Heme

female 11.7-16.0 g/dL

male 13.2-17.3 g/dL

hgb

< 7 requires transfusion (arrhythmia concern)

female 35-47%

male 39-50%

hct

indicates FVE/FVD

150k-400k per microliter

platelets

< 10k or active bleeds

<2%

reticulocytes

too many = BAD

11-12 sec

PT (prothrombin time)

• how long blood takes to clot

INR (international normalized ratio)

normal = 1

therapeutic range = 2-3

PT ratio

30-45 sec

PTT (partial prothrombin time)

• increases with heparin

20-30 sec

aPTT (activated partial thromboplastin time)

• therapeutic is 1.5-2.5x normal

iron deficiency

anemia etiology r/t decreased RBC production

• RBCs microcytic (small) & hypochromic (less red) r/t blood loss, intake, meds, energy demands

B12 deficiency

anemia etiology r/t decreased RBC production

• RBCs macrocytic (large) r/t intake, pernicious anemia

pernicious anemia

• anemia r/t decreased RBC production

• deficiency of intrinsic factor (gastric mucosa) → failure to absorb B12

• treat w/ B12 injections

• mouth care (glossitis)

• safety when ambulating (hypotension)

folic acid deficiency

anemia etiology r/t decreased RBC production

• RBCs macrocytic (large) r/t intake, malabsorption, meds

aplastic anemia

• anemia r/t decreased RBC production

• arrested development of ALL blood cells in bone marrow

• found w/ agranulocytosis & thrombocytopenia

• d/t injury of pluripotent stem cell (idiopathic, myelotoxic agents, viruses)

• monitor for infections, bleeding

• provide transfusions, splenectomy

acquired hemolytic anemia

• anemia r/t RBC destruction

• megaloblastic/macrocytic RBCs r/t abnormal immune function, physical trauma to cells, chemical rx

antibody

abnormal immune function in acquired hemolytic anemia

• loss of self recognition (______ reaction)

heart

physical trauma to cells in acquired hemolytic anemia

• bypass surgery, mechanical ______ valve, burns, vascular disease, etc.

infection

chemical reaction in acquired hemolytic anemia

• ________, toxins, parasites, snake venom

anemia risk factors

• hx of disorders w/ chronic blood loss

  • colon cancer, GI BLEED

• chronic diseases

• diet deficiencies

  • iron, folic acid, vit B12

• genetic disorders

• exposure to toxic agents

  • lead, insecticides

• meds

  • certain antibiotics, NSAIDs, salicylates, thiazide diuretics, metformin, chemotherapy

anemia clinical manifestations

• lack of hgb → inadequate tissue oxygenation

  • fatigue

  • pallor (NO CYANOSIS)

  • tachycardia

  • palpitations

  • orthostatic hypotension

  • coldness

  • SOB esp. w/ exertion

  • glossitis (beefy smooth tongue)

  • cheilitis (cracked lip corners)

  • weight loss

• long term

  • HF

  • finger clubbing

  • nail changes

  • pica (weird food cravings)

    • dirt, clay, chewing ice

  • cognitive, coping, sexual issues

anemia care interventions

• monitor/labs

  • to identify anemia type, monitor progress, infection

  • blood in excretion (poop)

  • check reticulocyte count for slow bleed

• diet

  • iron (meat, greens, beans)

  • B12 (meat, fortified cereals)

  • folic acid (fish, beans, grains)

• meds

  • iron/B12 supplements

    • NO B12 PO for pernicious anemia

  • transfusions

  • erythropoietin

  • splenectomy

    • for aplastic anemia

    • spleen macrophages/antibodies break down blood cells, overactive

blood transfusion complications

• non-infectious

  • fatal hemolytic reactions

  • volume overload

  • acute lung injury

  • febrile (fever) reactions

• infectious

  • HIV

  • hepatitis B & C

  • higher rates of nosocomial infection

polycythemia

• too many RBCs

• vera (primary):

