West Coast University NUR 120

1. West Coast UniversityNUR 120 Hematologic System (Blood Disorders) Iron Deficiency Anemia Pernicious Anemia Thrombocytopenia Immunologic System (Immune System Disorders) HIV/AIDS

2. The Hematologic System The hematologic system is the: • Blood • Blood Cells • Lymph • And organs involved with blood formation

3. Bone Marrow • Is the blood-forming (hematopoeitic) organ. • Produces most of the cells of the blood including: RBC – erythrocytes WBC – leukocytes and Platelets • Bone Marrow also is involve in the immune responses.

4. Bone Marrow • Releases: 2.5 billion RBC each day in healthy adult. 2.5 billion platelets and 1 billion white blood cells per kilogram of body weight. • Fetus – blood components are produced in the liver and spleen and by the last trimester in the bone marrow.

5. Bone Marrow • At birth: Blood producing marrow is present to every bone. • Flat bones – sternum, skull, pelvis, and shoulder girdles contain active blood producing marrow throughout life. • As person age blood producing marrow decreases in the long bones and in small and irregularly shaped bones.

6. Blood Producing Bone Marrow • 18 years – blood production is limited to the ends of the long bones • Adulthood – fatty tissue replaces inactive bone marrow.

7. Blood Producing Bone Marrow • Process of blood production: Bone marrow first produces stem cells. Stem cells are immature, undifferentiated cells that are capable of maturing into any one of several types of blood cells: RBC’s, WBC’s, or platelets depending on the body’s need. Also called pluripotent, multipotent and totipotent.

8. Blood Cell Development Cont: • Committed Stem Cell- also called the precursor cell or the unipotent stem cell enters maturational pathway and then differentiate into one cell type. • Committed stem cell actively divide but require the presence of a specific growth factor for Maturation and some hormones • E.g. cytokines.

9. Erythropoietin • Is a growth factor made in the kidneys that is specific for RBC. • RBC growth factor produced in the kidney in same amount as RBCs destruction. • When tissue oxygenation is less than normal (hypoxia) the kidney increases the production of erythropoietin. • Synthetic erythropoietin (PROCRIT, EPOGEN, EPO) has the same effect on bone marrow as the naturally occurring erythropoietin.

10. Erythropoiesis • Erythropoeisis – the production of RBC. - Process where it involves selective maturation of stem cells into mature erythrocytes. - This process ensures that there is enough RBCs for good oxygenation without too many cells that could thicken the blood and slow its move.

11. Blood Components • Blood is composed of plasma and cells. • Plasma – part of the body’s extracellular fluid. Similar to interstitial fluid. • Contains several more times protein the interstitial fluid. • E.g. Albumin, Globulins, and Fibrinogen • Cells – RBCs, WBCs, and Platelets.

12. Albumin, Globulin and Fibrinogen • Albumin- Increases the osmotic pressure of the blood which prevents plasma from leaking into the tissues. • Globulins - have many function e.g transporting other substances and protecting the body against infection. • Fibrinogen – is a protein molecule that can be activated to form fibrin. • Fibrin molecules assemble together to form structures important in the blood clotting process.

13. Red Blood Cells (Erythrocytes) • Largest proportion of the blood cells. • Mature RBCs has no nucleus and has biconcave disk shape. • Has flexible membrane that allows RBC to change shape without breaking as they pass through a narrow, winding capillaries.

14. Red Blood Cells (Erythrocytes • Number of RBC varies from person to person according to gender, age and general health. • Normal range – 4,200,000 to 6, 100,000/mm3. • Life span – 120 days after being released into the blood. • Old cells are trapped and destroyed in the tissues, spleen and liver. Some part of destroyed RBCs (Iron) are recycled and used to make RBCs.

15. Red Blood Cells (Erythrocytes) • RBCs produce hemoglobin (Hgb). • The heme part of hemoglobin molecules needs a molecule of iron. Only when a heme molecule that is complete with iron can it transport up to four molecules of OXYGEN. • The globin portion carries Carbon Dioxide. RBC also can buffersand help maintain acid-base balance

16. Hemoglobin • Has the ability to combine loosely with oxygen. • With only a small amount of drop of O2 level in the tissues, a greater increase in the transfer of O2 from hemoglobin to tissues occurs. • Transfer of O2 to tissues is called oxygen dissociation.

17. Substances needed to form Hemoglobin and RBCs • Iron ( Fe) • Vitamin B12 ( Cyanocobalamin) • Folic Acid ( Folate) • Copper (Ug) • Pyridoxine ( Vit. B6) • Cobalt (Co) and • Nickel • Lack of these substances can lead to ANEMIA

18. White Blood Cells(Leukocytes) • Performs action critical to inflammation or immunity. • May types of WBCs all have specialized functions. • Most are formed in the Bone Marrow • WBCs protect the body from the effect of invasions by organisms.

