NURS 405 Week 5 Wednesday

Question 1

Iron-Deficiency Anemia

Answer 1

• Decreased RBC production
• Most common nutritional disorder in the world
• Most susceptible- very young, poor diets, women in reproductive years

Question 2

Causes of Iron-Deficiency Anemia

Answer 2

• Inadequate dietary intake (5-10% ingested iron is absorbed)
• Malabsorption
• Blood loss: 2mL whole blood contain 1 mg iron
• Hemolysis
• Pregnancy

Question 3

Clinical Manifestation of Iron Deficiency Anemia

Answer 3

Early: asymptomatic
General: pallor, glossitis (inflammation of the tongue), cheilitis (inflammation of the lips)
- headache, paresthesia, burning sensation of the tongue (from lack of Fe in the tissues)

Question 4

Iron Deficiency Anemia Diagnostic

Answer 4

Low iron level, normal or low transferrin level
CBC
Microcytic, hypochromic RBCs
Stool – occult blood
May need endoscopy or colonoscopy for diagnosis

Question 5

Iron Deficiency Treatment

Answer 5

• Treat underlying cause
• Replace iron, nutrition, oral or parenteral iron supplementation, transfusions of RBCs
• Enhance absorption of iron
• Patient teaching

Question 6

Oral Fe

Answer 6

Inexpensive / convenient

• 1 hour prior to food, best absorbed in acidic
  1. Absorbed best by duodenum and proximal jejunum (enteric coated are not necessary)
  2. Daily dose = 150-200 mg daily of elemental Fe (can take this 3-4 x per day)
  3. Fe best absorbed in acidic environment (take 1 hour prior to food)
  4. Undiluted liquid Fe can stain teeth (drink through a straw!)
  5. GI side effects: heartburn, constipation, diarrhea, black stools.
• SE: heartburn, constipation, diarrhea, black stools

Question 7

IM / IV Fe

Answer 7

Parenteral Fe: IM or IV, switch needles between draw and administartion due to Fe staining skin

Question 8

Thalassemia

Answer 8

Decreased RBC production
- Caused by group of inherited microcytic disease
- Common in ethnic groups - Mediterranean / Asia / middle east / Africa
- Problem with globulin protein –> abnormal Hgb synthesis and hemolysis
Autosomal recessive – 2 types:
minor (heterozygous) 🡪 mild form
major (homozygous) 🡪 severe

Question 9

Megaloblastic Anemia

Answer 9

Decreased RBC Production
- Abnormally large (macrocytic) red blood cells
Group of disorders caused by impaired DNA synthesis and presence of megaloblasts
Easily destroyed because of fragile cell membranes
4 classifications

Question 10

Pancytopenia

Answer 10

Decreased RBCs, WBCs, Platelets

Question 11

Acute Blood Loss

Answer 11

Loss of volume (trauma, surgery, GIB, …) 🡪 hypovolemic shock
Body responds by increasing plasma volume
With fluid resuscitation a dilutional anemia also occurs
Labs will not reflect an acute bleed for 2-3 days (until the fluids can shift)

Question 12

Chronic Blood Loss

Answer 12

Abnormal menstrual bleeding or slow GI bleeding
If rate of RBC loss > rate of generation 🡪 dilutional anemia
Intestinal absorption of iron is not fast enough to replace what is lost

Question 13

Hemolytic Anemia

Answer 13

Increased RBC destruction
- Genetic or acquired :physical, infectious agents or toxins
- General manifestations of anemia
SPECIFIC
- JAUNDICE
- Enlargement of spleen (primary site of RBC destruction) and liver
** Maintenance of renal function is a major focus of treatment **

Question 14

Categorical Causes of Anemia

Answer 14

1. Decreased / Abnormal RBC production
2. Blood Loss
3. RBC Destruction

Question 15

Decreased RBC Production Examples

Answer 15

1. Deficient nutrients
   - Iron / Cobalamin / Folic Acid
2. Decreased erythropoietin (KIDNEY)
3. Decreased iron availability in (LIVER)

Question 16

Blood Loss Examples

Answer 16

1. Chronic Hemorrhage
   - Bleeding duodenal ulcer
   - Colorectal cancer
   - Liver disease
2. Acute Trauma
3. Ruptured aortic aneurysm
4. GI Bleeding

Question 17

Increased RBC destruction Examples

Answer 17

1. Hemolysis
   - Sickle cell disease
   - Medication
   - Incompatible blood
   - Trauma (cardiopulmonary bypass)

Question 18

Hypochormic

Answer 18

Pale Color

Question 19

Normochromic

Answer 19

Normal Color

Question 20

Microcytic

Answer 20

Small cell

Question 21

Macrocytic

Answer 21

Big Cells

Question 22

MCV

Answer 22

Red blood cell size (Mean Cell Volume)

Question 23

MCH

Answer 23

Mean cell hemoglobin - amount of Hgb in the cell (color)

Question 24

MCHC

Answer 24

Mean cell hemoglobin concentration - Hbg concentration in relationship to cell volume

Question 25

Normocytic, normochromic - etiology?

