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Severe Anemia

INTRODUCTION 1 Patients Profile . 4 Patients History 5 Physical Assessment ... 6 ANATOMY AND PHYSIOLOGY .. 7 PATHOPHYSIOLOGY .. 16 MEDICAL MANAGEMENT .. 17
Diagnostic Exams ..... 18 Laboratory Exams .. 24

NURSING CARE PLAN 32

Introduction
Anemia, per se, is not a specific disease but a sign of an underlying disorder. It is by far the most common hematologic condition. Anemia, a condition in which the hemoglobin concentration is lower than normal, reflects the presence of fewer than normal RBCs within the circulation. As a result, the amount of oxygen delivered to the body tissues is also diminished.

Three broad etiologic categories:


Loss of RBCs Decreased production of RBCs Increased destruction of RBCs

Iron deficiency anemia typically results when the intake of dietary iron is inadequate for hemoglobin synthesis. The body can store about one fourth to one third of its iron, and it is not until those stores are depleted that iron deficiency anemia actually begins to develop. Iron deficiency anemia is the most common type of anemia in all age groups, and it is the most common type of anemia in the world.

The most common cause of iron deficiency in men and post menopausal women is bleeding (from ulcers, gastritis, inflammatory bowel disease, or gastrointestinal tumors). The most common cause of iron deficiency anemia in pre menopausal women is menorrhagia (excessive menstrual bleeding) and pregnancy with inadequate iron supplementation. Patients with chronic alcoholism often have chronic blood loss from the gastrointestinal tract, which causes iron loss and eventual anemia. Other causes include iron malabsorption, as is seen after gastrectomy or with celiac disease.

Patients with iron deficiency primarily have the symptoms if anemia. If the deficiency is severe or prolonged, they may also have a smooth, sore tongue, brittle and ridged nails, and angular cheilosis (an ulceration of the corner of the mouth). These signs subside after iron replacement therapy. The health history may be significant for multiple pregnancies, gastrointestinal bleeding, and pica (a craving for unusual substances, such as ice, clay, or laundry starch).

Patients Profile Name: Address: Gender: Age: Civil Status: Birthdate: Birthplace: Occupation: Nationality: Religion: E., D. V. L. Pila, Laguna Female 42 Married October 18, 1968 Pila, Laguna Housewife Filipino Catholic

Admission Date: Admission Time: Hospital:

June 25 ,2011 5:33 PM Laguna Provincial Hospital

Admitting Physician: Attending Physician:

Dr. T Dr. L

Medical Diagnosis: G3P3 (3003) AUB, Severe Anemia

HISTORY

ADMISSION 1 month prior to admission, the patient experienced prolonged menses. 1 pad per day and fully soaked for 1 month straight. A day prior to admission, the patient developed extreme weakness, thus admitted to the institution. No history of admission by any illness possible. Does not take any maintenance pills. Does not take any multivitamins.

History of Present Illness

Past Health History

Social History

A housewife. The patient is not taking tobacco. Not taking alcohol. Her husband does not take any tobacco nor alcohol The patient have no history of hyper/hypotension, diabetes mellitus, respiratory problems and others. No history of congenital disorders.

Family History

The patient is G3 P3 (3003). Her LMP is May 20, 2011 All siblings are born alive via NSVD. Maternal History

History of Present Illness


1 month prior to admission, the patient experienced prolonged menses. 1 pad per day and fully soaked for 1 month straight. A day prior to admission, the patient developed extreme weakness, thus admitted to the institution.

Past Health History


No history of admission by any illness possible. Does not take any maintenance pills. Does not take any multivitamins.

Social History
A housewife. The patient is not smoking. Not taking alcohol. Her husband does not take any tobacco nor alcohol

Family History
The patient have no history of hyper/hypotension, diabetes mellitus, respiratory problems and others. No history of congenital disorders.

Maternal History
The patient is G3 P3 (3003). Her LMP is May 20, 2011. All siblings are born alive via NSVD.

Physical Assessment
GENERAL SURVEY
Cooperative attitude and behavior.Erect posture, coordinated, smooth and steady gait.Weakness and fatigue noted.Speech is clear and moderately paced.Peripheral numbness noted.V/S taken and recorded as ff.: BP = 90/60 mmHg, PR = 81 bpm, RR = 19 cpm, T=36.6O

Physical Assessment
SKIN, HAIR AND NAILS
Skin is pale, dry, intact, smooth and without lesions, Skin pinched easily and immediately returns to its original position. Hair is natural and evenly distributed. Nails are pale and thick.Capillary refill is more than 2 seconds.

