G.C. is a 78-year-old widow who relies on her late husband’s Social Security income for all of her expenses.

Over the past few years, G.C. has eaten less and less meat because of her financial situation and the trouble of preparing a meal “just for me.” She struggles financially to buy medicines for the treatment of hypertension and arthritis. She goes to the outpatient clinic complaining that over the past 2 to 3 months she has felt increasingly tired, despite sleeping well at night. Her vital signs (VS) are 136/76, 16, 80. She denies any dyspnea or palpitations. The nurse practitioner orders blood work. G.C.’s chemistry panel findings are all within normal limits and a stool guaiac test result is negative. Her other results are shown in the chart.

Laboratory Test Results

White blood cell (WBC) count                             7600/mm³

Hematocrit (Hct)                                                  27.3 %

Hemoglobin (Hgb)                                               8.3 mg/dL

Platelets                                                                151,000/mm³

Red Blood Cell (RBC) Indices

Mean corpuscular volume (MCV)                                                            65 mm³                               

Mean corpuscular hemoglobin (MCH)                                                    31.6 pg                                                        

MCH concentration (MCHC)                                                                    35.1 %

Red cell distribution width (RDW)                                                            15.6 %

Iron (Fe)                                                                                                    30 mcg/dL

Total iron-binding capacity (TIBC)                                                          422 mcg/dL

Ferritin                                                                                                      8 mg/dL

Vitamin B₁₂                                                                                               414 pg/mL

Folate                                                                                                        188 ng/mL

1.   Which laboratory values are normal, and which are abnormal?

2.   Explain the significance of each abnormal result.

3.   Based on these results and her history, what condition does G.C. have? 4. What individuals are at risk for this condition?

4.   What individuals are at risk for this condition?

5.   What other signs and symptoms of this condition do you assess for in G.C.?

6.   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 than you used to?

c.     “How far can you walk until you get short of breath?”

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

7.   Discuss the treatment options for her condition.

8.   The physician starts G.C. on ferrous sulfate (Feosol) 325 mg orally once per day. What teaching needs to be done regarding this medication?

MCH concentration (MCHC As you are evaluating your teaching about ferrous sulfate, you determine that additional instruction is needed if G.C. says:

a.  “My stools will likely turn a tarry, black color soon.”

b. “I can take the iron and my calcium supplements at the same time.”

c.  “I will increase my fluid and fiber intake as long as I am on the iron.”

d. “Taking the tablets when I eat my meals will help my stomach not be upset.”

10.  Discuss some ideas that might help her with her meal planning.

11.  You teach G.C. about foods she should include in her diet. You determine that she understands your teaching if she states she will increase her intake of which of the following foods?

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

12.  What evaluative parameters could you use to determine whether G.C.’s condition is improving?

SOLUTION – G.C. 78-year-old widow relies on late husband’s Social Security income

1. Normal and Abnormal Laboratory Values:
   • Normal Values: White blood cell (WBC) count, Hematocrit (Hct), Platelets, Mean corpuscular volume (MCV), Mean corpuscular hemoglobin (MCH), Mean corpuscular hemoglobin concentration (MCHC), Red cell distribution width (RDW), Vitamin B12, Folate.
   • Abnormal Values: Hemoglobin (Hgb), Iron (Fe), Total iron-binding capacity (TIBC), Ferritin.
2. Significance of Abnormal Results:
   • Low Hemoglobin (Hgb), Hematocrit (Hct), and Ferritin indicate iron-deficiency anemia, which can lead to fatigue and weakness.
   • Low Iron (Fe) and Total iron-binding capacity (TIBC) confirm iron deficiency.
3. Diagnosis and Risk Factors:
   • G.C. likely has iron-deficiency anemia due to her low hemoglobin, hematocrit, ferritin, and iron levels, as well as her symptoms of fatigue and weakness.
   • Risk factors for iron-deficiency anemia include poor dietary intake of iron-rich foods, chronic blood loss (e.g., gastrointestinal bleeding), and conditions that impair iron absorption (e.g., celiac disease).
4. Other Signs and Symptoms:
   • Pallor, shortness of breath, dizziness, brittle nails, and headache are additional signs and symptoms of iron-deficiency anemia.
5. Impact of Fatigue on Activities of Daily Living:
   • Option c. “How far can you walk until you get short of breath?” would best help determine the impact of fatigue on her activities of daily living, as it directly assesses her functional capacity.
6. Treatment Options:
   • Treatment for iron-deficiency anemia typically includes oral iron supplementation, dietary modifications to increase iron intake, and addressing underlying causes of iron loss or malabsorption.
7. Teaching about Ferrous Sulfate:
   • Advise G.C. to take ferrous sulfate on an empty stomach to enhance absorption, but if gastrointestinal upset occurs, she can take it with food.
   • Instruct her to avoid taking iron supplements with calcium supplements, as calcium can impair iron absorption.
   • Encourage increased fluid and fiber intake to prevent constipation, a common side effect of iron supplementation.
8. Additional Instruction Needed for Ferrous Sulfate:
   • Option a. “My stools will likely turn a tarry, black color soon.” If G.C. believes this, she needs additional teaching, as black, tarry stools are associated with gastrointestinal bleeding, not iron supplementation.
9. Meal Planning Ideas:
   • Encourage G.C. to include more iron-rich foods in her diet, such as lean meats, poultry, fish, beans, lentils, fortified cereals, spinach, and dried fruits.
10. Dietary Foods to Increase Iron Intake:
    • Option c. Beans and dark green, leafy vegetables are good sources of non-heme iron, which is important for individuals with iron-deficiency anemia.
11. Evaluative Parameters for Improvement:
    • Improvement in symptoms such as fatigue and weakness.
    • Increase in hemoglobin, hematocrit, and ferritin levels on repeat laboratory tests.
    • Resolution of signs of iron deficiency, such as pallor and brittle nails.
    • Increase in energy levels and ability to perform activities of daily living without excessive fatigue.