Iron deficiency anaemia: the condition every nurse needs to take seriously

The telltale signs of a condition that’s widely misunderstood, plus how to improve outcomes

The telltale signs of a common condition thats widely misunderstood, plus how to improve outcomes

  • Theres a lack of understanding among clinicians and the public about the potential consequences of iron deficiency anaemia
  • Nurses across acute, community and social care settings are likely to be caring for people who have the condition, but it often goes undiagnosed
  • How you can spot the signs and symptoms and the questions you need to ask patients
Iron deficiency anaemia is a lack of red blood cell production resulting from a low supply of iron Picture: iStock

For Bintu Bangura, one of the best things about her job as an anaemia nurse specialist is the ability to make a visible impact


The telltale signs of a common condition that’s widely misunderstood, plus how to improve outcomes

  • There’s a lack of understanding among clinicians and the public about the potential consequences of iron deficiency anaemia
  • Nurses across acute, community and social care settings are likely to be caring for people who have the condition, but it often goes undiagnosed
  • How you can spot the signs and symptoms – and the questions you need to ask patients
Iron deficiency anaemia is a lack of red blood cell production resulting from a low supply of iron
Picture: iStock

For Bintu Bangura, one of the best things about her job as an anaemia nurse specialist is the ability to make a visible impact on people’s lives – and to witness their rapid improvement.

‘This condition is devastating – it can wreck people’s lives and have a big impact on them, but you can really see the benefit of treating them,’ she says. ‘You see them come in looking really washed out, really down, and if you manage the anaemia effectively, you see them coming in and looking and feeling really great.’

A common condition with potentially serious consequences

Bintu Bangura: Iron deficiency anaemia
often goes undiagnosed

Iron deficiency anaemia is common.

In the UK, it has a prevalence of 2.5% in adult men and post-menopausal women, rising to 14% in pre-menopausal women, and around 23% in those who are pregnant, according to the National Institute for Health and Care Excellence (NICE).

NICE describes it as diminished red blood cell production due to low iron stores in the body.

Reasons why someone may develop iron deficiency anaemia

It has multi-factorial causes, broadly attributed to dietary deficiency, malabsorption (not being able to absorb the iron you eat, sometimes due to medication), increased blood loss (for example, through surgery or trauma) or increased requirement for iron, for example during pregnancy, says NICE.

Yet despite its high prevalence – and potentially serious consequences – iron deficiency anaemia is poorly understood.

‘Most people don’t think iron deficiency anaemia is a serious condition, but sometimes that’s not the case’

Bintu Bangura, anaemia nurse specialist

‘Nurses will see it in the community, in hospitals, in the GP surgery, and care homes, but much of the time it will just go undiagnosed,’ says Ms Bangura, who is lead nurse for the anaemia team at King’s College Hospital NHS Foundation Trust in London, and president of the Anaemia Nurse Specialist Association.

‘The bottom line is that most people don’t think it’s a serious condition – some people think it’s something that will resolve on its own, but sometimes that’s not the case. If you don’t treat it, it gets worse.

Why non-specialist nurses need to know what to look for

Non-specialist nurses often don’t take it seriously enough, and frequently aren’t equipped to spot and manage it effectively, she warns.

‘It’s always at the bottom of the list when you think about medical conditions. But it has a real impact on people’s lives if it’s not looked at.

‘The other thing is that some nurses don’t know what to look for, how to test for it, how to treat it, or how to make referrals. They need to look out for the signs and symptoms (see box).

Signs and symptoms of iron deficiency anaemia

Very common symptoms of iron deficiency anaemia

  • Dyspnoea (difficulty breathing)
  • Fatigue
  • Headache

Common symptoms

  • Cognitive dysfunction
  • Restless leg syndrome
  • Vertigo

Other symptoms

(Source: NICE clinical knowledge summary on anaemia – iron deficiency)

The telltale signs of iron deficiency anaemia and nursing interventions

‘If a patient is saying they’re feeling dizzy or weak, having palpitations, feeling lethargic, tired all the time, short of breath or can’t do exercise or even climb the stairs like they used to be able to, those are all telltale signs there’s something going on,’ says Ms Bangura.

