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► HEMATOLOGY – the scientific study

of the structure and functions of


blood in health and in disease.

► BLOOD – is the circulatory fluid of


the CV system which is circulating
constantly through a closed circuit of
tubes.
► FUNCTIONS:
► supply oxygen from the lungs and
absorbed nutrients from the GIT to the
cells
► remove waste products from tissues to the
kidneys, skin and lungs for excretion
► transport hormones from their origin in the
endocrine glands to other parts of the
body
► protect the body form dangerous
microorganism
► promote Hemostasis ( to stop bleeding)
► regulate body temperature by heat
transfer – vasoconstriction and
► CHARACTERISTICS:
► Color
 Arterial Blood
 Venous Blood
► Viscosity – 3-4 times more viscous than water
► pH – 7.35-7.45
► Specific gravity - 1.048 to 1.066 ( 1.055 – 1.065)
► Volume – 5 liters or approx. 7-8% of the
body weight of an average-sized adult
► Composition
► Liquid phase: PLASMA (55%)
► - A light yellow substance which is one of
the major fluids of the body. Major function
is to maintain the blood volume within the
vascular compartment.
► 92% Water
► 7% Proteins ( albumin-
gammaglobulins, fibrinogen,
prothrombin)
► Electrolytes (.g. Na+,,Ca 2+,, HCO3ˉ, CIˉ),
► Miscellaneous (less than 1%): sugars,
fats, vitamins, hormones
Solid phase: formed elements
(45%)
Erythrocytes/ RBC
► Are biconcave discs (AKA
discocytes) which are less
than 7.5 micrometers in
diameter.
► Carries about 200-300
million molecules of
hemoglobin (heme-
globin-iron) that attach
oxygen within each RBC,
responsible for 97% of O2
transport
► Contains carbonic
anhydrase that joins CO2
to water that eventually
dissociates, responsible for
72%
of CO2 transport
► LIFESPAN
Erythropoiesis
Requirements in the prdxn:
1. Precursor cells
2. Proper microenvironment
3. Adequate supplies of Iron, B12, Folic acid,
CHON, pyridoxine, and traces of copper
Hematopoietic stem cells
Poietin Stimulation
Differentiation
Immature erythrocytes
Leave the bone marrow via veins and
enter general circulation or nucleated
reticulocyte
Travel the spleen
Undergo conditioning and evolve to
mature erythrocytes
Released to general circulation
Leukocytes/ WBC
► Whitish in color
because they lack
hemoglobin.
► Classified according
to microscopic
appearance-
presence or
visibility of
granules.
Granulocytes
 Neutrophils
First line of defense, most common type of leukocyte but a short
lifespan of only 10-12 hours making them ineffective in destroying
infectious agents
Helpful in localizing the infection and in immobilizing the pathogens
until other WBCs arrive
Eosinophils
Weak phagocytic action, elevated during asthma attacks. Usually
activated during parasitic invasion (Schistosomes / blood flukes),
Lifespan= hours to 3 days
Modulates or reduce IgE mediated allergic reactions
Basophils
not phagocytic in nature, they are mediators
in inflammatory process. Releases histamine
and heparin and chemotactic factor for
eosinophils. Induces IgE mediated allergic reactions
Agranulocytes
1. Lymphocytes
a. T- cells – differentiated in the Thymus and lives long
cell-mediated response
b. B- cells – differentiated in the bone marrow,
antibody-mediated immune response (Humoral)
c. NK- cells / natural killers / null lymphocytes- poorly
understood in killing tumor cells and virally infected
cells.
2. Monocytes
- upon release in the bone marrow and travel to the
different tissues, it is just a hypoactive phagocytic cell,
become a Macrophage when it attaches to the
endothelium of organs and performs its full phagocytic
function.
Thrombocytes/ Platelets
-functions:
(1) occlude small openings of blood
vessels,
(2) provision of chemical components in
the molecular cascade leading to
coagulation
HEMATOPOIESIS
 process of blood cell production.
 at birth, it is accomplished in the liver, spleen,
thymus, lymph nodes and red bone marrow. After
birth, it is confined in the red bone marrow ( but
some WBCs are still produced in the lymphatic
tissues).
 during childhood, all blood cells are essentially
produced in marrow sites of the flatbones of the
skull, clavicle, sternum, ribs, vertebrae, and pelvis
 After puberty, hematopoiesis becomes localized
within the flatbones of the sternum, ilium, ribs, and
vertebrae, sometimes occurring in the proximal
ends of long bones (humerus and femur)
 all formed elements come from one stem cell or the
HEMOCYTOBLAST. Cell differentiation gives rise to
Assessment of the Hematologic
System
1. Risk
Factor Analysis
• Non-Modifiable
a. Age
- immune response is diminished in both very
young and very old
- anemia prevalence increases with age
- folic acid deficiency in growth spurt (infants and
adolescents)
- because some laboratory results are age- specific
b. Sex
- women have lower hemoglobin and hematocrit
levels, more prevalence of agranulocytosis
- hemophilia, bleeding expressed among males
- because some laboratory results are sex-specific
c. Race

