🔬 Full Blood Count (FBC) — Normal Ranges & Interpretation
| Parameter | Normal Range (Adult) | Low — Consider | High — Consider |
|---|
| Haemoglobin (Hb) — Male | 130–175 g/L | Anaemia (iron/B12/haemolysis) | Polycythaemia vera, dehydration |
| Haemoglobin (Hb) — Female | 120–155 g/L | Anaemia, pregnancy, blood loss | Erythrocytosis |
| White Cell Count (WCC) | 4.0–11.0 ×10⁹/L | Neutropenia, viral illness, aplastic anaemia | Infection, leukaemia, steroids |
| Neutrophils | 2.0–7.5 ×10⁹/L | Febrile neutropenia risk (<0.5 severe) | Bacterial infection, CML |
| Platelets | 150–400 ×10⁹/L | Thrombocytopaenia — bleeding risk | Reactive thrombocytosis, ET |
| MCV | 80–96 fL | <80 microcytic — iron deficiency, thalassaemia | >96 macrocytic — B12/folate, alcohol |
| MCHC | 315–360 g/L | Hypochromia — iron deficiency | Spherocytosis |
📊 Reticulocyte Count
Normal reticulocytes0.5–2.5% (25–85 ×10⁹/L)
Low reticulocytesHypoproliferative — aplastic, renal failure
High reticulocytesHaemolysis or post-haemorrhage response
Reticulocyte Production Index (RPI)>2 = adequate marrow response
Nursing: Ensure sample processed within 6 hours. Document haematinics if reticulocytes low before initiating replacement therapy.
🔭 Blood Film Assessment
- Hypochromia: pale RBCs with increased central pallor — iron deficiency
- Microcytosis: small RBCs — IDA, thalassaemia, sideroblastic anaemia
- Macrocytosis: large RBCs — B12/folate deficiency, liver disease, hypothyroidism
- Blasts: immature cells — leukaemia (EMERGENCY — notify haematologist immediately)
- Target cells: liver disease, haemoglobin C, thalassaemia
- Sickle cells: sickle cell disease
- Rouleaux: myeloma, inflammatory states
- Schistocytes: microangiopathic haemolytic anaemia (TTP/HUS/DIC)
🩸 Coagulation Screen — Reference Values
| Test | Normal Range | Prolonged/Abnormal Causes | Nursing Action |
|---|
| PT (Prothrombin Time) | 11–13 seconds | Warfarin, liver disease, factor II/V/VII/X deficiency, DIC | Check INR; withhold anticoagulant per protocol |
| INR | 0.9–1.2 (therapeutic 2–3) | >3.5 bleeding risk; >5 withhold anticoagulation | Report >4 immediately; seek reversal advice |
| APTT | 25–35 seconds | Heparin, haemophilia A/B, lupus anticoagulant | Ratio >2.5 — review heparin dose |
| Fibrinogen | 2.0–4.5 g/L | <1.0 g/L — DIC, hyperfibrinolysis, severe liver disease | Prepare cryoprecipitate if <1.5 g/L in active bleed |
| D-dimer | <0.5 mg/L FEU | Elevated: DVT/PE, DIC, infection, malignancy, pregnancy | Clinically interpret with pre-test probability score |
🦴 Bone Marrow Biopsy — Nursing Care
Pre-Procedure
- Verify informed consent and check coagulation (platelet >50 ×10⁹/L preferred)
- Stop antiplatelet/anticoagulant agents per local protocol
- Explain positioning: prone or lateral decubitus for posterior iliac crest
- Prepare local anaesthetic (lidocaine 1–2%), skin-prep, biopsy tray
- Anxiolysis: consider Entonox or oral midazolam per protocol
Post-Procedure Monitoring
- Apply firm pressure dressing for 10–15 minutes
- Monitor site every 30 min × 2 hours for haematoma, bleeding, neuro signs
- Bed rest 1–2 hours; avoid heavy lifting 48 hours
- Observe for signs of haematoma expansion — increasing pain, swelling, pallor
- Discharge criteria: dry site, stable obs, pain controlled with oral analgesia
