Hematology

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Hematology
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Hematology
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  1. **Overview: Structures and Function-
    Hematology: the study of blood and blood forming tissues (bone marrow, blood, spleen and lymph system)

    -Important to evaluate pt's abiliyt to transport Oxyggen, Carbon dioxide, maintain intravascular volume, coagulate blood and combate ineections

    • =>Hematologic system
    • Bone marrow
    • Blood
    • =>Lymphatic system: Lymph vessels and tissue
    • =>Spleen
    • =>Liver
  2. **Hematopoiesis
    blood cell production, Occurs within the red bone marrow: Flat, irregular bones (not in arms or legs or long bones=Yellow marrow=adipose tissues)

    -Sternum, hips, pelvis, vertebrae, sacrum, ribs, flat cranial bones and scapulae.

    Three types of cells develop from non-differentiated immature blood cells in the bone marrow called hematopoietic stem cells

    Rate of blood cell production is dependent on the body’s needs; kicks into action in cases of anemia

    -at birth: all bone marrow is red and aging causes replacement of adipose/yellow tissue, so as an adult, only half of your bone marrow is red. We lose that ability to make more RBCs as you age.

    -WBCs last hours to days or weeks in bloodstream-platelets last 10 days.

    -RBCs last only 120 days.
  3. **Blood Cell Development (hematopoesis)
    -Basophils, Eosinophils and Neutrophils: made from myeloblast

    Monocyte from Monoblast

    Lymphocyte from Lymphoblast

    Thrombocytes: Stem cells > Megakaryoblast > Megakaryocyte -> thrombocytes (platelets)

    Erythrocytes: Stem cells > Erythroblast > Normoblast > Reticulocyte > Erythrocytes (RBCs)
  4. **Blood &  THREE FUNCTIONS
    • -Two major components: plasma and blood cells.
    • -160 lb person: has 4.7-5.5 L (5-6 quards of blood)

    • Classified as a type of connective tissue that performs three functions
    • 1. Transportation
    • 2. Regulation
    • 3. Protection

    **Functions of Blood

    • 1. Transportation
    • Oxygen from lungs to cells; and gasses in general -assissts in maintaing acid-base balance
    • Nutrients from GI tract to cells
    • Hormones from endocrine glands to cells
    • Metabolic wastes from cells to lungs, liver, and kidneys

    • 2.Regulation by blood are:
    • Fluid and electrolyte balance
    • Acid–base balance
    • Body temperature

    • 3. Protection
    • BLood provides protection; Combats invasion of pathogens and other foreign substances; Maintains homeostasis of blood coagulation
  5. **Blood Components
    Plasma (aka SERUM) comprises 55% of blood-mainly water but also has electrolytes, gases, nutrients (glucose, amino acids, lipids), waste and proteins in it

    -"serum: plasma minus the clottinfg factors.

    -plamsa proteins: albumin, globulin and clotting factors.

    -predominant protein is albumin: produced in the liver, mulitple important functions; maintains oncotic pressure SO LOW ALBUMIN means third spacing and edema b/c no oncotic pressure to keep your fluids into the vascular system.

    -other protiens: clotting factors-immunglobulins in plasmaBlood cells comprise 45% of blood

    • => Components of blood Video..
    • -In humans, mature RBCs, transport oxygen from lungs to rest of body. Hemoglobin (red pigment-Iron Pigment-binds with oxygen and transports it to all the cells in body
    • -2.4 million RBC made per second-5 billion RBCs per micorliter of blood
    • -WBCs (leukocytes); normally 4-11 k per microliter of blood; main funtion-fight infection and foreign materials
    • -Clotting due to platelets or thrombocytes. 200-500 K per microliter of blood.
  6. **Blood Cell Functions (three types)
    Erythrocytes (RBCs): Transportation of gases and assist in maintaining acid–base balance

    Leukocytes (WBCs): Protection from infections (regulation)

    Thrombocytes (platelets): Promote blood coagulation in response to injury (protection)
  7. **Erythropoiesis:  
    -Reticulocyte
    -Hemolysis
    -Bilirubin
    • process of RBC productiion is regulated by cellular oxygen requirements and general metabolic activiity. It is stimulated by hypoxia nad controlled by erythropoietin (a glycoprotien growth factor synthesized and released primary by the kidney)
    • -RBC life span: 120 days.
    • -Protein, iron, folate/folic acid, cobalamin/Vitamin B12, niacin, ascorbic acid and Vitamin E needed for Erythropoiesis.

