Hematologic Alterations Study Notes

ANATOMY AND PHYSIOLOGY OF THE HEMATOLOGIC SYSTEM

• Circulatory System components: Arteries and Veins
• Blood components: Red Blood Cells (RBCs), White Blood Cells (WBCs), Platelets
• Leukocytes (WBCs) subtypes:
  • Basophil, Eosinophil, Neutrophil
  • Granulocytes (WBCs)
• Erythrocyte (RBC) and Platelets

BLOOD CLOT — PATHOPHYSIOLOGY AND DIMENSIONS

• Blood clot formation as a response to injury and stagnation of flow
• Interruption in blood flow can lead to tissue ischemia and damage to other organs
• Psychosocial implications: Anxiety, PTSD in postoperative or life-threatening contexts
• Safety considerations:
  • Postoperative prophylactic measures to prevent clots
  • Increased risk in aging adults

BLOOD CLOT — DIAGNOSTICS

• D-Dimer: elevated result could indicate a blood clot
  • ext{D-Dimer}
    ightarrow ext{positive if clotting activity is present}
• Ultrasound: evaluates veins and blood flow
• CT: used when further testing is indicated (e.g., suspected PE or stroke)

BLOOD CLOT — MANIFESTATIONS

• Pulmonary Embolism (PE): chest pain worsened by deep breathing, tachycardia, dyspnea, lightheadedness, hemoptysis
• Myocardial Infarction (MI): chest pain radiating to left arm, dyspnea, diaphoresis
• Stroke: facial weakness, speech difficulty, visual deficits, unilateral weakness, seizures; FAST (Face, Arm, Speech, Time)

DEEP VEIN THROMBOSIS (DVT) — PATHOPHYSIOLOGY

• Clot forms in large veins, typically in the lower extremities
• Etiology: immobility, dehydration

DVT — CLINICAL PRESENTATION

• Lower extremity edema below the knee, redness, swelling, tenderness, warmth
• Lab Testing and Diagnostic Studies:
  • Venous Doppler
  • Contrast venography
• Interventions:
  • Medications: Low molecular weight heparin (enoxaparin, Lovenox), unfractionated heparin
  • Early ambulation when appropriate
• Complications:
  • Pulmonary emboli (PE)
  • Post-thrombotic syndrome
  • Bleeding risks from anticoagulants

ANEMIA — DEFINITION AND GENERAL IMPACT

• Hematologic condition where the concentration of hemoglobin or RBCs is not sufficient for physiological needs
• Insufficient oxygen delivery -> manifestations like weakness, dizziness, pallor

IRON DEFICIENCY ANEMIA (IDA) — OVERVIEW

• Most common form of anemia worldwide
• Hb’s role: carrying oxygen to tissues; Hb production requires iron
• Diagnosed when Hb deviates two below the standard mean for sex and age
• Pathophysiology: poor nutrition, blood loss, GI disorders, chronic diseases

IRON DEFICIENCY ANEMIA — CLINICAL PRESENTATION

• SOB, fatigue, pallor, palpitations, dizziness, glossitis, cheilitis
• Lab and Diagnostic Studies:
  • Serum ferritin
  • Total iron-binding capacity (TIBC)
  • Reticulocyte count
  • Bone marrow examination (occasionally)
  • Stool test (GI blood loss assessment)

IRON DEFICIENCY ANEMIA — IMPACT ON HEALTH

• Fatigue, social isolation (due to symptoms and functional limitation)
• Physiological/Psychosocial: blood loss, fatigue
• Safety: decreased mobility and nutritional deficiencies increase risk; Aging adult considerations

IRON DEFICIENCY ANEMIA — ROLE OF THE NURSE

• Client education on iron-rich foods
• Iron-rich diet and iron supplementation
• Hydration
• Safety considerations: fall prevention, monitoring fatigue

FOLIC ACID DEFICIENCY

• Pathophysiology: insufficient folic acid (vitamin B9) for healthy RBC production
• Causes: poor diet, alcoholism, malabsorption, increased demand (e.g., pregnancy)
• Clinical manifestations: fatigue, pallor, dyspnea, glossitis, cheilitis; No neurological symptoms
• Diagnostic Findings: low serum folate, CBC, B12 levels (to differentiate from B12 deficiency)
• Treatment:
  • Increase dietary folic acid (leafy greens, citrus, beans, fortified grains)
  • Folic acid supplementation: $1\ ext{mg}$ daily

