Hemoglobin is a protein in the blood that carries oxygen and carbon dioxide to and from the tissues and organs back to the lungs. The body makes hemoglobin through iron, a natural component of red blood cells (RBC).
Normal hemoglobin levels are 14 -18 g/dL for adult males and 12 – 16 g/dL for adult females. What is considered “low” will vary between facilities and patients.
Causes
Low hemoglobin is often caused by low iron levels in the blood or iron deficiency anemia and may lead to severe health conditions, including heart problems. Other causes of low hemoglobin include:
- Diet low in iron
- Recent gastrointestinal surgery
- Heavy menstrual bleeding
- Gastrointestinal bleeding
- Recent blood donation
- Pregnancy
- Growth spurts in children
- Certain medical conditions like anemia, sickle cell disease, cancer, cirrhosis, chronic kidney disease, and leukaemia
Signs and Symptoms
Signs and symptoms of low hemoglobin include:
- Weakness
- Fatigue
- Shortness of breath
- Cyanosis
- Pale skin and gums
- Fast and irregular heartbeat
A complete blood count, including red blood cell count and hemoglobin level, can help confirm low hemoglobin and other blood cell abnormalities.
Nursing Process
The treatment and management of low hemoglobin include diagnosing and treating the underlying cause. Nursing care includes patient education of the cause, prognosis, and complications of the condition, provision of iron supplementation, adherence to an iron-rich diet, monitoring of symptoms, and lifestyle modifications.
Nursing Assessment
Initial Evaluation
The initial evaluation of a patient with suspected low hemoglobin involves a thorough medical history and physical examination. Key aspects to assess include:
Medical History: Review the patient’s history for risk factors such as chronic illnesses (e.g., kidney disease, cancer), recent surgeries, infections, or medications that may contribute to low haemoglobin. Inquire about symptoms such as fatigue, weakness, dizziness, shortness of breath, and paleness, which are common in anaemia.
Physical Examination: Perform a comprehensive physical examination focusing on signs of anaemia, such as pallor (pale skin and mucous membranes), tachycardia (rapid heart rate), hypotension (low blood pressure), and signs of underlying conditions that may contribute to anaemia.
Laboratory Tests: Obtain baseline laboratory tests, including complete blood count (CBC) to measure haemoglobin levels, haematocrit (percentage of red blood cells), mean corpuscular volume (MCV), and reticulocyte count (immature red blood cells). Additional tests may include iron studies, vitamin B12 and folate levels, and renal function tests to identify the underlying cause of anemia.
Ongoing Monitoring
Symptom Tracking: Keep track of changes in the patient’s symptoms, such as fatigue levels, exercise tolerance, and any signs of worsening anaemia. Document any improvements or setbacks and adjust interventions accordingly.
Laboratory Monitoring: Regularly monitor the patient’s haemoglobin levels, haematocrit, and other relevant laboratory parameters to assess the effectiveness of treatment and make necessary adjustments to the care plan.
Assessment of Complications: Be vigilant for potential complications of low haemoglobin, such as heart failure, angina (chest pain), or cognitive impairment. Early detection and intervention are essential to prevent further deterioration.
Nursing Intervention
Medical Management
Iron Supplementation: For patients with iron-deficiency anaemia, oral or intravenous iron supplementation may be prescribed to replenish iron stores and increase haemoglobin levels. Nurses should educate patients on the importance of adherence to iron therapy and monitor for potential side effects such as gastrointestinal discomfort.
Vitamin B12 and Folate Supplementation: For patients with anemia due to vitamin B12 or folate deficiency, appropriate supplementation is necessary. Nurses should ensure that patients receive the correct dosage and monitor for signs of improvement.
Blood Transfusions: In cases of severe anaemia or when rapid correction is needed, blood transfusions may be required. Nurses play a vital role in preparing and monitoring patients during transfusions to ensure safety and efficacy.
Dietary Modifications
Nutrition Education: Educate patients on the importance of a balanced diet rich in iron, vitamin B12, and folate. Encourage the consumption of iron-rich foods such as red meat, poultry, fish, leafy green vegetables, and fortified cereals.
