and issues based on priorities

3. Implement safe and evidenced-based quality

interventions to address health needs, problems
STUDENT ACTIVITY
and issues
SHEET
4. Evaluate specific components of health program
and services based on parameter/criteria
LESSON TITLE: PHYSIOLOGICAL CHANGES IN AGING
AFFECTING THE HEMATOPOIETIC AND LYMPHATIC
Care of the Older Adult
LESSON PREVIEW (5 minutes)
BS NURSING / THIRD YEAR
Book, pen and notebook, index card/class
Session # 15
list References:
Mauk, K. L. (2018). Gerontological Nursing:
Materials: Competencies for Care (4th ed.). Jones &
SYSTEM Bartlett Learning.
Avillion,A.Chapter 3 Geriatric Assessment.
LEARNING OUTCOMES: Retrieved July29, 2020, from
https://s3.amazonaws.com/
Upon completion of this lesson, the nursing student can: EliteCME_WebSite_2
013/f/pdf/NTX08GAI15.pdf
1. Assess with the older client his/her health
status/competence Themes, U. (2016, November 17). 17. Care of
2. Formulate either the client a plan of care to address Patients with Hematologic Disorders. Retrieved
the identified health conditions, needs problems July 30, 2020, from https://nursekey.com/17-care
of-patients-with-hematologic-disorders/

The instructor should summarize the previous topic. Explain the Hook Activity.

Let’s check your prior knowledge. You will give the specific function of each blood component or organ. Write
your answers on the space provided.

1. RBC _________________________________________________
2. WBC _________________________________________________
3. Platelets______________________________________________
4. Thymus_______________________________________________
5. Bone Marrow __________________________________________

MAIN LESSON (25 minutes)

Please review the Anatomy and Physiology of Hematopoietic and Lymphatic System

The Hematologic System

Hematology is the study of blood and blood-forming tissues. This includes bone marrow, blood, spleen, and lymph
system. A basic knowledge of hematology is useful in clinical settings to evaluate the patient’s ability to transport
oxygen and carbon dioxide, maintain intravascular volume, coagulate blood, and combat infections. Assessment of
the hematologic system is based on the patient’s health history, physical examination, and results of diagnostic
studies.
Age-related hematologic changes are reflected by a decline in bone marrow cellularity, an increased risk of
myeloproliferative diseases, anemia, and a declining adaptive immunity.

∙ Bone marrow changes in adult life

Normal aging is associated with anatomic and functional changes in both bone marrow and thymus. The
percentage of marrow space occupied by the hematopoietic tissue declines gradually from 90% after birth to
30% by age 70 with the remaining space being taken up by fat. A similar change occurs in the thymus, where
involution begins after birth
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PHINMA Education (Department of Nursing) 1 of 7
and is reflected anatomically by a reduction in lymphoid mass with an increase in fat and functionally by a steady
decrease in the production of naïve T cells.

∙ Peripheral blood cell changes with aging

In normal individuals, erythropoietin levels rise with age, yet a significant portion of the population becomes
anemic (10–50%, depending on the population studied).Approximately one third of anemia occurring in older
persons remains unexplained with regard to cause.

Although no significant change is seen in the peripheral blood leukocyte count with aging, several qualitative
neutrophil defects have been described in accordance with age

From the available data, it appears that there are no, or very limited changes in platelet number with

age Clinical Consequences of Age-related Changes in Bone Marrow and Thymus

Anemia and immune deficiency are observed in late life in individuals without other recognizable disease, but
these are typically mild and associated with minimal morbidity or mortality. If clinicians detect anemia, they usually will
review the mean corpuscular volume measurement (included in the CBC) to see if the red cells are smaller or bigger
than normal. We do this because the size of the red blood cells can help point doctors towards the underlying cause
of anemia.
Hence anemia is often described as:
o Microcytic: red cells smaller than normal
o Normocytic: red cells of a normal size
o Macrocytic: red cells larger than normal

With the thymic involution the naïve T cells in the periphery decreases and the memory T cells reach senescence
accounting for the elderly persons having difficulties responding to old and new antigens and demonstrate impaired
reactions to vaccinations.

