Hematology and Communicable Diseases PDF

Blood  Average adult male – 4.7-5.5 liters  Blood- liquid tissue  Classified as connective tissue  Varies in color according to oxygen content Blood Constituents Plasma – 55% Serum- plasma minus clotting factors Plasma proteins ✓ Fibrinogen- ✓ aids in blood clotting ✓ Albumin ✓ Creates an...

Blood  Average adult male – 4.7-5.5 liters  Blood- liquid tissue  Classified as connective tissue  Varies in color according to oxygen content Blood Constituents Plasma – 55% Serum- plasma minus clotting factors Plasma proteins ✓ Fibrinogen- ✓ aids in blood clotting ✓ Albumin ✓ Creates an osmotic pressure that draws water from the tissues into the blood ✓ Globulins ✓ Main component of antibodies Formed elements - 45% (RBCs, WBCs, platelets) Blood Cell Formation  Hematopoiesis- process by which blood cells are formed  Continuously produced in red bone marrow of iliac crest, sternum, ribs and ends of long bones  Stem cells in red bone marrow continuously divide, giving rise to cells that become the formed elements  Stem cells are immature, undifferentiated cells that are capable of maturing into any one of several types of blood cells (WBC, RBC, platelets) Erythrocytes (RBCs) Carry oxygen bound to hemoglobin  4.2 to 6.1 million per cubic millimeter of blood Small biconcave, disk-shaped cells without nuclei  Hemoglobin  Carrier of oxygen  Acts as buffer to maintain acid base balance  Heme part needs a molecule of iron  Also need protein, iron, folate, vitamin B12, riboflavin, pyridoxine to form hemoglobin and RBCs  Hemoglobin, combined with oxygen, gives blood its characteristic red color Erythropoiesis  Process of RBC production  Hemolysis  RBCs live about 120 days and are broken down chiefly in liver and spleen, where they are engulfed by large phagocytic cells  2.5 million RBCs are produced every second, and an equal number continuously destroyed by the spleen and liver Erythropoietin  Tissue hypoxia is stimulus for RBC production  Hormone erythropoietin is released by the kidneys in response to hypoxia and stimulates bone marrow to increase RBC production  When tissue oxygenation is normal or high, kidney reduces erythropietin levels, slowing the production of RBCs  Synthetic erythropietin – Epotein alfa-stimulates RBC production Leukocytes (WBCs)  5000 to 10,000 per cubic millimeter of blood  Granulocytes  Formed and mature in red bone marrow  Neutrophils, basophils, eosinophils  Many live only few days, others months or years  Agranulocytes  Produced in lymphoid tissue of red bone marrow and some mature in thymus  Lymphocytes and monocytes  Many live only few days, others months or years WBCs Continued  Neutrophils- (SEGS) 55% to 70%  Increase in response to inflammation or infection  Eosinophils- 1% to 4%  Increase with parasitic infection or allergic reaction  Basophils- 0.5% to 1%  Increase with inflammation or allergic reaction  Lymphocytes- 20% to 40%  T cells and B cells  Monocytes- 2% to 8%  Function as potent phagocytes Thrombocytes (Platelets)  Necessary for blood clotting  150,000 to 400,000 per cubic millimeter  Not cells in themselves but result from fragmentation of certain large cells in red bone marrow, called megakaryocytes  Do not have nuclei and only live about 5 to 9 days  Normally 80 % of platelets circulate and 20% are stored in spleen Hemostasis  Injury occurs to blood vessel, causing constriction  Platelets release platelet factors that aggregate around wound  Prothrombin activator is formed  Thromboplastin converts prothrombin to thrombin  Thrombin converts fibrinogen to fibrin  Fibrin threads trap plasma and blood cells and form clot  Factor XIII stabilizes clot  Plasminogen converts to plasmin  Plasmin breaks clot into fibrin split products and dissolves it Hemostasis  First stage- platelets along with plasma proteins agglutinate at injury site; platelet factors are released and thromboplastin is formed  Second stage- thromoboplastin activates conversion of prothrombin to thrombin in presence of calcium  Third stage- thrombin and fibrinogen form fibrin and with presence of calcium, a fibrin clot forms  Fourth stage- clot breaks into fibrin and split products and is removed, called fibrinolysis Clot Formation  Factor X combines with other factors to form prothrombin activator  Prothrombin activator transforms prothrombin into thrombin  Thrombin transforms fibrinogen into long fibrin strands  Thrombin also activates factor XIII, which draws fibrin strands together into a dense meshwork Clotting factors  Substances that promote clotting; activated in specific sequence  13 Clotting factors  I Fibrinogen VIII Antihemophilic factor  II Prothrombin IX Plasma thromboplastin component (Christmas Factor)  