Case Study #2

Ann Clairmont
10/28/2014
Nutrition Therapy 1

1. Evaluate the patients admitting history and physical. Are

there any signs or symptoms that support the diagnosis
of anemia?
The patients admitting history and physical do support the
diagnosis for anemia. The patient talks about shortness of breath
earlier in her pregnancy, which can be a sign of anemia because
she is not getting enough oxygen due to the reduced level of red
blood cells and hemoglobin. Her body has to work harder to get
oxygen to the fetus and her body as well.
She also says in her history that she has experienced more
fatigue during this pregnancy. Fatigue is a symptom of anemia
because the body is not receiving enough oxygen due to low red
blood cell count. Iron is also an important factor in the production
of cell energy (ATP) and that can cause fatigue if the body is not
producing enough energy or ATP.
She also was admitted for vaginal bleeding. Excessive
vaginal bleeding can lead to anemia if adequate amount of iron
is not being consumed. Internal bleeding could have happened
from the fall and that could be causing excessive bleeding and
causing low hemoglobin.
In her assessment they stated she had pale skin. This is a
sign of anemia because the low red blood cell count can cause a
paleness of the skin. They also talk about pale sclera and this is
also a symptom of anemia because of low hemoglobin.
She has poor dietary intake. This can lead to anemia
because she is not getting the required nutrients such as iron.
During pregnancy nutritional requirements are increased due to
the needs of the fetus. She is also not taking her vitamin
supplement regularly.1,2
2. What laboratory values or other tests support this
diagnosis? List all abnormal values and explain the likely
cause for each abnormal value.
6

RBC (x10 /mm )

Hemoglobin (hgb,
g/dL)
Hematocrit (Hct, %)
Mean cell volume
(m3)
Retic (%)
Mean Cell Hgb (pg)
Mean cell Hgb content
(g/gL)
RBC distribution (%)

Ref. Range
4.2-5.4
12-15

Mrs. Morriss levels

3.8
9.1

37-47
80-96

33
72

0.8-2.8
26-32

0.2
23

31.5-36

28

11.6-16.5

22

Total iron binding

240-450
465
capacity (g/dL)
Ferritin (g/dL)
20-120
10
ZPP (mol/mol)
30-80
84
Folate (ng/dL)
5-25
2
The red blood cell count is below the normal limit and this
can be because of deficiency in iron due to poor nutrient intake.
Since she is pregnant her need for iron is greater and she is not
meeting those needs, which is contributing to a low red blood
cell count.
Her hemoglobin count is low and this is a good indicator of
iron deficiency because iron makes part of the protein
hemoglobin and if iron is not present then hemoglobin synthesis
is affected.
Her hemocratic level is low due to the low red blood cell
count. During pregnancy blood volume has increased
substantially. The hemocratic level measures the amount of red
blood cells within the total blood volume and because she has
such low red blood cells already due to iron deficiency this
number is going to be low due to the lack of RBCs.
Mean cell volume determines the size of the cells and what
type of anemia the patient has. If that number is below 80 m3 it
can mean that the cell is hypochromic and microcytic due to iron
deficiency.
Mean cell hemoglobin content measures the amount of
hemoglobin per RBC. Her low MCHC is due to the decreased
amount of red blood cells and small size of cells.
Red blood cell distribution measures the size and volume of
red blood cells. Her red blood cell distribution is low because her
cells are microcytic.
Total binding capacity determines the proteins ability to
bind to iron. This number is higher than the normal limit because
the body produces more transferrin to try and maximize what
iron is left in the body.
Serum ferritin is what iron binds to within the liver, spleen,
and bone marrow when being stored by the body. Low ferritin
levels are usually due to low iron in the body.
ZPP is a direct indicator of iron deficiency because it is only
found in red blood cells when heme production is inhibited
because of the lack of iron in the body.
Folate is an important vitamin during pregnancy. Her folate
level is below the normal level and this is due to her poor
nutrient intake and inconsistency in taking her prenatal
vitamins.1,2
3. Mrs. Morriss physician ordered additional lab work when
her admitting CBC revealed 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.
Mrs. Morriss low hemoglobin is a concern because
hemoglobin is what carries oxygen to the rest of the body and
the fetus. During pregnancy the fetus receives the nutrients first
and then the mother. If levels are already low and the fetus is
getting what little there is then it leaves very little for the
mother. During pregnancy hemoglobin normally decreases
during the first and second trimester because of blood level
expansion. During the third trimester they can remain low if iron
supplements are not taken. Other hematological values do
change during pregnancy. Blood volume expands to
approximately 50% by the end of pregnancy. Not only is there a
decrease in hemoglobin due to blood expansion but serum
albumin, other serum proteins, and water-soluble vitamins
decrease. There is an increase in fat-soluble vitamins,
triglycerides, cholesterol, and free fatty acids.1
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.
o Hemolytic anemia: happens when there are defects in RBC
membranes by oxidative damage and eventually to cell
lysis. Can be caused by vitamin E deficiency or toxicity.
o Macrocytic anemia: can be caused by a deficiency in folate or
B12. It can also be caused by chronic liver disease and
alcoholism.
o Megaloblastic anemia- is characterized by large, immature,
abnormal RBC progenitors in the bone marrow. This can be
caused by a deficiency in folic acid or vitamin B12.
o Microcytic anemia: can be caused by iron deficiency,
thalassemia, anemia of chronic diseases, and lead poisoning.
o Pernicious anemia: is a megaloblastic, macrocytic anemia
caused by a deficiency in vitamin B12, mainly because of the
lack of intrinsic factor.
o Sickle cell anemia: is a chronic hemolytic anemia where there
is a defect in the hemoglobin synthesis, which produces
sickle shaped RBCs that get caught in capillaries and cannot
carry oxygen well.
o Normocytic anemia- is when the production of red blood cells
decreases and there is an increased destruction of RBCs. 1,2

