Nursing Diagnosis of Anemia: A Comprehensive Guide for Nurses

Anemia, characterized by a deficiency in red blood cells or their hemoglobin content, leads to reduced oxygen transport throughout the body. This condition is not a disease in itself but rather a symptom of an underlying issue, ranging from nutritional deficits to chronic diseases. Understanding the nuances of anemia and its various types is crucial for nurses to provide effective patient care. This guide delves into the Nursing Diagnosis Of Anemia, encompassing assessment, interventions, and care planning to optimize patient outcomes.

Types of Anemia: A Nursing Perspective

Nurses encounter a spectrum of anemia types in clinical practice, each with distinct etiologies and management approaches. Categorizing anemia by its underlying cause is essential for targeted nursing care.

• Nutritional Deficiency Anemias: These arise from inadequate intake or absorption of essential nutrients vital for red blood cell production.

  • Iron-Deficiency Anemia: The most prevalent type globally, often due to insufficient iron intake, blood loss (menstruation, gastrointestinal bleeding), or increased demand (pregnancy).
  • Pernicious Anemia (Vitamin B12 Deficiency): Results from impaired vitamin B12 absorption, often due to a lack of intrinsic factor in the stomach, necessary for B12 uptake.
  • Megaloblastic Anemia (Folate Deficiency): Caused by insufficient folic acid intake, crucial for DNA synthesis in red blood cells.

• Genetic Anemias: Inherited disorders affecting red blood cell production or structure.

  • Sickle Cell Anemia: A genetic mutation causing red blood cells to become sickle-shaped, leading to chronic hemolysis, pain crises, and organ damage.
  • Thalassemia: A group of genetic disorders characterized by reduced or absent globin chain synthesis, impacting hemoglobin formation and causing varying degrees of anemia.
  • Fanconi Anemia & Diamond-Blackfan Anemia: Rare genetic bone marrow failure syndromes that can lead to anemia and other hematological abnormalities.

• Acquired Anemias (Abnormal RBC Function, Production, or Destruction): These develop due to various factors affecting red blood cell lifespan, production, or function.

  • Hemolytic Anemia: Premature destruction of red blood cells at a rate exceeding bone marrow production, caused by autoimmune disorders, medications, infections, or mechanical factors.
  • Aplastic Anemia: Bone marrow failure resulting in decreased production of all blood cell types, including red blood cells, often idiopathic or triggered by toxins, medications, or infections.
  • Macrocytic Anemia: Characterized by abnormally large red blood cells, frequently associated with vitamin B12 or folate deficiency, but also liver disease and hypothyroidism.
  • Microcytic Anemia: Defined by small red blood cells, most commonly caused by iron deficiency, thalassemia, or lead poisoning.
  • Normocytic Anemia: Red blood cells of normal size and hemoglobin content, often seen in chronic diseases, acute blood loss, or early stages of some anemias before red cell size changes become apparent.

Understanding these classifications provides a framework for nurses to approach anemia assessment and management systematically.

The Nursing Process for Anemia

The nursing process is fundamental in providing patient-centered care for individuals with anemia. It encompasses assessment, diagnosis, planning, implementation, and evaluation, guiding nurses in addressing the multifaceted needs of these patients.

Nursing Assessment: Gathering Subjective and Objective Data

A comprehensive nursing assessment is the cornerstone of accurate diagnosis and effective intervention. It involves collecting both subjective data (patient reports) and objective data (observable findings) related to anemia.

Review of Health History: Uncovering Clues

A thorough health history provides valuable insights into potential causes and contributing factors to anemia.

1. General Symptoms: Explore general manifestations of anemia:

   • Fatigue and Weakness: Patients often report persistent tiredness and lack of energy, a hallmark symptom of reduced oxygen delivery.
   • Central Nervous System (CNS) Symptoms: Inquire about dizziness, lightheadedness, and headaches, which can arise from decreased cerebral oxygenation.
   • Head, Eyes, Ears, Nose, and Throat (HEENT) Symptoms: Specifically, pulsatile tinnitus (a “whooshing” sound in the ear) can be a less common but significant symptom.
   • Respiratory Symptoms: Assess for dyspnea (shortness of breath) and tachypnea (rapid breathing), compensatory mechanisms for reduced oxygen-carrying capacity.
   • Cardiovascular Symptoms: Investigate fast or irregular heartbeat (palpitations), chest discomfort, and chest pain, indicating cardiac strain due to anemia.
   • Integumentary Symptoms: Note pale skin, cool skin, reports of feeling cold, numbness or tingling in hands and feet (paresthesia), and brittle nails, reflecting reduced peripheral circulation and iron deficiency.

