Medical and Surgical Nursing

Hematology Lecture Notes

Prepared by: Mark Fredderick R. Abejo RN,, MAN
✔ 70 b neutrophils
MEDICAL AND SURGICAL NURSING ✔ 175 b platelets

Blood Vessels
 Veins
 Arteries
 Capillaries

Blood Forming Organs

 Liver
 Thymus
 Spleen
Hematology  Bone Marrow
 Lymph nodes
Lecturer: Mark Fredderick R. Abejo RN, MAN  Lymphoid organ
OVERVIEW OF THE STRUCTURE AND FUNCTION
OF THE HEMATOLOGIC SYSTEM CHARACTERISTICS:
 Color
o Arterial Blood
o Venous Blood
 Fraction of body weight 8 %
HEMATOLOGY – the scientific study of the structure and  Volume Female: 4 -5 L
functions of blood in health and in disease.  Male: 5 - 6 L
 Temperature 38 C ( 100.4 F )
BLOOD – is the circulatory fluid of the CV system which is  pH 7.35 - 7.45
circulating constantly through a closed circuit of tubes.  Viscosity (relative to water)
Whole blood: 4.5-5.5
FUNCTIONS: Plasma: 2.0
► supply oxygen from the lungs and absorbed  Specific gravity - 1.048 to 1.066 ( 1.055 – 1.065)
nutrients from the GIT to the cells  Composition:
► remove waste products from tissues to the kidneys,
skin and lungs for excretion Liquid phase: PLASMA (55%)
► transport hormones from their origin in the
endocrine glands to other parts of the body ► - A light yellow substance which is one of
► protect the body form dangerous microorganism the major fluids of the body. Major function is to
► promote Hemostasis ( to stop bleeding) maintain the blood volume within the vascular
► regulate body temperature by heat transfer – compartment
vasoconstriction and vasodilation

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 ► 92% Water
vertebrae, sometimes occurring in the proximal ► Serum
ends of long bones (humerus and femur) ► Plasma Proteins – all produced in the LIVER 
❖ All formed elements come from one stem cell or the Albumin – most abundant, maintains osmotic
HEMOCYTOBLAST. Cell differentiation gives rise to the cell pressure
lines with the help of growth factors.  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+,, HCO3ˉ, CIˉ),

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

Adult bone marrow produces :

✔ 175 b RBCs
 1
MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN
▪ Involved in the release of chemical
Solid phase: FORMED ELEMENTS / mediators
✔ Prostaglandin
CELLELAR COMPONENTS (45%)
✔ Serotonin
✔ Histamine
RBC (Erythrocytes) – only component which is ✔ Bradykinin
anucleated ▪ For inflammation
N = 4-6 million/mm3
⮚ Are biconcave discs (AKA discocytes) which are ⮚ Non-granulocytes (agranulocytes)
less than 7.5 micrometers in diameter.
⮚ 1. Monocytes – largest WBC (macrophage)
⮚ ERYTHROPOIESIS process of formation of RBC ⮚ ▪ Upon release in the bone marrow and
ERYTHROPOETIN hormone produced primarily by travel to the different tissues, it is just a
the kidney; necessary for erythropoiesis hypoactive phagocytic cell, become a
⮚ HEMOGLOBIN iron-containing protein of RBC, Macrophage when it attaches to the
delivers oxygen to tissue endothelium of organs and performs its
⮚ Carries about 200-300 million molecules of full phagocytic function.
hemoglobin(heme-globin-iron) that attach oxygen ▪ Long term phagocytosis (months)
within each RBC, responsible for 97% of O2 ▪ KUPFFER – kidneys
transport ▪ HISTOCYTES – skin and subcutaneous
⮚ Molecules of Hgb (carries oxygen) ▪ ALVEOLAR macrophage – lungs
( Ave. 12 - 18 g/dL) ▪ MICROGLIA – CSF
Female: 12-16 g/dL ▪ MACROPHAGE - blood
Male: 13-18 g/dL 2. Lymphocytes
⮚ HEMATOCRIT – red cell percentage in whole
blood (three times of normal Hemoglobin) ▪ B cells (bone marrow)
FEMALES: 36-42% differentiated in the bone marrow,
MALES: 42-48% antibody-mediated immune response
(Humoral)
⮚ Substances needed for maturation of RBC 1. ✔ For immunity
FOLIC ACID – prevents neural tube deficit; needed ▪ T cells (Thymus)
in the FIRST trimester of pregnancy ✔ For immunity
2. IRON – needed in the THIRD trimester ✔ Differentiated in the Thymus and
3. VIT B12 (Cyanocobalamin) lives long cell-mediated response
4. VIT C (Ascorbic Acid) ✔ Target site of HIV
5. VIT B6 (Pyridoxine)  AIDS incubation period: 6 mos
6. INTRINSIC FACTOR (released in stomach’s – 5 years; window period🡪 6
parietal cells) mos
⮚ Normal lifespan – 80-120 days  AZT 🡪 ZIDOVUDINE or
⮚ Spleen – kills RBCs in the red pulp RETROVIR : drug of choice for
aids
WBCs (Leukocytes)  WESTERN BLOT –
confirmatory test for aids
N = 5,000-10,000/mm3  Kaposi’s SARCOMA
▪ NK cells
⮚ Granulocytes ✔ Natural killer cells
1. Neutrophils – most abundant, 60-70% of total ✔ Anti-tumor and anti-viral properties
WBCs
▪ First line of defense, most common type of Humoral (Antibody-Mediated) Immune Response
leukocyte but a short lifespan of only 10-
12 hours making them ineffective in B Cells
destroying infectious agents – Matures into Plasma Cells responsible for Antibody
▪ Helpful in localizing the infection and in production
immobilizing the pathogens until other
WBCs arrive 5 Classes of Immunoglobulins (MADGE) :
▪ for acute inflammation – Immunoglobulin M (IgM)
• 1st immunoglobulin produced in an immune
2. Eosinophils– allergic reactions responsepresent in plasma, too big to cross
▪ Weak phagocytic action, elevated during membrane barriers
asthma attacks. – Immunoglobulin A (IgA)
▪ Usually activated during parasitic • Sound in body secretions like saliva, tears, mucus,
invasion (Schistosomes / blood flukes) bile, milk & colostrum
▪ Lifespan= hours to 3 days – Immunoglobulin D (IgD)
▪ Modulates or reduce IgE mediated • Present only in the plasma & is always attached to
allergic reactions the B Cell
– Immunoglobilin G (IgG)
3. Basophils – not phagocytic in nature, they are
• 80% of circulating antibodies
mediators in inflammatory process.
 • Can cross the placenta and provide passive allergic response
immunity
• Present in all body fluids
– Immunoglobulin E (IgE) PLATELETS (Thrombocytes)
• Responsible for Allergic & hypersensitivity
reactions
N = 150-450 thousand mm3
• Stimulates Mast cells & Basophils to release
Histamine which mediates inflammation & the

