Outcomes (NOC)	Interventions (NIC) and Rationales
Oral Hygiene • Bleeding _____ • Oral mucosa lesions _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Oral Health Restoration • Monitor lips, tongue, mucous membranes, tonsillar fossae, and gums for moisture, color, texture, presence of debris, and infection using good lighting and a tongue blade to provide information for planning interventions. • Assist the patient to select soft, bland, and nonacidic foods to decrease irritation of oral mucosa. • Use a soft toothbrush for removal of dental debris. • Use toothettes or disposable foam swabs to stimulate and clean cavity with minimal trauma to gingiva. • Instruct and assist patient to perform oral hygiene after eating and as often as needed to avoid breakdown of oral mucosa. • Avoid use of lemon-glycerin swabs and commercial mouthwashes to prevent excessive drying of the mucosa.

Outcomes (NOC)

Interventions (NIC) and Rationales

Oral Hygiene

• Bleeding _____

• Oral mucosa lesions _____

Oral Health Restoration

• Monitor lips, tongue, mucous membranes, tonsillar fossae, and gums for moisture, color, texture, presence of debris, and infection using good lighting and a tongue blade to provide information for planning interventions.

• Assist the patient to select soft, bland, and nonacidic foods to decrease irritation of oral mucosa.

• Use a soft toothbrush for removal of dental debris.

• Use toothettes or disposable foam swabs to stimulate and clean cavity with minimal trauma to gingiva.

• Instruct and assist patient to perform oral hygiene after eating and as often as needed to avoid breakdown of oral mucosa.

• Avoid use of lemon-glycerin swabs and commercial mouthwashes to prevent excessive drying of the mucosa.

Nursing Diagnosis

Risk for bleeding related to decreased platelets, treatment-related side effects, and/or inherent coagulopathies

Patient Goals

1. Maintains tissue integrity

2. Has no evidence of bleeding or bruising

Outcomes (NOC)	Interventions (NIC) and Rationales
Blood Coagulation • Bleeding _____ • Bruising _____ • Petechiae _____ • Ecchymosis _____ • Purpura _____ • Hematuria _____ • Hemoptysis _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Bleeding Precautions • Monitor for signs and symptoms of persistent bleeding (e.g., check all secretions for frank or occult blood) to detect internal bleeding. • Monitor coagulation studies, including prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, fibrin degradation/split products, and platelet counts to determine bleeding risk. • Avoid injections (IV, IM, subcutaneous) to prevent bleeding into tissue surrounding puncture site. • Use electric razor instead of straight-edge razor for shaving to reduce potential for skin nicks. • Protect patient from trauma to reduce tissue damage and subsequent bleeding into tissue. • Administer blood products (e.g., platelets, fresh frozen plasma) to replace coagulation factors. • Tell patient to avoid invasive procedures; if they are necessary, monitor closely for bleeding, to reduce potential for internal bleeding. • Instruct the patient/caregiver to avoid aspirin or other anticoagulants to prevent additional bleeding risk.

Outcomes (NOC)

Interventions (NIC) and Rationales

• Monitor for signs and symptoms of persistent bleeding (e.g., check all secretions for frank or occult blood) to detect internal bleeding.

• Monitor coagulation studies, including prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, fibrin degradation/split products, and platelet counts to determine bleeding risk.

• Avoid injections (IV, IM, subcutaneous) to prevent bleeding into tissue surrounding puncture site.

• Use electric razor instead of straight-edge razor for shaving to reduce potential for skin nicks.

• Protect patient from trauma to reduce tissue damage and subsequent bleeding into tissue.

• Administer blood products (e.g., platelets, fresh frozen plasma) to replace coagulation factors.

• Tell patient to avoid invasive procedures; if they are necessary, monitor closely for bleeding, to reduce potential for internal bleeding.

• Instruct the patient/caregiver to avoid aspirin or other anticoagulants to prevent additional bleeding risk.

Nursing Diagnosis

Deficient knowledge related to lack of information regarding the disease process, activity, and medication as evidenced by frequent questioning about disease management, anxiety, restlessness

Patient Goal

Verbalizes required knowledge and skills to manage disease process at home

Outcomes (NOC)	Interventions (NIC) and Rationales
Knowledge: Disease Process • Specific disease process ____ • Cause and contributing factors _____ • Signs and symptoms of disease ____ • Usual course of disease process ____ • Signs and symptoms of disease complications ____ • Precautions to prevent complications of disease _____ Measurement Scale 1 = No knowledge 2 = Limited knowledge 3 = Moderate knowledge 4 = Substantial knowledge 5 = Extensive knowledge	Teaching: Disease Process • Appraise patient’s current level of knowledge related to specific disease process to plan appropriate interventions. • Describe disease process. • Describe common signs and symptoms of the disease so patient will know what to expect. • Discuss treatment/therapy options to decrease anxiety and prevent complications. • Discuss lifestyle changes that may be required to prevent future complications and/or control the disease process so patient will be knowledgeable and able to manage own care or direct others in care. • Refer patient to local community agencies/support groups for continued education and support. • Provide the phone numbers to call if complications occur to enable control of complications.

