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
