Ch. 33 Hematologic System

Here's a structured and digestible summary of the material for easier comprehension:

Assessment: Hematologic System

Conceptual Focus Areas:

• Clotting

• Functional Ability

• Gas Exchange

• Infection

• Perfusion

Learning Outcomes:

1. Understand the structures and functions of the hematologic system.

2. Differentiate between types of blood cells and their functions.

3. Explain the process of hemostasis (blood clotting).

4. Identify age-related changes in the hematologic system.

5. Gather subjective and objective data for hematologic assessments.

6. Conduct a physical assessment of the hematologic system.

7. Distinguish normal vs. abnormal hematologic findings.

8. Explain diagnostic studies, their significance, and related nursing responsibilities.

Key Terms to Know:

• Ecchymoses – Bruising due to bleeding under the skin.

• Erythropoiesis – RBC production.

• Fibrinolysis – Breakdown of blood clots.

• Hematopoiesis – Blood cell formation.

• Hemolysis – Destruction of RBCs.

• Leukopenia – Low WBC count.

• Neutropenia – Low neutrophil count.

• Pancytopenia – Deficiency of all blood cells.

• Petechiae – Small pinpoint bruises.

• Reticulocyte – Immature RBC.

• Thrombocytopenia – Low platelet count.

• Thrombocytosis – Excess platelets.

Hematologic System Overview

Hematology is the study of blood and its components, including:

• Bone marrow (produces blood cells)

• Blood (carries oxygen, nutrients, and fights infections)

• Spleen (filters blood, destroys old RBCs, stores platelets)

• Lymph system (immune function, circulates WBCs)

Functions of the Hematologic System:

• Transportation: Oxygen (O₂), carbon dioxide (CO₂), nutrients, and waste.

• Regulation: Maintains pH, fluid balance, and temperature.

• Protection: Blood clotting and immune defense.

Structures and Functions of Blood Components

Bone Marrow & Hematopoiesis

• Bone marrow produces all blood cells.

• Red marrow is found in flat bones (pelvis, ribs, sternum, vertebrae).

• Stem cells differentiate into RBCs, WBCs, or platelets based on body needs.

• Erythropoietin (from kidneys) stimulates RBC production when oxygen levels drop.

Blood Composition

• Plasma (55%) – Mostly water, proteins (albumin, globulin, fibrinogen), electrolytes, nutrients.

• Blood cells (45%) – RBCs, WBCs, platelets.

Blood Cells and Their Functions

Erythrocytes (RBCs)

• Function: Transport oxygen (O₂) & carbon dioxide (CO₂), maintain acid-base balance.

• Flexible biconcave shape allows passage through capillaries.

• Contain hemoglobin, which binds to O₂.

• Life span: 120 days, then broken down in spleen/liver.

🔹 Erythropoiesis:

• Stimulated by hypoxia (low O₂).

• Requires iron, folic acid, B vitamins, protein for production.

• Controlled by erythropoietin (produced in kidneys).

🔹 Hemolysis (RBC Destruction):

• Old RBCs are broken down in the spleen, liver, and bone marrow.

• Releases bilirubin, which the liver processes.

Leukocytes (WBCs) – Immune Defense

Two Main Types:

1. Granulocytes (contain granules)

   • Neutrophils (65-75%): First responders, fight infections.

   • Eosinophils (2-5%): Fight parasites & allergies.

   • Basophils (<1%): Release histamine (inflammatory response).

2. Agranulocytes (no granules)

   • Lymphocytes (20-25%): B-cells (antibody production), T-cells (cell-mediated immunity), Natural Killer (NK) cells.

   • Monocytes (3-8%): Develop into macrophages, engulf debris/pathogens.

🔹 Neutropenia: Low neutrophil count → increased risk of infection.
🔹 Leukopenia: Low WBC count → risk for infection.

Thrombocytes (Platelets) – Clotting Function

• Function: Initiate blood clotting by forming platelet plugs.

• Produced in bone marrow from megakaryocytes.

• Life span: 8-11 days.

• Stored in the spleen until needed.

• Regulated by thrombopoietin (TPO) (produced in liver).

