Idiopathic Thrombocytopenic Purpura

I. INTRODUCTION

Idiopathic thrombocytopenic purpura (ITP) is a blood disorder of unknown cause characterized

by an abnormal decrease in the number of platelets in the blood. Platelets are cells in the blood that help

stop bleeding. People who have ITP often have purple bruises (purpura) that appear on the skin or on the

mucous membranes. The bruises mean that bleeding has occurred in small blood vessels under the skin. A

person who has ITP may also have bleeding that result in tiny red or purple dots on the skin. These

pinpoint-sized dots are called petechiae and it may look like a rash. Idiopathic thrombocytopenic purpura,

also known as immune thrombocytopenic purpura is classified as an autoimmune disease. In an

autoimmune disease the body forms antibodies that destroy its own blood platelets. Platelets are marked

as foreign by the immune system and eliminated in the spleen, or sometimes the liver.

There are three types of ITP: acute (temporary or short-term), chronic (long-lasting), and

recurrent (intermittent). Acute ITP generally lasts less than 6 months. It mainly occurs in children, both

boys and girls, and is the most common type of ITP. Acute ITP often occurs after an infection caused by a

bacteria or a virus. Chronic ITP is long-lasting (6 months or longer) and mostly affects adults. However,

some teenagers and children can get this type of ITP. Chronic ITP affects women 2 to 3 times more often

than men. Treatment depends on how severe the bleeding symptoms are and the platelet count. In mild

cases, treatment may not be needed. Recurrent ITP was characterized by intermittent episodes of

thrombocytopenia followed by periods of recovery, unrelated to therapeutic intervention. It is a rare, mild,

self-limited type of ITP, although intracranial hemorrhage may occur in a profoundly thrombocytopenic

child. Recurrence may occur close or far apart to a previous isolated thrombocytopenia episode.

This study is a case of a 2-month old baby boy, admitted at Pediatric unit of Manila Adventist

Medical Center due to fever, petechial rashes, and purpura on his trunk and extremities. The patient has

been diagnosed with Idiopathic Thrombocytopenic Purpura (ITP). The scope of this study encloses the

admission date, November 27, 2009 until his discharged date on December 10, 2009. The study includes

the maternal history, birth and past medical history of the patient. The disease process will provide the

students the knowledge on how the disease acquired and progresses. The laboratory exam and diagnostic

procedures use to diagnose ITP is also included as well as medication and health teaching given. The

purpose of this study is to let the students understand and have the knowledge on how to deal with clients

with idiopathic thrombocytopenic purpura.

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II. DEMOGRAHIC DATA

This is a case of a 2-month old baby boy born on September 23, 2009 via normal spontaneous

delivery with assisted midwife at their home in Makati City. In the course of this study, the patient was

named as Barney to protect his identity. Barney and his parents are currently residing at 319 Duhat Street,

Comembo Makati City. His father is a born-again Christian while his mother is a Seventh-day Adventist

believer. Both of his parents are a Filipino citizen and finished secondary education. Barney’s mother is a

plain housewife while his father is a tricycle driver. In this study the informants are his parents.

Barney was admitted at Pediatric Unit of Manila Adventist Medical Center on November 27,

2009 with an initial diagnosis of Idiopathic Thrombocytopenic Purpura vs. Evans Syndrome. He was

discharged on December 10, 2009 with the final diagnosis of Idiopathic Thrombocytopenic Purpura.

III. CHIEF COMPLAINT

Fever and generalized petechial rahes (face, trunk, and extremities):

“Ang init ng katawan niya at ang dami niyang pasa at rashes” (“His body is hot and have lots of

bruises and rashes”), as verbalized by the patient’s mother.

IV. HISTORY OF PRESENT ILLNESS

Barney was apparently well until four (4) days prior to admission (PTA) when he was noted to

have undocumented fever and petechial rashes on his face and buccal mucosa. His mother gave him

antipyretic (Calpol) which provided a temporary relief.

Three (3) days PTA, rashes had already spread on his extremities. His fever had gradually

decreased but the rashes remained all over his body and extremities.

Morning PTA, the persistence of the condition prompted the parents to consult at a nearby

hospital wherein a decreased hemoglobin, hematocrit, erythrocytes, segmenters and eosinophils were

noted. On the other hand, he had increased amounts of lymphocytes and monocytes. There were

generalized petechial rashes and ecchymoses on the trunk and extremities noted. They were advised

admission but due to room unavailability, they were referred and transferred to Manila Adventist Medical

Center and were subsequently admitted.

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V. PAST MEDICAL HISTORY

Prior to diagnosis of having Idiopathic thrombocytopenic purpura, Barney did not have any

serious illness since birth. He is completely immunized with BCG, OPV, 1st dose of DPT, 1st and 2nd

dose of Hepatitis B vaccine. He has not undergone any operations, no recorded injury and no known

allergies to any food or drug.

A). Birth History:

According to Barney's mother, during her pregnancy, she had a hard time working at the

computer shop. She always feels restless and over fatigued after the day’s work. The mother noted that

she had urinary tract infection during her 6th month of pregnancy to Barney, thus she took Amoxicillin,

three times a day for 7 days.

Natal History

Barney was delivered via normal spontaneous delivery at home with assisted midwife. No NBS

and APGAR scoring done according to his mother. He had a birth weight of 4.1 kg. (9 lbs.), with no

fetomaternal complications noted.

Postnatal History

Barney was in a good condition at birth. There were no complications noted during the first 28

days of his life. He was breastfed by his mother.

B). Growth and Development History:

Barney grow rapidly both in size and his ability to perform tasks. He can regard with social smile

directly at people, making cooing sounds, can locate a sound in front of him, but not one behind,

differentiates cry; cries to seek attention and kicks and waves his arms when he is excited. He can turns

from side to back and shows eye coordination to light and objects.

Barney can recognize familiar face, enjoys sucking- puts hand in mouth, anticipate being feed

when in feeding position and becomes more aware and interested in environment.

C). Childhood Illnesses:

Barney did not have any serious illnesses. He just had experienced fever sometimes.

D). Immunizations/Vaccination History:

Barney was completely immunized with BCG, OPV, 1st dose of DPT and two doses of Hepatitis

B vaccine.

3

E). Operations, Injuries, Hospitalizations, Allergies:

Barney did not undergo any operations, no injuries recorded, and no known allergies to any food

and drug.

4

49HPN

VI. FAMILY MEDICAL HISTORY WITH GENOGRAM

Most of the family members of Barney are well and in good condition aside from his grandfathers

who have hypertension and his mother who has asthma. Recent studies have found a high number of ITP

patients with a positive family history indicating the likely existence of a genetic susceptibility for ITP.

The genogram shows that there is no known history of ITP or any hematologic disorder within his family.

5

64HPN

28Well

27Well

19Well

23Well

16Well

13Well

9Well

40Well

2 mos.

ITP

62Well

39Well

34Well

30Well

49Well

24Well

19Well

14Well

11Well

21Asthma

LEGEND:

= Male

= Female

= Patient

VII. PERSONAL, SOCIAL, ENVIRONMENTAL HISTORY

Barney is the only child who lives with his parents and 10 other household members in a small

two bedroom house. His father is the breadwinner of their family and provides all the needs of his wife

and son.

VIII. DEVELOPMENTAL TASKS

Freud’s Psychoanalytical Theory: Oral Phase

In this stage, infants are so interested in oral stimulation or pleasure during this time. According

to this theory, infants suck for enjoyment or relief of tension, as well as for nourishment.

Barney usually sucks his hands and sucks milk from his mother’s breast which he enjoys and

gives nourishment to him.

Erikson’s Psychosocial Theory: Trust vs. Mistrust

Infants whose needs are met when those needs arise, whose discomforts are quickly removed,

who are cuddled, played with and talked to, come to view the world as a safe place and people as helpful

and dependable. However, when their care is inconsistent, inadequate, or rejecting, it fosters a basic

mistrust.

Barney depends on his mother to meet his needs. When he cries, he was comforted by his mother

and was subsequently breastfed and his mother is always there to provide his needed care.

Piaget’s Cognitive Development: Sensorimotor ( Primary Circular Reaction)

Sensorimotor intelligence is practical intelligence, because words and symbols for thinking and

problem solving are not yet available at this early age. Primary Circular Reaction refer to activities related

to a child’s own body and shows that repetition of behaviors occurs.

Barney usually put his thumb to his mouth and enjoys the sensation of sucking it. He smiles

whenever he hears his parent’s voice and when his name was called. He cries as a response to pain.

Fowler’s Developmental Theory

In this stage, infant centers on relationship with primary caregiver. Barney centers his relationship

to his mother. He usually cries when his mother is not around that is why they always bond together.

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IX. GORDON’S ASSESSMENT

Health-Perception/Health Management Pattern

Before Barney was admitted, his mother usually brought him to the nearest health center for his

vaccination. His mother gives him vitamins and he is breastfed. When Barney had fever, they gave him

antipyretic (Calpol) which provided a relief. Four days before Barney was admitted, his mother noticed

petechial rashes all over his body and thought it was just a common rash. When the fever had gradually

decreased but the rashes all over his body remained, they got worried and brought him to the nearest

hospital.

Upon hospitalization Barney had been diagnosed with ITP. His parents did not know where and how

their son acquired his disease. His mother believes that this hospitalization will help his son to recover.

Nutritional/Metabolic Pattern

Barney was born a healthy baby boy with a birth weight of 4.1 kg (9 lbs.). The normal weight

gain for 0-4 months is 170 grams (.37 lbs) per week. Before he was admitted, his appetite was very good.

He usually fed every 2-3 hours within 5-10 minutes. He is taking Tiki-tiki vitamins.

During his hospitalization, his appetite was slightly reduced and his admitting weight was

decreased from 5.8 kg to 5.6 kg which is still within the normal range. Barney was not allowed to take

any vitamins during the course of his hospitalization.

Elimination Pattern

Before Barney was admitted, he had 2-3 bowel movement everyday with yellow color, not foul in

odor, formed, and moderate in amount.

During his hospitalization, his bowel movement has not changed. His stool has the same

characteristics as before. He has no problem in urination as evidenced by normal urinalysis results.

Activity/Exercise Pattern

Before Barney was admitted he usually played with peek-a-boo and rattles with his mother. He

enjoys listening to her voice and in return he smiles and laughs. Barney cries whenever he feels hungry

and when his diaper was soaked with urine and stool. He takes a bath everyday.

During his hospitalization, he still smiles and laughs whenever his mother played with him but

most of the time he cries.

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Sleep/Rest Pattern

Normally baby’s average sleeping rate is 15-16 hours. Barney sleeps mostly at night and will stay

awake much longer during the day and takes 2-3 naps a day according to his mother.

During his hospitalization, his sleeping pattern had been disturbed because of routine vital signs

taking and whenever he undergoes laboratory and diagnostic procedures.

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X. PHYSICAL ASSESSMENT

PhysicalAssessment

November 27, 2009(Admission Day)

November 29, 2009(Initial Visit)

a. General Appearance: Admitted this 2 month old baby boy with fever and petechial rashes on face, trunk, and extremities, awake, alert, not in cardiorespiratory distress.

Assessed this 2 month old baby boy admitted on 10/27/09, afebrile, still with generalized petechial rashes and ecchymoses, asleep, on supine position with IVF of #4 D5IMB 500cc x 24 cc/hr on left hand, patent and infusing well.

b. Vital Signs: BP – 100/90 mmHgT – 39.3 C

HR – 137 beats/minRR – 40 breaths/min

Wt – 5.8 kg. (12.8 lbs.)

BP – 100/70 mmHgT – 36. 1 C

HR – 119 beats/minRR – 30 breaths/min

Wt – 5.6 kg. (12.3 lbs)

c. Skin: Warm, pale, good skin turgor, with generalized petechial rashes on face, trunk and extremities

Pale, good skin turgor, still with generalized petechial rashes on face, trunk and extremities

d. Head and Neck:Normocephalic, flat fontanels, no lesions, no clad

Normocephalic, flat fontanels (anterior fontanel /open), no lesions, no cladHead Circumference: 41 cm

e. Eyes:

Pupil reactive to light, pale palpebral conjunctiva

Pupil reactive to light, pale palpebral conjunctiva, presence of conjunctival hemorrhage on left eye

f. Ears: Intact tympanic membrane, no discharge

Intact tympanic membrane, no discharge

g. Nose: Symmetrical, no deformity, no skin lesions, no swelling, no discharge

Symmetrical, no deformity, no skin lesions, no swelling, no discharge

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h. Mouth and Throat: Presence of petechial rashes on buccal mucosa and tongue midline

Presence of petechial rashes on buccal mucosa and tongue midline

i. Breasts: No lumps, no discharge No lumps, no discharge

j. Chest/Lungs: Symmetrical chest expansion, no retractions, clear breath sounds

Symmetrical chest expansion, no retractions, clear breath soundsChest Circumference: 44 cm

k. Heart: Dynamic precordium, normal rate, regular rhythm, no murmurs

Dynamic precordium, normal rate, regular rhythm, no murmurs

l. Abdomen: Globular, soft, normoactive bowel sound

Globular, soft, normoactive bowel soundAbdominal circumference: 43.5 cm

m. Back Presence of petechiae and ecchymoses, no back deformities

Presence of petechiae and ecchymoses, no back deformities, diaper rash on the buttocks

n. Extremities: Full and equal pulse, presence of petechiae and ecchymoses on upper and lower extremities

Full and equal pulse, presence of petechiae and ecchymoses on upper and lower extremities

o. Genitalia: Grossly normal, no hernia, no discharge

Grossly normal, no hernia, no discharge

p. Rectal: No hemorrhoids No hemorrhoids

q. Neurologic Assessment:

Not assessed Calm, active reflexes ( sucking, rooting, moro, palmar, tonic neck, and babinski reflex )

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X1. REVIEW OF SYSTEMS

Systems November 27, 2009(Admission Day)

