Edward Atkins

10/28/2014

1.
Evaluate the patients admitting history and physical. Are there any signs or
symptoms that support the diagnosis of anemia?
In the chief complaint section when she was admitted she complained of using the
restroom where she noticed a small amount of vaginal bleeding and had abdominal
pain for the next hour after. She is also pregnant which can cause an increase need
for iron in the body. Lack of iron in the diet can lead to an anemia. She also reported
being short of breathe which is a sign of an anemia present. She says she is more
tired during this pregnancy than other previously this could be because anemia
causes fatigue in the body

2.
What laboratory values or other tests support this diagnosis? List all abnormal
values and explain the likely cause for each abnormal value.
Her red blood cell count is low- 3.8x103/mm3, recommended level is 4.2-5.4 for
females.

This allows us to determine if an anemia exists in the patient.

Hemoglobin is low- 9.1 g/dl, the recommended level is 12-15 for females.

Hematocrit is low- 33%, recommended level is 37-47% for females.

Mean Cell Volume is low-72m3, recommended level is 80-96 m3.
Retic is low, .2%, recommended level is 0.8 to 2.8%
Mean Cell Hgb is low 22pg, the recommended level is 26-32pg.
RBC distribution is high, 22% the recommended level is 11.6 to 16.5%.
Platelet count is high, 282mm3, the recommended level is 140-440
Total Iron binding capacity is high- 465dL, the recommended level is 240-450dL.
Ferritin is low- 10dL, the recommended level is 20-120 for females.
ZPP is high-84mol, the recommended level is 30-80mol.

Folate is low- 2dL, the recommended level is 5-25.

3.
Mrs. Morriss physician ordered additional lab work when her admitting CBC
revealed a low hemoglobin. Why is this a concern? Are there normal changes in
hemoglobin associated with pregnancy? If so, what are they? What other
hematological values, if any, normally change in pregnancy?
This is very important because hemoglobin is the protein in red blood cells that
carries oxygen to other cells in our body. During pregnancy mild anemia can be
expected because of increased overall blood volume however many women lack the
iron to get through the 2nd and 3rd trimester. When your body lacks iron it becomes
anemic. This could possibly be a concern

4.
There are several classifications of anemia. Define each of the following:
megaloblastic anemia, pernicious anemia, normocytic anemia, microcytic anemia,
sickle cell anemia, and hemolytic anemia.
Megaloblastic anemia- Red blood cells produced when the body doesnt get enough
B12. The cells are bigger than normal and cannot transport hemoglobin as
efficiently.
Pernicious Anemia- can't absorb enough vitamin B12 from food. This is because
they lack intrinsic factor, a protein made in the stomach. A lack of this protein leads
to vitamin B12 deficiency.
normocytic anemia- is a decrease production of normal sized red blood cells,
increase of HbS as seen in sickle cell anemia, increase in plasma volume, B2 and B6
deficiency. This type of anemia has a mean corpuscular volume of 80-100 which is
within normal range but the hematocrit and hemoglobin levels are decreased.
Microcytic anemia- small red blood cells present in blood, seen in pap smear results
and most likely is caused by iron deficiency.
Sickle Cell anemia- a heredity form of anemia in which the bodies blood cells are
distorted into a crescent shape at low oxygen levels. Most common in African
descent.

5.
What is the role of iron in the body? Are there additional functions of iron
during fetal development?

65 to 75% of the iron in the body is hemoglobin which is vital for the transport of
oxygen throughout the body to other cells. Myoglobin carries oxygen to muscles and
also requires iron to operate.
During pregnancy the mothers need to take in more iron because the amount of
blood in the body increases as a whole. The fetus and placenta requires extra iron to
operate efficiently. This correlates to an increase need for iron in the diet, especially
in the second and third trimester when iron reserves run low. USRDA recommends
women have 18mg of iron per day and say pregnant women should have 30mg per
day. Iron-deficiency anemia during pregnancy is associated with preterm delivery,
low birth weight, and infant mortality.
http://my.clevelandclinic.org/health/diseases_conditions/hic_Am_I_Pregnant/hic_Goo
d_Nutrition_During_Pregnancy_for_You_and_Your_Baby/hic_Increasing_Iron_in_Your_D
iet_During_Pregnancy

6.
Several stages of iron deficiency actually precede iron-deficiency anemia.
Discuss these stagesincluding the symptomsand identify the laboratory values
that would be affected during each stage.

7.
What potential risk factor(s) for the development of iron-deficiency anemia can
you identify from Mrs. Morriss history?
Iron-deficiency anemia during pregnancy is associated with preterm delivery, low
birth weight, and infant mortality.

8.
What is the relationship between the health of the fetus and maternal iron
status? Is there a risk for the infant if anemia continues?

9.
Discuss the specific nutritional requirements during pregnancy. Be sure to
address all macro- and micronutrients that are altered during pregnancy.
During pregnancy a mother is required to intake more nutrients.
Iron- RDA recommends 27 mg, do not exceed 45 mg.
Baby Benefits- Helps prevent premature delivery.
Mother Benefits- Wards off anemia in pregnant women.
Calcium- RDA recommends 1000mg per day but not to exceed 2500mg.

