OXYGENATION

By :

Hermie M. Pueyo M.D.,R.N.

 OXYGENATION
Within 6 minutes that the body had no oxygen,
it may cause death.

Primary Systems Involve :

1. Cardiovascular – heart, blood vessels and
lymphatic vessels
- circulates blood
2. Respiratory – lungs, tracts, and muscles
- oxygenate blood
3. Blood – red blood cells and plasma
- carries oxygen
 Cardiovascular System
1. Heart - pumps the blood
2. Vascular - carries the blood &
lymph fluid
a. blood vessels
b. lymph vessels
HEART
- hollow, muscular organ, lies in the
mediastinum, and rest on the diaphragm
- about the size of a fist that its function is to
pump 5-6 liters of blood in just one minute
BLOOD VESSELS
Arteries carries oxygenated blood except the

pulmonary and umbilical arteries

- thicker wall than the veins, and had no valve

Veins carries deoxygenated blood except

pulmonary and umbilical veins
- thinner-walled than arteries with valves

Capilliaries are very thin-walled blood vessel

lined with single layer of endothelial cells
- permits rapid transport of nutrients and
removal of metabolic wastes
LYMPHATIC VESSELS

• Returns 3 L of fluid/day
to circulatory veins near
the heart
• Right lymphatic duct
• Thoracic duct
 Blood
Circulation
 The Heart Coverings
• Pericardium – a double serous membrane
• Visceral pericardium
• Parietal pericardium
• Pericardial fluid fills the
space between the
layers of pericardium
 The Heart Walls
• Three layers
• Epicardium
• Outside layer
• Parietal pericardium
• Connective tissue layer
• Myocardium
• Middle layer
• Mostly cardiac muscle
• Endocardium
• Inner layer
• Endothelium
The Heart Chambers

- Right and left side act as separate pumps

- Four chambers
• Receiving chambers
• Right atrium
• Left atrium
• Discharging chambers
• Right ventricle
• Left ventricle
 The Heart Valves
- Allow blood to flow in only one direction
- Four valves
• Atrioventricular valves
• Bicuspid valve (left)
• Tricuspid valve (right)
• Semilunar valves
• Pulmonary semilunar valve
• Aortic semilunar valve
The Associated Great Vessels

- Vena cava
Enters right atrium
- Pulmonary arteries
Leave right ventricle
- Pulmonary veins (four)
Enter left atrium
- Aorta
Leaves left ventricle
 Coronary Circulation
• Blood in the heart chambers does not nourish the
myocardium
• The heart has its own nourishing circulatory system
• Coronary arteries (first branch of the aorta)
- Left anterior descending artery
- Left Circumflex artery
- Right coronary artery
• Cardiac veins
• Blood empties into the right atrium via the
coronary sinus
The Heart Conduction System
• Special tissue sets the pace
• Sinoatrial node
• Pacemaker
(60-100 bpm)
• Atrioventricular node
• Atrioventricular bundle
(40-60 bpm)
• Bundle branches
• Purkinje fibers
The Cardiac Cycle
• Equivalent to one complete heartbeat
• Systole = contraction
• Diastole = relaxation
 The Heart sounds :
 1st heart sound (S1) – closure of AV valves
“Lubb”

 2nd heart sound (S2) - closure of

“Dubb” semilunar valves

 3rd heart sound (S3) - vibration secondary to rapid

( ventricular gallop ) ventricular filling of diastole stage

 4th heart sound (S4) - atrial systole or kick with

( atrial gallop ) resistance of the ventricle
The Cardiac Output
• Cardiac output (CO - amount of blood pumped by
each side of the heart in one minute
CO = (heart rate [HR]) x (stroke volume [SV])
75 bpm X 75 ml = 5625 ml of blood/min
• Stroke volume - volume of blood pumped by
each ventricle in one contraction
1. Preload = the myocardial fiber length of the left
ventricle at end of diastole (Frank-starling Law)
2. Afterload = the resistance to left ventricular ejection
3. Contractile state of the heart
 When conducting a physical examination
of a patient, the nurse should be aware
that a pathologic S4 extra heart sounds is
the result of
..
a. a physiologic splitting of the aortic and
pulmonic valves with inspiration.
b. increased in resistance of ventricular
filling following atrial contraction.
c. opening of the stenotic valve.
d. mitral valve prolapse
Neurologic factors regulating heart
functions
1. Autonomic nervous system
- sympathetic:
(+) inotropic effect
(+) chronotropic effect
- parasympathetic :
(-) inotropic effect
(-) chronotropic effect
2. Receptors – located in carotid & aortic bodies
- chemoreceptors- increase heart rate in
response to decrease O2 and
increase CO2 in blood
- baroreceptors - increase or decrease heart
rate resulting in blood
pressure changes
 Pulse
- pressure wave
of blood

Grade 0 - no pulse

(shock)
Grade 1 - weak
Grade 2 and 3 – normal
Grade 4 – bounding
(hypertension)
 Which of the following clinical
manifestations would support a nursing
diagnosis of decreased cardiac output? .
a. Cool, moist skin
b. Bounding peripheral pulses
c. Increased urinary output
d. Diminished breath sounds
 CARDIAC
DISORDERS
Inflammation and Infection of
Structural Heart Layers

Pericarditis – inflammation of the pericardium

Types :
acute pericarditis –
effusive producing
serous or hemorrhagic
exudates (tamponade)
chronic pericarditis –
marked by progressive
pericardial thickening
(constrictive)
Clinical findings:
- pain mimics M.I.
- pain may be aggravated by breathing and
movement and typically decreases when
the client sits and leans forward.
- pericardial friction rub is classic sign
- in the presence of cardiac tamponade –
pulsus paradoxus and signs of CHF
Pulsus paradoxus – an abnormal fall of systolic
BP of >10mmhg during inspiration
Laboratory findings:
 Echocardiography is diagnostic of choice
 pericardiocentesis reveals (+) pericardial fluid
culture

