BUENAS MORNIE!

ANEMIA
 • PERNICIOUS
VITAMIN B12 DEFICIENCY

• FOLIC ACID DEFICIENCY

• IRON DEFICENCY
HYPOTENSION
• MAJOR DEPRESSIVE DISORDER
• SEIZURE DISORDER
• Clients Name/Initials: AMD
• Age: 32 years old
• Gender: Female
• Hospital Admitted:
Eduardo L. Joson Memorial Hospital

• Date Admitted: 01-19-09

 Chief Complaint on Admission:
Hypotension accompanied by severe body
weakness
 History of Present Illness:

• The patient (01-17-09), about 8:30 in the

morning, after taking their breakfast has had
severe body weakness and developed pallor skin
on her extremities, face, anterior palm, and felt her
feet tingling, with measured Blood Pressure of
50/30 mmHg, relieved slightly by resting, had her
B.P. 60/40 mmHg but with continuous weakness,
had three (3) vomiting episodes and below normal
B.P. range, hence admitted to ELJMH.
 Review of Systems
• Fatigue/loss of energy

• Abnormally slow heart rate (bradycardia)

Present, (56-67 bpm, adynamic)

• Excessive passing of gas (burps)

• Hair or nails (please describe)

more pale as observed by the patient’s mother,
also brittle than normal nails (as observed)
• Dizziness

• Numbness or tingling sensation

both lower extremities measured approximately 5 inches
below the patella through the toes

• Muscle weakness (where?)

Present, both lower extremities

• Anxiety/nervousness

• Depression

• Do you have suicidal thoughts or plans?

Absent/but had a suicidal attempt
 Past and Current Medical
Condition
• has seizure episodes
– (has had her last attack last 2006)

• Gabapentin (Neurontin)

• Mental disorder (Major Depressive Disorder)

which happens to be diagnosed as
theoretically-based by the group.
 History of Hospitalization and
Surgical Operation
• When the patient was 14 years old, had a
suicidal attempt

• January 6, 2000 – PJGMRMC, consulted

because of low Blood Pressure level and
diagnosed with Anemia.
 Family Medical History

• Her mother also has anemia. Her

maternal grandmother and aunt
also were/are anemic.
• Breakfast: Fried Egg, 1 cup of rice
• Lunch: Fried Fish, 1 cup of rice
• Supper: Vegetables, 1 cup of rice
• Snacks: 2 pieces Pan de sal, no fillings
• Preferences: Coffee in the morning, sweet candies, sinigang
na baboy are her preferences.
•
• Usual Fluid Intake Water
• Type and Amount: 5 glasses, NAWASA
• Food Restrictions (if any): Dark colored foods/High Caloric as
ordered by her physician.
• Problem with ability to eat: None
• Supplementation: Ferrous sulfate. “Umiinom din yan ng
vitamins,
• Enervon” as verbalized by her
mother.
• ELIMINATION PATTERN
• Urination
• Frequency: Usually 5 times a day
• Color: Amber yellow
• Urinary Complaints: Nothing
• Home remedies: Nothing
• Bedtime: usually from 8 pm to
5 am (but interchangeable as
verbalized by the elder sister
and mother)
• Hours of sleep: 9 hours (estimated)
• Siesta: yes
• Sleep Routines: praying before
sleep
 Physical Examination
GENERAL SURVEY:
– The patient is medium built, with proportionate weight
and height, and has no observable of muscle atrophy to
any parts of her body. She can walk with a personal
assistant; with symmetrical movements and size of
bilateral body parts. The skin is pale more in upper
extremities, palm and nails, with slightly combed, evenly
distributed hair; fingernails are properly trimmed. She is
fully awake and oriented to time, place and persons. She
hears and sees that others also hears and sees. She is
passive and slightly aggressive to others sometimes but
cooperative. She is able to relax and maintain eye
contact and has spontaneous clear words.
• Vital signs:
• Temperature: 36.8°C/ax
• Pulse rate: 67 bpm/weak, regular
• Respiratory rate: 18 cpm
• Blood Pressure: 90/60 mmHg
• Position of client: Lying
• Height: 5’6”
• Weight: 57 kgs. / 125.4 lbs.
• LOC: Conscious/coherent
 Cephalocaudal Examination
• Cranium
• Temporal Arteries
• Face
• with pale soft palate and pale oral mucosa
• with presence of 4 dental carries on molar teeth

