Nsg Ass Dx ITP

7/22/2019 Nsg Ass Dx ITP

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II. NURSING PROCESS

A. ASSESSMENT

1. PERSONAL DATA

The following relevant information with regards to the patient was obtained

through an interview process conducted by the nurse-researcher with the parents of the

client. It was agreed upon that the information gathered by the nurse-researcher would

be held confidential as the information would be utilized for the sole purpose of the

case study.

a. Demographic DataThis is a case of a 2-year old boy born on November 9, 2010 via normal

spontaneous delivery at a tertiary hospital in Angeles City, Pampanga. In the

course of this study, the patient will be named as Baby X to protect his identity.

Baby X and his parents are currently residing at Brgy. Senora in Porac, Pampanga.

Both of his parents are natural born Filipino Citizen and of Kapampangan

descent. They are members of the Roman Catholic Church. He is the first and

only child of his parents. . He was admitted in the general ward of a privatetertiary hospital in Angeles City last October 12, 2013 at 5:59 in the afternoon,

with a chief complaint of skin rashes as lifted from the chart. His initial diagnosis

is T/C Idiopathic Thrombocytopenic Purpura and he was confined for four (4)

days. He was discharged from the hospital last October 15, 2013 at 7:15pm, with

the final diagnosis of Idiopathic Thrombocytopenic Purpura.

b. Socio-Economic and Cultural Factors

Baby Xs family consists of three (3) members. His father is 23 years old, a

graduate of Computer Science course, and currently works in a tire service

center in Clarkfield, Pampanga as a tire curator. The mother is 25 years old, took

up a vocational course in dressmaking, and currently works in an electronics


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company in Clarkfield, Pampanga as a merchandiser. Both of them go to work

every day, in shifting schedules, except in the weekends where they take their

days off. When they go to work, they ask the grandmother of Baby X, who lives

just 2 houses away from them, to look after him. On their days off, they are

usually at home and take care of Baby X.

As narrated by the clients mother, Baby X is a typical 2-year old boy who is

very curious about the world around him. He likes to explore about unfamiliar

objects and likes to do pretend during play, using familiar objects and situations

to process his daily experience. He is also on the process of discovering his

blossoming language skills, asking many why, what, and how questions to

the people surrounding him. He is an active boy who likes to play with the older

kids in their neighborhood, usually in a game of basketball, as told by his father.

Baby X enjoys dancing upon request, acting out songs, and joins in singing the

refrains of his favorite song. His sleeping time is at an average of 10-11 hours a

day, usually sleeps at around 8PM and wakes up at 6AM. He also takes afternoon

naps, usually 30 minutes to an hour, as told by his mother. As for his eating

pattern, Baby X eats 3 times a day and is fond of eating rice and chicken dishes.

The parents combined salary for one month is estimated at around Php

28,000.00. The recommended share of each family member according to the

National Economic Development Authority (NEDA) must be at least Php 2,768.60

per month. The family is considered to be financially adequate because each

family member receives Php 9,333 per month, which is more than the

requirement of the NEDA. Their expenses include food allowance, monthlyutilities (water, electricity, cellular phone load), and transportation allowance.

The whole family is an active member of the Roman Catholic Church. They

go to church and hear mass every Sunday, and observe religious practices/events


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in the Catholic calendar. Despite their Catholic faith, Baby Xs mother admits she

goes to a mananawas, whenever a family member gets sick, before they seek

consult from a doctor. She said this is a practice she got from her mother. Other

than that, she said they have no other superstitious or religious practice related

to health.

c. Environmental Factors

The family owns their house and it is made up of concrete and wood

materials. There are 3 occupants in their house, and they are considered as a

nuclear family. It is a bungalow type and consists of a bedroom, a living room, a

kitchen, a dining area and bathroom. They live in a compound-type, owned by

the fathers family. Their house is located in a small barangay, with proximity of

an estimated 300 meters from the barangay hall and barangay health center.

2. MATERNAL-CHILD HEALTH HISTORY

a. Antepartal / Prenatal Data

The mother of Baby X had her last menstrual period (LMP) on Feb 2010 andher pregnancy was confirmed via a home pregnancy test on the first week of

March 2010. She is a primigravida. Baby X 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 3.1 kg. (6.9 lbs.), with no

fetomaternal complications as stated.

b. Postpartum HistoryBaby X was in a good condition at birth. There were no complications noted

during the first 28 days of his life.


