Medsurg Anemia

What is anemia

NOT a disease

sign/symptom of underlying disorder

reduction in mass of circulating RBCs/quantity of hemoglobin/dec volume (hematocrit)

results in tissue hypoxia

What is the screening test for all anemias

CBC (hemoglobin and hematocrit)

Causes of Anemia

decreased RBC production, blood loss (acute/chronic), inc RBC destruction

Hemoglobin

transport oxygen to tissues (mild = 10-12, mod = 6-10, severe <6)

hematocrit

proportion of RBCs in 1 mL plasma

Red Blood Cell Count (RBC)

how many red blood cells are in sample

Mean Corpuscular Volume (MCV)

measures average size of RBCs

Mean Corpuscular Hgb Concentration (MCHC)

measures average color of RBCs

Red Cell Distribution Width (RDW)

measures the variability of the size of RBC’s in the sample

Classifying Anemias

1. Morphological characteristics (cellular level and describe RBC size/color; more accurate)

   1. Etiologic characteristics (underlying cause/clinical conditions; more typical, how pt care is determined)

Classifying Anemias via Size

Microcytic (MCV <80 FL)

• iron deficiency

• vit B6

• copper deficiency

• thalassemia

• led posioning

Macrocytic (MCV >100 FL)

• megaloblastic

• vit B12/folate

• vegan diets

• GI surgery

• ETOH and liver disease

Normocytic (MCV 80-100 FL)

• sickle cell

• chronic disease

• aplastic anemia

• hemolytic anemias

• acute blood loss

Classifying Anemias: Color

Hypochromic (MCH < 27 PG)

• pale

• iron deficiency

Normochromic (MCH 27-31 PG)

• normal RBC

Hyperchromic (MCH >31 PG)

• high amount of hb

• alcohol use

Normocytic and normochromic anemias

Acute blood loss, CKD, chronic disease

Macrocytic, normochromic aneimias

vitamin B12 deficiency, folic acid deficiency, liver disease, alcohol

Microcytic, hypochromic anemias

iron deficiency, lead poisoning

decreased hemoglobin synthesis

iron deficiency

decreased number of RBC precursors

aplastic anemia, inherited disorders, chronic diseases/disorders, medication/chemicals, radiation

defective DNA synthesis

vitamin B12 and folic acid deficiency

Blood loss acute

post op bleeding, acute Gi bleed, splenic sequestration (blood gets trapped in spleen)

Blood loss chronic

gastritis, haemorrhoids, menstural flow, chronic GI bleed

Increased RBC destruction

hemolytic anemia

Acquired anemia

extrinsic

antibodies against the RBCs or in cancer/DIC/ECMO, thrombocytopenia purpura

Hereditary anemia

intrinsic

sickle cell, enzyme deficiencies, enzyme abnormalities

Initial Symptoms of Anemia

may be asymptomatic initially (body is compensating)

cardiovascular: tachycardia, palpitations

pulmonary: dyspnea on exertion

orthostatic changes: BP and pulse lying, sitting, standing

Compensatory Mechanisms of Anemia

• redistiribution of blood from tissues requireing less O2 (blood goes to organs w/ higher o2 needs like brain and heart)

  • skin → pallor

• cardiac: heart rate increases, BP lowers

• body tries to make more RBCs in bone marrow (fails)

• jaundice - hemolysis of RBCs

• causes increase of bilirubin (itchy)

• hear systolic murmurs and bruits

• angina, MI, things that overwork the heart

Manifestations of Anemia: Cardiovascular

mild: palpitations

moderate: inc palpitations and bounding pulse

severe: inc HR, inc pulse pressure, systolic murmmurs, intermittent claudication (craming in legs), angina, HF, MI

Manifestations of Anemia: Eyes

severe: icteric conjunctiva and sclera, retinal hemorrhage, blurred vision

Manifestations of Anemia: GI

severe: anorexia, hepatomegaly, splenomegaly, problems swallowing, sore mouth

Manifestations of Anemia: General

mild: mild fatigue (maybe)

moderate: fatigue

severe: sensitivity to cold, weight loss, lethargy

Manifestations of Anemia: Mouth

severe: glossitis, smooth tongue

Manifestations of Anemia: Musculoskeletal

severe: bone pain

Manifestations of Anemia: Pulmonary

mild: exertional dyspnea

moderate: dyspnea

severe: tachypnea, orthopnea, dyspnea at rest

Manifestations of Anemia: Neurologic

moderate: “roaring in the ears”

