Anemia

ANEMIAS (general)

Definitions Condition in which the hemoglobin concentration is lower than normal 12.6-17.4 Reflects the presence of fewer than the normal number or erythrocytes Results in decrease amount of oxygen delivered to the tissues Sign of an underlying disorder Classification Hypoproliferative: Deficit in RBC production MCV—size of the RBC Iron deficiency low MCV low reticulocytes low Iron, % saturation, ferritin high TIBC B12 deficiency ­ high MCV low vitamin B22 Megaloblastic anemia Folate deficiency ­ high MCV Bleeding: RBC loss Acute blood loss (GI, trauma, menstrual cycle), ¯ MCV Hemolytic: excess RBC destruction Sickle cell – RBC abnormal shaped & bone marrow attempts to produce more, and they will become more sickled & too young & the body will hemolysis & hypoxia (triggering kidney to produce RBC by stimulating the liver to produce young RBC) in the body will occur & jaundice & anemia   Diagnostic studies: General CBC RBC indices Iron Studies Serum iron level Total iron binding capacity Ferritin ^ when looking for Iron deficiency  Vitamin B12 Folate Level (folic acid levels) Haptoglobin & Erythropoietin Levels Bone Marrow Aspiration Other tests for underlying chronic illness, malignancy, blood loss MCV --> mean corpuscular volume – size of erythrocyte So you can do the labs and if the MCV shows a change can it be diagnosed by that?   Complications: General Heart failure Paresthesia Delirium gradual HBG loss 50% cardiopulmonary collapse with acute HBG loss 30% does this usually happen after SX? activity, disease & life style may ­increase symptoms   Geriatric Considerations Impacts functioning Decreased mobility Increased depression Increased risk for falling Delirium (esp. hospitalized) Clinical manifestations Fatigue Dyspnea Confusion   Assessment: Health History Medications Alcohol intake BC alcohol needs a lot to be digested Family history Nutritional Assessment Intake of iron & nutrients (B12 & folic acid) BC different PT with cultures have different diets & if malnourished Cardiac Status HF (pushing of blood is compromised causing issues on the blood) Gastrointestinal System Because of bleeding loss without being noticed Neurological Examination   Clinical Manifestations: Weakness, fatigue, and general malaise Pallor skin and mucous membranes No HBG within the system Tachycardia (BC trying to compensate for the HBG loss), palpitations, dyspnea, dizziness, and orthopnea Nausea, vomiting, anorexia, and glossitis Paresthesia, ataxia, poor coordination, and confusion Jaundice—in megaloblastic or hemolytic anemia Tongue smooth & red—iron deficiency Beefy, red, & sore – megaloblastic anemia Angular chelilosis (ulcerated corners of the mouth)—both Carve ice, dirt (pica), starch—iron Identify anemia in dark skin?     Diagnosis Nursing Diagnosis: Fatigue Imbalanced nutrition, less than body requirements Ineffective tissue perfusion Collaborative problems/potential complications: Heart Failure Angina Chest pain—BC parts of the myocardia may be blocked causing pain Paresthesia Confusion Injury related to falls Depressed mood  PT goes into further anemia, because they aren’t doing much   Planning/Goals Major goals Decreased fatigue Attainment of adequate nutrition Maintenance of adequate tissue perfusion Nice pink color Compliance with prescribed therapy Prevention/absence of complications Not in a short time because body needs to get used to the change   Interventions: Managing Fatigue Prioritizing and balancing activities Maintain physical activity and exercise Maintaining Adequate Nutrition Healthy diet Dietary supplements I.e. vitamins & multivitamins but NOT iron, B12, or folic acid because that needs to be monitored by the physician Many PT do not like iron because they can become constipated Activity Intolerance Replace lost volume Supplemental oxygen Because with cardiopulmonary distress O2­ is important O2 is the main thing with anemia Promoting Compliance Patient/family teaching Monitoring/managing Complications   Evaluations: Expected Outcomes Reports less fatigue Attains and maintains adequate nutrition Maintain adequate perfusion Absence of complications

