OUR LADY OF FATIMA

UNIVERSITY
COLLEGE OF NURSING
VALENZUELA CAMPUS

Anemia Unspecified

In Partial Fulfillment of requirements of NCM 107B RLE leading to the degree

of Science in Nursing

Presented to:
Mrs. Evangeline Orata, RN, MAN
Presented by:
Bungay, Maria Paula M.
BSN 4Y 2-1
Group 1B
August 28, 2015

TABLE OF CONTENTS

I. Introduction
II. Objectives
III. Patients Profile
IV. Anatomy and Physiology
V. Pathophysiology
VI. Laboratory Examination Results
VII. Gordons Assessment
VIII. Nursing Care Plans
IX. Drug Study
X. Health Teachings

I. INTRODUCTION
The main function of a red blood cell or erythrocyte is to carry and
transport oxygen to the different parts of the body. The normal RBC count is
4-6 million/mm3. Hemoglobin (Hgb), an iron-bearing protein, is found inside
an erythrocyte. Molecules of this iron containing protein are responsible for
transporting the bulk of oxygen that is carried in the blood.
The more hemoglobin molecules the RBC contain, a higher amount of oxygen
will they be able to carry. If the hemoglobin is defective, the erythrocyte will
also malfunction. A red blood cell is just a vessel; the one that performs the
oxygen transportation is the hemoglobin. Normal hemoglobin is 13-18
grams/dl in males and 12-16 grams/dl in females. A decrease in the RBC or
hemoglobin or the oxygen-carrying ability of a blood is termed as anemia.
Erythrocyte Formation
RBCs are produced by the bone marrow a process known as erythropoiesis.
Before a red blood cell is formed, the hematopoietic stem cell first produces
an uncommitted stem cell to be formed to committed progenitor cell.
Progenitor cells are not only the precursor of RBC, but also of lymphocytes
and megakaryocytes (antecedent of platelets). Before an erythrocyte is
formed the progenitor cells develop an erythroblast, then a reticulocyte, and
finally erythrocyte (RBC). A hormone, erythropoietin, which is secreted by the
kidney, also controls RBC production by stimulating the bone marrow.
Types of anemia
Hypoproliferative Anemias
This type of anemia covers all condition where the bone marrow incapable of
producing enough cells to develop to erythrocyte. Lack of erythropoietin may
also be a contributing factor of the abnormality. The following types of
anemia are under this classification:

Aplastic anemia In this condition, the precursor cells (stem or

progenital cells, which is responsible in forming components of blood)
are extremely deficient, thereby, production of all formed elements
(including RBC, lymphocyte, megakaryocytes) are reduced. Because of
the depressed bone marrow function, it is replaced by fat cells leading
to anemia, excessive bleeding (thrombocytopenia) and infections
(depressed WBC count). This type of anemia is also a common
example of a pancytopenic disorder.

Iron-deficiency anemia It is also called microcytic, hypochromic

anemia. This is type of anemia is the most common form among all
ages, and is characterized by a low iron concentration in the body.

Megaloblastic anemia A macrocytic, normochromic anemia results as

the essential factors (vitamin B12 and folic acid) for normal DNA
synthesis are missing causing suppression of mitosis in the bone
marrow and allowing the RNA or protein synthesis to take place for the
progression of cell growth without cell division. The resulting cells
remain enlarged (because mitosis is absent).

1. 1. Vitamin B12 deficiency Vitamin B12 or cobalamin is required

for normal DNA synthesis. It is not synthesized in the tissues of but
solely depends on the dietary intake of meat, liver, dairy products and
sea foods.
2. 2. Folic Acid Deficiency folic acid is also important for the DNA
synthesis of cells. The dietary sources of folate are meats, eggs, leafy
vegetables which are easily available.
Hemolytic Anemias
This type of anemia refers to the state where hemolysis(erythrocyte
destruction) causes symptoms of anemia. Classification of this condition is
further narrowed into intrinsic (inherited) or extrinsic (damage in erythrocyte
is caused by environmental factors).

Intrinsic Hemolytic Anemia

1. Sickle Cell anemia an inherited disorder on the beta chain of the

hemoglobin resulting to abnormally shaped red blood cells. In this
condition an abnormal hemoglobin S (HbS) is contained in the RBCs
causing distortions or sickling of the red blood cells.
2. Thalassemia group of genetic disorders that involve a defective
hemoglobin- chain synthesis. Thalassemia majoris threatening disease
characterized by severe anemia, hemolysis and ineffective
erythropoiesis. Thalassemia minor is a mild form of anemia. The
affected individual has only one defective gene and is asymptomatic.

Extrinsic Hemolytic Anemia

1. Immune hemolytic anemia a persons own antibodies destroy his own

red blood cells (hemolysis).

2. Mechanical hemolytic anemia hemolysis is caused by trauma or

physical injuries that disrupt red blood cells altering and tearing them
through the small vessels.

II. OBJECTIVES
Nurse Centered
1. Describe factually, the personal and pertinent family history of the
patient and relate it to the present condition.
2. Perform comprehensive physical assessment.
3. Trace the book-based and client-centered pathophysiology
4. Determine the predisposing and precipitating factors and the signs and
symptoms and relate to the disease process.
5. Enumerate and describe the diagnostic and laboratory procedures as well
as the nursing responsibilities in relation to the disease condition
6. Enumerate the different treatment modalities and their indication
specifically for the patients condition.
7. Identify the pharmacologic treatment provided to the patient, relate the
actions of each drug with the disease process and evaluate the patients
response to the medications given.
8. Identify nursing diagnoses, formulate short-term goals, carry out
appropriate interventions and evaluate the plan.
9. Appraise the effectiveness of medical and surgical nursing management
in treating the patient.
10. List the preventive measure for the occurrence of Anemia.
Patient Centered
1. Report understanding of the disease process.
2. Understand the indications of the different diagnostic procedures and
medical management involved in her care.
3. Cooperate with the necessary medical and nursing interventions.
4. Adhere with the health teachings provided.
5. Understand the different ways of health promotion and prevention in
relation to the disease condition.
6. Demonstrate improved conditions as evidenced by absence of further
complications.

