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8/6/2019 Case Presentation Group 8 . Edited
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Microscopicpolyangiitis (MPA) is a
systemic pauci-immune
necrotizing vasculitisthat affects mainly
small vessels.
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Facts:
MPA is a rare type of
autoimmune disease.
Incidence rate is
approximately 1:100,000 with
the slight predominance inmen.
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The average age onset is
50 years, and is very rare
in children.
The most common
antineutrophil cytoplasmic
autoantibodies (ANCA)-associated small vessel
vasculitis
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What is ANCA?
Antineutrophil cytoplasmic
autoantibodies are antibodies
directed against the bodys
neutrophils and monocytes.
Two types of these
autoantibodies are identified
that are present in patients
with this disease.
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P-ANCA(perinuclear staining)
-70% of patients with
MPA.
C-ANCA
(cytoplasmic
staining) -30% of the
cases.
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Clients name: D.B.
14-year old, Female
Filipino, RomanCatholic
3rd year High Schoolstudent
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She had an active high
school social life withno history of sexual.
activity or drug abuse.
She was born and is
residing at Las PinasCity with her mother
and her sister.
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Patient DB had skin
asthma when she wasfive years old and was
ruled out before she
reached twelve.
No other past illnesses
were cited.
Immunization status:
complete immunization
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General Appearance
Upon assessment, the patient isweak looking but with no signs
of cardio-respiratory distress.
Admission Vital Signs
BP: 130/80 mmHg PR: 80 bpm
RR: 20cpm Temp: 36.5 C
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Withedematous
facial feature
and
periorbital
edema.
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With presence ofdandruff and
falling of hair
uponobservation.
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The patient
reported episodeof red spots
before her eyes
prior to her
admission to San
Juan De Dios
Hospital.
With pale
conjunctiva.
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Lips appeared
dry and scaly.
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Skin
Dry and slightly
pale.
With presence
of ecchymosis in
both arms.
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NAILS
With visible
splinter
hemorrhage
.
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NECK
With right
Intrajugularcatheter
access.
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Cardiovascular
Hypertensive.
Noted of taking anti-
hypertensive drugs.
Upon assessment,
the patients blood
pressure: 130/80
mmHg.
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With
ecchymosis onboth arms.
Visible striae
noted on
upper andlower limbs.
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(+) bipedal edema
upon assessment.
Upon palpation there
is no complain of painand discomfort.
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Breast/Axilla
with striae in both side
of the axilla.
Genitals
Appeared to be
edematous.
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HEMATOLOGY09-March-2011
Results
12-March-2011
Results
13-March-2011
Results
PT patient
PT control
PT INR
PT activity
APTT
APTT control
10 - 14 sec.
11 - 14 sec.
0 - 1.4
70 - 130%
25 - 39
25 - 39
14.1 sec.
12.5 sec.
1.16
83%
High 54.6
34.6
13.3 sec.
12.5 sec.
1.08 sec.
91%
34.6
10.6 sec.
12.5 sec.
0.81 sec.
130%
27.3
34.6
HEMATOLOGY Normal Range
09-March-2011
Results
12-March-2011
Results
13-March-2011
Results
PT patient 10 - 14 sec. 14.1 sec. 13.3 sec. 10.6 sec.
PT control 11 - 14 sec. 12.5 sec. 12.5 sec. 12.5 sec.
PT INR 0 - 1.4 sec. 1.16 sec. 1.08 sec. 0.81 sec.
PT activity 70 - 130% 83% 91% 130%
APTT 25 - 39High 54.6
27.3
APTT
control 25 - 39 34.6 34.6 34.6
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HEMATOLOGYNORMAL
RANGE
11-March-2011
Results
12-March-2011
Results
16-March-2011
Results
Leukocytes
5.0 - 10.0 x
109/L High 11.95 High 10.10 High 11.10
Erythrocytes 4.6 - 6.2 x1012/L
Low 2.80 Low 3.22 Low 3.95
Hemoglobin 12 - 17 g/dL Low 9.1 g/dL Low 8.9 g/dL 12.8 g/dL
Hematocrit37 - 47 %
Low 27.39% Low 27% 37.7%
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Thrombocytes 150 450 x109/L
160 x 109/L 175 x 109/L Low 146 x
109/L
Neutrophils 50 70 % High 84.3% High 78.1%
Lymphocytes 20 40 % Low 9.3% Low 10% Low 12%
Monocytes0 7 %
4.9% 5.9% High 8.4%
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Eosinophils 0 5 % 1% 1%
Basophils 0 1 % 0.5% 0.5%
Granulocyte 0 1 % High 83.5%
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CLINICAL
CHEMISTRY
NORMAL
RANGE
12-March-2011
Results
15-March-2011
Results
Blood Urea
Nitrogen 7 17 mg/dL High 95 High 69
Creatinine 0.52 1.04
mg/dLHigh 4.2 High 2.25
