Hematology PPT Notes - Good for bio and patho class PDF

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Hematology PPT Notes Hematology v WBCs, RBCs, platelets ß Blood products v Plasma contains proteins (fibrinogen, albumin), clotting factors, nutrients, and enzymes

Hematology Dx v INR & PTT – screen for amount of time it takes to clot & drug efficiency v Bone marrow aspiration and biopsy o Reason: checks for quantity and quality of cells § Also checks if there is an infection inside the body o Immunophenotype: identify malignant conditions and establish prognosis o Characteristics of aspiration: semi-clear fluid o Location of site: sternum/iliac crest (anterior and posterior [easier access]) § Depends on everything of the patient o Where is the procedure done? At the bedside o Medication used for analgesic: midazolam (Versed) v Biopsy: o Reason: architecture of bone marrow and quality o Get informed consent and thoroughly explain procedure § Risks and benefits (always include death) § Alternatives if they refuse the Tx o Before aspiration: clean the skin using aseptic technique; apply local anesthetic through skin and periosteum of the bone (no anesthetic for bone, so pain will happen once bone is hit) § 5cc will be aspirated § Actual aspiration has sharp and deep pain because of suction § Tell patient to take deep breaths during the procedure § If aspiration and biopsy à 2 different injections v Complications of the bone marrow aspiration and biopsy o Bleeding (low platelet count or taking aspirin) § Pressure applied at the site with several minutes and cover site with sterile dressing § Site will ache for 1-2 days § Recommend warm shower § Offer patient analgesic for pain

Hematologic System v Blood and blood forming sites, including bone marrow and reticuloendothelial system (RES) v Blood – composed of 2 parts o Plasma: fluid portion of blood

o Blood cells: erythrocytes, leukocytes, and thrombocytes v Hematopoiesis – creation of blood cells v Bone Marrow o Stem cells § Myeloid – this is where the blood cells are created • Erythrocytes • Leukocytes • Platelets § Lymphoid • Lymphocytes o Stroma – connective tissue and blood

Erythrocytes (Red Blood Cells) v Types of Erythrocytes o Hemoglobin – makes up 95% of mature erythrocytes o Reticulocytes – immature RBCs v Erythropoiesis o Initiated by erythropoietin which is secreted by the kidney o Requires: § Healthy stem cells § Folic acid § Vitamin B12 § Iron v Iron stores and metabolism v Destruction – iron is stored in the body as ferritin and is stored in the liver v Patients who are chronically anemic will need these to create RBCs o Vitamin b12 o Folate o Iron o Erythropoietin v Vitamin B12 (water soluble vitamin) o Helps with DNA replication o Changes inactive form of folate to the active form o Without B12, this won’t occur! o Very similar in composition as fat soluble vitamins, even though it’s water soluble § Because it can be stored in the body (liver) § Hard to be vitamin B12 deficient for that reason when it comes to intake (can be deficient if you don’t have the intrinsic factor to absorb it though) v Tell patient: o Eat sources with adequate iron and vitamin B12 o Foods high in iron: green leafy veggies, red meat, pork, poultry, beans, legumes, nuts o Foods high in vitamin B12: fish, shellfish, organ meats, dairy products o Foods high in folate: veggies (kale, spinach)

Leukocytes (White Blood Cells) v Granulocytes o Eosinophils – increase with allergic reaction o Basophils – contains histamine o Neutrophils – increase with bacterial infections § Bands: immature neutrophils • Left shift in bands – lots of immature neutrophils in body o Means that there’s an infection v Agranulocytes o Monocytes – phagocytic/fungal o Lymphocytes § T-cells – Responsible for cell-mediated immunity; recognizes objects as foreign AKA surveillance system § B-cells – Responsible for humoral immunity; mature into plasma cells to create antibodies

Hematology Dx Procedures v CBC o WBC’s o RBC’s o Platelets v Total Iron Binding Capacity o High: means the pt is having iron deficiency anemia § We shouldn’t have that much protein in our body § It is high because iron stores are low v Bone Marrow Biopsy o Nursing Implications: Before § Check vital signs § Receive consent from the patient § Educate patient about process and care § Put patient in prone or lateral position because the bone marrow will be aspirated from iliac crest o Nursing Implications: During § Check vital signs § Administer sedative per MD order § Prepare for biopsy and maintain sterility § Prepare the vials and make sure the MD collected enough fluid o Nursing Implications: After § Label the vial correctly and at AT THE BEDSIDE • Date & time § Make sure the patient is stable and isn’t bleeding • Bones are very vascular, put pressure on the site to minimize bleeding § Monitor for S/S of infection

• Increased temperature • Increased BP and then later on decreased BP because of lost volume (bleeding) § Internal bleeding • Will see increased heart rate • Increased BP, and then decreased BP because loss of volume § Tell patient they will be on BR for next 30-60 min § Don’t use anticoagulants and/or aspirin until MD says it’s okay

