Medical and Surgical Nursing

Hematology Lecture Notes

Prepared by: Mark Fredderick R. Abejo RN,, MAN

Adult bone marrow produces :

175 b RBCs
70 b neutrophils
175 b platelets

Blood Vessels
Veins
Arteries
Capillaries
MEDICAL AND SURGICAL NURSING
Blood Forming Organs
Hematology Liver
Thymus
Lecturer: Mark Fredderick R. Abejo RN, MAN Spleen
Bone Marrow
Lymph nodes
Lymphoid organ
OVERVIEW OF THE STRUCTURE AND FUNCTION OF
THE HEMATOLOGIC SYSTEM CHARACTERISTICS:
Color
o Arterial Blood
HEMATOLOGY the scientific study of the structure and o Venous Blood
functions of blood in health and in disease. Fraction of body weight 8%
Volume Female: 4 -5 L
BLOOD is the circulatory fluid of the CV system which is Male: 5 - 6 L
circulating constantly through a closed circuit of tubes. Temperature 38 C ( 100.4 F )
pH 7.35 - 7.45
FUNCTIONS: Viscosity (relative to water)
supply oxygen from the lungs and absorbed nutrients Whole blood: 4.5-5.5
from the GIT to the cells Plasma: 2.0
remove waste products from tissues to the kidneys, Specific gravity - 1.048 to 1.066 ( 1.055 1.065)
skin and lungs for excretion Composition:
transport hormones from their origin in the endocrine
glands to other parts of the body Liquid phase: PLASMA (55%)
protect the body form dangerous microorganism
promote Hemostasis ( to stop bleeding) - A light yellow substance which is one of
regulate body temperature by heat transfer the major fluids of the body. Major function
vasoconstriction and vasodilation is to maintain the blood volume within the
vascular compartment
Hematopoiesis
Process of blood cell production.
At birth, it is accomplished in the liver, spleen,
thymus, lymph nodes and red bone marrow.
After birth, it is confined in the red bone marrow ( but
some WBCs are still produced in the lymphatic
tissues).
During childhood, all blood cells are essentially
produced in marrow sites of the flatbones of the skull,
clavicle, sternum, ribs, vertebrae, and pelvis
After puberty, hematopoiesis becomes localized
within the flatbones of the sternum, ilium, ribs, and
vertebrae, sometimes occurring in the proximal ends
of long bones (humerus and femur)
All formed elements come from one stem cell or the 92% Water
HEMOCYTOBLAST. Cell differentiation gives rise Serum
to the cell lines with the help of growth factors. Plasma Proteins all produced in the LIVER
Albumin most abundant, maintains osmotic
pressure
Globulin
Alpha transports bilirubin, steroids and
hormones
Beta transports iron and copper
Gamma transports immunoglobulins
Prothrombin clotting factor
Fibrinogen clotting factor

Electrolytes ( Na+,,Ca 2+,, HCO3, CI),

Miscellaneous (less than 1%): sugars, fats, vitamins,
hormones

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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

Solid phase: FORMED ELEMENTS / Non-granulocytes (agranulocytes)

CELLELAR COMPONENTS (45%)
1. Monocytes largest WBC (macrophage)
Upon release in the bone marrow and travel
RBC (Erythrocytes) only component which is to the different tissues, it is just a hypoactive
anucleated phagocytic cell, become a Macrophage
N = 4-6 million/mm3 when it attaches to the endothelium of
Are biconcave discs (AKA discocytes) which are less organs and performs its full phagocytic
than 7.5 micrometers in diameter. function.
Long term phagocytosis (months)
ERYTHROPOIESIS process of formation of RBC KUPFFER kidneys
ERYTHROPOETIN hormone produced primarily by HISTOCYTES skin and subcutaneous
the kidney; necessary for erythropoiesis ALVEOLAR macrophage lungs
HEMOGLOBIN iron-containing protein of RBC, MICROGLIA CSF
delivers oxygen to tissue MACROPHAGE - blood
Carries about 200-300 million molecules of 2. Lymphocytes
hemoglobin(heme-globin-iron) that attach oxygen
within each RBC, responsible for 97% of O2 transport B cells (bone marrow)
Molecules of Hgb (carries oxygen) differentiated in the bone marrow, antibody-
( Ave. 12 - 18 g/dL) mediated immune response (Humoral)
Female: 12-16 g/dL For immunity
Male: 13-18 g/dL T cells (Thymus)
HEMATOCRIT red cell percentage in whole blood For immunity
(three times of normal Hemoglobin) Differentiated in the Thymus and lives
FEMALES: 36-42% long cell-mediated response
MALES: 42-48% Target site of HIV
AIDS incubation period: 6 mos
Substances needed for maturation of RBC
5 years; window period 6 mos
1. FOLIC ACID prevents neural tube deficit;
needed in the FIRST trimester of pregnancy AZT ZIDOVUDINE or
2. IRON needed in the THIRD trimester RETROVIR : drug of choice for
3. VIT B12 (Cyanocobalamin) aids
4. VIT C (Ascorbic Acid) WESTERN BLOT confirmatory
5. VIT B6 (Pyridoxine) test for aids
6. INTRINSIC FACTOR (released in stomachs Kaposis SARCOMA
parietal cells) NK cells
Normal lifespan 80-120 days Natural killer cells
Spleen kills RBCs in the red pulp Anti-tumor and anti-viral properties

