Exam 2 - Heme

WBC normal range

5-10

RBC normal range

4.5-5.5

Hgb normal range

12-17.4

Hct normal range

36-52

MCV normal range

84-96

MCH normal range

28-34

MCHC normal range

32-36

Platelet normal range

140-400

RDW normal range

11.5-15.5

MPV normal range

7.4-10.4

Erythrocytes

RBC

-Reticulocyte = immature RBC produced in bone marrow and released into blood prematurely

-Carry hemoglobin to provide O2 to tissues

Leukocytes

WBC

-Protect the body from bacterial invasion

-Neutrophils arrive within 1 hour, then monocytes

Thromboycytes

Platelets

-Not technically cells, circulate freely, activate with vessel wall injury (hemostasis)

-Lifespan 8-11 days

-Aid in coagulation

Health History

-Ethnicity and family history

-Prior episodes of bleeding

-Nutritional/diet history

-OTC medications and supplements/herbal remedies

-Bleeding, clotting, miscarriages

-Fatigue and weakness, dyspnea, SOB

-History of radiation (pelvic) or chemotherapy (damage to lone bone bone marrow where RBC are made

-Hobbies/occupational/military exposure to toxins

-Alcohol consumption

Physical Assessment

skin, oral cavity, lymph nodes, respiratory, cardiovascular, genitourinary, musculoskeletal, abdominal, central nervous system, gynecologic

Megaloblastic anemia risk factors

deficiency in vitamin B12 (cobalamin) or folate (vitamin B9)

-Individuals who follow a strict vegan or vegetarian diet without B12 supplementation, older adults, and pregnant people

Folic acid deficiency risk factors

People with poor diets, high alcohol use, pregnant women

Diagnostics and Therapeutics

-CBC

-Coagulation studies

-Bone marrow aspiration and biopsy (diagnose iron deficiency)

-Splenectomy

-Apheresis (separates blood into its specific parts to remove something, and is then put back into the body once completed

-Therapeutic phlebotomy

what is anemia

decreased erythrocytes

-bottom line issue = decreased oxygen carrying capacity to tissues

development of anemia

the more rapidly anemia develops, the more severe the symptoms

-an otherwise healthy person can often tolerate as much as 50% gradual reduction in Hgb (months) without pronounced symptoms

-rapid loss of as little as 30% (minutes) may cause vascular collapse in the same person

-with gradual onset Hgb of 9-11 usually has no symptoms except dyspnea on exertion and tachypnea

3 classifications of anemia

hypoproliferative, bleeding, hemolytic

hypoproliferative anemia

defective RBC production

-megaloblastic → bone marrow produced abnormally large immature RBC due to impaired DNA synthesis

-decreased erythropoiesis → iron deficiency

-kidney disease

-inflammation

-aplastic → bone marrow fails to make enough RBC and platelets

-cancer/inflammation

bleeding anemia

blood loss

-GI tract, epistaxis, trauma, genitourinary

hemolytic anemia

altered erythropoiesis → could be from sickle cell disease or thalassemia (inherited blood disorder that prevents the body from making enough Hgb)

-G-6-PD deficiency → inherited, lack of G-6-PD enzyme, causing premature breakdown

-Hypersplenism (hemolysis) → spleen destroys RBC too soon

-Drug induced anemia

-Autoimmune anemia

-Mechanical heart valve

symptoms of anemia

-yellowing in eyes

-paleness, coolness, and yellowing of skin (paleness in skin represents blood loss or decreased RBC production; jaundice occurs bc cells are damaged and release pigment making kin and eyes yellow)

-SOB

-muscular weakness

-changed stool color

-fatigue, dizziness, fainting

-low BP, rapid HR, heart palpitations

-chest pain, angina, heart attack

-spleen enlargement

megaloblastic anemia

folate and B12 deficiency

-results in abnormally large erythrocytes which are usually destroyed before they even leave the bone marrow

-diagnosed by serum testing for levels

-B12 is only found in foods of animal origin

-folate is found in green leafy vegetables and liver (folic acid is a supplement, pregnant women take to prepare for increased blood volume)

folic acid deficiency

-Stored as compounds referred to as folates

-Depleted within months when intake is deficient or needs are increased

-Pregnant women (need for increased erythrocyte production)

-Folic acid deficiency in pregnancy women can lead to neural tube defects, such as spina bifida

-Alcohol increases folic acid requirements (patients who use alcohol typically have a diet deficient in folic acid)

B12 deficiency

pernicious (means to cause harm)

-meaning of pernicious anemia = absence of intrinsic factor normally secreted from gastric cells, B12 cannot be absorbed by the ileum

-malabsorption (crohn’s, gastrectomy, ileal resection, bariatric surgery, older populations)

-lack of intrinsic factor (this binds to B12 and takes it to the terminal ileum where it is absorbed, intrinsic factor antibody test)

-inadequate intake in strict vegans with no meat or dairy intake

-certain medications such as histamine blockers or antacids

symptoms of megaloblastic anemia: folate and B12

weakness, listlessness, fatigue, pallor

symptoms of megaloblastic anemia: B12 only

-neurological symptoms (myelin and spinal cord damage) → paresthesia, confusion, lack of proprioception

