HEMATOLOGICAL SYSTEMS

I Blood forming organs 1. Thymus removed myasthenia gravis 2. Liver largest gland 3. Lymph nodes 4. Lymphoid organs payers patch 5. Bone marrow 6. Spleen destroys RBC II Blood vessels 1. Veins SVC, IVC, Jugular vein blood towards the heart 2. Artery carries blood away from the 1. Aorta, carotid 3. Capillaries III Blood - 45% formed elements 55% plasma fluid portion of vlood. Yellow color. Serum Plasma CHONs (Produced in Liver) 1. Albumin- largest, most abundant plasma Maintains osmotic pressure preventing edema FXN: promotes skin integrity 2. Globulins alpha transports steroids Hormones & bilirubin - Transports iron & copper Gamma transport immunoglobulins or antibodies 3. Prothrombin fibrinogen clotting factor to prevent bleeding

Formed Elements: 1. RBC (erythrocytes) Spleen life span = 120 days (N) 3 6 M/mm3 - Anucleated - Biconcave discs - Has molecules of Hgb (red cell pigment) Transports & carries O2

SICKLE CELL ANEMIA

sickle shaped RBC. Should be round. Impaired circulation of RBC. -immature cells hemolysis of RBC decreased hgb 3 NURSING PRIORITY: 1. a/w avoid deoxygenating activities - High altitude is bad 2. Fluid deficit promote hydration 3. Pain & comfort HGB ( HEMOGLOBIN) F= 12 14 gms % M = 14-16 gms %

Hct 3x hgb 12 x 3 = 36 (HAMATOCRIT) F 36 42% 14 x 3 = 42 M 42 48%

Average 42% - Red cell percentage in whole red Substances needed for maturation of RBC a.) Folic acid b.) Iron c.) Vit C d.) Vit B12 (cyanocobalamin) e.) Vit B6 (Pyridoxine) f.) Intrinsic factor Pregnant: 1st trimester- Folic acid prevent neural tube deficit 3rd tri iron Life span of rbc 80 120 days. Destroyed at spleen. NON-GRANULOCYTES 1. Monocytes (macrophage) - largest WBC - involved in long term phagocytes - For chronic inflammation - Other name macrophage Macrophage Macrophage Macrophage Macrophage in CNS- microglia in skin Histiocytes in lungs alveolar macrophage in Kidneys Kupffer cells

WBC leucocytes 5,000 10,000/mm3 GRANULOCYTES 1. Polymorphonuclearneutrophils Most abundant 60-70% WBC - fx short term phagocytosis For acute inflammation 2. PM Basophils -Involved in Parasitic infection - Release of chem. Mediator for inflammation Serotonin, histamine, prostaglandin, bradykinins 3. PM eosinophils - Allergic reactions

2. Lymphocytes B Cell L bone marrow or bursa dependent T cell devt of immunity- target site for HIV NK cell natural killer cell Have both antiviral & anti-tumor properties 3.Platelets (thrombocytes) N- 150,000 450, 000/ mm3 it promotes hemostasis prevention of blood loss by activating clotting - Consists of immature or baby platelets known as megakaryocytes target of virus dengue - Normal lifespan 9 12 days

Drug of choice for HIV Zidovudine (AZT or Retrovir) Standard precaution for HIV gloves, gown, goggles & mask Malaria night biting mosquito Dengue day biting mosquito Signs of platelet dysfunction: a.) Petecchiae b.) Ecchemosis/ bruises c.) Oozing or blood from venipuncture site

ANEMIA
1.) IRON DEFICIENCY ANEMIA
chronic normocytic, hypocromic (pale), microcytic anemia due to inadequate absorption of iron leading to hypoxemic injury. INCIDENCE RATE: 1. Common developed country due to high cereal intake Due to accidents common on adults 2. Common tropical countries blood sucking parasites 3. Women 15 35yo reproductive yrs 4. Common among the poor poor nutritional intake

