Lewis Et Al. Chapter 30 Jessica Stoefen, MN, RN, CCRN

Lewis et al.
Chapter 30
Jessica Stoefen, MN, RN, CCRN
Copyright © 2017, Elsevier Inc. All Rights Reserved.

• A deficiency in
• Number of erythrocytes (RBCs)
• Quantity of hemoglobin
• Volume of packed RBCs (hematocrit)

• RBC function
• Transport oxygen (O2) from lungs to
systemic tissues
•Carry carbon dioxide from tissues to lungs

• Not a specific disease
• Manifestation of a pathologic process
• Diagnosed based on
• Complete blood count (CBC)
• Reticulocyte count
•Peripheral blood smear

• Classified as
• Morphologic
• Cellular characteristics
• Descriptive, objective laboratory information
• Etiologic
• Underlying cause

• Caused by body’s response to tissue
hypoxia
• Manifestations vary based on rate of
development, severity of anemia,
presence of co-existing disease
• Hemoglobin (Hgb) levels are used to
determine severity of anemia

7
• Pallor
• ↓ Hemoglobin
• ↓ Blood flow to the skin
• Jaundice
• ↑ Concentration of serum bilirubin
• Pruritus
• ↑ Serum and skin bile salt concentrations
• Result from additional attempts by
heart and lungs to provide adequate O2
to tissues
• Cardiac output maintained by
increasing heart rate and stroke
volume

• Subjective Data
• Important health information
• Past health history
• Medications
• Surgery or other treatments
• Dietary history
•Functional health patterns

• Objective Data
• General
• Integumentary Lewis et al. Table
• Respiratory 30-4
• Cardiovascular
•Gastrointestinal
• Neurologic
• Diagnostic findings
• Fatigue
• Imbalanced nutrition: Less than body
requirements
• Ineffective health management
• Assume normal activities of daily living
•Maintain adequate nutrition
• Develop no complications related to
anemia
• Patients with fatigue
• Alternate rest and activity
• Prioritize activities
• Accommodate energy levels
• Maximize O2 supply for vital functions
• Provide assistance to minimize risk for
injury
• Evaluate nutritional needs
• Nursing care varies
• Numerous causes of anemia
• Patient specific needs
See Lewis et al. p. 607

Table 30-1 & 30-2
classifications of
anemias
• Anemia is not normal
• More common in the 70s and beyond
• Often related to an underlying cause
• Signs and symptoms may go
unrecognized
•Other health issues
• May be mistaken for normal aging

• Erythropoietin (EPO) is a glycoprotein
primarily produced in the kidneys (10%
in liver)
•↑ Number of stem cells committed to RBC
production
• Shortens time to mature RBCs

• Life span of an RBC is 120 days
• Three alterations in erythropoiesis may
decrease RBC production:
• Decreased hemoglobin synthesis
• Defective DNA synthesis in RBCs
•Diminished availability of erythrocyte
precursors

• Most common nutritional disorder in
the world
• Most susceptible
• Very young
• Poor diet
•Women in reproductive years

• Inadequate dietary intake
• 5% to 10% of ingested iron is absorbed
• Malabsorption
• Iron absorption occurs in the duodenum
• Diseases or surgery that alter, destroy, or
remove absorption surface of this area of
intestine cause anemia

• Blood loss
• 2 mL whole blood contain 1 mg iron
• Major cause of iron deficiency in adults
• Chronic blood loss most commonly
through GI and GU systems
• Hemolysis
• Pregnancy contributes to this condition
• General manifestations of anemia
• Pallor is most common
• Glossitis is second
• Inflammation of tongue
• Cheilitis is also found
• Inflammation of lips

• Laboratory findings
• Hgb, Hct, MCV, MCH, MCHC,
reticulocytes, serum iron, TIBC, bilirubin,
platelets
• Stool occult blood test
• Endoscopy
• Colonoscopy

• Goal
• Treat underlying disease causing reduced
intake or absorption of iron
• Replace iron
• Nutritional therapy
• Oral iron supplements
• Transfusion of packed RBCs

• Oral iron
• Inexpensive
• Convenient
• Factors to consider
• Enteric-coated or sustained-release capsules
are counterproductive
• Daily dose is 150 to 200 mg

