I.

Nursing Care Management of Problems on Oxygenation (Transport)

Hematology is the study of blood and blood-forming tissues. This includes bone marrow, blood,
spleen and lymph system.

Structures and Functions of Hematologic System

Bone Marrow – where blood cell production (hematopoesis) occurs.

Blood – a type of connective tissue that performs three major functions:

1. Transportation of oxygen, nutrients, hormones, and waste product around the body
2. Regulation of fluid, electrolyte and acid-base balance
3. Protective – ability to clot and combat infection

3 types:
1. Erythrocytes (RBC)
Hemoglobin- functions to bind with oxygen and carbon dioxide
Hemolysis – destruction of erythrocytes; occurs in the bone marrow, liver or spleen

2. Leukocytes (WBC)
Types and functions of Leukocytes
Type Cell Function
Granulocyte
Neutrophil Phagocytosis, especially during the early phase of
inflammation
Eosinophil Phagocytosis (not as effective as neutrophils)
allergic response; protection from parasitic
infections
Basophil Inflammatory response and allergic response;
release of bradykinin, heparin, histamine, serotonin;
limited phagocytosis
Agranulocytes
Lymphocytes Cellular and humoral immune response
Monocytes Phagocytosis; cellular immune response

3. Thrombocytes (Platelets) – to initiate the clotting process by producing the initial platelet
plug in the early phases of the clotting process.

Normal Clotting Response

Hemostasis – blood clotting process
 Vascular spasm
 Platelet plug formation
 Coagulation

Intrinsic pathway – activated by collagen exposure from endothelial injury when the blood vessel is
damaged

Extrinsic pathway - initiated when tissue is released extravascularly from injured tissues
Coagulation Factors
Coagulation Names
Factor
I Fibrinogen
II Prothrombin
 III Thromboplastin
Thrombokinase
Tissue factor
IV Calcium
V Proaccelerin
Labile Factor
Ac globulin
VI Not in use (now obsolete)
VII Prothrombin conversion accelerator
VIII Antihemophilic globulin
Antihemophilic factor
IX Plasma thromboplastin component
Antihemophilic factor B
X Stuart factor
XI Plasma thromboplastin antecedent
Antihemophilic factor C
XII Hageman factor
XIII Fibrin-stabilizing factor

Spleen
- Produces RBC during fetal development (Hematopoietic Function)
- Ability to remove old and defective RBCs from the circulation (Filtration Function)
- Has rich supply of lymphocytes, monocytes and stored immunoglobulins (Immunologic
Function)
- Storage site for RBCs and platelets (Storage Function)

Lymph System
- Carries fluid from interstitial spaces to the blood

Liver
- Functions as a filter
- Produces all procoagulants
- Hepcidin regulates iron balance

ASSESSMENT OF HEMATOLOGIC SYSTEM

1. Health History
a. History of blood disordres
2. Medications (OTC drugs such as vitamins, herbal products and dietary supplements)
3. Surgery or other treatments
4. Functional Health Patterns
5. Physical Assessment

Diagnostic Studies
1. Complete Blood Count and Peripheral Blood Smear (evaluates shape and appearance)
2. Blood Typing and RH factor
3. Clotting Studies
4. Iron Metabolism
5. Urine Studies

Radiologic Studies
1. CT or MRI for evaluation of liver, spleen and lymph nodes
2. Bone scan
Biopsies
1. Bone Marrow
2. Lymph Node Biopsy

ANEMIA
ETIOLOGIC CLASSIFICATION OF ANEMIA
1. Decreased RBC Production
Decreased Hemoglobin Synthesis
Causes Diagnosis Management
Iron Deficiency May be due to Serum Iron Drug Therapy with
inadequate dietary Endoscopic studies to oral iron supplements.
intake, malabsorption, detect GI bleeding
blood loss or Stool exam
hemolysis.
Thalassemia Absent or reduced DNA testing Blood transfusion
globin proteins ->
insufficient production
of normal
haemoglobin
Defective DNA Synthesis
Cobalamin (Vit. B12) Gastric mucosa is not Schilling Test Vit. B12 injection
Deficiency secreting intrinsic
factor which is
required for
Cobalamin absorption
Folic Acid Deficiency Inadequate dietary Blood serum exam: Folic acid
intake normal folic acid level supplementation
Chronic alcoholism is 300mg/dl
Pregnancy
Prolonged drug
theraoy
Decrease Number of RBC Precursor
Aplastic Anemia Result of depressed Bone Marrow Exam Blood Transfusion
bone marrow/ Bone Marrow
destruction of bone Transplant
marrow.
May result to
pancytopenia.
2. Blood Loss
Acute Trauma CBC Identification of
Blood vessel rupture source of blood loss.
Blood Transfusion
Chronic Gastritis CBC Identification of
Menstrual flow source of blood loss.
Hemorrhoids Blood Transfusion
3. Increased RBC Destruction (Hemolytic Anemia)
Sickle Cell Anemia Recessive hereditary Peripheral Smear Symptomatic
blood disorder treatment and
characterized by prevention of crisis.
erythrocytes that
contain Hgb-S
precipitated by
infection, stress,
dehydration, exposure
to cold and acidosis.