Meal Planning: Assist patients in planning meals that incorporate a variety of nutrient-dense foods to support optimal hemoglobin levels. Provide resources and recipes to help patients make healthy dietary choices.
Patient Education and Support
Medication Adherence: Emphasize the importance of adhering to prescribed medications and supplementation for anaemia management. Educate patients on the potential side effects and how to manage them.
Emotional Support: Offer emotional support and reassurance to patients experiencing low haemoglobin. Listen to their concerns and provide empathetic care to address their emotional and psychological needs.
Follow-Up Care
Regular Follow-Up: Schedule regular follow-up visits to monitor the patient’s progress, reassess symptoms, and adjust the care plan as needed. Ensure the patient knows when to seek medical attention for worsening symptoms or complications.
Addressing Barriers: Identify and address any barriers to the patient’s progress, such as medication side effects, dietary non-compliance, or psychosocial factors. Collaborate with the patient to find practical solutions.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for low hemoglobin, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for low hemoglobin.
Activity Intolerance
Low hemoglobin levels can be detrimental to a patient’s performance, mobility, and overall health. Low hemoglobin limits the body’s capacity to transport oxygen, causing fatigue and reducing work or exercise capacity.
Nursing Diagnosis: Activity Intolerance
Related to:
- Disease process
- Low hemoglobin
- Imbalance between oxygen supply/demand
- Fatigue
As evidenced by:
- Exertional dyspnea
- Expresses fatigue
- Generalized weakness
- Tachycardia
- Tachypnea
Expected outcomes:
- Patient will report the ability to perform activities of daily living without dyspnea or extreme fatigue.
- Patient will identify interventions to reduce activity intolerance.
Assessment:
1. Assess the degree of activity intolerance.
Assess the severity of activity intolerance. Can the patient walk more than 50 feet? Climb stairs? Are they fatigued at rest? What activities can they no longer perform?
2. Assess the patient’s oxygen saturation.
Activity intolerance and fatigue may be precipitated by decreased oxygen saturation.
3. Assess for signs of activity intolerance.
Signs of activity intolerance, fatigue, and reduced tissue oxygenation include dyspnea on exertion, dizziness, headaches, palpitations, and pallor.
Interventions:
1. Encourage adequate rest periods.
Activity intolerance may be aggravated by fatigue. Adequate rest periods can reduce fatigue and promote activity tolerance.
2. Encourage the patient to ask for help.
The patient may be reluctant to ask for help with self-care or household responsibilities. Explain that this increases their risk of injury and will further worsen activity intolerance and fatigue. Help them identify tasks that can be delegated.
3. Instruct on activities that require minimal exertion.
Slowing down may be difficult if the patient is accustomed to an active lifestyle. Instruct on low-impact ways the client can stay active such as short walks, stretching, or light yoga.
4. Administer medications as indicated.
Medications like iron supplements and erythropoietin replacement can help improve low hemoglobin and iron, reducing symptoms of fatigue and activity intolerance.
Decreased Cardiac Output
A decrease in cardiac output can result from blood loss and low hemoglobin.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Decreased oxygenated blood in the heart
- Inadequate cardiac muscle contraction
- Blood loss
- Difficulty of the heart muscle to pump
- Low hemoglobin
As evidenced by:
- Tachycardia
- Blood pressure fluctuations
- Cardiac arrhythmias
- Chest pain
- Diminished pulses
- Cool, clammy skin
- Dizziness and headache
- Fainting
- Weakness
- Fatigue
- Pallor
- Cyanosis
Expected outcomes:
- Patient will demonstrate blood pressure and heart rate within normal limits.
- Patient will manifest normal sinus rhythm on ECG.
- Patient will have no complaints of dizziness, fainting, or weakness.
Assessment:
1. Closely monitor the vital signs.
A severe decrease in hemoglobin causes an increase in heart rate and can lead to hypertension over time. These compensatory mechanisms are an attempt to increase the level of oxygenated blood throughout the body.
