Band Cells (aka Stab Cells)
"Baby" WBCs. They have unsegmented nuclei. Developmental stage of the neutrophil immediately preceding the mature segmented form.
What is a "shift to the left"
Relative increase in immature forms of blood cells. On a cascade diagram of how blood cells mature, the immature cells are on the left side of the old, standard diagram, thus the term. So, left shift typically means there are more band cells (% bands) in a CBC with differential. Bands are "baby white cells." If the body is producing and mobilizing a large number of new white cells, then the body is attempting to fight off a very active infection. Normally, we only have 2-6% of our white cells as bands. If that percentage increases, then the infection is such that the body feels it's necessary to kick the baby white cells out of the nest before their time in order to join in the fight.
Preferred diagnostic test for evaluating deep lymph nodes is:
CT scan is now the preferred diagnostic test for evaluating deep lymph nodes. It is less invasive than lymphangiography, requires less patient preparation, and has no major side effects.
Pernicious anemia results from:
The absence of a glycoprotein intrinsic factor secreted by the gastric mucosa
What is polycythemia
A condition that results in an increased level of circulating red blood cells in the bloodstream. People with polycythemia have an increase in hematocrit, hemoglobin, or a red blood cell count above the normal limits.
What is Disseminated Intravascular Coagulation
aka DIC, a grave disease process in which the patient experiences both bleeding and intravascular clotting at the same time. It results from the overstimulation of clotting and anticlotting processes in response to disease or injury, including septicemia, obstetrical complications, malignancies, tissue trauma, transfusion reactions, burns, shock, or snake bites.
The most severe risk for a patient with agranulocytosis is...
Infection. Agranulocytosis is a potentially fatal condition of the blood characterized by a severe reduction in the number of granulocytes. Both the WBC count and the differential neutrophil counts are extremely low. The patient with this disorder is highly susceptible to a life-threatening infection.
CBC (Complete Blood Count)
Several tests analyzing the 3 major cells manufactured in the blood marrow. Includes RBC count, WBC count, H&H levels, erythrocyte index, hemoglobin levels, WBC differential, examination of the peripheral blood cells. Can indicate infection, anemia
Measures the size and hemoglobin content, provides info about the average volume or size of a single RBC (MCV - Mean Corpuscular Volume)
MCV - Mean Corpuscular Volume
Measured in the Erythrocyte Index, the MCV measures the size and volume of a single RBC
MCH - Mean Corpuscular Hemoglobin
Measured in the Erythrocyte Index, the MCH measures the average amount (weight) of hemoglobin within a RBC
MCHC - Mean Corpuscular Hemoglobin Concentration
Measured in the Erythrocyte Index, the MCHC measures the average percentage or concentration of hemoglobin within the RBC
The most informative of all the hematological tests. All 3 blood cell lines can be examined. Allong with the WBC differential, allows examination of the size, shape and structure of individual RBCs and platelets, differentiates between various forms of anemias and blood dyscrasias (pathologic condition or disorder such as leukemia or hemophilia in which the constituents of the blood are abnormal or are present in abnormal quantity).
To diagnose pernicious anemia. Measures the absorption of radioactive Vit B12 before and after parenteral injection of intrinsic factor. The level of Vit B12 is measured in urinary excretion. Normal range - 8% - 40% excretion within 24 hours.
Megaloblastic Anemia Profile
Is replacing the Schilling Test, it is a serum test that measures Vit B12 methylmalonic acid, and homocysteine levels.
To diagnose pernicious anemia. Gastric secretions are minimal and pH remains elevated even after injections of histamine.
To diagnose metastatic involvement of the lymph nodes. Raidological exam, contrast medium is injected into the lymph vessel of the hand or foot, followed by visulization of the lympatic system. (Note: CT is now the preferred method of examination)
Bone marrow aspiration or biopsy
To diagnose when other tests (peripheral smear) do not clearly establish. Removal via needle aspiration of bone marrow or biopsy, sample is from posterior ilium crest or sternum and examination. It specifically can diagnose and analyze treatment response of persons with marked anemia, neutropenia (decreased WBCs), acute leukemia and thrombocytopenia (decreased number of platelets)
Hematological and Lymphatic System Disorders - Assessment
Malaise, fatigue, weakness. Signs - patient may complain of history of illness, easy bruising, bleeding tendency with petechiae & ecchymosis, non-healing cuts and bruises, draining lesions, jaundice. Symptoms - GI symptoms, cardiovascular and respiratory changes, headache, numbness, tingling, paresthesia, behavioral changes.
