chapter 41:

assessment of the hematologic system

(yellow highlight = in powerpoints)
intro of hematologic system:
 includes blood, blood cells, lymph, organs involved in blood
formation/storage
 helps body meet the human need for oxygenation & tissue perfusion
(blood delivers oxygen)
o all systems depend on
any problem affects total body health & well-being

Fig. 41-1 Role of the hematologic system in meeting the

human need for oxygenation and tissue perfusion.

anatomy & physiology review:

 bone marrow:
o blood forming (hematopoietic) organ
 produces most of the cells of the blood
 rbcs/erythrocytes
 wbcs/leukocytes
 platelets
o also involved in the immune response
o healthy adult releases (per day)
 2.5 billion rbcs
 2.5 billion platelets per kilogram of body weight
 1 billion wbcs
o blood produced in many bones in childhood, only in flat bones
(sternum, skull, pelvic and shoulder girdles) and the ends of long
bones in adults
o older adults – amount of fatty marrow increases leaving only a
small portion of the remaining marrow to produce blood
o production:
 (1) stem cells:
 immature
 unspecialized (undifferentiated) cells that
o able to become one of many blood cells (rbcs,
wbcs, platelets)
 dependent on the body’s needs
 (2) committed stem cell/precursor cell:
 enters a single “growth pathway”
 can then specialize into one cell type (differentiate)
 actively divide but need a specific growth hormone for
specialization (i.e. erythropoietin for rbc)
 many different growth factors for wbc and platelet
growth
Fig. 41-2 Bone marrow cell growth and differentiation
pathways.
 blood components:
o plasma and cells
 plasma:
 part of ECF
 found between cells
 contains more protein than interstitial fluid contains
 3 major types:
o (1) albumin:
 increases the osmotic pressure of the
blood (prevents plasma leaking into the
tissues)
o (2) globulins
 transport other substances and
protecting the body against infection
 main protein of antibodies
o (3) fibrinogen
 inactive protein that is activated to make
fibrin
 fibrin molecules get together to
make structures in the process of
blood clotting
 blood cells:
 all three are different in structure, where they mature,
and function
 (1) RBCs aka erythrocytes:
o largest # of these
o mature RBCs:
 no nucleus
 bioconcave disk shape
 flexible membrane
 together these allow them to change
shape without breaking as they pass
through the narrow and winding
capillaries
 lifespan of about 120 days after being
released into the blood
 contain thousands of Hgb molecules
o # of RBCs varies with age, gender and health
o normal range: 4,200,000 to 6,100,000/ mm3
o start as stem cells  myeloid pathway 
progress in stages  mature RBC (aka
erythrocytes)
o as RBCs age, their membranes become more
fragile
 old cells are trapped and then destroyed
(in the tissues, spleen, and liver)
 some parts are recycled, like iron, and
used to make new RBCs
o each RBC produces Hgb
 the heme part of each Hgb molecule
needs a molecule of iron
 when heme & iron combine – heme
molecule can transport up to 4
molecules of oxygen
 iron is an essential part of Hgb
 the globulin part of Hgb carries CO2
 acid/base balance
 the most important part of Hgb: ability
to combine with oxygen loosely
 small drop in oxygen level in the
tissues  great increase in
transfer of oxygen from Hgb to
tissues occurs
o known as oxygen
dissociation
o important to help meet
body’s needs for oxygen
o some problems change the
speed and amount of
oxygen released to the
tissues
 total # RBCs is carefully controlled
 ensure enough RBCs are present
for good oxygenation without
having too many cells that could
“thicken” the blood and slow the
flow
 RBC production/erythropoiesis
(selective growth of stem cells
into mature erythrocytes) must
be balanced with RBC
destruction/loss body’s need for
tissue perfusion by ensuring
adequate delivery of oxygen
 trigger fro RBC production =
increased need for tissue
oxygenation
 erythropoietin is produced at the
same rate as RBC destruction or
loss occurs to maintain a constant
level of circulating RBCs
 when oxygenation to the tissues
is less than normal (hypoxia) the
kidneys release more
erythropoietin  growth factor
then stimulates the bone marrow
to increase RBC production
 when oxygenation is normal or
high  kidney reduces
erythropoietin levels  slows
RBC production
 synthetic erythropoietin (Procrit,
Epogen, EPO) has the same effect
on bone marrow as naturally
occuring
 many substances are needed to form
Hgb and RBCs including
 iron
 vitamin B12
 folic acid
 copper
 pyridoxine
 cobalt
 nickel
 lack of any of these = anemia – the
result of any problem that reduces the
function or the number of RBCs to the
point tissue oxygen needs are not
completely met
o RBCs also act as buffers that help with
acid/base
 (2) WBCs:
o perform actions necessary for protection
through the inflammation and the immune
system
o many types of WBCs all with “special”
functions
o many are formed in the bone marrow
 (3) platelets:
o smallest of the blood cells
o formed as fragments of a giant precursor cell in
the bone marrow (megakaryocyte)
o stick to injured blood vessel walls and form
“platelet plugs” that can stop the flow of blood
from the injured site
o they also produce substances important to
blood clotting (coagulation)
o help keep blood vessels intact by beginning the
repair of damage
 perform by aggregation (clumping)
o production of platelets in the bone marrow is
controlled by growth factors (thrombopoietin)
o after they leave the bone marrow, they are
stored in the spleen and then released slowly
until they meet the body’s needs
o 80% circulate, 20% stored in spleen normally
o platelet life span is 1-2 weeks

