Anemia is a condition characterized by a deficiency in red blood cells or hemoglobin, leading to reduced oxygen transport throughout the body. This common health issue can stem from various causes, including blood loss, decreased red blood cell production, or increased red blood cell destruction. Understanding anemia and its management is crucial in nursing practice. Nurses play a vital role in assessing, diagnosing, and implementing effective care plans for patients with anemia. This article will delve into the nursing care of anemia, focusing on NANDA nursing diagnoses and evidence-based interventions to optimize patient outcomes.
Anemia can range from mild and temporary to severe, chronic, and life-threatening. It may arise from nutritional deficiencies, genetic disorders, cancer, autoimmune diseases, exposure to toxins, infections, or as a consequence of other chronic illnesses. Recognizing the diverse etiologies and manifestations of anemia is paramount for nurses to provide holistic and patient-centered care.
Types of Anemia
Nurses encounter and manage various types of anemia in clinical practice. These can be broadly categorized based on their underlying causes:
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Anemias due to Nutritional Deficiencies:
- Iron-deficiency anemia: The most prevalent type globally, often resulting from inadequate iron intake, absorption issues, or blood loss.
- Pernicious anemia: Caused by vitamin B12 deficiency, typically due to impaired absorption in the stomach.
- Megaloblastic anemia: Characterized by large, abnormal red blood cells, frequently due to deficiencies in vitamin B12 or folate.
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Genetic Anemias:
- Sickle cell anemia: An inherited blood disorder causing red blood cells to become rigid and sickle-shaped, leading to pain and complications.
- Thalassemia anemia: A group of inherited disorders affecting hemoglobin production, resulting in varying degrees of anemia.
- Fanconi anemia: A rare genetic disease that can lead to bone marrow failure and anemia.
- Diamond-Blackfan anemia: A rare bone marrow disorder primarily affecting red blood cell production.
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Anemias due to Abnormal RBC Function, Production, or Destruction:
- Hemolytic anemia: Characterized by the premature destruction of red blood cells.
- Aplastic anemia: A condition where the bone marrow fails to produce enough blood cells, including red blood cells.
- Macrocytic anemia: Anemia characterized by abnormally large red blood cells, often related to vitamin B12 or folate deficiency.
- Microcytic anemia: Anemia characterized by abnormally small red blood cells, commonly associated with iron deficiency or thalassemia.
- Normocytic anemia: Anemia where red blood cells are of normal size and color but insufficient in number, often seen in chronic diseases.
Understanding the specific type of anemia is critical as it guides treatment strategies and nursing interventions.
Nursing Process for Anemia
The nursing process provides a systematic approach to caring for patients with anemia. This involves assessment, diagnosis, planning, implementation, and evaluation.
Nursing Assessment
A comprehensive nursing assessment is the cornerstone of effective care for patients with anemia. It involves gathering subjective and objective data to understand the patient’s condition thoroughly.
Review of Health History
1. General Symptom Assessment: Nurses should inquire about common symptoms associated with anemia:
- General: Fatigue, generalized weakness are hallmark symptoms due to reduced oxygen delivery.
- Central Nervous System (CNS): Dizziness, lightheadedness, and headaches can occur due to decreased cerebral blood flow and oxygenation.
- Head, Eyes, Ears, Nose, and Throat (HEENT): Pulsatile tinnitus, a pounding or “whooshing” sound in the ear, may be reported.
- Respiratory: Dyspnea (shortness of breath) and tachypnea (rapid breathing) are compensatory mechanisms for reduced oxygen-carrying capacity.
- Cardiovascular: Fast or irregular heartbeat, palpitations, chest discomfort, and chest pain can arise as the heart works harder to compensate for anemia.
- Integumentary: Pale skin, cool skin, reports of feeling cold, numbness in hands and feet, and brittle nails can be observed due to reduced blood flow and oxygenation to peripheral tissues.
Alt text: Nurse assessing patient’s pale skin, a key indicator of anemia, by gently pressing on the fingertip to evaluate capillary refill and color return.
