Blood Components and Complete Blood Count

Blood Components & Origin

• All blood components originate in the bone marrow
• Bone marrow stem cells differentiate into red blood cells (erythrocytes), white blood cells (leukocytes), and platelets (thrombocytes)

Complete Blood Count (CBC)

• A CBC evaluates red blood cells, white blood cells, and platelets
• Lab values vary based on the patient's age and gender
• Different laboratories will have different normal ranges for different lab tests
• Use the lowest female range and the highest male range to remember one value range per test

Red Cell Count (RBC)

• Hematocrit: 37-50%
• Hemoglobin: 12-16.5 (x 10^6/microliter of blood)

White Blood Count (Total WBC)

• Normal Range: 5,000 – 10,000 (per microliter of blood)
• Neutrophils: 47% - 63% (% of total WBCs)
• Lymphocytes: 24% - 40% (% of total WBCs)

Platelets

• Normal Range: 150,000 – 400,000 (per microliter of blood)
• A CBC is performed using an automated instrument
• It measures various parameters, including counts of cells in a person's blood sample
• CBC results provide information about the number of cell types and indication of physical characteristics of some cells
• Standard CBC screens for a wide range of conditions and diseases
• Diagnoses conditions like anemia, infection, inflammation, bleeding disorders, or leukemia
• Monitors the condition and/or effectiveness of treatment after diagnosis
• Monitors treatment known to affect blood cells (chemotherapy or radiation therapy)

Red Blood Cells (Erythrocytes)

• Hemoglobin in erythrocytes binds oxygen in the lungs and delivers it to the body
• Hypoxia develops when not enough red blood cells are present, which produces universal signs and symptoms

RBC Lab Tests

• Red blood cell (RBC) count measures the number of RBCs in a person's blood sample
• Hematocrit measures the percentage of a person's blood that consists of red blood cells
  • Low Hct means the patient is losing blood internally or externally
    • Critical Low: <15% indicates heart failure
    • Critical High: >60% indicates blood clotting problems
  • Hct affected by the person's fluid status
    • High Hct caused by DEHYDRATION
    • Low Hct caused by FLUID OVERLOAD
  • Hct often ordered with a hemoglobin test to verify accuracy
    • Decreased Hct and Hgb indicate blood loss
• Hemoglobin measures the amount of oxygen-carrying protein in the blood, measured in grams
• Reticulocyte count measures the absolute count or percentage of immature red blood cells in blood
  • Elevated levels mean mature RBCs are depleted, and the body is relying on immature RBCs
• Red blood cell indices provide information on the physical characteristics of RBCs (MCV, MCH, MCHC, RDW)
  • RBC indices lab tests are used to determine if a person has Anemia and what type of anemia
    • MCV = Mean corpuscular volume, measurement of the average size of RBCs
    • MCH = Mean corpuscular hemoglobin, calculation of the average amount of oxygen-carrying hemoglobin inside a red blood cell
    • MCHC = Mean corpuscular hemoglobin concentration, calculation of the average percentage of hemoglobin inside a red cell
    • RDW = Red cell distribution width, calculation of the variation in the size of RBCs
• Elevated red blood cell count conditions: Polycythemia
  • Cardiovascular disease
  • Stress
  • Polycythemia vera
  • Smokers
  • High altitude
  • Hemoconcentration and dehydration
  • Renal cell carcinoma and other erythropoietin-producing neoplasms
• Decreased red blood cell count conditions: Anemia
  • Anemias
  • Hemolysis
  • Chronic renal failure
  • Hemorrhage
  • Failure of marrow production

Anemias: Not Enough Red Blood Cells

• There are over 400 types of anemias in three groups
  • Anemia caused by blood loss
  • Anemia caused by decreased or faulty red blood cell production
  • Anemia caused by destruction of red blood cells
• Delivering oxygen to tissues relies on hemoglobin binding to red blood cells for gas exchange
• HYPOXIA develops when there are not enough red blood cells

Clinical Manifestations Common to All Anemias

• Low hemoglobin and hematocrit levels with reduced RBCs
• Plasma expansion results in "watery" blood

Signs & Symptoms of Anemia Caused by Hypoxia (Low Oxygen Levels in Blood)