November 29, 2009(Initial Visit)

a. Skin: () rashes (-) lumps(-) itching(-) dryness() pallor() petechiae and purpura on extremities and trunk

() rashes (-) lumps(-) itching(-) dryness() pallor() petechiae and purpura on extremities and trunk

b. Head: (-) headache(-) head injury

(-) headache(-) head injury

c. Eyes: (-) pain(-) redness(-) double vision(-) glaucoma(-) cataracts

(-) pain() conjunctival hemorrhage(-) double vision(-) glaucoma(-) cataracts

d. Ears: (-) hearing loss(-) tinnitus(-) discharge

(-) hearing loss(-) tinnitus(-) discharge

e. Nose and Sinuses: (-) frequent colds(-) nasal stuffiness(-) nose bleeds

(-) frequent colds(-) nasal stuffiness(-) nose bleeds

f. Mouth and Throat: () lesions on gums(-) sore throat(-) hoarseness

() lesions on gums with buccal petechial rashes(-) sore throat(-) hoarseness

g. Neck (-) goiter (-) goiter

h. Breasts: (-) lumps (-) lumps

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(-) pain(-) nipple discharge

(-) pain(-) nipple discharge

i. Respiratory: (-) cough(-) sputum(-) hemoptysis

(-) cough(-) sputum(-) hemoptysis

j. Cardiac: (-) heart problem(-) hypertension(-) pain

(-) heart problem(-) hypertension(-) pain

k. GIT: (-) hematemesis(-) food intolerance(-) vomiting(-) melena(-) hemorrhoids

(-) hematemesis(-) food intolerance(-) vomiting(-) melena(-) hemorrhoids

l. Urinary: (-) nocturia(-) dysuria(-) hematuria

(-) nocturia(-) dysuria(-) hematuria

m. Genital: (-) discharges(-) hernias

(-) discharges(-) hernias (+) diaper rash

n. Musculoskeletal: (-) joint pains(-) weakness(-) limitation of movement(-) paralysis

(-) joint pains(-) weakness(-) limitation of movement (-) paralysis

o. Peripheral Vascular: (-) cramps(-) thrombophlebitis

(-) cramps(-) thrombophlebitis

p. Neurological: (-) seizures(-) numbness

(-) seizures(-) numbness(+) reflexes ( sucking, rooting, moro, palmar grasp, tonic neck, babinski )

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q. Psychiatric: (-) tension (-) tension

r. Hematologic: (-) anemias() easy bruising or bleeding(-) past transfusions

(-) anemias() easy bruising or bleeding(+) past transfusions ( 3 PRBC/ 2 Platelet concentrate on admission day, Nov. 27, 2009)

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XII. COURSE IN THE WARD

Date and Time Doctor’s OrderNursing Observations and

Evaluation

27 November 2009

2:18am -Please admit patient to room of choice under the service of Dr. Duldulao

-Further assessment to follow

-Diet for age

-V/S q4

Diagnostic-CBC with Platelet Count, Coomb’s Test, Blood Typing, Blood CS

-Reticulocyte Count, Peripheral Blood Smear, PT, PTT

-Urinalysis

Therapeutic #1-D5IMB 500cc x 24cc/hr

-Admitted to room 407-2

-Breastfed by the motherWt – 5.8 kg. (12.8 lbs.)

BP – 100/90 mmHgT – 39.3 CHR – 137 beats/minRR – 40 breaths/min

CBC:↓RBC - 1.55↓Hgb - 48↓Hct - 0.13↑WBC - 20.74↑Lymphocyte - 0.44↓Segmenters - 0.38↓Platelet - 6Coomb’s Direct (-)Coomb’s Indirect (-)Blood Type: A+

Reticulocyte Count - 5.3%PT - 13.8PTT Control - 28 Patient - 33

Sp Gr: 1.015pH: 6Glucose (-)Protein (-)WBC: 0-1RBC: 0-1

-D5IMB hooked @ 6:30am & regulated @desired rate

14

6:30am

12:30pm

-Inform Dr. Duldulao

-Refer to Dr. Naranjo for hematologic evaluation

-Ampicillin 150mg IV q6

-Amikacin 30mg IV q8

-Save serum for possible crossmatching

-Inform Dr. Naranjo

-For SGPT, TB, B1, B2, reverse blood typing

-Neuro vital signs q2

-Blood transfusion regimen (slow connection) once properly secured, typed, and crossmatched to be given as ff:

> 1st aliquot: 35cc x 4hrs- 4hrs rest> 2nd aliquot: 45cc x 4hrs- 4hrs rest>3rd aliquot: 55cc x 4hrs

-Please clarify / verify result of blood type including autoconnial, major, and minor cross matching

-Secure consent.

-Transfuse PRBC properly typed and crossmatched (autoconnial, major, and minor crossmatching) as follow:

>1st degree: BT #1- 35cc to run for 4hrs then rest for 4hrs>2nd degree: BT #2- 45cc to run for 4hrs then rest for 4hrs

-Dr. Duldulao informed

-Referred Dr. Naranjo

-Antibiotic drug

-Used to treat bacterial infection

-Saved blood transfusion

-Dr. Naranjo informed

SGPT - 37u/LTB - 26.6umol/LB1 - 17.3umol/LB2 - 9.3umol/L

-Eyes: 2mm reacting briskly

-Checked and verified doctor’s order-Secured right indication for patient-Physical assessment done

-Blood properly typed and crossmatchedBlood type: “A+”

-Consent secured

CBC: Indications for BT↓RBC - 1.55↓Hgb - 48↓Hct - 0.13

-PRBC 35cc transfused and consumed-PRBC 45cc transfused and consumed

15

12:40pm

4:42pm

7:20pm

>3rd degree: BT #3- 55cc to run for 4hrs, 4hrs rest

>BT #4&5-Transfuse 2 units of platelet concentrate, type specific a fast drip and may be given in PRBC, transfused

-V/S monitoring to q15 for 1st hour then q20 on the 2nd hour then hourly when on transfuse

-Inform PROD once blood provided accordingly

-IV TF > #2 D5IMB 500cc x 24cc/hr

-May give Paracetamol 100mg/ml drops, 0.6ml now

-PRBC 55cc transfused and consumed.

APC: Indication for BT↓Platelet-6-2 units of platelet concentrate transfused and consumed.

q15 T – 37.7HR -160RR -36BP -100/70

q30T -38.6HR -156RR -35BP -100/70

-Informed accordingly.

-D5IMB hooked @ 4:42pm & regulated @ desired rate

-Antipyretic drug givenT - 38.6◦C

28 November 2009

7:30am

7:45am

9:00am

-Rounds with Dr. Duldulao

-For bed bath daily by nurse-in-charge

-Watch out for urine output and for occurence of hematuria for PROD ASAP

-Update Dr. Naranjo

-Repeat CBC with platelet count, reticulocyte count 6hrs post 3rd PRBC

-Bed bath done

UO – 300cc-Watched out for melena, hematuria or hematochesia

-Dr. Naranjo updated

CBC:RBC - ↓3.91Hgb - 116Hct - ↓0.32WBC - 9.00Lymphocytes - ↑0.62

16

9:35am

10:45am

3:45pm

5:08pm

6:35pm

-For Na+, K+, Ca++, Cl at 9am

-Strict I&O monitoring

-For monitoring of vital signs to q2hrs; include neuro vital signs

-Suggest STAT cranial UTZ to R/O intracranial bleed (↑ sleeping time)

-Watch out for occurrence of seizure

-May give Paracetamol 100mg/ml, 0.6ml now then q4hrs PRN

-For STAT cranial ultrasound today

-For cranial CT scan without contact instead of cranial UTZ

-Schedule CT scan (without contact) at Mediscan at 8:30am tomorrow (November 29, 2009)

-Patient may go out on pass

-IVF TF: #3 D5IMB 500cc x 24 cc/hr

Segmenters - ↓0.23Eosinophils - ↓0.07Stabs - ↓0.04Platelet - ↓7Reticulocyte Count - ↑2.5

Na+: 137K+: 3.9Ca++: 2.25Cl: 104

-I&O strictly monitored

T -36.6HR -136RR -41BP -100/70Neuro V/S – 2mm RB

-No seizures noted

-Antipyretic drug givenT - 37.8◦C

-Cranial UTZ done @ Fe Del Mundo Hospital

-Procedure doneImpression:-Small focus of hemorrhage, left vermis-Mild fronto-temporal lobe atrophy-#3 D5IMB hooked @ 6:35pm regulated @ desired rate

17

29 November 2009(1 st DUTY DAY) 6:50am -Please give Diphenhydramine

6mg IV 15-30mins before the procedure

- IVF TF: #4 D5IMB 500cc x 24 cc/hr

-Apply zinc oxide, on diaper rashes TID

-For Bone Marrow Aspiration tomorrow am at Fe del Mundo Hospital

-Secure consent for BMA

-Secure needs for the procedure● Sterile gloves #2● Betadine #1● Alcohol #1● Cotton applicator● Sterile gauze (2 pads) ● Syringe (10cc) #4● Lidocaine #2● Slides #10

-Show next stool to PROD

-Set abdominal circumference now then OD, record with separate sheet

-Antihistamine drug given forrelief of allergy condition

-#4 D5IMB hooked @ 7:00am & regulated @ desired rate

-Emollients & skin protective used to prevent diaper rash

-Secured consent

-Needs secured for the procedure

Stool:C- yellowO-non foulC-formed solidA-small

-AC: 43.5cm

30 November 2009

7:00am -May go out on pass today for BMA at Fe del Mundo Hospital at 10am

-For private conduction with Pedia resident

-Bone Marrow Aspiration done at Fe del Mundo Hospital

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10:40am

12:00nn

10:50pm

-Shift IVF to heplock, without on-pass

-Administered Diphenhydramine (Benadryl) 6mg IV.

-S/P BMA right tibial

-Apply direct pressure

- Administer Paracetamol (Calpol) 0.6ml drops.

-Inform Dr. Duldulao of Dr. Naranjo’s suggestions.

-Start Hydrocortisone 10mg IV q8

-For repeat CBC with platelet count if with significant bleeding

-Refer to PROD, if with bloody stools

-Please have / get official CT scan result at Mediscan

-IVF shifted to heplock

-Administered prior to BMA for sedation

Results:-Cellular marrow with noted increase in megakaryocyte. There is also abundant erythrocyte in different stage of maturation with binucleation.

-Granulocytes intact. There is a predominance of lymphocytes but do not appear premature.

-Symptoms: reactive marrow consistent with immune mediated ITP

-Direct pressure applied

-Paracetamol administered for relief to mild to moderate pain.

V/S: T-36.5ºCPR-165 bpmRR-62brpmBP-100/70 mmHg

-Dr. Duldulao informed o Dr. Naranjo’s suggestion

-Glucocorticosteroid drug given for immunosuppresive effect of antibodies↓Platelet-7

-CBC not repeated

-Referred to PROD

Impression:-Small focus of hemorrhage,

19

left vermis-Mild fronto-temporal lobe atrophy

01 December 2009

1:10am -IVF TF: #5 D5IMB 500cc x 24 cc/hr

-#5D5IMB hooked @ 1:10am & regulated @ desired rate

02 December 2009

1:50am

8:45am

6:05pm


-Update Dr. Naranjo

-Suggestions:-Repeat CBC with platelet count tomorrow at 5am to include reticulocyte count




CBC:RBC - ↓3.30Hgb - ↓96Hct - ↓0.28WBC - ↓4.70Lymphocytes - ↑0.78Segmenters - ↓0.17Platelet - ↓10RC - ↑4.6

-#7 D5IMB hooked @ 6:05pm & regulated @ desired rate

03 December 2009

4:35am

8:15am


-For change whole IV set

-For repeat CBC with platelet count to include reticulocyte count tomorrow (December 03, 2009) at 5am

-Update Dr. Naranjo

-Continue Hydrocortisone as

-Changed whole IV set

CBC:RBC - ↓3.30Hgb - ↓96Hct - ↓0.28WBC - ↓4.70Lymphocytes - ↑0.78Segmenters - ↓0.17Platelet - ↓10RC - ↑4.6


-Hydrocortisone continued

20

8:30am

previously ordered while patient is admitted


↓Platelet-10


04 December 2009

6:00am

12:15nn


-D/C Amikacin

-D/C Ampicillin after 12nn dose today


-Amikacin discontinued

-Ampicillin discontinued

05 December 2009

7:30am

1:00pm

9:05pm

9:10pm

-Update Dr. Yuson

-Repeat CBC with platelet count today at 8am


-Rounds with Dr. Yuson

-Suggest: To complete antibiotics for 10-14 days

-Discontinue Hydrocortisone(1) If vaccine-related usually recovers spontaneously(2) Age of patient

-Close follow-up of 3-4 days with CBC with platelet count and peripheral blood smear

-Update Dr. Duldulao

-Dr. Yuson updated

CBC:RBC- ↓3.70Hgb- 110Hct- ↓0.32WBC- 7.80Lymphocytes- ↑0.69Segmenters- ↓0.20Platelet- ↓10

-#10 D5IMB hooked @ 1:00pm & regulated @desired rate

-Antibiotics completed

-Hydrocortisone discontinued

-Updated Dr. Duldulao

21

-Please start Amoxicillin 100mg/ml 0.7ml TID x 7 days

-Hold temporarily Hydrocortisone as per Dr. Yuson’s opinion

-Strict I&O, please indicate what kind of fluid taken, if breast feeding, please note length of feeding

