Joaquin P.

Venus III,MD,RN

PUTLA MO. ANEMIC KA NOH?!

IKAW NANGINGITIM KA NA! CYANOTIC KA! INTUBATE KITA!

Lumayas
Cecil: Mare, pwede ba, dito muna ako sa inyo? Lumayas ako sa amin. Kasi, buntis ako. Rain: Dapat, sa taong nakabuntis sa yo ka pumunta! Cecil: Kaya nga rito ako pumunta, eh. Nandiyan ba si pare?

Blood

Functions of Blood

Transport of:
Gases, nutrients, waste products Processed molecules Regulatory molecules

Regulation of pH and osmosis Maintenance of body temperature Protection against foreign substances Clot formation

Composition of Blood

Plasma

Liquid part of blood

Pale yellow made up of 91% water, 9% other

Colloid: Liquid containing suspended substances that dont settle out

Albumin: Important in regulation of water movement between tissues and blood Globulins: Immune system or transport molecules Fibrinogen: Responsible for formation of blood clots

Formed Elements

Red blood cells (erythrocytes) White blood cells (leukocytes)

Granulocytes
Neutrophils Eosinophils Basophils

Agranulocytes
Lymphocytes Monocytes

Platelets (thrombocytes)

Production of Formed Elements

Hematopoiesis or hemopoiesis: Process of blood cell production Stem cells: All formed elements derived from single population
Proerythroblasts: Develop into red blood cells Myeloblasts: Develop into basophils, neutrophils, eosinophils Lymphoblasts: Develop into lymphocytes Monoblasts: Develop into monocytes Megakaryoblasts: Develop into platelets

Hematopoiesis

Erythrocytes

Structure

Biconcave, anucleate Hemoglobin Lipids, ATP, carbonic anhydrase Transport oxygen from lungs to tissues and a few carbon dioxide from tissues to lungs

Components

Function

Hemoglobin

Consists of: 4 globin molecules: Transport carbon dioxide (carbonic anhydrase involved), nitric oxide 4 heme molecules: Transport oxygen Iron is required for oxygen transport

Erythropoiesis

Production of red blood cells

Stem cells proerythroblasts early erythroblasts intermediate late reticulocytes

Erythropoietin: Hormone to stimulate RBC production

Hemoglobin Breakdown

Leukocytes

Protect body against microorganisms and remove dead cells and debris Movements Ameboid Diapedesis Chemotaxis

Types Neutrophils: Small phagocytic cells Eosinophils: Reduce inflammation, allergy Basophils: Release histamine and increase inflammatory response Lymphocytes: Immunity Monocytes: Become macrophages

Thrombocytes

Cell fragments pinched off from megakaryocytes in red bone marrow Important in preventing blood loss

Platelet plugs Promoting formation and contraction of clots

Sige lang! Tsugi ka sa akin mamaya!

LAUGH BREAK
ANAK: ITAY SA SWELDO NYO PUNTA TAYO NG SN? TATAY: ANG LAKI-LAKI MO NA BULOL KA PA? PARA SN LANG! ANAK: ANO PO BA ANG TAMA? TATAY: SHOENART! NARYUSIP!

Hemostasis
Arrest of bleeding Events preventing excessive blood loss Vascular spasm: Vasoconstriction of damaged blood vessels followed immediately by vasodilation Platelet plug formation Coagulation or blood clotting

Platelet Plug Formation

Coagulation

Pathways Extrinsic Intrinsic Stages Activation of prothrombinase Conversion of prothrombin to thrombin Conversion of fibrinogen to fibrin

Clot Formation

Fibrinolysis

Clot dissolved by activity of plasmin, an enzyme which hydrolyzes fibrin

MOMMY TAPOS NA PO AKO LIGO!

LAUGH BREAK
AMO: DAY BAKIT MAY BUKOL SI JUNIOR? INDAY: COMPROMISING SAFETY WITH USELES AESTHETICS, THE NOT-SOWELL ENGINEERED ARCHITECTURAL DESIGN OF OUR KITCHEN LAVATORY AFFECTED THE BOYS CRANIUM WITH A SLIGHT BOIL AT THE LEFT TEMPLE NEAR THE AUDITORY ORGAN... AMO: NAGNONOSEBLEED AKO!!!! INDAY: OH, ITS CALLED EPISTAXIS ATI!

