HEMATOLOGY

Granulocytes
Blood - Neutrophils – most abundant, 60-70% of total WBCs. First line
- Average volume is 5 – 6 liters or approximately 6 quarts of defense, most common type of leukocyte but a short lifespan
- pH is 7.35 – 7.45 of only 10-12 hours making them ineffective in destroying
- Arterial blood is usually bright red in color compared to venous infectious agents. For acute inflammation
blood which has a darker color, due primarily to the large - Eosinophils– allergic reactions. Weak phagocytic action,
concentration of oxyhemoglobin found in arterial blood elevated during asthma attacks. Usually activated during
parasitic invasion (Schistosomes / blood flukes). Lifespan=
Function: hours to 3 days. Modulates or reduce IgE mediated allergic
- Transportation reactions
o Respiratory – transport of gases by the RBC - Basophils – not phagocytic in nature, they are mediators in
o Nutritive – transport of digested nutrients from the inflammatory process. Involved in the release of chemical
GIT to the different cells of the body mediators
o Excretory – transport of metabolic wastes to the o Prostaglandin
kidneys and excreted as urine o Serotonin
- Regulation o Histamine
o Hormones and other molecules that help regulate o Bradykinin
metabolism are also carried in the blood
o Thermoregulation Non-granulocytes (agranulocytes)
o Maintains water content of cells - Monocytes – largest WBC (macrophage). A hypoactive
- Protection phagocytic cell, become a Macrophage when it attaches to the
o Phagocytosis endothelium of organs and performs its full phagocytic function.
o Haemostais Long term phagocytosis (months)
o KUPFFER – kidneys
COMPONENTS OF THE BLOOD: o HISTOCYTES – skin and subcutaneous
- Plasma: fluid portion of the blood. Approximately 90% Water. o ALVEOLAR macrophage – lungs
- Water o MICROGLIA – CSF
- Solutes o MACROPHAGE - blood
i. Albumin - Lymphocytes: Lymphocytes are created in the bone marrow
ii. Electrolytes and migrate to the Thymus where they mature
iii. Nutrients - B cells (bone marrow) differentiated in the bone marrow,
iv. Hormones antibody mediated immune response (Humoral). For
v. Enzymes immunity
vi. Waste products - T cells (Thymus) : attacks antigens directly. destroy target
Blood cells cells thru secretions of Lymphokines and Perforin ( “Kiss
- ERYTHROCYTES OR RBC of Death”) which is inserted to the cell membrane, shortly
- Function primarily to ferry Oxygen in the blood to all cells after that, the target cell ruptures.
in the body. Lifespan of 120 days only o Killer T Cells – binds to the surface of invading
- Hemoglobin in the RBC binds with the Oxygen as it is cells, disrupt the cell membrane & destroy it by
transported in the blood altering it’s environment
o Female : 12 – 16 g/100ml o Helper T cells – helps to stimulate the B Cells to
o Male : 13 – 18 g/100ml mature into Plasma Cells which synthetize &
- Normal RBC count: about 4 – 6 million/mm³ secrete immunoglobulins (Antibodies)
- Hematocrit (HCT) – percentage of RBC per given volume o Suppressor T Cells – Reduces the Humoral
of blood and is an important indicator of the Oxygen- response
carrying capacity of the blood o NK cells/ Natural killer cells: Anti-tumor and
o Female : 37 – 48% anti-viral properties
o Male : 45 – 52%
- ERYTHROPOIESIS process of formation of RBC Humoral (Antibody-Mediated) Immune Response: 5 Classes of
Immunoglobulins (MADGE) :
- ERYTHROPOETIN hormone produced primarily by the
- Immunoglobulin M (IgM): 1st immunoglobulin produced in an
kidney; necessary for erythropoiesis
immune response present in plasma, too big to cross membrane
- HEMOGLOBIN iron-containing protein of RBC, delivers
barriers
oxygen to tissue
- Immunoglobulin A (IgA): Sound in body secretions like saliva,
Substances needed for maturation of RBC tears, mucus, bile, milk & colostrum
- FOLIC ACID – prevents neural tube deficit; needed in the - Immunoglobulin D (IgD): Present only in the plasma & is
always attached to the B Cell
FIRST trimester of pregnancy
- Immunoglobilin G (IgG): Can cross the placenta and provide
- IRON – needed in the THIRD trimester
passive immunity
- VIT B12 (Cyanocobalamin)
- Immunoglobulin E (IgE): Responsible for Allergic &
- VIT C (Ascorbic Acid)
hypersensitivity reactions. Stimulates Mast cells & Basophils to
- VIT B6 (Pyridoxine)
release Histamine which mediates inflammation & the allergic
- INTRINSIC FACTOR (released in stomach’s parietal cells) response
- Spleen – kills RBCs in the red pulp
- THROMBOCYTES OR PLATELETS
- LEUKOCYTES OR WBC - N = 150-450 thousand mm3
- N = 5,000-10,000/mm3
 - Promotes hemostasis  prevention of blood loss  - check site frequently for bleeding
promote clothing mechanisms. - give pain relievers to relieve pain
- MEGAKARYOCYTES – immature/baby platelets; target
site of DHF MYELOPROLIFERATIVE DISORDER
- Normal lifespan: 9-12 days POLYCYTHEMIA : Increase number of blood cells

