5 Nursing care plans for anemia | Anemia nursing interventions

Anemia is a condition in which the hemoglobin concentration is lower than normal.

Classification of anemias

Hypoproliferative anemias (due to deficient red cell production).

In hypoproliferative anemias, the bone marrow is unable to produce an adequate number of erythrocytes. Inadequate red cell production may be due to damage to the bone marrow from drugs (e.g., chloramphenicol) or chemicals (e.g., benzene) or to a deficiency in factors (e.g., iron, vitamin B12, folic acid, erythropoietin) needed for red cell production.

• Iron deficiency
• Vitamin B12 deficiency (megaloblastic)
• Folate deficiency (megaloblastic)
• Decreased erythropoietin production

Hemolytic anemia (due to destruction of erythrocytes)

In hemolytic anemias, premature destruction of erythrocytes occurs. The increased destruction of erythrocytes leads to tissue hypoxia, which in turn stimulates erythropoietin production. This increased production is reflected in an increased reticulocyte count as the bone marrow responds to the loss of erythrocytes. Hemolysis may be caused by an abnormality within the erythrocytes themselves

• Altered erythropoiesis (sickle cell anemia, thalassemia, other hemoglobinopathies)
• other hemoglobinopathies)
• Drug-induced anemia
• Autoimmune-induced anemia
• Mechanical heart valve-induced anemia

PATHOPHYSIOLOGY

Erythropoietin is a naturally occurring protein hormone produced and released by the kidneys (90%) and liver (10%).

The kidneys are stimulated to release erythropoietin when blood oxygen levels are too low, and then stimulate stem cells in the bone marrow to develop and produce red blood cells.

People with impaired kidney function (e.g., chronic kidney disease) often become anemic because their kidneys cannot produce erythropoietin. In other chronic diseases (cancer, congestive heart failure, human immunodeficiency virus [HIV], rheumatic diseases), elevated cytokines (such as interleukin 6) may decrease erythrocyte production in the bone marrow, reduce the erythropoietic response in the bone marrow, limit iron recycling from the liver, decrease iron absorption from the intestine, and shorten erythrocyte survival. Recombinant human erythropoietin (epoetin alpha) has provided some benefits to patients with CKD, some patients receiving chemotherapy for cancer, and patients undergoing treatment for HIV infection, but may carry risks for life-threatening cardiovascular events. Because anemia can also be caused by other causes such as blood loss, hemolysis, and inadequate dietary intake of iron, vitamin B12 (cobalamin), or folate, these causes must be ruled out before the actual cause of the anemia can be determined.

Clinical manifestations

In general, the faster anemia develops, the more severe its symptoms. An otherwise healthy person can often tolerate a gradual drop in hemoglobin of up to 50% without marked symptoms or significant inability to work, whereas a rapid loss of as little as 30% in the same person can lead to profound vascular collapse.

A person who has become gradually anemic, with hemoglobin levels between 9 and 11 g/dL, usually has few or no symptoms except mild tachycardia on exertion and fatigue.

Patients with hypothyroidism and decreased oxygen demand may be completely asymptomatic with hemoglobin levels of 10 g/dL, without tachycardia or increased cardiac output.

Patients with coexisting

cardiac, vascular, or pulmonary disease may experience more severe

anemia symptoms (e.g., dyspnea, chest pain, muscle pain or cramping) at higher hemoglobin levels than patients without these concurrent health problems.

Etiology 

There are three main causes of anemia. They are blood loss, increased destruction of erythrocytes, and decreased erythrocyte production. Within these causes, there are a number of specific etiologies. Some examples of these specific causes include genetic causes (e.g., thalassemia), nutritional causes (e.g., iron deficiency), physical causes (e.g., trauma, enlarged or injured spleen), chronic diseases (e.g., kidney disease), malignancies (e.g., neoplasms), and infectious diseases (e.g., viruses, bacteria, and protozoa).

Anemia in adults is usually defined as an Hgb of less than 11 g/dL, with severe anemia defined as an Hgb of less than 8 g/dL. Not all sources agree with these numbers. For example, Maakaron opines that anemia is defined by the lower limits of the Hgb range and that “the World Health Organization (WHO) has chosen 12.5 g/dl for adult men and women. In the United States, limits of 13.5 g/dL for men and 12.5 g/dL for women are probably more realistic” .

Anemia is a common condition that occurs in all age groups, both men and women, and in all racial and ethnic groups.

Anemias are associated with many physiological complications, including shortness of breath, fatigue, dizziness, decreased cognition, sleep disturbances, sexual dysfunction, and significant impairment.

