B.

SC NURSING
MEDICAL SURGICAL NURSING-I
UNIT VIII
CARE OF PATIENTS WITH BLOOD
DISORDERS
MEGALOBLASTIC ANEMIA &
APLASTIC ANEMIA

Ms. J.Jaslina Gnanarani

Associate Professor
 Specific objectives
By the end of the class , the students will be able to
• Review the physiology of blood
• Define Anemia.
• Understand the significance and incidence of Anemia.
• List the Causes of Anemia.
• Explain the Types of Anemia.
• Describe the Pathophysiology of each type of Anemia.
• Enumerate the Clinical features of Anemia
• Outline the Diagnostic evaluation.
• Explain in detail the Management of Anemia.
 Overview
• Introduction.
• Definition.
• Incidence.
• Causes.
• Types.
• Pathophysiology.
• Clinical features.
• Diagnostic evaluation.
• Management.
 Definition

Anemia (An-without,emia-blood)
Anemia is a decrease in the RBC count, hemoglobin
and/or Hematocrit values resulting in a lower ability for the
blood to carry oxygen to body tissues .
Classification
 Etiological classification

b. Defective DNA synthesis

 Cobalamine [ vitamin b12 ] deficiency

 Folic acid deficiency

c. Decreased number of erythrocyte precursors

 Aplastic anemia

 Anemia of myleoproliferative disease

 Types of anemia

1. Anemia Caused By Decreased Erythrocyte

Production:

Megaloblastic
anemia.

Aplastic anemia
 Megaloblastic anemia

DEFINITION:

Megaloblastic anemia are a group of disorders

caused by impaired DNA synthesis and characterized by the

presence of large RBC’s.

Classification:

Cobalmine deficiency Folic acid deficiency

 Cobalamine deficiency
DEFINITION

It is a major type of Megaloblastic anemia associated

with vitamin B12 deficiency, it is called pernicious
anemia
 Etiology

• Autoimmune gastric • Drugs like Ascorbic

mucosal atrophy acid, neomycin
• Dietary deficiency
drugs interfere with
• Deficiency of gastric
intrinsic factor. B12 absorption
• Pernicious anemia
• Graves’ disease
• Gastrectomy
• Intestinal malabsorption • Bacterial overgrowth
: Celiac , Crohn’s
• alcoholism
• Increased requirements
• pancreatic insufficiency
• Drugs like Ascorbic acid, neomycin drugs
interfere with vitamin B12 absorption

• Graves’ disease

• bacterial overgrowth

• pancreatic insufficiency

• alcoholism
 Morphological classification

 Vitamin B12 deficiency

 Folic acid deficiency belong th the morphological
classification: Normochromic Macrocytic Anemia
3.Normochromic, Macrocytic Anemia:
It has normal MCHC, high MCV.
The cells are larger than normal over 100 fl and normal color.
These include:
 Pathophysiology

Defect in gastric mucosal, after gastrectomy, or

small bowel disease

Inhibiting folic acid transport

Reducing DNA synthesis in precursor cells

These cells undergo improper DNA synthesis and increased

in size and cause anemia
Pathophysiology
 Clinical manifestations

• Severe pallor

• Slight jaundice

• Fatigue

• Weight loss

• Parasthesia of the hands and feet

• Difficulty with gait

 Diagnostic evaluation

• CBC and Blood smear

• Folic acid

• Vitamin B12

• Gastric analysis

• Schilling test
Schilling Test- classic test for PA (Rarely done)
• First Step: Patient is given an oral dose of radio
labelled vitamin B12, with 24-hour Urine collection
for Radioactivity.
• Second Step: first step, with the addition of oral
intrinsic factor is done to check for an increase in
vitamin B12 absorption
• The Schilling test helps to differentiate PA from other
forms of B12 deficiency, such as Imerslund-Grasbeck
Syndrome (IGS),
• IGS is a vitamin B12-deficiency caused by mutations
in the cobalamin receptor called as Cubilin.
 Collaborative care