Hemostasis (blood clotting) PRIMARY SECONDARY

POLYCYTHEMIA POLYCYTHEMIA
Three Major Phases - Polycythemia vera: all - Known cause high altitude
1. Platelet Plug Formation cells are elevated  erythropoietin  inc.
 Platelets adhere and stick to vessel lining that are damaged RBCs production
forming a Platelet Plug or White Thrombus (ERYTHROCYTOSIS)
 Platelets release chemicals to attract more platelets - Hematocrit >60%
to the injured site - Median age 65 years
2. Vascular Spasms - All blood cells are elevated
 Platelets release Serotonin causing spasms of the blood - Splenomegaly
vessel, constricting it & decreasing blood flow - Bone marrow become fibrotic – burnt out/spent phase =
3. Coagulation or Blood Clotting myeloid metaplasia or AML
 Thromboplastin is released by damaged cells plasma - Death results from thrombosis, hemorrhage or rarely AML
 Clotting Factors form an activator that triggers the Clotting
Cascade SIGNS AND SYMPTOMS
 a Blood Clot is formed - Ruddy complexion - thrombophlebitis
 Serum is squeezed out within the hour pulling the ruptured - Hypervolemia - atherosclerosis
edges together - Headache - hyperuricemia
- Dizziness - pruritus
PLASMA CLOTTING FACTORS - Tinnitus - erythromelalgia
I. Fibrinogen - Fatigue - dyspnea
II. Prothrombin - Paresthesia - claudication
III. Tissue Thromboplastin - Blurred vision - angina
IV. Calcium - Hypertension
V. Proacelerin DIAGNOSTIC TEST
VII. Proconvertin
- Elevated hematocrit
VIII. Antihemophilic Factor
- Presence of jak2 gene
IX. Christmas Factor
X. Stuart – Prower Factor - Low levels of erythropoietin
XI. Plasma Thromboplastin - Bone marrow aspiration
Antecedent COMPLICATIONS
XII. Hageman Factor - Thrombosis
XIII. Fibrin Stabilizing Factor - Hemorrhage
Compatible Blood Types MEDICAL MANAGEMENT
- Reduced risk of thrombosis
Hematopoiesis (Blood Cell Formation) - Reduced risk of AML
- Occurs in the Red Bone Marrow, chiefly in flat bones like - Palliative therapy
Skull, ribs, pelvis, sternum and proximal epiphyses of the - low dose aspirin
humerus and femur - phlebotomy (Hallmark)
- Extramedullary Hematopoiesis - the liver and the spleen - hydroxyurea – suppress marrow function
produces blood cells - antihypertensive drugs
- lipid lowering agents
Bone marrow aspiration: Used to determine size and shape of
- allopurinol
RBCs, WBCs and platelet precursors and to examine various
- anagrelide – inhibits platelet aggregation
maturational abnormalities. Most definitive test
- interferon alpha 2b – controlling blood counts
Nursing Responsibility
Preprocedure DISORDERS PLATELETS AND CLOTTING MECHANISM
- explain the purpose, obtain consent
- inform client of pain or of what to expect HEMOPHILIA
- give sedatives as ordered - Hereditary coagulation defect, usually transmitted to affected
male by female carrier through sex – linked recessive gene,
Procedure resulting in prolonged clotting time.
- place patient in lateral position, with site of aspiration - Most common type is Hemophilia A or Classic Hemophilia -
uppermost factor VIII deficiency (called Antihemophilic Factor / AHF)
- clean pt’s skin with antiseptic sol’n - Hemophilia B or Christmas Disease – factor IX deficiency
- administer local anesthesia to numb skin and subcutaneous (called the Christmas Factor)
tissues - Male inherits hemophilia from their mothers, and females inherit
- apply ice on the contralateral side to relieve pain the carrier status from their fathers.
o Found predominantly, but not exclusive, in male off
Postprocedure springs
- apply pressure until bleeding stops - Bleeding occurs due to impaired ability to form fibrin clot
 - Chronic microcytic anemia due to inadequate absorption of iron
ASSESSMENT leading to hypoxemic tissue injury
- Abnormal bleeding in response to trauma or surgery. - Classification: Hypo proliferative
(muscles/joints) - Most definitive way to diagnose anemia: Bone marrow
- Joint bleeding causing pain, tenderness, swelling, and limited aspiration
range of motion. - Pathophysiology: Iron loss exceeds intake depleting iron
- Tendency to bruise easily. reserves  fewer RBC are produced anemia develops RBC,
- Epistaxis normal but few in number *hgb & hct normal  bone marrow
- Hemarthrosis (bleeding in joints causing pain, swelling and compensates speeds up production (microlytic/small RBC) 
limited movement) symptoms of anemia worsen

