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  1. 1. FolicAcid Deficiency: MoreWine, Anyone? Pharmacotherapy Casebook, 11th Ed Leslie Dawson Kathaleen Osterritter Suphanith Simthong Chung Siu
  2. 2. ChiefComplaint “My stomach hurts and I have been throwing up today.”
  3. 3. History of Present Illness  Laura Jones is a 43-year-old woman with a 1-day history of vomiting and mild abdominal pain.The pain radiates down to the lower abdominal quadrants bilaterally. She presents to the ED after experiencing some chest discomfort late in the day. She denies any fevers, chills, or similar pains in the past. She also complains of loose stools and chronic fatigue for the past 2–3 months.
  4. 4. Past Medical History Fibromyalgia Celiac disease Hypothyroidism Osteopenia History of endometriosis Placenta previa—s/pTAH– BSO
  5. 5. Family History  Mother positive for lupus  sister with Crohn disease  negative for DM, CAD, CVA, CA
  6. 6.  Married; (+) alcohol—three to four glasses of wine per day, increased recently from one to two glasses after her mother-in-law moved in  (+) smoking tobacco 0.5 ppd × 25 years  (–) recreational drug use  unemployed Social History
  7. 7. Meds  Levothyroxine 100 mcg PO daily  OrthoTri-Cyclen Lo 1 tab PO daily
  8. 8.  Doxycycline—rash Allergies
  9. 9. Review of Systems  (+) Generalized weakness  (–) dizziness; (–) weight gain or loss; (–) fever; (–) vision or hearing changes; (–) cough, chest pain, palpitations; (–) shortness of breath  (+) nausea/vomiting, abdominal pain, loose stools  (–) rectal bleeding; (–) nocturia or dysuria  (+) bilateral lower extremity weakness  (–) edema, rashes, or petechiae; (–) symptoms of depression or anxiety; (–) history of bleeding problems orVTE
  10. 10. Gen  Caucasian female who appears generally ill, but nontoxic VS  BP 135/90 mm Hg, P 82 bpm, RR 40,T 35.5°C; Ht 64′′,Wt 52 kg Skin  No petechiae, rashes, ecchymoses, or active lesions; decreased skin turgor HEENT  Atraumatic/normocephalic; PERRLA, EOMI; conjunctivae pink, sclera white; TMs intact and reactive; nares patent; tongue is large and erythematous; dry mucous membranes. Neck/Lymph Nodes  Normal ROM; no JVD, adenopathy, thyromegaly, or bruits Lung/Thorax  Lungs CTA bilaterally CV  RRR; no murmurs, gallops, or rubs Abd  Soft, nondistended, with midepigastric and right flank and right lower quadrant tenderness; (+) bowel sounds Genit/Rect  Deferred MS/Ext  Lower extremities warm with 2+ bipedal pulses; no clubbing, cyanosis, or edema Neuro  CN II–XII grossly intact; decreased muscle strength 3/5 bilaterally in upper and lower extremities; DTRs 2+ throughout Physical Examination
  11. 11. Labs Na 138 mEq/L Hgb 12.6 g/dL AST 128 IU/L Folate 2.8 ng/mL K 4.2 mEq/L Hct 37.2% ALT 52 IU/L B12 242 pg/mL Cl 102 mEq/L RBC 3.78 × 106/mm3 Alk phos 142 IU/L CO2 21 mEq/L Plt 217 × 103/mm3 GGT 288 IU/L BUN 7 mg/dL WBC 6.3 × 103/mm3 T. bili 2.1 mg/dL SCr 0.52 mg/dL MCV 120.4 µm3 Alb 3.4 g/dL Glu 89 mg/dL MCH 40.5 pg TSH 2.06 mIU/L Amylase 404 IU/L MCHC 33.6 g/dL T4, free 1.2 ng/dL Lipase 679 IU/L RDW 12.1%
  12. 12. Assessment Acute pancreatitis secondary to alcohol use Dehydration Macrocytic anemia secondary to folate deficiency
  13. 13. 1.a.What subjective and objective information indicates the presence of anemia secondary to folate deficiency?  Subjective information:  chronic fatigue for the past 2–3 months, generalized weakness, bilateral lower extremity weakness [objective as well], chest discomfort late in the day, vomiting, abdominal pain radiating bilaterally, loose stools  Objective information:  tongue is large and erythematous, decreased muscle strength 3/5 bilaterally in upper and lower extremities, midepigastric and right flank and right lower quadrant tenderness. Folate 2.8 ng/mL, RBC 3.78 × 106/mm3, MCV 120.4 µm3, MCH 40.5 pg, BP 135/90 mm Hg, P 82 bpm, RR 40, T 35.5°C; Ht 64′′,Wt 52 kg
  14. 14. 1.b.What additional information is needed to fully assess this patient’s anemia?  More information about this patient’s dietary habits, MMA level to rule out B12 deficiency, homocysteine testing may also help confirm the diagnosis, as could erythrocyte folate levels. I’d like additional information on this patient’s stooling habits, including the presence or absence of steatorrhea.
