Assess and Analyze the Impact of Nutrition on the Hematological System

Learning Outcomes

By the end of this section, you should be able to:

• 9.1.1 Recognize cues that indicate the impact of nutrition on the hematological system.
• 9.1.2 Analyze cues to determine the impact of nutrition on the hematological system.

Assessment of Nutrition and the Function of the Hematological System

Early recognition of hematologic abnormalities and micronutrient deficiency signs can lead to prompt interventions. Nurses play a key role in assessment, delivery of age-appropriate intervention, and education aimed at restoration and prevention of recurrence. Through a comprehensive client assessment, the nurse can apply the nursing process specific to nutritional practices that impact hematologic function. Considering the client’s nutritional preferences, the nurse can develop strategies to promote hematologic wellness.

Providing holistic care to clients is a core competency for nurses; however, the quality of nutritional assessments and decision-making can be inconsistent due to variations in clinical experience and settings of practice (Lulloff et al., 2019). Delays in diagnosing excessive or deficient nutritional intake can lead to hematologic abnormalities, which can result in life-threatening complications and long-term disease consequences. Accurate assessment of the client’s nutritional status with early intervention gives clients the best chance for recovery.

Nurses who provide continuity and consistency through frequent assessment are well-positioned to recognize subtle changes and to work collaboratively with the health care team to develop a plan of care. Assessment of nutritional impact on the hematological system crosses multiple domains of clients’ needs with emphasis on physiological and psychosocial integrity and management of care.

Physiological and Psychosocial Assessment

The nurse should begin the assessment with a health history. The client’s age and sex are important to consider as bone marrow function and immunity decrease with age, and sex influences specific risk factors for hematologic changes (Márquez et al., 2020). The health history includes past medical and surgical history, with emphasis on blood disorders and any past episodes of bleeding, autoimmune disease, and gastrointestinal disease that may result in malabsorption. Surgical history should include the presence of postoperative complications such as poor wound healing and excessive bleeding or bruising. The nurse should explore family medical history because hereditary anemias and certain metabolic conditions can impact hematopoiesis. Also, because many medications have known hematologic side effects, the nurse should obtain an accurate list of the client’s current medications, including over-the-counter products, vitamins, herbs, and nutritional supplements that may provide cues to risk factors when analyzing health data.

The purpose of a nutritional assessment is to identify risk factors and specific nutritional deficiencies, to determine nutritional needs, and to identify the physiological, psychosocial, and socioeconomic factors that may affect hematologic function (Serón-Arbeola, 2022). Dietary history, including the client’s eating and drinking habits, could highlight specific nutrient deficiencies; however, obtaining accurate dietary intake is challenging. If time permits, the use of a food diary actively completed by the client is helpful. Behavioral and emotional considerations and social determinants of health also must be explored (Walker-Clarke et al., 2022). Specific themes to discuss include:

• Access to food
• Aversion to specific foods
• Mental health influences of eating, such as anxiety and depression
• Food preparation knowledge and skill
• Time constraints and family meal patterns
• Attitudes and beliefs surrounding food consumption

A physical assessment will include subjective and objective data (Table 9.1), be system-based, and include vital signs and anthropometric measurements, specifically, height, weight, and body mass index (BMI). Of particular importance is the amount of weight loss (percentage) experienced over a specific period of time. Rapid, unexpected weight loss of 5–10% from baseline is a risk factor for systemic manifestations of nutritional deficiencies. Triceps skinfold thickness (TSF) and midarm circumference (MAC) are used with increased frequency to further define nutritional status, particularly in clients with concerns of malnutrition. TSF correlates with fat mass and MAC with protein composition (Serón-Arbeola et al., 2022).

Subjective and Objective Findings	Related Nutritional Deficiency
Anemia:PallorFatigueChanges in energy levelDyspnea, tachypneaTachycardiaHypotensionDizzinessFaintingDifficulty sleepingAbility to maintain ADLs and recreational activitiesUnusual food cravings (pica)Electrocardiogram (ECG/EKG) abnormalities	Iron, copper, vitamin B12, vitamin C, vitamin E, folate
Thrombocytopenia/Coagulopathy:Gingival bleedingEasy bruisingPetechiae (Figure 9.2)Prolonged bleedingBloody stoolProlonged menstrual cycle	Vitamin K, vitamin C, vitamin E, vitamin B12
Neutropenia:Frequent feversFrequent infectionsDelayed wound healing	Copper, vitamin D, vitamin B12, vitamin C

Table 9.1 Assessment for Potential Nutritional Deficiencies (sources: Le, 2016; Yu, 2019)

Clinical Tip

Ask Open-ended Questions

Nurses should always ask clients open-ended questions to elicit a more informative history. For example, the nurse could ask “How often do you eat red meat each month?” (instead of “Do you eat red meat?”).

Figure 9.2 Petechiae, a condition characterized by small nonblanching spots as a result of bleeding, may be caused by a vitamin C deficiency. (credit: “This photograph depicts a close view of a patient’s skin revealing the presence of numerous perifollicular petechiae, the etiology had yet to be determined”/Centers for Disease Control and Prevention, Public Domain)

Management of Care: Diagnostic Assessment

Blood analysis is the primary diagnostic method for evaluating concerns of hematologic changes impacted by nutritional deficiencies; however, nutritional screening, often performed by a registered dietician, should be completed first in a comprehensive assessment (Table 9.2).

