Focus on Anemia Copyright 2007 2004 2000 Mosby

Anemia • A deficiency in the § Number of erythrocytes (red blood cells [RBCs]) § Quantity of hemoglobin § Volume of packed RBCs (hematocrit) Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia • Diverse causes such as § Blood loss § Impaired production of erythrocytes § Increased destruction of erythrocytes Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Causes of Anemia Fig. 31 -1 Copyright © 2007, 2004, 2000, Mosby, Inc. ,

Anemia • RBC function § Transport oxygen (O 2) from lungs to systemic tissues § Carry carbon dioxide from the tissues to the lungs Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia • Not a specific disease • Manifestation of a pathologic process • Identified and classified by laboratory diagnosis Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia • Classified as § Morphologic • Cellular characteristics • Descriptive, objective laboratory information § Etiologic • Underlying cause Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia Clinical Manifestations • Caused by the body’s response to tissue hypoxia • Hemoglobin (Hb) levels are used to determine the severity of anemia Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia Integumentary Manifestations • Pallor § ↓ Hemoglobin § ↓ Blood flow to the skin • Jaundice § ↑ Concentration of serum bilirubin • Pruritus § ↑ Serum and skin bile salt concentrations Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia Cardiopulmonary Manifestations • Additional attempts by the heart and lungs to provide adequate O 2 to the tissues • Cardiac output maintained by increasing the heart rate and stroke volume Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

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Anemia Clinical Manifestations • Mild = Hb 10 to 14 g/dl § May exist without symptoms § Possible symptoms • Palpitations, dyspnea, diaphoresis • Moderate = Hb 6 to 10 g/dl § Increased cardiopulmonary symptoms § Experienced at rest or during activity Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia Clinical Manifestations • Severe = Hb <6 g/dl § Involve multiple body systems • Integument • Eyes • Mouth • Cardiovascular Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia Clinical Manifestations • Severe = Hb <6 g/dl § Manifestations (cont'd) • Pulmonary • Neurologic • Gastrointestinal (GI) • Musculoskeletal Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia Nursing Assessment • Subjective data § Important health information • Past health history • Medications • Surgery or other treatments Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia Nursing Assessment • Subjective data § Functional health patterns • • • Health perception–health management Nutritional-metabolic Elimination Activity-exercise Cognitive-perceptual Sexuality-reproductive Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia Nursing Assessment • Objective data § § § General Integumentary Respiratory Cardiovascular Gastrointestinal Neurologic Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia Nursing Diagnoses • Activity intolerance • Imbalanced nutrition: Less than body requirements • Ineffective therapeutic regimen management • Potential complication: Hypoxemia Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia Nursing Management • Goals § Assume normal activities of daily living § Maintain adequate nutrition § Develop no complications related to anemia Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia Nursing Implementation • Dietary and lifestyle changes • Blood or blood product transfusions • Drug therapy Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia Nursing Implementation • Oxygen therapy • Patient teaching § Nutrition intake § Compliance with drug therapy Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia Gerontologic Considerations • Common in older adults § Chronic disease § Nutritional deficiencies • Signs and symptoms may go unrecognized or mistaken for normal aging changes Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Erythrocyte Production • Erythropoietin (EPO) is a glycoprotein primarily produced in the kidneys (10% in the liver) § ↑ Number of stem cells committed to RBC production § Shortens the time to mature RBCs Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Erythrocyte Production • Life span of an RBC is 120 days • Three alterations in erythropoiesis that decrease RBC production § Decreased hemoglobin synthesis § Defective DNA synthesis in RBCs § Diminished availability of erythrocyte precursors Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Iron-Deficiency Anemia • One of the most common chronic hematologic disorders • Iron is present in all RBCs as heme in hemoglobin and in a stored form • Heme accounts for two thirds of the body’s iron Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Normal Iron Metabolism Fig. 30 -4 Copyright © 2007, 2004, 2000, Mosby, Inc. ,

Iron-Deficiency Anemia Etiology • Inadequate dietary intake § 5% to 10% of ingested iron is absorbed • Malabsorption • Blood loss • Hemolysis Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Iron-Deficiency Anemia Clinical Manifestations • General manifestations of anemia • Pallor is the most common finding • Glossitis is the second most common § Inflammation of the tongue Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Iron-Deficiency Anemia Diagnostic Studies • Laboratory findings § Hb, Hct, MCV, MCHC, reticulocytes, serum iron, TIBC, bilirubin, platelets • Stool guaiac test • Endoscopy • Colonoscopy Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Iron-Deficiency Anemia Collaborative Care • Goal is to treat the underlying disease § Increased intake of iron § Nutritional therapy § Oral or occasional parenteral iron supplements § Transfusion of packed RBCs Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Iron-Deficiency Anemia Drug Therapy • Oral iron § Inexpensive § Convenient § Factors to consider • Enteric-coated or sustained-release capsules are counterproductive • Vitamin C is helpful with absorption of Iron Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Iron-Deficiency Anemia Drug Therapy • Oral iron § Factors to consider (cont’d) • Best absorbed as ferrous sulfate in an acidic environment • Liquid iron should be diluted and ingested through a straw • Side effects • Heartburn, constipation, diarrhea Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Iron-Deficiency Anemia Nursing Management • At-risk groups § Premenopausal women § Pregnant women § Persons from low socioeconomic backgrounds § Older adults § Individuals experiencing blood loss Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Iron-Deficiency Anemia Nursing Management • • • Diet teaching Supplemental iron Discuss diagnostic studies Emphasize compliance Iron therapy for 2 to 3 months after the hemoglobin levels return to normal Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Folic Acid Deficiency • Also a cause of megaloblastic anemia • Folic acid is required for DNA synthesis § RBC formation and maturation Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Folic Acid Deficiency • Common causes § Poor nutrition § Malabsorption syndromes § Drugs § Alcohol abuse and anorexia § Lost during hemodialysis Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Folic Acid Deficiency • Clinical manifestations are similar to those of cobalamin deficiency • Insidious onset • Absence of neurologic problems • Treated by replacement therapy • Encourage patient to eat foods with large amounts of folic acid Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia of Chronic Disease • Underproduction of RBCs • Mild shortening of RBC survival

Anemia of Chronic Disease • Causes § End-stage renal disease • Primary factor: ↓ Erythropoietin § Chronic liver disease § Chronic inflammation § Malignant tumors § Chronic endocrine diseases Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia of Chronic Disease • Anemia of chronic disease findings § ↑ Serum ferritin § ↑ Iron stores § Normal folate and cobalamin levels Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Anemia of Chronic Disease • Treating underlying cause is best • Rarely blood transfusions • Erythropoietin therapy Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Reference • Black, J. & Hawks, M. Medical Surgical Nursing Clinical Management for Positive Outcomes. St Louis: Saunders. Elsevier. Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.