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 B 12; 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.

CARE SETTING
Treated at the community level, except in the presence of severe cardiovascular/immune compromise.

RELATED CONCERNS
AIDS
Burns: thermal/chemical/electrical (acute and convalescent phases)
Cancer
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

ACTIVITY/REST
May report:

May exhibit:

Fatigue, weakness, general malaise

Loss of productivity; diminished enthusiasm for work
Low exercise tolerance
Greater need for rest and sleep
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

CIRCULATION
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)

EGO INTEGRITY
May report:
May exhibit:

Negative feelings about self, ability to handle situation/events

Depression

ELIMINATION
May report:

May exhibit:

History of pyelonephritis, renal failure

Flatulence, malabsorption syndrome (ID)
Hematemesis, fresh blood in stool, melena
Diarrhea or constipation
Diminished urine output
Abdominal distension

FOOD/FLUID
May report:

May exhibit:

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)
Beefy red/smooth appearance of tongue (PA; folic acid and vitamin B 12 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)

HYGIENE
May report:
May exhibit:

Difficulty maintaining activities of daily living (ADLs)

Unkempt appearance, poor personal hygiene
Hair dry, brittle, thinning; premature graying (PA)

NEUROSENSORY
May report:

May exhibit:

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
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 Rombergs
sign, paralysis (PA)

PAIN/DISCOMFORT
May report:

Vague abdominal pains; headache (ID)

Oral pain

RESPIRATION
May report:
May exhibit:

SAFETY

History of TB, lung abscesses

Shortness of breath at rest and with activity
Tachypnea, orthopnea, and dyspnea

May report:

May exhibit:

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
Low-grade fever, chills, night sweats
Generalized lymphadenopathy
Petechiae and ecchymosis (aplastic)

SEXUALITY
May report:

May exhibit:

Changes in menstrual flow, e.g., menorrhagia or amenorrhea in women (ID)

Loss of libido (men and women)
Impotence in men
Pale cervix and vaginal walls

TEACHING/LEARNING
May report:

Discharge plan
considerations:

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)
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.

DIAGNOSTIC STUDIES
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).
Schillings 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.

NURSING PRIORITIES
1.
2.
3.
4.

Enhance tissue perfusion.

Provide nutritional/fluid needs.
Prevent complications.
Provide information about disease process, prognosis, and treatment regimen.

DISCHARGE GOALS
1.
2.
3.
4.

ADLs met by self or with assistance of others.

Complications prevented/minimized.
Disease process/prognosis and therapeutic regimen understood.
Plan in place to meet needs after discharge.

NURSING DIAGNOSIS: Activity intolerance

May be related to
Imbalance between oxygen supply (delivery) and demand
Possibly evidenced by
Weakness and fatigue
Reports of decreased exercise/activity tolerance
Greater need for sleep/rest
Palpitations, tachycardia, increased BP/respiratory response with minor exertion
DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL:
Endurance (NOC)
Report an increase in activity tolerance (including ADLs).
Demonstrate a decrease in physiological signs of intolerance, e.g., pulse, respirations, and BP remain within
patients normal range.
Display laboratory values, e.g., Hb/Hct, within acceptable range.

ACTIONS/INTERVENTIONS

RATIONALE

Energy Management (NIC)

Independent
Assess patients ability to perform normal tasks/ADLs,
noting reports of weakness, fatigue, and difficulty
accomplishing tasks.

Influences choice of interventions/needed assistance.

Note changes in balance/gait disturbance, muscle

weakness.

May indicate neurological changes associated with

vitamin B12 deficiency, affecting patient safety/risk of
injury.

Monitor BP, pulse, respirations during and after activity.

Note adverse responses to increased levels of
activity(e.g., increased heart rate [HR]/BP, dysrhythmias,
dizziness, dyspnea, tachypnea, cyanosis of mucous
membranes/nailbeds).

Cardiopulmonary manifestations result from attempts by

the heart and lungs to supply adequate amounts of oxygen
to the tissues.

Recommend quiet atmosphere; bedrest if indicated. Stress

need to monitor and limit visitors, phone calls, and
repeated unplanned interruptions.

Enhances rest to lower bodys oxygen requirements, and

reduces strain on the heart and lungs.

Elevate head of bed as tolerated.

Enhances lung expansion to maximize oxygenation for

cellular uptake. Note: May be contraindicated if
hypotension is present.

