Anemia is a condition in which the hemoglobin concentration
is lower than normal; it reflects the presence of fewer than
the normal number of erythrocytes
Classification of Anemias
 according to whether the deficiency in erythrocytes
is caused by a defect in their production or by their
destruction
1. Hypoproliferative Anemias - does not produce
adequate numbers of erythrocytes (bone marrow
damage resulting from medication e.g.,
CHLORAMPHENICOL, chemical e.g., BENZENE or
from the lack of factors e.g., lack of iron etc.
2. Hemolytic Anemias,- premature destruction of
erythrocytes results in the liberation of hemoglobin
from the erythrocytes into the plasma (INIDICATION
INCLUDE HYPERBILIRUBINEMIA , TISSUE HYPOXIA
INCREASE RETICULOCYTE)
It is usually possible to determine whether the presence of
anemia in a given patient is caused by destruction or by
inadequate production of erythrocytes on the basis of the
following factors
 bone marrow’s ability to respond to decreased
erythrocytes
 The degree to which young erythrocytes proliferate
 presence or absence of end products of erythrocyte
destruction
Clinical Manifestations
 Fatigue
 Dyspnea
 chest pain
 muscle pain
 Cramping
Assessment and Diagnostic Findings
 Hemoglobin
 Hematocrit
 reticulocyte count
 mean corpuscular volume (MCV)
 red cell distribution width
 total iron-binding capacity [TIBC], percent saturation,
and ferritin
 Vitamin B12 and folate
Complications
 heart failure
 paresthesia
 Delirium
Medical management
 Transfusion of packed red blood cells (PRBCs).
Gerontologic Considerations
 The impact of even mild anemia on function in
older adults is significant and may include
decreased physical performance, decreased
mobility, increased frailty, increased rates of
depression, increased risk for falling, and
delirium
 fatigue, dyspnea, and confusion may be seen
more readily in the older adult who is anemic
HYPOPROLIFERATIVE ANEMIA
Iron Deficiency Anemia
 results when the intake of dietary iron is inadequate
for hemoglobin synthesis
 can also occur when total body iron stores are
adequate, but the supply of iron to the bone marrow
is inadequate; this type is referred to as functional
iron deficiency
 most common type
Most common cause of iron deficiency anemia in men and
postmenopausal women
 ulcers, gastritis
 inflammatory bowel disease
 GI tumors
 In premenopausal woman, it is menorrhagia
 Patients with chronic alcoholism or who take aspirin,
steroids, or nonsteroidal anti-inflammatory drugs
(NSAIDs)
 gastrectomy, bariatric surgery, or with celiac or
other inflammatory bowel disease
 proton pump inhibitors, H2 blockers can also
decrease iron absorption
Clinical manifestations
 smooth, red tongue; brittle and ridged nails; and
angular cheilosis
Assessment or Diagnostic findings
 bone marrow aspiration(definitive method of
establishing the diagnosis)
 low serum ferritin levels
 low serum iron levels
 elevated TIBC
 hemoglobin level falls
 MCV decreases
 Hematocrit and RBC levels low
 Soluble transferring receptor (can be used in
differentiating between infection anemia or
deficiency anemia)
Medical Management
1. Oral iron supplementation (sulfate, ferrous
gluconate, and ferrous fumarate)
2. In some cases, oral iron is poorly absorbed, , IV
administration of iron may be needed
  Ferric gluconate (Ferrlecit) 125 mg is diluted in
100 mL normal saline and infused over 1 hour
 Iron sucrose (Venofer): Each 5 mL contains 100
mg elemental iron; 100–200 mg can be given
undiluted as a slow IV push injection over 2 to 5
minutes
Nursing Management
 Preventive Education: Food sources high in iron
include organ meats (e.g., beef or calf’s liver,
chicken liver), other meats, beans (e.g., black,
pinto, and garbanzo), leafy green vegetables,
raisins, and molasses
 Take with a with a source of vitamin C
 In taking iron meds, GI side effects primarily
constipation, but also cramping, nausea, and
vomiting
 limit GI side effects by the addition of a stool
softener or the use of sustained release
formulations to limit nausea or gastritis
NOTE: Antacids or dairy products should not be taken
with iron, because they greatly diminish its absorption