  • increased RBCs with normal/low epo

  • genetic, usually later life onset

• secondary:

  • increased RBCs and increased epo

  • from hypoxia (high elevation), tumors, cardiopulmonary disease

polycythemia clinical manifestations

• increased CBC: hbg, hct, histamines

• hypercoagulation

• organ/tissue congestion

• increased blood viscosity

• increased blood volume

• increased BP

  • dizziness

  • vertigo

  • headache

  • itchiness (from increased histamine)

  • burning of hands/feet

  • visual disturbances

  • tinnitus

polycythemia care interventions

• administer fluids, myelosuppressives (suppress hematopoiesis)

• phlebotomy as ordered (releases some blood)

• monitor O2

• educate: avoid altitudes, stop smoking

  • hypoxia stimulates erythropoiesis in kidney

• bone marrow biopsy

  • nurse role:

    • pre-assess coagulation, meds

    • during: positioning, pain, V/S

    • after: apply pressure until bleeding stops, clean sterile dressing, monitor V/S, S/S infection, pain

thrombocytopenia

• platelet deficiency d/t decreased production, increased destruction

• r/t immune, thrombotic (drugs, disease), heparin-induced thrombocytopenia & thrombosis

thrombocytopenia clinical manifestations

• plt <150,000

• HITT: 50% from baseline

• bleeding risk: <50k

• severe: <10k

• platelet loss → bleeding

  • petechiae

  • purpura (larger purple bruises)

  • blood in stool/urine

  • increased abdominal girth

  • decreased H&H

  • unusual pain

  • increased abdominal girth

thrombocytopenia care interventions

• figure out cause, assess plt count, CBC, liver & renal

• careful w/ pt handling

• avoid IM, SC injections, aspirin

• oral hygiene w/ minimal friction

• immune thrombocytopenia

  • corticosteroids, platelet transfusion, IVIG, splenectomy, thrombopoietin, romiplostim

• HITT thrombocytopenia

  • stop heparin immediately, plasmapheresis, argatroban

HITT

antibody response to heparin that activates platelets to aggregate/clot (thrombosis)

• heparin uses them all up in HITT thrombocytopenia

• lack of available platelets → bleeding

• solution: stop heparin, start plasmapheresis (machine for removal/filtering of blood), give argatroban (thrombin inhibitor)

extrinsic pathway

coagulation pathway

• tissue damage → prothrombin → thrombin

• coumadin (aka warfarin) acts on this pathway

• labs for coumadin

  • prothrombin time (PT) >12

  • INR normal 1, therapeutic 2-3

intrinsic pathway

coagulation pathway

• blood vessel damage → thromboplastin mediates prothrombin → thrombin

• heparin acts on this pathway

• labs for heparin:

  • partial thromboplastin time (PTT) >45 sec

  • activated PTT 20-30 sec, therapeutic 1.5-2.5x

bleeding tendencies

• decreased plt count

• defective platelets

• drug toxicities; anticoagulant therapy

• low vitamin K

• severe liver/renal disease

clotting tendencies

• increased platelet activity

• estrogen

• smoking

• increased lipids

• sluggish blood flow

  • dehydration

  • vessel compression

  • polycythemia

  • shock

bone marrow aspiration

• aspiration of red bone marrow from posterior iliac crest or sternum

  • for biopsy, diagnosis/evaluation

• invasive procedure (conscious sedation/local anesthetic)

• risks: bleeding and infection

bone marrow aspiration nursing care

• pre-procedure

  • assess coagulation studies/labs & VS

  • receive consent

  • assess meds

• during procedure

  • position pt, help maintain position

  • treat pain

  • monitor VS

• post-procedure

  • bleeding prevention → pressure (turn pt onto site of procedure), ice, bed rest for 30-60 min

  • monitor VS

  • observe for bleeding

  • pt teaching

    • avoid positioning on site

    • S/S infection (redness, tenderness, fever, drainage, odor)

    • fall risk education