Medical and Surgical Nursing

Hematology Lecture Notes

Prepared by: Mark Fredderick R. Abejo RN,, MAN

Adult bone marrow produces :

 175 b RBCs
 70 b neutrophils
 175 b platelets

Blood Vessels
 Veins
 Arteries
 Capillaries
MEDICAL AND SURGICAL NURSING
Blood Forming Organs
Hematology  Liver
 Thymus
Lecturer: Mark Fredderick R. Abejo RN, MAN  Spleen
 Bone Marrow
 Lymph nodes
 Lymphoid organ
OVERVIEW OF THE STRUCTURE AND FUNCTION OF
THE HEMATOLOGIC SYSTEM CHARACTERISTICS:
 Color
o Arterial Blood
HEMATOLOGY – the scientific study of the structure and o Venous Blood
functions of blood in health and in disease.  Fraction of body weight 8%
 Volume Female: 4 -5 L
BLOOD – is the circulatory fluid of the CV system which is  Male: 5 - 6 L
circulating constantly through a closed circuit of tubes.  Temperature 38 C ( 100.4 F )
 pH 7.35 - 7.45
FUNCTIONS:  Viscosity (relative to water)
► supply oxygen from the lungs and absorbed Whole blood: 4.5-5.5
nutrients from the GIT to the cells Plasma: 2.0
► remove waste products from tissues to the kidneys,  Specific gravity - 1.048 to 1.066 ( 1.055 – 1.065)
skin and lungs for excretion  Composition:
► transport hormones from their origin in the
endocrine glands to other parts of the body Liquid phase: PLASMA (55%)
► protect the body form dangerous microorganism
► promote Hemostasis ( to stop bleeding) ► - A light yellow substance which is one of
► regulate body temperature by heat transfer – the major fluids of the body. Major function
vasoconstriction and vasodilation is to maintain the blood volume within the
vascular compartment
Hematopoiesis
 Process of blood cell production.
 At birth, it is accomplished in the liver, spleen,
thymus, lymph nodes and red bone marrow.
 After birth, it is confined in the red bone marrow (
but some WBCs are still produced in the lymphatic
tissues).
 During childhood, all blood cells are essentially
produced in marrow sites of the flatbones of the
skull, clavicle, sternum, ribs, vertebrae, and pelvis
 After puberty, hematopoiesis becomes localized
within the flatbones of the sternum, ilium, ribs, and
vertebrae, sometimes occurring in the proximal
ends of long bones (humerus and femur)
 All formed elements come from one stem cell or the ► 92% Water
HEMOCYTOBLAST. Cell differentiation gives ► Serum
rise to the cell lines with the help of growth factors. ► Plasma Proteins – all produced in the LIVER
 Albumin – most abundant, maintains osmotic
pressure
 Globulin
 Alpha – transports bilirubin, steroids and
hormones
 Beta – transports iron and copper
 Gamma – transports immunoglobulins
 Prothrombin – clotting factor
 Fibrinogen – clotting factor

► Electrolytes ( Na+,,Ca 2+,, HCO3ˉ, CIˉ),

► Miscellaneous (less than 1%): sugars, fats,
vitamins, hormones

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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

Solid phase: FORMED ELEMENTS /

CELLELAR COMPONENTS (45%)  Non-granulocytes (agranulocytes)

1. Monocytes – largest WBC (macrophage)

RBC (Erythrocytes) – only component which is  Upon release in the bone marrow and
anucleated travel to the different tissues, it is just a
N = 4-6 million/mm3 hypoactive phagocytic cell, become a
 Are biconcave discs (AKA discocytes) which are Macrophage when it attaches to the
less than 7.5 micrometers in diameter. endothelium of organs and performs its
 full phagocytic function.
 ERYTHROPOIESIS process of formation of RBC  Long term phagocytosis (months)
 ERYTHROPOETIN hormone produced primarily  KUPFFER – kidneys
by the kidney; necessary for erythropoiesis  HISTOCYTES – skin and subcutaneous
 HEMOGLOBIN iron-containing protein of RBC,  ALVEOLAR macrophage – lungs
delivers oxygen to tissue  MICROGLIA – CSF
 Carries about 200-300 million molecules of  MACROPHAGE - blood
hemoglobin(heme-globin-iron) that attach oxygen 2. Lymphocytes
within each RBC, responsible for 97% of O2
transport  B cells (bone marrow)
 Molecules of Hgb (carries oxygen) differentiated in the bone marrow,
( Ave. 12 - 18 g/dL) antibody-mediated immune response
Female: 12-16 g/dL (Humoral)
Male: 13-18 g/dL  For immunity
 HEMATOCRIT – red cell percentage in whole  T cells (Thymus)
blood (three times of normal Hemoglobin)  For immunity
FEMALES: 36-42%  Differentiated in the Thymus and
MALES: 42-48% lives long cell-mediated response
 Target site of HIV
 Substances needed for maturation of RBC
 AIDS incubation period: 6 mos
1. FOLIC ACID – prevents neural tube deficit;
– 5 years; window period 6
needed in the FIRST trimester of pregnancy
mos
2. IRON – needed in the THIRD trimester
3. VIT B12 (Cyanocobalamin)  AZT  ZIDOVUDINE or
4. VIT C (Ascorbic Acid) RETROVIR : drug of choice for
5. VIT B6 (Pyridoxine) aids
6. INTRINSIC FACTOR (released in stomach’s  WESTERN BLOT –
parietal cells) confirmatory test for aids
 Normal lifespan – 80-120 days  Kaposi’s SARCOMA
 Spleen – kills RBCs in the red pulp  NK cells
 Natural killer cells
WBCs (Leukocytes)  Anti-tumor and anti-viral properties

