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01.02 Nursing Care and Pathophysiology for Anemia

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Pathophysiology: Anemia is when there is a low red blood cell (RBC) count. This is caused by blood loss, a decrease in red blood cell (RBC) production or increased RBC destruction.

Overview

  1. ↓ Amount of RBCs or hemoglobin in blood
  2. ↓ Capacity of blood to carry oxygen

Nursing Points

General

  1. Types
    1. Iron-Deficiency
      1. Inadequate iron supply – 60% of anemias
    2. Pernicious
      1. Vitamin B12 deficiency
      2. Lack of Intrinsic Factor
    3. Aplastic
      1. ↓ Production of all blood cells in the bone marrow
    4. Sickle Cell Anemia – see Sickle Cell Anemia Lesson

Assessment

  1. Pallor
  2. Fatigue
  3. Weakness
  4. Tachycardia
  5. Hypotension
  6. Angina
  7. Dyspnea
  8. ↓ Hgb, Hct, RBC levels
  9. ↓ MCV, MCH, Iron, B12 levels
    1. Schilling test (for Pernicious anemia)
  10. Spoon-like nails
  11. Pica – craving non-food substances like ice, dirt, clay, starch.

Therapeutic Management

  1. Assess for occult blood
  2. Monitory laboratory studies (Hgb, Hct)
  3. Increase iron intake in diet
    1. Green leafy vegetables
    2. Organ meat
  4. Provide Iron or B12 supplements
    1. Administer IM via Z-track method
    2. Take PO Iron on an empty stomach
  5. Limit visitors to patients with aplastic anemia
    1. Will also have ↓ WBCs

Nursing Concepts

  1. Oxygenation
    1. May require supplemental oxygen
    2. Monitor s/s poor oxygenation
    3. Assess for dyspnea
  2. Perfusion
    1. Monitor vital signs
    2. Assess for chest pain
  3. Nutrition
    1. If caused by nutritional deficiencies – provide supplements as ordered
    2. Educate patient on food choices

Patient Education

  1. Increased intake of iron or B12 containing foods
  2. Medication instructions for iron or B12 supplements
  3. Possible Neutropenic or Thrombocytopenic precautions in Aplastic Anemia
  4. Energy conservation techniques
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Nursing Care Plan for Anemia

Reference Links

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Video Transcript

This lesson is going to cover Anemia. It’s sort of an umbrella term, so we’re going to cover some of the most common ones you’ll see in practice and be tested on.

By definition, Anemia is a decreased capacity or ability of the blood to carry oxygen out to the tissues. So here’s a normal red blood cell. It usually has 4 hemoglobin molecules on it that have iron to bind to oxygen. So, if you have less RBCs or less hemoglobin, or issues with any of this structure, there will be issues carrying oxygen to the tissues. These are the four most common types of anemia, so we’ll go through them briefly. The most common of all anemias is Iron-Deficiency anemia. The iron is what binds the oxygen to the hemoglobin – without iron, the oxygen can’t bind and can’t be delivered to the tissues. The other type is called Pernicious Anemia. This is the result of a B12 deficiency, but the core of it is actually due to a deficiency in a protein called Intrinsic Factor in the stomach. Intrinsic Factor is responsible for absorption of B12, so if we don’t have it, we can’t absorb B12. Vitamin B12 is required for making hemoglobin, so ultimately it will affect the ability of the red blood cells to carry oxygen. The 3rd type is Aplastic Anemia – this is an autoimmune condition in the bone marrow that causes it to stop making all blood cells – red, white, and platelets. So, obviously, if you’re literally not making the blood cells, then you won’t be able to carry oxygen. The last one you need to know about is Sickle Cell Anemia, which we’ll talk about in detail in the next lesson, so be sure to check that out. Now, to be clear – there’s also hemorrhagic anemia, which is caused by bleeding – so we always want to make sure the patient isn’t bleeding before we assume it’s one of these deficiencies.

So what are we going to see in our assessment of a patient with anemia? Well if we aren’t perfusing oxygen to the tissues, we’ll see severe pallor, cold skin, weakness and fatigue. With the decrease in circulating oxygen, our heart is going to try to compensate – the heart rate will go up significantly, the blood pressure may drop. With the lack of oxygen they may have dyspnea or even chest pain. We’ll definitely see abnormal labs. A decreased Hgb, RBC, as well as a decreased MCV or MCH – those are just indicators of the size and color of the red blood cells – without iron, the color will be less red, without B12, the cells with be smaller, etc. We may also see decreased iron or B12 levels. A couple of other symptoms we may see with chronic anemia are spoon-like nails and Pica. Their fingernails will scoop upward instead of downward, that’s why it’s called spoon-like. And Pica is when patients crave non-food substances like dirt or clay or chalk or even ice. Both of those are signs of chronic, long-term anemia.

So, we want to monitor lab work with regular CBC’s. If we have a patient with a low hemoglobin or RBC count, we want to again make sure there isn’t any bleeding going on that we may have missed. We can assess their urine and stool for occult blood to see if there’s bleeding we couldn’t see. We’ll also monitor iron and B12 levels and then supplement. Patients can increase the iron in their diet – this is actually a common question in nursing school and on the NCLEX – what foods are high in iron. Your best bet will always be green leafy vegetables like spinach and kale and organ meats like liver and kidney. We can also supplement iron or B12. If we give them IM, we want to use the Z-track method. To do that, when you give an IM, you’re going to pull the skin down or to the side, inject the needle, then release the skin when you pull out the needle. The goal is to close that needle track so the iron or B12 doesn’t track backwards into the skin. So if this is your skin, and here’s the muscle – you’re inserting the needle usually at a 60-90 degree angle. When you release the skin, it will stagger like this, so the meds don’t track backward. There’s also a PO form of iron, which needs to be taken on an empty stomach to make sure it can be absorbed. And quickly, for patients with aplastic anemia, remember that they will also have decreased white blood cells, so their immune system will be depleted – so we want to limit visitors to avoid exposure to any kind of infection.

Our top nursing priority concepts for a patient with Anemia are going to be oxygenation, perfusion, and nutrition. We may need to supplement oxygen, monitor hemodynamics in case of bleeding, and ensure they get enough iron and B12 in their diet. Check out the care plan attached to this lesson for more detailed nursing interventions and rationales.

So let’s recap – Anemia is a decreased oxygen carrying capacity of the blood. It can be decreased red blood cells, decreased hemoglobin, or a decreased ability to bind oxygen. Some of the causes are iron-deficiency, B12 deficiency due to a lack of intrinsic factor, aplastic anemia where the bone marrow stops making cells, or loss of blood from bleeding. Patients will be pale, weak, fatigued, tachycardic, and may have spoon-like nails or Pica if it’s chronic. We want to give them oxygen if needed and replace iron, B12 or transfuse blood if necessary. And of course we want to monitor the CBC – hemoglobin, hematocrit, red blood cells, MCV, MCH, and iron and B12 levels. And don’t forget – always verify that there isn’t any source of bleeding that we’re missing before we just go to iron supplements.

So those are the basics of anemia, check out the resources attached to this lesson to learn more. Now, go out and be your best self today. And, as always, happy nursing.

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