Republic of the Philippines

NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

College of Nursing
City of Cabanatuan

HYPOPROLIFERATIVE ANEMIA PROBABLY

PERNICIOUS
VITAMIN B12 DEFICIENCY
FOLIC ACID DEFICIENCY
IRON DEFICENCY
HYPOTENSION
MAJOR DEPRESSIVE DISORDER
SEIZURE DISORDER

By:

Nicanor M. Domingo III

GROUP LEADER

Adrian M. Ortiz
Jayson A. Espino
Karen N. Guansing
Jasper Ian T. Enoza
Dianne Joi H. Viloria
Emmaruth B. Gamboa
Melvin Renz C. Pascual
Reina Jean D.V. Munar
Dannich Maika O. Esteban
MEMBERS

~ALL OF BSN III-A

A.Y. 2009-2010~

Submitted to:

VERNYL A. OPLADO, M.D.

Medical-Surgical Nursing (NCM102)

EDUARDO L. JOSON MEMORIAL HOSPITAL

-CASE BASE HOSPITAL-
----------------------------------------------------------------------------------
APRIL 2008
 DEMOGRAPHIC DATA

Clients Name/Initials: AMD

Age: 32 years old
Gender: Female
Address: San Isidro, Cabanatuan City
Civil Status: Single
Nationality: Filipino
Religion: Roman Catholic
Occupation: None
Educational Attainment: High school Graduate
Ward and Bed number: FMW Bed 2
Date Admitted: 01-19-09
Hospital Admitted: Eduardo L. Joson Memorial Hospital

1. CLINICAL HISTORY

1.1 Chief Complaint on Admission:

Hypotension accompanied with severe body weakness

1.2 History of Present Illness:

The patient (01-17-09), about 8:30 in the morning, after taking their breakfast has
had severe body weakness and developed pallor skin on her extremities, face, anterior
palm, and felt her feet tingling, with measured Blood Pressure of 50/30 mmHg, relieved
slightly by resting, had her B.P. 60/40 mmHg but with continuous weakness, had three
(3) vomiting episodes and below normal B.P. range, hence admitted to ELJMH.

1.3 Review of Systems:

GENERAL
Fatigue/loss of energy Present
Fever or chills Absent
Unexpected weight loss over 10 pounds Absent
Bleeds Absent

EYES
Do you wear glasses or contact lenses? Absent
Eye problems Absent
Eye discharge, injury, infection Absent

EARS, NOSE THROAT & MOUTH

Loss of hearing or ringing-tinnitus Absent
Nasal allergies Absent
Nose bleeds (epistaxis) Absent
Sinus disease Absent
Hoarseness or sore throat Absent
Sleep apnea Absent
Bleeding gums Absent
Do you have dental bridges or dentures Absent
Toothache Absent

RESPIRATORY
Chronic cough (more than one month) Absent
Daily sputum production Absent
Shortness of breath Absent
Spitting/coughing up blood (hemoptysis) Absent
Wheezing Absent

CARDIOVASCULAR
Abnormally rapid heart rate (tachycardia) Absent
Abnormally slow heart rate (bradycardia) Present, (56-67 bpm, adynamic)
Chest pain or angina Absent

GASTROINTESTINAL
Excessive passing of gas (/burps) Present
Recent changes in bowel habits Absent
Constipation Absent
Rectal bleeding or blood in stools Absent
Black stools (melena) Absent
Jaundice, liver disease Absent

GENITOURINARY
Blood in urine (hematuria) Absent
Difficulty starting to urinate (hesitancy) Absent

INTEGUMENTARY/BREAST
Hair or nails (please describe) Present, more pale as observed by
the patient’s mother, also brittle
than normal nails (as observed)
Change in mole or birthmark/location Absent
Skin rashes or itching (please circle which) Absent
Breast lumps Absent
Breast pain Absent

ENDOCRINE
Excessive hunger Absent
Excessive thirst Absent
Excessive urination Absent

NEUROLOGICAL
Confusion Absent
Dizziness Present
Frequent headaches Absent
Memory loss Absent
Numbness or tingling sensation Present, both lower extremities
measured approximately 5 inches below the
patella through the toes

MUSCULOSKELETAL
Back pain Absent
Broken Bones/fractures (where?) Absent
Muscle pain or cramps (where?) Absent
Muscle weakness (where?) Present, both lower extremities

ALLERGIC/IMMUNOLOGIC/INFECTIOUS DISEASES

Food allergies Absent

PSYCHIATRIC
Alcohol abuse Absent
Anxiety/nervousness Present
Depression Present
Do you have panic attacks? Absent
Do you have suicidal thoughts or plans? Absent/but had a suicidal attempt
Drug abuse Absent
Unable to sleep (insomnia) Absent

