Submitted by: N-211 Group 2 Bonifacio, Jimmyn Briones, Carla Jillian Canlas, Jessica Cena, Mary Ruth Cortez,

Norman Damian, Faye Dayco, Julian Alexander Defiesta, Diane De Jesus, Khristine Marie Doliente, Diana Submitted on: September 16, 2011

ANEMIA

I. INTRODUCTION

DISEASE PROCESS

Anemia is a medical condition in which the red blood cell count or hemoglobin is less than normal. The normal level of hemoglobin is generally different in males and females. For men, anemia is typically defined as hemoglobin level of less than 13.5 gram/100ml and in women as hemoglobin of less than 12.0 gram/100ml. These definitions may vary slightly depending on the source and the laboratory reference used. Because hemoglobin normally carries oxygen from the lungs to the tissues, anemia leads to hypoxia in organs. Because all human cells depend on oxygen for survival, varying degrees of anemia can have a wide range of clinical consequences. Anemia is the most common disorder of the blood. There are several kinds of anemia, produced by a variety of underlying causes. Anemia can be classified in a variety of ways, based on the morphology of RBCs, underlying etiologic mechanisms, and discernible clinical spectra, to mention a few.

DISEASE PROCESS

The three main classes of anemia include excessive blood loss acutely such as a hemorrhage or chronically through low-volume loss, excessive blood cell destruction or deficient red blood cell production Anemia is typically diagnosed on a complete blood count. Apart from reporting the number of red blood cells and the hemoglobin level, theautomatic counters also measure the size of the red blood cells by flow cytometry, which is an important tool in distinguishing between the causes of anemia. Examination of a stained blood smear using a microscope can also be helpful, and is sometimes a necessity in regions of the world where automated analysis is less accessible.

STATISTICS

Anemia is the most common and widespread nutritional disorder in the world. As well as affecting a large number of children and women in developing countries, it is the only deficiency which is also significantly prevalent in industralized countries. The numbers are staggering: 2 billion people over 30% of the worlds population are anaemic, many due resource-poor areas,

STATISTICS

In the Philippines, anemia affects almost 70% of infants (611 months), 30% of preschool children (1271 months) and 40% of schoolchildren (612 years) and pregnant women . Serial national surveys highlight both the importance of anemia and the slow progress in the reduction of prevalence of anemia. Government has institutionalized food fortification but there are concerns regarding regulatory compliance and penetration of fortified products to vulnerable areas

RATIONALE

We, as a group, have chosen this case to present because anemia is most common disorder of the blood and we wanted to do a prcised study on it. We also want our audience, readers, and listeners to fully understand the disease causes, processes, preventions, signs and symptoms of This case presentation can be used as a tool in learning and a guide for people of all ages and to those who may want to know about anemia.

OBJECTIVES

-GENERAL

The Group 2 of N-211 will gain more information and knowledge about the disease and will lead to certain new facts about the said condition, such as cause of disease, pathophysiology, manifestations, related factors, as well as proper nursing care management and medical regimens to be rendered. This acquired information may also help the other groups or students on how to properly manage and care for patients with the same condition.

-SPECIFIC

For client centered objectives, possible causes of the disease should be fully explained to the patient and the intervention the patient can do without the help or service of the nurse. Prevention measures must be explained to lower the chances of the patients condition to get worse. Do all that we can to accelerate the patients healing process and to make sure they know enough about dengue to prevent it from happening again. As for us, we should know anemia causes, signs and symptoms, prevention and interventions. We should gain knowledge from this case presentation by learning the anatomy and physiology, pathophysiology, and the indications of the medications administered

II. NURSING HISTORY

PERSONAL DATA

Full name: M.M Home Address: Cembo Makati City Age: 35 y/o Sex: Female Race: Asian Civil Status: Married Birth date: October 8, 1976 Birth Place: Laguna Weight: 47 kg Height: 52 Religion: Roman Catholic Nationality: Filipino Languages Spoken: English and Filipino Language Understood: English and Filipino Date admitted: September 9, 2011 Time admitted: 15:30 pm / 3:30 pm Informant: Patient Percentage of reliability: 70%

CHIEF COMPLAINT:

The clients chief complaint is weakness, myalgia and athralgia

HISTORY OF PRESENT ILLNESS:

6 months PTA, the patient experienced difficulty of breathing for which she was hospitalized at St. Lukes with the assessment of Pneumonia with pleural infusion aspiration, the patient was given orulax and was advised pleural infusion aspiration however it was differed due to abnormal clotting time. 1 week PTA, the patient sought consult to our institution due to the persistence of symptoms and was eventually emitted for blood transfusion. The patient now comes for another blood transfusion hence this admission. The patient currently complains of generalized weakness, myalgia and athralgia.

