HEMATOLOGY

Serum
➢ plasma minus fibrinogen
Albumin
➢ Provides osmotic pressure (low albumin > edema)
➢ Binds hormones, drugs…
Y-globulin
➢ Antibodies

BLOOD CELLS
Erythrocytosis
➢ Lack of oxygen: high altitude, COPD
Leukocytosis
➢ Infections
➢ Leukemia
Neutrophils
➢ Infection, acute stress
Hemoglobin
➢ Oxygen carrying protein in red blood cells
➢ Male adult 14 – 16g/dl
➢ Female adult 12 – 15g/dl
Eosinophils
➢ Allergies, parasites
Lymphocytes
➢ Viral infections, TBC
Leukopenia
➢ Radiation
➢ Bone marrow suppression
Thrombocytopenia
➢ DIC
➢ Bone marrow suppression
 Note: hemorrhage may be false low if blood is obtained with capillary finger stick
(“milking”)

Direct Coomb’s test

➢ Test for antibodies on patient’s erythrocytes
Positive if:
1. Hemolytic transfusion reaction (mismatch)
2. Autoimmune hemolytic anemia
3. Erythroblastosis fetalis

Indirect Coomb’s test

➢ Test for antibodies in patient’s sacrum
Positive if:
1. Sensitation from previous transfusion
2. Rh sensitation from previous pregnancy
3. Maternal antibodies bind to fetal RBCs > hemolysis

ANEMIAS

Acute blood loss

➢ Hematocrit remains normal in acute phase

Chronic blood loss

➢ May lead to iron deficiency

Iron deficiency
➢ Search for occult bleeding, especially in elderly

Vit. B12 or folate deficiency

➢ Required for RBC maturation in bone marrow

Alcoholics
➢ B12 and folate deficiency common

Pregnancy
➢ Folate deficiency common (supplementation)

Pernicious anemia
➢ Chronic gastritis type A (autoimmune disease)
➢ Antibodies against intrisic factor from stomach
➢ >reduced vit. B12 absorption in small bowels

Sickle cell anemia

➢ Abnormal hemoglobin (electrophoresis)
➢ “sickle cells” seen on blood smear
➢ Painful crises, leg ulcers

Thalassemias
➢ Abnormal hemoglobin (electrophoresis)
➢ “target crises” on smear
Hemolysis
➢ Antibodies against RBCs
➢ Fragile RBCs
➢ Blood hemolysis > increased serum bilirubin

Assessment
1. Fatigue
2. Pale skin and mucosa

All Anemias
✔ Check CBC, blood smear, hematocrit, hemoglobin and iron

Aplastic Anemia
✔ Low reticulocyte count indicates decreased prodution of RBCs

Thalassemia Sickle Cell Anemia

✔ Hemoglobin electrophoresis shows abnormal hemoglobin

Pernicious Anemia
✔ Schilling test: to evaluate vitamin B12 absorption
 Implementation
1. Provide rest periods to avoid fatigue
2. Assist with blood trasfusions
3. Monitor for transfusion reactions: pruritus, chills fever, shock

Transfusion Risk
ABO incompatibility – 1:33,000
Febrile reaction – 1:200
HIV – 1:500,00
Hepatitis B or C – 1:60,000

!!!Note: most fatal transfusion reactions are due to a mismatch caused by

clerical error

TRANSFUSION REACTIONS

Patients with this blood type: have these serum antibodies

 O >> A and B
 A >> B
 B >> A
 AB >> none
 Rh negative>> may or may not have Rh bodies (only if previous contact with Rh +
blood)

ASSESSMENT

Hemolytic Reaction (10-20 minutes):

1. Chills, headache
2. Lower back pain
3. Flushing, “head feels full”
4. Signs of shock
5. Acute renal failure (oliguria

Febrile Reaction(30 minutes):

Allergic Reaction
1. Chills, headache
2. Elevated temperature
3. Pruritus
4. Hives, wheezes
5. Anaphylaxis

IMPLEMENTATION

Hemolytic or Febrile Reaction

1. Immediately stop transfusion
2. Keep IV access – replace transfusion with normal saline
3. Call physician

Allergic Reaction
1. If hives are the only sign: proceed at slower rate (check institutional guidelines)
2. Prepare epinephine if signs of anaphylaxis occur
 ACUTE LEUKEMIA

ALL (3-7 years) – prognosis is fair

1. Fatigue, weakness, anorexia
2. Fever
3. Petechiae –size of pinheads
4. Ecchymoses –large bruise area
5. AML (all ages) – prognosis is poor
6. Fatigue, weakness, anorexia
7. Fever
8. Petechiae
9. Ecchymoses
10. Lymphadenopathy, splenomegaly
11. Auer rods in myeloblast

Implementation
1. Monitor vital signs
2. Watch for bleeding
3. Watch for signs of infection
4. Minimize side effects of chemotheraphy

