Chapter 31 Nursing Management: Anemia

Cause: Decreased RBC Production
>>Deficient nutrients – Iron, Vitamin B-12, Folic Acid

>>Decreased erythropoietin
>>Decreased iron availability

Cause: Blood Loss
>>Chronic hemorrhage – Bleeding duodenal ulcer, Colon cancer

>>Acute trauma

Cause: Increased RBC Destruction
>>Hemolysis –
Sickle cell disease, Medication (e.g., methyldopa (Aldomet)
Incompatible blood
Trauma (e.g.,cardioplumonary bypass)
Sickle cell disease has a high incidence among ?
African American
Thalassemia has a high incidence among ?
African Americans and people of Mediterranean origin.
Tay-Sachs disease has the highest incidence in families of ?
Eastern European Jewish origin, especially the Ashkenazi Jews.
Pernicious anemia has a high incidence among?
Scandinavians and African Americans.
Morphologic Classification and Etiologies of Anemia for Normocytic, normochromic (normal size and color)?
Acute blood loss, hemolysis, chronic kidney disease, chronic disease, cancers, sideroblastic anemia, refractory anemia, diseases of endocrine dysfunction, aplastic anemia, sickle cell anemia, pregnancy
Morphologic Classification and Etiologies of Anemia for Macrocytic, normochromic (large size, normal color) ?
Cobalamin (vitamin B12) deficiency, folic acid deficiency, liver disease (including effects of alcohol abuse), postsplenectomy
Morphologic Classification and Etiologies of Anemia for Microcytic, hypochromic (small size, pale color) ?
Iron-deficiency anemia, thalassemia, lead poisoning
Integument symptoms of Mild (Hb 10-14 g/dl [100-140 g/L]) ?
None
Integument symptoms of Moderate (Hb 6-10 g/dl [60-100 g/L])
None
Integument symptoms of Severe (Hb <6 g/dl [<60 g/L])
Pallor, jaundice,* pruritus*
Eyes symptoms of Mild (Hb 10-14 g/dl [100-140 g/L]) ?
None
Mouth symptoms of Mild (Hb 10-14 g/dl [100-140 g/L]) ?
None
Cardiovascular symptoms of Mild (Hb 10-14 g/dl [100-140 g/L]) ?
Palpitations
Pulmonary symptoms of Mild (Hb 10-14 g/dl [100-140 g/L]) ?
Exertional dyspnea
Neurologic symptoms of Mild (Hb 10-14 g/dl [100-140 g/L]) ?
None
Gastrointestinal symptoms of Mild (Hb 10-14 g/dl [100-140 g/L]) ?
None
Musculoskeletal symptoms of Mild (Hb 10-14 g/dl [100-140 g/L]) ?
None
General symptoms of Mild (Hb 10-14 g/dl [100-140 g/L]) ?
None
Eyes symptoms of Moderate (Hb 6-10 g/dl [60-100 g/L])
None
Mouth symptoms of Moderate (Hb 6-10 g/dl [60-100 g/L])
None
Cardiovascular symptoms of Moderate (Hb 6-10 g/dl [60-100 g/L])
Increased palpitations, “bounding pulse”
Pulmonary symptoms of Moderate (Hb 6-10 g/dl [60-100 g/L])
Dyspnea
Neurologic symptoms of Moderate (Hb 6-10 g/dl [60-100 g/L])
“Roaring in the ears”
Gastrointestinal symptoms of Moderate (Hb 6-10 g/dl [60-100 g/L])
None
Musculoskeletal symptoms of Moderate (Hb 6-10 g/dl [60-100 g/L])
None
General symptoms of Moderate (Hb 6-10 g/dl [60-100 g/L])
Fatigue
Eyes symptoms of Severe (Hb <6 g/dl [<60 g/L])
Icteric conjunctiva and sclera,* retinal hemorrhage, blurred vision
Mouth symptoms of Severe (Hb <6 g/dl [<60 g/L])
Glossitis, smooth tongue
Cardiovascular symptoms of Severe (Hb <6 g/dl [<60 g/L])
Tachycardia, increased pulse pressure, systolic murmurs, intermittent claudication, angina, HF, M

Hb, Hemoglobin; HF, heart failure; MI, myocardial infarction.

