1.Evaluate the patient’s admitting history and physical.

Are
there any signs or symptoms that support the diagnosis of
anemia?
Yes, there are.
She was much more tired, and she also describes binge short of
breath.
And their Pale skin could be a sign to.
When returns to her dietary intake we discovered that her diet
was poor in nutrients and vitamins, especially iron, and she
didn’t adhere to pregnancy vitamins.
2.What laboratory values or other tests support this diagnosis?
List all abnormal values and explain the likely cause for each
abnormal value.
Test Her values Should be
RBC 3.8 4.2-5.4 F
Hemoglobin 9.1 g/dl 12-15g/dlF
Hematocrit 33% 37-47% F
Mean cell volume 72μm3 80-96μm3F
Total iron binding capacity 465μg/dl 240-450μg/dlF
Ferritin 10μg/dl 20-120μg/dlF

3.Mrs. Morris’s 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?
Yes, there are a normal change in hemoglobin during
pregnancy, when pregnant the blood volume increases to
supply the fetus and pregnancy needs. This causes a decrease
hemoglobin and serum albumin also.
The normal hemoglobin level for non-pregnant women is (12-15
g/dL), when pregnant (11.5 g/dL) is acceptable.
In Mrs. Morris condition her hemoglobin levels dropped lower
than (11.5 g/dL) it was (9.1g/dL).
We should mention that also there is other changes occurred
during pregnancy in concentration serum protein and water-
soluble vitamins lead to its decline, while the concentration of
other lipid such as triglycerides, cholesterol and fee fatty acids
increase.
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.
1.Megaloblastic anemia:
Disturbed synthesis of DNA results breakage of platelets in the
red blood cells and bone marrow
Usually caused by folic acid or vitamin B12 deficiency or both.
2.Pernicious anemia:
A macrocytic, megaloblastic anemia caused by a deficiency of
vitamin B12
Associated with Helicobacter pylori infection .
3.Normocytic anemia:
Decreased the mean cells volume (MCV) from the normal range.
4.Microcytic anemia:
Decrease in size of the red blood cells.
5.sickle cell anemia:
Chronic hemolytic inherited anemia, resulting in defective
hemoglobin synthesis which produces sickled red blood cells
(RBC) that occlusion of small blood vessels.
6.Hemolytic anemia:
Oxidative damage to cells, it’s occurred in newborns, especially
preemies.
5. What is the role of iron in the body? Are there additional
functions of iron during fetal development?
Iron plays a crucial role in the body, particularly in the
production of red blood cells and the transportation of oxygen
throughout the body. It is an essential component of
hemoglobin, the protein in red blood cells that binds to oxygen
and carries it to tissues and organs.
During fetal development, iron serves is necessary for the
formation of the fetal liver, which produces blood cells until the
bone marrow takes over this role. Iron also contributes to the
development of the central nervous system and is involved in
the synthesis of neurotransmitters. Additionally, iron is required
for the growth and development of various organs and tissues
in the fetus.
6.Several stages of iron deficiency actually precede iron-
deficiency anemia. Discuss these stages-including the
symptoms - and identify the laboratory values that would
be affected during each stage?.
