I.

Vitamin B12 deficiency anemia

Vitamin B12 deficiency anemia is a condition in which your body does not have enough healthy red blood cells,
due to a lack (deficiency) of vitamin B12. This vitamin is needed to make red blood cells, which carry oxygen to all parts of
your body. Without enough red blood cells, your tissues and organs don’t get enough oxygen. Without enough oxygen,
your body can’t work as well.
Folic acid, also called folate, is another B vitamin. Anemias caused by a lack of vitamin B12 or a lack of folate are 2
types of megaloblastic anemia. With these types of anemia, the red blood cells don’t develop normally. They are very
large. And they are shaped like an oval, not round like healthy red blood cells. This causes the bone marrow to make
fewer red blood cells. In some cases the red blood cells die sooner than normal.
A. Causes
 Lack of intrinsic factor
 Surgery that removes or bypasses the end of the small intestine
 The inability to make intrinsic factor may be caused by several things, such as:
o Chronic gastritis
o Surgery to remove all or part of the stomach (gastrectomy)
o An autoimmune condition, where the body attacks its own tissues
B. Signs & Symptoms
 Weak muscles
 Numb or tingling feeling in hands and feet
 Trouble walking
 Nausea
 Decreased appetite
 Weight loss
 Irritability
 Lack of energy or tiring easily (fatigue)
 Diarrhea
 Smooth and tender tongue
 Fast heart rate
C. Diagnostic/Labs
This type of anemia is usually found during a medical exam through a routine blood test. Your healthcare
provider will take your medical history and give you a physical exam.
Your provider may give you additional blood tests. You may also have other evaluation procedures, such as a
bone marrow biopsy.
D. Treatment
 Folate deficiency anemia: Treatment involves eating a healthy diet and taking folic acid supplements as
prescribed by your doctor. In most cases, folic acid supplements are taken orally.
 Vitamin B-12 deficiency anemia, including pernicious anemia: For milder cases of vitamin B-12 deficiency,
treatment may involve changes to your diet and vitamin B-12 supplements in pill form or as a nasal spray.
Your doctor may suggest vitamin B-12 injections, particularly if your vitamin B-12 deficiency is severe.
 Vitamin C deficiency anemia: Treatment for anemia related to vitamin C deficiency is with vitamin C tablets.
Additionally, you increase your intake of foods and beverages that contain vitamin C.
E. Nursing Management
1. Fatigue
 Assess the specific cause of fatigue
 Assess the client’s ability to perform ADLs
 Monitor hemoglobin, hematocrit, RBC count
 Educate energy-conservation techniques
 Provide supplemental oxygen therapy, as needed
2. Risk for infection
 Assess for local or systemic signs of infection, such as fever, chills, swelling, pain, and body malaise
  Monitor WBC count
 Instruct the client to avoid contact with people with existing infections
 Teach the client and visitors proper hand washing
3. Risk for bleeding
 Assess the skin for bruises and petechiae
 Assess for any bleeding from the nose, gums, urinary or GI tract
 Monitor platelet count
 Instruct the client about bleeding precautions
II. Folic Acid deficiency anemia
Folate, or folic acid, is a type of B vitamin. It helps to:
 Make DNA
 Repair DNA
 Produce red blood cells (RBCs)
If you don’t have enough folate in your diet, you may end up with a folate deficiency. Certain drinks and foods,
such as citrus juices and dark green vegetables, are particularly good sources of folate. Not eating enough folate can lead
to a deficiency in just a few weeks. Deficiency may also occur if you have a disease or genetic mutation that prevents
your body from absorbing or converting folate to its usable form.
Folate deficiency can cause anemia. Anemia is a condition in which you have too few RBCs. Anemia can deprive
your tissues of oxygen it needs because RBCs carry the oxygen. This may affect their function. Folate is particularly
important in women of childbearing age. A folate deficiency during pregnancy can lead to birth defects.
A. Causes
Folate is a water-soluble vitamin. It dissolves in water and isn’t stored in your fat cells. This means that you need
to keep taking folate, as your body can’t develop a reserve. People release excess amounts of water-soluble vitamins
in their urine.
 Diet – A diet low in fresh fruits, vegetables, and fortified cereals is the main cause of folate deficiency. In
addition, overcooking your food can sometimes destroy the vitamins. Folate levels in your body can become
low in just a few weeks if you don’t eat enough folate-rich foods.
