Nursing Process: The Patient With Anemia

Nursing Interventions
MANAGING FATIGUE
The most frequent symptom and complication of anemia is fatigue.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 consequent 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 activity. The distress from fatigue is often related to an individual’s responsibilities and life demands as well as the amount of assistance and support received from others. Nursing interventions can focus on assisting the patient to prioritize 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.

MAINTAINING ADEQUATE NUTRITION
Inadequate intake of essential nutrients, such as iron, vitamin B12, folic acid, and protein can cause some anemias. The symptoms associated with anemia (eg, fatigue, anorexia) can in turn interfere with maintaining adequate nutrition. A healthy diet should be encouraged. Because alcohol interferes with the utilization of essential 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.

MAINTAINING ADEQUATE PERFUSION
Patients with acute blood loss or severe hemolysis may have decreased tissue perfusion from decreased blood volume or reduced 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.

PROMOTING COMPLIANCE WITH PRESCRIBED THERAPY
For patients with anemia, medications or nutritional supplements are often prescribed to alleviate or correct the condition. These patients need to understand the purpose of the medication, how to take the medication and over what time period, and how to manage any side effects of therapy. To enhance compliance, the nurse can assist patients in developing ways to incorporate the therapeutic 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 consequences, as in the case of high-dose corticosteroids to manage hemolytic 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.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS
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 gradually 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. Initially mild but gradually progressive confusion may develop.

Evaluation
EXPECTED PATIENT OUTCOMES
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 prescribed
e. Verbalizes understanding of rationale for using recommended nutritional supplements
f. Verbalizes understanding of rationale for avoiding nonrecommended 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, palpitations, 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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