• Fatigue (decreased energy production)
• Tachypnea (increased respiratory rate)
• Tachycardia (increased heart rate to circulate red blood cells more freely)
• Pallor (pale skin & mucous membranes caused by low hemoglobin or RBCs)

Overview: Causes of Anemia

• Anemia by blood loss
  • Gastrointestinal (GI) Conditions include upper or lower GI bleeds
  • NSAID overuse (Risk factor: Patients with chronic pain)
  • Excessive menstruation or childbirth complications
• Anemia due to Excessive RBC destruction: Hemolytic Anemias
  • RBCs die quicker than the bone marrow can replace them
    • Intrinsic - inherited defective RBCs
    • Extrinsic - everything else
  • Inherited - sickle cell & thalassemia
  • Stressors - Infections, drugs, snake, or spider venom, etc.
  • Toxins - advanced liver or kidney disease
  • Autoimmune – Antibody mediated, Lupus; cancer; Rh factor; drugs
  • Spleen - blood moves more slowly thru an enlarged spleen, causing RBCs to become prematurely destroyed before getting through the spleen
• Anemia due to Decreased or Faulty RBC Production
  • Nutritional Deficiencies: (Iron, Vitamin B-12, and Folate are necessary components of RBC production)
• Bone marrow & Stem cell problems: Leukemia and lymphoma are examples. Aplastic anemia, osteomyelitis, etc
• Sickle Cell Anemia (this anemia also falls into category #2 above)
• Other conditions associated with decreased or faulty RBCs
  • Advanced kidney disease
  • Hypothyroidism - causes lowered iron levels in the blood
  • Chronic diseases – INFLAMMATION causes production of cytokines that then destroy all blood cells including erythrocytes.

Kidney Connection & Anemia

• Erythropoietin (made in kidneys) signals bone marrow to make more RBCs
• If kidneys are damaged, erythropoietin is not excreted, and RBCs are not made
• Erythropoietin injections are given to patients with severe anemia caused by kidney failure or bone marrow failure (AIDS/blood or bone marrow cancers/aplastic anemia/chemotherapy)
• These injections can increase RBC production eliminating the need for a blood transfusion

Anemia due to Decreased or Faulty RBC Production: Nutritional Deficiency Anemias

• Three vitamins/minerals required to produce RBCs are Folate, Vit B12, and Iron
• Iron deficiency is the most common and widespread nutritional disorder globally
• Bone marrow needs iron to make hemoglobin
  • Iron deficiencies are caused by lack of iron in the diet or by blood loss
    • Metabolic demands of pregnancy and breastfeeding
    • Blood loss through excessive menstruation, childbirth, or blood
    • Digestive conditions (Crohn's) OR removal of stomach/small intestines
    • Medications, excess caffeine
• Iron Replacement: Mineral supplements/ Iron injections; Foods – soybeans, lentils and beans, red meat, chicken, fish, fortified foods

Vitamin B-12

• Cobalamin: required to make RBCs
• Used to treat many conditions including: memory loss; Alzheimer's disease; boosting mood, energy, concentration, the immune system, and slowing aging
• Conditions: heart disease, lowering high homocysteine levels, male infertility, diabetes, sleep disorders, depression, mental disorders, weak bones, AIDS, inflammatory bowel disease, asthma, allergies, skin disease called vitiligo, preventing cervical and other cancers, and skin infections

Causes of Low Vitamin B-12 Levels

• Dietary: Eating little or no meat may cause a lack of B-12
• Lack of Intrinsic Factor (IF): protein excreted by the stomach is needed for Vitamin B12 absorption
  • B-12 is destroyed in gastric juices if not bound to Intrinsic Factor
  • If stomach/upper intestine is damaged or removed, Intrinsic factor is not secreted so lifelong B12 replacement injections required

Folate (Vit B-9): Folic Acid

• Integral part of cell growth, especially RBCs
• Deficiencies during pregnancy can cause birth defects of baby's brain and spine
• Low Folate levels may be caused by:
  • Overcooking or eating too few vegetables may cause a folate deficiency
  • Other: Pregnancy, medications, alcohol abuse, intestinal diseases

