Hematology Lisa

HEMATOLOGY I.

Blood Types – presence or absence of A or B antigens on RBC membranes is on basis of blood types; everyone has antibodies termed anti-A or anti-B that react with A or B antigens. Hemolysis occurs when donor blood does not match recipient’s blood. A. Types 1. Type A – A antigens, B antibodies. If received B or AB, the anti-B antibodies will react with B-antigen present in B blood and cause agglutination. Can receive A & O. 2. B – B antigens, A antibodies. Can get B & O. 3. AB – A & B antigens, no antibodies. Can get A, B, AB, & O. universal recipient 4. O – does not have A or B antigens. Has A & B antibodies. Universal donor, but can only get O blood. B. Rh factor 1. Rh+ has D antigen & no anti-D antibody 2. Rd negative person does not have D antigen but if exposed to Rh+ will form anti-D antibody which will act against the Rh antigens with future exposure

II.

Blood component therapy A. common blood components 1. whole blood – 500cc in volume, for volume, used by ER & OR 2. packed RBCs – used mostly by med-surge 3. platelets – help with clotting 4. fresh frozen plasma – coagulation factors 5. cryoprecipitate – coagulation factors & fibrinogen 6. albumin – hypoalbuminemia, low COP 7. granulocytes – white cells B. Procedure for administering blood – 1. need permit to receive blood, rare to give without consent – exception – trauma 2. typing & crossmatching to determine compatible. Emergency – give any kind of blood and deal with consequences later – rare 3. assess for previous blood transfusion. If had reaction more likely to have reaction. Give leukocyte poor RBC, problem usually comes from WBC 4. base line vitals before, temperature, skin assessment. watch FVE 5. base line breath sounds. Watch for FVE 6. Baseline skin assessment, look for rashes & petechiae.

7. start IV fluids – normal saline only. Start IV site if they don’t already have one. Blood tubing has two spikes: spike blood & spike NS. 18 gauge cath “Green 18” blood viscous, can also run thru 20 8. get blood from blood bank 9. must have 2 licensed people check blood paper work on bag, blood bank ID on patient, check paper label with 1 glued on back 10. check blood make sure isn’t cloudy, ck for bubbles and expiration date. Make sure its red & not smoky gray color 11. from time you sign blood out you have 30 minutes to get blood up & infusing. Beyond 30 min, you can’t take back to blood bank. No store in refrigerator 12. after blood infusing often - check vitals before and every 5 minutes within the first 15 minutes & then every 15 minutes - most hospitals require you to stay with client for first 15 minutes - do not leave patent in first 15 minutes, checking for FVO & reactions - do with every bag 13. run first 15 minutes at 60mL.hr (1mL.min for 1st 15 min) 14. can increase if vitals are normal & have no problems 15. must be run in 4 hours, must be finished w/I 4 hours, if no FVO is present can be run in 2 hours. 16. Tubing only good for 2 units 17. Never add anything to infusing blood except NS, can run in bag or thin out 18. Blood kept in special refrigerators – if giving massive amounts – need to be warmed in blood warmer C. types of blood transfusion reactions 1. acute reactions A. febrile, non-hemolytic 1. most common, not life-threatening 2. chills, fever w/I 2 hours of infusion, administer antipyretic as needed 3. client’s antibodies react to WBC in donor’s blood, happens most often in people had previous reactions & developed antibodies 4. leukocyte poor blood can be used if client known to have this problem. In-line filters can be used B. acute hemolytic 1. life-threatening 2. occurs when donor blood incompatible w/ recipients. From error in matching w/ patient id before giving. Antibodies in recipient combine w/ antigens on donor erythrocytes causing aggulation & hemolysis 3. chills, fever, low back pain, nausea, dyspnea, blood in urine; hypotension, bronchospasm & anaphalaxis possible

