Anemia, a condition characterized by a deficiency in red blood cells or hemoglobin, leads to reduced oxygen transport throughout the body. This hematologic disorder can arise from various underlying causes, including blood loss, impaired red blood cell production, or accelerated red blood cell destruction. Understanding the nuances of anemia, its diverse types, and its impact on patient health is crucial for nurses to provide effective care. This article delves into the nursing diagnosis for anemia, offering a comprehensive guide for assessment, interventions, and care planning.
Types of Anemia
Nurses encounter and manage a spectrum of anemia types, broadly categorized by their etiology:
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Anemias Due to Nutritional Deficiencies:
- Iron-deficiency anemia: The most prevalent form, 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, immature red blood cells, frequently stemming from folate or vitamin B12 deficiency.
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Genetic Anemias:
- Sickle cell anemia: An inherited condition causing red blood cells to become sickle-shaped, leading to vaso-occlusion and chronic anemia.
- Thalassemia anemia: A group of genetic disorders affecting hemoglobin production, resulting in varying degrees of anemia.
- Fanconi anemia: A rare genetic disease causing bone marrow failure and various congenital abnormalities.
- Diamond-Blackfan anemia: A rare inherited disorder characterized by red blood cell aplasia.
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Anemias Due to 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 leading to a deficiency in all blood cell types, 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 cell size is normal, but the overall count is low, often seen in chronic diseases or acute blood loss.
Nursing Process for Anemia
The nursing process is fundamental to managing patients with anemia. Treatment strategies are tailored to the specific type and underlying cause of anemia. For instance, acute anemia from blood loss necessitates volume resuscitation, potentially with blood products. Conversely, chronic conditions like sickle cell anemia require comprehensive management, especially during pain crises. Nurses play a pivotal role in assessing, diagnosing, planning, implementing, and evaluating care for patients with anemia.
Nursing Assessment for Anemia
A thorough nursing assessment is the cornerstone of effective care for patients with anemia. It involves gathering subjective and objective data across physical, psychosocial, emotional, and diagnostic domains.
Review of Health History (Subjective Data)
1. Elicit General Symptoms: Explore common anemia symptoms:
- General: Fatigue, generalized weakness, and decreased stamina are hallmark symptoms due to reduced oxygen-carrying capacity.
- Central Nervous System (CNS): Dizziness and lightheadedness arise from reduced cerebral blood flow. Headaches can occur due to cerebral vasodilation in response to hypoxia.
- Head, Eyes, Ears, Nose, and Throat (HEENT): Pulsatile tinnitus, a “whooshing” sound in the ear, can be a less common symptom related to altered blood flow dynamics.
- Respiratory: Dyspnea (shortness of breath) and tachypnea (rapid breathing) are compensatory mechanisms to increase oxygen intake.
- Cardiovascular: Palpitations, chest discomfort, fast or irregular heartbeat, and chest pain can result from the heart working harder to compensate for reduced oxygen delivery.
- Integumentary: Pale skin (pallor) and cool skin are due to decreased blood flow to the periphery. Patients may report feeling cold and experience numbness in hands and feet (peripheral neuropathy) and brittle nails.
2. Investigate Medical History: Focus on conditions affecting bone marrow and chronic diseases:
- Bone Marrow Disorders: A history of leukemia or other blood cancers is significant as these directly impact red blood cell production in the bone marrow.
- Chronic Conditions: Chronic kidney disease often leads to reduced erythropoietin production, a hormone essential for red blood cell formation. Rheumatoid arthritis and other chronic inflammatory conditions can also suppress red blood cell production, leading to anemia of chronic disease.
3. Medication Review: Identify medications known to induce hemolytic anemia:
- Certain medications can trigger the destruction of red blood cells. These include cephalosporins, levodopa, levofloxacin, nitrofurantoin, NSAIDs (nonsteroidal anti-inflammatory drugs), and penicillins. A detailed medication history is vital.
4. Activities and Risk Factor Assessment: Explore occupational and environmental exposures:
- Inquire about the patient’s occupation and hobbies to identify potential exposure to environmental toxins. Substances like tranquilizers, pesticides, paints, solvents, and hair dyes can be environmental causes of anemia by affecting bone marrow function or red blood cell survival.
