Quiz 5 RBC Disorders, Upper GI, Lower GI

N220 Pathophysiology Spring 26 Week 9, 10, 11

What is the purpose of a Complete Blood Count (CBC)?

Use the values to assess and identify any abnormalities

• Blood Cells Quantity (RBCs, WBCs, PLTs)

• Oxygen Carrying Capacity

• RBC Morphology

• Blood Disorders

What are the 4 main values of CBC? What are normal values of each one?

• WBC (white blood cells

• RBC (red blood cells)

• Hgb (hemoglobin)

• Hct (hematocrit)

What are the 4 main values of CBC? Description & What are normal values of each one? (WBC)

Description: Total white blood cell count

Normal Value: 5,000 - 10,000 / mm³

What are the 4 main values of CBC? Description & What are normal values of each one? (RBC)

Description: Total Mature Red Blood Cell Count

Normal Value: 4.5 - 5.5 / mm³

What are the 4 main values of CBC? Description & What are normal values of each one? (Hgb)

Description: Total hemoglobin level

Normal value: 14-17 g/100 mL

What are the 4 main values of CBC? Description & What are normal values of each one? (Hct) What is abnormal Hct?

Description: Proportion of RBCs to plasma

Normal value: 42 - 52%

Anemia: Depressed hematocrit %

Polycythemia: Elevated hematocrit %

Explain Erythropoiesis & how red blood cells (RBCs) are monitored?

Process which produces red blood cells (erythrocytes) and monitored by the Complete Blood Count (CBC)

Define Anemia and how does it affect the tissues?

• Deficit of mature, healthy RBCs in circulation

• Insufficient delivery of O2 to the tissues

Define Polycythemia

Over-proliferation of RBCs in the bone marrow

What is hematopoiesis? What are the two stages?

• Hemostatic process

• Bone marrow stem cells → Differentiate blood cells

• Two stages: Proliferation & Maturation

  • Proliferation: “-poietin” → suffix for growth or multiplication of specific cell types

  • Maturation: Bone marrow stem cells mature to WBCs, RBCs, PLTs

What is purpose of RBCs

Most numerous cell type in circulation: Transporters

• Deliver O2 to tissues via hemoglobin chains

• Remove CO2 from tissues for release via lungs

Where are RBCs made, lifespan, and what’s it made of

Manufactured in bone marrow by stem cells

• Lifespan = 120 days

• Reticulocytes: Immature RBCs

More than one third of an RBC is made of hemoglobin

• Heme: red pigment, contains iron

• Globin: protein chain

What is Erythropoiesis? What is it stimulated by? What adequate nutrition does it need?

Process which produces red blood cells (erythrocytes)

Stimulated by decreased O2 in circulation

• Detected by the kidneys which then secrete the hormone erythropoietin

• Triggers bone marrow to produce more RBCs

Requires adequate

• Protein

• Vitamin B12

• Iron

• Folic Acid

What are stages of Erythropoiesis?

1. Kidneys secrete Erythropoietin

   1. Bone marrow stem cell → myeloid stem cell

2. Proerythroblast → Erythroblast

   1. Huge nucleus

   2. Hemoglobin synthesis begins this phase

3. Normoblast

   1. Nucleus shrinks

   2. Hemoglobin quantity increases

4. Reticulocyte

   1. Nucleus ejected

   2. Erythrocyte within 24 - 48 hours

   3. Remain in bone marrow ~ 1 day → released into circulation

   4. Reticulocytes are indication of erythropoietic activity

What organ recycles aged, lysed and dead RBCs? What is it broken down into? Where is it stored?

• Spleen

• Broken down into component parts

  • Iron

  • Bilirubin

• Recycled to make new RBCs, stored in liver or secreted as waste

  • May cause problems for liver, spleen

Complete Blood Count; Description & Normal Value for MCV

Description: Average red blood cell size

Normal Value: 78 - 100 µm³

Complete Blood Count; Description & Normal Value for MCH

Description: Amount of Hgb present per cell

Normal value: 25 - 35 pg

Complete Blood Count; Description & Normal Value for MCHC

Description: Proportion of cell occupied by Hgb

Normal value: 32 - 36 %

What is RBC morphology? What are the different categories?

