Anemias

April 15, 2023Anaemias...L.A 1

*Anemia

s


*Definition…

*Anemia is the lack of sufficient

circulating hemoglobin to

deliver oxygen to tissues


*Def…2

*Anemia refers to a deficit of

red blood cells (RBC) or

hemoglobin (Hb) in the blood,

resulting in decreased oxygen-

carrying capacity.


*Causes of anaemia.

*1. Blood loss related to:

*Trauma and ulceration.

*Decreased production of platelets.

*Increased destruction of platelets.

*Decreased number of clotting factors.


*Causes of anaemia…

*2. Impairment of RBC production caused by nutritional deficiency.*Iron deficiency in

*Folic acid deficiency; megaloblastic anemia.

*Vitamin B12 deficiency; causes megaloblastic anemia; called pernicious anemia if due to lack of intrinsic factor

*Vitamin B6 deficiency.

*Lead poisoning; lead absorbed by the bone marrow attaches to newly formed rbc and inhibits synthesis of heme.


*Causes…

*3. Decreased erythrocyte production.

*Secondary hemolytic anemias associated with chronic infection, renal disease, and drugs.

*the ability of the bone marrow to produce RBCs is significantly decreased.

*Bone marrow depression; leukemia, aplastic anemias.


*Causes…

*4. Increased erythrocyte destruction.

*Extrinsic factors:*Drugs and chemicals.

*Infections; Parvovirus

*Antibody reactions; passively acquired antibodies against Rh, a, or b isoimmunization, autoimmune hemolytic anemia, burns, poisons (including lead poisoning).


*Causes…

*4. Increased erythrocyte destruction:

*Intrinsic factors:

*Abnormalities of the RBC membrane.

*Enzymatic defects; glucose-6-

phosphate dehydrogenase deficiency.

*Abnormal Hb synthesis; sickle cell

disease, thalassemia syndromes.


*Causes…

*4. Increased erythrocyte destruction:*In hemolytic anemias, the RBCs are destroyed at abnormally high rates, primarily by the spleen.

*Bone marrow activity increases to compensate

*Bone marrow hypertrophies

*Jaundice results; bilirubin accumulation

*Iron builds up (hemosiderosis) and may deposit on tissues.


*Causes…

*5. May result from chronic illness

such as chronic renal

failure(anemia of chronic

disease).


*IRON DEFICIENCY ANEMIA

(MICROCYTIC,

HYPOCHROMIC)


* IRON DEFICIENCY ANEMIA (MICROCYTIC, HYPOCHROMIC)

*Iron deficiency anemia is a condition in which the total body iron content is decreased below a normal level, affecting hemoglobin synthesis. RBCs appear pale and are small.


*Pathophysiology and Etiology*Chronic blood loss (GI bleeding, excessive menstrual bleeding, hookworm infestation),

*Insufficient intake of iron (weight loss, inadequate diet),

*Iron malabsorption (small bowel disease, gastroenterostomy), or

*Increased requirements (pregnancy, periods of rapid growth).


*Pathophysiology and Etiology

*Decreased hemoglobin may result in insufficient oxygen delivery to body tissues.

*Symptoms generally develop when hemoglobin has fallen to less than 11 g/100 ml.


*Clinical Manifestations

*Headache, dizziness, fatigue, tinnitus

*Palpitations, dyspnea on exertion, pallor of skin and mucous membranes

*Smooth, sore tongue; cheilosis (lesions at corners of mouth)

*Koilonychia (spoon-shaped fingernails)

*Pica (craving to eat unusual substances)


*Diagnostic Evaluation

*CBC and iron profile;

*Decreased hemoglobin, hematocrit, serum iron, and ferritin;

*Normal or elevated total iron-binding capacity.

*Determination of source of chronic blood loss may include sigmoidoscopy, colonoscopy, upper and lower GI studies, stool and urine for occult blood examination.


*Management

*Correction of chronic blood loss.

*Oral or parenteral iron therapy.

