DMMA College of Southern Philippines College of Nursing

In Partial Fulfillment of the Requirements in Related Learning Experiences

A CASE STUDY IN SEVERE ANEMIA

Submitted to: Jameson Wils D. Ong I Clinical Instructor

Submitted by: Roy Baconga Adel Lyde Bernales Michelle Flores Wella Orbigoso Prettylyn Vallescas

BSN III Group 1

TABLE OF CONTENTS PAGE Acknowledgement------------------------------------------------------------------Introduction---------------------------------------------------------------------------Objective of the Study-------------------------------------------------------------Patients Profile----------------------------------------------------------------------Family Background-----------------------------------------------------------------Genogram -----------------------------------------------------------------------------Physical Assessment--------------------------------------------------------------Anatomy and Physiology---------------------------------------------------------Pathophysiology---------------------------------------------------------------------Laboratory Results------------------------------------------------------------------Symptomatology---------------------------------------------------------------------Definition of Terms------------------------------------------------------------------Nursing Care Plan-------------------------------------------------------------------Drug Study-----------------------------------------------------------------------------Health Teaching-----------------------------------------------------------------------Evaluation--------------------------------------------------------------------------------

ACKNOWLEDGEMENT We will not be able to finish this case presentation without the help of those people who sincerely gave their support to us. We would like to thank all the people who generously gave their time, ideas and resources for the success of this presentation. To the family of our chosen patient, for their time, and full participation. To all our clinical instructors who gave us freedom and the challenge to discover on our own what life would need in this kind of profession. To Mr. Jameson Wils D. Ong, I for supervising us in our duty in Medical Mission Group Hospital in Tagum City. To the staff of Medical Mission Group Hospital who supported us and make us feel warmth. To our few Group mates whose heart, mind and soul is certain to make this Case Presentation on Severe Anemia be informative and possible. To all our classmates and friends, who generously share their knowledge to us, whose friendship, inspiration, and support. And finally, to GOD Almighty the GREAT PHYSICIAN and the AUTHOR OF LIFE from whom wisdom comes. We thank HIM for the guidance and strength.

INTRODUCTION If youre like most people who beat up on the snooze button each morning, an earlier bedtime is the way to end your energy crisis. But if no amount of rest helps, it may not be sleep that your body is craving. You may have a form of anemia. If you have anemia, people may say you have tired blood. That's because anemia a condition in which there aren't enough healthy red blood cells to carry adequate oxygen to your tissues can make you feel tired. Anemia saps your energy by depriving your cells of oxygen. This happens when your blood has too few red blood cells or too little hemoglobin that transports oxygen through the bloodstream. Without oxygen, no living cell can survive. Without a specialized system of oxygen transport to cells, no complex multi-cellular organism which carry oxygen to and carbon dioxide away from the thirty trillion cells of the human body are basic requirements for health and itself. Anemia is a common blood disorder. Women and people Anemia is a common blood disorder. Women and people with chronic diseases are at increased risk of the with chronic diseases are at increased risk of the condition. Some people learn that their hemoglobin is condition. Some people learn that their hemoglobin is low, which indicates anemia, when they go to donate low, which indicates anemia, when they go to donate blood. Low hemoglobin may be a temporary problem blood. Low hemoglobin may be a temporary problem remedied by eating more iron-rich foods or taking a remedied by eating more iron-rich foods or taking a multivitamin containing iron. However, it may also be a multivitamin containing iron. However, it may also be a warning sign of blood loss in your body that may be warning sign of blood loss in your body that may be causing you to be deficient in iron. If you're told that you causing you to be deficient in iron. If you're told that you can't donate blood because of low hemoglobin, ask your can't donate blood because of low hemoglobin, ask your doctor if you should be concerned. If you suspect you doctor if you should be concerned. If you suspect you have anemia, see your doctor. Anemia can be a sign of have anemia, see your doctor. Anemia can be a sign of serious illnesses. Treatments for anemia range from serious illnesses. Treatments for anemia range from taking supplements to undergoing medical procedures taking supplements to undergoing medical procedures and even just eating healthy varied diet.