WBCs (Leukocytes) Humoral (Antibody-Mediated) Immune Response

N = 5,000-10,000/mm3 B Cells
Matures into Plasma Cells responsible for Antibody
Granulocytes production
1. Neutrophils most abundant, 60-70% of total
WBCs 5 Classes of Immunoglobulins (MADGE) :
First line of defense, most common type of Immunoglobulin M (IgM)
leukocyte but a short lifespan of only 10-12 1st immunoglobulin produced in an immune
hours making them ineffective in destroying responsepresent in plasma, too big to cross
infectious agents membrane barriers
Helpful in localizing the infection and in Immunoglobulin A (IgA)
immobilizing the pathogens until other Sound in body secretions like saliva, tears, mucus,
WBCs arrive bile, milk & colostrum
for acute inflammation Immunoglobulin D (IgD)
Present only in the plasma & is always attached to the
2. Eosinophils allergic reactions B Cell
Weak phagocytic action, elevated during Immunoglobilin G (IgG)
asthma attacks. 80% of circulating antibodies
Usually activated during parasitic invasion Can cross the placenta and provide passive immunity
(Schistosomes / blood flukes) Present in all body fluids
Lifespan= hours to 3 days Immunoglobulin E (IgE)
Modulates or reduce IgE mediated allergic Responsible for Allergic & hypersensitivity reactions
reactions Stimulates Mast cells & Basophils to release
Histamine which mediates inflammation & the
3. Basophils not phagocytic in nature, they are allergic response
mediators in inflammatory process.
Involved in the release of chemical
mediators PLATELETS (Thrombocytes)
Prostaglandin
Serotonin N = 150-450 thousand mm3
Histamine
Bradykinin Promotes hemostasis prevention of blood loss
For inflammation promote clotting mechanisms
MEGAKARYOCYTES immature/baby platelets;
target site of DHF
Normal lifespan: 9-12 days

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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

b. Sex
women have lower hemoglobin and hematocrit levels,
more prevalence of agranulocytosis
hemophilia, bleeding expressed among males
because some laboratory results are sex-specific

c. Race
Blacks have lower hemoglobin levels than whites (more
prevalent sickle cell anemia)

d. Family history
Because some hematologic disorders are inherited:
Anemia
Thrombocytopenia
Bleeding disorders (hemophilia and Von
Willebrands Dse),
Congenital Blood Disorder (Sickle Cell
anemia)
Jaundice, infections, delayed healing,
Cancer
Autoimmune dse (aplastic anemia, pernicious
anemia)

Hemostasis (Blood Clotting) e. Congenital lack of the intrinsic factor

Three Major Phases Modifiable

1. Platelet Plug Formation
Platelets adhere and stick to vessel lining that are a. Exposure to certain chemical and drugs
damaged forming a Platelet Plug or White Radiation overexposure
Thrombus Anti-neoplastic drugs/ chemotherapy
Platelets release chemicals to attract more platelets Chemical Oxidants (e.g benzene, nitrites, lead, arsenic,
to the injured site etc.)
2. Vascular Spasms Drugs (chloramphenicol, sulfonamide, anti-convulsant,
Platelets release Serotonin causing spasms of the streptomycin, hair dyes
blood vessel, constricting it & decreasing blood
flow 2. History Chief complaint
3. Coagulation or Blood Clotting Disorders of the hematologic system often affects all
Thromboplastin is released by damaged cells organs and tissues
plasma Clotting Factors form an activator that Determine:
triggers the Clotting Cascade
a Blood Clot is formed o Onset
Serum is squeezed out within the hour pulling the abrupt or gradual?
ruptured edges together since childhood or recent
o Allergen triggered response? Seasonal?
Plasma Clotting Factors o How long do the allergic manifestations last? Relieved
I Fibrinogen or persist once the allergen is removed?
II Prothrombin
III Tissue Thromboplastin o Quality and quantity
IV Calcium How severe? Massive bleeding? How long does
V Proacelerin it last?
VII Proconvertin How long do the bleeding episodes last and how
VIII Antihemophilic Factor severe they are?
IX Christmas Factor Does blood ooze from a site or does sudden
X Stuart Prower Factor massive bleeding occur?
XI Plasma Thromboplastin How often do bleeding episodes occur and how
Antecedent long do they last?
XII Hageman Factor What does the client do to stop them?
XIII Fibrin Stabilizing Factor Is there any break in skin integrity?
Compatible Blood Types Swelling? Edema? Fever? Pain? Tenderness?
Pruritus? Redness? Or drainage?
Assessment of the Hematologic System
Note allergic manifestations such as rhinitis,
sneezing, nasal stuffiness, postnasal drip, sore
1. Risk Factor Analysis throat, voice changes, hoarseness, wheezing,
persistent cough, dyspnea, malaise, fatigue,
Non-Modifiable tearing or altered hearing acuity.
a. Age o Severity and location
immune response is diminished in both very young and Rest can alleviate fatigue? Bleeding of joints?
very old Can rest alleviate fatigue? (s/sx of anemia)
anemia prevalence increases with age Ask how activities and activity tolerance changed
folic acid deficiency in growth spurt (infants and over time
adolescents) Does the client bruise easily?
because some laboratory results are age- specific Has bleeding in the joints?
Number and saturation of sanitary pads
Anaphylactic reactions? Or simple allergic
response?

