Pruritus may or may not be present, depending on the disorder; it frequently accompanies Hodgkin and non-Hodgkin lymphoma, although the exact cause of the pruritus is unknown. Patients tend to regard pruritus as a nuisance and not to associate it with the blood disorder. Questions about pruritus should focus on the approximate time the patient first noticed pruritus, what aggravates it, and what home remedies seem to relieve the itching. Ask also about the condition of the skin of the lower extremities. The lower extremities seem to be especially vulnerable to blood abnormalities. Adult patients with sickle cell disease frequently have leg ulcers [5,6].

The complete blood count (CBC) with white blood cell (WBC) differential is one of the most important tests for evaluating the status of the patient's hematologic system; the CBC with differential provides a measure of the blood's ability to carry and transport oxygen (erythrocyte measurement) and to resist invading infectious organisms (leukocyte measurement). The CBC with differential usually requires approximately 7 mL of venous blood [20].

The incidence of infection and the absolute neutrophil count (ANC) are inversely related: as ANC falls, the incidence of infection rises. The patient having an ANC less than 500 cells/mcL is at increased risk for developing an infection. Institute infection prevention measures, such as good hand washing technique and isolation and aseptic technique with any invasive procedure. It is important that both nurse and patient practice good hand washing techniques. Isolation of the patient is controversial. The patient should be educated to avoid contact with individuals with known infections, with recently immunized individuals, and with large crowds [26].

Platelet transfusions can be administered to individuals to prevent bleeding with platelet counts less than reference range, prior to medical procedures with shared decision making, and to treat bleeding associated with thrombocytopenia or platelet dysfunction [50].

These reactions may be mild enough to go unnoticed, or they may be severe enough to result in anaphylaxis. In general, the greater the number of transfusions the patient receives, the greater the risk for developing antibodies against blood or blood products. Because of the large number of transfusions received by patients with sickle cell disease or cancer, be especially attuned to their increased risk for developing a reaction. With any reaction during a transfusion [59]:

In patients with sickle cell disease experiencing pain crises, the lower back, knee/shin area, and hips are the sites most often affected. A higher number of pain sites are found in patients with depression and in those 45 years of age and older [69].

Nursing management during an acute bleeding episode involves the IV administration of the deficient factor—either factor VIII^AHF human or factor IX human. With joint pain and hemarthrosis, splinting or casting the involved joint may be indicated. Whenever a patient with hemophilia is admitted to the hospital, nursing assessments are directed toward the prompt recognition of hemorrhage [3].

After the diagnosis of pernicious anemia and the initiation of vitamin B12 therapy, the patient's hemogram quickly returns to normal. Results of the peripheral blood smear may begin to improve as early as 4 days after the initiation of vitamin therapy. In addition, a dramatically increased sense of well-being accompanies the hematology improvement. The patient with pernicious anemia is committed to a lifetime of vitamin B12 therapy. Noncompliance causes the return of symptoms and possibly more dramatic consequences, such as neurologic involvement. Thus, these patients must understand the rationale for vitamin B12 therapy and comply completely with the chemotherapeutic regimen. Vitamin B12 therapy administered before the onset of neurologic signs and symptoms is ideal. When these signs and symptoms have already appeared, prompt and accurate diagnosis and treatment is imperative. Physical therapy may help restore some use and function, but residual neurologic damage may persist for life [3].

Leukemia occurs in acute forms (involving proliferation of immature cells) and chronic forms (involving proliferation of mature cells) and can affect the erythrocyte or any of the white cell precursors. The four most common types of leukemia are: acute lymphocytic leukemia (ALL), chronic lymphocytic leukemia (CLL), acute myeloid leukemia (AML), and chronic granulocytic leukemia (CGL). The principles guiding nursing management are similar for all the leukemias [108,109].