Index S.no Contents Page number 1 2 3 fileThalassemia can be considered as haemolytic and hypo...

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1 Index S.no Contents Page number 1 Introduction 2 2 Learning objectives 3 3 Time plan 4 3 Patient profile 5 4 History of the patient 8 5 Growth and development 11 6 Physical examination 12 7 Systemic examination 14 8 Nutritional assessment 15 9 Drug file 16 10 Definition, incidence, classification 17 11 Etiology 18 12 Pathophysiology 19 13 Clinical manifestations 20 14 Assessment and diagnostic findings 22 15 Medical management 24 16 Nursing management 26 17 Complications 27 18 Nursing diagnosis 28 19 Nursing process 29 20 Health education 34 21 Conclusion 36 22 Bibliography 37

Transcript of Index S.no Contents Page number 1 2 3 fileThalassemia can be considered as haemolytic and hypo...

Page 1: Index S.no Contents Page number 1 2 3 fileThalassemia can be considered as haemolytic and hypo proliferative anaemia related to abnormal haemoglobin . 3 OBJECTIVES 1. To develop attitude

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Index

S.no Contents Page number

1 Introduction 2

2 Learning objectives 3

3 Time plan 4

3 Patient profile 5

4 History of the patient 8

5 Growth and development 11

6 Physical examination 12

7 Systemic examination 14

8 Nutritional assessment 15

9 Drug file 16

10 Definition, incidence, classification 17

11 Etiology 18

12 Pathophysiology 19

13 Clinical manifestations 20

14 Assessment and diagnostic findings 22

15 Medical management 24

16 Nursing management 26

17 Complications 27

18 Nursing diagnosis 28

19 Nursing process 29

20 Health education 34

21 Conclusion 36

22 Bibliography 37

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INTRODUCTION

The word Thalassemia is derived from the Greek word “Thalassa” means the

great sea. The disease was first described by Cooley in 1925. It was first noticed

in patients originating from the littoral countries of the Mediterranean Sea. At

present the disease has been found in several countries all over the world. There

are millions of people as carriers of Thalassemia given and every year

thousands of thalassemic children are born in our country.

Thalassemia is a group of hereditary haemolytic anaemia characterised by

reduction in the size of haemoglobin. It produces hypo chromic microcytic

anaemia due to defective haemoglobin of RBC, haemolysis and ineffective

Erythropoiesis. Thalassemia can be considered as haemolytic and hypo

proliferative anaemia related to abnormal haemoglobin

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OBJECTIVES

1. To develop attitude and skills by providing comprehensive nursing care

2. To promote good self-esteem and confidence

3. To learn and provide health education to child’s family members

4. To promote interpersonal relationship with the child and parents

5. To reduce further complications

6. To gain experience of effective planning

7. To study the disease process in practical

8. To explain the mother regarding knowledge about the disease condition and

the treatment modalities.

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TIME PLAN

Date Time Activities performed

10-10-12 7.30 am to

12 noon

Greeted the staff and family members

Self introduction to the staff and family members

Established the rapport

History collected about the child

Comprehensive assessment performed

11-10-12 7.30 am to

12 noon

Greeted the staff and mother

Provided comfortable bed and position

Assessed the child’s diagnostic evaluations

Provided tepid sponging

Administered the medications

12-10-12 7.30 am to

12 noon

Greeted the staff and family members

Provided comfortable bed and position to child

Administered the medications

Health education was given regarding fluid intake to

mother

Provided psychological support

15-10-12 7.30 am to

12 noon

Greeted the staff and mother

Provided comfortable bed and position to child

Administered the medications

Health education was given regarding prevention of

complications

Psychological support was given to the family

members and child

16-10-12 7.30 am to

12 noon

Greeted the staff and family members

Provided comfortable bed and position

Administered the medications

Health education was given regarding prevention of

disease and proper follow up care

Thanked the child and mother as well as the staff

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PATIENT PROFILE

Name of the child :

Chronological age : 2 years

Sex : female

Developmental age : Toddler

Religion : Hindu

Ward : 9th floor

Unit :

IP number :

Permanent address :

Date of admission : 5-10-12

Diagnosis : Thalassemia

Informant : mother, father, case sheet, doctors

Date of care study started : 10-10-12

Date of care study finished : 16-10-12

Reason for hospitalisation

Child admitted for poor feeding, pallor, fatigue, and fever and reduced Hb

levels for one week.

