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Diffentials (called “Diff”) – Type of WBC for Cancer patients.
CBC with differential and CBC are totally different.
1. Granulocytes (contains intracellular granules, cytoplasm) which contain hydrolytic enzyme
that are cytotoxic to to foreign organisms.
*PolyMorphoNuclear granulocytes (PMN) 38-70%. 80 ml/day production. 3days of life span

Neutrophils : 55 – 70% (biggest proportion)
a. Seg-Neutrophils(mature), Band-Neurophils(immature – phagocytic activity, elevated #
means bone marrow is already used up) Neutrophenia – deficiency of neutrophil – prone to
infection. Elevated band – even though it’s immature – it’s better than the bone marrow not
working at all – it can still do phagocytic activities.

Eosinophils : 1 - 3%. (*Eosinophil – rise up to 15% when you have bee sting or
any other infection. It will give you good indication of infection.)
Indicator of Allergic Reaction with Basophils. (Both rise)

Basophils : 0 - 2% (make up of heparin, inflammatory mediator)
(*Basophil – when you have Allergic reaction, Work as secreting heparin,
histamine. Severe allergic, congested reactions. Histamine dilates large artery,
constricts small veins, smooth muscle.)
2. Agranulocytes

Monocytes : 1 - 8% (contains prostaglandin (PGE2) - a mediator of inflammatory response, sore.
Tell cytokines and ILs about infection) *Monocyte – Late inflammation – still do phagocytic activity.
They eat up, tell other lymphocytes there is a problem. – eat large dead ones.

Lymphocytes 15 - 45%.(2nd largest proportion)(Cell Mediated Immunity, humoral immunity) : Very
powerful WBC. T and B cells.
Reticulocyte(immature RBC) counts : 0.5 - 2%. Bone marrow functions for erythropoiesis.
1. Increased – Hemolytic anemia, bleeding
2. Decreased – Pernicious, Aplastic anemias (autoimmune anemias)
3. If there’s no Folic acid, Thiamin complex, No Vit.B12(pernicious), Vit.C and no Protein, you are
wasting time for making RBC. (don’t work for Aplastic anemia)
4. Each RBC contains 300mil.Hbs. 1 Hb Has 4 oxygen.
5. If you are severely anemic – your bone marrow will kick them(rectic) out. When you stop
chemo and give ferrous sulfate, MD says to check Reticulocyte, if it goes up, anemia will
be over soon. In order to make RBCs, you need to have erythropoietin(enzyme from
Kidney to make RBC). Kidney tells it to B.marrow. (Kidney should be healthy)
6. Aplastic – you don’t look for Retic counts. (the factory is gone)
7. CBC and Retic count – Is it’s going up?(↑immature RBC) It’s good.(B.marrow’s still
working) So they can start chemo therapy again.
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Classification of Anemia (RBC’s not in the normal range)
1. Blood loss
2. Deficient RBC production (iron, Vb12, folic acid, bone marrow failure or suppression –
myelofibrosis, aplastic anemia, marrow toxin : (drugs, radiation), infectious agents.
3. Excessive RBC destruction

Hemolytic anemia

Defective glycolysis (G6PD def.)

Membrane abnormalities

Physical causes : Prosthetic heart valve.(Mitral valve replacement – break RBC) (By nurse :
clumsy hanging of blood)
4. Defective Hemoglobin synthesis (by genetic cause itself)

Thalassemias (alpha, beta)

Sickle cell anemia.
5. Anemias of Chronic Diseases

Renal disease

Liver disease

Endocrine disorders (Cushing’s, Addison’s diseases, Adrenal Cortex problems, Thyroid
problems, myxedema(hypothyroidism), goiter problem)

