Summary Nurs 330 - Exam 2 study guide

Notes for Exam 2:
Ch. 19, 39, 40; 27, 28, 30; 49, 50, 51; 61,62, 63
(1) Hematological disorders
(2) HIV
(3) Pulmonary disorders
(4) MS disorders
(5) Endocrine disorders

(1) Hematologic system anatomy and physiology:
- Peripheral and central tissue perfusion and gas exchange rely on this system
- Clotting in appropriate areas of tissue injury prevent excessive bleeding and maintains
perfusion (whole-body)
- BONE MARROW AND BLOOD CELLS:
o Produce RBCs, erythrocytes, WBCs, leukocytes, platelets; also involved in
immune response
o Cell-producing bone marrow presents only in flat bones and the end of long
bones- adults; decrease in blood cell producing marrow with aging
o Stages of cell production (hematopoiesis):
 Bone marrow produces BLOOD STEM CELLS
 COMMITTED STEM CELLS enter single growth pathway and begins
differentiation
 Use specific growth factors to continue growth and multiplying
- RBC- oxygen carrying capacity HBG
o Erythropoietin= RBC growth factor; produced in the kidneys; synthetic
erythropoietin agents; lack of iron, B12, folic acid, copper, pyridoxine, cobalt,
nickel= anemia
o Healthy, mature RBC can live 120 days
o Iron= essential part of RBC for hemoglobin
o Increase in tissue need for O2= trigger RBC production
- WBC- infection and immunity
- Platelet- clot formation
o Controlled by growth factor thrombopoietin
o Stored in spleen (80% stored and 20% circulating)
- Plasma- extracellular fluid high in proteins specifically albumin, globulin, and fibrinogen
o Albumin increases osmotic pressure keeps from leaking into tissues.
o Globulin- antibody
o Fibrinogen- inactive protein activated by fibrin
- Hemostasis= multi-stepped process of controlled BLOOD CLOTTING:
o Balance blood clotting actions w/ anti-blood clotting actions
o 1- PLATELET AGGREGATION- platelet come together to form a platelet plug
when activated; NOT CLOTS and only last a few hours; too few circulating
platelets impairs clotting
o 2- BLOOD CLOTTING CASCADE- intrinsic/extrinsic factors= formation of a
fibrin clot (depends on presence of clotting factors, calcium, additional platelets);
end of activation cascade (activation of FIBRIN) is when clotting begins

,  Clotting factors= inactivated enzymes that become activated during this
step “chain reaction”
 Last steps= thrombin-prothrombin and fibrinogen-fibrin
o 3- FORMATION OF COMPLETE FIBRIN CLOT- active fibrin links together to
form fibrin threads= meshlike base; clotting factors secure base; more blood cells
and proteins attract to the base= BLOOD CLOT
o Purpose of anti-clotting factors is to limit clot formation to damaged areas only
- Reticuloendothelial system= part of the immune system; phagocytic cells located in
reticular CT; involved in blood cell formation, destruction, storage of fatty materials, etc;
e.g. reticuloendothelial cells located in the spleen dispose of disintegrated erythrocytes
Hematologic patient assessment:
- Assess possible nutritional deficiencies
- Physical assessment:
o Skin:
 Pallor
 Jaundice
 Assess nail beds for pallor cyanosis
 Pallor of gums, conjunctivae
 Gums for active bleeding
 Petechiae
 Ecchymoses
 Dry skin= poor perfusion
 Body hair pattern
o Head and neck:
 Oral mucosa
 Tongue (smooth?)
 Fissures corner of mouth
 Lymph nodes
o Resp:
 Rate/depth at rest and activity
 Any SOB?
o CV:
 Weak and thread pulses
 Distended neck veins
 Edema
 Phlebitis
 BP tends to be lower with anemia and higher with excessive RBC
o Urinary/kids:
 Hematuria
 Proteins in urine
o MS:
 Tenderness over areas of bone
 Assess ROM
 Joint swelling/pain
o ABD:
 Enlarged spleen and liver may occur with hematological problems

,  GI bleeds
o CNS:
 Risk for brain bleeds
- Diagnostic:
o Blood labs:
 CBC= # of RBC, WBC, hematocrit, hemoglobin present in 1 L of blood
 WBC count with differential leukocytes
 MCV= average volume or size of individual RBC (classifying anemias)
 MCH/MCHC= weight/amt of hemoglobin
 Reticulocyte count (normal is 2% of circulating RBCs= immature)
 Platelet count
o Labs that measure bleeding and coagulation:
 PT= how long it takes blood to clot (levels and fxning of some clotting
factors) 11-12.5 seconds; PT may be prolonged when factors are deficient
 INR= normal mean or standard for PT; 0.8-1.1; pts on warfarin therapy
should maintain INR between 2-3
 PTT= assess intrinsic factors; deficiency in certain clotting factors
prolongs time; 1.5-2 x normal values
 D-dimer= protein fragment that is produced when blood clot is dissolved;
+ results may indicate significant clot formation and break down in body
 Fibrin degradation products (FDP)= d-dimer (post thrombotic event)
o Bone marrow- aspiration and biopsy; reflects the degree and quality of BONE
MARROW ACTIVITY PRESENT
 Local anesthetic
 Heavy sensation when needle is inserted w/ possible “crunching sound”
 Brief sensation of pain during aspiration
 PREVENT BLEEDING POST OP- cover sit and closely assess 24 hrs;
ASA free analgesic
Hematological conditions + nursing care:
- Hematological problems- interfere with production, fxn, maintenance of blood cells=
alterations in perfusion, clotting, gas exchange
- Types of anemias:
o Sickle cell disease/anemia: ALTERATIONS IN TISSUE PERFUSION; increased
clotting, decreased O2, etc
 Abnormal hemoglobin chains (40%+ of HbS) = sickle shaped = sticky and
fragile RBCs
 Sickled RBCs clump= vaso-occlusive event (blocking blood flow)- leads
to tissue hypoxia= ischemia in affected tissue
 Repeated VOEs and prolonged impaired perfusion in large
vessels= long-term damage in tissue and organs; eventually result
in organ failure
 Hemolytic= blood cell destroying
 Inheritance= autosomal-recessive pattern of inheritance (mutation
chromosome 11)- HbS+HbS= affected; most common among African
American in US
 Average life expectancy= 40 years