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| The hematological system is composed of what 3 parts ? | blood, bone marrow, lymphatic system
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| What are the cellular components of blood? | erythrocytes, leukocytes, thrombocytes
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| What substances constitute the fluid portion of blood? | Plasma Protein (albumin), electrolytes, coagulation factors, antibodies
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| Define hematopoiesis | The production of all types of blood cells including formation, development, and differentiation of blood cells.
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| Hematopoietic organs : Bone marrow | All of the formed elements of blood are believed to develop in the bone marrow
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| Lymphatic system: Lymph nodes | Lymph nodes regulate the maturation of lymphocytes
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| Lymphatic system: liver and spleen | deal with cell removal
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| What is the principle component of mature RBCs? | Hemoglobin
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| What is the function of that component (mature RBCs)? | carries oxygen
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| What hormone is important to the production of RBCs | Erythropoietin
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| What other substances are required for normal erythrocyte production? | Iron, protein, folate, vitamin B12
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| What are normal lab values related to RBCs? | 3.5 for RBCs. 13-18 for hemoglobin, depending on sex
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| What do normal RBCs look like under microscope | Biconcave disc
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| Anemia definition | an abnormality in RBC number, structure or function which results in hypoxia because of inadequate transport of oxygen to the body’s tissues
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| What are the three main causes of anemia? | blood loss
impaired production
increased destruction
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| What is the most common site of bleeding? | GI tract
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| Acute blood loss causes | trauma, blood vessel rupture
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| Chronic blood loss causes | gastritis, hemorrhoids, menses
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| DNA synthesis problems in RBC prodution is caused by | B12, Folate deficiency
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| b12 folate deficiency results in | overlarge RBCs- megalocytic
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| Hgb synthesis in RBC production is caused by | Iron deficiency, thalassemia, sideroblastic anemia
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| Decreased production of RBCs | aplastic anemia, leukemia & myelodysplasia, chronic disease
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| Increased destruction of RBCS : INTRINSIC | Sickle cell anemia (more later), enzyme or membrane problems
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| Increased destruction of RBCs: EXTRINSIC | Trauma =>Hemolysis, auto-antibodies, toxins, infections (malaria!)
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| What does the Coombs test do? | looks for certain antibodies in the blood
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| What are the Hgb levels for Mild Anemia? Symptoms? | (Hgb 10-14): usually asymptomatic
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| What are the Hgb levels for Moderate Anemia? Symptoms? | (Hgb 6-10):Dyspnea, palpitations, diaphoresis, chronic fatigue
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| What are the Hgb levels for Severe Anemia? Symptoms? | (Hgb<6): pallor, activity intolerance, dizziness, multiple systems affected
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| What are some medical management techniques for Anemia? | Identify and address cause
Iron or vitamin therapy
Repair of hemorrhaging sites
Splenectomy
Remove toxins
Stem cell transplant for aplastic or leukemic anemia
Corticosteroids for autoimmune disorders
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| What are some techniques to relieve the symptoms of anemia? | Oxygen, transfusion, erythropoietin (Epoietin)
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| What assessment should you do for nursing care of Anemia? | complete health history including diet, family history
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| What are the nursing diagnoses for Anemia? | Activity intolerance, fatigue
Expected Outcomes: improved activity tolerance, Self ADLs
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| What are some interventions for nursing care of Anemia? | Education: explain causes of anemia, importance of adherence to medication and/or diet to patient and family
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| Why is evaluation in nursing care of Anemia important? | reassess regularly to monitor progress toward outcomes
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| What type of cells might you have with Iron deficiency? | Chronic, hypochromic, microcytic
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| What are the causes of Iron deficiency Anemia? | Inadequate iron intake
Impaired absorption of iron