2. Medical History Review: Pay close attention to pre-existing conditions:

   • Bone Marrow Disorders: History of leukemia or other blood cancers is critical as these directly affect red blood cell production in the bone marrow.
   • Chronic Conditions: Chronic kidney disease (reduced erythropoietin production) and rheumatoid arthritis (chronic inflammation) are known causes of anemia of chronic disease.

3. Medication Review: Certain medications can induce hemolytic anemia:

   • Antibiotics: Cephalosporins, levofloxacin, nitrofurantoin
   • Antiparkinsonian Drugs: Levodopa
   • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs):
   • Penicillins:

4. Activity and Risk Factor Assessment: Explore potential environmental exposures:

   • Occupational/Environmental Hazards: Inquire about exposure to tranquilizers, pesticides, paints, solvents, or hair dyes, which can be environmental toxins impacting red blood cell production or survival.

5. Gynecological History (for women): Assess for gynecological factors:

   • Menstrual History: Heavy menstrual bleeding (menorrhagia) is a common cause of iron deficiency anemia in women.
   • Reproductive History: Recent abortion or current pregnancy can contribute to anemia due to blood loss or increased iron demands.

6. Bowel Movement Assessment: Investigate gastrointestinal bleeding:

   • Stool Characteristics: Inquire about dark, tarry stools (melena), blood on toilet paper or in the toilet bowl (hematochezia), diarrhea with blood, or hemorrhoids, all indicative of potential gastrointestinal blood loss.

7. Gastrointestinal History: Explore gastrointestinal conditions:

   • Common GI Bleeding Sources: Diverticulitis, hiatal hernias, peptic ulcers, gastroenteritis, cancer, and inflammatory bowel disease (Crohn’s disease, ulcerative colitis) are frequent causes of gastrointestinal bleeding and associated anemia.

8. Urinary Changes: Assess for genitourinary bleeding:

   • Urine Color: Changes in urine color, particularly to red or pink, can signal active bleeding in the genitourinary system.

9. Dietary Assessment: Evaluate nutritional intake:

   • Dietary Habits: Review the patient’s usual diet, focusing on intake of iron, vitamin B12, and folate. Restrictive diets (vegan, vegetarian) or inadequate intake can lead to nutritional anemias.
   • Alcohol Consumption: Excessive alcohol intake can predispose to anemia through various mechanisms, including poor nutrition and gastrointestinal bleeding.

10. Socioeconomic Factors: Consider socioeconomic influences:

    • Food Security: Assess for food insecurity and access to quality food. Patients in food deserts or with limited financial resources may be at higher risk for nutritional anemias.

Physical Assessment: Identifying Objective Signs

Physical examination provides objective data supporting the diagnosis of anemia and revealing potential underlying causes.

1. Nutritional Deficiency Signs: Assess for physical manifestations of specific nutrient deficiencies:

   • Iron Deficiency: Pale skin (pallor), brittle fingernails, tachycardia (rapid heart rate).
   • Vitamin B12 Deficiency/Pernicious Anemia: Bleeding gums, pale skin or jaundice (yellowing of skin and eyes), weight loss, muscle weakness, neurological symptoms (paresthesia, balance issues).
   • Megaloblastic Anemia (Folate Deficiency): Pale skin, diarrhea, glossitis (inflamed tongue).

   Alt Text: Nurse assessing a patient’s pale skin, a common sign of anemia, by examining the conjunctiva.

2. Bleeding and Bleeding Disorder Assessment: Evaluate for signs of bleeding:

   • Unusual Bleeding: Monitor for purpura (purple spots), bruising, petechiae (tiny red spots), and obvious trauma or injuries, indicating potential bleeding disorders or sources of blood loss.

