NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Blood and Lymphatic System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Spleen

Focus topic: Medical–Surgical Nursing

Definition: A gland-like organ located in the upper left part of the abdominal cavity; it is a storage organ for red corpuscles and, because of a large number of macrophages, acts as a blood filter.

Characteristics
A. Functions as a blood reservoir.
B. Purifies blood by removing waste and infectious organisms.
C. Destroys old red blood cells.
D. Is the primary source of antibodies in infants and children.
E. Produces lymphocytes, plasma cells, and antibodies in adults.
F. Produces erythrocytes in fetus.
G. Destroys erythrocytes when they reach the end of their life span.

Medical–Surgical Nursing: Hypersplenism

Focus topic: Medical–Surgical Nursing

Definition: The premature destruction of erythrocytes, leukocytes,
and platelets.

Characteristics
A. The most common form of hypersplenism is congestive splenomegaly, usually due to portal hypertension secondary to cirrhosis.
B. Other causes are idiopathic thrombocytopenia, thrombosis, stenosis, or atresia.
C. Secondary hypersplenism occurs in association with leukemias, lymphomas, Hodgkin’s disease, and tuberculosis.
D. Treatment: correct underlying condition and/or splenectomy.

Medical–Surgical Nursing: Rupture of the Spleen

Focus topic: Medical–Surgical Nursing

Definition: Traumatic rupture following violent blow or trauma to the spleen.

Assessment
A. Assess weakness due to blood loss.
B. Evaluate abdominal pain and muscle spasm particularly in the left upper quadrant.
C. Assess for rebound tenderness.
D. Assess for referred pain to left shoulder.
E. Palpate for tenderness.
F. Check leukocytes (well over 12,000).
G. Assess for progressive shock with rapid, thready pulse; drop in blood pressure; and pallor.

Implementation
A. Prepare for surgical intervention—splenectomy.
B. Prevent infection.
C. Monitor vital signs closely.

Medical–Surgical Nursing: Splenectomy

Focus topic: Medical–Surgical Nursing

Definition: Excision of the spleen.

Assessment
A. Evaluate indications for surgical intervention.

  • Trauma.
  • Hypersplenism.
  • Idiopathic thrombocytopenia.
  • Hodgkin’s disease.
  • Lymphoma.

B. Observe for signs of infection.
C. Assess vital signs for baseline data.

Implementation
A. Prevent thrombus formation.

  • Initiate bed exercises.
  • Ambulate early.
  • Provide adequate hydration.

B. Prevent respiratory complications due to reduced expansion of left lung and location of spleen near diaphragm.

  • Turn, cough, and deep-breathe every 2 hours.
  • Maintain intermittent positive-pressure breathing (IPPB) if prone to upper respiratory infection (URI).

C. Prevent infection if rupture occurs.

  • Observe for signs of infection.
  • Administer antibiotics.

Medical–Surgical Nursing: Neoplastic Blood Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Leukemia

Focus topic: Medical–Surgical Nursing

Definition: A malignant disorder of blood-forming tissue characterized by neoplastic proliferation of hematopoietic cells or their precursors.

Medical–Surgical Nursing

Characteristics
A. The increased proliferation process alters the cell’s ability to mature and/or function correctly.
B. In acute processes the predominant cell is poorly differentiated, but in chronic processes the leukemic cell is well defined.
C. Anemia results from an increased number of white blood cells that are immature and do not function normally, and a decreased number of red blood cells, hemoglobin, and platelets.

D. Diagnostic tests.

  • Bone marrow aspiration/biopsy.
  • Differential count.

E. Etiology—predisposing factors.

  • Excess radiation exposure.
  • Viral factors.
  • Immune alteration.
  • Noxious chemicals and drugs.
  • Bone marrow alterations.

Assessment
A. Assess for sudden high fever with abnormal bleeding.
B. Assess for nosebleeds, purpura, ecchymosis, petechiae, or prolonged menses.
C. Evaluate general nonspecific symptoms such as weakness, lethargy, low-grade fever.
D. Evaluate recurrent infections if any of the above symptoms are present.

Implementation
A. Administer chemotherapeutic agents.

  • Specific drugs and combinations are ordered according to the specific type of leukemia and whether it is acute or chronic.
  • See chemotherapy drugs and protocol in Oncology Nursing.

B. Prevent complications related to the side effects of drugs.

  • Proper mouth care (ulcerations and bleeding).
  • Anorexia.

C. Maintain fluid and electrolyte balance.
D. Administer Zyloprim (allopurinol) to combat problems associated with increased serum uric acid (from rapid destruction of body tissue).
E. Provide high-calorie, high-vitamin diet to prevent weight loss, weakness, debilitation.
F. Provide emotional support for

  • Alopecia.
  • Altered body image.
  • Fear of dying.
  • Depression.
  • Financial burden.

