3.6 Iron-Deficiency Anemia
A common type of anemia is iron-deficiency anemia (IDA). 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 risk factors[3],[4]:
- 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. Individuals who consume vegetarian diets may experience iron deficiency due to the lack of iron consumption from meat products. Infants and young children who are exclusively breastfed may also be at risk due to inadequate iron intake. Elderly individuals also may experience increased risk of iron-deficiency anemia related to poor dietary intake
- Increased Iron Requirements: Certain conditions, such as pregnancy and rapid growth during childhood, can increase the body’s iron requirements. 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.
- Blood Loss: Chronic or acute blood loss from medical conditions such as gastrointestinal or genitourinary bleeding, or excessive blood loss during 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 (such as inflammatory bowel disease) or gastric bypass surgeries that affect the absorption process.
Assessment
Physical Examination
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[5],[6]
| Body System | Clinical Manifestations |
|---|---|
| Skin | Pallor; cold extremities; thin, brittle, or spoon-shaped (koilonychia) nails. View an image of koilonychia.[7] |
| Cardiovascular | Generalized fatigue and weakness, tachycardia (rapid heart rate), palpitations, and angina (chest pain). In severe anemia, myocardial infarction (heart attack) can occur due to decreased oxygenation. |
| Respiratory | Dyspnea (shortness of breath) and tachypnea (rapid respiratory rate), especially during physical activity. |
| Musculoskeletal | Generalized weakness. |
| Gastrointestinal | Glossitis (inflammation of the tongue), causing a smooth or sore tongue.
View an image of glossitis.[8] |
| Nervous | Headaches and dizziness. In severe anemia, fainting may occur. |
| Behavior/Psychological | Pica, the craving and consumption of non-food items (e.g., ice, clay, dirt). |
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.[9],[10],[11] Review normal reference ranges for common diagnostic tests in “Appendix A – Normal Reference Ranges.”
Nursing Diagnoses
Nursing priorities for clients 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.[12]
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[13]:
- Fatigue
- Decreased Activity Tolerance
- Ineffective Peripheral Tissue Perfusion
- Imbalanced Nutrition: Less Than Body Requirements
- Readiness for Enhanced Knowledge
Review information about creating nursing diagnoses in the “Diagnosis” section of the “Nursing Process” chapter of Open RN Nursing Fundamentals, 2e.
Outcome Identification
Nursing care should always be individualized and client-centered. Outcome identification includes setting short- and long-term goals and creating specific expected outcome statements for nursing diagnoses identified for the client.[14]
Review information about setting in the “Outcome Identification” section of the “Nursing Process” chapter in Open RN Nursing Fundamentals, 2e.
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[15],[16]:
- 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).[17]
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.[18],[19],[20],[21]
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).
Read more details about oxygen therapy, hypoxia, and ABG in the “Oxygen Therapy” chapter of Open RN Nursing Skills, 2e.
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.
Read additional information about blood transfusions in the “Anemia” section of this chapter.
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.[22]
Read more about How to Measure Physical Activity Intensity at the Centers of Disease Control and Prevention website.
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.
Read more about fall prevention strategies in the “Preventing Falls” section of the “Safety” chapter of Open RN Nursing Fundamentals, 2e.
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.
Selected NIC Nursing Interventions to Promote Energy Management[23],[24]
- Correct physiological causes of fatigue, as prescribed.
- Monitor nutritional intake to ensure adequate energy resources.
- Monitor cardiovascular response to activity (i.e., tachycardia, dyspnea, dysrhythmias, diaphoresis, pallor, respiratory rate, blood pressure).
- Teach activity organization and pacing techniques to prevent fatigue.
- Assist the client to establish realistic activity goals.
- Encourage rest periods alternated with activity periods.
- Encourage physical activity (i.e., performance of activities of daily living [ADLs] and ambulation consistent with the client’s energy resources).
- Teach the client to recognize signs and symptoms of fatigue that require reduction in activity.
- Encourage verbalization of feelings about fatigue and limitations.
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 health teaching about medications 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[25]:
- 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 gastrointestinal upset and constipation. Although iron is best absorbed on an empty stomach, it may be taken with food if gastrointestinal upset occurs. Fiber and fluids should be encouraged to prevent constipation.
- 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.
- If iron is prescribed as an intramuscular injection, the Z-track method is preferred due to iron’s irritating and discoloring nature.
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 such as broccoli, yellow peppers, and Brussels sprouts.
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[26]:
- 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.
Iron-Deficiency Anemia Scenario
A female client is diagnosed with iron-deficiency anemia and is prescribed iron supplements. She receives health teaching about incorporating iron-rich foods into her diet. On follow-up laboratory testing, the nurse notices the client’s hemoglobin increases from 9.7 g/dL to 10.6 g/dL, and the client reports decreased heart palpitations during exercise. The nurse evaluates these results and determines the expected outcomes are partially met and the nursing plan of care is continued until the next follow-up appointment is scheduled.
