ANEMIA NURSING CARE PLAN

SCENARIO:

MR.ASHA AGED 34 YEARS BROUGHT TO THE EMERGENCY ROOM ACCOMP AINED BY SIGNIFICANT FAMILY MEMEBER.EXPLAINED THAT PATIENT HAD DIZZINESS
FOLLOWED BY FALL AN HOUR BACK .WHEN PATIENT IS BROUGHT TO THE CLINIC PATIENT IS CONSCIOUS.PATIENT COMPLAINED THAT SINCE TWO WEEKS HE HAD EPISODES OF
PALPITATIONS,ACCOMPANIED BY MALAISE, GENERAL WEAKNESS,

ON ASSESSMENT PATIENT HAD ELEVATED HEART RATE 67 BEATS PER MINUTE , PALLE, COOL EXTRIMITIES, DRY SKIN AND DRY COATED TONGUE, DYSPNEA WITH
EXERTION ,RESTLESSNESS ,IRRITABILITY,BLOOD PRESSURE RECORDED AS 60/100 MM OF HG .AND ALSO PATIENT IS FOUND TO BE THIN.

ASSESSMENT NURSING GOAL PLANNING / IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS
Sub data : patient complaints Fatigue related to To improve 1. Assess the specific cause of fatigue. The specific cause of fatigue is tissue Patient reported
about inability to do daily decreased hemoglobin level hypoxia from normocytic anemia; increased
activities due to weakness, hemoglobin levels http://youtu.be/NW30MvZVX Other related medical problems can hemoglobin level
fatigue, restlessness. as evidenced by oQ also compromise activity tolerance. and fatigue is
lack of energy. reduced
Obj data : on observation
patient looks pallor, poor
capillary refilling of nailbuds,
tried. Fatigue can limit the client’s ability to
participate in self-care and perform
Assess the client’s ability to perform activities of their role responsibilities in family and
daily living (ADLs) and the demands of daily society, such as working outside the
living. home.

Decreased RBC indexes are associated

with the decreased oxygen-carrying
capacity of the blood. It is critical to
compare serial laboratory values to
Monitor hemoglobin, hematocrit, RBC counts, and
reticulocyte counts.
Assist the client in developing a schedule for daily
activity and rest. Stress the importance of frequent
rest periods.
Educate energy-conservation techniques.
Instruct the client about medications that may
stimulate RBC production in the bone marrow.
evaluate the client’s progression or
deterioration and identify changes
before they become life-threatening.
Energy reserves may be depleted
unless the client respects the body’s
need for increased rest. A plan that
balances periods of activity with rest
periods can help the client complete
desired activities without adding
fatigue levels.
Clients and caregivers may need to
learn skills for delegating tasks to
others, setting priorities, and clustering
care to use the available energy to
complete desired activities.
Organization and time management can
help the client conserve energy and
reduce fatigue.
Recombinant human erythropoietin, a
hematological growth factor, increases
hemoglobin and decreases the need for
RBC transfusions.
 Oxygen saturation should be kept at
90% or greater.

Provide supplemental oxygen therapy as needed.

Packed RBCs increase the oxygen-

carrying capacity of the blood.

Anticipate the need for the transfusion of packed

RBCs.
The occupational therapist can teach
the client about using assistive devices.
The therapist also can help the client
and family evaluate the need for Patient reported
Refer the client and family to an occupational additional energy-conservation increased Hb levels
therapist. measures in the home setting. and no evidence of
infection.
 Risk for infection
Sub data : patient complaints of related to low Hb improve Hb levels
fever with chills, pain swelling, levels or low and prevent
body malaise. immunity. infection.

Obj data : on observation of lab Opportunistic infections can easily

reports patient is having develop, especially in
increased WBC count, ESR immunocompromised clients.
rate.
1. Assess for local or systemic signs of
A low white blood cell count
infection, such as fever, chills, swelling,
(leukopenia) decreases disease-fighting
pain, and body malaise. cells (leukocytes) in your blood. In
general, for adults, a count lower than
http://youtu.be/vdWEuk6dF3c 4,000 white blood cells per microliter
of blood is considered a low white
blood cell count.
Monitor WBC count.
A simple fever is significant enough
not to pay attention to. A need for
antibiotic therapy may be indicated.

