ASSESSMENT AND DIAGNOSTIC PROCEDURES History A thorough history will help the nurse identify symptoms related to abnormalities

with the hematologic system as well as current or potential problems. Information learned from a thorough history and physical exam could help prevent undesirable responses to current therapies and treatment plans. The essential assessment is contingent on obtaining both subjective and objective data as previously defined. Biographic and Demographic Data Assessment of biographic and demographic data includes information regarding age, race, gender, and ethnicity, all of which can impact the susceptibility to some hematologic disorders. Chief Complaint The current issue is the focus of why the patient is being evaluated currently. Unless the patient already has some knowledge of his hematologic system from previous evaluations, he usually will not know that he has a hematologic problem. He will merely know that he does not feel well. From the questions asked during the history taking, nurses can begin to determine whether or not they think that the patient is having a problem that arises from the hematologic system. The chief complaint tells the health care provider, in the patients own words, what problem(s) she is currently experiencing. Presenting Symptoms If patients are having problems with the erythrocyte, or RBC component, of their hematologic system, the usual presenting symptom is fatigue or weakness. The patient may say I used to be able to make my bed in the morning after I got up, but now I am too tired to even do that. Another common presenting symptom of a hematologic problem is shortness of breath. In this situation patients may complain that they get tired and short of breath just walking around their own house. If patients are having problems with the leukocytes, neutrophils, or WBC component of their hematologic system, they usually present with increasing episodes of illness and fevers. Finally, patients who present with unusual bleeding may be having problems with their platelets or thrombocytes or with their clotting mechanism.

Past Medical History The history provides information from the patients perspective and understanding. In assessing the patient, the nurse asks questions to determine what is happening to the patient, that is, what the patient is feeling and experiencing. In comparison to other systems (e.g., cardiovascular, nervous,

reproductive), it is very unusual to ask questions about the hematologic system directly. These questions are suggestive of changes in the composition and characteristics of the blood cells. Diseases that involve any of the hematologic organs will result in hematologic disorders. For example, cancer suppresses bone marrow, and liver disease impacts the clotting factors. Kidney disease also greatly impacts the hematologic system because it results in poor production of erythropoietin. Erythropoietin is a hormone produced by the kidney that promotes the differentiation and production of red blood cells in bone marrow. It starts the production of hemoglobin, the molecule within red blood cells that transports oxygen. Gastrointestinal (GI) disorders such as Crohns disease also impact blood cell production and function because the GI tract is the primary source of the nutrients needed for blood cell development and because GI diseases carry a high propensity for bleeding. Similarly, any surgical manipulation of the component hematologic organs can have deleterious consequences. Assessment findings of previous gastrectomy, colectomy, or splenectomy warrant further diagnostic workup. Family History Many hematologic disorders have familial patterns. Genetic information offers clues as to possible hematologic problems that are known to be common in specific populations. Familial patterns also can be the result of similar environmental exposure or behavior modeling within the family. For example, patients with families who engage in smoking, eat poor diets, or are not very active are more prone to engage in similar behaviors.

PHYSICAL ASSESSMENT Inspection Simple observation allows the health care provider to observe the patients general appearance and exertional effort, both of which yield clues in an assessment of the hematologic system. Patients who are short of breath, fatigued, or exhibit poor stamina and poor mental acuity may be at risk of anemia or infection. Fever is a very serious sign that warrants prompt attention even in the absence of other clinical signs. For patients who are neutropenic (decreased neutrophil supply), oftentimes fever is the only observable indicator of infection in this very vulnerable population. Skin Changes in skin color often indicate erythrocyte disorders such as anemia (pale, loss of pallor), liver failure (yellow, jaundice), polycythemia vera (pink, flushed), or rapid breakdown of erythrocytes (brown, dark). Platelet and/or clotting derangements often produce tiny capillary bleeds manifesting as petechiae, purpura, or ecchymosis. The appearance of these skin changes, especially in the