- Results expected 5–10 working days; provide written information
💉 Peripheral Blood Stem Cell (PBSC) Collection
Mobilisation Phase Nursing
- Administer G-CSF (filgrastim/lenograstim) SC daily for 4–5 days
- Monitor FBC daily — target CD34+ cells in peripheral blood
- Bone pain management: paracetamol, NSAID if renal function adequate
- Monitor for splenic enlargement (rare rupture risk — report left upper quadrant pain)
Apheresis Session Nursing
- Large-bore central venous access (PICC/Hickman/apheresis catheter)
- Citrate anticoagulation — monitor for hypocalcaemia (tingling, cramps, tetany)
- Replace calcium gluconate IV if symptomatic; oral calcium supplements
- Session duration: 3–5 hours; target CD34+ ≥2×10⁶/kg for autologous
- Post-apheresis: monitor FBC, calcium, blood pressure, site haemostasis
⚠️ Iron Deficiency Anaemia (IDA)
Diagnostic Criteria
Ferritin<30 µg/L (confirms IDA)
Serum ironLow
TIBCElevated
Transferrin saturation<20%
MCV / MCHLow — microcytic hypochromic
IV Iron Infusion Protocol (e.g. Ferric Carboxymaltose)
- Pre-infusion: confirm allergy history, IV access (18G+), resuscitation equipment at bedside
- Pre-medication: per local policy (antihistamine not routinely recommended for newer formulations)
- Dose: calculated by Ganzoni formula or body weight/Hb-based chart
- Rate: first 15 min slow (test dose concept) — observe continuously
- Monitoring: BP, HR, SpO₂ at 0, 15, 30 min then every 30 min
- Duration: typically 15–60 min depending on preparation
🚨
Anaphylaxis Monitoring: Signs — urticaria, bronchospasm, hypotension, angioedema. Stop infusion immediately. Adrenaline (epinephrine) 0.5 mg IM (1:1000) — vastus lateralis. Lay patient flat, legs elevated. Call emergency team. Document reaction and report to pharmacovigilance.
💊 B12 & Folate Deficiency
Hydroxocobalamin (B12) IM Protocol
- Neurological involvement: 1 mg IM on alternate days until no further improvement, then 1 mg every 2 months
- No neurological involvement: 1 mg IM 3×/week × 2 weeks, then 1 mg every 3 months
- Injection site: deltoid or gluteus; rotate sites; warn patient of pain/discolouration
- Do not delay treatment awaiting results if neurological symptoms present
Dietary Sources
- B12: meat, fish, eggs, dairy, fortified cereals
- Folate: leafy greens (spinach, broccoli), legumes, fortified bread, citrus fruits
- Counsel on cooking methods — boiling destroys folate; steam where possible
🔴 Autoimmune Haemolytic Anaemia (AIHA)
Direct Antiglobulin Test (DAT / Coombs Test)
Warm AIHAIgG positive — steroids first-line
Cold AIHAIgM/complement — warm patient, avoid cold
Steroid Therapy Nursing
- Prednisolone 1 mg/kg/day PO — monitor blood glucose (steroid-induced hyperglycaemia common)
- Monitor Hb, reticulocytes, LDH, bilirubin (haemolysis markers)
- Signs of haemolysis: jaundice, dark urine (haemoglobinuria), fatigue, tachycardia
- Transfuse if Hb <70 g/L or symptomatic — crossmatch may be difficult; inform blood bank of DAT positive
💀 Aplastic Anaemia
Horse Anti-Thymocyte Globulin (hATG) Protocol
- Day 1–4: hATG 40 mg/kg/day IV over 12–18 hours
- Pre-medications: methylprednisolone, antihistamine, paracetamol 30 min before each dose
- Monitor: serum sickness (days 7–14) — fever, rash, arthralgia, renal impairment