Outcomes (NOC)

Interventions (NIC) and Rationales

Knowledge: Disease Process

• Specific disease process ____

• Cause and contributing factors _____

• Signs and symptoms of disease ____

• Usual course of disease process ____

• Signs and symptoms of disease complications ____

• Precautions to prevent complications of disease _____

Measurement Scale

1 = No knowledge

2 = Limited knowledge

3 = Moderate knowledge

4 = Substantial knowledge

5 = Extensive knowledge

Teaching: Disease Process

• Appraise patient’s current level of knowledge related to specific disease process to plan appropriate interventions.

• Describe disease process.

• Describe common signs and symptoms of the disease so patient will know what to expect.

• Discuss treatment/therapy options to decrease anxiety and prevent complications.

• Discuss lifestyle changes that may be required to prevent future complications and/or control the disease process so patient will be knowledgeable and able to manage own care or direct others in care.

• Refer patient to local community agencies/support groups for continued education and support.

• Provide the phone numbers to call if complications occur to enable control of complications.

^*Nursing diagnoses listed in order of priority.

eNursing Care Plan 31-2 Patient With Neutropenia

Nursing Diagnosis

Risk for infection related to inadequate secondary defenses (immunosuppression), altered response to microbial invasion, and environmental exposure to pathogens

Patient Goals

1. Adheres to infection control and protection practices

2. Experiences no signs or symptoms of infection, reducing the risk of septic shock

Outcomes (NOC)	Interventions (NIC) and Rationales
Risk Control: Infectious Process • Acknowledges personal risk for infection _____ • Identifies risk in everyday situations _____ • Identifies strategies to protect self from others with infection _____ • Monitors environment for factors associated with infection risk _____ • Develops effective infection control strategies _____ • Practices infection control strategies ____ • Monitors changes in general health status _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Infection Prevention • Maintain isolation techniques as appropriate to reduce exposure to environmental pathogens. • Screen all visitors for communicable disease to prevent the transmission of harmful pathogens to patient. • Remove fresh flowers and plants from patient areas to avoid introduction of pathogens. • Follow neutropenic precautions to avoid exposure to pathogens. • Monitor for systemic and localized signs and symptoms of infection to promote early detection of infection. • Monitor absolute granulocyte count, WBC count, and WBC differential results to identify signs of and potential for infection. • Inspect skin and mucous membranes for redness, extreme warmth, or drainage to detect infection. • Teach patient and caregiver how to avoid infections (e.g., personal hygiene techniques of hand washing, oral care, skin hygiene, and pulmonary hygiene). • Teach the patient and caregivers about signs and symptoms of infection and when to report them to the health care provider to receive early treatment of infection. • Report suspected infections to infection control personnel in order to promptly initiate antibiotic therapy. • Instruct patient to take antibiotics as prescribed to prevent microbial resistance.

Outcomes (NOC)

Interventions (NIC) and Rationales

Risk Control: Infectious Process

• Acknowledges personal risk for infection _____

• Identifies risk in everyday situations _____

• Identifies strategies to protect self from others with infection _____

• Monitors environment for factors associated with infection risk _____

• Develops effective infection control strategies _____

• Practices infection control strategies ____

• Monitors changes in general health status _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Infection Prevention

• Maintain isolation techniques as appropriate to reduce exposure to environmental pathogens.

• Screen all visitors for communicable disease to prevent the transmission of harmful pathogens to patient.

• Remove fresh flowers and plants from patient areas to avoid introduction of pathogens.

• Follow neutropenic precautions to avoid exposure to pathogens.

• Monitor for systemic and localized signs and symptoms of infection to promote early detection of infection.

• Monitor absolute granulocyte count, WBC count, and WBC differential results to identify signs of and potential for infection.

• Inspect skin and mucous membranes for redness, extreme warmth, or drainage to detect infection.

• Teach patient and caregiver how to avoid infections (e.g., personal hygiene techniques of hand washing, oral care, skin hygiene, and pulmonary hygiene).

• Teach the patient and caregivers about signs and symptoms of infection and when to report them to the health care provider to receive early treatment of infection.

• Report suspected infections to infection control personnel in order to promptly initiate antibiotic therapy.

• Instruct patient to take antibiotics as prescribed to prevent microbial resistance.