III Tissue X Stuart factor  IV Calcium ions XI Plasma thromboplastin antecedent  V Proaccelerin XII Hageman factor XIII Fibrin stabilizing factor  VII Serum prothrombin conversion accelerator Lymphatic System Lymphatic vessels and lymphoid organs  Take up excess tissue fluid and return it to bloodstream  Absorb fats at intestinal villi and transport them to bloodstream  Help defend the body against disease  Lymph flows from a lymphatic capillary to a lymphatic vessel, to a lymphatic duct, which enters a subclavian vein  Lymphedema- when too much interstitial fluid develops or when something interferes with reabsorption of lymph Spleen  Destroys old and imperfect RBCs  Breaks down Hgb released from destroyed RBCs  Stores platelets  Filters antigens Liver  Main production site for prothrombin and most of blood clotting factors  Proper liver function and bile production are critical to formation of vitamin K in the intestinal tract  Vitamin K is essential for producing blood clotting factors VII, IX, and X and prothrombin  Converts bilirubin which is the end product of hemoglobin breakdown, to bile and stores extra iron Lymph Nodes Small, oval lymphatic organs ranging in diameter from pinhead size up to 1 inch  Filter foreign substances from lymph  Usually occur in groups, can be superficial or deep  Can only palpate superficial nodes, others require x- ray  Lymphatic vessels are located in all portions of body except CNS and offer little resistance to passage of cancer cells Lymph Nodes Cont’d  Assessed by palpating with pads of fingers for enlargement, tenderness and mobility  Normal -small, mobile, smooth and nontender  Abnormal -tender, hard, fixed or enlarged  Lymphadenopathy- enlarged lymph nodes > 1 cm  Infection, autoimmune disorder, metastasis of cancer 0255_Bihilar__sup_mediastinal_lymphadenopathy Changes with Aging  Decrease in red bone marrow and stem cells  Low normal Hgb  Inadequate nutritional iron intake  Serum iron and iron-binding capacity decreases  Decreased bone marrow reserve of granulocytes  Minimal elevation of WBC during infection  Changes in vascular integrity  Easy bruising Changes with Aging  Nail beds may not be reliable to test capillary refill  Pallor may not be reliable indicator of anemia, need lab testing  Yellow-tinged skin may not be reliable indicator of increased serum bilirubin levels, need lab testing  May have thickened or discolored nails. Use another body area such as lip to do capillary refill Assessment of Hematologic System  History of anemia, bleeding disorders, and blood diseases  History of prolonged bleeding after injury, dental extractions, or surgery  History of surgeries  Family history of malignancies, sickle cell disease, hemophilia  Current drug use, including over-the-counter and herbal meds, vitamins, dietary supplements  Chemotherapy agents, radiation, and antiretroviral agents  Alcohol  Chemical exposure Assessment of Hematologic System Cont’d  Inspect skin for pallor or jaundice  Inspect mucous membranes and nail beds for pallor or cyanosis  Assess gums for active bleeding, any lesions or draining areas  Inspect for petechiae, purpura or ecchymoses Assessment of Hematologic System Cont’d  Inspect and palpate all lymph node areas  Assess respiratory effort while client at rest and after physical activity  Assess if fatigues easily  Auscultate heart rate for murmurs, irregular rhythms and abnormal BP  Inspect urine for hematuria  Inspect stool for occult blood Assessment of Hematologic System Cont’d  Examine superficial surfaces of bones, by applying intermittent firm pressure with fingertips  Palpate for enlarged spleen gently and cautiously  Palpate for enlarged liver Terms of Hematologic Dysfunction  Pancytopenia- reduction in RBCs, WBCs and platelets  Dyscrasia- synonym for disease, especially hematologic disease Diagnostics of RBCs  Total RBC count- 4.7 to 6.1, 4.2-4.5 (male and female, respectively) million per cubic mm of blood  Hgb- amount of Hgb in blood  Hct- ratio of RBC volume to whole blood volume  Morphology- shape and appearance of RBCs  Red blood cell indices  MCV- estimates average size of RBC  MCH and MCHC- measure content of Hgb in RBCs  Reticulocyte count- increases in hemolytic anemia and sickle cell disease Dysfunction of RBCs  Erythrocytosis – abnormal increase in RBCs  Causes: polycythemia vera or hypoxic disorders, dehydration  Erythrocytopenia – deficiency in number of RBCS  Causes: blood loss, anemia, overhydration Diagnostics of WBCs  Total WBC count- 5000 to 10,000 per cubic millimeter of blood  WBC differential count- measures percentage of each type of leukocyte Differential adds to 100% Important to know that differential is reported in percentages because an