N = 5,000-10,000/mm3 Humoral (Antibody-Mediated) Immune Response

 Granulocytes B Cells
1. Neutrophils – most abundant, 60-70% of total – Matures into Plasma Cells responsible for Antibody
WBCs production
 First line of defense, most common type of
leukocyte but a short lifespan of only 10- 5 Classes of Immunoglobulins (MADGE) :
12 hours making them ineffective in – Immunoglobulin M (IgM)
destroying infectious agents • 1st immunoglobulin produced in an immune
 Helpful in localizing the infection and in responsepresent in plasma, too big to cross
immobilizing the pathogens until other membrane barriers
WBCs arrive – Immunoglobulin A (IgA)
 for acute inflammation • Sound in body secretions like saliva, tears, mucus,
bile, milk & colostrum
2. Eosinophils– allergic reactions – Immunoglobulin D (IgD)
 Weak phagocytic action, elevated during • Present only in the plasma & is always attached to
asthma attacks. the B Cell
 Usually activated during parasitic – Immunoglobilin G (IgG)
invasion (Schistosomes / blood flukes) • 80% of circulating antibodies
 Lifespan= hours to 3 days • Can cross the placenta and provide passive
 Modulates or reduce IgE mediated immunity
allergic reactions • Present in all body fluids
– Immunoglobulin E (IgE)
3. Basophils – not phagocytic in nature, they are • Responsible for Allergic & hypersensitivity
mediators in inflammatory process. reactions
 Involved in the release of chemical • Stimulates Mast cells & Basophils to release
mediators Histamine which mediates inflammation & the
 Prostaglandin allergic response
 Serotonin
 Histamine
 Bradykinin PLATELETS (Thrombocytes)
 For inflammation
N = 150-450 thousand mm3

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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

 Promotes hemostasis  prevention of blood loss   folic acid deficiency in growth spurt (infants and
promote clotting mechanisms adolescents)
 MEGAKARYOCYTES – immature/baby platelets;  because some laboratory results are age- specific
target site of DHF
 Normal lifespan: 9-12 days

b. Sex
 women have lower hemoglobin and hematocrit levels,
more prevalence of agranulocytosis
 hemophilia, bleeding expressed among males
 because some laboratory results are sex-specific

c. Race
 Blacks have lower hemoglobin levels than whites
(more prevalent sickle cell anemia)

d. Family history
 Because some hematologic disorders are inherited:
– Anemia
– Thrombocytopenia
– Bleeding disorders (hemophilia and Von
Willebrand’s Dse),
– Congenital Blood Disorder (Sickle Cell
anemia)
– Jaundice, infections, delayed healing,
– Cancer
– Autoimmune dse (aplastic anemia,
pernicious anemia)
Hemostasis (Blood Clotting)
e. Congenital lack of the intrinsic factor
Three Major Phases
1. Platelet Plug Formation Modifiable
– Platelets adhere and stick to vessel lining that are
damaged forming a Platelet Plug or White a. Exposure to certain chemical and drugs
Thrombus  Radiation overexposure
– Platelets release chemicals to attract more  Anti-neoplastic drugs/ chemotherapy
platelets to the injured site  Chemical Oxidants (e.g benzene, nitrites, lead,
2. Vascular Spasms arsenic, etc.)
– Platelets release Serotonin causing spasms of the  Drugs (chloramphenicol, sulfonamide, anti-
blood vessel, constricting it & decreasing blood convulsant, streptomycin, hair dyes
flow
3. Coagulation or Blood Clotting 2. History – Chief complaint
– Thromboplastin is released by damaged cells  Disorders of the hematologic system often affects all
– plasma Clotting Factors form an activator that organs and tissues
triggers the Clotting Cascade  Determine:
– a Blood Clot is formed
– Serum is squeezed out within the hour pulling the o Onset
ruptured edges together  abrupt or gradual?
 since childhood or recent
Plasma Clotting Factors o Allergen triggered response? Seasonal?
I Fibrinogen o How long do the allergic manifestations last?
II Prothrombin Relieved or persist once the allergen is removed?
III Tissue Thromboplastin
IV Calcium o Quality and quantity
V Proacelerin  How severe? Massive bleeding? How long does
VII Proconvertin it last?
VIII Antihemophilic Factor  How long do the bleeding episodes last and
IX Christmas Factor how severe they are?
X Stuart – Prower Factor  Does blood ooze from a site or does sudden
XI Plasma Thromboplastin massive bleeding occur?
Antecedent  How often do bleeding episodes occur and how
XII Hageman Factor long do they last?
XIII Fibrin Stabilizing Factor  What does the client do to stop them?
Compatible Blood Types  Is there any break in skin integrity?
 Swelling? Edema? Fever? Pain? Tenderness?
Assessment of the Hematologic System Pruritus? Redness? Or drainage?

