Anemia Nursing Diagnosis & Care Plans

Terminology

  • Anemia means a low oxygen-carrying capacity 
  • Caused by either a low amount of red blood cells or dysfunctional red blood cells 

Pathophysiology

Anemia is a condition in which the number of red blood cells circulating in the bloodstream is abnormally low or dysfunctional. Blood contains, among other blood cells, red blood cells. These red blood cells are specialized cells that aid in gas exchange and oxygen delivery. 

Red blood cells help carry oxygen from the lungs to the tissues in the body and carbon dioxide from the tissues back to the lungs. These cells contain hemoglobin – allowing red blood cells to carry oxygen. 

Blood cells need vitamins and enzymes such as vitamin B12, folate, iron, and other substances to carry out their functions. 

Any deficiencies or malfunctioning in producing red blood cells decrease oxygen-carrying capabilities. 

Anemia can be an acute or chronic condition with symptoms ranging from mild to severe, requiring hospitalization. 

There are several different types of anemia which all have other causes. 

Types of Anemia and Causes 

Iron deficiency anemia

  • Most common type of anemia 
  • Results from loss or malabsorption of iron
  • May present with small RBCs (microcytic) 
  • Iron is one building block of hemoglobin needed to transport oxygen
  • Occurs in women with heavy menstruation, patients with gastrointestinal ulcers, and people that have a poor diet

Vitamin B-12 deficiency anemia 

  • Vitamin B-12, folate, and iron are necessary to build red blood cells
  • Deficiencies in Vitamin B-12 can occur in two ways: inadequate consumption of nutrients containing Vitamin B-12 or the inability to absorb it. 
  • Having enough Vitamin B-12 but being unable to absorb it is then called pernicious anemia 

Folic acid deficiency anemia 

  • Similar to Vitamin B-12 anemia in that the cause may be either poor nutrition or malabsorption 

Aplastic anemia 

  • Bone marrow fails to produce red blood cells
  • It may be caused by infections, medications, autoimmune diseases, and exposure to chemicals

Sickle cell disease 

  • A genetic disease that results in a defective hemoglobin formation
  • This leads to red blood cells assuming an abnormal, crescent shape
  • Reduces life cycle of blood cells leading to chronic anemia 

Autoimmune hemolytic anemia 

  • Due to abnormal immune function leading to the destruction of red blood cells mainly at a faster rate than new cells can be produced

Risk Factors 

  • Poor diet/ malnourishment: a diet low in iron, vitamin B-12, and folate prevents new red blood cell formation 
  • Age: Individuals over the age of 65 are at a higher risk for anemia 
  • Menstruation: women of childbearing age have a greater risk for anemia due to blood loss from menstruation 
  • Pregnancy: During pregnancy, the body produces more blood to promote the growth of the baby; insufficient intake of nutrients needed to build red blood cells may lead to anemia
  • Intestinal disorders: Gastrointestinal disorders that affect the absorption of nutrients may cause anemia; examples are celiac disease, peptic ulcer, and inflammatory bowel disease
  • Chronic conditions: Any condition that compromises the life cycle of RBCs may lead to anemia. For example, bone marrow and the kidneys play a role in RBC production. Any chronic condition of these organs may lead to decreased red blood cell production
  • Family history: Sickle cell disease is a genetic condition and can be the cause of chronic anemia 
  • Frequently donating blood: Donating blood frequently in a short period may not give the body enough time to produce red blood cells and cause anemia
  • Medication: Salicylates and thiazides are some examples of medicines that may be associated with anemia 

Signs and Symptoms 

Individuals with anemia present in similar ways but can have additional unique symptoms that are specific to a type of anemia

  • Fatigue 
  • Somnolence 
  • Weakness 
  • Shortness of breath/ dyspnea on exertion
  • Dizziness/ lightheadedness 
  • Pallor (ears, nose, nail beds, palmar crease, conjunctivae) 
  • Cool to the touch 
  • Cold intolerance 
  • Brittle nails 
  • Tachycardia/ palpitations 
  • Headaches 
  • Orthostatic hypotension 
  • Decreased oxygen saturation levels 
  • Signs and symptoms specific to vitamin B-12 deficiency
    • Glossitis (smooth-beefy red tongue) 
    • Paresthesias (abnormal sensation in feet and hands and poor balance) 
  • Signs specific to iron deficiency anemia
    • Craving for ice or non-edible items 

Diagnosis 

Values may vary among different references and also differ between genders. 