🔹 Thrombocytopenia: Low platelet count → risk of bleeding.
🔹 Thrombocytosis: High platelet count → risk of clots (thrombosis).

Summary Table: Blood Functions

Key Processes:

Hemostasis (Blood Clotting Process)

1. Vasoconstriction – Blood vessels constrict to reduce blood loss.

2. Platelet Plug Formation – Platelets stick to injury site and clump together.

3. Coagulation Cascade – Fibrin forms a stable clot.

4. Fibrinolysis – Clot dissolves after healing.

Important Clinical Considerations

• Assessing RBCs:

  • Low RBCs → Anemia (fatigue, pallor, shortness of breath).

  • High RBCs → Polycythemia (risk of clots).

• Assessing WBCs:

  • High WBCs → Infection, inflammation, leukemia.

  • Low WBCs → Increased infection risk.

• Assessing Platelets:

  • Low → Bleeding risk (thrombocytopenia).

  • High → Clotting risk (thrombocytosis).

Digestible Summary of Normal Iron Metabolism, Clotting, and Hematologic Organs

Normal Iron Metabolism

• Daily iron requirement: 25 mg

• Iron absorption: 1-2 mg from diet; rest is recycled from RBC breakdown.

• Iron transport: Transferrin (produced by liver) carries iron in the blood.

• Iron storage:

  • 2/3 of iron → Found in RBC hemoglobin & muscle myoglobin.

  • 1/3 of iron → Stored as ferritin & hemosiderin (bone marrow, spleen, liver, macrophages).

• Iron loss: Mostly minimal, except in blood loss. Small amounts lost in urine, sweat, bile, and GI tract.

• Iron deficiency: Leads to reduced hemoglobin production, affecting oxygen transport.

Normal Clotting Mechanisms (Hemostasis)

Hemostasis = Stopping Bleeding

1. Vascular injury & vasoconstriction

   • Blood vessels constrict to minimize blood loss.

   • Vasoconstriction lasts 20-30 minutes to allow time for clot formation.

2. Adhesion

   • Endothelial injury exposes sticky proteins (e.g., von Willebrand factor (vWF), collagen) → Platelets adhere.

3. Clotting cascade activation

   • Platelets change shape & bind to proteins (e.g., fibrinogen, vWF).

   • Platelets release adenosine diphosphate (ADP) → Recruits more platelets & clotting factors.

4. Blood clot formation

   • Intrinsic & extrinsic pathways lead to activation of thrombin.

   • Thrombin converts fibrinogen → fibrin, forming a stable clot.

5. Clot retraction & dissolution (Fibrinolysis)

   • Antithrombins (e.g., heparin, protein C, antithrombin III) prevent excessive clotting.

   • Fibrinolysis dissolves clots via plasminogen → plasmin, which breaks down fibrin.

🔹 Excessive fibrinolysis = Bleeding risk due to increased breakdown of fibrin.

Hematologic Organs & Their Functions

1. Spleen

• Location: Upper left abdomen.

• Functions:

  • Hematopoietic: Produces RBCs during fetal development.

  • Filtration: Destroys old RBCs & recycles iron.

  • Immunologic: Contains lymphocytes & monocytes to fight infection.

  • Storage: Holds RBCs & 1/3 of platelets.

2. Lymphatic System

• Functions:

  • Carries lymph fluid (filtered interstitial fluid) into circulation.

  • Transports proteins, fats, hormones back into blood.

  • Filters bacteria & foreign particles via lymph nodes.

• Lymph nodes:

  • Filter pathogens and immune response activation.

  • Over 200 lymph nodes are scattered throughout the body (largest cluster in the abdomen).

🔹 Lymphedema: Swelling caused by blocked lymph flow (e.g., after mastectomy).

3. Liver

• Produces:

  • Clotting factors needed for blood coagulation.

  • Bilirubin & bile for fat digestion.

  • Hepcidin, which regulates iron balance.

• Iron Storage:

  • Stores excess iron from blood transfusions or iron overload disorders.

• Iron Regulation:

  • Iron overload/inflammation → Increased hepcidin → Less iron released.

