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4 Aplastic Anemia Nursing Care Plans

December 2011 Nurse Licensure Examination Results
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Aplastic anemia is a condition where bone marrow does not produce sufficient new cells to replenish blood cells. The condition, per its name, involves both aplasia and anemia. Typically, anemia refers to low red blood cell counts, but aplastic anemia patients have lower counts of all three blood cell types: red blood cells, white blood cells, and platelets, termed pancytopenia.

Signs and Symptoms of Aplastic Anemia

Anemia with malaise, pallor and associated symptoms such as palpitations
Thrombocytopenia (low platelet counts), leading to increased risk of hemorrhage, bruising and petechiae
Leukopenia (low white blood cell count), leading to increased risk of infection
Reticulocytopenia (low reticulocyte counts)

Causes of Aplastic Anemia

In many cases, the etiology is considered to be idiopathic (cannot be determined), but one known cause is an autoimmune disorder in which white blood cells attack the bone marrow.

Aplastic Anemia Nursing Care Plans

Risk for infection related to decreased resistance and increased susceptibilitysecondary to leukopenia

Aplastic anemia is characterized by the depression of hemato-poietic activity in bone marrow affecting all blood cells. In effect, serum level of RBC, WBC and Platelets are depleted. Apparently, WBCs or leukocytes are the ones responsible in acting against foreign microorganisms that invade the body. Such event of a depleted leukocytes can highly predisposes the individual to acquire various secondary infec-tions since the body is said to be immuno-compromised. Thus, a nursing diagnosis of risk for infection was derived.

Assessment

Nursing Dx

Planning

NursingInterventions

Rationale

Expected Outcome

S = OO = the client manifested the ff. s/sx:

weakness
easy fatigability
dryness of lips
bloodstained gums and teeth
with untrimmed and dirty fingernails
with limited range of motion
lab values suggest a decreased in WBC count, neutrophils, hematocrit, hemoglobin and
thrombocytes

= the client may further manifest:

-hyperthermia

-flushed skin

-irritability

-restlessness

-various signs of different systemic infection such as:

Resp: Cough, colds, adventitious breath sounds

Skin: rashes, itchiness, wounds, untimely wound healing

GI: nausea, vomiting, abdominal discomfort

GU: dysuria, abnormal discharges and other associated symptoms

Risk for infection related to decreased resistance and increased susceptibilitysecondary to leukopenia

Short term:After 4 hours of NI, the client will identify interven-tions to reduce/ prevent risk for infection.Long term:After 3 days of NI, the client will display techniques and lifestyle changes conducive for her health promotion and disease prevention and she will be free from signs of potential infection.

1. Maintain established rapport2. Monitor vital signs, especially temp.3. Stress proper hand washing techniques by all caregivers between therapies4. Monitor visitors/ caregivers of the client. Instruct SO to limit visitors especially those with known contagious illnesses.

5. Maintain aseptic/sterile techniques as much as possible

6.Advise the use of facial mask when going outside the client’s room

7. Encouraged early ambulation, deep breathing and turning exercises as indicated.

8. Provide regular catheter/ perineal care as indicated

9. Reinforce teachings about diet. Avoid raw meats, fruits and vegetables. Consume prescribed nutritionally adequate menus.

10. Enforce strict bed rest. Provide the client her favorite books as necessary.

11. Review to the client and SO about the nature of the disease and the interventions needed.

12. Instruct the client to report significant changes that she may experience typical to a presence of infection.

13. Refer to other members of the health care team.

1. to gain trust & relieve anxiety2. to obtain baseline data; also, fever is usually the initial sign of infection3. hand washing is the primary measure against nosocomial infections/ cross contamination4. prevents unwanted exposure of the client to other communicable diseases

5. to avoid cross contamination

6. reverse isolation is an important for clients who are immuno-suppressed

7. simple exercises helps tone body built and strengthen the body system.

8. to prevent growth of microorganisms

9. to provide an optimum nutrition to meet daily needs of client; raw food can contain microorganisms that may precipitate infection

10. client is in great need of staying on her room to avoid potential exposure to pathogenic elements

11. helps alleviate anxiety; can also foster cooperation and compliance to prescribed therapeutics

12. to intervene with such events accordingly

13. promotes inter-disciplinary care rendered to the client

Short term:The client shall have identified interventions to reduce/prevent risk for infectionLong term:The client shall have displayed techniques and lifestyle changes conducive for her health promotion and disease prevention and have been free form signs of potential infection.

Other Possible Nursing Diagnoses for Aplastic Anemia

Activity intolerance RT insufficient oxygen secondary to diminished red blood cell count
Risk for impaired oral mucus membrane RT tissue hypoxia and vulnerability
Risk for ineffective therapeutic regimen management RT insufficient knowledge of causes, prevention and signs and symptoms of complications