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c. Infant Feeding

According to the mother, Baby X was breastfed for only three days after he

was born. The reason for this is because whenever he would try and suck milk

from his mother, there would be blood in the breast milk. He would vomit and

there would be streaks of blood in his vomitus as well. Since then, he was bottle-

fed and would consume an average of 3 to 4 bottles at 50 to 70 ml of formula

milk with a feeding interval of 3 to 4 hours per day. By the start of his 2nd

month,

Baby X consumes 3 bottles at 120 ml content of milk per day. During his 6th

month, he is able to consume 200 to 240 ml at each of four or five feedings per

day.

d. Growth and Development

Current Weight: 16.7 kgs (Ideal Wt: 11.3-18.0kg)

Based on FNRI Standard Table of Height and Weight for Age of Filipino, the

patients weight is within the expected weight of a 2 year and 11 months old

child.

1. Eriksons Psychosocial Theory: Autonomy vs Shame and DoubtThe development of autonomy during the toddler period is centered on

childrens increasing ability to control their bodies, themselves, and their

environment. They want to do things for themselves, using their newly acquired

motor skills of walking, climbing, and manipulating and their mental powers of

selection and decision making.

In this stage, Baby X learned to walk and become more mobile. According tohis mother, he started walking at age 12 months. He would walk away from her

whenever they are playing and pick toys that which he would play with. He also

began to voice out what he wants to wear and what to eat.


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Much of the learning in this stage is acquired through imitating the activities

and behaviors of others. Negative feelings of doubt and shame arise when

children are made to feel small and self-conscious, when their choices are

disastrous, when others shame them, or when they are forced to be dependent

in areas in which they are capable of assuming control.

The parents of Baby X let him do things on his own and allow him to explore

his independence. They encourage him to try new things and reassure him that

its acceptable to make or commit a mistake. They criticize his wrong actions and

behavior in a gentle, non-embarrassing manner to develop his confidence.

2. Piagets Cognitive Development: Sensorimotor (Primary Circular Reaction)

Children progress from reflex activity through simple repetitive behaviors to

imitative behavior. They develop a sense of cause-and-effect as they direct

behavior toward objects. They display a high level of curiosity, experimentation,

and enjoyment of novelty and begin to develop a sense of self as they are able to

differentiate. Problem solving is primarily trial and error. They become aware

that objects have permanencethat an object exists even though it is no longervisible.

As described the clients mother, Baby X enjoys being busy with a lot of

activities. He explores the different ways to travel like crawling, rolling, running,

climbing and jumping. He likes pretending animals, moving using his hands and

feet. He enjoys riding his toy tricycle, using pedals some of the time. At 9

months, Baby X began to realize that an object exists even if it can no longer beseen, a sign that his memory is developing.


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3. Freuds Psychoanalytical Theory: Anal Stage

Interest during the second year of life centers in the anal region as sphincter

muscles develop and children are able to withhold or expel fecal material at will.

At this stage the climate surrounding toilet training can have lasting effects on

childrens personalities.

Baby X started potty training when he was 1 year and 10 months. According

to the mother, Baby X can sit on the toilet bowl on his own but there would be

times that he still wants his mother beside him for assistance. He still wears

diaper but hes able to inform his mother when he wants to move bowel.


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3. FAMILY HEALTH-ILLNESS HISTORY

Synthesis:

The above figure shows the schematic diagram of the pertinent family history

from the patient up to the second degree relationship. Most of the family members

of Baby X 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 Baby Xs immediate family.

However, his father verbalized that one of his first-degree cousin in the paternal

side has a history of leukemia and hemophilia.

5652

HPN

53

48

23

25

Asthma

2

ITP

26 30


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4. HISTORY OF PAST ILLNESS

The history of patients past illness includes all medical conditions that the

patient had which are identified to be non-associated with the patients current medical

diagnosis. The following information was provided by the patient s parents through an

interview process conducted by the nurse-researcher.

In December 2010, the client was hospitalized due to high fever, chills, and

cough. He was diagnosed with Pneumonia. He was confined for a week and was

pharmacologically treated with an unrecalled medication, according to his mother.

Baby X got well and his health was back to normal. They were lost to follow-up.

In May 2011, Baby X was hospitalized due to Amoebiasis. He manifested a

high fever for 2 days, with frequent loose stools and a loss in appetite. The mother

also mentioned something about a blood infection detected thru a CBC test but

cannot recall the exact diagnosis given. Baby X was given antipyretics, antibiotics

and steroids and recovered well. They were lost to follow-up.

In December 2011, Baby X had a medical condition called Phimosis, the non-retraction of prepuce, which resulted to a recurrent Urinary Tract Infection. His

pediatrician advised to have him circumcised. He was treated with antibiotics for

the UTI.


