HYPOPROLIFERATIVE ANEMIAS

APLASTIC ANEMIA - MEDICAL MANAGEMENT

- CURE: hematopoietic stem cell transplant (HSCT) - REQ: YOUNGER than 60, healthy, who have a compatible donor - MANAGED: with immunosuppressive therapy, (combo of antithymocyte globulin (ATG) and cyclosporine or androgens - S/E: fever, chills, sudden onset of a rash or bronchospasm may herald anaphylaxis and requires prompt management, serum sickness (fever, rash, arthralgias, and pruritus, can be reduced by corticosteroids, may take weeks to resolve) - immunosuppressants prevent the patient's lymphocytes from destroying the stem cells - corticosteroids are NOT very useful as immunosuppressive agents in LONG TERM, b/c susceptible to bone complications them - supportive therapy: any offending agent is discontinued, pt supported with transfusions of PRBCs and platelets - infections are AGGRESSIVELY treated - death usually caused by infection (bacterial or fungal)

IRON DEFICIENCY ANEMIA - ASSESSMENT AND DIAGNOSTIC FINDINGS

- DEFINITIVE method of diagnosis: bone marrow aspiration - strong correlation between iron stores and hemoglobin levels - iron stores depleted = hemoglobin level falls - diminished iron stores = small erythrocytes. MCV, size, DECREASES - hematocrit and RBC levels = low in relation to hemoglobin - other lab tests that measure iron stores are useful but not as precise as ferritin levels - pts w/ iron deficiency anemia have LOW serum iron level and an ELEVATED TIBC, (transport protein supplying the marrow with iron, transferrin)

CLASSIFICATION OF ANEMIAS

- PHYSIOLOGICAL approach classifies anemia according to whether the deficiency in erythrocytes is caused by a defect in their production (hypoproliferative), by their destruction (hemolytic), or by their loss (bleeding) - HYPOPROLIFERATIVE anemias - bone marrow does NOT produce adequate numbers of RBC's - reflected by a low or inappropriately normal reticulocyte (baby RBC) count -may result from marrow damage due to meds (Chloromycetin), chemicals (benzene), or from a lack of factors (iron, vitamin B12, folic acid, erythropoietin) necessary for RBC formation - HEMOLYTIC anemias - destruction of rbc results in leak of hemoglobin from the rbc into the plasma; its converted in large part to bilirubin and the bilirubin level rises - increased rbc destruction leads to tissue hypoxia, which stimulates rbc production, increased production reflected in an increased reticulocyte count as the bone marrow responds to the loss of erythrocytes - hemolysis can result from an abnormality W/I THE ERYTHROCYTE ITSELF (sickle cell disease, glucose-6-phosphate dehydrogenase deficiency), W/I THE PLASMA (hemolytic anemias), or from DIRECT INJURY TO RBC W/I THE CIRCULATION (hemolysis caused by a mechanical heart valve)

FOLIC ACID + VIT B12 - ASSESSMENT AND DIAGNOSTIC FINDING

- SERUM LEVELS of both vitamins can be measured - vitamin B12 assay is typically the initial test used

ANEMIA

- a condition in which the hemoglobin concentration is lower than normal - reflects the presence of fewer than the normal number of erythrocytes (RBCs) w/i the circulation - amount of oxygen delivered to body tissues is also diminished

APLASTIC ANEMIA

- a rare disease caused by: decrease in or damage to marrow stem cells damage to the microenvironment within the marrow replacement of the marrow with fat. - in addition to severe anemia, significant NEUTROPENIA and THROMBOCYTOPENIA also occur

APLASTIC ANEMIA - NURSING MANAGEMENT

- assess carefully for signs of infection and bleeding - monitor for s/e: hypersensitivity reaction to ATG - long-term cyclosporine therapy s/e effects,: renal or liver dysfunction, hypertension, pruritus, visual impairment, tremor, and skin cancer - inform that the metabolism of ATG is altered by many meds so check for drug-drug interactions - stress importance of not abruptly stopping their immunosuppressive therapy

ANEMIAS - NURSING INTERVENTIONS

- assist patient to prioritize activities and establish a balance between activity and rest - if chronic anemia: maintain SOME physical activity and exercise to prevent the deconditioning. assess for other conditions that trigger fatigue, pain, depression, sleep disturbance - healthy diet should be encouraged, inform patient that alcohol interferes with the utilization of nutrients, advise MODERATION, supplements (vitamins, iron, folate, protein) may be prescribed

APLASTIC ANEMIA - PATHO

- can be acquired, congenital, but most cases are idiopathic - viral infections and pregnancy can trigger it - may be caused by: MEDS, CHEMICALS, or RADIATION DAMAGE - may produce marrow aplasia: benzene and benzene derivatives (airplane glue, paint remover, dry-cleaning solutions) - potential causes, toxic materials: inorganic arsenic, glycol ethers, plutonium, radon

