HEMATOLOGIC DISORDERS  Pallor – conjunctiva

 Jaundice –(hemolytic)
HEMATOLOGIC SYSTEM  Petecchiae – small pinpoint hemorrhage
Refers to the blood and blood forming organs.  Ecchymosis- small bruises
 BLOOD - transports cellular components and  Hematoma –large bruise
products from one part of the body to another.  Lymph node enlargement
 It is composed of plasma(55%) and cellular  Spleenomegaly or hepatomegaly
component(45%)- RBC, WBC, Platelets.
 Slightly alkaline 7.35-7.45 DIAGNOSTIC PROCEDURE
 5-6 L or 70-75 ml/kg BW or 7 to 10% of BW  BLOOD
CBC with differential
 The formation of the RBC,WBC and platelets a. Hemoglobin – Males13-16 gm/dl
begins in the bone marrow - Females 12-14 gm/dl
 Stem cells are produced in the bone marrow b. Hematocrit – Males 42-50%
 Initially stem cells are not differentiated - Females 40-48%
ELEMENTS OF BLOOD c. RBC – Males 4,600,000 – 6,200,000 mm3
 PLASMA – liquid component. Serum – plasma Females 4,200,000 – 5,400,000 mm3
without the clotting factor. d. WBC – N=5,000 – 10,000 cu.mm
 90% water and the rest are plasma proteins *neutrophils – N=60-70%
(albumin and globulin), clotting factors etc. *eosinophils – N=1-4%
 FORMED ELEMENTS – RBC,WBC and *basophils – N=0–0.5%
Platelets *monocytes – N=2-6%
FORMED COMPONENTS *lymphocytes – N=20-30%
 RED BLOOD CELLS (RBC) e. Platelets – N=200,000-350,000 per cu.mm
 Erythrocytes- life span is 120 days.
 Hemoglobin – made from Heme (Fe+) and COAGULATION SCREEN
globin  Prothrombin time-11-16 secs. (time for clotting
 Carries hemoglobin to provide O2 to tissues after thromboplastin and Ca are added to
plasma)
 Erythropoeisis Need – erythropoietin
factor(kidney), Iron, Vit.B 12, Folic Acid,  Coumadin tx Warfarin INR less
Vit.B6(Pyridoxine) and Protein. 2 2.5-3.5
 Fe deficiency ( from bleeding in the GI / etc., or  Partial Thromboplastin Time-60-70secs(after
heavy menstrual flow ) Partial T reagent is+plasma)
 Folic acid – diet. Absorbed in proximal small  Best single screening test for
intestine coagulation d/o
 Vit. B 12- meat/products. Combines with intrinsic  Activated Partial Thromboplastin Time -30-45
factor ( found in stomach). Problem for secs . Same as ptt.
gastrectomy –partial or total  Most specific for heparin tx
 HEMOLYSIS  Clotting Time – N= 5 to 10
 Aged erythrocytes loose their elasticity and minutes
become trapped in small blood vessels.
 Removed from the blood by the RES particularly  Bleeding Time – N=30 sec – 6
liver and spleen. minutes
 Hemoglobin – recycled others breaks down to
BLOOD CHEMISTRY
form bilirubin and secreted in the bile.
NPO 6-8 HRS.
 Fe- recycled others lost in feces / urine or
 a. Blood Urea Nitrogen
menstrual flow
(BUN) – N=10-20mgs/dl
WHITE BLOOD CELLS (WBC)
 b. Creatinine – N=0.7-
 Leukocytes – fights infection
1.4mgs/dl
 GRANULOCYTES
 c. Uric acid – N= 2.5-8.0
1.Neutrophils – essential in preventing or limiting
mg/dl
bacterial infection via phagocytosis
(polymorphonuclear neutrophils / lecukocytes ) (1st  d. Cholesterol – N=150-
step phagocytosis) 300 mg/dl
2.Easinophils – involved in allergic reactions; digests  e. Bilirubin – Total
foreign proteins N=0.1-1.0 mg/dl
3. Basophils- contains histamines integral part of  direct (N=0.1-
hypersensitivity reactions. 0.2mg/dl)
 AGRANULOCYTES  indirect (N=0.1-
 1.Monocytes – phagocytosis esp against 0.8mg/dl)
fungus( 2nd step)
 2.Lymphocytes – integral component of immune SPECIAL BLOOD TEST
system.