*Oral ferrous sulfate preferred and least expensive;

*Treatment continues until hemoglobin level is normalized and iron stores replaced (up to 6 months).


*Management

*Parenteral therapy *When patient cannot tolerate or is noncompliant with oral therapy. *May use iron dextran (imferon) or iron sorbitex (jectofer).


*Complications

*Predispose to ischemic organ damage, such as myocardial infarction or cerebrovascular accident.

*Anaphylaxis to parenteral iron therapy.


*Nursing Assessment

*Obtain history of symptoms, dietary intake, past history of anemia, possible sources of blood loss.

*Examine for tachycardia, pallor, dyspnea, and signs of GI or other bleeding.

April 15, 2023Anaemias...L.A 21*Nursing

Diagnoses

*Imbalanced Nutrition: Less Than Body Requirements related to inadequate intake of iron

*Activity Intolerance related to decreased oxygen-carrying capacity of the blood

*Ineffective Tissue Perfusion related to decreased oxygen-carrying capacity of the blood


*Nursing Interventions

*Promoting Iron Intake*Encourage foods rich in iron; Nutritionist

*Administer iron replacement

*Increasing Activity Tolerance*Assess level of fatigue and normal sleep pattern; determine activities that cause fatigue.

*Assist in developing a schedule of activity, rest periods, and sleep.

*Encourage conditioning exercises to increase strength and endurance.


*Nursing Interventions..

*Maximizing Tissue Perfusion*Assess patient for palpitations, chest pain, dizziness, and shortness of breath; minimize activities that cause these symptoms.

*Elevate head of bed and provide supplemental oxygen as ordered.

*Monitor vital signs and fluid balance.


*Nursing Interventions..

*Patient Education and Health Maintenance

*proper nutrition and good sources of iron

*iron-fortified cereals and bread, green leafy vegetables, dried fruits, legumes, nuts.

*Teach patient about iron supplementation.

*Take iron on empty stomach, with full glass of water or fruit juice.


*Liquid iron forms may stain teeth

*Anticipate:*Epigastric discomfort,

*Change in color of stool to green or black, and

*Nausea, constipation, or diarrhea.

*Prevent and treat constipation with increased fiber, fluids, and exercise.


*Evaluation: Expected Outcomes

*Incorporates several foods high in iron into diet; takes prescribed iron supplementation as ordered

*Tolerates increased activity; obtains sufficient rest

*Vital signs stable without complaints of chest pain, palpitations, or shortness of breath


*Megaloblas

tic Anemia:

Pernicious


*MEGALOBLASTIC ANEMIA: PERNICIOUS

*A megaloblast is a large, nucleated erythrocyte with delayed and abnormal nuclear maturation.

*Pernicious anemia is a type of megaloblastic anemia associated with vitamin B12 deficiency.



*Vitamin B12 is necessary for normal

deoxyribonucleic acid synthesis in maturing

RBCs.

*Pernicious anemia demonstrates familial

incidence related to autoimmune gastric

mucosal atrophy.

*Normal gastric mucosa secretes a substance

called intrinsic factor, necessary for absorption

of vitamin B12 in ileum.


*Pathophysiology and Etiology…

*If a defect exists in gastric mucosa, or after gastrectomy or small bowel disease, intrinsic factor may not be secreted and orally ingested B12 not absorbed.

*Some drugs interfere with B12 absorption, notably ascorbic acid, cholestyramine, colchicine, neomycin, cimetidine, and hormonal contraceptives.

*Primarily a disorder of older people.



*Of anemia: *pallor, fatigue, dyspnea on exertion, palpitations.

*Of underlying GI dysfunction: *sore mouth, glossitis, anorexia, nausea, vomiting, loss of weight, indigestion, epigastric discomfort, recurring diarrhea or constipation.


*Clinical Manifestations…

*Of neuropathy (occurs in high percentage of untreated patients):

*paresthesia that involves hands and feet,

*gait disturbance, bladder and bowel dysfunction, psychiatric symptoms caused by cerebral dysfunction.


