Iron Deficiency Anemia Nursing Care Plan & Management

Notes

Description

Iron deficiency anemia is one of the most common hematologic disorders among children.

  • Iron deficiency anemia develops when body stores of iron drop too low to support normal red blood cell (RBC) production.
  • Iron equilibrium in the body normally is regulated carefully to ensure that sufficient iron is absorbed in order to compensate for body losses of iron.
  • Iron deficiency is defined as a decreased total iron body content.
  • Iron deficiency anemia occurs when iron deficiency is severe enough to diminish erythropoiesis and cause the development of anemia.

Pathophysiology

Iron is vital for all living organisms because it is essential for multiple metabolic processes, including oxygen transport, DNA synthesis, and electron transport.

  • Iron equilibrium in the body is regulated carefully to ensure that sufficient iron is absorbed in order to compensate for body losses of iron.
  • Whereas body loss of iron quantitatively is as important as absorption in terms of maintaining iron equilibrium, it is a more passive process than absorption.
  • In healthy people, the body concentration of iron (approximately 60 parts per million [ppm]) is regulated carefully by absorptive cells in the proximal small intestine, which alter iron absorption to match body losses of iron.
  • Persistent errors in iron balance lead to either iron deficiency anemia or hemosiderosis. Both are disorders with potentially adverse consequences.
  • Iron uptake in the proximal small bowel occurs by 3 separate pathways; these are the heme pathway and 2 distinct pathways for ferric and ferrous iron.
  • Heme iron is not chelated and precipitated by numerous dietary constituent that renders nonheme iron nonabsorbable, such as phytates, phosphates, tannates, oxalates, and carbonates.

Image credit to : nhlbi.nih.gov

Statistics and Incidences

Iron deficiency is the most prevalent single deficiency state on a worldwide basis.

  • In North America and Europe, iron deficiency is most common in women of childbearing age and as a manifestation of hemorrhage.
  • Depending upon the criteria used for the diagnosis of iron deficiency, approximately 4-8% of premenopausal women are iron deficient.
  • A study of the national primary care database for Italy, Belgium, Germany, and Spain determined that annual incidence rates of iron deficiency anemia ranged from 7.2 to 13.96 per 1,000 person-years.
  • Higher rates were found in females, younger and older persons, patients with gastrointestinal diseases, pregnant women and women with a history of menometrorrhagia, and users of aspirin and/or antacids.
  • Infants consuming cow milk have a greater incidence of iron deficiency because bovine milk has a higher concentration of calcium, which competes with iron for absorption.
  • During childbearing years, an adult female loses an average of 2 mg of iron daily and must absorb a similar quantity of iron in order to maintain equilibrium; because the average woman eats less than the average man does, she must be more than twice as efficient in absorbing dietary iron in order to maintain equilibrium and avoid developing iron deficiency anemia.

Causes

Causes of iron deficiency anemia may include:

  • Dietary factors. Meat provides a source of heme iron, which is less affected by the dietary constituents that markedly diminish bioavailability than nonheme iron is; the prevalence of iron deficiency anemia is low in geographic areas where meat is an important constituent of the diet; in areas where meat is sparse, iron deficiency is commonplace.
  • Hemorrhage. Bleeding for any reason produces iron depletion; if sufficient blood loss occurs, iron deficiency anemia ensues.
  • Hemosiderinuria, hemoglobinuria, and pulmonary hemosiderosis. Iron deficiency anemia can occur from loss of body iron in the urine; if a freshly obtained urine specimen appears bloody but contains no red blood cells, suspect hemoglobinuria.
  • Malabsorption of iron. Prolonged achlorhydria may produce iron deficiency because acidic conditions are required to release ferric iron from food; then, it can be chelated with mucins and other substances (e.g., amino acids, sugars, amino acids, or amides) to keep it soluble and available for absorption in the more alkaline duodenum.
  • Iron-refractory iron deficiency anemia (IRIDA). Iron-refractory iron deficiency anemia (IRIDA) is a hereditary disorder marked by with iron deficiency anemia that is typically unresponsive to oral iron supplementation and may be only partially responsive to parenteral iron therapy.

