Anemia, child health nursing, b. Sc 3rd year

1. LESSON PLAN ON
CARE OF CHILD WITH ANEMIA
SUBMITTED TO:
Dr. S. SUJATHA,
HOD,
DEPARTMENT OF CHILD HEALTH NURSING,
CON- PIMS.
SUBMITTED BY:
K. SIVASAKTHI,
M.SC NURSING IIND
YEAR,
CON- PIMS.

2. NAME OF THE STUDENT : K.Sivasakthi
COURSE : Msc.Nursing IInd
year
BATCH : 2021-23
SUBJECT : Child Health Nursing
TOPIC : Care of child with anemia
METHOD OF TEACHING :Lecture cum discussion
AUDIO VISUAL AIDS : ppt
DATE/ TIME :
VENUE :
DURATION : 1 hr

3. GENERAL OBJECTIVE:
At the end of the class the student will be able to acquire knowledge on care of child with anemia and develop positive attitude and skills
towards care of child with anemia.
SPECIFIC OBJECTIVES:
By the end of the class, the students will be able to:
• define anemia
• describe the classification of anemia
• list the diagnosis of anemia
• define the iron deficiency anemia
• explain the etiology of iron deficiency anemia
• enumerate the pathophysiology of anemia
• enlist the clinical features of iron deficiency anemia
• list the diagnostic evaluation for iron deficiency anemia
• explain the management of iron deficiency anemia
• discuss the prevention of anemia
• brief about megaloblastic anemia
• explain about aplastic anemia
• list the common nursing diagnosis.

4. S.
no
Specific
objective
Content Teacher
Activity
Student
Activity
Av
aids
Evaluation
1
2
3
The students will be
able to define
anemia
The students will be
able to describe the
classification of
anemia.
CARE OF CHILD WITH ANEMIA
Introduction:
Anemia refers to a lower than normal number of red blood
cells in the blood. The principal function of red blood cells
is to carry oxygen from the lungs and distribute it
throughout the entire body.
Definition:
Anemia is defined as reduction in the volume of red blood
cells or in concentration of hemoglobin, below the lower
limit of the normal range for age and sex of the individual.
Classification
I. Classification based on morphology
II. Classification based on etiology
A. Based on morphology
Based on mean corpuscular volume, anemia is of three
types:
1. Microcytic: Abnormally small RBCs are present
in Iron deficiency anemia and certain non-iron
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S What is meant by
anemia?
What are all the
classification of
anemia?

5. deficiency anemia like Sideroblastic anemia and
Thalassemia.
2. Normocytic anemia: RBCs are normal in shape
but anemia occurs due to blood loss, hemolysis or
bone marrow failure.
3. Macrocytic Anemia: In this type, the RBCs. are
abnormally large in shape. It is usually due to
vitamin B2 Or folic acid deficiency. Example of
this type is Megaloblastic anemia.
On the basis of hemoglobin content in RBCs, anemia may
be:
1. Hypochromic: Abnormally decreased
hemoglobin content.
2. Normochromic: Normal hemoglobin content.
B. Based on etiology there are 3 types of anemia:
• Anemia due to blood loss
• Anemia due to impaired red cell production
• Anemia due to increased red cell destruction
1. Anemia due to blood loss
• Acute post hemorrhagic anemia
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6. • Chronic post hemorrhagic anemia
2. Anemia due to impaired red cell production
A disturbance in red blood cell formation may lead to
anemia. These disturbances are:
A. Deficiency of substances essential for erythropoiesis
i. Iron deficiency anemia
ii. Vitamin B12 and folate deficiency
B. Disturbance of proliferation and differentiation of
stem cells:
i. Aplastic anemia
ii. Aplasia of pure red cells
C. Disturbance of bone marrow function or due to
systemic disease:
i. Anemia due to infection
ii. Anemia due to renal disease
iii. Anemia in liver disease
iv. Anemia in disseminated malignancy
V. Anemia in endocrinopathies
D. Anemia due to bone marrow dysfunction
i. Leukemia
ii. Myelosclerosis
iii.Multiple myeloma
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7. 4 The students will be
able to list the
diagnosis of anemia.
E. Congenital anemia.
i. Sickle cell anemia
ii. Congenital dyserythropoietic anemia
3. Anemia due to increased destruction of red blood
cells
A. Anemia due to intracorpuscular defect
i. Sickle-cell anemia
ii. Thalassemia
B. Anemia due to extracorpuscular defect
i. Hemolytic disease of newborn
ii. Effect of toxic drugs
iii. Effect of venoms or poisoning from substances like
lead
iv. Thermal injury or burns
v. Transfusion reactions
vi. Infections like infectious mononucleosis
Diagnosis of Anemía
Anemia can be diagnosed on the basis of:
1. Hemoglobin estimation
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What are all the
Diagnosis for
anemia?