Blood Grouping
Determined by antigens (agglutinogens) on surface of RBCs Antibodies (agglutinins) can bind to RBC antigens, resulting in agglutination (clumping) and hemolysis (rupture) of RBCs Groups ABO and Rh

BLOOD CLASSIFICATION
MAJOR BLOOD GROUPS A, B, AB, O Blood compatibility and systems of classification are based on the presence or absence of specific antigens present on RBCs as well as specific antibodies in the plasma

BLOOD CLASSIFICATION

If the antigen A on the RBCs of the donors comes in contact with the Antibody A of the recipient and vice versa, agglutination and clumping will occur. E.g. Type A blood transfused into B recipient

BLOOD CLASSIFICATION

O negative is called the

UNIVERSAL DONOR because there are no antigens on the RBCs and the Rh factor is not present

BLOOD CLASSIFICATION
AB

positive is called the

UNIVERSAL RECIPIENT because there are no antibodies in the serum, and the Rh factor is present.

BLOOD CLASSIFICATION
In

agglutination and clumping of RBCs, hemolysis occurs, and releases hemoglobin into the plasma. Problems occur with the destruction of the donors RBCs by the plasma of the recipients cells.

ABO Blood Groups

Agglutination Reaction

Rh Blood Group

First studied in rhesus monkeys Types

Rh positive: Have these antigens present on surface of RBCs Rh negative: Do not have these antigens present

Hemolytic Disease of the Newborn (HDN)

Mother produces anti-Rh antibodies that cross placenta and cause agglutination and hemolysis of fetal RBCs

Rh factor

Rh is positive, or factor is present, in 85% to 95% of the population Rh is negative, or factor is absent , in 5 % to 15% of the population Normal plasma does not contain Rh antibodies. Antibodies are formed in Rh negative blood if transfused with Rh positive blood; thus, the recipient is sensitized to the Rh factor and subsequent Rh positive blood might result in a severe transfusion reaction

Erythroblastosis Fetalis

Diagnostic Blood Tests

Type and crossmatch Complete blood count Red blood count

Hemoglobin measurement Hematocrit measurement

White blood count Differential white blood count Clotting

MAMA MAY AMOY ISDA! PARANG NASA LOOB NITO!

LAUGH BREAK
BATA 1: ALAM BA NINYO ANG TAPANG NG DAGA SA AMIN. KUMAKAIN NG LASON SA DAGA! BATA 2: WALA YAN SA DAGA SA AMIN, ANG KINAKAIN NIYA KINUKUHA NIYA SA MOUSE TRAP! BATA 3: WALA PALA IYANG MGA DAGA SA AMIN. NANGRE-RAPE NG PUSA!!!

ASSESSMENT

HISTORY

History Disease of bone marrow and/or producing organs Treatment that depressed bone marrow activity (especially chemotherapy or radiation therapy) Family history of problems (inheritance pattern) Blood transfusion

HISTORY
Bleeding

problems occurring during pregnancy, labor and delivery, or immediately after delivery in both mother and infant Presence of chronic disorders or disease processes Effects of aging

EFFECTS OF AGING

Assessment area Nail beds ( check for capillary refill) Pallor, cyanosis, and decreased capillary refill is often noted in hematologic disorders In elderly: Nails are typically thickened and discolored. Need to use another body area, such as the lips to assess capillary refill

EFFECTS OF AGING

HAIR DISTRIBUTION
Thin or absent hair on trunk and extremities may indicate poor oxygenation and blood supply In elderly: Older adults are losing body hair, but often is an even pattern distribution that has occurred slowly overtime. Lack of hair on lower legs and toes may indicate poor circulation

EFFECTS OF AGING

SKIN MOISTURE AND COLOR

Skin dryness, pallor and jaundice may occur with anemia, leukemia, etc In elderly: Dry skin is a normal aspect of aging and thus becomes an unreliable indicator of skin moisture Pigment loss and skin changes along with some yellowing occur with aging. Pallor that is not associated with anemia may be noted in older adults, because they tend not to go outdoors and get exposed to sunlight

EFFECTS OF AGING

Evaluate effect of hematologic disorder has on clients activities of daily living?

How long has client experienced symptoms? What are current activities and metabolic requirements of the client? Presence or absence of bleeding episodes Ability to control pain Presence of appropriate coping or defense mechanism

EFFECTS OF AGING
Evaluate effect of hematologic disorder has on clients activities of daily living? Assess clients current nutritional status Evaluate current blood values Evaluate status of respiratory and cardiovascular systems in maintaining homeostasis

LAUGH BREAK
KONDUKTOR: SAAN PO KAYO BABA MISIS? MISIS: CUBAO LANG! KONDUKTOR: ANAK PO BA NINYO IYAN? BAKIT ANG PANGIT? MISIS: BUWISIT NA KONDUKTOR IYON. SOBRA KUNG MAMINTAS. ANG TAGAL NG INSPECTOR. MAIREKLAMO NGA!

