Nursing Diagnosis: Risk for Bleeding related to low hemoglobin and bone marrow malfunction secondary to aplastic anemia. ; Iron deficiency is defined as a decreased total iron body content. Nursing Care Plan for Thrombocytopenia 2. (https://www.cancer.gov/publications/fact-sheets?msclkid=7446ef3fa9e111ec86449ced5f55f9e4), (https://www.merckmanuals.com/home/blood-disorders/spleen-disorders/enlarged-spleen?msclkid=46277053a9e211ecaa9aaec74a1acaf8), Pathology & Laboratory Medicine Institute (R. Tomsich). 2. Therefore, Hb determinations are important in the evaluation of anemia. 2. Nursing Diagnosis: Fatigue Related to: Disease process Diminished oxygen-carrying capacity of the blood document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. St. Louis, MO: Elsevier. Assess the specific cause of fatigue.The specific cause of fatigue is tissue hypoxia from normocytic anemia. Oral iron formulations appear to be similarly effective and tolerated. Assess the degree of activity intolerance.Assess the severity of activity intolerance. White blood cells are part of the persons immune system because white blood cells help in fighting infection and other diseases. Thrombocytopenia Nursing Diagnosis and Nursing Care Plan Treatment for iron deficiency anemia may include iron supplements or changes in diet to increase iron intake. Cleveland Clinic. Patients may experience low hemoglobin as a result of bleeding or coagulation abnormalities. And the process by which they develop can be seen in the bone marrow biopsy. With decreased hemoglobin that serves as the pigment in the red blood cells, the patient may becomepale because of the lack or decrease in the pigment that is hemoglobin. Instruct on activities that require minimal exertion.Slowing down may be difficult if the patient is accustomed to an active lifestyle. Significantly increased - hepatitis, liver necrosis or ischemia, 2. Anemia Nursing Care Plans | anemia, hemoglobin and more | Medasia.Store Silvestri, L. A. Most patients have a rudimentary understanding of the hematological system and terminology. Organization and time management can help the client conserve energy and reduce fatigue. For example, if your hemoglobin levels are low, your healthcare provider may do tests that reveal you have iron-deficiency anemia. 2014. This handbook is designed for practicing nurses and nursing students, providing guidance in selecting appropriate nursing diagnoses and writing care plans. To prevent hemorrhages in patients. Monitor patient for S&S of infection - increased temp. A value greater than 20 g/dL (200 g/L) can lead to obstruction of the capillaries as a result of hemoconcentration. Desired Outcome: The patient will have an absence of bleeding, a hemoglobin (HB) level of . 1. Desired Outcome: The patient will express comprehension of energy conservation. Fatigue can affect a person's motivation to perform activities and makes him/her vulnerable to a sedentary lifestyle. Each gram of Hb can carry 1.34 mL of oxygen per 100 mL of blood. Option C:Decreased hemoglobin is one of the signs that form the diagnosis of anemia. Encourage the patient to verbalize feelings about his or her limitations. Youre losing blood from injury or illness. Encourage adequate rest periods.Activity intolerance may be aggravated by fatigue. Hemoglobin is a protein in the blood that carries oxygen and carbon dioxide to and from the tissues and organs back to the lungs. Nursing Diagnosis: Deficient Knowledge related to inadequate resources and information with the condition secondary to anemia, as evidenced by verbalizations on the lack of understanding of the disease, inability to follow directions, constant inquiries, and conveyed incorrect information. The ultimate reference for nursing diagnoses from experts at NANDA-I has been updated in a new edition. Desired Outcomes: The patient will report feeling more energized. If your test results show low hemoglobin levels, your healthcare provider will explain why you have this symptom, what it means and how it will be treated. However, the universal treatment scheme is through careful medical management and supportive therapy. To prevent anemia, lifestyle modifications must be made. Increased reticulocyte count is associated with hemolytic anemia. On a scale of 0 to 10, ask the patient to rate his/her perceived level of exertion. NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023. 8. Fatigue brought on by anemia manifests itself in various ways, affecting cognitive capacity and social and emotional well-being. A nurse should know that a diagnosis of hemolytic anemia is associated with all of the following except: A. Abnormality in the circulation of plasma. Administer blood products as indicated.A blood transfusion may be indicated for patients with low hemoglobin and bleeding. Clinical alert An Hb value less than 5.0 g/dL (50 g/L) can lead to heart failure and death. Annals of the New York Academy of Sciences,1450(1), 1531. Stress the importance of frequent rest periods.Energy reserves may be depleted unless the client respects the bodys need for increased rest. As an Amazon Associate I earn from qualifying purchases. Decrease in the reticulocyte count. Reticulocytes are immature red blood cells, and due to their lack of biconcave shape, their stability cannot be guaranteed in the sheer stress it would be subjected to in the blood circulation. Diagnostic procedures are important to help in diagnosing the type of anemia which will be based on the changes in the RBC levels and the findings in the bone marrow aspiration. Saunders comprehensive review for the NCLEX-RN examination. 