Anemia,

Leukemia,
Polycythemia
a condition marked by a deficiency of
red blood cells or of hemoglobin in the
blood, resulting in pallor and weariness.
Main Causes of Anemia
 Anemia from active bleeding
 Loss of blood through heavy menstrual
bleeding or wounds can cause anemia
 Gastrointestinal ulcers or cancers such as
cancer of the colon may slowly ooze
blood and can also cause anemia
 Iron deficiency anemia: The bone marrow
needs iron to make red blood cells.
What Causes Anemia
 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 Blood Loss
 Red blood cells can be lost through
bleeding, which often can occur slowly
over a long period of time, and can go
undetected.
 This kind of chronic bleeding commonly
results from the following:
 Gastrointestinal conditions such as
ulcers, hemorrhoids ,gastritis (inflammation
of the stomach), and cancer
Cont…
 Use of nonsteroidal anti-inflammatory
drugs (NSAIDs) such
as aspirin or ibuprofen, which can cause
ulcers and gastritis
 Menstruation, especially if menstrual
bleeding is excessive
Anemia Caused by
Decreased or Faulty Red Blood
Cell Production
 With this type the body may produce too
few blood cells or the blood cells may not
function correctly
 Red blood cells may be faulty or
decreased due to abnormal red blood
cells or a lack of minerals
and vitamins needed for red blood cells
to work properly.
Conditions associated with
these causes of anemia
 SickleCell Anemia
 Iron-deficiency anemia
 Vitamin deficiency
 Bone marrow and stem cell problems
 Other health conditions
Sickle Cell Anemia
 isan inherited disorder
 Red blood cells become crescent-
shaped because of a genetic defect.
 They break down rapidly, so oxygen does
not get to the body's organs, causing
anemia.
 The crescent-shaped red blood cells can
also get stuck in tiny blood vessels,
causing pain
Iron-deficiency anemia
 occurs because of a lack of the mineral
iron in the body. Bone marrow in the
center of the bone needs iron to make
hemoglobin, the part of the red blood cell
that transports oxygen to the body's
organs.
 Without adequate iron, the body cannot
produce enough hemoglobin for red
blood cells
Causes of Iron Deficiency
Anemia
 An iron-poor diet, especially in infants,
children, teens, vegans, and vegetarians
 The metabolic demands of pregnancy
and breastfeeding that deplete a
woman's iron stores
 Menstruation
 Frequent blood donation
 Endurance training
 Digestiveconditions such as Crohn’s
disease or surgical removal of part of the
stomach or small intestine
 Certain drugs, foods, and caffeinated
drinks
Vitamin-deficiency anemia
 may occur when vitamin b12 and folate
are deficient. These two vitamins are
needed to make red blood cells.
Conditions leading to anemia
caused by vitamin deficiency
include:
 Megaloblastic: Vitamin B12 or folate or both
are deficient
 Pernicious: Poor vitamin B12
absorption Dietary deficiency: Eating little or
no meat may cause a lack of vitamin B12,
while overcooking or eating too few
vegetables may cause a folate deficiency.
 Other causes of vitamin deficiency:
pregnancy, certain medications, alcohol
abuse, intestinal diseases such as tropical
sprue and celiac disease
 Duringearly pregnancy, sufficient folic
acid can help prevent the fetus from
developing neural tube defects such
as spina bifida
Bone marrow and stem cell
problems
 may prevent the body from producing
enough red blood cells. Some of the stem
cells found in bone marrow develop into
red blood cells.
 If stem cells are too few, defective, or
replaced by other cells such as
metastatic cancer cells, anemia may
result
Anemia resulting from bone
marrow or stem cell problems
include:
 Aplastic anemia occurs when there's a
marked reduction in the number of stem
cells or absence of these cells. Aplastic
anemia can be inherited, can occur
without apparent cause, or can occur
when the bone marrow is injured by
medication, radiation, chemotherapy,
infection
Cont…
 Thalassemia occurs when the red cells
can't mature and grow properly.
 Thalassemia is an inherited condition that
typically affects people of Mediterranean,
African, Middle Eastern, and Southeast
Asian descent.
 This condition can range in severity from
mild to life-threatening; the most severe
form is called Cooley's anemia.
 Lead exposure is toxic to the bone
marrow, leading to fewer red blood cells.
 Lead poisoning occurs in adults from
work-related exposure and in children
who eat paint chips, for example.
 Improperly glazed pottery can also taint
food and liquids with lead.
Anemia associated with other
conditions
 usually occurs when there are too few
hormones necessary for red blood cell
production
 Conditions causing this type of anemia
include the following: Advanced kidney
disease, hypothyroidism, Other chronic
diseases, such as cancer,
infection, lupus, diabetes,
and rheumatoid arthritis, Old age
Anemia Caused by
Destruction of Red Blood Cells
 When red blood cells are fragile and
cannot withstand the routine stress of the
circulatory system, they may rupture
prematurely, causing hemolytic anemia.
 Hemolytic anemia can be present at birth
or develop later.
 Sometimes there is no known cause.
Known causes of hemolytic
anemia may include:
 Inherited conditions, such as sickle cell
anemia and thalassemia
 Stressors such as infections, drugs, snake or
spider venom, or certain foods
 Toxins from advanced liver or kidney disease
 Inappropriate attack by the immune system
(called hemolytic disease of
he newborn when it occurs in the f of fetus
pregnant woman)
Cont….
 Vascular grafts, prosthetic heart valves,
tumors, severe burns, exposure to certain
chemicals, severe hypertension, and
clotting disorders In rare cases,
an enlarged spleen can trap red blood
cells and destroy them before their
circulating time is up.
Assessment and Diagnostic
Findings

