Hematologic system

What does the hematologic system consist of?

• It consists of blood and the sites where blood is produced, including the bone marrow and the RES system

What does plasma contain?

• Nutrients, hormones, electrolytes, waste, clotting factors proteins

What does blood contain: 55% of blood volume is plasma and 45% consists others 

Blood

• what are the 3 primary cell types

• What is the process of hematopoiesis

  • Location?

  • differentiations?

• Thrombocyopenia?

• Thrombocytosis?

3 cells:

• erythrocytes (RBC)

• Leukocytes (WBC)

• Thrombocytes (platelets)

Hematopoiesis: replenish blood cells - primary site is the bone marrow- stem cells begin the process of differentiation into myeloid or lymphoid cells

• myloid cells - non-lymphoid WBC, RBC production and platelets

if not function properly can produce leukemia

Thrombocytopenia: low platelet count - risk of bleeding

Thrombocytosis: high platelet count - risk of blood clots

Erythrocytes (red Blood Cells)

• primary weight by 

• responsible for

A condition caused by bleeding?

Consists primarily of hemoglobin, which is iron

oxygen readily binds to hemoglobin in the lungs and is carried as oxyhemoglobin in arterial blood - primary function 

When the bone marrow releases immature RBC called reticulocytes, sometimes its a normal response for bleeding in disease states 

Erythroposisis 

• what is the process of forming RBC 

• How are old RBC removed 

Myeloid stem cells in the bone marrow are activated for differentiation by stimulation of erythropoietin from the kidneys creating erythroblasts

Depending on supplies- folic acid, VB12, iron

Old RBC are removed from blood by reticuloendothelial cells - in liver and spleen

Iron Deficiency anemia

• only .5 -1 mg is absorbed in Small intestine 

• What is the patho?

Microcytic anemia 

• what is

Patho: rapidly depleted bone marrow stores decrease hemoglobin syntheisis = small and low amount of erythrocytes 

Microcytic anemia usually from blood loss from heavy menstruation or bleeding of the GI tract

• older audlts = GI dx or colon 

• stool samples 

Vitamin B12 and Folic acid

• derived from?

required for DNA synthesis of RBC 
derived from diet 

must have a functional intestinal mucosa for absorption 

B12 combines with. intrinsic factor produced in the stomach and absorbed in the distal ileum 

Those with partial or total gastrectomy - limited intrensic factor so cat absorb B12 

Luekocytes -WBC

• 2 types 

• what’s included in those 2 types 

• What are they used for

• Which patient would be presnt with which dx? 

Granulocytes: granules in cytoplasm - protect the body from invasion by bacteria or foreign body 

• Neutrophils (WBC)

  • band cells: increase with neutrophil demand (infection) - bandemia 

    • rise with fever, tachy, systemic inflammatory response (RA, gout, ETC)

• Eosinophils - parasitic and allergic reaction

• basophils - released in exposure to allergens

Agranuloyctyes

• monocytes: differentiate the tissue to macrophages

  • macorhpage- effective against fungi and viruses

• Lymphocytes - in Bone marrow ad cortex of thymus

  • t-lymphocytes: release lymphokines to kill forgein cells and enhance phagocytic response

    • cellular immunity delays allergic reaction, rejection of foreign tissue, destruction of tumor cells 

  • B-lymphocytes: humoral immunity 

    • differentiate into plasma cells and produce atibodies called immunoglobulin

Platelets (thrombocytes)

• role

Plasma and plasma proteins

• contains

Contor bleeding - circulate in the blood in an inactive state - vascular injury = platelets collect at the site and are activated forming platelet plug 

90% is water, plasma proteins and clotting factors - fibrogen

Plasma proteins = albumin and the globulins 

• albumin helps maintain the fluid balance in vascular system 

Hemostasis

• primary and secondary pathways 

• what dx would a person with defect in factor 5 and factor 12?

Activated through intrinsic or extrinsic pathway - reaction of the cascade forms fibrin 

Factor 5 deficency- inc clotting risk 

factor 12 deficnecy - inc bleeding risk 

Complete Blood count with differentiation 

• WBC count

• Hemoglobulin

• Hemotacrit

Assessing the patient with low hemoglobin and hematocrit

Pallor - most common 

fatigue, dyspnea, palpitations. poor activity tolerance, headaches, tinnitus, anorexia, indigestion, irratablity, difficulty sleeping, abnormal menstruation, impotence, loss of libido, chest pain 

What is the difference between hemodilution and hemoconcentration

• definition

• what to do?