Suggest patient change position slowly; monitor for

dizziness.

Postural hypotension or cerebral hypoxia may cause

dizziness, fainting, and increased risk of injury.

Assist patient to prioritize ADLs/desired activities.

Alternate rest periods with activity periods. Write out
schedule for patient to refer to.

Promotes adequate rest, maintains energy level, and

alleviates strain on the cardiac and respiratory systems.

Provide/recommend assistance with activities/ambulation

as necessary, allowing patient to do as much as possible.

Although help may be necessary, self-esteem is enhanced

when patient does some things for self.

Plan activity progression with patient, including activities

that patient views as essential. Increase activity levels as
tolerated.

Promotes gradual return to normal activity level and

improved muscle tone/stamina without undue fatigue.
Increases self-esteem and sense of control.

Identify/implement energy-saving techniques, e.g.,

shower chair, sitting to perform tasks.

Encourages patient to do as much as possible, while

conserving limited energy and preventing fatigue.

Instruct patient to stop activity if palpitations, chest pain,

shortness of breath, weakness, or dizziness occur.

Cellular ischemia potentiates risk of infarction and

excessive cardiopulmonary strain/stress may lead to
decompensation/failure.

Discuss importance of maintaining environmental

temperature and body warmth as indicated.

Vasoconstriction (shunting of blood to vital organs)

decreases peripheral circulation, impairing tissue
perfusion. Patients comfort/need for warmth must be
balanced with need to avoid excessive heat with resultant
vasodilation (reduces organ perfusion).

ACTIONS/INTERVENTIONS

RATIONALE

Energy Management (NIC)

Collaborative
Monitor laboratory studies, e.g., Hb/Hct and RBC count,
arterial blood gases (ABGs).
Provide supplemental oxygen as indicated.

Identifies deficiencies in RBC components affecting

oxygen transport and treatment needs/response to therapy.

Administer as indicated:
Colony-stimulating factors (CSFs), e.g., aldesleukin
(Interleukin-2);

Maximizing oxygen transport to tissues improves ability

to function.

Whole blood/packed RBCs (PRCs), blood products

as indicated. Monitor closely for transfusion
reactions.

CSFs may be given to stimulate growth of specific blood

elements.

Prepare for surgical intervention if indicated.

Increases number of oxygen-carrying cells; corrects

deficiencies to reduce risk of hemorrhage in acutely
compromised individuals. Note: Transfusions are reserved
for severe blood loss anemias with cardiovascular
compromise; used after other therapies have failed to
restore homeostasis.
Bone marrow transplant may be done in presence of bone
marrow failure/aplastic anemia.

NURSING DIAGNOSIS: Nutrition: imbalanced, less than body requirements

May be related to
Failure to ingest or inability to digest food/absorb nutrients necessary for formation of normal RBCs
Possibly evidenced by
Weight loss/weight below normal for age, height, and build
Decreased triceps skin-fold measurement
Changes in gums, oral mucous membranes
Decreased tolerance for activity, weakness, and loss of muscle tone
DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL:
Nutritional Status (NOC)
Demonstrate progressive weight gain or stable weight, with normalization of laboratory values.
Experience no signs of malnutrition.
Demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight.

ACTIONS/INTERVENTIONS

RATIONALE

Nutrition Therapy (NIC)

Independent
Review nutritional history, including food preferences.

Identifies deficiencies, suggests possible interventions.

ACTIONS/INTERVENTIONS

RATIONALE

Nutrition Therapy (NIC)

Independent
Observe and record patients food intake.

Monitors caloric intake or insufficient quality of food

consumption.

Weigh periodically as appropriate (e.g., weekly).

Monitors weight loss and effectiveness of nutritional

interventions.

Recommend small, frequent meals and/or between-meal

nourishment.

May reduce fatigue and thus enhance intake while

preventing gastric distension. Use of Ensure/Isomil or
similar product provides additional protein and calories.

Suggest bland diet, low in roughage, avoiding hot, spicy,

or very acidic foods as indicated.

When oral lesions are present, pain may restrict type of

foods patient can tolerate.

Have patient record and report occurrence of nausea/

vomiting, flatus, and other related symptoms such as
irritability or impaired memory.

May reflect effects of anemias (hypoxia, vitamin B12

deficiency) on organs.

