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Function of Blood

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-Transports oxygen from the lungs. -Brings nutrients from GI tract to the cells -Protects the body from dangerous micro-organisms -Promotes hemostasis/Blood clotting -Regulates body temp

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Blood Forming Organs

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Bone marrow Thymus Spleen Liver Lymph nodes

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Hematopoiesis

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Process of blood cell production. Takes place primarily in the bone marrow (flat bones and end of long bones in adults)

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Blood Components

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Plasma Red Blood Cells White Blood Cells Platelets

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Plasma

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55% of blood Composed mostly of water Contains proteins, electrolytes, gases, nutrients

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Plasma Proteins

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Albumin Globulins (3 types) Fibrinogen Prothrombin

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Blood Cells

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45% of blood Formed from stem cells (undifferentiated) Three types: Erythrocytes (red blood cells) Leukocytes (white blood cells) Thrombocytes (platelets)

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Erythrocytes

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Transport of gases Assist in maintaining acid base balance

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Leukocytes

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Protection from infection, cancer

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Platelets

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Promote blood coagulation in response to injury

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Erythrocyte structure and function

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Thin cell wall to facilitate diffusion of gases Flexible cell wall, able to alter shape to pass through small capillaries Primarily composed of hemoglobin Live approx 120 days Growth factor Erythropoietin involved in development

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Hemoglobin

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Produced by erythrocytes Each normal RBC contains hundreds of thousands of Hgb molecules Each molecule of Hgb needs one molecule of iron to transport up to four molecules of oxygen.

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Leukocytes structure and function

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Appear white when separated from blood Two categories: Granulocytes, Agranulocytes 5 types of WBC, various functions

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Platelets structure and function

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Smallest of blood cells Perform most of their functions through aggregation Develop in the bone marrow Growth factor thrombopoietin involved in development

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Hemostasis: The process of blood clotting

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Vascular spasm Plug formation Development of fibrin clot Lysis of clot

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Coagulation Modifiers (pharma)

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Heparins Coumadin Direct Thrombin inhibitors Selective factor Xa inhibitor Aggregation inhibitors

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Hematologic Assessment - Testing

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Complete Blood Count Reticulocyte Count Peripheral Blood Smear Coomb's Test Coagulation Screening Tests Bone Marrow Aspiration and Biopsy

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Reticulocyte Count

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Used to determine the responsiveness of the bone marrow to the depletion of circulating RBCs.

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Peripheral Blood Smear

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Looking at the blood under a microscope to determine the abnormalities or variations of RBCs, WBCs, and Platelets.

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Coomb's Test

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Used for blood typing and crossmatching. Identifies antibodies on RBCs.

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Coagulation Screening Tests

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Partial Thromboplastin Time (PTT): used to identify deficiencies of coagulation factors, prothrombin and fibrinogen. Prothrombin Time (Pro-Time or PT): measures the activity and interactions of prothrombin, fibrinogen, factors V, VII, and X.

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Bone Marrow Aspiration and Biopsy

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Performed to evaluate the pt's hematological status when other tests show persistent abnormal findings, that indicate problems with blood cell production or maturation.

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Erythrocyte Disorders

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Erythrocytes are the major cell in the blood Responsible for tissue oxygenation RBC disorders include problems in production, function, and destruction.

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Anemia

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Decreased production of RBCs, Hgb, or hematocrit (HCT)

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Polycythemia

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Excess production of RBCs

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Anemia symptoms

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Integumentary: Pallor, jaundice, pruritis Cardiopulmonary: increased HR, tachypnea, orthopnea, dyspnea at rest, orthostatic hypotension, decreased oxygen saturation. GI: anorexia, sore mouth, splenomegaly, hepatomegaly General: sensitivity to cold, lethargy

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Nutritional Deficit Anemias

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Iron Deficient Anemia Vitamin B12 Anemia Folic Acid deficient anemia

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Iron Deficiency Anemia

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A c microcytic anemia due to inadequate absorption of iron. Most common anemia worldwide Often affects the very young, menstuating women, vegetarians, and people with very poor diets

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Symptoms - Iron deficiency anemia

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Often asymptomatic Headache, dyspnea, dizziness, cold sensitivity, pallor Brittleness of hair, dry spoon shaped nails

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Nursing Care - Iron deficiency anemia

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Monitor for signs of bleeding Encourage pt to rest to conserve energy Encourage iron rich diet, consult dietary Medicate as odered Pt. education

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Vitamin B12 Deficiency Anemia

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A macrocytic anemia Results from poor intake of vitamin B12 rich foods More frequent in vegetarian diets or dairy free diets. Common in alcoholics Pernicious anemia is the most common form, results from poor absorption of B12 due to lack of intrinsic factor in the stomach

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Vitamin B12 deficiency - Symptoms

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Pallor, yellow pale skin with pernicious anemia Glossitis (red beefy tongue) Fatigue Weight loss Pernicious anemia may cause parasthesias (burning or prickling sensation) in the hands and feet Poor balance

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Vitamin B12 deficiency - Nursing Care

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Encourage rest Patient may require B12 injections for life (pernicious) Regulate diet, increase calories Promote gentle mouth care

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Folic Acid or Folate Deficiency Anemia

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A macrocytic anemia Manifestations are similar to B12 deficiency Nervous system function remains normal Disease develops slowly

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Folic Acid or Folate Deficiency Anemia - Causes

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Poor nutrition (most common) Malabsorption syndromes such as Crohn's disease Chronic alcohol abuse with malnutrition.

