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anemia
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OUR LADY OF FATIMA UNIVERSITYCOLLEGE OF NURSINGVALENZUELA CAMPUS
Anemia UnspecifiedIn Partial Fulfillment of requirements of NCM 107B RLE leading to the degree of Science in
Nursing
Presented to:
Mrs. Evangeline Orata, RN, MAN
Presented by:Bungay, Maria Paula M.
BSN 4Y 2-1 Group 1B
August 28, 2015
TABLE OF CONTENTS
I. Introduction
II. Objectives
III. Patient’s Profile
IV. Anatomy and Physiology
V. Pathophysiology
VI. Laboratory Examination Results
VII. Gordon’s Assessment
VIII. Nursing Care Plans
IX. Drug Study
X. Health Teachings
I. INTRODUCTION
The main function of a red blood cell or erythrocyte is to carry and transport oxygen to the different parts of the body. The normal RBC count is 4-6 million/mm3. Hemoglobin (Hgb), an iron-bearing protein, is found inside an erythrocyte. Molecules of this iron containing protein are responsible for transporting the bulk of oxygen that is carried in the blood.
The more hemoglobin molecules the RBC contain, a higher amount of oxygen will they be able to carry. If the hemoglobin is defective, the erythrocyte will also malfunction. A red blood cell is just a vessel; the one that performs the oxygen transportation is the hemoglobin. Normal hemoglobin is 13-18 grams/dl in males and 12-16 grams/dl in females. A decrease in the RBC or hemoglobin or the oxygen-carrying ability of a blood is termed as anemia.
Erythrocyte Formation
RBC’s are produced by the bone marrow a process known as erythropoiesis. Before a red blood cell is formed, the hematopoietic stem cell first produces an uncommitted stem cell to be formed to committed progenitor cell. Progenitor cells are not only the precursor of RBC, but also of lymphocytes and megakaryocytes (antecedent of platelets). Before an erythrocyte is formed the progenitor cells develop an erythroblast, then a reticulocyte, and finally erythrocyte (RBC). A hormone, erythropoietin, which is secreted by the kidney, also controls RBC production by stimulating the bone marrow.
Types of anemia
Hypoproliferative Anemias
This type of anemia covers all condition where the bone marrow incapable of producing enough cells to develop to erythrocyte. Lack of erythropoietin may also be a contributing factor of the abnormality. The following types of anemia are under this classification:
Aplastic anemia –In this condition, the precursor cells (stem or progenital cells, which is responsible in forming components of blood) are extremely deficient, thereby, production of all formed elements (including RBC, lymphocyte, megakaryocytes) are reduced. Because of the depressed bone marrow function, it is replaced by fat cells leading to anemia, excessive bleeding (thrombocytopenia) and infections (depressed WBC count). This type of anemia is also a common example of a pancytopenic disorder.
Iron-deficiency anemia – It is also called microcytic, hypochromic anemia. This is type of anemia is the most common form among all ages, and is characterized by a low iron concentration in the body.
Megaloblastic anemia – A macrocytic, normochromic anemia results as the essential factors (vitamin B12 and folic acid) for normal DNA synthesis are missing causing suppression of mitosis in the bone marrow and allowing the RNA or protein synthesis to take place for the progression of cell growth without cell division. The resulting cells remain enlarged (because mitosis is absent).
1. 1. Vitamin B12 deficiency – Vitamin B12 or cobalamin is required for normal DNA synthesis. It is not synthesized in the tissues of but solely depends on the dietary intake of meat, liver, dairy products and sea foods.
2. 2. Folic Acid Deficiency – folic acid is also important for the DNA synthesis of cells. The dietary sources of folate are meats, eggs, leafy vegetables which are easily available.
Hemolytic Anemias
This type of anemia refers to the state where hemolysis(erythrocyte destruction) causes symptoms of anemia. Classification of this condition is further narrowed into intrinsic (inherited) or extrinsic (damage in erythrocyte is caused by environmental factors).
Intrinsic Hemolytic Anemia
1. Sickle Cell anemia – an inherited disorder on the beta chain of the hemoglobin resulting to abnormally shaped red blood cells. In this condition an abnormal hemoglobin S (HbS) is contained in the RBC’s causing distortions or sickling of the red blood cells.
2. Thalassemia – group of genetic disorders that involve a defective hemoglobin- chain synthesis. Thalassemia majoris threatening disease characterized by severe anemia, hemolysis and ineffective erythropoiesis. Thalassemia minor is a mild form of anemia. The affected individual has only one defective gene and is asymptomatic.
Extrinsic Hemolytic Anemia
1. Immune hemolytic anemia – a person’s own antibodies destroy his own red blood cells (hemolysis).
2. Mechanical hemolytic anemia – hemolysis is caused by trauma or physical injuries that disrupt red blood cells altering and tearing them through the small vessels.
II. OBJECTIVES
Nurse – Centered
1. Describe factually, the personal and pertinent family history of the patient and relate it to the present condition.
2. Perform comprehensive physical assessment. 3. Trace the book-based and client-centered pathophysiology 4. Determine the predisposing and precipitating factors and the signs and symptoms and
relate to the disease process. 5. Enumerate and describe the diagnostic and laboratory procedures as well as the nursing
responsibilities in relation to the disease condition 6. Enumerate the different treatment modalities and their indication specifically for the
patient’s condition. 7. Identify the pharmacologic treatment provided to the patient, relate the actions of each
drug with the disease process and evaluate the patient’s response to the medications given.