1.4 Past and Current Medical Condition

The patient has seizure episodes but no drugs were ordered in the hospital since
the chief complaint upon admission is hypotension with severe body weakness. The
patient has had her last attack last 2006. The mother interviewed verbalize that her
daughter was been attacked by seizure three times (the dates were not questioned); the
episodes noted by the mother was unclear (minutes); there are drugs used by the patient
and Gabapentin (Neurontin) was the only one noted by the group interviewers as also
stated by the mother, frequency of taking not questioned. Also, the patient has a form of
mental disorder (Major Depressive Disorder) which happens to be diagnosed as
theoretically-based by the group.

1.5 History of Hospitalization and Surgical Operation

 When the patient was 14 years old, she made a cut through her umbilicus to
inguinal area (now obvious of keloid formation) using a pen knife and was then admitted
to Dr. PJGMRMC and rendered surgical repair (suture).

January 6, 2000 – PJGMRMC, consulted because of low Blood Pressure level

and diagnosed with Anemia. She was there to receive blood transfusions and blood tests,
also urinalysis; she was then relieved as manifested by exhibiting normal B.P. level and
discharged after four (4) days in female medical ward.

1.6 Family Medical History

Her mother also has anemia. Her maternal grandmother and aunt also were/are
anemic.
The type of anemia of mother, grandmother and aunt was not known either. There
were no history of cancer and other chronic disease noted as verbalized by the mother
and sister of the patient.

2. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN

2.1 Client’s Description of Her Health

Before Admission: “Nanghihina sya ‘non, tapos grabe yung hilo niya, natumba
pa nga e, maputlang-maputla” as verbalized by the mother.

At Present: “Hindi na masyadong mababa yung B.P. ko, medyo okay na rin
yung pakiramdam ko di tulad dati ‘nung dinala ko dito…hindi na din nahihilo” as
verbalized by the patient.

2.2 Health Management

On self:
“Ako, nag-eexercise ako, ayan naglalakad-lakad. Pero minsan tinutulog ko
na din saka yung pagkain ko” as verbalized by the patient.

Of Family:
“Ako na nga nagpapaligo dyan, pinupunasan ko din pag umaga.Yung
vitamins niya kelangan meron lagi saka pinaiinom ko din kahit walang pambili,
iniraraos ko. Pag naman maglalakad ‘yan, tinutulungan ng kapatid nya, minsan
 ako, yung binti nya saka paa, pag sumasakit, hinihimas-himas ko din” as
verbalized by the mother of the patient.

Expectations from Hospitalization:

“Okay naman dito, buti nga at konti lang yung pasyente dito sa kwarto e.
Ayos naman, sana nga at pagalingin yung anak ko, wala na kasi kaming pera pag
nagtagal pa dito” as verbalized by the mother.

Anticipation of Problems with Caring for Self upon Discharge:

“Wala naman masyado, kaso nga lang, yan ngang paglalakad niya,
kelangan din ng tulong kasi baka matumba. Saka yung mga gamot nyang iinumin,
kelangan talagang tuloy-tuloy, sabi kasi ng doktor nya ‘yon” as verbalized by the
mother.

Knowledge of Treatment or Practices Prescribed:

“Yung mga laboratories na ginagawa sa kanya, oo alam ko naman yon e,

sa kapatid ko kasi saka sakin ganyan din ginagawa, kaya okay lang. Tinitingnan
ko na nga din yung mga resulta ng Hemoglobin nya e, kung mababa ba o ano.
Sanay na din ako sa mga estudyante dito, talagang kailangang manggising sila ng
alas kwatro, importante kasi yung B.P. kaya nga pagtapos mag-B.P. eh tinatanong
ko yung resulta” as verbalized by the mother.

Reaction to the Above Prescription:

“Okay naman dito, kaso nga lang ang tagal na namin nandito, gusto na
naming umuwi, ayos naman si doc, saka yung mga ginagawa ng taga Laboratory,
buti nga’t nasa oras din” as verbalized by the mother.

3. NUTRITION AND METABOLIC PATTERN

Usual Food Intake before Admission

Breakfast: Fried Egg, 1 cup of rice

Lunch: Fried Fish, 1 cup of rice
Supper: Vegetables, 1 cup of rice
Snacks: 2 pieces Pan de sal, no fillings
 Preferences: Coffee in the morning, sweet candies, sinigang na baboy
are her preferences.