These agents are effective against

killing an infection
Instruct the client to report signs and symptoms of
infection immediately.

These can be a source of infection for

the immunocompromised client.
Anticipate the need for an antibiotic, antiviral,
Children 12 years of age or younger are
and antifungal therapy..

Instruct the client to avoid contact with people
with existing infections.
If the client is hospitalized, provide a private room
for protective isolation.
Instruct the client to avoid eating raw fruits and
vegetables and uncooked meat.
Stress the importance of daily hygiene, mouth
at risk because they can be carriers of
infection, especially upper respiratory
infection.
Environmental changes may be
important if the absolute neutrophil
count is less than 500/mm3. Protective
isolation precautions may include
placing the client in a private room,
limiting visitors, and having all people
who contact the client use mask,
gowns, and gloves. These clients are at
significant risk for infection.
These food items can harbor bacteria.
A low-bacterial diet protects the client
from exposure to pathogens.
These preventive measures help avoid
skin breakdown and lessen the risk of
infection.
Patient reported
normal WBC &
Practicing hand hygiene is an effective PLATELLET count,
way to prevent infections. Washing and incidence of
hands can prevent the spread of germs, bleeding is reduced
 care, and perineal care. including those that are resistant and Hb levels are
to antibiotics. improved.

Teach the client and visitors proper handwashing. Colony-stimulating factors (CSFs),

long-acting
pegfilgrastim, filgrastim are
medications used to stimulate the
production of infection-fighting white
blood cells.

Administer WBC growth factor to stimulate the

production of neutrophils.

Sub data : patient complaints of Risk for bleeding

bleeding from nose, gums, and related to bone To improve Hb
skin bruises, petechie. marrow levels and to
transplantation. prevent the
Obj data : on observation of incidence of
lab reports, WBC count is less bleeding during
and PLATELLETS count is bone marrow
less. transplantation.

Bruises and petechiae are usually

evident when the platelet count drops
to 20,000 mm3.

The early assessment facilitates

Assess the skin for bruises and petechiae. 
immediate treatment. These sites are
most common for spontaneous
bleeding.

Assess for any frank bleeding from the nose,
gums, vagina, or urinary or gastrointestinal tract.
Monitor platelet count.
A low platelet count or
thrombocytopenia is caused by a bone
marrow malfunction resulting from
nutritional deficiencies, drugs, certain
viral causes, or aplastic anemia. The
risk for bleeding is increased as platelet
count is decreased.

http://youtu.be/UGFuo1ULUIU
These tests help identify the site of
bleeding.
 Patient reported
Monitor stool (guaiac) and urine (Hemastix) for normal physical
occult blood. activity.
Repeated blood sampling over time can
lead to anemia. Consolidation
minimizes the number of venipunctures
and optimizes blood volume.

Consolidate laboratory blood sampling test.

Eating a diet high in fiber and drinking

a lot of fluids to avoid constipation or
using a stool softener and other
laxatives as prescribed if having
difficulty passing stool.

Instruct the client in dietary modifications to

reduce constipation.
Once the client’s platelet count drops to
50,000mm3, bleeding precaution should
be instituted immediately to avoid the
risk of spontaneous bleeding. 

Instruct the client about bleeding precautions.

Precautionary measures include:
  Instruct the client to use
an electric shaver, not a razor.
 Use a soft toothbrush when
brushing the teeth.
 Using pads instead of tampons.
 Avoid rectal procedures such as
suppositories, enemas, and
rectal temperature readings.
 Using a water-based lubricant
during sexual intercourse to
reduce friction (KY Jelly or
Astroglide)

Platelet replacement may be required to

reduce the risk of bleeding.
Premedication with antihistamine and
antipyretics reduces transfusion
reaction side effects.
Activity
Sub data : patient complaints intolerance related
of general weakness, fatigue, to imbalance To promote normal
dyspnea. between oxygen physical activity by
supply and maintaining
Obj data : on observation demand as balance between Anticipate the need for a platelet transfusion once
patient is unable to do daily evidenced by oxygen supply and the platelet count drops to a very low value.
physical activity, pallor. generalized demand.
weakness.