Assessment in Hematologic Disorders v Physical Assessment o Check for pallor § Check skin § Check nail beds § Check conjunctivae & mucous membranes v If any symptoms use, o OLDCARTS v Decreased Hgb à heart will have to work harder to perfuse efficiently o Fatigue due to decreased RBC’s o SOB o Tachycardia due to decreased perfusion o Paresthesia o Hypoxia o Check tongue – will look enlarged, beefy and red o Enlarged spleen or liver – will be tender o Dizziness because of hypoxia o Lower thought process due to decreased blood to brain o Heavy menstrual cycles à anemia o Pica: eating non nutritious foods § Low ferritin level – crave ice, salt, and dirt v Interventions for low Hgb o Administer O2 v Health history o Ask about medication § NSAIDs or meds that might make you bleed § Anticoagulants (PO) – warfarin § OTC § Herbals o Ask about recent surgeries and trauma o Ask about their nutrition v Physical Assessment o Skin o Oral cavity o Lymph nodes

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o Cardiovascular o GU o Musculoskeletal o Abdominal o CNS o GYN o General Family History Ethnicity Nutritional History Medication History o Prescribed o OTC o Herbal Supplements

Anemias v Anemia o Not a specific disease but caused by other disorder o Anything lower than the normal Hgb range o Anything lower than erythrocytes o Not a specific disease, but a sign of a bigger underlying problem o Hgb carries O2 to the tissues – if Hgb is low, then the amount of O2 carried to the tissues is decreased v Lower than normal hemoglobin and fewer than normal circulating erythrocytes v Types of Anemias: o Hypoproliferative: decrease in production of RBCs § Causes: iron, vitamin B12 or folate deficiency, decreased erythropoietin production, and cancer § Iron, vitamin B12, and folate are key components for the RBCS • A deficiency in this à reduced RBC production § Erythropoietin: hormone that stimulates bone marrow to create RBCs • Found in the kidney • ESRF à decreased erythropoietin à less RBC’s produced o Medication: synthetic erythropoietin (Epogen) § Dosage: 1 – 3 times/week § Route: SubQ or IV § Cancer can also cause a defect in a production of RBCS § D/t à taking high amount of vitamin B12 § Dx: low reticulocyte count o Hemolytic: excess premature destruction of RBCs § Excess destruction of RBC’s à release of Hgb à increased free bilirubin in blood § Causes: tissue hypoxia due to decreased oxygen d/t decreased Hgb

§ Caused by altered erythropoiesis, or other causes such as hypersplenism, drug induced or autoimmune processes, and mechanical heart valves § Examples: • Leukemia – when chemo is used because it destroys RBC’s as well • Hypersplenism: over reactive spleen o Spleen helps remove all the damaged cells from the blood stream o But when the spleen is too over reactive it removes the cells to early and quickly • Abnormality within the cell o sickle cell • Within plasma o immune hemolytic anemias • Direct injury to cell – mechanical heart valve • Blood loss o Trauma, bleeding from GI tract, and GU o Dx: MCV, RDW, H&H, Iron, Total iron capacity, B12 levels, CBC v Primary Managementfor Anemia o Correct or control the cause o Bleeding via GI tract – needs to be stopped o Transfusion of PRBCs o Treatment for a specific type of anemia – iron deficiency (replace iron), vitamin b12 (replace it)

Iron-Deficiency Anemia v Most common type of anemia due to inadequate intake v Risk factors: o blood loss (IBD: UC, Crohn’s) o pre-menopausal women à heavy menstrual cycle o chronic alcoholism (aspirin, NSAIDS) à chronic blood loss à anemia o iron malabsorption à d/t gastric bypass/celiac disease/IBD/medication (PPI/H2B) v Clinical Manifestations o Dizziness, dyspnea, fatigue o Intolerance to cold o Irritability o Nail bed changes (spoon shaped), pallor, tongue changes (smooth tongue), cheilosis (cracks at corner of mouth) o Pediatric Patients – short attention span, decrease in school performance v Iron studies o Total iron binding capacity – high o Ferritin – low o Serum iron – low o Transferrin - high o Bone marrow aspiration – most dx