Anemia due to Decreased RBC Production: BM Damage

• Aplastic Anemia
  • Destruction of bone marrow [BM] stem cells. Causes pancytopenia = ALL blood cells are depressed
  • Develops because of bone marrow damage
    • Damage may be present at birth or occur after exposure to radiation, chemotherapy, autoimmune disease, toxic chemicals, some drugs, or infection
  • Viruses linked to development include hepatitis, Epstein-Barr, cytomegalovirus, parvovirus B19 and HIV
  • Treatment: Medications, blood transfusions, and stem-cell transplants
• S/S may develop slowly or suddenly
  • Fatigue and rapid heart rate (low RBCs)
  • Frequent infections (low WBCs)
  • Bleeding tendencies (low platelets) as evidenced by bleeding gums/nose bleeds/petechiae, easy bruising, heavy menstrual cycles, G.I. bleeding, etc

Anemia Due to Faulty RBC Production: Sickle Cell Anemia

• Sickle cell anemia (an autosomal recessive defect of hemoglobin) is the most common inherited blood disorder in the United States
  • Individuals with the single defective gene have sickle cell “TRAIT”
  • Those with 2 defective genes have sickle cell “DISEASE”

Sickle Cell Crisis Types

• Vaso-occlusive: Sickled red blood cells trigger blood clot formation, leading to tissue damage resolving within a week
  • Tissue damage is minor and can resolve within a week, can include- Stroke, Pulmonary infarction, Myocardial infarction, Gangrene.
• Sequestration: Sickled red blood cells are removed from circulation by the spleen, causing hypovolemic shock
  • Severity depends on the blood amount removed and held in the spleen and liver, thus reducing the circulating red blood cells
• Aplastic: Exhaustion of bone marrow prevents erythropoiesis from keeping up with replacement needs
  • Sickled red blood cells have a lifespan of 10-20 days
  • Constant stress on bone marrow stems cells can eventually lead to bone marrow failure

Nursing Considerations for Treating all Types of Sickle Cell Crisis

• Nursing priorities include, Oxygen for hypoxia, IV fluids to prevent dehydration, Pain meds to address painful clotting

Polycythemia: Too Many RBCs

• Opposite of anemia
• Can cause hyperviscosity or thrombosis
• Primary (Absolute): Polycythemia vera is an inherited condition
  • Affects primarily Caucasians with European Jewish ancestry, can occur at any age, mostly men
• Secondary (Relative): physiologic response to chronic hypoxia to make more RBCs for oxygen transport

Causes of Polycythemia

• Sleep Apnea causes either Obstructive Sleep Apnea or Central Sleep Apnea
  • Both result in oxygen deprivation
• COPD patients have chronic obstructive pulmonary diseases, which hamper gas exchange in the lungs
• Heart failure patients experiencing reduced tissue profusion
  • Low oxygenation will trigger a increase in production of RBCs
• Pulmonary disease impair gas exchange
  • Decrease in oxygen will produce hypoxia
• High Altitude is the body's compensation for lower 02 levels by making more RBCs to carry oxygen
  • Takes 6-8 weeks to build up enough erythrocytes
• EPO shots: athletes "Blood doping" for performance enhancement or abuse anabolic steroids use (erythropoietin) shots

Signs & Symptoms of Polycythemia

• Caused by reduced blood flow of viscous blood and clotting
  • Plethora: ruddy complexion
  • Fatigue
  • Dizziness
  • Headache
  • Thick blood increases workload on the heart high B/P
  • Decreased perfusion to the brain due to sluggish blood flow of thick blood

Treatment of Polycythemia

• Periodic phlebotomy
• Oxygen
• CPAP
• Aspirin to prevent blood clotting
• Radioactive phosphate

White Blood Cells: Leukocytes

• Leukocytes found throughout the body, including in the blood and lymphatic system and are divided into 5 types:
  • Granulocytes: all end in "phil," specifically, Neutrophils, Eosinophils, and Basophils
  • Agranulocytes: all end in "cytes," specifically, Lymphocytes and Monocytes

Types of White Blood Cells & Function

• Neutrophils: increase in acute bacterial infection
• Eosinophils: increase in allergy attacks
• Basophils: increase during stress/allergy
• Agranulocytes (all end in "cytes") increase in chronic bacterial or viral infection
• Associated Organs: Bone Marrow, Thymus, Spleen
• Lymphocytes: increase in chronic bacterial or viral infection, these are further broken down into T-cells and B-cells
  • T-cells (Killer, Helper, Suppressor, Memory, etc.)
  • B-cells (antibodies)
• Monocytes: Non-specific phagocytes that become macrophages when needed to fight infection in tissue

