Medicine

Methodological instruction

Methodological instruction

to practical lesson of nurse-bachelour students

 

LESSON № 3

  Theme 1. Anaemia. Disturbance of  hemostasis system.

  Theme 2. Leucopenia. Leucocytosis. Leucosis.

 

  Aim: To be able to evaluate changes of physical and chemical parameters of blood after blood loss for ground reasonable pathogenetic therapy of posthemorage syndrome. To be able to evaluate based on laboratory data a state of coagulate and anticoagulate systems of blood and explain pathogenesis hyper- and hypocoagulative syndromes, to be able to define and analyze quantitative changes of erythrocytes and haemoglobin in anaemia, to be able to define and analyze quantitative changes of erythrocytes and haemoglobin in anaemia. To learn to analyse hematologic picture of various kinds of leuсosis. To be able to discern various kinds of leucocytosis and leucopenias, to evaluate their clinical significance

 

Professional motivation

Blood loss frequently occures both in peace, and  military time. During first and second world wars blood loss was  the reason of death of  30-33 % of wounded.  Preservation of life of blood lost victim depends on time and the medical measures thet would be provided . It is necessary to take into account, that the consequences of blood loss depends  not only on the amount  of  blood loss, but also both from speed of blood loss and for reactivity of the organism. The hardness of blood loss is evaluated, mainly  accordiny to disturbance of hemodynamic and physic and chemical parameters of blood. The main principle  of pathogenetic therapy - transfusion of blood and blood substitues with the purpose of correction the hemodynamic  parameters and stimulation of blood formation.

The liquid state of blood is provided with difficult interaction of three systems – coagulative, ancoagulative and fibrinolytic. Alteration each of them can cause to decrease or increase of coagulation of blood. The decrease of coagulation(hypocoagulation) appears like hemorrhagic syndrome. It’s appears as results of alteration thrombocytous-vessels hemostatic(thrombocytopenia and thrombocytopathia) or disturbance of various stages of coagulation of blood (hemophilia A, B, C, afibrinogenemia). The increase of coagulation of blood (hypercoagulation) is considered as major mechanism formation of thrombus. One of the most serious consequences is alteration of hemostasis, which includes both hyper- and hypocoagulation, is syndrome of disseminated intravascular coagulation of blood – DIC-syndrome. It develops as complication in traumatic, anaphilaxic or cardiogenic shock, malignant tumours, acute kidney insufficiency, exfoliation of placenta, septicemia, massive hemolysis. The consequences of disturbances coagulation of blood quite often acquire menancing character and demand emergency measures from the medical staff.

Anemia appears on the base of various diseases, intoxycations, bloodloss. Therefore clinicists of various specialities often find them in the practical activity. The quantitative changes erythrocytes and hemoglobin are one of the most important parameters for diagnosis of anemia and its treatment. Changes of these parameters also judge about effect of treatment. Using the quantitative characteristics of erythrocytes and haemoglobin gives possibility to define one more clinicaly important parameter - colour index. Basing on a colour index one can judge about the saturation of erythrocytes by haemoglobin. The value of a colour index (norm, decrease, increase) has diagnostic mean.

Steady growth of number of leucosis among the population of many countries of the world and high lethality demand steadfast attention to the given pathology. Preventive measures have the large significance in struggle with leucosis. Therefore it is important for the future doctor to acquire existing submissions about etilogy of leucosis (chemical cancerogens, ionizating radiation, virus infection). Each form of leucosis differs by characteristic shifts of cytostructure of peripheral blood and bone marrow. On these features differential diagnostics of leucosis is constructed. It is necessary to mark that the therapy of leucosis mainly pathogenetic. The deepening of our submissions about separate chains of pathogenesis will promote perfecting of purposeful treatment. Leucocytosis and leucopenias are considered as a reaction hematopoietic system due to action of physiological and pathological irritations. Leucocytosis is a pathological symptom of many diseases. In a basis of leucocytosis lay pathophysiological mechanisms connected with proliferation, maturation going out of leucocytes and their flow into vessels and redestribution. Different kinds of leucocytosis may be the additional criteri for establish the diagnosis. Eosinophilia, for example, is characterized for allergy reactions, neutrophile leucocytosis - for acute inflamation processes. Leucopenia may depend upon oppressive influence of some toxines on the maturation and outflow of leucocytes from the bone-marrow. Often these phenomenas are observed during the infectious diseases. They have significanse for the differential diagnostic. If for the disease is characterised leucocytosis, the availability of leucopenia testifies on depression of hemopoietic system. It is regarded as a criteri weakenes of reactivity of the body on action of pathological factors. Directness and character of changes of white blood cells due to various diseases - significant for the diagnosis and control of the treatment.

