Anemia, characterized by a deficiency in red blood cells or their impaired function, leads to reduced hemoglobin levels and insufficient oxygen supply throughout the body. This condition arises from various factors, including blood loss, decreased red blood cell production, or accelerated red blood cell destruction. Anemia manifests in numerous forms, ranging from mild and transient to chronic and persistent. Its development can be attributed to poor nutrition, genetic predispositions, cancer, autoimmune disorders, exposure to toxic substances, infections, or as a secondary effect of chronic illnesses.
Types of Anemia
Nurses frequently encounter and manage diverse types of anemia, broadly categorized as follows:
- Nutritional Deficiency Anemias:
- Iron-deficiency anemia (the most prevalent type)
- Pernicious anemia
- Megaloblastic anemia
- Genetic Anemias:
- Sickle cell anemia
- Thalassemia anemia
- Fanconi anemia
- Diamond-Blackfan anemia
- Anemias Due to RBC Dysfunction, Production, or Destruction:
- Hemolytic anemia
- Aplastic anemia
- Macrocytic anemia
- Microcytic anemia
- Normocytic anemia
Treatment strategies for anemia are contingent upon its specific type and underlying etiology. For instance, acute anemia resulting from blood loss may necessitate volume resuscitation using blood products. Conversely, sickle cell anemia, a chronic and severe form, demands specialized inpatient care during pain crises, requiring nurses to possess expertise in its assessment and management.
Nursing Process in Anemia Management
The nursing process is fundamental to managing patients with anemia. It begins with a thorough nursing assessment to gather comprehensive patient data.
Nursing Assessment
The initial step in nursing care involves a detailed nursing assessment, encompassing the collection of physical, psychosocial, emotional, and diagnostic information. This section outlines subjective and objective data pertinent to anemia.
Review of Health History
1. Identify General Symptoms: Assess for common symptoms of anemia:
- General: Fatigue, generalized weakness
- Central Nervous System (CNS): Dizziness, lightheadedness, headaches
- Head, Eyes, Ears, Nose, and Throat (HEENT): Pulsatile tinnitus (pounding or “whooshing” sound in the ear)
- Respiratory: Dyspnea, tachypnea
- Cardiovascular: Rapid or irregular heartbeat, palpitations, chest discomfort, chest pain
- Integumentary: Pale skin, cool skin, reports of feeling cold, numbness in extremities, brittle nails
2. Medical History Review: Pay close attention to conditions impacting bone marrow function, such as leukemia or other hematologic malignancies, as bone marrow is the site of red blood cell production. Chronic conditions like chronic kidney disease or rheumatoid arthritis can also contribute to anemia.
3. Medication Review: Certain medications can induce hemolytic anemia, including:
- Cephalosporins
- Levodopa
- Levofloxacin
- Nitrofurantoin
- NSAIDs
- Penicillins
4. Activity and Risk Factor Interview: Explore the patient’s occupation and hobbies to identify potential exposure to environmental factors like tranquilizers, pesticides, paints, solvents, or hair dyes, which can be anemia triggers.
5. Gynecological History (for women): Determine gynecological status, noting heavy menstrual bleeding, recent abortions, or current pregnancy, as these can contribute to anemia.
6. Bowel Movement Bleeding History: Inquire about changes in bowel habits and the presence of blood in stools. Assess for dark, tarry stools, blood on toilet paper or in the toilet bowl, diarrhea with bleeding, or hemorrhoids causing bright red bleeding.
7. Gastrointestinal History: Investigate gastrointestinal issues that commonly cause bleeding and subsequent anemia:
- Diverticulitis
- Hiatal hernias
- Peptic ulcers
- Gastroenteritis
- Cancer
- Inflammatory bowel disease
8. Urine Changes: Ask about alterations in urine color, which can indicate bleeding within the genitourinary system.
9. Dietary Assessment: Review the patient’s typical diet. Deficiencies in vitamins and minerals elevate the risk of nutritional anemias. Excessive alcohol intake can also predispose individuals to anemia-causing conditions. Note vegan or vegetarian diets that may lack sufficient iron and vitamin B12.
10. Socioeconomic Status: Assess economic status, as food insecurity or inability to afford nutritious food increases the risk of nutritional anemias.
