Anemia Nursing Diagnosis & Care Plan: Comprehensive Guide for Nurses

Anemia is a condition characterized by a deficiency in red blood cells or hemoglobin, leading to reduced oxygen-carrying capacity and systemic hypoxia. This hematological disorder arises from various etiologies, including blood loss, impaired red blood cell production, or heightened red blood cell destruction. Understanding anemia, its diverse types, and the crucial role of nursing care is paramount for effective patient management and improved outcomes. This guide provides a comprehensive overview of anemia, focusing on nursing diagnoses and evidence-based care plans to equip nurses with the knowledge and strategies needed to deliver optimal care.

Types of Anemia: A Clinical Overview

Anemia is not a singular disease but rather a symptom of underlying conditions. Classifying anemia by its cause is essential for targeted treatment. Nurses should be familiar with the different types of anemia, which can be broadly categorized based on etiology:

• Nutritional Deficiencies:
  • Iron-Deficiency Anemia: The most prevalent type, often due to inadequate iron intake, absorption issues, or blood loss.
  • Pernicious Anemia: Caused by vitamin B12 deficiency due to impaired absorption in the stomach, often related to a lack of intrinsic factor.
  • Megaloblastic Anemia: Characterized by large, immature red blood cells, commonly resulting from deficiencies in vitamin B12 or folate.
• Genetic Factors:
  • Sickle Cell Anemia: An inherited blood disorder causing red blood cells to be sickle-shaped, leading to vaso-occlusion and chronic anemia.
  • Thalassemia Anemia: A group of inherited disorders affecting hemoglobin production, resulting in varying degrees of anemia severity.
  • Fanconi Anemia: A rare genetic disease leading to bone marrow failure and various congenital abnormalities.
  • Diamond-Blackfan Anemia: A rare inherited bone marrow failure syndrome primarily affecting red blood cell production.
• Abnormal RBC Function, Production, or Destruction:
  • Hemolytic Anemia: Premature destruction of red blood cells, which can be inherited or acquired.
  • Aplastic Anemia: Bone marrow failure resulting in a deficiency of all blood cell types, including red blood cells.
  • Macrocytic Anemia: Anemia characterized by abnormally large red blood cells, often overlapping with megaloblastic anemia.
  • Microcytic Anemia: Anemia characterized by abnormally small red blood cells, commonly seen in iron deficiency and thalassemia.
  • Normocytic Anemia: Anemia where red blood cell size is normal, but the number is reduced, often associated with chronic diseases.

Understanding these classifications helps nurses anticipate potential complications and tailor their nursing interventions effectively.

Nursing Process for Anemia: A Step-by-Step Approach

The nursing process provides a structured framework for delivering patient-centered care. In the context of anemia, it encompasses assessment, diagnosis, planning, implementation, and evaluation, ensuring a holistic and systematic approach to patient management.

Nursing Assessment: Gathering Crucial Data

A thorough nursing assessment is the cornerstone of effective anemia management. It involves collecting subjective and objective data to understand the patient’s condition comprehensively.

Review of Health History: Uncovering Clues

1. General Symptom Evaluation: Elicit information about common anemia symptoms:

   • General: Fatigue, generalized weakness, reduced stamina.
   • Central Nervous System (CNS): Dizziness, lightheadedness, headaches, vertigo.
   • Head, Eyes, Ears, Nose, and Throat (HEENT): Pulsatile tinnitus (pounding or “whooshing” sound in the ear).
   • Respiratory: Dyspnea (shortness of breath), tachypnea (rapid breathing).
   • Cardiovascular: Palpitations, tachycardia (fast heart rate), chest discomfort, chest pain (angina).
   • Integumentary: Pallor (pale skin), cool skin, cold intolerance, numbness or tingling in extremities, brittle nails.

