Anemia

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ANEMIAS (general)

Definitions

Condition in which the hemoglobin concentration is lower than normal

12.6-17.4

Reflects the presence of fewer than the normal number or erythrocytes

Results in decrease amount of oxygen delivered to the tissues

Sign of an underlying disorder

Classification

Hypoproliferative: Deficit in RBC production

MCV—size of the RBC

Iron deficiency

low MCV

low reticulocytes

low Iron, % saturation, ferritin

high TIBC

B12 deficiency

­ high MCV

low vitamin B22

Megaloblastic anemia

Folate deficiency

­ high MCV

Bleeding: RBC loss

Acute blood loss (GI, trauma, menstrual cycle), ¯ MCV

Hemolytic: excess RBC destruction

Sickle cell – RBC abnormal shaped & bone marrow attempts to produce more, and they will become more sickled & too young & the body will hemolysis & hypoxia (triggering kidney to produce RBC by stimulating the liver to produce young RBC) in the body will occur & jaundice & anemia

Diagnostic studies: General

CBC

RBC indices

Iron Studies

Serum iron level

Total iron binding capacity

Ferritin

^ when looking for Iron deficiency

Vitamin B12

Folate Level (folic acid levels)

Haptoglobin & Erythropoietin Levels

Bone Marrow Aspiration

Other tests for underlying chronic illness, malignancy, blood loss

MCV --> mean corpuscular volume – size of erythrocyte

So you can do the labs and if the MCV shows a change can it be diagnosed by that?

Complications: General

Heart failure

Paresthesia

Delirium

gradual HBG loss 50%

cardiopulmonary collapse with acute HBG loss 30%

does this usually happen after SX?

activity, disease & life style may ­increase symptoms

Geriatric Considerations

Impacts functioning

Decreased mobility

Increased depression

Increased risk for falling

Delirium (esp. hospitalized)

Clinical manifestations

Fatigue

Dyspnea

Confusion

Assessment:

Health History

Medications

Alcohol intake

BC alcohol needs a lot to be digested

Family history

Nutritional Assessment

Intake of iron & nutrients (B12 & folic acid) BC different PT with cultures have different diets & if malnourished

Cardiac Status

HF (pushing of blood is compromised causing issues on the blood)

Gastrointestinal System

Because of bleeding loss without being noticed

Neurological Examination

Clinical Manifestations:

Weakness, fatigue, and general malaise

Pallor skin and mucous membranes

No HBG within the system

Tachycardia (BC trying to compensate for the HBG loss), palpitations, dyspnea, dizziness, and orthopnea

Nausea, vomiting, anorexia, and glossitis

Paresthesia, ataxia, poor coordination, and confusion

Jaundice—in megaloblastic or hemolytic anemia

Tongue smooth & red—iron deficiency

Beefy, red, & sore – megaloblastic anemia

Angular chelilosis (ulcerated corners of the mouth)—both

Carve ice, dirt (pica), starch—iron

Identify anemia in dark skin?

Diagnosis

Nursing Diagnosis:

Fatigue

Imbalanced nutrition, less than body requirements

Ineffective tissue perfusion

Collaborative problems/potential complications:

Heart Failure

Angina

Chest pain—BC parts of the myocardia may be blocked causing pain

Paresthesia

Confusion

Injury related to falls

Depressed mood

PT goes into further anemia, because they aren’t doing much

Planning/Goals

Major goals

Decreased fatigue

Attainment of adequate nutrition

Maintenance of adequate tissue perfusion

Nice pink color

Compliance with prescribed therapy

Prevention/absence of complications

Not in a short time because body needs to get used to the change

Interventions:

Managing Fatigue

Prioritizing and balancing activities

Maintain physical activity and exercise

Maintaining Adequate Nutrition

Healthy diet

Dietary supplements

I.e. vitamins & multivitamins but NOT iron, B12, or folic acid because that needs to be monitored by the physician