Answer 25

Acute blood loss, CKD, CA, starvation, sickle cell anemia, pregnancy (you don't have enough RBC due to condition)

Question 26

Microcytic, Hypochromic - etiology

Answer 26

Fe-deficiency anemia vitamin B6 or copper deficiency lead poisoning

Question 27

Macrocytic, normochromic - etiology

Answer 27

Cobalamin (vitamin B12) deficiency, folic acid deficiency, liver disease

Question 28

Erythropoietin

Answer 28

Glycoprotein primarily produced in the kidneys (10% liver) --> stimulate erythropoiesis (production of RBC)

Question 29

MOA Erythropoietin

Answer 29

Kidney sense low O2 due to low RBC --> increase erythropoietin production --> stimulates erythropoietin in bone marrow --> erythropoiesis --> increase blood O2 levels , so decrease EPO production

Question 30

Thalassemia Minor

Answer 30

Body adapts to reduction of Hgb | Often does not require treatment, asymptomatic

Question 31

Thalassemia Major

Answer 31

can be life threatening, may cause physical and mental growth and development delays, splenomegaly, hepatomegaly, and cardiomyopathy, prominent jaundice Treatment: blood transfusions, chelating agents that bind iron, zinc, vit C, splenectomy Goal = keep Hgb around 10 g/dL Fe supplements should NOT BE GIVEN! Stem cell transplants = only cure for thalassemia

Question 32

Cobalamin (Vitamin B12) Deficiency - Meg

Answer 32

Type of megaloblastic anemia Dietary deficiency Deficiency of gastric intrinsic factor (H. Pylori, pernicious anemia - absence of IF) Malabsorption (Celiac, Crohn’s, small bowel resection) Chronic alcoholism Increases requirement (pregnancy) long-term H2 blockers, PPIs, strict vegetarians

Question 33

Folic Acid Deficiency -Meg

Answer 33

``` Type of megaloblastic anemia Dietary Malabsorption (Celiac, Crohn’s, small bowel resection) Chronic alcoholism Increases requirement (pregnancy) Chronic hemodialysis ```

Question 34

Drug induced Suppression of DNA synthesis - Meg

Answer 34

A type of megaloblastic anemia | Long list of drugs (see UpToDate) that interfere with purine or pyrimidine metabolism

Question 35

Inborn Errors - Meg

Answer 35

A type of megaloblastic anemia | Defective folate metabolism

Question 36

Nursing Management for Megaloblastic Anemias

Answer 36

Determine cause Genetic counseling – early detection and treatment, patients with positive family history should be evaluated for symptoms Safety – diminished sensitivity to heat and pain from neurologic impairment (protect from burns, falls, trauma) Monitor for patient’s adherence to treatment Assess neurologic difficulties Patient may need more frequent assessments for gastric CA (risk may be increased in patients with pernicious anemia)

Question 37

Vitamin B 12 Deficiency - Treatment

Answer 37

Gastrointestinal Manifestations: Sore, red, beefy tongue, anorexia, nausea, vomiting, and abdominal pain Neuromuscular manifestations: Weakness, ataxia, impaired cognition, paresthesia of feet and hands Dx: Macrocytic RBCs, Serum B12 levels are reduced, folate normal suggests B12 (cobalamin) deficiency Tx: Without cobalamin administration, individuals will die in 1 to 3 years As long as supplemental cobalamin is used, the anemia can be reversed Can replace with intramuscular, oral or nasal B12 (Latest studies support oral in high doses)

Question 38

Folic Acid Deficiency- Treatment

Answer 38

Folic acid required for DNA synthesis Signs/sx similar to B12 deficiency anemia except: NO NEUROLOGIC SYMPTOMS! Folate levels are low, B12 levels are normal Treatment: Folic acid: 1 mg/day orally Malabsorption or chronic alcoholism: up to 5 mg/day

Question 39

Anemia of Chronic Disease

Answer 39

``` Caused by: Chronic inflammation Autoimmune and infectious disorders Heart Failure Malignant diseases Bleeding ``` Diagnostics: elevated serum ferritin, normal folate and B12 levels Treatment: correct underlying problem, erythropoietin if from renal disease and anemia from CA

Question 40

Aplastic Anemia (rare)

Answer 40

Pancytopenia! ☹ (decreased RBCs, WBCs, Platelets) Can be chronic or acute related to sepsis or hemorrhage. ``` Usually acquired Idiopathic or Autoimmune Chemical agents, toxins Drugs Radiation viral or bacterial infections ``` Clinical manifestations: abrupt or insidious: fatigue, dyspnea, CV and cerebral responses, increased risk for bleeding, susceptible to infection, sepsis, death. Watch for fever! Diagnostics: CBC. Normocytic/normochromic anemia. Reticulocytes are low, bleeding times are increased. Bone marrow biopsy. Treatment: stem cell transplants, high-dose immunosuppression or corticosteroids.

Question 41

Nursing Implications Blood Loss

Answer 41

Replace volume to prevent shock Identify the source of hemorrhage and stop Watch for s/s shock – don’t rely on labs alone Pain, shock LR, Albumin, and Plasma Expanders Once volume is corrected, focus on RBCs (takes 2-5 days to make more RBCs in response to erythropoietin) May need PRBC transfusions