Anemia occurs when there are not enough red blood cells or red blood cells do not function properly, resulting in low hemoglobin and a lack of oxygen throughout the body.
Anemia is caused by blood loss, decreased red blood cell (RBC) production, or the destruction of RBCs. There are many types of anemia. While some anemias are mild and temporary, others can be chronic and lifelong. Anemia can develop from a poor diet, a genetic condition, cancer, autoimmune diseases, toxic chemicals, infection, or as a side effect of chronic conditions.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Decreased Cardiac Output
- Fatigue
- Imbalanced Nutrition: Less Than Body Requirements
- Ineffective Tissue Perfusion
Types of Anemia
The following is a list of anemias the nurse may encounter and treat:
- Types of anemia caused by nutritional deficiencies:
- Iron-deficiency anemia (the most common type of anemia)
- Pernicious anemia
- Megaloblastic anemia
- Types of anemia caused by genetics:
- Sickle cell anemia
- Thalassemia anemia
- Fanconi anemia
- Diamond-Blackfan anemia
- Types of anemia caused by abnormal RBC function, production, or destruction:
- Hemolytic anemia
- Aplastic anemia
- Macrocytic anemia
- Microcytic anemia
- Normocytic anemia
Nursing Process
Anemia will likely result from a larger condition, and treatment will depend on the type of anemia and underlying cause. For example, acute anemia may result from blood loss and require volume resuscitation with blood products. On the other hand, Sickle cell anemia is a chronic and severe form of anemia that requires inpatient treatment when a pain crisis occurs, and nurses must understand how to assess and manage it appropriately.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to anemia.
Review of Health History
1. Determine the patient’s general symptoms.
Check for the following symptoms of anemia:
- General: fatigue, general weakness
- CNS: dizziness, lightheadedness, headaches
- HEENT: pounding or “whooshing” sound in the ear (pulsatile tinnitus)
- Respiratory: dyspnea, tachypnea
- Cardiovascular: fast or irregular heartbeat, palpitations, chest discomfort, chest pain
- Integumentary: pale skin, cool skin, reports of feeling cold, numbness in the hands and feet, brittle nails
2. Review the medical history of the patient.
Pay special attention to conditions that affect the bone marrow, like a history of leukemia or other blood cancers, since this is where RBCs are formed. Other chronic conditions like chronic kidney disease or rheumatoid arthritis may also cause anemia.
3. Review medications.
The following medications may cause hemolytic anemia:
- Cephalosporins
- Levodopa
- Levofloxacin
- Nitrofurantoin
- NSAIDs
- Penicillins
4. Interview the patient about their activities and possible risk factors.
Inquire about the patient’s occupation or hobbies to uncover whether they are exposed to tranquilizers, pesticides, paints, solvents, or hair dyes, as these are possible environmental causes of anemia.
5. For women, identify the gynecological status of the patient.
Identify if there is a presence of heavy menstrual bleeding, a recent abortion, or a current pregnancy that may contribute to anemia.
6. Ask the patient about bleeding with bowel movements.
Patients must recognize the importance of changes in bowel habits and not ignore blood in the stool. Inquire about dark, tarry stools, blood observed on toilet paper or in the toilet bowl after a bowel movement, diarrhea with bleeding, or hemorrhoids causing bright red bleeding.
7. Identify the patient’s gastrointestinal history.
The following gastrointestinal problems commonly cause bleeding and associated anemia:
- Diverticulitis
- Hiatal hernias
- Peptic ulcers
- Gastroenteritis
- Cancer
- Inflammatory bowel disease
8. Determine if the patient has changes in their urine.
Ask the patient for any changes in the urine color. Abnormal urine color can indicate active bleeding in the genitourinary system.
9. Assess the patient’s diet.
Review the patient’s usual diet. A diet that lacks vitamins and minerals increases the risk of nutritional anemias. Excessive alcohol intake can predispose the patient to conditions causing anemia. Some patients on vegan or vegetarian diets may not consume the correct foods for adequate iron and vitamin B12.