Pulmonary symptoms of Severe (Hb <6 g/dl [<60 g/L])
Tachypnea, orthopnea, dyspnea at rest
Neurologic symptoms of Severe (Hb <6 g/dl [<60 g/L])
Headache, vertigo, irritability, depression, impaired thought processes
Gastrointestinal symptoms of Severe (Hb <6 g/dl [<60 g/L])
Anorexia, hepatomegaly, splenomegaly, difficulty swallowing, sore mouth
Musculosketetal symptoms of Severe (Hb <6 g/dl [<60 g/L])
Bone pain
General symptoms of Severe (Hb <6 g/dl [<60 g/L])
Sensitivity to cold, weight loss, lethargy
Subjective Data: Past health history
Recent blood loss or trauma; chronic liver, endocrine, or renal disease (including dialysis); GI disease (malabsorption syndrome, ulcers, gastritis, or hemorrhoids); inflammatory disorders (especially Crohn’s disease); smoking, exposure to radiation or chemical toxins (arsenic, lead, benzenes, copper); infectious diseases (HIV) or recent travel suggesting exposure to infection; angina, myocardial infarction; history of falling
Subjective Data: Medications
Use of vitamin and iron supplements; aspirin, anticoagulants, oral contraceptives, phenobarbital, penicillins, nonsteroidal antiinflammatory drugs, phenacetin, quinine, quinidine, phenytoin (Dilantin), methyldopa (Aldomet), sulfonamides, herbal products
Subjective Data: Surgery or other treatments
Recent surgery, small bowel resection, gastrectomy, prosthetic heart valves, chemotherapy, radiation therapy
Subjective Data: Dietary history:
General dietary patterns, consumption of alcohol, pica
Subjective Data: Health perception-health management
Family history of anemia; malaise
Subjective Data: Nutritional-metabolic
Nausea, vomiting, anorexia, weight loss; dysphagia, dyspepsia, heartburn, night sweats, cold intolerance
Subjective Data: Elimination
Hematuria, decreased urinary output; diarrhea, constipation, flatulence, tarry stools, bloody stools
Subjective Data: Activity-exercise
Fatigue, muscle weakness and decreased strength; dyspnea, orthopnea, cough, hemoptysis; palpitations; shortness of breath with activity
Subjective Data: Cognitive-perceptual
Headache; abdominal, chest, and bone pain; painful tongue; paresthesias of feet and hands; pruritus; disturbances in vision, taste, or hearing; vertigo; hypersensitivity to cold; dizziness
Subjective Data: Sexuality-reproductive
Menorrhagia, metrorrhagia; recent or current pregnancy; male impotence
Objective Data: General
Lethargy, apathy, general lymphadenopathy, fever
Objective Data: Integumentary
Pale skin and mucous membranes; blue, pale white, or icteric sclera; cheilitis; poor skin turgor; brittle, spoon-shaped fingernails; jaundice; petechiae; ecchymoses; nose or gingival bleeding; poor healing; dry, brittle, thinning hair
Objective Data: Respiratory
Tachypnea
Objective Data: Cardiovascular
Tachycardia, systolic murmur, dysrhythmias; postural hypotension, widened pulse pressure, bruits (especially carotid); intermittent claudication, ankle edema
Objective Data: Gastrointestinal
Hepatosplenomegaly; glossitis; beefy, red tongue; stomatitis; abdominal distention; anorexic
Objective Data: Neurologic
Headache, roaring in the ears, confusion, impaired judgment, irritability, ataxia, unsteady gait, paralysis, loss of vibration sense
Objective Data: Possible Findings
↓ RBCs,
↓ Hb;
↓ Hct;
↑ or ↓ reticulocytes,
MCV, serum iron, ferritin, folate, or cobalamin (vitamin B12);
heme (guaiac)-positive stools;
↓ serum erythropoietin level; ↑ or ↓ LDH, bilirubin, transferrin

GI, Gastrointestinal; Hb, hemoglobin; Hct, hematocrit; LDH, lactic dehydrogenase; MCV, mean corpuscular volume; RBCs, red blood cells.

Acute interventions may include ?
Blood or blood product transfusions;
Drug therapy (e.g., erythropoietin, vitamin supplements)
Volume replacement, and oxygen therapy to stabilize the patient.

Dietary and lifestyle changes can reverse some anemias so that the patient can return to the former state of health.