    -Reticulocyte: immature erythrocyte. Count measures the rate at which niw RBCs appear in ciirculation, can develop into mature RBC into 48 hours of release into the circulation. ; useful in evaluating the rate and adquacy of erythrocyte production.

    -Hemolysis: destruction of RBCs by monocytes and macrophages removes abnormal, defective, damaged and old RBCs from circulation. oormally occurs in the bone marrow, live and spleen.

    -Bilirubin is one main component of RBC, so destrction results in increased bilirubin to be process by the body. In normal mechanisms, the liver is able to conjugate tand excrete all bilirubin that is released!
  8. **RBCs 
    -Erythropoietin
    -no nucleaus, donut shaped to maximize surface area to maximize the ability to attract oxygen molecules and diffusion of gasses.

    Flexible shape and thin cellular membrane allows for transportation and diffusion of gases

    Composed primarily of hemoglobin: Heme (iron compound) and Globin (simple protein); to make this you need the essential protein, irons, folate/folic acid and vitamin B12 (cobalamine)

    -Oxyhemoglobin: oxygen bound; gives red color-hemoglobin can act as acid-base buffer-attract CO2 in tissues and transporting in lungs for removal

    Limited lifespan of 120 daysIncreased reticuloyctes released when body cannot keep up with demand; Reticulocyte are increased in anemia, basically bone marrow are kicking out RBCs befre they're really ready so increased percentage of immature RBCs in blood (you can test, seen with increased bleeding (so body is compensating for anemia; are they as effective as RBCS??)

    -Hemolysis occurs in bone marrow, spleen and liver, when that occurs, you have bilirubin waste product that is excreted through GI tract.

    • =>Production regulated by cellular oxygen requirement
    • Erythropoietin-hormone that is made in the kidneys. Renal patients get "Ipogen" synthetic hormone so their kidenys can continue to make RBCs
    • Essential nutrientsHormones
  9. **Iron Metabolism
    => Iron: To make RBCs, iron is needed for hemoglobin, Anemic --take iron supplements.

    • Critical for Hgb synthesis Obtained from food and dietary supplements
    • Absorbed in duodenum and upper jejunum (No regulated pathway of IRON excretion, so it's all GI absorbed (recycled to make new RBCs by Macrophages!)
    • 2/3 bound in hemoglobin and 1/3 stored as ferritin (measurable)
    • Carried by transferrin in plasma (protein in plasma)
    • Recycled after hemolysis by macrophages to make new RBCS.
    • Usual dietary sources? Leafy greens, shellfish, beans, tofu, nuts, seeds, beef, grains.

    -Test iron, chelation therapy, chronic blood transfusions?
  10. **Iron Studies 
    -Serum Iron
    -Serum Ferritin
    -Transferrin
    -TIBC?
    Serum iron: measures total iron in blood, doesn't differential where it's coming from or what it's attached to. NOt best indicator b/c fluctuates day by day

    Serum ferritin: iron storage protein, MOST USEFUL ESTIMATE of Iron in bodyTransferrin: Principal transport protien of iron, increases with deficiency or low iron levels as body tries to capture more iron, must be captured by transferrin so it can be used

    => Transferrin saturation: Measures how much iron is immediately available for use. Decreased w/ iron deficiency

    => TIBC: (total Iron Binding Capacity) Measurement of all proteins available for binding iron; Varies inversely with iron stores (indirect measure of transferritin, usually also overestimates-not the best measure)
  11. **RBC Studies
    Hgb- measurement of oxygen carrying capacity of blood; usually higher in men, but levels off after age 55

    Hct- % of RBCs compared with total blood volume (usually 3x the value of the hemoglobin)

    Total RBC count- number of circulating RBCs
  12. **Hemoglobin:
    Decreased: reduiced in cases of anemia, hemorrhage, hemodilution such as that ocuring whe n the fluid folume is sexcessive

    Increases: found in polycythemia or in states of hemoconcentration, which can develop from volume depletion.
  13. **Hematocrit Value:
    Dtermined by spinning blood in a centrifuge, which causes RBCs and plasma to separage. RBC heaving so settle to bottom.

