Anemia is the most common hematologic disorder in which the hemoglobin level is lower than normal, reflecting the presence of a decrease in number or derangement in function of red blood cells within the circulation. As a result, the amount of oxygen delivered to body tissues is also lessened.
Anemia may be classified in many ways. In iron deficiency anemia, it is a hypochromic, microcytic type of anemia, resulting from inadequate iron supplementation, chronic blood loss seen in men and older women who have ulcers or GI tumors and younger women with heavy menstruation.
Aplastic anemia, on the other hand, is caused by damage to hematopoietic stem cells and the bone marrow. This causes a depression of all blood elements: (pancytopenia): red blood cells (anemia), white blood cells (leukopenia), and platelets (thrombocytopenia). While pernicious anemia is caused by faulty absorption of vitamin B12 from the GI tract, which is required in the production of red blood cells.
Nursing Care Plans
Nursing care plan for clients with anemia includes: assess risk factors, decrease fatigue, maintenance of adequate nutrition, maintenance of adequate tissue perfusion, compliance with prescribed treatment regimen, and be free from complications.
Here are four (4) nursing care plans (NCP) for anemia (aplastic, iron deficiency, cobalamin, pernicious):
1. Fatigue
Fatigue: An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level
May be related to
- - Decreased hemoglobin and diminished oxygen-carrying capacity of the blood.
Possibly evidenced by
- - Exertional discomfort or dyspnea.
- - Inability to maintain usual level of physical activity.
- - Increased rest requirements.
- - Report of fatigue and lack of energy.
Desired Outcomes
- - Client will verbalize use of energy conservation principles.
- - Client will verbalize reduction of fatigue, as evidenced by reports of increased energy and ability to perform desired activities.
| Nursing Interventions | Rationale |
|---|---|
| Assess the specific cause of fatigue. | The specific cause of fatigue is due to tissue hypoxia from normocytic anemia; Other related medical problems can also compromise activity tolerance. |
| Assess the client’s ability to perform activities of daily living (ADLs), and the demands of daily living, | Fatigue can limit the client’s ability to participate in self-care and perform his or her role responsibilities in family and society, such as working outside the home. |
| Assist the client in planning and prioritizing activities of daily living (ADL). | This will allow the client to maximize his/her time for accomplishing important activities. Not all self-care and hygiene activities need to be completed i the morning. Likewise, not all housework needs to be completed in one day. |
| Assist the client in developing a schedule for daily activity and rest. Stress the importance of frequent rest periods. | Energy reserves may be depleted unless the client respects the body’s need for increased rest. A plan that balances periods of activity with periods of rest can help the client complete desired activities without adding levels to fatigue. |
| Monitor hemoglobin, hematocrit, RBC counts, and reticulocyte counts. | Decreased RBC indexes are associated with decreased oxygen-carrying capacity of the blood. It is critical to compare serial laboratory values to evaluate progression or deterioration in the client and to identify changes before they become potentially life-threatening. |
| Educate energy-conservation techniques. | Clients and caregivers may need to learn skills for delegating task to others, setting priorities, and clustering care to use available energy to complete desired activities. Organization and time management can help the client conserve energy and reduce fatigue. |
| Instruct the client about medications that may stimulate RBC production in the bone marrow. | Recombinant human erythropoietin, a hematological growth factor, increases hemoglobin and decreases the need for RBC transfusions. |
| Provide supplemental oxygen therapy, as needed. | Oxygen saturation should be kept at 90% or greater. |
| Anticipate the need for the transfusion of packed RBCs. | Packed RBCs increase oxygen-carrying capacity of the blood. |
| Refer the client and family to an occupational therapist. | The occupational therapist can teach the client about using assistive devices. The therapist also can help the client and family evaluate the need for additional energy-conservation measures in the home setting. |
2. Deficient Knowledge
Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.
May be related to
- - Complexity of treatment.
- - Lack of recall.
- - Lack of resources.
- - New condition or treatment.
- - Unfamiliarity with the disease condition.