PAST MEDICAL HISTORY

According to the patient, she has skin allergies. She had no previous hospitalization besides this and her recent hospitalization in St. Lukes Medical City. The patient didnt experience having serious health problems other than fever, colds and cough before.

Gordons Functional Health Pattern Health Perception-Health Management Pattern

Prior to Hospitalization The patient received her health in the state of good condition. She perceives health as wealth and she values her health a lot. She manages her health by practicing proper hygiene and eating nutritious foods.

During Hospitalization The patient did not see herself as a total ill person because she can do the things she usually does like doing errands. She rely her present condition with the help of the therapeutic personnel and by following the prescribed medications. The patient drinks a lot and eats a lot of vegetables.

Analysis and Interpretation The patients condition doesnt affect her health perception and due to her age, she has knowledge about her situation.

Nutritional- Metabolic Pattern

Elimination Pattern

The patient eats 3 times a day. According to the patient, she eats meat, fish and vegetables. She does not have any allergies on drugs. Her appetite is moderate and usually depends on the food being served. She didnt complain any difficulty in swallowing. The patient does not have any The patient can still urinate and difficulty on her elimination defecate by himself without any pattern. She usually urinates 5-6 assistance from her relatives. times a day without any difficulty. He didnt feel any pain in urination. The patient defecates once a day. The patient could perform activities The patient could perform the for her daily living. According to activities of her daily living. her, she often does her errands alone as a form of exercise for her. The patient has a close relationship with her family. She is also responsible person and knows all his duties and responsibilities.

The patient should drink a lot of water and eat meals regularly.

Her condition doesnt affect her elimination pattern.

Activity-Exercise Pattern

Her condition doesnt affect her activity-exercise pattern.

Role-Relationship Pattern

The patient had more to me to bond Her condition doesnt affect her with his family. She learned to role-relationship pattern. appreciate the beauty of having a family that gives strength and support no matter what.

LABORATORY DIAGNOSIS

LABORATORY : CBC DATE / 9/08/11

Components

Normal Range

Actual Findings

Analysis & I nterpretation

RBC Hemoglobin Hematocrit Differential Count Neutrophils Lymphocytes Eosinophil Platelet MCV( Mean Corpuscular volume ) MCH MCHC(Mean corpuscular hemoglobin concentration)

4.20-5.40 11.6-15.5 36.0-17.0

3.28 10.0 29.2

40-74 19-48 3-9 150,000-400,000 82-98m^3 28-33 32-38g/dL

61 34 3 9,000 89 31 34

The patient has a Low RBC that cause low available to bind oxygen The patient hemoglobi n decreased that would cause decrease the deliver of O2 through the circulation to body tissues Low platelet count

LABORATORY: CBC DATE: 9/10/11

Components y y y y y y y y y y y y y y WBC Lymphocytes Gran% Mid HGB RBC MCV MCH MCHC RDW-CV RDW PLT MPV PDW

Normal Range 4.0-10.0 0.8-4.0 50.0-70.0 10.0-15.0 110-150 4.20-5.40 82-95.0 fL 27.0-31. 320-360 32-38 35.0-56.0 11-15% 70-110 15.0-17.0 0.108-0.282

Actual Findings 4.6x10^q/l 1.0x10^q/l 0.6x10^q/l 12.9 76 2.36 85.4 27.4 322 34.5 45.0 14x10^q/l 98 16.3 0.113

Analysis & I nterpretation

The patient hemoglob in decreased that would cause decrease the deliver of O2 through the circulation to body tissues The patient has a Low RBC that cause low available to bind oxygen

NURSING RESPONSIBILITIES DURING DIFFERENT LABORATORY PROCEDURES Red Blood Cell Count Before Explain to the patient that RBC count is used to evaluate the number of RBCs and to detect possible blood disorders. Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when. Explain to the patient that she may experience slight discomfort from the needle puncture and the tourniquet. Inform the patient that she needs to restrict foods and fluids. During Ensure subdermal bleeding has stopped before removing pressure. After If a hematoma develops at the venipuncture site, apply warm soaks.

