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Flashcards in week 7- anemia Deck (32)
1

Anemia

Reduction in either the number of red blood cells, the amount of hemoglobin, or the hematocrit

Reduced RBCs result in tissue hypoxia

Hypoxia results in clinical sign (not a specific disease); anemia is a manifestation of several abnormal conditions

2

Types of Anemia

• Intrinsic-eg: Sickle Cell Disease, Enzyme deficiency (G6PD)
• Extrinsic- eg: Antibodies (autoimmune)
• Decreased Erythrocyte Production-eg: Iron Deficiency, leukemia
• Blood Loss- eg: acute (trauma) chronic (gastritis, menstrual)

3

Manifestations of Anemia- skin

Cool to touch

Cold intolerance

Brittle nails (lose convex shape..become concave and fingers club-like)

Pallor, especially: ears, nail beds, palmar creases, conjunctivae, circumoral (around the mouth)

4

Manifestations of Anemia- cradiovascular

Tachycardia (without activity)
• HR increases with activity and during/after meals
• Murmurs and gallops when anemia severe
• Orthostatic hypotension

5

Manifestations of Anemia- Respiratory

Dyspnea on exertion
Decreased oxygen saturation






6

manis of anemia-Neurological

Increased somnolence and fatigue
Headache
Irritable
Difficulty concentrating, memory

7

Sickle Cell Disease

Genetic disorder resulting in chronic anemia, pain, disability, organ damage, increased risk for infection, and early death

Sickle cell disease state and sickle cell trait

Sickle cell Crisis
• Extensive cell sickling
• May occur weekly or once per year
• Impaired blood flow results in vasospasm
• Can lead to tissue ischemia and infarction
• Repeated blockages can result in organ damage or failure

8

incidence of sickle cell

Incidence: 1 in 350 to 500 African Americans, also affects Mediterranean, Caribbean south and Central Americans, Arab or East Indian descent

9

Sickle Cell Disease: Pathophysiology

Main problem of the disorder is formation of abnormal hemoglobin chains

Cells may return to normal shape when causative factors resolved, O2 levels and perfusion normalize

Some cells permanently affected

RBCs with >40% HbS live 12-15 days (N=120 days)

Results in hemolytic anemia

10

Triggers of Sickle Cell Disease

• Hypoxia
• Dehydration
• Infection
• Venous stasis
• Pregnancy
• High altitude
• ETOH consumption
• Low or high environmental or body temperature
• Stress (emotional or physical exertion)
• Acidosis
• Anaesthesia

11

Sickle Cell Disease: Laboratory Assessment

• Hemoglobin S (HbS)
• Number of RBCs with permanent sickling
• Hematocrit
• Reticulocyte count
• Total bilirubin (Bilirubin results from the breakdown of heme which is released with the breakdown of hemoglobin (therefore RBC breakdown)
• Total white blood cells
• Imaging assessment

12

Sickle Cell Disease: Clinical Manifestations

Symptoms vary greatly from person to person but complications include:
• Cardiovascular changes
• Skin changes
• Abdominal changes
• Renal and urinary changes
• Musculoskeletal changes
• CNS changes
• What does your assessment include?

13

Organs with high need for oxygen are most often affected

CV-pulmonary infarctions can lead to pulmonary hypertension or MI
Risk for high-output HF
Assess for: SOB, general fatique or weakness, murmurs, S3, increased JVD, Compare PP, temp, cap refill in all extremities-may be cool with diminished or absent pulses, HR may be increased, BP low to average with decreased pulse pressure.

14

assess for

Skin- Pallor or cyanosis, assess lips, tongue (grey) palms, soles conjunctivae and nail beds cyanotic, jaundice (d/t RBC destruction and release of bilirubin). Inspect roof of mouth in patients with dark skin for yellowish appearance, and skin for itching, assess skin for venous stasis ulcers (hands/feet)

Priapism-prolonged penile erection, very painful, may last hours, usually cannot urinate during episode

Abdo- hepatomegaly, splenomegaly-both first to be damaged due to hypoxia and ischemia. Assess for guarding and rebound tenderness. Diffuse leg and back pain in SC crisis

MSK- joint swelling, increased temp, decrease ROM, pain

Retinal- obstruction results in detachments or blindness

CNS-low grade fever, seizures, manifestations of stroke

Psychosocial: behavioural changes may indicate cerebral

hypoxia- observe pt and discuss with family.