CHRONIC LEUKEMIA

CML (50 years) – prognosis is poor

1. Fatigue, weakness, anorexia 3. Night sweats
2. Fever 4. Splenomegaly

CLL (70 years) – prognosis is fair

1. Insidious onset 3. Low lg levels
2. Few symptoms 4. Infectiions

MULTIPLE MYELOMA
Neoplasm of plasma cells – infiltrates bones, skull and vertebrae
Assessment
1. Fatigue 5. Elevated ESR
2. Back pain 6. “punched out” lesion on x-ray
3. Anemia
4. Thrombocytopenia

Laboratory
1. Blood protein electrophoresis shows “spike” proteins
2. Presence of “Bence Jones” CHON in the urine

Medications
1. Antibiotics
2. analgesic
3. chemotheraphy

Note: abnormal immunoglobulins are produced by neoplastic plasma cells.

These protein can be filtered into the urine (Bence Jones proteins) and severely
damage the kidneys!
LYMPHOMA – Neoplasm of lymph nodes

HODGKIN’S DISEASE
➢ No leukemic component
➢ Spreads from lymph node to lymph node

NON-HODGKIN LYMPHOMAS
➢ Often have leukemic component
➢ Common in AIDS patients

Assessment
1. Weakness, fatigue
2. Loss of appetite
3. Fever, night sweats
4. Painless enlargement of lymph nodes
5. Enlarged liver and spleen
6. Diagnosis: lymph node biopsy

Implementation
1. Monitor for signs of infection
2. Provide comfort measures for fever and night sweats

Chemotherapy
➔ For generalized disease
➔ MOPP or some other schedule
Radiotherapy
➔ For localized disease
➔ Skin care: water, mild soaps. Avoid rubbing.

BLEEDING DISORDERS

Platelet defect
➢ Bleeding into skin and mucous membranes
➢ Males and females

Coagulation defect
➢ Bleeding into joints, muscle, viscera
➢ Mainly males

Vascular defect
➢ Purpura- bleeding into the skin
➢ Gastrointestinal bleeding
➢ Mainly females

THROMBOCYTOPENIA

Platelets < 100,000/uL increased bleeding risk

Platelets < 20,000/uL spontaneous bleeding
Platelets < 10,000/uL CNS bleeding
 MUSCULOSKELETAL

ARTHRITIS

RHEUMATOID ARTHRITIS
➢ Autoimmune disease

Assessment
1. Morning stiffness
2. Swelling of 3 or more joints
3. Involves: wrist, MCP and PIP
4. Subcutaneous nodules
5. Rheumatoid factor in serum

Characteristics hand deformity:

1. Ulnar deviation of digits
2. “swan neck” deformity
3. X-ray:
4. Joint erosions
5. Periarticular bone erosion

OSTEOARTHRITIS
➢ Degenerative disease

Assessment
1. Progressive pain
2. Relieved by rest
3. Involves weight bearing joints, hip joint, knee joint
4. Loss of cartilage
5. Narrowed joint space
6. Subchondral cysts and sclerosis
7. New bone formation (marginal osteophytes)

Implementation
1. Range of motion exercises
2. Exercises to maintain muscle strength (but minimize weight – bearing
activities)
3. Encourage weight loss to reduce stress on joints
4. Warm tub baths to relief stiffness
Note: proper use of cane: hold in hand opposite of “bad” leg.

GOUT
➢ Deposits of urate crystal in synovial tissue > acute inflammation

Note: 90% of cases are due to under-excretion of uric acid

10% of cases are due to over-production of uric acid

Implementation
1. Bed rest during acute attack
2. Use cradle to keep bedcovers elevated
3. Encourage fluid intake (3L/day)
4. Hot packs (reduce muscles spasm and pain)
5. Cold packs (reduce swelling and pain)
 Medications
1. Asymptomatic hyperuricemia: no medication necessary
2. Mild attacks: analgesics (acetaminophen)
3. Severe attacks: colchicine, NSAIDs
4. Allupurinol: reduces uric acid production
5. Probenecid: increases renal uric acid excretion

Client Education
1. Encourage weight loss but avoid crash diets
2. Avoid alcohol
3. Limit food high in purines (anchovies, shellfish, organ meats)

SYSTEMIC LUPUS ERYTHEMATOSUS

➢ Chronic inflammatory disease of connective tissue(autoimmune)

Assessment
1. Weakness, fatigue
2. Anorexia, weight loss
3. Photosensitivity
4. Butterfly rash (spare nasolabial fold)
5. Discoid rash
6. Anemia
7. Arthritis
8. Nephrotic syndrome

Laboratory
1. Leukopenia
2. Thrombocytopenia
3. Antinuclear antibodies
4. False positive test for syphilis

Implementation
1. Emotional support
2. Protective clothing and sun screen if clients is photosensitive
3. Heat packs for joint pain
4. Monitor for signs of renal damage: edema, hypertention

Medications
1. Steroids (topical for skin, systemic if organ involvement)