Hemodilution falsely low hematocrit

• sx: weight gain, moist mucus, edema, HTN, crackles, S3 gallop, mitral valve, increased urine output, distended neck vein 

• fluid volume overload - RSHF

• Diurusis patients - restrict/monitor I and O, daily weights, electrolytes 

Hemoconcentration = falsely elevated hemotacrit 

• sx: weight loss, dry mucus, delayed skin turgor, orthostatic hypotension, decreased pulse pressure, dec urinary output, inc HR, dec BP

• Isotonic hydration - inc plasma and oral hydration

Assessing the patient with low WBC count

• ANC 

• Fever??

• Neutropenic precautions 

Assess absolute neutrophil count (ANC)

Severity is classified into: 

• ANC 1,500 - 1,000 =mild neutropenia 

• ANC 999 - 500 = moderate neutropenia

• ANC less than 500 = severe neutropenia 

Assessment of multisystem - because patients with neutropenia aren’t able to manifest the classic signs of infection - watch for fever above 100.4 fever

Neutropneic diet 

masks

hygiene had wash 

no florist or edible arrangments 

What is the Nurisng Multisystemic Assessment

• skin

• oral mucosa

• respitory 

• GI 

• neuro 

Skin: tenderness, erythema, edema, breaks, moisture, central line 

oral mucosa: moisture, lesions, color, pain, change in taste - swish and spit 

Respiratory: cough, sore throat, tahypena pain on inspiration, ltne breath sounds, sputum color, consistent 

GI: palpate abdomen ascultate assess for change in bowel pattern changes 

nuero: headache, neck stiffness, visual disturbance, level of consciousness, orientation, behavior 

How to assess the patient at risk for bleeding 

• History and Physical Examination for a patient with a hematologic disorder, emphasizing the need for a multi-systemic assessment and a focus on the integumentary system (skin).

• Petechiae are the smallest type of bleeding spots under the skin.

  • Size: Pinpoint size

  • Appearance: Tiny, flat, non-blanching red, blue, or purple dots, often appearing in clusters

  • Significance: Petechiae are the classic sign of a primary hemostasis defect, problem with platelets or the capillary vessel walls.

  • Most Common Association: Severe Thrombocytopenia platelets responsible for sealing tiny breaks in capillaries too low in number or dysfunctional, allowing blood to leak out of the smallest vessels into the skin.

• Purpura describes larger areas of bleeding into the skin.

  • Size: Larger spots Lesions larger than 1cm called ecchymoses (bruises).

  • Appearance: Flat, non-blanching macules or patches that are red, purple, or brownish-black.

  • Significance: Purpura can indicate a wider range of conditions

    • Thrombocytopenic Purpura: Occurs when purpura is caused by a low platelet count -Immune Thrombocytopenia (ITP),

    • Non-Thrombocytopenic Purpura: Occurs when the platelet count is normal, but the purpura is caused by vessel damage

    • Palpable Purpura: An important clinical finding where the lesions feel raised or bumpy. This often signals Vasculitis (inflammation of the blood vessels) and can be a sign of a serious underlying illness (e.g., Rocky Mountain spotted fever, meningococcemia, or autoimmune disorders)

What questions are u askin when asseing for the risks of bleeding?

• Hx?

Labs you are assessing

Physical examination

• nosebleeds, dental work, menstruation - iron replacement, childbirth - blood transfusion, surgery blood transfusions, early bruising, family 

If at risk - no tubes rectal - no injection deep , fall risk

Labs: CBC, peripheral blood smear, PT/INR, PTT, Platlet function assay

Thrombocytopenia: low platelet count

• <50,000 - bleeding precautions

Physical exam: petechiae, ecchymosis, bleeding at puncture site, hypotension, tachy, dizziness, epistaxis, hemoptysis, abdominal pain or back pain, hematemesis, abdominal distension, rectal bleeding, vaginal bleeding, headache, mental status change, blurred vision

What does PT/PTT/INR mesure

PT = time needed for factor VIIa to form a complex with tissue factor and clot - 11 to 13.5 seconds 

• porlonged PT = Factor 7 deficency

INR= standardized Pt times from several laboratories - used to monitor Warfarin - (2-3 if heparin) 

PTT - elevated may indicate definceny infcator 7, 8, 11 (25 to 35 seconds )

What is bone marrow aspiration and biopsy?

• what’s it do 

• Nursing care?

Provides information to assess how a person's blood cells are being formed - assess the quantity and quality of each type of cell produced by marrow 

• procedure: informed consent - requires local anesthetia 

Nursing care: pain, antianxiety meds, deep breathes, post-procedure education

Anemia - dec number of RBC

• Classified as?

• What is the medical management and nursing management?

