ANEMIA

What is anemia?
Deficiency in:
The number of erythrocytes
Quantity or quality of hemoglobin
The volume of RBCs
Manifestations:
Hemoglobin levels are used to determine severity
Mild (Hgb 10-12g/dl) : will mostly be asymptomatic. May experience palpations or dyspnea
on exertion
Moderate (Hgb 6-10 g/dl): Bounding pulse, fatigue, and roaring in ears.
Severe Hgb <6 g/dl: Will see many symptoms all over the body symptom.
Tachycardia, murmurs, angina, heart failure, MI, tachypnea, dyspnea at rest, headache,
irritability, depression, sensitive to cold, weight loss, lethargy

Iron Deficiency Anemia

Most common chronic hematologic disorder
Decreased hemoglobin synthesis
Progresses gradually. Usually in young kids, pregnant aged women, and those with poor diets.
Manifestations

May result due to

Inadequate dietary intake
Malabsorption
Blood loss usually through the GI and GU systems
Hemolysis
Diagnostic Studies
Hct, Hgb, RBC count, serum iron, serum ferritin, total iron-binding capacity
Stool exam for occult blood
Collaborative therapy
No enteric coated iron its counterproductive and expensive.
Take iron 1 hour before meals because iron is absorbed best in an acidic environment
Liquid iron is taken through a straw. Can stain the patients teeth.

May experience GI side effects : heartburn, constipation, and diarrhea.

Iron DRUG ALERT: some preparations of IV iron have an increased risk for
reactions, monitor patient accordingly.
Dizziness, headache, and thrombophlebitis at IV site.
Nursing Actions
Use Z track method when administering iron IM, and different needle for withdrawal
and administration.
Causes black stools
May need stool softeners and possibly laxatives
Regular checkups and blood studies.
Diet teaching
Iron therapy will need to be continued for 2-3 months after Hgb returns to normal.

Thalassemia
Inadequate production of normal hemoglobin
Decreased erythrocyte production
Due to absent or reduced globulin protein
Autosomal recessive gene
2 types
Thalassemia minor asymptomatic. No treatment because the body adapts to the
change.
Thalassemia major
Life threatening disease.
Both physical and mental growth is retarded
Patient is pale and displays signs of anemia.
Jaundice from hemolysis of RBCs
Pronounced splenomegaly d/t spleen trying to remove the damaged RBCs
Hepatomegaly and cardiomyopathy d/t iron deposition.
Managed by: blood transfusions or potentially stem cell transplants

Megaloblastic Anemias
Impaired DNA synthesis characterized by large RBCs
Easily destroyed
2 most common classifications
Vit B12 Deficiency (aka Cobalamin): due to lack of intrinsic factor (pernicious
anemia)
A decrease in HCl in the stomach. An acidic environment is needed to secrete
IF.
S/S: sore, red, beefy tongue, anorexia, N/V, abdominal pain, weakness,
paresthesia, confusion
Without cobalamin. Patient will die in 1-3 years.
Folic Acid deficiency
Develops insidiously and symptoms are similar to above.
The only difference is there is an absence of neurological problems
Anemia caused by blood loss
Normal Hgb Female: 11.7-16 g/dl & 13.2-17.3 g/dl
Normal Hct female: 35-47% & Male 29-50%

 Acute can lead to shock and RBC available to carry O2 can be significantly decreased
Chronic effects usually related to depletion of iron
Nursing management
Prevent shock
Identify source of hemorrhage and stop the blood loss.
Administer LR
Once volume is replaced, correct the RBC loss (blood transfusions may be
needed and supplemental iron)

Sickle Cell Disease

Inherited autosomal recessive disorders, Abnormal form of hemoglobin
Management focuses on prevention of crisis
Genetic counseling is recommended
Asymptomatic unless sickling episode occurs
Sickling episodes:
Trigged by low oxygen tension in the blood
Ex. Stress, surgery, blood loss, infection, dehydration
A severe, painful, acute exacerbation of RBC sickling causing a vaso-occlusive crisis
Hypoxia occurs, tissue infarction, severe pain, and organ damage
Can persist for days to weeks
Joint swelling, tenderness, fever, HTN, N/V, pallor, jaundice, fatigue, enlarged spleen
or liver may be present
Management:
O2 for hypoxia and to control sickling
Pain management
Rest
Warm compresses
Teach patients to avoid high altitudes, maintain fluid intake, treat infections quickly,
avoid tight clothing, avoid strenuous exercise
Hydroxyuria: antisickling agent