severe: headache, vertigo, irritability, depression, impaired thought processes

Manifestations of Anemia: Skin

severe: pallor, jaundice, itching

Assessment Questions

1. Have you felt unusually tired or fatigued recently?

2. Have you experienced unusual weakness?

3. Have you experienced shortness of breath with exercise or otherwise?

4. Have you felt dizzy, or have you fainted?

5. Have you felt easily confused or lost your concentration?

6. Has your skin become unusually pale; including decreased pinkness/color in your lips, gums or lining or your eyelids? Are nail beds or palms blanched?

7. Have you experienced a rapid heartbeat/palpitations?

8. Have you been unusually cold?

9. Have you been felling sad or depressed (sleeping a lot, not doing ADLs, socially isolated)?

10. Have you craved and chewed ice (pagophagia) recently?

11. What was your last period like?

Nursing Management: Anemia

clinical problems: fatigue, nutritionally compromised, impaired tissue perfusion

Goals: correct cause of anemia (most important), assume normal ADLs, maintain adequate nutrition, develop no complications from anemia

Gerontologic considerations for Anemia

inc risk for morbidity/mortality

• Modest change in RBC mass occurs in older adults (1 pt drop in hb due to dec estrogen/testosterone)

• Anemia is not a normal finding!

• identify underlying cause

  • not eating well → iron deficiency

  • unrecognized bleeding w/ hemorrhoids or GI

  • chronic disease

• may go unrecognized (attributed to normal aging)

Iron Deficiency Anemia

most common nutrition disorder worldwide

causes: inadequate dietary intake, iron malabsorption (in duodenum), blood loss, hemolysis

risk factors: GI surgery, GI bleeding, kidney disease, cancer

most risk: young people, old people, mensurating/reproductive years

early symptoms: asymptomatic

s/s: pallor (most common finding), glossitis, cheilitis

additional labs: serum iron (dec), total iron binding capacity (inc), transferrin (dec), ferritin (dec), stool occult blood, enodscopy/colonoscopy, bone marrow biopsy (of all other tests are inconclusive)

Nursing Management of Iron Deficiency Anemia

iron supp. for 2-3 mnths

treat underlying problem

replace iron

• pill is black (warn pt about darker stools), best taken 1 hr before meals, take w/ vit V to increase absoprtion, sit upright for 30 mins, can cause constipation

• PO or IV supplement

• dietary sources of iron: beef, veal, lamb, pork, beef/chicken liver, clams, sardines, oysters, shrimp tofu, black beans, lentils, tahini, tempeh, and beans

  • fortified bread and cereal

  • vegetables (spinach, soybeans, and canned pumpkin, asparagus, brussel sprouts)

  • fruits: dried apricots/figs, prune juice, raspberries, or rasins

  • soy milk, molasses, seeds, nuts

Vitamin B12 Deficiency

“pernicious anemia,” rare autoimmune disorder (mostly family histories)

causes: chronic alcohol use, diet deficiency, intestinal malabsorption

risk factors: absence of intrinsic factor released in stomach (familial, autoimmune) and GI surgery

clinical manifestations: sore, red, beefy, shiny tongue; anorexia; N/V; abdominal pain; neuromuscular manifestations (ataxia, muscle weakness, reduced vibratory and position senses)

additional labs: serum folate level (normal), serum cobalamin level (low), test for anti-intrinsic factor antibodies, endoscopy and biopsy (r/t inc risk for GI cancer)

Nursing Management of Vitamin B12 Deficiency

treat underlying problem

death can occur w/in 1-3 yrs if not treated

replace cobalamin/B12: IM, intranasal, and diet modifications (REQUIRED FOR LIFE)

reduce risk for injury: fall prevention, physical therapy, protect the feet (paresthesia risk)

Folic Acid Deficiency

folic acid needed for DNA synthesis → RBC formation and maturation (megaloblastic anemia)

causes: chronic alcohol use, chronic hemodialysis, diet deficiency, medications (metformin and hemotomin), malabsorption syndromes (celiac disease, Crohn’s disease, small bowel resection), pregnancy due to inc requirement (folic acid prenatals)

clinical manifestations: similar to cobalamin deficiency, insidious onset, dysphagia, diarrhea, flatulence, cheilosis, stomatitis, neurologic symptoms )thiamine deficiency)

additional labs: serum folate (low) and serum B12 (normal)