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Present medical history

Child admitted with the complaints of fever on & off high grade intermittently.

H/O pallor, fatigue, decrease level of Hb%, poor feeding and there is no history

of jaundice and melena.

Past medical history

Last year child had been admitted on 20-08-11 in the thiruvallur GH hospital for

fever recurrent respiratory infection, weight loss, lethargy, poor intake of feed

for one month, antibiotics were given. Blood test done for all investigations,

reports will be all blood cell counts are decreased and erythroid study shows

hyper cellular and eryhtroid hyperplasia, treated with blood transfusion every

month.

Family history

No history of consanguineous marriage, no family history of communicable

diseases.

55years 50years

27years 25years 24 years

2 years

Key notes

-

-Male

-Female

- Sick child

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Socioeconomic history

Type of the family : joint family

Bread winner : father

Occupation : painter

Family income : Rs.5000/ month

Care giver of the child : mother

Housing condition : own home

Method of sewage disposal : closed system

Water sources : well water and corporation

Animal in the house : no pet animals

No Intake of alcohol, smoking and drug abuse by parents and tolerance in the

family.

Birth history

a. Antenatal history

Booked : Thiruvallur GH hospital

Immunized : TT given

Obstetrical history: G1, p1, L1, obstetrical history Normal.

Medications : no history of medication other than FST, calcium.

Consanguinity : no

H/O Infections : no h/o infections like TORCH, STD, AIDS, and Hep-B.

Rh incompatibility : not present.

b. Intranatal history

Period of gestation : 40 weeks

Mode and place of delivery : Normal delivery in thiruvallur GH

Birth weight of the child : 2.5kg

First cry after birth time : cried 2 minutes after birth

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c. Post natal history

History of critical care : no

Prelacteal fluids : no

Time of initiation of breast feed : after one hour of birth

Feeding difficulties : no

Immunization schedule

S.no Age Name of the

vaccine

Dose Route Preventable

disease

Adverse

reactions

1 At birth BCG

Oral polio (zero)

0.05ml

2 drops

Intra

dermal

oral

Primary complex

Poliomyelitis

2 1 ½

month

DPT , hepatitis

hip vaccine

Polio 1st

0.5ml

2drops

IM

Oral

Diphtheria,

pertusis, tetanus,

Hep-B, Hip

poliomyelitis

3 2 ½

month

Pentavalent

Polio-2nd

0.5ml

2 drops

IM

Oral

Diphtheria,

pertusis, tetanus,

Hep-B, Hip

poliomyelitis

4 3 ½

month

Pentavalent

Polio 3rd

0.5ml

2drops

IM

Oral

Diphtheria,

pertusis, tetanus,

Hep-B, Hip

poliomyelitis

5 9month Measles 0.5ml S/C Measles

6 1 year MMR 0.5ml Intra

dermal

Mumps, measles,

rubella.

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Growth and development of the child

Growth monitoring done during immunization and hospitalization

Mile stone achievement

Social smile : 6 weeks

Head control : 3 months

Reaches an object and holds it : 5 to 6 months

Sitting with support : 6 months

Sitting without support : 8 months

Standing with support : 9 months

Feeding self with spoon : 11 months

Running : 18 months

Climbing stairs : 20-24 months.

Gross motor development: The major motor skill during the toddler year is the

development of locomotion between 2-3 years of age refinement of the upright,

biped position is evident in improved co ordination and equilibrium. At age 2

years, toddlers can walk up and down stairs and by age 2 ½ years they can using

both feet.

Fine motor development: It is demonstrated increasingly skillful manual

dexterity. By 2 years of age toddler use their hands to built towers and by the 3

years of age they draw circles and paper.

Developmental theories

Psychosocial development (Erickson’s theory)

Autonomy Vs. shame and doubt: The developmental task of toddler hood is

acquiring a sense of autonomy while overcoming a sense of doubt and shame.

The toddler has the newly gained modality of holding on and letting go. To hold

on and let go is evident with use of the hands, mouth, eyes and eventually the

sphincters when toilet training is began. Child is able to control their bodies.

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Psychosexual development (Sigmund Freud’s theory)

Anal stage: interest during the second year of life centers in the anal region as

sphincter muscles develop and children are able to withhold or expel fecal

material at will.

At this stage the climate surrounding toilet training can have lasting effects on

children’s personalities.

