Nursing College

1. Blood disorders
Medical surgical nursing
By:
Dr. Raafat AL-Awadhi

2. Anemia is operationally defined as a reduction in one
or more of the major RBC measurements: Decreased
hemoglobin, RBC count, and hematocrit.
Hb level of a patient which is below the normal
ranges of that age and sex.
For adults:
WHO criteria define anemia as hemoglobin level
lower than 12 g/dL in women and 13 g/dL in men .
Anemia is not a disease but a manifestation of
disease
ANEMIA

3. Volume changes/acute bleeding and
anemia
normal
Hct
(a/b%):Normal
Dehydration
Hct:Increase
d
Acute blood
loss(early)
Hct:unchange
d
Chronic
anemia
Hct: Low
1 2 3 4 5
Increase
d plasma
volume
Hct: Low
b
a

4. Causes of anemia
Decreased RBC production
–Deficient nutrients
• Iron
• Cobalamin ( vita.B12)
• Folic acid
• Decreased erythropoietin
• Decreased iron availability

5. Blood loss
–Chronic hemorrhage
• Bleeding duodenal ulcer
• Colorectal cancer
• Liver disease
• Acute trauma
• Ruptured aortic aneurysm
• GI bleeding
Causes of anemia

6. Increased RBC destruction
–Hemolysis
• Sickle cell disease
• Medication (eg. Methyl dopa)
• Incompatible blood
• Trauma(cardiopulmonary bypass)
Causes of anemia

7. Clinical Manifestations
• Specific manifestations vary depending on the
rate at which the anemia has evolved, its
severity, and any coexisting disease.
• Hemoglobin (Hgb) levels are often used to
determine the severity of anemia.
• Mild states of anemia (Hgb 10 to 12 g/dL
[100 to 120 g/L]) may exist without causing
symptoms.

8. • In moderate anemia (Hgb 6 to 10 g/dL [60 to
100 g/L]) the cardiopulmonary symptoms are
increased.
• In severe anemia (Hgb less than 6 g/dL [60
g/L]) the patient has many clinical
manifestations involving multiple body
systems.

10. Diagnosis and investigation:
• Is the patient anemic?
• What is the type of anemia?
• What is the cause of anemia?

11. • The symptoms and findings are related to
anemia itself or to the underlying disease that
causes anemia .
Diagnosis and investigation:

12. Clinical Diagnosis
• Made by combination of factors including: patient history,
physical signs and changes in hematologic profile (CBC).
• Signs and symptoms usually non-specific:
• fatigue, weakness, gastrointestinal symptoms (nausea,
constipation and diarrhea), shortness of breath -
especially after exertion.
• Physical signs of anemia are usually not specific for the
cause.
12

13. Some Other examples for history and
physical examination
• The duration of symptoms (acute/insidious)
• Bleeding ? Nose/skin/urine/mens/stool etc
• Family history
– Anemia, gall stones and splenectomy
– Bleeding disorder
• Occupation, hobbies,dietary history,alcohol or drug
use,travel history etc (toxic/infectious contacts)
• Ask for skin and hair/nail changes

14. Clinical symptoms and findings of anemia
• Anemia leads to two symptom complexes
• Tissue hypoxia
• Compensatory attempts
• Fatigue, weakness
–Tiredness, lassitude, reduced exercise tolerence
–Generalized muscular weakness
• Pallor /skin or mucous membranes

15. Pallor (paleness):
• Look at
– Mucous membranes of mouth and pharynx
– Conjunctivae,lips, nail beds,palms
• Creases of the palms lose their pink colour when the Hb < 7g/dL
• In pernicious anemia there is a lemon yellow pallor.
• Pallor + mild scleral icterus suggests hemolytic anemia.
• Pallor+ petechiae suggests severe bone marrow failure
Clinical symptoms and findings of anemia

16. • Some other skin/mucosal changes
– Premature graying of hair:pern.anemia
– Hair loss and fragility + spooning of the nails:iron deficiency
– Chronic leg ulcers:Sickle cell or other hemolytic anemia
– Glossitis/burning sense :Pern. anemia, iron deficiency(rare)
– Chelitis(angular stomatitis):iron def.
– Siideropenic dysphagia: iron def.
– Painful ulcerative mouth lesions: aplastic anemia/leukemia
Clinical symptoms and findings of anemia

17. Clinical symptoms and findings of anemia
Cardiovascular System(1)
• Palpitation and dyspnea (during activity)
• Angina pectoris
• Claudicatio intermittans
• Murmurs: Mid systolic (rarely diastolic) , mainly
pulmonary valvular or apical or over major
peripheral arteries or jugulary veins

18. Clinical symptoms and findings of anemia
Central nervous system
• Headache
• Faintness
• Giddiness
• Tinnitus
• Decreased concentration ability
• Drowsiness,decreased muscle strength
• Clouding of consciousness
• Symptoms are more prominent in older patients
• Paresthesias:Vitamin B12 deficiency (or other).