 Blood studies. In an initial evaluation, the

hemoglobin, hematocrit, reticulocyte count, and
RBC indices, particularly the mean corpuscular
volume and red cell distribution width are taken to
assess for the presence of anemia.
 Iron studies. Serum iron level, total iron binding
capacity, percent saturation, and ferritin, as well
as serum vitamin B12 and folate levels, are all
useful in diagnosing anemia.
 CBC values. The remaining CBC values are useful
in determining whether the anemia is an isolated
problem or part of another hematologic
condition.
Medical Management

 Nutritional supplements. Use of nutritional

supplements should be appropriately taught
to the patient and the family because too
much intake cannot improve anemia.
 Blood transfusion. Patients with acute blood
loss or severe hemolysis may have decreased
tissue perfusion from decreased blood
volume or reduced circulating erythrocytes,
so transfusion of blood would be necessary.
 Intravenous fluids. Intravenous fluids replace
the lost volumes of blood or electrolytes to
restore them to normal levels.
Nursing Management

 Themanagement of anemia by nurses

should be accurate and appropriate so
that objectives and goals would be
achieved.
Nursing Assessment

 Health history and physical exam. Both

provide important data about the type of
anemia involved, the extent and type of
symptoms it produces, and the impact of
those symptoms on the patient’s life.
 Medication history. Some medications
can depress bone marrow activity,
induce hemolysis, or interfere with folate
metabolism.
 History of alcohol intake. An accurate history of
alcohol intake including the amount and duration
should be obtained.
 Family history. Assessment of family history is
important because certain anemias are inherited.
 Athletic endeavors. Assess if the patient has any
athletic endeavor because extreme exercise can
decrease erythropoiesis and erythrocyte survival.
Nutritional assessment. Assessing the nutritional
status and habits is important because it may
indicate deficiencies in essential nutrients such as
iron, vitamin B12, and folic acid.
Diagnosis

 Based on the assessment data, major nursing

diagnosis for patients with anemia include:
 Fatigue related to decreased hemoglobin
and diminished oxygen-carrying capacity of
the blood.
 Altered nutrition, less than body requirements,
related to inadequate intake of essential
nutrients.
 Altered tissue perfusion related to insufficient
hemoglobin and hematocrit.
Leukemia
 alsospelled leukaemia, is a group of
cancers that usually begin in the bone
marrow and result in high numbers of
abnormal white blood cells.
 These white blood cells are not fully
developed and are called blasts or
leukemia cells.
Common leukemia signs and
symptoms include:

 Fever or chills.
 Persistent fatigue, weakness.
 Frequent or severe infections.
 Losing weight without trying.
 Swollen lymph nodes, enlarged liver or spleen.
 Easy bleeding or bruising.
 Recurrent nosebleeds.
 Tiny red spots in your skin (petechiae)
How leukemia forms