Assess social supports, coping mechanisms, disease progression, lifestyle changes, limitations and response to disease

15

Sickle Cell Disease Interventions:

Potential for Multiple Organ Dysfunction
Interventions include:
• Oxygen therapy- to treat hypoxia
• Rest- to decrease metabolic requirements
• Hydration- oral or IV to reduce blood viscosity & maintain renal function
• Transfusion therapy-for aplastic crisis

Pain is the most common problem:
• Pain is often undertreated*
• Drug therapy—During the acute phase 48 hours of continuous IV opioid analgesics
• Patient controlled analgesia may be effective
• Complementary and alternative therapies
eg: warm room, distraction, relaxation techniques, positioning, aromatherapy, therapeutic touch, warm soaks/compresses

16

Sickle Cell : Potential for Sepsis

Interventions include:
Prevention and early detection strategies
Drug therapy

17

Patient Teaching: Prevention of Crisis
DO

Drink 3-4 L of fluid per day
Notify HCP at first signs of infection or illness
Have annual Flu vaccine, consider pneumonia vaccine
Wear socks/gloves when cold out
Mild, low-impact exercise when well
Communicate diagnosis to all HCPs
Consider genetic counseling

18

Patient Teaching: Prevention of Crisis
DONT

Drink alcohol or smoke
Participate in strenuous physical activity
Expose yourself to temp extremes
Fly in planes with unpressurized cabins
Travel to high altitude cities

19

Iron Deficiency Anemia (Microcytic)

• Most common type of anemia. Can result from:
• blood loss
• poor intestinal absorption
• or inadequate diet
• If mild—symptoms of weakness and pallor
• Evaluate adult patients for abnormal bleeding, especially from the GI tract
• Treatment—
• increasing oral intake of iron from food sources, oral iron supplements, or IM iron solutions.

20

Vitamin B12 Deficiency Anemia (Macrocytic)

Lack of vitamin B12

Due to:
Poor intake of foods containing vitamin B12
Vegetarian or lacking dairy products
tapeworm
overgrowth of intestinal bacteria

21

Pernicious Anemia

Anemia resulting from failure to absorb vitamin B12


Caused by a deficiency of intrinsic factor

-Acid is required for the secretion of intrinsic factor and with gastric mucosal atrophy there is a decrease in hydrochloric acid secretion

-GI surgery, Crohn’s Disease

-Often not diagnosed until around age 60

-May be mild, moderate or severe

-Usually develops slowly and has few symptoms

-Manifestations:
(Pallor
Jaundice
Glossitis (smooth, beefy-red tongue)*unique to B12 deficiency anemia
Fatigue
Weight loss
Parasthesia (affects nervous system function)
Poor balance))

22

Treating B12 Deficiency

Diet
Animal proteins, eggs, nuts, dairy products, dried beans, citrus fruit, leafy green vegetables

Vitamin supplements if severe (for life)
B12 injections weekly then monthly
Maintenance on cyanocobalamin nasal spray

Monitor B12 and folic acid levels

23

Folic Acid Deficiency Anemia

• Manifestations similar to those of vitamin B12 deficiency, but nervous system functions remain normal
• Common causes—
poor nutrition *most common cause
Malabsorption ie: Crohn’s disease
alcohol abuse
Drugs (Anticonvulsants, oral contraceptives)
• Treatment:
Diet
Folic acid supplementation

24

Aplastic Anemia

• Deficiency of circulating RBCs because of failure of the bone marrow to produce these cells
• Pancytopenia(Deficiency of all three cell types occurring together due to bone marrown suppression: RBC, WBC, Plt)
• Most cases are acquired
• Long term exposure to toxic agents, S/E drugs, infection
• Up to 50% cause unknown or hereditary