Define the types of anemia
Hypovolemic - deficiency in RBCs and other components due to hemorrhage - short term
Aplastic - unknown cause, may be congenital, marrow failure - can be short or long term
Pernicious - metabolic defect
Iron deficiency - RBCs have decreased level of hemoglobin from dietary insufficiency -
Sickle Cell - abnormal, crescent shape of RBC - long term
Hemolytic - increased RBC destruction ()
Macrocytic - Folic acid deficient
Below normal range levels of RBCs, hemoglobin and/or hematocrit, causes an insufficient amount of oxygen to be delivered to cells and tissues.
STAGE 1: Injury - activates clotting factors that produce prothrombin activator (PTA)
STAGE 2: In the presence of Ca, platelet chemicals and PTA (and Vit K) prothrombin is activated to form thrombin
STAGE 3: Thrombin activates fibrinogen. Activated fibrinogen forms fibrin fibers or the fibrin net. The net traps other blood cells platelets, and particles to form the clot.
Loss of 1000 mL is severe (complications include hypovolemic shock). Usually related to internal or external hemorrhage. Loss of volume causes decrease of oxygen to tissues and cells. Average total volume = (6000 mL (6 L or 12 pints), most can tolerate a loss of up to 500 mL.
S & S - restlessness, subtle rise in respiratory rate, weakness, stupor, irritability, and pale, cool, mosit skin.
Early stage - Occurs with (750 - 1000 mL) blood loss, heart rate is less than 100/min and bpm is normal.
Occurs with excessive (over 1000 - 1500 mL) blood loss, heart rate is over 100/min and bpm is orthostatic.
Occurs with excessive (over 1500 - 2600 mL or 30% - 40% of total volume) systolic pressure is less than 90 and pulse is over 120 bpm.
Irreversible end-organ damage can occur with blood loss of 1500 - 2000 mL.
Subjective - thirst, weakness, irritability, restlessness
Objective - decreased bp; rapid, weak, thready pulse; rapid respirations; cold & clammy skin with pallor; oliguria (inability to produce uria sufficient to support metabolic waste elimination, less than 30 mL/hr); mental disorientation; physical collapse with prostration (exhaustion)
All 3 major blood elements (RBC, WBC, Platelets) from the bone marrow are reduced or absent
Cause unknown as in Idiopathic Aplastic Anemia
Hemorrhage from the nose, i.e.: nosebleed
Hypovolemic Anemia Diagnostic Test
Because when blood loss is sudden plasma volume might not yet have had a chance to increase, the loss of RBCs is not reflected in laboratory data and therefore lab values may seem normal or even high for 2-3 days. However, once the plasma is replaced the RBC mass is less concentrated and then the H & H levels are severely decreased, often to half the normal values.
Hypovolemic Anemia Medical Management
Stop blood loss. Treat for shock and lost volume (IV of normal saline, a 2 L bolus can be used in extreme cases). Mechanical ventilation may be needed (oxygen therapy restores oxygen that is decreased because of decreased hemoglobin in blood). Packed RBC infusion if hemoglobin is less than 6 or hypovolemia continues. Monitor hemoglobin. 1 unit of packed
RBCs should raise hemoglobin by 1 g/dL. Iron may be given because it boosts bone marrow production of RBCs.
Hypovolemic Anemia Nursing Intervention
Keep patient warm and flat. Take V/S often. Prevent injury, measure I&O esp. for minimum of 30 mL/hr. Amount of blood loss correlates to amount of urine output decrease - 1000 - 1500 mL blood loss = 20-30 mL urine/hr, 1500 - 2000 mL blood loss = less than 20 mL urine per hour, 2000+ blood loss = anuria (very low urine output).
Prognosis - without treatment death will occur. With aggressive treatment, prognosis is good.
The absence of a glycoprotein intrinsic factor (due to gastric mucosal atrophy) secreted by the gastric mucosa, it is an autoimmunedisease in which antibodies in the parietal walls of the stomach prevent the production of the intrinsic factor. It is a progressive, megaloblastic, macrocytic anemia primarily affecting older adults, intrinsic factor is essential for the absorbtion of Vit. B12
Is essential to combine with Vit. B12. If it is not available transport is prevented of B12 to the ileum where B12 is normally absorbed. Deficiency of B12 affects growth and maturity of all body cells including RBCs in the marrow. The membrane of the RBC becomes fragile and ruptures easily. This vitamin is also related to nerve myelination, its absence leads to progressive demylination and degeneration of nerves and white matter.
Extreme weakness with dyspnea, fever, hypoxia. With progression weight loss, slight icterus (jaundice) with pallor. Skin may be a pale lemon-yellow because of the excessive destruction of the RBCs which causes the bile pigments to increase in the blood serum. Edema of the legs, intermittent constipation and diarrhea.