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Sickle Cell Disease (Anemia)

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-Genetic disease -Results in chronic anemia, pain, disability, organ damage, increased risk for infection, early death -Caused by an autosomal recessive inheritance of two defective gene alleles for hemoglobin synthesis. -Red blood cells assume abnormal, rigid, sickle shape. -Causes decreased blood flow

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Sickle Cell Disease - Physical Assessment

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Pain is most common symptom of SCD crisis Cardiovascular changes Skin changes Kidney and urinary changes Musculoskeletal changes

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Conditions that cause sickling

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Hypoxia Dehydration Pregnancy - due to vascular strain Alcohol consumption Cold weather, cold water consumption, swimming Strenuous exercise Emotional stress High altitudes

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Sickle Cell Disease - Medical Management

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Children born with SCD require close observation Folic Acid 1 mg. daily for life Children from birth - 5 take PCN (penicillin) daily due to immature immune system Painful crises are treated symptomatically Hydroxyurea has been shown to decrease crisis episodes.

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Sickle Cell Disease - Nursing Care

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Primarily supportive care Frequent pain assessments Administration of prescribed medications Hydrate with caffeine-free beverages and IV fluids Administer oxygen Keep patient warm Complementary therapies Psychosocial support for patient and family Education re: methods to prevent crisis.

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Aplastic Anemia

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Inability of bone marrow to produce mature erythrocytes. Usually occurs with leukopenia (reduction of leukocytes) and thrombocytopenia (reduction of thrombocytes) Most common variety is acquired 50% of cases cause is unknown Pts. with severe, untreated aplastic anemia have a rapid fatal outcome All patients should be referred to a hematologist.

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Aplastic Anemia - Assessment

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Weakness and fatigue Pallor Purpura and Petechiae Frequent bacterial and fungal infections Mucosal and skin bleeding

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Aplastic Anemia - Treatment

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-Blood transfusions are used when anemia causes disability or the bleeding is life threatening -Stem cell transplant is the most effective treatment -Splenectomy may be necessary for patients with enlarged spleen that is either destroying normal RBCs or suppressing their development. -Mild cases may be treated with supportive care and use of growth factors such as Epogen. -Antibiotics often administered due to leukopenia

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Polycythemia

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Overproduction of erythrocytes Blood is hyperviscous Underlying cause is unknown

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Polycythemia Vera (PV)

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Most common variety of Polycythemia Fatal if untreated Is a cancer of the blood

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Polycythemia Vera - Assessment

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Increased RBC, Hgb, HCT Facial skin and mucous membranes are dark, flushed Pruritis (itchy skin) Hypertension Prone to clot formation Headache, dizziness

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PV - Management and Care

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Pheresis (removal of RBCs and whole blood to reduce viscosity) Increased hydration to help prevent clotting Anticoagulant therapy ASA for decreased clot formation (unless there is risk for GI bleed) Assess for early signs of thromboembolic events Patient education

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White Blood Cells

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WBC (Leukocyte) provide protection from infection and cancer development

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Leukocyte disorders

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Conditions characterized by an abnormal production of blood cells in the bone marrow. Leukemia Lymphomas Multiple Myeloma

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Leukemia

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-Bone marrow produces abnormal white cells that are called leukemia cells or leukemia blast cells. -These cells divide and copy indefinitely -Leukemia cells don't die or become damaged. -They eventually crowd out normal blood cells. -Low level of normal cells can decrease oxygenation to tissues, affect clotting, and affect body's ability to fight infection.

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Leukemia Signs and Symptoms

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Frequent infections Fatigue/Weakness Bleeding - most often nose bleeds Bruising Fever/Chills Anorexia, weight loss Swollen or tender lymph nodes Bone or joint pain

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Leukemia - Most Common

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Acute myeloid leukemia (AML) Acute lymphoblastic leukemia (ALL) Chronic myeloid leukemia (CML) Chronic lymphocytic leukemia (CLL) Leukemias are named based on whether they are acute or chronic, and by the type of white blood cell that is affected.

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Leukemia Treatments

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Watchful waiting with chronic leukemias Immediate treating with acute leukemias

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Leukemia Treatment Options

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Chemotherapy Radiation therapy Stem cell transplant

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Hematopoietic Stem Cell Transplant (HSCT)

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-Standard treatment for leukemia and other hematopoietic cancers -3 types: Allogeneic, Autologous, and Synergetic -Cells transplanted may be obtained by marrow harvest, peripheral blood stem cell harvesting, or umbilical cord blood harvesting.

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Leukemia - Nursing Care

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-Treat side effects related to chemotherapy or radiation therapy -Monitor patient for bleeding -Educate pt. on s/s of, and ways to minimize bleeding -Educate pt. on avoiding infection in hospital, home, and community -Provide psychosocial support. Refer to support groups.