There are many forms of anemia, each with its own cause. Anemia can be temporary or long term, and it can range from mild to severe. See your doctor if you're feeling fatigued for unexplained reasons, especially if you're at risk of anemia. Some anemias, such as iron deficiency anemia, are common. But don't assume that if you're tired, you must be anemic. Fatigue has many causes besides anemia. Anemia can be a symptom of many different serious problems, including cancer. Anemia is a great problem globally and worse in developing countries, but it is by no means absent in industrialized nations and millions of Filipinos suffer from anemia, which is serious and is usually caused by blood loss from an injury or hemorrhage and the demands of pregnancy. Approximately 43.9% Filipinos pregnant women are estimated to develop anemia, while many are unreported. Anemia can occur during pregnancy due to low levels of iron and folic acid (folate) and changes in the blood. During the first 6 months of pregnancy, the fluid portion of a womans blood (the plasma) increases faster than the number of red blood cells. This dilutes the blood and can lead to anemia. Anemia affects many body systems. It can also lead to many complications. This is the goal of health care providers, to prevent any occurrence of complications. Ultimately, it is hoped that with timely intervention to control this complication of anemia, improved patient outcomes on in terms of morbidity and mortality will be achieved.

OBJECTIVE OF THE STUDY General Objectives: To have a better understanding on the effects and possible complicationsof severe anemia. To obtain essential data from the health history of our patient that is useful to further understand the disease and we could come up with the most effective nursing interventions. This also aims to help the researchers, readers, students and nursing enthusiast to further understand and know the right information regarding this case. And lastly, to systematically evaluate the effect of disease management programs for patients with severe on processes and outcomes of care.

Specific Objectives: Find a challenging case for the case study. Establish good rapport to the patient and his significant others in order to gain trust and cooperation. Gather patient family health history that is fundamental for the onset of her illness. Illustrate the anatomy and physiology related to the clients conditions Illustrate the pathophysiology of the clients condition. Study and analyze the orders given by the physician. Define the diagnostic test undergone by the pt. and its implication. Classify prescribed drugs given by the pt. as the basis of his recovery. To formulate the nursing care plan to identify the present and possible problem of the patient. Do health teachings with regards to his conditions.

PERSONAL DATA: Name: Sex: Age: Address: Birthday: Birthplace: Nationality: Religion: Civil Status: Rafael Mirafuentes Cudera Male 78 years old P 3B Manggayon, Compostela Valley Province October 24, 1931 Cebunga Cebu Filipino Roman Catholic Widow

MEDICAL DATA: Admission Date: Admission Time: Chief Complaint: December 29 , 2009 6:32 PM Pallor , Dizziness

Admitting Diagnosis:Anemia severe prob and to Ureterolithiasis ; R/O DM Hospital: Ward and Room: Medical Mission Group of Hospital Station W B 38

Attending Physician:Felipe Balingit III G.M.D

FAMILY BACKGROUND

Patients Health History Patient's health history is the first part and one of the most sinificant aspects in case studies. It is a systematic collection of subjective and objective data, ordering and a step by step process inculcating detailed information in determining client's history, health status, functional status and copping pattern. These vital information provide a conceptual baseline data utilized in developing nursing diagnosis, subsequent plans for individualized care and for the nursing process application as a whole.

BRIEF HISTORY OF PRESENT ILLNESS A. History of Present Illness Month PTA, admitted at a local hospital due to pallor and was discharged improving. Week PTA, positive pallor accompanied with on and off dizziness persistence to admission. B. Past Health Problem/Status According to him it was the 1st time to be hospitalized of his disease, He also has no known allergy of kind. He never had a serious illness like this before to be brought to the hospital. He said that he experience cough, colds, fever, stomachache and headache also diarrhea on the past. He used to smoking and drinking when he was 15 years old but he quit at the age of 60. C. Family History Illness As claimed by patient during the interview, there is a family history of asthma on father side. It includes his grandfather and his 1 sister and 1 brother. His grandfather died because of aging. While his grandmother died of malaria. D. Brief Social, Cultural and Religious Background a. Educational Background - He is a high school graduate. b. Occupation - farmer, and they have farm c. Religious Practices - He is a solid Roman Catholic who hears mass every Sunday and on special days like fiesta, Christmas and his birthday. d. Economic Status -His not able to estimate his earnings.

