HEMATOLOGY

JCYUSANTOS
 Functions of Blood
 Transport of:
 Gases, nutrients, waste products
 Processed molecules
 Regulatory molecules
 Regulation of pH and osmosis
 Maintenance of body temperature
 Protection against foreign substances
 Clot formation
Composition of Blood
Plasma
 Liquid part of blood
 Pale yellow made up of 91% water, 9% plasma
proteins
 Albumin: Important in regulation of water
movement between tissues and blood
 Globulins: Immune system or transport
molecules
 Fibrinogen: Responsible for formation of blood
clots
Formed Elements
 Red blood cells (erythrocytes)
 White blood cells (leukocytes)
 Granulocytes
 Neutrophils
 Eosinophils
 Basophils
 Agranulocytes
 Lymphocytes
 Monocytes
 Platelets (thrombocytes)
Production of Formed Elements
 Hematopoiesis or hemopoiesis:
Process of blood cell production
 Stem cells: All formed elements
derived from single population
 Proerythroblasts: Develop into red blood
cells
 Myeloblasts: Develop into basophils,
neutrophils, eosinophils
 Lymphoblasts: Develop into lymphocytes
 Monoblasts: Develop into monocytes
 Megakaryoblasts: Develop into platelets
Hematopoiesis
Erythrocytes
 Structure
 Biconcave,
anucleate
 Components
 Hemoglobin
 Lipids, ATP, carbonic
anhydrase
 Function
 Transport oxygen
from lungs to tissues
and carbon dioxide
from tissues to lungs
 Hemoglobin

 Consists of:
 4 globin molecules: Transport carbon dioxide
(carbonic anhydrase involved), nitric oxide
 4 heme molecules: Transport oxygen
 Iron is required for oxygen transport
 Erythropoiesis

 Production of red blood cells

Stem cells proerythroblasts early
erythroblasts intermediate late
reticulocytes
 Erythropoietin: Hormone to stimulate RBC
production
Hemoglobin Breakdown
Leukocytes
 Types
 Neutrophils: Small
 Protect body phagocytic cells
against  Eosinophils: Reduce
microorganisms inflammation
and remove dead  Basophils: Release
histamine and
cells and debris
increase inflammatory
 Movements response
 Ameboid  Lymphocytes:
 Diapedesis Immunity
 Chemotaxis  Monocytes: Become
macrophages
Leukocytes
Thrombocytes
 Cell fragments
pinched off from
megakaryocytes in
red bone marrow
 Important in
preventing blood
loss
 Platelet plugs
 Promoting
formation and
contraction of clots
Hemostasis

 Arrest of bleeding
 Events preventing excessive blood
loss
 Vascular spasm: Vasoconstriction of
damaged blood vessels
 Platelet plug formation
 Coagulation or blood clotting
Platelet Plug Formation
Coagulation
 Stages
 Activation of
prothrombinase
 Conversion of
prothrombin to
thrombin
 Conversion of
fibrinogen to fibrin
 Pathways
 Extrinsic
 Intrinsic
Clot Formation
 EXTRINSIC
 Clotting process is initiated by tissue
damage and blood loss
 INTRINSIC
 Clotting mechanism within the vessel
where blood loss and tissue trauma are
not present
Fibrinolysis

 Clot dissolved by
activity of
plasmin, an
enzyme which
hydrolyzes fibrin
Blood Grouping