- Blacks have lower hemoglobin levels than whites


(more prevalent sickle cell anemia)
d. Family history
- because some hematologic disorders
are inherited
-Anemia, thrombocytopenia, bleeding
disorders (hemophilia and Von
Willebrand’s Dse), Congenital Blood
Disorder (Sickle Cell anemia),
Jaundice, infections, delayed healing,
cancer, autoimmune dse (aplastic
anemia, pernicious anemia)
e. Congenital lack of the intrinsic factor
• Modifiable
a. Exposure to certain
chemical and drugs
- Radiation
overexposure
- Anti-neoplastic
drugs/ chemotherapy
- Chemical Oxidants
(e.g benzene, nitrites,
lead, arsenic, etc.)
- Drugs
(chloramphenicol,
sulfonamide, anti-
convulsant,
streptomycin, hair
dyes
2. History – Chief complaint
• Disorders of the hematologic system
often affects all organs and tissues
• Determine:

- onset
 abrupt or gradual?
 since childhood or recent
allergen triggered response?
Seasonal?
How long do the allergic
manifestations last? Relieved or persist
once the allergen is removed?
quality and quantity= how severe? Massive
bleeding? How long does it last?
How long do the bleeding episodes last and how
severe they are?
Does blood ooze from a site or does sudden
massive bleeding occur?
How often do bleeding episodes occur and how
long do they last?
What does the client do to stop them?
Is there any break in skin integrity?
Swelling? Edema? Fever? Pain? Tenderness?
Pruritus? Redness? Or drainage?
Note allergic manifestations such as rhinitis,
sneezing, nasal stuffiness, postnasal drip, sore
throat, voice changes, hoarseness, wheezing,
persistent cough, dyspnea, malaise, fatigue, tearing
severity and location= rest can alleviate
fatigue? Bleeding of joints?
 Can rest alleviate fatigue? (s/sx of anemia)
 Ask how activities and activity tolerance
changed over time
 Does the client bruise easily?
 Has bleeding in the joints?
 Number and saturation of sanitary pads
 anaphylactic reactions? Or simple allergic
response?
precipitating factors
 Anticoagulant? – bleeding
 Bone Marrow suppression – anemia, leukemia, and
thrombocytopenia
 Antineoplastic drugs? Antibiotics? Radiation?
 Infectious agents? Corticosteroids or
immunosuppressive drugs?
 Allergic triggers (inhalants such as pollens and
dust, contact agents such as dyes and cosmetics,
ingested agents such as foods and drugs, injectable
agents such as drugs, vaccine and insect venom)
aggravating and relieving factors
 salicylates containing OTC may aggravate bleeding
 what relieves allergic manifestations
3. Past Medical History
a. Major illnesses and hospitalization
• Previous hematologic problems
• Surgical procedures that may
affect the hematologic system
• Liver problems
• Any bleeding disorders
How long was the bleeding problem? Do any
members of the family have a history of bleeding?
Is bleeding linked with any specific event or
procedure? Does it occur with menses or following
minor trauma? Any frequency of nose bleeding?
Does he bruise easily? Any petechiae?
How severe are any of the bleeding episodes? What is
the durations?
Any history of hepatic/ splenic or renal disease?
Recently taken medications?

b. Medications- aspirin, chloramphenicol,


antineoplastic drugs
c. Allergies- Hx of allergies and BT and/reactions
d. Family History
4. Psychosocial Hx and Lifestyle
a. Occupation- exposure to chemicals
and radiation

b. Habits- nutritional, substance


abuse, alcohol abuse
Review of Systems/ Physical
Examination
1. SKIN
- pallor

- ruddy skin

- jaundice
- dry skin, brittle, spoon shaped with longitudinal
ridges
petechiae
purpura and ecchymoses
rashes, urticaria, pruritus
2. EYES
- visual disturbances (anemia and polycythemia)
- blindness (retinal hemorrhage related to
thrombocytopenia and bleeding do)
- scleral jaundice (hemolytic anemia)

3. EARS
- vertigo, tinnitus (severe anemia)
- bleeding in auditory canal
(bleeding do)
4. NOSE
- epistaxis (thrombocytopenia
and bleeding disorders)
► 5. MOUTH
► - smooth, glossy, bright red tongue and sore tongue
(pernicious and Fe def. anemia)
► - gingival bleeding (thrombocytopenia and bleeding
disorders)