8. Identify nursing diagnoses, formulate short-term goals, carry out appropriate interventions and evaluate the plan.
9. Appraise the effectiveness of medical and surgical nursing management in treating the patient.
10. List the preventive measure for the occurrence of Anemia.
Patient – Centered1. Report understanding of the disease process. 2. Understand the indications of the different diagnostic procedures and medical management involved in her care. 3. Cooperate with the necessary medical and nursing interventions. 4. Adhere with the health teachings provided. 5. Understand the different ways of health promotion and prevention in relation to the disease condition. 6. Demonstrate improved conditions as evidenced by absence of further complications.
III. Patient’s Profile
Name: MS. AC
Age: 16 years old
Nationality: Filipino
Religion: Roman Catholic
Civil Status: Single
Date Admission: August 16, 2015
Time of Admission: 10:54 PM
Ward: Pediatric Ward
Initial Diagnosis: Blood Dyscrasia probably ALL
Diagnosis: Anemia, Unspecified
HISTORY OF PAST ILLNESS
Ms. AC usually had conditions such as coughs and colds as well as fever, which they
treated, as stated by her father, by giving her BIOGESIC or other over the counter drugs. Father
stated that she already experienced serious infections such as chickenpox and measles. The last
time she was admitted to the hospital was June 15, 2015. Ms. AC has no family history of
Anemia. She has no known food and drug allergies. Ms. Ac is not fond of eating meat and
vegetables and she would often miss her mealtime. At the young age she started working as a
maid and stop going to school due to financial problem. As stated by Ms. AC her sleeping
pattern is usually at 2 A.M.
PHYSICAL ASSESSMENT
Physician’s Physical Assessment done by the Resident on Duty (August 16, 2015), lifted
from the patient's chart)
Height: 59 cm
Weight: 41 kg
Vital Signs as follows:
T: 36.6°C PR: 112 bpm RR: 42cpm BP: 110/60 mmHg SAO2: 98%
GENERAL SURVEY
Ms. AC, Assessed/received patient lying on bed, awake and conscious. With the following vital signs:
Temperature: 36.6 °C
Pulse rate: 112 bpm
Respiratory rate: 42 bpm
Blood Pressure: 110/60 mmHg
SAO2: 98%
1. PHYSICAL EXAMINATION (IPPA Cephalocaudal Approach)
August 16 (SUNDAY) First Nurse-Patient Interaction
a. General Appearance
AC 16 year old female, Filipino, Roman Catholic, born on December 15, 1998 in
Manila and currently residing at Acasia Malabon City admitted for the first time in
JRRMMC.
Vital Signs
Temp: 36°C
PR: 112bpm
RR: 42 cpm
b. Height and Weight
Height: 59 cm
Weight: 41 kgs.
c. Examination of the Skin
Brown in complexion uniformed in skin color
Skin is warm to touch
(+) ecchymosis in upper and lower extremities
d. Examination of Hair and Nails
Hair is equally distributed
No infestations and dandruff
No depressions noted upon palpation
With dirty finger and toenails
With normal capillary refill of 2 seconds
With nail beds, smooth in texture, convex curvature of finger plate; angle of 160
degrees.
e. Examination of the Skull and Face
Skull rounded with no presence of lesions or deformations
With symmetric facial movements
Uniformed color
f. Examination of the Eyes
Eyebrows and lashes are evenly distributed
Eyelids are symmetrical
With approximately 15-20 involuntary blinks per minute
Pink palpebral conjuctiva
g. Examination of the Ears
Auricles are in symmetrical size, aligned with outer cantus
Pinna coils after being folded
Client responds to normal voice tones
minimal presence of cerumen on both ears
h. Examination of the Nose
External nose is properly aligned in between eyes and straight
With nasal flaring, no discoloration noted, no tenderness and no lesions
Nasal septum is in middle and intact
Presence of clear nasal secretions
i. Examination of the Mouth
Outer upper and lower lips are pink in color with soft and smooth texture and have
the ability to purse lips
Inner lips and buccal mucosa is uniform and pink in color, smooth texture and
glistening
With incomplete set of teeth
The tongue is in central position, pink in color, slightly rough, with raised taste buds
and can be able to move side to side and up and down
Uvula is positioned in midline of soft palate
Can open and clench jaw without difficulty
j. Examination of the Neck
Neck is symmetrical
No masses noted
Coordinated head movement with slight difficulty
Trachea in midline at the suprasternal notch upon inspection and palpation
k. Examination of the Lymph Nodes
Lymph nodes not palpable, slightly movable
No enlargement noted
l. Examination of the Chest (Lungs)
Normal respiratory rate (20 cpm)
Symmetrical chest expansion
Presence of any adventitious breath sounds upon auscultation
m. Examination of Abdomen
Without abdominal distention upon inspection and palpation
Absence of wounds and lacerations upon inspection
n. Examination of the Heart
With normal, regular, rate and rhythm of the heart upon auscultation
o. Examination of Extremities
Extremities are symmetrical and no deformations and tenderness
There is no presence of edema
Radial pulse is regular and not bounding
p. Examination of Lower Extremities
No presence of lesions present
Extremities symmetrical with no deformations and tenderness
There is no presence of edema
CRANIAL NERVE ASSESSMENT
CRANIAL NERVE TYPE FUNCTION METHOD OF FINDINGS
ASSESSMENT
CRANIAL NERVE I
(Olfactory)
Sensory Smell The Student Nurse
asked the patient to
close her both eyes. He
was asked to smell and
to identify aromas such
as Vinegar and alcohol,
which was prepared by
the student nurse (SN).
Actual findings:
AC is able to smell
and identify different
scents such as
alcohol and vinegar.
CRANIAL NERVE II
(Optic)
Sensory Vision and
Visual fields
The SN asked Bah Tuh
to read a newspaper
first with the right eye
and then with the left
and finally both eyes
with a distance of 12
inches.
