Lippincott Certification Review Medical-Surgical Nursing

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Lippincott Certification Review Medical-Surgical Nursing SEVENTH EDITION

Clinical Editor LAURA M. WILLIS, DNP, APRN, FNP-C, CMSRN Family Nurse Practitioner/Lead APC Bon Secours Mercy Health Wittenberg University Health Center Springfield, Ohio

Acquisitions Editor: Susan Hartman Development Editor: Phoebe Jordan-Reilly Editorial Coordinator: Chester Anthony Gonzalez Marketing Manager: Amy Whitaker Production Project Manager: Frances Gunning Manager, Graphic Arts & Design: Stephen Druding Manufacturing Coordinator: Bernard Tomboc Prepress Vendor: Straive

Seventh Edition

Copyright © 2018 Wolters Kluwer © 2012 by Lippincott Williams & Wilkins. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at shop.lww.com (products and services).

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Cataloging-in-Publication Data available on request from the Publisher ISBN: 978-1-9752-2070-9

This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.

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It is with appreciation that I dedicate this book to: The incredible nurses who provide tireless care to patients and their families every day. And, to my family for your love and support. Dedication

Contributors and Consultants

Keelin Cromar, RN, MSN Adjunct Faculty Wilson School of Nursing Midwestern State University Wichita Falls, Texas

Katrin Moskowitz, DNP, FNP, PMHNP APRN New England Mind Matters Torrington, Connecticut

Lauren Pohlman, BSN Registered Nurse Emergency Department Bon Secours Mercy Health Fairborn, Ohio Luke Pohlman, AGACNP-BC APRN Intensive Care Unit Premier Health Troy, Ohio

Margaret Gingrich, BSN, MSN Professor of Nursing Department of Nursing Harrisburg Area Community College Harrisburg, Pennsylvania Joseph Gucwa, EMT-P, RN, BSN Flight Nurse Trauma One Flight Services UF Health Shands Jacksonville Jacksonville, Florida

Leigh Trujillo, DNP, MSN Manager of Quality and Risk Department of Quality Community Stroke and Rehabilitation Center Crown Point, Indiana

Mary K. Hunt, DNP, CNM, ENP-BC, FNP-BC, PMHNP-BC Assistant Professor Department of Psychiatric Nursing Frontier Nursing University Versailles, Kentucky Rachel Koransky-Matson, DNP, MSN, FNP-C, CNE Diabetes Nurse Practitioner Department of Endocrinology

Jane Von Dohre, MSN Registered Nurse Emergency Trauma Center Miami Valley Hospital Dayton, Ohio

Northern Light Mayo Dover-Foxcroft, Maine

Estella Wetzel, DNP, APRN, FNP-C Regional Clinical Faculty, Instructor

Phyllis Magaletto, MS, RN, BC RN Professor Department of Nursing Cochran School of Nursing Yonkers, New York

Family Nurse Practitioner Frontier Nursing University Versailles, Kentucky

vii

Foreword

Medical–surgical nursing is alive and well! Once considered a basic skill required of all nurses, medical–surgical nursing has become increasingly complex, evolving into a vital specialty nurs ing practice. Medical–surgical nurses care for a growing number of health care consumers with complex medical needs as well as keep current with continuing developments in health care sci ence, technology, and economics. They overcome the challenges these developments can bring to providing patient care while continuing to provide high-quality nursing care to diverse patient populations in all stages of life. Specialty certification is the most important step a registered nurse can take in their career. It signifies a nurse’s commitment to professional growth and development and, most importantly, to provide safe, effective, timely, and high-quality patient care. Research by the American Board of Nursing Specialties confirms that certification validates specialized knowledge, enhances profes sional credibility and autonomy, indicates professional growth, and provides evidence of profes sional commitment. Lippincott’s Review for Medical-Surgical Nursing Certification will certainly help you in your pursuit of certification as a medical–surgical nurse. This review book offers the most current con tent typically included in medical–surgical nursing certification tests by both the Medical-Surgical Nursing Certification Board (MSNCB) of the Academy of Medical Surgical Nurses (AMSN) and the American Nurses Credentialing Center (ANCC). The core content of this new edition has been attentively revised to reflect the best available practices that influence medical–surgical nursing. It includes review topics on the foundations of nursing, legal and ethical aspects of nursing, principles of medical–surgical nursing and wound care, and disruptions in homeostasis. It also reviews the different body systems and associated diseases that certification exams frequently cover and that medical–surgical nurses commonly encounter. The content includes cultural and ethnic beliefs and practices, evidence-based practice, safety issues, health maintenance and wellness, and lifestyle management. Covered are collabora tion, patient’s bill of rights and self-determination, the developmental theories of Jean Piaget and Abraham Maslow, nutrition, substance use, abuse and neglect, complementary therapies, herbal remedies, adult immunizations, and laboratory values. The posttest practice questions have been extensively revised along with new questions at the end of each chapter. Additionally, an all-new online quiz bank can be found on to provide you with extra practice as you review this book. Access this free learning tool using the code printed at the front of your book. Whether you’re a newly graduated nurse exploring the specialty of medical–surgical nursing, a displaced nurse reentering the nursing profession, or a seasoned nurse wanting to update your skills and knowledge in medical–surgical nursing or become certified in this prestigious specialty, I know you’ll find this book a valuable addition to your library. More importantly, this book will give you the knowledge and confidence you need to ace the medical–surgical nursing certification exam. I wish you well as you move forward in this major endeavor—becoming certified as a medical– surgical nurse.