White Blood Cell Count Before Explain to the client that the WBC test is used to detect an infection and inflammation Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when. Inform the client that she should avoid strenuous exercise for 24 hours before the test. Also inform her that she should avoid eating heavy meal before the test. If the patient is treated for an infection, advise her that this test will be repeatedto monitor her progress. Notify the laboratory and physician of medications the patient is taking that may affect the test results: they may need to be restricted. During Ensure subdermal bleeding has stopped before removing pressure. After If hematoma develops at the venipuncture site, apply warm soaks. If the hematoma is large, monitor pulses distal the venipuncture site. Inform the client that she may resume her usual diet, activity, and medications discontinued before the test as ordered. A patient with severe leucopenia, they have little or no resistance to infection and requires protective isolation.

HEMOGLOBIN Before Explain to the patient that the hbg test is used to detect anemia or polycythemia or to assess his response to treatment. Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when. Explain to the patient that she may experience slight discomfort from the needle puncture and the tourniquet. During Ensure subdermal bleeding has stopped before removing pressure. After If hematoma develops at the venipuncture site, apply warm soaks.

HEMATOCRIT Before Explain to the patient that RBC count is used to evaluate the number of RBCs and to detect possible blood disorders. Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when. Explain to the patient that she may experience slight discomfort from the needle puncture and the tourniquet. Inform the patient that she needs to restrict foods and fluids. During Ensure subdermal bleeding has stopped before removing pressure. After If hematoma develops at the venipuncture site, apply warm soaks.

III. ANATOMY AND PHYSIOLOGY

ANEMIA ANATOMY

To better understand anemia, it helps to understand the anatomy and composition of blood.

BLOOD
is a circulating tissue that carries nourishment and oxygen to the cells and tissue. Blood is composed of 3 cell types that are suspended in a protein-rich fluid called plasma:
1. 2. 3.

Red blood cells (erythrocytes) White blood cells (leukocytes) Platelets (thrombocytes)

RED BLOOD CELLS

contain hemoglobin, which is the molecule that carries oxygen to the tissues. A decrease in the number of red blood cells reduces the amount of oxygen that can be carried by the bloodstream. This can result in poor exercise tolerance and fatigue.

Normal ranges for the total number of red blood cells in adults are: 1. 4.6-6.2 million per cubic millimeter (males) 2. 4.2-5.4 million per cubic millimeter (females)

WHITE BLOOD CELLS

are an important part of the immune system. There are several types of white cells (leukocytes) present in the blood. These cells mainly function to fight infection. Normal total ranges for white blood cells are: 4,500 11,000 (per cubic millimeter). Slightly higher counts are normal in children.

PLATELETS
are the smallest of the blood cells. They play an essential role in the blood clotting system. A platelet count: 150,000-400,000 per cubic millimeter is considered a normal range.

PHYSIOLOGY OF IRON DEFICIENCY

Iron is involved in multiple critical body functions. The predominant use of iron is for the creation of heme groups that are incorporated into hemoglobin and myoglobin. Iron is additionally involved in the production of cytochromes and other enzymes (Segel, Hirsh & Feig, 2002; Wu et al., 2002). Immediately bioavailable iron is bound in the bloodstream to a specific carrier protein called transferrin. Iron in excess of immediate needs will be stored in the liver, spleen, and bone marrow as ferritin (Wu et al., 2002).

THREE STAGES OF IRON DEFICIENCY

Initial stage iron depletion, occurs when stored iron in the bone marrow diminishes due to insufficient supply of iron. Second stage iron deficiency, during which storage levels become substantially reduced and hemoglobin synthesis begins to be affected. Final stage iron deficiency anemia, develops when iron stores are insufficient to maintain hemoglobin production.

This advanced stage will be reflected in low hemoglobin and hematocrit values. It is important for the practitioner to understand that by the time low hemoglobin or hematocrit levels are discovered on routine screening, the iron stores have been significantly depleted and will need replenishment. In order to prevent iron deficiency infants and children need to absorb approximately 0.8 milligrams of dietary iron per day to support normal growth and replace normal physiological losses.