 

1. Program of independent students preparation

 

Theme 1 of practical lesson

1.     Disturbance of general blood volume: olygocytemic and polycytemic normovolemia, simple, olygocytemic and polycytemic hypo- and hypervolemia 

2.     Characteristic of blood loss: reasons of blood loss, mechanisms of  going out of blood from vessels, consequences of blood loss

3.     Mechanisms of immediate compensation: spasm of peripheral vessels, going out of blood from depot, transition of liquid from tissues into vessels, tachycardia, increase of heart output, deepening and become more frequent of breath, increase  of blood coagulation

4.     Remote mechanisms of compensation: intensification of erytropoesis, restoring of protein component of blood

5.     Principles of pathogenetic therapy: restoring of circulatting liquid volume, restoring of an amount erythrocytes and hemoglobin, restoring of blood proteins content

6.     General notion about pathology of hemostasis: hypercoagulation, hypocoagulation, clinical manifestations hyper- and hypocoagulation

7.     Suppression vascular-thrombocyte hemostasis: thrombocytopenia, idiopathic thrombocytopenia purpura, thrombocytopenia of newborn, medicinal thrombocytopenia, immune thrombocytopenia, thrombocytopathy, Villebrand’s disease, medicinal thrombocytopathy

8.     Suppression of coagulative hemostasis: hemophilia A, hemophilia B, hemophilia C, hemorrhage on ground K-hypovitaminosis.

9.     DIC-syndrome: essence of process, feature of thrombus formation, reasons of DIC-syndrome,

10. Stages of DIC-syndrome, lesion of organs in DIC-syndrome, pathogenetical principles of treatment

11. Classification of the pathological kinds of eryrthrocytes, elements of normal regeneration, elements of pathological regeneration, regenerative cells

12. Elements of normal regeneration: erythroblast, basophilic normocyte, polychromophilic normocyte, oxyphilic normocyte, reticulocyte

13. Elements of pathological regeneration: megaloblasts, megalocytes

14. Degenerative   kinds of the erythrocytes: hypochromial erythrocytes, anisocytes, poykilocytes, erythrocytes with Joly’s bodies, erythrocytes with Kebot’s ring, erythrocytes with basophilic granules

15. General information about anemias: definition of concept “anemia”, etiology of various kinds of anemia

16. Classification of anemias: by pathogenesis, colour index,  type of erythropoiesis,  regenerative ability of  bone marrow

17. Posthemorrhagic anemia: acute posthemorrhagic anemia, chronic posthemorrhagic anemia, principles of   posthemorrhagic anemia treatment

18. Hemolytic anemias: hereditary – membranopathies (hereditary microspherocytosis, hereditary stomatocytosis, hereditary elliptocytosis, hereditary pyropoikilocytosis, hereditary echinocytosis, hereditary  akantocytosis, enzymopathies (caused by deficiency of glucose-6-phosphatedehydrogenase, caused by deficiency of pyruvatekinase), hemoglobinopathies (sickle-cell anemia, thalassemia; acquired – toxic hemolitic, immune hemolitic, mechanical, acquired membranopathy.

