Hematology-Patient Care – Flashcards
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Complete Blood Count (CDC)
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RBC: RBC Count, Hemoglobin (Hb), Hematocrit (Hct) (Indices) WBC: WBC Count, Differential (+ / -) Platelet Count Miscellaneous
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Primary Disorders of Cells
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RBC: Anemias (can also be secondary), Sickle Cell Disease, Polycythemia, Hemolysis WBC: leukemia Platelets: Essential Thrombocytosis, Idiopathic Thrombocytopenia Others
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Secondary effects on Blood and Bone Marrow
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Infection Inflammation Coagulopathies Toxic Substances (including Drugs): DI Hemolytic Anemia, DI Thrombocytopenia, DI Neutropenia Secondary Polycythemia: Smokers-high hgb levels , High Attitudes'
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Blood
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avg adult: 5.5L cells (rbc, wbc, platelet): 45% plasma (water, proteins, some waste products): 55%
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Hematopoeisis
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Hematopoiesis is the process whereby mature blood cells form from pluripotent stem cells. Several types of growth factor stimulate the production of mature cells. Like all blood cells, white blood cells, leukocytes, are produced in the bone marrow. They develop from stem cells that mature into one of the five major types of white blood cells: Neutrophil, Lymphocytes, Monocytes, Eosinophils, Basophils
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different cell types...
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Anisocytosis: Cells are not uniform (some big and some little) Poikilocytosis: Abnormal shape of cells Target Cells: seen in patients with a splenectomy Howell-Jolly Bodies: Seen in patients with anemia Spherocytes: Look like balls Elliptocytes: Schistocytes: Seen in hemolytic anemia fragments
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in splenomegaly, you may see..
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the enlarged spleen-splenomegaly sequesters platelets and source of the thrombocytopenia
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RBC Information
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produced at a rate of 2 mill cells/sec life span=120 days mature cells look like a biconcave disc/donut like early development are nucleated; mature lack nucleus+contains Hgb (Fe containing compd)
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Evaluate RBC (anemia)..
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RBC count hemoglobin hematocrit OR.... (Hb/HCT or H/H) *low H/H= anemic
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Anemias...
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hypoproleration: -Marrow Damage -Iron Deficiency -renal Disease maturation: -Thalassemia -Iron Deficiency -Folate Deficiency -B-12 Deficiency hemorrhage/hemolysis: -Acute Blood Loss -Hemolysis -Autoimmune Disease
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elements necessary for RBC production
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Erythropoietin (Kidney), Iron , and Co-Factors (Vitamin B12 AND Folic Acid)
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Lab values...
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RBC count: Males 4.6 - 6.2 million / μL AND Females 4.2 - 5.4 million / μ L) Hemoglobin count (this is the functional component of rbc; production stops in mature rbc; carries o2 and co2 from tissue): Males 13.5 - 18 gm/dL AND females 12 - 16 gm/dL Hematocrit count (% of total volume of RBC relative to the total volume of whole blood; determined from calculated value): Males 40 - 54 % AND females 38-47%
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RBC Ct. / Hb / Hct Relationships
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RBC count / Hb / Hct are closely related Hct ≈ 3 X Hb (estimated) **Exception: Abnormal sizes or shapes OR Altered Hb synthesis
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yellow serum..
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indicative of hemolysis
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buffy coat...
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seen in leukemia
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Primary Polycythemia (vera)
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↑ RBC #'s ↑ RBC Mass Myeloproliferative disease of bone marrow
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Things to look out for in blood work
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Hemoconcentration--increase in RBC Ct., Hb & Hct; and will see Dehydration Hemodilution--decrease in RBC Ct, Hb, & Hct; will see Over hydrated Be careful with one-point H/H evaluation (Use combination of Clinical picture with Lab values)
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RBC indices
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MCV: Mean Corpuscular Volume (this is the avg volume of RBC in femtoliters 10^15/L); calculate as--> MCV = (Hct x 1000)/ (RBC Ct) MCH: Mean Corpuscular Hemoglobin (this is the measure of average hemoglobin wt of RBC in picograms 10^12/g); calculate as-> MCH= (Hgb)/(RBC ct) MCHC: Mean Corpuscular Hemoglobin [conc] (this is the average concentration of Hb in a given RBC Volume as a %); calculated as-->MCHC= mass/volume=Hgb/Hct *tends to be at maximal concentration and unusual seeing increase in MCHC
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Values seen in adults' rbc indeces
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MCV=82-93 *test that gives enough insight MCH=22-34 MCHC=31-38% *automated gets you all three values*
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Low MCV, Low Hematocrit
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MICROcytic HYPOchromic anemia.
