HEMATOLOGY
IT’S ALL ABOUT THE BLOOD. AND MEMORIZING 500 MILLION LAB VALUES…
BASICS
Bone marrow makes blood cells—Where?
Sternum, ribs, scapulae, clavicles, pelvis, flat cranial bones, ends of
long bones
Iliac crest most common site for bone marrow aspiration! (or
sternum).
Side note—pain meds, pressure on site for 5-10 min if risk of bleeding
Blood: erythrocytes (RBCs), leukocytes (WBCs), thrombocytes
(platelets)
Spleen
Lymph
WHAT TO ASSESS THAT CAN AFFECT
HEMATOLOGY STUFF?
Old folks…
Decr stem cells so slowed blood cell production
Decr Hgb after middle age
Decr response to infection w/ WBC production (old folks need more
ABX)
Assessment
Past/family Hx/surgeries
Meds, nutrition
Exercise, reproductive pattern
Bleeding signs & lab values
WHAT TO MEMORIZE…
RBCs (erythrocytes): males 4.3-5.7; females 3.8-5.1
Hemoglobin: males 13.2-17.3; females 11.7-16
Hematocrit: males 39-50%; females 35-57%
Hgb and Hct always correlate… Hgb about 1/3 Hct, so if you forget
one ;)
Mean Corpuscular Volume (MCV): 80-100 fL
Mean Corpuscular Hemoglobin (MCH): 27-34 pg
Mean Corpuscular Hemoglobin Concentration: 32-36%
WHAT DO THESE MEAN?
RBCs
Hemolysis: destroyed damaged/abnormal RBCs
Hemoglobin: this is the iron-including protein that carries O2. So how much O2
the RBCs are able to carry
Low w/ anemia (RBCs w/o enough hemoglobin) or hemodilution (not enough RBCs)
Hematocrit: percentage of RBCs of total blood volume
Low w/ hemodilution (watered down blood…)
MCV: size of RBC
Defines micro vs. macrocytic problems!
MCH: how much hemoglobin in RBC
Low w/ iron deficiency anemia—b/c less hemoglobin!
MCHC: percentage of hemoglobin in RBC
MORE TO MEMORIZE
Total WBCs: 5000-10,000 uL
Never Let Monkeys Eat Bananas…
Neutrophils: 2500-8000
Lymphocytes: 1000-4000
Monocytes: 100-700
Eosinophils: 50-500
Basophils: 25-100
AND WHAT DO THESE MEAN?
As y’all know… High WBC = infection.
Neutrophils, lymphocytes & monocytes: generally high w/ any infection/inflammation
Eosinophils: high w/ parasitic infections
Basophils: high w/ allergic responses
What’s the left shift?
When you look at lab results, they count all the cells and show the most immature
ones on the left. So a left shift means that there are more immature cells. More
immature cells means that a lot more are being produced recently. This is a normal
response to infection!
If you see a right shift… Your body has a lot of grandpa cells and isn’t producing new
cells like it should. This means your pt is immunocompromised and that’s BAD!!
LEUKOPENIA/NEUTROPENIA
Since normal WBC count is 5000-10,000, less than 4000 is leukopenia
Normal neutrophil count is 2500-8000, less than 1000 is neutropenia
Either one = immunocompromise
Neutropenic precautions (also apply to leukopenia… same concept)
Hand hygiene
Isolation
Limit/screen visitors
No fresh flowers/plants/fruits/veggies. Fresh stuff must come from
nutritionist (specially cleaned)
Temp Q2 or Q4 hrs, watch for S&S of infection!
MORE STUFF TO MEMORIZE
Erythrocyte Sedimentation Rate (ESR): <30 mm/hr (a little
higher in women)
Platelets: 150,000-450,000
Prothrombin time (PT): 11-16 sec
Activated Partial Thromboplastin Time (PTT): 25-35 sec
International Normalized Ratio (INR): 2-3
ESR
Basically, messed up RBCS are heavier and they sink faster. So
the more damaged RBCs, the higher the ESR
Increased ESR = inflammation (if not w/ incr WBC, just
inflammation w/o infection)
CLOTTING
Platelets <50,000 BAD—imminent bleeding. Stay w/ pt and call
Dr.