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UrinalysisMarch 11, 2011
PHYSICAL CHEMICAL
Color: YELLOWAlbumin: +++
Sugar: TRACE
Reaction: 7.5
Transparency: SLIGHTLY TURBID
Quantity: 25 mL
Specific Gravity: 1.010
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Manifestation from the book Actual ManifestationCONSTITUTIONAL SYMPTOMS
Fever & myalgiaNo
Malaise, fatigue Yes
Weight loss No (weight gain due to generalizededema)
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Manifestation from the book Actual Manifestation
Skin manifestations
SplinterHemorrhage
Yes
Skin rash, palpable
purpura, skin ulcerationsNecrosis and
gangrene/Necrotizing nodules
No
Pulmonary Manifestation
Hemoptysis, Dysnea, cough,
pulmonary rales,respiratoryory distress
No
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Hypertension Yes
Signs of cardiac failure,
myocardial infarction No
Gastrointestinal Involvement
GI bleeding, melena Yes
Bowel
ischemia/perforation/pancrea
titis
No
Cardiovascular
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Nervous System Manifestation
Seizures/ /brain swelling Yes
tingling sensation No
Renal Involvement
Uremia, generalized edema,
proteinuria, red blood cells in the
urine
Yes
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CAUSE:
IdiopathicPredisposing Factor
Gender/Sex: Men
Autoimmune Infection Malignancy Drug Therapy
Triggers production on p-ANCA
(antineutrophil cytoplasmic
antibodies)
Large antibodies bind to
neutrophil
Activate immune complexes
Deposits in small vessel walls
Increase Vascular permeability
Release of vasoactive amines and mast cells
Neutrophil
Releases
toxins
Causes a
release of
lytic
enzyme
FromWBC
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Endothelial Injury
INFLAMMATION
Of small blood vessels
Damage
peripheralnerves Nerve
InfarctionNerves are
deprived of
nutrients
Damage to vessels
of glumeruli
Impairs renal function:
PROTEINURIAHEMATURIA
FATIGUE
SWELLINGOF LEGS
EDEMA
ANEMIA
UREMIA
Constitution
al
Symptoms:
FEVER
WEIGHT
LOSS
MALAISE
Skin Lesions:
PALPABLE
PURPURA
NECROSIS
GANGRENE
Cardiovascular
Signs/symptoms
HYPERTENSION
CHEST PAINCARDIAC
FAILURE
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DRUG NAME
CYCLOPHOSPHAMIDE
50mg/tab 1 tab POODCLASSIFICATION
Antineoplastic or cytotoxic
DRUG ACT
IO
NCyclophosphamide first is converted by the liver into
two chemicals, acrolein and phosphoramide.
Acrolein and phosphoramide are the active
compounds, and they slow the growth of cancer cellsby interfering with the actions of deoxyribonucleic
acid (DNA) within the cancerous cells. It is, therefore,
referred to as a cytotoxic drug.
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Indication
Treatment of vasculitis
DRUG OF CHOICE for the treatment of MPA.
Cyclophosphamide has a significant
ability to suppress the immune system.
Thus, the medicine is very effective in thetreatment of immunologicallymediated
diseases, including some forms of vasculitis.
i C id i
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Nursing Consideration
1. Check for allergic history2. Periodically check renal function because the drug
is toxic for the kidneys
3. Teach patient to drink plenty of fluids because thisdrug can damage kidneys and bladder
4. The drug is immunosuppressive, monitor patientfor signs of infection
5. Causes depletion of number of blood cells, monitor
patients blood test
DRUG NAME
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DRUG NAME
PREDNISONE30mg 1 tab, 2 tabs post breakfast
CLASSIFICATION:
Corticosteroid (Glucocorticoid)
DRUG ACTIONSuppresses the immune system and
inflammation. This synthetic corticosteroid
mimic the action of cortisol (hydrocortisone),the naturally-occurring corticosteroid
produced in the body by the adrenal glands.
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IndicationDRUG OF CHOICE for treatment of vasculitis in combination
with cyclophosphamide.
Nursing Consideration
1. Check and record BP during dose stabilization
period at least 2 times daily. Report an
ascending pattern.2. Be alert to possibility of masked infection and delayed
healing.3. Obtain fasting blood glucose, serum electrolytes, and
routine laboratory studies at regular intervals during
long-term steroid therapy.
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4. Be alert to signs of hypocalcemia.
5. Monitor bone density.
6. Be aware that long-term
corticosteroid therapy is notimmediately interrupted. Tapering is
done.
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DRUG NAME
METHYLPREDNISOLONE1g in 50mL D5W IV infusion
Single orderCLASSIFICATION:
Corticosteroid
(Glucocorticoid)
DRUG ACTIONMethylprednisolone is a synthetic (man-made)
corticosteroid. It mimics the action of cortisol
(hydrocortisone), the naturally-occurringcorticosteroid produced in the body by the adrenal
glands. Corticosteroids block inflammation and are
used in a wide variety of inflammatory diseases.
I di ti
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Indication
For treating inflammatory conditions (vacultitis).