 Note allergic manifestations such as rhinitis,

1. Risk Factor Analysis sneezing, nasal stuffiness, postnasal drip, sore
throat, voice changes, hoarseness, wheezing,
Non-Modifiable persistent cough, dyspnea, malaise, fatigue,
tearing or altered hearing acuity.
a. Age
 immune response is diminished in both very young o Severity and location
and very old  Rest can alleviate fatigue? Bleeding of joints?
 anemia prevalence increases with age  Can rest alleviate fatigue? (s/sx of anemia)

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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

 Ask how activities and activity tolerance

changed over time
 Does the client bruise easily? 4. NOSE
 Has bleeding in the joints? – epistaxis (thrombocytopenia and bleeding
 Number and saturation of sanitary pads disorders)
 Anaphylactic reactions? Or simple allergic
response? 5. MOUTH
– smooth, glossy, bright red tongue and sore tongue
o Precipitating factors (pernicious and Fe def. anemia)
 Anticoagulant? – bleeding – gingival bleeding (thrombocytopenia and bleeding
 Bone Marrow suppression – anemia, disorders)
leukemia, and thrombocytopenia
 Antineoplastic drugs? Antibiotics? Radiation? 6. LUNGS
 Infectious agents? Corticosteroids or – dyspnea, orthopnea (anemia)
immunosuppressive drugs?
 Allergic triggers (inhalants such as pollens and 7. CARDIOVASCULAR SYSTEM
dust, contact agents such as dyes and – tachycardia, palpitation, murmurs, angina
cosmetics, ingested agents such as foods and (anemia)
drugs, injectable agents such as drugs, vaccine
and insect venom) 8. GIT
– dysphagia (mucous membrane atrophy due to iron
o Aggravating and relieving factors def. anemia)
 salicylates containing OTC may – abdominal pain( bleeding)
aggravate bleeding – hepatomegaly, splenomegaly (hemolytic anemia)
 what relieves allergic manifestations – hematemesis, melena (thrombocytopenia and
bleeding disorders
3. Past Medical History
9. GUT
a. Major illnesses and hospitalization – hematuria (bleeding disorders)
 Previous hematologic problems – amenorrhea and menorrhagia
 Surgical procedures that may affect the – (iron def. and bleeding do)
hematologic system
 Liver problems 10. MUSCULOSKELETAL
 Any bleeding disorders – joint pain (hemophilia)
– back pain
o How long was the bleeding problem? Do any – sternal tenderness and bone pain
members of the family have a history of – (sickle cell crisis)
bleeding? –
o Is bleeding linked with any specific event or 11. NERVOUS SYSTEM
procedure? Does it occur with menses or – headache, confusion
following minor trauma? Any frequency of – (anemia, polycythemia)
nose bleeding? Does he bruise easily? Any – brain hemorrhage
petechiae? – (thrombocytopenia and bleeding disorders)
o How severe are any of the bleeding episodes? – peripheral neuropathy,
What is the durations? – paresthesis, loss of balance (pernicious anemia)
o Any history of hepatic/ splenic or renal
disease? Recently taken medications?
DIAGNOSTIC PROCEDURES
b. Medications- aspirin, chloramphenicol, antineoplastic
drugs
c. Allergies- Hx of allergies, BT and/reactions 1. COMPLETE BLOOD COUNT
d. Family History
a. RBC count- # of RBCs/ mm3 of blood, to diagnose anemia
4. Psychosocial Hx and Lifestyle and ploycythemia
a. Occupation- exposure to chemicals and radiation b. Hemoglobin- # of grams of hgb/ 100ml of blood; to
b. Habits- nutritional, substance abuse, alcohol abuse measure the oxygen-carrying capacity of the blood
c. Hematocrit – expressed in %; measures the volume of
RBCs in proportion to plasma; used also to diagnose anemia
and ploycythemia and abnormal hydration states
Review of Systems/ Physical Examination d. RBC indices- measure RBC size and hemoglobin content
a. MCV (mean corpuscular volume)
1. SKIN b. MCH (mean corpuscular hemoglobin)
– pallor c. MCHC (mean corpuscular hemoglobin
– ruddy skin concentrarion)
– jaundice e. Platelet count- # of Platelet/ mm3; to diagnose
– dry skin, brittle, spoon shaped with longitudinal thrombocytopenia and subsequent bleeding tendencies
ridges f. WBC count- of WBCs/ mm3 of blood; to detect infection
or inflammation
2. EYES g. WBC Differential count- determines proportion of each
– visual disturbances (anemia and polycythemia) WBC in a sample of 100 WBCs; used to classify leukemias
– blindness (retinal hemorrhage related to Normal Values
thrombocytopenia and bleeding do)
– scleral jaundice (hemolytic anemia) RBC: Women – 4.2-5.4 million/mm3
Men – 4.7-6.1 million/mm3
3. EARS Hgb: Women – 12-16 g/dl
– vertigo, tinnitus (severe anemia) Men – 13-18 g/dl
– bleeding in auditory canal Hct : Women – 36-42%
– (bleeding do) Men – 42-48%
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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