5. Gynecological Status for Women: Assess menstrual and reproductive history in women:
- Heavy menstrual bleeding (menorrhagia) is a common cause of iron-deficiency anemia in women. Recent abortions or current pregnancy can also contribute to anemia due to blood loss or increased iron demands.
6. Bowel Movement Bleeding History: Inquire about gastrointestinal bleeding:
- Changes in bowel habits, particularly blood in the stool, should be carefully evaluated. Dark, tarry stools (melena) indicate upper gastrointestinal bleeding. Blood on toilet paper or in the toilet bowl (hematochezia) suggests lower gastrointestinal bleeding, as do diarrhea with bleeding and hemorrhoids causing bright red bleeding.
7. Gastrointestinal History: Explore conditions predisposing to gastrointestinal bleeding:
- Certain gastrointestinal problems are frequently associated with bleeding and subsequent anemia. These include diverticulitis, hiatal hernias, peptic ulcers, gastroenteritis, cancer (especially colorectal cancer), and inflammatory bowel disease (Crohn’s disease, ulcerative colitis).
8. Urine Changes: Assess for hematuria (blood in urine):
- Changes in urine color, particularly red or pink urine, may indicate bleeding within the genitourinary system, potentially contributing to anemia.
9. Dietary Assessment: Review nutritional intake:
- A detailed dietary history is essential to identify nutritional deficiencies. A diet lacking in iron, vitamin B12, and folate increases the risk of nutritional anemias. Excessive alcohol intake can also predispose individuals to conditions that cause anemia, such as liver disease and folate deficiency. Vegan or vegetarian diets, if not well-planned, may lack sufficient iron and vitamin B12.
10. Socioeconomic Factors: Consider economic status and food access:
- Patients living in food deserts or facing financial constraints may have limited access to quality, nutritious food, increasing their vulnerability to nutritional anemias.
Physical Assessment (Objective Data)
1. Nutritional Deficiency Signs: Observe for physical indicators of nutritional deficiencies:
- Iron Deficiencies:
- Pale skin (pallor) is a classic sign.
- Brittle fingernails (koilonychia) are another characteristic finding.
- Tachycardia (rapid heart rate) can be a compensatory response to reduced oxygen-carrying capacity.
- Vitamin B12 Deficiency/Pernicious Anemia:
- Bleeding gums may be present.
- Pale skin or jaundice (yellowing of the skin and eyes) can occur.
- Weight loss may be a symptom.
- Muscle weakness can result from neurological effects of B12 deficiency.
- Megaloblastic Anemia:
- Pale skin is common.
- Diarrhea may be present.
- Inflamed tongue (glossitis) is a distinctive finding.
2. Bleeding and Bleeding Disorders: Assess for signs of bleeding and bleeding tendencies:
- Bleeding disorders like hemophilia, intestinal conditions like ulcers, and medications like aspirin or warfarin can lead to bleeding and anemia. Monitor for unusual bleeding manifestations such as purpura (purple spots), bruising, or petechiae (small red or purple spots). Assess for any obvious trauma or injuries that could be contributing to blood loss.
3. Neurological Assessment: Evaluate neurological function:
- Due to reduced oxygen delivery to the brain, patients with anemia may exhibit neurological changes. Closely monitor for vision disturbances, memory loss, poor coordination, headache, irritability, and paresthesias (abnormal sensations like tingling or numbness).
4. Eye Examination: Assess the conjunctiva and sclera:
- Low iron levels can cause the conjunctiva (lining of the eyelids and surface of the eye) to appear pale pink or white instead of their normal red color. A blue tint to the sclera (whites of the eyes) can also be indicative of iron-deficiency anemia.
5. Cardiopulmonary Assessment: Evaluate heart and lung function:
- Reduced circulating red blood cells negatively impact the cardiopulmonary system. Patients may experience chest discomfort or dyspnea. Assess for tachycardia, tachypnea, and hypoxia (low oxygen saturation). Anemia increases the risk of heart failure due to increased cardiac workload.
6. Lymph Node Palpation: Examine lymph nodes:
- Conduct a thorough palpation of lymph nodes to detect any enlargement (lymphadenopathy). Enlarged lymph nodes may suggest infection or neoplasia (cancer), both of which can contribute to decreased red blood cell production.
Diagnostic Procedures (Objective Data)
1. Blood Tests: Utilize blood tests to identify and classify anemia:
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Complete Blood Count (CBC) with differential: This is a foundational test providing critical information:
- Red blood cell count: Measures the number of red blood cells.