19. Clinical symptoms and findings of anemia
Reproductive system
• Menstrual changes:
– Amenorrhea ,
– Menorrhagia(mostly a cause of anemia)
• Loss of libido

20. Koilonychia - spoon shaped nail

21. Angular stomatitis
glossitis
Nutritional deficiency anemia

22. Basic hematologic lab tests
• Complete blood count (CBC) –
Amount of hemoglobin – Number, size, and shape of
red blood cells (RBCs) – Number of white blood cells
(WBCs) and platelets – +/- automated WBC
differential
• Manual differential/manual peripheral smear review
• Abnormalities that fall outside of established
parameters result in manual review

23. Normals
COMPONENT NORMAL RANGES
WBC 4.8-10.8 x 103/μL
RBC Male 4.7-6.1 x 106/μL; Female 4.2-5.4 x 106/μL
Hgb Male 14-18 g/dL; Female 12-16 g/dL
Hct Male 42-52%; Female 37-47%
MCV 80-100 fL
MCH 27-31 pg
MCHC 32-36%
RDW 11.5-14.5%
Plt 150,000-350,000/μL
Retic 0.5-2.0%
23

24. Hypoproliferative Anaemias
Failure of cell
maturation
Nuclear
breakdown
Cytoplasmic
breakdown
Megaloblastic Anaemia
Defective DNA synthesis
Folate or B12 deficiency Haem defect Globin defect
Thalassemia
Sickle cell A
Fe Phorph
IDA, SA

25. Anaemia
Hypoproliferative Hemolytic
RPI < 2 RPI > 2
Hb% < 12, Hct <
38%

26. Mean Cell Volume (MCV)
• RBC volume (rather) is measured by
• The Mean Cell Volume or MCV and RDW
Microcytic
< 80 fl
MCV
Normocytic Macrocytic
80 -100 fl > 100 fl
< 6.5 µ 6.5 - 9 µ > 9 µ

27. Anaemia Workup - MCV
Microcytic
MCV
Normocytic Macrocytic
Iron Deficiency IDA
Chronic Infections
Thalassemias
Hemoglobinopathies
Sideroblastic Anemia
Chronic disease
Early IDA
Hemoglobinopathies
Primary marrow disorders
Combined deficiencies
Increased destruction
Megaloblastic anemias
Liver disease/alcohol
Hemoglobinopathies
Metabolic disorders
Marrow disorders
Increased destruction

28. Microcytic Anaemias
MCV < 80 fl Serum Iron TIBC BM Perls stain
Iron Def. Anemia ↓↓ ↑↑ 0
Chronic Infection ↓↓ ↓↓ + +
Thalassemia ↑↑ N + + + +
Hemoglobinopathy N N + +
Lead poisoning N N + +
Sideroblastic ↑↑ N + + + +

29. IDA – Special Tests
Iron related tests Normal IDA
Serum Ferritin (pmo/L) 33-270 < 33
TIBC (µg/dL) 300-340 > 400
Serum Iron (µg/dL) 50-150 < 30
Saturation % 30-50 < 10
Bone marrow Iron ++ Absent

30. Macrocytic Anaemias
A. Megaloblastic Macrocytic – B12 and Folate↓
B. Non Megaloblastic Macrocytic Anaemias
1. Liver disease/alcohol
2. Hemoglobinopathies
3. Metabolic disorders, Hypothyroidism
4. Myelodystrophy, BM infiltration
5. Accelerated Erythropoesis -↑destruction
6. Drugs (cytotoxics, immunosuppressants, AZT, anticonvulsants)

31. Anaemia Diagnosis - Summary
 If Hb% is low – Do not start on Iron straight away
 Ask for RCC, Hematocrit – Derive MCV, MCH, MCHC
 Order for Reticulocyte count – Is RPI < 2 % or > 2%
 Thoroughly look for blood loss – acute / chronic / occult
 Is it hypo-proliferative or hemolytic or hemorrhagic anaemia
 If hypo proliferative – Microcytic or Macrocytic? (MCV, RDW)
 If microcytic – IDA or others – Spl. Iron tests, BM Iron
 If macrocytic – Megaloblastic (B12, FA) or Normoblastic BM
 If normocytic – Anaemia of chr. Disease – Liver, MRD, Ca
 Peripheral smear study for RBC size, shape, colouration etc.
 If retic. count is ↑- HA work up; Hb EP, spl. tests

