What is Anemia?
Anemia is a deficiency in the:
- Number of erythrocytes (RBCs)
- Quantity of hemoglobin
- Or both
Anemia is not a specific disease but rather a manifestation of a pathologic process. It is classified by laboratory review of Complete Blood Count (CBC), Reticulocyte count, and Peripheral blood smear.
Classification
Morphologic
Based on cellular characteristics - the appearance and size of red blood cells
Etiologic
Based on underlying cause - what is causing the anemia
Clinical Manifestations
Clinical manifestations are caused by the body's response to tissue hypoxia. Manifestations vary based on rate of development, severity of anemia, and presence of co-existing disease.
Integumentary
- Pallor - ↓ Hemoglobin, ↓ Blood flow to skin
- Jaundice - ↑ Serum bilirubin
- Pruritus - ↑ Bile salt concentrations
Cardiopulmonary
- Heart & lungs work harder to provide O₂
- Increased heart rate & stroke volume
- Increased O₂ unloading from HGB
Dark Skin Assessments:
- Pallor: Brown skin = yellow-brown, Black skin = ashen gray
- Check oral mucosa and nail beds
- Jaundice: Check oral mucosa, hard palate, and sclera
Nursing Diagnoses
Goals: Assume normal activities of daily living, maintain adequate nutrition, develop no complications related to anemia
Gerontologic Considerations
Anemia is common in older adults due to:
- Chronic disease
- Nutritional deficiencies
⚠️ Important: Signs and symptoms may go unrecognized or may be mistaken for normal aging changes.
Iron-Deficiency Anemia
The most common type of anemia worldwide. Understanding the causes, symptoms, and treatment is crucial for nursing practice.
Etiology (Causes)
Inadequate Dietary Intake
Only 5% to 10% of ingested iron is absorbed by the body
Malabsorption
Iron absorption occurs in the duodenum. Diseases or surgery that alter this area cause anemia
Blood Loss
2 mL whole blood = 1 mg iron. Major cause in adults (GI/GU systems, pregnancy)
Clinical Manifestations
- General manifestations of anemia
- Pallor - most common finding
- Glossitis - 2nd most common (inflammation of tongue)
- Cheilitis - inflammation of lips
Diagnostic Studies
Laboratory Findings: Hgb, Hct, MCV, MCH, MCHC, reticulocytes, serum iron, TIBC, bilirubin, platelets
Severity Classification
Mild
Hgb 10-12
Moderate
Hgb 6-10
Severe
Hgb < 6
Additional Tests
Collaborative Care
Goal: Treat the underlying disease causing reduced intake or absorption of iron
- Replace iron
- Nutritional therapy
- Oral or occasional parenteral iron supplements
- Transfusion of packed RBCs
Drug Therapy
Oral Iron Therapy
- Inexpensive and convenient
- Daily dose: 150 to 200 mg
- Best absorbed as ferrous sulfate in acidic environment
- Liquid iron should be diluted and ingested through a straw
⚠️ Important: Enteric-coated or sustained-release capsules are counterproductive
Side Effects: Heartburn, constipation, diarrhea
Parenteral Iron Therapy
Indications:
- Malabsorption
- Oral iron intolerance
- Need for iron beyond normal limits
- Poor patient compliance
- Can be given IM or IV
- IM may stain skin
- Continue iron therapy for 2 to 3 months after hemoglobin levels return to normal
Cobalamin (Vitamin B12) Deficiency
A type of megaloblastic anemia caused by impaired DNA synthesis and presence of megaloblasts.
Etiology
Most Common Cause: Pernicious anemia, which is caused by an absence of Intrinsic Factor (IF)
- Insidious onset
- Begins in middle age or later
- Predominant in Scandinavians and African Americans
Other Causes
Clinical Manifestations
General manifestations of anemia develop slowly due to tissue hypoxia.