8. The hemoglobin content of RBCs is below the lower
limit of normal range for a particular age and sex, the
person is said to be anemic.
Age Hb(g/dl)
0-1 month 13.4-19.9
1-2 month 10.7-17.1
2-3 month 9.0-14.1
3-6 month 9.5- 14.1
6 -1 year 11.3-14.1
2. Peripheral blood film examination
The following abnormalities can be seen in the blood
smear:
i. Variation in size of RBCs (Anisocytosis)
ii. Variation in shape of RBCs (Poikilocytosis)
iii. Inadequate hemoglobin content (Hypochromasia)
3. Red cell Indices
Measurement of red cell indices helps to diagnose the
type and severity of anemia.
4. Leucocyte, reticulocyte and platelet count
Estimation of leucocyte and platelet count helps
distinguish pure anemia from pancytopenia, in which red
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9. 5 The students will be
able to define the
iron deficiency
anemia.
cells, granulocytes and platelets, all are reduced. In
anemia due to hemolysis or blood loss, neutrophil and
platelet counts are elevated.
5. Bone marrow examination
Bone marrow aspiration may be performed because
cellular changes within the marrow are diagnostic of many
hematologic conditions like leukemia.
A. IRON DEFICIENCY ANEMIA
Iron deficiency anemia is the most common hematologic
disorder of infancy and childhood. It is caused by lack of
sufficient iron for the synthesis of hemoglobin.
Iron Absorption and Metabolism
The iron required for Hemoglobin synthesis is derived
from two sources-ingestion of food rich in iron and
recycling of iron from broken RBCs. Dietary iron is
absorbed in the small intestine and either passed into
bloodstream or stored in intestinal epithelial cells as
ferritin. The iron in blood stream binds to iron- transport
molecule-Transferrin and is then delivered to the RBCs in
the bone marrow, where it combines with the other
cornponents of hemoglobin. If iron is not used for
hemoglobin formation, it is stored as ferritin or
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What is meant by
iron deficiency
anemia?

10. 6. The students will be
able to explain the
etiology of iron
deficiency anemia.
hemosiderin. Normally about 67% of the body's iron is
bound to heme and 30% of iron is o as ferritin or
hemosiderin.
Etiology
Several factors may contribute to iron deficiency anemia
including:
1. Increased blood loss
2. Insufficient iron supply at birth
3. Insufficient iron intake
4. Impaired iron absorption
1. Increased blood loss
Chronic iron deficiency anemia may be caused by
increased blood loss due to following conditions: Peptic
ulcer, polyps, Meckel's diverticulum, hematuria,
hemoptysis, parasitic infestation and epistaxis.
2. Insufficient iron supply at birth
Infants born to anemic mothers receive an inadequate
supply of iron from the mother during intrauterine life.
Also, if the baby is a preterm or had lost blood before or
during the process of birth, he is prone to iron deficiency
anemia.
3. Inadequate Iron intake
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What may be
etiological factors
for iron
deficiency
anemia?

