INTRODUCTION

Paroxysmal nocturnal hemoglobinuria (PNH) sometimes referred to as

Marchiafava Micheli syndrome is a descriptive term for the clinical

manifestation of red cell breakdown with release of hemoglobin into the urine that

is manifested most prominently by dark-colored urine in the morning. The term

"nocturnal" refers to the belief that hemolysis is triggered by acidosis during sleep

and activates complement to hemolyze an unprotected and abnormal red cell

membrane. However, this observation later was disproved. Hemolysis is shown

to occur throughout the day and is not actually paroxysmal, but the urine

concentrated overnight produces the dramatic change in color. PNH is now

known to be a consequence of nonmalignant clonal expansion of one or several

hematopoietic stem cells that are deficient in GPI-anchor protein (GPI-AP)

acquired through a somatic mutation of PIG-A.

Paroxysmal nocturnal hemoglobinuria is a rare disease which affects 1 out

of 5 million people. It has been suggested that, PNH may be more frequent in

Southeast Asia and in the Far East. Men and women are affected equally, and

no familial tendencies exist.

PNH may occur at any age from children (10%) as young as 2 years to

adults as old as 83 years, but it frequently is found among young adults with a

median age at the time of diagnosis was 42 years (range, 16-75 year old). In

childhood through adolescence, patients presented with more of the primary

features of aplastic anemia than the normal adult population. Other

complications, such as infections and thrombosis, occurred with equal frequency

in all age groups.

The disease process is insidious and has a chronic course, with a median

survival of about 10.3 years. Twenty-two of the 80 patients (28%) survived for 25

years. Of the 35 patients who survived for 10 years or more, 12 had spontaneous

clinical recovery at which time no PNH-affected cells were found among the red

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cells or neutrophils during their prolonged remission, but a few PNH-affected

lymphocytes were detectable in 3 of 4 patients tested.

Laboratory diagnosis can include specialized test, such as sucrose

hemolysis test, ham acid hemolysis test and fluorescent-activated cell analysis.

Treatment is mainly supportive, consisting of transfusion therapy, anticoagulation

therapy, antibiotic therapy, corticosteroids therapy and supplement therapy which

includes folic acid and iron. HSCT may be curative. Stress and strenuous

activities are contraindicated to the client. A change and adjustment in lifestyle is

encouraged for the client to be able to function in his fullest potential, minimize

the effects of the disease and somehow live a normal life.

On March 16, 2007, the U.S. Food and Drug Administration (FDA)

approved Soliris (eculizumab) for the treatment of PNH. This medicine works by

blocking part of the immune system. It should help decrease the number of blood

transfusions needed and the number of episodes of blood in the urine.

During the year 2008 to 2009, only one case of PNH is recorded at the

Tarlac Provincial Hospital. (TPH medical record).

Reason for choosing such case for presentation

Paroxysmal Nocturnal Hemoglubinuria is a rare disease which really

captures the group’s interest among the other cases of the confined patients. It

gave a thrill for all of us since we do not have any idea about it and find it very

challenging.

The researchers are eager to study about the disease due to lack of

information, facts and studies. It is a new exploration. Our curiosity towards the

condition of our patient gave us a lot of questions just like how does the disease

affects an individual in different aspects; physically, emotionally, and socially and

somehow to help this client to promote and restore client wellness by providing

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their needs and knowing the nursing responsibilities when caring the client. It is

an opportunity for us to study this disease to equip the group with knowledge and

skills to be able to manage future clients with the same disease in providing a

quality nursing care.

Importance of the case study

This case study is made for different purposes whereas it connects the

past, present and something to do in the future time. It is intended to educate,

inform and change untoward behaviors regarding the disease—Paroxysmal

Nocturnal Hemoglubinuria.

This case study will help the client to recover faster and maintain holistic

sense of wellness through applied effective management of the problem

experience by the client and it can also lessen the functional burden of the client

by understanding the treatment process and able to cope and adapt in the

present condition and also the client will be able to know the importance of taking

care of own self.

On the side of the group this case study can help each member to gain

new information about the disease and its etiology, pathophysiology, clinical

manifestations as well as the standard medical and nursing management so that

we may apply this newly-acquire knowledge to our client as well as similar

situations in the future. The group will learn new clinical skills as well as sharpen

our current clinical skills required in the management of the client with

paroxysmal nocturnal hemoglubinuria. Through this study the group members

will develop a sense of unselfish love and empathy in rendering nursing care to

the client so that the group may be able to serve future clients with a higher level

of holistic understanding as well as individual care.

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On the side of the College of Nursing this study can be a documented

guide for the students it can be a source of facts and knowledge not only for the

students within the college but open to all students who are interested on

studying about the disease.

On the side of nursing profession, this study will serve as a symbol of

importance of the nursing profession and the field of education on dealing with

client with paroxysmal nocturnal hemoglubinuria.

Objectives (nurse centered)

General Objectives

The case study aimed to represent a comprehensive study of the chosen

patient’s condition called paroxysmal nocturnal hemoglubinuria and to know

systematically the disease and its medical and nursing management and

responsibilities while taking care of the client.

Specific objectives

This study aims to:

1. Assess properly to determine the contributing factors regarding to the

clients disease and identify any present abnormalities:

a. Personal Data

b. Family history of health and illness

c. History of past illness

d. History of present illness

e. 13 areas of assessment

2. Gather the needed data that can help to understand how and why the

disease occurs

a. Diagnostic and Laboratory Procedures

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b. Anatomy and Physiology

c. Pathophysiology book base and client centered

3. Develop an individualized plan considering client characteristics or the

situation and setting a specific, measurable, attainable, realistic and time

bounded plan that reflect the onset, date of problem identified

a. Planning (nursing care plan)

4. Provide an appropriate interventions for every problems encountered

and monitor the client’s response to treatment and therapies through means

of physical assessment and communication with the client

a. Medical management

b. Surgical management

c. Nursing management

5. Judge the effectiveness of chosen interventions, nursing care, and the

quality of care provided

a. Client’s daily program in the hospital

6. Describe the general condition of the client upon discharge and know

the take home medications, exercise, treatment for the client, provide health

teachings and inform client for OPD follow-ups

a. Discharge Planning

7. Broaden the knowledge of each member through further research

about the latest news articles and journals regarding to the client disease

a. Related literature

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II. Nursing Process

A. Assessment

1. Personal Data

a. Demographic Data

Name: Mr. X

Address: Victoria Tarlac

Age: 33 year old

Nationality: Filipino

Civil Status: Married

Occupation: Tricycle driver

Religion: Born Again Christian

Health Care Financing: Parents

Date Admitted: February 10, 2009

Admitting Diagnosis: Paroxysmal Nocturnal

Hemoglubinuria

Final Diagnosis: Paroxysmal Nocturnal Hemoglubinuria

b. Environmental Status

The client is currently residing at Victoria, Tarlac for about 10 years now.

He lives with his family in a house made up of wood and concrete with

cemented floor, located at a rice farm. Their forms of transportation are

through tricycles, jeepneys, or just merely by walking. Garbage is disposed

properly through segregation which is then collected by the garbage collector

in their place. Their water source comes from a water pump. Their area is not

congested according to the patient. He is aware about his neighbors, but not

much aware of the health source in their community.

c. Lifestyle

The client wakes up each morning around 8 - 10 o’clock and starts the day

with a cup of coffee. After breakfast and rest, the client cleans the house and

their backyard. After cleaning the house, Mr. X always finds time to listen to

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the radio and watch the television as one of his past time and is also his way

to rest and relaxed. The client’s food preferences were mostly pork, poultry

products and seldom eat vegetables. According to him, he only eats

vegetables once a month. He said that even if their viand is vegetable, he

insist her mother to cook other food, specifically meat or he sets aside the

vegetables and only eats the meat. At noon, the client tends to sleep for

about 4 hours per day. The client verbalized that he early goes to sleep at

around 8 o’clock in the evening. He doesn’t use mosquito nets when sleeping

because he said that it bothers him when he always urinates at night. He

added that he doesn’t use any slippers inside their house but wears them

outside. They used to put their left over foods in a basket. Meal time was the

time where the family bonds and the time they get to know what happens

within the whole day. The client also verbalized that he doesn’t have any

vices.

d. Social

The client stated that he knows to speak and is able to understand

Ilocano, Tagalog, and English. He verbalized that he use to attend to the

Roman Catholic and Aglipayan Church but he claimed that he is a Born Again

Christian. According to him, he is not a member of any organizations.

e. Psychologic

According to the client, financial problems and his disease are his primary

stressors. He said that praying is his way to cope up with his problems; he

believes that when he prays everything will be alright. The client speaks in a

casual way during the interview and he said that he doesn’t say/speak bad

words.

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2. Family History of Health and Illness

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FATHER SIDE MOTHER SIDE

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suicide A&WA&W A&WA&W A&WA&WA&W A&W

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PNH

LEGEND

3. History of Past Illness

According to the client, he first experienced to have the signs and

symptoms of PNH when he was at the age of 29. He said that he used to urinate

frequently at night with a tea colored urine; without pain when urinating, and

urinates a large amount of urine but he doesn’t know the exact volume of urine

being excreted. He assumed and told himself that it was just normal and he did

not tell it to his parents. Few days later, the other family members noticed that he

is already pale in appearance, but he told them that it was just normal. The client

just ignored his condition. Days passed by, he said that he always felt headache,

abdominal pain, difficulty of breathing, fever and weakness. To relieve his

headache and fever, he said that he took Medicol or Alaxan and Biogesic. Until

one day, he felt severe weakness and fell to the ground while sweeping their

backyard. Because of the said incident, his family has decided to bring him to the

hospital in their place in manila. He was sent to Philippine General Hospital. He

had experienced to have blood transfusion (washed RBC) for several times

there. The doctor prescribed him to take Ferrous Sulfate. According to the client,

he continued to take Ferrous Sulfate as a supplement. He was admitted to many

different hospitals because of his condition, he was hospitalized for about 4 times

for the past 4 years. First, he was admitted at PGH and the others are in Tarlac

Provincial Hospital. He also said that he does not go to the hospital for follow-up

check-ups.

According to him, he had chicken pox when he was in grade 4. He said

that he had all the immunizations. According to him, he experience to have

cough and colds only twice a year. He doesn’t have any allergies. According to

him, he did not have any other severe diseases in the past except his current

condition.

4. History of Present Illness

Five days prior to admission the client stated that he experienced

shortness of breath, pallor for five days and generalized body weakness.

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According to the patient, when he is experiencing headache he takes a rest to

relieve it and takes paracetamol if it is accompanied by fever. He also stated that

the symptoms happen on a sudden onset. When he felt that he cannot handle

the severe body weakness and his parents noticed that he is very pale, his

parents have decided to take him to the hospital immediately. He was confined to

Tarlac Provincial Hospital on February 10 with an admitting diagnosis of

paroxysmal nocturnal hemoglobinuria.

5. Physical Examination

13 Areas of Assessment

I. Social Status

Mr. X is a 33 year old man who’s currently residing at Victoria

Tarlac together with his family. He is a jeepney driver for about two years

now but due to his current condition, he cannot be able to continue his

work. He was married one year ago and not yet bless with any children.

He described his family as having a close ties wherein he believed that

whatever problems and chaos that the family will encounter is can be

solved by helping each other and through prayers. Financial aspect is

sometimes the problem that the family undergone. But he verbalized that

his salary is just enough to sustain their daily needs. He interacts with

different people to their place and doesn’t have misunderstanding getting

along with them.

