Hematology

Based on the sources you provided, here is a review of blood components, the lymphatic system, platelets/clotting factors, blood administration, and etiologies/pathologies related to hematology, followed by a review of the nursing process as it relates to hematological disorders:

B. Review of blood components

Blood is a mixture of several components including Red Blood Cells (RBCs), also known as erythrocytes, platelets (also known as thrombocytes), clotting factors, plasma, White Blood Cells (WBCs), proteins, hormones, electrolytes, and enzymes.

  • Red Blood Cells (RBCs) or Erythrocytes: These are made in the spongy center of the bone marrow. The majority of production occurs in the vertebrae, ribs, sternum, skull, pelvis, and long bones of the leg. RBCs transport oxygen (O2) from the lungs to the tissues and carry carbon dioxide (CO2) from the tissues back to the lungs. This transport is made possible by hemoglobin within the RBCs. RBCs have a lifespan of about 120 days and are then filtered out of circulation by the liver and spleen. RBCs have various proteins called antigens, the major ones being A and B, which determine blood type. Another important antigen is the Rh factor. Normal RBC values are males 4.6-6 million cells/microliter and females 4-5 million cells/microliter.

  • Platelets or Thrombocytes: These are produced in the bone marrow. They activate the clotting system by forming a platelet plug in a broken vessel. Their normal lifespan is about 10 days, and normal lab values are 150,000-400,000.

  • Clotting Factors: These are numbered I through XIII and include Fibrinogen (factor I) and Thrombin (factor II). They form a stable fibrin matrix over an injured area, protecting the site while it heals. The liver manufactures clotting factors.

  • Plasma: This is a clear, straw-colored fluid that carries RBCs, platelets, and clotting factors through the circulatory system. It is mostly water and also contains plasma proteins, albumin, and globulins.

  • White Blood Cells (WBCs): There are five major types: Basophils (initiate inflammatory response), Eosinophils (parasitic infections, allergic reactions), Neutrophils (fight bacterial infections), Monocytes/Macrophages (ingest foreign antigens), and Lymphocytes (B cells produce antibodies, T cells include T helper and T cytotoxic cells). Normal WBC count is 5,000-10,000.

C. Lymphatic system

The lymphatic system consists of small vessels, ducts, and nodes. It collects plasma left behind in the tissues and returns it to the venous system. Lymph fluid is composed of plasma and WBCs. Lymph nodes are small patches of lymphatic tissue that filter microorganisms from the lymph system.

D. Platelets/Clotting Factors

  • Platelets (Thrombocytes): As mentioned earlier, platelets are produced in the bone marrow and play a crucial role in hemostasis. When a blood vessel is injured, platelets adhere to the site and form a platelet plug, activating the clotting system.

  • Clotting Factors: These are primarily manufactured by the liver. They are essential for the coagulation cascade, which ultimately leads to the formation of a stable fibrin matrix over the injured area, stopping the bleeding. Deficiencies in clotting factors can lead to bleeding disorders like hemophilia.

E. Blood Administration

  • 1. Blood types: Blood types are determined by the presence or absence of A and B antigens on the surface of RBCs.

    • Type A: has the A antigen.

    • Type B: has the B antigen.

    • Type AB: has both A and B antigens. AB+ is considered the universal recipient.

    • Type O: has neither A nor B antigen. O- is considered the universal donor. The Rh factor is another RBC antigen; individuals are either Rh positive (with the antigen) or Rh negative (without the antigen). Blood for transfusion must be typed and crossmatched to ensure compatibility.

  • 2. Blood products: Various blood products are available for transfusion:

    • Packed Red Blood Cells (PRBCs): Given for anemia, low Hgb or Hct.

    • Whole Blood: Not explicitly detailed, but listed as a blood product.

    • Platelets: Given when the platelet count is <20,000 or during mass transfusions. Each unit transfused typically increases the level by 5,000-10,000 cells.

    • Fresh Frozen Plasma (FFP): Contains all clotting factors and plasma proteins and is given for conditions like warfarin overdose and DIC.

    • Cryoprecipitate: Contains only fibrinogen and factor VIII and is given for hypofibrinogenemia.

    • Albumin and Globulin: Also listed as blood products. Autologous transfusion involves using the patient’s own blood that was donated and stored before a procedure.

  • 3. Administration reactions: Blood transfusion can lead to several types of reactions:

    • Hemolytic: Response to antigen, occurs shortly after starting blood. Signs and symptoms include hypotension, dyspnea, back pain, chest tightness, and hematuria.

