NURSING CARE PLAN ANEMIA

 A. UNDERSTANDING

Anemia is a condition in which a decrease in hemoglobin (Hb) or red blood cell (erythrocytes) results in a decrease in the capacity of red blood cells in carrying oxygen (Badan POM, 2011)

Anemia is a disease of less blood, which is characterized by hemoglobin (Hb) and red blood cells (erythrocytes) lower than normal. If hemoglobin levels of less than 14 g / dl and erythrocytes are less than 41% in men, then the man is said to be Anemia. Similarly in women, women who had hemoglobin levels of less than 12 g / dl and erythrocytes of less than 37%, then the woman was said to be Anemia. Anemia is not a disease, but is a reflection of the state of a disease or due to impaired body function. Physiologically Anemia occurs when there is a lack of hemoglobin to transport oxygen to the tissues.

Anemia is defined as a decrease in the volume of erythrocytes or Hb levels to below the range of values ​​applicable to healthy people. Anemia is a symptom of underlying conditions, such as loss of blood components, inadequate or insufficient nutrients needed for blood cell formation, resulting in decreased oxygen-carrying capacity of the blood and many types of Anemia with various causes. (Marilyn E, Doenges, Jakarta, 2002)

Anemia is a condition in which the number of red blood cells or hemoglobin concentration falls below normal (Wong, 2003). Anemia is a term that shows the low count of red blood cells and hemoglobin and hematocrit levels below normal (Smeltzer, 2002: 935). Anemia is reduced to below the normal value of red blood cells, hemoglobin quality and volume of packed red bloods cells (hematocrit) per 100 ml of blood (Price, 2006: 256).

Thus Anemia is not a diagnosis or disease, but rather a reflection of the state of a disease or disorder of body function and fundamental pathotisiological changes are described through careful anemnesis, physical examination and laboratory information.

B. ANEMIA CLASSIFICATION

Classification based on physiological approach:

1. Hypoproliferative Anemia, namely deficiency Anemia of red blood cell count caused by defect of red blood cell production, including:

1. Aplastic Anemia

Cause:

• neoplastic / cytoplastic agents

• radiation therapy

• Certain antibiotics

• convulsant antibiotics, thyroid, gold compounds, phenylbutasone, benzene

• viral infections (especially hepatitis)

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Decrease in the number of erythropoitin (stem cells) cells in the bone marrow

Stem cell abnormalities (impaired cleavage, replication, deference)

Humoral / cellular resistance

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Stem cell disorders in the bone marrow

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The number of red blood cells produced is inadequate

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Pansitopenia

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Aplastic Anemia

Symptoms:

• Symptoms of Anemia in general (pale, weak, etc.)

• Platelet deficiency: ecchymosis, petechiae, epitaxis, gastrointestinal bleeding, urinary bleeding, central nervous system hemorrhage.

• Morphological: Normochromic normocytic Anemia

2. Anemia in renal disease

Symptoms:

• Blood urea nitrogen (BUN) greater than 10 mg / dl

• Hematocrit down 20-30%

• Red blood cells appear normal in peripheral blood smears

The cause is decreased survival of red blood cells as well as erythopoitin deficiency

3. Anemia in chronic diseases

Chronic inflammatory diseases associated with Normochromic normocytic Anemia (red blood cells of normal size and color). These disorders include rheumatoid arthritis, lung abscess, osteomylitis, tuberculosis and various malignancies

4. Iron deficiency Anemia

Cause:

• Inadequate iron intake, increased need during pregnancy, menstruation

• Impaired absorption (post gastrectomy)

• Permanent blood loss (neoplasm, polyps, gastritis, varicose esophagus, hemorrhoids, etc.)

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Disorders of erythropoesis

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The absorption of iron from the intestine is less

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Little red blood cells (less amount)

Poor red blood cells hemoglobin

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Iron deficiency Anemia

Symptoms:

• Atrophy of the tongue papillae

• The tongue is pale, red, inflamed

• Angular stomatitis, pain in the corner of the mouth

• Morphology: Microcytic hypochromic Anemia

5. Megaloblastic Anemia

Cause:

• Deficiency of vitamin B12 deficiency and folic acid deficiency

• Malnutrition, malabsorption, intrinsic factor decline

• Parasitic infections, intestinal and malignant diseases, chemotherapeutic agents, tapeworm infections, feeding infected fresh fish, alcoholics.