- Hemoglobin/hematocrit: Measures the oxygen-carrying capacity of red blood cells and the percentage of blood volume comprised of red blood cells, respectively.
- Reticulocyte count: Measures the number of immature red blood cells, indicating bone marrow production rate.
- MCV (mean corpuscular volume): Measures the average size of red blood cells (useful for classifying anemias as microcytic, normocytic, or macrocytic).
- RDW (red cell distribution width): Measures the variation in red blood cell size.
- Platelet count: Evaluates platelet levels, important in some types of anemia and bone marrow disorders.
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Iron profile: Assesses iron status:
- Serum iron: Measures the amount of iron circulating in the blood.
- Ferritin: Measures iron stores in the body.
- Total iron-binding capacity (TIBC): Measures the blood’s capacity to bind and transport iron.
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Folate and vitamin B12 levels: Determine levels of these essential vitamins for red blood cell production.
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Additional Lab Tests for Underlying Conditions:
- Coagulation screenings (aPTT, PT/INR): Assess for bleeding disorders.
- Lead levels: Rule out lead poisoning as 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: Employ imaging for acute anemia or to identify underlying causes:
- Ultrasonography: Rapidly evaluates for intraperitoneal bleeding (bleeding within the abdominal cavity).
- Chest X-rays: Useful in severe anemia to assess for cardiomyopathy (heart muscle disease) or acute chest syndrome (in sickle cell anemia).
- CT scans of the abdomen: Detect masses, internal bleeding, or abnormalities of the spleen and other abdominal organs that could contribute to anemia.
- Esophagogastroduodenoscopy (EGD): Diagnoses acute upper gastrointestinal (GI) bleeding.
- Outpatient colonoscopy: Evaluates lower GI bleeding.
3. Bone Marrow Aspiration: Consider for inconclusive cases:
- Bone marrow analysis is generally not required for routine anemia diagnosis. However, it may be necessary if lab results are inconclusive or to investigate bone marrow disorders as the underlying cause of anemia.
Nursing Interventions for Anemia
Nursing interventions are crucial for patient recovery and focus on addressing the underlying cause of anemia and managing its symptoms.
1. Identify and Manage the Cause: Target the root cause of anemia:
- Anemia is often secondary to other conditions. Identifying and managing the underlying cause is paramount. Potential causes include:
- Acute blood loss (e.g., trauma, surgery, gastrointestinal bleeding)
- Nutritional deficiencies (iron, vitamin B12, folate)
- Conditions affecting bone marrow (e.g., aplastic anemia, myelodysplastic syndromes)
- Chronic renal disease (leading to erythropoietin deficiency)
- Hemophilia and other bleeding disorders
- Autoimmune and rheumatological conditions (e.g., rheumatoid arthritis, lupus)
- Increased red blood cell destruction (e.g., faulty mechanical heart valves, hemolytic anemia, disseminated intravascular coagulation (DIC))
- Medication side effects
2. Administer Intravenous (IV) Fluids: Restore intravascular volume in blood loss:
- IV fluids, such as isotonic saline, are administered to increase intravascular volume, particularly in cases of trauma or acute blood loss, helping to maintain blood pressure and tissue perfusion.
3. Blood Transfusion: Transfuse packed red blood cells (RBCs) judiciously:
- Packed red blood cells (RBCs) transfusion is indicated for actively bleeding patients and those with severe, symptomatic anemia, typically when hemoglobin levels are 7 g/dL or less. Transfusion thresholds may vary based on patient condition and comorbidities.
4. Oxygen Therapy: Provide supplemental oxygen as needed:
- Anemia reduces oxygen-carrying capacity, potentially leading to hypoxia and dyspnea. Administer supplemental oxygen via nasal cannula or face mask to maintain adequate oxygen saturation levels, as prescribed.
5. Supplementation: Administer prescribed supplements:
- Supplementation addresses specific nutritional deficiencies. The type, dosage, and route of administration depend on the deficiency:
- Oral/IV iron: For iron-deficiency anemia. Oral iron is typically the first-line treatment, while IV iron may be used for patients who cannot tolerate or absorb oral iron, or in cases of severe deficiency.