 Determined by antigens
(agglutinogens) on surface of RBCs
 Antibodies (agglutinins) can bind to
RBC antigens, resulting in
agglutination (clumping) or hemolysis
(rupture) of RBCs
 Groups
 ABO and Rh
BLOOD CLASSIFICATION
 MAJOR BLOOD GROUPS
 A, AB, B, O
 Blood compatibility and systems of
classification are based on the presence
or absence of specific antigens present
on RBCs, as well as specific antibodies in
the plasma
 There are two antigens, or
agglutinable substances, presnt on
RBC’s : A and B
 Neither antigen is present in O
 A is present in A
 B is present in B
 A and B are present in AB
 There are two antibodies present in
the plasma:
 Both antibodies are present in O
 Anti- B is present in A
 Anti- A is present in B
 Neither is present in AB
 If the antigen A on the RBCs of the
donors comes in contact with the
antibody A of the recipient and vice
versa, agglutination and clumping will
occur. (Example: type A blood
transfused into type B recipient)
 O negative is called the universal
donor because there are no antigens
on the RBCs and the Rh factor is not
present
 AB positive is called the universal
recipient because there are no
antibodies in the serum and the Rh
factor is present
ABO Blood Groups
Agglutination Reaction
Rh Blood Group
 First studied in rhesus monkeys
 Types
 Rh positive: Have these antigens present on
surface of RBCs
 Rh negative: Do not have these antigens
present
 Hemolytic disease of the newborn (HDN)
 Mother produces anti-Rh antibodies that
cross placenta and cause agglutination and
hemolysis of fetal RBCs
Erythroblastosis Fetalis
Diagnostic Blood Tests
 Type and crossmatch
 Complete blood count
 Red blood count
 Hemoglobin
measurement
 Hematocrit
measurement
 White blood count
 Differential white
blood count
 Clotting
Blood Disorders

 Erythrocytosis: RBC  Hemophilia

overabundance  Thrombocytopenia
 Anemia: Deficiency  Leukemia
of hemoglobin
 Septicemia
 Iron-deficiency
 Pernicious  Malaria
 Hemorrhagic  Infectious
 Hemolytic mononucleosis
 Sickle-cell  Hepatitis
ASSESSMENT
ASSESSMENT
 HISTORY
 Disease of the bonemarrow and RBC producing
organs
 Treatment that depressed bone marrow activity
 Family history
 Blood transfusion
 Bleeding problems occuring during
pregnancy, labor and delivery
 Presence of chronic d/o
 Effects of aging
 Age related assessment
EFFECTS OF AGING
 ASSESSMENT AREA
 NAIL BEDS (check for capillary refill)
 Pallor, cyanosis, and decreased capillary
refill is often noted in hematologic problems
 In elderly:
 Nails are typically thickened and discolored
 Need to use another body area, such as the
lips to assess capillary refill
 HAIR DISTRIBUTION
 Thin or absent hair on trunk and
extremities may indicate poor
oxygenation and blood supply to area
 In elderly:
 Older adults are losing body hair, but often
in an even pattern distribution that has
occurred slowly over time
 Lack of hair on lower legs and toes may
indicate poor circulation
 SKIN MOISTURE AND COLOR
 Skin dryness, pallor and jaundice may occur with
anemia, leukemia
 In elderly:
 Dry skin is a normal aspect of aging and thus
becomes an unreliable indicator of skin
moisture
 Pigment loss and skin changes along with some
yellowing occur with aging
 Pallor that is not associated with anemia may
not be noted in older adults, because they tend
not to go outdoors and get exposed to sunlight
ASSESSMENT, cont’n
 Evaluate effect hematologic disorder has on client’s
ADL
 How long has client experienced symptoms?
 What are current activities and metabolic
requirements of the client?
 Presence or absence of bleeding episodes?
 Ability to control pain
 Presence of appropriate coping or defense
mechanism
 Assess client’s nutritional status
 Evaluate current blood values
 Evaluate status of respiratory and cvs system in
maintaining homeostasis
COLLECTING SUBJECTIVE DATA
 Weakness, fatigue, palpitations
 Nausea, dyspnea
 Pain, numbness, prickling or tingling sensations; bone
and joint pain a predominant symptom
 Irritability, bleeding from the nose and mouth,
bruising
 Ashen, pale, cyanotic, or jaundice sclera, headache
 Reports of skin breakdown and delayed healing
 Numbness, burning of feet
 Complaints of persistent or sporadic fever
COLLECTING OBJECTIVE DATA
 Tachycardia
 Pallor or jaundice, the latter possibly indicating destrcuction
of the RBC or specific liver, GB, or splenic alterations
 Pruritus
 Petechiae, ecchymosis, purpura
 Skin lesions
 Excess joint edema
 Mouth ulcerations, red beefy or smooth tongue
 Hypotension
 Painful lymph nodes
 Macular rash
 Blood in stools
 Hemoptysis
 hematuria
DIAGNOSTICS
 BONE MARROW ASPIRATION/BIOPSY
 All formed cell elements within normal range
 Evaluates presence, absence or ratio of cells
characteristic of a suspected disease
 Preferable site:
 Posterior iliac crest
 Client preparation: local anesthetic is used, as
well as analgesia, feeling of pressure when
bonemarrow is being withdrawn
 After test: observe for bleeding at the site,
apply pressure to site, bed rest fo approx. 30
min afterward, analgesics as indicated
Activated partial thromboplastin
time