• Oral iron
• Factors to consider
• Best absorbed as ferrous sulfate in an acidic
environment
• Liquid iron should be diluted and ingested
through a straw
• Side effects
• Heartburn, constipation, diarrhea

• Parenteral iron
• Indicated for malabsorption, oral iron
intolerance, need for iron beyond normal
limits, poor patient compliance
• Can be given IM or IV
• IM may stain skin
• Z-track

• At-risk groups
• Premenopausal women
• Pregnant women
•Persons from low socioeconomic
backgrounds
• Older adults
•Individuals experiencing blood loss

• Diet teaching
• Supplemental iron
• Discuss diagnostic studies
• Emphasize compliance
• Iron therapy for 2 to 3 months after
Hgb levels return to normal

• A group of diseases involving
inadequate production of normal Hgb
• Results in decreased erythrocyte
production
• Problem with globulin protein
•Abnormal Hgb synthesis
• Hemolysis occurs
• Autosomal recessive genetic basis
• One thalassemic gene
• Thalassemia minor
• Two thalassemic genes
• Thalassemia major

• Thalassemia minor
• Frequently asymptomatic
• Moderate anemia
• Microcytosis
• Hypochromia
• Body adapts to reduction of Hgb – thus no
treatment is indicated

• Life-threatening
• Physical and mental growth often
retarded
• Pale and jaundiced
• Splenomegaly, hepatomegaly, and
cardiomyopathy
• Symptoms develop in childhood
• As the bone marrow responds to the
deficit of O2 -carrying capacity of the
blood, RBC production is stimulated, and
marrow becomes packed with immature
erythroid precursors that die
•Chronic bone marrow hyperplasia
• Hepatitis C
• No specific drug or diet is effective in
treating thalassemia
• Blood transfusions or exchange
transfusions with chelating agents that
bind to iron to reduce iron overloading
• Splenectomy

• Group of disorders
• Caused by impaired DNA synthesis
• Presence of megaloblasts
• Majority result from deficiency in
• Cobalamin (vitamin B12)
•Folic acid

• Intrinsic factor (IF)
• Protein secreted by parietal cells of gastric
mucosa
• IF is required for cobalamin absorption
in the distal ileum
• If IF is not secreted, cobalamin will not be
absorbed

• Most commonly caused by pernicious
anemia
• Which is caused by an absence of IF
•Insidious onset
• Begins in middle age or later
• Predominant in Scandinavians and African
Americans

• Can also occur:
• GI surgery
• Chronic diseases of the GI tract
• Excessive alcohol or hot tea ingestion
• Smoking
•Long-term users of H2-histamine receptor
blockers and proton pump inhibitors
• Strict vegetarians
develop slowly due to tissue hypoxia
• GI manifestations:
• Sore tongue, anorexia, nausea, vomiting, and
abdominal pain
• Neuromuscular manifestations:
• Weakness, paresthesias of feet and hands,
↓ vibratory and position senses, ataxia, muscle
weakness, and impaired thought processes
• Macrocytic RBCs have abnormal shapes and
fragile cell membranes
• Serum cobalamin levels are decreased
• Normal serum folate levels and low
cobalamin levels suggest megaloblastic
anemia is due to cobalamin deficiency
• Upper GI endoscopy with biopsy of gastric
mucosa
• Parenteral or intranasal administration
of cobalamin is treatment of choice
• Patients will die in 1-3 years without
treatment
•This anemia can be reversed with ongoing
treatment but long-standing
neuromuscular complications may not be
reversible

• Also a cause of megaloblastic anemia
• Folic acid is required for DNA synthesis
• RBC formation and maturation
• Clinical manifestations are similar to
those of cobalamin deficiency, but
absence of neurologic problems
differentiates them
• Common causes
• Dietary deficiency
• Malabsorption syndromes
• Drugs
• Increased requirement
•Alcohol abuse and anorexia
• Loss during hemodialysis

• Serum folate level is low
• Normal is 3 to 16 mg/mL (7 to 36 mol/L)
• Serum cobalamin level is normal
• Treated by replacement therapy
• Usual dose is 1 mg per day by mouth
• Encourage patient to eat foods with
large amounts of folic acid
• Early detection and treatment
• Ensure safety
•Diminished sensations to heat and pain
from neurologic impairment
• Focus on compliance with treatment
• Regular screening for gastric cancer

At an outpatient clinic, K.L.’s 78-year-old grandma is found
to have a Hgb of 8.7 g/dL (87 g/L) and a Hct of 35%. Based
on the most common cause of these findings in the older
adult, the nurse collects information regarding
a. a history of jaundice and black tarry stools.
b. a 3-day diet recall of the foods the patient has eaten.
c. any drugs that have depressed the function of the bone
marrow.
d. a history of any chronic diseases such as cancer or renal
disease.

