Sickle Cell Anemia Nursing Care Plan

Subjective Data:
 Fatigue
 Pain crisis
o Severe pain
o All over body
 Shortness of breath
 Chest pain
 Irritability
Objective Data:
 Swelling of hands / feet
 Fever
 Jaundice
 Cyanosis
 Presence of sickled cells on histologic exam

Nursing Interventions and Rationales

 Assess respiratory status
o Rate
o Use of accessory muscles
o Cyanosis
*During a SC crisis, red blood cells cannot effectively deliver oxygen to the tissues resulting in
poor perfusion. Frequent infections often result in pneumonia and cause shortness of breath
and chest pain.

 Monitor cardiac status

o Perform 12-lead ECG
*Changes in respiratory status and hypoxia may lead to arrhythmias.

 Assess for and manage pain

o Administer medications
o Apply warm compresses
*Poor perfusion results in damage to the tissues and organs which causes intense throbbing
pain that may change location from one body part to another.
*Avoid using cold compresses as cold causes further vasoconstriction and exacerbates pain and
crisis. Warm compresses dilate vessels to promote circulation and reduce pain and muscle
tension.

 Administer medications / blood products as necessary

o IV fluids (prevent or treat dehydration)
o Analgesics for pain – opioids may be used
o Antibiotics for infections
o Hydroxyurea – prevents sickling of red blood cells to reduce the number of crisis
episodes
*Medication is given to manage the symptoms of a crisis event and treat any underlying
infections that may cause a crisis. In some cases, blood transfusions may be necessary to
manage crisis events and increase perfusion to vital organs.

 Monitor vital signs carefully

 Monitor respiratory status and breath sounds
 Assess for signs of infection
o Fever
*Bacterial infections may be severe and often result in pneumonia. Frequent infections weaken
the organ systems and may lead to organ failure.

 Assess for and manage dehydration

*Stress on the organ systems from dehydration can exacerbate the pain of a crisis. Encourage
adequate hydration and administer IV fluids to promote adequate blood viscosity.

 Provide wound care as necessary

*Decreased peripheral circulation often results in changes in the skin and delayed wound
healing.

 Encourage routine eye exams

*Sickling of red blood cells can damage the vessels in the eyes over time and cause blindness.

 Monitor vital signs closely

*Decreased circulating blood volume can occur resulting in tachycardia and hypotension

 Minimize stress
o Teach guided imagery techniques
o Encourage deep breathing exercises
o Provide resources for stress management
*Stress and physical activity increase the body’s metabolic need for oxygen. Reducing stress
helps preserve fluid balance and provides better individual pain control.

 Assess for changes in consciousness and mentation

*The brain is sensitive to fluctuations in oxygen balance. Decreased perfusion of brain tissue
may result in confusion, loss of consciousness or stroke.

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Nursing Assessment
Assessment of the child include:

 Dietary history. A dietary history is important; vegetarians are more likely to develop iron
deficiency unless their diet is supplemented with iron; national programs of dietary iron
supplementation are initiated in many portions of the world where meat is sparse in the
diet and iron deficiency anemia is prevalent.
 History of hemorrhage. Bleeding is the most common cause of iron deficiency, either from
parasitic infection (hookworm) or other causes of blood loss; with bleeding from most
orifices (hematuria, hematemesis, hemoptysis), patients will present before they develop
chronic iron deficiency anemia; however, gastrointestinal bleeding may go unrecognized.
 Physical exam. Anemia produces nonspecific pallor of the mucous membranes; a number
of abnormalities of epithelial tissues are described in association with iron deficiency
anemia; these include esophageal webbing, koilonychia, glossitis, angular stomatitis, and
gastric atrophy.

Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses are:

 Fatigue related to decreased hemoglobin and diminished oxygen-carrying capacity of the

blood.
 Deficient knowledge related to the complexity of treatment, lack of resources, or
unfamiliarity with the disease condition.
 Risk for infection
 Risk for bleeding

Nursing Care Planning and Goals

The major nursing care planning goals for patients with iron deficiency anemia are:

 Client/caregivers will verbalize the use of energy conservation principles.

Client/caregivers will verbalize reduction of fatigue, as evidenced by reports of increased
energy and ability to perform desired activities.
 Client/caregivers will verbalize understanding of own disease and treatment plan.
 Client will have a reduced risk of infection as evidenced by an absence of fever, normal
white blood cell count, and implementation of preventive measures such as proper hand
washing.
 Client will have vital signs within the normal limit.
 Client will have a reduced risk for bleeding, as evidenced by normal or adequate platelet
levels and absence of bruises and petechiae.