Less than this, you probably need a platelet transfusion.
*NOTE: apparently now the official critical value is technically
<10,000. So know that. But really <50,000 is pretty bad too!!! So be
concerned if it’s low.
Platelets >1 million BAD—imminent thrombosis (DIC, stroke,
etc), also urgent!
Be familiar with basics of clotting cascade
PLATELETS & DA SPLEEN
Basically all you need to know is splenectomy = decr WBCs and
immunocompromise.
Platelet levels actually go up.
WHY?
The spleen’s job is to take care of getting rid of old RBCs, house WBCs, and
pull in lots of platelets (about 30% of those in circulation)
So when you take out the spleen, you take out lots of WBCs. Takes about 6
mo for body to compensate and immune function to recover
But also, when you take out the spleen, you don’t have as many platelets
pulled out of circulation. So platelet levels rise!
That’s why the main concern is immune function immediately after
splenectomy!
CLOTTING LABS
Warfarin labs: PT & INR. For PT, therapeutic level should be
higher than the normal range (so > 11-16). For INR, therapeutic
level should be between 2-3
Heparin lab: PTT. Therapeutic level should be higher than normal
(so >25-35)
EVEN MORE TO MEMORIZE
Serum iron: 50-175 mcg/dL
Total Iron Binding Capacity (TIBC): 250-450 mcg/dL
Ferritin: 10-250 mcg/dL
Transferrin (protein that binds iron): 190-380 mcg/dL
Pro tip: iron & ferritin go up together, and then TIBC & transferrin
go down together (inversely related)
NOW FOR THE DISORDERS
HEMOPHILIA
Hereditary X-linked recessive (more common in men) *except for
Von Willebrand—this is autosomal dominant
Type A (classic, most common): no factor VIII
Type B (Christmas disease): no factor IX
Von Willebrand: no Von Willebrand coagulation factor
Need clotting factors replaced at regular intervals, during crisis,
AND before any procedures (may need continuous infusion)
If minor bleed, stop acute bleed & give missing factor. Treat for
72 hrs. If surgery, 10-14 days.
Cryoprecipitate: factor VIII & fibrinogen, for classic hemophilia
WHAT TO WATCH FOR IN HEMOPHILIA
Joint bleeds—if you see a little bump, can be very dangerous.
Rest, Ice, Analgesics (no aspirin cuz bleeding), ROM without
weight-bearing as soon as bleeding is controlled
Intracranial bleeds—stroke, any change in LOC
Hemorrhage into neck/pharynx—airway obstruction
Watch for blood-born infections, thrombosis
Now blood products are screened for Hepatitis, HIV, etc. Before
this, many hemophiliacs ended up with these diseases
ANEMIA
Deficiency in 1 of 3 things: # of erythrocytes, how much
hemoglobin, hematocrit (volume of packed RBCs)
What does the body do? Shift O2 from tissuesblood, shift
bloodmore important tissues, incr CO/HR/SV, Incr # of RBCs
produced
IRON DEFICIENCY ANEMIA
Most common
Causes: diet/absorption/GI problems, bleeding (including menstruation), alcohol
(affects absorption)
S&S: pallor, glossitis/tongue burning, cheilitis (cracked corners of lips), headache,
paresthesias
Microcytic (decr MCV) and less hemoglobin (decr MCH)
Iron (can give IV, IM, or PO)
Taking w/ orange juice improves absorption
Taking w/ milk decreases absorption
Liquid iron can stain teeth (dilute & use straw)
Common GI side effects
Black stools are normal
IM iron can stain the skin (use Z-track)
THALASSEMIA
Genetic: more common Mediterranean and near equator
Can be Major: homozygous. NO hemoglobin production, so need
transfusions very often (at least every week)
Or Minor: heterozygous. May not need transfusions or show symptoms
unless adults and something triggers it
S&S: pallor, thickened cranium/maxilla/bone marrow hyperplasia, growth
retardation, death, WHY?
Microcytic (decr MCV), incr serum iron
Because iron isn’t being used to make hemoglobin, it just accumulates.
