Hello, Clinic Review family. It's Dr. Sharon with Clinic Reviews. Today, we're going to continue going through the blue book, which you can see right there over my shoulder.
We're going to be talking about pernicious anemia. Do you know anything about that? I bet you don't, unless you have it. All right, let's get started. Hello family, Klimek Review family.
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So let's go ahead and get started. This isn't going to be nearly as long as some of my other videos because pernicious anemia is not a particularly complicated, from a nursing perspective, it's not particularly complicated. Whether you know what pernicious anemia is or not, just remember anemia, anemia always means low hemoglobin.
So if you get... any anemia question, whether it's pernicious anemia, iron deficiency anemia, and it says something about low hemoglobin, that's a good answer. Okay.
So let's go ahead and get started with this. A nurse is educating a patient newly diagnosed with pernicious anemia, which statement by the patient indicates correct understanding of the pathophysiology. So you know I teach as I go through the questions rather than doing a lecture up front. Pernicious anemia occurs when my body attacks my red blood cells directly. Pernicious anemia happens because my body is unable to absorb enough folic acid.
Pernicious anemia is caused by the lack of intrinsic factor needed to absorb vitamin B12. Pernicious anemia is the result of severe iron deficiency in my diet. So which statement by the patient indicates a correct understanding? So we know it's not D because it would be iron deficiency anemia. So the correct answer is actually C, if you don't know what the patho is of pernicious anemia.
So intrinsic factor allows us to absorb vitamin B12. Vitamin B12 is necessary for the production of red blood cells. So if you don't have enough intrinsic factor, you can't absorb vitamin B12.
Just so that you know, another name for vitamin B12 is extrinsic factor. So the intrinsic factor, which is what we have, we make it in our body, we don't eat it. Intrinsic factor B12, we take into our body, it's extrinsic.
The intrinsic factor is responsible to help absorb the extrinsic factor, which is vitamin B12. And if we don't have it, then we're anemic. When assessing risk factors for pernicious anemia, which of the following should the nurse consider? Autoimmune disorders, chronic gastritis or gastric surgery, high dietary intake of folic acid, family history of pernicious anemia, long-term use of proton pump inhibitors, history of sickle cell disease.
So there is some relationship between the secretion of gastric acid and intrinsic factor. So whenever you have an absorption problem or poor gastric secretions, you're going to have less intrinsic factor. So chronic gastritis or gastric surgery is a correct answer.
That does apply to pernicious anemia and the long-term use of proton pump inhibitors as well. So B and E are correct answers. So just remember. that, that intrinsic factor is associated with the secretion of gastric acid and stuff going on in the stomach. And when you have gastric surgery, you know, they remove like three quarters of the stomach, right?
So that's a problem. You're not making as much gastric acid. So B and E are true statements. High dietary intake of folic acid, it has nothing to do with folic acid, okay?
It has to do with how much our intrinsic factor our body makes and then our intake of vitamin B12, which is extrinsic factor. So it has nothing to do with folic acid. It makes sense that D would be a correct answer.
There is a genetic component to pernicious anemia, so that's correct. History of sickle cell disease, there's no relationship between sickle cell disease and pernicious anemia. So how about autoimmune disorders? You may just have to memorize it. Autoimmune means that your own immune system is attacking the body.
And so it is associated, pernicious anemia is associated with various, not just one, but various autoimmune disorders. So if our body's not making enough intrinsic factor, there's a relationship between that and our own immune system attacking our own body. So anyway, those are the things that are risk factors for pernicious anemia. A patient with pernicious anemia is most likely to present with which initial complaint?
Fatigue and weakness, hair loss, night sweats, frequent nosebleeds. So this isn't a platelet problem. This isn't a clotting factor problem.
So we're going to get rid of D. Hemoglobin doesn't have anything to do with the thinness of the blood, okay, or the clotting of the blood. So we're crossing that one off. Now, it is anemia, low hemoglobin, low red blood cell count, right? So how does a person feel?
When they're anemic, well, they feel fatigued. Don't they fatigue and weakness? So it's most likely to present with which initial complaint.
So if you're just purely guessing, honestly, the one that makes the most sense is A, and B and C really are not symptoms associated with pernicious anemia. A patient with pernicious anemia who has neurologic symptoms is most likely to be prescribed which of the following. So neurologic symptoms are associated with pernicious anemia, like numbness and tingling, balance issues. Those are some things that are associated with pernicious anemia. So they're most likely to be prescribed which of the following?
Oral ferrous sulfate supplements. Ferrous sulfate is iron. This is not iron deficiency anemia.