Clinical manifestations: (Manifestations are caused by the body’s response to tissue hypoxia)
Management:

Blood Transfusion
- The introduction of whole blood or components of the blood into the venous circulation

Blood and blood products

1. Whole Blood (citrated) -500ml/unit
Indication: replenishes both intravascular volume and the oxygen carrying capacity of the blood

2. Packed RBC -250ml/unit; Should be transfused over 2 to 3 hours; if patient cannot tolerate
volume over a maximum of 4 hours, it may be necessary for the blood bank to divide a unit into
smaller volumes, providing proper refrigeration of remaining blood until needed.
80% of plasma and other blood components are removed
Indication: restores on the oxygen carrying capacity of the blood

3. Platelet concentrate (30ml/unit): Administer as rapidly as tolerated (usually 4 units every 30 to 60

minutes). Each unit of platelets should raise the recipient’s platelet count by 6000 to 10,000/mm3:
Indication: use to treat/ prevent bleeding

4. Granulocyte concentrate: May be beneficial in selected population of infected, severely

granulocytopenic patients (less than 500/mm3) not responding to antibiotic therapy and who are
expected to experienced prolonged suppressed granulocyte production.
Indication: use to treat infections.
Before administration there should be a pre-transfusion RBC compatibility

5. Plasma (200ml/unit)
Provides coagulation factors
6. Albumin (50ml/unit) Indication: It expands blood volume rapidly. Increases plasma albumin level.
Attracts fluid from interstitial space to the blood vessel.
Assess patient for possible circulatory overload
7. Clotting factors (fibrinogen) 10ml/unit
Indication: Used to prevent or treat bleeding
8. Cryoprecipitate 10-20ml/unit
Contains high concentration of fibrinogen and antihemophilic factor

Nursing Interventions
1. Verify doctor’s order. Inform the client and explain the purpose of the procedure.
2. Check for cross matching and typing. To ensure compatibility
3. Obtain and record baseline vital signs
4. Practice strict asepsis
5. At least 2 licensed nurse check the label of the blood transfusion. Check the following:
a. Serial number
b. Blood component
c. Blood type
d. Rh factor
e. Expiration date
6. Screening test (VDRL, HBsAg, malarial smear) – this is to ensure that the blood is free from blood-
carried diseases and therefore, safe from transfusion.
7. Warm blood at room temperature before transfusion to prevent chills.
8. Identify client properly. Two Nurses check the client’s identification.
9. Use needle gauge 18 to 19 to allow easy flow of blood.
10. Use BT set with special micron mesh filter to prevent administration of blood clots and particles.
 11. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction
usually occurs during the first 15 to 20 minutes.
12. Monitor vital signs. Altered vital signs indicate adverse reaction (increase in temp, increase in
respiratory rate)
13. Do not mix medications with blood transfusion to prevent adverse effects. Do not incorporate
medication into the blood transfusion. Do not use blood transfusion lines for IV push of medication.
14. Administer 0.9% NaCl before; during or after BT. Never administer IV fluids with dextrose.
Dextrose based IV fluids cause hemolysis.
15. Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate,
transfuse quickly (20 minutes) clotting factor can easily be destroyed.
16. Observe for potential complications. Notify physician.
In presence of reaction:
 Stop the transfusion immediately, and notify the physician.
 Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access
for possible IV drug infusion.
 Send the blood bag and tubing to the blood bank for repeat typing and culture.
 Draw another blood sample for plasma hemoglobin, culture, and retyping.
 Collect a urine sample as soon as possible for hemoglobin determination.
 Intervene according to signs and symptoms.

Transfusion Reactions: (Acute or Delayed)

Cause Clinical manifestation Management
Acute hemolytic reaction Chills, fever, low back pain,  Treat shock and DIC if present
Infusion of ABO-incompatible flushing, tachycardia,  Draw blood samples for serologic
whole blood, RBC’s. hypotension, dark urine, testing slowly to avoid hemolysis
Antibodies in the recipeints jaundice, AKI, cardiac arrest,  Send urine to laboratory
plasma attach to antigens on death  Maintain BP with IV colloidal
transfused RBCs causing RBC solutions
destruction  Insert IFC

Febrile, Non-Hemolytic Reaction
(most common)
Sensitization to donor WBCs,
platelets and plasma proteins
Mild allergic reaction
Sensitivity to foreign plasma
proteins
Anaphylactic and Severe allergic
reaction
Sensitivity to donor plasma
proteins
Infusion of IgA proteins to
IgA deficient recipient who
has developed IgA antibody
Circulatory Overload Reaction
Fluid administered faster that
the circulation can
accommodate
Sepsis reaction
Transfusion of bacterially
infected blood components
Transfusion related acute lung
injury (TRALI)
Sudden chills and fever (rise
in temperature of 1Oc),
headache, flushing anxiety,
vomiting, muscle pain.
Flushing, itching, urticarial
Anxiety, urticarial, dyspnea,
wheezing, progressing to
cyanosis, bronchospasm,
hypotension, shock and
possible cardiac arrest.
Cough, dyspnea, pulmonary
congestion, headache,
hypertension, tachycardia,
distended neck veins.
Rapid onset of chills, high
fever, vomiting, diarrhea,
marked hypotension and
shock
Fever, hypotension,
tachypnea, dyspnea, decreased
 Give antipyretics as prescribed –
avoid aspirin

 Give antihistamine (antamine),
corticosteroids as directed
 Transfusion maybe started slowly

 Initiate CPR if indicated
 Have epinephrine ready
 Do not restart transfusion

 Place patient upright
 Administer prescribed antidiuretics
and oxygen
 Adjust transfusion rate
 Obtain culture of patient’s blood and
send blood bag and tubing to
laboratory
 Treat septicemia as directed

 Send bag with remaining blood and
tubing to laboratory
Reaction between transfused
antileukocyte antibodies and
recipients leukocytes causing
pulmonary inflammation and
capillary leak
oxygen saturation, frothy  Provide oxygen and administer
sputum corticosteroids
 Anticipate chest x-ray
 Initiate CPR as needed