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5. HISTORY OF PRESENT ILLNESS

This part of the case study focuses on Baby Xs medical conditions, medical

managements and treatments that are deemed contributory and significant to the

patients admitting Medical Diagnosis.

On September 11, 2013, Baby X was hospitalized due to high fever, non-

productive cough, lethargy, and generalized petechial rashes. According to the

mother, his platelet count was down to 50. He was diagnosed with Pnemonia and

Dengue Fever. He was given fluid resuscitation, bronchodilators, and steroids and

was discharged last Sept. 22, 2013. They were scheduled to follow up on the 28th

of

October.

On October 11, 2013, the night PTA, the mother noticed a hematoma at

patients back and right leg, violet blue in color and about the size of a 25 cent coin.

She thought it was just a bruise caused by Baby Xs playing. The following day,

October 12, new hematomas were noted at patients right and left arms and left

lower quadrant of abdomen, all violet blue in color, and almost the size of a 25 cent

coin each. Pinpoint red petechiae marks were also noted at Baby Xs back. Theydecided to bring him in a secondary hospital in Angeles City but their family

pediatrician was not available that time so they were told to go to his other clinic in

a tertiary hospital, also in Angeles City. Upon consultation, they were given requests

for laboratory work-ups. They had the work-ups done that same day, and results

yields a platelet count of 10, significantly below normal and poses a risk for

spontaneous bleeding. Hence Baby Xs admission that afternoon, with a diagnosis of

T/C ITP.


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6. PHYSICAL EXAMINATION

Physical

Assessment

October 12, 2013

(Admission Day, as lifted fromchart)

October 15, 2013

(First NPI)

a. GeneralAppearance:

Admitted this 2 years, 11 month

old boy with petechial rashes

and some ecchymosis on trunk,

and extremities, awake, alert,

not in cardiorespiratory distress.

Assessed this 2 yr old boy awake,

alert, afebrile, not in respiratory

distress.

b.

Vital Signs: T 36.3

o

CHR120 cpm

RR25 bpm

Wt16.7 kg (38.1 lbs.)

T36. 5

o

CHR119 cpm

RR30 bpm

c. Skin: Warm, pale, good skin turgor,with generalized petechial rashes

on face, trunk and extremities.

Warm, good skin turgor, with

some lightly colored ecchymosis

on trunk & right lower extremity.

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

Head Circumference: 41 cm

Normocephalic, flat fontanels,

no lesions, no clad.

e. Eyes: Pupil reactive to light, palepalpebral conjunctiva.

Pupil reactive to light, pale

palpebral conjunctiva.

f. Ears: Intact tympanic membrane, nodischarge.

Intact tympanic membrane, no

discharge.

g. Nose: Symmetrical, no deformity, noskin lesions, no swelling, no

discharge.

Symmetrical, no deformity, no

skin lesions, no swelling, no

discharge.


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h. Mouth andThroat:

Uniform pink in color, soft,

moist, smooth texture.

Uniform pink in color, soft,

moist, smooth texture.

i. Chest/Lungs: Symmetrical chest expansion, noretractions, clear breath sounds.

Symmetrical chest expansion, noretractions, clear breath sounds

j. Heart: Dynamic precordium, normalrate, regular rhythm, no

murmurs.

Dynamic precordium, normal

rate, regular rhythm, no

murmurs.

k. Abdomen: Globular, soft, normoactivebowel sound.Abdominal circumference: 43.5

cm

Globular, soft, normoactive

bowel sound

l. Back Presence of petechiae andecchymoses, no back

deformities.

Presence of ecchymoses, no back

deformities.

m. Extremities: Full and equal pulse, presence ofpetechiae and ecchymoses on

upper and lower extremities

Full and equal pulse, presence of

ecchymoses on lower

extremities.

n. Genitalia: Grossly normal, no hernia, nodischarge

Not assessed

o. Rectal: No hemorrhoids Not assessed

p. NeurologicAssessment:

Not assessed Not assessed


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7. DIAGNOSTIC AND LABORATORY FINDINGS

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.

Below are the series of results of diagnostics that was done to the patient

during his hospitalization.

HEMATOLOGY REPORT

Complete Blood Count (CBC)

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).


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Diagnostic /

Laboratory

Procedure

Date

Ordered

Date

Result IN

Indication(s)

or Purpose(s)

Results

(1st

, 2nd

,

3rd

)

Normal

Values

(Units used

in the

hospital)

Analysis and

interpretation of

results

Hemoglobin 1. Date

Ordered

Oct. 12,

2013

Result In:

Oct 12,

2013

Measures the

amount of

hemoglobin in

blood and is a

good

indication of

the blood's

ability to carry

oxygen

throughout

the body.

