Chapter 30 Nursing Assessment: Hematologic System

Hematologic- The study of blood and blood-forming tissue. The hematologic system includes: Bone Marrow Blood Spleen Lymph System

Bone Marrow
Hematopoiesis- the production of blood cells. Bone Marrow- The soft material that fills the central core of bones. Hematopoiesis occurs within the bone marrow. Blood cells are actively produced in the red bone marrow. In adults, the red marrow is found primarily in the flat and irregular bones. All three types of blood cells (Red Blood Cells [RBCs], White Blood Cells [WBCs], and Platelets) develop in the bone marrow. The type of cell that is formed form the hematopoietic stem cell is determined by the needs of the body at that time.

Blood
Blood is a type of connective tissue that preforms three major functions: Transportation Regulation Protection There are two major components of blood, plasma and blood cells.

Plasma
Approximately 55% of blood is plasma. Plasma is composed primarily of water, but also contains proteins, electrolytes, gases, nutrients, and waste. The term serum refers to plasma minus its clotting factors.

Blood Cells
About 45% of the blood is composed of formed elements, or blood cells. There are three types of blood cells: Erythrocytes (RBCs) Leukocytes (WBCs) Thrombocytes (Platelets) The primary function of erythrocytes is oxygen transportation. The primary function of leukocytes is protection of the body form infection. The primary function of platelets is to promote blood coagulation.

Erythrocytes
The primary function of RBCs includes transport of gases (both oxygen and carbon dioxide) and assistance in maintaining acid-base balance. Erythrocytes are primarily composed of a large molecule called hemoglobin. Hemoglobin- A complex protein-iron compound composed of heme (an iron compound) and globin (a simple protein), which functions to bind with oxygen and carbon dioxide. Oxygen attaches to the iron on hemoglobin, and carbon dioxide attaches to the globin portion of hemoglobin. Erythropoiesis- The process of RBC production. Erythropoiesis is regulated by cellular oxygen requirements and general metabolic activity. It is stimulated by hypoxia and controlled by erythropoietin, a glycoprotein growth factor synthesized and released by the kidney. Erythropoietin stimulates the bone marrow to increase erythrocyte production. Many essential nutrients are necessary for erythropoiesis, including protein, iron, folate (folic acid), cobalamin (vitamin B12), riboflavin (vitamin B2), and pyridoxine (vitamin B6). Hemolysis- The destruction of RBCs. Hemolysis by monocytes and macrophages removes abnormal, defective, damaged, and old RBCs from circulation. Hemolysis normally occurs in the bone marrow, spleen, and liver.

Leukocytes
Leukocytes originate form stem cells within the bone marrow. There are two main groups of leukocytes: 1) Granulocytes- Contain granules within their cytoplasm. a. Neutrophils b. Basophils c. Eosinophils 2) Agranulocytes- Do not contain granules within their cytoplasm. a. Lymphocytes b. Monocytes The neutrophil is the most common type of granulocyte, accounting for 50 to 70% of all WBCs. Neutrophils are the primary phagocytic cells involved in acute inflammatory response. They are also the first to arrive at an injury site. Mature neutrophils are called segmented (seg). Immature neutrophils are called bands. Eosinophils account for only 2 to 4% of all WBCs. They have a similar but reduced ability for phagocytosis. One of their primary functions is to engulf antigen-antibody complexes formed during an allergic response. Eosinophils are also able to defend against parasitic infections. Basophils make up less than 2% of all WBCs. They have a limited role in phagocytosis. If a basophil is stimulated by an antigen or by tissue injury, it will respond by releasing substances within the granules. This is part of the response seen in allergic and inflammatory reactions. Lymphocytes, one of the agranular leukocytes, makes up 20 to 40% of all WBCs. The main function of lymphocytes is related to the immune response,. Lymphocytes have two subtypes, B and T cells. Monocytes, the other type of agranular leukocyte, makes up 4 to 8% of all WBCs. Monocytes are potent phagocytic cells. They can ingest small or large masses of matter such as bacteria, dead, cells, tissue debris, and old or defective RBCs. Monocytes are the second type of WBC to arrive at the scene of an injury. Number of WBC by Type Never Let Monkeys Eat Bananas Most Neutrophils Lymphocytes Monocytes Eosinophils Least Basophils

Thrombocytes
The primary function of thrombocytes, or platelets, is to initiate the clotting process by producing an initial platelet plug in the early phase of the clotting process. Platelets originate from stem cells within the bone marrow. The stem cell undergoes differentiation by transforming into a megakaryocyte, which produces platelets. Platelet production is partly regulated by thromopoietin, a growth factor that acts on bone marrow to stimulate platelet production. It is produced in the liver, kidneys, smooth muscle, and bone marrow. Typically platelets have a life span of only 5 to 9 days.