- Ciclosporin: started day 1 and continued 6–12 months; monitor trough levels (target 150–250 ng/mL), renal function, BP, gingival hyperplasia
G-CSF Nursing (Filgrastim)
- 5 µg/kg SC daily — to stimulate neutrophil recovery
- Bone pain expected — paracetamol; monitor FBC daily initially
- Protective isolation for neutropenic patients (see Leukaemia tab)
🧬 Thalassaemia Management
Transfusion Protocol (Thalassaemia Major)
- Target pre-transfusion Hb: 95–105 g/L (suppress ineffective erythropoiesis)
- Frequency: every 3–4 weeks; use leucodepleted, phenotypically matched blood
- Monitor transfusion reactions; extended crossmatch for alloimmunised patients
- Hepatitis B vaccination essential; annual cardiac and liver MRI (T2*) for iron loading
Iron Chelation — Deferasirox Monitoring
Dose14–28 mg/kg/day PO (oral dispersible tablet)
RenalMonitor creatinine monthly — dose reduce if rise >33%
HepaticLFTs monthly; suspend if ALT >5× ULN
Auditory/visualAnnual audiogram and ophthalmology review
Target serum ferritin<1000 µg/L
🔬 Leukaemia Classification Overview
| Type | Cell Origin | Onset | Key Features | Primary Treatment |
|---|
| AML Acute Myeloid | Myeloid blast | Acute (days/weeks) | Pancytopenia, blasts >20%, fatigue, bleeding, infection | Induction chemo (7+3), allo-SCT |
| ALL Acute Lymphoblastic | Lymphoid blast | Acute | Common in children; CNS involvement; lymphadenopathy | Multi-agent chemo, CNS prophylaxis, allo-SCT if HR |
| CML Chronic Myeloid | Myeloid — BCR-ABL1 | Chronic (months) | Splenomegaly, leukocytosis; Philadelphia chromosome | Imatinib/nilotinib TKI (oral) |
| CLL Chronic Lymphocytic | B-lymphocyte | Indolent | Lymphocytosis, lymphadenopathy, autoimmune cytopaenias | Watch & wait; ibrutinib; venetoclax |
💊 Induction Chemotherapy Nursing — AML (7+3 Regimen)
Cytarabine (Ara-C) Nursing
- 100–200 mg/m² continuous IV infusion over 7 days via central line
- Assess for cytarabine syndrome (fever, myalgia, conjunctivitis) — steroid eye drops prophylaxis with high-dose
- Neurotoxicity (high-dose): cerebellar signs — ataxia, nystagmus, dysarthria; hold drug and report
- Monitor FBC daily; mucositis assessment — oral hygiene protocol
Daunorubicin (Anthracycline) Nursing
- 45–60 mg/m² IV days 1–3; MUST be given via confirmed central venous access
- Vesicant — extravasation risk: inspect site before each dose; STOP if pain/swelling
- Cardiotoxicity: baseline LVEF (echocardiogram/MUGA) required; cumulative dose limit
- Urine turns red/orange for 1–2 days — reassure patient this is normal
- Alopecia: hair loss begins 2–3 weeks after start — psychological support
⚗️ Tumour Lysis Syndrome (TLS) — Prevention & Management
🚨
EMERGENCY: TLS occurs within 12–72 hours of initiating treatment. Can cause fatal arrhythmias, renal failure, and seizures.
Metabolic Abnormalities to Monitor
HyperuricaemiaUric acid >476 µmol/L
HyperkalaemiaK⁺ >6.0 mmol/L — arrhythmia risk
HyperphosphataemiaPO₄ >1.45 mmol/L
HypocalcaemiaCa <1.75 mmol/L — tetany risk
CreatinineRising — renal failure indicator
Frequency: 4–6 hourly first 24h; 6–8 hourly subsequently in high risk
Prevention Interventions
- Allopurinol: 300 mg/day PO — start 24–48h before treatment; reduces uric acid production
- Rasburicase: 0.2 mg/kg IV — rapid urate reduction; contraindicated in G6PD deficiency (haemolysis risk); keep blood sample on ice
