patient case for school of nursing

· Mean corpuscular hemoglobin (MCH), is a measure of the average amount of hemoglobin per red blood cell.IN this case is slightly low.

RDW 15.6%- Abnormal Finding - Adult: variation of 11%–14.5%.

· Red Blood Cell Distribution Width is essentially an indicator of the degree of anisocytosis, a blood condition characterized by RBCs of variable and abnormal size.

Clinical Significance of Increased RDW can be an indicator of: Iron-deficiency anemia

Fe 30 mcg/dL-Abnormal Finding - Female: 60–160 mcg/dL. Decreased Serum Iron Levels can be because of:

· Insufficient dietary iron: Because all body iron is from dietary intake, a persistently reduced intake will lead to reduced serum levels.

· Because all body iron is from dietary intake, a persistently reduced intake will lead to reduced serum levels. Patient reports poor intake, and not been able to eat properly.

· Iron-deficiency anemia: This anemia results when iron and iron stores become depleted.

Iron deficiency results in a decreased production of hemoglobin, which in turn results in a small, pale (microcytic, hypochromic) RBC.

Ferritin 8 mg/dl -Abnormal Findings- 10–150 mcg/L (SI units)

· Decreases in ferritin levels indicate a decrease in iron storage associated with iron-deficiency anemia.

· A ferritin level of below 10 mg/100 mL is diagnostic of iron-deficiency anemia.

· A decrease in serum ferritin level often precedes other signs of iron deficiency, such as decreased iron levels or changes in red blood cell (RBC) size, color, and number.

· Only when protein depletion is severe can ferritin be decreased by malnutrition.

Folate 188 ng/mL Abnormal Findings 5–25 ng/mL

· This test quantifies the folate level in the blood. It is used in patients who have megaloblastic anemia. It is also used to assess nutritional status, especially in alcoholics.

c) Based on these results and her history. What would be your patient’s diagnosis?

Based on her results, clinical presentation, and physical examination I can said the patient has Anemia.

Anemia is defined as a reduction in the number of red blood cells (RBCs), hemoglobin concentration, or hematocrit. In general, a hemoglobin concentration in adults below 13.6 g/dL for men or below 12 g/dL for women suggests anemia. Although certain signs and symptoms are sometimes associated with anemia, the diagnosis is often based on laboratory data alone. In this case, patient reports increasingly tired, apparently with decrease in exercise tolerance, and not been able to eat properly due economic situation which is an indication of nutritional deficiencies. However, she slept well at night, and denies dyspnea or palpitations, as well upon assessment vital signs WNL. In addition, the fecal occult blood test to check for blood in the stool which it would suggest bleeding in the GI tract was negative, and not further testing was required.

Anemia is more common in individuals older than 65 years. The most common cause of anemia in the elderly is anemia of chronic disease (ACD), followed by nutritional deficiencies (iron, B12, folate), and possibly, decreased marrow response to erythropoietin.

A CBC with differential is the most important laboratory test. IDA is commonly discovered incidentally during a routine CBC. Once IDA is diagnosed, the history may reveal factors that would cause iron deficiency, such as a recent hemorrhage, GI bleeding, menorrhagia, multiple pregnancies, or inadequate nutrition.

Iron Deficiency Anemia (IDA) is the most common type of anemia in the world and the most common nutrient deficiency. In the adult population, IDA predominantly affects women of reproductive age and older adults. Dietary iron is absorbed in the duodenum of the small intestine. The amount of iron absorbed from the intestine is determined by several factors, including the iron content of the meal, the form of iron being ingested, the individual's iron status, and the presence or absence of other substances that can enhance or inhibit iron absorption.

When iron requirements increase or intake declines, the small intestine increases absorption of iron to meet the increased demand. If there is no additional supply of iron to meet this increased demand, the body's iron stores begin to be depleted. At this point, several hematologic parameters are affected. The ferritin levels decline as body iron stores decrease. As body iron stores are depleted, the transferrin saturation decreases, leading to a reduced supply of iron to the RBC precursors, resulting in impaired (iron-deficient) erythropoiesis. At this stage, however, an overt microcytic anemia may not yet be present. Once the iron stores are truly depleted and no iron is available for erythropoiesis, an overt microcytic, hypochromic anemia is present, which manifests in the CBC by a low hemoglobin concentration. The RBC indices are the last to change (decreased MCV, MCH, and MCHC). However, the RDW may be elevated well before the MCV decreases as it reflects the newer, smaller RBCs entering the circulation

d) Epidemiologically speaking, what individuals are at risk for this condition?