Iron Metabolism
Iron is absorbed in the duodenum and upper jejunum. Only 5 to 10% of ingested iron is absorbed. Iron is present in all RBCs as heme in hemoglobin and in stored forms. The heme in hemoglobin accounts for 2/3 of the bodys iron. When the stored iron is not replaced, hemoglobin production is reduced. Transferrin, which is synthesized in the over, serves as a carrier plasma protein for iron. The degree to which transferrin is saturated with iron is a reliable indicator of the iron supply for developing RBCs. As a part of normal iron metabolism, iron is recycled after macrophages in the liver and spleen phagocytize old and damaged RBCs. The recycled iron binds to transferrin in the plasma or is stored as ferritin or hemosiderin.

Normal Clotting Mechanisms

Hemostasis- the stoppage of bleeding. Four components contribute to normal hemostasis: 1) Vascular Response 2) Platelet Plug Formation 3) The development of the Fibrin Clot on the platelet plug by plasma clotting factors 4) Lysis of the Clot

Vascular Response When a blood Bessel is inured, an immediate local vasoconstrictive response occurs. Vascular spasms may last for 20 to 30 minutes, allowing time for platelet response and plasma clotting factors to be activated. Platelet Plug Formation Platelets are activated when they are exposed to interstitial collagen form an injured blood vessel. Platelets stick to one another and form clumps. Aggregation- The process of platelets clumping together. Plasma Clotting Factors Plasma proteins circulate in inactive forms until stimulated to initiate clotting through one of two pathways, intrinsic or extrinsic. Intrinsic Pathway o Activated by collagen exposure form endothelial injury when the blood vessel is damaged. Extrinsic Pathway o Initiated when tissue factor or tissue thromboplastin is released extravascularly from injured tissues. Regardless of whether clotting is initiated by substances internal or external to the blood vessel. Coagulation ultimately follows the same final common pathway of the clotting cascade. Thrombin, in the common pathway, is the most powerful enzyme in the coagulation process. It converts fibrinogen to fibrin, which is an essential component of blood clots. The plasma clotting factors are labeled with both names and roman numerals. Lysis of a Clot Just as some blood elements foster coagulation (procoagulants), others interfere with clotting (anticoagulants). Anticoagulation may be achieved by two means, antithrombin activity and fibrinolysis. Antithrombin keeps blood in a fluid state by antagonizing thrombin, a powerful coagulant. Endogenous heparin, protein C, and protein S are examples of anticoagulants.

The second means of maintaining blood in its fluid form is fibrinolysis, a process resulting in the dissolution of the fibrin clot. The fibrinolytic system is initiated when plasminogen is activated into plasmin. Thrombin is one of the substances that can activate the conversion of plasminogen to plasmin, thereby promoting fibrinolysis. The plasmin attacks either fibrin or fibrinogen by splitting the molecules into smaller elements know as fibrin split products (FSPs).

Spleen
Another component of the hematologic system is the spleen, which is located in the upper left quadrant of the abdomen. The functions of the spleen can be classified into four major functions: 1) Hematopoietic- Produces RBCs during fetal development. 2) Filtration- Removes old and damaged RBCs. 3) Immunologic- Filtering bacteria especially gram-positive cocci. 4) Storage- Stores RBCs, and approximately 30% of the bodys platelets.

Lymph System
The lymph system, consisting of lymph fluid, lymphatic capillaries, ducts, and lymph nodes, carries fluid form the interstitial spaces to the blood, it is by means of the lymph system that proteins and fat from the GI tract and certain hormones are able to return to the circulatory system. The lymph system also returns excess interstitial fluid to the blood which is important in preventing edema. A primary function of lymph nodes is filtration of pathogens and foreign particles that are carried by lymph to the nodes.

Liver
The liver functions as a filter. It also produces all the procoagulants that are essential to hemostasis and blood coagulation. Additionally, it stores iron that is in excess of tissues needs, which can occur with frequent blood transfusions or diseases that cause iron overload.

Effects of Aging on the Hematologic System

The amount of red marrow and the number of stem cells decrease with aging. However, there does not appear to be a complete depletion even in very old adults. The remaining stem cells maintain their functional capacity to divide, but the percentage of marrow space occupied by hematopoietic tissue declines progressively after the age of 70. Although the older adult is still capable of maintaining adequate blood cell levels, the reserve capacity leaves the older adult more vulnerable to possible problems with clotting, oxygen transport, and fighting infection, especially during periods of increased demand, this results in diminished ability of an older adult to compensate for an acute or chronic illness. Iron absorption is not impaired in the older patient but adequate nutritional intake of iron may be decreased, the osmotic fragility of RBCs is increased in the older person. This may account for a slight increase in mean corpuscular volume (MCV) and slight decrease in mean corpuscular hemoglobin concentration (MCHC) of RBCs in some older individuals. The total WBC count and differential are generally not affected by aging. However, a decrease in humoral antibody response and decrease in T cell function may occur, during infection the older adult may have only a minimal elevation in total WBC count. Platelets are unaffected by the aging process. However, changes in vascular integrity form aging can manifest as easy bruising.

