Nursing Care Management of

Patients with Anemia

By Sawiji, S.Kep., Ns., M.Sc

Mobile phone: 081 328 028333
E-mail: sawijiamani@gmail.com

BASIC SCIENCE DEPARTMENT

MUHAMMADIYAH UNIVERSITY OF GOMBONG
CENTRAL JAVA INDONESIA
Table of contents

• What is Anemia • Assessment and Diagnostic Findings

• Classification • Medical Management
• Pathophysiology • Nursing Management
• Nursing Assessment
• Hypoproliferative Anemia
• Diagnosis
• Hemolytic Anemia
• Planning & Goals
• Causes • Nursing Interventions
• Clinical Manifestations • Evaluation
• Prevention • Discharge and Home Care Guidelines
• Complications • Documentation Guidelines
What is Anemia

• Anemia is a condition that is slowly rising in cases across all countries. Every
age and every stage can be affected by anemia, and though others may
consider this as a simple condition, it could blow out of proportion if left
untreated.

• Anemia is a condition in which the hemoglobin concentration is lower than

normal.
• Anemia reflects the presence of fever than the normal number of
erythrocytes within the circulation.
• Anemia is not a specific disease state but an underlying disorder and the most
common hematologic condition.
Classification

• A physiologic approach classifies anemia according to whether the deficiency in

erythrocytes is caused by a defect in their production, by their destruction, or by
their loss.

• Hypoproliferative anemias. In hypoproliferative anemias, the marrow cannot

produce adequate numbers of erythrocytes.
• Hemolytic anemias. There is premature destruction of erythrocytes that results in
the liberation of hemoglobin from the erythrocytes into the plasma; the released
hemoglobin is then converted into bilirubin, therefore bilirubin concentration rises.
• Bleeding anemias. Bleeding anemias are caused by the loss of erythrocytes in the
body.
Pathophysiology

• The pathophysiology of anemias is drawn according to the cause of the

disease.

• Hypoproliferative Anemia
• Decreased erythrocyte production. There is decreased erythrocyte
production, reflected by an inappropriately normal or low reticulocyte
count.
• Marrow damage. As a result of marrow damage, inadequate
production of erythrocyte occurs due to the medications or chemicals
or from a lack of factors.
• Hemolytic Anemia
• Premature destruction. Premature destruction of erythrocytes results in the liberation
of hemoglobin from the erythrocytes into the plasma.
• Conversion. The released hemoglobin is converted in large part to bilirubin, resulting in
high concentration of bilirubin.
• Erythropoietin production. The increased erythrocyte destruction leads to tissue
hypoxia which stimulates erythropoietin production.
• Increased reticulocytes. This increased production is reflected in an increased
reticulocyte count as the bone marrow responds to the loss of erythrocytes.
• Hemolysis. Hemolysis is the end result, which can result from an abnormality within
the erythrocyte itself or within the plasma, or from direct injury to the erythrocyte
within the circulation.
Causes

• It is usually possible to determine whether the presence of anemia is caused

by destruction or inadequate production of erythrocytes on the basis of the
following factors.

• Response. The marrow’s response to decreased erythrocytes as evidenced by

an increased reticulocyte count in the circulation blood.
• Proliferation. The degree to which young erythrocytes proliferate in the bone
marrow and the manner in which they mature as observed in the bone
marrow biopsy.
• Destruction. The presence or absence of end products of erythrocyte
destruction within the circulation.
• Clinical Manifestations
• In general, the more rapidly the anemia develops, the more
aggressive is its symptoms.
• Decreased hemoglobin. A patient with anemia has hemoglobin levels
between 9 to 11 g/dL.
• Fatigue. Fatigue occurs because there is inadequate oxygen levels in the
tissues that should have been carried by hemoglobin.
• Tachycardia. The heart compensates for the decrease in oxygen by pumping
out more blood so it can reach peripheral tissues in the body.
• Dyspnea. Difficulty of breathing occurs because of the decreased
concentrations of oxygen in the blood.
• With decreased hemoglobin that serves as the pigment in the red blood cells,
the patient may become pale because of the lack or decrease in the pigment
that is hemoglobin.
Prevention

• To prevent anemia, lifestyle modifications must be made.