IV. PATHOPHYSIOLOGY

Predisposing Risk Factors Lifestyle Choices Gender

Precipitating Risk Factors Autoimmune Blood Disorders

Autoimmunity

Activation of Cytotoxic T Cells

Targets own marrow stem cells

Depletion and damage of hematopoietic stem cells Clinical Manifestations: Lethargy Fatigue Reduced blood in fingers and toes Skin discoloration Vitiligo

Reduction in bone marrow progenitors

Deficiency in the rare capacity of hematopoietic tissue

Reticular Fibers

Connective Tissue Disease

Depletion and damage of Hematopoietic stem cells

Depression or cessation of activity of all blood producing elements

Pancytopenia

Clinical Manifestations: Fatigue Shortness of Breath Skin Rash Dizziness Headache Lightheadedness Weakness Sleeping problem

Anemia

Medical Treatment: Blood transfusion Antibiotics, antiviral

V. COURSE IN A WARD

SEPTEMBER 9, 2011

1700H Admitted a 35 y/o female, per wheelchair accompanied by ER staff - Has a chief complaint of difficulty of breathing - Ongoing IV PNSSiL at 820cc level regulated and infusing well - Ushered to bed safely & comfortably - Oriented to ward rules & hospital regulations - Ward officer informed of this admission

1700H Encouraged adequate rest, instructed to take iron rich foods - Lab work-up - For transfusion of 6 units platelet concentrated or 1 unit platelet pheresis type specific - For CBC with PC post BT 1925H For transfusion of 6 units platelet concentrated or 1 unit platelet pheresis type specific after blood cross matching - Blood cross matching done - Vital signs are taken and recorded as follows: TEMP 37.6 C, PR 80, RR 22, BP 90/60

- Blood transfusion started at 1 u platelet concentrated type O positive with serial number 2011-036937 - Monitored and observed for any untoward manipulations 1940H above 1 unit consumed, 2nd unit with serial # 2011-036938 started 2000H continued monitoring, 2nd unit consumed, 3rd unit hooked with serial number 2011-036954 2015H 4th unit with serial number 2011-038064 hooked

2025H 5th unit with serial number 2011-038077 hooked 2040H 6th unit with serial number 2011-036580 hooked 2100H BT complete - Vital signs are taken and recorded as follows: TEMP 36.4 C, PR 74, RR 26, BP 100/70 - Watched out for DOB, wheezes, fever, edema, and anaphylactic reaction

2110H For CBC with OPC post BT after 6 units due at 0245H - Advised to eat iron rich foods - Adequate bed rest provided - Monitored for any untoward manipulations - Attended 2000H with Hgb count of 10.0 g/dL - Encouraged adequate rest - Advised to eat iron rich foods 2000H with platelet count of 9000/mm - Above IVF maintained and regulated - Watched out for any untoward signs & symptoms

2300H For CBC with OPC post BT after 6 units due at 0245H done - Result referred to P61 Manuel with new orders made & carried out 0200H For repeat CBC with OPC new done - Results in and referred to P61 Manuel

SEPTEMBER 10, 2011

Time 0700H Focus Anemia Management -Advised patient to eat iron rich foods -Adequate bed rest provided -Needs are attended & monitored for any untoward manipulations Evaluation/R esponse Patient reveals an increase activity tolerance Nursing Responsibilities Elevate the head of bed as tolerated to enhance lung expansion to maximize oxygenation for cellular uptake; Monitor laboratory studies especially platelet count.

VI. DRUG STUDY

Name of Drug

Classification

DRF

SE & AE

Control Precautions

Nursing Responsibilities

Paracetamol

Pain Reliever Pyretic

325 to 650mg PO Q4 to Q6 or 1g PO TID or QID, PRN *maximum 4g daily Given to patient: 500mg 1tab PO Q24 PRN for fever during BT

Hemaologic: hemolytic anemia, neutropenia, leucopenia, pancytopenia Hepatic: jaundice Metabolic: hypoglycemia Skin: rash, urticaria

> Contraindicated in patients hypersensitive drugs. > Use cautiously in patients with long term alcohol use because therapeutic doses cause hepatotoxicity in theses patients.

1. Make sure patient has completely swallowed the medication. 2. Advice patient that drug is only for short-term use and to consult prescriber if giving to children for longer than 5 days or adults for longer than 10 days. 3. Advise patient or caregiver that many OTC products contain acetaminophen; be aware when calculating total daily dose. 4. Tell patient not to use for marked fever (higher than 103.1 F or 39.5 C), fever persisting longer than 3 days, or recurrent fever unless directed by prescriber.