4. must be prevented – must be recognized quickly & transfusion stopped. Take down all tubing, hang new tuning & infuse NS slowly. Thorough assessment, notify MD, obtain required blood & urine specimen. Document! C. Allergic 1. usually because of sensitivity to plasma protein in blood 2. itching, flushing 3. stop transfusion, infuse NS, notify MD. Administer antihistamine (Benadryl) to resolve problem & blood can be resumed 4. if severe, blood will not be restarted. Epinephrine & steroids may be needed 5. Future – patient should get antihistamine before transfusion D. circulatory overload 1. usually happens because client sensitive to overload, CHF, or nurse infused too quickly 2. PRBC better than whole blood unless volume is needed 3. Diuretic may be given after transfusion or between 2 units 4. S&S: dyspnea, tachycardia, anxiety, crackles, pink frothy sputum 5. Nurse should place client in upright position, feet down, stop blood, infuse NS @ KVO, notify MD. May need oxygen, diuretics 3. delayed reactions to blood transfusions A. delayed hemolytic 1. usually mild & requires no intervention 2. usually will occur w/I 2 weeks of transfusion – takes this long for antibodies to get strong & damage donor blood. Client usually home by this time & doesn’t recognize a problem 3. cells are hemolyzed per RES & its gradual 4. fever, anemia, increased bilirubin, jaundice, subsequent transfusions could be acute hemolytic B. infections 1. hepatitis B or C 2. HIV 3. Malaria 4. Syphilis C. iron overload 1. occurs w/ clients that get frequent transfusions 2. can cause sever organ damage 3. requires iron chelation therapy D. graft vs. host disease

1. graft starts attacking host 2. affects immune compromised patients -N/V -rash -fever -diarrhea III. assessment of hematological system A. nursing assessment B. diagnostic studies 1. lab tests A. CBC 1. CBC – with diff – RBC, platelets, WBC with different types id’d 2. Peripheral blood smear – sizes & shapes of cells identified B. ESR – erythrocyte sedimentation rate – indicated inflammation C. Clotting studies D. Iron studies E. Blood typing & Rh factor F. Bence Jones protein – random urine specimen, negative – normal, positive-multiple myeloma 2. Radiologic tests A. lymphangiography (dye) B. scans (bone scan, liver/spleen) 3. biopsies A. bone marrow aspiration & biopsy 1. PRE: -anterior or posterior iliac crest: must empty bladder before, must remain very still -signed informed consent -premeditate for pain – will be sore for several days assess platelet count before 2. POST: -hold pressure several minutes, 5-10 or longer -patent needs to stay in bed for couple of hours at least 2 hours B. lymph node aspiration & biopsy 1. local anesthetic 2. small dressing after IV.

RBC’s normal 4-6 million A. main function – have hemoglobin that transports oxygen Hct = 3 x Hbg. RBC live 120 days, normally removed from blood by reticuloendothelial cells (RES) which are responsible for phagocytosis of damaged or old cells found in liver, spleen, lymph nodes. Released iron recycles to make new hemoglobin in bone marrow. Immature RBC called reticilocytes.

Stem cell → erythroblast → reticulocyte → erythrocyte B. low RBCs – anemia – more rapid the onset the more sever symptoms 1. overall S&S with low RBCs a. restlessness – if they weren’t before, in situation where they might be bleeding, ex – post op b. dyspnea – no hemoglobin carrying o2 (activity intolerance, impaired gas exchange) c. fatigue, malaise, lethargy, HA (activity intolerance) d. dizziness, fainting (high risk for injury) e. pallor – pale nail beds f. tachycardia, palpitation, chest pain (b/c of increase o2), MI g. depression – can’t keep up with ADLs h. cheilosis/angular stomatitis – cracking in corner of mouth i. glossitis – inflamed tongue 2. general mgt & nursing care for low RBCs aimed at correcting underlying problem if possible & controlling symptoms a. alternate rest & activity b. diet iron – organ meats, eggs, dark leafy greens, folic acid _same as iron), B12 (red meats, liver) c. meds – iron, folic acid, B12 injections d. o2 e. blood transfusions f. assessment: alcohol, anticonvulsants, & oral contriceptives alter folic acid absorption 3. anemia’s – not disease but manifestation of pathology

