INTRODUCTION

Anemia is a clinical condition that results from an insufficient supply of healthy red blood cells (RBCs), erythrocytes, to oxygenate the bodys tissue adequately; hypoxia results. The anemias are classified by either the etiology or the morphology of the specific anemia. It is caused in one of the three ways: 1) decrease production of healthy RBCs, 2) increase RBC destruction (hemolysis), or 3) loss of blood. The production of RBCs, erythropoiesis, takesplace in the bone marrow. The requirements for healthy RBCs include precursor cells, reticulocytes, and adequate supplies of iron, vitamin B12, folic acid, protein, pyridoxine, and traces of copper. If any of these factors is missing, the RBCs will be fragile, misshapen, of abnormal size, lacking hemoglobin, or too few. Increase destruction of RBCs can be due to extrinsic causes such as physical trauma while intrinsic causes may include defective hemoglobin. Anemia may also be due to acute blood loss, most commonly seen in trauma or vessel rupture. Morphologic classification is based on erythrocyte size, shape, and color. Morphologic categories include 1. normocytic/normochromic (normal size and color), 2. macrocytic/normochomic (large size, normal color), and 3. microcytic/hypochomic (small size, pale color). TYPES A. ANEMIA CAUSED BY DECREASED ERYTHROCYTE PRODUCTION Decrease production may be due to (1) decrease synthesis of normal hemoglobin, as seen in iron deficiency anemia and thalassemia; (2) defective DNA synthesis, as seen in megaloblastic anemia resulting from cobalamin (vitamin B12) and folate deficiency; or (3) reduced availability of erythrocyte precursors as seen in aplastic anemia.

1. Iron Deficiency Anemia (IDA) is a chronic, hypochromic, microcytic

anemiaresulting from an insufficient supply of iron in the body. Without iron, hemoglobin concentration in the RBCs is reduced and the cells are unable to oxygenate the bodys tissues adequately, resulting in anemia. Major risk factors for IDA include (1) insufficient dietary intake of iron, (2) blood loss, (3) impaired absorption of iron, and (4) excessive demands for RBC production as a result of hemolyis.

2. Thalassemia is a group of genetic disorders that result in inadequate

normal Hb production. Whereas IDA affects heme synthesis, thalassemia disrupts the synthesis of globin. These disorders include alphathalassemia, a relatively benign and asymptomatic condition; beta-

thalassemia minor, a mild to moderate form of microcytic anemia; and beta-thalassemia major, a severe, microcytic, hypochromic anemia that may be fatal. These disorders also cause hemolysis. All are chronic conditions.

3. MegaloblasticAnemiasare a group of disorders caused by impaired DNA

synthesis resulting in defective RBCs. These anemia share the morphology of megaloblasts (large, abnormal, and premature RBCs) in the blood and bone marrow. They are caused by deficiencies of cobalamin (vitamin B12) and folic acid.

a. Cobalamin (vitamin B12) Deficiency/ Pernicous Anemiais an

autoimmune disorder characterized by the absence of intrinsic factor (IF) in gastric secretions, leading to malabsorption of cobalamin (vitamin B12).

b. Folic Acid Deficiency Anemia. Inadequate amounts of folate in the

diet is the usual cause of folate deficiency, with the disorder developing most often in the poor, pregnant women, and in chronic alcoholics. Because folatehelps in the synthesis of DNA, a folate deficiency results in fewer cell divisions and, therefore, decrease red blood cell production. A deficiency in folate during pregnancy is also associated with birth disorders call neural tube defects, such as spina bifida.

4. Aplastic Anemia is caused by failure of the bone marrow, leading to

insufficient production of peripheral blood elements. The marrow failure is due to primary defects in, or damage to, the stem cell or marrow microenvironment. Aplastic anemia may be either hereditary or acquired.

B. ANEMIA CAUSED BY INCREASE ERYTHROCYTE DESTRUCTION

1. Hemolytic Anemia is an end result of many conditions that lead to

hemolysis. Hemolysis, the premature destruction of erythrocytes, can result from physical damage, intrinsic membrane defects, abnormal Hb, erythrocytic enzymatic defects, immune destruction of RBCs by macrophages, or hypersplenism. Anemia occurs when the bone marrow fails to replace RBCs at the rate they are destroyed.