5. What is the role of iron in the body? Are there additional

functions of iron during fetal development?
The role of iron in the body is to perform oxidation and
reduction reactions. Iron is a very reactive element that reacts
well with oxygen and it makes up part of the protein called
hemoglobin and myoglobin. Hemoglobin is found in red blood
cells and its main function is to carry oxygen to the tissues and
pick carbon dioxide up from those tissues to take back to the
lungs. Myoglobin is heme-containing protein found in muscle and
it acts as a storage reservoir for oxygen. Iron also plays a role in
the process of cellular respiration and energy generation of ATP.
Iron also plays a role in immune function and cognitive
performance.
Additional roles of iron during fetal development are that it
is a key nutrient in the development of the myelin, monoamine
synthesis, and neuronal and glial energy metabolism. It also is
important in the development of the collagen bone matrix
synthesis.1
6. Several stages of iron deficiency actually precede irondeficiency anemia. Discuss these stages---including the
symptomsand identify the labrotory values that would
be affected during each stage.
In the first stage of iron-deficiency anemia it is called the
early negative iron balance. During the first stage there really are
no symptoms and sometimes it is hard to detect during this
stage.
The second stage of iron deficiency there is severe iron
depletion. When you look at the lab results during this stage you
can see that the iron stores are low and serum ferritin falls.
Hemoglobin levels are within normal limits. The lab values that
are affected in the second stage are iron stores,
reticulooendothetlial marrow iron, transferrin iron-binding
capacity plasma ferritin, and iron absorption. During this stage
the symptoms might be paleness and fatigue.
The third stage of iron-deficiency anemia is inadequate
body iron and dysfunction and disease. During this stage there is
depletion in iron stores, serum iron falls, transferrin levels begin
to rise, and hemoglobin synthesis decreases. In stage 3 the lab
values that are affected during this stage is plasma iron,
transferrin saturation, sideroblasts, and erythrocytes
protoporphyin. During this stage symptoms are increase in
fatigue and a decrease in concentration.
Stage 4 is iron-deficiency anemia. During this stage there
is additional reduction in hemoglobin production and then
hypochromic and microcytic erythrocytes are produced. During