PHYSICAL ASSESSMENT I. GENERAL SURVEY Patient received lying on bed in a semi-fowlers position, awake. Conscious and responsive with foley catheter attached to urobag with bloody color urine. He is Rafael Mirafuentes Cudera, 78 years old and he lives in P 3B Manggayon, Compostela Valley Province and was admitted to Medical Mission Group Hospital and Health Services Coopertive of Tagum. II. VITAL SIGNS Afebrile with temperature of 36.6C, a blood pressure of 100/80mmHg,a cardiac rate of 72bpm and a respiration of 21cpm. III. SKIN: Upon assessment, the patients skin is pale with poor skin turgor, no presence of lesions and edema. Afebrile, with temperature of 36.6C. IV. EYE AND VISION: Eye brows-hair is evenly distributed, symmetrically aligned with equal movement, equally distributed eye lashes, no presence of discharges on the eyelids; pupils are equal in size and black in color. Pt. can react to light and respond to visual stimulus. V. MOUTH (teeth, tongue, and lips) With dentures, pink gum, moist and firm texture; tongue in central position, pink in color with no lesions noted and dry lips. VI. SPEECH: Speak in soft tone voice with unclear speech.

VII. HEAD: Normacephalic and symmetrical with frontal, temporal, parietal, and occipital prominence; no lesions noted upon inspection; with grey hair with no presence of dandruff. VIII. THROAT AND NECK: Neck moves freely without any discomfort, no visible distended veins and no lesions noted. IX. RESPIRATORY SYSTEM: Equal chest expansion with normal respiration of 21cpm.

X. CIRCULATORY SYSTEM: Normal blood pressure at 100/80mmHg with regular rhythm at 72bpm with full pulsation. XI. ELIMINATION: Eliminates regularly; defecated at least one times with no difficulty in bowel movement; with soft formed stool and brownish in color. XII. GENITOURINARY SYSTEM: Urinated with bloody colored urine , output; 200cc/ 2hours. XIII. NEUROLOGIC SYSTEM: Conscious able to cooperate with the task given; oriented with time, place, and person; able to answer upon questioning.

ANATOMY AND PHYSIOLOGY OF BLOOD

BLOOD is a specialized body fluid that delivers necessary substances to the body cells such as nutrients and oxygen and transport waste products away from those same cells. REDBLOOD CELLS are the most abundant of the blood cells and they contain the oxygen- carrying protein, hemoglobin that function in the transport of oxygen. Also called as erythrocytes.

WHITE BLOOD CELLS Constitute only 1 % of the total blood volume, they serve various roles in immunity and inflammation. They include the granulocytes, the lymphocytes and the monocytes. Also called as leukocytes. PLATELETS Are small cell fragments that are involved in the blood clotting. Also called as thrombocytes.

LABORATORY RESULTS Hemoglobin (HGB) 01/03/2010- 05:55 PM Hemoglobin, massc : 3.3 g/dl Hemoglobin (HGB) 01/03/2010 07:32 AM Hemoglobin, massc: 4.5 g/dl CREATININE TEST 01/02/2010 9:04 AM Concentration: 109.9 umol/l Result: Normal Reference: 80.0-115.0 OCCULT BLOOD 01/02/2010 Specimen: stool Results: negative FECALYSIS RESULT 01/02/2010 Color: dark brown Consistency: formed NO OVA OR OTHER INTESTINAL PARASITES FOUND HEMOGLOBIN (HGB) 01/02/2010 Hemoglobin, massc 3.9 g/dl HEMOGLOBIN (HGB) 01/01/2010 5:37 PM Hemoglobin, massc 4.2 g/dl PROTHROMBIN TIME (12/31/2009) Clotting Time (CT) 3 mins. 15 secs. Bleeding Time (BT) 1 min. 15 secs. RETICULOCYTE COUNT (12/30/2009 04:21 PM) Result: 1.9% Normal: Adult 1-2 Infant 4-8 2-6 mins 1-3 mins. M 13.5-18.0 g/dl M 13.5-18.0 g/dl M 13.5 18.0 g/dl Normal Values M 13.5 18.0 g/dl