increase in percentage of one type of cell always means a decrease of another type of WBC WBC Differential  WBC with diff is needed to determine the type of infection  During acute bacterial infection, body’s first line of defense is neutrophils  Bands or stabs (immature neutrophils)  Neutrophils or segs or segmented neutrophils (mature neutrophils)  Increased numbers of circulating neutrophils is a common response with infection as the bone marrow responds to an increased need for phagocytes WBC Differential  Along with neutrophilia, a shift to the left is common in acute infection  This means there are more immature neutrophils, also called bands or stabs, in circulation than normal, indicating an appropriate bone marrow response  Mature neutrophils are much more effective in fighting infection WBC Differential  Eosinophils- primary function is to attack antigen- antibody complexes formed in an allergic reaction; elevated with parasitic infections  An increased number of lymphocytes (T cells and B cells) occurs in chronic bacterial and acute viral infections  Monocytes are the second type of WBCs to arrive at an injury so they increase late in acute bacterial infections Comparison of Normal Differential to a “ Shift to Left” Normal differential “Shift to left” Total WBC 5000 Total WBC 15,000 Stabs or Bands 3% Stabs or Bands 10% Segmented Neutrophils 61% Segmented Neutrophils 65% Eosinophils 4% Eosinophils 3% Basophils 1% Basophils 1% Lymphocytes 26% Lymphocytes 17% Monocytes 5% Monocytes 4% Dysfunction of WBCs  Leukocytosis: WBC > 10,000  Causes: infection, inflammation, trauma, stress, corticosteroids, malignancies  Leukopenia: WBCs < 5000  Causes: chemotherapy drugs, failure of bone marrow  Neutropenia: neutrophil count 400,000  Causes: chronic inflammatory diseases, advanced carcinomas Diagnostics of Thrombocytes  aPTT- normally 30 to 40 seconds;  PT- normally 11 to 12.5 seconds; measures time needed to form a clot and factors I, II, V, VII, and X  INR- reports relationship of patient’s PT to a normal control  0.8 to 1.1 Other Diagnostics of Hematologic System  Iron profile- serum ferritin, iron, total iron-binding capacity, folate, vitamin B 12, reticulocyte count  CT, MRI, PET Bone Marrow Aspiration/Biopsy  Preparation:  Signed consent  Prep site  Inform will feel brief, sharp pain or burning sensation when marrow aspirated  Procedure: aspiration-insertion of bone marrow needle and aspiration of small volume of blood and marrow. Biopsy- small skin incision and use of special needle (Jamshidi) and obtain a core of marrow  Post procedure: Pressure dressing and monitor site q 15 minutes for 1 hour Lymph Node Biopsy Preparation: Inform may feel slight pressure sensation  Procedure: biopsy of lymph node Post procedure:  Sterile dressing  Monitor for bleeding and infection  Mild analgesic for discomfort Scarlet fever  Infection caused by Group A streptococcus (GAS)  Clinical manifestations: high fever with vomiting, chills, malaise, enlarged tonsils covered with exudate, strawberry tongue, rash, swollen cervical lymph nodes  Transmission- airborne and direct contact with infected person, droplet spread or contaminated articles or ingestion of contaminated milk or food  Incubation 2-5 days  Diagnosis is made by throat culture that shows GAS Scarlet fever Collaborative Care  Penicillin V or erythromycin if sensitive to PCN  Encourage fluids  Cool mist humidifier  Soft foods, warm liquids, cold foods  Droplet precautions along with standard precautions if hospitalized  Analgesics for sore throat-gargles, lozenges, cool mist Complications  Rheumatic fever, pneumonia, arthritis, glomerulonephritis Cat Scratch Fever  Disease caused by Bartonella henselae  Cats can carry the bacteria in their saliva; in 90% of cases child has had a recent interaction with a cat, usually obtaining a scratch from the cat  Bartonella is transmitted between cats via cat fleas  Incubation period: 7 to 10 days  Clinical manifestations: headache, fatigue, fever, lymphadenopathy  Diagnosis: serum antibodies for antigens to Bartonella Cat Scratch Fever Cont’d Most often self-limiting, resolving in 2-4 months Standard precautions only Antibiotics if ordered Teach parents  that children should avoid rough play with cats  to immediately wash any bites or scratches with soap and running water  that cats should never be allowed to lick open wounds on child  to control fleas on cats Diphtheria Infection caused by Corynebacterium diphtheriae  Clinical manifestations: low-grade fever, hoarseness and sore throat, malaise, pharyngeal lymphadenopathy  Characteristic white/gray pharyngeal membrane– pharynx, uvula, tonsils, soft palate  This pseudomembrane can cause edema in neck and cause airway