  • Iron deficiency → Decreased hepcidin → More iron released from storage.

Key Takeaways

✔ Iron metabolism relies on dietary intake, RBC recycling, and proper liver function.
✔ Clotting is a carefully balanced process—excess can cause thrombosis, while too little can lead to bleeding.
✔ The spleen, liver, and lymphatic system all play vital roles in blood health, immunity, and clotting.

Digestible Summary of Gerontologic Considerations & Hematologic System Assessment

Effects of Aging on the Hematologic System

• Bone marrow changes:

  • Decreased marrow mass & cellularity → Increased fat content in marrow.

  • Reduction in hematopoietic tissue from 80-100% at birth → 50% at age 30 → 30% at age 70.

  • Older adults maintain adequate blood cell levels but have reduced reserve capacity, making them more vulnerable to clotting, oxygen transport issues, and infections.

• Red Blood Cells (RBCs):

  • Hemoglobin (Hgb) levels decline with age, but low-normal levels are common.

  • Decreased iron levels due to:

    • Lower intestinal iron absorption

    • Decreased total iron-binding capacity

    • Fragile RBC membranes → Slight increase in mean corpuscular volume (MCV) and decrease in mean corpuscular hemoglobin concentration (MCHC).

  • Anemia may be unexplained in 30-40% of cases.

  • Blunted response to erythropoietin → Older adults cannot produce new RBCs (reticulocytes) efficiently after hemorrhage or hypoxia.

• White Blood Cells (WBCs):

  • Total WBC count remains stable, but:

    • Neutrophils may slightly increase.

    • Lymphocyte count decreases → Weakened immune response.

    • Minimal WBC elevation during infections → Delayed or muted immune response.

• Platelets & Clotting Factors:

  • Platelet count remains stable but may become stickier (increased adhesiveness).

  • Increased clotting factors → Higher risk of thrombosis (venous thromboembolism, VTE).

  • Aging-related vascular changes → Easy bruising.

Table 33.3: Effects of Aging on Hematologic Studies

Case Study: A.J. (63-year-old woman with weakness, pallor, and SOB)

A.J. presents to the emergency department with symptoms of fatigue, pallor, bruising, and shortness of breath (SOB). She had a recent cold & sinus infection, requiring two rounds of antibiotics.

Discussion Questions

1. Possible causes of A.J.’s symptoms?

   • Anemia (iron deficiency, chronic disease, blood loss, B12/folate deficiency)

   • Infection (e.g., lingering bacterial or viral illness)

   • Cardiac or pulmonary issues (e.g., heart failure, chronic obstructive pulmonary disease, COPD)

   • Medication side effects (e.g., anticoagulants, chemotherapy, NSAIDs)

2. Is her condition stable or an emergency?

   • Pallor, SOB, and fatigue could indicate a severe issue (e.g., anemia, internal bleeding, infection).

   • Needs urgent evaluation (CBC, iron studies, possible transfusion if Hgb is critically low).

3. What type of assessment is appropriate?

   • Focused assessment (based on symptoms of fatigue, pallor, SOB, bruising, and recent infection).

   • If symptoms worsen rapidly, an emergency assessment is needed.

4. Key assessment questions for A.J.:

   • History of anemia, bleeding disorders, or recent blood loss?

   • Dietary intake (iron, B12, folate sources)?

   • Menstrual history (if applicable)?

   • Recent illnesses or infections?

   • Fatigue severity and impact on daily life?

Hematologic System Assessment

A thorough health history and symptom review is crucial in evaluating hematologic conditions.

Key Assessment Areas

1. Health History:

   • Previous hematologic problems (e.g., anemia, clotting disorders).

   • Medical conditions (e.g., liver disease, kidney disease, GI malabsorption).

   • History of infections or blood clotting disorders.

2. Medications:

   • Anticoagulants (e.g., warfarin, heparin) → Bleeding risk.

   • Chemotherapy → Bone marrow suppression.

   • Iron supplements, B12, folic acid intake.

3. Surgical History:

   • Splenectomy → Increased infection risk.

