Download Vegan Vitamin B-12 Food Sources

Situation
Alan Belford age 78 was admitted for the surgical repair of a left hip fracture which he sustained in a fall
at home. His recovery is progressing slowly second to complaints of fatigue and weakness. He is 3 days
post op.
Background
Past medical History: He has been complaining of weakness, fatigue and a 10 pound weight loss over
the past 6 months. He suffers from HTN (he takes lisinopril 20 mg po daily) and angina (he takes atenolol
50 mg po daily, ASA 81 mg po daily). Previous smoker, occasional alcohol use.
Social history: He lives at home with his wife. He is a retired factory worker living on a small pension and
social security with a total monthly income of $2500. He has 3 grown children that live close by.
Assessment
Height: 6’ 1”
Weight: 165
BMI: 21 Vital signs: 124/68 HR 88
Diagnostic tests: CBC RBC 3.2, HGB 7.9, HCT 25% platelets 300,000, reticulocytes 0.4%, MCV 130µL
Serum iron, ferritin, TIBC all WNL, Shillings test +
Physical assessment:
Head: normo cephalic, normal hair distribution, Face: symmetrical smile, Eyes: sclera white, inferior
conjunctiva pale, Mouth: dentition in good repair, no lesions noted, tongue looks swollen and red.
Neuro: A& O x 3 forgets the day and time
Thorax: AP: transverse 1:2 ratio, lungs clear, equal expansion RR 20 non labored O2 sat 95% room air
HR regular without murmurs.
Abdomen: Evidence of old surgery in right inguinal region, no prominent veins, no visible pulsations,
non distended, Bowel sounds + x 4 quadrants. Non tender to light palpation
Upper extremity: equal strength bilaterally but weak, capillary refill > 3 sec. numbness on fingertips,
decreased sensation & vibratory sense.
Lower extremity: L hip limited ROM (no abduction surgical dressing dry & intact), R hip limited and
painful ROM, sparse hair on the lower extremities, capillary refill > 4 sec bilaterally, extremities cool with
limited sensation and vibratory sense.
Mr. Belford has been diagnosed with Pernicious Anemia.
Medications:
Morphine sulfate 15 mg orally every 3-4 hours as needed PRN pain > 6/10
Tramadol 25-50 mg orally every 4-6 hours as needed for pain < 6
Lisinopril 20 mg orally daily
ASA 81mg orally daily
Colace 100mg orally daily
Atenolol 50 mg orally daily
Cyanocobalamin 1000mcg IM daily x 1 week
Oxygen 2L per nasal cannula (titrate to keep O2 sat>92%)
Recommendations: Your plan of care for B 12 deficiency
1. Briefly describe the pathophysiology of Pernicious anemia (place in concept map)
Normally, a protein termed intrinsic factor (IF) is secreted by the parietal cells of the gastric mucosa. IF is
required for cobalamin (extrinsic factor) absorption. Therefore if IF is not secreted, cobalamin will not be
absorbed. (Cobalamin is normally absorbed in the distal ileum.) There are many causes of cobalamin
deficiency. The most common cause is pernicious anemia, a disease in which the gastric mucosa is not
secreting IF because of antibodies being directed against the gastric parietal cells and/or IF itself. Other
causes of cobalamin deficiency include gastrectomy, chronic gastritis, nutritional deficiency, chronic
alcoholism, and hereditary enzymatic defects of cobalamin utilization (see Table 31-8). (Lewis 668)
Pernicious anemia (PA) is an autoimmune disorder in which the body fails to make enough healthy red
blood cells (RBCs). The body requires vitamin B-12 and a type of protein called intrinsic factor (IF) to
make red blood cells. Vitamin B-12, or cobalamin, is found in certain foods and medications. IF is a
protein made by the stomach’s mucosal (mucus-secreting) cells, called parietal cells. When vitamin B-12
enters the body, it binds with IF. The two are then absorbed in the last part of the small intestine.
2. Why is Mr. Belford at risk for the development of pernicious anemia? Answer here
Advanced age, might increase the risk of both malnutrition and malabsorption.
United States, most cases of vitamin B12 deficiency are due to malabsorption (atrophic gastritis)
rather than inadequate intake.
The elderly, defined as individuals 65 years of age or older, are more likely to develop a vitamin
B12 deficiency because they are at risk for both malabsorption and malnutrition.
The frail elderly, especially, might have dietary insufficiency for a number of reasons, including
cognitive dysfunction, social isolation, mobility limitations, and poverty.
Long-term adherence to a strict vegetarian or vegan diet.
Atrophic gastritis: hypochlorhydria and achlorhydria, the body does not produce enough pepsin
and hydrochloric acid to release from protein the food-bound vitamin B12.