You may be at increased risk for iron deficiency at certain ages:

· Infants between 6 and 12 months, especially if they are fed only breast milk or are fed formula that is not fortified with iron. The iron that full-term infants have stored in their bodies is used up in the first 4 to 6 months of life. Babies who were born prematurely may be at an even higher risk, as most of a newborn’s iron stores are developed during the third trimester of pregnancy.

· Children between ages 1 and 2, especially if they drink a lot of cow’s milks. Cow’s milk is low in iron.

· Teens, who have increased need for iron during growth spurts.

· Older adults, especially those over age 65.

Certain lifestyle habits may increase your risk for iron-deficiency anemia, including vegetarian or vegan eating patterns. Not eating enough iron-rich foods, such as meat and fish, may result in you getting less than the recommended daily amount of iron.

e) What other signs and symptoms of this condition would you assess for in this case?

The presentation of anemia can be variable, depending on the acuteness of onset and the ability of the cardiopulmonary system to compensate. If the patient is healthy and the onset of anemia is gradual, there are few signs or symptoms until the hemoglobin value falls below 7.5 g/dL. Patients may initially experience fatigue, malaise, headache, dyspnea, irritability, and a mild decrease in exercise tolerance. Further declines in hemoglobin concentration may be associated with a markedly reduced exercise capacity, resting tachycardia, and dyspnea requiring supplemental oxygen. Other nonspecific findings that can accompany long-term, moderate to severe anemia include wide pulse pressure, midsystolic or pansystolic murmur, confusion, lethargy, brittle nails, glossitis, angular cheilitis, and spoon-shaped nails. Pallor of the mucous membranes, lips, conjunctivae, nail beds, and palmar creases is a common sign of anemia. Also, symptoms of increased bruising may be a clue to a potential bleeding disorder contributing to blood loss and iron deficiency.

f) Which question would best help you determine the impact of fatigue on her activities of

daily living?

a. Are you upset about feeling more tired?

b. Do you sleep more now that you used to?

c. How far can you walk until you get SOB?

d. Have you been able to do what you would like to do?

Fatigue is an overwhelming, sustained sense of exhaustion with decreased capacity for physical

and mental work at a usual level. Therefore, the best means to assess how fatigue is affecting

all areas of life are by determining whether the patient too tired to take part in daily activities,

relationships, social events, and community activities.

g) Discuss the treatment option for her diagnosis

The most appropriate treatment protocols will depend upon the underlying cause. In instances where the problem is precipitated by a relatively simple explanation such as a nutritional deficiency, ingesting iron or other appropriate supplements or tailoring a diet rich in that nutrient might resolve the issue.

Iron replacement therapy with 60 to 120 mg of elemental iron daily is indicated if hemoglobin is less than 11 g/dL, along with an increase in iron-rich food intake.

The usual adult therapeutic dose is 150 to 200 mg of elemental iron per day in divided doses until anemia is corrected. Lower doses may still be effective and be better tolerated. If the anemia is severe, the patient has an iron malabsorption problem, or oral iron is not tolerated, replacement should be by parenteral (intramuscular or intravenous) administration of iron. In this case, the patient should be referred to a hematologist for intravenous administration of iron because it has traditionally been associated with adverse reactions. The intravenous iron formulations, iron carboxymaltose and ferumoxytol, have a much safer profile than older preparations.

Most patients with IDA are diagnosed and treated by their primary health care providers. Patients who are referred to a hematologist for consultation generally return to the primary health care provider once the anemia has been corrected, or at least once an accurate diagnosis has been made and the patient is receiving stable iron replacement therapy.

Referral to a hematologist should be considered if there are not adherence to treatment or exist an intolerance of oral iron replacement, persistent IDA necessitating parenteral iron therapy, and persistent microcytic anemia despite iron replacement and the exclusion of other conditions.

Nonpharmacologic Management.