2. Assess cardiovascular status.
Low hemoglobin levels can cause a decrease in oxygen delivery to the heart. Poorly oxygenated blood can lead to an increased risk of arrhythmias, heart failure, and ischemia if left untreated. Assess for chest pain, activity intolerance, and difficulty breathing.
3. Monitor ECG.
Low hemoglobin can result in tachycardia and irregular heart rhythms reflected on ECG.
Interventions:
1. Reduce cardiac stress.
Low hemoglobin can impair cardiac output by causing tachycardia and increased stroke volume. Decrease the workload of the heart by minimizing activity.
2. Treat the underlying cause.
Control blood loss and manage the cause of low hemoglobin. Replace red blood cells and iron through supplements, blood transfusions, and bone marrow transplants if necessary.
3. Anticipate a possible blood transfusion.
A severe decrease in hemoglobin requires a blood transfusion to improve the cardiac output and assist in circulating oxygenated blood throughout the body.
4. Administer medications as ordered.
Intravenous iron therapy or an erythropoietin-stimulating agent can be given to improve the hemoglobin levels of patients with conditions such as anemia or renal disease.
Fatigue
A low hemoglobin level means the patient cannot transport adequate oxygen to the different body organs and tissues, causing the patient to feel weak, tired, and easily fatigued.
Nursing Diagnosis: Fatigue
Related to:
- Disease process
- Diminished oxygen-carrying capacity of the blood
As evidenced by:
- Difficulty maintaining usual physical activity
- Difficulty maintaining usual routines
- Expresses a lack of energy
- Expresses weakness
- Expresses tiredness
- Insufficient physical endurance
- Inadequate role performance
- Lethargy
Expected outcomes:
- Patient will demonstrate interventions to reduce fatigue.
- Patient will identify factors that aggravate feelings of tiredness and weakness.
Assessment:
1. Assess the severity, frequency, and activities that aggravate fatigue.
Fatigue can limit the patient’s ability to perform role responsibilities or perform in their career or complete schoolwork. Assess if there are certain times or other factors that contribute to fatigue.
2. Assess laboratory values.
Monitoring complete blood counts helps determine the progression of the patient’s condition and the effectiveness of interventions.
Interventions:
1. Set realistic goals.
Help the patient plan tasks and set limits for each day. Have them prioritize and complete the most important tasks when energy reserves are highest.
2. Administer medications as needed.
Patients with low hemoglobin may be given erythropoietin-stimulating drugs to help generate more red blood cells.
3. Provide supplemental oxygen.
If cells and tissues are not receiving adequate oxygenation, supplemental oxygen may be required.
4. Eat iron-rich foods.
If the patient has iron-deficiency anemia, they may need to increase iron in the diet by eating red or organ meats, fish, green leafy vegetables, beans, and nuts.
Impaired Gas Exchange
Hemoglobin is the protein that transports oxygen in the blood. If hemoglobin levels are too low, gas exchange will be impaired.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Ineffective gas exchange process
- Low hemoglobin levels
- Blood loss
- Reduced blood supply to the lungs
- Disrupted blood flow (ventilation perfusion mismatch)
As evidenced by:
- Dyspnea
- Tachypnea
- Use of accessory muscles
- Headache or dizziness
- Change in mentation
- Change in skin color (pale or cyanotic)
- Cold extremities
- Tachycardia
- Palpitations
- Prolonged capillary refill time
- Anxiety
- Restlessness
- Fatigue
Expected outcomes:
- Patient will not experience respiratory distress.
- Patient will demonstrate oxygen saturation levels and breathing patterns within normal limits.
- Patient will report relief of dyspnea and anxiety.
Assessment:
1. Assess respiratory status.
Very low hemoglobin levels may cause shortness of breath and changes in the rate and rhythm of breathing.
2. Monitor the oxygen saturation.
Pulse oximetry detects the amount of hemoglobin that is bound with oxygen. A drop in oxygen saturation requires immediate management.