 APTT
 Normal 30 -45 sec
 Sensitive in monitoring heparin; draw 1
hr before next heparin dose
 May be used to detect circulating
anticoagulant
 Nursing consideration:
 Do not draw samples from an arm into which
heparin is infusing
 PROTHROMBIN TIME
 10-13 sec
 Production of prothrombin depends on adequate
intake and utilization of Vitamin K
 Used in the management of Coumadin therapy
 INR ( International normalized ratio)
 Normal INR is 1.0-2.0
 INR should be maintained at 2.0 -3.0 for
individuals with risk for clots ( atrial fibrillation
and history of recent DVT) and 2.5 – 3.5 for
individuals with mechanical heart valves
CLOTTING TIME
 Measures the time required for the
interaction of all factors involved in the
clotting practice
 N: 8 to 15 min
 Nursing considerations:
 The client should not receive heparin therapy for
3 hours prior to specimen collection
 Test results is prolonged by any anticoagulant
therapy, test tube agitation, or high temperature
changes that may affect the specimen
PLATELET COUNT
 Platelet function in hemostatic plug formation, clot
retraction and coagulation factor activation
 Platelets are produced by the bone marrow to
functions in hemostasis
 150, 000 to 400,000 cells/uL
 Nursing considerations:
 Monitor the side for bleeding in clients with known
throbocytopenia
 High altitudes, chronic cold water, and exercise
increase platelet count
 Bleeding precautions should be instituted in client
with a low platelet count
Erythrocyte sedimentation rate
 The rate at which erythrocytes settle
out of anticoagulated blood in 1 hour
 Not diagnostic of any particular
disease but indicates disease process
is ongoing
 Normal value: 0 – 30 mm/hour,
depending on age of client
RBC COUNT
HEMOGLOBIN and HEMATOCRIT
 Hemoglobin
 Main component of erythrocytes and serves as
the vehicle for the transportation of oxygen and
carbon dioxide
 Are important in identifying anemia
 Male: 14-16.5 g/dl
 Female : 12-15 g/dl
 Hematocrit
 Represents Red blood mass
 Used in identification of anemia or polycythemia
 Male : 42% - 52%
 Female : 35 – 47%
RETICULOCYTE COUNT
 Provides information regarding cause
of the anemia
 Distinguishes between decreased
production or excessive loss or
destruction of RBCs
ERYTHROCYTE INDICES
 Aids in describing anemias
 Provides information regarding
relationship between size, number
and hemoglobin content of RBC’s
SERUM IRON AND TOTAL IRON
BINDING CAPACITY
 Aids in classification of anemia
 Aids in differentiating between acute
and chronic anemia
PLATELET COUNT
 Check platelet level
 if low platelet count – potential for
spontaneous hemorrhage
Serum bilirubin
 Aids in evaluating degree of
hemolysis of red blood cells
 Increased levels may indicate
destruction of RBC’s
VITAMIN B12 LEVEL
 Determines adequacy of B12 levels
Serum folate level
 Aids in classification of anemia
Sickle cell preparation
 Analysis of reaction to hypoxia
 Sickling of cells suggests sickle cell
anemia or sickle cell trait
Hemoglobin electrophoresis

 Separation into various hemoglobin

types through the utilization of an
electric field
 Presence of hemoglobin A or S
indicates presence of sickle cell
anemia or sickle cell trait
 Presence of Hemoglobin F indicates
presence of thalassemia
WBC COUNT AND DIFFERENTIAL
 Determines total number of
leukocytes
 Evaluates each type and proportion of
WBC’s
 Aids in diagnosis of infection and
blood disorders such as leukemia
Gastric analysis
 Absence of hydrochloric acid in
gastric contents indicates pernicious
anemia
SCHILLING TEST
 Used in classifying anemias,
especially vitamin B12 disorders
 Aids in differentiating between
intrinsic factor deficiency and an
intestinal malabsorption disorder