This is the chapter39

1. Hematology Review

2. Hematology
• Hematology is the study of blood and
the disorders related to it.

3. • The concepts of peripheral and central
tissue PERFUSION and gas exchange
(oxygenation) rely on the hematologic
system, because the blood is the oxygen
delivery system
• Perfusion is the total arterial blood flow
through the tissues (peripheral perfusion)
and blood that is pumped by the heart
(central perfusion)

4. • Clotting is a complex, multi-step process
by which blood forms a protein-based
structure (clot) in an appropriate area of
tissue injury to prevent excessive bleeding
while maintaining whole-body blood flow
(perfusion).

5. Bone marrow
• First produces blood stem cells, which are immature,
unspecialized (undifferentiated) cells that are capable of
becoming any type of blood cell
• The next stage in blood cell production is the committed
stem cell (or precursor cell). A committed stem cell
enters one growth pathway and can at that point
specialize (differentiate) into only one cell type.
• Example : Erythropoietin

6. • Blood is composed of plasma and cells.
Plasma is an extracellular fluid containing
proteins.
The three major types of plasma proteins
are : Albumin, globulins, and fibrinogen.

7. Plasma
• Albumin = maintains the osmotic pressure
of the blood, preventing the plasma from
leaking into the tissues
• Globulins = Transporter other substances
and as antibodies, protecting the body
against infection
• Fibrinogen = activated to form fibrin,
which is critical in the blood CLOTTING
process

8. BLOOD CELLS
• Three major cell types, all of which arise
from hematopoietic stem cells located
primarily in the bone marrow: red blood
cells (RBCs), white blood cells (WBCs),
and platelets.
• Human blood is composed of ∼45%
cellular components and ∼55% plasma

9. Blood cells age and count
WBC Life span is 13-20 days
RBC life span is 120 days
Platelets life span is 5-9 days

10. White Blood Count (Leukocytes)
Component
Tests
Reference Range
WBC
0 - 1 day old 9.4-34.4 K/mm3
1 - 7 days old 5.0-25.0 K/mm3
1 week to 1 month old 5.0-19.5 K/mm3
1 month to 2 years old 6.0-17.0 K/mm3
2 years to 6 years old 5.0-14.5 K/mm3
6 to 12 years old 4.5-13.6 K/mm3
>12 years old 5-10 Thousand/mm3
WBC
Alterations
Leukocytosis:
WBCs>10,500 infections and leukemia
Leukopenia:
WBCs below 4000
Overwhelming bacterial or viral
infections,
 drugs such as chemotherapy,
barbiturates, antibiotics.
Bone marrow disorders, a plastic
anemia

11. Under the microscope

12. Neutrophils
 42-75% = 2.4-8.1 k/mm3 or 2400- 8100 cell/mm3
 Also called ‘segs’ because its nuclei looks segmented
• Infection-fighters against bacterial infections.
• Decreased Neutrophil levels may be the result of severe
infection or in response to various medications, particularly
chemotherapy
WBC Types

13. Lymphocytes
 20-51% =1.2-5.5 K/mm3 or 1200-5500 cell/mm3
 Natural Killer cells targeting viruses
WBC Type

14. • Lymphocytosis – increase lymphocyte
number --------- mostly viral infection , can
be cancer
• Lymphocytopenia – decrease
lymphocyte number .
Immunosuppression, auto-immune
disordes. Certain viral infections:

15. Esinophils
 0.0- 10% = 0 – 1.1K/mm3 or 0-1100 cell/mm3
• Increase in response to allergic disorders

16. Basophils
 0.0-0.8%= 0-.9k/mm3 or 0-900 cell/mm3.
• Increase in cases of chronic infections and
allergy, CML, polycythemia Vera, Leukemia.
• Release histamine & heparin potent mediator of
inflammation .
• Often occurring together with eosinophilia
• Can store information for the T cells.

17. Monocytes
 1.7- 9.3%= 0.1-1 k/mm3 or100-1000 cell/mm3
increase in response to all kinds of infections as
macrophages (phagocytosis) and vacuum
cleaner to Neutrophils.
• AUTOIMMUNE DISEASES , MONONUCLEOSIS

18. RBC
• The RBCs produce hemoglobin (Hgb). Each normal mature RBC contains
hundreds of thousands of hemoglobin molecules. Each hemoglobin
molecule needs iron to be able to transport up to four molecules of oxygen.
Therefore, iron is an essential part of hemoglobin. Hemoglobin also carries
carbon dioxide. RBCs also help maintain acid-base balance
• RBC production or erythropoiesis (selective growth of stem cells into mature
erythrocytes) must be properly balanced with RBC destruction or loss
• BALANCE IS IMPORTANT
Example : When tissue oxygen is less than normal (hypoxia), the kidney releases
more erythropoietin, which then increases RBC production in the bone marrow. When
tissue oxygen is normal or high, erythropoietin levels fall, slowing RBC production.
Synthetic erythrocyte stimulating agents (ESAs) such as Procrit, Epogen, and EPO have,
the same effect on bone marrow as the naturally occurring erythropoietin

