► HEMATOLOGY

– the scientific study of the structure and functions of blood in health and in disease.

► BLOOD

– is the circulatory fluid of the CV system which is circulating constantly through a closed circuit of tubes.

► FUNCTIONS: ► supply

oxygen from the lungs and absorbed nutrients from the GIT to the cells ► remove waste products from tissues to the kidneys, skin and lungs for excretion ► transport hormones from their origin in the endocrine glands to other parts of the body ► protect the body form dangerous microorganism ► promote Hemostasis ( to stop bleeding) ► regulate body temperature by heat transfer – vasoconstriction and

► ►

CHARACTERISTICS: Color
 Arterial Blood  Venous Blood

Viscosity – 3-4 times more viscous than water ► pH – 7.35-7.45 ► Specific gravity - 1.048 to 1.066 ( 1.055 – 1.065) ► Volume – 5 liters or approx. 7-8% of the body weight of an average-sized adult ► Composition ► Liquid phase: PLASMA (55%) ► - A light yellow substance which is one of the major fluids of the body. Major function is to maintain the blood volume within the vascular compartment.

► 92%

Water ► 7% Proteins ( albumingammaglobulins, fibrinogen, prothrombin) ► Electrolytes (.g. Na+,,Ca 2+,, HCO3ˉ, CIˉ),
► Miscellaneous

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

Erythrocytes/ RBC

Solid phase: formed elements (45%)
Are biconcave discs (AKA discocytes) which are less than 7.5 micrometers in diameter. Carries about 200-300 million molecules of hemoglobin (hemeglobin-iron) that attach oxygen within each RBC, responsible for 97% of O2 transport Contains carbonic anhydrase that joins CO2 to water that eventually dissociates, responsible for 72% of CO2 transport LIFESPAN

Erythropoiesis
Requirements in the prdxn: 1. Precursor cells 2. Proper microenvironment 3. Adequate supplies of Iron, B12, Folic acid, CHON, pyridoxine, and traces of copper

Hematopoietic stem cells Poietin Stimulation Differentiation Immature erythrocytes Leave the bone marrow via veins and enter general circulation or nucleated reticulocyte Travel the spleen Undergo conditioning and evolve to mature erythrocytes Released to general circulation

Leukocytes/ WBC ► Whitish in color because they lack hemoglobin. ► Classified according to microscopic appearancepresence or visibility of granules.

Granulocytes  Neutrophils First line of defense, most common type of leukocyte but a short lifespan of only 10-12 hours making them ineffective in destroying infectious agents Helpful in localizing the infection and in immobilizing the pathogens until other WBCs arrive Eosinophils Weak phagocytic action, elevated during asthma attacks. Usually activated during parasitic invasion (Schistosomes / blood flukes), Lifespan= hours to 3 days Modulates or reduce IgE mediated allergic reactions Basophils not phagocytic in nature, they are mediators in inflammatory process. Releases histamine and heparin and chemotactic factor for eosinophils. Induces IgE mediated allergic reactions

Agranulocytes 1. Lymphocytes a. T- cells – differentiated in the Thymus and lives long cell-mediated response b. B- cells – differentiated in the bone marrow, antibody-mediated immune response (Humoral) c. NK- cells / natural killers / null lymphocytes- poorly understood in killing tumor cells and virally infected cells. 2. Monocytes - upon release in the bone marrow and travel to the different tissues, it is just a hypoactive phagocytic cell, become a Macrophage when it attaches to the endothelium of organs and performs its full phagocytic function.

Thrombocytes/ Platelets -functions: (1) occlude small openings of blood vessels, (2) provision of chemical components in the molecular cascade leading to coagulation

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 HEMOCYTOBLAST. Cell differentiation gives rise to

1. Risk

Factor Analysis • Non-Modifiable

Assessment of the Hematologic System

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)

d. Family history - because some hematologic disorders are inherited -Anemia, thrombocytopenia, bleeding disorders (hemophilia and Von Willebrand’s Dse), Congenital Blood Disorder (Sickle Cell anemia), Jaundice, infections, delayed healing, cancer, autoimmune dse (aplastic anemia, pernicious anemia) e. Congenital lack of the intrinsic factor

• Modifiable a. Exposure to certain chemical and drugs - Radiation overexposure - Anti-neoplastic drugs/ chemotherapy - Chemical Oxidants (e.g benzene, nitrites, lead, arsenic, etc.) - Drugs (chloramphenicol, sulfonamide, anticonvulsant, streptomycin, hair dyes

2. History – Chief complaint • Disorders of the hematologic system often affects all organs and tissues • Determine: - onset  abrupt or gradual?  since childhood or recent allergen triggered response? Seasonal? How long do the allergic manifestations last? Relieved or persist once the allergen is removed?

