1. Disorders of the Hematological System

2. Blood and Lymph Two of the body’s most important functions are:
Transportation
Protection-from foreign invaders
Achieved through the circulatory and lymph systems
Blood is the primary transportation fluid

3. Blood Cells RBC’s, WBC’s, and Platelets
Blood cells are made in bone marrow
Other structures involved in the blood cell production are:
Kidneys (Erythropoietin)
Liver (stores iron)
Lymph system (breaks down blood cells, produces WBC)

4. Red Blood Cell Production (RBC)
Erythropoiesis is the process of making red blood cells
Stimulated by decreased PO2
The kidneys releases Erythropoietin
Reticulocytes are immature RBC’s
Iron, folic acid, and Vitamin B12 are needed for RBC production
Iron is needed for Hemoglobin production

5. Red Blood Cells (RBC) Normal Values
Males
Females
Increased: Dehydration, Polycythemia
Decreased: Anemia, Leukemia, Post-hemorrhage

6. Hemoglobin (Hgb) Contained within RBC’s – red pigment
Oxygen carrying compound of the RBC
Normal Values
Males g/dL
Females g/dL
Increased: Dehydration, COPD, Polycythemia
Decreased: Anemia, leukemia, Post-hemorrhage

7. Hemoglobin Erythrocytes are classified according to:
To measure Hgb, RBC’s are broken and Hgb is released and counted
Hemoglobin content is expressed as normochromic or hypochromic anemia
Erythrocytes are classified according to:
Size, shape and color
RBCs size is usually expressed as: macrocytic, microcytic, or normocytic
Average life span of an RBC = 120 days

9. Hematocrit A measure of the packed cell volume of RBCs
Expressed as a % of the total blood volume
Normal Values
Males 42-52%
Females 37-47%

10. Hematocrit Increased: Polycythemia, dehydration
Decreased: Anemia, leukemia, hemorrhage, fluid overload

11. White Blood Cells
Have nuclei, are colorless, live from a few days  several years
Primarily involved in body defenses such as destruction of bacteria and viruses
“Differential” – blood count in which the different kinds of WBCs are counted and reported  can discriminate between virus and backteria

12. Platelets Also called “thrombocytes
Normal Values 150, ,000 cells/microliter – involved with clotting
5-9 day life span
Increased- Polycythemia, granulocytic leukemia
Decreased- Bleeding, thrombocytopenia, Chemotherapy

13. Erythrocyte Indices MCV, MCH, MCHC Will help determine type of anemia
Iron Deficiency
Folic Acid Deficiency
B12 Deficiency
Definition of Corpuscular: A living cell

14. Mean Corpuscular Volume (MCV)
Volume (size) of the RBC
Hematocrit divided by RBC Count
Low
RBC = Microcytic (small)
Iron Deficiency Anemia
High
RBC = Macrocytic (large)
B12
Folic Acid Deficiency Anemia

15. Mean Corpuscular Hemoglobin (MCH)
Weight of hemoglobin in a RBC
Hemoglobin divided by the total RBC count
Low
Hypochromic (Deficient of hemoglobin)
Iron Deficient Anemia
High
Hyperchromic- Lab error

16. Mean Corpuscular Hemoglobin Concentration (MCHC)
Concentration of hemoglobin in the RBC
The hemoglobin is divided by the RBC
Low
Hypochromic (deficient of hemoglobin)
Iron Deficiency Anemia
High
Hyperchromic
Lab Error

17. Blood Types Genetically determined
Determined by the presence or absence of specific antigens on the outer surface of the RBC
In certain blood types, the antigens on the RBC are accompanied by antibodies in the plasma.

18. Blood Types O – Good Donor, Bad Receiver
Contains A and B antibodies at birth
A- Very selective- receives A only
Contains B antibodies at birth
B- Very selective- receives B only
Contains A antibodies at birth
AB – Good Receiver, Bad Donor
Does not contain A or B antibodies

19. Rh Factor Located on the surface of RBCs “positive” = have the factor
“negative” = do not have the factor
When an Rh- person has been exposed to
Rh+ blood, antibodies develop within 2 weeks
No reaction with this first exposure.