Usual Fluid Intake Water

Type and Amount: 5 glasses, NAWASA

Food Restrictions (if any): Dark colored foods/High Caloric as ordered by her
physician.
Problem with ability to eat: None
Supplementation: Ferrous sulfate. “Umiinom din yan ng vitamins,
Enervon” as verbalized by her mother.

4. ELIMINATION PATTERN
Urination
Frequency: Usually 5 times a day
Color: Amber yellow
Urinary Complaints: Nothing
Home remedies: Nothing

Bowels
Time, Frequency, and Consistency: “minsan isang beses lang isang
araw” as verbalized by her mother. “sa umaga” as added. “medyo maitim
yung dumi nya, medyo lang naman” as replied by the mother in SN’s
question.
Complaints: “wala naman” as verbalized by the mother.
Home Remedies: Nothing

5. ACTIVITY AND EXERCISE PATTERN

Assistive Devices: with assistance from mother or present relative
Usual daily/weekly Activities: “Naglalakad-lakad kasama ko, ganon” as
verbalized by the mother.
Limitations of Physical Activity: “di kasi siya pwedeng mag-exercise mag-isa
kasi nga baka tumumba, bumababa kasi yung B.P. nya” as verbalized by
her mother.

6. SLEEP AND REST PATTERN

Usual Sleep Pattern
 Bedtime: usually from 8 pm to 5 am (but interchangeable as
verbalized by the elder sister and mother)
Hours of sleep: 9 hours (estimated)
Siesta: yes
Sleep Routines: praying before sleep
Number of pillows: 3 pillows; 2 pillows on her thigh and arms respectively and
one pillow on head.
Sleep Problems: “minsan di makatulog sa gabi” as verbalized by her mother.
Usual Remedies: none

7. SELF-PERCEPTION PATTERN
What the client is most concerned about
“yung B.P. niya, yung paa nyang parang namamanhid, saka lagi nyang sinasabi,
umuwi na daw kami” as verbalized by the mother and checked thru patient’s interview.
Present health goals
“gusto kong lumakas ulit” as verbalized by the patient.
Effects of present illness to self
“ayan. Lagi na lang kasing andito sa ospital. Matagal na yang di nagagawa yung
gusto nya. Gusto nga nyan yung kumikita ng pera, yung nag-uurong tapos babayadan
sya” as verbalized by the mother.
How Does the Client See/Feel about Self?
“di kasi ko sanay dito ospital” as verbalized by the patient, “pero malakas pa din
yan, pag inaatake nga lang ng low blood” as verbalized by the mother

8. ROLE-RELATIONSHIP PATTERN
Language spoken: Tagalog
Manner of Speaking: Clear words as heard by observers, normal speed
Significant Person/s to the Client: Mother and elder sister
Complaints Regarding the Family: None
Living with (members of family): Mother, father and three (3) siblings

9. STRESS MANAGEMENT PATTERN

Decision making ability: present
Significant stress in the past year: none
Management of stress: walking
Expectations from the nurses: “okay naman sila eh” as verbalized by the
mother.
10. VALUES AND BELIEF SYSTEM
Source of strength: God and her family
Religious practices: Praying before sleep. The client has rosary on her bed.

11. NURSING ASSESSMENT: Physical Examination

GENERAL SURVEY:
The patient is medium built, with proportionate weight and height, and has no
observable of muscle atrophy to any parts of her body. She can walk with a personal
assistant; with symmetrical movements and size of bilateral body parts. The skin is pale
more in upper extremities, palm and nails, with slightly combed, evenly distributed hair;
fingernails are properly trimmed. She is fully awake and oriented to time, place and
persons. She hears and sees that others also hears and sees. She is passive and slightly
aggressive to others sometimes but cooperative. She is able to relax and maintain eye
contact and has spontaneous clear words.

CEPHALOCAUDAL EXAMINATION:
Date performed: 01-21-2009
Time started: 7:30 a.m.
Time ended: 8:15 a.m.
Vital signs:
Temperature: 36.8°C/ax
Pulse rate: 67 bpm/weak, regular
Respiratory rate: 18 cpm
Blood Pressure 90/60 mmHg
Position of client: Lying
Height: 5’6”
Weight: 57 kgs. / 125.4 lbs.
Conscious/coherent
Head and Face:
1. Cranium
-normocephalic
-No signs of tenderness and lesions
-Hair is lustrous with no parasites
2. Temporal Arteries
-palpable
3. Face
 -no tenderness in the frontal and maxillary sinuses
-with presence of 4 dental carries on molar teeth
-with yellowish teeth
-tongue is pinkish, no presence of sores
-with pale soft palate and pale oral mucosa
4. Cranial Nerve V and VII
-for CN V—symmetrical muscle strength on both sides
-for CN VII—equal facial expressions, movement and strength. The patient
smiles when told to smile, the patient frowns when told to frown with no
difficulty and pain.
- The anterior 2/3 of the tongue is a taste-sensor, the experiment are as follows:
• Orange – sour
• Sugar bits – sweet
• Table salt – salty

5. Cranial Nerve I
-intact sense of smell, the patient smelled the orange when blindfold; and able to
distinguish different odors by spraying an alcologne in the ward.