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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

o Precipitating factors 6. LUNGS

Anticoagulant? bleeding dyspnea, orthopnea (anemia)
Bone Marrow suppression anemia, leukemia,
and thrombocytopenia 7. CARDIOVASCULAR SYSTEM
Antineoplastic drugs? Antibiotics? Radiation? tachycardia, palpitation, murmurs, angina (anemia)
Infectious agents? Corticosteroids or
immunosuppressive drugs? 8. GIT
Allergic triggers (inhalants such as pollens and dysphagia (mucous membrane atrophy due to iron def.
dust, contact agents such as dyes and cosmetics, anemia)
ingested agents such as foods and drugs, abdominal pain( bleeding)
injectable agents such as drugs, vaccine and hepatomegaly, splenomegaly (hemolytic anemia)
insect venom) hematemesis, melena (thrombocytopenia and bleeding
disorders
o Aggravating and relieving factors
salicylates containing OTC may aggravate 9. GUT
bleeding hematuria (bleeding disorders)
what relieves allergic manifestations amenorrhea and menorrhagia
(iron def. and bleeding do)
3. Past Medical History
10. MUSCULOSKELETAL
a. Major illnesses and hospitalization joint pain (hemophilia)
Previous hematologic problems back pain
Surgical procedures that may affect the hematologic sternal tenderness and bone pain
system (sickle cell crisis)
Liver problems
Any bleeding disorders 11. NERVOUS SYSTEM
headache, confusion
o How long was the bleeding problem? Do any (anemia, polycythemia)
members of the family have a history of brain hemorrhage
bleeding? (thrombocytopenia and bleeding disorders)
o Is bleeding linked with any specific event or peripheral neuropathy,
procedure? Does it occur with menses or paresthesis, loss of balance (pernicious anemia)
following minor trauma? Any frequency of nose
bleeding? Does he bruise easily? Any petechiae?
o How severe are any of the bleeding episodes? DIAGNOSTIC PROCEDURES
What is the durations?
o Any history of hepatic/ splenic or renal disease?
Recently taken medications? 1. COMPLETE BLOOD COUNT

b. Medications- aspirin, chloramphenicol, antineoplastic drugs a. RBC count- # of RBCs/ mm3 of blood, to diagnose anemia
c. Allergies- Hx of allergies, BT and/reactions and ploycythemia
d. Family History b. Hemoglobin- # of grams of hgb/ 100ml of blood; to measure
the oxygen-carrying capacity of the blood
4. Psychosocial Hx and Lifestyle c. Hematocrit expressed in %; measures the volume of RBCs
a. Occupation- exposure to chemicals and radiation in proportion to plasma; used also to diagnose anemia and
b. Habits- nutritional, substance abuse, alcohol abuse ploycythemia and abnormal hydration states
d. RBC indices- measure RBC size and hemoglobin content
a. MCV (mean corpuscular volume)
b. MCH (mean corpuscular hemoglobin)
Review of Systems/ Physical Examination c. MCHC (mean corpuscular hemoglobin
concentrarion)
1. SKIN e. Platelet count- # of Platelet/ mm3; to diagnose
pallor thrombocytopenia and subsequent bleeding tendencies
ruddy skin f. WBC count- of WBCs/ mm3 of blood; to detect infection or
jaundice inflammation
dry skin, brittle, spoon shaped with longitudinal ridges g. WBC Differential count- determines proportion of each
WBC in a sample of 100 WBCs; used to classify leukemias
2. EYES Normal Values
visual disturbances (anemia and polycythemia)
blindness (retinal hemorrhage related to RBC: Women 4.2-5.4 million/mm3
thrombocytopenia and bleeding do) Men 4.7-6.1 million/mm3
scleral jaundice (hemolytic anemia) Hgb: Women 12-16 g/dl
Men 13-18 g/dl
3. EARS Hct : Women 36-42%
vertigo, tinnitus (severe anemia) Men 42-48%
bleeding in auditory canal WBC: 5000-10,000/mm3
(bleeding do) Granulocytes
Neutrophils: 55-70%
Eosinophils: 1-4%
4. NOSE Basophils: 0.5-1.0%
epistaxis (thrombocytopenia and bleeding disorders) Agranulocytes
Lymphocytes: 20-40%
5. MOUTH Monocytes: 2-8%
smooth, glossy, bright red tongue and sore tongue Platelets: 150,000-450,000/mm3
(pernicious and Fe def. anemia)
gingival bleeding (thrombocytopenia and bleeding
disorders)
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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