LAUGH BREAK
UMAKYAT ANG INSPECTOR NG BUS.... MISIS: SOBRANG MANLAIT ANG KUNDOKTOR NYO! GUSTO KONG IREKLAMO! INSPEKTOR: TAMA PO ANG GAGAWIN NINYO! ETO PO ANG LAPIS AT PAPEL. ISULAT NINYO ANG INYONG REKLAMO. PARA MAKASULAT KAYO AKIN MUNA ANG UNGGOY NINYO...

DIAGNOSTICS

ACTIVATED PARTIAL THROMBOPLASTIN TIME

Evaluates

how well the coagulation sequence (INTRINSIC PATHWAY) is functioning by measuring the amount of time it takes for recalcified, citrated plasma to clot after partial thromboplastin is added to it. The test screens for deficiencies and inhibitors of all factors except VII and XIII Value : 20 to 36 seconds, depending on the type of activator used

aPTT

Nursing consideration If the client is receiving intermittent heparin therapy, draw the blood sample 1 hour before the next scheduled dose Do not draw samples from an arm into which heparin is infusing Transport specimen to the lab immediately

PROTHROMBIN TIME and INR Prothrombin is a Vitamin K dependent glycoprotein produced by the liver that is necessary for firm fibrin clot formation Each laboratory establishes a normal value or control value based on the method used to perform the PT test.

PROTHROMBIN TIME and INR

The Pt measures the amount of time it takes for clot formation and is used to monitor response to warfarin sodium (Coumadin) therapy or to screen for dysfunction of the extrinsic system resulting from liver disease, vitamin K deficiency, or DIC Value: 2 seconds (plus or minus) of the control is considered normal

PT and INR contn

The INR standardized the PT ratio and is calculated in the lab setting by raising the observed PT ratio to the power of The International Sensitivity Index specific to the thromboplastin reagent used The INR measures the effects of oral anticoagulants

PT and INR

Values: PT : 9.6 to 11.8 seconds (male adult ) and 9.5 to 11.3 seconds ( female adult) INR: 2.0 to 3.0 for standard warfarin therapy INR: 3.0 to 4.5 for high dose warfarin therapy

PT and INR

Nursing consideration: A baseline PT should be drawn before anticouagulation therapy is started; note the time of collection on lab form Provide direct pressure to the venipuncture site for 3 to 5 minutes if a coagulation defect is present Concurrent warfarin therapy with heparin therapy can lengthen the PT for up to 5 hours after dosing

PT and INR
Nursing consideration: Orally administered anticoagulation therapy usually maintains the PT at 1.5 to 2 times the lab control value Diets high in green leafy vegetables can increase the absorption of Vitamin K which shortens the PT A Pt that is greater than 30 sec places the client at risk for hemorrhage

CLOTTING TIME

The time required for the interaction of all factors involved in the clotting process Value: 8 to 15 min Nursing considerations: The client should not receive heparin therapy for 3 hours before specimen collection because the heparin therapy will affect the results The test results is prolonged by any anticoagulant therapy, test tube agitation, high temperature changes that may affect the specimen

SPECIAL HAT (mexican style)

Religious
Daddy: Anak, mabait ba ang boyfriend mo? Anak: Opo, Tatay. Daddy: Religious ba siya? Anak: Naku, Sobra talagang religious! Daddy: Saan ba siya nakatira? Anak: Nandoon po sa simbahan, nagmimisa ngayon!!

PLATELET COUNT

Platelet function in hemostatic plug formation, clot retraction, and coagulation factor activation Platelets are produced by the bone marrow to function in hemostasis Value: 150,000 to 400, 000 cells/ml Nursing considerations:

Monitor venipuncture site for bleeding in clients with known thrombocytopenia High altitudes, chronic cold weather and exercise increase platelet counts Bleeding precautions should be instituted in clients with a low platelet count

ERYTHROCYTE STUDIES
1.

ERYTHROCYTE SEDIMENTATION RATE

A.

B.

C.

D.

The rate at which erythrocytes settle out of anti-coagulated blood in 1 hour Not diagnostic of any particular disease but indicative that a disease process is ongoing Normal Value: 0 to 30 mm/hr, depending on the age of patient Nursing consideration: -Fasting is not necessary, but a fatty meal may cause plasma alterations

ERYTHROCYTE STUDIES
2. HEMOGLOBIN AND HEMATOCRIT

Hemoglobin is the main component of erythrocytes and serves as the vehicle for the transportation of oxygen and CO2 Hemoglobin determinations are important in identifying anemia Hematocrit represents red blood cell mass and is an important measurement in the identification of anemia and polycythemia

Hemoglobin and Hematocrit

Hemoglobin
Normal

value: 14 16.5 g/dl (male) : 12 - 15 g/dl (female)

Hematocrit
Normal

value: 42% - 52% (male) : 35% - 47 % (female)