absence of recent identifiable injury, should be reported immediately so that a laboratory analysis can be performed. In patients with known hematologic deficiencies, assessment of the skin must be included during all routine assessments and whenever laboratory values or assessments of other body systems suggest hematologic derangement. Head and Neck The structures of the head, particularly the eyes and mouth, provide useful evidence in the evaluation of the patient with known, potential, or suspected hematologic derangement. Using a penlight, gloved hand, and tongue depressor, the nurse should thoroughly assess the gums, lips, tongue, and teeth. Symptoms warranting further collaboration and intervention include tenderness, increased or decreased saliva, inflammation, reddening, ulcerations, and bleeding. These symptoms are most worrisome in patients with neutropenia because they indicate signs of infection. See Chapter 64 for further discussion. Pernicious and iron deficiency anemia also produce a characteristic symptom of smooth tongue texture and pale gums. With respect to the eyes, health care providers should assess the sclera for color and swelling. The appearance of yellow, jaundiced sclera warrants immediate reporting to the health care provider because this indicates an accumulation of bile pigment due to rapid or excessive hemolysis and also is a sign of liver disease. The neck should be inspected for signs of lymph node enlargement or tenderness, especially in the submaxillary, tonsillar, or supraclavicular regions. Chest Structures in the chest that yield clues to hematologic system health include the heart and the lymph nodes. The heart is a sensitive indicator of most abnormalities; for example, the heart rate will increase (tachycardia) in response to both infection and anemia. A widening pulse pressure is another compensatory mechanism to counteract inefficient oxygen delivery. The lymph nodes in the mediastinum or the axilla will become enlarged and tender in the presence of infection, lymphoma, and other metastatic cancers. Abdomen Abdominal tenderness is a general complaint, the appearance of which warrants a more detailed work-up. The first task is to isolate (if appropriate) the source of the tenderness, so as to identify which organ is involved. Enlarged spleens (splenomegaly) or livers (hepatomegaly) are general indicators of increased blood cell destruction, the cause of which must be identified. Additionally liver tenderness may be associated with clotting system abnormalities. Further blood studies are warranted whenever a complaint of abdominal tenderness is found. DIAGNOSTIC TESTS/PROCEDURES A. Blood Examinations (CBC) a. Used to monitor a patients prgres response to treatment b. Most common laboratory test: Hgb and Hct test

B.

C.

D.

E.

1. Hgb Test: measures the amount of Hgb in the peripheral blood by weight 2. Reticulocyte count- measures the number of immature RBCs circulating in the blood a. Provides useful information about the erythropoietic activity of the bone marrow 3. Differential WBC Count 4. Platelet Count 5. RBC Count Peripheral Blood Smear a. Identifies the color, size, shape and contents of RBC i. Color: (Normochromic, Hypochromic) ii. Anisocytosis: (Normocytic, Microcytic, Macrocytic) iii. Poilocytosis: (Leptocytes, Spherocytes) Coagulation Studies a. aPTT: N- 25-35 sec i. Measure the number of seconds in which a clot forms b. PT: N- 10-13 sec i. Also measures the time needed to form a blot but specifically measures clotting factors Lymphangiography a. A radiologic technique used for visualization of the lymphatic system flow and nodes to detct the presence or stage of disease b. Radiologist makes a small incision between the toes or fingers and instills dye. An iodone-based dye is injected and radiographs are taken then and again after 24 and 48 hour after instillation of dye c. Nursing responsibility: i. Pre-procedure: 1. Obtain informed consent 2. Assess patient for allergy to iodine 3. Local anesthesia is used before the needle insertion 4. Inform patient that he may experience a sensation of warmth and flushing as the iodine based dye is injected 5. The examiner may ask the patient to walk ii. Post Procedure: 1. Elevate affected limb for 24 hours 2. Assess patient for signs of bleeding/adverse reaction to the dye 3. Assess the affected extremity for any change in sensorimotor function Bone Marrow Examination Purposes 1. To evaluate abnormal blood cells 2. Monitor the effects of bone marrow depressants 3. Monitor the patients response to treatment

4. Help diagnose disorders a. Bone Marrow Aspiration ii. Most common procedure for obtaining a bone marrow sample iii. Indications 1. Severe anemia 2. Thrombocytopenia 3. Acute leukemia 4. Neutropenia b. Bone Marrow Biopsy i. Indicated when a large sample of bone marrow is needed ii. Indications: 1. Pancytopenia 2. Lymphoma 3. Myelofibrosis 4. Metastatic tumor 5. Multiple myeloma Nursing Responsibility: Pre-procedure: 1. Education, preparation and emotional support of the patient before bone marrow aspiration 2. Remind the patient to lie still during the entire procedure Post-procedure 1. Apply pressure dressing over the aspiration site 2. Advise patient to lie on the biopsied side 3. Monitor the site every 15 minutes 4. An ice bag maybe applied to the site