4. In certain pathophysiologic states such as severe anemia, the rate of adequate oxygen delivery is impaired. There are many forms of anemia, each with its own cause. Assist the client in developing a schedule for daily activity and rest. To enhance the patients endurance and strength. Range of motion ROM) exercises is important to patients with activity intolerance because ROM exercise will strengthen the muscle and joints of the patient. Hello, Im a BSN student at the Catholic University of Eastern Africa. iron deficiency, thalassemia, pernicious anemia, hemoglobinopathies, reactions to physical agents (severe burns, artificial heat valves), occurs after transfusions, hemorrhages, burns. NURSING | Free NURSING.com Courses 2. Instruct the patient and their visitors on proper handwashing techniques. Reviewed: November 02, 2022. A schedule that alternates periods of activity and rest is recommended to help the patient achieve his/her planned activities without becoming fatigued. Instruct the patient to consume iron-rich foods to help build-up hemoglobin stores. Option C:Fatigue is a sign of anemia but it is not a complication. A severe low hemoglobin level for men is 13.5 gm/dL or lower. Although 150 mg or more of daily elemental iron was previously recommended, studies show improved absorption and tolerability with lower dosing or every-other-day dosing. This article is the best and easy to understand. Rationale: As the patient progressed and had successfully finished the given activities, it is best to insert a few more tasks to practice the patients tolerance and to maintain their improvements. Individual cultural or religious restrictions and personal preferences. may email you for journal alerts and information, but is committed Please try again soon. Assess for signs of activity intolerance.Signs of activity intolerance, fatigue, and reduced tissue oxygenation include dyspnea on exertion, dizziness, headaches, palpitations, and pallor. Check the patients skin for the presence of bruises and petechiae. Oxygen saturation should be checked and monitored to assess the level of oxygen and carbon dioxide in the patients blood. Based on the assessment data, major nursing diagnosis for patients with anemia include: The major goals for a patient with anemia include: Nursing interventions are based on the data assessed by the nurse and on the symptoms that the patient manifests. Chaparro, C. M., & Suchdev, P. S. (2019). 1. D. Elevated indirect bilirubin. https://doi.org/10.1111/nyas.14092. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. B. Ecchymosis. D. 35 to 40 g/dL. It is possible to deplete the bodys energy reserves if the patient ignores its needs and demands. Having anemia, also referred to as low hemoglobin, can make you feel tired and weak. Very Well Health. Monitor the patients blood indices such as hematocrit, hemoglobin, RBC counts, and special tests such as reticulocyte counts. Mildly increased myositis, pancreatitis, MI, CHF, shock, mononucleosis, C. Interventions - monitor liver enzyme lab values & for jaundice, check patients medication profile for liver toxic medications, Liver enzymeC. Ineffective Tissue Perfusion Nursing Diagnosis & Care Plan Low hemoglobin is often caused by low iron levels in the blood or iron deficiency anemia and may lead to severe health conditions, including heart problems. Option A: Fatigue is a symptom of anemia as a result of decreased oxygenation. If a disease or condition affects your bodys ability to produce red blood cells, your hemoglobin levels may drop. Please see our Privacy Policy, The Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to Planning Care. This article has made it easy for me to understand. Have them prioritize and complete the most important tasks when energy reserves are highest. Diseases, conditions and other factors that affect red blood cell production include: Your bone marrow constantly produces red blood cells. The nurse should use words and languages that the patient and the family members will easily understand. Examine the patients skin for any bruising, petechiae, or any pronounced bleeding from the nose, mouth, vaginal area, gastrointestinal or urinary tract. Check patient for S&S of allergies5. Educate the patient about bleeding precautions.Bleeding precautions like using a soft toothbrush and the use of an electric shaver instead of a razor can decrease the risk of spontaneous bleeding. St. Louis, MO: Elsevier. Apply pressure over the site as appropriate when bleeding occurs.Bleeding can be stopped by applying pressure to allow blood to clot. The most frequent symptom and complication of anemia is: A. Nursing Diagnosis: Activity Intolerance related to low hemoglobin and imbalance between oxygen supply and demand secondary to pernicious anemia. Educate energy-conservation techniques.Clients and caregivers may need to learn skills for delegating tasks to others, setting priorities, and clustering care to use the available energy to complete desired activities. The patient should be taught about time management and organization that will help the patient conserve and reduce fatigue. Option A: Bleeding gums is a symptom of idiopathic thrombocytopenia purpura. Precautionary steps that decrease the risk of skin breaking would also reduce the likelihood of bleeding. The patient will demonstrate improved wellness as indicated by the absence of fever and within the normal WBC count. The hemoglobin level is lower than normal, reflecting a decrease in number or derangement in the function of red blood cells within the circulation. Ask the patient and the family members about their knowledge about the condition, the disease process, possible causative factors, and treatment. This encourages the client to still do as much as possible while conserving limited energy and preventing fatigue. C. Organ meats. Nursing Interventions Nursing interventions are based on the data assessed by the nurse and on the symptoms that the patient manifests. Nursing Care Plan for: Activity Intolerance, Anemia, Low Hemoglobin, Sickle Cell Anemia, Iron Deficiency, Pernicious, Aplastic Anemia, Folic Acid Deficiency, and Thalassemia. Included below are affiliate links from Amazon at no additional cost from you. If that's your situation, they'll treat your anemia with supplements. For the purpose of ensuring tissue compatibility for organ transplantation, HLA typing should be performed. Check dietary protein intake, 1. 