4 Hypoproliferative Anemias - Iron Deficiency-Aplastic-Megaloblastic Anema

INTRODUCTION
• Iron deficiency anemia typically results

when the intake of dietary iron is inadequate
for hemoglobin synthesis.
• The body can store about one fourth to one
third of its iron, and it is not until those
stores are depleted that iron deficiency
anemia actually begins to develop.
• Iron deficiency can also occur when total
body iron stores are adequate, but the
supply of iron to the bone marrow is
inadequate
• This type is referred to as functional iron
deficiency
Care of Clients with Nonmalignant Hematologic Disorder: Hypoproliferative Anemia - IRON DEFICIENCY, APLASTIC, MEGALOBLASTIC ANEMIA by: Ivy Mancera, RN, MSN
INTRODUCTION
• Iron deficiency anemia is the most common
type of anemia in all age groups, and it is
the most common anemia in the world,
affecting one in eight persons.
• It is particularly prevalent in developing
countries, where inadequate iron stores can
result from inadequate intake of iron (seen
with vegetarian diets) or from blood loss
• Bleeding should be considered the cause of
iron deficiency anemia until proven
otherwise
INTRODUCTION
• The most common cause of iron
deficiency anemia in men and
postmenopausal women is
bleeding from ulcers, gastritis,
inflammatory bowel disease, or GI
tumors.
• The most common causes of iron
deficiency anemia in
premenopausal women are
menorrhagia (excessive menstrual
bleeding) and pregnancy with
inadequate iron supplementation.
INTRODUCTION
• Patients with chronic alcoholism or who
take aspirin, steroids, or nonsteroidal
anti-inflammatory drugs (NSAIDs) often
have chronic blood loss from the GI
tract, which causes iron loss and
eventual anemia.
• Other causes include iron malabsorption,
as is seen after gastrectomy, bariatric
surgery, or with celiac or other
inflammatory bowel disease
• Medications (proton pump inhibitors, H2
blockers) can also decrease iron
absorption
CLINICAL MANIFESTATIONS
• Patients with iron deficiency primarily
have symptoms of anemia.
• If the deficiency is severe or prolonged,
they may have
• A smooth, red tongue
• Brittle and ridged nails
• Angular cheilosis
• These signs subside after iron
replacement therapy.
• The health history may be significant
for multiple pregnancies, GI bleeding,
and pica
Assessment and Diagnostic Findings
• The definitive method of establishing
the diagnosis of iron deficiency anemia
is bone marrow aspiration
• The aspirate is stained to detect iron,
which is at a low level or even absent.
• Few patients with suspected iron
deficiency anemia undergo bone
marrow aspiration.
• The diagnosis can be established with
other tests, particularly in patients with
a history of conditions that predispose
them to this type of anemia.
• A strong correlation exists between
laboratory values that measure iron stores
and hemoglobin levels.
• After iron stores are depleted (as reflected
by low serum ferritin levels), the
hemoglobin level falls.
• The diminished iron stores cause small
erythrocytes to be produced by the marrow.
• As the anemia progresses, the MCV, which
measures the size of the erythrocytes, also
decreases.
• Hematocrit and RBC levels are also
low in relation to the hemoglobin
level.
• Other laboratory tests that measure
iron stores are useful but not as
precise as ferritin levels.
• Patients with iron deficiency anemia
have a low serum iron level and an
elevated TIBC, which measures the
transport protein supplying the
marrow with iron as needed (also
referred to as transferrin)
• Other disease states, such as infection
and inflammatory conditions, can also
cause a low serum iron level and
TIBC, as well as an elevated ferritin
level.
• If these are suspected, measuring the
soluble transferring receptor can aid in
differentiating the cause of anemia.
• This test result will be increased in the
setting of iron deficiency, but not in
chronic inflammation
Medical Management
• Except in the case of pregnancy, the
cause of iron deficiency should be
investigated.
