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Chapter 9: Applying Clinical Judgment to Promote Nutrition for Hematologic Wellness

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Chapter 9: Applying Clinical Judgment to Promote Nutrition for Hematologic Wellness

18 problems · 0 figures

Case Study 9.1.1 §9.1 source ↗

Read the following clinical scenario and then answer the questions that follow. This case study will evolve throughout the chapter.

Grant continues with his assessment of Ms. Foster. She reports difficulty sleeping for the past several months and poor concentration. Over the past 3 days, she has been short of breath with little exertion and lightheaded. As Grant discusses her diet history and food preferences, Ms. Foster reports that she constantly craves ice; otherwise, her diet consists of bread, chicken, and canned vegetables. While Grant continues to perform his assessment, her primary care physician (PCP) calls to report Ms. Foster’s hemoglobin as 6.2 gm/dL from the morning labs and requests additional diagnostic evaluation to determine the etiology of her severe anemia. Grant recognizes that older adults are at risk for nutritional anemias and suspects this for Ms. Foster. He understands the importance of a thorough history and assessment to avoid potentially life-threatening complications of anemia. Grant has completed his assessment of Ms. Foster and has obtained the following blood samples as ordered by her PCP:

• CBC

• Serum iron

• Ferritin

• Folate

• Vitamin B12

Her CBC confirms severe microcytic anemia (hemoglobin 6.0 gm/dL with a low mean corpuscle volume). Since Ms. Foster has symptomatic anemia with shortness of breath and lightheadedness, Grant notifies the emergency department physician and requests an additional evaluation. An ECG and chest radiograph are performed; the physician determines that the source of Ms. Foster’s symptoms is unlikely related to hemorrhage and is most likely related to a nutritional deficiency. An order to transfuse 1 unit of packed red blood cells over 2–4 hours is received.

Grant recognizes that iron deficiency is the most common cause of nutritional microcytic anemia. He is also aware that the turnaround time for laboratory iron studies is 24–48 hours. He updates Ms. Foster and her daughter with the plan of care and determines the priority nursing diagnosis to be impaired gas exchange, related to anemia; imbalanced nutrition, less than body requirements, related to iron deficiency.

Which nutritional screening tool should the nurse anticipate as part of Ms. Foster’s evaluation?
  1. a.
    Nutritional Risk Screening 2002 (NRS2002)
  2. b.
    Malnutrition Universal Screening Tool (MUST)
  3. c.
    Mini Nutritional Assessment (MNA-SF)
  4. d.
    Nutritional Risk in Critically Ill (NUTRIC)

Answer

C. Mini Nutritional Assessment (MNA-SF)
The Mini Nutritional Assessment is a nutritional screening tool for older clients.

Case Study 9.1.2 §9.1 source ↗

Read the following clinical scenario and then answer the questions that follow. This case study will evolve throughout the chapter.

Grant continues with his assessment of Ms. Foster. She reports difficulty sleeping for the past several months and poor concentration. Over the past 3 days, she has been short of breath with little exertion and lightheaded. As Grant discusses her diet history and food preferences, Ms. Foster reports that she constantly craves ice; otherwise, her diet consists of bread, chicken, and canned vegetables. While Grant continues to perform his assessment, her primary care physician (PCP) calls to report Ms. Foster’s hemoglobin as 6.2 gm/dL from the morning labs and requests additional diagnostic evaluation to determine the etiology of her severe anemia. Grant recognizes that older adults are at risk for nutritional anemias and suspects this for Ms. Foster. He understands the importance of a thorough history and assessment to avoid potentially life-threatening complications of anemia. Grant has completed his assessment of Ms. Foster and has obtained the following blood samples as ordered by her PCP:

• CBC

• Serum iron

• Ferritin

• Folate

• Vitamin B12

Her CBC confirms severe microcytic anemia (hemoglobin 6.0 gm/dL with a low mean corpuscle volume). Since Ms. Foster has symptomatic anemia with shortness of breath and lightheadedness, Grant notifies the emergency department physician and requests an additional evaluation. An ECG and chest radiograph are performed; the physician determines that the source of Ms. Foster’s symptoms is unlikely related to hemorrhage and is most likely related to a nutritional deficiency. An order to transfuse 1 unit of packed red blood cells over 2–4 hours is received.

