Podcast
Questions and Answers
A patient with anemia is experiencing fatigue and shortness of breath. What is the underlying physiological cause of these symptoms?
A patient with anemia is experiencing fatigue and shortness of breath. What is the underlying physiological cause of these symptoms?
- Reduced oxygen-carrying capacity of the blood due to decreased hemoglobin. (correct)
- Excessive iron stores interfering with cellular metabolism.
- Increased red blood cell production leading to hyperviscosity.
- Elevated white blood cell count causing systemic inflammation.
Which set of laboratory findings would the nurse expect to see in a patient with polycythemia vera?
Which set of laboratory findings would the nurse expect to see in a patient with polycythemia vera?
- Normal hemoglobin, normal hematocrit, and normal red blood cell count.
- Increased hemoglobin, increased hematocrit, and increased red blood cell count. (correct)
- Decreased hemoglobin, decreased hematocrit, and decreased red blood cell count.
- Decreased hemoglobin, increased hematocrit, and normal red blood cell count.
A patient with pernicious anemia is prescribed Vitamin B12 injections. Which statement explains why injections are necessary instead of oral supplements?
A patient with pernicious anemia is prescribed Vitamin B12 injections. Which statement explains why injections are necessary instead of oral supplements?
- Oral B12 is only effective for iron-deficiency anemia.
- Injections provide a faster route of delivery.
- Oral B12 is toxic for patients with pernicious anemia.
- Pernicious anemia impairs the absorption of oral B12 in the stomach. (correct)
Which intervention is most important for the nurse to perform immediately if a patient exhibits signs of a blood transfusion reaction?
Which intervention is most important for the nurse to perform immediately if a patient exhibits signs of a blood transfusion reaction?
A patient with anemia reports experiencing dizziness and lightheadedness. What is the priority nursing intervention related to this symptom?
A patient with anemia reports experiencing dizziness and lightheadedness. What is the priority nursing intervention related to this symptom?
A patient with a history of chronic obstructive pulmonary disease (COPD) is diagnosed with secondary polycythemia. What is the most likely cause of this condition in this patient?
A patient with a history of chronic obstructive pulmonary disease (COPD) is diagnosed with secondary polycythemia. What is the most likely cause of this condition in this patient?
A nurse is teaching a patient with iron-deficiency anemia about dietary modifications. Which food should the nurse recommend to enhance iron absorption?
A nurse is teaching a patient with iron-deficiency anemia about dietary modifications. Which food should the nurse recommend to enhance iron absorption?
What nursing diagnosis is most appropriate for a patient with anemia who reports constant fatigue and weakness?
What nursing diagnosis is most appropriate for a patient with anemia who reports constant fatigue and weakness?
The nurse is preparing to administer an intramuscular iron injection to a patient with iron-deficiency anemia. Which technique is essential to prevent skin staining?
The nurse is preparing to administer an intramuscular iron injection to a patient with iron-deficiency anemia. Which technique is essential to prevent skin staining?
A patient receiving a blood transfusion develops chills, lower back pain, and a fever. What is the nurse's priority action?
A patient receiving a blood transfusion develops chills, lower back pain, and a fever. What is the nurse's priority action?
Which of the following foods, if consistently absent from the diet, would most likely contribute to iron-deficiency anemia?
Which of the following foods, if consistently absent from the diet, would most likely contribute to iron-deficiency anemia?
What is the primary function of red blood cells (RBCs) in the body?
What is the primary function of red blood cells (RBCs) in the body?
The nurse is caring for a patient with anemia. Which assessment finding is most indicative of tissue hypoxia?
The nurse is caring for a patient with anemia. Which assessment finding is most indicative of tissue hypoxia?
Which of the following interventions is most important to include in the care plan of a patient with a platelet count of 20,000/mm3?
Which of the following interventions is most important to include in the care plan of a patient with a platelet count of 20,000/mm3?
A patient with pernicious anemia is likely to exhibit which neurological symptom?
A patient with pernicious anemia is likely to exhibit which neurological symptom?
Which of the following nursing interventions is most appropriate for a patient with anemia who has impaired oral mucous membrane integrity?