• Anemia may be a sign of a curable GI
cancer or of uterine fibroid tumors.
• Stool specimens should be tested for
occult blood.
• People 50 years of age or older should
have a colonoscopy, endoscopy, or x-
ray examination of the GI tract to
detect ulcerations, gastritis, polyps, or
cancer
Medical Management
• Individuals with celiac disease or who have had
gastric surgery may not absorb iron adequately from
their diet and therefore become iron deficient
• Oral iron supplementation is considered to be the
primary mode of treating iron deficiency anemia.
• Several oral iron preparations—ferrous sulfate, ferrous
gluconate, and ferrous fumarate—are available for
treating iron deficiency anemia.
• The hemoglobin level may increase in only a few
weeks, and the anemia can be corrected in a few
months.
• Iron store replenishment takes much longer, so the
patient must continue taking the iron for as long as 6
to 12 months
Medical Management
• In some cases, oral iron is
poorly absorbed or poorly
tolerated, or iron
supplementation is needed
in large amounts.
• In these situations, IV
administration of iron may
be needed.
• Several doses are required
to replenish the patient’s
iron stores
Parenteral Iron Formulations
• Older formulations of parenteral
iron had a high molecular weight,
and the risk of hypersensitivity
reactions, including anaphylaxis,
was significant.
• Newer formulations have a low
molecular weight, and the risk of
anaphylaxis is markedly reduced.
• Ferric gluconate (Ferrlecit): Each 5
mL contains 62.5 mg elemental iron
• 125 mg is diluted in 100 mL
normal saline and infused over 1
hour
• 5 mL undiluted is given as a slow
IV push injection over 5 minutes
• Although the likelihood of an
allergic reaction is extremely low,
a test dose is often given prior to
the first infusion
• Iron sucrose (Venofer)
• Each 5 mL contains 100 mg
elemental iron
• 100–200 mg can be given
undiluted as a slow IV push
injection over 2 to 5 minutes.
• This procedure can be repeated as
often as every 3 days for a total
cumulative dose of 1000 mg within
a 2-week period.
Nursing Management
• Preventive education is important,
because iron deficiency anemia is
common in menstruating and pregnant
women.
• Food sources high in iron include organ
meats (e.g., beef or calf’s liver, chicken
liver), other meats, beans, garbanzo,
leafy green vegetables, raisins, and
molasses.
• Taking iron-rich foods with a source of
vitamin C (e.g., orange juice) enhances
the absorption of iron.
Nursing Management
• The nurse helps the patient select a
healthy diet.
• Nutritional counseling can be provided for
those whose usual diet is inadequate.
• Patients with a history of eating fad diets
or strict vegetarian diets are counseled
that such diets often contain inadequate
amounts of absorbable iron.
• The nurse encourages the patient to
continue iron therapy for as long as it is
prescribed even though the patient may
no longer feel fatigued
Nursing Management
• Iron supplements are usually given in the
oral form.
• Because iron is best absorbed on an
empty stomach, the patient is instructed
to take the supplement an hour before
meals.
• Most patients can use the less expensive,
more standard forms of ferrous sulfate.
• Many patients have difficulty tolerating
iron supplements because of GI side
effects (primarily constipation, but also
cramping, nausea, and vomiting).
Nursing Management
• Decreasing the frequency of taking iron
supplements, or taking with food can
mitigate the GI symptoms, but will
diminish absorption of the iron
• It may take longer to replete the iron
stores.
• While taking iron with vitamin C
increases absorption of the iron, it also
increases the frequency of side effects
Nursing Management
• Some iron formulations are designed to
limit GI side effects by the addition of a
stool softener or the use of sustained -
release formulations to limit nausea or
gastritis.
• Tablets with enteric coating may be poorly
absorbed.
• Slow-release formulations should be
avoided because the iron is released
beyond the duodenum, the site of
maximal iron absorption
Nursing Management
• If taking iron on an empty stomach
causes gastric distress, the patient may
need to take it with meals.