    -represents the percentage of RBCs compared with the total blood volume

    -generally is three times the hemoglobin value, parallel conditions to increase or decrease as Hemoglobin (HgB)
  14. **RBC indices:
    special indicators that reflect RBC volume, color, and hemoglobin saturation

    -may provide insight into the cause of anemia.

    -MCV: determination of relative size of RBCs. Low: reflection of microcytosis and High is macrocytosis.

    -MCH: measurement of average weight of Hgb/RBCS. Low indication of microcytosis and High MCH: macrocytosis

    -MCHC: Evaluation of RBC saturation with Hbg. Low MCHC indication of hypochromia, high MCHC evident in spherocytosis.
  15. **RBC Indices (CBC)
    • => MCV (mean corpuscular volume) average volume or size of RBC
    • -help us to classify anemias.
    • -most useful, usually decreased with anemias like iron def and thallasemia
    • -Increased with folic acid and B12 supplementationNormocytic, microcytic (decreased size), or macrocytic- refers to volume/size

    • => MCH (Mean corpuscular Hemoglobin)
    • - average weight of Hgb per RBCNormocytic, microcytic, or macrocytic of the volume
    • -"corpuscular" means cell.
    • -directly correlates to MCV
    • -Macrocytic cell has increased HGB level vs Microcytic cell.

    • => MCHC (mean corpuscular hemoglobin concentration)
    • - average concentration or percentage of Hgb within a given volume of RBCsNormochromic or hypochromic
    • -usually used for quality control of your speciment, not clincially useful for diagnosis as MCV and MCH

    • => RDW (RBC Distribution Width)
    • - measurement of variation of RBC size (standard size of 6-8 micrometer in diameter)
  16. **Reticulocyte Count
    Immature red blood cells; measures how fast RBCs being made in body

    Normally present in blood for 2 days before developing into mature RBCs (Normal: 1-2% of RBCs)

    Counts rise with blood loss or hemolytic anemia--example-Sickle Cells. (RBCs destroyed prematurely)

    May also initally rise with high altitude because less oxygen in the air.; until body kind of adjusts. Hiking mountains makes you more SOB compared to sealevel.
  17. **WBCs
    Two categories of leukocytes are granulocytes (three types) and agranulocytes (two types)

    • Granulocytes originate from the myeloid cell
    • Highly variable lifespan-

    • Leukocytes appear white when separate, army of blood cells that fight against infection, inflammation, tissue necrosis, trauma, stress (emotional and physical)
    • -agranulocytes: no granules in the nuclei.
    • -Life span of WBC is variable depending on the roles
  18. **WBC Type and Function
    • => Granulocytes:primary function is phagocytosis (WBC ingest any forgeign organism, digest and kill it)
    • -Neutrophils: Most common granulocyte. Phagocytosis, Early phase of inflammation
    • -Eosinophil: Phagocytosis, parasitic infections. In granules, it has highly strong chemicals that degrade surfaces of Parasites
    • -Basophils: Inflammmatory response, allergic response (think back to asthma--release all histamines and cytokines that increase allergic reactions)

    • => Agranulocytes: Lymphocytes and Monocytes.
    • -Lymphocyte: Cellular, humoral immune response
    • -Monocyte: Phagocytosis, cellular immune response
  19. **Neutrophils & Neutropenia
    50-70% of total WBC count & most common granulocyte.

    • => Primary cells in acute inflammatory response
    • First responders, once they engulf the pathogen, they die in 1-2 days
    • Increased release with demand -> Diagnostic indicator for inflammation/infection!
    • Short lifespan (24-48 hours)

    => Mature/segmented: More effective phagocytes (nucleus is segmented)

    • => Immature/bands: Shift to the left ; WBC differentials-bands
    • -In severe infections: more granulocytes are released from the bone marrow as a compensatory mechanism. TO meet theincreased demant, many young, immature neutrophils (bands) are released into circulation.

