ANEMIA

PRE TEST
1. A 25 yr old G3 P3 female presents with a
history of fatigue, ice craving and dyspnea
upon exertion. She was unable to tolerate her
prenatal vitamins during pregnancy, because
of nausea. Examination reveals pallor and
spooning of her nails. Laboratory examination
reveals low hgb and hct, low MCV and MCH,
high RDW, low Ferritin level, high TIBC level
2. A 35 year old woman comes to the office because of
generalized weakness and a “pins and needles” feeling
in her lower extremities for the past 3 weeks. She
states that she feels “unsteady” on her feet. She
exercises daily, rarely drinks alcohol, and a vegan.
Since this is the first time you have met this woman,
she tells you that she has not had any major illnesses,
but has been hospitalized multiple times over the past
few years for anorexia nervosa. Examination shows
weakness of the proximal and distal muscles of the
lower extremities. There is impaired propioception
and vibratory sensation. The gait is ataxic. Diagnostic
results are the ff: low hgb and hct, blood smear
showed high MCV and polynucleated neutrophils and
decreased Schilling test
3. A 46 year male is seen by her family physician
because she is feeling poorly. The patient has
a known history of Rheumatoid Arthritis.
Physical Examination showed pallor of the
skin and mucosal membranes. Diagnostic
examinations are the following: increased in
serum Hepcidin, decreased TIBC and EPO
level, there is also an decrease serum
transferrin
4. A 30 yr old patient comes in an OPD clinic
complaining of headache and dizziness. He is
known to have seizure disorder as a complication
of Meningitis when he was 3 years old. He has a
maintenance medication of Phenytoin 100mg
every 8 hours. Upon examination, the nurse notes
an increase in respiratory rate and pulse rate. The
patient verbalized he had episodes of dyspnea
and chest pain in performing ADL’s. Significant
Diagnostic examination revealed low hgb and hct,
high MCV, Polynucleated Neutrophils
 OBJECTIVES
• At the end of the lecture the students
– Will be able know different types of anemia in
terms of their specific clinical manifestations
– Will be able to identify anemia according to the
results of different diagnostic examinations
– Will be able to construct NCPs for each types of
anemia
 REVIEW
• Blood – components and functions
• RBC index – hct/hgb/rbc
• Hematopoeisis – formation of blood
• Erythropoeisis – formation of RBC
• Leukopoesis – formation of WBC
• Thrombopoeisis – formation of platelets
 ANEMIA INDICATORS
1. Packed Cell Volume (PCV) / Hct Vol in a given blood occpd by RBC when packed

2. RBC count Number of RBC in a given volume of blood

3. Hb/Hgb concentration Total amount of Hb in a given volume of RBC .

4. Mean Corpuscular Volume (MCV) Average volume of RBC

5. Mean Corpuscular Hb (MCH) Average amount of Hb in RBC

6. Mean Corpuscular Hb Concentratiion (MCHC) Concentration of Hb in a given volume of RBC

7. Normocytic cells Normal sized cell

8. Microcytic cells Small sized cell

9. Macrocytic cells Large sized cells

10. Normochromic cells Normal color or normal degree of hemoglobinization

11. Hypochromic cells Less degree of hemoglobinization

12. Hyperchromic cells High degree of hemoglobinization

13. Red cell Distributive Width Variations in the size of the cells
 ANEMIA

BASIC PRINCIPLES:
1. More proliferative to less proliferative
2. Nuclear maturation
3. Cytoplasmic maturation
 ANEMIA ACCDG TO WHO
Population Normal Hb Mild Anemia Moderate Severe Anemia
Anemia
6 – 59 months > 11.0 10.0 – 10.9 7.0 – 9.9 < 7.0

5 – 11 years old > 11.5 11.0 – 11.4 8.0 – 10.9 < 8.0

12 – 14 years old > 12.0 11.0 – 11.9 8.0 – 10.9 < 8.0

Non Pregnant > 12.0 11.0 – 11.9 8.0 – 10.9 < 8.0
> 15 years old
Pregnant > 11.0 10.0 – 10.9 7.0 – 9.9 < 7.0

Men > 13.0 11.0 – 12.9 8.0 – 10.9 < 8.0

> 15 years old
DIFFERENT TYPES OF ANEMIA
Macrocytic,
Megaloblastic
Anemia (B12 & B9)

Decreased Red cell Microcytic (Iron

production Deficiency) Anemia

Normocytic (Aplastic
Increased Red cell
ANEMIA Anemia & Anemia of
destruction
Chronic Disease)

Blood loss
MACROCYTIC MEGALOBLASTIC
ANEMIA

1. FA DEFICIENCY
2. VIT B 12 DEFICIENCY
FOLIC ACID DEFICIENCY ANEMIA
FOLIC ACID RICH FOODS
 VIT B 9 DEFICIENCY CAUSES
REDUCED INTAKE INCREASED DEMAND IMPAIRED
(MOST COMMON) (MOST COMMON) ABSORPTION

