This document discusses different types of anemia. It begins by defining anemia as a decrease in red blood cells or hemoglobin. The most common types of anemia in adults are then listed as iron deficiency, pernicious, folic acid deficiency, and aplastic anemia. Anemia is divided into categories caused by blood loss, decreased red blood cell production, red blood cell destruction, or fluid overload. Common symptoms are then outlined. Risk factors, diagnostic tests, treatment options, and nursing considerations are provided for several specific types of anemia, including iron deficiency, aplastic, pernicious, and folic acid deficiency anemia.

1. Prepared by: Sangita shrestha
Manisha dhungana

2.  Anemia is usually defined as a decrease in the
amount of red blood cells (RBCs) or the amount of
hemoglobin in the blood. It can also be defined as
a lowered ability of the blood to carry oxygen.
 Iron deficiency anemia, pernicious anemia, folic
acid deficiency anemia and aplastic anemia are the
anemias most commonly seen in adults.

3. There are more than 400 types of anemia, which are
divided into three groups:
 Anemia caused by blood loss
 Anemia caused by decreased or faulty red blood
cell production
 Anemia caused by destruction of red blood cells
 Anemia caused by fluid overload

4. Anemia symptoms vary depending on the cause of
your anemia but may include:
 Fatigue
 Weakness
 Pale skin
 A fast or irregular heartbeat
 Shortness of breath
 Chest pain
 Dizziness
 Cognitive problems
 Cold hands and feet
 Headache

6. These factors place you at increased risk of anemia:
 A diet lacking in certain vitamins. Choosing a diet
that is consistently low in iron, vitamin B-12 and
folate increases your risk of anemia.
 Intestinal disorders. Having an intestinal disorder
that affects the absorption of nutrients in your
small intestine — such as Crohn's disease and
celiac disease — puts you at risk of anemia.
Surgical removal of or surgery to the parts of your
small intestine where nutrients are absorbed can
lead to nutrient deficiencies and anemia.

7.  Menstruation. In general, women who haven't
experienced menopause have a greater risk of iron
deficiency anemia than do men and
postmenopausal women. That's because
menstruation causes the loss of red blood cells.
 Pregnancy. If you're pregnant, you're at an
increased risk of iron deficiency anemia because
your iron stores have to serve your increased blood
volume as well as be a source of hemoglobin for
your growing baby.

8.  Chronic conditions. For example, if you have
cancer, kidney or liver failure, or another chronic
condition, you may be at risk of anemia of chronic
disease. These conditions can lead to a shortage of
red blood cells.
Slow, chronic blood loss from an ulcer
or other source within your body can deplete your
body's store of iron, leading to iron deficiency
anemia.

9.  Family history. If your family has a history of an
inherited anemia, such as sickle cell anemia, you
also may be at increased risk of the condition.
 Other factors. A history of certain infections, blood
diseases and autoimmune disorders, alcoholism,
exposure to toxic chemicals, and the use of some
medications can affect red blood cell production
and lead to anemia.

10.  Common types of anemia
Common types of anemia and their causes
include:
 Iron deficiency anemia: It is a condition in which the
total body iron content is decreased below the
normal level, affecting hemoglobin synthesis.
This type of anemia is often caused by
blood loss, such as from heavy menstrual bleeding,
an ulcer, cancer, a polyp somewhere in your
digestive system, and prolonged use of aspirin or
drugs known as nonsteroidal anti-inflammatory
drugs (NSAIDs), pregnancy, a lack of iron supply in
diet, inability to absorb iron.

11.  Iron deficiency anemia is caused by a
shortage of the element iron in your body.
our bone marrow needs iron to make
hemoglobin. Without adequate iron, our
body can't produce enough hemoglobin for
red blood cells. Decreased hemoglobin may
result in insufficient oxygen delivery to the
tissue. And cause anemia.

12.  Headache, dizziness, fatigue, tinnitus.
 Palpitations, dyspnea on exertion, pallor of
skin and mucous membrane
 In developing countries: smooth, sore
tongue, cheilosis, koilonchia( spoon shaped
nails) and pica

13.  CBC and iron profile: decreased hemoglobin,
hematocrit, serum iron, and ferritin; eleveted
red cells in distribution width and normal or
elevated total iron binding capacity.
 Determination of source of chronic blood loss
may include sigmoidoscopy, colonoscopy,
upper and lower GI studies, stools and urine
for occult blood examination.