20. Rh Factor
On any exposure thereafter, the Antibodies will attack Rh positive blood.
“Rh incompatibility” = mother’s antibodies hemolyze the fetal RBCs  rupture and loss of contents of cells

21. Rh Factor RhoGAM – intramuscular (or IV) injection
Action: desensitization antibodies
Next baby’s intrautero development without the potential complications associated with Rh incompatibility
Who (include blood type and Rh factor) will need to receive Rhogam?
A women who is Rh Negative and is pregnant (prophylaxis) or has just given birth (baby is Rh positive)

22. Rh Factor When is RhoGAM given? 2 injections
1. between 20-28wks pregnancy
2. within 72 hrs. post partum

23. Who’s the Best?
Which blood type (including Rh factor) is the universal donor?
O negative
Which blood type is the universal recipient?
AB positive

24. Lymphatic System

25. LYMPHATIC SYSTEM A subdivision of the cardiovascular system
Consists of:
Lymph vessels
Lymph fluid
Lymph tissue
Basic Functions:
Maintenance of fluid balance
Production of lymphocytes
Absorption and transportation of lipids from intestine to bloodstream

26. LYMPHATIC SYSTEM
Lymph is a specialized fluid formed in the tissue spaces and transported by way of lymphatic vessels to eventually  reenter the circulatory system.
Lymphatic Tissue
Lymph nodes
Tonsils
Spleen
Thymus

27. DISORDERS OF THE HEMATOLOGIC AND LYMPHATIC SYSTEMS

28. Anemia Characterized by low RBC count, ↓ hematocrit and hemoglobin
Look at CBC indices to determine RBC health
Anemia causes delivery of an insufficient supply of oxygen AND nutrients to the cells
Loss of the O2-carrying element in the blood results in a supply/demand imbalance in vital organs.

29. Anemia Causes Hemorrhage Impaired production of RBC’s
Increased destruction of RBC’s (hemolysis)
Nutritional deficiencies

30. Diagnostic Tests: Coombs’ Test Hemoglobin Electrophoresis Schilling
Sickledex
TIBC
Gastric Analysis

31. Coombs Test
Direct Antiglobulin test – identifies autoantibodies against RBCs
Coombs + = autoimmune hemolytic anemia, hemolytic disease of the newborn, lymphomas, LE, mycoplasma infection, and infectious mononucleosis

32. General Signs and Symptoms of Anemia
Big five
DOE
Chest pain
Palpitations(Tachycardia)
Dizziness (Vertigo)
Pallor
Anorexia
Disorientation
Dyspepsia
Fatigue
Headache
Insominia

33. Hypovolemic Shock
May be caused by severe dehydration or extreme blood loss
May require 1000 mL loss before severe s/s
Initial s/s:
Thirst
Weakness
Restlessness
Later s/s
Hypotension
Tachycardia and weak, thready pulse
Pallor and cold, clammy skin
Oliguria
Disorientation
Prostration

34. Hypovolemic Shock H&H will not decrease until ~6-8 hours Treatment
If bleeding source obvious: direct pressure
If not, intervention ASAP
IV fluids (Isotonic/Volume expanders: NS) O2
O negative blood transfusion
Platelets
Plasma
Factor 7

35. Nursing Interventions
Monitor blood and fluid restoration
Identify blood loss sites to control bleeding
VS frequently
I/O – particularly careful monitoring of urine output
Patient teaching

36. Pernicious Anemia
Caused by autoimmune disease: There is an absence of glycoprotein intrinsic factor that is usually secreted by the stomach and assists with the absorption of Vitamin B12.
Without this factor, Vitamin B12 is unavailable for the maturation of the Red Blood Cell Production.

