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
•
Paresthesias
•
Confusion
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.
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