2. Medical History Review: Focus on conditions that impact bone marrow function and red blood cell production:

   • History of leukemia or other hematologic malignancies.
   • Chronic kidney disease (CKD), which reduces erythropoietin production.
   • Rheumatoid arthritis and other chronic inflammatory conditions that can lead to anemia of chronic disease.

3. Medication Review: Identify medications known to induce hemolytic anemia:

   • Cephalosporins (antibiotics).
   • Levodopa (Parkinson’s disease medication).
   • Levofloxacin (antibiotic).
   • Nitrofurantoin (antibiotic).
   • Nonsteroidal anti-inflammatory drugs (NSAIDs).
   • Penicillins (antibiotics).

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

   • Exposure to tranquilizers, pesticides, paints, solvents, or hair dyes, which can be environmental causes of anemia.

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

   • Heavy menstrual bleeding (menorrhagia).
   • Recent abortion or miscarriage.
   • Current pregnancy, which increases iron demands.

6. Bowel Movement History: Inquire about changes in bowel habits and signs of gastrointestinal bleeding:

   • Melena (dark, tarry stools) indicating upper GI bleeding.
   • Hematochezia (bright red blood in stool) suggesting lower GI bleeding.
   • Bleeding with hemorrhoids.
   • Diarrhea with blood.

7. Gastrointestinal History: Investigate pre-existing gastrointestinal conditions associated with bleeding:

   • Diverticulitis.
   • Hiatal hernia.
   • Peptic ulcers.
   • Gastroenteritis.
   • Gastrointestinal cancers.
   • Inflammatory bowel disease (IBD) such as Crohn’s disease and ulcerative colitis.

8. Urinary Changes: Assess for hematuria (blood in urine):

   • Changes in urine color, which may indicate genitourinary bleeding.

9. Dietary Assessment: Evaluate nutritional intake and dietary habits:

   • Dietary deficiencies in iron, vitamin B12, and folate.
   • Excessive alcohol consumption, which can impair nutrient absorption and bone marrow function.
   • Vegan or vegetarian diets lacking adequate iron or vitamin B12 sources.

10. Socioeconomic Status: Consider socioeconomic factors impacting access to nutritious food:

    • Food insecurity and limited access to quality food, increasing the risk of nutritional anemias.

Alt text: A nurse palpates the conjunctiva of a patient’s eye to assess for pallor, a key indicator of anemia during a physical examination.

Physical Assessment: Objective Signs of Anemia

1. Nutritional Deficiency Assessment: Look for physical signs associated with specific nutritional anemias:

   • Iron Deficiency: Pallor, brittle fingernails, tachycardia.
   • Vitamin B12 Deficiency/Pernicious Anemia: Bleeding gums, pallor or jaundice, weight loss, muscle weakness.
   • Megaloblastic Anemia: Pallor, diarrhea, glossitis (inflamed tongue).

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

   • Purpura, bruising, petechiae (small, pinpoint hemorrhages) on the skin.
   • Signs of trauma or injuries.
   • History of hemophilia or other bleeding disorders.
   • Medication use such as aspirin or warfarin (anticoagulants).

3. Neurological Assessment: Assess for neurological manifestations due to reduced oxygen delivery to the brain:

   • Vision disturbances.
   • Memory loss or cognitive impairment.
   • Poor coordination.
   • Headache.
   • Irritability.
   • Paresthesias (numbness or tingling).

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

   • Pale pink or white conjunctiva (inner lining of the eyelid) indicating low iron levels.
   • Blue sclera (whites of the eyes) suggesting iron-deficiency anemia.

5. Cardiopulmonary Assessment: Evaluate cardiovascular and respiratory systems for effects of anemia:

   • Chest discomfort or pain.
   • Dyspnea.
   • Tachycardia.
   • Tachypnea.
   • Hypoxia (low oxygen saturation).
   • Signs of heart failure.

6. Lymph Node Palpation: Examine lymph nodes for enlargement:

   • Palpable lymphadenopathy may indicate infection or neoplasia (cancer), which can contribute to anemia.