VITAMIN B12 DEFICIENCY — PERNICIOUS ANEMIA

• Pathophysiology: B12 absorption requires intrinsic factor produced in the stomach; B12 is essential for RBC formation
• Etiology/ Causes: malabsorption, nutritional deficits, vegan diet, chronic gastritis
• Clinical Presentation: fatigue, SOB, headaches, pallor, dizziness; nervous system and cognitive manifestations
• Lab Testing and Diagnostic Studies:
  • CBC
  • B12 level
  • Folate levels
• Role of the Nurse (HR considerations):
  • Environmental factors (vegetarian diet risks)
  • Fall risk with prolonged deficiency
  • Client education on diet and prescribed medications

APLASTIC ANEMIA

• Pathophysiology: rare; decreased/damaged bone marrow stem cells
• Etiology: congenital, acquired, idiopathic; infections, pregnancy, certain meds, chemicals, radiation
• Clinical Manifestations: neutropenia, thrombocytopenia, fatigue, pallor, dyspnea, purpura, recurrent infections, lymphadenopathy, splenomegaly, retinal hemorrhages
• Treatment: Bone marrow transplant if < 60 years old; immunosuppressive therapy

SICKLE CELL ANEMIA

• Pathophysiology: inherited; sickle-shaped RBCs
• Etiology: recessive; both parents carry sickle cell trait
• Impact on Health (Physiological/Psychosocial): vaso-occlusive crises, pain, fatigue; annual eye exams; transfusions
• CLINICAL PRESENTATION: anemia, painful crises, joint swelling, visual deficits, fever, priapism
• Lab Testing and Diagnostic Studies:
  • Peripheral blood smear for hemoglobin S
  • Sickle turbidity test
  • Hemoglobin electrophoresis
  • Sickle cell (solubility) test
  • CBC, reticulocyte count, bilirubin, LDH
• ROLE OF THE NURSE:
  • Environmental factors: avoid extreme temperatures and high altitudes
  • Client education: pain control, hydration, symptom management, stress reduction, vaccinations, surgical considerations, complications

SICKLE CELL ANEMIA — SUPPORTIVE CARE AND HEALTH MAINTENANCE

• Pain management strategies
• Hydration and electrolyte balance
• Vaccinations and infection prevention
• Regular screenings (eyes, organ function)

THALASSEMIA

• Definition: genetic disorder with reduced ability to produce normal hemoglobin -> anemia
• Two major types: Alpha and Beta-Thalassemia Major (Cooley’s anemia)
• Treatment:
  • Transfusions
  • Chelation therapy (subcutaneous Deferoxamine)

GLUCOSE-6-PHOSPHATE DEHYDROGENASE DEFICIENCY (G-6-PD)

• Pathophysiology: genetic deficiency leading to premature RBC hemolysis under triggers
• Clinical Manifestations: pallor, jaundice, hemoglobinuria
• Diagnosis: screening test for G-6-PD activity
• Treatment: stop causative medication; transfusions if needed
• Causes: genetics, infections, medications, foods

POLYCYTHEMIA VERA

• Pathophysiology: rare myeloproliferative disorder with excess RBC production -> thickened blood, higher clot risk
• Causes: genetic mutation, bone marrow abnormality; secondary causes include hypoxia and tumors
• Clinical Manifestations: flushing, splenomegaly, headaches, dizziness, fatigue, paresthesia, thrombophlebitis, pruritus
• Diagnostic Findings: elevated erythrocyte mass; normal oxygen saturation; enlarged spleen
• Treatments:
  • Phlebotomy (approximately $500\ ext{mL}$ of blood removed once or twice per week)
  • Medications: radioactive phosphorus, hydroxyurea (Hydrea), aspirin to prevent thrombolytic complications

BLOOD CANCERS OVERVIEW

• Cancers affecting the blood; disrupt production and function of blood cells
• Most start in the bone marrow, where stem cells mature into WBCs, RBCs, or platelets; cancerous cells impair function

HODGKIN LYMPHOMA

• Pathophysiology: originates in lymph nodes; relatively rare
• Causes: viruses (EBV, Hep C, HIV), environmental exposure, prolonged immunosuppression
• Diagnostics: ESR, excisional lymph node biopsy, chest X-ray, CT, viral testing
• Manifestations: Reed-Sternberg cells, lymphadenopathy (neck, supraclavicular, mediastinal), organ compression symptoms, anemia, B symptoms (fever, night sweats, weight loss)
• Treatment: chemotherapy and radiation