Which of the following nursing interventions is most appropriate for a patient with anemia who has impaired oral mucous membrane integrity?
A nurse is caring for a patient receiving packed red blood cells. How frequently should the nurse monitor the patient for a reaction during the initial phase of the transfusion?
A nurse is caring for a patient receiving packed red blood cells. How frequently should the nurse monitor the patient for a reaction during the initial phase of the transfusion?
A male patient's hemoglobin level is 13.0 g/dL. How should the nurse interpret this result?
A male patient's hemoglobin level is 13.0 g/dL. How should the nurse interpret this result?
A patient with polycythemia vera is at increased risk for which of the following complications?
A patient with polycythemia vera is at increased risk for which of the following complications?
Which of the following is a compensatory mechanism in secondary polycythemia?
Which of the following is a compensatory mechanism in secondary polycythemia?
The physician orders the administration of intravenous normal saline alongside a blood transfusion. What is the primary purpose of infusing normal saline?
The physician orders the administration of intravenous normal saline alongside a blood transfusion. What is the primary purpose of infusing normal saline?
Which nursing intervention is appropriate for a patient with anemia experiencing dyspnea?
Which nursing intervention is appropriate for a patient with anemia experiencing dyspnea?
What is the rationale for instructing a patient taking liquid iron supplements to use a drinking straw?
What is the rationale for instructing a patient taking liquid iron supplements to use a drinking straw?
A patient with anemia is being discharged. Which instruction about activity is most appropriate?
A patient with anemia is being discharged. Which instruction about activity is most appropriate?
Why is it important for a patient with anemia to maintain good oral hygiene?
Why is it important for a patient with anemia to maintain good oral hygiene?
A patient with polycythemia vera is prescribed aspirin. What is the primary reason for this medication?
A patient with polycythemia vera is prescribed aspirin. What is the primary reason for this medication?
What is indicated by ecchymosis observed during a physical examination?
What is indicated by ecchymosis observed during a physical examination?
A patient with anemia complains of palpitations. What should the nurse monitor to assess this symptom?
A patient with anemia complains of palpitations. What should the nurse monitor to assess this symptom?
Which of the following interventions is most helpful in conserving energy for a patient with anemia?
Which of the following interventions is most helpful in conserving energy for a patient with anemia?
Which of the following is a sign of a hemolytic transfusion reaction?
Which of the following is a sign of a hemolytic transfusion reaction?
A nurse is educating a patient about the importance of including iron-rich foods in their diet. Which of the following foods should the nurse recommend?
A nurse is educating a patient about the importance of including iron-rich foods in their diet. Which of the following foods should the nurse recommend?
Which vitamin is essential for the absorption of iron in the body?
Which vitamin is essential for the absorption of iron in the body?
What is the primary reason for monitoring hemoglobin and hematocrit levels in patients with anemia?
What is the primary reason for monitoring hemoglobin and hematocrit levels in patients with anemia?
Which of the following is a common early sign or symptom of anemia?
Which of the following is a common early sign or symptom of anemia?
A nurse is planning care for a patient with decreased activity tolerance related to tissue hypoxia. Which intervention is most appropriate?
A nurse is planning care for a patient with decreased activity tolerance related to tissue hypoxia. Which intervention is most appropriate?
A patient with anemia reports a craving for non-food items such as clay. What term is associated with this behavior?
A patient with anemia reports a craving for non-food items such as clay. What term is associated with this behavior?
A patient with longstanding anemia is exhibiting increased respirations and heart rate. What physiological response is most likely occurring?
A patient with longstanding anemia is exhibiting increased respirations and heart rate. What physiological response is most likely occurring?
Flashcards
What is Anemia?
What is Anemia?
A condition where the circulating blood is deficient in red blood cells (RBCs) or hemoglobin, reducing oxygen delivery to tissues.
What causes a decrease in RBCs?
What causes a decrease in RBCs?
Impaired production, increased destruction, or blood loss.
Signs and symptoms of Anemia include.
Signs and symptoms of Anemia include.
Pallor, tachycardia, tachypnea, fatigue, shortness of breath, lightheadedness, dizziness, weakness, palpitations.
What to monitor in Anemia?