III. Patients Profile

Name: MS. AC
Age: 16 years old
Nationality: Filipino
Religion: Roman Catholic
Civil Status: Single
Date Admission: August 16, 2015
Time of Admission: 10:54 PM
Ward: Pediatric Ward
Initial Diagnosis: Blood Dyscrasia probably ALL
Diagnosis: Anemia, Unspecified
HISTORY OF PAST ILLNESS
Ms. AC usually had conditions such as coughs and colds as well as
fever, which they treated, as stated by her father, by giving her BIOGESIC or
other over the counter drugs. Father stated that she already experienced
serious infections such as chickenpox and measles. The last time she was
admitted to the hospital was June 15, 2015. Ms. AC has no family history of
Anemia. She has no known food and drug allergies. Ms. Ac is not fond of
eating meat and vegetables and she would often miss her mealtime. At the
young age she started working as a maid and stop going to school due to
financial problem. As stated by Ms. AC her sleeping pattern is usually at 2
A.M.
PHYSICAL ASSESSMENT
Physicians Physical Assessment done by the Resident on Duty (August
16, 2015), lifted from the patient's chart)
Height: 59 cm
Weight: 41 kg
Vital Signs as follows:
T: 36.6C

PR: 112 bpm

RR: 42cpm

BP: 110/60 mmHg

SAO2: 98%

GENERAL SURVEY
Ms. AC, Assessed/received patient lying on bed, awake and conscious.
With the following vital signs:
Temperature: 36.6 C
Pulse rate: 112 bpm
Respiratory rate: 42 bpm
Blood Pressure: 110/60 mmHg
SAO2: 98%
1. PHYSICAL EXAMINATION (IPPA Cephalocaudal Approach)
August 16 (SUNDAY) First Nurse-Patient Interaction
a. General Appearance
AC 16 year old female, Filipino, Roman Catholic, born on
December 15, 1998 in Manila and currently residing at Acasia Malabon
City admitted for the first time in JRRMMC.
Vital Signs
Temp: 36C
PR: 112bpm
RR: 42 cpm
b. Height and Weight
Height: 59 cm
Weight: 41 kgs.
c. Examination of the Skin
Brown in complexion uniformed in skin color
Skin is warm to touch
(+) ecchymosis in upper and lower extremities
d. Examination of Hair and Nails
Hair is equally distributed
No infestations and dandruff
No depressions noted upon palpation
With dirty finger and toenails

 With normal capillary refill of 2 seconds

With nail beds, smooth in texture, convex curvature of finger plate;
angle of 160 degrees.
e. Examination of the Skull and Face
Skull rounded with no presence of lesions or deformations
With symmetric facial movements
Uniformed color
f. Examination of the Eyes
Eyebrows and lashes are evenly distributed
Eyelids are symmetrical
With approximately 15-20 involuntary blinks per minute
Pink palpebral conjuctiva
g. Examination of the Ears
Auricles are in symmetrical size, aligned with outer cantus
Pinna coils after being folded
Client responds to normal voice tones
minimal presence of cerumen on both ears
h. Examination of the Nose
External nose is properly aligned in between eyes and straight
With nasal flaring, no discoloration noted, no tenderness and no
lesions
Nasal septum is in middle and intact
Presence of clear nasal secretions
i. Examination of the Mouth
Outer upper and lower lips are pink in color with soft and smooth
texture and have the ability to purse lips
Inner lips and buccal mucosa is uniform and pink in color, smooth
texture and glistening
With incomplete set of teeth

 The tongue is in central position, pink in color, slightly rough, with

raised taste buds and can be able to move side to side and up and
down
Uvula is positioned in midline of soft palate
Can open and clench jaw without difficulty
j. Examination of the Neck

Neck is symmetrical

No masses noted

Coordinated head movement with slight difficulty

Trachea in midline at the suprasternal notch upon inspection and

palpation

k. Examination of the Lymph Nodes

Lymph nodes not palpable, slightly movable
No enlargement noted
l. Examination of the Chest (Lungs)
Normal respiratory rate (20 cpm)
Symmetrical chest expansion
Presence of any adventitious breath sounds upon auscultation
m. Examination of Abdomen

Without abdominal distention upon inspection and palpation

Absence of wounds and lacerations upon inspection

n. Examination of the Heart

With normal, regular, rate and rhythm of the heart upon auscultation
o. Examination of Extremities
Extremities are symmetrical and no deformations and tenderness
There is no presence of edema
Radial pulse is regular and not bounding
p. Examination of Lower Extremities
No presence of lesions present
Extremities symmetrical with no deformations and tenderness
There is no presence of edema

CRANIAL NERVE ASSESSMENT

CRANIAL

TYPE

FUNCTION

CRANIAL

Senso

Smell

NERVE I

ry

NERVE

METHOD OF

FINDINGS

ASSESSMENT

The Student Nurse Actual

asked the patient findings:

(Olfactory)

to close her both AC

eyes.

He

is

able

was smell

to
and

asked to smell and identify different

to identify aromas scents such as
such

as

Vinegar alcohol

and

and alcohol, which vinegar.

was

prepared

by

the student nurse

(SN).
CRANIAL

Senso

Vision

NERVE II

ry

Visual fields

(Optic)

and The SN asked Bah Actual

Tuh

to

read

newspaper

a Findings:
first AC

cannot

with the right eye anything

see
when

and then with the her left eye was

left and finally both
eyes
distance
inches.

with
of

covered,

a when

while
covering

12 the right eye the

left can read the
words written in
the

newspaper.