Despite his current condition, he still manages to interact with other

patient and health workers during his confinement in the hospital. His wife

is the one who stays and guide with him. The family perceived his

condition as alerting and felt nervous about it. He is not a member or

joined to any organizations in their place. The client is a Born Again

Christian and regularly attends services. He believed that life is very

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important. In times of difficulties, he seldom goes and talked with his

cousin, who is a Pastor and also his good friend to get some advice.

Norms

Social support is involved in mitigating the human stressful

response and associated illness. It meets a fundamental human need or

social ties, making life less stressful, thus indirectly contributing to good

health outcomes. Social responsibilities include forming new friendships

and assuming some community activities. Social functioning of an

individual is to form relationships with others. Social support is a

perception that one has an emotional and tangible resource to fall on

when needed; perceived social support is being followed by the family to

express the love of the family, financial aspect is one of the normal

constraints in the family. (Nursing fundamentals by Daniels; an

introduction to health and physical assessment in nursing by D’Amico and

Barbarito)

Analysis

The patient’s social status can be described as normal; he has

support system (the family) which he can turn to when facing difficult

periods particularly upon encountering emotional or coping crisis and has

a strong foundation of emotional stability. The client’s spiritual relationship

with God is very strong and he has a strong faith with Him. He also has

closed family ties and interacts well with others. He also communicates

with his fellowmen thus, he gain many friends.

II. Mental Status

Physical Appearance and Behavior

During the interview, Mr. X wears a shorts and shirt which are

appropriate for his age and for the weather. We have observed that he

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was not properly groomed, have untrimmed nails on both fingers and toes

and with uncombed hair. He looks pale and weak.

Mr. X facial expressions were appropriate for his feeling and mood

of conversation he was able to established good eye contact. When asked

to walk, he exhibits an erect posture, a smooth gait and symmetrical body

movements. He is cooperative throughout the interview and answered all

questions asked.

Level of Consciousness and Orientation

The client was conscious, coherent and responsive during the

interview. He was oriented with the time, place where he is and

recognizes the persons who are with him.

Intellectual Function

Mr. X is a graduate of 2 year Sea Man course. His ability to read

and write matched his educational level. He was able to understand every

question that was asked from him and he was able to respond to them

appropriately. He was able to remember past experiences during younger

years and recall family history.

Speech

Mr. X can speak Ilocano and Tagalog. He was able to speak

spontaneously with coherent speech. He was able to express himself.

Norms

The patient should appear relaxed with appropriate amount of

concern for the assessment. He should exhibit erect posture, a smooth

gait and symmetrical body movements with regards to posture and

movements. The patient should be clean and well-groomed and should

wear appropriate clothing for age, weather, and socio-economic status.

Facial expression should be appropriate to the content of the conversation

and should be symmetrical. The speech should have an effortless flow.

The patient’s ability to read and write should match his educational level.

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He should be aware of self and the environment and should be able to

respond appropriately to questions being asked. (Health Assessment and

Physical Examination 2nd Ed, Estes pp.656-663)

Analysis

Based on the norms given, there were no major deviations from

normal on the mental status of the patient. However, the patient has poor

personal hygiene such as not properly groomed, untrimmed nails,

uncombed hair which are associated by prolonged confinement in the

hospital.

III. Emotional Status

During the interview, Mr. X told us that “pagkakasakit ay swerte

swerte lang”. He considered that having a disease is just a bad luck

(malas). It was noted that he has a positive coping and acceptance of his

health condition. He has a strong faith in God that he considered prayers

as his source of strength.

Likewise, his relationship with his family is harmonious and conflicts

are easily resolved. During his stay in the hospital, his family is always

there beside him to support and serve whatever he needs. Aside from this,

he also added that he usually talked to their ‘pastor’ which is his cousin,

who is also his friend to asked for advice. He is also fond of watching

television during his free time. This is also his means of entertainment and

a sort of relieving stressful events in his life.

Norms

Emotional wellness is the ability to manage stress and to express

emotions appropriately. It involves the ability to recognize, accept and

express feelings, and to accept one’s limitations. (Fundamentals Of

Nursing, Kozier, pg 173.) Normal coping pattern or emotions stability could

include acceptance of the problem, adjustment to it, expressing of self-

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perception and self-control of emotions, probable temporary use of

defense mechanism and support system (Fundamentals of Nursing by

Kozier). Carrying out emotional feelings through words and facial

expressions are normal signs of present physical condition (Nursing

Fundamentals by Daniels)

Analysis

The emotional state of the patient is well established. He does not

show any emotional feeling and weaknesses while in the hospital despite

having a health condition. The patient manifest acceptance with regards

to his health condition and keep on being strong and enjoying life he had

now and he spontaneously felt support from his family and friends. He is

also capable of controlling his emotions.

IV. Motor Stability

Prior to BT the patient experienced severe body weakness and he

was mostly confined on bed due to easy fatigability. After BT the patient

regains his strength. He’s able to ambulate without assistance but still

cannot tolerate too much activity. The patient is able to transfer from bed

to chair and vice versa.

NORMS:

Motor stability is the ability to move freely, easily, rhythmically, and

purposefully in the environment. People must move to protect themselves

from trauma and to meet their basic needs. It is vital to independence; a

fully immobilized person is vulnerable and dependent as an infant.

(Fundamentals of Nsg. by Kozier)

Analysis

The patient was not able to tolerate too much activity and perform

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ADL’s due to easy fatigability. Blood transfusion is his way of regaining

his strength.

V. Body Temperature

The client’s general skin is warm to touch during the interview. The

following table indicates the client’s body temperature.

Date and hours

Temperature (0C) Analysis

2/11/09 8 am 36.5 0C Normal

10 am 36.7 0C Normal

1:30 pm 36.8 0C Normal

3:00 pm 37.1 0C Normal

2/12/09 8 am 37.8 0C Abnormal

12 noon 38 0C Abnormal

2 pm 38.3 0C Abnormal

3:30 pm 38.4 0C Abnormal

4:30 pm 38 0C Abnormal

6 pm 37.8 0C Abnormal

10 pm 37.3 0C Normal

2/13/09 8 am 37.2 0C Normal

10 am 37.4 0C Normal

2 pm 37.5 0C Normal

5 pm 38.9 0C Abnormal

6 pm 38.7 0C Abnormal

8 pm 38.5 0C Abnormal

10 pm 37.9 0C Abnormal

2/14/09 6 am 38 0C Abnormal

8 am 37.8 0C Abnormal

10 am 37 0C Normal

2 pm 37 0C Normal

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6 pm 37.2 0C Normal

2/15/09 6 am 38.2 0C Abnormal

6 pm 36.5 0C Abnormal

2/16/09 8 am 36.9 0C Normal

10 am 36.7 0C Normal

12 noon 37.2 0C Normal

1:30 pm 37.2 0C Normal

4 pm 37.2 0C Normal

10 pm 38.9 0C Abnormal

2/17/09 4 pm 38.5 0C Abnormal

10 pm 38.2 0C Abnormal

2/18/09 6 am 37.2 0C Normal

2 pm 38.8 0C Abnormal

5 pm 37.2 0C Normal

2/18/09 4 pm 37.3 0C Normal

10 pm 38.1 0C Abnormal

Norms

A healthy person's body temperature fluctuates between 97°F

(36.1°C) and 100°F (37.8°C), with the average being 98.6°F (37°C). The

body maintains stability within this range by balancing the heat produced

by the metabolism with the heat lost to the environment. Core body

temperature was established by the temperature of blood perfusing the

area of the hypothalamus (body’s temperature control center) which can

trigger the body’s physiological response to temperature. (Health

assessment and physical examination 3rd edition by Mary Ellen Zator

Estes)

Fever may suggest infections, and bleeding. A fever occurs when

the thermostat resets at a higher temperature, primarily in response to an

infection. To reach the higher temperature, the body moves blood to the

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warmer interior, increases the metabolic rate, and induces shivering.

(www. fpnotebook.com /Hemeonc/Hemolysis/PrxysmlNctrnlHmglbnr.htm )

Analysis

During the stay in the hospital, client was experienced fever almost

all the time. His fever is a response to what is happening to his body. Due

to his condition, because of inability of protein to bind into the cell

membrane whereas lacking of these complimentary protein act on the T-

lymphocytes of the cell which are primary responsible for the immune

response. These complimentary proteins cannot bind on the cell, infection

may possibly occur which is the primary cause f fever in the client.

VI. Circulatory StatusThe client’s general skin color is pale in appearance including his

conjunctiva, lips, tongue, gums, palms and nails. His peripheral pulses are

regular but apical pulse was very visible. No abnormal heart sound noted.

Capillary refill is at the speed of 5 seconds for both fingers and toes.

The client’s blood pressure and pulse rate are noted in the following table:

Date and hours Blood pressure(mmHg) Analysis

2/11/09 8 am 90/60 Abnormal

10 am 100/80 Abnormal

1:30 pm 100/60 Abnormal

3:00 pm 100/70 Abnormal

2/12/09 8 am 100/60 Abnormal

12 noon 100/60 Abnormal

2 pm 100/60 Abnormal

3:30 pm 110/60 Abnormal

4:30 pm 100/70 Abnormal

6 pm 110/70 Abnormal

10 pm 100/60 Abnormal

2/13/09 8 am 100/70 Abnormal

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10 am 110/80 abnormal

2 pm 100/60 Abnormal

5 pm 130/90 abnormal

6 pm 120/70 normal

8 pm 110/70 abnormal

10 pm 90/60 Abnormal

2/14/09 6 am 90/70 Abnormal

8 am 100/70 Abnormal

10 am 100/70 Abnormal

2 pm 110/70 Abnormal

6 pm 110/70 Abnormal

2/15/09 6 am 110/70 Abnormal

6 pm 110/70 Abnormal

2/16/09 8 am 90/60 Abnormal

10 am 100/70 Abnormal

12 noon 100/70 Abnormal

1:30 pm 100/70 Abnormal

4 pm 120/70 Abnormal

10 pm 110/70 Abnormal

2/17/09 4 pm 120/80 Abnormal

10 pm 110/70 Abnormal

2/18/09 6 am 100/60 Abnormal

2/18/09 4

pm

120/80 normal

10 pm 130/90 abnormal

Date and hours Pulse rate(beats per min) Analysis

2/11/09 8 am 89 Normal

10 am 86 Normal

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1:30 pm 87 Normal

3:00 pm 88 Normal

2/12/09 8 am 95 Normal

12 noon 96 Normal

2 pm 98 Normal

3:30 pm 106 Abnormal

4:30 pm 100 Normal

6 pm 94 Normal

10 pm 96 Normal

2/13/09 8 am 94 Normal

10 am 86 Normal

2 pm 105 *Abnormal

5 pm 102 Abnormal

6 pm 92 Normal

8 pm 91 Normal

10 pm 99 Normal

2/14/09 6 am 94 Normal

8 am 98 Normal

10 am 99 Normal

2 pm 98 Normal

6 pm 87 Normal

2/15/09 6 am 87 Normal

6 pm 90 Normal

2/16/09 8 am 88 Normal

10 am 88 Normal

12 noon 87 Normal

1:30 pm 86 Normal

4 pm 88 Normal

10 pm 86 Normal

2/17/09 4 pm 88 Normal

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10 pm 85 Normal

2/18/09 6 am 88 Normal

2/18/09 4 pm 106 Abnormal

10 pm 86 Normal

Norms

In a healthy young adult, the pressure at the highest of the pulse

(systolic pressure) is approximately 120 mmHg, and the pressure at the

lowest point of the pulse (diastolic pressure) is approximately 80 mmHg.

The normal pulse rate of a healthy young adult is 60-100 beats per

minute. Normal capillary refill is at the speed of 2-3 seconds. Lips,

conjunctiva, gums, nail beds and palms are should be pinkish in colour.

