By: Group 1-Section N

Identifying Data

Name of Patient : Mr. MSex : MaleAge : 81 years oldCivil Status : MarriedNationality : FilipinoReligion : R.C.Address : Tuleda, CamotesDate Admitted : July 24, 2009Time :

Informant : Daughter Mode of Admission : Wheelchair

Vital Signs on Admission

Temperature : 37.9CHeart Rate : 90 bpmRespiratory Rate : 26 cpmWeight : 47kgHeight : 5’2

Chief of Complaints : excessive gum bleeding

A case of Mr M, 81 y.o., male from Tudela Camotes, 3 weeks PTA pt. experience episodes of gum bleeding. Pt’s SO decided to take him to see a doctor and advised to undergo laboratory exam.

On July 21, 2009, pt underwent Complete Blood Count with a result of low platelet (15,000) and pt was given Hemonstan and Cephalexin to relieve the bleeding.

On July 24, 2009 pt was admitted for the first time at ECS by Dr. Guinocor with an admitting diagnose of gum bleeding to consider THROMBOCYTOPENIA PURPURA

Arthritis Hypertension Smoker

Date Ordered Diagnostic/Laboratory Examination

No. Result Significance

July 21, 2009 CBC- Platelet 140-440 10 x 3 cumm

15,000 May indicate thrombocytopenia

July 24, 2009 CBC - Hematocrit Male: 41-53%

27.3% May indicate anemia

July 24, 2009 CBC- RBC Male:4.7-6.1 x 10 /L

3.71 May indicate hemorrhagic

infections and bleeding

July 24, 2009 CBC- Hemoglobin Male:14-18 mg/dl

8.4 May indicate excessive bleeding

Laboratory Result

Subjective Objective

Communication “Lima ka tuig na sya nga bungol” as verbalized by the daughter

EENTPatient is sleeping during the assessment

Oxygenation“Nag lisud sya ug ginhawa” as verbalized by the daughter

RespirationThe child's cycle per minute is 26 cpm

Circulation“Wala man sa gi reklamo nga sakit sa tiil” as verbalized by the daughter

Heart RhythmPatient manifested signs regular hearth rhythm or pulse rate of 90 bpm ( apical)

Nutrition“Nihugo sya mayo sukad sya nasakit” as verbalized by the daughter.

The patient is not wearing any dentures.

Elimination“Maglisod man siya ug kalibang unya gamay ra kayo siya ug hugaw” as verbalized by the daughter.

Bowel SoundsBowel is graded as hypo 1-2 /minute. The patient has no abdominal distention. Urine color is light yellow, clear consistency with aromatic odor

Management of Health& IllnessNot applicable

Ability to follow TreatmentsThe patient religiously follow medications for bleeding and follows Low Salt Diet per doctor's order.

Subjective Objective

Skin Integrity“Nang lagom man na iyang panit” as verbalized by the daughter.

Patient has cold clammy skin.Peticheae seen distributed around upper extremities.Bruises noted on Left Arm

Activity/Safety“Nag sige lang sy aug higda sukad sya na admit” as verbalized by the daughter.

LOC & OrientationPatient is sleeping during assessment

Comfort/Sleep/Awake“Magmata-mata siya ug gabie kay mag lisud man siya ug ginhawa” as verbalized by the daughter.

Other Signs of PainNo signs of pain

CopingThe wife is taking care of him in the hospital while the daughter is supporting financially. The daughter expressed difficulty in acquiring blood and platelet.

Observed non-verbal behaviorThe patient is resting. The family were discussing on where to look for blood for blood transfusion.

Gum Bleeding - absent of clotting factor (platelets are destroyed).

Gum Bleeding - absent of clotting factor (platelets are destroyed).