- IV hydration: 2–3 L/m²/day — maintain urine output >80–100 mL/hour
- Strict fluid balance: hourly urine output; furosemide if oliguric
- Avoid potassium-containing IV fluids; restrict dietary potassium
- Continuous cardiac monitoring for ECG changes (peaked T waves in hyperkalaemia)
🌡️ Febrile Neutropenia — 4-Hour Protocol
TARGET: Antibiotics within 60 minutes of presentation (door-to-needle)
- Identify: Temp ≥38.0°C (or >37.5°C twice), ANC <0.5 ×10⁹/L or expected to fall
- 0–15 min: Alert doctor immediately; IV access; blood cultures ×2 (peripheral + central if CVC present)
- 15–30 min: FBC, CRP, LFTs, U&E, CXR, urine MC&S; clinical assessment
- 30–60 min: Prescribe and administer IV antibiotics as per local protocol
- Empiric coverage: Pseudomonas aeruginosa + Staphylococcus aureus (MRSA if risk factors)
💡
Organisms to cover: Gram-negative — Pseudomonas aeruginosa, E. coli, Klebsiella. Gram-positive — Staphylococcus aureus, CoNS, Streptococcus. Common empiric: Piperacillin-tazobactam ± gentamicin or meropenem if penicillin allergy/resistance
🥗 Neutropenic Precautions
Neutropenic Diet (ANC <0.5)
- Avoid raw or undercooked meat, fish, eggs, shellfish
- No soft cheeses, unpasteurised dairy, deli meats
- No raw sprouts, unwashed fruit/vegetables; peel all fruit
- No fresh flowers or plants in room (Aspergillus risk)
- Well-cooked food only; avoid buffets and restaurant food
Protective Isolation
- Single room with positive pressure (HEPA filtration preferred)
- Strict hand hygiene — alcohol gel + soap and water with diarrhoea
- Surgical mask for staff and visitors with respiratory symptoms
- Limit visitors; no one with active infection
- Daily oral hygiene with chlorhexidine mouthwash
- Antifungal prophylaxis (fluconazole/posaconazole) per protocol
💊 CML — Imatinib Adherence Monitoring
Standard dose400 mg PO once daily with meal and large glass of water
Molecular response targetBCR-ABL1 ≤0.1% (MMR) at 12 months
Warning — suboptimalBCR-ABL1 >1% at 12 months — adherence review + mutation testing
Adherence Monitoring & Side Effects
- Oedema (periorbital, ankle) — manage with dose reduction or diuretics
- Nausea — take with food; antiemetics if needed
- Muscle cramps — magnesium supplementation may help
- Hepatotoxicity — LFTs monthly initially; hold if ALT >5× ULN
- Patient education: DO NOT stop without haematologist advice — risk of blast crisis
🎗️ Hodgkin vs Non-Hodgkin Lymphoma
| Feature | Hodgkin Lymphoma (HL) | Non-Hodgkin Lymphoma (NHL) |
|---|
| Pathology | Reed-Sternberg cells; CD30+/CD15+ | Heterogeneous; B-cell or T-cell types |
| Age distribution | Bimodal: 15–35 and >55 years | Increases with age; varies by subtype |
| Spread pattern | Contiguous lymph node spread | Non-contiguous; extra-nodal common |
| B-symptoms | Fever, night sweats, weight loss >10% | Present in aggressive subtypes |
| Common treatment | ABVD; PET-adapted therapy | R-CHOP (diffuse large B-cell lymphoma) |
| Prognosis | Generally favourable (>85% cure rate in localised) | Highly variable by subtype and stage |
💉 R-CHOP Nursing — Rituximab Infusion Reactions
⚠️
Infusion-Related Reactions (IRR) highest during first infusion — first 30–120 minutes are critical. Reaction rate up to 77% cycle 1.
