1. Essentials of Hematology Gail L. Lupica PhD, RN, CNE Nursing 211

2. Hematology:  The study of blood and blood forming tissues (bone marrow, blood, spleen and lymph system)  Clinical Relevance … Essential blood components are necessary for clot formation (…pharm to reverse that process). Oxygenation Immune function transport

3. WHOLE BLOOD  Plasma - 55% >>>  Formed elements- 45% - proteins 6%- albumins globulins fibrinogin Water- 92% of plasma other solutes 2% PLTS LEUKOCYTES (WBCs) ERYTROCYTES

5. Three Types of Formed Elements  Three types of “blood cells”: Erythrocytes (RBCs) Leukocytes (WBCs) Thrombocytes (PLTSs)

9. LET’S TALK ABOUT ERYTHROCYTES (RBC’s)_  Disc shape  Flexible  Live 120 days  Produce Hgb  Heme component needs Fe to carry 4 O2 molecules

11. Erythrocytes:  Hemoglobin is the oxygen carrying component (protein) of the erythrocyte.  It makes up 90% of the cell’s weight.  A single erythrocyte can carry 300 hemoglobin molecules, which pick up O2 from the lungs, carry it to the tissues and exchange it for the by-product of cellular metabolism = WHAT’S THAT???  Hgb gives blood it’s red color.

12. Erythrocyte/Hgb  Clinical Relevance-  Administering packed red blood cells (PRBCs) is giving the patient only the erythrocyte portion of the blood for its O2 carrying capacity.  Each heme site, is produced and bound with Ferrous Iron. An Fe deficient diet disenables these cells to bind to Fe and the pt is ANEMIC!! WHAT KIND OF ANEMIA IS THIS?????

14. Erythrocyte/Hgb  CO (carbon monoxide) competes with the O2 on the on the Heme molecule. The affinity of CO is 200x greater than O2. THIS WOULD RESULT IN…????  WHICH PATIENTS HAVE BEEN EXPOSED TO CO???

15.  The hormone, erythropoietin, prompts the bone marrow to form a Red blood cell according to demands of the body, from an immature cell.  In fact, WBCs and platelets also develop from that same immature stem cell according to demands.

16. Clinical Relevance… Erythropoietin is secreted by the kidney. Patients in end stage renal disease are terribly anemic!!

17. Let’s Talk about Leukocytes = White Blood Cells (WBCs)  They’re white.  There’s five different kinds with very variable life spans. (We’ll talk about that more in the “immune” unit.)

18. Cont’d  Five types of WBC: 1.Neutrophil: most common, accounts for 50-70% of all WBCs. They are a key player in the immune response …responsible for phagocytosis in an acute inflammatory response. EVER HEARD OF NEUTROPENIC PRECAUTIONS??? 2. Eosinophils:2-4% of WBCs with some ability for phagocytosis 3. Basophils: < 2% of WBCs

19. Types of WBCs cont’d  4. Lymphocytes : 20-40% of all WBCs, … t-lymphocytes (cell mediated) and B-lymphocytes (humoral immunity) form the basis of the immune response.  5. Monocytes: 4-8% of all WBCs. They are phagocytes.

20. Thrombocytes = Platelets  Platelets that initiate the clotting process.  Platelet “plugs” are initiated at the site of any break of capillary integrity. 1. WHAT HAPPENS IF THEY’RE TOO MANY??? 2.WHAT HAPPENS IF THEY’RE TOO FEW?? WHAT’S THE NORMAL PLT RANGE???

22.  Let’s look at some more structures and functions of the hematologic system: and Explain their importance…

23. The Spleen  Removes old RBCs from the circulation  Helps to Makes RBCs (Returns the iron component of hemoglobin to the bone marrow for reuse)  Filters circulating bacteria with its rich supply of lympocytes, monocytes and immunoglobins  Stores RBCs and PLTS -WHAT WOULD HAPPEN IF YOUR SPLEEN ENLARGED??? = SPLENOMEGALY

24. The Liver’s Role  manufactures prothrombin (and other clotting factors).  manufactures albumin  manufactures bile which is critical to the absorption of fat soluble vitamins like vitamin K (A,E,D).  Vitamin K in turn…. produces blood clotting factors Vll, lX, X)  The liver converts bilirubin to bile and stores large quantities of blood and extra iron.

25. PLT aggregation  Platelets clump and are attracted to each other when “activated”.  Platelet plugs begin the blood clotting cascade.  Substances that activate PLT activation include ADP, Ca+, thromboxane A2 (TXA2), and collagen.  These substances may come from the PLT or from the endothelial lining.

