Perniciou

s
Anemia
ALMINAR, Julia
ARCUENO, Princess
ARIZALA, Rowena
ATIENZA, Janella
 Table of
Contents
I. SUMMARY OF THE CASE I. ANY SPECIAL PROCEDURE OR
OPERATION

II. INTRODUCTION OF THE II. FORMULATION OF NURSING

CASE DIAGNOSIS

III. III.
PATHOPHYSIOLOGY PDAR

IV. CORRELATE DOCTOR’S ORDER IV. NURSING SKILLS

TO LABORATORY RESULTS TO [T’S VIDEO
S/SX

V. DISCHARGE
V. DRUG PLAN
STUDY
 I. SUMMARY OF THE
CASE
Gender: Female
Age: 80 years old
Chief Complaint: Malaise for a month
Past Medical History: Hashimoto thyroiditis and Osteoporosis
Personal History: Non-smoker not an alcoholic. No known allergies
Family History: No known medical family history
● Normal vital signs
● In the hospital the patient showed signs and symptoms of:
○ generalized pallor including anemic conjunctiva
○ jaundice on the face
○ bulbar conjunctiva
○ slightly swollen thyroid gland
○ jugular venous distention
○ leg edema
II. INTRODUCTION OF
THE CASE
Pernicious Anemia (PA) is a type of vitamin B12 deficient anemia caused by an autoimmune
illness in which the body fails to create enough intrinsic factors.

Vitamin B12 is required for the formation of red blood cells.

General signs and symptoms of PA include;

● Pale skin or a pale coloration in the tissue that lines the inner of the eyelids (conjunctiva),
● Feeling very tired
● Tachycardia
● Trouble breathing
● Headache
● Muscle pains.
II. INTRODUCTION OF
THE CASE
Signs and symptoms associated with the brain are;
● Problems with memory
● Confusion
● Mood problems
● Tingling or burning feeling on the skin
● Numbness
● Weakness in the arms or legs and
● Trouble with balance

A complete clinical evaluation, including detailed patient history and specific laboratory testing,
can confirm the diagnosis of pernicious anemia.

Vitamin B12 (hydroxocobalamin or cyanocobalamin) is injected into the muscle to treat

pernicious anemia.
III.
PATHOPHYSIOLO
GY
 IV. CORRELATE
DOCTOR’S ORDER TO
THE LABORATORY
RESULTS TO
PATIENT’S SIGNS AND
Complete Blood Count
Result Reference Range Interpretation

WBC 56 × 102/μl 5,000 - 10,000 /μl Normal

Neutrophil 73.5% 50% - 70% Increased

Monocyte 3.7% 3% - 8% Normal

Lymphocyte 21.6% 20% - 40% Normal

Eosinophil 1.2% 0% - 6% Normal

Basophil 0.0% 0% - 0.2% Normal

Red Blood Cell 90 x104 /μl 4.2 - 5.4 x106 /μl Decreased

Hemoglobin 3.6 g/dl 12 - 14 g/μl Decreased

MCV 125.6 fL 80 - 100 fl Increased

MCH 40.0 pg 27.5 - 33.2 pg Increased

MCHC 31.9% 33% Decreased

Platelet 9.4 × 104/μl 15 - 45 × 104/μl Decreased

Serological Test
Result Reference Range Interpretation

LD 3612 IU/l 119–229 IU/L Increased

LD 1 51% 14-26 % Increased

LD2 37% 29-39 % Normal

Indirect bilirubin 2.48 mg/dl 0.2-0.8 mg/dl Increased

HPT < 10 mg/dl 41-165 mg/dl Decreased

● Vitamin B12 Test
○ Result: < 50 pg/ml (below normal range)
○ Normal range: 190-950 pg/m
○ Pernicious Anemia

● Chest X-ray
○ Result: Chest X-ray revealed 60% of cardiothoracic ratio and bilateral
pleural effusions.
○ Malaise and jugular vein distension

● Endoscopy
○ Result: (+) Atrophic Gastritis

● Bone marrow aspiration

○ Result: Hypercellular bone marrow and abnormal erythroblast carrying
megaloblastic change and abnormality of nuclear division
Immunological Test
Result Reference Range Interpretation