Iron Deficiency Anemia

Causes low iron stores ¼ - 1/3 is what the body stores – what is showed before the PT will show symptoms Chronic blood loss low iron intake Iron malabsorption Pregnancy blood flow  increases iron­, more O2 is needed --> depleted from the iron, usually told to take multivitamin because of this Alcoholics -- depleted iron as well because alcohol needs iron to digest, & they are usually malnourished as well Intrinsic factor in the GI but in bariatric SX – it may be lost   Clinical manifestations Smooth, sore tongue Brittle and ridged nails Angular cheilosis Diagnostic findings Bone marrow aspiration low ferritin levels low MCV low HCT and RBC levels   Medical/Nursing Management Treat underlying cause Bleeding (cancer, tumors) Stool for occult blood People over age of 50-> colonoscopy, endoscopy, or X-ray of GI tract Celiac & gastric surgery -> inadequate iron absorption Iron supplements GI side effects -> Use of Stool softeners increases­ constipation because it is a hard supplement—important to be given a stool softener— increase in­ grains in diet to soften stool Orange juice ­ absorption in the body 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; add stool softener if needed. Remember that stools will become dark in color. 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. PAGE 931 Take on empty stomach Very important Increase iron in diet Vitamin C sources enhances iron absorption

Vitamin B12 & Folate deficiency Anemias

Vitamin B12 Etiology B12 absorbed in the GI tract by the intrinsic factor cells – which is why in the bariatric SX when the intrinsic factor cells are depleted it can cause a B12 deficiency B12 & folate main DNA formation   Strict vegetarians (no meat or dairy products) Faulty absorption in GI tract Crohn’s disease Gastric surgery Chronic use of PPIs and metformin Absence of intrinsic factor Pernicious anemia

Folate etiology Deficiency found in those who do not consume uncooked vegetables Increases folic acid requirements Alcohol Chronic hemolytic anemia Woman who are pregnant Malabsorptive diseases Celiac disease

Clinical manifestations Clinical manifestations similar Mild jaundice Mouth and tongue soreness May coexist together Neurologic manifestations of Vitamin B12 deficiency do not occur with folic acid deficiency Paresthesia Loss of proprioception

Diagnostic Vitamin B12 Can you do B12 to diagnose B12 & folate deficency? Schilling test Don’t use it any more—very costly Administer a little medication of B12 & wait to see if PT digested it correctly – see if Pt has intrinsic factor Methylmalonic acid level Intrinsic antibody factor

Medical/Nursing management Folate Deficiency Increasing folate in the diet Folic acid 1 mg daily (IM for malabsorption problems) Easy to treat—one a week & it will begin to ­ increase  B12 Deficiency Vitamin B 12 replacement Replacement with food first & then once identified then it will go into the injection course of medications Absence of intrinsic factor >>> IM injections of Vitamin B12 Injections ONCE a month—if lacking intrinsic factor Nursing does not suggest this to PT but to the doctor!! Celiac disease, with exacerbations, more than once a month, depending on the order of the DOCTOR Assess ambulation, gait, stability PT/OT referral Small amounts, bland food

Sickle Cell Anemia

Severe hemolytic anemia Results from inheritance of the sickle hemoglobin (HbS) gene à defective hemoglobin molecule that acquires a crystal-like formation when exposed to low oxygen tension African, Middle East, and Mediterranean descents Sickle Cell trait (carrier)

Pathophysiology Decrease O2 in the body Defective HbS because viscous Formation of gel like substance containing HbB crystals Clumping of crystals into long chains Becoming very painful, not transferring O2 Formation of parallel array of filaments Disruption Cell assumes crescent shape Sickling Rigid Sticky Fragile Agglutination & circulation is impaired Give large amount of pain medication—very addictive can cause respiratory distress because PT want more medication—Nurse needs to monitor this process because of this to avoid this crisis If PT goes into crisis—PT is to receive O2 (#1) & fluid (to deglutinate the cells, very important) Microinfarcts Tissue hypoxia Further sickling

Clinical manifestations Jaundice Chronic anemia Tachycardia, cardiac murmurs, and cardiomegaly Ischemia/infarction Pain, swelling, and fever Sickle Cell Crisis (Acute Vaso-occlusive Crisis) Entrapment of erythrocytes in microcirculation Hypoxia, inflammation, and necrosis to a region Which is why fluids are important to be given With perfusion: free radicals create oxidative damage to vessel Endothelium of vessel becomes dysfunctional Crisis >> Acute Chest Syndrome Fever, respiratory distress, and new infiltrates on CXR Mimic infection (often the cause) Rule out PE

Treatment PRBC, ABX, bronchodilators, inhaled nitric oxide, and mechanical ventilation Mechanical ventilation – sickle cells went into little vessels of the lungs, which is difficult to be moved, areas must be open & ready  New infiltrated—antibiotics   Difficulty breathing—bronchodilators Crackles—something to eliminate the fluid Mimicking infections (fever, because of the infiltration)—interventions will be O2 , antibiotics, fluids (not overloaded because there may be crackles, blood transfusion with none-to-little saline (body can only handle a little), one or the other)