    • Anaphylactic: Reaction to plasma proteins, occurs within 30 minutes. Mild reactions involve hives, while severe reactions include wheezing, bronchospasm, hives, chills, dizziness, and edema.

    • Febrile: Recipient’s antibodies react to donor leukocytes, starts within 30-90 minutes. Signs and symptoms include fever, chills, and headache.

    • Circulatory Overload: Patient’s cardiovascular system cannot manage the additional fluid load, can occur anytime during or hours after. Signs and symptoms include cough, frothy sputum, cyanosis, and decreased BP. Interventions for a blood transfusion reaction include stopping the transfusion immediately, keeping the IV open with normal saline, notifying the physician, nursing supervisor, and blood bank, being prepared to administer medications like oxygen, epinephrine, Solu-Cortef, Lasix, and antipyretics, saving the unused portion of the blood bag and tubing, and being prepared to collect blood and urine samples.

F. Etiologies/Pathologies

  • 1. Anemia: Characterized by an abnormally low number or altered characteristics of RBCs, leading to a decrease in oxygen to the tissues. Symptoms can include fatigue, dizziness, and near syncope or syncope.

    • a. secondary to blood loss: Can be caused by hemorrhage, gradual blood loss, GI bleed, surgery, trauma, or ineffective clotting. Manifestations include pale, cold, clammy skin, confusion, thirst, hypotension, tachycardia, and oliguria.

    • b. aplastic: Occurs when the bone marrow stops working, leading to the suppression of all blood components (RBCs, WBCs, platelets). Etiologies include medications (chemotherapy agents, chloramphenicol, streptomycin, steroids), radiation, viral infections, and inherited tendency. Clinical manifestations include ecchymosis or petechiae, excessive bleeding, frequent infections, fatigue, weakness, dizziness, dyspnea, and palpitations.

    • c. iron deficiency: Caused by decreased iron intake, malabsorption, blood loss, or hemolysis. Signs and symptoms include fatigue, weakness, pallor, dizziness, and dyspnea. Treatment involves iron supplements and managing symptoms.

    • d. folic acid: Can result from poor diet, malabsorption, drugs (Dilantin, sulfa, steroids, estrogen), increased needs during pregnancy, and ETOH abuse. Signs and symptoms include glossitis, diarrhea/constipation, pallor, weight loss, muscle pain, and insomnia.

    • e. pernicious: Occurs due to the inability to absorb Vitamin B12 from the stomach, often due to a lack of intrinsic factor. Vitamin B12 is essential for RBC production and nerve myelination; deficiency can cause irreversible nerve damage. Signs and symptoms include weakness, dyspnea, fatigue, hypoxia, glossitis, and neurological symptoms like behavior changes, paresthesia, ataxia, poor memory, and numbness. Treatment involves Vitamin B12 replacement for life.

    • f. hemolytic: Involves the destruction of RBCs once they are released into circulation, even though the bone marrow produces adequate amounts. Etiologies include infections, drug interactions, certain cancers, blood transfusions, and Hemolytic Anemia of the Newborn (where the mother's antibodies attack the baby's Rh-positive blood cells). Signs and symptoms include pallor, extreme fatigue, tachycardia, SOB, hypotension, jaundice, and a positive direct Coombs test. Sickle Cell Anemia is a genetic disease where normal RBCs become sickle-shaped, leading to chronic anemia, fragility, and potential blockages in small capillaries causing pain crises.

  • 2. Hemophilia: A genetic disease where a person lacks some clotting factors normally found in plasma.

    • Hemophilia A: Factor VIII is missing.

    • Hemophilia B: Factor IX is missing. It is a sex-linked disease, with females being carriers and males typically manifesting the disease. The hallmark sign is uncontrollable bleeding, often occurring in joints after trauma, causing swelling and pain.

  • 3. Polycythemia vera: Characterized by too many RBCs, leading to a high hemoglobin level. The increased number of cells makes the blood viscous, impairing circulation and potentially causing clots . Symptoms include headache, dizziness, ringing in the ears, blurred vision, and the patient may appear "ruddy" .

  • 4. Thrombocytopenia: A condition where a person has too few platelets. This can be due to too few platelets being made in the bone marrow or too many platelets being destroyed in circulation . Chemotherapy and radiation can cause thrombocytopenia. Destruction can be due to conditions like Idiopathic Thrombocytopenia Purpura (ITP) and Thrombotic Thrombocytopenic Purpura (TTP), which involve abnormal immunologic processes. Symptoms include petechiae, gingival bleeding, purpura, epistaxis, and unusual or prolonged bleeding.