FOOD PREFERENCE PREGNANCY ALCOHOL INTAKE

DRUGS –
HEATING LACTATION SULFA/PHENYTOIN
RAPID GROWTH ORAL CONTRACEPTIVE
SPURTS PILLS

IDA

HEMOLYTIC ANEMIA

CA CELLS
VIT B9 DEFICIENCY SIGNS/SYMPTOMS
VIT B 9 DEFICIENCY ANEMIA LAB
FINDINGS

DECREASED
CBC – LOW HCT CBC – LOW HGB
SERUM B9 LEVEL

CBC – LOW RBC CBC – HIGH MCV CBC – NORMO TO

COUNT MACROCYTIC HYPERCHROMIA

CBC –
BONE MARROW –
HYPERSEGMENTED PANCYTOPENIA
MEGALOBLASTIC
NEUTROPHILS
VIT B9 DEFICIENCY TREATMENT

FA SUPPLEMENT
FOLIC ACID RICH
OF 4-5MG DAILY
FOODS
PO

FA PARENTERAL
1MG/DAY FOR 1
WEEK
VIT B9 DEFICIENCY TREATMENT
1 HOUR BEFORE
OR 2 HOURS AFTER NAUSEA
MEALS

LOSS OF APPETITE BLOATING

BITTER OR
UNPLEASANT
MOOD CHANGES
TASTE IN THE
MOUTH

DON’T GIVE IN
LARGE DOSES
VIT B 12 DEFICIENCY
VIT B12 RICH FOODS
 VIT B12 DEFICIENCY CAUSES
IMPAIRED ABSORPTION
REDUCED INTAKE INCREASED DEMAND
(MOST COMMON)

GASTRECTOMY
VEGAN DIET UNCOMMON
INTAKE OF CORROSIVES
BREASTFED BABY W/
VEGAN MOTHER ELDERLY - ACHLORHYDRIA
PT W/ PEG OR
GASTROSTOMY TUBE
PANCREATITIS
TAPE WORM INFESTATION

BACTERIAL OVERGROWTH

PERNICIOUS ANEMIA DEFECTIVE ILIUM –

SPRUE/CROHN’S/TB/SX
(MOST COMMON)
 PERNICIOUS ANEMIA
• Macrocytic, megaloblastic anemia……….
due to Vit B12 deficiency…………
due to IF deficiency……….
w/c must be due to…….
AUTO IMMUNE destruction of gastric fundus mucosa.
• Common after age 40 ---- 60 to 80 years old
• SISTER DSES THAT RUN IN THE FAMILY
– Hashimoto thyroiditis
– Autoimmune Addison’s dse
– Vitiligo
VIT B12 DEFICIENCY S/Sx
 VIT B 12 DEFICIENCY ANEMIA LAB
FINDINGS

DECREASED SERUM CBC – LOW RBC

CBC – LOW HCT CBC – HIGH HGB
B12 LEVEL COUNT

CBC –
CBC – HIGH MCV CBC -
HYPERSEGMENTED PANCYTOPENIA
(macrocytic) HYPERCHROMIA
NEUTROPHILS

BONE MARROW –
SCHILLINGS TEST
MEGALOBLASTIC
 SCHILLING TEST

1. ORAL RADIO LABELED B 12

1. ORAL RADIO LABELED B 12 1. ORAL RADIO LABELED B 12 2. IM B12
2. IM B12 3. COLLECT URINE X 24 HOURS
2. IM B12
3. COLLECT URINE X 24 HOURS 4. B12 +IF
3. COLLECT URINE X 24 HOURS 4. B12 +IF 5. COLLECT URINE X 24 HOURS
6. AB/ANTI PARASITIC X 7DAYS
5. COLLECT URINE X 24
7. B12, THEN COLLECT URINE X 24 HOURS

1. ORAL RADIO LABELED B 12 1. ORAL RADIO LABELED B 12

2. IM B12 2. IM B12
3. COLLECT URINE X 24 HOURS 3. COLLECT URINE X 24 HOURS
4. B12 +IF 4. B12 +IF
5. COLLECT URINE X 24 HRS 5. COLLECT URINE X 24 HRS
6. AB/ANTI PARASITIC X 7DAYS 6. AB/ANTI PARASITIC X 7DAYS
7. B12 THEN COLLECT URINE X 24 HOURS 7. B12 THEN COLLECT URINE X 24 HOURS
8. B12 + PANCREATIC ENZYME 8. B12 + PANCREATIC ENZYME
9. COLLECT URINE X 24 HOURS 9. COLLECT URINE X 24 HOURS
 VIT B 12 DEFICIENCY ANEMIA
TREATMENT