:Depletion
Stage l: early negative iron balance, the iron stores in the body
start to become depleted, but the hemoglobin levels remain
.normal. Symptoms in this stage are often absent or mild
:Laboratory values that may be affected in this stage
Serum ferritin: Serum ferritin levels are the most sensitive
.indicator of iron stores
Stage ll : iron stores continue to deplete, the production of
(RBC) is affected, the hemoglobin concentration remains within
.the normal range
:Symptoms in this stage may include
.Fatigue (Weakness), Decreased exercise tolerance
:Laboratory values that may be affected include
mean cell volume, the average size of (RBC) may start to )MCV(
.decrease, indicating smaller (RBC)
Transferrin saturation, (a protein that carries iron)
.transferrin saturation may decrease
:Deficiency
Stage lll : inadequate body iron, dysfunction, and disease. if
iron deficiency continues to progress, it eventually leads to iron
deficiency anemia, which is characterized by decreased
:hemoglobin levels and smaller (RBC). Symptoms in this stage
fatigue, Shortness of breath, Rapid heartbeat, Pale skin,
.Weakness, Dizziness
:Laboratory values that may be affected include
Hemoglobin (Hb): Hemoglobin levels decrease, resulting in
.anemia
Mean cell volume (MCV): MCV continues to decrease,
.indicating smaller red blood cells
Ferritin: Ferritin levels decrease, indicating severely
.depleted iron stores
.Stage lV:Clinical damage, Iron deficiency anemia
Iron stores are insufficient to maintain (RBC) synthesis,
leading to anemia, Iron deficiency anemia is characterized
by a significant reduction in hemoglobin levels and a
.decrease in (MCV), Dysfunction and anemia are present
Symptoms in this stage: severe fatigue, defects in epithelial
tissues, gastritis, anorexia and pica, koilonychia – a sign of
.iron deficiency
.If sever, cardiovascular and respiratory changes
:laboratory values affected
all the same as stage lll plus Erythrocytes, these values are
.affected on much larger range then all the other stages
What potential risk factor(s) for the development of iron-.7
deficiency anemia can you identify from Mrs. Morris’s
?history
Pregnant women require increased iron intake to support
the growing fetus and the expansion of their own blood
.volume
Return to her diet we noticed their intake was not sufficient
.enough for nutrient, protein
.and iron ,
She also mentions that she is a picky eater and does not
.always take prenatal vitamin
.She is a smoker and takes extra caffeine
what is the relationship between the health of the fetus .8
and material iron state? Is there a risk for infant if anemia
?continues
The maternal iron status is directly connected to the fetus's
iron states, it is playing a crucial role in the health of the
.fetus
Iron essential for the production of red blood cells and
oxygen transport, it is important for fetus developing and
.his muscles and neural systems
Anemia during pregnancy can lead to inadequate oxygen
supply to the fetal growth restriction or low birth weight, it
may increase the risk of preterm birth and development
delays in the infant, and can affect the iron stores of the
.newborn
Discuss the specific nutritional requirements during .9
pregnancy. Be sure to address all macro-and micronutrients
.that are altered during pregnancy
:Macronutrient*
Protein: During the first half of the pregnancy the RDA is 0.8
.g/kg/day
The need for protein increases in the second half of the
pregnancy, the RDA is 71g/day, based on 1.1gm/kg/day of pre-
pregnant weight. For each additional fetus 25g/day of
.additional protein is recommended
Carbohydrates:DRI for carbohydrates while pregnant is an
estimated average requirement of 135g/day, The RDA is
.175g/day ,135-175 is the recommended amount
.Fiber: DRI for fiber during pregnancy is 28g/day
Fat: There is no DRI for fat while pregnant, there is however an
AI of 13g/day for omega 6 polyunsaturated fatty acids and an AI
.of 1.4g/day for omega 3 polyunsaturated fatty acids
.Water: 8-10 glasses
:micronutrient*
.Folic Acid: RDA is 600mcg/day
.Vitamin B6: RDA is 1.9 mg/day
.Vitamin B12: RDA is 2.6 mcg/day
.Choline: RDA is 450 mg/day
Vitamin C: RDA is80 mg/day (ages 14-18) , and (85 mg/day ages
.19-50)
Vitamin A: RDA is 750 mcg (2500 IU)/day ages 14-18, and 770
.mcg (2567 IU)/day ages 19-50, should not exceed 3000 IU
.Vitamin D: RDA is 15 mcg/day
.Vitamin E: RDA is15 mg/day
Vitamin K: RDA is 75 mcg/day ages 14-18, and 90mcg/day ages
.19-50
Calcium: RDA is 1300 mg/day ages 14-18 and 1000 mg/day ages
.19-50
.Copper: RDA is 1 mg/day
.Fluoride: RDA is 3mg/day
.Iodine: RDA is 220mcg/day
.Iron: RDA is 27 mg/day
Magnesium: RDA is 400 mg/day ages 14-18, 350 mg/day ages
.19-30, and 360mg/day ages 31-50
Phosphorus: RDA is 1250 mg/day ages 14-18 and 700 mg/day
.ages 19-50
.Sodium: RDA is 1500 mg/day
.Zinc: RDA is 12 mg/day ages 14-18 and 11 mg/day ages 19-50
10.What are best deity sources of iron? Describe the
differences between heme and nonheme iron.
There are several good sources of iron:
1. Red meat: liver, kidney, heart, Beef, lamb, and pork are rich in
heme iron, which is highly absorbable by the body.