    **Neutropenia: condition in which the absolute neutrophil count is less than 1000 cells per microlite. Severe neutropenia is associated with <500 Neutrophils. REsults from a disease processess such as leukemia or bone marrow depression.
  20. **Eosinophils
    Account for only 2% to 4% of all WBCs

    • Have a reduced ability for phagocytosis compared to neutrophils; released in larger quantitines
    • -release chemicals like histamines-destroy parasite surfaces

    • One of they're primary roles: Engulf antigen–antibody complexes formed during an allergic response
    • Defend against parasites and are seen in some neoplastic and connective tissue disorders
    • Do not respond to viral or bacterial pathogens!
  21. **Basophils
    • Make up less than 2% of all leukocytes
    • Similar to mast cells (but mast cells are bigger and thick in tissue, but basophils circulate in in blood stream)
    • -They release substances when stimulated by antigents; like during an asthma attack Limited role in phagocytosis
    • Have cytoplasmic granules that contain heparin, serotonin, and histamine
    • Substances released during allergic and inflammatory reactions
    • -Cytoplasmic granules: contain chemical mediators (heparin and histamin) so whe stimulated by antigen or by tissue injury -> part of response in allergic and inflammatory reaction.
  22. **Lymphocytes
    • Comprise 30-40% of total WBC
    • Form the basis of humoral and cellular immune responses

    Two subtypes of lymphocytes: B cells, T cells

    • -B cells differentiate into plassma cells that produce antibodies and memory cells (remember past antigent history and make a faster response); especially effective against bacteria!
    • -T cells: orignialte in bone marrow but differentiate in Thymus!! Termed Cell Mediated Immunity b/c intracellular pathogen, effective against viruses, fungi and tumors. Inovled in organ rejection (reacts against self antigents and hypersensitive reactions-like rashes)

    Immune response mediated by the release of cytokines

    -NK Natural Killer Cells are lymphocytes that do not require pprior exposure to antigens to kill iviruses infected cells and activate T cells

    -involved in rejection and contact hypersensitivity reactions.
  23. **Monocytes
    • Comprise 4-8% and are the largest WBC
    • -specially named: Kupffer cells in liver, osteoclasts in blone, alveolar macrophages in the lung.

    -When they're circulating in blood, they're called "monocytes" but when they differentiate in tissue to become macrophages and Have a long lifespan (reside weeks in damaged tissue to keep that fighting response)

    -can injest small or larger masses of matter: bacteria, dead cells, tissue debris, defective and old RBCs

    Responsible for phagocytosis and presentation of antigen

    Macrophage-bound antigen highly immunogenic

    Can fuse together to form a giant multinucleated cell

    -Trigger immune response when they're presented to circulating T or B lymphocytes, so THEY START THE IMMUNE RESPONSE & WAR!

    -multiple macrophages can glom together to engulf a huuuuge bacteria. c:

    -THe giant cell then encapsulated by collagen leading to formation of granuloma (what you see in Tuberculosis on chest xray- on latent TB especially, cavity of necrotic tissue); so basicallly you just have bacteria/bacilli walled off in this one area.
  24. **Neutrophils:
    WBC that hunt and kill bacteria, becomes polarized and starts chasing off the bacteria.
  25. **WBC Count
    Provides total count of WBCs and there's a percentage of each wbc (differential) so still a level of concern.