Purpura - purple bruises that appears on the skin caused by bleeding under it or on the mucos membrane (e.g. mouth)

- bruises mean that bleeding has occured in small vessels under the skin

  

Purpura - purple bruises that appears on the skin caused by bleeding under it or on the mucos membrane (e.g. mouth)

- bruises mean that bleeding has occured in small vessels under the skin

   Dyspnea- decrease oxygenation in the blood due to decrease in blood volume because of bleedingDyspnea- decrease oxygenation in the blood due to decrease in blood volume because of bleeding

Petechiae - tiny red or purple spots on the skin. Bleeding under the skin causes the purple, brown, and red color of the petechiae

Petechiae - tiny red or purple spots on the skin. Bleeding under the skin causes the purple, brown, and red color of the petechiae

Blood Normally, 7-8% of human body weight is from blood. In adults,

this amounts to 4-5 quarts of blood. This essential fluid carries out the critical functions of transporting oxygen and nutrients to our cells and getting rid of carbon dioxide, ammonia, and other waste products. In addition, it plays a vital role in our immune system and in maintaining a relatively constant body temperature. Blood is a highly specialized tissue composed of many different kinds of components. Four of the most important ones are red blood cells, white blood cells, platelets, and plasma.

Red blood cells, or erythrocytes , are relatively large microscopic cells without nuclei. Red blood cells normally make up 40-50% of the total blood volume. They transport oxygen from the lungs to all of the living tissues of the body and carry away carbon dioxide. The red cells are produced continuously in our bone marrow from stem cells at a rate of about 2-3 million cells per second

Hemoglobin is the gas transporting protein molecule that makes up 95% of a red blood cell. Each red blood cell has about 270,000,000 iron-rich hemoglobin molecules. The red color of blood is primarily due to oxygenated red cells.

White blood cells, or leukocytes exist in variable numbers and types but make up a very small part of blood's volume. Leukocytes are not limited to blood. They occur elsewhere in the body as well, most notably in the spleen, liver, and lymph glands. Most are produced in our bone marrow from the same kind of stem cells that produce red blood cells. Some white blood cells (called lymphocytes ) are the first responders for our immune system. They seek out, identify, and bind to alien protein on bacteria, viruses, and fungi so that they can be removed. Other white blood cells (called granulocytes and macrophages ) then arrive to surround and destroy the alien cells. They also have the function of getting rid of dead or dying blood cells as well as foreign matter such as dust and asbestos.

Platelets , or thrombocytes , are cell fragments without nuclei that work with blood clotting chemicals at the site of wounds. They do this by adhering to the walls of blood vessels, thereby plugging the rupture in the vascular wall. They also can release coagulating chemicals which cause clots to form in the blood that can plug up narrowed blood vessels. Recent research has shown that platelets help fight infections by releasing proteins that kill invading bacteria and some other microorganisms. In addition, platelets stimulate the immune system. Individual platelets are about 1/3 the size of red cells. They have a lifespan of 9-10 days. Like the red and white blood cells, platelets are produced in bone marrow from stem cells.

Plasma is the relatively clear liquid water (92+%), sugar, fat, protein and salt solution which carries the red cells, white cells, platelets, and some other chemicals. Normally, 55% of our blood's volume is made up of plasma. About 95% of it consists of water. As the heart pumps blood to cells throughout the body, plasma brings nourishment to them and removes the waste products of metabolism. Plasma also contains blood clotting factors, sugars, lipids, vitamins, minerals, hormones, enzymes, antibodies, and other proteins.

IS A DISEASE IN WHICH ANTIBODIES FORM AND DESTROY’S THE BODY’S PLATELET

Risk factors:

AGE ( more common in children)SEX ( more common in young women)

Predisposing factors:

PREVIOUS VIRAL INFECTION ( children)MEDICATIONS ( sulfa drugs)IMMUNE DISORDER

Unknown Etiology

Formation of antibodies against platelets

Platelets recognized as foreign bodies

Antibodies bind with antigen of platelet membranes

Platelets destroyed by macrophages

Decreased number of platelets

SIGNS & SYMPTOMSPurpuraPetechiaeHematomasExcessive Menstruation For WomenBlood In The Urine Or Stool

INTRACEREBRAL HEMORRHAGE GASTROINTESTINAL BLEEDING

A Diagnostic Exam/Laboratory Test: CBC : determine that there are no blood abnormalities other than

low platelet count, and no physical signs except for signs of bleeding. Despite the destruction of platelets by splenic macrophages, the spleen is normally not enlarged.