*Diagnostic Evaluation*CBC and blood smear:

*decreased hemoglobin and hematocrit; marked variation in size and shape of RBCs with a variable number of unusually large cells

*Folic acid (normal) and B12 levels (decreased).

*Gastric analysis:*volume and acidity of gastric juice diminished.

*Schilling test:*For absorption of vitamin B12 uses small amount of radioactive B12 orally and 24-hour urine collection to measure uptake: decreased.


*Management

*Parenteral replacement with

hydroxocobalamin or cyanocobalamin

(B12) is necessary by I.M.

*injection every month.


*Complications

*Neurologic:

*paresthesia, gait disturbances,

bowel and bladder

dysfunction, and cerebral

dysfunction may be persistent.


*Nursing

Assessment

*Assess for pallor, tachycardia, dyspnea on

exertion, exercise intolerance to determine

patient's response to anemia.

*Assess for paresthesia, gait disturbances,

changes in bladder or bowel function, altered

thought processes indicating neurologic

involvement.

*Obtain history of gastric surgery or GI disease.


*Nursing Diagnoses

*Disturbed Thought Processes related to

neurologic dysfunction in absence of

vitamin B12

*Impaired Sensory Perception (kinesthetic)

related to neurologic dysfunction in

absence of vitamin B12



*Improving Thought Processes

*Administer parenteral vitamin B12 as prescribed.

*Provide patient with quiet, supportive environment; reorient to time, place, and person if needed; give instructions and information in short, simple sentences and reinforce frequently.


*Nursing Interventions….

*Minimizing the Effects of Paresthesia

*Assess extent and severity of paresthesia, imbalance, or other sensory alterations.

*Refer patient for physical therapy and occupational therapy as appropriate.

*Provide safe environment;


*Nursing

Interventions….

*Patient Education and Health

Maintenance

*Monthly vitamin B12 administration for

life.

*TCA every 6 months for hematologic

studies and GI evaluation;

April 15, 2023Anaemias...L.A 41*Note!

*Patients with pernicious anemia

have higher incidence of gastric

cancer and thyroid dysfunction;

*Periodic stool examinations for occult

blood, gastric cytology, and thyroid

function should be done.


*MEGALOBLASTIC

ANEMIA:

Folic Acid Deficiency


*MEGALOBLASTIC ANEMIA: Folic Acid Deficiency

Def….

*Chronic megaloblastic anemia

caused by folic acid (folate)

deficiency.



*Dietary deficiency, malnutrition, marginal diets, excessive cooking of foods; commonly associated with alcoholism.

*Impaired absorption in jejunum (eg, with small bowel disease).

*Increased requirements *chronic hemolytic anemia, pregnancy).


*Pathophysiology and Etiology…*Impaired utilization from folic acid

antagonists (methotrexate) and other

drugs (phenytoin, broad spectrum

antibiotics, sulfamethoxazole, alcohol,

hormonal contraceptives).



*Of anemia: *fatigue, weakness, pallor, dizziness, headache, tachycardia.

*Of folic acid deficiency: *sore tongue, cracked lips.



*Folic acid level acid will be decreased.

*CBC will show decreased RBC,

hemoglobin, and hematocrit

*Increased mean corpuscular volume

and mean corpuscular hemoglobin

concentration.


*Management

*Oral folic acid replacement on daily basis.


*Complications

*Folic acid deficiency has been implicated in the etiology of congenitally acquired neural tube defects.


*Nursing Assessment

*Obtain nutritional history.

*Monitor level of dyspnea,

tachycardia, and development of

chest pain or shortness of breath for

worsening of condition.


*Nursing Diagnosis

*Imbalanced Nutrition: Less Than

Body Requirements related to

inadequate intake of folic acid



*Improving Folic Acid Intake*foods rich in folic acid:

*Beef liver, peanut butter, red beans, oatmeal, broccoli, asparagus.