Encourage/assist with good oral hygiene; before and after

meals, use soft-bristled toothbrush for gentle brushing.
Provide dilute, alcohol-free mouthwash if oral mucosa is
ulcerated.

Enhances appetite and oral intake. Diminishes bacterial

growth, minimizing possibility of infection. Special
mouth-care techniques may be needed if tissue is
fragile/ulcerated/bleeding and pain is severe.

Collaborative
Consult with dietitian.

Aids in establishing dietary plan to meet individual needs.

Monitor laboratory studies, e.g., Hb/Hct, blood urea

nitrogen (BUN), prealbumin/albumin, protein, transferrin,
serum iron, vitamin B12, folic acid, TIBC, serum
electrolytes.

Evaluates effectiveness of treatment regimen, including

dietary sources of needed nutrients.

Administer medications as indicated, e.g.:

Vitamin and mineral supplements, e.g.,
cyanocobalamin (vitamin B12), folic acid (Folvite),
ascorbic acid (vitamin C);

Replacements needed depend on type of anemia and/or

presence of poor oral intake and identified deficiencies.

Oral iron supplements, e.g., ferrous sulfate (Feosol,

Mol-Iron, Fer-In-Sol), ferrous gluconate (Fergon),
ferrous fumarate (Ircon, Femiron);

May be useful in some types of iron deficiency anemias.

Oral preparations are taken between meals to enhance
absorption and usually correct anemia and replace iron
stores over a period of several months.

Iron dextran (InFeD) IM/IV;

Administered until estimated deficit is corrected.

Reserved for those who cannot absorb or comply with
oral iron therapy or when blood loss is too rapid for oral
replacement to be effective.

Antifungal or anesthetic mouthwash, if indicated.

May be needed in the presence of stomatitis/glossitis to

promote oral tissue healing and facilitate intake.

NURSING DIAGNOSIS: Constipation/Diarrhea

May be related to
Decreased dietary intake; changes in digestive processes
Drug therapy side effects
Possibly evidenced by
Changes in frequency, characteristics, and amount of stool
Nausea/vomiting, decreased appetite
Reports of abdominal pain, urgency, cramping
Altered bowel sounds
DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL:
Bowel Elimination (NOC)
Establish/return to normal patterns of bowel functioning.
Demonstrate changes in behaviors/lifestyle, as necessitated by causative, contributing factors.

ACTIONS/INTERVENTIONS

RATIONALE

Bowel Management (NIC)

Independent
Determine stool color, consistency, frequency, and
amount.

Assists in identifying causative/contributing factors and

appropriate interventions.

Auscultate bowel sounds.

Bowel sounds are generally increased in diarrhea and

decreased in constipation.

Monitor intake and output (I&O) with specific attention

to food/fluid intake.

May identify dehydration, excessive loss of fluids or aid

in identifying dietary deficiencies.

Encourage fluid intake of 25003000 mL/day within

cardiac tolerance.

Assists in improving stool consistency if constipated.

Helps maintain hydration status if diarrhea is present.

Recommend avoiding gas-forming foods.

Decreases gastric distress and abdominal distension.

Assess perianal skin condition frequently, noting changes

or beginning breakdown. Encourage/assist with perineal
care after each bowel movement (BM) if diarrhea is
present.

Prevents skin excoriation and breakdown.

Discuss use of stool softeners, mild stimulants, bulkforming laxatives, or enemas as indicated. Monitor
effectiveness.

Facilitates defecation when constipation is present.

ACTIONS/INTERVENTIONS

RATIONALE

Bowel Management (NIC)

Collaborative
Consult with dietitian to provide well-balanced diet high
in fiber and bulk.

Fiber resists enzymatic digestion and absorbs liquids in its

passage along the intestinal tract and thereby produces
bulk, which acts as a stimulant to defecation.

Administer antidiarrheal medications, e.g., diphenoxylate

hydrochloride with atropine (Lomotil), and waterabsorbing drugs, e.g., Metamucil.

Decreases intestinal motility when diarrhea is present.

NURSING DIAGNOSIS: Infection, risk for

Risk factors may include
Inadequate secondary defenses, e.g., decreased hemoglobin, leukopenia, or decreased granulocytes (suppressed
inflammatory response)
Inadequate primary defenses, e.g., broken skin, stasis of body fluids; invasive procedures; chronic disease,
malnutrition
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL:
Risk Control (NOC)
Identify behaviors to prevent/reduce risk of infection.
Immune Status (NOC)
Be free of signs of infection, achieve timely wound healing (if present).