Physical Assessment
EYES
Reflection of light is symmetric. Eye movement is smooth and symmetric throughout all nine directions. Pale conjunctiva, clear and free of swelling or lesion. Cornea is transparent. Iris is round and evenly colored. Constriction noted for papillary response.

Physical Assessment
EARS Ears are equal in size bilaterally. Smooth with no lesions. Color is consistent with facial color. No tenderness or discharge noted.

Physical Assessment
HEAD AND NECK
Scalp is symmetric, round, hard and smooth. Face is symmetric. Neck is smooth, and can control movement. No enlargement or lesions noted

Physical Assessment
MOUTH, THROAT, NOSE AND SINUS
Pale lips, No lesions noted. Tongue is red. Uvula hangs freely, tonsils present and not enlarged. Nasal structure is smooth and symmetric. No tenderness noted. Patency of nostrils is good. Bright light seen on sinuses during transillumination.

Physical Assessment
THORACIC AND LUNG Scapulas are symmetric and not protruding. Thorax appears symmetric. Chest expansion is normal. Normal breath sounds. No adventitious sounds noted.

Physical Assessment
HEART
No blowing, swishing or other sounds heard during auscultation. No murmurs noted.

Physical Assessment
ABDOMEN
Color is pale. No lesions and rashes noted. Symmetric. Bowel sound is 7 and normal.

ANATOMY AND PHYSIOLOGY

CIRCULATORY SYSTEM

LYMPATHIC SYSTEM

FEMALE REPRODUCTIVE SYSTEM

MENSTRUAL CYCLE

PATHOPHYSIOLOGY

Non modifiable: Age Gender Hereditary

Marked changes in estrogen and progesterone level

Modifiable: Lifestyle Hormones Malignancy

Lost cyclic endometrial stimulation that arises from an/ovulatory cycle Stimulation of endometrial growth Proliferation w/out periodic shedding causes the endometrium to outgrow its blood supply Enlarged uterus

Tissue breaks down and sloughs from uterus

Chronic stimulation of higher level of estrogen

Leads to episode of frequent heavy bleeding

Subsequent healing of the endometrium is irregular and dyssynchronous Tissue hypoxia Reduction in amount of oxygen available to the tissues

Decreased hemoglobin level

Dec. oxygen, carrying capacity of the blood

(+) pallor

Muscle weakness

Easy fatigability

MEDICAL MANAGEMENT

DIAGNOSTIC EXAMINATIONS

ULTRASOUND
A pelvic ultrasound is used to determine the shape, size, and position of organs in the pelvis, and can detect tumors, cysts, stones in the urinary tract, or extra fluid in the pelvis, and help find the cause of symptoms such as pelvic pain, urinary problems, or abnormal menstrual bleeding.

Impression: Slightly enlarged uterus with heterogeneous echotexture. Thickened endometrium. Unremarkable = ovaries, cervix and posterior cul de sac.

NUTRITIONAL THERAPY
Diet as tolerated - patient is on DAT diet as ordered, for her to supplement all the nutrients she needs before and after the blood transfusion. This was prepared to reduce the risk of iron deficiency anemia .advise the patient to take iron rich foods. Iron rich foods such as: Dark, leafy greens (spinach, collards) Dried fruit (prunes, raisins) Iron-enriched cereals and grains (check the labels) Beans, lentils, chick peas and soybeans Artichokes

INTRAVENOUS FLUID THERAPY


IV therapy is the fastest way to deliver fluids and medications throughout the body. It is used to establish or maintain a fluid or electrolyte balance and to administer continuous or intermittent medication. The patient was infused with D5LR (1L x 8) which is a hypertonic solution; its action is to pull the fluids from the interstitial and intravascular compartments to the blood vessels, thus, lessening the risk for hypovolemic shock. The patient was also hooked with Plain Normal Saline Solution (1L KVO) as Blood Transfusion mainline, it is an isotonic solution which is used because they don't move water in or out of the cell- meaning they are most compatible with human blood as opposed to hypertonic and hypotonic solutions. It is also used after blood transfusion because it is the only compatible diluent after transfusion. Its sole content of Sodium and Chloride does not cause blood reactions and hemolysis that may be dangerous to the client.