(Fundamentals of Nursing by Barbara Kozier, et al.)

Analysis

Client’s blood pressure rates were mostly abnormal compared on

the normal values. Pulse rates were somehow normal but it can also

exceed to normal values. The client pale appearance including his

conjunctiva, lips, tongue, gums, palms and nails may be an indicative of

poor circulation of blood in the body. Because red blood cells are

immaturely breaking down or hemolysis happens with this condition, blood

does not carry enough RBCs which are responsible for the red coloration

of the body surfaces.

VII. Respiratory Status

Mr. X was admitted with a chief complaint of difficulty of breathing,

weakness and pallor. Upon admission, O2 inhalation therapy was given

with a rate of 1-2 lpm. Nail clubbing was present on both hands and feet

nails. Breathing pattern is effortless and use of accessory muscles was

noted during the interview. He has a regular breathing pattern. No

abnormal breath sounds heard. Resonant sound is heard during

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percussion. The thorax is slightly elliptical in shape. The ratio of the AP

diameter to the transverse diameter is approximately 1:2.

The patient’s respiratory rate throughout the hospital confinement:

DATE AND TIME RATE INTERPRETATION2-11-09 22 Abnormal8AM 25 Abnormal10AM 22 Abnormal1:30PM 23 Abnormal3-11PM 21 abnormal

02-12-09 21 Abnormal8AM 26 Abnormal12PM 25 Abnormal2PM 33 *Abnormal3:30PM 25 Abnormal6PM 28 Abnormal10PM 28 Abnormal

2-13-09 6 am 26 Abnormal8AM 35 Abnormal10AM 26 Abnormal2PM 24 Abnormal

(3-11PM) 5PM 26 Abnormal6PM 29 Abnormal8PM 31 Abnormal10PM 29 abnormal

2-14-09(11-7AM) 25 Abnormal8AM 23 Abnormal10AM 22 Abnormal2PM 19 normal3-11PM 20 normal

02-15-09(11-7AM) 20 normal3-11PM 20 normal

2-16-09 (8AM) 30 Abnormal10AM 25 Abnormal12PM 27 Abnormal1:30PM 25 Abnormal4PM 26 Abnormal10PM 30 Abnormal

2-17-09(4PM) 30 Abnormal10PM 28 Abnormal

2-18-09(11-7AM) 26 Abnormal7AM 25 Abnormal10AM 24 Abnormal

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Norms

Normal RR is 14-20 cycles per minute. Normal respirations are

regular and even in rhythm. Depth of inspiration is unexaggerated and

effortless. Accessory muscle should not be used. Normal lung tissues

produce resonant sound during percussion. Adventitious sounds should

be absent.

The normal thorax is slightly elliptical in shape and the ratio of AP

diameter to the transverse diameter is approximately 1:2 to 5:7. In other

words, the normal adult is wider from side to side then front to back.

( Health Assessment and PE, Estes pg. 451-470)

Analysis

The patient has RR greater than 20 cpm, which means that he is

tachypneic. Tachypneic is frequently present in hypermetabolic and

hypoxic state. By increasing the RR, the body is trying to supply additional

oxygen to meet the body’s demands.

VIII. State of Physical Rest and Comfort

Mr. X usually wakes 6 o’clock in the morning and starts the day with

a cup of coffee and continues to exercise by doing house hold chores. The

client verbalized that he sometimes feels dizzy and difficulty of breathing

while doing house chores. He can work as a driver and perform activities

of daily living with full self care without the help of others. During vacant

time, he usually watches television as a form of relaxation plays basketball

or just mingle around and talked to some friends. On a daily basis, he

sleeps for about 7 to 8 hours at night and takes a 4 hours nap in the

afternoon while resting from work. Mosquitoes from their house

sometimes interrupt him but most of the time his rest and sleeping time

was not interrupted. He sometimes watches DVD’s to catch his sleep. The

client usually feels hungry every time he woke up in the morning.

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During his stay in the hospital, he was mostly confined on bed

wherein he cannot perform daily activities like eating, taking a bath,

voiding, and getting dress and requires assistance from others. He

verbalized to feel fatigue and shortness of breath even when doing light

activities. He usually sleeps for about 4 hours with some interruptions from

others patients and health workers that provide cares and procedures

every now and then. His sleep was also interfered whenever he feels the

urge to void for about 10 times in a night. He appears lethargic, restless

and irritable, weak in appearance and yawns frequently. The environment

in the hospital is not conducive and is also one factor that the client cannot

rest enough. The hospital room is not well ventilated, warm in temperature

and the weather is also hot making the client uneasy.

Norms

The sleep wake cycle is very important to young adults. They

usually have an active lifestyle, and are thought to require 7 to 8 hours of

sleep each night but may do well on less. Maintaining a regular sleep-

wake rhythm is more important than the number of hours actually slept.

Sleep exerts physiologic effects on both the nervous system and

other body structures. Sleep in one way restores normal levels of activity

and normal balance among parts of the nervous system. It is also

necessary for protein synthesis, which also allows repair processes to

occur. (Kozier et. al., Fundamentals of Nursing 7th edition)

Analysis

Client experienced no complete sleep hours and irregular sleep

pattern. Compared with the normal values, client has an inadequate

amount of sleep which made him to become emotionally irritable, have

poor concentration, and experiencing difficulty in making decisions. The

client manifest discomfort from environmental temperature and lack of

ventilation which also affects his sleep and comfort.

23

IX. Reproductive Status

Mr. X was circumcised when he was 12 years old. He verbalized

that they don’t use any contraceptive method. The client doesn’t have any

children yet. No abnormal findings were noted like tenderness,

enlargement, or nodular growth on his penis and scrotum as stated by the

client. He verbalized that he is experiencing erectile dysfunction since the

time that he felt his illness which making their marriage sexual lie and

function to be impaired.

Norms

Penile erection is managed by two different mechanisms. The first

one is the reflex erection, which is achieved by directly touching the penile

shaft. The second is the psychogenic erection, which is achieved by erotic

or emotional stimuli. The former uses the peripheral nerves and the lower

parts of the spinal cord, whereas the latter uses the limbic system of the

brain. In both conditions, an intact neural system is required for a

successful and complete erection. Stimulation of penile shaft by the

nervous system leads to the secretion of nitric oxide (NO), which causes

the relaxation of smooth muscles of corpora cavernosa (the main erectile

tissue of penis), and subsequently penile erection. Additionally, adequate

levels of testosterone (produced by the testes) and an intact pituitary

gland are required for the development of a healthy erectile system.

Analysis:

As can be understood from the mechanisms of a normal erection,

client’s impotence was develop due to hormonal deficiency, which is

disorder of the neural system, and lack of adequate penile blood supply or

psychological problems. Restriction of blood flow was arising from

impaired endothelial function which makes the client impotence. This

problem makes the client to be emotionally worried thus he feels that he

24

cannot perform his role as a husband to his wife and he cannot render his

worth in achieving their sexual satisfaction.

X. Nutritional Status

Mr. X weighs 58kg with a height of 5’7”. His computed body mass

index is 20.67. Prior to admission, the patient usually eats pork and does

not eat vegetables. Upon admission, he eats food served by the hospital.

But he still doesn’t eat vegetables, he only eat meat. He doesn’t have

difficulty of eating because he has a good set of teeth. He drinks an

average of 8-10 glasses of water a day. The patient stated that he have

lost his appetite that resulted to loss of weight from 68kg to 58kg.

BMI= weight in kg

m2

= 58 kgs. (1.675 m)2

= 58 kgs. 2.805625

BMI = 20.67 Norms

Nutrition is the sum of all the interactions between an organism and

the food it consumes. Nutrients are organic are organic and inorganic

substances found in foods and are required for body functioning. People

require the essential nutrients in food for the growth and maintenance of

all body tissues and the normal functioning of all body processes.

Several approaches attempt to approximate water needs for the

average healthy adult living in a temperate climate. The Institute of

Medicine advises that man consume roughly 3 liters (about 13 cups) of

total beverages a day and women consume 2-2 liters (about 9 cups) of

total beverages a day.

25

Many health professionals consider the BMI to be a more reliable

indicator of changes in body fat stores and whether a person’s weight

appropriate to height and may provide useful instrument of malnutrition. A

BMI with a result of 16 is considered as malnourished; BMI of 16-19 is

undernourished. BMI of 20-25 is normal. BMI; of 26-30 is over weight; BMI

of 31-40 is moderately obese to severely obese and greater than 40 is

morbidly obese (Kozier)

Analysis

The patient knows the right food to eat but he is not fond of eating

vegetable. He meets the daily water requirement. Due to his condition he

demonstrated loss of appetite and he loss weight of about 10 kilograms.

Despite the client’s condition his BMI is within normal range.

XI. Elimination Status

Client used to urinate frequently (5- times in day and -10 times in

night) with different volume which is most prominent in night time wherein

his urine becomes more tea like color in appearance without foul smell.

Defecates 1 to 2 times per day with brownish color stool. Patient

verbalized that she has no difficulty in voiding and defecating.

Norms

Normal urine output for an individual is 1200 to 1500 ml for 24hrs.

With color clarity of straw, amber transparent, faint aromatic odor and no

presence of blood. (Fundamentals of Nursing by Kozier)

Medications can have an impact on the client’s elimination health

and pattern. Diuretic increase urine production. Anti depressants,

antihypertensive and some antihistamines and OTC cold medications may

lead to urinary retention. (Nursing Fundamentals by Daniels)

26

Analysis

Tea colored urine present to the client is a manifestation of his

condition where in there is an immature breakdown of RBCs in the body

which is eventually accumulates in the urine that makes it color tea like.

Urine is more concentrated during night time because body is at rest and

does not require a lot of movement unlike in daytime.

XII. Sensory Status

Client doesn’t wear any reading aid, his pupils size are 4mm equal.

He has an intact visual acquity, sclera is anecteric and cardinal fields of

gaze are intact, in assessing corneal light reflex the reflected light seen

symmetrically in the center of each cornea, conjunctiva is pale and moist.

Reaction to light on both eyes is brisk. With uniform reaction to

accommodation. Mr. X has the ability to respond to light touch, superficial

pain and temperature. His sense of smell is normal and he can distinguish

foul and fresh odor. Client’s both nostrils are patent, no evident swelling of

the frontal and maxillary sinuses and excessive mucus discharges. With

regards to the auditory perception, Mr. X can hear spoken words w/ a 2

feet distance away from the client. Lips are pale and dry, gums are pale-

red in color, no bleeding and swelling noted. Buccal mucosa is pale in

color, smooth and moist, no lesions and halitosis noted. Tongue is also

pale in color, moist and rough, able to perform normal tongue movements,

asked client to move tongue side to side up and down. Client can

differentiate food according to taste, gag reflex present. Tonsils are

graded 1+, uvula located on the midline (Normal, no signs of

inflammation).

