Anemia

- lower than normal concentration of hemoglobin

- not a specific disease but a sign of an underlying disorder

 Classifications
Hypoproliferative- decreased production of rbc
Bleeding- blood loss
Hemolytic- rbc destroyed before their life span

 Types/Subtopics
I. Iron Deficiency Anemia
II. Aplastic anaemia
III. Megaloblastic anemia
-Pernicious Anemia (Vit. B12 deficiency)
-Folic Acid Deficiency Anemia
IV. Hemolytic Anemia
V. Sickle Cell Disease
VI. Thalassemia
VII. Polycythemia Vera

 Etiology
- Blood loss
- Deficient erythropotein
- Excessive hemolysis

 Risk factors
 Predisposing
-family hx
-65 and up
-menstruation
 Precipitating
- lack in iron, b12, folate
- intestinal disorder
- infants and children that are not breastfed
- unhealthy diet
- vegetarian
- repeated blood donor
- chemotherapy/radiation
- pregnancy

HEMATOPOIESIS - production of all blood cells

Normal erythrocyte production:

Iron - helps make hgb
B12 - for formation of hgb
- helps regulate DNA synthesis
Folate - convert rbc to energy
B6 - helps Increase amount of o2 by hgb

Organs that help rbc production:

1. Kidney - produce erythropotein to stimulate BM to produce RBC
2. Spleen - filter worn out damaged cell
3. Liver - converts damaged or destroyed rbc to bilirubin then excretes in bile

 Characteristics of RBC
- biconcave, disc shaped
- 8 microns (size)
Size
a. macrocytic - >8
b. Normocytic - 7-8
c. microcytic - <6
Color
a. Hyperchromic - Darker
b. Normochromic - Red orange with central pallor
c. Hypochromic - central pallor is increased
Life span - 120 days

I. Iron Deficiency Anemia- chronic, hypochromic, microcytic anemia resulting from

insufficient supply of iron in body.

 Signs & Symptoms

• Extreme fatigue
• Weakness
• Pale skin
• Chest pain, fast heartbeat or shortness of breath
• Headache, dizziness or lightheadedness
• Cold hands and feet
• Inflammation or soreness of your tongue
• Brittle nails
• Unusual cravings for non-nutritive substances, such as ice, dirt or starch
• Poor appetite, especially in infants and children with iron deficiency anemia

 Complications
• Enlarged heart or heart failure.
• Premature births and low birth weight babies.
• Growth problems.

 Laboratory/Diagnostic Procedures
✓ Bone Marrow Aspiration
- Low level or absent iron
✓ Hematological Test
• Complete Blood Count (CBC)
- Decreased RBC
- Decreased hemoglobin and hematocrit
- Decreased Mean Corpuscular Volume (MCV)
• Iron Studies
- Decreased serum ferritin levels
- Decreased serum iron levels
- Increased Total Iron Binding Capacity (TIBC)

 Medical management
 Oral Iron Preparations (ferrous sulfate, ferrous gluconate and ferrous fumarate) for 6-8
months – taken an hour before meals, best absorbed on empty stomach. IV or IM
administration of Iron (if oral is intolerable)

 Nursing Management
 Check for bleeding
 Z-Track technique for administering iron dextran deep into the
gluteus maximus muscle/buttocks (volume of iron required in IM maybe excessive
causing some local pain and possible staining of the skin
 Monitor patient for bleeding and hemoglobin levels and other major signs and
symptoms…assessing diet, menstrual cycles etc.
 Educating how to take IRON supplements:
o Take iron on an empty stomach (increases absorption…may take with small amounts of
food due to stomach upset)
o Take with Vitamin C…glass of orange juice (helps increase absorption)
o Don’t take with any milk products, calcium, or antacids (decreases absorption) and wait 2
hours in between
o Stools will turn black which is normal while taking iron supplements (tarry stools or
having stools with blood..not normal)
o For liquid preparations: mix in a drink, drink with straw, and brush teeth afterwards (can
stain teeth)
o Side effects: constipation (drink plenty of fluids and take over the counter stool softener
if needed)
o May give IV iron or blood transfusion if severe per md order

II. Aplastic Anemia- a rare disease in which the bone marrow and the hematopoietic stem
cells that reside there are damaged. This causes a deficiency of all three blood cell types
(pancytopenia): red blood cells (anemia), white blood cells (leukopenia), and platelets
(thrombocytopenia)

 Signs & Symptoms

• Headache
• Dizziness
• Shortness of breath with exertion
• Fatigue
• Pale skin
• Chest pain
• Irregular heart beat
• Enlarged heart
• Fevers
• Mouth sores
• Infections
• Unexplained or easy bruising
• Bleeding (Prolonged or Heavy)
• Blood in the stool
• Nausea
• Skin rashes

 Complications
• Problems with growth and development
• Cancers
• Heart failure
• Uncontrolled bleeding
• Severe infections

