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Hematologic System
- Consist of blood, bone marrow and reticuloendothelial system
Blood
- Composed of: RBC, WBC and Platelets
Bone Marrow
- Site of hematopoiesis
myeloid
lymphoid
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Precursor for:
- 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
Lymphocytes
T-Lymphocytes
- Releases lymphokines for enhanced phagocytic activity - Responsible for delayed allergic reaction and foreign tissue rejection - Responsible for destruction of tumor 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
B-Lymphocytes
- Releases immunoglobulin or antibodies
T cells on the right, platelet on the center and rbc at the left
Platelets
- For clotting mechanism - Circulate freely in an inactive state in the endothelium - Normal life span of 7-10 days
Diagnostic Findings
Test Red Blood Cells Hemoglobin Normal Range M: 4.7 6.1 x 106 F: 4.2 5.4 x 106 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 Description
Hematocrit Platelets
Indicates proportion of plasma and RBCs 20, 000/mm3 serious; 10, 000/mm3 life-threatening
Test
White blood cells
Normal Range
5,000 10,000/mm3
Description
Neutrophils
40 75%
Indicates bacterial infection, inflammation, stress and steroids. Increased after bacterial and viral infection
Lymphocytes
20 50%
Monocytes
1 10%
Increased in acute and chronic infection, and inflammation Increased in allergic states, parasites and metastatic tumors Increase is very rare
Eosinophils
0 6%
Basophils
0 2%
Anemia
- Hemoglobin concentration is lower than normal
- Lower RBC than normal lower amount of oxygen delivered
Classifications of Anemia
1. Hypoproliferative - marrow cannot produce adequately - due to medications - lack of co-factors
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
Hypoproliferative Anemia
A. Iron Deficiency Anemia
- Inadequate intake of Iron resulting to low manufacture of hgb - 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
Assessment
1. Pallor
Diagnostic Finding
Bone Marrow Aspiration - Most definitive - Low ferritin level - Seldom used
Medical Management
1. Iron Preparation - Ferrous sulfate, Ferrous gluconate 6 month therapy 2. Iron Dextran - IM for poor iron absorption
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
B. Aplastic Anemia
- Rare disease where there is decrease or damage to marrow stem cells FAT - Significant neutropenia + thrombocytopenia are also seen
Causes:
1. Idiopathic 2. Exposure to myelotoxic agents, autoimmune disorder
Diagnostic Finding
Bone Marrow Aspiration
- Most definitive - Demonstrates conversion of red bone marrow to fatty red bone marrow
Assessment
1. Pancytopenia 2. Petechiae, purpura, bleeding, pallor, weakness, tachycardia, fatigue 3. Infections are common
Medical Management
1. 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
Nursing Interventions
1. Administer immunosuppressive medications
Hemolytic Anemia
- RBCs have a shortened lifespan
- Insufficient O2 causes the cell to assume a sickle shape causes clumping together and later obstruction e.g. fever, emotional and physical stress, cold environment - Genetic factor - Sickling response is reversed when provided with adequate O2 and hydration - After repeated sickling, the cell become permanently sickled.
Manifestations
Spleen
Lungs CNS Kidneys Bone Skin Eye
infection
Chest pain, dyspnea, Weakness Dehydration
Widening of medullary Bone pain spaces Skin ulcer Scarring and hemorrhage Pain , decrease healing Decreased vision; blindness
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
3. Aplastic Crisis
- Results from infection with the human parvovirus
- Causes production of RBC to shut down for about 10 days and level falls rapidly & marrow cannot compensate
Medical Management
1. Hydroxyurea
- Chemotherapeutic agent used to decrease permanent formation of sickle cells
- S/E: a. Chronic suppression of WBC
2. Arginine
- Enhances nitric oxide potent vasodilator to decrease pulmonary pressure
3. Transfusion Therapy
- Long term RBC transfusion - Risks include: a. Iron Overload b. Infection and thrombosis from the site c. Hepatitis and HIV d. Significant financial cost
3. Supportive Therapy
PAIN significant 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)
Nursing Interventions
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
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
Assessment
1. Asymptomatic most of the time 2. Pallor, jaundice and hemoglobinuria
Diagnostic Test
1. Screening Test (NB Screening) 2. Quantitative Assay of G-6-PD
Medical Management
1. Stop the offending medications 2. Transfusion if severe hemolysis occurs (Mediterranean Type)
Nursing Management
1. Pt is educated and given a list of medications to avoid 2. Medic-Alert
Polycythemia Vera
- Uncontrolled mechanisms of the myeloid stem cells resulting to hypercellular bone marrow activity. - erythrocyte, leukocyte and platelet counts are elevated
Manifestations:
a. Increase blood volume - headache, dizziness, tinnitus, fatigue, paresthesia and blurred vision.
b. Increase blood viscosity - angina, claudication, dyspnea, thrombophlebitis
Diagnostic Test
1. Elevated erythrocyte count
Complications
1. Thromboses - CVA - MI 2. Bleeding - Very large platelets but dysfunctional
Medical Management
1. Phlebotomy - to diminish blood viscosity
Nursing Management
Nurses 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
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
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
Medical Management
1. 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
Nursing Management
A. Extensive teaching about activity restrictions and self care measures
1. Avoid aspirin, NSAIDs, herbs and alcohol 2. OTC cold remedies are avoided 3. Dental hygiene to avoid dental extractions 4. Nasal packing is avoided 5. Splint joints for signs of bleeding 6. Avoid all injections if possible 7. Invasive procedures should be minimized or performed after administration of factor replacements 8. Frequently assess surgical sites post surgery 9. Wear Medic-Alert bracelet 10. Frequent v/s monitoring
B. Analgesics for pain associated with hematoma and hemorrhage to joints C. Warm bath promotes relaxation
- 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
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
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
E. Bacterial Contamination
- Incidence is very low - Usually due to organisms on the donors skin - Most bacteria cannot survive in cold temperature used to store RBC platelets are at greater risk s/sx: - Fever, chills & hypotension - Transfusion is discontinued - IV with NSS - Notify physician and blood bank is informed - Blood container is returned to blood bank for C & S test