• Doing so diminishes iron absorption by as
much as 40%, thus prolonging the time
required to replenish iron stores.
• Antacids or dairy products should not be
taken with iron, because they greatly
diminish its absorption.
• Polysaccharide iron complex forms are
also available; they have less GI toxicity
but are more expensive
Nursing Management
• Liquid forms of iron that cause less GI
distress are available.
• Iron replacement therapy should not cause a
false-positive result on stool analyses for
occult blood even though it may change the
color of stool.
• IV supplementation may be used when the
patient’s iron stores are completely depleted,
the patient cannot tolerate oral forms of iron
supplementation or both.
• The nurse needs to be aware of the type of
parenteral formulation of iron ordered so that
the risk of anaphylaxis may be determined
Nursing Management
• High molecular formulations are
associated with a much higher
incidence of anaphylaxis and therefore
are now infrequently used
• Administering a test dose of low
molecular formulations of iron dextran
is recommended
• The nurse needs to assist the patient
in understanding the need for repeated
dosing to replenish iron stores or to
maintain iron stores in the setting of
chronic blood loss, such as dialysis, or
chronic GI bleeding
Patient Education
• Take iron on an empty stomach (1 hour
before or 2 hours after a meal),
preferably with orange juice or other
forms of vitamin C.
• Iron absorption is reduced with food,
especially dairy product
• 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
Patient Education
• Add stool softener if needed.
• Remember that stools will become dark in
color.
• Prevent gastrointestinal distress by using
the following schedule if more than one
tablet a day is prescribed:
• Start with only one tablet per day for a
few days, then increase to two tablets per
day, then three tablets per day.
• This method permits the body to adjust
gradually to the iron.
Patient Education
• If unable to tolerate oral iron
supplements due to gastrointestinal
distress and these interventions are
inadequate, take at least one tablet daily
rather than stop completely.
• Reduced dosage will necessitate longer
treatment duration to adequately replete
iron stores.
• 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.
INTRODUCTION
• Aplastic anemia is a rare disease caused
by a decrease in or damage to marrow
stem cells, damage to the
microenvironment within the marrow, and
replacement of the marrow with fat.
• Stem cell damage is caused by the body’s
T cells mediating an inappropriate attack
against the bone marrow, resulting in
bone marrow aplasia (markedly reduced
hematopoiesis).
• Significant neutropenia and
thrombocytopenia also occur.
Pathophysiology
• Aplastic anemia can be acquired or,
rarely, congenital, but most cases are
idiopathic
• Viral infections and pregnancy can
trigger it, or it may be caused by
certain medications, chemicals, or
radiation damage.
• Agents that may produce marrow
aplasia include benzene and benzene
derivatives (airplane glue, paint
remover, dry-cleaning solutions).
Clinical Manifestations
• The manifestations of aplastic anemia
are often insidious.
• Complications resulting from bone
marrow failure may occur before the
diagnosis is established.
• Typical complications are infection and
the symptoms of anemia:
• Fatigue
• Pallor
• Dyspnea
• Purpura (bruising) may develop later and
should trigger a CBC and hematologic
evaluation if these were not performed
initially.
• If the patient has had repeated throat
infections, cervical lymphadenopathy may
be seen.
• Other lymphadenopathies and splenomegaly
sometimes occur.
• Retinal hemorrhages are common.
• In many situations, aplastic anemia
occurs when a medication or chemical is
ingested in toxic amounts.
• It develops after a medication has been
taken at the recommended dosage.
• This may be considered an idiosyncratic
reaction in those who are highly
susceptible, possibly caused by a
genetic defect in the medication
biotransformation or elimination
process.