2. Sickle Cell Anemia. Sickle cell disease (SCD) is a group of inherited

disordes of mutant hemoglobin (HbS) that causes the characteristic sickling of RBCs. Sickling occurs only under conditions of low oxygenation. The abnormally shaped RBCs become trapped in capillaries, causing organ damage from infarcts and tissue hypoxia, or are damage in transit, leading to severe anemia. TYPE OF ANEMIA A. ANEMIA CAUSED BY DECREASED ERYTHROCYTE PRODUCTION Iron Deficiency Anemia CAUSATIVE FACTORS (1) Insufficient dietary intake of iron - Malnutrition, Economic constraints, poor dentition, poor appetite Excellent Source of Iron: Almonds, asparagus, beans, carrots, cauliflower, celery, liver, egg yolk, soybeans (2) Blood loss - GI tract (most common site) bleeding, most common in men; Accidents 3) Impaired absorption of iron - Diarrhea, celiac disease, gastrectomy, tannates (in tea and coffee), carbonates, antacid magnesium trisilicate, eating clay and starch. (4) Excessive demands for RBC production as a result of hemolyis (1) Genetically - Mediterranean, African, Southeast Asia origin Those who inherit alpha-genes have alpha thalassemia. Those who inherit one betagene have thalassemia minor; two beta-genes have thalassemia major. (1) Insufficient dietary intake: Rare with cobalamin but common with folate. (2) Drugs that impede absorption in the stomach - Purine analogs (azathioprine), pyrimidine analogs (5-FU), ribonnucleotidereductase inhibitors (hydroxyurea), anticonvulsants (phenytoin), and oral contraceptives. (3) Drugs that impair SIGNS AND SYMPTOMS - Fatigue, weakness - Shortness of breath - Pallor (earlobes, face, palms and mouth, nail bed, conjunctiva) - Brittle spoon-like nails - Cheilosis (sore at the corners of the mouth) - Cheilitis (inflammation of the lips) - Smooth and sore tongue, Glossitis (inflammation of the tongue) - Dizziness - Pica (clay or starch) Angular stomatitis (inflammation of the mucosa of the mouth)

Thalassemia

Pain Failure to thrive Frequent infections Diarrhea Splenomegaly Hepatomegaly Jaundice Bone marrow hyperplasia

Megaloblastic Anemia

a. Cobalamin (vitamin B12)

Deficiency/ Pernicous Anemia Pallor, slight jaundice with a complaint of weakness Smooth, sore, beefy red tongue (glossitis) Diarrhea Paresthesia (altered sensation such as numbness or tingling in the extremeties)

a. Cobalamin
(vitamin B12) Deficiency/ Pernicous Anemia b. Folic Acid Deficiency Anemia

uptake in the ileum Nitrous oxide, cholestyramine, para-aminosalicylic acid, neomycin, metformin, phenformin, and colchicine (4) Genetic Disorders Imerslund-Grasbeck syndrome (defects in the ileal receptors of IF), hereditary trascobalamin II (TCII) deficiency (5) Impaired absorption resulting from medications, neoplasms, GI diseases, or surgical resection of the terminal ileum. (6) GI disorders Gastric atrophy, geastrectomy, gastric stapling, bypass for pancreatic insufficiency of protease, which release Cbl from r binders so Cbl can bing with IF (7) Zollinger-Ellison Syndrome

Aplastic Anemia -

(1) Hereditary Fanconi syndrome, dyskeratosis congenital, Shwachman-Diammond syndrome, Pearson syndrome, Diamond-blackfan syndrome, Amegakaryocytic thrombocytopenia (absent radius [TAR] syndrome) (2) Acquired High-dose radiation and chemotherapy drugs (e.g., antimetabolites, alkylating agents) Toxic chemicals: hair and aniline dyes, herbicides and insecticides, benzene and its derivatives (gasoline, mothballs, paint and varnish removers, dye-cleaning solutions and household cleaners) Certain drugs: chloramphenicol,