14.  Early diagnosis and correction of chronic
blood loss
 Oral and parenteral iron therapy

15. Nursing Assessment
 Obtain history of symptoms, dietary intake, past
history of anemia, possible sources of blood loss.
 Examine for tachycardia, pallor, dyspnea, and signs of
GI or other bleeding.
Nursing Diagnoses
 Imbalanced Nutrition: Less Than Body Requirements
related to inadequate intake of iron
 Activity Intolerance related to decreased oxygen-
carrying capacity of the blood
 Ineffective Tissue Perfusion related to decreased
oxygen-carrying capacity of the blood

16. Nursing Interventions
 Promoting Iron Intake
 Assess diet for inclusion of foods rich in iron.
Arrange nutritionist referral as appropriate.
 Administer iron replacement as ordered. Technique
of parenteral iron administration:
◦ Allow small amount of air in syringe and use new 2-inch
needle for injection to avoid tracking medication through
subcutaneous tissue and resulting painful induration.
◦ Retract skin over muscle of upper outer quadrant of
buttock laterally before inserting needle (Z-track technique)
to prevent leakage along track and staining of skin.

17.  This very rare life-threatening anemia is caused by bone
marrow hypopalsia or aplasia resulting in pancytopania(
insufficient numbers of RBCs, WBCs and platelets). . A
variety of diseases, such as leukemia, myelodysplasia or
myelofibrosis, can cause anemia by affecting blood
production in your bone marrow. The effects of these
types of cancer and cancer-like disorders vary from a mild
alteration in blood production to a complete life-
threatening shutdown of the blood-making process.
Other cancers of the blood or bone marrow
— such as multiple myeloma, myeloproliferative disorders
and lymphoma — also can cause anemia.
 Causes of aplastic anemia include infections, drugs ,
chemical toxins and autoimmune diseases.

18. Many diseases, conditions, and factors can cause
aplastic anemia, including:
 Toxins, such as pesticides, arsenic, and benzene.
 Radiation and chemotherapy (treatments for cancer).
 Medicines, such as chloramphenicol (an antibiotic
rarely used in the United States).
 Infectious diseases, such as hepatitis, Epstein-Barr
virus, cytomegalovirus, parvovirus B19, and HIV.
 Autoimmune disorders, such as lupus and
rheumatoid arthritis.
 Pregnancy. (Aplastic anemia that occurs during
pregnancy often goes away after delivery.)

19.  Anemia with malaise, pallor and associated
symptoms such as palpitations
 Thrombocytopenia (low platelet counts), leading to
increased risk of hemorrhage, bruising and
petechiae
 Leukopenia (low white blood cell count), leading to
increased risk of infection
 Reticulocytopenia (low counts of reticulocytes, that
is, immature red blood cells)

20.  CBC and peripheral blood smear show decreased
RBC, WBC, platelets (pancytopenia)
 Bone marrow aspiration and biopsy: bone marrow
is hypocellular or empty with greatly reduced or
absent hematopoiesis.

21. 1.Remove of causative agent or toxin.
2.Allogenic bone marrow transplantation (BMT) –
treatment of choice for patient with severe
aplastic anemia. This treatment option provides
long-term survival for 75% to 90% of patients,
depending on the age of the patient, history of
prior blood transfusions, and source of marrow.
3.Immunosuppressive treatment with
cyclophosphamide and antirhymocyte globulin or
cyclophospamide. This treatment option provides
long-term survival for 60% to 70% of patients.

22. 4. Androgens (oxymetholone or testosterone
enanthate) may stimulate bone marrow
regeneration; significant toxicity
encountered. They may be used when other
treatments have failed.
5. Supportive treatment includes platelet and
RBC transfusions, antibiotics, and antifungals.