Laura M. Willis, DNP, APRN, FNP-C, CMSRN Family Nurse Practitioner/Lead APC Bon Secours Mercy Health Wittenberg University Health Center Springfield, Ohio

Contents

CONTRIBUTORS AND CONSULTANTS. . . . . . . . . . . . . . VII

FOREWORD. . . . . . . . . . . . . . . . . . . . . . . . . . . . IX

MEDICAL–SURGICAL NURSING CERTIFICATION. . . . . . . . . 1

Chapter 1

FOUNDATIONSOFNURSING.. . . . . . . . . . . . . . . . . . .7

Chapter 2

LEGAL AND ETHICAL ASPECTS OF NURSING . . . . . . . . . . . 23

Chapter 3

PRINCIPLES OF MEDICAL–SURGICAL NURSING. . . . . . . . . 37

Chapter 4

PRINCIPLESOFWOUNDCARE.. . . . . . . . . . . . . . . . . .50

Chapter 5

DISRUPTIONS IN HOMEOSTASIS . . . . . . . . . . . . . . . . . 60

Chapter 6

CARDIOVASCULAR DISORDERS. . . . . . . . . . . . . . . . . . 91

Chapter 7

HEMATOLOGIC DISORDERS. . . . . . . . . . . . . . . . . . . 119

Chapter 8

RESPIRATORY DISORDERS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

Chapter 9

NEUROLOGICDISORDERS.. . . . . . . . . . . . . . . . . . . 159

Chapter 10

MUSCULOSKELETAL DISORDERS. . . . . . . . . . . . . . . . . 184

Chapter 11

GASTROINTESTINAL DISORDERS. . . . . . . . . . . . . . . . 201

Chapter 12

SKINDISORDERS.........................221

Chapter 13

RENAL AND URINARY TRACT DISORDERS. . . . . . . . . . . . 252

Chapter 15

REPRODUCTIVE SYSTEM DISORDERS. . . . . . . . . . . . . . 270

Chapter 16

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Contents

IMMUNE SYSTEM DISORDERS. . . . . . . . . . . . . . . . . . 295

Chapter 17

EYE, EAR, AND NOSE DISORDERS. . . . . . . . . . . . . . . . .309

Chapter 18

PERIOPERATIVE NURSING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324

Chapter 19

APPENDIX. . . . . . . . . . . . . . . . . . . . . . . . . . . . .333

INDEX............................................................... 427

8 Hematologic Disorders

Chapter

Introduction ●● The average adult human has 4.5 to 5.5 L of blood in their body.

●● Blood circulates in the cardiovascular system, carrying oxygen and removing waste from cells. ●● The continuous movement of blood prevents stasis, which can increase the risk of infection and injury. ●● Red blood cells (RBCs), white blood cells (WBCs), and platelets are subject to pathologic alterations that can cause severe disruptions in homeostasis. ●● Nursing history ●● The nurse asks the patient about their chief complaint . ●● A patient with a hematologic disorder may report any of the following signs or symptoms: aching bones, anorexia, bleeding gums, bruising, dyspnea, fatigue, infection, lethargy, malaise, nausea, nosebleeds, numbness, paresthesia, swollen and tender lymph nodes, tarry stools, tingling, vomiting, and heavy menses. ●● The nurse then questions the patient about their present illness . ●● Ask the patient about their symptoms, including when they started, associated symptoms, location, radiation, intensity, duration, and frequency. ●● Question the patient about what factors make the symptoms feel better or worse. ●● The nurse asks about medical history . ●● Ask about the present and past use of prescription and over-the-counter drugs, herbal remedies, and vitamin and nutritional supplements because many of these products can interfere with hematologic function. ●● Ask the patient about previous problems, such as anemia, leukemia, enlarged lymph nodes, malabsorption, and spleen or liver disorders. ●● Ask about previous treatments, such as blood transfusions and radiation treatments. ●● Question the patient about their diet, and look for deficiencies—for example, in folic acid, iron, or vitamin B 12 . ●● Ask about previous infections (cytomegalovirus [CMV], hepatitis C virus, Epstein–Barr virus [EBV], herpes simplex virus, and COVID-19). ●● The nurse then assesses the family history .

●● Ask about a family history of blood and lymph disorders, acquired and genetic. ●● Ask about a family history of cancers involving the blood or lymph systems. ●● The nurse obtains a social history . ●● Ask about ethnicity and race.

●● Inquire about the use of cigarettes, alcohol, and recreational drugs. ●● Ask about occupational or household exposure to radiation or chemicals. ●● Physical assessment ●● The nurse begins with inspection . ●● Observe the patient’s general appearance. Do they appear alert, confused, tired, or irritable? ●● Note the patient’s skin color; look for ecchymosis, diaphoresis, dyspnea, lesions, petechiae, and swelling of the lymph nodes. ●● Note the size and color of their tongue. ●● Ask the patient whether their abdominal girth is enlarged. Copyright © 2025 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.