- Oral/IM vitamin B12: For vitamin B12 deficiency (pernicious anemia). Oral B12 may be sufficient for dietary deficiencies, while intramuscular (IM) injections are necessary for pernicious anemia due to absorption issues.
- Oral/IV/IM folate: For folate deficiency. Oral folate is generally effective, but IV or IM routes may be used in specific situations.
6. Education on Oral Iron Supplementation: Provide comprehensive instructions:
- Educate patients on maximizing the effectiveness of oral iron supplements and managing side effects:
- Side effects: Common side effects include gastrointestinal problems such as constipation, black, tarry stools (which is normal with iron supplementation), and a metallic taste.
- Administration:
- Take on an empty stomach for optimal absorption.
- Administer with water or fruit juice (vitamin C enhances iron absorption). Avoid taking with milk, antacids, tea, or coffee, as these can impair absorption.
- Take 1 hour before or 2 hours after meals. If gastrointestinal upset occurs, it can be taken with food, but absorption may be reduced.
7. Erythropoietin for Renal Disease: Administer erythropoietin-stimulating agents (ESAs):
- In chronic kidney disease, the kidneys produce insufficient erythropoietin (EPO), a hormone that stimulates red blood cell production. Administering synthetic EPO (e.g., epoetin alfa, darbepoetin alfa) stimulates bone marrow to produce more red blood cells, improving anemia associated with renal disease.
8. Bone Marrow and Stem Cell Transplantation Preparation: For severe aplastic anemia:
- For patients with severe aplastic anemia, hematopoietic stem cell transplantation (bone marrow or peripheral blood stem cell transplant) may be considered. Healthy stem cells from a donor replace the patient’s damaged bone marrow. Younger patients with a matched sibling donor are often the best candidates.
9. Dietitian Referral: Consult a registered dietitian:
- Refer patients to a registered dietitian for comprehensive dietary counseling. Dietitians can provide tailored education and guidance on incorporating recommended foods rich in iron, vitamin B12, and folate into their diet.
10. Patient Education on When to Seek Medical Attention: Instruct on recognizing worsening symptoms:
- Advise patients to seek prompt medical attention if their anemia symptoms worsen despite treatment. Instruct them to go to the nearest emergency department if they experience:
- Breathing difficulties or shortness of breath
- Lightheadedness or dizziness, especially if severe or causing falls
- Chest discomfort or chest pain
- Bright red bleeding in the stool (hematochezia), indicating active lower gastrointestinal bleeding.
Nursing Care Plans for Anemia
Nursing care plans for anemia guide the prioritization of assessments and interventions, establishing both short-term and long-term goals. Common nursing diagnoses associated with anemia and examples of care plans include:
Acute Pain (Specific to Sickle Cell Anemia)
Nursing Diagnosis: Acute Pain
Related to:
- Sickling of red blood cells, leading to vaso-occlusion and ischemia
- Lack of perfusion and oxygenation to tissues and extremities
As evidenced by:
- Intense pain complaints, localized or generalized
- Pain described as stabbing, sharp, or throbbing
- Reduced activity level due to pain
- Restlessness and agitation
- Distractive behaviors (e.g., pacing, watching TV, excessive talking)
Expected outcomes:
- Patient will report a decrease in pain intensity to a manageable level (e.g., ≤ 2 on a 0-10 scale) by discharge.
- Patient will verbalize understanding of triggers that precipitate pain crises.
- Patient will adhere to the prescribed pain medication regimen and other pain management strategies.
Assessment:
- Pain Assessment: Conduct a comprehensive pain assessment using a validated pain scale (numeric rating scale, FACES scale). Assess pain characteristics (quality, location, intensity, duration), frequency, precipitating and relieving factors, and effectiveness of current pain management interventions.
- Acute Chest Syndrome Monitoring: Assess for signs and symptoms of acute chest syndrome, a life-threatening complication of sickle cell anemia involving vaso-occlusion in the pulmonary vasculature. Monitor for chest pain, fever, dyspnea, cough, and new pulmonary infiltrates on chest X-ray.
- Pain Medication Regimen Review: Evaluate the patient’s current pain medication regimen, including adherence, dosage, frequency, and effectiveness. Sickle cell pain crises can be exacerbated by missed medication doses or inadequate pain management.
Interventions:
- Hydration: Administer IV fluids as prescribed. Intravenous hydration is a priority in managing sickle cell crises. Adequate hydration helps to reduce blood viscosity, slow or reverse the sickling process, and alleviate pain. Encourage oral fluid intake as tolerated.