Categorized RBC based on appearance on peripheral blood smear

• Normocytic

• Normochromic

• Microcytic

• Hypochromic

• Megaloblastic

Normocytic

Normal cell size

Normochromic

Normal amount of Hgb

Microcytic

Small cell size

Hypochromic

Reduced amount of Hgb

Megaloblastic

Abnormally large, immature and dysfunctional cells

What is Folic Acid (Folate) necessary for?

Necessary for RBC production

What is Vit B12 necessary for?

Necessary for RBC production

What is Iron needed for?

Needed for Hgb production

Review Question: Red blood cells differ from other cell types in the body because they

A. Contain cytoplasmic protein

B. Have no cytoplasmic organelles

C. Have a longer life span

D. Contain glycolytic enzymes

B. Have no cytoplasmic organelles

The primary source of erythropoietin is the

A. Bone marrow

B. Kidney

C. Lung

D. Liver

B. Kidney

What are the Anemia Etiologies?

Relative Anemia

• Hemodilution

  • concentration of RBCs low because plasma has increased, RBC count is normal, the plasma is just too much that it dilutes

Absolute Anemia

• Insufficient production

  • bone marrow cannot produce enough RBCs to meet needs

• Extrinsic loss of destruction

  • Trauma or surgery; bleeding out; RBCs destroyed faster than produced

• Inherited disorder

  • Genetic mutation; abnormal hemoglobin or misshapen cells

General effects (Clinical Implications) of Anemia

• Reduction in oxygen carrying capacity

  • Tissue hypoxia (tissues don’t get enough oxygen)

  • Hypercarbia (elevated CO2 levels)

• Compensatory mechanisms to restore tissue oxygenation

  • Increased cardiac output and flow to vital organs

  • Enhanced unloading of oxygen by hemoglobin in tissues

  • Increase in erythropoietin activity

• Increased Oxygen demands

Anemia General S/S; Mild, Moderate, Severe

Mild

• Usually no clinical symptoms

Moderate

• Fatigue, generalized weakness, loss of stamina

• Tachycardia and exertional dyspnea

Severe

• Hypotension, vasoconstriction, pallor

• Tachypnea, dyspnea

• Tachycardia, angina pectoris, heart failure

• Intermittent claudication, night cramps in muscles

• Headache, lightheadedness, faintness

• Tinnitus, roaring in the ears

• Enlarged spleen

What CONDITIONS cause Insufficient RBC production?

• Iron Deficiency Anemia

• Folic acid Deficiency

• Pernicious Anemia

• Aplastic Anemia

• Chronic Reneal Failure

Iron Deficiency Anemia: Etiology

Insufficient iron for hemoglobin synthesis

• Abnormally small RBCs unable to carry sufficient O2 to tissues

Iron Deficiency Anemia: Pathogenesis

Leads to production of abnormally small RBCs that are unable to carry sufficient O2 to tissue

• Hypochromic RBCs

• Microcytic RBCs

Iron Deficiency Anemia: Risk Factors

Demographic

• Elderly

• Female

• Pregnancy

Diet

• Vegan/vegetarian

• Low Vit C

• Poor dentition

• Bowel disease

• Cancer

Social

• Poverty

• ETOH overuse (Alcohol overuse)

• Stress

• Depression

Iron Deficiency Anemia: Clinical Manifestations

• General S/S of Anemia (gradual onset)

• PICA (craving nonfood substances)

  • Dirt, clay, ice, laundry starch, cardboard, hair

• Koilonychias (spoon shaped nails)

• Blue sclerae (white part of eye appears blue)

Iron Deficiency Anemia: Treatments

Treat underlying cause

• Iron (Fe) replacement

  • Iron supplement tablets

  • Ferrous Sulfate elixir

  • Iron Sucrose Injection

Foods that ENHANCE Iron absorption

• Citrus fruits

• Tomatoes

• Chili peppers

Foods that IMPAIR iron Absorption

• Tea

• Cereal (if it contains phytates)