2. PERIPHERAL BLOOD SMEAR 7. COAGULATION SCREENING TESTS

To determine the variations/ abnormality in RBCs, WBCs and
Platelets: normal size and shape (normocytes) and normal color
(normochromic)
3. DIRECT ANTIGLOBULIN EST (Coombs Test)
Used in cross matching blood when transfusion reaction occurs,
test umbilical cord for Erythroblastosis fetalis and diagnose
acquired hemolytic anemia
a. Bleeding Time measures the ability to stop bleeding after
small puncture wound
b. Partial Thromboplastin Time (PTT) used to identify
deficiencies of coagulation factors, prothrombin and fibrinogen;
monitors heparin therapy.
c. Prothrombin Time (Pro-time) determines activity and
interaction of the Prothrombin group: factors V (preacclerin),
VII (proconvertin), X (Stuart-Power factor), prothrombin and
fibrinogen; used to determine dosages of oral anti-coagulant.

4. INDIRECT ANTIGLOBULIN TEST Normal Values

Identifies antibodies to RBC antigens in the serum of clients Reticulocytes: 25-75 x 10 9/L
who have greater than normal chance of developing transfusion Bleeding Time: 2.75-8 min
reactions. Partial Thromboplastin Time (PTT): 20-35 sec.
Prothrombin Time (PT): 12-14 sec.
5. RETICULOCYTE COUNT

Used to determine the responsiveness of the bone marrow to the BLOOD DISORDERS
depletion of circulating RBCs (probably due to hemolytic
anemia or hemorrhage) I. IRON DEFICIENCY ANEMIA (IDA) chronic
microcytic anemia due to inadequate absorption of iron
6. BONE MARROW ASPIRATION and BIOPSY leading to hypoxemic tissue injury
Used to determine size and shape of RBCs, WBCs and platelet A. INCIDENT RATE
precursors and to examine various maturational abnormalities. 1. Developed countries (d/t high intake of cereals
and milk)
2. Accidents (adults)
3. Tropical areas (blood sucking parasites)
4. Women 15-35 (reproductive age)
5. Common among the poor (poor nutrition)

B. PREDISPOSING FACTORS
1. Chronic blood loss
Trauma
Menstruation
GIT bleeding
Hematemesis
Melena (UGIB)
Hematochezia (LGIB) (d/t E.
histolytica DOC: metronidazole)
2. Inadequate intake of iron rich food
3. Inadequate absorption of iron due to
Chronic diarrhea
R/t increased cereal intake with decreased
animal CHON ingestion, related to subtotal
gastrectomy
Malabsorption syndrome
4. Improper cooking of foods

C. SIGNS AND SYMPTOMS

Nursing Responsibility
Preprocedure - explain the purpose, obtain consent
- inform client of pain or of what to
expect
- give sedatives as ordered
Procedure - place patient in lateral position, with
site of aspiration uppermost
- clean pts skin with antiseptic soln
- administer local anesthesia to numb
skin and subcutaneous tissues
- apply ice on the contralateral side to
relieve pain
Postprocedure - apply pressure until bleeding stops
- check site frequently for bleeding
- give pain relievers to relieve pain
1. Usually asymptomatic, first sign: weakness and
fatigue
2. Headache, dyspnea, dizziness, palpitations, cold
sensitivity, generalized body malaise, pallor
3. Brittleness of hair, spoon shaped nails
(koilonychia 180 degrees ang normal) d/t
hypoxia atrophy of epidermal cells
4. Atrophic glossitis, stomatitis, dysphagia
D. DIAGNOSTICS: ALL DECREASED!
1. RBC
2. Hgb
3. Hct
4. Reticulocytes
5. Iron
E. NURSING MANAGEMENT
1. Monitor for signs of bleeding of all hema test
including urine, stool and GIT
2. Enforce CBR so as not to overtire patient
3. Encourage increased iron diet (Damo! green
leafy vegetables, California raisins, organ meat,
legumes, yolk, dried foods

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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