Nursing Management:
 medications for pain relief:
steroids, morphine, antibiotics
 bed rest, and place the patient in leaning
forward position.
 pericardiocentesis
Infective Endocarditis – infection of the
endocardium or heart valves resulting from
invasion of bacteria or other organisms.
Etiology:
- primarily infection
streptococcus viridians – subacute I.E.
staphylococcus aureus - acute I.E.
- predisposing factors
history of valvular disease
IV drug users
indwelling catheter placement
Clinical findings:
- fever with chills, dyspnea, chest pain
- new heart murmur or a change in an
existing murmur
- Osler’s node (infective thrombus)
reddish tender lesions on the pads of the
fingers, hands, toes
- Janeway’s lesions
non-tender hemorrhagic lesions on the
fingers, toes, nose, and ear lobes
- embolization (CVA)
Laboratory findings:
 elevated WBC & ESR, (+) blood culture

 Echocardiogram shows valvular damage.

Nursing management:
 administer prescribed medications such as

antibiotics, anticoagulants, pain relievers

 prepare the client for possible valve

replacement
 discuss the need for prophylactic antibiotics

before doing any invasive procedures or event

that can cause transient bacteremia
Which of the following factors, if noted in
patients history, indicates a
predisposition for the development of
endocarditis? …

a. crowded living conditions

b. multiple sex partners
c. intravenous drug use
d. family tendency toward heart disease
Rheumatic Fever
- is a diffuse inflammatory disease secondary
to delayed response to an infection by
group A-beta hemolytic streptococcus

Organs involve : Jones Criteria (2M or 2m1M)

1. heart - Carditis prolonged P-R
2. joints - Arthritis arthralgia
3. SQ tissue - SQ nodules fever
4. Skin - Erythema marginatum ESR
5. CNS - Chorea C-reactive protein
Cardiac Complications :
- cardiomegaly (carditis) leading to CHF
- rheumatic valvular disease

Management :
- priority is eradication of streptococcal infection
by giving antibiotics
- bed rest to decrease O2 demand and to
decrease joint pains
- supportive therapy
Valvular Defects
-usually affected is the mitral valve
a. Insufficiency or Regurgitation
(failure of the valve to close completely)
b. Stenosis (narrowing of the
valve opening)

Etiology:
- rheumatic endocarditis
(most common)
- congenital defects

- degenerative changes
Clinical findings:
 murmurs

 signs of CHF

 angina pectoris

 cardiomegaly
 Laboratory findings :
 Echocardiogram

-note the valvular structure and functions

Nursing management:
 low sodium diet

 diuretics, anticoagulants, digitalis

 prophylactic antibiotic before any invasive

procedures
 valve replacement
Congestive Heart Failure
(CHF)-
- is a syndrome of
pulmonary or systemic
congestion

- caused my decrease
myocardial contractility
- resulting in inadequate
cardiac output to meet
tissue O2 requirement
 Clinical Findings:
Left- sided CHF
- dyspnea on exertion, orthopnea

- crackles , blood-tinged frothy sputum

- pale cool extremities, weak pulse
- oliguria
- elevated PAWP (8-15 mmHg)
Right-sided CHF
- neck vein engorgement
- hepatomegaly, jaundice, ascites
- bipedal pitting edema, weight gain
- polyuria at night
- elevated CVP (4-10 mmH20)
Nursing management:
- high back rest, O2 and bed rest; legs should be
in dependent position even it is edematous
- low sodium diet, low fat diet, restrict fluids
- Drugs:
diuretics (Thiazides & Furosemide) -
reduce the preload
vasodilators (ACE-i) – reduce the afterload
Digitalis - to increase cardiac contractility
- contraindicated to high output failure
Which of the following assessment
findings would suggest to the home
health nurse that the patient is
developing congestive heart failure
(CHF)?.

a. Orthopnea
b. Weight loss
c. Fever
d. Calf pain
Which of the following conditions would a
nurse expect when assessing a patient
who has right-sided heart failure? ..

a. weak pulse
b. Peripheral edema
c. Decreased urinary output
d. Paroxysmal nocturnal dyspnea
Coronary Artery Disease (CAD)

- results from a focal

narrowing of coronary
arteries due to intimal
plaque formation,
which deprive the
coronary blood flow.
 Etiology and Risk factors:

Non Modifiable Modifiable

- heredity - cigarette smoking
- age (>40 y.o.) - hypertension
- sex (women) - OCP
- Obesity
- sedentary lifestyle
Manifestations:
1. Angina Pectoris – chest pain
stable angina – triggered by stress.
unstable angina – anginal attacks at rest.
Prinzmetal’s angina – coronary spasm.
2. Myocardial Infarction –
permanent tissue damage
3. Sudden cardiac death – death from cardiac
causes within 24hours from the onset of
symptoms

- retrosternal chest pain typically described as

burning or squeezing that may radiate to the

arm, jaw, neck and shoulder.
- epigastric pain, restlessness, dyspnea
Laboratory findings:
- ECG :
angina (ST depression T wave inversion)
AMI (ST elevation , Q wave &
T wave inversion)
- cardiac enzymes: elevated CPK, LDH,
myoglobin and troponin levels (AMI)
- angiography – allergies to iodine , force fluids
mark peripheral pulses,
extend extremity
Management : main goals
Angina - prevent progression to M.I
MI - prevent complications :
Cardiac dysrhythmias
Heart failure
Dressler’s syndrome
Nursing management:
1. Drug therapy : MONA for pain management
M – morphine (for pain and induce rest)
O - oxygen (prevent anoxic cell damage)
N - nitrates (vasodilator to increase
the coronary blood flow)
A - aspirin (antiplatelets to promote good
blood viscosity)
- Beta- blockers (propanolol), Calcium-channel

blockers (Verapramil), antilipemic (statins),

thrombolytics (streptokinase), anticoagulants,
stool softeners (docuates)
2. provide ongoing assessment - ICU for MI

