II.

NURSING PROCESS
A. ASSESSMENT

1.

PERSONAL DATA The following relevant information with regards to the patient was obtained

through an interview process conducted by the nurse-researcher with the parents of the client. It was agreed upon that the information gathered by the nurse-researcher would be held confidential as the information would be utilized for the sole purpose of the case study.

a.

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

spontaneous delivery at a tertiary hospital in Angeles City, Pampanga. In the course of this study, the patient will be named as Baby X to protect his identity. Baby X and his parents are currently residing at Brgy. Senora in Porac, Pampanga. Both of his parents are natural born Filipino Citizen and of Kapampangan descent. They are members of the Roman Catholic Church. He is the first and only child of his parents. . He was admitted in the general ward of a private tertiary hospital in Angeles City last October 12, 2013 at 5:59 in the afternoon, with a chief complaint of skin rashes as lifted from the chart. His initial diagnosis is T/C Idiopathic Thrombocytopenic Purpura and he was confined for four (4) days. He was discharged from the hospital last October 15, 2013 at 7:15pm, with the final diagnosis of Idiopathic Thrombocytopenic Purpura.

b.

Socio-Economic and Cultural Factors Baby Xs family consists of three (3) members. His father is 23 years old, a

graduate of Computer Science course, and currently works in a tire service center in Clarkfield, Pampanga as a tire curator. The mother is 25 years old, took up a vocational course in dressmaking, and currently works in an electronics

company in Clarkfield, Pampanga as a merchandiser. Both of them go to work every day, in shifting schedules, except in the weekends where they take their days off. When they go to work, they ask the grandmother of Baby X, who lives just 2 houses away from them, to look after him. On their days off, they are usually at home and take care of Baby X.

As narrated by the clients mother, Baby X is a typical 2-year old boy who is very curious about the world around him. He likes to explore about unfamiliar objects and likes to do pretend during play, using familiar objects and situations to process his daily experience. He is also on the process of discovering his blossoming language skills, asking many why, what, and how questions to the people surrounding him. He is an active boy who likes to play with the older kids in their neighborhood, usually in a game of basketball, as told by his father. Baby X enjoys dancing upon request, acting out songs, and joins in singing the refrains of his favorite song. His sleeping time is at an average of 10-11 hours a day, usually sleeps at around 8PM and wakes up at 6AM. He also takes afternoon naps, usually 30 minutes to an hour, as told by his mother. As for his eating pattern, Baby X eats 3 times a day and is fond of eating rice and chicken dishes.

The parents combined salary for one month is estimated at around Php 28,000.00. The recommended share of each family member according to the National Economic Development Authority (NEDA) must be at least Php 2,768.60 per month. The family is considered to be financially adequate because each family member receives Php 9,333 per month, which is more than the requirement of the NEDA. Their expenses include food allowance, monthly utilities (water, electricity, cellular phone load), and transportation allowance.

The whole family is an active member of the Roman Catholic Church. They go to church and hear mass every Sunday, and observe religious practices/events

in the Catholic calendar. Despite their Catholic faith, Baby Xs mother admits she goes to a mananawas, whenever a family member gets sick, before they seek consult from a doctor. She said this is a practice she got from her mother. Other than that, she said they have no other superstitious or religious practice related to health.

c.

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

materials. There are 3 occupants in their house, and they are considered as a nuclear family. It is a bungalow type and consists of a bedroom, a living room, a kitchen, a dining area and bathroom. They live in a compound-type, owned by the fathers family. Their house is located in a small barangay, with proximity of an estimated 300 meters from the barangay hall and barangay health center.