Platelet growth pathway. Erythrocyte growth pathway.

 accessory organs of blood formation

o spleen & liver are important accessory organs for blood production
 regulate the growth of blood cells and form factors that
ensure proper blood clotting
 spleen:
 located under the diaphragm, left of the stomach
 3 types of tissue, all balance to blood cell production
and destruction and assist with immunity
o (1) white pulp
 filled with WBCs (lymphocytes,
macrophages especially)
 major site of antibody production
 as whole blood filters through,
unwanted cells (i.e. bacteria, old RBCs)
are removed
o (2) red pulp
 contains enlarged blood vessels
(sinuses) that store RBCs and platelets
o (3) marginal pulp
 contains the ends of many arteries and
other blood vessels
 destroys old or imperfect RBCs
 breaks down the hemoglobin released from these
destroyed cells
 stores platelets
 filters antigens
 spleenectomy patient:
o • less able to rid themselves of disease
causing organisms
o are at increased risk for infection and sepsis
 liver:
 site for production of prothrombin and most of the
blood clotting factors
 proper liver function and bile production
o important in forming vitamin K in the
intestinal tract
 needed to produce blood clotting factors
VII, IX, X and prothrombin
 large quantities of whole blood and blood cells can be
stored in the liver
 liver also converts bilirubin, an end product of Hgb
breakdown, to bile and stores excess iron within the
ferritin protein

 hemostasis/blood clotting
o hemostasis - process of controlled blood clotting
 localized blood clotting occurs in damaged blood vessels to
prevent excessive blood loss as blood continues to circulated
to all other areas for tissue perfusion
 complex process that balances blood clotting actions with
anti-clotting actions
 injury occurs – 3 processes that result in blood clotting
 (1) platelet aggregation and formation of a platelet
plug
o begins forming a platelet plug by having
platelets clump together
 normally they are individual cell-like
structures in circulation
 activation causes platelet membranes to
become sticky (allowing them to clump)
 when they clump they form large
semisolid plugs in blood vessel lumens
and walls, disrupting blood flow
 these ‘plugs’ are not clots and cannot
provide complete hemostasis
 substances that cause platelets to clump
together include adenosine diphosphate
(ADP), calcium, thromboxane A2, and
collagen
 platelets secrete some of these
themselves
 some are external
 platelet plugs start the cascade that ends
with blood clotting locally
 too few platelets present  blood
clotting is impaired  increased risk for
bleeding & hemorrhage
 (2) blood clotting cascade
o cascade triggered by platelet plug formation
o can occur from both intrinsic and extrinsic
factors
o the final result is much larger than the event
that triggers it (landslide)
 hard to stop once set into motion
o involves intrinsic and extrinsic factors
 intrinsic factors – problems or
substances directly in the blood that
make platelets clump and then trigger
the blood clotting cascade
 circulating debris
 prolonged venous stasis
 continuing the cascade to the
point where it reaches blood
clotting requires adequate
amounts of all factors & cofactors
(table 41-2)
 extrinsic factors – those outside the cell
that can also induce platelet plugs to
form
 usually the result of changes in
the blood vessels rather than in
the blood
 the most common is trauma that
damages blood vessels and
exposes the platelets to collagen
o collagen activates platelets
and causes clumping
o platelet plug is formed
within seconds of the
trauma
o blood clotting cascade is
started sooner by this
pathway than intrinsic
because some steps are
bypassed
 other blood vessel changes that
can trigger platelets to clump
include inflammation, bacterial
toxins, or foreign proteins
 when these platelet plugs are formed
because of (a) abnormal blood/intrinsic
factors or (b) exposure to inflamed or
damaged blood vessels/extrinsic factors
the end result is the same (formation of
a fibrin clot and local blood coagulation)
 the steps between formation of a platelet
plug and formation of a fibrin clot
depend on what clotting factors are
present
 plus, more calcium and more
platelets are needed with each
step
 clotting factors are inactive enzymes
that become activated in a sequence
 last part of sequence is the
activation of fibrinogen into
fibrin
 at each step, the activated enzyme
(from the previous step) activates
the next enzyme
 the last two steps are the
activation of thrombi from
prothrombin and the conversion
(by thrombin) of fibrinogen into
fibrin
 ONLY FIBRIN MOLECULES
CAN BEGIN THE FORMATION
OF A TRUE CLOT