11. 7. The students will be
able to enumerate
the pathophysiology
of anemia.
Maternal supply of iron is sufficient for first 4-5 months
of infant's life. The preterm infants who received an
insufficient maternal supply of iron can develop anemia
as early as 2 months after birth. If iron intake is
insufficient, after maternal suppty is exhausted, iron
deficiency can result. Infants fed on cow's mik should
receive iron supplements as cow's milk is a poor source of
iron. The iron intake should be increased in diet of all
infants and children, as iron requirement is high during
these years of growth, But supply is less due to
imbalanced diet and poor eating habits.
4. Impaired iron absorption
Factors that reduce iron absorption include:
• Malabsorption syndrome
• Chronic diarrhea
• Intake of antacids and tea after meáls
Pathophysiology
Due to any etiologic factor
Sufficient iron is not available for hemoglobin synthesis
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How iron
deficiency
anemia occurs?

12. 8. The student will be
able to enlist the
clinical features of
iron deficiency
anemia.
The production of hemoglobin is decreased
The newly formed RBCs become smaller (microcytic)
and less filled with hemoglobin (hypochromic)
Decreased hemoglobin levels and reduced oxygen
carrying capacity of the blood.
Clinical Features
The most common clinical feature of iron deficiency
anemia is pallor. When hemoglobin level falls below 5-6
gm/dl, following features may develop in the child:
• Irritability
• Listlessness
• Constipation
• Cardiac enlargement
• Tachycardia
• Weakness
• Dyspnea on exertion
• Poor attention span
• Reduced alertness
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13. 9. The student will be
able to list the
diagnostic evaluation
for iron deficiency
anemia.
• Cardiac failure may occur
• Long standing or chronic iron deficiency anemia
causes epithelial changes in some patients like
koilonychia (spoon shaped nails). atrophic
glossitis and angular stomatitis.
Diagnostic Evaluation
Anemia may be mild, moderate or severe. It can be
diagnosed on the following basis:
i. History of the child
A thorough dietary history is essential in making the
diagnosis of iron deficiency anemia. The history usually
reveals high milk intake and low intake of iron containing
solid foods.
ii. Blood test
• Hemoglobin level is below 11 gm/dl.
• Hematocrit is below 33%.
• Mean corpuscular volume (MCV) is below 70 um3
in infants and below 75 um3
in children.
• Reticulocyte count is reduced.
• Serum Ferritin concentration is below 10 mg /ml.
• Serum iron value is below 30 ug/dl.
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E What are all the
diagnostic
measure for iron
deficiency
anemia?

14. 10. The student will be
able to explain the
management of iron
deficiency anemia.
• Total iron binding capacity (TIBC) is elevated to
350 ug/dl in an attempt to absorb more iron from
exogenous sources.
• Ratio of serum iron to TIBC is below 10-12%.
iii. Peripheral blood smear
The smear shows microcytic and hypochromic red cells
which may vary in shape (poikilocytosis) and size
(anisocytosis).
iv. Stool test
Stool is tested for presence of occult blood which indicates
bleeding from the gastrointestinal tract.
MANAGEMENT
Management of iron deficiency anemia depends on the
underlying cause. Children with iron deficiency anemia
are treated with oral or parenteral iron therapy.
i. Oral iron therapy
A therapeutic dose of 6 mg/kg/day of elemental iron given
orally in 3 divided doses provide an optimal count of iron
needed for hemoglobin synthesis. With this dose, the
hemoglobin level should rise by 0.4 g/dl per day. Oral iron
therapy should be continued for at least 6-8 weeks after
the hemoglobin has fetched normal level.
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How will you
give oral iron
therapy?