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§ But highly invasive so MD will start with blood studies first (total iron binding capacity, ferritin, and serum iron) Very important for nurses to teach patients about prevention of iron deficiency o Women with heavy menstrual periods and pregnant women Teach about foods high in iron o Liver o Black or pinto beans o Green leafy veggies o Garbanzo beans o Raisins and molasses Teach patients to eat these foods with vitamin C rich foods like orange juice – because it helps with absorption of iron Medications o Sometimes PO iron is not enough à other medications o Examples: Ferrous sulfate, ferrous fumarate, ferrous gluconate o Nursing Implications to teach patients § Iron is BEST absorbed on an empty stomach and with vitamin C • Vitamin C: citrus, strawberries, tomatoes, or broccoli • Take supplement 1 hour before meals • Take supplements between meals • May cause GI upset, if taken with meals, absorption decreased by 50% § If iron is given IM • Use z-track method • Only in severe cases because it is a vesicant § If iron is given PO in a LIQUID • Use a straw because medication stains teeth and brush teeth after administration § Normal to have green, tarry stools bc of Fe – teach pt about this Outcome of medication treatment o 1 week: improved reticulocyte count o 1 month: improved Hgb count, decreased symptoms, and increased energy level Teach patients à it will take a while (weeks – months) to reach normal iron levels o Cannot be corrected quickly If H&H is low à blood transfusion o If pt is a Jehovah’s witness, give this patient ferrous dextran § But this medication takes from days to weeks to work § Inform these pts about the consequences of not accepting blood products Iron is administered in the form of ferritin – bc that’s how it’s found in the body

Folic Acid Deficiency Anemia (megaloblastic) v d/t decreased intake of uncooked green leafy vegetables and liver v Vitamin B12 converts folic acid into an active form for DNA production v Risk populations o Patients who do not eat uncooked vegetables

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Alcoholics d/t increased folic acid requirements Patients with chronic hemolytic anemias Pregnant women d/t increased folic acid requirements Celiac disease

v Dx o Red cell folate levels o Macrocytic, increased MCV & MCH v Clinical manifestations o Similar to pernicious anemia BUT NO neurological issues

Pernicious Anemia (megaloblastic) v Pernicious anemia is deficiency of vitamin B12 caused by the absence of the intrinsic factor o Intrinsic factor secreted by cells in the gastric mucosa o Intrinsic factor then binds to vitamin B12 to be carried to the ileum where it’s then absorbed v Risk factors: o GI issues/surgeries o Vegetarians v Medications: o PPI à inhibit absorption o H2B o Metformin v Vitamin B12 converts folic acid to the active form o Required for DNA production v Deficiency in enzymes in the intestine to aid in absorbing vitamin B12 v Clinical Manifestations o Sx of progressive remissions and exacerbations o Similar to iron deficiency anemia, but pernicious anemia has more neurological manifestations § Confusion, paresthesia in extremities, and neuropathy § Tongue may be beefy or bright red, smooth, and sore § Difficulty maintaining balance / proprioception o Vitamin B12 can only be given PO if there is an inadequate B12 intake v Vitamin B12 given for pernicious anemia shouldn’t be given PO – because these patients lack the intrinsic factor so they can’t absorb it o If you give it PO, the patient WILL NOT ABSORB it because they do not have the intrinsic factor v Can give vitamin B12 à IM, SUBQ, or INTRANASAL v PO vitamin B12 can be given if it’s due to lack of intake o d/t long term use of PPI or gastric surgeries v Diagnostics o Schillings test – to help determine if it’s enzyme issue or malabsorption issue § Classic way to dx pernicious anemia

§ Pt will receive a small dose of radioactive vitamin B12 and a non-radioactive parenteral dose of vitamin B12 § If radioactive vitamin B12 is found in the urine, patient has pernicious anemia because they didn’t absorb it d/t the lack of the intrinsic factor o Intrinsic antibody tests § Presence of antibodies that bind and prevent absorption § Not indicative o Measuring folate in the RBC’s is more sensitive v Vitamin B12 deficiency can be due to: o Decreased PO intake o Lack of intrinsic factor v Medications that decrease absorption of vitamin b12 o Pantoprazole (proton pump inhibitor) § Give these pts vitamin b12 supplement § They can absorb vitamin b12 PO bc they have the intrinsic factor v Vitamin B12 – cyanocobalamin

Vitamin B12 (Cyanocobalamin) v Medication that’s administered v Route: IM/Deep SubQ/Intranasal o Intranasal – if enzyme is absent or if there’s malabsorption à administer 1 hour before or after eating § given 1 time/week v Monthly injections done for the rest of their lives – since intrinsic factor cant be replaced v 1 mg PO DAILY v I mg IM MONTHLY v Therapeutic goals o Increased reticulocytes within 1 week o Increase energy

Sickle Cell Anemia v Severe hemolytic anemia that occurs from the inheritance of the sickle hemoglobin gene o Causes Hgb shape to be affected o Hemoglobin loses round pliable disk shape and becomes dehydrated, rigid, and sickle shaped v If the RBC becomes rigid and sickled, they lose the ability to carry O2 o That’s why these patients become anemic and tissues lack perfusion v The sickled RBCs adhere to each other and lead to obstructions o Prevents blood flow to organs because of sickle cell clots v If the sickle cell obtains an adequate amount of O2 before it becomes rigid, it can go back to its normal shape o Tell patients to seek treatment as soon as possible for the best outcome v Diagnostics