33. • Definition :
• It is a state of anemia in which there is
• inadequate amount of iron for hemoglobin
synthesis
• Causes :
• Poor intake of iron.
• Decreased absorption.
• Increased demand in growth.
• Blood loss ( hemorrhage –injury –irregular or
excessive menstruation ).
Iron-deficiency anemia

35. Clinical Manifestations
• Pallor is the most common finding, and glossitis
(inflammation of the tongue) is the second most
common. Another finding is cheilitis (inflammation of
the lips).
• The patient may report headache, paresthesias, and a
burning sensation of the tongue, all of which are caused
by lack of iron in the tissues.
• Clinical pictures :
• Feature of anemia .
• Koilonychia(spoon shape nails).
• Atrophy of papilla of tongue.
• Angular stomatitis .
• Britte hair

36. Diagnostic Studies
• History and physical examination
• Hct and Hb levels
• RBC count including morphology
• Reticulocyte count
• Serum iron
• Serum ferritin is decreased.
• Bone marrow iron stories empty

37. • Iron replacement
• Oral iron
• →tab: ferrous sulphate 500mg-daily
• →cap: ferrous gluconate 250mg-daily.
• Parental →IM inj only
Management

38. Hemolytic anemia
• Definition :
• It is caused by increase destruction of RBCs
,shorting of red cells survival stimulates B.M
to compensatory increase in RBCs production

39. Causes
Congenital:
– Spherocytosis
– Thalasemia
– Sickle cell anemia
– G6PD deficiency
Acquired:
• Immune:
– Transfusion reaction
– Worm &cold antibody
– Drug induced.
• Non immune :
– Microangiopathy
– Infection
– Hypersplenism
– Systemic disease

40. Thalassemia
Definition
• Thalassemia is an autosomal-recessive genetic disorder that results in inadequate
normal Hb production.
• Whereas IDA affects heme synthesis, thalassemia disrupts the synthesis of globin.
• Those who inherit just one beta-gene (heterozygotes) have
thalassemia minor, also called thalassemia trait, the carrier state of
thalassemia major.
• Those who inherit both beta-genes (homozygotes) have
thalassemia major, which results in a profound and life-
threatening anemia.

43. • Bossing of head and prominent
• Growth retardation
• Intermittent infection
• Severe anemia.
• Splenomegaly(early).
• Hepatomegaly Slow to develop
Clinical Manifestations

44. • Investigation :
• All investigation of anemia
• Hb-electrophoresis.
• X-ray for skull show.
• Management :
• Beta thalasemia:
• Blood transfusion →regular every 4-6 weeks.
• Folic acid supplements
• Splenoectomy
• Bone marrow transplantation
• Desferoxamin inj. For 12hours infusion
• Alpha thalasemia:
– a)Pt Requires no treatment should be taking
– .b)Folic acid and avoid oxidation drug.

45. • Sickle cell disease
• It is an autosomal necessive disorder resulting
from the presence of structurally abnormal Hb
in the RBC

48. • Clinical Manifestations
• Signs of anemia.
• Increase susceptibility to infection.
• Chronic leg ulcers.
• Persistent hemolytic.
• Aseptic necrosis of bone
• Blindness.
• Bossing of skull.

49. • Management:
• Bone-marrow transplantation
• Hydroxyl are a 500-750mg day that increase levels Hb.
• Supportive measures:
• Folic acid 5mgday.
• Treat and prevent infection.
• Avoid precipitation factors.
• Blood-transfusion I.V fluid and antibiotic.
• Analgesic.
• Oxygen

50. Prevention Of Anemia
• Detect risk
• factor of anemia and make health education.
• High nutritional diet.
• Avoid bad cooking of food.
• Supplementary as prophylaxis.
• Early management of peptic ulcer.
• Avoid drug which causes anemia.
• Family planning.
• Avoid alcohol and smoking.
• Avoid bad habit.
• Blood-transfusion as prophylaxis.
• Restrict coffee and tea.