Actual Findings:
AC cannot see
anything when her
left eye was covered,
while when covering
the right eye the left
can read the words
written in the
newspaper. When
using both eyes he
can read the
newspaper by using
her left eye.
CRANIAL NERVE
III
(Oculomotor)
Motor Extraocular
movement,
movement of
sphincter of
pupil and
ciliary muscles
of the lens
The SN asked patient to
close first his one eye as
a penlight was
introduced on the
uncovered eye. Upon
the application of light,
pupil size and changes
Actual Findings:
Upon the
introduction of light
on each pupil of the
patient, constriction
of the pupil was
noticed. It also
were noticed. The same
thing was done on the
other eye. Also, the
blinking of the eyelids
of the patient was
assessed during the
whole period of the
interview. In addition,
the student nurse who
was holding a penlight
asked the patient to
concentrate looking on
the penlight then
observe for constriction
of the pupil and then
after that the student
nurse told the patient
to look at the wall
without moving the
head then observe for
dilation of pupil.
constricts upon
focusing on the
penlight holding by
the student nurse
and dilates when
looking at the wall
without moving the
head.
CRANIAL NERVE
IV
(Trochlear)
Motor Extraocular
movements
specifically
movements of
eyeball in
downward
lateral
directions.
The SN made use of a
penlight and moved it
in different directions:
upward lateral, right
side, downward lateral,
and left side. The SN
instructed the patient
to follow the
movements of the
penlight through his
Actual Findings:
AC has good,
coordinated eye
movements (both
eyes) and is able to
follow the direction
of the penlight with
her eyes without
moving her head.
eyes only without
moving his head.
CRANIAL NERVE
V
(Trigeminal)
Sensory
and
Motor
Sensation of
cornea, skin of
face and nasal
mucosa,
muscle of
mastication,
sensation of
skin surface.
The SN made use of the
corneal reflex test by
gently touching the
cornea with sterile
cotton and gently
stroking the eyelashes.
And uses a pin to test
for skin sensation.
The group also
observed the patent
when eating and
speaking.
Actual Findings:
Ac elicited blinking
reflex.
She can also
differentiate the
dullness or
sharpness of the pin.
She is able to make
chewing
movements, open
the mouth against
resistance, and
move her jaw from
side to side
CRANIAL NERVE
VI
(Abducens)
Motor Extraocular
movement,
lateral
movement of
the eyeball
The student nurse
asked patient to move
the eyeballs in lateral
sides.
Actual Findings:
AC was able to move
both eyeballs
laterally.
CRANIAL NERVE
VII
(Facial)
Sensory
and
Motor
Facial
expressions,
sense of taste
on the anterior
two thirds of
the tongue and
The student nurse
asked patient to smile,
raise his eyebrows and
puff out his cheeks, and
frown.
The student nurse also
Actual Findings:
AC was able to smile,
puff out her cheeks
and raise his
eyebrows and frown
her face. AC was
movement of
muscles in the
face.
asks the patient to taste
salt and sugar.
able to identify the
difference of salt,
and sugar.
CRANIAL NERVE
VIII
(Acoustic)
Sensory Hearing and
Balance
The student nurse
whispered a word to his
and instructed his to
repeat the word
whispered.
Performed the
Romberg’s Test.
Instructed patient to
close his eyes and stand
straight with hands on
side.
Actual findings:
AC can hear on both
ears.
Actual findings:
The patient was able
to balance her self
without any
excessive swaying
movements.
CRANIAL NERVE
IX
Glossopharyngeal
Sensory
and
Motor
Sense of taste
on the
posterior one-
third of the
tongue,
pharyngeal
movement and
swallowing.
The student nurse
instructed the patient
to drink water and
swallow it. And asked
the patient to moves
his tongue in different
sides.
Actual findings:
AC demonstrated (+)
gag reflex.
CRANIAL NERVE X
(Vagus)
Sensory
and
Motor
Taste, Salivary
glands,
pharyngeal
muscles, larynx
For taste, the student
nurse introduced a
sugar and salt on the
posterior part of the
Actual findings:
AC was able to
identify the different
taste of the
tongue. For motor, the
SN introduced a tongue
depressor on the
anterior part of the
tongue.
substances and was
able to elicit gag
reflex upon
introducing a tongue
depressor at the
back of the tongue,
normal swallowing
noted.
CRANIAL NERVE
XI
(Accessory)
Motor Motor to neck
and upper
back muscles
Applied a force on the
head and shoulders,
instructed patient to
resist the force
Actual findings:
AC was able to exert
force on the head
and shoulders upon
the student nurse
applied force.
CRANIAL NERVE
XII
(Hypoglossal)
Motor Tongue
muscles
Asked the patient to
protrude tongue and
move it from side to
side.
Actual findings:
AC was able to
protrude the tongue
without any
deviation and move
it from side to side.
IV. ANATOMY AND PHYSIOLOGY
The production of red blood cells is referred to as erythropoiesis. Mature red blood cells
develop from hemocytoblasts. This development takes about 7 days and involves three to four
mitotic cell divisions, so that each stem cell gives rise to 8 or 16 cells. The various cell types in
erythrocyte development are characterized by the gradual appearance of hemoglobin and
disappearance of ribonucleic acid (RNA) in the cell
the progressive degeneration of the cell's nucleus which is eventually extruded from the cell the
gradual loss of cytoplasmic organelles, for example mitochondria a gradual reduction in cell size.