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Reticulocytes
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Young RBC with residual blue hue from RNA Slightly larger than mature RBC the primary is found in bone marrow Nl (normal) circulation = 0.5 to 1.7 % Flow cytometry method = 1 - 2 % increase in Retics: Bld loss with nl bone marrow; hemolysis; Replacement of a deficiency
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Deficiency Anemias
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Microcytic Anemia: MCV 93, Vitamin B 12 &/or Folic Acid Deficiency, others
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MCV Increased (>93)
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Reticulocytosis Macrocytic or Megaloblastic Anemia (ie B 12 or Folic Acid) Alcoholism Liver Disease Some drugs
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MCV Normal
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Acute Hemorrhage Myelophthic Anemia Aplastic Anemia
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MCV Decreased (<82)
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Microcytic Anemia (ie Iron Deficiency) B-6 responsive Anemia Chronic Blood loss Anemia of Chronic Disease Lead Poisoning
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Basic Iron Kinetics:
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a. Total Iron= 4,000 mg b. RBC= 2/3 in RBC 2,500mg c. Circulating Enzymes= 500mg d. Storage= 1,000mg e. Females less storage of iron due to menstrual cycle 500-700mg -females less to start with
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Serum B12
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Normal >200 pg/ml (Vit B12 def is around <100pg/ml)
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Serum Folate
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Normal>4 ng/ml (Folate deficiency is around <3)
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Grades of Anemia
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1) < LLN - 10 g/dl 2)<10-8 g/dl 3)<8-6.5 g/dl 4) <6.5 g/dl 5) death
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Howell-Jolly Bodies (Seen in patients with anemia)
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Megaloblastic Anemia Thalassemia Myelodysplastic Syndrome Lead Poisoning Post-splenectomy
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Target Cells (seen in patients with a splenectomy)
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Hemolytic Anemia Thalassemia Liver Disease Post Splenectomy
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Schistocytes (Seen in hemolytic anemia fragments *get helmet cells; rbc fragments)
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Hemolytic Anemia D. I. C. Snake bites
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Sickled Cell
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Not donut/biconcave disc shaped rbc are supposed to be pliable; the sickle is not pliable they can plug up different systems
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Bone Marrow Exam
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Marrow Aspirate -E / G Ratio (erythrocyte / Granulocyte)->Nl = 1 : 3 -Cell Morphology -Iron Stain for stores Marrow Biopsy -Cellularity -Morphology
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Lab Tests to Monitor Therapy
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CDC with differential=chemotherapy Replacement Treatment= Vit B12, Folate, Iron
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If reticulocytes go from 1 to 10
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bone marrow isn't functional (Excess Reticulocytes effect on MCV?***LOTS of reticulocytes FALSELY elevates MCV***)
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Erythrocyte Sedimentation Rate"ESR"
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Measure of rate of RBC settle from plasma Depends On: Plasma protein content; Size & Shape of RBC; RBC Concentration (H/H) Why Settle Faster: -↑ Plasma proteins lower Zeta potentia around RBC -Lower Zeta → rouleaux formation Proteins = Phase reactants
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ESR...
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Macrocytes settle faster Microcytes settle slower Poikilocytes (odd shapes) unable to rouleaux ↑ Hb/Hct = slow ESR ↓ H/H (anemic) will appear to have an ↑ESR
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increase LDH
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CVA (strokes) Hemolytic Anemia Pernicious Anemia (megaloblastic anemia) Pulmonary Infarction Liver & Kidney disease Heart: (myocardial infarction, others) "Cancer" + Others
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Bilirubin Blood Levels
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Indirect : 0.2 - 0.7 mg/dl Direct : 0.1 - 0.3 mg/dl Total : 0.3 - 1 mg/dl Bilirubin: T. = I + D
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Hemolysis
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1. Associated with LOW H/H 2. Abnormal lysis of RBCs 3. Shortened life span of RBCs to half (60 days) 4. Types: a. Intravascular: Free Hb in circulation leads to kidney toxicity i. Haptoglobin goes down ii. Hb GOES DOWN b. Extravascular: i. Hb STAYS THE SAME ii. no effect on direct bilirubin 5. ***TRANSFUSE when Hb <8***
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Haptoglobin Lab Test
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1. Made in the liver 2. Phase reactive protein 3. ***BINDS with free-Hb to prevent kidney damage AND prevent Fe Loss*** 4. ***Range=41-165 mg/dL*** 5. Increased Serum Haptoglobin: a. Acute rheumatic disease b. Biliary Obstruction c. Ulcerative colitis d. Other INFLAMMATORY conditions 6. Decreased Serum Haptoglobin: a. CLD (chronic liver disease) b. Primary liver disease c. Drug induced hemolytic anemia (As well as other hemolytic anemias) d. Transfusion reaction e. Secondary G6PD Deficiency
