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AGING OF PHYSIOLOGIC SYSTEM HEMATOLOGIC AND LYMPHATIC SYSTEM REPORTERS: CAMARILLO, KRISHEL LAGORRA, SANDARA GWEN  HEMATOLOGIC ASSESSMENT Anatomic and Physiologic Overview The hematologic system consists of the blood and the...

AGING OF PHYSIOLOGIC SYSTEM HEMATOLOGIC AND LYMPHATIC SYSTEM REPORTERS: CAMARILLO, KRISHEL LAGORRA, SANDARA GWEN  HEMATOLOGIC ASSESSMENT Anatomic and Physiologic Overview The hematologic system consists of the blood and the sites where blood is produced, including the bone marrow and the reticuloendothelial system (RES). Blood is a specialized organ that differs from other organs in that it exists in a fluid state. Blood is composed of plasma and various types of cells. Plasma is the fluid portion of blood; it contains various proteins, such as albumin, globulin, fibrinogen, and other factors necessary for clotting, as well as electrolytes, waste products, and nutrients. About 55% of blood volume.  Blood The cellular component of blood consists of three primary cell types erythrocytes(red blood cells [RBCsl, red cells), leukocytes (white blood cells [WBCs]), and thrombocytes (platelets). These cellular components a blood normally make a cells have a short lifespan. The need for the body to replenish its supply of cells; this process is termed hematopoiesis.  Blood The primary site of the hematopoiesis is the bone marrow. During embryonic development and in other condition, liver and spleen may be involved. Excessive clotting is equally dangerous, because it can obstruct blood flow to vital tissues. To prevent this, the body has a fibrinolytic mechanism that eventually dissolves clots (thrombi) formed within blood vessels. The balance between these two systems, clot (thrombus) formation and clot dissolution or fibrinolysis, is called hemostasis.  Blood Cells The normal erythrocyte is a biconcave disk that resembles a soft ball compressed Erythrocytes (Red between two fingers. The membrane of Blood Cells) the red cell is very thin so that Bases, such as oxygen and carbon dioxide, can easily diffuse across it; the disk shape provides a large surface area that facilitates the absorption and release of oxygen molecules. Mature erythrocytes have no nuclei, and they have many fewer metabolic enzymes than do most other cells. The presence of a large amount of hemoglobin enables the red cell to perform its principal function, the transport of oxygen between the lungs and tissues.  OXYHEMOGLOBIN Oxyhemoglobin is a brighter red than hemoglobin that does not contain oxygen (reduced hemoglobin); thus, arterial blood is a brighter red than venous blood. The oxygen readily dissociates (detaches) from hemoglobin in the tissues, where the oxygen is needed for cellular metabolism.Whole blood normally contains about 15 g of hemoglobin per 100 mL of blood.  ERYTHROPOIESIS Erythroblasts arise from the primitive myeloid stem cells in bone marrow. The erythroblast is an immature nucleated cell that gradually loses its nucleus. At this stage, the cell is known as a reticulocyte. Further maturation into an erythrocyte entails the loss of the dark-staining material within the cell and slight shrinkage. The mature erythrocyte is then released into the circulation. RED BLOOD CELL DESTRUCTION The average lifespan of a normal circulating erythrocyte is 120 days. Aged erythrocytes lose their elasticity and become trapped in small blood vessels and the spleen. They are removed from the blood by the reticuloendothelial cells, particularly in the liver and the spleen. As the erythrocytes are destroyed, most of their hemoglobin is recycled. Some hemoglobin also breaks down to form bilirubin and is secreted in the bile.. Leukocytes (White Blood Cells) Leukocytes are divided into no general categories: granulocytes and lymphocytes. In normal blood, the total leukocytes count is 4000 - 11,000 cell/mm^3 Of these, approximately 60%-80% are granulocytes and 20%-40% are lymphocytes. Both of these types of leukocytes primarily protect the body against infection and tissue injury.  Function of Leukocytes Leukocytes protect the body from invasion by bacteria and other foreign entities. The major function of neutrophils is phagocytosis. Neutrophils arrive at a given site within 1 hour after the onset of an inflammatory reaction and initiate phagocytosis, but they are short-lived. This process constitutes a second line of defense for the body against inflammation and infection. Macrophages also digest senescent (aging or aged) blood cells, primarily within the spleen.  