The young red cell is called a reticulocyte because of a network of ribonucleic acid
(reticulum) present in its cytoplasm. As the red cell matures the reticulum disappears. Between
2 and 6% of a newborn baby's circulating red cells are reticulocytes, but this reduces to less than
2% in the healthy adult. However, the reticulocyte count increases considerably in conditions in
which rapid erythropoiesis occurs, for example following hemorrhage or acute hemolysis of red
cells. A reticulocyte normally takes about 4 days to mature into an erythrocyte. In health,
erythropoiesis is regulated so that the number of circulating erythrocytes is maintained within a
narrow range. Normally, a little less than l% of the body's total red blood cells are produced per
day and these replace an equivalent number that have reached the end of their life span.
However that still represents a huge 200,000,000,000 cells. Erythropoiesis is stimulated by
hypoxia (lack of oxygen).
However, oxygen lack does not act directly on the hemopoietic tissues but instead
stimulates the production of a hormone, erythropoietin. This hormone then stimulates
hemopoietic tissues to produce red cells. Erythropoietin is a glycoprotein. It is inactivated by the
liver and excreted in the urine. It is now established that erythropoietin is formed within the
kidney by the action of a renal erythropoietin factor erythrogenin on plasma protein,
erythropoietinogen. Erythrogenin is present in the juxtaglomerular cells of the kidneys and is
released into the blood in response to hypoxia in the renal arterial blood supply.
Various other factors can affect the rate of erythropoiesis by influencing erythropoietin
production. Thyroid hormones, thyroid-stimulating hormone, adrenal cortical steroids,
adrenocorticotrophic hormone, and human growth hormone (HGH) all promote
erythropoietin formation and so enhance red blood cell formation (erythropoiesis). In thyroid
deficiency and anterior pituitary deficiency, anemia may occur due to reduced erythropoiesis.
Polycythemia (excess red blood cell production) is often a feature of Cushing's
syndrome. However, very high doses of steroid hormones seem to inhibit erythropoiesis.
Androgens (male hormones) stimulate and estrogens (female hormones) depress the
erythropoietic response. In addition to the effects of menstrual blood loss, this effect may
explain why women tend to have a lower hemoglobin concentration and red cell count than
men. Plasma levels of erythropoietin are raised in hypoxic conditions (low oxygen levels).
This produces erythrocytosis (increase in the number of circulating erythrocytes) and
the condition is known as secondary polycythemia. A physiological secondary polycythemia is
present in the fetus (and residually in the new-born) and in people living at high altitude
because of the relatively low partial pressure of oxygen in their environment. Secondary
polycythemia occurs as a result of tissue hypoxia in diseases such as chronic bronchitis,
emphysema and congestive cardiovascular abnormalities associated with right-to-left
shunting of blood through the heart, for example Fallot's of tetralogy. Erythropoietin is also
produced by a variety of tumors of both renal and other tissues. The oxygen carrying capacity of
the blood is increased in polycythemia but so is the thickness (viscosity) of the blood. The
increased viscosity produces circulatory problems such as raised blood pressure. There is a
condition known as primary polycythemia (polycythemia rubra vera), where there are increases
in the numbers of all the blood cells, and plasma erythropoietin levels are normal. The cause of
this condition is unknown. The underlying cause of secondary polycythemia is treated with the
aim of eliminating hypoxia. Vene section (blood letting) is sometimes employed to
reduce red cell volume to normal levels. Frequently blood is removed,
centrifuged to remove cells and the plasma returned to the patient (plasmapheresis). In anemia
there is a reduction in blood hemoglobin concentration due to a
decrease in the number of circulating erythrocytes and/or in the amount of hemoglobin they co
ntain. Anemia occurs when the erythropoietic tissues cannot supply enough normal
erythrocytes to the circulation. In anemia due to abnormal red cell production, increased
destruction and when demand exceeds capacity, plasma erythropoietin levels are increased.
However, anemia can also be caused by defective production of erythropoietin as, for example,
in renal disease.
A. Definition
Anemia is a condition where red blood cells are not providing adequate oxygen to body
tissues. Red blood cells provide oxygen to body tissues. There are many types and causes of
anemia.
B. Causes
Anemia is caused by many different things at it has a lot of subtypes. However, the main
presenting factor is the lack of healthy circulating red blood cells to carry oxygen systemically.
Here is a quick overview of the different subtypes of anemia:
1. Iron Deficiency Anemia
Iron is needed for healthy production of red blood cells. Iron is a building block of healthy red
blood cells. A deficiency in iron would result in immature, microsomic, and hypochromic red
blood cells. Also, fewer RBCs will be produced by the marrow. This type of anemia is the most
common type of anemia.
2. Folic-Acid Deficiency Anemia
Folate is also known as Folic Acid. This type of anemia results from a deficiency of this B vitamin.
This particular type of anemia is particularly common among pregnant women as the developing
fetus uses up the mother’s folate stores. In folate deficiency anemia, the red blood cells are
macrosomic and are called megalocytes or megaloblasts. This is the reason why this form of
anemia is called Megaloblastic Anemia
3. Thalassemia
Thalassemia is a form of anemia that is inherited. In this type of anemia, the body makes an
abnormal form it hemoglobin, the major protein in RBCs that carry oxygen. In alpha-
thalassemia, the genes related to alpha globin are mutated or are missing. In beta thalassemia, a
gene defect also affects the production of beta globin. Thalassemia major is categorized if you
inherit the genetic defect from both parents. If only one parent however transmits the defect, it
is termed Thalassemia minor. Both conditions result to an abnormal form of hemoglobin and
leads to excessive RBC destruction leading to anemia.