Normal Values PLATELET COUNT( 12/30/2009 04:22 PM) Thrombocytes, numc : 281 x10 3/uL CREATININE, FBS, SERUM URIC ACID 12/30/2009 Creatinine 131.0 Uric Acid 393.6 Triglyceride 0.4 URINALYSIS RESULT ( 12/29/2009) Color: bloody red Transparency: cloudy Albumin: ++++ Reaction: Negative Sp. Gravity: 1.020 Pus cells: 3-5 RBC cells: PACKED HEMATOLOGY RESULT Hemoglobin, massc: 3.0 g/dl Leucocytes, numc: 5.3 x 10 3/ul Neutrophils: Segmenters : 0.59 Stab: 0.05 0.02 0.06 Lymphocytes: 0.32 Monocytes: 0.03 Eusophils: 0.01 Packed Cell volume (hct): 10.5 0.20- 0.35 0.02- 0.06 0.01- 0.03 M 32.6- 47.5 M 11.3-15.7 g/dl M 2.6-8.8 M 80-115 umol/ L F 53-97 umol/L M 210-420 umol/L F 150-350 umol/L 0.9 1.6 mmol/L M 134-377

ULTRASOUND RESULT (12/30/2009) Kidneys: Left kidney measures 8.4x4.3x1.4 cm Right kidney measures 8.5x4.8x16 cm There is no significant disparity in the sizes, shapes and locations of both kidneys. No evident mass calculus, or any abnormality in the scans obtained. Both ureters were not visualized. The urinary bladder is distended. Attached to the lower left lateral wall and floor is an irregularly shaped complex structure, measuring 6.8x5.1x5.6 cm (LWT) The prostate gland is slightly enlarged, measuring 33.5x38.5x28.1 mm (LWT), weighing 19 grams. No focal lesions were seen.

IMPRESSION: 1.) Normal kidneys ultrasonically 2.) Urinary bladder mass 3.) Prostate gland enlargement, Grade 1

SYMPTOMATOLOGY

Symptoms

Actual

Scientific Basis is a reduced amount of oxyhemoglobin in skin or mucous membrane, a pale color which can be caused by illness, emotional shock or stress, avoiding excessive exposure to sunlight, anemia or genetics. a range of afflictions, varying from a general state of lethargy to a specific work-induced burning sensation within one's muscles. Is a symptom of a number of different conditions of the head. Headache is caused by a disturbance of the pain-sensitive structures in the head. is a debilitating symptom that is the experience of unpleasant or uncomfortable respiratory sensations.

Clinical Significance

Pallor

is not usually clinically significant unless it is accompanied by a general pallor (pale lips, tongue, palms, mouth and other regions with mucous membranes). is considered a symptom because it is reported by the patient instead of being observed by others.

Fatigue

Headache

x

Dyspnea

x

It is a common symptom of numerous medical disorders, particularly those involving the cardiovascular and respiratory systems; dyspnea on exertion is the most common presenting complaint for people with respiratory impairment.

DEFINITION OF TERMS

Granulocytes

- are a category of white blood cells characterised by the presence of

granules in their cytoplasm.They are also calledpolymorphonuclear leukocytes (PMN or PML) because of the varying shapes of the nucleus, which is usually lobed into three segments. In common parlance, the term polymorphonuclear leukocyte often refers specifically to neutrophil granulocytes,the most abundant of the granulocytes.

Lymphocytes - is a type of white blood cell in the vertebrate immune system. Functionally distinct subsets of lymphocytes correlate with their appearance. Most, but not all large granular lymphocytes are more commonly known as the natural killer cells (NK cells). The small lymphocytes are the T cells and B cells. Lymphocytes play an integral role in the body's defenses.

Monocytes - is a type of white blood cell, part of the human body's immune system. Monocytes have two main functions in the immune system: (1) replenish resident macrophages and dendritic cells under normal states, and (2) in response to inflammation signals, monocytes can move quickly (approx. 8-12 hours) to sites of infection in the tissues and divide/differentiate into macrophages and dendritic cells to elicit an immune response.