• Cranial Nerve V and VII

• Cranial Nerve I
• External Eye Structure
– pink to pale bulbar and palpebral conjunctivae
• Visual Acuity
• Extraocular Muscle Function (CN 3, 4, 6)
• Pupillary reflexes
• External Ear
• Hearing
• Musculoskeletal structure
• Lymph nodes
• Thyroid Gland
• Cranial Nerve XI
• Carotid Arteries
• Neck Veins
• Musculoskeletal structure, skin nails
– pale anterior palm
– pale, well trimmed nails
– abnormal capillary refilling time due to skin color
– (+) keloid formation on L upper extremity

• Musculoskeletal Function (Range Of

Motion)
• Brachial and Radial Arteries
– weak pulse (69 bpm)
– obvious brachial veins on both arms
• Deep Tendon Reflexes (upper
extremities)
• Breast and Axilla
• Anterior Thorax
• Posterior Thorax
– asymmetric chest expansion L upon inspection and palpation on back (upon
sitting position

• Precordium
– adynamic precordium upon auscultation, presence of S4 but
unclearly notified
• Abdominal Quadrants
• Internal Organs
• Musculoskeletal structure, skin nails
(lower extremities)
– tingling sensation on both lower extremities
– -pale, untrimmed nails
– -abnormal capillary refilling time due to skin color

• Musculoskeletal Function (Range Of

Motion)
– normal ROM except the feet

• Popliteal, Tibial, and Pedal Arteries

– weak pulse upon palpation (63 bpm)
• Deep Tendon Reflexes and Plantar
Reflexes (knee-jerk reflexes are normoactive but plantar
reflexes were not tested due to patient’s decision of lower
extremities’ tingling sensation )

• Genitalia
 INITIAL MEDICAL DIAGNOSIS

Anemia
Hypotension
LABORATORY STUDIES
NURSING RESPONSIBILITIES TO
EACH LAB EXAM
 T/C MAJOR DEPRESSIVE BEHAVIOR
• Self hatred Absent/present
when committed
suicide
• Poor concentration Present
• Fatigue Present
• Digestive problems Present
• Lethargic Present
• Agitated Present
• Forgetfulness Present
• Psychomotor agitation Present
• The patient is depressed and slightly aggressive (she kisses the hands
of the observer agitatedly, cheering) (activity as claimed by the patient’s
mother but defended that her daughter is still in normal functioning,
verbalizing: “ganyan talaga yan, pero hindi naman siya yung sira
talaga”, she has a depressed (sad) mood which appears to the
observer as a personality trait. When taking the patient’s blood
pressure, she always actively straightens her arms.
• She does not, however, have illusions, delusions
or hallucinations.
APPEARANCE:
• Age: 32 years
• Height: 5’6”; Weight: 57 kgs.
• Manner of dressing: normal, neat dress
• Grooming: Slightly combed hair,
untrimmed toe nails
» Observed poor sense of personal grooming
• Attitude:
– Hostile but cooperative
• Behavior:
– Psychomotor agitation, no signs of athetotic movements,
normal eye contact with the observers and family
members
– No mannerisms
• Mood and affect:
– Neutral to euthymic with no presence of Alexithymia
– Depressed
• Speech:
– Clear, spontaneous words of normal intensity, normal
rate
• Thought content and process:
– No flight of ideas, delusions or hallucinations
– Had her suicide attempt 18 years ago, however,
no attempt was observed since then.
• Judgment:
– Can make decisions
• *Since there were no collaborative actions
made by the family to psychiatric health
professionals to diagnose the patient’s
mental disorder, the group based the
diagnosis on the theories and concepts
inscribed in published books and references
on internet and journals. Symptoms were
collected as observed and took the
appropriate one as the diagnosis hence
added to consider on medical diagnosis
made.
– Group 1
PATHOPHYSIOLOGY OF
HYPOPROLIFERATIVE ANEMIA
(Folic Acid Deficiency – IDA,
Hypotension)
PATHOPHYSIOLOGY OF
PERNICIOUS ANEMIA
DEFINITIVE MEDICAL DIAGNOSIS

HYPOPROLIFERATIVE ANEMIA PROBABLY

PERNICIOUS
VITAMIN B12 DEFICIENCY
FOLIC ACID DEFICIENCY
IRON DEFICENCY
HYPOTENSION
MAJOR DEPRESSIVE DISORDER
SEIZURE DISORDER
SHORT SUMMARY OF THE PATIENT’S COURSE IN THE E.R./WARD