G. Provide client education.

  • Drugs—dosage and side effects.
  • Associated treatments.
  • Disease process.

H. Prevent infections, ulcerations, hemorrhage.

Medical–Surgical Nursing: Acute Myeloid Leukemia

Focus topic: Medical–Surgical Nursing

Characteristics
A. Incidence: occurs more commonly at adolescence and after age 55. Slightly higher incidence in males. Onset can be insidious or rapid.
B. Pathophysiology: uncontrolled proliferation of myeloblasts (precursors of granulocytes), which replace normal cells in the marrow.

Assessment
A. Assess for anemia and symptoms of dyspnea, fatigue, pallor, palpitations.
B. Assess for symptoms of platelet deficiency: epistaxis, gingival bleeds, purpura, petechiae, or bleeding in major systems.
C. Assess for symptoms of local abscesses, elevated temperature, chills.
D. Palpate for splenomegaly.
E. Assess for lymph node enlargement and difficulty with respiration and swallowing.
F. Assess for bone pain.
G. Evaluate CNS involvement with signs of increased intracranial pressure (ICP).
H. Check for hyperuricemia (excessive uric acid).

Implementation
A. Administer chemotherapy, called induction therapy.

  • Ara-C (cytarabine), Cerubidine (daunomycin), Novantrone (mitoxantrone), or Idamycin (idarubicin).
  • Seventy percent of clients suffer a relapse and long-term survival is only 5%.

B. Bone marrow transplant is another option for treatment.
C. Administer antibiotics for increased temperature.
D. Monitor platelet administration when bleeding occurs.
E. Administer allopurinol when hyperuricemia occurs.

Medical–Surgical Nursing: Chronic Myeloid Leukemia

Focus topic: Medical–Surgical Nursing

Characteristics
A. Incidence: primarily a disease of young adults (age 30 to 50). Thought to have a genetic origin. Philadelphia chromosome is involved.
B. Pathophysiology: abnormal stem cell leading to a marked increase of granulocytes and megakaryocytes (platelet cells). The mature neutrophil is the cell that is predominant.
C. Clients may be without symptoms.

Assessment
A. Assess for fatigue and malaise.
B. Palpate for large, tender spleen.
C. Observe skin for pallor, purpura, nodules.
D. Assess for abdominal discomfort.
E. Evaluate fever, heat intolerance, or increased perspiration.
F. Assess for retinal hemorrhage.
G. Assess for bone pain.
H. Assess anemia.
I. Evaluate increased uric acid level.

Implementation
A. Administer oral alkylating agent Myleran (busulfan) and Hydrea (hydroxyurea).
B. Prepare for splenectomy or irradiation.
C. Instruct client and family in preventive principles.

  • Good nutrition.
  • Prevention of infection.
  • Complicating signs.
  • Skin care.
  • Adequate rest to minimize weakness.

Medical–Surgical Nursing: Chronic Lymphocytic Leukemia

Focus topic: Medical–Surgical Nursing

Characteristics
A. Incidence—insidious onset, most common in ages 50 to 70.
B. Pathophysiology—the small lymphocyte (B cell) is the predominant cell type and eventually leads to decreased production of other hematopoietic cells.

Assessment
A. Many clients are asymptomatic but diagnosed by increased lymphocyte count.
B. Assess classic signs.

  • Weakness, fatigue, and lymphadenopathy.
  • Anemia.
  • Weight loss.
  • Abdominal discomfort with hepatomegaly/ splenomegaly.
  • Vesicular skin lesions.

C. Assess less common signs.

  • Excessive diaphoresis.
  • Infection.

Implementation
A. Administer drugs: Leukeran (chlorambucil), Cytoxan (cyclophosphamide), and glucocorticoids.

  • Clients who don’t respond may go into remission with Fludara (fludarabine).
  • Fludara may cause bone marrow depression; clients at risk for infections.

B. Prepare for splenectomy in some cases.
C. Prevent infection, be especially oriented toward maintaining clean skin.
D. Observe for complications: thrombocytopenia.
E. Provide emotional support.

Medical–Surgical Nursing: Acute Lymphocytic Leukemia

Focus topic: Medical–Surgical Nursing

Characteristics
A. Incidence—usually appears before age 15 but is highest in 3- to 4-year-olds. Males slightly more at risk. More than 80% of all children survive 5 years or more.
B. Pathophysiology—uncontrolled proliferation of lymphoblasts with eventual reduction of other blood cells.

Assessment
A. Assess for malaise, fatigue, and fever.
B. Assess bone involvement, and lymph and spleen alterations.
C. Check for bleeding gums, skin, and nose.
D. Evaluate CNS symptoms, especially stiff neck and headache.