      Theme 2 practical lesson

1.                 Classification of leucosis. Definition of the notion “leucosis”, FAB-classification of acute leucosis, acute myeloblastic leucosis, acute lymphoblastic leucosis, chronic myeloid leucosis, chronic lymphoid leucosis, stages of a progression of chronic leucosis

2.                 Etiology of leucosis The role of chemical mutagenes, role of ionizing radiation and of  virus infection, role of virus infection

3.                 Mechanisms of leucosogenes, point mutations, chromosome transformations, virus transduction, insertion, gene amplification

4.                 Disturbance of  blood cells formating in leucosis

5.                 Hematologic difference between acute and chronic leucosis

6.                 Picture of blood of acute myeloblastic leucosis

7.                 Picture of blood of chronic lymphocyte leucosis, picture of blood of chronic myelocytic leucosis, leucemic clone

8.                 Complications of leucosis: anaemia, trombocytopenia, hemorrhagic syndrome, reduction of resistance to the infectious agents

9.                 Leucocytosis, absolute leucocytosis, relative leucocytosis, neutrophilosis, eosinophilia, basophilia, lymphocytosis, monocytosis

10.             Mechanisms of leucocytosis occur

11.             Leucopenias, absolute leucopenia, relative leucopenia, neutropenia, eosinopenia, lymphocytopenia, monocytopenia, agranulocytosis, aleukia, pancytopenia

12.             Mechanisms of leucopenias occur

13.             Shifts of leucocytes formula, regenerative shift, hyperregenerative shift, degenerative shift, regenerative-degenerative shift, nuclear shift to the right

14.             Leucomoid reaction

 

2. Examples of the tests and real-life tasks

Test 1. After massive blood loss victim had  hypovolemic shock with development  of deep hypoxia.  Its  consequences will have an effect, first of all, on activity of:

А. Lungs  

В. Kidneys   

С. Spleen    

D. Brain     

Е. Heart.

Test 2. In the patient in time accident on Chernobel atomic power station  arose hemorrhagic syndrome, which was showed by hemorrhage in skin and mucous membrain, appearance of blood in urine, faces and phlegmon. The mechanism of hemorrhagic syndrome consists of:

A. Activation of fibrinolytic  system  

B. Accumulation of heparin in blood

C. Decrease amount of thromocytes

D. Violation of structure of fibrinogene     

E. Lesion vascular wall

Test 3. At 40 year old man, which is in branch of reanimation, the decrease of hematocrite up to    0,30 l/l is revealed. What process, most probable, has resulted in such state?                 

A. Intensive sweating 

B. Frequent vomiting 

C. Long diarrhea

D. A gastric bleeding   

E. Strengthened urineproduction

 

Task 1. Victim is delivered in receiving branch of hospital by the casual transport through 8 minutes after traffic incident. Complains on  pain in  stomach with irradiation into the right shoulder. The skin is  pale, is covered with cold sweat. Arterial pressure - 95/70 mm Hg, pulse – 102 beats for 1 minute, breath - 28 for 1 minute.  The blood was taken immediately on analysis  an amount of erythrocytes - 4,2×1012/l, hemoglobin content - 122 g/l.

1.  Analyse these data. What parameters deviate from norm?

2.  What it is possible to think about in this case?

3.  How does it explained painless of skin? What does it mean  this reaction?

4.   How  do you evaluate the increase of rate  pulse and breath?

Task 2. Amount of erythrocytes of the patient 3,5∙1012/l, contain of hemoglobin - 86 g/l.

1. What is this state name?

2. Define colour index.

3. What does it testifie about?

 

3. Answers to the assessments and questions of the real-life tasks

Tests: 1 – D, 2 – C, 3 – D.

 

Task 1

1.  A victim has low   arterial pressure, increase of rate pulse and breath. Parameters of blood without essential changes.

2.  May assume presence of internal bleeding in the patient.

3.  The paleness of skin is connected with spasm of peripheral vessels. It is protective reaction, which arise in a  results of excitation  of sympaticoadrenal system. It is directed on improvement of blood supply of  brain and heart.

4. The increase of pulse and breath has compensatory significance.

Task 2

1. This state is called anemia.

2. Colour index (CI) = 86 ∙ 3 : 350 = 0,74.

3. The colour index testifies about the decrease of saturation of erythrocytes by hemoglobin   (hypochromic anemia).

 

4. Informational sources

Basic

1.     Pathological physiology / Yu.I. Bondarenko, M.R. Khara, V.V. Faifura, N. Ya. Potikha. Ternopil: Ukrmedkniga, 2006. – 312 p.

2.     Methodological instructions

Additional:

1. Robbins basic pathology, 7/e / Kumar et al. – Indian reprint, 2004. – 873 p.

 

5. Students’ practical activities

Theme 1 practical lesson

Work 1. Real-life tasks solve.

