CASE STUDY 3: Iron-deficiency Anemia

Roy 1st Level Assessment: Subjective + Objective

(What health condition exists)

subjective: fatigue, dizziness, SOB with exertion,

objective: pale skin, HR 108, O2 91%, cap refill >3 sec

RATIONALE: findings indicate decreased oxygen delivery and blood loss, as evidence by fatigue, pallor and melena.

Roy 2nd Level Assessment: Subjective + Objective

(Why health condition exists)

• GI bleeding

• decreased Iron stores

RATIONALE: chronic blood loss reduces iron availability, impairing hemoglobin production and oxygen delivery

Lab Interpretation and Rationale:

RBC/HGB/HCT

findings: low HGB/HCT

rationale: anemia

Subjective Correlation:

RBC/HGB/HCT

findings: fatigue, dizziness, SOB with exertion

rationale: hypoxia, manifestations of anemia

Objective Correlation:

RGB/HGB/HCT

findings: pale skin, tachycardia (HR 108), hypoxia (O2 sat 91% )

rationale: all signs of oxygen deficit

Lab interpretation & Rationale:

MCV (mean corpuscular volume)

findings: low MCV

rationale: Microcytic Anemia classic in iron deficiency

Correlation

associated with chronic blood loss, leading to smaller, pale RBCs

Lab Interpretation & Rationale:

Ferritin

findings: 8ng/mL = severely low ferritin levels

rationale:iron stores are extremely low in value

subjective correlation:

Ferritin

subjective correlation: black, tarry stools (melena)

this is a hallmark of GI bleeding

objective correlation:

ferritin

objective correlation: positive stool guaiac

confirms occult blood in stool

Diagnosis connection

the lab values and clinical signs (fatigue, pale appearance, melena) point directly to iron-deficiency anemia caused by chronic GI blood loss. his daily NSAID use is the likely source of mucosal damage leading to occult bleeding

Nursing Diagnosis

Inadequate tissue perfusion related to decreased oxygen delivery because of decreased iron stores as evidenced by capillary refill >3 seconds, oxygen saturation 91% on room air, and HGB 7.9 g/dL

SMART goal

patient will demonstrate improved oxygenation by increasing HGB to > 10 g/dL, reporting reduced fatigue, and walking 20 feet without shortness of breath within 5 days of initiating iron supplementation

Intervention 1 with rationale: (diet)

1. administer oral iron supplements with vitamin c + education on avoiding foods w/calcium during administration —> this directly treats the cause of anemia and inadequate tissue perfusion by replenishing iron stores and improving RBC production

intervention 2 with rationale: (meds)

2. discontinue NSAID use and notify provider to assess for GI damage —> this targets the risk for ongoing blood loss and addresses the root causes of iron deficiency, reducing the risk of further decline in tissue perfusion and oxygenation.

Expected Outcomes

• improved hemoglobin and ferritin levels

• resolution of melena and increased activity tolerance

Evaluation

• monitor follow-up lavs (HGB< HCT, ferritin) to confirm improvement

• patient will report less fatigue and show increased tolerance of physical activity

• absence of GI bleeding symptoms (e.g., black stools) will be confirmed during assessments