Implementation
A. Prepare for induction therapy.
B. Maintain therapy when in remission.
C. Administer drugs.

  • Purinethol (mercaptopurine; 6-MP) and Trexall.
  • Oncovin (vincristine) and Deltasone (prednisone) intermittently.

D. Complete remission occurs in more than 90% of clients treated with drug protocols.

Medical–Surgical Nursing: Malignancy of the Lymphatic System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Hodgkin’s Disease

Focus topic: Medical–Surgical Nursing

Definition: A chronic, progressive, neoplastic, invariably fatal reticuloendothelial disease involving the lymphoid tissues of the body. It is most common between the ages of 20 and 40. While the exact etiology is unknown, the suspected sources are viral (20% of clients are infected with Epstein-Barr virus), environmental, genetic, and immunologic. Onset is often insidious.

Medical–Surgical Nursing

Assessment
A. Assess for painless enlargement of cervical lymph nodes.
B. Assess for severe pruritus.
C. Evaluate irregular fever, night sweats.
D. Palpate for splenomegaly and hepatomegaly.
E. Observe for jaundice, weight loss.
F. Assess edema and cyanosis of the face and neck.
G. Evaluate pulmonary symptoms including dyspnea, cough, chest pain, cyanosis, and pleural effusion.
H. Assess for fatigue, malaise, and anorexia, which indicate progressive anemia.
I. Evaluate bone pain and vertebral compression.
J. Assess nerve pain and paraplegia.
K. Assess laryngeal paralysis.
L. Evaluate increased susceptibility to infection.
M. Assess degree of staging—crucial to treatment regimen.

  • Stage I: Disease is restricted to single anatomic site, or is localized in a group of lymph nodes; asymptomatic. Treatment: If nodes are above diaphragm, radiation alone. Depending on size of nodes, chemotherapy may be added.
  • Stage II: Two or three adjacent lymph nodes in the area on the same side of the diaphragm are affected. Treatment: Same as above. If lymph nodes are large, combination radiation and chemotherapy.
  • Stage II(E): Localized extralymphatic site on same side of diaphragm.
  • Stage III: Disease is widely disseminated on both sides of diaphragm into the lymph areas and organs. Treatment: Full-dose chemotherapy and radiation to areas of enlarged nodes.
  • Stage IV: Involvement of bone, bone marrow, pleura, liver, skin, gastrointestinal tract, central nervous system, and gradually the entire body. Treatment: Six rounds of chemotherapy with CT and PET scans for monitoring; may also get radiation.

N. B symptoms: fever over 38°C (100.4°F), night sweats, more than 10% weight loss.

Implementation
A. Provide supportive relief from effects of radiation and chemotherapy.

  • Side effects include nausea and vomiting.
  • Controlled by premedication of sedatives and antiemetic agents.

B. Assist client to maintain as normal a life as possible during course and treatment of disease.

  • Counsel client and family to accept process of treatment.
  • Provide supportive assistance in dealing with feelings of anger, depression, fear, and loneliness.

C. Prevent infection as body’s resistance is lowered.
D. Continually observe for complications: pressure from enlargement of lymph glands on vital organs.

Medical–Surgical Nursing: Non-Hodgkin’s Lymphoma

Focus topic: Medical–Surgical Nursing

Definition: A malignant disorder (involving malignant B cells) that originates from lymphoid tissues but is not characterized as Hodgkin’s disease.

Assessment
A. Assess for enlarged lymph nodes; painless.
B. Unexplained fever, night sweats, weight loss, fatigue.
C. Assess for gastrointestinal involvement—jaundice, abdominal cramping, bloody diarrhea, bowel obstruction.
D. Ureteral obstruction may cause hydronephrosis.
E. Compression of the spinal cord may impair neurologic function.
F. Hemolytic anemia may occur late in the disease.
G . Diagnosis.

  • Biopsy of suspicious node.
  • Staged like Hodgkin’s disease.
  • Once diagnosis is made, chest x-ray, CT scan, bone marrow, and blood work are done to determine stage.
  • Treatment is based on these features.

H. Prognosis—varies among types.

  • Good survival rate with low-grade localized lymphomas.
  • Aggressive type—one-third survival rate.

Implementation
A. Based on actual classification of disease—same as for Hodgkin’s disease.

  • Radiation treatment of choice for nonaggressive form.
  • Chemotherapy combination is used for aggressive form.
  • Interferon recently approved for follicular lowgrade lymphomas.

B. Remission may occur but typically the disease recurs more aggressively.
C. Bone marrow and blood stem transplants may prolong survival—considered for clients younger than age 60.

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