3. For hospitalized patients, the nurse should provide a private room for protective isolation. To prevent the spread of infectious diseases. Anticipate the need for the transfusion of packed RBCs.Packed RBCs increase the oxygen-carrying capacity of the blood. The therapist also can help the client and family evaluate the need for additional energy-conservation measures in the home setting. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Inadequate blood flow can slow peristalsis and digestion of the intestines. It is more than a feeling of drowsiness or sleepiness. Patient will discuss and demonstrate interventions to prevent bleeding. Get to know the nursing assessment cues, goals, related factors, and interventions with rationale . Nursing care includes patient education of the cause, prognosis, and complications of the condition, provision of iron supplementation, adherence to an iron-rich diet, monitoring of symptoms, and lifestyle modifications. If required, adjust O 2 levels. The patient and the family members will express knowledge about the patients treatment plans. Nursing Diagnosis: Deficient Knowledge related to low hemoglobin level secondary to aplastic anemia evidenced by inaccurate follow-through of instructions, questioning members of the health care team, and verbalization of inaccurate information. Iron is necessary for the production of hemoglobin, which carries oxygen in the blood. Decreased hemoglobin and diminished oxygen-carrying capacity of the blood. Manner of proliferation If there is an increase in infiltration and production of immature red blood cells in the bone marrow, it could indicate certain kinds of anemia. It affects 3% of adults and is slightly more common in women younger than 50 years. Rationale: Anemic patients (most importantly immunocompromised patients) are prone to having infections due to opportunistic pathogens. However, some clients repeatedly receiving rHuEPO develop anti-rHuEPO neutralizing antibodies leading to the development of pure red cell aplasia (PRCA) (Susantad et al., 2021). The data to be documented consists the following: Lets reinforce what youve learned with this 5-item NCLEX practice quiz about Anemia. Exercise during and after cancer treatment has been shown to be safe and sound to reduce fatigue, increase physical fitness, and enhance health-related quality of life. Desired Outcome: The patient will have normal platelet levels with the absence of bleeding, bruising and petechiae. It is the authoritative guide to nursing diagnoses, reviewed and approved by the NANDA International Diagnosis Development Committee (DDC). During the planning stages, consider the use of antibiotics, antifungal drugs, and antiviral medications in advance. 14 to 16 g/dL. Term MCV - Mean Corpuscular Vol This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. The biochemical mechanism of acupressure describes the stimulation of specific acupoints along the meridian leads to complex neuro-hormonal responses that lead to the overrun of cortisol and cause a relaxation response. Clients with nutritional anemia due to iron deficiency should be educated on food that is rich in iron. Achieve accuracy in nursing care plans with ease and confidence using Ackleys Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care, 12th Edition. Nursing Diagnosis: Ineffective Tissue Perfusion (Renal) related to low levels of cellular components required for oxygen delivery secondary to chronic anemia as evidenced by hemoglobin level of 6.9 g/dL. Interpretation of Urinalysis Abnormalities Cont. The WHO criterion for anemia in adults is a hemoglobin value of less than 12.5 g/dL. It is important to instruct the patient to eat foods that contain essential nutrients which are needed to promote RBC formation. Check for activity intolerance symptoms. Anemia is a medical condition wherein a person lacks sufficient RBC count, hemoglobin, and hematocrit values resulting in a reduced oxygen-carrying and transport capacity of the blood to the bodys vital tissues. Kumar A, Sharma E, Marley A, et al. 4. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. 5. BMJ Open Gastroenterology 2022;9:e000759. Alcoholism, exposure to toxic chemicals, dietary problems, and the use of medication that may affect red blood cell production are some of the causative factors of low hemoglobin levels. Every age and every stage can be affected by anemia, and though others may consider this as a simple condition, it could blow out of proportion if left untreated. The editors have updated all introductory chapters in this seminal text to provide crucial information for nurses to comprehend assessment, its connection to diagnosis and clinical reasoning, and the purpose and application of taxonomic structure at the bedside. C. 9 to 11 g/dL. Explain the functions of blood constituents such as red blood cells, white blood cells, and platelets. 3. identify if the intervention is independent, dependent or collaborative. Ineffective Tissue Perfusion Nursing Care Plan 2. Although there are several tests to directly determine the RBC mass, these tests are expensive and somewhat cumbersome. 2. Provide information about alternative forms of activities that relieve fatigue, such as acupressure and yoga.Acupressure is a component of traditional Chinese medicine that uses pressure via finger, thumb, or device to stimulate specific acupoints for therapeutic purposes. Nursing Diagnosis: Fatigue related to lack of decreased oxygen-carrying capacity of blood due to decreased hemoglobin levels, secondary to anemia, as evidenced by frequent rest periods, dyspnea or pain during exercise, and verbalized exhaustion. They may also analyze different types of hemoglobin in your red blood cells, or hemoglobin electrophoresis.