19. • Many substances are needed to form
hemoglobin and RBCs, including iron,
vitamin B12 , folic acid, copper. A lack of
any of these substances can lead to
anemia, which results in unmet tissue
oxygen needs because of a reduction in
the number or function of RBCs

20. RBC
RBCs
0 - 1 day old 4.0-6.6 M/mm3
1 - 7 days old 3.9-6.3 M/mm3
7 days - 1 month old 3.0-5.4 M/mm3
1 month to 2 years old 3.7-5.3 M/mm3
2 to 6 years old 4.2-5.3 M/mm3
6 to 12 years old 4.2-5.5 M/mm3
Female >12 years old 4.2-5.4 M/mm3
Male >12 years old 4.7-6.1 M/mm3

22. Platelets
They are the smallest blood cells
Function: When activated, platelets stick to injured blood vessel
walls and form platelet plugs that can stop the flow of blood at the
injured site. They also produce
substances important to blood CLOTTING and aggregate (clump
together) to perform most of their functions(primary
hemostasis)
Lifespan: circulation for 8–9 days
Concentration: 150,000 to 450,000/μLcells

23. • After platelets leave the bone marrow,
they are stored in the spleen and then
released slowly to meet the body's needs.
Normally 80% of platelets circulate and
20% are stored in the spleen.

24. Definition Causes
Thrombocytosis Increase in number
of platelets to >
400,000/μL (absolute)
 Cancer (e.g., CML)
 Infections (e.g., tuberculosis)
 Splenectomy
 Hemolytic anemia
 Inflammation (e.g., rheumatoid
arthritis, celiac disease, connective tissue
disorders, or inflammatory bowel disease)
Thrombocytopenia Decrease in number
of platelets to <
150,000/μL (absolute)
 See “Thrombocytopenia”

25. Accessory Organs of Blood
Formation
• The spleen and liver are important accessory organs for blood production.
They help regulate the growth of blood cells and form factors that ensure
proper CLOTTING.
• The spleen destroys old or imperfect RBCs, breaks down the hemoglobin
released from these destroyed cells, stores platelets, and filters antigens
• The spleen contains three types of tissue: white pulp, red pulp, and
marginal pulp
• White pulp is filled with white blood cells (WBCs) and is a major site of
antibody production. As whole blood filters through the white pulp, bacteria
and old RBCs are removed.
• Red pulp is the storage site for RBCs and platelets
• Marginal pulp contains the ends of many blood vessels
• THINK ? Anyone who has had a splenectomy has reduced immune
functions and an increased risk for infection and sepsis

26. Hemostasis and Blood Clotting
• Hemostasis is the multi-stepped process of controlled blood CLOTTING. It
results in localized blood clotting in damaged blood vessels to prevent
excessive blood loss while continuing blood PERFUSION to all other areas.
This complex function balances blood clotting actions with anti-clotting
actions
CLOTTING STEPS
• sequential processes result in blood clotting are :
1. Constriction of the blood vessel.
2. Formation of a temporary “platelet plug
3. Activation of the coagulation cascade.
4. Formation of “fibrin plug” or the final clot.

27. • The liver produces prothrombin and other blood
CLOTTING factors. Also, proper liver function is
important in forming vitamin K in the intestinal
tract. (Vitamin K is needed to produce clotting
factors VII, IX, and X and prothrombin.) Large
amounts of whole blood and blood cells can be
stored in the liver. The liver also stores extra iron
within the protein ferritin.

28. • Intrinsic factors are conditions, such as
circulating debris or venous stasis, within
the blood itself that can activate platelets
and trigger the blood CLOTTING cascade

30. • Extrinsic factors outside of the blood can
also activate platelets.
• The most common extrinsic event is trauma that damages blood vessels and
exposes the collagen in vessel walls. Collagen then activates platelets to form a platelet
plug within seconds.
• Other blood vessel changes that can activate platelets include
inflammation, bacterial toxins, or foreign proteins.

31. Summary of the blood clotting
cascade.

32. Anticlotting Forces Fibrinolysis
• Because blood CLOTTING occurs through a rapid cascade process, in
theory it keeps forming fibrin clots whenever the cascade is set into motion
until all blood throughout the entire body has coagulated and PERFUSION
stops. Therefore, whenever the clotting cascade is started, anti-clotting
forces are also started to limit clot formation only to damaged areas so
normal perfusion is maintained everywhere else. When blood clotting and
anti-clotting actions are balanced, clotting occurs only where it is needed,
and normal perfusion is maintained.

