NCP Anemias (Iron Deficiency, Pernicious, Aplastic, Hemolytic)

Anemia is a symptom of an underlying condition, such as loss of blood components, inadequate elements, or lack of required nutrients for the formation of blood cells, that results in decreased oxygen-carrying capacity of the blood. There are numerous types of anemias with various causes. The following types of anemia are discussed here: iron deficiency (ID), the result of inadequate absorption or excessive loss of iron; pernicious (PA), the result of a lack of the intrinsic factor essential for the absorption of vitamin B12; aplastic, due to failure of bone marrow; and hemolytic, due to red blood cell (RBC) destruction. Nursing care for the anemic patient has a common theme even though the medical treatments vary widely.
Treated at the community level, except in the presence of severe cardiovascular/immune compromise.
Burns: thermal/chemical/electrical (acute and convalescent phases)
Cirrhosis of the liver
Heart failure: Chronic
Psychosocial aspects of care
Renal failure: acute
Renal failure: chronic
Rheumatoid arthritis
Pulmonary tuberculosis (TB)
Upper gastrointestinal/esophageal bleeding
Patient Assessment Database
May report:
Fatigue, weakness, general malaise
Loss of productivity; diminished enthusiasm for work
Low exercise tolerance
Greater need for rest and sleep
May exhibit:
Tachycardia/tachypnea; dyspnea on exertion or at rest (severe or aplastic anemia)
Lethargy, withdrawal, apathy, lassitude, and lack of interest in surroundings
Muscle weakness and decreased strength
Ataxia, unsteady gait
Slumping of shoulders, drooping posture, slow walk, and other cues indicative of fatigue

May report:
History of chronic blood loss, e.g., chronic gastrointestinal bleeding, heavy menses (ID); angina, heart failure (HF) (due to increased cardiac workload)
History of chronic infective endocarditis
Palpitations (compensatory tachycardia)
May exhibit:
Blood pressure (BP): Increased systolic with stable diastolic and a widened pulse pressure; postural hypotension
Dysrhythmias, electrocardiogram abnormalities, e.g., ST-segment depression and flattening or depression of the T wave; tachycardia
Throbbing carotid pulsations (reflects increased cardiac output as a compensatory mechanism to provide oxygen/nutrients to cells)
Systolic murmur (ID)
Extremities (color): Pallor of the skin and mucous membranes (conjunctiva, mouth, pharynx, lips) and nailbeds, or grayish cast in black patients; waxy, pale skin (aplastic, PA) or bright lemon yellow (PA)
Sclera blue or pearl white (ID); jaundice (PA)
Capillary refill delayed (diminished blood flow to the periphery and compensatory vasoconstriction)
Nails brittle, spoon-shaped (koilonychia) (ID)
May report:
Negative feelings about self, ability to handle situation/events
May exhibit:
May report:
History of pyelonephritis, renal failure
Flatulence, malabsorption syndrome (ID)
Hematemesis, fresh blood in stool, melena
Diarrhea or constipation
Diminished urine output
May exhibit:
Abdominal distension
May report:
Decreased dietary intake, low intake of animal protein/high intake of cereal products (ID)
Mouth or tongue pain, difficulty swallowing (ulcerations in pharynx)
Nausea/vomiting, dyspepsia, anorexia
Recent weight loss
Insatiable craving or pica for ice, dirt, cornstarch, paint, clay, and so forth (ID)
May exhibit:
Beefy red/smooth appearance of tongue (PA; folic acid and vitamin B12 deficiencies)
Dry, pale mucous membranes
Skin turgor poor with dry, shriveled appearance/loss of elasticity (ID)
Stomatitis and glossitis (deficiency states)
Lips: Cheilitis, i.e., inflammation of the lips with cracking at the corners of the mouth (ID)
May report:
Difficulty maintaining activities of daily living (ADLs)
May exhibit:
Unkempt appearance, poor personal hygiene
Hair dry, brittle, thinning; premature graying (PA)
May report:
Headaches, fainting, dizziness, vertigo, tinnitus, inability to concentrate
Insomnia, dimness of vision, and spots before eyes
Weakness, poor balance, wobbly legs; paresthesias of hands/feet (PA); claudication
Sensation of being cold
May exhibit:
Irritability, restlessness, depression, drowsiness, apathy
Mentation: Notable slowing and dullness in response
Ophthalmic: Retinal hemorrhages (aplastic, PA)
Epistaxis, bleeding from other orifices (aplastic)
Disturbed coordination, ataxia; decreased vibratory and position sense, positive Romberg’s sign, paralysis (PA)
May report:
Vague abdominal pains; headache (ID)
Oral pain
May report:
History of TB, lung abscesses
Shortness of breath at rest and with activity
May exhibit:
Tachypnea, orthopnea, and dyspnea
May report:
History of occupational exposure to chemicals, e.g., benzene, lead, insecticides, phenylbutazone, naphthalene
