HEMATOLOGIC NURSING
1. Long bone > produce RBC > ERYHTROPOEITIN > produced by the kidneys > stimulates the long bone to produce RBC
2. Spongy bone > stem cells > red marrow > RBC synthesis > RBC
3. Concrete bone > yellow marrow > fats
Life-threatening complication of fracture
1. Fat Embolism
2. Pulmonary Embolism
Manifestations
1. Dyspnea
2. Pleuritic chest > chest pain
3. Blue spots and ecchymosis on the site
Blood components
1. RBC – Erythrocytes > low RBC > Anemia
APLASTIC ANEMIA
2. WBC – Leukocytes > low WBC > Leukopenia
3. Platelets – Thrombocytes > low platelet > Thrombocytopenia
(Pancytopenia)
RED BLOOD CELLS (RBC)
RBC Normal range: 4.5-6.5 million (most abundant)
HGB: 12-16g/dL
Oxygen carrier of the blood
HCT: Male 42-52% / Female 40-50%
Percentage of hemoglobin carrying oxygen
NLE: Most specific indication of anemia? RBC
WHITE BLOOD CELLS (WBC)
WBC (protection from infection) Normal range: 5k – 10k count
High WBC > indicates presence of infection > SEPTICEMIA
Low WBC > indicates risk for infection > IMMUNOSUPPRESSION
1. Bands – immature WBC
2. Segs (segmentor) – mature WBC
NLE: Which of the following indicates occurrence of infection?
A. when the bands outnumber the segmentors
B. when the segmentors outnumber the bands
Types of WBC
A. Granulocytes
1. NEUTROPHILS – protects from Bacterial infection > short term phagocytosis > acute infection > pus and dead skin
2. BASOPHILS – secretes heparin (anti-coagulant) > inflammation > wound (external)
3. EOSINOPHILS – protects from parasitic infection > inflammation > lungs (internal)
B. Non-Granulocytes
1. MONOCYTES – protects from bacterial infection > converted into macrophages >long term phagocytosis > chronic
infection
2. LYMPHOCYTES – protects viral infection
B Cells – lymph nodes > humoral immunity > protects the blood > destroys infection in the blood
T Cells – thymus > cellular immunity > cells from cellular damage > protects the cell > destroy abnormal cells
o T-helper cells: determines or recognize the type of infection
o T-killer cells: destroys abnormal cells
AIDS > low CDT4 cells
<200 count = indicates positive AIDS
<100 count = indicates immunosuppression
PLATELETS
Platelets (clotting factor > indicates bleeding) Normal range: 150k – 450k count
Platelet respond on the site of injury > Thromboplastin > Prothrombin (Heparin – PTT) > Thrombin (Coumadin – PT)
> Fibrinogen > Fibrin > clotting factor
NLE:
ANTICOAGULANTS – prevent clot formation
HEPARIN (IV) – prevent conversion of thromboplastin to prothrombin
COUMADIN/WARFARIN (ORAL) – prevent conversion of prothrombin to thrombin
Blood types Destroys Transfuse
A B A, O
B A B, O
AB X A, B, AB, O (universal recipient)
O AB O (universal donor)
Nursing Alert during Blood Transfusion
1. Blood typing, cross-matching, transfusion orders must be checked by 2 nurses
- if 1 nurse is available > go to the nearest nursing station
2. If 2 units are received
- transfuse only the 1st unit and send another unit in the laboratory
3. Cardiopulmonary status must be cleared prior to transfusion
4. Prepare
- blood set
- large bore needle gauge #18
- IV=PNSS (saline solution) > D5 containing > causes hemolysis
- alternative line > for emergency purpose
5. In case of transfusion reaction and no error on labelling of blood
- return blood to the blood bank
PHASES OF TRANSFUSION REACTION
COMPLICATIONS OF BLOOD TRANSFUSION
1. Hemolytic Reaction – occurs 10-20 minutes
1. Pulmonary Edema > Cause: Rapid Infusion
Manifestations Low BP
Flushing
Dyspnea
Headache
Rales/Crackles
2. Febrile Reaction – occurs after 30 minutes
Plan of Care
High temperature
Low infusion rate
Warm to touch
High backrest
Chills & fever > administer paracetamol
DOC: Diuretics – to eliminate excess fluids
Shivering > covering with a blanket
2. Transfusion Reaction > Cause: Incompatible Blood
3. Anaphylactic Reaction – occurs late
Manifestations
Pruritus
Short of breathe
Hives > if hives only – just slow the
Wheezing
infusion
Tightness of the throat
Dyspnea
Plan of Care
BLOOD DISORDERS
Stop the infusion 1. Iron-Deficiency Anemia (IDA)
High backrest Iron – use for RBC Synthesis
Change the transfusion to NSS Characteristics: Microcytic & Hypochromic RBCs
