This document provides information about hemoglobin and anemia. It describes the structure and function of hemoglobin, located within red blood cells, and how it transports oxygen throughout the body. Signs and symptoms of low hemoglobin (anemia) are discussed. Dietary and non-dietary causes of anemia are outlined. The normal hemoglobin levels for adult women and populations at higher risk for anemia are defined. Recommended protocols for referral for low hemoglobin values are presented.

1. Hemoglobin Self Study Carolyn Jenkins MSN, RN-BC Susan Eviston RD,LD Created June 2008 Reviewed Aug. 2011

2. Objectives for: Hemoglobin Self Study: At the end of the self study, the participant will: Describe the structure and function of Hemoglobin. Identify signs and symptoms of low hemoglobin. Review the SC-DHEC WIC Recommended Referral Protocol for Abnormal Hemoglobin.

3. It begins with a blood test for the Hemoglobin Level Blood is composed of Red Blood Cells, White Blood Cells, Platelets, Plasma Proteins and Water. Almost ½ of the blood is Red Blood Cells. There are approximately 4-5 Million Red Blood Cells per cubic millimeter of blood.

4. What is the shape of a red blood cell? A D C B Circle your answer

5. Red Blood Cells live 80-120 days. Hemoglobin is located in Red Blood Cells and uses the Red Blood Cell as a vehicle to travel through the body. One Red Blood Cell contains approximately 300 Hemoglobin molecules. IF you chose B, You are correct. B

6. What is the shape of hemoglobin? A D B C Circle your answer

7. One Red Blood Cell carries approximately 300 Hemoglobin molecules to the lungs where they pick up oxygen. The oxygen travels in hemoglobin to the brain, heart, kidneys, liver, fingers and toes where it is released from hemoglobin to be used by the cells in the body. If you chose C, you are correct.

8. Each Hemoglobin molecule has 4 IRON (Heme) complexes Each IRON complex can hold an oxygen molecule. 4 oxygen molecules X 300 Hemoglobin molecules in each Red Blood Cell = 1200 oxygen molecules in each Red Blood Cell. All body cells need oxygen to live. http://healthguide.howstuffworks.com/hemoglobin-picture.htm

9. a low oxygen level. a high oxygen level. an unchanged oxygen level. Circle your answer Low hemoglobin reading would indicate A. B. C.

10. NON-DIETARY REASON BLEEDING INFECTION CHRONIC DISEASES Examples: Sickle cell Gastrointestinal diseases Liver disease Cancer Bone disease DIETARY REASON IRON DEFICIENCY PROTEIN, VITAMIN, and / or COPPER DEFICIENCY If you chose A, you are correct. Low Hemoglobin =Anemia There are diet and non-diet reasons for Anemia.

11. 12-16 g/dl 6-7 g/dl 30-40 g/dl 9-11 g/dl Circle your answer What is the normal measure of hemoglobin for adult women? A. B. C. D.

12. Populations at increased risk for Low Hemoglobin Women of child bearing age Pregnant women Postpartum women Children People living in chronic poverty If your answer is A, you are correct. 12-16 g/dl

13. SIGNS & SYMPTOMS OF LOW HEMOGLOBIN MIGHT INCLUDE: DIZZINESS WEAKNESS FATIGUE HEAD ACHE DIFFICULTY IN WAKING BEHAVIOR CHANGE: INCLUDING IRRITABILITY, RESTLESSNESS, POOR JUDGMENT, LACK OF INTEREST, INDIFFERENCE SHORTNESS OF BREATH RAPID BREATHING RAPID HEART BEAT PALE OR DUSKY BLUE LIPS, NAILBEDS, EARLOBES

14. SC-DHEC WIC State Plan 10/10 Recommended Referral Protocol for Abnormal Hemoglobin In the first few weeks after delivering a baby, the mother is at increased risk of low hemoglobin due to bleeding (refer to dietary and non-dietary reasons for anemia). Read Recommended Referral Protocol for Abnormal Hemoglobin WIC State Plan 10/10

15. SC-DHEC WIC Recommended Referral Protocol for Abnormal Hemoglobin What is the procedure for referral for Hemoglobin value of 6.9 g/dl or below? ANSWER: If Hgb is 6.9 or below, repeat the test to verify accuracy but do not delay referral for consult. Call the WIC participants primary care provider (PCP) for an immediate referral on the same day as WIC office visit. If unable to reach participant’s PCP, refer to an urgent care center or emergency room for a visit the same day. Schedule nutrition counseling at another visit. Reference: SC-DHEC State WIC Plan 10/10 Attachment M.

16. SC-DHEC WIC Recommended Referral Protocol for Abnormal Hemoglobin What client information will give you clues about the client’s health status with low hemoglobin? ANSWER: Clues about the clients health status when their hemoglobin is low can be obtained from your assessment. Is this client in the at risk population? Check clients history, signs and symptoms. Reference: Slide 10-13

17. SC-DHEC WIC State Plan 10/10 Recommended Referral Protocol for Abnormal Hemoglobin Who needs to be notified when a client is refusing or declining follow-up for low hemoglobin? ANSWER If client is declining or refusing follow-up for low hemoglobin, notify the PCP and contact your supervisor for assistance. Reference: Slide 18 and SC-DHEC State WIC Plan 10/10 Attachment M.

18. When a client declines or refuses follow-up for low hemoglobin: A client may have difficulty making appropriate decisions if oxygen level in the brain is too low. The low hemoglobin can result from bleeding after delivery of the baby. A client may not realize the danger of bleeding and low hemoglobin and the importance of seeing the Primary Care Provider. The client’s health and safety are the priority. WIC providers acting in good faith do not need the client’s consent to share medical information about low hemoglobin with the Primary Care Provider and client’s family in order to obtain follow-up health care for the client’s health and safety.

19. Dietary Effects on Hemoglobin Four IRON Complexes on Each Hemoglobin allow the Hemoglobin to pick up the oxygen molecule to deliver to body cells. Low iron will decrease the ability of the hemoglobin to pick up oxygen. Balanced meals provide the body with protein, vitamins, copper, and IRON to make hemoglobin.

20. oranges, lemons, limes rice, noodles, corn tortillas tomatoes, corn, broccoli beef, fish, pork Circle your answer Which foods are high in IRON? A. B. C. D.

21. If you chose D, you are correct. D. beef, fish, pork Beef Liver Fish Pork Peas Beans Enriched cereal and bread. Foods Rich in IRON

22. Did you know??? Vitamin C increases absorption of iron when taken with iron rich foods. Choose dark green vegetables and citrus fruit. Coffee, Tea, Soda, and Chocolate interfere with iron absorption. Cooking with an iron skillet increases iron absorption.

23. References: Corwin, E.J. (2000). Handbook of Pathophysiology . 2nd ed. Pg. 148 Philadelphia,PA: Lippincott Huether, S.E. & McCance, K.L. (2004). Structure and Function of the Hematologic System. In Understanding Pathophysiology. 3 rd ed. Pg. 507-535. St. Louis, MI: Mosby Huether, S.E. & McCance, K.L. (2004). Alteration of Hematologic Function. In Understanding Pathophysiology. 3 rd ed. Pg. 538-544. St. Louis, MI: Mosby National Institute of Health. US Dept. of Health and Human Services. National Health, Blood, and Lung Institute. Anemia. Retrieved on August 3, 2011 from http://www.nhlbi.nih.gov/health/dci/Diseases/anemia/anemia_links.html Carolyn Jenkins MSN, RN-BC 6/08 updated 8/2011