  • CBC
    • Hemoglobin <10 g/ dL
    • Hematocrit <36% 
    • RBCs <4 x 1012
  • Positive bone marrow aspiration for anemia 
  • Colonoscopy to determine if there is any bleeding 
  • Fecal occult blood sample 

Treatment 

  • Diet modification 
  • Supplemental treatment 
  • Lifestyle adjustments 
  • Blood transfusions 

Nursing Care Plans for Anemia 

Fatigue r/t insufficient oxygen supply to the body 

Expected Outcome: The patient will verbalize decreased fatigue as evidenced by reports of increased energy and well-being. 

Assess the patient’s ability to carry out ADLs. 

Fatigue can interfere with ADLs and social and role responsibilities depending on the severity.
Assess the cause of fatigue. 

Fatigue may derive from multiple sources, such as limited oxygen-carrying ability due to reduced red blood cells and other medical problems such as comorbidities or depression.
Assess for factors that may contribute to fatigue. 

Poor nutrition and inadequate amounts of sleep may further worsen symptoms of fatigue. In addition, certain anemias such as iron deficiency anemia and vitamin B-12 anemia nutrition plays an important part. Iron, vitamin-12, and folate are needed to produce red blood cells.
Monitor hematocrit, hemoglobin, RBC count, and reticulocyte count.

A decreased value may indicate a reduced ability of the blood to carry oxygen. Serial lab work allows for close monitoring for changes and worsening of anemia.
Teach energy-conserving techniques. 

Delegation, prioritizing tasks, and grouping tasks may help conserve energy and reduce fatigue. 
Help guide the patient with prioritizing activities for the day. 

Prioritizing is a helpful technique to conserve energy. Most essential tasks can be completed in the morning when energy levels are the highest. Not all self-care and housework responsibilities need to be completed in one sitting or day. 
Assist with creating a daily plan that is achievable. 

Daily schedules help the patient visualize all to-dos that need to be completed without being overwhelming. In addition, planning rest periods ensures to keep fatigue levels low. 
Teach about RBCs stimulating medication if ordered.

Erythropoietin helps stimulate RBC production and reduces the need for blood transfusions. 
Anticipate the need for blood transfusions. 

Packed red blood cell transfusions help increase oxygen-carrying capacity.

Deficient Knowledge r/t complexity of the disease

Expected Outcome: The patient will have an enhanced knowledge about the disease process as evidenced by explaining the disease and treatment plan. 

Assess the patient’s and family’s familiarity with the medical terminology. 

Most people are not familiar with hematological diseases and therefore don’t understand medical terms used by doctors and nurses. 
Assess current knowledge about the disease. 

An initial knowledge base provides a good starting point in the education process. Some informational points may need reiteration, while others may be well known. For example, most people understand the term anemia and what it means but lack specific knowledge about certain types of anemia. 
Explain standard terms used in context with anemia and cover the function of blood and blood cells. 

Patients usually don’t know the hematological system on a cellular level.
Explain diagnostic tests and procedures. 

Often multiple tests and procedures are necessary for diagnosis.
Patient education for iron deficiency: 

Teach about foods containing iron, folic acid, and vitamin B-12

Food sources containing nutrients to produce red blood cells are red meat, organ meat, egg yolk, kidney beans, and green leafy vegetables.
Instruct the patient to take iron supplements with meals.

Taking iron with food increases absorption and reduces gastrointestinal irritation. 
Inform the patient that stools may look darker or green while taking iron supplements. 