2. Poultry: Chicken and turkey are good sources of iron,
especially the dark meat.
3. Fish and seafood: Oily fish like salmon, sardines, and tuna
contain iron, as well as shellfish like clams, mussels, and oysters.
4. Legumes: Beans, lentils, chickpeas, and soybeans are
excellent plant-based sources of iron.
5. Nuts and seeds: Almonds, cashews, pumpkin seeds, and
sesame seeds are good sources of iron.
6. Leafy green vegetables: Spinach, kale, Swiss chard, and
collard greens are rich in iron.
7. Fortified foods: Some cereals, bread, and other grain
products are fortified with iron, making them good options.
Different between heme and nonheme iron:
Heme iron is found in animal-based foods, particularly in red
meat, poultry, and seafood. Non-heme iron, on the other hand,
is found in both plant-based foods and animal-based foods.
Heme iron is generally more easily absorbed by the body
compared to non-heme iron.
Heme iron is bound to a molecule called heme, which gives it a
characteristic red color. Non-heme iron is not bound to heme
and does not have the same red color.
Heme iron can enhance the absorption of non-heme iron when
consumed together in a meal. The presence of heme iron can
help improve the absorption of non-heme iron from plant-
based foods.
heme iron is generally more easily absorbed, a well-balanced
diet can provide sufficient iron from both heme and non-heme
sources. Combining non-heme iron sources with vitamin C-rich
foods can also enhance the absorption of non-heme iron.
.

11.Explain the digestion and absorption of dietary iron.

In the stomach, iron is released from food by the action of
stomach acid (hydrochloric acid), This acid helps convert
iron into a form that can be easily absorbed.
The partially digested food then moves into the duodenum,
the first part of the small intestine. Here, iron encounters
an enzyme called gastric acid protease, which further
breaks down iron complexes.
Iron absorption primarily occurs in the duodenum and
upper part of the small intestine.
12.Assess Mrs. Morris’s height and weight. Calculate her
BMI and % usual body weight.
Height:167.64cm.
Weight: 61.23 kg.
BMI=61.23/(1.67)2=22.91 (normal BMI).
IBW first 150 cm 45kg 2.5 2.25
176.64 – 150 =17.64 cm 15.87kg 17.64 ??
(15.87)
*IBW 45 + 15.87 = 60.87 kg.
%IBW 61.23 / 60.87x100 = 100.59 % .
13.Check Mrs. Morris’s prepregnancy weight. Plot her
weight gain on the maternal weight gain curve. Is her
weight gain adequate? How does her weight gain
comparepto the current recommendations? Was the
weight gain from her previous pregnancies WNL?
In her 23rd week of pregnancy, her weight is 61.23 kg, and her
weight before pregnancy was 64.41 kg, The normal and healthy
weight gain during the 2 trimester of pregnancy is between (11 –
16 kg) from WNL for women of normal weight.
Her weight gain rate during the development of pregnancy was
less than normal, while her weight gain during her previous
pregnancies was somewhat appropriate.
14. Determine Mrs. Morris's energy and protein
requirements. Explain the rationale for the method you
used to calculate these requirements.
*Total Energy Requirement:
TER = BMR + TEF + Physical activity.
1.BMR = 0.9 x 24 x 61.23 = 1322.56 kcal/day.
2.TEF(10%) = 1322.56 x 10% / 100 = 132.25 kcal/day.
3.Physical activity(20%)=1322.56x20/100=264.51kcal/day.
*TEF=1322.56+132.25+264.51=1719.32 kcal/day.
Pregnant in 23rd week + 450 kcal =2169.32 kcal/ day.
*protein (25%) : 2169.32x25/100=542.33.
/4 =135.58 g of protein per day.
15. Using her 24-hour recall, compare her dietary intake to
the energy and protein requirements that you calculated in
Question 14.
Using USDA, the 24-hour recall shows that she is not
eating near enough calories, or protein. She needs to take
more protein and calories to reach her recommended
amount.
16. Again using her 24-hour recall, assess the patient's
daily iron intake. How does it compare to the
recommendations for this patient (which you provided in
question #9)?
Based off recommended amount of iron is 27mg/day for
pregnant woman, in her 24 hours recall she takes a little
less.
For that and based on her test results she should be
monitored and increased her intake from iron to ensure
that she is consuming the correct amount daily.