1. 117 g/L 110-160

g/L

Level of hemoglobin is

within normal range.

Indicates an adequate

amount of oxygen in

the blood.

2. Date

OrderedOct. 14,

2013

Result In:

Oct 14,

2013

2. 102 g/L

Level of hemoglobin is

below normal range.Indicates an

insufficient amount of

oxygen in the blood.

Hematocrit Date

Ordered

Oct. 12,2013

Result In:

Oct. 12,

2013

Often used in

place of RBC

count, it is ameasure of

the volume of

RBC in whole

blood

expressed as a

percentage.

0.32 0.31-.43 Level of hematocrit is

within normal range.

Indicates a normalvolume of red blood

cells in whole blood.

2. Date

Ordered

Oct. 14,

2013

Result In:

Oct 14,

2013

0.28 Level of hematocrit is

below normal.

Indicates a slight

impairment in the

bone marrow.


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Leukocytes

Count

Date

Ordered

Oct. 12,

2013

Result In:

Oct. 12,

2013

Used to

determine the

number of

WBCs in a

cubic milliliter

of blood.

3.84 5-15.5 x

10^9/L

The number of WBC is

below normal

indicating that the

patient is

immunocompromised.

Differential

Count:

Lymphocytes

Date

Ordered

Oct. 12,

2013

Result In:

Oct. 12,2013

It determines

the bodys

ability to fight

infections. It is

used to

determine

immunecompetence.

0.57 0.20-0.65 The lymphocyte level

is normal which

suggests bodys

capability to fight

infections.

Platelet Date

Ordered

Oct. 12,

2013

Result In:

Oct. 12,

2013

Measures

number of

circulating

platelets in

venous or

arterial blood.

10 150 - 400 x

109/L

Platelet is below

normal, results in

prolonged bleeding

time and impaired clot

retraction.

Date

Ordered

Oct. 14,

2013

Result In:

Oct 14,

2013

51

Platelet is below

normal, results in

prolonged bleeding

time and impaired clot

retraction.

Nursing Responsibilities

Before the procedure:

Inform the patients parentsthat the test is used to evaluate numerous conditions

involving the red blood cells and platelets.


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Obtain a history of the patients complaints, including a list of known allergens

(especially allergies or sensitivities to latex), and inform the appropriate health care

practitioner accordingly.

Obtain a list of medications the patient is taking, including herbs, nutritional

supplements, and nutraceuticals. The requesting health care practitioner and

laboratory should be advised if the patient regularly uses these products so that

their effects can be taken into consideration when reviewing results.

Review the procedure with the patient. Inform the patient that specimen collection

takes approximately 5 to 10 minutes. Address concerns about pain related to the

procedure. Explain to the patient that there may be some discomfort during the

venipuncture.

There are no food, fluid, or medication restrictions unless by medical direction.

During the procedure:

Instruct the patient to cooperate fully and to follow directions. Direct the patient to

breathe normally and to avoid unnecessary movement.

Observe hospitals standard protocol.

After the procedure:

Observe venipuncture site for bleeding or hematoma formation. Apply paper tape

or other adhesive to hold pressure bandage in place, or replace with plastic

bandage.

A written report of the examination will be sent to the requesting health care

practitioner, who will discuss the results with the patient

Follow-up test results and report abnormal findings that need immediate

interventions and management.


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HEMOSTASIS REPORT

Diagnostic /

Laboratory

Procedure

Date

Ordered

Date Result

IN

Indication(s) or

Purpose(s)

Results (1st,

2nd, 3rd)

Normal

Values (Units

used in the

hospital)

Analysis and

interpretation

of results

Clotting Time Date

Ordered

Oct. 12,

2013

Result In:

Oct. 12,

2013

To gauge the

integrity of part

of the blood

clotting

process.

5 mins 2.00-5.00

mins

On the upper

normal range.

Indicates mild

coagulation

problem.

Bleeding

Time

Date

Ordered

Oct. 12,

2013

Result In:

Oct. 12,

2013

Measures the

activity of the

intrinsic and

common

pathways of

coagulation.

6 mins 1.00-3.00

mins

Indicates

prolonged

bleeding time

and mild

impairment in

blood clotting

factors.


Inform the patients parents that the test is used to evalua te the bleeding and

clotting time.








venipuncture.



