Anemia Nursing Care Management: A Study Guide

Anemia is not a disease in itself, it is a sign that something else is wrong. At the bedside it shows up as fatigue, tachycardia, dyspnea, and pallor as the blood loses its capacity to carry oxygen. Find the cause, support oxygenation, and manage the fatigue.

What is Anemia?

Anemia is a condition in which the hemoglobin concentration is lower than normal, reflecting fewer erythrocytes in the circulation than expected. It is the most common hematologic condition and points to an underlying disorder rather than standing alone.

Classification

A physiologic approach classifies anemia by whether the erythrocyte deficiency comes from defective production, destruction, or loss.

• Hypoproliferative anemias. The marrow cannot produce enough erythrocytes.
• Hemolytic anemias. Premature destruction of erythrocytes releases hemoglobin into the plasma, where it converts to bilirubin, so bilirubin rises.
• Bleeding anemias. Caused by loss of erythrocytes from the body.

Pathophysiology

The pathophysiology follows the cause.

Hypoproliferative Anemia

Decreased erythrocyte production shows as an inappropriately normal or low reticulocyte count. Marrow damage from medications, chemicals, or a lack of needed factors leaves inadequate erythrocyte production.

Hemolytic Anemia

Premature destruction of erythrocytes liberates hemoglobin into the plasma, most of which converts to bilirubin, so bilirubin runs high. The increased destruction causes tissue hypoxia, which stimulates erythropoietin production. That shows as a rising reticulocyte count as the marrow responds to the loss. Hemolysis is the end result, arising from an abnormality within the erythrocyte itself, within the plasma, or from direct injury to the erythrocyte in the circulation.

Causes

You can usually tell whether anemia is from destruction or inadequate production by three things: the marrow's response (rising reticulocyte count in circulating blood), the degree to which young erythrocytes proliferate and mature in the marrow (seen on biopsy), and the presence or absence of end products of erythrocyte destruction in the circulation.

Clinical Manifestations

The faster anemia develops, the more aggressive the symptoms. A patient with anemia has hemoglobin between 9 to 11 g/dL. Fatigue follows from inadequate tissue oxygen. The heart compensates with tachycardia, pumping more blood to reach peripheral tissue. Dyspnea comes from lower blood oxygen. With less hemoglobin, the pigment in red cells, the patient looks pale.

Prevention

Lifestyle changes help. Iron-rich foods add to the body's hemoglobin, and iron supplements raise hemoglobin levels.

Complications

• Heart failure. The heart pumps faster to compensate until the muscle wears out and fails.
• Paresthesias. Develop when muscles lack delivered oxygen.
• Delirium. Insufficient oxygen to the brain, a fatal complication of anemia.

Assessment and Diagnostic Findings

Several hematologic studies pin down the type and cause.

• Blood studies. Initial workup uses hemoglobin, hematocrit, reticulocyte count, and RBC indices, especially mean corpuscular volume and red cell distribution width.
• Iron studies. Serum iron, total iron binding capacity, percent saturation, ferritin, plus serum vitamin B12 and folate.
• CBC values. The rest of the CBC shows whether anemia is isolated or part of another hematologic condition.

Medical Management

Management is directed at correcting or controlling the cause.

• Nutritional supplements. Teach the patient and family that overuse will not improve anemia.
• Blood transfusion. Patients with acute blood loss or severe hemolysis may have decreased tissue perfusion from low blood volume or reduced circulating erythrocytes, so transfusion may be needed.
• IV fluids. Replace lost blood volume or electrolytes to restore normal levels.

Nursing Management

Nursing Assessment

• Health history and physical exam. Point to the type of anemia, the extent and type of symptoms, and their impact on the patient's life.
• Medication history. Some drugs depress marrow activity, induce hemolysis, or interfere with folate metabolism.
• Alcohol history. Get an accurate account of amount and duration.
• Family history. Some anemias are inherited.
• Athletic endeavors. Extreme exercise can decrease erythropoiesis and erythrocyte survival.
• Nutritional assessment. May reveal deficiencies in iron, vitamin B12, and folic acid.

Diagnosis

• Fatigue related to decreased hemoglobin and diminished oxygen-carrying capacity.
• Altered nutrition, less than body requirements, related to inadequate intake of essential nutrients.
• Altered tissue perfusion related to insufficient hemoglobin and hematocrit.

Planning & Goals

Goals: decreased fatigue, adequate nutrition, adequate tissue perfusion, compliance with prescribed therapy, and absence of complications.

Nursing Interventions

To manage fatigue, help the patient prioritize activities and strike a balance between activity and rest. Patients with chronic anemia still need some physical activity and exercise to prevent the deconditioning that comes with inactivity.

To maintain nutrition, encourage a diet packed with essential nutrients, tell the patient that alcohol interferes with nutrient use and to avoid or limit it, and individualize dietary teaching with family members and cultural food preferences in mind.

To maintain perfusion, monitor vital signs and pulse oximeter readings closely during transfusion.

To promote compliance, help the patient fold the therapeutic plan into everyday activities. Patients on high-dose corticosteroids may need help obtaining insurance coverage or alternative ways to get their medications.

Evaluation

Expected outcomes: reports less fatigue, attains and maintains adequate nutrition, maintains adequate perfusion, and has no complications.

Discharge and Home Care Guidelines

Instruct the patient to eat iron-rich foods to build hemoglobin stores, enforce strict compliance with prescribed iron supplements, and stress regular medical and lab followup to track disease progression and response to therapy.

Documentation Guidelines

Document baseline and subsequent assessment findings including signs and symptoms; cultural or religious restrictions and personal preferences; plan of care and persons involved; teaching plan; the client's responses to teaching, interventions, and actions performed; attainment of or progress toward the desired outcome; and long-term needs and who is responsible for actions to be taken.