A. ESR – N=0 to 20 mm/hr (inflamm process)
 a. T lymphocytes – kills foreign cells directly/
B. SCHILLING’S TEST – for pernicious anemia (lack
enhance phagocytosis. Responsible for delayed
intrinsic factor needed for the absorption of Vit B 12 in
allergic reactions, rejection of foreign
GI)
tissues(transplanted organs) and destruction of
1. prep NPO x 8 hours
tumor cells.( Cellular Immunity )
2. radioactive oral Vit.B12 given first then
 b. B Lymphocytes – capable of differentiating
3. Vit.B12 nonradioactive given IM-flush oral
into plasma cells. This produce antibodies called
B12 in urine 2 hours after 24hr. urine collection for
Ig which are protein molecules that destroy
radioactive
foreign materials. ( Humoral Immunity)
 PLATELETS- play a role in controlling bleeding. Vit.B12; N = 15-40% of oral dose excreted (inc. means
During vascular injury they collect at the site of B12 not absorbed secondary to lack intrinsic factor)
the injury and to each other forming a platelet
plug that stops bleeding.—forming fibrin. OTHER TESTS
ASSESSMENT
 Urine and Stool
 PHYSICAL S/S
 Urinalysis
  Hematest
 Hemoccult – prep; -no dark colored food
x 24 hours prior to test
 Radiologic
 CXR
 Scan
 Lymphangiography
 Bone Marrow aspiration and biopsy
 Bone Marrow Aspiration and Biopsy
 Assess the quantity and quality of each
type of cell produced in the bone
marrow
 Preferred site – iliac crest, sternum or
tibia
 Before: consent, position exposing the
site
 After: pressure to site x5miuntes
ERYTHROCYTE DISORDERS
 Anemia – reduction below normal level in
number of erythrocytes, quantity of hemoglobin
and volume of packed RBC’s.
 Basic underlying – tissue hypoxia
 Related = blood loss, nutritional
deficiency (Fe,Vit.B12, folic acid), lack of
RBC production or bone marrow failure.
 Hx of anemia secondary to genetics –
thalassemia and sickle cell.
ANEMIA
 Signs and Symptoms – depends upon
severity and chronicity and age.
 a. Mild – asymptomatic;
palpitations, dyspnea and diaphoresis
following strenuous exertion.
 b. Moderate – increased
palpitations, dyspnea, and diaphoresis;
fatigue at rest or during activity.
 c. Severe – pale and exhausted
all the time, severe palpitations,
sensitivity to cold, loss of appetite,
profound weakness, angina.
 Iron Deficiency Anemia
Causes:
 Inadequate absorption – increased
requirement
 Inadequate intake of iron rich foods
 Physiologic need – more in children and
pregnant women
 Physiologic loss – menstruation
 Blood loss – trauma, GI bleeding
Fe Deficiency Anemia
 Signs and Symptoms:
 Palpitations, dizziness, easy fatigability
 Cold sensitivity, pallor
 Brittle nails, and hair
 Plummer-vinsons syndrome – soreness
and inflammation of mouth and tongue
(stomatitis and glossitis)
 Hypochromic,microcytic RBC
 Koilonychia – thin concave nails raised
at edges (spoon nails)
DX Fe Def. Anemia
 Low Hemoglobin
 Normal then Microcytic, hypochromic cells
 Serum fe low
 Peripheral blood smear – poikilocytosis (different
shapes of RBC)
 Nursing management:
*Oral iron – route of choice; given after meals
(taken 3 x a day)
liquid iron intake with straw because it stains; mixed
with 1 glass cold H2O,
best absorbed with Vitamin C;
stool becomes tarry and constipation may occur. Eg.