• A CBC reveals pancytopenia (a
decrease in all myeloid stem cell–
derived cells) with a neutrophil
count less than 1500/ µL,
hemoglobin less than 10 g/dL,
and platelets less than 50,000/µL
• A bone marrow aspirate shows an
extremely hypoplastic or even
aplastic (very few to no cells)
marrow replaced with fat
Medical Management
• It is presumed that the T lymphocytes of
patients with aplastic anemia destroy the
stem cells and consequently impair the
production of erythrocytes, leukocytes, and
platelets.
• Despite its severity, aplastic anemia can be
successfully treated in most people.
• Those who are younger than 60 years, who
are otherwise healthy, and who have a
compatible donor can be cured of the
disease with hematopoietic stem cell
transplant
Medical Management
• Serum sickness, as evidenced by fever, rash,
arthralgias, and pruritus, may develop in some
patients, but the incidence can be reduced by
using corticosteroids concomitantly
• If it does develop, serum sickness may take
weeks to resolve.
• Immunosuppressants prevent the patient’s
lymphocytes from destroying the stem cells.
• If relapse occurs (i.e., the patient becomes
pancytopenic again), reinstitution of the same
immunologic agents may induce another
remission, although response rates are much
lower
Medical Management
• Corticosteroids are not very useful as immunosuppressive
agents in the long term, because patients with aplastic
anemia are particularly susceptible to the development of
bone complications from corticosteroids (aseptic necrosis
of the head of the femur).
• Supportive therapy plays a major role in the
management of aplastic anemia.
• Any offending agent is discontinued.
• The patient is supported with transfusions of PRBCs and
platelets as necessary
• Infections are aggressively treated.
• Death usually is caused by infection, either bacterial or
fungal
Nursing Management
• Patients with aplastic anemia
are vulnerable to problems
related to erythrocyte,
leukocyte, and platelet
insufficiencies.
• They should be assessed
carefully for signs of infection
and bleeding.
Nursing Management
• If patients require long-term
cyclosporine therapy, they should be
monitored for long-term effects,
including renal or liver dysfunction,
hypertension, pruritus, visual
impairment, tremor, and skin cancer.
• Each new prescription needs careful
assessment for drug–drug
interactions.
• Patients also need to understand the
importance of not abruptly stopping
their immunosuppressive therapy.
INTRODUCTION
• In the anemias caused by
deficiencies of vitamin B12 or folic
acid, identical bone marrow and
peripheral blood changes occur
because both vitamins are essential
for normal DNA synthesis.
• The erythrocytes that are produced
are abnormally large and called
megaloblastic red cells.
• Other cells derived from the myeloid
stem cell (nonlymphoid leukocytes,
platelets) are also abnormal.
INTRODUCTION
• A bone marrow analysis reveals hyperplasia (an
abnormal increase in the number of cells), and
the precursor erythroid and myeloid cells are
large and bizarre in appearance.
• Many of these abnormal erythroid and myeloid
cells are destroyed within the marrow, so the
mature cells that do leave the marrow are
actually fewer in number. Thus, pancytopenia
can develop.
• Those cells that are released into the circulation
are often abnormally shaped.
• The neutrophils are hypersegmented.
• The platelets may be abnormally large.
INTRODUCTION
• The erythrocytes are abnormally shaped, and
the shapes may vary widely (poikilocytosis).
• Because the erythrocytes are very large, the
MCV is very high, usually exceeding 110 fl.
• Megaloblastic anemias develop slowly (over
months) and thus the body can compensate
well for a long time; symptoms of anemia
may not develop until the anemia is very
severe
• In Caucasians, the skin develops a lemon-
yellow color resulting from simultaneous
pallor and mild jaundice that results from a
mild hemolysis of red cells.
Pathophysiology - Folic Acid Deficiency
• Folic acid is stored as compounds
referred to as folates.
• The folate stores in the body are
much smaller than those of vitamin
B12 and can become depleted within
months when the dietary intake of
folate is deficient
• Folate is found in green vegetables
and liver.
• Thus, folate deficiency occurs in
people who rarely eat uncooked
vegetables.