Nursing Management of Folic Acid Deficiency

replacement therapy: PO, how long they need meds dependent on what cause is (alcoholics get folic acid for life)

consume foods high in folic acid: dark green leafy vegetables, enriched grain products and breakfast cereals, orange juice, peanuts, and beans

Aplastic Anemia

peripheral blood pancytopenia (decrease in all blood cells)

rare

can be moderate or severe (potentially fatal bleeding from lack of platelets)12

causes: autoimmune disorder (most common), exposure to drugs/toxins, radiation, toxic injury to bone marrow stem cells, inherited stem cell defect, viral/bacterial infections

clinical manifestations: abrupt or insidious onset, fatigue, dyspnea, neutropenia → susceptible to infection, thrombocytopenia → bleeding, risk for septic shock and death

additional labs: Hgb/WBCs/PLT (dec), reticulocyte count (dec), serum iron (inc), total iron binding capacity (TBIC) (inc), bone marrow biopsy

Nursing Management of Aplastic Anemia

identify/treat causitive agent

provide supportive care until pancytopenia resolves

prevent complications from infection and bleeding (neutropenic precautions: no plants/raw foods, gown and mask w/ pt)

if left untreated prognosis is VERY poor: treatment stem cell transplant; the less blood transfusions they receive the better their outcome

Anemia of Chronic Disease

develops 1-2 mnths after disease activity

causes: cancer, autoimmune disorders, HIV, hepatitis, malaria, heart failure, chronic inflammation, bleeding episodes

clinical manifestations: typically asymptomatic, low hgb can lead to symptoms, similar symptoms to other anemias

additional labs: normocytic/normochromic, serum ferritin (high), iron (low), serum folate (normal), serum cobalamin (normal)

Nursing Management of Anemia of Chronic Disease

treat chronic disease (prevent from getting worse)

healthy diet is important

blood transfusion

erythropoietin (EPO) therapy (help body make more RBCs)

• injected into skin, subcut, or IV

Anemia from Chronic Blood Loss

similar to iron deficiency anemia

causes: bleeding ulcer, Gi bleeding, hemorrhoids, menstrual/postmenopausal bleeding

main effect is chronically low iron stores

identify source and stop bleeding

treat iron deficiency w/ iron replacement

Anemia from Acute Blood Loss

sudden loss of volume due to:

• trauma

• surgical complications

• vascular rupture (AAA)

main complication = hypovolemic shock (develops quickly)

signs/symptoms (labs take a day or two to change so this is more important)

• hypotension

• tachycardia

• tachypnea

• dec urine output

• low O2 saturation

• weak peripheral pulses

• clammy and cool skin

• pallor

• obvious blood

• pain (abdominal)

• edema, welling, internal bleeding (bruising)

labs: H&H (may be normal 2-3 dys then dec), low RBCs

management: replace blood volume → prevent shock (fluids first to buy time to get blood), promoting coagulation → prevent more bleeding (replace w/ 1:1:1 RBC, plasma, plt), find and treat underlying cause, monitor vital signs, assessment, supplemental iron

Blood Component Therapy

type and cross (needs to be labeled correctly)

blood only good for 3-4 dys

informed consent

18-20 gauge IV for adults

verify patency of IV prior to requesting blood

once you get blood it needs to be hung w/in 30 min and must be infused w/in 4 hrs of getting to the unit (needs to be done in 4hrs)

Y type tubing with macroaggregate filter (150-260): blood on one side of Y, saline on the other)

RN cosign for product-to-patient verification

vital signs (baseline)

stay with patient for first 15 min or 50mL (when pt is most likely to have reaction)

reassess vital signs at 15 min

check pt every 30-60 min

Transfusion Reactions (Hemolytic reaction)

most common cause: transfusion of ABO incompatible blood

manifestations: fever, chills, back/abd/chest/flank pain, infusion site pain, inc HR, dsypnea, tachypnea, dec BP, hemoglobinuria, acute jaundice, dark urine, bleeding, AKI, shock, cardiac arrest, DIC, death

sentinel event

1. stop transfusion, maintain IV line w/ saline and stay w/ pt

2. notify blood bank and HCP

3. recheck identifying tags and numbers

4. monitor VS, u/o, treat per HCP

5. save blood bag and tubing, send to blood bank

6. collect ordered blood/specimens and document according to policy

Infusion of ABO-incompatible whole blood RBCs or components containing <10mL of RBCs (acute hemolytic reaction)

