Case Study Paroxysmal Nocturnal Hemoglobinuria

Paroxysmal Nocturrnal Hemoglobinuria PNH Nursingcasestudy.blogspot.com INTRODUCTION 1 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 cells or neutrophils during their prolonged remission, but a few PNH-affected lymphocytes were detectable in 3 of 4 patients tested. 2 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 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 3 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. 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 4 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 b. Anatomy and Physiology c. Pathophysiology book base and client centered 5 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 II. Nursing Process A. Assessment 6 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 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 7 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. 2. Family History of Health and Illness 8 FATHER SIDE MOTHER SIDE ? Old age ? Old age 6 ? Old age ? Old age 5 A&W 0 3 A&W 7 A&W 3 1 A&W 6 A&W 6 3 PNH 3 5 A&W 7 A&W 0 3 1 suicide 6 A&W 0 LEGEND 3 A&W 0 2 A&W 8 7 3 3 3 A&W Male Female Deceased Male Deceased Female Married Children Patient Alive & Well Paroxysmal Nocturnal Hemoglubinuria A&W PNH 3. History of Past Illness 9 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. According to the patient, when he is experiencing headache he takes a rest to 10 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 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. 11 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 was not properly groomed, have untrimmed nails on both fingers and toes and with uncombed hair. He looks pale and weak. 12 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. 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) 13 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 selfperception 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 14 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 ADL‘s due to easy fatigability. Blood transfusion is his way of regaining his strength. V. Body Temperature 15 The client‘s general skin is warm to touch during the interview. The following table indicates the client‘s body temperature. Temperature (0C) 36.5 0C 36.7 0C 36.8 0C 37.1 C 37.8 0C 38 0C 38.3 0C 38.4 0C 38 0C 37.8 0C 37.3 0C 37.2 0C 37.4 0C 37.5 C 38.9 0C 38.7 0C 38.5 0C 37.9 0C 38 0C 37.8 0C 37 0C 37 0C 37.2 0C 38.2 0C 36.5 0C 36.9 0C 0 0 Date and hours 2/11/09 8 am 10 am 1:30 pm 3:00 pm 2/12/09 8 am 12 noon 2 pm 3:30 pm 4:30 pm 6 pm 10 pm 2/13/09 8 am 10 am 2 pm 5 pm 6 pm 8 pm 10 pm 2/14/09 6 am 8 am 10 am 2 pm 6 pm 2/15/09 6 am 6 pm 2/16/09 8 am Analysis Normal Normal Normal Normal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Normal Normal Normal Normal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Normal Normal Normal Abnormal Abnormal Normal 16 10 am 12 noon 1:30 pm 4 pm 10 pm 2/17/09 4 pm 10 pm 2/18/09 6 am 2 pm 5 pm 2/18/09 4 pm 10 pm 36.7 0C 37.2 0C 37.2 0C 37.2 0C 38.9 0C 38.5 0C 38.2 0C 37.2 0C 38.8 C 37.2 0C 37.3 0C 38.1 0C 0 Normal Normal Normal Normal Abnormal Abnormal Abnormal Normal Abnormal Normal Normal 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 warmer interior, increases the metabolic rate, and induces shivering. (www.fpnotebook.com/Hemeonc/Hemolysis/PrxysmlNctrnlHmglbnr.htm) Analysis 17 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 Tlymphocytes 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 Status The 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 2/11/09 8 am 10 am 1:30 pm 3:00 pm 2/12/09 8 am 12 noon 2 pm 3:30 pm 4:30 pm 6 pm 10 pm 2/13/09 8 am 10 am 2 pm Blood pressure (mmHg) 90/60 100/80 100/60 100/70 100/60 100/60 100/60 110/60 100/70 110/70 100/60 100/70 110/80 100/60 Analysis Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal abnormal Abnormal 18 5 pm 6 pm 8 pm 10 pm 2/14/09 6 am 8 am 10 am 2 pm 6 pm 2/15/09 6 am 6 pm 2/16/09 8 am 10 am 12 noon 1:30 pm 4 pm 10 pm 2/17/09 4 pm 10 pm 2/18/09 6 am 2/18/09 4 pm 10 pm 130/90 120/70 110/70 90/60 90/70 100/70 100/70 110/70 110/70 110/70 110/70 90/60 100/70 100/70 100/70 120/70 110/70 120/80 110/70 100/60 120/80 abnormal normal abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal normal 130/90 abnormal Date and hours 2/11/09 8 am 10 am 1:30 pm 3:00 pm 2/12/09 8 am Pulse rate (beats per min) 89 86 87 88 95 Analysis Normal Normal Normal Normal Normal 19 12 noon 2 pm 3:30 pm 4:30 pm 6 pm 10 pm 2/13/09 8 am 10 am 2 pm 5 pm 6 pm 8 pm 10 pm 2/14/09 6 am 8 am 10 am 2 pm 6 pm 2/15/09 6 am 6 pm 2/16/09 8 am 10 am 12 noon 1:30 pm 4 pm 10 pm 2/17/09 4 pm 10 pm 2/18/09 6 am 2/18/09 4 pm 96 98 106 100 94 96 94 86 105 102 92 91 99 94 98 99 98 87 87 90 88 88 87 86 88 86 88 85 88 106 Normal Normal Abnormal Normal Normal Normal Normal Normal *Abnormal Abnormal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Abnormal 20 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 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: 21 DATE AND TIME 2-11-09 8AM 10AM 1:30PM 3-11PM 