Moral developmental theory (Kohlberg’s theory)

Pre conventional level: This is punishment and obedience orientation, culturally

oriented to the labels of good/bad and right/wrong, child integrates these in

terms of the physical or pleasurable consequences of their action.

Spiritual development (Fowler’s theory)

Intuitive-projective: toddlerhood is primarily a time of imitating the behavior of

the others child initiative the religious gestures and behaviors of others without

comprehending and meaning or significance to the activities.

Intellectual development (Piaget’s theory)

Pre operational phase- pre conceptual phase: At approximately 2 years of age

the child enters the pre conceptual phase, cognitive development, which lasts

until about 4 years child learning column, shapes, sizes and dentures.

Language and speech development:

Gestures precede or accompany each of the language mile stone up to 30

months of age (putting phone to ear, pointing). After sufficient language

development gestures phase out and the pace of word learning increases child

starts beginning to ask questions and speaks about 900 words.

Parallel play:

Children play in one place individually. Short attention on play enjoyment of

play and change on play are present.

Sensory development

Vision - Normal

Hearing - Normal

Touch - Normal

Taste - Normal

Smell - Normal

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PHYSICAL EXAMINATION

1. General appearance : moderate body built

2. Behaviour : alert

3. Head

Size : Normal

Symmetry : symmetrical

Fontanells : closed

4. Face

Symmetry : symmetry

Eye set : Normal

Other findings : no

5. Eye

Eyelids : Normal

Eye lashes : Normal

Lacrimal gland : Normal

Pupils : reactive to light

Colour activity : Normal

Colour vision : Normal

6. Ear

Symmetry : Normal symmetry

Alignment : Normal

Hearing activity : Normal

7. Nose

Shape : symmetry

Discharge : Normal discharge

Air entry : bilateral air entry Normal

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Patency of nose : patent

Mucus : present

8. Mouth

Lips : moist, soft, smooth

Tongue : pale, dry, mobility

9. Throat

Frenulum : Normal

Tonsils : Normal

Adenoids : Normal

Palate : intact and drone shaped

Dentition : canines (cuspids) +

, total number of teeth- 16

10. Neck

Length : Normal

Symmetry : Normal

Movement : Normal

Parotid gland : Normal

Tracheal position : Normal

Thyroid position : Normal

Lynphnodes : enlargement of lymphnodes +

11. Skin

Soft and smooth, skin turgor is Normal.

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SYSTEMIC EXAMINATION

Central nervous system

General appearance : Normal

Behaviour : restless and crying

Stage of consciousness : conscious

Motor function : Normal

Muscular mass : Normal shape and contour

Muscle tone : Normal and adequate

Muscle strength : Normal

Involuntary movements : not present.

Respiratory system

Shape : circular & Normal

Size : Normal

Movement : bilateral symmetrical and co-ordinaly with breathing

Breathing pattern : Normal vesicular breath sounds

Frenitus : not present

Cough expectorant : not present

Use of respiratory muscles : no

Abnormality of breathing : no

Oxygen saturation : 100%

Axillary area : no obvious nodes

Cardio vascular system

Pulse rate : 106/minute

Blood pressure : 90/60 mmhg

Cardiac sounds : S1, S2 heard, no murmur present

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Gastrointestinal system

Contour : Normal

Distension : not present

Visible peristalsis : not seen

Umbilicus : Normal

Organomegally : not present

Mass : not present

Bowel movement : Normal

Bowel elimination : Normal elimination pattern

Genitourinary system

Genetalia : Normal, no vulval oedema

Elimination : Normal urinary elimination

Musculo skeletal system

Spine : Normal curvature

Extremities : no genetic abnormalities

Range of motion : Normal in both extremities.

VITAL SIGNS

Temperature : 99.70F

Pulse : 110/minute

Respiration : 32/minute

Blood pressure : 90/60mmHg

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ANTHROPOMETRIC MEASUREMENT

Height : 100 cm

Weight : 11kg

Head circumference : 48cm

Chest circumference : 44cm

Mid arm circumference : 15cm

Dentition : first molar

Canines (cuspids), total number of teeth - 16

NUTRITIONAL ASSESSMENT

Nutritional status = Actual Weight of the Child X100

Expected Weight of the Child

= 11 X 100 = 84.6%

13

Nutritional status = normal

Daily fluid requirement= 70ml/kg/day i.e. = 70X11= 770ml/day

Protein requirement :

