Higher Institute of Health Specialties

Post Graduate Diploma in Adult Critical Care

Semester Two- 2022-2023
Complex Critical Care Nursing Theory

ANEMIA
P R E PA R E D B Y: M O H A M E D S A L E H A L D O O H
S U P E R V I S E D B Y: M R . S A M I R
OBJECTIVEAS:
• Define and explain anemia.
• Indicate the prevalence of Anemia.
• Explore the types and causes of anemia.
• Classify the etiologies and risk factors for the development of Anemia.
• Interpret the pathophysiology of Anemia.
• Examine the symptoms of anemia.
• Explain the diagnostic tests used to confirm a diagnosis of Anemia.
• Discuss and explain the medical management available for Anemia.
• Identify nursing care and management role in taking care of patients
with Anemia with updated evidence.
INTRODUCTION:
• What is the
average lifespan
of red blood cells?

• What is the
function of blood?
DIFFENATION:

• Anemia is a medical condition characterized by a

decrease in the number of red blood cells or a decrease
in the amount of hemoglobin in the blood(lower than
12.0 in females and 13.0 g/dL in males, hemoglobin is
the protein in red blood cells that carries oxygen to
tissues throughout the body.

Chaparro and Suchdev (2019).

PREVALENCE:

WHO estimates that 40% of children 6–59 months of age, 37% of

pregnant women, and 30% of non-pregnant women 15-49 years of
age worldwide are anemic.

In ICU:
Approximately two-thirds present with a hemoglobin concentration
of less than 12 g/dl on admission, and 97% become anemic by Day
8.

WHO, (2023)
PREVALENCE:
In Sultanate of Oman:
• Prevalence of anemia among children in 2019 (24% of children
ages 6-59 months) and substantially varying by governorate
(31.3% in Ad Dhahirah versus 15.4% in Dhofar)
• Prevalence of anemia among women of reproductive age (29% of
women ages 15-49) and prevalence rates varied substantially
among governorates, affecting only 15.1% of non-pregnant
women living in Al-Wusta, but 38.8% of those in Al-Buraimi.
Petry et al, (2020)
TYPES OF ANEMIA: MORPHOLOGY
TYPES OF ANEMIA: CUSES

1- Blood Loss Anemia.

2- Hemolytic Anemias.
- Congenital Hemolytic
Anemias.
- Acquired Hemolytic
Anemia.
3- Deficiency Anemias.
- Iron-Deficiency Anemia.
- Megaloblastic Anemias.
- Anemia of Chronic Disease.
- Aplastic Anemia.
GROUP ACTIVIT Y: FOR 5 MINUTES

Each group will talk briefly about the types of anemia.

Group 1: Define Blood Loss Anemia and Hemolytic

Anemias(Congenital Hemolytic Anemias).

Group 2: Define Acquired Hemolytic Anemia.

Group 3: Define Iron-Deficiency Anemia and Megaloblastic

Anemias.

Group 4: Define Anemia of Chronic Disease and Aplastic Anemia.