  15. 15. 2.a.Assess the severity of the anemia based on the subjective and objective information available.  Anemia is defined as an abnormally low hemoglobin concentration in the blood.This can be related to bleeding, although when no source of bleeding is uncovered, insufficient dietary intake of vegetables and increased amount of alcohol intake for instance and GI malabsorption may be the cause (Kline & Chiplinski, 2020). Celiac disease can be an example of a GI malabsorption occuring in our patient. Given our 43YO patients' systems of fatigue, generalized weakness, dry mucous membranes, I would say her symptoms are mild. Anemias are going to have classic symptoms of fatigue, weakness and shortness of breath related to decreased oxygen carrying capacity (Kline & Chiplinski, 2020). Her vital signs are stable BP 135/90 mm Hg, P 82 bpm, RR 40,T 35.5°C; Ht 64′′,Wt 52 kg, her folate level is 2.8ng/mL which is low. Majority of her symptoms relate back to her primary diagnosis of acute pancreatitis.To note, Mrs. Jones there are psychosocial and economic factors to access. Mrs. Jones' mother-in-law just moved in which made her want to drink one- two more glasses of wine nightly. She is also unemployed.This can be putting a strain on her and her family.
  16. 16. 2 . b .Create a list of the patient’s drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness, safety, and patient adherence.  Mrs. Jones is currently taking Levothyroxine 100mcg PO daily andOrthoTricyclen LO 1 tablet PO Daily.  Levothyroxine is a drug of a choice for hypothyroidism, which is appropriate for Mrs. Jones since she has pmhx of hypothyroidism.This is the drug of choice for thyroid replacement because it is chemically stable and relatively inexpensive (Cook & Greer, 2020).There are a few adverse effects to consider when taking Levothyroxine. These are under-replacement, over- replacement, and potentially causing heart failure, atrial fibrillation, angina pectoris, and myocardial infarction.The patient should take this medication daily, the half-life is seven days (Cook & Greer, 2020).  OrthoTri Cyclen LO is an oral contraceptive, which is not appropriate for Mrs. Jones related to her hysterectomy. Given this information it is important to include that some females take oral contraceptives to decrease menopausal symptoms.These symptoms include irregular periods, night sweats, and hot flashes. Although, if taking this medication is a must, the patient should take this medication after eating dinner or at bedtime to help with an upset stomach or nausea. It is important to take this medication at the same time each day, 24 hours apart (Cook & Greer, 2020).  We will be adding some medications to Mrs. Jones medication list for this admission to treat her acute pancreatitis and anemia.  Given Mrs. Jones’ dry mucous membranes I would assess whether she needs IV fluids related to her acute pancreatitis.This helps reduce the risk of SIRS and organ failure (Cook & Greer, 2020). I would also assess her electrolytes, although those are within normal range.  We will relieve her abdominal pain with NSAIDS [Diclofenac].  If there is a source of bacterial contamination antimicrobials or antibiotics will need to be ordered. For instance, meropenem or metronidazole [Flagyl] (Cook & Greer, 2020).  For her anemia, folate deficiency she should receive a supplement.Alcohol interferes with folic acid absorption. Mrs. Jones should supplement 1 to 5mg daily of folic acid to replace stores. As her nurse we can educate her on foods to intake that are high in folate. For instance, beef life, green leafy vegetables, orange juice, and rice (Cook & Greer, 2020).  Mrs. Jones should continue to take all her medications.These medications do not pose a risk for interactions.They are appropriate for her diagnosis and safe for use.