Fig. 41-5 Summary of blood-clotting cascade.

TABLE 41-2 The Clotting Factors
• (3) formation of a complete fibrin clot
o last phase of blood clotting
o fibrinogen = protein made in the liver
o enzyme thrombin removes the end portions of
fibrinogen converting it to active fibrin
 active fibrin molecules link together to
form fibrin threads
 make a netlike base to form a blood clot
o once fibrin mesh is formed, clotting factor XIII
tightens up the mesh (makes it more stable and
dense)
 more platelets stick to the threads of the
mesh & attract other blood cells and
proteins  forms an actual blood clot
 as this clot tightens (retracts) then the
serum is squeezed out and clot
formation is complete

 anti-clotting forces
o keeps forming fibrin clots whenever the cascade is set off until all
blood throughout the entire body has coagulated  this widespread
clotting would lead to death
 when cascade is started, anti-clotting forces are also started
to limit clot formation only to damaged areas
 normal blood flow is maintained everywhere else
o involves 2 actions:
 (1) ensures that activated clotting factors are present only in
limited amounts
 (2) prevents over-enlargement of the fibrin clot (fibrinolysis)

Fig. 41-6 The process of fibrinolysis.

o activation of blood clotting cascade  certain anti-clitting

substances are also activated (protein C, protein S, antithrombin
III)
 protein C & S increase the breakdown of clotting factors IX &
X
 antithrombn III inactivates thrombin and clotting factors IX
and X
 these prevent clots from
o (a) becoming too large
o (b) forming in an area where blood clotting is
not needed
 deficiency in any of these clotting factors = increased r/f PE,
MI and strokes
o fibrinolysis limits the size of blood clots by dissolving fibrin clot
edges with special enzymes
 process begins by activating plasminogen to plasma
 plasmin (an enzyme) digests fibrin, fibrinogen, prothrombi
 this controls the size of the fibrin clot

hematologic changes associated with aging:

 aging (changes in older adults)
o changes the cellular and plasma components of the blood
o decreased blood volume
o lower levels of plasma proteins (r/t low dietary intake of proteins
and reduced protein production by the older liver)
o bone marrow ages – produces fewer blood cells
 total RBC and WBC counts (especially lymphocyte counts)
are lower
 WBC count does not rise as high with infection as it does in
younger people
o no change in platelet counts
o lymphocytes less reactive to antigens and lose immune function
o antibody levels and responses are lower and slower in older adults
o hemoglobin levels fall after middle age (r/t iron deficient diets)
assessment history
 chart 41-2 – Gordon’s

Chart 41-2 HEMATOLOGIC ASSESSMENT

Using Gordon's Functional Health Patterns
ACTIVITY-EXERCISE PATTERN
How does your energy level seem to you compared with last year at this
time?
Do you feel rested after a typical night's sleep?
Have you experienced any dizziness or light-headedness?
Does your heart ever seem 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?
NUTRITION-METABOLIC PATTERN
Have you noticed any change in your skin lately?
How easily do you bruise?
Do your gums ever bleed? Under what conditions?
How much meat do you eat in a week?
How often do you eat salads or other green leafy vegetables?
Are you taking any vitamin or mineral supplements?
Do your feet and hands usually feel warm or cold?
Has your weight changed by 5 pounds or more this year?
How often do you take aspirin or any other NSAID?
What drugs do you take daily?
 patient history
o age & gender are important!
 at all ages women have lower blood counts then men
 greater difference during menstrual years
o r/t
 (a) blood loss from menstruation may
occur slightly faster than blood cell
production
 (b) a blood dilution caused by fluid
retention from female hormones
o bone marrow function and immune activity decrease with age
o personal factors to include
 liver function
 liver makes clotting factors
 ask about manifestations that may indicate liver
problems
o jaundice
o anemia
o gallstones
 previous radiation therapy for cancer could result in
some permanent hematologic function impairment (if
marrow-forming bones were in radiation path)
 presence of known immunologic or hematologic disroders
 current drug use
 check all drugs the patient is using/has used in the
past 3 weeks
 ask about antibiotic use
o prolonged antibiotic therapy can lead to
 clotting problems
 bone marrow depression
 table 41-3
penicillin G, penicillin V, aspirin, ibuprofen, naproxen

