Is anemia a common occurrence in older adults?

Read the following case studies in your Bowles Case Study book. Answer the specified questions listed with each case study.
• Case 11.7: Anemia (starts on p. 140)
o If it is the Summer or Winter term, answer questions 2, 7 and 9
Case 15.6: Hydration Management (starts on p. 191)
• If it is the Summer or Winter term, answer questions 1, 3, 5, and 6

Case 11.7 ■ Anemia
M╛╛r. Brown is an 83-year-old male with a past medical history that includes HTN,
CAD, congestive cardiomyopathy, and coronary artery bypass grafting (at age 73).
He was recently diagnosed with anemia by his primary care provider and was referred
to a specialist. He is being seen by a hematologist/oncologist who performed blood
tests and a bone marrow biopsy and diagnosed myelodysplastic syndrome (MDS).
Mr. Brown has been sent to the infusion center at the hospital for a blood transfusion.
He is accompanied by his son and wife. After Mr. Brown completes �check-in, he
receives his identification bracelet, and the nurse verifies orders for the blood transfusion.
The nurse brings Mr. Brown and his family into a treatment room at the infusion
center and proceeds with the transfusion center treatment protocol.
Upon interviewing Mr. Brown for the infusion center initial assessment, the nurse
learns that the patient reports a 3-month history of fatigue and occasional palpitations,
which he attributed to his heart condition. He states he would often rest in the
afternoon; napping a couple of hours would make him feel better, then he would
have enough energy to get through the rest of his day. He reports the symptoms got
worse about 4 weeks ago; he began to feel dizzy whenever he would get up after
sitting for any length of time, and he felt that he was becoming too weak. His wife
interjects, “He was so weak when he stood up that he almost fell a couple of times. So
I insisted he make an appointment to see the doctor.” This prompted him to schedule
an �appointment with his primary care provider. The physician examined him in the
office and informed him that he may have anemia and that he needed laboratory studies
to evaluate for this condition.

1. What symptoms does Mr. Brown report that may be experienced
   with anemia?
2. Is anemia a common occurrence in older adults? What
   co-morbid conditions can increase the incidence?
   The primary care provider ordered a complete blood count, thyroid-stimulating hormone
   (TSH), iron studies, serum B12, folate, and comprehensive metabolic panel and
   found the following abnormal results: hemoglobin 8.5, hematocrit 26, platelet count
   110,000; MCV 104, peripheral smear showed increased blasts and ringed sideroblasts;
   BUN 22, creatinine 1.1; serum B12, folate, iron, and TSH within normal limits.
3. Which of Mr. Brown’s laboratory values confirm the
   diagnosis of anemia?
   Mr. Brown’s primary care provider refers him to a specialist promptly. One week later,
   he followed up with the hematologist/oncologist and had additional outpatient blood
   work and a bone marrow aspiration. His hemoglobin dropped to 7.0, requiring a
   blood transfusion.
4. What is MDS? What are the overall goals for treatment?
   The hematologist instructed Mr. Brown to go to the infusion center at the hospital where
   he would have additional blood drawn for typing and cross matching and subsequently
   receive two units of packed red blood cells. Mr. Brown reports to the nurse that the
   hematologist also explained other medical interventions that he could have for treatment
   of this condition, which included “shots to make my body produce more blood
   cells, vitamins, chemotherapy, or bone marrow transplant.” Mr. Brown states, “I decided
   to have the blood transfusion. . . . I don’t know if I will do anything else after this.”
5. What patient teaching should the nurse provide regarding the
   procedure of a blood transfusion?
6. What should Mr. Brown’s comment, “ . . . I don’t know if I will do
   anything else after this” prompt the nurse to do?
   The nurse reviews Mr. Brown’s home medications, allergies, and history of past blood
   transfusions and any reactions experienced. He denies any known allergies and reports
   that the only blood transfusion he has had in the past was when he had his open heart
   surgery, and he did not have any reaction or complication. Mr. Brown states that he
   took his medications this morning with the exception of a baby aspirin as directed by
   his physician.
   The nurse completes further assessment and finds the following: Mr. Brown
   denies chest pain or shortness of breath. He states, “I get winded if I do any walking.”
   He denies abdominal complaints and reports he has a little swelling of his feet and
   ankles “ . . . but I have that all the time . . . elevating my legs makes it go down.” He
   denies any dizziness, headache, or chills.
   Physical examination: BP 140/80, heart rate 88 per minute, respirations 18 per minute,
   temperature 98.7; pulse oximetry 94% on room air. Skin, pale; HEENT, conjunctiva
   no jugular venous distention; trace edema of feet and ankles bilaterally; pedal pulses
   +2 = bilaterally.
7. What is the purpose of the nursing assessment prior to the
   blood transfusion? Does Mr. Brown appear to be stable for this
   procedure?
8. Put the following steps in correct order for transfusing blood
   according to standard protocol.
   a. Collect a set of vital signs 15 minutes after the transfusion
   has started.
   b. Assure a large bore angiocath or central line intravenous
   access is available.
   c. Set the IV pump to allow for a 3-hour time period of
   infusion.
   d. Obtain the packed red blood cells (PRBCs) from the blood bank.
   e. Validate the patient’s identification, blood type, donor type,
   and expiration of the blood product at the bedside with
   another licensed professional.
   Mr. Brown receives his first unit of blood without reaction and actually naps through
   most of the transfusion. While receiving the second unit of blood, the nurse notes that
   Mr. Brown’s blood pressure has increased to 150/90, his pulse is somewhat bounding,
   his temperature remains normal (98.6), and pulse oximetry remains good on room
   air (98%). The nurse checks for other signs and symptoms. Mr. Brown denies chest
   pain, dizziness, fever, chills, cough, or headache. Physical examination shows: respiratory,
   lungs clear; cardiovascular, regular rate and rhythm; edema of lower extremities
   remains the same.
9. What may these symptoms represent? What action should the
   nurse take?
10. Briefly review various types of transfusion reactions a patient
    may experience with blood products.
    Two weeks later, Mr. Brown and his wife visit the oncologist/hematologist’s office for
    a routine follow-up. They have discussed further treatment options and have made the
    decision to continue with supportive care. Use the website Myelodysplastic Syndromes at
    www.cancer.gov/cancertopics/pdq/treatment/myelodysplastic/Patient/page3 to answer
    Question 11.
11. Under the category of “supportive treatment,” what other options
    besides transfusion therapy and antibiotics are available?
12. If Mr. Brown uses one of these options, why might a community
    health nurse be required to administer the drug