4. Vitamin B12 Deficiency Anemia
This form of anemia is due to lack of sufficient cyanocobalamin or Vitamin B12. This type
of anemia results to macrocosmic, hypochromic RBCs. This is often referred to as Pernicious
anemia. The cause of this type of anemia could be a dietary deficiency, or a disease that impairs
its proper absorption such as Celiac disease or Crohn’s disease.
5. Hemolytic Anemia
Hemolytic Anemia is a type of anemia that results from excessive lysis or destruction of RBCs.
This type of anemia has a lot of causes and it also has different subtypes. The destroying factor
may be intrinsic, or extrinsic, depending on the specific cause. In this type of anemia, RBCs are
rapidly destroyed, resulting to a low number of oxygen-carrying RBCs leading to anemia. This
type of anemia does not occur though if the bone marrow is capable of producing much more
RBCs than those destroyed.
6. Aplastic Anemia
In Aplastic anemia, there is a deficiency in sufficient production of red blood cells by the bone
marrow. There are two types of this: idiopathic, or secondary. In idiopathic aplastic anemia,
there is no clear cause as to why the bone marrow is unable to produce new, mature red blood
cells. In secondary aplastic anemia, the failure results as a sequel from another disorder such as
renal disease (where there is decreased erythropoietin), chemotherapy, radiation, and others.
7. Sickle-Cell Anemia
This type of anemia is caused by a particular type of hemoglobin called hemoglobin S.
Hemogloin S changes the shape of red blood cells especially during times of low oxygen
saturation of the blood. Hemoglobin S causes cells to become shaped like sickles or crescents.
These RBCs are unable to properly carry oxygen, and they often get lodged into capillaries and
block them.
C. Symptoms
Symptoms of anemia may vary from the specific subtype, but these are some of the general
signs and symptoms:
Fatigue
Pallor
Cyanosis
Low hematocrit and RBC levels on a Complete Blood Count
Chest pain
Dizziness and Headaches
Paresthesia
Skin mottling
Shortness of Breath
Confusion and restlessness
Cold hands and feet
Tachycardia
D. Management
Management of anemia depends on the specific deficiency or the specific subtype. Nonetheless,
conventional management includes:
1. Supplementation with Iron, Folate, or Vitamin B 12
2. Use of corticosteroids in anemia’s where there is destruction of RBCs
3. Blood Transfusions
4. Erythropoietin supplementation
5. Rest
6. Treatment of the underlying condition that causes the anemia
E. Prevention
Prevention of anemia is possible. Ensuring that you eat a proper diet is one of the keys towards
prevention of this disease. Supplement your diet with foods rich in iron, folate, vitamin B12 and
vitamin C such as green leafy vegetables, dairy, eggs, organ meats, lentils, beans, meat, and
others. If there is an underlying medical condition that may cause anemia, consult your doctor
as to how to manage this condition.
V. PATHOPHYSIOLOGY
Anemia Schematic Diagram
Predisposing Factors-Sex (menstruation)-Genetics
Precipitating Factors
-Inadequate Iron intake & faulty diet-Blood Loss-Pregnancy
Decreased intake of iron rich foods, with blood loss
Iron in the body is used up
Decreased iron reserves needed for hemoglobin
production
Decreased RBC production due to lack of hemoglobin
Iron Deficiency Anemia
Decreased oxygen and hemoglobin
Pallor due to decreased hemoglobin
Weakness due to decreased overall oxygen supply
Headache due to decreased oxygen supply to the brain
If prolonged:*Chest Pain (Lack of oxygen in the heart)
*Shortness of Breath even with rest *Paresthesia (indicates nerve affectation)
*Disorientation and Confusion (if the brain is severely deprived of oxygen)
*Low RBC and Hematocrit levels
VI. LABORATORY EXAMINATION RESULTS
1.) Hematology complete blood count
Procedure Date Purpose Normal Results ImplicationHematology Complete Blood Count
August 16-27, 2015
This test is used to evaluate anemia, leukemia, reaction to inflammation and infections, peripheral blood cellular characters, State of hydration and dehydration, Polycythemia, to manage chemotherapy decisions.
WBC: 10^3/ulNeutrophil:0.40-0.60 (H)Lymphocytes:0.20-0.40 (L)Monocytes:0.02-0.08Eiosinophil:0.01-0.03Basophil:0.00-0.02Hgb:12.5-16.2g/LHct:0.37-0.42 (H)RBC:4.50-5.50 10^2/LMCV:88-96 FL (L)MCH:27-33pgMCHC:330-360 g/L (L)RDW:12.70%-22.70%Platelet:10^3/ulMPV:4.50-7.50 (H)
WBC: 9.54Neutrophil: 41.5Lymphocytes: 43.2Monocytes:1.0Eiosinophil:5.8Basophil:0Hgb: 5.3Hct:30.9RBC:3.72
MCV:83.1MCH:28.5MCHC:34.3RDW:40.9
Platelet:9MPV:-
Abnormal results of high WBC which indicates infection along with high Neutrophil and lymphocytes count. This indicates the abnormal blood flow and other systemic affection due to the patient’s disease also considering her low immune system function. The rise and fall of other results have been altered due to other medical treatments and procedures done to the client.
Nursing Intervention:
Explain test procedure. Explain that slight discomfort may be felt when the skin is
punctured.
Encourage to avoid stress if possible because altered physiologic status influences and
changes normal hematologic values.
Explain that fasting is not necessary. However, fatty meals may alter some test results as a
result of lipidemia.
Apply manual pressure and dressings over puncture site on removal of dinner.
Monitor the puncture site for oozing or hematoma formation.
Instruct to resume normal activities and diet.