    Differential measures the percentage of each type of leukocyte

    • => Terms
    • Leukocytosis: increased WBC in blood, especially during infection
    • Leukopenia: reduction in WBC number, typical in cancer and various diseasses (bone marrow depression) WBC <4000.
    • Neutropenia: abonrmally few number of neutrophils. Cancer/chemo: decrease wbc count--> neutropenic isolation (wear maskk and gloves and if you're sick, you're not allowed in that room!)
  26. **Thrombocytes (aka Platelets)
    • Fragments of megakaryocyte; Flow freely in circulation
    • Have a life span of up to 10 days
    • -Clotting factors stablilize platelet plug
    • -production partially regualted by thrombopoietin- a growth factor that's made in liver, kidneys, smooth muscle and bone marrow.
    • Primary function is to initiate clotting process via platelet plug
    • Participate in clot shrinkage and retraction (to break down the clot)
    • Platelet count measured with the CBC; normal 2-500 K, DON"T GIVE ANTICOUAGULANT IF LESS THAN 100 K.
  27. **Normal Iron metabolism:
    -Approx 1 mg of every 10-20 mg of iron ingested is absobed in the duodenum and upper jejunus. SO only 5-10% absorbed.

    -Two thrids of totaly body iron is bound to heme in erythrocytes and Muscle cells (myglobin)

    -Other third: stored as ferritin and hemosiderin in the bone marrow, spleen and liver.

    -Hemoglobin production is reduced, when stored iron is NOT replaced.

    -Transferrin: synthesized in liver, ssevers a a carrier plasma protein for iron. Transferrin saturation degree is relable indicator of the iron supply for develping RBCs.

    -Iron recycled after macrophages in the lvier and spleen phagocytize or ingest and destroy, old and damaged RBCs.

    • --Only about 3% is lost daily in urine, sweat, bile and epithelial cells in the GI track. SO Blood Loss is most common cause of Iron loss. c:
    • Figure 30.3: Visual illustration.
  28. **Hemostasis
    -Our bodies always struggling to maintain hemostasis: balance between clothing and lysis

    -important to minimize blood loss with injury

    • -FOUR COMPONENTS OF NORMAL HEMOSTASIS:
    • 1. Vascular Response: Immediate vasoconstriction (last 20-30 min), arterial clamps down on itself to stop bleeding and then platelets form a plug
    • 2. Platelet plug formation: adhesiveness of platelets & aggegation/agglutination (formation of clumps)
    • 3. Formation of a fibrin clot: conclusion of a complex series of reactions involving different clotting or coagulation factors.
    • 4. Ultimate lysis of clot when the vessels finally heal: we have procoagulants VS. ANTICOAGULANTS to keep blood in fluid state. May be acheived by antithrombin activity (by antagonizeing thrombin) and finbrinolysis: process resulting in dissolution of fibrin
  29. **Platelet Response
    Activated with exposure to injured blood vessel or interstitial collagen in the vessel.

    Become adhesive and aggregate to form platelet plug-which drug decreases platelet aggregation: PLAVIX.

    Facilitate reactions of plasma clotting factors during clotting cascade

    In order for blood clotting to occur, you have to have sufficient number of platelets. Check the CBC.
  30. **Development of Fibrin Clot
    -There's two pathways: Intrinsic and Extrinisc

    • => Plasma clotting factors stimulated by
    • Intrinsic Pathway- exposure to subendothelial substances by factor XII
    • Extrinsic Pathway- thromboplastin released from injured tissue reacts with factor VII

    => Clotting terminates in common pathway, where thrombin is activated

    => Thrombin converts fibrinogen to fibrin to form clot

    • => When clot needs to be broken down: Lysis via antithrombin (heparin-indogenous in our own bodies and Protein CNS activity and fibrinolysis
    • -clotting factors always named by roman numberals and they're always present in circulatory system until they're initiated with one of these two pathways.

    note: prothrombin is converted to thrombin which then actiates fibrinogen into fibrin (to form clot)
  31. **Blood Coagulation: Lab Tests (what drugs to check?)
    • aPTT/PTT: Evaluates the function of the intrinsic and common pathways of clot formation
    • -Check LOVENOX/HEPARIN
    • -time amount of time of blood takes to clot in test tube after reagent is added.