Tg Ab > 4000 IU/l <20 IU/l Increased

TPO Ab 397 IU/ml <35 IU/L Increased

Gastric parietal cell Ab Positive

Intrinsic factor antibodies Positive

DAT Positive

Anti IgG Positive

IgG 1802 mg/dl 700-1600 mg/dl Increased

V.
DRUGSTUD
Y
 LEVOTHYROXI
NE
Name Dose, Route, and Mechanism of Action Nursing Consideration
Frequency

Generic Name: Dose: 100μg/day Levothyroxine is a ● Monitor and report signs of excessive or
Levothyroxine synthetic (man-made) inadequate dosing.
Route: Oral Route version of the principle ● Assess heart rate, ECG, and heart sounds,
Brand Name: thyroid hormone, especially during exercise.
Synthroid Frequency: Once a thyroxine (T4) that is ● Report any rhythm disturbances or
day made and released by symptoms of increased arrhythmias,
the thyroid gland. including palpitations, chest discomfort,
Thyroid hormone shortness of breath, fainting, and
increases the metabolic fatigue/weakness.
rate of cells of all ● Assess episodes of angina pectoris at rest
tissues in the body. and during exercise.
● Monitor and report signs of CNS toxicity,
including irritability and sleep loss.
 RISEDRONATE
SODIUM
Name Dose, Route, and Mechanism of Action Nursing Consideration
Frequency

Generic Name: Dose: 2.5mg Risedronatic acid binds to bone ● Lab tests: Baseline and periodic
Risedronate hydroxyapatite. Bone resorption serum calcium, phosphorus, and
Sodium Route: Oral Route causes local acidification, releasing alkaline phosphatase.
risedronic acid which is taken into ● Monitor carefully for and
Brand Name: Frequency: Once a osteoclasts by fluid-phase immediately report S&S of GI
Actenol day endocytosis. Endocytic vesicles are bleeding and hypocalcemia.
acidified, releasing risedronic acid ● Learn administration guidelines
to the cytosol of osteoclasts where regarding upright position, empty
they induce apoptosis through stomach, and spacing relative to
inhibition of farnesyl calcium supplements and antacids
pyrophosphate synthase. Inhibition must be strictly followed.
of osteoclasts results in decreased ● Report any of the following to the
bone resorption. physician: eye irritation,
significant GI upset, or flu-like
symptoms.
 METHYLCOBALA
MIN
Name Dose, Route, and Mechanism of Action Nursing
Frequency Consideration

Generic Name: Dose: 1mg It works by functioning in the production of a ● Obtain a careful
Methylcobalamin compound called myelin, which covers and history of
Route: protects nerve fibers. Methylcobalamin sensitivities.
Brand Name: Intramuscular (I.M.) rejuvenates the damaged neuron. Without enough ● Advice to consult a
Methyl B-12 methylcobalamin, myelin sheath does not form doctor if the patient
Frequency: properly due to which nerve fibers suffer and experienced any
T.I.W for the 1st people experience irreversible nerve damage. An allergic reaction.
week, followed by intrinsic factor made in the stomach must be ● Caution should be
Q.wk. up to 2 present in the intestinal tract to allow its proper exercised in patients
months absorption. People lacking this factor show with history of liver
vitamin B12 deficiencies such as pernicious disease, any allergy,
anemia. Methylcobalamin is used as a cofactor in during pregnancy
methionine transferase enzyme, an enzyme which and breastfeeding.
converts amino acid homocysteine to methionine
via folate cycle.
 SODIUM FERROUS
CITRATE
Name Dose, Route, and Mechanism of Action Nursing Consideration
Frequency

Generic Name: Dose:100 mg Absorbed iron is bound to plasma ● Lab tests: Monitor Hgb and
Sodium Ferrous transferrin and enters the general reticulocyte values during therapy.
Citrate Route: Orally circulation. Iron bound to Investigate the absence of satisfactory
transferrin is taken into response after 3 weeks of drug
Brand Name: Frequency: Once a erythroblasts in bone marrow and treatment.
Ferrocyte day used for synthesis of hemoglobin. ● Continue iron therapy for 2–3 months
Sodium ferrous citrate increases after the hemoglobin level has
serum iron levels without being returned to normal (roughly twice the
affected by gastric acid secretion: period required to normalize
Increases in serum iron levels hemoglobin concentration).
achieved by sodium ferrous ● Monitor bowel movements as
citrate were similar to those constipation is a common adverse
achieved by ferrous sulfate and effect.
ferrous fumarate
I. SPECIAL
PROCEDU
RES OR
OPERATIO
N
ENDOSCOPY
CHEST X-RAY
BONE MARROW ASPIRATION
II. FORMULATION
OF NURSING
DIAGNOSIS
Fatigue Risk for deficient fluid volume