Iron Deficiency Anemia: Nursing Considerations

Monitor for Fe replacement side effects

• Nausea

• Black stools

• Teeth staining

• Pain upon injection and can cause Orthostatic hypotension (IV forms)

Beware of Iron Toxicity

Folic Acid Deficiency Anemia: Etiology

• Inadequate Intake

  • Limited consumption of fresh, minimally cooked food

  • ETOH (alcohol) overuse

• Malabsorption

  • Malabsorption syndrome (E.g. Celiac Disease)

  • Inflammatory bowel disease (E.g. Crohn’s Disease)

  • Gastric Surgery

• Increased Demand

  • Pregnancy

  • Lactation

  • Infancy

  • Cancer

  • Hemodialysis

Folic Acid Deficiency Anemia: Pathogenesis

Deficiency causes formation of megaloblasts

• Very similar to Vit B12 deficiency

Folic Acid Deficiency Anemia: Risk Factors

• Inadequate Intake

  • Limited consumption of fresh, minimally cooked food

  • ETOH (alcohol) overuse

• Malabsorption

  • Malabsorption syndrome (E.g. Celiac Disease)

  • Inflammatory bowel disease (E.g. Crohn’s Disease)

  • Gastric Surgery

• Increased Demand

  • Pregnancy

  • Lactation

  • Infancy

  • Cancer

  • Hemodialysis

Folic Acid Deficiency Anemia: Clinical Manifestations

• General S/S of Anemia

• Malnutrition

• Depression

• Forgetfulness

• Painful ulcerations of cheeks and tongue

• Fissuring of lips and mouth

Folic Acid Deficiency Anemia: Treatments

• Folic Acid Supplements

• Dietary Sources of Folate (Vit B9)

  • Spinach

  • Asparagus

  • Avocado

  • Broccoli

  • Eggs

  • Milk

  • Bread & Pasta

  • Etc….

Folic Acid Deficiency Anemia: Nursing Considerations

• Associate low folate with neural tube deficits (spina bifida) in infants

Vitamin B12 Anemia: Etiology

• Inadequate intake

• Malabsorption

• Genetic Mutation

  • Intrinsic factor deficiency (pernicious)

Vitamin B12 Anemia: Pathogenesis

• Disruption in DNA synthesis of blast cells;

• RBCs cannot be properly synthesized → Megaloblastic RBCs

  • Poor oxygen carrying capacity

Vitamin B12 Anemia: Risk Factors

Malabsorption

• Gastritis

• Gastrectomy

• Crohn’s Disease

Inadequate Intake

• Veganism

• ETOH overuse

Genetic Mutation

• Intrinsic factor deficiency (pernicious)

Vitamin B12 Anemia: Clinical Manifestations

• General S/S of Anemia

• Brain fog memory issues, lack of motivation or prolonged feelings of apathy

• Mood swings and grouchiness

• Fatigue, low energy

• Neuropathy (tingling in extremities)

• Muscle weakness

• Depression, dementia, blindness, or brain damage

Vitamin B12 Anemia: Treatments

• Treat underlying cause

  • B12 Supplements or B12 Rich diet

• Cyanocobalamin (Vitamin B12)

  • Usually administered via IM injection

  • Also available in PO and intranasal spray

Vitamin B12 Anemia: Nursing Considerations

• Patient education on dietary sources of B12

Aplastic Anemia: Etiology

Caused by toxic, radiant or immunologic injury to the bone marrow stem cells

• Diagnosed via bone marrow biopsy

  • 10-15% of severe aplastic anemia cases evolve into myelodysplastic syndrome and leukemia

Aplastic Anemia: Pathogenesis

Stem cell disorder characterized by reduction of hematopoietic tissue, fatty marrow replacement and pancytopenia

• Damaged bone marrow and hematopoietic stem cells are unable to sufficiently produce mature cells

  • Low WBCs

  • Low Plts

  • Low RBCs

  • Low Retic count (indicates failure of bone marrow response)

Aplastic Anemia: Clinical Manifestations

Onset of S/S may be abrupt or insidious

• General S/S of anemia due to low RBCs

• Additional S/S include those to low Plts (bleeding)

