hematologic system2

HEMATOLOGIC SYSTEMMa. Victoria Recinto, RN, USRNUniversity of the Philippines ManilaPhilippine General Hospital

OverviewBlood Plasma (55%)SerumPlasma proteins (all produced in liver) albumin, globulin, prothrombin and fibrinogenFormed elements (45%)Blood vessels- arteries, arterioles, veins, venules, capillariesBlood forming organs- liver, spleen, thymus, lymph nodes, lymphoid organ, bone marrow

OverviewAlbumin-most abundant, largest of all plasma proteinmaintains osmotic pressure, preventing edemaGlobulinAlpha- transports hormones, steroids and bilirubinBeta- transports iron and copperGamma- transports Ig or Ab Prothrombin and fibrinogen- clotting factors to prevent bleeding

OverviewFormed Elements (Cellular component)RBC- lifespan 80-120 daysAnucleated cellWith molecules of Hgb with O2N- F- 12-14 g% M- 14-16 g%Hct- RBC % in whole bloodN- F- 36-42 % M- 42- 48% (always 3X Hgb)

OverviewFormed Elements (Cellular component)RBCBiconcave discs (S-shaped in Sickle Cell Anemia)Sickle cell crisis: hemolysis dehydration and hypoxemiaVasooclussive Crisis (Agglutination) ischemia due to blood flow hypoxia anaerobic metabolism lactic acid formationFocus of care: airway, hydration and comfort

Normal RBCSickle Cell

OverviewFormed Elements (Cellular component)Substances needed for RBC maturationFolic acidIronVit B12 (Cyanocobalamin)Vit B6 (Pyridoxine)Vit CIntrinsic factor

OverviewFormed Elements (Cellular component)WBCGranulocytesPMN (60-70% of total WBC)Short-term phagocytosisN lifespan- 24-48 hrsBasophilsParasitic infectionReleases chemical mediators: PG, bradykinins, serotonin, histamineEosinophilsAllergic reactions

OverviewFormed Elements (Cellular component)WBCAgranulocytesMonocytesLargest WBCLong-term phagocytosisLymphocytesB-cellT-cellNatural Killer Cells-with anti-tumor, antiviral property

OverviewFormed Elements (Cellular component)Thrombocytes/Platelets- N lifespan- 9-12 daysPromotes hemostasis- prevention of blood loss r/t blood clotting mechanismConsists of immature baby platelets (Megakaryocytes)- attacked in Dengue virusP. falciparum- most fatal, can cause irreversible brain damage

Thrombocytes/Platelets

OverviewS/Sx of platelet dysfunctionPetechiaeEcchymosis/bruisingOozing of blood from venipuncture sites

Iron Deficiency Anemia (IDA)

r/t inadequate Fe+2 absorption, resulting from RBC destruction hypoxemic tissue injuryIncidence RateDeveloped countries Tropical zones due to blood-sucking parasitesF- 15-35 y/oLow socio-economic status malnutrition


Predisposing FactorsChronic blood loss due to trauma, menses, GI bleeding (hematemesis, melena, hematochezia)Inadequate Fe+2 in dietImpaired Fe+2 absorption due toChronic diarrheaMalabsorption syndrome cereal intake with low-animal proteinSubtotal gastrectomyImproper cooking of foods


Signs and SymptomsUsually asymptomaticCerebral hypoxia- headache, dizziness, dyspneaPalpitations, cold-sensitivityPallor, gen. body malaiseBrittle hair, spoon-shaped nails (koilonychia) due to atrophy of epidermal cells


Koilonychia


Signs and SymptomsPlummer Vinsons Syndrome- atrophic glositis, stomatitis, dysphagia due to atrophy of papilla of the tongue, mouth and pharyngeal cellsPica- due to neuronal degeneration that affects cognitive functions


Plummer Vinsons Syndrome


Diagnostic Procedures RBC, Hgb, Hct, Reticulocytes, Fe+2, Ferritin


Nursing ManagementMonitor all S/ of bleeding including urine, stool and GITCBRIntake of Fe+2 rich foodsGreen, leafy, vegetables,Organ liver meatEgg yolkLegumesCalifornia raisins


Nursing ManagementAvoid tannates in hot tea (impairs Fe+2 absorption)Administer meds as orderedOral Iron preparationFeSO4, Fe+2 gluconate, Fe+2 fumarateTaken with food to avoid GI irritationIn diluting liquid Fe+2 preparation: use straw to prevent staining of teethTaken with Vit C to absorption Monitor S/E: anorexia, N/V, abdominal pain, diarrhea/constipation, melena


Nursing ManagementAdminister meds as orderedParenteral Iron preparationAdminister using z-tract method to prevent discoloration and leakage to tissuesNo massage at injection site, encourage ambulation instead