Some laboratory results can determine the client’s nutritional status. Prealbumin levels can be used to evaluate the client’s protein status. Transferrin is a protein that transports iron through the blood to different tissues and organs and is often measured when iron deficiency is suspected as a cause of anemia. Complete blood count (CBC), serum iron level, serum vitamin B_12, and folate levels should also be checked. Blood tests for specific vitamin deficiencies may be necessary for clients who have gastrointestinal malabsorption (Read et al., 2021; Socha et al., 2020).

When blood results fail to confirm a diagnosis in symptomatic clients, a bone marrow aspiration and/or biopsy may be necessary to evaluate the production of hematologic stem cells and the bone marrow microenvironment for evidence of malfunction.

Diagnostic Study	Hematologic or Other Manifestation	Nursing Considerations
Nutritional Screening Tools	More than 5% weight loss over past 3 months	Age and population specificClient languageComplete within 48 hours of admission
Nutritional Risk Screening 2002 (NRS2002)	All hospitalized clients	Not applicable
Malnutrition Universal Screening Tool (MUST)	Community clients	Not applicable
Mini Nutritional Assessment (MNA-SF)	Older clients	Not applicable
Nutritional Risk in Critically Ill (NUTRIC)	Critically ill clients	Not applicable
CBC With Differential Complete Metabolic Profile	Bruising, petechiaeGingival bleedingDyspneaTachycardia	Total volume of blood obtained in 24 hours; check facility policyIs there a fasting requirement?Appropriate collection tubeHandling requirements: specific days processed; temperature of sample once obtained
Albumin, Prealbumin, Vitamin D (25OHD)	Poor wound healing
Haptoglobin, Lactate Dehydrogenase (LDH), Reticulocyte, Vitamin E	Hemolytic anemiaThrombocytosis
Ferritin, Iron, Transferrin	Microcytic anemia (small red blood cell)
Folate, Vitamin B12	Macrocytic anemia (large red blood cell)Neutropenia
Vitamin C	Excessive bleeding and bruisingBrittle, spoon-shaped nails
Vitamin K, PT/PTT	Prolonged bleedingCoagulopathy
Copper	Anemia (normocytic)NeutropeniaMalabsorption (diarrhea, failure to thrive)
Bone Marrow Aspiration/Biopsy	Overlapping hematologic abnormalities	Does the client need sedation?

Table 9.2 Diagnostic Studies

Analysis of Nutrition and the Hematologic System

Developing clinical judgment requires the nurse to recognize laboratory abnormalities and associate significance to the client’s history and physical assessment (NCSBN, 2022). Making connections between a client’s diet history—such as lacking red meat, a critically low hemoglobin, and signs and symptoms of anemia—will result in identification of potential complications and anticipation of medical intervention. See Table 9.3.

Among nutritional blood disorders, iron deficiency anemia is the most common with increased prevalence in young children, pregnant women, and older adults (Burton et al., 2020). Iron deficiency anemia is characterized by a low hemoglobin concentration with small (microcytic), pale (hypochromic) red blood cells. The nurse should consider other nutrient-related hematologic disorders as well:

• Vitamin B₁₂ deficiency
• Folate deficiency
• Vitamin K deficiency
• Vitamin C deficiency
• Vitamin D deficiency

Deficiency	Conditions and Individuals at Risk	Medical Management	Nursing Considerations
Iron deficiency	InfantsMenstruating femalesOlder adults over 65 yearsVegans	Ferrous sulfate 100–200 mg/day for adults dosed on severity of anemiaOrally or intravenouslyDose dependent on age and hemoglobin level	Take 1 hour before or 2 hours after mealsTake with vitamin C to increase absorptionAvoid antacids, proton pump inhibitors (may decrease iron absorption)Common side effect: constipation; increase fiber in dietFood sources: red meat, beans, dark green leafy vegetables, iron-fortified foodsMonitor labs every 3 weeks during first 2 months of therapy
Vitamin B12	Autoimmune gastritisCeliac diseaseInflammatory bowelGastric bypass or ileal resectionStrict vegansPancreatic insufficiencyAlcohol use disorder	Vitamin B12 intramuscularly or high dose Vitamin B12 orally dailyDiet modification	Clients with malabsorption syndrome or gastric resection require parenteral administrationProtect vials from lightTake with meals to increase absorptionFood sources: animal meat, fish, eggs, dairy
Folate	Pregnant clientsClients with alcohol use disorder, malabsorption, hemolytic anemia, eczema	Folic acid, orally once dailyDose dependent on age	Take antacids at least 2 hours after folic acidTake folic acid early in pregnancy for prevention of neural tube defectsMay turn urine intensely yellowFood sources: leafy green vegetables, fruits, nuts, eggs, meats
Vitamin K	NewbornsLiver diseaseCystic fibrosisCeliac diseaseInflammatory bowel disease	Phytonadione may be given intramuscularly, subcutaneously, or orally; dose is dependent on condition and ageIntravenously in life-threatening bleeding	Lab analysis impacted by drugs: warfarin, antacids, antibiotics, aspirinFood sources: cheese, green vegetables, meat, eggs
Vitamin C (scurvy)	Food insecurityInfants only receiving cow’s milkAlcohol use disorderSmokingEating disorderGI tract disorderType 1 diabetesIron overload	Ascorbic acid 100–300 mg/day for children and 500–1000 mg/day for adultsDiet modifications	May decrease response to warfarin and antibioticsMay interfere with blood and urine glucose testFood sources: citrus fruits, tomatoes, strawberries, cantaloupe, peppers
Vitamin D	Residential/assisted livingDark skin tonesObesityChronic diseaseDecreased exposure to sunlight	Vitamin D3 (cholecalciferol) orally daily or high dose orally weekly	Order lab as 25(OH)Laboratory analysis impacted by barbiturates and corticosteroidsFood sources: fatty fish, liver, fortified milk