Pathophysiology - Folic Acid Deficiency
• Alcohol increases folic acid requirements,
and, at the same time, patients with
alcoholism usually have a diet that is
deficient in the vitamin.
• Folic acid are also increased in patients with
liver disease, chronic hemolytic anemias and
in women who are pregnant, because the
need for erythrocyte production is increased
in these conditions.
• Some patients with malabsorptive diseases of
the small bowel, such as celiac disease, may
not absorb folic acid normally
Pathophysiology - Vit B12 Deficiency
• A deficiency of vitamin B12 can occur
in several ways.
• Inadequate dietary intake is rare but
can develop in strict vegans who
consume no meat or dairy products.
• Faulty absorption from the GI tract is
more common, particularly in the
older adult.
• 10% to 20% of older adults have low
B12
• 5% to 10% have symptoms related to
this deficiency
• Decreased B12 absorption also
occurs in conditions such as
Crohn’s disease or after ileal
resection, bariatric surgery, or
gastrectomy.
• Chronic use of histamine blockers,
antacids, or proton pump inhibitors
to reduce gastric acid production
can also inhibit B12 absorption, as
can the use of the drug metformin
(Glucophage) in managing
diabetes
• Another cause is the absence of
intrinsic factor the resultant anemia is
called pernicious anemia.
• Intrinsic factor is normally secreted by
cells within the gastric mucosa
• It binds with dietary vitamin B12 and
travels with it to the ileum, where the
vitamin is absorbed.
• Without intrinsic factor, orally
consumed vitamin B12 cannot be
adequately absorbed, and erythrocyte
production is eventually diminished.
• Even if adequate vitamin B12 and
intrinsic factor are present, a
deficiency may occur if disease
involving the ileum or pancreas
impairs absorption.
• Pernicious anemia tends to run in
families
• It is primarily a disorder of adults,
particularly older adults.
• The body normally has large stores
of vitamin B12, so years may pass
before the deficiency results in
anemia.
• Because the body compensates so
well, the anemia can be severe
before the patient becomes
symptomatic.
• Patients with pernicious anemia
have a higher incidence of gastric
cancer than the general population
• These patients may benefit from
having endoscopies at regular
intervals to screen for early gastric
cancer
• Symptoms of folic acid and vitamin
B12 deficiencies are similar, and
the two anemias may coexist.
• The neurologic manifestations of
vitamin B12 deficiency do not
occur with folic acid deficiency, and
they persist if vitamin B12 is not
replaced.
• Careful distinction between the
two anemias must be made
• After the body stores of vitamin B12 are depleted,
the patient may begin to show signs and
symptoms of the anemia.
• Onset and progression of the anemia are so
gradual, the body can compensate well until the
anemia is severe, so the typical manifestations of
anemia (weakness, listlessness, fatigue) may not
be apparent initially.
• Hematologic effects of vitamin B12 deficiency are
accompanied by effects on other organ systems,
particularly the GI tract and nervous system.
• Patients with pernicious anemia develop a
smooth, sore, red tongue and mild diarrhea
• They are extremely pale, particularly in the
mucous membranes.
• They may become confused; more often, they
have paresthesias in the extremities (particularly
numbness and tingling in the feet and lower legs).
• They may have difficulty maintaining their balance
because of damage to the spinal cord, and they
also lose position sense (proprioception).
• These symptoms are progressive, although the
course of illness may be marked by spontaneous
partial remissions and exacerbations.
• Without treatment, patients can die after several
years, usually from heart failure secondary to
anemia.
• Serum levels of both vitamins can be
measured.
• In the case of folic acid deficiency,
even small amounts of folate increase
the serum folate level, sometimes to
normal.
• Measuring the amount of folate within
the red cell itself (red cell folate) is
therefore a more sensitive test in
determining true folate deficiency,
although not commonly performed.
