Republic of the PhilippinesNUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

College of NursingCity of Cabanatuan

HYPOPROLIFERATIVE ANEMIA PROBABLYPERNICIOUS

VITAMIN B12 DEFICIENCY FOLIC ACID DEFICIENCY

IRON DEFICENCY HYPOTENSIONMAJOR DEPRESSIVE DISORDERSEIZURE DISORDER

By:

Nicanor M. Domingo IIIGROUP 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 AbsentUnexpected weight loss over 10 pounds AbsentBleeds Absent

EYES Do you wear glasses or contact lenses? Absent

Eye problems AbsentEye discharge, injury, infection Absent

EARS, NOSE THROAT & MOUTH Loss of hearing or ringing-tinnitus AbsentNasal allergies AbsentNose bleeds (epistaxis) AbsentSinus disease AbsentHoarseness or sore throat AbsentSleep apnea AbsentBleeding gums AbsentDo you have dental bridges or dentures AbsentToothache Absent

RESPIRATORY Chronic cough (more than one month) AbsentDaily sputum production AbsentShortness of breath AbsentSpitting/coughing up blood (hemoptysis) AbsentWheezing Absent

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

GASTROINTESTINAL Excessive passing of gas (/burps) PresentRecent changes in bowel habits AbsentConstipation AbsentRectal bleeding or blood in stools AbsentBlack stools (melena) AbsentJaundice, liver disease Absent

GENITOURINARY Blood in urine (hematuria) AbsentDifficulty 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 AbsentSkin rashes or itching (please circle which) AbsentBreast lumps AbsentBreast pain Absent

ENDOCRINE Excessive hunger AbsentExcessive thirst AbsentExcessive urination Absent

NEUROLOGICAL Confusion AbsentDizziness PresentFrequent headaches AbsentMemory loss AbsentNumbness or tingling sensation Present, both lower extremities

measured approximately 5 inches below the patella through the toes

MUSCULOSKELETAL Back pain AbsentBroken Bones/fractures (where?) AbsentMuscle pain or cramps (where?) AbsentMuscle weakness (where?) Present, both lower extremities

ALLERGIC/IMMUNOLOGIC/INFECTIOUS DISEASES

Food allergies Absent

PSYCHIATRIC Alcohol abuse AbsentAnxiety/nervousness PresentDepression Present Do you have panic attacks? AbsentDo you have suicidal thoughts or plans? Absent/but had a suicidal attempt Drug abuse AbsentUnable 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

AnemiaHypotension

To consider MAJOR DEPRESSIVE BEHAVIOR

Worthlessness AbsentSelf hatred Absent/present when committed suicide Poor concentration PresentReduced sex drive Present as claimed by motherFatigue PresentDigestive problems PresentLethargic PresentAgitated PresentSelf-harm or suicidal attempts AbsentForgetfulness PresentPsychomotor 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.

11

Family History of ANEMIA

DNA mutation Folic Acid Deficiency

Change in bone marrow function

Altered Pluripotential stem cells

Altered lymphoid stem cellsAlteration in myeloid stem cells/erythroid marrow

RBC Production

Change in production of lymphocytes

Hgb

Nitrous oxide

Blood Pressure

Blood perfusion to organs/organ systems

Hematocrit

Brittle hair

Pallor

dyspnea

O2 in cells and tissues

Restlessness Sleep-pattern disturbance

O2 supply to CNS

Muscle weakness

Loss of balance

Fatigue

Prolonged borderline Hgb

Cardiac decompression on L ventricle

Ventricular hypertrophy

Asymmetric lung expansion L

4th heart sound (S4)

Blood Viscosity

Blood Pressure

Cyanosis

Mother and aunt (X-linked)

I.D.A

Altered folate absorption

PteGlu7 hydrolyzed to pterylglutamate

Folic acid formation

enterocytic action

Reduction to CH3H4PteGlu

products pass across basolateral membrane

PATHOPHYSIOLOGY OF HYPOPROLIFERATIVE ANEMIA

(Folic Acid Deficiency – IDA, Hypotension)

Weakness

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

DNA mutation

Megaloblast RBC

RBC production

Methionine/MTR

Altered production of cathecholamines; neurotransmitters

Neurologic problems

DepressionMood changes

Peripheral neuritis

Tingling sensation on both lower

extremities/Paresthesia

PATHOPHYSIOLOGY OF PERNICIOUS ANEMIA (Vitamin B12 DEFICIENCY)

Hct Hgb

14. DEFINITIVE MEDICAL DIAGNOSIS

HYPOPROLIFERATIVE ANEMIA PROBABLY PERNICIOUS

VITAMIN B12 DEFICIENCY FOLIC ACID DEFICIENCY

IRON DEFICENCY HYPOTENSIONMAJOR DEPRESSIVE DISORDERSEIZURE 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 (PERNICIOUS AND FOLIC ACID D.A.)

SIGNS AND SYMPTOMS MANIFESTED BY PATIENT

Smooth sore, red tongue AbsentMild diarrhea Absent

Pale PresentConfused Absent

Paresthesia PresentDifficulty in maintaining gait Present

Weakness PresentFatigue Present

Irritability PresentMood swings Present

Asymmetrical chest expansion PresentDyspnea in exertion Absent

Presence of S4 upon auscultation PresentRapidly bounding pulse Absent

Weight loss Absent *Not seen Burps*Not seen Weak pulse

SIGNS AND SYMPTOMS - REFERENCE MATERIALS (IRON DEFICIENCY ANEMIA)

SIGNS AND SYMPTOMS MANIFESTED BY PATIENT

Pallor PresentFatigue Present

Pica Absent Alopecia Absent

Lightheadedness AbsentConstipation Absent

Fainting AbsentMissed menstrual cycle Absent

Glosstis PresentKoilonychia Absent

Pruritus AbsentLoss 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.

VS.

VS.

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 1st – physiological need

Fatigue 1st – physiological need

Sleep Pattern Disturbance 1st – physiological need

Deficient knowledge 1st – physiological need

Altered thought process 1st – physiological need

Self-care deficit 2nd – safety need

Anxiety 3rd – love and belongingness need

High Risk for injury

Risk for suicide

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.