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

⮚ Promotes hemostasis 🡪 prevention of blood loss 🡪 Assessment of the Hematologic

promote clotting mechanisms
⮚ MEGAKARYOCYTES – immature/baby platelets; System 1. Risk Factor Analysis
target site of DHF
⮚ Normal lifespan: 9-12 days
Non-Modifiable

a. Age
✔ immune response is diminished in both very young
and very old
✔ anemia prevalence increases with age
✔ folic acid deficiency in growth spurt (infants and
adolescents)
✔ because some laboratory results are age- specific

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)
Hemostasis (Blood Clotting)
d. Family history
✔ Because some hematologic disorders are inherited: –
Three Major Phases
Anemia
1. Platelet Plug Formation
– Thrombocytopenia
– Platelets adhere and stick to vessel lining that are
damaged forming a Platelet Plug or White – Bleeding disorders (hemophilia and Von
Willebrand’s Dse),
Thrombus
– Congenital Blood Disorder (Sickle Cell
– Platelets release chemicals to attract more
anemia)
platelets to the injured site
– Jaundice, infections, delayed healing,
2. Vascular Spasms
– Cancer
– Platelets release Serotonin causing spasms of the
– Autoimmune dse (aplastic anemia,
blood vessel, constricting it & decreasing blood
pernicious anemia)
flow
3. Coagulation or Blood Clotting
e. Congenital lack of the intrinsic factor
– Thromboplastin is released by damaged cells –
plasma Clotting Factors form an activator that Modifiable
triggers the Clotting Cascade
– a Blood Clot is formed a. Exposure to certain chemical and drugs
– Serum is squeezed out within the hour pulling the ✔ Radiation overexposure
ruptured edges together ✔ Anti-neoplastic drugs/ chemotherapy
✔ Chemical Oxidants (e.g benzene, nitrites, lead,
Plasma Clotting Factors arsenic, etc.)
I Fibrinogen ✔ Drugs (chloramphenicol, sulfonamide, anti
II Prothrombin convulsant, streptomycin, hair dyes
III Tissue Thromboplastin
IV Calcium 2. History – Chief complaint
V Proacelerin ✔ Disorders of the hematologic system often affects all
VII Proconvertin organs and tissues
VIII Antihemophilic Factor
✔ Determine:
IX Christmas Factor
X Stuart – Prower Factor
o Onset
XI Plasma Thromboplastin
▪ abrupt or gradual?
Antecedent
▪ since childhood or recent
XII Hageman Factor
o Allergen triggered response? Seasonal?
XIII Fibrin Stabilizing Factor
o How long do the allergic manifestations last?
Compatible Blood Types
Relieved or persist once the allergen is
removed?

