3.6 Iron-Deficiency Anemia

A common type of anemia is iron-deficiency anemia. Iron-deficiency anemia is characterized by a lack of sufficient iron in the body, leading to decreased production of hemoglobin and red blood cells.^[1],[2]

Iron-deficiency anemia can develop due to several reasons, including the following:

• Inadequate Dietary Intake: Not consuming enough iron-rich foods in the diet can lead to a deficiency. Iron is found in foods such as meat, fish, poultry, legumes, and leafy green vegetables.
• Increased Iron Requirements: Certain conditions, such as pregnancy, rapid growth during childhood, and increased blood loss during menstruation, can increase the body’s iron requirements.
• Blood Loss: Chronic or acute blood loss from conditions, like gastrointestinal bleeding, ulcers, or heavy menstruation, can deplete the body’s iron stores.
• Poor Iron Absorption: Some individuals may have difficulty absorbing iron from their diet due to gastrointestinal disorders or surgeries that affect the absorption process.^[3],[4]

Certain populations are at increased risk for developing iron-deficiency anemia. Infants and young children who are exclusively breastfed may be at risk due to inadequate iron intake. Adolescents and women of childbearing age who experience heavy menstrual blood loss may also be at higher risk. Dietary supplementation with iron during pregnancy is often necessary to ensure the developing fetus and placenta receive adequate nutritional support due to the increased iron demands of pregnancy. Individuals who consume vegetarian diets may also experience iron deficiency due to the lack of iron consumption from meat products. Additionally, individuals with intestinal compromise such as inflammatory bowel disease or those who have undergone gastric bypass surgery may be at increased risk for inadequate absorption. Finally, elderly individuals also may experience increased risk of iron-deficiency anemia related to poor dietary intake.^[5],[6]

Assessment

Physical Assessment

Clinical manifestations of iron-deficiency anemia are related to the decreased oxygenation of tissues due to decreased levels of hemoglobin. See Table 3.6a for a summary of clinical manifestations of iron-deficiency anemia across body systems.

Table 3.6a. Clinical Manifestations of Iron-Deficiency Anemia^[7],[8]

Diagnostic Testing

To identify the presence of iron-deficiency anemia, health care providers order various laboratory tests to examine the levels of iron and hemoglobin present in the blood. These tests may include a CBC, serum ferritin, serum iron level, and total iron-binding capacity. Other diagnostic tests may include laboratory studies to examine blood levels of transferrin, a glycoprotein that binds to iron in the bloodstream and is important for transporting iron throughout the body. Low levels of transferrin are often present in iron-deficiency anemia.^{[11],[12],[13]}

Nursing Diagnoses

Nursing priorities for patients with anemia involve addressing inadequate oxygenation, managing fatigue and activity intolerance, identifying nutritional deficiencies, administering prescribed medications, monitoring blood transfusions, providing education and support, and collaborating with the health care team for comprehensive care.^[14]

Nursing diagnoses for clients with iron-deficiency 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. Recall that symptoms of anemia are related to decreased hemoglobin and decreased transportation of oxygen to the tissues and organs, which can result in fatigue and shortness of breath.

Nursing diagnoses include the following^[15]:

• Fatigue
• Decreased Activity Tolerance
• Ineffective Peripheral Tissue Perfusion
• Imbalanced Nutrition: Less Than Body Requirements
• Readiness for Enhanced Knowledge

Outcome Identification

Nursing care should always be individualized and patient-centered. No two people are the same, and neither should nursing care plans be the same for two people. Goals and outcomes should be tailored specifically to each patient’s needs, values, and cultural beliefs. Patients and family members should be included in the goal-setting process when feasible. Involving patients and family members promotes awareness of identified needs, ensures realistic goals, and motivates their participation in the treatment plan to achieve the mutually agreed upon goals and live life to the fullest with their current condition.^[16]

Outcome identification includes setting short- and long-term goals and creating specific expected outcome statements for nursing diagnoses identified for the client. Goals are broad, general statements, and outcomes are specific and measurable. Expected outcomes are statements of measurable action for the client within a specific time frame that are responsive to nursing interventions.^[17]

Outcome statements are always patient-centered. They should be developed in collaboration with the patient and individualized to meet a patient’s unique needs, values, and cultural beliefs. They should start with the phrase “The patient will…” Outcome statements should be directed at resolving the defining characteristics for that nursing diagnosis. Additionally, the outcome must be something the patient is willing to cooperate in achieving. Outcome statements should also contain five components easily remembered using the “SMART” mnemonic^[18]:

• Specific
• Measurable
• Attainable/Action oriented
• Relevant/Realistic
• Time frame

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

• The client will verbalize three energy management strategies.
• The client’s vital signs will remain within normal limits during activity.
• The client will verbalize three preferred food sources containing iron.
• The client will verbalize when to contact the health care provider for severe symptoms of anemia, including worsening shortness of breath on exertion and chest pain.