Eyes and Vision

1. External Eye Structure
-no tenderness and lesions in the eyelids
-pink to pale bulbar and palpebral conjunctivae
-anicteric sclerae
2. Visual Acuity
-no difficulty in reading at normal conditions noted, the client is reading
pocketbooks with no noted difficulty as verbalized by the client herself
3. Extraocular Muscle Function (CN 3, 4, 6)
-eyeballs move in parallel and conjugate direction without oscillations using a ball
pen changed in oblique and parallel directions by the observer about 1 feet away
from the patient
-no nystagmus
-no ptosis
4. Pupillary reflexes
-pupils are equally round and reactive to light and accommodation (size of pupils
not been able to measure)
-black iris with grayish lining on the outer structure
Ears and Hearing
1. External Ear
-same color with face
-no visible and palpable lumps and lesions

2. Hearing
-with bilateral equal hearing acuity noted
-no diminished hearing

Neck
1. Musculoskeletal structure
-no tenderness and lesions present
-sternocleidomastoid muscles are functional
2. Lymph nodes
-no observable lymph node enlargement
3. Thyroid Gland
-no enlargement
-soft upon palpation
4. Cranial Nerve XI
-able to shrug shoulders and turn his head against resistance
5. Carotid Arteries
-symmetrical rate and rhythm
-no distention and tenderness
6. Neck Veins
-no distention nor flattened jugular vein

Upper Extremities
1. Musculoskeletal structure, skin nails
-no myalgia
- (+) keloid formation on L upper extremity
-pale, well trimmed nails
-pale anterior palm
-abnormal capillary refilling time due to skin color
2. Musculoskeletal Function (Range Of Motion)
-normal ROM, the patient is in sitting position while testing ROM exercises
3. Brachial and Radial Arteries
-palpable with no distention and tenderness
-weak pulse (69 bpm)
 -obvious brachial veins on both arms
4. Deep Tendon Reflexes
-DTR’s (biceps and triceps) are normoactive using a reflex hammer

Thorax
1. Breast and Axilla
-no bulges and tenderness in the chest area
-axilla has no lesions and palpable nodes present
2. Anterior Thorax
-dull sound upon percussion on 4th-5th intercostal space
-no breast secretions or lumps noted
3. Posterior Thorax
-asymmetric chest expansion L upon inspection and palpation on back (upon
sitting position)
-normal breath sounds with no presence of rales and wheezing
4. Precordium
-with no palpable pulsations over the aortic (2nd ICS R) and pulmonic (2nd ICS L)
areas
-presence of palpable pulsations over the mitral area (5th ICS MCL L)
-adynamic precordium upon auscultation, presence of S4 but unclearly notified

Abdomen

1. with keloid formation from umbilical area diagonally to inguinal area L

2. Quadrants
-normal bowel sounds at 4/min (RUQ), 3/min at LUQ, and 5/min at RLQ
3. Internal Organs
-Liver is slightly palpated, smooth with no presence of hepatomegaly
-Spleen and kidneys were not palpated due to difficulty; obvious with no presence
of splenomegaly

Lower Extremities
1. Musculoskeletal structure, skin nails
-no myalgia noted
-tingling sensation on both lower extremities
-pale, untrimmed nails
-abnormal capillary refilling time due to skin color
 2. Musculoskeletal Function (Range Of Motion)
-normal ROM except the feet
3. Popliteal, Tibial, and Pedal Arteries
-are present with no signs of distention
-weak pulse upon palpation (63 bpm)
4. Deep Tendon Reflexes and Plantar Reflexes
-knee-jerk reflexes are normoactive but plantar reflexes were not tested due to
patient’s decision of lower extremities’ tingling sensation

Genitals
1. Genitalia
-no hernia noted
-no lesions, parasites and tenderness noted
-no previous histories of burning, swelling, redness or rashes noted

12. INITIAL MEDICAL DIAGNOSIS

Anemia
Hypotension
To consider MAJOR DEPRESSIVE BEHAVIOR

Worthlessness Absent
Self hatred Absent/present when committed suicide
Poor concentration Present
Reduced sex drive Present as claimed by mother
Fatigue Present
Digestive problems Present
Lethargic Present
Agitated Present
Self-harm or suicidal attempts Absent
Forgetfulness Present
Psychomotor agitation Present

The group, for two days obtaining data from the patient and her family diagnosed
a psychiatric disorder Major depressive disorder based on their observation made and
interview, since:

The patient is depressed and slightly aggressive (she kisses the hands of the
observer agitatedly, cheering) (activity as claimed by the patient’s mother but defended
that her daughter is still in normal functioning, verbalizing: “ganyan talaga yan, pero
hindi naman siya yung sira talaga”, she has a depressed (sad) mood which appears to the
observer as a personality trait. When taking the patient’s blood pressure, she always
actively straightens her arms.