Fe So4, Fe Gluconate, Fe Fumarate
Treatment for Fe def. 2
*Parenteral – avoid tissue staining by using
separate aspiration injection needles; Z-tract method
and deep IM; do not massage but encourage
ambulation. Ex. Fe dextran(imferon) , Fe Sorbitex
( Jectofer)
*Dietary – increased in iron and roughage
*Blood transfusion
Megaloblastic Anemia
 Folic acid deficiency – decrease in folic acid
 Causes
 poor dietary intake (green vegetables,
organ meats, meats, fresh fruits)
 impaired absorption in upper jejunum
 increased requirement –pregnancy
 impaired utilization – folic acid
antagonists like
 S/s – fatigue,weakness,pallor etc.
 DX – low serum folate
 TX- Oral Folic acid, increase diet, treat cause
 Pernicious anemia – Vitamin B12
(cyanocobalamine) deficiency of intrinsic factor
in the gastric mucosa which is necessary for
absorption of Vit.B12.
 Signs and Symptoms:
 Hemolytic jaundice – macrocytic
hypochromic
 Tingling sensations, paresthesias
 Beefy red tongue
 Deficiency or absence of hydrochloric
acid in the stomach
 +Schillings test
 Diagnostic assessment:
 Schilling’s test
 Gastric analysis
 Nursing management:
 Drug therapy – Vit B12 injections
(monthly) for life
 Folic acid – reverses anemia, decreases
neurological symptoms
 Transfusion therapy
 Avoid activities that could lead to
injury/changes in balance
APLASTIC ANEMIA
 Depressed bone marrow activity secondary to
antineoplastics, radiation, insecticide, drugs and
chemical toxins.
Laboratory Assessment: pancytopenia
 Erythrocytopenia (anemia)
 Leukocytopenia(infection -URTI --
sepsis)
 Thrombocytopenia (bleeding gums,
nose, GI etc.)
 Nursing management:
 Blood transfusion
 Prevent and treat infections
 Bone marrow transplant
 Drug – corticosteroids; estrogen
 Identify and withdraw offending agent
POLYCYTHEMIA
 Polycythemia ( compensatory response to
hypoxia - inc. RBC, hemoglobin)
 POLYCYTHEMIA VERA-unknown cause
 Proliferative disorder of the bone marrrow with
increse in RBC,WBC & platelets
 S/S - increase blood volume and viscosity
 Reddish skin,head-ache, painful fingers and
toes,hepato/splenomegaly, HPN, prone to CVA
and MI.

 Treatment
 Phlebotomy to decrease blood
 Increase fluid to reduce blood viscosity
 Monitor for signs of bleeding
 Chemotherapy to inhibit hyperactivity of the
bone marrow
 Administer analgesics, antihistamines(pruritus)
Leukocyte Disorder
 Leukopenia is condition of fewer WBCs than
normal, results from neutropenia or lymphopenia
 Neutropenia results from decreased production
or increased destruction of neutrophils
 Medical management varies depending on
cause
 Nursing management is towards preventing and
managing infections
 Leukocytosis is an increased level of WBCs
 Leukemia is a neoplastic proliferation of one
particular cell
 Leukemia – most common of childhood (3-5 y/o)
cancer; abnormal proliferation of WBC in blast
form.
Predisposing factors:
 Radiation – Xrays. CV lab
 Survivors of Hiroshima
 Chemical induced - fertilizers
Leukemia
 Proliferation of the WBC in the bone marrow,
spleen, liver, lymph nodes.
 Classification
 1. Cell type - lymphocytic, granulocytic ,
monocytic
 2. Maturity of Malignant cells
 Acute - immature cells
 Chronic - differentiated cells
Types of Leukemia
*Acute lymphocytic leukemia (ALL)
 80-85%of childhood leukemia
 95% chance of obtaining
remission with diagnostic
assessment
 75% chance of surviving over 5
years
*Acute non-lymphocytic anemia (ANLL)
 granulocytic and monocytic
 60-80% will obtain remission
with treatment
 30-40% cure rate
S/S OF LEUKEMIA
 Anemia – weakness, pallor, dyspnea
 Petechiae, spontaneous bleeding
 Infection, - fever, malaise
 Enlarged lymph nodes, liver and spleen
 Abdominal pain, weight loss, anorexia
 Bone pain due to expansion of marrow
MANAGEMENT : Leukemia
*Supportive therapy – rest, blood transfusion,
prevent infection, promote nutrition, oral hygiene, skin
care
*Drug therapy – antileukemia – oncovin,
prednisone, methotrexate (2-3 yrs.)