29. Anti-platelet drugs  Helps prevent thrombus formation in the arteries. What diseases do they prevent?

30. THE DRUGS YOU NEED TO KNOW!!!!!! 1.ASPIRIN - inhibits an enzyme needed by PLTS to synthesize TXA2. 1.PLAVIX - blocks binding of ADP to the PLT ADP receptor site. 2.TICLID - blocks binding of fibrinogen to the GP 11b/11a receptor on the PLT surface. (Called GP 11b/11a receptor antagonists) 3.PERSANTINE - same

31. The Blood Clotting Cascade  The blood clotting cascade is triggered by a PLT plug.  It’s result of either an intrinsic factor (from the blood itself—toxins, debris, Ag-Ab) or an extrinsic factor (from trauma to the blood vessel lining)  Different clotting factors are involved along the way and the two pathways join a common clotting pathway.

32. The Blood Clotting Cascade  No matter what started the cascade, the end result is the same, A FIBRIN CLOT. ………….IS THIS GOOD OR BAD?????????

33. Thrombus arising in valve pocket at upper end of superficial femoral vein

34. Anticoagulant Medications  Inhibit clot formation in the venous system.  They do not dissolve but inhibit new clot formation and inhibit growth of existing clots.  What would dissolve a clot???

36. THE DRUGS YOU NEED TO KNOW!!!!!!  Heparin- inhibits the conversion of fibrinogen to fibrin.  LMWH—LOVENOX Have more stable responses at recommended doses so get less risk of bleeding without needing to check PTT.  Coumadin - Prevents the hepatic synthesis of Vitamin K.

37. MEMORIZE Hgb 12-16 14-18g/dl Hct 37-47 42-52% WBC 5-10,000 /uL PLT 150-400,000

38. ANEMIA-  Anemia is the reduction in either the number of red blood cells, or the amount of Hgb, or Hct  Anemia is not a specific disease but a manifestation of one of several abnormal conditions.

39. ANEMIAS we’ll look at:  Sickle cell anemia  Iron deficiency anemia  B12 deficiency anemia  Aplastic anemia  Polycythemia vera

40. Sickle cell anemia  Genetic disorder  Abnormal Hgb chains  react to lower oxygen states,  change their shape and pile together.  block blood flow causing even more hypoxia to the tissues.

42. Sickle cell anemia  What triggers the sickling???--- dehydration, infections, strenuous exercise, stress!!  Sequelae??--… Pain, disability, organ damage, increased risk for infection, and early death ensues. Why is this pt in pain??? Why do the organs damage??? Why are they at risk for infection???

45. QUESTION A client with sickle cell disease is admitted with a diagnosis of Left arm fracture. Which nursing intervention would be the most helpful to prevent vasocclusive pain? 1. Obtaining blood pressures every 2 hours 2. Administering pain medication every 3-4 hours as ordered 3. Monitoring arterial blood gas results 4. Administering IV fluids at an ordered rate of 200 ml/hr

46. Iron Deficiency Anemia  This common type of anemia can result from blood loss, or inadequate diet. Evaluate adult clients for abnormal bleeding. Supplemental iron is the treatment.

47. QUESTION 3. The nurse caring for a client with iron deficiency has performed dietary teaching of foods high in iron. The nurse recognizes that teaching has been effective when the client selects which meal plan? 1. Hamburger, French fries, and orange juice 2. Sliced veal, spinach salad, whole-wheat roll 3. Vegetable lasagna, Caesar salad, toast 4. Bacon, lettuce, and tomato sandwich, potato chips, and tea

48. Vitamin B 12 Deficiency Anemia (pernicious anemia)  B12 is necessary to move folic acid into the cell where DNA synthesis occurs and RBC production can take place.  B12 deficiency reduces folic acid transport, inhibiting DNA synthesis.  Pernicious anemia is caused by failure to absorb vitamin B 12.  Intrinsic factor is secreted by the gastric mucosa & is needed to absorb B12.

50. B12 deficiency… Glossitis, a smooth tongue as a result of vitamin B12 deficiency anemia

51. QUESTION 5. Which clinical manifestation, noted in a client with pernicious anemia, would indicate that the client has been noncompliant with B 12 injections? 1. Hyperactivity in the evening hours 2. Weight gain of 5 pounds in one week 3. Paresthesia of hands and feet 4. Diarrhea stools several times a day

52. Aplastic Anemia  Deficiency of circulating red blood cells– Failure of Bone marrow.  Occurs because of injury to precursor cell-long term exposure to toxic agents, ionizing radiation, or infection  Usually occurs with leukopenia and thrombocytopenia  Pancytopenia common  Splenectomy may be performed NURSING DIAGNOSES…

53. Polycythemia Vera  A sustained increase > production in blood hemoglobin/RBCs Excessive leukocyte production..HTN, thrombosis, K+  Treat: Phlebotomy  Treat: Increased hydration  Treat: Anticoagulants Nursing Diagnoses…