White Blood Cell (WBC) Count

• Total WBC count is the number of white blood cells in a sample of blood
• White blood cell differential may identify/count various types of white blood cells present to provide a clue about active fighting in the body

Elevated White Blood Cell (WBC) Count

• Increased WBC conditions (Leukocytosis)
  • Neutrophils: acute bacterial infections
  • Lymphocytes: viral infection and/or chronic bacterial infection
  • Eosinophils: allergies or parasitic infection

Decreased White Blood Cell (WBC) Count

• Decreased WBC conditions (Leukopenia)
  • Steroids or medicines containing them (i.e., prednisone)
  • Chemotherapy
  • Bone marrow failure (aplastic anemia or cancer (Leukemia)
  • Use of Antiseizure medication such as Tegretol

Cancers Affecting WBCs

• Leukemias, Lymphomas, and Multiple Myelomas are all cancers of the blood-forming organs from genetic information errors
  • Errors result in cell development arrested/replicated repeatedly, and abnormal blood cell proliferation
  • Nearly every stage of the hematopoietic process gives rise to a cancer type
  • Three broad categories of blood cancers are Leukemias, Lymphomas, and Multiple Myelomas

3 Types of Blood Cancer

• Leukemias: Cancer of white blood cells (Exception: Myelogenous leukemia)
• Lymphoma: Cancer originating in the lymphatic system (lymphocytes)
• Myelomas: Cancer that affects B-Cell type that makes antibodies

Leukemia Defined

• Malignant growth of leukocytes leading to over-production of nonfunctioning white blood cells in the bone marrow
  • Overproduction grows faster than the functioning cells, and eventually cancerous cells crowd/damage all functioning blood cells in the bone marrow, resulting in anemia, infections, and bleeding problems

Leukemia Classification

• Classification by speed of progression and the type of cells involved
  • Acute or chronic
  • Myeloid or lymphocytic
  • Acute myeloid (or myelogenous) leukemia (AML)
  • Chronic myeloid (or myelogenous) leukemia (CML)
  • Acute lymphocytic (or lymphoblastic) leukemia (ALL)
  • Chronic lymphocytic leukemia (CLL)

Leukemia Classification - Speed

• Acute Leukemia: Abnormal blood cells are immature blood cells (blasts) that cannot carry out normal functions
• Acute Leukemia multiplies rapidly, worsening the disease requiring aggressive, timely treatment
• Chronic Leukemia: Some produce an excess of cells, and some cause too few cells. More mature blood cells replicate or accumulate slowly & can function normally
• Chronic Leukemia often progresses slowly & some forms initially produce no early symptoms.

Leukemia Classification - Cell Type Affected

• Lymphocytic Leukemia: affects lymphoid cells (lymphocytes), which form lymphoid or lymphatic tissue.
• Lymphoid tissues make up the immune system
• Myelogenous Leukemia: affects myeloid cells, and these cells give rise to red blood cells, white blood cells & platelet-producing cells.

Symptoms of Leukemia

• Fatique, low fever, night sweats, weight loss.
• Lymphadenopathy: Swelling lymph nodes that may swell randomly
• Anemia
• Infection
• Bleeding problems Pallor: malignant cells crowd bone marrow, decreasing erythrocyte and thrombocyte production and causing a pale skin color

Lymphoma

• Blood cancer that affects the lymphatic system causing overproduction of malfunctioning lymphocytes
• Overproduction compromises the immune system & Lymphoma can develop in lymph nodes, bone marrow, blood, spleen, & other organs

Hodgkin's Lymphoma & Non-Hodgkin's Lymphoma

Hodgkin's Lymphoma

• B-Cell lymphocytes are affected
• Reed-Sternberg Cells are present
• 20-30 years old (more common in younger population) and older adults [60-70]
• Cervical, inguinal, axillary, and Retroperitoneal node involvement
• Uncommon extra nodal involvement
• Symptoms include painless swollen lymph nodes, fever/ night sweats, generalized weakness, weight loss, bone Marrow damage
• Radiation therapy, Chemotherapy, Immunotherapy & Bone Marrow transplant are common treatment methods
• Approximately 90% curability

