3.12 Aplastic Anemia

Aplastic anemia is a relatively rare but serious medical condition characterized by a significant reduction or absence of all three major blood cell types: red blood cells (RBCs), white blood cells (WBCs), and platelets. A reduction in all three major blood cell types is known as pancytopenia. Pancytopenia occurs when the bone marrow fails to produce an adequate number of blood cells, leading to a decrease in circulating levels in the bloodstream. In aplastic anemia, the bone marrow fails to produce enough cells. It can also stop producing cells completely. This deficiency of blood cells can lead to severe and life-threatening complications.^[1],[2]

There are two main types of aplastic anemia: acquired or inherited. Acquired aplastic anemia is the most common form of the disease. It often occurs without an identifiable cause and is believed to be the result of an autoimmune reaction in which the body’s own immune system attacks the bone marrow. Exposure to toxins, viral infections, and radiation therapy can also lead to acquired aplastic anemia.

Inherited aplastic anemia is a rare form of the disease. In inherited aplastic anemia, the body has genetic mutations that impact bone marrow production and function. This is also referred to as Fanconi anemia.

Aplastic anemia can occur in any population, but is more common in young adults and adolescents. The onset of the disease can be either sudden or slowly progress and is often identified as symptoms emerge.^[3],[4]

Assessment

Physical Examination

Early symptoms of aplastic anemia are related to fatigue, infections that last a long time, and easy bruising or bleeding. A summary of common clinical manifestations of aplastic anemia is provided in Table 3.12. Note that the clinical manifestations are primarily related to the decreased oxygen-carrying capacity due to abnormally low levels of red blood cells, increased risk of infection due to abnormally low levels of white blood cells, and increased risk of bleeding due to low levels of platelets.

Table 3.12. Clinical Manifestations of Aplastic Anemia^[5],[6]

Diagnostic Testing

Aplastic anemia is characterized by a reduction in red blood cells, white blood cells, and platelets on a CBC. Review normal reference ranges for common diagnostic tests in “Appendix A – Normal Reference Ranges.” The structure and appearance of the cells may also be examined with a peripheral blood smear. If abnormalities are noted, a provider will likely order a bone marrow aspiration and biopsy. These tests are important for confirming the diagnosis by examining the amount, structure of cells, and the health of the bone marrow.^[7],[8],[9]

Nursing Diagnoses

Nursing diagnoses for clients with aplastic anemia are formulated based on the client’s assessment data, medical history, and specific needs. These nursing diagnoses guide the development of individualized care plans and interventions.

Nursing diagnoses for clients with aplastic anemia may include the following:

• Fatigue
• Risk for Infection
• Risk for Bleeding
• Impaired Gas Exchange
• Activity Intolerance
• Readiness for Enhanced Knowledge

Outcome Identification

Outcome identification includes setting short- and long-term goals and creating specific expected outcome statements for nursing diagnoses identified for each client. Expected outcomes are statements of measurable action for the client within a specific time frame that are responsive to nursing interventions.

Sample expected outcomes for common nursing diagnoses related to aplastic anemia are as follows:

• The client will remain free from excessive bleeding.
• The client will remain free from infection.
• The client will identify three measures to conserve energy and prevent fatigue.

Interventions

Medical Interventions

Medical interventions for aplastic anemia address the reduced production of blood cells and improve the client’s blood counts and overall health. The specific treatment plan depends on the severity of aplastic anemia, the underlying cause, and the client’s individual health status. Common medical interventions and medications used to manage aplastic anemia include the following:

• Blood Transfusions: In severe cases of aplastic anemia with critically low blood cell counts, blood transfusions may be administered. Transfusions of whole blood provide an immediate increase in red blood cells, white blood cells, and platelets, alleviating symptoms and preventing complications.
• Immunosuppressive Therapy: Immunosuppressive medications are used to suppress the immune system’s attack on the bone marrow.
• Hematopoietic Stem Cell Transplantation: For younger clients and those with severe aplastic anemia, a hematopoietic stem cell transplant (bone marrow transplant) may be considered. This procedure involves replacing the damaged bone marrow with healthy stem cells from a compatible donor.
• Growth Factors: Medications like erythropoietin and granulocyte-colony stimulating factor (G-CSF) can stimulate the production of specific blood cell types, such as red blood cells and white blood cells
• Avoidance of Certain Medications: Some medications like those used in chemotherapy can exacerbate aplastic anemia and should be discontinued or changed, if possible.^[10],[11]

Nursing Interventions

Nursing interventions for aplastic anemia address the reduced production of blood cells, manage symptoms, and prevent complications. Interventions focus on promoting client well-being, providing education, and supporting the client’s physical and emotional needs.

Common nursing interventions for aplastic anemia include energy management, bleeding precautions, infection protection, medication management, health teaching, and supportive care^[12],[13]:

• Energy Management: Review interventions under “Energy Management” in the “Iron-Deficiency Anemia” section.
• Bleeding Precautions: Review interventions for “Bleeding Precautions” in the “Thrombocytopenia” section.
• Infection Protection: Review interventions for “Infection Protection” in the “Leukopenia” section.
• Medication Management: Ensure the client receives prescribed medications, including immunosuppressive therapy or growth factors.
• Health Teaching and Counseling: Provide education to the client and their family members about aplastic anemia, its pathophysiology, and potential causes. Explain the importance of adhering to treatment plans and regular follow-ups with health care providers.
• Supportive Care: Offer emotional support and create a compassionate environment to help the client cope with the challenges associated with aplastic anemia.

Evaluation

During the evaluation stage, nurses determine the effectiveness of nursing interventions for a specific client. The previously identified expected outcomes are reviewed to determine if they were met, partially met, or not met by the time frames indicated. If outcomes are not met or only partially met by the time frame indicated, the nursing care plan is revised. Evaluation should occur every time the nurse implements interventions with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with other members of the interprofessional team.