Name of Drug

Classification

DRF

SE & AE

Control Precautions

Nursing Responsibilities

Benadryl

Antihistamine

Sedation/Slee p: Adult, 25 to 50mg PO HS Nonproductiv e cough: (syrup) 25mg PO Q4 to Q6

CNS: drowsiness, confusion, vertigo, dizziness, sleepiness CV: palpitations, hypotension, tachycardia EENT: blurred vision, nasal congestion GI: nausea, dry mouth, diarrhea, constipation GU: urine retention, urinary frequency

> Avoid use in patients taking MAO inhibitors. > Use with caution in patients with prostatic hyperplasia, asthma, COPD, increased intraocular pressure

1. Stop drug 4 days before diagnostic skin testing because antihistamines can prevent, reduce, or mask positive skin test response. 2. Alternate injection sites to prevent irritation, Give I.M. injection deep into large muscle. 3. Don t confuse diphenhydramine with dimenhydrinate; don t confuse Benadryl with Bentyl, or benazepril.

Name of Drug

Classification

DRF

SE & AE

Control Precautions

Nursing Responsibilities

Chlorphena mine Maleate

Antihistamine

Adults and Children 12 years and older: 4mg PO Q4 to Q6 or 8 to 12mg PO Q8 to Q12.

CNS: drowsiness, confusion, vertigo, dizziness, sleepiness CV: hypotension, tachycardia GI: nausea, dry mouth, diarrhea, constipation GU: urine retention, urinary frequency

> Use cautiously in elderly patients and those with hyperthyroidism.

1. Warn patient to avoid alcoholic beverages. 2. Tell patient that coffee and tea may reduce drowsiness. 3. Inform Patient sugar free gum and hard candies may relieve dry moth.

VII. MEDICAL AND SURGICAL MANAGEMENT

A blood transfusion is a safe, common procedure in which blood is given to you through an intravenous (IV) line in one of your blood vessels. Blood transfusions are done to replace blood lost during surgery or due to a serious injury. A transfusion also may be done if your body can't make blood properly because of an illness. During a blood transfusion, a small needle is used to insert an IV line into one of your blood vessels. Through this line, you receive healthy blood. The procedure usually takes 1 to 4 hours, depending on how much blood you need.

Important Information About Blood The heart pumps blood through a network of arteries and veins throughout the body. Blood has many vital jobs. It carries oxygen and other nutrients to your body's organs and tissues. Having a healthy supply of blood is important to your overall health. Blood is made up of various parts, including red blood cells, white blood cells, platelets (PLATE-lets), and plasma. Blood is transfused either as whole blood (with all its parts) or, more often, as individual parts.

To prepare blood for a transfusion, some blood banks remove white blood cells. This process is called white cell or leukocyte (LU-ko-site) reduction. Although rare, some people are allergic to white blood cells in donated blood. Removing these cells makes allergic reactions less likely. Not all transfusions use blood donated from a stranger. What does blood do? When a donor gives blood, special equipment is used to separate the donation into a number of different specific blood components, including:

red blood cells, which transport oxygen around the body and are used to treat anemia platelets these help to stop the flow of blood when a person is cut or injured; platelet transfusions can be used to prevent excessive bleeding in certain groups of people, such as those who are having chemotherapy treatment (powerful medication to treat cancers) plasma a liquid that makes up most of the volume of blood; plasma contains many nutrients needed by the bodys cells, as well as proteins that help the blood to clot if a patient is bleeding. white blood cells, which are used to fight infection

Safety In the UK and other Western countries, there are very rigorous regulations regarding blood donations and blood transfusions. The aim of the regulations is to minimize the risk of a person being given blood that's been contaminated with a virus, such as hepatitis C, or receiving blood from a blood group that's unsuitable for them. Compared to other everyday risks, the likelihood of getting an infection from a blood transfusion is very low. All blood donors are unpaid volunteers. They're very carefully selected and tested to make sure that the blood they donate is as safe as possible.

You must be correctly identified to make sure that you get the right blood transfusion. Wearing an identification band with your correct details is essential. You will be asked to state your full name and date of birth, and the details on your identification band will be checked before each bag of blood is given. Because of inherent risks, transfusion should be prescribed only for conditions for which there is no other treatment.

