Hematology

What is Anemia (High Level)?

A ↓ than normal hemoglobin and ↓ circulating RBC; a sign for an underlying cause.

Major anemia types by mechanism?

Hypoproliferative (inadequate production)

Hemolytic (destruction faster than production) - may also be due to blood loss.

Causes of hypoproliferative anemia?

Meds/chemicals

Lack of erythropoietin

Iron

Vitamin B12

Folic Acid 

Cancer

Causes of hemolytic anemia (examples)?

Hypersplenism 

Drug-induced anemia 

Autoimmune anemia 

Mechanical heart-valve related anemia.

Classic clinical manifestations of anemia?

Fatigue/weakness/malaise

Somnolence

Headache

Irritability

Dizziness/syncope

Pallor

Jaundice

Paresthesia

Tachycardia/palpitaations

Dyspnea on exertion

Sensitivity to cold

Brittle/ridged/spoon nails

Angular cheilosis

Pica

Tongue changes (beefy red & sore in megaloblastic; smooth & red in iron deficiency).

Core labs in anemia workup?

CBC (RBC, Hgb, Hct)

RBC indices (MCV/MCH/MCHC)

Iron studies (TIBC, ferritin)

Sickle-cell test

Schilling test

Bone marrow biopsy.

What does MCV indicate and typical patterns

RBC size: normocytic normal

Iron deficiency: microcytic

 B12/folate deficiency: macrocytic

What do MCH & MCHC tell you?

MCH = amount of Hgb per RBC (normo vs hypochromic)

MCHC = Hgb concentration relative to cell size.

TIBC and ferritin meanings?

TIBC reflects transferrin

Ferritin reflects total iron stores (low ferritin = iron deficiency).

What does the Schilling test evaluate?

Vitamin B12 absorption with/without intrinsic factor (pernicious anemia).

Most common anemia?

Iron deficiency Anemia

Iron Deficiency Anemia key causes?

Low dietary iron

Blood loss (ulcers, gastritis, IBD, GI tumors)

Menorrhagia

Pregnancy without supplementation

Vegetarian diet

Intestinal hookworms prevalent in developing countries

IDA hallmark clinical signs?

Smooth red tongue

Brittle/rigid nails

Angular cheilosis

Pica

Koilonychia/spoon nails

Medical management of IDA?

Determine cause

Iron supplements

Increase vitamin C to enhance absorption

Nursing teaching for oral iron?

Take 1 h before or 2 h after meals (between meals)

If GI upset, may take with meals (↓ absorption ~40%)

Liquid via straw & rinse mouth; stools dark green/black.

Parenteral iron & follow-up?

Use Z-track for severe cases

Recheck iron in 4–6 weeks.

Diet pointers for IDA?

Meats, beans, green leafy vegetables; orange juice (vitamin C).

What is aplastic anemia?

Rare

Decreased/damaged bone-marrow stem cells =↓ RBCs (often pancytopenia).

S/S of aplastic anemia?

May be subtle

Infection

Fatigue

Purpura

Retinal hemorrhages

Medical management of aplastic anemia?

Hematopoietic stem cell transplant

Immunosuppressive therapy

Nursing priorities in aplastic anemia?

Monitor for infection and bleeding

What deficiencies cause megaloblastic anemia (B12/Folate)?

Vitamin B12 and/or folic acid

Pernicious anemia is a type

Classic S/S of megaloblastic anemia?

Often insidious

Fatigue

Smooth sore red tongue

Mild diarrhea

Pallor

Paresthesia (LE)

Confusion

Loss of balance

Management & nursing for megaloblastic anemia?

Replace B12/folate;

Inspect skin

Assess gait/stability

Small frequent bland soft foods

Supplement diet.

Who is commonly affected & what’s the RBC change?

More common in African descent (also Middle East, Mediterranean, some India tribes)

RBCs become dehydrated, rigid, sickle-shaped with low O2 tension

Can revert if re-oxygenated before rigid.

Patho consequences of sickling?

Adhesion in small vessels → ↓ blood flow, ischemia/infarction → pain, swelling, fever

Increased viscosity → low oxygen delivery

Prognosis overview?

Average life expectancy rarely exceeds 60s

Common S/S in SCD?

Jaundice

Pain

Enlargement of facial/skull bones

Cardiac: tachycardia, murmurs, enlargement, HF.

Major complications to monitor?