02-12-09 8AM 12PM 2PM 3:30PM 6PM 10PM 2-13-09 6 am 8AM 10AM 2PM (3-11PM) 5PM 6PM 8PM 10PM 2-14-09(11-7AM) 8AM 10AM 2PM 3-11PM 02-15-09(11-7AM) 3-11PM 2-16-09 (8AM) 10AM 12PM 1:30PM 4PM 10PM 2-17-09(4PM) 10PM 2-18-09(11-7AM) 7AM 10AM Norms RATE 22 25 22 23 21 21 26 25 33 25 28 28 26 35 26 24 26 29 31 29 25 23 22 19 20 20 20 30 25 27 25 26 30 30 28 26 25 24 INTERPRETATION Abnormal Abnormal Abnormal Abnormal abnormal Abnormal Abnormal Abnormal *Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal abnormal Abnormal Abnormal Abnormal normal normal normal normal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Abnormal Normal RR is 14-20 cycles per minute. Normal respirations are regular and even in rhythm. Depth of inspiration is unexaggerated and 22 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. 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 23 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 sleepwake 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. IX. Reproductive Status 24 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 cannot perform his role as a husband to his wife and he cannot render his worth in achieving their sexual satisfaction. 25 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. Many health professionals consider the BMI to be a more reliable indicator of changes in body fat stores and whether a person‘s weight 26 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) Analysis 27 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 palered 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 spoken words from a distance of 2ft. Nostril should be patent, there should 28 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. XIII. . Skin Appendages 29 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 160 0. 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 darkskinned 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 30 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. 31 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/ Date ordered Indications or Normal Analysis and Laboratory and date purposes Results values Interpretation of procedure results data February Hemoglobin 10,2009 - is a measure of 31 g/l 120-180 Below normal range: the total amount of In response to 8:23 am hemoglobin in the decrease RBC, blood. It carries hemoglobin also oxygen to the cells decrease from the lungs and carbon dioxide away from the cells to the lungs 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. Below normal range. Decreased RBC result in lysis of RBC due to lack of RBC MCV MCHC MCH used to evaluate the size, weight and hemoglobin concentration of .90 T/L 4.2-6.3 32 RBC‘s. Oxygen transportation is its major function. WBC Lymphocytes - determines the number of circulating WBC‘s in the blood. It monitors the presence of infection in the body. - platelets are the first line of protection against bleeding. 8.1 G/L 0.225 4.1-10.9 0.6-4.1 decay accelerating factor(CD55 and CD59) on RBC. Within normal range. low lymphocytes indicates decrease activity of the bone marrow Platelet 168 G/L 140-440 Within normal range Blood typing RH Factor ―A‖ + DIFFERENTIAL COUNTS: Hematology- This diagnostic test is a tool that provides information about the hematologic system of the patient. Diagnostic/ Date ordered Indications or Normal Analysis and Laboratory and date purposes Results values Interpretation of procedure results data February Hemoglobin 13,2009 - is a measure of 36 g/l 120-180 Below normal range: 33 6:57 am 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 measure the .87 L/L percentage of red blood cells in 100 ml of whole blood. Determines if the client is hydrated or dehydrated. . .370-.510 In response to decrease RBC, hemoglobin also decrease . Hematocrit Below normal range: can be a sign of the presence of hemorrhage, anemia, hyperthyroidism, dietary deficiency and pregnancy Below normal range. Decreased RBC result in lysis of RBC due to lack of decay accelerating factor(CD55 and CD59) on RBC. RBC MCV MCHC MCH used to evaluate 1.01 T/L the size, weight and hemoglobin concentration of RBC‘s. Oxygen transportation is its major function. 4.2-6.3 WBC lymphocytes - determines the 6.9 G/L number of 1.2 circulating WBC‘s in the blood. It 4.1-10.9 0.6-4.1 Within normal range 34 monitors presence infection body. Platelet in the of the - platelets are the first line of protection against bleeding. 141 G/L 140-440 Within normal range Blood typing RH Factor MCV - average volume of individual RBC‘s calculated average weight of hemoglobin per RBC average concentration or percentage of hemoglobin per RBC ―A‖ + 85.7 FL 80-97 Within normal range MCH 35.6 pg 26-32 above normal range. Due to macrocytic anemia. MHCH 414 g/l 310-360 above normal range. Due to macrocytic anemia. 