LYMPHOCYTES Mature lymphocytes are small cells with scanty cytoplasm. Immature lymphocytes are produced in the marrow from the lymphoid stem cells. A second major source of production is the thymus. Mature lymphocytes are the principal cells of the immune system, producing antibodies and identifying other cells and organisms as "foreign."  Function of Lymphocytes The primary function of lymphocytes is to attack foreign material. One group of lymphocytes (T lymphocytes) kills foreign cells directly or releases lymphokines, substances that enhance the activity of phagocytic cells. Plasma cells, in turn, produce antibodies called immunoglobulins (Ig), which are protein molecules that destroy foreign material by several mechanisms. This process is known as humoral immunity. GERONTOLOGIC CONSIDERATIONS In elderly patients, the bone marrow's ability to respond to the body's need for blood cells (erythrocytes, leukocytes, and platelets) may be decreased. In addition, in elderly patients, the bone marrow may be more susceptible to the myelosuppressive effects of medications. As a result of these factors, when an elderly person needs more blood cells, the bone marrow may not be able to increase production of these cells adequately. Leukopenia (a decreased number of circulating leukocytes) or anemia can result. HEMATOLOGIC STUDIES The most common tests used are the complete blood count (CBC) and the peripheral blood smear. The CBC identifies the total number of blood cells (leukocytes, erythroçytes, and platelets) as well as the hemoglobin, hematocrit (percentage of blood volume consisting of erythrocytes), and RBC indices. This process is referred to as the manual examination of the peripheral smear, which may be part of the CBC.  ANEMIA Anemia is a condition in which the hemoglobin concentration is lower than normal. It reflects the presence of fewer than normal number of erythrocytes within the circulation. Anemia is not specific disease state but a sign of underlying disorder. It is by far the most common hematologic condition. Classification of Anemias Anemia may be classifed insenema ways. A physiologic approach classifies an according to whether the deficiency in erythrocytes is caused by a defect in then production (hypoproliferative in less a by their destruction (hemolytic anemia), or by their loss (bleeding). In hypoproliferative anemias, the marrow cannot produce adequate numbers of erythrocytes. Decreased erythro cyte production is reflected by an inappropriately normal or low reticulocyte count.  In hemolytic anemias, premature destruction of erythrocytes results in the liberation of hemoglobin from the erythrocytes into the plasma; the released hemoglobin is converted in large part to bilirubin and therefore, the bilirubin concentration rises. The increased erythrocyte destruction leads to tissue hypoxia, which in turn stimulates erythropoietin production. Complications General complications of severe anemia include heart failure, paresthesias, and delirium. Patients with underlying heart disease are far more likely to have angina or symptoms of heart failure than those without heart disease. Complications associated with specific types of anemia are included in the description of each type.  MEDICAL MANAGEMENT Management of anemia is directed toward correcting or controlling the cause of the anemia; if the anemia is severe, the erythrocytes that are lost or destroyed may be replaced with a transfusion of packed red blood cells (PRBCs). GERONTOLOGIC CONSIDERATIONS Anemia is the most common hematologic condition affecting elderly patients. A systematic review has found that anemia affects 40% of elderly patients admitted to hospitals and 47% of elderly patients in long-term care facilities (Gaskell, Derry, Moore, et al., 2008). In the population at large, anemia occurs in 26% of men and 20% of women older than 85 years of age (Steensma & Tefferi, 2007). A review among the elderly has noted that increased fragility, decreased mobility and exercise performance, increased risk of falling, diminished cognitive function, increased risk of developing dementia and major depression, and lower skeletal muscle and bone density are associated with anemia (Steensma & Tefferi, 2007).  