Iron Deficiency Anemia 

• Iron deficiency in the body due to a variety of causes
• Blood loss due to conditions such as gastric or duodenal ulcers, diverticula, hemorrhoids, ulcerative colitis, injury or trauma, or certain medications such as aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs)
• Inadequate diet, such as eating foods that do not contain enough iron
• Malabsorption syndromes, such as when dietary iron is not utilized
• The most common form of anemia

ACD anemia 

• Primarily due to slowed production of red blood cells as a result of low reticulocyte production
• Develops slowly and becomes apparent only after some time has passed
• Symptoms are usually associated with the disease causing the anemia, rather than the anemia itself. Examples include anemia associated with chronic kidney disease, chronic malnutrition, or cancer.
• Second most common form of anemia.

Pernicious anemia

• An autoimmune disease
• It is characterized by the formation of autoantibodies against the parietal cells of the stomach and their secretory product, intrinsic factor, which is required for the absorption of vitamin B12.
• Conditions that interfere with the body’s absorption and utilization of B12 include Crohn’s disease and Whipple’s disease, gastrectomy or gastric bypass, and use of chemotherapeutic drugs.

Aplastic anemia – bone marrow failure.

• May be associated with conditions that affect the production and secretion of erythropoietin, such as certain cancers and treatments, and renal, hepatic, or endocrine disorders.
• Other known causes include exposure to chemicals such as benzene, insecticides, and solvents; certain drugs such as chemotherapy, gold, anti-seizure drugs, and some antibiotics; viruses such as HIV and Epstein-Barr; immune disorders such as systemic lupus erythematosus and rheumatoid arthritis; radiation; and certain inherited disorders such as Fanconi anemia.

Hemolytic anemia –

• characterized by accelerated destruction of red blood cells.
• Several types of hemolytic anemias, including sickle cell anemia. 

Causes

• Hereditary factors such as sickle cell anemia,
• Blood transfusion reactions, immune disorders,
• Acute viral or infectious agents,
• Certain medications such as quinidine, penicillin, and methyldopa, and toxins such as chemicals and poisons.

Diagnostic Studies

• Complete blood count (CBC):
• Hemoglobin (Hgb):
• Hematocrit (Hct):
• Hgb electrophoresis:
• RBC (also called erythrocyte) count: 
• Reticulocyte count: Immature RBCs.
• RBC survival time:
• Erythrocyte fragility test: 
• Erythrocyte sedimentation rate (ESR):• WBCs: • Platelet count:
• Erythropoietin: 
• Serum iron:• Total iron-binding capacity (TIBC):
• Serum ferritin: 
• Vitamin B12 (cobalamin) and folate (folic acid, RBC folate):
• Serum bilirubin:
• Serum lactate dehydrogenase (LDH): 

5 Nursing diagnosis for anemia 

• Activity Intolerance
• imbalanced Nutrition: less than body requirements
• Constipation/Diarrhea
• risk for Infection
• deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, prevention of crisis, and discharge needs.

Activity intolerance 

Associated with anemia and decreased oxygen-carrying capacity of the blood, which is accompanied by a decrease in red blood cells. Imbalance between oxygen supply and demand (anemia).

Possibly detectable by

• Reports of fatigue, feeling weak
• Abnormal heart rate or blood pressure response to activity
• Exertion-induced dyspnea

Desired outcomes

After treatment, Hgb and Hct scores are within medical targets, and the patient perceives exertion as 3 or less on a scale of 0 to 10 and tolerates activity as evidenced by a respiratory rate (RR) of 12 to 20 breaths/minute, the presence of eupnea, a heart rate (HR) of 100 beats/minute or less, and the absence of dizziness and headache.

Report an increase in activity tolerance, including ADLs.

Demonstrate a decrease in physiologic signs of intolerance – pulse, respiration, and blood pressure remain within the patient’s normal range.

Laboratory values (Hgb/Hct) are within acceptable range.