  17. 17. 2.c.Could the patient’s folate deficiency have been caused by drug therapy or comorbidity?  Mrs. Jones folate deficiency could have been caused by her celiac disease and increased amount of alcohol intake, but I do not think Levothyroxine or OrthoTri Cyclen could have caused her to have decreased levels of folic acid. Celiac disease is a GI disorder leading to malabsorption in the gut (Cook & Greer, 2020). Unfortunately, for Mrs. Jones folic acid is absorbed in the GI tract which probably was not occurring in her case due to her previous diagnosis.
  18. 18. 2. d .Why is it important to differentiate folate deficiency from vitaminB12 deficiency, and how is this accomplished?  It is important to quickly differentiate folate deficiency from Vitamin B12 deficiency becauseVitamin B12 deficiency can cause neurologic and hematologic complications (Cook & Greer, 2020). The patient typically presents with bilateral paresthesia, as well as your typical anemia symptoms. If this is not treated, it can progress to ataxia, dementia-like symptoms, psychosis, and vision loss (Cook & Greer, 2020). Individuals withVit B12 deficiency you will see laboratory findings of MCV elevated, a peripheral blood smear showing macrocytosis accompanied by hyper segmented polymorphonuclear leukocytes.This is one of the earliest indications of the disease.This patient's bilirubin levels may be elevated, low reticulocyte count, low B12 level, and low HCT (Cook & Greer, 2020).
  19. 19. 3.a.What are the goals of pharmacother apy for this patient’s anemia?  Pharmacotherapy is based on initiating appropriate drug replacement therapy treatment based on etiology and pertinent drug interactions.  The patient will adhere to the treatment plan for the one month with success by taking a 1mg folic acid tablet daily, and recording daily intake on a note pad to keep a record.  The patient will display a normal in folate levels, 4.0 to 17.0 nanograms per milliliter (ng/mL) in one week (“Folic acid - test,” n.d.).  The patient is able to achieve a dietary goal of having three foods high in folic acid with each meal daily.  The patient will recognize three signs and symptoms of anemia by the end of one week.  The patient will be able to walk approximately 50 feet without verbalizing complaints of fatigue or exhibiting signs of fatigue in one week.
  20. 20. 3.b.What nondrug therapies may be used to correct this patient’s folic acid deficiency?  Folic acid deficiency treatment consists of replacement therapy and dietary changes, even for patients with absorption problems. Because humans cannot synthesize sufficient folate to meet total daily requirements, they depend on nutritional sources. Dietary sources rich in folate include fresh green leafy vegetables, dairy products, legumes, whole grains, citrus fruits, and animal organs such as the liver and kidney. Limiting alcohol interferes with folic acid absorption and utilization at the cellular level and decreases hepatic stores of folic acid (DiPiro et al, 2020).
  21. 21. 3.c.What feasible pharmacother apeutic alternatives are available for treating this patient’s anemia?  Folic acid:Taking a daily folic acid tablet will help you increase your folate levels.The synthetic version of the B vitamin folate is called folic acid. By active and passive transport mechanisms, folate is transported across the intestinal wall and absorbed in the jejunum (Khan & Jialal, n.d.).The villi are harmed by celiac disease, making it impossible for your body to absorb the nutrients it needs for growth and wellness.Therefore, celiac disease can prevent folate absorption, leading to a shortage. One of the frequent side effects of celiac disease is anemia brought on by folic acid malabsorption.  Ascorbic acid (Vitamin C) tablet multivitamin:The pancreatitis Mrs. Jones has makes it more challenging for the body to absorb folic acid. Consequently, vitamin and mineral supplements are needed as replacements depending on the type of anemia, the presence of low oral intake, and any diagnosed deficiencies.Vitamins are essential for maintaining health because they serve as the body's building blocks. For the body to grow and operate properly, vitamin C is required. In addition, it is crucial to immune system operation. Anemia can result from a vitamin C deficiency because vitaminC is necessary for the production of red blood cells and maintaining healthy red blood cells.
  22. 22. 3 . d .Createan individualized, patientcentered,teambasedcare planto optimizemedication therapyforthis patient.Include specificdrugs,dosageforms, doses,schedules,anddurationsof therapy.
