Anemias

*Anemia is the lack of sufficient
circulating hemoglobin to
deliver oxygen to tissues
Anaemias...L.A 2 4 March 2015

4 March 2015Anaemias...L.A 3
*Anemia refers to a deficit of red
blood cells (RBC) or hemoglobin
(Hb) in the blood, resulting in
decreased oxygen-carrying
capacity.

*
*1. Blood loss related to:
*Trauma and ulceration.
*Decreased production of platelets.
*Increased destruction of platelets.
*Decreased number of clotting
factors.

*
*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.

*
*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.

*
*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).

*
*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.

*
*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.

*
*5. May result from chronic illness
such as chronic renal failure(anemia
of chronic disease).

*
*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.

*
*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).

*
*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.

*
*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)

*
*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.

*
*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).Anaemias...L.A 17 4 March 2015

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

*
*Predispose to ischemic organ
damage, such as myocardial
infarction or cerebrovascular
accident.
*Anaphylaxis to parenteral iron
therapy.

*
*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.

*
*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

*
*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.

*
*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.

*
*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.

*
*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

*
*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.

*
*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.Anaemias...L.A 30 4 March 2015

*
*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.

*
*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.

*
*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.Anaemias...L.A 33 4 March 2015

*
*Parenteral replacement with
hydroxocobalamin or cyanocobalamin
(B12) is necessary by I.M.
*injection every month.

*
*Neurologic:
*paresthesia, gait disturbances,
bowel and bladder dysfunction,
and cerebral dysfunction may
be persistent.

*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.

*
*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.

*
*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;

*Monthly vitamin B12 administration for life.
*TCA every 6 months for hematologic studies
and GI evaluation;

*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.

*
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).

*
*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.

*Oral folic acid replacement on
daily basis.

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

*
*Obtain nutritional history.
*Monitor level of dyspnea, tachycardia,
and development of chest pain or
shortness of breath for worsening of
condition.

*
*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.

*
*Community and Home Care
Considerations
*Encourage pregnant patient to maintain
prenatal care and to take folic acid
supplement.

*
*Patient Education and Health
Maintenance
*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.

*
*Eats appropriate and nutritious
diet;
*Takes folic acid supplements as
prescribed

*
*Aplastic anemia is a disorder
characterized by bone marrow
hypoplasia or aplasia resulting in
pancytopenia (insufficient numbers of
RBCs, WBCs, and platelets).

*
*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).

*
*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.

*
*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.

*
*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.

*
*Androgens (oxymetholone or testosterone
enanthate) may stimulate bone marrow
regeneration
*Supportive treatment includes platelet
and RBC transfusions, antibiotics, and
antifungals.

*
*Clonal Hematologic Diseases:
*Paroxysmal Nocturnal
Hemoglobinuria,
*Myelodysplasia, And
*Acute Myelogenous Leukemia.

*
*Obtain thorough history that includes
medications, past medical history,
occupation, hobbies.
*Monitor for signs of bleeding and
infection.

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

*
*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.

*
*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.

*Remains afebrile with no signs or
symptoms of infection
*Episodes of bleeding rapidly
controlled

Anemias

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