Bleeding time - is prolonged Bone Marrow Examination - may be performed on patients over

the age of 60 and those who do not respond to treatment. Increase in the production of megakaryocytes.

Tourniquet Test – bp taken, cuff inflated half way bet. Systolic and diastolic ,left inflated for 5 minutes. (+) many petechiae.

Anti-platelet antibodies.

Pharmacologic: corticosteroids, azathioprene(imuran) – used to inhibit immune

system production of anti-platelet IVIg (steroids) - intravenous steroids (methylpredinisolone or

prednisone) intravenous immunoglobulin (IVIg) or a combination   Anti-D - A relatively new strategy in treatment with anti-D, but

the patient must be Rh-positive Steroid-sparing agents - dangerously low platelet counts, and a

poor response to other treatments, IVIg treatment Immunosuppresants like mycophenolate mofetil and azathioprine are becoming more popular for their effectiveness for pre-splenectomy.

Vincristine, a chemotherapy agent -Extreme cases (very rare, especially in children) may require the infusion of, to stop the immune system from destroying platelets.  However, vincristine, a vinca alkaloid, has significant of side effects and its use in treating ITP must be approached with caution.

Pharmacologic: Thrombopoietin Receptor Agonists -

Romiplostim (trade name Nplate)

Eltrombopag (if joint pain- no salicylates and ibuprofen)

Experimental and novel agents Dapsone (also called Diphenylsulfone, DDS, or Avlosulfon) The off-label use of rituximab, a chimeric monoclonal antibody against the B

cell surface antigen CD20, has been shown in preliminary studies to be an effective alternative to splenectomy in some patients.

Promising results have been reported in a small phase II study of the experimental kinase inhibitor tamatinib fosdium

Platelet transfusion - Alone for emergency H. pylori eradication

DIET

Medications: -Ranitidine 50mg IVTT every 8 hours -Tranexamic Acid 500 mg IVTT every 12 hours -Lactulose 30cc HS -Ceftazidime IVTT every 8 hours ANST(-) -Salbutamol 1 neb now -Furosemide 1 amp IVTT now

Laboratory exam: -Urinalysis -Complete Blood Count -Stool Examination -Hematologic Examination

Others: -PNSS 1 liter @ 30gtts/min

Name of Drug

Generic(Brand)

Date order

ed

Classification

DoseFreq

Route

Mechanism of

Action

Specific Indicatio

n

Side Effects

Nursing Implication

lactulose laxatives Increases water content and softens the stool. Lowers the pH of the colon, which inhibits the diffusion of ammonia from the colon into the blood, thereby reducing blood ammonia levels

Treatment of chronic constipation in adults and geriatric patients. Adjunct in the management of portal-systemic (hepatic) encephalopathy (PSE)

GI: belching,Cramps, distention, flatulence,diarrhea,ENDO:hyperglycemia

BEFORE:-assess patient for abdominal distention, presence of bowel sounds,and normal pattern of bowel function-Assess color, consistency, and amount of stool produced.DURING:-Mix with fruit juice, water, milk or carbonated citrus beverage to improve flavorAFTER:-Encourage patients to use other forms of the diet, increasing fluid intake, and increasing mobility-Caution patient that this medication may cause belching, flatulence or abdominal cramping

Name of Drug

Generic(Brand)

Date order

ed

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DoseFreq

Route

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Action

Specific Indicatio

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Side Effects

Nursing Implication

SULCRALFATE Gastrointestinal/ Hepatobiliary drugs

Forms a complex by binding with positively charged proteins, that adheres to ulcer site. This selectively forms a protective coat that protect the lining against peptic acid,pepsin and bile salt