Dietary assessment, including types of foods and timing of ingestion, is essential when treating nutritional causes of IDA. Individuals with restrictive diets, such as vegetarian and vegan diets, may need nutritional counseling to assist them in choosing iron-rich foods that are in keeping with their belief and practices. Other referrals may be required as evaluation for the cause of the iron deficiency progresses, such as referral to an internist or gastroenterologist to exclude any GI malabsorption, however, in this case, may will need a referral to social worker for financial assistant to help to provide de financial aid to buy nutritional products.

h) What diet you would recommend her:

a. Whole-wheat pastas and skim milk

b. Lean cuts of poultry, pork and fish

c. Beans and dark green, leafy vegetables

d. cooked cereals, such as oats and bananas.

I would recommend leafy greens, especially dark ones, are among the best sources of nonheme iron. Meat and poultry. All meat and poultry contain heme iron. Red meat, lamb, and venison are the best sources. Poultry and chicken have lower amounts. Beans are good sources of iron for vegetarians and meat eaters alike. They’re also inexpensive and fortified foods. Many foods are fortified with iron.

Iron from animal sources is absorbed better by the body. However, you can help your body absorb plant-based iron by eating a fruit or vegetable that is high in vitamin C (for example, red bell peppers, kiwis, oranges).

i) What would be your initial supplement for this patient? (be specific about the name,

dose, frequency, etc.)

The recommended dietary allowance (RDA) includes the iron you get from both the food you eat and any supplements you take for women after 51 years is 8mg/day.

Pharmacologic Management.

· Ferrous sulfate 325 mg TID by mouth

· Vitamin C 500 mg by mouth daily to improve iron absorption.

The usual adult therapeutic dose is 150 to 200 mg of elemental iron per day in divided doses until anemia is corrected. Lower doses may still be effective and be better tolerated. Although the traditional dosage of ferrous sulfate is 325 mg (65 mg of elemental iron) orally three times a day, lower doses (eg, 15-20 mg of elemental iron daily) may be as effective and cause fewer side effects. To promote absorption, patients should avoid tea and coffee and may take vitamin C (500 mg ) with the iron pill once daily. If ferrous sulfate has unacceptable side effects, ferrous gluconate, 325 mg daily (35 mg of elemental iron) is a possible alternative for patients who cannot tolerate ferrous sulfate.

Nonpharmacologic Management

Patients with mild to moderate anemia usually have mild symptoms aspects to their care are safeguarding adequate rest, hydration, and a well-balanced diet that provides adequate vitamin and mineral intake.

j) What teaching you would you provide your patient about the supplement you just prescribed above

Patients should receive education about the use of iron supplements to ensure adequate treatment and an understanding of the prescribed regimen. Iron absorption is optimum when iron is taken 30 minutes before meals with ascorbic acid. Absorption can be reduced by as much as 40% to 50% if it is taken with meals; however, iron on an empty stomach can cause more side effects, leading to noncompliance with medication. Calcium can significantly inhibit iron absorption. Multivitamins with calcium or dairy products should be taken 1 to 2 hours after an iron supplement. Ascorbic acid enhances absorption of iron; therefore, concurrent ingestion of foods rich in vitamin C, such as orange juice, should be encouraged.

Discussion of side effects, such as constipation and nausea, should be included in the treatment plan along with strategies for management of these complaints (stool softeners, taking iron at bedtime). Anticipatory guidance should also include notice that stool may become a dark tar color. Patients who are intolerant of one preparation may find another that produces fewer or no side effects. As a health care provider will encourage the patient to try various preparations before recommending parenteral iron. For most people, a good diet provides enough iron.

Taken at normal doses, iron supplements may cause upset stomach, stool changes, and constipation.

Iron can interact with many different drugs and supplements. Review the list of medication with your health care provider if you have a chronic health condition or are taking out of counter medications such as antacids, antibiotics, calcium, and others.

REF:

Buttaro, T. M., PolgarBailey, P., SandbergCook, J., Trybulski, J. (022020). Primary Care, 6th Edition. [[VitalSource Bookshelf version]]. Retrieved from vbk://9780323570152

Pagana, K. D., Pagana, T. J. (20171031). Mosby's Manual of Diagnostic and Laboratory Tests - Elsevier eBook on VitalSource, 6th Edition. [[VitalSource Bookshelf version]]. Retrieved from vbk://9780323446624

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