-CBC with platelet count after 3 days, please set aside peripheral blood smear

-If IV out, may not re-intact IVF

-Antibiotic drug given for skin infection

I –breastfeed 6 times per shift (10-15mins)O- 200 cc + 1 BM

-IVF not re-inserted

06 December 2009

4:05am

10:50am

9:00pm


-Please observe closely for new petechial appearance and other bleeding

-Repeat CBC, platelet on December 08, 2009

-↓ Neuro vital signs to q4

-Rounds with Dr. Yuson

-Repeat CBC, platelet tomorrow (December 07, 2009) instead of December 08, 2009

-Observed closely for new petechial appearance and other bleeding

-No CBC done

-Neuro V/S: 2.5 reacting briskly

CBC:RBC - ↓3.96Hgb - 118Hct - ↓0.34WBC - 7.40Lymphocytes - ↑0.76Segmenters - ↓0.20Platelet - ↓19Monocytes - ↑0.08

08 December 2009

8:00am -Follow-up of Dr. Yuson on December 10, 2009 at Fe del Mundo Medical Center 9am-12nn

-Dr. Yuson followed-up

22

-With repeat CBC, PC, Reticulocyte count before follow-up

-No CBC, PC, Reticulocyte count done before follow-up

09 December 2009

8:05am

10:55am


Home Meds:

-Amoxicillin 100mg/ml, 0.7ml TID for 5 days

-Follow-up on December 14at OPD 10am-12pm

-Please provide baby book c/o IOD, provide AP’s cellphone number


-May go out on pass tomorrow with intern to Fe del Mundo, Banawe, for follow-up with Dr. Yuson

-Home medications for infant instructed to parents

-Baby book provided-AP’s cellphone number given

10 December 2009

2:00pm -May go home as previously ordered

-Home Meds: Amoxicillin 100mg/ml drops, 0.7ml TID x 2 days more

-Follow-up with AP at OPD, every Thursday 10am-12nn with repeat platelet count (weekly follow-up)

-Discharged with improved condition

CBC:RBC - ↓3.93Hgb - 116Hct - ↓0.34WBC - 6.70Lymphocytes - ↑0.75Segmenters - ↓0.17Platelet - ↓20

23

XIII. LABORATORY RESULTS/DIAGNOSTIC PROCEDURES

Biosave Medical and Diagnostic Center

(1) Complete Blood Count Test with Actual Platelet Count

Date: 26 November 2009

Hematology

Test Normal Value Units Results

HemoglobinMale: 14-17

Female: 12-14gms % ↓ 6.7

HematocritMale: 42-52

Female: 37-47vol % ↓ 0.20

Leukocytes 5-10 x 109/L 5.0

ErythrocytesMale: 5-6

Female: 4.5-5.5x 1012/L ↓ 2.38

Differential Count Result

Segmenters 0.55-0.65 ↓ 0.27

Lymphocytes 0.21-0.30 ↑ 0.64

Monocytes 0.04-0.06 ↑ 0.08

Eosinophils 0.02-0.04 ↓0.01

Platelet Count

Test Normal Value Units Results

Platelet Count 150-450 x 109/L ↓ 68

The 2-month old patient was referred to MAMC because of generalized petechiae and because of

his initial laboratory results from Biosave Medical and Diagnostic Center (complete blood count test with

actual platelet count) which revealed decreased amounts of hemoglobin, hematocrit, erythrocytes,

segmenters and eosinophils. On the other hand, he has increased amounts of lymphocytes and monocytes.

There was no bleeding, yet there was obvious ecchymoses on the trunk and extremities. The parents of

the patient were advised to admit their son in the institution if sepsis work up and if there are possible

24

blood or platelet disorders to have further management and care of continuous manifestations of the

client’s hematologic disorder (Black; Medical-Surgical Nursing; 4th ed.; 1993; Pp. 1328-1332).

25

Manila Adventist Medical Center

(2) Hematology Test

Complete Blood Count Test with Reticulocyte and Actual Platelet Count

Dates: 10 December 2009 – 27 November 2009

10 December 2009 / 5:00AM




28 November 2009 / 11:49PM

27 November 2009 / 7:29AM

Test Name:

Hematology

Reference

RangeUnit

Results with Dates

10 December

5:00AM

07 December

5:17AM

05 December

9:21AM

03 December

5:02AM

28 November

11:49PM

27 November

7:29AM

Reticulocyte Count 0.4-2.1 % ↑ 3.3 ↑ 4.6 ↑ 2.5 ↑ 5.3

CBC with Platelet

Red Cell Count 4.00-6.00 10^12/L ↓ 3.93 ↓ 3.96 ↓ 3.70 ↓ 3.30 ↓ 3.91 ↓ 1.55

Hematocrit 0.37-0.47 L/L ↓ 0.34 ↓ 0.34 ↓ 0.32 ↓ 0.28 ↓ 0.32 ↓ 0.13

Hemoglobin 110-160 g/L 116 118 110 ↓ 96 116 ↓ 48

White Cell Count5.00-

10.0010^9/L 6.70 7.40 7.80 ↓ 4.70 9.00 ↑ 20.74

26

Differential Count

Lymphocytes 0.25-0.35 ↑ 0.75 ↑ 0.76 ↑ 0.69 ↑ 0.78 ↑ 0.62 ↑ 0.44

Monocytes 0.03-0.07 0.07 ↑ 0.08 0.05 0.04 0.04 0.07

Eosinophils 0.01-0.03 0.01 0.01 0.03 0.01 ↑ 0.07 0.03

Basophils 0-0.01 0.00

Segmenters 0.50-0.65 ↓ 0.17 ↓ 0.15 ↓ 0.20 ↓ 0.17 ↓ 0.23 ↓ 0.38

Stabs 0.05-0.10 ↓ 0.01 ↓ 0.04 ↓ 0.02

Atypical Cells 0.02 0.06

Morphology

Hypochromasia ++

Anisocytosis Micro+

Platelet Count 140-450 10^3/uL ↓ 20 ↓ 19 ↓ 10 ↓ 10 ↓ 7 ↓ 6

Red Blood Cell Indices

MCV 75.0-86.0 fL 85.8 85.9 ↑ 86.2 84.8 82.9 85.2

MCH 24.0-30.0 pg 29.5 29.8 29.7 29.1 29.7 ↑ 31.0

MCHC 31.0-35.0 g/dL 34.4 34.7 34.5 34.3 ↑ 35.8 ↑ 36.4

27

28

Purpose and Interpretation of Results:

Diagnosis of a blood disorder depends primarily on laboratory analysis. Although dozens of

specific tests are used to diagnose individual disorders, all cases generally call for a (1) complete blood

count (CBC) to determine the number of leukocytes and erythrocytes; (2) a total differential count to

indicate the relative percentages of the different leukocytes; (3) coagulation studies such as prothrombin

time (PT) or partial thromboplastin time (PTT) and bleeding time; (4) a bone marrow aspiration and

biopsy to determine both the cellularity of the bone marrow and the morphology of the cells present; and

(5) a peripheral blood smear ( a study of the morphology of blood cells to help differentiate various

anemias and blood dyscrasias). The results of laboratory tests also guide therapy (Black; Medical-

Surgical Nursing; 4th ed.; 1993; Pp. 1328-1332).

RETICULOCYTE COUNT

A reflection of RBC production, the reticulocyte count measures the responsiveness of the bone

marrow to a diminished number of circulating erythrocytes. Specifically, this test measures the number of

reticulocytes released from the bone marrow into the blood. Based from the patient’s laboratory results,

he has a continuous increase in his reticulocyte count. The latest result is 3.3%. An increase in the

reticulocyte count indicates an increase in erythrocyte production, probably due to excessive RBC

destruction (e.g., hemolytic anemia) or loss (e.g., hemorrhage). A decrease in the reticulocyte count may

indicate bone marrow failure or pernicious anemia. In addition, it is employed to evaluate the

effectiveness of therapy for pernicious anemia and bone marrow failure. Although the patient has a

continuous increase of his reticulocyte count, the amount of his red blood cells is continually decreasing.

Referring to the patient’s bone marrow aspiration (BMA) results, there is cellular marrow with noted

increase in megakaryocyte. There are also abundant erythrocytes in a different stage of maturation with

binucleation. His body may be producing high amounts of erythrocytes as compensation for excessive

RBC loss due to insufficient amounts of platelet and clotting factors, which makes the client prone to

injuries and bleeding (Black; Medical-Surgical Nursing; 4th ed.; 1993; Pp. 1328-1332).

COMPLETE BLOOD COUNT (CBC) TEST

The CBC includes the red blood cell (RBC) count, hemoglobin, hematocrit, red cell indices,

white blood cell (WBC) count with or without differential, and platelet count. CBC is done to determine

general health status and to screen for a variety of disorders such as anemia and infection. It provides

important information about the kinds and number of cells in the blood, especially red blood cells, white

blood cells, and platelets (Black; Medical-Surgical Nursing; 4th ed.; 1993; Pp. 1328-1332).

29

Red Blood Cell Count

The RBC count measures the number of RBC’s per cubic millimeter (mm3) of blood. These

values are useful in verifying findings from other hematologic tests used to diagnose anemia (↓RBC) and

polycythemia (↑RBC). Normal values vary with age and sex. Our patient is an infant boy. Infants have

not yet fully developed a strong immune system at their age. Their blood production will not be good

enough, especially when a disorder or disease attacks their health, particularly disorders that affect the

hematologic system. The incidence of ITP in children is 85% of who are under 8 years of age wherein the

disease is self-limiting. Based on the patient’s laboratory results, he has a continuous decrease of his red

blood cells from his admission day up to his succeeding hospital days. The latest result is 3.93 x 10^12/L.

Red blood cell count or RBC production is decreased by anemia, fluid overload, recent hemorrhage, and

leukemia. Referring to the CT scan of the head, there is a small focus of hemorrhage on the left vermis,

which could be the main cause of the patient’s decreasing RBC amount and reduced hematologic values

as well. The patient is anemic due to insufficient amounts of his red blood cells. Thus, the patient’s

hematologic system is not able to provide enough oxygen to tissues. As a tendency, there is lack of

energy in the patient’s activities (Black; Medical-Surgical Nursing; 4th ed.; 1993; Pp. 1328-1332).

Hematocrit

Often used in place of the RBC count, hematocrit measures the percent volume of RBCs in whole

blood. This test is useful in the diagnosis of anemia, polycythemia, and abnormal hydration states. The

hematocrit value is roughly three times the hemoglobin concentration. Normal values also vary with age

and sex. Based on the patient’s laboratory results, there is a continuous decrease of his hematocrit level

except for his 8th hospital day (December 05) which revealed a normal result. The latest result is 0.34L/L.

Hematocrit level is decreased by hemodilution (fluid overload), anemia, and acute massive blood loss.

The amount of his red blood cells is low, making the hemoglobin and hematocrit levels decreased as well.

Thus, the blood is also less viscous in nature because of decreased RBC production (Black; Medical-


Hemoglobin

The hemoglobin determination evaluates the hemoglobin content of erythrocytes by measuring

the number of grams of hemoglobin/100 ml of blood. This measurement helps indicate anemias and

polycythemia in clients. Normal hemoglobin levels vary with age and sex. Based on the patient’s

laboratory results, he has decreased amounts of his hemoglobin level only on two separate days, upon his

admission (November 27) and on his 6th hospital day (December 03). The latest result is 116g/L.

Hemoglobin level is decreased by hemodilution, anemia, and recent hemorrhage. The patient had a recent

30

hemorrhage as referred to in his head CT scan. The amount of his red blood cells is abnormally low,

making the hemoglobin and hematocrit levels decreased eventually. Decreased levels of hemoglobin

content evaluate poor iron status and oxygen carrying capacity of erythrocytes in the patient’s

hematologic system, making the patient weak and not playful at times. The patient is also possible to have

difficulty of breathing and respiratory distress because of instances of having a decrease in his

hemoglobin level, indicating insufficient oxygen circulating in the body for proper functioning of systems

(Black; Medical-Surgical Nursing; 4th ed.; 1993; Pp. 1328-1332).

White Blood Cell Count

The WBC count measures the number of WBCs in a cubic millimeter (mm3) of blood. It helps

detect infection of inflammation and is useful in monitoring a client’s response to chemotherapy or

radiation therapy. Based on the client’s laboratory results, he has an increased amount of white blood

cells during his initial laboratory test upon admission (November 27). White blood cell count or WBC

production is increased by infection, leukemia, and tissue necrosis. The patient is having an infection due

to his recent hemorrhage and due to other factors. Normal production of erythocytes in the bone marrow

depends on genetically normal precursor cells, functioning bone marrow, and an adequate intake of iron,

vitamin B12, and folic acid. If any of these factors is missing, erythrocytes may be fragile, misshapen,

abnormally large or small, deficient in hemoglobin, or too few in numbers. As a reaction for this, his

WBCs tend to increase in number as a compensatory mechanism to fight against infection. On the other

hand, the patient has a decreased amount of white blood cells only on his 6th hospital day (December 03),

with regards to his laboratory results. White blood cell count or WBC production is decreased by bone

marrow depression. The latest result is 6.70 x 10^9/L. If the bone marrow is depressed, it cannot produce

sufficient amounts of leukocytes to fight against infection. It will only produce immature cells that would

enable foreign cells to invade the immune system, making the patient eventually susceptible to infection

and blood disorders (Black; Medical-Surgical Nursing; 4th ed.; 1993; Pp. 1328-1332).

WHITE BLOOD CELL DIFFERENTIAL

This test determines the proportion of the five types of WBCs in a sample of 100 WBCs. To

figure the actual (absolute) number of a specific cell, multiply the percentage of the cell by the total WBC

count. The differential helps in evaluating the body’s capacity to resist and overcome infection and in

detecting and identifying leukemias (Black; Medical-Surgical Nursing; 4th ed.; 1993; Pp. 1328-1332).

31

Lymphocytes

Lymphocytes form the integral part of the immune system. Based on the patient’s laboratory

results, he has a continuous increase of his lymphocytes from his admission day (November 27) up to his

succeeding hospital days. The latest result is 0.75. The amount of lymphocytes is increased by viral

infections (infectious mononucleosis, pertussis, and tuberculosis), lymphocytic leukemia, and chronic

bacterial infections. An elevated number of lymphocytes occur in response to infection and usually

directed proportional to the degree of bacterial or viral invasion (Black; Medical-Surgical Nursing; 4 th ed.;

1993; Pp. 1328-1332).

