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Nursing management of patient with blood disorder

objective: After four hours of lecture discussion, the level 1V student will be able to: Review the anatomy and physiology of the blood Relate the diagnostic test result to the blood disorder Discuss different blood disorder Develop nursing care plan utilizing nursing process in caring patient with blood disorders

Anatomy and physiology of the blood

Blood is an aqueous mixture consisting of plasma and cells - Is a sticky opaque fluid with a metallic taste - Is slightly alkaline, pH of 7. 35 7. 45 - Temp. of 38C or 100. 4 F - 8% of body weight, volume in healthy males is 5 6 liters

- is a straw colored liquid consisting of approximately 90% water and 10

% protein

Characteristics and function of formed elements of the blood

1. Erythrocytes (rbc) - 4 6 million per mm - Salmon colored biconcave disks, sacs of hgb. Most organelles have been ejected - Fxn: transport O2 bound to hgb molecules; also transport small amount of co2

2. Leukocytes (wbc)
- 4000- 11, 000mm - Granulocytes: a. Neutrophils 40 70% of wbc; active phagocytes; number increases rapidly during short-term or acute infections b. Eosinophils 1- 4% of wbc; kills parasitic worms; increase during allergy attack; might phagocytize antigen-antibody complexes and inactivate some inflammatory chemicals

c. Basophils 0- 1% of wbc
Granules contain histamine ( vasodilator chemicals) which is discharge at sites of inflammation Agranolucytes: a. Lymphocytes- 20 45 % of wbc - Part of immune system; one group (B lymphocytes) produces antibodies; other group (T lymphocytes) involved in graft rejection, fighting tumors and viruses, and activating B lymphocytes -

b. Monocytes 4 8% 0f wbc
- Active phagocytes that become macrophages in the tissues; long-term clean-up; increase in number during chronic infections such as TB

3. Platelets- 250,000- 500,000

- Called megakaryocytes coz they are fragments of bizarre multinucleate - Needed for normal blood clotting; initiate clotting cascade by clinging to broken area; helps to control blood loose from broken blood vessels - Accelerated by the hormone thrombopoietin

How blood cell formulated?

-through hematopoiesis that occurs in red bone marrow or myeloid tissue - In flat bones: skulls and pelvis, ribs, sternum and proximal epiphyses of the humerus and femur - Each type of blood cells- is produced in different numbers in response to changing body needs and different stimuli - Matured cells are discharge into the blood vessels surrounding the area - All the formed elements arise from a common types of stem cells the hemocytoblast in red bone marrow - The stem cells renews itself by mitosis

What regulate the RBC?

- Erythropoietin circulates in the blood at all times and RBCS are formed in constant rate. - Kidney plays the major role in releasing this hormones, liver produce some NORMAL LIFESPAN FOR AN RBC = 120 DAYS

- Is the % of blood cells in a volume of blood - Normal value= 42% - 45% of blood volume

- Stoppage of blood flow - This response which is fast and localized involves many substances normally present in plasma, as well as some that are released by platelets and injured tissue cells.

Platelet plug forms sticky and cling to the damage site, Anchored platelets release chemicals that attract more platelets to the site to formed a white thrombus or platelet plug. Vascular spasm occur anchored platelet release serotonin which cause the blood vessel s into spasm resulting to decrease blood loss after clotting can occur Coagulation event occur - release of thromboplastin. Coagulation time = 3 to 6 minutes



AB--------------------------------A,B----------------------------------NONE---------------------------------------------A,B,AB,O B-------------------------------------B-------------------------------------ANTI A--------------------------------------------B,O A-----------------------------------A-------------------------------------ANTI B------------------------------------------A,O O------------------------------NONE-------------------------------ANTI A, B----------------------------------O, UNIVERSAL DONOR

Antigen is a substance that body recognizes as foreign, it stimulates the immune system to release antibodies RH BLOOD GROUP the RBC carry the-Rh antigen


- Increase RBC and Hgb production - Compensatory response to chronic hypoxia: Hypoxia ->increase Erythropoietin production by the kidneys>stimulation of the bone marrow to increase RBC production

Occurs most frequently in middle age and Jewish men Hyperplasia of the bone marrow Increase RBC (erythrocytosis); increase WBC (leukocytosis); increase platelets (thrombocytosis)