37. Signs and Symptoms Subjective Objective Palpitations Nausea Flatulence
Indigestion
Soreness and burning of the tongue
Tingling of the hands and feet
Impaired proprioception
Objective
Smooth and erythematous tongue
Gum infection
Mental disorientation
Personality changes
Behavior problems
Severe neurological impair from destroyed Spinal Cord Tracts

38. Diagnostic Tests Gastric Analysis – determine pH Schilling test
Subject will get two doses of vitamin B-12 (cobalamin). The first dose is taken by mouth. The second dose is radioactive and is given as a shot 2-6 hours later. Urine is tested for radioactive B12
Reveals malabsorption of Vit B12
Serum Megaloblastic Anemia Profile (serum level of B12) soon to replace Schilling test
Will reveal serum levels of Vit B12 + more
Gastric Analysis – determine pH

39. Medical Management Medication
B 12 injections
Folic acid supplement
Iron replacement
Transfused with Packed RBC if severe anemia
CBC every 3-6 months

40. Iron-deficiency Anemia
Plenty of RBC, normal H &H sometimes, but hypochromic
Causes
Diet
Usually chronic bleeding
Body’s demand exceeds its absorption
Pregnancy
Infants
Young adolescents
Malabsorption of iron as in celiac disease or sprue
Subtotal gastrectomy because iron needs an acid environment to be absorbed.

41. Iron Deficiency Anemia
Signs and Symptoms
Sore, Swollen Tongue
Cracks in the side of the mouth
Brittle nails
Increased frequency of infections
PICA- Ice, dirt, paint etc.
Restless Leg Syndrome

42. Iron Deficiency Anemia
Medical Management
Because less than 10% of iron is absorbed in the duodenum, high doses of Iron supplement are needed
Additional Vitamin C has shown to enhance iron absorption
See p. 277 Box 7-2 for food sources of nutrients needed for Erythropoiesis

43. Z-track
Because some patients cannot tolerate oral preparations of iron, Iron can be given IV or IM. The z-track method of giving iron dextran is preferred to prevent staining

44. Sickle Cell Anemia EMcrit.org
Genetic --Recessive homozygous
Predominately found in the African and African-American Population
First crisis usually occurs at weeks of age
Pathophysiology: After the hemoglobin molecules give up their oxygen, some of them may cluster together and form long, rod-like structures.

45. Sickle Cell Anemia
A sickle cell is an abnormal, crescent-shaped RBC containing hemoglobin S (a defective hemoglobin molecule)
Sickle Cell crisis – an episode of acute “sickling” of RBCs which causes occlusion and ischemia in distal blood vessels
Sickling  clumping or aggregation of these misshapen RBCs which lodge in small vessels

46. Health maintenance for patients with sickle cell disease starts with early diagnosis, preferably in the newborn period and includes penicillin prophylaxis, vaccination against pneumococcus bacteria and folic acid supplementation.
Pulmonary Hypertension

47. Sickle Cell Maintenance
Health maintenance for patients with sickle cell disease
Starts with early diagnosis, preferably in the newborn period
Vaccination against pneumococcus bacteria (infections are a major complication of Sickle-Cell anemia)
Folic acid supplementation
Prevention of infection and dehydration

48. Medical Management Supportive Pain is biggest problem Rehydration
PCA pump is indicated
Long-term MS therapy with breakthrough pain meds
Rehydration
Packed cells for anemia but clients have problems with iron overload
Probable treatment/cure is stem cell transplant

49. Aplastic Anemia aka Hypoplastic Anemia
Congenital Aplastic Anemia is caused by a chromosomal alteration
Acquired Aplastic Anemia related to chemical exposures.
Cause of 70% of acquired aplastic anemias remains unknown (idiopathic)

50. Aplastic Anemia People are pancytopenic when:
Reduced or absent red blood cells
Reduced or absent white blood cells
Reduced or absent platelets

51. Aplastic Anemia Signs/Symptoms: Pallor Bleeding tendencies Dyspnea
Palpitations
Repeated infection with high fevers
Fatigue, weakness
General malaise