Many PT do not like iron because they can become constipated

Activity Intolerance

Replace lost volume

Supplemental oxygen

Because with cardiopulmonary distress O2­ is important

O2 is the main thing with anemia

Promoting Compliance

Patient/family teaching

Monitoring/managing Complications

Evaluations:

Expected Outcomes

Reports less fatigue

Attains and maintains adequate nutrition

Maintain adequate perfusion

Absence of complications

Iron Deficiency Anemia

Causes

low iron stores

¼ - 1/3 is what the body stores – what is showed before the PT will show symptoms

Chronic blood loss

low iron intake

Iron malabsorption

Pregnancy blood flow increases iron­, more O2 is needed --> depleted from the iron, usually told to take multivitamin because of this

Alcoholics -- depleted iron as well because alcohol needs iron to digest, & they are usually malnourished as well

Intrinsic factor in the GI but in bariatric SX – it may be lost

Clinical manifestations

Smooth, sore tongue

Brittle and ridged nails

Angular cheilosis

Diagnostic findings

Bone marrow aspiration

low ferritin levels

low MCV

low HCT and RBC levels

Medical/Nursing Management

Treat underlying cause

Bleeding (cancer, tumors)

Stool for occult blood

People over age of 50-> colonoscopy, endoscopy, or X-ray of GI tract

Celiac & gastric surgery -> inadequate iron absorption

Iron supplements

GI side effects -> Use of Stool softeners

increases­ constipation because it is a hard supplement—important to be given a stool softener— increase in­ grains in diet to soften stool

Orange juice ­ absorption in the body

Increase the intake of vitamin C (citrus fruits and juices, strawberries, tomatoes, broccoli) to enhance iron absorption. Eat foods high in fiber to minimize problems with constipation; add stool softener if needed. Remember that stools will become dark in color.

Prevent staining the teeth with a liquid preparation by using a straw or placing a spoon at the back of the mouth to take the supplement. Rinse the mouth thoroughly afterward. PAGE 931

Take on empty stomach

Very important

Increase iron in diet

Vitamin C sources enhances iron absorption

Vitamin B12 & Folate deficiency Anemias

Vitamin B12 Etiology

B12 absorbed in the GI tract by the intrinsic factor cells – which is why in the bariatric SX when the intrinsic factor cells are depleted it can cause a B12 deficiency

B12 & folate main DNA formation

Strict vegetarians (no meat or dairy products)

Faulty absorption in GI tract

Crohn’s disease

Gastric surgery

Chronic use of PPIs and metformin

Absence of intrinsic factor

Pernicious anemia

Folate etiology

Deficiency found in those who do not consume uncooked vegetables

Increases folic acid requirements

Alcohol

Chronic hemolytic anemia

Woman who are pregnant

Malabsorptive diseases

Celiac disease

Clinical manifestations

Clinical manifestations similar

Mild jaundice

Mouth and tongue soreness

May coexist together

Neurologic manifestations of Vitamin B12 deficiency do not occur with folic acid deficiency

Paresthesia

Loss of proprioception

Diagnostic

Vitamin B12

Can you do B12 to diagnose B12 & folate deficency?

Schilling test

Don’t use it any more—very costly

Administer a little medication of B12 & wait to see if PT digested it correctly – see if Pt has intrinsic factor

Methylmalonic acid level

Intrinsic antibody factor

Medical/Nursing management

Folate Deficiency

Increasing folate in the diet

Folic acid 1 mg daily (IM for malabsorption problems)

Easy to treat—one a week & it will begin to ­ increase

B12 Deficiency

Vitamin B 12 replacement

Replacement with food first & then once identified then it will go into the injection course of medications

Absence of intrinsic factor >>> IM injections of Vitamin B12

Injections ONCE a month—if lacking intrinsic factor

Nursing does not suggest this to PT but to the doctor!!

