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29 terms

Hematological System

Hematopoietic system disease and blood dyscrasias.
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Blood
Red in color.Transports materials to and from tissues, vehicle for transport of cellular requirements for life, emliminates waste products from tissues and bloodstream. O2 transport system. Regulates acid-base balance. Serves as protection via clotting factors and lymphocytes.
RBCs. >>> transports O2, waste.
WBCs. >>> patrol for infection, phagocytizeforeign bodies (MPS; mononuclear phagocytic system)
PLTs.
Plasma. >>> albumin (regulates fluid balance), alpha and beta. Composes 55% of blood.
Globulins >>> Gamma globulins, fibrinogen (clotting factors)
Cells compose 45% of blood volume.
RBCs- Hgb (O2 transport), Hct (% volume of RBCs in blood sample drawn) , MCV, MCB, MCHC (shape of red blood cell)
WBCs >>> 60% granular, (neutrophils, eosinophils, basophils), kill and engulf antigens (neutrophils, eosinophils, basophils are involved in phagocytizing/ lymphocytes and monocytes activate a reaction as part of the immune system).
Platelets >>> clotting factors. Smallest blood cells that we have, fragments of cells. Platelet count is the best test to send to send for blood dyscrasia testing. Produced in bone marrow and stored in spleen.
Cryoprecipitation >>> fresh frozen plasma.
Platelet + fibrin + clotting factor = clot.
Formed by bone marrow, spleen and liver.
Whole blood is infused for trauma victims.
Reticuloendothelial system (RES)
...
Blood forming organs
Bone marrow. >>> located in ends of long bones and in the middle of flat bones. Pelvis is often used for bone marrow aspirates. Lymphoid line: produced T&B Lymphocytes (what becomes your immune system). Myeloid line: Monocytes, myelocytes, mecrophages, WBCs, RBCs, and platelet production.
* Leukemia generally strikes the lymphoid line or the myeloid line; lymphocytic or myelocytic leukemia.
Spleen. >>> fights infections, houses lymphocytes and macrophages. Destroys old RBCs and stores platelets and WBCs.
Liver. >>> produces prothrombin, vitamin K, synthesizes fibrinogen, stores iron, HUGE role in detoxification.
Coagulation process
Liquid blood becomes a solid gel material that can become a semisolid material or hard like a scab.
Clotting factors act in the intrinsic and extrinsic pathways.
Intrinsic pathway (initiated by injury to a blood vessel lining): trauma, antigen-antibody reaction, venous clots, bacterial toxins.
Extrinsic pathway (initiated by changes outside of the blood vessel): tissue trauma, injury that causes damage to the outside of the blood vessel wall.
Clotting process: trigger (extrinsic or intrinsic) > Common pathway > prothrombin activated via vitamin K > Prothrombin forms Thrombin > Thrombin activation forms fibrinogen > fibrinogen forms fibrin > fibrin clot formed.
Heparin interferes with fibringoen forming
fibrin.
Coumadin interferes with prothrombin forming thrombin.
Antidote for HEPARIN is PROTAMINE SULFATE
Antidote for COUDMADIN is VITAMIN K.
Fibrinolysis = stops cascade from continuing.
Thrombolytics: "clot-busters"; synthetic drugs that do the same thing as the body in terms of fibrinolysis.
Thrombolytics are famous for preventing large heart attacks.
What do the blood levels have to look like in order to give thrombolytics?
1.5-2x the normal levels.
BLOOD TYPES
A, B, AB, & O; surface proteins on RBCs.
Rh factor- proteins on membrane surface of the blood cell.
You get the blood type of what you inherit from your parents, and over time your body will make its own anitbodies against the other antigen.
When a baby is born, the baby inherits the blood type and Rh factor according to the parents.
A- A antigen, B antibody, Anti-B serum anitbody >>> may accept from A/O.
B- B antigen, A antibody, Anti-A serum antibody >>> may accept from B/O.
AB- A&B antigen, universal recipient >>> may recieve from A/B/O.
O- Universal donor; no antigens, Anti-A and Anti-B serum antibodies >>> May receive from O.
Type O blood can only receive type O blood.
Rh+ or Rh- >>> protein on the membrane of the RBCs, you cannot give a Rh- person Rh+ blood and vice versa.
85% of population is Rh+.
* Women are given an IM injecction (3mo prior to delivery) of Rogan > suppresses the immune response so that women having babies with a different Rh factor than themselvevs can have up to 3 successful pregnancies.
O- blood= most valuable blood, can be given to anybody.


Must get consent from the pt before a blood transfusion.
** Most often packed cells are given, because pts usually dont need the other volume and compnents like plasma.
Truma pts who are actively bleeding should receive whole blood.
FFP has clotting factors in it > given to people whole are having clotting disorders.