 ask about use of blood thinners & NSAIDs

o indicates that the person has a blood clotting
problem or has a health problem that requires
changing blood clotting activity
o anticoagulant, fibrinolytics, platelet inhibitors
 figure 41-5
 anticoagulant drugs
 work by interfering with one or
more steps in the blood clotting
cascade
 prevent new clots from forming
 limit or prevent the extension of
formed clots
 cannot breakdown existing clots
 classified as
o thrombin inhibitors
o vitamin k antagonists
o indirect factor x inhibitors
 fibrinolytic drugs/thrombolytic drugs
 break down fibrin threads
(selectively) that are already there
in the formed blood clot
 fibrin degradation is started by
activation of the inactive tissue
protein plasminogen to plasmin
(active form)
o plasmin attacks and
degrades the fibrin
molecule
 fewer effects on the
fibrinogen molecule
 the action of these drugs is the
selective breakdown of formed
fibrin clots (w/less effect on clot
formation)
 best clot breakdown with less
disruption of blood clotting
 1st line therapy for problems with
small, localized form clots
o MI
 given within only
first 6 hours of
onset of symptoms
 not r/t drug activity
(these can break
down clots older
than 6 hours) but
tissue that has been
without oxygen for
more than 6 hours
is not likely to
benefit (risks
outweigh the
benefits)
o limited arterial thrombosis
o thrombotic strokes
 platelet inhibitors
 drugs that either
o (a) prevent platelets from
becoming active
o (b) prevent activated
platelets from clumping
together
 most widely used drug is aspirin
o inhibits the production of
substances that can trigger
platelet activation
(thromboxane, i.e.)
 other drugs change the platelet
membrane
o reducing its “stickiness”
OR
o prevent activators from
binding to platelet
receptor sites
 dietary patterns
 socioeconomic status
 collect information about
 occupation
 hobbies
 location of housing
 this information may indicate an exposure to
agents/chemicals
o affect bone marrow growth
o affect hematologic function

o nutrition status
 diet can alter cell quality (therefore affect blood clotting)
 ask patient to record everything eated for previous week
 use this information to determine the causes of
o anemias
 diets high in fat and carbs and low in
protein, iron and vitamins can cause
many types of anemia & can decrese the
functions of all blood cells
o protein def.
o vitamin def.
o mineral def.
 ask about alcohol consumption
 can cause nutritional def. both
 liver transplant reduce blood clotting
 certain dietary habits can enhance blood clotting
 diets high in vitamin k (leafy green veggies) 
increased rate of blood clotting
o assess amount of salads and other raw veggies
patient eats
 assess whether patient routinely takes supplemental
vitamins
 assess the amount of calcium in the diet or in supplement
 assess patient’s ability to understand and follow instructions
related to
 diet
 procedures/tests
 prescribed drugs or diets
 ask about personal resources
 finances
o person with poor income may have a diet low
in iron and protein because food sources with
these are more expensive
 social support