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o Hemoglobin electrophoresis: how sickle cell anemia is diagnosed § Measures and identifies different types of Hgb in the blood § That’s when they can identify Hgb S Risk factors o Change in temperature – colder temperature o Low O2 o Dehydration o Stress o Cold à vasoconstriction à slows the blood flow Sickle cell crisis CM’s o Low hemoglobin (9-11) o Will have perfusion problems § Capillary refill § Temperature o Fever o Abdominal pain o Joint pain o Pallor o Jaundice o Occlusions can lead to stroke, MI, and PE o Renal failure o Heart failure o Affects emotional status à depression Interventions (based off importance) o Bed rest – to decrease O2 consumption o O2 (100% NRB) o Assess pain – because vasoocclusions are extremely painful § Morphine/fentanyl o Hydration – extremely important § Give PO and IV fluids § Make sure pt is well hydrated o Some cells are super damaged à low H&H à patient will need a blood transfusion o Promote coping o Education of disease process o Monitor for complications Teach patient: o Stay hydrated! Even if your cells become sickled, but you’re well hydrated, then a clot could be prevented because there’s enough pressure to bust through it § Dehydration can exacerbate the disease and throw them into a crisis o Avoid infection o See MD if you experience these symptoms § Fever, inflammation, and pain

Care of Pt’s With Anemia – interventions v Balance physical activity and rest à regain their energy v Compliance with medication, doctor’s visits, and food v Explain potential CMs they may see if the anemia comes back o Paresthesia o Paleness o Fatigue, weakness o Beefy red tongue v Maintain adequate nutrition v Maintain adequate perfusion v Patient education to promote compliance with medications and nutrition v Monitor VS and pulse ox – provide supplemental O2 PRN v Monitor for potential complications o Heart failure – look at ECG (less than 45bpm) o Angina – due to lack of O2 to heart o Paresthesia, confusion, depression o Risk for falls and injuries v Be compliant with medication

Hemophilia v Rare disorder where the blood doesn’t clot normally because it lacks the blood clotting factors o Factor VIII, IX, or XI deficiency o This usually diagnosed early in childhood v Labs: o Severe: 5% v Severity o Degree and factor of the deficiency o How big the trauma is to the area v Clinical manifestation – signs of bleeding o Mild, moderate, or severe bleeding o Spontaneous bleeding – excessive bleeding from cuts, injuries, procedures, dental work, vaccinations; large and deep bruises; pain, swelling tightness in joints, blood in urine and stool; nose bleeds with no specific cause § 75% of joints is bleeding (knees, elbows, wrists, elbows, and shoulders) § With babies – will see irritability v 3 different types of hemophilia – classified by what clotting factor is deficient o Hemophilia Type A – most common type § Caused by clotting factor VIII deficiency § X-linked trait (male) § Hematomas more common o Hemophilia Type B § Caused by clotting factor IX deficiency

§ X-linked trait (male) o Hemophilia Type C § Caused by clotting factor XI deficiency v Males are most affected by this v Intervention o FFP – fresh frozen plasma and frozen concentrates (VIII and IX) § Given to patients when they’re actively bleeding o DDAVP – desmopressin § Synthetic form of vasopressin § Increases plasma factor VIII § *Does not work with hemophilia B or C or severe hemophilia A o Factor replacement § When actively bleeding § Children receive it prophylactically o Teach these patients to avoid aspirin and NSAIDS – because it’ll make them bleed more o Recombinant forms of the factors § For non-emergency and to prevent bleeding prophylactically § Human plasma and synthetically made cells o When patient is actively bleeding, then they will need fresh frozen plasma and factor replacement o Advise patients to avoid high contact sports, activities to minimize trauma and risk of bleeding § Rest immobilization and ice the extremity if there’s any trauma § Neurological assessment • Initial s/s: confusion and lethargy o Some patient’s and family members are shown how to administer factor medications at home in case there’s any bleeding o Teach these patients to avoid any OTC meds, herbal supplements, and alcohol because it’ll mess with bleeding o Dental procedures that include bleeding might be very dangerous for these patients § Before getting dental procedures done, notify MD so they can get a factor infusion prophylactically

Ex of Coagulation Disorders v v v v

Cirrhosis of liver – because the liver creates clotting factors Anti-thrombolytic therapy – if patient is prone to blood clots Braun-Willebrand’s disease – makes you prone to bleeding Vitamin K deficiency

DIC – Disseminated Intravascular Coagulation v Not a disease but a sign of an underlying disorder v Initiates inflammation and coagulation in vasculature à clotting factors consumed à clotting factors consumed à bleeding results à tissue ischemia à d/t blood loss

v DIC – when you have small blood clots throughout the bloodstream, blocking small blood vess...