Pathophysiology

A decrease in red blood cells (RBC) or hemoglobin (HGB). The body uses the
RBCs to transport Oxygen via HGB (HGB binds oxygen to the RBC). The oxygen
is then bussed around the body and dropped off to the cells for the cell to perform
cellular respiration creating ATP AKA energy. With oxygen (aerobic cellular
respiration) the cells produce their ATP and have a byproduct of CO2, which we
breath out. Without oxygen (anaerobic respiration) the cells use fatty chains to get
their energy which has the byproduct of ketones (super acidic). Having the body be
in a state of low oxygenation (hypoxia) creates an unbalanced pH which then
denatures proteins making cells not be able to read their code/instructions because
the code (DNA/RNA) is made out of proteins… While being anemic for short term
is easier for the body to bounce back, long term anemic or rapid severe anemia is a
bicycle kick to the body… AKA no good. It is important to note that you need
BOTH RBCs and HGB for a working system of oxygenation.

Etiology
There are many causes of anemia, the most life threatening is massive hemorrhage,
but other causes such as lack of iron, severe burns, cancers, bone marrow disorders
like multiple myeloma or leukemia can be just as detrimental.

Some of the types of anemia:

 Iron Deficiency Anemia: Usually caused by hemorrhage or lack of Iron (or

lack of ability to absorb iron). Treated with iron supplements/diet changes
and blood transfusions.
 Vitamin Deficient Anemia: Due to Folic Acid (vitamin B12) deficiency or
lack of ability to absorb B12. Treated with B12 supplements and diet
changes.
 Aplastic Anemia: The bone marrow is not producing enough RBCs. Treated
with blood transfusions and also bone marrow biopsies to diagnose specific
issue with the bone marrow.
 Hemolytic Anemia: Due to RBCs being destroyed. What is causing the
lysing of the RBCs can be from a range of problems including infection,
autoimmune disorders, etc. Treatment is dependant on the cause. If due to
infection, treatment is antibiotics, if autoimmune treatment may be
medications that suppress the autoimmune system. Cardiac and vascular
specialists should be consulted for this condition in case it is due to a
mechanical factor like the heart valves.
 Sickle Cell Anemia: This is a genetic disorder where the blood cells become
sickle shaped, causing clots, hemolysis, and poor perfusion. Treatment is
 focused on pain control, fluid resuscitation and sometimes blood
transfusions.

Desired Outome
Stopping the cause of the anemia and returning the blood counts (RBC/HGB) back
to normal limits.

Anemia Nursing Care Plan

Subjective Data:

 Fatigue/weakness
 Dizziness
 Lightheadedness
 Shortness of Breath (SOB)

Objective Data:

 Bleeding/Hemorrhaging
 (internal and external)
 ***consider stroke like symptoms, patient may be have a hemorrhagic
stroke!***
 Pale skin
 Shortness of Breath (SOB)
 Potential ECG changes
 Hypotension (from blood loss)
 Tachycardia (from hypotension/blood loss)
 Syncope (also from hypotension/blood loss)
 Low lab values: HGB/RBC.

Nursing Interventions and Rationales:

1. Assess for bleeding/Hemorrhage and stop source if found. GI bleed: Give pantoprazole
(Protonix), potential surgical intervention to stop the bleeding. External hemorrhage: Don’t
forget about menstruation for females, soaking more than 1 pad in an hour is very concerning for
too much blood loss! Internal hemorrhage: outside of the GI tract but inside the skin.
o GI bleeding: This entails my least favorite thing to do, and the nurse
doesn’t even do it, but the nurse usually needs to be present because
it invades the patient’s self respect and dignity. Therefor you get to be
in the patient’s visual field while they are being pillaged in their back
end.

The provider will place a gloved finger into the rectum and needs to
 have feces on it when it comes out. The feces is placed on a hemoccult
card where a developing solution is married with the stool giving the
provider insight of whether or not there is blood in the stool. If the
card turns blue it is positive for blood.

As a nurse you will ask the patient if they have black/tarry stools
(upper GI bleed) or bright red blood (lower GI bleed) in their stools.

Give pantoprazole (Protonix), a proton pump inhibitor (PPI) that

decreases the amount of acid in the GI lining. This reduces the
ulceration which could be (and most likely is) causing the GI bleed.

External hemorrhage: Found by examining the patient’s full body

(front and back). Apply pressure to any hemorrhage. Replace lost
volume if hemoglobin is below 8 (this number is different per
hospital, per doctor and per situation, but 8 is a general number that
you don’t want people’s hemoglobin to be below).