Increase rbc,wbc,platelet -> increase Bld.volume and Viscosity -> thromboembolism and capillary overdistention -> rupture - > hemorrhage ->hypovolemia; Organ infiltration -> hepatomegaly, Spleenomegaly,cerebral hypoxia,arthralgia


Predisposing factors:  Long term hypoxia: COPD,CHF,SMOKING. LIVING IN HIGH


Signs and Symptoms:

Symptoms of two are the same Headache, epistaxis, dizziness, tinnitus, blurred vision, fatigue, weakness, pruritus, exertional dyspnea, increased BP and pulse Ruddy complexion, lips become reddish purple Petechia and bruises due to platelet dysfunction Susceptible for thrombi formation Causes hyperuricemia increase uric acid bld level RBC count is over 6 million; Hgb over 18mg/dl, Hct over 55% Increased risk for CVA and MI due to thromboembolism

Nursing management ASSESSMENT:

History taking for the s&s Assess for nutritional status for inadequate dietary intake due to GI symptoms of fullness and dyspepsia Observe for bruises and changes in color Check for neck vessels distention, listen apical, radial, pedal pulses Check Homans signs and edema Observe for dyspnea, epistaxis Listen to the breath sound Checked pupils responses and presence of numbness or tingling

Nursing diagnosis
Ineffective Tissue Perfusion r/t decreased blood circulation Knowledge deficit r/t disease process and treatment Risk for injury r/t dizziness


- most common type of anemia and occurs when the body does not have enough iron to synthesize functional hgb. - Found frequently in premature or LBW infants, adolescent girl, alcoholic and the elderly

Reduced O2 carrying capacity of the blood from nutrients deficiencies that disrupts hematopoiesis or hemoglobin synthesis

Decreased dietary intake Decreased iron absorption from GIT Chronic intestinal or uterine blood loss Increased bodily needs for iron such as during growth period and pregnancy

SIGNS AND SYMPTOMS: Pallor Easy fatigability Weakness Anorexia Weight loss Headache/dizziness Brittle hair, nails Syncope Amenorrhea Cold sensitivity Tachycardia Palpitation

- The patient will relate disease process and treatment
- The patient will have increased circulation - The patient will relate measures to avoid injury

Nursing Intervention
Explain the cause of disease, symptoms, side effect of medication and possible complication, and any procedures to be done Administer O2 as ordered check VS frequently Assess Homan signs and thrombi formation
Positioning patient slowly to prevent dizziness Allow ADL if patient is able Provide HTP : to drink at least 3 L of H2O daily; elevate feet when resting; avoid restrictive clothing; wear support hose; take medication as ordered; report for chest pain, joint pain, fever or activity intolerance etc. Keep appointment for laboratory test and physician checks

Medical/surgical management
Phlebotomy removal of blood from the vein about 350500ml q other day til hct is 40% Radioactive phosphorus and radiation therapy to decrease the production of blood cells in the bone marrow

Busulfan (Myleran); Chlorambucil (Leukeran); Cylophosphamide (Cytoxan) and mechlorethamine or nitrogen mustard = to decrease bone marrow production Allopurinol (Zyloprim) = to decrease production of uric acid Antihistamine = for pruritus Analgesic

Diet therapy
Increased calories and protein Low in sodium to decrease fluid volume Avoid iron containing food

Decreased availability of oxygen to the tissue TYPES of Anemia: 1. Iron deficiency 2. Folate deficiency 3. Aplastic 4. Pernicious

Acute/chronic blood loss Inadequate dietary intake of vitamins/minerals needed for RBC production Decreased RBC production by the bone marrow Increased destruction of RBC Increased demands of vitamins/minerals needed for RBC production

Signs and symptoms:

Pallor easy fatigability weakness anorexia weight loss syncope brittle hair and nails Cold sensitivity Tachycardia Palpitation Dizziness Headache Paresthesia Amenorrhea

Iron Deficiency Anemia

Microcytic, hypochromic anemia From menses for females GI bleeding for men Assessment: - Vinson-Plummers Syndrome: stomatitis,dysphagia, atrophic glossitis (smooth, sore tongue) - Cheilosis (cracks at the side of the lips) - Koilonychia (spoon-shaped/concave fingernails) - Pica (craving of non-edible substance - Tinnitus - Cardiovascular symptoms 7.5g/dl:increase PR, chest pain