Norms

The client should be able to perceive light touch, superficial pain,

and temperature accurately and perceive the location of stimulus. During

assessment of auditory perception the client should be able to hear

27

spoken words from a distance of 2ft. Nostril should be patent, there should

be no evidence of swelling around the nose and eyes and lastly the client

should distinguish and identify the odors w/ each nostril. Breath should

smell fresh; lips and membranes should be pink and moist w/ no evidence

of lesions and inflammations. Tongue should be in the midline of the

mouth; the dorsum of the tongue must be pink, moist and rough (from the

taste buds) and must be w/o lesions. It should move freely and the

strength of the tongue is symmetrically strong, buccal mucosa should be

moist, smooth and free from lesions. Gums should be pale-red stippled

surface on light skinned people. Gum margins should be defined, no

presence of swelling and bleeding. Normal tonsilar size is graded 1+ or

2+, no swelling and exudates present, uvula in on the midline. Corneal

light reflex (light reflex) should be symmetrically in the center of each

cornea. Both eyes should move smoothly and symmetrically in each of the

six fields of gaze conjunctiva must appear pinkish and moist. (Health

assessment and physical examination 3rd edition by Mary Ellen Zator

Estes). Adult’s pain perception and behavior exhibited when experiencing

pain may be gender-based behaviors or by own interpretation of pain that

she/he is feeling. (Fundamentals of Nursing by Kozeir)

Analysis

Client’s pale appearance of the skin and mucous membranes

(conjunctiva and mucosa) may indicate signs of anemia or perfuse

bleeding.(Medical Surgical Nursing 11th Edition by Brunner and Suddarths)

Due to his condition, he don’t have enough blood supply wherein his

hemoglobin level is below normal (39 g/l compared to 120-10 normal) thus

making the client appearance to be pale. Hematocrit level (0.17) from a

normal 0.37-0.47 value is also very low. Other than that, client does not

show any significant deviations from the normal values and thus,

considerately shows no sensory impairment.

28

XIII. . Skin Appendages

Mr. X’s skin was pale all over the body but most apparently on the

face, mouth, lips, and conjunctiva. It is dry with minimize perspiration,

rough and warm to touch. It has no lesions and it is non tender. It returns

to its original state rapidly when the skin is pinched and released. Scalp

was pale white and there were no signs of infestation or lesions. No

dandruff found. His hair is equally distributed, rough and black in color. He

has untrimmed fingernails and toenails which pale in color and clubbing

was also evident on both his fingernails and toenails. They appeared

convex and wide and angle of the nail base was greater than 1600. Nail

surface was smooth and its thickness was uniform throughout. The

venipuncture site was located on his left cephalic vein.

Norms

Normally, the skin is a uniform whitish pink or brown color,

depending on patient’s race. No skin lesions should be present. It should

be dry with minimize perspiration. Moisture on the skin will vary from one

body area to another with perspiration normally present on the hands,

axilla, face, and in between the skin folds. Skin surface temperature be

warm and equal bilaterally. Hands and feet may be slightly cooler than the

rest of the body. Skin surfaces should be non tender. It should normally

feel smooth, even and firm except where there is significant hair growth. A

certain amount of roughness can be normal. When the skin is pinched, it

should return to its original contour when released. The scalp should be

pale white to pink in light-skinned individuals and light brown in dark-

skinned individuals. There should be no sign of infestations or lesions.

Seborrhea may be present. Hair may feel thin, straight, course, thick or

curly. It should be shinny and resilient when traction is applied. Normally,

the nails have a pink cast in light skinned individuals and are brown in

dark skinned individuals. The nail surface should be smooth and slightly

rounded or flat. Its thickness should be uniform throughout, with no

29

splintering or brittle edges. The angle of the nail base should be

approximately 1600.

Analysis

Mr. X skin was pale which is due to low hemoglobin. Untrimmed toe

nails and fingernails indicate self care deficit and clubbing of the nails

result from long-standing hypoxia. Mr. X also has poor peripheral

circulation which is indicated by slow capillary refill.

Client is at risk for infection with regards to the venipuncture he

had.

30

6. Diagnostic and Laboratory Procedures

DIFFERENTIAL COUNTS:Hematology- This diagnostic test is a tool that provides information about the hematologic system of the patient.

Diagnostic/ Laboratory procedure

Date ordered and date results

Indications orpurposes Results

Normalvalues

Analysis and Interpretation of

data

HemoglobinFebruary 10,2009

8:23 am

- is a measure of the total amount of hemoglobin in the blood. It carries oxygen to the cells from the lungs and carbon dioxide away from the cells to the lungs

31 g/l 120-180 Below normal range: In response to decrease RBC, hemoglobin also decrease

Hematocrit - measure the percentage of red blood cells in 100 ml of whole blood. Determines if the client is hydrated or dehydrated.

.092 L/L .370-.510 Below normal range: can be a sign of the presence of hemorrhage, anemia, hyperthyroidism, dietary deficiency and pregnancy.

RBC MCV MCHC MCH

used to evaluate the size, weight and hemoglobin concentration of

.90 T/L 4.2-6.3 Below normal range.Decreased RBC result in lysis of RBC due to lack of

31

RBC’s. Oxygen

transportation is its major function.

decay accelerating factor(CD55 and CD59) on RBC.

WBC Lymphocytes

- determines the number of circulating WBC’s in the blood. It monitors the presence of infection in the body.

8.1 G/L0.225

4.1-10.90.6-4.1

Within normal range. low lymphocytes indicates decrease activity of the bone marrow

Platelet - platelets are the first line of protection against bleeding.

168 G/L 140-440 Within normal range

Blood typing “A”

RH Factor +

DIFFERENTIAL COUNTS:Hematology- This diagnostic test is a tool that provides information about the hematologic system of the patient.

Diagnostic/ Laboratory procedure

Date ordered and date results

Indications orpurposes Results

Normalvalues

Analysis and Interpretation of

data

HemoglobinFebruary 13,2009 - is a measure of 36 g/l 120-180 Below normal range:

32

6:57 amthe total amount of hemoglobin in the blood. It carries oxygen to the cells from the lungs and carbon dioxide away from the cells to the lungs

In response to decrease RBC, hemoglobin also decrease.

Hematocrit - measure the percentage of red blood cells in 100 ml of whole blood. Determines if the client is hydrated or dehydrated.

.87 L/L . .370-.510 Below normal range: can be a sign of the presence of hemorrhage, anemia, hyperthyroidism, dietary deficiency and pregnancy

RBC MCV MCHC MCH

used to evaluate the size, weight and hemoglobin concentration of RBC’s. Oxygen

transportation is its major function.

1.01 T/L 4.2-6.3 Below normal range.Decreased RBC result in lysis of RBC due to lack of decay accelerating factor(CD55 and CD59) on RBC.

WBC lymphocytes

- determines the number of circulating WBC’s in the blood. It

6.9 G/L1.2

4.1-10.90.6-4.1

Within normal range

33

monitors the presence of infection in the body.

Platelet - platelets are the first line of protection against bleeding.

141 G/L 140-440 Within normal range

Blood typing “A”

RH Factor +

MCV - average volume of individual RBC’s

85.7 FL 80-97 Within normal range

MCH - calculated average weight of hemoglobin per RBC

35.6 pg 26-32 above normal range.Due to macrocytic anemia.

MHCH - average concentration or percentage of hemoglobin per RBC

414 g/l 310-360 above normal range.Due to macrocytic anemia.

34

DIFFERENTIAL COUNTS:Hematology- This diagnostic test is a tool that provides information about the hematologic system of the patient.

Diagnostic/ Laboratory procedure

Date ordered and date results

Indications orpurposes Results

Normalvalues

Analysis and Interpretation of

data

HemoglobinFeb. 14, 2009

7:05 am- is a measure of the total amount of hemoglobin in the blood. It carries oxygen to the cells from the lungs and carbon dioxide away from the cells to the lungs

45 g/l 120-180 Below normal range: In response to decrease RBC, hemoglobin also decrease

Hematocrit - measure the percentage of red blood cells in 100 ml of whole blood. Determines if the client is hydrated or dehydrated.

.097 L/L .370-.510 Below normal range: can be a sign of the presence of hemorrhage, anemia, hyperthyroidism, dietary deficiency and pregnancy

RBC MCV MCHC MCH

used to evaluate the size, weight and hemoglobin concentration of RBC’s. Oxygen

. 1.14 T/L 4.2-6.3 Below normal range.Decreased RBC result in lysis of RBC due to lack of decay accelerating factor(CD55 and

35

transportation is its major function.

CD59) on RBC.

WBC lymphocytes

- determines the number of circulating WBC’s in the blood. It monitors the presence of infection in the body.

5.4 G/L1.4

4.1-10.90.6-4.1

Within normal range

Platelet - platelets are the first line of protection against bleeding.

127 G/L 140-440 Low platelet indicates decrease activity of the bone marrow

Blood typing “A”

RH Factor +

MCV - average volume of individual RBC’s

85.5 FL 80-97 Within normal range.

MCH - calculated average weight of hemoglobin per RBC

39.5 pg 26-32Below normal range.Due to macrocytic anemia.

36

MHCH - average concentration or percentage of hemoglobin per RBC

464 g/l 310-360 Above normal range.Due to macrocytic anemia.

DIFFERENTIAL COUNTS:Hematology- This diagnostic test is a tool that provides information about the hematologic system of the patient.

Diagnostic/ Laboratory procedure

Date ordered and date results

Indications orpurposes Results

Normalvalues

Analysis and Interpretation of

data

HemoglobinFeb. 16, 2009

2:00 pm- is a measure of the total amount of hemoglobin in the blood. It carries oxygen to the cells from the lungs and carbon dioxide away from the cells to the lungs

58 g/l 120-180 Below normal range: In response to decrease RBC, hemoglobin also decrease

Hematocrit - measure the percentage of red blood cells in 100 ml of whole blood. Determines if the client is hydrated or dehydrated.

.152 L/L .370-.510 Below normal range: can be a sign of the presence of hemorrhage, anemia, hyperthyroidism, dietary deficiency and pregnancy

37

RBC MCV MCHC MCH

used to evaluate the size, weight and hemoglobin concentration of RBC’s. Oxygen

transportation is its major function.

1.80T/L 4.2-6.3 Below normal range.Decreased RBC result in lysis of RBC due to lack of decay accelerating factor(CD55 and CD59) on RBC.

WBC Lymphocytes

- determines the number of circulating WBC’s in the blood. It monitors the presence of infection in the body.

4.5 G/L1.2

4.1-10.90.6-4.1

Within normal range

Platelet - platelets are the first line of protection against bleeding.

104 G/L 140-440 Low platelet indicates decrease activity of the bone marrow

Blood typing “A”

RH Factor +

MCV - average volume of individual RBC’s

84.4FL 80-97 Within normal range

38

MCH - calculated average weight of hemoglobin per RBC

32.2 pg 26-32 Above normal range.Due to macrocytic anemia.

MHCH - average concentration or percentage of hemoglobin per RBC

382 g/l 310-360Above normal range.Due to macrocytic anemia.

Nursing responsibilities: Before

prepare the client instruct client and family about requirements or restrictions(when and what to eat and drink, how long to fast) explain to the client on how the procedure is done and why is it necessary

During assist the client use standard precautions and sterile technique as appropriate use the correct procedure for obtaining the specimen provide client comfort, privacy and safety ensure correct labeling, storage and transportation of specimen

After nursing care of the client and follow-up activities and observations compare previous and current test results

Blood Chemistry Date Purpose Result Normal values Analysis

39

BUN

Creatinine

02-13-09 To asses for electrolyte imbalance.

18.71

353.6

2.9-8.2 mmol/L

53-106mmol/L

Elevated BUN and creatinine level indicates decreased kidney perfusion.

Nursing Responsibilities

Before Explain the test procedure and the importance of the test.

During Adhere to understand the precaution. Apply pressure to the venipuncture site. Explain that some bruising discomfort and swelling may appear at the site and that warm, moist compress can

alleviate this. Monitor for signs of infection.After

Label the container and send to the laboratory. Do hand washing after the test.