19. Neutrophils • First internal line of defense against invaders especially bacteria. • Destroys invaders through phagocytosis. • Responsible for continuous, instant, nonspecific protection. • The number of actual mature neutrophils is used to measure a client’s risk for infection: the higher the numbers, the greater the resistance against infection.

20. Macrophages • They are also known as monocytes when they are not mature. • Move from blood to tissues when they mature. Lung – alveolar macrophages connective tissues- histiocytes Brain – Microglial cell Liver – Kupffer cell Peritoneum – Peritoneal macrophage Bone – Osteoclast Joints – Synovial type A cell Kidney – mesanglial cell.

21. Macrophages ( Function) • Important in immediate inflammatory response. • Stimulates the longer-lasting immune response of the of the anti-body mediated immunity (AMI). • Phagocytosis • Repair of injured tissues • Antigen presenting/processing • Secretions of cytokines that helps to control the immune system.

22. Basophils • Make up 1% of the total circulating WBCs. • These cells cause the manifestations of inflammation. • Contains vasoactives amines that act on blood vessels. Includes heparin, histamine, serotonin, kinins, and leukotrienes. • When release into the blood most of these chemicals act on the smooth muscles and blood vessel walls. • Heparin inhibits blood and protein clotting • Histamine constricts small veins and respiratory smooth muscles. Constrictions inhibits blood flow and decrease venous return. This results in blood collection to capillaries and small arterioles. • Kinins dilate arterioles and increase capillary permeability. Theses actions cause blood plasma to leak into interstitial space (vascular leak syndrome)

23. Eosinophils • Contains many vasoactive chemicals also. Usually make up 1% to 2 % of the total WBC count. • Function- act against infections of parasitic larvae. • Increases in number during an allergic reaction because eosinophils degrade the vasoactive chemicals released by the other leukocytes.

24. Platelets • They are the smallest of the blood cells. • Fragments from giant precursor cell in the bone marrow known as Megakaryocytes. • Stick to injured blood vessel walls and form platelets plug that can stop the flow of blood from the injured site.

25. Platelets • They also produce substances important to coagulation. • Help keep blood vessels intact by beginning repair of damage to small blood vessels. They perform most of their functions by aggregation (clumping). • Production in the bone marrow is also precisely controlled by growth factors (thrombopoieitin). • After leaving the bone marrow, they are stored in the spleen and then released slowly to meet the body’s need. • Normally 80% of platelets circulates and 20 % stored in the spleen. • Life span: 1 – 2 weeks

26. Accessory Organs of Hematopoiesis • Spleen – located under the diaphragm to the left of the stomach. • Composed of three types of tissues: white pulp, red pulp and marginal pulp. • These help to balance blood cells production and blood cells destruction and assist with immunity. • The spleen destroys old or imperfect RBCs, breaks down the hemoglobin released from destroyed RBCs stores platelets and filters antigen. • Thus after splenectomy, clients are not efficient at ridding the body of disease-causing organisms and are at greater risk for infection and sepsis.

27. Liver • Main production site for prothrombin and most of the blood clotting factors. • Proper liver function and bile production are critical to the formation of Vitamin K in the intestinal tract. • Vitamin K is essential for producing blotting factors VII, IX, and X. Large quantities of whole blood and blood cells can be stored in liver. • Also converts bilirubin to bile and stores iron within the protein ferritin. • Small amount of erythropoeitin are also produced in the liver.

28. Assessments of the Hematopoeitic System/Functions Health History base on Gordon’s Functional Health Pattern • Activity –Exercise Pattern questions guide: • Ask on energy level in comparison of last year. • How rested after a typical night sleep. • Any experiences of dizziness or light headedness • Is the heart seems to pound? • How much exercise do you get? How often? What type? • Do you feel you have enough energy to do what you want or need to do?

29. Assessments of the Hematopoeitic System/Functions • Family History and Genetic Risk- Bleeding Disorders e.g. Hemophilia • Personal History – e.g. liver function, known immunologic or hematologic disorder, and current drug use? Check all drugs pt is taking in the past 3 weeks/ • Ask about use of ATBs.(prolonged use can lead to clotting problems or bone marrow depression. • Diet History • Socioeconomic Status • Current Health Problems

30. Physical Assessment • Skin Assessment- Inspect color of the skin, nail beds. Note: People with darker skin – pallor and cyanosis easily detected in the oral mucous membrane and the conjunctivae of the eye while jaundice is in the roof of the mouth. • Head and neck assessment – lymph nodes , symmetrical, light palpation. • Respiratory Assessment • Cardiovascular Assessment • Renal and Urinary Assessment • Musculoskeletal Assessment – paresthesias of lower extremity • Abdominal Assessment • CNS assessment • Psychosocial Assessment

