I.

Introduction

Anemia is one of the most common blood disorders. Although it is not a disease process but it can cause further complications that can cause great harm to ones health. This is why Ive chosen this case. To know what complications anemia may cause. What are the treatments and preventions for it? What causes anemia and is there any types of it? How this disorder progresses in ones body? By having this case as a reference for others, it will be a great help to treat this condition more efficiently and understand the pathophysiology of anemia, so as a nurse I will be able to anticipate what are the interventions I should do to my patient and what are the orders might the doctor ask.

II. Patients Profile

Name: Ms. MBL Age: 43 y/o Civil Status: Single Address: Purok 4 Brgy. Balibago C5RL Health Insurance: none Room No.: 207 Attending Physician: Dr. Hingzon Admitting Physician: Dr. de Guzman Date of admission: 7/30/11 Admission Dx: Anemia r/o renal pathology r/o blood dyscrasia Time of admission: 11:30 am Sex: Female Religion: Roman Catholic Birthday: 10/24/67

History of Past Illness: Last week, pt. MBL had a persistent vomiting. As a result, she cannot consume her meals properly. Patient tends to decline on taking medication and consultation and decided to rest instead. Patient complaints of headache and dizziness then afterwards experienced fatigue. History of Present Illness: After being admitted, pt. MBR still feels weak and looks pale. Shed been able to consume her meals and took medications as prescribed by her attending physician. As a result her condition got better but still need to be transfused with blood.

III. Case Description

Anemia is a decrease in number of red blood cells (RBCs) or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin deficiency. Because hemoglobin normally carries oxygen from the lungs to the tissues, anemia leads to hypoxia in organs. Because all human cells depend on oxygen for survival, varying degrees of anemia can have a wide range of clinical consequences. Anemia is the most common disorder of the blood. There are several kinds of anemia, produced by a variety of underlying causes. Anemia can be classified in a variety of ways, based on the morphology of RBCs, underlying etiologic mechanisms, and discernible clinical spectra, to mention a few. The three main classes of anemia include excessive blood loss (acutely such as a hemorrhage or chronically through low-volume loss), excessive blood cell destruction (hemolysis) or deficient red blood cell production (ineffective hematopoiesis).

There are more than 400 types of anemia, which are divided into three groups:
y y y

Anemia caused by blood loss Anemia caused by decreased or faulty red blood cell production Anemia caused by destruction of red blood cells Anemia Caused by Blood Loss Red blood cells can be lost through bleeding, which can occur slowly over a long period of time, and can often go undetected. This kind of chronic bleeding commonly results from the following:

y y y

Gastrointestinal conditions such as ulcers, hemorrhoids, gastritis (inflammation of the stomach), and cancer Use of nonsteroidal anti-inflammatory drugs (NSAIDS) such as aspirin or Motrin Menstruation and childbirth in women, especially if menstrual bleeding is excessive and if there are multiple pregnancies Anemia Caused by Decreased or Faulty Red Blood Cell Production The body may produce too few blood cells or the blood cells may not function correctly. In either case, anemia can result. Red blood cells may be faulty or decreased due to abnormal red blood cells or the a lack of minerals and vitamins needed for red blood cells to work properly. Conditions associated with these causes of anemia include the following:

y y y y y

Sickle cell anemia Iron deficiency anemia Vitamin deficiency Bone marrow and stem cell problems Other health conditions

Anemia Caused by Destruction of Red Blood Cells When red blood cells are fragile and cannot withstand the routine stress of the circulatory system, they may rupture prematurely, causing hemolytic anemia. Hemolytic anemia can be present at birth or develop later. Sometimes there is no known cause (spontaneous). Known causes of hemolytic anemia may include:
y y y y y y

Inherited conditions, such as sickle cell anemia and thalassemia Stressors such as infections, drugs, snake or spider venom, or certain foods Toxins from advanced liver or kidney disease Inappropriate attack by the immune system (called hemolytic disease of the newborn when it occurs in the fetus of a pregnant woman) Vascular grafts, prosthetic heart valves, tumors, severe burns, chemical exposure, severe hypertension, and clotting disorders In rare cases, an enlarged spleen can trap red blood cells and destroy them before their circulating time is up

