لخّصلي

Discussion
The findings of the present study indicated the positive effect of the nursing care
program supplemented with iron intake on blood parameters and fatigue of the
patients undergoing chemotherapy. It was also shown that the hemoglobin of the
patients in the intervention group increased after the nursing care program and
the severity of their anemia decreased, confirming the effect of training strategies
to increase iron absorption and intake. Similarly, Rezaee Seraji et al. showed that
the hemoglobin concentration of people who did aerobic exercise increased com-
pared to patients who did not perform the aerobic exercise (27). However, the au-
thors emphasized aerobic exercise, and the changes in hemoglobin ratio were not
very noticeable. In contrast, in the present study and physical activity, the patients
received iron and proper nutrition training to increase iron absorption. The re-
sults proved the significant impact of the intervention.
One of the essential issues in treating patients with cancer is maintaining
blood parameters to be within the normal range or close to it. When the patient
refers to chemotherapy, nurses decide to perform or not to perform chemo-therapy after reviewing the results of blood cell counts. Thus, the implementation of the treatment program depends entirely on the patient's blood test results. If the blood count decreases, the treatment program will be stopped, affecting the survival of patients. In cancer control and treatment programs, the management
of blood parameters, including the maintenance of hemoglobin within the nor-mal range, is of great importance. Accordingly, the studies reviewed above indicat-ed that anemia reduces the prognosis of cancer patients (29), influences the effec-tiveness of cancer treatments, and increases the likelihood of tumor cell resis-tance to treatment, which ultimately reduces the survival of the patient (30).
Studies have shown that a decrease in the level of erythrocytes and anemia is
one of the most common and persistent problems in cancer patients (31), and its
severity depends on the extent of the disease and the severity of treatment. It has
been reported that anemia increases the risk of death by 65% in patients with vari-ous cancers (27). Kitano et al. showed that 84% of the patients developed anemia while undergoing chemotherapy and 72% of the patients who had no anemia be-
came anemic during chemotherapy (32). Bernardo's study also found that 73% of
patients developed anemia after starting chemotherapy (33). The prevalence of
anemia was 50% in solid cancers, as reported in Groopman's study and 35% in Se-shardi's study (34, 35). Probably the discrepancies observed in the frequencies re-ported in various studies are due to the type of study, the studied population, and
the definition of anemia. The research sample in the present study included the
patients with mild anemia or no symptoms of anemia, and thus the sample was
different from those examined in previous studies. The results showed that pa-
tients who had attended the nursing care program supplemented with iron in-
take were less likely to have anemia during the treatment. It was also shown that
the patients' hemoglobin level increased by one gram during the intervention, in-
dicating that perhaps one of the factors that can affect the patients' fatigue is the
hemoglobin level since the patients reported lower levels of fatigue after the in-
crease in hemoglobin and iron intake in the form of the nursing care program
that focused on doing exercise and daily activities, as was confirmed in other stud-
ies (36, 37). However, Cella et al. showed that the patients who had a 2-gram in-
crease in hemoglobin reported less fatigue (38). These conflicting results can be
attributed to the differences in the research population, nursing care program,
and other factors. Nevertheless, the results show that improving anemia and he-
moglobin levels can affect the severity of fatigue. Other studies also suggested
that increasing hemoglobin levels reduces the patient's physical fatigue and im-
proves the patient's physical function (38). On the other hand, anemia can lead to
further problems such as fatigue (38, 39).
The present study suggested that a significant reduction in the fatigue scores
of the patients in the intervention group indicated the effectiveness of the nurs-ing care program. Studies have shown that fatigue is one of the most complex and common problems associated with cancer (40, 41). Fatigue in cancer patients may
be caused by the disease process or related treatments called cancer-induced fa-
tigue (42). Among the various cancer treatments, chemotherapy is the most com-
mon cause of fatigue in patients (43). Cancer-induced fatigue in many patients is
so severe that, if left untreated, it disrupts and limits their daily activities (44). In
the present study, a specific tool was used to measure anemia-related fatigue. This
study was also different from other studies in terms of the procedure taken. There-
fore, it is possible to discuss anemia-related fatigue with more confidence. As
shown, the nursing care program with an emphasis on iron intake can significant-
ly affect anemia-induced fatigue. Limited studies have been performed using this
tool, which were primarily descriptive and did not use any intervention. For in-
stance, Ghaffari et al. measured the relationship between the severity of fatigue
and anemia and reported a moderate level of anemia-induced fatigue (24). In Tim-
othy's study, 40% of patients suffered from moderate fatigue (36). Khozimeh et al.
showed that the use of energy-saving strategies significantly reduced the patient's
fatigue compared to the control group and the patients in the intervention group
better managed their fatigue. Their main energy-saving strategy was to create a
balance between the rest and activity times during fatigue induced by the disease
(45). Another study by Abdollahi and Shujaedin suggested that the training proto-
col improved all aspects of the quality of life and increased physical performance
in the intervention group compared to the control group (46), as was evident in
the present study. Despite the effectiveness of exercise in controlling fatigue, stud-
ies have shown that the most frequently used strategies by patients were lying
down (80.7%) and worshiping (77.9%) and the least frequently used strategies were
exercise (5%) and stretching movements (21.4%). Accordingly, it can be argued that
the first thing a person does in the face of an unpleasant feeling, such as fatigue, is
to stop working and taking a rest. Furthermore, patients wrongly believe that
their fatigue increases if they do things such as exercise and walking, and thus
they do these activities less frequently (47). However, according to several studies,
doing exercise plays an essential role in reducing the severity of fatigue (48-50).
The present study also suggested that the severity of fatigue was lower in the
patients in the control group, but it was not significantly different from the fa-
tigue level reported by the participants in the intervention group. One reason is
that supplying iron reserves after taking iron supplements, which was effective in
reducing fatigue in this group of patients. Besides, the participation of the pa-tients in the control group in the treatment program and the emphasis on iron intake can be other reasons that have led to an increase in hemoglobin levels in
the control group