WBC: 5000-10,000/mm3 - give sedatives as ordered

Granulocytes
Neutrophils: 55-70% Procedure - place patient in lateral position, with
Eosinophils: 1-4% site of aspiration uppermost
Basophils: 0.5-1.0% - clean pt’s skin with antiseptic sol’n
Agranulocytes - administer local anesthesia to numb
Lymphocytes: 20-40% skin and subcutaneous tissues
Monocytes: 2-8% - apply ice on the contralateral side to
Platelets: 150,000-450,000/mm3 relieve pain

Postprocedure- apply pressure until bleeding stops

- check site frequently for bleeding
2. PERIPHERAL BLOOD SMEAR - give pain relievers to relieve pain
7. COAGULATION SCREENING TESTS
To determine the variations/ abnormality in RBCs, WBCs
and Platelets: normal size and shape (normocytes) and a. Bleeding Time – measures the ability to stop bleeding
normal color (normochromic) after small puncture wound
b. Partial Thromboplastin Time (PTT) – used to identify
3. DIRECT ANTIGLOBULIN EST (Coomb’s Test) deficiencies of coagulation factors, prothrombin and
fibrinogen; monitors heparin therapy.
Used in cross matching blood when transfusion reaction c. Prothrombin Time (Pro-time) – determines activity and
occurs, test umbilical cord for Erythroblastosis fetalis and interaction of the Prothrombin group: factors V
diagnose acquired hemolytic anemia (preacclerin), VII (proconvertin), X (Stuart-Power factor),
prothrombin and fibrinogen; used to determine dosages of
4. INDIRECT ANTIGLOBULIN TEST oral anti-coagulant.

Identifies antibodies to RBC antigens in the serum of clients Normal Values

who have greater than normal chance of developing
transfusion reactions. Reticulocytes: 25-75 x 10 9/L
Bleeding Time: 2.75-8 min
5. RETICULOCYTE COUNT Partial Thromboplastin Time (PTT): 20-35 sec.
Prothrombin Time (PT): 12-14 sec.
Used to determine the responsiveness of the bone marrow to
the depletion of circulating RBCs (probably due to hemolytic
anemia or hemorrhage) BLOOD DISORDERS
6. BONE MARROW ASPIRATION and BIOPSY I. IRON DEFICIENCY ANEMIA (IDA) – chronic
microcytic anemia due to inadequate absorption of iron
Used to determine size and shape of RBCs, WBCs and leading to hypoxemic tissue injury
platelet precursors and to examine various maturational
abnormalities. A. INCIDENT RATE
1. Developed countries (d/t high intake of cereals
and milk)
2. Accidents (adults)
3. Tropical areas (blood sucking parasites)
4. Women 15-35 (reproductive age)
5. Common among the poor (poor nutrition)

B. PREDISPOSING FACTORS
1. Chronic blood loss
 Trauma
 Menstruation
 GIT bleeding
 Hematemesis
 Melena (UGIB)
 Hematochezia (LGIB) (d/t E.
histolytica  DOC: metronidazole)
2. Inadequate intake of iron rich food
3. Inadequate absorption of iron due to
 Chronic diarrhea
 R/t increased cereal intake with decreased
animal CHON ingestion, related to
subtotal gastrectomy
 Malabsorption syndrome
4. Improper cooking of foods

C. SIGNS AND SYMPTOMS

1. Usually asymptomatic, first sign: weakness
and fatigue
2. Headache, dyspnea, dizziness, palpitations,
cold sensitivity, generalized body malaise,
pallor
Nursing Responsibility 3. Brittleness of hair, spoon shaped nails
(koilonychia  180 degrees ang normal)  d/t
Preprocedure - explain the purpose, obtain consent hypoxia  atrophy of epidermal cells
- inform client of pain or of what to 4. Atrophic glossitis, stomatitis, dysphagia
expect

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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