Duodenal and Gastric ulcers, chronic gastritis

CONTRAINDICATIONS: Not intended for IV administration

Constipation, diarrhea, nausea, gastric discomfort,, indigestion, dry mouth,rash, pruritus, back pain, dizziness, drowsiness, vertigo

BEFORE:-Obtain patients history and drug history as well as hypersensitivity-Monitor gastric pH (>5 should be maintained; blood in stools-Monitor patient for severe, persistent constipation

DURING:-Give on empty stomach 1 hr before meals and at bedtime.-do not crush or chew tablets

AFTER:-Instruct patient to take medication in empty stomach-Caution patient to avoid antacids within 30 mins of drug or 1 hr after this drug

Sources:PPD Nursing Drug Guide2007 Edition , pages 507

Name of Drug

Generic(Brand)

Date order

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DoseFreq

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Side Effects

Nursing Implication

TRANEXAMIC ACID Cardiovascular Drugs

Inhibits breakdown of fibrin clots. It acts primarily by blocking the binding plasminogen and plasmin to fibrin; direct inhibition of plasmin occurs only to a limited degree.

Treatment and prophylaxis of hemorrhage associated with excessive fibrinolysis. Prophylaxis of hereditary angioedema.

CONTRAINDICATION:•Hypersensitivity•Patients with active intravascular clotting because of the risk of thrombosis.•Severe Renal insufficiency•Patients with microscopic hematuria

•Gastrointestinal disturbances•Hypotension, particularly after rapid IV administration.•Thrombotic complications have been reported.•Instances of transient disturbance of color vision associated with its use.

BEFORE:•Assess patients history, if with active intravascular clotting, predisposed to thrombosis; hemorrhage due to disseminated intravascular coagulation•Monitored anticoagulant cover•Perform eye examination•Perform liver function tests•Obtain prothrombin time of the patientDURING:Maybe mixed with most solutions but not with penicillin'sAFTER:Should not be used in patients with active intravascular clottingPossibility for skin reaction such as a wide spread, patchy rash with associated blisters.Advice patient to report visual abnormalities to the physician.

Name of Drug

Generic(Brand)

Date order

ed

Classification

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Route

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Action

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Nursing Implication

Cefuroxime Antibiotic

Cephalosporins (second generation)

Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death

•Parenteral: dermatologic infections caused by S. Aureus, S. Pyogens, E. coli, kleibsiella, enterobacter

•Contraindications and cautions: •Contraindicated with allergy to cephalosporins and penicillins

•GI: nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence•Hematologic: Bone marrow depression, (decreased WBC,decreased platelets, decreased hct)

Parenteral drug:BEFORE:•Avoid alcohol while taking this drug and for 3 days after because severe reactions often occurDURING:•You may experience these side effects: stomach upset or diarrheaAFTER:Report severe diarrhea, difficulty of breathing, unusual tiredness or fatigue, pain at injection site.

Name of Drug

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Metronidazole •Antibiotic•Anti-Bacterial•Amebicide•Anti-protozoal

Bactericidal: Inhibits DNA synthesis in specific (obligate) anaerobes, causind cell death; anti-protozoal-trichomonacidal, amebicidal: Biochemical mechanism of action is not known.

Indications: Acute infection with susceptible anaerobic bacteria

Contraindications: Contraindicated with hypersensitivity to metronidazole

CNS: headache, dizziness, ataxia, vertigo, fatigue,GI: unpleasant metallic taste, anorexia, nausea, vomiting, diarrhea, GI upset, cramps

BEFORE:•Take the drug with food if GI upset occurs. •Do not drink alcoholDURING:You may experience these side effects: dry mouth with strange metallic taste, frequent mouth care, sucking sugarless candies may help); nausea, vomiting, diarrhea (eat frequent meals).AFTER:Report for severe GI upset, dizziness, unusual fatigue, or weakness, fever, chills.