15. ii. Parenteral iron therapy
A parenteral iron preparation, Iron dextran which contains
50 mg elemental iron per ml is used, when therapeutic
result of oral iron therapy is not achieved. Iron
requirement of the body is determined by the following
equation:
Iron required (mg) = wt (kg) x Hb deficit (g/dl) x 4
Daily dose of iron dextran should be limited to 50 mg in
infants and 100 mg in adults. It is administered
intramuscularly using 'z-tract' method, deeply into large
muscle mass. Side effects of parenteral iron therapy
include pain, chills, fever, arthralgia shock and even fatal
anaphylaxis.
Iron may be given intravenously also, by dissolving it in
250-500 ml of saline which is infused slowly over 6-8
hours. A small dose may be given initially as sensitivity
test.
iii. Blood Transfusion
When anemia is severe, the child may go into congestive
heart failure. When the hemoglobin level is below 4
gm/dl, only packed red cells should be given slowly. Also
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16. one or two doses of Frusemide 1-2 mg/kg, intravenously
should be given to prevent circulatory overload.
Nursing Management of Patients on Iron Therapy
Nursing management focuses on parental education,
which is very essential for the success of iron therapy.
Parental education consists of teaching about:
i. Proper administration of iron supplements
ii. Side effects of iron therapy
iii. Improving dietary iron intake
1. Proper administration of iron supplements
Parents should be educated that:
▪ Iron medication should be given between meals,
when presence of free hydrochloric acid is
greatest, because an acid environment facilitates
iron absorption.
▪ The medication should not be administered with
milk or tea as both of them reduce iron absorption.
▪ The medication should be given with any form of
ascorbic acid (Vitamin C) such as a citrus fruits or
juice, because Vitamin C helps reduce iron to its
most soluble form.
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What are all the
nurses role on
providing iron
therapy?

17. ▪ Liquid iron preparation can stain teeth
temporarily, so the medication should be given to
infants with a medicine dropper or syringe placed
towards the back of mouth to prevent teeth stains.
Older children can drink the diluted solution
through straw and then rinse the mouth or brush
teeth after drinking the medicine, to prevent teeth
discoloration.
ii. Side effects of iron therapy
Side effects of oral iron therapy include abdominal
cramps, nausea, vomiting, diarrhea or constipation. Iron
should be given with meals to prevent gastrointestinal
irritation.
iii. Improving dietary iron intake
Parents should be counseled about improving the child's
dietary intake of iron. They should be told about the
following facts:
▪ Iron is present widely in animal and plant foods,
e.g. meat, liver, kidney, egg yolk, green leafy
vegetables and fruits like apple.
▪ At the time of weaning, iron rich diet should be
given to the infant.
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effects of iron
therapy?

18. 11 The students will be
able to discuss the
prevention of
anemia.
▪ Food should be prepared in utensils made up of
iron, to increase the iron content of the food
Prevention
An important responsibility of the nurse is to educate
parents so that iron deficiency anemia can be prevented,
Following recommendations can help prevent iron
deficiency anemia:
❖ Formulas for full term infants should contain iron,
so that infant gets about 1mg iron/kg/ day.
❖ Iron fortified milk formulas should be used for
non-breastfed infants.
❖ Weaning diet should include iron rich foods like
pulses, green vegetables, fruits, etc.
❖ Children should be made to wear shoes while
playing to prevent worm infestation.
❖ Hookworm infestation should be managed with
Antihelminthic drugs.
❖ Food should be cooked in iron utensils.
❖ Iron supplements should be administered to
preterm and low birth weight infants having low
iron stores.
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What are all the
strategies to
prevent iron
deficiency
anemia?

19. 12. The students will be
able to brief about
megaloblastic
anemia.
❖ During pubertal growth spurt, iron needs of body
are increased, so iron supplements are necessary
during adolescence.
B. MEGALOBLASTIC ANEMIA
Deficiency of vitamin B2 and folic acid impairs the
maturation of erythrocytes leading to formation of
abnormally large erythrocytes known as 'megaloblasts'.
During normal erythropoiesis, several cell divisions
occur. The daughter cells formed at each stage is smaller
than the parent cell because there is not much time for cell
enlargement between divisions. When deficiency of
vitamin B12 or folic acid occurs, the rate of DNA and RNA
synthesis is reduced, delaying cell division. The cells thus
get extra time between divisions so they grow larger than
normal, resulting in formation of megaloblasts.
Etiology
Megaloblastic anemia results from deficiency of vitamin
B12 and folic acid which may occur in the following
conditions:
Inadequate dietary intake of vitamin B12 and folic
acid is seen in exclusively breastfed infants,
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What is meant by
megaloblastic
anemia?