 Increased intake of food rich in

vitamin B12
 Parentral administration of
Cyanocobalamine 1000mg daily
for two week
 Intranasal form of
cyanocobalamine (nasobal),
weekly one dose
 High dose of oral Cobalamine
or sublingual Cobalamine
 Novel Therapies

• Sodium N-[8-(2-hydroxybenzoyl)amino]
caprylate (SNAC), enhances both bioavailability
and metabolic stability of B12.It is lipophilic
and able to pass through cellular membranes
with greater ease.
• Recombinant intrinsic factor for increasing
absorption of Cbl through the ileum from pea
plant recombinants
• Sublingual delivery 500 μg of cyanocobalamin
given either orally or sublingually,
 Complications

• Neurological complication

• Paresthesia

• Gait disturbance

• Bladder and bowel dysfunction

• Cerebral dysfunction may be persistent

 Folic acid deficiency

Definition:

Chronic megaloblastic anemia caused by folic acid

(folate) deficiency
 Etiology

• Poor nutrition, lack of vegetables, citrus fruits, nuts, beans

• Malabsorption syndrome

• Small bowel disorder

• Drugs like oral contraceptives, anti-seizures decreased

absorption

• Alcohol abuse and anorexia

• hemodialysis
 Pathophysiology

Folic acid requires for DNA synthesis leading for RBC

formation and malnutrition

Folic acid deficiency

The disease develops slowly

Symptoms are attributed to other problems

 Clinical manifestations

• Fatigue
• Weakness, dizziness
• Pallor
• Headache
• Tachycardia
• Sore tongue
• Cracked lips
• Dyspepsia
• Smooth beefy red tongue
 Diagnostic evaluation

• Vitamin B12

• Folic acid

• CBC- Decreased RBC, Hb, hematocrit

COMPLICATION

 Congenital acquired neural tube defects

 Management

Nutritional therapy

Diet includes liver, organ meats, eggs, cabbage

Replacement therapy

Folic acid dose is 1mg mouth

In malabsorption states upto 5mg/day

 Nursing diagnosis

• Imbalanced nutrition less than body requirements related

to parent’s lack of knowledge of age appropriate
nutritional needs.

Interventions

• Encourage the administration of iron in an empty

stomach

• Instruct the patient to keep iron supplements

• Instruct the patient to expect black stools

• Poor nutritional habits may be attributable to a lack of

resources.
APLASTIC ANEMIA
 Definition
It is a disorder characterized by bone marrow hypoplasia
(hypocellular) in pancytopenia (insufficient no's of RBCs,
WBCs, platelet)
It is the damage to bone marrow stem cells, or
damage to the microenvironment within the
marrow, and replacement of the marrow with fat.
It results in bone marrow aplasia ( decrease in all blood cell
types).
INCIDENCE:
• The incidence of aplastic anemia is low
• Approximately 4 of every 1 million persons
 Causes

CONGENITAL: ACQUIRED:
• Fanconi syndrome  Exposure to myelotoxic
agents
• Caused by  Benzene,Alkalyting agents
chromosomal
 Chemical agent, Drugs, toxins
alterations
• Radiation
• Approximately 30% of  Pregnancy
the aplastic anemia's
appear in the  Viral, bacterial infection
childhood are  Approximately 70% aplastic
inherited anemia’s idiopathic
 Morphological classification
• Morphologically, Aplastic anemia (those characterized by
disappearance of RBC precursors from the marrow)
• 1.Normochromic, Normocytic Anemia:
It has normal MCHC, normal MCV.
The cells are normal in size and normal color.
 Pathophysiology
Decrease in or damage to marrow stem cell
↓
Damage to microenvironment with in the marrow
↓
Replacement of marrow with fat
↓
T cell mediate an inappropriate attack against the bone marrow
↓
Resulting in bone marrow aplasia
(markedly reduced hematopoiesis)
↓
Severe leukopenia and thrombocytopenia occur
↓
Pancytopenia occurs
S/s of Aplastic anemia depend on all Conitions

