Hematologic Studies

8/4/2019 Hematologic Studies

1/54

Hematologic Disorders

Jan Leynard Camposagrado, RN, USRN, MN


2/54

- Consist of blood, bone marrow and reticuloendothelial system

- Blood is also considered an ORGAN

- Plasma is the fluid portion of theblood (55%)

Hematologic System


3/54

Blood

- Composed of: RBC, WBC and Platelets

- 45% of blood volume

- Carries oxygen, nutrients and wastes from system

- Also carries hormones and antibodies


4/54

Bone Marrow

- Site of hematopoiesis

- Marrow activity is limited topelvis, ribs, vertebrae and sternumin adult

- Liver and spleen resume blood production in marrow destruction

- Within the bone marrow are stem cells capable of differentiation

myeloid lymphoid


5/54

Slide 002


6/54


7/54

Red Blood Cells

- Disk shape provides large surface for ABSORPTION andRELEASE of oxygen molecules

- Primary function

- 120 days and removed by the reticuloendothelial cells

- Most of the iron is recycled to form new hemoglobin

- 5-day process of erythropoiesis


8/54

White Blood Cells

- Protect the body from invasion by bacteria and other foreign entities

- Neutrophils arrive at the site within 1 hour of inflammation

- Initiate phagocytosis but short-lived

- Monocytes follow and continue phagocytosis for longer periods

- Macrophages are effective against fungi and viruses


9/54

Lymphocytes

- Releases lymphokines for enhanced phagocytic activity

T-Lymphocytes

- Responsible for delayed allergic reaction and foreign tissue rejection

- Responsible for destruction of tumor cells


10/54

3 Main Groups of T-Lymphocytes

1. Killer T-cells- Sensitized and stimulated in the presence of antigen- Destroy abnormal cells

2. Helper T-cells- Enhance activities of T-cells & B-cells

- Reduced in patients with HIV

3. Suppressor T-cells- Have the effect of switching off the immune system

- Controls too much T-cells


11/54

- Releases immunoglobulin or antibodies

B-Lymphocytes

- Function in hypersensitivity reactionEosinophils & Basophils

- Eosinophils are impt in the phagocytosis of PARASITES


12/54


13/54

T cells on the right, platelet on the center and rbc at the left


14/54


15/54

- For clotting mechanism- Circulate freely in an inactive state in the endothelium- Normal life span of 7-10 days

Platelets


16/54

Test Normal Range Description

Red Blood Cells M: 4.7 6.1 x 106

F: 4.2 5.4 x 106

Hemoglobin M: 13.5 17.5 g/dL

F: 11.5 15.5 g/dL

Delivers oxygen through circulation to

body tissues and returns CO2 from

tissues to lungs

Hematocrit M: 40 52%

F: 36 48%

Indicates proportion of plasma and

RBCs

Platelets 150, 000 400, 000/mm3 20, 000/mm3 serious;

10, 000/mm3 life-threatening

Diagnostic Findings


17/54

Test Normal Range Description

White blood cells 5,000 10,000/mm3

Neutrophils 40 75% Indicates bacterial infection, inflammation,

stress and steroids.

