Choice # 1: 12 yo Kathy
Iron deficiency anemia is a condition that is caused by low levels of iron in the blood which leads to deficient production of the hemoglobin that is found in the red blood cell (RBC) which is necessary for proper oxygenation of the cells in the body. It is considered to be the most common type of anemia worldwide with about 25% of the world’s population being anemic (Mantadakis et al., 2020). According to Moustarah & Mohiuddin (2021), dietary iron has two forms
(heme and non heme). Heme forms only come from animal derived foods and seems to be absorbed better and more easily than non heme iron.
In regards to Kathy’s new diagnosis of iron deficiency anemia, I would make sure to ask about the patients eating habits including diet type, consumption of cow milk, exercise habits, menstruation, and whether or not the child was a picky eater. The answers to these questions would create different pathways to possible correction of anemia. For example, if the patient consumes a normal diet, I would recommend adding foods high in iron to their daily regimen such as green leafy vegetables (kale, broccoli, spinach), beans such as lentils, red meats (liver, organ meats, beef), turkey, pork, chicken, fish, and prunes (Cafasso & Link, 2021). If it was mentioned that Kathy drank a lot of cow milk, I would educate the parents and child that this could lead to possible anemia and that consumption of milk should be limited to the proper proportions for her age group. If it was found that Kathy was a picky eater, an iron supplement would be recommended because being a picky eater could prevent Kathy from consuming the proper food items that she needs to increase iron levels. Lastly, if Kathy was menstruating, I would further ask when she began menstruating and how her flow was. This would be done to analyze whether she has a heavy flow that could contribute to loss of iron. Clinical practice guidelines for iron deficiency includes assessing for behavioral disturbances, impaired cognitive function, fatigue, and PICA (ice eating). Oral supplementation is considered be 3-6 mg/kg/day and treatment should continue for 3 months after the correction of anemia (RCH, 2019). In order to increase absorption of iron supplement, I would recommend taking the iron with orange juice and on an empty stomach.
Choice #3 Anne COPD
The key to effectively manage COPD is to alleviate acute symptoms and decreasing the occurrence of exacerbations in the future. According to the American Thoracic Society (ATS), an exacerbation is defined as an acute change in the patient’s normal baseline in terms of cough, dyspnea and sputum, that merits a change in therapy (Evensen, 2010). In Anne’s case, she has worsening productive cough with sputum, shortness of breath, hypoxic, and has diminished breath sounds with wheezes. Based on these symptoms, I would deem her exacerbation of moderate exacerbation as her symptoms cannot be controlled with an increase of her regulation medication (Symbicort) alone. Her vitals are slightly abnormal but she does not have altered mental status, chest tightness, fever or increasing confusion which is the hallmark of respiratory compromise that requires hospitalization (Evensen, 2010).
I would confirm what dose of Symbicort Anne is taking and review if she takes if as directed, along with any other medications or supplements she may have started. If she is taking the lower dose Symbicort, I can increase it to the higher strength: 160/4.5 for adequate control. Next, I would prescribe antibiotics for her moderate exacerbation. Patients with COPD exacerbations often have high levels of bacteria in their lower airways and therefore will benefit from antibiotics (Evensen, 2010). Antibiotic treatment options include narrow spectrum agents such as amoxicillin, ampicillin, Bactrim or doxycycline. If Anna has taken antibiotics recently, then a broad-spectrum agent such as Augmentin or cephalosporins can be considered (Evensen, 2010). Lastly, I would add a short course of corticosteroids to improve hypoxemia and expiratory volume. I would prescribe prednisone 40mg daily PO for seven days. According to the AECOPD, tapering if not necessary and inhaled corticosteroids have no role in managing an acute COPD exacerbation (Evensen, 2010).
Prevention and Education:
I would have a conversation with Anne to assess if she understands what her condition is, how it affects her body, what happens where there is a flare, and how to prevent or reduce the impact of COPD in her life. I would recommend staying active with regular exercise, stay away from second-hand smoking (or smoking in general), eating a healthy diet, and taking medications as ordered. Lastly, it is also important for Anne to know her vaccination status as it also helps in the prevention of exacerbations and reduce mortality. People with COPD need to manage their lung inflammation as it can cause permanent damage and block airways. Vaccine-preventable diseases such as the flu can cause increased inflammation and therefore can be averted through vaccinations. The CDC recommends that people with COPD get annual influenza vaccines and pneumococcal vaccine for those over 65 years old. Anne is 68 years-old so this recommendation applies to her (Evensen, 2010).