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RBC Hemoglobin Summary
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Intravascular Hemolysis: Hb (down), Haptoglobin (down), reticulocytes (up) Extravascular Hemolysis: Hb (down), Haptoglobin (normal), reticulocytes (up)
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Summary Overview Anemia
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Retics 2%= increased destruction/loss (increased LDH and bilirubin but decreased haptoglobin=hemolysis; s/s of bleeding=recent acute blood loss)
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WBC
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Neutrophils Monocytes, basophils, eosinophils, lymphocytes
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Granulocytes (basophils, eosinophils, neutrophils, monocytes)
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Bone Marrow Derived Cells Circulating Life Span: 6 - 12 hrs Cells can migrate to tissue, but can not return Tissue Life Span: 2 - 3 days Granules: -Biochemical mediators of inflammation & immune function -Enzymes that destroy microbes & catabolize debris
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Neutrophils
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Granulocyte Segmented Nucleus PMN's : Polymorphonuclear: (3 - 5 lobes) *wbc high bc of PMNs Function: -Inflammation reactant -Infection
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Eosinophils
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PMN / Segs : (2 to 3 lobes) Granules in cytoplasm Granules stain orange-red with eosin Function: -Ingest & kill parasites -Involved in immediate type hypersensitivity -Neutralize histamine Elevated #'s: -parasitic diseases & -hypersensitivity
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Basophils
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PMN / Seg Granules: stain dark blue Function: -Major role in immediate type hypersensitivity -Granules contain histamine
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Monocytes
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Nucleus: single (Not a PMN) Granulocyte (ground glass appearance) Function: -Same as neutrophils (inflammation & infection) -Clot dissolution - plasminogen activator -Part of immune response -More capable than neutrophils to kill intracellular pathogens -Can kill some tumor cells -Cell Surface interacts with platelets (?)
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ANC (Absolute Neutrophil Count): Absolute number of neutrophils
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ANC=Total WBC * % of neutrophils (bands + segs) ***MINIMUM ANC FOR CHEMOTHERAPY=1,500***
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Band
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a. Metamyelocyte b. Pre-neutrophil c. Increased #' s: 2ndary to infection d. Inc = functional bone marrow e. Analogous to Reticulocyte f. "Shift to the Left" g. Not commonly done due to automated CBC ( ANC )
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WBC with Differential
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Normal: 5 - 11,000 Neutrophils: 45 - 75% (4 - 6,000) Monocytes: 5-10% (500-1000) Eosinophils: 0-5% (<450) Basophils: 0-1% (<50) Lymphocytes: 10-45% (2-5000)
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WBC Terms
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Leukopenia: 11,000 Neutropenia: 6,000 i. ANC > 7,000 (or > 7 x 109) ii. Tissue damage iii. Inflammation iv. Infection v. Ketoacidosis vi. Steroids vii. Catecholamines viii. OTHER: Spleenectomy Eosinophilia: (Eosinopenia?) Basophilia: (Basopenia ?) Lymphocytosis & Lymphopenia
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Risk of infection _____ as ANC ______
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increases; decreases
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Key Cell=NEUTROPHILS
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Assessing NeutrophilsThe Absolute Neutrophil Count (ANC).... ANC = Total WBC x % of neutrophils (bands and segs)
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Neutrophilic Band Cell
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Metamyelocyte Pre-neutrophil increase #s: secondary to infection Inc = functional bone marrow Analogous to Reticulocyte "Shift to the Left" Not commonly done due to automated CBC ( ANC )
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Myeloid Kinetics...
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Bone Marrow: E /. G ratio : 1 / 3 1 x 10^9 neutrophils / Kg produced ea day Circ life span: 6 to 12 hrs Marrow Time: 5 - 14 days Proliferation / maturation / storage Severe Infection: Maturation decrease 48 to 72 hrs Infection: Immature cells (ie band Neutrophils) Shift to the left
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Neutrophil Compartments
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Bone Marrow -Production (not available) -Storage : 33 to 50 % mature Neutrophils Circulation (blood vessels): -Circulating Neutrophils: 25 % (part of WBC CT) -Attached to Margins of Vessels: 25 %
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Factors that Affect # Circ Neutrophils
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Partition of marrow storage - marginal & circulating pool is dynamic Inc Circulating Neutrophils -Response to Infection -Shift out of marrow storage -Adm of glucocorticoids -Causes release of marrow and margin Neutrophils -Rel of catecholamines (endogenous or exogenous) -Will inc neutr ct 2 to 3 X
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If you have too many (>100K) WBC...