Reticulocytes - are immature red blood cells, typically composing about 1% of the red cells in the human body. Reticulocytes develop and mature in the red bone marrow and then circulate for about a day in the blood stream before developing into mature red blood cells.

Hemoglobin - is the iron-containing oxygen-transport metalloprotein in the red blood cells of vertebrates and the tissues of some invertebrates.

NURSING CARE PLAN

Nursing Diagnosis: Risk for infection related to decreased hemoglobin production. Date 01/05/10 Cues Objectives Needs Nursing Intervention Rationale Evaluatio n

Within 8 Health 1.)Stress 1.) To reduce/ Goal met hour span perception proper hand correct existing as of care - Health hygiene by all risk factor. evidence patient will Managem caregivers by: demonstra ent between patient te no sign Pattern therapies/clien was able of ts. 2.) To limit to infection exposures, thus demonstr such as 2.) Monitor reduce crossate no increase client's contamination. sign of in body visitors/ infection temperatu caregivers for such ass re. respiratory 3.) At high risk increase illness. Offer for nosocomial/ in body mask and healthcare temperat tissues to associated ure. client/visitors infections. who are coughing/ 4.) To prevent sneezing. pneumonia. 3.) Instruct in daily mouth care. 4.)Monitor/ assist with use of adjuncts. 5.)To avoid bladder distention/ urinary stasis. 6.) To promote wellness.

5.)Maintain adequate 7.) Premature hydration, discontinuation stand/ sit to of treatment void, and when client catheterize, if begins to feel necessary well may result in return of infection 6.) Review and potential individual drug resistant

nutritional strains. needs, appropriate 8.) Inappropriate exercise use can lead to program and development of need for rest. drug-resistant strains/ 7.) Emphasize secondary necessity of infections. taking antivirals/antib 9.) To increase iotics, as awareness of directed. and prevention of communicable 8.) Discuss diseases. importance of not taking 10.) To reduce antibiotic/ incidence/ using leftover transmission of drugs unless global infections. specifically instructed by healthcare provider. 9.) Provide information/ involve in appropriate community and national education programs. 10.) Discuss precautions with client engaged in international travel and refer for immunizations .

Nursing Diagnosis: Impaired physical mobility related to decrease muscle strength Date 01/05/10 Cues S: Kapuyan ko maglakaw -lakaw ug magtindog -tindog, as verbalized by the pt. Objectives Needs Nursing Intervention 1.) Note situations such as surgery, fractures, amputation, tubing ( catheter) Rationale 1.) That may restrict movement Evaluation

After Activity 8hour Exercise span of Pattern care patient will able to participate in the desired activities without complaint of tiredness.

O: - body weakness - slowed movement -gait changes

Goal partially met as verbalized 2.) To note any by pt. dili incongruencies na ko with reports of maglisod ug abilities. lihok dili parehas sa 2.) Observe 3.) Feeling of una na movement frustrations, kapuyan ko. when client is powerlessness unaware of may impede observation attainment of goals. 3.) Note emotional/ 4.) For position behavioral changes/ responses to transfers. problems of immobility. 5.) To maintain position of 4.) Instruct in function and use of side reduce risk of rails, overhead pressure trapeze, roller ulcers. pads 6.)To permit 5.) Support maximal effort/ affected body involvement in parts/joints activity using pillow air mattress. 7.) To reduce fatigue. 6.) Administer medications 8.) Limits prior to activity fatigue, as needed for maximizing pain relief. participation 7.) Schedule 9.) Promotes activities with well-being and adequate rest maximizes

periods during the day.

energy production.

8.) Identify 10.) Enhances energy self- concept concerning and sense of techniques for independence. ADLs. 9.) Encourage adequate intake of fluids, nutritious foods. 10.) Encourage participation in self care, occupational diversional/ recreational activities.

