Anemia: am I the only one who thinks it's all complicated?

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Specializes in mostly PACU.

Hey all, new FNP here. I wanted to know if anyone had some easy or quick tips for diagnosing and treating different types of Anemia. One of the things I'm noticing is that a lot of my patients were placed on iron supplements without really having the diagnostic work up to determine if iron deficiency is the true cause of their anemia (I work in LTC). What I have been doing is d/c'ing the iron and ordering an iron panel. Then I'll decide what to do from there. The problem is, I'm not that great at interpreting the results! For example, I have a lady who's H/H dropped over the last month. I think the Hct was 34.5 or something like that and is now 29.7. I did iron studies and everything was within the normal range. Fe, Ferritin, TIBC, etc. were all normal. This lady does have CKD. I think it's stage 3 now. Her last GFR was in the 30s. I'm going to recheck a CBC, BMP on Monday because she was recently hospitalized for urosepsis. So I'm not sure if the worsening kidney function and anemia was really a reflection of that. OR this lady needs to see a GI doc for a possible bleed. Anyway, just want to hear some of your thoughts. Thanks

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Specializes in allergy and asthma, urgent care.

Hi,

I hope I can help a bit. In my previous life I was a Medical Technologist and I worked for several years in a hematology lab. There are 5 parameters you need to look at when evaluating anemia-1)H & H, RBC count 2) Red cell size (MCV), 3) RBC hemoglobin content (MCHC), 4) RDW, and 5) retic count. Knowing these values will help you determine what's causing the anemia, and therefore how to treat it. If the patient has a normochromic, normocytic anemia (MCV

Microcytic, hypochromic cells with elevated RDW is most commonly Fe deficiency. Microcytic, hypochromic with normal RDW may be a hemoglobinopathy, such as thalessemia. Macrocytic, normochromic anemia with inc. RDW is usually B12 or folate deficiency, or pernicious anemia. An increased retic count is the body's normal response to anemia. An increase in RDW (variation in red cell size) of over 15% shows that new cells differ in size from older ones, and might be the first sign of a developing anemia. It was drummed in my head in both Med Tech school and nursing school that you never, never treat a non-life threatening anemia until you know the cause, or you might treat inappropriately and mess up lab results so you can't determine the underlying cause.

That's anemia in a nut shell. Obviously, you often have to go on and do iron studies and all the other tests you did. But just a quick look at the CBC can point you in the right direction. Hope this helps.

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Specializes in Emergency, Outpatient.

I would do stool for occult blood, erythropoietin level, B12, folate levels, don't forget anemia of chronic disease and MDS in your differential. I suspect her anemia was secondary to infection, CRF, with what you are describing and the rest of her CBC is wnl's. I would not refer her unless her anemia worsened, failed to correct, or she had evidence of a GI bleed.

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Specializes in mostly PACU.

Thaks guys, that was very helpful. Like I mentioned in the previous post, she is supposed to have labs drawn again on Monday so that I can continue my investigation. I'll let you know what I find. I might have to add a differential though, because I just ordered a CBC. I don't think I'll see the retic count with a regular CBC, will I?

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Specializes in allergy and asthma, urgent care.

A retic count is usually ordered separately and is not part of a regular CBC and differential. It will be interesting to see what you fins out-be sure to let us know!

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Specializes in mostly PACU.

I just realized today that the retic count is separate, so I ordered it. The repeat labs showed a lower H&H. I think the Hct went from 29 to 28.4 or something like that in one week. So far the patient is asymptomatic. I'm pretty sure the problem is chronic disease, but I just wanted to make sure. My other thought was something GI related, but I'm not ready to send her to the GI doc yet.

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is she on dialysis yet? is she seeing a nephrologist?

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Specializes in mostly PACU.

No, and I doubt she will go on dialysis. I work in LTC. Most of these people are not candidates for extensive treatment such as dialysis. She will not likely see a nephrologist, but be managed by myself and the primary doc until she passes away.

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I am so with ya girl. Anemia was the most confusing thing for me in the whole program. And it's very important to know your stuff if you work LTC. I also work in LTC snd have been trying to make some little guide sheets for easy access as to what to order when and how to interpret the results. It realyy gives me fits and frustrates me!:confused:

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Honestly I would ask an attending about this issue because you don't want to miss anything like an anemia secondary to malignancy. If her anemia is secondary to one cause, then figuring out the etiology is relatively simple, however, if the etiology is multifactorial, it can get confusing. It may be wise to have someone who is more experienced and can help you through this until you are more comfortable.

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Specializes in mostly PACU.
Honestly I would ask an attending about this issue because you don't want to miss anything like an anemia secondary to malignancy. If her anemia is secondary to one cause, then figuring out the etiology is relatively simple, however, if the etiology is multifactorial, it can get confusing. It may be wise to have someone who is more experienced and can help you through this until you are more comfortable.

The attending MD is involved for the most part. He is on vacation right now, so in the meantime I'm doing some investigation so to speak. I definately will need a more experienced person to help me. If the patient needs something like Procrit or B12 injections, etc. I would not feel comfortable initiating something like that.

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Specializes in mostly PACU.
I am so with ya girl. Anemia was the most confusing thing for me in the whole program. And it's very important to know your stuff if you work LTC. I also work in LTC snd have been trying to make some little guide sheets for easy access as to what to order when and how to interpret the results. It realyy gives me fits and frustrates me!:confused:

Glad to see I'm not alone! I was beginning to think I was just stupid! (well not really, but kind of, lol) :lol2:

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