‘In those circumstances, nurses need to ask more questions – ask about diet, lifestyle, about medications, because some medications are contraindicated for iron absorption.

‘All of these things help to get a clear picture of the patient.’

‘If it is not managed well, it can cause lots of problems… even angina and heart attack’

Ms Bangura

The main nursing interventions are to assess the patient, take a good medical history and do investigations such as blood tests that will determine the stage of the anaemia and how severe, mild or moderate it is, she says.

If you are not sure if the patient is iron-deficient, you can refer on to a doctor with knowledge of anaemia management or a specialist anaemia service if there is one locally, for further assessment, she adds.

If a patient now finds they struggle to climb stairs, the nurse needs to investigate Picture: iStock

The dangers of not taking iron deficiency anaemia seriously

First-line treatment is oral iron, but this is not suitable for all patients with underlying conditions because of side effects. ‘In a hospital setting when someone is severely iron-deficient, the first line will be intravenous iron for patients who are not able to absorb oral iron adequately,’ says Ms Bangura.

‘Patients who are pre-operative and need fast replenishment of iron before surgery can also have it intravenously. If they don’t respond to oral or intravenous treatment, that will tell you there’s something underlying that will need further investigation.’

Ms Bangura warns of the dangers of not taking iron deficiency anaemia seriously. ‘If it is not managed well, it can cause lots of problems. Patients can experience fainting, chest pains, even angina or heart attack, or if you have congestive heart failure, it can worsen. It can affect you and your quality of life if it’s not managed properly.’

A lack of anaemia nurse specialists despite increasing patient complexity

Picture: iStock

Unfortunately, Ms Bangura says, there are not many anaemia nurse specialists, and not many hospitals have a specific anaemia service.

Most anaemia nurses are advanced nurse practitioners, often in a relevant field such as renal or cardiology.

Their role generally involves running nurse-led clinics, including outreach, managing their own case load, and providing advice to other healthcare professionals. Most are nurse prescribers.

‘There should be more anaemia nurses because it is a specialist role,’ says Ms Bangura. ‘It’s not just giving iron; it’s about trying to know more about anaemia management because there are different kinds of anaemia, and trying to understand that we’re getting more and more patients with comorbidities that are being affected by anaemia, like the renal population, the IBD [inflammatory bowel disease] population, the heart failure population.

‘All of these patient groups need to be managed for anaemia, so you need that specialist role to know how to manage them, and to have an in-depth knowledge of what’s going on.’

Steve Evans experiences chronic
fatigue and difficulty breathing

‘If it wasn’t for my anaemia nurse, I don’t think I’d still exist’

Steve Evans would like nothing more than to run about and play with his grandchildren – but even a short walk in the garden leaves him exhausted.

Mr Evans, from Bromley in Kent, has iron deficiency anaemia due to conditions including an internal bleed and polycystic kidneys. He requires frequent blood transfusions and iron infusions.

It was several years ago that his anaemia was diagnosed. ‘He felt quite ill and couldn’t breathe properly,’ says his wife, Debbie.

‘It was a Friday night, and I said he should go to A&E but he wouldn’t – he said he’d be fine. Later in the evening he got worse and worse and we went to A&E. There was a lovely doctor who did lots of blood tests and said to him that he was very anaemic, which was causing the breathing problems because he didn’t have enough blood flow.

‘She did one last blood test and said he was losing blood from somewhere – there was an internal bleed. He was in hospital for two weeks and they found he’d actually had a mild heart attack because of the lack of blood going round his body. Since then, they’ve been trying to find out what the bleed is.’