Monocytes

Monocytes are phagocytic cells that constitute the reticulo-endothelial system and are responsible

for removing all foreign particulate material that enters the body. Based on the patient’s laboratory

results, he has a very minimal increase in amount of monocytes by 0.01 only on his 10 th hospital day

(December 07). The latest result is 0.07. Monocytes are increased by infections (tuberculosis, malaria,

Rocky Mountain spotted fever), collagen vascular diseases, and monocytic leukemia. The patient had a

recent viral infection (Black; Medical-Surgical Nursing; 4th ed.; 1993; Pp. 1328-1332).

Eosinophils

Eosinophils are essential to protect against parasitic infections and to modulate IgE mediated

allergic responses. Based on the patient’s laboratory results, the patient has a low amount of eosinophils

when he was referred to MAMC. However, on his 1st hospital day (November 28), he has an increased

amount of eosinophils. The latest result is 0.01. Eosinophils are decreased by stress response and

Cushing’s syndrome. On the other hand, they are increased by allergic reactions, parasitic infestations,

skin diseases, neoplasms, and pernicious anemia. The patient is having several blood transfusions which

make him possibly allergic to it that’s why he only had BT upon his admission. In addition, the patient is

developing purpura and ecchymoses that’s why the amount of his eosinophils is increased, being a

response to the allergic reactions from infection (Black; Medical-Surgical Nursing; 4 th ed.; 1993; Pp.

1328-1332).

Basophils

Basophils form the integral part of hypersensitivity reactions. Based on the patient’s laboratory

results, the amount of his basophils are normal, 0.00. It is usually decreased by corticosteroids, allergic

reactions, and acute infections. Decline is unlikely to be detected because normal count is within zero to

32

minimal range. However, they are increased by leukemia, some hemolytic anemias, and polycythemia

vera (Black; Medical-Surgical Nursing; 4th ed.; 1993; Pp. 1328-1332).

Segmenters, Stabs, and Atypical Cells

Based on the patient’s laboratory results, the patient has a continuous decrease in his segmenters

just like his RBCs. The latest result is 0.17.

Based on the patient’s laboratory results, the patient has a continuous decrease in his stabs just

like his RBCs. The latest result is 0.01. Early in the response to infection, immature forms of neutrophils

will be seen. These are called stab or band cells. The presence of these immature cells is called “a shift to

the left” and can be the earliest sign of a WBC response, even before the WBC becomes elevated. There

is also a presence of atypical cells. The latest result is 0.02 (Black; Medical-Surgical Nursing; 4 th ed.;

1993; Pp. 1328-1332).

MORPHOLOGY / PERIPHERAL BLOOD SMEAR

A peripheral blood smear is an examination of the peripheral blood to determine variations and

abnormalities in erythocytes, leukocytes, and platelets. Cells of normal size and shape are termed

normocytes. Cells of normal color are called normochromic. Abnormalities of erythrocyte size, shape,

and color usually indicate some form of anemia. The patient has positive hypochromasia and anisocytosis

based on his laboratory results. There is a presence of those abnormal cells in the blood. Hypochromic

cells appear pale because of abnormally low hemoglobin content particularly due to the patient’s anemic

condition. Anisocytes vary from normal in size characterized by any of the anemias also (Black; Medical-


ACTUAL PLATELET COUNT (APC) TEST

The platelet count measures the number of circulating platelets in venous or arterial blood and

evaluates thrombocyte (platelet) production, which has a role in blood clotting. The count is valuable in

assessing the severity of thrombocytopenia (abnormally low platelet count), which could result in

spontaneous bleeding. Based on the patient’s laboratory results, the patient has a continually low level of

his platelet count. On the other hand, his platelet count is gradually increasing but does not reach the

normal range. The latest result is 20 x 10^3/uL. Low platelet count results in prolonged bleeding time and

impaired clot retraction. Platelet count is usually decreased by Idiopathic Thrombocytopenia Purpura

(ITP), viral infection, AIDS, hemolytic disorders, chemotherapeutic drugs or radiation, hypersplenism or

splenomegaly, infiltrative bone marrow disease, and disseminated intravascular coagulation. The client is

diagnosed to have ITP. The client is prone to have bleeding disorders and is at risk for injuries. He is at

33

risk for easy bruising (bleeding in the skin that causes a characteristic skin rash called pinpoint red spots

or petechial rash), gum bleeding (bleeding in the mouth) or nosebleed, and internal bleeding. As

manifested on the patient’s hospital days, he had rashes, purpura, and ecchymoses which imply poor

platelet function because of insufficient amount of the essential blood component (Black; Medical-


RED BLOOD CELL INDICES

RBC indices measure erythrocyte size and hemoglobin content. These values derive from the

RBC count and hemoglobin level. The three RBC indices – mean corpuscular volume (MCV), mean

corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) – are helpful

in assessing the various anemias (Black; Medical-Surgical Nursing; 4th ed.; 1993; Pp. 1328-1332).

Mean Corpuscular Volume (MCV)

It measures the average size or volume of individual erythocytes. Based on the patient’s

laboratory results, he had a minimal increase in amount of MCV by 0.20 on his 8 th hospital day

(December 05). It means that there are abnormally large (i.e., macrocytic) cells. The latest result is

85.8fL. MCV is increased by pernicious anemia, macrocytic anemia, folic acid or vitamin B12 deficiency

anemias. The patient is anemic due to RBC loss (Black; Medical-Surgical Nursing; 4 th ed.; 1993; Pp.

1328-1332).

Mean Corpuscular Hemoglobin (MCH)

It measures hemoglobin content within erythrocyte of average size. Based on the patient’s

laboratory results, the client has normal amounts of MCH on his succeeding hospital days except for his

admission day (November 27). He had an increased amount of MCH that day. It indicates that macrocytic

cells with abnormally large volume of hemoglobin are present in the blood. There is also hemoglobin

deficiency (hypochromic cells). The latest result is 29.5pg. MCH is increased by macrocytic anemia


Mean Corpuscular Hemoglobin Concentration (MCHC)

It measures average hemoglobin concentration within 100 ml of packed red cells. Based on the

patient’s laboratory results, he had increased amounts of MCHC for his first two days in the hospital

(November 27 and 28). However, he had normal amounts of it for the following days. MCHC remains

normal when MCHC > 32 because cells are oversized (i.e., fewer cells can be packed together within

100ml. The latest result is 34.4g/dL. MCHC is increased by spherocytosis. A spherocyte is an abnormal

34

spheric red cell that contains more than the normal amount of hemoglobin, which could be the reason for

insufficient hemoglobin in the RBCs because they are not evenly distributed (Black; Medical-Surgical

Nursing; 4th ed.; 1993; Pp. 1328-1332).

35

(3) Clinical Chemistry Test (Ca, Na, K, Cl)

Date: 28 November 2009 / 11:05AM

Test Name:

Clinical ChemistryResult Unit Reference Range

Calcium 2.25 mmol/L 2.10-2.55

Sodium 137 mmol/L 137-145

Potassium 3.9 mmol/L 3.6-5.0

Chloride 104 mmol/L 98-107


The test is helpful in assessing hydration and deficiencies of elements, which serve as major

electrolytes of the body and which are the major cations and anions within cells. It is followed carefully in

patients with uremia and in those with steroid therapy such as for our client, because one of the major

treatments for ITP is steroid therapy. Based on the patient’s laboratory results, he has normal and

sufficient amounts of calcium, sodium, potassium, and chloride in the intracellular and extracellular

compartments in the fluid and blood system of the body (Black; Medical-Surgical Nursing; 4 th ed.; 1993;

Pp. 1328-1332).

(4) Clinical Chemistry Test (SGPT, Bilirubin)


Test Name:

Clinical ChemistryResult Unit Reference Range

SGPT (ALT) 37.0 U/L 9.0-52.0

Bilirubin T/D

Total Bilirubin 26.6 umol/L 17-180

Indirect Bilirubin (Bu)

[Unconjugated]17.3 umol/L 10.0-180.0

Direct Bilirubin (Bc)

[Conjugated]9.3 umol/L 0-10

36


Alanine aminotransferase (ALT), formerly SGPT, assess functions of the liver, heart, kidney, and

muscle cells and if there are damages to those organs. Elevations of this test accompany acute

hepatocellular alteration.

Serum bilirubin measures direct and indirect levels together. Direct bilirubin is increased with

impaired biliary excretion, causing conjugated fraction to accumulate in plasma. Indirect bilirubin is

increased with excessive erythrocyte hemolysis.

Based on the patient’s laboratory results, he has normal amounts of SGPT and serum bilirubin.

Thus, it indicates that his hepatic, biliary tract, and exocrine pancreatic system including the liver, heart,

kidney, and other organs are properly functioning (Black; Medical-Surgical Nursing; 4 th ed.; 1993; Pp.

1328-1332).

(5) Coagulation Test (PTT, PT)


Test Name:

CoagulationResult Unit Reference Range

PTT

Control 28.0 Sec 23.7-42.5

Patient 33.0 Sec

PT

Patient 13.8 Sec 10.8-13.8

Activity 79.8 %

INR 1.12


Laboratory studies provide the most crucial evidence for pinpointing the type and cause of a

bleeding disorder. Initially, four basic laboratory tests are performed to discern whether the bleeding

problem is due to a vascular, coagulation, or platelet defect. These tests include bleeding time, PT,

platelet count, and PTT. Ninety-nine percent of all bleeding disorders are diagnosed by the PT and PTT.

Partial thromboplastin time (PTT) is a complex method for testing normalcy of intrinsic

coagulation process. It is employed to identify deficiencies of coagulation factors, prothrombin, and

37

fibrinogen. It also monitors heparin therapy. Prolongation of time indicates coagulation disorder due to

deficiency of a coagulation factor. It is not a diagnostic for platelet disorders.

Prothrombin time (Pro time / PT) determines activity and interaction of factors V, VII, X,

prothrombin, and fibrinogen. It is also used to determine dosages of oral anticoagulant drugs.

Prolongation of time indicates person receiving anticoagulants; abnormally low fibrinogen concentration;

deficiencies of factors II, V, VII, and X; presence of circulating anticoagulants as seen in lupus

erythematosus; and impaired prothrombin activity.

Based on the patient’s diagnostic test results, he has normal results with regards to PTT and PT

test, which indicates normal intrinsic coagulation process of clotting factors. He has no deficiencies with

fibrinogen concentration (Black; Medical-Surgical Nursing; 4th ed.; 1993; Pp. 1328-1332).

(6) Coomb’s Test


Test Name: Results Normal Values

Coomb’s Direct Negative Negative

Coomb’s Indirect Negative Negative


Direct antiglobulin test (Coomb’s test) is used to detect certain antigen-antibody reactions

between serum antibodies and RBC antigens, differentiate between various forms of hemolytic anemia,

determine unusual blood types, and test for hemolytic diseases in newborns. The direct antiglobulin test

examines erythrocytes for the presence of antibodies (agglutinins) that damage erythrocytes without

causing clumping or hemolysis. It is used to crossmatch blood for blood transfusions, test umbilical cord

for erythroblastosis fetalis, and diagnose acquired hemolytic anemia.

The indirect antiglobulin test identifies antibodies to erythrocyte antigens in the serum of clients

who have a greater than normal chance of developing transfusion reactions. Both tests are agglutination

procedures that use a suspension of RBCs.

Based on the patient’s diagnostic test results, he has negative results for both direct and indirect

Coomb’s test which indicate normal results. There is no presence of agglutinins that damage the RBCs


38

(7) Group and RH Type Test


Test Name: Result

Group and RH Type “A” positive


This test is essential in order to determine the patient’s blood type that would properly crossmatch

and fit in the blood transfusion procedures. Blood transfusion is needed because of lack of blood

components and in order to give and maintain an enough supply of oxygen in the patient’s body system.

The patient has a blood type of A+, which has anti-B antibodies (Black; Medical-Surgical Nursing; 4 th

ed.; 1993; Pp. 1328-1332).

(8) Routine Culture and Sensitivity Test


Growth: No growth

Organism(s) Isolated: No organism isolated


This test is used to assess for the presence and growth of abnormal organisms or whether there is

isolation of organisms (Black; Medical-Surgical Nursing; 4th ed.; 1993; Pp. 1328-1332).

(9) Urine Analysis


Macroscopic

Color:

Transparency:

Volume:

Chemical

Specific Gravity:

Result

Light Yellow

Clear

60 mL

Result

1.010

7.0

Microscopic

White Blood Cells:

Red Blood Cells:

Epithelial Squamous:

Epithelial Round:

Amorphous Sediment:

Crystals:

Result

0-2/HPF

0-1/HPF

Occasional

None

None

None

39

pH Reaction:

Glucose:

Ketone:

Blood Occult:

Protein:

Nitrite:

Leucocyte Esterase:

Negative

Negative

Negative

Negative

Negative

Negative

Casts:

Mucus:

Bacteria:

None

Negative

Occasional


Urine analysis (urinalysis) is a physical, microscopic, or chemical examination of urine. The

specimen is physically examined for color, turbidity, and specific gravity. Then it is spun in a centrifuge

to allow collection of a small amount of sediment, which is examined microscopically for blood cells,

casts, crystals, pus, and bacteria. Chemical analysis may be performed to measure the pH and to identify

and measure the levels of ketones, sugar, protein, blood components, and many other substances. Based

on the patient’s laboratory results, the color of his urine is light yellow, which is a very healthy sign,

which indicates that there is no presence of kidney or urinary disorders in the patient. There is no blood

occult present in the urine, which indicates that there is no internal, or intestinal bleeding that takes place

in the patient’s digestive system. His renal system is functioning well (Black; Medical-Surgical Nursing;

4th ed.; 1993; Pp. 1328-1332).