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A. blood loss anemia people losing blood menstrual cycle GI bleed Trauma victim B. hypoproliferative anemia’s – decreased erythropoiesis (low reticulocyte count; RBC live normal life, but there are too few of them) 1. Lack of stimulation – kidneys – erythropoietn not there No kidneys or damaged from renal failure] Drugs: CSF – erythropoietn, epogen Hypothyroid 2. lack of factors needed to make RBC A. iron deficiency (microcytic) must have iron in diet

make little bitty cells B. specific symptoms of iron deficiency anemia -

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smooth red tongue (glossittis), inflammation of tongue, sore angular stomatitis/cheilosis/cracking in corner of mouth pica – eating non-food items: dirt, chalk, ice cravings – classic sign of iron deficiency brittle ridged fingernails C. care specific to iron deficiency: children – usually poor diet adults – blood loss, women- menses assess for Hx of bleeding stool for occult or frank blood diet rich in iron – organ meats, dark leafy greens, eggs meds – iron gluconate, iron sulafate – best given in acid environment – empty stomach w/ OJ teach stools look dark, tarry – may look like blood loss; constipation – fiber, fluid, activity; take 6-12 months of being on iron to replenish stores liquid iron – use straw – may stain teeth IM – use Z track, stain skin IV – will drop BP, allergic reaction – test dose before give, Benadryl

Vitamin B12 deficiency – also called megoblastic (large cell) anemia; cobalamin deficiency; pernicious amemia when only problem is lack of intrinsic factor. S/S: may take years to manifest due to fairly large stores of B12. B12 + folic acid = DNA synthesis. Red sore tongue (glossitis), angular stomatitis/cheilosis, vitiligo (white patchy spots on skin), neurological symptoms: parasthesias – numbness & tingling, proprioception. Source for B12 same as iron; lethargic, tired difference = impaired neurological functioning, see above neuro. Test specific for B12 = schilling test. Schilling test – receive oral dose of radioactive B12. If absorbed there will be radioactivity in urine, and small intestine is not problem. If no radioactive B12 in urine – is it stomach or small intestine? Test is repeated and given radioactive intrinsic factor. If radioactive urine comes thru – stomach/intrinsic factor is problem, true pernicious anemia. Does not come thru than small intestine is problem, if have plenty of intrinsic factor its just called B12 deficiency. Specific care for B12 – neurological problems we need to prevent. Safety – shoes their feet may not be getting adequate circulation. Temperature – check with thermometer. Oral care – no acidic, or spicy foods. B12 – IM at first daily, then weekly, may need to be on the rest of their life.

Folic acid deficiency – also called megaoblastic. Folic acid + B12 = RBCs. Lot of same problems as iron & B12. Foods: dark leafy greens, *OJ, liver, *peanuts, *whole grains breads. Drinking alcohol, oral contraceptives, anticonvulsants impairs absorption of folic acid. S/S: same as B12 except no neuro problems!!! Glossititis, angular stomatitis (cracking of mouth), vitiligo, brittle ridged nails. Dx: measuring folic acid w/I RBC Nursing care for folic acid – diet, folic acid supplements, oral care. Anemia from bone marrow/pancytopenia 1. aplastic anemia/pancytopenia: RBCs low, WBC low, platelets low, total marrow failure, usually b/c of chronic exposure to certain drugs or chemicals (painters, people who work in or live by chemical plants), usually ioiopathlogic –no known cause. Decreased RBC=anemia, decreased WBC=infection, decreased platelets=risk for bleeding. S/S: infection, anemia (fatigue, pallor, dyspnea), purpura (bruising), repeated throat infections. Nursing care: supportive care & bone marrow transplant. 2. Myelodysplastic syndrome (MDS) Make cells but they are messed up – amount is normal, labs look ok but have anemia symptoms. Abnormal development of cells; most common is RBC being macrocytic (large), but WBC & platelets can also be affected. Many cells die before leaving bone marrow, & those relapses have reduced ability to do what supposed to do. Most turn into acute myeloid leukemia. Most often due to age, but can occur secondary to chemical exposure or chemotherapy. S/S: like pancytopenia Dx: test reveals macrocytic red cells Tx: symptomatic care, allogenic bone marrow transplant., transfusion of blood & platelets, neupogen & erythropoietn. Hemolytic anemias: RBC detruction Erthrocytes destroyed for whatever reason, hypoxia develops & signals kidneys to release erythropoietn, so bone marrow stimulated to make more RBC & they get releases prematurely as reticulocytes. As this continues – jaundice occurs.