Interventions

Medical Interventions

Medical interventions for anemia address the underlying cause of anemia and improve the client’s hemoglobin levels and overall health. The specific treatment plan depends on the severity of the anemia, the underlying cause, and the client’s individual health status. Common medical interventions and medications prescribed to address anemia include the following^[19],[20]:

• Treating Underlying Conditions: If the iron deficiency is due to an underlying condition, such as gastrointestinal bleeding or excessive menstrual bleeding, treating the primary condition is essential to correct the anemia.
• Iron and Other Nutritional Supplements: The primary treatment for iron-deficiency anemia involves oral or intravenous iron supplementation. Oral iron supplements are commonly prescribed and come in various forms, such as ferrous sulfate, ferrous gluconate, and ferrous fumarate. These supplements help replenish iron stores and increase hemoglobin levels. Combining iron supplementation with dietary changes can enhance iron absorption.

In severe cases of iron-deficiency anemia, or when oral iron is not well-tolerated or not effective, intravenous iron therapy may be administered. IV iron is given directly into the bloodstream and can rapidly correct iron deficiency.

Clients are encouraged to eat iron-rich foods, such as red meat, poultry, fish, beans, lentils, spinach, and fortified cereals. Vitamin C can enhance the absorption of nonheme iron (found in plant-based foods and iron supplements).

• Blood Transfusions: In severe cases of symptomatic, severe anemia (i.e., dyspnea or chest pain) or hemoglobin levels less than 7 g/dL, transfusions of red blood cells are typically prescribed to rapidly increase hemoglobin levels.
• Recombinant Human Erythropoietin: Clients who have a low hemoglobin related to chronic kidney disease or cancer may be prescribed recombinant human erythropoietin. Recombinant human erythropoietin stimulates erythropoietin, a hormone produced by the kidneys that plays an essential role in the production and maturation of red blood cells (RBCs).^[21]

Nursing Interventions

Nursing interventions for anemia focus on maintaining adequate oxygenation, promoting energy management and managing fatigue, administering iron and other nutritional supplements, and providing health teaching to promote client well-being and prevent complications.^{[22],[23],[24],[25]}

Maintain Adequate Oxygenation

Maintaining adequate oxygenation is a nursing priority. Nurses monitor pulse oximetry (SpO2) readings and heart rate and administer oxygen therapy as needed to maintain adequate oxygenation. However, it is important to keep in mind that although SpO2 is an efficient method for monitoring a client’s oxygenation status, it is an estimate and not always accurate. If the client is severely anemic with a significantly decreased hemoglobin level, they may have a normal SpO2 reading because their existing hemoglobin is saturated with oxygen, even though the available oxygen is not enough to meet the metabolic demands of their body. If the client has deteriorating respiratory status, a more specific measurement of oxygen dissolved in the blood may be obtained from an arterial blood gas (ABG).

Administer Blood Product Transfusion

Clients with symptomatic, severe anemia (i.e., dyspnea and/or chest pain) are prescribed blood transfusion(s) to rapidly increase their hemoglobin levels and improve oxygenation levels. Registered nurses administer blood products according to hospital policies and protocols and assess the client for transfusion reactions and potential complications. Nurses also evaluate the effectiveness of blood transfusions by monitoring the client’s hemoglobin level. For each unit of RBCs transfused, the client’s hemoglobin level can be anticipated to increase by 1g/dL.

Promote Energy Management

In addition to ensuring adequate oxygenation, another priority nursing intervention is helping clients manage fatigue and improve their activity tolerance. Fatigue can significantly affect a client’s overall functioning and quality of life. It can impact their ability to perform their role responsibilities at home and at work and participate in self-care.