Symptoms of anemia may include the following:

y y y y y y y

Fatigue decreased energy weakness shortness of breath lightheadedness palpitations (feeling of the heart racing or beating irregularly) looking pale Symptoms of severe anemia may include:

y y y y

chest pain, angina, or heart attack dizziness fainting or passing out rapid heart rate

Some of the signs that may indicate anemia in an individual may include:
y

Change in stool color, including black and tarry stools (sticky and foul smelling), marooncolored, or visibly bloody stools if the anemia is due to blood loss through the gastrointestinal tract. rapid heart rate low blood pressure

y y

y y y y y

rapid breathing pale or cold skin yellow skin called jaundice if anemia is due to red blood cell breakdown heart murmur enlargement of the spleen with certain causes of anemia

PATHOPHYSIOLOGY OF ANEMIA All blood cells are produced by hematopoiesis in the bone marrow. The major raw material essentials for this process are proteins, vitamin [B12], folic acid, and iron. Pathophysiology of anemia differs according to its etiology. Acute or chronic red blood cell loss, inadequate production of red blood cells in the bone marrow, or an increased hemolysis can produce anemia. When anemia develops because of hemorrhage, the reduction in red blood cell numbers causes a decrease in blood volume and the cardiovascular (CV) system becomes hypovolemic. Anemia becomes evident when the maximum level of hemodilution occurs, usually within 3 days after the acute blood loss. Hemodilution occurs in response to decreased blood volume when fluid moves from the interstitium into the intravascular space to expand the plasma volume. The decrease in blood viscosity from the lower number of red blood cells, along with increased intravascular fluid, causes the blood to flow faster through the CV system and the flow becomes more turbulent. This process causes pressure on the ventricles, the heart dilates, and heart valve dysfunction develops. Hypoxia contributes to the changes in the CV and respiratory systems in anemia by causing the blood vessels to dilate and the heart to contract more forcefully, which further increases the demand for oxygen. Tissue hypoxia causes the rate and depth of breathing to increase. Hemoglobin, the oxygen-carrying protein in the red blood cells (RBCs), releases that oxygen to the tissues more rapidly. When anemia becomes severe, the body directs blood to the vital organs, such as the heart and the brain, and renal blood flow decreases. Decreased renal blood flow in turn causes an activation of the renin-angiotensin system response, leading to salt and water retention. This process increases blood volume to improve kidney function without changing tissue hypoxia in other organs.

Treatment

y y y y

Nutritional supplements (iron, Vit. B12, folic acid, Vit. C) Treatment of infection, inflammations or malignancies Erythropoietin Blood transfusion

Complications

Effects of Anemia in Pregnant Women Pregnant women with significant anemia may have an increased risk for poor pregnancy outcomes, particularly if they are anemic in the first trimester. Complications from Anemia in Children and Adolescents In children, severe anemia can impair growth and motor and mental development. Children may exhibit a shortened attention span and decreased alertness. Children with severe iron-deficiency anemia may also have an increased risk for stroke. Effects of Anemia in the Elderly Anemia is common in older people and can have significantly more severe complications than anemia in younger adults. Effects of anemia in the elderly include decreased strength and increased risk for falls. Anemia may have adverse effects on the heart and increase the severity of cardiac conditions, including reducing survival rates from heart failure and heart attacks. Even mild anemia may possibly lead to cognitive impairment or worsen existing dementia. Effects of Vitamin B12 Deficiencies and Pernicious Anemia In addition to anemia, vitamin B12 deficiency can cause neurologic damage, which can be irreversible if it continues for long periods without treatment. Anemia in Patients with Cancer Anemia is particularly serious in cancer patients. In people with many common cancers, the presence of anemia is associated with a shorter survival time. Anemia in Patients with Kidney Disease Anemia is associated with higher mortality rates and possibly heart disease in patients with kidney disease. Anemia in Patients with Heart Failure The combination of anemia and heart failure can increase the risk of hospitalization or death by 30 - 60%. Patients with heart failure whose hemoglobin levels decline do worse than patients with stable levels.

