NURSING INSTITUTION IN anemia

Compiled by group 4:
1. Dela Novitasari / 1614201005
2. Eka Puji Lestari / 1614201035
3. Listia Ardiani / 1614201014
4. Reny Angraini / 1614201041
5. Siti Nopiyanah / 1614201021
6. Tresna Dinullah Antoni / 1614201066
 Understanding anemia

Anemia (in Greek: No blood) is the condition

when the number of red blood cells or the amount of
hemoglobin (the carrier protein oxygen) in the red
blood cells is below normal. Anemia is reduced to
below the normal value of erythrocytes, the quantity
of hemoglobin, and the volume of packed red blood
cells (hematocrit) per 100 ml of blood.
 Anemia or anemia etiology

1. Bleeding
2. Lack of nutrients such as iron, vitamin B12, and
folic acid. (Barbara C. Long, 1996)
3. Chronic diseases, such as kidney failure, lung
abscess, bronchiectasis, empyema, etc.
4. Blood disorders
5. The inability of the bone marrow to form blood
cells. (Arif Mansjoer, 2001)
 Classification

Pathophysiologically anemia consists of:

1. Decreased production: deficiency anemia,
aplastic anemia.
2. Increased destruction: anemia due to bleeding,
hemolytic anemia.
In general anemia is grouped into:

1. Microcytic anemia hipokrom

a. Iron deficiency anemia
b. Anemia of chronic disease
2. Macrocytic anemia
a. Pernicious Anemia
b. Folic acid deficiency anemia
 Advance….
3. Anemia due to bleeding
a. Acute bleeding
b. Chronic bleeding
4. Hemolytic anemia
5. Aplastic anemia
 Clinical Manifestations

Common symptoms that are often encountered in

anemic patients include: pale, weak, tired, cold
sweat, tachycardia, hypotension, palpitations.
(Barbara C. Long, 1996). Tachypnea (during
physical exercise), skin and mucosal changes (in Fe
deficiency anemia). Anorexia, diarrhea, jaundice are
common in pernicious anemia patients (Arif
Mansjoer, 2001)
 Supporting investigation

On laboratory examination found:

1. The amount of Hb is lower than normal (12 - 14 g
/ dl)
2. Ht levels decreased (normal 37% - 41%)
3. Increased total bilirubin (in hemolytic anemia)
4. Visible reticulocytosis and spherocytosis in
peripheral blood smears
5. There is pancytopenia, empty bone marrow
replaced with fat (in aplastic anemia)
 nursing care in anemic patients

