Iron deficiency anemia (IDA), the most common form of anemia, is a condition in which there is a decrease in normal body stores of iron and hemoglobin levels. IDA is caused by inadequate intake of iron, inadequate storage of iron, excessive loss of iron, or some combination of these conditions. The red blood cells (RBCs), which become pale (hypochromic) and small (microcytic), have a decreased ability to transport oxygen in sufficient quantities to meet body needs. Anemia is defined as a decrease in circulating RBC mass; the usual criteria for anemia are hemoglobin of less than 12 g/dL with a hematocrit less than 36% in women and hemoglobin less than 14 g/dL with a hematocrit less than 41% in men. Generally, IDA is more common in people who are economically disadvantaged because of the high cost of a well-balanced diet with iron-rich foods. Complications from IDA include infection and pneumonia. For patients suffering from pica (the urge to eat clay and other inappropriate items), lead poisoning may result from increased intestinal absorption of lead. Although it is a rare condition, Plummer-Vinson syndrome (IDA associated with difficulty swallowing, enlarged spleen, and spooning of the nails) may occur in severe cases of IDA, especially in middle-aged women who have recently had their teeth extracted.
The most common causes of IDA are menstrual blood loss and the increased iron requirements of pregnancy. Pathological bleeding, particularly gastrointestinal (GI) bleeding, is a common cause of iron depletion in men. Iron malabsorption can lead to IDA. Pathological causes include GI ulcers, hiatal hernias, malabsorption syndromes such as celiac disease, chronic diverticulosis, varices, and tumors. Other causes include surgeries such as partial gastrectomy and the use of prosthetic heart valves or vena cava filters.
Nursing care plan assessment and physical examination
Inquire about recent weight loss, fatigue, weakness, dizziness, irritability, inability to concentrate, sensitivity to cold, heartburn, loss of appetite, diarrhea, or flatulence. Establish a history of difficulty in swallowing, which is a sign of long-term oxygen deficit, as esophageal webbing ensues. Elicit any history of neuromuscular effects, including vasomotor disturbances, tingling or numbness of the extremities, or pain along a nerve. Ask if the patient has experienced difficulty in breathing on exertion, rapid breathing, or palpitations. With infants and children, ask the parents to establish a history of growth patterns. With premenopausal women, ask about heavy bleeding during menses. Ask female patients for a pregnancy history.
Take a complete diet and illness history. Ask if the patient regularly eats foods that are rich in iron, such as whole grains, seafood, egg yolks, legumes, green leafy vegetables, dried fruits, red meats, and nuts; ask if she or he takes iron in vitamin supplements. Elicit the patient’s history of alcohol use. With infants, ask if breastfeeding or bottle-feeding has been used and if any iron supplements have been added to the diet. Establish any history of frequent nosebleeds. With elderly patients, elicit a history of food preparation and diet planning to find out who takes responsibility for the patient’s diet. Ask the patient if she or he has had recent cravings for strange food (especially clay, laundry starch, or ice).
Inspect the patient’s mouth for signs of inflammation (stomatitis) or eroded, tender, and swollen corners (angular stomatitis). Observe the tongue to see if it is inflamed and smooth because of atrophy of the papillae (glossitis). Note the color of the patient’s skin to see if it is pale with poor turgor. Note the color of the patient’s sclera, which may be pearly white to bluish. Inspect the patient’s fingernails to check for brittleness; note the shape of the fingernails, which may be spoon-shaped with central depressions and raised borders. Check the patient’s hair to see if it is brittle and easily broken. In later stages, ankle edema may be present. Note any breathlessness or rapid breathing. Auscultate for heart sounds, noting rapid heart rate or a functional systolic murmur.
Patients may be anxious or fearful about symptoms that have made it difficult for them to function at their usual level of energy. Discomfort from oral mucosa symptoms may prove upsetting. A pregnant patient may have additional stress over the well-being of her baby. Some patients may be resistant to proposed changes that would disrupt long-held eating patterns. Patients may also be upset about body changes such as pallor and weight loss.
Nursing care plan primary nursing diagnosis: Activity intolerance related to imbalance between oxygen supply and demand.
Nursing care plan intervention and treatment plan
The two primary goals of treatment are to diagnose and correct the underlying cause of the iron deficiency and to correct the iron deficit. Medication therapy involves administering supplemental iron, which often shows results in the form of increased patient energy within 48 hours. Blood transfusions are not recommended for iron supplementation and should not be used to treat IDA unless there is cerebrovascular or cardiopulmonary compromise. Dietary supplementation of iron-rich food is needed to complement therapy and serve as a preventive model against future recurrence of the anemia. Pregnant women may also need to take prenatal vitamins and iron supplements.
Nursing interventions focus on preventing infections, promoting comfort, and teaching the patient. Patients with IDA are apt to have other nutritional deficiencies that place them at risk for infection. Use good hand-washing techniques, and encourage the patient to avoid contact with people with known upper respiratory infections. If the patient experiences discomfort from oral lesions, provide mouth care. To limit activity intolerance, allow rest periods between all activities. Before the patient’s discharge, arrange for home health follow-up if needed.
Teach the patient and significant others the causal relationships between bleeding tendencies and poor diet in relation to this anemia. Discuss the need to pace activities and allow for periods of rest. Emphasize to the patient the need for a well-balanced diet rich in iron; provide a list of iron-rich foods. Explain that any excess in iron stores may cause toxicity. Teach the patient that certain foods and medications—such as milk and antacids—interfere with the absorption of iron. Explain that stools normally turn greenish to black in color with iron therapy and that constipation may occur. Iron-rich foods such as fresh vegetables and red meat tend to be expensive, so that budget planning activities or assistance in attaining food stamps or other assistive programs may be essential. A social service referral or arranging of home care needs may be necessary. Parents of infants may need follow-up home visits to ensure that the growth and development of the child are progressing normally.
Nursing care plan discharge and home health care guidelines
Teach the patient that a well-balanced diet rich in both iron and iron supplements is necessary to prevent a recurrence of the anemia and provide a list of iron-rich foods. Advise continuation of
iron supplementation therapy even after the patient begins to feel better. Teach the route, dosage, side effects, and indications for use of iron supplements. Infection is a possibility because of the patient’s weakened condition. Therefore, stress the importance of meticulous wound care, good hand-washing techniques, and periodic dental checkups. Emphasize the need for the patient to report immediately to the physician any signs of infection, such as fever or chills.