23.  Untreated severe aplastic anemia is almost
always fatal, generally because of
overwhelming infection. Even with treatment,
morbidity and mortality caused by infections
and bleeding are high.
 Late complications, even after successful
treatment, include clonal hematologic
diseases such as paroxysmal nocturnal
hemoglobinuria, myelodysplasia, and acute
myelogenous leukemia

24. Nursing Assessment
 Obtain thorough history that includes
medications, past medical history,
occupation, hobbies.
 Monitor for signs of bleeding and infection.
Nursing Diagnoses
 Risk for Infection related to granulocytopenia
secondary to bone marrow aplasia
 Risk for Injury related to bleeding

25. Nursing Interventions
 Minimizing Risk of Infection
 Care for patient in protective environment while
hospitalized in private room with strict hand
washing and avoidance of any contaminants (see
Patient Education Guidelines, page 944).
 Encourage good personal hygiene, including daily
shower or bath with mild soap, mouth care, and
perirectal care after using the toilet.
 Monitor vital signs, including temperature,
frequently; notify health care provider of oral
temperature of 101° F (38.3° C) or higher.
 Minimize invasive procedures or possible trauma
to skin or mucous membranes.
 Obtain cultures of suspected infected sites or
body fluids.

26. Minimizing Risk of Bleeding
 Use only soft toothbrush or toothette for mouth care
and electric razor for shaving; keep nails short by
filing.
 Avoid I.M. injections and other invasive procedures.
 Prevent constipation with stool softeners as
prescribed.
 Restrict activity based on platelet count and active
bleeding.
 Monitor pad count for menstruating patient; avoid
use of vaginal tampons.
 Control bleeding by applying pressure to site, using
ice packs and prescribed topical hemostatic agents.
 Administer blood product replacement as ordered;
monitor for allergic reaction, anaphylaxis, and
volume overload.

27.  A megaloblast is a large, nucleated
erythrocyte with delayed and abnormal
nuclear maturation. Pernicious anemia is a
type of megaloblastic anemia associated with
vitamin B12 deficiency because of lack of
intrinsic factor in gastric secretion.

28.  Vitamin B12 is necessary for normal deoxyribonucleic
acid synthesis in maturing RBCs.
 Pernicious anemia demonstrates familial incidence
related to autoimmune gastric mucosal atrophy.
 Normal gastric mucosa secretes a substance called
intrinsic factor, necessary for absorption of vitamin
B12 in ileum. If a defect exists in gastric mucosa, or
after gastrectomy or small bowel disease, intrinsic
factor may not be secreted and orally ingested B12 not
absorbed.
 Some drugs interfere with B12 absorption, notably
ascorbic acid, cholestyramine, colchicine, neomycin,
cimetidine, and hormonal contraceptives.
 Primarily a disorder of older people.

29.  pernicious anemia, disease in which the
production of red blood cells (erythrocytes) is
impaired as the result of the body’s inability
to absorb vitamin B12, which is necessary for
red blood cells to mature properly in the
bone marrow. Pernicious anemia is one of
many types of anemia, a disease marked by a
reduction in red blood cells or in the oxygen-
carrying substance hemoglobin found in
those cells.

30. Clinical Manifestations
 Of anemia:”pallor, fatigue, dyspnea on exertion,
palpitations. May be angina pectoris and heart
failure in the elderly or those predisposed to
heart disease.
 Of underlying GI dysfunction:”sore mouth,
glossitis, anorexia, nausea, vomiting, loss of
weight, indigestion, epigastric discomfort,
recurring diarrhea or constipation.
 Of neuropathy (occurs in high percentage of
untreated patients): paresthesia that involves
hands and feet, gait disturbance, bladder and
bowel dysfunction, psychiatric symptoms caused
by cerebral dysfunction.

31. A diagnosis of PA requires several different tests. It
requires a:
 complete blood count (CBC) test
 vitamin B-12 deficiency test
 IF deficiency test
 proof of stomach destruction
 CBC measures the amount of:
- hemoglobin - protein bound to oxygen
to carry it throughout the blood
- hematocrit - used to measure how much
space red blood cells use within the blood

32. Management
 Parenteral replacement with
hydroxocobalamin or cyanocobalamin (B12) is
necessary by I.M. injection from health care
provider, generally every month.
Complications
 Neurologic: paresthesia, gait disturbances,
bowel and bladder dysfunction, and cerebral
dysfunction may be persistent.

33. Nursing Assessment
 Assess for pallor, tachycardia, dyspnea on
exertion, exercise intolerance to determine
patient's response to anemia.
 Assess for paresthesia, gait disturbances,
changes in bladder or bowel function, altered
thought processes indicating neurologic
involvement.
 Obtain history of gastric surgery or GI
disease.