Celiac disease, with exacerbations, more than once a month, depending on the order of the DOCTOR

Assess ambulation, gait, stability

PT/OT referral

Small amounts, bland food

Sickle Cell Anemia

Severe hemolytic anemia

Results from inheritance of the sickle hemoglobin (HbS) gene à defective hemoglobin molecule that acquires a crystal-like formation when exposed to low oxygen tension

African, Middle East, and Mediterranean descents

Sickle Cell trait (carrier)

Pathophysiology

Decrease O2 in the body

Defective HbS because viscous

Formation of gel like substance containing HbB crystals

Clumping of crystals into long chains

Becoming very painful, not transferring O2

Formation of parallel array of filaments

Disruption

Cell assumes crescent shape

Sickling

Rigid

Sticky

Fragile

Agglutination & circulation is impaired

Give large amount of pain medication—very addictive can cause respiratory distress because PT want more medication—Nurse needs to monitor this process because of this to avoid this crisis

If PT goes into crisis—PT is to receive O2 (#1) & fluid (to deglutinate the cells, very important)

Microinfarcts

Tissue hypoxia

Further sickling

Clinical manifestations

Jaundice

Chronic anemia

Tachycardia, cardiac murmurs, and cardiomegaly

Ischemia/infarction

Pain, swelling, and fever

Sickle Cell Crisis (Acute Vaso-occlusive Crisis)

Entrapment of erythrocytes in microcirculation

Hypoxia, inflammation, and necrosis to a region

Which is why fluids are important to be given

With perfusion: free radicals create oxidative damage to vessel

Endothelium of vessel becomes dysfunctional

Crisis >> Acute Chest Syndrome

Fever, respiratory distress, and new infiltrates on CXR

Mimic infection (often the cause)

Rule out PE

Treatment

PRBC, ABX, bronchodilators, inhaled nitric oxide, and mechanical ventilation

Mechanical ventilation – sickle cells went into little vessels of the lungs, which is difficult to be moved, areas must be open & ready

New infiltrated—antibiotics

Difficulty breathing—bronchodilators

Crackles—something to eliminate the fluid

Mimicking infections (fever, because of the infiltration)—interventions will be O2 , antibiotics, fluids (not overloaded because there may be crackles, blood transfusion with none-to-little saline (body can only handle a little), one or the other)

Crisis

Pulmonary HTN

CT Scan: diminished perfusion

Elevated BNP

Pulmonary artery pressures elevated

Lung assessment may be normal

Pulse oximetry may be normal

Pulmonary arteries are stretched

Stroke

Ischemic strokes common in young children and older adults

Hemorrhagic stroke more common in younger adults

Result from decreased cerebral blood flow due to anemia, hemolysis, increased hypoxic stress

If sickle cell is not treated

Medical management: red cell transfusions to reduce level of Hemoglobin S to prevent cerebral edema

Reproductive problems

Low testosterone, low libido, erectile dysfunction, infertility

Common signs

Episodes of priapism (prolonged erection of penis without sexual stimulation that can contribute to significant pain, decreased libido, and impotence

EMERGENCY – organ can be killed, sickle cells are agglutinated in the penis, engorged with sickle cells, circulation will not be able to get back— >10 min without intervention necrosis can occur because of the lack of circulation

Contraception important when on hydroxyurea due to teratogenic effects; concerns about hydroxyurea and infertility in men

Diagnostic findings & prognosis

Low hematocrit with sickle cells noted on blood smear

Confirmation: hemoglobin electrophoresis

Diagnosed in infancy

Average life expectancy suboptimal

Death commonly due to heart disease, lung disease, kidney disease, infection, and neurologic system disease

Medical/Nursing Management

Stem Cell Transplant

Pharmacologic Therapy

Hydroxyurea (chemotherapy agent)

Folic acid replacement

Treat infections promptly

Influenza & pneumococcal vaccinations

Transfusion Therapy

Supportive Therapy

Pain management

Adequate hydration

Supplemental oxygen

Decrease fatigue and inflammation

Nursing Diagnoses

Acute pain and fatigue

Risk for infection

Planning/Goals

Relief of pain

Decreased incidence of crisis

Absence of complications

Interventions

Pain management

Managing fatigue

Preventing and managing infection

Promoting coping skills

Minimizing deficient knowledge

Preventing/managing potential complications