Chapter 30 and 31: Hematologic System and Hematologic Problems

Question 1

Gerontologic considerations

Answer 1

Very few changes. May drop slightly, but remain in normal limits. Have a diminished reserve capacity. Have less reserve so harder to fight back after illness esp. with clotting, oxygen transport, and fighting infection. Anemia is NOT an expected finding!
Hgb is only decreased slightly. Need to look for other causes if low. Anemia causes in older adults: 1/3 is nutritional, 1/3 is renal insufficiency or chronic inflammation, 1/3 is unexplained.
Decreased samt red marrow=decreased reserve capacity=harder to fight back.

Question 2

Heredity

Answer 2

Hemophilia, sickle cell disease, thalassemia, hemochromatosis; also possibly leukemia, pernicious anemia, and clotting disorders

Question 3

Medications

Answer 3

Salicylates (i.e. ASA)- platelet function; NSAIDs=- inhibit platelet aggregation; Herbs- MANY herbs affect coagulation; Oral contraceptives- increased clotting risks; Immunosuppressants- affects WBCs; chemo- affects all cells

Question 4

Past surgical procedures

Answer 4

Splenectomy: spleen holds 300 mL of blood, 1/3 of platelets. WBC storage=protective agent. removed=higher circulating platelet level, decreased RBC storage and destruction, decreased immune functioning
Duodenal or ileal surgeries: interferes with iron absorption (B12 absorbed in the ileum, iron absorbed in the duodenum)
Partial or total gastrectomy or ileal resection: affects intrinsic factor (made by parietal cells) and B12 absorption (ileum)
Gastric bypass: interferes with iron absorption (intrinsic factor)
Ileal resection: affects intrinsic factor-B12 absorption

Question 5

Ethnic Decent

Answer 5

African Americans (sickle cell disease), northern Europeans (pernicious anemia), mediterranean’s (thalassemia)

Question 6

Alcohol or cigarette use

Answer 6

GI bleeding, vitamin deficiencies, damages the liver where clotting factors are made 
Smoking leads to hypoxia, affects platelets (promotes platelet aggregation=increased Hct. Increased viscosity d/t interference with oxygenation [promotion of secondary polycythemia-more RBCs to accommodate decreased O2 binding)

Question 7

Nutritional History

Answer 7

Inadequate intake could lead to anemia’s
Must have iron, cobalamin, folic acid to develop RBCs. Liver, meat, eggs, whole-grain, potatoes, leafy green veggies, dried fruits, legumes, citrus fruits

Question 8

Joint Pain

Answer 8

Autoimmune disorder, gout from uric acid from breakdown of cells (hemolytic anemia). Bleeding into the joints, pain from leukemia. Achy bones can happen from pressure of expanding bone marrow in leukemia. Parathesias, numbness, tingling can happen with pernicious anemia

Question 9

Cobalamin

Answer 9

B12

Question 10

Lymph nodes

Answer 10

Should be

Question 11

Pallor and cyanosis

Answer 11

Pallor in mild anemia, cyanosis in severe

Question 12

Clubbing

Answer 12

Chronic anemia (i.e. SCD [Sickle cell disease]). High CO2 associated with hypoxemia. CO2 dilates vessels in fingers=hypertrophy over time

Question 13

Petechiae, bruising, purpura

Answer 13

=platelets. Signs of bleeding; usually a platelet disorder (bleeding into joints or muscles is more likely to be a coagulation factor problem)

Question 14

Splenomegaly

Answer 14

Spleen’s function is to filter the blood, clear microorganisms and antigens, remove abnormal and old RBCs, and store platelets and WBCs, fights the bacteria of meningitis and pneumonia. Can trap all the blood cells, stores 30% of the boy’s platelets (will have a higher circulating level of platelets and potential clotting problems once the spleen is removed). When enlarged it doesn’t work as well and can lead to a decrease in blood cells, increased risk for rupture (s/s: may be asymptomatic, may have abd pain, early satiety, anemia, thrombocytopenia, leukopenia). Splenectomy is done to increase blood cell count or for splenic rupture. Post splenectomy can have immunologic deficiencies leading to a lifelong risk for infection; recommend pneumovax, influenza vaccine
Recycles everything from RBCs. Chronic anemic issue=bad RBC=spleen destroys them. take spleen out to stop it

Question 15

Assess the 3 major blood cells formed in the bone marrow.

Answer 15

CBC

Question 16

Think 12-16. Decreases in anemia, hemorrhage, fluid overload(hemedilution). Increases in polycythemia, dehydration (hemeconcentration).

Answer 16

Hemoglobin

Question 17

Percentage of RBCs in the total blood volume. Affected by the same things as Hgb. Think 35-45. (Hgbx3)

Answer 17

Hematocrit

Question 18

Total RBCs (think 4-5) and types

Answer 18

MCV- Mean corpuscular volume=size (low is small)
MCH Mean corpuscular hemoglobin=weight (low is hypochromia)
MCHC Mean corpuscular hemoglobin concentration=saturation with Hgb (how much of the RBC is saturation with Hgb)

Question 19

Indicates infection/inflammation/leukemia. Total count and differential count which tells the percentage of each type. If lots of bands is called “shift to the left.” Can have a normal ___ but abnormal differential like with neutropenia (multiply the total ___ by the percentage of neutrophils). Should be 4,000-11,000

Answer 19

WBCs
Basophils=allergic response, histamine
Eosinophils=antigen immune response, allergic reactions
Neutrophils=70%, phagocytic, main warriors
Elevated bands=sign of infection. (seg+band)total WBC
Absolute neutrophil count should be 1500-7000. @1000, cautious.

