BUENAS MORNIE!

ANEMIA

• PERNICIOUS

VITAMIN B12 DEFICIENCY

• FOLIC ACID DEFICIENCY

• IRON DEFICENCY

HYPOTENSION

• MAJOR DEPRESSIVE DISORDER

• SEIZURE DISORDER

• Clients Name/Initials: AMD

• Age: 32 years old

• Gender: Female

• Hospital Admitted:

Eduardo L. Joson Memorial Hospital

• Date Admitted: 01-19-09

Chief Complaint on Admission:Hypotension accompanied by severe body

weakness

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.

Review of Systems• Fatigue/loss of energy

• Abnormally slow heart rate (bradycardia) Present, (56-67 bpm, adynamic)

• Excessive passing of gas (burps)

• Hair or nails (please describe) more pale as observed by the patient’s mother, also brittle than normal nails (as observed)

• Dizziness

• Numbness or tingling sensationboth lower extremities measured approximately 5 inches below the patella through the toes

• Muscle weakness (where?) Present, both lower extremities

• Anxiety/nervousness

• Depression

• Do you have suicidal thoughts or plans? Absent/but had a suicidal attempt

Past and Current Medical Condition

• has seizure episodes – (has had her last attack last 2006)

• Gabapentin (Neurontin)

• Mental disorder (Major Depressive Disorder) which happens to be diagnosed as theoretically-based by the group.

History of Hospitalization and Surgical Operation

• When the patient was 14 years old, had a suicidal attempt

• January 6, 2000 – PJGMRMC, consulted because of low Blood Pressure level and diagnosed with Anemia.

Family Medical History

• Her mother also has anemia. Her maternal grandmother and aunt

also were/are anemic.

• 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.• ELIMINATION PATTERN• Urination • Frequency: Usually 5 times a day

• Color: Amber yellow• Urinary Complaints: Nothing• Home remedies: Nothing

• 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

Physical ExaminationGENERAL 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.

• 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.• LOC: Conscious/coherent

Cephalocaudal Examination• Cranium

• Temporal Arteries

• Face• with pale soft palate and pale oral mucosa

• with presence of 4 dental carries on molar teeth

• Cranial Nerve V and VII

• Cranial Nerve I

• External Eye Structure– pink to pale bulbar and palpebral conjunctivae

• Visual Acuity• Extraocular Muscle Function (CN 3, 4, 6)• Pupillary reflexes• External Ear• Hearing• Musculoskeletal structure• Lymph nodes• Thyroid Gland• Cranial Nerve XI

• Carotid Arteries

• Neck Veins

• Musculoskeletal structure, skin nails– pale anterior palm

– pale, well trimmed nails

– abnormal capillary refilling time due to skin color

– (+) keloid formation on L upper extremity

• Musculoskeletal Function (Range Of Motion)

• Brachial and Radial Arteries– weak pulse (69 bpm)

– obvious brachial veins on both arms

• Deep Tendon Reflexes (upper extremities)

• Breast and Axilla

• Anterior Thorax

• Posterior Thorax– asymmetric chest expansion L upon inspection and palpation on back (upon

sitting position

• Precordium– adynamic precordium upon auscultation, presence of S4 but

unclearly notified

• Abdominal Quadrants

• Internal Organs

• Musculoskeletal structure, skin nails (lower extremities)

– tingling sensation on both lower extremities– -pale, untrimmed nails– -abnormal capillary refilling time due to skin color

• Musculoskeletal Function (Range Of Motion)

– normal ROM except the feet

• Popliteal, Tibial, and Pedal Arteries– weak pulse upon palpation (63 bpm)

• 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 )

• Genitalia

INITIAL MEDICAL DIAGNOSIS

Anemia

Hypotension

LABORATORY STUDIES

NURSING RESPONSIBILITIES TO EACH LAB EXAM

T/C MAJOR DEPRESSIVE BEHAVIOR

• Self hatred Absent/present when committed

suicide • Poor concentration Present• Fatigue Present• Digestive problems Present• Lethargic Present• Agitated Present• Forgetfulness Present• Psychomotor agitation Present

• 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.

• She does not, however, have illusions, delusions or hallucinations.

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. – Group 1

PATHOPHYSIOLOGY OF HYPOPROLIFERATIVE ANEMIA(Folic Acid Deficiency – IDA, Hypotension)

PATHOPHYSIOLOGY OF PERNICIOUS ANEMIA

DEFINITIVE MEDICAL DIAGNOSIS

HYPOPROLIFERATIVE ANEMIA PROBABLY

PERNICIOUS

VITAMIN B12 DEFICIENCY

FOLIC ACID DEFICIENCY

IRON DEFICENCY

HYPOTENSION

MAJOR DEPRESSIVE DISORDER

SEIZURE DISORDER

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:

• CBC• Stool Exam with occult blood• For cross matching• RBS• 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

DESCRIPTION OF Dx• Folic acid deficiency – folic acid, a vitamin that is

necessary for normal RBC production, is stored in compounds referred to as folates.