(10) CT Scan of the Head


Plain axial CT images were obtained.

A small focus of hemorrhage is seen on the left side of the vermis.

No extra axial hematoma.

Ventricle is normal in size.

No midline shift demonstrated.

No abnormal calcification seen.

Peripheral sulci in the frontal and temporal lobes are accentuated.

There is beginning closure of both occipital sutures.

40

Impression:

Small focus of hemorrhage, left vermis.

Mild fronto-temporal lobe atrophy

Purpose and Interpretation of Result:

The cranial CT scan is essential to assess and determine any deformities or damages in the

skeletal system of the patient’s head. Based on the diagnostic procedure done with the patient, the result

reveals a small focus of hemorrhage in the left vermis and mild fronto-temporal lobe atrophy which

contributes a lot to the decreasing blood component values of the patient for a couple of days (Black;

Medical-Surgical Nursing; 4th ed.; 1993; Pp. 1328-1332).

(11) Blood Transfusion


Blood Transfusion #

Volume of Blood Desired

Remarks

BT 1 35cc

Transfuse PRBC properly typed and crossmatched (autoconnial, major and minor crossmatching)

1st aliquot: 35cc to run for 4hours then rest for 4hours

BT 2 45cc


2nd aliquot: 45cc to run for 4hours then rest for 4hours

BT 3 55cc


3rd aliquot: 55cc to run for 4hours

BT 4 2unitsTransfuse 2units of platelet concentrate, type specific as fast drip and may be given in between PRBC transfusion.

BT 5 2unitsTransfuse 2units of platelet concentrate, type specific as fast drip and may be given in between PRBC transfusion.

Purpose:

Blood transfusion is the administration of whole blood or a component, such as packed red

cells, to replace blood lost through trauma, surgery, or disease. Blood for transfusion is obtained from a

healthy donor or donors whose ABO blood group and antigenic subgroups match those of the recipient

and who have an adequate hemoglobin level.

41

This procedure is really essential and necessary for our patient because of the continuous

decrease in amounts of several blood components, particularly the red blood cells and hemoglobin which

are generally responsible for maintaining the iron status and oxygenation that would circulate in the

bloodstream; and platelets that are mainly responsible for the clotting action in response to bleeding and

inflammation (Black; Medical-Surgical Nursing; 4th ed.; 1993; Pp. 1328-1332).

42

XIV. NURSING OR DIAGNOSTIC PROCEDURES WITH NURSING RESPOSIBILITIES

1. CT Scan - is a method of taking an image of the brain. CT stands for computed tomography, a

procedure that produces a clear, two-dimensional image of the brain that shows abnormalities such as

brain tumors, blood clots, strokes, or damage due to head injury. A CT scan can help identify the cause of

Alzheimer's-like symptoms either by finding an abnormality or by ruling out certain conditions.

A. Indications for procedure

The doctor may recommend a CT scan to help pinpoint the location of an infection or blood clot and

detect internal injuries and internal bleeding or intracranial hemorrhage.

B. Procedure with Nursing Responsibilities

Preparing a patient for a CT scan depends on which part of the body is being scanned. The patient

may be asked to remove his clothing and wear a hospital gown. He will need to remove any metal objects,

such as jewelry, that might interfere with image results. Some CT scans require the patient to drink a

contrast liquid before the scan or have contrast injected into a vein in his arm during the scan. A contrast

medium blocks X-rays and appears white on images, which can help emphasize blood vessels, bowel or

other structures. If a test involves a contrast medium, the doctor may ask the patient to fast for a few

hours before the test. Depending on the part of the body being scanned, the doctor may ask the patient to

take laxatives, enemas or suppositories, or temporarily modify his diet. If an infant or toddler is having

the CT scan, the doctor may give the child a sedative to keep him or her calm and still. Movement blurs

the images and may lead to incorrect results. Ask the doctor how best to prepare a child. The parent may

be allowed to stay with his or her child during the test. If so, he or she may be asked to wear a lead apron

to shield him or her from X-ray exposure.

C. Risks and Complications

CT scan risks are similar to those of conventional X-rays. During the CT scan, the patient is briefly

exposed to radiation. Although rare, the contrast medium involved in a CT scan poses a slight risk of

allergic reaction. Most reactions are mild and result in hives or itchiness. For people with asthma who

become allergic to the contrast medium, the reaction can be an asthma attack. In rare instances, an allergic

reaction can be serious and potentially life-threatening including swelling in patient’s throat or other areas

of his body. If the patient experience hives, itchiness or swelling in his throat during or after his CT exam,

immediately inform the technologist or doctor. If the patient had a reaction to a contrast medium in the

past, and need a diagnostic test that may require a contrast medium again, inform the doctor. Be sure to

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let the doctor know if the patient has kidney problems, since contrast material that's injected into a vein is

removed from the body by the kidneys and could potentially cause further damage to the kidneys.

2. Bone Marrow Aspiration (BMA) - the removal of a small amount of bone marrow (usually from the

hip) through a needle. The needle is placed through the top layer of bone and a liquid sample containing

bone marrow cells is obtained through the needle by aspirating (sucking) it into a syringe. The suction

causes pain for a few moments.


A bone marrow is done to look for the cause of problems with red blood cells, white blood cells,

or platelets in people who have conditions such as thrombocytopenia, anemia, or an abnormal white blood

cell count.


Before the test, parents should know that their child will most probably cry, and that restraints

may be used. To provide comfort, and help their child through this procedure, parents are commonly

asked to be present during the procedure. Crying is a normal infant response to an unfamiliar

environment, strangers, restraints, and separation from the parent. Infants cry more for these reasons than

because they hurt. An infant will be restrained by hand or with devices because they have not yet

developed the physical control, coordination, and ability to follow commands as adults have. The

restraints used thus aim to ensure the infant's safety. After the needle is removed, the biopsy site is

covered with a clean, dry pressure bandage. The patient must remain lying down and is observed for

bleeding for one hour. The patient's pulse, breathing, blood pressure, and temperature are monitored until

they return to normal. The biopsy site should be kept covered and dry for several hours.


Bone marrow exams don't usually pose a big risk. Complications are rare, and those that do occur

are often mild. They include excessive bleeding, particularly in people with a low platelet count,

Infection, especially in people with weakened immune systems, breaking of needles within the bone,

which may cause infection or bleeding, long-lasting discomfort at the biopsy site, and complications

related to sedation, such as an allergic reaction, nausea or irregular heartbeats.

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3. 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.


Blood transfusions are done to replace blood lost during surgery or due to a serious injury. A

transfusion also may be done if the body can't make blood properly because of an illness.


Check if the patient’s blood has been typed and cross-matched. Verify that patient or significant

others (SO) have signed a written consent form. Instruct the patient or SO about signs and symptoms of

transfusion reaction (itching, hives, swelling, shortness of breath, fever, chills). Take patient’s

temperature, pulse, respiration, and blood pressure to establish baseline for comparing vital signs during

transfusion. Double check the labels with another nurse or physician to make sure that the ABO group

and Rh type agree with the compatibility record. Check the number and type on the donor blood label and

on the patient’s chart are correct. Check the patient’s identification by asking the patient’s name or SO

and checking the identification wristband. Check the blood for gas bubbles and any unusual color or

cloudiness (gas bubbles may indicate bacterial growth and abnormal color or cloudiness may be a sign of

hemolysis). Make sure PRBC transfusion is initiated within 30 minutes after removal of the PRBC from

the blood bank refrigerator. Be alert for signs of adverse reactions.


The risks of blood transfusions include transfusion reactions (immune-related reactions), non-immune

reactions, and infections. Immune-related reactions occur when your immune system attacks components

of the blood being transfused or when the blood causes an allergic reaction. Most transfusion reactions

occur because of errors made in matching the recipient's blood to the blood transfused. These

administrative errors may occur because of mislabeled blood samples or misread labels. Much effort is

made to prevent these errors; they occur about once in every 14,000 transfusions. Even receiving the

correct blood type sometimes results in a mild transfusion reaction. These reactions may be mild or

severe. Most mild reactions are not life-threatening when treated quickly. Even mild reactions, though,

can be frightening. Severe transfusion reactions can be life-threatening. Mild allergic reactions may

involve itching, hives, wheezing, and fever. Severe reactions that involve anaphylactic shock can be life-

threatening.

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Fluid overload is a common type of non-immune reaction. Fluid overload can occur when you

receive too much fluid through transfusions, especially if you have not experienced blood loss before the

transfusion. Fluid overload may require treatment with medicines to increase urine output (diuretics) to

rid your body of the excess fluid. Very rarely, a person can develop iron overload after having many

repeated blood transfusions. This condition, sometimes called acquired hemochromatosis, is often treated

with medicine. Too much iron can have an effect on many organs in the body.

The transmission of viral infections, such as hepatitis B or C or HIV, through blood transfusions

has become very rare because of the safeguards enforced by the U.S. Food and Drug Administration

(FDA) on the collection, testing, storage, and use of blood. The risk of infection from a blood transfusion

is higher in less developed countries, where such testing may not happen and paid donors are used. It is

possible for blood, especially platelets, to become contaminated with bacteria during or after donation.

Transfusion with blood that has bacteria can result in a systemic bacterial infection. Because of the

precautions taken in drawing and handling donated blood, this risk is small. There is a greater risk for

bacterial infection from transfusions with platelets. Unlike most other blood components, platelets are

stored at room temperature. If any bacteria are present, they will grow and cause an infection when the

platelets are used for transfusion.

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XV. NORMAL PHYSIOLOGY

The Immune System

The immune system is composed of many interdependent cell types that collectively protect the

body from bacterial, parasitic, fungal, viral infections and from the growth of tumor cells. Many of these

cell types have specialized functions. The cells of the immune system can engulf bacteria, kill parasites or

tumor cells, or kill viral-infected cells. Often, these cells depend on the T helper subset for activation

signals in the form of secretions formally known as cytokines, lymphokines, or more specifically

interleukins.

The organs of the immune system include the lymphatic vessels, lymph nodes, tonsils, thymus,

Peyer's patch, and spleen. Each of these organs either produces the cells that participate in the immune

response or serves as a site for immune function. Lymphocytes, a type of white blood cell, are

concentrated in the lymph nodes, which are masses of tissue that act as filters for blood at various places

throughout the body-most notably the neck, under the arms, and in the groin. As the lymph (white blood

cells plus plasma) filters through the lymph nodes, foreign cells are detected and overpowered.

The tonsils, located at the back of the throat and under the tongue, contain large numbers of

lymphocytes and filter out potentially harmful bacteria that might enter the body via the nose and mouth.

Peyer's patches, scattered throughout the small intestine and appendix, are lymphatic tissues that perform

this same function in the digestive system. The thymus gland, located within the upper chest region, is

another site of lymphocyte production, though it is most active during childhood. The thymus gland

continues to grow until puberty, protecting a child through the critical years of early development, but in

adulthood it shrinks almost to the point of vanishing.

Marrow, the soft tissue at the core of bones, is a key producer both of lymphocytes and of another

component of blood, the hemoglobin-containing red blood cells. Because of its critical role in the immune

system, it is a very serious decision to allow marrow to be extracted (itself an extremely serious operation,

of course) for use in a cancer treatment, as described in Noninfectious Diseases. The spleen, in addition to

containing lymphatic tissue and producing lymphocytes, acts as a reservoir for blood and destroys worn-

out red blood cells.

The functioning of the immune system also calls into play a wide array of substances, most

notably antibodies and the two significant varieties of lymphocyte: B cells and T cells. Antibodies, the

most well known of the three, are proteins in the human immune system that help fight foreign invaders.

B cells (B lymphocytes) are a type of white blood cell that gives rise to antibodies, whereas T cells (T

lymphocytes), are a type of white blood cell that plays an important role in the immune response. T cells

are a key component in the cell-mediated response, the specific immune response that utilizes T cells to

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neutralize cells that have been infected with viruses and certain bacteria. There are three types of T cells:

cytotoxic, helper, and suppressor T cells. Cytotoxic T cells destroy virus-infected cells in the cell-

mediated immune response, whereas helper T cells play a part in activating both the antibody and the

cell-mediated immune responses. Suppressor T cells deactivate T cells and B cells when needed, and thus

prevent the immune response from becoming too intense.

The Blood

The primary function of blood is to supply oxygen and nutrients as well as constitutional

elements to tissues and to remove waste products. Blood also enables hormones and other substances to

be transported between tissues and organs. Problems with blood composition or circulation can lead to

downstream tissue malfunction. Blood is also involved in maintaining homeostasis by acting as a medium

for transferring heat to the skin and by acting as a buffer system for bodily pH.

The blood is circulated through the lungs and body by the pumping action of the heart. The right

ventricle pressurizes the blood to send it through the capillaries of the lungs, while the left ventricle

repressurizes the blood to send it throughout the body. Pressure is essentially lost in the capillaries, hence

gravity and especially the actions of skeletal muscles are needed to return the blood to the heart.

Normally, 7-8% of human body weight is from blood. In adults, this amounts to 4-5 quarts of

blood. This essential fluid carries out the critical functions of transporting oxygen and nutrients to our

cells and getting rid of carbon dioxide, ammonia, and other waste products. In addition, it plays a vital

role in our immune system and in maintaining a relatively constant body temperature.

Blood Components

A. Red blood cells (Erythrocytes)

Red blood cells are relatively large microscopic cells without nuclei. Red cells normally make up

40-50% of the total blood volume. They transport oxygen from the lungs to all of the living tissues of the

body and carry away carbon dioxide. The red cells are produced continuously in the bone marrow from

stem cells at a rate of about 2-3 million cells per second. Hemoglobin is the gas transporting protein

molecule that makes up 95% of a red cell. Each red cell has about 270,000,000 iron-rich hemoglobin

molecules. People who are anemic generally have a deficiency in red cells. The red color of blood is

primarily due to oxygenated red cells. Human fetal hemoglobin molecules differ from those produced by

adults in the number of amino acid chains. Fetal hemoglobin has three chains, while adults produce only

two. As a consequence, fetal hemoglobin molecules attract and transport relatively more oxygen to the

cells of the body.

