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Clinical Case Study

Iron Deficiency Anemia:

A Clinical Case Study
Myriam Jean Cadet

ron deficiency anemia (IDA) is

I the result of low iron stores in

the body due to decreased red
blood cell (RBC) production (Short
Management of iron deficiency anemia is important because of its
link to increased morbidity and mortality. Careful assessment, mon-
itoring, and management of iron replacement therapy are crucial
& Domagalski, 2013). Api, Breyman, for caring for patients with this condition.
Çetiner, Demir, and Ecder (2015)
indicated 50% of cases of anemia
are related to iron deficiency.
According to the World Health
Organization (2018), approximately Allergies. She is allergic to sulfa, minute, oxygen saturation 94% on
30% of the world’s population (2 which caused hives when she took room air
billion people) has anemia; the con- it 4 years ago. Head and neck. Patient has a
dition affects mostly females and Medications. Medications include beefy red tongue and pale conjunc-
children. the following: lisinopril/hydrochlor- tiva.
Management of IDA is important othiazide (Prinzide®) 20 mg/12.5 Cardiac. Auscultation identifies
because of its link to increased mor- mg by mouth daily, aspirin 81 mg regular rhythm without any mur-
bidity and mortality (Shander et al., by mouth daily, atorvastatin mur. No peripheral edema is noted.
2014). For example, IDA may cause (Lipitor®) 20 mg by mouth at night, Respiratory. The patient’s chest
permanent cognitive impairment in metformin (Glucophage®) 500 mg expansion is symmetrical, with no
children, fatigue or heart failure in by mouth twice daily, ergocalciferol adventitious breath sounds. She
adults, and serious maternal and 800 units orally once daily, and complains of mild shortness of
fetal complications (Api et al., 2015; ibandronate (Boniva®) 150 mg breath when walking long dis-
Hennek et al., 2016). Empirical every month. tances.
research found understanding the Social history. The patient denied Gastrointestinal (GI). Patient’s
etiology, diagnosis, treatment, man- any drug and alcohol use or smok- abdominal wall is soft and non-ten-
agement, and evaluation of IDA is ing. She retired 4 years ago as a der without any masses. Bowel
key to effective care (Short & social worker. sounds are active in all four quad-
Domagalski, 2013). A clinical case Family history. She has a family rants. She denies any nausea,
study is presented, followed by the history of CAD, DM, and HTN. Her weight loss or gain, vomiting, or
discussion of implications for mother died at age 55 from CAD. diarrhea.
patient care in clinical practice. Her father died of prostate cancer at Neurologic. The neurological exam
age 70. Both her siblings have been is unremarkable with no decreased
diagnosed with HTN. sensation to light touch.
Subjective Data Genitourinary. The patient denies
dysuria, hematuria, urinary inconti-
History of Present Illness Objective Data nence, or polyuria.
Chief complaint. A 68-year-old Musculoskeletal. The patient denies
Physical Exam and Review of joint stiffness, pain, or swelling.
African-American female came to Systems
the clinic because of progressive Although she denies any intermit-
lethargy, dizziness, and fatigue that The patient is 5 feet 6 inches tall tent numbness and tingling in the
began 3 months earlier. and weighs 200 pounds. legs, they are cool to the touch.
Medical and surgical history. The Vital signs. Heart rate 100 beats Patient has an unsteady gait and
patient has a history of type 2 dia- per minute, blood pressure 130/80 she uses a cane to walk; she denies
betes mellitus (DM), hypertension mm Hg, respirations 20 breaths per any history of falls.
(HTN), coronary artery disease

Myriam Jean Cadet, PhD, APRN, FNP-C, is Adjunct Faculty, Lehman College, Bronx, NY.
(CAD), and osteoporosis. She had a
Caesarean section 23 years ago.