Pre-Medications (30 min before rituximab)
- Paracetamol 1g PO
- Chlorphenamine (chlorpheniramine) 10 mg IV or PO
- Methylprednisolone 100 mg IV (if not already receiving corticosteroids in regimen)
- Omeprazole/lansoprazole (gastric protection with steroids)
Initial Infusion Rate (Cycle 1)
0–30 min50 mg/hour
30–60 min (if tolerated)100 mg/hour
Subsequent 30-min escalations+50 mg/hour; max 400 mg/hour
Monitoring — First 30 Minutes (Critical Window)
- Nurse at bedside for first 30 minutes of each infusion
- Vital signs (BP, HR, SpO₂, temp) every 15 minutes for first hour
- Observe for: flushing, urticaria, bronchospasm, hypotension, rigors, fever
If IRR Occurs:
- STOP infusion immediately
- Maintain IV access; administer 0.9% NaCl fluid challenge
- Bronchospasm/hypotension: adrenaline 0.5 mg IM (1:1000)
- Once resolved ≥30 min: restart at 50% previous rate
- Grade 3–4 reactions: discontinue rituximab — inform haematologist
📷 PET-CT Scan Nursing Preparation
Pre-Scan Instructions
- Fast for 4–6 hours (water allowed)
- Avoid strenuous exercise 24 hours before — reduces muscle FDG uptake
- Blood glucose must be <11 mmol/L before FDG injection (hyperglycaemia reduces scan quality)
- Avoid caffeine and sugary drinks day before scan
- Diabetic patients: coordinate insulin timing with nuclear medicine team
- Keep patient warm (reduces brown fat FDG uptake)
Post-Scan
- Radioactivity (FDG half-life 110 min): avoid prolonged contact with children/pregnant women 6 hours post
- Increase fluid intake to flush radiotracer
- Deauville score used for response assessment in lymphoma (1–5 scale)
💀 Multiple Myeloma — CRAB Criteria
C — Calcium>2.75 mmol/L (corrected)
R — RenalCreatinine >177 µmol/L or GFR <40
A — AnaemiaHb <100 g/L or >20 g/L below normal
B — BoneLytic lesions on CT/PET-CT; osteoporosis
Bortezomib (Velcade) Peripheral Neuropathy Monitoring
- Grading: Grade 1 (tingling) → Grade 4 (loss of function)
- SC administration preferred over IV (reduced neuropathy incidence)
- Assess at each cycle: pins-and-needles, pain, weakness in hands/feet
- Reduce dose if Grade 2 with pain or Grade 3: discuss with haematologist
- Pyridoxine 100–300 mg/day may help — evidence limited
🏥 Stem Cell Mobilisation (Myeloma Autologous SCT)
- Mobilisation: cyclophosphamide + G-CSF or G-CSF alone (plerixafor if poor mobiliser)
- Daily FBC monitoring; apheresis when CD34+ circulating cells >10–20/µL
- Central line care — prevent catheter-related bloodstream infection (CRBSI)
- Post-conditioning (high-dose melphalan): profound mucositis — oral cryotherapy protocol (ice chips)
- Engraftment expected day +10–14: monitor daily FBC for neutrophil recovery
🚨 Spinal Cord Compression — Oncological Emergency
SPINAL CORD COMPRESSION = MEDICAL EMERGENCY — Act within hours
- Symptoms: back pain (often first sign — 95%), bilateral leg weakness, sensory level, bowel/bladder dysfunction
- Action: dexamethasone 16 mg IV immediately (reduces oedema)
- Imaging: urgent whole-spine MRI within 24 hours (ideally <4 hours if ambulatory status deteriorating)
- Neurosurgical/radiation oncology referral: same-day; decompressive surgery vs radiotherapy decision
- Nursing: log-roll only; urinary catheter if retention; DVT prophylaxis; pressure area care
- Outcome: treatment within 24 hours of paralysis onset significantly improves recovery
🫀 DVT/PE Diagnosis
Wells Score — DVT (0–8)
| Clinical Feature | Points |
|---|
| Active cancer (treatment within 6 months) | +1 |
| Paralysis/paresis or recent immobilisation of leg | +1 |
| Bedridden >3 days or surgery within 12 weeks | +1 |
| Localised tenderness along deep venous system | +1 |
| Entire leg swollen | +1 |
| Calf swelling >3 cm vs asymptomatic side | +1 |
| Pitting oedema (symptomatic leg only) | +1 |
| Collateral superficial veins (non-varicose) | +1 |
| Alternative diagnosis at least as likely | −2 |
Score ≤1Low probability — D-dimer
Score 2–6Moderate — Ultrasound
Score ≥7High — Anticoagulate; ultrasound
PE Diagnosis Pathway
- Wells PE score ≤4 and D-dimer negative — PE excluded
- Wells PE score >4 or D-dimer positive — CTPA (CT pulmonary angiography)
- Echocardiogram for haemodynamic assessment of massive PE
💊 Anticoagulation Comparison
| Agent | LMWH | UFH | DOACs |
|---|
| Route | SC once/twice daily | IV infusion | PO once/twice daily |
| Monitoring | Anti-Xa (renal failure/obesity/pregnancy) | APTT ratio 1.5–2.5 | None routinely |
| Renal dosing | Dose reduce eGFR <30 | Safe in renal failure | Contraindicated eGFR <15–30 |
| Reversal | Protamine (partial) | Protamine (complete) | Idarucizumab (dabigatran); andexanet alfa (Xa inhibitors) |
| HIT risk | Low | Higher (0.5–3%) | None |
| Pregnancy | Safe (first choice) | Safe (second line) | Contraindicated |
Reversal Agents Summary
- Protamine sulfate: reverses UFH (1 mg per 100 units UFH); partially reverses LMWH
- Idarucizumab (Praxbind): 5g IV — complete rapid reversal of dabigatran
- Andexanet alfa (Ondexxya): reverses rivaroxaban, apixaban, edoxaban; high/low dose bolus + infusion
- Vitamin K: warfarin reversal (1–10 mg PO/IV; 12–24h for full effect)
- 4-factor PCC (Beriplex/Octaplex): rapid warfarin reversal in life-threatening bleeding
⚠️ Heparin-Induced Thrombocytopaenia (HIT)
🚨
HIT is a prothrombotic emergency — paradoxically causes clotting despite low platelets. STOP all heparin (including flushes) immediately if suspected.