Predisposing factor: 1. Chronic blood loss a.Trauma b. Mens c.GIT bleeding: i. Hematemesisii. Melena upper GIT duodenal cancer iii. Hematochezia lower GIT large intestine fresh blood from rectum 2. Inadequate intake of food rich in iron 3. Inadequate absorption of iron due to : a. Chronic diarrhea b. Malabsorption syndrome celiac disease-gluten free diet. Food for celiac pts- sardines c. High cereal intake with low animal CHON ingestion d. Subtotal gastrectomy 4. Improper cooking of food Signs & Symptoms: 1. Asymptomatic 2. Headache, dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor 3. Brittle hair, spoon shaped nails (KOILONYCHIA)=Dec O2=hypoxia=atrophy of epidermal cells 4. Atropic glossitis, dysphagia, stomatitis 5. Pica abnormal craving for non edible food (caused by hypoxia=dec tissue perfusion=psychotic behavior) Brittle hair, spoon shaped nail atrophy of epidermal cells N = capillary refill time < 2 secs N = shape nails biconcave shape, 180 Atrophy of cells Plummer Vinsons Syndrome due to cerebral hypoxia 1. Atropic glossiti inflammation of tongue due to atrophy of pharyngeal and tongue cells 2. Stomatitis mouth sores 3. Dysphagia Diagnostic Exam: 1. RBC 2. Hgb 3. Reticulocyte 4. Hct 5. Iron 6. Ferritin Nursing Management: 1. Monitor signs of bleeding of all hema test including urine & stool 2. Complete bed rest dont overtire pt =weakness and fatigue=activity intolerance 3. Encourage iron rich food 2. Raisins, legumes, egg yolk 4. Instruct the pt to avoid taking tea - impairs iron absorption 5. Administer meds a.) Oral iron preparation Ferrous SO4 Fe gluconate Fe Fumarate Nursing Management: oral iron meds: 1. Administer with meals to lessen GIT irritation 2. If diluting in iron liquid prep adm with straw Straw 1. Lugols 2. Tetracycline 3. Oral iron 4. Macrodantine 3. Give Orange juice for iron absorption 4. Monitor & inform pts S/E a. Anorexia

b. c. d. e.

n/v Abdominal pain Diarrhea or constipation Melena

If pt cant tolerate oral iron prep administer parenteral iron prep example: 1. Iron dextran (IV, IM) 2. Sorbitex (IM) Nursing Management: parenteral iron prep 1. Administer of use Z tract method to prevent discomfort, discoloration leakage to tissues. 2. Dont massage injection site. Ambulate to facilitate absorption. 3. Monitor S/E: a.) Pain at injury site b.) Localized abscess (nana) c.) Lymphadenopathy d.) Fever/ chills e.) Urticaria itchiness f.) Hypotension anaphylactic shock Anaphylactic shock give epinephrine

2. PERNICIOUS ANEMIA
- megaloblastic, chronic anemia due to deficiency of intrinsic factor leading to * Hypochlorhydria decrease Hcl acid secretion. - Lifetime B12 injections. With CNS involvement. Predisposing factor 1. Subtotal gastrectomy removal stomach 2. Hereditary 3. Infl dse of ileum 4. Autoimmune 5. Strict vegetable diet STOMACH Parietal or ergentaffen Oxyntic cells Fxn produce intrinsic factor For reabsorption of B12 For maturation of RBC Diet high caloric or CHO to correct wt loss Signs & Symptoms: 1. Headache dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor 2. GIT changes a. Red beefy tongue PATHOGNOMONIC mouth sores b. Dyspepsia indigestion c. Wt loss d. Jaundice 3. CNS Most dangerous anemia: pernicious due to neuroglogic involvement. a. Tingling sensation b. Paresthesia c. (+) Rombergs test Ataxia d. Psychosis Diagnostic Exam: Fxn secrets Hcl acid Fx aids in digestion