o Quality and quantity
▪ How severe? Massive bleeding? How long does it
last?
▪ How long do the bleeding episodes last and
how severe they are?
▪ Does blood ooze from a site or does sudden
massive bleeding occur?
▪ How often do bleeding episodes occur and how
long do they last?
▪ What does the client do to stop them?
▪ Is there any break in skin integrity?
MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN
▪ Ask how activities and activity tolerance
changed over time
▪ Does the client bruise easily?
▪ Has bleeding in the joints?
▪ Number and saturation of sanitary pads
▪ Anaphylactic reactions? Or simple allergic
response?
o Precipitating factors
▪ Anticoagulant? – bleeding
▪ Bone Marrow suppression – anemia,
leukemia, and thrombocytopenia
▪ Antineoplastic drugs? Antibiotics? Radiation? ▪
Infectious agents? Corticosteroids or
immunosuppressive drugs?
▪ Allergic triggers (inhalants such as pollens and
dust, contact agents such as dyes and
cosmetics, ingested agents such as foods and
drugs, injectable agents such as drugs, vaccine
and insect venom)
o Aggravating and relieving factors
▪ salicylates containing OTC may
aggravate bleeding
▪ what relieves allergic manifestations
3. Past Medical History
a. Major illnesses and hospitalization
✔ Previous hematologic problems
✔ Surgical procedures that may affect the
hematologic system
✔ Liver problems
✔ Any bleeding disorders
o How long was the bleeding problem? Do any
members of the family have a history of
bleeding?
o Is bleeding linked with any specific event or
procedure? Does it occur with menses or
following minor trauma? Any frequency of
nose bleeding? Does he bruise easily? Any
petechiae?
o How severe are any of the bleeding episodes?
What is the durations?
o Any history of hepatic/ splenic or renal
disease? Recently taken medications?
b. Medications- aspirin, chloramphenicol, antineoplastic
drugs
c. Allergies- Hx of allergies, BT and/reactions
d. Family History
4. Psychosocial Hx and Lifestyle
a. Occupation- exposure to chemicals and radiation b.
Habits- nutritional, substance abuse, alcohol abuse
Review of Systems/ Physical Examination
1. SKIN
– pallor
▪ Swelling? Edema? Fever? Pain? Tenderness?
Pruritus? Redness? Or drainage?
⌦ Note allergic manifestations such as rhinitis,
sneezing, nasal stuffiness, postnasal drip, sore
throat, voice changes, hoarseness, wheezing,
persistent cough, dyspnea, malaise, fatigue,
tearing or altered hearing acuity.
o Severity and location
▪ Rest can alleviate fatigue? Bleeding of joints? ▪
Can rest alleviate fatigue? (s/sx of anemia)
3
– ruddy skin
– jaundice
– dry skin, brittle, spoon shaped with longitudinal
ridges
2. EYES
– visual disturbances (anemia and polycythemia) –
blindness (retinal hemorrhage related to
thrombocytopenia and bleeding do)
– scleral jaundice (hemolytic anemia)
3. EARS
– vertigo, tinnitus (severe anemia)
– bleeding in auditory canal
– (bleeding do)
4. NOSE
– epistaxis (thrombocytopenia and bleeding
disorders)
5. MOUTH
– smooth, glossy, bright red tongue and sore tongue
(pernicious and Fe def. anemia)
– gingival bleeding (thrombocytopenia and bleeding
disorders)
6. LUNGS
– dyspnea, orthopnea (anemia)
7. CARDIOVASCULAR SYSTEM
– tachycardia, palpitation, murmurs, angina
(anemia)
8. GIT
– dysphagia (mucous membrane atrophy due to iron
def. anemia)
– abdominal pain( bleeding)
– hepatomegaly, splenomegaly (hemolytic anemia) –
hematemesis, melena (thrombocytopenia and
bleeding disorders
9. GUT
– hematuria (bleeding disorders)
– amenorrhea and menorrhagia
– (iron def. and bleeding do)
10. MUSCULOSKELETAL
– joint pain (hemophilia)
– back pain
– sternal tenderness and bone pain
– (sickle cell crisis)
–
11. NERVOUS SYSTEM
– headache, confusion
– (anemia, polycythemia)
– brain hemorrhage
– (thrombocytopenia and bleeding disorders) –
peripheral neuropathy,
– paresthesis, loss of balance (pernicious anemia)
DIAGNOSTIC PROCEDURES
 e. Platelet count- # of Platelet/ mm3; to diagnose
1. COMPLETE BLOOD COUNT thrombocytopenia and subsequent bleeding tendencies f.
WBC count- of WBCs/ mm3 of blood; to detect infection
a. RBC count- # of RBCs/ mm3 of blood, to diagnose anemia or inflammation
and ploycythemia g. WBC Differential count- determines proportion of each
b. Hemoglobin- # of grams of hgb/ 100ml of blood; to WBC in a sample of 100 WBCs; used to classify leukemias
measure the oxygen-carrying capacity of the blood c. Normal Values
Hematocrit – expressed in %; measures the volume of RBCs
in proportion to plasma; used also to diagnose anemia and RBC: Women – 4.2-5.4 million/mm3
ploycythemia and abnormal hydration states d. RBC Men – 4.7-6.1 million/mm3
indices- measure RBC size and hemoglobin content a. MCV Hgb: Women – 12-16 g/dl
(mean corpuscular volume) Men – 13-18 g/dl
b. MCH (mean corpuscular hemoglobin) Hct : Women – 36-42%
c. MCHC (mean corpuscular hemoglobin Men – 42-48%
concentrarion)
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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

