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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