34. Nursing Diagnoses
 Disturbed Thought Processes related to
neurologic dysfunction in absence of vitamin
B12
 Impaired Sensory Perception (kinesthetic)
related to neurologic dysfunction in absence
of vitamin B12

35. Nursing Interventions
 Improving Thought Processes
 Administer parenteral vitamin B12 as
prescribed.
 Provide patient with quiet, supportive
environment; reorient to time, place, and
person if needed; give instructions and
information in short, simple sentences and
reinforce frequently.
.

36. Minimizing the Effects of Paresthesia
 Assess extent and severity of paresthesia,
imbalance, or other sensory alterations.
 Refer patient for physical therapy and
occupational therapy as appropriate.
 Provide safe, uncluttered environment; make
sure personal belongings are within reach;
provide assistance with activities as needed

37.  Patient Education and Health Maintenance
 Advise patient that monthly vitamin B12
administration should be continued for life.
 Instruct patient to see health care provider
approximately every 6 months for
hematologic studies and GI evaluation; may
develop hematologic or neurologic relapse if
therapy inadequate.

38.  Chronic megaloblastic anemia caused by folic acid
(folate, B9) deficiency.
Pathophysiology and Etiology
 Dietary deficiency, malnutrition, marginal diets,
excessive cooking of foods; commonly associated
with alcoholism.
 Impaired absorption of iron in jejunum (eg, with
small bowel disease).
 Increased requirements (eg, with chronic hemolytic
anemia, exfoliative dermatitis, pregnancy).
 Impaired utilization from folic acid antagonists
(methotrexate) and other drugs (phenytoin, broad
spectrum antibiotics, sulfamethoxazole, alcohol,
hormonal contraceptives).

39. Clinical Manifestations
 Of anemia: fatigue, weakness, pallor,
dizziness, headache, tachycardia.
 Of folic acid deficiency: sore tongue, cracked
lips.
Diagnostic Evaluation
 Vitamin B12 and folic acid level: folic acid will
be decreased.
 CBC will show decreased RBC, hemoglobin,
and hematocrit with increased mean
corpuscular volume and mean corpuscular
hemoglobin concentration.

40. Management
 Oral folic acid replacement on daily basis.
Complications
 Folic acid deficiency has been implicated in
the etiology of congenitally acquired neural
tube defects.

41. Nursing Assessment
 Obtain nutritional history.
 Monitor level of dyspnea, tachycardia, and
development of chest pain or shortness of
breath for worsening of condition.
Nursing Diagnosis
 Imbalanced Nutrition: Less Than Body
Requirements related to inadequate intake of
folic acid

42. Nursing Interventions
 Improving Folic Acid Intake
 Assess diet for inclusion of foods rich in folic
acid: beef liver, peanut butter, red beans,
oatmeal, broccoli, asparagus.
 Arrange nutritionist referral as appropriate.
 Assist alcoholic patient to obtain counseling
and additional medical care as needed.

43. Community and Home Care Considerations
 Encourage pregnant patient to maintain prenatal
care and to take folic acid supplement.
 Provide alcoholic patient with information about
treatment programs and Alcoholics Anonymous
meetings in the community.
 Patient Education and Health Maintenance
 Teach patient to select balanced diet that
includes green vegetables (asparagus, broccoli,
spinach), yeast, liver and other organ meats,
some fresh fruits; avoid overcooking vegetables.
 Encourage patient to follow up periodically to
monitor CBC.

45. Introduction
 Sickle cell anemia is an inherited form of anemia
— a condition in which there aren't enough
healthy red blood cells to carry adequate oxygen
throughout your body.
 Normally, your red blood cells are flexible and
round, moving easily through your blood vessels.
In sickle cell anemia, the red blood cells become
rigid and sticky and are shaped like sickles or
crescent moons. These irregularly shaped cells
can get stuck in small blood vessels, which can
slow or block blood flow and oxygen to parts of
the body.

46.  There's no cure for most people with sickle
cell anemia. However, treatments can relieve
pain and help prevent further problems
associated with sickle cell anemia.