What to monitor in Anemia?
Signup and view all the flashcards
Nursing diagnoses for Anemia?
Nursing diagnoses for Anemia?
Signup and view all the flashcards
Vitamins to help produce RBCs?
Vitamins to help produce RBCs?
Signup and view all the flashcards
Observations during blood transfusion?
Observations during blood transfusion?
Signup and view all the flashcards
Signs of a transfusion reaction?
Signs of a transfusion reaction?
Signup and view all the flashcards
Interventions for transfusion reaction?
Interventions for transfusion reaction?
Signup and view all the flashcards
Good sources of Iron?
Good sources of Iron?
Signup and view all the flashcards
Foods that contribute iron to the body?
Foods that contribute iron to the body?
Signup and view all the flashcards
Good sources of Vitamin C?
Good sources of Vitamin C?
Signup and view all the flashcards
What is polycythemia?
What is polycythemia?
Signup and view all the flashcards
What are the two types of polycythemia?
What are the two types of polycythemia?
Signup and view all the flashcards
Expected hematocrit in polycythemia?
Expected hematocrit in polycythemia?
Signup and view all the flashcards
Ecchymosis?
Ecchymosis?
Signup and view all the flashcards
Pernicious anemia symptom?
Pernicious anemia symptom?
Signup and view all the flashcards
Platelet count is 20,000/mm3?
Platelet count is 20,000/mm3?
Signup and view all the flashcards
Discontinue transfusion if a pt is having a reaction?
Discontinue transfusion if a pt is having a reaction?
Signup and view all the flashcards
Normal lab values for HgB?
Normal lab values for HgB?
Signup and view all the flashcards
Normal lab values for Hematocrit?
Normal lab values for Hematocrit?
Signup and view all the flashcards
RBC function?
RBC function?
Signup and view all the flashcards
What fluid infusions are used with blood transfusions?
What fluid infusions are used with blood transfusions?
Signup and view all the flashcards
Study Notes
Anemia
- Condition with a deficiency in red blood cells (RBCs) and/or hemoglobin (Hgb) in circulating bolld
- Results in reduced oxygen delivery to tissues, as hemoglobin carries oxygen
- Can arise from impaired RBC production
- Can arise from increased RBC destruction
- Can arise from blood loss (massive or chronic)
Signs and Symptoms of Anemia
- Pallor may occur
- Tachycardia may occur
- Tachypnea may occur
- Fatigue may occur
- Shortness of breath may occur
- Lightheadedness may occur
- Dizziness may occur
- Weakness may occur
- Palpitations may occur
Nursing Considerations for Anemia
- Monitor hemoglobin (Hbg) and hematocrit (Hct) levels
- Monitor responses to therapy
- Monitor fatigue level
- Monitor ability to ambulate safely and perform activities of daily living (ADLs)
- Assess dyspnea and oxygen saturation
- Assess for pallor in the skin and conjunctivae
Nursing Diagnoses for Anemia
- Decreased activity tolerance related to tissue hypoxia and dyspnea
- Imbalanced nutrition: less than body requirements related to disease, treatment, or lack of knowledge about adequate nutrition
- Impaired oral mucous membrane integrity related to altered dietary status
Interventions for Anemia
- Monitor vital signs before and after activity
- Plan care to conserve energy after periods of activity
- Assist the patient with self-care activities as needed
- Encourage limiting visitors, calls, and interruptions to conserve energy
- Administer oxygen as ordered to relieve dyspnea
- Consult a dietitian for diet instruction if dietary deficiency causes anemia
- Teach patients with folic acid deficiency to include foods from each food group at every meal
- Supplement instruction as ordered
- Vitamin B12 injections are given for life to patients with pernicious anemia, because oral B12 isn't absorbed
- Administer intramuscular iron injections through the Z-track method
- Use a drinking straw when administering liquid iron supplements
- Provide oral hygiene to keep the oral cavity clean and prevent infection
- Encourage soft, bland foods while healing
- Suggest a soft toothbrush for oral care because it is gentler until healing occurs
Vitamin Supplementation for Anemia
- Iron
- Folic acid
- Vitamin B12
Monitoring During Blood Transfusion
- Observe the patient closely for the first 15 minutes of the blood transfusion, due to risk of reaction
Signs of a Transfusion Reaction
- Rash
- Elevated temperature, increase of 1.8°F (1°C) from baseline
- Aches (back pain, chest pain, headache)
- Chills
- Tachycardia (especially if increased from baseline)
- Increased respirations (increase from baseline)
- Oliguria (low or no urine output)
- Nausea/GI issues like diarrhea
- Back pain
- Chest pain
- Itching
- Shortness of breath
- Headache
- Nausea and vomiting
- Anxiety
- Hypotension
- Feeling of impending doom
Nursing Interventions for a Transfusion Reaction
- Stop the transfusion immediately, and note the time
- Stay with the patient and closely monitor them
- Monitor vital signs every five minutes
- Disconnect the blood tubing at the access site, and replace it with new tubing and 0.9% normal saline to keep the vein open.
