NURSING PROCESS: THE PATIENT WITH ANEMIA
The health history and physical examination provide important data about the type of anemia involved, the extent and type of symptoms it produces, and the impact of those symptoms on the patient’s life. Weakness, fatigue, and general malaise are com-mon, as are pallor of the skin and mucous membranes (sclera, oral mucosa).
Jaundice may be present in patients with megaloblastic anemia or hemolytic anemia. The tongue may be smooth and red (in iron deficiency anemia) or beefy red and sore (in megaloblastic ane-mia); the corners of the mouth may be ulcerated (angular cheilo-sis) in both types of anemia. Individuals with iron deficiencyanemia may crave ice, starch, or dirt (known as pica); their nails may be brittle, ridged, and concave.
The health history should include a medication history, because some medications can depress bone marrow activity or interfere with folate metabolism. An accurate history of alcohol intake, in-cluding the amount and duration, should be obtained. Family his-tory is important, because certain anemias are inherited. Athletic endeavors should be assessed, because extreme exercise can decrease erythropoiesis and RBC survival in some athletes.
A nutritional assessment is important, because it may indi-cate deficiencies in essential nutrients such as iron, vitamin B12, and folic acid. Children of indigent families may be at higher risk for anemia because of nutritional deficiencies. Strict vegetarians are also at risk for megaloblastic types of anemia if they do not supplement their diet with vitamin B12.
Cardiac status should be carefully assessed. When the hemo-globin level is low, the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tis-sue. This increased cardiac workload can result in such symptoms as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepato-megaly) and by peripheral edema.
Assessment of the gastrointestinal system may disclose com-plaints of nausea, vomiting (with specific questions as to the appearance of any emesis [eg, looks like “coffee grounds”]), me-lena or dark stools, diarrhea, anorexia, and glossitis (inflammation of the tongue). Stools should be tested for occult blood. Women should be questioned about their menstrual periods (eg, excessive menstrual flow, other vaginal bleeding) and the use of iron sup-plements during pregnancy.
The neurologic examination is also important because of the effect of pernicious anemia on the central and peripheral nervous systems. Assessment should include the presence and extent of peripheral numbness and paresthesias, ataxia, poor coordination, and confusion. Finally, it is important to monitor relevant labo-ratory test results and to note any changes over time.
Based on the assessment data, major nursing diagnoses for the anemic patient may include:
• Activity intolerance related to weakness, fatigue, and gen-eral malaise
• Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients
• Ineffective tissue perfusion related to inadequate blood vol-ume or hematocrit
• Noncompliance with prescribed therapy
Based on the assessment data, potential complications that may develop include:
• Heart failure
The major goals for the patient may include increased tolerance of normal activity, attainment or maintenance of adequate nutri-tion, maintenance of adequate tissue perfusion, compliance with prescribed therapy, and absence of complications.
The most frequent symptom and complication of anemia is fa-tigue. This distressing symptom is too often minimized by health care providers. Fatigue is often the symptom that has the greater negative impact on the individual’s level of functioning and con-sequent quality of life. Patients describe the fatigue from anemia as oppressive. Fatigue can be significant, yet the anemia may not be severe enough to warrant transfusion. Fatigue can interfere with an individual’s ability to work, both inside and outside the home. It can harm relationships with family and friends. Patients often lose interest in hobbies and activities, including sexual ac-tivity. The distress from fatigue is often related to an individual’s responsibilities and life demands as well as the amount of assis-tance and support received from others.
Nursing interventions can focus on assisting the patient to pri-oritize activities and to establish a balance between activity and rest that is realistic and feasible from the patient’s perspective. Patients with chronic anemia need to maintain some physical activity and exercise to prevent the deconditioning that results from inactivity.
Inadequate intake of essential nutrients, such as iron, vitamin B12, folic acid, and protein can cause some anemias. The symptoms as-sociated with anemia (eg, fatigue, anorexia) can in turn interfere with maintaining adequate nutrition. A healthy diet should be en-couraged. Because alcohol interferes with the utilization of essen-tial nutrients, the nurse should advise the patient to avoid alcoholic beverages or to limit their intake and should provide the rationale for this recommendation. Dietary teaching sessions should be individualized, including cultural aspects related to food preferences and food preparation. The involvement of family members enhances compliance with dietary recommendations. Dietary supplements (eg, vitamins, iron, folate, protein) may be prescribed as well.