   • GI surgeries (gastrectomy, gastric bypass, ileal resection) → Affects iron & B12 absorption.

   • History of excessive bleeding after procedures?

4. Functional Health Patterns:

   • Fatigue, weakness, cold intolerance → Anemia?

   • Unusual bruising/bleeding → Clotting disorder?

   • Shortness of breath → Oxygen transport issue?

5. Nutrition & Metabolism:

   • Dietary history (iron, B12, folate sources)?

   • Weight changes, nausea, vomiting?

6. Elimination Patterns:

   • Black/tarry stools (GI bleeding)?

   • Bloody or dark urine?

7. Activity & Exercise:

   • Fatigue with minimal activity?

   • Shortness of breath with exertion?

8. Sleep Patterns:

   • Rested after sleep, or persistent fatigue?

9. Cognitive & Sensory Changes:

   • Numbness/tingling (B12 deficiency, anemia, peripheral neuropathy)?

   • Vision/hearing/taste changes?

10. Self-Perception & Emotional Impact:

• Impact of symptoms on daily life, self-image, and stress levels?

11. Environmental & Occupational Risks:

• Exposure to radiation, chemicals (e.g., benzene, pesticides, vinyl chloride)?

• Work in high-risk environments (mechanics, petroleum industry, farming, military)?

12. Sexual Health & Reproduction:

• Menstrual history (heavy bleeding, clotting, irregular cycles)?

• History of erectile dysfunction (vascular issues, anemia, B12 deficiency)?

13. Coping & Stress Tolerance:

• Support system availability?

• Methods for handling symptoms & stress?

14. Religious & Cultural Considerations:

• Concerns about blood transfusions?

Key Takeaways

✔ Aging affects RBC production, clotting function, and immune response.
✔ Older adults have a decreased ability to compensate for anemia, hypoxia, and infections.
✔ Assessment should focus on hematologic history, symptoms of anemia, clotting, and immune function.
✔ Fatigue, pallor, shortness of breath, and bruising warrant further hematologic evaluation.
✔ A.J.’s case highlights the importance of recognizing anemia-related symptoms in older adults.

Digestible Summary of A.J.'s Case Study: Subjective & Objective Data

1. Subjective Assessment Findings

A.J. is a 63-year-old woman with complaints of fatigue, pallor, shortness of breath (SOB) with exertion, and easy bruising.

Key Findings from A.J.’s Self-Reported History:

• Medical History:

  • Mild osteoarthritis.

  • No regular healthcare visits for 5 years, except for a recent sinus infection requiring two courses of antibiotics.

• Medications & Supplements:

  • Metamucil (fiber supplement), Vitamins C, E, and D with calcium.

  • No prescribed medications or iron supplements.

• Health Perception & Management:

  • Denies history of anemia, cancer, or bleeding disorders.

  • Believes in natural therapy & organic food.

  • Drinks one glass of red wine daily.

  • Reports gradual increase in SOB with exertion.

• Nutritional-Metabolic:

  • Low meat intake (possible iron deficiency).

  • High carbohydrate diet (pasta).

• Elimination:

  • Denies black/tarry stools (no obvious GI bleeding).

  • Occasional constipation, normal urination.

• Activity & Exercise:

  • SOB with exertion, unable to perform daily activities without stopping to rest.

  • No dyspnea at rest.

  • Stiff joints in the morning, steady walking but feels weak.

• Sleep & Rest:

  • Sleeps 8-9 hours but still feels tired.

  • Naps during lunch breaks and days off.

• Cognitive-Perceptual:

  • Mild hearing loss, no tingling/numbness.

• Value-Belief:

  • Prefers natural therapies over traditional medications.