DRUG STUDY Generic Name: Furosemide Brand Name: Lasix Classification: Diuretics Mechanism of Action: A potent loop diuretic that inhibits sodium and chloride reabsorption at the proximal and distal tubules and the ascending loop of Henle. Adverse Reaction: CNS: Vertigo, headache, dizziness, paresthesia, weakness, restlessness, fever CV: orthostatic hypotension, thrombophlebitis with I.V administration EENT: transient deafness, blurred or yellowed vision GI: abdominal discomfort and pain, diarrhea, anorexia, nausea, vomiting, constipation, pancreatitis GU: nocturia, polyuria, frequent urination, oliguria Hematologic: agranulocytes, leucopenia, anemia Hepatic: hepatic dysfunction Musculoskeletal: muscle spasm Skin: dermatitis, purpura Contraindications and Cautions: Contraindicated in patients hypersensitivity to drug and in those with anuria. Use cautiously in patient with hepatic cirrhosis and in those allergic to sulfonamides. Use during pregnancy only if potential benefits to mother clearly outweigh risks to fetus. Nursing Considerations Monitor weight, blood pressure, and pulse rate routinely with long term use and during rapid diuresis. Use can lead to profound water and electrolyte depletion. Monitor uric acid level, especially in patients with a history of gout. Dont confuse furosemide with torsemide or Lasix with Lonox.

Patient Teaching Advise patient to take drug with food to prevent GI upset, and to take drug in morning to prevent need to urinate at night. Inform patient of possible need for potassium or magnesium supplements. Tell patient to check with prescriber or pharmacist before taking OTC drugs. Teach patient to avoid direct sunlight and to use protective clothing and a sunblock because of risk of photosensitivity reactions.

Generic Name: Mebendazole Brand Name: Vermox Classification: Anthelmmintic Mechanism of Action: Irreversibly blocks glucose uptake by susceptible helminths, depleting glycogen stores needed for survival and reproduction of the helminths, causing death Adverse Reaction: GI: Transient abdominal pain, diarrhea Other: Fever Contraindications and Cautions: Contraindicated with allergy to mebendazole, pregnancy ( embryotoxic and teratogenic; avoid use, especially during first trimester) Use cautiously with lactation

Patient Teaching Chew or swallow whole or crushed and mixed with food. Pinworms are easily transmitted; all family members should be treated for complete eradication. Use strict handwashing and hygiene measures. Launder undergarments, bed linens, and nightclothes daily. Disinfect toilet facilities daily and bathroom floors periodically. You may experience these side effects: Nausea, abdominal pain, diarrhea (eat frequent small meals) Report fever, return of symptoms, severe diarrhea.

Evaluation

After the case study the researchers were able to:

-

Discuss the total overview of Anemia Gather patient family health history that is fundamental for the onset of her illness. Discuss the anatomy and physiology related to the clients conditions Discuss the pathophysiology of the clients condition. Discuss the diagnostic test undergone by the pt. and its implication. Classify prescribed drugs given by the pt. as the basis of his recovery. Formulate the nursing care plan to identify the present and possible problem of the patient.

-

Do health teachings with regards to his conditions.

.

Exercise and Activity: Emphasize the need to maintain regular exercise and activities; to maintain muscle strength and motility, to help activities; to help prevent bone demineralization, to decrease protein breakdown and to promote good circulation of the body system. However, avoid contact sports, crowds, and persons system. Passive exercise like breathing can also help the patient to feel calm and comfortable. Home Teaching: Teach the patient/folks the importance of monitoring the progress and compliance with the treatment regimen. Patient needs ongoing education and reinforcement on the multiple dietary requirement she needs. Patient needs health promotion activities and health screening. Emphasize to the patient the importance of having regular check-up to know her present condition.

Out patient Follow-up Out After discharged, patient may go to clinic for follow-up check-up after a week. As part of this follow-up care, she should receive blood test to check for the level of her RBC and Hgb.

Diet: Encourage intake of high biologic value protein foods such as eggs, dairy products and meats (causes positive nitrogen balance needed for growth and healing). Encourage high calorie and high iron containing foods like liver, red meat, seafood, poultry, eggs, beans and peas, dark green leafy vegetables such as spinach and raisins, nuts, and seeds.