  23. 23. Folic acid  Once a day, take a 1 mg folic acid tablet by mouth. After four months, once the clinical symptoms have subsided and the test values have returned to normal, reduce the dose to 0.4 mg once a day (Skidmore-Roth, 2020, p. 1717).  The synthetic version of the B vitamin folate is called folic acid. The patient's folic acid deficiency-related anemia is replaced with vitamin and mineral supplements. Mrs. Jones consumes three to four glasses of wine daily, lowering folic acid absorption, cellular use, and hepatic folic acid storage. Please avoid taking your folic acid within two hours of consuming antacids with aluminum or magnesium, which could prevent the folic acid from absorbing correctly (Skidmore-Roth, 2020, p. 1717).
  24. 24. Ascorbic acid  Take one 500 mg oral multivitamin tablet of ascorbic acid (vitamin C) by mouth daily (Skidmore-Roth, 2020, p. 1719).  Mrs. Jones's current pancreatitis and past Celiac disease make it more challenging for the body to absorb folic acid. However, for the body to grow and operate properly, vitamin C is required. It also has a significant impact on immune system performance.
  25. 25. Lactated Ringer's  Administer IV lactated ringer's bolus of 20 ml/kg followed by 150- 300ml/hr for the first 24 hours. If she reponses to this therapy as assessed by BUN, the rate should be reduced to 2ml/kg/hr for 48 hours.  Goals for fluid therapy when manging acute pancreatitis focus on a heart rate less than 120/min, mean arterial pressure 65-85mmhg, urinary output greater than 0.5 to 1ml/kg/hr, invasive measures of stroke volume or intrathoracic blood volume (Cook & Greer, 2020). All patients with acute pancreatitst should receive supportive care to prevent sepsis (Cook & Greer, 2020).
  26. 26. Ondansetron  Administer IV ondansetron (Zofran) 2mg /ml as needed [PRN] every 4 hours-8 hours as needed for a week.  Ondansetron works by inhibiting the activities of serotonin, a chemical your body naturally produces that may result in nausea and vomiting (Skidmore-Roth, 2020, pp. 1147-1149).Therefore, you should give treatment based on a specific pathophysiologic cause of nausea and vomiting. It would be best to prevent nausea for the predicted durations by providing the necessary antiemetics using the most efficient route, considering the medication's side effects.
  27. 27. Promethazine  For the initial dose of Promethazine (Phenergan), take 25 mg orally.Then, take 12.5 to 25 mg every four to six hours as necessary (Skidmore-Roth, 2020, p. 1288) for nausea or vomiting.  Motion sickness, nausea, vomiting, and vertigo are other side effects that Promethazine can treat or avoid.The patient can take Promethazine with food, water, or milk to lessen stomach upset. Due to this medication, individuals may experience lightheadedness, drowsiness, or decreased alertness.Therefore, do not forget to alert the patient to any activities that call for awareness.
  28. 28. Nonsterioidal Anti- inflammatory/ Ibuprofen • For Mild to Moderate Paid [1-5] Ibuprofen given orally initial dose 400mg. Follow-up dosing are 200mg to 400mg every 4 hours as needed. Maximum doses of 4 in a 24-hour period. • For Moderate to Severe Paid [6-10] Morphine given IV Initial dose 0.5mg/ml. Follow up dosing 0.5mg/ml-1mg/ml every 2-3hours as needed. Maximum doses of 4 in 24 hours. Notify the provider if the patient is requiring more pain medication. • Morphine causes biliary pressure, but there is no evidence to indicate that it is contraindicated (Cook & Greer, 2020).
  29. 29. Meropenem  Meropenem IV administration of 1g every 8 hours run over 1 hour. Total duration of therapy [which may include oral step-down therapy] is 4-7days following infection control.  Treatment depends on the severity of illness and microbiology data. Patients treated for intra-abdominal infections should be assessed for occurrence of drug-related adverse effects (Cook & Greer, 2020).
  30. 30. Metronidazole  Metronidazole (Flagyl) take one 500mg tablet every 8 hours by mouth for 5 days (after discharge) following adequate source control.  Oral regimens are appropriate for individuals with mild to moderate infections (Cook & Greer, 2020).
  31. 31. Famotidine  Take one 20 mg oral tablet of famotidine (Pepcid) orally in the morning at least one hour prior to your first meal for six weeks.  By inhibiting the histamine receptors in your stomach that cause acid production, H2 blockers are designed to cure sudden heartburn and reduce the quantity of acid your stomach produces. H2 blockers decrease acid for up to 12 hours and begin reducing heartburn symptoms in only 15 to 30 minutes (Skidmore-Roth, 2020, pp. 623). H2 blockers are therefore recommended over proton pump inhibitors.
