A nurse is assessing a client who is at risk for the development of pernicious anemia

Anemia occurs when there are not enough red blood cells or red blood cells do not function properly resulting in low hemoglobin and a lack of oxygen throughout the body.  

Iron-deficiency anemia is the most common type of anemia and is appropriately named, as it is a lack of iron in the body. This can result from blood loss, pregnancy, or poor absorption. 

Other types of anemia that may be encountered are vitamin-deficiency anemia (low levels of vitamin B12 or folate), aplastic anemia (the bone marrow stops making blood cells), and hemolytic anemia (when blood cells are destroyed faster than they are replaced).

The Nursing Process

Anemia will likely be the result of a larger condition that nurses will manage. Treatment will depend on the type of anemia and underlying causes such as infection, cancer, or inherited disorders. Sickle cell anemia is a complicated and severe form of anemia that requires inpatient treatment when a crisis occurs. A pain crisis is very painful and has life-threatening complications that nurses must understand how to appropriately assess for and treat.

Nursing Care Plans Related to Anemia

Imbalanced Nutrition: Less Than Body Requirements Care Plan

Iron-deficient and vitamin-deficient anemia can occur due to poor dietary intake or an inability to absorb nutrients.

Nursing Diagnosis: Imbalanced Nutrition

Related to: 

• Inability to absorb iron or vitamins 
• Lack of vitamin B12 and folate in the diet 
• Pregnancy 
• Gastric bypass surgery 
• Inflammatory bowel diseases 
• Vegetarian diet 

As evidenced by: 

• Pale skin 
• Feeling cold 
• Fatigue 
• Rapid heartbeat 
• Brittle nails 
• Hair loss 
• Craving ice (pagophagia) 
• Headaches 

Expected Outcomes: 

• Patient will display an improvement in iron and B-12 levels through lab testing 
• Patient will add three foods high in iron, B-12, and folic acid to their diet 
• Patient will recognize the signs and symptoms of anemia and when to call their doctor

Imbalanced Nutrition: Less Than Body Requirements Assessment

1. Assess lab values.
Monitor red blood cell count, hemoglobin, hematocrit, ferritin, iron, and total iron-binding capacity for abnormalities.

2. Assess the patient’s usual diet.
Assess for nutritional gaps in the patient’s diet by taking a history of foods they normally eat as well as any food allergies they may have.

3. Assess access to healthy foods.
Assess if access to food prevents the patient from obtaining nutritionally-balanced foods that are high in vitamins.

Imbalanced Nutrition: Less Than Body Requirements Interventions

1. Instruct on a healthy diet.
Iron-rich foods include dark green, leafy vegetables, nuts, and eggs. Foods high in vitamin B-12 include meat and dairy products. Folic acid is found in legumes, citrus juices, and dark green leafy vegetables.

2. Consider supplements.
Patients may be prescribed oral supplements of iron or vitamin B-12 (cyanocobalamin) if they cannot get enough from their diet. Patients may also receive vitamin B-12 injections regularly usually administered by a nurse.

3. Encourage prenatal supplements.
Pregnant patients should be instructed on the importance of prenatal vitamins which contain iron and folate. These vitamins are essential to support a healthy pregnancy and prevent birth defects.

4. Improve iron absorption.
Some patients struggle with absorbing iron and will need instruction on when and which foods to eat to increase absorption. It is easier for the body to absorb meat and seafood iron-containing products. Iron in vegetables, grains, and seeds is more difficult for the body to absorb. Vitamin C can help with the absorption of iron when taken with a meal. Tannins in tea and coffee can inhibit the absorption of iron.

Fatigue Care Plan

A lack of oxygen-carrying red blood cells will result in decreased energy and fatigue.

Nursing Diagnosis: Fatigue

Related to: 

• Decreased hemoglobin 

As evidenced by: 

• Exhaustion 
• Inability to maintain physical activity 
• Increased need for rest 
• Reported lack of energy 
• Lethargy 

Expected Outcomes: 

• Patient will verbalize techniques to conserve energy 
• Patient will report an increase in energy and ability to perform tasks 

Fatigue Assessment

1. Monitor CBC.
Assess the patient’s complete blood count including red blood count and hemoglobin levels. These will be low in anemic patients.

2. Assess for chronic conditions that worsen anemia.
Chronic conditions can cause and contribute to anemia. These include pregnant patients, those with cancer, or autoimmune diseases. Treating the underlying cause of anemia should be a priority.