2. Medical History Review: It is essential to review the patient’s medical history, paying close attention to conditions that may contribute to anemia:
- History of leukemia or other blood cancers, as these can directly affect bone marrow function and red blood cell production.
- Chronic conditions like chronic kidney disease or rheumatoid arthritis, which are often associated with anemia due to various mechanisms, including reduced erythropoietin production or chronic inflammation.
3. Medication Review: Certain medications can induce hemolytic anemia, and a thorough medication history is crucial. These include:
- Cephalosporins
- Levodopa
- Levofloxacin
- Nitrofurantoin
- NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)
- Penicillins
4. Activity and Risk Factor Assessment: Nurses should inquire about the patient’s occupation and hobbies to identify potential environmental exposures to substances that can cause anemia:
- Exposure to tranquilizers, pesticides, paints, solvents, or hair dyes, as these may contain chemicals that can suppress bone marrow function or cause hemolytic anemia.
5. Gynecological Status (for women): For female patients, gynecological history is relevant to assess potential causes of anemia:
- Heavy menstrual bleeding (menorrhagia) is a common cause of iron-deficiency anemia.
- Recent abortion or current pregnancy can also contribute to anemia due to blood loss or increased iron demands.
6. Bowel Movement Assessment: Changes in bowel habits and the presence of blood in the stool should be carefully assessed:
- Inquire about dark, tarry stools (melena), which indicate upper gastrointestinal bleeding.
- Ask about blood observed on toilet paper or in the toilet bowl after a bowel movement (hematochezia), which suggests lower gastrointestinal bleeding.
- Assess for diarrhea with bleeding.
- Determine if hemorrhoids are present and causing bright red bleeding.
7. Gastrointestinal History: Various gastrointestinal problems can lead to bleeding and subsequent anemia:
- Diverticulitis
- Hiatal hernias
- Peptic ulcers
- Gastroenteritis
- Cancer (gastrointestinal cancers)
- Inflammatory bowel disease (Crohn’s disease, ulcerative colitis)
8. Urine Assessment: Changes in urine color can indicate bleeding in the genitourinary system. Nurses should inquire about:
- Hematuria (blood in urine), which may suggest bleeding in the kidneys, bladder, or urinary tract.
9. Dietary Assessment: A thorough dietary history is essential to identify nutritional deficiencies:
- Review the patient’s usual diet, focusing on intake of iron, vitamin B12, and folate.
- Assess for dietary restrictions, such as vegan or vegetarian diets, which may increase the risk of deficiencies if not properly managed.
- Inquire about excessive alcohol intake, as it can predispose to conditions causing anemia and interfere with nutrient absorption.
10. Socioeconomic Status: Economic factors can significantly impact nutritional status and contribute to anemia:
- Assess if the patient lives in a food desert, lacking access to affordable and nutritious food.
- Determine if the patient’s financial situation limits their ability to afford quality food, increasing the risk of nutritional anemias.
Physical Assessment
1. Nutritional Deficiency Assessment: Physical signs often accompany nutritional deficiencies associated with anemia:
- Iron deficiencies:
- Pale skin (pallor)
- Brittle fingernails (koilonychia)
- Tachycardia (rapid heart rate)
- Vitamin B12 deficiency/pernicious anemia:
- Bleeding gums
- Pale skin or jaundice (yellowing of the skin and eyes)
- Weight loss
- Muscle weakness
- Megaloblastic anemia:
- Pale skin
- Diarrhea
- Inflamed tongue (glossitis)
Alt text: Close-up of a nurse examining a patient’s fingernails for brittleness, a potential sign of iron-deficiency anemia, noting the texture and shape of the nail bed.
2. Bleeding and Bleeding Disorder Assessment: Nurses should assess for signs of bleeding or bleeding disorders:
- Monitor for unusual bleeding, such as purpura (small purple spots), bruising, or petechiae (tiny red or purple spots).
- Assess for signs of obvious trauma or injuries that may be contributing to blood loss.