Crisis  Pulmonary HTN CT Scan: diminished perfusion Elevated BNP Pulmonary artery pressures elevated Lung assessment may be normal Pulse oximetry may be normal Pulmonary arteries are stretched Stroke  Ischemic strokes common in young children and older adults Hemorrhagic stroke more common in younger adults Result from decreased cerebral blood flow due to anemia, hemolysis, increased hypoxic stress If sickle cell is not treated Medical management: red cell transfusions to reduce level of Hemoglobin S to prevent cerebral edema Reproductive problems Low testosterone, low libido, erectile dysfunction, infertility Common signs Episodes of priapism (prolonged erection of penis without sexual stimulation that can contribute to significant pain, decreased libido, and impotence EMERGENCY – organ can be killed, sickle cells are agglutinated in the penis, engorged with sickle cells, circulation will not be able to get back— >10 min without intervention necrosis can occur because of the lack of circulation Contraception important when on hydroxyurea due to teratogenic effects; concerns about hydroxyurea and infertility in men

Diagnostic findings & prognosis Low hematocrit with sickle cells noted on blood smear Confirmation: hemoglobin electrophoresis Diagnosed in infancy Average life expectancy suboptimal Death commonly due to heart disease, lung disease, kidney disease, infection, and neurologic system disease

Medical/Nursing Management Stem Cell Transplant Pharmacologic Therapy Hydroxyurea (chemotherapy agent) Folic acid replacement Treat infections promptly Influenza & pneumococcal vaccinations Transfusion Therapy Supportive Therapy Pain management Adequate hydration Supplemental oxygen Decrease fatigue and inflammation Nursing Diagnoses Acute pain and fatigue Risk for infection Planning/Goals Relief of pain Decreased incidence of crisis Absence of complications Interventions Pain management Managing fatigue Preventing and managing infection Promoting coping skills Minimizing deficient knowledge Preventing/managing potential complications

Aplastic Anemia (pancytopenia)

Bone marrow fails to produce adequate amounts of erythrocytes, leukocytes, and platelets Primary Cause: Idiopathic Other Common Causes Congenital or inherited Exposure to chemicals or radiation Drug induced Viral infection

Pathophysiology Bone marrow suppressed or destroyed ---> Failure to produce adequate stem cells ---> Insufficient amount of erythrocytes, leukocytes, and platelets produced ---> Pancytopenia (anemia, leukopenia, and thrombocytopenia)

Clinical Manifestations Anemia Fatigue, pallor, dyspnea Leukopenia Multiple infections Thrombocytopenia Purpura, petechiae, or ecchymosis

Diagnostic Findings & Medical Management Hematology - pancytopenia ↓ granulocytes ↓ thrombocytes ↓ RBCs Bone marrow biopsy Hypoplastic or aplastic marrow replaced with fat Hematopoietic Stem Cell Transplant (HSCT) Immunosuppressants Cyclosporine Methylprednisolone Transfusion Therapy PRBCs Platelets

Nursing Management Administer transfusion therapy as prescribed Administer oxygen as needed Monitor and record Vital signs I & O Lab values Occult blood in emesis, stools, and urine AVOID GIVING PATIENT IM INJECTIONS! Monitor for infection, bleeding, and bruising

Neutropenia

A neutrophil count less than 2000/mm3

Pathophysiology ↓ production or ­↑ destruction of neutrophils ---> making the individual susceptible to infection

Causes Aplastic anemia Metastatic cancer, lymphoma, leukemia Chemotherapy Radiation therapy Megaloblastic anemia Drug induced Immunological disorders Infections

Diagnostics & Manifestations Absolute neutrophil count (ANC) Risk of infection increases proportionately with decrease in neutrophil count: Significant risk when less than 1000/mm3 High risk when less than 500/mm3 Definite risk when less than 100/mm3 No definite manifestations CBC with differential may identify neutropenia prior to onset of infection

Management Dependent on the cause Immunosuppressants Corticosteroids Granulocyte colony-stimulating factor Filgrastim Withholding chemotherapy or radiation therapy If fever occurs, patient admitted to hospital. Cultures of blood, urine, sputum, Chest X-ray obtained Broad spectrum antibiotics initiated until cultures results available Prevention of complications Risk for infection Neutropenic Precautions Reverse Isolation Patient Teaching Identify signs/symptoms of infection and when to report these findings Identify appropriate measures to prevent infection Describe actions to take should an infection occur