Alt text: A lab technician in blue gloves carefully handles vials of blood samples, preparing them for hematological analysis to diagnose anemia and identify its specific type.

Diagnostic Procedures: Confirming Anemia and Identifying the Cause

Diagnostic procedures are essential to confirm the presence of anemia, determine its type, and identify underlying causes.

1. Blood Tests: A comprehensive panel of blood tests is crucial for anemia diagnosis:

   • Complete Blood Count (CBC) with differential:
     • Red blood cell count (RBC).
     • Hemoglobin (Hgb).
     • Hematocrit (Hct).
     • Reticulocyte count (immature red blood cells).
     • Mean corpuscular volume (MCV – RBC size).
     • Red cell distribution width (RDW – variation in RBC size).
     • Platelet count.
   • Iron Profile:
     • Serum iron.
     • Ferritin (iron storage).
     • Total iron-binding capacity (TIBC).
   • Folate and Vitamin B12 levels.

   Additional blood tests to investigate underlying conditions:

   • Coagulation screenings (aPTT, PT/INR) to assess for bleeding disorders.
   • Lead levels to rule out lead poisoning as a cause of anemia.
   • Factor assays for specific bleeding disorders.
   • Coombs test to detect autoimmune hemolytic anemia.

2. Imaging Scans: Used in specific cases to identify underlying causes or complications:

   • Ultrasonography: Rapid assessment for intraperitoneal bleeding in acute anemia.
   • Chest X-ray: Evaluates for cardiomyopathy (heart muscle disease) in severe anemia.
   • CT scans of the abdomen: Detect masses, internal bleeding, or spleen abnormalities.
   • Esophagogastroduodenoscopy (EGD): Diagnoses upper gastrointestinal (GI) bleeding.
   • Colonoscopy: Evaluates for lower GI bleeding in outpatient settings.

3. Bone Marrow Aspiration: Reserved for complex or inconclusive cases:

   • Bone marrow analysis may be necessary if lab results are unclear or to diagnose bone marrow disorders.

Nursing Interventions: Restoring Hematological Balance

Nursing interventions for anemia are multifaceted, aiming to address the underlying cause, alleviate symptoms, and prevent complications.

1. Identify and Manage the Underlying Cause: Treatment is tailored to the specific etiology of anemia:

   • Acute blood loss: Manage bleeding and restore blood volume.
   • Nutritional deficiencies (iron, vitamin B12, folate): Supplement deficient nutrients.
   • Bone marrow conditions: Treat underlying bone marrow disorders.
   • Chronic renal disease: Manage CKD and consider erythropoietin-stimulating agents.
   • Hemophilia: Manage bleeding episodes and provide factor replacement therapy.
   • Autoimmune and rheumatological conditions: Manage underlying autoimmune diseases.
   • Increased RBC destruction (hemolytic anemia, DIC): Address the cause of hemolysis.
   • Medication side effects: Adjust or discontinue causative medications if possible.

2. Administer IV Fluids: Volume resuscitation in cases of acute blood loss or hypovolemia.

3. Blood Transfusion: Reserved for severe symptomatic anemia or active bleeding:

   • Packed red blood cells (PRBCs) transfusions are typically indicated for hemoglobin levels ≤ 7 g/dL or in actively bleeding patients.

4. Oxygen Therapy: Address hypoxia and dyspnea related to reduced oxygen-carrying capacity:

   • Administer supplemental oxygen as needed to maintain adequate oxygen saturation.

5. Supplement Administration: Replace deficient nutrients based on the type of anemia:

   • Iron supplementation: Oral or intravenous iron preparations.
   • Vitamin B12 supplementation: Oral, intramuscular (IM), or intravenous vitamin B12.
   • Folate supplementation: Oral, intravenous, or intramuscular folate.

