Anemia, a condition characterized by a deficiency in red blood cells (RBCs) or hemoglobin, leads to reduced oxygen-carrying capacity in the blood, impacting overall bodily functions. This deficiency results in low hemoglobin levels and insufficient oxygen delivery to the body’s tissues and organs.
Anemia arises from various underlying causes broadly categorized into blood loss, impaired RBC production, or heightened RBC destruction. The spectrum of anemia ranges from mild, transient forms to chronic, lifelong conditions. Contributing factors include poor nutrition, genetic predispositions, cancer, autoimmune disorders, exposure to toxins, infections, and side effects from chronic illnesses.
In this guide, we will explore the nursing process for anemia, focusing on NANDA nursing diagnoses and developing effective care plans to address patient needs.
Understanding Anemia: Types and Causes
Nurses encounter and manage diverse types of anemia. These can be classified based on their etiology:
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Nutritional Deficiency Anemias:
- Iron-deficiency anemia (most prevalent globally)
- Pernicious anemia (Vitamin B12 deficiency due to absorption issues)
- Megaloblastic anemia (often caused by folate or B12 deficiency)
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Genetic Anemias:
- Sickle cell anemia (abnormal hemoglobin structure)
- Thalassemia anemia (reduced globin production)
- Fanconi anemia (bone marrow failure)
- Diamond-Blackfan anemia (red cell aplasia)
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Anemias from RBC Dysfunction, Production, or Destruction:
- Hemolytic anemia (premature RBC destruction)
- Aplastic anemia (bone marrow failure to produce all blood cell types)
- Macrocytic anemia (abnormally large RBCs)
- Microcytic anemia (abnormally small RBCs)
- Normocytic anemia (normal size RBCs but insufficient number)
Nursing Assessment for Anemia
The nursing process begins with a comprehensive assessment to gather subjective and objective data, crucial for formulating accurate nursing diagnoses and care plans.
Review of Health History (Subjective Data)
1. General Symptom Inquiry: Assess for common anemia symptoms:
- General: Fatigue, generalized weakness
- Central Nervous System (CNS): Dizziness, lightheadedness, headaches
- Head, Ears, Eyes, Nose, and Throat (HEENT): Pulsatile tinnitus (pounding or “whooshing” ear sounds)
- Respiratory: Dyspnea (shortness of breath), tachypnea (rapid breathing)
- Cardiovascular: Palpitations, fast or irregular heartbeat, chest discomfort, chest pain
- Integumentary: Pale skin, cool skin, cold sensations, numbness in extremities, brittle nails
2. Medical History Review: Identify pre-existing conditions impacting bone marrow function (e.g., leukemia, blood cancers) or chronic diseases like chronic kidney disease or rheumatoid arthritis that can induce anemia.
3. Medication Review: Document medications that may trigger hemolytic anemia, such as cephalosporins, levodopa, levofloxacin, nitrofurantoin, NSAIDs, and penicillins.
4. Activity and Risk Factor Interview: Explore occupational or hobby-related exposures to toxins like tranquilizers, pesticides, paints, solvents, or hair dyes, which are potential environmental causes of anemia.
5. Gynecological History (for women): Determine gynecological status, including heavy menstrual bleeding (menorrhagia), recent abortion, or current pregnancy, as these can contribute to anemia.
6. Bowel Movement Bleeding Inquiry: Question about changes in bowel habits, specifically dark, tarry stools (melena), visible blood on toilet paper or in the toilet bowl, diarrhea with blood, or bleeding hemorrhoids.
7. Gastrointestinal History: Investigate gastrointestinal conditions associated with bleeding and anemia: diverticulitis, hiatal hernias, peptic ulcers, gastroenteritis, cancer, and inflammatory bowel disease.
8. Urine Changes Assessment: Ask about alterations in urine color, which can indicate genitourinary bleeding.
9. Dietary Assessment: Review typical dietary intake to identify nutritional deficiencies in vitamins and minerals that increase risks for nutritional anemias. Note excessive alcohol intake and dietary choices like vegan or vegetarian diets that may lack iron or vitamin B12.