3. Obtain ABGs.
Arterial blood gas (ABG) testing can detect alterations in gas exchange through evaluation of the following:
- Oxygen content (O2CT)
- Oxygen saturation (SaO2)
- Partial pressure of oxygen (PaO2)
- Partial pressure of carbon dioxide (PaCO2)
- Blood pH
- Bicarbonate (HCO3)
Interventions:
1. Treat the underlying condition.
Low hemoglobin levels may indicate that the body is not making enough red blood cells (RBCs), that RBCs are destroyed more rapidly than they are produced, or that there has been significant blood loss. Managing the underlying cause can treat the impaired gas exchange caused by low hemoglobin.
2. Place the patient in a High-Fowler position.
High Fowler’s or an upright position improves gas exchange by maximizing lung expansion.
3. Apply oxygen as ordered.
Oxygen treatment can improve perfusion to tissues and alleviate the symptoms of dyspnea and anxiety.
4. Administer blood products as needed.
Depending on the cause of low hemoglobin, the patient may require blood transfusions to increase hemoglobin levels and relieve impaired gas exchange.
5. Prepare for the possible use of airway devices and mechanical ventilators.
Insert an airway device (such as an endotracheal tube) if breathing difficulties persist. Mechanical ventilators can facilitate gas exchange if supplemental oxygen is not enough.
Risk for Bleeding
Patients may experience low hemoglobin as a result of bleeding or coagulation abnormalities.
Nursing Diagnosis: Risk for Bleeding
Related to:
- Low hemoglobin
- Trauma
- Surgical intervention
- Sickle cell anemia
- Internal bleeding
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at the prevention of signs and symptoms.
Expected outcomes:
- Patient will discuss and demonstrate interventions to prevent bleeding.
- Patient will demonstrate hemoglobin, hematocrit, and coagulation values within acceptable limits.
Assessment:
1. Assess for any signs of bleeding.
Bruising or hematomas, blood in the stool or urine, pallor, dizziness, tachycardia, or hypotension are signs of bleeding.
2. Assess and monitor laboratory values.
Low hemoglobin, hematocrit, platelet count, and alterations in PT/aPTT levels can signal issues with bleeding.
Interventions:
1. Educate the patient about bleeding precautions.
Bleeding precautions like using a soft toothbrush and the use of an electric shaver instead of a razor can decrease the risk of spontaneous bleeding.
2. Apply pressure over the site as appropriate when bleeding occurs.
Bleeding can be stopped by applying pressure to allow blood to clot.
3. Administer blood products as indicated.
A blood transfusion may be indicated for patients with low hemoglobin and bleeding.
4. Locate the cause and stop the bleeding.
Early identification and intervention through imaging, procedures, or surgery can prevent internal bleeding and worsening complications.
Nursing Diagnoses and Rationales for Low Haemoglobin
1. Fatigue
Rationale: Low hemoglobin levels result in decreased oxygen-carrying capacity of the blood, leading to inadequate oxygenation of tissues and organs. This can cause persistent feelings of fatigue and lack of energy. Assessing the patient’s energy levels regularly and implementing strategies to conserve energy, such as scheduling periods of rest and avoiding overexertion, are essential. Providing supplemental oxygen if indicated and ensuring a nutrient-rich diet can also help manage fatigue.
2. Activity Intolerance
Rationale: The reduced oxygen delivery to muscles and tissues caused by low hemoglobin can lead to activity intolerance. Patients may experience shortness of breath, increased heart rate, and fatigue during physical exertion. Regularly assessing the patient’s activity levels, encouraging gradual increases in physical activity, and providing periods of rest are important. Nutritional support to enhance energy reserves and, if necessary, blood transfusions to increase hemoglobin levels can improve tolerance to activity.
3. Risk for Infection
Rationale: Anemia can compromise the immune system, making the body more susceptible to infections. Monitoring for signs of infection, maintaining strict aseptic techniques, and educating patients on proper hygiene practices are vital. Nutritional support to strengthen the immune system and considering prophylactic antibiotics if indicated can help reduce infection risk.
