Assessment of the Hematologic System

Chapter 41

Anatomy and Physiology Review• Bone marrow• Blood components

• Red blood cells (erythrocytes)• White blood cells (leukocytes)• Platelets

• Accessory organs of hematopoiesis• Spleen• Liver

• Plasma• Proteins

• Albumins• Globulins• Fibinogen

• Water• Platelets• Leukocytes• Erythrocytes

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Figure 19-8.   Hematopoiesis. Hematopoiesis from the stem cell pool; activity

mainly in the bone marrow and in the peripheral blood.Modified from Harmening DM, editor: Clinical hematology and fundamentals of hemostasis, ed 3, Philadelphia, 1997, FA Davis

Erythrocyte

growth pathway

Platelet growth

pathway.

Blood Components: Plasma

Figure 19-13.   Iron cycle. Iron (Fe) released from gastrointestinal epithelial cells circulates in the bloodstream associated with its

plasma carrier, transferrin. It is delivered to erythroblasts in bone marrow, where most of it is incorporated into hemoglobin. Mature

erythrocytes circulate for approximately 120 days, after which they become senescent and are removed by mononuclear phagocyte

system (MPS). Macrophages of MPS (mostly in spleen) break down ingested erythrocytes and return iron to the bloodstream directly or

after storing it as ferritin or hemosiderin.

Figure 19-14.   Role of

erythropoietin regulation of red

blood cell production and

delivery of oxygen. In addition to

decreased oxygen in the

atmosphere, other stimulators of

erythropoietin release include

anemia or decreased population

of mature red blood cells (RBCs),

decreased hemoglobin

synthesis, decreased blood flow,

and hemorrhage or excessive

bleeding. In response to

decreased blood oxygen, the

kidneys release erythropoietin,

which stimulates erythrocyte

production in the bone marrow.

From Thibodeau GA, Patton KT: Anatomy & physiology, ed

5, St Louis, 2003, Mosby

Figure 19-15.   Metabolism of bilirubin released by heme breakdown. MPS, Mononuclear phagocyte system.

Hemostasis/Blood Clotting

• Platelet aggregation• Blood clotting cascade• Intrinsic factors• Extrinsic factors• Fibrin clot formation• Fibrinolysis

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Clotting Factors (Table 41-2)I. FibrinogenII. ProthrombinIII. Tissue thromboplastinIV. CalciumV. ProaccelerinVI. Discovered to ba an artifactVII.ProconvertinVIII.Antibemophilic factorIX. Plasma thromboplastin componentX. Stuart-Prower factorXI. Plasma thromboplastin antecedentXII.Hageman factorXIII.Fibrin-stabilizing factor

Figure 19-19.   The "cascade" theory of

coagulation. Recent changes in the cascade theory

are shown in blue

Drugs (table 42-3, p 877)

• Anticoagulants: interfere with steps in blood clotting. Limit or prevent extension of clots and prevent new clots

• Fibrinolytics: selectively degrade fibrin threads in the formed blood clot

• Platelet Inhibitors: prevent platelets from becoming active or activated platelets from clumping together

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Assessment • Gordon’s Functional Health Patterns

• Demographic data• Age and Gender

• Personal history• Diet history• Liver function• Known immunological or hematological disorders• Occupation• Drugs

• Prolong use of antibiotics (clotting problems, bone marrow suppression)

• Blood thinners• NSAID• Anticoagulant• Fibrinolytic durgs• Platelet inhibitors (Aspirin)

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Assessment

• Family history and genetic risk• Hemophilia• Recurrent nosebleeds, postpartum hemorrhage• Sickle cell

• Current health status• Women – menorrhagia• Fatigue

Physical Assessment

• Skin – pallor; jaundice; petechia; bruising

• Respiratory – capillary fill, breathing difficulties

• Cardiovascular – BP; heart sounds, signs of phlibitis

• Renal and urinary – hematuria; increase urine proteins

• Musculoskeletal – rib/sternal tenderness, limit ROM

• Abdominal – enlarged spleen, enlarge liver

• Central nervous system – change in neurological

degeneration, tremors

• Psychosocial – effects of chronic illness

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Diagnostic Assessment: Tests of cell number and function:

• Complete blood count• RBC, WBC, HCT, HgB; size, shape and proportions of different

cell types (e.i. sickle cell)

• Reticulocyte count • determine bone marrow function

• Hemoglobin electrophoresis • detect abnormal form of hemoglobin (e.i. sickle cell)

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Diagnostic Assessment: Tests of cell number and function:

• Leukocyte alkaline phosphatase• Increase during episode of infection or stress

• Coombs’ test• Detects antibodies against RBC• Presence of antibodies cause hemolytic anemia

• Serum ferritin, transferrin, and total iron-binding capacity• Increase in TIBC and iron levels = hematologic

problems (iron deficiency anemia• Transferrin

Diagnostic TestTests Measuring Bleeding and Coagulation

• Capillary fragility test• Petechiae

• Bleeding time test• Normal bleeding – 1 to 9 minutes

• Prothrombin time • Clotting time• Reflect how much clotting factors II, V, VII, and X• PT = 11 to 13 sec

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Diagnostic TestTests Measuring Bleeding and Coagulation

• International normalized ratio (INR)• Establishes the normal mean• INR = 0.7 to 1.8• Pt on anticoagulant therapy (warfin) INR – 2.0 to

3.0

• Partial thromboplastin time• Intrinsic clotting cascade and action of clotting

factors II, V, VII, IX, XI and XII.

• Platelet agglutination/aggregation• Ability of platelets to clump

Other Tests

• Radiographic examinations• Isotopes to evaluate bone marrow function• Standard X-rays

• Bone destruction• Enlargement of spleen and liver

• Bone marrow aspiration and biopsy• Patient preparation• Procedure• Followup

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Follow-up Care

• Give client education.• Cover with dressing; observe for 24 hours. • Administer mild analgesic.• Apply ice pack.• Avoid contact sports or any activity that

might result in trauma to the area.

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