Lecture Outlines | Course Schedule | Main Menu | Resources

RBCs / Hemoglobin / Hematocrit / Indices / Reticulocytes / Iron Studies
Folate / Vitamin B12 / Hemolytic panel / Peripheral Blood Smear
Treatment of anemia / Transfusions / Treatment of polycythemia

Objectives: 

1. Identify the critical values for hemoglobin and hematocrit.
2. Define anemia, polycythemia, microcytic, normocytic, macrocytic, hypochromic, and normochromic.
3. Use the rule of 3's to determine values of hemoglobin and hematocrit if given RBC value.
4. Describe the relationship between fluid status and hematocrit.
5. Determine the probable cause of anemia using RBC indices.
6. Discuss the usefulness of the reticulocyte count in determining the type of anemia.
7. Identify lab values that support anemia diagnosis - iron studies, folate, cyanocobalamine, glucose-6-phosphate dehydrogenase, haptoglobin.
8. Describe the clinical symptoms of a patient with anemia.
9. List persons most at risk for different types of anemias.
10. Plan nursing care for a patient with anemia. 
11. List major points to teach a patient with anemia and the family.
12. Plan a diet for a patient with iron deficiency, folate-deficiency and cyanocobalamine deficiency anemias.
13. Teach a patient how long it will take to correct anemia depending upon method of treatment.
14. Discuss with patient how to manage symptoms associated with chronic anemia.
15. List major factors to consider before a blood transfusion.
16. Describe the symptoms of a person with polycythemia.
17. Plan nursing care for a patient with polycythemia. 

Hematology

This site is a good review of all of the blood cells and lab tests:
http://www.neosoft.com/~uthman/blood_cells.html

What do you need to make good Blood Cells?

Hematological Studies

nRBC’s

uHct, Hbg
uIndicies
uReticulocyte count
uPeripheral smear

nWBC’s with differential
nPlatelets

Critical Values

nHgb < 6 or > 22
n Hct < 18% or > 54%

Functions of Blood    

n Delivery
n Removal of waste products
n Prevents blood loss
n Primary carrier of immunity

RBC’s

nMeasurement of oxygenation status

nEach gram of Hgb can carry 1.34 gram O₂

RBC Analysis

Erythrocytes

nFunction

uTransport oxygen & carbon dioxide
uAcid-base balance

n Lifespan 120 days

 RBCs removed by spleen

Increased removal

n Enlarged spleen
n Artificial heart valves
n Abnormal RBCs

Elevated RBCs (polycythemia)

n Heart disease
n COPD
n Polycythemia vera
n Severe dehydration (burns, diarrhea)
n Hemoglobinopathies

Decreased RBCs (anemia)

n Hemoglobinopathy
n Cirrhosis
n Hemolytic anemia
n Hemorrhage
n Dietary deficiency
n Cancers 
n Bone marrow failure
n Prosthetic valves
n Renal disease
n Normal pregnancy
n Rheumatoid or collagen-vascular diseases

Drug effects on RBCs

nDrugs that increase RBC’s

ugentamycin  
umethyldopa

n Drugs that decrease RBCs

u chlormaphenicol 
u hydantoins
u quinidine

 Hemoglobin   

n % saturation tells amount of Hgb carrying full amount of oxygen
n % saturation usually > 90
n Low Hgb with 100% saturation can still be hypoxic

Types of Hemoglobin

n Hbg A           normal
n Hbg F            fetal
n Hbg S            sickle cell
n Hgb C           found in African Americans
n Hgb H           Alpha Thalessemia

n Sickle cell disease (homozygous SS) - Hgb S 80-100%
n Sickle cell trait (heterozygous SA) - Hgb S 20-40%; Hgb A 60-80%
n Hemoglobin C disease - Hgb C 90-100%
n Hemoglobin H disease - Hgb A 65-95%; Hgb H 5-30%
n Thalessemia major (homozygous) - Hgb A 0-35%; Hgb F 65-100%
n Thalessemia minor (heterozygous) - Hgb A 60-95%; Hgb F 5-35%

Drugs that decrease Hgb

n Antibiotics
n Antineoplastics
n Aspirin
n Indomethacin
n Rifampin
n Sulfonamides

Transfusions

n Usually transfuse if Hgb < 8 g/dl
n Renal patients – wait until < 6
n Elderly – may transfuse at 10