• The classic method of determining the cause
of vitamin B12 deficiency was the Schilling
test, but because of decreased availability of
test components and cost, this test is rarely
used.
• Other methods of establishing the diagnosis
are now more commonly used.
• The vitamin B12 assay is typically the initial
test used, but current methods render the
test results to be either falsely positive or
falsely negative
• Although it is possible to measure
methylmalonic acid and homocysteine levels
in vitamin B12 deficiency, these levels also
increase in the setting of renal insufficiency.
• It is expensive to measure these levels,
which also limits the utility of the test.
• A more useful, easier test is the
intrinsic factor antibody test.
• A positive test indicates the presence
of antibodies that bind the vitamin
B12–intrinsic factor complex and
prevent it from binding to receptors in
the ileum, thus preventing its
absorption.
• Although this test is not specific for
pernicious anemia alone, it can aid in
the diagnosis.
Medical Management
• Folate deficiency is treated by increasing the
amount of folic acid in the diet and
administering 1 mg of folic acid daily.
• Folic acid is given intramuscularly only to
people with malabsorption problems.
• Although many multivitamin preparations now
contain folic acid, additional supplements may
be necessary because the amount may be
inadequate to fully replace deficient body
stores.
• Patients who abuse alcohol should receive folic
acid as long as they continue to consume
alcohol.
Medical Management
• Vitamin B12 deficiency is treated by vitamin B12
replacement.
• Vegans can prevent or treat deficiency with oral
supplements with vitamins or fortified soy milk.
• When the deficiency is due to the more common
defect in absorption or the absence of intrinsic
factor, replacement is by monthly intramuscular
injections of vitamin B12.
• A small amount of an oral dose of vitamin B12
can be absorbed by passive diffusion, even in the
absence of intrinsic factor
• Large doses are required if vitamin B12 is to be
replaced orally
Medical Management
• As vitamin B12 is replaced, the reticulocyte count
rises within 1 week, and in 4 to 8 weeks the blood
counts return to normal
• The tongue feels better and appears less red in
several days.
• The neurologic manifestations require more time
for recovery
• If there is severe neuropathy, the patient may
never recover fully.
• To prevent recurrence of pernicious anemia,
vitamin B12 therapy must be continued for life.
Nursing Management
• Assessment of patients who have or are at risk for
megaloblastic anemia includes inspection of the
skin, mucous membranes, and tongue.
• Mild jaundice may be apparent and is best seen in
the sclera without using fluorescent lights.
• Vitiligo (patchy loss of skin pigmentation) and
premature graying of the hair are often seen in
patients with pernicious anemia.
• Because of the neurologic complications
associated with these anemias, a careful
neurologic assessment is important, including
tests of position, vibration sense, and cognitive
function.
Nursing Management
• The nurse needs to pay particular attention to
ambulation and should assess the patient’s
gait and stability, as well as the need for
assistive devices (e.g., canes, walkers) and
for assistance in managing daily activities.
• Of particular concern is ensuring safety when
position sense, coordination, and gait are
affected.
• Physical and occupational therapy referrals
may be needed.
• If sensation is altered, the patient needs to be
instructed to avoid excessive heat and cold
Nursing Management
• Because mouth and tongue soreness
may limit nutritional intake, the nurse
advises the patient to eat small
amounts of bland, soft foods
frequently.
• The nurse also may explain that other
nutritional deficiencies, such as
alcohol-induced anemia, can induce
neurologic problems.
• The patient must be taught about the
chronicity of the disorder and the
need for monthly vitamin B12
injections or daily oral vitamin B12
even in the absence of symptoms.
Nursing Management
• If parenteral replacement is
used, many patients can be
taught to self-administer their
injections.
• The gastric atrophy associated
with pernicious anemia
increases the risk for gastric
carcinoma, so the patient needs
to understand that ongoing
medical follow-up and screening
are important

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INTRODUCTION

• Iron deficiency anemia typically results

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