• 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.

• 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.

• Hypotension refers to an abnormally low blood pressure.

• 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.– The most common time of onset is between the

ages of 30 and 40 years, with a later peak between 50 and 60 years

Seizure Disorder/Epilepsy is a common chronic neurological disorder characterized by recurrent unprovoked seizures.

MEDICAL/SURGICAL PLANS AND

INTERVENTIONS

Blood Transfusions If Necessary Blood Pressure Monitoring Folic Acid Replacement/Vitamin B-

Complex Replacement Blood Tests (To monitor Hematocrit and

Hemoglobin)

• No Recommended Surgical Interventions

DRUG STUDY• Ferrous sulfate (Rhea Ferrous Sulfate)

– 200mg cap 1 capsule BID– P.O. – Monitor for adverse reaction– Assess bowel elimination– Do not give with milk and antacids– Instruct client to take the whole capsule, do not crush nor chew– Store in an airtight container– Monitor vital signs– Monitor complete blood count to evaluate effectiveness of treatment– Monitor changes in stool– Plan activities and allow for periods of rest – Administer medication on an empty stomach – Monitor dietary intake

• Folic Acid (Folicard) 0.5 mg cap, 1 cap BID P.O.

• Necessary nutrient for erythropoeisis – Monitor Hct and Hgb levels– Advise patient to take drug as prescribed– Instruct patient to increase intake of foods rich in

folic acid in diet

• Metoclopramide

• Brand Name: Not observed

• 1 ampule PRN for vomiting– Tell the patient or family the action of the

medication before administration– Monitor for adverse effects– Monitor blood pressure– Advise to avoid alcoholic drinks– Tell patient to take 30 minutes before meals

• Gabapentin (Neurontin) capsule • Dose not questioned. Frequency: TID

– Tell patient/SO (s) to avoid drinking alcohol if in treatment (if situation permits)

– Tell family/patient not to skip a dose if possible

– Educate that this can be taken with or without food

– Patients should be instructed to take Gabapentin only as prescribed.

• Multivitamins (K-A plus) 1 cap O.D. P.O.

– Assess patient for sign of nutrition deficiency prior to and throughout therapy

– Instruct to notify for side effects of medication to physician

– Encourage to comply on medication– Instruct patient and or family that it may be taken

with or without food (May be taken w/ meals for better absorption or if GI discomfort occurs).

Nsg. Dx applicable for the Patient– 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

NURSING CARE PLANS(NCPs)

Nursing Diagnosis:

• Activity intolerance related to imbalanced between oxygen supply (delivery) and demand as evidenced by decreased hemoglobin and weakness (as verbalized by the patient)

• Assess patient’s ability to perform normal task or activities of daily living.

• Note changes in balance/ gait disturbance, muscle weakness • Recommend quiet atmosphere, bed rest if indicated.• Elevate the head of the bed as tolerated • Provide or recommend assistance with activities or ambulation

as necessary, allowing patient to do as much as possible.• Plan activity progression with patient, including activities that the

patient views essential. Increase levels of activities as tolerated • Identify or implement energy saving technique like sitting while

doing a task.• Teach patient to cease activities when dizziness, palpitations and

DOB occurs• Instruct patient to have adequate rest periods/sleep especially

between activitiesCOLLABORATIVE:• Monitor laboratory studies. Hgb or Hct and RBC count

Nursing Diagnosis:

• Nausea related to hypotension as evidenced by episode of vomiting, BP – 90/40 mmHg (4pm) HR: 54 bpm (4pm) and verbal reports of the patient of increased salivation.

• Check the patient’s vital signs and note signs of dehydration

• Provide diet and snacks with substitutions of preferred foods when available (e.g. decaffeinated carbonated beverages, gelatin) in a moderate level

• Encourage patient to avoid fatty and fried foods, if not take in moderate sequence

• Provide clean, pleasant smelling and quiet environment. Avoid the offending odors

• Advise patient and or SO(s) to provide clear water, ice cubes when simple nausea came

• Collaborative: Administer antiemetic (Metoclopramide 1 amp PRN for vomiting episodes

Nursing Diagnosis:

• Fatigue related to anemia; depression as evidenced by decreased performance, restlessness, facial depression

• Determine the ability to participate in activities/level of mobility

• Assess degree of sleep disturbances• Note patient’s belief about what is causing the

fatigue and what relieves it• Review availability and current use of support

systems/SOs• Evaluate need for individual assistance/assistive

devices• Increase activity level as the patient can tolerate

Nursing Diagnosis:

• Sleep Pattern Disturbance related to fatigue, interruptions for therapeutic, monitoring, and laboratory tests within the hospital as manifested by observed disturbances and verbal reports of the patient of pattern disturbance.