Nursing intervention
Promote rest to reduce O2 demands Render oral care and good skin care Diet: iron rich food

Medical Mgt.
o Iron supplement: oral FeSO4; parenteral Imferon o Oral should be given pc to prevent GI irritation o Oral liquid iron to be administered with straw to prevent permanent staining of the teeth o Vit. C increase iron absorption o Do not administer with milk, antacid these will inhibit absorption o Inferon: Z-track to prevent staining of the skin o Do not massage site injection to prevent leakage of medication to subcu. layer o Iron salt change color of stool to dark green or black o Oxygen therapy o Blood transfusion

Folate deficiency anemia/megaloblastic anemia

- Produced RBCs are abnormally large due to Vit 12 or folic acid deficiency Etiology:

Poor dietary intake Eat Uncooked fruits and vegetables Alcoholism Chronic malnutrition Pregnancy

Prolonged TPN Malignancy Chronic Hemodialysis Malabsorption Anorexia nervosa

Assessment Cracked lips, smooth, sore tongue and mild dirrhea Same as pernicious anemia Bone marrow analysis reveals hyperplasia Poikilocytosis(abnormally-shaped RBC) Extreme paleness, especially in mucous membrane Confusion, paresthesia in extremeties, lose of maintaining balance Lose of position sense (proprioception Mild jaundice, vilitigo, pemature of graying skin (+)Schilling test MANAGEMENT: Well balance diet, assess ambulation, gait and stability Folic acid 1mg/day; instruct to avoid extreme hot or cold

Pernicious anemia/B12 deficienccy

Lack of intrinsic factor in gastric secretion Is an autoimmune disease in which parietal cells are destroyed and the gastric mucosa atrophies Macrocytic, hyperchromic anemia Onset 50 to 60 yrs. old ETIOLOGY: Gastric surgery Crohns disease

Decreased Intrinsic factor production by the parietal cells of the stomach ->decreased Vit, B12 absorption ->decreased RBC production -> decrease DNA synthesis in maturing RBC -> impairment of cell integrity

Diagnostic test
Schillings test most definitive diagnostic test - Oral radioactive Vit 12 is administered - IM nonradioactive Vit 12. To push the radioactive Vit 12 into the urine - Collect 24 hours urine specimen - Decreased excretion of Vit 12 in the urine indicates (+)

Beefy red, inflamed tongue ( most characteristic manifestation) Achlorhydria( absence of free Hcl acid in the gastric juice Tingling, numbness Lack of balance, uncoordinated movement Confusion Paralysis Depression, psychosis Jaundice

Collaborative MGT
Vit 12 im: daily for 7 days; weekly for 10 weeks; monthly lifetime 100mg/Mos. Hydrochloric acid p.o. for 1 week Iron therapy Blood transfusion as needed Physical examination every 6 months

Aplastic anemia
- Hypoplasia of the bone marrow - Fat replaces bone marrow - Pancytopenia drop in the # of RBC: anemia, leukopenia,thrombocytopenia ETIOLOGY: cause unknown - Congenital Medications Infection - Acquired heavy metals Hepatitis - Idiopathic

Diagnostic test
Bone marrow aspiration/biopsy
Adult: posterior iliac crest the most common site Prone position during the procedure Brief, sharp pain is normally experienced as bone marrow is aspirated Child: Tibia most common site Side-lying position during the procedure Apply pressure at the puncture site to prevent bleeding

Medical treatment
- ATG (Atgam) antihymocyte globulin an Immunosuppressive therapy to suppress the rxn causing the aplastic anemia and allow the bone marrow to recover - Given OD through CVC for 7 to 10 days - Transfusion of plt. and Packed RBC

Surgical tx
BM transplant Cyclosporine (sandimmune) an immnunosuppressant is given for BMT to decrease the graft rejection

Pharmacological tx
Antibiotic for infection Steroids and Androgen used to stimulate the bone marrow

Acquired Hemolytic Anemia

- Hemolysis or destruction of RBCS

Autoimmune rxn. Radiation Bld transfusion Chemicals

arsenic lead medication clostridium perfringens

Signs and Symptoms

Mild fatigue Elevated LDH Pallor Palpitation Dyspnea Pallor Low Hb, Hct Jaundice Hypotension Back and joint pain