- Inquire about a history of bleeding disorders like hemophilia.
- Review medication use, including aspirin or warfarin, which can increase bleeding risk.
3. Neurological Assessment: Anemia can affect the nervous system due to reduced oxygen supply to the brain:
- Monitor for vision disturbances, memory loss, poor coordination, headache, irritability, and paresthesias (numbness or tingling).
4. Eye Examination: Eye examination can reveal signs of anemia:
- Low iron levels may cause the vascular area of the eyes to appear pale pink or white instead of the normal red.
- A blue tint to the sclera (white part of the eye) may indicate iron-deficiency anemia.
5. Cardiopulmonary Assessment: Anemia impacts the heart and lungs due to reduced oxygen-carrying capacity:
- Assess for chest discomfort or dyspnea.
- Monitor for tachycardia, tachypnea, and hypoxia (low oxygen saturation).
- Be aware of the increased risk of heart failure in patients with anemia.
6. Lymph Node Palpation: Palpate lymph nodes to assess for enlargement, which may indicate infection or neoplasia (cancer):
- Infection and cancer can both contribute to decreased red blood cell production and anemia.
Diagnostic Procedures
Diagnostic procedures are essential to confirm anemia, determine its type, and identify underlying causes.
1. Blood Tests: Various blood tests are crucial in diagnosing and differentiating types of anemia:
- Complete Blood Count (CBC) with differential:
- Red blood cell count: Measures the number of red blood cells.
- Hemoglobin/hematocrit: Measures the amount of hemoglobin and the proportion of red blood cells in the blood.
- Reticulocyte count: Measures the number of new red blood cells being produced by the bone marrow.
- MCV (mean corpuscular volume): Measures the average size of red blood cells (helps classify anemia as microcytic, normocytic, or macrocytic).
- RDW (red cell distribution width): Measures the variation in red blood cell size.
- Platelet count: Assesses platelet levels, which can be affected in some bone marrow disorders.
- Iron profile:
- Iron: Measures the amount of iron in the blood.
- Ferritin: Measures the body’s iron stores.
- Total iron-binding capacity (TIBC): Measures the blood’s capacity to bind and transport iron.
- Folate and vitamin B12 levels: Measure serum levels of these essential vitamins.
Additional lab tests to investigate underlying conditions:
- Coagulation screenings (aPTT, PT/INR): Assess for bleeding disorders.
- Lead levels: Detect lead poisoning, a cause of anemia.
- Factor assays: Investigate specific clotting factor deficiencies.
- Coombs test: Detects antibodies that destroy red blood cells (in hemolytic anemia).
2. Imaging Scans: Imaging is used, particularly in acute anemia, to identify underlying causes or complications:
- Ultrasonography: Offers rapid evaluation for intraperitoneal bleeding (bleeding within the abdominal cavity).
- Chest X-rays: Useful in severe anemia causing cardiomyopathy (heart muscle disease).
- CT scans of the abdomen: Detect masses, internal bleeding, or abnormalities of the spleen and other abdominal organs.
- Esophagogastroduodenoscopy (EGD): Diagnoses acute upper GI bleeding.
- Outpatient colonoscopy: Considered to diagnose lower GI bleeding.
3. Bone Marrow Aspiration: Bone marrow analysis is typically reserved for cases where lab results are inconclusive or to investigate bone marrow disorders:
- Bone marrow aspiration and biopsy can provide information about red blood cell production and identify abnormalities in the bone marrow.
Nursing Interventions
Nursing interventions are aimed at addressing the underlying cause of anemia, managing symptoms, and preventing complications.
1. Identify and Manage the Cause: Addressing the root cause of anemia is paramount. Interventions vary based on the etiology:
- Acute blood loss: Requires immediate measures to stop bleeding and restore blood volume.
- Nutritional deficiencies (iron, vitamin B12, and folate): Supplementation and dietary modifications are essential.
- Conditions affecting the bone marrow: Treatment depends on the specific condition and may include medications, transfusions, or bone marrow transplantation.