31. Common Assessment Abnormalities • Skin – pallor, jaundice, cyanosis, leg ulcers (malleoli), purpura (ecchymosis- decrease Plts), peticchia (pinpoint bleeding),hematoma. • Eyes- yellow sclera, pallor (conjunctiva). • Nose – epistaxis – low Platelet Ct. • Mouth – pallor, gingival/mucosa ulceration. • Lymph Nodes- enlarge, tender to touch. • Heart and Chest – tachycardia, >100 bpm, palpitation. Orthostasis, Hypertension ( initial reaction of anemia). • Abdominal – Hepatomegaly, Splenomegaly • Nervous System – Paresthesis of feet and hand, low B12 or Folate. Weakness – low Hgb. • Musculoskeletal – Pain in pelvis, ribs, spine, sternum Joint swelling – hemophilia, sickle cell anemia.

32. Hematologic Changes Associated with Aging • As bone marrow ages, it produces fewer blood cells. Total RBC and WBC are lower in older adults. • Platelets count do not appear to change with age. • Antibody levels and responses are lower in older adults.

33. Hematologic Changes Associated with Aging • Changes the cellular and plasma component of blood. • Several factors causes decrease blood volume in older adults and tend to have lower levels of plasma proteins and decreased plasma osmotic pressure ( decreased intake of dietary protein) which also causes some loss of blood volume into the interstitial space.

34. Hematologic Changes Associated with Aging • Lymphocytes become less reactive to antigen and have a loss of immune function. • WBC count does not rise as high in response to infections in older people and younger people. • Hemoglobin levels also change with age. Hemoglobin levels in men and women fall after middle age. Iron deficient diets may play in a role in this reduction.

35. Iron Deficiency Anemia/Pernicious Anemia – is an abnormally low amount of circulating red blood cells (RBC’s ), hemoglobin concentration, or both. Iron Deficiency Anemia – is the most common anemia. Lack of Iron (Fe) that promotes formation of Hgb. Pernicious Anemia – due to deficiency of intrinsic factor produced by gastric mucosa which is necessary for absorption of Vit B 12.

36. Causes of Anemia • Blood Loss • Inadequate RBC production • Increase RBC destruction • Insufficient or defective hemoglobin

37. Common Risk Factor for Anemia • Acute or Chronic Blood loss – menorrhagia, GI ulcers/bleed • Increased Hemolysis – defective hemoglobin (sickle cell), impaired glycolysis (G6PD- Glucose 6phosphate dehydrogenase) deficiency anemia, transfusion reaction, autoimmune diseases. • Mechanical Trauma to RBC’s – mechanical heart valve, cardiopulmonary bypass.

38. Common Risk Factor for Anemia • Dietary Insufficiency – Iron Deficiency - Vit. B 12 deficiency - Folic Acid Deficiency - Pica or persistent eating of substances not normally considered food (non-nutritive value ) for at least 1 month. • Bone – Marrow Suppression – exposure to radiation or chemicals. Aplastic anemia – results in decreased number of red blood cells as well as decreased platelets and WBC.

39. Diagnostic Procedures for Anemia • Lab Assessment: 1. CBC (Complete Blood Count) RBC – major carrier of Hgb in the blood Hgb- transport O2 and Co2 to and from the cells and can be used as index of oxygen carrying capacity of the blood. Hematocrit (Hct) – percentage of RBCs in relation to the total blood volume. Platelets – important for clcot formation

40. RBC indices to determine type and cause of most anemias • Mean Corpuscular Volume (MCV) – size of red blood cell : Normocytic, microcytic, macrocytic. • Mean Corpuscular Hemoglobin (MCH) – to determine the amount of hemoglobin per RBC. Normochromic – normal amt. of Hgb per cell, Hypochromic – decreased amt. of Hgb per cell. • Mean Corpuscular Hgb Concentration (MCHC) – to indicate Hgb amt. relative to the size of the cell. • In Iron deficiency anemia – there is decreased MCV, MCH, MCHC and classified as microcytic, hypochromic anemia. • In pernicious anemia – there is increased MCV and classified as macrocytic anemia.

41. Diagnostic Studies/Procedures for Anemia 2. Iron Studies • Total Iron Binding Capacities (TIBC) – reflects an indirect measurement of serum transference. Serum Ferritin– is indicator of total body iron stores. Serum Iron – measures the amt. or iron in the blood. Low serum iron and elevated TIBC indicates iron deficiency anemia

42. Diagnostic Studies/Procedures for Anemia • Hemoglobin Electrophoresis – separates normal Hbg from abnormal. Use to detect thalassemia and sickle cell disease. • Schilling’s Test – measures Vit. B12 absorption with and without intrinsic factor. It is used to differentiate between malabsorption and pernicious anemia. Procedure in a form of handouts. • Bone Marrow Examination – diagnoses aplastic anemia(failure of bone marrow to produce RBC as well as WBCs and platelets).