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●● Next, the nurse uses palpation . ●● Palpate peripheral pulses, noting strength, rhythm, and rate. ●● Palpate the lymph nodes, noting temperature, consistency, mobility, shape, size, and tenderness; compare nodes on one side of the body with those on the other side. ●● Palpate the abdomen, noting tenderness, ascites, or enlarged organs. ●● Then the nurse auscultates . ●● Listen to heart sounds, noting abnormal sounds, rhythms, bradycardia, or tachycardia. ●● Auscultate the abdomen, noting bowel sounds, bruits, or venous hums. ●● Listen to all lung fields, noting any abnormal sounds. ●● The nurse then uses percussion . ●● Percuss the liver and spleen to estimate size. ●● Note the size and location of other abdominal organs. Anemias ●● Anemia exists when the body does not have enough RBCs or when RBCs do not have enough hemoglobin. ●● Types of anemia include blood loss or hemolysis and aplastic, iron deficiency, and megaloblastic anemias (see Types of anemia , pages 121–123). Disseminated Intravascular Coagulation ●● Description ●● Disseminated intravascular coagulation (DIC) is a serious blood coagulation disorder that occurs as a complication of conditions that accelerate blood clotting. ●● DIC is characterized by suppression of the fibrinolytic system and the development of small clots in the microcirculation, which consume clotting factors, resulting in excessive bleeding. ●● The disorder can result from septicemia, obstetric complications (abruptio placentae and amniotic fluid embolism), cancer, blood transfusion reactions, and liver disease. ●● Altered tissue profusion and multiple organ failure can occur; the mortality rate can exceed 50%. ●● Signs and symptoms ●● The main sign is abnormal bleeding, evidenced by cutaneous oozing, petechiae, ecchymosis, hematomas, gastrointestinal (GI) bleeding, and bleeding from wounds and IV sites. ●● Signs of organ compromise include dyspnea, oliguria, and muscle or abdominal pain; shock can also occur. ●● Diagnosis and treatment

●● Laboratory tests show a steadily decreasing platelet count; elevated prothrombin time (PT), partial thromboplastin time (PTT), plasma d-dimer, and fibrin degradation products; and decreased hemoglobin and hematocrit. ●● Medical management aims to identify and treat the underlying disorder, promote oxygenation, replace fluids and electrolytes, and provide hemodynamic support. ●● Treatments include platelets, cryoprecipitate, and fresh frozen plasma. ●● Nursing interventions ●● Early recognition of DIC improves patient outcomes; closely monitor for signs and symptoms of patients at risk. ●● When a patient has DIC, avoid trauma to skin or wounds to minimize bleeding, protect the patient from injury, and avoid dislodging clots. ●● Apply pressure to puncture sites until bleeding stops. ●● Monitor the patient’s vital signs, and administer IV fluids and blood products as ordered. ●● Monitor the patient’s intake and output carefully and record blood loss. ●● Watch for signs of tissue ischemia and failure. ●● Provide emotional support to the patient and family. Copyright © 2025 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.

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Disseminated Intravascular Coagulation

Box 8-1: Types of Anemia

This chart summarizes the etiology, signs and symptoms, medical management, and nursing interventions for each type of anemia, which is defined as a decreased number of red blood cells (RBCs). Description and Etiology Signs and Symptoms Medical Management Nursing Interventions

Anemia from blood loss Anemia resulting from the loss of more than 500 mL of blood • Acute blood loss, as in trauma or surgery • Chronic blood loss, as in menstrual or GI bleeding

• RBC count below normal on serum blood tests • Acute blood loss: sudden onset of symptoms, such as hypovolemia, hypotension, hypoxemia, irritability, stupor, weakness, tachycardia, and cool, moist skin • Chronic blood loss: gradual and vague symptoms, such as exertional dyspnea, increased fatigue, and pallor • Exertional dyspnea, fatigue, infections, pallor, and palpitations • Hemorrhage—bleeding (nasal, oral, rectal, or vaginal), ecchymosis, petechiae, or purpura • Low platelet, RBC, and WBC counts • Dry bone marrow—low number of stem cells found upon aspiration

• The source of the bleeding is identified and controlled through medical or surgical means. • Transfusion and iron supplementation may be needed. Packed RBCs are typically used if a blood transfusion is required. • Shock must be treated if it occurs. • Initial treatment involves removing the causative agent, if possible, and administering blood component transfusions. • Medications such as antithymocyte globulin (ATG), cyclosporine, granulocyte colony– stimulating factors, and granulocyte–monocyte colony–stimulating factor may be administered. • The idiopathic form of the disease is treated with steroids. • If the anemia cannot be reversed or if it results from an autoimmune disturbance, stem cell transplantation is recommended; this treatment is more effective if the patient does not receive blood products first and is younger than age 30.

• Monitor patient’s stool, urine, vomitus, or sputum for blood. • Control blood loss by applying pressure to obvious bleeding sites. • Preform dressing changes as needed to assess blood loss. • Utilize assessment skills to identify signs and symptom of internal bleeding. • Help identify the causative agent. • Assist a weak patient with daily activities. • If the patient has pancytopenia, take safety precautions and steps to control infection and bleeding because their ability to fight infection and sustain clotting is decreased. • Help the patient and family cope with the severity of the illness and its prognosis. (Death may result from infection or hemorrhage.) • If the patient is receiving ATG, perform skin testing, and monitor for allergic reaction.