Physical Assessment
1. Nutritional Deficiency Assessment: Identify physical signs of nutritional deficiencies:
- Iron deficiencies:
- Pale skin
- Brittle fingernails
- Tachycardia
- Vitamin B12 deficiency/pernicious anemia:
- Bleeding gums
- Pale skin or jaundice
- Weight loss
- Muscle weakness
- Megaloblastic anemia:
- Pale skin
- Diarrhea
- Glossitis (inflamed tongue)
2. Bleeding and Bleeding Disorder Assessment: Evaluate for bleeding tendencies or disorders like hemophilia, gastrointestinal conditions like ulcers, or medication use (e.g., aspirin, warfarin) that may cause bleeding. Monitor for skin bleeding signs such as purpura, bruising, or petechiae. Assess for trauma or injuries.
3. Neurological Assessment: Due to reduced oxygen delivery to the brain, neurological changes may occur in anemia. Monitor for vision disturbances, memory loss, poor coordination, headache, irritability, and paresthesias.
4. Eye Examination: Examine the eyes for pallor in the vascular areas, suggesting iron deficiency. A blue tint to the sclera may also indicate iron-deficiency anemia.
5. Cardiopulmonary Assessment: Assess the cardiopulmonary system, as anemia impacts heart and lung function. Monitor for chest discomfort or dyspnea. Assess for tachycardia, tachypnea, and hypoxia. Be aware of the increased risk of heart failure in anemic patients.
6. Lymph Node Palpation: Perform a thorough palpation of lymph nodes for enlargement, which could indicate infection or neoplasia, both potentially causing reduced red blood cell production.
Diagnostic Procedures
1. Blood Tests: Blood tests are crucial to identify and classify anemia:
- Complete Blood Count (CBC) with differential:
- Red blood cell count
- Hemoglobin/hematocrit
- Reticulocyte count
- MCV (mean corpuscular volume)
- RDW (red cell distribution width)
- Platelet count
- Iron Profile: (iron, ferritin, and total iron-binding capacity)
- Folate and Vitamin B12 Levels
Additional tests to identify underlying causes of anemia may include:
- Coagulation screenings (aPTT, PT/INR)
- Lead levels
- Factor assays
- Coombs test
2. Imaging Scans: Imaging assists in diagnosing underlying causes or complications of acute anemia.
- Ultrasonography: For rapid evaluation of intraperitoneal bleeding.
- Chest X-rays: Useful for severe anemia causing cardiomyopathy.
- CT scans of the abdomen: To detect masses, internal bleeding, or splenic and abdominal organ abnormalities.
- Esophagogastroduodenoscopy (EGD): To diagnose acute upper GI bleeding.
- Outpatient colonoscopy: For diagnosing lower GI bleeding.
3. Bone Marrow Aspiration: In cases with inconclusive lab results, bone marrow analysis may be necessary.
Nursing Interventions for Anemia
Nursing interventions are vital for patient recovery. Key interventions for anemia management are detailed below.
1. Cause Identification and Management: Address the underlying conditions causing anemia, such as:
- Acute blood loss
- Nutritional deficiencies (iron, vitamin B12, folate)
- Bone marrow disorders
- Chronic renal disease
- Hemophilia
- Autoimmune and rheumatological conditions
- Increased RBC destruction (mechanical valves, hemolytic anemia, DIC)
- Medication side effects
Each cause requires tailored interventions.
2. IV Fluid Administration: Administer IV fluids as prescribed to increase intravascular volume in cases of trauma or acute blood loss.
3. Blood Transfusion: Transfuse packed red blood cells (RBCs) as ordered, typically for actively bleeding patients or those with severe, symptomatic anemia and hemoglobin levels ≤ 7 g/dL.
4. Oxygen Therapy: Provide supplemental oxygen as needed to manage hypoxia or dyspnea associated with reduced oxygen-carrying capacity in anemia.
5. Supplement Administration: Administer supplements based on identified deficiencies:
- Oral/IV iron
- Oral/IM vitamin B12
- Oral/IV/IM folate
6. Patient Education on Oral Iron Supplementation: Educate patients on optimizing oral iron supplement effectiveness:
- Potential side effects: gastrointestinal issues like constipation, black stools, metallic taste.
- Administration guidelines:
- On an empty stomach
- With water or fruit juice (vitamin C enhances absorption)
- 1 hour before or 2 hours after meals (can take with food if GI upset occurs)
7. Erythropoietin Administration for Renal Disease: For patients with renal disease, administer synthetic erythropoietin to stimulate RBC production, as kidney dysfunction reduces natural erythropoietin production.