3. minimize anxiety
4. minimize metabolic demands –
rest and proper sleep
5. prepare client for possible surgical treatment
(PTCA and CABG)
6. provide client and family teaching
 Which of the following statements, if
made by the patient during a nursing
assessment, would be indicative of a risk
factor for coronary artery disease?..
a.“ I have a cholesterol level of 190mg/dL.
b. “I had a parent diagnosed with angina
at age of 40 years.”
c. “My blood pressure is consistently
100/60 mm Hg.”
d. “ I had recent weight loss of 15 lbs.”
A nurse should expect a patient
diagnosed with angina pectoris to report
chest pain during which of the following
activities? …

a. Taking a deep breath

b. Moving the extremities
c. Climbing a flight of stairs
d. Sleeping in supine position
Disturbance in Conduction
Atrioventricular Blocks
- is a conduction defect within the AV
junction that impairs conduction of
atrial impulses to ventricular pathways.
Types :
a. First degree
- AV junction conducts all impulses but
duration of conduction is prolonged
PR interval is > 0.20 sec
b. Second degree (Mobitz type I and II)
- AV junction conducts only some impulses
arising from atria
dropped QRS complex
c. Third degree
- AV junction blocks all impulses to the
ventricles, causing the atria & ventricles
to dissociate and beat independently
P wave and QRS complex dissociation
Etiology
- myocardial ischemia
digitalis toxicity
B-blockers

Manifestations :
- fainting or syncope (most common)
- bradycardia, palpitation
- dizziness, mental confusion
- low blood pressure
- dyspnea, cyanosis
Interventions :

First degree
- discontinuance of causative drugs
- observation
Second degree
- atropine
- pacemaker
Third degree
- peacemaker insertion
 A nurse is performing an assessment on a client
admitted to the hospital with a chest pain.
When evaluating a rhythm strip, the nurse
discovers that the client is in first degree heart
block. The client ask the nurse what “first
degree heart block” means, and the nurse tells
the client which of the following?.
a. There is slowed conduction from one
point to another point in the heart.
b. If the client lies very still, the problem
will go away.
c. This is a serious problem, and the client
require a pacemaker.
d. It means nothing and will not require any
treatment.
HYPERTENSION
- a blood pressure more than 140/90 mmhg
Components :
Classification

1. Primary hypertension = No specific cause

2. Secondary hypertension = result of other
disorders
- cardiovascular disorder
- renal disorder, endocrine disorder
- pregnancy, hyperlipidemia
3. Malignant hypertension =diastolic >120mmHg
- requires emergency treatment because
target organ damage can occur quickly
Stages
High Normal = 130 – 139/ 85-89 mmHg
Stage I = 140 – 159/ 90-99
Stage II = 160 - 179/ 100 -109
Stage III = 180- 209/ 110 – 119
Stage IV = >210 / >120
Clinical Manifestations :
- may be asymptomatic
- headache, dizziness, tinnitus
- visual disturbances
- chest pain
- flushed face, epistaxis
- tachycardia, tachypnea
Nursing Interventions:
- Bed rest with head of the bed elevated 45’
- weight reduction

- sodium restriction, low fat diet

- Moderate intake of caffeine-containing products

- Avoidance of smoking

- Regular exercise program

- relaxation techniques

- Antihypertensive medications

- Avoid nasal decongestants

VASCULAR
DISORDERS
Artery and Arterioles

Peripheral Arterial Occlusive

Disease
- a conditions that involve narrowing or
occlusion of the arterial lumen which result to
deprivation of O2 and nutrients to the distal
affected part
Etiology:
- arteriosclerosis (hardening of arterioles)
- atherosclerosis (intimal deposition of fibrous
tissue, calcium & cholesterol)
- thrombosis (development of blood clots in
blood vessels cause by trauma)
- embolism (thrombus travels through the blood

stream and lodge in blood vessels)

- vasospasm (Raynaud’s disease)
- inflammation
(Burger’s disease or thromboangitis obliterans)
- vascular disease (scleroderma and SLE )
Clinical findings:
- intermittent claudication

calf pain during walking, relieved by rest

- rest pain
deep forefoot burning pain during night
- coldness, pallor of extremities, loss of hair,
pulselessness, pain upon elevation
- leg ulcers (pale deep and cyanotic)

- cellulitis, atrophy, gangrenous changes

- Allen’s test
make a tight fist, compress the
radial and ulnar arteries then open the hand,

normally it regains color w/n 6 seconds

- Dependent rubor
lower extremities became pale when
elevated in 1 min/ 1 foot
when in dependent position
it turns into dusky & purplish discoloration
- Ankle – Brachial Index
Higher systolic ankle pressure
Higher systolic brachial pressure
Laboratory findings:
- Doppler UTZ flow vector and
Ultrasonic doppler scanning
(obtain qualitative and quantitative
information about blood flow)
- Arteriography (contrast dye injected into

the arteries and x-ray films are made

to note some occlusions)
Nursing Management
- Nonpharmacologic interventions :
weight reduction, walking exercise, low fat
diet, smoking cessation, avoid caffeine
- alleviate pain and increase tissue perfusion :
administer prescribed analgesic (NSAIDs)
vasodilators, anti coagulants, anti-lipemic
- Fowler’s position at rest and warm compress
- avoid crossing legs
avoid exposure to cold
avoid constrictive socks and stockings
A nurse has given instructions about
modifying lifestyle behaviors to a patient
who has Reynaud’s disease. Which of the
following statements, if made by the
patient , would indicate the need for
further teaching?..