Decreased cardiac output Impaired skin integrity

Activity intolerance
Ineffective breathing pattern

Imbalanced nutrition: Less

Risk for bleeding
than body requirement

Ineffective tissue perfusion Deficient knowledge

Impaired gas exchange Impaired oral mucous membrane

Risk for infection Risk for heart failure and neurological deficits
III. PDAR
(Problem, Data, Action, Response)
 Problem Data Action Response

Fatigue related to ● Chief complaint of malaise ● Assisted the patient in Patient was able to
decrease ● Generalized pallor daily activities . verbalized reduction of
hemoglobin count ● CBC result: ● Made sure to have the call fatigue, as evidenced by
bell near the patient’s bed. reports of increased energy
- Red blood cell 90 ×10 /μl ● Educated about the and ability to perform
- Hemoglobin 3.6 g/dl importance of rest desired activities.
- MCV: 125.6 fL intervals every activity of
- MCH: 40.0 pg the patient.
- MCHC: 31.9 % ● Instructed about different
- Platelet: 9.4 × 10 /μl relaxation activities.
● Administered with Sodium
● Serological test:
ferrous citrate 100mg
- Lactate Dehydrogenase (LD): 3612 IU/l
● Immunological tests:
- Thyroglobulin Ab >4000 IU/ml\
- TPO Ab: 397 IU/ml
- Positive DAT (direct Coombs test)
 Problem Data Action Response

Deficiency of ● The patient's chief complaint is malaise Educated about the The patient exhibited
vitamin B12 1 month prior to admission. importance of eating an increase in
● Vitamin B12 levels were below the enough foods with hemoglobin level,
detection limit. iron, vitamin c, and improvement in
● CBC result: folic acid. anemia-related
- Red blood cell: 90 ×104 /μl symptoms
- Hemoglobin: 3.6 g/dl Administered vitamin
- Reticulocyte: 3.1 × 104 /μl b12 injection as
ordered by the
physician.
 Problem Data Action Response

Imbalanced ● Vitamin B12 deficiency ● Monitored body weight After providing

Nutrition: Less ● Gastritis
than body ● Decrease in RBC’s
requirement r/t ● Generalized pallor
failure to absorb ● Fatigue
nutrients ● Bulbar conjunctiva
necessary for the ● Anemic conjunctiva
formation of ● CBC result:
RBC’s - Red blood cell: 90 ×104 /μl
- Hemoglobin: 3.6 g/dl
- Reticulocyte: 3.1 × 104 /μl
changes
● Monitored pallor, redness and
dryness of conjunctival tissue
● Formulated a dietary plan that
is rich in iron, economical and
easy to prepare.for the patient.
● Encouraged intake of folic acid
supplements
● Informed the client and its
family members about sources
of different folic acid-rich
foods
nursing intervention,
the client was able to
exhibit relevant
normal levels of
laboratory value
(hemoglobin and RBC
level) and maintained
adequate nutrition.
IV. NURSING SKILLS
VIDEO
● Vitamin B12 Intramuscular Injection
V. DISCHARGE
PLAN
 Medicatio
n the patient to intake iron or folic acid supplements.
- Advise

- Instruct patients to take bowel movement softeners

- Explain to the patient and family the medications and their purposes, as well as the

specific dosage, frequency, and method of administration.

Environmen
t safe environment
- Clean and
Treatment
- Advise to seek care immediately if a patient has dark or bloody bowel movements.

- Continue the prescribed medication and contact the health care provider if there are any

complications observed or illness does not improve with the said treatment.

- This illness may require continuous medication and monitoring for the rest of the patient's life.

- Strict complaint to the doctor's order on shots of Vitamin B12 to be done three times weekly for 3

weeks, followed by once weekly up to 2 months.

 Health
- Teaching
Educate the patient about the said condition.

- Limit physical activities that may weaken the patient.

- Instruct the patient that treatment must continue for life if diagnosed as having pernicious

anemia.

Outpatien
t the patient to continue follow-up check-ups with the physician.
- Advise

- Instruct the patient to seek immediate care if she experienced extreme fatigue
Diet
- Advise the patient to eat foods rich in iron and protein such as nuts, meat, dark leafy green

vegetables, and beans.

- Advise the patient not to drink coffee, tea, or other liquids with caffeine.

- Encourage fluid intake. Liquids help prevent constipation.

- Advise patient to eat foods that have folate. Foods with folate include leafy green vegetables,

citrus fruits, and fortified cereals

Spiritua
l
- Advise family to provide presence with the patient.

- Assist the client with prayer.

- Promote a positive and safe environment.

 Thanks!
ALMINAR, JULIA
ARCUENO, PRINCESS
ARIZALA, ROWENA
ATIENZA, JANELLA

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