DOC: Bronchodilation (epinephrine)
Manifestations – 4F’s Vinson-Plummer’s Syndrome
Black stool – normal
Stomatitis
Fatigue (tiredness) Staining of the teeth – taken with
Dysphagia
Fainting straw
Atrophic glossitis
Forgetfulness IM (Imferon Iron Dextran)
F(p)allor Cheilosis – cracks in the lips o Given via Z-tract (zigzag) – to prevent
Koilonychia – concave nails
leakage in SQ tissue
And
Dont’s of Iron – stimulants and calcium > lower absorption
Dyspnea Cardiomegaly
C(k)ape
Tachycardia (first sign of anemia)
Tsaa
“pale white tongue”
Milk
Plan of Care Egg
1. DIET: High Iron 2. Megaloblastic Anemia aka ‘ Malabsorption Anemia’
- low folic acid (vit B9) and low cyanocobalamin (vit B12)
Organ meat (liver/spleen/kidney) Characteristics: Macrocytic & Hyperchromic RBCs
Lean meat Causes
Green leafy vegetables 1. Overcooking of green leafy vegerables
2. IRON SUPPLEMENT 2. Alcoholic > low in vitamin B1 and B9
Manifestations
Oral 1. IDA + ‘SORE TONGUE’
o Best taken before meals 2. 4F’s + Dyspnea and Tachycardia (IDA manifestations)
o With orange juice Plan of Care
o With vitamin c 1. Encourage green leafy vegetables (broccoli, cauliflower,
Constipation spinach, and asparagus)
High fiber diet 2. Folic acid 1mg/day per orem
High fluid intake
3. Pernicious Anemia
- lack of intrinsic factor that absorbs vitamin B12 (cyanocobalamin)
- Vit B12 functions – rbc production and myelin sheath formation
Causes
1. Gastric surgery > gastrectomy & antrectomy
Billroth I – anastomosis between the duodenum and the gastric remnant
Billroth II – anastomosis the remnant stomach to the proximal jejunum
Manifestations
1. IDA + ‘BEEFY RED TONGUE’ + Peripheral Neuritis
2. 4F’s + Dyspnea and Tachycardia (IDA manifestations)
3. Neurologic – paresthesia, uncoordinated movements, ALOC
Diagnostic Test: SCHILLING’S TEST
Green radioactive B12 (oral)
24 hour urine collection
40% vitamin b12 in the urine
(+) Pernicious Anemia
Plan of Care
1. Vitamin B12 given via IM per month for life
2. Given HCl solution 10ml mix with water for 1 week after vit B12 administration
4. Sickle Cell Anemia
- sickling and clamping of RBCs
Characteristics: Crescent-shaped RBCs
Predisposing factors
1. Dehydration
2. Stress
If rigid – IRREVERSIBLE
3. Infection
If not rigid - REVERSIBLE
4. Surgery
5. High altitude
Vaso-occlusive crisis
1. Sequestration of blood in the spleen – splenomegaly
2. Destruction of RBC – anemia
3. Pooling of blood in the spleen > low blood volume in the extremities – hypovolemic shock
4. Joint pain – polyarthritis
Plan of Care
1. Priority
Hydration – IV fluids and high fluid intake
O2 administration
Pain management – Initially=NSAIDS > Prolonged/Recurrent=Morphine Sulfate (Narcotic Analgesic)
2. Blood transfusion – to treat anemia
3. Avoid flexion and Encourage leg extension – to prevent occlusion
4. DIET: low iron > destroys RBC > IRON TOXICITY (overdose) and Administer folic acid to replace iron
Diagnostic Tests
1. Sickledex (sickle-turbidity test)
Blood mix with sickledex solution = result is cloudy > (+) sickle-cell anemia
2. Hgb Electrophoresis
introduction of electricity causes clamping of RBC
5. Thalassemia
- low and defective Hgb
Types
1. Alpha Thalassemia – alpha chain of Hgb is defective
2. Beta Thalassemia – beta chain of Hgb is defective
- minor > mild anemia
- moderate > moderate anemia
- major > severe anemia (Cooley’s anemia – inherited blood disorder that affects a person’s ability to produce beta
protein causing anemia)
Manifestations
1. Major symptoms – ANEMIA
2. Thinning of Bone Matrix – overwork of the bone in attempt to overcome destructed RBC
Skeletal deformity – bossing of maxilla
Pathologic fracture
Retarded growth
3. Splenomegaly – spleen destroys abnormal RBC
4. Iron toxicity – destroyed RBC leaves iron
5. Hemosiderosis –iron deposits in the organs due to destroyed RBC
Diagnostic Test: CBC – result is low Hgb level
Plan of Care
1. Anemia – promote rest and non-strenuous activity
2. Avoid contact sports – due to pathologic fracture
3. DIET: low in iron and high in folic acid
4. Iron toxicity – ANTIDOTE: DEFEROXAMINE > increase excretion through urine and feces > be alert for visual and