Question 20

Below 100,000 is thrombocytopenia. Thrombocytosis would be >400,000 and cause excessive clotting.
Should be 150,000-400,000

Answer 20

Platelets

Question 21

Indicates the presence of abnormal or immature cells. Looks more closely at the types of cells, shapes of cells, maturity of cells. May also be performed when a person has s/s that suggest a condition affecting blood cell or lifespan.

Answer 21

Peripheral smear

Question 22

Measures clotting time. Normal is 25-35 seconds, but up to 70 if on anticoagulant. Focuses on the intrinsic pathway in the blood clotting process. Monitors the effects of heparin

Answer 22

aPTT/PTT (activated partial thromboplastin time)

PTT (3)+ heparin (7)=10

Question 23

Measures clotting time. Normal 11-13 seconds. Focuses on extrinsic pathway in the blood clotting process. Monitors effects of coumadin.

Answer 23

PT (prothrombin time)

Question 24

Standardized way of reporting the PT. Normal 0.9-1.1 but 2-3 if on anticoagulation. Monitors effects of coumadin

Answer 24

INR (international normalized ratio)

Question 25

Shows hyper coagulability; helps diagnose PE, DIC. Degradation product of cross-linked fibrin (byproduct of the breakdown of a clot), meaning there has been a thrombosis of some sort.

Answer 25

D-dimer

Question 26

Shows bleeding risk; helps diagnose DIC.
Products of dissolving clots.
___ can increase if plasmin has been activated somewhere without there being a clot.
High levels of ___ suggest DIC

Answer 26

FSP (fibrin split products)
FDPs (fibrin degradation products)- in both fill in the blanks
Each of these possess anticoagulation factors themselves too

Question 27

If low suggests bleeding risk if high suggests hyper coagulability

Answer 27

Fibrinogen

Question 28

Used to identify sickle cell anemia, thalassemia. Measures the different types of hemoglobin in the blood. Hub s should sickle cell anemia. Hub C is found in types of hemolytic anemias, diagnose thalassemia.

Answer 28

Hemoglobin electrophoresis

Question 29

Immature RBBCs. Increased in bleeding, hemolytic anemia. Decreased in other types of anemia.

Answer 29

Reticulocyte count

Need more RBC=EPO release to bone marrow=make more RBC. Immature RBC=reticulocyte

Question 30

Measure the settling rate of RBCs. Shows increased cell destruction. Usually indicative of inflammation.

Answer 30

Erythrocyte sedimentation rate (ESR)

Question 31

Iron tests

Answer 31

TIBC=total iron binding capacity. All proteins that bind or transport iron between the tissues and the bone marrow. Take iron where it needs to go.
2/3 of total body iron bound the heme in erythrocytes and muscle cells.
Ferritin=body iron stores- bone marrow, spleen, liver, and macrophages (recycle iron when RBC/muscle breakdown)
Transferrin saturation=better indicator of iron availability than iron because this iron is already bound and ready to be used. If iron is not bound to transferrin, it cannot be used

Question 32

Urine test used to determine whether the body absorbs B12 (cobalamin). Ct is given an oral dose of radioactive B12 and then 2-6 hours later is given a non-radioactive injection of B12. Urine is then collected to see how much B12 is absorbed. Several stages of this test can be given to determine if the problem is with intrinsic factor. Low level in urine=properly absorbing. High level=intrinsic factor problem.

Answer 32

Schilling test

Question 33

MAY use conscious sedation and local anesthetic. Preferred site- posterior iliac crest. VERY PAINFUL. Gives a full evaluation of hematopoiesis. Need signs consent. Pressure dressing over site. Lie on rolled towel for additional pressure for 30-60 minutes post procedure. May be sore for 3-4 days after.
Look for shadowing, bleeding

Answer 33

Bone marrow Examination

Question 34

Low RBC production: deficiencies, aplastic anemia (not making anything), anemia of chronic disease. Blood loss. High RBC destruction: SCD, G6DP, external damage (rhabdo, crush injuries, dialysis). Risk of fatigue and possible hypoxia.

Answer 34

Anemias (low RBCs, Hgb, Hct)

Question 35

Hemophilia, von Willebrands. ITP, TTP, HIT, DIC. Risk of bleeding.

Answer 35

Thrombocytopenia (low platelets)

Question 36

Risk of infection

Answer 36

Neutropenia (low neutrophils/WBCs)

(segs+bands)xWBC

Question 37

All cell types are low. Process of aplastic anemia.

Answer 37

Pancytopenia

Question 38

Causes thrombocytopenia, anemia, leukopenia

Answer 38

Splenomegaly

Question 39

Hypoxia is the primary cause (increase RBC, won’t help if not enough O2). Can cause stroke. Too many cells. Can be primary or secondary.

Answer 39

Polycythemia

Question 40

Too much iron. Can be deadly. Absorption increases to toxic levels. Body will deposit it in all organs to try to get rid of it.

Answer 40

Hemachromatosis

Question 41

cancers

Answer 41

Leukemia, hodgkins lymphoma, non-hodgkins lymphoma, multiple myeloma