35 DIFFERENTIAL COUNTS: Hematology- This diagnostic test is a tool that provides information about the hematologic system of the patient. Diagnostic/ Date ordered Indications or Normal Analysis and Laboratory and date purposes Results values Interpretation of procedure results data Feb. 14, 2009 Hemoglobin - is a measure of 45 g/l 120-180 Below normal range: 7:05 am the total amount of In response to hemoglobin in the decrease RBC, blood. It carries hemoglobin also oxygen to the cells decrease from the lungs and carbon dioxide away from the cells to the lungs 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 Below normal range. Decreased RBC result in lysis of RBC due to lack of decay accelerating factor(CD55 and 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 36 transportation is its major function. WBC lymphocytes - determines the number of circulating WBC‘s in the blood. It monitors the presence of infection in the body. - platelets are the first line of protection against bleeding. 5.4 G/L 1.4 4.1-10.9 0.6-4.1 CD59) on RBC. Within normal range Platelet 127 G/L 140-440 Low platelet indicates decrease activity of the bone marrow Blood typing RH Factor MCV - average volume of individual RBC‘s ―A‖ + 85.5 FL 80-97 Within range. normal MCH calculated average weight of hemoglobin per RBC 39.5 pg 26-32 Below normal range. Due to macrocytic anemia. 37 464 g/l MHCH average concentration or percentage of hemoglobin per RBC 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/ Date ordered Indications or Normal Analysis and Laboratory and date purposes Results values Interpretation of procedure results data Feb. 16, 2009 Hemoglobin - is a measure of 58 g/l 120-180 Below normal 2:00 pm the total amount of range: In response hemoglobin in the to decrease RBC, blood. It carries hemoglobin also oxygen to the cells decrease from the lungs and carbon dioxide away from the cells to the lungs 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 38 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. - platelets are the first line of protection against bleeding. 4.5 G/L 1.2 4.1-10.9 0.6-4.1 Within normal range Platelet 104 G/L 140-440 Low platelet indicates decrease activity of the bone marrow Blood typing RH Factor MCV - average volume of individual RBC‘s ―A‖ + 84.4FL 80-97 Within normal range 39 MCH calculated average weight of hemoglobin per RBC 32.2 pg 26-32 Above normal range. Due to macrocytic anemia. Above normal range. Due to macrocytic anemia. MHCH average concentration or percentage of hemoglobin per RBC 382 g/l 310-360 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 40 Blood Chemistry BUN Date 02-13-09 Purpose To asses for electrolyte imbalance. Result 18.71 Normal values 2.9-8.2 mmol/L Analysis Elevated BUN and creatinine level indicates decreased kidney perfusion. Creatinine 353.6 53-106mmol/L 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. 41 VII. Anatomy and Physiology 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) 42 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 43 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 Fe 3+ 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) 44 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 cellmediated 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, 45 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). 46 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 47 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) 48 8. Pathophysiology 49 50 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 environment 6. 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 51 Nursing Care Plans (Date Identified) Assessment S > 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 Dx IneffectiveTissue Perfusion: peripheral r/t decreased Hgb concentration in blood Planning After 6 hours of nursng intervention, the client will display an increase in peripheral tissue perfusion. Intervention 1. Independent a. Assist client to semifowler‘s position R: To promote maximum lung expansion to increase oxygenation and tissue perfusion. b. Assist client to do deep breathing exercises R: 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 techniques R: Helps promote rest and relaxation which conserves pt.‘s energy and decreases the body‘s demand for oxygen. 2. Collaborative a. 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. Expected Outcome The pt. will display an increase in peripheral tissue perfusion as manifested by: a. improvement in capillary refill b. good peripheral pulses c. normal heart rate and respiratory rate d. verbalization of improvement in level of energy e. improvement in disposition f.improvement of Hgb/Hct values 52 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. 53 Assessment S: > 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 (12 hours) O: > 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 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 Planning 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 Intervention 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, 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. Expected Outcome 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 activities c. improvement of skin and nail color, peripheral pulses and capillary refill which indications good circulation d. increase in independence 54 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 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. 