IV. Medical & Surgical Management

Management
PNSS 1L + 40 mEqs KCl x 12 CBC

Implication
To gradually correct the deficient in fluid (hypertonic) To detect any symptoms, such as weakness, fatigue or bruising and diagnose conditions, such as anemia, infection, and other disorders. To know the type and prepare for possible blood transfusion. Measure the concentration of electrolytes for both diagnosis and management. Used to evaluate blood disorders. Measures and records the electrical activity of the heart in exquisite detail Used to diagnose conditions affecting the chest, its contents, and nearby structures To check for occult or hidden blood. It can help detect substances or cellular material in the urine associated with different metabolic and kidney disorders. Done because the body cannot produce blood properly due to an underlying cause.

Blood Typing Na+ K+ Peripheral Smear ( Peripheral blood smear) ECG Chest X-ray PA Fecalysis c occult blood Urinalysis

BT PRBC 2 U

V. Drug Study

Drugs
Iberet 500mg 1tab BID Multivitamins with Iron Used to provide vitamins and iron that are not taken in through the diet.

Nursing Management
Give between meals with water but may give with meals if gastrointestinal discomfort occurs. Eggs and milk inhibit absorption Monitor serum iron, total iron-binding capacity, reticulocyte count, hemoglobin, and ferritin. Assess for clinical improvement, record of relief of symptoms (fatigue, irritability, pallor, paresthesia, and headache).

OMX 1 cap BID Probiotics Modifying the microflora, secreting antibacterial substances, competing with pathogens to prevent their adhesion to the intestine, competing for nutrients necessary for pathogen survival, and producing an antitoxin effect. Make sure patient doesnt have badly injured GI tract.

Godex DS 1cap TID Cardiac drugs Increases nucleic acid synthesis and mtDNA copy number for repair of mitochondria. Drug should be taken with food. Watch out for bowel obstructions. Watch out for any signs and symptoms of hypersensitivity.

Almitrine + Raubasine (Duxaril) 1tab BID Antihypoxic drug. The improvement in the blood gas parameters under almitrine-raubasine is linked to an improvement of the efficacy of the alveolar capillary exchange mechanism without modification of the ventilatory parameters.

Do not give on pregnant women Watch for neurologic symptoms like prickling, formication and numbness Safety precaution due to the risk for drowsiness and dizziness.

L. Carnitine (Carnicor) 1 tab TID Cardiac drugs

Monitor patients tolerance during 1st week of therapy and after increasing dosage Caution patient not to share drug with others

Facilitates the transport of fatty acids into cellular mitochondria. The fatty acids are then used to produce energy.

May give enteral liquid alone or dissolved in drinks or liquid foods Do not refrigerate solution

Co amoxiclav (Natravox) 1.2g IV q 8 ANST (-) Penicillin antibiotic Amoxicillin inhibits transpeptidase, preventing cross-linking of bacterial cell wall and leading to cell death. Addition of clavulanate (a beta-lactam) increases drug's resistance to beta-lactamase (an enzyme produced by bacteria that may inactivate amoxicillin).

Give with or without food. Monitor patient carefully for signs and symptoms of hypersensitivity reaction. Check patient's temperature and watch for other signs and symptoms of superinfection, especially oral or rectal candidiasis. As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, foods, and herbs

VI. General Nursing Care

 Assess patients ability to perform normal task or activities of daily living.  Monitor vital sign (Blood Pressure, pulse, and respirations) during and after activity.  Suggest client change position slowly; monitor for dizziness.  Note changes in balance/gait, disturbances, muscle weakness.  Recommend quiet atmosphere, bed rest if indicated.  Elevate the head of the bed as tolerated.  Provide or recommend assistance with activities or ambulation as necessary, allowing patient to do as much as possible.  Plan activity progression with patient, including activities that the patient views essential. Increase levels of activities as tolerated.  Identify or implement energy saving technique like sitting while doing a task.  Instruct client to stop activity if palpitations, chest pain, shortness of breath, weakness, or dizziness occur.  Monitor laboratory studies. Hg or hct and RBC count, arterial blood gases (ABGs).  Provide supplemental oxygen as indicated.  Administer the following, as indicated: Whole blood, packed RBCs (PRCs); blood products as indicated.  Monitor closely for transfusion reactions.