Possibly evidenced by
- - Inaccurate follow-through of instructions.
- - Questioning members of health care team.
- - Verbalized inaccurate information.
Desired Outcomes
- - Client will verbalize understanding of own disease and treatment plan.
| Nursing Interventions | Rationale |
|---|---|
| Assess current knowledge of the diagnosis, disease process, possible causative factors, and treatment. | Determining the client’s current knowledge and perceptions will facilitate the planning of individualized teaching. Clients may have a general understanding of anemia related to iron deficiency but limited knowledge of other types of anemia. |
| Assess the client’s and family’s understanding of the new medical vocabulary. | Usually, people have a limited understanding of medical vocabulary, hence are not exposed to the language being used by the health care professionals. |
| Explain the importance of the diagnostic procedures (such as complete blood count), bone marrow aspiration and a possible referral to a hematologist. | Diagnosing a type of anemia will be based on the changes in the RBC indexes and the findings in the bone marrow aspiration. |
| Explain the hematological vocabulary and the functions of blood elements, such as white blood cells, red blood cells, and platelets. | Clients usually have a basic knowledge of the hematological system. |
| Instruct client to avoid known risk factors. | Causative factors such alcoholism, exposure to toxic chemicals, dietary deficiencies, and the use of some medications can affect red blood cell production and lead to anemia. |
| For aplastic anemia: | |
| Histocompatibility antigens may lead to donor marrow rejection. |
| The human leukocyte antigen (HLA) test, also known as HLA typing or tissue typing, identifies antigens on the white blood cells (WBCs) that determine tissue compatibility for organ transplantation |
| The treatment of choice in clients without HLA-matched donors is immunosuppression with granulocyte-macrophage-colony-stimulating factors, cyclophosphamide, anti-thymocyte globulin, and cyclosporine. |
| Hematopoietic stem cell transplantation (HCT) is an effective therapy for many life-threatening diseases. Usually, a client’s own (autologous) cells or (allogeneic) cells from a donor with same genetic makeup are used. |
| Explain the potential complications associated with immunosuppressive therapy. | |
| Earliest symptoms include a red maculopapular rash, dryness of the eye, abdominal pain, and jaundice. |
| Clients with Chronic GVHD may present with a variety of symptoms. Skin rash and mouth sores are among the common initial signs of the disease. The rash is often slightly raised and may be itchy. |
| Rejection happens when a sensitization to histocompatibility antigens acquired during previous blood transfusions and carries a high mortality rate. Conditioning regimens using cyclophosphamide (Cytoxan) and total lymphoid irradiation show a decrease in the risk for graft failure. |
| For nutritional deficiency anemia: | |
| Vitamin B12 injections used to treat low levels (deficiency) of this vitamin. They are given monthly for the remainder of the client’s life. It elevates levels of vitamin B12, a deficiency caused by a lack of intrinsic factor that impairs the vitamin absorption. |
| A balanced diet that includes a variety of foods from each food group usually contains essential nutrients needed to promote RBC formation. Clients need to have an adequate intake of dark-green leafy vegetables, animal products, including fish, meat, poultry, eggs, milk, and fortified breakfast cereals. |
| The dosage and frequency of administration will depend on the severity of anemia. Iron supplements are given orally with meals to prevent gastric upset. Intramuscular injections are also available given via Z-track method to prevent leakage of the solution in the subcutaneous tissue along the needle tract. While folic acid is given orally with a full glass of water. |
| For blood loss anemia: | |
| Recombinant human erythropoietin, a hematological factor, elevates hemoglobin levels and decreases the need for a transfusion of packed RBC. |
| One unit of packed RBC raises the hemoglobin level by 1 g/dL. |
3. Risk For Infection
Risk for Infection: At increased risk for being invaded by pathogenic organisms.
Risk Factors
- - Bone marrow malfunction.
- - Marrow replacement with fat in aplastic anemia.
Possibly evidenced by
- [not applicable].
Desired Outcomes
- - Client will have a reduced risk of infection as evidenced by an absence of fever, normal white blood cell count, and implementation of preventive measures such as proper hand washing.