 nurse needs to be aware of the type of
parenteral formulation of iron ordered so that
the risk of anaphylaxis may be determined
 The nurse needs to assist the patient in
understanding the need for repeated dosing to
replenish iron stores or to maintain iron stores
Aplastic Anemia
 decrease in or damage to marrow stem cells,
damage to the microenvironment within the
marrow, and replacement of the marrow with
fat
 body’s T cells mediating an inappropriate attack
against the bone marrow
 Neutropenia and thrombocytopenia also occur.
Pathophysiology
 acquired or, rarely, congenital, but mostly
idiopathic
 RISK FACTORS: Viral infections, pregnancy
Chemical or radiation damage
 benzene and benzene derivatives
 inorganic arsenic, glycol ethers, plutonium, and
radon
Clinical Manifestations
 fatigue
 pallor
 dyspnea
 Typical signs of infection
 Purpura
 Splenomegaly
 Retinal hemorrhages
 cervical lymphadenopathy (throat infection)
Assessment and diagnostic Findings
 CBC reveals pancytopenia
 neutrophil count less than 1500/ µL,
 hemoglobin less than 10 g/dL
 platelets less than 50,000/µL
Medical Management
1. hematopoietic stem cell transplant (HSCT)
2. immunosuppressive therapy, commonly using a
combination of antithymocyte globulin (ATG)
and cyclosporine or androgens
Side effects: fever and chills, onset of rash and
bronchospasm may results in anaphylaxis
Serum sickness, as evidenced by fever, rash,
arthralgias, and pruritus (administer corticosteroids)
3. If relapse occurs (i.e., the patient becomes
pancytopenic again), reinstitution of the same
immunologic agents may induce
4. Supportive therapy (transfusions of PRBCs and
platelets as necessary)
Nursing Management
1. assessed carefully for signs of infection and
bleeding
2. monitor for side effects of therapy
3. cyclosporine therapy should be monitored for
long-term effects, including renal or liver
dysfunction, hypertension, pruritus, visual
impairment, tremor, and skin cancer
4. Patients also need to understand the
importance of not abruptly stopping their
immunosuppressive therapy
Megaloblastic Anemia
 deficiencies of vitamin B12 or folic acid, vitamins are
essential for normal DNA synthesis
 erythrocytes that are produced are abnormally large
and called megaloblastic red cell
 bone marrow analysis reveals hyperplasia
 pancytopenia can develop since abnormal erythroid
and myeloid cells are destroyed within the marrow
and mature cells that leave the marrow are actually
fewer in number
 neutrophils are hypersegmented
 erythrocytes are abnormally shaped and vary in
shape (poikilocytosis)
 platelets may be abnormally large
 skin develops a lemon yellow color resulting from
simultaneous pallor and mild jaundice
Pathophysiology
Folic Acid Deficiency  Premature graying of the hair
 when the dietary intake of folate is deficient n 2. pay particular attention to ambulation and should
become depleted within month assess the patient’s gait and stability
 Folate deficiency occurs in people who rarely eat 3. Physical and occupational therapy referrals may be
uncooked vegetables.
needed
 Alcoholism
4. If sensation is altered, the patient needs to be
 Folic acid requirements are also increased in
patients with liver disease, chronic hemolytic
instructed to avoid excessive heat and cold
anemias 5. advise the patient to eat small amounts of bland,
 women who are pregnant soft foods frequently
 malabsorptive diseases HEMOLYTIC ANEMIA
Vitamin B12 Deficiency  erythrocytes have a shortened lifespan – which
 inadequate dietary intake leads to hypoxia
 Faulty absorption from the GI  stimulates an increase in erythropoietin
 Crohn’s disease
release from the kidney
 ileal resection, bariatric surgery, or gastrectomy
 histamine blockers, antacids, or proton pump  Erythropoietin then stimulates the bone
inhibitors marrow to compensate by producing new
 use metformin (Glucophage) in managing diabetes erythrocytes (called reticulocytes)
 absence of intrinsic factor (pernicious anemia) Note: laboratory features: the reticulocyte count is
Clinical Manifestations elevated, the fraction of indirect (unconjugated)