VIII. NURSING CARE PLAN

Nursing Intervention Analysis of intervention Related to imbalance Short term: Independent: Influences choice of between oxygen After 8 hours of Assess patient to intervention or Subjective: Activity intolerance "Nanghihina ako " as related to imbalance supply(delivery) and nursing intervention perform activities of needed assistance. demand the patient will be daily living. To alleviate strain verbalized by the between oxygen able to report Recommend quiet on the heart and patient. supply(delivery) and lungs and enhances possibly evidenced measurable increase environment Objective: demand. by report of fatigue in activity tolerance. atmosphere, bed rest rest to lower body's *Fatigue oxygen requirements. and weakness Long term: if indicated. *Weakness After 3 days of Elevate the head of Enhances lung *Pale decreased nursing intervention the bed as tolerated. expansion to *Greater need sleep exercise/activity the patient will be Provide assistance maximize and rest oxygenation for level able to demonstrate with activities or *V/S taken as cellular uptake. an increase in ambulation as follow: To provide self related to activity activity tolerance necessary. BP: 90/60 mmHg esteem. intolerance including activities Dependent: *Medications help to of daily living. Administer increase blood medication as pressure. prescribed by the To replace blood physician. loss. Blood transfusion To maintain as order by the hydration status. doctor. To identifies RBC Regulate IV fluid components that may Collaborative: affect the transport of Monitor for oxygen and treatment laboratory result. needs or response to Assess therapy. cardiopulmonary response to physical To note activity, including v/s progression/ accelerating degree before, during and of fatigue. after activity.

Cues

Nursing Diagnosis

Analysis

Objectives

Evaluation After 8 hours of nursing intervention the patient was able to report measurable increase in activity tolerance. After 3 days of nursing intervention the patient was able to demonstrated an increased in activity tolerance

Cues
Subjective: "Wala akong ganang kumain "as verbalized by the patient. Objective: yBMI is <20% or more under ideal weight yWeakness Poor muscle tone yExcessive loss of hair. yCapillary fragility

Nursing Diagnosis
Risk for nutrition imbalanced less than body requirements.

Analysis
Related to failure to ingestion/ or absorb nutrients necessary for formation of normal RBCs possibly evidenced by weight loss decreased triceps skin fold measurement, changes in gums/oral Imbalanced Nutrition.

Objectives
Short term: After 8 hours of nursing intervention client will be able to verbalized understanding of causative factor when known and necessary intervention. Long term: After a month of nursing intervention the Patient will be able to gain weight.

Nursing intervention
Independent: y Ascertain understanding of patients needs. y Determine psychological factors, culture or religious desires/influences y Encourage patient to choose foods that are appealing. y Prevent unpleasant odors/sights. Dependent: y Administer medication as prescribed by the physician. Collaborative: y Consult to dietitian team as indicated.

Analysis of intervention

Evaluation

After 8 hours of nursing y To determine what information intervention to provide client. client was able to y That may affect verbalized understanding of food choices. causative factors. y To stimulate After a month of appetite. nursing y May have a negative effect on intervention the patient was able appetite/eating. y To help regain to gain weight. weight. y To implement interdisciplinary team management.

IX. HEALTH TEACHING

Medications Instruct patient to take medications (Chloremidine Maleate, Paracetamol and Benadryl) in right time. Exercise Instruct the patient to avoid strenuous activities (to prevent having fatigue). Advice patient to do exercises that avoids in having trauma and dehydration

Treatment Administer Blood transfusion as prescribed if the hemoglobin is less than 7.0 after proper cross matching. Administer iron supplements, folic acid as prescribed. Administer Oxygen to increase tissue perfusion. Maintain adequate hydration either by Intravenous infusion if pt. is in the hospital or increase fluid intake if pt is at home.

Hygiene Proper hygiene, Warm bath before going to bed to get proper sleep . Clean beddings will create a feeling of goodness and well being.

Out-patient The patient should understand her/his sickness and must follow the teachings given by the nurse. Follow up with the Doctor is also important and patient should not miss his/her appointment. Religiously taking the prescribed medication is vital.

Diet Instruct patient to eat High in calories/ high in protein / Iron rich foods is important Like ( liver. meats. egg yolks. dark green leafy vegetables. bread and cereals. kidney beans. raisins) Safety and security Instruct patient to do proper hygiene to avoid infection and by not exposing to crowded areas, have a bed rest. Avoid physical/mental and emotional stress. Refer to the physician for any advices.

THANK YOU! FROM GROUP 2 OF N211