  32. 32. Loperamide  The recommended starting dose of loperamide (Imodium) is four 4 mg capsules by mouth, followed by one 2 mg capsule for each unformed stool as needed.The maximum recommended daily dose is 16 mg, or eight capsules (Skidmore-Roth, 2020, p. 1679).  Usually, within 48 hours, clinical improvement is visible. Antidiarrheal medications allow your body to absorb more liquid and slow food passage through your intestines, which lessens diarrhea.
  33. 33. Nicotine transdermal patch  Long-acting (Nicoderm CQ): Since Mrs. Jones smoked 0.5 packs daily, she needs to start with 21 mg patches (Skidmore-Roth, 2020, p. 1092).The patient will put on the 21 mg/day patches for six weeks before switching to the 14 mg/day patches for two weeks (Skidmore-Roth, 2020, p. 1092).The patient will finish using the third stage (7 mg per day) patches for an additional two weeks.Ten weeks will be spent on treatment in total.  To prevent skin irritation, instruct the patient to apply one patch each morning to any area of the body without hair and rotate the spot daily.At bedtime, the patch needs to be taken off and replaced.The patient can take off the patch if they experience insomnia or have vivid dreams.
  34. 34. Problem # 1 chronic fatigue for the past 2– 3 months  You should evaluate the client's capacity to carry out activities of daily living as a provider.The client's ability to engage in self-care and fulfill social and familial obligations, such as working outside the home, may be limited by anemia-related fatigue.Take note of the client's pulse rate, blood pressure, breathing pattern, dyspnea, usage of accessory muscles, and skin tone before, during, and after the activity to gauge how much the client can endure. Assist the client in setting up a log of activities to track exercise tolerance. Exercise might be challenging while anemic.Too much will make your symptoms worse and make you more easily exhausted. If you get too little, you'll miss advantages like more energy, less stress, and overall higher quality of life.As a provider, you should advise the patient by starting with 10- to 15-minute exercise and working your way up to sessions lasting 30- to 60 minutes three or four times a week. Of course, the health advantages increase as you exercise more.
  35. 35. Problem #2 Loose stools  Anti-diarrheal drugs are administered to lessen the frequency of loose stools. Loperamide allows your body to absorb more liquid by slowing the passage of food through your intestines.There have been complaints about loose stools; therefore, you want to teach patients to track how often they pass feces.Tell the patient to avoid gluten since she has celiac disease; if she does eat it, she will get diarrhea.
  36. 36. Problem #3 Nausea  A precise pathophysiologic cause of nausea and vomiting should be the basis for treatment.You should pay attention to the time frames that the sickness is predicted. Additionally, when the patient has vomited, give dental care. By removing the taste and smell of the vomit, oral care helps to lessen the stimulus for another vomiting episode. Every patient's nausea and vomiting and the results of any therapies should be documented. Consider the onset, duration, timing, amount of emesis, pattern frequency, setting, connected circumstances, aggravating actors, and previous medical and social histories when evaluating and documenting the client's episodes of nausea and vomiting. As necessary, implement suitable dietary measures, such as low-fat, frequent, small, and nothing-by-mouth status. Avoiding fatty, spicy, or salty foods may be helpful.
  37. 37. Problem #4 Pancreatitis, untreated  To treat her pancreatitis, Mrs. Jones must learn about diet and reduce alcohol usage. Mild abdominal pain that spreads to both lower abdominal quadrants is the primary symptom of Mrs. Jones' pancreatitis.The patient consumes more wine than is typical for women—three to four glasses daily.The amount of alcohol the patient drinks aggravate pancreatic discomfort.Teach the patient to follow a low-fat diet, to consume whole grain bread and cereals, lean cuts of meat, to eat five to six little meals daily rather than three large ones, to eat a variety of fruits and vegetables, and to drink a lot of water to avoid being dehydrated. Use calorie counts three days in a row with each meal to determine the client's total nutritional intake and identify a deficit or excess intake.