Patients need to be aware that a change in stool color to dark green is normal while still monitoring for black tarry stools, which may indicate gastrointestinal bleeding. 
Tell patients to take liquid iron with a straw and follow up with oral care. 

Iron may stain the teeth.
Use the Z-track method for intramuscular injections. 

This technique prevents leakage into the subcutaneous tissues.
Patient education for vitamin B-12 deficiency:

Teach about food sources high in vitamin B-12.

Examples are animal protein, fish, eggs, nuts, dairy products, and citrus fruits. For pernicious anemia, educate about the need for vitamin B-12 shots. The injections may start weekly and transition to monthly. These injections may have to be given for the rest of the patient’s life.
Patient education for sickle cell anemia: 

Teach about sickle cell crisis prevention.

Drink plenty of fluids daily 
Stay current on immunizations
Avoid strenuous physical activities 
Avoid extremely hot or cold environments
Avoid alcohol and smoking 

Specific activities mentioned above may lead to a sickle cell crisis. Therefore, it is important to prevent situations where the individual becomes hypoxic or hypoxemic.
Offer resources for genetic counseling. 

Patients need to be informed about the hereditary aspect of sickle cell anemia.
Patient education for aplastic anemia: 

Educate about bone marrow transplant as a treatment option. 

Hematopoietic stem cell transplantation with donor cells has the highest success rate in treating aplastic anemia. 
Explain that after bone transplant, the patient will have to take anti-rejection medication to prevent rejection of the donated stem cells. 

If the patient is not a candidate for bone marrow transplantation, immunosuppression could be a treatment option. Patients that are not candidates or whose anemia is due to autoimmune disease may benefit from treatment with medications that suppress the immune system. 

Acute Pain r/t tissue hypoxia

This nursing diagnosis pertains to sickle cell anemia. In sickle cell anemia, red blood cells lose their normal shape and become sickle-shaped. These deformed blood cells can get stuck in small blood vessels and block the blood flow to tissues causing a lack of oxygen supply and, therefore, pain.

Expected outcome: 

  • Patient will demonstrate a controlled pain rating of no more than 2/10 
  • Patient will adhere to the pain medication regimen 
  • Patient will verbalize factors that exacerbate a sickle cell crisis and ways to avoid them.
Assess the patient’s pain level at least every four hours and as needed using a numeric or faces pain scale. 

Using the pain scale allows the healthcare team to appropriately treat pain and follow up on the effectiveness of pain medication. In addition, frequent pain assessment is necessary because pain can be very sudden and unpredictable. 
Assess the type of pain. Acute, chronic, or a mixture of two kinds. 

Patients with sickle cell anemia have different types of pain. Acute pain manifests suddenly and unpredictably during, for example, a crisis episode and chronic pain from already damaged tissues and organs. Both types of pain need to be considered during treatment.
Assess for the need for physiotherapy and other non-pharmacological pain relief methods. 

Some patients with chronic joint pain from the disease may benefit from supplemental approaches. 
Provide adequate hydration either via oral liquids or intravenous fluids. 

Keeping hydrated is essential because it helps slow down the sickling process by decreasing blood viscosity and preventing red blood cells from sticking together.
Administer blood transfusions as ordered. 

Blood products help increase the number of normal red blood cells and reduce the number of faulty red blood cells. As a result, more cells can now carry oxygen to the tissues, decreasing pain caused by hypoxic tissues.
Administer pain medication as ordered. 

It is important to treat pain in acute episodes and pain that is chronic from tissue damage.
Encourage complementary therapies. 

Other pain-relieving measures such as keeping the room at a warm temperature, applying warm compresses, offering warm blankets, teaching relaxation techniques, distraction, and frequent positioning, can all help reduce pain.

Risk for Bleeding

Risk factor: Malfunctioning bone marrow 

Assess for signs of bleeding. 