Lymphocytes 20 50% Increased after bacterial and viral infection

Monocytes 1 10% Increased in acute and chronic infection,

and inflammation

Eosinophils 0

6% Increased in allergic states, parasites andmetastatic tumors

Basophils 0 2% Increase is very rare


18/54

Anemia- Hemoglobin concentration is lower than normal

- Lower RBC than normallower amount of oxygen delivered

Three Broad Etiologic Categories:1. Loss of RBCdue to bleeding

2. Decreased production of RBC

3. Increased destruction of RBC

- Deficiency in co-factors- Lack of erythropoietin

- Overactive RES

- Abnormal RBC


19/54

Classifications of Anemia

1. Hypoproliferative - marrow cannot produce adequately- due to medications

- lack of co-factors

II. Hemolytic Anemia - premature destruction of RBC


20/54

Nursing Diagnosis

1. Activity Intolerance r/t weakness, fatigue & general malaise

2. Imbalanced Nutrition, less than body requirement r/t inadequate intake

of essential nutrients

3. Ineffective tissue perfusion r/t inadequate blood volume


21/54

Hypoproliferative Anemia

A. Iron Deficiency Anemia- Inadequate intake of Iron resulting to low manufacture ofhgb

- Most common anemia

- Most common cause in male adult & post menopausal women is bleeding

- Most common cause in pre-menopausal women is menstruation

- Alcoholism causes GIT blood loss


22/54

Assessment1. Pallor

2. Weakness and fatigue

3. Irritability

Diagnostic FindingBone Marrow Aspiration

- Most definitive

- Low ferritin level

- Seldom used


23/54

Medical Management

1. Iron Preparation

- Ferrous sulfate, Ferrous gluconate6 month therapy

2. Iron Dextran

- IM for poor iron absorption

- ANST before giving the full dose


24/54

Nursing Interventions

1. Give iron supplements between meals

2. Given with vit. C or multivitamins or fruit juice

3. Dont give iron with milk or antacid

4. Use a straw in liquid iron forms

5. Instruct pt. of S/E: constipation, black stool, foul aftertaste

6. Instruct high iron foods: Liver, bread and cereals, dark green leafy,meat, raisins, egg yolk, beans


25/54

B. Aplastic Anemia- Rare disease where there is decrease or damage to marrow stem cellsFAT

- Significant neutropenia + thrombocytopenia are also seen

Causes:

1. Idiopathic2. Exposure to myelotoxic agents, autoimmune disorder

- benzene, gold compounds,chloramphenicol, arsenic, sulfonamides


26/54

Diagnostic FindingBone Marrow Aspiration- Most definitive

- Demonstrates conversion of red bone marrow to fatty red bone marrow

Assessment1. Pancytopenia

2. Petechiae, purpura, bleeding, pallor, weakness, tachycardia, fatigue

3. Infections are common


27/54

Medical Management1. Bone Marrow Transplantation

- Treatment of choice if a suitable donor exists

2. Immunosuppressive Therapy- Presumed that pts lymphocytes destroy the stem cell

- Antithymocyte & cyclosporine

3. Supportive Therapy

- Transfusion of RBC and platelets

- Discontinue any offending agents


28/54


1. Administer immunosuppressive medications

2. Administer blood transfusion as prescribed

3. Advise pt to obtain Medic-Alert bracelet

4. Assess carefully for signs of infection and bleeding


29/54

Hemolytic Anemia

A. Sickle Cell Anemia- RBCs have a shortened lifespan

- RBC = decreased available O2 hypoxia

- Hemoglobin (hemoglobin A) is partly or completely replaced by an abnormalsickle hemoglobin (hemoglobin S)

- Happens when there is decreased O2 tension


30/54


31/54

Spleen Primary site of sickling infarctionand phagocytosis by macrophage

infection

Lungs Infarctionpulmonary HPN Pulmonary infiltrate Chest pain, dyspnea,

CNS Infarction CVA Weakness

Kidneys Sicklingdamage to renal medulla Hematuria, renalfailure

Dehydration

Bone Increased erythroid production

(compensation)

Widening of medullary

spaces

Bone pain

Skin Infarction Skin ulcer Pain , decrease healing

Eye Infarction Scarring andhemorrhage

Decreased vision;blindness

Manifestations


32/54

Sickle Cell Crisis

1. Vasoocclusive Crisis- Most common

- Stasis of blood with clumping of the cells in the microcirculation,ischemia and infarctionnecrosis

- s/sx: fever, pain and tissue engorgement

2. Splenic Sequestration

- Life threatening caused by pooling of blood in the spleen (autosplenectomy)

- Liver and Lungs are involved in adults

- s/sx: profound anemia, hypovolemia and shock


33/54

3. Aplastic Crisis

- Causes production of RBC to shut down for about 10 days andlevel falls rapidly & marrow cannot compensate