o family history & genetic risk

 accurate family history bc many disorders affecting blood
and clotting are inherited
 has anyone in family had
o hemophilia
o frequent nosebleeds
o postpartum hemorrhages
o excessive bleeding after tooth extractions
o heavy bruising after relatively mild trauma
o sickle cell disease/sickle cell trait
 sickle cell disease is most often see
among African Americans but anyone
can have the trait
o current health problems
 swelling of lymph nodes?
 excessive bruising/bleeding?
 spontaneous or induced by trauma?
 amount and duration of bleeding after routine dental
work?
 menorrhagia (excess menstrual flow)?
 estimate # of pads/tampons used during most recent
menstrual cycle
o whether this amount represents a change from
her usual pattern
 menstrual clots?
 estimate clot size using coins or fruit (clots are “dime
sized” or “size of lemons”)
 SOB on exertion?
 palpitations?
 frequent infections? any or all of these symptoms may
 fevers? occur with hematologic disease
 recent weight loss?
 headaches?
 paresthesias?
 single most common symptom of anemia = fatigue
 occurs bc O2 delivery to cells is less than oxygen needs
o cells use oxygen to make ATP (needed to
perform cellular work)
 when oxygen decreases  ATP
production decreases  all cellular
work decreases  fatigue increases
 ask patients about
o feeling tired
o needing more rest
o losing endurance during
normal activities
 ask them to compare their
activities during the past month
with those of the same month a
year ago
 determine if they have other
symptoms of anemia:
o vertigo
o tinnitus
o sore tongue

 physical assessment
o assess the whole body bc blood problems may cause oxygen delvery
to be less than what is needed for whole body
o problems (with whole body)
 tissue perfusion
 oxygenation
o some assessment findings associated with hematologic problems
are less reliable when seen in an older adult (see chart 41-1)
o equipment needed:
 stethoscope
 blood pressure cuff
 pen light

o skin assessment
 color: skin for pallor or jaundice mucous membranes and
nail beds for pallor or cyanosis pallor of the gums,
conjunctivae, and palmar creases indicates decreased
hemoglobin levels and poor tissue oxygenation
 assess gums for
 active bleeding
o in response to light pressure
o brushing teeth
o any lesions or draining areas
 inspect for petechiae (pinpoint hemorrhagic lesions in the
skin) and large bruises (echymoses)
 bruises may cluster together
 bleeding from NG tubes, endotracheal tubes, central lines,
peripheral IV sites or Foleys
 check skin turgor
 ask about itching
 dry skin or itching can indicate hematologic disease
 culture tidbit:
 easier to see in darker skin colors in these places:
o pallor & cyanosis
 oral mucous membranes
 conjunctiva of the eye
o jaundice
 roof of mouth
o petechiae
 palms of hands/soles of feet
o bruises
 seen as darker areas of skin and
palpated as slight swellings or irregular
skin surfaces
 ask about pain when skin surfaces are
touched lightly or palpated

o head & neck assessment

 check for pallor or ulceration of mouth mucosa
 tongue
 completely smooth (pernicious anemia)
 beefy red (nutritional deficiencies)
 assess for jaundice of sclera
 inspect and palpate all lymph nodes
 document any lymph node enlargement
 include where palpation of the enlarged node causes
pain
 important whether the enlarged node moves or
remains fixed in position with palpation

o respiratory assessment
 blood problems reduce oxygen delivery  lungs work harder
to make adjustments that can maintain tissue perfusion
 assess the rate and depth of respirations while the patient is
 at rest
 doing mild physical activity (i.e. 20 steps in 10 secs)
o whether they can complete a ten word sentence
without stopping for a breath
o assess whether many anemias cause
 fatigued easily these as a result of
 SOB at rest or on exertion respiratory changes
 needs an extra pillow to sleep made as adjustments
comfortably at night to reduced oxygen
delivery to tissues
o cardiovascular assessment
 blood problems  reduced oxygen delivery  heart works
harder to make adjustments to maintain tissue perfusion
 observe for
 chest heaves
 distended neck veins
 edema
 signs of phlebitis
 listen for
 murmurs
 gallops
 irregular rhythms
 abnormal blood pressure
o systolic lower than normal (anemia)
o excessive RBCs = higher BP
 severe anemias  heart tries to adjust to compensate for a
continuous reduction in oxygen delivery  enlargement of
right ventricle, heart disease

o renal & urinary assessment

 bleeding may present as gross or occult hematuria (blood in
urine)
 voided sample for
o color: may be grossly bloody red or dark
brownish gold urine
o proteins: with a urine dipstick
 protein & blood in urine increases
protein content (??)