Nursing ManagementAdminister meds as orderedParenteral Iron preparationMonitor S/E:Pain at injection siteLocalized abscessLymphadenopathyFever and chillsSkin rashesPruritus, urticaria anaphylactic shock hypoTN, laryngospasm, give Epi IV

Pernicious AnemiaMost dangerous of all anemiasChronic disorder, resulting in deficiency of intrinsic factor Hypochlorhydria or HCl secretionPredisposing Factors: unknown causeSubtotal gastrectomyHereditaryInflammation disorders of the ileumAutoimmune disorderStrict vegetarian diet

Pernicious AnemiaStomachParietal/ Argentaffin/Oxyntic cellsIntrinsic factor productionNeeded for reabsorption of Vit B12Needed for RBC maturationMaintains myelin sheath and spinal cord integrityHCI secretionAids in digestion

Pernicious AnemiaSigns and SymptomsHeadache, dizziness, dyspnea, palpitations, cold sensitivity, general body malaise, pallorGIT changesMouth soresRed, beefy tongueDyspepsia (Indigestion)Weight lossJaundice

Pernicious Anemia(+) Red, Beefy Tongue

Pernicious AnemiaSigns and SymptomsCNS involvementTingling sensationParesthesiaNumbness(+) Rombergs test ataxiaPsychosis

Pernicious Anemia(+) Rombergs test

Pernicious AnemiaDiagnostic ProcedureSchillings Test reveals (-) HClNursing ManagementCBRDiet: calorie, protein, Fe+2, Vit CAdminister Vit B12 injections at monthly intervals for lifetime as orderedIf given p.o.- may develop tolerance to medsAvoid using irritating mouthwashes, use soft-bristled toothbrushAvoid applying electrical heating pads burns due to CNS changes

Aplastic AnemiaStem cell disorder due to BM depression Pancytopenia RBC- anemia WBC- leukopenia platelets- thrombocytopenia

Aplastic AnemiaPredisposing FactorsChemicals- Benzene and derivativesIrradiationImmunologic injuryDrugsBroad spectrum antibiotics- Chloramphenicol, SulfonamidesChemo agents- Methotrexate, N2 mustard, VincristinePhenylbutazone

Aplastic AnemiaSigns and Symptoms ofAnemiaLeukopenia (S/Sx of infection)Thrombocytopenia (S/Sx of platelet dysfunction)Diagnostic ProcedureCBC- pancytopeniaBM biopsy or aspiration (frequent site- common iliac crest)- fatty streaks in BM

Aplastic AnemiaNursing ManagementRemoval/Treatment of underlying causeInstitute BT as orderedCBRO2 as orderedReverse isolationMonitor for S/Sx of infectionAvoid IM, SQ or any venipuncture Use electric razor in shaving

Aplastic AnemiaNursing ManagementAdminister meds as orderedCorticosteroidsImmunosuppresantse.g. Anti-Lymphocyte Globulin (ALG) thru central venous catheter for about 6 days to 3 wks (for max. effect of the drug)

Blood TransfusionObjectivesTo replace circulating blood volumeTo O2 carrying capacity of the bloodTo combat infection (whole blood- with WBC)To prevent bleeding (platelet concentrate, cryoprecipitate)

Nursing Management: BT

Proper refrigeration


Proper typing and cross-matchingType O- universal donorType AB- universal recipient85% of population- is Rh (+)


Aseptically assemble materialsFilter setIsotonic solution- to prevent hemolysisLarge bore needle (G 18-19)


Instruct another RN to recheck: Pt nameBlood productBlood type and cross-matchingExpiration dateSerial no.


Check blood pack for any bubbles, sediments, cloudiness and dark discoloration- bacterial contamination


Never warm the blood product let it warm (by covering with towel) to room T (not to destroy blood products) For emergency cases, where multiple rapid BT (8 units of blood) is needed, may use special warming device


BT should be completed for < 4 hrs because it can lead to blood deterioration, should be given within 30 mins after removal from refrigeratorAvoid mixing drug to BT line (always single line)


Regulate BT to 10-15 gtts/min (100 cc/hr) to prevent circulatory overloadMonitor VS before, during and after BT- because majority of BT reactions occur at this period

BT reactionsH-emolytic A-llergicP-yrogenicC-irculatory overloadA-ir embolismT-hrombocytopeniaC-itrate intoxicationH-yperkalemia

Nursing Management: during BT reaction

Stop BTNotify MDFlush with NSSAdminister isotonic solution to prevent ATN and shockSend back blood to blood bank for re-examinationObtain urine and blood samples for lab testMonitor VS, I/O