Assessment Nursing diagnosis

Nursing goal

Nursing Intervention

Rationale Outcome Criteria

Evaluation

S= “Naglisud siya ug ginhawa”as stated by pt’s S.O.O= seen pt lying in bed,asleep.= c ongoing IVF of PNSS,1 L at KVO rate infusing well at left arm= c Oxygen inhalation vianasal prong at2-3L/min= pallor of skin & mucous membrane= c bluish skin discoloration on left & right upper arms= difficulty breathing at rest, noted = productive cough observed= fine crackles heard upon auscultation= c resp. rate of 26 cpm - tachypnea

Impaired Gas Exchange r/t decreased oxygen-carrying capacity of blooddue to bleeding

Scientific base:A change in the pt’s respiratory rate or pattern may be one of the earliest indicators of the need for oxygen therapy. The change in respiratory rate may result from hypoxemia which is a decrease in the arterial tension in the blood manifested by difficulty breathing,cyanosis and cool extremities.Hypoxemia usually leads to hypoxia, which is a decrease in O2 supply to the tissues.

After 30 mins to 1 hour of nurse-pt interventions, patient will be able to demonstrate improved ventilation/ oxygenation.

Independent:1.Promote frequent position changes such as Semi-Fowler’s,side-lying & deep breathing coughing exercises 2. Assess patient’s v/s and evaluate for any adverse effects of CO2 toxicity (such as difficulty breathing

3.Encourage adequate rest & limit activities within patient’s tolerance 4. Ensure patient to maintain adequate fluid intake at least 1-2 L/day,unless contraindicated and regular output

-Promotes lung expansion & drainage of retained secretions.

-Excess CO2 blood gas levels may cause respiratory obstruction as a result of long-term use of oxygen therapy

-helps limit oxygen requirements & consumption

-mobilization of secretions & output prevents fluid overload

Assessment Nursing diagnosis

Nursing goal

Nursing Intervention

Rationale Outcome Criteria

Evaluation

This condition may occur as a result of two factors: from inadequate O2 supply or from inadequate O2 delivery.One type of hypoxia associated with blood disorders such as bleeding is Anemic hypoxia.This is a result of decreased effective Hgb concentration which causes a decrease in the O2-carrying capacity of the blood.Reference:Med-Surgical Nursing.Brunner,Vol 1Page 723-724

5. Provide fluids with electrolytes if decreased appetite

6. Explain to pt & family about disease process & mgt of symptoms

7. Assist pt to develop strategies for monitoring therapeutic regimen

 Dependent: 1.Suction secretions as indicated 2.Adjust O2 levels if patient shows adverse effects as

indicated.

-Provide supplemental fluid & calories if not met by adequate food intake

-pt will be able to identify successful mgt techniques & improve coping skills

-promotes early recognition of changes for proactive response

-to maintain airway

-to detect any developing complications usually from prolonged O2 therapy

After 30 mins of nurse-pt interventions,pt has able to progressively demonstrate improved oxygenation as evidenced by the following:

1.reduced pallor of skin & mucous membrane

2. diminished appearance of bluish skin discoloration on left & right upper arms

3.no longer showed difficulty breathing at rest  4.able to cough out secretions effectively

Assessment Nursing diagnosis

Nursing goal

Nursing Intervention

Rationale Outcome Criteria

Evaluation

5. diminished crackles heard upon auscultation

1.Goal was partially met, as patient showed signs of progressively healthy skin color & mucous membrane 2. Goal was partially met as pt showed diminished appearance of bluish skin discoloration on his right & left upper arms

Assessment Nursing diagnosis

Nursing goal

Nursing Intervention

Rationale Outcome Criteria

Evaluation

3. Goal was partially met as patient no longer had difficulty breathing at rest due to use of oxygen inhalation at 2L/min via nasal prong and with a respiratory rate of  4. Goal was met as patient was able to cough out secretions effectively. 5. Goal was partially met as patient still had crackles heard upon auscultation

Assessment

Nursing diagnosis

Nursing goal

Nursing Interventio

n

Rationale Outcome

Criteria

Evaluation

S – “ mag sige lag paminhud akung tiil dong “ as verbalized by the patient.