Clinical Manifestations

The signs of iron deficiency anemia include:

  • Below average body weight. The child with iron deficiency anemia consumes more calcium than other nutrients, making them lighter than the average weight for their age.
  • Pale skin and mucous membranes. The hemoglobin in red blood cells gives blood its red color, so low levels during iron deficiency make the blood less red; that’s why the skin and mucous membranes can lose its healthy, rosy color in people with iron deficiency.
  • Anorexia. Loss of appetite is common, with milk as their only food source.
  • Growth retardation. Due to a decrease in the consumption of other food sources, the growth of the child becomes stunted.
  • Listlessness. The child who has less hemoglobin in the blood becomes listless and weak due to a decrease in oxygen circulating towards the brain.

Assessment and Diagnostic Findings

Although the history and physical examination can lead to the recognition of the condition and help establish the etiology, iron deficiency anemia is primarily a laboratory diagnosis.

  • Complete blood count. The CBC documents the severity of the anemia. In chronic iron deficiency anemia, the cellular indices show a microcytic and hypochromic erythropoiesis—that is, both the mean corpuscular volume (MCV) and the mean corpuscular hemoglobin concentration (MCHC) have values below the normal range for the laboratory performing the test.
  • Peripheral smear. Examination of the erythrocytes shows microcytic and hypochromic red blood cells in chronic iron deficiency anemia; the microcytosis is apparent in the smear long before the MCV is decreased after an event producing iron deficiency.
  • Serum iron, total binding capacity, and serum ferritin. Low serum iron and ferritin levels with an elevated TIBC are diagnostic of iron deficiency; while a low serum ferritin is virtually diagnostic of iron deficiency, a normal serum ferritin can be seen in patients who are deficient in iron and have coexistent diseases (eg, hepatitisor anemia of chronic disorders); these test findings are useful in distinguishing iron deficiency anemia from other microcytic anemias.
  • Hemoglobin electrophoresis and measurement of hemoglobin A2. Hemoglobin electrophoresis and measurement of hemoglobin A2 and fetal hemoglobin are useful in establishing either beta-thalassemia or hemoglobin C or D as the etiology of the microcytic anemia.
  • Reticulocyte hemoglobin content. Mateos Gonzales et al assessed the diagnostic efficiency of commonly used hematologic and biochemical markers, as well as the reticulocyte hemoglobin content (CHr) in the diagnosis of iron deficiency in children, with or without anemia.
  • Stool testing. Testing stool for the presence of hemoglobin is useful in establishing gastrointestinal (GI) bleeding as the etiology of iron deficiency anemia.
  • Incubated osmotic fragility. Microspherocytosis may produce a low-normal or slightly abnormal MCV; however, the MCHC usually is elevated rather than decreased, and the peripheral smear shows a lack of central pallor rather than hypochromia.
  • Tissue lead concentrations. Measure tissue lead concentrations; chronic lead poisoning may produce a mild microcytosis; the anemia probably is related to the anemia of chronic disorders.
  • Bone marrow aspiration. A bone marrow aspirate can be diagnostic of iron deficiency; the absence of stainable iron in a bone marrow aspirate that contains spicules and a simultaneous control specimen containing stainable iron permit establishment of a diagnosis of iron deficiency without other laboratory tests.

Medical Management

Medical care starts with establishing the diagnosis and reason for the iron deficiency.

  • Iron therapy. Oral ferrous iron salts are the most economical and effective medication for the treatment of iron deficiency anemia; of the various iron salts available, ferrous sulfate is the one most commonly used.
  • Management of hemorrhage. Surgical treatment consists of stopping hemorrhage and correcting the underlying defect so that it does not recur; this may involve surgery for treatment of either neoplastic or nonneoplastic disease of the gastrointestinal (GI) tract, the genitourinary (GU) tract, the uterus, and the lungs.
  • Diet. The addition of nonheme iron to national diets has been initiated in some areas of the world.
Pharmacologic Management

Medications for iron deficiency anemia include:

  • Iron products. These agents are used to provide adequate iron for hemoglobin synthesis and to replenish body stores of iron.
  • Parenteral iron. Reserve parenteral iron for patients who are either unable to absorb oral iron or who have increasing anemia despite adequate doses of oral iron; it is expensive and has greater morbidity than oral preparations of iron.