LABORATORY EXAMINATIONS

COMPLETE BLOOD COUNT


Normal Values Hemoglobin (11.515.5 g/dL) Result Result (June 25) (June 26) 6.0 10.2 Remarks Clinical Significance Due to excessive blood loss; Decreased in anemia, hemorrhage, and hemolytic reactions;

Decreased

COMPLETE BLOOD COUNT


Normal Values Hematocrit
36- 48%

Result (June 25) 18%

Result (June 26) 30%

Remarks

Clinical Significance Due to excessive blood loss; Defines the volume of hemoglobin per RBC; used to determine the color or concentration of hemoglobin per RBC

Decreased

COMPLETE BLOOD COUNT


Normal Values Result (June 25) Result (June 26) Remarks Clinical Significance

Platelet

150,00 400,000/mm3

764

Abnormal Increased in conditions leukemia and in of excess response to bleeding infection, or clotting. inflammation, and dehydration;

COMPLETE BLOOD COUNT


Normal Values Result (June 25) Result (June 26) Remarks Clinical Significance

White Blood Cells

4,50012300 11,000/mm3

Increased

Indication that infection is present.

COMPLETE BLOOD COUNT


Normal Values Result Result Remarks (June (June 25) 26) Clinical Significance

Segmenters / Neutrophils

45-75%

62

Normal

A stained slide of the blood is needed to perform the differential. The percentages of the different WBCs are estimated, and the slide is microscopically checked for abnormal characteristics in WBCs, RBCs, and platelets.

COMPLETE BLOOD COUNT


Normal Result Result Values (June (June 25) 26) Eosinophils Lymphocytes Monocytes
0-6% 20-50% 1-10%

Remarks

Clinical Significance

4% 29% 05%

Normal

Normal Normal

COMPLETE BLOOD COUNT


Normal Values Result Result (June (June 25) 26) Remarks Clinical Significance

Red (4.2-5.4 Blood x106) Cells

2.62

Decreased

Indication that anemia is present; Decreased in anemia; increased in dehydration, polycythemia

COMPLETE BLOOD COUNT


Normal Result Result Remarks Values (June (June 25) 26) Mean Corpuslucar Volume 81-96% 86 Normal Clinical Significance

COMPLETE BLOOD COUNT


Normal Result Result Remarks Values (June (June 25) 26) Mean Corpuscular Hemoglobin 27.5 33.5 pg/cell 22 Clinical Significance

Indicate Measures the average small size or volume of each (microcyt RBC: small size ic) in (microcytic) in ironaverage deficiency anemia; size and large size (macrocytic) volume typical of pernicious of each anemia RBC

COMPLETE BLOOD COUNT


Normal Result Result Values (June (June 25) 26) Mean 33Corpuscular 36g/dL Hemoglobin Concentration 26.5 Remarks Clinical Significance Measures the weight of hemoglobin per RBC; useful in differentiating types of anemia in a severely anemic patient

Indicate (hypochromi c concentratio n of hemoglobin) in microcytic anemia

COMPLETE BLOOD COUNT


Normal Values Result (June 25) 6.4 14.1 10.0% Result Remarks Clinical Significance (June 26) Normal Normal Normal

Mean Platelet Volume Red Blood Cell Distribution Width Platelet Distribution Width

5.0 15.0fL 11-14.5% 9-13fL

CLINICAL BLOOD CHEMISTRY


June 27, 2011 Normal Values Result Remarks Clinical Significance

Sodium

135-148 mEq/L

144.3

Normal

Increased in dehydration and diabetes insipidus; decreased in overload of IV fluids, burns,diarrhea, or vomiting

CLINICAL BLOOD CHEMISTRY


June 27, 2011 Normal Values Result Remarks Clinical Significance

Potassium

3.5-5 mEq/L

3.93

Normal

Increased in renal failure, extensive cell damage, and acidosis; decreased in vomiting, diarrhea, and excess administration of diuretics or IV fluids

CLINICAL BLOOD CHEMISTRY


June 27, 2011 Normal Values Result Remarks Clinical Significance

Biochan Creatinine UV

0.6-1.2 mg/dL

0.61

Normal

Produced at a constant rate and excreted by the kidney; increased in kidney disease

CLINICAL BLOOD CHEMISTRY


June 27, 2011 Normal Values Result Remarks Clinical Significance

BUN Kinetic UV (Blue)

7-18 mg/dL

4.0

Decreas ed

Increased in renal disease and dehydration; decreased in liver damage and malnutrition