stage 4 the lab value that is affected is the erythrocytes, which

can be seen under a microscope. During this stage the
symptoms are dizziness, shortness breath, and weakness. In
extreme cases symptoms might be glossitis cheilosis, concave
nails, and dysphasia. 1,2
7. What potential risk factor(s) for the development of irondeficiency anemia can you identify from Mrs. Morris
history?
Mrs. Morriss risk factors for the development of irondeficiency are not taking her prenatal vitamins consistently
during her pregnancy, deficient in nutrient intake, and she is
deficient in iron rich foods within her diet. Pregnancy is a risk
factor for developing iron-deficiency anemia because much more
iron is needed to accommodate the blood expansion during
pregnancy.1
8. What is the relationship between the health of the fetus
and maternal iron status? Is there a risk for the infant if
anemia continues?
The relationship between the health of fetus and maternal
iron status is that iron is needed to help bring oxygen to the
fetus. If iron status is inadequate hemoglobin synthesis will be
reduced and this compromises the delivery of oxygen to the
uterus, placenta, and fetus. Iron also helps with the development
of the fetal and neonatal brain development during pregnancy. It
also is a cofactor in the collagen bone matrix synthesis. If the
status of iron is inadequate then fetal growth retardation and
premature birth can occur.
If anemia continues than the infant is at risk for a low birth
weight and inferior neonatal health after birth. Low birth weight
can be associated with infant mortality and morbidity. LBW
infants can also have smaller organs, which can put them at risk
for hypertension, obesity, learning disorders, behavior problems,
glucose intolerance, and cardiovascular disease.1
9. Discuss the specific nutritional requirements during
pregnancy. Be sure to address all macro- and
micronutrients that are altered during pregnancy.
During pregnancy addition nutritional needs need to be
met at this time. Pregnant womens metabolism increases by
15% during pregnancy. Only during the first trimester will they
eat the same that they have been eating before they were
pregnant. During the second trimester pregnant women should
be increase their nutrient intake by 340 to 360 kcal/day. The third
trimester they should increase their nutrient intake by another
112 kcal/day.
Additional protein is needed during pregnancy for the
maternal and fetal tissues. The need for protein increases with

each trimester, with the third trimester needing the most. In the
first half of pregnancy her protein needs would be the same as if
she were not pregnant. In the second half of pregnancy they
recommend 71 g/day.
There are no additional needs for carbohydrates and lipids
during pregnancy. The only time lipids and carbohydrates would
be altered would be if they need to meet their energy needs.
Other than that the recommended daily amount is sufficient. The
daily recommended for carbohydrates is 135 g/ day.
They recommend that pregnant eat more fiber. Foods they
recommend are whole-grain breads and cereals, leafy green and
yellow vegetables, and fresh and dry fruit. This helps provide
extra vitamins and minerals. The daily recommended for fiber is
28 g/day.
Vitamin B6 is a catalyst for many reactions involving
neurotransmitter production. It can also reduce nausea and
vomiting during pregnancy. They recommend a higher intake
during pregnancy. The daily recommended is 1.9 mg/day.
Folate aids in the synthesis of DNA, erythropoiesis, and
fetal and placenta growth during pregnancy. Normal daily
recommendations for folate are 400 mcg/day but during
pregnancy it is increased to 600 mcg/day.
Vitamin B12 is said to help the in development of the fetal
brain during pregnancy. Inadequate consumption of B12 can
affect cognitive and motor development. They recommend a
higher intake of vitamin B12 during pregnancy. The recommended
daily intake of Vitamin B12 is 2.6 g/day.
Choline is an essential nutrient that cannot be synthesized
by the body. It helps with the structural integrity of the cell
membrane, cell signaling, and never impulse transmission, and is
a major source of methy groups. The daily recommendation
during pregnancy is 450 mg/day.
Vitamin C helps aid in collagen synthesis and is an
antioxidant. The daily recommended is higher for pregnant
women and it is 85 mg/day
Vitamin A intake is supposed to be increased during
pregnancy but supplementation of Vitamin A is not advised
because it can cause neural crest defects. The daily
recommended is 750 g/day.
During the first trimester calcium intake is supposed to
increase and then return to normal during the 2nd and 3rd
trimester. The recommended amount of calcium during the first
trimester is 1300 and then in the second and third it drops back
down to 1000
Phosphorus intake is higher during the first trimester at
1250 mg/day and then it drops back down to 700 mg/day.

Daily recommendation for Magnesium is 400mg/day.