Subjective - Patient complains of palpitations, nausea, flatulence, indigestion. Tongue is sore and burning. Weakness and difficulty swallowing (dysphagia), tingling of the hands & feet, loss of the sense of body positon.
Objective - smooth and erythematous tongue, infection of the teeth and gums. Mental disorientation, personality changes, behavioral problems, severe neurologic impairments can result including partial or total paralysis from destruction of the nerve fibers of the spinal cord.
Pernicious Anemia - Diagnostic Tests
Schilling test shows malabsorption of Vit B12. Serum Megablastic Anemia Profile is replacing Schilling test, it reveals serum methylmalonic acid and homocysteine. Bone marrow aspiration reveals abnormal RBC development. RBCs are too large and odd shaped and the B12 levels are reduced. Gastric analysis may be done and will show a decrease in hydrochloric acid (an acidic environment is required for the secretion of intrinsic factor).
Pernicious Anemia - Medical Mgmt
Oral Vit B12 is ineffective (no intrinsic factor in the stomach). Cyanocobalamin (B12) injections can be given IM or in a nasal spray (Nascobal). Folic acid and iron may be given. Treatment is 1,000 units IM daily for 2 weeks, then weekly until the hematocrit is normal, then monthly for life. A CBC is done q3-6months for life.
Pernicious Anemia - Nursing Interventions
V/S q4h. Mouth care several times a day. Diet high in protein, vitamins & minerals. Add lightweight blankets (anemia patients are sensitive to cold). Interventions should conserve energy and prevent injury (due to nerve myelination).
Pernicious Anemia - Prognosis
Terminal in 1-3 years without treatment. With treatment the patient could be asymptomatic. The potential for gastric carcinoma is increased in pernicious anemia, patient should be evaluated for this often.
Aplastic Anemia (Aplasia)
Failure of the normal process of cell generation and development. Can be congenital or acquired. Acquired Aplastic Anemia is directly related to exposure to viral infeciton, medications, chemicals (e.g.: benezene, insecticides, arsenic, alcohol), radiation or chemotherapy. The hematopoietic tissue is replaced by fatty marrow causing a defect in RBC production. 70% of acquired cases are idiopathic (cause unknown). Patient may be pancytopenic (absent or deficient in RBCs, WBCs AND Platelets). The incidence is low (4 in every 1 million people)
Aplastic Anemia - Manifestations
May have acute onset or develop over several weeks or months. With suppression of all 3 types of blood cells, patient may develop signs and symptoms of all 3 - e.g.: suppression of WBCs may result in infection, suppression of RBCs may lead to anemia, suppression of thrombocytes may cause petechiae. Repeated infection with high fever, fatigue, weakness, general malaise, dyspnea, palpitations. Mortality is high from complications of infection and hemorrhage. Bleeding tendencies can be petechiae, ecchymoses, bleeding gums, epistaxis, GI & genitourinary system bleeding
Aplastic Anemia - Assessment
Subjective - includes history of exposure to chemicals such as insecticides and drugs in addition to family history of aplastic anemia.
Objective - monitor for pallor, signs of infection and bleeding tendencies, also dypsnea and tachycardia
Aplastic Anemia - Diagnostic Tests
Bone marrow aspiration biopsy shows hypoplastic or aplastic fatty deposits, decrease in cellular elements with increased yellow marrow and depressed hematopoietic activity.
Aplastic Anemia - Medical Management
Diagnose cause and remove if possible, e.g.: related to a med or radiation therapy, avoid blood transfusions if possible to prevent iron overloading and the development of antibodies to tissue antigens, platelet transfusions to treat serious thrombocytopenia, bone marrow transfusions, spleenectomy, steriods and androgens are sometimes used to stimulate bone marrow. Immunosuppressive therapy with antithymocyte globulin and cyclosporine or Cytoxan has become important for patients who are not candidates for bone marrow transplantation or hematopoietic stem cell transplant(treatments of choice for patients under 45)
Aplastic Anemia - Nursing Interventions
Patients are highly susceptible to infection so prevention is critical and include strict surgical aseptic technique for dressing changes and IV site care. Avoid IM injections and rectal meds or temperature-taking to prevent mucous membrane and skin impairment. Observe for even the smallest trauma which might cause the patient to bleed. Monitor urine and stool for occult or gross blood. The patient must be educated to protect themselves from excessive bleeding, to avoid infection (esp. of the urinary tract or respiratory system) and to maintain a balance of rest with activities.
Aplastic Anemia - Prognosis
75% fatal if untreated. Medical management will improve outcome significantly in aggressively treated patients. The object of care is to produce remission and prolong survival.
Iron Deficient Anemia