Tn.H came to the hospital RSUD saint On

February 13, 2014 at 08.30 WIB, the patient
complained of nausea, vomiting, weakness,
dizziness in the morning, dizziness felt after the
move. When studied, the results of blood pressure
100/60 mmHg pulse: 85 x / min Respiration: 28 x /
min Temperature: 37.2 0C, HB: 7.9 g / dl
1. Assessment
a. Patient's Biodata
• Name : Tn. H
• Age : 80 years old
• Gender : Male
• Status : Married
• Religion : Islam
• Ethnicity : Sundanese
• Education : Elementary School
• Occupation : Farmer
• No. RM : 0182
• Medical diagnosis : Anemia
• Hospital admission date : February 12, 2014, Wednesday
• Date of Review : February 13, 2014, Thursday
• Address : Kp. Cipanengah RT 01 / RW 06
b. Identity responsible
• Name : Tn. A
• Age : 35 years old
• Gender : Male
• Education : Elementary School
• Occupation : Labor
• Relationship with patient : Child
• Address : Kp. Cipanengah RT 01 / RW
06
2. The main complaint
Patient says headache (dizziness).
3. Current medical history
patients complain of nausea, vomiting,
weakness, dizziness in the morning, dizziness
felt after the move
4. Past medical history
The patient's family said the patient had
experienced the illness now before entering
the hospital.
5. Family health history
The patient's family says they have no
hereditary disease
6. Functional Patterns According to Gordon
• Pattern of health perception
According to the client's health is very important and valuable, if clients
experience impaired clients directly seek treatment to a general
practitioner
• Pattern of nutrition
Before ill: Clients eat 3x a day, eat rice, side dishes, vegetables, drink +
8 cups (2000 cc) per day
During illness: Clients eat 3x a day to eat porridge, drink 5 cups (1250
cc)
• Pattern of elimination
Before getting sick: Client CHAPTER 1x daily with yellow softening
consistency. Client BAK 4-5 x daily with clear yellow and distinctive
odor.
During illness: Client CHAPTER 3x daily with black liquid consistency.
Client BAK 4-5x daily with clear yellow color and distinctive odor
• Patterns of activity and exercise
Before sick: Before the client's illness perform daily activities
independently
During illness: Clients engage in family-assisted activities and nurses
• Cognitive pattern
Before illness: Clients view health is important. Clients can think and act
and can solve the problem.
During illness: Clients can still think and make decisions if there is a
problem the client discussed with nurses and hospital personnel
• Break pattern
Before sick: Clients sleep from 21:00 to 05:00 pm
During illness: During illness the sleeping client starts at 21-00
intermittently waking up due to stomach
• Pattern of self-concept
Identity: The client is a head of a household who works in a city
Ideal self: The client's expectations after coming home from the client's
hospital can work again to support his family
Self-esteem: The client is not ashamed of the state of affairs in the
hospital today.
Self-image: The client feels sad about his illness
• Pattern of relationship and role
Before sick: Relation with good and harmonious family
During illness: Relationships with families both with nurses and with
patients around them are good
• Reproductive and sexual patterns
Clients get married and have children 5
• Coping with stress
Every client there is a problem discussed with family and
nurse
• Confidence / trust
Clients are Muslim and always pray for healing.
 Physical examination

– General situation: Good

– Level of consciousness: Apathy
– Vital signs
• Blood pressure: 100/60 mmHg
• Nadi: 85 x / min
• Respiratory: 28 x / min
• Temperature: 37,20C
 Head to toe check
• Head / hair
Symmetrical, hair color black and gray, hair spread evenly, no
tenderness, no lumps, hair looks clean.
• Eyes
Symmetrical, poor vision, anemic conjunctiva, sclera not jaundice,
looks clean.
• Ear
Symmetrical, looks clean, hearing lack of no bleeding, no serumen.
• Nose
Symmetrical, looks clean, no bumps, normal smell, no secretions, no
dirt, no cuts, no bleeding.
• Mouth
Symmetrical, incomplete teeth, no stomatitis, cyanosis lips.
• Neck
Symmetrical, no enlarged thyroid gland, good swallowing function, no
lesions.
• Chest (lung and heart)
Symmetrical chest, regular heart sound, breathing 28 x / min, no
lesions, no tenderness.
• Abdomen
Symmetrical, flat stomach shape, no fluid accumulation no
lesions, no tenderness.
• Genetalia
No complaints or abnormalities.
Top eccentricity
• Symmetrical, there is tenderness in the left hand because of an
infusion, no abnormalities, rather weak.
• Lower eccentricity
• Symmetrical, no tenderness, looks clean.
 NURSING DIAGNOSES

1. Disturbance of tissue perfusion b.d change of

O2 bond with Hb, decrease Hb concentration
in blood.
2. Activity intolerance b.d supply imbalance and
oxygen demand.
3. Nutrition imbalance less than body needs b.d
imbalance food intake.
 Intervention
NOC
After a nursing action of 1 X 24 hours is expected to reach the outcome
criteria:
1. Circulation status
NIC
1. Monitor vital signs
• Monitor blood pressure, temperature, pulse,
breathing appropriately
• Monitor skin color, temperature and humidity
• central or peripheral cyanosis monitor
• identification of possible causes of change of
vital signs
 Implementation

• Monitor blood pressure, temperature, pulse,

breathing appropriately
• Monitor skin color, temperature and humidity
• Monitor central or peripheral cyanosis
• identifies possible causes of vital signs change