Chapter 41

Assessment of the Hematologic System

Anatomy and Physiology Review

• Bone marrow is the source of all blood cells, including immune system cells

• Red blood cells (erythrocytes) • White blood cells (leukocytes)• Platelets smallest of blood cells. They stick to

injured blood vessel walls and form platelet plugs that can stop the flow of blod from the injured site. They produce substances important to coagulation (clotting) They perform most of their job by aggregation (clumping)

Accessory Organs of Blood Formation • They help regulate growth of blood cells & form factors that

ensure proper blood clotting.• SPLEEN: under the diaphragm to the left of the stomach. It

has 3 types of tissue WHITE PULP: filled with WBC and major site of antibody production. RED PULP: contains enlarged blood vessels that store RBC’s and platelets. MARGINAL PULP contains the ends of many arteries and other blood vessels. It’s main function is to destroy old & imperfect RBC’s break down the hemoglobin from bad cells , stores platelets and filters antigens. A patient can live without their spleen has a reduced immune system and prone to infection.

• KNOW THIS SLIDE

Accessory Organs of Blood Formation • LIVER: Site for producing prothrombin and most of the blood

clotting factors. Produce bile forms vitamin K in the intestinal tract which is needed to produce blood clotting factors VII, IX, X & prothrombin. Large quantities of whole blood cells and whole blood can be stored in the liver. Also stores iron and converts bilirubin to bile.

• KNOW THIS SLIDE

Hemostasis/Blood Clotting

• Platelet aggregation• Blood clotting cascade• Intrinsic factors: problems directly in the blood

itself that make platlet clump and then clot.• Extrinsic factors: outside of the cell that can also

induce platelet plugs to form usually due to changes in the blood vessels rather than in the blood Ex trauma

• Fibrin clot formation: Last Phase of blood clotting, protein made in the liver, that helps make threadlike mesh to form a clot.

Platelets and Blood Clotting

Anticlotting Forces

Assessment

• Patient history

• WHAT WOULD YOU ASK?• WHAT WOULD YOU LOOK FOR?

Drugs

• Anticoagulants—interfere with steps in blood clotting; limit or prevent extension of clots and prevent new clots CAN YOU NAME ANY?

• Fibrinolytics also know as Thrombolytic drugs—selectively degrade fibrin threads in the formed blood clot. Best seen in clots for MI, or clot strokes.

• Platelet Inhibitors—prevent platelets from becoming active or activated platelets from clumping together (NSAIDS)

Assessment

• Nutritional status• Family history and genetic risk• Current health problems

Physical Assessment

• Skin• Head and neck• Respiratory• Cardiovascular• Renal and urinary• Musculoskeletal• Abdominal• Central nervous system• Psychosocial

Diagnostic Assessment

• Tests of cell number and function: • Complete blood count• Reticulocyte count• Hemoglobin electrophoresis• Leukocyte alkaline phosphatase• Coombs’ test• Serum ferritin, transferrin, and total iron-

binding capacity

Tests Measuring Bleeding and Coagulation

• Capillary fragility test• Bleeding time test• Prothrombin time • International normalized ratio • Partial thromboplastin time• Platelet agglutination/aggregation

Other Tests

• Radiographic examinations• Bone marrow aspiration and biopsy

Bone Marrow Aspiration and Biopsy

• Patient preparation• Procedure• Follow-up care

NCLEX TIME

Question 1

A nurse interviews an older female patient who is complaining of 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. “Do you have a history of cardiovascular disease?”

B. “Can you tell me about your diet?”C. “Have you been feeling depressed lately?” D. “What medications do you routinely take?”

Question 2

The patient’s hematologic assessment results are:Red blood cell count: 3.8 million/mm3

Total iron binding capacity: 225 mcg/dLIron: 50 mcg/dLHemoglobin: 10 g/dLHematocrit: 35%

These results suggest that the patient may be experiencing:

A. Chronic hypoxiaB. A malignancyC. A liver disorder D. Hemorrhage

Question 3

The patient is complaining of increased fatigue, bleeding gums, and frequent “chills.” What is the most appropriate initial nursing intervention?

A. Notify the physician of the patient’s complaints. B. Review the laboratory analysis for signs and

symptoms of bone marrow suppression.C. Review the laboratory analysis for signs and

symptoms of infection. D. Administer the prescribed antibiotics to manage

the patient’s current infection.

Question 4

The patient was transitioning from IV heparin therapy to oral warfarin. Therapeutic anticoagulation of the patient is best assessed by:

A. Partial thromboplastin time of 24.3 seconds

B. Prothrombin time of 18 secondsC. International normalized ratio of 2.5D. Bleeding time of 5 minutes

Question 5

After obtaining a patient’s blood pressure, you notice petechiae upon removal of the blood pressure cuff. What should be the nurse’s priority intervention?

A. Obtain a blood sample to assess the patient’s coagulation status.

B. Ask the patient about a history of bleeding disorders.

C. Ask the patient about medications he is currently taking.

D. Ask the patient if he is experiencing bone, sternum, or rib pain.