Bleeding can occur in obvious and not obvious ways. The most common sites for spontaneous bleeding are the nose, gums, and the urinary or gastrointestinal tract.
Monitor lab values such as hematocrit, hemoglobin, and platelet count closely. 

Hematocrit and hemoglobin may be chronically low with certain anemias. In addition, platelet count may be affected by aplastic anemia. In aplastic anemia, the bone marrow is malfunctioning. However, any blood cells, including platelets, are produced in the bone marrow. Therefore, defective bone marrow may cause thrombocytopenia (low platelet count).
Note any signs on the skin that indicate bleeding. 

Petechiae and bruising may occur on the skin as a result of bleeding. Petechiae can occur in clusters and appear like a rash on the skin. It usually does not blanch and can be found anywhere on the body, including the inside of the mouth and the eyelids. 
Assess stool and urine for occult (not visible) blood. 

If there is suspicion of bleeding that is not obvious, an occult stool test and a urine analysis may be ordered. These tests can also help clarify the origin of bleeding.
Instruct the patient on bleeding precautions.

Use a soft-bristled toothbrush
Do not floss between teeth 
Avoid contact sports 
Avoid handling sharp objects 
Avoid blowing the nose or scratching inside of the nose 
Use an electric razor when shaving 
Wear shoes or slippers; do not walk barefoot 
Use stool softeners to prevent straining
Avoid bending at the waist 
Do not wear tight or rubbing clothes 
Apply firm pressure for at least 5 minutes to a bleeding area

The activities mentioned above may increase the risk of bleeding if the patient’s platelet count is below 50,000/mm3.
Teach about when to call the doctor. 

Bleeding from a body part 
Abdominal pain 
Dark bowel movements 
Blood in stool or urine
 Petechiae and bruising
Headache that does not respond to acetaminophen

Any of these signs may indicate bleeding.
Anticipate the need for blood product transfusions. 

If hematocrit, hemoglobin, or platelet count falls below a certain threshold and the patient becomes symptomatic, the physician may order blood products such as packed red blood cells and platelets.

More Care Plans:

Acute Pain

Knowledge Deficit

Fatigue

Risk for Bleeding

Ineffective Tissue Perfusion

Impaired Gas Exchange

References:

Anemia – Symptoms and causes. Mayo Clinic. (2022). Retrieved 9 June 2022, from https://www.mayoclinic.org/diseases-conditions/anemia/symptoms-causes/syc-20351360.

Moawad, H. (2021). Find out Why Your Red Blood Cell Function Might Be Impaired. Verywell Health. Retrieved 9 June 2022, from https://www.verywellhealth.com/anemia-causes-4783780.

Lights, V., & Seladi-Schulman, Ph.D, J. (2021). What You Need to Know About Anemia. Healthline. Retrieved 9 June 2022, from https://www.healthline.com/health/anemia.

7 Risk Factors That Could Lead to Anemia – Lindenberg Cancer & Hematology Center Marlton, NJ 08053. Lindenberg Cancer & Hematology Center Marlton, NJ 08053. Retrieved 9 June 2022, from https://lindenbergcancer.com/blog/7-risk-factors-that-could-lead-to-anemia/.

Iron-Deficiency Anemia. Hematology.org. Retrieved 9 June 2022, from https://www.hematology.org/education/patients/anemia/iron-deficiency.

Anemia: Symptoms, Types, Causes, Risks, Treatment & Management. Cleveland Clinic. (2020). Retrieved 9 June 2022, from https://my.clevelandclinic.org/health/diseases/3929-anemia.

Badireddy, M., Baradhi, K., & (Hughes), A. (2022). Chronic Anemia (Nursing). Ncbi.nlm.nih.gov. Retrieved 9 June 2022, from https://www.ncbi.nlm.nih.gov/books/NBK568790/.
Aplastic anemia – Diagnosis and treatment – Mayo Clinic. Mayoclinic.org. (2022). Retrieved 9 June 2022, from https://www.mayoclinic.org/diseases-conditio

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