Aplastic anemia Anemia that is caused by damage or suppression of the bone marrow leading to decreased blood cell production for all blood cell lines • Drug therapy with a chemotherapeutic drug, chloramphenicol, mephenytoin, phenylbutazone, or a sulfonamide • Exposure to environmental or occupational hazards, such as benzene, insecticides, or radiation • Infection, such as cytomegalovirus, Epstein– Barr virus, hepatitis, parvovirus B19, human immunodeficiency virus, or

miliary tuberculosis • Congenital causes

• Unknown etiology or an autoimmune disturbance (50% of cases)

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Chapter 8

Box 8-1: Types of Anemia (continued)

Description and Etiology

Signs and Symptoms

Medical Management

Nursing Interventions

Congenital hemolytic anemia: sickle cell anemia Anemia characterized by production of misshapen (sickle shaped) RBCs that do not bend or move easily through the vascular system. These cells may cause blockages or the damaged cells are destroyed. • Inherited (found primarily in persons of African descent due to heredity) Congenital hemolytic anemia: thalassemia Anemia characterized by missing amino acid chains that make up hemoglobin causing a deficiency in hemoglobin. • Inherited (primarily affects people of African, Asian, and Mediterranean descent) Iron deficiency anemia Anemia caused by iron supplies within the body • Chronic blood loss without iron replacement • Poor nutrition • Decreased iron absorption from the intestines • Increased need for iron, such as during childhood or pregnancy

• Abnormally shaped blood cells found on blood smear • Painful vaso-occlusive events in the extremities, lungs, or other affected organs (sickle cell crisis) • Other symptoms similar to other chronic anemias

• Hydroxyurea (Droxia or Hydrea) is a

• If the patient has sickle cell anemia, provide genetic counseling and options regarding gene replacement therapy. • Teach the patient to avoid factors that may precipitate sickle cell crisis, such as cold exposure, dehydration, excessive exercise, high altitudes, and smoking. • Monitor the patient closely during sickle cell crisis, especially regarding pain management and oxygenation.

chemotherapeutic drug that is used to reduce frequency of sickle cell crisis. • Supportive interventions are used to prevent infection, relieve pain, and provide fluid and oxygen during a sickle cell crisis, which can cause massive organ damage. • Stem cell transplant offers the chance for disease cure. • Genetic therapy is being investigated to facilitate prevention and cure. • Blood product transfusions are the primary treatment. • Chelating agents are used to remove excess iron from the blood after multiple transfusions have been administered. • Splenectomy may be required for severe thalassemia. • Stem cell transplant also is an option. • The cause of blood loss or nutritional deficits should be identified and corrected. • Oral iron supplementation may be prescribed. If the patient is unable to tolerate it, a parenteral iron formulation may be administered IM method or IV. • In extreme cases, blood transfusions may be administered.

• Cardiac problems, such as cardiomegaly, heart failure, and murmurs • Enlarged spleen • Excessive hematopoiesis and iron overload • Jaundice may also occur • Other symptoms similar to other chronic anemias • Fatigue due to RBC lack of ability to carry oxygen • Shortness of breath, pallor, dizziness, and headache • Cold sensitivity related to iron’s role in regulating body temperature • Brittle, spoon-shaped nails with longitudinal ridges • Cheilosis (painful mouth cracks or sores) and red, shiny tongue • Hypochromic, microcytic anemia (on blood smears); low serum iron level; and elevated serum iron-binding capacities

• Provide genetic counseling. • Monitor for activity intolerance due to impaired oxygenation.

• Help determine the cause of bleeding by testing stool, urine, vomitus, and sputum for blood. • Teach the patient how to take oral iron. Advise the patient to take iron pills with meals to reduce GI irritation and to continue therapy until the underlying problem is corrected. • Teach the patient about adverse reactions to oral iron therapy, such as black stools, constipation or diarrhea, and GI disturbances. • Educate the patient about nutrition, including the need for iron-rich foods and adequate vitamin C to enhance iron absorption.

(continued)

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Hemophilia

Box 8-1: Types of Anemia (continued)

Description and Etiology

Signs and Symptoms

Medical Management

Nursing Interventions

Megaloblastic anemia Anemia characterized by a predominance of megaloblast RBCs and a relative lack of normal RBC; includes pernicious, vitamin B 12 deficiency, and folic acid deficiency anemias • Gastric surgery, particularly of the terminal ileum where vitamin B 12 is absorbed; strict vegetarian diets; and prolonged exposure to nitrous oxide • Aging and long-term gastritis (pernicious anemia) • Alcoholic malnutrition and malabsorption (folic acid deficiency anemia)

• Provide care for oral mucous membranes to help relieve glossitis. • Teach the patient how to increase dietary intake of folic acid and vitamin B 12 . • Refer the patient with anemia related to alcohol • If the patient has a vitamin B 12 deficiency, teach them about long-term treatment with an oral or parenteral vitamin B 12 supplement. Treatment typically calls for IM administration of cyanocobalamin (B 12 ). misuse to an alcohol treatment program.

• Fatigue, loss of coordination, neuropathy, and paresthesia of the extremities • Gastritis, glossitis (red, beefy tongue), and malabsorption with anorexia and weight loss • Decreased RBC, platelet counts, and vitamin levels.

• Monthly administration of parenteral vitamin B 12 typically is required for pernicious and vitamin B 12 deficiency anemias. • An oral folic acid supplement and dietary improvement typically are required for a patient with folic acid deficiency, which commonly results from nutritional deficits.