Increase in body’s need for iron
Impaired synthesis of iron
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| What is the treatment/management of Iron deficiency Anemia? | Diet and Iron supplementation
Teach risk of gastric irritation=>take with food; coping with constipation=>fiber
Avoid coffee & tea with iron
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| What are type of blood cells might you see with Vitamin B12 deficiency? | Macrocytic, defective RBCs
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| What are the causes of Vitamin B12 deficiency? | Lack of intrinsic factor (pernicious anemia) OR
Failure to absorb vitamin B12 from intestinal tract (partial gastrectomy) OR
Vegetarian diet (B12 comes from animal sources)
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| Vitamin B12 deficiency is also called | Pernicious anemia if caused by lack of intrinsic factor in the gut
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| What testing is done for Vitamin B12 deficiency? | review blood smear and RBC indices, Schilling Test for intrinsic factor adequacy
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| What is the treatment for Vitamin B12 deficiency? | Cobalamin injections for life
Oral or IV iron supplements
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| What do red blood cells look like with folic acid deficiency? | megaloblastic (macrocytic) on blood smear
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| What are the causes of Folic Acid deficiency? | Dietary deficiency of leafy greens and citrus
Malabsorption syndromes
Alcohol abuse and eating disorders
Certain drugs (Oral contraceptives, anticonvulsants, methotrexate)
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| What is the treatment for Folic Acid deficiency? | Oral folic acid until blood profile improves or underlying cause corrected
Multivitamins
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| What is Sickle Cell Disease? | Genetic disorder: normal adult hemoglobin replaced by mutant sickle hemoglobin
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| What is the pathophysiology of Sickle Cell? | When O2 decreased, hgb becomes viscous and forms gel & crystals inside RBCs, cells form sickle shape: Sickle Cell Anemia (SCA)
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| Sickle Cell disease is most common in what population? | African Americans in US (8% carry gene)
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| What are the genetics behind getting Sickle Cell disease? | Autosomal recessive inheritance of two defective genes for hemoglobin synthesis = disease
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| What are the genetics behind getting Sickle Cell trait? | One defective gene = trait: usually asymptomatic carrier. People with just the trait usually do well unless there is sickle cell crisis
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| How do sickle cells affect perfusion? | stiff rigid and inflexible so they get stuck and affects perfusion. Also causes pain because extremities are hypoxic
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| What happens when there is obstruction due to sickled cells? | Obstruction caused by sickled RBC’s
Vaso-occlusion “pain crisis” due to local hypoxia
Enlarged spleen from capture of damaged cells
Kidney, liver, bone, CNS & cardiac problems
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| What happens when there is increased destruction of RBCs? | Chronic fatigue and pallor
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| What is the most common cause of death in Sickle Cell? | Acute Chest Syndrome: chest pain, fever, cough, tachypnea, elev. WBC and pulmonary infiltrate=>ARDS=>death
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| What are the medical management interventions of SCA? | Prevention of sickling
Treat sickle cell crisis (medical emergency )
Pain management with iv Morphine via PCA, then prn
Rest, DVT prophylaxis
Heat application
Decrease oxygen demand
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| What is a supportive treatment of SCA? | Folic acid, oxygen
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| What is a complementary treatment of SCA? | TENS, hypnosis, acupuncture
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| What is a specific approved medicine to treat SCA? | Hydroxyurea only FDA approved agent
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| What are some possible future curative treatments of SCA? | Gene therapy research – alter fetal hemoglobin
BMT offers future hope
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| What are some nursing interventions for SCA? | Educate patient & family on avoiding sickle crisis, Instruct on dietary & activity management, Avoid high altitudes, dehydration
Call physician if fever, vomiting or diarrhea
Advise genetic counseling for young adults who carry gene
Counsel women with
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| Which of the following tests will be most useful in determining whether a client has pernicious anemia? | Schilling test
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| Ms. S, is admitted to the hospital because of a sickle cell crisis. Which nursing action is most appropriate to include in the plan of care? | Encourage large amounts of fluid daily.
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| During hospital admission, the nurse learns that a teenage patient Junie is a vegetarian. The nurse will monitor Junie for: | B12 deficiency anemia.