4. Impaired Gas Exchange
Rationale: Low hemoglobin levels impair the blood’s ability to transport oxygen, leading to impaired gas exchange in the lungs. Patients may present with symptoms such as shortness of breath, tachypnea, and cyanosis. Regularly assessing respiratory status, including oxygen saturation levels, and providing supplemental oxygen as needed are essential. Encouraging deep breathing exercises and ensuring a comfortable environment to promote effective breathing can help improve gas exchange.
5. Altered Tissue Perfusion
Rationale: Inadequate hemoglobin levels can result in decreased oxygen delivery to tissues, leading to altered tissue perfusion. This can cause symptoms such as dizziness, pallor, and cool extremities. Regularly monitoring vital signs, including blood pressure and heart rate, and assessing peripheral circulation are crucial. Interventions to enhance circulation, such as positioning the patient appropriately and providing warmth, can help improve tissue perfusion.
6. Anxiety
Rationale: Low hemoglobin levels can cause or exacerbate anxiety due to physical symptoms such as shortness of breath and weakness, as well as concerns about health and well-being. Regular psychological assessments and providing mental health support can help manage anxiety. Educating patients about their condition, involving them in care planning, and providing reassurance can empower them and reduce anxiety levels.
7. Impaired Oral Mucous Membrane
Rationale: Anemia can lead to alterations in the oral mucous membrane, causing discomfort and increasing the risk of infections. Regular oral assessments and maintaining good oral hygiene can help. Providing a nutrient-rich diet and considering oral supplements can promote oral health.
8. Deficient Knowledge
Rationale: Patients may lack understanding of the causes, symptoms, and management strategies for low hemoglobin levels. Providing comprehensive education on the condition, its potential complications, and self-care measures, such as medication adherence and dietary modifications, is crucial for effective management. Encouraging patients to ask questions and involving them in care planning can enhance their understanding and compliance.
9. Ineffective Tissue Perfusion
Rationale: Low hemoglobin levels reduce the oxygenation of tissues, leading to symptoms such as pallor, cold extremities, and delayed wound healing. Regularly monitoring tissue perfusion, including capillary refill time and skin temperature, and implementing strategies to improve circulation, such as positioning and warmth, are important. Nutritional support to enhance red blood cell production and, if necessary, blood transfusions can improve tissue perfusion.
10. Risk for Falls
Rationale: Anemia-related symptoms such as dizziness, weakness, and fatigue can increase the risk of falls. Assessing the patient’s risk for falls, implementing fall prevention strategies, and ensuring a safe environment are essential. Educating patients on how to recognize and manage symptoms and providing assistive devices if needed can help reduce the risk of falls.
REFERENCES
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Anemia. WebMD. https://www.webmd.com/a-to-z-guides/understanding-anemia-basics
- Cleveland Clinic. (2022, July 18). Hemoglobin test: What it is, procedure & results. https://my.clevelandclinic.org/health/diagnostics/17790-hemoglobin-test
- Cleveland Clinic. (2022, April 5). Low hemoglobin: Causes, signs & treatment. https://my.clevelandclinic.org/health/symptoms/17705-low-hemoglobin
- Cleveland Clinic. (2022, February 18). Arterial blood gas (ABG): What it is, purpose, procedure & levels. https://my.clevelandclinic.org/health/diagnostics/22409-arterial-blood-gas-abg
- Low Hemoglobin. Cleveland Clinic. https://my.clevelandclinic.org/health/symptoms/17705-low-hemoglobin
- Low hemoglobin count. Mayo Clinic. https://www.mayoclinic.org/symptoms/low-hemoglobin/basics/causes/sym-20050760
- Low Hemoglobin: Everything You Need to Know. Very Well Health. Published: https://www.verywellhealth.com/low-hemoglobin-5217077
- Mayo Clinic. (2022, February 11). Anemia – Diagnosis and treatment – Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/anemia/diagnosis-treatment/drc-20351366
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
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