Anemia

Definition and Classification

Anemia is a deficiency in the number of erythrocytes (red blood cells [RBCs]), the quantity or quality of hemoglobin, and/or the volume of packed RBCs (hematocrit). It is a prevalent condition with many diverse causes such as blood loss, impaired production of erythrocytes, or increased destruction of erythrocytes (Fig. 31-1). Because RBCs transport oxygen (O₂), erythrocyte disorders can lead to tissue hypoxia. This hypoxia accounts for many of the signs and symptoms of anemia. Anemia is not a specific disease. It is a manifestation of a pathologic process.

Anemia is classified by review of the complete blood count (CBC), reticulocyte count, and peripheral blood smear. Once anemia is identified, further investigation is done to determine its specific cause.¹

Anemia can result from primary hematologic problems or can develop as a secondary consequence of diseases or disorders of other body systems. The various types of anemia can be classified according to either morphology (cellular characteristic) or etiology (cause). Morphologic classification is based on erythrocyte size and color (Table 31-1). Etiologic classification is related to the clinical conditions causing the anemia^2,3 (Table 31-2). Although the morphologic system is the most accurate means of classifying anemias, it is easier to discuss patient care by focusing on the etiology of the anemia.

TABLE 31-1

MORPHOLOGY AND ETIOLOGY OF ANEMIA

Morphology	Etiology
Normocytic, normochromic (normal size and color) MCV 80-100 fL, MCH 27-34 pg	Acute blood loss, hemolysis, chronic kidney disease, chronic disease, cancers, sideroblastic anemia, endocrine disorders, starvation, aplastic anemia, sickle cell anemia, pregnancy
Microcytic, hypochromic (small size, pale color) MCV <80 fL, MCH <27 pg	Iron-deficiency anemia, vitamin B₆ deficiency, copper deficiency, thalassemia, lead poisoning
Macrocytic (megaloblastic), normochromic (large size, normal color) MCV >100 fL, MCH >34 pg	Cobalamin (vitamin B₁₂) deficiency, folic acid deficiency, liver disease (including effects of alcohol abuse), postsplenectomy

MCH, Mean corpuscular hemoglobin; MCV, mean corpuscular volume.

TABLE 31-2

CLASSIFICATION OF ANEMIA

Decreased RBC Production

Decreased Hemoglobin Synthesis

• Iron deficiency

• Thalassemias (decreased globin synthesis)

• Sideroblastic anemia (decreased porphyrin)

Defective DNA Synthesis

• Cobalamin (vitamin B₁₂) deficiency

• Folic acid deficiency

Decreased Number of RBC Precursors

• Aplastic anemia and inherited disorders (e.g., Fanconi syndrome)

• Anemia of myeloproliferative diseases (e.g., leukemia) and myelodysplasia

• Chronic diseases or disorders

• Medications and chemicals (e.g., chemotherapy, lead)

• Radiation

Blood Loss

Acute

• Trauma

• Blood vessel rupture

• Splenic sequestration crisis

Chronic

• Gastritis

• Menstrual flow

• Hemorrhoids

Increased RBC Destruction (Hemolytic Anemias)

Hereditary (Intrinsic)

• Abnormal hemoglobin (sickle cell disease)

• Enzyme deficiency (G6PD)

• Membrane abnormalities (paroxysmal nocturnal hemoglobinuria, hereditary spherocytosis)

Acquired (Extrinsic)

• Macroangiopathic: physical trauma (prosthetic heart valves, extracorporeal circulation)

• Microangiopathic: disseminated intravascular coagulopathy (DIC), thrombotic thrombocytopenic purpura (TTP)

• Antibodies (isoimmune and autoimmune)

• Infectious agents (e.g., malaria) and toxins

G6PD, Glucose-6-phosphate dehydrogenase.

Cultural & Ethnic Health Disparities

Hematologic Problems

• Sickle cell disease has a high incidence among African Americans.

• Thalassemia has a high incidence among African Americans and people of Mediterranean origin.

• Tay-Sachs disease has the highest incidence in families of Eastern European Jewish origin, especially the Ashkenazi Jews.

• Pernicious anemia has a high incidence among Scandinavians and African Americans.

Clinical Manifestations

The clinical manifestations of anemia are caused by the body’s response to tissue hypoxia. Specific manifestations vary depending on the rate at which the anemia has evolved, its severity, and any coexisting disease. Hemoglobin (Hgb) levels are often used to determine the severity of anemia.

Mild states of anemia (Hgb 10 to 12 g/dL [100 to 120 g/L]) may exist without causing symptoms. If symptoms develop, it is because the patient has an underlying disease or is experiencing a compensatory response to heavy exercise. Symptoms include palpitations, dyspnea, and mild fatigue.2,3

In moderate anemia (Hgb 6 to 10 g/dL [60 to 100 g/L]) the cardiopulmonary symptoms are increased. The patient may experience them while resting, as well as with activity.

In severe anemia (Hgb less than 6 g/dL [60 g/L]) the patient has many clinical manifestations involving multiple body systems (Table 31-3).