NURSING DIAGNOSIS Based in the assessment data, major nursing diagnosis of patient with anemia may include: 01 03 Fatigue related to decreased Altered tissue perfusion related hemoglobin and dime ished to inadequate hemoglobin and oxygen-carrying capacity of hematocrit Noncompliance with prescribed therapy the blood 02 Altered nutrition, less than body requirements, related to inadequate intake of essential nutrients Collaborative Problems/Potential Complications may develop include: Based on the assessment data, potential complications that may include: Heart failure Paresthesias Confusion *Angina PLANNING AND GOALS The major goals for the patient may include decreased fatigue, attainment or maintenance of adequate nutrition, maintenance of adequate tissue perfusion, compliance with prescribed therapy, and absence of complications. NURSING INTERVENTIONS Managing Fatigue Maintaining adequate nutrition Maintaining adequate perfusion Promoting Compliance With Prescribed Therapy Monitoring and Managing Potential Complications  A severe hemolytic anemia that results from SICKLE CELL ANEMIA inheritance of the sickle hemoglobin gene. This gene causes the hemoglobin molecule to be defective. The sickle hemoglobin (HbS) acquires a crystal-like formation when exposed to low oxygen tension. The erythrocyte containing HbS loses its round, pliable, biconcave disk shape and becomes deformed, rigid, and sickle shaped. The term sickle cell trait refers to the carrier state for SC diseases; the most benign type of SC disease, in that less than 50% of the hemoglobin within an erythrocyte is HbS. However, if two people with sickle cell trait have children, the children may inherit two abnormal genes and will have sickle cell anemia.  CLINICAL MANIFESTATIONS Symptoms of sickle cell anemia vary and are only somewhat based on the amount of HbS. Symptoms and complications result from chronic hemolysis or thrombosis. Sickled cells are rapidly hemolyzed and thus have a very short lifespan (10 to 12 days). Anemia is always present; usually hemoglobin values are 7 to 10 g/dL. Jaundice - The bone marrow expands Tachycardia, cardiac murmurs, and often an enlarged heart (cardiomegaly). Dysrhythmias and heart failure may occur in adults. Complications of sickle cell anemia include infection, stroke, renal failure, impotence, heart failure, and pulmonary hypertension. MEGALOBLASTIC ANEMIA In the anemias caused by deficiencies of vitamin B12 or folic acid, identical bone marrow and peripheral blood changes occur because both vitamins are essential for normal DNA synthesis. The erythrocytes that are produced are abnormally large and are called megaloblastic red cells. Other cells derived from the myeloid stem cell (non- lymphoid leukocytes, platelets) are also abnormal. In advanced stages of disease, the hemoglobin value may be as low as 4 to 5 g/dL, the leukocyte count 2000 to 3000/mm, and the platelet count less than 50,000/mm'. Those cells that are released into the circulation are often abnormally shaped. The neutrophils are hypersegmented. The platelets may be abnormally large. The erythrocytes are abnormally shaped, and the shapes may vary widely (poikilocytosis).  FOLIC ACID DEFICIENCY Folic Acid is stored as compound referred to as folates. The folate stores in the body are much smaller than to those of Vitamin B12 and they are quickly depleted when the dietary intake of folate is deficient (within 4 months).  VITAMIN B12 DEFICIENCY A deficiency of vitamin B12 can occur in several ways. Inadequate dietary intake is rare but can develop in strict vegetarians who consume no meat or dairy products. Even if adequate vitamin B12 and intrinsic factor are present, a deficiency may occur if disease involving the ileum or pancreas impairs absorption. Pernicious anemia, which tends to run in families, is primarily a disorder of adults, particularly the elderly. The body normally has large stores of vitamin B12, so years may pass before the deficiency results in anemia. Because the body compensates so well, the anemia can be severe before the patient becomes symptomatic.  