6. Education on Oral Iron Supplementation: Provide comprehensive patient education to optimize oral iron therapy:

   • Inform patients about common side effects: constipation, dark stools, metallic taste, gastrointestinal upset.
   • Instructions for administration:
     • Take on an empty stomach for optimal absorption.
     • Administer with water or fruit juice (vitamin C enhances absorption).
     • Take 1 hour before or 2 hours after meals; may take with food if GI upset occurs.

7. Erythropoietin Administration for Renal Disease: Stimulate red blood cell production in CKD patients:

   • Administer synthetic erythropoietin (e.g., epoetin alfa) as prescribed to stimulate bone marrow RBC production.

8. Prepare for Bone Marrow or Stem Cell Transplantation: Considered for severe aplastic anemia:

   • For severe aplastic anemia, stem cell transplantation from a matched donor may be necessary to replace the patient’s failing bone marrow.

9. Dietitian Referral: Provide nutritional counseling and dietary guidance:

   • Refer patients to a registered dietitian for personalized dietary recommendations to address nutritional deficiencies.

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

    • Instruct patients to seek immediate medical attention if they experience:
      • Breathing difficulties.
      • Lightheadedness or dizziness.
      • Chest discomfort or pain.
      • Bright red bleeding in stool.
      • Worsening fatigue or weakness despite treatment.

Alt text: A nurse is seated beside a patient in a hospital bed, engaging in a conversation about anemia management and self-care strategies during a patient education session.

Anemia Nursing Care Plans: Addressing Key Nursing Diagnoses

Nursing care plans provide a roadmap for individualized patient care, prioritizing nursing diagnoses and outlining specific interventions and expected outcomes. Common nursing diagnoses associated with anemia include:

Acute Pain (Specific to Sickle Cell Anemia)

Nursing Diagnosis: Acute Pain related to vaso-occlusion and reduced tissue perfusion secondary to sickling of red blood cells, as evidenced by patient report of pain, restlessness, and altered activity level.

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

Defining Characteristics: Intense pain complaints, pain described as stabbing, sharp, or throbbing, reduced activity, restlessness, distractive behaviors.

Expected Outcomes:

• Patient will report pain reduction to a tolerable level (e.g., ≤ 2/10 on pain scale) by discharge.
• Patient will verbalize understanding of triggers for sickle cell pain crises.
• Patient will adhere to prescribed pain management regimen.

Nursing Interventions:

1. Pain Assessment: Conduct comprehensive pain assessment using pain scales (numeric or FACES), assess pain characteristics, duration, frequency, precipitating factors, and effectiveness of current pain management.
2. Acute Chest Syndrome Monitoring: Assess for signs and symptoms of acute chest syndrome (chest pain, fever, dyspnea, abnormal chest X-ray), a life-threatening complication of sickle cell anemia.
3. Pain Medication Regimen Review: Evaluate patient adherence to pain medication regimen, assess dosage and frequency, and identify potential barriers to effective pain management.
4. Hydration: Administer intravenous fluids as prescribed to promote hemodilution, reduce sickling, and improve pain. Encourage oral fluid intake.
5. Analgesic Administration: Administer analgesics as ordered, often requiring high doses of narcotics or patient-controlled analgesia (PCA) to manage severe sickle cell pain crises. Monitor for over-sedation and respiratory depression.
6. Blood Transfusion (if indicated): Prepare for and administer blood transfusions as prescribed to improve hemoglobin levels and reduce vaso-occlusion.
7. Patient Education: Sickle Cell Crisis Prevention: Educate patients on triggers for sickle cell crises (dehydration, infection, cold exposure, stress) and strategies for prevention, including maintaining hydration, preventing infections, avoiding cold, managing stress, and medication adherence.

Decreased Cardiac Output

Nursing Diagnosis: Decreased Cardiac Output related to reduced oxygen-carrying capacity and increased cardiac workload secondary to anemia, as evidenced by tachycardia, hypertension, and potential chest pain.

Related Factors: Inadequate blood volume, decreased oxygenated blood to the heart, increased cardiac workload, severe blood loss, low red blood cell count.