- Shillings test Nursing Management: 1. Enforce CBR 2. Administer B12 injections at monthly intervals for lifetime as ordered. IM- dorsogluteal or ventrogluteal. Not given oral due pt might have tolerance to drug 3. Diet high calorie or CHO. Increase CHON, iron & Vit C 4. Avoid irritating mouthwashes. Use of soft bristled toothbrush is encouraged. 5. Avoid applying electric heating pads can lead to burns

3. APLASTIC ANEMIA
stem cell disorder due to bone marrow depression leading to pancytopenia all RBC are decreased PANCYTOPENIA Decrease RBC Anemia decrease WBC leukopenia decrease platelets thrombocytopenia

Increase WBC leukocytocys Increase RBC polycythemia vera complication stroke, CVA, thrombosis Predisposing factor: 1. 2. 3. 4. Chemicals Banzene & its derivatives radiation Immunologic injury Drugs cause bone marrow depression a. Broad spectrum antibiotic - Chlorampenicol - Sulfonamides bactrim b. Chemo therapeutic agents Methotrexate alkylating agents Nitrogen mustard anti metabolic Vincristine plant alkaloid

Signs & Symptoms: 1. Anemia: a. Weakness & fatigue b. Headache, dizziness, dyspnea c. cold sensitivity, pallor d. palpitations 2. Leucopenia increase susceptibility to infection 3. Thrombocytopenia Peticchiae Oozing ofblood from venipuncture site ecchymosis Diagnostic Exam: 1. CBC pancytopenia 2. Bone marrow biopsy/ aspiration at post iliac crest reveals fatty streaks in bone marrow Nursing Management: 1. Removal of underlying cause 2. Blood transfusion as ordered 3. Complete bed rest 4. O2 inhalation 5. Reverse isolation due leukopenia 6. Monitor signs of infection 7. Avoid SQ, IM or any venipuncture site = HEPLOCK 8. Use electric razor when shaving to prevent bleeding 9. Administer meds Immunosuppresants

Anti lymphocyte globulin (Alg) given via central venous catheter, 6 days 3 weeks to achieve max therapeutic effect of drug.

DISSEMINATED INTRAVASCULAR COAGULATION (DIC)

- Acute hemorrhagic syndrome char by wide spread bleeding & thrombosis due to a def of clotting factors (Prothrombin & Fibrinogen). Predisposing factor: 1. Rapid BT 2. Massive trauma 3. Massive burns 4. Septicemia 5. Hemolytic reaction 6. Anaphylaxis 7. Neoplasia growth of new tissue 8. Pregnancy Signs & Symptoms: 1. Petechiae widespread & systemic (lungs, lower & upper trunk) 2. Ecchymosis widespread 3. Oozing of blood from venipunctured site 4. Hemoptysis cough blood 5. Hemorrhage 6. Oliguria late sx Diagnostic Exam: 1. CBC reveals decrease platelets 2. Stool for occult blood (+) Specimen stool 3. Opthalmoscopic exam sub retinal hemorrhage 4. ABG analysis metabolic acidosis pH pH ph ph ph HCO3 PCO2 PCO2 HCO3 HCO3

R O M E

respiratory alkalosis respiratory acidosis metabolic alkalosis metabolic acidosis

Diarrhea metabolic acidosis Vomitting metabolic alkalosis Pyloric stenosis metabolic alkalosis vomiting Ileostomy or intestinal tubing metabolic acidosis Cushings metabolic alkalosis DM- metabolic acid Chronic bronchitis respiratory acid with hypoxemia, cyanosis Nursing Management 1. Monitor signs of bleeding hema test + urine, stool, GIT 2. Administer isotonic fluid solution to prevent shock. 3. Administer O2 inhalation 4. Administer meds a. Vit K aquamephyton b. Pitressin or vasopressin to conserve water. 5. NGT lavage - Use iced saline lavage 6. Monitor NGT output 7. Provide heplock 8. Prevent complication: hypovolemic shock Late signs of hypovolemic shock : anuria

BLOOD TRANSFUSION

Objectives: 1. To replace circulating blood volume 2. To increase O2 carrying capacity of blood 3. To combat infection if theres decrease WBC 4. To prevent bleeding if theres platelet deficiency