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DNA synthesis is disrupted

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Impaired maturation of red blood cell nuclei

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Megaloblas (large erythroblasts)

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Erythrocyte immaturity and hypofunction

2. Anemia of hemolytic, which is deficiency Anemia of red blood cell count caused by destruction of red blood cell:

• Influence of certain drugs

• Hookin disease, lymphosarcoma, multiple myeloma, chronic lymphocytic leukemia

• Glucose 6 dihydrigenase phosphate deficiency

• Autoimmune process

• Transfusion reactions

• Malaria

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Mutation of erythrocyte cells / changes in erythrocyte cells

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Antigesn on erythrocytes changes

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Considered a foreign body by the body

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Red blood cells are destroyed by lymphocytes

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Anemia hemolysis

Anemic degrees according to WHO and NCI (National Cancer Institute)

C. ETIOLOGY:

1.     Hemolysis (erythrocyte breaks easily)

2.     Bleeding

3.     Bone marrow suppression (eg by cancer)

4.     Nutrient deficiency (nutritional Anemia), including iron deficiency, folic acid, pyridoxine, vitamin C and copper

According to the POM (2011), Causes of Anemia are:

1.     Consume less foods containing iron, vitamin B12, folic acid, vitamin C, and the elements necessary for the formation of red blood cells.

2.     Excessive menstrual blood. Women who are menstruating susceptible to Anemia due to iron deficiency when blood is menstruating much and he does not have enough iron supply.

3.     Pregnancy. Pregnant women are prone to Anemia because the fetus absorbs iron and vitamins for growth.

4.     Certain diseases. Diseases that cause persistent bleeding in the digestive tract such as gastritis and appendicitis can cause Anemia.

5.     Certain medications. Some types of drugs can cause gastric bleeding (aspirin, anti-inflation, etc.). Other drugs can cause problems in the absorption of iron and vitamins (antacids, birth control pills, antiarthritis, etc.).

6.     Surgical removal of part or all of the stomach (gastrectomy). This can cause Anemia because the body is less absorbing iron and vitamin B12.

7.     Chronic inflammatory diseases such as lupus, rheumatic arthritis, kidney disease, problems with the thyroid gland, some cancers and other diseases can cause Anemia because it affects the process of formation of red blood cells.

8.     In children, Anemia can occur due to hookworm infection, malaria, or dysentery that causes severe blood deficiency.

D. PATHOPHYSIOLOGY

The presence of Anemia reflects the presence of a marrow failure or excessive red blood cell loss or both. Marrow failure (eg reduced erythropoesis) may result from nutritional deficiencies, toxic exposure, tumor invasion or other unknown causes. Red blood cells can be lost through bleeding or haemolysis (destruction).

Red cell lysis (dissolution) occurs mainly in the phagocytic cells or in the reticuloendothelial system, especially in the liver and spleen. The byproduct of this process is bilirubin which will enter the bloodstream. Any increase in red blood cell destruction (haemolysis) is immediately reflected by an increase in plasma bilirubin (normal concentration ≤1 mg / dl, levels above 1.5 mg / dl resulting in jaundice of the sclera).

If red blood cells are destroyed in the circulation, (in hemplic disorders) then hemoglobin will appear in plasma (hemoglobinemia). If the plasma concentration exceeds plasma haptoglobin capacity (binding protein for free hemoglobin) to bind it all, hemoglobin diffuses in the renal glomerulus and into the urine (hemoglobinuria).

Conclusions about whether Anemia in a patient is caused by the destruction of red blood cells or inadequate production of red blood cells can usually be obtained on the basis of: 1. Reticulocyte count in the blood circulation; 2. the degree of proliferation of pink blood cells in the bone marrow and the way they are matured, as seen in the biopsy; And presence or absence of hyperbilirubinemia and hemoglobinemia.

Anemia

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Decreased blood viscosity

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Peripheral blood flow resistance

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Decreased O2 transport to the network

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Hypoxic, pale, weak

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Heart burden increased

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Heart work increases

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Heart trouble

E. PATHWAY ANEMIA (Patrick Davey, 2002)

 PATHWAY ANEMIA

F. SIGNS AND SYMPTOMS

1.     Weak, tired, lethargic and tired

2.     Often complain of dizziness and eyes dizzy

3.     Advanced symptoms in the form of eyelids, lips, tongue, skin and palms become pale.Pucat due to lack of blood volume and Hb, vasokontriksi