From Braunstein, E. M. (2022). Overview of anemia. Merck Manual Professional Version. https://www.merckmanuals.com/home/ blood-disorders/anemia/overview-of-anemia

Hemophilia

●● Description ●● Hemophilia is a hereditary bleeding disorder that results from the lack of specific clotting factors. ●● Hemophilia A, called “classic hemophilia,” results from deficiency of factor VIII and is the most prevalent type of hemophilia, representing about 80% to 85% of cases. ●● Hemophilia B, sometimes called “Christmas disease,” results from deficiency of factor IX and is seen in around 15% of cases. ●● Hemophilia A and B are X-linked recessive traits; female carriers have a 50% chance of transmitting the gene to each child; sons who receive the gene have the disease, whereas daughters who receive the gene are carriers; patients with the disease are usually identified in childhood. ●● Hemophilia produces bleeding, though the degree of bleeding varies depending on the degree of clotting factor deficiency. ●● Mild hemophilia usually causes bleeding only during major surgery or trauma. ●● Moderate hemophilia occasionally causes spontaneous bleeding in addition to bleeding during surgery and from trauma. ●● Severe hemophilia causes spontaneous bleeding; bleeding from minor trauma may be severe. ●● Signs and symptoms ●● Signs of hemophilia include excessive bleeding from wound and puncture sites, hematomas, ecchymosis, spontaneous bleeding (epistaxis), and GI bleeding. ●● Bleeding into joints (hemarthrosis) is a common occurrence; this can lead to joint inflammation, pain, and stiffness. ●● A change in level of consciousness can signal intracranial bleeding. ●● Diagnosis and treatment ●● If a family history of hemophilia is present, chorionic villous sampling or amniocentesis may be completed for diagnosis before birth.

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●● Laboratory testing includes clotting factor assays, which will reveal the type and severity of disease. ●● Additional laboratory testing includes a complete blood count (CBC); PT, which often remains normal; and PTT, which may be prolonged by two to three times normal. ●● Treatment typically consists of replacement of deficient clotting factors (VIII or IX); however, patients can develop antibodies to factor concentrates, which reduces their effectiveness. ●● Tranexamic acid and epsilon aminocaproic acid inhibit fibrinolysis and can be used to stabilize clots. ●● Desmopressin (DDAVP) can be used to induce a transient rise in factor VIII. ●● The monoclonal antibody emicizumab has been found to mimic the function of factor VIII and is considered a breakthrough in hemophilia treatment. ●● Nursing interventions ●● During bleeding episodes, administer clotting factors or plasma as ordered. ●● Prevent trauma and limit activity when bleeding occurs. ●● Minimize injections and apply pressure for at least 10 minutes to puncture sites. ●● Monitor vital signs and be alert for hemodynamic changes. ●● Administer analgesics and cold packs for joint pain; promote joint mobility when bleeding is controlled. ●● Teach the patient and family about the disease process, monitoring, treatment, and genetic testing. Hodgkin Lymphoma ●● Description ●● Hodgkin lymphoma is a malignant B lymphocyte cell line disease of the lymph system that primarily affects those between ages 15 and 30 and those older than age 55. ●● The malignant cell associated with Hodgkin lymphoma is the Reed–Sternberg cell, a giant, morphologically unique cell that is usually an abnormal type of B lymphocyte. ●● Although the cause is unknown, this cancer is associated with viral infections (EBV) and prolonged immunosuppression; a genetic and environmental association may also exist. ●● It is among the most treatable of adult cancers and has a better prognosis than malignant or non-Hodgkin lymphoma. ●● Signs and symptoms ●● This cancer is characterized by greatly enlarged, painless, movable lymph nodes in the cervical or supraclavicular area. ●● The patient may also experience fever, night sweats, severe pruritus, and weight loss (referred to as “B” or systemic symptoms). ●● Symptoms resulting from compression by the enlarged lymph nodes depend on the area involved. ●● Diagnosis and treatment ●● Laboratory testing may include an immunohistochemistry, a blood test that can detect cells that are found on the surface of Reed–Sternberg cells.

●● Lymph node biopsy showing Reed–Sternberg cells supports the diagnosis. ●● Staging is done after the initial diagnosis of Hodgkin lymphoma is confirmed.

●● The stage of disease is determined by biopsies of distant lymph nodes, bilateral bone marrow biopsies, lymphangiography, computed tomography scan or magnetic resonance imaging of the thorax and abdomen, positron emission tomography, chest x-ray, a CBC, and serum alkaline phosphatase. ●● A splenectomy is usually done during staging. ●● Hodgkin lymphoma has four stages (see Staging lymphomas , page 125). ●● Generally, all stages of Hodgkin lymphoma are treated with a combination of chemotherapy and radiation. ●● Autologous stem cell transplantation and immunotherapy are used for disease resistant to standard treatment. ●● Nursing interventions ●● Provide supportive care related to the adverse effects of radiation therapy and chemotherapy (see Nursing implications in oncology care , pages 348–354). ●● Provide psychological support to help the patient cope with the diagnosis, treatment, and effects of treatment. ●● Provide education to the patient and their family regarding the diagnosis of Hodgkin lymphoma and its treatment. Copyright © 2025 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.