• May also include S/S due to low WBCs

Aplastic Anemia: Treatments

• Blood Transfusions

  • RBCs, PLTs, Plasma

• Bone Marrow Transplants

• Bone Marrow Stimulants

  • NEUPOGEN (Stimulates WBC production)

  • EPOGEN or ARANESP (Stimulates RBC production)

• Prophylactic antibiotics

Aplastic Anemia: Nursing Considerations

Precautions to minimize risk for injury, blood loss, and infection

Chronic Renal Failure: Etiology

Impaired renal endocrine function

Chronic Renal Failure: Pathogenesis

Decreased erythropoietin production leads to decreased RBC production

Chronic Renal Failure: Risk Factors

Long term hemodialysis

Chronic Renal Failure: Clinical Manifestations

• General S/S of anemia

• Normocytic

• Normochromic cells

Chronic Renal Failure: Treatments

• Epogen

• Aranesp

• May also require PRBC transfusions

Chronic Renal Failure: Nursing Considerations

Monitor and assess for signs of Renal Failure when long-term hemodialysis

Blood Work: Signs of Iron Deficiency Anemia

• Hypochromic, Microcytic RBCs

• Low MCV, MCH, and MCHC

• Serum ferritin level decreased

• Serum Iron level decreased

• Total Iron binding capacity (TIBC) increased

Blood work: Sign of Vitamin B12 Anemia

• Megaloblastic (enlarged, oval shaped)

• Serum B12 decreased

• Serum Folate decreased

Blood Work: Signs of Folic Acid Deficiency Anemia

• Serum Folate <4 ng/mL

• Low Hgb/Hct level

Blood Work: Signs of Aplastic Anemia

• Low WBCs

• Low Plts

• Low RBCs

• Low Retic count indicates failure of marrow response

Blood work: Sign of Chronic Renal Failure

• Leads to decreased RBC production

• Normocytic, Normochromic

• Low EPO levels

• General S/S Anemia

Extrinsic RBC loss/destruction conditions

• Hemorrhagic Anemia

• Hemolytic Anemia

Hemorrhagic Anemia Etiology (Acute & Chronic)

Acute

• Moderate to large volume of total circulating blood loss in short time period

  • Surgery

  • Trauma

  • Acute GI bleed

Chronic

• Small to moderate volume of total circulating blood loss over long time period

  • Menorrhagia

  • Chronic GI bleed

Hemorrhagic Anemia Pathogenesis (Acute & Chronic)

Deficiency in total circulating blood volume Acute or Chronic

Hemorrhagic Anemia Risk Factors (Acute & Chronic)

Acute

• Surgery

• Trauma

• Acute GI bleed

Chronic

• Menorrhagia

• Chronic GI bleed

Hemorrhagic Anemia Clinical Manifestations (Acute & Chronic)

Stages of Hemorrhagic Shock

Mild: (<20% Blood Volume Loss)

• Cool Extremities

• Pallor

• Diaphoresis

• Increased capillary refill time

• Anxiety

Moderate: (20-40% Blood Volume Loss)

• Tachycardia

• Tachypnea

• Oliguria

• Orthostatic Hypotension

• Confusion or Lethargy

Severe: (>40% Blood Volume Loss)

• Severe tachycardia

• Severe hypotension

• Hemodynamic instability

• Obtunded or Comatose

Hemorrhagic Anemia Treatments (Acute & Chronic)

• Treat underlying cause

• Transfusion of blood products

Hemorrhagic Anemia Nursing Considerations (Acute & Chronic)

• Monitor Closely for changes from baseline

• Mental status changes can be early sign

• Correlation between palpable pulses and systolic BP

Hemolytic Anemia Etiology

Implanted Devices (Mechanical)

• Mechanical heart valves

• Cardiopulmonary bypass machines

Immune Response (Autoimmune response)

• Transfusion reaction to incompatible blood type

• Hemolytic disease of the Newborn

Hypersplenism (Organ Dysfunction)

• Long term or excessive ETOH ingestion

• SLE

• RA

Substances (Chemical)

• Snake venom

• Hypotonic infusion

• Chemicals (arsenic)