4.     Tachycardia and heart noise (increased blood flow rate) Angina (chest pain)

5.     Dyspnea, shortness of breath, fatigue during activity (reduced O2 delivery)

6.     Headache, weakness, tinnitus (ear buzzing) describes the decrease in oxygenation in the CNS

7.     Severe Anemia disorders GI and CHF (anorexia, nausea, constipation or diarrhea)

 Figure 2

Anemia Signs

G. POSSIBLE COMPLICATIONS ARISING

Common complications from Anemia are:

a)    Heart failure,

b)    Seizures.

c)     Bad muscle development (long term)

d)   Power concentration decreased

e)    The ability to process the audible information decreases

H. SPECIAL AND SUPPORTING EXAMINATION

1.     Hb levels, hematocrit, red blood cell index, white blood cell studies, Fe content, iron bonding capacity measurement, folate, vitamin B12, platelet count, bleeding time, prothrombin time, and partial thromboplastin time.

2.     Bone marrow aspiration and biopsy. Unsaturated iron-binding capacity serum

3.     Diagnostic examination to determine the presence of acute and chronic disease as well as the source of chronic blood loss.

I. MEDICAL MANAGEMENT

Management Anemia is aimed at finding the cause and replacing the lost blood:

1. Aplastic Anemia:

·        Bone marrow transplant

·        Provision of immunosuppressive therapy with antitimosit globolin (ATG)

2. Anemia in renal disease

·        In dialysis pills should be treated with iron and folic acid

·        Availability of recombinant erythropoietin

3. Anemia in chronic diseases

Most patients are asymptomatic and do not require treatment for the anemic, with successful treatment of underlying abnormalities, bone marrow iron is used to make blood, so Hb increases.

4. Anemia in iron deficiency

·        Wanted cause of iron deficiency

·        Using oral iron preparations: ferrous sulfate, ferrous gluconate and ferrous fumarate.

5. Megaloblastic Anemia

·        Vitamin B12 deficiency is treated with vitamin B12 administration, when it is caused by defec- tion or unavailability intrinsic factor can be given vitamin B12 by IM injection.

·        To prevent recurrence Anemia of vitamin B12 therapy should be continued during the life of patients suffering from pernicious Anemia or non-corrected malabsorption.

·        Folic acid deficiency Anemia with diet and folic acid addition 1 mg / day, IM in patients with impaired absorption.

J. NURSING ASSESSMENT

Assessment is the first and basic step in the overall nursing process (Boedihartono, 1994). Assessment of patients with Anemia (Doenges, 1999) includes:

1. Activity / rest

Fatigue, weakness, general malaise. Loss of productivity, decreased passion for work Tolerance to low exercise. Needs to rest and sleep more

2. Circulation

History of chronic blood loss, history of chronic infective endocarditis, palpitations

3. Integrity of the ego

Religious or cultural beliefs influence the choice of treatment, such as the refusal of blood transfusions

4. Elimination

Kidney failure, Hematemesi, Diarrhea or constipation

5. Food / liquid

Decreased appetite, nausea / vomiting, weight loss.

6. Pain / comfort

Location of pain, especially abdominal area and head

7. Breathing

Shortness of breath during breaks and activities

8. Sexuality

Menstrual changes such as menorrhagia, amenorrhea. Decreased sexual function

9. Observation of Anemia manifestation

a)    General Manifestations

•        Muscle weakness

•        Easily tired

•        Pale skin

b)    Manifestation of the central nervous system

•        Headache

•        Dizzy

•        Fireflies

•        Sensitize stimuli

•        The process of thinking is slow

•        Decrease of viewing field

•        Apathetic

•        Depression

c)     Shock (Anemia loses blood)