2. Concerning Subjective Findings

The following symptoms raise concern for anemia, poor oxygenation, and possible nutritional deficiencies:

1. Fatigue & weakness: Suggests anemia or poor oxygen delivery.

2. Shortness of breath with exertion: Could indicate low hemoglobin levels, iron deficiency, or heart/lung problems.

3. Pallor & easy bruising: Possible iron deficiency anemia, B12/folate deficiency, or platelet dysfunction.

4. Diet lacking iron-rich foods (low meat intake): Raises concern for iron-deficiency anemia.

5. History of infection requiring multiple antibiotics: Could indicate weakened immune response or chronic illness.

6. Still feeling tired despite adequate sleep: Suggests anemia, chronic illness, or nutritional deficiency.

3. Recommended Physical Assessment

A focused hematologic assessment should be performed, emphasizing signs of anemia, clotting abnormalities, and nutritional deficiencies.

Physical Exam Priorities:

✅ General Appearance:

• Pallor (skin, conjunctiva, mucous membranes)

• Fatigue or weakness

✅ Vital Signs:

• Heart rate (tachycardia from anemia?)

• Blood pressure (hypotension or orthostatic changes?)

• Oxygen saturation (low due to poor O₂ transport?)

✅ Skin Assessment:

• Pallor (low hemoglobin/anemia?)

• Bruising/ecchymoses (platelet or clotting disorder?)

• Petechiae (low platelets?)

• Jaundice (hemolysis or liver disease?)

✅ Mouth & Tongue:

• Glossitis (B12/iron deficiency?)

• Bleeding gums (low platelets?)

✅ Lymph Node Palpation:

• Enlarged, fixed, or tender nodes (infection, malignancy?)

✅ Abdominal Exam:

• Enlarged spleen (splenomegaly from anemia, hemolysis, leukemia?)

• Enlarged liver (liver disease, iron overload?)

✅ Heart & Lungs:

• Tachycardia (compensatory for anemia?)

• Low O₂ saturation (severe anemia?)

• Heart murmurs (possible anemia-related changes?)

✅ Neurological Exam:

• Weakness, dizziness (hypoxia, B12 deficiency?)

✅ Musculoskeletal System:

• Joint swelling/pain (bleeding disorders, arthritis?)

• Bone tenderness (possible leukemia, myeloma?)

4. Individualizing the Physical Assessment for A.J.

• Given her history of weakness and shortness of breath, assess oxygenation (pulse oximetry), heart rate, and blood pressure changes.

• Since she prefers natural remedies and hasn't seen a doctor in 5 years, assess for undiagnosed chronic conditions.

• Due to her dietary habits (low meat, high carbs), check for signs of iron deficiency, B12/folate deficiency.

• Since she bruises easily, assess for platelet abnormalities or clotting disorders.

5. Objective Data & Abnormal Findings

Key Physical Exam Abnormalities to Look for:

6. Next Steps & Nursing Considerations

Diagnostic Tests:

1. Complete Blood Count (CBC)

   • Low Hgb/Hct → Anemia

   • Low RBCs → Iron/B12 deficiency, chronic disease

   • Low platelets → Bleeding disorder, bone marrow dysfunction

   • Elevated WBCs → Infection, leukemia

2. Iron Studies

   • Low iron, ferritin, or total iron-binding capacity (TIBC) → Iron-deficiency anemia

3. Vitamin B12 & Folate Levels

   • Low levels → B12 or folate deficiency anemia

4. Coagulation Tests (PT, INR, aPTT, D-dimer)

   • Increased bleeding time → Clotting disorder or liver disease

5. Reticulocyte Count

   • Low count → Decreased bone marrow response (iron/B12 deficiency, chronic disease)

6. Peripheral Blood Smear

   • Abnormal RBC shapes → Sickle cell, hemolysis, leukemia

7. Key Takeaways

✔ A.J.’s symptoms (fatigue, pallor, SOB, bruising) suggest possible anemia, clotting disorder, or chronic illness.
✔ Her diet (low in meat, high in pasta) raises concerns for iron or B12 deficiency.
✔ A focused hematologic physical exam is needed, including skin, lymph nodes, spleen, heart, and lungs.
✔ Diagnostic tests (CBC, iron studies, vitamin B12, clotting tests) are essential for confirmation.

Digestible Summary of A.J.’s Case Study: Physical Assessment & Diagnostic Studies

1. Concerning Physical Assessment Findings

A.J.'s physical assessment reveals several red flags indicating possible anemia, hypoxia, and clotting abnormalities.