  • 5. Leukemia: Mentioned as a condition that can be diagnosed through a cytology exam of cells obtained during a bone marrow biopsy. The source does not provide details on lymphocytic or myelogenous types.

  • 6. Hodgkin’s Disease/a. Non-Hodgkin’s/b. Hodgkin’s: Not mentioned in the provided sources.

  • 7. Lymphedema: Not mentioned in the provided sources.

II. Nursing Process

  • A. Subjective Data:

    • 1. Chief Complaint: Assessment includes the history of present illness, focusing on onset, severity, precipitating events, self-care measures, and effects.

    • 2. General Health: Past medical history includes information about cancer or cancer treatment, blood transfusions, and medications (e.g., NSAIDs).

    • 3. Psychosocial History: Functional assessment covers activities/exercise, sleep and rest, occupation, and hobbies. Nutrition is also part of the functional assessment.

  • B. Objective Data:

    • 1. Physical Findings: The physical exam in a hematological assessment includes monitoring vital signs (tachycardia, tachypnea, hypotension, orthostatics), height and weight, general survey (responsiveness, mood, posture), skin (color, dryness, bruising, brittle nails), head and neck (bleeding), thorax (respiratory and heart rate/sounds), and abdomen (liver enlargement, stool/urine for blood). The presence of petechiae and purpura are important physical findings.

    • 2. Diagnostic Tests: Several diagnostic tests are used in hematology:

      • a. CBC (Complete Blood Count): Includes RBC count, Mean Corpuscular Volume (MCV), Hemoglobin (Hgb), Hematocrit (Hct), and WBC count (with differentials like neutrophils, lymphocytes, and monocytes). Normal ranges for RBC, Hgb, Hct, and WBC are provided.

      • b. Red Blood Cell Count (RBC): Measures the number of RBCs, with normal ranges provided.

      • c. White Blood Cell Count (WBC): Measures the number of WBCs, with normal ranges and types listed.

      • d. Bone Marrow Biopsy: May be performed if blood tests are abnormal to assess blood cell production and can provide a cytology exam of cells.

      • g. Iron studies: Include measurements of total iron, total iron-binding capacity (TIBC), and ferritin to assess iron resources for RBC production.

      • h. Coomb’s: The direct Coombs test is mentioned in the diagnosis of autoimmune hemolytic anemia.

  • B. Nursing Diagnosis: The source mentions several therapeutic actions relevant to nursing diagnoses:

    • Pain: Addressed in the context of sickle cell crisis, requiring close monitoring and medication administration.

    • Potential for Injury: Patients at risk for bleeding require minimizing invasive procedures, applying pressure after venipuncture, and avoiding damage to mucous membranes.

    • Activity intolerance: For patients with anemia, nursing interventions include administering oxygen, blood products, allowing for rest, and clustering care.

  • D. Implementation:

    • 1. Nutrition: Dietary considerations are important in managing anemias, such as increasing iron-rich foods for iron deficiency anemia and folate-rich foods for folic acid deficiency.

    • 2. Pharmacological Agent: Various medications are used, including hematopoetin (Epoetin Alpha) for patients with kidney failure and anemia, blood products for anemia and bleeding, iron supplements, folic acid, Vitamin B12, antibiotics and steroids for aplastic anemia, and Hydroxyurea (antineoplastic) for frequent sickle cell crises.

    • 3. Transplants: Bone marrow transplant is a treatment option for aplastic anemia.

    • 4. Blood Products: Administration of blood products (PRBCs, platelets, FFP, cryoprecipitate) is a key intervention for various hematological disorders. Strict safety checks and monitoring for transfusion reactions are crucial.

    • 5. Radiation Therapy: Mentioned as a potential cause of aplastic anemia and in relation to thrombocytopenia but not as a direct nursing implementation in this context.

    • 6. Surgical Intervention: Therapeutic phlebotomy is a treatment for polycythemia vera . While splenectomy is not defined, the spleen's role in clearing old RBCs suggests it might be a surgical intervention in some hematological conditions.

    • 7. Prevention: Includes patient education on preventing crises (e.g., in sickle cell anemia by avoiding dehydration and stressors) and preventing bleeding in patients with thrombocytopenia or clotting disorders.

  • E. Evaluation: Evaluation of nursing care involves assessing if desired outcomes are met, such as lab values within normal limits, client expresses pain relief, client maintains optimal activity levels, client verbalizes feelings of well-being, and the client remains free of injury.

  • F. Community Resources: The source mentions the American Society of Hematology and Cox and Mercy support groups for Cancer and other disorders as resources. The American Cancer Society and American Heart Association are not mentioned in the provided sources.