– FROM EMERGENCY ROOM (01-19-09-Monday/8

a.m.)
– Advised to have Full Diet
– Inserted an IV fluid D5LR 1 liter for 8 hours on right
cephalic vein
– Vital signs taken and recorded
– Prescribed to have laboratories including:
• CBC
• Stool Exam with occult blood
• For cross matching
• RBS
• Creatinine, uric acid
• Prescribed medications such as:
– Ferrous sulfate 1 cap BID P.O.
– Folic acid 1 cap BID P.O.
– Multivitamins 1 cap OD P.O.
– IN THE WARD (01-19-09-Monday)
– Positioned in trendelenburg
– Weak in appearance
– On full diet
– Laboratory studies requested
– Doctor ordered Metoclopramide 1 amp PRN for vomiting
» Metoclopramide 1 amp administered intravenously
(4pm)
– For blood typing
– BP – 90/40 mmHg (4pm) HR: 54 bpm
– BP – 90/40 mmHg (8pm) HR: 54 bpm
– BP – 80/40 mmHg (12mn) HR: 70 bpm
– Continued oral medications (6pm)
– Position changed to supine
• (01-20-09-Tuesday)
– D5LR was changed to Plain NSS for 10-11
gtts/min (12mn)
– BP – 110/80 mmHg (4am) HR: 62 bpm
– Blood sample taken by medical technologist
(6pm)
– Diet changed to diabetic’
(6pm)
– Intake and output monitored and recorded
– Still for BT
 DESCRIPTION OF Dx
• Folic acid deficiency – folic acid, a vitamin that is
necessary for normal RBC production, is stored in
compounds referred to as folates.
• Pernicious anemia (also known as Biermer's
anemia, Addison's anemia, or Addison-Biermer
anemia) is a form of megaloblastic anemia due to
vitamin B12 deficiency, caused by impaired
absorption of vitamin B-12 due to the absence of
intrinsic factor in the setting of atrophic gastritis,
and more specifically of loss of gastric parietal cells
.
• Iron deficiency anemia is the common type of
anemia, and is also known as sideropenic
anemia. It is the most common cause of microcytic
anemia. Iron deficiency anemia is an advanced
stage of iron deficiency. When the body has
sufficient iron to meet its needs (functional iron),
the remainder is stored for later use in the
bone marrow, liver, and spleen as part of a finely
tuned system of human iron metabolism.
• Hypotension refers to an abnormally low
blood pressure.
• Major Depressive Disorder (also known as
clinical depression, major depression, unipolar
depression, or unipolar disorder) is a mental
disorder characterized by a pervasive low mood,
low self-esteem, and loss of interest or pleasure in
normally enjoyable activities.
– The most common time of onset is between the
ages of 30 and 40 years, with a later peak
between 50 and 60 years
Seizure Disorder/Epilepsy is a common chronic
neurological disorder characterized by recurrent
unprovoked seizures.
 MEDICAL/SURGICAL PLANS AND
INTERVENTIONS

 Blood Transfusions If Necessary

 Blood Pressure Monitoring
 Folic Acid Replacement/Vitamin B-
Complex Replacement
 Blood Tests (To monitor Hematocrit and
Hemoglobin)
• No Recommended Surgical Interventions
 DRUG STUDY
• Ferrous sulfate (Rhea Ferrous Sulfate)
– 200mg cap 1 capsule BID
– P.O.
– Monitor for adverse reaction
– Assess bowel elimination
– Do not give with milk and antacids
– Instruct client to take the whole capsule, do not crush nor chew
– Store in an airtight container
– Monitor vital signs
– Monitor complete blood count to evaluate effectiveness of treatment
– Monitor changes in stool
– Plan activities and allow for periods of rest
– Administer medication on an empty stomach
– Monitor dietary intake
• Folic Acid (Folicard) 0.5 mg cap, 1 cap BID
P.O.
• Necessary nutrient for erythropoeisis
– Monitor Hct and Hgb levels
– Advise patient to take drug as prescribed
– Instruct patient to increase intake of foods rich in
folic acid in diet
• Metoclopramide
• Brand Name: Not observed
• 1 ampule PRN for vomiting
– Tell the patient or family the action of the
medication before administration
– Monitor for adverse effects
– Monitor blood pressure
– Advise to avoid alcoholic drinks
– Tell patient to take 30 minutes before meals
• Gabapentin (Neurontin) capsule
• Dose not questioned. Frequency: TID
– Tell patient/SO (s) to avoid drinking alcohol if
in treatment (if situation permits)
– Tell family/patient not to skip a dose if
possible
– Educate that this can be taken with or
without food
– Patients should be instructed to take
Gabapentin only as prescribed.
• Multivitamins (K-A plus) 1 cap O.D. P.O.