- Chronic renal disease: Erythropoietin-stimulating agents are often used to increase red blood cell production.
- Hemophilia: Management focuses on preventing and treating bleeding episodes.
- Autoimmune and rheumatological conditions: Treatment of the underlying autoimmune disease is crucial; immunosuppressants may be used.
- Increased red blood cell destruction (faulty mechanical valves, hemolytic anemia, DIC): Management targets the cause of hemolysis and may include medications, surgery, or transfusions.
- Side effects of medications: Discontinuation or adjustment of offending medications may be necessary.
2. Administer IV Fluids: Intravenous fluids are crucial in cases of trauma or acute blood loss to increase intravascular volume and maintain blood pressure.
3. Blood Transfusion: Packed red blood cells (RBCs) transfusions are indicated for actively bleeding patients and those with severe symptomatic anemia, typically with a hemoglobin level of 7 g/dL or less. Transfusions improve oxygen-carrying capacity and alleviate symptoms.
4. Oxygen Therapy: Supplemental oxygen is administered as needed to patients experiencing hypoxia or dyspnea due to anemia. This helps to increase oxygen availability to tissues.
5. Administer Supplements: Supplementation is essential for nutritional anemias. The type and route depend on the specific deficiency:
- Oral or IV iron supplements for iron-deficiency anemia.
- Oral or intramuscular (IM) vitamin B12 for pernicious anemia and vitamin B12 deficiency.
- Oral, IV, or IM folate for folate deficiency.
6. Educate on Oral Iron Supplementation: Patient education is crucial for effective oral iron therapy:
- Inform patients about common side effects, including gastrointestinal upset (constipation), black, tarry stools (normal with iron supplementation), and metallic taste.
- Provide instructions on how to administer iron supplements for optimal absorption:
- Take on an empty stomach if tolerated.
- Take with water or fruit juice (vitamin C enhances iron absorption).
- Take 1 hour before or 2 hours after meals; if GI upset occurs, may take with food.
7. Erythropoietin for Renal Disease: For patients with chronic kidney disease-related anemia, erythropoietin-stimulating agents are used:
- Administer synthetic erythropoietin (e.g., epoetin alfa) as prescribed to stimulate red blood cell production in the bone marrow.
8. Prepare for Bone Marrow/Stem Cell Transplant: In severe aplastic anemia, bone marrow or stem cell transplantation may be considered:
- For eligible patients, particularly younger individuals with a matched donor (often a sibling), prepare them for possible bone marrow or stem cell transplantation. This procedure replaces the patient’s damaged bone marrow with healthy donor cells.
9. Dietitian Referral: Referral to a registered dietitian is beneficial for patients with nutritional anemias:
- Dietitians can provide individualized dietary counseling and education on iron-rich, vitamin B12-rich, and folate-rich foods to improve nutritional intake.
10. Patient Education – When to Seek Medical Attention: Educate patients on recognizing worsening symptoms and when to seek immediate medical care:
- Advise patients to consult their healthcare provider if anemia symptoms worsen despite treatment.
- Instruct them to go to the nearest emergency department if they experience:
- Breathing difficulties
- Lightheadedness or dizziness
- Chest discomfort
- Bright red bleeding in the stool
Nursing Care Plans for Anemia
Nursing care plans help organize and prioritize nursing care for patients with anemia. Using NANDA nursing diagnoses, care plans guide assessment, interventions, and outcome evaluation. Here are examples of nursing care plans for common NANDA diagnoses related to anemia:
Acute Pain
Nursing Diagnosis: Acute Pain related to sickling of red blood cells occluding blood vessels and lack of perfusion and oxygenation to extremities, as evidenced by intense complaint of pain, pain described as stabbing, sharp, or throbbing, reduced activity, restlessness, and distractive behaviors.
Expected Outcomes:
- Patient will report a decrease in pain to a tolerable level (e.g., ≤ 3/10 on a pain scale) by discharge.
- Patient will verbalize understanding of triggers for sickle cell pain crisis.
- Patient will adhere to prescribed pain medication regimen.