When using both

eyes he can read
the

newspaper

by using her left

eye.
CRANIAL

Motor

Extraocular

The

NERVE III

movement,

patient

(Oculomotor)

movement

first his one eye as Upon

of sphincter a

SN

asked Actual

to

close Findings:

penlight

was introduction

of pupil and introduced on the light

ciliary
muscles
the lens

the

uncovered

on

eye. pupil

of Upon

of

of
each
the

the patient,

application of light, constriction

pupil

size

changes

and the

pupil

of
was

were noticed. It also

noticed. The same constricts

upon

thing was done on focusing on the

the other eye. Also, penlight holding
the blinking of the
eyelids

of

the nurse and dilates

patient

was when looking at

assessed

during the wall without

the whole period of

the

interview.

addition,

the

holding

penlight asked the

patient

to

concentrate
looking

on

the

penlight

then

observe

for

constriction of the
pupil

and

after

that

moving

In head.

student nurse who

was

by the student

then
the

student nurse told

the

the patient to look

at the wall without
moving the head
then

observe

for

dilation of pupil.
CRANIAL

Motor

Extraocular

The SN made use Actual

NERVE IV

movements

of a penlight and Findings:

(Trochlear)

specifically

moved

movements

different directions: coordinated eye

it

of eyeball in upward

in AC

has

good,

lateral, movements

downward

right

side, (both eyes) and

lateral

downward

directions.

and left side.

lateral, is able to follow

The

the direction of

SN instructed the the penlight with

patient

to

follow her eyes without

the movements of moving

the

her

penlight head.

through

his

only

eyes

without

moving his head.

CRANIAL

Senso

Sensation of The SN made use Actual

NERVE V

ry

cornea, skin of

(Trigeminal)

and

of face and reflex

Motor

nasal

gently touching the blinking reflex.

mucosa,

cornea with sterile She

muscle

the

corneal Findings:
test

by Ac

elicited
can

also

of cotton and gently differentiate the

mastication,

stroking

sensation of eyelashes.

the dullness

And sharpness of the

skin

uses a pin to test pin.

surface.

for skin sensation.

The

group

or

She is able to

also make

chewing

observed

the movements,

patent when eating open the mouth

and speaking.

against
resistance,

and

move

jaw

her

from side to side

CRANIAL

Motor

Extraocular

The student nurse Actual

NERVE VI

movement,

asked

(Abducens)

lateral

move the eyeballs AC was able to

movement

in lateral sides.

of

patient

to Findings:
move

the

eyeballs

eyeball

laterally.

CRANIAL

Senso

Facial

NERVE VII

ry and expressions,

(Facial)

Motor

sense

both

The student nurse Actual

asked

of smile,

patient
raise

to Findings:
his AC was able to

taste on the eyebrows and puff smile,

puff

out

anterior two out his cheeks, and

her cheeks and

thirds of the frown.

raise

tongue and The student nurse eyebrows

movement
of

also

muscles patient

in the face.

asks
to

his
and

the frown her face.

taste

salt and sugar.

AC was able to
identify

the

difference
salt, and sugar.

of

CRANIAL

Senso

Hearing and The student nurse Actual

NERVE VIII

ry

Balance

whispered a word findings:

(Acoustic)

to

his

and AC can hear on

instructed
repeat

his

the

to both ears.

word

whispered.
Actual
findings:
The patient was
Performed

the able to balance

Rombergs

Test. her self without

Instructed

patient any

excessive

to close his eyes swaying

and stand straight movements.
with hands on side.
CRANIAL

Senso

Sense

of The student nurse Actual

NERVE IX

ry

taste on the instructed

Glossopharyn

and

posterior

geal

Motor

one-third of water and swallow demonstrated

patient

the findings:

to

drink AC

the tongue, it. And asked the (+) gag reflex.

pharyngeal

patient to moves

movement

his

and

different sides.

tongue

in

swallowing.
CRANIAL

Senso

Taste,

For

taste,

NERVE X

ry

Salivary

student

(Vagus)

and

glands,

introduced a sugar AC was able to

Motor

pharyngeal

and

muscles,

posterior

larynx

the

salt

nurse findings:
on
part

tongue.

motor,

the Actual

the

the identify

the

of different taste of
For the

substances

SN and was able to

introduced
tongue
on

a elicit gag reflex

depressor

the

upon introducing

anterior a

part of the tongue.

tongue

depressor at the
back

of

tongue,

the

normal

swallowing
noted.

CRANIAL

Motor

Motor

to Applied a force on Actual

NERVE XI

neck

(Accessory)

upper back shoulders,

muscles

and the

head

instructed

and findings:
AC was able to
patient exert

to resist the force

the

force
head

shoulders

on
and

upon

the

student

nurse

applied

force.
Actual
CRANIAL
NERVE XII
(Hypoglossal)

Motor

Tongue

Asked the patient findings:

muscles

to protrude tongue AC was able to

and move it from protrude
side to side.

tongue
any

the
without

deviation

and move it from

side to side.

IV. ANATOMY AND PHYSIOLOGY

The production of red blood cells is referred to as erythropoiesis.

Mature red blood cells develop from hemocytoblasts. This development takes
about 7 days and involves three to four mitotic cell divisions, so that each
stem cell gives rise to 8 or 16 cells. The various cell types in erythrocyte
development are characterized by the gradual appearance of hemoglobin
and disappearance of ribonucleic acid (RNA) in the cell
the progressive degeneration of the cell's nucleus which is eventually
extruded from the cell the gradual loss of cytoplasmic organelles, for example
mitochondria a gradual reduction in cell size.
The young red cell is called a reticulocyte because of a network
of ribonucleic acid (reticulum) present in its cytoplasm. As the red cell
matures the reticulum disappears. Between 2 and 6% of a newborn baby's
circulating red cells are reticulocytes, but this reduces to less than 2% in the
healthy adult. However, the reticulocyte count increases considerably in
conditions in which
rapid erythropoiesis occurs, for example following hemorrhage or acute

hemolysis of red cells. A reticulocyte normally takes about 4 days to mature

into an erythrocyte. In health, erythropoiesis is regulated so that the number
of circulating erythrocytes is maintained within a narrow range. Normally, a
little less than l% of the body's total red blood cells are produced per day and
these replace an equivalent number that have reached the end of their life
span. However that still represents a huge 200,000,000,000 cells.
Erythropoiesis is stimulated by hypoxia (lack of oxygen).
However, oxygen lack does not act directly on the hemopoietic tissues
but

instead

stimulates

the

production of a hormone,

erythropoietin.