BLOOD TRANSFUSION
Blood transfusion is an intervention used to replace active blood loss from the body. The type of blood used for the patient is 1 unit of PRBC for replacement of RBC loss. The patients V/S should be checked every 1 hour to monitor transfusion reactions such as fever, hypotension, tachycardia, etc. The drop factor of blood transfusion is 10 gtts./min. with side drip of PNSS 1L. Dipenhydramine 1 capsule 30 ml was taken prior to BT as an anti histamine. Cross matched Blood type: A Blood transfusion started: 6-26-11 > 4:30am removed: 6-26-11 > 10:30pm

DRUG STUDY

DRUG
GENERIC NAME: Mefenamic acid BRAND NAME: Ponstan, Ponstel CLASSIFICATION: central nervous system agent; analgesic; nsaid; antipyretic DOSAGE, ROUTE & FREQUENCY: Acute Pain Adults and Children (14 yr or age and older) PO 500 mg, followed by 250 mg every 6 h as needed. Usually not used more than 1 wk. Primary Dysmenorrhea Adults and Children (14 yr of age and older) PO 500 mg, followed by 250 mg every 6 h starting with onset of bleeding and associated symptoms.

ACTION Relief of pain including muscular, rheumatic traumatic, dental, post-op and postpartu m pain, headache migraine, fever, dysmenor rhea

INDICATI ON Aspirinlike drug that has analgesic antipyretic , & antiinflammat ory activities

CONTRA INDICATION

ADVERSE REACTION PRECAUTION: If rash occurs, Administration should be stopped ,asthmatics, Hx of liver and kidney disease ADVERSE RXN: GI discomfort, diarrhea or constipation, gas pain, nausea, vomiting, drowsiness

NURSING CONSIDERATION
Assessment & Drug Effects Assess patients who develop severe diarrhea and vomiting for dehydration and electrolyte imbalance. Lab tests: With long-term therapy (not recommended) obtain periodic complete blood counts, Hct and Hgb, and kidney function tests. Patient & Family Education Discontinue drug promptly if diarrhea, dark stools, hematemesis, ecchymoses, epistaxis, or rash occur and do not use again. Contact physician. Notify physician if persistent GI discomfort, sore throat, fever, or malaise occur. Do not drive or engage in potentially hazardous activities until response to drug is known. It may cause dizziness and drowsiness. Monitor blood glucose for loss of glycemic control if diabetic. Do not breast feed while taking this drug without consulting physician.

Patients in whom aspirin, iodides, or any NSAID has caused allergic-type reactions; preexisting renal disease; active ulceration or chronic inflammation of GI tract.

DRUG
GENERIC NAME: Ferrous Sulfate BRAND NAME: CLASSIFIC ATION: Iron Supplement DOSAGE, ROUTE & FREQUENC Y: ORALADUL TS, ELDERLY: 2-3 mg/kg/day or 50-100mg elemental iron 2 time/day up to 100mg 4 time/day. CHILDREN: 3 mg/kg/day elemental iron in 1-3 divided doses.

ACTION
Ferrous Sulfate is an essential component in the formation of hemoglobin, myoglobin and enzymes. It is necessary for effective erythropoiesis and transport or utilization of oxygen

INDICATI ON

CONTRA INDICATION
Ferrous sulfate (or other oral iron products) are considered contraindicated in patients with hemosiderosis, hemochromotosis, hemolytic anemias, or known hypersensitivity to any component of the product. Because of the GI irritating properties of the drugs, oral iron products are also considered contraindicated by some clinicians in patients with GI ulcerative diseases

ADVERSE EFFECT
Side Effects of Ferrous Sulfate Mild, transient nausea Heartburn Anorexia Constipation Diarrhea Adverse Reactions of Ferrous Sulfate Large doses may aggravate peptic ulcer, regional enteritis, and ulcerative colitis. Severe Iron Poisoning: Vomiting Severe abdominal pain Diarrhea Dehydration Hyperventilation Pallor or cyanosis cardiovascular collapse

NURSING CONSIDERATION
Store all forms at room temperature.Give between meals with water but may give with meals if gastrointestinal discomfort occurs.Transient staining of mucous membranes and teeth will occur with liquid iron preparation. To avoid, place liquid on the back of the tongue with dropper or use straw.Avoid simultaneous administration of antacids or tetracycline.Do not crush sustained-release preparations.Eggs and milk inhibit absorption.Monitor serum iron, total iron-binding capacity, reticulocyte count, hemoglobin, and ferritin.Monitor daily pattern of bowel activity and stool consistency.Assess for clinical improvement, record of relief of symptoms (fatigue, irritability, pallor, paresthesia, and headache).Patient Teachings for Clients Taking Ferrous SulfateExpect stools to darken in color.If gastrointestinal discomfort occurs, take after meals or with food.Do not take within 2 hours of antacids because it prevents absorption.