*Radiation
*Bone marrow transplant
LYMPHOMA
 Lymphatic tissue (lymphocytes)
 A. HODGKIN’s – malignant neoplasms
of lymphatic tissue originating in lymph
nodes proliferating to spleen and liver
 Signs and Symptoms –
enlarged non tender nodes,
abdominal pain
(spleenomagaly),
cough,dyspnea,dysphagia
(enlarged mediastinal nodes)
 DX lymph node biopsy
-prescence of Reed Sternberg
cells(malignant cells-Hodgkins
 Management – chemotherapy-
MOPP (Nitrogen Mustard
Oncovin Procarbazine
Prednisone ), radiation
b. NON HODGKIN’S – tumor originating in lymphatic
tissue characterized by diffuse, undifferentiated cell;
prognosis is poorer than Hodgkin’s.( no Reed Sternberg
cells)
Management:
 *chemotherapy
 *radiotherapy and
 *surgery for diagnosis and
staging
THROMBOCYTOPENIA
 Decrease platelet production(bone marow
supression, chemo/radiotherapy
 Increase platelet destruction(infection)
 S/s - petechiae,ecchymosis(eg ,site of
venipuncture), hematoma, bleeding-nose,GI,GU
 TX - treat underlying disease, Platelet
transfusion
PLASMA DISORDERS
Hemophilia
 Congenital blood dyscrasia characterized by
disturbance in blood clotting.Appears in males
but is transmitted by females.
 Hemophilia A- classic - Factor 8 anti hemophilia
factor
 Hemophilia B- Factor 9 - Christmas factor
 X-linked traits affect males
 Dx - PTT prolonged
 S/s - easily bruised, prolonged bleeding from
nose, mouth or laceration, hematuria
 Tx- Pressure on bleeding site, plasma
concentrate/ cryoprecipitate, Factor 8/9
concentrate
BLOOD TRANSFUSION
 Whole blood
 Packed RBC
 Platelet Concentrates
 Fresh Frozen Plasma - plasma+ clotting factors
 Plasma deriv.- clotting factors +10ml plasma
eg Cryoprecipitate
 Albumin
BLOOD TRANSFUSION
Procedure
 1. Consent for blood transfusion
 2. Identification of patient and blood- pts hospital
no., name, type of infusion, expiration date etc. ;
 3.Obtain vitals signs - immediately before
starting, 15 minutes after then every 30 minutes
for the next 2-3 hrs and end. Also 1 hr after
transfusion
 4. Start slowly at 2ml/ minute . Monitor for
adverse reactions.
 5. Record in BT chart.
BLOOD TRANSFUSION
ADVERSE REACTION
1. ALLERGIC - sensitive to plasma protein
s/s - flushing, itchiness, rash, wheezing
Tx- stop BT, KVO with saline, antihistamine
2. FEBRILE - sensitive to donor wbc, platelets & plasma
proteins
s/s - sudden chills, fever, headache, flushing
Tx - Stop BT, send blood samples and blood bags
to blood bank. Monitor temp. Antipyretics as prescribed.

3.SEPTIC - transfusion of blood with bacteria

s/s - chills, high fever, hypotension
TX - stop BT., get blood culture fr. Pt and return
blood bags
4.CIRCULATORY OVERLOAD - fast administration
s/s - distended neck veins, dyspnea, crackles at
base of lungs
TX - stop BT, semi fowlers position, diuretics as
ordered,O2
5.HEMOLYTIC - incompatible blood products
S/s - chills, fever, low back pain, inc HR & RR,
Hypotension
TX- Stop BT, notify MD and blood bank, treat
shock, antihistamine