NAME OF DRUGS, GENERIC NAME, BRAND NAME
DATE ORDERED, DATE TAKEN/GIVEN, DATE
CHANGED
ROUTE OR ADMINISTRATION
DOSAGE AND FREQUENCY OF
ADMINISTRATION
GENERAL ACTION, MECHANISM OF
ACTION
INDICATION OR PURPOSES
CLIENT’S RESPONSE TO
THE MEDICATION
Blood Transfusion DO: August 17,21, 23, 2015
Right Brachial arteryq 24
One unit of packed red
blood cells has the
same amount of
oxygen carrying red
blood cells as a unit of
whole blood. For each
unit of RBCs
transfused, the average
70 kg adult’s
hemoglobin will usually
increase by 1 g/dL the
and their hematocrit by
2-3 percent. Packed
red blood cells have a
hematocrit between
70% and 80%, so they
are among the most
viscous of the blood
products to transfuse.
To increase the
oxygen-carrying
capacity in anemic
patients.
Client’s response to medication is effective as evidence by lowering down the patient’s temperature
NURSING RESPONSIBILITIES:
Plain NSS (IVF)
1. Verify the doctor’s order.
2. Know the type, amount and indication of IV therapy.
3. Practice strict asepsis.
4. Inform client and explain purpose of therapy.
5. PRIME IV tubing to expel air. This will prevent air embolism.
6. Clean the insertion site of IV needle from center to the periphery with alcoholized
cotton swab.
7. Monitor patient frequently for:
a. Signs of infiltration / sluggish flow
b. Signs of phlebitis / infection
c. Dwell time of catheter and need to be replaced
d. Condition of catheter dressing
8. Check the level of the IVF.
9. Correct solution, medication and volume.
10. Check and regulate the drop rate to ensure administration of proper volume of IV
fluid as ordered.
11. Change the IVF solution if needed.
Packed RBC (Blood Transfusion)
1. Verify the physician’s written order and make a treatment card according to hospital
policy.
2. Observe the 10 Rs when preparing and administering any blood or blood
components.
3. Explain the procedure/rationale for giving blood transfusion to reassure patient and
significant others and secure consent. Get patient histories regarding previous
transfusion.
4. Explain the importance of the benefits on Voluntary Blood Donation (RA 7719-
National Blood Service Act of 1994).
5. Request prescribed blood/blood components from blood bank to include blood
typing and cross matching and blood result of transmissible Disease.
6. Using a clean lined tray, get compatible blood from hospital blood bank.
7. Wrap blood bag with clean towel and keep it at room temperature.
8. Have a doctor and a nurse assess patient’s condition. Countercheck the compatible
blood to be transfused against the cross matching sheet noting the ABO grouping
and RH, serial number of each blood unit, and expiry date with the blood bag label
and other laboratory blood exams as required before transfusion.
9. Get the baseline vital signs- BP, RR, and Temperature before transfusion. Refer to
MD accordingly.
10. Give pre-meds 30 minutes before transfusion as prescribed.
11. Do hand hygiene before and after the procedure.
12. Prepare equipment needed for BT (IV injection tray, compatible BT set, IV catheter/
needle G 19/19, plaster, torniquet, blood, blood components to be transfused, Plain
NSS 500cc, IV set, needle gauge 18 (only if needed), IV hook, gloves, sterile 2×2
gauze or transplant dressing, etc.
13. If main IVf is with dextrose 5% initiate an IV line with appropriate IV catheter with
Plain NSS on another site, anchor catheter properly and regulate IV drops.
14. Open compatible blood set aseptically and close the roller clamp. Spike blood bag
carefully; fill the drip chamber at least half full; prime tubing and remove air bubbles
(if any). Use needle g.18 or 19 for side drip (for adults) or g.22 for pedia (if blood is
given to the Y-injection port, the gauge of the needle is disregarded).
15. Disinfect the Y-injection port of IV tubing (Plain NSS) and insert the needle, from BT
administration ser and secure with adhesive tape.
16. Close the roller clamp of IV fluid of Plain NSS and regulate to KVO while transfusion
is going on.
17. Transfuse the blood via the injection port and regulate at 10-15gtts/min initially for
the first 15 minutes of transfusion and refer immediately to the MD for any adverse
reaction.
18. Observe/Assess patient on an on-going basis for any untoward signs and symptoms
such as flushed skin, chills, elevated temperature, itchiness, urticaria, and dyspnea.
If any of these symptoms occur, stop the transfusion, open the IV line with Plain NSS
and regulate accordingly, and report to the doctor immediately.
19. Swirl the bag gently from time to time to mix the solid with the plasma N.B one B.T
set should be used for 1-2 units of blood.
20. When blood is consumed, close the roller clamp, of BT, and disconnect from IV lines
then regulate the IVF of plain NSS as prescribed.
21. Continue to observe and monitor patient post transfusion, for delayed reaction
could still occur.
22. Re-check Hgb and Hct, bleeding time, serial platelet count within specified hours as
prescribed and/or per institution’s policy.
23. Discard blood bag and BT set and sharps according to Health Care Waste
Management (DOH/DENR).
24. Fill-out adverse reaction sheet as per institutional policy.
25. Remind the doctor about the administration of Calcium Gluconate if patient has
several units of blood transfusion (3-5 more units of blood).
VII. GORDON'S ASSESSMENT
A. Health Perception and Management o Client can’t recall well if She was completely immunized.o Client was brought to the hospital for management.