Functional Health Pattern

Health Perception
There is a known genetic influence in certain hematologic conditions. As well as in other blood diseases that follow familial patterns. For example, sickle cell disease occurs primarily in African Americans, and pernicious anemia occurs most commonly in persons of northern European descent. Sickle Cell Disease (SCD)- A group of inherited, autosomal recessive disorders characterized by the presence of an abnormal form of hemoglobin in the erythrocyte (RBC). Pernicious Anemia- A progressive megaloblastic macrocytic anemia resulting from inadequate gastric secretion of intrinsic factor necessary for absorption of cobalamin (vitamin B12).

Nutritional-Metabolic Pattern
A dietary history may provide clues about the cause of anemia. Iron, cobalamin, and folic acid are necessary for the development of RBCs. Iron and folic acid deficiencies are associated with inadequate intake of foods such as liver, meat, eggs, whale-grain and enriched breads and cereals, leafy green vegetables, dried fruits, legumes, and citrus fruits, folic acid deficiencies may be offset by a diet including foods that are also high in iron. Any changes in the skins texture or color should be explored. Any petechiae or ecchymotic areas on the skin should be noted. If present, the frequency, size and cause should be documented. Petechiae are more likely to occur where clothing constricts the circulation. Many of the medications used to treat cardiovascular disease can also cause abnormalities in hematopoietic cell production or coagulation. Pulmonary disorders that lead to hypoxemia may cause chronic stimulation of erythropoietin and result in polycythemia. Polycythemia- An abnormal condition with excessive levels of red blood cells. Petechiae- Small purplish-red lesion. Resulting from localized hemorrhage. Ecchymosis- The escape of blood into the tissue form ruptured blood vessels.

Elimination Pattern
Ask if blood has been noticed in urine or stool. Ask about recent stool hemnoccult test or colonoscopy.

Activity-Exercise Pattern
Because fatigue is a prominent symptom in many hematologic disorders, ask about feelings of tiredness.

Sleep-Rest Pattern
Fatigue secondary to a hematologic problem often will not be resolved following sleep.

Cognitive-Perceptual Pattern
Arthralgia (joint pain) may be caused by a hematologic problem and should be assessed, Hemarthrosis (blood in a joint) occurs in patients with bleeding disorders and can be painful.

Self-Perception Pattern
The effect of the health problem or the patients perception of self and personal abilities should be determined,

Role-Relationship Pattern
It is known that a person who has been exposed to radiation has a higher incidence of certain hematologic problems. The same is true of a person who has been exposed to chemicals (e.g. benzene, lead, naphthalene, phenylbutazone).

Sexuality-Reproductive Pattern
A carful menstrual history should be obtained from women, including the age at which menarche and menopause began, duration and amount of bleeding, incidence of clotting and cramping, and any associated problems, men should be asked about impotence because this is not uncommon in men with hematologic problems.

Coping-Stress Tolerance Pattern

The patient with a hematologic problem often needs help with ADLs.

Value-Belief Pattern
Some hematologic problems are treated with blood transfusions or a bone marrow transplant. Determine if these types of treatments cause any conflict with their value-belief system.

Objective Data
Physical Examination
Although a full examination should be performed on patients suspected of a hematologic disorder, certain aspects of the physical examination are specifically relevant in hematologic disorders. These include the skin, lymph nodes, spleen, and liver.

Lymph Node Assessment

Superficial lymph nodes can be evaluated by light palpation. Deep lymph nodes cannot be palpated and are best evaluated by radiologic examination. Ordinarily, lymph nodes are not palpable in adults. If node is palpable, it should be small (0.5 to 1 cm), mobile, firm, and nontender to be considered a normal finding.

Palpation of Liver or Spleen

Both the liver and spleen are normally not delectable by palpating the abdomen, unless enlarged.

Skin Assessment
In hematologic disorders, assessment of the skin may be a valuable source of information. In patients with RBC disorders the skin may be pale or have pasty skin tones, or have cyanotic tinged in severe anemia, Erythrocytosis often produces small vessel occlusions causing a purple, mottled appearance of the face, nose, fingers, or toes. Clubbing of the fingers can be seen with chronic anemia. Leukocyte disorders may cause infections skin lesions or malignant nodular lesions. During the physical assessment of the skin, look carefully for petechiae, ecchymosis, and spider nevus (a form of telangiectasia) because these can indicate bleeding disorders. Spider Nevus- Form of telangiectasia characterized by a round red central portion and branching radiations resembling the profile of a spider; usually develop on face, neck, or chest. Telangiectasia- Small angioma with tendency to bleed; focal red lesions, coarse or fine red line.