 Disease
Diseases that affect absorption in the gastrointestinal tract can cause folate deficiencies. Such diseases
include:
o Crohn’s disease
o Celiac disease
o Certain types of cancers
o Severe kidney problems that require dialysis
 Genetics – Some people have a genetic mutation that hinders their body from properly and efficiently
converting dietary or supplemental folate to its usable form, methylfolate.
 Medication side effects
Certain medications can cause folate deficiency. These include:
o Phenytoin (Dilantin)
o Trimethoprim-sulfamethoxazole
o Methotrexate
o Sulfasalazine
 Excessive alcohol intake – Alcohol interferes with folate absorption. It also increases folate excretion
through the urine.
B. Signs & Symptoms
 Fatigue
 Gray hair
 Mouth sores
 Tongue swelling
 Growth problems
 C. Diagnostics/Labs
Folate deficiency is diagnosed with a blood test. Doctors will often test the folate levels of pregnant women
during their prenatal checkups.
D. Treatment
Treatment involves increasing the dietary intake of folate. You can also take a folate or folic acid supplement.
Those with a genetic mutation that affects folate absorption, known as MTHFR, need to take methylated folate in
order to avoid deficiency.
E. Nursing management
1. Fatigue
 Assess the specific cause of fatigue
 Assess the client’s ability to perform ADLs
 Monitor hemoglobin, hematocrit, RBC count
 Educate energy-conservation techniques
 Provide supplemental oxygen therapy, as needed
2. Risk for infection
 Assess for local or systemic signs of infection, such as fever, chills, swelling, pain, and body malaise
 Monitor WBC count
 Instruct the client to avoid contact with people with existing infections
 Teach the client and visitors proper hand washing
3. Risk for bleeding
 Assess the skin for bruises and petechiae
 Assess for any bleeding from the nose, gums, urinary or GI tract
 Monitor platelet count
 Instruct the client about bleeding precautions
III. Iron deficiency anemia
Iron deficiency anemia is a common type of anemia — a condition in which blood lacks adequate healthy red blood
cells. Red blood cells carry oxygen to the body's tissues.
A. Causes
 Blood loss – Blood contains iron within red blood cells. So if you lose blood, you lose some iron. Women with
heavy periods are at risk of iron deficiency anemia because they lose blood during menstruation. Slow,
chronic blood loss within the body — such as from a peptic ulcer, a hiatal hernia, a colon polyp or colorectal
cancer — can cause iron deficiency anemia. Gastrointestinal bleeding can result from regular use of some
over-the-counter pain relievers, especially aspirin.
 A lack of iron in your diet – Your body regularly gets iron from the foods you eat. If you consume too little
iron, over time your body can become iron deficient. Examples of iron-rich foods include meat, eggs, leafy
green vegetables and iron-fortified foods. For proper growth and development, infants and children need
iron from their diets, too.
 An inability to absorb iron – Iron from food is absorbed into your bloodstream in your small intestine. An
intestinal disorder, such as celiac disease, which affects your intestine's ability to absorb nutrients from
digested food, can lead to iron deficiency anemia. If part of your small intestine has been bypassed or
removed surgically, that may affect your ability to absorb iron and other nutrients.
 Pregnancy – Without iron supplementation, iron deficiency anemia occurs in many pregnant women
because their iron stores need to serve their own increased blood volume as well as be a source of
hemoglobin for the growing fetus.
B. Signs & Symptoms
 Extreme fatigue
 Weakness
 Pale skin
 Chest pain, fast heartbeat or shortness of breath
 Headache, dizziness or lightheadedness
  Cold hands and feet
 Inflammation or soreness of your tongue
 Brittle nails
 Unusual cravings for non-nutritive substances, such as ice, dirt or starch
 Poor appetite, especially in infants and children with iron deficiency anemia
C. Diagnostics/Labs
 Red blood cell size and color – With iron deficiency anemia, red blood cells are smaller and paler in color
than normal.
 Hematocrit – This is the percentage of your blood volume made up by red blood cells. Normal levels are
generally between 34.9 and 44.5 percent for adult women and 38.8 to 50 percent for adult men. These
values may change depending on your age.
 Hemoglobin – Lower than normal hemoglobin levels indicate anemia. The normal hemoglobin range is
generally defined as 13.5 to 17.5 grams (g) of hemoglobin per deciliter (dL) of blood for men and 12.0 to
15.5 g/dL for women. The normal ranges for children vary depending on the child's age and sex.
 Ferritin – This protein helps store iron in your body, and a low level of ferritin usually indicates a low level of
stored iron.
D. Treatment
 Take iron tablets on an empty stomach – If possible, take your iron tablets when your stomach is empty.
However, because iron tablets can upset your stomach, you may need to take your iron tablets with meals.