WBC: 5000-10,000/mm3
Granulocytes
Neutrophils: 55-70%
Eosinophils: 1-4%
Basophils: 0.5-1.0%
Agranulocytes
Lymphocytes: 20-40%
Monocytes: 2-8%
Platelets: 150,000-450,000/mm3

2. PERIPHERAL BLOOD SMEAR

Nursing Responsibility
To determine the variations/ abnormality in RBCs, WBCs
and Platelets: normal size and shape (normocytes) and Preprocedure - explain the purpose, obtain consent -
normal color (normochromic) inform client of pain or of what to
expect
3. DIRECT ANTIGLOBULIN EST (Coomb’s Test) - give sedatives as ordered

Used in cross matching blood when transfusion reaction
occurs, test umbilical cord for Erythroblastosis fetalis and
diagnose acquired hemolytic anemia
4. INDIRECT ANTIGLOBULIN TEST
Identifies antibodies to RBC antigens in the serum of clients
who have greater than normal chance of developing
transfusion reactions.
5. RETICULOCYTE COUNT
Used to determine the responsiveness of the bone marrow to
the depletion of circulating RBCs (probably due to hemolytic
anemia or hemorrhage)
6. BONE MARROW ASPIRATION and BIOPSY
Used to determine size and shape of RBCs, WBCs and
platelet precursors and to examine various maturational
abnormalities.
Procedure - place patient in lateral position, with site of
aspiration uppermost
- clean pt’s skin with antiseptic sol’n
- 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
7. COAGULATION SCREENING TESTS
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.

Normal Values

Reticulocytes: 25-75 x 10 9/L

Bleeding Time: 2.75-8 min
Partial Thromboplastin Time (PTT): 20-35 sec.
Prothrombin Time (PT): 12-14 sec.

BLOOD DISORDERS
I. IRON DEFICIENCY ANEMIA (IDA) – chronic
microcytic anemia due to inadequate absorption of iron
leading to hypoxemic tissue injury

A. INCIDENT RATE
1. Developed countries (d/t high intake of cereals
 and milk) ▪ R/t increased cereal intake with decreased
2. Accidents (adults) animal CHON ingestion, related to
3. Tropical areas (blood sucking parasites) subtotal gastrectomy
4. Women 15-35 (reproductive age) ▪ Malabsorption syndrome
5. Common among the poor (poor nutrition) 4. Improper cooking of foods

B. PREDISPOSING FACTORS C. SIGNS AND SYMPTOMS

1. Chronic blood loss 1. Usually asymptomatic, first sign: weakness
▪ Trauma and fatigue
▪ Menstruation 2. Headache, dyspnea, dizziness, palpitations,
▪ GIT bleeding cold sensitivity, generalized body malaise,
✔ Hematemesis pallor
✔ Melena (UGIB) 3. Brittleness of hair, spoon shaped nails
✔ Hematochezia (LGIB) (d/t E. (koilonychia 🡪 180 degrees ang normal) 🡪 d/t
histolytica 🡪 DOC: metronidazole) hypoxia 🡪 atrophy of epidermal cells
2. Inadequate intake of iron rich food 4. Atrophic glossitis, stomatitis, dysphagia
3. Inadequate absorption of iron due to
▪ Chronic diarrhea