40

VII. Anatomy and Physiology

ERYTHROPOIESIS

Erythropoiesis is the development of mature red blood cells

(erythrocytes). Like all blood cells, erythroid cells begin as pluripotential stem

cells. The first cell that is recognizable as specifically leading down the red

cell pathway is the proerythroblast . As development progresses, the nucleus

becomes somewhat smaller and the cytoplasm becomes more basophilic,

due to the presence of ribosomes. In this stage the cell is called a basophilic

erythroblast . The cell will continue to become smaller throughout

development. As the cell begins to produce hemoglobin, the cytoplasm

attracts both basic and eosin stains, and is called a polychromatophilic

erythroblast . The cytoplasm eventually becomes more eosinophilic, and the

cell is called an orthochromatic erythroblast . This orthochromatic erythroblast

will then extrude its nucleus and enter the circulation as a reticulocyte .

Reticulocytes are so named because these cells contain reticular networks of

polyribosomes. As reticulocytes loose their polyribosomes they become

mature red blood cells.( www.som.tulane.edu)

41

Erythrocytes: (a) seen from surface; (b) in profile, forming rouleaux; (c)

rendered spherical by water; (d) rendered crenate by salt. (c) and (d) do not

normally occur in the body.

RED BLOOD CELL, OR ERYTHROCYTE, is a hemoglobin-containing

blood cell in vertebrates that transports oxygen and some carbon dioxide to

and from tissues. Erythrocytes are formed in the red bone marrow and

afterward are found in the blood. They are the most common type of blood

cell and the vertebrate body's principal means of delivering oxygen from the

lungs or gills to body tissues via the blood (Dean 2005).

Erythrocytes consist mainly of hemoglobin, a complex molecule

containing heme groups whose iron atoms temporarily link to oxygen

molecules in the lungs or gills and release them throughout the body.

Oxygen can easily diffuse through the red blood cell's cell membrane.

Hemoglobin also carries some of the waste product carbon dioxide back from

the tissues. The color of erythrocytes is due to the heme group of

hemoglobin.

The blood plasma alone is straw-colored, but the red blood cells

change color depending on the state of the hemoglobin: when combined with

oxygen the resulting oxyhemoglobin is scarlet, and when oxygen has been

42

released the resulting deoxyhemoglobin is darker, appearing bluish through

the vessel wall and skin.

Erythrocytes develop from committed stem cells through

reticulocytes to mature erythrocytes in about seven days and live a

total of about 120 days.

he heme constituent of hemoglobin are broken down into Fe3+ and biliverdin.

The biliverdin is reduced to bilirubin, which is released into the plasma and

recirculated to the liver bound to albumin. The iron is released into the plasma

to be recirculated by a carrier protein called transferrin. Almost all

erythrocytes are removed in this manner from the circulation before they are

old enough to hemolyze. Hemolyzed hemoglobin is bound to a protein in

plasma called haptoglobin which is not excreted by the kidney.

(newworldencyclopedia.org)

The G6PD(Glucose-6-dehydrogenase) gene provides instructions for

making an enzyme called glucose-6-phosphate dehydrogenase. This

enzyme, which is active in virtually all types of cells, is involved in the normal

processing of carbohydrates. It plays a critical role in red blood cells, which

carry oxygen from the lungs to tissues throughout the body. This enzyme

helps protect red blood cells from damage and premature destruction.

glucose-6-phosphate dehydrogenase deficiency disrupt the normal

structure and function of the enzyme or reduce the amount of the enzyme in

cells.

Without enough functional glucose-6-phosphate dehydrogenase, red blood

cells are unable to protect themselves from the damaging effects of reactive

oxygen species. The damaged cells are likely to rupture and break down

prematurely (undergo hemolysis). Factors such as infections, certain drugs,

and ingesting fava beans can increase the levels of reactive oxygen species,

causing red blood cells to undergo hemolysis faster than the body can

replace them. This loss of red blood cells causes the signs and symptoms of

hemolytic anemia, which is a characteristic feature of glucose-6-phosphate

dehydrogenase deficiency.( /ghr.nlm.nih.gov)

43

LYMPHOCYTE is a type of white blood cell (leukocyte) in the

vertebrate immune system. The two main types of lymphocytes are T cells

and B cells, which function in the adaptive immune system. Other

lymphocyte-like cells are commonly known as natural killer cells, or NK cells,

and are part of the innate immune system. The NK cells are sometimes

labeled "large granular lymphocytes," while the T cells and B cells are labeled

as "small lymphocytes."

Types of lymphocytes

A stained lymphocyte surrounded by red blood cells viewed using a

light microscope.

The two main categories of lymphocytes are the B lymphocytes (B

cells) and T lymphocytes (T cell), both of which are involved in the adaptive

immune system (Alberts 1989). B cells specifically are involved in the humoral

immune system and produce antibodies, while T cells are involved in the cell-

mediated immune system and destroy virus-infected cells and regulate the

activities of other white blood cells (Alberts 1989). In essence, the function of

T cells and B cells is to recognize specific “non-self” antigens, during a

process known as antigen presentation. Once they have identified an invader,

44

the cells generate specific responses that are tailored to maximally eliminate

specific pathogens, or pathogen infected cells.

B cells respond to pathogens by producing large quantities of

antibodies that then neutralize foreign objects like bacteria and viruses. In

response to pathogens, some T cells, called "helper T cells," produce

cytokines that direct the immune response while other T cells, called

"cytotoxic T cells," produce toxic granules that induce the death of pathogen

infected cells.

The adaptive immune system, also called the "acquired immune

system" and "specific immune system," is a response of the body whereby

animals that survive an initial infection by a pathogen are generally immune to

further illness caused by that same pathogen. The adaptive immune system

is based on dedicated lymphocytes.

The basis of specific immunity lies in the capacity of immune cells to

distinguish between proteins produced by the body's own cells ("self" antigen

—those of the original organism), and proteins produced by invaders or cells

under control of a virus ("non-self" antigen—or what is not recognized as the

original organism).

45

Although the complement system has traditionally been considered part

of the innate immune system, research in recent decades has revealed that

complement is able to activate cells involved in both the adaptive and innate

immune response. Complement triggers and modulates a variety of immune

activities and acts as a linker between the two branches of the immune

response. In addition, the complement system maintains cell homeostasis by

eliminating cellular debris and immune complexes. (www.nature.com)

The complement system distinguishes "self" from "non-self" via a

range of specialized cell-surface and soluble proteins. These homologous

proteins belong to a family called the "regulators of complement activation

(RCA)" or "complement control proteins (CCP)". The complement system is

an enzyme cascade that helps defend against infection. Many complement

proteins occur in serum as inactive enzyme precursors (zymogens); others

reside on cell surfaces. The complement system bridges innate and acquired

immunity by Augmenting antibody (Ab) responses and immunologic memory,

Lysing foreign cells, Clearing immune complexes and apoptotic cells.

Complement components have many biologic functions (eg, stimulation of

chemotaxis, triggering of mast cell degranulation independent of IgE).

(www.merck.com)

Members of this family are:

complement receptor 1 (CR1 or CD35)

membrane cofactor protein (MCP or CD46)

C4b-binding protein (C4BP).

decay-accelerating factor (DAF or CD55)

factor H (fH)

The complement system is an enzyme cascade that helps defend

against infection. Many complement proteins occur in serum as inactive

enzyme precursors (zymogens); others reside on cell surfaces. The

46

complement system bridges innate and acquired immunity by Augmenting

antibody (Ab) responses and immunologic memory, Lysing foreign cells,

Clearing immune complexes and apoptotic cells. Complement

components have many biologic functions (eg, stimulation of chemotaxis,

triggering of mast cell degranulation independent of IgE). (wikipedia.org)

In addition, membrane components (decay-accelerating factor, CD55 and

CD59, and membrane inhibitor of C8 and C9 insertion) are important

regulating proteins. The complement cascade is a dual-edged sword, causing

protection against bacterial and viral invasion by promoting phagocytosis and

inflammation. Pathologically, complement can cause sub-stantial damage to

blood vessels (vasculitis), kidney basement membrane and attached

endothelial and epithelial cells.( questdiagnostics.com)

47

8. Pathophysiology

48

B. PLANNING

Nursing Priorities Based on Maslow’s Hiearchy of Needs:

A. Enhance tissue perfusion

1. Ineffective Tissue perfusion: Peripheral r/t decreased hemoglobin concentration in blood

B. Provide nutritional/fluid needs

2. Imbalanced nutrition: less than body requirements r/t decrease intake of essential nutrients

C. Prevent complications brought about by disease

3. Activity Intolerance r/t imbalance between oxygen supply delivery and demand

4. Self-care deficit: Bathing/Hygiene r/t weakness and tiredness

5. Disturbed sleep pattern r/t excessive stimulation from environment6. Anxiety r/t change in health status and role function

7. Risk for Infection r/t inadequate seco0.ndary defenses (decreased hemoglobin)

D. Provide information about disease process, prognosis and treatment regimen

8. Deficient knowledge (PNH) r/t lack of exposure

49

Nursing Care Plans(Date Identified)Assessment Planning Intervention Expected

OutcomeS> fatigue and shortness of breath when doing light physical activities like eating, urinating in bed pan, oral and body hygiene and changing clothes> general body weakness

O> requires SO’s assistance when accomplishing ADLs> pale conjunctiva, oral and nasal mucosa and integument> carpal and tarsal clubbing> hair growth on fingers and toes absent> capillary refill of 5 seconds in fingernails, 4-5 seconds in toenails> Tachycardia = 105 bpm> Tachypnea = 33 cpm> Hgb value = 36 g/l> Hct values = 0.17

Nsg DxIneffectiveTissue Perfusion: peripheral r/t decreased Hgb concentration in blood

After 6 hours of nursng intervention, the client will display an increase in peripheral tissue perfusion.

1. Independenta. Assist client to semifowler’s positionR: To promote maximum lung expansion to increase oxygenation and tissue perfusion.

b. Assist client to do deep breathing exercisesR: Helps regulate rate of breathing and anxiety to conserve pt.’s energy.

c. Provide and quiet environment and provide comfort measures. c.1 Change linens regularly. c.2 Instruct SOs to minimize talking with the pt. c.3 Provide back massage as needed. c.4 Assist pt. in doing guided imagery and visualization relaxation techniquesR: Helps promote rest and relaxation which conserves pt.’s energy and decreases the body’s demand for oxygen.

2. Collaborativea. Assist in obtaining specimen for laboratory studies (Hb/Hct, RBC count, ABG)R: Identifies deficiencies in RBC composition and monitors the pt’s status in terms of oxygenation and perfusion. Also serves as a parameter for client’s progress in achieving activity tolerance.

The pt. will display an increase in peripheral tissue perfusion as manifested by:a. improvement in capillary refillb. good peripheral pulsesc. normal heart rate and respiratory rated. verbalization of improvement in level of energye. improvement in dispositionf.improvement of Hgb/Hct values

50

SE: PNH is a condition in which there is a continuous autoimmune destruction of RBCs. A significant decrease in the total number of circulating RBCs would lead to inadequate amount of oxygen perfused to the tissues of the body. Poor perfusion at the peripherals would cause clubbing, prolonged capillary refill time, pale nailbeds, weak pulses and fatigue. Compensatory mechanisms like tachycardia and tachypnea help increase tissue perfusion which is also evident in the pt.

b. Provide supplemental oxygen as indicated.R: Maximizing oxygen-carrying capacity of RBCs to transport to tissues of the body.

c. Administer packed RBC blood transfusion as indicated.R: Increases the number of oxygen-carrying cells to correct inadequate tissue perfusion.