 folic acid and vitamin B12 deficiencies are similar bilirubin is increased, and the supply of haptoglobin (a
 neurologic manifestations is present in vitamin B12 binding protein for free hemoglobin) is depleted as
deficiency more hemoglobin is released
 weakness
 listlessness
Sickle Cell Disease
 Fatigue
 results from inheritance of the sickle hemoglobin
Pernicious anemia develop:
(HbS) gene
 smooth, sore, red tongue and mild diarrhea,
 HbS acquires a crystal-like formation when exposed
extremely pale, may become confused
to low oxygen tension. The oxygen level in venous
 confuse
blood can be low enough to cause this change
 paresthesia
 erythrocyte containing HbS loses its round, pliable,
Assessment and diagnostic findings
biconcave disc shape and becomes dehydrated,
 Schilling test
rigid, and sickle shaped
 vitamin B12 assay
 they adhere to each other, blood flow to a region or
 methylmalonic acid and homocysteine levels
an organ may be reduced
 intrinsic factor antibody test (positive test  Cold can aggravate the sickling process due to
indicates the presence of antibodies, preventing vasoconstriction
its absorption)  Less severe forms include sickle cell hemoglobin C
Medical Management (SC) disease, sickle cell hemoglobin D (SD) disease,
Folate deficiency and sickle cell beta-thalassemia
1. diet and administering 1 mg of folic acid daily
2. IM (with malabsorption problems) Clinical manifestations
Vitamin B12  Anemia is always present; usually, hemoglobin
1. oral supplements with vitamins or fortified soy values range between 5 and 11 g/dL
milk  Jaundice
2. IM (malabsorption problems or absence of  Tachycardia
 Cardiac murmurs
intrinsic factor)
 Cardiomegaly
Note: To prevent recurrence of pernicious anemia,
 Dysrhythmias and heart failure
vitamin B12 therapy must be continued for life
 slower circulation, such as the spleen, lungs, and
central nervous system
Nursing Management  hypoxic damage or ischemic necrosis
1. Inspection of the skin, mucous membranes, and  pneumonia and osteomyelitis
tongue.  Complications of sickle cell disease include
infection, stroke, kidney injury, impotence,
Patient with pernicious anemia
heart failure, and pulmonary hypertension
 Vitiligo
Sickle Cell Crisis
 Mild jaundice
  acute vaso-occlusive crisis- which results from
entrapment of erythrocytes and leukocytes in the
microcirculation, causing tissue hypoxia,
inflammation, and necrosis
 Aplastic crisis results from infection with the human
parvovirus.
 Sequestration crisis results when other organs pool
the sickled cells.
Acute chest syndrome
 fever, respiratory distress (tachypnea, cough,
wheezing)
 infiltrates seen on the chest x-ray
Causes: infections of Chlamydia pneumoniae and
Mycoplasma pneumonia, pulmonary fat embolism,
pulmonary infarction, pulmonary thromboembolism, and
bone marrow embolism
Management:
1. red cell transfusion,
2. antimicrobial therapy,
3. bronchodilators, inhaled nitric oxide therapy,
4. When respiratory failure ensues, mechanical
ventilation
Pulmonary Hypertension
 Complain of fatigue, dyspnea on exertion, dizziness,
chest pain or syncope
 Pulse oximetry measurements are typically normal,
and breath sounds are clear to auscultation
 Doppler echocardiography may be useful in
identifying those with elevated pulmonary artery
pressure
 natriuretic peptide can serve as a useful biomarker
for pulmonary hypertension
Stroke
 Decreased cerebral blood flow due to anemia,
hemolysis, and increased hypoxic stress
 Medical management of stroke includes red cell
transfusions to reduce the level of hemoglobin S
Reproductive problems
 Low testosterone levels, low libido, erectile
dysfunction, and infertility can occur
 priapism (prolonged erection of the penis, typically
without sexual stimulation
 Contraception is important when hydroxyurea
(Hydrea) is used to treat SCD as it may be
teratogenic
 Menarche may be delayed in females
 nurse should initiate open discussions about sexual
and reproductive concerns with patients prescribed
this therapy
Assessment and Diagnostic findings for SCD
 a low hematocrit and sickled cells on the smear
 white blood cell (WBC) and platelet counts are often
higher