LEG AMPUTATION

Assessment
1. Peripheral vascular disease > claudication
2. (pain when walking, rapid relief when resting)
3. Cyanosis
4. Ulcer formation
5. Gangrene: foul smell, blackened wound
 Implementation
1. Watch for signs of infection and sepsis

Postoperative
1. Bandages should be applied in a diagonal figure 8 pattern
2. Elevate stump for first 12 hours
3. Monitor wound drainage (keep tourniquet at bedside for emergencies)
4. Exercise to improve arm strength

Client Education
1. Explain “phantom pain”
2. Encourage frequent repositioning in bed
3. Massage stump to improve vascularity

CRUTCHES & CANES

CRUTCHES
Fitting
✔ Measure from anterior fold of axilla to heel, add 6 inches

There should be 2 inch space between axillary fold and underarm piece to
prevent damage to brachial plexus (clutch paralysis)

Basic stance
✔ Crutches should rest in front and lateral of feet

2-point gait
➔ Advance right crutch and left foot together
➔ Advance left crutch and right foot together

3-point gait (used if only one leg is injured)

➔ Advance both crutches and involved leg forward
➔ Advance healthy foot while keeping body weight on crutches

4-point gait (similar to 2-point gait, but slower and more stable)
➔ Advance right crutch
➔ Advance left foot
➔ Advance left crutch
➔ Advance right foot

CANES

Fitting
✔ highest point should be at level of greater trochanter
✔ Handpiece should allow 30deg. Flexion at elbow

Use
1. Hold cane in hand opposite to injured leg
2. Advance cane and injured leg at same time
3. Don’t lean body over canne
 THE NERVOUS SYSTEM

SIGNS AND SYMPTOMS

Decorticate posture
➢ Legs extended, arms flexed
➢ damage above mid brain

Decerebrate posture
➢ Legs and arms extended, wrist pronation
➢ damage to mid brain

Asterix
➢ “flapping tremor”(wrist joint and fingers”)
➢ liver failure

Ataxia
➢ Reeling, wide gait
➢ cerebellar disease, alcoholism

Athetosis
➢ Slow involuntary snakelike movements
➢ (especially face, necck and upper extremities), damage to basal ganglia

Chorea
➢ Burst of rapid, jerky movements
➢ huntington’s disease (chorea plus intellectual decline), rheumatic fever

Cogwheel rigidity
➢ Jerking of arm muscles when passively stretched
➢ cardinal sign of parkinson’s disease, side effect of antipsychotic drugs
Gower’s sign
➢ Proximal muscle weakness
➢ characteristics way to rise from the floor (duchenne’s muscles atropy)

CENTRAL NERVOUS SYSTEM

FRONTAL LOBE
Major functions
1. Behavioral functions
2. Learned motor functions
3. Language motor center

PARIETAL LOBE
Major functions
1. Integrates sensory information
2. Spatial awareness

TEMPORAL LOBE
Major functions
1. Memory
2. Emotions
 3. Language recognition

OCCIPITAL LOBE
Major functions
1. Visual recognition

BASAL GANGLIA
Major functions
1. Involuntary components of movement

CEREBELLUM
Major functions
1. Balance, “fine tuning” of movement

BRAIN STEM
Major functions
1. Vital centers, (respiration, cardiovascular)

Note: the dominant hemisphere contains the language centers and is usually
the left brain (in right – handed person)

AUTONOMIC NERVOUS SYSTEM

HEART
Sympathetic
1. Increased heart rate
2. Increased conduction
3. Increased force
Parasympathetic
1. Decreased heart rate

GI tract
Sympathetic
➢ Reduced motility

Parasympathetic
➢ Increased motility

RECTUM
Sympathetic
➢ Allows filling

Parasympathetic
➢ Empties rectum
➢ Relaxes internal sphincter

BLADDER
Sympathetic
➢ Allows filling

Parasympathetic
➢ Empties bladder
➢ Relaxes internal sphincter

ERECTION
 Parasympathetic
➢ Maintains erection

EJACULATION
Sympathetic
➢ Triggers ejaculation

PUPILS OF THE EYE

Sympathetic
➢ Big (mydriasis)
Parasympathetic
➢ Small (mydriasis)

SALIVARY GLAND
Parasympathetic
➢ Secretion

BLOOD VESSELS
Sympathetic
 Depends on receptors:
 constricts
 dilates

CRANIAL NERVES

OLFACTORY
Major functions
➢ Smell

OPTIC
Major functions
➢ Vision

OCULOMOTOR, TROCLEAR, ABDUCENT

Major functions
➢ Eye movements

TRIGEMINAL
Major functions
➢ Facial sensation, jaw movements

FACIAL
Major functions
➢ Taste, facial expression

ACOUSTIC
Major function
➢ Hearing & balance

GLOSSOPHARYNGEAL
Major functions
➢ Taste, throat sensation, gag & swallow

VAGUS
Major functions
 ➢ Gag & swallow, parasympathetic activity

ACCESSORY
Major functions
➢ Neck & back muscles

HYPOGLOSSAL
Major functions
➢ Tongue movements