Signs of activity intolerance and


Assess manifestations of activity intolerance. Tell
the patient to rate perceived exertion on a 0-10
scale.
http://youtu.be/VSVYgivfs9c
Check oximetry; inform physician O2 saturation
92% or less.
Assess the risk of falling and enforce applicable
strategies.
decreased tissue oxygenation include
dyspnea on exertion, headaches,
dizziness, palpitations, and
verbalization of increased exertion
level (rated perceived exertion or RPE
is more than 3). The patient should end
or lessen the activity until signs of
increased exertion are no longer
present.
Supplementary oxygen is needed for
O2 saturation 92% or less.
Patients may not be aware of the
weakness and limitations leading to
reduced strength due to anemia’s
potentially slow, progressive nature.
Failure to monitor patients and lack of
enforcement may lead to serious
injuries and prolonged hospitalization.
 Depression over the inability to
perform activities can be a source of
stress and frustration.

These methods boost oxygen delivery

to the tissues.

Assess emotional response to limitations in This helps the patient to cope.

physical activity. Acknowledgment that living with
activity intolerance is both physically
and emotionally difficult. Patient reported no
doubts about
treatment and health
condition.
Encourage deep breathing techniques and
administer oxygen as prescribed.

Allow verbalization of feelings regarding

limitations.

This develops endurance while

preventing problems caused by
 prolonged bed rest.

To improve activity and promote good

circulation.

Aid in a gradual increase of activities to tolerance

as the patient’s strength progress.

Gradually progress patient activity with the

following:
Duration and frequency should be increased
before intensity.

 Range-of-motion (ROM) exercises in bed,

gradually increasing duration and
frequency (then intensity) to sitting and
then standing.
 Deep-breathing exercises three or more
times daily.
 Sitting up in a chair 30 minutes three
times daily.
Lessening any interruptions allows the
 Walking in room 1 to 2 minutes TID.
patient to rest and benefit
 Walking down the hall 20 feet or walking
 through the house, then slowly progressing
walking outside the house, saving energy
for the return trip.
Allow time for the patient to have undisturbed
rest.
Give blood components (commonly packed
RBCs) via an intravenous catheter as prescribed.
Observe and report for any signs of transfusion
from sleep until anemia is resolved.
This method will increase the number
of RBCs circulating in the blood,
which eventually increases the blood’s
oxygen-carrying capacity.
These measures lessen the risk of
transporting the wrong type of blood to
the patient.
150 units/kg IV 3 times each week, or
600 units/kg subcutaneously once each
week, or darbepoetin alfa 200 mcg
every 2 weeks. Red cell production is
improved through addition EPO (red
blood cells are not responsive to
normal EPO levels in chronic
conditions.

Sub data : patients questions
about health condition,
medical treatment.
Obj data : on observation
patient is anxious, asking
frequent questions about
condition.
reaction. Confirm type and crossmatching.
may be given to restore Hgb and
depleted iron and other deficiencies if
necessary. People with chronic disease,
usually older individuals, may not have
Deficient regular dietary intake of these
knowledge related substances. Supplements will boost
to treatment as To improve
normal erythropoiesis.
evidenced by knowledge about
questioning health treatment and
care team. health condition. Improvements in dietary intake and
strength also may help reduce
symptoms.
Tell the patient that symptoms are commonly
relieved, and tolerance for the activity will
increase with the treatment regimen. Treatment Close monitoring will serve as a guide
may include the following: for the optimal progression of activity.
Packed RBC or erythropoietin replacement
(recombinant EPO [epoetin-α]): 
Determining the client’s current
knowledge and perceptions will
facilitate the planning of individualized
Iron and other supplements (cobalamin, folate): 
teaching. Clients may have a general
understanding of anemia related to iron
deficiency but limited knowledge of
other types of anemia.
Usually, people have a limited
Dietary adjustment and improvement:  understanding of medical vocabulary,