Nursing intervention	Rational
Screen for signs of activity intolerance. Ask patient to rate perceived exertion on a scale of 0-10.	Dyspnea on exertion, dizziness, palpitations, headache, and verbalization of increased exertion level are signs of activity intolerance and decreased tissue oxygenation, and the patient should discontinue or modify activity until signs of increased exertion on activity are no longer present.
Assess fall risk and implement appropriate strategies.	Because of the potentially slow, progressive nature of this anemia, patients may be unaware of their weaknesses and limitations, resulting in impaired strength and balance. Patient falls can lead to serious injury, prolonged hospitalization, and even death.
Monitor oximetry; report O2 saturation of 92% or less.	O2 saturation of 92% or less may mean supplemental oxygen is needed.
Administer oxygen as prescribed; encourage deep breathing.	Both interventions increase tissue oxygenation.
Facilitate care provider coordination to provide at least 90 minutes of uninterrupted rest.	Fewer rest interruptions allow patients to enjoy the undisturbed rest/sleep they need until anemia is resolved.
Encourage patient to gradually increase activities to tolerance as condition improves.	This promotes endurance while preventing problems caused by prolonged bed rest.
Administer blood components (usually packed red cells) through an intravenous catheter as prescribed.	This increases the number of circulating erythrocytes, which in turn increases the oxygen-carrying capacity of the blood.
Review type and crossmatch and patient identifiers with a colleague, and watch for and report signs of a transfusion reaction.	These measures reduce the risk of giving the patient the wrong blood type and allow for rapid treatment if a transfusion reaction occurs.

Unbalanced diet: less than the body needs

May be related to

Inadequate food intake or inability to digest food or absorb nutrients

Possibly evidenced by

• Reports of food intake below recommended daily allowance Weight loss or weight below ideal range
• Pale mucous membranes Abnormal laboratory tests

Desired results 

Nutritional status

Evidence of progressive weight gain or stable weight with normalization of laboratory values. No evidence of malnutrition. Demonstration of behavioral or lifestyle changes to achieve and maintain appropriate weight.

Nursing intervention	Rational
Review of dietary history, including food preferences.	Identify deficiencies and suggest possible interventions. (A daily food diary over a period of time may be required to identify anemia associated with nutrient deficiencies, e.g., no meat in diet-iron and vitamin B12 deficiency or few leafy vegetables in diet-folic acid deficiency).
Observation and recording of the patient’s food intake.	Monitor caloric intake or inadequate quality of food intake.
Regular weighing at appropriate intervals, e.g., weekly.	Monitors weight loss and effectiveness of dietary interventions.
Recommend small, frequent meals and food between meals.	May improve food intake while preventing gastric distention. Use of liquid supplements such as Ensure, Boost, or similar products provides additional protein and calories.
Recommend a low-fiber sparing diet and avoid hot, spicy, or very acidic foods, if indicated.	If oral lesions are present, pain may limit the types of foods the patient can tolerate.
Have the client record and report the occurrence of nausea or vomiting, bloating, and other related symptoms, such as irritability or memory problems.	May reflect the effects of anemia (e.g., hypoxia or vitamin B12 deficiency) on organs and systems of the body.
Encourage or support good oral hygiene before and after meals; use a soft-bristled toothbrush for gentle brushing. Provide dilute, alcohol-free mouthwash if oral mucosa is ulcerated.	Promotes appetite and oral intake. Reduces bacterial growth and minimizes the possibility of infection. Special oral care techniques may be required for friable, ulcerated or bleeding tissues and severe pain.

Constipation

May be related to

• Poor eating habits, changes in gastrointestinal motility Side effects of medications

Possibly detectable by

• Changes in frequency, consistency, and quantity of stool
• Reports of abdominal pain, urgency, cramping
• Altered bowel sounds

Desired results

• Bowel emptying
• Return to normal patterns of bowel function.
• Evidence of behavioral changes or lifestyle changes needed due to causative or contributing factors.

Nursing intervention	Rational
Determine color, consistency, frequency, and quantity of stool.	Helps identify causative or contributing factors and appropriate interventions.
Auscultation of bowel sounds.	Bowel sounds are generally increased in diarrhea and decreased in constipation.
Monitor intake and output (I&O) with special attention to food and fluid intake.	May reveal dehydration and excessive fluid loss or help identify nutritional deficiencies.
Promote fluid intake of 2500 to 3000 ml/day within cardiac tolerance.	Helps improve stool consistency in constipation. Helps maintain hydration status in diarrhea.
Recommend avoiding gas-forming foods.	Reduces stomach discomfort and abdominal distension.
Assess perianal skin condition regularly and watch for changes or incipient decay. After each bowel movement (BM), stimulate and support perineal care during diarrhea.	Prevent skin abrasions and decay.
Discuss use of stool softeners, mild stimulants, volumizing laxatives, or enemas, as needed. Monitor for effectiveness.	Facilitates defecation in constipation.

Risk of infection

Risk factors may include.

• Inadequate secondary defenses
• decreased hemoglobin, leukopenia, or decreased granulocytes; suppressed inflammatory response
• Inadequate primary defenses – injured skin, congestion of body fluids, invasive procedures, chronic disease, malnutrition

Desired outcomes

• Identify behaviors to avoid and reduce risk of infection. Severity of infection Show no signs of infection; achieve timely wound healing, if present.