Assessments:
- Pain Assessment: Perform comprehensive pain assessment using a numeric or FACES pain scale, evaluating character, duration, frequency, precipitating factors, and effectiveness of current pain management interventions.
- Acute Chest Syndrome Assessment: Monitor for signs of acute chest syndrome, a life-threatening complication of sickle cell anemia (chest pain, fever, dyspnea, abnormal chest X-ray findings).
- Pain Medication Regimen Review: Assess patient’s adherence to pain medication regimen, including doses and frequency, to identify potential issues contributing to pain crises.
Interventions:
- Hydration: Provide intravenous hydration as prescribed to reduce sickling and improve blood flow. Encourage oral fluid intake.
- Analgesic Administration: Administer analgesics as prescribed, which may include narcotics, often via patient-controlled analgesia (PCA) for severe pain. Monitor for adequate pain control and avoid over-sedation.
- Blood Transfusion: Prepare for and administer blood transfusions as ordered to improve hemoglobin levels and prevent complications.
- Sickle Cell Crisis Prevention Education: Educate patient on triggers to avoid (dehydration, infection, cold exposure, stress) and importance of medication adherence and preventive measures.
Decreased Cardiac Output
Nursing Diagnosis: Decreased Cardiac Output related to inadequate blood volume, decreased oxygenated blood to the heart, and increased cardiac workload secondary to anemia, as evidenced by tachycardia, hypertension, cardiac arrhythmias, chest pain, and diminished peripheral pulses.
Expected Outcomes:
- Patient will demonstrate blood pressure and heart rate within normal limits for their age and condition.
- Patient will exhibit a normal sinus rhythm on ECG.
- Patient will report absence of chest pain.
Assessments:
- Vital Sign Monitoring: Monitor vital signs closely, particularly heart rate and blood pressure, to detect compensatory mechanisms and potential heart failure.
- Cardiovascular History Review: Obtain a detailed cardiovascular history, noting pre-existing heart conditions that may exacerbate the effects of anemia on cardiac output.
- Cardiovascular Status Assessment: Assess for signs and symptoms of decreased cardiac output, including chest pain, dyspnea, edema, and fatigue.
- Red Blood Cell Count Review: Review CBC results, focusing on RBC count, hemoglobin, and hematocrit, to correlate anemia severity with cardiac status.
- ECG Monitoring: Obtain and monitor ECG to identify arrhythmias or other cardiac abnormalities related to anemia.
Interventions:
- Reduce Cardiac Stress: Promote rest and reduce activity levels to decrease cardiac workload.
- Anemia Treatment: Implement treatment for the underlying cause and type of anemia, which may include transfusions, supplements, or medications.
- Prepare for Blood Transfusion: Prepare patient for possible blood transfusion if anemia is severe and contributing to decreased cardiac output.
- Address Underlying Cause of Anemia: Investigate and address the cause of anemia (e.g., chemotherapy-induced anemia, bleeding) to facilitate cardiac recovery.
Fatigue
Nursing Diagnosis: Fatigue related to decreased hemoglobin and reduced oxygen-carrying capacity, as evidenced by exhaustion, inability to maintain physical activity, increased need for rest, reported lack of energy, and lethargy.
Expected Outcomes:
- Patient will verbalize energy conservation techniques.
- Patient will report an increase in energy levels and ability to perform desired activities.
Assessments:
- CBC Monitoring: Monitor CBC results, particularly hemoglobin and hematocrit levels, to assess the severity of anemia-related fatigue.
- Chronic Condition Assessment: Assess for underlying chronic conditions (pregnancy, cancer, autoimmune diseases) that may contribute to or worsen anemia and fatigue.
- Fatigue Impact Assessment: Evaluate the impact of fatigue on the patient’s daily life, including activities of daily living, roles, and responsibilities.
Interventions:
- Energy Conservation Education: Instruct patient on energy conservation strategies: plan rest periods, prioritize activities, delegate tasks, and cluster activities to minimize energy expenditure.