Plus you’re giving them transfusions. So lots of iron can get toxic
Treat with blood transfusions AND Desferal or Ferriprox (these are iron
chelators—bind out iron to excrete)
PERNICIOUS ANEMIA
Not enough Vit B12 (aka cobalamin)
This can be b/c of not enough intrinsic factor (IF) that the body
needs to absorb Vit B12. Or from chronic alcoholism, GI surgery,
Chron’s, Diverticulitis, etc
More common w/ Scandinavians and African Americans
S&S: like iron deficiency anemia + neuro stuff (ataxia, confusion,
weakness, dementia, paresthesia)
Macrocytic (incr MCV)
Treatment MUST be B12 through another route that doesn’t
require it to be absorbed through GI system
1000 ug IM (or nasally) daily for 2 wks, then less often until HCT
becomes normal
FOLIC ACID DEFICIENCY
Folic acid required to make hemoglobin
Causes: diet, decr absorption, oral contraceptives, anti-
epileptics, alcoholism, anorexia, hemodialysis
Macrocytic (incr MCV)
Fun fact about alcoholics. They almost always need iron + folic
acid
ANEMIA OF CHRONIC DISEASE
Any inflammation, infection, malignancy, autoimmunity, etc
With any major disease, watch Hgb and Hct. Perfusion is very
important, especially for healing
APLASTIC ANEMIA
This is BAD. Basically stem cells stop making ALL blood cells =
pancytopenia
They need transfusions very early.
Can get it from cancer, antibiotics, pregnancy, or more
Incr risk of infection (decr WBC), fatigue/dyspnea,
cardiovascular, cerebral vascular response (decr RBC), risk for
bleeding (decr platelets)
SICKLE CELL ANEMIA
Genetic: autosomal recessive. More common w/ Africans
Americans (and some other races…)
Mutated hemoglobin: cell sickles w/ decr oxygen
The PAIN is from hypoxia. The cells sickle, clump together, and
block blood flow. Can cause a stroke, heart attack, major organ
damage, etc. Tissues die. Can cause shock
This can last for days to weeks. Not fun.
Like chronic anemia until a crisis. Triggered by hypoxia… So
avoid things like high altitude, dehydration, anemia, sickness
(get vaccines), intense exercise (need more O2)
SICKLE CELL TREATMENT
Primary is preventing triggers
Treat necrotic areas
Lots of narcotics!! Morphine decr pain and O2 demand (same
concept as MI) After crisis is over, get off meds
Stem cell transplants: can potentially cure. But you have to take
out almost all their original blood cells so they are severely
pancytopenic, and then reinfuse the donor cells. So don’t do
unless no other option and very severe!!
QUESTIONS
The nurse is providing education to a patient about a bone
marrow aspirate test. Which places should the nurse inform the
patient that they could possibly expect to have the bone
marrow withdrawn from? (SATA)
Sternum
Femur
Phalanges
Clavicle
Epiphyses of the humerus
The nurse is providing education to a patient about a bone
marrow aspirate test. Which places should the nurse inform the
patient that they could possibly expect to have the bone marrow
withdrawn from? (SATA)
Sternum
Femur
Phalanges
Clavicle
Epiphyses of the humerus
A patient is having a bone marrow aspirate test performed.
Which bone should the doctor obtain the marrow from in order
for the patient to have the most therapeutic outcome?
Scapulae
Cranial bone
Metatarsal bone
Iliac crest of the pelvis
A patient is having a bone marrow aspirate test performed.
Which bone should the doctor obtain the marrow from in order
for the patient to have the most therapeutic outcome?
Scapulae
Cranial bone
Metatarsal bone
Iliac crest of the pelvis (less pain & decreased risk of fracture)
Red blood cells are broken down and recycled on average after
what amount of time?
30 days
72 hours
90 days
120 days
Red blood cells are broken down and recycled on average after
what amount of time?
30 days
72 hours
90 days
120 days
A male patient comes into the E.R. complaining of being tired
after brief periods of exertion and he appears to be pale in color.
The doctor orders a CBC, what lab value is abnormal?