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Once the white cell counts gets higher they can get symptomatic and can get clogging (leukostasis)...maybe have cancer Clinical Limits with Infection: ~ 40,000 WBC = 50,000 (Neutrophils 95%): Sx?
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WBC grades
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WBC 1) < LLN - 3000 2) < 3000 - 2000 3) < 2000 - 1000 4) <1000 5) Death Neutrophil ANC: 1) < LLN - 1500 2) < 1500 - 1000 3) < 1000 - 500 4) < 500 5) Death
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Summary of Neutrophil Issues
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Neutrophilia: Infections Inflammation Acute Hemorrhage Acute Myeloid Leukemia Exercise Steroids Fight or Flight Neutropenia: Overwhelming Infection Viral Infection Chemotherapy Radoatopm Therapy Hypersplenism
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Lymphocytes
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Essential Cell in Host Defenses Major Components: -B - Cells: Antibody producing cells -T - Cells: Cell mediated immune function -NK Cells: Macrophage like function Divided by Surface Phenotype & Gene Rearrangement -Surface Antigen: CD #
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Lymphocyte Problems
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Leukemia -Acute Lymphoblastic (B or T Cell) -Chronic Lymphocytic (B or T Cell) Lymphomas -B or T or NK Cell -Hodgkin's -Non-Hodgkin's
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Lymphocyte..
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Types: -NK Cells -B - Cells -T - Cells All formed in bone marrow from "stem cell" -B-Cells mature in B.M.--->Lymphoid Tissue -T-Cells in B.M.---->Processed in Thymus
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Lymphocyte overview
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NK cells: large, grandular; functions like macrophage B cells: small lymphocytes; humoral immunity; functions like immunoglobulin T cells: small lymphocytes; cellular immunity
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Types
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i. NK Cells: CD 16 and CD56 positive ii. B - Cells: CD 19 and CD20 positive, surface ig 3. T - Cells: CD3, CD4 (helper), or CD8 (suppressor) positive
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Lymphocyte Issues
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Lymphocytosis: Pertussis Mononucleosis Measles Chicken Pox Mumphs Hepatitis Addison's Diseasd Ulcerative Colitis Lymphocytic Leukemia Lymphocytopenia: Chemotheraphy Radiation Therapy Corticosteroids Cushing Syndrome
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Plasma Cells
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Terminally differentiated cells of B-Lymphocytes lineage Each produce single antibody protein Immune globulin factories Abundant in lymph nodes & marrow
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Major Problem with WBC=Leukemia
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a. All cell types can get Acute or Chronic form: b. Neutrophils 1. Acute Myelogenous Leukemia (AML) 2. Chronic Myelogenous Leukemia (CML) c. Lymphocytes 1. Acute Lymphoblastic Leukemia (ALL) 2. Chronic Lymphocytic Leukemia (CLL)
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Body's Coagulation System
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Clotting Factors / Cascade (Plasma) -extrinsic System (PT time: 10 - 12 sec) -intrinsic System (PTT time: 25 - 38 sec) Platelets (thrombocytes) *150,000 -450,000; BT= 3 - 7 min -Non-nucleated, oblong disk like fragments -Cytoplasmic fragments from Megakaryocyte -Megakaryocytes in bone marrow: < 0.1% -Life span: 9 - 12 days
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Platelet Terminology
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Normal Platelet Count: 150,000 - 450,000 Thrombocytopenia: 450,000 Petechial rash: Pin point hemorrhages Ecchymosis: Bruise
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Thrombocytopenia
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Decreased Platelet Production: Marrow Damage ( Toxins; Malignancy); Congenital; Ineffective Production (B 12 Def, Folate Def.) Abnormal Distribution: Splenomegaly; Liver Disease Increased Destruction: Non-immune (DIC: Disseminated Intravascular Coagulopathy; Others); Immune (Drug Induced; ITP: Idiopathic thrombocytopenia purpura; SLE: Systemic lupus erythematosis)
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Platelet Grading *KNOW THESE*
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Gr 0-normal: 150,000 - 450,000 Gr 1: < 150,000 - 75,000 Gr 2: < 75,000 - 50,000 Gr 3: < 50,000 - 25,000 Gr 4: < 25,000 Gr 5: Death
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Avoid IM injections for those with
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low platelet counts (100K: Major surgery/spinal tap - >50K: Trauma/minor surgery - >20K: Prevention of bleeding in pts with sepsis, leukemia & malignancy - >5K-10K Normal Individuals - <5000 ITP Pts at Low Risk - 20K Consider Platelet Tx in ex: Drug Induced
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Platelet Transfusion Types (you develop ab against them)
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Pooled Single donor Irradiated Leuko reduced CMV safe
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Transfusions
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≤ 10,000 : Prophylactic in failure of production ≤ 20,000 : Signs of hemorrhagic diathesis (petechiae or mucosal bleeding) ≤ 50,000 : Pts with active hemorrhage or recent or planned procedures. Guide: 5 Units of pooled or single donor platelets will usually ↑ platelet ct by 25 - 50,000.