• Diet rich in iron. Ingestion of iron-rich foods could help prevent

anemia because it adds to the hemoglobin in the body.
• Iron supplements. Iron supplements can also be taken to increase the
hemoglobin levels in the body.
Complications

• Anemia has general complications and this includes:

• Heart failure. As the heart compensates by pumping faster than the

normal rate, the heart muscles gradually weaken until the muscles
wear out and the heart fails to function.
• Paresthesias. Paresthesias develop when the muscles do not have
enough oxygen delivered to them.
• Delirium. Insufficient oxygen in the brain results in delirium and is
considered a fatal complication of anemia.
Assessment and Diagnostic Findings

• A number of hematologic studies are performed to determine the type and

cause of anemia.

• Blood studies. In an initial evaluation, the hemoglobin, hematocrit, reticulocyte

count, and RBC indices, particularly the mean corpuscular volume and red cell
distribution width are taken to assess for the presence of anemia.
• Iron studies. Serum iron level, total iron binding capacity, percent saturation,
and ferritin, as well as serum vitamin B12 and folate levels, are all useful in
diagnosing anemia.
• CBC values. The remaining CBC values are useful in determining whether the
anemia is an isolated problem or part of another hematologic condition.
Medical Management

• Management of anemia is directed towards correcting or controlling the

cause of anemia.

• Nutritional supplements. Use of nutritional supplements should be

appropriately taught to the patient and the family because too much intake
cannot improve anemia.
• Blood transfusion. Patients with acute blood loss or severe hemolysis may
have decreased tissue perfusion from decreased blood volume or reduced
circulating erythrocytes, so transfusion of blood would be necessary.
• Intravenous fluids. Intravenous fluids replace the lost volumes of blood or
electrolytes to restore them to normal levels.
Nursing Management

• The management of anemia by nurses should be accurate and

appropriate so that objectives and goals would be achieved.
Nursing Assessment

• The assessment of anemia involves:

• Health history and physical exam. Both 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.
• Medication history. Some medications can depress bone marrow activity, induce hemolysis, or
interfere with folate metabolism.
• History of alcohol intake. An accurate history of alcohol intake including the amount and
duration should be obtained.
• Family history. Assessment of family history is important because certain anemias are inherited.
• Athletic endeavors. Assess if the patient has any athletic endeavor because extreme exercise can
decrease erythropoiesis and erythrocyte survival.
• Nutritional assessment. Assessing the nutritional status and habits is important because it may
indicate deficiencies in essential nutrients such as iron, vitamin B12, and folic acid.
Diagnosis

• Based on the assessment data, major nursing diagnosis for patients

with anemia include:

• Fatigue related to decreased hemoglobin and diminished oxygen-

carrying capacity of the blood.
• Altered nutrition, less than body requirements, related to inadequate
intake of essential nutrients.
• Altered tissue perfusion related to insufficient hemoglobin and
hematocrit.
Planning & Goals

• The major goals for a patient with anemia include:

• Decreased fatigue
• Attainment or maintenance of adequate nutrition.
• Maintenance of adequate tissue perfusion.
• Compliance with prescribed therapy.
• Absence of complications.
Nursing Interventions

• Nursing interventions are based on the data assessed by the nurse and on the
symptoms that the patient manifests.

• To manage fatigue:

• Prioritize activities. Assist the patient in prioritizing activities and establishing

balance between activity and rest that would be acceptable to the patient.
• Exercise and physical activity. Patients with chronic anemia need to maintain
some physical activity and exercise to prevent the deconditioning that results
from inactivity.
• To maintain adequate nutrition:

• Diet. The nurse should encourage a healthy diet that is packed with
essential nutrients.
• Alcohol intake. The nurse should inform the patient that alcohol
interferes with the utilization of essential nutrients and should advise
the patient to avoid or limit his or her intake of alcoholic beverages.
• Dietary teaching. Sessions should be individualized and involve the
family members and include cultural aspects related to food preference
and preparation.
• To maintain adequate perfusion:

• Blood transfusion monitoring. The nurse should monitor the patient’s

vital signs and pulse oximeter readings closely.
• To promote compliance with prescribed therapy:

• Enhance compliance. The nurse should assist the patient to develop

ways to incorporate the therapeutic plan into everyday activities.
• Medication intake. Patients receiving high-dose corticosteroids may
need assistance to obtain needed insurance coverage or to explore
alternative ways to obtain these medications.
Evaluation

• Included in the expected patient outcomes are the following:

• Reports less fatigue.