108 March-April 2018 • Vol. 27/No. 2

Iron Deficiency Anemia: A Clinical Case Study

Diagnostics. Laboratory results laboratory findings to confirm IDA with inadequate response to oral
are as follows: hemoglobin (Hgb) 7 are increased TIBC; decreased Hgb, therapy for IDA. This improves iron
g/dl, hematocrit 23%, mean corpus- serum ferritin, serum transferrin sat- stores more quickly than oral treat-
cular volume (MCV) 73 fl/red cell, uration, serum iron concentration; ment, and carries no concerns
mean corpuscular hemoglobin and presence of microcytic hypo- about absorption or GI side effects.
(MCH) 25 pictograms/cell, mean chromic red cells (Api et al., 2015; However, the major disadvantage of
corpuscular hemoglobin concentra- Camaschella, 2015). intravenous therapy with iron
tion (MCHC) 30 g/dl, increased The patient’s shortness of breath, sucrose (Venofer®) or ferric gluco-
total iron-binding capacity (TIBC) dizziness, fatigue, cool lower nate (Ferrlecit®) is infusion reaction
550 mcg/dl, low serum iron 50 extremities, and beefy red tongue (DeLoughery, 2014).
mcg/dl, and low serum ferritin 15 are consistent with a diagnosis of
ng/ml. IDA. Abnormal laboratory values
also supported the diagnosis. Serum Implications for Practice
ferritin is the most accurate test to Because IDA may affect any
Discussion diagnose IDA (Api et al., 2015). This race/ethnicity and age, nurse practi-
patient was diagnosed with micro- tioners need to assess individuals’
Etiology cytic hypochromic anemia charac- risk factors to provide appropriate
IDA may be caused by decreased terized by production of RBCs that care across the lifespan. For in-
production of RBCs, potentially are smaller than normal. It is associ- stance, women are at higher risk of
related to poor diet (e.g., deficient ated with MCV less than 80 fl/red developing IDA anemia because of
iron, folate, or vitamin B12 intake). cell (normal 80-100 fl/red cell). blood loss during menstruation and
It also can occur secondary to Hypochromia is characterized by the first 6 months of pregnancy.
increased iron requirements during MCHC less than 32 g/dl (normal Prematurity, feeding of only breast
infancy, pregnancy, or lactation 32-36 g/dl), with RBCs having less milk or formula (12-24 months),
(Camaschella, 2015). Blood loss is color than normal (DeLoughery, and lack of fortified iron intake in
another potential cause of iron defi- 2014). The most common cause of diets by age 6 months put infants at
ciency anemia, perhaps related to microcytic hypochromic anemia is risk of developing IDA. Likewise,
surgery or heavy menstruation. IDA. older adults are at increased risk of
Finally, a high rate of RBC destruc- developing IDA because of chronic
tion (e.g., hemolytic anemia or tha- Management diseases (National Institutes of
lassemia) may cause IDA. The The first-line treatment for IDA is Health [NIH], n.d.).
patient in this case study was found oral iron replacement therapy (e.g., Many side effects are associated
to have low serum iron, ferritin, ferrous sulfate, ferrous gluconate, with iron replacement therapy. For
and MCV, but high TIBC; which are ferrous fumarate) for 3-6 months instance, common reactions to fer-
consistent results for IDA (Api et al., for iron stores repletion (Cama- rous sulfate and ferrous gluconate
2015). schella, 2015). A patient can be include vomiting, dyspepsia, nau-
given two to four divided doses of sea, and diarrhea (Short & Doma-
Diagnosis of IDA ferrous sulfate by mouth (150-300 galski, 2013). Anaphylaxis or hyper-
Differential diagnoses. The differ- mg, or 2-3 mg/kg/day). Other forms sensitivity is an adverse complica-
ential diagnoses formulated for this include ferrous gluconate or fuma- tion associated with the supple-
patient were as follows (Heeney & rate 2-3 mg/kg/day orally given in ment iron dextran (DexFerrum®)
Finberg, 2014; Knollmann-Ritschel two to four divided doses. (DeLoughery, 2014). Patient educa-
& Markowitz, 2017): Although ferrous gluconate and tion should include medication
1. Iron deficiency anemia ferrous fumarate are effective iron effects, such as constipation and
2. Decreased iron absorption salts replacement therapy, iron sul- dark stools, during iron replace-
3. Lead poisoning fate is used most frequently for IDA ment therapy (Short & Domagalski,
4. Thalassemia trait treatment. Iron sulfate is inexpen- 2013). If patients are unable to tol-
The diagnosis of IDA is not only sive and convenient, and can treat erate an oral iron replacement, par-
based on results of a complete patients with IDA effectively enteral replacement is another
blood count, but also on the (Camaschella, 2015). Also, oral iron option. Iron dextran is recommend-
patient’s clinical history and pres- therapy is associated with GI side ed intravenously to treat IDA
entation. Diagnosis can be made effects (e.g., stomach ache, consti- (DeLoughery, 2014). Careful assess-
with measures of RBC size, such as pation); treatment adherence can ment, monitoring, and manage-
MCV, MCH, and MCHC (Hennek et be difficult (Short & Domagalski, ment of iron replacement therapy
al., 2016; Short & Domagalski, 2013). Low doses of iron may are crucial for patients with IDA to
2013). Other tests for patients with decrease potential GI symptoms ensure safe administration.
potential IDA include serum fer- and increase adherence to treat-
ritin, iron level, TIBC, and/or trans- ment (DeLoughery, 2014). continued on page 120
ferrin (American Society of Parenteral administration of iron
Hematology, 2018). Expected classic therapy may be useful for patients

March-April 2018 • Vol. 27/No. 2 109

Api, O., Breyman, C., Çetiner, M., Demir, C., & 28(4), 637-652. doi:10.1016/j.hoc.2014.
Ecder, T. (2015). Diagnosis and treat- 04.009
Iron Deficiency Anemia
ment of iron deficiency anemia during Knollmann-Ritschel, B.E., & Markowitz, M.
pregnancy and the postpartum period: (2017). Educational case: Lead poison-
continued from page 109

Iron deficiency anemia working group ing. Academic Pathology, 4, 1-3.

consensus report. Journal of Turkish doi:10.1177/2374289517700160
Society of Obstetrics & Gynecology, National Institutes of Health (NIH). (n.d.). Iron-
12(3) 173-181. doi:10.4274/tjod.01700 deficiency anemia. Retrieved from
IDA affects patients across the
Camaschella, C. (2015). Iron-deficiency ane- https://www.nhlbi.nih.gov/health/health-
life span (NIH, n.d.). Nurse practi-
mia. New England Journal of Medicine, topics/topics/ida/prevention
tioners should screen patients for
372(19), 1832-1843. doi:10.1056/NEJM Shander, A., Goodnough, L.T., Javidroozi, M.,
ra1401038 Auerbach, M., Carson, J., Ershler, W.B.,
risk factors for IDA, and also assess

DeLoughery, T.G. (2014). Microcytic anemia. ... Lew, I. (2014). Iron deficiency anemia
clinical presentation and laboratory
New England Journal of Medicine, – bridging the knowledge and practice
results. They should prioritize
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Hennek, J.W., Kumar, A.A., Wiltschko, A.B., Short, M.W., & Domagalski, J.E. (2013). Iron
complications during iron replace-

Patton, M.R., Lee, S.Y.R., Brugnara, C., deficiency anemia: Evaluation and man-
ment therapy.
... Whitesides, G.M. (2016). Diagnosis of agement. American Family Physician,
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120 March-April 2018 • Vol. 27/No. 2

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