33. Hematologic Changes
Associated with Aging
 Decrease in blood volume with lower levels of
plasma proteins
 Bone marrow produces fewer blood cells
 RBC, WBC counts lower
 Lymphocytes less reaction to antigens, lose
immune function
 Hemoglobin levels fall after middle-age
Copyright © 2018 Elsevier Inc. All rights reserved. 33

34. Assessment:
Noticing and Interpreting
 Age, gender
 Liver function
 Drug use (prescribed, OTC, illicit)
 Dietary patterns
 Socioeconomic status
 Previous radiation therapy
 Occupation, hobbies
 Location of home
 Use of “blood thinners,” NSAIDs
 Nutrition status
 Family history and genetic risk
 Current health problems
Copyright © 2018 Elsevier Inc. All rights reserved. 34

35. Physical Assessment
 Skin ( nail bed , ecchymosis and petechia
 ENT . The tongue is smooth in pernicious anemia and
 iron deficiency anemia or smooth and beefy red in other nutrition deficiencies , Scleral jaundice , lymph node
enlargement )
 Respiratory
 Cardiovascular .
 Kidney and urinary
 Musculoskeletal
 Abdominal – enlarged spleen
 Central nervous system
 Psychosocial
Copyright © 2018 Elsevier Inc. All rights reserved. 35

36. Diagnostic Assessment
peripheral blood smear
is made by taking a drop of blood and spreading it over a slide. It can
be read by an automated calculator or a technologist with a
microscope. This rapid test provides information on the sizes, shapes,
and proportions of different blood cell types within the peripheral blood
36

37. Hemoglobin and Hematocrit
Component Tests Reference Range
Hemoglobin
0 - 1 day old 14.5-22.5 gm/dl
1 - 7 days old 13.5-21.5 gm/dl
7 days - 1 month old 10.0-18.0 gm/dl
1 month to 2 years old 10.5-13.5 gm/dl
2 to 6 years old 11.5-14.5 gm/dl
6 to 12 years old 11.5-15.5 gm/dl
Female >12 years old 12.0-16.0 gm/dl
Male >12 years old 14.0-18.0 gm/dl
Hematocrit
0 - 1 day old 45.0-67.0 %
1 - 7 days old 42.0-66.0 %
7 days - 1 month old 31.0-55.0 %
1 month to 2 years old 33.0-40.0 %
2 to 6 years old 34.0-42.0 %
6 to 12 years old 35.0-45.0 %
Female >12 years old 37.0-47.0 %
Male >12 years old 42.0-52.0 % ( three times hgb)

38. In patients with anemia,
MCV (Mean corpuscular volume or size of RBC)= 80-99 fl
•Microcytic anemia (MCV below normal range)
iron deficiency anemia and thalassemia
•Normocytic anemia (MCV within normal range)
sepsis, hemolysis, plastic anemia, pregnancy
Anemia of chronic disease, also called anemia of
inflammation, is associated with underproduction of RBCs
and mild shortening of RBC survival
•Macrocytic anemia (MCV above normal range)
vitamin B12 and folic acid deficiency, alcoholism

39. MCH
(Mean corpuscular hemoglobin)
=wt of hemoglobin/RBC.
Mirrors MCV results
27.0-31.0 pg
Low in Hypochromic anemia (low
Hgb)
MCHC:
Mean corpuscular hemoglobin
=Concentration of Hgb /RBC
Normal: 32-36% or 29-36.2 gm/dl
• Decreased MCHC (Hypochromic)
microcytic anemia,
•MCHC is elevated
("hyperchromic") in burns,
hereditary spherocytosis, sickle cell
disease, increased iron storage
RDW
(red blood cell distribution width)
= measure variation in RBCs unequal
sizes ,
Normal 11.5-14.5%

40. pernicious anemia

41. IRON DEFICICNEY LABS
• IRON
• 65% is bound to Heme.
• Measurement of the iron concentration refers specifically to the Fe
+++ bound to the transferrin and not to the iron circulating as free
hemoglobin in the blood.

42. • Iron in the food is absorbed by the intestinal epithelium.
• Iron is ingested as Fe +++ form and is converted to Fe ++ form for
the absorption.
• The conversion of Fe +++ to Fe ++ form takes place in the stomach
where gastric acid HCL provides the acidity to reduce the iron.
• Vitamin c helps conversion of Fe +++ to Fe ++
• Ferric (Fe+++) iron is reduced to Ferrous (Fe++) by vit.C and this
ferrous form is absorbed very easily.
• Milk and antacid bind to iron and reduce its absorption
• In the blood, this absorbed iron attaches with the transport protein
(Transferrin).