BT- blood transfusion Erythrocytapheresis a procedure that removes abnormal RBCS and replaces a healthy one

Surgical tx
Splenectomy to stop destruction of RBC Pharmacological: - Corticosteroids to decrease the autoimmune response - Folic acid to increase the production of RBC

SICKLE CELL Disease/INHERITED HYMOLYTIC ANEMIA Genetic disorder caused by recessive genes Has an abnormal Hb. S instead of Hb A in the RBC The person with one S gene (HbsA) has sickle cell trait The person with two S genes (Hbss) has sickle cell disease

Diagnostic Procedure
Sickledex or sickle cell test
- A screening test to infant to diagnose sickle cell disease - If Hb S is present, a Hb electrophoresis is done to distinguish between sickle trait and sickle cell disease - If the Hb electrophoresis test is negative, the client has the sickle cell trait and not sickle cell disease.

Factors can precipitate sickle cell crisis

Dehydration Fatigue Infection Emotional stress Alcohol consumption Blood Loss Anesthesia Exposure to cold

Effect of sickle cell to circulatory system

Obstruction of vessels and rupturing it and these become infarct and ischemic that can cause: S &S

Chronic anemia Cardiomegaly Fatigue Jaundice Chronic leg ulcer Tachypnea priapism

Dyspnea Arrhythmias Fever Severe pain Loss of bld supply Joint pain, swollen and tender

Medical management
Antibiotics Genetic Counselling Large amount of oral and IV fluid Pharmalogical: - Folic acid OD to assist in the production of RBC - Cetiedel citrate antisickling effect by changing the RBC membrane. - Trental (Pentoxifylline) reduces blood viscosity, increase RBC flexibility, lengthens the time between sickle cell crises - Blood transfusion during crisis - Patient-Controlled Analgesia with morphine during crisis

Nursing management
Ineffective Tissue Perfusion r/t decreased # of RBC and decreased oxygenation as evidenced by dyspnea, tingling sensation and numbness of LE

Administer IV as ordered Offer 8 to 10 glasses of H20/day Monitor for symptoms of obstructed vessels such as: pain, leg ulceration, abdominal tenderness, dyspnea, confusion and blurred vision Administered Blood. product as ordered Close monitoring for possible BT RXN Elevate head; administer O2 as ordered

Alteration in comfort: Pain r/t occlusion of small vessels by sickled cells as evidenced by---

Assess the severity, location and type of pain Monitor analgesic administration by PCA pump Support joints and LE with pillows Keep bed linens off knees and ankles with a bed cradle

Activity Intolerance r/t imbalance between O2 supply and demand as E/B weakness, fatigue, tingling and numbness

Assist with ADL Teach the importance of alternating periods of rest with activity

Knowledge deficit r/t prescribed TX, disease process

Teach about the disease process Assist to take medication Explain the importance of avoiding stress and infection Stress the importance od adequate rest in a routine basis Explain to avoid high altitudes and nonpressurized airplane Discuss the important of avoiding tight-fitting -, restrictive clothing and strenuous exercise, smoking and cold temp Advice to receive flue vaccine and pneumococcal vaccine

White blood disorder

1. Leukemia - Is a malignancy of blood-forming tissues in which the bone marrow produces increased numbers of immature WBC that are incapable of protecting the body from infections

Two classification of Leukemia

1. Acute leukemia subtype: a.)AML Acute myelocytic leukemia -Malignant, affect monocytes, granulocytes, erythrocytes and platelets common in adolescence and 55yrs of age Survival: -1-3 yrs with chemo; 2-5 mos. if untreated b.)CML Chronic myelocytic leukemia Malignancy of the myeloid cell that leads to uncontrolled proliferation of granulocytes; common in adult -Characterized by Philadelphia chromsomes - WBC count: 15,000 -500,000 Survival:3 -5 yrs if without BM transplant 2. Chronic leukemia subtype: a.)ALL Acute lymphocytic leukemia - Malignant proliferation of lymphoblasts arising from a disorder of a single lymphoid stem cell. Most common in children Survival: - 5 yrs with chemo and radiation therapy; 50% can be cured b.)CLL Chronic Lymphocytic Leukemia- caused by proliferation of small, abnormal B-lymphocytes WBC: between 20,000 and 100,000 develop with advanced age

Survival: 5 7 yrs.