    • -aPTT normal range: 30-40 seconds
    • -PTT: 60-70 Seconds

    • PT/INR: Evaluates the function of the extrinsic and common pathways of the coagulation cascade
    • -Check WARFARIN/COUMADIN
    • -International normalized ratio-based on standardization for oral anticoagulation therapy
    • -PT: 1.5 -2.5 x Baselline-INR: standardized number (2-3 is normal)
  32. **Spleen Location & 4 Functions
    • Part of lymphatic system; Largest of the SECONDARY lymphoid organs.
    • Primary Lymph: thymus
    • Located in the upper left quadrant next to kidney

    • **Spleen: Functions (four of them)
    • 1.Hematopoietic: Able to produce RBCs during fetal development, as you age, it lose that ability but can resume if youneed (like sickle cell)

    • 2. Filtration
    • Remove old and damaged RBCs from circulation
    • Removes hemoglobin from RBCs and returns iron component to the bone marrow for reuse/recycling
    • Filters out bacteria, especially encapsulated organisms

    3. Immunologic: Contains a rich supply of lymphocytes, monocytes, and stored immunoglobulins

    • 4. Storage: Stores RBCs and approximately 30% of total mass of platelets which can be released at will.
    • -More than 300 mL of blood can be stored.
    • -one third of platetlets are in spleen
    • -Therefore in splenectomy: higher circulating levels of platelets than a person who still has his or her spleen.
  33. **Lymphatic System
    • => Consists of Lymph fluid, Lymphatic vessels,
    • Lymphatic organs: Spleen, Thymus (up on chest), Lymph nodes (all over body)

    -One way vessels, parallels cardiovasc syseem, eventually drains into venous system.

    -carries fluid from interstital areas to blood and vice versa (prevention of edema)

    -Transport nutrients and body waste , drains interstitial fluid and transport WBCs.
  34. **Lymph fluid
    Pale yellow fluid formed when interstitial fluid is collected through lymph capillary walls

    Circulates through special vasculature (lymphatic system)

    • Too much interstitial fluid or reduced absorption leads to lymphedema: May occur as a complication of mastectomy or lumpectomy (because a pt may have had many lymph nodes removed b/c checked for cancer, so they may get lymphedema in that same arm.
    • Preacautions with masectormy: NO BP or IV sticks b/c circulation isn't as good.

    -Lymph fluid formation increaswes when interstitial fluid increases, thereby forcing more fluids into the lymph system. Too much interstital fluid development or rabsorption of lymp interference reslustlts in lymphedema. This can be a complication of mastectomy or lumpectomy with dissection of axillary nodes is often caused by obstructiion of lymph flow from the removal of lymph nodes.
  35. **Lymphatic System: Lymph Nodes
    Enlargment of lymph nodes are sign of infection or cancer

    Normal feeling: mobile, firm, non-tender and less than 1 cm

    Small clumps of lymphatic tissue found in groups along lymph vessels at various sites

    Over 200 lymph nodes throughout the bodyLargest concentration of lymph nodes is in the abdomen surrounding the GI tract

    Primary function is filtration of pathogens and foreign particles carried by lymph fluid

    Located both superficially and deep

    Important in diagnosis cancer metastasis
  36. **Liver
    Filters blood

    Immune function

    Stores iron

    • Synthesizes procoagulants (clotting factors)
    • -Hepcidin: produced by the live, key regularor of iron balance. Stimulated by iron overload or infllammation. It reduceds the release of stored iron from enteryocytes in the intestines and macrophages.

    Absorbs and stores Vitamin K

    Produces albumin-Ascites! Hepatic faillure--They're not prooduing albumin so no oncotic pressure to keep pressure into vascular system so they have those big bellies "third spacing of fluids"; and bleed a lot because not synthezing their proaculgants. SO have to give then Vit K.

    Vit K. is imp; to convert coagulants to biological active clotting factors.
  37. **Hematologic System: Effects of Aging
    Reduction in red marrow and stem cells, making RBCs

    • Hgb levels decline after middle age
    • -healthy older pts are not able to produce retuiculocytes in response to hemmorrhage or hypoxemia as well as younger adults.
    • -RBC plasma membranes more faragile: slight increase in MMCV, sligh decrease in MCHC or RBCs
    • -Total WBC count and differential are not affected BUT decreases in humoral antibody response and T Cell FUnction may occur.
    • -often: decreased Iron intake.