NON-HODGKIN LYMPHOMA

• Pathophysiology: neoplastic growth of lymphoid tissue
• Causes: HCV, HIV, environmental agents (pesticides, Agent Orange), autoimmune disorders, long-term immunosuppressive therapy
• Diagnostics: flow cytometry, excisional lymph node biopsy, CT, viral testing
• Manifestations: lymphadenopathy, organ compression symptoms, B symptoms (fever, night sweats, weight loss)
• Treatment: chemotherapy, radiation, interferon

MULTIPLE MYELOMA

• Pathophysiology: malignant plasma cells in bone marrow with bone destruction
• Clinical manifestations: CRAB symptoms – Hypercalcemia, Renal dysfunction, Anemia, Bone destruction
• Diagnostics:
  • Protein electrophoresis (Bence Jones proteins or M protein)
  • Blood urea nitrogen (BUN)/Creatinine
  • Radiology (CT, MRI, PET)
  • Elevated total protein
  • CBC
  • Bone biopsy or bone marrow aspiration
  • Plasma cell FISH
  • 24-hour urine protein testing
• Treatment: chemotherapy (primary), corticosteroids (e.g., Decadron), radiation therapy, bisphosphonates

LYMPHOMA AND MYELOMA — IMPACT ON OVERALL HEALTH

• Physiological/Psychological impact, fatigue and weakness
• Safety considerations: management of fatigue, activities of daily living (ADLs), emotional support, rest, and education

LEUKEMIA overview

• Pathophysiology: bone marrow makes more lymphocytes than needed; healthy WBCs, RBCs, and platelets can be outnumbered
• Types discussed: Acute Lymphoblastic Leukemia (ALL); Chronic Myelogenous Leukemia (CML)
• Etiology: environmental factors, past exposure to radiation or chemotherapy, genetics, viral factors (unknown)

ACUTE LYMPHOBLASTIC LEUKEMIA (ALL)

• Pathophysiology: excess lymphocytes; immature B or T cells proliferate; healthy blood components become outnumbered
• Clinical Manifestations: fatigue, easy bruising, fever, weight loss, abdominal or bone pain, frequent infections, petechiae, swollen lymph nodes, anemia, thrombocytopenia
• Lab Testing and Diagnostic Studies:
  • CBC, peripheral smear
  • Bone marrow aspiration/biopsy
  • CT, MRI
• Treatments: corticosteroids (Prednisone), epoetin alfa, chemotherapy, stem cell transplant
• Impact on health: anxiety, depression, insomnia; infection and bleeding risk due to neutropenia

CHRONIC MYELOGENOUS LEUKEMIA (CML)

• Pathophysiology: genetic mutation; Philadelphia chromosome (shortened chromosome 22); etiology unknown
• Epidemiology: median age ~$56$ years
• Clinical Presentation: extreme tiredness, weight loss, fever, left-sided pain, night sweats
• Lab Tests and Diagnostic Studies: CBC with differential, bone biopsy, bone marrow aspiration, cytogenetic analysis
• Impact on Health: psychosocial support (including family), pain management, safety considerations; risk of anemia and infection; aging adult ADL support

BLOOD TRANSFUSIONS

• Indications: anemia, various cancers, hypovolemic shock; transfusion of plasma, platelets, or red blood cells as needed
• Safety Considerations:
  • Type and crossmatch
  • Risks: transfusion reaction, exposure to viruses/bacteria (HBV, HCV), transfusion-related circulatory overload, iron overload, patient refusal

BLOOD TRANSFUSION — NURSE'S ROLE

• Administration: obtain informed consent; assess vital signs and IV patency; use 0.9% saline with blood tubing; monitor in room for first 15 minutes
• Reaction management: identify signs of reaction, stop transfusion, notify provider, follow hospital protocol

HEMORRHAGE

• Pathophysiology: significant blood loss; adults can tolerate ~$14\%$ loss before risk of hypoperfusion increases
• Types/contexts:
  • Epidural, subdural, subarachnoid, intracerebral hemorrhage
  • Skull anatomy: bone, dura, arachnoid, pia; subarachnoid space contains CSF
• Impact on health: hypovolemic shock, decreased cardiac output, circulatory insufficiency, hypoxemia; altered mental status due to reduced circulatory blood volume and oxygenated hemoglobin
• Safety: orthostatic hypotension (≥$20\,\text{mmHg}$ drop in systolic BP when standing)
• Aging adult considerations: comorbidities increase bleeding risk with anticoagulants, NSAIDs, antiplatelet therapy