- Results from infection with the human parvovirus

- s/sx: anemia and pallor


34/54

Medical Management1. Hydroxyurea

- Chemotherapeutic agent used to decrease permanent formation of sickle cells

- S/E: a. Chronic suppression of WBC b. Potential development of malignancy

3. Transfusion Therapy

- Long term RBC transfusion- Risks include: a. Iron Overload

b. Infection and thrombosis from the sitec. Hepatitis and HIVd. Significant financial cost

2. Arginine

- Enhances nitric oxidepotent vasodilator to decrease pulmonary pressure


35/54

3. Supportive Therapy

PAINsignificant issue

a. Lasting hours to days

b. Adequate hydration is important

c. O2 may also be required

d. Pain medication may be given (aspirin, nsaids, morphine)

e. Physiotherapy can also be used (heat, massage)f. Cognitive and behavioral intervention (distraction, relaxation)


36/54


1. Managing pain

- Make use of pain scale

- Relaxation and breathing exercises

2. Preventing and Managing Infection

- Monitor s/sx of infection

3. Minimizing deficient knowledge

- inform: Keep warm

Maintain hydration

Avoid stressful events


37/54

B. G-6-PD- Glucose-6-Phospate Dehydrogenase Deficiency- G-6-PD produces an enzyme w/in the erythrocyte for membrane stability- Hemolysis only results when erythrocytes are stressed

- Commonly affected: African-American, Greek, Italian, Asian and Jewish

- X-linked defects- Medications causing hemolysis:

1. Anti-malarial2. Bactrim/Septra3. Aspirin

5. HydroDIURIL6. OHA7. Chloramphenicol4. Vit. K


38/54

Assessment1. Asymptomatic most of the time2. Pallor, jaundice and hemoglobinuria

3. Hemolysis is often mild and self limiting

Diagnostic Test1. Screening Test (NB Screening)

2. Quantitative Assay of G-6-PD


39/54

Medical Management1. Stop the offending medications

2. Transfusion if severe hemolysis occurs (Mediterranean Type)

Nursing Management1. Pt is educated and given a list of medications to avoid

2. Medic-Alert


40/54

Polycythemia Vera- Uncontrolled mechanisms of the myeloid stem cellsresulting to hypercellular bone marrow activity.

- erythrocyte, leukocyte and platelet counts are elevated

Manifestations:

a. Increase blood volume - headache, dizziness, tinnitus, fatigue, paresthesiaand blurred vision.