Protein =2gm/day/kg

Child is 11 kg weight

So protein requirement = 2X11=22gms/day

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DRUG FILE

Name of the drug Dose Route &

frequency

Action Side effects Nurse’s

responsibilities

Inj. Cefatoxime

sodium

250mg IV & bd It is a Cephalosporin acts

by Inhibiting cell wall

synthesis and assembly of

cell components leading to

bacterial death

Nausea,

Vomiting

Liver and renal

toxicity

Check for

anaphylaxis

T.vitamin B complex 0ral & bd To treat all condition of

body building

Rare

complications

-

T.vitamin-C 100mg oral & bd Prevention of scurvy and

similar condition

Rare

complications

-

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THALASSEMIA DISEASE CONDITION

Definition

The word Thalassemia is derived from the Greek word “Thalassa” means the

great sea. Thalassemia is a group of hereditary haemolytic anaemia

characterised by reduction in the size of haemoglobin. It produces hypo chromic

microcytic anaemia due to defective haemoglobin of RBC, haemolysis and

ineffective Erythropoiesis.

Incidence

It is estimated that nearly 6000-8000 thalassemic children are born every year in

India, hence over the 1, 00,000 Thalassemia in the country the disease is more

common among Sindhi, Punjabi and gujratis.

Classification

There are 3 types of Thalassemia

1. Thalassemia major

2. Thalassemia intermedia

3. Thalassemia minor

a. Thalassemia major

It is a severe form of the illness and associated with homozygous state. In this

condition, Thalassemic genes are inherited from both parents and synthesis of

beta chain is markedly reduced. Erythropoises becomes ineffective leading to

haemolysis and anaemia. Anaemia stimulated production of erythropoietin

resulting more ineffective erythropoises, expansion of medullary cavity of

different bones occurs. Extra medullary haemopoises lead to hepatomegally. It

is associated with absent of beta chain synthesis.

b. Thalassemia intermedia

It is a state of chronic haemolytic anaemia caused by deficient alpha or beta

chain synthesis. It is also a homozygous form. The clinical manifestation of this

is mainly intercurrent illness with exaggeration of anaemia and persistent

jaundice. These patients will have liver dysfunction, osteoporosis, mild

hepatomegally and chronic anaemia.

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c. Thalassemia minor

It is a mild form of the illness produced by heterozygosisity of either alpha or

beta chain. Its clinical manifestations are mild anaemia, mild jaundice and

abdominal pain. This condition is usually diagnosed during the family study of

a child having thalassemia major. The prognosis of this condition is excellent.

Severity of thalassemia:

Three groups

a. Type of mutation affecting beta chain synthesis

b. Presence of alpha chain mutation

c. Effect of gamma chain synthesis

ETIOLOGY

1. Alpha chain synthesis is reduced due to gene deletion

2. Beta chain thalassemia is usually caused by point mutation

3. Delta – beta thalassemia is due to suppression of both beta and delta chain

synthesis

4. Absent or defective synthesis of Hb%

5. Decreased life span of RBC

6. Presence of haemoglobin can insoluble iron form

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PATHOPHYSIOLOGY

Due to causes

Partial or complete deficiency in the synthesis of beta chain of Hb molecules

Defective Hb formation

Hb becomes molecules unstable

Damage RBCs

Severe anaemia {β-thalassemia}

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CLINICAL MANIFESTATIONS

S.no Book picture Patient picture

1 Haemoglobin Decreased

2 Pallor Present

3 Recurrent infection present

4 Depressed nasal bridge Present

5 Enlargement of lymph Absent

6 Exposure of malformed teeth Absent

7 Poor feeding Present

8 Irregular fever Present

Other systems: bone deformities in the face, fatigue, growth failure, shortness

of breath, yellowish skin.

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DIAGNOSTIC EVALUATION

History collection

A physical examination may reveal a swollen spleen

Blood samples will be taken and sent to laboratory for examination

Red blood cells will appear and abnormally shaped when blood are under a

microscope

A complete blood count

A test called haemoglobin electrophoresis shows the presence of an

abnormal form of haemoglobin

Haemoglobin values are reduced, MCV, MCH, MCHC values are low.

Reticulocyte count increased or may below

RBCs in peripheral smear shows hypochromia, anisocytes, poikilocytosis,

microcytosis, nucleated RBCs and target cells

Bone marrow study shows hyper cellular and erythroid hyperplasia.