a. “I eat diet low in fat”.

b. “I smoke one pack of cigarettes a
day”.
c. “I have a glass of wine with dinner”.
d. “I spend time out in the sun.”
ANEURYSMS
- an abnormal dilatation of the arterial wall
caused by localized weakness and stretching
in the medial layer of arterial wall.
Common site and Complications:
aortic – SHOCK
cerebral - CVA
Types :
fusiform – involves the entire circumference
of the arterial segment
saccular –localized outpouching of arterial wall
dissecting – created when blood separates the
layers of the artery forming a
Clinical Manifestations :
- pulsating pain, headache
- pulsating mass in the abdomen (aortic)
- systolic bruit over the aorta
- if ruptured : signs of CVA and shock

Diagnostic Tests :
- abdominal UTZ
- CT scan and MRI
- angiography
Nursing Interventions :
- key element is to control BP
antihypertensive medications
- avoid Vasalva’s maneuver & straining
- bed rest
- prepare for surgical management :
clamps and excision
 A nurse has an order to institute aneurysm
precautions for a client with cerebral aneurysm.
Which of the following items would the nurse
write on the care plan of this client?.
a. Instruct the client not to strain with
bowel movements.
b. Allow the client to read and watch
television
c. Limit the cigarettes to three sticks per
day.
d. Encourage the client to take his or her own
daily bath.
Veins and Veinules

Deep Vein Thrombophlebitis ( DVT )

– development of blood clots and
inflammation particularly in the
deep veins
= tibial, popliteal, iliac, femoral;
axillary & subclavian
superficial veins
= saphenous; median cephalic and
basilic
Etiology:
Virchow’s triad :
1. venous stasis
- immobility, obstruction, operation
that requires Lithotomy position

2. hypercoagulability
- blood dyscrasias, OCP’s, dehydration
3. venous wall damage
- fractures, IV injection
Clinical findings:
- unilateral swelling is a classic sign of DVT
- erythema and warm of affected extremity with
or without fever
- Homan’s sign (pain in calf muscle upon
plantar dorsoflexion)

Laboratory findings:
- Doppler UTZ flow meter and
Venous dupplex scanning– determine the flow
of blood & patency of vessels
- phlebography- visualize both normal and

abnormal veins and the

cusps of the valve.
Nursing management:
- administer prescribed medications such as :
anticoagulant (heparin),
fibrinolytic (streptokinase and urokinase),
analgesics.
- prevent stasis by :
passive & active exercise,
avoid prolong standing & sitting,
avoid constrictive clothing
- prevent hypercoagulability by :
maintain adequate hydration,
avoid OCP’s
- prevent vein wall injury
avoid IV infiltration
- relieve discomfort by :
elevation of extremities and warm packs
- client teaching about the complications such
as pulmonary embolism
- do not massage the extremity, wear anti-
embolic stocking
- orient the possibilities of bleeding problems
while on anticoagulant therapy
- record the circumference of the thigh and
calves
 A client visits the clinic with complaints of
right calf tenderness and pain. It would
be most important for the nurse to ask
which of the following questions? …

a. “Do you exercise excessively?”

b. “Have you had any fractures in the
last year?”
c. “What type of birth control do you
use.”
d. “Are you under a lot of stress?”
Varicose veins
– are dilated, tortuous, superficial and deep
veins with incompetent valve.

Clinical findings:
 venous pressure changes during walking

 pain in the legs with dull aching after standing

 Ulcer may noted brown and edematous

 ankle edema

0 – No edema
1 – barely detectable
2 - deeper depression; normal foot/leg contours
3 – deep depression; foot/leg swelling
4 - deeper depression; severe foot/leg swelling
Nursing management:
increase venous return:
- maintain elastic pressure over the
affected area for 6-8 weeks

- promote regular movement of the

affected area
- elevated the affected area
- avoid constrictive clothing
- sit allowing the feet touching the floor
educate client of possible complications:
hemorrhage, ulcers and DVT
orient for surgical intervention: stripping and
The nurse teaches the client about elastic
stockings. Which of he following statements, if
made by the client, indicates to the nurse that
teaching was successful? ….

a. “I will wear the stockings until the

physician tells me to remove them.”
b. “I should wear the stockings even
when I am sleep.”
c. “Every four hours I should remove the
stocking for a half hour.”
d. “I should put on the stocking before getting
out of the bed in the morning.”
THE END
 BLOOD
- whole blood consist of
formed elements
(blood cells)
suspended in a liquid
component which is
plasma.
- types :

a. arterial blood
b. venous blood
Hematopoiesis
Blood Cells
a. Erythrocytes (Red Blood Cells, RBC)
- major cellular element of circulating blood
- biconcave disks without nucleus
- contain hemoglobin
- life span is 120 days
Reticulocytes
- immature erythrocytes with nucleus, which
travels to spleen from bone marrow for
its maturation
Hemoglobin
- consist of heme (iron and porphyrin) and
simple protein (globin)
- ability to bind oxygen loosely and reversibly
b. Leukocytes
( White Blood Cells; WBC )
- defend the body against
invasion by infectious
organism