o musculoskeletal assessment
 rib or sternal tenderness (important sign of leukemia [cancer
of the blood])
 occurs when the bone marrow greatly overproduces
cells  increasing the pressure in the bones
 look at skin over superficial bones (ribs and sternum) by
applying firm pressure with the fingertips
 assess RO(joint)M
 document
o swelling
o joint pain
o motion limitation

o abdominal assessment
 spleen – usually not palpable
 lies just beneath the abdominal wall, under the ribs on
the left side
 enlarged spleen
o occurs with many hematologic problems
o detected by percussion
o palpation is more reliable
o can be IDed by its movement during
respiration
o during palpation – have the patient lie relaxed,
supine position while you stand on the
patient’s right and palpate the ULQ
 be gently and cautious
 spleen could be tender and easily
ruptured
 liver
 palpate liver’s edge in RUQ of abdomen
 hepatic enlargement often occurs with hematologic
problems
 may be palpable as much as 4-5 cm below the R costal
margin
 usually not palpable in the epigastrium
 chronically bleeding GI ulcer or polyp
 if under stomach or the small intestine
o obvious blood may not be visible in the stool
OR
o such a small amount is passed each day that
patient is not aware
THEREFORE
o obtain a stool specimen for occult blood testing

o cns assessment
 examine cranial nerves and test neurological function
 some problems cause specific changes
o vitamin b12 def. – impairs cerebral, olfactory,
spinal cord and peripheral nerve function
 severe chronic def – permanent
neurologic degeneration
 many neurologic problems in patients with leukemia
o result of bleeding, infection, tumor spread
 when a patient with a suspected bleeding disorder has
head trauma
o expand assessment to include frequent neuro
checks and mental status exams
o
o other manifestations
 fever
 chills
 night sweats

 psychosocial assessment
o may have chronic illness (hemophilia or cancer) or acute episode of
a chronic disease (pernicious anemia)
 develop raport
 learn what coping mechanisms have been successful before
 ask about social support networks, community resources,
financial health
 any problem in these areas can interfere with the
patient’s adherence to therapy and recovery

 diagnostic assessment
o laboratory assessment
 most definitive signs are often lab and test results
 see chart 41-3

 test of cell number and function

 peripheral blood smear
o drop of blood spread over a slide
o read by an automated calculator or
technologist with a microscope
o can provide information within peripheral
blood on the
 sizes

 shapes
 approximate proportions of different
blood cell types
 complete blood count
o includes:
 RBC count
 all circulating RBCs in 1 mm3 of
blood
 WBC count
 all leukocytes in 1 mm3 of blood
 WBC count with differential
o percentage of different
types of leukocytes
circulating in blood
 Hct
 percentage of RBCs in the total
blood volume
 Hgb
 total amount of Hgb in the blood
o can measure other features of the RBCs
 MCV (mean corpuscular volume)
 measures the average
volume/size of a single RBC
 useful for classifying anemias
 when elevated – cell is larger than
normal (macrocytic)
o megoblastic anemias
 when decreased – cell is smaller
than normal (microcytic)
o iron deficiency anemia
 MCH (mean corpuscular hgb)
 average amount of hgb by weight
in a single RBC
 MCHC (mean corpuscular hgb
concentration)
 average amount of Hgb by
percentage in a single RBC
 when decreased – cell has a
hemoglobin deficiency and is
hypochromic (a lighter color)
o iron deficiency anemia
 reticulocyte count
o helpful in determining bone marrow function
o reticulocyte = immature RBC that still has its
nucleus
o elevated – indicates that RBCs are being
produced faster than they can mature
 desired:
 in anemic patients
 after hemorrhage
o indicates bone marrow is
responding to a decrease
in the total RBC mass
 not desired:
 without a precipitating cause
o indicates health problems
 polycythemia vera
(a malignant
condition in which
the bone marrow
overproduces
RBCs)
o normally 2% of RBCs are reticulocytes
 hemoglobin electrophoresis
o detects abnormal forms of Hgb
 Hgb S in sickle cell
o hemoglobin A is the major type of Hgb in the
normal RBC from an adult
o decreased Hgb A levels with increasing levels of
other types of Hgb indicate a hematologic
problem
 i.e. sickle cell dz
 leukocyte alkaline phosphatase (LAP)
o enzyme produced by normal mature
neutrophils
o elevated – occur during episodes of infection or
stress
o an elevated neutrophil count w/out an elevated
LAP occurs with some types of leukemia
 coomb’s tests (direct & indirect)
o used for blood typing
o direct:
 detects the presence of antibodies
(antiglobulins) against RBCs that may
be attached to a person’s RBCs (??)
 healthy people can make these
antibodies in certain diseases
 SLE directed against
 mono patient’s own
 lymphomas RBCs
 usually causes a hemolytic anemia
o indirect:
 detects the presence of circulating
antiglobulins
 determines whether the patient has
serum antibodies to the type of RBCs
that he or she is about to receive by
transfusion
 serum ferritin, transferrin, and the total iron-binding
capacity (TIBC) tests
o measure iron levels
o abnormal levels of TIBC and iron occur with
hematologic problems
 iron deficiency anemia
o serum ferritin
 measures the amount of iron present as
free iron in the plasma
 amount of serum ferritin is r/t the
amount of intracellular iron (1% of total
body iron stores)
 means to assess total iron stores
 people with serum ferritin within 10
grams of normal range for their gender
hace adequate iron stores
 those with ten grams or more
lower than the normal have
inadequate iron stores
o difficulty recovering from
blood loss
o transferrin
 protein that transports dietary iron from
the intestines to cell storage sites
 measured by measuring the amount of
iron that can be bound to serum
transferrin indirectly and then
determining whether enough transferrin
is present
 this is the total iron binding capacity or
TIBC test
 in healthy people, 30%
transferrin is bound to iron in the
blood
 measured by taking a sample of
blood and adding measured
amounts of iron to it
 TIBC calculated when blood no
longer binds the iron but allows it
to precipitate
 increases – a person is deficient
in serum iron and stored iron
levels
o adequate amount of
transferring but less than
30% is bound to serum
iron