Task 1. The activation of two endocrine glands play the part in immediate mechanisms of blood loss compensation.

1. Name this glands.

2. What hormonts of this glands take part in the compensation of blood loss?

3. What is a mechanism of action of this hormones ?

Task 2. The patient lost 20 % of blood in crash.

1. What is a quantity of hematocrite parameter (normal, lower, the highest) in 10 minutes, in 3 hour, in 1 month after blood loss?

2. Ground their opinion.

Task 3. The patient lost 20 % of blood.

1. Is  such blood loss dangerous to his life?

2. What disorders arise after massive blood loss?

Design the protocol in form the solution of problems.

Task 4. At experimental animal is taken blood in test-tube, which contain sodium citrate. At what stage the process of coagulation of blood will be suspended in use given anticoagulants.

Task 5. For recognise of hemophilia kind to three portions of blood of the inspected patient was added samples of plasma, according without VІІ, ІХ, ХІ factors coagulation of blood. The normalization of time  coagulation of blood has passed in test-tube, in which were added test plasma with expressed deficiency VШ and ХІ factors.

1. What kind of hemophilia is in the patient?

2. What type of hemostasis pathology does this disease belong to?

3. What coagulative factor deficiency is it?

Task 6. In the ill child of the 2-nd years with expressed hemorrhagic syndrome was revealed sabsence antigemophilic globulin (factor VШ) in plasma of blood.

1. What disease the child does suffer from?

2. Indicate, what phase of blood coagulation of primary hemostasis is disturbed in this case?

3.    What mechanisms of prothrombinase activity formation – external or internal –   will be defective?  

Task 7. The patient suffers from hereditary coagulophathy because deficit of the factor ХІІ (Hageman).

1. What phase of blood coagulation does change in this case?

2. How does fibrinolisis change in the patient?

Task 8. Hemorrhagic syndrome arose in the patient after operation on pancreas. What mechanism of hemostasis does damage?

Task 9. At inspection of the patient with atherosclerosis doctor determined body’s weight – 120 kg, increase of blood coagulation property.

1. Explain the mechanism of this phenomenon.

       2. Explain connection between obesity, atherosclerosis and system of hemostasis.

 

Work 2. Analysis of hemograms

1. Analyse and estimate quantity of each indicator of red blood (erythrocytes, hemoglobin, CI): norm, more, less.

2. Select the type of anemia according to colour index: normochromic, hyperchromic, hypochromic.

3. Give the examples of diseases in wich this anemia occurs.

 

Hemogram 1

Eryth-rocy-tes

Hemo-glo-

bin

CI

ESR

Leu-

kocy-

tes

Baso-

phils

Eosi-

no-

phils

Neutrophils

Lym-

pho-

cytes

Mo-

no-cy-

tes

meta-

myelо-

cytes

stab-

nucle-

onic

segmen-

tonucle-

onic

∙1012/l

g/l

 

mm/h

∙109/l

%

%

%

%

%

%

%

2,9

60

0,62

9

6

1

2

-

5

56

31

5

 

Hemogram 2

Eryth-rocy-tes

He-mo-glo-

bin

CI

ESR

Leu-

kocy-

tes

Ba-so-

phils

Eosi-

no-

phils

Neutrophils

Lym-

pho-

cytes

Mo-

no-cy-

tes

meta-

myelо-

cytes

stab-

nucle-

onic

segmen-

tonucle-

onic

∙1012/l

g/l

 

mm/h

∙109/l

%

%

%

%

%

%

%

3,25

100

0,92

7

7

1

3

1

4

55

31

5

 

Hemogram 3

Eryth-rocy-tes

He-mo-glo-

bin

CI

ESR

Leu-

kocy-

tes

Ba-so-

phils

Eosi-

no-

phils

Neutrophils

Lym-

pho-

cytes

Mo-

no-cy-

tes

meta-

myelо-

cytes

stab-

nucle-

onic

segmen-

tonucle-

onic

∙1012/l

g/l

 

mm/h

∙109/l

%

%

%

%

%

%

%

3,80

130

1,03

8

5

1

4

-

2

59

28

6

Hemogram 4

 