Symptoms persist and affect everyday life

Constant tiredness will be familiar to many people with iron deficiency anaemia Picture: iStock

Mr Evans, who has retired on medical grounds from his job as a railway plumber, is a patient of the anaemia service at King’s College Hospital in London.

Nevertheless, the effects of the anaemia persist. ‘I feel very, very tired all the time,’ he says. ‘I was just saying to my wife that I didn’t really do much yesterday – went to see my daughter and the grandchildren and I just sat there for a little while and had a walk up and down the garden and today my legs feel like lead weights. It makes it very hard to walk a long distance and my breathing does get very bad.

‘My grandchildren want me to play with them – the oldest two are ten and eight and I used to play with them a lot. When they were younger, they used to jump all over me, but it got to the stage where they weren’t allowed to jump on me at all. They know that, but they still want me to run and stuff with them, and I can’t – and you can’t explain to the youngest, who is four. We tell him that Grandad isn’t well, and you can see him looking at me and thinking I don’t look ill.’

Ms Evans says it’s very noticeable when her husband’s blood iron gets low. ‘You’re sitting talking to him and he just falls asleep.’

Mr Evans has nothing but praise for his nurse, Bintu Bangura. ‘She is the best nurse in the NHS,’ he says. ‘Not just for me, but for all her patients. When my consultants haven’t listened, she has always been there. If it hadn’t been for her, I don’t think I’d still exist.’

The nurse’s role in patient education

A regimen of regular blood tests enables patients and clinicians to keep up to date with
the individual’s iron status Picture: iStock

Nurses also have a role in educating patients, Ms Bangura says. This can be anything from dietary advice to explaining, for example to renal patients, that they need iron infusion because diet or pills alone won’t be enough.

‘We encourage patients to know their iron status – what their levels are – so we encourage them to have regular blood tests, to attend appointments, and to see their doctor if they have any signs or symptoms,’ says Ms Bangura.

‘We encourage them to take their medication and if they are having any side-effects to tell us so we can find alternative management.’

According to NICE, referral should be arranged urgently using a suspected cancer pathway for people aged over 60 with iron deficiency anaemia, or women aged over 55 with post-menopausal bleeding.

Urgent referral should be considered for people aged under 50 with rectal bleeding.

Low levels of public awareness about anaemia in general

People may not realise that their tiredness could be due to iron deficiency anaemia Picture: iStock

Julie Thompson, information manager with the Guts UK charity, says that iron deficiency anaemia is a symptom of a number of digestive conditions.

‘Between four and 13% of referrals to gastro [services] are as a consequence of having iron deficiency anaemia, and it’s really about looking to find out the cause of it. It’s a big thing,’ she says.

One of the challenges is that people often don’t know they have a problem, Ms Thompson says. ‘It’s particularly common in pre-menopausal women, but a lot of people are walking around and simply don’t know they have it. I don’t think the general public are aware of it at all, actually.

‘They know about bits of specific advice, such as seek advice if you have blood in your poo or your urine, but I don’t think they are aware of the anaemia side of things more generally.’

Having experienced low iron levels herself, Ms Thompson is only too aware of the impact it can have. ‘I was completely and utterly exhausted – for example, I went out for a meal and I wasn’t actually anaemic – I was just on the borderline – and I fell asleep at the table.

‘I wouldn’t want to generalise, as my experience won’t be the same as everyone’s – some people wouldn’t notice at all – but that’s how it was for me.’

Dry or damaged hair may indicate an
individual is lacking iron

Signs of iron deficiency

Common or very common signs

  • Angular cheilosis (inflammation of the corners of the mouth)
  • Atrophic glossitis (changes in the texture and colour of the tongue)
  • Diffuse and moderate alopecia
  • Dry and rough skin, dry and damaged hair
  • Pallor

Less common signs

  • Nail changes
  • Tachycardia

(Source: NICE clinical knowledge summary on anaemia – iron deficiency)

Jennifer Trueland is a health journalist

Further information

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