Anemia
Anemia
Introduction:
Many pathological conditions affect the erythrocytes, ranging from mild anemia to life threatening RBC lysis. A decrease in functional RBCs with a resulting oxygenation deficit is termed anemia and is a common problem experienced by critically ill patients. Polycythemia a disorder in which the number of circulating RBCs is increased, is seen less often. It leads to increased blood viscosity and thrombotic complications.
Definition of anemia:
The term anemia refers to a reduction in the number of circulating RBCs or hemoglobin, which leads to inadequate oxygenation of tissues.
Etiological classification:
1. Blood loss (bleeding)
2. Impaired RBC production (hypoproliferative anemia as iron deficiency ), table (1)
3. Increased RBC destruction (hemolytic anemia as sickle cell).
General clinical manifestation:
• Weakness.
• General malaise.
• Fatigue.
• Pallor of the skin & mucous membrane.
• Angular cheilosis (corners mouth ulceration).
• Tachycardia.
• Dyspnea.
• Palpitation.
• Dizziness.
• Orthopnea
• Chest pain.
• Muscle pain or cramps.
• Peripheral edema.
• Cardiomegaly.
• Hepatomegaly.
Diagnostic finding:
• ↓ RBC count, HB & HCT levels.
• ↑Bilirubin level in hemolytic anemia
• Low serum ferritin
• Blood smear reveals sickled cells in sickle cell anemia.
• Reticulocyte, platelet, WBC count decreased in aplastic anemia.
• Stool test for occult blood
Assessment:
• History (medication, alcohol intake & family history)
• Clinical manifestations
• Laboratory results.
• Colonoscopy & endoscopy
Medical management:
• Identification & removal the causative agents.
• Supplemental oxygen.
• Blood component therapy.
• Cardiovascular support.
• Splenectomy may be performed for hemolytic anemia.
• Bone marrow transplantation may be performed for aplastic anemia.
• Correction of dehydration for sickle cell anemia.
Nursing management:
• Managing fatigue.
• Maintaining adequate nutrition.
• Maintaining adequate perfusion.
• Promoting compliance with prescribed therapy.
• Monitoring and managing potential complications.
|Table (1) Impaired RBC production (hypoproliferative anemia). |
|Iron deficiency |Folic acid deficiency |Vitamins B12 deficiency |
|Intake of dietary iron is inadequate for |Lack of intake or absorption of folic |A deficiency of Vitamins B12. |
|hemoglobin synthesis. |acid. | |
| | | |
|Causes: |Causes: |Causes: |
|Inadequate intake of iron. |Inadequate intake of folic acid. |GIT malabsorption after ileal resection |
|Blood loss |Alcoholism. |or gastrectomy. |
|Malabsorption. |Increase requirement with pregnancy & |Absence of intrinsic factor (pernicious |
| |hemolytic anemia. |anemia). |
| |Malabsorption. |Inadequate intake. |
| | | |
|Clinical manifestations: |Clinical manifestations: |Clinical manifestations: |
|Weakness. |Poor oxygenation. |Weakness |
|General malaise. |Dizziness. |Fatigue |
|Fatigue. |Irritability. |Extremely pale. |
|Headache. |Dyspnea. |Smooth, red, sore tongue. |
|Pallor of the skin & mucous membrane. |Pallor. |Mild diarrhea. |
|Pica. |Headache. |Confused, paresthesias (numbness, |
|Angular cheilosis (corners mouth |Oral ulcer |tingling) |
|ulceration). |Tachycardia. |Proprioception (lose position sense). |
|Tongue smooth & red. |Tongue sore& beefy red. |Leukopenia. |
|Brittle, ridged & concave nails. | |Thrombocytopenia. |
|Paresthesias. | | |
|Continue. Table (1) Impaired RBC production (hypoproliferative anemia). |
|Iron deficiency |Folic acid deficiency |Vitamins B12 deficiency |
| | | |
|Diagnostic testes: |Diagnostic testes: |Diagnostic testes: |
|↓ RBC count, Hgb & Hct levels. |Serum folate |Schilling test. |
|↓ Iron level |Red cell folate |Intrinsic factor antibody test. |
|↓ RBC with hypochromia & microcytes |Macrocytosis. |↓ RBC count& Hgb. |
|↓ Ferritin level. |Abnormal platelet appearance. |↓WBC & platelets. |
| | | |
|Medical management: |Medical management: |Medical management: |
|Ferrous sulfate PO with ascorbic acid. |Folic acid Po or IM. |Vitamin B12, IM or deep SC. |
|Iron supplements IV or IM. | | |
| | | |
|Nursing managements: |Nursing managements: |Nursing managements: |