10. Determine the patient’s economic status.
If the patient lives in a food desert or is unable to afford quality food, they are at risk for experiencing nutritional anemias.
Physical Assessment
1. Assess for any nutritional deficiencies.
Nutritional deficiencies are often associated with obvious physical symptoms, such as:
- 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
- Inflamed tongue (glossitis)
2. Assess for any obvious bleeding or bleeding disorder.
Bleeding disorders like hemophilia, intestinal conditions like ulcers, or medications like aspirin or warfarin may result in bleeding. Monitor for unusual bleeding to the skin, such as purpura, bruising, or petechiae. Assess for signs of obvious trauma or injuries.
3. Perform a neurological assessment.
Due to low levels of oxygen-carrying blood to the brain, patients with anemia may display alterations in the nervous system. Monitor closely for vision disturbances, memory loss, poor coordination, headache, irritability, and paresthesias.
4. Examine the patient’s eyes.
Low levels of iron may cause the vascular area of the eyes to become pale pink or white. A blue tint to the sclera indicates iron-deficiency anemia.
5. Perform a cardiopulmonary assessment.
A low level of circulating RBCs negatively affects the heart and lungs. The patient may experience chest discomfort or dyspnea. Assess for tachycardia, tachypnea, and hypoxia. There is an increased risk of heart failure with anemia.
6. Palpate the lymph nodes.
Conduct a thorough examination for any palpable lymph node enlargement that might indicate an infection or neoplasia. Infection and cancer can cause a decrease in RBCs.
Diagnostic Procedures
1. Draw blood to identify the type of anemia.
The following blood tests are used to differentiate the type of 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 content)
- Folate and vitamin B12
The following lab tests may aid in diagnosing underlying conditions causing anemia:
- Coagulation screenings (aPTT, PT/INR)
- Lead levels
- Factor assays
- Coombs test
2. Assist with imaging scans.
Imaging scans are utilized with acute anemia to determine an underlying cause or complications.
- Ultrasonography offers quick evaluation for intraperitoneal bleeding
- Chest X-rays are useful with severe anemia causing cardiomyopathy
- CT scans of the abdomen detect masses, internal bleeding, or abnormalities with the spleen and other abdominal organs
- Esophagogastroduodenoscopy (EGD) can diagnosis acute upper GI bleeding
- Outpatient colonoscopy may be considered to diagnosis lower GI bleeding
3. Prepare for bone marrow aspiration.
While not necessary for most patients with anemia, bone marrow analysis may be required if lab results are inconclusive.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with anemia.
1. Identify and manage the cause.
Anemia results from conditions that affect RBC production or cause RBC destruction. Possible causes of anemia include the following, with each requiring individual interventions:
- Acute blood loss
- Nutritional deficiencies (iron, vitamin B12, and folate)
- Conditions affecting the bone marrow
- Chronic renal disease
- Hemophilia
- Autoimmune and rheumatological conditions
- Increased red blood cell destruction (faulty mechanical valves, hemolytic anemia, DIC)
- Side effects of medications
2. Administer IV fluids as ordered.
IV fluids can increase the intravascular volume in instances of trauma or acute blood loss.
3. Transfuse blood as ordered.
Packed red blood cells (RBCs) should only be transfused to actively bleeding patients and those with severe and symptomatic anemia with a hemoglobin level of 7 g/dL or less.
4. Apply oxygen as needed.
Since RBCs are the oxygen-carrying components of blood, if the patient is anemic, they may experience hypoxia or dyspnea. Apply supplemental oxygen as needed.
5. Administer supplements as recommended.
Supplements and their prescribed route will depend on the patient’s deficiencies and include:
- Oral/IV iron
- Oral/IM vitamin B12
- Oral/IV/IM folate
6. Educate on oral iron supplementation.
For patients to get the most benefit from iron supplements, provide the following education:
- Side effects include gastrointestinal problems such as constipation, black, tarry stools, and metallic taste
- How to administer:
- On an empty stomach
- With water or fruit juice (or any source of vitamin C to aid in absorption)
- 1 hour prior or 2 hours after meals (may take with food if GI upset occurs)
7. Administer erythropoietin for patients with renal disease.
With renal disease, the kidneys cannot produce enough erythropoietin (EPO), which is necessary to maintain healthy RBCs. Administering synthetic EPO stimulates the production of RBCs.