10. Socioeconomic Status: Evaluate economic factors like living in food deserts or inability to afford nutritious food, increasing the risk of nutritional anemias.
Physical Assessment (Objective Data)
1. Nutritional Deficiency Signs: Observe for physical manifestations of nutritional deficits:
- Iron deficiency: Pale skin, brittle fingernails, tachycardia
- Vitamin B12 deficiency/pernicious anemia: Bleeding gums, pale or jaundiced skin, weight loss, muscle weakness
- Megaloblastic anemia: Pale skin, diarrhea, glossitis (inflamed tongue)
2. Bleeding or Bleeding Disorder Signs: Detect signs of bleeding disorders, such as purpura, bruising, petechiae, or obvious trauma. Consider medications like aspirin or warfarin that increase bleeding risk.
3. Neurological Assessment: Evaluate neurological function for signs of oxygen deprivation in the brain, including vision changes, memory loss, poor coordination, headache, irritability, and paresthesias.
4. Eye Examination: Inspect the conjunctiva and sclera. Pale pink or white conjunctiva may indicate iron deficiency. A blue tint to the sclera can also suggest iron-deficiency anemia.
5. Cardiopulmonary Assessment: Assess heart and lung function for signs of compromised oxygenation. Monitor for chest discomfort, dyspnea, tachycardia, tachypnea, and hypoxia. Be vigilant for signs of heart failure.
6. Lymph Node Palpation: Examine lymph nodes for enlargement, which could indicate infection or neoplasia, both potentially causing decreased RBC production.
Diagnostic Procedures
1. Blood Tests: Obtain blood samples for diagnostic evaluation:
- Complete Blood Count (CBC) with differential: RBC count, hemoglobin, hematocrit, reticulocyte count, MCV, RDW, platelet count.
- Iron Profile: Serum iron, ferritin, total iron-binding capacity (TIBC).
- Vitamin Levels: Folate and vitamin B12 levels.
- Coagulation Studies: aPTT, PT/INR (if bleeding disorder suspected).
- Lead Levels: (if lead poisoning suspected).
- Factor Assays: (if inherited bleeding disorder suspected).
- Coombs Test: (to detect autoimmune hemolytic anemia).
2. Imaging Scans: Utilize imaging for acute anemia to identify underlying causes or complications:
- Ultrasonography: Rapid assessment for intraperitoneal bleeding.
- Chest X-rays: Evaluate for cardiomyopathy in severe anemia.
- CT Scans of Abdomen: Detect masses, internal bleeding, or spleen/abdominal organ abnormalities.
- Esophagogastroduodenoscopy (EGD): Diagnose upper gastrointestinal (GI) bleeding.
- Outpatient Colonoscopy: Diagnose lower GI bleeding.
3. Bone Marrow Aspiration: Consider bone marrow analysis if lab results are inconclusive, especially in cases of suspected bone marrow disorders.
NANDA Nursing Diagnoses for Anemia
Based on assessment data, relevant NANDA nursing diagnoses for patients with anemia include:
Acute Pain
Nursing Diagnosis: Acute Pain
Related to: Sickling of red blood cells occluding blood vessels, leading to ischemia and lack of perfusion and oxygenation to extremities (primarily in Sickle Cell Anemia).
As evidenced by: Intense pain complaints anywhere in the body, pain described as stabbing, sharp, or throbbing, reduced activity, restlessness, distractive behaviors (pacing, watching TV, talking on the phone).
Expected Outcomes:
- Patient will report pain reduction to a tolerable level (e.g., 2/10) by discharge.
- Patient will verbalize understanding of triggers for pain crises.
- Patient will adhere to prescribed pain management regimen.
Nursing Assessments:
- Pain Assessment: Conduct comprehensive pain assessment using numeric or FACES scales, noting character, duration, frequency, triggers, and alleviating factors.