O - Seen patient lying on bed sleeping with i.v at the right arm.   - Blue discoloration of skin.   - Bloody gums noted.   - pale color skin noted.- Pale color skin noted.

ineffective tissue perfusion related to decrease circulating blood volume due to bleeding

Scientific base:

ITP is an autoimmune disorder  the antibodies destroy the platelets lowering the platelet count,sometimes to dangerous levels, at which time symptoms such as bruising, nosebleeds, or hemorrhaging may appear.

After 1-2 hours of nursing intervention the patient will be able to demonstrate increased perfusion.

-Teach patient assist about passive ROM exercise.

-Elevate lower limbs as appropriate.

- Elevate head of bed during sleep.

-Encourage diet rich in iron such as chicken liver or other organ meat if not contraindicated.

- Provide increase fluid intake.

- Encourage patient to take adequate rest period of time.

- Provide patient and family teaching of disease process and techniques in managing associated symptoms.

-Enhance circulation and venous return.

-To reduce edema.

- To increase gravitational blood flow.

- To increase blood level.

- To facilitate blood circulation throughout the body.- To decrease metabolic and oxygen need, enhancing oxygenation in blood.- Promote patient’s coping skills in self care management.

After 2 hours of patient nurse intervention the patient showed the following signs :

-Patient verbalized reduced sensation of numbness in the legs.

- Decreased blood stain in the gums.

- Manifest signs of relief and comfort.

-

Assessment

Nursing diagnosis

Nursing goal

Nursing Interventio

n

Rationale Outcome

Criteria

Evaluation

S: “Nagdugo iyahang lagus “, as stated by the SO.

O: -received pt sleeping with IVF PNSS 1liter at 30gtts/min infusing well on left arm

-petechea .5cm distributed in the upper extremities

-bluish pigment on the right arm

-blood stained sputum due to gum bleeding

-constipation

Risk for injury, hemorrhage related to altered clotting factor

Scientific base:

After 4-8hrs of nursing intervention,pt will:

-modify environment as indicated to enhance safety

-demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury

-verbalize understanding of individual factors that contribute to possibility of injury

-Perform thorough assessment regarding safety issues when planning for client care

-ascertain knowledge of safety needs/injury prevention and motivation

-note clients age,gender,developmental stage,decision-making ability,level of competence

-assess clients muscle strength, gross and fine motor coordination

-failure to accurately assess and intervene or refer these issues can place the client at needless risk and creates negligence issues for the healthcare practitioner

-to prevent injury in home,community, and work setting

-affects clients ability to protect self and others, and influences choice of interventions and teaching

-to identify risk for falls

Assessment

Nursing diagnosis

Nursing goal

Nursing Interventio

n

Rationale Outcome

Criteria

Evaluation

-provide healthcare within a culture of safety*maintain bed in lowest position with wheels locked*place assistive devices within reach*instruct client/SO to request assistance as needed*monitor environment fro potentially unsafe conditions and modify as needed

-provide information regarding disease/condition that may result in increased risk of injury

-identify interventions/safety devices

-to prevent errors resulting in client injury, promote client safety, and model safety behaviors for client/SO

-to promote safe physical environment and individual safety

After 4-8hrs of nursing intervention,pt will be able to demonstrate the following:

-less petechea

-less bluish pigment

-less incidence of blood stained sputum due to gum bleeding

Based from Nursing Diagnosis Priority Problem 1 – Impaired Gas Exchange

Goals of Care

Improving airway patency Promoting rest and conserving energy Promoting fluid intake Maintaining nutrition Promoting patient’s knowledge Maintaining and managing potential complications

Based from Nursing Diagnosis Priority Problem 2 – Ineffective tissue perfusion

Goals of Care

Promote adequate circulation Maintain optimal nutrition Ensure hydration and fluid intake Provide rest & adequate sleep Promote patient and family knowledge (patient education)