obstruction-emergency  Most often occurs in children less than 15 years old who are unimmunized; routine infant vaccine can prevent it Diptheria Collaborative Care Transmission- strict droplet precautions along with standard precautions  Complete bed rest  Watch for signs of respiratory distress and obstruction; provide humidification, humidified oxygen and suctioning as needed  Diagnosis: culture from the membrane to check for corynebacterium Diptheria Collaborative Care Medical management  Antitoxin- skin test to rule out sensitivity to horse serum; have epinephrine available  Antibiotics- pcn or erythromycin  Tracheostomy for airway obstruction  Treatment of infected contacts and carriers  Complications-myocarditis,neuritis Pertussis (Whooping Cough) Acute respiratory disorder caused by Bordetella pertussis Incubation period usually 7-10 days  Prodromal stage: upper respiratory infection for 1-2 weeks  Paroxysmal stage: Severe cough with high-pitched “whooping” sound for 1-4 weeks; vomiting Transmission-droplet precautions along with standard precautions Nursing considerations  Bedrest  Suction prn  Observe for signs of airway obstruction  Takes several weeks to months for full recovery Pertussis Collaborative Care  Reduce factors that promote paroxysms- dust, smoke, sudden change in temperature, chilling, activity, excitement  Symptoms of airway obstruction- increased restlessness, apprehension, retractions, cyanosis Hospitalization if infant or dehydrated  Antimicrobial therapy  Increased oxygen and humidity- humidifier or tent  Intubation may be necessary Complications: pneumonia, seizures, encephalopathy, death Tetanus  Acute, often fatal, neurologic disease caused by toxins produced by Clostridium tetani  Rare in US but still common in other countries due to lack of immunization  Spores can enter body through contaminated wound, a burn or by injecting contaminated street drugs  Fatality rate has decreased in US can result in death Tetanus  Clinical manifestations: headache, spasms, crankiness, cramping of jaw (lockjaw), difficulty swallowing, stiff neck, fever, elevated BP, tachycardia  Spasms that progress in a descending fashion beginning at the jaw- to spasms of neck, arms, legs, and stomach  Spasms or contractions in children may be so severe as to cause fractures  Recovery can be long- children may have to spend several weeks in ICU with mechanical ventilation Tetanus Cont’d  Tetanus immunoglobulin  Tetanus vaccine  IV antibiotics: PCN G  Manage pain  Adequate nutrition and hydration  Quiet environment with reduced external stimuli to decrease incidence of spasms  Sedatives and muscle relaxants to reduce pain and prevent seizures Tetanus Cont’d  Complications: breathing problems, fractures, elevated BP, dysrhythmias, clotting in blood vessels of lungs, pnuemonia, and coma  Routine immunization and booster every 10 years  More than 5 yrs and has wound-vaccinate  All wounds should be cleaned thoroughly and use proper antiseptic  If wound is deep and contamination is suspected, the child should be seen by health care professional Mumps  Contagious disease caused by paramyxovirus  Characterized by fever and parotitis (inflammation and swelling of parotid gland)  Other clinical manifestations: malaise, anorexia, headache, abdominal pain  Occurs most often in unimmunized children age 5-19 years  Transmission- direct contact with saliva or droplet spread from infected person; most communicable just before and after swelling begins Mumps  Diagnosis based on history and clinical symptoms and blood tested for presence of mumps immunoglobulin G (IgG) or immunoglobulin M (IgM)  One third of all infected prepubertal boys also develop orchitis- inflammation of a testicle  Isolation- droplet precautions while in hospital  Diet modifications- soft, bland diet; fluids Mumps Collaborative Care  Bedrest until swelling subsides  Analgesics for pain and antipyretics  If orchitis, ice packs to testicles and gentle testicular support (tight-fitting underpants) Immunization against mumps for all children  First MMR by 15 months old  Second MMR between 4-6 years old Complications: sensorineural deafness from auditory neuritis, encephalitis with seizures, sterility in adult males (rare) Poliomyelitis  Infection caused by the highly infectious poliovirus, which is an enterovirus  Virus invades the central nervous system and can cause total paralysis  Most commonly occurs in young children – often called infantile paralysis. Rare in US but still seen in developing countries  Incubation- usually 7-14 days  Clinical manifestations:  Initially fever, fatigue, headache, vomiting, stiff neck, limb pain  Progresses to tremors of extremities and possible paralysis Poliomyelitis