- Acute Chest Syndrome Monitoring: Assess for acute chest syndrome in sickle cell patients (vaso-occlusion in pulmonary vasculature), monitoring for chest pain, fever, dyspnea, and infiltrates on chest X-ray.
- Pain Medication Regimen Review: Evaluate patient’s adherence to pain medication, doses, and frequency to identify potential undertreatment or missed doses contributing to pain crises.
Nursing Interventions:
- Hydration: Administer IV fluids as prescribed to reduce sickling and improve blood flow. Encourage oral fluid intake.
- Analgesia: Administer analgesics as ordered, often including narcotics, possibly via PCA pump, closely monitoring for pain relief and avoiding over-sedation.
- Blood Transfusions: Prepare for and administer blood transfusions as prescribed to improve oxygen-carrying capacity and prevent complications, especially in severe anemia.
- Patient Education: Educate patients on sickle cell crisis triggers (dehydration, infection, cold exposure, stress) and preventative measures, medication adherence, and importance of hydration.
Alt text: Illustration depicting sickle-shaped red blood cells in sickle cell anemia, highlighting the abnormal shape compared to healthy red blood cells.
Decreased Cardiac Output
Nursing Diagnosis: Decreased Cardiac Output
Related to: Inadequate blood volume, decreased oxygenated blood available to the heart, increased cardiac workload due to anemia, and potential for heart muscle fatigue.
As evidenced by: Decreased cardiac output measurements, tachycardia, hypertension, cardiac arrhythmias, chest pain, diminished peripheral pulses.
Expected Outcomes:
- Patient will demonstrate stable blood pressure and pulse within normal limits.
- Patient will exhibit normal sinus rhythm on ECG.
- Patient will report absence of chest pain.
Nursing Assessments:
- Vital Signs Monitoring: Monitor vital signs frequently, noting tachycardia and hypertension as compensatory mechanisms. Be alert for signs of heart fatigue and potential heart failure if these are uncontrolled.
- Cardiovascular History: Obtain cardiovascular history to identify pre-existing conditions that may exacerbate decreased cardiac output in anemia.
- Cardiovascular Status Assessment: Assess cardiovascular status, recognizing anemia’s impact on heart failure progression due to reduced oxygen delivery and compromised circulation.
- Red Blood Cell Count Review: Check RBC count, MCV, and peripheral blood smear to evaluate RBC volume and characteristics affecting cardiac output.
- ECG Monitoring: Obtain ECG to detect arrhythmias, which can occur as the heart compensates for reduced oxygen carrying capacity by pumping faster and potentially irregularly.
Nursing Interventions:
- Reduce Cardiac Stress: Implement measures to minimize cardiac workload, such as promoting rest and managing fluid balance to prevent fluid overload.
- Anemia Treatment: Address the underlying cause and type of anemia through appropriate medical interventions (e.g., supplements, blood transfusions) to improve circulating volume and oxygen delivery.
- Blood Transfusion Preparation: Prepare for potential blood transfusion in severe anemia to augment cardiac output and oxygen transport.
- Address Anemia Etiology: Identify and address the root cause of anemia (e.g., discontinue medication-induced anemia if feasible and ordered) to support cardiac function recovery.
Alt text: Image showing an electrocardiogram (ECG) readout, a diagnostic tool used to monitor heart rhythm and detect cardiac abnormalities in patients with anemia.
Fatigue
Nursing Diagnosis: Fatigue
Related to: Reduced oxygen-carrying capacity due to decreased hemoglobin levels in anemia, leading to insufficient oxygen delivery to tissues and energy depletion.
As evidenced by: Reports of exhaustion, inability to maintain usual physical activity levels, increased need for rest, reported lack of energy, lethargy.
Expected Outcomes:
- Patient will verbalize energy conservation techniques.
- Patient will report increased energy levels and improved ability to perform daily activities.
Nursing Assessments:
- Complete Blood Count (CBC) Monitoring: Regularly assess CBC, including RBC count and hemoglobin levels, to track the severity of anemia and its impact on fatigue.