  38. 38. Problem # 5 Dehydration  Health issues and even potential death can result from dehydration. Due to her decreased fluid intake from vomiting, the patient is dehydrated. Dehydration can be avoided by instructing the patient to drink water to replenish lost fluids. Instruct the patient to drink eight glasses of water per day or 2 quarts/0.5 gallons, but not more than 1.5 quarts per hour. Consuming more than 1.5 quarts per hour can result in a medical emergency by dangerously lowering the blood's salt concentration ("How much water should I drink?: Urgent care treatment for dehydration," n.d.). Mild dehydration can typically be reversed by drinking liquids. However, you should visit the emergency room if the dehydration is severe and does not improve after 48 hours of oral replenishment.The provider will typically put the patient on nothing by mouth diet to rest the pancreas and reduce gastrointestinal secretions.Thus appropriate intravenous hydration is required.Weight increase is a sensitive and reliable indicator of fluid volume balance and a nutritional assessment, so weigh yourself as soon as you wake up in the morning, before breakfast.Weight is measured every day at the same time with minimal clothing on and the same quantity of clothing using a reliable scale.
  39. 39. Problem #6 Mild abdominal pain  For one week, take one acetaminophen (Tylenol) 650 mg tablet orally every 6 hours as needed for temporary relief.The maximum daily dose of acetaminophen for a healthy adult weighing at least 150 pounds is 4,000 milligrams in 24 hours (Skidmore-Roth, 2020, pp. 66-68).Acetaminophen is typically advised for mild to moderate pain as a first-line treatment because it can lower fevers. In addition, because it doesn't have any negative side effects like stomach pain and bleeding, acetaminophen is typically considered safer than other non-opioid painkillers.
  40. 40. Problem #7 Nicotine dependence  Given that the patient smoked 0.5 packs per day for 25 years, combined nicotine replacement therapy (NRT) is a feasible option for treating this patient's nicotine dependence.This approach may be more successful than utilizing only one kind of NRT.You can use a smoking cessation method like nicotine replacement therapy (NRT) or the drug bupropion, which lessens cigarette cravings. According to studies, smokers often have greater homocysteine concentrations than non-smokers, and low folate levels have been linked to higher mortality rates from all causes and cardiovascular disease (Zhou,Yu et al., 2018). Education on quitting smoking will help those who are folic acid deficient and be good for their health. Most smokers want to quit but worry they won't be able to. Inquire about the patient's desire to stop smoking.A significant motivation could be a provider's guidance and encouragement.
  41. 41. Problem #8 Alcohol dependence  After her mother-in-law moved in, Mrs. Jones raised her daily wine consumption from one to two glasses to three to four. Even if alcohol was not the cause of her acute pancreatitis, she should abstain from alcohol entirely for at least six months to give her pancreas time to heal.The provider should recommend that the patient refrains from drinking alcohol after that, but if you do decide to do so, remember that you must adhere to the low-risk drinking recommendations.Alcohol should still only be drunk in moderation, the CDC advises, with women restricting intake to one drink or less per day on days when alcohol is consumed (Centers for Disease Control and Prevention, 2022).
  42. 42. Team – BasedCare
  43. 43. PrimaryCare Doctor  Depending on the etiology and any relevant drug interactions, the primary care doctor will start the right drug replacement therapy treatment.The patient's current medications, medical history, and social background will all be discussed with the patient in order to determine whether they may be causing or exacerbating anemia. It's crucial to keep all of your visits when receiving therapy for anemia and to adhere to the recommended course of action, particularly if your symptoms are altering or developing.Avoid making any major lifestyle adjustments without first consulting a doctor, especially when starting or discontinuing any medications or supplements.The patient can be instructed by the primary care physician to eat naturally high folate foods and take supplements; it should be noted, however, that excessive folate supplementation may increase the risk of cancer.
  44. 44. Dietician  A dietician offers dietary recommendations to high-risk patients and supplements their meals with folic acid to avoid the development of deficiencies.The dietician can also examine the patient's typical diet for their pancreatitis. By recording the foods the patient often eats and any possible food allergies, the dietitian can look for nutritional gaps in their diet. Consider asking a nutritionist to evaluate your dietary requirements and provide you with the recommended nutrition.Then, the patient can create a diet plan tailored to the nutritional needs with the dietitian's help.