Cancer.
Nutrients needed for Erythropoiesis
1. Vitamin B12(cobalamin) – RBC maturation(very important – pure protein)
e.g. Liver, red meat (vegetarians have trouble with this, don’t eat too much meat)
2. Folic acid – RBC maturation(important), prevent dementia, cancer – 1mg/day.
e.g. Green leafy vegetables, liver, fish, legumes, whole grains.(red onion, tomato, cherry tomato,
peppers, red cabbages)
3. Iron – Hemoglobin synthesis
e.g. Liver, red meats, eggs, dried fruits, legumes, green vege. Whole grains, enriched bread, cereals,
potatoes.
4. Vitamin B6 – Hemoglobin synthesis (drinking milk helps)
e.g. Meats, Whole grains, legume (dried peas, beans, lentils), potatoes, bananas
5. Amino acids – Synthesis of nucleoproteins
e.g. Eggs, meats, milk, poultry, fish, legumes, nuts
6. Vitamin C – Conversion of Folic acid to active form, absorption of iron.
e.g. Citrus fruits, leafy green, strawberries, cantaloupe.(cross important vitamins to cells) – do not
take too much.
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*Vitamin B complex – important for erythropoiesis. B1, 2, 6, 12 complex.
Blood (Body : 5-6 liters (5% of body weight))
Blood components:

Plasma : 55% - 90% water (pale yellow liquid)

10% Solutes(*Within 6-8% proteins ; albumin 55%, globulin 38%, fibrinogen 7%)

2 - 4% Organics – Cholesterol, Glucose, Aminoacids, Triglycerols, Urea, Lactic acid,
Hormones, Enzymes.


Inorganics – Na, CL, K. HCO3, Ca etc.(Electrolytes)
Cells 45% - RBC, WBC, Platelet.
Platelets : prevent loss of blood thru breaks in blood vessel walls.
Platelets are not true cells (no contain nuclear)
Prevent blood loss by 1. sticking together to block small breaks in blood vessels and capillary.
Blood products
Packed RBC – packed RBCs, less fluid(remains plasma, albumin , platelets) – (You just

need RBC not the whole blood)
Frozen RBC – can store for 3 years(-87c) after thawing, use in 24 hour. Successful

washings with normal saline remove majority of WBCs and plasma protein(for patient who has
previous febrile reaction to transfusion)

Platelets – for platelets less than 10,000.

Fresh frozen plasma – liquid portion of whole blood. Not contain platelets(contain clotting
factors). Can use albumin(plasma expander).
The infusion takes place as rapid as the client can tolerate) – **IT HAS BLOOD
CLOTTING FACTOR.

Albumin – Hyperosmolar solution acts by moving water from extravascular to
intravascular space.(from tissue to vessels) (↑ oncotic pressure)

Granulocyte transfusion – for neutropenic clients with infections. The surfaces of
granulocytes contain numerous antigens that can cause severe antibody antigen
reaction. Infused over 45-60 min.
Blood transfusion
Blood types.

Type A - has A antigen(if B type blood is given, anti-B antibodies reaction causes hemolysis)

Type B - has B antigen(if A type blood is given, anti-A antibodies reaction causes to hemolysis)

Type O – has No Antigen, so Universal Donor.

Type AB - has both A and B antigen ,so Universal Recipient (Selfish one)
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Type and crossmatching – 2 things we need to know, Blood Type and RH factor.(- or +)

85% is Positive(US) – can receive both.

15% is Negative(US) can’t get positive. (Type O / RH- : can’t get any blood other than exact
same match – worst blood to have)
Coombs’ test (before Blood Transfusion)
(differentiation among types of hemolytic anemias/ detection of antibodies)
1. Direct : detection of antibodies attached to RBCs. (pt-RBC + Antigen/RBC)
2. Indirect : detection of antibodies attached to Serum. (pt-Serum + Antigen/RBC)
(If Pt has antibodies – Serum(or with RBC) mixes with RBCs of Antigens)
Before Blood Transfusion :
1.
Assess Lab. Values (Hb – less than 6gm with symptoms, defiantly 4gm below, platelets –
less than 20,000 cells). As long as body system’s not affected, it’s unnecessary. If Pt
is hemodynamically unstable, you have no choice but hanging the blood)
2.
If the blood viscosity is too high, kidney will be damaged. So you should have baseline
before you give blood.
3.
Assess the client’s vital signs, Urine output/color, skin color, Lung sounds, history of
transfusion reactions, BUN, Creatinine level, K.
4.
Blood works : type and cross matching for compatibility (Check CBC, Hb, hematuria?
Lung clear? Enzyme;kidney function? Voiding’s okay? – need to well document)
5.
Check for Consent form, Physician’s order.
Blood Transfusion.