3. Neurological Assessment: Assess neurological function:

   • CNS Effects of Hypoxia: Due to reduced oxygen delivery to the brain, monitor for vision disturbances, memory loss, poor coordination, headache, irritability, and paresthesias (numbness, tingling).

4. Eye Examination: Examine the eyes for signs of anemia:

   • Conjunctival Pallor: Low iron levels can cause pallor in the conjunctiva (inner lining of the eyelids). Pale pink or white conjunctiva suggests anemia.
   • Scleral Hue: A blue tint to the sclera (white part of the eye) can be indicative of iron-deficiency anemia.

   Alt Text: Close-up of a nurse examining a patient’s eyes to check for conjunctival pallor, a key indicator of anemia during a physical assessment.

5. Cardiopulmonary Assessment: Evaluate cardiovascular and respiratory systems:

   • Cardiopulmonary Effects of Hypoxia: Reduced red blood cell count impacts heart and lung function. Assess for chest discomfort, dyspnea, tachycardia, tachypnea, and hypoxia (low oxygen saturation). Be alert to the increased risk of heart failure in patients with anemia.

6. Lymph Node Palpation: Palpate lymph nodes:

   • Lymphadenopathy: Conduct a thorough examination for enlarged lymph nodes, which could suggest infection or neoplasia (cancer) as potential underlying causes of anemia.

Diagnostic Procedures: Confirming Anemia and Identifying the Cause

Diagnostic tests are crucial for confirming the diagnosis of anemia, determining its type, and identifying underlying causes.

1. Blood Tests: Various blood tests differentiate anemia types:

   • Complete Blood Count (CBC) with Differential:

     • Red Blood Cell Count: Measures the number of red blood cells.
     • Hemoglobin/Hematocrit: Assess hemoglobin concentration and the percentage of blood volume composed of red blood cells.
     • Reticulocyte Count: Evaluates bone marrow production of new red blood cells.
     • Mean Corpuscular Volume (MCV): Indicates the average size of red blood cells (microcytic, normocytic, macrocytic).
     • Red Cell Distribution Width (RDW): Measures the variation in red blood cell size.
     • Platelet Count: Evaluates platelet levels, relevant in bone marrow disorders.

   • Iron Profile:

     • Serum Iron: Measures iron circulating in the blood.
     • Ferritin: Reflects iron stores in the body.
     • Total Iron-Binding Capacity (TIBC): Indicates the blood’s capacity to bind and transport iron.

   • Folate and Vitamin B12 Levels: Measure serum folate and vitamin B12 concentrations to diagnose nutritional anemias.

   • Coagulation Screenings (aPTT, PT/INR): Assess for bleeding disorders.

   • Lead Levels: Screen for lead poisoning, a cause of microcytic anemia.

   • Factor Assays: Investigate specific clotting factor deficiencies in bleeding disorders.

   • Coombs Test: Detects antibodies against red blood cells in hemolytic anemia.

2. Imaging Scans: Used in acute anemia to identify underlying causes or complications:

   • Ultrasonography: Rapidly evaluates for intraperitoneal bleeding (bleeding within the abdominal cavity).
   • Chest X-rays: Useful in severe anemia causing cardiomyopathy (heart muscle disease).
   • Computed Tomography (CT) Scans of the Abdomen: Detect masses, internal bleeding, or abnormalities in the spleen and other abdominal organs.
   • Esophagogastroduodenoscopy (EGD): Diagnoses upper gastrointestinal (GI) bleeding.
   • Outpatient Colonoscopy: Evaluates lower GI bleeding.

3. Bone Marrow Aspiration: Reserved for inconclusive cases:

   • Bone Marrow Analysis: May be necessary if lab results are unclear, to directly assess bone marrow function and red blood cell production.

Nursing Interventions for Anemia

Nursing interventions aim to manage the underlying cause of anemia, alleviate symptoms, and prevent complications.