Etiologic Classification of Anemia: Decreased Hemoglobin Synthesis caused by?
Iron deficiency

Thalassemias (decreased globin synthesis)

Sideroblastic anemia (decreased porphyrin)

Etiologic Classification of Anemia: Defective DNA Synthesis?
Cobalamin (vitamin B12) deficiency

Folic acid deficiency

Etiologic Classification of Anemia: Decreased Number of Erythrocyte Precursors?
Aplastic anemia

Anemia of myeloproliferative diseases (e.g., leukemia) and myelodysplasia

Chronic diseases or disorders

Etiologic Classification of Anemia: Acute?
Trauma,
Blood vessel rupture
Etiologic Classification of Anemia: Chronic?
Gastritis

Menstrual flow

Hemorrhoids

Etiologic Classification of Anemia: Intrinsic?
Abnormal hemoglobin (Hb S-sickle cell anemia)

Enzyme deficiency (G6PD)

Membrane abnormalities (paroxysmal nocturnal hemoglobinuria, hereditary spherocytosis)

DNA, Deoxyribonucleic acid; G6PD, glucose-6-phosphate dehydrogenase; Hb S, hemoglobin S. Hemolytic anemias

Etiologic Classification of Anemia: Extrinsic?
Physical trauma (prosthetic heart valves, extracorporeal circulation)

Antibodies (isoimmune and autoimmune)

Infectious agents, medications, and toxins (malaria)

Etiologic Classification of Anemia: Increased Erythrocyte Destruction called?
*Hemolytic anemias.
Etiologic Classification of Anemia?
Decreased Erythrocyte Production
The clinical manifestations of anemia are caused by?
the body’s response to tissue hypoxia.
If symptoms develop, it is because the patient has ?
an underlying disease or is experiencing a compensatory response to heavy exercise.
Pallor results from ?
reduced amounts of hemoglobin and reduced blood flow to the skin.
Jaundice occurs when?
hemolysis of RBCs results in an increased concentration of serum bilirubin.
Pruritus occurs because ?
of increased serum and skin bile salt concentrations.
the sclera of the eyes and mucous membranes should be evaluated for jaundice because ?
they reflect the integumentary changes more accurately, especially in a dark-skinned individual.
Integumentary changes include?
pallor, jaundice, and pruritus.
Cardiopulmonary manifestations of severe anemia result from?
additional attempts by the heart and lungs to provide adequate amounts of oxygen to the tissues.
Cardiac output is maintained by ?
increasing the heart rate and stroke volume.
The low viscosity of the blood contributes to ?
the development of systolic murmurs and bruits.
In extreme cases or when concomitant heart disease is present, angina pectoris and myocardial infarction (MI) may occur if ?
myocardial O2 needs cannot be met.
Heart failure (HF), cardiomegaly, pulmonary and systemic congestion, ascites, and peripheral edema may develop if ?
he heart is overworked for an extended period of time.
What should be included in the plan of care?
Ongoing assessment of the patient’s knowledge regarding adequate nutritional intake and compliance with safety precautions to prevent falls and injury and drug therapies
Normally, 1 mg of iron is lost daily through?
feces, sweat, and urine in the adult male
1.5 mg/day is lost daily through?
normal menstruating women.
The median total iron loss with pregnancy is?
about 500 mg, or almost 2 mg/day over the 280 days of gestation.5
Iron-deficiency anemia may develop from ?
inadequate dietary intake, malabsorption, blood loss, or hemolysis.
Dietary iron may be inadequate for those individuals who have higher iron needs such as?
woment who are menstruating or pregnant
Malabsorption of iron may occur after ?
certain types of gastrointestinal (GI) surgery and in malabsorption syndromes.
As iron absorption occurs in the duodenum, malabsorption syndromes may involve disease of the?
duodenum in which the absorption surface is altered or destroyed.
Blood loss is a major cause of?
iron deficiency in adults.
Two milliliters of whole blood contain ?
1 mg of iron
The major sources of chronic blood loss are from ?
the GI and genitourinary (GU) systems.
GI bleeding is often ?
not apparent
Loss of 50 to 75 ml of blood from the upper GI tract is required for stools to appear?
black (melena).
The black color in stool results from?
the iron in the RBCs.
Common causes of GI blood loss are?
peptic ulcer, gastritis, esophagitis, diverticuli, hemorrhoids, and neoplasia.
GU blood loss occurs primarily from ?
menstrual bleeding.
he average monthly menstrual blood loss is about 45 ml and causes the loss of about ?
22 mg of iron.
Postmenopausal bleeding can contribute to anemia in a?
susceptible older woman.
Nutrients Needed for Erythropoiesis?
Cobalamin (vitamin B12)
Folic acid
Iron
Vitamin B6
Amino acids
Vitamin C
Cobalamin (vitamin B12) role in Erythropoiesis?
RBC maturation
Folic acid role in Erythropoiesis?
RBC maturation
Vitamin C iron role in Erythropoiesis?
Hemoglobin synthesis
Vitamin B6 role in Erythropoiesis?
Hemoglobin synthesis
Amino acids role in Erythropoiesis?
Synthesis of nucleoproteins
Vitamin C role in Erythropoiesis?
Conversion of folic acid to its active forms, aids in iron absorption
Food Sources for Cobalamin (vitamin B12)?
Red meats, especially liver
Food Sources for Folic acid?
Green leafy vegetables, liver, meat, fish, legumes, whole grains
Food Sources for Iron?
Liver and muscle meats, eggs, dried fruits, legumes, dark green leafy vegetables, whole-grain and enriched bread and cereals, potatoes
Food Sources for Vitamin B6?
Meats (especially pork and liver), wheat germ, legumes, potatoes, cornmeal, bananas
Food Sources for Amino acids?
Eggs, meat, milk and milk products (cheese, ice cream), poultry, fish, legumes, nuts
Food Sources for Vitamin C?
Citrus fruits, leafy green vegetables, strawberries, cantaloupe
Pregnancy contributes to iron deficiency because of
the diversion of iron to the fetus for erythropoiesis, blood loss at delivery, and lactation.
In addition to anemia of chronic renal failure, dialysis treatment may induce iron-deficiency anemia because of
the blood lost in the dialysis equipment and frequent blood sampling.
the most common finding clinical symptoms related to iron deficiency anemia.
Pallor
the second most common finding clinical symptoms related to iron deficiency anemia.
glossitis (inflammation of the tongue) and 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.
What are the lab findings for a patient with Iron deficiency?
Hb/Hct ↓