    • Increased osmotic fragility of RBCs and break down easier
    • Decrease in humoral and cellular immunity

    • => Overall effects:
    • More vulnerable to problems with clotting, oxygen transport, and fighting infection
    • Diminished ability to compensate with illness
  38. **Hematologic System: Assessment: Subjective data
    Prior hematological problems

    Hereditary: sickle cells, thalasemia, hemophila

    Surgeries (stomach, intestinal, splenectomy, tumor removal): GI affect vitamin B12 absorption

    Excessive bleeding (in response to past injuries.)

    Problems with wound healing

    History of blood transfusions: take in account of iron overload.

    Drug, alcohol use

    Exposure to radiation, environmental toxins
  39. **Hematologic System: Medications that may cause Bleeding .
    • => Herbal Medications
    • Ginkgo biloba
    • Garlic in large amounts
    • Ginger (not dried ginger)
    • Ginseng (Asian)
    • Feverfew
    • Saw Palmetto (Serenoa repens)
    • Willow bark (where aspirin comes from)

    • => Over-the-Counter
    • Acetylsalicylic acid (Aspirin)
    • NSAIDS
    • Ibuprofen
    • Some antidepressants (platelet suppression)

    => Antineoplastic Medications (bone marrow suppression): chemo therapy drugs
  40. **Cigarette smoking:
    Increases low densit lipoprotiein (LDL) cholesterol and levels of Carbon Dixoide, leading to hypoxia nad altering the anticoagulant properties of the ndothelium. Increases platelet reactivty, plama fibriongo, hematocrit and blood viscosity.
  41. **Review of Systems
    • Blood in stool, urine, or emesis
    • Changes to skin, urine or stool
    • Fatigue, change in ADLs
    • Dyspnea, palpitations
    • Easy bruising or bleeding
    • Arthralgia
    • Swelling in neck, armpits, groin
    • Menstrual history
    • Intrapartum/postpartum bleeding
    • Impotence
    • Stress, coping mechanisms
    • Any cultural, religious, or spiritual practices that would inhibit the transfusion of blood, bone marrow, certain medications or treatments
  42. **Assessment: Objective Data
    • => Complete head to toe exam
    • Skin (pallor, flushing, jaundice, cyanosis, petechiae, ecchymosis)--too much coumadin or clotting issues
    • Eyes (jaundiced sclera-ictoris?, conjunctival pallor, blurred vision, diplopia-double vision)

    Nose (epistaxis)

    Mouth (gingival and mucous membrane changes, smooth tongue "glossitis")

    • Lymph Nodes (enlarged, tender or nontender)
    • -consistently swollen, nontendener lymph node may be sign of malignancy (Hogkin's lymphoma)
    • -enlarged, tneder: acute infectionHeart and chest (tachycardia, palpitations, altered B/P, low O2 sat)
    • -Orthostasis: (HR/BP >20 mmHg from baseline from moving)--common with anemia especiallly is low blood fovolume

    Abdomen (hepatomegaly, splenomegaly, distended abd)

    Nervous system (paresthesia of feet and hands, weakness, headache, nuchal rigidity-B12 def?)

    Musculoskeletal system (bone pain, joint swelling,

    • women: menstrual history, clotting, cramps, amount of bleeding, and problems associated with anemia (Post partum)
    • -Vascular problem and impotence
    • -hemarthrosis: blood in joint
  43.  GENERAL OBJECTIVE TERMS & ME
    ANINGS
    -Cyanosis: Bluish discoloration of skin and mucous Membranes --redueced Hgb, excessie concentration of deoxyhemoglobin in blood

    -Excoriation: scratch ofr abrasion of skin: from inentse pruritus (unpleaseant cutaneous sesnation) could mean lymhoma, or increased biliruin

    -Leg Ulcer: sickle cell disease

    -Spider nevus: elevated estrogen levels as in pregnancy or liver disease

    -Purpura, Petechia (pinpoint), hematomas (clotted localized blood): decreased platelets or clotting favtors resulting in hemmorrhage into the skin