Table 9.3 Management of Common Nutrition-Related Blood Disorders (sources: Burton et al., 2020; Maxfield & Crane, 2022; Nemati et al., 2022; Sizar et al., 2022; Socha et al., 2020)

Nursing Considerations

As the client’s relevant information is identified, the nurse will apply the nursing process, determine related nursing diagnoses, and prepare to implement evidence-based care. Potential nursing diagnoses for aiding the client in the restoration of hematologic wellness include (Doenges et al., 2022):

• Imbalanced nutrition, undernutrition
• Fatigue, related to malnutrition
• Failure to thrive, related to nutritional deficiency
• Frail elderly syndrome, related to malnutrition
• Knowledge deficit, related to nutrients needed for hematologic wellness
• Decreased activity tolerance, related to fatigue
• Impaired skin integrity, related to anemia, nutritional deficiency
• Impaired memory, related to anemia
• Infection, delayed wound healing, related to nutritional deficiency
• Impaired gas exchange, related to anemia
• Risk for infection, related to nutritional deficiency
• Risk for bleeding, related to nutritional deficiency
• Risk for falls, related to anemia
• Risk for unstable blood pressure, related to anemia
• Risk for constipation, after iron supplementation
• Risk for ineffective tissue perfusion, related to anemia
• Risk for delayed child development, related to nutritional deficiencies

Unfolding Case Study

Part A

Read the following clinical scenario and then answer the questions that follow. This case study will evolve throughout the chapter.

Grant continues with his assessment of Ms. Foster. She reports difficulty sleeping for the past several months and poor concentration. Over the past 3 days, she has been short of breath with little exertion and lightheaded. As Grant discusses her diet history and food preferences, Ms. Foster reports that she constantly craves ice; otherwise, her diet consists of bread, chicken, and canned vegetables. While Grant continues to perform his assessment, her primary care physician (PCP) calls to report Ms. Foster’s hemoglobin as 6.2 gm/dL from the morning labs and requests additional diagnostic evaluation to determine the etiology of her severe anemia. Grant recognizes that older adults are at risk for nutritional anemias and suspects this for Ms. Foster. He understands the importance of a thorough history and assessment to avoid potentially life-threatening complications of anemia. Grant has completed his assessment of Ms. Foster and has obtained the following blood samples as ordered by her PCP:

• CBC
• Serum iron
• Ferritin
• Folate
• Vitamin B₁₂

Her CBC confirms severe microcytic anemia (hemoglobin 6.0 gm/dL with a low mean corpuscle volume). Since Ms. Foster has symptomatic anemia with shortness of breath and lightheadedness, Grant notifies the emergency department physician and requests an additional evaluation. An ECG and chest radiograph are performed; the physician determines that the source of Ms. Foster’s symptoms is unlikely related to hemorrhage and is most likely related to a nutritional deficiency. An order to transfuse 1 unit of packed red blood cells over 2–4 hours is received.

Grant recognizes that iron deficiency is the most common cause of nutritional microcytic anemia. He is also aware that the turnaround time for laboratory iron studies is 24–48 hours. He updates Ms. Foster and her daughter with the plan of care and determines the priority nursing diagnosis to be impaired gas exchange, related to anemia; imbalanced nutrition, less than body requirements, related to iron deficiency.

1.

Which nutritional screening tool should the nurse anticipate as part of Ms. Foster’s evaluation?

1. Nutritional Risk Screening 2002 (NRS2002)
2. Malnutrition Universal Screening Tool (MUST)
3. Mini Nutritional Assessment (MNA-SF)
4. Nutritional Risk in Critically Ill (NUTRIC)

2.

Ms. Foster’s priority nursing diagnosis is impaired gas exchange, related to anemia; imbalanced nutrition, less than body requirements, related to iron deficiency. What other nursing diagnosis should the nurse consider addressing during this visit?

1. Knowledge deficit, related to nutrients needed for hematologic wellness
2. Impaired skin integrity, related to anemia, nutritional deficiency
3. Impaired memory, related to anemia
4. Infection, delayed wound healing, related to nutritional deficiency