TABLE 31-3

MANIFESTATIONS OF ANEMIA

Body System	Severity of Anemia
Body System	Mild (Hgb 10-12 g/dL [100-120 g/L])	Moderate (Hgb 6-10 g/dL [60-100 g/L])	Severe (Hgb <6 g/dL [<60 g/L])
Integument	None	None	Pallor, jaundice,* pruritus*
Eyes	None	None	Icteric conjunctiva and sclera,* retinal hemorrhage, blurred vision
Mouth	None	None	Glossitis, smooth tongue
Cardiovascular	Palpitations	Increased palpitations, “bounding pulse”	Tachycardia, increased pulse pressure, systolic murmurs, intermittent claudication, angina, heart failure, myocardial infarction
Pulmonary	Exertional dyspnea	Dyspnea	Tachypnea, orthopnea, dyspnea at rest
Neurologic	None	“Roaring in the ears”	Headache, vertigo, irritability, depression, impaired thought processes
Gastrointestinal	None	None	Anorexia, hepatomegaly, splenomegaly, difficulty swallowing, sore mouth
Musculoskeletal	None	None	Bone pain
General	None or mild fatigue	Fatigue	Sensitivity to cold, weight loss, lethargy

^*Caused by hemolysis.

Integumentary Changes.

Integumentary changes include pallor, jaundice, and pruritus. Pallor results from reduced amounts of hemoglobin and reduced blood flow to the skin. Jaundice occurs when hemolysis of RBCs results in an increased concentration of serum bilirubin. Pruritus occurs because of increased serum and skin bile salt concentrations. In addition to the skin, the sclera of the eyes and mucous membranes should be evaluated for jaundice because they reflect the integumentary changes more accurately, especially in a dark-skinned individual.

Cardiopulmonary Manifestations.

Cardiopulmonary manifestations of severe anemia result from additional attempts by the heart and lungs to provide adequate amounts of oxygen to the tissues. Cardiac output is maintained by increasing the heart rate and stroke volume. The low viscosity of the blood contributes to the development of systolic murmurs and bruits. In extreme cases or when concomitant heart disease is present, angina pectoris and myocardial infarction (MI) may occur if myocardial O₂ needs cannot be met. Heart failure (HF), cardiomegaly, pulmonary and systemic congestion, ascites, and peripheral edema may develop if the heart is overworked for an extended period.

Nursing Management Anemia

This section discusses general nursing management of anemia. Specific care related to various types of anemia is discussed later in this chapter.

Nursing Assessment

Subjective and objective data that should be obtained from a patient with anemia are presented in Table 31-4.

TABLE 31-4

NURSING ASSESSMENT
Anemia

Subjective Data

Important Health Information

Past health history: Recent blood loss or trauma; chronic liver, endocrine, or renal disease (including dialysis); GI disease (malabsorption syndrome, ulcers, gastritis, or hemorrhoids); inflammatory disorders (especially Crohn’s disease); smoking, exposure to radiation or chemical toxins (arsenic, lead, benzenes, copper); infectious diseases (HIV) or recent travel with possible exposure to infection; angina, myocardial infarction; history of falling

Medications: Use of vitamin and iron supplements; aspirin, anticoagulants, oral contraceptives, phenobarbital, penicillins, nonsteroidal antiinflammatory drugs, omeprazole, phenacetin, phenytoin (Dilantin), sulfonamides, herbal products

Surgery or other treatments: Recent surgery, small bowel resection, gastrectomy, prosthetic heart valves, chemotherapy, radiation therapy

Dietary history: General dietary patterns, consumption of alcohol

Functional Health Patterns

Health perception–health management: Family history of anemia; malaise

Nutritional-metabolic: Nausea, vomiting, anorexia, weight loss; dysphagia, dyspepsia, heartburn; night sweats, cold intolerance

Elimination: Hematuria, decreased urine output; diarrhea, constipation, flatulence, tarry stools, bloody stools

Activity-exercise: Fatigue, muscle weakness and decreased strength; dyspnea, orthopnea, cough, hemoptysis; palpitations; shortness of breath with activity

Cognitive-perceptual: Headache; abdominal, chest, and bone pain; painful tongue; paresthesias of feet and hands; pruritus; disturbances in vision, taste, or hearing; vertigo; hypersensitivity to cold; dizziness

Sexuality-reproductive: Menorrhagia, metrorrhagia; recent or current pregnancy; male impotence

Objective Data

General

Lethargy, apathy, general lymphadenopathy, fever

Integumentary

Pale skin and mucous membranes; blue, pale white, or icteric sclera; cheilitis (inflammation of the lips); poor skin turgor; brittle, spoon-shaped fingernails; jaundice; petechiae; ecchymoses; nose or gingival bleeding; poor healing; dry, brittle, thinning hair

