Description

Progressive fatigue with shortness of breath Col Casey Kilroy is a 50-year-old female with progressive fatigue and shortness of breath. She reports that she was sent to the office after attempting to donate blood and was turned away due to being anemic. She states the fatigue started a few months ago. She noticed she would not finish a round of gold without using a cart. She states it comes on quickly and goes away with rest. She reports the fatigue limits her from accomplishing her daily tasks. Her associated symptoms are shortness of breath while doing housework that is relieved with rest, lightheaded when she exercises, headaches, ice chewing, and heavy menstrual periods with heavy bleeding for 4 days with periods that last 7-8 days. She also reports some tingling in her legs that she contributes to poor circulation. She has a past medical history of GERD, arthritis, a tubal ligation and appendectomy. She denies any history of smoking or drug use. He endorses a glass of wine a day. She follows a vegan diet. Her family history includes Crohn’s disease, diabetes and colon cancer. Her immunizations are up to date and she has had a recent pap test and mammogram. Admission Orders (do not write an explanation of the order(s), ONLY the order) 1. DX: (1) : Iron deficiency Anemia 2. Admit to: Medical Surgical Unit –Dr. Amber, call upon arrival with rm # 3. Isolation/Precautions: standard 4. Allergies: No known allergies 5. Diet: NPO 6. Activity: up as tolerated 7. IV: large bore IVs 8. IVF: NS at 100ml /hr 1 unit PRBC if hgb >8 9. Labs: Every 4-hour H&H, Type and cross match. Stool for Ova and parasites. PT/INR. 10. AM LABS: CBC, BMP, 11. RADS (US, CT, XRAYs)/Diagnostic tests: Endoscopy - Colonoscopy 12. PT/OT/Nutrition/SW/Pysch/etc. Consults: Dietary, Respiratory Therapy 13. Consult: GI – Trace Guaiac positive Hematology – New diagnosis of Anemia 14. Screening (s): HIV, TB, PNA vaccine, flu shots, etc: None 15. Medications: Venofer 10mg in 50 ml NS over 15 minutes every 3 days for 5 total doses Protonix 40 mg IV BID Zofran 4 mg IV q6h PRN for Nausea or Vomiting Acetaminophen 1000 mg IV Q6H PRN fever greater than 101.5, pain less than 5. maximum 4000 mg/day 16. Non-pharmacological Management: Education on Pathophysiology of Iron deficiency Anemia, Risk factors of the disease, Symptoms of Iron Deficiency Anemia, Prevention of progression of Iron Deficiency Anemia. Dietary education on foods high in iron. Obtain Blood Consent Nursing Orders Daily weights Neuro checks every hour Vital Signs Q 4 hours Obtain IV access Place on continuous telemetry Call if Hgb <8 DVT prophylaxis GI prophylaxis Code Status Full Discharge planning and required follow-up care Discharge patient home on PO medications when stable F/U with PCP within 24-48 hours. F/U with GI, OBGYN Take medications as ordered. Do not stop or skip the medications even if you feel better without consulting the PCP. Call your healthcare provider right away if you have any of the following: Tiredness that persists for 2 to 3 days, decreased exercise tolerance, chest pain or pressure feeling, persistent SOB at rest or with mild activities, fever over 100.4°F (38.0°C), sweats, increase and pounding heart rate, difficulty catching breath, persistent cough, blood in the sputum feeling of impending doom. Discharge patient home when symptoms have resolved and patient is hemodynamically stable. Plan Rationale and Supporting Documentation DX: Iron Deficiency Anemia Iron deficiency anemia is a state in which iron stores in the body are inadequate to preserve homeostasis. It’s a type of microcytic anemia characterized by small, pale RBCs and depleted iron stores. It’s the most common anemia worldwide, accounting for 60% of anemias in patients older than 65 years