Equally important, the patient and family must understand the role of nutritional supplements in the proper context, because many forms of anemia are not the result of a nutritional deficiency. In such cases, excessive intake of nutritional supplements will not improve the anemia. A potential problem in individuals with chronic transfusion requirements occurs with the indiscriminate use of iron. Unless an aggressive program of chelation therapy is implemented, these individuals are at risk for iron overload from their transfusions alone. The addition of an iron supplement only exacerbates the situation.
Patients with acute blood loss or severe hemolysis may have de-creased tissue perfusion from decreased blood volume or re-duced circulating RBCs (decreased hematocrit). Lost volume is replaced with transfusions or intravenous fluids, based on the symptoms and the laboratory findings. Supplemental oxygen may be necessary, but it is rarely needed on a long-term basis unless there is underlying severe cardiac or pulmonary disease as well. The nurse monitors vital signs closely; other medications, such as antihypertensive agents, may need to be adjusted or withheld.
For patients with anemia, medications or nutritional supplements are often prescribed to alleviate or correct the condition. These pa-tients need to understand the purpose of the medication, how to take the medication and over what time period, and how to man-age any side effects of therapy. To enhance compliance, the nurse can assist patients in developing ways to incorporate the therapeu-tic plan into their lives, rather than merely giving the patient a list of instructions. For example, many patients have difficulty taking iron supplements because of related gastrointestinal effects. Rather than seeking assistance from a health care provider in managing the problem, some of these patients simply stop taking the iron.
Abruptly stopping some medications can have serious conse-quences, as in the case of high-dose corticosteroids to manage he-molytic anemias. Some medications, such as growth factors, are extremely expensive. Patients receiving these medications may need assistance with obtaining needed insurance coverage or with exploring alternatives for obtaining these medications.
A significant complication of anemia is heart failure from chronic diminished blood volume and the heart’s compensatory effort to increase cardiac output. Patients with anemia should be assessed for signs and symptoms of heart failure. A serial record of body weights can be more useful than a record of dietary intake and output, because the intake and output measurements may not be accurate. In the case of fluid retention resulting from congestive heart failure, diuretics may be required.
In megaloblastic forms of anemia, the significant potential complications are neurologic. A neurologic assessment should be performed for patients with known or suspected megaloblastic anemia. Patients may initially complain of paresthesias in their lower extremities. These paresthesias are usually manifested as numbness and tingling on the bottom of the foot, and they grad-ually progress. As the anemia progresses and damage to the spinal cord occurs, other signs become apparent. Position and vibration sense may be diminished; difficulty maintaining balance is not uncommon, and some patients have gait disturbances as well. Ini-tially mild but gradually progressive confusion may develop.
Expected patient outcomes may include:
1) Tolerates activity at a safe and acceptable level
a) Follows a progressive plan of rest, activity, and exercise
b) Prioritizes activities
c) Paces activities according to energy level
2) Attains and maintains adequate nutrition
a) Eats a healthy diet
b) Develops meal plan that promotes optimal nutrition
c) Maintains adequate amounts of iron, vitamins, and protein from diet or supplements
d) Adheres to nutritional supplement therapy when pre-scribed
e) Verbalizes understanding of rationale for using recom-mended nutritional supplements
f) Verbalizes understanding of rationale for avoiding non-recommended nutritional supplements
3) Maintains adequate perfusion
a) Has vital signs within baseline for patient
b) Has pulse oximetry (arterial oxygenation) value within normal limits
4) Absence of complications
a) Avoids or limits activities that cause dyspnea, palpita-tions, dizziness, or tachycardia
b) Uses rest and comfort measures to alleviate dyspnea
c) Has vital signs within baseline for patient
d) Has no signs of increasing fluid retention (eg, peripheral edema, decreased urine output, neck vein distention)
e) Remains oriented to time, place, and situation
f) Ambulates safely, using assistive devices as necessary
g) Remains free of injury
h) Verbalizes understanding of importance of serial CBC measurements
i) Maintains safe home environment; obtains assistance as necessary.