The effects of aging on hematologic studies

Study Changes

CBC Studies

Hgb Normal; possibly slight decrease in men

MCV May be slightly increased

MCHC May be slightly decreased

WBC count Diminished response to infection

Platelets Unchanged but possible increase in adhesiveness

Clotting Studies

Partial thromboplastin time Decreased

Fibrinogen May be elevated

Factors V, VII, IX May be elevated

ESR Increased significantly

D-dimers Increased

Iron Studies

Serum iron Decreased

 Total iron-binding capacity Decreased

Ferritin Increased

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PHINMA Education (Department of Nursing) 2 of 7
Study Changes

Erythropoietin May be decreased

The Lymphatic System

The lymphatic system, for most people, is associated with the immune system to such a degree that the two
systems are virtually indistinguishable. The lymphatic system is the system of vessels, cells, and organs that carries
excess fluids to the bloodstream and filters pathogens from the blood. The swelling of lymph nodes during an infection
and the transport of lymphocytes via the lymphatic vessels are but two examples of the many connections between
these critical organ systems.

As people age, the immune system becomes less effective in the following ways. These changes in immune function
may contribute to the greater susceptibility of older people to some infections and cancers.

∙ The immune system becomes less able to distinguish self from nonself (that is, to identify foreign antigens). As a
result, autoimmune disorders become more common.
∙ Macrophages (which ingest bacteria and other foreign cells) destroy bacteria, cancer cells, and other antigens
more slowly. This slowdown may be one reason that cancer is more common among older people. ∙ T cells
(which remember antigens they have previously encountered) respond less quickly to the antigens. ∙ There are
fewer white blood cells capable of responding to new antigens. Thus, when older people encounter a new
antigen, the body is less able to remember and defend against it.
∙ Older people have smaller amounts of complement proteins and do not produce as many of these proteins as
younger people do in response to bacterial infections.
∙ Although the amount of antibody produced in response to an antigen remains about the same overall, the
antibodies become less able to attach to the antigen. This change may partly explain why pneumonia,
influenza, infective endocarditis, and tetanus are more common among older people and result in death more
often. These changes may also partly explain why vaccines are less effective in older people and thus why it
is important for older people to get booster shots (which are available for some vaccines).

Gerontologic Considerations

Physiologic aging is a gradual process that involves cell loss and organ atrophy. Aging leads to a decrease in
bone marrow mass and cellularity and an increase in bone marrow fat. However, peripheral blood cell concentrations
in healthy older adults are similar to those of younger adults. Although the older adult is still capable of maintaining
adequate blood cell levels, the reserve capacity leaves the older adult more vulnerable to possible problems with
clotting, transporting oxygen, and fighting infection, especially during periods of increased demand. This results in a
diminished ability of an older adult to compensate for an acute or chronic illness.

Hemoglobin levels begin to decrease in both men and women after middle age, with the low-normal levels seen in
most older people. Total serum iron, total iron-binding capacity, and intestinal iron absorption are all decreased in
older adults. Iron deficiency is usually responsible for the low hemoglobin levels. Healthy older patients are not able to
produce reticulocytes in response to hemorrhage or hypoxemia as well as younger adults.

The RBC plasma membranes are more fragile in the older person. This may account for a slight increase in mean
corpuscular volume (MCV) and a slight decrease in mean corpuscular hemoglobin concentration (MCHC) of RBCs in
some older individuals. It is essential to assess for signs of disease processes such as GI bleeding before concluding
that decreased hemoglobin levels are caused solely by aging. Thus iron-deficiency anemia is a diagnosis that should
be made after other causes have been ruled out.

The total WBC count and differential are generally not affected by aging. However, decreases in humoral antibody
response and T cell function may occur. During an infection, the older adult may have only a minimal elevation in the
total WBC count. These laboratory findings suggest a diminished bone marrow reserve of granulocytes in older adults
and reflect the possible impaired stimulation of hematopoiesis. The number of platelets is unaffected by the aging
process, but functionally they may have increased adhesiveness. Changes in vascular integrity related to aging can
manifest as easy bruising.

