TOPIC 1

REVIEW OF A & P OF THE HEMATOLOGIC & LYMPHATIC SYSTEM

AND ASSESSMENT OF PATIENTS WITH HEMATOLOGICAL
DISORDERS

By Kok Ying Fern

Learning Outcomes
◦ By the end of the topic, you should be able to do the following :
1. Identify the components of blood
2. Describe the sequence of events in the process of blood clotting
3. Explain the data that should be obtained on assessment of patient with
hematological or lymphatic disorder
4. Explain the laboratory and diagnostic studies used in evaluation of the
hematological and lymphatic system
5. Discuss the nursing care for patient undergoing the respective diagnostic tests
 Anatomy & Physiology of
Hematologic
The hematologic system comprises the blood and blood-forming organs, primarily the bone marrow.
The four main components include plasma, red blood cells, white blood cells and platelets.
• Red blood cells (RBCs) carry carbon dioxide and oxygen to the body. Each RBC lives for about 4
months.
• White blood cells (WBCs) are part of the body's immune system. WBCs help fight infections and
diseases. Some WBC have short life of 1 to 3 days, while others have a longer lifespan of 5 to 20
days.
• Platelets are cells that help with clotting. Their average life span is 8 to 10 days.
• Plasma is the main component of blood and consists mostly of water, with proteins, ions, nutrients
and wastes mixed in.
Sequence of events in the process
of blood clotting
◦ Blood clotting (coagulation), it is complex and regulated process that prevents
excessive bleeding when blood vessels are damaged. The following is the process
of blood clotting:
1. Vasoconstriction: When a blood vessel is injured, the first response is
vasoconstriction of the blood vessel to reduce blood flow to the site of injury. It is
a temporary measure to limit blood loss.
2. Primary Hemostasis: Primary hemostasis involves the formation of a platelet
plug at the site of injury.
a. Adhesion: Platelets adhere to the exposed collagen fibers in the damaged
blood vessel wall which is facilitated by the protein von Willebrand factor
(vWF).
b. Activation: Adhered platelets become activated and change shape. They
release chemical ( ADP and thromboxane A2), which further activate
additional platelets.
c. Aggregation: Activated platelets clump together to form a temporary
plug that helps seal the injury site.
Cont’ Sequence of events in the process
of blood clotting