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. 55 Assessment S: > Frequent daytime naps (12 hours) > Feels that he lacks energy and is always tired > Has difficulty in falling asleep at night O: > less than age-normed 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 Planning After 8 hours of nursing intervention the client will report an improvement in sleep/rest pattern. Intervention 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 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 Expected Outcome After appropriate nursing intervention, client will report an improvement in sleep/rest pattern as manifested by: a. verbalization of increase in energy and physical activity b. reduction or absence of yawning, irritability and restlessness c. increase in total time of continuous, uninterrupted night time sleep 56 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 insufficiency by taking daytime naps which is also evident in the pt. e.4 provide clean and comfortable bed e.5 assist pt. to wear comfortable clothes R: 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. 57 Assessment S > ―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 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. Planning After 8 hours of proper nursing interventions, the client will maintain an adequate nutritional status Intervention > 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 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 Expected Outcome 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 nourishment 58 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 associated with a decrease hemoglobin level can in turn interfere with maintaining adequate nutrition. 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, 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, 59 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, 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. 60 - 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 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 S: > reports fatigue O: > mostly confined in bed > requires assistance from SO in accomplishing selfcare hygiene activities > weak and pale in appearance > with foul body odor > limited movements Planning After 6 hours of appropriate nursing interventions, the client will be able to: a. bathe with assistance of caregiver or Intervention > 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 Expected Outcome 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 61 significant Dx: others as Self-care deficit: needed and b. remain Bathing/Hygiene r/t free of body odor and weakness and tiredness maintain SE: intact skin PNH is charaterized by RBC destruction with release of hemoglobin into the urine. Hemoglobin is the 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. tolerance and promotes self-care > Provide pain relief measures: ice packs, heat and analgesics 45 minutes before bathing. - pain relief promotes participation in selfcare and preserves dignity > Teach use of adaptive bathing equipment such as long-handled brushes, washcloth mitt, shower chair, etc. - 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 62 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 unit of PRBC with serial # of 090489 after typing • 11:00am consumed 3rd unit • 02-14-09, 1:45pm hooked 3rd unit of PRBC with serial # of 2007859232 after typing • 5:40pm consumed 4th unit • 02-16-09, 7:30am hooked 4th unit of PRBC with serial # of 2007858859 after typing. • 11:30am consumed 5th unit • 02-17-09, 3:00am hooked 5th unit of PRBC with serial # of 2007859171 after typing. • 6:30am consumed 6th unit • 02-18-09, 5:20am hooked 6th unit of PRBC with serial # of 2007859061 after typing A blood transfusion is a relatively simple medical procedure that doctors use to make up for 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. PRBC is indicated for :to increase the bloods ability to transport oxygen and carbon dioxide No allergic reaction occurred 63 • 9am consumed 64 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.  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. 65 MEDICAL MANAGEMENT /TREATMENT DATE ORDERED: GENERAL DESCRIPTION INDICATION OR PURPOSE CLIENT‘S INITIAL REACTION TO TREATMENT Well hydrated CLIENT‘S INITIAL RESPONSE TO TREATMENT Normal PNSS Feb. 10, 2009 Feb. 11, 2009 Feb. 12, 2009 Feb. 13, 2009 Feb. 14, 2009 Feb. 15, 2009 Feb. 16, 2009 Feb. 17, 2009 Feb. 18, 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 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 =0.154 mole/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 Plain normal saline solution (PNSS) is used frequently in intravenous drips (IVs) for patients who cannot take fluids orally and have developed severe dehydration. 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 . 