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B. White blood cells (Leukocytes)

White blood cells exist in variable numbers and types but make up a very small part of blood's

volume--normally only about 1% in healthy people. White blood cells are the largest of the blood cells

but also the fewest. There are 5,000 to 10,000 white blood cells per micro liter. There are several different

types of white cells but all are related to immunity and fighting infection. Leukocytes are not limited to

blood. They occur elsewhere in the body as well, most notably in the spleen, liver, and lymph glands.

Most are produced in our bone marrow from the same kind of stem cells that produce red blood cells.

Others are produced in the thymus gland, which is at the base of the neck. Some white cells (called

lymphocytes) are the first responders for our immune system. They seek out, identify, and bind to alien

protein on bacteria, viruses, and fungi so that they can be removed. Other white cells (called granulocytes

and macrophages) then arrive to surround and destroy the alien cells. They also have the function of

getting rid of dead or dying blood cells as well as foreign matter such as dust and asbestos. Red cells

remain viable for only about 4 months before they are removed from the blood and their components

recycled in the spleen. Individual white cells usually only last 18-36 hours before they also are removed,

though some types live as much as a year.

C. Platelets (Thrombocytes)

Platelets are only about 20% of the diameter of red blood cells, the most numerous cell of the

blood. The normal platelet count is 150,000-450,000 per microliter of blood, but since platelets are so

small, they make up just a tiny function of the blood volume. The principal function of platelets is to

prevent bleeding. Platelets are produced in the bone marrow, the same as the red blood cells and most of

the white blood cells. They are produced from very large bone marrow cells called megakaryocytes. As

megakaryocytes develop into giant cells, they undergo a process of fragmentation that results in the

release of over 1,000 platelets per megakaryocytes. The dominant hormone controlling megakaryocytes

development is thrombopoietin.

Platelets are not only the smallest blood cell, they are the lightest. Therefore they are pushed out

from the center of flowing blood to the wall of the blood vessel. There they roll along the surface of the

vessel wall, which is lined by cells called endothelium. The endothelium is a very special surface, like

Teflon, that prevents anything from sticking to it. However when there is injury or cut, and the

endothelial layer is broken, the tough fibers that surround a blood vessel are exposed to the liquid flowing

blood. It is the platelets react first to injury. The tough fibers surrounding the vessel wall, like an envelop,

attract platelets like a magnet, stimulate the shape change, and platelets the lump onto these fibers,

providing the initial seal to prevent bleeding, the leak of red blood cells and plasma through the vessel

injury.

49

Platelets are vital for normal blood clotting. Produced in the bone marrow, they circulate in the

blood until they are needed. When there is an injury to a blood vessel, platelets adhere to the injury site

(with the help of von Willebrand factor, which acts as the “glue”), aggregate with other platelets, release

compounds that stimulate further aggregation, and form a loose platelet plug in a process called

hemostasis.

50

XVI. PATHOPHYSIOLOGY

A. Pathophysiology Diagram

Etiology: Idiopathic Predisposing factors:-Common in children less than 2-4 y.o.-Previous exposure to bacterial infection during prenatal period. (UTI of mother)-Recent live/attenuated vaccines

Risk factors:-Age (common in children and young adults)-Gender (common in women)

Inflammatory response of the body

Fever-T-39.3°C

Body weaknessDec. 1, 2009

Stimulates immune system

Dominance of pro-inflammatory cytokines & T-cell repertoire

Abnormal autoimmune reaction(Auto-immunity)

Production of anti-bodies

Nov. 27, 2009 Dec. 5,2009Paracetamol (Calpol) Amoxicillin Ampicillin (Omnipen) (Amoxil)Amikacin (Amikin)

React with platelet membrane

Platelet become antigenic

Anti-bodies bind with viral or bacterial antigen

Phagocytosed by splenic macrophages

Destruction of platelets

Production of antibodies against glycoproteinIgG coated the platelets

Lab Results:White Cell Count:

Nov. 27, 2009 ↑20.74 x109/LNov. 28, 2009 9.00 x109/LDec. 3, 2009 ↓4.70 x109/LDec. 5, 2009 7.80 x109/LDec. 7, 2009 7.40 x109/LDec. 10, 2009 6.70 x109/L

Nov.30, 2009Hydrocortisone

(Cortef)

Legend:- Manifestation- Lab results- Medications- Diagnosticprocedures

51

↓ platelet count

Blood Transfusion:Nov. 27, 2009

BT 1-35 cc PRBCBT 2-45cc PRBCBT 3-55cc PRBCBT 4-2 units platelet concentrateBT 5-2 units platelet concentrate

Bone Marrow AspirationNov. 30, 2009

Lab Results: Platelet count: (Reference range 140-450 x 103/UL) Nov. 27, 2009 ↓ 6 x 103/ULNov. 28, 2009 ↓7 x 103/ULDec. 3, 2009 ↓10 x 103/ULDec. 5, 2009 ↓10 x 103/ULDec. 7, 2009 ↓19 x 103/ULDec. 10, 2009 ↓20 x 103/UL

↑ number of cytotoxic cells

Nov.29, 2009Diphenhydramine

(Benadryl)

PainNov.30, 2009

↑ Demand in number of platelets

↑ Workload for Megakaryocytes to produce new platelets

Damaged megakaryocyte

↓ platelet lifespan

52

Altered clotting Delayed wound healing

If blood vessel has been damaged

Leak in blood vessel

Lab Results:Coagulation Test:

PTT(Reference range 23.7-42.5 sec)•control-28.0 sec•patient-33.0 sec

PT(Reference range 10.8-13.8 sec)•patient- 13.8 sec•activity-70.8 % • INR-1.12

*The coagulation test is normal. There is altered blood clotting due to decreased number of platelets and not due to absence of clotting factors.

Local hemorrhage

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Physical Assessment:Nov. 27, 2009-petechial rashes on face, trunk, extremeties,

buccal mucosa, tongue midline & left eyeNov. 29, 2009-purpura on face, extremeties & trunk

↓ Blood volume

Dehydration

Narrow pulse pressure 100/90 bpm

↓ number of RBC

↓ number of Hgb

Pale skin colorNov.27, 2009

When there is intracranial hemorrhage

Hemorrhagic shock

Possible complication:DEATH

Permanent loss of brain function

CT-Scan of the Head:Nov. 29, 2009

A small focus of hemorrhage is seen on the left side of vermis.

Lab Results: Date: Hgb Hct

(110-160 g/L) (0.37-0.47 L/L)Nov. 27, 2009 ↓48 ↓0.13Nov. 28, 2009 116 ↓0.32Dec. 3, 2009 ↓96 ↓0.28Dec. 5, 2009 110 ↓0.32Dec. 7, 2009 118 ↓0.34Dec. 10, 2009 116 ↓0.34

↓Oxygen supply

Body weaknessDec. 1, 2009

54

B. Pathophysiology Narrative

Idiopathic thrombocytopenic purpura (ITP), also called immune thrombocytopenic purpura, is a

blood-clotting disorder that can lead to easy or excessive bruising and bleeding. ITP results from

unusually low levels of platelets, the cells that help the blood clot. ITP is a common manifestation of

autoimmune disease in children. The syndrome maybe preceded by bacterial/viral infection.

In the patient’s case previous infection of the mother and recent live/ attenuated vaccines

triggered him to acquire the disease. The dominance of pro-inflammatory cytokines and T cell repertoire

causing the body to develop fever and cough as an inflammatory response of body against infection that

persist in patient creating a permissive environment for the emergence of previously suppressed auto

antibodies that will triggers the immune system to have an abnormal autoimmune reaction where in the

antibodies produced bind with viral antigen and cross react with platelet causing the platelet membrane

proteins become antigenic and stimulate the immune system to produce auto antibodies and cytotoxic

cells. These auto antibodies are against platelet glycoprotein GPIIb-IIIa or GP1b-IX that attributed to the

ability of these auto antibodies to coat circulating platelets. Instead of only phagocytosing the viral

antigen by splenic macrophages what happens is, it also phagocytosed the antibody coated platelet

because the body cannot distinguished self from non self. Cytotoxic cells damage megakaryocyte

production of new platelets causing the platelets to survive only a few hours instead of normal which is 7-

10 days that result in destruction of platelets because of cytotoxic T cells and splenic macrophages that

result in decrease platelets count.

There is altered blood clotting due to decrease number of platelets and not due to absence of

clotting factors. Thus, delayed wound healing is present that results to hemorrhage. On the other hand

when blood vessels have been damaged leakage in blood vessels is also manifested that results in local

hemorrhage. There are three things that can happen if there is hemorrhage. First, it will result to decrease

in blood volume and because of it dehydration can occur and narrow pulse pressure will be evident.

Second, a decrease in number of RBC and hemoglobin causes decrease in oxygen supply to the body;

leading to body weakness and pale skin color as manifested by the patient. Third, petechial rashes and

purpura on the face, trunk, extremities, buccal mucosa, tongue midline and left eye will be visible because

of ruptured blood vessel. On Barney’s CT scan result there is a small focus of hemorrhage seen on the left

side of his vermis. This finding may result to permanent loss of brain function and probably death.

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VII. NURSING CARE PLAN

Problem Prioritization

1. Acute pain

2. Risk for further bleeding

3. Fever

4. Risk for infection

5. Body weakness

6. Lack of knowledge

7. Disabled family coping

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NURSING PROBLEM with

CUES

NURSING DIAGNOSIS with RATIONALE (with

reference)

(SMART) GOALS/ OBJECTIVES

NURSING INTERVENTIONS

RATIONALE FOR INTERVENTIONS

EXPECTEDOUTCOMES

EVALUATION

1. Acute painDate: Nov. 30,2009

Subjective:

“Iyak siya ng iyak dahil kakatapos niya pa lang ng bone marrow aspiration”, as verbalized by the mother.

Objective:

• moaning • vigorous cry• T – 36.5 ˚C• ↑ HR-62 bpm• ↑ RR-165 bpm• BP 100/70mmhg• Restlessness• Irritability

Acute pain related to actual tissue damage.

Rationale:An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; pain may be sudden or slow onset, vary in intensity from mild to severe, and be constant or recurring; duration of pain is less than 6 months; and period of pain has an anticipated or predictable end. (Parks and Taylor’s Nursing Diagnosis Reference Manual 7th edition; p. 508)

Short term goal:

Within 30 minutes to 1 hour of nursing interventions, the patient will show signs of relief from pain and discomfort as evidence by having a good cry, not irritable, and by being calm. Long term goal:

After 2-3 days of nursing interventions, patient will be free from pain discomfort as evidenced by continually being calm and not irritable.

1. Assessed child’s physical symptoms and behavioral cues such as moaning and crying.

2. Repositioned the client and gave other comfort measures.

3. Applied heat or cold as appropriate to the pain site.

1. Young child lacks verbal skills to describe variation in pain sensation. Observations of non-verbal behavior provide alternative means to assess pain in a child. (Nursing Diagnosis Reference Manual 7th ed. p.509)

2. Non pharmacologic techniques decrease the pain and may enhance the effectiveness of analgesics if given by reducing muscle tension.(Nursing Diagnosis Reference Manual 7th ed. p.509)

3. Applying heat relaxes the muscles and decreases pain. Applying cold results in vasoconstriction reducing inflammatory response and reducing pain.(Nursing Diagnosis Reference Manual 7th ed.

1. Child will demonstrate improve comfort through less cry, smiling, playful behavior, good appetite (breastfeed) and responsive behavior.

Short term goal:Goal not met. The patient is still in pain and discomfort.

Long term goal:Goal met. The patient was free of pain and discomfort.

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4. Helped the child obtained an interrupted rest periods.

5. Anticipated and checked the patient from time to time for onset of pain.

6. Administered pain medication as ordered, Paracetamol (Calpol) 0.6ml drops

7. Provided non-pharmacologic treatment such as giving bonding or encouraging touch therapy of the mother for the infant and providing classical music.

p.509)

4. Adequate rests promotes the child’s well being and enhances the effectiveness of pain medication.(Nursing Diagnosis Reference Manual 7th ed. p.509)

5. Careful pain management can improve relief.(Nursing Diagnosis Reference Manual 7th ed. p.509)

6. Relief of mild to moderate pain. (MIMS)

7. Touch is the most intimate and meaningful of nonverbal techniques that could also be therapeutic. It lessens pain and diverts the child’s feelings when he is aware that the primary caregiver (mother) is present. The type of children to which children prefer to listen often conveys and soothes their mood.

58

8. Provided a variety of stimulating toys and divertional activities and play for the infant such as playing a “peek-a-boo” and rattles.

(Pillitteri, Adele; MCHNursing; p.998)

8. It is an additional, yet important and creative interventions that can divert the child’s attention, promote a sense of well-being, and make the child more invigorated. It can also enhance and develop the child’s neurologic system and reflex activities as well.(Pillitteri, Adele; MCHNursing; p. 1054)

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CUES

NURSING DIAGNOSIS with RATIONALE

(with reference)




EXPECTEDOUTCOMES

EVALUATION

2. Risk for Further Bleeding

Date: Nov. 29, 2009

Subjective:

“Ang dami niyang pasa at rashes” as verbalized by the patient’s mother.