Assessment Planning Intervention Expected OutcomeS:> fatigue and shortness of breath when doing light physical activities like eating, urinating in bed pan, oral and body hygiene and changing clothes> frequently naps during daytime (1-2 hours)

O:> confined to bed most of the time> pt. depends on assistance of SO

After 1 hour of daily nursing intervention, client will display a gradual progressive tolerance of physical activity w/o report of chest pain upon exertion

1. Independent:a. Limit activities and decrease external stimulus.R: Limitation decreases oxygen demand and decreasing stimulus promotes relaxation and decreases anxiety which can also increase oxygen demand.

b. Assist patient to gradually increase activity level. Start from simple ADLs like combing hair,

After appropriate nursing intervention, pt. will display a gradual increase in activity tolerance as manifested by:a. increase in capacity to do ADLs b. absence of chest pain and SOB while doing daily activitiesc. improvement of skin

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in accomplishing ADLs like eating, urinating in bed pan, oral and body hygiene and changing clothes> appears generally weak> fingernails and conjunctiva pale> tachycardia = 103 bpm> tachypnea = 33 cpm> low HB= 36 g/l> low HCT= 0.17

Dx:Activity intolerance [Level III] r/t imbalance between oxygen supply and demand

SE:PNH is a condition in which the RBC count is decreased because of continuous hemolysis. Pale fingernails and conjunctiva as well as low Hb/Hct indicates an abnormally low RBC count.

An increase in physical activity will cause the cells to increase their demand for oxygen to meet the increased metabolic state. However, the amount of oxygen supplied by the RBC is decreased because of the decrease in the number of circulating RBCs. Therefore, fatigue is evident even in

brushing teeth and eating. Progress to mild activity like active-assistive ROMs and then ambulating with assistance.R: Gradual increase in activity level ensures that the pt.’s heart is not overworked and the complications of prolonged immobility will be prevented.

c. Record and document pt.’s VS before, during and after activities and correlate with presence or absence of SOB.R: Provides a baseline trend to monitor pt.’s tolerance on the activity. Also provides a source for evaluation for the client’s progress to increase his activity tolerance.

d. Instruct pt. to avoid activities which increase abdominal pressure. (e.g. straining during defecation)R: It can cause bradycardia which would decrease tissue perfusion to all tissues including the myocardial tissues.

and nail color, peripheral pulses and capillary refill which indications good circulationd. increase in independence

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doing light physical activities and the body’s compensatory mechanism in response to decreased oxygenation at the tissue level is to increase the heart rate and respiratory rate.

Assessment Planning Intervention Expected OutcomeS:> Frequent daytime naps (1-2 hours)> Feels that he lacks energy and is always tired> Has difficulty in falling asleep at night

O:> less than age-normed

After 8 hours of nursing intervention the client will report an improvement in sleep/rest pattern.

Independent:a. Explain the necessity for therapeutic and monitoring procedures while the client is hospitalized.R: Pt. is more apt to be tolerant of disturbances by staff if he understands the reasons and importance of care.

b. Restrict the intake of foods and fluids rich in caffeine

After appropriate nursing intervention, client will report an improvement in sleep/rest pattern as manifested by:a. verbalization of increase in energy and physical activityb. reduction or absence of yawning, irritability and

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total sleep time (7-8 hours)> lethargic> irritable and restless> yawns frequently> weak in appearance> Frequent conversations from SO > Interruption of rest and sleep due to therapeutic and monitoring activities of health care workers in hospital

Dx:Disturbed sleep pattern r/t excessive stimulation from environment

SE:Excessive environmental stimulus causes a disruption in the normal sleep-wake cycle of the pt. Disturbance in sleep esp. night time reduces the length of REM sleep. Insufficient REM sleep causes the pt. to feel fatigue and lack of energy. The pt. also manifests frequent yawning and irritability. The body compensates for the

R: Increases pt.’s wakefulness and delay falling asleep.

c. Support continuation of usual bedtime rituals.R: Promotes relaxation and readiness for sleep.

d. Increase interaction time between pt. and SOs/staff during day and reduce physical and mental activities late in the day and at night. Minimize unnecessary disturbances during hours of sleep at night.R: Planned activities during daytime and reduction of stimulation during night time promotes continuous, uninterrupted sleep.

e. Provide comfort measure e.1 provide evening snack if available e.2 hygiene (bed bath and oral care) e.3 massage and back rub e.4 provide clean and comfortable bed e.5 assist pt. to wear comfortable clothesR: Promotes drowsiness, aid in relaxation and falling asleep.

f. Reduce fluid intake in the evening and advice client to urinate/defecate before sleeping if necessary.R: Decreases the need to get up and go to bathroom during night time and prevents interruption of REM sleep.

restlessnessc. increase in total time of continuous, uninterrupted night time sleep

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insufficiency by taking daytime naps which is also evident in the pt.

Assessment Planning Intervention Expected OutcomeS > “Hindi ako mahilig kumain ng prutas at gulay”.> reports difficulty in eating d/t weakness, requires assistance from SO when eating

O > Eats only the meat and

After 8 hours of proper nursing interventions, the client will maintain an adequate nutritional status

> Monitor percentage of meals and snacks client consumes. Report a pattern of inadequate intake. - an awareness of the amount of foods/fluids the client consumes alerts the nurse to deficits in nutritional intake. Reporting an inadequate intake allows for prompt intervention.

> Perform or assist with anthropometric

After hours of proper nursing interventions, the client will be albe to maintain an adequate nutritional status as evidenced by:

a. identification of nutritional requirements b. consume adequate

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rice of the meal served by the hospital> Lost 10 kg. since Feb. 14,2009> weak and pale in appearance

Dx:Imbalanced nutrition: less than body requirements r/t decrease intake of essential nutrients

SE: In PNH, the red blood cells are broken down accompanied by the release of hemoglobin into the urine which contributes to the low hemoglobin level that is circulating within the body. Iron, folic acid and Vit.B12 are essential for hemoglobin synthesis and erythropoiesis. All of these elements are derived from the diet. Inadequate intake of these essential nutrients can further aggravate the decrease in hemoglobin concentration in the circulation. The symptoms

measurements such as skinfold thickness, mid-upper arm circumference (MAC), and mid-upper arm muscle circumference (MAMC) if indicated. Report measurements lower than normal. - anthropometric measurements such as skinfold thickness, MAC, MAMC provide information about the amount of muscle mass, body fat, and protein reserves the client has. These assessments assist in evaluating the client’s nutritional status.

> Implement measures to improve oral intake: a. perform actions to relieve gastrointestinal distention if present- distention of the gastrointestinal tract(especially the stomach and duodenum) can result in stimulation of the satiety center and subsequent inhibition of the feeding center in the hypothalamus. This effect, along with discomfort that occurs with distention, decreases appetite. b. increase activity as allowed and tolerated- activity usually promotes a general feeling of well-being, which can result in improved appetite. c. maintain a clean environment and a relaxed, pleasant atmosphere- noxious sights and odors can inhibit the feeding center of the hypothalamus. Maintaining a clean environment helps prevent this from occurring. In addition, maintaining a relaxed,

nourishment

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associated with a decrease hemoglobin level can in turn interfere with maintaining adequate nutrition.

pleasant atmosphere can help reduce stress and promote a feeling of well-being, which tends to improve appetite and oral intake. c. encourage a rest period before meals if indicated- the physical activity of eating requires some expenditure of energy. Fatigue can reduce the client’s desire and ability to eat. d. provide oral hygiene before meals- oral hygiene freshens the mouth by moistening the oral mucous membrane and removing unpleasant tastes. This can improve the taste of foods/fluids, which helps stimulate appetite and increase oral intake. e. serve foods/fluids that are appealing to the client and adhere to personal and cultural preferences whenever possible- these foods most likely stimulate appetite and promote interest in eating. f. serve frequent, small meals rather than large ones if client is weak, fatigues easily, and/or has a poor appetite- providing small rather than large meals can enable a client who is weak or fatigues easily to finish a meal. g. if client is experiencing dyspnea, place him in a high Fowler’s position and provide supplemental oxygen therapy during meals if indicated- because a person cannot swallow and breath at the same time, relief of dyspnea increases the likelihood of maintaining a good oral intake. In addition,

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relieving dyspneadecreases the client’s anxiety about and preoccupation with breathing efforts and increases the ability to focus on eating and drinking. h. perform actions to compensate for taste alterations- enhancing the taste of foods/fluids and providing nutritious alternatives to those that taste unpleasant to the client help to stimulate appetite and improve oral intake. i. limit fluid intake with meals unless the fluid has a high nutritional value- when the stomach becomes distented, its volume receptors stimulate the satiety center in the hypothalamus and the client reduces his oral intake. Drinking fluids with meals distends the stomach and may cause satiety before an adequate amount of food is consumed.

> Ensure that meals are well balanced and high in essential nutrients. - in order to meet his nutritional needs a. instruct client to avoid or limit intake of alcoholic beverages- it interferes with the utilization of essential nutrients needed by the body b. instruct client to increase intake of iron, folic acid and Vit.B12 rich foods such as liver, leafy green vegetables and legumes- iron, folic acid and Vit.B12 are essential for hemoglobin synthesis and erythropoiesis c. advise client to increase intake of foods

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ric in Vit.C- it is known that Vit.C enhances iron absorption within the body

> administer vitamins and minerals if ordered - needed to maintain metabolic functioning

Assessment Planning Intervention Expected OutcomeS:> reports fatigue

O:> mostly confined in bed> requires assistance from SO in accomplishing self-care hygiene activities> weak and pale in appearance> with foul body odor> limited movements

Dx:Self-care deficit:

Bathing/Hygiene r/t

weakness and tiredness

SE: PNH is charaterized by RBC destruction with release of hemoglobin into the urine. Hemoglobin is the

After 6 hours of appropriate nursing interventions, the client will be able to:

a. bathe with assistance of caregiver or significant others as needed and b. remain free of body odor and maintain intact skin

> Develop a bathing care plan based on the client’s own history of bathing practices that addresses skin needs, self-care needs, client response to bathing, and equipment needs. - bathing is a healing rite and should be comforting experience that concentrtes on the client’s needs, rather than being a routinely scheduled task

> Plan activities to prevent fatigue during bathing; seat with feet supported. - energy conservation increases activity tolerance and promotes self-care

> Provide pain relief measures: ice packs, heat and analgesics 45 minutes before bathing. - pain relief promotes participation in self-care and preserves dignity

> Teach use of adaptive bathing equipment such as long-handled brushes, washcloth mitt, shower chair, etc.

After 6 hours of appropriate nursing interventions, the client will be able to:

a. bathe with assistance of caregiver or significant others as needed and b. remain free of body odor and maintain intact skin

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oxygen carrying compound in the blood that carries oxygen to the cells of the body. As the hemoglobin concentration is depleted, the oxygen supply within the cells is also decreased which in turn is associated to the easy fatigability of an individual and causes decrease tolerance to ADL’s.

- adaptive devices extend the client’s reach, increase speed and safety, and decrease exertion and reduce caregiver burden

> provide privacy: have only one caregiver providing bathing assistance, encourage a traffic-free area and postprivacy signs. - the client perceives less privacy if more than one caregiver participates or if bathing takes place in a central bathing area in a high-traffic location that allows staff to enter freely during care

> Keep the client warmly covered. - some clients may experience evaporative cooling during and after bathing, which produces an unpleasant cold sensation

> Use tepid water when bathing. - hot water promotes skin dryness

C. Medical Management

Blood transfusion of PRBC

1st unit• 02-12-09, 9:45pm hooked 1st unit

of PRBC with serial # of 09-0490 after typing

• 1:45am consumed 2nd unit

• 02-13-09, 7:45 am hooked 2nd

A blood transfusion is a relatively simple medical procedure that doctors use to make up for

PRBC is indicated for :to increase the bloods ability to transport oxygen and carbon dioxide

No allergic reaction occurred

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unit of PRBC with serial # of 09-0489 after typing

• 11:00am consumed3rd unit

• 02-14-09, 1:45pm hooked 3rd unit of PRBC with serial # of 2007-859232 after typing

• 5:40pm consumed4th unit

• 02-16-09, 7:30am hooked 4th unit of PRBC with serial # of 2007-858859 after typing.