2. MATERNAL-CHILD HEALTH HISTORY

a. Antepartal / Prenatal Data The mother of Baby X had her last menstrual period (LMP) on Feb 2010 and her pregnancy was confirmed via a home pregnancy test on the first week of March 2010. She is a primigravida. Baby X was delivered via normal spontaneous delivery at home with assisted midwife. No NBS and APGAR scoring done according to his mother. He had a birth weight of 3.1 kg. (6.9 lbs.), with no fetomaternal complications as stated.

b. Postpartum History Baby X was in a good condition at birth. There were no complications noted during the first 28 days of his life.

c. Infant Feeding According to the mother, Baby X was breastfed for only three days after he was born. The reason for this is because whenever he would try and suck milk from his mother, there would be blood in the breast milk. He would vomit and there would be streaks of blood in his vomitus as well. Since then, he was bottlefed and would consume an average of 3 to 4 bottles at 50 to 70 ml of formula milk with a feeding interval of 3 to 4 hours per day. By the start of his 2 nd month, Baby X consumes 3 bottles at 120 ml content of milk per day. During his 6 th month, he is able to consume 200 to 240 ml at each of four or five feedings per day.

d. Growth and Development Current Weight: 16.7 kgs (Ideal Wt: 11.3-18.0kg) Based on FNRI Standard Table of Height and Weight for Age of Filipino, the patients weight is within the expected weight of a 2 year and 11 months old child.

1. Eriksons Psychosocial Theory: Autonomy vs Shame and Doubt The development of autonomy during the toddler period is centered on childrens increasing ability to control their bodies, themselves, and their environment. They want to do things for themselves, using their newly acquired motor skills of walking, climbing, and manipulating and their mental powers of selection and decision making.

In this stage, Baby X learned to walk and become more mobile. According to his mother, he started walking at age 12 months. He would walk away from her whenever they are playing and pick toys that which he would play with. He also began to voice out what he wants to wear and what to eat.

Much of the learning in this stage is acquired through imitating the activities and behaviors of others. Negative feelings of doubt and shame arise when children are made to feel small and self-conscious, when their choices are disastrous, when others shame them, or when they are forced to be dependent in areas in which they are capable of assuming control.

The parents of Baby X let him do things on his own and allow him to explore his independence. They encourage him to try new things and reassure him that its acceptable to make or commit a mistake. They criticize his wrong actions and behavior in a gentle, non-embarrassing manner to develop his confidence.

2. Piagets Cognitive Development: Sensorimotor (Primary Circular Reaction) Children progress from reflex activity through simple repetitive behaviors to imitative behavior. They develop a sense of cause-and-effect as they direct behavior toward objects. They display a high level of curiosity, experimentation, and enjoyment of novelty and begin to develop a sense of self as they are able to differentiate. Problem solving is primarily trial and error. They become aware that objects have permanence that an object exists even though it is no longer visible.

As described the clients mother, Baby X enjoys being busy with a lot of activities. He explores the different ways to travel like crawling, rolling, running, climbing and jumping. He likes pretending animals, moving using his hands and feet. He enjoys riding his toy tricycle, using pedals some of the time. At 9 months, Baby X began to realize that an object exists even if it can no longer be seen, a sign that his memory is developing.

3. Freuds Psychoanalytical Theory: Anal Stage Interest during the second year of life centers in the anal region as sphincter muscles develop and children are able to withhold or expel fecal material at will. At this stage the climate surrounding toilet training can have lasting effects on childrens personalities.

Baby X started potty training when he was 1 year and 10 months. According to the mother, Baby X can sit on the toilet bowl on his own but there would be times that he still wants his mother beside him for assistance. He still wears diaper but hes able to inform his mother when he wants to move bowel.

3. FAMILY HEALTH-ILLNESS HISTORY

56

52 HPN

53

48

26

23

Asthma

25

30

2 ITP

Synthesis: The above figure shows the schematic diagram of the pertinent family history from the patient up to the second degree relationship. Most of the family members of Baby X are well and in good condition aside from his grandfathers who have hypertension and his mother who has asthma. Recent studies have found a high number of ITP patients with a positive family history indicating the likely existence of a genetic susceptibility for ITP. The genogram shows that there is no known history of ITP or any hematologic disorder within Baby Xs immediate family. However, his father verbalized that one of his first-degree cousin in the paternal side has a history of leukemia and hemophilia.

4.