•        Peripheral perfusion of laborers

•        The skin is moist and cold

•        Low blood pressure and blood pressure are as regimental

•        Increased frequency of jatung

K. NURSING DIAGNOSIS AND COLLABORATION PROBLEMS WHO MAY ARRIVE

1.   Ineffective tissue perfusion b.d change of O2 bond with Hb, decrease Hb concentration in blood.

2.   Nutrition imbalance less than body needs b.d inadekuat food intake.

3.   Self-care deficit b.d weakness

4.   Infection risk b.d inadequate secondary defense (decrease in Hb)

5.   Activity intolerance b.d supply imbalance and oxygen demand.

6.   Disturbance of gas exchange b.d perfusion ventilation

7.   Ineffectiveness of the pattern of breath b.d fatigue

8.   Fatigue b.d Anemia

L. NURSING PLANNING

NO	NURSING DIAGNOSIS	OBJECTIVES	INTERVENSI
1	Ineffective tissue perfusion b / d decrease in Hb and blood concentration, reduced oxygen supply	After performed nursing actions during ......... client network perfusion hours adekuat with criteria: ·         Red mucous membranes ·         Conjunctiva is not anemic ·         Akral warm ·         Vital signs within the normal range	Peripheral Sensation Management •         Monitor the presence of certain areas that are only sensitive to heat / cold / sharp / dull •         Monitor the presence of paretese •         Instruct the family to observe the skin if there are lesions or lacerations •         Use hand protection for hand protection •         Limit movement to the head, neck and back •         Monitor CHAPTER capabilities •         Collaboration of analgesic administration •         Monitor the presence of thromboplebitis •         Discuss the cause of the sensation change
2	The nutritional imbalance is less than the body's need for lack of intake, anorexia	After performed nursing actions during .......... Nutritional status of the client adequately with the outcome criteria: •         The increase in body weight in accordance with the purpose •         Ideal weight according to height •         Be able to identify nutritional needs •         No signs of malnutrition •         Indicates improved taste function of swallowing •         No significant weight loss occurs •         Adequate income •         Signs of malnutrition •         Conjunctival membranes and pale mukos •         Lab Value: Total protein: 6-8 gr% Albumin: 3.5-5.3 gr% Globulin 1.8-3.6 gr% HB not less than 10 gr%	NIC: Nutrition Management ·         Assess for food allergies ·         Collaborate with nutritionists to determine the number of calories and nutrients the patient needs. ·         Instruct patient to increase Fe intake ·         Advise patients to increase protein and vitamin C ·         Give the sugar substance ·         Make sure the diet is high in fiber to prevent constipation ·         Provide selected foods (already consulted with nutritionists) ·         Teach the patient how to make daily diary records. ·         Monitor the amount of nutrients and calorie content ·         Provide information on nutritional needs ·         Assess the patient's ability to get the needed nutrients Nutrition Monitoring ·         BB patients within normal limits ·         Monitor weight loss ·         Monitor the type and number of activities that are commonly performed ·         Monitor child or parent interactions during meals ·         Monitor the environment during meals ·         Schedule treatment and no action during meal hours ·         Monitor dry skin and pigmentation changes ·         Skin turgor monitor ·         Monitor drought, dull hair, and easily broken ·         Monitor nausea and vomiting ·         Monitor albumin, total protein, Hb, and Ht levels ·         Favorite food monitor ·         Monitor growth and development ·         Pallor, redness, and dryness of conjunctival tissue ·         Monitor calorie and nutritional intake ·         Note the presence of edema, hyperemic, tongue hypertonic papilla and oral cavity. ·         Note if the tongue is magenta, scarlet
3	Self-care deficit b / d physical weakness	After nursing actions during ......... .jam the client's self-requirements are met with the outcome criteria: ·         Client is free from body odor ·         Express the convenience of the ability to perform ADLs ·         Can perform ADLS with help	NIC: Self Care assistane: ADLs •         Monitor client's ability for self-care. •         Monitor clients' needs for personal hygiene, dressing, ornamental, toileting and eating utensils. •         Provide help until the client is fully capable of self-care. •         Encourage clients to perform normal daily activities according to their abilities. •         Encourage to do it independently, but give help when the client is unable to do so. •         Teach clients / families to encourage independence, to provide assistance only if the patient is unable to do so. •         Provide routine daily activities according to ability. •         Consider the age of the client if encouraging the implementation of daily activities.