3. Secondary Hemostasis: It involves the coagulation cascade, a series of enzymatic reactions that lead to
the formation of a stable blood clot.
a. Intrinsic and Extrinsic Pathways: The coagulation cascade can be initiated through the intrinsic or
extrinsic pathways
-The intrinsic pathway is activated by factors within the blood and is triggered when blood contacts a
foreign surface, like collagen exposed during injury.
- The extrinsic pathway is initiated by tissue factor (TF), which is released from damaged tissues outside
the blood vessel.
b. Common Pathway: Both pathways converge into a common pathway, where several clotting factors,
such as Factor X and Factor II (prothrombin), interact in a series of reactions.
c. Formation of Thrombin: The common pathway ultimately leads to the activation of prothrombin into
thrombin by Factor Xa and Factor Va, among other factors.
Cont’ Sequence of events in the process
of blood clotting
4. Thrombin Activation: Thrombin (enzyme in blood clotting) converts soluble
fibrinogen into insoluble fibrin that forms a mesh-like structure that traps blood
cells and reinforces the platelet plug to create a stable clot.
5. Fibrin Formation: Fibrin strands continue to polymerize and create a meshwork, which
\ traps more platelets, red blood cells and other components of blood to form a solid clot.
6. Clot Retraction: After clot formation, the clot contracts and becomes denser to
further seal the injury site.
7. Platelet Release: As the clot forms and stabilizes, platelets release additional factors that
promote clot formation and wound healing.
8. Clot Dissolution: Once the injury is repaired, the clot is no longer needed. A process called
fibrinolysis begins, in which plasmin breaks down fibrin strands, leading to the dissolution of
the clot.
Anatomy & Physiology of the
Lymphatic System
◦ The lymphatic system is a network of vessels, nodes and organs responsible for maintaining
fluid balance, filtering foreign substances and pathogens and supporting the immune system.
Key components include:
1. Lymph Nodes: These small, bean-shaped structures filter lymph fluid for pathogens and
abnormal cells, initiating an immune response when needed.
2. Lymphatic Vessels: These vessels transport lymphatic fluid with white blood cells, proteins
and waste products.
3. Spleen: The spleen filters blood, removing damaged blood cells and storing platelets.
4. Thymus Gland: This gland plays a vital role in immune system development, particularly in
early life
5. Tonsils and Adenoids: These tissues help defend against infections by trapping and
destroying pathogens.
 Data obtained on assessment of patient with hematological
or lymphatic disorder
◦ Assessing is a crucial step in diagnosing and managing their condition.
◦ Here's a list of key data that should be obtained during the assessment :
1.Medical History:
-Age, gender and ethnicity.
-Chief complaint and reason for seeking medical attention.
-Medical and surgical history.
-Family history of hematological or genetic disorders.
-Medication history, including any current or recent use of anticoagulants or medications that can
affect blood or lymphatic function.
-Allergies and drug sensitivities.
-Social history including tobacco and alcohol use and exposure to environmental toxins.
Cont’ Data obtained on assessment of patient with
hematological or lymphatic disorder
2. Symptoms and Presenting Complaints:
-Specific hematological or lymphatic symptoms such as bleeding, bruising, petechiae,
pallor,
fatigue, lymph node enlargement or unexplained weight loss.
-Pain or discomfort in the abdomen, bones or joints.
-Any signs of infection or immune-related symptoms.
3. Physical Examination:
-General appearance and vital signs.
-Examination of the skin, looking for signs of pallor, rashes or petechiae.
-Palpation of lymph nodes for size, tenderness and consistency.
-Examination of the abdomen for organomegaly (enlarged liver or spleen).
-Assessment of the musculoskeletal system for joint pain or swelling.
-Neurological examination if there are signs of neurological involvement.
Cont’ Data obtained on assessment of patient with
hematological or lymphatic disorder
4. Laboratory and Diagnostic Tests:
-Complete Blood Count to assess red blood cells, white blood cell and platelets
-Peripheral blood smear to evaluate blood cell morphology.
-Coagulation profile including prothrombin time (PT), activated partial thromboplastin time (aPTT) and
international normalized ratio (INR).
-Bone marrow aspiration and biopsy to assess the cellular composition of the bone marrow.
-Genetic testing or molecular studies to identify specific genetic mutations associated with hematological
disorders.
-Serum chemistry panel to evaluate organ function and electrolyte levels.
-Flow cytometry or immunophenotyping to characterize abnormal lymphoid populations.
-Coagulation factor assays if bleeding disorders are suspected.
-Hemoglobin electrophoresis to diagnose hemoglobinopathies like sickle cell disease or thalassemia.
-Radiological studies (e.g., ultrasound, CT, MRI) to assess lymph node or organ involvement.
 Cont’ Data obtained on assessment of patient with hematological or
lymphatic disorder
5. Specialized Hematological Tests:
-Hemoglobin A1c for diabetes monitoring.
-Iron studies (serum iron, ferritin, transferrin saturation) to evaluate iron metabolism.
-Coombs test (direct and indirect) to assess for hemolytic anemias.
-Thrombophilia screening for clotting disorders.
-Tests for specific markers or proteins associated with hematological malignancies (e.g., leukemia, lymphoma).
6. Assessment of Bone Marrow Function:
-Assessing bone marrow function including the production of blood cells in certain cases.
7. Psychosocial Assessment:
-Assess the patient's emotional and psychological well-being as living these disorders can be emotionally challenging.
8. Consultation with Specialists:
- Depending on the specific disorder, the patient may need referrals to hematologists, oncologists or other specialists
for further evaluation and management.
A comprehensive assessment of patients with hematological or lymphatic disorders is crucial for accurate diagnosis
and appropriate management. Treatment options and prognosis often depend on identifying the underlying cause and
the extent of organ involvementt.
 Laboratory and diagnostic studies used in evaluation of the hematological and lymphatic system