48.  Sickle cell anemia is caused by a mutation in the gene that tells
your body to make hemoglobin — the red, iron-rich compound
that gives blood its red color. Hemoglobin allows red blood cells
to carry oxygen from your lungs to all parts of your body. In
sickle cell anemia, the abnormal hemoglobin causes red blood
cells to become rigid, sticky and misshapen.
 The sickle cell gene is passed from generation to generation in a
pattern of inheritance called autosomal recessive inheritance.
This means that both the mother and the father must pass on
the defective form of the gene for a child to be affected.
 If only one parent passes the sickle cell gene to the child, that
child will have the sickle cell trait. With one normal hemoglobin
gene and one defective form of the gene, people with the sickle
cell trait make both normal hemoglobin and sickle cell
hemoglobin. Their blood may contain some sickle cells, but they
generally don't experience symptoms. However, they are carriers
of the disease, which means they can pass the defective gene on
to their children.

49.  The loss of red blood cell elasticity is central to the
pathophysiology of sickle-cell disease. Normal red blood
cells are quite elastic, which allows the cells to deform to
pass through capillaries. In sickle-cell disease, low-
oxygen tension promotes red blood cell sickling and
repeated episodes of sickling damage the cell membrane
and decrease the cell's elasticity. These cells fail to return
to normal shape when normal oxygen tension is restored.
As a consequence, these rigid blood cells are unable to
deform as they pass through narrow capillaries, leading to
vessel occlusion and ischaemia.
 The actual anaemia of the illness is caused by haemolysis,
the destruction of the red cells, because of their shape.
Although the bone marrow attempts to compensate by
creating new red cells, it does not match the rate of
destruction. Healthy red blood cells typically function for
90–120 days, but sickled cells only last 10–20 days.

51.  Severe pain
 Anemia
 Chest pain and difficulty breathing
 Strokes
 Joint pain and arthritis and bone infarctions
 Blockage of blood flow in the spleen or liver
 Severe infections
 Vision problems
 Delayed growth

52.  The patient with sickle trait usually has a
normal hemoglobin level, normal hematocrit,
and a normal blood smear. In contrast the
patient with the sickle cell anemia has a low
hematocrit and sickled cells on the smear.
The diagnosis is confirmed by hemoglobin
electrophoresis.

53.  Treatment for sickle cell anemia is the focus
of continued research. However, aside from
the equally important aggressive
management of symptoms and
complications, there are currently few
primary treatment modalities for sickle cell
disease.
 Peripheral blood stem cell transplant
 Pharmacologic therapy
 Transfusion therapy
 Supportive therapy

54.  Peripheral blood stem cell transplant
It may cure sickle cell anemia. However, this
treatment modality is available to only a small
subset of affected patients, because of either the
lack of a compatible donor or because severe organ
damage( eg, renal, liver, lung) that may be already
present in the patient is a contraindication for
PBSCT.

55.  Pharmacologic therapy
Hydroxyurea(Hydrea) a chemotherapy agent has
been shown to be effective in increasing fetal
hemoglobin levels in patients with sickle cell
anemia, thereby decreasing the formation of sickle
cells.
 Transfusion therapy
RBC transfusion therapy has been shown to be
highly effective in several situations: in acute
exacerbation of anemia, in the prevention of severe
complications from anesthesia and surgery, in
improving the response to infection.

56.  Supportive therapy
supportive care is equally important. Pain
management is a significant issue. The use of
medication to relieve is important. Aspirin is
very useful in diminishing mild to moderate
pain; it also diminishes inflammation and
potential thrombosis. NSAIDs are useful for
moderate pain or combination with opiod
analgesics.

57.  Acute pain related to tissue hypoxia due to
agglutination of sickled cell with in blood
vessels
 Risk for infection

58.  Managing pain
- Guide the rate of pain using pain scale.
- Provide analgesic agent.
- Apply relaxation techniques, breathing exercise
and distraction to the patient
 Prevention and managing infection
- Monitor patient for sign and symptom of
infection
- Provide the prescribed antibiotics
- Assess for the sign of dehydration

59.  Promoting coping skills
- Establish therapeutic relationship to the patient
- Encourage patient on their strength rather than
defecit.
- Allow the patient to make dicisions about daily
care and explain the rationale.
 Minimizing Deficient knowledge
- Explain all the potential side effects of the used
drugs
- Give the sufficient knowledge about the disease
process to the patient

60.  Promoting home and community based care
- Provide knowledge on self care and hygiene
- Provide follow up care.
- Encourage for communication
- Guidelines should be given regarding when to
seek the urgent care.