Grant recognizes that iron deficiency is the most common cause of nutritional microcytic anemia. He is also aware that the turnaround time for laboratory iron studies is 24–48 hours. He updates Ms. Foster and her daughter with the plan of care and determines the priority nursing diagnosis to be impaired gas exchange, related to anemia; imbalanced nutrition, less than body requirements, related to iron deficiency.

Ms. Foster’s priority nursing diagnosis is impaired gas exchange, related to anemia; imbalanced nutrition, less than body requirements, related to iron deficiency. What other nursing diagnosis should the nurse consider addressing during this visit?
  1. a.
    Knowledge deficit, related to nutrients needed for hematologic wellness
  2. b.
    Impaired skin integrity, related to anemia, nutritional deficiency
  3. c.
    Impaired memory, related to anemia
  4. d.
    Infection, delayed wound healing, related to nutritional deficiency

Answer

A. Knowledge deficit, related to nutrients needed for hematologic wellness
The client will need education regarding foods rich in iron to consume at home.

Case Study 9.2.3 §9.2 source ↗

Read the following clinical scenario and then answer the questions that follow. This case study is a follow-up to Case Study Part A.

Grant is planning a discharge for Ms. Foster as she completes her blood transfusion. He recognizes that Ms. Foster may be experiencing fatigue or drowsiness from the medical interventions and anxiety and/or fear related to the need for a major modification to her diet. Further, he is aware that the emergency department environment can be distracting to learning. With these factors in mind, Grant determines that he will focus the discharge education on iron replacement therapy, follow-up with her PCP, and referral to a dietician.

He develops the following goal for Ms. Foster’s discharge education: Provide oral and written information on iron replacement therapy including dose, route, frequency, side effects, and administration considerations immediately before discharge. Grant will include a list of food sources rich in iron and inform Ms. Foster that taking her iron supplement with 4–6 oz of orange juice can improve iron absorption.

Which of the following psychosocial factors should be considered first as the nurse prepares a list of iron-rich foods?
  1. a.
    Cultural and religious preferences
  2. b.
    Home-cooked or prepared meals
  3. c.
    Social influences
  4. d.
    Availability and variety

Answer

B. Home-cooked or prepared meals
Using Maslow’s hierarchy of needs framework, understanding the physical environment should be the first consideration. It is essential to understand if the client will be cooking or eating prepared meals before considering other options.

Case Study 9.2.4 §9.2 source ↗

Read the following clinical scenario and then answer the questions that follow. This case study is a follow-up to Case Study Part A.

Grant is planning a discharge for Ms. Foster as she completes her blood transfusion. He recognizes that Ms. Foster may be experiencing fatigue or drowsiness from the medical interventions and anxiety and/or fear related to the need for a major modification to her diet. Further, he is aware that the emergency department environment can be distracting to learning. With these factors in mind, Grant determines that he will focus the discharge education on iron replacement therapy, follow-up with her PCP, and referral to a dietician.

He develops the following goal for Ms. Foster’s discharge education: Provide oral and written information on iron replacement therapy including dose, route, frequency, side effects, and administration considerations immediately before discharge. Grant will include a list of food sources rich in iron and inform Ms. Foster that taking her iron supplement with 4–6 oz of orange juice can improve iron absorption.

Which of Ms. Foster’s risk factors for worsening anemia is modifiable?
  1. a.
    Hypertension
  2. b.
    Diabetes
  3. c.
    Decreased taste
  4. d.
    Decreased food intake

Answer

D. Decreased food intake
Eating smaller portions more frequently is a strategy that can overcome decreased food intake that occurs due to getting full quickly. Although hypertension and diabetes are not risk factors for worsening anemia, decreased taste is a physiological consequence of the change in density of taste buds that occurs with aging.

Case Study 9.3.5 §9.3 source ↗

Read the following clinical scenario and then answer the questions that follow. This case study is a follow-up to Case Study Parts A and B.