HISTORY OF PAST ILLNESS The history of patients past illness includes all medical conditions that the

patient had which are identified to be non-associated with the patients current medical diagnosis. The following information was provided by the patient s parents through an interview process conducted by the nurse-researcher.

In December 2010, the client was hospitalized due to high fever, chills, and cough. He was diagnosed with Pneumonia. He was confined for a week and was pharmacologically treated with an unrecalled medication, according to his mother. Baby X got well and his health was back to normal. They were lost to follow-up.

In May 2011, Baby X was hospitalized due to Amoebiasis. He manifested a high fever for 2 days, with frequent loose stools and a loss in appetite. The mother also mentioned something about a blood infection detected thru a CBC test but cannot recall the exact diagnosis given. Baby X was given antipyretics, antibiotics and steroids and recovered well. They were lost to follow-up.

In December 2011, Baby X had a medical condition called Phimosis, the nonretraction of prepuce, which resulted to a recurrent Urinary Tract Infection. His pediatrician advised to have him circumcised. He was treated with antibiotics for the UTI.

5.

HISTORY OF PRESENT ILLNESS This part of the case study focuses on Baby Xs medical conditions, medical

managements and treatments that are deemed contributory and significant to the patients admitting Medical Diagnosis.

On September 11, 2013, Baby X was hospitalized due to high fever, nonproductive cough, lethargy, and generalized petechial rashes. According to the mother, his platelet count was down to 50. He was diagnosed with Pnemonia and Dengue Fever. He was given fluid resuscitation, bronchodilators, and steroids and was discharged last Sept. 22, 2013. They were scheduled to follow up on the 28 th of October.

On October 11, 2013, the night PTA, the mother noticed a hematoma at patients back and right leg, violet blue in color and about the size of a 25 cent coin. She thought it was just a bruise caused by Baby Xs playing. The following day, October 12, new hematomas were noted at patients right and left arms and left lower quadrant of abdomen, all violet blue in color, and almost the size of a 25 cent coin each. Pinpoint red petechiae marks were also noted at Baby Xs back. They decided to bring him in a secondary hospital in Angeles City but their family pediatrician was not available that time so they were told to go to his other clinic in a tertiary hospital, also in Angeles City. Upon consultation, they were given requests for laboratory work-ups. They had the work-ups done that same day, and results yields a platelet count of 10, significantly below normal and poses a risk for spontaneous bleeding. Hence Baby Xs admission that afternoon, with a diagnosis of T/C ITP.

6.

PHYSICAL EXAMINATION

Physical Assessment

October 12, 2013 (Admission Day, as lifted from chart)

October 15, 2013 (First NPI)

a. General Appearance:

Admitted this 2 years, 11 month old boy with petechial rashes Assessed this 2 yr old boy awake, and some ecchymosis on trunk, alert, afebrile, not in respiratory and extremities, awake, alert, distress. not in cardiorespiratory distress. T 36.3 oC HR 120 cpm RR 25 bpm Wt 16.7 kg (38.1 lbs.) T 36. 5 oC HR 119 cpm RR 30 bpm

b. Vital Signs:

c. Skin:

Warm, pale, good skin turgor, Warm, good skin turgor, with with generalized petechial rashes some lightly colored ecchymosis on face, trunk and extremities. on trunk & right lower extremity.

d. Head and Neck:

Normocephalic, flat fontanels, no lesions, no clad. Head Circumference: 41 cm

Normocephalic, flat fontanels, no lesions, no clad.

e. Eyes:

Pupil reactive to light, pale palpebral conjunctiva.

Pupil reactive to light, pale palpebral conjunctiva.

f. Ears:

Intact tympanic membrane, no discharge.

Intact tympanic membrane, no discharge.

g. Nose:

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

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

h. Mouth and Throat:

Uniform pink in color, soft, moist, smooth texture.

Uniform pink in color, soft, moist, smooth texture.

i.

Chest/Lungs:

Symmetrical chest expansion, no retractions, clear breath sounds.

Symmetrical chest expansion, no retractions, clear breath sounds

j.

Heart:

Dynamic precordium, normal rate, regular rhythm, no murmurs.