Impaired proprioception (difficulty identifying ones position in space, which may progress to difficulty with balance) - Fair-haired or prematurely gray - GI : weight loss, appetite loss, nausea, vomiting, abdominal distension, diarrhea - Neurologic disorder: Paresthesia (altered sensation such as numbness or tingling in the extremeties), poor gate, memory loss, cognitive problems, depression b. Folic Acid Deficiency Anemia - Pallor, progressive weakness, fatigue - Shortness of breath, cardiac palpitations - Glossitis, Cheilosis - GI: same as in Pernicous Anemia - Neurological symptoms in Vitamin B12 deficiency are not seen in folic acid deficiency - Fatigue, weakness, headache - Dyspnea, rapid heart rate - Pallor - Frequent infections - Unexplained bruising, easy bruising - Nosebleeds, bleeding gums - Heavy menses - Blood in the stool - Prolonged bleeding from cuts - Skin rash - Bone pain - Foot swelling - Fever

B. ANEMIA CAUSED BY INCREASE ERYTHROCYTE DESTRUCTION Hemolytic Anemia

sulfonamides, quinacrine, phenylbutazone, anticonvulsants (Phenytoin and Mephenytoin), gold compounds, streptomycin, tripenelamine, meprobamate, carbon tetrachloride, arsenic. - Autoimmune disorders such as systemic lupus eryhtematosus - Infectious agents: hepatitis, Epstein-Barr virus, human immunodeficiency virus, parvovirus, military tuberculosis, and mycobacterial infections - Diseases of the bone marrow: leukemia, graft-versus-host disease. Eosinophilic fasciitis, and fulminant hepatitis - Preganacy (rare like autoimmune) - Idiopathic (an environmental etiology is rarely identified) Hemolysis can result from: (1) Hereditary disorders - Intracorpuscular defects (G-6PD) (2) Acquired Hemolytic condition - Immune reactions - Toxic chemicals: arsenic, lead copper, and certain snake venoms - Drugs: penicillin, ampicillin, cephalothin, methicillin, phenylbutazone, phenacetin, quinine, quinidine, and L-dopa - Parasitic disease that disruots RBC membrane (malaria, Clostridium welchii) - Physical damage to the RBC membrane: hemodialysis, heart-lung machines and prosthetic cardiac valves

The client with hemolytic anemia may suffer all the general manifestations of anemia. Pallor, severe fatigue, malaise, weakness, lightheadedness Fever Exertional dyspnea Headache Vertigo Sensitivity to cold Weight loss Glossitis Cheilosis Cheilitis Paresthesias Confusion Loss of balance Mental depression Dry skin, brittle nails, spoon-shaped concave nails Pallor Jaundice Fatigue Irritability Large joints and surrounding tissue may become swollen during crisis

Sickle Cell Anemia

(1) Genetically Areas of the world where malaria is endemic: Africa, Mediterranean, Middle East, India

Priapism (abdominal, painful continuous erection of the penis) may occur if the penile vein are obstructed Pain

POSSIBLE COMPLICATIONS

Anemia diminishes the capability of individuals who are affected to perform physical labor. This is a result of one's muscles being forced to depend on anaerobic metabolism. The lack of iron associated with anemia can cause many complications, including hypoxemia, brittle or rigid fingernails, cold intolerance, impaired immune functioning, and possible behavioral disturbances in children. Hypoxemia resulting from anemia can worsen the cardio-pulmonary status of patients with pre-existing chronic pulmonary disease. Brittle or rigid fingernails may be a result of abnormal thinness of nails due to insufficient iron supply. Cold intolerance occurs in one in five patients with iron deficiency anemia, and becomes visible through numbness and tingling. Impaired immune functioning leading to increased likelihood of sickness is another possible complication. Finally, chronic anemia may result in behavioral disturbances in children as a direct result of impaired neurological development in infants, and reduced scholastic performance in children of school age. Behavioral disturbances may even surface as an attention deficit disorder.

DIAGNOSIS Procedures: 1. Complete Blood Count (CBC)is a series of tests used to evaluate the composition and concentration of the cellular components of blood. It measures the following: The number of red blood cells (RBCs) The number of white blood cells (WBCs) The total amount of hemoglobin in the blood The fraction of the blood composed of red blood cells (hematocrit) The mean corpuscular volume (MCV) the size of the red blood cells CBC also includes information about the red blood cells that is calculated from the other measurements: MCH (mean corpuscular hemoglobin) - the average mass of hemoglobin per red blood cell in a sample of blood. MCHC (mean corpuscular hemoglobin concentration) - the average mass of hemoglobin per red blood cell in a sample of blood. The platelet count is also usually included in the CBC.