- Proliferation of Immature WBCS---- Immune system

compromised state-- production of RBCs and Platelets Hypertrophy of the Bone marrow (bone pain) organ Infiltration: hepatomegaly; Splenomegaly;renal insufficiency; hyperuricemia; arthralgia; Increase ICP (meningeal infiltration)

COLLABORATIVE MANAGEMENT MEDICAL MGT: Chemotherapy Bone marrow transplantation Blood transfusion NURSING INTERVENTION:  PROTECT FROM INFECTION: Reverse isolation/protective isolation; Practice asepsis; Limit visitors; Do not allow people with infection to visit; Avoid fresh fruits/fresh flowers in the unit; Avoid raw foods  PREVENT TRAUMA and BLEEDING: minimize parenteral injection, use small needle, apply pressure at injection site for 5 mins.,support/handle body parts gently,use soft-bristled toothbrush/soft swab, use electric razors, do not administer ASA  CONSERVE ENERGY/O2 SUPPLY: adequate rest, Oxygen therapy


LAB RESULTS -- OVERALL SYMPTOMS -- SYMPTOMS MANIFESTATION Immature WBCs - Persistent infections -- fever, chills Decreased RBCs - Anemia -- fatigue, pallor, malaise, tachycardia, tachypnea -- petechiae,bruising, melena, gingival bleeding, menorrhagia, epistaxis

Decreased platelets

--- Bleeding

Chemotherapeutic agents to treat leukemia



Vincristine(oncovin) Prenisone(deltasone) 6-mercaptopurine or 6-MP(purinethol) Methotrexate daunorubicin Hcl(cerubidine) cytarabine or era-C(cytosar-U) 6-thioquanine(thioguanine) Doxorubicin Hcl(Adriamycin) Chlorambucil(Leukeran), COP(cytoxan,oncovin,prednisone




DAT(daunorubicin,ara-C, thioguanine

DESCRIPTION - severely reduced number of granulocytes:basophils,

eosinophils, neutrophils Etiology: medication toxicity, neoplastic disease, chemotherapy, radiation therapy, bacterial and viral infection
Signs & symptoms:

headache Chills Fever fatigue mucous membrane ulceration of the nose, mouth, pharynx, vagina, and rectum WBC and neutrophils is low

Collaborative Mgt.
Culture and sensitivity if fever occur and ulceration Blood transfusion to provide mature leukocytes Filgrastin (Neopogen)- a human granulocyte colony stimulating factors Protective isolation Antibiotic specific for cultured microorganism Soft bland diet high in calories, protein and vitamins

Nursing intervention
Infection control:
Follow aseptic technique in any procedures Environment must be kept very clean Should avoid crowds Avoid hot and cold temperature Client reports any signs or symptoms of infection Adequate amount of fluids Monitor wbc Provide rest between activities



DIC(DISSEMINATED INTRAVASCULAR COAGULATION) - A syndrome and not a disease - Occurs due to primary disease process or condition like: burns, acute leukemia, metastatic cancer, polycythemia vera, pheochromocytoma, shock, acute infection, septic abortion, abruptio placenta, BT rxn. and trauma - A condition of alternating clotting and hemorrhaging

- Primary

disease stimulation of clotting mechanism -- microthrombi formation process and Fibrinolysis Depletion of clotting factors and Bleeding Obstruction of circulation tendency leads to organ and tissue necrosis. In bleeding - hemorrhage.

Signs and Symptoms

Purpura( reddish purple patches on the skin) chest and abdomen Oozing of blood from venipuncture, mucous membrane, surgical wound Decreased urine output Increased prothombine time and Partial thromboplastin time, thrombin time Decreased fibrinogen and platelet count

Collaborative Mgt.
Lab. Test D DIMER test measures a fibrin split product that is released when a clot breaks Treatment of primary disease. Ex. Infection antibiotic,CA chemotherapy Whole blood or blood products to normalize clotting factor levels Platelets and Packed RBC Cryoprecipitate or fresh-frozen plasma to nomalize clotting factor levels Heparin to prevent the formation of more microthrombi Aminocaproic acid (Amicar) to stop bleeding it inhibit the fibrinolytic process **Fibrinolysis is the process of breaking fibrin apart