The observers diagnosed her using the DSM IV manual, under mood disorder
(mood centers the trait of the patient). We, the observers, happened to diagnose for
having her had a suicidal attempt (feeling of worthlessness and family problem),
decreased need for sleep vs. sleep disturbance, fatigue, and family has observed her to be
agitated, and lethargic. As accorded, she only happens to be interested and or pleasured if
doing her normal work in their area (washing plates for income).
She does not, however, have illusions, delusions or hallucinations.

According to her mother, she had never been to a psychiatrist to examine her
mental situation.
Level of Consciousness: Conscious and coherent
Appearance:
Age: 32 years
Height: 5’6”; Weight: 57 kgs.
Manner of dressing: normal, neat dress
Grooming: Slightly combed hair, untrimmed toe nails
Observed poor sense of personal grooming
Attitude:
Hostile but cooperative

Behavior:
Psychomotor agitation, no signs of athetotic movements, normal eye contact with the
observers and family members
No mannerisms

Mood and affect:

Neutral to euthymic with no presence of Alexithymia
Depressed

Speech:
Clear, spontaneous words of normal intensity, normal rate

Thought content and process:

No flight of ideas, delusions or hallucinations
Had her suicide attempt 18 years ago, however, no attempt was observed since then.
Judgment:
Can make decisions

*Since there were no collaborative actions made by the family to psychiatric health
professionals to diagnose the patient’s mental disorder, the group based the diagnosis on
the theories and concepts inscribed in published books and references on internet and
journals. Symptoms were collected as observed and took the appropriate one as the
diagnosis hence added to consider on medical diagnosis made.
 Mother and Family History of ANEMIA
aunt (X-
linked)
11 Altered folate absorption
DNA mutation Folic Acid Deficiency
PteGlu7 hydrolyzed to
I.D.A pterylglutamate
Change in bone marrow function
Folic acid formation
Altered Pluripotential stem cells
enterocytic action

Alteration in myeloid stem
cells/erythroid marrow
RBC Production
Altered lymphoid stem cells
Change in production of
lymphocytes
Reduction to
CH3H4PteGlu
products pass across
basolateral membrane

Hgb Hematocrit Blood Viscosity

Prolonged
borderline Hgb Nitrous oxide Brittle hair
Blood Pressure
Pallor
Blood Pressure
Cardiac dyspnea Cyanosis
decompression
on L ventricle Blood perfusion to
organs/organ systems O2 in cells
and tissues

Ventricular Asymmetric
hypertrophy lung
expansion L
O2 supply to CNS

4th heart sound (S4)

Muscle weakness

Loss of balance
Sleep-pattern
disturbance Restlessness Fatigue

Weakness

PATHOPHYSIOLOGY OF
HYPOPROLIFERATIVE ANEMIA
(Folic Acid Deficiency – IDA, Hypotension)
 T/C Atrophic gastritis as frequent burping

Gastric parietal cells’ atrophy

Production of Intrinsic factor (IF)

Binding capacity of IF/B12

on terminal ileum

Vitamin B12 transportation by

Transcobalamin II via portal
circulation ( TCII/B12)

Vitamin B12 endocytosis

VITAMIN B12 DEFICIENCY

Methionine/MTR
DNA mutation

Altered production of
Megaloblast RBC cathecholamines; neurotransmitters
RBC production

Hct Hgb Neurologic problems Peripheral neuritis

Tingling sensation on
Mood changes Depression both lower
extremities/Paresthesia

PATHOPHYSIOLOGY OF PERNICIOUS ANEMIA

(Vitamin B12 DEFICIENCY)
 14. DEFINITIVE MEDICAL DIAGNOSIS

HYPOPROLIFERATIVE ANEMIA PROBABLY

PERNICIOUS
VITAMIN B12 DEFICIENCY
FOLIC ACID DEFICIENCY
IRON DEFICENCY
HYPOTENSION
MAJOR DEPRESSIVE DISORDER
SEIZURE DISORDER

15. SHORT SUMMARY OF THE PATIENT’S COURSE IN THE E.R./WARD

• FROM EMERGENCY ROOM (01-19-09-Monday/8 a.m.)