IX. Anecdotal

08 01 11

Today, weve started our first duty on Sta. Rosa Community Hospital (SRCH) with Maam Vizcarra. We had our orientation first about what to expect in the area, what are the requirements and things we should review. Afterwards, we had our patients assigned to us individually. I was assigned at room 207 Female Medical Ward. My patient had anemia r/o renal pathology r/o blood dyscrasia. After introducing myself to my patient, I already took her vital signs. Then Ive started talking to my patient to know the history of her illness and as I was talking to her, Im starting doing my head to toe assessment. Ive noted all of my abnormal findings and provide proper health teachings about her condition. I told her what to eat and what to avoid. After our first interaction with the patient, weve started giving oral medications. We should recite it first to our Clinical Instructor first before giving it to the patient. After my recitation, I went to my patient and explaining the action of each of her medications to her. Then on my free time, we were asked to make a SOAPIE for our patient. When our C.I started checking our SOAPIEs, shed thought us how to make a SMART SOAPIE and I find it very convenient to use. Then afterwards, I went to the station and borrow the chart to copy some details for my case. After copying my case, I went back to my patient and get her 12nn vital signs and prepare her medications for 1pm. Then after signing our charts by our C.I, thats the end of our duty for that day.

08 02 11

Im assigned for today at 207, Female Surgical Ward. I handled two patients, one of them is from yesterday and the other one is newly admitted. After getting the census, I immediately went to my patients asking my previous one how shes doing. Then I took her vital signs and talk for a while. Afterwards, Ive proceeded to my other client. Ive started introducing myself to her and ask why shes been admitted. I took her vital signs and found out that shes febrile. I went to the station and ask if my client had already taken her PRN meds and found out that she already did, so I now asked my client to let me borrow a towel so I can do some TSB to her to lower her temperature. While I was doing my intervention, Im talking to her to know how did she got her high fever and did some head to toe assessment as well. After 15 minutes, Ive rechecked her temperature and it subsided into normal range. Then Ive prepared her oral medications and give it to her after she finished eating. Ive regulated her IVF and make my SOAPIE. Ive improved my SOAPIE making skills for today but still Im no good at planning. Afterwards, Ive took the vital signs of my clients and give their 1pm medications then thats the end of our duty for today.

08 03 11

Today, our Clinical Instructor decided not to have exposure to our affiliated hospital, SRCH, so we end up having group discussion in the school. Our C.I thought us about Pharmacology. It is divided into two parts: Pharmacokinetics and Pharmacodynamics. For today, our C.I discussed about Pharmacokinetics. These include the four actions of drug in pharmacokinetics: the absorption, distribution, metabolism and excretion. Ive learned new things in this discussion about drugs. Knowing the different drugs that should be taken with food or must be taken without food. These concepts were important for us nursing and Im glad that our C.I had discussed it with us since it is not part of our curriculum.

08 08 11

I was assigned at room 208, Male Medical Ward for today. I only had one patient to handle and he has a diabetic foot. Ive introduced myself first and start getting his vital signs. Ive checked hi IVF and regulated it. Then I had my assessment while talking to him and getting information on how did he end up into his present condition right now. Ive checked the dressing on his wound and found out that its still dry and intact. Then Ive prepared his oral medications and give it to him. I signed his chart and let my C.I signed on it too. Then I went back to my patient and give him and his S.O some health teachings about his condition to improve it. Ive emphasized things about his lifestyles and maintenance of his skin integrity. Afterwards, Ive decided to make my SOAPIE and let our C.I checked it. Im glad that Ive finally able to create a SMART SOAPIE. Then Ive stay for a while to my patient regulating his IVF and waiting for the side drip medication to be emptied so I can close it for a while. After getting the vital signs and giving 1pm medications, weve finished and leave. And thats the end of our duty at S

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