- Analgesia: Administer analgesics as prescribed, often requiring opioid medications. Sickle cell patients often develop tolerance to opioids and may require high doses to achieve adequate pain control. Some patients may benefit from patient-controlled analgesia (PCA) for more effective pain management. Closely monitor for pain relief and potential side effects of opioids, such as sedation and respiratory depression.
- Blood Transfusion: Prepare for and administer blood transfusions as indicated. Blood transfusions may be necessary to improve hemoglobin levels, reduce the proportion of sickle cells, and prevent worsening complications. Some patients with sickle cell anemia may receive chronic blood transfusions on an outpatient basis to prevent recurrent crises.
- Patient Education on Crisis Prevention: Educate patients and families about triggers that can precipitate sickle cell pain crises and strategies for prevention. Key education points include maintaining adequate hydration, preventing infections (through vaccination and hygiene), avoiding exposure to cold temperatures, managing stress, and adhering to prescribed medications (e.g., hydroxyurea).
Decreased Cardiac Output
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Reduced preload due to inadequate blood volume and filling of the heart
- Decreased oxygenated blood supply to the heart muscle
- Impaired cardiac muscle contractility
- Low blood pressure and reduced afterload
- Increased cardiac workload as the heart compensates for anemia
- Severe blood loss and reduced circulating red blood cells
As evidenced by:
- Objective measurements of decreased cardiac output (if available, e.g., via hemodynamic monitoring)
- Tachycardia (rapid heart rate) as a compensatory mechanism
- Hypotension (low blood pressure), although hypertension may occur initially as compensation
- Cardiac arrhythmias (irregular heartbeats)
- Chest pain (angina) due to myocardial ischemia
- Diminished peripheral pulses
Expected outcomes:
- Patient will demonstrate stable blood pressure and heart rate within acceptable limits for their age and condition.
- Patient will maintain a normal sinus rhythm on ECG monitoring.
- Patient will report absence of chest pain or a reduction to a tolerable level.
Assessment:
- Vital Sign Monitoring: Monitor vital signs frequently, including heart rate, blood pressure, respiratory rate, and oxygen saturation. Anemia triggers compensatory mechanisms like increased heart rate and blood pressure. Closely monitor for signs of heart fatigue, which could lead to heart failure if tachycardia and hypertension are uncontrolled.
- Cardiovascular History: Obtain a detailed cardiovascular history, including any pre-existing cardiovascular diseases (e.g., hypertension, coronary artery disease, heart failure). Pre-existing cardiovascular conditions, combined with anemia, significantly increase cardiac workload and strain on the heart.
- Cardiovascular Status Assessment: Assess for signs and symptoms of decreased cardiac output and heart failure. Anemia can exacerbate heart failure, reducing oxygen-carrying capacity and compromising blood circulation. Assess for edema, jugular venous distention, shortness of breath, and fatigue.
- Red Blood Cell Count Review: Review complete blood count (CBC) results, particularly red blood cell count, hemoglobin, and hematocrit. Assess red blood cell indices (MCV, MCH, MCHC) to help determine the type of anemia. The RBC count and characteristics directly impact cardiac output and oxygen delivery.
- ECG Monitoring: Obtain an electrocardiogram (ECG) to assess heart rhythm. Anemia can cause cardiac arrhythmias, including tachycardia and atrial fibrillation, as the heart attempts to compensate for reduced oxygen delivery.
Interventions:
- Reduce Cardiac Stress: Implement measures to reduce cardiac workload. Encourage rest and limit physical activity to decrease myocardial oxygen demand. Manage pain and anxiety, as these can increase cardiac stress.
- Treat the Underlying Anemia: Address the underlying cause of anemia based on its type and etiology. Effective treatment of anemia will improve oxygen-carrying capacity, reduce cardiac workload, and improve overall organ function.
- Prepare for Blood Transfusion: Prepare the patient for possible blood transfusion if indicated for severe anemia. Blood transfusion can rapidly improve oxygen-carrying capacity and cardiac output in patients with significant anemia.
- Address the Cause of Anemia: Identify and treat the underlying cause of anemia. If anemia is secondary to medication (e.g., chemotherapy), collaborate with the physician to adjust or discontinue the medication if clinically appropriate and feasible.