Osmotic fragility test shows decreased fragility

Sr.Bilirubin level is moderately elevated

Sr.iron level is high

Platelet count is usually Normal or increased

Radiological findings

- Bone marrow hyperplasia

- Skull bones show hair on end appearance due to vertical trabecular or

striation from widening of the diploic space and atrophy of the outer surface of

the skull.

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DIAGNOSTIC INVESTIGATIONS

Name of the

investigation

Normal value Patient’s value Remark

Hemoglobin 8gm 14gms Abnormal;

Bleeding

time

2-7 minutes

2 minutes

Normal

Clotting time 5-8 minutes 4 minutes Normal

Total count 6000-11,000

cells/mm3

6,200 cells/mm3

Normal

Differential

count

P-58%

L-40%

E-2%

P-64%

L-37%

E-4%`

Normal

Total RBC

count

2.5 million cells/mm3

2.0 million cells mm

Abnormal

Blood urea 20-40mg/dl 22mgs/dl Normal

Blood sugar 70-1`0mgl/dl 100mg/dl Normal

Serum

creatinine

0.8-1.2mg/dl 0.8mg/dl Normal

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MANAGEMENT

Repeated blood transfusions

It is given at regular interval to maintain the haemoglobin level at least 10 to 11

gm/dl. Interval and amount of blood transfusions depends upon the level of

haemoglobin. A child usually 10-15ml/kg every 2 to 3 weeks washed. Packed

RBCs are transfused, special precaution to be taken during transfusion to

prevent complications. Transfusion related infections can be prevented specific

protection with immunizing agents. Neocyte transfusions with new RBCs

having longer life span can also be given though it is not being used at present.

Iron chelation therapy

Iron chelating agent desferrioxamine is recommended to prevent complications

repeated blood transfusion, i.e. hemosiderosis and hemochromotosis. It is given

as continuous subcutaneous infusion in the dose of 25 to 50mg/day over a

period of 8 hours to 12 hours.

Special micro infusion pump is used. Usually this therapy is given at night and

5 to 6 hours night per week. It is given after 10-15th maintained between 1000-

2000ng/ml.

Vitamin-C 100mg/day is given concurrently to enhance the iron excretion.

Overdose of this chelating agent may result in growth retardation, visual

problems and hearing toxicity.

Intravenous desferrioxamine therapy is indicated in patients with poor

compliance and large iron induced cardiac disease. It is far more expensive than

Sc therapy. Oral iron chelating agent defereprone (DFP) is now available with

less toxicity. The dose is 75 to 100 mg/kg/day in 2 to 3 divided doses. The

common side effects are joint pain, nausea, abdominal pain.

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Folic acid supplements

Folic acids supplementations are recommended where as iron therapy and

dietary iron should be avoided in prevent more iron deposition.

Supportive management

Supportive management is important to manage associated problems and treat

complications (like CCF, Hepatic failure), vaccination with hepatitis-B to be

given prevents transfusion related infection along with other routine

immunization. Emotional support is very essential to the parents and child.

Basic supportive nursing care is very important to prevent various

complications.

Bone marrow transplantation

Bone marrow transplantation is a effective treatment modality with potential of

curing thalassemia. Defective stem cells are replaced by Normal stem cells. It is

extremely expensive and possible in only very selective cases.

Splenectomy

Splenectomy is indicated when the child need very frequent blood transfusions

and develop hypertension or big spleen causing discomfort.

New approaches:

Now approaches in the management of thalassemia are gene therapy and gene

manipulation. In gene therapy insertion of Normal gene is done in the stem cells

to correct underlying defects. It is done in two approaches i.e. somatic and

transgenic. In gene manipulation, excess of alpha chain is decreased by

increasing the gamma chains.

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NURSING MANAGEMENT

1. Assessment of child condition to prevent complications that can be done as

hospital based or community based.

2. Preparation for repeated hospitalization for treatment of the disease and its

complications

3. Arrangement of necessary diagnostic measures

4. Administration of blood transfusion and iron chelating agent with

appropriate precautions for specific therapy.

5. Provisioning of the supportive care with rest comfort nutrition diet

restrictions of iron containing food. Vitamin supplementation, immunization,

hygiene care and other symptomatic care.

6. Prevention of infection by aseptic techniques and promotion of general

cleanliness

7. Pre operative and post operative care during splenectomy with necessary

health education after the surgery

8. Information regarding treatment plan, prognosis and complications to be

given to parent and family members with appropriate explanation.

9. Emotional support to the parents and family for effective coping about the

stress of the illness.

