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N308 Care of the Adult with
Hematopoietic stressors
Blood Production Problems
(Quantity Problems)

UNDERPRODUCTION

OVERPRODUCTION
IMPAIRED PRODUCTION

• Hypoproliferative
• Microcytic (RBCs small)
• Macrocytic (RBCs large)
• Hypochromic (↓Hemoglobin)
• Hyperchromic (↑Hemoglobin)
Circulation - Patho
Circulation
Circulation - Purpose



Movement of
nutrients and
medications
Oxygenation
Homeostasis
•
•
Fluid balance
Acid-base balance
Blood Cells
Blood Cells
Plasma




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Plasma proteins
Clotting factors
Other substances:
nutrients, enzymes
Waste products
Gases
Albumin



Maintains fluid balance
Binds substances to
transfer in plasma, i.e.,
meds
Maintains osmotic forces
ANEMIA
A client without sufficient red blood cells is said to
be anemic.
Normal Red Blood Cell Count


4.0 – 5.4 million u/L
Males are often
slightly higher than
females
Testing for CBC




Non-fasting
Can take blood sample from vein, artery
or capillary
Do not use vein where I. V. is located
Do not massage area (heel stick, or fingers)
• False low
 If tourniquet on too long, remove, wait, then try again
 False high
Hemoglobin & Hematocrit


Hemoglobin
Normal Adult
•

12-17 gm/dl

Hematocrit
•
36-51% of whole blood
volume
Is generally 3X the
hemoglobin value
Mean Corpuscular Hemoglobin

Amount of hemoglobin in an average red
blood cell.

Normal MCH level is between 26 and 33
picograms (one trillionth of a gram) of
hemoglobin per red blood cell.
MCV and RDW




MCV – Mean Corpuscular Volume
Average amount of space occupied by
each red blood cell.
The normal MCV level = between 78 and
98 cubic micrometers (abbreviated um3)
RDW – Red cell Distribution Width:
Differences in sizes of the cells
Normal RDW = variation of 11%-14.5%
Common Cause:
Hemorrhagic Blood Loss





Menstruation
Childbirth
Gastro-intestinal
Trauma
Abnormal cell
morphology, i.e.,
hemophilia
Common Cause:
Poor Nutrition


Inadequate intake of
nutrients
Inadequate
absorption of
nutrients (iron, folic
acid, Vit. B12)
Anemia
Iron Deficiency Anemia

Microcytic,
hypochromic
disorder
s/s Iron Deficiency


Early: fatigue, weakness, pale skin
Late: dyspnea, chest pain, muscle pain,
cramping
Diagnostics





Hgb
Hct
Reticuloctye count
indices
MCV
RDW
Too much iron in the body


Hemochromatosis
•
•
Genetic
Iron absorbed from GI
tract
Common in
Caucasian descent
Hemochromatosis




Serial screening tests – alpha fetal proteins
Serum iron studies
Genetic counseling
Tx: removal of blood
Iron Studies





Serum iron level
TIBC
% saturation
Ferritin
Differentiation of iron
amounts in different
areas of the body
Vitamin B12 Deficiency





Pernicious anemia
Macrocytic
normochromic
Lack of intrinsic factor
Cheilosis, smooth sore
tongue, neurological
problems
Schilling Test
Schilling Test



The Schilling test is performed to
evaluate Vitamin B12 absorption.
Excretion of 8 to 40% of the radioactive
Vitamin B12 within 24-hours is normal.
The Schilling test is most commonly
used to evaluate patients for pernicious
anemia.
Folic Acid Deficiency




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Macrocytic,
normochromic
Malnutrition
Alcoholics
Serum folate levels
Birth defects
Folic Acid (B9)




Malabsorption
Antibiotics:
ampicillin,
tetracycline
Estrogen
Symptoms similar to
B12
Drugs and Anemia




AZT(Zidovudine)
Phenytoin
Methotrexate
G6PD deficiency
Chronic Illness



Renal disease
Rheumatoid arthritis
Cancer
Kidney Dysfunction Patients



Likely to be anemic
Under produce
erythropoietin
Uremia: bone
marrow less likely to
respond to the
erythropoietin that is
produced
Hemolysis









(erythrocyte destruction)
Hereditary Spherocytosis
Heavy metals (lead, copper)
Malaria
Prosthetic heart valves
Vasculitis
Malignant hypertension
Sepsis
Chemical poisoning
Autoimmune diseases
Pregnant women have ↓ RBCs


Dilutional
Fluid retention
dilutes RBCs
If RBCs are TOO HIGH you have
polycythemia




Sluggish flow
↑ clotting
Tissue hypoxia
High altitude
Polycythemia VERA



Overproduction of
ALL blood cell types
Blood removal is the
treatment
Bone marrow
suppression drugs
Other causes of ↑ RBCs



Dehydration
Smoking
Drugs
•
•
Gentamycin
Methyldopa
Types of Anemia

Hemolytic

Nutritional
• Thalassemia
• Sickle cell
• Spherocytosis
• Iron deficiency
• Folic Acid
• Vitamin B12
Types of Anemia

Production
Impairment
• Aplastic

Bone Marrow
suppression
• Cancer therapy
Thrombocytopenia



Not enough platelets
Coagulation
problems
Bleeding
Thrombocytopenia


Manual examination
of peripheral smear
Nursing: safety of
patient: shaving,
toothbrush,
medications
Idiopathic Thrombocytopenic
Purpura (ITP)




Acute vs. chronic
1-6 weeks post viral
illness
Self-limiting
Dx: exclusion of other
causes of
thrombocytopenia
DIC is Triggered by?







Sepsis
Trauma
Cancer
Shock
Toxins
Allergic Reactions
Emergency situation
NURSING CARE FOR DIC






Maintain optimal oxygenation
Manage fluid replacement
Monitor electrolyte imbalances
Administer vasopressor meds as
ordered
Protect from falls/injury
Provide emotional reassurance
Clotting tests


Prothrombin time (PT)
International Normalized
Ratio (INR)
Clotting tests

Partial prothrombin time
(PTT)
Bone Marrow Biopsies:
Blood Transfusions:
Nursing Responsibilities


Verify, Verify, Verify with 2
nurses!
• Patient identification (name,
record #, B.D.)
• Correct blood type, blood
unit, exp. date
• Set up I.V. access with
saline
• Answer patient questions
Hang blood, use blood tubing
with filter
Blood Transfusion Reactions:




Febrile Non-hemolytic – most common
Acute hemolytic – most dangerous
Allergic reaction
Circulatory overload
Blood Transfusion Reactions:




Bacterial contamination
TRALI – transfusion related acute lung injury –
potentially fatal
Delayed hemolytic reaction
Disease acquisition
Blood Transfusions:
Nursing Responsibilities


Monitor Vital signs
frequently
Unit to hang < 4 hours,
note patient condition to
regulate flow.
TRANSFUSION REACTION!




Stop the blood
Have someone call M.D.
Raise the head of the
bed
Apply 02
TRANSFUSION REACTION!



Hang new saline bag
and tubing
Monitor urine for
amount/blood
Frequent VS