Nursing Management

Nursing care of a child with iron deficiency anemia include the following:

Nursing Assessment

Assessment of the child include:

  • Dietary history. A dietary history is important; vegetarians are more likely to develop iron deficiency unless their diet is supplemented with iron; national programs of dietary iron supplementation are initiated in many portions of the world where meat is sparse in the diet and iron deficiency anemia is prevalent.
  • History of hemorrhage. Bleeding is the most common cause of iron deficiency, either from parasitic infection (hookworm) or other causes of blood loss; with bleeding from most orifices (hematuria, hematemesis, hemoptysis), patients will present before they develop chronic iron deficiency anemia; however, gastrointestinal bleeding may go unrecognized.
  • Physical exam. Anemia produces nonspecific pallor of the mucous membranes; a number of abnormalities of epithelial tissues are described in association with iron deficiency anemia; these include esophageal webbing, koilonychia, glossitis, angular stomatitis, and gastric atrophy.
Nursing Diagnosis

Based on the assessment data, the major nursing diagnoses are:

  • Fatigue related to decreased hemoglobin and diminished oxygen-carrying capacity of the blood.
  • Deficient knowledge related to the complexity of treatment, lack of resources, or unfamiliarity with the disease condition.
  • Risk for infection
  • Risk for bleeding
Nursing Care Planning and Goals

The major nursing care planning goals for patients with iron deficiency anemia are:

  • Client/caregivers will verbalize the use of energy conservation principles.
    Client/caregivers will verbalize reduction of fatigue, as evidenced by reports of increased energy and ability to perform desired activities.
  • Client/caregivers will verbalize understanding of own disease and treatment plan.
  • Client will have a reduced risk of infection as evidenced by an absence of fever, normal white blood cell count, and implementation of preventive measures such as proper hand washing.
  • Client will have vital signs within the normal limit.
  • Client will have a reduced risk for bleeding, as evidenced by normal or adequate platelet levels and absence of bruises and petechiae.
Nursing Interventions

The nursing interventions for a child with iron deficiency anemia are:

Administer prescribed medications, as ordered: 

  • Administer IM or IV iron when oral iron is poorly absorbed.
  • Perform sensitivity testing of IM iron injection to avoid risk of anaphylaxis.
  • Advise patient to take iron supplements an hour before meals for maximum absorption; if gastric distress occurs, suggest taking the supplement with meals — resume to between-meals schedule if symptoms subside.
  • Inform patient that iron salts change stool to dark green or black.
  • Advise patient to take liquid forms of iron via a straw and rinse mouth with water.

Reduce fatigue

  • Assist the client/caregivers in developing a schedule for daily activity and rest.
  • Stress the importance of frequent rest periods.
  • Monitor hemoglobin, hematocrit, RBC count, and reticulocyte counts.
  • Educate energy-conservation techniques.
  • Encourage patient to continue iron therapy for a total therapy time (6 months to a year), even when fatigue is no longer present.

Educate the client and caregivers about iron deficiency anemia:

  • Explain the importance of the diagnostic procedures (such as complete blood count), bone marrow aspiration and a possible referral to a hematologist.
  • Explain the importance of iron replacement/supplementation.
  • Educate the client and the family regarding foods rich in iron (organ and other meats, leafy green vegetables, molasses, beans).

Prevent infection

  • Assess for local or systemic signs of infection, such as fever, chills, swelling, pain, and body malaise.
  • Monitor WBC count; anticipate the need for antibiotic, antiviral, and antifungaltherapy.
  • vInstruct the client to avoid contact with people with existing infections.
  • Stress the importance of daily hygiene, mouth care, and perineal care.