This hormone then stimulates hemopoietic tissues to produce red cells.

Erythropoietin is a glycoprotein. It is inactivated by the liver and excreted in
the urine. It is now established that erythropoietin is formed within the kidney
by the action of a renal erythropoietin factor erythrogenin on plasma protein,
erythropoietinogen. Erythrogenin is present in the juxtaglomerular cells of the
kidneys and is released into the blood in response to hypoxia in the renal
arterial

blood

supply.

Various other factors can affect the rate of erythropoiesis by influencing

erythropoietin production. Thyroid hormones, thyroid-stimulating hormone,
adrenal cortical steroids, adrenocorticotrophic hormone, and human growth
hormone

(HGH)

all

promote

erythropoietin formation and so enhance red blood cell formation

(erythropoiesis). In thyroid deficiency and anterior pituitary deficiency,
anemia may occur due to reduced erythropoiesis.
Polycythemia (excess red blood cell production) is often a feature
of Cushing's syndrome. However, very high doses of steroid hormones seem
to

inhibit

erythropoiesis.

Androgens (male hormones) stimulate and estrogens (female hormone

s) depress the erythropoietic response. In addition to the effects of menstrual
blood loss, this effect may explain why women tend to have a lower
hemoglobin concentration and red cell count than men. Plasma levels of
erythropoietin are raised in hypoxic conditions (low oxygen levels).
This produces erythrocytosis (increase in the number of circulating
erythrocytes) and the condition is known as secondary polycythemia. A
physiological secondary polycythemia is present in the fetus (and residually

in the new-born) and in people living at high altitude because of the relatively
low partial pressure of oxygen in their environment. Secondary polycythemia
occurs as a result of tissue hypoxia in diseases such as chronic bronchitis,
emphysema

and

congestive

cardiovascular

abnormalities

associated with right-to-left shunting of blood through the heart, for example
Fallot's of tetralogy. Erythropoietin is also produced by a variety of tumors of
both renal and other tissues. The oxygen carrying capacity of the blood is
increased in polycythemia but so is the thickness (viscosity) of the blood. The
increased viscosity produces circulatory problems such as raised blood
pressure. There is a condition known as primary polycythemia (polycythemia
rubra vera), where there are increases in the numbers of all the blood cells,
and plasma erythropoietin levels are normal. The cause of this condition is
unknown. The underlying cause of secondary polycythemia is treated with
the

aim

of eliminating hypoxia. Vene

section (blood letting) is sometimes employed to

reduce red cell volume to normal levels. Frequently blood is removed,
centrifuged to remove cells and the plasma returned to the patient
(plasmapheresis). In anemia there is a reduction in blood hemoglobin
concentration

due

to

decrease in the number of circulating erythrocytes and/or in the amount of he

moglobin they contain. Anemia occurs when the erythropoietic tissues cannot
supply enough normal erythrocytes to the circulation. In anemia due to
abnormal red cell production, increased destruction and when demand
exceeds capacity, plasma erythropoietin levels are increased. However,
anemia can also be caused by defective production of erythropoietin as, for
example, in renal disease.
A. Definition
Anemia is a condition where red blood cells are not providing
adequate oxygen to body tissues. Red blood cells provide oxygen to body
tissues. There are many types and causes of anemia.
B. Causes

Anemia is caused by many different things at it has a lot of subtypes.

However, the main presenting factor is the lack of healthy circulating red
blood cells to carry oxygen systemically. Here is a quick overview of the
different subtypes of anemia:
1. Iron Deficiency Anemia
Iron is needed for healthy production of red blood cells. Iron is a building
block of healthy red blood cells. A deficiency in iron would result in immature,
microsomic, and hypochromic red blood cells. Also, fewer RBCs will be
produced by the marrow. This type of anemia is the most common type of
anemia.
2. Folic-Acid Deficiency Anemia
Folate is also known as Folic Acid. This type of anemia results from a
deficiency of this B vitamin. This particular type of anemia is particularly
common among pregnant women as the developing fetus uses up the
mothers folate stores. In folate deficiency anemia, the red blood cells are
macrosomic and are called megalocytes or megaloblasts. This is the reason
why this form of anemia is called Megaloblastic Anemia
3. Thalassemia
Thalassemia is a form of anemia that is inherited. In this type of anemia, the
body makes an abnormal form it hemoglobin, the major protein in RBCs that
carry oxygen. In alpha-thalassemia, the genes related to alpha globin are
mutated or are missing. In beta thalassemia, a gene defect also affects the
production of beta globin. Thalassemia major is categorized if you inherit the
genetic defect from both parents. If only one parent however transmits the
defect, it is termed Thalassemia minor. Both conditions result to an abnormal
form of hemoglobin and leads to excessive RBC destruction leading to
anemia.
4. Vitamin B12 Deficiency Anemia