Baby benefits- builds bone and teeth

Mother benefits- protects against bone disease and also could prevent high
blood
pressure while pregnant.
Choline- RDA recommends 450 mg per day, do not exceed 3,500 mg.
Baby Benefits- Helps prevent problems in the spinal cord and brain, called
neural tube
defects, and enhances brain development.
Mother benefits-Builds strong bones and may help prevent high blood
pressure.
Docosahexaenoic Acid (DHA) one of the omega-3 fatty acids. RDA recommends
300mg per day.
Baby Benefits: Helps boost brain development and vision.
Mother benefits-May reduce your risk of heart disease in the future.
Folic acid- RDA recommends 600mcg per day.
Baby Benefits- Helps protect against spinal cord birth defects during the first
30 days
of pregnancy, helps prevent early miscarriage and premature
delivery.
Mother benefits- Prevents anemia.
Iodine- RDA recommends 250 mcg per day, do not exceed 1,100 mcg.
Baby Benefits- Needed for brain and nervous system development; important
for
preventing stunted growth, severe mental disability, and deafness;
important in
preventing miscarriage and stillbirth.
Mother Benefits- Important for a healthy thyroid.
Potassium- RDA recommends 4,700 mg per day.
fluid

Mother Benefits- Helps keep blood pressure in check and maintain proper
balance; necessary for normal heart beat and energy.

Riboflavin- RDA recommends 1.4 mg per day.

Mother Benefits- Needed to produce energy; helps your body use the protein
from
food.
Vitamin B6- RDA recommends 1.9 mg per day.
Mother Benefits- Helps produce protein for new cells, boosts the immune
system, and
helps form red blood cells.

Vitamin B12- RDA recommends 2.6 mg per day.

and

Mother Benefits: Helps produce red blood cells and helps your body use fat
carbohydrates for energy.

Vitamin C- RDA recommends 85 mg per day, do not exceed 2000 mg.

Mother Benefits- Makes it easier for your body to absorb iron from plant
foods; builds
strong bones and teeth; boosts immunity; keeps blood
vessels strong and red blood
cells healthy.
Vitamin D- RDA recommends 600 IU per day, do not exceed 4000 IU.
Baby Benefits- Helps your baby's body use calcium to build bones and teeth.
Mother Benefits- Helps your body absorb calcium from food and use it to
build your
bones and teeth.
http://www.webmd.com/baby/pregnancy-diet-nutrients-you-need?page=2

10. What are best dietary sources of iron? Describe the differences between heme
and nonheme iron.
Whole Grain Total Cereal, 3/4 cup -- 22 mg
Cheerios, 1 cup -- 10 mg
Enriched rice, 1 cup cooked -- 8 mg
Canned white beans, 1 cup -- 8 mg
Beef, 3 oz cooked -- 3 mg
Lamb, 3 oz cooked -- 2 mg
White meat chicken, 3 oz. cooked -- 1 mg
The difference between heme iron and non heme iron is that heme iron comes from
animals where iron is attached to the protein called heme protein. In plants it isn't
connected to heme protein so it is called non-heme iron. Heme iron is absorbed 735% and non hem iron is absorbed at a rate 2-20%.
http://whfoods.org/genpage.php?tname=dailytip&dbid=347
11. Explain the digestion and absorption of dietary iron.
When iron is digested in the body it is mainly absorbed through the duodenum via
active transport using protein DMT-1, heme iron is absorbed by the enterocyte.

Once inside iron can bind to ferritin or it can leave the enterocyte via basolateral
transporter known as ferroportin.
http://courses.washington.edu/conj/bess/iron/iron.htm

12. Assess Mrs. Morriss height and weight. Calculate her BMI and % usual body
weight.

13. Check Mrs. Morriss prepregnancy weight. Plot her weight gain on the maternal
weight gain curve. Is her weight gain adequate? How does her weight gain compare
to the current recommendations? Was the weight gain from her previous
pregnancies WNL?

14. Determine Mrs. Morriss energy and protein requirements. Explain the rationale
for the method you used to calculate these requirements.

15. Using her 24-hour recall, compare her dietary intake to the energy and protein
requirements that you calculated in Question 14.

16. Again using her 24-hour recall, assess the patients daily iron intake. How does
it compare to the recommendations for this patient (which you provided in question
#9)?

17. Identify the pertinent nutrition problems and the corresponding nutrition
diagnoses.
Mrs. Morris came explaining she was pregnant with her third child and is
experiencing shortness of breathe and more than normal fatigue. Her lab work
came back showing very low blood work across the board.
18. Write a PE S statement for each nutrition problem.

19. Mrs. Morris was discharged on 40 mg of ferrous sulfate three times daily. Are
there potential side effects from this medication? Are there any drugnutrient
interactions? What instructions might you give her to maximize the benefit of her
iron supplementation?
The effectiveness of ferrous sulfate can be increased by combining it with an
ascorbic acid such as vitamin c (Orange juice) and with meat containing amino
acids with MFP factor.
20. Mrs. Morris says she does not take her prenatal vitamin regularly. What
nutrients does this vitamin provide? What recommendations would you make to her
regarding her difficulty taking the vitamin supplement?

21. List factors that you would monitor to assess her pregnancy, nutritional, and
iron status.
In regards to the the pregnancy status you want to monitor the patients nutritional
and iron status. To have a better understanding of patients overall health you should
monitor beverage intake, food intake, total energy intake, types of food, meal
pattern, food variety, prenatal vitamin intake in regards to folate, B6, B12, vitamins
A, C, D, K. You should also monitor to ensure they are getting proper nutrient intake
such as calcium, iron and zinc. You may also want to monitor how educated they
themselves are in relation to iron-deficiency anemia. You can also request the run
an all inclusive nutritional anemia profile. You should also monitor the amount of
fatigue reported by the patient, using the other pregnancies as baseline.

22. You note in Mrs. Morriss history that she received nutrition counseling from the
WIC program. What is WIC ? Should you refer her back to that program? What are
the qualifications for enrollment? Are there any you can confirm for her referral?
Factors you wan
http://www.mayoclinic.org/diseases-conditions/iron-deficiencyanemia/basics/symptoms/con-20019327
http://www.everydayhealth.com/heart-health/anemia.aspx