Anemias

Structure of the Hematologic System

• Blood is a key component of the hematologic system
• Blood cells make up 45% of the blood's volume

Red Blood Cells (RBCs)

• Erythrocytes are the primary type of red blood cell
• Hemoglobin, which contains iron, is the main component of erythrocytes
• Hemoglobin enables the oxygen-carrying capacity of blood
• RBCs have a lifespan of approximately 120 days

White Blood Cells (WBCs)

• Leukocytes are the primary type of white blood cell
• Leukocytes help the body fight infection and tissue injury
• A normal WBC count ranges from 4,000 to 11,000

Platelets

• Thrombocytes are also known as platelets
• Platelets have a lifespan of about 7-10 days

Bone Marrow

• Bone marrow is the site of blood cell production
• Bone marrow is highly vascular
• Self-replicating stem cells are found in the bone marrow

Plasma

• Plasma constitutes the fluid portion of blood, and is about 90% water
• Albumin and globulin are the proteins found in plasma
• Plasma makes up 50% of blood volume

Reticuloendothelial System (RES)

• RES is part of the hematologic system

Changes Associated with Aging

• Leukopenia, also known as anemia, manifests as a result of age
• There is a decreased response of bone marrow to produce erythrocytes, platelets, and leukocytes The number of circulating leukocytes decreases
• The development of T cells and B cells declines with age
• Bone marrow may become more susceptible to the suppressive effects of medications
• The body's demand for RBCs may exceed the bone marrow's production capacity

Hematologic Diseases

• Anemia occurs when hemoglobin concentration is lower than the usual level
• Anemia indicates fewer than normal circulating RBCs
• Diminished oxygen delivery to tissues results from anemia
• Anemia is often a sign of an underlying disorder

Hypoproliferative Anemia

• Hypoproliferative anemia primarily involves erythrocytes
• The bone marrow does not produce enough RBCs
• Iron deficiency is a common cause

Iron Deficiency Anemia

• Insufficient dietary iron leads to inadequate hemoglobin synthesis
• Deficiency in vitamin B12 or folic acid can also lead to anemia (megaloblastic anemia)
• Glucophage and metformin can inhibit B12 absorption

Anemia Treatments

• Treatment includes parenteral iron and oral supplements for 6-12 months

Anemia Medical Management

• Testing stool for occult blood is a part of medical management
• Colonoscopy, endoscopy, and X-rays of the GI tract are used for those over 50 to assess the environment for gastritis, polyps, diverticulitis, cancers, and ulcerations

Folic Acid Deficiency

• Increase folic acid in the patient's diet
• Administer 1 mg of folic acid daily orally; patients with malabsorption receive it intramuscularly
• Alcohol abusers should receive folic acid as long as they continue to consume alcohol

B12 Deficiency

• B12 replacement can be oral in small amounts
• Intramuscular injections are administered for life on a monthly basis if oral absorption is not possible

Nursing Management of Anemia

• Patient education is key for preventative measures
• Patients need to stay on the course of oral supplements, even if they feel better after 2-12 months, for best results
• Iron is best absorbed on an empty stomach; instruct patients to take supplements at least 1 hour before or 2 hours after meals to avoid absorption reduction with food
• Orange juice, citrus juice, strawberries, broccoli, and tomato enhance iron absorption and its side effects because of Vitamin C
• Side effects include constipation, nausea, cramping, and vomiting
• When constipation becomes an issue, instruct the patient to eat foods high in fiber and add a stool softener to their regimen
• Dark tarry stool is a common side effect

Medication Reconciliation and Nutrition

• Nutrition includes foods high in iron
• Organ meats such as liver are high in iron, along with garbanzo beans and raisins
• Folate is found in green leafy vegetables
• Vitamin C in foods such as orange juice enhances iron absorption
• Nutritional counseling is a key measure in patient care

Nursing Assessment for Anemia

• Assess skin, mucous membranes, and tongue
• Prescribe a bland diet and soft foods for patients with sensitive tongue and oral mucous membranes

Comprehensive Neurological Assessment

• Assess cognitive function, positioning, gait stability, and level of assistance
• Referrals for physical and occupational therapy may be needed
• Jaundice might be present during visual assessment

Skin Assessment

• Patches of skin pigment loss occur as a sign of vitiligo
• Premature graying of hair is common in pernicious anemia patients

Hemolytic Anemia

• Includes premature destruction of erythrocytes
• Other forms include sickle cell anemia, thalassemia, G-6-PD deficiency, and immune hemolytic anemia