Prevent bleeding

  • Monitor platelet count; instruct the client/caregivers about bleeding precautions.
  • Anticipate the need for a platelet transfusion once the platelet count drops to a very low value.
  • Assess the skin for bruises and petechiae.
Evaluation

Goals are met as evidenced by:

  • Client/caregivers will verbalize the use of energy conservation principles.
  • Client/caregivers will verbalize reduction of fatigue, as evidenced by reports of increased energy and ability to perform desired activities.
  • Client/caregivers will verbalize understanding of own disease and treatment plan.
  • Client will have a reduced risk of infection as evidenced by an absence of fever, normal white blood cell count, and implementation of preventive measures such as proper hand washing.
  • Client will have vital signs within the normal limit.
  • Client will have a reduced risk for bleeding, as evidenced by normal or adequate platelet levels and absence of bruises and petechiae.

Documentation Guidelines

Documentation for a child with iron deficiency anemia include:

  • Baseline and subsequent assessment findings to include signs and symptoms.
  • Individual cultural or religious restrictions and personal preferences.
  • Plan of care and persons involved.
  • Teaching plan.
  • Client’s responses to teachings, interventions, and actions performed.
  • Attainment or progress toward the desired outcome.
  • Long-term needs, and who is responsible for actions to be taken.

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Nursing Care Plan

Fatigue

Fatigue: An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.

May be related to

  • Decreased hemoglobin and diminished oxygen-carrying capacity of the blood.

Possibly evidenced by

  • Exertional discomfort or dyspnea.
  • Inability to maintain usual level of physical activity.
  • Increased rest requirements.
  • Report of fatigue and lack of energy.

Desired Outcomes

  • Client will verbalize use of energy conservation principles.
  • Client will verbalize reduction of fatigue, as evidenced by reports of increased energy and ability to perform desired activities.
Nursing Interventions Rationale
Assess the specific cause of fatigue. The specific cause of fatigue is due to tissue hypoxia from normocytic anemia; Other related medical problems can also compromise activity tolerance.
Assess the client’s ability to perform activities of daily living (ADLs), and the demands of daily living, Fatigue can limit the client’s ability to participate in self-care and perform his or her role responsibilities in family and society, such as working outside the home.
Assist the client in planning and prioritizing activities of daily living (ADL). This will allow the client to maximize his/her time for accomplishing important activities. Not all self-care and hygiene activities need to be completed i the morning. Likewise, not all housework needs to be completed in one day.
Assist the client in developing a schedule for daily activity and rest. Stress the importance of frequent rest periods. Energy reserves may be depleted unless the client respects the body’s need for increased rest. A plan that balances periods of activity with periods of rest can help the client complete desired activities without adding levels to fatigue.
Monitor hemoglobin, hematocrit, RBC counts, and reticulocyte counts. Decreased RBC indexes are associated with decreased oxygen-carrying capacity of the blood. It is critical to compare serial laboratory values to evaluate progression or deterioration in the client and to identify changes before they become potentially life-threatening.
Educate energy-conservation techniques. Clients and caregivers may need to learn skills for delegating task to others, setting priorities, and clustering care to use available energy to complete desired activities. Organization and time management can help the client conserve energy and reduce fatigue.
Instruct the client about medications that may stimulate RBC production in the bone marrow. Recombinant human erythropoietin, a hematological growth factor, increases hemoglobin and decreases the need for RBC transfusions.
Provide supplemental oxygen therapy, as needed. Oxygen saturation should be kept at 90% or greater.
Anticipate the need for the transfusion of packed RBCs. Packed RBCs increase oxygen-carrying capacity of the blood.
Refer the client and family to an occupational therapist. The occupational therapist can teach the client about using assistive devices. The therapist also can help the client and family evaluate the need for additional energy-conservation measures in the home setting.

Deficient Knowledge

Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.

May be related to

  • Complexity of treatment.
  • Lack of recall.
  • Lack of resources.
  • New condition or treatment.
  • Unfamiliarity with the disease condition.

Possibly evidenced by

  • Inaccurate follow-through of instructions.
  • Questioning members of health care team.
  • Verbalized inaccurate information.