SIGNS AND SYMPTOMS

IMPLEMENTATION
- Micrositic
- Administer factor VIII concentrate. - First sign: weakness and fatigues
- Monitor for bleeding and maintain bleeding precautions. - Headache, dyspnea, dizziness, palpitations, cold sensitivity,
- Monitor for joint pain; IMMOBILIZE the affected extremity if generalized body malaise, pallor
joint pains occur. - Brittleness of hair, spoon shaped nails (koilonychia 180 degrees
- Monitor urine for hematuria. ang normal)  d/t hypoxia  atrophy of epidermal cells
- Instruct the parents regarding activities for the child, - Atrophic glossitis, stomatitis, dysphagia
emphasizing the avoidance of contact sports. NURSING MANAGEMENT
- Instruct the parents on how to control bleeding (direct/indirect - Monitor for signs of bleeding of all hema test including urine,
pressure) stool and GIT
- DDVAP (Desmopressin) – promotes the release of Factor VIII - Enforce CBR so as not to overtire patient
in hemophilia A - Encourage increased iron diet (Damo! green leafy vegetables,
- Use soft toothbrush and point out need for regular dental California raisins, organ meat, legumes, yolk, dried foods
checkups - Avoid tannates in tea and coffee because it impairs iron absorption
- Refer to National Hemophilia Association - Administer medications as ordered.
- Emphasize avoidance of Aspirin - FeSO4, Fe Fumarate, Fe Gluconate
- Provide diet information as excess weight places further stress o Administer with meals to lessen GIT irritation
on joints o Use straw for liquid form
R - Rest
o Administer with orange juice/vit.c to facilitate
I - Immobilize
absorption
C - Cold Compress
o Monitor s/e : anorexia, nausea, abdominal pain,
E - Elevate
diarrhea, melena
BLOOD DISORDERS
Anemia RBC (80-120 days)  destroyed in Spleen Hgb
- decrease oxygen carrying capacity of the blood. Conditions in Hemoglobin breaks into:
which the number of RBC’s or amount of hemoglobin is lower - Globin
than normal leads to hypoxia and ischemia - Heme
A. Ferrous
Classifications of anemia : Etiology - Bilirubin
Bleeding Hypoproliferative Hemolytic - Biliverdin
Rbc loss Low rbc production Increase rbc B. Ferritin
destruction ** Early sign of anaphylactic shock: dyspnea
Accidents/trauma Iron deficiency Enlarged spleen
Surgery Vit b12 deficiency Sickle cell PERNICIOUS ANEMIA
Childbirth Folic acid Thalassemia - chronic anemia resulting from deficiency of intrinsic factor
deficiency leading to hypochlorhydria (decreased HCl secretion)
Ruptured blood Vit.c deficiency G6PD - etiology: IDIOPATHIC
vessels - vit. B12 deficiency – pernicious anemia
Menorrhagia Chronic disease Drug induced - lack of b12 food *green and leafy vegetables / lack of intrinsic
Epistaxis Low erythropoietin factor in the stomach (absorption of vitamin b12 in the small
Hemorrhoids Cancer intestine)
GI bleeding/ulcers
cancer
SIGNS AND SYMPTOMS
- Headache, dizziness, dyspnea, palpitation, cold sensitivity, pallor
Lack of Erythropoietin and generalized body malaise
- hypopoliferative - GIT changes: Mouth sores, Red beefy tongue, Dyspepsia or
- hormone produced by the kidneys – stimulate RBC indigestion, Weight loss, Jaundice
production - CNS changes – PA is the most dangerous form of anemia
- hypoxia - Tingling sensation, Paresthesia, Ataxia, Psychosis
DIAGNOSTICS
IRON DEFICIENCY ANEMIA – indicates decreased reabsorption of vitamin B12; confirms presence