Iron intake is higher during pregnancy and at its greatest
demand after week 20. Pregnant women should consume citric
acid to help aid in the absorption of iron. The daily recommended
for iron is 27 mg per day.
Daily recommended for zinc is 12 mg/day during the first
trimester and 11 during the second and third trimester.
Iodine intake is supposed to higher during pregnancy.
Iodine is important in the metabolism of macronutrients because
it is part of the thyroxine molecule. Most people receive their
sufficient amount of iodine through iodized salt.
Copper intake is supposed to be higher during pregnancy.
An inadequate intake of copper can lead to poor embryo
development. It can also lead to oxidative stress, abnormal cross
linking, and altered cell signaling.1,2
10.
What are best dietary sources of iron? Describe the
differences between heme and nonheme iron.
The best dietary sources for iron are liver, being the best,
fish, oysters, clams, enriched or fortified cereals and breads, lean
meat, and poultry. These sources of iron all contain heme iron
and this type of iron is easier for our body to absorb. Dried bean
and vegetables are good plant sources of iron but they contain
non-heme iron and are harder for our bodies to absorb.
The difference between heme and non-heme is that heme
is found only in animal- based foods and is more absorbable than
non-heme Heme iron is what is found in myoglobin and
hemoglobin. While 50-60% of iron found in animal products is
heme the rest is non-heme iron and is harder for our bodies to
absorb. Non-heme is also the only iron found in plant sources.3
11.
Explain the digestion and absorption of dietary iron.
Both heme and non-heme iron are digested and absorbed
differently. Heme iron when digested is hydrolyzed from
hemoglobin to heme. This happens in the stomach and small
intestines by proteases. A heme carrier protein (hcp 1) then
carriers heme from the small intestines into the cytosol where
the ferrous iron is enzymatically removed. This usually happens
in the duodenum portion of the small intestines. The free iron
then binds to apoferritin to form ferritin. The absorption of iron
into the blood through the protein FP1 by active transport.
Non-heme iron must be hydrolyzed in the stomach by the
gastric secretions pepsin and HCl to be absorbed. Some of the
Fe2+ can be absorbed in the stomach or in the small intestines.
Its main transport is through DMT1 into the cytosol. The
synthesis of DMT 1 can be affected by the status of iron. If iron
levels are low DMT1 is increased and if iron level stores are high
DMT1 synthesis is low. The excess Fe3+ can be absorbed in the

more acidic environment of the stomach but once it reached the

basic environment of the small intestines is usually forms
Fe(OH)3. Any other Fe3+ requires vitamin C to reduce down to Fe2+
to then be absorbed. Non-heme is then moved into the blood the
same way as heme.1,3
12.
Access Mrs. Morriss height and weight. Calculate
her BMI and % usual body weight. 2
-Convert weight in lbs to kgs:
1420.453592=64.4kgs
-Convert height in cm to m:
165cm100=1.65m
-Calculate BMI:
64.4(1.65)2= 23.7
-Calculate %UBW:
(100142)/135= 105.2%
13.
Check Mrs. Morriss prepregnancy weight. Plot her
weight gain on the maternal weight gain curve. Is her
weight gain accurate? How does her weight gain compare
to the current recommendations? Was the weight gain
from her previous pregnancies WNL?
Mrs. Morris has not gained the enough weight for being at
23 weeks pregnant. According to the chart she should have
gained at least ten pounds in 23 weeks. She has only gained
7lbs. She has a normal BMI so she should gain any where from
25-35lbs throughout her pregnancy. According to her history she
has not gained enough weight during her last two pregnancies.1
14.
Determine Mrs. Morriss energy and protein
requirements. Explain the rationale for the method you
used to calculate these requirements. 2
-Estimated energy requirements calculations:
EER= 354-(6.9131) + 1.0 {(9.3664.4) + (7261.65)}
EER= 354-(6.9131) + 1.0 {(602.784+1197.9)}
EER= 354- (6.9131)+1.01800.684
EER= 354-(6.9131)+ 1800.684
EER= 354-214.31+1800.684
EER=1661 kcal/day
-Pregnancy adjustment for EER 2nd trimester:
EER= 1661 kcal/day+ 340 kcal/day
EER=2001 kcal/day
-Calculation for protein requirements:
PR=64.4kgs1.1g/day
PR= 71 g/day

15.
Using her 24-hour recall, compare her dietary intake
to the energy and protein requirements that you
calculated in question 14.
When you calculate her dietary intake from her 24-hourrecall she is way below her estimated energy requirement. She is
supposed to be at 2001 kcal/day and she is at 1500 kcal/day. She
is significantly under the recommended nutritional intake. This
supports the theory that she has poor nutritional status.
Her required protein when calculated is suppose to be 71
g/day. Her protein was at about 48 g/day, which is significantly
below her recommended amount.4
16.
Again using her 24-hour recall, assess the patients
daily iron intake. How does it compare to the
recommendations for this patient (which you provided in
question #9)?
Iron recommendations for pregnant women are higher than
the recommended daily requirement for non-pregnant women.
According to her 24-hour-recall she was under her requirements
for that day but she was only under by 1 mg. She consumed a
total amount of 26 mg of iron according to her dietary recall. The
daily recommended for pregnant women is 27 mg so she is the
almost at her daily recommended.4
17.
Identify the pertinent nutrition problems and the
corresponding nutrition diagnosis.
The pertinent nutritional problem is that she is pregnant
with iron-deficiency anemia. Since she is in her 23rd week of
pregnancy the demand for iron has gone up so the risk of her
health status decreasing is high. Her nutritional diagnosis is that
she has poor nutritional intake. Since she has poor nutritional
intake she is inadequate in all of her vitamin and minerals. She is
also deficient in protein and fiber. She has absolutely no fruit in
her diet. She also does not take her prenatal vitamin
supplements regularly and this also aids in her poor nutritional
status. She does not consume any water throughout her day and
the recommended fluid is 8-10 cups a day. She is also not
supposed to be consuming alot caffeine in one day. Mrs. Morris
smokes two cigarettes a day, which depletes nutrients in your
body and is not recommended during pregnancy. Mrs. Morris is
underweight for being in her 23rd week of pregnancy. She has not
gained a sufficient amount of weight during this pregnancy.1
18.
Write a PES statement for each nutrition problem.
-Iron deficiency related to poor nutritional intake as
evidence by pale skin, pale sclera, fatigue, and shortness
of breath.
-Low pregnancy weight related to poor nutritional intake as
evidence by 24-hour-recall and blood values.