52. Diagnostic Tests Diagnostic tests Bone Marrow Aspiration
Hypoplastic or aplastic fatty deposits
CBC may show normocytic and normochromic blood cells

53. Medical Management Need to know cause!
Blood transfusion with caution (need to preserve immune system for bone marrow transplant)
Spleenectomy if spleen is enlarged
Steroids and/or androgens used to stimulate bone marrow
Immunosuppressive therapy or cyclosporine

54. Bone Marrow Transplant
Involves taking cells that are normally found in the bone marrow (stem cells), filtering those cells, and giving them back either to the patient or to another person.
The goal of BMT is to transfuse healthy bone marrow cells into a person after their own unhealthy bone marrow has been eliminated.
Stem cells, when transplanted, find their way to the recipient's marrow and begin to differentiate and produce all types of blood cells that are needed by the body.

55. Polycythemia Abnormal ↑ in RBC’s Two types Primary Secondary
Myeloproliferative disease: overproduction by the bone marrow
Related to a Stem Cell abnormalityIncreased WBC, RBC and platelets
Secondary
Usually related to chronic hypoxia – a physiologic response to compensate for hypoxia Increased RBC
Chronic hypoxia maybe d/t: pulmonary disease, CV disease, high altitude, tissue hypoxia

56. Polycythemia Vera Signs and Symptoms:
↑ blood volume and viscosity  HTN, angina, HF, thrombophlebitis
Venous distention
GI bleeding
Hepatomegaly and splenomegaly from organ engorgement

57. Polycythemia Vera Diagnostic Tests: H and H (Plasma and RBC volume ↑)
Reticulocyte and Erythrocyte counts
Platelets and RBC’s
Bone Marrow exam

58. Polycythemia Vera

59. Polycythemia Vera Medical Management Repeated plebotomy
Myelosuppressive agents
Allopurinol for gout
True Chronic Disease requires lifetime treatment
Population can be non-compliant until very ill
Death by thrombosis

60. Disorders of Leukocytes

61. Agranulocytosis Severe reduction of Granulocytes Basophils Eosinophils
Neutrophils
Low WBC count (leukopenia)
Usually caused by medication and/or toxic substances(includes herbal substances!)

62. Agranulocytosis Signs and Symptoms: Fever and chills
Headache and fatigue
Infections
Ulceration of the mucous membranes
Pneumonia and UTIs

63. Medical Management Need to know the cause Transfusion of Packed RBC
G-CSF (filgrastim or Neupogen)
Neutropenic precautions (Reverse Isolation)
Death by Infection

64. Nursing Interventions
A patient with a compromised WBC system is highly susceptible to life-threatening infections.
List nursing interventions directed toward protecting the patient from potential sources of infection.

65. Leukemia Malignancy involving the hematopoetic system.
Characterized by rapidly developing white cells that overwhelm the bone marrow, lymph system, spleen and liver
Complications include infiltration and damage to organs as well as the central nervous system
Increased susceptibility to infections

66. Leukemia Four Major Types: Acute lymphocytic leukemia (ALL)
Acute Myelogenous leukemia (AML)
Chronic Myelogenous leukemia (CML)
Chronic Lymphocytic leukemia (CLL)

67. Leukemia S/SX Irrelevant complaints at first Petechiae/Ecchymosis
Malaise
Fatigue
Irritability
Petechiae/Ecchymosis
Mucous membrane bleeding
Bone pain
Meningial irritation
Enlarged lymph nodes

68. Leukemia Diagnostic Tests WBC ↓, ↑, or excessively ↑ Bone Marrow Bx.
CXR
Lymph Node Bx.
LP, CT scan

69. Medical Management
Chemotherapy – interrupt cell growth at multiple points in the cell cycle
Bone marrow transplant and stem cell therapy
Death by infection, hemorrhage and/or Graft-Verses-Host Disease if BMT treated
More to follow in Oncolgy Nursing