• Heavy metals (lead)

• Infection (malaria)

Hemolytic Anemia Pathogenesis

RBCs are destroyed faster than they are replaced

Hemolytic Anemia Risk Factors

Malaria infection

Transfusion reactions

Hypersplenism (SLE, RA)

Mechanical Heart Valves

Cardiopulmonary bypass machines

Hemolytic Anemia Clinical Manifestations

S/S vary mild or severe

• Dark or bloody urine

• Jaundice

• Splenomegaly

Hemolytic Anemia Treatment

• Treat underlying cause

• Transfusion of blood products only when critically necessary

Blood Work: Signs of Hemorrhagic Anemia

• Low RBC level

• Normocytic, Normochromic

• Low Hgb/Hct levels

Blood work: Signs of Hemolytic Anemia

• Low RBC level

• Low Hgb/Hct levels

• Elevated Reticulocyte count

What are the inherited blood anemia disorders?

Sickle Cell Anemia

Thalassemia

Sickle Cell Anemia: Etiology

Inherited genetic mutation

• African American, Arab, Asian descent

Sickle Cell Anemia: Pathogenesis

Abnormal HGB (hemoglobin) production resulting in decreased O2 carrying capacity

Misshaped RBCs leading to increased RBC hemolysis (destruction)

• Dysmorphic

Sickle Cell Anemia: Risk Factors

• Genetics, family hx

• Ancestry

Sickle Cell Anemia: Clinical Manifestations

• May be asymptomatic

• General S/S anemia

• Jaundice

• Pain episodes (mild to severe)

• Splenomegaly

• Stunted growth

Sickle Cell Anemia: Treatment

Rx to prevent RBC sickling

• Voxelotor

• Hydroxyurea

Folic Acid Supplement

Reduce Risk for exacerbation (SCC)

• Vaccinations

Allogenic Bone Marrow Transplant

Gene Therapy (limited availability)

Sickle Cell Anemia: Nursing Consideration

SCD Crisis Management

• Identify and treat cause

• Pain management

• Supplemental O2

• Blood transfusions

• Hydration

What is polycythemia? What are the two types of conditions?

Excess production of blood cells

• Polycythemia vera (Primary)

• Induced Polycythemia (Secondary)

Polycythemia Vera: Etiology

Idiopathic genetic mutation

Polycythemia Vera: Pathogenesis

Genetic mutation of bone marrow stem cells causes overproduction of RBCs, WBCs, and PLTs

Polycythemia Vera: Risk Factors

• Viruses

• Autoimmune

Polycythemia Vera: Clinical Manifestations

Usually insidious onset of S/S

• Pruritus

• HA

• Weakness

• Fatigue

• Dyspnea

• Dizziness

• Visual disturbances

• Weight loss

• Enlarged spleen

• Abdominal discomfort

• Erythromelalgia

  • Increased PLT aggregation → tiny blood clots in extremities vessels

Polycythemia Vera: Treatment & Nursing Considerations

• Therapeutic phlebotomy

• Radiation

• Chemotherapy

• Interferon alpha: off label use now being researched

Secondary Polycythemia: Etiology

Chronic hypoxia

Secondary Polycythemia: Pathogenesis

Compensatory response to chronic hypoxia causes overproduction of erythropoietin → high RBC levels

Secondary Polycythemia: Risk Factors

• High altitude

• Lung Disease (COPD, ILD)

• Renal tumors

• Heart failure

Secondary Polycythemia: Clinical Manifestations

Usually insidious onset of S/S

• Pruritus

• HA

• Weakness

• Fatigue

• Dyspnea

• Dizziness

• Visual disturbances

• Weight loss

• Enlarged spleen

• Abdominal discomfort

• Erythromelalgia

  • Increased PLT aggregation → tiny blood clots in extremities vessels

Secondary Polycythemia: Treatment & Nursing Considerations

• Treat underlying cause

• Admin O2

Blood Product Administration S/S

Monitor closely for S/S of transfusion reaction

• Urticaria

• Pruritis

• Fever/Chills

• Respiratory Disease/Dyspnea

• Hypotension

• Hematuria