Parenteral vitamin B12 injections. Well, vitamin B12 is not absorbed well, so that would make sense. IV immunoglobulins, that's not the intrinsic factor or an extrinsic factor, so that doesn't make any sense. Large doses of oral folic. acid.
So no, actually they're treated with IM or sub-QB12. So parenteral, enteral, E-N-T-E-R-A-L, enteral means through the GI tract. So if you eat something, swallow something, chew something, something goes through a PEG tube, through a G-tube, that's enteral.
If you give it another way, other than through the GI tract, whether it's IV or IM, that's parenteral. So it's actually given IM and it's like a monthly shot. IM or sub-Q. A patient is receiving IM vitamin B12 injections. Which nursing interventions are appropriate to ensure safe and effective care?
Now let's do this the right way. So this is a SATA question. So we're going to read through all the answers.
Then we're going to go back and turn them into a series of true-false statements. So which nursing interventions are appropriate for treating pernicious anemia? I'm sorry, which are appropriate for when giving IMB12.
That's really what we're asking. Shake the vial vigorously before drawing up the medication. Use the Z-TRAC method for IM injections if indicated. Monitor hemoglobin and hematocrit levels regularly. Administer the injection in the deltoid only.
Assess for injection site reactions or discomfort. Instruct the patient on the potential need for lifelong therapy. Okay, so there's a number of answers there that right off the bat I think are correct. So let's go ahead and turn this into a series of true-false statements.
So this has to do with IMB12 injections. When giving IMB12 injections, I should shake the vial vigorously before drawing up the medication. Now you may say, I don't know if I'm supposed to shake it vigorously. Well, if you don't know, that's like, if you don't know specifically for B12, then think generally.
So do we ever shake vials vigorously? Like ever? Like if we're mixing, like if we're mixing a powder into a liquid, sometimes we'll shake it longer.
or roll it longer, but we never shake anything vigorously. Like we just don't do that. So why would we shake this vigorously?
We know that when we're vigorously shaking things, sometimes it damages the medication. So I don't like A. When giving an IMB12, I would use the Z-TRAC method if indicated.
Well, yeah, I would if it's indicated. That's just a good NCLEX and or if indicated. It's a good NCLEX answer when it says if indicated.
So I like that answer. When giving IMB12, I would monitor hemoglobin and hematocrit levels regularly. Well, yes, because I'm...
giving it for the purpose of watching their anemia, right? They're anemic. So yeah, I got to watch their hemoglobin hematocrit, see if it's working. When giving IMB12, I administer the injection in the deltoid only.
So you may say, well, I don't know. Well, do you know of any medications that we only give it in the deltoid? I've never heard of that.
Okay. I've never heard of only giving it in the deltoid. Sometimes we give it only in the hip, but I've never given it only in the deltoid.
That's like... one of the smallest muscles you can possibly give it in. There's no reason to think it could only be given in the deltoid.
And it has an extreme word in it. The word only is an extreme word. I avoid answers with extreme words like never, only, always. I avoid answers with extreme words in them unless I'm absolutely sure they're right. And there's no reason to think D is right, so I'm going to not pick that.
When giving IMB12, I would assess for injection site reactions or discomfort. Well, that just makes sense. Y'all, don't throw your common sense out the window. That makes sense.
Remember, SATA questions are not about what did you memorize. It's about can you think clinically, can you reason clinically, can you think conceptually, and make good clinical decisions. So I like E.
When giving IM B12, I would instruct the patient on the potential need for lifelong therapy. So this isn't specific to B12. It's actually specific to pernicious anemia. It doesn't say they have pernicious anemia.
So the question is, would they have to be on this lifelong? I don't know of any reason we give vitamin B12 except for with pernicious anemia. And it is lifelong.
So they don't just start making intrinsic factor. Okay. So most of the time, people who are taking extrinsic factor, I don't know of any reason to give extrinsic factor except for if they have intrinsic. factor deficit, which is pernicious anemia.
So that would be a true statement. So remember, use your clinical reasoning. In order to get this question right, you have to really know why they're taking B12.
You have to know general principles of IM, and you need to know what to monitor with this. So this is a pretty good question. This is a higher level question. It may not have seemed that difficult to you because it's in the middle of our pernicious anemia question bank.
But if you got this, just... got it in the middle of your NCLEX and there were no other pernicious anemia questions, you might go, huh, what? So make sure you associate the extrinsic factor with the intrinsic factor, which is pernicious anemia, okay?
In reviewing the treatment plan for a patient with pernicious anemia, the nurse recognizes which interventions are commonly included. Monthly vitamin B12 injections, folic acid supplements, monitoring CBC periodically, high iron diet, neurological assessments, oral vitamin B12 supplements. I know this is sort of repetitive from the last question, but I just want to show you different ways that similar concepts can be tested different ways.