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Thrombocytosis
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Platelet count > 450,000 Transient Increase: 450,000 - 600,000 -Reactive -Physical Stress -Trauma / surgery -Exercise, Infection, or Ovulation > 600,000: Assoc. with Myeloproliferative Disorder Symptomatic: > 1,000,000 -↑ viscosity -Vascular sledging -Inappropriate clotting > 1,000,000: Should Treat & Monitor
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Coagulation and Hemostasis
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Complex, physiological cascade Primary Hemostasis : -initiation of cascade sequence Secondary Hemostasis : -Thrombin generation -Formation of fibrin clots Clotting cascade & Platelet interaction
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Routine Monitoring Tests
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Clotting Factors are made in the Liver Routine Tests for Blood Coagulation: PT : prothrombin time I.N.R. International Normalized Ratio aPTT : activated partial thromboplastin time TT : Thrombin time * Patients with abnormal bleeding *Coagulation abnormalities in pts with Liver Disease *Assessment of hemostasis pre-operative *Anticoagulant drug monitoring *Others
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Prothrombin Time (PT)
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Extrinsic Pathway Vitamin K Factors : II, V, VII, & X Nl PT : ~ 12 - 15 (vs control) Therapeutic PT : 1 ½ to 2 X nl Therapeutic PT : 18 to 24 sec Monitor Warfarin anticoagulant therapy
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International Normalize Ratio (INR)
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Standardization of PT Variability Calculation ratio of PT values Nl : 1 Therapeutic: 2 - 3 (or higher ?) Use: Monitor Warfarin Tx
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Prolonged PT or INR
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Warfarin Therapy Vitamin K Deficiency Liver disease D.I.C. (disseminated intravascular coagulopathy) Factor II, V, VII, X & fibrinogen deficiencies Factor Inhibitors
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Activated Partial Thromboplastin (aPTT)
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Integrity : -Intrinsic Pathway: VIII, IX, XI & XII -Common Pathway: II, V, X & fibrinogen Evaluate Un Fx Heparin Nl : 22 - 35 Therapeutic 60 - 100
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aPTT : Prolongation
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Factor Inhibitors von Willebrand disease (vWD) (Low F VIII) Heparin therapy Direct thrombin inhibitors Direct factor Xa inhibitors Warfarin only mild elevation
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Thrombin Time (TT)
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Measures final step of clotting pathways Conversion of Fibrinogen to fibrin
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Causes of Prolonged TT..
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Heparin therapy Direct thrombin inhibitors Direct aX inhibitors Presence of fibrin / fibrinogen degredation products Hypofibrinogenemia Elevated serum proteins
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Anti-Factor Xa Activity
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Adequacy of anticoagulation of patients on drugs that interfer with Xa activity Heparin Low molecular weight heparin Direct Xa inhibitors
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Fibrin Degradation Products (FDP)
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Fibrin D-Dimer Plasmin cleaves fibrin at multiple sites Releases various FDP's D-Dimer is the major FDP Elevated D-dimer -From fibrin (not fibrinogen) -Elevation indicates recent or ongoing intravascular blood coagulation ie : DVT or PE
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Fibrinogen Assay
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Made in the liver Nl : 1.5 to 4 Acute phase reactant: Inc in inflammation Need levels > 2 for sufficient fibrin clot stabilization. Pre-surgical evaluation: > 2 levels
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Coagulation Evaluation
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D.I.C. Anticoagulation therapy vonWillebrand disease Hemophilia Factor V Leidan - hypercoagulate state Protein C & S Deficiency Antithrombin Deficiency
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Exam Expectations
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Hb/Hct RBC indices: mcv, mch, and mchc Wbc/anc Platelet ct Grading Hb, ANC, and platelets Clotting: nl & therapeutic -PT -INR -aPTT