200,000 platelets
3000 neutrophils
1mill/mm3 RBC’s
O2 saturation 96%
A male patient comes into the E.R. complaining of being tired
after brief periods of exertion and he appears to be pale in color.
The doctor orders a CBC, what lab value is abnormal?
200,000 platelets
3000 neutrophils
1mill/mm3 RBC’s
O2 saturation 96%
A patient comes into the E.R. after a traumatic accident and has
lost a lot of blood. The initial lab report reveals several abnormal
values, which of the following is the most concerning?
Hemoglobin 8g/dL & Hematocrit 20%
BUN 8
Na+ 134mEq/L
K+3.5mEq/L
A patient comes into the E.R. after a traumatic accident and has
lost a lot of blood. The initial lab values reveal several abnormal
values, which of the following is the most concerning?
Hemoglobin 8g/dL & Hematocrit 20%
BUN 8
Na+ 134mEq/L
K+3.5mEq/L
A patient is being treated for pernicious (B12) anemia, you as the
nurse would expect their mean corpuscular volume to be what?
50fL
85fL
125fL
95fL
A patient is being treated for pernicious (B12) anemia, you as
the nurse would expect their mean corpuscular volume to be
what?
50fL
85fL
125fL
95fL
A vegan is being treated for iron deficiency anemia. Which of the
following lab values could the nurse expect to find? SATA
MCV 70fL
MCHC 38%
MCH 22pg
MCHC 28%
MCV 112fL
A vegan is being treated for iron deficiency anemia. Which of the
following lab values could the nurse expect to find? SATA
MCV 70fL
MCHC 38%
MCH 22pg
MCHC 28%
MCV 112fL
Which lab values are within normal limits in reference to WBC’s?
SATA
Neutrophils 8000
Basophils 28
Lymphocytes 4500
Eosinophils 53
Monocytes 98
Which lab values are within normal limits in reference to WBC’s?
SATA
Neutrophils 8000
Basophils 28
Lymphocytes 4500
Eosinophils 53
Monocytes 98
A patient has lung cancer and has been receiving chemotherapy
for 1yr., their most recent lab values reflect a state of
leukopenia/neutropenia. What values correlate with this
diagnosis?
Leukocytes 4500 & Neutrophils 2800
Leukoctyes 9000 & Neutrophils 3000
Lymphocytes 1000 & Neutrophils 2500
Leukocytes 2000 & Neutrophils 1500
A patient has lung cancer and has been receiving chemotherapy
for 1yr., their most recent lab values reflect a state of
leukopenia/neutropenia. What values correlate with this
diagnosis
Leukocytes 4500 & Neutrophils 2800
Leukoctyes 9000 & Neutrophils 3000
Lymphocytes 1000 & Neutrophils 2500
Leukocytes 2000 & Neutrophils 1500
What precautions/restrictions is a leukopenic/neutropenic patient
under during a hospital stay? SATA
Contact precautions
Balanced diet including fresh fruit & vegetables
Regular handwashing
Regular exercise outside the room
Strict temperature monitoring
What precautions/restrictions is a leukopenic/neutropenic patient
under during a hospital stay? SATA
Contact precautions
Balanced diet including fresh fruit & vegetables
Regular handwashing
Regular exercise outside the room
Strict temperature monitoring
A patient was in a car accident and hit the steering wheel
fracturing their 10th rib (left side), which resulted in the rupturing
of their spleen. What is the big concern after the splenectomy?
The patient may bleed out b/c the spleen’s responsibility was to
sequester platelets
The patient will become Fe+ deficient because the spleen helped to
breakdown hemoglobin from old RBC’s and recycle the Fe+ out of it
The patient is at an increased risk of DVT’s because of the long term
recovery they will have to undergo
The patient is at an increased risk for infection due to a loss of stored
WBC’s
A patient was in a car accident and hit the steering wheel
fracturing their 10th rib (left side), which resulted in the rupturing
of their spleen. What is the big concern after the splenectomy?
