Heme Flashcards
Anemia
A symptom (not a disease) caused by deficiency in the:
- # of RBC’s (erythrocytes)
- quantity of hgb and/ or
- volume of packed RBC’s (hct)
Caused by:
- blood loss
- RBC production problems (bone marrow problem)
- RBC destruction
Problem: decreased O2 to tissues and organs
-respiratory system is going to show first response when trying to compensate for anemia
How is anemia classified?
Size: MCV (mean corpuscular volume)
- microcytic: RBC is physically smaller, look at iron deficiency anemia
- normocytic: normal RBC
- macrocytic: RBC is larger than it’s supposed to be, folic acid and B12 deficiency
Color: MCH (mean corpuscular hgb)
- hypochromic: RBC is pale when looked at under the microscope, attributed to iron deficiency anemia
- normochromic: normal RBC
Or classified by underlying cause
Anemia - Elderly
elderly are prone to anemia, but being elderly is not a cause of anemia
- decreased # of stem cells but not decrease in function
- decreased reserve of any cell type leads to decrease response to illness
- WBC have decreased immune response to illnesses and therefore more likely to become ill (same with anemia, decreased # of RBC then they are going to have decreased response)
- Hgb decreases after middle age, reaches lowest point in elderly
- worse in institutionalized d/t nutritional intake (not as good and elderly don’t absorb as much) and comorbidities.
watch for GI bleed, as elderly are more prone to GI bleeds which can cause anemia
Anemia: S/O data
Pallor (severe anemia0
Cheilitis (infection of lips, swollen red patch in corner of mouth)
Glossitis (infection of tongue, looks smooth and glossy)
HA (not enough O2 to brain)
Pica in children could be caused by Fe def
Decreased appetite - esp in children
Brittle nails
Fatigue (milder symptom)
weakness
Coolness of hands and feet
palpitations and DOE (mild to moderate)
Dyspnea at rest (moderate anemia)
tachycardia, tachypnea, orthostatic hypotension (severe anemia)
may be asymptomatic with mild anemia
Blood level to check for anemia Hgb:
10-12 = mild anemia 6-10 = moderate <6 = severe anemia
blood transfusion given at 8-9
FA Def Anemia: S/O data
GI Sx: dyspepsia anorexia N/V abdominal pain
B12 Def Anemia: S/O data
CNS and Neuromuscular Sx: impaired thinking confusion dementia paraesthesias of hands and feet decreased sensation ataxia muscle weakness decreased proprioception
Anemia Nursing Dx:
activity intolerance r/t fatigue, weakness aeb increased pulse and respirations w/ activity
-outcomes -> tolerate ADL; vitals WNL
imbalanced nutrition r/t poor intake, anorexia aeb wt loss, low serum albumin, Fe
-outcomes -> body wt maintenance or increased Hct and Hgb, Albumin WNL
Hypoxemia r/t decreased hgb aeb dyspnea, decreased O2 sat, cyanosis/pallor
-outcomes -> no dyspnea, O2 sat WNL, skin color pink
B12 Def specific Dx:
risk for injury d/t muscle weakness and decreased sensation - more susceptible to burns
Iron (Fe) Deficiency Anemia: Cause
Insufficient Fe for hemoglobin synthesis
microcytic (small RBCs) or decreased RBC production
most common anemia in world (30%)
Iron (Fe) Deficiency Anemia: Risk Factors
more common in:
children
women in child bearing years (due to period)
populations with increased Fe need (teens and women with pregnancy)
Slow persistent blood loss (GI surgery due to crones disease, malabsorption syndromes like celiacs disease - not absorbing as much nutrients as we need to create healthy RBCs, GI bleed)
Alcoholism
Vegetarianism
Iron Def Anemia: Diagnostic Tests
CBC:
decreased hgb and hct
(Hgb: 10-14 = mild, 6-10 moderate, <6 = severe)
decreased MCV
decreased Ferretin <10 (measure iron storage)
decreased retic count (reticulocytes - displays immature RBCs)
decreased Fe
increased TIBC (total iron binding concentration - low in iron so ability to bind iron increases)
Iron Def Anemia - S/O data
test stool for occult blood called guiac (tells us if pt has GI bleed)
-melena: black appearance d/t iron in stool (means blood is higher in GI tract)
-at least 50-75ml blood loss in order to impact blood supply that we can dx with iron deficiency anemia
UA (dark brown and looking for blood in urine sample)
Endoscopy, colonoscopy (looking for bleed)
menstrual cycle info (average blood loss is 45ML in each cycle, if more than this pt at risk of developing anemia)
Iron Def Anemia: Plan/ Intervention
Medication therapy:
- ferrous sulfate: 150-200 mg/day 1 hour BEFORE meals to increase absorption, if tolerated (iron can be hard on stomach)
- take with vitamin C to increase absorption
- fiber decreases absorption (that’s why you take 1 hour before meals or 2 hours after)
- if liquid administration - may stain teeth (use straw and can mix with orange juice)
- takes 2-3 weeks to increase ferretin