3. Assess the extent of fatigue in daily life.
Inquire about activities the patient can or cannot perform, the effect it has on their responsibilities and roles, and how they manage their symptoms.

Fatigue Interventions

1. Instruct on energy conservation.
Plan rest periods, delegate tasks to others, cluster activities together, prioritize activities when energy levels are highest.

2. Apply oxygen.
Patients being treated for anemia in the hospital may require supplemental oxygen for very low hemoglobin levels.

3. Administer blood transfusions.
If a patient is severely anemic or has suffered a blood loss causing anemia, blood transfusions may help with fatigue.

4. Administer erythropoietin injections.
Epogen and Procrit are two common injections given that stimulate the bone marrow to produce red blood cells. Patients with cancer, HIV, or kidney disease often have severe anemia and require these injections.

Acute Pain Care Plan

Acute pain is a nursing diagnosis specific to sickle cell anemia. This genetic condition causes red blood cells to ‘sickle’ and clump together, decreasing blood flow and perfusion causing a pain crisis.

Nursing Diagnosis: Acute Pain

Related to: 

• Sickling of red blood cells occluding blood vessels 
• Lack of perfusion and oxygenation to extremities 

As evidenced by: 

• Intense complaint of pain anywhere in the body 
• Pain described as stabbing, sharp, or throbbing 
• Reduced activity 
• Restlessness 
• Distractive behavior (pacing, watching tv, talking on the phone) 

Expected Outcomes: 

• Patient will report a decrease in pain to a level of 2/10 by discharge 
• Patient will verbalize an understanding of behaviors that trigger a pain crisis 
• Patient will adhere to the prescribed pain medication regimen 

Acute Pain Assessment

1. Assess pain.
Perform a complete pain assessment using a numeric or FACES pain scale. Assess character, duration, frequency, precipitating factors, and any interventions.

2. Assess for acute chest syndrome.
Acute chest syndrome is vaso-occlusion that occurs in the pulmonary vasculature. It is life-threatening and the most common cause of death in sickle cell patients. Monitor for symptoms of chest pain, fever, dyspnea, and infiltrates on a chest x-ray.

3. Assess pain medication regimen.
Many sickle cell pain crises occur due to missed doses of pain medication or an inadequate regimen. Assess the patient’s adherence as well as doses and frequency of pain medication.

Acute Pain Interventions

1. Provide fluids.
IV hydration is a priority for treating a sickle cell crisis. IV fluids will stop or slow the sickling process and reduce pain. Patients should also be encouraged to drink plenty of fluids.

2. Administer analgesics.
Sickle cell patients often have a very high pain tolerance and will receive high doses of narcotics. Some patients may be on a PCA pump until their pain is better controlled. The nurse should closely monitor the patient and provide adequate pain control without over-sedating the patient.

3. Administer blood transfusions.
Depending on the patient’s hemoglobin level, blood transfusions may be necessary to prevent worsening complications and correct anemia. Some patients may receive long-term transfusions monthly on an outpatient basis.

4. Educate on preventing a sickle cell crisis.
Patients should be educated on triggers of a sickle cell crisis to prevent them. Maintaining hydration, preventing infections, avoiding exposure to cold weather, reducing stress, and adhering to medications are necessary to manage sickle cell anemia.

References and Sources

1. Anemia. (n.d.). American Society of Hematology. Retrieved February 24, 2022, from https://www.hematology.org/education/patients/anemia
2. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
3. Epoetin Alfa (Injection Route) Side Effects. (2022, February 1). Mayo Clinic. Retrieved February 24, 2022, from https://www.mayoclinic.org/drugs-supplements/epoetin-alfa-injection-route/side-effects/drg-20068065?p=1
4. Friend A, Girzadas D. Acute Chest Syndrome. [Updated 2021 Jun 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441872/
5. Iron. (n.d.). Harvard T.H. Chan School of Public Health. Retrieved February 24, 2022, from https://www.hsph.harvard.edu/nutritionsource/iron/
6. Iron-Deficiency Anemia. (n.d.). American Society of Hematology. Retrieved February 24, 2022, from https://www.hematology.org/education/patients/anemia/iron-deficiency
7. Sickle Cell Crisis. (2020, September 23). Michigan Medicine. Retrieved February 24, 2022, from https://www.uofmhealth.org/health-library/hw253529