Nursing Intervention
Assess previous condition such infection, trauma, CA, Monitor I&O closely and record Monitor color, VS, peripheral pulses, neurological checks If abdominal bleeding is suspected measure abdominal girth every 4 hours Assess surgical wounds, all body orifices for bleeding Assess presence of pulmonary edema, hypotension tachycardia, confusion restlessness, convulsion and coma

Is an inherited bleeding disorder in which there is a lack of clotting factors - The trait is carried on the recessive X chromsome a mother is asymptomatic but can pass the trait to the son who manifest the symptoms TYPES: 1. HEMOPHILIA A lacking of clotting factorsVIII 2. HEMOPHILIA B (CHRISTMAS DISEASE) lacking of factor IX -

Three Classification of Hemophilia

1. Severe factor level less than 1% of normal 2. Moderate factor level 1% to 5% normal 3. Mild factor level 40% normal

Signs & Symptoms

Bleeding main symptom Hemarthrosis bleeding into the joint -> causing pain swelling, redness and fever Spontaneous ecchymoses and bleed from the mouth and GIT & Urinary Complication: INTRACRANIAL HEMORRHAGE

LAB. Test Partial thromboplastin time(PTT) result is prolonged Diagnosed by deficient or absent blood level of factors VIII or IX

administration of clotting factors VIII & IX Hemophilia A fresh frozen plasma and cryoprecipitate that has factor VIII Hemophilia B - fresh frozen plasma that contain factor IX

Desmopressin acetate (DDAVP) Aminocaproic Acid (Amicar) ** To decrease fibrinolytic process

Nursing Intervention
Deficient knowledge r/t disease process: Discuss ways to improve the safety of the clients home environment Advise not to take ASA Encourage to use electric razor and soft-bristled toothbrush Refer to genetic counselling Encourage client to wear Medic-Alert bacelet

Alteration in Comfort Pain r/t inflammation/swelling of tissue and joints Assess for bruising, swelling and joint discomfort Apply ice and pressure to bleeding site Immobilize with a supportive device Administer analgesic as ordered Risk for Injury r/t altered clotting factors: Transfuse clotting factors as ordered Encourage to avoid activities that may cause harm Post emergency medical # for future need. Prevent injuries: wear gloves, long-sleeved clothing when doing household chores, participate in noncontact sport and activities

- Is a decreased in the number of platelet in the blood - The decrease may R/T:
 aplastic anemia tumors, leukemia and chemotherapy Infection or viral illnesses Increased platelet destruction as in DIC or thrombocytopenic purpura that is either drug induced or idiopathic( occurring without cause)

Signs and Symptoms

Petechia Ecchymosis Bleeding from mucous membrane Very low Platelet count ; Prolonged Bleeding Time Hb, Hct is low; BMA shows mostly immature platelets Collaborative Mgt: Transfusion of platelet concentration Apheresis( removal of unwanted components) to remove the autoantibodies Splenectomy - primary site of platelet destruction Corticosteroids to prolong platelet life and strengthen the capillaries Immunosuppressive drugs, gamma globulin, and Vit K High fiver diet

Nursing intervention
Activity should be undertaken to prevent trauma Assess level of pain on pain scale and coping ability Monitor VS, neuro andmental status Assess skin and excretions for signs of bleeding Handle very carefully in all nursing procedures Teach to use razor for shaving, soft bristles toothbrush, wear slippers at all time. Do not take ASA. Eat high fiver diet, blow nose very gently

Test questions Identification: Identify the ff: write the correct answer.
1. 2. 3. Sickledex or Hb.Electrophoresis - are the diagnostic test for sickle cell anemia Anemia decreased number of RBCs and low Hb and hct level DIC is not a disease but a syndrome that occurs because of a clients having a primary disease or condition 4. Hemophilia is a recessive X chromosome inherited bleeding disorder in which the client is lacking clotting factors 5. Severe hemophilia one of the classification of hemophilia wherein the level factor is less than1% of normal 6. Agranulocytosis a severely reduced number of granulocytes(basophil, eosinophils, and neutrophils 7. Leukemia a malignancy of blood forming tissues in which the bone marrow produces increased numbers of immature WBC 8. Phlebotomy one of the treatment of polycytemia which is the removal of blood from a vein 9. Polycythemia is a disease in which there is an increased production of RBC 10. Iron deficiency Anemia - the most common type of anemia and occurs when the body does not have enough iron to synthesize functional Hb.