4. Avoid tannates in tea and coffee because it C. DIAGNOSTICS

impairs iron absorption 1. SCHILLINGS TEST indicates decreased
5. Administer medications as ordered reabsorption of vitamin B12; confirms presence
Oral iron preparations (300mg OD) of pernicious anemia
FeSO4, Fe Fumarate, Fe Gluconate
NURSING MANAGEMENT D. NURSING MANAGEMENT
1. Administer with meals to lessen 1. Enforce complete bed rest (consistent to all types
GIT irritation of anemia)
2. Use straw for liquid form 2. Administer Vit B12 injections at MONTHLY
3. Administer with orange juice or
intervals for lifetime as ordered; common site:
vitamin C to facilitate absorption
4. Inform client of SE/monitor for dorso and ventrogluteal, no drug toxicity because
a. Anorexia it is water soluble and is easily excretable; oral
b. Nausea and vomiting forms might develop tolerance.
c. Abdominal pain 3. Increase caloric intake, CHON, CHO, Fe, Vit C
d. Diarrhea/constipation 4. Encourage client to use soft bristled toothbrush
e. Melena and avoid irritating mouthwashes (remember
Parenteral Iron Preparations there are mouthsores!)
Iron Dextran IM or IV 5. Avoid heat application (there is numbness
Sorbitex IM remember?) may lead to burns
NURSING MANAGEMENT
1. Administer using z-tract method III. APLASTIC ANEMIA stem cell disorder leading to bone
to prevent discomfort,
marrow depression pancytopenia (all blood cells
discoloration and leakage
2. Avoid massaging of injection site decreased) anemia, leucopenia, thrombocytopenia
instead encourage pt. to ambulate
to facilitate absorption A. PREDISPOSING FACTORS
3. Monitor SE 1. Chemicals
a. Pain at injection site Benzene and its derivatives
b. Localized abscess 2. Irradiation
c. Lymphadenopathy 3. Immunologic injury
d. Fever and chills
4. Drugs
e. Pruritus and urticaria
Hypotension Broad spectrum antibiotics
anaphylactic shock Chloramphenicol
epinephrine Sulfonamides (Bactrim)
Chemotherapeutic Agents
RBC (80-120 days) destroyed in Spleen Hgb Nitrogen Mustard (Anti-metabolite)
Hemoglobin breaks into: Vincristine (plant alkaloid)
Globin Methotrexate (alkylating agent)
Heme Phenylbutazones
A. Ferrous
1. Bilirubin
2. Biliverdin
B. SIGNS AND SYMPTOMS
B. Ferritin 1. Headache, dizziness, dyspnea, palpitations,
Early sign of anaphylactic shock: dyspnea pallor, cold sensitivity, generalized body malaise
2. Leukopenia (increased susceptibility to
infections)
II. PERNICIOUS ANEMIA chronic anemia resulting from 3. Thrombocytopenia
deficiency of intrinsic factor leading to hypochlorhydria Petechiae
Ecchymoses
(decreased HCl secretion); IDIOPATHIC
Oozing of blood from venipuncture sites

A. PREDISPOSING FACTORS C. DIAGNOSTICS

1. Subtotal gastrectomy 1. CBC pancytopenia
2. Hereditary factors 2. Bone Marrow Biopsy or Aspirate
3. Inflammatory disorders of the ileum Posterior iliac crest
4. Autoimmune Would reveal fat necrosis in the bone
5. Strictly vegetarian diet marrow
Stomach (widest area of alimentary canal)
Argentaffin/oxyntic/parietal cells in stomach
D. NURSING MANAGEMENT
produces IF promotes reabsorption of vit
B12 (Cyanocobalamin) maturation of 1. Removal of underlying cause
RBC 2. BT as ordered
If absent IF dyspepsia weight loss 3. Enforce complete BR
so increase calories in diet 4. Administer O2 inhalation
Secretes HCl acid it aids in digestion 5. Reverse isolation
Immature RBCs sequestered in spleen 6. Monitor for signs of infection
bilirubinemia jaundice 7. Avoid IM, SQ or any venipuncture sites
8. instruct: use electric razor when shaving
B. SIGNS AND SYMPTOMS 9. Medications as ordered
1. Headache, dizziness, dyspnea, palpitation, cold
Immunosuppressants via central venous
sensitivity, pallor and generalized body malaise
catheter
2. GIT changes
Anti-lymphocyte globulin (ALG)
Mouth sores, Red beefy tongue, Dyspepsia
given within 6 days 3 weeks to
or indigestion, Weight loss, Jaundice
achieve maximum therapeutic effect
3. CNS changes PA is the most dangerous form of
anemia
Tingling sensation, Paresthesia, Ataxia,
Psychosis

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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

IV. SICKLED CELL ANEMIA - is a life-long blood disorder
characterized by red blood cells that assume an abnormal,
rigid, sickle shape
2. Patients will take a 1 mg dose of folic acid daily
for life.
3. From birth to five years of age, they will also
have to take penicillin daily due to the immature
immune system that makes them more prone to
early childhood illnesses.
4. Painful crises are treated symptomatically with
analgesics; pain management requires opioid
administration at regular intervals until the crisis
has settled
5. The first approved drug for the causative
treatment of sickle-cell anaemia, hydroxyurea,
was shown to decrease the number and severity
of attacks
6. Bone marrow transplants have proven to be
effective in children