Collaborative Care  Transmission- direct contact with persons with active infection; spread via fecal-oral and pharyngeal routes; period of communicability not exactly known  No specific treatment  Tracheostomy tray at bedside  Complete bed rest during acute phase  May require mechanical ventilation  Physical therapy for muscles  No cure but can be prevented with polio vaccine Complications: permanent paralysis, respiratory arrest, HTN Chickenpox Varicella-zoster virus  Prodromal: slight fever, malaise, anorexia, headache and mild abdominal pain  Lesions appear first on scalp, face, and trunk; pruritic macules that become papules, then vesicles; vesicles erupts and then lesions scab and crust Transmission- spread by direct contact, droplet, contaminated object Incubation period- 14-16 days Chickenpox  Isolation – airborne and contact for a minimum of 5 days after onset of rash and as long as vesicular lesions are present--until all vesicles are crusted; communicable from 1 – 2 days before rash and ends 6 days after the onset of the lesions, when crusts have formed  Children may return to school or childcare once lesions have crusted  Avoid use of aspirin due to Reye’s syndrome; use acetaminophen. Chickenpox  Topical application of calamine lotion or baking soda baths  Keep child’s fingernails cut short  Teach child to apply pressure to pruritic area instead of scratching-can scar  Keep child cool Chickenpox Collaborative Care  Most often is self limiting  Antiviral agent- acyclovir and Immune globulin in high risk children, pregnant women, newborns exposed to maternal varicella.  Antihistamines for itching  Complications- abscesses, cellulitis, pneumonia, thrombocytopenia, arthritis, hepatitis, encephalitis, meningitis, glomerulonephritis  Varicella zoster causes a lifelong latent infection, reactivation results in herpes zoster (shingles) Fifth disease (Erythema Infectiosum) Agent: Human parvovirus B19 (HPV)  Rash in three stages: erythema on face; maculopapular red spots on upper and lower extremities; rash subsides but reappears if skin irritated or traumatized; moves peripherally  Incubation period: 4-28 days  Transmission: respiratory secretions and blood, mother to fetus  Isolation not necessary  Antipyretics, analgesics, antiiflammatory drugs  Complications: arthritis that may become chronic, fetal death if mother infected during pregnancy Roseola (Exanthem Subitum) Agent: Human herpesvirus type 6  Persistent high fever for 3-4 days in child who appears well  Rose-pink macules on trunk first that blanch, then neck, face, and extremities; lymphadenopathy to the neck and behind ears, inflamed pharynx, cough, coryza  Transmission and communicability unknown; standard precautions  Incubation – 5-15 days Nursing considerations  Teach parents measures to lower temperature Complications: may be responsible for recurrent febrile seizures, encephalitis, meningitis Measles (Rubeola) Measles virus  Prodromal: fever, cough, coryza, conjunctivitis  Followed by Koplik’s spots on buccal mucosa  Incubation period- 10-20 days.  Erythematous maculopapular rash, begins on face and spreads downward; turns brown after 3 days when symptoms subside  Transmission- direct contact with droplets of infected person; communicable from 3 days before and 5 days after rash appears  Complications: otitis media, pneumonia, bronchiolitis, croup, diarrhea, encephalitis Measles (Rubeola)  Vitamin A supplements  Antibiotics to prevent secondary bacterial infection in high risk child  Isolation until 5th day; airborne precautions if in hospital  Bedrest during prodromal and febrile period- first 3-4 days  Antipyretics, avoid chilling; seizure precautions if child prone to seizures Measles (Rubeola)  Dim lights- if photophobia present; clean eyelids with warm saline solution to remove crusts; keep child from rubbing eyes; check cornea for signs of ulceration  Humidifier for room for coryza/cough – acute inflammation of nasal mucosa with profuse nasal discharge  Fluids and soft bland diet  Keep skin clean and maintain hydration; use tepid baths prn Rubella (German Measles) Rubella virus  Prodromal: none in children, low fever and sore throat, headache, malaise, coryza, cough, lymphadenopathy in adolescent or adult  Maculopapular rash Transmission: droplet spread and contaminated articles; mother to fetus Incubation – 14 to 21 days  Contact precautions in addition to standard precautions. Isolate child from potentially pregnant women Rubella (German Measles)  Comfort- antipyretics and analgesics  Medical management: nonspecific  Complications: rare for arthritis or encephalitis  Maternal rubella during pregnancy can result in miscarriage, fetal death, or congenital deformities Rubella