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? 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

severity and location= rest can alleviate fatigue? Bleeding of joints?  Can rest alleviate fatigue? (s/sx of anemia)  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?

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) 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

How long was the bleeding problem? Do any members of the family have a history of bleeding? 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? How severe are any of the bleeding episodes? What is the durations? Any history of hepatic/ splenic or renal disease? Recently taken medications? b. Medications- aspirin, chloramphenicol, antineoplastic drugs c. Allergies- Hx of allergies and 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

1.
-

Review of Systems/ Physical Examination

SKIN

pallor ruddy skin

jaundice - dry skin, brittle, spoon shaped with longitudinal ridges

petechiae purpura and ecchymoses rashes, urticaria, pruritus

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 - backpain (hemolysis) - joint pain (hemophilia) -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 – characterized by paloor, weakness and lightheadedness, severe anemia manifests with chronic severe fatigue, exertional dyspnea, headache or vertigo Bleeding d/o –petechiae, purpura and ecchymosis, spontaneous bleeding from the nose, gingival, vagina, and rectum, oozing of blood from cuts and venipuncture sites, jaundice, conjunctival hematemesis, hematuria and back and flank pain Hemophilia – lifelong bleeding tendencies such as excessive bleeding and circumcision or dental extraction, repeated episodes of spontaneous bleeding into joints and lifethreatening bleeding Immunodeficiencies – hx of recurrent infxns esp of mucous membranes (oral cavity, anorectal, genitourinary, respiratory); poor wound healing, diarrhea

DIAGNOSTIC PROCEDURES: 1. Complete Blood Count

a. RBC count- # of RBCs/ mm3 of blood, to diagnose anemia and ploycythemia b. Hemoglobin- # of grams of hgb/ 100ml of blood; to measure the oxygen-carrying capacity of the blood c. Hematocrit – expressed in %; measures the volume of RBCs in proportion to plasma; used also to diagnose anemia and ploycythemia and abnormal hydration states d. RBC indices- measure RBC size and hemoglobin content a. MCV (mean corpuscular volume) b. MCH (mean corpuscular hemoglobin) c. MCHC (mean corpuscular hemoglobin concentrarion) e. Platelet count- # of Platelet/ mm3; to diagnose thrombocytopenia and subsequent bleeding tendencies f. WBC count- of WBCs/ mm3 of blood; to detect infection or inflammation g. WBC Differential count- determines proportion of each WBC in a sample of 100 WBCs; used to classify leukemias

► 2.

Picture 4

Peripheral Blood Smear- to determine the variations/ abnormality in RBCs, WBCs and Platelets: normal size and shape (normocytes) and normal color (normochromic)

Normocytic-normochromic

3. DIRECT ANTIGLOBULIN EST (Coomb’s Test) – used in cross matching blood when transfusion reaction occurs, test umbilical cord for Erythroblastosis fetalis and diagnose acquired hemolytic anemia 4. INDIRECT ANTIGLOBULIN TESTidentifies 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)

Bone Marrow Aspiration
BONE MARROW ASPIRATION and BIOPSY- used to

determine size and shape of RBCs, WBCs and platelet precursors and to examine various maturational abnormalities.

NURSING RESP: Preprocedure - explain the purpose, obtain consent - inform client of pain or of what to expect - give sedatives as ordered Procedure position, with uppermost numb tissues to - place patient in lateral site of aspiration - clean pt’s skin with antiseptic sol’n - administer local anesthesia to skin and subcutaneous - apply ice on the contralateral side relieve pain

Postprocedure - apply pressure until bleeding stops - check site frequently for bleeding

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.

CBC

Normal Values

RBC: Women – 4.2-5.4 million/mm3 Men – 4.7-6.1 million/mm3 Hgb: Women – 12-16 g/dl Men – 13.5-18 g/dl Hct : Women – 37-47% Men – 42-52% WBC: 4000-9000/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

Peripheral Blood Smear: Normocytic, Normochromic Coomb’s Test: Direct – Negative Indirect – Negative Reticulocytes: 25-75 x 10 9/L Bleeding Time: 2.75-8 min Partial Thromboplastin Time (PTT): 2035 sec. Prothrombin Time (PT): 12-14 sec.

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