Size:

• Normocytic- normal average size RBC

• macrocytic - larger than normal - iron 

• microcytic - smaller than normal

Color

• Normochronic - normal in color 

• Hyperchromic: Darker cellular contents

• Hypochromic: pale 

Hypoproliferative anemias: the bone marrow cannot produce adequate numbers of erythrocytes 

hemolytic anemias: involve premature destruction of erythrocytes 

Nursing management: onset duration, metabolic requirements, concurrent medical conditions

• Complications: heart failure, paresthesias and confusion 

• Nursing care focuses on: managing fatigue - can cause dec QOL

• promote nutrition -iron B12, folic acid, avoid alcohol

• maintain perfusion - transfusion or IV supplemnetal O2 monitor vitals

resolve the underlying cause

What are different types of anemia:

Iron deficiency

Renal Dx

Aplastic Anemia 

Megaloblastic anemia - B12 or folic acid deficiency 

thalassemua 

immune hemolytic anemia

Iron deficency anemia

• Patho 

• recognize cues - Sx

• analyze cues 

• nursing education 

• meds

depletion of iron stores

Sx: fatigue, dizziness, pic, lightheadedness, palpations

Physical exam: circumoral pallow, conjunctival pallor, brittle nails, angular cheilitis, tachy, hypotension, murmurs 

Labs: dec retics, iron, ferritin, iron saturation, increased TIBC

Medications: iron PO

Nursing education: food ditery considerations iron managment 

Anemia of kidney dx

• patho

dec kidney function - dec erthytopoetin production - concurrent iron deficiency due to dialysis

sx: fatigue, decreased activity tolerance

Physical exam: circumoral pallor, conjunctival pallor, brittle nails, angular cheilitis (cracks on side mouth), tachy, hypotension, murmurs

Labs: elevated creatine, low-normal MCV

Meds: ESA(erythropoetin stimulating agents) Epogen, Darbeoppotien

Nursing action: ESA stroke, VTE, HTN, titrate epo to the goal Hb

Vitamin B12 anemia is????

deficient in VB12 intake - poor Gi absorption, pernicious anemia

sx: beefy red sore tongue, fatigue, peripheral neuropathy

Physical exam: circumoral pallor, conjuctival palloe, brittle nails, tachy, murmur, hypotension

Labs: CBC - increased MCV, low B12 level, low reticulocyte

Meds: B12 replacement IM/mouth - life oloong for pernicious anemia

dietary counseling oral supplements frofied milk soy for vegans

Thalassemia what is it and nursing

Patho: heredity anemia - characterized by hypochromia, microcytosis hemolysis

sx: severity of major fatality in 1st few years

physical exam: circumoral pallor, conjunctival pallor, brittle nails, tachy, murmur, hypotension

Labs: low MCV and MCH, hemolysis markers

Solutions: beta Thalassmia- chronic transfusion therapy

Monitor for iron overload, elevated ferritin ue to chronic transfusions

Polycythemia: too many cells in the blood 

POLYCYTHEMIA VERA: a myeloproliferative disorder in which the myeloid stem cells have escaped normal control mechanisms 

Secondary polycythemia: caused by excessive production of erythropoietin 

• rare very thick blood can cause strokes, clotting increase hematocrit

Sickle cell anemia:

• Assessment 

• Nursing diagnoses 

• interventions 

Assessment:

inherited disorder → abnormal Hb (Hb S) → sickled RBCs.

Triggers: infection, dehydration, stress, cold, hypoxia.

Key findings: pain crisis, fatigue, jaundice, pallor, low H&H, ↑ bilirubin.

Watch for: stroke, acute chest syndrome, renal failure.

Nursing Diagnoses:

• Acute pain r/t tissue ischemia.

• Risk for infection r/t splenic dysfunction.

• Fatigue r/t anemia.

Interventions:

• Pain: Opioids, warm compresses, relaxation.

• Hydration: IV/oral fluids (3–4 L/day).

• Oxygen: Maintain O₂ >95%.

• Prevent infection: Vaccines, antibiotics, hand hygiene.

• Medications: Hydroxyurea, folic acid, transfusions.

• Education: Avoid triggers—cold, dehydration, high altitude, stress.

Evaluation:

• Pain controlled, oxygen stable, no crisis, patient verbalizes understanding.

