Perfusion, Cellular Regulation Assessment of the Hematologic System C.Bailey, DNP, RN, CNE 8/09; Rev 7/11, 3/17, 3/20 Anatomy & Physiology Review Bone marrow Blood components Red blood cells (erythrocytes) White blood cells Platelets Plasma Accessory organs Spleen Liver Weni Carpenter, MSN, RN 2018 Erythrocytes (RBCs) Transport gases Erythropoiesis Erythropoietin Essential nutrients • Iron • cobalamin (vit. B12) • folic acid Reticulocyte Immature RBC Erythrocytes (RBCs) Hemoglobin Iron + Protein Oxygen binder Hemolysis Occurs in bone marrow, liver, spleen Increases bilirubin in blood Lab Values Red Blood Cell Count (RBC) 4.7 – 6.1 x 106/µL (Male) 4.2 – 5.4 x 106/µL (Female) Reticulocyte Count .5% - 2% Hematocrit (Hct) 42 - 52% (Male) 37-47% (Female) Hemoglobin (Hgb) 14 - 18 gm/dL (Male) 12 - 16 gm/dL (Female) Lab Values Mean corpuscular volume (MCV) Mean Corpuscular Hemoglobin (MCH) 83-100 fL 27-34 g/dL Mean Corpuscular Hemoglobin Concentration (MCHC) 32%-37% Leukocytes (WBC’s) WBC’s (5,000 – 10,000 µL) What’s a “Differential”? Developmental considerations Effects of Steroids Assessment Assessing without labs Where would you look? What might you see in high RBC or low? Signs and symptoms Granulocytes Neutrophils: Injury/infection/inflammation Segmented “Segs”: (50% - 70%) Band: (0% - 8%) Eosinophils: (0% - 4%) Allergic reaction Basophils: (0% - 2%) Limited allergic and inflammation Agranulocyte Monocytes: (4% - 8%) Potent phagocytic cells Arrive 2nd after neutrophils Agranulocyte Lymphocytes: (20% - 40%) B-Cells Form plasma cells that produce antibodies (immunoglobulins) that mediate humoral immunity T-Cells Mediate cellular immunity involved in cellular immune response Teamwork & Collaboration Reflect on the core importance of lab results in directing a patient’ s plan of care. On a systems level, what can interfere with accuracy of reporting? What occupational risks do our lab colleagues accept in their work? Example of a “Shift” Absolute Neutrophil Count ANC measured indirectly by multiplying the white blood cell count times the percent of neutrophils in the differential of the white count. Normal range for ANC is 1.5 to 8.0 (1500 to 8000/mm3.) Sample Calculation WBC count: 6,000 cells/mm3 Segs: 30% of the WBCs Bands: 3% of the WBCs Neutrophils (segs + bands): 33% of the WBCs ANC: 33% X 6,000 = 2,000/mm3 ANC of 2,000/mm3, by convention = 2.0 Normal range: 1.5 to 8.0 (1,500 to 8,000/mm3) Interpretation: Normal Assessment Assessing without labs Where would you look? What might you see in high RBC or low? Signs and symptoms Think, Pair, Share If you see an increase in neutrophils with a rise in bands……… If you see increased lymphocytes with a decline in total WBC……. If you see normal WBC in person taking long-term steroids……… Lymph System Fluid Nodes Spleen How can we use to assess? Thrombocytes: Platelets (150- 400 X 103/µL) Thrombocytopenia Aid in blood clotting Maintain capillary integrity Damage occurs platelets activated Also act to shrink & retract clots Normal Clotting Mechanisms Three components Vasoconstriction Platelet plug the hole Activate clotting factors (I – XIII) thrombin converts fibrinogen to fibrin Lysis of clot (Reset) Labs Associated with Clotting Bleeding and Coagulation Prothrombin Time (PT) • 11 - 12 sec International Normalized Ratio (INR) • Normal: 1 • Warfarin therapy (Coumadin) 2 – 3 Partial Thromboplastin Time (PTT) • Normal: 21 – 35 sec Anti-factor Xa (Anti-Xa) • 0.5 – 1.0 IU/mL • 0.3 - 0.7 IU/mL (LMWH) Medications & Clotting!! Binds to anti-thrombin Heparin LMWH • enoxaparin Lab Assessment Antidote Inhibit Vitamin K synthesis Coumadin Lab Assessment Antidote Anticlotting Forces Medications & Clotting! Factor XA Anticoagulants (Direct Thrombin Inhibitors) apixaban (Eliquis) rivaroxaban (Xarelto) dabigatran (Pradaxa) Antidote for dabigatran • andexanet alfa (IV bolus) Medications and Clotting! Fibrinolytic Medications “Clot busters” Tissue Plasminogen Activator Streptokinase Tenecteplase Alteplase Reteplase Anistreplase Hemostasis/Blood Clotting Create a list of priority nursing interventions for a patient with a traumatized blood vessel. Hemo Assessment Without looking in your book, develop a list of questions the nurse would ask the client regarding: Physiological questions Family history Genetic history Work history Environmental hazards Nutritional status Physical Assessment Without looking at your book, computer, or phone (this means you!) list findings the nurse might expect in a person with an oxygen delivery/tissue perfusion problem? Skin Head and neck Respiratory Cardiovascular Renal and urinary Musculoskeletal Abdominal Central nervous system Psychosocial HCO3 Bone Marrow Aspiration Bone Marrow Aspiration and Biopsy How would you prepare the patient for this procedure? What nursing care is necessary during the procedure? How will the nurse care for the patient after the procedure, including preparation for discharge? What follow-up care is necessary? Growth and Develop Differences in young Difference in elderly Medical comorbitites Question 1 A nurse interviews an older female patient who reports progressive fatigue, shortness of breath, and headaches. What question should the nurse ask first to collect more data surrounding the possible cause of the patient’s symptoms? A. B. C. D. “Do you have a history of cardiovascular disease?” “Can you tell me about your diet?” “Have you been feeling depressed lately?” “What medications do you routinely take?” Question 2 A patient is reporting increased fatigue, malaise, bleeding gums, and frequent “chills.” What is the most appropriate initial nursing intervention? Notify the physician of the patient’s symptoms. Review the laboratory analysis for signs and symptoms of bone marrow suppression. C. Review the laboratory analysis for signs and symptoms of infection. D. Obtain vital signs and blood cultures and administer antipyretic medications. A. B. Question 3 A patient is transitioning from IV heparin therapy to oral warfarin. Therapeutic anticoagulation of the patient is best assessed by: A. B. C. D. Partial thromboplastin time of 24.3 seconds Prothrombin time of 18 seconds International normalized ratio of 2.5 Bleeding time of 5 minutes The patient’s complete blood count shows a hemoglobin of 20 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding? A. “Has there been any recent weight loss?” B. “Do you have any history of lung disease?” C. “What is your intake of fruits and vegetables?” D. “Have you noticed any dark or bloody stools?” A nurse is caring for four patients. After reviewing today’s laboratory results, which patient should the nurse see first? a. Patient with an international normalized ratio of 1.2 b. Patient with a platelet count of 128,000/mm3 c. Patient with a prothrombin time (PT) of 28 seconds d. Patient with a red blood cell count of 5.1 mil/mcL