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Non-Hodgkin Lymphoma

Non-Hodgkin Lymphoma ●● Description ●● Non-Hodgkin lymphoma describes a group of malignant neoplasms arising from abnormal lymphocytes that affect the immune system; this disease typically produces systemic symptoms as it is usually disseminated when diagnosed. ●● It may be associated with viral infection (T-cell lymphotropic virus, EBV, human immunodeficiency virus, congenital immunodeficiency, autoimmune diseases, or immunosuppression after organ transplantation) ●● Exposure to radiation and chemicals, including certain herbicides and insecticides, has been linked to an increased lymphoma risk. ●● The prognosis for non-Hodgkin lymphoma varies greatly and depends on the histologic type and progression of the disease. ●● Signs and symptoms ●● Non-Hodgkin lymphoma can affect any organ or tissue and produces a wide range of symptoms. ●● Signs and symptoms resemble those of Hodgkin lymphoma. ●● Fever, painless lymphadenopathy, night sweats, severe pruritus, chest pain or pressure, shortness of breath, cough, abdominal pain or swelling, and weight loss are common signs and symptoms. ●● Diagnosis and treatment ●● Diagnostic procedures are similar to those for Hodgkin lymphoma; however, Reed–Sternberg cells are not present. ●● Staging is similar to Hodgkin lymphoma (see Staging lymphomas ). ●● Radiation therapy, chemotherapy, immunotherapy, targeted therapy, and stem cell transplantation are used to treat non-Hodgkin lymphoma. ●● Nursing interventions ●● Educate the patient and family about treatment, transfusions, chemotherapy, and stem cell transplantation. ●● Initiate interventions similar to those for leukemia and Hodgkin lymphoma. ●● Prevent infection. ●● Support nutritional status. Hodgkin lymphoma and non-Hodgkin lymphoma are classified into stages so that treatment protocols can be established and outcomes predicted. The Lugano classification system is used that is based on the original Ann Arbor classification system. Stage I Involvement of a single lymph node region OR Localized involvement of a single extranodal organ or site Stage II Involvement of two or more lymph node regions on the same side of the diaphragm OR Localized involvement to a single associated extranodal organ or site and its regional lymph nodes with or without other lymph node regions on the same side of the diaphragm Stage III Involvement of lymph node regions on both sides of the diaphragm that may also be accompanied by localized involvement of an extranodal organ or site, by involvement of the spleen, or by both Stage IV Widespread involvement of one or more extralymphatic sites with or without associated lymph node involvement OR Isolated extralymphatic organ involvement with distant (nonregional) nodal involvement Extralymphatic sites include the liver, lungs, bone marrow, pleurae, bone, and skin as well as tissues separate from but near to major lymphatic clusters. The spleen is considered a lymphatic site. Letter Designation The stages are also accompanied by a letter designation that refers to patient symptoms as follows: • A means absence of the specific symptoms listed in B but may include other common symptoms such as pruritus. • B includes the presence of at least one of the following three symptoms: ––Temperature greater than 100.4°F (38°C) ––Unexplained loss of more than 10% of body weight in the preceding 6 months ––Drenching night sweats Box 8-2: Staging Lymphomas

From American Cancer Society (ACS). (2023). Hodgkin lymphoma . https://www.cancer.org/cancer/hodgkin-lymphoma/about.html

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Chapter 8

Leukemia

●● Description ●● Leukemias are a group of malignant disorders of the hematopoietic system and are characterized by the uncontrolled proliferation of immature WBCs. ●● Leukemias are classified by onset and severity of symptoms (acute or chronic) and by the precursor cell (myeloid or lymphoid) involved in the formation of the abnormal cells (National Cancer Institute [NCI], 2023a) (see Types of leukemia, page 128). ●● Although the cause of leukemia is unknown, it has been linked to genetic damage to bone marrow cells, which transforms normal cells into malignant cells—chronic exposure to chemicals such as benzene, use of drugs that cause aplastic anemia, radiation exposure, and chemotherapy; it is also linked to Down syndrome and other chromosomal abnormalities. ●● Leukemia causes uncontrolled WBC (leukocyte) proliferation that interferes with the production of other cells, leading to thrombocytopenia and anemia; the immature leukocytes decrease immunocompetence and increase susceptibility to infection. ●● Signs and symptoms ●● Patients with acute or chronic leukemia may report vague signs and symptoms, such as fatigue, malaise, petechiae, night sweats, bone or joint pain, and weight loss. ●● Acute leukemia produces anemia, bleeding, and symptoms of infection such as sudden onset of high fever. ●● Hepatosplenomegaly and lymphadenopathy may also be present; chronic leukemia causes milder anemia and splenomegaly; however, many patients are asymptomatic at the time of diagnosis. ●● Additional signs and symptoms depend on the organ or tissue involved—for example, central nervous system involvement may cause headache and vomiting. ●● Diagnosis and treatment ●● Diagnosis is usually based on a CBC with differential and bone marrow aspirate that reveal leukemic blast cells. ●● Phased chemotherapy and targeted therapy, with or without stem cell transplantation, is standard treatment for leukemia (see Nursing implications in oncology care , pages 348–354). ●● Radiation and immunotherapy are also used to augment leukemia treatment. ●● Patients with low-risk chronic lymphocytic leukemia may not receive treatment if they are asymptomatic. ●● Stem cell transplantation is used to treat leukemia. ●● In allogenic transplantation , donor stem cells are transplanted into the patient. ●● Before transplantation, the patient undergoes chemotherapy and sometimes radiation to eliminate the leukemic cells; these procedures destroy all the patient’s bone marrow in preparation for grafting from the donor. ●● The principal complication of this type of transplantation is graft-versus-host disease, a type of organ rejection in which the transplanted cells reject the patient. ●● Autologous transplantation is an alternative method where the patient’s own stem cells are harvested during remission; these cells are then treated to remove residual tumor cells and reinfused after the patient undergoes immunosuppressant chemotherapy and radiation therapy; this method can help to avoid graft versus host disease because the patient receives their own cells.