Vital Signs:

• BP: 100/70 (lying) → 88/60 (standing) (Orthostatic Hypotension)

  • Concerning: Suggests dehydration, anemia, or blood loss.

• Pulse: 110 (lying) → 124 (standing) (Tachycardia)

  • Concerning: Compensatory response to low hemoglobin (anemia) or hypoxia.

• Respiratory Rate: 26 breaths/min

  • Concerning: Suggests oxygen deprivation due to anemia.

• O₂ Saturation: 90% on Room Air

  • Concerning: Indicates mild hypoxia, possibly due to anemia.

Skin & Mucous Membranes:

• Pale skin & conjunctivae

  • Concerning: Suggests low hemoglobin (Hgb) → Anemia.

• Ecchymoses (bruises) on arms and legs, scattered petechiae

  • Concerning: Possible thrombocytopenia (low platelets) or clotting disorder.

• Smooth, shiny tongue

  • Concerning: Suggests B12 or iron deficiency anemia.

Respiratory & Cardiovascular:

• Lungs clear, but diminished breath sounds at bases

  • May indicate: Poor oxygenation from anemia or reduced physical activity.

• No jugular venous distention (JVD)

  • Good sign: No signs of heart failure.

Neurological & Musculoskeletal:

• Weakness, dyspnea on exertion

  • Concerning: Likely due to poor oxygen transport from anemia.

• No numbness, tingling, or peripheral edema

  • Good sign: No overt signs of B12 neuropathy or fluid overload.

2. Likely Diagnostic Tests for A.J.

(A) Complete Blood Count (CBC)

To confirm anemia and assess severity:

• Hemoglobin (Hgb) & Hematocrit (Hct) → Expected low (anemia).

• Red Blood Cell (RBC) Count & Indices (MCV, MCH, MCHC) →

  • Microcytic (low MCV) → Iron-deficiency anemia.

  • Macrocytic (high MCV) → B12 or folate deficiency anemia.

• White Blood Cell (WBC) Count & Differential → Rule out infection or leukemia.

• Platelet Count → Check for thrombocytopenia (low platelets, bleeding risk).

(B) Iron Studies (for suspected Iron-Deficiency Anemia)

• Serum Iron → Likely low.

• Ferritin (Iron Storage Protein) → If low, confirms iron deficiency.

• Total Iron-Binding Capacity (TIBC) → Likely elevated (body trying to bind more iron).

• Transferrin Saturation → Expected low (iron not binding properly).

(C) Vitamin B12 & Folate Levels

• If low: Suggests B12 or folate deficiency anemia.

• If normal: Confirms iron-deficiency as primary cause of anemia.

(D) Reticulocyte Count

• Measures bone marrow’s ability to produce new RBCs.

• If low → Bone marrow suppression or vitamin deficiency.

• If high → Recent blood loss or hemolysis.

(E) Coagulation Studies (for bruising & petechiae)

• Platelet Count → Likely low (thrombocytopenia).

• Prothrombin Time (PT) & INR → To assess clotting ability.

• Activated Partial Thromboplastin Time (aPTT) → To check intrinsic clotting pathway.

• D-dimer → Rule out DIC or hypercoagulability.

(F) Peripheral Blood Smear

• Helps identify abnormal RBC shapes, immature WBCs (leukemia), or schistocytes (hemolysis).

(G) Stool Occult Blood Test

• To rule out chronic GI bleeding as a cause of anemia.

(H) Bone Marrow Biopsy (if necessary)

• If pancytopenia (low RBCs, WBCs, platelets) is present, bone marrow suppression or leukemia should be considered.

3. Expected Findings Based on A.J.’s Case

4. Key Takeaways

✔ A.J.'s symptoms (fatigue, pallor, SOB, bruising) strongly suggest anemia and possible clotting abnormalities.
✔ Iron deficiency anemia is likely, but B12/folate deficiency or chronic disease anemia should also be considered.
✔ Diagnostic workup should include CBC, iron studies, vitamin levels, reticulocyte count, and coagulation tests.
✔ If thrombocytopenia (low platelets) is confirmed, further investigation into clotting disorders is necessary.
✔ If signs of GI bleeding are found, an occult blood test or endoscopy may be needed.