I. Granulocytes
(Polymorphonuclears)
II. Agranulocytes
( Mononuclears )
Granular Leukocytes
Polymorphoneuclears )
- the immature cells are called blasts
- neutrophils – phagocytic cells that
arrive early at the site of
inflammation
- Eosinophils – responsible for allergic
reaction and parasitic
infection
- Basophils - responsible also for
allergic reaction, contains
heparin
Agranulocytes ( Mononuclears)
- Lymphocytes
B lymphocytes – produce antibodies
- plasma cells is most mature cells
T lymphocytes – kill foreign cells directly,
virus and fungi, responsible for
graft reaction
Null Cells (Natural Killer Cells) – defend
against micro-organism,
viral and malignant cells
- Monocytes – the largest leukocytes that can
phagocytize large foreign particles,
cell fragments and necrotic tissues
- enter to the tissue to form macrohages.
c. Thrombocytes (platelets)
- formation results from fragmentation of
megakaryocytes
- control bleeding by aggregating & adhering to
sites of vascular injury forming a plug.
- release substances that activate coagulation Fx
- life span is 7-14 days
Plasma – liquid portion of blood compose of
water, plasma protein, electrolytes and
non-electrolytes, and metabolic waste products
Plasma protein
Albumin – responsible for osmotic pressure
Globulins :
Alpha and Beta - binding globulins
- transport hormones
Gamma - contains antibodies (GAMED)
Fibrinogen – thrombin acts on fibrinogen
to form fibrin clots
Plasminogen – is activated into the
enzyme plasmin which lyze
fibrin
 Hemostasis :
Bleeding/injury
I
Vasoconstriction
Plasminogen
I
I
Platelet aggregation Plasmin
( temporary plug) I

I I

I I
Clotting factor activation -------------- I
I I
I
Intrinsic pathway (8,9,10,11,12) Extrinsic pathway (3,7,10) I
(PTT ) (PT) Vit K dep. I
I I I I
I Prothrombin activation I I
I I
Thrombin I
RETICULOENDOTHELIAL SYSTEM
- responsible for removing the foreign
particulate material that enters the body
- composed of special tissue macrophages
located in:
. Spleen - site of activity for most
macrophages
. Lymph nodes
. Liver - Kupffer cells
. Brain -Microglia
. Lungs - alveolar macrophages (dust cells)
. Peritoneum
Which of the following laboratory values
would the nurse expect to be elevated in
a patient with a parasitic infection who
recently immigrated to the United states?

a. White blood cell count

b. Reticulocytes count
c. Eosinophils count
d. Sedimentation rate
HEMATOLOGIC
DISORDERS
Disorders of Erythrocytes ( RBC )

a. Anemia
b. Polycythemia

Fe, folic acid, vit. B 12, pyrodoxine, copper

Erythropoiesis --------------- RBC (hemoglobin)

(bone marrow) (15 gms of hg/dL)
Anemia
- a decrease in hemoglobin content (< 10 mg/dL)
that impairs O2 transport.
1. anemia secondary to blood loss
- acute blood loss ( trauma )
- chronic blood loss (intestinal parasitism)

2. anemia secondary to reduced erythrocyte production

- iron deficiency anemia
- megaloblastic anemia (Vit. B12, (pernicious)
and folic acid deficiency)
- bone marrow failure ( aplastic )
- end-stage renal failure ( decrease in erythropoietin
production )
3. anemia secondary to excessive erythrocyte
destruction (hemolytic anemia)
- sickle cell anemia
- thalassemia
- hereditary spherocytosis
- glucose-6-phosphate
dehydrogenase deficiency
- infectious agents (malaria)
A patient admitted to the hospital with a
diagnosis of chronic renal failure should
be assessed for which of the following
manifestations? ..

a. hypotension
b. fatigue
c. flushed skin
d. painful urination
IRON DEFICIENCY ANEMIA
- Iron stores are depleted resulting to a decrease
production of hemoglobin
Etiology :
- blood loss (menstruation)
- poor nutrition
Manifestations :
- pallor, weakness and fatigue, pica, irritability,
dizziness, headache, dyspnea, tachycardia
atrophic glossitis (smooth red beefy tongue),
spoon shaped brittle nails (koilonychia)
Diagnostics :
- CBC = hemoglobin < 10 mg/dl
RBC count < 3 million cells/mm3
- Blood smear (hypochromic & microcytic RBC)
- Iron Profile
* low serum iron level (<50-150ug/dL)
* low ferritin and hemosiderin (iron stores)
* high TIBC (transferrin) (>250-350g/dL)
 Interventions :
- Iron rich food ( dark green leafy vegetables,

fruits meat, poultry, fish )

- Give iron supplements between meals for
better
absorption (given at least 6 months)
- Give with fruit juices or Vit. C
(increase absorption)
- Do not give with milk & antacids
(decrease absorption)
- Liquid iron preparation stains the teeth and
- Black stool & constipation is expected during
oral iron supplements
- iron supplements Iron injectables

(Iron dextrans) are given using Z-track

technique to avoid staining on the skin
- Don’t massage the injection site
- Blood transfusion for severe anemia

(hgb <8 mg/dL)

BLOOD TRANSFUSSION
Blood Group system :
- ABO
- Rh (Rhesus)

ABO BLOOD GROUP SYSTEM

Blood Types Antigen Antibodies

Type A (41%) A B
Type B (10%) B A
Type AB (4% ) AB none (universal recipient)
Rh Group System

• Named because of the presence or

absence of one of eight Rh antigens
(agglutinogen D)
• Positive (has D antigen)
Negative (absence of D antigen)
• Most Americans are Rh+
• Problems can occur in mixing Rh+ blood
into a body with Rh– blood
 Rh Dangers During Pregnancy and
Blood Transfusion
• The mismatch of an Rh– mother carrying an Rh+ baby
can cause problems for the unborn child
• The first pregnancy usually proceeds without
problems
• The immune system is sensitized after the first
pregnancy
• In a second pregnancy, the mother’s immune
system produces antibodies to attack the Rh+
blood (hemolytic disease of the newborn)
• To prevent sensitization – give anti-Rh antibodies
Rho-GAM during exposure
Complications of Blood Transfusion :
 Hemolytic transfusion reaction
- donor blood is incompatible with the recipient’s blood
- most fatal, may present chills, diaphoresis and back
pains
 Febrile non-hemolytic reaction