Non-Hodgkin's Lymphoma

• T- and B-Cell are affected
• More common over50s (95%).
• Cervical, axillary, inguinal, femoral node involvement
• Same as Hodgkin's including pleural effusion, abdominal pain, splenomegaly
• Less than 25% curability

Multiple Myelomas

• Is cancer that starts in a type of B-Cell Lymphocyte called plasma cells in the bone marrow, making all kinds of proteins
• Classed by the type of bad antibodies (immunoglobulins) being attacked
• Myeloma proteins crowd, lowering good antibodies
• More common in men and develops after 40
• bone marrow stop good antibodies and produce protein referred to"monoclonal" or M protein
• MM cells wear down hardness of shell or cortex of bone such that bone breaks easily
• These lesions cause pain and pathological spontaneous fractures

Multiple Myeloma Signs & Symptoms

• Calcium in blood
• Renal Failure (Myeloma nephrosis). Caused by the paraproteins(abnormal antibody)
• Anemia: BM not functioning + kidney not producing hormone
• Bone pain and fractures
• Survival is 3-5 years.

Platelets ~ Thrombocytes

• Platelets, are cell fragments that are vital to normal blood clotting
• People without enough platelets are at risk for excessive bleeding and bruising
• CBC measures the number and size of platelets
• Liver regulates platelets by producing hormone THROMBOPOIETIN
• A platelet count is general, a platelet count is low due to bone Marrow (either not making enough or destroying/using it up)
• Too many are held in the spleen

Platelets ~ Thrombocytes - Number

Increase in Platelet Count in following conditions:

• some cancers
• inflammatory conditions
• birth control pills
• recovery phase of trauma/surgery

Decrease in number of Platelets may be shown in following conditions:

• autoimmune disorder
• medications
• some "G" herbs
• Chemotherapy/radiation
• some cancers
• DIC (Disseminated Intervascular Coagulation)

Signs of Bleeding

• Hemorrhage – blood comes blood from blood vessels
• Menorrhagia – period is heavier
• Epistaxis – blood coming from nose
• Petechiae – pinpoint capillaries bleeding
• Purpura - discoloration on skin
• Ecchymosis – blood is causing bruising

Causes of Thrombocytopenia (Platelet Count <140,000)

3 Type of Thrombocytopenia

• Thrombocytopenia (platelet count<140,000)-Thrombocytes is reduced
• Thrombocytopenia: autoiummune, IgG connects with platelets which destroys the function, results in low platelet

Thrombotic Thrombocytopenia Purpura TTP

• Damage by widespread where is damage, triggers platelet distrcution
• S/S: FEVER is not feeling well

Drug Induced THROMBOCYTopenia

• Heparin
• S/S: (Epistaxis),( GI Bleeds)(Menorrhagia) Treatment- eliminate cause and give platelet transfusion

Thrombosis

• Thrombosis is blood clots that occurs with arteries or veins
• Thrombosis with abnormal blood flow which is caused by increased pressure and low turbulence
  • Turbulent is damage with vessels which damage
  • Treatment: reduce blood cells

Treatment of Thrombosis

• Anti-coagulant drugs to prevent future

Treatment of Thrombosis - Anticoagulation Aides

• Heparin-Injected-Fast acting
• Comadin~OralMed.L/oog acting
• Asprin -ORal~small dose every day will protect causing GI bleeding
• Thrombolytic- clot buster- drug which breaks down heart attack and to clot

Pertinent Test for problems with Bleeding

• Bleeing-Time- Test PTT an PT INR-
• Clotting,
• D-Dimer- Done to determine the blood Clot for in body,

Disseminated Intravasular coagulation

• Disseminated intravcular coagulation
• DIC: Coagulation with hemorrhaging
• DIC: A is not a illness, and there’s an underlying

Triggers for Clotting

• Inflammation activation
• Vasulature enethoieum

S/S (Clotting Phase)

• Dvt
• Renal failure
• Difficulty breathing
• Numbless
• Liver function
• S/S(Hemorrhhage) and Treatment- Life support is treating with fluids/IV to maintain and gives antibiotics, stopping process, which reduces Platelet Test- is abnormal.