This form of anemia is due to lack of sufficient cyanocobalamin or

Vitamin B12. This type of anemia results to macrocosmic, hypochromic RBCs.
This is often referred to as Pernicious anemia. The cause of this type of
anemia could be a dietary deficiency, or a disease that impairs its proper
absorption such as Celiac disease or Crohns disease.
5. Hemolytic Anemia
Hemolytic Anemia is a type of anemia that results from excessive lysis or
destruction of RBCs. This type of anemia has a lot of causes and it also has
different subtypes. The destroying factor may be intrinsic, or extrinsic,
depending on the specific cause. In this type of anemia, RBCs are rapidly
destroyed, resulting to a low number of oxygen-carrying RBCs leading to
anemia. This type of anemia does not occur though if the bone marrow is
capable of producing much more RBCs than those destroyed.
6. Aplastic Anemia
In Aplastic anemia, there is a deficiency in sufficient production of red blood
cells by the bone marrow. There are two types of this: idiopathic, or
secondary. In idiopathic aplastic anemia, there is no clear cause as to why the
bone marrow is unable to produce new, mature red blood cells. In secondary
aplastic anemia, the failure results as a sequel from another disorder such as
renal disease (where there is decreased erythropoietin), chemotherapy,
radiation, and others.
7. Sickle-Cell Anemia
This type of anemia is caused by a particular type of hemoglobin called
hemoglobin S. Hemogloin S changes the shape of red blood cells especially
during times of low oxygen saturation of the blood. Hemoglobin S causes
cells to become shaped like sickles or crescents. These RBCs are unable to
properly carry oxygen, and they often get lodged into capillaries and block
them.
C. Symptoms

Symptoms of anemia may vary from the specific subtype, but these are some
of the general signs and symptoms:

Fatigue

Pallor

Cyanosis

Low hematocrit and RBC levels on a Complete Blood Count

Chest pain

Dizziness and Headaches

Paresthesia

Skin mottling

Shortness of Breath

Confusion and restlessness

Cold hands and feet

Tachycardia

D. Management
Management of anemia depends on the specific deficiency or the specific
subtype. Nonetheless, conventional management includes:
1. Supplementation with Iron, Folate, or Vitamin B 12
2. Use of corticosteroids in anemias where there is destruction of
RBCs
3. Blood Transfusions
4. Erythropoietin supplementation
5. Rest
6. Treatment of the underlying condition that causes the anemia

E. Prevention
Prevention of anemia is possible. Ensuring that you eat a proper diet is one of
the keys towards prevention of this disease. Supplement your diet with foods
rich in iron, folate, vitamin B12 and vitamin C such as green leafy vegetables,

dairy, eggs, organ meats, lentils, beans, meat, and others. If there is an
underlying medical condition that may cause anemia, consult your doctor as
to how to manage this condition.

V. PATHOPHYSIOLOGY
Anemia Schematic Diagram

Predisposing Factors
-Sex (menstruation)
-Genetics

Precipitating Factors
-Inadequate Iron intake &
faulty diet
-Blood Loss
-Pregnancy

Decreased intake of iron

rich foods, with blood
loss

Iron in the body is used

up
Decreased iron reserves
needed for hemoglobin
production

Decreased RBC
production due to lack of
hemoglobin
Iron Deficiency Anemia

Decreased oxygen and

hemoglobin

Pallor due to
decreased hemoglobin

Headache due to
decreased oxygen supply
to the brain

Weakness due to
decreased overall oxygen
supply

If prolonged:
*Chest Pain (Lack of oxygen in the heart)
*Shortness of Breath even with rest
*Paresthesia (indicates nerve affectation)
*Disorientation and Confusion (if the
brain is severely deprived of oxygen)
*Low RBC and Hematocrit levels

VI. LABORATORY EXAMINATION RESULTS

1.) Hematology complete blood count
Procedur
e
Hematolog
y
Complete
Blood
Count

Date
August
16-27,
2015

Purpose

Normal

Results

This test is
used
to
evaluate
anemia,
leukemia,
reaction to
inflammatio
n
and
infections,
peripheral
blood
cellular
characters,
State
of
hydration
and
dehydration
,
Polycythemi
a,
to
manage
chemothera
py
decisions.

WBC:
10^3/ul
Neutrophil:
0.40-0.60
(H)
Lymphocyt
es:
0.20-0.40
(L)
Monocytes:
0.02-0.08
Eiosinophil:
0.01-0.03
Basophil:
0.00-0.02
Hgb:
12.516.2g/L
Hct:
0.37-0.42
(H)
RBC:
4.50-5.50
10^2/L
MCV:
88-96
FL
(L)
MCH:
27-33pg
MCHC:
330-360
g/L (L)
RDW:
12.70%22.70%
Platelet:
10^3/ul
MPV:
4.50-7.50
(H)

WBC:
9.54
Neutrophil
: 41.5
Lymphocy
tes: 43.2
Monocyte
s:
1.0
Eiosinophi
l:
5.8
Basophil:
0
Hgb:
5.3
Hct:
30.9
RBC:
3.72
MCV:
83.1
MCH:
28.5
MCHC:
34.3
RDW:
40.9
Platelet:
9
MPV:
-

Implicatio
n
Abnormal
results
of
high WBC
which
indicates
infection
along with
high
Neutrophil
and
lymphocyt
es
count.
This
indicates
the
abnormal
blood flow
and other
systemic
affection
due to the
patients
disease
also
considering
her
low
immune
system
function.
The
rise
and fall of
other
results
have been
altered due
to
other
medical
treatments
and
procedures
done to the
client.

Nursing Intervention:
Explain test procedure. Explain that slight discomfort may be felt when
the skin is punctured.
Encourage to avoid stress if possible because altered physiologic status
influences and changes normal hematologic values.
Explain that fasting is not necessary. However, fatty meals may alter some
test results as a result of lipidemia.
Apply manual pressure and dressings over puncture site on removal of
dinner.
Monitor the puncture site for oozing or hematoma formation.
Instruct to resume normal activities and diet.

NAME OF
DRUGS,
GENERIC
NAME,
BRAND NAME

DATE ORDERED,
DATE
TAKEN/GIVEN,
DATE CHANGED

Blood
Transfusion

DO: August 17,21,

23, 2015

ROUTE OR
ADMINISTRATI
ON DOSAGE
AND
FREQUENCY OF
ADMINISTRATI
ON
Right Brachial
artery
q 24

GENERAL
ACTION,
MECHANISM OF
ACTION

INDICATION
OR
PURPOSES

One unit of packed

To increase the

red blood cells has

oxygen-

the same amount

carrying

of oxygen carrying

capacity in

red blood cells as

anemic

a unit of whole

patients.

blood. For each

unit of RBCs
transfused, the
average 70 kg
adults hemoglobin
will usually
increase by 1 g/dL
the and their
hematocrit by 2-3
percent. Packed
red blood cells
have a hematocrit
between 70% and
80%, so they are
among the most
viscous of the
blood products to
transfuse.