Fatigue
Nursing Diagnosis: Fatigue
Related to:
- Reduced oxygen-carrying capacity of the blood due to decreased hemoglobin levels
As evidenced by:
- Subjective reports of exhaustion and overwhelming tiredness
- Inability to maintain usual physical activity levels
- Increased need for rest and sleep
- Reported lack of energy and motivation
- Lethargy and decreased alertness
Expected outcomes:
- Patient will verbalize and implement energy conservation techniques to manage fatigue.
- Patient will report a perceived increase in energy levels and improved ability to perform activities of daily living.
Assessment:
- Complete Blood Count (CBC) Monitoring: Monitor CBC results, particularly red blood cell count and hemoglobin levels. These values are typically low in patients with anemia and directly correlate with fatigue levels.
- Chronic Condition Assessment: Assess for co-existing chronic conditions that can contribute to or worsen anemia and fatigue. These include pregnancy, cancer, autoimmune diseases, chronic kidney disease, and heart failure. Addressing underlying conditions is crucial for managing anemia-related fatigue.
- Fatigue Impact Assessment: Assess the extent and impact of fatigue on the patient’s daily life. Inquire about activities the patient can and cannot perform due to fatigue, the impact on their roles and responsibilities (work, family, social), and coping mechanisms they currently use to manage fatigue.
Interventions:
- Energy Conservation Education: Instruct the patient on energy conservation techniques to minimize fatigue. Strategies include:
- Planning rest periods throughout the day.
- Delegating tasks to family members or caregivers when possible.
- Clustering activities together to reduce unnecessary movement and exertion.
- Prioritizing activities and performing the most important tasks when energy levels are highest.
- Oxygen Administration: Administer supplemental oxygen as prescribed, particularly for hospitalized patients with very low hemoglobin levels or respiratory symptoms. Supplemental oxygen can improve oxygen delivery and reduce fatigue associated with hypoxia.
- Blood Transfusion Consideration: Prepare for and administer blood transfusions as indicated for severe anemia or significant blood loss. Blood transfusion can rapidly improve oxygen-carrying capacity and alleviate fatigue.
- Erythropoietin Administration: Administer erythropoietin-stimulating agents (ESAs) as prescribed (e.g., epoetin alfa injections). ESAs stimulate bone marrow to produce red blood cells, increasing hemoglobin levels and reducing fatigue in 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:
- Impaired absorption of iron or vitamins due to gastrointestinal disorders or surgery
- Inadequate dietary intake of iron, vitamin B12, and folate
- Increased nutritional demands during pregnancy
- Malabsorption syndromes (e.g., celiac disease, inflammatory bowel disease)
- Vegetarian or vegan diets lacking proper supplementation
As evidenced by:
- Pale skin (pallor)
- Reports of feeling cold (cold intolerance)
- Fatigue and weakness
- Rapid heartbeat (tachycardia)
- Brittle nails (koilonychia)
- Hair loss (alopecia)
- Unusual cravings, such as craving ice (pagophagia)
- Headaches
Expected outcomes:
- Patient will demonstrate improvement in iron and vitamin B12 levels as evidenced by follow-up lab testing.
- Patient will incorporate at least three foods rich in iron, vitamin B12, and folic acid into their daily diet.
- Patient will verbalize understanding of the signs and symptoms of anemia and when to seek medical advice.
Assessment:
- Laboratory Value Assessment: Monitor relevant laboratory values, including red blood cell count, hemoglobin, hematocrit, ferritin, serum iron, and total iron-binding capacity (TIBC). These tests assess iron status and identify nutritional anemias.
- Dietary History: Obtain a detailed dietary history to identify nutritional gaps and deficiencies. Assess the patient’s usual food intake, including food preferences, dietary restrictions, and any food allergies.
- Access to Healthy Foods Assessment: Assess the patient’s access to healthy, nutritious foods. Consider socioeconomic factors, food insecurity, and availability of grocery stores or healthy food options in their community.
Interventions:
- Nutritional Counseling: Provide comprehensive dietary education and counseling on a healthy, balanced diet rich in iron, vitamin B12, and folate.
- Iron-rich foods: Include dark green leafy vegetables (spinach, kale), lean red meat, poultry, fish, beans, lentils, nuts, and eggs.
