64 Polycythemia
Overview/pathophysiology
Polycythemia is a chronic disorder characterized by excessive production of red blood cells (RBCs), platelets, and myelocytes. As these increase, blood volume, blood viscosity, and hemoglobin (Hb) concentration increase, causing excessive workload for the heart and congestion of some organs (e.g., liver, kidney).
Secondary polycythemia results from an abnormal increase in erythropoietin production (e.g., because of hypoxia that occurs with chronic lung disease or prolonged living in altitudes greater than 10,000 ft) or with renal tumors. Polycythemia vera is a primary disorder arising from a chromosomal mutation (a single recurrent JAK2 mutation) most often affecting men of Jewish descent, with onset in late midlife. Polycythemia vera results in increased RBC mass, leukocytosis, and slight thrombocytosis. Because of increased viscosity and decreased microcirculation, mortality is high if the condition is left untreated. In addition, there is potential for this disorder to evolve into other hematopoietic disorders, such as myelofibrosis and acute leukemia.
Assessment
Signs and symptoms:
Fatigue, muscle pain, headache, dizziness, paresthesias, visual disturbances, dyspnea, thrombophlebitis, joint pain, painful pruritus, night sweats, chest pain, and a feeling of “fullness,” especially in the head.
Physical assessment:
Hypertension, engorgement of retinal blood veins, crackles (rales), weight loss, cyanosis, changes in mentation or mood (delirium, psychotic depression, mania), ruddy complexion (especially palmar aspects of hands and plantar surfaces of feet), splenomegaly, hepatomegaly, gastrointestinal (GI) disturbances (ulcers, GI bleed).
Diagnostic tests
Complete blood count:
Increased RBC mass (8-12 million/mm3), Hb (18-25 g/dL), hematocrit (Hct) (more than 54% in men and 49% in women), and leukocytes; and overproduction of thrombocytes are diagnostic of polycythemia.
Uric acid levels:
May be increased because of increased nucleoprotein, an end product of RBC breakdown.
O2 saturation:
Nursing diagnosis:
Acute pain
related to headache, angina, pruritus, and abdominal and joint discomfort occurring with altered circulation caused by blood hyperviscosity
Desired Outcomes: Within 1 hr of intervention, patient’s subjective perception of discomfort decreases, as documented by pain scale. Objective indicators, such as grimacing, are absent or diminished. Patient states that lifestyle behaviors are not compromised because of discomfort.
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess for presence of headache, angina, abdominal pain, and joint pain. Devise a pain scale with patient, rating discomfort from 0 (no pain) to 10 (worst pain). | The patient provides a personal baseline report, enabling nurse to more effectively monitor subsequent increases and decreases in pain. Use of a pain intensity scale allows more accurate documentation of discomfort and subsequent relief obtained after analgesia has been administered. |
| Assess for patient complaints of calf pain and tenderness. | These are indicators of peripheral thrombosis, which should be reported promptly for immediate intervention. |
| In the presence of joint or skin discomfort, rest the joint and elevate the extremity. Use gentle range-of-motion (ROM) exercises as tolerated. Caution patient to avoid crossing legs and wearing restrictive clothing. Apply cool compresses or ice. | Elevation may help increase circulation and prevent pooling of hyperviscous blood in the joints. ROM helps improve circulation. Ice is used (short term) to decrease severe joint pain. Note: In the presence of pruritus, skin may become painful and swollen, exacerbated by heat or exposure to water. Topical antihistamines or lotions generally are not helpful. |
| Administer analgesics as prescribed. | Analgesics reduce pain. |
| Note: Avoid analgesics containing aspirin or nonsteroidal antiinflammatory drugs unless prescribed by health care provider. | These drugs may exacerbate bleeding associated with thrombocytosis (high number of ineffective platelets) but may be helpful in alleviating microvascular symptoms. |
| Instruct patient to request analgesic before pain becomes too intense. | Pain is easier to control before it becomes severe. Prolonged stimulation of pain receptors results in increased sensitivity to painful stimuli and will increase the amount of drug required to relieve pain. |
| Encourage use of nonpharmacologic pain control, such as relaxation and distraction. | These are pain measures that potentiate analgesics and do not have side effects. |
| For more information, see “Pain,” p. 37. |
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