1. Identify and Manage the Cause: Address the root cause of anemia:

   • Causative Factors: Anemia stems from conditions affecting red blood cell production or causing destruction. Identify and manage underlying causes such as acute blood loss, nutritional deficiencies, bone marrow disorders, chronic renal disease, hemophilia, autoimmune conditions, hemolytic processes, and medication side effects. Tailor interventions to the specific etiology.

2. Administer Intravenous (IV) Fluids: Volume resuscitation for acute blood loss:

   • Fluid Replacement: IV fluids increase intravascular volume in cases of trauma or acute blood loss, improving hemodynamic stability and tissue perfusion.

3. Blood Transfusion: Replace red blood cells in severe cases:

   • Packed Red Blood Cells (PRBCs): Transfuse PRBCs for actively bleeding patients and those with severe, symptomatic anemia (hemoglobin ≤ 7 g/dL). Transfusion thresholds may vary based on patient condition and comorbidities.

4. Oxygen Therapy: Support oxygenation:

   • Supplemental Oxygen: Anemia reduces oxygen-carrying capacity, potentially leading to hypoxia and dyspnea. Administer supplemental oxygen as needed to maintain adequate oxygen saturation.

5. Supplement Administration: Address nutritional deficiencies:

   • Iron Supplementation: Oral or IV iron for iron deficiency anemia.
   • Vitamin B12 Supplementation: Oral or intramuscular (IM) vitamin B12 for pernicious anemia.
   • Folate Supplementation: Oral, IV, or IM folate for folate deficiency anemia.

6. Educate on Oral Iron Supplementation: Maximize iron absorption and minimize side effects:

   • Patient Education:
     • Side Effects: Inform patients about common side effects like constipation, black, tarry stools, and metallic taste.
     • Administration Guidelines:
       • Empty Stomach: Take on an empty stomach for optimal absorption.
       • With Vitamin C: Administer with water or fruit juice (vitamin C source) to enhance iron absorption.
       • Timing: Take 1 hour before or 2 hours after meals. If gastrointestinal upset occurs, may take with food.

7. Erythropoietin Administration: Stimulate red blood cell production in renal disease:

   • Erythropoiesis-Stimulating Agents (ESAs): In chronic kidney disease, kidneys produce insufficient erythropoietin (EPO), essential for red blood cell production. Administer synthetic EPO (e.g., epoetin alfa) to stimulate bone marrow erythropoiesis.

8. Prepare for Bone Marrow/Stem Cell Transplantation: Consider for severe aplastic anemia:

   • Hematopoietic Stem Cell Transplant: For severe aplastic anemia, healthy stem cells from a donor replace the patient’s damaged bone marrow. Younger patients with a matched donor (sibling preferred) are better candidates.

9. Dietary Referral: Nutritional counseling:

   • Registered Dietitian Consultation: Refer patients to a dietitian for personalized education on iron, vitamin B12, and folate-rich foods to address nutritional deficiencies.

10. Patient Education: When to Seek Medical Attention: Empower patients to recognize worsening symptoms:

    • Warning Signs: Advise patients to seek immediate medical attention if symptoms worsen despite treatment or if any of the following occur:
      • Breathing difficulties
      • Lightheadedness or dizziness
      • Chest discomfort
      • Bright red blood in the stool

Nursing Care Plans for Anemia: Addressing Specific Nursing Diagnoses

Nursing care plans provide structured frameworks for addressing specific nursing diagnoses related to anemia, guiding assessments and interventions to achieve patient-centered goals.

Acute Pain (Related to Sickle Cell Anemia)

Nursing Diagnosis: Acute Pain

Related to: Sickling of red blood cells occluding blood vessels, lack of perfusion and oxygenation to tissues.

As evidenced by: Intense pain complaints, pain described as stabbing, sharp, or throbbing, reduced activity, restlessness, distractive behaviors.

Expected Outcomes:

• Patient will report pain reduction to ≤ 2/10 by discharge.
• Patient will verbalize understanding of pain crisis triggers.
• Patient will adhere to prescribed pain medication regimen.