• 11:30am consumed5th unit

• 02-17-09, 3:00am hooked 5th unit of PRBC with serial # of 2007-859171 after typing.

• 6:30am consumed6th unit

• 02-18-09, 5:20am hooked 6th unit of PRBC with serial # of 2007-859061 after typing

• 9am consumed

loss of blood — or any part of the blood, such as red blood cells or platelets. The whole procedure usually takes about 2 to 4 hours, depending on how much blood is needed.

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Nursing Responsibilities

Before : Obtain blood from the blood bank, just before starting the transfusion. Do not store the blood in the net on the nursing unit because lack of temperature control may damage the blood. Prepare G- 18-20 IV needle or catheter for administering blood transfusion.

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Use saline to prime the set and flush the needle before blood transfusion. Double-check labels on the bags of blood that are about to be given to ensure the units are intended for that

recipient, During:

Stay with the patient 15- 30 minutes for allergic reaction The health care practitioner gives the blood to the recipient slowly, generally over 2 to 4 hours for each unit of

blood. After:

Assess for allergic reaction After that, a nurse checks on the recipient periodically and must stop the transfusion if an adverse reaction occurs.

MEDICAL MANAGEMENT /TREATMENT

DATE ORDERED:

GENERAL DESCRIPTION

INDICATION OR PURPOSE

CLIENT’S INITIAL

REACTION TO

TREATMENT

CLIENT’S INITIAL

RESPONSE TO

TREATMENT

PNSS Feb. 10, 2009

Feb. 11, 2009

Feb. 12, 2009

Feb. 13, 2009

Feb. 14, 2009

Plain normal saline solution is a solution of 0.9% w/v of NaCl, about 300 mOsm/L. Physiological saline is 9g NaCl dissolved in 1 liter water. The mass of 1 milliliter of normal saline is 1.009 grams. The

Plain normal saline solution (PNSS) is used frequently in intravenous drips (IVs) for patients who cannot take fluids orally and have developed severe dehydration.

Well hydrated Normal

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Feb. 15, 2009

Feb. 16, 2009

Feb. 17, 2009

Feb. 18, 2009

molecular weight of sodium chloride is approximately 58 g/mole, so 58g NaCl is 1 mole. Since saline contains 9 grams NaCl, the concentration is 9g/L divided by 58g/mole =0.154mole/L. Since NaCl dissociates into two ions – sodium and chloride – 1 molar NaCl is 2 osmolar. It contains 154 mEq/L of Na+ and Cl−. It has a slightly higher degree of osmolality (i.e. more solute per liter) compared to blood .

Normal saline is typically the first fluid used when dehydration is severe enough to threaten the adequacy of blood circulation and is the safest fluid to give quickly in large volumes. It is also the only solution compatible with blood .

MEDICAL MANAGEMENT/TREATMENT

DATE ORDERED/PERFORMED/CHANGED

GENERAL DESCRIPTION

INDICATION OR PURPOSE

CLIENT’S INITIAL RESPONSE TO

TREATMENT

Oxygen inhalation

1-2 lpm via nasal cannula

Date ordered:02-10-09

Date discontinued:02-11-09

Administration of oxygen and monitoring of its effectiveness

To relieve difficulty in breathing

difficulty in breathing was relieve

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NURSING RESPONSIBILITIES

BEFORE ASSESS -Skin and mucous membrane. Note color whether there is cyanosis -breathing patterns -chest movements -chest wall configuration -lung soundsDURING -explain to the client the procedure -wash hands and observe appropriate infection control -provide client privacy -set up the oxygen equipment and the humidifier -turn on the oxygen: check if the oxygen is flowing freely, there should be no kinks and bubbles -apply the appropriate oxygen delivery deviceAFTER -assess the clients vital sign, color, ease of respirations and provide support while the client is to the adjusting of to the device -assess the client in 15-30 minutes, depending on the client’s condition and regularly thereafter -assess the client regularly for sign of hypoxia, tachycardia, confusion, dyspnea, and restless -check the liter flow and the level of water in humidifier in 30 minutes and whenever providing care to the client -make sure that safety precautions are followed -document findings in the client’s record

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Name of Drug Date ordered/,

Date taken/given,

Date changed

Route of Admin. & Dosage &

Frequency of Admin.

General Action, Mechanism of

Action

Indications/ Purposes

Client’s response to Medicine with

actual Side Effect

Generic: AcetaminophenBrand: Paracetamol

02-12-09 IVP, 300mg nowP.O 500mg after 4 hrs

Acetaminophen belongs to a class of drugs called analgesics (pain relievers) and antipyretics ( fever reducers). The exact

Acetaminophen is used for the relief of fever as well as aches and pains associated with

Decrease in the client’s temperature noted.

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mechanism of action of acetaminophen is not known. Acetaminophen relieves pain by elevating the pain threshold, that is, by requiring a greater amount of pain to develop before a person feels it. It reduces fever through its action on the heat-regulating center of the brain.

many conditions.

Nursing Responsibility: • Take this medication as directed. • Do not take more acetaminophen than recommended. • Do not use for more than 10 days without consulting your doctor. • This medication is not to be given to children under 3 years of age without your doctor's approval.

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Ascorbic Acid (water-soluble vitamin)

Date ordered: Feb 12, 2009

Oral; 500mg once a day

Vitamin Stimulates

collagen formation and tissue repair

Involved in oxidation-reduction reactions throughout body

Raises vitamin C level in the body

Recommended daily allowance Frank and subclinical scurvy Extensive burns Delayed fracture or wound healing Postoperative wound healing Severe febrile or chronic disease states Prevention of vitamin C deficiency in patients with poor nutritional habits or increased requirements

Able to tolerate. No adverse reaction noted

Nursing Responsibilities: Prior: Explain the purpose of taking the medication and any side effects associated with the medication use Assess patent’s condition before starting therapy During Monitor for adverse reactions and drug interactions Administer the medication with the right dosage, route, and frequency. If adverse GI reactions occur, monitor patient’s hydration Stress proper nutritional habits to prevent recurrence of deficiency Advise patient with vitamin C deficiency to decrease or stop smoking After Document all information after administration of the drug Observe patient for any reactions.

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NAMES OF DRUGS (GENERIC AND BRAND NAME)

DATE ORDERED/ DATE TAKEN/GIVEN, DATE CHANGED/D/C

ROUTE OF ADMIN. & DOSAGE & FREQUENCY OF ADMIN.

GEN. ACTION, MECH. OF ACTION

INDICATIONS/S PURPOSE/S

CLIENT’S RESPONSE TO MED. W/ ACTUAL S/E

Calcium Gluconate

02-16-09 IVP 10 cc Replaces and maintains calcium

- Treatment of hypocalcemia in those conditions requiring prompt increases in plasma calcium for - Emergency cardio tonic effect - For blood transfusion

-

Nursing Responsibilities: Assess patient’s calcium level before and ate therapy.If hypercalcemia occurs, stop the drug and notify the physician.Instruct patient to avoid foods containing Oxalic Acid, Phytic Acid, and Phosphorus because interactions may interfere with calcium absorption.After injection, make sure that the patient remains at recumbent position for 15 minutes.Precipitate will form if the drug is given IV with sodium Bicarbonate or other alkaline drug. Use an in-line filter.

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NAMES OF DRUGS (GENERIC AND BRAND NAME)

DATE ORDERED/ DATE TAKEN/GIVEN, DATE CHANGED/D/C

ROUTE OF ADMIN. & DOSAGE & REQUENCY OF ADMIN.

GEN. ACTION, MECH. OF ACTION

INDICATIONS/S PURPOSE/S

CLIENT’S RESPONSE TO MED. W/ ACTUAL S/E

Ferous Sulate

02-12-09 Oral, 1 cap OD

Provides elemental iron and essential component in formation of hemoglobin.

- iron deficiency - able to tolerate the medication. - client experience constipation

Nursing Responsibilities: - Assess the patient’s iron deficiency before starting the therapy.- Give tablets with juice or water.- To avoid staining of teeth, give suspension with straw and place drops at the back of the throat.- Don’t crash or allow the patient to chew extended release forms.- Give the drug in between meals, but if GI upset continues, give the patient foods except eggs, milk products, coffee, and tea, which may impair absorption.- Inform the patient that there will be discoloration in the stool.- Encourage the patient to at fiber rich foods, such as string beans and pineapple juice.

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NAMES OF DRUGS (GENERIC AND BRAND NAME)

DATE ORDERED/ DATE TAKEN/GIVEN, DATE CHANGED/D/C

ROUTE OF ADMIN. & DOSAGE & REQUENCY OF ADMIN.

GEN. ACTION, MECH. OF ACTION

INDICATIONS/S PURPOSE/S

CLIENT’S RESPONSE TO MED. W/ ACTUAL S/E

Folic Acid 02-16-09 Oral, 1 cap OD

Stimulates normal erythropoiesis and nucleoprotein synthesis.

- Folic Acid is effective in the treatment of megaloblastic anemias due to a deficiency of Folic Acid (as may be seen in tropical or nontropical sprue) and in anemias of nutritional origin, pregnancy, infancy, or childhood.

- able to tolerate the medication. - no adverse reactions noted.

Nursing Responsibilities: - Assess Folic Acid deficiency before starting the therapy.- Make sure that the patient is getting properly balanced diet.- Tell patient to report hypersensitivity reactions like difficulty of breathing.- Instruct the patient to avoid drinking and eating foods with alcohol because it increases folic acid requirements.- Give vitamin B12 with this therapy if needed.

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Type of Diet Date Ordered General description

Indication/ Purpose

Specific foods taken

Clients Response

Diet as Tolerated 02-10-09 Patient can eat whatever food he can tolerate w/o specific restrictions.

Ordered when the patient’s appetite, ability to eat and tolerance for food is regained.

Rice, vegetables, meat

Client understands the need to be in the DAT diet. He is able to tolerate the diet

Nursing Responsibilities:

> make sure that the client takes in a well balanced diet.

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Blood Chemistry

Date Purpose Purpose Result Normal values Analysis

BUNCreatinine

02-13-09

BUN is made up of urea, which is an end product of the metabolism of protein by the liveCREATININE is end product of muscle metabolism.

To asses for electrolyte imbalance.

18.71353-6

2.9-8.2 mmol/L 53-106mmol/L

Elevated BUN and creatinine level indicates decreased kidney perfusion.

Nursing ResponsibilitiesBefore Explain the test procedure and the importance of the test.During Adhere to understand the precaution.Apply pressure to the venipuncture site.Explain that some bruising discomfort and swelling may appear at the site and that warm, moist compress can alleviate this. Monitor for signs of infection.After Label the container and send to the laboratory.Do hand washing after the test.