– Assess patient for sign of nutrition deficiency

prior to and throughout therapy
– Instruct to notify for side effects of medication to
physician
– Encourage to comply on medication
– Instruct patient and or family that it may be taken
with or without food (May be taken w/ meals for
better absorption or if GI discomfort occurs).
Nsg. Dx applicable for the Patient
– Activity intolerance
– Nausea
– Fatigue
– Sleep Pattern Disturbance
– Deficient knowledge
– Altered thought process
– Self-care deficit
– Anxiety
– High Risk for injury
– Risk for suicide
1st – physiological need
1st – physiological need
1st – physiological need
1st – physiological need
1st – physiological need
1st – physiological need
2nd – safety need
3rd – love and
belongingness need
NURSING CARE PLANS
(NCPs)
Nursing Diagnosis:
• Activity intolerance related to imbalanced
between oxygen supply (delivery) and
demand as evidenced by decreased
hemoglobin and weakness (as verbalized by
the patient)
• Assess patient’s ability to perform normal task or activities of
daily living.
• Note changes in balance/ gait disturbance, 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.
• Teach patient to cease activities when dizziness, palpitations and
DOB occurs
• Instruct patient to have adequate rest periods/sleep especially
between activities
COLLABORATIVE:
• Monitor laboratory studies. Hgb or Hct and RBC count
Nursing Diagnosis:
• Nausea related to hypotension as evidenced
by episode of vomiting, BP – 90/40 mmHg
(4pm) HR: 54 bpm (4pm) and verbal reports
of the patient of increased salivation.
• Check the patient’s vital signs and note signs of
dehydration
• Provide diet and snacks with substitutions of preferred
foods when available (e.g. decaffeinated carbonated
beverages, gelatin) in a moderate level
• Encourage patient to avoid fatty and fried foods, if not take
in moderate sequence
• Provide clean, pleasant smelling and quiet environment.
Avoid the offending odors
• Advise patient and or SO(s) to provide clear water, ice
cubes when simple nausea came
• Collaborative: Administer antiemetic (Metoclopramide 1
amp PRN for vomiting episodes
Nursing Diagnosis:
• Fatigue related to anemia; depression as
evidenced by decreased performance,
restlessness, facial depression
• Determine the ability to participate in activities/level
of mobility
• Assess degree of sleep disturbances
• Note patient’s belief about what is causing the
fatigue and what relieves it
• Review availability and current use of support
systems/SOs
• Evaluate need for individual assistance/assistive
devices
• Increase activity level as the patient can tolerate
Nursing Diagnosis:
• Sleep Pattern Disturbance related to fatigue,
interruptions for therapeutic, monitoring, and
laboratory tests within the hospital as
manifested by observed disturbances and
verbal reports of the patient of pattern
disturbance.
Nursing Diagnosis:
• Deficient knowledge, related to lack of
information about a well- balanced diet and
foods containing folic acid/Vitamin B12
• Assess the readiness of the patient/family to learn
• Discuss foods required for a well-balanced diet, as
well as dietary sources of folic acid (such as eggs,
vegetables)
• Develop a dietary plan with mother or sister of
patient which includes food preferences and foods
that are easy and quick to prepare
• Discuss the importance of taking the folic acid
supplement/vitamins
• Advise to continue taking it even after she begins
to feel better
Nursing Diagnosis:
• Altered thought processes probably related
to mental disorder vs. cerebral hypoxia as
manifested by altered mood states, altered
sleep patterns, passive and aggressive
behavior
• Assess degree of orientation to time, place, person, and
situation regularly.
• Orient to surroundings and reality as needed.
• Assess for environmental and situational factors that may
contribute to change in mood or affect.
• Demonstrate acceptance of patient as an individual (from
nurses to the family members)
• It is important to communicate to patient one’s acceptance
her regardless of her behavior. Establish this to the SOs of
the patient
• Monitor laboratory values and report any significant
changes.
• Assist with grooming and bathing for the patient.
Nursing Diagnosis:
• Self-care Deficit: hygiene, grooming, toileting
related to fatigue as manifested by slightly
combed hair and untrimmed nails
(decreased sense of personal grooming),
with personal assistant in toileting
Nursing Diagnosis:
• Mild Anxiety related to change in
environment and routines as evidenced by
restlessness, sleep pattern disturbance and
