Anemia is a low number of red blood cells or low hemoglobin, so the blood carries less oxygen. It can come from blood loss, low iron or vitamins, or chronic disease. Your priorities are managing fatigue, preventing falls, and treating the cause safely.
Each care plan below follows the nursing process (ADPIE).
Activity Intolerance
- Less oxygen carried to the tissues
- Low hemoglobin
- Fatigue and weakness
- Shortness of breath with activity
- Tachycardia with activity
- Pale skin and nail beds
- Client completes self-care with rest periods within 48 hours
- Client returns to usual activities as hemoglobin improves
- Hemoglobin, hematocrit, and iron studies
- Heart rate, BP, and SpO2 with activity
- Fatigue level
- Signs of bleeding
| INTERVENTION | RATIONALE |
|---|---|
| Cluster care and plan rest periods | Rest lowers oxygen demand. |
| Give iron, B12, or folic acid as ordered | These help the body make red blood cells. |
| Give blood transfusions as ordered, following the safety checks | Transfusions quickly raise hemoglobin when it is very low. |
| Monitor closely during the first 15 minutes of a transfusion | Most serious reactions happen early. |
EVALUATION
- Client completes self-care with less fatigue
- Vital signs stay stable with activity
- Hemoglobin is improving
Risk for Falls
- Dizziness and weakness
- Orthostatic hypotension
- Client remains free of falls during the hospital stay
- Client uses safe mobility habits at home
- Fall risk score
- Orthostatic vital signs
- Dizziness with position changes
| INTERVENTION | RATIONALE |
|---|---|
| Teach slow position changes | This gives the body time to adjust BP. |
| Assist with walking and keep the call light in reach | Help reduces fall risk during weakness. |
| Teach to take oral iron with vitamin C and expect dark stools | Vitamin C helps absorb iron. Dark stools are a normal side effect. |
| Teach iron-rich foods like leafy greens, beans, and lean meats | Diet helps maintain iron levels. |
EVALUATION
- Client has no falls
- Client demonstrates slow position changes
- Client lists iron-rich foods
Practice this in Everyday RN
Hang a blood transfusion safely during a full med-surg shift.
Play Everyday RNQuick answers
What should the nurse do first if a client develops chills and back pain during a blood transfusion?
Stop the transfusion, keep the IV line open with normal saline using new tubing, and notify the provider and blood bank.
How should oral iron be taken?
On an empty stomach if tolerated, with vitamin C to help absorption, and not with milk or antacids. Expect dark green or black stools.
For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.