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1. Nursing management (SOAPIE/R)

S O A P I E> fatigue and shortness of breath when doing light physical activities like eating, urinating in bed pan, oral and body hygiene and changing clothes> frequently naps during daytime for 1-2 hours

> confined to bed most of the time> pt. depends on assistance of SO in accomplishing ADLs like eating, urinating in bed pan, oral and body hygiene and changing clothes> appears generally weak> fingernails and conjunctiva pale> tachycardia = 103 bpm> tachypnea = 33 cpm> low HB= 36 g/l> low HCT= 0.17

Activity intolerance [Level III] r/t imbalance between oxygen supply and demand

After 1 hour of daily nursing intervention, client will display a gradual progressive tolerance of physical activity w/o report of chest pain upon exertion

1. Independent:a. Limited activities and decrease external stimulus.

b. Assisted patient to gradually increase activity level. Started from simple ADLs like combing hair, brushing teeth and eating. Progressed to mild activity like active-assistive ROMs and then ambulating with assistance.

c. Recorded and documented pt.’s VS before, during and after activities and correlate with presence or absence of SOB.

d. Instructed pt. to avoid activities which increase abdominal pressure. (e.g. straining during defecation)

Pt. displayed gradual increase in activity tolerance as manifested by:a. increase in physical activity tolerance from complete dependence in doing ADLs to accomplishment of simple tasks like feeding, urinating and defecating with assistanceb. absence of SOB while doing daily activitiesc. improvement of skin and nail color, d. decreased capillary refill time from 5 seconds to 4

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secondsd. increase in independence while doing tasks

S O A P I E> fatigue and shortness of breath when doing light physical activities like eating, urinating in bed pan, oral and body hygiene and changing clothes> general body weakness> shortness of breath when doing physical activities like standing up to urinate and changing

> requires SO’s assistance when accomplishing ADLs> pale conjunctiva, oral and nasal mucosa and integument> carpal and tarsal clubbing> hair growth on fingers and toes absent> capillary refill of 5 seconds in fingernails, 4-5 seconds in toenails> tachycardia =

IneffectiveTissue Perfusion: Periperal r/t decreased Hb concentration in blood

After 6 hours of nursng intervention, the client will display an increase in peripheral tissue perfusion.

1. Independenta. Assisted client to semifowler’s position

b. Assisted client to do deep breathing exercises

c. Provided and quiet environment and provide comfort measures. c.1 Changed linens regularly. c.2 Instructed SOs to minimize talking with the pt. c.3 Provided back massage as needed. c.4 Assisted pt. in doing guided imagery and visualization relaxation techniques

2. Collaborativea. Assisted in obtaining specimen

The pt. showed improvement in peripheral tissue perfusion as manifested by:a. improvement in capillary refill(from 5 seconds to 4 seconds)b. verbalization of improvement in level of energyc. improvement in dispositiond. improvement in skin colore.improvement of Hgb/Hct values

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positions 103 bpm> tachypnea = 33 cpm> low HB= 36 g/l> low HCT= 0.17

for laboratory studies (Hb/Hct, RBC count, ABG)

b. Provided supplemental oxygen as indicated.

c. Administered packed RBC blood transfusion as indicated.

S O A P I E> Frequent daytime naps for 1-2 hours> Feels that he lacks energy and is always tired> Has difficulty in falling asleep at night

> less than age-normed total for 7-8 hours night time sleep> lethargic> irritable and restless> yawns frequently> weak in appearance> Frequent conversations from SO > Interruption of rest and sleep due to therapeutic and

Disturbed sleep pattern r/t excessive stimulation from environment

After 8 hours of nursing intervention the client will report an improvement in sleep/rest pattern.

1. Independent:a. Explained the necessity for therapeutic and monitoring procedures while the client is hospitalized.

b. Restricted the intake of foods and fluids rich in caffeine

c. Supported continuation of usual bedtime rituals.

d. Increased interaction time between pt. and SOs/staff during day and reduce physical and mental activities late in the day and at night. Minimize unnecessary disturbances during

Pt. reported an improvement in sleep/rest pattern as manifested by:a. verbalization of increase in energy b. reduction of yawning, irritability and restlessnessc. increase in total time of continuous, uninterrupted night time sleep (from 4 hours to

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monitoring activities of health care workers in hospital

hours of sleep at night.

e. Provided comfort measures e.1 provide evening snack if available e.2 hygiene (bed bath and oral care) e.3 provided massage and back rub e.4 provided clean and comfortable bed e.5 assisted pt. to wear comfortable clothes

f. Reduced fluid intake in the evening and advice client to urinate/defecate before sleeping if necessary.

7 hours)

S O A P I E> “Hindi ako mahilig kumain ng prutas at gulay”.> reports difficulty in eating d/t weakness, requires assistance from

> Eats only the meat and rice of the meal served by the hospital> Lost 10 kg. since Feb.14, 2009> weak and pale in appearance

Imbalanced nutrition: less than body requirements r/t decrease in appetite

After 8 hours of proper nursing interventions, the client will maintain an adequate nutritional status

> Monitor percentage of meals and snacks client consumes. Report a pattern of inadequate intake.

> Performed or assisted with anthropometric measurements such as skinfold thickness, mid-upper arm circumference (MAC), and mid-upper arm muscle

After 8 hours of proper nursing interventions, the client was able to maintain an adequate nutritional status as evidenced by:

a. identification

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SO when eating

circumference (MAMC) if indicated. Reported measurements lower than normal.

> Implemented measures to improve oral intake: a. performed actions to relieve gastrointestinal distention if present b. increased activity as allowed and tolerated c. maintained a clean environment and a relaxed, pleasant atmosphere c. encouraged a rest period before meals if indicated d. provided oral hygiene before meals e. served foods/fluids that are f. served frequent, small meals rather than large ones if client is weak, fatigues easily, and/or has a poor appetite g. if client is experiencing dyspnea, placed him in a high Fowler’s position and provided supplemental oxygen therapy during meals if indicated h. performed actions to compensate for taste alterations

of nutritional requirements b. consume adequate nourishment

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i. limited fluid intake with meals unless the fluid has a high nutritional value

> Ensured that meals are well balanced and high in essential nutrients such as foods rich in iron. Offer dietary supplements if indicated.

> administered vitamins and minerals if ordered

S O A P I E> reports fatigue

> mostly confined in bed> requires

Self-care

deficit:

After 6 hours of appropriate

> Developed a bathing care plan based on the client’s own history of bathing practices that

After 6 hours of appropriate nursing

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assistance from SO in accomplishing self-care hygiene activities> weak and pale in appearance> with foul body odor> limited movements

Bathing/Hygie

ne r/t

weakness and

tiredness

nursing interventions, the client will be able to:

a. bathe with assistance of caregiver or significant others as needed and b. remain free of body odor and maintain intact skin

addresses skin needs, self-care needs, client response to bathing, and equipment needs. > Planned activities to prevent fatigue during bathing; seat with feet supported.

> Provided pain relief measures: ice packs, heat and analgesics 45 minutes before bathing.

> Teached use of adaptive bathing equipment such as long-handled brushes, washcloth mitt, shower chair, etc.

> provided privacy: have only one caregiver providing bathing assistance, encourage a traffic-free area and postprivacy signs.

> Kept the client warmly covered.

> Used tepid water when bathing.

interventions, the client was able to:

a. bathe with assistance of caregiver or significant others as needed and b. remained free of body odor and maintain intact skin

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B. EVALUATIONPatient’s daily program in the hospital.

Daily Program 02-13-09 02-14-09 02-15-09 02-16-09 02-17-09 02-18-09

Nursing Problems1. Ineffective Tissue perfusion: Peripheral r/t decreased hemoglobin concentration in blood

2. Activity Intolerance r/t imbalance between oxygen supply delivery and demand

3. Disturbed sleep pattern r/t excessive stimulation from environment

4. Imbalanced nutrition: less than body requirements r/t decreased intake of essential nutrients

5. Self-care deficit: Bathing/Hygiene r/t weakness and tiredness

√

√

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Vital signs RR:35PR: 94BP: 110/80T: 37.2

RR: 23PR: 87BP: 100/70T: 37.8

RR:25PR: 87BP: 100/70T: 38.2

RR:30PR: 88BP: 100/70T: 36.7

RR: 30 PR: 88BP: 110/70T: 38.2

RR: 26PR: 106BP: 100/60T: 38.8

Diagnostic & Lab. Procedures Hgb: 36 g/LHct: 0.87 L/LRBC: 1.01 T/L

Hgb: 45 g/LHct: 0.097 L/LRBC: 1.14 T/L

Hgb: 58 g/LHct: 0.152 L/LRBC: 1.80T/L

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MCH: 35.6 pgMHCH: 414 g/L

BUN: 2.9-8.2 mmol/LCrea: 53-106 mmol/L

MCH: 39.5 pgMHCH: 464 g/L

MCH: 32.2 pgMHCH: 382 g/L

Medical and Surgical Mgt. IVF: PNSS @ 30-31 gtts/min

BT: 1 “u” PRBC

IVF: PNSS @ 30-31 gtts/min

BT: 1 “u” PRBC

IVF: PNSS @ 30-31 gtts/min

IVF: PNSS @ 30-31 gtts/min

BT: 1 “u” PRBC

IVF: PNSS @ 30-31 gtts/min

BT: 1 “u” PRBC

IVF: PNSS @ 30-31 gtts/min

BT: 1 “u” PRBC

Drugs1. Ascorbic Acid2. Calcium Gluconate3. Fe SO44. Folic Acid

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Diet DAT DAT DAT DAT DAT DAT

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METHOD

MEDICATIONS prescribed are as follows:

B-Complex 250 mg/cap OD

Vitamin C 500 mg tab/ OD

Ferrous Sulfate 1 cap OD

EXERCISE

- the client was instructed by the physician to avoid strenuous activities,

wherein heavy exercise is also prohibited.

TREATMENT/TEST

- the client was instructed to have a Hgb/Hct test a week after being

discharged.

HEALTH TEACHINGS

- Encouraged not to hold the urge to urinate.

- Encouraged the client to have a proper hygiene and do hand washing

properly before and after eating.

- Taught the client some of the stress-coping strategies such as seeking

help from others, expressing his feelings assertively, to think positive

and always seek God for help.

- Encouraged to take rest if he feels weak.

- Instructed the family members of the patient to give emotional support.

- Discussed the basic disease process of the condition of the patient to

his family embers.

- Encouraged the client to stay away from the other people with illness

such as cough and colds, because he is immunosuppressed.

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OPD/FOLLOW-UP CHECK-UPS

- The client was instructed to have a follow-up check-up to the OPD

section of TPH after a week.

DIET

- Instructed the client to eat foods rich in Iron, Vitamin C, Vitamin B-

complex, Fiber and Protein.

Foods rich in Iron:

Liver

Deep green colored vegetables

Internal Organs

Milk

Foods rich in Vit. C

Citrus fruits like guavas and mangoes, and areavailable to the

season

Foods rich in B-complex, Fiber and Protein

Green leafy vegetables

Fruits

Meat

Fish

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IV. RECOMMENDATION

The group recommends that the patient should have to do the following:

Encouraged not to hold the urge to urinate to prevent the occurence of

urinary tract retention and infection.

Encouraged the client to have a proper hygiene and to practice hand

washing before and after eating.

Taught the client some of the stress-coping strategies such as seeking

help from others, expressing his feelings assertively, to think positive

and always seek God for help.

Encouraged to take rest if he feels weak, to prevent the injury.

Instructed the family members of the patient to give emotional support,

to elevate self-esteem and sense of belongingness.

Discussed the basic disease process of the condition of the patient to

his family members for them to know what to do.

Encouraged the client to stay away from the other people with illness

such as cough and colds, because he is immunosuppressed.

V. BIBLIOGRAPHY

o Fundamentals of Nursing by Kozier et al.

o Fundamentals of Nursing by Daniels et al.

o Physical Assessment by Estes et al.

o Medical Surgical Nursing by Suddarth and Brunner et al.

o http://www.answers.com/topic/erectile-

dysfunction#Pathophysiology

o http://www.answers.com/fever

o http://www.mayoclinic.com/health/water/NU00283

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