Gastrointestinal
- Sore tongue
- Anorexia
- Nausea & vomiting
- Abdominal pain
Neuromuscular
- Weakness
- Paresthesias of feet & hands
- ↓ Vibratory and position senses
- Ataxia
- Muscle weakness
- Impaired thought processes
Diagnostic Studies
- Macrocytic RBCs with abnormal shapes and fragile cell membranes
- Decreased serum cobalamin levels
- Normal serum folate + low cobalamin = megaloblastic anemia due to cobalamin deficiency
- Upper GI endoscopy with biopsy of gastric mucosa
Collaborative Care
⚠️ Critical: Parenteral or intranasal administration of cobalamin is the treatment of choice
1-3 years
Patients will die without treatment
Important: This anemia can be reversed with ongoing treatment, but long-standing neuromuscular complications may not be reversible
Folic Acid Deficiency
Another cause of megaloblastic anemia. Folic acid is required for DNA synthesis, RBC formation, and maturation.
Key Difference from B12 Deficiency
Clinical manifestations are similar to cobalamin deficiency, but the absence of neurologic problems differentiates them.
Common Causes
Diagnostic Studies
- Serum folate level is low (Normal: 3 to 25 mcg/mL or 7 to 57 nmol/L)
- Serum cobalamin level is normal
Treatment
- Replacement therapy: Usual dose is 1 mg per day by mouth
- Encourage patient to eat foods with large amounts of folic acid
Anemia of Chronic Disease (Anemia of Inflammation)
A type of anemia associated with chronic inflammatory conditions and diseases.
Causes
Chronic inflammation from:
Pathophysiology
- Underproduction of RBCs
- Mild shortening of RBC survival
- Normocytic, normochromic, and hypoproliferative RBCs
- Usually mild anemia but can become severe if untreated
Laboratory Findings
- ↑ Serum ferritin
- ↑ Iron stores
- Normal folate and cobalamin levels
Treatment
Best Approach: Treating the underlying cause
- Rarely blood transfusions
- Conservative use of erythropoietin therapy
Aplastic Anemia
Aplastic Anemia is characterized by pancytopenia - a decrease in all blood cell types:
- Red blood cells (RBCs)
- White blood cells (WBCs)
- Platelets
It features hypocellular bone marrow and ranges from chronic to critical.
Incidence & Types
2 per 1 million
Low incidence - affects 2 of every 1 million persons
Congenital
Chromosomal alterations present from birth
Acquired
Results from exposure to ionizing radiation, chemical agents, viral and bacterial infections
Clinical Manifestations
- Abrupt or gradual development
- Symptoms caused by suppression of any or all bone marrow elements
- General manifestations of anemia (Fatigue, dyspnea)
- Cardiovascular and cerebral responses
- Neutropenia
Diagnostic Studies
Diagnosis confirmed by laboratory studies:
- Low Hgb, WBC, and platelet values
- Low reticulocyte count
- Prolonged bleeding time
- Elevated serum iron and TIBC
- Hypocellular bone marrow with increased fat content (yellow marrow)
Nursing & Collaborative Management
- Identify and remove causative agent (when possible)
- Provide supportive care until pancytopenia reverses
- Prevent complications from infection
- Prevent hemorrhage
3-6 months
Median survival for severe untreated aplastic anemia
Hope: 20% survive longer than 1 year. Immune therapies and bone marrow transplantation can be curative.
Polycythemia Vera
Polycythemia Vera is a neoplastic disease arising from a chromosomal mutation
It causes increased production of:
This leads to increased blood viscosity, blood volume, and congestion of organs/tissues with blood.
Signs & Symptoms
Hypervolemia & Hyperviscosity
- Hypertension (HTN)
- Ruddy face
Other Manifestations
- Splenomegaly
- Thrombophlebitis
- Hemorrhagic phenomena
- Epigastric pain
- Hyperuricemia (gout, pruritus)
Management
Phlebotomy
Removal of blood to reduce viscosity
Hydration
Keep well hydrated
Allopurinol
For hyperuricemia/gout
Myelosuppressive Agents
To reduce blood cell production
Patient Teaching Points
- Keep well hydrated
- Elevate feet when sitting
- PROM/AROM, exercise
- Use electric shaver
- Use soft toothbrush
- Report chest pain immediately
Test Your Knowledge
Answer the following questions to check your understanding of anemia types and management.
1. What is the most common clinical manifestation of iron-deficiency anemia?
Correct! Pallor is the most common finding in iron-deficiency anemia. Glossitis is the second most common.