    -Chrloroma; tumor arising for myeloid tissue and containing a pale green pigment

    -Plasmacytoma: tumor arising from abnormal plasma cells (means multiple myeloma that has infiltrated tissue)

    -Jaundiced sclera: accumulationof bile pigment resulting from rapid or excessive hemolysis or liver disease or infliltration

    -Conjunctival pallor: paleness/decrease coloration in the conjunctive:--low Hemoglobin level (anemia)

    Blurred vision, diplopia,: --enemia, polycythemia

    -Epistaxis: spontaneous bleeding from nares: may occur with low platelet counts, especially if bending down for a long time, performing valsava manuveer.

    -Bone pain: Multiple myeloma

    -Artharlgia: Joint pain; sickle cell.

    -Lymphadenopathy: Lymph nodes enlarged: means infection, foreign infliltrations, systemic diseases (leukemia, lmphoma,metastatic cancer)

    -Hepatomegaly: palpable liver: leukemia, cirrhosis, fibrosiss secondary to iron overload from sickle cell disease or thalassemia

    -Splenomegaly: palpable spleen: anemia, thrombocytop;enia, leukemia, lymphomas, malaria, cirrhosis, trauma, portal HTN.

    -Parastehsias: cobalamin deficiency

    -Weakness: anaemia/low hgb level

    • Headache (severe): thrombocytopenia Inter crani
    • al hemmorahage.
  44. **Thrombocytopenia:
    <100 K; bleeding may occur, sponatneous hemorrhage below 10 K.

    Thrombocytosis: Excessive platelets: disorder that occurs with inflammation and some malignant disorders.

    • **Diagnostic Studies
    • CBC: assesses each of major Blood cells-

    • Pancyotpenia: all blood counts are low (extreme blood loss or bone marrow suppression
    • Peripheral Smear
    • RBC indicesIron studies
    • Folate/cobalamin levels
    • Clotting studiesCT/MRI( liver, spleen and lymph node
  45. **Biopsies=> Bone Marrow
    Aspiration: into the hip because that's red marrow!

    • Aspiration and biopsy
    • Posterior iliac crest
    • Informed consent
    • Analgesic because pain, “Pressure feeling”- Sharp but brief pain with aspiration
  46. **Lymph Node Biopsies:
    • => Open
    • Excision of LN (entire lymp node)Informed consentSterile dressing

    • =>Closed (needle)
    • Informed consentPotential for bleedingSterile dressing

    • =>Lymphangiography
    • Contrast mediaEvaluates deep nodes
  47. **Blood typing
    • RBCs have blood group antigens (A and B) found on their membranes
    • -O blood have no antigens
    • This forms the basis for the ABO blood typing system
    • The presence or absence of the two inherited antigens is the basis for the four blood groups

    • => 4 Groups:
    • Blood group A has A antigens and anti-B antibodies (so they can Receive only A blood)
    • Blood group B has B antigens and anti-A antibodies (so they can only receive B)
    • Blood group AB has both A and B antigens and no antibodies (they can receive both A & B blood)
    • Blood group O has neither A nor B antigens and both antibodies (only receive O blood)

    • -O Negative is the universal donor.
    • -AB+ is universal recipient.
  48. **The Rh factor
    The Rh system is based on a third antigen (D) on the surface of RBCs

    Rh-positive people have the D antigen

    Rh-negative people do not the D antigen

    If a Rh-negative person is exposed to Rh positive blood an antibody (anti D) is made and with the next exposure hemolysis will occur

    • Especially of concern in obstetrics
    • -If mother is RH Negative and Baby happens to be positive, then she would need to receive rhogam. Positive Mother's are safe. :)
  49. **Iron Metabolism tests:
    -Serium Iron: measurement of the amt of protein bound iron circulating in the serum

    -TIBC: measurement of all proteins that act to bind or transport iron b/w the tissues and bone marrow (indirect measurement, overestimates transferrin leves by 16-20 %)


    -Transferrin Saturation: better indicator of the avaiability of iron for erythropoiesis than serum iron because, unlike serum iron, the iron bound to transferrin is readily availalble for the body to use.

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