In pernicious anemia, missing IF needed to attach B12 in the small intestine impairs the uptake of
vitamin B12. Undiagnosed and untreated pernicious anemia affects 1%–2% of the elderly
population. 24
Pernicious anemia occurs frequently in persons of Northern European ancestry (particularly
Scandinavians) and African Americans. In African Americans, the disease tends to begin
early, occurs with higher frequency in women, and is often severe.
CDC: While several studies have found that mild cobalamin deficiency is most common in elderly
White men and least common in Black or African-American and Asian-American women, 2,3,16,24
the differences are not sufficient to support sex- or race-specific nutrient recommendations. 10
3. What are the collaborative lab tests to identify this type of anemia? (place in concept
map)
CBC, Iron profile, cobalamin, Folate, Shilling
4. What is the purpose of a Schillings test? Answer here
Schilling test is ordered if there is a vitamin B12 deficiency to determine if their stomach is producing
“intrinsic factor.” Intrinsic factor required for vitamin B12 absorption. Without it, the body will be unable
to absorb vitamin B12, resulting in pernicious anemia.
If the results of this test are normal, it means that intrinsic factor is lacking and you have pernicious
anemia. If the results are abnormal, your doctor will perform stage three.
5. What are appropriate focused assessments for a patient who has a Vitamin B12 deficiency?
General symptoms of anemia related to cobalamin deficiency develop because of tissue hypoxia (see
Table 31-3).
GI manifestations include a sore, red, beefy, and shiny tongue; anorexia, nausea, and vomiting; and
abdominal pain.
Typical neuromuscular manifestations include weakness, paresthesias of the feet and hands, reduced
vibratory and position senses, ataxia, muscle weakness, and impaired thought processes ranging from
confusion to dementia.
6. Mr. Belford, who is a vegetarian, is in need of assistance when ordering his meals.
List foods rich in vitamin B12 that are appropriate for a vegetarian diet.
Vegan Vitamin B-12 Food Sources
Food
Almond milk, fortified with vitamin
B12
Coconut milk, fortified with vitamin
B12
Nutritional yeast
Soymilk, original, fortified with
vitamin B-12
Vegan mayonnaise
Tempeh
Ready-to-eat cereal, fortified with
vitamin B-12
Serving
Vitamin B-12 (mcg)
1 cup
3*
1 cup
3*
1 tablespoon
2
1 cup
1.2*
1 tablespoon
100 grams
0.24
0.12
1/2–3/4 cup
0.6–6*
Vegetarian Vitamin B-12 Food Sources
Food
Yogurt, plain, low-fat
Milk, low-fat
Cottage cheese, 1%
Cheese, Swiss
Egg
Ice cream, vanilla
Serving
8 ounces
8 ounces
3/4 cup
1 ounces
1 whole, mediulm
1/2 cup
Vitamin B-12 (mcg)
1.37
1.15
1.07
0.95
0.39
0.26
*May vary depending on product.
All nutritional information from USDA National Nutrient Database for Standard
Reference or food manufacturer labeling
A, What is the recommended daily intake of B12?
Vitamin B-12 RDA
Life Stage Group
Infants:
0 to 6 months
Vitamin B-12 (mcg)
0.4
6 to 12 months
Children:
1 to 3 years
4 to 8 years
Males:
9 to 13 years
14 to 50 years
51+
Females:
9 to 13 years
14 to 50 years
51+
Pregnancy
Lactation
0.5
0.9
1.2
1.8
2.4
2.4**
1.8
2.4
2.4**
2.6
2.8
** Vitamin B-12 intake should be from supplements or fortified foods due to the agerelated increase in food bound malabsorption.
RDA from United States Department of Agriculture Library; DRI Table: RDA and AI for
Vitamins and Elements
7. The HCP has prescribed Vitamin B 12 to be given IM to Mr. Belford.
Discuss the desired effect and possible side effects of this treatment.
8. What other possible medications or supplements can be used to treat Pernicious
anemia?
Parenteral (cyanocobalamin or hydroxocobalamin) or intranasal (Nascobal, CaloMist)
administration of cobalamin is the treatment of choice. Without cobalamin administration,
these individuals will die in 1 to 3 years.
A typical treatment schedule consists of 1000 mcg of cobalamin IM daily for 1-2 weeks and then
weekly until the hematocrit is normal, and then monthly for life. High-dose oral cobalamin and
sublingual cobalamin are also available for those in whom GI absorption is intact. As long as
supplemental cobalamin is used, the anemia can be reversed
9. .What safety concerns would you have for Mr. Belford while he is hospitalized?
Identify priority nursing diagnosis based on his type anemia (place in concept map)
Risk for injury, risk for falls, confusion, fatigue:
Develop a list of interventions for basic anemia.
10. Prioritize interventions for a patient with pernicious anemia. Assess, treat, teach.
See the Nursing Care plan I gave you