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CLINICAL CHEMISTRY

Diagnostic /

LaboratoryProcedure

Date

Ordered

Date ResultIN

Indication(s) or

Purpose(s)

Results (1st,

2nd, 3rd)

Normal

Values (Units

used in thehospital)

Analysis and

interpretationof results

Reticulocyte

Count

Date

Ordered

Oct. 12,

2013

Result In:

Oct. 12,

2013

A reflection of

RBC production,

reticulocyte

count measures

responsiveness

of bone marrow

to a decreased

number of

circulatingerythrocytes.

Specifically, this

measures

number of

reticulocytes

relased from

bone marrow

into blood.

6.2 0.50-2.00 % Indicates that

red cells are

being

produced and

released by

the bone

marrow at an

appropriate

rate.



Explain to the patient that the serum electrolyte test is used to determine the

electrolyte content of blood.

Advise the patient that the test requires a blood sample. Explain that he may

experience slight discomfort from the needle puncture and the tourniquet.

Instruct the patient to fast for 6 hours before the test. Notify the laboratory and

physician of medications the patient is taking that may affect test results; they

may need to be restricted.


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During the test:

Perform a venipuncture. Collect the sample in a 3- or 4-mL clot activator tube.

After the test:

Apply direct pressure to the venipuncture site until bleeding stops.If a hematoma

develops at the venipuncture site, apply direct pressure.

Tell the patient to resume medications that were discontinued before the test, as

ordered.


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BONE MARROW ASPIRATION

Bone Marrow Aspiration is a test used to assess and identify most blood dyscrasias

such as aplastic anemia, leukemia, pernicious anemia, and thrombocytopenia. A sample of

bone marrow is obtained by inserting a needle or biopsy instrument into a bone (usually

the posterior iliac crest or sternum).

Date ordered:Oct. 13, 2013

Date performed:Oct. 14, 2013

Result Date:Oct. 19, 2013

The result of flow cytometry done in UST hospital yield negative for any blood

disorder as per clients mother disclosure.



Inform the client of the plan and approximate time for the bone marrow aspiration.

Secure consent form. Check the clients medical history of allergies, especially to local anesthetics or

latex.

Obtain a sterile bone marrow aspiration tray and add the type and strength of local

anesthetic according to the physicians orders.


Determine the site from which the physician intends to obtain the sample of bone

marrow.

Position the client on his/her back or side to facilitate access to aspiration site.

Suggest distraction techniques to avoid focusing on the pressure or discomfort

associated with puncturing the bone.

Label the specimen and ensure its delivery to the laboratory.


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Follow Standard Precautions when there is a potential for contact with blood from

the client, equipment, and bedside environment.


Limit the clients activity for approximately 30 minutes after the procedure.

Monitor the puncture site frequently for continued bleeding; change or reinforce

the dressing as needed.

Report prolonged bleeding, unusual pain at the site, and signs of an infection.

Illustration:


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CHEST RADIOGRAPHY

An X-ray is an imaging test that uses small amounts of radiation to produce pictures

of the organs, tissues, and bones of the body. When focused on the chest, it can help

spot abnormalities or diseases of the airways, blood vessels, bones, heart, and lungs.


Result Date:Oct. 12, 2013

Interpretation:

Chest PA/L (Pedia)

Compared with chest taken 9-18-13, present study shows clear lungs. Heart and

great vessels are within normal size and configuration. Other chest structures are not

remarkable.



Verify doctors order. Explain the procedure to the patient; its purpose, how it is done, and takes only 5-10

minutes to complete. Inform the patient that there are no food or fluid restrictions.

Instruct patient to remove belt or metal buttons and underclothes and to put on a

gown.


Assist in positioning the patient so that x-ray films can be obtained from the most

useful angles.


Assist the patient in returning to his comfortable position.

Document the date and time the procedure was done.


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Peripheral Blood Smear (PBS)

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

variations and abnormalities in erythocytes, leukocytes, and platelets.


Result date:Oct. 12, 2013

Result:

Normocytic, hypochromic RBC without anisopoikilocytosis . WBC are decreased

with lymphocytic predominance. There are no blasts. Platelets are markedly decreased.

Impression:

T/C Acute Leukemia.


Inform the patients parents that the test is used to evaluate the bleeding and

clotting time.








venipuncture.



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Instruct the patient to cooperate fully and to follow directions. Direct the patient to

breathe normally and to avoid unnecessary movement.

Observe hospitals standard protocol.


Observe venipuncture site for bleeding or hematoma formation. Apply paper tape

or other adhesive to hold pressure bandage in place, or replace with plastic

bandage.

A written report of the examination will be sent to the requesting health care

practitioner, who will discuss the results with the patient

Follow-up test results and report abnormal findings that need immediate

interventions and management.

Documents

Nsg Ass Dx ITP