** you can also give only platelets if the pt has poor coagulation.
Cryoprecipitation: contains clotting factors (given for hemophilia).
Blood is hung on a pump, FFP is run by gravity drip.
Make sure that you have the right pt and the right blood type.
Pharmacy gives you the IV tubing that you need.
Reactions will occur w/i the first 50mL given during a blood transfusion.
Always give blood slowly!!!
Blood should never hang for more than 5 hours >>> clots, warms up d/t environmental temperature which encourages bacterial growth.
Blood must be kept refrigerated.
* Do VS before starting blood, every 15min for the first hr, then every 30 min during the transfusion, then an hour after the transfusion is completed.
Temperatures in the 99 range will prbably get tylenol.
Any change above 2 degrees is an indication of an adverse reaction to a blood transfusion, STOP THE TRANSFUSION IMMEDIATELY IF THE TEMPERATURE STARTS TO RISE DURING THE TRANSFUSION, ASSESS THE PT, AND CALL MD.
A 2-degree rise in temp is very significant in 1 hour.
Cryoprecipitate is only about 20Ml's, so it can just be run in on its own under a steady drip.
Start a brand new line if someone is getting mulitple units > when you get the tubing, (2 ports; 1 going to saline, the other going to blood), clamp the line containing the blood, open up saline and prime the tubing with NS, then start the blood.
PLTs can be given over 30min and FFP can be given over 30-60min.
* NS has to be given with blood! Dextrose is hypotonic and the blood cells will rupture.
* Make sure that you look at your pt periodically, you dont want to miss an early reaction. PHYSICALLY TAKE TEMP.
* The longer that the blood is frozen, the higher the risk for the blood becoming contaminated.
Sepsis = same as bacterial infection.
ALWAYS INFUSE BLOOD AT LEAST FOUR HOURS IF NOT SLOWER, ALWAYS GO AS SLOW AS YOU CAN.
TX FOR BLOOD REACTIONS
Stop the blood, run NS.
Assess VS.
Call MD, can always grab the resident on call.
Give anti-inflammatory meds ahead of time of Hx of allergy.
Get a urine sample and send to lab.
Collect blood and urine samples.
Send blood back to blood bank.
Fill out reaction form.
HOW MANY RN'S ARE IN THE ROOM WHEN HANGING THE BLOOD?
2 nurses.
IF PTS COMPLAIN OF FEVER, CHILL, HEADACHE, ITCHING, OR HIVES.
Febrile reaction
S/S: SEVERE APPREHENSION, SENSE OF IMPENDING DOOM, BACK PAIN, CHEST PAIN, HTN, TACHYCARDIA.
Hemolytic reaction.
S/S: HIVES, RAASHES, ITCHING.
Allergic reaction.
PHYSICAL EXAM: PTS WITH BLOOD DYSCRASIAS
Color of skin and mucus membranes > moist? dry? pale? nosebleeds?
Ecchymosis (black & blue), hematoma, purpura (bleeding under the skin; very large area of a big bruise, can encompass an entire extremity), and petechiae (classic sign of a bleeding disorder) > people who have blood disorders develop these types of things w/o being hurt.
Vital signs >
Edema >
Palpate for lymph nodes, enlarged spleen and liver.
Percuss liver and spleen.
* you have to rely on blood tests and what the pt is telling you.
Anemia/Bleeding disorders
Pale, feel lowsy, no energy.
Weakness, fatigue that is chronic.
SOB > low Hgb, low Hct casues poor oxygenation and the body tries to compensate via deep breathing to re-oxygenate the tissues.
Heart murmurs develop.
VS are stable.
Phlebitis.
Poor oxygenation.
Edema.
Lymph obstruction.
Ascites not relatedt o a cardia cause.
Third-spacing edema.
Palpable lymph nodes, liver or spleen.
Low CBC counts.
Hx? Clotting factor problems? Bleeding problems?
Frank, occult blood
Active bleeding is ensuing.
Bloody stool indicates upper GI tract bleed.
Red/maroon coloration of stool indicates a lower GI bleed.
Pt may vomit blood.
What are we going to do for this pt? CBC, Pt, PTT platelet count, fibrinogen level, INR, bleeding time.
As we get older...
Bone marrow ages like we do > tends to make a decreased amt of certain things: Hgb, WBCs (^ risk of infection), clotting time, ptt, fibrin, clotting factors, iron.
ESR increased.
MCV increased.
MCHC decreased.
Anemia of chronic disease
Anemia cused by a chronic illness (RA, DM, COPD).
Drug activity starts to dimish after long term therapy.
Chronic illness suppresses bone marrow > decreased RBCs, WBCs, PLTs, Hgb, Hct.
Bone marrow can still produce the cells, but not in the numbers that they used to be.