B. Nutrition/ Metabolismo Not fond of eating meats and fruits
C. Eliminationo Voids usually 5 times a dayo Urine color is yellowo Defecates usually every other day.
D. Activity/Exerciseo Bed rest with semi-fowlers position. o Minimal movements
E. Sexuality/Reproductiveo Singleo No history of STDS
F. Cognitive/Perceptualo Responds to stimuli physically.o Undergrad
G. Roles/Relationshipo Singleo Well-supported by the family
H. Self-Perception/ Self-Concepto Hopeful to be relieve and treatedo Manages healthy lifestyle before her condition
I. Value/Beliefo Catholico Has a strong faith in God
J. Coping/ Stresso Anemia since December 2014o Copes up with problems
K. Sleep/Resto Difficulties in sleeping, always sleeps lateo Not enough rest intervals
L. Medication Historyo Meds for her previous hospitalization in January 2015
VIII. NURSING CARE PLAN
#1 ACTIVITY INTOLERANCE R/T IMBALANCE BETWEEN OXYGEN SUPPLY (DELIVERY) AND DEMAND
ASSESSMENT DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION
Subjective:
♦ “Nanghihina ako,kadalasan hindi ko matapos ang mga gawain ko
(I’m feeling weak, I can’t even complete my chores
)” as verbalized by the patient.
Objective:
♦ Fatigue.
♦ Greater need for sleep and rest.
♦ Activity intolerance related to imbalance between oxygen supply (delivery) and demand.
Short term:
After 8 hours of nursing interventions the patient will:
♦ Report an increase in activity tolerance including activities of daily living.
♦ Demonstrate a decrease in physiological signs of intolerance.
♦ Display laboratory
Independent:
♦ Assess patient’s ability to perform normal task or activities of daily living.
♦ Note changes in balance/ gait disturbance, muscle weakness.
♦Recommend quiet atmosphere, bed rest if indicated.
♦Elevate the head of
♦Influences choice of interventions or needed assistance.
♦ May indicate neurological changes associated with vitamin B12 deficiency, affecting patient safety or risk of injury.
♦Enhances rest to lower body’s oxygen requirements, and reduces strain on the heart and lungs.
♦ Patient reveals an increase in activity tolerance, demonstrating a reduction in physiological signs of intolerance and laboratory values within normal range.
♦ V/S taken as follows: T: 36.9 P: 75 R: 18 BP: 100/80
values within acceptable range.
Long term:
After months of nursing interventions, the patient:
♦ Is free form weakness and risk for complications has been prevented.
the bed as tolerated.
♦Provide or recommend assistance with activities or ambulation as necessary, allowing patient to do as much as possible.
♦ Plan activity progression with patient, including activities that the patient views
♦ Enhances lung expansion to maximize oxygenation for cellular uptake.
♦ Although help may be necessary, self esteem is enhanced when patient does some things for self.
♦ Promotes gradual return to normal activity level and improved muscle tone or stamina without undue fatigue.
essential. Increase levels of activities as tolerated.
♦ Identify or implement energy saving technique like sitting while doing a task.
Collaborative:
♦ Monitor laboratory studies. Hb or Hct and RBC count, arterial blood gases (ABGs).
♦ Encourages patient to do as much as possible, while conserving limited energy and preventing fatigue.
♦ Identifies deficiencies in RBC components affecting oxygen transport and treatment needs or response to therapy.
#2 IMPAIRED GAS EXCHANGE R/T OXYGEN CARRYING CAPACITY OF BLOOD
ASSESSMENT DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION
Subjective: Madalas akong mahilo at nahihirapang huminga verbalized by patient
Objective:
visual disturbance
headache uponawakening
restless
irritable
pale in appearance
diaphoresis
AbN ABG/
Impaired gas exchange related to oxygen carrying capacity of blood
Short term:
After 5-10 mins of nursing intervention the patient will be able to breath with in patient range through supplemental oxygenation and lessen complaints of dizziness
Long term:
After 3 days of continuous nursing intervention the patient will be able to demonstrate impaired ventilation and adequate oxygenation
Diagnostic:
monitor vital signs especially respiratory rate and record
review lab results on CBC and ABG’s
Assess energy level and activity tolerance
Therapeutic:
Administer O2 therapy as ordered
Assists on needs
Demonstrate deep
serve as baseline data for alterations
To assess respiratory deficiency
To identify needs for assistance
To alleviate difficulty of breathing
Provide comfort for the patient
To promote oxygenation to the patient
To maintain airway
Helps limit O2 needs
To enhance Fe absorption
Short term:
Goal met, patient is able to breath within normal range with no complaints of dizziness.
Long term:
Goal partially met. Patient’s condition demonstrates impaired ventilation and controlled within normal level, no signs of any complications noted.
arterialpH
Polycythemia
dyspnea
♦ V/S taken as follows: T: 36.9 P: 75 R: 18 BP: 100/80
of tissues by ABG within
Client’s normal limit and
Absence of symptoms of respiratory distress.
breathing exercise
Demonstrate head of bedand position the client appropriately
Educative:
Encourage the adequate rest and limit activities to within client’s tolerance
Discuss importance of taking iron supplement and vitamin C.
#3 INEFFEFTIVE TISSUE PERFUSION
ASSESSMENT DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION
Subjective: none
Objective: >HGB level (low) 56g/L>Pail nail beds>Pale palpebral conjunctiva>Low pulse rate 46 bpm>Dry scaly skin
Ineffective tissue perfusion related to decreased hemoglobin concentration as evidenced by low HGB levels 56g/L
Short term: after 1 hour of nursing intervention the patient will be able to verbalize understanding of condition therapy given.
Long term: after 1 week of nursing intervention the patient will be able to increase tissue perfusion such as HGB level within normal range and pulse rate returns to normal levels.