 leukemia is thought to
occur when some
blood cells acquire
mutations in their DNA
— the instructions
inside each cell that
guide its action.
 There may be other
changes in the cells
that have yet to be
fully understood that
could contribute to
leukemia.
Cont…
 Certain abnormalities cause the cell to
grow and divide more rapidly and to
continue living when normal cells would
die.
 Over time, these abnormal cells can
crowd out healthy blood cells in the bone
marrow, leading to fewer healthy white
blood cells, red blood cells and platelets,
causing the signs and symptoms of
leukemia.
Classification
 Acute leukemia - the abnormal blood
cells are immature blood cells (blasts).
 They can't carry out their normal
functions, and they multiply rapidly, so the
disease worsens quickly.
 Acute leukemia requires aggressive,
timely treatment.
Cont….
 Chronic leukemia. There are many types:
 Some produce too many cells and some
cause too few cells to be produced.
 involves more mature blood cells, these blood
cells replicate or accumulate more slowly and
can function normally for a period of time
 Some forms initially produce no early
symptoms and can go unnoticed or
undiagnosed for years.
The second type of
classification is by type of
white blood cell affected:
 Lymphocytic leukemia- affects the
lymphoid cells (lymphocytes), which form
lymphoid or lymphatic tissue which makes
up your immune system
 Myelogenous leukemia- affects the
myeloid cells which give rise to red blood
cells, white blood cells and platelet-
producing cells.
The major types of
leukemia are:
 Acute lymphocytic leukemia (ALL) - most
common type of leukemia in young
children. ALL can also occur in adults.
 Acute myelogenous leukemia (AML) -
occurs in children and adults, and is the
most common type of acute leukemia in
adults.
 Chronic lymphocytic leukemia (CLL) -
most common chronic adult leukemia,
person may feel well for years without
needing treatment.
Cont….
 Chronic myelogenous leukemia (CML) -
mainly affects adults. A person with CML
may have few or no symptoms for months
or years before entering a phase in which
the leukemia cells grow more quickly.
 Other types - including hairy cell
leukemia, myelodysplastic syndromes and
myeloproliferative disorders.
Risk factors

 Previous cancer treatment. People who've

had certain types of chemotherapy and
radiation therapy for other cancers have an
increased risk of developing certain types of
leukemia.
 Genetic disorders. Genetic abnormalities
seem to play a role in the development of
leukemia. Certain genetic disorders, such as
Down syndrome, are associated with an
increased risk of leukemia.
 Exposure to certain chemicals. Exposure to
certain chemicals, such as benzene — which
is found in gasoline and is used by the
chemical industry — is linked to an increased
risk of some kinds of leukemia.
 Smoking - increases the risk of acute
myelogenous leukemia
 Family history of leukemia - If members of
family have been diagnosed with leukemia,
risk of the disease may be increased.
Nursing Management
 Prevent infection
 Patients with leukemia have an impaired
ability to fight infection and therefore we must
be diligent in preventing infection. This
includes strict hand hygiene, which is the most
effective infection prevention measure.
 Promote normothermia
 Progressive hyperthermia may occur,
therefore it's essential to monitor body temp
closely, especially if patient is receiving
chemotherapy.
Nursing Management
 Sepsis surveillance
 Patients undergoing leukemia treatment are at
higher risk for developing sepsis, so make sure to
monitor them closely and notify the MD when
needed.
 Educate patient and loved ones about infection
prevention
 The patient and support system must be compliant
with infection prevention measures for this to be
successful, not just the health care team. They
must understand its importance and be equally as
diligent.
 Educate patient and loved ones about
plan of care, symptoms to expect, and
when to get concerned
 The more the patient and family can
predict or be aware of, the better. This
helps to decrease anxiety and increase
compliance if people can anticipate
what may happen, why we’re initiating
certain interventions, as well as their
importance.
 Prevent skin breakdown
 Due to various meds and/or
compromised immune response and/or
malnutrition, patients with leukemia are at
a higher risk for skin breakdown and
delayed wound healing. Therefore, it is
essential to take extra care to prevent
breakdown
 Avoid procedures that would increase
infection risk: inserting foley catheters,
injections, lines, and tubes.
 Must weigh risk versus benefit, and
patients with leukemia are at a much
higher risk for infection, so the benefit of
said procedures may not outweigh the
risk
 Initiate bleeding precautions
 Clotting factors are impaired and therefore
patients with leukemia are at an increased risk
for bleeding.
 Cluster care and conserve energy
 Energy conservation is essential. We must
maximize the time in which the patient is able
to care for themselves. Feedings, ambulating
and toileting is the priority. Therefore, do not
disturb their sleep unnecessarily. Cluster labs,
vitals, and other aspects of care as clinically
appropriate.
 Assess and address pain appropriately; promote
non-pharmacological interventions (massage, pillow
support, cool/heat therapy, aromatherapy, guided
imagery, and so forth)
 Pain is very common and can be difficult to control.
Pain medications may be ordered scheduled rather
than PRN. Ensure you’re assessing what works for the
patient, promoting a calm and restful environment,
and avoiding any movements that would
exacerbate pain. Assess appropriately (type,
severity, precipitating and aggravating factors, what
relieves the pain, and so forth). Leverage non-
pharmacological interventions to complement
pharmacological interventions by timing
appropriately.
 Promote assistive devices to conserve
energy
 Walkers, wheelchairs, canes, shower
chairs, are all things that can help the
patient conserve energy while still
participating in their own care. Make sure
to educate and visualize a return
demonstration before allowing
independent use.
 Time pain medications and antiemetics to
be at their peak for therapy, chemo, and
meals.
 By timing these meds to be at their peak
when anticipating increased pain and
nausea, you can increase intake and their
ability to participate in therapy.
 Therefore, be proactive with these
medications rather than reactive to
maximize their benefit and the patient’s
response.
 Promote self-care, independence, and
ADL’s
 Increased fatigue can prevent patients
from participating in their own care.
Patients will most likely need assistance in
caring for themselves.
 Prioritize their activities to promote those
that are involved in their own care
(conserve energy to feed self over
walking up and down halls).
 Closely monitor intake and output, assess
for signs of dehydration (skin turgor,
mucous membranes, cap refill).
 Dehydration and kidney compromise is a
potential complication, therefore we must
watch for it diligently.
 Treatments for leukemia include
chemotherapy (major treatment modality
for leukemia), radiation therapy,
biological therapy, targeted therapy, and
stem cell transplant
 Acute leukemia needs to be treated
when it is diagnosed, with the goal of
inducing a remission (absence of
leukemia cells in the body).
Polycythemia
 isa slow-growing blood cancer in which
your bone marrow makes too many red
blood cells
 These excess cells thicken your blood,
slowing its flow.
 They also cause complications, such as
blood clots, which can lead to a heart
attack or stroke.
Polycythemia
 divided into two main categories; primary
and secondary
 Polycythemia can be linked to secondary
causes, such as, chronic hypoxia or
tumors releasing erythropoietin.
 Polycythemia vera is due to abnormally
increased red cell production in the bone
marrow
 Polycythemia vera isn't common.
 It usually develops slowly, and person might
have it for years without knowing
 Often the condition is found during a blood
test done for another reason.
 Without treatment, it can be life-threatening,
but proper medical care can help ease signs,
symptoms and complications of this disease.
 Over time, in some cases there's a risk of
progressing to more-serious blood cancers,
such as myelofibrosis or acute leukemia.
Symptoms