8. Bone Marrow and Stem Cell Transplantation Preparation: For severe aplastic anemia, prepare patients for potential stem cell or bone marrow transplantation to replace damaged bone marrow with healthy donor cells.
9. Dietitian Referral: Refer patients to dietitians for personalized dietary guidance on foods rich in iron, vitamin B12, and folate.
10. Guidance on Seeking Medical Attention: Advise patients to seek prompt medical attention if symptoms worsen or for emergency signs such as:
- Breathing difficulties
- Lightheadedness
- Chest discomfort
- Bright red stool bleeding
NANDA Nursing Care Plans for Anemia
NANDA nursing diagnoses guide the development of nursing care plans, prioritizing assessments and interventions for both short-term and long-term patient care goals. Examples of nursing care plans for anemia include:
Acute Pain (Related to Sickle Cell Anemia)
Nursing Diagnosis: Acute Pain
Related to:
- Sickling of red blood cells causing blood vessel occlusion
- Reduced perfusion and oxygenation to tissues
As evidenced by:
- Intense pain complaints throughout the body
- Pain described as stabbing, sharp, or throbbing
- Reduced activity level
- Restlessness
- Distractive behaviors (pacing, watching TV, excessive talking)
Expected Outcomes:
- Patient will report pain reduction to a level of 2/10 by discharge.
- Patient will verbalize understanding of pain crisis triggers.
- Patient will adhere to prescribed pain medication regimen.
Assessments:
- Pain Assessment: Conduct a comprehensive pain assessment using numeric or FACES scales, noting character, duration, frequency, triggers, and current interventions.
- Acute Chest Syndrome Assessment: Monitor for acute chest syndrome, a severe vaso-occlusive complication in pulmonary vasculature, characterized by chest pain, fever, dyspnea, and chest X-ray infiltrates.
- Pain Medication Regimen Review: Evaluate patient adherence to pain medication, doses, and frequency, as inadequate pain management contributes to sickle cell crises.
Interventions:
- Fluid Administration: Prioritize IV hydration to halt or slow sickling and alleviate pain. Encourage oral fluid intake.
- Analgesic Administration: Administer analgesics, often high doses of narcotics, potentially via PCA pump, ensuring effective pain control without over-sedation.
- Blood Transfusion Administration: Prepare for blood transfusions based on hemoglobin levels to prevent complications and correct anemia. Some patients may require ongoing monthly transfusions.
- Patient Education on Sickle Cell Crisis Prevention: Educate patients on triggers to avoid, such as dehydration, infections, cold exposure, stress, and medication non-adherence.
Decreased Cardiac Output (Related to Anemia)
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Inadequate cardiac filling volume
- Reduced oxygenated blood supply to the heart
- Impaired cardiac muscle contractility
- Low blood pressure affecting cardiac pumping
- Increased cardiac workload due to anemia
- Severe blood loss
- Reduced red blood cell count
As evidenced by:
- Measurable decreased cardiac output
- Tachycardia
- Hypertension
- Cardiac arrhythmias
- Chest pain
- Diminished peripheral pulses
Expected Outcomes:
- Patient will achieve blood pressure and pulse rates within normal limits.
- Patient will exhibit normal sinus rhythm on ECG.
- Patient will report absence of chest pain.
Assessments:
- Vital Sign Monitoring: Monitor vital signs for compensatory mechanisms like increased heart rate and blood pressure, and detect potential heart fatigue leading to heart failure.
- Cardiovascular History Review: Note any pre-existing cardiovascular conditions that may exacerbate reduced 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 volume, size, and shape via CBC and peripheral blood smear to assess their impact on cardiac output.
- ECG Monitoring: Obtain ECG to detect arrhythmias caused by the heart’s compensatory effort to pump more blood due to oxygen deficiency.
Interventions:
- Cardiac Stress Reduction: Minimize cardiac strain by addressing anemia, which increases heart rate, stroke volume, and fluid retention, adding workload to the heart.
- Anemia-Specific Treatment: Treat anemia based on its type and cause to restore organ function and improve cardiac output.
- Blood Transfusion Preparation: Prepare for blood transfusion in severe anemia to augment cardiac output and oxygen delivery.