antibodies int he recipients plasma attach to antigens on transfused RBCs

s/s: fever (w/ or w/out chills), pain (back/abd/flank/chest), infusion site pain, inc HR, dyspnea, tachypnea, dec BP, hemoblobinuria, acute jaundice, dark urine, bleeding, acute kidney injury, shock, cardiac arrest, DIC, death

management: monitor/maintian BP w/ IV fluids, treat shock and DIC, draw blood samples, give prescribed diurets to maintain urine flow, insert indwelling cath, stop transfusing

prevention: verify and document pt ID from sample collection to product infusion, pre transfusion perform a 2-person ID for compatibility (just like meds but more stress)

Sensitivity to foreign plasma proteins (mild allergic reaction)

s/s: flushing, itching, hives

management: give ordered antihistamine/corticosteroid/epinephrine, w/ mild symptoms infusions can be restarted slowly w/ HCP’s order, do not restart if fever/pulmonary symptoms develop

prevention: prophylactic antihistamines/steroids and consider washed RBCs/plts

Sensitivity to donor plasma proteins (severe allergic reaction)

s/s: anxiety, abd pain, hives, dyspnea, wheexing, progressing to angioedema, bronchospasm, dec BP, shock, possible cardiac arrest

management: monitor VS, start CPR if needed, adminsister O2, have epi ready, give ordered antihistamines/corticosteroids/beta2agonists, do not restart transfusion

prevention: transfuse extensively washed RBC products (all plasma has been removed), use blood from IgA deficient donor, use autologous components

Fluid given faster than circulation can accommodate (circulatory overload)

people w/ heart or renal disease are at risk

s/s: cough, dyspnea, pulmonary congestion, adventitious breath sounds, headache, hypertensions, inc HR, distended neck veins

management: monitor VS, place pt upright w/ feet in dependent position, obtain chest x-ray, give prescribed diuretics and O2

prevention: adjust transfusion volume and flow rate based on pt size and clinical status, have blood bank divide future units into smaller aliquots for better spacing of fluid infused

Pt antibodies react to donor antigens present on WBCs*, plts, or plasma proteins or donor plasma antibodies react against cellular antigens in recipient’s blood (febrile, nonhemolytic reaction)

s/s: sudden chills, rigors, fever (raise of temp >1 degree C), headache, and vomiting

management: give antipyretics as prescribed (acetaminophen), do not restart transfusion unless HCP orders

prevention: consider leukocyte-reduced blood products

Massive blood transfusion reaction

can occur with replacement of 10 or more RBC units w/in 24 hrs

RCB transfusions do not contain clotting factors, albumin, and plts

s/s: hypothermia and dysrhythmias (rapid infusion of large quantities of cold blood), citrate toxicity and hypocalcemia (from citrate a storage solution and citrate binds to calcium), hyper/hypokalemia

management: monitor VS, labs and monitor clotting stat/electrolyte levels, monitor ECG for changes from electrolyte problems

prevention: use blood warming equipment, infuse ordered 10% calcium gluconate, platelets and plasma will also be given (counteract dilution effect of RBC transfusion)

Transfusion of bacterially infected blood components (sepsis)

s/s: rapid onset of chills, rigors, fever, vomiting, diarrhea, marked dec BP, shock

management: monitor VS, obtain blood cultures (and other tests), treat septicemia as directed (antibiotics, IV fluids, vasopressors)

prevention: collect, process, store, and transfuse blood products according to blood banking standards and complete transfusion w/in 4h of starting time

Transfusion-Related Acute Lung Injury (TRALI) reaction

b/w transfused antileukocyte antibodies and recipient’s leukocytes causing p. inflammation and capillary leak

leading cause of transfusion related deaths

occurs w/in 1-6 hrs of transfusion

s/s: fever, chills, hypotension, tachypnea, frothy sputum, dyspnea, hypoxemia, resp failure, noncardiogenic p. edema

management: monitor VS, provide O2, start CPR (if needed), draw blood for arterial blood gases and HLA (antileukocyte antibodies) to discern hemolysis or circulatory overload, obtain chest x-ray

prevention: provide leukocyte reduced products, blood bank personnel will identify donors who are implicated in TRALI reactions and not allow them to donate