BT reactionsH-emolytic ReactionhypoTN, red urine (Portwine urine), headache, dizziness, flushed skin, dyspnea, lumbar/sternal/flank painNursing Management: see previous slideA-llergic ReactionFever, dyspnea, skin rashes, urticaria, bronchial wheezing, laryngospasmNursing Management: see previous slide + antihistamine and Epinephrine if with hypoTN and laryngospasm as ordered

BT reactionsP-yrogenic ReactionFever, chills, headache, dyspnea, tachycardia, palpitation, diaphoresisNursing Management: see previous slide + antipyretics or antibiotics as orderedC-irculatory overloadDyspnea, rales, crackles, exertional discomfortNursing Management: see previous slide + diuretics as ordered

Disseminated Intravascular Coagulation (DIC)Acute systemic hemorrhagic condition characterized by widespread and spontaneous bleeding and thrombosis due to deficiency of platelets (prothrombin and fibrinogen)

Disseminated Intravascular Coagulation (DIC)Predisposing Factors (unknown cause)Rapid, frequent BTMassive trauma, burnsAnaphylaxisSepticemiaNeoplasiaPregnancy

Disseminated Intravascular Coagulation (DIC)Signs and SymptomsWidespread and systemic petechiae and ecchymosisOozing of blood from venipuncture sitesHemorrhageHemoptysisOliguria late sign

Disseminated Intravascular Coagulation (DIC)Diagnostic ProceduresCBC- plateletsOpthalmoscopic exam- subretinal hemorrhageStool (+) for occult bloodABG- metabolic acidosis

Disseminated Intravascular Coagulation (DIC)Nursing ManagementMonitor for S/Sx of bleeding at urine, stool and GITAdminister isotonic solution as orderedO2 as orderedAdminister meds as orderedVit KPitressin (Vasopressin)- ADH

Disseminated Intravascular Coagulation (DIC)Nursing ManagementInstitute NGT decompression by gastric lavage1L cold plain NSS, monitor NGT outputMonitor for S/ of Cx: hypovolemic shock, late S/- anuria

HEMATOLOGIC SYSTEMWhich of the following observations of a pt who has pernicious anemia would indicate that the goal of care has been achieved?

HEMATOLOGIC SYSTEMA. pts skin has no petechiaeB. tongue has lost its beefy red colorC. no dependent edemaD. good appetite

HEMATOLOGIC SYSTEMA pt is to be transfused with a unit of whole blood. If the pt were to develop an allergic reaction, the RN would expect to administer which of the following drugs?

HEMATOLOGIC SYSTEMA. Diphenhydramine HCl (Benadryl)B. Metoclopramide (Plasil)C. Pseudoephedrine HCl (Sudafed)D. Promethazine HCl maleate (Phenergan)

HEMATOLOGIC SYSTEMWhich of the following statements, if made by a pt who has iron deficiency anemia, would indicate that the pt understands the meds instructions?

HEMATOLOGIC SYSTEMA. I will report any clay-colored stools.B. I will the keep the tablets in the ref.C. I will take the pills with orange juice.D. I will expect my urine to become red-tinged.

HEMATOLOGIC SYSTEMA client who has nutritional anemia has responded satisfactorily to the tx. In an addition to an increased Hgb, improvement in the clients condition would best be indicated by the results of which of these lab tests?

HEMATOLOGIC SYSTEMA. serum protein levelB. platelet countC. leukocyte countD. hematocrit determination

HEMATOLOGIC SYSTEMA RN should instruct a pt who has a dx of folic acid deficiency anemia to increase intake of which of the following foods?

HEMATOLOGIC SYSTEMA. dairy productsB. green, leafy vegetablesC. citrus juicesD. fish and poultry* as well as liver, grains, yeasts, legumes

HEMATOLOGIC SYSTEMA pt who consumes excessive alcohol has a prescription of folic acid supplements. A nurse should recognize that the desired effect of this meds is to

HEMATOLOGIC SYSTEMA. promote maturation of RBCB. stimulate production of the intrinsic factorC. enhance the synthesis of clotting factorsD. increase the rate of glucose uptake

HEMATOLOGIC SYSTEMPernicious anemia in an elderly pt most likely is the result ofA. atrophy of the stomach liningB. reduced function of the bone marrowC. diminished liver metabolismD. erosion of the intestinal rugae

HEMATOLOGIC SYSTEMThe nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. Place in order of priority the actions that the nurse would take to administer the blood.A. Ask a LPN to assist in confirming blood compatibility and verifying client identityB. Ensure that an informed consent has been signedC. Insert an 18- or 19-gauge IV catheter into the clientD. Obtain the unit of blood from the blood bank

hematologic system2

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