43. • Transferrin represents the major protein that binds to iron.
The majority of the iron is bound to transferrin.
• This is a transport protein synthesized in the liver.
• This regulates iron absorption.
• Total iron-binding capacity (TIBC) is the capacity of
transferrin to bind to iron..
• TIBC measures the total amount of iron that apotransferrin has the
capacity to bind.
• TIBC refers to the amount of iron that could be bound by saturation
of transferrin and other minor iron-binding proteins present in the
serum or plasma.
• TIBC is the sum of all protein-bound to iron.
• TIBC increases by 70% of the patients with iron deficiency anemia.
• When serum iron falls then TIBC increases.

44. • Ferritin
-Ferritin represents stored iron.
- Up to 30% of the total iron is stored as Ferritin.
Iron is stored as ferritin in the body in the liver, spleen, and bone
marrow.
Serum Ferritin is the best diagnostic test for iron deficiency anemia.
Because ferritin is the measure of the iron stores in the body.

47. Red blood cell distribution
width( RDW )
• measure of the range of variation of red
blood cell volume
• An elevated RDW (red blood cells of
unequal sizes) is known as anisocytosis
• "width" refers to the width of the volume curve (distribution width, here
presented as the coefficient of variation, or CV), not the width of the cells.
Thus, it is a reasonably accurate term.
• Mathematically, the RDW-CV is calculated with the following formula:
RDW-CV = (Standard deviation of MCV ÷ MCV) × 100.

48. • High RDW may be a result of the
presence of fragments, groups of
agglutination, and/or abnormal shape of
red blood cells.
• Iron-deficiency anemia usually presents
with high RDW and low MCV.
• Folate and vitamin B12 deficiency anemia
usually presents with high RDW and high
MCV.
• Normal RDW is less than 12-16 %

49. Reticulocytes
• are immature red blood cells (RBCs). In
the process of erythropoiesis (red blood
cell formation), reticulocytes develop and
mature in the bone marrow and then
circulate for about a day in the blood
stream before developing into mature red
blood cells.

50. Reticulocytes count
• evaluate your bone marrow's ability to
produce red blood cells (RBCs);
• to help distinguish between various
causes of anemia;
• to help monitor bone marrow response
and the return of normal marrow function
following chemotherapy,

51. The Schilling test
• The Schilling test measures vitamin B 12
absorptions by assessing increased
urine radioactivity after an oral dose of
radioactive cobalamin.

52. Hemoglobin electrophoresis
• detects abnormal forms of hemoglobin,
such as hemoglobin S in sickle cell
disease. Hemoglobin A is the major type
of hemoglobin in an adult.

53. COOMBS TEST
also known as antiglobulin test (AGT
Direct and indirect
• The direct Coombs test detects antibodies that are stuck
to the surface of the red blood cells
• The indirect Coombs' test detects the presence of
circulating antiglobulins. The test is used to determine
whether the patient has serum antibodies to the type of
RBCs that he or she is about to receive by blood
transfusion

54. Tests Measuring Bleeding and
Coagulation.
 Prothrombin time (PT)- 11 and 12.5 seconds
 International normalized ratio (INR) - 0.8 and 1.1
 Partial prothromboplastin time (PTT)- 25 to 35
 Anti-factor Xa test - measures the amount of anti-activated factor X (anti-Xa) in blood,
which is affected by heparin. It is used mainly to monitor heparin levels in patients treated with either
 standard unfractionated heparin or low-molecular-weight heparin.
 Platelet aggregation rate
 Bleeding time - test determines how quickly your
blood clots to stop bleeding. The test involves making
small punctures in your skin. About 2-9 minutes

55. Bone marrow biopsy
Preparation
• Explain the procedure to the patient. A mild sedative will be given 1
hour before the test, if ordered.
• Tell the patient the test usually takes only 5 to 10 minutes and that
more than one bone marrow specimen may be required.
• Let him know a blood sample will be collected before the biopsy for
laboratory testing.
• Make sure the patient has signed a consent form.
• Check the patient for hypersensitivity to the local anesthetic.
• After confirming with the doctor, tell the patient which bone-
sternum, anterior or posterior iliac crest, vertebral spinous process,
ribs, or tibia – will be used as the biopsy site.

56. Nursing Interventions
• While the marrow slides are being prepared, apply pressure to the biopsy site until
bleeding stops.
• Clean the biopsy site and apply a sterile dressing.
• Monitor the patient’s vital signs and the biopsy site for signs and symptoms of
infection
Complications
• Hemorrhage and infection

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