RN Recap: Iron-Deficiency Anemia
View a brief YouTube video overview of iron-deficiency anemia[27]:
- American Society of Hematology. (n.d.). Anemia. https://www.hematology.org/education/patients/anemia ↵
- American Society of Hematology. (n.d.). Iron-deficiency anemia. https://www.hematology.org/education/patients/anemia/iron-deficiency ↵
- American Society of Hematology. (n.d.). Anemia. https://www.hematology.org/education/patients/anemia ↵
- American Society of Hematology. (n.d.). Iron-deficiency anemia. https://www.hematology.org/education/patients/anemia/iron-deficiency ↵
- American Society of Hematology. (n.d.). Anemia. https://www.hematology.org/education/patients/anemia ↵
- American Society of Hematology. (n.d.). Iron-deficiency anemia. https://www.hematology.org/education/patients/anemia/iron-deficiency ↵
- Warner, M. J., & Kamran, M. T. (2023). Iron Deficiency Anemia. StatPearls [Internet]. [Figure, iron deficiency - spoon shaped nail. Image courtesy S Bhimji MD]https://www.ncbi.nlm.nih.gov/books/NBK448065/figure/article-23767.image.f3/ ↵
- Bouquat, J. (n.d.). Atrophic glossitis [Figure]. https://www.brown.edu/Courses/Digital_Path/systemic_path/hn/atrophicglossitis.html ↵
- American Society of Hematology. (n.d.). Anemia. https://www.hematology.org/education/patients/anemia ↵
- American Society of Hematology. (n.d.). Iron-deficiency anemia. https://www.hematology.org/education/patients/anemia/iron-deficiency ↵
- MedlinePlus. (2016). Blood count tests. National Library of Medicine. https://medlineplus.gov/bloodcounttests.html ↵
- Makic, M. B., & Martinez-Kratz, M. R. (2023). Ackley and Ladewig’s Nursing diagnosis handbook: An evidence-based guide to planning care (13th ed.). Elsevier. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification, 2021-2023. Thieme Publishers New York. ↵
- Ernstmeyer, K., & Christman, E. (Eds.). (2024). Nursing fundamentals 2E. Open RN | WisTech Open. https://wtcs.pressbooks.pub/nursingfundamentals/ ↵
- American Society of Hematology. (n.d.). Anemia. https://www.hematology.org/education/patients/anemia ↵
- American Society of Hematology. (n.d.). Iron-deficiency anemia. https://www.hematology.org/education/patients/anemia/iron-deficiency ↵
- Susantad, T., Fuangthong, M., & Tharakaraman, K. et al. (2021). Modified recombinant human erythropoietin with potentially reduced immunogenicity. Scientific Reports, 11, 1491. https://doi.org/10.1038/s41598-020-80402-1 ↵
- American Society of Hematology. (n.d.). Anemia. https://www.hematology.org/education/patients/anemia ↵
- American Society of Hematology. (n.d.). Iron-deficiency anemia. https://www.hematology.org/education/patients/anemia/iron-deficiency ↵
- Wagner, C. M., Butcher, H. K., & Clarke, M. F. (2024). Nursing interventions classifications (NIC) (8th ed.). Elsevier. ↵
- Makic, M. B., & Martinez-Kratz, M. R. (2023). Ackley and Ladewig’s Nursing diagnosis handbook: An evidence-based guide to planning care (13th ed.). Elsevier. ↵
- Centers for Disease Control and Prevention. (2022). Perceived exertion (Borg rating of perceived exertion scale). U.S. Department of Health & Human Services. https://www.cdc.gov/physical-activity-basics/measuring/?CDC_AAref_Val=https://www.cdc.gov/physicalactivity/basics/measuring/exertion.htm ↵
- Wagner, C. M., Butcher, H. K., & Clarke, M. F. (2024). Nursing interventions classifications (NIC) (8th ed.). Elsevier. ↵
- Makic, M. B., & Martinez-Kratz, M. R. (2023). Ackley and Ladewig’s Nursing diagnosis handbook: An evidence-based guide to planning care (13th ed.). Elsevier. ↵
- Mayo Clinic. (2023). Drugs and supplements: Iron supplement (oral route, parenteral route). https://www.mayoclinic.org/drugs-supplements/iron-supplement-oral-route-parenteral-route/description/drg-20070148 ↵
- Martin, P. (2023). 7 anemia nursing care plans. NursesLabs. https://nurseslabs.com/anemia-nursing-care-plans/#h-nursing-diagnosis ↵
- Open RN Project. (2024, March 24). Health Alterations - Chapter 3 Hematological - Iron deficiency anemia [Video]. YouTube. CC BY-NC 4.0 https://www.youtube.com/watch?v=vR5rDPn1m6E ↵
Characterized by a lack of sufficient iron in the body, leading to decreased production of hemoglobin and red blood cells.
Thin, brittle, or spoon-shaped nails often resulting from iron-deficiency anemia.
Heart rate over 100 beats per minute.
Chest pain.
Heart attack.
Shortness of breath.
Rapid respiratory rate.
Inflammation of the tongue.
The craving and consumption of non-food items (e.g., ice, clay, dirt).