Respiratory

Tachypnea

Cardiovascular

Tachycardia, systolic murmur, dysrhythmias; postural hypotension, widened pulse pressure, bruits (especially carotid); intermittent claudication, ankle edema

Gastrointestinal

Hepatosplenomegaly; glossitis; beefy, red tongue; stomatitis; abdominal distention; anorexia

Neurologic

Headache, roaring in the ears, confusion, impaired judgment, irritability, ataxia, unsteady gait, paralysis, loss of vibration sense

Possible Diagnostic Findings

↓ RBCs, ↓ Hgb; ↓ Hct; ↑ or ↓ reticulocytes, MCV, serum iron, ferritin, folate, or cobalamin (vitamin B₁₂); heme (guaiac)–positive stools; ↓ serum erythropoietin level; ↑ or ↓ LDH, bilirubin, transferrin (see Table 31-6)

LDH, Lactate dehydrogenase; MCV, mean corpuscular volume.

Nursing Diagnoses

Nursing diagnoses for the patient with anemia include, but are not limited to, those presented in Nursing Care Plan 31-1.

Nursing Care Plan 31-1 Patient With Anemia

Nursing Diagnosis *

Patient Goals

1. Participates in activities of daily living without abnormal increases in blood pressure and pulse

2. Reports increased endurance for activity

Outcomes (NOC)	Interventions (NIC) and Rationales
Fatigue Level • Exhaustion _____ • Loss of appetite _____ • Decreased motivation _____ • Lassitude _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None Energy Conservation • Recognizes energy limitations _____ • Balances activity and rest _____ • Uses energy conservation techniques _____ • Organizes activities to conserve energy _____ • Maintains adequate nutrition _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Energy Management • Correct physiologic status deficits (e.g., chemotherapy-induced anemia) as priority items. • Encourage alternate rest and activity periods to provide activity without tiring the patient. • Monitor cardiorespiratory response to activity (e.g., tachycardia, dysrhythmias, dyspnea, diaphoresis, pallor, respiratory rate) to evaluate activity intolerance. • Limit number of visitors and interruptions by visitors to provide rest periods. • Assist the patient in assigning priority to activities to accommodate energy levels to promote tolerance for important activities. • Arrange physical activities (e.g., avoid activity immediately after meals) to reduce competition for O₂ supply to vital functions. • Assist with regular physical activities (e.g., ambulation, transfers, personal care) to minimize fatigue and risk of injury from falls. • Instruct patient and caregiver to recognize signs and symptoms of fatigue that require reduction in activity to promote self-care. • Instruct patient and caregiver to notify health care provider if signs and symptoms of fatigue persist to review treatment plan.

Outcomes (NOC)

Interventions (NIC) and Rationales

Fatigue Level

• Exhaustion _____

• Loss of appetite _____

• Decreased motivation _____

• Recognizes energy limitations _____

• Balances activity and rest _____

• Uses energy conservation techniques _____

• Organizes activities to conserve energy _____

• Maintains adequate nutrition _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Energy Management

• Correct physiologic status deficits (e.g., chemotherapy-induced anemia) as priority items.

• Encourage alternate rest and activity periods to provide activity without tiring the patient.

• Monitor cardiorespiratory response to activity (e.g., tachycardia, dysrhythmias, dyspnea, diaphoresis, pallor, respiratory rate) to evaluate activity intolerance.

• Limit number of visitors and interruptions by visitors to provide rest periods.

• Assist the patient in assigning priority to activities to accommodate energy levels to promote tolerance for important activities.

• Arrange physical activities (e.g., avoid activity immediately after meals) to reduce competition for O₂ supply to vital functions.

• Assist with regular physical activities (e.g., ambulation, transfers, personal care) to minimize fatigue and risk of injury from falls.

• Instruct patient and caregiver to recognize signs and symptoms of fatigue that require reduction in activity to promote self-care.

• Instruct patient and caregiver to notify health care provider if signs and symptoms of fatigue persist to review treatment plan.

Nursing Diagnosis

Imbalanced nutrition: less than body requirements related to inadequate nutritional intake and anorexia as evidenced by weight loss, low serum albumin, decreased iron level, vitamin deficiencies

Patient Goals

1. Maintains dietary intake that provides minimum daily requirements of nutrients

2. Attains normal blood values of nutrients necessary to prevent anemia

Outcomes (NOC)	Interventions (NIC) and Rationales
Nutritional Status • Nutrient intake _____ • Weight/height ratio _____ Nutritional Status: Biochemical Measures • Serum albumin _____ • Serum transferrin _____ • Hemoglobin _____ • Hematocrit _____ • Total iron-binding capacity _____ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviation from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range	Nutrition Management • Determine, in collaboration with dietitian, number of calories and type of nutrients needed to meet nutritional requirements to plan interventions. • Teach patient how to keep a food diary to help evaluate nutritional intake. • Monitor recorded intake for nutritional content and calories to evaluate nutritional status. • Provide appropriate information about nutritional needs and how to meet them to increase intake of essential nutrients needed. • Encourage increased intake of protein, iron, and vitamin C to provide nutrients needed for maximum iron absorption and hemoglobin production. • Encourage increased intake of foods high in iron to provide nutrient needed for hemoglobin production.