- fever and chills due to sensitivity to leukocyte or

platelet antigen – most common
 Allergic and Anaphylactic reactions

- rashes and itchiness, dyspnea, bronchospasm due to

sensitivity in foreign proteins in plasma
A child presents in the clinic with iron deficiency
anemia. As the nurse, you would expect which
of the following symptoms to be present in this
patient?….

a. Abdominal pain and vomiting

b. Poor posture and unclear speech
c. Bradycardia and dyspnea
d. Poor muscle tone and decreased activity
MEGALOBLASTIC ANEMIA
- the RBC produced are abnormally large and easily
destroyed due to disturbed DNA synthesis

- Etiology :
1. poor intake of vitamin B12 and/or folic acid
- Vitamin B 12 def. is common in strict vegetarians
- Folic acid is common in alcoholism and pregnancy
2. malabsorption
- sprue, parasitism
3. lack of intrinsic factor ( pernicious anemia)
- chronic gastritis, gastrectomy
Manifestations :
- pallor, weakness, fatigue, irritability,
- smooth sore red tongue, mild jaundice
- neurologic manifestations such as
paresthesias occur with Vitamin B 12
deficiency but not with folate deficiency
- vetiligo and premature graying of skin is
associated with Vitamin B 12 deficiency
- neural tube defects (folic acid deficiency)
Diagnostics :
- CBC : low hemoglobin and RBC count
- Blood Smear (macrocytic RBC)
- Unconjugated hemoglobin is elevated
- Schilling’s Test for Vitamin B 12 deficiency
- serum folate < 4/ngml
Interventions :
- meat diet for Vitamin B12 & folic acid deficiency
- oral Vitamin B 12 preparation for those with
deficient intake of Vitamin B 12.
- if the anemia is secondary to absence of
intrinsic factor or malabsorption :
IM Vitamin B 12 is given monthly throughout life
- folic acid is given through IM for 10 days
followed by oral preparation
- Folate supplements should never given without
pernicious anemia is being ruled out
- Iron supplements
 Which of the following observations of a
patient who has pernicious anemia would
indicate that the goal of care has been
achieved? ..

a.The patient’s skin has no petechiae.

b.The patient’s tongue has lost its beefy
red color.
c.The patient has no dependent edema.
d.The patient has a good appetite.
APLASTIC ANEMIA
- deficiency of circulating erythrocytes resulting
from arrested development of red blood cells
due to hypoplastic bone marrow
Etiology :
congenital (Fanconi’s anemia)
exposure to myelotoxic agents
autoimmune disorders
Clinical Manifestations :
1. Pancytopenia
2. signs of : anemia
bleeding
recurrent infection
Diagnostics :
CBC : RBC count< 1 million/mm3 (normocytic)
WBC < 1000/mm3
platelets <30,000/mm3
bone marrow aspiration (iliac crest)
conversion of red marrow to fatty marrow
Interventions :
- discontinue immunosuppressive drugs
- bone marrow transplant is the treatment of
choice for autoimmune etiology
- blood transfusion
- reverse isolation to prevent patient acquiring
infection
- minimize invasive procedures
SICKLE CELL DISEASE
- Sickle cell disease is caused by the
inheritance
of an abnormal gene where in hemoglobin A

is replaced by abnormal sickle hemoglobin S

- valine replaces glutamic acid

Presentations :
1. Sickle cell trait – heterozygous (mild form)
2. Sickle cell anemia – homozygous ( severe)
3. Sickle cell crises – onset of pain
Pathophysiology :
- Insufficient O2 and dehydration cause the
cells to sickle and cells become rigid and
clumped together
- this clumping together result to hemolytic
anemia and crisis
Manifestations :
- hemolytic anemia
jaundice, hepato-splenomegaly, cholelithiasis
fatigue and weakness

- thrombosis and infarction

pain, claudications, ulcers, CVA
Diagnostics :
- blood smear (sickle shape)
- Sickle-Turbidity Test (use for screening)
blood mixed with sickledex solution,
cloudiness indicates the presence of Hb S
Interventions : supportive therapy
- care focus is to prevent crisis:
preventing exposure to infection,
maintaining normal hydration and enough
oxygenation, rest
- packed RBC transfusion
- pain management in vaso-occlusive crisis
(morphine)
 A nurse is assigned to care for a client in
labor who has diagnosis of sickle cell
anemia. The nurse prepares to
implement which of the following to
assist in preventing a sickling crisis from
occurring during labor? ..

a. Reassure the client

b. Administer oxygen
c. Maintain strict asepsis
d. Monitor the temperature
THALASSEMIA
- an autosomal recessive disorder
characterized by the reduced production of
one of the globin chains (alpha or beta) in
the synthesis of hemoglobin
- this decrease hemoglobin production
increases the rigidity of the RBC results to
premature destruction of these cells leading
to hemolytic anemia
Classified :
1. alpha
2. beta (classic thalassemia, most common)
Types :
1. Major (homozygous) = severe anemia
2. Minor (heterozygous) = asymptomatic
Signs and Symptoms :
- greenish yellow skin tone
- hepatosplenomegaly, cholelithiasis
- anemia
Laboratories :
- blood smear (target cells)
- elevated fetal hemoglobin
(gamma hemoglobin)
- elevated S. bilirubin
Interventions :
- bimonthly or monthly packed RBC
transfusion is the mainstay of therapy
- splenectomy
- chelation therapy with deferoxamine IV
- alternate period of rest and activity
GLUCOSE-6-PHOSPHATE
DEFICIENCY
- an X-linked defects which deficiency in this
enzyme leads to RBC membrane instability
due to poor glucose metabolism
- hemolysis may results after a stressed
condition such as fever or exposed to certain
drugs and chemical oxidants
(antimalarial, sulfonamides, aspirin, OHA, etc.)