History of exposure to radiation either as a treatment modality or by accident
History of cancer, cancer therapies
Cold and/or heat intolerance
Previous blood transfusions
Impaired vision
Poor wound healing, frequent infections
May exhibit:
Low-grade fever, chills, night sweats
Generalized lymphadenopathy
Petechiae and ecchymosis (aplastic)
May report:
Changes in menstrual flow, e.g., menorrhagia or amenorrhea in women (ID)
Loss of libido (men and women)
Impotence in men
May exhibit:
Pale cervix and vaginal walls
May report:
Family tendency for anemia (ID, PA)
Past/present use of anticonvulsants, antibiotics, chemotherapeutic agents (bone marrow failure), aspirin, anti-inflammatory drugs, or anticoagulants
Chronic use of alcohol
Religious/cultural beliefs affecting treatment choices, e.g., refusal of blood transfusions
Recent/current episode of active bleeding (ID)
History of liver, renal disease; hematologic problems; celiac or other malabsorption disease; regional enteritis; tapeworm manifestations; polyendocrinopathies; autoimmune problem (e.g., antibodies to parietal cells, intrinsic factor, thyroid and T-cell antibodies)
Prior surgeries, e.g., splenectomy; tumor excision; prosthetic valve replacement; surgical excision of duodenum or gastric resection, partial/total gastrectomy (ID, PA)
History of problems with wound healing or bleeding; chronic infections, chronic granulomatous disease, or cancer (secondary anemias)
Discharge plan
DRG projected mean length of inpatient stay: 4.3 days or depending on type/cause of anemia and severity of complications
May require assistance with treatment (injections); self-care activities and/or homemaker/maintenance tasks; changes in dietary plan
Refer to section at end of plan for postdischarge considerations.
Complete blood count (CBC):
Hemoglobin (Hb) and hematocrit (Hct): Decreased in anemias and overhydration caused by excessive IV fluids, bleeding problems, bone marrow suppression.
Erythrocyte (RBC) count: Decreased (PA), severely decreased (aplastic); mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH) decreased and microcytic with hypochromic erythrocytes (ID), elevated (PA); pancytopenia (aplastic).
Stained RBC examination: Detects changes in color and shape (may indicate particular type of anemia).
Reticulocyte count: Varies; helps assess bone marrow function, e.g., decreased (PA, cirrhosis, folic acid deficiency, bone marrow failure, radiation therapy); elevated (blood loss/hemolysis, leukemias, compensated anemias).
White blood cells (WBCs): Total cell count and specific WBCs (differential) may be increased (hemolytic) or decreased (aplastic).
Platelet count: Decreased (aplastic); elevated (ID); normal or high (hemolytic).
Erythrocyte sedimentation rate (ESR): Elevation indicates presence of inflammatory reaction, e.g., increased RBC destruction or malignant disease.
RBC survival time: Useful in the differential diagnosis of anemias because RBCs have shortened life spans in pernicious and hemolytic anemias.
Erythrocyte fragility test: Decreased (ID); increased fragility confirms hemolytic and autoimmune anemias.
Hemoglobin electrophoresis: Identifies type of hemoglobin structure, aids in determining source of hemolytic anemia.
Serum folate and vitamin B12: Aids in diagnosing anemias related to deficiencies in dietary intake/malabsorption.
Serum iron: Absent (ID); elevated (hemolytic, aplastic).
Serum total iron-binding capacity (TIBC): Increased (ID); normal or slightly reduced (AP).
Serum ferritin: Decreased (ID).
Serum bilirubin (unconjugated): Elevated (PA, hemolytic).
Serum lactate dehydrogenase (LDH): May be elevated (PA).
Bleeding time: Prolonged (aplastic).
Schilling’s test: Decreased urinary excretion of vitamin B12 (PA).
Guaiac: May be positive for occult blood in urine, stools, and gastric contents, reflecting acute/chronic bleeding (ID).
Gastric analysis: Decreased secretions with elevated pH and absence of free HCl (PA).
Bone marrow aspiration/biopsy examination: Cells may show changes in number, size, and shape, helping to differentiate type of anemia, e.g., increased megaloblasts (PA); fatty marrow with diminished or absence of blood cells at several sites (aplastic).
Endoscopic and radiographic studies: Checks for bleeding sites, e.g., acute/chronic gastrointestinal (GI) bleeding.
1. Enhance tissue perfusion.
2. Provide nutritional/fluid needs.
3. Prevent complications.
4. Provide information about disease process, prognosis, and treatment regimen.
1. ADLs met by self or with assistance of others.
2. Complications prevented/minimized.
3. Disease process/prognosis and therapeutic regimen understood.
4. Plan in place to meet needs after discharge.