Internal hemorrhage: Can be from a laceration to the liver or the

spleen. Assess for abdominal pain and swelling.

Don’t forget about hemorrhaging in the brain- look for signs and
symptoms of stroke.
2. HGB Normal Value: Male: 13.5 - 16.5 g/dL | Female: 12.0 - 15.0 g/dL RBC Normal Value: Male:
4.5 - 5.5 x106/cells/mm3 Female: 4.0 - 4.9 x106/cells/mm3 Folic Acid (B-12) Normal Value: 2 - 20
ng/mL Ferritin Normal Value: 20-300 ng/mL Iron Normal Value: 50-175 ug/dL
o There are many blood lab values a nurse can monitor while treating
a patient with anemia. Here are the most important.

HGB: Hemoglobin (Hbg), an iron containing compound, is the main

protein in Red Blood Cells (RBCs). It enables oxygen and carbon
dioxide (CO2) to bind to RBCs for transport throughout the body.

This is the most commonly looked at lab value to assess need for a
blood transfusion. Every institution, Doctor, and person is different
but as a general rule, a hemoglobin below 8 requires a blood
transfusion.

RBCs: Red Blood Cells (RBCs) contain hemoglobin which is

responsible for oxygen transport throughout the body. RBCs are
primarily produced in the bone marrow, they have a life span of 120
days and are destroyed in the spleen and liver. RBC production is
regulated by erythropoietin (EPO) which is produced and released
from the kidneys.
 Folic Acid (B12): Folic acid is an essential water soluble B vitamin.
It is stored in the liver and is an important part of Red Blood Cell
(RBC) and White Blood Cell (WBC) function, DNA replication, and
cell division.

Ferritin: Ferritin is a protein that stores iron. It is formed in the liver

spleen and bone marrow. Ferritin in the blood is usually proportional
to stored ferritin. Ferritin is a more sensitive and specific test for
identifying iron-deficiency anemia, however, it is usually measured in
conjunction with total iron binding capacity and iron.

Iron: Iron (Fe) is an element that is an important component of

hemoglobin in red blood cells. Hemoglobin transports oxygen from
the lungs to all the cells of the body. Most of the iron in the body is
located in hemoglobin, but some iron is located in myoglobin as well
as some iron is stored in the liver, bone marrow, and spleen. The
storage form of iron is ferritin. Iron is transported in the blood by a
protein called transferrin.
3. Blood product administration: Packed Red Blood Cells (PRBC) Fresh Frozen Plasma (FFP)- one
unit for every 4 units of PRBC
o If the source of the anemia is blood loss, you want to stop the source
if possible and replace the blood. If you are unable to stop the source
and the patient losses greater than 40% of their blood, give a massive
blood transfusion rapidly.
4. Cardiac Monitoring: 12-lead ECG 5-lead monitoring
o Decreased blood volume is problematic for the heart, so make sure
the heart is still kicking it the proper way (normal sinus rhythm) or as
proper as it can. Monitor for any changes in ECG, tell the patient to
inform you of any new symptoms like chest pain or shortness of
breath.

Anemic patients are more likely to experience ST depression, QT

prolongation, T wave depression, and R wave difference.
5. Fall Precautions
o High risk of syncope, especially if the patient is hemorrhaging. Keep
the patient lying flat or in trendelenburg position if hypotensive.
6. Oxygenation monitoring/Administration
o The purpose of your RBCs binding hemoglobin and oxygen is to
deliver oxygen to your cells so they can perform aerobic respiration,
giving you the energy to perform ADLs.

If you limit the number of RBCs or HGB, you limit the O2 in your
blood.

Check for oxygen saturation, monitor it, and if it falls below 94% give
2L NC to start with, increase as needed. Oh and call your
 Respiratory Therapist because they are your best friends and need to
monitor the patient too. Friends don’t let friends drive drunk monitor
oxygenation alone.
7. Iron or B12 Supplements/Diet changes
o Educate the patient on foods that are high in iron (red meats, dark
leafy vegetables, etc) or high in folic acid AKA B12 (rice, pasta,
beans) and if the patient is unable to get enough through their diet,
they may have to use supplements.

Review the patient’s medication list.

Iron supplements are likely to decrease absorption of Quinolone and

Tetracycline Antibiotics as well as Levodopa, Levothyroxine,
Methyldopa, CellCept, Penicillamine, and Bisphosphonates.

Folic Acid supplements are likely to increase side effects of 5-

Fluorouracil and Capecitabine. It might also decrease the efficacy of
Fosphenytoin, Methotrexate, Phenobarbital, Phenytoin, Primidone,
and Pyrimethamine.

Description

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 electrolytesto 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.