Leukemia:

• what is it

neoplastic proliferation of one particular hematopoietic cell type: Leukemia is characterized by the rapid and uncontrolled production of abnormal, immature white blood cells (leukocytes)

unregulated proliferation of leukocytes in the bone marrow - classified according to the stem cells line involved, either lymphoid or myeloid

• chronic or acute

Acute Myeloid leukemia

Results from a defect in the hematopoietic stem cell differentiation into myeloid cells

Symptoms result from insufficient production of normal red blood cells - bleeding and infection = complications

• fever, infection, neutropenia, enlarged spleen, gum hyperplasia

Tx: aggressive administration of chemotherapy - neutropenia

Nursing intervention: infection prevention, promoting comfort, patient education

Acute lymphoid leukemia

results from the uncontrolled proliferation of immature cells from lymphoid stem cells

Normal hematopoiesis is inhibited, resulting in a reduced number of leukocytes, erythrocytes, and platelets

Tx: Induction therapy

Infections and viral infections are common

Nursing priorities: prevention of infection and bleeding managment sx nausea and pain

Lymphomas

Neoplasms of lymphoid tissue - derived from B lymphocytes 

hodgkin lymphonma

non-Hodgkin lymphomas

Hodgkin Lymphoma 

• patho

Patho: malignant cell of Hodgkin lymphoma is the Reed-Sternberg cel a large tumor cell that is morphologically unique and is thought to be immature lymphoid origin - it is the pathological hallmark and essential diagnostic criterion for Hodgkin dx

painless enlargement of one or more lymph nodes, mediastinal mass on CXR, pruritus

Cues; cough, pulmonary infiltrates, jaundice, abdominal pain, bone pain and B-symptoms, fever, W/O chills, drenching sweats, unintentional weight loss

mild anemia, CBC, ESR, LDH, liver and kidney function

Tx: focused on cure, early stage cure, - chemotherapy, radiation therapy

outcomes - monitor for secondary cancers , hypothyroidism, CVD

Non-Hogkin Lymphoma 

Patho: heterogeneous group of cancers that originate from the neoplastic growth of lymphoid tissue 

• involve malignant B lymphocytes and T lymphocytes

Cue presentations are variable

Analyze cues B Sx: recurrent fever, drenching night sweats, unintentional weight loss

Histopathology, immunophenotyping, cytogenetic analyzes of malignant dx

Radiation can be a treatment for T but chemotherapy 

Outcome: reduce infection risk, patients receiving abdominal radiation therapy may experience nausea and diarrhea but not hair loss all patients experience fatigue

Multiple Myeloma

A malignant dx of the most mature form of B lymphocytes the plasma cell: results in production of high levels of ineffective immunoglobulins 

Sx: bone pain

• elderly: back pain and who has an elevated total protein level should be evaluated by possible myeloma

No cure but tx focuses on corticosteroids and chemotherapy

Hematological considerations keys

What are the nursing conditions for hematological dx

• nursing diagnosis 

Diagnosis 

• risk for infection - neutropenia

• risk for bleeding - thrombocytopenia

• fatigue anemia and Tx side effects

• acute or chronic pain related to bone involvement or procedures 

• avoid large crowds 

• imbalanced nutrition

• ineffective coping/anxiety related to cancer diagnosis and prolonged treatment 

• risk for injury related to weakened bones lesions or falls

What are the nursing conditions for hematological dx

• nursing intervention

Intervention

• neutropenic and bleeding precautions - avoid crowds, monitor for bleeding - use soft toothbrush and electric razor 

• monitor for signs of infection anemia and bleeding status 

• medications, accurate adequate nutrition and hydration - small frequent meals and oral care 

• encourage rest and energy conservation 

• emotional and psychological support, counseling education, coping 

• safety measures - prevent falls, handle gently, avoid invasive procedures

• educate patient and family of signs of infection 

What are the nursing interventions for hematological dx

What are the nursing interventions for hematological dx

Disseminated intravasucalr cogulation

not a dx but a sign of an underlying condition

normal hemostatic mechanisms are altered so that a massive amount of tiny clots form in the microcirculation

Tx focuses on the underlying cause

monitor and manage potential complications

Leads to clotting and bleeding at the same time - liver brain and kidney damage

What are therapies for blood disorders

Splenectomy

Therapeutic apheresis: blood is taken from the patient and passed through a centrifuge to remove a specific component

Therapeutic phlebotomy: removal of a certain amount of blood under controlled conditions

Blood transfusions 

Pretransfusion assessment, correct technique, and monitor for complications of transfusion

• febrile nonhemolytic transfusion reaction

• Acute hemolytic reaction - most dangerous and potentially life-threatening - when the donor’s blood is incompatible with the recipient

• delayed hemolytic reaction - 14 days after transfusion, the antibody has increased to the extent that a reaction can occur - the hemolysis of the erythrocytes is extravascular via the RES and occurs gradually

• Allergic reaction - Urticaria, generalized itch, rash, wheezing

• Circulatory overload - TACO is the second leading cause of transfusion-related deaths - if to much blood is infused to quickly, hypervolemia may occur

Nursing action: 

• type and screen 

• premedicate

• BP check 

• start transfusion 

• 15 min BP check 

• reaction stop 

• emergency meds - epi, steroid, benedryl, pepticid, H2 blocker