• Caused by
• Chronic inflammation
• Autoimmune and infectious disorders
• HIV, hepatitis, malaria
• Heart failure
• Malignant diseases
• Bleeding episodes

• Associated with
• Underproduction of RBCs
• Mild shortening of RBC survival
• Normocytic, normochromic, and
hypoproliferative RBCs
• Usually a mild anemia but can become
severe if the underlying disorder is
untreated
• Anemia of chronic disease findings
• ↑ Serum ferritin
• ↑ Iron stores
• Normal folate and cobalamin levels
• Treating underlying cause is best
•Rarely blood transfusions
• Conservative use of erythropoietin
therapy
• Pancytopenia
• Decrease in all blood cell types
• Red blood cells (RBCs)
• White blood cells (WBCs)
• Platelets
• Hypocellular bone marrow
• Ranges from chronic to critical

• Rare
• Annual rate of 2-5 new cases/million/year
• Usually acquired
• Idiopathic
• An autoimmune basis is presumed

• Abrupt or gradual development
• Symptoms caused by suppression of
any or all bone marrow elements
• Fatigue, dyspnea
•Cardiovascular and cerebral responses
• Neutropenia

• Diagnosis confirmed by laboratory
studies
• Low Hgb, WBC, and platelet values
•Low reticulocyte count
• Elevated serum iron and TIBC
• Hypocellular bone marrow with increased
fat content (yellow marrow)

• Identify and remove causative agent
(when possible)
• Provide supportive care until
pancytopenia reverses
• Prevent complications from infection
• Prevent hemorrhage

• Prognosis of severe untreated aplastic
anemia is poor
• Advances in treatment options have
significantly improved outcomes
•Immune therapies and bone marrow
transplantation can be curative

• Anemia resulting from blood loss may
be caused by either acute or chronic
problems
•Acute blood loss occurs as a result of
sudden hemorrhage
• Sources of chronic blood loss are similar to
those of iron-deficiency anemia

• Causes of sudden hemorrhage
• Trauma
• Complications of surgery
• Conditions or diseases that disrupt
vascular integrity
• Hypovolemic shock
• Compensatory increased plasma volume with
diminished O2 -carrying RBCs

• Caused by body’s attempts to maintain
adequate blood volume and meet
oxygen requirements
• Clinical signs and symptoms are more
important than laboratory values

• Pain
• Internal hemorrhage
• Tissue distention, organ displacement, nerve
compression
• Retroperitoneal bleeding
• Numbness
• Pain in lower extremities
• Shock is major complication
• With sudden blood volume loss, values
may seem normal or high for 2 to 3
days
• Once plasma volume is replaced, low
RBC concentrations become evident
• Low RBC, Hgb, and Hct levels show up and
reflect actual blood loss

• Replacing blood volume to prevent
shock
• Identifying source of hemorrhage
and stopping blood loss
• Correcting RBC loss
• Providing supplemental iron

• May be impossible to prevent if caused
by trauma
• Postoperative patients
• Monitor blood loss
• Administer blood products for anemia
• No need for long-term treatment

• Sources of chronic blood loss:
• Bleeding ulcer
• Hemorrhoids
•Menstrual and postmenopausal blood loss
• Management involves
• Identifying the source
• Stopping the bleeding
• Providing supplemental iron as needed

Lewis Et Al. Chapter 30 Jessica Stoefen, MN, RN, CCRN

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Lewis et al.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

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Copyright © 2017, Elsevier Inc. All Rights Reserved.

See Lewis et al. p. 607

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

Copyright © 2017, Elsevier Inc. All Rights Reserved.

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