Objective:

Petechial Rashes and ecchymoses on body and extremities

Hematology: (Nov. 28, 2009)

-Platelet: 6 103/UL↓ -Hgb: 116 -Hct: 0.32 ↓ V/S as follows:

(Nov. 29, 2009) -T: 36.1°C -HR: 119 bpm -RR: 30 bpm -BP: 100/70mmHg

High Risk for Injury: Bleeding related to decreased platelet count

Rationale:

Platelets play an important role in clotting and bleeding. In people with a low platelet count, bleeding is more likely to occur, even after a slight injury. Low platelet count may result in spontaneous bleeding.(Merck Manual, 2009, Sec. 3, chapter 49)

Short term goal:

Within the shift, patient’s risk for further bleeding is reduced as evidenced by vital signs within normal range, absence of narrowed pulse pressure and decreased signs of bleeding (bruises/ petechiae, epistaxis, bleeding gums, abdominal pain, hematemesis, hematuria, melena).

Long term goal:

Within 2-3 days of nursing interventions, patient will maintain reduced risk of further bleeding as evidence by normal platelet count and absence of any signs of bleeding (bruises/petechiae)

1. Assessed and monitored vital signs.

2. Assessed for any signs of bleeding.

3. Monitored platelet count.

4. Avoided IV /SC injections and rectal procedures (such as enemas and rectal temperature taking) as necessary.

5. Placed sign over patient’s bed as reminder of bleeding precautions.

1. Increased heart rate and orthostatic changes accompany bleeding. (NCP. 3rd ed., Schroeder & Jones, 1994, p 389)

2. Bleeding may be obvious (bruises/ petechiae epistaxis, bleeding gums, abdominal pain, hematemesis, melena, hematuria). (NCP. 3rd ed., Schroeder & Jones, 1994, p 389, 422)

3. Spontaneous bleeding can occur at platelet count <50,000/mm3

4. Can stimulate bleeding; to reduce unnecessary trauma. (NCP. 3rd ed., Mc McCarthy & Schroeder, 1994, p 383, 423)

5. To apply pressure after venipunctures and prevent unnecessary trauma. (NCP. 3rd ed.,

1. Patient will reduce risk of bleeding.

2. Patient will be free from any injury.

Short term goal:

Goal partially met. After 8 hours shift, patient still at risk for bleeding but eventually reduced as evidenced by vital signs within normal range, absence of narrowed pulse pressure and diminished signs of bleeding (epistaxis, hematemesis, hematuria, melena)

Nov. 29, 2009V/S as follows:BP– 90/60 mmHgT– 36. 2°CHR– 122 bpm

60

6. Maintained safe environment for patient.

7. Transfused platelets concentrate as prescribed.

8. Administered Hydrocortisone as ordered.

Puzas, 1994, p 425)

6. To prevent falls/ injury.(NCP. 3rd ed., Schroeder, 1994, p 422)

7. To restore platelets level. (NCP. 3rd ed., Schroeder & Jones, 1994, p 389)

8. Inhibition of prostaglandin formation by hydrocortisone enhances hemostasis by allowing vasoconstriction to be maintained.( Blajchman et al, 1979 p 63)

RR– 34 bpm

Long term goal:

Goal partially met. After 3 days of nursing interventions, patient maintained reduced risk for bleeding as evidenced by diminished signs of bleeding (bruises/petechiae).

Dec. 3, 2009Hematology:Platelet = 10 x 103/UL Hgb- 0.28 ↓Hct- 0.96 ↓

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CUES


reference)




EXPECTEDOUTCOMES

EVALUATION

3. FeverDate: Nov. 27, 2009

Subjective:

"Nilalagnat siya" as verbalized by the patient’s mother.

Objective:

Skin is warm to touch, flushed skin

V/S as follows: -T: 39.3°C -HR: 137 bpm -RR: 40 bpm -BP:100/90mmHg Hematology: -WBC: 20.74 -Platelet: 6 103/UL↓

Hyperthermia related to inflammatory response

Rationale:

Fever is considered one of the body's immune mechanisms to attempt a neutralization of a perceived threat inside the body. Temperature is ultimately regulated in the hypothalamus. When the set point is raised, the body increases its temperature through both active generations of heat and retaining heat and vasoconstriction both reduces heat loss through the skin and causes the person increases temperature. (NCP 7th Edition; Doenges; pp 775)

Short term goal:

After 2 hours of nursing interventions the patient’s body temperature will decrease from 39.3°C to 37.5°C.

Long term goal:

After 2-3days of nursing interventions the patient’s body temperature will be stable within normal range.

1. Monitored client temperature (degree and pattern), note shaking chills/ profuse diaphoresis.

2. Monitored environmental temperature; limited/added bed linens as indicated.

3. Provided tepid sponge baths, avoid use of alcohol

4. Administered Calpol as indicated.

5. Provide blankets.

1. Temperature of 38.9-41°C suggests acute infection due to disease process.

2. Room temperature and number of blanket should be altered to maintain near-normal body temperature.

3. May help to reduce fever. Alcohol can cause chills and elevates body temperature and can also dry the skin.

4. Use to reduce fever by its central action on the hypothalamus.

5. Use to reduce fever, usually higher than 104-105F and is a helpful aid to prevent chills.

Patient will demonstrate normal temperature of 37.5°C.

Short term goal:

Goal met. After 2 hours of nursing interventions, patient’s body temperature decreased as evidenced by normal body temperature of 37.5°C and absence of any complications.

Long term goal:

Goal met.After 2-3 days of nursing interventions, patient’s body temperature remained stable.

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http://en.wikipedia.org/wiki/Hypothalamus


CUES


reference)




EXPECTEDOUTCOMES

EVALUATION

4. Risk for InfectionDate: Nov. 27, 2009

Subjective:

“Ang daming test na ginagawa sa kanya, ang daming beses nyang kinunan ng dugo”as verbalized by the patient’s mother.

Objective:

the patient is staying in the hospital

presence of IVF puncture sites

Undergoing invasive procedure like blood transfusion.

broken skin/impaired skin integrity because of needle insertion from the IVF

Risk for infection may be related to presence of IVF, undergoing invasive procedure and being immune-compromised.

Rationale:

Broken skin because of presence of IVF and undergoing invasive procedures like blood transfusion and bone marrow aspiration may cause infection because of impaired skin integrity. (Luxner, Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed., 2005, p.50)

Short term goal:

After 30 minutes of nursing interventions the significant others will be able to perform appropriate hand washing.

Long term goal:Within the hospital days the client’s IV site will be clean and dry, without redness, edema, drainage or odor.

1. Assessed temperature every 4 hours.

2. Assessed IV site for edema, infiltration, redness, and warmth every 4 hour.

3. Washed hands before and after providing care for patient. Teach family of the child to wash hands frequently.

4. Changed IV site and tubing every 24 to 72 hours according to protocol.

1. Temperature above 37.5˚ or increase WBC may indicate development of infection. (Luxner, Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed., 2005, p.50)

2. Indicates phlebitis or dislodgement of infusion catheter for administration of fluids and IV medications. (Luxner, Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed., 2005, p.50)

3. Hand washing prevents the spread of microorganisms that may cause infection.(Luxner, Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed., 2005, p.51)

4. Prevents bacterial growth and prolonged irritation to vein. (Luxner, Karla, Delmar’s Pediatric Nursing Care

1. After the interventions the significant others will demonstrate proper hand washing procedures.

2. After the interventions the client’s IV site will be clean and dry, without redness, edema, drainage or odor.

Short term goal:

Goal met. After 30 minutes of nursing interventions the significant others was able to demonstrate proper hand washing.

Long term goal:

Goal met. During the patient’s hospital days the client’s IV site has been clean and dry, without redness, edema, drainage or odor.

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5. Administered Amikacin and Amoxicillin as ordered by physician.

Plan, 3rd ed., 2005, p.51)

5. Prevents irritation to vein and phlebitis as the drug action; for prophylaxis.(Luxner, Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed., 2005, p.53)






EXPECTEDOUTCOMES

EVALUATION

64

CUES reference)

5. Body WeaknessDate: Dec. 01, 2009

Subjective:

“Hindi masyadong ngumingiti sa amin si baby kapag nilalambing namin siya. Parang nananamlay siya,” as verbalized by the patient’s mother.

Objective:

(+) Irritability (+) Restlessness Discomfort (+) Pallor on skin

and mucous membrane

V/S as follows: -T-39.3°C -PR: 137 bpm -RR: 40bpm -BP: 100/90mmHg Hematology: -RBC: 1.55 -Hgb: 48 -Hct: 0.13 -WBC: 20.74 ↑ -Lympho: 0.44 Minimal ↓ in

Activity intolerance r/t generalized weakness and low oxygen supply in the body 2° to decreased RBC and decreased hemoglobin.

Rationale:

RBC is responsible for the delivery of oxygen to our body. Decreased levels caused decreased supply of oxygen to different parts of the body which eventually leads to fatigue.Intolerance in activity may affect the client physiologically and psychologically, and may not complete required or desired daily activities. (Geisller-Murr;2005:389)

Short term goal:

After 8 hours of nursing interventions, the patient will be able to tolerate activity as evidenced by interaction with parents such as responding through smiling and being able to tolerate feeding.

Long term goal:

After 3 days of nursing interventions, the patient will be able to continually experience comfort as evidenced by being interactive most of the time with people and responding positively through smiling and moving spontaneously.

1. Assessed functional ability/extent of impairment initially and on a regular basis.

2. Evaluated action of irritability and fatigue of the patient from parents.

3. Provided quiet environment and uninterrupted rest periods. Encouraged parents to have rest periods for the child before feeding.

4. Instructed parents and assisted in changing position at least every 2 hours (supine/side lying).

5. Set goals with parents/significant others for play or activities of the baby (solitary) such as making cooing sounds, providing objects with sounds (colored rattles), colored mobiles, etc.

1. Identifies strengths/deficiencies and may provide information regarding recovery to the parents. (Doenges;2006:232)

2. Effects of anemia may be cumulative, necessitating assistance. (Doenges;2006:232)

3. Restores energy needed for activity, cellular regeneration, and tissue healing. (Doenges;2006:232)

4. Reduces risk of tissue ischemia/injury. (Doenges;2006:233)

5. Promotes a sense of expectation of progress/improvement, including enhancement of the infant’s immune system and development of his reflexes such as grasping reflex. (Doenges;2006:233)

1. Patient will be able to demonstrate measurable increase in activity tolerance.

2. Patient show absence of body weakness.

Short term goal:

Goal partially met. Patient was able to demonstrate measurable increase in activity through being responsive to others but still maintained low levels of CBC results, making the patient less energetic.

Long term goal:

Goal partially met. Patient was able to participate in play activity as evidenced by smiling and energetic movements whenever

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feeding/ decreased sucking during feeding

6. Recommended breastfeeding for the baby.

7. Monitored CBC (laboratory results) especially RBC and platelet.

8. Transfused PRBC and platelet concentrate as prescribed.

9. Provided supplemental fluids such as IVF#5 (D5IMB 500cc x 24cc/hr)

6. Breastfeed milk is more nutritious for infants. It has certain antibodies that give more protection to the baby against diseases. (Doenges;2006:233)

7. Decreased levels indicate actual problems and may pose possible complications. (Doenges;2006:233)

8. It is essential to replace blood lost through disease. This would enable the body’s system to replace RBCs and hemoglobin which are responsible for maintaining the iron status and oxygenation of the body and the platelets that are responsible for clotting action in response to inflammation and bleeding. (Doenges;2006:233)

9. To avoid dehydration and exhaustion.(Doenges;2006:233)

parents and nurses make cooing sounds or provide colorful mobiles and objects with sounds.

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CUES


reference)




EXPECTEDOUTCOMES

EVALUATION

6. Lack of Knowledge

Date: Nov.27, 2009

Subjective:

“ hindi ko alam kung bakit nagkaganito ang anak ko” as verbalized by the patient’s mother.

Objective:

Questions/ request for information, verbalization of problem

Statement of misconception

Knowledge Deficit related to unfamiliarity with disease

Rationale:

There is a presence of knowledge deficit due to some unfamiliar information that causes some confusion to the client that needs to be discussed. (http://www.scribd.com)

Short term goal:

After 1 hour of nursing intervention the mother of the patient will verbalize accurate information about diagnosis, prognosis, and potential complications of the disease.

Long term goal:

After 2 days of nursing intervention the mother of the patient will initiate necessary lifestyle changes for her baby and correctly perform necessary procedures and explain reasons for the actions.

1. Reviewed with SO understanding of specific diagnosis, treatment alternatives, and future expectations.

2. Provided anticipatory guidance with SO regarding treatment protocol.

3. Reviewed with SO the importance of maintaining optimal nutritional status.

4. Assessed oral mucous membranes routinely, noting erythema, ulceration.

5. Advised patient’s mother concerning skin and hair care: e.g., avoid chlorinated water; avoid exposure to strong wind

1. Validates current level of understanding, identifies learning needs, and provides knowledge

2. Patient’s mother has the right to know (be informed) and participate in decision tree. Accurate and concise information helps dispel fears and anxiety.

3. Facilitates recovery

4. Early recognition of problems promotes early intervention, minimizing complications that may impair oral intake and provide avenue for systemic infection.

5. Prevents skin irritation.

1. The patient will verbalize accurate information about diagnosis, prognosis, and potential complications.

2. The patient will initiate necessary lifestyle changes for her baby and correctly perform necessary procedure and explain reasons for the actions.

Short term goal:

Goal met. The patient’s mother identified information about diagnosis and potential complications.

Long term goal:

The patient’s mother initiated necessary lifestyle changes for her baby and correctly performs necessary procedures and explains reasons for the actions.

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and extreme heat or cold.

6. Reviewed purpose and preparations for diagnostic studies.

7. Stated objectives clearly in learner’s term.

8. Provided written information/guidelines for the patient’s mother to refer to as necessary

9. Avoided all injections and rectal temperature.

10. Be alerted for sulfa- containing medication.

6. Anxiety/fear of the unknown increases stress level, Knowledge of what to expect can diminish anxiety.

7. To meet learner’s need.

8. Reinforces learning process.

9. To avoid stimulation of bleeding.

10. It can alter platelet function.

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CUES


reference)




EXPECTEDOUTCOMES

EVALUATION

7. Disabled Family Coping

Subjective: “Hindi naming matanggap mag-asawa na ganito ang nangyari sa anak namin.” as verbalized by the patient’s mother.