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

RBC (80-120 days) 🡪 destroyed in Spleen 🡪 Hgb

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
4. Avoid tannates in tea and coffee because it
impairs iron absorption
5. Administer medications as ordered
▪ Oral iron preparations (300mg OD)
✔ FeSO4, Fe Fumarate, Fe Gluconate
 NURSING MANAGEMENT
1. Administer with meals to lessen
GIT irritation
2. Use straw for liquid form
3. Administer with orange juice
or vitamin C to facilitate
absorption
4. Inform client of SE/monitor for
a. Anorexia
b. Nausea and vomiting
c. Abdominal pain
d. Diarrhea/constipation
e. Melena
▪ Parenteral Iron Preparations
✔ Iron Dextran IM or IV
✔ Sorbitex IM
 NURSING MANAGEMENT
1. Administer using z-tract
method to prevent discomfort,
discoloration and leakage
2. Avoid massaging of injection
site instead encourage pt. to
ambulate to facilitate
absorption
3. Monitor SE
a. Pain at injection site
b. Localized abscess
c. Lymphadenopathy
d. Fever and chills
e. Pruritus and urticaria🡪
Hypotension 🡪
anaphylactic shock 🡪
epinephrine
Hemoglobin breaks into:
▪ Globin
▪ Heme
A. Ferrous
1. Bilirubin
2. Biliverdin
B. Ferritin
Early sign of anaphylactic shock: dyspnea
II. PERNICIOUS ANEMIA – chronic anemia resulting
from deficiency of intrinsic factor leading to
hypochlorhydria (decreased HCl secretion);
IDIOPATHIC
A. PREDISPOSING FACTORS
1. Subtotal gastrectomy
2. Hereditary factors
3. Inflammatory disorders of the ileum
4. Autoimmune
5. Strictly vegetarian diet
▪ Stomach (widest area of alimentary
canal)
✔ Argentaffin/oxyntic/parietal cells in
stomach produces IF 🡪 promotes
reabsorption of vit B12 (Cyanocobalamin)
🡪 maturation of RBC
✔ If absent IF🡪 dyspepsia 🡪 weight loss 🡪
so increase calories in diet
✔ Secretes HCl acid 🡪 it aids in digestion
✔ Immature RBCs 🡪 sequestered in spleen
🡪 bilirubinemia 🡪 jaundice
B. SIGNS AND SYMPTOMS
1. Headache, dizziness, dyspnea, palpitation, cold
sensitivity, pallor and generalized body
malaise
2. GIT changes
▪ Mouth sores, Red beefy tongue,
Dyspepsia or indigestion, Weight loss,
Jaundice
3. CNS changes – PA is the most dangerous form of
anemia
▪ Tingling sensation, Paresthesia, Ataxia,
Psychosis
C. DIAGNOSTICS
1. SCHILLING’S TEST – indicates decreased
reabsorption of vitamin B12; confirms
presence of pernicious anemia

D. NURSING MANAGEMENT
1. Enforce complete bed rest (consistent to all
types of anemia)
 2. Administer Vit B12 injections at MONTHLY ▪ Broad spectrum antibiotics
intervals for lifetime as ordered; common site: ✔ Chloramphenicol
dorso and ventrogluteal, no drug toxicity ✔ Sulfonamides (Bactrim…)
because it is water soluble and is easily ▪ Chemotherapeutic Agents
excretable; oral forms might develop ✔ Nitrogen Mustard (Anti-metabolite)
tolerance. ✔ Vincristine (plant alkaloid)
3. Increase caloric intake, CHON, CHO, Fe, Vit C ✔ Methotrexate (alkylating agent)
4. Encourage client to use soft bristled ▪ Phenylbutazones
toothbrush and avoid irritating mouthwashes
(remember there are mouthsores!) B. SIGNS AND SYMPTOMS
5. Avoid heat application (there is numbness 1. Headache, dizziness, dyspnea, palpitations,
remember?) 🡪 may lead to burns pallor, cold sensitivity, generalized body
malaise
III. APLASTIC ANEMIA – stem cell disorder leading to 2. Leukopenia (increased susceptibility to
bone marrow depression 🡪 pancytopenia (all blood infections)
cells decreased) 🡪 anemia, leucopenia, 3. Thrombocytopenia
thrombocytopenia ▪ Petechiae
▪ Ecchymoses
▪ Oozing of blood from venipuncture sites
A. PREDISPOSING FACTORS
1. Chemicals C. DIAGNOSTICS
▪ Benzene and its derivatives
1. CBC – pancytopenia
2. Irradiation 2. Bone Marrow Biopsy or Aspirate
3. Immunologic injury ▪ Posterior iliac crest
4. Drugs