Defining Characteristics: Decreased cardiac output, tachycardia, hypertension, cardiac arrhythmias, chest pain, diminished peripheral pulses.

Expected Outcomes:

• Patient will maintain blood pressure and heart rate within acceptable limits for their baseline.
• Patient will demonstrate a stable cardiac rhythm on ECG monitoring.
• Patient will report absence of chest pain or discomfort.

Nursing Interventions:

1. Vital Sign Monitoring: Monitor vital signs closely, particularly heart rate and blood pressure, for signs of compensatory mechanisms or cardiac decompensation.
2. Cardiovascular History Assessment: Obtain a thorough cardiovascular history to identify pre-existing cardiac conditions that may exacerbate the effects of anemia on cardiac output.
3. Cardiovascular Status Assessment: Assess for signs and symptoms of heart failure, as anemia can worsen pre-existing heart failure or contribute to its development.
4. Red Blood Cell Count Monitoring: Monitor CBC results, particularly RBC count, hemoglobin, and hematocrit, to assess the severity of anemia and its impact on cardiac function.
5. ECG Monitoring: Obtain ECGs as ordered to assess for cardiac arrhythmias, which can be exacerbated by anemia.
6. Reduce Cardiac Stress: Implement measures to reduce cardiac workload, such as promoting rest, managing pain and anxiety, and optimizing oxygenation.
7. Treat Underlying Anemia: Implement interventions to treat the underlying cause of anemia, as improving hemoglobin levels will directly improve cardiac output.
8. Prepare for Blood Transfusion (if severe anemia): Prepare for and assist with blood transfusions for patients with severe anemia to improve oxygen-carrying capacity and cardiac output.
9. Address Underlying Cause of Anemia: Collaborate with the healthcare team to address and manage the underlying cause of anemia, such as bleeding, nutritional deficiencies, or chronic diseases.

Fatigue

Nursing Diagnosis: Fatigue related to decreased oxygen-carrying capacity secondary to anemia, as evidenced by patient report of exhaustion, lack of energy, and inability to maintain usual activity levels.

Related Factors: Decreased hemoglobin levels, reduced oxygen delivery to tissues.

Defining Characteristics: Exhaustion, inability to maintain physical activity, increased need for rest, reported lack of energy, lethargy.

Expected Outcomes:

• Patient will verbalize energy conservation techniques and strategies to manage fatigue.
• Patient will report improved energy levels and ability to perform desired activities within their limitations.

Nursing Interventions:

1. CBC Monitoring: Monitor CBC results, particularly hemoglobin and hematocrit levels, to assess the severity of anemia and its contribution to fatigue.
2. Assess Contributing Chronic Conditions: Assess for underlying chronic conditions (pregnancy, cancer, autoimmune diseases) that may worsen anemia and fatigue.
3. Fatigue Assessment in Daily Life: Assess the impact of fatigue on the patient’s daily activities, roles, and responsibilities, and how they are currently managing their fatigue.
4. Energy Conservation Education: Instruct patients on energy conservation techniques, such as planning rest periods, prioritizing activities, delegating tasks, and clustering activities.
5. Oxygen Administration (if indicated): Administer supplemental oxygen as ordered for hospitalized patients with severe anemia and hypoxia.
6. Blood Transfusion (if severe anemia): Prepare for and assist with blood transfusions for patients with severe anemia or acute blood loss contributing to fatigue.
7. Erythropoietin Injections (if indicated): Administer erythropoietin injections as prescribed for patients with chronic kidney disease, cancer, or HIV-related anemia to stimulate RBC production and reduce fatigue.

Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to inadequate intake or absorption of essential nutrients (iron, vitamin B12, folate) secondary to dietary deficiencies or malabsorption, as evidenced by pallor, fatigue, and abnormal lab values.