Case 15.6 ■ Hydration Management
M╛╛rs. Williams is an 88-year-old African American woman admitted to the acute
care unit with dehydration following acute gastroenteritis. Her sister found her
at home this morning, very weak, unable to walk without assistance, and confused.
Mrs. Williams indicates that she’s had nausea, vomiting, and diarrhea for several days
and a feeling of “bloating” for a couple of months.
Before hospitalization, Mrs. Williams was living alone on the third floor of an
apartment complex for older adults. She no longer drives. Her social history includes
being widowed with one daughter who lives in another state and one sister who lives
within walking distance from Mrs. Williams’s apartment complex. Mrs. Williams is a
retired office worker and her income consists of her monthly Social Security benefit
check and a small pension. She is described by her sister as limited in activities such
as shopping, traveling, and cooking because of fatigue and periods of confusion. She
reports fatigue associated with activities of daily living (ADL).
Mrs. Williams has a medical history of hypertension treated with furosemide and
an ACE inhibitor, as well as osteoarthritis (particularly of knees) treated with OTC ibuprofen.
Her sister also reports that Mrs. Williams has lost “a good bit” of weight in the
past 6 months. Mrs. Williams agrees that she has a decreased appetite but is unsure
how many pounds she has lost. On admission to the nursing unit, she is oriented to
person but not to place or date. Vital signs on admission are BP 100/56, HR 94, R 12,
T 100.2°F orally. Weight is 130 pounds, height 5 feet 2 inches. Her complete blood
count (CBC) is within normal limits with WBCs 8.1 × (10)3, RBCs 4 × (10)6, HGB 12 g/
dL, HCT 42%, and platelets 400 × (10)3.