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PHINMA Education (Department of Nursing) 3 of 7
Assessment

A. Diagnosis of any concurrent chronic or progressive illness such as cancer or heart or kidney
disease B. Medication listing, including over-the-counter and herbal remedies.
C. History of surgery or trauma
D. Baseline level of function and activity level and documentation of change of status
E. Lifestyle factors: smoking, alcohol use, depression, obesity, poor nutrition and sedentary
lifestyle F. Family history of diagnosed blood disorders in first-degree relatives
G. Occupational exposures during the patient’s work career to chemicals or pollutants

Nursing Diagnoses:
∙ Activity intolerance, related to weakness and fatigue
∙ Impaired gas exchange, related to decreased hemoglobin
∙ Nutrition: less than body requirements, related to poor nutritional intake and anorexia
∙ Ineffective therapeutic regimen management, related to lack of knowledge about appropriate nutrition
and medication

Goal:
∙ Report the ability to perform required activities of daily living.
∙ Consumption of nutritious meals

Implementation:
1. Providing support and teaching for the patient and family
2. Protecting the skin from dryness, cracking, and injury
3. Encourage recreational and diversional activities consistent with the patient’s general functional
ability 4. Advising and referral regarding nutritional intake.

Evaluation:
∙ The patient was able carry out usual daily activities without shortness of breath or fatigue. ∙ The patient was
able eat three nutritious meals, containing sufficient iron, folic acid, vitamin C, and protein daily.

CHECK FOR UNDERSTANDING (15 minutes)

You will answer and rationalize this by yourself. One (1) point will be given to correct answer and another one (1) point
for the correct ratio. You are given 15 minutes for this activity:

Multiple Choice

The instructor will now rationalize the answers to the students and will encourage them to ask questions and to
discuss among themselves.

1. The nurse would instruct the client to eat which of the following foods to obtain the best supply of vitamin
B12? A. Whole grains
B. Green leafy vegetables
C. Meats and dairy products
D. Broccoli and Brussels sprouts

ANSWER: ________
RATIO:_______________________________________________________________________________________
____
_____________________________________________________________________________________________
____
_____________________________________________________________________________________________
____
2. A vegetarian client was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates
that the client does not understand nutritional counseling? The client:
A. Adds dried fruit to cereal and baked goods
B. Cooks tomato-based foods in iron pots
C. Drinks coffee or tea with meals
D. Adds vitamin C to all meals

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PHINMA Education (Department of Nursing) 4 of 7
ANSWER: ________
RATIO:_______________________________________________________________________________________
____
_____________________________________________________________________________________________
____
_____________________________________________________________________________________________
____

3. Mr. Santos, 79-years-old, was admitted with iron deficiency anemia. Which question is most appropriate for the
nurse to ask in determining the extent of the client’s activity intolerance?
A. “What activities were you able to do 6 months ago compared to the present?”
B. “How long have you had this problem?”
C. “Have you been able to keep up with all your usual activities?”
D. “Are you more tired now than you used to be?”

ANSWER: ________
RATIO:_______________________________________________________________________________________
____
_____________________________________________________________________________________________
____
_____________________________________________________________________________________________
____

4. The nurse is assessing a client’s activity intolerance by having the client walk on a treadmill for 5 minutes. Which of
the following indicates an abnormal response?
A. Pulse rate increased by 20 bpm immediately after the activity
B. Respiratory rate decreased by 5 breaths/minute
C. Diastolic blood pressure increased by 7 mm Hg
D. Pulse rate within 6 bpm of resting phase after 3 minutes of rest.

