Assessment of Hematologic System(2)

Subjective Data

Past Health History

• prior hematologic problems, hereditary disease, liver, spleen diseases

Medications

• herbal therapies, anti-neoplastic agents, HIV meds, anti-coagulant therapy

Surgery or other treatments

• Splenectomy, surgical excision of duodenum, gastrectomy, bleeding problems

Functional Health Patterns

Health Perception-Health Management Pattern

• Genetic issue
• Alcohol history
• Hemetemesis

Nutritional-Metabolic Pattern

• Dietary history
• Any changes in skin’s texture or color
• Lumps or swelling in neck, armpits, or groin

Elimination Pattern

• Black, tarry stool, hemooccult test

Activity-Exercise Pattern

• Feeling of tiredness
• Malaise, dyspnea, palpitations
• Any changes in ability to perform ADL

Cognitive-Perceptual Pattern

• Arthralgia (joint pain), hemarthrosis, paresthesia, numbness, tingling

Lymph node assessment

• Superficial lymph node; eval with light palpation
• Assess systematically (location, size, degree of fixation, tenderness, texture)
• Normal finding
  • not palpable in adults
  • If palpable, it should be small (0.5-1cm), mobile, firm, non-tender
• Abnormal; tender, hard, fixed, enlarged
• Start from head to axillary nodes, epitrochlear node, inguinal lymph node

Objective Data

Palpation of liver or spleen

Skin assessment

• Should be examined over entire body in a systemic manner
• Pale
• Cyanosis
• Purple, mottled appearance
• Clubbing of fingers
• Petechiae or ecchymoses
• Infectious skin lesions
• Skin mucosal bleeding v.s spontaneous bleeding

Diagnostics

Laboratory Studies

• CBC; Complete Blood Count 전혈구검사
• Peripheral smear; morphology (shape & appearance) of blood cells
• Pancytopenia 범혈구 감소증; Marked ↓ in # of RBC, WBC, & platelet
• Red blood cells
  • Total RBC count
    • Normal; M; 4.3-5.7/ F; 3.8-5.1

Red Blood Cells

Hemoglobin; Hb

• measurement of gas-carrying capacity of RBC
• Normal; M; 13.2-17.3 g/dL/ F; 11.7-16.0 g/dL
• Reduced; Anemia, hemorrhage, hemodilution 체액량과다
• Increased; polycythemia 다혈구증, hemoconcentration 체액량고갈, dehydration

Hematocrit; Hct

• % of RBC compared with total blood volume
• Reduction or elevation can be seen in the same condition that ↑ or ↓Hb
• Normal; M; 39-50%/ F; 35-47%

RBC indices 적혈구지수

MCV (mean corpuscular volume)

• hct*10/ (RBC *106)
• Determination of relative size of RBC
• Normal; 80-100 fL
• Low; microcytosis vs high; macrocytosis

MCH (mean corpuscular Hb)

• hb*10/ (RBC *10⁶)
• Measurement of average wt of hb/RBC
• Low; microcytosis or hypochromia vs high; macrocytosis
• Normal; 27-34 pg

White Blood Cells

Total count of WBC; normal (4000-11000)

• High; infection, inflammation, tissue injury
• Low; bone marrow depression, leukemia
• Leukopenia; WBC count less than 4000

WBC differential count

• Measures % of each type of leukocyte
• More granulocyte with infection; bands released “shift to the left”
• ANC; absolute neutrophil count; by multiplying total WBC count by % of neutrophils
• Neutropenia 호중구감소증; ANC less than 1000; a/w leukemia, bone marrow depression, high risk of infection

Platelet Count

• Normal 150,000-400,000

Thrombocytopenia 혈소판감소증

• less than 150,000
• Bleeding can occur with above

Thrombocytosis 혈소판증가증

• excessive platelet
• occurs with inflammation, malignant disorders
• can cause excessive clotting

Iron Metabolism

Clotting Studies

1. Activated partial thromboplastin time (aPTT); assess intrinsic coagulation status; normal (25-35sec)
2. D-dimer; measure a fragment of fibrin; used in diagnosis of hypercoagulable conditions; normal (<250ng/mL)
3. Fibrin degradation products (FDP); reflection of degree of fibrinolysis
4. Prothrombin time (PT); extrinsic coagulation by measurement of factors 1, 2, 5, 7, 10; normal (11-16sec)
5. Thrombin time; reflection of adequacy of thrombin; prolonged thrombin time -> inadequate coagulation 2^nd to ↓ thrombin activity
6. International normalized ratio (INR) ; standardized system of reporting PT; normal (0.8-1.2)

Biopsies

Bone marrow exam

1. Full eval of hematopoiesis
2. Obtain specimens for cytology
3. Preferred site; posterior iliac crest 장골능후부> anterior iliac crest 전장골능, sternum 흉골
4. Sedation, pain meds
5. Complications; possibility of damaging underlying structure, hemorrhage, infection
6. Monitor V/S
7. Apply pressure dressing after procedure
8. Assess biopsy site for bleeding
9. Soreness over puncture site; 3-4 days

Lymph node biopsy

Other tests

• Molecular Cytogenetics & Gene Analysis
  • Done on samples from bone marrow & lymph node biopsy
  • Example
    • Fluorescent in situ hybridization (FISH) 형광원위치혼성화법; abnormal extra chromosome
    • Spectral karayotyping (SKY) ; chromosomal translocation of 22 to 9
• Radiologic studies; CT or MRI
  • For evaluating spleen, liver, lymph node