Diagnostic Studies of the Hematologic System

The most direct means of evaluating the hematologic system is through laboratory analysis and other diagnostic studies.

Laboratory Studies
Complete blood count (CBC) involves several laboratory tests. When the entire CBC is suppressed, a condition termed pancytopenia exists. Pancytopenia- Marked decrease in the number of red blood cells, white blood cells, and platelets.

Red Blood Cells

Normal values of some RBC tests are reported separately for men and women because values are based on body mass and men usually have a larger body mass. The hemoglobin (Hgb) value is reduced in cases of anemia, hemorrhage, and states of hemodilution, such as those that occur when the fluid volume is excessive. Increase in hemoglobin are found in polycythemia or in states of hemoconcentration, which can develop from volume depletion (dehydration). The hematocrit (Hct) value represents the percentage of RBCs compared with total blood volume. Reductions and elevations of hematocrit value are seen in the same conditions that raise and lower the hemoglobin value. The hematocrit value generally is three times the hemoglobin value. The total RBC count in not always reliable in determining the adequacy of RBC function. Consequently, other data, such as hemoglobin, hematocrit, and RBC indice, must also be evaluated.

Lab Values
Red Blood Cell Count (RBC) 4.3 to 5.7 (male) 3.8 to 5.1 (female) 3.8 to 5.5 (infants/child) Hematocrit (Hct) 39 to 50% (male) 35 to 47 % (female) 31 to 43% (child) Hemoglobin (Hgb) 13.2 to 17.3 (male) 11.7 to 16 (female) Mean Corpuscular Volume (MCV)- average volume or size of RBCs. 83 to 100

Mean Corpuscular Hemoglobin (MCH)- Average weight of hemoglobin. 27 to 34 g/dl Mean Corpuscular Hemoglobin Concentration (MCHC)- Average concentration of hemoglobin in on RBC. 32 to 37%

White Blood Cells

Elevations in WBC count over 11,000 are associated with infection, inflammation, tissue injury or death, and malignancies. A total WBC count less than 4,000 (Leukopenia) is associated with bone marrow depression, severe or chronic illness, and/or some types of leukemia. Patients receiving steroids may not have an elevated WBC count during an illness. At birth infants have ah higher WBC count, which returns to normal adult levels in 2 to 3 weeks. Total WBC count is lower in the elderly. Pregnant women may have higher levels of neutrophils and lymphocytes. The WBC differential is of considerable significance because it is possible for the total WBC count to remain essentially normal despite a marked change in one type of leukocyte.

Lab Values with Differential

WBC- 4,000 to 11,000 Bands- 0 to 8% Segs- 50 to 70% Eosinophils- 0 to 4% Basophils- 0 to 2% Lymphocytes- 20 to 40% Monocytes- 4 to 8% Neutropenia- An abnormal reduction of the neutrophil count to less than 1,000.

Platelet Count
The platelet count is the number of platelets per microliter of blood. Thrombocytopenia- A reduction in platelet count, fewer than 100,00. Thrombocytosis- A condition marked by excessive platelets; a disorder that occurs with inflammation and some malignant disorders. Bleeding may occur with thrombocytopenia. Spontaneous hemorrhage is possible once platelet counts fall below 10,000. The most likely complication related to thrombocytosis is excessive clotting.

Lab Values
Normal Platelet Count- 150,00 to 400,00

Iron
Transferrin saturation is a better indicator of the availability of iron for erythropoiesis than serum iron because, unlike serum iron, the iron bound to transferrin is readily available for the body to use.

Lab Values
Serum Iron- 50 to 175 mcg/dl Transferrin Saturation- 15 to 50% Radiologic Studies Radiologic studies for the hematology system involve primarily the use of computed tomography (CT) or magnetic resonance imaging (MRI) for evaluating the spleen, liver, and lymph nodes. Biopsies Biopsy procedures specific to hematologic assessment are bone marrow examination and lymph node biopsy.

Bone Marrow Examination Bone marrow examination is important in the evaluation of many hematologic disorders. The examination of the marrow may involve aspiration only or aspiration with biopsy, the benefits gained from bone marrow examination are: 1) A full evaluation of hematopoiesis 2) The ability to obtain specimens for cytopathology and chromosomal abnormalities. The preferred site for both aspiration and biopsy of bone marrow is the posterior iliac crest. After the marrow aspiration pressure must be applied. The site is covered with a sterile pressure dressing. Vital signs must be assessed. If bleeding does not stop, have the patient lay on the side of the aspiration or biopsy for 30 to 60 minutes. Soreness over the puncture site for 3 to 4 days after the procedure is normal.