4T Score (Pre-Test Probability)
| Category | 2 points | 1 point | 0 points |
|---|
| Thrombocytopaenia | >50% fall; nadir ≥20 | 30–50% fall; nadir 10–19 | <30% fall; nadir <10 |
| Timing of fall | Days 5–10; ≤1 day if recent heparin | >10 days; <1 day (recent heparin within 30d) | <4 days without recent heparin |
| Thrombosis/other | New thrombosis; skin necrosis; anaphylaxis | Progressive or recurrent thrombosis | None |
| Other causes | None apparent | Possible other cause | Definite other cause |
Score ≤3Low — HIT unlikely
Score 4–5Intermediate — send PF4 antibody; consider alternative anticoagulant
Score 6–8High — STOP heparin; start argatroban
Argatroban Nursing (DTI)
- 2 µg/kg/min IV continuous infusion (reduce to 0.5 µg/kg/min in hepatic impairment)
- Monitor APTT every 2 hours until therapeutic (target 1.5–3× baseline); then daily
- Dose adjust to maintain APTT target; titrate by 25% increments
- Warfarin overlap: check chromogenic factor X to assess true anticoagulation
- PF4 antibody (ELISA) confirms HIT; functional assay (SRA) gold standard
- Avoid warfarin in acute HIT phase — risk of warfarin-induced skin necrosis
VTE Prophylaxis
- Medical: LMWH (enoxaparin 40 mg SC daily) or UFH 5000 units BD/TDS
- Surgical: LMWH from 12h post-op ± mechanical (TED stockings/IPC devices)
- Assess Caprini (surgical) or Padua (medical) score on admission
- GCC context: document contraindications — active bleeding, severe thrombocytopaenia, recent neurosurgery
🧬 Antiphospholipid Syndrome (APS)
- Criteria: ≥2 positive tests (lupus anticoagulant, anticardiolipin IgG/IgM, anti-β2GPI) 12 weeks apart
- Clinical: DVT/PE, arterial thrombosis (stroke), recurrent pregnancy loss
- Anticoagulation: warfarin (INR 2–3 for venous; 2.5–3.5 for arterial/recurrent); DOACs generally avoided in high-risk APS (triple positive)
- Catastrophic APS (CAPS): multiorgan failure — anticoagulate + steroids + IVIG ± plasma exchange
- Nursing: strict INR monitoring; medication adherence education; avoid OCP (thrombogenic)
🔬 Thrombophilia Screening
Do NOT screen during acute thrombosis or while on anticoagulation (false results)
| Condition | Test | Timing |
|---|
| Factor V Leiden | APC resistance / genetic PCR | Any time (genetic) |
| Prothrombin G20210A | Genetic PCR | Any time (genetic) |
| Protein C deficiency | Protein C functional assay | Off warfarin >2 weeks |
| Protein S deficiency | Protein S functional/antigen | Off warfarin >2 weeks; not in pregnancy |
| Antithrombin deficiency | AT activity assay | Off heparin >24h; not in acute thrombosis |