Nursing Diagnosis:

• Deficient knowledge, related to lack of information about a well- balanced diet and foods containing folic acid/Vitamin B12

• Assess the readiness of the patient/family to learn• Discuss foods required for a well-balanced diet, as

well as dietary sources of folic acid (such as eggs, vegetables)

• Develop a dietary plan with mother or sister of patient which includes food preferences and foods that are easy and quick to prepare

• Discuss the importance of taking the folic acid supplement/vitamins

• Advise to continue taking it even after she begins to feel better

Nursing Diagnosis:

• Altered thought processes probably related to mental disorder vs. cerebral hypoxia as manifested by altered mood states, altered sleep patterns, passive and aggressive behavior

• Assess degree of orientation to time, place, person, and situation regularly.

• Orient to surroundings and reality as needed.• Assess for environmental and situational factors that may

contribute to change in mood or affect.• Demonstrate acceptance of patient as an individual (from

nurses to the family members)• It is important to communicate to patient one’s acceptance

her regardless of her behavior. Establish this to the SOs of the patient

• Monitor laboratory values and report any significant changes.

• Assist with grooming and bathing for the patient.

Nursing Diagnosis:

• Self-care Deficit: hygiene, grooming, toileting related to fatigue as manifested by slightly combed hair and untrimmed nails (decreased sense of personal grooming), with personal assistant in toileting

Nursing Diagnosis:

• Mild Anxiety related to change in environment and routines as evidenced by restlessness, sleep pattern disturbance and feelings of discomfort

• Assess patient level of anxiety• Assess patient’s coping mechanisms in

handling anxiety• Acknowledge awareness of patient’s anxiety• Reassure patient that she is safe. Stay with

the patient if appears to be necessary.• Establish a working relationship with the

patient through continuity of care.• Orient patient to the environment as needed.

Nursing Diagnosis:

• Risk for Suicide related to previous suicidal attempt

• Note behaviors indicative of intent (e.g. gestures)• Ask directly if person is thinking of acting on

thoughts/feelings• Determine presence of SO(s) who are available for

support• Maintain straightforward communication

Encourage expression of feelings and make time to listen to concerns

• Maintain observation of patient and check environment for hazards that could be used to commit suicide Involve family/SO(s) in planning

Nursing Diagnosis:

• High risk for injury related to paresthesia and possible seizure episode

• Assess mood, coping abilities, personality styles and evaluate individual’s response to violence in surroundings.

• Provide information regarding disease/conditions that may result in increased risk of injury.

• Assist the client when walking, be sure to have a watcher when going out from bed

• Identify interventions/safety devices. Refer to physical or occupational therapist as appropriate.

• Provide bibliotherapy/written resources and promote community education programs geared to increasing awareness of safety measures and resources available to individual.

• Educate patient and or relative (SOs) to take the prescribed anti-seizure medication Gabapentin (Neurontin) in the right frequency and dosage, and safety measures available (e.g. raise side rills of the bed, wear loose clothes).

PATIENT AND FAMILY TEACHING GUIDE

• REST:• Have a regular daily rest and activity program by stretching upper and lower

extremities.• Avoid emotional upsets. Listen to concerns and fears, etc. and provide

encouragement.• DRUG THERAPY:• Take each drug as prescribed daily. (Patient-Family teaching guide in

prescribed medications – pls. refer to Drug Study – XVIII)• Develop a check-off system (e.g. daily chart) to ensure medication have been

taken.• Take pulse rate each day before taking medications. Know the parameters that

your health care provider wants for your health.• DIETARY THERAPY:• Consult the written diet plan and list of permitted and restricted foods.• 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.• Broadening diet to include chicken, eggs, fish, even ketchup – and tomato --

contains vitamin B12• Moderate intake of caffeinated foods or drinks.

• ACTIVITY PROGRAM:• Try to increase walking and other activities gradually,

provided do not cause fatigue and dyspnea.• Always make sure that the patient has an assistant in

walking, and other such circumstances.• Keep regular appointments with health care provider.• Exercises focused on improving sense of balance may

help if nerve damage caused to be unsteady while walking.

• Swimming should usually be avoided.• Promote active exercises when in bed to assistive active

when walking to promote maximal activity potential of patient.

• ONGOING MONITORING:• Know YOUR limit.• Surround the patient with people who love you and will help you.• 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.

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

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

• Monitor the patient’s blood pressure. Document if necessary.• Recall the symptoms experienced when illness began appearance of

previous symptoms may indicate a recurrent.• 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.

SINCERELY,

NICANOR M. DOMINGO IIIJASPER IAN T. ENOZAJAYSON A. ESPINO

DANNICH MAIKA O. ESTEBANEMMARUTH B. GAMBOA

KAREN N. GUANSINGREINA JEAN D.V. MUNAR

ADRIAN M. ORTIZ MELVIN RENZ C. PASCUAL

DIANNE JOI H. VILORIA

NEUST BSN III-AGroup 1