Grant starts discharge education with Ms. Foster by sharing his intended goal and time frame for completion. Ms. Foster’s daughter offers to retrieve the car to expedite discharge. Grant suggests that she stay for the education and participate in identifying potential barriers to the plan. Ms. Foster reports that her anemia should be resolved since she received a blood transfusion. Grant explains to Ms. Foster that the lifespan of transfused red blood cells is approximately 60 days and that she will need to start oral iron replacement therapy as soon as possible to restore her hematologic wellness. He then modifies his educational plan to include an overview of red blood cell production, signs and symptoms of anemia, and the expected time for recovery of symptoms.

A holistic approach to client teaching includes consideration of which of the following?
  1. a.
    Spiritual influences
  2. b.
    Family presence
  3. c.
    Medical diagnosis
  4. d.
    Family medical history

Answer

A. Spiritual influences
A holistic approach to client teaching includes spiritual influences, emotional influences, physical influences, and social determinants of health.

Case Study 9.3.6 §9.3 source ↗

Read the following clinical scenario and then answer the questions that follow. This case study is a follow-up to Case Study Parts A and B.

Grant starts discharge education with Ms. Foster by sharing his intended goal and time frame for completion. Ms. Foster’s daughter offers to retrieve the car to expedite discharge. Grant suggests that she stay for the education and participate in identifying potential barriers to the plan. Ms. Foster reports that her anemia should be resolved since she received a blood transfusion. Grant explains to Ms. Foster that the lifespan of transfused red blood cells is approximately 60 days and that she will need to start oral iron replacement therapy as soon as possible to restore her hematologic wellness. He then modifies his educational plan to include an overview of red blood cell production, signs and symptoms of anemia, and the expected time for recovery of symptoms.

Which of the following age-specific considerations should the nurse consider first before initiating the educational session with Ms. Foster?
  1. a.
    Hearing or vision changes
  2. b.
    Cognitive function
  3. c.
    Preferred spoken language
  4. d.
    Level of alertness

Answer

B. Cognitive function
The client’s cognitive functioning will determine if a caregiver needs to be present for the educational session.

Case Study 9.4.7 §9.4 source ↗

Table 9.4 in the book ↗
Food Item Serving Size Iron Content
Tofu ½ cup 3 mg
Kidney beans ½ cup 2 mg
Beef liver 3 oz 5 mg
Canned white beans 1 cup 8 mg
Boiled lentils ½ cup 3 mg
Fortified breakfast cereal ½ cup 18 mg
Potato, baked, flesh and skin 1 medium size 2 mg
Tomatoes, canned, stewed ½ cup 2 mg
Iron-Rich Foods (source: National Institutes of Health, 2023)

Read the following clinical scenario and then answer the questions that follow. This case study is a follow-up from Case Study Parts A, B, and C.

After discussing Ms. Foster’s symptoms in relation to her anemia, Grant reviews iron replacement therapy, including the importance of taking iron with a citrus beverage such as orange juice to aid in iron absorption. He informs Ms. Foster that most insurance companies will not cover the cost of iron replacement as it can be purchased over the counter. Grant further offers to search her local pharmacy website to determine the cost and formulations available. He provides a written client education handout on iron deficiency anemia as well as instructions for Ms. Foster to call her PCP for a follow-up appointment in 3 weeks. Grant then discusses several foods that are iron rich (Table 9.4) and helps Ms. Foster identify 3 food items that she feels she can incorporate into her daily diet. Ms. Foster’s daughter repeats the items needed to initiate this plan and offers to take her mother to the store before returning home. Ms. Foster reminds her daughter that she has groceries delivered every other week but will increase to a weekly delivery to ensure fresh or frozen spinach availability daily. At this point, Grant asks Ms. Foster the following: “How confident are you that you can make this change, on a scale of 0 to 10, with 10 being extremely confident?”

Ms. Foster reports a confidence level of 8, vocalizing her motivation to actively participate in her grandson’s wedding in 3 months. Grant feels confident that he and Ms. Foster have developed a solid plan in a collaborative manner. He provides Ms. Foster with a copy of the plan and educational materials and recommends she ask her PCP for a referral to a registered dietitian to help with meal planning. He adds the nursing care plan to Ms. Foster’s electronic medical record to ensure that her PCP’s office will have access during the follow-up appointment.

What stage of change is Ms. Foster in at the conclusion of the nurse’s teaching session?
  1. a.
    Contemplative
  2. b.
    Pre-contemplative
  3. c.
    Preparative
  4. d.
    Action

Answer

C. Preparative
Ms. Foster is choosing food options and making plans for meals. She will be in the action stage of change once she begins modifying her diet.