MCV ↓

Reticulocytes N or slight ↓

Serum Iron ↓

TIBC ↑

Transferrin ↓

Ferritin ↓

Bilirubi N or ↓

Hb, Hemoglobin; Hct, hematocrit; MCV, mean corpuscular volume; N, normal; TIBC, total iron-binding capacity.

What are the lab findings for a patient with Thalassemia major?
Hb/Hct ↓

MCV N or ↓

Reticulocytes ↑

Serum Iron ↑

TIBC ↓

Transferrin ↓

Ferritin N or ↑

Bilirubi N or ↓

Hb, Hemoglobin; Hct, hematocrit; MCV, mean corpuscular volume; N, normal; TIBC, total iron-binding capacity.

What are the lab findings for a patient with Cobalamin deficiency?
Hb/Hct ↓

MCV ↑

Reticulocytes N or ↓

Serum Iron N or ↑

TIBC N

Transferrin Slight ↑

Ferritin ↑

Bilirubi N or Slight ↑

Hb, Hemoglobin; Hct, hematocrit; MCV, mean corpuscular volume; N, normal; TIBC, total iron-binding capacity.

What are the lab findings for a patient with Folic acid deficiency?
Hb/Hct ↓

MCV ↑

Reticulocytes N or ↓

Serum Iron N or ↑

TIBC N

Transferrin Slight ↑

Ferritin ↑

Bilirubi N or Slight ↑

Hb, Hemoglobin; Hct, hematocrit; MCV, mean corpuscular volume; N, normal; TIBC, total iron-binding capacity.

What are the lab findings for a patient with Aplastic anemia?
Hb/Hct ↓

MCV N or slight ↑

Reticulocytes ↓

Serum Iron N or ↑

TIBC N or ↑

Transferrin N

Ferritin N

Bilirubi N

Hb, Hemoglobin; Hct, hematocrit; MCV, mean corpuscular volume; N, normal; TIBC, total iron-binding capacity.