 Diagnosis is confirmed by hemoglobin
electrophoresis.
Prognosis
 Death is most commonly due to heart disease (32%),
lung disease (28%), kidney disease (16%), infection
(14%), and neurologic system disease (12%); less
commonly, death results from GI tract or liver
disease (9%) and cancer (<1%)
Medical Management
1. Hematopoietic Stem Cell Transplant
2. Hydroxyurea is a chemotherapy agent that is
effective in increasing fetal hemoglobin
Side effects of hydroxyurea include chronic suppression of
leukocyte formation, teratogenesis, and potential for later
development of a malignancy.
3. require daily folic acid replacements to maintain the
supply required for increased erythropoiesis from
hemolysis
4. infections must be treated promptly with
appropriate antibiotics
5. Hydration is important but must be carefully
monitored as fluid overload can develop quickly
6. Pulmonary function should be monitored regularly
to detect pulmonary hypertension
Thalassemia
 are a group of hereditary anemias characterized
by hypochromia (an abnormal decrease in the
hemoglobin content of erythrocytes), extreme
microcytosis (smaller-than-normal
erythrocytes), hemolysis, and variable degrees
of anemia
 defective synthesis of hemoglobin
 classified into two major groups according to
which hemoglobin chain is diminished: alpha or
beta
 Alpha thalassemias are milder than the beta
forms, seems to be very effective in protecting
against severe malaria
 beta-thalassemia varies depending on the
extent to which the hemoglobin chains are
affected
 Long-term survivors of beta thalassemia may
experience neurologic complications, such as
cognitive dysfunction, peripheral neuropathy,
and cerebrovascular disease
Clinical manifestations: severe anemia, marked
hemolysis, and ineffective erythropoiesis
Management
1. HSCT
 2. Usually treated with transfusion of PRBCs and  increased volume of RBCs
iron chelation.  hematocrit is elevated (more than 55% in
males, more than 50% in females
Glucose-6-Phosphate Dehydrogenase Deficiency  Dehydration (decreased volume of plasma) can
 e G-6-PD gene is the source of the abnormality in cause an elevated hematocrit
this disorder
Polycythemia is classified as either primary or secondary.
 inherited an enzyme that is so defective that they
have a chronic hemolytic anemia, it affects 1. Primary polycythemia, also called polycythemia vera,
membrane stability is a proliferative disorder.
 All types of G-6-PD deficiency are inherited as X- 2. Secondary polycythemia is caused by excessive
linked defects production of erythropoietin.
 type of deficiency found in the Mediterranean  reduced amount of oxygen, which acts as a
population is more severe hypoxic stimulus
 Causes include heavy cigarette smoking,
Oxidant drugs have hemolytic effects for people with G-
obstructive sleep apnea, COPD, or cyanotic
6-PD deficiency.
heart disease, high altitude,
 antibacterial agents sulfadiazine, nitrofurantoin hemoglobinopathies, genetic mutation and
(Macrodantin) neoplasms.
 antimalarial agents primaquine, and dapsone,
Management:
 phenazopyridine (Pyridium), rasburicase,
(Elitek) 1. If mild secondary polycythemia occurs, treatment
 methylthioninium chloride (methylene blue) may not be necessary
 tolonium chloride (toluidine blue). 2. therapeutic phlebotomy may be necessary in
symptomatic patients to reduce blood viscosity and
In affected people, a severe hemolytic episode can also result volume
from ingestion of fava beans, menthol, tonic water, and some Note: should not be used when the cause for an
Chinese herb elevated RBC level is an appropriate, compensatory
Clinical Manifestations response to tissue hypoxia

 develop pallor
 jaundice
 hemoglobinuria (i.e., hemoglobin in the urine

Assessment and Diagnostic Findings

 quantitative assay of G-6-PD

Medical Management

1. stop the offending medication

2. Transfusion is necessary only in the severe hemolytic
state

Nursing Management

1. educate about the disease and given a list of

medications and substances to avoid
2. should always seek advice before taking any
new medication or supplement
3. Genetic counseling may be indicated

Polycythemia