D. DIAGNOSTICS: ALL DECREASED!  If absent IF dyspepsia  weight loss 

1. RBC so increase calories in diet
2. Hgb  Secretes HCl acid  it aids in digestion
 Immature RBCs  sequestered in spleen
3. Hct
 bilirubinemia  jaundice
4. Reticulocytes
5. Iron B. SIGNS AND SYMPTOMS
1. Headache, dizziness, dyspnea, palpitation, cold
E. NURSING MANAGEMENT sensitivity, pallor and generalized body
1. Monitor for signs of bleeding of all hema test malaise
including urine, stool and GIT 2. GIT changes
2. Enforce CBR so as not to overtire patient  Mouth sores, Red beefy tongue,
3. Encourage increased iron diet (Damo!  Dyspepsia or indigestion, Weight loss,
green leafy vegetables, California raisins, Jaundice
organ meat, legumes, yolk, dried foods 3. CNS changes – PA is the most dangerous form
4. Avoid tannates in tea and coffee because it of anemia
impairs iron absorption  Tingling sensation, Paresthesia, Ataxia,
5. Administer medications as ordered Psychosis
 Oral iron preparations (300mg OD)
 FeSO4, Fe Fumarate, Fe Gluconate
 NURSING MANAGEMENT
1. Administer with meals to lessen
C. DIAGNOSTICS
GIT irritation
2. Use straw for liquid form 1. SCHILLING’S TEST – indicates decreased
3. Administer with orange juice reabsorption of vitamin B12; confirms
or vitamin C to facilitate presence of pernicious anemia
absorption
4. Inform client of SE/monitor for D. NURSING MANAGEMENT
a. Anorexia 1. Enforce complete bed rest (consistent to all
b. Nausea and vomiting types of anemia)
c. Abdominal pain
2. Administer Vit B12 injections at MONTHLY
d. Diarrhea/constipation
e. Melena intervals for lifetime as ordered; common site:
 Parenteral Iron Preparations dorso and ventrogluteal, no drug toxicity
 Iron Dextran IM or IV because it is water soluble and is easily
 Sorbitex IM excretable; oral forms might develop
 NURSING MANAGEMENT tolerance.
1. Administer using z-tract 3. Increase caloric intake, CHON, CHO, Fe, Vit
method to prevent discomfort, C
discoloration and leakage 4. Encourage client to use soft bristled
2. Avoid massaging of injection toothbrush and avoid irritating mouthwashes
site instead encourage pt. to (remember there are mouthsores!)
ambulate to facilitate 5. Avoid heat application (there is numbness
absorption
remember?)  may lead to burns
3. Monitor SE
a. Pain at injection site
b. Localized abscess III. APLASTIC ANEMIA – stem cell disorder leading to
c. Lymphadenopathy bone marrow depression  pancytopenia (all blood
d. Fever and chills cells decreased)  anemia, leucopenia,
e. Pruritus and urticaria thrombocytopenia
Hypotension 
anaphylactic shock  A. PREDISPOSING FACTORS
epinephrine
1. Chemicals
 Benzene and its derivatives
RBC (80-120 days)  destroyed in Spleen  Hgb
Hemoglobin breaks into:
2. Irradiation
 Globin 3. Immunologic injury
 Heme 4. Drugs
A. Ferrous  Broad spectrum antibiotics
1. Bilirubin  Chloramphenicol
2. Biliverdin  Sulfonamides (Bactrim…)
B. Ferritin  Chemotherapeutic Agents
Early sign of anaphylactic shock: dyspnea  Nitrogen Mustard (Anti-metabolite)
 Vincristine (plant alkaloid)
 Methotrexate (alkylating agent)
II. PERNICIOUS ANEMIA – chronic anemia resulting  Phenylbutazones
from deficiency of intrinsic factor leading to
hypochlorhydria (decreased HCl secretion); B. SIGNS AND SYMPTOMS
IDIOPATHIC 1. Headache, dizziness, dyspnea, palpitations,
pallor, cold sensitivity, generalized body
A. PREDISPOSING FACTORS malaise
1. Subtotal gastrectomy 2. Leukopenia (increased susceptibility to
2. Hereditary factors infections)
3. Inflammatory disorders of the ileum 3. Thrombocytopenia
4. Autoimmune  Petechiae
5. Strictly vegetarian diet  Ecchymoses
 Stomach (widest area of alimentary  Oozing of blood from venipuncture sites
canal)
 Argentaffin/oxyntic/parietal cells in C. DIAGNOSTICS
stomach produces IF  promotes 1. CBC – pancytopenia
reabsorption of vit B12 (Cyanocobalamin) 2. Bone Marrow Biopsy or Aspirate
 maturation of RBC  Posterior iliac crest

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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

 Would reveal fat necrosis in the bone  Hand-Foot Syndrome

marrow  Splenic Crisis
 Infections
D. NURSING MANAGEMENT  Acute Chest Syndrome
1. Removal of underlying cause  Pulmonary Arterial Hypertension
2. BT as ordered  Delayed growth and puberty
3. Enforce complete BR  Stroke
4. Administer O2 inhalation  Eye problem
5. Reverse isolation  Priapism
6. Monitor for signs of infection  Gallstone
7. Avoid IM, SQ or any venipuncture sites  Ulcers of the leg
8. instruct: use electric razor when shaving  Multiple organ failure
9. Medications as ordered
 Immunosuppressants via central venous C. DIAGNOSIS
catheter 1. CBC reveals hgb of 6-8g/dl , increase
 Anti-lymphocyte globulin (ALG) – reticulocyte count, low hct
given within 6 days – 3 weeks to 2. HemoglobinElectrophoresis, confirmatory
achieve maximum therapeutic effect diagnosis for sickled cell anemia
3. Urinalysis – UTI
4. Chest Xray and CT scan – pulmonary
complication