 tests measuring bleeding and coagulation

 capillary fragility test
o measures how easily capillaries are damaged
o intracapillary pressure is increased by
occluding venous outflow or by applying
controlled negative pressure to a skin area
 usually, a BP cuff is inflated to a
pressure halfway between the systolic
and diastolic pressures
 pressure maintained for 5 minutes
 petechiae appear below cuff are counted
 normally 5-10 appear
 when the number increases –
o the cause of excessive
bleeding or bruising is
capillary fragility
 not poor platelet
action
 bleeding time test
o evaluates vascular and platelet activity during
hemostasis
o spring-loaded lancet that makes a uniform
wound depth is applied to the forearm while a
BP cuff remains inflated at 40 mmHg
 blood is blotted from the site at 30
second intervals
 time required for bleeding to stop is
recorded
 normal bleeding time ranges from 1-9
minutes
 prothrombin time (PT)
o measures how long blood takes to clot
o reflects how much of the clotting factors II, V,
VII, and X is present and how well they’re
functioning
o when enough are present, the PT is between 11
and 13 seconds or within 85% to 100% of the
time needed for a control sample of blood to
clot
o prolonged when one or more clotting factors is
lacking (i.e. in liver disease)
o sodium warfarin/Coumadin therapy is also
monitored with PT levels
 appropriate when PT is prolonged 1.5 to
2 times the patient’s normal PT value
 depends on specific reason for
Coumadin therapy
o now used less often to assess how fast blood
clots because control blood is taken from
different people
 INR used instead
 international normalized ratio (INR)
o measures the same process as PT just in a
different way
 establishes a normal mean or standard
PT
o calculated by dividing the patient’s PT by the
established standard PT
o normal ranges between 0.7 and 1.8
o when using to monitor Coumadin therapy
 goal is between 2.0 and 3.0 regardless of
actual PT in seconds
 desired range is individualized for
specific patient factors
 partial thromboplastin time (PTT)
o assesses the intrinsic clotting cascade and the
action of factors II, V, VIII, XI and XII
o prolonged PTT when lacking any of these
factors
 hemophilia
 disseminated intravascular coagulation
(DIC)
 factors II, IX and X are vit k dependent
and are produced in liver
 liver disease can decrease their
levels
o prolonging PTT
o Heparin therapy is monitored by PTT
 therapeutic range is 1.5-2.0 times
cnormal values
o controversy over accuracy if taken through a
saline lock/vascular access device instead of
through a separate new venipuncture
(especially when the pt is also receiving
heparin therapy)
 proven to be an accurate reflection of
PTT
 platelet aggregation (ability to clump)
o tested by mixing the patient’s plasma with a
substance called ristocetin
o degree of clumping is noted
o clumping can be impaired
 von Willebrand’s disease
 during the use of certain drugs
 aspirin
 anti-inflammatory agents
 psychotropic drugs
 pleatelet inhibitors
 imaging assessment
o can include radioisotopic imaging
o isotopes – used to evaluate the bone marrow for sites of active
blood cell formation and sites of iron storage
o radioactive colloids – used to determine organ size and liver and
spleen function
o patient is given radioactive isotope 3 hours prior to procedure
 patient is then taken to nuclear medicine dept for scan
 must lie still for about an hour
 no special preparation or follow up care is needed
o standard x-rays used for diagnoses of some hematologic problems
 multiple myeloma – classic bone destruction, “swiss cheese”
appearance on x-ray