 Don't take iron with antacids – Medications that immediately relieve heartburn symptoms can interfere with
the absorption of iron. Take iron two hours before or four hours after you take antacids.
 Take iron tablets with vitamin C – Vitamin C improves the absorption of iron. Your doctor might recommend
taking your iron tablets with a glass of orange juice or with a vitamin C supplement.
F. Nursing management
1. Fatigue
 Assess the specific cause of fatigue
 Assess the client’s ability to perform ADLs
 Monitor hemoglobin, hematocrit, RBC count
 Educate energy-conservation techniques
 Provide supplemental oxygen therapy, as needed
2. Risk for infection
 Assess for local or systemic signs of infection, such as fever, chills, swelling, pain, and body malaise
 Monitor WBC count
 Instruct the client to avoid contact with people with existing infections
 Teach the client and visitors proper hand washing
3. Risk for bleeding
 Assess the skin for bruises and petechiae
 Assess for any bleeding from the nose, gums, urinary or GI tract
 Monitor platelet count
 Instruct the client about bleeding precautions
IV. Anemia of chronic disease
Anemia of chronic disease refers to having low levels of red blood cells as a result of autoimmune diseases (diseases
in which the body’s immune system attacks joints and/or body organs) or other chronic illnesses. Chronic diseases are
those that last longer than 3 months. This condition is also called anemia of inflammation or anemia of inflammation
and chronic disease (AI/ACD).
A. Causes
 Chronic diseases may cause changes in red blood cells, the oxygen-carrying blood cells made by bone
marrow. These changes can cause red blood cells to die sooner and slow down their production.
  In anemia of chronic disease, the iron that is normally recycled from old red blood cells to help make new
red blood cells is retained within a system of cells called macrophages. This limits the amount of iron
available to help create new red blood cells.
 In addition, the way that iron is metabolized within cells is impaired. (Metabolism is a series of organized
chemical reactions needed by the body to survive.)
B. Signs & Symptoms
 Feeling tired or weak
 Having pale skin
 Having shortness of breath
 Sweating
 Being dizzy or feeling faint
 Rapid heartbeat
 Having headaches
C. Diagnostics/Labs
The test looks for a low level of hemoglobin. This substance is the red pigment in the blood that carries oxygen.
A normal hemoglobin level is 12.3-15.3 g/dL for adult women and 14-17.5 g/dL for adult men. A fingerstick test can
be used to measure hemoglobin.
A bone marrow biopsy may also be performed. The bone marrow biopsy is performed in an outpatient setting
under either local anesthesia or light sedation and involves collecting a sample of bone marrow by inserting a needle
into the pelvis. Increased iron stores in the bone marrow, in addition to a low serum iron level, indicate anemia of
chronic disease.
D. Treatment
Blood transfusions may be used when the anemia is especially severe (hemoglobin < 8.0 g/dL). Transfusions are
not used as a long-term therapy because of risks—such as iron overload and potential immune system side effects—
that may increase the risk of getting an infection.
A synthetic form of EPO may be given by subcutaneous (under the skin) shots if EPO levels are reduced. You may
also receive supplemental iron therapy if EPO is used as a treatment. If you are receiving EPO therapy, your
hemoglobin levels will be checked every few weeks to see if it is helping. Usually, therapy is adjusted so that your
hemoglobin levels fall in the 11-12 g/dL range.
E. Nursing management
1. Fatigue
 Assess the specific cause of fatigue
 Assess the client’s ability to perform ADLs
 Monitor hemoglobin, hematocrit, RBC count
 Educate energy-conservation techniques
 Provide supplemental oxygen therapy, as needed
2. Risk for infection
 Assess for local or systemic signs of infection, such as fever, chills, swelling, pain, and body
malaise
 Monitor WBC count
 Instruct the client to avoid contact with people with existing infections
 Teach the client and visitors proper hand washing
3. Risk for bleeding
 Assess the skin for bruises and petechiae
 Assess for any bleeding from the nose, gums, urinary or GI tract
 Monitor platelet count
 Instruct the client about bleeding precautions
References:
https://www.medicinenet.com/pernicious_anemia/article.htm
https://nurseslabs.com/tag/folic-acid-deficiency-anemia/
https://www.mayoclinic.org/diseases-conditions/iron-deficiency-anemia/symptoms-causes/syc-20355034
https://my.clevelandclinic.org/health/diseases/14477-anemia-of-chronic-disease/management-and-treatment
https://www.hopkinsmedicine.org/health/conditions-and-diseases/folate-deficiency-anemia