• Advised to have Full Diet
• Inserted an IV fluid D5LR 1 liter for 8 hours on right cephalic vein
• Vital signs taken and recorded
• Prescribed to have laboratories including:
i. CBC
ii. Stool Exam with occult blood
iii. For cross matching
iv. RBS
v. Creatinine, uric acid
• Prescribed medications such as:
• Ferrous sulfate 1 cap BID P.O.
• Folic acid 1 cap BID P.O.
• Multivitamins 1 cap OD P.O.

IN THE WARD (01-19-09-Monday)

• Positioned in trendelenburg
• Weak in appearance
• On full diet
• Laboratory studies requested
• Doctor ordered Metoclopramide 1 amp PRN for vomiting
 Metoclopramide 1 amp administered intravenously (4pm)
• For blood typing
• BP – 90/40 mmHg (4pm) HR: 54 bpm
• BP – 90/40 mmHg (8pm) HR: 54 bpm
• BP – 80/40 mmHg (12mn) HR: 70 bpm
• Continued oral medications (6pm)
• Position changed to supine
 (01-20-09-Tuesday)
• D5LR was changed to Plain NSS for 10-11 gtts/min (12mn)
• BP – 110/80 mmHg (4am) HR: 62 bpm
• Blood sample taken by medical technologist (6pm)
• Diet changed to diabetic’ (6pm)
• Intake and output monitored and recorded
• Still for BT

16. DATA FROM TEXTBOOK

Description of Diagnosis

Megaloblastic anemia- in anemias caused by deficiencies of vitamin B12 or folic acid,

identical bone marrow and peripheral blood changes occur, because both vitamins are
essential for normal DNA synthesis.
Folic acid deficiency – folic acid, a vitamin that is necessary for normal RBC
production, is stored in compounds referred to as folates. The folate stores in the body are
much smaller than those of vitamin B12, and they are quickly depleted when the dietary
intake of folate is deficient.

Pernicious anemia (also known as Biermer's anemia, Addison's anemia, or Addison-

Biermer anemia) is a form of megaloblastic anemia due to vitamin B12 deficiency,
caused by impaired absorption of vitamin B-12 due to the absence of intrinsic factor in the
setting of atrophic gastritis, and more specifically of loss of gastric parietal cells.

While the term 'pernicious anemia' is sometimes also incorrectly used to indicate
megaloblastic anemia due to any cause of vitamin B12 deficiency, its proper usage refers
to that caused by atrophic gastritis and parietal cell loss only. It is the most common
cause of adult vitamin B-12 deficiency

Iron deficiency anemia is the common type of anemia, and is also known as
sideropenic anemia. It is the most common cause of microcytic anemia. Iron deficiency
anemia is an advanced stage of iron deficiency. When the body has sufficient iron to meet
its needs (functional iron), the remainder is stored for later use in the bone marrow, liver,
and spleen as part of a finely tuned system of human iron metabolism. Iron deficiency
ranges from iron depletion, which yields little physiological damage, to iron deficiency
anemia, which can affect the function of numerous organ systems. Iron depletion causes
the amount of stored iron to be reduced, but has no effect on the functional iron.
However, a person with no stored iron has no reserves to use if the body requires more
iron. In essence, the amount of iron absorbed and stored by the body is not adequate for
growth and development or to replace the amount lost.

Hypotension refers to an abnormally low blood pressure. This is best understood as a

physiologic state, rather than a disease. It is often associated with shock, though not
necessarily indicative of it. Hypotension is the opposite of hypertension, which is high
blood pressure. Hypotension can be life-threatening.

Major Depressive Disorder (also known as clinical depression, major depression,

unipolar depression, or unipolar disorder) is a mental disorder characterized by a
pervasive low mood, low self-esteem, and loss of interest or pleasure in normally
enjoyable activities. Major depression is a disabling condition which adversely affects a
person's family, work or school life, sleeping and eating habits, and general health.