"When all else fails, go back and look at the chronic disease."
What do people who have RBC disorders go on?
Folic acid (builds a healthy nucleus), iron (hgb production and O2 binding), Vitamin C, Vitamin K (clotting).
Diag's
CBC.
HBS- hemoglobin sickle cell.
Coomb's- indirect Coombs test, can tell if there are circulating antibodies in blood. Indicative of a past hemolytic reaction.
ESR- Measures how quickly RBCs settle out of plasma in a volume of blood. Decreased in anemia and increased in chronic disease.
MCV- size of RBCs.
MCH- wt of Hgb.
MCHC- volume of Hgb.
Hct- % RBC volume.
Ferritin- measures stored iron.
PLT count.
PT time.
PTT time.
Bleeding time.
Bone marrow aspirate > last resort, invasive. Usually taken from iliac crest. Tests function and health of bone marrow. VERY PAINFUL! Pts usually get a small 2x2 dressing and VS are monitored for 1hr along with BR. Then the pt is d/c'd. NO ASPIRIN PRODUCTS!! > bleeding possibility. Tylenol may be taken after returning home.
Lymph node Bx > leukemias, lymphomas.
Abd ultrasound > tumors.
Abd cat scan > tumors.
Abd MRI > tumors; more effective than cat scan.
D-dimer: test that is done for people who you suspect are bleeding. When you have bleeding, you have clot formation and something has to stop that clotting. The d-dimer looks for fibrin degradation products; + indicated that there is breakdown of fibrin > indicative of a clot. A CLASSIC WAY TO DIAGNOSE DIC, DVT, PE, SICKLE CELL ANEMIA, STROKE/CVA.
WHAT DO MANY DRUGS GIVEN OTC CAUSE?
Decresed WBCs, PLTs, Hgb.
What do antiinflammatory drugs cause?
Bleeding problems; prolonged ptt, pt times.
Stomach bleeding/damage.
What do OTC antibiotics often cause?
Decreased WBCs, PLTs.
HEMOLYTIC REACTION
Most serious.
Clot formation.
Caused by blood incompatibility; wrong type or wrong Rh.
90% of people who get these reactions die.
A/B/O or Rh +/- incompatibility.
Starts w/i 30 min of transfusion.
Acute fever, chills, headache, apprehension ("i dont feel right"), sense of impending doom.
* Severe: shock, SOB, hypotension, ^ HR, chest pain, low back pain (inflammation of liver) >>> STOP THE BLOOD.
Tx: stop blood immediately, grab a quick set of vitals, call the doc on call. Support the pt via ICU transfer, vasopressors for hyoptension, volume expanders (albumin), intubation, emergency hemodialysis.
FEBRILE REACTIONS
Reaction to antibodies in the blood.
* Reacting to WBCs or the plasma- spikes a temp.
Occurs about 30 mintues after transfusion is started.
Acute fever, chills, headaches, anxiety, muscle pain.
Tylenol, benadryl, antihistamines- given before transfusion if pt has a hx of allergic reactions to blood.
"Buffy coating"- washed cells, its a fluid that they put the white blood cells through and try to remove anything on the surface that would mount an adverse reaction.
Leukocyte poor blood- blood without WBCs.
People with hx of allergies are at risk for this type of reaction.
Hives, rashes, itching >>> may sometimes go all the way to anaphylaxis
BACTERIAL INFECTIONS
CONTAMINATION OF BLOOD ITSELF.
Hypotension, fever spike, ^ HR, chills.
Support the pt >>> could go all the way to anaphylaxis.
STOP BLOOD IMMEDIATELY (WITH ANY REACTION).
CIRCULATORY OVERLOAD
Giving the blood too fast.
Pts with heart disease and heart failure cannot take 500mL of blood over 2 or 3 hours and not go into heart failure.
PURELY A VOLUME ISSUE.
If multiple untis of blood are given, Lasix is given in between infusions >>> Lasix > Blood > Lasix > Blood.
Chart lasix as a one time dose after the blood unit.
SOB, crackles, chest pain, HTN, ^ HR.
Lasix & O2 are even more effective > ordered by MD.
Go as long as you can, as slow as you can, to prevent problems.
ALLERGIC REACTION
Pt is mounting a response to the foreign plasma proteins in the blood.
IF PTS COMPLAIN OF FEVER, HEADACHE, CHILLS, ITCHING, OR HIVES:
An allergic or febrile reaction.
IF PTS COMPAIN OF ^ HR, ^ RR, SOB:
Circulatory overload.
IF PTS COMPLAIN OF HYPOTENSION, CHEST PAIN, LOW BACK PAIN, FLANK PAIN, APPREHENSION, AND SENSE OF IMPENDING DOOM:
Hemolytic reaction.