Case Study 9.4.8 §9.4 source ↗

Table 9.4 in the book ↗
Food Item Serving Size Iron Content
Tofu ½ cup 3 mg
Kidney beans ½ cup 2 mg
Beef liver 3 oz 5 mg
Canned white beans 1 cup 8 mg
Boiled lentils ½ cup 3 mg
Fortified breakfast cereal ½ cup 18 mg
Potato, baked, flesh and skin 1 medium size 2 mg
Tomatoes, canned, stewed ½ cup 2 mg
Iron-Rich Foods (source: National Institutes of Health, 2023)

Read the following clinical scenario and then answer the questions that follow. This case study is a follow-up from Case Study Parts A, B, and C.

After discussing Ms. Foster’s symptoms in relation to her anemia, Grant reviews iron replacement therapy, including the importance of taking iron with a citrus beverage such as orange juice to aid in iron absorption. He informs Ms. Foster that most insurance companies will not cover the cost of iron replacement as it can be purchased over the counter. Grant further offers to search her local pharmacy website to determine the cost and formulations available. He provides a written client education handout on iron deficiency anemia as well as instructions for Ms. Foster to call her PCP for a follow-up appointment in 3 weeks. Grant then discusses several foods that are iron rich (Table 9.4) and helps Ms. Foster identify 3 food items that she feels she can incorporate into her daily diet. Ms. Foster’s daughter repeats the items needed to initiate this plan and offers to take her mother to the store before returning home. Ms. Foster reminds her daughter that she has groceries delivered every other week but will increase to a weekly delivery to ensure fresh or frozen spinach availability daily. At this point, Grant asks Ms. Foster the following: “How confident are you that you can make this change, on a scale of 0 to 10, with 10 being extremely confident?”

Ms. Foster reports a confidence level of 8, vocalizing her motivation to actively participate in her grandson’s wedding in 3 months. Grant feels confident that he and Ms. Foster have developed a solid plan in a collaborative manner. He provides Ms. Foster with a copy of the plan and educational materials and recommends she ask her PCP for a referral to a registered dietitian to help with meal planning. He adds the nursing care plan to Ms. Foster’s electronic medical record to ensure that her PCP’s office will have access during the follow-up appointment.

What should the nurse recognize first when modifying a nutritional plan for change?
  1. a.
    Change is a cyclic process.
  2. b.
    Motivational interviewing is the preferred method to determine success of the prior plan.
  3. c.
    Goals of the initial plan for change are important.
  4. d.
    Barriers to success of the initial nutritional change plan exist.

Answer

A. Change is a cyclic process.
The nurse should recognize that change is a cyclic process and that successes and failures are expected.

9-1 §9.RQ source ↗

Which nutritional deficiency listed increases the risk for bleeding?
  1. a.
    Vitamin K
  2. b.
    Iron
  3. c.
    Vitamin B12
  4. d.
    Folate

Answer

A. Vitamin K
Vitamin K is a fat-soluble vitamin necessary for the synthesis and activation of coagulation factors II (prothrombin), VII, IX, and X.

9-2 §9.RQ source ↗

The nurse is providing nutritional counseling to a client planning pregnancy. The nurse should emphasize the importance of consuming what micronutrients to avoid macrocytic anemia?
  1. a.
    Vitamin D
  2. b.
    Vitamin E
  3. c.
    Folic acid
  4. d.
    Vitamin C

Answer

C. Folic acid
Folate deficiency in pregnancy can lead to macrocytic anemia in mothers and neural tube defects in fetuses.