 Itchiness, especially  Shortness of breath

following a warm  Numbness, tingling,
bath or shower burning or weakness
 Headache Dizziness in your hands, feet,
 Bleeding or bruising, arms or legs
usually minor  A feeling of fullness
 Weakness or bloating in your
 Fatigue left upper abdomen
due to an enlarged
 Blurred vision spleen
 Excessive sweating  Fevers
 Painful swelling of  Unexplained weight
one joint, often the loss
big toe
Causes

 One of a group of blood cancers known

as myeloproliferative neoplasms.
 It occurs when a mutation in a gene
causes a problem with blood cell
production.
 Normally, body regulates the number of
each of the three types of blood cells —
red blood cells, white blood cells and
platelets.
 in polycythemia vera, bone marrow
makes too many of some blood cells.
Risk factors

 Polycythemia vera can occur at any age,

but it's more common in adults older than
60.
Complications

 Blood clots. Increased blood thickness

and decreased blood flow, as well as
abnormalities in your platelets, increase
your risk of blood clots.
 Blood clots can cause a stroke, a heart
attack or a blockage of an artery in your
lungs (pulmonary embolism) or in a vein
deep within a muscle (deep vein
thrombosis).
 Enlarged spleen (splenomegaly) - spleen
helps body fight infection and filter
unwanted material, such as old or
damaged blood cells
 The increased number of blood cells
caused by polycythemia vera makes
spleen work harder than normal, which
causes it to enlarge.
 Problems due to high levels of red blood
cells - Too many red blood cells can lead
to a number of other complications,
including open sores on the inside lining of
stomach, upper small intestine or
esophagus (peptic ulcers) and
inflammation in joints (gout).
 Otherblood disorders - In rare cases,
polycythemia vera can lead to other
blood diseases, including a progressive
disorder in which bone marrow is
replaced with scar tissue (myelofibrosis), a
condition in which stem cells don't mature
or function properly (myelodysplastic
syndrome), or cancer of the blood and
bone marrow (acute leukemia).
Treatment
 Low-dose aspirin may also help reduce
burning pain in feet or hands.
 Medication to decrease blood cells
 For people with polycythemia vera who
aren't helped by phlebotomy alone,
medications, such as hydroxyurea (Droxia,
Hydrea),
 to suppress bone marrow's ability to
produce blood cells might be used.
 Phlebotomy (bloodletting) has long been
the mainstay of therapy for polycythemia
vera (PV).
 The object is to remove excess cellular
elements, mainly red blood cells, to
improve the circulation of blood by
lowering the blood viscosity
Blood tests

 An increase in the number of red blood cells

and, in some cases, an increase in platelets or
white blood cells
 Increased percentage of red blood cells that
make up total blood volume (hematocrit
measurement)
 Elevated levels of the iron-rich protein in red
blood cells that carries oxygen (hemoglobin).
 Very low levels of a hormone that stimulates
bone marrow to produce new red blood cells
(erythropoietin)
Bone marrow aspiration or
biopsy

A bone marrow
aspiration is usually
done at the same
time. During an
aspiration, a
sample of the
liquid portion of
marrow is
withdrawn