10. Teaching the parent about importance of follow up, blood transfusion,

investigation, sign of complication, dietary and available treatment facilities.

11. Referral and necessary guidance for available support and community

facilities

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Preventive measures

Antenatal screening in the first trimester of pregnancy by amniocentesis or

chronic callous sampling or fetoscopy help to detect thalassemia in fetal life,

genetic counselling in that respect is very important preventive measures which

guide the parent to decide whether to continue pregnancy with thalassemic fetus

or to terminate the pregnancy (by MTP) of affected foetus.

Carriers can be detected by simple blood examination or by identification of

thalassemic gene. Creation of awareness among public regarding detection of

thalassemia gene before marriage and marital counselling are also very

important preventive aspect.

Prognosis

Prognosis of thalassemia major is poor. Severe anaemia and early onset of

manifestations have poorer prognosis. Presence of complications also results in

poor out come.

Patients with thalassemia may continue their life up to 5 to 6 decade.

Thalassemia minor may lead a Normal life.

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Complications

1. Congestive cardiac failure

2. Hepatic failure

3. Aplastic crisis

4. Intercurrent infection

5. Gall stone

6. Growth retardation

7. Delayed puberty

8. Hemosiderosis

9. Hemochromatosis

10. Transfusion related infection

11. Complication related to iron chelation therapy

12. Endocrinopathies

13. Skeletal complication

14. Multi organ dysfunction (MOD)

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NURSING DIAGNOSIS

Impaired tissue perfusion related to reduced haemoglobin.

Imbalanced nutrition less than body requirement related to poor feeding

Risk for infection related to reduced haemoglobin level and low nutritional

status.

Chronic pain related to skeletal changes.

Ineffective family coping related to poor prognosis.

Knowledge deficit regarding child care in long term chronic illness with

haemolytic anaemia.

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NURSING PROCESS-I

Assessment Nursing diagnosis Plan of action Implementation Rationale Evaluation

Subjective data:

mother says that her

child has difficulty in

breathing, restless,

crying, fatigue

Objective data: child

has dyspnea and

tachypnea and restless,

fatigue

Diagnosis: Impaired

tissue perfusion related

to reduced

haemoglobin.

Goal: To improve the

tissue perfusion

Assess the vital

signs

Vital signs are monitored

and recorded.

Temperature: 98.40F

Pulse: 120/minute

Respiration: 36/minute

To know the base

line data

Mother

verbalised that

her child has

reduced

dyspnea, and

breaths better. Provide clean and

comfortable

environment

Provided clean and

comfortable environment

as well as comfortable

bed

To provide relief

from discomfort

Provide nasal

oxygen

Provided nasal oxygen To increase the O2

level in blood

Provide

nutritional

advices

High calorie diet is

advised

To provide energy

and to reduce

fatigue

Reassess the

child’s condition

Vital signs are monitored

and recorded again

Temperature: 98.40F

Pulse: 120/minute

Respiration: 36/minute

To know the effect

our intervention for

further plan.

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NURSING PROCESS -II

Assessment Nursing diagnosis Plan of action Implementation Rationale Evaluation

Subjective data:

The mother says that

the child is not taking

feeds properly

Objective data:

The child looks tired

and lethargy

Diagnosis: Imbalanced

nutrition less than body

requirement related to

poor feeding.

Goal: to improve the

nutritional status

Assess the

general condition

of the child

Assessed the general

condition of the child

To know about

base line data

The child

looks active

and she is able

to drink small

feed

Provide small

frequent feeds

Provided small frequent

feeds and the child after

feeding

To improve the

nutritional status

Explain disease

condition

Explained the disease

condition to the mother

To remove anxiety

Provide

comfortable bed

and position

Provided comfortable bed

and position

To promote good

sleep

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NURSING PROCESS-III

Assessment Nursing diagnosis Plan of action Implementation Rationale Evaluation

Subjective data:

child’s mother says

that she is very

anxious and worried

about the child’s

condition

Objective data:

The mother looks very

dull and anxious

Diagnosis: Fear &

Anxiety related to

disease condition and

management and

outcome.

Goal: to alleviate the

parents anxiety

Explain the

parents about the

condition of the

child

Explained the parents

about the condition of the

child

To remove anxiety Mother’s

anxiety and

fear removed

Explain about the

nutrition to be

given

Explained about the

nutrition to be given with

diet plan.