Dynamic precordium, normal rate, regular rhythm, no murmurs.

k. Abdomen:

Globular, soft, normoactive bowel sound. Abdominal circumference: 43.5 cm

Globular, soft, normoactive bowel sound

l.

Back

Presence of petechiae and ecchymoses, no back deformities.

Presence of ecchymoses, no back deformities.

m. Extremities:

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

Full and equal pulse, presence of ecchymoses on lower extremities.

n. Genitalia:

Grossly normal, no hernia, no discharge

Not assessed

o. Rectal:

No hemorrhoids

Not assessed

p. Neurologic Assessment:

Not assessed

Not assessed

7.

DIAGNOSTIC AND LABORATORY FINDINGS Diagnosis of a blood disorder depends primarily on laboratory analysis.

Although dozens of specific tests are used to diagnose individual disorders, all cases generally call for a (1) complete blood count (CBC) to determine the number of leukocytes and erythrocytes; (2) a total differential count to indicate the relative percentages of the different leukocytes; (3) coagulation studies such as prothrombin time (PT) or partial thromboplastin time (PTT) and bleeding time; (4) a bone marrow aspiration and biopsy to determine both the cellularity of the bone marrow and the morphology of the cells present; and (5) a peripheral blood smear (a study of the morphology of blood cells to help differentiate various anemias and blood dyscrasias). The results of laboratory tests also guide therapy.

Below are the series of results of diagnostics that was done to the patient during his hospitalization.

HEMATOLOGY REPORT Complete Blood Count (CBC) The CBC includes the red blood cell (RBC) count, hemoglobin, hematocrit, red cell indices, white blood cell (WBC) count with or without differential, and platelet count. CBC is done to determine general health status and to screen for a variety of disorders such as anemia and infection. It provides important information about the kinds and number of cells in the blood, especially red blood cells, white blood cells, and platelets (Black; Medical-Surgical Nursing; 4th ed.; 1993; Pp. 13281332).

Diagnostic / Laboratory Procedure

Date Ordered Date Result IN 1. Date Ordered Oct. 12, 2013 Result In: Oct 12, 2013

Indication(s) or Purpose(s)

Results (1st, 2nd, 3rd)

Normal Values (Units used in the hospital) 110-160 g/L

Analysis and interpretation of results

Hemoglobin

2. Date Ordered Oct. 14, 2013 Result In: Oct 14, 2013

Measures the amount of hemoglobin in blood and is a good indication of the blood's ability to carry oxygen throughout the body.

1. 117 g/L

Level of hemoglobin is within normal range. Indicates an adequate amount of oxygen in the blood.

2. 102 g/L

Level of hemoglobin is below normal range. Indicates an insufficient amount of oxygen in the blood.

Hematocrit

Date Ordered Oct. 12, 2013 Result In: Oct. 12, 2013 2. Date Ordered Oct. 14, 2013 Result In: Oct 14, 2013

Often used in place of RBC count, it is a measure of the volume of RBC in whole blood expressed as a percentage.

0.32

0.31-.43

Level of hematocrit is within normal range. Indicates a normal volume of red blood cells in whole blood.

0.28

Level of hematocrit is below normal. Indicates a slight impairment in the bone marrow.

Leukocytes Count

Date Ordered Oct. 12, 2013 Result In: Oct. 12, 2013

Used to determine the number of WBCs in a cubic milliliter of blood.

3.84

5-15.5 x 10^9/L

The number of WBC is below normal indicating that the patient is immunocompromised.

Differential Count: Lymphocytes

Date Ordered Oct. 12, 2013 Result In: Oct. 12, 2013

It determines the bodys ability to fight infections. It is used to determine immune competence. Measures number of circulating platelets in venous or arterial blood.

0.57

0.20-0.65

The lymphocyte level is normal which suggests bodys capability to fight infections.

Platelet

Date Ordered Oct. 12, 2013 Result In: Oct. 12, 2013

10

150 - 400 x 109/L

Platelet is below normal, results in prolonged bleeding time and impaired clot retraction.