What are the lab findings for a patient with Chronic disease?
Hb/Hct ↓

MCV N or ↓

Reticulocytes N or ↓

Serum Iron N or ↓

TIBC ↓

Transferrin N or ↓

Ferritin N or ↑

Bilirubi N

Hb, Hemoglobin; Hct, hematocrit; MCV, mean corpuscular volume; N, normal; TIBC, total iron-binding capacity.

What are the lab findings for a patient with Acute blood loss?
Hb/Hct ↓

MCV N or ↓

Reticulocytes N or ↑

Serum Iron N

TIBC N

Transferrin N

Ferritin N

Bilirubi N

Hb, Hemoglobin; Hct, hematocrit; MCV, mean corpuscular volume; N, normal; TIBC, total iron-binding capacity.

What are the lab findings for a patient with Chronic blood loss?
Hb/Hct ↓

MCV ↓

Reticulocytes N or ↑

Serum Iron ↓

TIBC ↓

Transferrin N

Ferritin N

Bilirubi N or ↓

Hb, Hemoglobin; Hct, hematocrit; MCV, mean corpuscular volume; N, normal; TIBC, total iron-binding capacity.

What are the lab findings for a patient with Sickle cell anemia?
Hb/Hct ↓

MCV N

Reticulocytes ↑

Serum Iron N or ↑

TIBC N

Transferrin N

Ferritin N

Bilirubi ↑

Hb, Hemoglobin; Hct, hematocrit; MCV, mean corpuscular volume; N, normal; TIBC, total iron-binding capacity.

What are the lab findings for a patient with Hemolytic anemia?
Hb/Hct ↓

MCV N or ↑

Reticulocytes ↑

Serum Iron N or ↑

TIBC N or ↓

Transferrin N

Ferritin N or ↑

Bilirubi ↑

Hb, Hemoglobin; Hct, hematocrit; MCV, mean corpuscular volume; N, normal; TIBC, total iron-binding capacity.

The main goal of collaborative care of iron-deficiency anemia is to?
to treat the underlying disease that is causing reduced intake (e.g., malnutrition, alcoholism) or absorption of iron.
If the iron deficiency is from acute blood loss, the patient may require?
a transfusion of packed RBCs.
Iron is absorbed best from the duodenum and proximal jejunum. Therefore enteric-coated or sustained-release capsules, which release iron farther down in the GI tract?
counterproductive and expensive.
The daily dosage of iron should provide ?
150 to 200 mg of elemental iron.
Iron is best absorbed as ferrous sulfate (Fe21) in an acidic environment. For this reason and to ?
avoid binding the iron with food, iron
iron should be taken ?
1 hour before meals, when the duodenal mucosa is most acidic.
All patients should know that the use of iron preparations will cause their stools to become?
black because the GI tract excretes excess iron.
Constipation is common, and the patient should be started on ?
stool softeners and laxatives when started on iron.
enhances iron absorption?
vitamin C (ascorbic acid) or orange juice, which contains ascorbic acid,
Enteric-coated or sustained-release iron ?
should not be used.
individuals who are at an increased risk for the development of iron-deficiency anemia?
premenopausal and pregnant women, persons from low socioeconomic backgrounds, older adults, and individuals experiencing blood loss.
To replenish the body’s iron stores, the patient needs to continue to take iron therapy for?
2 to 3 months after the hemoglobin level returns to normal.
Patients who require lifelong iron supplementation should be monitored for?
potential liver problems related to the iron storage.
The overall goals are that the patient with anemia will?
(1) assume normal activities of daily living,

(2) maintain adequate nutrition, and

(3) develop no complications related to anemia.

Anemia is?
a deficiency in the number of erythrocytes (red blood cells [RBCs]), the quantity of hemoglobin, and/or the volume of packed RBCs (hematocrit).
It is a prevalent condition with many diverse causes such as?
blood loss, impaired production of erythrocytes, or increased destruction of erythrocytes
Because RBCs transport oxygen (O2), erythrocyte disorders can lead to?
tissue hypoxia.
The various types of anemia can be grouped according to ?
either a morphologic (cellular characteristic) or an etiologic (underlying cause) classification.
The main goal of collaborative care of iron-deficiency anemia is to ?
treat the underlying disease that is causing reduced intake (e.g., malnutrition, alcoholism) or absorption of iron