Desired Outcomes

  • Client will verbalize understanding of own disease and treatment plan.
Nursing Interventions Rationale
Assess current knowledge of the diagnosis, disease process, possible causative factors, and treatment. Determining the client’s current knowledge and perceptions will facilitate the planning of individualized teaching. Clients may have a general understanding of anemia related to iron deficiency but limited knowledge of other types of anemia.
Assess the client’s and family’s understanding of the new medical vocabulary. Usually, people have a limited understanding of medical vocabulary, hence are not exposed to the language being used by the health care professionals.
Explain the importance of the diagnostic procedures (such as complete blood count), bone marrow aspiration and a possible referral to a hematologist. Diagnosing a type of anemia will be based on the changes in the RBC indexes and the findings in the bone marrow aspiration.
Explain the hematological vocabulary and the functions of blood elements, such as white blood cells, red blood cells, and platelets. Clients usually have a basic knowledge of the hematological system.
Instruct client to avoid known risk factors. Causative factors such alcoholism, exposure to toxic chemicals, dietary deficiencies, and the use of some medications can affect red blood cell production and lead to anemia.
For aplastic anemia:
  • Explain that blood transfusions from prospective marrow donors should be avoided.
Histocompatibility antigens may lead to donor marrow rejection.
  • Explain the need for rapid human leukocyte antigen (HLA) typing.
The human leukocyte antigen (HLA) test, also known as HLA typing or tissue typing, identifies antigens on the white blood cells (WBCs) that determine tissue compatibility for organ transplantation
  • Explain that immunosuppressive therapy is the treatment of choice in clients without HLA-matched donors and/or older than 40 years of age.
The treatment of choice in clients without HLA-matched donors is immunosuppression with granulocyte-macrophage-colony-stimulating factors, cyclophosphamide, anti-thymocyte globulin, and cyclosporine.
  • Explain that allogeneic hematopoietic stem cell transplantation is the standard treatment for clients younger than 40 years old who have HLA-identical related donors.
Hematopoietic stem cell transplantation (HCT) is an effective therapy for many life-threatening diseases. Usually, a client’s own (autologous) cells or (allogeneic) cells from a donor with same genetic makeup are used.
Explain the potential complications associated with immunosuppressive therapy.
  • Acute graft-versus-host disease (GVHD).
Earliest symptoms include a red maculopapular rash, dryness of the eye, abdominal pain, and jaundice.
  • Chronic GVHD.
Clients with Chronic GVHD may present with a variety of symptoms. Skin rash and mouth sores are among the common initial signs of the disease. The rash is often slightly raised and may be itchy.
  • Rejection of donor marrow.
Rejection happens when a sensitization to histocompatibility antigens acquired during previous blood transfusions and carries a high mortality rate. Conditioning regimens using cyclophosphamide (Cytoxan) and total lymphoid irradiation show a decrease in the risk for graft failure.
For nutritional deficiency anemia:
  • Explain the importance of vitamin B12 replacement.
Vitamin B12 injections used to treat low levels (deficiency) of this vitamin. They are given monthly for the remainder of the client’s life. It elevates levels of vitamin B12, a deficiency caused by a lack of intrinsic factor that impairs the vitamin absorption.
  • Educate the client and the family regarding food rich in iron, folic acid, and vitamin B12.
A balanced diet that includes a variety of foods from each food group usually contains essential nutrients needed to promote RBC formation. Clients need to have an adequate intake of dark-green leafy vegetables, animal products, including fish, meat, poultry, eggs, milk, and fortified breakfast cereals.
  • Educate the client and the family regarding replacement therapy with folic acid and iron.
The dosage and frequency of administration will depend on the severity of anemia. Iron supplements are given orally with meals to prevent gastric upset. Intramuscular injections are also available given via Z-track method to prevent leakage of the solution in the subcutaneous tissue along the needle tract. While folic acid is given orally with a full glass of water.
For blood loss anemia:
  • Instruct the client about certain medications that may stimulate the production of RBC in the bone marrow.
Recombinant human erythropoietin, a hematological factor, elevates hemoglobin levels and decreases the need for a transfusion of packed RBC.
  • Explain that a transfusion of packed RBCs may be needed.
One unit of packed RBC raises the hemoglobin level by 1 g/dL.


Risk For Infection

Risk for Infection: At increased risk for being invaded by pathogenic organisms.

Risk Factors

  • Bone marrow malfunction.
  • Marrow replacement with fat in aplastic anemia.

Possibly evidenced by

  • [not applicable].