E. MEDICAL MANAGEMENT
1. Children born with sickle-cell disease will
undergo close observation.
IV. SICKLED CELL ANEMIA - is a life-long blood 2. Patients will take a 1 mg dose of folic acid
disorder characterized by red blood cells that assume daily for life.
an abnormal, rigid, sickle shape 3. From birth to five years of age, they will also
have to take penicillin daily due to the
immature immune system that makes them
more prone to early childhood illnesses.
4. Painful crises are treated symptomatically
with analgesics; pain management requires
opioid administration at regular intervals until
the crisis has settled
5. The first approved drug for the causative
treatment of sickle-cell anaemia, hydroxyurea,
was shown to decrease the number and
severity of attacks
6. Bone marrow transplants have proven to be
effective in children

F. NURSING MANAGEMENT

1. Administer O2 & Blood Transfusion as Rx

2. Maintain adequate hydration
3. Avoid tight clothing that could impair
circulation.
4. Keep wounds clean and dry.
5. Provide bed rest to decrease energy
expenditure and oxygen use.
6. Encourage patient to eat foods high in
calories, CHON, with folic acid
A. PREDISPOSING FACTORS supplementation.
1. Hereditary factors 7. Analgesics:
2. African ,South/Central American people and o Acetaminophen
Mediterranean countries o Morphine
o avoid aspirin as it enhances
B. SIGNS AND SYMPTOMS acidosis,which promotes sickling
Related to anemia: 8. Avoid anticoagulants( sludging is not due to
1. Shortness of breath clotting ).
2. Dizziness 9. Antibiotics.
3. Headache 10. Avoid activities that require so much energy.
4. Coldness in the hands and feet 11. Keep arms and legs from extreme cold.
5. Pale skin 12. Decrease emotional stress.
6. Chest pain 13. Provide good skin care
Related to pain:
1. Sickle Cell Crisis - Sickle cell crises often V. THALASSEMIA MAJOR (Cooley’s anemia)
affect the bones, lungs, abdomen, and joints.  B - thalassemia refers to an inherited hemolytic
- A sickle cell crisis occurs when sickled red anemia, characterized by reduction or absence of
blood cells form clumps in the bloodstream. the B-globulin chain in Hgb synthesis
These clumps of cells block blood flow through  Fragile RBC & short life span
the small blood vessels in the limbs and  Autosomal recessive pattern of inheritance
organs. This can cause pain and organ damage  Insufficient B-globulin chain synthesis allows large
amounts of unstable chains to accumulate
Complications of Sickle Cell Crisis

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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

 Precipitates of alpha chains that form cause RBC’s 4. Painful fingers & toes from paresthesias
to be rigid & easily destroyed, leading to severe 5. Altered mentation
hemolytic anemia = chronic hypoxia 6. Weakness, fatigue, night sweats, bleeding
 Skeletal deformities: pathologic fractures tendency
 Hemosiderosis – excess iron supply, which leads to 7. Hyperuricemia – from increased RBD
iron deposits in the organ tissues leading to formation and destruction
decreased function B. DX TESTS
1. CBC
A. CLINICAL MANIFESTATIONS 2. BONE MARROW ASPIRATION &
1. onset is usually insidious Biopsy
2. Sx are primarily related to progressive
anemia, expansion of marrow cavities of the C. MANAGEMENT
bone & developmemnt of hemosiderosis 1. HYPERVISCOSITY
3. Early Sx often include progressive pallor, = phlebotomy @ intervals determined by CBC
poor feeding & lethargy results to decrease RBC mass
4. Further signs: hemorrhage, bone pain, =generally 250-500ml removal @ a time
exercise intolerance, jaundice, & protuberant 2. HYPERPLASIA
abdomen = myelosuppressive therapy,
5. hemosiderosis of the eye and lungs = generally using hydroxyurea or IV
radioactive
B. DIAGNOSTIC EVALUATION phosphorus (32P), biologic response
• Decrease hemoglobin modifier, ie alpha interferon
• RBC= increase in number 3. HYPERURICEMIA= allupurinol
• Hgb elctrophoresis (Zyloprim)
– elevated levels of HgF ( doesn’t hold O2 4. PRURITUS = antihistamines (cimitidine),
well ) low dose acetyl salicylic acid; certain anti-
– limited amount of HgA depressants (paroxetin), phototherapy,
cholestyramine