ACTIONS/INTERVENTIONS

RATIONALE

Infection Protection (NIC)

Independent
Perform/promote meticulous handwashing by caregivers
and patient.

Prevents cross-contamination/bacterial colonization.

Note: Patient with severe/aplastic anemia may be at risk
from normal skin flora.

Maintain strict aseptic techniques with procedures/wound

care.

Reduces risk of bacterial colonization/infection.

Provide meticulous skin, oral, and perianal care.

Reduces risk of skin/tissue breakdown and infection.

Encourage frequent position changes/ ambulation,

coughing, and deep-breathing exercises.

Promotes ventilation of all lung segments and aids in

mobilizing secretions to prevent pneumonia.

ACTIONS/INTERVENTIONS

RATIONALE

Infection Protection (NIC)

Independent
Promote adequate fluid intake.

Assists in liquefying respiratory secretions to facilitate

expectoration and prevent stasis of body fluids (e.g.,
respiratory and renal).

Stress need to monitor/limit visitors. Provide protective

isolation if appropriate. Restrict live plants/cut flowers.

Limits exposure to bacteria/infections. Protective

isolation may be required in aplastic anemia, when
immune response is most compromised.

Monitor temperature. Note presence of chills and

tachycardia with/without fever.

Reflective of inflammatory process/ infection, requiring

evaluation and treatment. Note: With bone marrow
suppression, leukocytic failure may lead to fulminating
infections.

Observe for wound erythema/drainage.

Indicators of local infection. Note: Pus formation may be

absent if granulocytes are depressed.

Collaborative
Obtain specimens for culture/sensitivity as indicated.

Verifies presence of infection, identifies specific

pathogen, and influences choice of treatment.

Administer topical antiseptics; systemic antibiotics.

May be used prophylactically to reduce colonization or

used to treat specific infectious process.

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis,

treatment, self-care, and discharge needs
May be related to
Lack of exposure/recall
Information misinterpretation
Unfamiliarity with information resources
Possibly evidenced by
Questions; request for information; statement of misconception
Inaccurate follow-through of instructions, development of preventable complications
DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL:
Knowledge: Illness Care (NOC)
Verbalize understanding of the nature of the disease process, diagnostic procedures, and potential complications.
Identify causative factors.
Verbalize understanding of therapeutic needs.
Initiate necessary behaviors/lifestyle changes.

ACTIONS/INTERVENTIONS

RATIONALE

Teaching: Disease Process (NIC)

Independent
Provide information about specific anemia and explain
that therapy depends on the type and severity of the
anemia.

Provides knowledge base from which patient can make

informed choices. Allays anxiety and may promote
cooperation with therapeutic regimen.

Discuss effects of anemias on preexisting conditions.

Anemias aggravate heart, lung, and cerebrovascular

disease.

Review purpose and preparations for diagnostic studies.

Anxiety/fear of the unknown increases stress level, which

in turn increases the cardiac workload. Knowledge of
what to expect can diminish anxiety.

Explain that blood taken for laboratory studies will not

worsen anemia.

This is often an unspoken concern that can potentiate

patients anxiety.

Review required diet alterations to meet specific dietary

needs (determined by type of anemia/deficiency).

Red meat, liver, egg yolks, green leafy vegetables, whole

wheat bread, and dried fruits are sources of iron. Green
vegetables, whole grains, liver, and citrus fruits are
sources of folic acid and vitamin C (enhances absorption
of iron).

Assess resources (e.g., financial) and ability to

obtain/prepare food).

Inadequate resources may affect ability to

purchase/prepare appropriate food items.

Encourage cessation of smoking.

Smoking decreases available oxygen and causes

vasonstriction.

Provide information about purpose, dosage, schedule,

precautions and potential side effects, interactions, and
adverse reactions to all prescribed medications.

Information enhances cooperation with regimen.

Recovery from anemias can be slow, requiring lengthy
treatment and prevention of secondary complications.

Stress importance of reporting signs of fatigue, weakness,

paresthesias, irritability, impaired memory.

Indicates that anemia is progressing or failing to resolve,

necessitating further evaluation/treatment changes.