The diagnosis of major depressive disorder is based on the patient's self-reported

experiences, behavior reported by relatives or friends, and a mental status exam. There is
no laboratory test for major depression, although physicians generally request tests for
physical conditions that may cause similar symptoms. The most common time of onset is
between the ages of 30 and 40 years, with a later peak between 50 and 60 years. Major
depression is reported about twice as frequently in women as in men, although men are at
higher risk for suicide

Seizure Disorder/Epilepsy is a common chronic neurological disorder characterized by

recurrent unprovoked seizures. These seizures are transient signs and/or symptoms of
abnormal, excessive or synchronous neuronal activity in the brain. About 50 million
people worldwide have epilepsy, with almost 90% of these people being in developing
countries. Epilepsy is more likely to occur in young children or people over the age of 65
years, but it can occur at any time. Epilepsy is usually controlled, but not cured, with
medication, although surgery may be considered in difficult cases.
 SIGNS AND SYMPTOMS IN THE REFERENCE MATERIALS VERSUS
PATIENT’S MANIFESTATIONS

SIGNS AND SYMPTOMS - REFERENCE MATERIALS SIGNS AND SYMPTOMS

(PERNICIOUS AND FOLIC ACID D.A.) MANIFESTED BY PATIENT
Smooth sore, red tongue VS. Absent
Mild diarrhea Absent
Pale Present
Confused Absent
Paresthesia Present
Difficulty in maintaining gait Present
Weakness Present
Fatigue Present
Irritability Present
Mood swings Present
Asymmetrical chest expansion Present
Dyspnea in exertion Absent
Presence of S4 upon auscultation Present
Rapidly bounding pulse Absent
Weight loss Absent
*Not seen Burps
*Not seen Weak pulse
SIGNS AND SYMPTOMS - REFERENCE MATERIALS SIGNS AND SYMPTOMS
(IRON DEFICIENCY ANEMIA) MANIFESTED BY PATIENT
Pallor VS. Present
Fatigue Present
Pica Absent
Alopecia Absent
Lightheadedness Absent
Constipation Absent
Fainting Absent
Missed menstrual cycle Absent
Glosstis Present
Koilonychia Absent
Pruritus Absent
Loss of appetite Absent
Seeing bright colors Absent
*
Are the manifestations observed that were not seen on reference materials

17. MEDICAL/SURGICAL PLANS AND INTERVENTIONS

• Blood Transfusions If Necessary

Blood Transfusion is the process of transferring blood or blood-based products
from one person into the circulatory system of another. Blood transfusions can be
life-saving in some situations, such as massive blood loss due to trauma, or can be
used to replace blood lost during surgery. Blood transfusions may also be used to
treat a severe anemia or thrombocytopenia caused by a blood disease. People
suffering from hemophilia or sickle-cell disease may require frequent blood
transfusions.
 Nursing responsibilities:
• The nurse has to get consent forms signed by the patient or a
qualified representative of the patient, except in the cases of
trauma or life saving situations if the patient is unable to make that
decision;
• The nurse is responsible for insuring that the right unit of blood is
to be administered to the right patient after typing and cross-
matching by the lab. This is done by checking the lot, serial
numbers, blood type, and expiration date with another nurse or
qualified lab personnel;
• The nurse has to take a complete set of vital signs for a baseline
data;

• After starting the transfusion, the vital signs must be checked after
15 minutes, then 30 minutes from then, then at one hour. Then
vital signs must be checked every hour, according to hospital
protocol;
• The vital signs are checked this often to monitor for a reaction to
the blood. If a reaction occurs, then the transfusion must be
stopped immediately and normal saline infused;
• The nurse should monitor if the patient took the pre-Blood
Transfusion medications if then ordered

• Blood Pressure Monitoring

• The nurse should carry the correct monitoring of blood
pressure report any severe abnormalities in the range with the
physician;
• The patient and his/her family should be informed if in
monitoring to anticipate such events

• Folic Acid Replacement/Vitamin B-Complex Replacement

Vitamin B12 (cobalamins), which also includes folate, is necessary for the
formation and maturation of red blood cells and the synthesis of DNA
(deoxyribonucleic acid), which is the genetic material of cells. Vitamin B12 is also
necessary for normal nerve function. Unlike most other vitamins, B12 is stored in
substantial amounts, mainly in the liver, until it is needed by the body.
• The nurse should suggest the patient the ordered frequency
to take the medications per orem
 • The nurse should note the medication has been taken
• Blood Tests (To monitor Hematocrit and Hemoglobin)
A blood test is a laboratory analysis performed on a blood sample that is usually
extracted from a vein in the arm using a needle, or via finger prick.
• The patient should be informed by the nurse that blood tests will be
done. Inform also on what are the things to expect from the test.
• The results of the laboratory should be kept in the chart or by
family when told to do laboratory; instruct or remind
relatives/patient.