8. Prepare the patient for possible bone marrow and stem cell transplantation.
For those with severe aplastic anemia, healthy stem cells from a donor replace the patient’s destructive bone marrow. Younger patients with a matched donor (usually a sibling) are the best candidates for a stem cell transplant or bone marrow transplant.
9. Refer the patient to a dietitian.
Dietitians can assist and educate the patient regarding recommended foods for nutritional deficiencies (iron, vitamin B12, and folate).
10. Advise the patient when to seek immediate medical attention.
Advise the patient to consult a healthcare provider if symptoms worsen despite treatments. If any of these signs are present, advise them to go to the nearest emergency department:
- Breathing difficulties
- Lightheadedness
- Chest discomfort
- Bright red bleeding in the stool
Nursing Care Plans
Once the nurse identifies nursing diagnoses for anemia, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for anemia.
Acute Pain
Acute pain is a nursing diagnosis specific to sickle cell anemia. This genetic condition causes red blood cells to ‘sickle’ and clump together, decreasing blood flow and perfusion causing a pain crisis.
Nursing Diagnosis: Acute Pain
Related to:
- Sickling of red blood cells occluding blood vessels
- Lack of perfusion and oxygenation to extremities
As evidenced by:
- Intense complaint of pain anywhere in the body
- Pain described as stabbing, sharp, or throbbing
- Reduced activity
- Restlessness
- Distractive behavior (pacing, watching tv, talking on the phone)
Expected outcomes:
- Patient will report a decrease in pain to a level of 2/10 by discharge.
- Patient will verbalize an understanding of behaviors that trigger a pain crisis.
- Patient will adhere to the prescribed pain medication regimen.
Assessment:
1. Assess pain.
Perform a complete pain assessment using a numeric or FACES pain scale. Assess character, duration, frequency, precipitating factors, and any interventions.
2. Assess for acute chest syndrome.
Acute chest syndrome is vaso-occlusion that occurs in the pulmonary vasculature. It is life-threatening and the most common cause of death in sickle cell patients. Monitor for symptoms of chest pain, fever, dyspnea, and infiltrates on a chest x-ray.
3. Assess pain medication regimen.
Many sickle cell pain crises occur due to missed doses of pain medication or an inadequate regimen. Assess the patient’s adherence as well as doses and frequency of pain medication.
Interventions:
1. Provide fluids.
IV hydration is a priority for treating a sickle cell crisis. IV fluids will stop or slow the sickling process and reduce pain. Patients should also be encouraged to drink plenty of fluids.
2. Administer analgesics.
Sickle cell patients often have a very high pain tolerance and will receive high doses of narcotics. Some patients may be on a PCA pump until their pain is better controlled. The nurse should closely monitor the patient and provide adequate pain control without over-sedating the patient.
3. Administer blood transfusions.
Depending on the patient’s hemoglobin level, blood transfusions may be necessary to prevent worsening complications and correct anemia. Some patients may receive long-term transfusions monthly on an outpatient basis.
4. Educate on preventing a sickle cell crisis.
Patients should be educated on triggers of a sickle cell crisis to prevent them. Maintaining hydration, preventing infections, avoiding exposure to cold weather, reducing stress, and adhering to medications are necessary to manage sickle cell anemia.
Decreased Cardiac Output
Anemia causes decreased cardiac function (central venous pressure and heart filling), decreasing cardiac output.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Inadequate filling of blood in the heart
- Decreased oxygenated blood to the heart
- Inadequate cardiac muscle contraction
- Low pressure to pump blood
- Difficulty of the heart muscle to pump oxygenated blood
- Increased cardiac workload
- Severe blood loss
- Low red blood cells
As evidenced by:
- Decreased cardiac output
- Tachycardia
- Hypertension
- Cardiac arrhythmias
- Chest pain
- Diminished pulses
Expected outcomes:
- Patient will demonstrate blood pressure and pulses within normal limits.