feelings of discomfort
• Assess patient level of anxiety
• Assess patient’s coping mechanisms in
handling anxiety
• Acknowledge awareness of patient’s anxiety
• Reassure patient that she is safe. Stay with
the patient if appears to be necessary.
• Establish a working relationship with the
patient through continuity of care.
• Orient patient to the environment as needed.
Nursing Diagnosis:
• Risk for Suicide related to previous suicidal
attempt
• Note behaviors indicative of intent (e.g. gestures)
• Ask directly if person is thinking of acting on
thoughts/feelings
• Determine presence of SO(s) who are available for
support
• Maintain straightforward communication
Encourage expression of feelings and make time
to listen to concerns
• Maintain observation of patient and check
environment for hazards that could be used to
commit suicide Involve family/SO(s) in planning
Nursing Diagnosis:
• High risk for injury related to paresthesia and
possible seizure episode
• Assess mood, coping abilities, personality styles and
evaluate individual’s response to violence in surroundings.
• Provide information regarding disease/conditions that may
result in increased risk of injury.
• Assist the client when walking, be sure to have a watcher
when going out from bed
• Identify interventions/safety devices. Refer to physical or
occupational therapist as appropriate.
• Provide bibliotherapy/written resources and promote
community education programs geared to increasing
awareness of safety measures and resources available to
individual.
• Educate patient and or relative (SOs) to take the prescribed
anti-seizure medication Gabapentin (Neurontin) in the right
frequency and dosage, and safety measures available (e.g.
raise side rills of the bed, wear loose clothes).
 PATIENT AND FAMILY TEACHING
• REST:
GUIDE
• Have a regular daily rest and activity program by stretching upper and lower
extremities.
• Avoid emotional upsets. Listen to concerns and fears, etc. and provide
encouragement.
• DRUG THERAPY:
• Take each drug as prescribed daily. (Patient-Family teaching guide in
prescribed medications – pls. refer to Drug Study – XVIII)
• Develop a check-off system (e.g. daily chart) to ensure medication have been
taken.
• Take pulse rate each day before taking medications. Know the parameters that
your health care provider wants for your health.
• DIETARY THERAPY:
• Consult the written diet plan and list of permitted and restricted foods.
• A well-balanced diet is essential to provide other elements for healthy blood cell
development, such as folic acid, iron, Vitamin A and vitamin C.
• Broadening diet to include chicken, eggs, fish, even ketchup – and tomato --
contains vitamin B12
• Moderate intake of caffeinated foods or drinks.
• ACTIVITY PROGRAM:
• Try to increase walking and other activities gradually,
provided do not cause fatigue and dyspnea.
• Always make sure that the patient has an assistant in
walking, and other such circumstances.
• Keep regular appointments with health care provider.
• Exercises focused on improving sense of balance may
help if nerve damage caused to be unsteady while
walking.
• Swimming should usually be avoided.
• Promote active exercises when in bed to assistive active
when walking to promote maximal activity potential of
patient.
• ONGOING MONITORING:
• Know YOUR limit.
• Surround the patient with people who love you and will help you.
• Know yourself and know warning signs or things that will trigger an
outburst. Also, don’t put yourself in situations which will purposely hurt
you and don’t engage in self-defeating behaviors.
• Most will require repeat blood counts. Also, repeat visits to the doctor's
office are likely in order to determine the response to treatment.
• Monitor for the safety of the patient; keep in mind that the patient has
seizure disorder, keep environment safe as conduciveness.
• Monitor the patient’s blood pressure. Document if necessary.
• Recall the symptoms experienced when illness began appearance of
previous symptoms may indicate a recurrent.
• Report immediately to health care provider any of the following:
– Bleeding gums
– Diarrhea
– Fatigue
– Impaired sense of smell
– Loss of deep tendon reflexes
– Loss of appetite
– Shortness of breath
– Sore mouth
– Tongue problems
• 5. Join the local support group with your family members.
 SINCERELY,

NICANOR M. DOMINGO III

JASPER IAN T. ENOZA
JAYSON A. ESPINO
DANNICH MAIKA O. ESTEBAN
EMMARUTH B. GAMBOA
KAREN N. GUANSING
REINA JEAN D.V. MUNAR
ADRIAN M. ORTIZ
MELVIN RENZ C. PASCUAL
DIANNE JOI H. VILORIA

NEUST BSN III-A

Group 1