- Oxygen Administration: Administer supplemental oxygen as prescribed for hospitalized patients with severe anemia and hypoxia.
- Blood Transfusion Preparation: Prepare for blood transfusions as ordered for severe anemia contributing to debilitating fatigue.
- Erythropoietin Administration: Administer erythropoietin injections (e.g., epoetin alfa) as prescribed to stimulate RBC production, especially for patients with chronic kidney disease, cancer, or HIV-related anemia.
Imbalanced Nutrition: Less Than Body Requirements
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to inadequate intake or absorption of iron, vitamin B12, or folate, or increased nutritional needs (e.g., pregnancy), as evidenced by pale skin, feeling cold, fatigue, rapid heartbeat, brittle nails, hair loss, pica (craving ice), and headaches.
Expected Outcomes:
- Patient will demonstrate improvement in iron, vitamin B12, and folate levels on lab testing.
- Patient will incorporate three iron-rich, vitamin B12-rich, and folate-rich foods into their diet.
- Patient will verbalize understanding of signs and symptoms of anemia and when to seek medical advice.
Assessments:
- Lab Value Monitoring: Monitor red blood cell count, hemoglobin, hematocrit, ferritin, iron, and total iron-binding capacity to assess for nutritional deficiencies.
- Dietary History Assessment: Obtain a detailed dietary history to identify nutritional gaps, food allergies, and dietary patterns.
- Access to Healthy Foods Assessment: Assess the patient’s access to affordable and nutritious foods, considering socioeconomic factors.
Interventions:
- Healthy Diet Education: Provide education on iron-rich foods (dark leafy greens, meat, eggs, nuts), vitamin B12-rich foods (meat, dairy), and folate-rich foods (legumes, citrus fruits, leafy greens).
- Supplement Consideration: Administer or educate on oral iron, vitamin B12 (cyanocobalamin), or folate supplements as prescribed. Vitamin B12 injections may be necessary for absorption issues.
- Prenatal Supplement Encouragement: Emphasize the importance of prenatal vitamins containing iron and folate for pregnant patients.
- Iron Absorption Improvement Strategies: Educate on strategies to improve iron absorption, such as consuming iron-rich foods with vitamin C and avoiding tannins (tea, coffee) with meals.
Ineffective Tissue Perfusion
Nursing Diagnosis: Ineffective Tissue Perfusion related to reduced oxygen-carrying capacity of the blood secondary to anemia (decreased RBCs, hemoglobin), as evidenced by lightheadedness, dizziness, headache, fatigue, changes in mentation, pallor, cold extremities, prolonged capillary refill, chest pain, shortness of breath, and low hemoglobin levels.
Expected Outcomes:
- Patient will demonstrate evidence of adequate tissue perfusion, including warm skin and color within normal limits for ethnicity.
- Patient will report relief of shortness of breath, chest pain, and fatigue.
- Patient will achieve and maintain a hemoglobin level > 10.0 g/dL (or individualized target).
Assessments:
- Medical and Family History Review: Determine patient’s medical and family history to identify predisposing factors for anemia and differentiate between acute and chronic anemia.
- Physical Assessment for Perfusion: Assess for signs of ineffective tissue perfusion: pallor, cool skin, respiratory changes, orthostatic hypotension, tachypnea, chest pain, and neurological changes.
- Hemoglobin Level Review: Monitor hemoglobin levels to assess the severity of oxygen-carrying capacity reduction.
Interventions:
- Chest Pain/Palpitation Investigation: Investigate reports of chest pain or palpitations promptly, obtaining an ECG to rule out cardiac ischemia or arrhythmias.
- Oxygen Administration: Administer supplemental oxygen to maintain SpO2 > 95% and improve tissue oxygenation.
- Safety Precautions Implementation: Implement fall precautions and safety measures due to potential lightheadedness, dizziness, vision changes, and muscle weakness.
- Erythropoietin Administration: Administer epoetin alfa injections as prescribed to stimulate RBC production, particularly in chronic anemia related to renal disease or other conditions.