VITAMIN B 12 DEFICIENCY - PATHO

- can develop in STRICT VEGANS who consume NO meat or dairy products, faulty absorption from GI tract (older adult) - decreased B12 absorption: Crohn's disease, after ileal resection, bariatric surgery, or gastrectomy - chronic use in : histamine blockers, antacids, or proton pump inhibitors (reduce gastric acid production), metformin (diabetics) - other cause: absence of intrinsic factor = pernicious anemia -w/o intrinsic factor, orally consumed vitamin B12 CANNOT be adequately absorbed and rbc production is eventually diminished - body normally has large stores of vitamin B12, so years may pass before the deficiency results in anemia - pts with pernicious anemia have a higher incidence of gastric cancer, may benefit from having endoscopies to screen for early gastric cancer

MEGALOBLASTIC ANEMIA

- caused by deficiencies of vitamin B12 or folic acid - erythrocytes ABNORMALLY shaped, vary widely (poikilocytosis), erythrocytes very large, the MCV is very high, usually exceeding 110 fl -megaloblastic anemias develop slowly (over months), the body can compensate well for a long time - Caucasians: skin develops a lemon-yellow color resulting from simultaneous pallor and mild jaundice (from mild hemolysis of red cells)

ANEMIAS - COMPLICATIONS

- complications of SEVERE anemia: HF, paresthesias, delirium - pts w/ heart disease likely to have angina or sympt of heart failure than those w/o heart disease - potential complication: HF, angina, paresthesia, confusion, injury related to falls , depressed mood

ANEMIA OF INFLAMMATION

- delineates the chronic diseases of inflammation, infection, and malignancy as causes for this type of anemia - many chronic inflammatory diseases are associated with a NORMOchromic, NORMOcytic anemia - hemoglobin level RARELY falls below 9 g/dL, and bone marrow has normal cellularity with increased stores of iron as the iron is diverted from the serum, erythropoietin levels are LOW, perhaps b/c of decreased production

FOLIC ACID DEFICIENCY - PATHO

- folate FOUND IN: green veggies and liver - DEFICIENCY IN: ppl who RARELY eat UNCOOKED veggies and consumers of alcohol - folic acid requirements increased in: pts w/ liver disease, chronic hemolytic anemias, pregnant women - malabsorptive diseases of the small bowel, such as celiac disease, may not absorb folic acid normally

FOLIC ACID + VIT B12 - MEDICAL MANAGEMENT

- folate deficiency tx: increase folic acid in diet and 1 mg of folic acid daily - pts who abuse alcohol should receive folic acid as long as they continue to consume alcohol - vitamin B12 deficiency tx: vitamin B12 replacement - vegans: oral supplements with vitamins or fortified soy milk. - if due to absorption or absence of intrinsic factor: monthly IM injections of vitamin B12 - reticulocyte count rises within 1 week, in 4 - 8 weeks the blood counts return to normal, tongue feels better and appears less red in several days -neurologic manifestations require more time for recovery; if severe neuropathy, pt may never recover fully - prevent pernicious anemia: vitamin B12 therapy must be continued for life

IRON DEFICIENCY ANEMIA - NURSING MANAGEMENT

- food sources HIGH in iron: organ meats (beef, calf's liver, chicken liver), other meats, beans (black, pinto, and garbanzo), leafy green vegetables, raisins, molasses - take foods with source of vitamin C (orange juice) b/c enhances absorption of iron - encourage to continue iron therapy as long as prescribed even if they don't feel fatigued anymore - GI side effects of iron: constipation, cramping, nausea, and vomiting - Solution: decrease frequency of iron supplements or take w/ food BUT will diminish absorption so it may take longer to increase iron stores - some iron supplement formulas limit GI S/E by addition of stool softener or use of sustained-release formulations to limit nausea or gastritis - AVOID slow-release formulations b/c iron is released beyond the DUODENUM (site of maximal iron absorption) - antacids or DAIRY should NOT be taken with iron (diminish absorption)

ANEMIAS - ASSESSMENT AND DIAGNOSTIC FINDINGS

- health history includes: medication history, accurate history of alcohol intake (amount and duration), family history is (certain anemias are inherited), athletic endeavors (extreme exercise can decrease erythropoiesis and erythrocyte survival) - nutritional assessment: may indicate deficiencies in iron, vitamin B12, and folate (STRICT VEGETARIANS @ RISK FOR MEGALOBLASTIC ANEMIAS) if they do not supplement their diet with B12, OLDER ADULTS too - assessment to include: presence of peripheral numbness and paresthesias, ataxia, poor coordination, and confusion. Delirium, particularly in older adults. important to monitor lab test results and any changes over time - hemoglobin, hematocrit, reticulocytes, and RBC indices, (MCV) and RDW especially useful - increased cardiac workload can result in: tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea, HF AEB enlarged heart (cardiomegaly) and liver (hepatomegaly) and peripheral edema - women: menstrual periods and use of iron supplements during pregnancy - CBC useful in determining whether the anemia is an isolated problem or part of another hematologic condition (leukemia or myelodysplastic syndrome (MDS) -bone marrow aspiration may be performed - other diagnostic studies may be performed to determine presence of underlying chronic illness (malignancy, blood loss, polyps or ulcers)