CLIENTS
RESPONSE
TO THE
MEDICATION
Clients
response to
medication is
effective as
evidence by
lowering
down the
patients
temperature

NURSING RESPONSIBILITIES:
Plain NSS (IVF)
1. Verify the doctors order.
2. Know the type, amount and indication of IV therapy.
3. Practice strict asepsis.
4. Inform client and explain purpose of therapy.
5. PRIME IV tubing to expel air. This will prevent air embolism.
6. Clean the insertion site of IV needle from center to the periphery
with alcoholized cotton swab.
7. Monitor patient frequently for:
a. Signs of infiltration / sluggish flow
b. Signs of phlebitis / infection
c. Dwell time of catheter and need to be replaced
d. Condition of catheter dressing
8. Check the level of the IVF.
9. Correct solution, medication and volume.
10.Check and regulate the drop rate to ensure administration of proper
volume of IV fluid as ordered.
11.Change the IVF solution if needed.
Packed RBC (Blood Transfusion)
1. Verify the physicians written order and make a treatment card
according to hospital policy.
2. Observe the 10 Rs when preparing and administering any blood or
blood components.
3. Explain the procedure/rationale for giving blood transfusion to
reassure patient and significant others and secure consent. Get
patient histories regarding previous transfusion.
4. Explain the importance of the benefits on Voluntary Blood Donation
(RA 7719- National Blood Service Act of 1994).

5. Request prescribed blood/blood components from blood bank to

include blood typing and cross matching and blood result of
transmissible Disease.
6. Using a clean lined tray, get compatible blood from hospital blood
bank.
7. Wrap blood bag with clean towel and keep it at room temperature.
8. Have a doctor and a nurse assess patients condition. Countercheck
the compatible blood to be transfused against the cross matching
sheet noting the ABO grouping and RH, serial number of each blood
unit, and expiry date with the blood bag label and other laboratory
blood exams as required before transfusion.
9. Get the baseline vital signs- BP, RR, and Temperature before
transfusion. Refer to MD accordingly.
10.Give pre-meds 30 minutes before transfusion as prescribed.
11.Do hand hygiene before and after the procedure.
12.Prepare equipment needed for BT (IV injection tray, compatible BT
set, IV catheter/ needle G 19/19, plaster, torniquet, blood, blood
components to be transfused, Plain NSS 500cc, IV set, needle
gauge 18 (only if needed), IV hook, gloves, sterile 22 gauze or
transplant dressing, etc.
13.If main IVf is with dextrose 5% initiate an IV line with appropriate IV
catheter with Plain NSS on another site, anchor catheter properly
and regulate IV drops.
14.Open compatible blood set aseptically and close the roller clamp.
Spike blood bag carefully; fill the drip chamber at least half full;
prime tubing and remove air bubbles (if any). Use needle g.18 or 19
for side drip (for adults) or g.22 for pedia (if blood is given to the Yinjection port, the gauge of the needle is disregarded).
15.Disinfect the Y-injection port of IV tubing (Plain NSS) and insert the
needle, from BT administration ser and secure with adhesive tape.
16.Close the roller clamp of IV fluid of Plain NSS and regulate to KVO
while transfusion is going on.

17.Transfuse the blood via the injection port and regulate at 1015gtts/min initially for the first 15 minutes of transfusion and refer
immediately to the MD for any adverse reaction.
18.Observe/Assess patient on an on-going basis for any untoward signs
and symptoms such as flushed skin, chills, elevated temperature,
itchiness, urticaria, and dyspnea. If any of these symptoms occur,
stop the transfusion, open the IV line with Plain NSS and regulate
accordingly, and report to the doctor immediately.
19.Swirl the bag gently from time to time to mix the solid with the
plasma N.B one B.T set should be used for 1-2 units of blood.
20.When blood is consumed, close the roller clamp, of BT, and
disconnect from IV lines then regulate the IVF of plain NSS as
prescribed.
21.Continue to observe and monitor patient post transfusion, for
delayed reaction could still occur.
22.Re-check Hgb and Hct, bleeding time, serial platelet count within
specified hours as prescribed and/or per institutions policy.
23.Discard blood bag and BT set and sharps according to Health Care
Waste Management (DOH/DENR).
24.Fill-out adverse reaction sheet as per institutional policy.
25.Remind the doctor about the administration of Calcium Gluconate if
patient has several units of blood transfusion (3-5 more units of
blood).

VII. GORDON'S ASSESSMENT

A. Health Perception and Management
o Client cant recall well if She was completely immunized.
o Client was brought to the hospital for management.
B. Nutrition/ Metabolism
o Not fond of eating meats and fruits
C. Elimination
o Voids usually 5 times a day
o Urine color is yellow
o Defecates usually every other day.
D. Activity/Exercise
o Bed rest with semi-fowlers position.
o Minimal movements
E. Sexuality/Reproductive
o Single
o No history of STDS
F. Cognitive/Perceptual
o Responds to stimuli physically.
o Undergrad
G. Roles/Relationship
o Single
o Well-supported by the family
H. Self-Perception/ Self-Concept
o Hopeful to be relieve and treated
o Manages healthy lifestyle before her condition
I. Value/Belief
o Catholic
o Has a strong faith in God
J. Coping/ Stress
o Anemia since December 2014
o Copes up with problems
K. Sleep/Rest
o Difficulties in sleeping, always sleeps late
o Not enough rest intervals
L. Medication History
o Meds for her previous hospitalization in January 2015

VIII. NURSING CARE PLAN

#1 ACTIVITY INTOLERANCE R/T IMBALANCE BETWEEN OXYGEN SUPPLY (DELIVERY) AND DEMAND
ASSESSMENT
Subjective:
Nanghihina
ako,kadalasan
hindi ko matapos
ang mga gawain
ko
(Im feeling weak,
I cant even
complete my
chores
) as verbalized
by the patient.