Access - more than 19 gauge needle (to let the RBC to get in without breaking the
membrane) Blood should not be interrupted so have good vein and needle to start with.

Solution – Normal Saline – Compatible.

Dextrose (hemolyzed), L.Ringer (coagulation). Never with D5W.

IV tube – filter

Medication – Lasix IVP 30min prior to administration for cardiac pt. (for light CHF pt) : to
prevent fluid overload.

Blood bag – check for Date, Rh and Blood Type, Expiration date, Name on the bag. Sign
with two RNs. (Check the bag with MD or RN) Blood is only hung by Regular staff(not by
per diem) because of matter of hospital legal support.

For 15 min after starting blood, stay with the pt. Do not give more than 25ml for initial 15
min. (most blood reaction occur) (25cc per 15 min (100cc in 1 hour) – 250gtt/15min : 16gtt/min :
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4gtt/15sec)
Blood Reaction :
When blood containing antibodies against the recipient's blood is infused, antigen-antibody complexes are
formed and released into the circulation. These complexes can destroy the transfused cells and initiate
inflammatory responses in the recipient's blood vessel wall and organs. Life threatening with DIC and
circulatory collapse.
1. Hemolytic reaction : (Within 10-15 min):

Apprehension(anxiety), H.Agglutination, Restlessness, Headache, Chest pain, Low back
pain, Shivering, SOB, Hypotension, Hematuria, all in 15 minutes.
2. Allergic reaction : (Anaphylatic Reaction)

Bronchospasm with Wheezing, Laryngeal Edema, itching (hypotension could be followed
by bronchospasm), urticaria, joint pain, hypotension. Because of hypotensin - Tachycardia
could happen. No.1 med for wheezing is Epinephrine(0.4 ml SC) - For very urgent
bronchospasm. Get somebody quick, get MD. Where is the epinephrine - Crash Cart.
Observe for pt’s Mental Status change. Benadryl 50mg for less severe reaction.
3. Febrile reaction : (within 30min) : blood is foreign body, immunity is responding.

Sensation of Cold, Tachycardia, Fever, Hypotension, SOB. Tylenol will help at the
moment for the fever. Septic shock(fever’s coming back after giving Tylenol) comes from
the bad blood. Blood was not well prepared. Hot temperature affects the condition of
blood - septic shock.
4. Bacterial Reaction (by Gram Negative organism) - Contaminated blood. - from wrong
handling.

tachycardia, hypotensin, fever, chills, shock.
5. Circulatory Overload :

Person with poor lung, poor heart easily get CHF.

Cough, Dyspnea, P.Congestion, HA, Hypertension, Tachycardia, Ditended jugular vein,
SOB, Lung sound, BP, Pulse, Raise pt’s head, check pt’s sensation q30min
6. Air Embolism

Sudden SOB, Chest pain, Coughing - Turn pt to the Left, Trendelenburg
position(prevent the air to go into the system, make it go to right lung), Hypertension, Cyanosis

Prime the tube first
If any reactioin occurs.
1. Stop infusin
2. Keep Vein Open with Normal Saline (first reaction of body – shrink blood vessels,
so Hypovolemic shock is on the way) – if MD’s not there, OPEN UP the N.S at 100ml per hour.
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Then get the Urine Specimen ASAP. (if Hb is in the urine, your kidney is on the way to
damage)
3. Call MD (report for signs)
4. Drugs - Epinephrine,(SC, constriction of smooth muscle, bronchodilation - let pt breathe)
Benadryl,(anti-histamine) Steroids(solumedrol IV – Serious case)
5. Save all blood, transfusion set, Urine to lab with slip - Legal Documentation.
6. Fill out Blood Transfusion Reaction Report
7. MD May order plenty of IV order with NS, Lasix to prevent renal failure (RBC in urine - renal
damage) - wash out the body fluids.
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