Instruct and demonstrate self-administration of oral iron

preparations:

Iron replacement usually takes 36 mo, whereas vitamin

B12 injections may be necessary for the rest of patients
life.

Discuss importance of taking only prescribed

dosages;

Overdose of iron medication can be toxic.

Advise taking with meals or immediately after

meals;

Iron is best absorbed on an empty stomach. However, iron

salts are gastric irritants and may cause dyspepsia,
diarrhea, and abdominal discomfort if taken on an empty
stomach.

Dilute liquid preparations (preferably with orange

juice) and administer through a straw;

ACTIONS/INTERVENTIONS

Undiluted liquid iron preparations may stain the teeth.

Ascorbic acid promotes iron absorption.

RATIONALE

Teaching: Disease Process (NIC)

Independent
Caution that BM may appear greenish black/tarry;

Excretion of excessive iron changes stool color.

Emphasize importance of good oral hygiene

measures.

Certain iron supplements (e.g., Feosol) may leave

deposits on teeth and gums.

Instruct patient/SO about parenteral iron administration,

e.g.:
Z-track administration of medication;

Prevents extravasation (leaking) with accompanying pain

and tissue damage.

Use separate needles for withdrawing and injecting

the medication;

Medication may stain the skin.

Caution regarding possible systemic reaction, (e.g.,

flushing, vomiting, nausea, myalgia) and discuss
importance of reporting symptoms.

Possible side effects of therapy requiring reevaluation of

drug choice and dosage.

Discuss increased susceptibility to infections, signs/

symptoms requiring medical intervention, e.g., fever, sore
throat; erythema/draining wound; cloudy urine, burning
with urination.

Decreased leukocyte production potentiates risk of

infection. Note: Purulent drainage may not form in
absence of granulocytes (aplastic).

Identify safety concerns, e.g., avoidance of forceful

blowing of nose, contact sports, constipation/straining for
stool; use of electric razors, soft toothbrush.

Reduces risk of hemorrhage from fragile tissues and

general decrease of coagulation factors.

Recommend avoiding use of heating pads or hot water

bottles; measuring temperature of bath water with a
thermometer.

Thermoreceptors in the dermal tissues may be dulled

because of oxygen deprivation, thus increasing the risk of
thermal injury.

Recommend routine observation of skin, noting changes

in turgor, altered color, local warmth, erythema,
excoriation.

Condition of the skin is affected by circulation, nutrition,

and immobility. Tissues may become fragile and prone to
infection and breakdown.

Identify measures for healthy skin, e.g.:

Reposition periodically and gently massage bony
surfaces when sedentary or in bed;

Increases circulation to all skin areas, limiting tissue

ischemia/effects of cellular hypoxia.

Keep skin surfaces dry and clean, limit use of soap;

Moist, contaminated areas provide excellent media for

growth of pathogenic organisms. Soap may dry
excessively and increase irritation.

Engage regularly in range of motion (ROM)

exercises;

Promotes circulation to tissues, prevents stasis.

ACTIONS/INTERVENTIONS

RATIONALE

Reality Orientation (NIC)

Independent
Suggest use of protective devices, e.g., sheepskin, eggcrate, alternating air pressure/water mattress, heel/elbow
protectors, and pillows as indicated.

Avoids skin breakdown by preventing/reducing pressure

against skin surfaces.

Review good oral hygiene, necessity for regular dental

care.

Effects of anemia (oral lesions) and/or iron supplements

increase risk of infection/bacteremia.

Instruct to avoid use of aspirin products.

Increases bleeding tendencies.

Refer to appropriate community resources when

indicated, e.g., social services for food stamps, Meals on
Wheels.

May need assistance with groceries/meal preparation.

POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on patients age, physical

condition/presence of complications, personal resources, and life responsibilities)
Activity intoleranceimbalance between oxygen supply (delivery) and demand.
Nutrition: imbalanced, less than body requirementsfailure to ingest or inability to digest food/absorb nutrients
necessary for formation of normal RBCs.
Infection, risk forinadequate secondary defenses, e.g., decreased hemoglobin, leukopenia, or decreased granulocytes
(suppressed inflammatory response); inadequate primary defenses, e.g., broken skin, stasis of body fluids; invasive
procedures; chronic disease, malnutrition.
Therapeutic Regimen: ineffective managementeconomic difficulties, perceived benefits.