ERYTHROCYTE STUDIES
3. Serum Iron

Iron is found mostly in hemoglobin Acts as a carrier of oxygen from the lungs to the tissues and indirectly aids in the return of carbon dioxide to the lungs Aids in diagnosing anemias and hemolytic disorders Values: male adult : 65 to 175 mcg/dl Female adult : 50 to 170 mcg/dl Nursing consideration: Level of iron will be increased if the client has ingested iron before the test

ERYHROCYTE STUDIES
RBC

COUNT

RBC

functions in hemoglobin transport which results in delivery of oxygen to the body tissues RBCs are formed by red bone marrow, have a life span of 120 days and are removed from the blood by the liver, spleen, and bone marrow

RBC COUNT
Aids

in diagnosing anemia and blood dyscrasias Evaluates the ability of the body to produce rbc in sufficient number Value: female adult : 4 million to 5.5 million cells/ul male adult : 4.5 million to 6.2 million cells/ul Nursing consideration: Fasting not required

LAUGH BREAK
ANAK: INAY, TINGIN KO PO HINDI NA NINYO AKO MAHAL. LAHAT NA LANG NG SABIHIN KO AY MALI! INAY: NAGKAKAMALI KA ANAK! MAHAL NA MAHAL KA NAMIN NI TATAY MO! ANAK: KITA NA NINYO! MALI NA NAMAN AKO! HMP!

WHITE BLOOD CELL COUNT

Function in the immune defense system of the body Assesses each leukocyte distribution Value : 4500 to 11000 cells/ul

White blood cell count

Nursing consideration: A shift to the left means that an increased number of immature neutrophils are in the peripheral blood A low wbc count with a left shift indicates a recovery from the bone marrow depression or an infection of such intensity that the demand for neutrophils in the tissue is greater than the capacity of the bone marrow to release them into the circulation

White blood cell count

Nursing consideration: A high wbc count with a left shift indicates an increased release of neutrophils by the bone marrow in response to an overwhelming infection or inflammation A shift to the right means that mature cells have more than the usual number of nuclear segments; found in liver disease, Down syndrome; or megaloblastic and pernicious anemia

BONE MARROW ASPIRATION/BIOPSY

All formed cell elements within normal range (erythrocytes, leukocytes, and platelets) Evaluates presence, absence or ratio of cells characteristic of a suspected disease Preferable site: Posterior iliac crest

BONE MARROW ASPIRATION/BIOPSY

Client preparation: Local anesthetic is used, as well as analgesics Feeling of pressure when bone marrow is entered; pain occurs as marrow is being withdrawn After test: Observe for bleeding at site Apply pressure to site Bed rest for approximately 30 min afterward Analgesics indicated

SICKLE CELL TEST/DEX

Number of hemoglobin S present Routine screening test for sickle cell trait or disorder False negative result in infants < 3 months False positive result can occur for up to 4 months after a transfusion of RBCs that are positive for the trait

HEMOGLOBIN ELECTROPHORESIS

Separates various hemoglobins and allows for identification of specific problem Differentiates between trait or disorder in sickle cell anemia Diagnosis of thalassemia and hemolytic anemia

FIBRIN SPLIT PRODUCTS

Increased destruction in DIC Fibrinolysis occurs in intravascular coagulation Abnormally high levels in DIC

LAUGH END
AMO: Sagutin mo ang telepon inday! INDAY: (baligtad ang hawak ng telephone receiver) Hilo? Hilo? AMO: Baligtarin mo! INDAY: Lohi? Lohi? AMO: Tanga, baligtarin mo ang telepono!!!! INDAY: Puntili, puntili

ANAK ANO YAN?

MAMA TUTUTULOG NA PO KO...!

LAUGH END

Have you seen the sexiest star in hollywood today? A. Paris Hilton? B. J. Lopez? C. Beyonce Knowles? Naaaaahh!........... ALL WRONG PO!

MS. BEAN!

LAUGH END!
Sabi Airforce: "No Guts No Glory!" Sabi Marines: "No Retreat No Surrender!" Sabi Army: "No Pain, No Gain!" Security Guards: "No I.D.No Entry! AU Nursing Students: No Audit, no diploma!

LAW OF THE SEED

MOST SEEDS NEVER GROW. FOR 1 APPLE TREE TO BEAR 500 APPLES, YOU NEED 10 SEEDS. IN LIFE, THIS PRINCIPLE MIGHT MEAN YOULL NEED TO GET 1 JOB, TALK TO 50 PEOPLE TO SELL ONE HOUSE, MEET 1000 ACQUINTANCES TO HAVE 1 SPECIAL PERSON

LAW OF THE SEED

IF WE REALLY WANT TO MAKE THINGS HAPPEN, WE USUALLY NEED TO TRY MORE THAN ONCE.... THATS THE LAW OF NATURE, JUST UNDERSTAND AND WORK WITH IT!

LUNCHTIME!