HUMAN NEEDS ASSESSMENT REVIEW

What should you expect to NOTICE in a patient with
adequate oxygenation and tissue perfusion related to
hematologic function?
Vital Signs
Heart rate and respiratory rate within normal range
Blood pressure within normal range
Physical Assessment
Able to speak a sentence of 12 words without stopping for
breath
Able to walk and talk without stopping for breath
Skin color normal (no cyanosis, pallor, or jaundice)
Oral mucous membrane and nail beds pink with rapid capillary
refill
Gums pink, no petechiae or bleeding
Appropriate distribution of body hair, especially on legs and
feet
Warm hands and feet, no dependent edema
Creases on palms of the hand (when stretched) red (or brown in
people with dark skin)
Skin clear with no large bruises or petechiae
Lower eyelid conjunctive red
Urine output just about equal to fluid intake
Urine clear and yellow
Psychological Assessment
Oriented and not confused
Energy level good, able to engage in desired work, recreational,
and personal activities
Laboratory Assessment
Red blood cell, hemoglobin, hematocrit, white blood cell, and
platelet levels within normal limits for age and gender
Reticulocyte count less than 2%

 bone marrow aspiration and biopsy

o bone marrow aspiration/biopsy often performed to evaluate
hematologic status when other tests are persistently abnormal
o can provide important info about bone marrow function
 production of blood cells
 production of platelets
o aspiration and biopsy = similar procedures
 aspiration – cells and fluid suctioned from bone marrow
 biopsy – solid tissue and cells are obtained by coring out an
area of bone marrow with a large bore needle
o physician’s request, signed informed consent
o can be performed by physician, adv practice nurse, PA, depending
on policy and law
o can be at pts bedside, in exam room or in lab
o determine what specific tests will be performed on the marrow
 determine how to handle specimen
 some tests require an addition or heparin (or other solution)

o patient preparation
 anxious or fearful beforehand
 those who have had one in the past are either more so
or less so
o depends on previous experience
 provide accurate information and emotional support
o some like to have their hand held
 explain the procedure
 tell them you will stay during the entire procedure
o occasionally a family member or firned is
permitted
 using a local anesthetic - explain the injection will feel
like a stinging or burning sensation
 expect a heavy sensation of pressure and pushing
while the needle is being inserted
 can hear a crunching sound or feel a scraping
sensation as the needle enters the bone
 brief sensation of painful pulling as the marrow is
being aspirated by mild suction in the syringe
o if a biopsy - more pressure and discomfort as
the needle is rotated in the bone
 assist patient onto examining table and expose site
 iliac crest (prone position OR side lying position
occasionally)
 sternum
 lab tech may also be present to ensure proper handling of
specimen

o procedure
 5-15 minutes
 patients may have pain
 type and amount of anesthesia or sedation depend on
physician, patient’s experience with previous bone marrow
aspiration/biopsy and the setting
 local anesthetic is injected into the skin around site
 may also receive mild tranquilized or rapid-acting
sedative (Versed or Amidate)
 some do well with guided imagery or autohypnosis
 invasive, therefore sterile precautions
 clean skin with disinfectant
 aspiration
 needle inserted with a twisting motion
 bone marrow aspirated by pulling back on the plunger
of the syringe
 when enough is aspirated, the needle withdrawn
rapidly while tissues at site are supported
 biopsy
 small skin incision is made and biopsy needle is
inserted
 pressure and several twisting motions are needed to
ensure coring and loosening of adequate amount of
bone marrow
 apply external pressure to site until hemostasis is
ensured
 a pressure dressing or sandbags applied to reduce
bleeding at the site

o follow-up care
 cover the site with a dressing after bleeing is controlled
 carefulyy observe for 24 hours for bleeding and infection
 a mild analgesic (aspirin-free) may be given for discomfort
 ice packs can be used to limit bruising
 instruct patient to inspect the site q 2 hours for 1st 24 hours
and note any bleeding or bruising
 advise to avoid contact sports or any possibly traumatic
activity fo 48 hours
 information obtained reflects degree and quality of bone
marrow present
 counts made on a narrow specimen
o whether different cell types are present in
expected quantities and proportions
 can confirm the spread of cancer cells from other tumor sites