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 does have side affects if taken on an empty
stomach. Such side effects include bloating, nausea, diarrhea,
heartburn, constipation, and darkening of the stool. There are
nutrient drug interactions such as foods that have oxalic acid,
phytate, and polyphenols can reduce the absorption of iron.
Some foods that contain these compounds are coffee, tea, and
spinach. This supplement should not be taken when eating these
foods. Iron also competes with phosphate and calcium because
they are absorbed through the same pathway in the small
intestine. 1,3
20.
Mrs. Morris says she does not take her prenatal
vitamins regularly. What nutrients does this vitamin
provide? What recommendations would you make to her
regarding her difficulty taking the vitamin supplement?
Prenatal vitamins provide:
-Folic acid
-Calcium
-Vitamin D
-Vitamin C
-Thiamine
-Riboflavin
-Niacin
-Vitamin B12
-Vitamin E
-Zinc
-Iron
-Iodine
Recommendations I would make to her to get her to take
her vitamins would be to put them in a weekly pillbox and
put them next a place she always goes to in the morning
such as her bathroom sink. If they are out and visible this
might help remind her to take them every day. She could
also carry one in her purse so when she is digging around
in her purse she is reminded to take them. She could also
set an alarm on her phone as a reminder to take them
every day.5
21.
List the factors that you would monitor to assess
her pregnancy, nutritional, and iron status.

-Monitor weight gain to make sure she is gaining the

appropriate weight each week.
-Monitor her nutritional status by having her keep a food
diary.
-Monitor iron status through blood work to see if her iron
supplements are improving her iron deficiency.
22.
You note in Mrs. Morriss 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 is a special supplemental nutrition program for
mothers, children, and infants. They help provide supplemental
food, health and nutritional screenings, breastfeeding and
support and referrals to healthcare, birth control and other
services for a lower cost. I would refer her back to the program
because I think it is a good resource while pregnant for food and
health care. They will help monitor her weight throughout the
rest of her pregnancy and give her nutritional counseling when
needed. The qualifications for enrollment are they must be a
resident of the state, pregnant, breastfeeding and/or postpartum,
or have a child up to the age of 5, and meet a family income
threshold. Qualifications I could confirm for her are pregnant and
she has children under the age of 5.6

References:
1. Mahan LK, Escott-Stump S, Raymond JL et al. Krause's Food & the
Nutrition Care Process. Elsevier Health Sciences; 2012.
2. Nelms M, Sucher K, Lacey K et al. Nutrition Therapy and
Pathophysiology. Cengage Learning; 2010.
3. Gropper SS, Smith JL. Advanced Nutrition and Human
Metabolism. 6.Wadsworth, Cengage Learning. 2013: 426-440.
4. Available at: https://www.supertracker.usda.gov/foodtracker.aspx.
Accessed October 26, 2014
5. Available at: http://www.webmd.com/baby/guide/prenatalvitamins. Accessed on October 26, 2014
6. Available at: http://wic.findfamilyresources.com/?
k=wic&p=&c=16476057181607997040&ad=50973887419&mt
=e&nk=g&ca=&mb=&ai=&a=aw&gclid=Cj0KEQjw_byiBRCu9qm
5lc28ufgBEiQAWq-ta57bcX7iEFAR3OCyJMxOYy1F_O2kMvydq1mu-CQ_EkaAqhj8P8HAQ. Accessed on October
26,2014.