- - Client will have vital signs within the normal limit.
| Nursing Interventions | Rationale |
|---|---|
| Assess for local or systemic signs of infection, such as fever, chills, swelling, pain, and body malaise. | Opportunistic infections can easily develop, especially in immunocompromised clients. |
| Monitor WBC count. | A low white blood cell count (leukopenia) is a decrease in disease-fighting cells (leukocytes) in your blood. In general, for adults a count lower than 4,000 white blood cells per microliter of blood is considered a low white blood cell count. |
| Instruct the client to report signs and symptoms of infection immediately. | A simple fever is significant enough not to pay attention to. A need for antibiotic therapy may be indicated. |
| Anticipate the need for antibiotic, antiviral, and antifungal therapy. | These agents are effective against killing an infection. |
| Instruct the client to avoid contact with people with existing infections. | These can be a source of infection for the immunocompromised client. Children, 12 years of age or younger are at risk because they can be carriers of infection, especially upper respiratory infection. |
| If the client is hospitalized, provide a private room for protective isolation. | Environmental changes may be important if the absolute neutrophil count is less than 500/mm3. Protective isolation precautions may include placing the client in a private room, limiting visitors, and having all people who come in contact with the client use mask, gown, and gloves. These clients are at a significant risk for infection. |
| Instruct the client to avoid eating raw fruits and vegetables and uncooked meat. | These food items can harbor bacteria. A low bacterial diet protects the client from exposure to pathogens. |
| Stress the importance of daily hygiene, mouth care, and perineal care. | These preventive measures help avoid skin breakdown and lessen the risk of infection. |
| Teach the client and visitors the proper hand washing. | Practicing hand hygiene is an effective way to prevent infections. Washing hands can prevent the spread of germs, including those that are resistant to antibiotics. |
| Administer WBC growth factor to stimulate the production of neutrophils. | Colony-stimulating factors (CSFs), long-acting pegfilgrastim, filgrastim are medications used to stimulate the production of infection-fighting white blood cells. |
4. Risk For Bleeding
Risk for Bleeding: At risk for a decrease in blood volume that may compromise health.
Risk Factors
- - Bone marrow malfunction.
- - Marrow replacement with fat in aplastic anemia.
Possibly evidenced by
- [not applicable].
Desired Outcomes
- - Client will have a reduced risk for bleeding, as evidenced by normal or adequate platelet levels and absence of bruises and petechiae.
| Nursing Interventions | Rationale |
|---|---|
| Assess the skin for bruises and petechiae. | Bruises and petechiae is usually evident when the platelet count drops to 20,000 mm3. |
| Assess for any frank bleeding from the nose, gums, vagina, or urinary or gastrointestinal tract. | Early assessment facilitates immediate treatment. These sites are most common for spontaneous bleeding. |
| Monitor platelet count. | A low platelet count or thrombocytopenia is caused by a bone marrow malfunction resulting from nutritional deficiencies, drugs, certain viral causes, or aplastic anemia. The risk for bleeding is increased as platelet count is decreased. |
| Monitor stool (guaiac) and urine (Hemastix) for occult blood. | These test help identify the site of bleeding. |
| Consolidate laboratory blood sampling test. | Repeated blood sampling over time can lead to anemia. Consolidation minimizes the number of venipunctures and optimizes blood volume. |
| Instruct the client in dietary modifications to reduce constipation. | Eating a diet high in fiber and drinking a lot of fluids to avoid constipation or using a stool softener and other laxatives as prescribed if having difficulty passing stool. |
Instruct the client about bleeding precautions.
| Once the client’s platelet count drops to 50,000mm3,bleeding precaution should be instituted immediately to avoid risk of spontaneous bleeding. |
| Anticipate the need for a platelet transfusion once the platelet count drops to a very low value. | Platelet replacement may be required to reduce the risk of bleeding. Premedication with antihistamine and antipyretics reduce transfusion reaction side effects. |
References and Sources : nurseslabs.com
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