- Chronic Condition Assessment: Identify co-existing chronic conditions (pregnancy, cancer, autoimmune diseases) that can worsen anemia and fatigue. Prioritize addressing underlying causes.
- Fatigue Impact Assessment: Evaluate the extent of fatigue’s impact on daily life, including activities the patient can and cannot perform, effects on roles and responsibilities, and current coping strategies.
Nursing Interventions:
- Energy Conservation Education: Instruct patients on energy conservation strategies: planning rest periods, delegating tasks, clustering activities, and prioritizing activities during peak energy times.
- Oxygen Therapy: Administer supplemental oxygen as prescribed for hospitalized patients with significantly low hemoglobin levels to alleviate hypoxia-related fatigue.
- Blood Transfusion Administration: Prepare for and administer blood transfusions for severe anemia or blood loss-induced anemia to improve oxygen delivery and reduce fatigue.
- Erythropoietin Injections: Administer erythropoietin injections (e.g., Epogen, Procrit) as ordered to stimulate bone marrow RBC production, particularly for patients with chronic conditions like cancer, HIV, or kidney disease-related anemia.
Alt text: Nurse assessing a patient for fatigue, illustrating a key aspect of nursing assessment for anemia, focusing on the patient’s reported exhaustion and energy levels.
Imbalanced Nutrition: Less Than Body Requirements
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to: Inadequate intake or absorption of essential nutrients like iron, vitamin B12, and folate, contributing to nutritional anemias; may be exacerbated by pregnancy, gastric bypass, IBD, or vegetarian diets.
As evidenced by: Pale skin, feeling cold, fatigue, rapid heartbeat, brittle nails, hair loss, pagophagia (ice craving), headaches.
Expected Outcomes:
- Patient will demonstrate improved iron and vitamin B12 levels through lab results.
- Patient will incorporate three iron, B12, and folate-rich foods into their daily diet.
- Patient will recognize anemia signs and symptoms and understand when to seek medical advice.
Nursing Assessments:
- Laboratory Value Monitoring: Monitor RBC count, hemoglobin, hematocrit, ferritin, iron, and TIBC for abnormalities indicating nutritional deficiencies.
- Dietary History Assessment: Assess patient’s usual diet, identifying nutritional gaps and any food allergies or restrictions that may contribute to deficiencies.
- Access to Healthy Foods Evaluation: Evaluate patient’s access to healthy, vitamin-rich foods, considering socioeconomic factors affecting food choices.
Nursing Interventions:
- Healthy Diet Education: Educate patients on iron-rich foods (dark leafy greens, nuts, eggs), vitamin B12 sources (meat, dairy), and folate-rich foods (legumes, citrus, dark greens).
- Supplementation Recommendations: Discuss and administer oral iron or vitamin B12 (cyanocobalamin) supplements as prescribed, particularly if dietary intake is insufficient. Vitamin B12 injections may be necessary for absorption issues.
- Prenatal Supplementation Encouragement: Emphasize the importance of prenatal vitamins containing iron and folate for pregnant patients to support maternal and fetal health and prevent neural tube defects.
- Iron Absorption Improvement Strategies: Educate patients on enhancing iron absorption: consuming heme iron (meat, seafood) which is more easily absorbed, combining non-heme iron (vegetables, grains) with vitamin C, and avoiding tannin-containing beverages (tea, coffee) with meals.
Alt text: Image showcasing various iron-rich foods, including leafy green vegetables, meat, and legumes, emphasizing dietary strategies to combat iron-deficiency anemia.
Ineffective Tissue Perfusion
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to: Reduced oxygen transport due to low RBC count or hemoglobin, bone marrow suppression, nutritional deficiencies, acute blood loss, chronic conditions impairing RBC production or function, and autoimmune destruction of RBCs.
As evidenced by: Lightheadedness or dizziness, headache, fatigue, changes in mental status, pallor, cold extremities, prolonged capillary refill time, chest pain, shortness of breath, low hemoglobin levels.