.
6. LUNGS
- dyspnea, orthopnea (anemia)
7. CARDIOVASCULAR SYSTEM
- tachycardia, palpitation, murmurs, angina (anemia)
8. GIT
- dysphagia (mucous membrane atrophy due to iron def.
anemia)
- abdominal pain( bleeding)
- hepatomegaly, splenomegaly (hemolytic anemia)
- hematemesis, melena (thrombocytopenia and bleeding
disorders)
9. GUT
- hematuria (bleeding disorders)
-amenorrhea and menorrhagia
(iron def. and bleeding do)
10. MUSCULOSKELETAL
- backpain (hemolysis)
- joint pain (hemophilia)
-sternal tenderness and bone pain
(sickle cell crisis)
11. NERVOUS SYSTEM
-headache, confusion
(anemia, polycythemia)
-brain hemorrhage
(thrombocytopenia and bleeding disorders)
-peripheral neuropathy,
paresthesis, loss of balance (pernicious
► Anemia – characterized by paloor, weakness and
lightheadedness, severe anemia manifests with
chronic severe fatigue, exertional dyspnea,
headache or vertigo
► Bleeding d/o –petechiae, purpura and ecchymosis,
spontaneous bleeding from the nose, gingival,
vagina, and rectum, oozing of blood from cuts and
venipuncture sites, jaundice, conjunctival
hematemesis, hematuria and back and flank pain
► Hemophilia – lifelong bleeding tendencies such as
excessive bleeding and circumcision or dental
extraction, repeated episodes of spontaneous
bleeding into joints and lifethreatening bleeding
► Immunodeficiencies – hx of recurrent infxns esp
of mucous membranes (oral cavity, anorectal,
genitourinary, respiratory); poor wound healing,
diarrhea
DIAGNOSTIC
PROCEDURES:
1. Complete Blood Count
a. RBC count- # of RBCs/ mm3 of blood, to diagnose anemia and
ploycythemia
b. Hemoglobin- # of grams of hgb/ 100ml of blood; to measure
the oxygen-carrying capacity of the blood
c. Hematocrit – expressed in %; measures the volume of RBCs in
proportion to plasma; used also to diagnose anemia and
ploycythemia and abnormal hydration states
d. RBC indices- measure RBC size and hemoglobin content
a. MCV (mean corpuscular volume)
b. MCH (mean corpuscular hemoglobin)
c. MCHC (mean corpuscular hemoglobin concentrarion)
e. Platelet count- # of Platelet/ mm3; to diagnose
thrombocytopenia and subsequent bleeding tendencies
f. WBC count- of WBCs/ mm3 of blood; to detect infection or
inflammation
g. WBC Differential count- determines proportion of each WBC in
a sample of 100 WBCs; used to classify leukemias
► 2. Peripheral Blood Smear- to
determine the variations/ abnormality
in RBCs, WBCs and Platelets: normal
size and shape (normocytes) and
Picture 4
normal color (normochromic)

Normocytic-normochromic
3. DIRECT ANTIGLOBULIN EST (Coomb’s
Test) – used in cross matching blood when
transfusion reaction occurs, test umbilical
cord for Erythroblastosis fetalis and
diagnose acquired hemolytic anemia
4. INDIRECT ANTIGLOBULIN TEST-
identifies antibodies to RBC antigens in the
serum of clients who have greater than
normal chance of developing transfusion
reactions.
5. RETICULOCYTE COUNT
- used to determine the responsiveness of the
bone marrow to the depletion of circulating
RBCs (probably due to hemolytic anemia or
hemorrhage)
Bone Marrow Aspiration
BONE MARROW
ASPIRATION and
BIOPSY- used to
determine size and shape
of RBCs, WBCs and platelet
precursors and to examine
various maturational
abnormalities.
NURSING RESP:
Preprocedure - explain the purpose, obtain
consent
- inform client of pain or of what to
expect
- give sedatives as ordered

Procedure - place patient in lateral


position, with site of aspiration
uppermost
- clean pt’s skin with antiseptic sol’n
- administer local anesthesia to
numb skin and subcutaneous
tissues
- apply ice on the contralateral side
to relieve pain

Postprocedure - apply pressure until bleeding stops


- check site frequently for bleeding
7. COAGULATION SCREENING TESTS
a. Bleeding Time – measures the ability to
stop bleeding after small puncture wound
b. Partial Thromboplastin Time (PTT) – used to
identify deficiencies of coagulation factors,
prothrombin and fibrinogen; monitors
heparin therapy.
c. Prothrombin Time (Pro-time) – determines
activity and interaction of the Prothrombin
group: factors V (preacclerin), VII
(proconvertin), X (Stuart-Power factor),
prothrombin and fibrinogen; used to
determine dosages of oral anti-coagulant.
Normal Values
CBC
RBC: Women – 4.2-5.4 million/mm3
Men – 4.7-6.1 million/mm3
Hgb: Women – 12-16 g/dl
Men – 13.5-18 g/dl
Hct : Women – 37-47%
Men – 42-52%
WBC: 4000-9000/mm3
Granulocytes
Neutrophils: 55-70%
Eosinophils: 1-4%
Basophils: 0.5-1.0%
Agranulocytes
Lymphocytes: 20-40%
Monocytes: 2-8%
Platelets: 150,000-450,000/mm3
Peripheral Blood Smear: Normocytic,
Normochromic
Coomb’s Test: Direct – Negative
Indirect – Negative
Reticulocytes: 25-75 x 10 9/L
Bleeding Time: 2.75-8 min
Partial Thromboplastin Time (PTT): 20-
35 sec.
Prothrombin Time (PT): 12-14 sec.