Manifestations :
- asymptomatic if no triggering factors
- anemia, jaundice, hemoglobinuria
- straw colored urine
Laboratories :
- Peripheral blood smear may reveal degraded
hemoglobin within the RBC (Heinz bodies)
- screening test or a quantitative assay of
enzyme
- elevated serum billirubin

Management :
- stop the offending medications, self-limiting
after 14 days
- educate about the disease and give patient
a list of medication to avoid
- rest and fluids
- blood transfusion
HERIDETARY SPHEROCYTOSIS
- characterized by an abnormal permeability of
the RBC membrane with the influx of the
sodium ions
- this permits the cells change into spherical
shape and destroy prematurely in the spleen.

Manifestations :
- anemia, jaundice, splenomegaly
- gallstone
Diagnostics :
- peripheral blood smear (sphere shape)
- UTZ of the spleen (splenomegaly)
- increased osmotic fragility test
- RBC easily ruptured when exposed to
hypotonic saline solution

Interventions :
- splenectomy and blood transfusion
- deferoxamine IV
Polycythemia
- an increase above normal in the number of
red blood cells in the circulating blood.

Types :
 polycythemia vera
a myeloproliferative disorder where the
etiology is unknown
 secondary polycythemia
develop in response to tissue hypoxia
(COPD)
Hallmarks of the Condition :
1. overproduction of erythrocytes
2. excessive myelocytes (leukocytes are normal)
3. overproduction of platelet
Clinical Manifestations :
 increase in blood viscosity
dusky redness of the mucosa (plethora)
hypertension, dizziness and headache
 CHF (DOB and orthopnea )
 thrombus formation (ulcers, MI, CVA,
gangrene)
 enlarge liver and spleen
 gout
Laboratory Findings :
- Hemoglobin of > 18 g/dL = males; >17 g/dL = females
- Hematocrit of > 54% = males; > 49 % = females
Nursing management :
 increase activity to prevent thrombi
 anticoagulants
 good hydration
 assist in venesection = removing 500 to 2000
ml of blood until Hct returns to normal
 myelosuppressive agents = chlorambucil
 limit iron intake
 treat the underlying cause if it is secondary
polycythemia
DISORDERS OF
LEUKOCYTES
(WBC)

1. LEUKEMIA
2. LYMPHOMA
3. MULTIPLE MYELOMA
Leukemia
– are malignant disorders of blood-forming
tissues characterized by uncontrolled
proliferation of immature WBC (blast) in the
bone marrow, liver, spleen and lymph nodes.

Etiology :
- unknown, genetic, environmental factors,
exposure to radiation, chemicals and
medications
 Classifications :
Acute Leukemias
- rapidly progressive
- fatal
Chronic Leukemias
- gradual in onset
- milder and have more
normal cells

10. Acute Lymphocytic - common in children; 90%

11. Acute Myelogenous - common in adult
12. Chronic Lymphocytic - Philadelphia chromosomes
13. Chronic Myelogenous - asymptomatic
Clinical Manifestations :
Hallmarks :
infection - fever, sorethroat
anemia - pallor, fatigue, headache, dizziness
bleeding - epistaxis, hematomas, bruises

 weakness and weight loss

 splenomegaly, hepatomegaly
 lymphadenopathies, bone pains
 gout, renal stones
 Laboratory Findings :
- CBC : WBC > 200,000/mm3
RBC and platelet relatively low

- Peripheral smear & bone marrow specimen

containing an abnormal number of immature
WBC (blasts)
- Lumbar puncture shows blasts in CSF
- Bone X-rays shows lesions
Nursing Management :
- monitor and prevent infection (major cause of death)
reverse isolation, aseptic technique, avoid invasive
procedures, low-bacteria diet (avoid raw or fresh
fruit and vegetables), avoid live plants, animals,
flowers in patient’s room
- prevent bleeding, pain relief
- avoid injections, rectal suppositories, blowing the
nose, constrictive or tight clothing, avoid NSAID’s
- use soft toothbrush, or electric razor
- manage anemia :
- alternate activity and rest
- high caloric diet
- provide information regarding treatments:
a. bone marrow transplant – recommended TX
b. chemotherapy – complications
- induced infection, anemia,
- body image
- bleeding & tumor lysis syndrome
(hyperuricemia and hyperkalemia)
- sterility
c. radiation therapy – adjunct to chemotherapy
d. leukopheresis – WBC separation
 A child is being treated for acute
lymphocytic leukemia and has a platelet
count of 50,000 cells/cu mm. Which of
the following measures would the nurse
include in the care plan? .

a. no rectal temperatures
b. respiratory isolation
c. bland diet
d. strict bed rest
Lymphomas
- are lymphoid neoplasm that
results in uncontrolled
proliferation of lymphocytes

Etiology :
- unknown
- immunosupression
- associated with :
Epstein-Barr virus and
infectious mononucleosis
Classifications :
1. Hodgkin’s disease
- chronic progressive neoplastic lymphoid
disorder characterized by proliferation of
Reed-Sternberg cells in the lymph nodes
with some progression to spleen and liver.
- common to 30-40 y.o.
2. Non-Hodgkin’s lymphoma
- a lymphoid disorder which starts from the
lymph nodes but sometimes arise from
outside of lymphoid system such as bone
marrow (common)
- quickly fatal if no effective treatment given
- common in middle and older years
Clinical Manifestations :
Hodgkin’s Disease
- painless enlarged lymph nodes often in the
cervical, axilla and groin region
- B symptoms (fever, night sweats, & wt. loss)
- cough and DOB secondary to mediastinal mass
- neurologic deficit if it infiltrates spinal cord
Non-Hodgkin’s Lymphoma
- pancytopenia is common