66 solute per liter) compared to blood . NURSING RESPONSIBILITIES BEFORE ASSESS -Skin and mucous membrane. Note color whether there is cyanosis -breathing patterns -chest movements -chest wall configuration -lung sounds DURING -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 device AFTER -assess the clients vital sign, color, ease of respirations and provide support while the client is to the adjusting of to the device MEDICAL MANAGEMENT /TREATMENT Oxygen inhalation 1-2 lpm via nasal cannula DATE ORDERED/PERFORMED/CHANGED Date ordered: 02-10-09 Date discontinued: 02-11-09 GENERAL DESCRIPTION Administration of oxygen and monitoring of its effectiveness INDICATION OR PURPOSE To relieve difficulty in breathing CLIENT‘S INITIAL RESPONSE TO TREATMENT difficulty in breathing was relieve 67 -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 68 Name of Drug Date ordered/, Date taken/given, Date changed 02-12-09 Route of Admin. & Dosage & Frequency of Admin. IVP, 300mg now P.O 500mg after 4 hrs General Action, Mechanism of Action Indications/ Purposes Client’s response to Medicine with actual Side Effect Generic: Acetaminophen Brand: Paracetamol Acetaminophen belongs to a class of drugs called analgesics (pain relievers) and antipyretics (fever reducers). The exact 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 heatregulating center of the brain. Acetaminophen is used for the relief of fever as well as aches and pains associated with many conditions. Decrease in the client‘s temperature noted. Nursing Responsibility: • Take this medication as directed. • Do not take more acetaminophen than recommended. 69 Ascorbic Acid (water-soluble vitamin) Date ordered: Feb 12, 2009 Oral; 500mg once a day  Vitamin  Stimulates collagen formation and tissue repair  Involved in oxidationreduction 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 • 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. 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. 70 NAMES OF DRUGS (GENERIC AND BRAND NAME) Calcium Gluconate DATE ORDERED/ DATE TAKEN/GIVEN, DATE CHANGED/D/C 02-16-09 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 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. 71 NAMES OF DRUGS (GENERIC AND BRAND NAME) Ferous Sulate DATE ORDERED/ DATE TAKEN/GIVEN, DATE CHANGED/D/C 02-12-09 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 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. 72 NAMES OF DRUGS (GENERIC AND BRAND NAME) Folic Acid DATE ORDERED/ DATE TAKEN/GIVEN, DATE CHANGED/D/C 02-16-09 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 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. 73 Type of Diet Diet as Tolerated Date Ordered 02-10-09 General description Patient can eat whatever food he can tolerate w/o specific restrictions. Indication/ Purpose Ordered when the patient‘s appetite, ability to eat and tolerance for food is regained. Specific foods taken Rice, vegetables, meat Clients Response 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. 74 Blood Chemistry Date Purpose Purpose Result Normal values Analysis BUN Creatinine 02-1309 BUN is made up of urea, which is an end product of the metabolism of protein by the live CREATININE is end product of muscle metabolism. 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. 75 1. Nursing management (SOAPIE/R) S > 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 O > 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 A Activity intolerance [Level III] r/t imbalance between oxygen supply and demand P 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 I 1. Independent: a. Limited activities and decrease external stimulus. E Pt. displayed gradual increase in activity tolerance as b. Assisted patient to gradually manifested by: increase activity level. Started a. increase in from simple ADLs like combing physical activity hair, brushing teeth and eating. tolerance from Progressed to mild activity like complete active-assistive ROMs and then dependence in ambulating with assistance. doing ADLs to accomplishment c. Recorded and documented of simple tasks pt.‘s VS before, during and after like feeding, activities and correlate with urinating and presence or absence of SOB. defecating with assistance d. Instructed pt. to avoid activities b. absence of which increase abdominal SOB while doing pressure. (e.g. straining during daily activities defecation) c. improvement of skin and nail color, d. decreased 76 > low HCT= 0.17 capillary refill time from 5 seconds to 4 seconds d. increase in independence while doing tasks S > 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 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 A IneffectiveTiss ue Perfusion: Periperal r/t decreased Hb concentration in blood P After 6 hours of nursng intervention, the client will display an increase in peripheral tissue perfusion. I 1. Independent a. 