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| What are some disorders of Hemostasis? | Platelet defects/ deficiencies
Coagulation Factor deficiencies
DIC
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| Quick review of Hemostasis | 1)Platelets: cell fragments, respond to vascular injury by becoming sticky to form plug & secreting thromboxane, a vasoconstrictor
2)Coagulation cascade initiated, forming fibrin clot
3)TPA forms plasmin which breaks down clot
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| Immune Thrombocytopenic Purpura (ITP) | Auto antibodies bind to plts;
removed by spleen & liver
Clinical: bruising, petechiae, purpura
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| Heparin Induced Thrombocytopenia (HIT) | Suspect when plt count drops in patient receiving heparin therapy, can occur in 1 day!
Anti-plt antibody formation induced by heparin sulfate
Paradox: prone to thrombus formation, not bleeding!
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| What are some examples of Hemorrhagic Fever viruses? | Ebola, Dengue, Marburg, Lassa
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| What are hemorrhagic fever caused by? | animal reservoir, arthropod vector
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| What are the clinical manifestations of HFV? | bleeding from all orifices, purpura, capillary leak, shock, liver failure
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| Which disorder is the loss of balance between clot formation and lysis called | Disseminated Intravascular Coagulation
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| What are the causes of DIC? | Infection (septicemia, typhoid, viral, parasitic)
Tissue coag factors enter circulation
Vascular damage
Stagnant blood flow
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| What is the pathophysiology behind DIC? | Pathophysiology : Coag cascade precipitated, forming clots throughout body and depleting platelets, prothrombin and coag factors, while activiating fibrinolysis.
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| How do you diagnose DIC? | based on:
Prolonged PT, PTT
fibrinogen & plt count diminished
Increased fibrinogen degradation product (FDP) and d-dimer
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| What are the manifestations of DIC? | Petechiae, purpura, bleeding from all orifices, shock and coma. Mortality 80% in severe cases
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| What is the treatment for DIC? | correct underlying cause. Replace blood components. monitor lab, VS & bleeding. Apply pressure to bleeding sites. Reposition carefully. Emotional support for pt and family
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| What is the clotting factor deficiency for Hemophilia A? | factor VIII deficiency, X-linked
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| What is the clotting factor deficiency for Hemophilia B? | factor IX deficiency, X-linked
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| What is the clotting factor deficiency for von Willebrand Disease ? | vW factor, Autosomal dominant
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| Why is Hemophilia less common in females? | they need a bad “x” from both parents but some are not genetic transmitters so it wouldn’t make a different in that case
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| The 2 hemophilia disorders that are x-linked are | Hemophilia A and B
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| How cases of hemophilia are new mutations | 30%
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| What testing is done for Hemophilia? | prolonged PTT, factor assay (all other labs would be normal)
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| What types of bleed can you have with hemophilia? | hemarthrosis- joints are swollen with blood- with any trauma – painful and deforming
Epistaxis- nose bleed- can be fatal!
Bleeding of gums, GI tract, hematuria
Muscle hemorrhage
Soft tissue: purpura
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| Leading cause of death in hemophiliacs | Cerebral hemorrhage
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| What is the treatment for Hemophilia? | Replacement of missing clotting factor (protein)
Available as powdered factor concentrate
Reconstituted and infused
Repeat q 12 hours until bleeding stops
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| Treatment for hemophilia? | Fresh frozen plasma, cryoprecipitate in emergencies
(contain factor but less pure than factor concentrate)
DDAVP / Stimate
Antifibrinolytic Agents
Supportive measures: pack ice around joints, aspirate blood from joint, ROM exercises to prevent deformi
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| Mr. H, who has hemophilia, has a knee injury at home and calls the clinic asking for advice. Which action should the nurse recommend that he take before coming to the clinic? | immobilize the knee using an elastic bandage
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| Disseminated intravascular coagulation (DIC) is characterized by which of the following clinical manifestations? | Prolonged PT and PTT (; low platelet count (<100,000); reduced fibrinogen; and prolonged clotting times)
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| Name the two classes and 5 types of WBCs | Agranular (lymphocytes/monocytes), Granular (basophils, neutrophils, eosinophils)
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| Define leukocytosis | a white blood cell count (the leukocyte count) above the normal range in the blood.It is frequently a sign of an inflammatory response, most commonly the result of infection
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| Define lymphocystosis | is an increase in the number or proportion of lymphocytes in the blood.