TYPES OF ANEMIA:
• Blood loss anemia:
Blood loss anemia, also known as hemorrhagic anemia, is a type of
anemia that occurs when there is an excessive loss of blood.
• Hemolytic anemias:
• Congenital hemolytic anemia:
These conditions are present from birth and can result from various
genetic abnormalities that affect the structure, function, or production
of red blood cells. It is caused by enzyme defects or RBC membrane
defects.
TYPES OF ANEMIA:
• Acquired hemolytic anemia:
Acquired hemolytic anemia is a type of anemia that occurs due to the
increased destruction (hemolysis) of red blood cells in the body.
Unlike congenital hemolytic anemia, which is inherited, acquired
hemolytic anemia is caused by external factors or conditions that
trigger the destruction of red blood cells.
TYPES OF ANEMIA:
• Deficiency anemias:
• Iron-deficiency anemia:
This is the most common cause of anemia in adults. It can result from
inadequate iron intake, poor absorption of iron by the body, or
increased iron requirements due to factors such as pregnancy or blood
loss.
TYPES OF ANEMIA:
• Megaloblastic Anemias:
Megaloblastic anemias are a group of blood disorders characterized by the
impaired production of red blood cells, leading to the presence of
abnormally large and immature red blood cells called megaloblasts. This
condition is primarily caused by deficiencies in vitamin B12 (cobalamin)
or folate (vitamin B9), which are essential for the normal maturation of
red blood cells.
Pernicious anemia:
Is a subtype of megaloblastic anemias, it occurs when the intestines
cannot properly absorb vitamin B12.
TYPES OF ANEMIA:
• Anemia of Chronic Disease:
Anemia of Chronic Disease (ACD), also known as anemia of
inflammation, is a type of anemia that occurs as a result of an
underlying chronic illness or inflammation. It is one of the most
common forms of anemia seen in individuals with chronic conditions
such as autoimmune disorders, chronic infections, inflammatory
bowel disease, cancer, or chronic kidney disease.
TYPES OF ANEMIA:
• Aplastic anemia:
Aplastic anemia is a rare and serious medical condition in which the
bone marrow fails to produce enough new blood cells, including red
blood cells, white blood cells, and platelets. It occurs when the bone
marrow, the spongy tissue inside the bones responsible for blood cell
production, is damaged or suppressed.
RISK FACTORS:
A diet that doesn't have enough of certain vitamins and minerals.
Problems with the small intestine.
Menstrual periods.
Pregnancy (folic acid and iron deficiency).
Chronic disease.
Family history.
Age (People over age 65 are at increased risk of anemia).
Other factors (alcohol, toxicity)
THE MOST COMMON ANEMIAS IN ICU
Iron-deficiency anemia Pernicious anemia Blood loss anemia
IRON-DEFICIENCY
ANEMIA:
• This is the most common type of
anemia in adults and occurs when the
body lacks sufficient iron to produce
an adequate amount of hemoglobin.
Iron is essential for the production of
red blood cells.
IRON-DEFICIENCY
ANEMIA: CAUSES
• Inadequate iron intake.
• Blood loss.
• Pregnancy and
breastfeeding.
• Malabsorption issues.
• Surgery or medical
procedures.
IRON-DEFICIENCY ANEMIA:

• Video
IRON-DEFICIENCY ANEMIA: PATHOPHYSIOLOGY

The body's stores of iron decrease as do the stores of

transferrin which binds and transports iron.

This leads to the depletion of red blood cells synthesis.

Resulting in decreased hemoglobin concentration and

decreased oxygen-carrying capacity of the blood.
IRON-DEFICIENCY
ANEMIA: SYMPTOMS
• Fatigue.
• Weakness.
• shortness of breath.
• Pallor.
• Chest pain, rapid heartbeat,
or shortness of breath
• Headache, dizziness, or light-
headedness
• Cold hands and feet
• Pica.
IRON-DEFICIENCY
ANEMIA: SYMPTOMS
• Irregular nails
• As hemoglobin levels
continue to drop, epithelial
tissue begins to express
structural and functional
changes such as brittle, thin,
ridged, and spoon-shaped
fingernails.
IRON-DEFICIENCY
ANEMIA:
SYMPTOMS

Glossitis:
• Caused by tongue
papillae atrophy
• This leads to
soreness and redness
of the tongue
IRON-DEFICIENCY ANEMIA:
DIAGNOSTIC STUDIES
Physical assessment and history.
Blood tests:
• CBC: HB, RBC, Mean corpuscular
volume (MCV) levels, Hematocrit levels.
• Iron profile:
Iron: normal 10 to 30 umol/L
Ferritin: normal men 40 to 300 ug/L
Women 20-200 ug/L
IRON-DEFICIENCY ANEMIA:
DIAGNOSTIC STUDIES