25

aplastic anemia assessment and treatment

Assessment:
• Weakness, pallor, petechiae, or ecchymosis
• Check CBC
• Bone marrow biopsy
Treatment:
• Blood transfusions *primary tx
• Only when anemia causes disability or is life-threatening
• Immunosuppressive therapy (ie: prednisone)
• Splenectomy
• If enlarged and destroying or suppressing RBCs

26

All Anemia Nursing Assessment Include:

1. Subjective
--Health Information
Past history
Medications
Surgery or treatments
----Functional
Family history
Nutritional
Elimination
Activity tolerance
Cognitive-perceptual changes

2. Objective-
General appearance
Integumentary-skin pallor (how do you assess with dark skin tones?)
Respiratory
Cardiovascular
GI
Neurological
Lab values

27

Transfusion Therapy

Pre-transfusion responsibilities:
• Verify consent obtained and signed
• Verify order
• Crossmatching (Tests donor’s and recipient’s blood for compatibility)
• Examine blood bag for identification
• Check expiration date.
• Inspect blood for discoloration, gas bubbles, or cloudiness
• Verify patient ID**
• Must be checked by two registered staff (RN or RPN…check agency policy)

Re-type and crossmatch q 72 hours usually

28

Re-type and crossmatch q 72 hours usually

Minimum 20 gauge angiocath
May use y-type (for PRBCs) or straight tubing (Plts)
Type of tubing filter depends on blood product (removes sediment)
Normal saline (0.9%) only compatible IV fluid
Never add any IV drugs to blood product

29

Transfusion Responsibilities

• Provide patient education
• Assess vital signs
• Begin transfusion slowly, and stay with patient first 15 to 30 minutes.
• Ask patient to report unusual sensations such as chills, shortness of breath, hives, or itching.
• Administer blood product per protocol.
• Assess for hyperkalemi (More common with PRBC)

Most severe reactions usually occur within first 50 ml
Infusion time depends on blood product and patient
Ie: usually 2 hrs for PRBCs (cannot hang longer than 4 hrs**)

Assess pts cardiac and fluid status-may need to infuse slower than 2 hrs. Monitor for fluid overload…S & S?
Often see lasix given between units of PRBCs to manage fluid overload….this depends on reason for transfusion! Not given if actively bleeding or dehydrated 

30

Types of Transfusions

When are these transfusions needed?
RBC- blood loss-trauma, surgery, hgb less than 8g/dL or hypoxemic
Platelets- thrombocytopenia
Plasma- bleeding caused by clotting deficiencies- haemorrhage DIC
Cryoprecipitate- factor VIII hemophelia
Granulocyte- neutropenia

31

Types of Transfusion Reactions

Febrile
Hemolytic
Allergic
Bacterial
Circulatory overload

32

Nursing Assessment & Interventions

Hemolytic- fever, chills, back pain, tachypnea, hypotension, hemoglobinuria, dark urine, jaundice, renal failure, shock, cardiac arrest.
Treatment: Stop blood transfusion, check blood product/patient verification, draw blood samples, obtain urine sample, Send samples and remaining blood to blood bank, maintain BP with IV fluid, monitor urinary output-may need catheter, treat shock

Febrile nonhemolytic- chills fever headache flushing muscle pain
Treatment- stop transfusion, treat fever, do not restart until reordered

Allergic Reaction- flushing, itching, hives, wheezing, cyanosis, shock
Treatment: stop transfusion, antihistamine, may be restarted is symptoms subside but for severe cases may need epinephrine, shock treatment

Circulatory overload- cough dyspnea, hypertension, increased JVD
Treatment: O2, high fowlers positioning, diuretics, morphine, decrease transfusion volume. Prevention includes transfusion over 2hours, longer if risk known and diuretics between units

Sepsis- rapid chills, high fever, vomiting, diarrhea and hypotension
Treatment: O2, IV fluids, antibiotics, vasopressors (as above for blood and also draw blood cultures)