CLINICAL MANIFESTATIONS Symptoms of folic acid and vitamin B12 deficiencies are similar, and the two anemias may coexist. However, the neurologic manifestations of vitamin B12 deficiency do not occur with folic acid deficiency, and they persist if vitamin B12 is not replaced. The hematologic effects of deficiency are accompanied by effects on other organ systems, particularly the GI tract and nervous system. Patients with pernicious anemia develop a smooth, sore, red tongue and mild diarrhea. they are extremely pale, particularly in the mucous membrane. NURSING MANAGEMENT Assessment of patients who have or are at risk of megaloblastic anemia includes inspections of the skin, mucosa membranes, and tongue. Mild Jaundice may be appear and best seen in the sclera in without using fluorescent lights. Vitiligo (patchy loss of skin pigmentation) and premature graying of the hair are often seen in patient it pernicious anemia. Because of the neurologic complication associated with these anemias, a careful neurologic assessment is important, including tests of position and vibration sense. Because mouth and tongue soreness may limit nutritional intake, the nurse advises the patient to eat small amounts of bland, soft foods frequently. The nurse also explain that other nutritional deficiencies, such as alcohol, induced anemia, can induce neurologic problems.  HODGKIN LYMPHOMA Hodgkin lymphoma is a relatively rare malignancy that has an impressive cure rate. It is somewhat more common in men than women and has two peaks of incidence: one in the early 20s and the other after 50 years of age. Disease occurrence has a familiar pattern. First-degree relatives have a higher-than-normal frequency of disease, but the actual incidence of this pattern is low. No increased incidence for nonblood relatives (eg, spouses) has been documented. Hodgkin lymphoma is seen more commonly in patients receiving chronic immunosuppressive therapy (eg, for renal transplant) and also in veterans of the military who were exposed to the herbicide Agent Orange. Hodgkin lymphoma is unicentric in origin in that it initiates in a single node. The disease spreads by contagious extension along the lymphatic system. Hodgkin lymphoma is the Reed-Sternberg cell, a gigantic tumor cell that is morphologically unique and is thought to be of immature lymphoid origin. The cause of Hodgkin lymphoma is unknown, but a viral etiology is suspected. Although fragments of the Epstein-Barr virus have been found in some Reed-Sternberg cells, the precise role of this virus in the development of Hodgkin lymphoma remains unknown.  CLINICAL MANIFESTATIONS Painless enlargement of one or more lymph nodes on one side of the neck. The individual nodes are painless and firm but not hard. The most common sites for lymphadenopathy are the cervical, supraclavicular, and mediastinal nodes; involvement of the iliac or inguinal nodes or spleen is much less common. abdominal pain Herpes zoster infections are common. A mild anemia is the most common hematologic finding. The leukocyte count may be elevated or decreased. The platelet count is typically normal, unless the tumor has invaded the bone marrow, suppressing hematopoiesis. Patients with Hodgkin lymphoma have impaired cellular immunity, as evidenced by an absent or decreased reaction to skin sensitivity tests (eg, Candida, mumps).  ASSESSMENT AND DIAGNOSTIC FINDINGS Lymph node biopsy and the finding of the Reed-Sternberg cell: Physical examination requires a careful, systematic evaluation of the lymph node chains, as well as the size of the spleen and liver. A chest x-ray and a CT scan of the chest, abdomen, and pelvis. Positron Emission Tomography ( PET ) Laboratory Tests; CBC, Platelet Count, ESR, Liver and Renal function studies. Bone Marrow Biopsy NURSING MANAGEMENT The potential development of a second malignancy should be addressed with the patient when treatment decisions are made. However, it is also important to tell patients that Hodgkin lymphoma is often curable. The nurse should encourage patients to reduce other factors that increase the risk of developing second cancers, such as use of tobacco and alcohol and exposure to environmental carcinogens and excessive sunlight. In addition, the nurse should provide education about relevant self-care strategies and disease management. NON- HODGKIN LYMPHOMAS The non-Hodgkin lymphomas (NHLs) are a heterogeneous group of cancers that originate from the neoplastic growth of lymphoid tissue. in NHL, the cells may vary morphologically. In contrast to Hodgkin lymphoma, the lymphoid tissues involved are largely infiltrated with malignant cells.  