Nursing Management& Principles:

1. Proper refrigeration 2. Proper typing & crossmatching Type O universal donor AB universal recipient 85% of people is RH (+) 3. Asceptically assemble all materials needed: a.) Filter set b.) Isotonic or PNSS or .9NaCl to prevent Hemolysis Hypotonic sol swell or burst Hypertonic sol will shrink or crenate c.) Needle gauge 18 - 19 or large bore needle to prevent hemolysis. d.) Instruct another RN to recheck the following . Pts name, blood typing & cross typing expiration date, serial number. e.) Check blood unit for presence of bubbles, cloudiness, dark in color & sediments indicates bacterial contamination. Dont dispose. Return to blood bank. f.) Never warm blood products may destroy vital factors in blood. - Warming is done if with warming device only in EMERGENCY! For multiple BT. - Within 30 mins room temp only! g.) Blood transfusion should be completed < 4hrs because blood that is exposed at room temp for > 2h causes blood deterioration. h.) Avoid mixing or administering drug at BT line leads to hemolysis i.) Regulate BT 10 15 gtts/min KVO or 100cc/hr to prevent circulatory overload j.) Monitor VS before, during & after BT especially q15 mins(local board) for 1st hour. NCLEX-q5min for 1st 15min. - Majority of BT reaction occurs within 1h.

BLOOD TRANSFUSION REACTIONS

H hemolytic Reaction A allergic Reaction P pyrogenic Reaction C circulatory overload A air embolism T - thrombocytopenia C citrate intoxication expired blood =hyperkalemia H hyperkalemia

1.HEMOLYTIC REACTION
Signs & Symptoms: Headache Dizziness Dyspnea Palpitation Lumbar/ sterna/ flank pain hypotension, flushed skin , (red) port wine urine.

Nursing Management: 1. Stop BT 2. Notify Doc 3. Flush with plain NSS 4. Administer isotonic fluid sol to prevent acute tubular necrosis & conteract shock 5. Send blood unit to blood bank for reexamination 6. Obtain urine & blood samples of pt & send to lab for reexamination 7. Monitor VS & Allergic Rxn

2.ALLERGIC REACTION
Signs & Symptoms: 1. Fever/ chills 2. Urticaria/ pruritus 3. Dyspnea 4. Laryngospasm/ bronchospasm 5. Bronchial wheezing Nursing Management: 1. Stop BT 2. Notify Doc 3. Flush with PNSS 4. Administer antihistamine diphenhydramine Hcl (Benadryl). Give bedtime.SE-Adult-drowsiness. Childhyperactive If (+) Hypotension anaphylactic shock administer epinephrine 5. Send blood unit to blood bank 6. Obtain urine & blood samples send to lab 7. Monitor VS & IO 8. Adm. Antihistamine as ordered for AllergicRxn, if (+) to hypotension indicates anaphylactic shock 3. administer epinephrine 9. Adm antipyretic & antibiotic for pyrogenic Rxn & TSB

3.PYROGENIC REACTION
Signs & Symptoms: a.) Fever/ chills b.) Headache c.) Dyspnea d. tachycardia e. palpitations f. diaphoresis

Nursing Management: 1. Stop BT 2. Notify Doc 3. Flush with PNSS 4. Administer antipyretics, antibiotics 5. Send blood unit to blood bank 6. Obtain urine & blood samples send to lab 7. Monitor VS & IO 8. Tepid sponge bath offer hypothermic blanket

4. CIRCULATORY OVERLOAD
Signs & Symptoms: b. Dyspnea c. Orthopnea d. Rales or crackles e. Exertional discomfort Nursing Management: 1. Stop BT 2. Notify Doc. Dont flush due pt has circulatory overload. 3. Administer diuretics

PRIORITY CASES Hemolytic Rxn 1st due to hypotension 1st priority attend to destruction of Hgb O2 brain damage Allergic 3rd Pyrogenic 4th Circulatory 2nd Hemolytic 2nd Anaphylitic 1st priority