• No Recommended Surgical Interventions

19. NURSING DIAGNOSES APPROPRIATE FOR THE CLIENT

• Activity intolerance 1st – physiological need

• Nausea
• Fatigue
• Sleep Pattern Disturbance
• Deficient knowledge
• Altered thought process
• Self-care deficit
• Anxiety
• High Risk for injury
• Risk for suicide
1st – physiological need
1st – physiological need
1st – physiological need
1st – physiological need
1st – physiological need
2nd – safety need
3rd – love and belongingness need
References:
Internet:
http://www.aafp.org/afp/20030301/979.html
http://www2.kumc.edu/coa/Education/AMED900/HypoproliferativeAnemia.htm
en.wikipedia.org

Published books:
Smeltzer, Bare, et.al. Brunner and Suddarth’s Textbook of Medical and Surgical
Nursing vol.1, pp. 883-885. 2004
Wallach, J. et.al. Interpretation of Diagnostic Tests 5th Ed. 2000.
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)
World Health Organization's International Statistical Classification of Diseases and
Related Health Problems (ICD-10)
Jones, K.J. (2004). Nursing Management Hematologic Problems. In S.M. Lewis, M.M.
Heitkemper, & S.R. Dirksen (Eds.), Medical-surgical Nursing: Assessment and
Management of Clinical Problems (pp. 705-755). St. Louis: Mosby.
Monthly Index of Medical Specialties (MIMS) Philippine 2007 Ed.
Philippine Pharmaceutical Directory (PPD) 2009 Ed.
Objective Data Seen/Observed:

• Decreased Hemoglobin
• Decreased Hematocrit
• Elevated Lymphocytes
• Elevated Uric Acid
• Elevated Random Blood Sugar
• Elevated Fasting Blood Sugar
• Elevated Blood Cholesterol Level
• Decreased Low Density Lipoprotein
• Slightly combed hair
• pink to pale bulbar and palpebral conjunctivae
• pale mucous membrane
• with presence of 4 dental carries on molar teeth
• Frequently burps
• (+) keloid formation on L upper extremity
• obvious brachial veins on both arms
• Pale skin, nails (integument)
• weak pulse
• With D5LR 1L on right cephalic vein
• Pale anterior palm
• Abnormal capillary refilling time
• Asymmetric chest expansion, Left
• Presence of S4 upon auscultation
• With keloid formation from umbilical area diagonally to perineal area, Left
• Tingling sensation on both lower extremities
• ROM decreased in lower extremities
• Paresthesia
• Cannot walk alone
• Mood swings as observed
• Mild Anxiety
• Observed Sleep pattern disturbance
• Slightly aggressive
• Passive
• Recurrent episodes of nausea
REST:
1. Have a regular daily rest and activity program by stretching
upper and lower extremities.

2. Avoid emotional upsets. Listen to concerns and fears, etc. and

provide encouragement.

DRUG THERAPY:
1. Take each drug as prescribed daily. (Patient-Family teaching
guide in prescribed medications – pls. refer to Drug Study –
XVIII)

2. Develop a check-off system (e.g. daily chart) to ensure

medication have been taken.

3. Take pulse rate each day before taking medications. Know the
parameters that your health care provider wants for your health.

DIETARY THERAPY:
1. Consult the written diet plan and list of permitted and restricted
foods.

2. A well-balanced diet is essential to provide other elements for

healthy blood cell development, such as folic acid, iron,
Vitamin A and vitamin C.

3. Broadening diet to include chicken, eggs, fish, even ketchup –

and tomato -- contains vitamin B12

4. Moderate intake of caffeinated foods or drinks.

ACTIVITY PROGRAM:
1. Try to increase walking and other activities gradually, provided
do not cause fatigue and dyspnea.

2. Always make sure that the patient has an assistant in walking,

and other such circumstances.

3. Keep regular appointments with health care provider.

 4. Exercises focused on improving sense of balance may help if
nerve damage caused to be unsteady while walking.

5. Swimming should usually be avoided.

6. Promote active exercises when in bed to assistive active when

walking to promote maximal activity potential of patient.

ONGOING MONITORING:
1. Know YOUR limit.

2. Surround the patient with people who love you and will help
you.

3. Know yourself and know warning signs or things that will

trigger an outburst. Also, don’t put yourself in situations which
will purposely hurt you and don’t engage in self-defeating
behaviors.

4. Most will require repeat blood counts. Also, repeat visits to the
doctor's office are likely in order to determine the response to
treatment.

5. Monitor for the safety of the patient; keep in mind that the
patient has seizure disorder, keep environment safe as
conduciveness.

6. Monitor the patient’s blood pressure. Document if necessary.

7. Recall the symptoms experienced when illness began

appearance of previous symptoms may indicate a recurrent.

8. Report immediately to health care provider any of the

following:

• Bleeding gums
• Diarrhea
• Fatigue
• Impaired sense of smell
• Loss of deep tendon reflexes
• Loss of appetite
• Shortness of breath
• Sore mouth
• Tongue problems
5. Join the local support group with your family members.