-pernicious anemia → smooth, sore red tongue

components of a hemogram

MCV, MCH, RDW, and MCHC

MCV

the average size of your RBC’s

MCH

mean cell Hgb

-the average mass of hemoglobin per RBC in a sample of blood

RDW

measure of the range of variation of RBC volume

MCHC

a measure of the concentration of hemoglobin in a given volume of packed RBCs

assessment of megaloblastic anemia

Tongue = beefy red and sore

Corner of mouth ulcerated = angular cheilitis

management of megaloblastic anemia

replace folate or vitamin B12

iron deficiency anemia

Results when the intake of dietary iron is inadequate for Hbg synthesis

-most common in all age groups

-1 in 8 people worldwide

-common in vegetarians, gastrectomy, celiac disease, weight loss surgery

-developing countries (inadequate iron rich foods, intestinal parasites)

-united states (blood loss in perimenopausal women, men, and postmenopausal women)

-blood loss uses up iron stores (chronic alcohol use with GI tract blood loss)

symptoms of iron deficiency anemia

-smooth, sore tongue

-angular cheilitis

-brittle ridged nails

-low serum ferritin levels (iron stores are depleted)

-MCV decreased (decreased iron stores cause production of small RBC)

-Hgb, Hct, and RBC low

Nursing diagnoses regarding iron deficiency anemia

-Fatigue r/t Hgb and diminished oxygen carrying capacity of the blood

-Imbalanced nutrition, less than body requirements, r/t inadequate intake of essential nutrients

-Activity intolerance related to inadequate hemoglobin and hematocrit

-Noncompliance with prescribed therapy

how to diagnose iron deficiency anemia

-Bone marrow aspiration is definitive, but rarely done (invasive and painful)

-Diagnosis can be made on summation of symptomatic history and iron studies

-Stool for occult blood

treatment of iron deficiency anemia

-oral iron supplement → take on empty stomach, don’t take with antacids/dairy/calcium, constipation or darken stools, vitamin C may increase absorption, iron stores take 6-12 months

-IV iron → small test dose to rule out anaphylaxis, epinephrine on hand

-IM iron → rare, use Z-track method to avoid skin stain

Anemia in ESRD

-Erythropoietin deficiency

-Blood loss thru dialysis machines

-Folate is dialyzed out

-treatment = Procrit or Epogen (iron supplements, try to maintain Hgb 11-12)

hemolytic anemia

erythrocytes have shortened lifespan

-hemoglobin broken down

-80% of heme is converted to unconjugated bilirubin

-lab results will show an elevated retic count, unconjugated bili is increased, leading to jaundice

-reticulocyte count elevated (immature RBCs)

inherited vs. acquired hemolytic anemia

inherited = sickle cells anemia, thalassemia, thalassemia major, G-6-PD deficiency

acquired = autoimmune hemolytic anemia, non immune-mediated hemolytic anemia, heart valve hemolysis, hypersplenism

secondary polycythemia

excessive production of erythropoietin

-may be caused by chronic hypoxia

-heavy smoking, COPD, OSA, high altitude, carbon monoxide exposure

secondary polycythemia s/sx and treatment

s/sx = rudder/redness, pain in hands and feet

treatment = reduce stimulus, therapeutic phlebotomy (500 mls once or twice a week)

causes of neutropenia

-Aplastic anemia from toxins or medications

-Metastatic cancers

-Myelodysplastic syndromes

-Chemotherapy

-Radiation therapy

-Risk for infection from exogenous and endogenous

-If pt is taking corticosteroids, that may not generate a fever with infection

neutropenia

neutrophil count less than 2000

-ANC (absolute neutrophil count)

-ANC less than 500 → high risk

-ANC less than 100 → greatest risk

treatment of neutropenia

depends on the cause

-Culture blood, urine, sputum, and XR

-Broad spectrum AB until the organism is identified

neutropenic precautions at the hospital

• assess

• report s/sx of infection

• culture and sensitivity

• private room with WBC less than 1000

• no sick visitors

• no rectal or vaginal procedures

• stool softener

• hygiene

• food hygiene and safe food handling

• change water pitcher, respiratory equipment containing water, denture cleaning fluids

neutropenic precautions at home

• hand, oral, and body hygiene

• skin integrity

• avoid birdcages and litter boxes

• consider avoiding gardening (soil) and fresh flowers in stagnant water

• high calorie and protein diet, 3L fluid unless otherwise restricted

• avoid crowds and sick people

Platelets

-Spleen holds about 1/3 of circulating platelets

-Primarily responsible for hemostasis from small vessels

-Lifespan of 8-11 days

-Low platelet count can lead to petechiae

thrombocytopenia

low platelet level

-reduced production (give platelets)

-increased destruction (treatment is splenectomy)

-increased consumption

-spontaneous bleeding/petechiae range 20-50

-risk for fatal hemorrhage less than 5

-risk of bleeding at higher count if platelets are dysfunctional from ASA or MDS

-# of platelets does not equate to clotting ability

primary thrombocytopenia

-Stem cell disorder within bone marrow

-Marked increased in platelets greater than 600,000 (may be dysfunctional)

-Affects women twice as much as men

-Median age of onset is 65-70

-May be asymptomatic until platelet count is greater than 1 million

-Hemorrhage (dysfunctional platelets) or vascular occlusion in deep veins and micro circulation

-Headaches*, TIAs, DVT, PE

quantitative platelet defects

thrombocytosis = elevated count

thrombocytopenia = decreased count

qualitative platelet defect

platelets are dysfunctional

medical management of platelet defects

eliminate precipitating cause, stop medication that is contributing, platelet transfusion

nursing management of platelet defects

OTC medication teaching, avoiding alcohol, notify healthcare providers

nursing interventions for thrombocytopenia

• No ASA

• No IM injections

• No catheters

• No rectal anything

• Ambulate with the pt

• Electric razors

• Stool softeners

• Smallest needle possible

• No flossing

• Lib lubricant

• Gentle suctioning