Nursing Interventions
The nursing interventions for a child with iron deficiency anemia are:

Administer prescribed medications, as ordered:

 Administer IM or IV iron when oral iron is poorly absorbed.
 Perform sensitivity testing of IM iron injection to avoid risk of anaphylaxis.
  Advise patient to take iron supplements an hour before meals for maximum absorption; if
gastric distress occurs, suggest taking the supplement with meals — resume to between-
meals schedule if symptoms subside.
 Inform patient that iron salts change stool to dark green or black.
 Advise patient to take liquid forms of iron via a straw and rinse mouth with water.
Reduce fatigue
 Assist the client/caregivers in developing a schedule for daily activity and rest.
 Stress the importance of frequent rest periods.
 Monitor hemoglobin, hematocrit, RBC count, and reticulocyte counts.
 Educate energy-conservation techniques.
 Encourage patient to continue iron therapy for a total therapy time (6 months to a year),
even when fatigue is no longer present.
Educate the client and caregivers about iron deficiency anemia:
 Explain the importance of the diagnostic procedures (such as complete blood count), bone
marrow aspiration and a possible referral to a hematologist.
 Explain the importance of iron replacement/supplementation.
 Educate the client and the family regarding foods rich in iron (organ and other meats, leafy
green vegetables, molasses, beans).
Prevent infection
 Assess for local or systemic signs of infection, such as fever, chills, swelling, pain, and body
malaise.
 Monitor WBC count; anticipate the need for antibiotic, antiviral, and antifungaltherapy.
 vInstruct the client to avoid contact with people with existing infections.
 Stress the importance of daily hygiene, mouth care, and perineal care.
Prevent bleeding
 Monitor platelet count; instruct the client/caregivers about bleeding precautions.
 Anticipate the need for a platelet transfusion once the platelet count drops to a very low
value.
 Assess the skin for bruises and petechiae.
Evaluation
Goals are met as evidenced by:

 Client/caregivers will verbalize the use of energy conservation principles.

 Client/caregivers will verbalize reduction of fatigue, as evidenced by reports of increased
energy and ability to perform desired activities.
 Client/caregivers will verbalize understanding of own disease and treatment plan.
 Client will have a reduced risk of infection as evidenced by an absence of fever, normal
white blood cell count, and implementation of preventive measures such as proper hand
washing.
 Client will have vital signs within the normal limit.
 Client will have a reduced risk for bleeding, as evidenced by normal or adequate platelet
levels and absence of bruises and petechiae.
Documentation Guidelines
Documentation for a child with iron deficiency anemia include:

 Baseline and subsequent assessment findings to include signs and symptoms.

 Individual cultural or religious restrictions and personal preferences.
 Plan of care and persons involved.
 Teaching plan.
 Client’s responses to teachings, interventions, and actions performed.
 Attainment or progress toward the desired outcome.
 Long-term needs, and who is responsible for actions to be taken.

Anemia Nursing Care Plan

Subjective Data:
 Fatigue / weakness
 Dizziness
 Shortness of breath
 Chest pain
 Headache
Objective Data:
 Pale or yellowish skin
 Bleeding / hemorrhage
 Syncope
 Hypotension
 Tachycardia
 Abnormal labs (CBC = decreased RBC and HGB)

Nursing Interventions and Rationales

 Assess for and control obvious signs of bleeding
o External bleeding
o Heavy menstruation (>1 pad per hour)
o GI bleed
*Excessive loss of blood results in decreased oxygenation and poor perfusion.

 Perform 12-lead ECG

*Decreased blood volume causes tachycardia and arrhythmias. Monitor for ST depression and
QT prolongation.

 Replace fluid volume per facility protocol

o IV fluids
o Blood transfusion for HGB <8 (per protocol and provider)
*For blood loss of >40% volume, immediate transfusion is required

 Monitor diagnostic testing

o Lab values
o CT scans for possible liver or spleen lacerations
o Fecal occult blood – non-invasive test to determine if there is a potential GI bleed

Lab values to monitor closely:

 HGB (Normal 12-15 g/dL females; 13.5 – 16.5 g/dL males)
 B12 (Normal 2 – 20 ng/mL)
 Ferritin (Normal 20-300 ng/mL) – the protein that stores iron
 Iron (Normal 50-175 ug/dL)

 Administer medications
 Pantoprazole (GI bleed) – helps reduce acid and stop bleeding of peptic ulcers
 IV fluids and electrolytes as necessitated by lab values
 B12 injections or oral supplements – for B12 deficiency
 Erythropoietin is a hormone that may be given to treat anemia caused by chemotherapy or
chronic kidney disease that stimulates production of red blood cells in the bone marrow

 Provide nutritional education

o Increase green leafy vegetables
o Incorporate foods high in vitamin C
o Intake of red meat, lamb, poultry and venison as well as fish and shellfish
o Intake of seafood and shellfish
o Limit or avoid intake of foods high in calcium

 Leafy greens such as spinach, kale and chard are high in iron and folate
 Vitamin C assists in the absorption of iron. Good choices include oranges, red peppers and
strawberries
 All meats and most fish and shellfish contain heme iron
 Calcium-rich foods such as raw milk, yogurt, cheese and broccoli are high in calcium, which
binds with iron and prevents absorption

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