- Patient will manifest normal sinus rhythm in ECG.
- Patient will have no complaints of chest pain.
Assessment:
1. Monitor the vital signs.
Anemia results in compensatory mechanisms such as increased heart rate and blood pressure. Monitor for possible heart fatigue that can lead to heart failure if tachycardia and hypertension are uncontrolled.
2. Obtain cardiovascular history.
Note any histories of cardiovascular diseases that may affect the blood supply. Decreased cardiac output due to cardiovascular diseases and anemia will add strain and workload to the heart.
3. Assess cardiovascular status.
Anemia can significantly impact the progression of heart failure (HF). It causes a decrease in oxygen-carrying and delivery capacity. It compromises blood circulation.
4. Check the RBC count
Check the RBC’s volume and quality in size and shape through complete blood count (CBC) and peripheral blood smear. The RBC count and its characteristics may affect the cardiac output and circulating blood in the body.
5. Obtain ECG.
Anemia can cause a fast and irregular heartbeat (arrhythmia) that can be seen in ECG. Anemia causes the heart to pump extra blood to compensate for a lack of oxygen.
Interventions:
1. Reduce cardiac stress.
Anemia can affect heart performance by increasing the heart rate and stroke volume. It will also reduce blood flow to the kidneys and fluid retention, putting additional strain on the heart.
2. Treat the anemia according to its type.
Manage anemia based on its type and cause. It will resume all the organ functions once the circulating volume is within normal limits. The heart will be able to pump acceptable cardiac output.
3. Prepare for a possible blood transfusion.
Severe anemia would necessitate a blood transfusion to supplement cardiac output and aid in circulating oxygenated blood throughout the body.
4. Stop the cause of anemia.
Anemia can be a result of treatment such as chemotherapy. Discontinue as ordered if the anemia is causing a life-threatening complication for the patient. Allow the heart to rest and be free from treatments or medications to maximize its function to pump quality RBCs.
Fatigue
A lack of oxygen-carrying red blood cells will result in decreased energy and fatigue.
Nursing Diagnosis: Fatigue
Related to:
- Decreased hemoglobin
As evidenced by:
- Exhaustion
- Inability to maintain physical activity
- Increased need for rest
- Reported lack of energy
- Lethargy
Expected outcomes:
- Patient will verbalize techniques to conserve energy.
- Patient will report an increase in energy and ability to perform tasks.
Assessment:
1. Monitor CBC.
Assess the patient’s complete blood count including red blood count and hemoglobin levels. These will be low in anemic patients.
2. Assess for chronic conditions that worsen anemia.
Chronic conditions can cause and contribute to anemia. These include pregnant patients, those with cancer, or autoimmune diseases. Treating the underlying cause of anemia should be a priority.
3. Assess the extent of fatigue in daily life.
Inquire about activities the patient can or cannot perform, the effect it has on their responsibilities and roles, and how they manage their symptoms.
Interventions:
1. Instruct on energy conservation.
Plan rest periods, delegate tasks to others, cluster activities together, prioritize activities when energy levels are highest.
2. Apply oxygen.
Patients being treated for anemia in the hospital may require supplemental oxygen for very low hemoglobin levels.
3. Administer blood transfusions.
If a patient is severely anemic or has suffered a blood loss causing anemia, blood transfusions may help with fatigue.
4. Administer erythropoietin injections.
Epogen and Procrit are two common injections given that stimulate the bone marrow to produce red blood cells. Patients with cancer, HIV, or kidney disease often have severe anemia and require these injections.
Imbalanced Nutrition: Less Than Body Requirements
Iron-deficient and vitamin-deficient anemia can occur due to poor dietary intake or an inability to absorb nutrients.
Nursing Diagnosis: Imbalanced Nutrition
Related to:
- Inability to absorb iron or vitamins
- Lack of vitamin B12 and folate in the diet
- Pregnancy
- Gastric bypass surgery
- Inflammatory bowel diseases
- Vegetarian diet
As evidenced by:
- Pale skin
- Feeling cold
- Fatigue
- Rapid heartbeat
- Brittle nails
- Hair loss
- Craving ice (pagophagia)
- Headaches
Expected outcomes:
- Patient will display an improvement in iron and B-12 levels through lab testing.
