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Anemia a Decrease in Oxygen-carrying Hemoglobin and Its Pathophysiology:Nursing Case Study

Saturday, 8 March 2014

Anemia is a decrease in the quantity of circulating oxygen-carrying pigment hemoglobin (Hb). It's considered a symptom of a disease. It can be categorized as acute or chronic and labeled as mild (Hb level greater than 10 g/dl), moderate (Hb level 6 to 10 g/dl), or severe (Hb level less than 6 g/dl). It can be classified according to cause or red blood cell (RBC) morphology.

Anemia results from decreased RBC production, blood loss, or RBC destruction (hemolysis). Physiologic response is based on the onset and severity of decreased Hb and the specific cause of RBC loss. Since Hb carries oxygen, decreased levels affect oxygen levels of the blood and can have a detrimental systemic effect on organs and body system function.

■ Tissue hypoxia
■ Shock
■ Hypotension
■ Cardiopulmonary compromise
■ Transfusion reaction

Nursing history by functional health pattern
Health perception and management
■ Fatigue, headaches, dizziness, irritability, cold intolerance, or palpitations at rest
■ Recent fever
■ History of bleeding, renal disease, liver disease, cancer, chronic infections, angina, or inflammation
■ Recent exposure to a chemical or myelotoxic substance or to large doses of radiation
■ Family history of a hemolytic disorder

Nutrition and metabolism

■ Weight loss, anorexia, nausea, or indigestion
■ Burning sensation of the tongue
■ Chewing or sucking ice

■ Tarry stools, constipation, diarrhea, or flatulence (all rare)
■ Brown, hazy urine (rare)
■ Gross blood in excretions (rare)

Activity and exercise
■ Fatigue and weakness
■ Increasing activity intolerance
■ Shortness of breath, palpitations, or claudication during exercise

Cognition and perception
■ Dizziness or difficulty concentrating

Sexuality and reproduction
■ Loss of libido, irregular menstruation or amenorrhea (if female), or impotence (if male)

Physical Examination

General appearance and nutrition
■ Fatigued
■ Facial puffiness

■ Pallor of skin and mucous membranes
■ Diaphoresis
■ Delayed wound healing
■ Purpura
■ Jaundice
■ Spider angiomas
■ Koilonychia (spoon nails)—late sign of iron deficiency
■ Cool skin

■ Dyspnea on exertion
■ Tachypnea
■ Orthopnea

■ Tachycardia
■ Cardiac enlargement
■ Murmurs
■ Dependent edema
■ Vascular bruits
■ Bounding arterial pulses

Diagnostic studies
■ Hb level may be decreased with iron deficiency, pernicious, hemolytic, and hemorrhagic anemias.
■ Hematocrit may be low.
■ RBC count may be below normal.
■ Microscopic evaluation of peripheral blood (performed by a hematologist) reveals the size, shape, color, and number of RBCs; it's useful in diagnosing the specific type of anemia.

Note: The morphologic classification of anemias is based on structural changes seen in RBCs, which are classified by size and hemoglobin content:

– Normocytic (normal size) and normochromic (normal color) RBCs are associated with anemias of sudden blood loss; pregnancy; such chronic diseases as cancer, kidney disease, or chronic infection; and some hemolytic anemias.

– Macrocytic (abnormally large) and normochromic RBCs are associated with pernicious anemia, folic acid anemia, vitamin B12 deficiency, and some hemolytic anemias.

– Microcytic (abnormally small) and normochromic RBCs are associated with anemias of chronic disease.

– Microcytic and hypochromic (pale‑colored) RBCs are associated with iron deficiency anemia and thalassemia.

■ Erythrocyte indices define the size, Hb weight, and Hb concentration of a typical RBC; mean corpuscular volume (MCV) gives the average cell size; mean corpuscular hemoglobin gives the average hemoglobin weight; and mean corpuscular hemoglobin concentration (MCHC) identifies the average hemoglobin volume. Low MCV and MCHC indicate microcytic, hypochromic anemia (such as iron deficiency anemia and thalassemia); a high MCV suggests macrocytic anemia (such as folic acid anemia or vitamin B12 deficiency).
■ Reticulocyte count, if low, may indicate hypoplastic or pernicious anemia; if high, it may indicate bone marrow response to anemia resulting from blood loss or hemolysis.
■ Erythrocyte fragility test, if low, may indicate thalassemia, iron deficiency anemia, or sickle cell disease; if high, it may indicate spherocytosis (hereditary disorder associated with autoimmune hemolytic anemia).
■ Direct Coombs' test may indicate autoimmune hemolytic anemia if the response is positive.
■ Hemoglobin electrophoresis identifies hemoglobin types by measuring the degree of negative charge
■ Sickle cell test identifies sickle cell disease and trait (Hb electrophoresis is then needed to differentiate the two disorders).
■ Serum iron level and total iron‑binding capacity (TIBC) with serum iron level decrease and TIBC increase indicate iron deficiency anemia.
■ Serum folic acid levels that result in low levels may indicate megaloblastic anemia.
■ Serum vitamin B12 levels that result in low levels could indicate inadequate dietary intake of vitamin B12 or a malabsorption disorder.
■ Bone marrow aspiration and biopsy used in histologic examination and differential count with erythroid‑myeloid ratio is useful for differential diagnosis of aplastic, hypoplastic, or pernicious anemia.
■ Liver‑spleen scan can detect splenomegaly associated with hereditary spherocytosis.

Teaching checklist
■ Type of anemia, its causes, and the treatment plan
■ Medications
■ Dietary modifications
■ Activity plan
■ Follow-up care
■ Community agencies and support groups
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