Digestible Summary of Biopsies & Hematologic Diagnostic Studies

1. Bone Marrow Examination

A bone marrow biopsy is done to evaluate blood cell production (hematopoiesis) and diagnose conditions like anemia, leukemia, multiple myeloma, and myelodysplastic syndromes.

Procedure:

• Preferred Site: Posterior iliac crest (hip bone).

• Steps:

  1. Local anesthesia and sedation (minimizes pain).

  2. Needle inserted into bone marrow cavity (pain when periosteum is penetrated).

  3. Aspiration of marrow sample (0.2–0.5 mL) → Examined under a microscope.

  4. Needle removed, pressure applied, and sterile dressing placed.

Key Uses of Bone Marrow Biopsy:

✔ Diagnoses blood disorders (e.g., leukemia, aplastic anemia, myeloma).
✔ Evaluates bone marrow function in chronic diseases.
✔ Helps monitor chemotherapy effects.

Complications & Nursing Care:

❌ Possible Risks:

• Bleeding (especially in thrombocytopenia).

• Infection (especially in neutropenic patients).

✅ Post-Procedure Care:

• Monitor vitals & bleeding.

• Lie supine for 30–60 min if bleeding occurs.

• Pain control: Mild soreness for 3–4 days is normal.

2. Lymph Node Biopsy

A lymph node biopsy helps diagnose lymphomas, infections, or metastatic cancer.

Types of Lymph Node Biopsies:

• Less invasive, but may miss abnormal cells | | Open Biopsy (Excisional Biopsy) | Surgical removal of entire lymph node | - Preferred if lymphoma is suspected

• Provides larger sample for cytopathologic testing |

✅ Post-Procedure Care:

• Monitor for bleeding (especially if platelet count is low).

• Check for infection signs.

• Sterile dressing changes as needed.

3. Key Blood Tests for Hematologic Disorders

(A) Complete Blood Count (CBC)

Indications:

• ↓ Hgb/Hct → Anemia (iron deficiency, B12 deficiency, chronic disease).

• ↓ WBCs → Leukopenia (bone marrow suppression, leukemia).

• ↓ Platelets → Thrombocytopenia (bleeding disorder).

(B) Iron Studies

Indications:

• ↓ Iron & Ferritin, ↑ TIBC → Iron Deficiency Anemia.

• ↑ Ferritin, Normal/Low TIBC → Chronic Disease Anemia.

(C) Vitamin B12 & Folate

Indications:

• ↓ B12 & Normal Folate → B12 Deficiency Anemia.

• ↓ Folate & Normal B12 → Folate Deficiency Anemia.

(D) Coagulation Tests (Clotting Studies)

Indications:

• ↑ PT/INR → Bleeding disorder or warfarin therapy.

• ↑ aPTT → Hemophilia, heparin therapy.

• ↑ D-Dimer → DIC, PE, or DVT.

4. Specialized Hematologic Tests

(A) Blood Smear

• Examines RBC, WBC, & Platelet shape & size.

• Useful in: Sickle cell disease, leukemia, megaloblastic anemia.

(B) Erythrocyte Sedimentation Rate (ESR)

• Measures RBC clumping rate (inflammation marker).

• Increased in: Infections, autoimmune diseases, cancers.

(C) Hemoglobin Electrophoresis

• Identifies abnormal hemoglobin (e.g., Hgb S in sickle cell anemia).

(D) Reticulocyte Count

• Measures new RBC production.

• ↑ in: Acute blood loss, hemolysis.

• ↓ in: Iron/B12 deficiency, bone marrow suppression.

(E) Bone Scan

• Detects bone marrow cancer (e.g., multiple myeloma, leukemia).

5. Key Takeaways

✔ Bone marrow biopsy & lymph node biopsy are crucial for diagnosing leukemia, lymphoma, and bone marrow disorders.
✔ CBC, iron studies, and vitamin B12/folate levels help differentiate types of anemia.
✔ Coagulation tests (PT, INR, aPTT, D-dimer) assess bleeding or clotting risks.
✔ Specialized tests like electrophoresis and bone scans detect blood cancers.