4	Risk of infection Risk factors: •         Infectious Procedures •         Insufficient knowledge to avoid exposure to pathogens •         Trauma •         Network damage and increased environmental exposure •         Rupture of the amniotic membrane •         Pharmaceutical agents (immunosuppressants) •         Malnutrition •         Increased exposure to pathogenic environments •         Imonusupresi •         Inadequate imum inhibition •         Inadequate secondary defense (decreased Hb, Leukopenia, suppression of inflammatory response) •         Inadequate primary body defense (incomplete skin, tissue trauma, decreased ciliary work, static body fluids, pH secretion changes, peristaltic changes) •         Chronic illness	After a nursing action during ......... .hour client's immune status increases with criteria: ·         Client is free from signs and symptoms of infection ·         Demonstrate ability to prevent infection ·         The number of leukocytes within normal limits ·         Demonstrate a healthy life behavior	NIC: Infection Control (Infection Control) •         Clean the environment after other patients use it •         Maintain isolation techniques •         Limit the visitor if necessary •         Instruct the visitors to wash hands while visiting and after visiting leave the patient •         Use an antimicrobial soap to wash your hands •         Wash hands every before and after kperawtan action •         Use a shirt, gloves as a protective device •         Maintain an aseptic environment during device installation •         Replace the peripheral IV location and line central and dressing according to general instructions •         Use intermittent catheter to reduce urinary bladder infection •         Tie the nutritional intake •         Provide antibiotic therapy if necessary Infection Protection (protection against infection) •         Monitor signs and symptoms of systemic and local infection •         Monitor granulocyte count, WBC •         Monitor susceptibility to infection •         Limit your visitors •         Filter visitors against infectious diseases •         Maintain isolation techniques k / p •         Apply skin care to the epidemic area •         Inspection of skin and mucous membranes against redness, heat, drainage •         Ispect the condition of the wound / surgical incision •         Encourage adequate nutrition •         Encourage fluid input •         Push the break •         Instruct the patient to take prescribed antibiotics •         Teach patient and family signs and symptoms of infection •         Teach how to avoid infection •         Report suspected infections •         Report positive culture
5	Activity intolerance b.d supply imbalance and oxygen demand	After nursing actions during ...... .. clients can move on with the outcome criteria: •         Participate in physical activity with appropriate TD, HR, RR •         Declare symptoms of worsening effects of OR & express its immediate onset •         Normal, warm & dry skin color •         Vitalize the importance of activity gradually •         Expressing the importance of exercise balance & rest •         Increased activity tolerance	Tolerance of activity •         Determine the cause of activity intolerance & determine whether the cause of physical, psychic / motivation •         Observe the restrictions of clients in the activity. •         Assess the suitability of daily client activities & breaks •         ↑ activity gradually, let the client participate can change position, move & care self •         Make sure clients change positions gradually. Monitor symptoms of activity intolerance •         When helping clients stand up, observe symptoms of intolerance such as nausea, pallor, dizziness, conscious disorders & vital signs •         Do a ROM exercise if the client can not tolerate the activity •         Help clients select activities they can afford to do
6	Disturbances of gas exchange b.d ventilation-perfusion	After nursing actions during ...... .. respiratory status: gas exchange improved with criteria: •         Demonstrate an adequate increase in ventilation and oxygenation •         Maintain pulmonary hygiene and free from signs of respiratory distress •         Demonstrate effective cough and clear breath sounds, no cyanosis and dyspnea (capable of removing sputum, able to breathe easily, no pursed lips) •         Vital signs in the normal range of	Oxygen Therapy •         Clean the mouth, nose and secret trachea •         Maintain a patent airway •         Adjust oxygenation equipment •         Monitor oxygen flow •         Maintain the patient's position •         Onservation of hypoventilation signs •         Monitor patient's anxiety for oxygenation Vital sign Monitoring •         Monitor TD, pulse, temperature, and RR •         Note the fluctuations in blood pressure •         Monitor VS when the patient is lying down, sitting, or standing •         Auscultate TD in both arms and compare •         Monitor TD, pulse, RR, before, during, and after activity •         Monitor the quality of the pulse •         Monitor the frequency and rhythm of the breathing •         Pulmonary sound monitor •         Monitor abnormal breathing patterns •         Monitor the temperature, color, and moisture of the skin •         Monitor peripheral cyanosis •         Monitor the presence of cushing triads (widened pulse pressure, bradycardia, increased systolic) •         Identify causes of vital sign changes
7	Fatigue b.d Anemia	After the nursing action during ...... .. client's fatigue is resolved by the criteria: •         Adequate activity abilities •         Maintain adequate nutrition •         Balance of activity and rest •         Using energy conservation techniques •         Maintain social interaction •         Identify physical and psychological factors that cause fatigue •         Maintaining the ability to concentrate	Energy management •         Monitor the client's response to the activity of tachycardia, dysrhythmias, dyspnea, pallor, and amount of respiration •         Monitor and record the number of clients sleep •         Monitor discomfort or pain during movement and activity •         Monitor nutrition intake •         Instruct the client to record signs and symptoms of fatigue •         Explain to the client the relationship of fatigue with the disease process •         Record activities that can increase fatigue •         Encourage clients to do that increases relaxation •         Increase restrictions on bedrest and activity

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