1.FROM ANEMIA: • Adventitious breath sound,

• Pallor abdominal pain, erythema,
• Weakness pain
• Fatigue • Exudates at wounds or sites
• Dyspnea of invasive procedure
• Palpitation 3. THROMBOCYTOPENIA:
2.FROM INFECTIONS • Bleeding from gums, nose,
• Associated with neutropenia GI tract, GU tract, Purpura,
• Fever, headache, diarrhea, petechiae, ecchymosis
malaise,
 DIAGNOSTIC EVALUATION:

 CBC- decrease RBC, WBC, Platelet

 Peripheral blood smear
 Bone marrow aspiration
COMPLICATION:
• Morbidity, mortality
• Paroxysmal nocturnal hemoglobinuria
• Myelodysplasia
• Acute mylogenous leukemia
 MANAGEMENT:

Bone marrow transplantation (BMT)

Peripheral blood stem cell transplantation
(PBSCT)
Immunosuppressive therapy
Combination of antithynocyte globulin and
cyclosporine
Transfusion of RBCs and platelet
 Drug therapy… contd

 Folic acid supplementation

 Patient teaching for long term care of patient

 Nursing diagnosis

• Activity intolerance related to weakness, fatigue, and general

malaise
• Altered nutritional Level, less than body requirements, related
to inadequate intake of essential nutrients

• Ineffective tissue perfusion related to inadequate blood volume

or HCT

• Ineffective Family Coping related to disabling and life-

threatening disease
 Nursing management

Managing fatigue:

• Assist the patient to prioritize activities and to establish a

balance between activity and rest.

• Patients with chronic anemia need to maintain some

physical activity and exercise to prevent the deconditioning
that results from inactivity.
 Nursing diagnosis

• Risk for infection related to inadequate secondary

defenses or immuno suppression.

• Ineffective tissue perfusion related to anemia.

• Deficient knowledge related to incomplete information

about the disease process.
 Patient health education
GENERAL ADVICE:
• Provide blankets and warm clothing to increase comfort and
aid circulation.

• Notify physician if excessive vomiting, coughing or straining

at stools occurs so that medication can be prescribed to
alleviate symptom.
• Avoid contact on gingival when brushing and flossing teeth.

• Transfuse whole blood and packed red blood cells as

ordered by physician.
 Nursing management
Minimizing the risk of Bleeding
 Avoid situations in which trauma may occur, such as shaving
with straight-edge razor,and ambulating after taking
medication

 Avoid forceful sexual intercourse and use adequate

lubrication.
 Bowel movements will be black from excess iron excretion.

 Keep skin clean and bedclothes dry.

 Monitor Hb/Hct and assess whether other factors (e.g.,

nutritional deficiencies, fluid and electrolyte disorders,
depression, etc.)
 Education on medications

• Avoid aspirin-containing products to prevent bleeding.

• Use of stool softeners or laxative
• Iron preparation taken on empty stomach cause dyspepsia,
abdominal discomfort, and diarrhoea Liquid iron preparations
should be well diluted and
taken through a straw (undiluted liquid iron stains teeth).
• Take iron on an empty stomach (1 hour before or 2 hours
after a meal).
• Avoid rectal thermometers
,suppository and enemas.
 References
1. Janice L.Hinkle,Kerry H.Cheever(2018) Brunner and
Suddarth’s Text Book of Medical Surgical Nursing ,14th
edition,south asian edition,vol II,Wolters Kluwer.pg no. 925-
938

2. Lewis,S.L.Heitkemper,M.Dirksen,S.R.etal.(2016).Medical
surgical nursing assessment and management of
clinicalproblems.2nd South Asian edition, Mosby Elsevier pg
no.1085- 1098

3. Lizy Sonia & Shaina sharma (2016).Medical Surgical Nursing-

prep Manual for Undergraduates, volI, Thomson Press, India,
Elsevier publishers.pg no.521