70. Nursing Interventions
Prevention of Infection
Patient education
Pain Control
Psycho-social support for coping

71. Coagulation Disorders

72. Disorders of Coagulation
Release of blood from the vascular sys. results from:
trauma or vessel damage
vessel inadequacy
disturbance of the function of platelets or clotting factors, or liver disease ( impairment of clotting mechanism)
Disorders can be congenital, acquired, or 2nd to disease or medication toxicity

73. Thrombocytopenia “Who Ate my Platelets?”
Idiopathic Thrombocytopenia (auto-immune disease)
Aplastic anemia
Leukemia
Tumors
Chemotherapy
Drugs
Alcohol
Infections/Sepsis

74. Thrombocytopenia Platelets < 150,000 (nml = 150,000-400,000/mmᶟ)
S/SX
Petechiae and eccymosis on the skin
Frank Bleeding
Low Platelet count on CBC
With extremely low platelet counts, fatal central nervous system or gastrointestinal hemorrhage can occur

75. Thrombocytopenia Management Corticosteroid therapy
Splenectomy if needed
IVIG
Immunosuppresive drug therapy
Platelets to increase count to 20,000
Plasmapheresis
Plasmapheresis involves selective removal of the patient's plasma, which is then replaced by albumin solution.
Time time needed to complete a treatment usually ranges from 1 1/2 - 3 hours. 

76. Hemophilia Disease of the royal family (don’t marry your cousin!)
X-linked hereditary trait
Hemophilia

77. Hemophilia Clinical Manifestations: Diagnostic Tests
Internal or external hemorrhage with large ecchymoses into tissue
Hemarthrosis = bleeding into a joint
Swelling, fever, pain
Diagnostic Tests
Blood work for Factors VIII or IX
absent or deficient

78. Medical Management
Replacement therapy—giving or replacing the clotting factor that’s too low or missing.
Most common: antihemophilic factor VIII is missing
Hemophilia B is missing factor IX
Check out the National Hemophilia Society website-

79. Hemophilia Crisis Usually involves trauma
After an IM injection
Usually involves trauma
Ice and elevate above heart
Apply pressure to bleeding
Immobilization of limb
Pain Management
Can be treated with cryoprecipitate (FFP)
Medic alert bracelet should be worn at all times

80. HIV and Hemophilia Usually associated with infusions prior to 1984
Heat inactivation of the virus has significantly reduced the client’s exposure to HIV

81. vonWillebrand’s Disease
Mild form of Hemophilia
S/Sx
Slow coagulation of blood (as opposed to none)
Spontaneous GI Bleeds
Epistaxis
Gingival Bleeding
Common occurrences: post partum, menorrhagia, post op

82. vonWillebrand’s Disease
Medical Management:
Usually treated with Cyroprecipitate (containing Factor VIII)
Fibrinogen
Fresh plasma
Desmopressin (DDAVP): Synthetic ADH (vasopressin)

83. Disseminated Intravascular Coagulation
A disorder in which the proteins that control blood clotting become abnormally active 
Small blood clots form in blood vessels
Plasma clotting factors are depleted during widespread clotting within small vessels  bleeding disorder and thrombosis.
Primary disorder initiates a generalized intravascular clotting

84. High Risk Diagnosis pg. 290, AHN

85. Medical Management Supportive in nature
Heparin therapy to calm the hypercoagulopathy
Lab tests confirm dx
Serum fibrinogen - low
(PT) - high
(PTT) - high
Platelets: depressed
D-Dimer(fibrin breakdown): elevated

86. Multiple Myeloma
A malignant neoplastic immunodeficiency disease of the bone marrow
Neoplastic plasma cells infiltrate the bone marrow  destruction of osseous tissue, esp. flat bones  pain, fractures, and skeletal deformities
“Monoclonal Protein” – the specific immunoglobulin produced by the myeloma cells

87. Disrupts erythrocyte, platelet and leukocyte production
Electrolyte disturbance from release of Calcium and Phosphorus from deteriorating bone cells
Gradual onset so it slips right by practitioners
Could present itself as a spinal fracture with cord compression

88. Signs and Symptoms Bone pain Fatigue Feeling ill Fever Night sweats
Weight loss is not common in the early stages.

89. Multiple Myeloma
Physically, patients are pale with diffuse bone tenderness, especially around the sternum (breastbone) and pelvis (hips).
Pathologic fractures (fractures caused by tumors) occur frequently.
The spine is the most common location for a pathological fracture. It can also happen in the ribs and pelvis.