1. What risk factors does this patient have for dehydration?
2. Given Mrs. Williams’s age and history, what assessments and
   laboratory tests should be done to further evaluate her fluid
   status at the time of admission?
3. Mrs. Williams’s sister asks whether the elevated temperature
   indicates that her sister needs antibiotics. What understanding
   should form the basis of the nurse’s response?
   Mrs. Williams is at risk for both acid–base and fluid–electrolyte disorders. Whether
   Mrs. Williams exhibits hyponatremia or hypernatremia will depend on the relative
   severity of the vomiting and diarrhea she experienced, and her ability to drink and
   absorb water. It is essential that her electrolytes be evaluated thoroughly both at baseline,
   and as treatment progresses.
4. Explain why Mrs. Williams is at risk for each of the following
   disorders, and what the laboratory and clinical findings would
   likely be if the condition existed: hypokalemia, hypernatremia,
   hyponatremia, metabolic acidosis, metabolic alkalosis.
5. What instructions should the RN give the certified nursing
   assistant (CNA) when delegating aspects of Mrs. Williams’s care?
   Mrs. Williams’s vomiting is controlled by antiemetics on admission to the unit, but
   she refuses oral intake other than occasional sips of water and chips of ice. She is
   started on an IV of 5% dextrose in 0.45% sodium chloride solution with 30 mEq K+/L
   at 150 mL per hour.
6. What considerations should the nurse have in administering
   this fluid replacement?
7. The CNA asks whether a Foley catheter can be inserted to
   help keep Mrs. Williams dry. What are the advantages and
   disadvantages of use of a Foley catheter in this situation?
8. What assessments should be repeated once Mrs. Williams’s fluid
   volume deficit is resolved?
   Following 3 days of IV fluid administration, antiemetics, and Imodium (loperamide),
   Mrs. Williams’s vomiting, diarrhea, and fluid volume deficit have resolved. Her
   IV �therapy is discontinued. Her confusion has decreased, but she still has trouble
   remembering date and place. She continues to experience anorexia and feeling that
   she’s “full” although she refuses more than occasional sips of clear liquids. She continues
   to have weakness and apathy. Her abdomen is soft and diffusely tender, with
   active bowel sounds. Lab studies now reveal anemia, and her stool is guaiac positive
   for blood. Endoscopy with biopsy is performed, and gastric carcinoma is diagnosed.
   A CAT scan reveals metastasis to the liver and lungs. Physicians determine that
   Mrs. Williams’s malignancies cannot be controlled, so cancer treatment will not be
   provided. Her daughter is notified, and all agree that Mrs. Williams’s care will continue
   in an inpatient hospice setting.
9. Using the National Cancer Institute’s Fact Sheet (n.d.) at www
   .cancer.gov/cancertopics/factsheet/Support/end-of-life-care, what
   suggestions might you recommend to Mrs. Williams’s daughter to
   provide emotional comfort to her mother?
10. There is conflicting research evidence regarding the efficacy of
    providing hydration at the end of life. How do you explain both
    points of view to Mrs. Williams’s daughter?
    Some patients are more comfortable without artificial hydration, whereas others are
    more comfortable when artificial hydration is used. The driving forces in the decision
    to provide artificial hydration are often emotional, cultural, religious, and/or moral
    convictions on the part of patients, families, and caregivers. Mrs. Williams and her
    daughter request that hydration be attempted to see whether it could improve her
    �cognitive status. The RN inserted a subcutaneous needle into her anterior thigh in
    order to administer fluids by hypodermoclysis. Mrs. Williams received 1 L of fluid
    within 24 hours, and improved her cognitive status. She died peacefully 3 days later
11. What are alternate routes of hydration when the oral route
    is no longer available? List the advantages and potential
    complications of routes for artificial hydration at end of life.
    Suggested Resources
    Dalal, S., & Bruera, E. (2004). Dehydration in cancer patients: To treat or not to treat. Journal of
    Supportive Oncology, 2, 467–479.
    Derrer, D. T. (2013). Dehydration in adults. WebMD. Retrieved from http://www.webmd
    .com/a-to-zguidess./dehydration-adults?page=4
    Hospice and Palliative Care Nurses Association. (2011). HPNA position statement. Artificial
    nutrition and hydration in advanced illness. Retrieved from https://www.hpna.org/�
    displayPage.aspx?Title1=Position%20Statements
    Mentes, J. C. (2012). Managing oral hydration. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer
    (Eds.), Evidence-based geriatric nursing protocols for best practice (4th ed., pp. 419–430).
    New York, NY: Springer Publishing Company.
    Morrow, A. (2014). Artificial nutition and hydration. About.com. Retrieved from http://dying
    .about.com/od/lifesupport/a/artificialfeed.htm
    Mulvey, M. (2014). Fluids and electrolytes: Balance and disturbance. In J. L. Hinkle &
    K. H. Cheever (Eds.), Brunner and Suddarth’s textbook of medical–surgical nursing
    (13th ed., pp. 247–249). Philadelphia, PA: Lippincott Williams & Wilkins.
    National Cancer Institute, U.S. National Institutes of Health. (n.d.). National Cancer Institute.
    FactSheet: End-of-life care: Questions and answers. Retrieved from http://www.cancer
    .gov/cancertopics/factsheet/Support/end-of-life-care
    Shepherd, A. (2011). Measuring and managing fluid balance. Nursing Times, 107(28), 12–16.
    Retrieved from http://www.nursingtimes.net/Journals/1/Files/2011/8/1/Fluid%20�balanceCorr
    .pdf.pdf

Sample Solution