Signs of activity intolerance due to decreased oxygenation of tissues include dyspnea on exertion, headaches, dizziness, palpitations, chest pain, and verbalization of fatigue. Nurses can ask clients to rate their perceived exertion level and use this rating to evaluate effectiveness of interventions. Perceived exertion is based on the physical sensations a person experiences during physical activity, including increased heart rate, increased respiration or breathing rate, increased sweating, and muscle fatigue.^[26]

Fatigue and muscle weakness can also increase the risk for falls, especially in older adults. Nurses implement appropriate fall prevention strategies according to the client’s level of fatigue and weakness.

Nurses play a significant role in helping clients regulate their energy, prevent fatigue, and optimize their functioning. Nursing Interventions Classification (NIC) is a standardized, comprehensive classification of nurse-initiated and physician-initiated nursing treatments. NIC provides a list of evidence-based nursing interventions under the “Energy Management” category that applies to a variety of medical conditions, including anemia. See selected nursing interventions from this category in the following box.

Nurses teach clients how to manage fatigue and improve their activity tolerance by balancing periods of activity with rest periods. Based on their level of fatigue, clients may also need to have their care clustered to use their available energy to complete desired activities and reduce fatigue. For example, the client may need to sit when performing tasks or take breaks between showering, dressing, and eating. They may require breaks before eating to maintain their energy to eat.

To improve activity intolerance and prevent potential complications resulting from immobility, nurses encourage clients to do as much activity as tolerated while using techniques to conserve limited energy and prevent fatigue.

Clients living at home may require assistance in completing their activities of daily living and in meal preparations, especially older adults. Nurses can assist in making referrals for home health care and/or meal delivery services, such as Meals on Wheels.

Nurses are aware that living with chronic fatigue and activity intolerance is both physically and emotionally difficult. Encouraging clients to verbalize their feelings regarding limitations helps facilitate their coping and resiliency.

Administer Iron and Other Nutritional Supplements

For clients with iron-deficiency anemia, nurses administer prescribed iron supplements and provide necessary medication teaching to promote absorption and manage side effects. Iron is available via oral (pill and liquid), intramuscular, and intravenous routes. Nurses play a key role in teaching clients the following topics regarding iron supplementation^[29]:

• Oral iron is absorbed best on an empty stomach, but if difficult to tolerate may be taken with food.
• Common side effects of iron are constipation and gastrointestinal upset. Increase fiber and fluids to treat constipation. Although iron is best absorbed on an empty stomach, it may be taken with food if gastrointestinal upset occurs.
• Iron can change the color of stools to black or a greenish/black color. Report changes in stool color to the provider.
• Liquid forms of iron can stain teeth. To prevent or reduce staining, iron preparations can be mixed with a small amount of water or fruit or tomato juice. Drinking the dose with a straw can also help prevent staining. When iron is prescribed for infants, it is generally given via medicine dropper. The dropper should be placed on the back of the tongue during administration. If teeth staining does occur, it can be removed by brushing the teeth with baking soda or hydrogen peroxide.
• Iron products should not be taken at the same time as dairy products, antacids, or calcium supplements, as these can interfere with the absorption of iron.

Clients are also encouraged to eat iron-rich foods such as red meat, poultry, fish, legumes, nuts, seeds, and green leafy vegetables. Clients are advised to enhance iron absorption from iron supplements and iron-rich foods by accompanying their intake with vitamin C food sources or supplements. Foods that are high in vitamin C are citrus fruits and fresh vegetables.

Clients with other types of anemia, such as folic acid deficiency or B12 deficiency, are prescribed related supplements and encouraged to eat food sources to address these deficiencies.

Health Teaching and Health Promotion

Nurses provide health teaching about anemia, causes, and treatments to promote client well-being and overall health by performing the following interventions^[30]:

• Assess the client’s current knowledge of anemia, causative factors, and treatment regimen.
• Assess the client’s resources and ability to obtain prescribed medications and prepare food sources to treat nutritional deficiencies.
• Explain potential side effects of prescribed medications and how to manage them.
• Explain the importance of diagnostic procedures.
• Educate the client and/or family members regarding food rich in iron, folic acid, and vitamin B12, based on the type of anemia diagnosed.
• Educate the client that if left untreated, anemia can contribute to increased risk of infection and illness because of its effect on the immune system.
• Educate the client on energy conservation techniques and fall precautions.
• Explain severe symptoms of anemia and when to contact the health care provider.

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.