1. Establish rapport
2. Monitor V/S
3. Identify changes related to systemic orPeripheral situations in circulation (e.g.altered mentation).
4. Monitor I&O
5. Provide psychological support for patient such as staying at the bedside ofthe patient.
6. Encouraged Quiet restful atmosphere.
7. Caution client to avoid activities thatIncrease cardiac workload.
8. Elevate HOB
1. To gain trust of patient.
2. To record baseline data.
3. To identify the causes of tissue perfusion
4. To identify if there is a decrease in the fluid retention of the body of the patient.
5. To prevent any signs of anxiety.
6. To prevent any agitation of the patient that may cause an increase in the vital signs.
Short term:After 1 hour of nursing intervention the patient shall be able to verbalize understanding of condition therapy given.
Long term:
After 1 week of nursing intervention the patient Shall be able to increase tissue perfusion such as HGB level within normal range and pulse rate returns to normal levels.
7. To prevent further complications that might occur with the activities.
8. To promote circulation for the patient.
IX. DRUG STUDY
NAME OF DRUGS, GENERIC NAME, BRAND NAME
DATE ORDERED, DATE
TAKEN/GIVEN, DATE CHANGED
ROUTE OR ADMINISTRATION
DOSAGE AND FREQUENCY OF
ADMINISTRATION
GENERAL ACTION, MECHANISM OF
ACTION
INDICATION OR PURPOSES
CLIENT’S RESPONSE TO THE
MEDICATION
Generic name: Paracetamol
Brand name:Calpol
DO: August 26, 2015
DG: August 16,-21, 2015
Dosage:• 600mg
Route:•Oral
Frequency:• q 4hrs
General Action: Analgesics Muscle Relaxants
Mechanism of Action: -Decreases fever by inhibiting the effects of pyrogens on the hypothalamus heat regulating centers & by a hypothalamic
-Action leading to sweating & vasodilatation.
Relief of mild-to-moderate pain; treatment of fever.
Client’s response to medication is effective as evidence by lowering down the patient’s temperature
NAME OF DRUGS, GENERIC NAME, BRAND NAME
DATE ORDERED, DATE
TAKEN/GIVEN, DATE CHANGED
ROUTE OR ADMINISTRATION
DOSAGE AND FREQUENCY OF
ADMINISTRATION
GENERAL ACTION, MECHANISM OF
ACTION
INDICATION OR PURPOSES
CLIENT’S RESPONSE TO THE
MEDICATION
Generic name:Furosemide
Brand name:Lasix
DO: August 26, 2015
DG: August 16,-21, 2015
Dosage:• 20mg
Route:•IV
Frequency:• mid and post BT
Furosemide inhibits absorption of sodium and chloride from the proximal and distal tubules and ascending limb of the loop of henle. Leading to a sodium rich diuresis, thus reducing edema associated to renal disease resulting to decrease BP.
Indicated for the patient as he has elevated blood pressure and edema.
The patient improves her condition as he had a decreased BP after 30 mins. of administration.
Nursing Responsibilities
Before:
Observe 10 R’s of administration of drugs ' Check doctor’s order three times and verify the patient Check the label of the drug, its name and its expiration date Wash hands before handling the medication Assess patient’s vital signs prior to administering the medication
During: Administer as indicated (right drug, right dosage, right frequency) Clean the IV insertion for medication with a cotton ball with alcohol. Gradually inject the drug into the port. Slow IV push to prevent infiltration and phlebitis. Administer cautiously and slowly with aseptic technique.
After: Observe for the sensitivity and side effects to the drug Reassess patient’s level of pain at least 15 and 30 minutes after parenteral administration Monitor circulatory and respiratory status and bladder and bowel function. Caution ambulatory patient about getting out of bed or walking.
X. HEALTH TEACHINGS
MEDICATION: Ferrous Sulfate tablet, 1 tablet O.D. Ascorbic Acid 1 tablet O.D.
EXERCISE: Perform passive ROM exercise like flexion, extension of the extremities. Brisk walking every morning.
TREATMENT: Blood transfusion if blood count falls below normal. Folic acid injection if available.
HEALTH TEACHING: Encourage participation in recreation and regular exercise program Provide appropriate level of environmental stimulation (ei;music, TV/ radio, personal
possessions and visitors) Suggest use of sleep aid/ promote normal sleep/rest.
OPD: Return to OPD for further check-up when there are changes on physical strength.
DIET: High fiber diet like vegetables and fruits. Protein rich diet Folic and vitamin B12 rich foods such as: liver, dried beans, peas, wheat products,
spinach, dark leafy vegetables, meat, eggs, milkSIGNS/SYMPTOMS:
Observe for signs and symptoms such as body weakness, poor skin turgor, pallor and weight loss.
RLE SUMMARY
As a student nurse, I have learned and gain new knowledge from this case study. Doing a case study is not an easy task since it entails a lot of hard work and understanding to come up with its content. But in the end, all efforts and hard work are all worth it because of the values and learning I have gained..
Upon completing this case study, I was able to come up with several conclusions. Despite of the early description of the condition, it is only in the recent times that Anemia was further elaborated. Few researchers can be trace to have been presented in etiology with touch of accuracy as many authors claim it to be of unknown cause. This case study however, aims to give ideas, classifications with regards to the origin, pathophysiology, clinical manifestations, diagnosis and treatment of the disease.
In addition, I have also learned that to become a nurse it requires a task to promote wellness to prevent diseases and help the patient. Specifically, by giving appropriate health teachings. Which are to be taught therapeutically and in a ways comprehensible to the patients including rationale to enhance compliance. Through this way, we are able to make a change and even save the lives of our patients. And seeing our patients get better gives us sense of fulfillment and satisfaction. Which inspires me to be more effective and efficient with the things I do to become a future nurse someday.
Bungay, Maria Paula M.
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