F. NURSING MANAGEMENT

1. Administer O2 & Blood Transfusion as Rx

2. Maintain adequate hydration
3. Avoid tight clothing that could impair
circulation.
4. Keep wounds clean and dry.
5. Provide bed rest to decrease energy expenditure
and oxygen use.
6. Encourage patient to eat foods high in calories,
CHON, with folic acid supplementation.
A. PREDISPOSING FACTORS 7. Analgesics:
1. Hereditary factors o Acetaminophen
2. African ,South/Central American people and o Morphine
Mediterranean countries o avoid aspirin as it enhances acidosis,which
promotes sickling
B. SIGNS AND SYMPTOMS 8. Avoid anticoagulants( sludging is not due to
Related to anemia: clotting ).
1. Shortness of breath 9. Antibiotics.
2. Dizziness 10. Avoid activities that require so much energy.
3. Headache 11. Keep arms and legs from extreme cold.
4. Coldness in the hands and feet 12. Decrease emotional stress.
5. Pale skin 13. Provide good skin care
6. Chest pain
Related to pain: V. THALASSEMIA MAJOR (Cooleys anemia)
1. Sickle Cell Crisis - Sickle cell crises often affect B - thalassemia refers to an inherited hemolytic
the bones, lungs, abdomen, and joints. anemia, characterized by reduction or absence of the
- A sickle cell crisis occurs when sickled red B-globulin chain in Hgb synthesis
blood cells form clumps in the bloodstream. Fragile RBC & short life span
These clumps of cells block blood flow through Autosomal recessive pattern of inheritance
the small blood vessels in the limbs and organs. Insufficient B-globulin chain synthesis allows large
This can cause pain and organ damage amounts of unstable chains to accumulate
Precipitates of alpha chains that form cause RBCs to
Complications of Sickle Cell Crisis be rigid & easily destroyed, leading to severe
Hand-Foot Syndrome hemolytic anemia = chronic hypoxia
Splenic Crisis Skeletal deformities: pathologic fractures
Infections Hemosiderosis excess iron supply, which leads to
Acute Chest Syndrome iron deposits in the organ tissues leading to decreased
Pulmonary Arterial Hypertension function
Delayed growth and puberty
Stroke A. CLINICAL MANIFESTATIONS
Eye problem 1. onset is usually insidious
Priapism 2. Sx are primarily related to progressive anemia,
Gallstone expansion of marrow cavities of the bone &
Ulcers of the leg developmemnt of hemosiderosis
Multiple organ failure 3. Early Sx often include progressive pallor, poor
feeding & lethargy
C. DIAGNOSIS 4. Further signs: hemorrhage, bone pain, exercise
1. CBC reveals hgb of 6-8g/dl , increase intolerance, jaundice, & protuberant abdomen
reticulocyte count, low hct 5. hemosiderosis of the eye and lungs
2. HemoglobinElectrophoresis, confirmatory
diagnosis for sickled cell anemia B. DIAGNOSTIC EVALUATION
3. Urinalysis UTI Decrease hemoglobin
4. Chest Xray and CT scan pulmonary RBC= increase in number
complication Hgb elctrophoresis
elevated levels of HgF ( doesnt hold O2
E. MEDICAL MANAGEMENT well )
1. Children born with sickle-cell disease will limited amount of HgA
undergo close observation.

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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

2. Assess for early S/Sx of thromboembolic

C. COMPLICATIONS
1. Splenomegaly
2. Growth retardation in the second decade
3. Endocrine abnormalities :
delayed development of secondary sex
characteristics most boys fail to undergo
puberty, girls menstruation problems
DM due to iron deposits in the pancreas
Hypermetabolic rates
4. Skeletal complications
Frontal & parietal bossing (Enlargement)
Maxillary hypertrophy leading to
occlusion
Premature closure of epiphyses of long
bones
Osteoporosis & pathologic fractures
5. Cardiac problems: pericarditis & CHF usual
cause of death
D. MANAGEMENT
1. Frequent and regular transfusion of packed
RBCs to maintain Hgb levels above 10 g/dL
2. Iron chelation therapy with deferoxamine
(Desferal) reduces toxic effects of excess iron
& increases iron excretion thru urine & feces
3. Splenectomy
4. Supportive management of symptoms
5. Bone marrow transplant
6. Prognosis and Survival rate is poor because of no
known cure
7. Often fatal in late adolescence or early adulthood
complications : swelling of limbs, increased
warmth, pain
3. Monitor CBC & assist with phlebotomy as
ordered
Patient Education
Educate about risk of thrombosis; encourage
patient to maintain normal activity pattern &
avoid long periods of rest
Avoid hot showers
Report @ regular intervals for follow up
blood
VII. HEMOPHILIA
Hereditary coagulation defect, usually
transmitted to affected male by female carrier
through sex linked recessive gene, resulting in
prolonged clotting time.
Most common type is Hemophilia A or Classic
Hemophilia - factor VIII deficiency (called
Antihemophilic Factor / AHF)
Hemophilia B or Christmas Disease factor IX
deficiency (called the Christmas Factor)
Male inherits hemophilia from their mothers, and
females inherit the carrier status from their
fathers.
Found predominantly, but not exclusive, in
male offsprings
Bleeding occurs due to impaired ability to form
fibrin clot