• Attains and maintains adequate nutrition.
• Maintains adequate perfusion.
• Absence of complications.
Discharge and Home Care Guidelines

• Health education is the main focus during discharge and for the home
care.

• Instruct the patient to consume iron-rich foods to help build-up

hemoglobin stores.
• Iron supplements. Enforce strict compliance in taking iron
supplements as prescribed by the physician.
• Follow-up. Stress the need for regular medical and laboratory follow-
up to evaluate disease progression and response to therapies.
Documentation Guidelines

• The data to be documented consists the following:

• Baseline and subsequent assessment findings to include signs and symptoms.

• Individual cultural or religious restrictions and personal preferences.
• Plan of care and persons involved.
• Teaching plan.
• Client’s responses to teachings, interventions, and actions performed.
• Attainment or progress toward desired outcome.
• Long-term needs, and who is responsible for actions to be taken.
•Practice Quiz: Anemia
• 1. The nurse begins to design a nutritional packet of information for a
patient diagnosed with iron-deficiency anemia. The nurse would
recommend an increased intake of:

• A. Fresh citrus fruits.

• B. Milk and cheese.
• C. Organ meats.
• D. Whole grain bread.
• 2. A nurse should know that a diagnosis of hemolytic anemia is
associated with all of the following except:

• A. Abnormality in the circulation of plasma.

• B. Decrease in the reticulocyte count.
• C. Defect in the erythrocyte count.
• D. Elevated indirect bilirubin.
• 3. The most frequent symptom and complication of anemia is:

• A. Bleeding gums.
• B. Ecchymosis.
• C. Fatigue.
• D. Jaundice.
• 4. What is the hemoglobin level of a patient with anemia?

• A. 21 to 25 g/dL.
• B. 14 to 16 g/dL.
• C. 9 to 11 g/dL.
• D. 35 to 40 g/dL.
• 5. The following are symptoms of anemia except:

• A. Fatigue.
• B. Dyspnea.
• C. Decreased hemoglobin.
• D. Hypertension.
•Answers and Rationale
• 1. Answer: C. Organ meats

• Organ meats are rich in iron, which is needed for patients with iron-
deficiency anemia.

• Option A: Fresh citrus fruits are rich in vitamin C that can boost the immune
system.
• Option B: Milk and cheese are rich in protein that can strengthen the
muscles.
• Option D: Whole grain bread are rich in carbohydrates that supply energy.
• 2. Answer: B. Decrease in the reticulocyte count.
• Increased reticulocyte count is associated with hemolytic anemia.

• Option A: Abnormality in the circulation of plasma occurs because of

the premature destruction of hemoglobin.
• Option C: Erythrocytes are being destroyed thus resulting in defect of
erythrocyte count.
• Option D: Indirect bilirubin is elevated because the released
hemoglobin is converted in large part to bilirubin.
• 3. Answer: B. Ecchymosis
• Ecchymosis is most common in anemia because blood vessels that are
weak ruptures and results into ecchymosis.

• Option A: Bleeding gums is a symptom of idiopathic

thrombocytopenia purpura.
• Option C: Fatigue is a sign of anemia but it is not a complication.
• Option D: Bilirubin concentration may be increased but not all results
in jaundice.
• 4. Answer: C. 9 to 11 g/dL

• A patient with anemia has decreased hemoglobin levels of 9 to 11

g/dL.
• 5. Answer: D. Hypertension

• Hypotension occurs in anemia because of hypoperfusion.

• Option A: Fatigue is a symptom of anemia as a result of decreased oxygenation.

• Option B: Dyspnea occurs in anemia because the body is starving for oxygen
that should have been carried by hemoglobin in the red blood cells towards the
body tissues.
• Option C: Decreased hemoglobin is one of the signs that form the diagnosis of
anemia.
THANK YOU