Nursing Diagnosis and Nursing Intervention


NCP for Anemia

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Nursing Care Plan for Anemia

NCP for Anemia


Definition of Anemia

Anemia is a medical condition in which the red blood cell count or hemoglobin is less than normal. The normal level of hemoglobin is generally different in males and females. For men, anemia is typically defined as hemoglobin level of less than 13.5 gram/100ml and in women as hemoglobin of less than 12.0 gram/100ml. These definitions may vary slightly depending on the source and the laboratory reference used.

Anemia Symptoms

Clinical symptoms that appear to reflect dysfunction of various systems in the body such as decrease in physical performance, impaired neurologic (nerve), which is manifested in changes in behavior, anorexia (emaciated body), and abnormal cognitive development in children. Often, too, growth abnormality, epithelial dysfunction, and reduced gastric acidity.

An easy way to know anemia with 5 signs: weak, tired, lethargic, tired, negligent. If it appears five of these symptoms, we can be sure a person has anemia. Another symptom is the appearance of sclera (white color on the lower eyelid).

Anemia can cause fatigue, weakness, lack of energy and the head was floating. If the anemia gets worse, can cause a stroke or heart attack.
Source : http://signssymptoms.blogspot.com/2011/04/anemia-symptoms.html

Nursing Assessment for Anemia
Assessment of patients with anemia (Doenges, 1999) include :
  1. Activity / rest
    Symptoms :
    fatigue, weakness, general malaise. Lost productivity: a reduction in enthusiasm for work. Low exercise tolerance. The need for sleep and rest more.
    Signs :
    tachycardia / takipnae; dyspnea during work or rest. Lethargy, withdrawn, apathetic, lethargic, and less interested in its surroundings. Muscle weakness, and decreased strength. Ataxia, the body is not upright. Shoulders down, slumped posture, slow, and other signs that indicate fatigue.
  2. Circulation
    Symptoms :
    A history of chronic blood loss, such as chronic gastrointestinal bleeding, heavy menstruation, angina, CHF (due to excessive cardiac work). History of chronic infective endocarditis. Palpitations (tachycardia compensation).
    Signs :
    Blood pressure: systolic to diastolic steady improvement, and widening pulse pressure, postural hypotension. Dysrhythmias: ECG abnormality, ST segment depression and T wave leveling or depression; tachycardia. The sound of the heart: systolic murmur. Extremity (color): pale skin and mucous membranes (conjunctiva, mouth, pharynx, lips) and the base of the nail. (Note: in black patients, white may appear to be grayish). Leather like waxy, pale or bright lemon yellow. Sclera: blue or pearly white. Slow capillary filling (decreased blood flow to the capillary and vasoconstriction compensation) nails: easily broken, shaped like a spoon (koilonikia). Hair: dry, easily breaking, thinning, gray hair grow prematurely.
  3. Integrity ego
    Symptoms :
    Religious beliefs / cultural influence treatment options, such as refusal of blood transfusions.
    Signs :
    depression.
  4. Elimination
    Symptoms :
    A history of pyelonephritis, kidney failure. Flatulen, malabsorption syndrome. Hematemesis, stool with fresh blood, melena. Diarrhea or constipation. Decrease in urine output.
    Signs :
    Abdominal distension.
  5. Food / fluid
    Symptoms :
    Decreased dietary input. Painful mouth or tongue, difficulty swallowing (pharyngeal ulcers). Nausea / vomiting, dyspepsia, anorexia. The presence of weight loss. Never satisfied to chew or sensitive to ice, dirt, corn flour, paint, clay, and so forth.
    Signs :
    Tongue looks red meat / subtle deficiency of folic acid and vitamin B12. Dry mucous membranes, pale. Skin turgor: ugly, dry, looks shriveled / lost elasticity. Stomatitis and glositis (deficiency status). Lips: selitis, such as inflammatory lips with the corner of his mouth cracked.
  6. Neurosensori
    Symptoms :
    Headache, throbbing, vertigo, tinnitus, inability to concentrate. Insomnia, decreased vision, and shadows on the eyes. Weakness, poor balance, unsteady legs, paresthesias hands / feet; klaudikasi. The sensation of being cold.
    Signs :
    Sensitive to stimuli, anxiety, depression tend to sleep, apathy. Mental: not able to respond, slow and shallow. Ophthalmic: hemoragis retina. Epitaksis: bleeding from the holes (aplastic). Impaired coordination, ataxia, decreased sense of vibration, and position, positive Romberg sign, paralysis.
  7. Pain / comfort
    Symptoms: abdominal pain, headache
  8. Breathing
    Symptoms :
    A history of tuberculosis, lung abscess. Short of breath at rest and activity.
    Signs :
    Tachypnoea, orthopnea, and dyspnea.
  9. Security
    Symptoms :
    A history of work exposure to chemicals,. History of exposure to radiation, either to treatment or accident. History of cancer, cancer therapy. Not tolerant of cold and heat. Previous blood transfusion. Impaired vision, poor wound healing, frequent infections.
    Signs :
    A low fever, chills, night sweats, general lymphadenopathy. Ptekie and ekimosis(aplastic).
  10. Sexuality
    Symptoms :
    Changes in menstrual flow, such as menorrhagia or amenorrhea. Lost libido (male and female). Imppoten.
    Signs :
    Pale vaginal walls.
Source : http://ncp-blog.blogspot.com/2011/05/ncp-for-anemia.html
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