Anemia

Anemia is a condition in which the hemoglobin concentration is lower than normal; it reflects the presence of fewer than the normal number of erythrocytes within the circulation. As a result, the amount of oxygen delivered to body tissues is also diminished. Anemia is not a specific disease state but a sign of an underlying disorder. It is by far the most common hematologic condition. A physiologic approach classifies anemia according to whether the deficiency in erythrocytes is caused by a defect in their production (hypoproliferative anemia), by their destruction (hemolytic anemia), or by their loss (bleeding).

Complications

General complications of severe anemia include heart failure, paresthesias, and delirium. Patients with underlying heart disease are far more likely to have angina or symptoms of heart failure than those without heart disease.

Aside from the severity of the anemia itself, several factors influence the development of anemia-associated symptoms: the rapidity with which the anemia has developed, the duration of the anemia (i.e., its chronicity), the metabolic requirements of the patient, other concurrent disorders or disabilities (e.g., cardiac, pulmonary, or renal disease), and complications or concomitant features of the condition that produced the anemia. In general, the more rapidly an anemia develops, the more severe are its symptoms. Pronounced symptoms of anemia include the following:

Dyspnea, chest pain, muscle pain or cramping, tachycardia
Weakness, fatigue, general malaise
Hemoglobin level less than 11 g/dL
Pallor of the skin and mucous membranes (conjunctivae, oral mucosa)
Jaundice (megaloblastic or hemolytic anemia)
Smooth, red tongue (iron-deficiency anemia)
Beefy, red, sore tongue (megaloblastic anemia)
Angular cheilosis (ulceration of the corner of the mouth)
Brittle, ridged, concave nails and pica (unusual craving for substances not normally considered food, such as starch, dirt, ice, etc.) are most often associated with iron-deficiency anemia.

Complete hematologic studies (e.g., hemoglobin, hematocrit, reticulocyte count, and red blood cell [RBC] indices, particularly the mean corpuscular volume [MCV] and RBC distribution width [RDW])
Iron studies (serum iron level, total iron-binding capacity [TIBC], percent saturation, and ferritin)
Serum vitamin B₁₂ and folate levels; haptoglobin and erythropoietin levels
Bone marrow aspiration
Other studies as indicated to determine underlying hematologic condition or chronic illness.

Management of anemia is directed toward correcting or controlling the cause of the anemia; if the anemia is severe, the erythrocytes that are lost or destroyed may be replaced with a transfusion of packed RBCs (PRBCs).

Gerontologic Considerations

Anemia is the most common hematologic condition affecting older patients, particularly those admitted to hospitals or in long-term care facilities. The overall prevalence of anemia increases with age, from 10% in persons 65 years of age to 50% in persons older than 85 years.

The impact of anemia on function is significant and may include decreased mobility, increased depression, increased risk of falling, and delirium when hospitalized. Prevalence increases particularly for those admitted to hospitals and long-term care facilities with increased risk for mortality when anemic for those with pre-existing renal or cardiac disease or for those who have had recent surgery.

The Patient With Anemia

Assessment

Obtain a health history with a medication and alcohol intake history, including OTC drugs and herbal supplements; perform a physical examination.
Ask patient about extent and type of symptoms experienced and impact of symptoms on lifestyle; medication history; alcohol intake; and athletic endeavors (extreme exercise).
Obtain a family history of inherited anemias.
Perform nutritional assessment: Ask about dietary habits resulting in nutritional deficiencies, such as those of iron, vitamin B₁₂, and folic acid.
Obtain and monitor relevant laboratory test results; note changes.
Assess cardiac status (for symptoms of increased workload or heart failure): tachycardia, palpitations, dyspnea, dizziness, orthopnea, exertional dyspnea, cardiomegaly, hepatomegaly, and peripheral edema.
Assess patient for gastrointestinal function: nausea, vomiting, diarrhea, melena or dark stools, occult blood, anorexia, glossitis; women should be questioned about their menstrual periods (e.g., excessive menstrual flow, other vaginal bleeding) and the use of iron supplements during pregnancy.
Assess patient for neurologic deficits (important with pernicious anemia): presence and extent of peripheral numbness and paresthesias, ataxia, poor coordination, confusion.

Diagnosis

Nursing Diagnoses

Fatigue related to decreased hemoglobin and diminished oxygen-carrying capacity of the blood
Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients
Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit
Noncompliance with prescribed therapy

Collaborative Problems/Potential Complications

Heart failure
Angina
Paresthesias
Injury related to falls
Depressed mood
Confusion

Planning and Goals

The major goals for the patient may include decreased fatigue, attainment or maintenance of adequate nutrition, maintenance of adequate tissue perfusion, compliance with prescribed therapy, and absence of complications.

Nursing Interventions

Managing Fatigue

Assist patient to prioritize activities and establish a balance between activity and rest.
Encourage patient with chronic anemia to maintain physical activity and exercise to prevent deconditioning.
Assess patient for other conditions that can exacerbate fatigue, such as pain, depression, and sleep disturbance.

Maintaining Adequate Nutrition

Encourage a healthy diet with essential nutrients, such as iron, vitamin B₁₂, folic acid, and protein.
Instruct patient to avoid or limit intake of alcohol.
Plan dietary education sessions for patient and family; consider cultural aspects of nutrition.
Discuss nutritional supplements (e.g., vitamins, iron, folate, protein) as prescribed.

Maintaining Adequate Perfusion

Monitor patient's vital signs and pulse oximeter readings closely, and adjust or withhold medications (antihypertensives) as indicated.
Administer supplemental oxygen, transfusions, and IV fluids as prescribed.

Promoting Compliance With Prescribed Therapy

Discuss with patient the purpose of their medication, ways to take the medication and over what time period, and how to manage any side effects; ensure that patient knows that abruptly stopping some medications can have serious consequences.
Assist the patient to incorporate the therapeutic plan into everyday activities, rather than merely giving patient a list of instructions.
Provide patient assistance to obtain needed insurance coverage for expensive medications (e.g., growth factors) or to explore alternative ways to obtain these medications.

Monitoring and Managing Complications

Assess patient with anemia for heart failure.
Perform a neurologic assessment for patients with known or suspected megaloblastic anemia.
Evaluate patient's gait, balance, and any complaint of paresthesias.

Evaluation

Expected Patient Outcomes

Reports less fatigue
Attains and maintains adequate nutrition
Maintains adequate perfusion
Displays absence of complications

For more information, see Chapter 33 in Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth's textbook of medical-surgical nursing (14th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Outline

Assessment
Diagnosis
Planning and Goals
Nursing Interventions
Evaluation

section name header

Introduction ⬇

Clinical Manifestations ⬆ ⬇

Assessment and Diagnostic Findings ⬆ ⬇

Medical Management ⬆ ⬇

Gerontologic Considerations ⬆ ⬇

Nursing Process ⬆