17. Identify the pertinent nutrition problems and the
corresponding nutrition diagnoses.
she is not consuming enough vitamins and mineral, she is
not getting enough protein, calories and other nutrients.
Her laboratory values that have to do with her nutrition are
not good and the increased nutrition required for her
pregnancy is not being met.
The corresponding nutrition diagnoses would be
inadequate mineral intake, imbalance of nutrients, altered
nutrition laboratory related values and increased nutrition
needs.
18. Write a PES statement for each nutrition problem
Anima related to iron deficiency as evidence by her test
results and poor diet for iron and nutrients.
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 drug-nutrient interactions?
What instructions might you give her to maximize the
benefit of her iron supplementation?
Ferrous sulfate is commonly used as an iron supplement
to treat or prevent iron deficiency anemia. While it is
generally safe and effective, there can be potential side
effects.
It may cause stomach upset, constipation, diarrhea, or
dark-colored stools.
Some individuals may experience nausea and vomiting,
especially if the medication is taken on an empty stomach.
Liquid forms of ferrous sulfate may stain the teeth. It is
recommended to rinse the mouth after taking the
medication to minimize this effect.
Regarding drug-nutrient interactions, it's important to note
that ferrous sulfate can interfere with the absorption of
certain medications and nutrients.
It is advised to take iron supplements at least2 hours
before or4 hours after taking medications such as
antibiotics, antacids, or thyroid medications. Additionally, it
is recommended to avoid taking iron supplements with
calcium-rich foods or beverages, as calcium can hinder
iron absorption.
To maximize the benefits of iron supplementation,
Take the medication as prescribed,take it with food, avoid
consuming it with calcium-rich foods or beverages.
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?
Prenatal vitamins are specifically designed to provide
essential nutrients that support a healthy pregnancy. They
typically contain higher levels of certain vitamins and
minerals that are important for both the mother and the
developing baby.
She’s complaining that the vitamin supplement hurts her
stomach, this is a side effect to some prenatal vitamins,
she can try a different type of supplement, such as the
chewable or liquid vitamins rather than those you swallow
whole.
21. List factors that you would monitor to assess her
pregnancy, nutritional, and iron status.
monitor the following factors to assess her pregnancy,
nutritional, and iron status:
1. Weight gain: Monitoring her weight gain throughout
pregnancy can provide insights into her overall nutritional
status.
2. Dietary intake: Assessing her dietary intake can help
determine if she is consuming a balanced and nutritious
diet. Using such things as a patient food log, 24 hr recall or
direct observation.
3. Iron levels: Regular monitoring of her iron levels,
including hemoglobin and ferritin levels, can help prevent
any deficiencies and guide appropriate supplementation.
4. Folate levels: Folate is crucial for fetal development,
particularly in the early stages of pregnancy. Monitoring
her folate levels can ensure she is getting enough to
support the baby's growth and prevent neural tube defects.
5. Vitamin D levels: Adequate vitamin D is important for
both the mother and baby's health. Monitoring her vitamin
D levels can help identify any deficiencies and guide
supplementation if necessary.
6. Blood pressure: Regular monitoring of blood pressure is
essential to detect any signs of gestational hypertension or
preeclampsia, which can have serious implications for both
the mother and baby.
7. Blood sugar levels: Monitoring blood sugar levels can
help identify gestational diabetes, a condition that can
develop during pregnancy. Proper management of blood
sugar levels is important for the health of both the mother
and baby.
8. Overall health and well-being: Assessing her overall
health and well-being, including any symptoms or
discomforts she may be experiencing, can provide insights
into her pregnancy status and overall nutritional status.
22. You note in Mrs. Morris's 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.
WIC stands for the Special Supplemental Nutrition
Program for Women, Infants, and Children. It is a federal
assistance program in the United States that provides
nutrition education, healthy food, and support to low-
income pregnant women, new mothers, and young
children. The program aims to improve the health and well-
being of these individuals by providing them with nutritious
food options, breastfeeding support, in order to be eligible
a women or child has to be in "Nutritional Risk." The
criteria for the nutritionally at risk may include anemia, poor
gestational weight gain, inadequate diet or Failure To Thrive
)FTT( in the infant or child. She is not only having anemia,
but she also has a low gestational weight gain and an
inadequate diet. I would most definitely refer her back to
the program, so that she could gain the additional help she
needs.