• Iron store levels will be low

(Ferritin)
• Stool routine: to identify the
presence of blood
• Endoscopy or colonoscopy: used
to detect GI bleeding
IRON-DEFICIENCY ANEMIA:
TREATMENT
Iron supplements:
• Iron sulfate 325mg PO 2 to 3 times per
day.
• Take it one hour before the meal.
• Vitamin C aids the absorption of iron.
Intravenous or IV iron
• Is sometimes used if the patient has a
malabsorption disorder or poor
tolerance of oral iron.
IRON-DEFICIENCY ANEMIA: TREATMENT
Medicines:
• Erythropoiesis-stimulating agent (ESA) (epoetin alfa) helps your
bone marrow make more red blood cells if this is causing your iron
deficiency. The recommended dosage of epoetin alfa is 100–150
U/kg subcutaneously three times per week along with supplemental
oral iron.
Blood transfusions:
• For critically ill patients and active bleeding, recommended to give
HB less than 7 g/dL.
Surgery may be needed to stop internal bleeding.
PERNICIOUS
ANEMIA:
Pernicious anemia is a
decrease in red blood cells
that occurs when the
intestines cannot properly
absorb vitamin B12.
PERNICIOUS
ANEMIA: CAUSES
• Weakened stomach lining (atrophic
gastritis).
• An autoimmune condition in which the
body's immune system attacks the actual
intrinsic factor protein or the cells in the
lining of your stomach that make it.
• Surgical removal of part or all of the
stomach.
PERNICIOUS
ANEMIA: CAUSES
• Inadequate intake of vitamin B12 from
food (meat and fish).
• Certain medications interfere with vitamin
B12 absorption.
• Genetic defects affect the production or
functioning of intrinsic factors.
PERNICIOUS ANEMIA: PATHOPHYSIOLOGY
The immune system produces antibodies that attack cells in the mucosal lining
of your stomach and nerve cells.

The antibodies block a critical protein called an intrinsic factor.

Intrinsic factor carries the vitamin B12 we get from food to special cells in your
small intestine.

Vitamin B12 is transported into your bloodstream.

Other proteins then carry the vitamin B12 to your bone marrow, where the
vitamin is used to make new red blood cells.

This process can’t happen when your immune system blocks your intrinsic
factor.
PERNICIOUS ANEMIA: PATHOPHYSIOLOGY
Lack of intrinsic factors (IF) (autoimmune destruction of
Gastric parietal cells and/or intrinsic factors)

Inability to absorb vitamin B12 from the small intestine

Insufficient creation of healthy RBC.

PERNICIOUS ANEMIA: SYMPTOMS
• Paleness of the skin and mucous membranes.
• Fatigue.
• Nausea and vomiting
• Glossitis (a swollen tongue).
• Loss of appetite.
Severe pernicious anemia will usually present with:
• Shortness of breath.
• Dizziness.
• Tachycardia.
• Enlarged liver.
PERNICIOUS ANEMIA: SYMPTOMS
Vitamin B12 deficiency may include the nervous system
symptoms:
• Short-term memory loss.
• Confusion.
• Depression.
• Imbalance.
• Irritability.
• Numbness and tingling in the hands and feet.
PERNICIOUS ANEMIA: DIAGNOSTIC STUDIES
• Physical assessment and history.
• Vitamin B12 level.
• Complete blood count (CBC).
• Iron profile (Serum folate, iron, and iron-binding capacity tests ).
• Reticulocyte count.
• Serum bilirubin levels.
• Methylmalonic acid (MMA) levels: High MMA levels confirm
vitamin B12 deficiency.
PERNICIOUS ANEMIA: DIAGNOSTIC STUDIES
• Homocysteine level: High homocysteine levels may be a sign of
vitamin B12 deficiency. Tests for the presence of the antibodies that
attack the parietal cells in your stomach and block the action of
intrinsic factors.
• Upper endoscopy: an endoscope to look for signs of degeneration
or atrophy of the lining of your stomach.
PERNICIOUS ANEMIA: TREATMENT