The patient may bleed out b/c the spleen’s responsibility was to
sequester platelets
The patient will become Fe+ deficient because the spleen helped to
breakdown hemoglobin from old RBC’s and retrieve the Fe+ out of it
The patient is at an increased risk of DVT’s because of the long term
recovery they will have to undergo
The patient is at an increased risk for infection due to a loss
of stored WBC’s
A male patient who is 66yrs. old is at the doctor’s office for his
regular yearly check up. When you the nurse are going in to take his
vital signs & prepare him to see the doctor, the patient remarks to
you that he had a cold recently and it felt like it took him 2 months to
get over it. What education can you provide the patient with that
would help him to understand the impact of aging on the body?
As you get older your body just gets really decrepit . . . Sucks to be you
As you get older your body has a harder time identifying infection
As you get older your body decr. production of stem cells & the immune
response slows down
Nothing happens to your body as you age, you probably imagined that &
we need to get you checked out for Alzheimer's Dementia
A male patient who is 66yrs. old is at the doctor’s office for his
regular yearly check up. When you the nurse are going in to take his
vital signs & prepare him to see the doctor, the patient remarks to
you that he had a cold recently and it felt like it took him 2 months
to get over it. What education can you provide the patient with that
would help him to understand the impact of aging on the body?
As you get older your body just gets really decrepit . . . Sucks to be you
As you get older your body has a harder time identifying infection
As you get older your body decr. production of stem cells & the
immune response slows down
Nothing happens to your body as you age, you probably imagined that &
we need to get you checked out for Alzheimer's Dementia
A female patient comes in complaining of general malaise, but
the specific cause of her discomfort could not be determined.
The doctor ordered an ESR test to be performed. What value is
abnormal & what is this test for?
8mm/hr, this test measures how fast RBC’s clot
17mm/hr, this test checks for Sickle Cell Disease
20mm/hr, this test checks for pregnancy
25mm/hr, this is a general test for inflammation
A female patient comes in complaining of general malaise, but
the specific cause of her discomfort could not be determined.
The doctor ordered an ESR test to be performed. What value is
abnormal & what is this test for?
8mm/hr, this test measures how fast RBC’s clot
17mm/hr, this test checks for Sickle Cell Disease
20mm/hr, this test checks for pregnancy
25mm/hr, this is a general test for inflammation
A patient presents with elevated serum Fe+ & Ferritin. What
would you expect to see in their labs on the computer? SATA
Incr. transferrin
200mg/dL Serum Fe+
Decrease Total Iron Binding Capacity (TIBC)
MCV of 50fL
300mg/dL Ferritin
A patient presents with elevated serum Fe+ & Ferritin. What
would you expect to see in their labs on the computer? SATA
Incr. transferrin
200mg/dL Serum Fe+
Decrease Total Iron Binding Capacity (TIBC)
MCV of 50fL
300mg/dL Ferritin
A patient is on warfarin (Coumadin), what lab values would
indicate that they have a therapeutic level of the drug in there
system? SATA
PTT 38secs
INR 4secs
PT 18secs
PT 8secs
PTT 30secs
INR 1
A patient is on warfarin (Coumadin), what lab values would
indicate that they have a therapeutic level of the drug in there
system? SATA
PTT 38secs
INR 4secs
PT 18secs
PT 8secs
PTT 30secs
INR 1
A patient is receiving heparin via IV while in the hospital as DVT
prophylaxis. What lab is used to monitor heparin therapeutic
levels & what value indicates that heparin is NOT at an effective
level in the blood?
PT & 25secs
PTT & 40secs
INR & 5secs
PTT & 30secs
A patient is receiving heparin via IV while in the hospital as DVT
prophylaxis. What lab is used to monitor heparin therapeutic
levels & what value indicates that heparin is not at an effective
level in the blood?
PT & 25secs
PTT & 40secs
INR & 5secs
PTT & 30secs
You are the RN caring for a 16 year old boy with severe A type
hemophilia. He is preparing for an appendectomy scheduled for the
following day. What factor do you plan to administer to him?
DDAVP
Cryoprecipitate
Fibrinogen
Factor IX
You are the RN caring for a 16 year old boy with severe A type
hemophilia. He is preparing for an appendectomy scheduled for the
following day. What factor do you plan to administer to him?