Objective:
Fatigue.

Greater need

DIAGNOSIS
Activity
intolerance
related to
imbalance
between oxygen
supply (delivery)
and demand.

OBJECTIVE

INTERVENTION

RATIONALE

Short term:

Independent:

After 8 hours of
nursing
interventions the
patient will:

Assess patients
ability to perform
normal task or
activities of daily
living.

Influences
choice of
interventions or
needed
assistance.

Note changes in
balance/ gait
disturbance,
muscle
weakness.

May indicate
neurological
changes
associated with
vitamin B12
deficiency,
affecting patient
safety or risk of
injury.

Report an
increase in
activity tolerance
including
activities of daily
living.

Demonstrate a
decrease in
physiological
signs of
intolerance.

Recommend
quiet
atmosphere, bed
rest if indicated.

Enhances rest to
lower bodys
oxygen
requirements,

EVALUATION

Patient reveals
an increase in
activity tolerance,
demonstrating a
reduction in
physiological
signs of
intolerance and
laboratory values
within normal
range.

for sleep and

rest.
Display
laboratory
V/S taken as
follows: T: 36.9
P: 75 R: 18 BP:
100/80

values within
acceptable
range.

Long term:

Elevate the
head of the bed
as tolerated.

and reduces
strain on the
heart and lungs.

Provide or
recommend
assistance with
activities or
ambulation as
necessary,
allowing patient
to do as much as
possible.

Enhances lung
expansion to
maximize
oxygenation for
cellular uptake.

After months of
nursing
interventions, the
patient:

Although help
may be
necessary, self
esteem is
enhanced when
patient does
some things for
self.

Is free form
weakness and
risk for
complications
has been
prevented.
Plan activity
progression with
patient, including

Promotes
gradual return to

activities that the

patient views
essential.
Increase levels of
activities as
tolerated.

normal activity
level and
improved muscle
tone or stamina
without undue
fatigue.

Identify or
implement
energy saving
technique like
sitting while
doing a task.

Encourages
patient to do as
much as possible,
while conserving
limited energy
and preventing
fatigue.

Collaborative:
Monitor
laboratory
studies. Hb or Hct
and RBC count,
arterial blood
gases (ABGs).

Identifies
deficiencies in
RBC components
affecting oxygen
transport and
treatment needs
or response to
therapy.

#2 IMPAIRED GAS EXCHANGE R/T OXYGEN CARRYING CAPACITY OF BLOOD

ASSESSME
NT
Subjective:
Madalas
akong
mahilo at
nahihirapang
huminga
verbalized
by patient
Objective:
visual
disturbance
headache
uponawakeni
ng
restless
irritable
pale in
appearance
diaphoresi

DIAGNOSIS

Impaired gas
exchange
related to
oxygen
carrying
capacity of
blood

OBJECTIVE

Short term:
After 5-10
mins of nursing
intervention
the patient will
be able to
breath with in
patient range
through
supplemental
oxygenation
and lessen
complaints
of dizziness

INTERVENTION

Diagnostic:

Long term:
After 3 days
of continuous
nursing
intervention
the patient will
be able to
demonstrate
impaired
ventilation and

monitor
vital signs
especially
respiratory
rate and
record
review lab
results on
CBC and
ABGs
Assess
energy
level and
activity
tolerance

RATIONALE

Therapeutic:

Administer
O2 therapy
as ordered
Assists on
needs
Demonstrat

serve as
baseline
data for
alterations
To assess
respiratory
deficiency
To identify
needs for
assistance
To alleviate
difficulty
of breathing
Provide
comfort for
the patient
To promote
oxygenation
to the
patient
To maintain
airway
Helps limit
O2 needs
To enhance
Fe

EVALUATION

Short term:
Goal met, patient is
able to breath within
normal range with no
complaints
of dizziness.

Long term:
Goal partially met.
Patients condition
demonstrates
impaired ventilation
and controlled within
normal level, no
signs of any
complications noted.

s
AbN ABG/
arterialpH

adequate
oxygenation
of tissues by
ABG within

Polycythe
mia

Clients normal
limit and

dyspnea

Absence of
symptoms
of respiratory
distress.

V/S taken
as follows:
T: 36.9 P:
75 R: 18
BP: 100/80

e deep
breathing
exercise
Demonstrat
e head of
bedand
position the
client
appropriate
ly

Educative:

Encourage
the
adequate
rest and
limit
activities to
within
clients
tolerance
Discuss
importance
of taking
iron
supplement
and vitamin
C.

absorption

#3 INEFFEFTIVE TISSUE PERFUSION

ASSESSME
NT

DIAGNOSIS

Subjective:
none

Ineffective
tissue
perfusion
related to
decreased
hemoglobin
concentratio
n as
evidenced by
low HGB
levels 56g/L

Objective:
>HGB level
(low) 56g/L
>Pail nail
beds
>Pale
palpebral
conjunctiva
>Low pulse
rate 46 bpm
>Dry scaly
skin

OBJECTIVE
Short term:
after 1 hour of
nursing
intervention
the patient will
be able to
verbalize
understanding
of condition
therapy given.
Long term:
after 1 week of
nursing
intervention
the patient will
be able to
increase tissue
perfusion such
as HGB level
within normal
range and
pulse rate
returns to
normal levels.

INTERVENTION
1. Establish
rapport
2. Monitor V/S
3. Identify
changes related
to systemic or
Peripheral
situations in
circulation (e.g.
altered
mentation).
4. Monitor I&O
5. Provide
psychological
support for
patient such as
staying at the
bedside of
the patient.
6. Encouraged
Quiet restful
atmosphere.
7. Caution client

RATIONALE

EVALUATION

1. To
gain Short term:
trust
of After 1 hour of
nursing intervention
patient.
2. To record
baseline
data.
3. To identify
the causes
of tissue
perfusion
4. To identify if
there is a
decrease in
the fluid
retention of
the body of
the patient.
5. To prevent
any signs of
anxiety.
6. To prevent
any
agitation of

the patient shall be

able to verbalize
understanding of
condition therapy
given.