51. • Heart failure.
• Bone deformity as bossing of skull and koilonychias.
• Growth retardation.
• Increase susceptibility to infection.
• Splenomegaly lead to splenoectomy.
• Hepatomegaly.
• Multiple transfusion causes iron overload that Caused
classification in liver (hepatochromatosis)
• that is lead to cirrhosis
• Death from cardiac failure.
• In iron therapy:
• Brownish of teeth.
• Black of stool
Complications

52. Nursing care of anemia
• Bed rest with monitor vital signs .
• Instruct patient to eat food rich with iron, vit B12,, vit c,
as(red meat, fish, fruits).
• I.V fluid as needed.
• Regular check of Hb level.
• Instruct patient to stop alcoholism and smoking
• Prepare patient for blood transfusion as needed.
• Observeany complication of blood transfusion.
• Observe S&S of complication of anemia.
• Don't give folic acid before vit B12 in Megaloblastic anemia
because that effect in nerves and make convulsion.
• Monitor S.E of treatment.

53. HEMOPHILIA
• commonly a deficiency of factor VIII, which is produced by the liver
and assists with thromboplastin formation in blood coagulation
• Both hemophilia A and B are inherited as X-linked recessive traits,
which affect males.
• Females are the carriers and do not have the disease.
• The clotting factors are present, but in a diminished capacity.
• The defective factor is unable to do its job in the clotting cascade,
so the cascade is halted and the fibrin clot is unable to form.

54. Assessment
• History of bleeding,
nosebleeds, and bruising
• Hemarthrosis into the joint
cavities of the knees, ankles,
elbows
• Hematoma with pain, swelling,
and limited motion
• Spontaneous hematuria

55. Diagnostic Testing
• Partial thromboplastin time (PTT) prolonged, indicating ineffective
clotting factors except factor VII (reference value 22.1–34.1
seconds for activated and 60–90 seconds if not activated)
• Low level of factor VII or IX coagulant
• Spontaneous genetic mutations may occur because some males in
the family tree do not have the disease
• Often no bleeding in first year of life, until child starts to walk and
fall; common first injury is oral mucosal membrane bleeding

56. Nursing Interventions
• Administration of factor VIII concentrate from pooled plasma
as prescribed by physician
• Administration of DDAVP (1-deamino-8D-arginine vasopressin),
a synthetic form of vasopressin to increase plasma factor VIII
in mild cases as prescribed by physician
• Corticosteriods for child with hematuria, hemarthrosis, and
synovitis as prescribed by physician
• Nonsteroidal anti-inflammatory drugs (NSAIDs) for relieving
pain; may interfere with platelet formation
• Avoid aspirin, which interferes with platelet function
• Avoid chronic use of demerol or codeine.
• Avoid heat or ice.
• Supportive care with exercise and physical therapy.

57. Leukemia
Leukemia / is a blood cancer caused by a rise in the number of white
blood cells in the body. The extra white blood cells don’t work right.
Types of Leukemia
1- Acute myelogenous leukemia
2- Acute lymphocyte leukemia
3- Chronic myelogenous leukemia
4- Chronic lymphocytic leukemia

58. Causes of Leukemia
Unknown causes but there are many pre-disposing
factors to the disease:-
1- Smoke
2- Exposed to a lot of radiation or certain chemicals
3- Radiation therapy or chemotherapy to treat cancer
4- A family history of leukemia
5- A genetic disorder

59. Clinical manifestation
1- excessive sweating, especially at night (called “night sweats”)
2- fatigue and weakness that don’t go away with rest
3- weight loss
4- bone pain and tenderness
5- painless, swollen lymph nodes (especially in the neck and armpits)
6- enlargement of the liver or spleen
7- red spots on the skin, called petechiae
8- bleeding easily and bruising easily
9- fever or chills
10- frequent infections
11-Ecchymosis

60. Treatment
1- Radiation therapy.
2- Chemotherapy.
3- Bone marrow transplant.
Complication of Leukemia
1- Thrombocytopenia.
2- Systemic hemorrhage.
3- Acute renal failure.
4- Alopecia.

61. Nursing intervention depended on anemia and Leukemia
1- Maintain the patient’s diet(high protein, vitamin, minerals, calories )
2- Administer oxygen
3- Provide rest for the patient
4- Protect patient from injury
5- Provide nutritional needs .
6- Administer medication as prescribed (Antibiotic to treat infections if present)
7- Monitor and record vital signs, urine out-put, laboratory studies, daily weight, stool and emesis
8- Monitor bleeding and infection
9-Administer IV fluids
10- Administer blood transfusion therapy as prescribed (platelets, packed RBC and blood.
11- Provide extra blankets if the patient feels cool( anemia)
12- Provide post chemotherapy care (leukemia )