Hypoxia

Poor wound healing

Infection

CVA

Renal failure

CHF

Impotence

Pulmonary HTN

Acute chest syndrome

Prevention & priorities in vaso-occlusive crisis?

Prevent: avoid cold, hydrate, vaccinate/avoid sick contacts.

Treat: oxygen, IV fluids, correct/prevent acidosis, pain management.

Medical & nursing management in SCD?

HSCT

Hydroxyurea

Transfusion/plasmapheresis

Supportive (opioids/NSAIDs, hydration)

Nursing: manage pain, monitor O2 sat, prevent infection, promote coping

 What is (PV) Polycythemia Vera and who gets it?

Proliferative myeloid stem cell disorder

Median age ~65

Survival ~14–24 yrs

Elevated hematocrit

PV symptoms & risks?

Ruddy complexion

Splenomegaly

HTNv

Pruritus

Erythromelalgia (burning hands/feet)

Thrombosis & bleeding risk

PV treatment?

Phlebotomy

Chemotherapy

Antiplatelets

What is Leukemia (General)?

Hematopoietic malignancy with unregulated leukocyte proliferation

Crowding suppresses other lines

Immunosuppression d/t lack of mature leukocytes infection = leading cause of death; ↑ bleeding risk.

Main classes of leukemia?

Acute vs Chronic

By cell line: AML, CML, ALL, CLL

Leukemia: AML patho & risks?

Defect in stem cells → myeloid lines (monocytes, granulocytes, erythrocytes, platelets);

Risks: prior cancer tx/radiation, polycythemia vera, Down syndrome.

Leukemia: AML prognosis & treatment?

Prognosis poor

Induction chemotherapy

HSCT.

Leukemia: AML manifestations?

Fever/infection (neutropenia)

Weakness/fatigue

Bleeding (thrombocytopenia)

Abdominal pain (hepatosplenomegaly)

Gum hyperplasia

Bone pain

Leukemia: CML overview & stages?

Mutation in myeloid stem cell → uncontrolled WBCs

Age >50

Chronic phase → transformation phase → accelerated/blast crisis

Leukemia: CML clinical features?

Malaise

Anorexia

Weight loss

Confusion

SOB (leukostasis)

Tender hepatosplenomegaly.

Leukemia: CML treatment?

Tyrosine kinase inhibitors (Gleevec)

HSCT

Chemo

Leukemia: ALL population, prognosis?

Most common in young children (boys > girls)

Peak age 4

Good prognosis—~85% event-free at 5 yrs.

Leukemia: ALL S/S & treatment?

Meningeal symptoms (cranial nerve palsies, HA, vomiting)

Liver/spleen/bone pain

Infection/bleeding

tx: chemo

HSCT

TKI if Ph+ (Ph+ALL)

Leukemia: CLL overview & population?

Malignant B-cell clone (mature)

Escape apoptosis → accumulation in marrow/blood

Most common adult leukemia

Majority >50 yrs (avg dx 72).

Leukemia: CLL clinical features & treatment?

Lymphadenopathy

Hepatosplenomegaly

Anemia

Thrombocytopenia

“B symptoms” (fever, night sweats, weight loss)

Early stage may observe

Immunotherapy + chemo

Potential complications across leukemias?

Infection

Bleeding

Renal dysfunction

Tumor lysis syndrome

Nutritional depletion

Mucositis

Depression

Key nursing interventions for mucositis & precautions?

Gentle oral care; soft toothbrush or sponge if counts low

NS rinses; perineal/rectal care

Neutropenic precautions (Private room, Handwashing, Avoid sick contacts, Oral hygiene, Meticulous IV care, Timely antibiotics).

What is lymphoma & main types?

Cancer of lymphocytes/lymph nodes (may involve spleen, GI, liver, marrow)

Two major types: Hodgkin’s (HL) and Non-Hodgkin’s (NHL)

Hodgkin’s Lymphoma (HL) hallmark cell & epidemiology?

Reed-Sternberg cell

Suspected viral etiology

Familial pattern

Bimodal 15–34 and >60

Starts in a single node/chain

Predictable spread

Excellent cure rate.

Hodgkin’s Lymphoma (HL) manifestations & treatment?

Painless neck lymphadenopathy

Pruritus

Fever

Sweats

Weight loss

Chemo ± radiation ± HSCT.

Non-Hodgkin’s Lymphoma (NHL) spread, epidemiology, causes?