CLINICAL MANIFESTATIONS One third of patients with NHLs have B symptoms (fever, drenching night sweats, and unintentional weight loss). Lymphomatous masses can compromise organ function. MEDICAL MANAGEMENT Treatment is determined by the classification of disease, the stage of disease, prior treatment (if any), and the patient's ability to tolerate therapy. Tolerance to therapy is largely dictated by renal, hepatic, and cardiac function; the presence of concurrent diseases; functional status; and age. If the disease is not aggressive and is localized, radiation alone may be the treatment of choice MULTIPLE MYELOMA Mutiple myeloma is a malignant disease of the most mature form of B lymphocytes, the plasma cells. The plasma cells secretes immunoglobulin proteins necessary for antibody production to fight infection. MULTIPLE MYELOMA  CLINICAL MANIFESTATIONS The classic presenting symptom of multiple myeloma is * bone pain NURSING ALERT! Any elderly patient whose chief complaint is back pain and who has an elevated total protein level should be evaluated for possible myeloma. * Anemia * Infections MEDICAL MANAGEMENT There is no cure for multiple myeloma. Even BMT or PB-SCT is considered to extend remission rather than provide a cure. Radiation therapy is very useful in strengthening the bone at a specific lesion, particularly one at risk for bone fracture or spinal cord compression. Therefore, radiation therapy is typically used in combination with systemic treatment such as chemotherapy.  NURSING MANAGEMENT Pain management is very important in patients with multiple myeloma. NSAIDs can be very useful for mild pain or can be administered in combination with opioid analgesics. GERONTOLOGIC CONSIDERATIONS The incidence of multiple myeloma increases with age; the disease rarely occurs in patients younger than 40 years of age. Because of the increasing older population, more patients are seeking treatment for this disease. Back pain which is often a presenting symptom in this disease, should be closely investigated in older patients. BMT or PBSCT is an option that can prolong remission and potentially cure some patients, but it is unavailable to most older people be. cause of concurrent diminished organ function (eg, kidney, lung, liver, heart) associated with aging.  PRIMARY THROMBOCYTHEMIA Primary thrombocythemia (also called essential thrombocythemia) is a stem cell disorder within the bone marrow. A marked increase in platelet production occurs, with the platelet count consistently greater than 600,000 mm Platelet size may be abnormal, but platelet survival is typically normal. Primary thrombocythemia, which affects women twice as often as men, tends to occur later in life (median age at diagnosis is 65 to 70 years). Survival does not appear to differ from the general population (Johansson, 2006), although conflicting findings have been reported (Brière, 2007). PRIMARY THROMBOCYTHEMIA  CLINICAL MANIFESTATIONS high platelet count Headache Blistering of oral mucosa Ecchymosis NURSING MANAGEMENT Nursing care includes an Assessment of the patient's lifestyle to determine the risk of bleeding from activity. A careful medication history is also obtained, including use of over- the-counter medications, herbs, and nutritional supple-ments. The nurse assesses for any history of recent viral illness and reports of headache or visual disturbances, which could be initial symptoms of intracranial bleeding. Understanding these changes is critical for providing optimal care to older adults, particularly in managing blood-related disorders and ensuring that treatments are both effective and safe. Understanding the psychological changes in older adults, particularly in relation to hematopoietic (blood-forming) and lymphopoietic (lymphocyte-forming) changes, is crucial for several reasons: Impact on Disease Perception and Management Influence on Treatment Outcomes Quality of Life Considerations Holistic Patient Care Psychological Effects of Chronic Illness Preventing and Managing Psychological Complications In summary, understanding the psychological changes in older adults, particularly in the context of hematopoietic and lymphopoietic disorders, is essential for providing comprehensive, compassionate, and effective care. It allows healthcare providers to address both the mental and physical aspects of aging, ultimately leading to better health outcomes and quality of life for elderly patients. Thank you for your attention