Document response to activity.
Assess current knowledge of the diagnosis, disease
process, possible causative factors, and treatment.
Assess the client’s and family’s understanding of
the new medical vocabulary.
ttp://youtu.be/ZuHdnTKBBg
Explain the importance of the diagnostic
procedures (such as complete blood count), bone
marrow aspiration, and a possible referral to a
hematologist.
Explain the hematological vocabulary and the
functions of blood elements, such as white blood
cells, red blood cells, and platelets.
hence are not exposed to the language
being used by the health care
professionals.
Diagnosing a type of anemia will be
based on the changes in the RBC
indexes and the findings in the bone
marrow aspiration.
Clients usually have a basic knowledge
of the hematological system.
Causative factors such as alcoholism,
exposure to toxic chemicals, dietary
deficiencies, and the use of some
medications can affect red blood cell
production and lead to anemia.
Histocompatibility antigens may lead
to donor marrow rejection.
The human leukocyte antigen (HLA)
test, also known as HLA typing or
tissue typing, identifies antigens on the
white blood cells (WBCs) that

Instruct the client to avoid known risk factors.
Explain that blood transfusions from prospective
marrow donors should be avoided.
Explain the need for rapid human leukocyte
antigen (HLA) typing.
Explain that immunosuppressive therapy is the
treatment of choice in clients without HLA-
matched donors and/or older than 40 years of age.
Explain that allogeneic hematopoietic stem cell
determine tissue compatibility for
organ transplantation.
In clients without HLA-matched
donors, the treatment of choice is
immunosuppression with granulocyte-
macrophage-colony-stimulating
factors, cyclophosphamide, anti-
thymocyte globulin, and cyclosporine.
HLA-identical related donors.
Hematopoietic stem cell transplantation
(HCT) is an effective therapy for many
life-threatening diseases. Usually, a
client’s own (autologous) or
(allogeneic) cells from a donor with the
same genetic makeup are used.The
earliest symptoms include a
red maculopapular rash, dryness of
the eye, abdominal pain, and jaundice
transplantation is the standard treatment for clients
younger than 40 years old with 

Clients with Chronic GVHD may

present with a variety of symptoms.
Skin rash and mouth sores are among
the common initial signs of the disease.
The rash is often slightly raised and
may be itchy.

Explain the potential complications associated

with immunosuppressive therapy:

Acute graft-versus-host disease (GVHD).. Rejection happens when a sensitization

to histocompatibility antigens acquired
during previous blood transfusions and
http://youtu.be/_ZV51400ykE carries a high mortality rate.
Conditioning regimens using
cyclophosphamide (Cytoxan) and total
lymphoid irradiation show a decrease
in the risk for graft failure.

Chronic GVHD. Vitamin B12 injections are used to treat

low levels (deficiency) of this vitamin.
They are given monthly for the
remainder of the client’s life. It
elevates vitamin B12, a deficiency
caused by a lack of intrinsic factors that
impair vitamin absorption.

Rejection of donor marrow.
Explain the importance of vitamin
B12 replacement.
Educate the client and the family regarding food
rich in iron, folic acid, and vitamin B12.
A balanced diet that includes various
foods from each food group usually
contains essential nutrients needed to
promote RBC formation. Clients need
to have an adequate intake of dark-
green leafy vegetables, animal
products, including fish, meat, poultry,
eggs, milk, and fortified breakfast
cereals.
The dosage and frequency of
administration will depend on the
severity of anemia. Iron supplements
are given orally with meals to prevent a
gastric upset.
Intramuscular injections are also
available via the Z-track method to
prevent leakage of the solution in the
subcutaneous tissue along the needle
tract. At the same time, folic acid is
given orally with a full glass of water.
Recombinant human erythropoietin, a
hematological factor, elevates
Educate the client and the family regarding hemoglobin levels and decreases the
replacement therapy with folic acid and iron. need for a transfusion of packed RBC

I One unit of packed RBC raises the

hemoglobin level by 1 g/dL.

nstruct the client about certain medications that

may stimulate RBC production in the bone
marrow

Explain that a transfusion of packed RBCs may be

needed.