- splenomegaly, hepatomegaly
- edema secondary to lymph node obstructions.
Laboratory Findings :
 Lymph node biopsy
Reed-Sternberg cells (+) in Hodgkin’s disease
 CT scan reveals lymph node involvement

Nursing Management :
 prepare the client for treatment base on
stages of disease
(radiation and chemotherapy)
 protect client for infection and bleeding
 maintain skin integrity
 bone marrow transplant in Non-Hodgkin’s
 A 15-year-old child is suspected of having
Hodgkin’s disease. It is most important
that a nurse perform which of the
following assessments during the initial
physical examination ?…

a. inspection of the mucus membrane

b. percussion of the kidneys
c. palpation of the lymph nodes
d. auscultation of the bowel sounds.
Hemorrhagic Disorders :
 Vascular disorders
- drug reactions and allergic disorders
- Vitamin C deficiency
 Platelet disorders
- thrombocytopenia ( DHF, ITP, DIC )
- Von Willebrand’s disease
 Clotting factors and Coagulation disorder

- Hemophilia A ( factor VIII def.),

Hemophilia B ( factor IX def.)
- liver disease
- coumadin drug toxicity (interfere in the
synthesis of Vit.K dependent clotting factors)
- heparin drug toxicity ( interfere the
action of thrombin )
 Hemostasis :
Bleeding/injury
I
Vasoconstriction Plasminogen
I I

Platelet aggregation Plasmin

( temporary plug) I
I I

I I
Clotting factor activation -------------- I
I I I

I I I
Intrinsic pathway (8,9,10,11,12) Extrinsic pathway (3,7,10) I
(PTT ) (PT) Vit K dep. I
I I I
I Prothrombin activation I I
I I
Thrombin I
I I
IDIOPATHIC THROMBOCYTOPENIC
PURPURA (ITP)
- the circulating platelets are bound to auto-
antibodies which then easily destroyed by
RES (spleen )
- platelet lifespan became shorter as 1-3 days
- unknown cause
Manifestations :
- easy bruising, heavy menses, petechiae on
the extremities and trunk, ecchymosis
- nose bleeding, gum bleeding, hemoptysis,
hematemesis, melena
Diagnostics :
- platelet count < 100,000 cu/mm3
- prolonged bleeding time with normal
coagulation time
- positive platelet antibody screening
- bone marrow aspiration shows increase
megakaryocytes
Interventions :
- nurse must alert the patient for NSAID’s
- assesses and bleeding precautions,
avoid Vasalva maneuver
- splenectomy is the treatment of choice
- immunosuppressant and platelet transfusion
DISSEMINATED INTRAVASCULAR
COAGULATION (DIC)
- rapid and extensive formation of clots, cause
the platelets and clotting factors to be depleted
- this results to bleeding and the potential
vascular occlusion of organs from
thromboembolus formation
Predisposing factors :
- abruptio placenta
- intrauterine fetal death
- amniotic fluid embolism
- sepsis, massive blood transfusion
Manifestations :
- uncontrolled bleeding
- bruising, purpura, petechiae(<3mm and
ecchymosis(>3mm)
- hematuria, hematemesis, melena
- signs of shock

Diagnostics :
- decreased
fibrinogen level, platelet count & hematocrit
- increased
PT, PTT, clotting time, fibrin split products
Interventions :
- remove the underlying cause
- vital signs and assess for bleeding and shock
- O2 therapy, volume replacement & blood
component therapy (fresh frozen plasma or
cryoprecipitate, platelet concentrates )
- avoid invasive therapy, control bleeding
- renal failure is the most common complication
 Which of the following actions would be
of the highest priority in the treatment of
disseminated intravascular coagulation
(DIC)?
..
a. Maintaining central volume
b. Correcting the triggering cause
c. Correcting the coagulation deficit
d. Maintaining strict intake and output
HEMOPHILIA
- an X-liked recessive trait (mother to son)
bleeding disorder secondary to deficiency of :
Clotting factor VIII (hemophila A)
- Classic hemophilia
Clotting factor IX (hemophilia B) –
- Christmas disease
- female is affected if father is hemophilic and
mother is carrier
Manifestations :
- abnormal bleeding in response to trauma and surgery
- joint bleeding causing pain, tenderness, swelling, and
limited range of motion
- tendency to bruise easily
Diagnostics :
- prolonged partial thromboplastin time (CF VIII and IX)
- normal bleeding time, prothrombin time, & platelet ct.

Interventions :
- maintain bleeding precaution
- prepare to administer factor VIII concentrate

or desmopressin
- immobilization & application of ice on the
affected extremity
- apply 15 mins pressure on superficial bleeding
- assess for neurological status for the risk of
intracranial hemorrhage
 An 8-year-old boy who has hemophilia A
falls in the classroom, injuring his ankle,
and is brought to the school nurse.
Immediate actions for first aid by the
nurse should include….

a. applying warm compresses

b. dispensing ibuprofen (Pediaprofen)
c. administering factor VIII
d. immobilizing the joint
DRUGS causing HEMORRHAGIC
PROBLEMS
HEPARIN sodium
- prevents thrombin from converting fibrinogen to fibrin.
- antidote : PROTAMINE SULFATE
WARFARIN sodium (coumadin)
- suppress coagulation by acting as an antagonist of
vitamin K
- antidote : Vitamin K ( Aquamephyton)
Thrombolytics (Streptokinase and Urokinase)
- activates plasminogen to generates plasmin
- antidote : Aminocarpic acid
Antiplatelet Medications (Aspirin, Ticlopidine )
- inhibit the aggregation of platelet
 Which of the following statements , if
made by a patient who has prescription
for warfarin sodium (coumadin), would
indicate the need for
further instruction?
..
a. “I should avoid using aspirin.”
b. “I should check my radial pulse daily.”
c. “I should limit consumption of green
vegetables.”
d. ”I should use an electric razor when I
shave.”