Digestible Summary of Molecular Cytogenetics, Gene Analysis & A.J.'s Diagnostic Findings

1. Molecular Cytogenetics & Gene Analysis

Purpose of Genetic Testing in Hematologic Disorders

• Identifies specific chromosomal abnormalities linked to leukemia, lymphomas, and other blood disorders.

• Determines treatment options, prognosis, and therapy response.

Common Genetic Tests in Hematology

2. A.J.'s Diagnostic Test Results

Ordered Tests:

• CBC

• Basic Metabolic Panel (Electrolytes, BUN, Creatinine)

• PT/PTT (Clotting Studies)

• Arterial Blood Gases (ABGs)

• Chest X-ray

Abnormal Results:

Normal Results:

• Arterial Blood Gases (ABGs): Normal → No acute respiratory/metabolic imbalances.

• Chest X-ray: Normal → No lung pathology detected.

3. Interpretation & Concerns

Most Concerning Findings:

✔ Severe anemia (Hgb = 5.9 g/dL, Hct = 18.2%) → Poor oxygen transport, high risk of hypoxia.
✔ Leukopenia (WBC = 2,600/μL) → Increased infection risk.
✔ Thrombocytopenia (Platelets = 72,000/μL) → Risk of spontaneous bleeding.
✔ Prolonged PT (18 sec) & aPTT (37 sec) → Clotting dysfunction, possible bone marrow failure, vitamin K deficiency, or liver dysfunction.

Likely Next Steps:

🔍 Further Blood Tests:

• WBC Differential → Check for neutropenia, lymphocytosis, blasts (leukemia).

• RBC Indices (MCV, MCH, MCHC) → Determine type of anemia.

• Iron Panel (Ferritin, Serum Iron, TIBC, Transferrin Saturation) → Rule out iron-deficiency anemia.

• Vitamin B12 & Folate → Rule out megaloblastic anemia.

• Reticulocyte Count → Assess bone marrow function.

• Peripheral Blood Smear → Identify abnormal cell shapes (e.g., blasts in leukemia, spherocytes in hemolysis).

• Bone Marrow Biopsy → Determine bone marrow function (likely aplastic anemia, leukemia, or myelodysplastic syndrome).

📌 Hospital Admission for Further Evaluation & Potential Transfusion.

4. NCLEX-Style Questions & Answers

1. Why do people living at high altitudes have increased Hgb & RBC counts?
✅ Answer: B – Hypoxia stimulates erythropoiesis.

2. Cancer arising from granulocytic cells in bone marrow leads to?
✅ Answer: D – Decreased phagocytosis of bacteria (neutropenia).

3. Warfarin interferes with which clotting mechanism?
✅ Answer: B – Activation of thrombin (Warfarin inhibits Vitamin K-dependent factors).

4. Expected lab finding in an older patient with infection?
✅ Answer: A – Mild leukocytosis (WBC increase with infection).

5. Key health history findings related to hematologic system?
✅ Answer: A – Jaundice (indicates hemolysis or liver dysfunction).

6. How should a nurse palpate lymph nodes?
✅ Answer: C – Lightly palpate superficial lymph nodes with finger pads.

7. What is a normal lymph node finding?
✅ Answer: B – Firm, mobile nodes (healthy response to infection).

8. Nursing care after a bone marrow biopsy? (Select all that apply)
✅ Answers: A, C, E

• A. Give analgesics as needed.

• C. Keep the sterile pressure dressing intact.

• E. Monitor vital signs & assess for bleeding.

5. Key Takeaways

✔ A.J.'s critical lab values suggest severe anemia, leukopenia, thrombocytopenia, and impaired clotting, requiring hospitalization.
✔ Further tests (WBC differential, iron panel, bone marrow biopsy) are needed to determine if the cause is leukemia, aplastic anemia, or another hematologic disorder.
✔ NCLEX-style questions reinforce hematology concepts, including erythropoiesis, leukemia, clotting pathways, and post-biopsy care.