HEMORRHAGE — CLINICAL PRESENTATION

• General hemorrhage symptoms: nausea, dizziness, cool skin, dyspnea, weakness, chest pain, confusion, tachycardia, tachypnea
• Signs of internal bleeding: hemoptysis or hematemesis
• Intracranial hemorrhage symptoms: headaches, slurred speech, facial numbness, unilateral weakness, decreased consciousness, seizures, difficulty with ambulation

HEMORRHAGE — LAB TESTING AND DIAGNOSTIC STUDIES

• CBC: evaluate RBCs, hemoglobin, hematocrit
• Platelet count: coagulation status
• Prothrombin time (PT) and partial thromboplastin time (PTT): assess for prolonged clotting times
• Head CT: identify brain hemorrhage
• Radiology: Chest X-ray, CT, ultrasound
• Endoscopy: assess GI tract for bleeding and potential ulcers needing ligation

HEMORRHAGE — ROLE OF THE NURSE

• Identify source of bleeding (external or internal)
• If external: wear gloves, apply direct pressure; ensure IV access; place large-bore IV catheter
• Administer IV fluids as prescribed with goal to maintain mean arterial pressure $ext{MAP} > 65\ \text{mmHg}$
• Safety: ensure proper type and crossmatch for transfusion

THROMBOCYTOPENIA

• Pathophysiology: low platelet levels due to reduced production, increased destruction, or increased consumption
• Causes (illustrative): leukemia, aplastic anemia, medications (e.g., methotrexate), infections (sepsis, TB, viral), chemotherapy, radiation, stem cell transplant
• Clinical Manifestations: platelet count < $20{,}000\,/\text{mm}^3$; excessive bleeding; increased bleeding with procedures; menstrual bleeding; nasal and gingival bleeding
• Diagnostic Findings: bone marrow aspiration/biopsy; Hep B/C screening; peripheral smear
• Treatment: platelet transfusion

SUMMARY OF KEY NUMBERS AND RANGES (SELECT)

• MAP target in hemorrhage management: $ext{MAP} > 65\ \text{mmHg}$
• Adult tolerance for blood loss before shock risk: $14\%$
• Platelet threshold for thrombocytopenia concern: $Platelets < 20{,}000\,/\text{mm}^3$
• Phlebotomy volume in Polycythemia Vera therapy: $ext{approximately } 500\ \text{mL}$ per session
• Transfusion risk dimensions include infections (HBV, HCV), transfusion reaction, circulatory overload, and iron overload
• Folate supplementation: $1\ \text{mg/day}$
• Phlebotomy frequency in PV: once or twice per week
• 65 mmHg MAP threshold for perfusion

CONNECTIONS TO FOUNDATIONAL PRINCIPLES

• Hematologic disorders illustrate the balance between production, destruction, and loss of blood components
• Oxygen transport and tissue perfusion are central to symptom development (dyspnea, fatigue, dizziness)
• Safety and ethics permeate care: informed consent for transfusions, fall risk management, infection prevention, vaccination, and psychosocial support
• Interprofessional care: diagnostic imaging (CT, ultrasound), lab tests (CBC, ferritin, TIBC, B12, folate), therapeutics (chelation, chemotherapy, transfusions, phlebotomy), and patient education

PRACTICAL IMPLICATIONS AND REAL-WORLD APPLICATIONS

• Postoperative patients are at risk for DVT; early ambulation and prophylaxis reduce risk
• IDA and B12/folate deficiencies can mimic each other; careful lab interpretation guides supplementation and dietary counseling
• Sickle cell disease requires chronic management to reduce vaso-occlusive crises and protect end-organ function (eye exams, transfusion management, hydration, infection prevention)
• Hemorrhage risk assessment is critical in older adults on anticoagulants or NSAIDs; monitoring PT/PTT and platelet counts guides therapy
• Blood cancers require a combination of chemo/radiation, targeted therapies, and supportive care (infection prevention, blood count support, transfusion planning)
• Ethical considerations: patient autonomy in transfusion decisions, consent for procedures, balancing risks and benefits of aggressive therapies in aging populations