Assessments:

1. Pain Assessment: Conduct comprehensive pain assessment (numeric/FACES scale), including character, duration, frequency, precipitating factors, and interventions.
2. Acute Chest Syndrome Assessment: Monitor for acute chest syndrome (vaso-occlusion in pulmonary vasculature), a life-threatening complication. Assess for chest pain, fever, dyspnea, and infiltrates on chest x-ray.
3. Pain Medication Regimen Review: Assess patient’s adherence to pain medication regimen, including doses and frequency.

Interventions:

1. Hydration: Administer IV fluids to promote hydration, reduce sickling, and alleviate pain. Encourage oral fluid intake.
2. Analgesia: Administer prescribed analgesics, often high doses of narcotics, potentially via patient-controlled analgesia (PCA). Monitor for adequate pain control and avoid over-sedation.
3. Blood Transfusion (as ordered): Transfuse blood based on hemoglobin level to prevent complications and correct anemia. Consider long-term transfusion therapy for some patients.
4. Patient Education: Sickle Cell Crisis Prevention: Educate patients on triggers to avoid (dehydration, infection, cold exposure, stress) and importance of medication adherence.

Decreased Cardiac Output

Nursing Diagnosis: Decreased Cardiac Output

Related to: Inadequate blood volume, decreased oxygenated blood to heart, inadequate cardiac muscle contraction, increased cardiac workload, severe blood loss, low red blood cells.

As evidenced by: Decreased cardiac output, tachycardia, hypertension, cardiac arrhythmias, chest pain, diminished pulses.

Expected Outcomes:

• Patient will demonstrate blood pressure and pulse within normal limits.
• Patient will manifest normal sinus rhythm on ECG.
• Patient will report no chest pain.

Assessments:

1. Vital Sign Monitoring: Monitor vital signs, noting compensatory mechanisms (tachycardia, hypertension) and signs of potential heart failure (uncontrolled tachycardia, hypertension).
2. Cardiovascular History: Obtain cardiovascular history, noting pre-existing conditions that may exacerbate cardiac strain in anemia.
3. Cardiovascular Status Assessment: Assess cardiovascular status for signs of heart failure, as anemia can worsen heart failure progression due to reduced oxygen delivery and increased cardiac workload.
4. Red Blood Cell Count Review: Check RBC count, MCV, and peripheral blood smear to evaluate red blood cell volume and characteristics impacting cardiac output.
5. Electrocardiogram (ECG): Obtain ECG to assess for arrhythmias (fast, irregular heartbeat) caused by cardiac compensation for reduced oxygen delivery.

Interventions:

1. Reduce Cardiac Stress: Minimize cardiac workload by managing anemia and addressing contributing factors.
2. Treat Anemia Etiology: Manage anemia based on type and cause to restore circulating volume and improve cardiac function.
3. Prepare for Blood Transfusion (as needed): Severe anemia may require blood transfusion to augment cardiac output and improve oxygen delivery.
4. Address Underlying Cause of Anemia: If anemia is secondary to treatment (e.g., chemotherapy), consider discontinuing or adjusting treatment as ordered to mitigate cardiac strain, if life-threatening complications arise.

Fatigue

Nursing Diagnosis: Fatigue

Related to: Decreased hemoglobin levels.

As evidenced by: Exhaustion, inability to maintain physical activity, increased need for rest, reported lack of energy, lethargy.

Expected Outcomes:

• Patient will verbalize energy conservation techniques.
• Patient will report increased energy levels and ability to perform tasks.

Assessments:

1. Complete Blood Count (CBC) Monitoring: Assess CBC, including RBC count and hemoglobin levels, to quantify anemia severity.
2. Chronic Condition Assessment: Assess for chronic conditions (pregnancy, cancer, autoimmune diseases) that can exacerbate anemia and fatigue.
3. Fatigue Impact Assessment: Inquire about the extent of fatigue’s impact on daily activities, responsibilities, and coping mechanisms.

Interventions:

1. Energy Conservation Education: Instruct on energy conservation strategies: plan rest periods, delegate tasks, cluster activities, prioritize activities during peak energy levels.
2. Oxygen Administration (as needed): Hospitalized patients with severe anemia may require supplemental oxygen to alleviate fatigue related to hypoxia.
3. Blood Transfusion (as needed): Blood transfusions may be indicated for severe anemia or blood loss-related fatigue.
4. Erythropoietin Injections (as ordered): Administer erythropoietin injections (epoetin alfa, darbepoetin alfa) to stimulate bone marrow red blood cell production in patients with chronic conditions (cancer, HIV, kidney disease).

Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements

Related to: Inability to absorb iron or vitamins, lack of vitamin B12 and folate in diet, pregnancy, gastric bypass surgery, inflammatory bowel diseases, vegetarian diet.

As evidenced by: Pale skin, feeling cold, fatigue, rapid heartbeat, brittle nails, hair loss, pica (craving ice – pagophagia), headaches.

Expected Outcomes:

• Patient will demonstrate improved iron and vitamin B12 levels on lab tests.
• Patient will incorporate three iron, vitamin B12, and folate-rich foods into diet.
• Patient will recognize anemia signs/symptoms and when to seek medical advice.

Assessments:

1. Laboratory Value Monitoring: Monitor RBC count, hemoglobin, hematocrit, ferritin, iron, and TIBC for abnormalities indicating nutritional deficiencies.
2. Dietary History Assessment: Assess patient’s usual diet, identifying nutritional gaps and food allergies.
3. Food Access Assessment: Evaluate patient’s access to healthy, vitamin-rich foods, considering socioeconomic factors and food insecurity.

Interventions:

1. Healthy Diet Education: Instruct on iron-rich foods (dark leafy greens, nuts, eggs), vitamin B12 foods (meat, dairy), and folate-rich foods (legumes, citrus, dark leafy greens).
2. Supplement Consideration: Consider oral iron or vitamin B12 supplements if dietary intake is insufficient. Vitamin B12 injections may be necessary for absorption issues.
3. Prenatal Supplement Encouragement: Educate pregnant patients on prenatal vitamins containing iron and folate for a healthy pregnancy and to prevent neural tube defects.
4. Iron Absorption Improvement Education: Educate on strategies to enhance iron absorption: consuming heme iron (meat, seafood), combining non-heme iron (plant-based) with vitamin C, avoiding iron absorption inhibitors (tea, coffee with meals).

Ineffective Tissue Perfusion

Nursing Diagnosis: Ineffective Tissue Perfusion

Related to: Bone marrow suppression, poor diet, deficiency in iron/vitamin B12, low oxygenated RBC supply, acute blood loss, impaired oxygen transport, chronic conditions, autoimmune RBC destruction.

As evidenced by: Lightheadedness/dizziness, headache, fatigue, altered mentation, pallor, cold extremities, prolonged capillary refill, chest pain, shortness of breath, low hemoglobin levels.

Expected Outcomes:

• Patient will demonstrate evidence of tissue perfusion (warm skin, normal skin color for ethnicity).
• Patient will report relief of shortness of breath, chest pain, and fatigue.
• Patient will achieve hemoglobin level > 10.0 g/dL.

Assessments:

1. Medical and Family History Review: Determine medical and family history to identify potential underlying causes or inherited anemias. Differentiate between acute and chronic anemia.
2. Physical Assessment: Perform physical assessment to identify signs of ineffective tissue perfusion: pallor, cold skin, respiratory changes, orthostatic hypotension, tachypnea, chest pain.
3. Hemoglobin Level Review: Review hemoglobin levels to quantify the severity of oxygen-carrying capacity reduction.

Interventions:

1. Chest Pain/Palpitation Investigation: Investigate reports of chest pain or palpitations with ECG to monitor for arrhythmias.
2. Oxygen Administration: Administer supplemental oxygen to maintain SpO2 > 95% to address hypoxia.
3. Safety Precautions Implementation: Implement fall and safety precautions due to CNS effects (lightheadedness, dizziness, vision changes, muscle weakness) increasing fall risk.
4. Epoetin Injections (as ordered): Administer epoetin alfa injections to stimulate red blood cell production in bone marrow, as prescribed.

References

(References from the original article would be listed here, ensuring they are relevant and credible. Since the original article does not explicitly list references, in a real-world scenario, you would ensure to include appropriate citations to support the medical information provided.)