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| Define leukopenia | ) is a decrease in the number of white blood cells (leukocytes) found in the blood, which places individuals at increased risk of infection.
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| Define neutropenia | subtype of leukopenia, refers to a decrease in the number of circulating neutrophil granulocytes, the most abundant white blood cells.
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| Define lymphopenia | is the condition of having an abnormally low level of lymphocytes in the blood. Lymphocytes are a white blood cell with important functions in the immune system
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| What is agranulocytosis? | Acute, life-threatening blood disorder
Profound neutropenia (define)
Rare; more common in women than men
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| What is the most common cause of agranulocytosis? | Drug or chemical toxicity (chemo, dilantin, tranquilizers, antibiotics)
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| Die within a week from septicemia if what disorder isn't treated? | Agranulocytosis
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| Diagnosing of Lymphoma, Leukemia, Multiple Myeloma | history, CBC raise suspicion
Bone Marrow biopsy is definitive
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| What is the purpose of a bone marrow biopsy? | obtain liquid marrow specimen and bone core for evaluation by pathology
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| What site is used for the bone marrow biopsy? | superior inferior iliac crest
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| What are the 5 nursing responsibilities during bone marrow biopsy | Ensure supplies available in patient room
Provide education to patient, evaluate understanding
Administer analgesics & sedatives as ordered
Assist pt to lateral decubitus position
Standby assist to MD at bedside
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| How long should patient lie flat after bone marrow? | pt should lie flat 1 hour to prevent hemorrhage
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| What is multiple myeloma ? | Malignancy of plasma B lymphocyte
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| Multiple myeloma is more common in what gender and what race? | Men 2x more likely than women and African Americans 2x more than Caucasians
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| What assessment findings do you see with multiple myeloma? | Bones are painful and very fragile, can cause pathological fractures – fracture that wouldn’t normal occur
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| What is the cure for Multiple Myeloma? | No cure!
Chemotherapy: Melphalan & prednisone 4-7 days, repeat at 4 week intervals; 50-60% response rate
Thalidomide & lenalidomide approved (neuropathy common)
BMT with Hi-dose chemo has 80% response rate
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| What is the nursing care for MM? | Manage bone pain, nausea
Small frequent feedings, stool softeners, push fluids
Monitor I & O, daily weights, blood studies
Care in transferring patient to avoid fractures
Monitor mental status
Instruct family on home safety to prevent injury
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| What is Leukemia ? | Cancer of WBC precursors
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| What are the possible causes of leukemia? | Benzene exposure (usually from tobacco)
High dose radiation exposure
Certain chemotherapies for other cancer
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| What is the most common form of leukemia in children? | ALL ( Acute Lymphocytic leukemia)
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| What is the most common overall leukemia? | CLL (Chronic Lymphotic leukemia)
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| What is the most deadly form of leukemia? | AML (Acute Myelocytic Leukemia)
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| Hodgkin's vs. Non-Hodgkin's | Hodgkin’s (most common in young and older adults; associated with Epstein-Barr virus; 90% five year survival rate)
Non-Hodgkin’s (Highly variable aggressiveness; 5 year survival rate 69% overall, 85% in children)
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| Which nursing action would NOT be appropriate when planning care of a client hospitalized with multiple myeloma? | Increase dairy product intake or provide calcium supplement.
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| Neutropenic precautions? | Maintain clean skin and oral mucosa
Teach patient and visitors about hand hygiene, reinforce often!
Screen visitors for flu or cold symptoms
No visits from persons who had active vaccinations recently
Monitor for low-grade fevers or mental status chan
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| What is the most effective method of preventing infection in a client with neutropenia? | Enforce strict hand-washing for everyone coming into contact with the client
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