- continue tx for at least 6 months even if you see increase (check labs in 2-3 weeks then 6 months to eval tx)
- Iv or Im administration d/t poor absorption of or intolerance of po form (usually for most severe cases)
- pt should also be started on stool softener or laxative as constipation is common
Megaloblastic Anemias:
a group of disorders caused by impaired DNA synthesis, characterized by:
-increased size of RBC (macrocytic), cells easily damaged d/t fragile membrane (so enlarged that they are fragile)
Two anemias in this category:
- folic acid (folate) deficiency
- pernicious anemia - cobalamin (Vit B12) deficiency
Folic Acid Deficiency
anemia d/t inadequate folic acid present for DNA synthesis leading to impaired formation and maturation of RBC
Labs:
- serum folate <5 mg/ml (abnormal; pt will be or have been dx w/ folic acid anemia)
- normal range: 5-25 mg/ml
Folic Acid Deficiency: Cause/Risks
- Poor nutrition - lacking fruits and veggies, grains (overcooking foods causing rich nutrients to leach out of foods)
- Malabsorption Syndromes (celiac, crohns)
- Increased demands during pregnancy and infancy
- chronic malnutrition such as alcoholism
- drugs that interfere with absorption (smoking, contraceptive, anti-seizure meds, methotrexate)
- cancer and RA pts have increased requirement (like pregnancy and infancy, meds cause interference of absorption)
- dialysis pt - FA is lost during tx
Folic Acid Deficiency: P/I
correct underlying cause
medication: folic acid replacement therapy
- folate 1 mg po/day up to 5mg if d/t malabsorption for 4 months then MVI with FA 0.4mg qd (if cause can’t be corrected or intake inadequate).
repeat labs q2 weeks for first 4 months than q month until stable
increase nutritional sources of FA
Folic Acid Def and B12 Def: Diagnostic Tests
decrease hgb, hct
increased MCV major deference with Iron def
normal retic count, Fe, TIBC
Decrease folate (FA Def)
Decrease cobalamin (B12)
if Dx w/ pern anemia going to do gastroscopy and biopsy to r/o gastric Ca
Schilling test - measure absorption of radioactive cobalamin (series of tests)
Schillings Test
series of tests done to measure absorption:
1st stage: radio labeled b12
2nd stage: IF with B12
3rd stage: two week course of antibiotics
4th stage: to give pt pancreatic enzymes
B12 Deficiency:
Vitamin B12 is a nutrient that helps keep the body’s nerve and blood cells healthy and helps make DNA
Cobalamin def has several causes and pernicious anemia (autoimmune) is the most common cause
Lack of IF means no absorption of Cobalamin (vit B12)
- IF normally secreted by parietal cells in gastric mucosa
- IF lost d/t gastric mucosal atrophy, autoimmune disease, lack of HCL acid (necessary for IF secretion), gastrectomy, small bowel resection involving ilium, IBD’s
- persons >40yrs
- esp northern europeans and african americans (at more risk b/c of increased # of people on meds in these populations that decrease gastric acid (H2 blockers, PPIs))
B12 Def - P/I
Assess for H2 Blocker or PPU use (discontinue use of these meds)
- decrease HCL in stomach (famotidine, ranitidine, omeprazole)
Cobalamin injections:
- 1000mg cobalamin (vitamin B12) Im daily x 2 weeks then weekly until hct normal, then monthly for life
-increase nutritional intake (eat liver - super high in b12)
-disease is fatal if not treated (1-2 yrs)
-if long term neuromuscular problems may be irreversible
-familial predisposition (evaluate for disease if FHx, important to Dx and Tx early b/c of neurological impairment)
-protect against burns and trauma d/t decreased sensation from neurological impairment
-life-long therapy required -compliance issues
-associated with gastric cancer (evaluate with EGD scope b/c higher risk for developing this cancer with b12 def)
Anemia of Chronic Disease
umbrella term to capture all other types of anemias caused by various diseases and other things going on with pt
many causes:
- kidney: lack of erythropoietin
- alcoholism: folic acid def
- chronic gastritis: blood loss
- liver disease/hepatitis
- chronic inflammation/malignancies
- endocrine disorders - hypothyroidism - associated with anemia
r/o other anemias: check Fe, Ferritin, folate, and cobalamin levels
tx: find cause
- transfusion rare unless severe
- erythropoietin therapy if anemia d/t renal and cancer therapies
Neutropenia
a reduction in neutrophils (>1000)
predisposes the pt to infection (often pts own flora)
common w/ chemotherapy and immunosuppressive therapy
normal signs of infection may not be present (As immune system isn’t working as well)
-low grade fever VERY significant as it may be only sign of infection
-neutropenic fever (greater than or equal to 38) and a neutrophil count <500 is a medical emergency as pt will not be able to fight off infection.