Desired Outcomes

  • Client will have a reduced risk of infection as evidenced by an absence of fever, normal white blood cell count, and implementation of preventive measures such as proper hand washing.
  • Client will have vital signs within the normal limit.
Nursing Interventions Rationale
Assess for local or systemic signs of infection, such as fever, chills, swelling, pain, and body malaise. Opportunistic infections can easily develop, especially in immunocompromised clients.
Monitor WBC count. A low white blood cell count (leukopenia) is a decrease in disease-fighting cells (leukocytes) in your blood. In general, for adults a count lower than 4,000 white blood cells per microliter of blood is considered a low white blood cell count.
Instruct the client to report signs and symptoms of infection immediately. A simple fever is significant enough not to pay attention to. A need for antibiotic therapy may be indicated.
Anticipate the need for antibiotic, antiviral, and antifungal therapy. These agents are effective against killing an infection.
Instruct the client to avoid contact with people with existing infections. These can be a source of infection for the immunocompromised client. Children, 12 years of age or younger are at risk because they can be carriers of infection, especially upper respiratory infection.
If the client is hospitalized, provide a private room for protective isolation. Environmental changes may be important if the absolute neutrophil count is less than 500/mm3Protective isolation precautions may include placing the client in a private room, limiting visitors, and having all people who come in contact with the client use mask, gown, and gloves. These clients are at a significant risk for infection.
Instruct the client to avoid eating raw fruits and vegetables and uncooked meat. These food items can harbor bacteria. A low bacterial diet protects the client from exposure to pathogens.
Stress the importance of daily hygiene, mouth care, and perineal care. These preventive measures help avoid skin breakdown and lessen the risk of infection.
Teach the client and visitors the proper hand washing. Practicing hand hygiene is an effective way to prevent infections. Washing hands can prevent the spread of germs, including those that are resistant to antibiotics.
Administer WBC growth factor to stimulate the production of neutrophils. Colony-stimulating factors (CSFs), long-acting pegfilgrastim, filgrastim are medications used to stimulate the production of infection-fighting white blood cells.

Risk For Bleeding

Risk for Bleeding: At risk for a decrease in blood volume that may compromise health.

Risk Factors

  • Bone marrow malfunction.
  • Marrow replacement with fat in aplastic anemia.

Possibly evidenced by

  • [not applicable].

Desired Outcomes

  • Client will have a reduced risk for bleeding, as evidenced by normal or adequate platelet levels and absence of bruises and petechiae.
Nursing Interventions Rationale
Assess the skin for bruises and petechiae. Bruises and petechiae is usually evident when the platelet count drops to 20,000 mm3.
Assess for any frank bleeding from the nose, gums, vagina, or urinary or gastrointestinal tract. Early assessment facilitates immediate treatment. These sites are most common for spontaneous bleeding.
Monitor platelet count. A low platelet count or thrombocytopenia is caused by a bone marrow malfunction resulting from nutritional deficiencies, drugs, certain viral causes, or aplastic anemia. The risk for bleeding is increased as platelet count is decreased.
Monitor stool (guaiac) and urine(Hemastix) for occult blood. These test help identify the site of bleeding.
Consolidate laboratory blood sampling test. Repeated blood sampling over time can lead to anemia. Consolidation minimizes the number of venipunctures and optimizes blood volume.
Instruct the client in dietary modifications to reduce constipation. Eating a diet high in fiber and drinking a lot of fluids to avoid constipation or using a stool softener and other laxatives as prescribed if having difficulty passing stool.
Instruct the client about bleeding precautions.

  • Instruct the client to use an electric shaver, not a razor.
  • Use a soft toothbrush when brushing the teeth.
  • Using pads instead of tampons.
  • Avoid rectal procedures such as suppositories, enemas, and rectal temperature readings.
  • Using a water-based lubricant during sexual intercourse to reduce friction (KY Jelly or Astroglide)
Once the client’s platelet count drops to 50,000mm3, bleeding precaution should be instituted immediately to avoid risk of spontaneous bleeding.
Anticipate the need for a platelet transfusion once the platelet count drops to a very low value. Platelet replacement may be required to reduce the risk of bleeding. Premedication with antihistamine and antipyretics reduce transfusion reaction side effects.
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