VI. POLYCYTHEMIA VERA

Underlying cause is unknown
Hyperplasia of all bone marrow elements
> increase RBC mass
> increase blood volume viscosity
> decrease marrow iron reserve
> Splenomegaly

A. ASSESSMENT
1. Reddish purple hue of skin & mucosa,
pruritus
2. Splenomegaly, hepatomegaly
3. Epigastric discomfort, abdominal discomfort
4. Painful fingers & toes from paresthesias
5. Altered mentation
6. Weakness, fatigue, night sweats, bleeding
tendency
7. Hyperuricemia from increased RBD
formation and destruction
B. DX TESTS
1. CBC
2. BONE MARROW ASPIRATION & Biopsy

C. MANAGEMENT
1. HYPERVISCOSITY
= phlebotomy @ intervals determined by CBC A. ASSESSMENT
results to decrease RBC mass 1. Abnormal bleeding in response to trauma or
=generally 250-500ml removal @ a time surgery. (muscles/joints)
2. HYPERPLASIA 2. Joint bleeding causing pain, tenderness,
= myelosuppressive therapy, swelling, and limited range of motion.
= generally using hydroxyurea or IV radioactive 3. Tendency to bruise easily.
phosphorus (32P), biologic response 4. Epistaxis
modifier, ie alpha interferon 5. Hemarthrosis (bleeding in joints causing pain,
3. HYPERURICEMIA= allupurinol swelling and limited movement)
(Zyloprim)
4. PRURITUS = antihistamines (cimitidine), B. IMPLEMENTATION
low dose acetyl salicylic acid; certain anti- 1. Administer factor VIII concentrate.
depressants (paroxetin), phototherapy, 2. Monitor for bleeding and maintain bleeding
cholestyramine precautions.
3. Monitor for joint pain; IMMOBILIZE the
affected extremity if joint pains occur.
D. NURSING INTERVENTION
1. Encourage/assist ambulation 4. Monitor urine for hematuria.

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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

5. Instruct the parents regarding activities for the B. Dx Tests:

child, emphasizing the avoidance of contact 1. marked decrease of blood platelets
sports. 2. low levels of fibrinogen & other clotting factors
6. Instruct the parents on how to control bleeding 3. prolonged prothrombin & partial thromboplastin
(direct/indirect pressure) times & abnormal erythrocyte
7. DDVAP (Desmopressin) promotes the release morphologic characteristics
of Factor VIII in hemophilia A
8. Use soft toothbrush and point out need for C. NURSING MANAGEMENT
regular dental checkups 1. Monitor for signs of bleeding of all hema tests :
9. Refer to National Hemophilia Association blood, urine, stool, git
10. Emphasize avoidance of Aspirin 2. Administer IV fluid replacement as ordered
11. Provide diet information as excess weight places 3. Administer oxygen inhalation as ordered
further stress on joints 4. Administer medications as ordered
Vitamin K
R - Rest Heparin
I - Immobilize Pitressin (Vasopressin) via heplock
C - Cold Compress 5. Provide Heplock, avoid IM, SQ and any
E - Elevate venipunctures
6. Institute NGT decompression
Iced saline solution
VIII. DISSIMENATED INTRAVASCULAR Cold saline solution
COAGULATION Lavage: 500-1000cc of water; monitor NGT
DIC is a disorder of diffuse activation of the clotting output
cascade that results in depletion of clotting factors in 7. Prevent complications
the blood. Hypovolemic shock (first sign: cold clammy
occurs when the blood clotting mechanisms are skin) (+) Anuria
activated all over the body instead of being localized
to an area of injury. IX. IDIOPATHIC THROMBOCYTOPENIA PURPURA
grave coagulopathy resulting from overstimulation of
clotting & anticlotting processess in response to Increased destruction of platelets with resultant
disease & injury platelet count of less that 100,000/mm3 characterized
Small blood clots form throughout the body, and by petechiae and ecchymoses of the skin.
eventually the blood clotting factors are used up and Exact cause unknown; may be autoimmune.
not available to form clots at sites of tissue injury. Spleen is the site for destruction of platelets
Clot - dissolving mechanisms are also increased often triggered by URTI or Childhood communicable
stimulated by many factors including infection in the disease Measles & chickenpox
blood & severe tissue injury burns and head injury,
reactions to blood transfusions, carcinomas and A. ASSESSMENT:
obstetrical complications such as retained placenta 1. Petechiae
after delivery. 2. Ecchymosis
3. Blood in any body secretions, bleeding form
mucous membranes, nosebleeds.
4. Decreased platelet count
5. Anemia
6. easy bruising
7. blood in stool or urine
8. CBC reveals platelet count below 20,000/mm3
9. Bone marrow aspiration done to rule out
leukemia