C. COMPLICATIONS D. NURSING INTERVENTION

1. Splenomegaly 1. Encourage/assist ambulation
2. Growth retardation in the second decade 2. Assess for early S/Sx of thromboembolic
3. Endocrine abnormalities : complications : swelling of limbs, increased
– delayed development of secondary sex warmth, pain
characteristics – most boys fail to undergo 3. Monitor CBC & assist with phlebotomy as
puberty, girls – menstruation problems ordered
– DM – due to iron deposits in the pancreas Patient Education
– Hypermetabolic rates  Educate about risk of thrombosis;
4. Skeletal complications encourage patient to maintain normal
– Frontal & parietal bossing (Enlargement) activity pattern & avoid long periods of
– Maxillary hypertrophy – leading to rest
occlusion  Avoid hot showers
– Premature closure of epiphyses of long  Report @ regular intervals for follow up
bones blood
– Osteoporosis & pathologic fractures
5. Cardiac problems: pericarditis & CHF – VII. HEMOPHILIA
usual cause of death  Hereditary coagulation defect, usually
transmitted to affected male by female carrier
D. MANAGEMENT through sex – linked recessive gene, resulting
1. Frequent and regular transfusion of packed in prolonged clotting time.
RBC’s to maintain Hgb levels above 10 g/dL  Most common type is Hemophilia A or Classic
2. Iron chelation therapy with deferoxamine Hemophilia - factor VIII deficiency (called
(Desferal) – reduces toxic effects of excess iron Antihemophilic Factor / AHF)
& increases iron excretion thru urine & feces  Hemophilia B or Christmas Disease – factor
3. Splenectomy IX deficiency (called the Christmas Factor)
4. Supportive management of symptoms  Male inherits hemophilia from their mothers,
5. Bone marrow transplant and females inherit the carrier status from
6. Prognosis and Survival rate is poor because of their fathers.
no known cure – Found predominantly, but not exclusive,
7. Often fatal in late adolescence or early in male offsprings
adulthood  Bleeding occurs due to impaired ability to
form fibrin clot

VI. POLYCYTHEMIA VERA

 Underlying cause is unknown
 Hyperplasia of all bone marrow elements
> increase RBC mass
> increase blood volume viscosity
> decrease marrow iron reserve
> Splenomegaly

A. ASSESSMENT
1. Reddish purple hue of skin & mucosa,
pruritus
2. Splenomegaly, hepatomegaly
3. Epigastric discomfort, abdominal
discomfort

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Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

and not available to form clots at sites of tissue

injury.
 Clot - dissolving mechanisms are also increased
stimulated by many factors including infection in
the blood & severe tissue injury – burns and head
injury, reactions to blood transfusions, carcinomas
and obstetrical complications such as retained
placenta after delivery.

A. ASSESSMENT
1. Abnormal bleeding in response to trauma or
surgery. (muscles/joints)
2. Joint bleeding causing pain, tenderness,
swelling, and limited range of motion.
3. Tendency to bruise easily.
4. Epistaxis
5. Hemarthrosis (bleeding in joints causing
pain, swelling and limited movement)

B. IMPLEMENTATION
1. Administer factor VIII concentrate. A. ASSESSMENT
2. Monitor for bleeding and maintain bleeding 1. purpura on lower extremities & abdomen
precautions. 2. hemorrhagic bullae, acral cyanosis, focal
3. Monitor for joint pain; IMMOBILIZE the gangrene in skin
affected extremity if joint pains occur.
4. Monitor urine for hematuria.
5. Instruct the parents regarding activities for
the child, emphasizing the avoidance of B. Dx Tests:
contact sports. 1. marked decrease of blood platelets
6. Instruct the parents on how to control 2. low levels of fibrinogen & other clotting
bleeding (direct/indirect pressure) factors
7. DDVAP (Desmopressin) – promotes the 3. prolonged prothrombin & partial
release of Factor VIII in hemophilia A thromboplastin times & abnormal
8. Use soft toothbrush and point out need for erythrocyte morphologic characteristics
regular dental checkups
9. Refer to National Hemophilia Association C. NURSING MANAGEMENT
10. Emphasize avoidance of Aspirin 1. Monitor for signs of bleeding of all hema tests
11. Provide diet information as excess weight : blood, urine, stool, git
places further stress on joints 2. Administer IV fluid replacement as ordered
3. Administer oxygen inhalation as ordered
R - Rest 4. Administer medications as ordered
I - Immobilize  Vitamin K
C - Cold Compress  Heparin
E - Elevate  Pitressin (Vasopressin) via heplock
5. Provide Heplock, avoid IM, SQ and any
venipunctures
VIII. DISSIMENATED INTRAVASCULAR 6. Institute NGT decompression
COAGULATION  Iced saline solution
 DIC is a disorder of diffuse activation of the  Cold saline solution
clotting cascade that results in depletion of  Lavage: 500-1000cc of water; monitor
clotting factors in the blood. NGT output
 occurs when the blood clotting mechanisms are 7. Prevent complications
activated all over the body instead of being  Hypovolemic shock (first sign: cold
localized to an area of injury. clammy skin) (+) Anuria
 grave coagulopathy resulting from overstimulation
of clotting & anticlotting processess in response to IX. IDIOPATHIC THROMBOCYTOPENIA PURPURA
disease & injury
 Small blood clots form throughout the body, and  Increased destruction of platelets with resultant
eventually the blood clotting factors are used up platelet count of less that 100,000/mm3