●● Blood component transfusions may be necessary to treat severe thrombocytopenia, leukopenia, and anemia resulting from the disease process or from treatment (see Blood and plasma transfusion compatibility, page 128). ●● Most RBC transfusions involve 250 to 300 mL/unit of packed RBCs; whole blood is seldom transfused to treat leukemia. ●● The blood must be refrigerated until it is used. ●● The nurse must: ●● Verify the provider order. ●● Ensure appropriate IV size (18G) for blood administration. ●● Educate the patient regarding the procedure. ●● Check crossmatching and blood typing and the blood product with at least one other licensed nurse based on facility policy. ●● Take baseline vital signs before transfusion, and monitor cardiac status before and during transfusion. Copyright © 2025 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.

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●● Administer blood through a filter (only with normal saline solution). ●● Infuse it slowly (2 to 4 hours/unit). ●● Observe for reactions, and record vital signs at least hourly and at the end of the transfusion (see Guide to immediate transfusion reactions , page 129). ●● Platelet transfusions may be prescribed. ●● Platelets should not be refrigerated. ●● The nurse must: ●● Verify the provider order. ●● Ensure appropriate IV access. ●● Educate the patient regarding the procedure. ●● Take baseline vital signs before transfusion. ●● Premedicate with steroids or antihistamines, as prescribed, to prevent reactions. ●● Administer platelets through a filter (only with normal saline solution). ●● A 6-unit IV bolus of platelets should be infused over 20 to 30 minutes. ●● Observe for reactions, and record vital signs at least hourly and at the end of the transfusion (see Guide to immediate transfusion reactions , page 129). ●● WBC transfusions, though rarely used, must be infused within 24 hours of collection; the process for WBC transfusions is similar to that for RBC transfusions. ●● Nursing interventions ●● Follow infection control procedures if the WBC count is low, also known as neutropenia —place a severely neutropenic patient in a private room with no flowers, plants, or fresh fruits; avoid unnecessary invasive procedures; limit patient contact with infected personnel or visitors; and teach hand hygiene techniques to the patient, family, and visitors. ●● Educate the patient about use of personal protective equipment (high quality mask) when in public places to decrease risk of respiratory infections (COVID-19, influenza, etc.). ●● For a patient with a low platelet count, monitor blood counts and take precautions to prevent bleeding— avoid parenteral injections, limit venipuncture, and advise the patient to use an electric razor for shaving and a soft toothbrush for brushing teeth. ●● Prevent or manage stomatitis (oral/GI mucosa breakdown) by inspecting the oral cavity daily and encouraging oral care with prescribed mouth rinses on a regular basis. ●● Teach the patient how to care for an indwelling vascular access device and how to detect signs of infection. ●● Educate patients undergoing chemotherapy about the side effects, adverse effects, and length of treatment. ●● Provide supplemental feedings as prescribed. ●● Conserve the patient’s energy, but promote independence. ●● Provide emotional support to the patient and family, and encourage them to verbalize feelings. Multiple Myeloma ●● Description ●● Multiple myeloma is a malignancy of plasma cells found in bone marrow; these cells are an important part of the immune system that make antibodies. ●● Malignant plasma cells produce an increased amount of a specific nonfunctional immunoglobulin. ●● Overgrowth of malignant cells can impair formation of all types of blood cells leading to anemia, thrombocytopenia, and/or leukopenia.

●● Myeloma cells also speed up osteoclast activity, causing weakling of bones and increased risk for fractures. ●● This type of cancer is slightly more common in men, and the rate for Black males is double that of White males. ●● Risk for multiple myeloma increases with age; most cases are diagnosed after age 65, and the average age of diagnosis is 75. ●● Other risks include radiation exposure, family history, obesity, and occupational exposure in petroleum related industries. ●● Signs and symptoms ●● Severe bone pain, confusion, weakness, dizziness, weight loss, fractures, renal failure, frequent infections, and skeletal deformities. Copyright © 2025 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited.

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Chapter 8

Box 8-3: Types of Leukemia

The following chart compares the incidence and signs and symptoms for various types of leukemia. Leukemia Incidence Signs and Symptoms

Acute leukemias Acute lymphocytic leukemia (ALL)

• Children under the age of 5 have the highest risk for developing ALL. Risk declines into the teens and 20s, then increases again after age 50. • Survival rates are higher in children than adults, and the prognosis for ALL is better than that of acute myeloblastic leukemia (AML). • Primarily affects those over 45; the incidence increases with age. • Survival rates for AML have improved with the use of autologous and allogenic bone marrow transplants. • Primarily affects men; the average age of diagnosis is 70 years. • CLL runs a long course (4–10 years) and rarely progresses to acute leukemia. • The average age at diagnosis is around 65 years of age. • CML may take years to cause issues and has had treatment breakthroughs including the oral medication imatinib (Gleevec).