DDAVP
Cryoprecipitate
Fibrinogen
Factor IX
You are an RN in a pediatric ED. You have a 4 year old patient with type
B hemophilia come in. His parents tell you that he was playing under a
table and bumped his head when he stood up. He was complaining of a
headache, but on the way to the hospital he fell asleep and appeared
more calm. What action do you recognize as a priority?
Obtaining a height and weight
Completing a CT scan
Assessing the patient’s eyesight using a tumbling E’s chart
Prepare a pediatric dose of aspirin to help relieve the patient’s
headache
You are an RN in a pediatric ED. You have a 4 year old patient with type
B hemophilia come in. His parents tell you that he was playing under a
table and bumped his head when he stood up. He was complaining of a
headache, but on the way to the hospital, he fell asleep and appeared
more calm. What action do you recognize as a priority?
Obtaining a height and weight
Completing a CT scan
Assessing the patient’s eyesight using a tumbling E’s chart
Prepare a pediatric dose of aspirin to help relieve the patient’s
headache
You are a nurse educator working with a patient who has sickle cell
anemia. What suggestion is not correct?
Inform the patient that she should carry her water bottle with
her everywhere she goes
Help the patient acquire a medic alert bracelet
Encourage physical activities, such as hiking, in order to prevent
stasis of blood
Encourage the patient to remain current with her immunizations
You are a nurse educator working with a patient who has sickle cell
anemia. What suggestion is not correct?
Inform the patient that she should carry her water bottle with
her everywhere she goes
Help the patient acquire a medic alert bracelet
Encourage physical activities, such as hiking, in order to
prevent stasis of blood
Encourage the patient to remain current with her immunizations
You are an RN working in a community health clinic. A patient
presents with a sore, red tongue, headache, and cracked lips.
Which supplement do you expect to administer?
B12
Folic acid
Ferrous citrate (iron supplement)
Intrinsic Factor
You are an RN working in a community health clinic. A patient
presents with a sore, red tongue, headache, and cracked lips.
Which supplement do you expect to administer?
B12
Folic acid
Ferrous citrate (iron supplement)
Intrinsic Factor
You are an RN on a med/surg floor. You have just taken vitals on a
patient with aplastic anemia. Which result is most concerning to
you?
BP 139/89
Respirations 22
Temp 100.1 degrees
HR 79
You are an RN on a med/surg floor. You have just taken vitals on a
patient with aplastic anemia. Which result is most concerning to
you?
BP 142/90
Respirations 22
Temp 100.1 degrees
HR 79
In a severely anemic patient, the nurse would expect to find:
Dyspnea and tachycardia
Cyanosis and pulmonary edema
Cardiomegaly and pulmonary fibrosis
Ventricular dysrhythmias and wheezing
In a severely anemic patient, the nurse would expect to find:
Dyspnea and tachycardia
Cyanosis and pulmonary edema
Cardiomegaly and pulmonary fibrosis
Ventricular dysrhythmias and wheezing
When caring for a patient with thrombocytopenia, the nurse
instructs the patient to:
Dab their nose instead of blowing
Be careful when shaving with a safety razor
Continue with physical activities to stimulate thrombopoiesis
Avoid aspirin because it may mask the fever that occurs with
thrombocytopenia
When caring for a patient with thrombocytopenia, the nurse
instructs the patient to:
Dab their nose instead of blowing
Be careful when shaving with a safety razor
Continue with physical activities to stimulate thrombopoiesis
Avoid aspirin because it may mask the fever that occurs with
thrombocytopenia
You are an RN caring for a patient with pancytopenia. Which of
these actions do you not need to implement?
Stop his visitor from bringing in flowers
Ensure that all his fruit only comes from the hospital’s cafeteria
Educate all family members about handwashing
Provide a mask for a visitor with a cold
You are an RN caring for a patient with pancytopenia. Which of
these actions do you not need to implement?
Stop his visitor from bringing in flowers
Ensure that all his fruit only comes from the hospital’s cafeteria
Educate all family members about handwashing
Provide a mask for a visitor with a cold