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

▪ Would reveal fat necrosis in the bone

marrow

D. NURSING MANAGEMENT
1. Removal of underlying cause
2. BT as ordered
3. Enforce complete BR
4. Administer O2 inhalation
5. Reverse isolation
6. Monitor for signs of infection
7. Avoid IM, SQ or any venipuncture sites
8. instruct: use electric razor when shaving
9. Medications as ordered
▪ Immunosuppressants via central venous
catheter
✔ Anti-lymphocyte globulin (ALG) –
given within 6 days – 3 weeks to
achieve maximum therapeutic effect

IV. SICKLED CELL ANEMIA - is a life-long blood A. PREDISPOSING FACTORS 1. Hereditary factors
disorder characterized by red blood cells that assume 2. African ,South/Central American people and
an abnormal, rigid, sickle shape Mediterranean countries

B. SIGNS AND SYMPTOMS

Related to anemia:
1. Shortness of breath
2. Dizziness
3. Headache
4. Coldness in the hands and feet
5. Pale skin
6. Chest pain
Related to pain:
1. Sickle Cell Crisis - Sickle cell crises 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
Complications of Sickle Cell Crisis
⮚ Hand-Foot Syndrome
⮚ Splenic Crisis
⮚ Infections
⮚ Acute Chest Syndrome
 ⮚ Pulmonary Arterial Hypertension
⮚ Delayed growth and puberty
⮚ Stroke
⮚ Eye problem
⮚ Priapism
⮚ Gallstone
⮚ Ulcers of the leg
⮚ Multiple organ failure
C. DIAGNOSIS
1. CBC reveals hgb of 6-8g/dl , increase
reticulocyte count, low hct
2. HemoglobinElectrophoresis, confirmatory
diagnosis for sickled cell anemia
3. Urinalysis – UTI
4. Chest Xray and CT scan – pulmonary
complication
E. MEDICAL MANAGEMENT
1. Children born with sickle-cell disease will
undergo close observation.
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
7
MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN
⮚ Precipitates of alpha chains that form cause RBC’s
to be rigid & easily destroyed, leading to severe
hemolytic anemia = chronic hypoxia
⮚ Skeletal deformities: pathologic fractures
⮚ Hemosiderosis – excess iron supply, which leads to
iron deposits in the organ tissues leading to
decreased function
A. CLINICAL MANIFESTATIONS
1. onset is usually insidious
2. Sx are primarily related to progressive
anemia, expansion of marrow cavities of the
bone & developmemnt of hemosiderosis
3. Early Sx often include progressive pallor,
poor feeding & lethargy
4. Further signs: hemorrhage, bone pain,
exercise intolerance, jaundice, & protuberant
abdomen
5. hemosiderosis of the eye and lungs
B. DIAGNOSTIC EVALUATION
• Decrease hemoglobin
• RBC= increase in number
• Hgb elctrophoresis
– elevated levels of HgF ( doesn’t hold O2
well )
– limited amount of HgA
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 –
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.
7. Analgesics:
o Acetaminophen
o Morphine
o avoid aspirin as it enhances
acidosis,which promotes sickling
8. Avoid anticoagulants( sludging is not due to
clotting ).
9. Antibiotics.
10. Avoid activities that require so much energy.
11. Keep arms and legs from extreme cold.
12. Decrease emotional stress.
13. Provide good skin care
V. THALASSEMIA MAJOR (Cooley’s anemia) ⮚ B -
thalassemia refers to an inherited hemolytic anemia,
characterized by reduction or absence of the B-globulin
chain in Hgb synthesis
⮚ Fragile RBC & short life span
⮚ Autosomal recessive pattern of inheritance ⮚
Insufficient B-globulin chain synthesis allows large
amounts of unstable chains to accumulate
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
RBC’s 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
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 2. Assess for early S/Sx of thromboembolic
discomfort complications : swelling of limbs, increased
4. Painful fingers & toes from paresthesias warmth, pain
5. Altered mentation 3. Monitor CBC & assist with phlebotomy as
6. Weakness, fatigue, night sweats, bleeding ordered
tendency Patient Education
7. Hyperuricemia – from increased RBD ✔ Educate about risk of thrombosis;
formation and destruction encourage patient to maintain normal
B. DX TESTS activity pattern & avoid long periods of
1. CBC rest
2. BONE MARROW ASPIRATION & ✔ Avoid hot showers
Biopsy ✔ Report @ regular intervals for follow up
blood
C. MANAGEMENT
1. HYPERVISCOSITY VII. HEMOPHILIA
= phlebotomy @ intervals determined by CBC ⮚ Hereditary coagulation defect, usually
results to decrease RBC mass transmitted to affected male by female carrier
=generally 250-500ml removal @ a time through sex – linked recessive gene, resulting
2. HYPERPLASIA in prolonged clotting time.
= myelosuppressive therapy, ⮚ Most common type is Hemophilia A or Classic
= generally using hydroxyurea or IV Hemophilia - factor VIII deficiency (called
radioactive Antihemophilic Factor / AHF)
phosphorus (32P), biologic response modifier, ie ⮚ Hemophilia B or Christmas Disease – factor
alpha interferon 3. HYPERURICEMIA= allupurinol IX deficiency (called the Christmas Factor)
(Zyloprim) ⮚ Male inherits hemophilia from their mothers,
4. PRURITUS = antihistamines (cimitidine), and females inherit the carrier status from
low dose acetyl salicylic acid; certain anti their fathers.
depressants (paroxetin), phototherapy, – Found predominantly, but not exclusive,
cholestyramine in male offsprings
⮚ Bleeding occurs due to impaired ability to
D. NURSING INTERVENTION form fibrin clot
1. Encourage/assist ambulation