 Hematocrit

n Varies with age and gender
n Critical values < 15% or > 60%

Interfering factors

n Abnormal RBC size
n Elevated WBCs
n Dehydration or fluid overload
n High altitudes

Rule of 3’s     

n Hemoglobin is 3 X’s RBC
n Hematocrit  is 3X’s hemoglobin

Drugs that decrease Hct

n Chloramphenicol
n Penicillin

Dehydration and Hgb

n Values of Hct & Hgb are inaccurate during active bleeding
n Will not know actual levels until patient is rehydrated

RBC Indicies

nCharacteristics of RBCs

n Mean Corpuscular volume (MCV)
n Mean Corpuscular Hemoglobin (MCH)
n Mean Corpuscular Hemoglobin Concentration (MCHC)
n Red blood cell distribution width (RDW)

Mean Corpuscular Volume

n Average volume or size
n MCV = Hematocrit (%) x 10 
                  RBC (million/mm³)
n Increased size   = macrocytic
n Decreased size = microcytic

Mean Corpuscular Hemoglobin  - Color

Normal     26-34 pg
< 26          Hypochromic
26-34        Normochromic
> 34          Not called hyperchromic

Mean Corpuscular Hemoglobin Concentration

Normal is 32-36%
  <32            Hypochromic
  32-36         Normochromic
  >36            Not  called   hyperchromic

Use of RBC indices

n Determine type of anemia
n Study table 2-2 on page 37

Macrocytic, hypochromic

• Folate deficiency

• Vitamin B12 deficiency

• Chemotherapy

• Hydantoin ingestion

Microcytic, hypochromic

• Chronic blood loss

• Iron deficiency (late)

• Thalessemia

• Lead poisoning

Microcytic, normochromic

• Renal disease

Normocytic, normochromic

• Acute blood loss

• Chronic illness

• Aplastic anemia

• Acquired hemolytic anemia

Reticulocyte count

n Immature RBC – still has nucleus
n Value varies with age
n Increased in accelerated erythropoiesis
n Decreased in marrow suppression
n Expect increased retics when treating anemias

Reticulocyte level and RBC indices provides more information on the type of anemia

Reticulocytosis, normal MCV

n Hemolytic

u sickle cell, autoimmune diseases, some infections, DIC, hypersplenism, valve problems, vasculitis, ITP

n Acute blood loss
n Glucose-6-phosphate dehydrogenase (G6PD) deficiency
n Partial or early treatment of deficiency anemias 
n Recovery from anemia

No Reticulocytosis and MCV Normal

n Early iron deficiency anemia
n Chronic illness: RA, renal disease, liver disease, GI disease, DM, hypothyroidisim
n Primary bone marrow failure: Cancer, cancer therapy, drugs
n Sideroblastic anemia

No Reticulocytosis and MCV high

n B12 deficiency
n Folic acid deficiency
n HIV infections

Low to normal reticulocytes, normal MCV

n Early iron deficiency
n Chronic illness
n Bone marrow failure

Low to normal reticulocytes, low MCV

n Late iron deficiency
n Chronic illness

Low to normal reticulocytes, high MCV

n Megaloblastic anemia
n Alcoholism
n Liver disease
n Drugs – antineoplastics,   antiinflammatory

Supporting lab studies

n Folate
n Vitamin B12
n Serum iron levels
n Total iron binding capacity
n Transferrin saturation
n Serum ferritin
n Glucose-6-phosphate dehydrogenase

Use of Other Tests

n If history, demographics, reticuloctye count, and types of cells all in agreement, treatment may be initiated without other tests
n If there is not a clear answer among tests, history, etc., then other tests needed

First tests done depends on demographics and /or cell size

• If  elderly look for occult bleeding

• If renal failure, many tests

• If normocytic or microctyic and appropriate demographics: Iron panel, ESR

• If normocytic and appropriate demographics: ESR, hemolysis panel.

