Patient Name: Addison, Biermer Date oI Admission: July 21, 2011

DOB: 05/19/1986 Wgt: 200lbs ChieI Complaint: Fatigue & Burning oI the mouth and tongue
Admitting Diagnosis: Malnutrition with possible Pernicious Anemia

Data
Nursing Dx Goals Interventions Rational Evaluation
Subjective:
-Tongue is sore and
burning
-Flatulence
-Indigestion
-Dysphagia
-Tingling oI the hands and
Ieet
-DiIIiculty walking
-Weight loss

-I've been having a hard
time staying awake
throughout the day.

'My tongue Ieels like its on
Iire

Objective:
-Smooth erythematous
tongue
-Bleeding gums
-Diarrhea
-InIection oI teeth and
gums
-Mental disorientation-
name
-day
-not oriented to location
'Where am I

Imbalanced nutrition: less
than body requirements

R/T: Sore Mouth
Diarrhea
Constipation

Secondary to:
Pernicious Anemia
1. Prior to discharge:
Patient will be Iree oI signs
oI malnutrition.

-As Evidenced By:
O Progressive weight
gain toward desired
goal
O Patient levels oI
vitamin B12 will be
within the range oI
200 - 900 pg/mL
(picograms per
milliliter)
O Patient alert and
oriented x3

2. Patient will verbalize an
understanding oI the disease
process and the need Ior liIe
time vitamin B12 therapy.

-As Evidenced By:
Patient verbalizing: I will
need to have cobalamin
(B12) injections regularly
Ior the rest oI my liIe to
prevent symptoms oI
anemia.


1. Assess patient vital signs
& signs oI improved
nutritional status
/malnutrition:
-weight gain
-serum B12 levels
-patient cognition
-satiety when eating

2. Plan diet with patient
high in vitamin B12, iron
and protein to promote
production oI healthy
erythrocytes, maximizes
energy
production, and decrease
symptoms oI anemia







3. Patient Teaching:
- Explain the chronic
nature oI pernicious
anemia and vitamin B12
deIiciency and assess
patient understanding oI
nutritional needs.
- Teach and assess
patient understanding oI
how to saIely selI-
administer Vitamin B12
injections and establish
schedule Ior monthly
injections
1. Assessing patient
vitals and nutritional
gains establishes
baseline Ior
assessing
improvements or
changes in tx.


2. A diet rich in
nutrients along with
B12 injections will
provide adequate
amounts oI necessary
nutrients to relieve
symptoms oI anemia.
Including patient in
Iood planning
provides patient with
a sense oI control
and may enhance
nutrition intake.

3. Patient will
understand the need
Ior liIe time
injections oI B12 in
order to maintain
maintenance limits.

B12 injections are
needed to saturate
B12 stores in the
body and resolve
clinical maniIestation
oI the deIiciency,
thereaIter to maintain
remission and
continuity oI care.
Prior to discharge:
-Pt is able to
comIortably remain
active Ior reasonable
amount oI time with
decreased instances oI
Iatigue and is alert and
oriented x3.

-Pt understands
importance oI proper
diet high in protein and
exhibits healthy menu
choice while in
Iacility.

-Patient is receptive to
selI care which
includes proper diet
and selI administering
oI B12 supplements
aIter discharge.