hearing disturbances
5. Blood transfusion for life
6. Aplastic Anemia
- hypoplasia of bone marrow > low bone marrow activity > PANCYTOPENIA
Manifestations
1. Low RBC > Anemia (dyspnea and fatigue)
2. Low WBC > Leukopenia (risk for infection)
3. Low PLATELET > Thrombocytopenia (risk for bleeding)
7. Leukemia
- immature WBC (high bands)
Manifestations
1. Low RBC > Anemia (dyspnea and fatigue)
2. High WBC > risk for infection
3. Low PLATELET > risk for bleeding
Priority: APLASTIC LEUKEMIA (bleeding – risk for injury)
Diagnostic Test: Bone Marrow Aspiration
Site for pedia – TIBIA (Posterior)
Site for adult – ILIAC CREST
Plan of Care
1. Bone marrow transplant (BT Precaution)
2. Chemotherapy
3. Stem cell therapy
8. Polycythemia Vera
Assess for thromboembolism
- hyperplasia of bone marrow
Avoid Iron
Manifestations
1. High RBC 2. Joint Pain – DOC: LOW-DOSE OF ASPIRIN
3. Pruritus
High blood viscosity – risk for thrombus
o Complications Well ventilated room/environment
Myocardial Infarction (MI) Calamine lotion
Cerebrovascular Accident (CVA)
4. Chemotherapy – DOC: METHROTREXATE (to lower
Deep Vein Thrombosis (DVT
bone marrow activity)
Organ Infiltration
9. Polycythemia
o Hepatomegaly & Splenomegaly
o Joint pain
High RBC Compensatory due to chronic hypoxia
o ruddy complexion (REDDISH SKIN) (shock, smoke inhalation / carbon monoxide poisoning and TOF)
o Pruritus and itchiness
Hyperuricemia Stimulates the bone marrow to produce RBC
Diagnostic Tests
High blood viscosity
1. Bone marrow aspiration
2. Radionuclide assessment (GOLD STANDARD TEST)
GOAL: REVERSErisk forHYPOXIA
THE thrombus formation
Plan of Care
Plan of Care
1. High viscosity
1. Oxygen administration
High fluid intake 2. Hydration
Avoid high altitude 3. Blood transfusion
10. Disseminated Intravascular Coagulation (DIC)
Abnormal activation of clotting with activation of fibrinolysis
Granules due to small fibrin
Signs of abnormal clotting Signs of abnormal bleeding
1. Coldness of extremity 1. Oozing of blood at the site of puncture
2. Acrocyanosis – persistent blue
discoloration in the hands and feet
Plan of Care
1. Blood transfusion
2. Cryoprecipitate > clotting factor
3. Bleeding precautions > REPORT for signs of bleeding
4. Fluid replacement
11. Idiopathic Thrombocytopenic Purpura (ITP)
- unknown low platelet count bleeding
- platelet is destroyed by own platelet antibody > viral infection in children
Manifestations
1. Bruising
2. Peterchiae
3. Bleeding gums and nose
4. Menorrhagia (excessive menstruation)
5. Purpura (purple skin)
Plan of Care
1. Platelet transfusion
2. Autoimmune – high dose of steroids (IMMURAN) > Immunosuppressant
3. Viral infection – IVIg (IV Immunoglobulin) > treat viral infection
4. Chemotherapy – plant alkaloids > ONCOVIN
5. Splenectomy – removal of part of spleen that destroys the platelet
6. Bleeding precaution
7. Plasmapheresis – removal of antibody in the plasma
12. VonWillebrand’s Disease
- inherited (autosomal dominant) or acquired bleeding disorder characterized by decreased level of VonWillebrand
factor and prolonged bleeding time
- Factor VIII deficiency
Manifestations
1. Bruising, gingival bleeding, epistaxis and menorrhagia
2. Prolonged bleeding time
Plan of Care
1. Factor VIII replacement via infusions of cryoprecipitate
2. DOC: AMICAR – to stabilize clot formation before dental procedures and before minor surgery
3. DOC: DESMOPRESSIN – to manage mild to moderate bleeding
4. Institute bleeding precautions
Iron Metabolism
1. Serum iron – measurement of the amount of protein-bound iron circulating in the serum
2. Total Iron-Binding Capacity (TIBC) – measurement of all proteins that act to bind or transport iron between the
tissues and bone marrow
3. Transferrin – largest of proteins that bind to iron (increase in people with iron deficiency anemia)
4. Transferrin saturation – decreases in iron deficiency anemia and increased in hemolytic and megaloblastic
anemia
NOTE: In addition to the skin, the sclera of the eyes and mucous membranes should be evaluated for jaundice
especially in a dark–skinned individual
NOTE: Patients with pernicious anemia have higher incidence of gastric cancer and thyroid dysfunction