Outcomes (NOC)

Interventions (NIC) and Rationales

Nutritional Status

• Nutrient intake _____

• Weight/height ratio _____

Nutritional Status: Biochemical Measures

• Serum albumin _____

• Serum transferrin _____

• Hemoglobin _____

• Hematocrit _____

• Total iron-binding capacity _____

Measurement Scale

1 = Severe deviation from normal range

2 = Substantial deviation from normal range

3 = Moderate deviation from normal range

4 = Mild deviation from normal range

5 = No deviation from normal range

Nutrition Management

• Determine, in collaboration with dietitian, number of calories and type of nutrients needed to meet nutritional requirements to plan interventions.

• Teach patient how to keep a food diary to help evaluate nutritional intake.

• Monitor recorded intake for nutritional content and calories to evaluate nutritional status.

• Provide appropriate information about nutritional needs and how to meet them to increase intake of essential nutrients needed.

• Encourage increased intake of protein, iron, and vitamin C to provide nutrients needed for maximum iron absorption and hemoglobin production.

• Encourage increased intake of foods high in iron to provide nutrient needed for hemoglobin production.

Nursing Diagnosis

Ineffective self-health management related to lack of knowledge about appropriate nutrition and medication regimen as evidenced by questioning about lifestyle adjustments, diet, medications

Patient Goal

Verbalizes knowledge necessary to maintain adequate nutrition and management of medication regimen

Outcomes (NOC)	Interventions (NIC) and Rationales
Knowledge: Diet • Recommended diet _____ • Dietary goals _____ • Healthy nutritional practices _____ • Potential food and medication interactions _____ Knowledge: Medication • Identification of correct name of medication(s) _____ • Medication therapeutic effects ____ • Medication adverse effects _____ • Correct use of prescribed medication _____ • Required laboratory tests for monitoring medication _____ Measurement Scale 1 = No knowledge 2 = Limited knowledge 3 = Moderate knowledge 4 = Substantial knowledge 5 = Extensive knowledge	Nutritional Counseling • Facilitate identification of eating behaviors to be changed. • Use accepted nutritional standards to assist patient in evaluating adequacy of dietary intake to evaluate adequacy. • Discuss nutritional requirements and patient’s perceptions of prescribed or recommended diet. • Provide referral or consultation with other members of the health care team to help patient maintain gains and adjustments throughout recovery. • Review with patient measurements of hemoglobin values to evaluate response to therapeutic plan. Teaching: Prescribed Medication • Instruct the patient on the purpose and action of each medication. • Instruct the patient on dosage, route, and duration of each medication to improve adherence. • Instruct the patient on possible adverse effects of each medication to ensure early detection of untoward responses to medication.

Outcomes (NOC)

Interventions (NIC) and Rationales

Knowledge: Diet

• Recommended diet _____

• Dietary goals _____

• Healthy nutritional practices _____

• Potential food and medication interactions _____

Knowledge: Medication

• Identification of correct name of medication(s) _____

• Medication therapeutic effects ____

• Medication adverse effects _____

• Correct use of prescribed medication _____

• Required laboratory tests for monitoring medication _____

Measurement Scale

1 = No knowledge

2 = Limited knowledge

3 = Moderate knowledge

4 = Substantial knowledge

5 = Extensive knowledge

Nutritional Counseling

• Facilitate identification of eating behaviors to be changed.

• Use accepted nutritional standards to assist patient in evaluating adequacy of dietary intake to evaluate adequacy.

• Discuss nutritional requirements and patient’s perceptions of prescribed or recommended diet.

• Provide referral or consultation with other members of the health care team to help patient maintain gains and adjustments throughout recovery.

• Review with patient measurements of hemoglobin values to evaluate response to therapeutic plan.

Teaching: Prescribed Medication

• Instruct the patient on the purpose and action of each medication.

• Instruct the patient on dosage, route, and duration of each medication to improve adherence.

• Instruct the patient on possible adverse effects of each medication to ensure early detection of untoward responses to medication.

^*Nursing diagnoses listed in order of priority.

Planning

The overall goals are that the patient with anemia will (1) assume normal activities of daily living, (2) maintain adequate nutrition, and (3) develop no complications related to anemia.

Nursing Implementation

The numerous causes of anemia necessitate different nursing interventions specific to the patient’s needs. Nevertheless, certain general components of care for all patients with anemia are presented in Nursing Care Plan 31-1.