1. Complete Blood Count (CBC):

• Provides information about the number and characteristics of blood cells including:
• Red blood cell count (RBC)
• Hemoglobin (Hb) concentration
• Hematocrit (Hct)
• Mean corpuscular volume (MCV)
• Mean corpuscular hemoglobin (MCH)
• Mean corpuscular hemoglobin concentration (MCHC)
• White blood cell count (WBC)
• Differential white blood cell count (counts of different types of white blood cells)
• Platelet count
2. Peripheral Blood Smear:
• A microscopic examination of a stained blood smear to assess the morphology and shape of blood cells.
 Cont’ Laboratory and diagnostic studies used in evaluation of the hematological and lymphatic
system
3. Blood Chemistry Panel:
• Includes a variety of blood chemistry tests that assess organ function and electrolyte balance such as:
• Serum electrolytes (sodium, potassium, calcium)
• Liver function tests (AST, ALT, bilirubin, ALP)
• Kidney function tests (creatinine, blood urea nitrogen or BUN)
• Serum albumin and total protein levels
• Glucose levels
4. Coagulation Profile:
• Evaluates the blood's ability to clot and includes tests such as:
• Prothrombin Time (PT)
• Activated Partial Thromboplastin Time (aPTT)
• International Normalized Ratio (INR)
• Fibrinogen level
• D-dimer assay
Cont’ Laboratory and diagnostic studies used in evaluation of
the hematological and lymphatic system
5. Bone Marrow Aspiration and Biopsy:
• Involves the collection of bone marrow tissue and cells from the hip bone (usually) to assess cell
morphology, cellularity and the presence of abnormal cells or disorders.
6. Serum Iron Studies:
• Includes tests like serum iron, ferritin and total iron-binding capacity (TIBC) to assess iron
metabolism and diagnose iron-related disorders.
7. Hemoglobin Electrophoresis:
• Used to identify and characterize hemoglobin variants including those associated with
hemoglobinopathies like sickle cell disease or thalassemia.
8. Flow Cytometry or Immunophenotyping:
• Helps identify and characterize abnormal lymphoid populations and diagnose lymphoproliferative
disorders.
 Cont’ Laboratory and diagnostic studies used in
evaluation of the hematological and lymphatic system
9. Genetic Testing:
• Molecular tests to identify specific genetic mutations associated with hematological
disorders such as the JAK2 mutation in polycythemia vera.
10. Coombs Test:
• Used to assess for hemolytic anemias and to detect the presence
of antibodies or complement proteins on the surface of red blood cells.
11. Thrombophilia Screening:
• Assess for clotting disorders, including tests for inherited thrombophilias like Factor V
Leiden mutation.
12. Imaging Studies:
• Radiological tests such as ultrasound, CT scans, MRI or PET scans to evaluate lymph
nodes, organs and the overall structure of the lymphatic system.
 Nursing care for patient undergoing the respective diagnostic
tests
◦ Providing nursing care for a patient undergoing diagnostic tests involves ensuring the patient's comfort,
safety and understanding of the procedures.
◦ Here's a general guideline for nursing care for some common diagnostic tests:
1. Complete Blood Count (CBC) and Peripheral Blood Smear:
• Explain the purpose of the tests to the patient and address any concerns.
• Verify the patient's identification and ensure correct labeling of blood samples.
• Assist in venipuncture or fingerstick for blood collection.
• Monitor the patient for any signs of bleeding or hematoma formation at the collection site.
• Ensure that pressure is applied to the puncture site to stop bleeding after the procedure.
• Provide emotional support, as some patients may have anxiety about blood draws.
• Document the date, time and results of the test accurately in the patient's medical record.
Cont’ Nursing care for patient undergoing the respective
diagnostic tests

2. Blood Chemistry Panel:

• Explain the purpose of the test and any fasting requirements to the patient.
• Verify the patient's identification and ensure correct labeling of blood samples.
• Assist in venipuncture for blood collection if needed.
• Monitor the patient for any signs of discomfort or complications during or after the procedure.
• Ensure the patient follows fasting instructions if required.
• Document the date, time and results of the test accurately.
Cont’ Nursing care for patient undergoing the respective
diagnostic tests
3. Coagulation Profile:
• Explain the purpose of the test to the patient.
• Verify the patient's identification and ensure correct labeling of blood samples.
• Assist in venipuncture for blood collection if needed.
• Monitor the patient for any signs of bleeding or hematoma formation at the collection site.
• Provide emotional support, especially if the patient is on anticoagulant medications or has
bleeding tendencies.
• Document the date, time and results of the test accurately.
Cont’ Nursing care for patient undergoing
the respective diagnostic tests
4. Bone Marrow Aspiration and Biopsy:
• Educate the patient about the procedure, including what to expect and
potential discomfort.
• Verify informed consent has been obtained.
• Assist with positioning the patient for the procedure.
• Administer local anesthesia as needed.
• Provide emotional support and reassurance throughout the procedure.
• Monitor vital signs and the patient's pain level during and after the procedure.
• Educate the patient on post-procedure care and activity restrictions.
• Document the procedure details, any complications, and the patient's response.
Cont’ Nursing care for patient
undergoing the respective diagnostic tests
5. Imaging Studies (Ultrasound, CT, MRI, PET):
• Prepare the patient for the specific imaging procedure as per hospital protocols.
• Ensure the patient is appropriately dressed and has removed any metal objects if required.
• Address any concerns or anxiety the patient may have about the procedure.
• Accompany the patient to the imaging area and ensure their safety and comfort.
• Monitor the patient for any adverse reactions during or after the procedure.
• Document the procedure details and any relevant findings.
Cont’ Nursing care for patient undergoing
the respective diagnostic tests
6. Lymph Node Biopsy:
• Educate the patient about the biopsy procedure and potential risks.
• Verify informed consent has been obtained.
• Assist with positioning the patient for the procedure.
• Administer local anesthesia as needed.
• Provide emotional support and reassurance throughout the procedure.
• Monitor vital signs and the patient's pain level during and after the procedure.
• Educate the patient on post-procedure care, including wound care and activity restrictions.
• Document the procedure details, any complications and the patient's response.
Cont’ Nursing care for patient
undergoing the respective diagnostic tests
◦ In all cases, communication with the patient is essential to address their concerns, provide
education and ensure their comfort.
◦ Additionally, accurate documentation of the procedure, patient response and results is crucial
for continuity of care and follow-up.
THE END