1. Assessment of the Hematologic System
Chapter 41
Assessment of the Hematologic System

2. Anatomy and Physiology Review
Bone marrow is the source of all blood cells, including immune system cells
Red blood cells (erythrocytes)
White blood cells (leukocytes)
Platelets smallest of blood cells. They stick to injured blood vessel walls and form platelet plugs that can stop the flow of blod from the injured site. They produce substances important to coagulation (clotting) They perform most of their job by aggregation (clumping)

3. Accessory Organs of Blood Formation
They help regulate growth of blood cells & form factors that ensure proper blood clotting.
SPLEEN: under the diaphragm to the left of the stomach. It has 3 types of tissue WHITE PULP: filled with WBC and major site of antibody production. RED PULP: contains enlarged blood vessels that store RBC’s and platelets. MARGINAL PULP contains the ends of many arteries and other blood vessels. It’s main function is to destroy old & imperfect RBC’s break down the hemoglobin from bad cells , stores platelets and filters antigens. A patient can live without their spleen has a reduced immune system and prone to infection.
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4. Accessory Organs of Blood Formation
LIVER: Site for producing prothrombin and most of the blood clotting factors. Produce bile forms vitamin K in the intestinal tract which is needed to produce blood clotting factors VII, IX, X & prothrombin. Large quantities of whole blood cells and whole blood can be stored in the liver. Also stores iron and converts bilirubin to bile.
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5. Hemostasis/Blood Clotting
Platelet aggregation
Blood clotting cascade
Intrinsic factors: problems directly in the blood itself that make platlet clump and then clot.
Extrinsic factors: outside of the cell that can also induce platelet plugs to form usually due to changes in the blood vessels rather than in the blood Ex trauma
Fibrin clot formation: Last Phase of blood clotting, protein made in the liver, that helps make threadlike mesh to form a clot.

6. Platelets and Blood Clotting

7. Anticlotting Forces

8. Assessment Patient history WHAT WOULD YOU ASK?
WHAT WOULD YOU LOOK FOR?

9. Drugs
Anticoagulants—interfere with steps in blood clotting; limit or prevent extension of clots and prevent new clots CAN YOU NAME ANY?
Fibrinolytics also know as Thrombolytic drugs—selectively degrade fibrin threads in the formed blood clot. Best seen in clots for MI, or clot strokes.
Platelet Inhibitors—prevent platelets from becoming active or activated platelets from clumping together (NSAIDS)

10. Assessment Nutritional status Family history and genetic risk
Current health problems

11. Physical Assessment Skin Head and neck Respiratory Cardiovascular
Renal and urinary
Musculoskeletal
Abdominal
Central nervous system
Psychosocial

12. Diagnostic Assessment
Tests of cell number and function:
Complete blood count
Reticulocyte count
Hemoglobin electrophoresis
Leukocyte alkaline phosphatase
Coombs’ test
Serum ferritin, transferrin, and total iron-binding capacity

13. Tests Measuring Bleeding and Coagulation
Capillary fragility test
Bleeding time test
Prothrombin time
International normalized ratio
Partial thromboplastin time
Platelet agglutination/aggregation

14. Other Tests Radiographic examinations
Bone marrow aspiration and biopsy

15. Bone Marrow Aspiration and Biopsy
Patient preparation
Procedure
Follow-up care

16. NCLEX TIME

17. Question 1
A nurse interviews an older female patient who is complaining of progressive fatigue, shortness of breath, and headaches. What question should the nurse ask
first to collect more data surrounding the possible cause of the patient’s symptoms?
“Do you have a history of cardiovascular disease?”
“Can you tell me about your diet?”
“Have you been feeling depressed lately?”
“What medications do you routinely take?”
Answer: B
Rationale: All are possible questions to ask a patient surrounding symptoms of fatigue, shortness of breath, and headaches. However, older patients are more likely to experience signs and symptoms of anemia (fatigue, shortness of breath, headaches) related to diet and chronically bleeding GI lesions (peptic ulcer disease).

18. Question 2 The patient’s hematologic assessment results are:
Red blood cell count: 3.8 million/mm3
Total iron binding capacity: 225 mcg/dL
Iron: 50 mcg/dL
Hemoglobin: 10 g/dL
Hematocrit: 35%
These results suggest that the patient may be experiencing:
Chronic hypoxia
A malignancy
A liver disorder
Hemorrhage
Answer: D
Rationale: The patient’s laboratory values are consistent with the presence of hemorrhage. Chronic hypoxia is unlikely because her red blood cell count is not elevated. Liver disorder is unlikely because her iron level is actually slightly low. The patient’s laboratory values are not consistent with the presence of a malignancy.

19. Question 3
The patient is complaining of increased fatigue, bleeding gums, and frequent “chills.” What is the most appropriate initial nursing intervention?
Notify the physician of the patient’s complaints.
Review the laboratory analysis for signs and symptoms of bone marrow suppression.
Review the laboratory analysis for signs and symptoms of infection.
Administer the prescribed antibiotics to manage the patient’s current infection.
Answer: B
The nurse should initially review the patient’s laboratory analysis for collective signs of pancytopenia related to the patient’s complaints of fatigue (anemia), bleeding gums (thrombocytopenia), and chills (neutropenia). Laboratory data are needed before informing the physician and making the decision to administer or not administer an antibiotic.

20. Question 4
The patient was transitioning from IV heparin therapy to oral warfarin. Therapeutic anticoagulation of the patient is best assessed by:
Partial thromboplastin time of 24.3 seconds
Prothrombin time of 18 seconds
International normalized ratio of 2.5
Bleeding time of 5 minutes
Answer: C
Rationale: International normalized ratio (INR) is a more accurate measure of anticoagulation therapy because of variations in prothrombin time (PT) values across different laboratories. The goal on warfarin therapy is usually to maintain the patient’s INR between 2.0 and 3.0 regardless of the actual PT in seconds.

21. Question 5
After obtaining a patient’s blood pressure, you notice petechiae upon removal of the blood pressure cuff. What should be the nurse’s priority intervention?
Obtain a blood sample to assess the patient’s coagulation status.
Ask the patient about a history of bleeding disorders.
Ask the patient about medications he is currently taking.
Ask the patient if he is experiencing bone, sternum, or rib pain.
Answer: B
Rationale: The priority question would be to see if the patient has a past medical history or family history of bleeding disorders, difficulty with bleeding, etc. A second priority question would be to assess what medications he is currently taking that may increase bleeding time as a cause of the petechiae. Bone pain is a sign of hematologic disease and baseline coagulation studies are needed in treatment of the patient, but these data points can occur safely after obtaining a more detailed patient history.