Correcting the cause of the anemia is ultimately the goal of therapy. Acute interventions may include blood or blood product transfusions, drug therapy (e.g., erythropoietin, vitamin supplements), volume replacement, and O₂ therapy to stabilize the patient. Dietary and lifestyle changes (described in sections on specific types of anemia) can reverse some anemias so that the patient can return to the former state of health. Assess the patient’s knowledge regarding adequate nutritional intake and adherence to safety precautions to prevent falls and injury.

Gerontologic Considerations

Anemia

Modest changes in RBC mass occur in older adults. Healthy older men have a modest decline in hemoglobin of about 1 g/dL between ages 70 and 88 years, in part because of the decreased production of testosterone. Only a minimal decrease in hemoglobin (about 0.2 g/dL) occurs between these ages in healthy women.

For older adults with anemia, about one third have a nutritional type of anemia (e.g., iron, folate, cobalamin). About another third have renal insufficiency and/or chronic inflammation, and the other third have anemia that is unexplained.

Cobalamin (vitamin B₁₂) and folate deficiency may occur in about 14% of older adults because of pernicious anemia, insufficient dietary intake, and malabsorption caused by low stomach acidity.⁴ Multiple co-morbid conditions in older adults increase the likelihood of many types of anemia occurring.

Clinical manifestations of anemia in older adults may include pallor, confusion, ataxia, fatigue, worsening angina, and heart failure.² Unfortunately, anemia may go unrecognized in older adults because these manifestations may be mistaken for normal aging changes or overlooked because of another health problem. By recognizing signs of anemia, you can play a pivotal role in health assessment and related interventions for older adults.

Anemia Caused by Decreased Erythrocyte Production

Normally RBC production (termed erythropoiesis) is in equilibrium with RBC destruction and loss. This balance ensures that an adequate number of erythrocytes is available at all times. The normal life span of an RBC is 120 days. Three alterations in erythropoiesis may occur that decrease RBC production: (1) decreased hemoglobin synthesis may lead to iron-deficiency anemia, thalassemia, and sideroblastic anemia; (2) defective deoxyribonucleic acid (DNA) synthesis in RBCs (e.g., cobalamin deficiency, folic acid deficiency) may lead to megaloblastic anemias; and (3) diminished availability of erythrocyte precursors may result in aplastic anemia and anemia of chronic disease (see Table 31-2).

Iron-Deficiency Anemia

Iron-deficiency anemia, one of the most common chronic hematologic disorders, is found in 2% to 5% of adult men and postmenopausal women in developed countries. Those most susceptible to iron-deficiency anemia are the very young, those on poor diets, and women in their reproductive years.5,6 Normally, 1 mg of iron is lost daily through feces, sweat, and urine.⁷

Etiology

Iron-deficiency anemia may develop as a result of inadequate dietary intake, malabsorption, blood loss, or hemolysis. (Normal iron metabolism is discussed in Chapter 30 on p. 616.) Normal dietary iron intake is usually sufficient to meet the needs of men and older women, but it may be inadequate for those individuals who have higher iron needs (e.g., menstruating or pregnant women). Table 31-5 lists nutrients needed for erythropoiesis.^8,9

TABLE 31-5

NUTRITIONAL THERAPY
Nutrients for Erythropoiesis

Role in Erythropoiesis	Food Sources
Cobalamin (Vitamin B₁₂)
RBC maturation	Red meats, especially liver, eggs, enriched grain products, milk and dairy foods, fish
Copper
Mobilization of iron from tissues to plasma*	Shellfish, whole grains, beans, nuts, potatoes, organ meats, dark green leafy vegetables, dried prunes
Folic Acid
RBC maturation	Green leafy vegetables, liver, meat, fish, legumes, whole grains, orange juice, peanuts
Iron
Hemoglobin synthesis	Liver and muscle meats, eggs, dried fruits, legumes, dark green leafy vegetables, whole-grain and enriched bread and cereals, potatoes
Niacin
Needed for maturation of RBC	High-protein foods such as peanut butter, beans, meats, avocado; enriched and fortified grains
Pantothenic Acid (Vitamin B₅)
Heme synthesis	Meats, vegetables, cereal grains, legumes, eggs, milk
Pyridoxine (Vitamin B₆)
Hemoglobin synthesis	Meats, fortified cereals, whole grains, legumes, potatoes, cornmeal, bananas, nuts
Riboflavin (Vitamin B₂)
Oxidative reactions	Milk and dairy foods, enriched bread and other grain products, salmon, chicken, eggs, leafy green vegetables
Vitamin E
Possible role in heme synthesis. Protection against oxidative damage to RBCs	Vegetable oils, salad dressings, margarine, wheat germ, whole-grain products, seeds, nuts, peanut butter
Amino Acids
Synthesis of nucleoproteins	Eggs, meat, milk and milk products (cheese, ice cream), poultry, fish, legumes, nuts
Ascorbic Acid (Vitamin C)
Conversion of folic acid to its active forms, aids in iron absorption	Citrus fruits, green leafy vegetables, strawberries, cantaloupe

^*Supplementation rarely needed and large amounts of copper are poisonous.