- Cause of Anemia Management: Address and manage the underlying cause of anemia, such as chemotherapy-induced anemia, discontinuing causative agents if life-threatening.
Fatigue (Related to Anemia)
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 and ability to perform activities.
Assessments:
- CBC Monitoring: Assess CBC, including RBC count and hemoglobin levels, to confirm anemia.
- Chronic Condition Assessment: Assess for chronic conditions (pregnancy, cancer, autoimmune diseases) that worsen anemia, prioritizing their management.
- Fatigue Impact Assessment: Evaluate the extent of fatigue on daily living, including activity limitations, role responsibilities, and coping strategies.
Interventions:
- Energy Conservation Education: Teach energy conservation strategies: rest periods, task delegation, activity clustering, and prioritizing activities during peak energy times.
- Oxygen Administration: Provide supplemental oxygen for hospitalized patients with very low hemoglobin levels.
- Blood Transfusion Administration: Administer blood transfusions for severe anemia or blood loss-related fatigue.
- Erythropoietin Injections: Administer erythropoietin injections (Epogen, Procrit) to stimulate bone marrow RBC production, especially for patients with cancer, HIV, or kidney disease.
Imbalanced Nutrition: Less Than Body Requirements (Related to Anemia)
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Impaired iron or vitamin absorption
- Dietary deficiency of vitamin B12 and folate
- 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 B-12 levels on lab tests.
- Patient will incorporate three iron, B-12, and folic acid-rich foods into their diet.
- Patient will recognize anemia signs and symptoms and know when to seek medical advice.
Assessments:
- Lab Value Monitoring: Monitor RBC count, hemoglobin, hematocrit, ferritin, iron, and total iron-binding capacity for abnormalities.
- Dietary Assessment: Assess usual dietary intake and identify nutritional gaps and food allergies.
- Access to Healthy Foods Assessment: Evaluate access to nutritious foods and potential food insecurity.
Interventions:
- Healthy Diet Education: Educate on iron-rich foods (dark leafy greens, nuts, eggs), vitamin B-12 foods (meat, dairy), and folic acid foods (legumes, citrus, dark greens).
- Supplement Consideration: Consider oral iron or vitamin B-12 supplements if dietary intake is insufficient. Vitamin B-12 injections may be required.
- Prenatal Supplement Encouragement: Emphasize prenatal vitamin importance for pregnant patients to ensure adequate iron and folate intake for healthy pregnancy and birth defect prevention.
- Iron Absorption Improvement Strategies: Educate on enhancing iron absorption by consuming meat and seafood sources, combining non-heme iron sources with vitamin C, and avoiding tannin-containing drinks (tea, coffee) with meals.
Ineffective Tissue Perfusion (Related to Anemia)
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Bone marrow suppression
- Poor diet or iron/vitamin B12 deficiency
- Low supply of oxygenated red blood cells
- Acute blood loss
- Impaired oxygen transport
- Chronic conditions (chronic kidney disease, rheumatoid arthritis, cancer)
- Autoimmune destruction of red blood cells
As evidenced by:
- Lightheadedness or dizziness
- Headache
- Fatigue
- Change 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 normal skin color for ethnicity.
- Patient will report relief from shortness of breath, chest pain, and fatigue.
- Patient will achieve a hemoglobin level >10.0 g/dL.
Assessments:
- Medical and Family History: Determine medical and family history to identify potential inherited anemias or anemias related to chronic conditions, differentiating between acute and chronic anemia.
- Physical Assessment: Assess for signs of decreased tissue perfusion due to low RBCs, including pale, cold skin, respiratory changes, orthostatic hypotension, tachypnea, and chest pain.
- Hemoglobin Level Review: Review hemoglobin levels as a direct indicator of oxygen-carrying capacity and tissue perfusion.
Interventions:
- Chest Pain and Palpitation Investigation: Investigate chest pain or palpitations with ECG to monitor for arrhythmias.
- Oxygen Administration: Administer supplemental oxygen to maintain SpO2 > 95% to address hypoxia from reduced oxygenated RBCs.
- Safety Precautions Implementation: Implement fall and safety precautions for patients experiencing lightheadedness, dizziness, vision changes, or muscle weakness due to CNS effects of anemia.
- Epoetin Injection Administration: Administer epoetin alfa injections as prescribed to stimulate RBC production in bone marrow.
References
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