Hemochromatosis
Iron overload
Primarily from genetic defect
Symptoms usually develop between ages 40-60
Early vs late symptoms
Early: nonspecific and include fatigue, arthralgia, impotence, abdominal pain, and
weight loss
Late: liver enlargement and eventually cirrhosis, DM, bronze pigmentation,
cardiomyopathy, arthritis
Lab increased serum iron, TIBC, and serum ferritin
Goal remove excess iron
Removal of 500 mL of blood each week for 2-3 years

Polycythemia (too much RBCs)

Increased number of RBC
Impairment of blood circulation as a result of hyperviscosity (thick blood) and
hypervolemia (too much fluid in blood)
Treatment reduce blood volume and viscosity via phlebotomy

 Polycythemia Vera
WBC and platelets are also involved.
Congestion of organs and tissues with blood
Circulatory manifestations occur due to hypertension caused by hypovolemia and
hyperviscosity
Headache, vertigo, dizziness, tinnitus, and visual disturbances.
Patients are predisposed to clotting
Evaluate fluid intake and output during hydration therapy
Assess nutritional status

Thrombocytopenia (destruction of Platelets)

Platelets below 150,000
Can be inherited but mostly acquired
Immune thrombocytopenic purpura (ITP)
Most common type
Destruction of circulating platelets
Survival rate of platelets is shortened
Thrombotic thrombocytopenic purpura (TTP)
uncommon
Heparin-induced thrombocytopenia (HIT)
Patients using heparin can potentially develop this when therapy is begun.
Arterial thrombosis can develop, DVT, and pulmonary emboli.
Bleeding is the most common symptom
Hemorrhage is a major complication
Patient teaching
Notify if any signs of bleeding
Prevent falls and injury
Do not blow nose forcefully
Do not bend head lower than waist
Prevent constipation
Electric razor
Do not puncture skin (tattoos, piercings)
Use soft tooth brush
Women keep track of amount of pads used during menstruation
Talk to HCP before any invasive procedures. Including dentist, manicures or pedis

BLOOD TRANSFUSIONS
Cross matching:
Blood bank is responsible for matching the patients blood type for compatibility
Nursing
Use at least a 19 gauge needle
Verify IV patency before requesting blood from the blood bank
Y-tubing or straight tubing with microaggregate filter
One arm for isotonic saline solution and other for blood product
Never use dextrose or LR with blood
Causes hemolysis (destruction of RBCs)
Never administer meds through blood infusion line
Consent signed and in client record

Make sure client understands procedure and S/S to report

Positive ID of donor blood and recipient is critical!
Strict ID when retrieving from blood bank
Check expiration date
Check for leaks, abnormal color, clots, bubbles
Return if found
On unit, dual check with licensed nurse
Patient ID and blood product ID
Take vitals prior to beginning transfusion
Contact HCP if fever
Administer as soon as it is brought to client
Do not refrigerate on nursing unit
If not used within 30 mins, return to blood bank
During 1st 15 minutes or 50 mL of blood, remain with patient
Any reaction will likely occur at this time
Infusion rate no more than 2mL/min
Quick intervention
PRBCs should not be infused quickly unless emergency exists
Blood-warming device if rapid replacement
Observe client during transfusion (every 30 mins) and up to 1 hr after.
Transfuse over 2-3 hrs
Should not take over 4 hours
Increased risk of bacterial growth
Blood unrefrigerated for 4 hours or longer should be returned to blood bank
If transfusion reaction occurs:
Stop transfusion
Maintain a patent IV line with saline (NEW TUBING)
Notify blood bank and HCP immediately
Recheck ID tag and numbers
Monitor vitals and urine output
Save blood bag and tubing to send to blood bank
Complete reaction reports
Collect required blood and urine specimens
Document
Blood bank and lab are responsible for identifying type of reaction