90. Diagnostics Radiographic skeletal studies Bone marrow aspiration Labs
Pancytopenia (low cells)
Hypercalcemia
Hyperuricemia
Elevated creatinine
Urinalysis
High protein

91. Multiple Myeloma Medical Management Supportive
Radiation and chemotherapy to reduce or impede tumor growth
Hypercalcemia tx.
Pain management

92. Multiple Myeloma Nursing Interventions: Pain management
Prevention infection
Prevention bone injury
Administration Chemo
Maintain hydration
I/O
Weight-bearing
Patient Education

93. Hodgkin’s Disease Enlargement of lymphoid tissue Affects men 2:1
Look! It’s Math!
’m so happy!
Enlargement of lymphoid tissue
Affects men 2:1
Bimodal peak (2 separate populations)
Early 20-30
Late 60-70
Accounts for <1% of all cancer cases
Differentiated by Lymphocyte cytology, Reed-Sternberg cell

94. Hodgkin’s Lymphoma
Hodgkin's disease may occur in a single lymph node, a group of lymph nodes, or, sometimes, in other parts of the lymphatic system such as the bone marrow and spleen.
This type of cancer tends to spread in a fairly orderly way from one group of lymph nodes to the next group.

95. Hodgkin’s Lymphoma Risk factors associated with this disease:
Age/Sex -- Hodgkin's disease occurs most often in people between 15 and 34 and in people over the age of 55. It is more common in men than in women.
Family History -- Brothers and sisters of those with Hodgkin's disease have a higher-than-average chance of developing this disease.
Viruses – Epstein-Barr virus is an infectious agent that may be associated with an increased chance of getting Hodgkin's disease.

96. Hodgkin’s Lymphoma Signs/Symptoms
A painless swelling in the lymph nodes in the neck, underarm, or groin
Unexplained recurrent fevers
Night sweats
Unexplained weight loss
Itchy skin

97. Hodgkin’s Lymphoma Diagnostic studies
CBC: elevated WBC
ESR
X-rays CT
MRI
Presence of Reed-Sternberg
cell
Reed-Sternberg cell: characterized by mirror image nuclei

98. Medical Management Radiation against localized tumors
Chemotherapy for early and late stages
Candidates for Neupogen because of suppressed neutrophil production
High risk for secondary malignancies especially leukemia

99. Non-Hodgkins Lymphoma
Absence of the Reed-Sternberg Cell
Usually described as “all other lymphomas”
More likely to spread beyond the lymph nodes
Comprised of approximately 10 different subtypes and 20 different disease entities
These subtypes are grouped into 3 biologic states- low grade, intermediate grade, and high grade lymphomas

100. Non-Hodgkins Lymphoma
S/Sx
Fatigue
Malaise
Anorexia

101. Non-Hodgkins Lymphoma
Diagnostic Tests:
Anemia
Increased platelets
Leukocytosis(increased and abnormal WBCs)
ESR-elevated
Hypercalcemia and elevated Alkaline Phosphatase
Positive Coombs test
Chest Xray
CT scan

102. Non-Hodgkins Lymphoma
Medical Management
Therapy is determined by several factors:
biologic state of the lymphoma
stage of lymphoma
presence or absence of symptoms (e.g., weight loss, night sweats, organ dysfunction)
overall general health of the patient
Chemo and radiation

103. Non-Hodgkin’s Lymphoma
Nursing Interventions
Supportive care during radiation and chemo
Observation for complications
Patient education
Participate in care planning