ANSWER: ________
RATIO:_______________________________________________________________________________________
____
_____________________________________________________________________________________________
____
_____________________________________________________________________________________________
____

5. A client with microcytic anemia is having trouble selecting food items from the hospital menu. Which food is best for
the nurse to suggest for satisfying the client’s nutritional needs and personal preferences?
A. Egg yolks
B. Brown rice
C. Vegetables
D. Tea

ANSWER: ________
RATIO:_______________________________________________________________________________________
____
_____________________________________________________________________________________________
____
_____________________________________________________________________________________________
____
6. Which of the following blood components is decreased in anemia?
A. Erythrocytes
B. Granulocytes
C. Leukocytes
D. Platelets
ANSWER: ________
RATIO:_______________________________________________________________________________________
____
_____________________________________________________________________________________________
____
_____________________________________________________________________________________________
____

7. Laboratory studies are performed for an elderly suspected of having iron deficiency anemia. The nurse reviews
the laboratory results, knowing that which of the following results would indicate this type of anemia? A. An
elevated hemoglobin level
B. A decreased reticulocyte count
C. An elevated RBC count
D. Red blood cells that are microcytic and hypochromic

ANSWER: ________

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PHINMA Education (Department of Nursing) 5 of 7
RATIO:_______________________________________________________________________________________
____
_____________________________________________________________________________________________
____
_____________________________________________________________________________________________
____

8. Changes in the immune system that accompany aging include:

A. T cells becoming less responsive to antigens.
B. more cytotoxic T cells responding to infections.
C. increased numbers of T helper cells.
D. higher levels of antibodies after initial exposure to antigens.

ANSWER: ________
RATIO:_______________________________________________________________________________________
____
_____________________________________________________________________________________________
____
_____________________________________________________________________________________________
____

9. With advancing age, the immune system

A. becomes more effective at combating disease.
B. remains the same and is not affected by the aging process.
C. becomes less effective at combating disease.
D. becomes more responsive to antigens.

ANSWER: ________
RATIO:_______________________________________________________________________________________
____
_____________________________________________________________________________________________
____
_____________________________________________________________________________________________
____

10. The increased incidence of cancer in the elderly reflects the fact that
A. immune surveillance increases.
B. their diets do not meet nutritional standards.
C. everyone is prone to disease.
D. immune surveillance declines with age.

ANSWER: ________
RATIO:_______________________________________________________________________________________
____
_____________________________________________________________________________________________
____
_____________________________________________________________________________________________
____

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION) The instructor
will now rationalize the answers to the students. You can now ask questions and debate among yourselves. Write the
correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:___________________________________________________________________________________
____
_________________________________________________________________________________________
____ _____________________________________________________________________
2. ANSWER: ________
RATIO:___________________________________________________________________________________
____
_________________________________________________________________________________________
____ _____________________________________________________________________
3. ANSWER: ________
RATIO:___________________________________________________________________________________
____
_________________________________________________________________________________________
____ _____________________________________________________________________
4. ANSWER: ________
RATIO:___________________________________________________________________________________
____
_________________________________________________________________________________________
____ _____________________________________________________________________
5. ANSWER: ________

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PHINMA Education (Department of Nursing) 6 of 7
RATIO:___________________________________________________________________________________
____
_________________________________________________________________________________________
____ _____________________________________________________________________
6. ANSWER: ________
RATIO:___________________________________________________________________________________
____
_________________________________________________________________________________________
____ _____________________________________________________________________
7. ANSWER: ________
RATIO:___________________________________________________________________________________
____
_________________________________________________________________________________________
____ _____________________________________________________________________
8. ANSWER: ________
RATIO:___________________________________________________________________________________
____
_________________________________________________________________________________________
____ _____________________________________________________________________
9. ANSWER: ________
RATIO:___________________________________________________________________________________
____
_________________________________________________________________________________________
 ____ _____________________________________________________________________
10. ANSWER: ________
RATIO:___________________________________________________________________________________
____
_________________________________________________________________________________________
____ _____________________________________________________________________

LESSON WRAP-UP (10 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help
you track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: CAT 3-2-1

Now it’s time to give your feedback. Please answer the questions below.

3-2-1
Three things you learned:
1)
____________________________________________________________________________________________
_ 2)
____________________________________________________________________________________________
_ 3)
____________________________________________________________________________________________
_

Two things that you’d like to learn more about:

1)
____________________________________________________________________________________________
_ 2)
____________________________________________________________________________________________
_

One question you still have:

1)
_____________________________________________________________________________________________

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PHINMA Education (Department of Nursing) 7 of 7