b. Increase blood viscosity - angina, claudication, dyspnea, thrombophlebitis

c. Increase BP

d. Generalized pruritus

e. Splenomegaly


41/54

Diagnostic Test1. Elevated erythrocyte count

2. Increased leukocyte and platelet

3. Elevated hematocrit (60%)

Complications1. Thromboses

- MI- CVA

2. Bleeding - Very large platelets but dysfunctional


42/54

Medical Management1. Phlebotomy - to diminish blood viscosity

2. Anagrelide (Agrylin)inhibits platelet aggregation

3. Interferon Alpha-2b (Intron-A)for pruritus- anti-histamines are not effective

4. Chemotherapeutic Agents (Hydroxyurea)

- Suppress bone marrow but increases risk for leukemia

- Lowers incidence of thrombolytic complications than phlebotomy


43/54

Nursing ManagementNurses role is primarily an EDUCATOR

1. Avoid smoking, obesity, poorly controlled hypertension

2. Avoid tight or restrictive clothing (stockings)3. Avoid crossing legs

4. Avoid aspirin

5. Minimize alcohol intake (GI bleeding)

6. Avoid Iron Preparations

7. Bathe in tepid or cool water or sodium bicarbonate


44/54

Hemophilia

Hemophilia A

- Deficient or defective factor VIII

Hemophilia B- Deficient or defective factor IX

- Both hemophilias are inherited as X-linked traits

- Females are carriers and are asymptomatic


45/54

Manifestations

1. Joint bleeding (hemarthrosis)75% of all bleeding

- knees, elbows, ankles, hips, wrist and shoulders

- Recurrent joint hemorrhages can result to ankylosis

2. Hematoma can occur without known trauma in severe factor deficiency

3. Damage sensation of the peripherals, weakness and atrophy

4. Spontaneous hematuria and GI bleeding

5. Most dangerous site of bleeding is the head


46/54

Medical Management1. Infusion of Factor VIII and IX

- Given during active bleeding or as preventive measure before procedures

- Patient and family are instructed how to administer by IV at home

- Patient sometimes develop antibodies to the concentrate- If so, we give Recombinant Factor VIIa

2. Aminocaproic Acid (Amicar)

- Used to treat mucosal bleeding

3. Demopressin (DDAVP)

- Used for pt with mild forms of Hemophilia A


47/54

Nursing Management

A. Extensive teaching about activity restrictions and self care measures

1. Avoid aspirin, NSAIDs, herbs and alcohol2. OTC cold remedies are avoided

3. Dental hygiene to avoid dental extractions4. Nasal packing is avoided5. Splint joints for signs of bleeding6. Avoid all injections if possible

7. Invasive procedures should be minimized or performed afteradministration of factor replacements

8. Frequently assess surgical sites post surgery

9. Wear Medic-Alert bracelet

10. Frequent v/s monitoring


48/54

B. Analgesicsfor pain associated with hematoma and hemorrhage to joints

C. Warm bath promotes relaxation

bl d d bl d d


49/54

Procuring blood and blood productsDonors should be in good health and without any of the ff:

1. History of viral hepatitis

2. History of blood transfusions

3. History of untreated syphilis or malaria

4. History of drug abuse of IV drug use5. Skin infections

6. Recent history of asthma, urticaria or allergy to medications

7. Pregnant

8. History of untreated exposure to infectious diseases

9. Recent tattoo

10. Cancer

11. Aspirin usage within 48-72


50/54

All donors are expected to meet the ffminimal requirements:

1. Body weight should exceed 50 kg (110lbs) for 450 mL donation

2. 17 y.o are disqualified

3. Oral temp should not exceed 37.5C

4. PR should be regular between 50-100 bpm

5. BP of 90/60180/100

6. Hgb should be at least: women - 12.5g/dL

men - 13.5g/dL


51/54

Complications of Blood Transfusion

A. Febrile Non-Hemolytic Reaction- Reaction of pts antibodies to donor WBC

- s/sx: chills and fever

- Antipyretics for fever

B. Acute Hemolytic Reaction- Pt antibodies combine with donor RBC and start hemolysis

- Incompatibility of blood (hemolysis)- Errors in blood component labeling and patient identification- s/sx: fever, chills, low-back pain

- n/v, chest tightness, dyspnea- hypotension, bronchospasm

- Most dangerous and life threatening


52/54

Management:

- Discontinue immediately- Meticulous attention to labels- Accurate identification of recipient- Maintain blood volume

C. Allergic Reaction- Due to hypersensitivity to allergens found in the transfused blood

- s/sx: urticaria, itching, flushing

Management:- anti-histamines for mild reactions

- Epinephrine and corticosteroid


53/54

D. Circulatory overload- Too much blood infused- s/sx: dyspnea, orthopnea, tachycardia, sudden anxiety

- Jugular vein distention, increased BP- Crackles at the base of the lungs

- if noted, transfusion is discontinued

- Notify physician

- KVO with NSS


54/54

E. Bacterial Contamination- Incidence is very low

- Usually due to organisms on the donors skin

- Most bacteria cannot survive in cold temperature used to storeRBCplatelets are at greater risk

s/sx:

- Fever, chills & hypotension

- Transfusion is discontinued

- IV with NSS- Notify physician and blood bank is informed

Documents

Hematologic Studies