Malabsorption of iron may occur after certain types of gastrointestinal (GI) surgery and in malabsorption syndromes. Surgical procedures may involve removal or bypass of the duodenum (see Chapter 42). As iron absorption occurs in the duodenum, malabsorption syndromes may involve disease of the duodenum in which the absorption surface is altered or destroyed.

Blood loss is a major cause of iron deficiency in adults. Two milliliters of whole blood contain 1 mg of iron. The major sources of chronic blood loss are from the GI and genitourinary (GU) systems. GI bleeding is often not apparent and therefore may exist for a considerable time before the problem is identified. Loss of 50 to 75 mL of blood from the upper GI tract is required for stools to appear black (melena). The black color results from the iron in the RBCs. Common causes of GI blood loss are peptic ulcer, gastritis, esophagitis, diverticuli, hemorrhoids, and neoplasia. GU blood loss occurs primarily from menstrual bleeding. The average monthly menstrual blood loss is about 45 mL and causes the loss of about 22 mg of iron. Postmenopausal bleeding can contribute to anemia in a susceptible older woman. In addition to anemia of chronic kidney disease, dialysis treatment may induce iron-deficiency anemia because of the blood lost in the dialysis equipment and frequent blood sampling.

Clinical Manifestations

In the early course of iron-deficiency anemia the patient may not have any symptoms. As the disease becomes chronic, any of the general manifestations of anemia may develop (see Table 31-3). In addition, specific clinical manifestations may occur related to iron-deficiency anemia. Pallor is the most common finding, and glossitis (inflammation of the tongue) is the second most common. Another finding is cheilitis (inflammation of the lips). In addition, the patient may report headache, paresthesias, and a burning sensation of the tongue, all of which are caused by lack of iron in the tissues.

Diagnostic Studies

Laboratory abnormalities characteristic of iron-deficiency anemia are presented in Table 31-6. Other diagnostic studies (e.g., stool guaiac test) are done to determine the cause of the iron deficiency. Endoscopy and colonoscopy may be used to detect GI bleeding. A bone marrow biopsy may be done if other tests are inconclusive.

TABLE 31-6

LABORATORY STUDY FINDINGS IN ANEMIAS

Etiology of Anemia	Hgb/Hct	MCV	Reticulocytes	Serum Iron	TIBC	Transferrin	Ferritin	Bilirubin	Serum B₁₂	Folate
Iron deficiency	↓	↓	N or slight ↓ or ↑	↓	↑	N or ↓	↓	N or ↓	N	N
Thalassemia major	↓	N or ↓	↑	↑	↓	↓	N or ↑	↑	N	↓
Cobalamin deficiency	↓	↑	N or ↓	N or ↑	N	Slight ↑	↑	N or slight ↑	↓	N
Folic acid deficiency	↓	↑	N or ↓	N or ↑	N	Slight ↑	↑	N or slight ↑	N	↓
Aplastic anemia	↓	N or slight ↑	↓	N or ↑	N or ↑	N	N	N	N	N
Chronic disease	↓	N or ↓	N or ↓	N or ↓	↓	N or ↓	N or ↑	N	N	N
Acute blood loss	↓	N or ↓	N or ↑	N	N	N	N	N	N	N
Chronic blood loss	↓	↓	N or ↑	↓	↓	N	N	N or ↓	N	N
Sickle cell anemia	↓	N	↓	N or ↑	N or ↓	N	N	↑	N	↓
Hemolytic anemia	↓	N or ↑	↑	N or ↑	N or ↓	N	N or ↑	↑	N	N

MCV, Mean corpuscular volume; N, normal; TIBC, total iron-binding capacity.

Collaborative Care

The main goal is to treat the underlying disease that is causing reduced intake (e.g., malnutrition, alcoholism) or absorption of iron. In addition, efforts are directed toward replacing iron (Table 31-7). Teach the patient which foods are good sources of iron (see Table 31-5). If nutrition is already adequate, increasing iron intake by dietary means may not be practical. Consequently, oral or occasionally parenteral iron supplements are used. If the iron deficiency is from acute blood loss, the patient may require a transfusion of packed RBCs.

TABLE 31-7

COLLABORATIVE CARE
Iron-Deficiency Anemia

Diagnostic

• History and physical examination

• Hct and Hgb levels

• RBC count, including morphology

• Total iron-binding capacity (TIBC)

• Stool examination for occult blood