- Patient will add three foods high in iron, B-12, and folic acid to their diet.
- Patient will recognize the signs and symptoms of anemia and when to call their doctor.
Assessment:
1. Assess lab values.
Monitor red blood cell count, hemoglobin, hematocrit, ferritin, iron, and total iron-binding capacity for abnormalities.
2. Assess the patient’s usual diet.
Assess for nutritional gaps in the patient’s diet by taking a history of foods they normally eat as well as any food allergies they may have.
3. Assess access to healthy foods.
Assess if access to food prevents the patient from obtaining nutritionally-balanced foods that are high in vitamins.
Interventions:
1. Instruct on a healthy diet.
Iron-rich foods include dark green, leafy vegetables, nuts, and eggs. Foods high in vitamin B-12 include meat and dairy products. Folic acid is found in legumes, citrus juices, and dark green leafy vegetables.
2. Consider supplements.
Patients may be prescribed oral supplements of iron or vitamin B-12 (cyanocobalamin) if they cannot get enough from their diet. Patients may also receive vitamin B-12 injections regularly usually administered by a nurse.
3. Encourage prenatal supplements.
Pregnant patients should be instructed on the importance of prenatal vitamins which contain iron and folate. These vitamins are essential to support a healthy pregnancy and prevent birth defects.
4. Improve iron absorption.
Some patients struggle with absorbing iron and will need instruction on when and which foods to eat to increase absorption. It is easier for the body to absorb meat and seafood iron-containing products. Iron in vegetables, grains, and seeds is more difficult for the body to absorb. Vitamin C can help with the absorption of iron when taken with a meal. Tannins in tea and coffee can inhibit the absorption of iron.
Ineffective Tissue Perfusion
Tissue perfusion requires adequate blood circulation to the tissues. Anemia results in a loss or destruction of RBCs, preventing oxygen from perfusing tissues.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- 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 (chronic kidney disease, rheumatoid arthritis, cancer)
- Body attacks own RBCs
As evidenced by:
- Lightheadedness or dizziness
- Headache
- Fatigue
- Change in mentation
- Pallor
- Cold extremities
- Prolonged capillary refill time
- Chest pain
- Shortness of breath
- Low hemoglobin levels
Expected outcomes:
- Patient will demonstrate evidence of perfusion through warm skin and color within the normal range for ethnicity.
- Patient will report relief of shortness of breath, chest pain, and fatigue.
- Patient will demonstrate a hemoglobin level >10.0 g/dL.
Assessment:
1. Determine the patient’s medical and family history.
Certain types of anemia may be inherited or can develop as a result of a chronic condition. Identify whether the anemia is acute or chronic by establishing a thorough history. Management will depend on the type and cause of anemia.
2. Perform a physical assessment.
Red blood cells are needed in all body processes. Low red blood cells (anemia) lead to decreased levels of oxygenated blood in the tissues, causing hypoxia and decreased bodily functions. Monitor for pale, cold skin, changes in respiration, orthostatic hypotension, tachypnea, and chest pain.
3. Review the hemoglobin level.
Low hemoglobin levels indicate a lack of oxygenated blood available to perfuse organs.
Interventions:
1. Investigate reports of chest pain or palpitations.
If the patient reports chest pain or discomfort, obtain an EKG to monitor for arrhythmias.
2. Apply oxygen.
A lack of oxygenated RBCs may result in hypoxia. Administer supplemental oxygen to keep SpO2 > 95%.
3. Implement safety precautions.
Anemia can affect the central nervous system and cause lightheadedness, dizziness, vision changes, and muscle weakness that could cause fainting and falls. Implement fall and safety precautions for patients experiencing these symptoms.
4. Administer epoetin injections as ordered.
Epoetin alfa is a synthetic form of the human hormone erythropoietin and increases RBC production in the bone marrow.
References
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