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Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

characterized by petechiae and ecchymoses of the 2. PNSS to prevent hemolysis

skin. 3. 18-19 gauge large bore needle to prevent
 Exact cause unknown; may be autoimmune. hemolysis
 Spleen is the site for destruction of platelets D. Instruct another RN to re-check the following:
 often triggered by URTI or Childhood 1. Name of patient
communicable disease – Measles & chickenpox 2. Bt and ct
3. Expiration date
A. ASSESSMENT: 4. Serial number
1. Petechiae E. Check blood unit for presence of bubbles, cloudiness,
2. Ecchymosis sediments and dark color as it may indicate
3. Blood in any body secretions, bleeding form contamination
mucous membranes, nosebleeds. F. NEVER WARM BLOOD PRODUCTS!  ROOM
4. Decreased platelet count TEMPERATURE ONLY
5. Anemia 1. Warming only done if you have dewarming devise
6. easy bruising 2. Warming only done during emergency situations 
7. blood in stool or urine if there is massive blood loss  massive transfusion
8. CBC reveals platelet count below 20,000/mm3 G. Transfusion should be completed in 4 HOURS
9. Bone marrow aspiration done to rule out because blood exposed to room temperature more
leukemia than 2 hours causes blood deterioration
H. Avoid mixing or administering drug at BT line to
B. MEDICAL MANAGEMENT: prevent hemolysis
Drug therapy: I. Regulate at KVO (10-15 gtts/min) at 100 cc/hour to
1. Prednisone – decreases anti-platelet prevent circulatory overload
J. MONITOR VS BEFORE, DURING, & AFTER
antibodies (monitor for infection)
TRANSFUSION ESPECIALLY EVERY 15 MINUTES
2. IVIG (Intravenous Immune Globulin) – FOR THE FIRST HOUR. Majority of BT reactions
helps to effectively increase platelet count occurs at these times
3. Anti-D Antibody – one dose treatment K. SIGNS OF BT REACTION (HAPCATCH)
 Given to pt’s 1 year but less than 19 1. Hemolytic reactions  life threatening.
years old PRIORITY
 Normal WBC and hemoglobin  Signs and symptoms
 no active bleeding present  Dizziness, Headache, Dyspnea,
 no concurrent infection Hypotension, Flushed skin, Lumbar,
 Diphenhydramine and hydrocortisine flank and sternal pain, diarrhea or
are made ready for possible allergic constipation, Portwine urine (red
reactions to the medication urine)
Platelet transfusion  Nursing Management
Splenectomy  Stop BT, Notify MD, Flush with
PNSS
C. NURSING MANAGEMENT  Administer Isotonic Solution to
1. Prevent, control and minimize bleeding. counteract shock and prevent acute
2. Prevent bruising tubular necrosis
3. Provide support to client and be sensitive to  Return blood unit to blood bank for
change in body image. re-examination
4. Protect from infection.  Obtain urine and blood sample of
5. Administer analgesics (acetaminophen) as client for re-examination and send to
ordered; avoid aspirin. lab
6. administer meds orally, rectally, or I.V.  Monitor VS and IO
rather than I.M.

BLOOD TRANSFUSIONS
2. Allergic reactions
I. OBJECTIVES  Signs and symptoms
A. To replace circulating blood volume  Fever, chills, dyspnea,
B. Increase oxygen carrying capacity of the blood Laryngospasm, bronchospasm,
C. Combat infections if decreased WBCs Bronchial wheezing, Urticaria,
D. Prevent bleeding if decreased PLT pruritus, skin rashes
 Nursing Management
II. NURSING MANAGEMENT/PRINCIPLES  Stop BT, Notify MD, Flush with
A. Proper refrigeration PNSS
B. Proper blood typing and cross-matching  Diphenhydramine administration as
ordered
 If (+) to hypotension, it indicates
anaphylactic shock
 Return blood unit to blood bank for
re-examination
 Obtain urine and blood sample of
client for re-examination
 Monitor VS and IO
3. Pyrogenic reactions
1. Type O – universal donor
 Signs and symptoms
2. Type AB – universal receipient
 Fever and chills
3. 85% of general population is Rh (+)
 Headache
 Blood expiration:
 Dyspnea
 Platelets : 5 days
 Tachycardia and palpitations
 RBC: 5-7 days, 250 cc
 Diaphoresis
C. Aseptically assemble all materials needed for BT
 Nursing Management
1. Filter set (BT set)
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MS Abejo
Medical and Surgical Nursing
Hematology Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,, MAN

 Stop BT
 Notify MD
 Flush with PNSS
 Administer antipyretics and
antibiotics as ordered
 Provide hypothermic blanket
 Return blood unit to blood bank for
re-examination
 Obtain urine and blood sample of
client for re-examination
 Monitor VS and IO
4. Circulatory overload
 Signs and symptoms
 Dyspnea
 Rales/crackles
 Orthopnea
 Nursing Management
 Stop BT
 Notify MD
 Administer loop diuretics as ordered
 NO FLUSHING!
 Monitor VS and IO
5. Air embolism
6. Thrombocytopenia
7. Citrate intoxication
8. Hyperkalemia  arrhythmia

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