ANEMIAS IN RENAL DISEASE

- in general, patients do not become significantly anemic until the glomerular filtration rate (GFR) is less than 30 mL/min/1.732

FOLIC ACID + VIT B12 - NURSING MANAGEMENT

- inspection of the skin, mucous membranes, and tongue. - careful neurologic assessment including tests of position, vibration sense, and cognitive function - particular attention to ambulation and assess the gait and stability and need for assistive devices - ensure safety when position sense, coordination, and gait are affected - avoid excessive heat and cold - mouth and tongue soreness may limit nutritional intake: eat small amounts of bland, soft foods frequently

APLASTIC ANEMIA - CLINICAL MANIFESTATIONS

- manifestations often insidious - complications: infection, symptoms of anemia (fatigue, pallor, dyspnea), purpura (should trigger a CBC and hematologic eval), throat infections, cervical lymphadenopathy, splenomegaly, retinal hemorrhages

ANEMIAS - CLINICAL MANIFESTATIONS

- more rapidly an anemia develops, more severe its symptoms - pt who is gradually anemic, with hemoglobin levels between 9 and 11 g/dL, usually has fewer or no symptoms other than slight tachycardia on exertion and possibly fatigue - weakness, fatigue, general malaise, pallor of skin and mucous membranes (conjunctivae, oral mucosa) = common in anemias - MEGALOBLASTIC: jaundice, angular cheilosis, brittle, ridged, concave nails, beefy red and sore tongue - IRON DEFICIENCY: smooth and red tongue and restless leg syndrome

HYPOPROLIFERATIVE ANEMIAS - IRON DEFICIENCY ANEMIA

- most common type of anemia in all age groups, the world, most common cause of BLOOD LOSS, prevalent in developing countries - seen with vegetarian diets or from blood loss - most common cause in men and POST-menopausal women: bleeding from ulcers, gastritis, inflammatory bowel disease, or GI tumors - most common cause in PRE-menopausal women: menorrhagia and pregnancy with inadequate iron supplementation - CHRONIC BLOOD LOSS (from GI tract): pts with chronic alcoholism, take aspirin, steroids, or NSAIDs - MALABSORPTION: seen after gastrectomy, bariatric surgery, celiacs, other inflammatory bowel disease; medications (proton pump inhibitors, H2 blockers) - iron deficiency pts will PRIMARILY have symptoms of anemia, if its severe/prolonged, may have smooth, red tongue; brittle and ridged nails; and angular cheilosis

APLASTIC ANEMIA - ASSESSMENT AND DIAGNOSTIC FINDINGS

- occurs when a med or chemical is ingested in toxic amounts - CBC reveals PANCYTOPENIA ( decrease in ALL myeloid stem cell-derived cells) - neutrophil <1500/μL, hemoglobin < 10 g/dL, and platelets <50,000/μL - bone marrow aspirate shows an extremely hypoplastic or even aplastic (very few to no cells) marrow REPLACED WITH FAT

IRON DEFICIENCY ANEMIA - MEDICAL MANAGEMENT

- stool specimens should be tested for OCCULT BLOOD - 50 years of age or older: colonoscopy, endoscopy, or x-ray of GI tract to detect ulcerations, gastritis, polyps, or cancer - pts w/ celiac disease, had gastric surgery may not absorb from their diet - PRIMARY MODE OF TX: oral iron supplementation - hemoglobin may increase in a few weeks, anemia can be corrected in a few months -iron store replenishment takes much longer, must take iron for as long as 6 - 12 months

FOLIC ACID + VITAMIN B12 - CLINICAL MANIFESTATIONS

- symptoms of folic acid and vitamin B12 deficiencies are similar, and the two anemias may coexist - vitamin B 12: neurologic manifestations, persist if B12 is not replaced - PERNICIOUS ANEMIA: smooth, sore, red tongue, mild diarrhea, extremely pale (mucous membranes), confused, paresthesias in extremities (numbness and tingling in feet and lower legs), difficulty w/ balance, lose position sense (proprioception). - symptoms are progressive, w/o treatment, patients can die after several years, usually from heart failure secondary to anemia