To improve the

child’s health

Teach about

follow up care

Taught about follow up

care

For the future

management

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NURSING PROCESS-IV

Assessment Nursing diagnosis Plan of action Implementation Rationale Evaluation

Subjective data:

Mother says that the

infant is warm to touch

Objective data:

The child looks febrile

Diagnosis: Risk for

infection related to

reduced haemoglobin

level and nutritional

deficiency

Goal: to prevent

infection

Assess the vital

signs

Vital signs are monitored

T-99.40F

P- 120/m

R-36/minute

To know the base

line data

Maintained

body

Temperature

in Normal

way Teach hand

washing and

hygiene

Educated the mother

about hand washing and

hygiene of the body

To avoid infection

Provide clean and

comfortable

environment

Provided clean and

comfortable environment

as well as comfortable

bed

To minimize the

chance of infection

Administer

antibiotics

Administered antibiotics

as per prescription

To prevent

infection

Reassess the vital

signs

Vital signs are monitored

and recorded again.

Temperature: 99.40F

Pulse: 120/minute

Respiration: 36/minute

To know the effect

of our intervention

and plan for further

actions.

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NURSING PROCESS-V

Assessment Nursing diagnosis Plan of action Implementation Rationale Evaluation

Subjective data:

mother says that she is

not having adequate

knowledge about the

management of her

child’s condition

Objective data: mother

looks confused and

asking many question

about her child’s

condition

Diagnosis:

Knowledge deficit

of mother regarding

child care in long

term chronic illness

with haemolytic

anaemia.

Goal: To improve

the knowledge level

of the mother about

the management of

Thalassemia

Assess the

knowledge level of

the mother

Knowledge level of the

mother is assessed by

asking questions about

her child’s condition

To know the base

line data

Mother

verbalised that

she has gained

good

knowledge

and assured to

do practice in

child care.

Explain about the

condition and the

procedure that are

planned to be done

for her child

A clear detail is given

regarding the disease

condition. &Details about

the investigations and

treatments available has

been explained to the

mother clearly

To make her

confident and to

improve her

knowledge

Provide health

education about diet

High protein & nutritious

diet is advised iron rich

diet are advised to avoid

To improve her

knowledge level

Provide

psychological

support

Psychological support

was given by speaking

about positive things

about the prognosis of t

her child

To make her

confident on her

child

Reassess the

mother’s knowledge

Mother’s knowledge is

reassessed again

To know the effect

our intervention

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34

HEALTH EDUCATION

Prevention efforts

1. Pre marital screening to make sure that couple is not carriers.

2. Provision of counselling and health education for the thalassemia families

and the public.

3. Provision of prenatal testing for thalassemia.

4. Reduction of marriage between relations.

Transfusion therapy

Transfusion therapy should begin once a diagnosis of thalassemia major is

confirmed.

1. Laboratory test (e.g. haematological molecular or Hb% electrophoresis and

other laboratory test such as high pressure liquid chromatography.

2. Genetic analysis to identify the nature of alpha and beta thalassemia

mutation as well as the pressure of the Xmm /restriction enzyme site- an

indicator that can help predict the severity of the disease and identify the

treatment regimen most appropriate to each patient.

Folic acid supplementation

Folic acid supplementation is recommended where as iron therapy and dietary

iron should be avoided to prevent more iron deposition.

Iron chelation therapy

Iron chelating agent desferrioxamine (desferal) is recommended to prevent

complication of repeated blood transfusions, i.e. hemosiderosis and

hemochromatosis. It is given as continuous subcutaneous infusion in the dose of

25 to 50 mg/kg/day over a period of 12 hours.

Oral iron chelating agent desferene (DFP) is now available with less toxicity.

The dose of 75 to 100mg/kg/day in 2 to 3 divided dose. The common side

effects are joint pain, nausea, vomiting, and pain abdomen.

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35

Supportive management

Supportive management is important to manage associated problems and to

treat complications.

Vaccination with hepatitis-B is to be given to prevent transfusion related

infection along with other routine immunization.

Emotional support

Emotional support is very essential to the parents and child. Basic supportive

nursing care is very important to prevent various complications.

Emotional support to the parents and family for effective coping about the stress

of the illness

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CONCLUSION

From this care study I gained knowledge about the care of the child with

thalassemia. I got an opportunity to provide a complete care to give health

education to the parents. I would like to thank my madam for giving this

opportunity and for her valuable guidance to me to widen my knowledge.

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