And it's not about whether you memorize the list. It's about what do you understand about pernicious anemia. So when treating pernicious anemia, I would expect monthly vitamin B12 injections.
That's true. When treating pernicious anemia, I would expect folic acid supplements. That's not true.
Folic acid has nothing to do with pernicious anemia. Treating pernicious anemia, I would expect to monitor the CBC periodically. Well, that's how you measure hemoglobin, hematocrit, and red blood cells.
So yes, that makes sense. When treating pernicious anemia, I would encourage a high iron diet. No, it's not iron deficiency anemia.
When treating pernicious anemia, I would do neurologic assessments. Yes, because there are neurologic components to pernicious anemia. So you could assess for muscle weakness, twitching, reflexes, paresthesias. that kind of thing. When treating pernicious anemia, I would expect oral vitamin B12 supplements.
Well, you can't do both A and F. You can't do them both. So when you see, when it's a SATA question and there's opposites there, you can only pick one of them, y'all. So don't pick them both, okay? So the correct answers are A, C, and E.
When assessing the neurological status of a patient with pernicious anemia, the nurse is most concerned about finding, about which finding? Recurrent headaches, bright red rash on the chest, weak peripheral pulses, or bilateral numbness and tingling in the hands and feet. Okay.
I'm going to get rid of peripheral pulses because just because someone's anemic doesn't mean they're fluid volume deficit. They could actually be fluid volume overloaded and be anemic. So I'm not going to go with weak peripheral pulses. And I don't know why they would have a bright red rash on the chest. That just doesn't make any sense to me.
But I do know neurologic symptoms are associated with pernicious anemia. And so I'm looking for those things, right? Like they're not, neurologic symptoms are not expected with pernicious anemia. They're an indication that it's getting worse. So recurrent headaches and numbness and tingling in the hands and feet are both, I would consider both of those neurologic things.
So which one is worse, recurrent headaches? Well, so anything, anytime something recurs. I'm less concerned about it because it's not new. Well, just because it's not new.
I'm always more concerned about new things than I am about recurrent things. And I'm talking at NCLEX, on the NCLEX. So bilateral numbness and tingling in the hands and feet, it doesn't say it's recurrent. It doesn't say it's sudden onset, but it also doesn't say it's recurrent. So to me, paresthesias, which don't seem to be recurrent, seem to be more concerning than a recurrent headache.
So that word recurrent. is what makes me less concerned about the headaches. And headaches are a very, very vague symptom, very vague.
It can be caused by things other than neurologic. In fact, it's often vascular. Headaches are often vascular problems. There's a neurovascular component, but it seems to be headaches have more of a vascular component than a neurologic component.
Which of the diagnostic findings are commonly associated with pernicious anemia? Macrocytosis, which is a large red blood cell, low serum B12 levels, positive shilling test, low ferritin, elevated methylmalonic acid or microcytosis. All right.
So what is associated with pernicious anemia? So if you don't know this, just you got to learn it's macrocytosis. It's a larger red blood cell rather than a smaller.
So microcytosis is a smaller red blood cell. Macrocytosis is larger. So pernicious anemia. Look, if you don't remember it on the NCLEX, it's not the end of the world.
But it is macrocytosis. So low serum B12 levels. Yes. The extrinsic factor isn't being absorbed.
So that level is low. So yes, positive shilling test. So shilling test is something we don't do much anymore.
It has something to do with giving radioactive B12 and watching to see if it's absorbed. And that's used to be how we would diagnose pernicious anemia, and we still can, but it's just not used as much anymore. So the positive shilling test is a diagnostic test.
Low ferritin level is not a diagnostic test. That's iron and it's not iron deficiency. Elevated methylmalonic acid. So yes, that is the newest test. Elevated methylmalonic acid is the newest test.
It doesn't involve giving somebody anything radioactive. And I looked it up and it's complicated. It's very complicated.
It has to do with... Some biochemical being transformed into another biochemical, and this first biochemical does not turn into this second biochemical. Then it eventually turns into MMA, and then their MMA levels are elevated. Y'all, like, it's complicated.
Feel free to look it up if you want to. But anyway, these are the diagnostic tests most often used for pernicious anemia. Y'all, that's it. There's not a lot to learn about it because it's just anemia because of low intrinsic factor. We can't give intrinsic factor.
So we just have to give higher levels of extrinsic factor. And hopefully it's going to be absorbed eventually if you give more or higher doses of extrinsic factor. There are some neurologic symptoms like paresthesias. But primarily early on, their symptoms are going to be like any anemia where they have fatigue and weakness.
Okay? All right. That's it.
I hope you have a great rest of your day. Thanks for being a part of the Clinic Review family. Bye.