The prevention or treatment of iron deficiency anemia due to inadequate diet, malabsorpt ion pregnancy, and blood loss.

DRUG GENERIC NAME: Cefuroxime BRAND NAME: Ceflin CLASSIFICATI ON: Antibiotic , anti infective DOSAGE: 500 mg ROUTE PO FREQUENCY: Three times a day

ACTION Exerts anti bacterial activity by inhibition of bacterial cell wall synthesis in suscepti ble species

INDICATI ON Effective in treatment of penicillina se producing gonorrhea , treats bone, joint infection, tonsillitis,p haryngitis, and also used in surgical prophylaxi s

CONTRA INDICATION

ADVERSE REACTION
nausea, vomiting, stomach pain, mild diarrhea, gas, upset stomach; cough, stuffy nose; stiff or tight muscles, muscle pain; joint pain or swelling; headache, drowsiness; feeling restless, irritable, or hyperactive; white patches or sores inside your mouth or on your lips; unusual or unpleasant taste in your mouth; diaper rash in an infant taking liquid cefuroxime; mild itching or skin rash; or vaginal itching or discharge.

NURSING CONSIDERATION
Question for history of allergies, particularly cephalosporins and penicillins. : Give without regards to meals. If GI upset occurs give with food or milk. Avoid crushing tablets due to bitter taste Suspension must be given with food. : Intramuscular injections must be administered deep IM to minimize discomfort. Assess mouth for white patches on mucous membranes and tongue. Monitor bowel activity and stool consistency carefully. Mild GI effects may be tolerable but increasing severity may indicate onset of antibiotic-associated colitis. Monitor input and output and renal function reports for nephrotoxicity. Be alert for superinfection: severe genital or anal pruritus, abdominal pain, severe mouth soreness, moderate to severe diarrhea Patient Teachings for Clients Taking Discomfort may occur with IM injection. Doses should be evenly spaced. Continue antibiotic therapy for full length of treatment. May cause GI upset (may take with food or milk).

Contraindic ated in patients with a known allergy to cephalospor in group of antibiotics.

DRUG
Generic Name: Diphenhydramin e HCL Brand Name: Benadryl Classification: Antihistamine Dosages and Route: Cap Adult & childn 12 yr 25-50 mg tid-qid. Syr Adult & childn 12 yr 12.5-25 mg qid. Childn 6 yr-<12 yr 12.5 mg qid, 2-<6 yr 6.25 mg qid. Not intended for use in childn <2 yr. Do not exceed max dose

ACTION
Diphenhydr amine competes with histamine at histamine receptor sites. It inhibits central acetylcholin e. It results in anticholiner gic, antipruritic, antitussive, and antiemetic effect. Diphenhydr amine produces antidyskinet ic and sedative effect

INDICATION Hypersensitivi ty reactionsMoti on sickness (PO only)Parkinso nism ( postencephali tic, arterioscleroti c, idiopathic,dru g/chemical induced).Nigh t ttime aid sleep (PO only)Antitussi ve (liquid or syrup only)

CONTRA INDICATION Lactation, asthma attack, newborn.Hype rsensitivity to histamines.

ADVERSE REACTION
Dominant paradoxical reactions (restlessness, insomnia, euphoria, nervousness, and tremors)Hallucin ationsSeizuresH ypersensitivity reactions (eczema, pruritus, rash, cardiac disturbances, and photosensitivity) CNS depression (sedation, apnea, hypotension, cardiovascular collapse, and death

NURSING CONSIDERATION
Give without regards to meals.Scored tablets may be crushed. Do not crush capsules or film-coated tablets.If patient is having acute allergic reactions, obtain history of recently ingested food, drugs, environmental exposure, and recent emotional stress.Monitor rate, depth, rhythm, and type of respiration.Monitor rate, depth, rhythm, and quality or rate of pulse.Assess lung sounds for rhonchi, wheezing, rales.Monitor blood pressure especially in elderly.Monitor children closely for paradoxical reaction.Tolerance to antihistamine effect generally does not occur; tolerance to sedative effect may occur.Avoid tasks that require alertness and motor skills until response to drug is established.Dry mouth, drowsiness, and dizziness may be an expected response of drug.Avoid alcoholic beverages.

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