Date Ordered Oct. 14, 2013 Result In: Oct 14, 2013

51

Platelet is below normal, results in prolonged bleeding time and impaired clot retraction.

Nursing Responsibilities Before the procedure: Inform the patients parents that the test is used to evaluate numerous conditions involving the red blood cells and platelets.

Obtain a history of the patients complaints, including a list of known allergens (especially allergies or sensitivities to latex), and inform the appropriate health care practitioner accordingly.

Obtain a list of medications the patient is taking, including herbs, nutritional supplements, and nutraceuticals. The requesting health care practitioner and laboratory should be advised if the patient regularly uses these products so that their effects can be taken into consideration when reviewing results.

Review the procedure with the patient. Inform the patient that specimen collection takes approximately 5 to 10 minutes. Address concerns about pain related to the procedure. Explain to the patient that there may be some discomfort during the venipuncture.

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

During the procedure: Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. Observe hospitals standard protocol.

After the procedure: Observe venipuncture site for bleeding or hematoma formation. Apply paper tape or other adhesive to hold pressure bandage in place, or replace with plastic bandage. A written report of the examination will be sent to the requesting health care practitioner, who will discuss the results with the patient Follow-up test results and report abnormal findings that need immediate interventions and management.

HEMOSTASIS REPORT
Diagnostic / Laboratory Procedure Clotting Time Date Ordered Date Result IN Date Ordered Oct. 12, 2013 Result In: Oct. 12, 2013 Indication(s) or Purpose(s) Results (1 , 2nd, 3rd)
st

Normal Values (Units used in the hospital) 2.00-5.00 mins

Analysis and interpretation of results On the upper normal range. Indicates mild coagulation problem.

To gauge the integrity of part of the blood clotting process.

5 mins

Bleeding Time

Date Ordered Oct. 12, 2013 Result In: Oct. 12, 2013

Measures the activity of the intrinsic and common pathways of coagulation.

6 mins

1.00-3.00 mins

Indicates prolonged bleeding time and mild impairment in blood clotting factors.

Before the procedure: Inform the patients parents that the test is used to evaluate the bleeding and clotting time. Obtain a list of medications the patient is taking, including herbs, nutritional supplements, and nutraceuticals. The requesting health care practitioner and laboratory should be advised if the patient regularly uses these products so that their effects can be taken into consideration when reviewing results. Review the procedure with the patient. Inform the patient that specimen collection takes approximately 5 to 10 minutes. Address concerns about pain related to the procedure. Explain to the patient that there may be some discomfort during the venipuncture. There are no food, fluid, or medication restrictions unless by medical direction.

During the procedure: Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. Observe hospitals standard protocol.

After the procedure: Observe venipuncture site for bleeding or hematoma formation. Apply paper tape or other adhesive to hold pressure bandage in place, or replace with plastic bandage. A written report of the examination will be sent to the requesting health care practitioner, who will discuss the results with the patient Follow-up test results and report abnormal findings that need immediate interventions and management.

CLINICAL CHEMISTRY

Diagnostic / Laboratory Procedure Reticulocyte Count

Date Ordered Date Result IN Date Ordered Oct. 12, 2013 Result In: Oct. 12, 2013

Indication(s) or Purpose(s)

Results (1st, 2nd, 3rd)

Normal Values (Units used in the hospital) 0.50-2.00 %

Analysis and interpretation of results Indicates that red cells are being produced and released by the bone marrow at an appropriate rate.

A reflection of RBC production, reticulocyte count measures responsiveness of bone marrow to a decreased number of circulating erythrocytes. Specifically, this measures number of reticulocytes relased from bone marrow into blood.

6.2

Nursing Responsibilities Before the procedure: Explain to the patient that the serum electrolyte test is used to determine the electrolyte content of blood. Advise the patient that the test requires a blood sample. Explain that he may experience slight discomfort from the needle puncture and the tourniquet. Instruct the patient to fast for 6 hours before the test. Notify the laboratory and physician of medications the patient is taking that may affect test results; they may need to be restricted.