Eryth-rocy-tes

He-mo-glo-

bin

CI

ESR

Leu-

kocy-

tes

Ba-so-

phils

Eosi-

no-

phils

Neutrophils

Lym-

pho-

cytes

Mo-

no-cy-

tes

meta-

myelо-

cytes

stab-

nucle-

onic

segmen-

tonucle-

onic

∙1012/l

g/l

 

mm/h

∙109/l

%

%

%

%

%

%

%

3,26

143

1,32

5

7

1

5

1

6

53

30

4

 

Work 3. Microscope study the picture of blood and bone marrow in various kinds of anemia:

Slide 1. Iron-deficiency anemia – blood

Slide 2. Pernicious (B12-deficiency) anemia – blood

Slide 3. Pernicious (B12-deficiency) anemia – bone marrow

 

Theme 2 practical lesson

Work 4. Microscopy investigation of blood smear sick on leucosis

Immersial microscopia is necessary to use for investigation. To study a picture of blood of following kinds of leucosis:

а) Acute undifferentiated leucosis

b) Acute myeloblast leucosis

c) Chronic myelocyte leucosis

d) Chronic lymphocyte leucosis

Pay attention to peculiarity of periferal blood cellular composition and leucocytes pathological forms presense. Write down protocol of experiment according to scheme. Results of investigations to give in form of drawing which reflects the picture of blood, sign all cell elements. During discussion of results to give answer for questions:

1.     Characterize cellular composition of periferal blood of acute undifferentiated leucosis.

2.     What typical changes of cellular structure of blood did you find in case of acute myeloblastic leucosis?

3.     What features of cellular structure of blood and bone marrow are characterized for chronic myelocyte leucosis?

4.     What changes of cellular structure of blood are characterized for chronic lymphocyte leucosis?

5.     Indicate distinctive features of blood of chronic erythroblastic leucosis.

6.     What hematologic differences between acute and chronic leucosis you observed?

 

Theme №2 practical lesson

Work 5. Counting of  leucocytic formula in smear of blood sick on  leucosis.

а) Acute undifferentiated leucosis

б) Acute myeloblastic leucosis

в) Chronic myelocytic leucosis

г) Chronic lymphocytic leucosis

Study smear in immersial microscope objective. For determination of leucocytic formula is necessary to calculate 100 leucocytes. Counting should be done in four various parts of smear, moving subject glass so that the fields of sight were on sufficient distance from either and other. For it also necessary pay attention to the form, sizes of cells, colour, granularity in protoplazma, form and colour of a nucleus. Put the results of counting in the table:

Basophiles

Eosinophiles

Neutrophiles

Lymphoblasts

Lymphocytes

Monocytes

Myeloblasts

Promyelocytes

Myelocytes

Metamyelocytes

Stabnucleonic

Segmentonuclenic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Seminar discussion of theoretical questions and practical work results

1.     Three group of anemias according to pathogenesis

2.     Posthemorrhagic anemia

3.     Hereditary hemolitic anemias

4.     Acquired hemolitic anemias

5.     Anemias because of erythropoiesis disorder

6.     The blood picture in posthemorrhagic anemia

7.     The blood picture in iron-deficiency anemia

8.     The blood picture in B12-deficitncy anemia

9.     The picture of bone marrow in B12-deficitncy anemia

10. 10.Immediate mechanisms of compensation after blood loss

11. 11.Remote mechanisms of compensation after blood loss

12. 12.DIC-syndrome: reasons, stage, pathogenesis of each stage, principles of treatment

13. 13.Hemophilia: kinds, pathogenesis, principles of treatment

14. Presentation of hemoblastoses, general characteristic of their basic groups

15. Leucoses as tumors. Principles of classification of leucoses (acute, chronic; myelo-, lymphо-; primary, secondary).

16. Etiology of leucoses: characteristic of leucosogenic factors of physical, chemical, biological nature. Mechanisms of their transforming action on the stem cells of bone marrow. Anomalies of genotype and constitution as factors of risk of origin and development of leucoses.