- Notify the doctor and the blood bank of what is occurring
- Call for help from other staff members
Medications for Transfusion Reactions
- Treatment is dependent on the type/severity of the reaction.
- Corticosteroids can be used to suppress the immune response
- Antihistamines can be used to decrease the immune response
- Antipyretics can be used to decrease the temperature
- Vasopressors (epinephrine, dopamine) can be used to open up the airways or increase renal blood flow
- Diuretics can be used to help get rid of excess fluid
Iron Deficiency Anemia
- Most often due to an inadequate intake of iron-rich foods
- Good food sources of iron include animal meats, legumes, iron-fortified grains, dried fruits and green leafy vegetables
Vitamin C and Iron Absorption
- Vitamin C can help the body absorb iron.
- Good food sources of Vitamin C include citrus fruits, strawberries, kiwis, mangos, tomatoes, broccoli, peppers and cabbage
Polycythemia
- Condition where the blood becomes thick with too many RBCs, which inhibits normal circulation
Types of Polycythemia
- Polycythemia vera (PV), also known as primary polycythemia, is a rare type of cancer.
- Most people with PV have a specific genetic mutation
- Onset is usually in adults over age 50
- RBCs, platelets, and white blood cells (WBCs) are all overproduced, and the bone marrow becomes packed with too many cells
- Organs become congested with cells, and the tissues become packed with blood as cells overproduced
- Thick blood and platelets lead to thrombosis and occlusion of vessels
- Secondary polycythemia results from long-term hypoxia
- Common coexisting conditions include COPD, cardiovascular problems such as chronic heart failure, high altitudes, and smoking
- The body makes more RBCs in response to the low oxygenation
- Considered a compensatory mechanism
Hematocrit Values in Polycythemia
- Affected patients will have an elevated hematocrit (Hct) level
- In polycythemia vera, laboratory tests show a hemoglobin level greater than 18 mg/dL and a hematocrit level greater than 55%.
- Normal hematocrit values are 43%-49% for males and 38%-44% for females.
Ecchymosis
- Larger areas of discoloration from hemorrhage under the skin
- Bruises
Pernicious Anemia Symptoms
- Numbness of the hands or feet
- Weakness
- Memory problems
Low Platelet Counts
- A plt platelet count of 20,000/mm3 requires initiating bleeding precautions
Blood Transfusion Reaction
- Discontinue the blood transfusion immediately if a patient is having a reaction to it
Normal WBC Count
- Normal lab value: 4,500-11,000/mm3
Normal Hemoglobin (Hgb) Values
- Male: 14-17.3 g/100 mL
- Female: 11.7-15.5 g/100 mL
Normal Hematocrit (Hct) Values
- Male: 43%-49%
- Female: 38%-44%
RBC Function
- Red blood cells (RBCs), with the help of hemoglobin, carry oxygen from the lungs throughout the body
- RBCs remove carbon dioxide (CO2) and transport it to the lungs
Low RBC Values
- Low red blood cell (RBC) values indicate the patient is anemic
- Symptoms of anemia include pallor, tachycardia, tachypnea, fatigue, shortness of breath (SOB), lightheadedness/dizziness, and palpitations
Additional Fluids During Transfusion
- 0.9% normal saline
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