• Anemia with fatigue and pallor • Bleeding, such as ecchymosis, gingival or rectal bleeding, and petechiae • Fever • Hepatosplenomegaly • Decreased hematocrit, hemoglobin level, and platelet count; lymphoblasts present on peripheral blood smear • Infections, particularly those of the mucous membranes, respiratory tract, and skin • Normal, decreased, or increased WBC count • Bone or joint pain, fever without infection, hepatosplenomegaly, lymphadenopathy, and weight loss • Enlarged spleen • Lymphadenopathy • Lymphocytosis (on peripheral blood smear) • Hepatosplenomegaly • Anemia and increased WBC and platelet counts • Presence of Philadelphia chromosome on genetic screening

Acute myeloid leukemia (AML)

Chronic leukemias Chronic lymphocytic leukemia (CLL)

Chronic myeloid leukemia (CML)

From Markman, M. (2022). Types of leukemia . City of Hope. https://www.cancercenter.com/cancer-types/leukemia/types

Box 8-4: Blood and Plasma Transfusion Compatibility

For a blood or plasma transfusion to be safe, the patient and donor must have compatible blood types. The chart below allows you to determine compatibility. Keep in mind that, before transfusing begins, the blood product must be crossmatched to fully establish donor–recipient compatibility. Blood Product Compatibility Chart Recipient Blood Type Compatible Whole Blood Type Compatible Red Blood Cell Type Compatible Plasma Type (Rh Match Not Needed)

O Rh+ O Rh− A Rh+ A Rh− B Rh+ B Rh− AB Rh+

O Rh+, O Rh−

O, A, B, AB O, A, B, AB

O Rh−

A Rh+, A Rh−

A Rh+, A Rh−, O Rh+, O Rh−

A, AB A, AB B, AB B, AB

A Rh−

A Rh−, O Rh−

B Rh−

B Rh−, O Rh−

AB Rh+, AB Rh−

AB Rh+, AB Rh−, A Rh+, A Rh−, B Rh+, B Rh−, O Rh+, O Rh− AB Rh−, A Rh−, B Rh−, O Rh−

AB Rh−

From American Society of Hematology. (2023). Blood safety and matching . https://www.hematology.org/education/patients/ blood-basics/blood-safety-and-matching

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Box 8-5: Guide to Immediate Transfusion Reactions

Any patient receiving a transfusion of blood or blood products is at risk for a transfusion reaction. An immediate reaction may occur during the transfusion itself or several hours after the transfusion. The chart below describes immediate reactions. Reaction Cause Signs and Symptoms Nursing Interventions Acute hemolytic

• Administration of incompatible blood • Antibodies in the blood targeting donor antigens

• Chest pain • Dyspnea • Facial flushing

• Monitor the patient carefully, especially during the first 15 minutes of any transfusion. If the patient exhibits signs of a reaction, stop the transfusion immediately. • Administer IV fluids, oxygen, epinephrine, and vasopressors, as ordered. • Observe the patient for signs of coagulopathy. • Provide antibiotics as ordered. • Monitor the patient for fever for several hours after completion of the transfusion. • Obtain blood cultures from a site other than IV infusion site. • Keep all blood bags and tubing and send them to the blood bank. • Relieve signs and symptoms with an antipyretic. • If the patient requires further transfusions, consider using a leukocyte removal filter.

• Fever • Chills • Hypotension • Flank pain • Bloody oozing at the infusion or surgical incision site • Nausea • Tachycardia

Bacterial contamination

• Contamination of blood product

• Chills • Fever • Vomiting • Abdominal cramping • Diarrhea • Shock

Febrile nonhemolytic

• Cytokines from leukocytes in transfused red cell or other blood components cause a reaction in the recipient

• Fever within 2 hours of transfusion

• Chills • Rigor

• Headache • Palpitation • Cough • Tachycardia

Transfusion-related acute lung injury (TRALI)

• Granulocyte antibodies in the donor or recipient react with one another and subsequently cause pulmonary edema in the recipient

• Severe respiratory distress within 6 hours of transfusion

• Stop the transfusion immediately.

• Fever • Chills • Cyanosis • Hypotension

• Provide oxygen as needed. • Monitor pulse oximetry. • Prepare for intubation and ventilatory support and hemodynamic monitoring.

Allergic reaction • Allergic reaction to the allogenic proteins in the donor’s plasma

• Urticaria • Fever • Nausea and vomiting

• Stop the transfusion and administer antihistamine, corticosteroid, or epinephrine, as ordered. • Prepare for intubation and respiratory support if the patient develops anaphylaxis. • Monitor intake and output, breath sounds, and blood pressure. • Administer diuretics as ordered. • Closely monitor older adult patients and those with a history of cardiac disease carefully because they are at higher risk.

• Anaphylaxis (facial swelling, laryngeal edema, respiratory distress) in extreme cases

Transfusion associated circulatory overload (TACO)

• Rapid infusion of blood or excessive volume of transfusion causes hypervolemia

• Chest tightness • Chills • Dyspnea

• Tachypnea • Hypoxemia

• Hypertension and jugular vein distention that occurs 2–6 hours after transfusion

From Suddock, J. T., & Crookston, K. P. (2022). Transfusion reactions. StatPearls . StatPearls Publishing. https://www.ncbi.nlm.nih. gov/books/NBK482202/

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