old [ CITATION Bar15 \l 1033 ]. Common causes include overt and/or occult blood loss, decreased iron absorption, bowel disease, medications, decreased dietary intake, and long term aspirin use. Physical findings include skin and/or conjunctiva pallor, red and smooth tongue, spoon shaped nails, cracked corners of mouth, tachycardia, palpitations, fatigue, exertional dyspnea, headache, exercise intolerance, and pica. Labaratory findings include elevated RDWs, decreased reticulocytes, ferritin level decreased, TBIC increased, and/or low serum iron [ CITATION Fer19 \l 1033 ]. Diagnostic testing includes guaiac for occult blood, stool for ova and parasites, a gastrointestinal endoscopy for bleeding, and clotting studies [ CITATION Dav19 \l 1033 ]. Management includes oral or IV iron replacement and treating the underlying cause. 1. DX: (1) : Iron deficiency Anemia 2. Admit to: Medical Surgical Unit –Dr. Amber, call upon arrival with rm # 3. Isolation/Precautions: standard 4. Allergies: No known allergies 5. Diet: NPO – for possible colonoscopy 6. Activity: up as tolerated 7. IV: large bore IVs –at least 20 g incase patient requires blood transfusion 8. IVF: NS at 100ml /hr 1 unit PRBC if hgb >8 (since patient is symptomatic, would transfuse) 9. Labs: Every 4-hour H&H, Type and cross match (in case patient requires blood transfusion). Stool for Ova and parasites. (to see if that is contributing to iron depletion) PT/INR (to check blood coags). 10. AM LABS: CBC, BMP, 11. RADS (US, CT, XRAYs)/Diagnostic tests: Endoscopy – Colonoscopy (since occult blood positive) 12. PT/OT/Nutrition/SW/Pysch/etc. Consults: Dietary (education on high iron foods given her vegan diet) , Respiratory Therapy to maintain Sp)2 >09% 13. Consult: GI – Trace Guaiac positive Hematology – New diagnosis of Anemia 14. Screening (s): HIV, TB, PNA vaccine, flu shots, etc: None 15. Medications: Venofer 10mg in 50 ml NS over 15 minutes every 3 days for 5 total doses (Iron replacement) Protonix 40 mg IV BID (to treat GI ulcer) Zofran 4 mg IV q6h PRN for Nausea or Vomiting Acetaminophen 1000 mg IV Q6H PRN fever greater than 101.5, pain less than 5. maximum 4000 mg/day 16. Non-pharmacological Management: Education on Pathophysiology of Iron deficiency Anemia, Risk factors of the disease, Symptoms of Iron Deficiency Anemia, Prevention of progression of Iron Deficiency Anemia. Dietary education on foods high in iron. Obtain Blood Consent Nursing Orders Daily weights Neuro checks every hour Vital Signs Q 4 hours Obtain IV access Place on continuous telemetry Call if Hgb <8 DVT prophylaxis GI prophylaxis Code Status Full Discharge planning and required follow-up care Discharge patient home on PO medications when stable F/U with PCP within 24-48 hours. F/U with GI, OBGYN Take medications as ordered. Do not stop or skip the medications even if you feel better without consulting the PCP. Call your healthcare provider right away if you have any of the following: Tiredness that persists for 2 to 3 days, decreased exercise tolerance, chest pain or pressure feeling, persistent SOB at rest or with mild activities, fever over 100.4°F (38.0°C), sweats, increase and pounding heart rate, difficulty catching breath, persistent cough, blood in the sputum feeling of impending doom. Discharge patient home when symptoms have resolved and patient is hemodynamically stable. Resources Barkley, T., & Myers, C. (2015). Practice considerations for the adult-gerontology acute care nurse practitioner. West Hollywood, CA: Barkley & Associates . Davis, J., & Silverman, M. (2019). Roberts and Hedges' clinical procedures in emergency medicine and acute care. Elsevier. Ferri, F. (2019). Ferri's best test: A practical guide to clinical labratory medicine and diagnostic imaging. Elsevier.