17. Children "peaks" of leucoses

18. Typical laws and features of pathogenesis of acute and chronic leucoses: violation of cellular composition of marrow and peripheral blood; morphological, cytogenetic, cytochemical, immunophenotypic characteristics; systemic violations in the organism

19. Progression of leucoses, concept of "blastic crisis". Metastases of leucoses

20. Principles of diagnostics and treatment of leucoses

21. Leucocytosis, principles of classification

22. Reasons and mechanisms of reactive leucocytosis development

23. Neutrophil, еоsinophil, basophil, lympho- and monocyte leucocytosis

24. A concept of the nuclear shift of neutrophils, its varieties

25. Leucopenia, principles of classification. Reasons, mechanisms of leucopenia and agranulocytosis (neutropenia) development. Pathogenesis of basic clinical signs

26. Acquired and inherited violations of structure and function of leucocytes. Leukemoid reactions

 

 

 

7. The initial level of knowledge and abilities is checked up by sjlve real-life situations from every theme, by answers for tests and constructive questions (presence of complete sets of tests amd real-life situations at a teacher).

 

8. Student should know:

1.     Reasons of blood loss

2.     Mechanisms of an going out of blood from vessels

3.     Consequence of blood loss

4.     Immediate mechanisms of compensation

5.     Remote mechanisms of compensation

6.     Diagnostic significance of main physical and chemical parameters of blood

7.     What is hyper- and hypocoagulation

8.     Clinical manifestations hyper- and hypocoagulation

9.     Reasons of occurrence thrombocytopenia

10. Reasons of occurrence thrombocytopathy

11. DIC-syndrome, stages of  DIC-syndrome

12. Lesion of organs in DIC-syndrome

13. Definition of concept “anemia”

14. Reasons of anemias occurrence

15. Classification of anemias

16. Classification of the pathological forms of erythrocytes in blood

17. Etiology and pathogenesis of various kinds of anemias

18. Scheme of blood cells forming

19. Classification of leucosis

20. Picture of blood of various forms of leucosis

21. Kinds of leucocytosis and leucopenias

22. Reasons of development of  leucocytosis and leucopenias

23. Differences between leucosis and leukemoid reaction

 

 

9. Students should be able to:

1.     To explain the mechanisms of urgent compensator responses after blood loss

2.     To explain the mechanisms of the remote compensator responses after blood loss

3.     Explain the pathogenesis of idiopathic thrombocyte purpura

4.     Explain the pathogenesis of thrombocytopenia of newborn

5.     Explain essence alteration of hemostasis in hemophilia A and B

6.     Explain the reasons of hemorrhage in hypovitaminosis

7.     Explain features formation of thrombus in DIC-syndrome

8.     Reveal essence alteration of hemostasis in each stage of DIC-syndrome

9.     Formulate principles pathogenetic treatment of DIC-syndrome

10. Evaluate state of hemostasis for data situational problems

11. To define an amount of erythrocytes and hemoglobin in blood

12. To calculate colour index using the simplified formula

13. To give interpretation to obtained results

14. 17. Distinguish the pathological forms of blood erythrocytes

15. Differentiate various kinds of anemias based on gualitative changes of erythrocytes

16. Describe a picture of blood and bone marrow of the various kinds of anemias

17. To explain the etiology and pathogenesis of leucosis

18. To differentiate cellular elements of blood and marrow of various forms of leucosis

19. To classify leucosis on the basis of hemathologic picture

20. To explain differences in cellular structure of blood of acute and chronic leucosis

21. To explain mechanisms of development of anemia and hemorrhagic syndrome, and also reduction of resistance  of an organism to the infectious agents in the patients  with leucosis

22. To classify leucocytosis and leucopenias

23. To explain mechanisms of leucocytosis and leucopenias occurrence

24. To calculate an amount of leucocytes in blood

25. To estimate an amount of leucocytes changes in pathological processes

26.  To identificate pathological forms of leucocytes in smear of  peripheral  blood sick on acute myeloblastic leucosis, chronic myeloid leucosis and chronic lymphoid leucosis.

27.  To analyse of leucogrammes sick on acute myeloblastic, chronic myeloid leucosis and chronic lymphoid leucosis

28.  To determine the leucocytic formula 

 

 

 

 

Methodological instruction made by prof. Yu.I. Bondarenko, as. prof. N.Ya. Potikha.

 

The methodological instruction was discussed

and confirmed at the Department sitting 

“29”  of August, 2013.  Minute № 2.