Anemia of Chronic Diseases

• Anemia of inflammation is caused by malignancy and infection
• Occurs in kidney disease patients with a GFR less than 30, which leads to cardiac output issues, reduced O2 utilization, cognitive function concerns, reduced immunoresponsiveness, and reduced libido
• Possible during critical illness
• Inflammatory proteins are commonly elevated due to aging
• Predisposition to weight loss, mobility issues, generalized weakness/frailty, and balance issues can occur

Anemia in Rheumatoid Arthritis Patients

• Symptoms are usually mild to moderate
• Hemoglobin rarely drops below 9

Anemia Treatment

• Successful treatment/management of the underlying disorder enables bone marrow iron to make erythrocytes, thus increasing hemoglobin levels

Aplastic Anemia

• A rare condition resulting from damage to bone marrow stem cells
• Can be idiopathic (unknown cause), acquired, or congenital (present at birth)
• Symptoms develop gradually without obvious warning signs
• Triggers include viral infections, pregnancy, certain chemicals/drugs, needs, or radiation-induced damage
• Symptoms: fatigue, weakness, pallor, dyspnea, pupura (small pin-like discolored hemorrhagic spots)

Aplastic Anemia Diagnosis and Treatment

• A complete blood count (CBC) should be ordered if symptoms are present
• Lab values: neutrophils less than 1500, hemoglobin less than 10, platelets less than 50
• Management: stem cell transplant for patients younger than 60, otherwise relatively healthy, with a compatible donor. In other patients, immunosuppressive therapy is utilized

Aplastic Anemia Nursing Assessment

• Assess for signs of infection and bleeding due to problems related to leukocytes, platelets, and erythrocytes
• Medication reconciliation should be done in addition to patient education

Polycythemia

• Increased RBCs
• 50% increase in females and 55% increase in males
• Primary Polycythemia Vera:
  • caused by proliferative disorder of stem cells
  • onset at 65 years old
    • life expectancy of 14+ years
    • possible death by thrombosis and hemorrhage
• Secondary Polycythemia:
  • excessive production of erythropoietin
    • caused by reduced oxygen, or hypoxia
    • affects COPD patients, smokers, people with sleep apnea, and people with heart disease
    • treatment depends on the underlying condition
    • therapeutic phlebotomy may be considered

Thrombocytopenia

• Characterized by low platelet levels stemming from:
  • decreased production of platelets in bone marrow
  • increased destruction of platelets
    • or increased consumption of platelets
• Risk factors:
  • leukemia patients
    • compromised immune systems
    • as a medicine side effect that can affect children and adults
• Possible indication of internal bleeding depending on level
  • bleeding and petechia may occur if platelet levels are less than 20,000

Thrombocytopenia: Assessments

• Diagnosing leukemia involves examining bone marrow through aspiration and biopsy
• Genetic reasoning for thrombocytopenia consists of autosomal recessive, autosomal dominance, and hepatitis B and C. Patients should be screened for these diseases
• Medical management includes addressing the underlying condition. Platelet transfusion may stop bleeding in cases of poor production

Thrombocytopenia Nursing Interventions

• Interventions include: - addressing the cause, duration, and patient condition - patient education - interventions promoting patient safety, taking pulse, fall prevention and being aware of bleeding risk

Patient Assessment Components

• Health and nutritional history
• Assess ethnicity, family history, prescription/OTC medications, herbal supplements and immunization data
• Focus on symptom onset by asking about functioning ability, disabilities, and coping mechanisms

Diagnostic and Therapeutic Approaches

• CBC
• PT/INR
• PTT
• Bone Marrow Exams (aspiration/biopsy requiring consent)

Therapeutic Approaches

• Pressure management
• Possible complications are bleeding and infection
• Mild analgesic (Tylenol) could provide comfort
• Splenectomy: surgical removal of the spleen
• Apheresis: separates specific blood components and returns the remainder following centrifuge. Useful for obtaining large amounts of platelets

Stem Cell Transplantation

• A stem cell transplant can treat hematologic disorders
• Allogenic transplantation involves donors can be more effective
• During autologous transplantation stem cells are extracted, stored, and returned to the patient at a later date
• Nursing diagnosis includes attention to nutrition, potential gas exchange issues, risk of injury, and fatigue