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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN
2. Joint bleeding causing pain, tenderness,
swelling, and limited range of motion.
3. Tendency to bruise easily.
4. Epistaxis
5. Hemarthrosis (bleeding in joints causing
pain, swelling and limited movement)

B. IMPLEMENTATION
1. Administer factor VIII concentrate.
2. Monitor for bleeding and maintain bleeding
precautions.
3. Monitor for joint pain; IMMOBILIZE the
affected extremity if joint pains occur.
4. Monitor urine for hematuria.
5. Instruct the parents regarding activities for
the child, emphasizing the avoidance of
contact sports.
6. Instruct the parents on how to control
bleeding (direct/indirect pressure)
7. DDVAP (Desmopressin) – promotes the
release of Factor VIII in hemophilia A
8. Use soft toothbrush and point out need for
regular dental checkups
9. Refer to National Hemophilia Association
10. Emphasize avoidance of Aspirin
11. Provide diet information as excess weight
A. ASSESSMENT places further stress on joints
1. Abnormal bleeding in response to trauma or
surgery. (muscles/joints) R - Rest
I - Immobilize 2. hemorrhagic bullae, acral cyanosis, focal
C - Cold Compress gangrene in skin
E - Elevate

VIII. DISSIMENATED INTRAVASCULAR B. Dx Tests:

COAGULATION 1. marked decrease of blood platelets
⮚ DIC is a disorder of diffuse activation of the 2. low levels of fibrinogen & other clotting
clotting cascade that results in depletion of factors
clotting factors in the blood. 3. prolonged prothrombin & partial
⮚ occurs when the blood clotting mechanisms are thromboplastin times & abnormal
activated all over the body instead of being erythrocyte morphologic characteristics
localized to an area of injury.
⮚ grave coagulopathy resulting from overstimulation of C. NURSING MANAGEMENT
clotting & anticlotting processess in response to 1. Monitor for signs of bleeding of all hema tests :
disease & injury blood, urine, stool, git
⮚ Small blood clots form throughout the body, and 2. Administer IV fluid replacement as ordered 3.
eventually the blood clotting factors are used up Administer oxygen inhalation as ordered 4.
and not available to form clots at sites of tissue Administer medications as ordered
injury. ▪ Vitamin K
▪ Heparin
⮚ Clot - dissolving mechanisms are also increased
▪ Pitressin (Vasopressin) via heplock
stimulated by many factors including infection in
5. Provide Heplock, avoid IM, SQ and any
the blood & severe tissue injury – burns and head
venipunctures
injury, reactions to blood transfusions, carcinomas
6. Institute NGT decompression
and obstetrical complications such as retained
▪ Iced saline solution
placenta after delivery.
▪ Cold saline solution
▪ Lavage: 500-1000cc of water; monitor
NGT output
7. Prevent complications
▪ Hypovolemic shock (first sign: cold
clammy skin)🡪 (+) Anuria

