Heme

female 11.7-16.0 g/dL

male 13.2-17.3 g/dL

hgb

< 7 requires transfusion (arrhythmia concern)

female 35-47%

male 39-50%

hct

indicates FVE/FVD

150k-400k per microliter

platelets

< 10k or active bleeds

reticulocytes

too many = BAD

11-12 sec

PT (prothrombin time)

* how long blood takes to clot

INR (international normalized ratio)

normal = 1

therapeutic range = 2-3

PT ratio

30-45 sec

PTT (partial prothrombin time)

* increases with heparin

20-30 sec

aPTT (activated partial thromboplastin time)

* therapeutic is 1.5-2.5x normal

iron deficiency

anemia etiology r/t **decreased RBC production**

* RBCs microcytic (small) & hypochromic (less red) r/t blood loss, intake, meds, energy demands

B12 deficiency

anemia etiology r/t decreased RBC production

* RBCs macrocytic (large) r/t intake, pernicious anemia

pernicious anemia

* anemia r/t **decreased RBC production**
* deficiency of intrinsic factor (gastric mucosa) → failure to absorb B12
* treat w/ B12 injections
* mouth care (glossitis)
* safety when ambulating (hypotension)

folic acid deficiency

anemia etiology r/t **decreased RBC production**

* RBCs macrocytic (large) r/t intake, malabsorption, meds

aplastic anemia

* anemia r/t **decreased RBC production**
* arrested development of **ALL** blood cells in bone marrow
* found w/ agranulocytosis & thrombocytopenia
* d/t injury of pluripotent stem cell (idiopathic, myelotoxic agents, viruses)
* monitor for infections, bleeding
* provide transfusions, splenectomy

acquired hemolytic anemia

* anemia r/t **RBC destruction**
* megaloblastic/macrocytic RBCs r/t abnormal immune function, physical trauma to cells, chemical rx

antibody

abnormal immune function in acquired hemolytic anemia

* loss of self recognition (______ reaction)

heart

physical trauma to cells in acquired hemolytic anemia

* bypass surgery, mechanical ______ valve, burns, vascular disease, etc.

infection

chemical reaction in acquired hemolytic anemia

* ________, toxins, parasites, snake venom

anemia risk factors

* hx of disorders w/ chronic blood loss
* colon cancer, **GI BLEED**
* chronic diseases
* diet deficiencies
* iron, folic acid, vit B12
* genetic disorders
* exposure to toxic agents
* lead, insecticides
* meds
* certain antibiotics, NSAIDs, salicylates, thiazide diuretics, metformin, chemotherapy

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anemia clinical manifestations

* lack of hgb → inadequate tissue oxygenation
* fatigue
* pallor (NO CYANOSIS)
* tachycardia
* palpitations
* orthostatic hypotension
* coldness
* SOB esp. w/ exertion
* **glossitis** (beefy smooth tongue)
* cheilitis (cracked lip corners)
* weight loss
* long term
* HF
* finger clubbing
* nail changes
* pica (weird food cravings)
* dirt, clay, chewing ice
* cognitive, coping, sexual issues

anemia care interventions

* monitor/labs
* to identify anemia type, monitor progress, infection
* blood in excretion (poop)
* check reticulocyte count for slow bleed
* diet
* iron (meat, greens, beans)
* B12 (meat, fortified cereals)
* folic acid (fish, beans, grains)
* meds
* iron/B12 supplements
* **NO B12 PO for pernicious anemia**
* transfusions
* erythropoietin
* **splenectomy**
* for aplastic anemia
* spleen macrophages/antibodies break down blood cells, overactive

blood transfusion complications

* non-infectious
* fatal hemolytic reactions
* volume overload
* acute lung injury
* febrile (fever) reactions
* infectious
* HIV
* hepatitis B & C
* higher rates of nosocomial infection

polycythemia

* too many RBCs
* vera (primary):
* increased RBCs with normal/low epo
* genetic, usually later life onset
* secondary:
* increased RBCs and increased epo
* from hypoxia (high elevation), **tumors**, cardiopulmonary disease

polycythemia clinical manifestations

* increased CBC: **hbg, hct, histamines**
* hypercoagulation
* organ/tissue congestion
* increased blood viscosity
* increased blood volume
* increased BP
* dizziness
* vertigo
* headache
* **itchiness (from increased histamine)**
* burning of hands/feet
* visual disturbances
* tinnitus

polycythemia care interventions

* administer fluids, myelosuppressives (suppress hematopoiesis)
* phlebotomy as ordered (releases some blood)
* monitor O2
* educate: avoid altitudes, stop smoking
* hypoxia stimulates erythropoiesis in kidney
* bone marrow biopsy
* nurse role:
* pre-assess coagulation, meds
* during: positioning, pain, V/S
* after: apply pressure until bleeding stops, clean sterile dressing, monitor V/S, S/S infection, pain

thrombocytopenia

* platelet deficiency d/t decreased production, increased destruction
* r/t immune, thrombotic (drugs, disease), heparin-induced thrombocytopenia & thrombosis

thrombocytopenia clinical manifestations

* plt

thrombocytopenia care interventions

* figure out cause, assess plt count, CBC, liver & renal
* careful w/ pt handling
* avoid IM, SC injections, aspirin
* oral hygiene w/ minimal friction
* **immune thrombocytopenia**
* corticosteroids, platelet transfusion, IVIG, splenectomy, thrombopoietin, romiplostim
* **HITT thrombocytopenia**
* stop heparin immediately, plasmapheresis, argatroban

HITT

antibody response to heparin that activates platelets to aggregate/clot (thrombosis)

* heparin uses them all up in HITT thrombocytopenia
* lack of available platelets → bleeding
* solution: stop heparin, start plasmapheresis (machine for removal/filtering of blood), give argatroban (thrombin inhibitor)

extrinsic pathway

coagulation pathway

* tissue damage → prothrombin → thrombin
* **coumadin** (aka warfarin) acts on this pathway
* labs for coumadin
* prothrombin time (PT) >12
* INR normal 1, therapeutic 2-3

intrinsic pathway

coagulation pathway

* blood vessel damage → thromboplastin mediates prothrombin → thrombin
* **heparin** acts on this pathway
* labs for heparin:
* partial thromboplastin time (PTT) >45 sec
* activated PTT 20-30 sec, therapeutic 1.5-2.5x

bleeding tendencies

* decreased plt count
* defective platelets
* drug toxicities; anticoagulant therapy
* low vitamin K
* severe liver/renal disease

clotting tendencies

* increased platelet activity
* estrogen
* smoking
* increased lipids
* sluggish blood flow
* dehydration
* vessel compression
* polycythemia
* shock

bone marrow aspiration

* aspiration of red bone marrow from posterior iliac crest or sternum
* for biopsy, diagnosis/evaluation
* invasive procedure (conscious sedation/local anesthetic)
* risks: bleeding and infection

bone marrow aspiration nursing care

* pre-procedure
* assess coagulation studies/labs & VS
* receive consent
* assess meds
* during procedure
* position pt, help maintain position
* treat pain
* monitor VS
* post-procedure
* bleeding prevention → pressure (turn pt onto site of procedure), ice, bed rest for 30-60 min
* monitor VS
* observe for bleeding
* pt teaching
* avoid positioning on site
* S/S infection (redness, tenderness, fever, drainage, odor)
* fall risk education