20. infants of mothers who are strictly vegetarian and
infants of anemic or malnourished mothers.
Malabsorption due to tropical sprue, crohn's
disease, celiac disease, chronic diarrhea, etc.
Treatment with anticonvulsants such as phenytoin
and mysolin.
Intrinsic defect of folic acid absorption.
Chemotherapy
Increased demand of vitamin B12 and folic acid.
Excess urinary folate loss, e.g. in active liver
disease and congestive heart failure.
Clinical Features
Following manifestations develop in patients with
megaloblastic anemia:
i. Pallor
ii. Sick look
ii. Irritability
iv. Anorexia
v. Failure to thrive
vi. Increased pigmentation on back of hands, fingers and
nose
vii. Glossitis
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What are all the
etiological factors
of megaloblastic
anemia?

21. vii. Tremors and developmental retrogression (rare)
viii. Neurological manifestations such as numbness,
paresthesia, weakness, ataxia and diminished reflexes.
Diagnostic Evaluation
It includes:
• Peripheral blood smear: It shows anisocytosis
and poikilocytosis with macrocytic red cells.
Polymorphonuclear leucocytes are seen, which
are large and have hypersegmented nuclei.
• Serum vitamin B and folic acid assay: The
normal range of vitamin B2 in serum is 200-900
pg/ ml. Values less than 100 pg/ml índicate
clinical deficient stage. The normal serum folate
level is 6-12 ng/ml. Value less than 4 ng/ml is
considered diagnostic of folate deficiency.
Management
Acute deficiency of vitamin B12 and folic acid can be
managed by administratíon of folic acid in dosage of 2-5
mg/day and vitamin B12 1 pg/day.
C. APLASTIC ANEMIA
Definition
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22. 13 The students will be
able to explain about
aplastic anemia.
Aplastic anemia occurs due to marked reduction in
precursor stem cells resulting in production of inadequate
number of erythrocytes, leucocytes and platelets.
Incidence and Etiology
Aplastic anemia can be either hereditary or acquired. The
hereditary form of Aplastic anemia is known as 'Fanconi's
anemia'. It is a rare autosomal recessive disorder. Acquired
Aplastic anemia can be either idiopathic or may result
from secondary causes. The most common cause of
Aplastic anemia is autoimmune suppression of blood cell
production. Certain toxins and pharmacological agents
implicated in the development of aplastic anemia are:
a. Toxic agents like benzene, toluene, insecticides and
arsenic.
b. Pharmacologic agents like antibiotics
(chloramphenicol, sulfonamnides), anti-inflammatory
agents (gold saits, phenylbutazone), anticonvulsants
(phenytoin, carbamazepine), antimalarias (quinine) and
oral hypoglycemic agents (tolbutamide ).
The age of onset of Fanconi's anemia is variable and
depends on exposure to the causal factors. The median age
of diagnosis is 6.5 years in males and 8 years in females.
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What is meant by
aplastic anemia?