Nursing intervention	Rational
Implement and encourage careful hand washing by nurses and patients.	Prevent cross-contamination or bacterial colonization. Note: Clients with severe or aplastic anemia may be at risk for normal skin flora.
Adhere to strict aseptic techniques during procedures and wound care.	Reduce risk of bacterial colonization and infection.
Meticulous skin, oral, and perianal care.	Reduces risk of skin or tissue damage and infection.
Promote frequent position changes and repositioning, coughing, and deep breathing exercises.	Promotes ventilation of all lung segments and helps mobilize secretions to prevent pneumonia.
Promote adequate fluid intake.	Helps liquefy respiratory secretions to facilitate expectoration and prevent congestion of body fluids in the lungs and bladder.
Emphasize the need to monitor and restrain visitors if necessary. Provide protective isolation if necessary. Restrict live plants and cut flowers.	Limit exposure to infectious agents. Protective isolation may be needed in aplastic anemia when immune response is most compromised.
Monitor temperature. Watch for chills and tachycardia with or without fever.	Indicate an inflammatory process or infection that needs investigation and treatment. Note: With bone marrow suppression, leukocyte failure can lead to fulminant infections.
Watch for wound redness and drainage.	Signs of local infection. Note: Pus formation may be absent if granulocyte count is decreased.

Inadequate knowledge of condition, prognosis, treatment, self-care, crisis prevention, and discharge needs

May be related to

• Lack of exposure, recall Misinterpretation of information Unfamiliarity with sources of information

Possibly demonstrable by

• Reports of the problem
• Inaccurate following of instructions

Desired outcomes

• Knowledge: Management of chronic disease.
• Verbalize understanding of the nature of the disease process, diagnostic procedures, and possible complications.
• Recognize causative factors. Verbalize understanding of therapeutic needs. Initiate necessary behavioral or lifestyle changes.

Nursing intervention	Rational
Provide information about specific anemias and explain that therapy depends on the type and severity of the anemia.	Provides a knowledge base from which the client can make informed decisions. Alleviates anxiety and can encourage cooperation with therapy to manage what may be a protracted illness.
Discusses the impact of anemia on pre-existing conditions.	Anemia exacerbates many underlying conditions, and resolution of anemia is affected by aging and developmental issues, nutritional and socioeconomic issues, and acute and chronic illness.
Review the purpose and preparations for diagnostic testing.	Knowing what to expect can reduce anxiety.
Explain that taking blood for laboratory tests will not make the anemia worse.	This is often an unspoken concern that can increase the patient’s anxiety.
Review dietary changes needed to meet specific nutritional needs based on type of anemia and deficiency	Red meat, liver, seafood, green leafy vegetables, whole grain breads, and dried fruits are sources of iron. Green vegetables, whole grains, liver, and citrus fruits are sources of folic acid and vitamin C, which promotes iron absorption.
Discuss which foods to avoid, such as coffee, tea, egg yolks, milk, fiber, and soy protein, if the client is eating iron-rich foods.	These foods block the absorption of iron and should be taken with another meal. For example, if red meat and milk are consumed at the same time, the absorption of iron from the meat may be blocked.
Assess resources, including financial resources, and ability to obtain and prepare food.	Insufficient resources may affect the ability to purchase and prepare appropriate foods.
Encourage smoking cessation.	Smoking decreases available oxygen and causes vasoconstriction.
Provide information about the purpose, dosage, schedule, precautions, and possible side effects, interactions, and adverse effects of all prescribed medications.	Information improves cooperation with therapy. Recovery from anemia can be slow and requires prolonged treatment and prevention of secondary complications.
Emphasize the importance of reporting signs of fatigue, weakness, paresthesias, irritability, and memory impairment.	Indicates that the anemia is progressing or not resolving, necessitating further investigation and treatment changes.
Dilute liquid preparations, preferably with orange juice, and administer through a straw.	Undiluted liquid iron preparations may discolor teeth. Ascorbic acid promotes iron absorption.
Recommend the use of protective devices, such as sheepskin, egg crate, alternating air pressure or water mattresses, heel and elbow pads, and cushions, if needed.	Prevent skin injury by avoiding or reducing pressure against the skin surface.
Review good oral hygiene and the need for regular dental care.	Effects of anemia such as oral lesions and use of iron supplements increase risk of infection and bacteremia.
Refer to appropriate community agencies as needed, such as social services for food stamps and Meals on Wheels.	May need assistance in obtaining food and preparing meals.