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

After the test: Apply direct pressure to the venipuncture site until bleeding stops.If a hematoma develops at the venipuncture site, apply direct pressure. Tell the patient to resume medications that were discontinued before the test, as ordered.

BONE MARROW ASPIRATION

Bone Marrow Aspiration is a test used to assess and identify most blood dyscrasias such as aplastic anemia, leukemia, pernicious anemia, and thrombocytopenia. A sample of bone marrow is obtained by inserting a needle or biopsy instrument into a bone (usually the posterior iliac crest or sternum).

Date ordered: Oct. 13, 2013 Date performed: Oct. 14, 2013 Result Date: Oct. 19, 2013

The result of flow cytometry done in UST hospital yield negative for any blood disorder as per clients mother disclosure.

Nursing Responsibilities Before the procedure: Inform the client of the plan and approximate time for the bone marrow aspiration. Secure consent form. Check the clients medical history of allergies, especially to local anesthetics or latex. Obtain a sterile bone marrow aspiration tray and add the type and strength of local anesthetic according to the physicians orders. During the procedure: Determine the site from which the physician intends to obtain the sample of bone marrow. Position the client on his/her back or side to facilitate access to aspiration site. Suggest distraction techniques to avoid focusing on the pressure or discomfort associated with puncturing the bone. Label the specimen and ensure its delivery to the laboratory.

Follow Standard Precautions when there is a potential for contact with blood from the client, equipment, and bedside environment.

After the procedure: Limit the clients activity for approximately 30 minutes after the procedure. Monitor the puncture site frequently for continued bleeding; change or reinforce the dressing as needed. Report prolonged bleeding, unusual pain at the site, and signs of an infection.

Illustration:

CHEST RADIOGRAPHY

An X-ray is an imaging test that uses small amounts of radiation to produce pictures of the organs, tissues, and bones of the body. When focused on the chest, it can help spot abnormalities or diseases of the airways, blood vessels, bones, heart, and lungs.

Date ordered: Oct. 10, 2013 Result Date: Oct. 12, 2013

Interpretation: Chest PA/L (Pedia) Compared with chest taken 9-18-13, present study shows clear lungs. Heart and great vessels are within normal size and configuration. Other chest structures are not remarkable.

Nursing Responsibilities Before the procedure: Verify doctors order. Explain the procedure to the patient; its purpose, how it is done, and takes only 5-10 minutes to complete. Inform the patient that there are no food or fluid restrictions. Instruct patient to remove belt or metal buttons and underclothes and to put on a gown. During the procedure: Assist in positioning the patient so that x-ray films can be obtained from the most useful angles. After the procedure: Assist the patient in returning to his comfortable position. Document the date and time the procedure was done.

Peripheral Blood Smear (PBS) A peripheral blood smear is an examination of the peripheral blood to determine variations and abnormalities in erythocytes, leukocytes, and platelets.

Date ordered: Oct. 12, 2013 Result date: Oct. 12, 2013

Result: Normocytic, hypochromic RBC without anisopoikilocytosis . WBC are decreased with lymphocytic predominance. There are no blasts. Platelets are markedly decreased.

Impression: T/C Acute Leukemia.

Before the procedure: Inform the patients parents that the test is used to evaluate the bleeding and clotting time. Obtain a list of medications the patient is taking, including herbs, nutritional supplements, and nutraceuticals. The requesting health care practitioner and laboratory should be advised if the patient regularly uses these products so that their effects can be taken into consideration when reviewing results. Review the procedure with the patient. Inform the patient that specimen collection takes approximately 5 to 10 minutes. Address concerns about pain related to the procedure. Explain to the patient that there may be some discomfort during the venipuncture. There are no food, fluid, or medication restrictions unless by medical direction.

During the procedure: Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. Observe hospitals standard protocol.

After the procedure: Observe venipuncture site for bleeding or hematoma formation. Apply paper tape or other adhesive to hold pressure bandage in place, or replace with plastic bandage. A written report of the examination will be sent to the requesting health care practitioner, who will discuss the results with the patient Follow-up test results and report abnormal findings that need immediate interventions and management.