response to leg elevation
• dependent rubor
• delayed wound healing
• arterial ulcers over bony prominences
• rest pain in toes

Question 20

PAD: Dx

Answer 20

• doppler u/s
• ankle-brachial index (divide the ankle systolic BP by the higher left and right brachial systolic BP)
• angiography
• MRI

Question 21

PAD: Tx

Answer 21

• modify risk factors
• decrease HTN
• lipid management
• exercise therapy (walking, pool activities)
• weight loss
• meds: antiplatelets, ACE inhibitors

Question 22

DVT

Answer 22

results from Virchow’s triad:

• venous stasis
• hypercoagulability
• endothelial injury

Question 23

DVT: S/Sx

Answer 23

in 50% of people:

• warmth
• redness
• pain
• swelling

Question 24

Venous Thrombosis: Risk Factors

Answer 24

• advanced age
• obesity
• recent surgery
• previous clot
• stoke
• OCP
• pregnancy
• smoking
• long distance travel

Question 25

Venous Thrombosis: Prevention

Answer 25

in hospital: - compression stockings - SCDs - heparin/LMWH (Lovenox)

Question 26

Venous Thrombosis: Tx

Answer 26

- IV Heparin - Thrombin inhibitors - IVC filter

Question 27

Acute PE: Definitions

Answer 27

Massive: - sustain hypotension - inotropic support required - PEA or bradycardia w/ shock Submassive: -myocardial necrosis or RV dysfunction w/ no systemic hypotension Low Risk: -normal levels of biomarker, no systemic hypotension or RV dysfunction

Question 28

PE: Risk Factors

Answer 28

DVT is the primary cause in hospitalized pts: - DVT - more than 7 days of immobilization - obesity - post op

Question 29

PE: S/Sx

Answer 29

- dyspnea - chest pain w/ inspiration - calf or thigh pain and/or swelling - cough - orthopnea (2+ pillow) - wheezing

Question 30

PE: Dx

Answer 30

- V/Q scan - pulmonary angiogram - spiral CT - doppler - D-dimer

Question 31

PE: Tx

Answer 31

- HOB up - O2 - call provider - bed rest to keep clots from moving - clot control: heparin > coumadin, thrombolytics, catheter directed thrombosis, embolectomy, IVC filter

Question 32

Hospital Risk Assessment for DVT

Answer 32

low risk: - age < 40 - minor surgery moderate risk: - age > 40 - minor surgery - additional risk factors high risk: - age > 60 - surgery highest risk: - age > 40 w/ multiple risk factors - hip or knee surgery/interventions - major trauma - SCI

Question 33

Hospital Interventions for DVT Prevention

Answer 33

low risk: - early ambulation - elastic stockings/or SCDs moderate risk: -heparin or LMWH (Lovenox) high risk: -same as moderate highest risk: - LMWH, fodaprimnux, or warfarin - SCDs

Question 34

Aneurysm

Answer 34

outpouching of dilated vessel wall most commonly caused by atherosclerosis True: wall of the artery forms the aneurysm w/ one vessel layer intact False (Pseudo): disruption of all arterial wall layers w/ bleeding contained usually occurs below renal arteries

Question 35

Aneurysm: S/Sx

Answer 35

- often asymptomatic until pain begins - JVD - edema in face and arms - pulsatile mass in periumbilical area - may present as kidney stones - sharp pain - tearing feeling radiating to back - older adults may have vague symptoms such as hypotension

Question 36

Aneurysm: Rupture

Answer 36

results in hypovolemic shock grey turner's sign if AAA (bruising on flank) monitor w/ CT, u/s, MRI, angiography, lab tests requires immediate surgical repair

Question 37

Aneurysm: Surgery

Answer 37

graft autotransfusion *still can develop aneurysm above graft, thrombosis, or infection

Question 38

Aneurysm: Pre-op Interventions

Answer 38

- NPO - bowel prep - skin cleaning - beta blockers given if hx of CVD

Question 39

Aneurysm: Post-op

Answer 39

- diuretics and antihypertensives (don't want unnecessary pressure/stress) - monitor ABGs, EKG, pain - aseptic technique on all arterial lines or invasive monitoring lines - if pt has NGT, monitor output and do oral care until NPO status is discontinued - assess LOC and neuro status (at risk for stroke) - monitor peripheral pulses - monitor urine output

Question 40

Aneurysm: Discharge Instructions

Answer 40

- avoid heavy lifting for 6 weeks post-op (>10lbs) - report fever, pain, or drainage from incision - monitor extremities (CMS) - make sure they are urinating to ensure kidneys are perfusing