 Laboratory/Diagnostic Procedures
✓ Bone Marrow Biopsy
- Hypoplastic or aplastic marrow (Increased fat, decreased hematopoietic cells)
✓ Hemoglobin F (Hb F)
- Elevated
✓ Leukocyte Alkaline Phosphate (LAP)
- Often increased
✓ HAM acid-serum test
- May be positive (+)

 Medical management
 Bone Marrow Transplant or Peripheral Blood Stem Cell Transplant (because of T-cells
attacking bone marrow)
 Splenectomy (when spleen is enlarged and destroying RBCs)

 Nursing management
 Check for bleeding
 Avoid IM injections (altered clotting factor)
 No Aspirin (platelet aggregation)
 Use only electric razor (decreases risk of bleeding due to decreased platelet count)
 Asses for sign and symptoms of bleeding and infection
 Avoid bleeding e.g. IM injection, sharps blade
 Avoid aspirin
III. Megaloblastic Anemia- caused by the Vit B12 & folic acid deficiency; impaired DNA
synthesis which later on results in defective, large RBCs (megaloblasts)

 Signs & Symptoms

• Pale or yellow skin
• Fast heart beat
• Shortness of breath
• Lack of energy, feeling tired
• Decreased appetite
• Irritability or fussiness
• Hair color changes
• Stomach upsets, nausea, diarrhea, gas, constipation
• Trouble walking
• Numbness or tingling in hands and feet
• Smooth and sore tongue
• Weak muscles

 Complications
• Problems with growth and development
• An enlarged heart, heart failure

 Laboratory/Diagnostic Procedures
✓ Bone Marrow Analysis
- Hyperplasia
- Hypercellular with megaloblastic features
✓ Schilling Test
- Classic method of determining the cause of Vit. B12 deficiency
✓ Intrinsic Factor Antibody Test
- Positive (+)

 Nursing management
ENSURE SAFETY (when position sense, coordination, and gate are affected)
 If sensation is altered, make sure to avoid excessive heat and cold
o Use soft toothbrush due to oral changes.
o Avoid activities that could lead to injury due to paresthesias or changes
in balance.
 Health Promotion; protection from sensory injury—burns, trauma; pt compliance with
replacement therapy

Vit B12 deficiency (Pernicious anemia)

 Increasing your vitamin B12 intake
 Good sources of vitamin B12 are meat, eggs and dairy products.
 Vegan Vit b12 eg. Nori eating 4 grams of dried purple laver to meet the daily
requirements for vitamin B-12 intake. Shitake mushroom
 Increasing folate intake
  Encourage to eat more green vegetables. Vegetables, such as broccoli, Brussels sprouts,
asparagus, peas, chickpeas and brown rice all contain naturally high levels of folate
 Administer vitamin b 12 injections (intramuscular….not orally because they aren’t
absorbing it in the GI system) as ordered by doctor. if severe anemia will need blood
transfusion
 Educated on safety: due to risk of injuries from unsteady gait…more clumsy from the
paresthesia
 Educate about importance of eating enough foods with iron, vitamin C, and folic acid
because these nutrients play a role in red blood cell production as well.
 Maintain good oral hygiene due to changes to tongue

Folic acid anemia

 Discuss the importance of taking the folic acid supplement. Advise to continue taking it
even after the patient begins to feel better.
 Discuss foods required for a well-balanced diet, as well as dietary sources of folic acid.

IV. Hemolytic Anemia- this is the end results of conditions that lead to hemolysis

 Signs & Symptoms

• Pale skin
• Jaundice, or yellowing of the skin and eyes
• Dark-colored urine
• Fever
• Weakness
• Dizziness
• Confusion
• Intolerance to physical activity
• Enlargement of the spleen and liver
• Fast heart beat
• Heart murmur

 Complications
• Gallstones or stones in the gallbladder
• Blood clots and pulmonary emboli (blood clots in the lungs)
• Kidney failure
• Shock
• Heart failure

 Laboratory/Diagnostic Procedures
- Inherited forms: Sickle cell anemia, Thalassemia, Thalassemia-Major
✓ Hematological Test
• Complete Blood Count (CBC)
- Increased reticulocyte count
- Increased fraction of indirect bilirubin
- Decreased plasma haptoglobin level
✓ The Coombs Test (Direct Antiglobulin Test)
- Immune Hemolytic Anemia
- Positive (+)

 Medical management
 Corticosteroids (decreases macrophages’ ability to clear the antibody-coated
erythrocytes)

 Nursing management
 Slow infusion of blood (10-15 ml over 30 mins) (difficult to cross match blood
when alloantibodies are present)

V. Sickle Cell Anemia- this is a group of inherited disorders of mutant hemoglobin that
causes the sicklimg of RBCs. Also this only occurs under conditions of low oxygenation.