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

Defining Characteristics: Pallor, feeling cold, fatigue, rapid heartbeat, brittle nails, hair loss, pica (craving non-food items like ice), headaches, abnormal lab values (low iron, B12, folate).

Expected Outcomes:

• Patient will demonstrate improvement in iron, vitamin B12, and folate levels as evidenced by follow-up lab testing.
• Patient will incorporate three or more food sources rich in iron, vitamin B12, and folic acid into their daily diet.
• Patient will verbalize understanding of signs and symptoms of anemia and when to seek medical advice.

Nursing Interventions:

1. Lab Value Monitoring: Monitor lab values related to nutritional anemias, including RBC count, hemoglobin, hematocrit, ferritin, iron, total iron-binding capacity, vitamin B12, and folate levels.
2. Dietary Assessment: Conduct a thorough dietary assessment, including dietary history, food allergies, and typical eating patterns, to identify nutritional gaps.
3. Assess Access to Healthy Foods: Assess socioeconomic factors and access to healthy, nutrient-rich foods that may contribute to nutritional deficiencies.
4. Nutritional Education: Healthy Diet: Provide education on a balanced diet rich in iron (dark leafy greens, nuts, eggs), vitamin B12 (meat, dairy), and folate (legumes, citrus fruits, leafy greens).
5. Supplement Education and Administration: Educate patients on prescribed oral iron, vitamin B12, or folate supplements. Administer vitamin B12 injections as ordered.
6. Prenatal Supplement Education: Counsel pregnant patients on the importance of prenatal vitamins containing iron and folate for maternal and fetal health.
7. Improve Iron Absorption Education: Educate patients on strategies to enhance iron absorption, such as consuming vitamin C-rich foods with iron-containing meals and avoiding tannins (tea, coffee) at mealtimes.

Ineffective Tissue Perfusion

Nursing Diagnosis: Ineffective Tissue Perfusion related to reduced oxygen-carrying capacity secondary to anemia, as evidenced by pallor, cool extremities, dizziness, and fatigue.

Related Factors: Bone marrow suppression, poor diet or deficiency in iron or vitamin B12, low supply of oxygenated RBCs, acute blood loss, impaired transport of oxygen, chronic conditions (CKD, rheumatoid arthritis, cancer), autoimmune destruction of RBCs.

Defining Characteristics: Lightheadedness or dizziness, headache, fatigue, altered mental status, pallor, cold extremities, prolonged capillary refill time, chest pain, shortness of breath, low hemoglobin levels.

Expected Outcomes:

• Patient will demonstrate evidence of adequate tissue perfusion, as evidenced by warm skin, appropriate skin color for ethnicity, and capillary refill within normal limits.
• 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 range).

Nursing Interventions:

1. Medical and Family History Review: Obtain a detailed medical and family history to identify potential underlying causes of anemia and determine if it is acute or chronic.
2. Physical Assessment: Perfusion Status: Perform a thorough physical assessment, focusing on indicators of tissue perfusion: skin color and temperature, capillary refill, vital signs, and neurological status.
3. Hemoglobin Level Monitoring: Review hemoglobin levels regularly to assess the severity of anemia and effectiveness of interventions.
4. Chest Pain/Palpitation Investigation: Investigate reports of chest pain or palpitations promptly, obtain an ECG to rule out cardiac ischemia or arrhythmias.
5. Oxygen Administration: Administer supplemental oxygen as prescribed to maintain SpO2 > 95% and improve tissue oxygenation.
6. Safety Precautions: Implement safety precautions to prevent falls and injuries related to dizziness, lightheadedness, and muscle weakness associated with ineffective tissue perfusion.
7. Epoetin Injections (if indicated): Administer epoetin alfa injections as prescribed to stimulate RBC production and improve tissue perfusion in appropriate patients (e.g., CKD-related anemia).

By utilizing these comprehensive nursing diagnoses and care plans, nurses can provide holistic, patient-centered care that addresses the multifaceted needs of individuals with anemia, promoting improved health outcomes and quality of life.