- Most common type for female and children of pernicious anemia
NURSING SCHILLING’S TEST MANAGEMENT
- Enforce complete bed rest - Bone marrow transplants have proven to be effective in children
- Administer Vit B12 injections at MONTHLY intervals for NURSING MANAGEMENT
lifetime as ordered; common site: dorso and ventrogluteal, no drug - Administer O2 & Blood Transfusion as Rx
toxicity because it is water soluble and is easily excretable; oral - Maintain adequate hydration
forms might develop tolerance. - Avoid tight clothing that could impair circulation.
- Increase caloric intake, CHON, CHO, Fe, Vit C - Keep wounds clean and dry.
- Encourage client to use soft bristled toothbrush - Provide bed rest to decrease energy expenditure and oxygen use.
and avoid irritating mouthwashes - Encourage patient to eat foods high in calories, CHON, with folic
- Avoid heat application (there is numbness remember?) may acid supplementation.
lead to burns - Analgesics: o Acetaminophen o Morphine o avoid aspirin as it
enhances acidosis, which promotes sickling
APLASTIC ANEMIA - Avoid anticoagulants( sludging is not due to clotting ).
- stem cell disorder leading to bone marrow depression  - Antibiotics.
pancytopenia (all blood cells decreased)  anemia, leucopenia, - Avoid activities that require so much energy.
thrombocytopenia - Keep arms and legs from extreme cold.
SIGNS AND SYMPTOMS - Decrease emotional stress.
- Headache, dizziness, dyspnea, palpitations, pallor, cold sensitivity,
generalized body malaise
- Leukopenia (increased susceptibility to infections)
- Thrombocytopenia  Petechiae  Ecchymoses  Oozing of
blood from venipuncture sites
DIAGNOSTICS
- CBC – pancytopenia
- Bone Marrow Biopsy or Aspirate
NURSING SCHILLING’S TEST MANAGEMENT
- Removal of underlying cause
- BT as ordered
- Enforce complete BR
- Administer O2 inhalation
- Reverse isolation
- Monitor for signs of infection
- Avoid IM, SQ or any venipuncture sites
- instruct: use electric razor when shaving
- Medications as ordered
- Immunosuppressants via central venous catheter
- Anti-lymphocyte globulin (ALG) – given within 6 days – 3
weeks to achieve maximum therapeutic effect

SICKLED CELL ANEMIA

- is a life-long blood disorder characterized by red blood cells that
assume an abnormal, rigid, sickle shape

PREDISPOSING FACTORS
- Hereditary factors
- African America
SIGNS AND SYMPTOMS
- Related to Anemia: SOB, Headache, dizziness, coldness in the
hands and feet, pale skin, chest pain
- Related to Pain: often affect the bones, lungs, abdomen, and
joints. A sickle cell crisis occurs when sickled red blood cells
form clumps in the bloodstream. These clumps of cells block
blood flow through the small blood vessels in the limbs and
organs. This can cause pain and organ damage
MEDICAL MANAGEMENT
- Children born with sickle-cell disease will undergo close
observation.
- Patients will take a 1 mg dose of folic acid daily for life
- 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.
- Painful crises are treated symptomatically with analgesics; pain
management requires opioid administration at regular intervals
until the crisis has settled
- The first approved drug for the causative treatment of sickle-cell
anaemia, hydroxyurea, was shown to decrease the number and
severity of attacks