Nursing Consideration
1. Watch for allergic reactions
2. Check the electrolyte and glucose reports
for early indications of electrolyte imbalanceor hyperglycemia
3. Keep accurate records of intake and output,
daily weights, vital signs4. Ask patients about any signs of infection
(sore throat, fever, malaise, nausea and
vomiting)
Oth D
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FUROSEMIDE 60mg 1 1/2tab q8 hrs
Loop diuretics Treatment ofedema
CLONIDINE 150mg /tab
1 tab BID
Central acting alpha
adrenergic
antihypertensivedrug
Hypertension
AMLODIPINE
10mg/tab
OD
Calcium Channel
Blocker
Hypertension
Used to prevent
angina
TELMISARTAN
40mg/tab 1
tab OD
Angiotensin II
receptor
antagonist
Hypertension
Other Dugs
NAME OF DRUG DOSAGE/FREQUENCY
CLASSIFICATION INDICATION
NAMEOF DRUG DOSAGE/FREQUENCY CLASSIFICATION INDICATION
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ENALAPRIL
(renital)
10mg /tab,
1/2 tab OD
Angiotensin
converting
enzyme (ACE)inhibitors.
Hypertension
CITICOLINE
500mg 1 cap, 1
capOD
ODCentral nervous
system stimulantPatient is noted to have
hypertensive
encepalopathy
CALCITRIOL1 tab 0.25mg
ODSynthetic
Vitamin D
Use to treat and
prevent low levels of
calcium in the bloodof patients with
damaged kidneys or
with patients in
hemodialysis
NAMEOF DRUG / CLASSIFICATION INDICATION
NAMEOF DRUG DOSAGE/FREQUENCY CLASSIFICATION INDICATION
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CALCIUM
CARBONATE1 tab 500mg
TID
Mineral electrolyte
replacement
supplements
Hyperphosphataemia in
chronic renal failure
FERROUS
SULFATE
325mg 1 tab post
lunch, 2 tabs
post dinner
Iron preparationUsed to treat and prevent
iron deficiency anemia
COTRIMOXAZOLE800mg /100mg
tab/tablet forte,
1 tab (every
Sunday, Tuesday
and Thursday)
Sulfamethoxazol
e and
trimethoprim
Prophylaxis for
infection
OMEPRAZOLE40 mg IV OD
Proton pump
inhibitor
Short-term
treatment of
active, benign
gastric ulcer
CLASSIFICATION INDICATION
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Problem/ SignificantI t ti E l ti
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NotationsInterventions Evaluation
Objective Data:
broken skin,traumatized tissue
Problem/ Significant
NotationsInterventions Evaluation
Objective Data:
broken skin,traumatizedtissue
presence of right
intrajugular
catheter access
needle pricks onthe arms from
invasive
procedures
Intrajugular access
cleaned and dressed
aseptically
Proper use of PPE
for staff and visitors
Problem/ SignificantI t ti E l ti
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NotationsInterventions Evaluation
Problem/ Significant
NotationsInterventions Evaluation
Sterile technique
for all invasive
procedure. Suggested to place
in protective
isolation.
Maintained ortaught asepsis for
dressing changes
and wound care.
Problem/ Significant
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Problem/ Significant
NotationsInterventions Evaluation
Immunosupressionrelated to
immunosuppressive
drugs
Cyclophosphamide
Prednisone
Proper handhygiene by all care
givers
Offer mask or
tissue to
client/visitors who
are
coughing,sneezing
to limit exposure
Follows medication
regimen
No noted signs of
infection (feveror pus on lesions)
Problem/ Significant
Maintained IV flow rate
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Problem/ Significant
NotationsInterventions Evaluation
Objective Data:y Hematemesis
(fresh blood,
scanty amount)
y Melena
(semi-formed,
moderate in
amountTarry stool)
y Auscultate BP,calculate
pulse pressure every 4
hours
y O
bserve for color of allexcretion to evaluate
for bleeding
Have a written record
of fluid intake, urine
output and daily weight.
Maintained IV flow rate
No bleeding
episodes noted
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Problem/ Significant
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Problem/ Significant
NotationsInterventions Evaluation
Objective Data:
y Blood Pressure: 150/90
mmHg
y
Generalized edema
y Pitting edema
grade 2
y Facial edema
Monitoring of vital signs q1
especially blood pressure
y Record an accurate intake and
output
Administer medication
as prescribed ( Diuretics,
antihypertensive)
Protected edematous
skin from injury
Fluid restriction of 1L
per day as ordered
Blood pressure :
110/70 mmHg
Patient still
edematous
Cautious in eatingand drinking
Problem/ Significant
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Problem/ Significant
NotationsInterventions Evaluation
Objective Data:
(+) Weakness(+) Fatigue
(+) Muscle
weakness
(+) Fatigue whenmoving
Assessed level of
activity intoleranceand degree of fatigue
Encouraged
alternating periods ofrest and ambulation
Encouraged and
assisted with gradualincreasing of periods
of exercises
Patient reported
no signs of
decrease in fatigue
and body malaise
Still requires full
assistance inmoving
Exhibited
increased interestin activities and
event
Problem/ Significanti l i
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NotationsInterventions Evaluation
Turned side to side
every 2 hours
Health teachings about
the importance of
ambulation
ROM exercises done
Collaborated withphysical therapist for
treatment plans and
interventions
Increases exercises
within physical
limits
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