*Nursing Interventions…

*Community and Home Care Considerations

*Encourage pregnant patient to maintain prenatal care and to take folic acid supplement.


*Nursing Interventions…


*Balanced diet that includes green vegetables (asparagus, broccoli, spinach), yeast, liver and other organ meats, some fresh fruits; avoid overcooking vegetables.

*TCA periodically to monitor CBC.


*Evaluation: Expected Outcomes

*Eats appropriate and nutritious diet;

*Takes folic acid supplements as prescribed


*Aplastic

anemia


*Definition….

*Aplastic anemia is a disorder

characterized by bone marrow

hypoplasia or aplasia resulting in

pancytopenia (insufficient numbers

of RBCs, WBCs, and platelets).


*Pathophysiology and Etiology*Destruction of hematopoietic stem cells may be through an immune-mediated mechanism.

*May be idiopathic or

*Caused by exposure to chemical toxins; ionizing radiation; viral infections, particularly hepatitis; certain drugs (eg, chloramphenicol).


*Pathophysiology and Etiology…

*May be congenital (Fanconi's

anemia).

*Clinical course is variable and

dependent on degree of bone marrow

failure; severe aplastic anemia is

almost always fatal if untreated.



*From anemia: *Pallor, weakness, fatigue, exertional dyspnea, palpitations.

*From infections associated with neutropenia:

*Fever, headache, malaise; abdominal pain, diarrhea; erythema, pain, exudate at wounds or sites of invasive procedures.


*Clinical Manifestations…

*From thrombocytopenia: *Bleeding from gums, nose, GI or GU tracts; purpura, petechiae, ecchymoses.



*CBC and peripheral blood smear:*decreased RBC, WBC, platelets (pancytopenia).

*Bone marrow aspiration and biopsy:

*bone marrow is hypocellular or empty with greatly reduced or absent hematopoiesis.


*Management

*Removal of causative agent or toxin.

*Bone marrow transplantation (BMT)

*Treatment of choice for patient with severe

aplastic anemia

*Immunosuppressive treatment with

corticosteroids, cyclosporine,

cyclophosphamide, antithymocyte globulin or

antilymphocyte globulin as single treatments or

in combinations.


*Management….

*Androgens (oxymetholone or

testosterone enanthate) may

stimulate bone marrow regeneration

*Supportive treatment includes

platelet and RBC transfusions,

antibiotics, and antifungals.


*Complications

*Clonal Hematologic Diseases:

*Paroxysmal Nocturnal

Hemoglobinuria,

*Myelodysplasia, And

*Acute Myelogenous Leukemia.


*Nursing Assessment

*Obtain thorough history that includes medications, past medical history, occupation, hobbies.

*Monitor for signs of bleeding and infection.


*Nursing Diagnoses…. Aplastic anemia

*Risk for Infection related to granulocytopenia secondary to bone marrow aplasia


*Nursing Interventions*Minimizing Risk of Infection

*protective environment

*strict hand washing

*Encourage good personal hygiene

*Monitor vital signs, including temperature

*Minimize invasive procedures or possible trauma to skin or mucous membranes.


*Nursing Interventions…..

*Minimizing Risk of Bleeding*Use only soft toothbrush

*Avoid I.M. injections and other invasive procedures.

*Prevent constipation with stool softeners as prescribed.

*Monitor pad count for menstruating patient;

*Control bleeding by applying pressure to site

*Administer blood product replacement as ordered;




*Minimize risk of infection

*Wash hands after contact with possible source of infection.

*Monitor temperature and report fever or other sign of infection

*Avoid crowds and people with illnesses.

*Avoid raw or undercooked foods.

*Use condoms and other safer sex practices.



*Advise patient to avoid exposure to potential bone marrow toxins: solvents, sprays, paints, pesticides.

*Teach patient to take only prescribed medications; avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), which may interfere with platelet function.


*Evaluation: Expected

Outcomes

*Remains afebrile with no signs or symptoms of infection

*Episodes of bleeding rapidly controlled

Healthcare

Anemias