9-3 §9.RQ source ↗

A middle-aged client with a history of alcohol use disorder is admitted to an acute care setting with symptoms of severe anemia. The nurse anticipates what nutrient(s) to be deficient?
  1. a.
    Iron
  2. b.
    Vitamin B12
  3. c.
    Calcium
  4. d.
    Copper

Answer

B. Vitamin B12
Long-term alcohol use can cause the malabsorption of Vitamin B12.

9-4 §9.RQ source ↗

The nurse notices that a client has excessive bruising and brittle nails. The client reports frequent infections. Which nutritional deficiency would the nurse expect for this client?
  1. a.
    Iron
  2. b.
    Protein
  3. c.
    Vitamin C
  4. d.
    Copper

Answer

C. Vitamin C
These are all possible signs of scurvy, or vitamin C deficiency.

9-5 §9.RQ source ↗

A nurse is preparing discharge instructions for a client who has just been diagnosed with iron deficiency anemia and will be starting oral iron replacement therapy. Which of the following is an important nursing consideration to include in the teaching plan?
  1. a.
    Hemoglobin should be checked in 6 months.
  2. b.
    Always take iron with milk or food to increase absorption.
  3. c.
    Always take iron with a citrus beverage, 1 hour before or 2 hours after meals, to increase absorption.
  4. d.
    Increase diet in fatty fish.

Answer

C. Always take iron with a citrus beverage, 1 hour before or 2 hours after meals, to increase absorption.
Iron is better absorbed when taken with vitamin C, found in orange juice, and on an empty stomach.

9-6 §9.RQ source ↗

Which nursing diagnosis is a priority for an older adult client just diagnosed with nutritional anemia?
  1. a.
    Risk for falls
  2. b.
    Risk for imbalanced nutrition, less than body requirements
  3. c.
    Frail elderly syndrome, related to malnutrition
  4. d.
    Risk for bleeding

Answer

A. Risk for falls
An older adult with anemia is likely to experience hypotension and/or lightheadedness, which is a significant risk for falls.

9-7 §9.RQ source ↗

The nurse is preparing discharge instructions for a client with anemia related to vitamin B12 deficiency. The nurse suggests which of the following food items be increased in the client’s diet?
  1. a.
    Animal meat, fish, eggs, and dairy
  2. b.
    Beans, seeds, and nuts
  3. c.
    Dark green leafy vegetables
  4. d.
    Citrus fruits and acidic raw vegetables

Answer

A. Animal meat, fish, eggs, and dairy
Animal meat, fish, eggs, and dairy are sources of vitamin B12.

9-8 §9.RQ source ↗

Which of the following psychosocial influences impacting nutritional goals for hematologic wellness is the best target for an initial nursing intervention?
  1. a.
    Health literacy
  2. b.
    Transportation
  3. c.
    Social support
  4. d.
    Cognitive function

Answer

A. Health literacy
Health literacy is the only modifiable psychosocial factor listed.

9-9 §9.RQ source ↗

Assessing a client’s readiness to learn about nutrition-related hematologic illness, utilizing a holistic approach, should include all of the following except:
  1. a.
    Providing written materials regarding vitamin C deficiency to the client immediately before discharge
  2. b.
    Determining the client’s preferred language for learning
  3. c.
    Discussing the client’s preferred learning style
  4. d.
    Delaying discharge education until the client’s significant other is present

Answer

A. Providing written materials regarding vitamin C deficiency to the client immediately before discharge
Providing written material before determining the client’s preferred learning style, without assessing their preference and without giving time to ask questions, is not consistent with holistic nursing care.

9-10 §9.RQ source ↗

When evaluating the effectiveness of a nutritional plan for iron deficiency anemia, the nurse considers which of the following factors?
  1. a.
    Behavior change typically takes 6 months to achieve, according to the Transtheoretical Model (TTM).
  2. b.
    Hemoglobin is expected to increase as a response to oral ferrous sulfate within 2 to 3 months of starting.
  3. c.
    An early sign suggesting improved anemia may include the client’s report of sleeping more.
  4. d.
    Shortness of breath may take several months to improve.

Answer

A. Behavior change typically takes 6 months to achieve, according to the Transtheoretical Model (TTM).
The nurse should consider that a change in behavior typically takes 6 months to achieve.

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Problems and answers are adapted from Nutrition for Nurses by Emerald Charity Bilbrew, Jody Vogelzang and Kelli Whittington, OpenStax, and are used under the CC BY-NC-SA 4.0 licence. Access for free at https://openstax.org/books/nutrition/pages/1-introduction. Illustrations: Copyright Rice University, OpenStax, under CC BY-NC-SA 4.0 license. This adaptation is released under the same licence, is non-commercial, and is neither affiliated with nor endorsed by OpenStax or Rice University.