23. Pathophysiology
In fetus, hematopoiesis occurs in liver and spleen and after
birth in bone marrow. Within the marrow, stem cells
differentiate into various types of blood cells. Any
abnormality of these stem cells leads to 'pancytopenia', a
condition in which all three types of blood cells are either
decreased or absent.
Clinical Features
The clinical features occurring due to reduction in the
number of platelets, leucocytes and erythrocytes are as
follows:
• Increased bruising due to decreased platelet count.
Increased susceptibility to infection due to
decreased WBC count.
• Pallor, weakness, breathing difficulty and
listlessness due to decreased RBC count.
• Impaired growth.
Diagnostic Evaluation
Diagnosis of aplastic anemia includes:
✓ History and clinical features
✓ Complete Blood Count (CBC): CBC shows
pancytopenia. In severe Aplastic anemia,
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24. Neutrophil counts are <500/ ul, Platelets are
<20,000/ ul, and Reticulocytes are < 1%.
✓ Bone marrow biopsy: Definitive diagnosis of
Aplastic anemia
Management
The goals of management are:
To provide symptomatic treatment
Restore bone marrow function and/or replace
pathological bone marrow with normal tissue.
a. Symptomatic treatment
• If platelet count is below 10,000 cell/ul, platelet
transfusions are done.
• If anemia is severe, packed red cells are given.
• If infections occur due to decreased WBC count,
antibiotics are given.
b. Restoration of bone marrow function
An attempt is made to restore bone marrow function
through the use of androgenic steroids and
Corticosteroids. Testosterone propionate may be given
sublingually or as intramuscular injection. Testosterone
converts fatty hypocellular bone marrow into nearly
normal bone marrow, which starts producing blood cells.
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25. The hematologic response to androgen therapy may take
about 2-6 months.
If Aplastic anemia occurs as a result of autoimmune
response, high doses of Dexamethasone or
immunosuppressive therapy in form of Antilymphocyte or
Antithymocyte globulin may be used.
c. Bone Marrow Replacement
For cases not responding to drug therapy, the treatment of
choice is bone marrow replacement. Bone marrow
transplantation is done if histocompatible sibling is
availabłe.
Nursing Management
The aim of nursing care is to prevent bleeding and
infection and manage problems related to anemia.
a. Prevention of bleeding
A nurse must take following actions to prevent bleeding:
i. Maintain skin integrity and prevent pressure sores
through use of air or water mattress while the child is
confined to bed.
ii. Minimize venipuncture sites by collecting all samples
in one chance, using small gauge needles.
iii. Avoid intramuscular injections.
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26. iv. Check platetet count before any invasive procedure.
v. Prevent bleeding from mucous membranes by:
a. Keeping the mouth clean and free of debris, through use
of soft brush or mouth wash.
b. Avoid taking rectal temperature and administration of
rectal drugs.
c. Use of topical thrombin or epinephrine to stop bleeding
from lips or nares.
b. Prevention of įnfection
A nurse must take following actions to prevent infection
in the anemic child:
i. Strict handwashing should be practiced by everyone
who comes in contact with the patient.
ii. Barrier nursing techniques like cap, mask, gown and
gloves should be used while handling child.
iii. Limit the number of visitors.
iv. No one with any infection should handle the child.
V. Isolate the child to prevent contact with other patients
having infections.
c. Management of problems associated with Anemia
i. Monitor the child's hemoglobin level on a regular basis.
ii. Administer oxygen if the child is dyspneic.
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27. 14. The students will be
able to list the
common nursing
diagnosis.
iii. Administer packed red cells, if prescribed.
iv. Monitor growth and development of the child.
v. Provide adequate rest to the child.
Nursing diagnosis:
1. Inadequate oxygenation
2. Fatigue and activity intolerance
3. Nutritional deficiencies
4. Blood transfusion management
5. Education and self care
Conclusion:
Anemia is not a disease but, a condition caused by various
underlying pathologic processes. A proper history and
physical examination is more important in an easy way of
approaching a child with anemia. Lab exams leads to
definitive cause of anemia. All cases of anemia are not
necessary to be transfused.
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28. SUMMARY:
So for we have discussed about the anemia, types, etiology, clinical features, diagnostic evaluation, management and prevention.
ASSIGNMENT:
Write a care plan for child with iron deficiency anemia. (Hb: 6g/dl)
POST EVALUATION:
What is meant by aplastic anemia?
What are all the common diagnostic evaluation for anemia ?
BIBLIOGRAPHY:
Book reference
• Pushpendra magon, Textbook of child health nursing”, 1st
edition, Jaypee publication, page no. 266-272
• Rimple sharma, “essential of pediatric nursing”, 2nd
edition, jaypee publication, page no: 433-442.
Net reference
• https://www.slideshare.net/HARINAGAR49/anemia-77665937
• https://www.slideshare.net/Binitabhattarai12/anemia-in-child