Expected Outcomes:
- Patient will demonstrate improved tissue perfusion evidenced by warm skin and skin color within normal range for ethnicity.
- Patient will report relief from shortness of breath, chest pain, and fatigue.
- Patient will achieve and maintain hemoglobin level >10.0 g/dL (or individualized target).
Nursing Assessments:
- Medical and Family History: Obtain thorough medical and family history to identify potential inherited anemias or anemia secondary to chronic conditions. Differentiate between acute and chronic anemia to guide management.
- Physical Assessment for Perfusion: Conduct comprehensive physical assessment to evaluate tissue perfusion, monitoring for pallor, cold skin, respiratory changes, orthostatic hypotension, tachypnea, and chest pain, indicating hypoxia.
- Hemoglobin Level Review: Regularly review hemoglobin levels to assess the severity of anemia and its direct impact on oxygen-carrying capacity and tissue perfusion.
Nursing Interventions:
- Chest Pain/Palpitation Investigation: Promptly investigate reports of chest pain or palpitations with ECG monitoring to rule out cardiac ischemia or arrhythmias.
- Oxygen Administration: Provide supplemental oxygen to maintain SpO2 > 95% to address hypoxia from reduced oxygen-carrying capacity.
- Safety Precautions Implementation: Implement fall precautions and safety measures due to potential lightheadedness, dizziness, vision changes, and muscle weakness, reducing fall risk.
- Erythropoietin Injections: Administer epoetin alfa injections as prescribed to stimulate RBC production in bone marrow and improve tissue oxygenation, especially in chronic anemia related to kidney disease or bone marrow suppression.
Alt text: Nurse assessing capillary refill time on a patient’s finger, a clinical method to evaluate peripheral tissue perfusion, relevant in anemia assessment.
Nursing Interventions for Anemia Management
General nursing interventions applicable across various anemia types include:
- Identify and Treat Underlying Cause: Determine and manage the root cause of anemia (e.g., blood loss, nutritional deficiency, chronic disease).
- Intravenous Fluid Administration: Administer IV fluids as ordered, especially in acute blood loss, to restore intravascular volume.
- Blood Transfusion Administration: Transfuse packed red blood cells (PRBCs) as prescribed for actively bleeding patients or those with severe symptomatic anemia (hemoglobin ≤ 7 g/dL).
- Oxygen Therapy: Apply supplemental oxygen as needed to address hypoxia and dyspnea.
- Supplement Administration: Administer prescribed supplements: oral/IV iron, oral/IM vitamin B12, oral/IV/IM folate, tailored to specific deficiencies.
- Oral Iron Supplementation Education: Educate patients on oral iron supplement administration: side effects (constipation, dark stools, metallic taste), administration on empty stomach with vitamin C source (water or fruit juice), 1 hour before or 2 hours after meals (can take with food if GI upset occurs).
- Erythropoietin Administration for Renal Disease: Administer erythropoietin for patients with renal disease to stimulate RBC production.
- Bone Marrow/Stem Cell Transplant Preparation: Prepare patients with severe aplastic anemia for potential bone marrow or stem cell transplantation.
- Dietitian Referral: Refer patients to a dietitian for nutritional counseling on iron, vitamin B12, and folate-rich diets.
- Patient Education on Medical Attention: Advise patients to seek immediate medical attention for worsening symptoms, breathing difficulties, lightheadedness, chest discomfort, or bright red stool bleeding.
Conclusion
Effective nursing care for patients with anemia relies on accurate NANDA nursing diagnoses and well-structured care plans. By conducting thorough assessments, identifying relevant diagnoses like Acute Pain, Decreased Cardiac Output, Fatigue, Imbalanced Nutrition, and Ineffective Tissue Perfusion, and implementing targeted interventions, nurses play a vital role in managing anemia, alleviating symptoms, and improving patient outcomes. A holistic approach encompassing medical interventions, nutritional support, patient education, and symptom management is crucial for comprehensive anemia care.
References
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