Unpredictable/erratic spread; more common in men/older adults

Causes may include gene damage

Viral infection

Autoimmune disease

Radiation/toxic chemicals

Incidence increasing

Prognosis varies by type.

Non-Hodgkin’s Lymphoma (NHL) clinical features & treatment?

Wide variation

Lymphadenopathy

Recurrent fever

Night sweats

Weight loss

Treatment depends on classification/stage/pt tolerance: chemo, radiation, immunotherapy, HSC

What is Multiple Myeloma (MM) and cure status?

Malignant plasma-cell disease in bone marrow with bone destruction

No cure

5-yr survival ~46.6%

Median age 70.

Multiple Myeloma (MM) manifestations?

Bone pain (back/ribs)

Osteoporosis/fractures

Hypercalcemia

Renal damage/failure

Anemia

Fatigue/weakness.

Multiple Myeloma (MM) medical & nursing?

Autologous HSCT

Chemo

Corticosteroids

Immunomodulatory drugs

Radiation

Nursing: pain mgmt, infection monitoring, education, activity restriction & infection prevention.

What is thrombocytopenia & S/S?

Low platelet count

Petechiae

Epistaxis

Bleeding gums

Menorrhagia

CNS/GI hemorrhage

Treatment & nursing for thrombocytopenia?

Platelet transfusions

Splenectomy

Bleeding precautions if platelets <50,000

Bleeding precautions—what to avoid/do?

AVOID

Avoid certain meds

IM injections

Foleys

Rectal temps

Suppositories

Enemas

Suctioning

Straight razors

DO

Smallest needle

5-min pressure post-venipuncture

Soft toothbrush

Lips lubricated

Discourage cough/blowing

Limit needle sticks

Assist ambulation

Hemophilia overview & genetics?

Hereditary coagulation disorder

X-linked recessive (males affected; females carriers)

A = factor VIII (8)  deficiency

B = factor IX (9) deficiency.

Hemophilia S/S?

Bleeding with circumcision

Early bruising

Prolonged bleeding from cuts

Hemarthrosis with joint deformities

Life-threatening bleeds (head/abdomen).

Hemophilia management & nursing?

Genetic counseling/prenatal dx

Plasma transfusion

Replace deficient factor

Desmopressin ↑ factor VIII

Nursing: prevent injury, medic alert, monitor hemorrhage, bleeding precautions, pain control, avoid antiplatelets, RICE.

Von Willebrand’s Disease (vWD) basics & S/S?

Inherited

Affects both sexes equally

vWF deficiency (needed for factor VIII activity)

S/S: epistaxis, heavy menses, prolonged bleeding from cuts, hematuria/melena, fluctuates.

Von Willebrand’s Disease (vWD) management?

Replace vWF or factor VIII

Desmopressin (synthetic vasopressin analogue)

Nursing similar to hemophilia

What is Disseminated Intravascular Coagulation (DIC) and common triggers?

Not a disease but a sign of underlying disorder

May be life-threatening

Triggers: Sepsis

Trauma (hemorrhage, burns, crush injuries)

Shock

Cardiopulmonary arrest

Cancer

Obstetric complications

Toxins

Allergic reactions

Disseminated Intravascular Coagulation (DIC) patho and early clue?

Massive microvascular clotting consumes factors/platelets → bleeding

First sign may be low platelets

Disseminated Intravascular Coagulation (DIC) clinical picture & labs?

Symptoms related to tissue ischemia/bleeding

Minimal occult bleeding → profuse hemorrhage

Common lab profile shown in slides (↓ platelets; prolonged coagulation; ↓ fibrinogen; ↑ fibrin split products/D-dimer).

DIC (Disseminated Intravascular Coagulation) treatment & nursing?

Treat cause

Correct ischemia

Improve oxygenation

Fuids/electrolytes

Maintain BP/vasopressors

Replace factors/platelets

Administer heparin to inhibit microthrombi

Nursing: frequent assessment for thrombi/bleed, target organ damage, avoid trauma/↑ICP activities, support fluid/perfusion, emotional support, early ID.

ITP basic mechanism? (Other Coagulation Issue)

Autoimmune

Antiplatelet antibodies shorten platelet lifespan

Severe hemorrhage risk in peripartum lacerations/cesarean.

TTP basic mechanism & complications? (Other Coagulation Issue)

Platelets abnormally clump in capillaries → inappropriate clotting

Failure to clot with trauma

Complications: AKI, MI, CVA.