Long term:
After 1 week of
nursing intervention
the patient Shall be
able to increase
tissue perfusion such
as HGB level within
normal range and
pulse rate returns to
normal levels.

to avoid activities
that
Increase cardiac
workload.
8. Elevate HOB

the patient
that may
cause an
increase in
the vital
signs.
7. To prevent
further
complicatio
ns that
might occur
with the
activities.
8. To promote
circulation
for the
patient.

IX. DRUG STUDY

NAME
NAME OF
OF
DRUGS,
DRUGS,
GENERIC
GENERIC
NAME,
NAME, BRAND
BRAND
NAME
NAME

Generic name:
Generic name:
Paracetamol
Furosemide
Brand name:
Brand name:
Calpol
Lasix

DATE
DATE
ROUTE
ROUTEOR
OR
ORDERED,
ORDERED,
ADMINISTRATI
ADMINISTRATI
DATE
DATE
ON
ONDOSAGE
DOSAGE
TAKEN/GIVEN,
TAKEN/GIVEN,
AND
AND
DATE
DATE
FREQUENCY
FREQUENCYOF
OF
CHANGED
CHANGED
ADMINISTRATI
ADMINISTRATI
ON
ON
Dosage:
Dosage:
DO: August 26, 600mg
DO: August 26, 20mg
2015
2015
DG: August
Route:
DG: August 16,- Route:
16,-21, 2015
Oral
21, 2015
IV
Frequency:
Frequency:
q 4hrs
mid and post
BT

GENERAL
ACTION,
GENERAL
MECHANISM
ACTION,
OF ACTION
MECHANISM
OF ACTION
General Action:
Furosemide
Analgesics
inhibits
Muscle
absorption of
Relaxants
sodium and
chloride from the
Mechanism of
proximal and
Action:
distal tubules
-Decreases fever
and ascending
by inhibiting the
limb of the loop
effects of
of henle. Leading
pyrogens on the
to a sodium rich
hypothalamus
diuresis, thus
heat regulating
reducing edema
centers & by a
associated to
hypothalamic
renal disease
resulting to
-Action leading
decrease BP.
to sweating &
vasodilatation.

INDICATION
OR
INDICATION
PURPOSES
OR
PURPOSES

CLIENTS
RESPONSE TO
CLIENTS
THE
RESPONSE
MEDICATION
TO THE
MEDICATION

Relief of mild- Clients

Indicated for The patient
to-moderate
response to
the patient as improves her
pain;
medication is
he
has condition as he
treatment of effective as
elevated
had a
fever.
evidence by
blood
decreased BP
lowering down
pressure and after 30 mins.
the patients
edema.
of
temperature
administration.

Nursing Responsibilities
Before:
Observe 10 Rs of administration of drugs '
Check doctors order three times and verify the patient
Check the label of the drug, its name and its expiration date
Wash hands before handling the medication
Assess patients vital signs prior to administering the medication
During:
Administer as indicated (right drug, right dosage, right frequency)
Clean the IV insertion for medication with a cotton ball with alcohol.
Gradually inject the drug into the port. Slow IV push to prevent
infiltration and phlebitis.
Administer cautiously and slowly with aseptic technique.
After:
Observe for the sensitivity and side effects to the drug
Reassess patients level of pain at least 15 and 30 minutes after
parenteral administration
Monitor circulatory and respiratory status and bladder and bowel
function.
Caution ambulatory patient about getting out of bed or walking.

X. HEALTH TEACHINGS
MEDICATION:
Ferrous Sulfate tablet, 1 tablet O.D.
Ascorbic Acid 1 tablet O.D.
EXERCISE:
Perform passive ROM exercise like flexion, extension of the extremities.
Brisk walking every morning.
TREATMENT:
Blood transfusion if blood count falls below normal.
Folic acid injection if available.
HEALTH TEACHING:
Encourage participation in recreation and regular exercise program
Provide appropriate level of environmental stimulation (ei;music, TV/
radio, personal possessions and visitors)
Suggest use of sleep aid/ promote normal sleep/rest.
OPD:
Return to OPD for further check-up when there are changes on physical
strength.
DIET:
High fiber diet like vegetables and fruits.
Protein rich diet
Folic and vitamin B12 rich foods such as: liver, dried beans, peas,
wheat products, spinach, dark leafy vegetables, meat, eggs, milk
SIGNS/SYMPTOMS:
Observe for signs and symptoms such as body weakness, poor skin
turgor, pallor and weight loss.

RLE SUMMARY
As a student nurse, I have learned and gain new knowledge from this
case study. Doing a case study is not an easy task since it entails a lot of hard
work and understanding to come up with its content. But in the end, all
efforts and hard work are all worth it because of the values and learning I
have gained..
Upon completing this case study, I was able to come up with several
conclusions. Despite of the early description of the condition, it is only in the
recent times that Anemia was further elaborated. Few researchers can be
trace to have been presented in etiology with touch of accuracy as many
authors claim it to be of unknown cause. This case study however, aims to
give ideas, classifications with regards to the origin, pathophysiology, clinical
manifestations, diagnosis and treatment of the disease.
In addition, I have also learned that to become a nurse it requires a task
to promote wellness to prevent diseases and help the patient. Specifically, by
giving appropriate health teachings. Which are to be taught therapeutically and
in a ways comprehensible to the patients including rationale to enhance
compliance. Through this way, we are able to make a change and even save
the lives of our patients. And seeing our patients get better gives us sense of
fulfillment and satisfaction. Which inspires me to be more effective and
efficient with the things I do to become a future nurse someday.
Bungay, Maria Paula M.

46

47