ch36 ah

Chapter 36: Assessment of the Hematologic System

Concepts

  • Priority Concepts:

    • Clotting: A key process involving the formation of blood clots to stop bleeding.

    • Perfusion: Total arterial blood flow through tissues (peripheral perfusion) and blood pumped by the heart (central perfusion).

Overview

  • Perfusion:

    • Involves both peripheral and central blood flow, ensuring nutrients and oxygen reach tissues.

  • Clotting:

    • A complex, multi-step process forming a protein-based structure known as a clot.

Hematologic Changes Associated with Aging

  • Decreased Blood Volume:

    • Accompanied by lower levels of plasma proteins.

  • Bone Marrow Activity:

    • Produces fewer blood cells, affecting both red and white blood cell counts.

  • Immune Function:

    • Lymphocytes become less reactive to antigens, diminishing immune responses.

  • Hemoglobin Decline:

    • Hemoglobin levels may fall after middle age.

Assessment Factors

  • Key Assessment Areas:

    • Age and gender

    • Liver function

    • Occupation and hobbies, home location

    • Drug use (prescribed, OTC, illicit)

    • Nutrition status

    • Finances and social support

    • Family history and genetic risk

    • Current health problems

Physical Assessment Components

  • Areas Assessed:

    • Skin

    • Head and neck

    • Respiratory system

    • Cardiovascular system

    • Kidney and urinary system

    • Musculoskeletal system

    • Abdominal region

    • Central nervous system

    • Psychosocial aspects

Laboratory Tests for Hematologic Assessment

  • Cell Number and Function Tests:

    • Peripheral Blood Smear

    • Complete Blood Count (CBC)

    • Reticulocyte Count

    • Hemoglobin Electrophoresis

    • Leukocyte Alkaline Phosphatase (LAP)

    • Serum Ferritin, Transferrin, TIBC

  • Bleeding and Coagulation Tests:

    • Prothrombin Time (PT)

    • International Normalized Ratio (INR)

    • Partial Prothromboplastin Time (PTT)

    • Anti-Factor Xa Test

    • Platelet Aggregation

    • D-Dimer

Complete Blood Count (CBC) Reference Ranges

  • RBC Counts:

    • Female: 4.2-5.4 million cells/µL

    • Male: 4.7-6.1 million cells/µL

  • WBC Counts: 5,000 - 10,000 cells/µL

  • Platelet Counts (PLTs): 150,000 - 400,000 cells/µL

  • Hemoglobin (Hgb):

    • Female: 12-16 g/dL

    • Male: 14-18 g/dL

  • Hematocrit (Hct):

    • Female: 37-47%

    • Male: 42-52%

Coagulation Reference Ranges

  • Prothrombin Time (PT): 11-12.5 seconds

  • INR Values:

    • Normal: 0.8-1.1

    • Therapeutic for Warfarin: 2-3

    • Therapeutic for Heart Valve: 2.5-3.5

  • D-Dimer: Less than 0.4 mcg/mL

  • Activated Partial Thromboplastin Time (APTT): 30-40 seconds

    • Therapeutic for Heparin: 1.2-2.5 times higher than normal

Additional Diagnostic Assessments

  • Imaging Assessments:

    • Radioisotopic imaging

    • Standard x-rays

    • Bone marrow aspiration and biopsy

Bone Marrow Aspiration and Biopsy

  • Procedure Preparation:

    • Patient education on the procedure and emotional support.

    • Ensure an informed consent form is signed.

  • Site of Extraction:

    • Typically taken from the iliac crest (hip) or sternum.

  • Post-procedure Care:

    • Inspect the site every 2 hours for 24 hours.

    • Avoid activities that could result in trauma.

    • Provide analgesics (aspirin-free) and ice packs for comfort.

Clinical Scenario

  • Question:

    • A client is transitioning from IV heparin to oral warfarin. What laboratory finding indicates effective warfarin treatment?

    • Options:

      • A. Bleeding time of 5 minutes

      • B. Prothrombin time (PT) of 18 seconds

      • C. International normalized ratio (INR) of 2.5

      • D. Partial thromboplastin time (PTT) of 24.3 seconds