  45. 45. Therapist  Mrs. Jones has increased her intake of alcohol daily ever since her mother-in-law moved in, and it seems like this is stressful for her. When your mental well-being deteriorates, a therapist is recommended. It makes it easier to deal with your challenging emotions if you talk them out.You can have weekly sessions with a therapist for a while. Instead of acting on angry feelings, a therapist encourages you to take a moment.The more you share what's going well for you and how you feel, the more positive feelings you generate.Therapists help you to understand the interrelationships between your emotions, thoughts, decisions, and behaviors.You'll acquire coping mechanisms, improve your mood, and find assistance for your issue.The client and family members may benefit from the resources, support networks, and counseling offered by the therapist to maintain connections and day-to-day functioning and manage the client's needs in the future. Mrs. Jones can get stress relief from a therapist, who can also assist the patient in self-help groups like Alcoholics Anonymous (AA). Alcoholics Anonymous offers peer-based support to those who are struggling with alcohol addiction. Participants use the program's 12 traditions in AA as they progress through the program's 12 steps.
  46. 46. Occupational Therapist  An occupational therapist is recommended since the patient has had chronic fatigue for the past 2-3 months.The occupational therapist can do an evaluation and teach the client about using assistive devices.The occupational therapist can also assist the client and family determine whether extra energy-saving measures in the home are necessary.
  47. 47. Implement theCare Plan
  48. 48. 4.a.What information should be provided to the patient to enhance compliance, ensure successful therapy, and minimize adverse effects?  Provide information on signs and symptoms of anemia for the patient to better recognize them when she is at home.  Provide patient with accessible and easy to understand information on dietary intake of folate and folic acid. Refer patient to the U.S. Food & Drug Administration guidelines on the nutritional and supplement facts of folate and folic acid.  Stress the importance of adherence to taking once a day Folic acid tablets. Providing the patient with the common side effects of upset stomach, nausea, diarrhea, irritability, confusion, skin reactions, behavior changes, and seizures.  Provide smoking cessation information to the patient and stress the importance of quitting smoking for the patient’s overall health to improve.  Coordinate a plan with the patient to lower the amount of alcoholic drinks per week. In order to enhance compliance, suggest to the patient to lower the amount of alcoholic drinks down to 2 glasses of wine per day and ultimately down to one glass of wine per day.
  49. 49. Foods that Provide Folate: Foods Fortified with FolicAcid: https://www.fda.gov/food/new-nutrition-facts- label/folate-and-folic-acid-nutrition-and- supplement-facts-labels
  50. 50. 4.b. Describe how care should be coordinated with other healthcare providers.  Ensure that the patient’s primary care physician is aware of any addition or cessation of medications.  Update and chart any intervention that was completed onto the patient’s virtual chart for easy access not only for the patient to view and other healthcare providers the patient may be seeing now or in the future.  Consult an occupational therapy session for patient evaluation to see if the patient needs any further therapy sessions or assistive devices to improve her physical activity. Communicate with occupational therapist for updates and any continuation of therapy sessions moving forward.  Recommend a therapist for the patient to address her recent life stressors and communicate with the therapist for updates and any continuation therapy sessions moving forward.
  51. 51. Followup: Monitor and Evaluate
  52. 52. 5 . a .What clinical and laboratory parameters should be used to evaluate the folic acid replacement therapy for achievement of the desired therapeutic outcome and to detect or prevent adverse effects?  Serum folic acid tests ordered with vitamin B12 levels should be part of the patient’s assessment of desired therapeutic outcome. The normal range of folic acid we are looking for is 2.7 to 17.0 ng/mL and the normal range of vitamin B12 is 160 to 950 pg/mL (Ashraf et al, 2008).  Clinical parameters to be utilized will be assessment of the patient’s existing symptoms of abdominal pain, loose stools, and chronic fatigue.The goal is the cessation of these symptoms post treatment of folic acid deficiency.
  53. 53. 5 . b . Develop a plan for follow- up that includes appropriate time frames to assess progress toward achievement of the goals of therapy.  Schedule folic acid andVitamin B12 lab levels to be drawn within 4 weeks after treatment initiation.  Continue to conduct lab tests of folic acid andVitamin B12 levels every four weeks until and after achievement of the goals of therapy.  At the patient’s four week follow up appointment, assessment of the patient’s abdominal pain, loose stools, and chronic fatigue will show that these symptoms have resolved or improved.
  54. 54. References
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