IX. IDIOPATHIC THROMBOCYTOPENIA PURPURA

⮚ Increased destruction of platelets with resultant

platelet count of less that 100,000/mm3

A. ASSESSMENT
1. purpura on lower extremities & abdomen

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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN
Bone marrow aspiration done to rule out
characterized by petechiae and ecchymoses of the leukemia
skin.
⮚ Exact cause unknown; may be autoimmune. ⮚ B. MEDICAL MANAGEMENT:
Spleen is the site for destruction of platelets ⮚ Drug therapy:
often triggered by URTI or Childhood 1. Prednisone – decreases anti-platelet
communicable disease – Measles & chickenpox antibodies (monitor for infection)
2. IVIG (Intravenous Immune Globulin) –
A. ASSESSMENT: helps to effectively increase platelet count
1. Petechiae 3. Anti-D Antibody – one dose treatment
2. Ecchymosis ✔ Given to pt’s 1 year but less than 19
3. Blood in any body secretions, bleeding form years old
mucous membranes, nosebleeds. ✔ Normal WBC and hemoglobin
4. Decreased platelet count ✔ no active bleeding present
5. Anemia ✔ no concurrent infection
6. easy bruising ✔ Diphenhydramine and hydrocortisine
7. blood in stool or urine are made ready for possible allergic
8. CBC reveals platelet count below 20,000/mm3 9. reactions to the medication
Platelet transfusion
 Splenectomy causes blood deterioration
H. Avoid mixing or administering drug at BT line to
C. NURSING MANAGEMENT prevent hemolysis
1. Prevent, control and minimize bleeding. I. Regulate at KVO (10-15 gtts/min) at 100 cc/hour to
2. Prevent bruising prevent circulatory overload
3. Provide support to client and be sensitive to J. MONITOR VS BEFORE, DURING, & AFTER
change in body image. TRANSFUSION ESPECIALLY EVERY 15 MINUTES
4. Protect from infection. FOR THE FIRST HOUR. Majority of BT reactions
5. Administer analgesics (acetaminophen) as occurs at these times
ordered; avoid aspirin. K. SIGNS OF BT REACTION (HAPCATCH) 1.
6. administer meds orally, rectally, or I.V. Hemolytic reactions 🡪 life threatening.
rather than I.M. PRIORITY
▪ Signs and symptoms
BLOOD TRANSFUSIONS ✔ Dizziness, Headache, Dyspnea,
Hypotension, Flushed skin, Lumbar,
flank and sternal pain, diarrhea or
constipation, Portwine urine (red
I. OBJECTIVES urine)
A. To replace circulating blood volume ▪ Nursing Management
B. Increase oxygen carrying capacity of the blood ✔ Stop BT, Notify MD, Flush with
C. Combat infections if decreased WBCs PNSS
D. Prevent bleeding if decreased PLT ✔ Administer Isotonic Solution to
counteract shock and prevent acute
II. NURSING MANAGEMENT/PRINCIPLES tubular necrosis
A. Proper refrigeration ✔ Return blood unit to blood bank for
B. Proper blood typing and cross-matching re-examination
✔ Obtain urine and blood sample of
client for re-examination and send to
lab
✔ Monitor VS and IO

2. Allergic reactions
1. Type O – universal donor 2. Type AB – universal ▪ Signs and symptoms
receipient ✔ Fever, chills, dyspnea,
3. 85% of general population is Rh (+) Laryngospasm, bronchospasm,
▪ Blood expiration: Bronchial wheezing, Urticaria,
✔ Platelets : 5 days pruritus, skin rashes
✔ RBC: 5-7 days, 250 cc ▪ Nursing Management
C. Aseptically assemble all materials needed for BT ✔ Stop BT, Notify MD, Flush with
1. Filter set (BT set) PNSS
2. PNSS to prevent hemolysis ✔ Diphenhydramine administration as
3. 18-19 gauge large bore needle to prevent ordered
hemolysis ✔ If (+) to hypotension, it indicates
D. Instruct another RN to re-check the following: anaphylactic shock
1. Name of patient ✔ Return blood unit to blood bank for
2. Bt and ct re-examination
3. Expiration date ✔ Obtain urine and blood sample of
4. Serial number client for re-examination
E. Check blood unit for presence of bubbles, cloudiness, ✔ Monitor VS and IO
sediments and dark color as it may indicate 3. Pyrogenic reactions
contamination ▪ Signs and symptoms
F. NEVER WARM BLOOD PRODUCTS! 🡪 ROOM ✔ Fever and chills
TEMPERATURE ONLY ✔ Headache
1. Warming only done if you have dewarming devise 2. ✔ Dyspnea
Warming only done during emergency situations 🡪 if there is ✔ Tachycardia and palpitations
massive blood loss 🡪 massive transfusion G. Transfusion ✔ Diaphoresis
should be completed in 4 HOURS because blood ▪ Nursing Management
exposed to room temperature more than 2 hours

10
MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

✔ Stop BT
✔ Notify MD
✔ Flush with PNSS
✔ Administer antipyretics and
antibiotics as ordered
✔ Provide hypothermic blanket
✔ Return blood unit to blood bank for
re-examination
✔ Obtain urine and blood sample of
client for re-examination
✔ Monitor VS and IO
4. Circulatory overload
▪ Signs and symptoms
✔ Dyspnea
 ✔ Rales/crackles
✔ Orthopnea
▪ Nursing Management
✔ Stop BT
✔ Notify MD
✔ Administer loop diuretics as ordered
✔ NO FLUSHING!
✔ Monitor VS and IO
5. Air embolism
6. Thrombocytopenia
7. Citrate intoxication
8. Hyperkalemia 🡪 arrhythmia

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MS Abejo