Objective:

Significant others display negative emotion towards baby’s condition

Family attempts supportive behaviors with less than satisfactory result.

Disabled family coping related to significant others unexpressed feelings of guilt, anxiety, despair and failure to deal adequately with underlying condition.

Rationale:

Family members are the source of strength and behavior of family member that disables their capabilities to address tasks essential to either person’s adaptation to the health challenge.(http://www.scribd.com)

Short term goal:

After 8 hours of nursing intervention, the SO will be able to understand and express feelings to expectations openly and honestly as appropriately within the family members.

Long term goal:

After 2 days of nursing intervention, the SO will be able to participate positively regarding patient care.

1. Noted the factors that may be stressful for the family like financial difficulty and lack of support group.

2. Assisted family to identify coping skills being used and how these skills are/are not helping them deal with situation.

3. Determined readiness of family members to be involved with care of patient.

4. Active-listen concerns: noted both over concern/ lack of concern, which may interfere with ability to resolve situation.

5. Acknowledged difficulty of the situation for the family, like reduce blaming or guilt.

6. Involved SO in the plan of care, provide instruction.

7. Refrained negative expression into positive one.

1. To assess causative factors and provide opportunity for appropriate referrals as much as possible. (Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed. 2005,p.50)

2. To promote wellness. (Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed. 2005,p.50)

3. To assess causative factor and underlying the willingness of the SO. (Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed. 2005,p.50)

4. To provide assistance to enable family to deal. (Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed. 2005,p.50)

5. To promote positive environment. (Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed. 2005,p.50)

6. To promote wellness. (Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed. 2005,p.50)

7. It helps to accept the situation easily and it will strengthen their faith towards the condition(Karla, Delmar’s

1. SO will be able to express feelings and expectations openly and honestly as appropriately

2. SO will be able to participate accordingly in care of patient within limits of family’s abilities and patient’s needs.

Short term goal:Goal met:After 8 hours of nursing intervention the SO has an open attitude and honest to expressed their feelings regarding baby’s condition and at the end of two-day duty they participated accordingly in caring the patient within the limits of patient’s needs.

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70

XVIII. MEDICATIONS/TREATMENT

A. GENERIC NAME(BRAND NAME)

B. GENERALCLASSIFICATION

OF DRUGS

A. INDICATIONTO PATIENT

B. OTHERINDICATIONS

C. DOSAGE

DRUG ACTION

A. SIDE EFFECTS

B. PRECAUTIONSAND SPECIAL

CONSIDERATION

(A) Amikacin (Amikin)

(B)Aminoglycoside Antibiotic

(A) Used to treat bacterial infection.

(B) Serious infection caused by the sensitive strains of pseudomonas aeroginosa, e. coli, klebsiella or staphylococcus.Uncomplicated UTI caused by organisms not susceptible to less toxic drugs.

(C) 30 mg IV q8

Binds to bacterial ribosomal subunit to cause misreading of the genetic code w/c leads to inaccurate peptide sequence of protein synthesis and bacteria death.

(A) Musculoskeletal: arthralgiarespiratory: apnea

(B) Contraindicated in patients with hypersensitivity to drug or other aminoglycosides. Use cautiously in patient with impaired renal function or neuromuscular disorder.

(A) Ampicillin (Omnipen)

(B) Beta-lactam Antibiotic

(A) Used to treat bacterial infection.

(B) Uncomplicated gonorrhea, GI infection or UTI’s

(C) 150 mg IV q6

Interferes with cell wall synthesis of susceptible organisms preventing bacterial multiplication, it also renders the cell wall osmotically unstable and burst due to osmotic pressure. Deactivated by beta- lactamase, an enzyme produced by resistant bacteria.

(A) CNS: seizure, lethargy G.I: diarrheaGO: nephropathyHematology: thrombocytopenia

(B) Contraindicated in patients with hypersensitivity to drug or other penicillin.*Before giving drugs assist patient about allergic reaction to penicillin.

(A) Hydrocortisone (Cortef)

(B)Glucocorticosteroid

(A) Used for immunosuppressive effect. Treatment of autoimmune disease/ hematologic disorder (idiophatic

Glucocorticosteroids with anti inflammatory effects because of its ability to inhibit prostaglandin of

(A) CNS: vertigo, insomniaCV: heart failureGI: pancreatitis, nausea and vomiting

71

thrombocytopenic purpura).

(B) Severe inflammation, adrenal insufficiency

(C) 10 mg IV q8

macrophages, leukocytes and fibroblast at sites of inflammation, phagocytosis and lysosomal enzyme release. It can also cause and reveals of increased capillary permeability.

(B) Contraindicated in patients with hypersensitivity to drug or its ingredients in those with systemic fungal infection. Determine whether the patient is sensitive to other corticosteroid.

(A) Diphenhydramine (Benadryl)

(B) Antihistamine

A) For the symptomatic relief of allergic condition including angio-edema, rhinitis and conjunctivitis and pruritic skin.

(B) Treatment of nausea and vomiting, particularly in the prevention and treatment of motion sickness.

(C) 6 mg IV

Acts on blood vessel, GI, respiratory system by antagonizing the effects of histamine for GI receptor site; decreases allergic response by blocking histamine; causes increased heart rate, vasodilation, and secretion, significant CNS depressant and anticholinergic properties.

(A) Orthostatic hypotension; palpitations, bradycardia, tachycardia, reflex tachycardia, extra systoles, sedation, dizziness, disturbed coordination.

(B) May cause drowsiness and dulling of mental alertness. It has been associated with clinical exacerbation of porphyria and is considered unsafe in porphyric patients.

(A) Paracetamol (Calpol)

(B) Antipyeretic

(A) Treatment of fever

(B) Relief of mild to moderate pain

(C) 0.6 ml drops 3x-4x/day

Decreases fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilation. Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not have anti inflammatory action because of its minimal effect on peripheral prostaglandin synthesis.

(A) Stimulation, drowsiness, nausea, vomiting, abdominal pain, hepatotoxicity, hepatic seizure (overdose), renal failure, leucopenia, neutropenia, hemolytic anemia.

(B) Patients with impaired kidney or liver function. Patient with alcohol dependence.

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(A) Amoxicillin (Amoxil)

(B) Penicillin/ Antibiotic

(A) Treatment of infection of skin and skin structure.

(B) Treatment of infection of respiratory tract, genitourinary tract, otitis media, meningitis, septicemia, sinusitis.

(C) 0.7 ml TID x 2 days

Prevents bacterial cell wall synthesis during replication.

(A) Dizziness, fatigue, insomnia, reversible hyperacidity, urticaria, maculopapular to expoliative, dermatitis, vesicular eruptions, itchy eyes, glossitis, stomatitis, dry mouth or tongue, abnormal taste sensation, laryngospasm, laryngeal edema, gastritis, anorexia.

(B) The possibility of superinfections with mycotic or bacterial pathogens should be kept in mind during therapy. If superinfections occur, amoxicillin should be discontinued and appropriate therapy instituted. Because of incompletely developed renal function in neonates and young infants, the elimination of amoxicillin may be delayed. Dosing of AMOXIL should be modified in pediatric patients 12 weeks or younger (≤ 3 months).

(A) Zinc Oxide (Diaparene)

(B) Emollients & skin protectives

(A) Used to treat or prevent diaper rash.

(B) Used to treat or prevent minor skin irritations (e.g., burns, cuts, poison ivy).

(C) Topical TID

It works by providing a skin barrier to prevent and help heal skin irritation.

(A) This medication is generally well tolerated when used as directed. There are no reports of any side effects due to the use of this medication. However, if you experience any unusual effects while using this medication, notify your doctor.

(B) Tell your doctor your medical history, especially of: other skin infections/problems,

73

http://www.medicinenet.com/script/main/art.asp?articlekey=451


http://www.rxlist.com/script/main/art.asp?articlekey=15038

allergies (especially drug allergies). Before using this medication, tell your doctor if you are pregnant. It is not known if this medication passes into breast milk. Consult your doctor before breast-feeding.

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XIX. DISCHARGE PLANNING

Proper nutrition and a healthy Immune system of the body are the key measures that can be

applied to prevent the spread of bacterial or viral infection in the body.

Medications

Barney is required to take amoxicillin (antibiotic) and prophylaxis from bacterial infection and to

skin rashes. Prevention of bacterial growth is necessarily to prevent the progress of the disease.

Exercise

Encourage the significant others to continuously try to make their child fit and interact

appropriately through body movements and vocalization but do not stress them too much to prevent any

problems that can occur within stressful activities.

Therapy/Treatment

Acute idiopathic thrombocytopenic purpura may be allowed to run its course without

intervention. Alternatively, it may be treated with glucocorticoids or immunoglobulin. Treatment with

platelet transfusion has met with limited success.

Health Teaching

It is important to instruct the parents to adhere to medications and the most commonly used

antiplatelets are aspirin, heparin, abciximad (reopro) as well as food such as grape skin extract, soy sauce

and to have a follow up check up to prevent developing any complications. Breastfeeding is very

important; it reduces the chances of infection and increases the immunity of the baby. Maintaining

cleanliness in the surrounding and proper hygiene can also be very beneficial because it promotes safety

and can help in boosting body’s defense and immune system and it is also an opportunity for the parents

to monitor and really give their best care for their baby. Informing the parents of the risk associated with

the disease and ensured that they understand the need to return the patient to the hospital if bleeding

occurs. Correct information and awareness of the disease can help in avoiding more complications that

may arise in the future.

Out Patient follow-up

Regular consultation to the physician is necessary to monitor the progress of the disease and

prevent any complications from developing.

75

Diet

The required diet for Barney is breastmilk which is best for him since he is just 2 months old.

Spiritual

Prayer and trusting the divine power is a healthy tip that a health care provider can give to their

patients. This will guide them spiritually and develop their faith in the almighty God that their baby will

recover and have a normal life in the future.

XX. CONCLUSION AND RECOMMENDATION

Idiopathic thrombocytopenic Purpura (ITP) is the condition of having a low platelet count of no

known cause. As most causes appear to be related to antibodies against platelets, we conclude that the

probable cause that triggered the onset of the ITP of Barney was the previous exposure to bacterial

infection during prenatal period of the mother which alters the immune response of Barney and recent

live/attenuated bacterial vaccines he received before he was admitted.

Having a child with an ITP may be a life-changing disease not only for the patient but also to his

family. We recommend the parents of a child with ITP must learn about their child’s health and condition

in order for them to manage the disease properly and appropriately in case the disease comes back again.

They must find the best hematologist available and work with them to decide which care plan is suitable

for their child. Treatment should be individualized and focused on bleeding symptoms and prevention of

treatment toxicity.

76

XXI. ACKNOWLEDGEMENT

We students of Manila Adventist College Block J from section C want to express our deep sense

of gratitude to all the individuals who have given their heart whelming full support in making this case

study possible.

To our Dear Almighty God for giving us wisdom, knowledge, strength, and patience to keep us

standing and for the hope that keep us believing that this case study would be possible and more

interesting.

We also wanted to thank our family who inspired, encouraged and fully supported us for every

trials that comes our way. To our parents and guardians for their unending financial and emotional

support and understanding, thank you for being our inspiration.

To our blockmates who willingly help us gathered and provided the necessary data and

information needed for this case study.

To Mr. Oemer Rey Daquila for the encouragement, guidance and support from the initial to the

final level of this case study enabled us to develop an understanding of the subject.

To our clinical instructors and all medical staff of Pediatric Unit of Manila Adventist Medical

Center who sincerely devoted their time and service in making of this case study.

Again, we thank you all from the bottom of our heart.

77

XXII. BIBLIOGRAPHY

Books:

Black, J. M., & Jacobs, E. M. (1993). Medical-Surgical Nursing: A Psychophysiologic Approach. 4 th ed. Hematologic Disorders (Pp. 1328-1332). USA: W. B. Saunders Company.

Kozier et al. “Fundamentals of Nursing” 8th Edition, Copyright 2007 by Pearson Education South Asia pte.Ltd

Lippincott Williams and Wilkins, “Nurses Quick Check: Diagnostic Tests, Copyright 2006 by Wolters Kluwer Company.

Marilyn E. Doenges, “Nursing Care Plans”, 4 th Edition, Copyright 1997 by F.A. Davis Company, Philadelphia, Pennsylvania.

Pilliteri, Adele “Maternal and Child Health Nursing: Care of the Child Bearing and Child Rearing Family”, 5th Edition. Copyright 2007 by Adele Pilitteri.

Sparks Shiela et al. “Nursing Diagnosis Reference Manual” 7th Edition, Copyright 2008 by Wolters Kluwer Company.

Taylor et al. “Fundamentals of Nursing”, 5th Edition, Copyright 2005 by Lippincott Williams and Wilkins

“PPD’s Nursing Drug Guide: For Nursing Students and Professional Nurses”, 2nd Edition, Copyright 2008 by Malan Press, Inc.

Internet Websites:

http://www.mayoclinic.com/health/ct-scan/MY00309. Mayo Clinic.com. Mayo Clinic Staff. January 12, 2008. Mayo Foundation for Medical Education and Research.

http://www.webmd.com/a-to-z-guides/blood-transfusion-risks-of-blood-transfusion. WebMD Better information. Better Health. December 27, 2007. Risk of Blood Transfusion. Healthwise Inc.

http://en.wikipedia.org/wiki/Blood_transfusion. Wikepedia the free encyclopedia

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http://en.wikipedia.org/wiki/Blood_transfusion

http://www.webmd.com/a-to-z-guides/blood-transfusion-risks-of-blood-transfusion

http://www.mayoclinic.com/health/ct-scan/MY00309

Documents

Idiopathic Thrombocytopenic Purpura