• If macrocytic: B₁₂, folate, TSH

Iron Studies

n Serum Iron     =     65 - 165 ug/dl
n TIBC              =    24.5 - 419 ug/dl
n Saturation       =    20 - 45%
n Ferritin, serum
        u Men       =    10 - 200 ug/dl
        u Women  =     5 - 400 ug/dl       

Iron Studies

n Serum iron levels – diurnal rhythm, draw early in day, no supplements for 24 hours
n Total iron binding capacity (TIBC) – reflects transferrin available to bind more iron
     u Normally 1/3 is free
n Transferrin saturation       serum iron  X 100
                                                  TIBC
n Serum ferritin – major iron storage protein, not reliable with chronic illness  

Low iron, high TIBC, high transferrin = iron deficiency
Low ferritin = iron deficiency anemia

Folate

n Required for synthesis of RBCs, WBCs, purines and pyridamines, amino acids
n Vitamin B12 needed to convert to active form
n Deficiency exists for 5 months prior to megaloblastic anemia
n Normal  = > 3.7 ng/ml

Drugs that decrease folate

n Alcohol
n Aminopterin
n Aminosalicylic acid
n Ampicillin
n Antimalarials
n Chloramphenicol
n Erythromycin

Vitamin B₁₂ (cyanocobalamin)

n Essential for synthesis of nucleic and amino acids
n Intrinsic factor in small intestine is necessary for absorption
n Takes 6-18 mo. deficiency to develop anemia
n Results in large RBCs, giant segmented neutrophils, large nucleated platelets
n   Normal  =  > 200 pg/ml  

Glucose-6-phosphate dehydrogenase (G6PD)

n Enzyme found especially in RBCs that is involved in a glucose degradation pathway alternative to Krebs cycle
n Tests for hereditary disorder that causes hemolytic anemias

n Bone marrow

n Coombs test: direct & indirect

 Peripheral blood smear

n Anisocytosis – variation in size
n Poikilocytosis – variation in shape
n Rouleaux formation – RBC stacks
n Spherocytes – round RBCs
n Basophilic stipplings – dark spots caused by abnormal Hgb synthesis-    uLead poisoning or severe anemia
n Howell-Jolly bodies – remnants of nuclear material - splenectomy; hemolytic anemia; megloblastic anemia; target cells – bell shaped, thinner, more fragile, less Hgb
n Schistocytes – fragments
n Sickle cells – crescent shaped

 Clinical picture in anemia

n Fatigue
n Pallor
n Dyspnea on exertion

Tips on care in anemia

n Deal with signs/symptoms
n With iron replacement
     u Reticulocytes increase in 4 - 7 weeks
     u Hct/Hgb increase in 6 weeks
n Acute blood loss
     u Reticulocyte count increases in 48 hours
     u Peaks in 4 - 7 days
     u Normal in 30 days
n Epogen replacement
     u Goal Hct 30 - 35%
     u Iron stores adequate
     u Androgens enhance response
     u Response in 2 - 6 weeks
n B12 replacement
     u Reticulocytes increase in 4 - 7 days
n Blood transfusions
      u Response: Packed cells increase Hgb 1-3 Gm
                             Packed cells increase Hct 3 - 9 %

n Anemias that are not corrected rapidly
     u Some anemias are chronic
     u Help person live with it
     u Help others understand it

Treatment

n Determined by cause
     u Dietary supplements
     u Transfusions

Transfusions

n Persons who cannot donate

• Current serious illness

• Pregnancy

• Anemia

• History of malaria or cancer

• Heart disease

• HIV

Typing and Crossmatching

nAntigens present on cell membranes

• Type A blood has A antigens

• Type B blood has B antigens

• Type O blood has no antigens

• Type AB blood has both antigens

nAntibodies present in plasma

• Type A blood has Anti-B

• Type B blood has Anti-A

• Type AB blood has neither

• Type O blood has both

Blood compatibility

Rh factor

n Antigen present on RBC

• Rh+ antigen present

• Rh – antigen absent

• Rh+ can receive negative blood

n Hepatitis tests
n Syphilis
n HIV
n Cytomeglovirus (CMV)
n Epstein-Barr virus

 Nursing considerations

n Allow rest periods between activities
n Teach proper nutrition if it is a nutritional deficit
n Blood transfusions

• Donor number

• ABO compatibility

• Rh compatibility

• Watch for reactions

 POLYCYTHEMIA

Types

• Primary – polycythemia vera – overactive bone marrow

• Secondary – due to chronic hypoxemia
      COPD
      CHF, congenital heart disease
   High altitudes

Clinical picture

n Ruddy complexion
n Prone to thrombi secondary to increased viscosity

Nursing considerations

n Encourage fluid intake
n Prevent dehydration (NPO)
n Encourage activity

Treatment

n Phlebotomy
n Antiplatelet agents
n Antineoplastic agents – last resort

Lecture Outlines | Course Schedule | Main Menu | Resources