Nursing Responsibilities: (1) Apply pressure on the venipuncture site after obtaining a sample (done by RMT). (2) Observe for bleeding. (3) Explain the purpose of the procedure. (4) Secure laboratory request prior to examination. 2. Bone Marrow Aspiration is the withdrawal of specimen of bone marrow. The sites are posterior superior iliac crest fro adults and proximal tibia for children. Nursing Responsibilities: (1) Secure consent. (2) Inform the client that the procedure may cause discomfort and pain. (3) Position the client in a prone or lateral position. (4) Monitor and maintain pressure dressing over punctured site for 10 minutes. (5) Assess for discomfort. (6) Administer prescribed pain meds.

3. Peripheral Blood Smear is a blood test that gives information about the
number and shape of blood cells.

4. Schillings Test is a urine test done to evaluate whether vitamin B12 is being absorbed by the body.
Nursing Responsibilities: (1) Instruct the patient to fast, may drink water, before starting the test, then eat normally for the next 24 hours. (2) You may ask the client to stop taking any medications for it may affect the test. (3) Instruct the client to have not undergone any parenteral (intramuscular injection) of vitamin B12 3 days prior to the test. (4) Instruct the client to wash their genital/perineal thoroughly with clean water and wipe with clean towel before obtaining urine sample. 5. Amniocentesis is the aspiration of amniotic fluid from the uterus. It is done at 14 to 16 weeks of pregnancy. Expected Outcomes: Iron deficien cy RBC count Hb/HcT RBC morpholo gy Reticuloc yte Platelets MCV MCH MCHC Serum Iron Mic/H N or N or + Thalasse mia N to - (beta trait +) Mic/H Cobalami n B12 Mac/N + - to N + - With malFolic acid Deficien cy Mac/N + - to N + Aplasti c Anemi a N/N N N N Hemoly tic Anemia N/N + Sickle Cell Anemia Sickle cells + +

+ +

N or +

absoption TIBC Serum Ferritin Bilirubin Marrow Aspirate + N or Absence of hemosiderin + + Megaloblasts Megaloblasts Aplastic : remaining cells normal -WBC N to + - Indirec t bilirubin N or +

Others

-Transferrin saturatio n

Hb electrophoresis, Amniocentesis

-Serum vit. B12 + Schilling

-Serum Folate

-Folate

+Hb S, Hb electrophoresis, -Haptoglobin, + Fibrinogen , + Urobilinogen, + Stercobilinogen, Amniocentesis

+ Increase or positive; - decrease or negative; Hb hemoglobin; HcT hematocrit; Hb S sickle hemoglobin; Mac/N macrocytic/normochromic; MCV mean corpuscular volume; MCH mean corpuscular hemoglobin; MCHC mean corpuscular hemoglobin concentration; Mic/H microcytic/hypochromic; N normal; N/N normocytic/normochromic; RBC red blood cell; TIBC total iron-binding capacity; WBC white blood cell

MEDICATION and THERAPY 1. Oxygen Therapy Oxygen therapy may be prescribed for clients with severe anemia because their blood has a reduced capacity for oxygen. Oxygen helps to prevent tissue hypoxia and lessen the workload of the heart as it struggles to compensate for the lower Hb levels. 2. Eryhtropoietin Subcutaneous injections of erythropoietin can be given to treat anemias of chronic disease because this drug increases the production of RBCs. For this drug to be effective, the client must have bone marrow capable of producing RBCs and sufficient nutrients for the production of RBCs. 3. Iron Replacement

Iron can be given to augment oral intake in cases where the need for iron is immediate or the demands are beyond dietary measures. The oral form of iron should used because it is inexpensive and convenient. It is usually given for mild forms of anemia. 4. Blood Transfusion Blood transfusions are valuable in treating anemia resulting from acute blood loss. It may also befit clients with severe chronic anemia (Hb<6 g/dL) who have responded poorly to other forms of therapy. Packed RBCs may be given to clients who have lost blood in surgery or due to trauma.