Increase intake Oral Vit B 12 IM Vit B 12

of B12 rich foods supplement supplement
• Animal • 1 mg daily • 1 mg weekly for
products 8 weeks
• 1mg monthly
for LIFE
VIT B 12 DEFICIENCY ANEMIA
TREATMENT
MICROCYTIC ANEMIA
IRON RICH FOODS
 TOTAL IRON IN THE BODY
IRON 3 – 5
GMS

FUNCTIONAL STORAGE
80% 20%

HGB 70% FERRITIN 15%

MYOGLOBIN HEMOSEDRIN
5% 5%

OTHERS 5%
 CAUSES OF IDA
Impaired Increased
Diet Blood loss
absorption demand
• Poor • Cow’s • Growth • Heavy
diet milk spurts menstruat
• Strict • Gastric • Pregnancy ion
Vegan bypass • Lactating • Colon
cancer
• PUD
 SIGNS & SYMPTOMS

EXERTIONAL
TACHYCARDIA TACHPNEA
DYSPNEA

WEIGHT LOSS VERTIGO TINNITUS

AMENORRHE FUNCTIONAL
ALOPECIA
A MURMUR
IRON DEFICIENCY ANEMIA S/Sx
 IRON DEFICIENCY ANEMIA LAB
FINDINGS
DECREASED
DECREASED DECREASED INCREASED
SERUM
HEMOSEDRIN SERUM IRON TRANSFERRIN
FERRITIN

DECREASED INCREASED INCREASED

TRANSFERRIN INCREASED TIBC TRANSFERRIN BILIVERDIN -
SATURATION RECEPTOR BILIRUBIN

CBC – LOW RBC CBC – LOW MCV

CBC – LOW HCT CBC – LOW HGB
COUNT (microcytic)

CBC – LOW HGB ANISOCYTOSIS

INCREASED
CONTENT AND/OR
PLATELETS
(hypochromic) POIKILOCYTOSIS
 IRON DEFICIENCY ANEMIA
TREATMENT

Treatment of Increase intake of Ferrous sulfate

Parenteral Iron
underlyring cause Iron rich foods 325 mg TID
• Heme • May cause GI • Risk of
• Pork upset, anaphylaxis
• Red meat constipation and
black stool
• Poultry
• Normal w/in 2
• Non heme
months
• Green leafy
• Cont 3 – 6
vegestables
months
 IRON REPLACEMENT
DECREASED ABSORPTION
ABSORPTION CAN BE WITH TEA, CEREALS,
BEST TAKEN ON EMPTY
ENHANCED BY: VIT C AND WHEAT AND
STOMACH
AMINO ACIDS FOODS/DRINKS
CONTAINING PHOSPHATES

DECREASED ABSORPTION
CONSTIPATION DARK STOOL
DUE TO AB & OTHER MEDS

LOSS OF APETITE NAUSEA

NORMOCYTIC ANEMIA
 ANEMIA OF CHRONIC DISEASE
CAUSES

COLLAGEN VASCULAR INFLAMM BOWEL DSE

THYROID DSE
DSE (RA,SLE) (COLITIS, CHRON’S)

CHRONIC INFECTIOUS
MALIGNANCY DISEASES (OM,TB, RENAL DISEASE
HIV,ETC)
IDA VS ACD
•IDA
•DECREASED SERUM Fe
•INCREASED TRANSFERRIN
•DECREASED FERRITIN

•ACD
•DECREASED SERUM Fe
•DECREASED TRANSFERRIN
•INCREASED FERRITIN

INCREASED
HEPCIDIN LEVEL
 ACD TREATMENT

TREAT UNDERLYING
EPO TRANSFUSION
DISEASE

CHELATION NO IRON SUPPLEMENT

Nursing Actions for a Patient who is Anemic
• Administer oxygen as prescribed
• Administer blood products as prescribed
• Administer erythropoietin as prescribed
• Reduce activities and stimuli that cause
tachycardia
• Allow for rest between periods of activity
• Elevate the pt’s head on pillows during episodes
of shortness of breath
• Provide extra blankets if the pt is feels cold
• Teach the pt/family about underlying disease
and how to manage the symptoms of anemia
POST
TEST
 NURSING DIAGNOSIS
1. Activity Intolerance related to imbalance between oxygen supply
(delivery) and demand
2. Ineffective tissue perfusion
3. Decreased cardiac output
4. Disturbed sensory perception
5. Impaired oral mucous membrane
6. Imbalance Nutrition: Less than body requirement
7. Constipation
8. Deficient knowledge
9. Low self esteem
10. Fatigue
11. Fear
12. Risk for infection
13. Risk for injury