- Vitamin B12-rich foods: Include meat, poultry, fish, eggs, dairy products, and fortified foods.
- Folate-rich foods: Include legumes, citrus fruits and juices, dark green leafy vegetables, and fortified grains.
- Supplement Recommendations: Discuss the potential need for dietary supplements, such as oral iron supplements or vitamin B12 supplements (cyanocobalamin), if dietary intake is insufficient to meet nutritional requirements. Vitamin B12 injections may be necessary for patients with pernicious anemia or malabsorption issues.
- Prenatal Supplementation Education: For pregnant patients, emphasize the importance of prenatal vitamins containing iron and folate. Prenatal vitamins are crucial for meeting increased nutritional demands during pregnancy and preventing neural tube defects in the fetus.
- Improve Iron Absorption Strategies: Educate patients on strategies to enhance iron absorption.
- Dietary sources of iron: Explain that heme iron (found in meat and seafood) is more readily absorbed than non-heme iron (found in plant-based foods).
- Vitamin C: Advise consuming vitamin C-rich foods (citrus fruits, tomatoes, peppers) or beverages (orange juice) with meals to enhance non-heme iron absorption.
- Avoid iron absorption inhibitors: Advise limiting consumption of tea, coffee, and calcium-rich foods (dairy products) with meals, as tannins and calcium can inhibit iron absorption.
Ineffective Tissue Perfusion
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Reduced oxygen-carrying capacity of the blood due to anemia
- Bone marrow suppression and decreased red blood cell production
- Poor dietary intake or deficiencies in iron or vitamin B12
- Acute blood loss
- Impaired transport of oxygen due to reduced hemoglobin
- Chronic conditions (chronic kidney disease, rheumatoid arthritis, cancer)
- Autoimmune hemolytic anemia (body attacks its own red blood cells)
As evidenced by:
- Subjective reports of lightheadedness or dizziness, especially with position changes
- Headache
- Fatigue and weakness
- Changes in mental status or mentation (confusion, irritability)
- Objective signs of pallor (pale skin and mucous membranes)
- Cold extremities (hands and feet)
- Prolonged capillary refill time (>3 seconds)
- Chest pain (angina)
- Shortness of breath (dyspnea)
- Low hemoglobin levels on laboratory testing
Expected outcomes:
- Patient will demonstrate evidence of adequate tissue perfusion, as evidenced by warm and dry skin, skin color within normal limits for ethnicity, and capillary refill time < 3 seconds.
- Patient will report relief of symptoms related to ineffective tissue perfusion, such as shortness of breath, chest pain, and fatigue.
- Patient will achieve and maintain a hemoglobin level > 10.0 g/dL (or individualized target range).
Assessment:
- Medical and Family History: Obtain a comprehensive medical and family history to identify potential risk factors for anemia and ineffective tissue perfusion. Certain types of anemia are inherited, while others are secondary to chronic conditions. Determine if the anemia is acute or chronic to guide management strategies.
- Physical Assessment for Perfusion: Perform a thorough physical assessment to evaluate tissue perfusion. Assess skin color and temperature, capillary refill time, peripheral pulses, blood pressure (including orthostatic blood pressure), respiratory rate and effort, and mental status. Monitor for signs of hypoxia, such as cyanosis.
- Hemoglobin Level Review: Review the patient’s hemoglobin level and other relevant hematologic parameters from the CBC. Low hemoglobin levels directly indicate reduced oxygen-carrying capacity and potential for ineffective tissue perfusion.
Interventions:
- Chest Pain and Palpitation Investigation: Investigate and promptly report any patient reports of chest pain or palpitations. Obtain an electrocardiogram (ECG) to monitor for cardiac arrhythmias or myocardial ischemia.
- Oxygen Administration: Administer supplemental oxygen as prescribed to improve oxygenation and tissue perfusion. Aim to maintain SpO2 > 95% or as ordered by the physician.
- Safety Precautions: Implement safety precautions to prevent falls and injuries related to dizziness, lightheadedness, vision changes, or muscle weakness associated with ineffective tissue perfusion. Educate patients on fall prevention strategies and ensure a safe environment.
- Erythropoietin Injections: Administer epoetin alfa or other erythropoietin-stimulating agents (ESAs) as prescribed. ESAs stimulate red blood cell production in the bone marrow, improving hemoglobin levels and tissue oxygenation.