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 E 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 energy c. improvement in disposition d. improvement in skin color e.improvement of Hgb/Hct values 77 standing up to urinate and changing positions seconds in toenails > tachycardia = 103 bpm > tachypnea = 33 cpm > low HB= 36 g/l > low HCT= 0.17 2. Collaborative a. Assisted in obtaining specimen for laboratory studies (Hb/Hct, RBC count, ABG) b. Provided supplemental oxygen as indicated. c. Administered packed RBC blood transfusion as indicated. S > Frequent daytime naps for 1-2 hours > Feels that he lacks energy and is always tired > Has difficulty in falling asleep at night O > less than agenormed total for 7-8 hours night time sleep > lethargic > irritable and restless > yawns frequently > weak in appearance > Frequent conversations from SO > Interruption of A Disturbed sleep pattern r/t excessive stimulation from environment P After 8 hours of nursing intervention the client will report an improvement in sleep/rest pattern. I 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 E Pt. reported an improvement in sleep/rest pattern as manifested by: a. verbalization of increase in energy b. reduction of yawning, irritability and restlessness c. increase in total time of continuous, 78 rest and sleep due to therapeutic and monitoring activities of health care workers in hospital mental activities late in the day and at night. Minimize unnecessary disturbances during 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. uninterrupted night time sleep (from 4 hours to 7 hours) S > ―Hindi ako mahilig kumain ng prutas at gulay‖. > reports difficulty in eating d/t O > Eats only the meat and rice of the meal served by the hospital > Lost 10 kg. since Feb.14, 2009 A Imbalanced nutrition: less than body requirements r/t decrease in appetite P After 8 hours of proper nursing interventions , the client will maintain I > Monitor percentage of meals and snacks client consumes. Report a pattern of inadequate intake. > Performed or assisted with anthropometric measurements E After 8 hours of proper nursing interventions, the client was able to maintain an adequate nutritional status 79 weakness, > weak and pale requires in appearance assistance from SO when eating an adequate nutritional status such as skinfold thickness, midupper arm circumference (MAC), and mid-upper arm muscle circumference (MAMC) if indicated. Reported measurements lower than normal. as evidenced by: a. identification of nutritional requirements b. consume adequate nourishment > 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 80 during meals if indicated h. performed actions to compensate for taste alterations 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 81 > reports fatigue > 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 After 6 hours of deficit: appropriate Bathing/Hygie nursing interventions ne r/t , the client weakness and will be able to: tiredness Self-care a. bathe with assistance of caregiver or significant others as needed and b. remain free of body odor and maintain intact skin > Developed 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. > Planned activities to prevent fatigue during bathing; seat with feet supported. After 6 hours of appropriate nursing 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 > Provided pain relief measures: ice packs, heat and analgesics 45 minutes before bathing. > Teached use of adaptive bathing equipment such as longhandled brushes, washcloth mitt, shower chair, etc. > provided privacy: have only one caregiver providing bathing assistance, encourage a trafficfree area and postprivacy signs. > Kept the client warmly covered. > Used tepid water when bathing. 82 B. EVALUATION Patient‘s daily program in the hospital. Daily Program Nursing Problems 1. 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 Vital signs 02-13-09 02-14-09 02-15-09 02-16-09 02-17-09 02-18-09 √ √ √ √ √ Diagnostic & Lab. Procedures RR:35 PR: 94 BP: 110/80 T: 37.2 Hgb: 36 g/L Hct: 0.87 RR: 23 PR: 87 BP: 100/70 T: 37.8 Hgb: 45 g/L Hct: RR:25 PR: 87 BP: 100/70 T: 38.2 RR:30 PR: 88 BP: 100/70 T: 36.7 Hgb: 58 g/L Hct: RR: 30 PR: 88 BP: 110/70 T: 38.2 RR: 26 PR: 106 BP: 100/60 T: 38.8 83 L/L RBC: 1.01 T/L MCH: 35.6 pg MHCH: 414 g/L 0.097 L/L RBC: 1.14 T/L MCH: 39.5 pg MHCH: 464 g/L 0.152 L/L RBC: 1.80T/L MCH: 32.2 pg MHCH: 382 g/L BUN: 2.98.2 mmol/L Crea: 53106 mmol/L Medical and Surgical Mgt. IVF: PNSS @ 30-31 gtts/min BT: 1 ―u‖ PRBC Drugs 1. Ascorbic Acid 2. Calcium Gluconate 3. Fe SO4 4. Folic Acid Diet √ √ √ DAT IVF: PNSS @ 30-31 gtts/min BT: 1 ―u‖ PRBC √ √ √ DAT √ √ √ DAT IVF: PNSS @ 30-31 gtts/min IVF: PNSS @ 30-31 gtts/min BT: 1 ―u‖ PRBC √ √ √ √ DAT IVF: PNSS @ 30-31 gtts/min BT: 1 ―u‖ PRBC √ √ √ DAT IVF: PNSS @ 30-31 gtts/min BT: 1 ―u‖ PRBC √ √ √ DAT 84 85 METHOD MEDICATIONS prescribed are as follows: B-Complex Vitamin C Ferrous Sulfate 250 mg/cap OD 500 mg tab/ OD 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. 86 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 Bcomplex, 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 87 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/erectiledysfunction#Pathophysiology o http://www.answers.com/fever o http://www.mayoclinic.com/health/water/NU00283 88