Some individuals may only require In some cases, weekly or monthly

vitamin B12 supplements, and intramuscular injections of vitamin
advice to start eating foods high in B12 may be required.
B12.
PERNICIOUS ANEMIA: TREATMENT

Cyanocobalamin Dosage:
• Initial dose: 1000 mcg intramuscularly or deep subcutaneously once
a day for 6 to 7 days
If clinical improvement and reticulocyte response is seen from the
above dosing:
• 100 mcg every other day for 7 doses
• 100 mcg every 3 to 4 days for 2 to 3 weeks
• Maintenance dose: 100 to 1000 mcg monthly
BLOOD LOSS ANEMIA:

• Anemia due to excessive bleeding

results when the loss of red blood cells
exceeds the production of new red
blood cells.
BLOOD LOSS
ANEMIA: ETIOLOGY
Causes and risk factors of
Blood Loss Anemia:
• Gastrointestinal conditions.
• Non-steroidal anti-
inflammatory drugs
(NSAIDs).
• A woman’s period.
• Post-trauma or post-surgery as
well.
BLOOD LOSS ANEMIA: PATHOPHYSIOLOGY:

Blood lost  Body pulls fluid intracellular to keep

the vein failed  Blood is diluted  Hematocrit
reduced  Iron depletion with blood loss  Bone
marrow failure to replace or make new RBC
BLOOD LOSS ANEMIA: SYMPTOMS
• Fatigue and weakness
• Pale skin and mucous membranes
• Shortness of breath
• Rapid heartbeat (tachycardia)
• Dizziness or lightheadedness
• Headaches
• Cold hands and feet
• Chest pain (if the anemia is severe)
BLOOD LOSS ANEMIA:
DIAGNOSIS
• Physical assessment and history.
• Blood tests, e.g., CBC.
• Peripheral smear.
• Imaging or endoscopy.
BLOOD LOSS ANEMIA: TREATMENT
Aims to address the underlying cause and replenish the lost blood.

Identifying and treating the source of bleeding.

Blood transfusion.

Iron supplementation.

Vitamin B12 or folate supplements.

COMPLICATIONS:
• Heart failure.
• Paresthesia.
• Delirium.
• Difficulty functioning because of
fatigue, shortness of breath, and
difficulty concentrating
COMPLICATIONS:
• Pregnancy complications such as
premature birth.
• Impaired growth and development in
children
• Death.
PREVENTION:
Iron deficiency anemia and Vitamin deficiency anemia can be avoided by a diet
that includes a variety of vitamins and minerals, including:
• Iron: Iron-rich foods include meat, beans, lentils, iron-fortified cereals, dark
green leafy vegetables, and dried fruit.
• Folate: It can be found in fruits and fruit juices, dark green leafy vegetables,
green peas, kidney beans, peanuts, and enriched grain products, such as bread,
cereal, pasta and rice.
• Vitamin B-12: Foods rich in vitamin B-12 include meat, dairy products, and
fortified cereal and soy products.
• Vitamin C: Foods rich in vitamin C include citrus fruits and juices, peppers,
broccoli, tomatoes, melons and strawberries. These also help increase iron
absorption.
GROUP ACTIVITY: 15 MINS
Each group will discuss one of the following nursing care plans:
• Fatigue R\T insufficient oxygen supply to the body. Group 1
• Altered tissue perfusion R\T insufficient hemoglobin and
hematocrit. Group 2
• Deficient Knowledge R\T complexity of the disease. Group 3
• Imbalanced Nutrition: Less Than Body Requirements R\T Inability
to absorb iron or vitamins. Group 4
NURSING
MANAGEMENT:
• Health history and physical exam.
• Medication history.
• Family history
• Nutritional assessment
NURSING MANAGEMENT:
To manage fatigue:
• Prioritize activities.
• Exercise and physical activity.
To maintain adequate nutrition:
• Diet.
• Alcohol intake.
NURSING
MANAGEMENT:
To maintain adequate perfusion:
• Blood transfusion monitoring.
To promote compliance with
prescribed therapy:
• Enhance compliance.
• Medication intake.
EVIDENCE-BASED PRACTICE:
EVIDENCE-BASED PRACTICE:
Methods:
• a multicenter, feasibility RCT to compare either a single dose of
ferric carboxymaltose 1000 mg
• IV or usual care in patients being discharged from the ICU with
moderate or severe anemia (hemoglobin 10 g/dL).
• Participants were randomly allocated on a 1:1 basis to receive either
i.v. iron (ferric carboxymaltose) or usual care, stratified on anemia
severity (Hb: <80 vs 80e100 g/L) and participant ICU length of stay
(LOS) (<7 vs >7 days).
EVIDENCE-BASED PRACTICE:
Results:
• Ninety-eight participants were randomly allocated (49 in each arm).
• Forty-seven of 49 (96%) participants received the intervention.
• Intravenous iron resulted in higher mean hemoglobin at 28 days
• Over 90 days after randomization. Infection rates were similar in
both groups.
• Hospital readmissions at 90 days post-ICU discharge were lower in
the i.v. iron group.
• Post-ICU hospital stay was shorter in the i.v. iron group but did not
reach statistical significance.
CONCLUSION:

• Video
Let’s
play
THANK YOU
ANY QUESTIONS?
REFERENCES:
• Anaemia. (2023, May 1). https://www.who.int/news-room/fact-sheets/detail/anaemia
• Anemia - StatPearls - NCBI bookshelf. (2022, August 8). National Center for Biotechnology
Information. https://www.ncbi.nlm.nih.gov/books/NBK499994/?report=reader
• Chaparro, C.M. and Suchdev, P.S. (2019), Anemia epidemiology, pathophysiology, and
etiology in low- and middle-income countries. Ann. N.Y. Acad. Sci., 1450:
15-31. https://doi.org/10.1111/nyas.14092
• Elstrott, B, Khan, L, Olson, S, Raghunathan, V, DeLoughery, T, Shatzel, JJ. The role of iron
repletion in adult iron deficiency anemia and other diseases. Eur J
Haematol. 2020; 104: 153– 161. https://doi.org/10.1111/ejh.13345
• Hayden, S. J., Albert, T. J., Watkins, T. R., & Swenson, E. R. (2012). Anemia in critical
illness. American Journal of Respiratory and Critical Care Medicine, 185(10), 1049-
1057. https://doi.org/10.1164/rccm.201110-1915ci
• How is anemia treated? (n.d.). Hematology-Oncology Associates of
CNY. https://www.hoacny.com/patient-resources/blood-disorders/anemia/how-anemia-treated
REFERENCES:
 Just a moment... (n.d.). Just a moment... https://www.osmosis.org/answers/pernicious-anemia
 Petry, N., Al-Maamary, S. A., Woodruff, B. A., Alghannami, S., Al-Shammakhi, S. M., Al-
Ghammari, I. K., Tyler, V., Rohner, F., & Wirth, J. P. (2020). National prevalence of
micronutrient deficiencies, anaemia, genetic blood disorders and over- and Undernutrition in
Omani women of reproductive age and preschool children. Sultan Qaboos University Medical
Journal [SQUMJ], 20(2), 151. https://doi.org/10.18295/squmj.2020.20.02.005
 Shah, A., Marian, I., Dutton, S. J., Barber, V. S., Griffith, D. M., McKechnie, S.,
Chapman, G., Robbins, P. A., Duncan Young, J., Walsh, T., & Stanworth, S. J. (2021).
INtravenous iron to treat anaemia following critical care (INTACT): A protocol for a
feasibility randomised controlled trial. Journal of the Intensive Care Society, 22(2), 182-
182. https://doi.org/10.1177/17511437211012163
 Team Dr Lal PathLabs. (2022, November 14). Diagnostic Centre and Pathology Lab for
Blood Test | Dr Lal PathLabs. https://www.lalpathlabs.com/blog/anaemia-types-symptoms-
diagnosis-and-more/