Medical Surgical

Anemia, Megaloblastic (Vitamin B12 and Folic Acid Deficiency)

The anemias caused by deficiencies of the vitamins B12 and folic acid show identical bone marrow and peripheral blood changes. Both vitamins are essential for DNA synthesis.


The two main vitamin deficiencies may coexist. In each case, hyperplasia of the bone marrow occurs, and the precursor erythroid and myeloid cells are large and bizarre in appearance. The RBC’s produced are abnormally large (megaloblastic). A pancytopenia (a decrease in all myeloid-derived cells) develops.

Vitamin B12 deficiency can occur from inadequate intake in strict vegetarians; faulty absorption from gastrointestinal tract; absence of intrinsic factor (pernicious anemia); disease involving the ileum or pancreas, which impairs B12 absorption; and gastrectomy. People with pernicious anemia have a higher incidence of gastric ulcer than the general public.

Folic acid deficiency occurs when intake of folate is deficicnet or the requirement is increased. People at risk include those who rarely eat uncooked vegetables or frutis, primarily elderly people living alone or people with alcoholism. Alcohol use, hemolytic anemia, and pregnancy increase folic acid requirements. Patients  with malabsoptive or small bowel disease may not absorb folic acid normally.

Clinical Manifestations

Symptoms are progressive and may be marked by spontaneous partial remissions and exacerbations.

  • Gradual development of signs of anemia (weakness, listlessness, and pallor)
  • Possible development of a smooth, sore, red, tongue and mild diarrhea (pernicious anemia)
  • Possible development of confusion, more often, paresthesias in the extremities ad difficulty keeping balance, loss of position sense
  • Lack of neurologic manifestations with folic acid deficiency alone
  • Vitiligo (patchy loss of skin pigmentation) and prematurely graying hair (often seen in pernicious anemia)
  • Without treatment, patients die, usually as a result of congestive heart failure from anemia

Assessment and Diagnostic Findings

  • Schilling test (primary diagnostic tool)
  • Complete blood count (Hgb value as low as 4 to 5 g/dl, WBC count 2,000 to 3,000/mm3, platelet count less than 50,000/mm3, MCV is very high, usually exceeding 110)
  • Serum levels of folate and vitamin B12 (folic acid deficiency and deficient vitamin B12)

Medical Management: Vitamin B12 Deficiency

  • Oral supplementation with vitamins or fortified soy milk (strict vegetarians)
  • Intramuscular injections of vitamin B12 for defective absorption or absence of intrinsic factor
  • Prevention of recurrence with lifetime vitamin B12 therapy for patient who has had pernicious anemia or non correctable malabsorption

Medical Management: Folic Acid Deficiency

  • Intake of nutritious die and 1 mg folic acid daily
  • Intramuscular folic acid for malabsorption syndromes
  • Folic acid taken orally as a separate tablet (except prenatal vitamins)
  • Folic acid replacement stopped when hemoglobin level returns to normal, with the exception of alcoholics, who continue replacement as along as alcohol intake continues

Nursing Management

  • Assess patients at risk for megaloblastic anemia for clinical manifestations (eg, inspect the skin, sclera, and mucous membranes for jaundice, note vitiligo or premature graying or smooth, red, sore tongue).
  • Perform careful neurologic assessment (eg, note gait and stability; test position and vibration sense).
  • Assess need for assistive devices (eg, cane, walkers) ans need for support and guidance in managing activities of daily living and home environment.
  • Ensure safety when position sense, coordination, and gait are affected.
  • Refer for physical or occupational therapy as needed.
  • When sensation is altered, instruct patient to avoid excessive heat and cold.
  • Advise patient to prepare bland, soft foods and to eat small amounts frequently.
  • Explain that other nutritional deficiencies, such as alcohol-induced anemia, can induce neurologic problems.
  • Instruct patient in complete urine collections for the Schilling test. Also explain the importance of the test and of complying with the collection.
  • Teach the patient about chronicity of disorder and  need for monthly vitamin B12 injections when patient has no symptoms. Instruct patient how to self-administer injections, when appropriate.
  • Stress importance of ongoing medical follow-up and screening, because gastric atrophy associated with pernicious anemia increases the risk of gastric carcinoma.

Reference: Joyce Young Johnson, Brunner & Sudddarth’s Textbook of Medical-Surgical Nursing 11th edition Lippincott Williams & Wilkins pp. 45-48

Medical Surgical


Anemia is a condition of lower-than-normal red blood cell (RBC)  count and hemoglobin (Hgb) level. It is often not a specific disease state but a sign of an underlying disorder. Anemia results in a diminished amount of oxygen delivery to body tissues.  There are many different kinds of anemia, but all can be classified as being due to a decrease in the production of RBC’s (hypoproliferative), excessive destruction of RBC’s  (hemolytic), or a loss of RBC’s (eg. gastrointestinal bleeding). Other etiologic factors  include deficits in iron and nutrients, hereditary factors, and chronic diseases. Complications of severe anemia include heart failure, paresthesias, confusion, and other problems specific to type of anemia.


Several factors influence symptom of development from anemia, including its severity, speed of development (the faster the onset, the more severe the symptoms), and duration (eg. its chronicity; long-term anemia may produce few or no symptoms); the patient’s metabolic requirements and concurrent disorders or disabilities (eg. cardiopulmonary disease); and special complications or features of the condition that produced the anemia. Pronounced symptoms of anemia include the following:

  • Dyspnea, chest pain, muscle pain or cramping, tachycardia
  • Weakness, fatigue, general malaise
  • Pallor of the skin and mucous membranes (sclera, oral mucosa)
  • Jaundice (megaloblastic or hemolytic anemia)
  • Smooth, red tongue (iron-deficiency anemia)
  • Beefy-red, sore tongue (megaloblastic anemia)
  • Angular cheilosis (ulceration of the corner of the mouth)
  • Brittle, ridged, concave nails and pica (unusual craving for starch, dirt, ice) in patients with iron-deficiency anemia


  • Complete hematologic studies (eg. Hgb, hematocrit, reticulocyte count, and RBC indices, particularly mean corpuscular volume)
  • Iron studies (serum iron level, total iron-binding capacity, percentage saturation, and ferritin)
  • Serum vitamin B12 and folate levels, haptoglobin and erythropoietin levels
  • Bone marrow aspiration and biopsy
  • Other studies as indicated to determine underlying illness

Gerontologic Considerations

Anemia is the most common hematologic condition affecting elderly people. In this population, bone marrow typically has a decreased ability to respond to the body’s need for blood cells. The inability to increase blood cell production  adequately in cases of increased need seriously affects cardiopulmonary function. Because elderly people with a concurrent cardiac or pulmonary problem may be unable to tolerate anemia, a prompt, through evaluation of the anemia is warranted.


The goal is to correct or control the cause of the anemia and replace lost or destroyed RBC’s by transfusing packed RBC’s. In elderly patients it is important to identify and treat the cause of anemia rather than considering it a consequence of aging.


Handbook for Brunner and Suddarth’s

Textbook of Medical-Surgical Nursing 11th edition

Joyce Young Johnson

Lippincott Williams & Wilkins pp.35-37