Blood Transfusion Management

• One unit of blood includes 450-500mL blood, 50mL anticoagulant. Blood consists of:
  • whole blood
    • PRBCs stored at 34.2°F or 4°C which may be stored for 42 days if special preservatives are added
  • platelets
    • must be stored at room temperature
    • lasts an approximate of 5 days
• Agitation of the blood is required while blood is stored

Blood Components and Donation Requirements

• Blood may contain albumin, Factor VIII, Factor IX, or immune globulin that are not in blood after one year if frozen
• American Red Cross sets blood donation requirements
• Donors must:
  • weigh at least 110 lbs to donate 450mL
  • be 17 and older
  • have a temperature no higher than 99.6°F
  • blood pressure with systolic levels between 80-180 and diastolic levels between 50-100, hemoglobin must be at least 12.5

Blood Donation

• Donor will remain in the recumbent state to sit safely
• Blood cannot be collected within 72 hours of surgery
• A primary blood benefit is the prevention of viral infection
• The donated blood will be tested for defects/infections

Blood Collection Methods

• Intro-op salvaging involves collecting, filtering, and re-infusing blood during surgery. This blood cannot be stored
• Hemodilution involves removing one to two blood units and replacing solution to dilute
• Autologous: common for elective surgery with possible iron supplement prescription
• Directed may not be as safe with friends and family that want to donate

Key Pre-Transfusion Measures

• Collected blood is tested for antibodies/viruses
• Pre-transfusion assessments include vital signs, fluid status, respiratory/ cardiac system evaluation, or skin
• Rh antigen is present on the erythrocyte's surface

Pre-Transfusion: Patient History

• Previous transfusion reactions symptoms require proper identification
• Obtain medical history, including pregnancies(↑Females)
• Be aware of reaction/incompatible blood issues

Pre-Transfusion: Patient Education

• Educate patients on the signs of adverse reactions/effects of blood transfusions
• Symptoms may have a low chance of patient contract, with compatibility assured via cross-matching practices

Nurse Expectations

• Obtain written consent and take baseline vitals

Safe Transfusion Protocol

• Take note of tubing changes and blood types with provider note and compare vital signs

Transfusion Reactions

• Always check labels with another RN pre and post transfusion
• Monitor and initiate first for the initial 30 minutes of transfusion

Refusal of Transfusion

• Patient must be competent and of full mental capacity/ fully oriented
• Take into account religious, cultural beliefs, and alternative treatments possible

Febrile Non-Hemolytic Reaction

• Occurs more frequently among multiple transfusions and in Rh negative women
• Requires other ruling out of other causes
• A sign may include chills, fever, or muscle aches

Acute Hemolytic Reaction

• A life-threatening instance/ reaction to incompatible blood

Dangerous Acute Hemolytic Reaction

• Requires only 10mL
• Signs and symptoms:
  • Fevers
  • Chills
  • Lower back pain
  • Nausea
  • Dyspnea
  • Chest tightness
  • Anxiety
  • Hemoglobin levels are not normal
  • Hypertension
  • Bronchospasms

Transfusion Associated Circulatory Overload (TACO)

• Aggravated/ exaggerated through increased hyperkalemia, age and medical history/ diagnoses
• Must assess properly to avoid overload that can stem from transfusions

Blood Transfusion: Signs & Symptoms

• Some recognizable signs of transfusion can cause distress through:
  • tachycardia
  • dyspnea
    • increased blood pressure/ anxiety
      • jugular vein distention can be present

Bacterial Contamination from Blood Transfusions

• A transfusion can cause contamination, often resulting from organisms on the donors' skin
• Platelets are frequently stored at room temperature, increasing the risk of contamination
• Meticulous phlebotomy lessens the chance of bacterial growth
• Sepsis can be seen several hours after transfusion

Transfusion Related Acute Lung Injury (TRALI)

• Often a severe reaction that is a cause of lung injury from transfusion
• Specific antibodies lead to reaction in donors that leads to acute symptoms

Transfusion Lung Injury Symptoms

• Acute shortness of breath and low O2 saturation
• Often pulmonary edema and necessitates quick supportive therapy

Delayed Hemolytic Reaction

• Signs and symptoms:
  • anemia
  • fever
  • increased bilirubin
    • jaundice

Transfusion Reaction Management

• Monitor patient vitals and consult doctor
• Blood products must be inspected
• A reaction requires attention to blood pressure monitor

Transfusion Outcomes

• A patient can demonstrate adequate cardiac output and homeostasis following a blood transfusion
• Fluid balance occurs, and the patient remains normothermic