B. MEDICAL MANAGEMENT:
Drug therapy:
1. Prednisone decreases anti-platelet antibodies
(monitor for infection)
2. IVIG (Intravenous Immune Globulin) helps
to effectively increase platelet count
3. Anti-D Antibody one dose treatment
Given to pts 1 year but less than 19 years
old
Normal WBC and hemoglobin
no active bleeding present
no concurrent infection
Diphenhydramine and hydrocortisine are
made ready for possible allergic reactions
to the medication
Platelet transfusion
Splenectomy

C. NURSING MANAGEMENT
1. Prevent, control and minimize bleeding.
A. ASSESSMENT 2. Prevent bruising
1. purpura on lower extremities & abdomen 3. Provide support to client and be sensitive to
2. hemorrhagic bullae, acral cyanosis, focal change in body image.
gangrene in skin 4. Protect from infection.
5. Administer analgesics (acetaminophen) as
ordered; avoid aspirin.
6. administer meds orally, rectally, or I.V. rather
than I.M.
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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

2. Allergic reactions
BLOOD TRANSFUSIONS Signs and symptoms
Fever, chills, dyspnea, Laryngospasm,
I. OBJECTIVES bronchospasm, Bronchial wheezing,
A. To replace circulating blood volume Urticaria, pruritus, skin rashes
B. Increase oxygen carrying capacity of the blood Nursing Management
C. Combat infections if decreased WBCs Stop BT, Notify MD, Flush with PNSS
D. Prevent bleeding if decreased PLT Diphenhydramine administration as
ordered
II. NURSING MANAGEMENT/PRINCIPLES If (+) to hypotension, it indicates
A. Proper refrigeration anaphylactic shock
B. Proper blood typing and cross-matching Return blood unit to blood bank for re-
examination
Obtain urine and blood sample of client
for re-examination
Monitor VS and IO
3. Pyrogenic reactions
Signs and symptoms
Fever and chills
Headache
Dyspnea
1. Type O universal donor Tachycardia and palpitations
2. Type AB universal receipient Diaphoresis
3. 85% of general population is Rh (+) Nursing Management
Blood expiration: Stop BT
Platelets : 5 days Notify MD
RBC: 5-7 days, 250 cc Flush with PNSS
C. Aseptically assemble all materials needed for BT Administer antipyretics and antibiotics
1. Filter set (BT set) as ordered
2. PNSS to prevent hemolysis Provide hypothermic blanket
3. 18-19 gauge large bore needle to prevent Return blood unit to blood bank for re-
hemolysis examination
D. Instruct another RN to re-check the following: Obtain urine and blood sample of client
1. Name of patient for re-examination
2. Bt and ct Monitor VS and IO
3. Expiration date 4. Circulatory overload
4. Serial number Signs and symptoms
E. Check blood unit for presence of bubbles, cloudiness, Dyspnea
sediments and dark color as it may indicate Rales/crackles
contamination Orthopnea
F. NEVER WARM BLOOD PRODUCTS! ROOM Nursing Management
TEMPERATURE ONLY Stop BT
1. Warming only done if you have dewarming devise Notify MD
2. Warming only done during emergency situations if
there is massive blood loss massive transfusion
Administer loop diuretics as ordered
G. Transfusion should be completed in 4 HOURS NO FLUSHING!
because blood exposed to room temperature more than Monitor VS and IO
2 hours causes blood deterioration 5. Air embolism
H. Avoid mixing or administering drug at BT line to 6. Thrombocytopenia
prevent hemolysis 7. Citrate intoxication
I. Regulate at KVO (10-15 gtts/min) at 100 cc/hour to 8. Hyperkalemia arrhythmia
prevent circulatory overload
J. MONITOR VS BEFORE, DURING, & AFTER
TRANSFUSION ESPECIALLY EVERY 15 MINUTES
FOR THE FIRST HOUR. Majority of BT reactions occurs
at these times
K. SIGNS OF BT REACTION (HAPCATCH)
1. Hemolytic reactions life threatening.
PRIORITY
Signs and symptoms
Dizziness, Headache, Dyspnea,
Hypotension, Flushed skin, Lumbar,
flank and sternal pain, diarrhea or
constipation, Portwine urine (red urine)
Nursing Management
Stop BT, Notify MD, Flush with PNSS
Administer Isotonic Solution to
counteract shock and prevent acute
tubular necrosis
Return blood unit to blood bank for re-
examination
Obtain urine and blood sample of client
for re-examination and send to lab
Monitor VS and IO

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MS Abejo