 Signs & Symptoms

• Dizzy
• SOB
• Tired
• Jaundice
• Muscle pain
• Splenomegaly

 Complications
• Increased infections
• Leg ulcers or serious sores
• Bone damage
• Early gallstones
• Kidney damage and loss of body water in the urine
• Eye damage
• Multiple organ failure

 Laboratory/Diagnostic Procedures
✓ Hematological Test
• Hemoglobin Electrophoresis
- diagnostic test that confirms sickle cell anemia
• Complete Blood Count
- Decreased hematocrit
• Blood Smear
- Sickled cells on smear

 Medical management
 Hydroxyurea
 Peripheral Blood Stem Cell Transplant
  Increasing fetal hemoglobin by a chemotherapeutic agent (hydrea) – decreases sickled
cells
 Oxygen/Arginine/Corticosteroids
 Pain medications

 Nursing management
 Sickling of RBCs: focus hydration, oxygen, pain, at risk for infection, monitor respiratory
status, neuro checks, at risk for acute chest syndrome, prevention of future crisis
episodes, medications, blood transfusions.
 IV fluids and oral fluid: dilutes blood and helps kidney function (blood flow is being
limited because RBCs are sticking together, clingy sila sa endothelium may proceed
to thrombembolipag masyado sila nagging clingy
 Bed rest keep extremities elevated and extended to prevent swelling and helps blood flow
 Educate about preventing infection (needs vaccines to be up-to-date, hand hygiene, avoid
extreme weather and physical activities, mental/physical stress, staying hydrated,
avoiding smoking, high altitudes)
 Remove restrictive clothing because it decreases perfusion
 Warm compresses
 Folic acid administration: helps make RBCs

VI. Thalassemia- an autosomal-recessive genetic disorder that results in inadequate normal

Hb production wherein the synthesis of globin (binds with oxygen and responsible for
transportation) is disrupted

 Signs & Symptoms

• Fatigue
• Weakness
• Pale or yellowish skin
• Facial bone deformities
• Slow growth
• Abdominal swelling
• Dark urine

 Complications
• Iron overload
• Infection

 Laboratory/Diagnostic Procedures
✓ Hematological Test
• Complete Blood Count (CBC)
- Decreased Mean Corpuscular Volume (MCV) *indication of thalassemia (often)*
• Blood Smear
- Microcytic (small RBC)
- Hypochromic (decreased hemoglobin in erythrocyte)
  Nursing management
 Strict blood transfusion monitoring (iron overload)
 Prevent injury (px bleeds easily)
 Assess for severe anemia, splenomegaly or hepatomegaly with abdominal enlargement,
frequent infections, bleeding tendencies e.g. epistaxis, and anorexia.
 Assist the client in planning and prioritizing activities of daily living (ADL)
 Prevent infection.
 Prevent bleeding.

 Medical Management
• Treat underlying cause
• Dietary modification and supplementations (Vitamins, iron, folate, protein)
• Transfusion of Packed Red Blood Cells (to replace lost or damaged erythrocytes; only if
anemia is severe) -
• Chelation therapy – prbc transfusion to prevent iron overload (Sickle Cell Anemia,
Thalassemia Major)
• Peripheral Blood Stem Cell Transplant (for Aplastic and Sickle Cell Anemia & Thalassemia
Major)
• Splenectomy (Aplastic, Sickle Cell, Hemolytic & Thalassemia Major)

VII. Polycythemia Vera- this is caused by the excessive activation of pluripotent stem cells
in the bone marrow which results in excessive production of erythrocytes, leukocytes and
platelets.

 Signs & Symptoms

• Lack of energy (fatigue) or weakness
• Headache
• Dizziness
• Shortness of breath and trouble breathing while lying down
• Vision problems, such as double vision, blurred vision, and blind spots
• Inability to concentrate
• Night sweats
• Face and becomes red and warm (flushed)
• Nosebleeds
• Bleeding gums
• Too much menstrual bleeding
• Coughing up blood
• Bruising
• Itchy skin (often after a hot bath)
• Gout
• Numbness
• High blood pressure

 Complications
• Blood clots resulting in a heart attack, stroke, or pulmonary embolism
• Liver and spleen enlargement
  Laboratory/Diagnostic Procedures
✓ Hematological Test
• Complete Blood Count
- Increased RBC
- Increased hemoglobin and hematocrit
- Increased erythrocyte mass
- Increased leukocytes
- Increased platelet count
- Very low levels of erythropoietin
✓ Physical Examination
- Enlarged spleen

 Medical management
 Phlebotomy – 500 ml initially once or twice weekly (reduce blood viscocity)
 Anagrelide (control thrombocytosis associated with PV)

 Nursing management
 Avoid aspirin and aspirin containing medications (alter platelets)
 Minimize alcohol intake, control hypertension (risk factor of thrombolytic complication)
– instruct s/sx of thrombosis
 Avoid Iron Supplements (stimulate RBC production)
 Health educate
 Assess for thrombotic complications
 Instruct to avoi aspirin
 Minimize alcohol intake