43. Nursing Care after Bone Marrow Aspiration • Apply pressure to the site for 5 to 10 minutes • Assess V/S frequently. • Apply pressure dressing. • Monitor for signs of bleeding and infection for 24 hours. Pt. going for Bone Marrow aspiration is position based on area where they will obtain the sample. Either prone or side lying. Local anesthesia to the site of aspiration is given and pt. is mildly sedated.

44. Nursing Assessment for Anemia. • Pallor – especially in the ear and nail beds, palmar crease and conjunctiva. • Fatigue – exercise intolerance, lethargy, orthostatic hypotension. • Tachycardia • Heart murmurs • Heart failure • Signs of bleeding- hematuria, melena, menorrhagia. • Dyspnea • Irritability – difficulty concentrating • Cool skin, cold intolerance.

45. Iron Deficiency Anemia • What Causes Iron Deficiency Anemia? • Poor absorption of iron by the body (Vitamin C aides in iron absorption) • Inadequate daily intake of iron • Pregnancy • Growth spurts or blood loss due to heavy period or internal bleeding. • Anemia develops slowly after the normal stores of iron have been depleted in the body and in the bone marrow. • Women, in general, have smaller stores of iron than men. Women also lose iron more frequently than men because of the blood loss during menstruation.

46. Iron Deficiency Anemia Signs and Symptoms specific for Iron Deficiency Anemia • Pale skin color (Pallor) • Fatigue • Irritability • Dizziness • Weakness • Shortness of breath • Sore tongue (smooth sore bright red tongue) • Brittle nails • Decreased appetite (especially in children) • Headache - frontal. The tests are: Red blood cell measures 4 x 10 (12 power), hemocrit (below 36%, NV – m: 40-54 ml/dl, w: 37 -47 ml/dl, and hemoglobin( below 10 g/dl); NV- m: 13-18 g/dl, w: 12.0 – 16.0 g/dl. Size of red blood cells (microcytic), serum iron level (low), and iron binding capacity in the blood (elevated).

47. Iron Deficiency Anemia Treatment of Iron Deficiency Anemia • Ferrous salts of iron are absorbed much more readily and are generally preferred. • Commonly available oral preparations Ferrous Sulfate,Ferrous Gluconate and Ferrous Fumarate(Hemocyte). All three forms are well absorbed. Ferrous sulfate is the least expensive and most commonly used oral iron supplement. • For iron replacement therapy, a dosage equivalent to 150 to 200 mg of elemental iron per day is recommended. • Ferrous sulfate, 325 mg of three times a day, will provide the necessary elemental iron for replacement therapy. • Hematocrit levels should show improvement within one to two months of initiation of therapy. • Take with meals if GI side effects occurs. • Give with Vit. C for better Iron absorption • D0not take with 2 hours of milk or antacids. • Stools will be black. • May cause constipation. Increase fluid intake and foods high in fiber. • Useof straw for liquid iron to prevent teeth staining.

48. Treatment of Iron Deficiency Anemia • Injectable iron dextran, containing 50 mg of iron per mL, is supplied in a 2-mL single-dose vial. • Adverse reactions include: headache, dyspnea, flushing, nausea and vomiting, fever, hypotension, seizures, urticaria, anaphylaxis.

49. Pernicious Anemia • Body stores of vitamin B12 are adequate for up to five years. • Symptoms are attributable primarily to anemia, although Glossitis, Jaundice, and Splenomegalymay be present. Vitamin B12 deficiency may cause: Decreased vibratory and positional sense Ataxia Paresthesias and Confusion. • Treatment of Vitamin B 12 Deficiency Anemia. Intramuscular, oral or intranasal preparations are available for B 12 replacement. • In patients with severe vitamin B12 deficiency, daily IM injections of 1,000 mcg of cyanocobalamin.

50. .Pernicious Anemia • Can not be prevented if due to lack of intrinsic factor. . • Some develop pernicious anemia due not getting enough Vitamin B12 in their diets. • Eating foods high in vitamin B12 can help prevent low vitamin B12 levels. • Good food sources of vitamin B12 include: Meats such as beef, liver (glandular meats), and poultry, Fish and Shellfish, yeast, Egg and Dairy products, such as milk, yogurt, and cheese, cereals and other fortified foods that have vitamin B12 added, Vitamin B12 also is found in multivitamins and in B-complex vitamin supplements. • Supplements for people at risk for vitamin B12 deficiency, such as strict vegetarians or people who have had stomach surgery is needed. • Older adults may have trouble absorbing vitamin B12.