|Encourage iron rich food. |Encourage folic acid rich food as green |Encourage vitamin B12 rich food. |
| |vegetables, beef & liver. | |
|Take iron rich food with vitamin C. | |Encourage patient to continue vitamin B12|
| |Encourage patient to continue folic acid |therapy as long as it is prescribed. |
|Encourage patient to continue iron |therapy as long as it is prescribed. | |
|therapy as long as it is prescribed. | |Assess the patient's gait and stability |
| |Care of skin & mucous membrane. |as well as the need for assistive |
|Dairy and antacids should not be taken | |devices. |
|with iron. |Special oral hygiene. | |
| | |Ensuring safety if position sense, |
| | |coordination and gait are affected. |
|Continue. Table (1) Impaired RBC production (hypoproliferative anemia). |
|Iron deficiency |Folic acid deficiency |Vitamins B12 deficiency |
|Nursing managements: |Nursing managements: |Nursing managements: |
|If liquid iron forms used, instruct | |Physical & occupational therapy referral |
|patient to take medication through a | |may be needed. |
|straw, rinse the mouth with water and | | |
|good oral hygiene. | |Instruct the patient to avoid excessive |
| | |hot or cold if sensation is altered. |
|Instruction given about constipation and | | |
|stool color (dark green or black). | |Special oral hygiene. |
| | | |
|Using Z- track techniques for IM. | |Instruct the patient & families to |
| | |prepare bland, soft food and eat small |
|Administrating iron deeply into buttock. | |amount frequently. |
| | | |
|Monitor for allergic reaction for IV | |Instruct the patient about the chronicity|
|iron. | |of their disorder and the necessity for |
| | |monthly vitamin B12. |
| | | |
Sickle cell anemia
(Subtype of hemolytic anemia)
Definition:
It is a severe hemolytic anemia that results from inheritance of the sickle hemoglobin gene, causes RBC to assume a sickle or crescent shape.
Causes:
• Hereditary hemolytic anemia caused by abnormal amount of hemoglobin S.
Clinical manifestations:
• Hypervescosity.
• Poor perfusion.
• Thrombosis.
• Jaundice.
• Altered mentation.
• Abdominal pain & cramp.
• Ache.
• Decrease joint mobility, gut.
• Delayed physical & sexual development.
• Hypoxemia.
• Enlarged & tender spleen.
• Tachycardia, cardiomegaly.
Complications:
• Heart failure.
• Pulmonary hypertension.
• CNS infarction.
• Hepatomegaly.
• Infection.
• Renal failure.
• Impotence.
• Blindness.
Diagnostic testes:
• ↓ Hgb levels.
• Sickled cell on the smear.
• Abnormal HG electrophoresis.
Medical management:
• Pharmacological therapy; Hydroxyurea (hydrea).
• Transfusion therapy.
• Pain management as narcotic.
• Oxygen therapy.
• Antibiotics.
• Hydration.
Nursing managements:
• Pain managing.
• Preventing & managing infection.
• Promoting coping skills.
• Minimizing deficit knowledge.
• Monitoring & managing potential complications.
• Promoting home & community based care.
Polycythemia
Definition:
It refers to increased volume of RBCs. It is classified either primary or secondary.
Polycythemia Vera:
• Polycythemia Vera or primary Polycythemia is a proliferative disorder in which the myeloid stem cells seem to have escaped normal control mechanisms.
• The bone marrow is hypercellular and the RBC, WBC and platelets counts are elevated.
Secondary Polycythemia:
• It is caused by excessive production of erythropoietin.
Clinical manifestations:
• Spleenmegaly.
• Headache, dizziness.
• Fatigue.
• Paresthesia, blurred vision.
• Angina, dyspnea.
• Thrombophlebitis.
• Pruritus.
• Erythromelalgia, is a burning sensation in the fingers & toes partially relieved by cooling.
Diagnostic tests:
• ↑RBC, WBC & platelets.
Complications:
• Thromboses
• Bleeding
Medical management:
• Phlebotomy
• Avoid iron supplement.
• Allopurinol (zyloprim) for elevated uric acid.
Nursing management:
• Assess risk factors for thrombotic complications.
• Instruct the patient regarding signs & symptoms of thrombosis.
• Patients with history of bleeding are advised to avoid aspirin and aspirin containing medications.
• Tepid or cool bathing for Pruritus.
• Applications of lotion and bath products.
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