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Lymphomas

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Cancers of the lymphoid tissue Due to an abnormal overgrowth of lymphocytes The growth of the cells occur in the lymph nodes and the spleen (not the bone marrow like leukemia)

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Two types of Lymphoma

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Hodgkin's Lymphoma (Hodgkin's disease) Non-Hodgkin's Lymphoma

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Hodgkin's Lymphoma

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Occurs in two major age groups: Teens and young adults Adults in their 50's and 60's Cause unknown One of the most treatable cancers Diagnosed by the specific cancer cell discovered during the examination of the biopsy of the lymph node Specific staging criteria

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Hodgkin's Lymphoma - Nursing Care

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Focuses on treating the side effects related to chemotherapy and radiation

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Side Effects of Chemotherapy and Radiation

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Pancytopenia nausea and vomiting Constipation or diarrhea Impaired liver function Skin problems from radiation Sterility in men

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Non-Hodgkin's Lymphoma

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-Includes all lymphoid lymphomas that do not have Reed-Sternberg cells -Represent a very diverse set of diseases -Exact cause unknown -Staging is more complicated than Hodgkin's -More common in men and older adults -Treatments include chemo, localized radiation, and hematopoietic stem cell transplantation.

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Non-Hodgkin's Lymphoma - Physical Assessment

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Pts. with indolent lymphoma usually have painless lymph node swelling Pts. with more aggressive lymphomas may have large abdominal or mediastinal masses that rapidly become symptomatic after diagnosis constitutional symptoms occur in 1/3 of pts.

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Multiple Myeloma

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-WBC cancer involving a mature lymphocyte known as the plasma cell which secrete antibodies. -When the myeloma cells are overproduced, few functional RBCs, WBCs, and Platelets are produced. -Multiple Myeloma cells also produce cytokines that increase the cancer cell growth rates and destroy bone. -Without treatment the disease causes progressive bone destruction, kidney failure, bleeding problems, and death.

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Multiple Myeloma - S/S

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Fatigue Anemia Bone pain Unexplained fractures Recurrent bacterial infections Kidney dysfunction

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Congenital Disorders of Coagulation

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Coagulation or clotting disorders can result from a clotting factor defect

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Common Clotting Factor disorders

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Hemophilias A and B Von Willebrand's disease

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Hemophilia

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hereditary bleeding disorders resulting from clotting factor deficiencies X-linked recessive trait Pt. has abnormal bleeding in response to any trauma Incidence is 1 in 10,000

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Hemophilia A

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Hemophilia A is the most common. A is caused by a deficiency in factor VIII. Treated with regular infusions of factor VIII

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Hemophilia B

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Less common Caused by deficiency in factor IX Treated with regular infusions of factor IX

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Transfusion Therapy

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Whole Blood Red Blood Cells Platelets Plasma Cryoprecipitate

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Transfusions - Nursing interventions

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Verify PCP order 2 nurses must check label for: Name and DOB of patient Blood component Blood type Rh factor Serial number Expiration date

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Administering blood products

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Verify patient's name and DOB Set up equipment Obtain a baseline set of vitals Begin transfusion slowly Obtain vitals every 15 minutes for first hour, then hourly Assess hourly or more often Remain with patient for the first 15 mins or longer Ask the pt. to report any chills, SOB, hives, itching, etc

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Hemolytic Reaction

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Caused by incompatibility between donor and recipient Clinical signs: Chills Fever Headache Dyspnea cyanosis Tachycardia Hypotension

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Hemolytic Reaction - Nursing Interventions

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Immediate response is crucial! STOP transfusion Send remaining blood back to the lab Notify PCP immediately Monitor Vitals Monitor I&O Place on oxygen Saline at KVO

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Febrile Reaction

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Caused by sensitivity of the patient's blood to the WBCs, platelets, or plasma proteins of donor's blood. Clinical signs: Fever Chills Flushed skin headache Muscle pain Anxiety

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Febrile Reactions - Nursing Interventions

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STOP transfusion Notify PCP Administer antipyretics as ordered Saline at KVO

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Allergic Reaction

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Caused by sensitivity to infused plasma proteins, or an antibody-antigen reaction (severe) Clinical Signs: Flushing Itching Hives Wheezing Anaphylaxis

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Allergic Reaction - Nursing Interventions

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STOP transfusion Notify PCP Administer antihistamine as ordered Saline at KVO Rapid Response if needed

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Bacterial Reaction

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Caused by administration of contaminated blood Clinical signs: High fever Chills Tachycardia Tachypnea Hypotension Abdominal Pain Vomiting, diarrhea

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Bacterial Reaction - Nursing interventions

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STOP transfusion Notify PCP Send remaining blood to lab Obtain blood culture from patient Administer IV fluids and antibiotics as ordered

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Circulatory Overload

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Caused by blood transfused faster than the patient's circulatory system can accomodate Clinical signs: Cough Dyspnea Crackles Distended neck veins Tachycardia Hypertension

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Circulatory Overload - Nursing Interventions

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STOP transfusion Notify PCP Administer diuretics as ordered Apply oxygen

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