HIT quick definition? (Other Coagulation Issue)

Immunity-mediated clotting disorder

Low platelets from heparin exposure

MEDS: Heparin—indications, route, therapeutic range, antidote, monitoring?

Indications: DVT/PE tx, ACS, thrombosis prophylaxis

SQ or IV

Therapeutic aPTT 60–80

Monitor bleeding/platelets

Antidote protamine sulfate

MEDS: Warfarin—indications, route, therapeutic range, antidote, monitoring?

Indications: DVT, PE, a-fib, mechanical valve

PO; INR 2–3 (3–4.5 for mechanical valve)

Monitor for bleeding, hepatitis

Skin necrosis

Antidote vitamin K

May need FFP.

MEDS: Erythropoietin use & caution?

Stimulates erythropoiesis

SQ/IV usually 3×/week

Used commonly for anemia in acute renal failure

Can dangerously elevate BP.

Therapies for Blood Disorders (Splenectomy—what is it?)

Surgical removal of spleen

Therapies for Blood Disorders (Therapeutic apheresis—what is it?)

Separates/removes a blood component by centrifuge

Returns rest to patient

Therapies for Blood Disorders (Therapeutic phlebotomy—what is it?)

Controlled removal of blood volume

Therapies for Blood Disorders (Blood component therapy—what’s separated?)

Blood into erythrocytes, platelets, plasma

Transfusion types?

Standard donation (compatible donor)

Autologous pre-collection (up to 6 weeks pre-op)

Intraoperative blood salvage (reinfuse filtered blood within 6 hrs)

Core PRBC nurse’s role (process highlights)?

Verify consent; explain procedure

Baseline vitals

Appropriate IV site/gauge

Ensure patency

Special tubing with filter

Pick up from bank

Check with another RN in patient room

FFP (Fresh Frozen Plazma) key points?

Frozen immediately after donation

Transfuse as soon as thawed

Infuse 200 mL rapidly (30–60 min) as tolerated

Regular Y-set or straight filtered tubing

Platelet transfusion key points?

No need for ABO match

200–300 mL

Fragile—infuse immediately over 15–30 min

Special set (smaller filter/shorter tubing)

Vital Signs before,15 min after, and at completion.

Blood type compatibility (summary)?

Tables provided on slide

Highlights: O- can give to everyone (universal donor)

AB+ can receive from everyone (universal recipient).

Universal nursing steps for suspected reaction after transfusion? (Transfusion)

Stop

Remove blood tubing

Start 0.9% NS

Assess

Notify provider & implement orders

Continue monitoring

Return bag/tubing to lab

Obtain samples

Document

Acute hemolytic reaction—why dangerous & S/S? (Transfusion)

Stop immediately!!!

Most dangerous

As little as 10 mL incompatible blood can trigger

Usually labeling/admin errors

S/S: fever, chills, low-back pain, tachycardia, hypotension, flushing, nausea, chest tightness/pain, tachypnea/dyspnea, anxiety/doom, hemoglobinuria.

Febrile nonhemolytic—cause, timing, S/S? (Transfusion)

Anti-WBC antibodies

Often within 2 hr

Most common reaction

S/S: chills, temp ↑ ≥1°F (0.5°C), flushing, hypotension, tachycardia.

Allergic reaction—timing & treatment? (Transfusion)

During or up to 24 h after

Sensitivity to component

Usually mild (hives, itching, flushing)

Treat with antihistamine (Benadryl)

If resolves, may resume slowly

Circulatory overload—risk, S/S, actions? (Transfusion)

Anytime during transfusion

From too much/too fast

Older adults & CHF highest risk

S/S: crackles, dyspnea, cough, orthopnea, tachycardia, anxiety, JVD

Actions: slow/stop, elevate HOB feet down, O2/diuretics/morphine per orders

Keep NS TKO 5–10 mL/hr.

Bacterial contamination—risk, S/S, actions? (Transfusion)

Greatest with platelets (room temp)

Transfuse within 4 hr

S/S: wheeze, dyspnea, chest tightness, cyanosis, hypotension, shock

Stop, send cultures, abx + IV NS

Key elements of neutropenic precautions?

Hand washing

Avoid sick contacts

Care for neutropenic pts first

Private room

Reverse isolation

Change water containers daily

Clean room

Low-microbial diet (avoid raw/unpeeled produce though evidence limited)

Oral hygiene

Meticulous IV care

Give antibiotics on time

Teach patient/family