INTRODUCTION

This case presentation aims to identify and determine the general health problems and needs
of the patient with an admitting diagnosis of Spontaneous Pneumothorax- secondary type. Our
group find interest in this case because of its rareness. This presentation also intends to help
patient promote health and medical understanding of such condition through the application of
the nursing skills

OBJECTIVES

• To raise the level of awareness of patient on health problems that he/she may
encounter.
• To facilitate patient in taking necessary actions to solve and prevent the identified
problems on his/her own.
• To help patient in motivating his/her to continue the health care provided by the
health workers.
• To render nursing care and information to patient through the application of the
nursing skills.

DEMOGRAPHIC DATA

• Name: F. M . A
• Gender: Female
• Civil Status: Married
• Occupation: Housewife
• Date of birth: January 20, 1960
• Age: 49
• Religion: Catholic
• Date admitted: July 30 , 2009
• Time of admission: 8:00 pm

Chief Complain
Pallor

Brief history of illness:

Patient was previously admitted last March 7, 2009 due to weakness and easy
fatigability. Diagnosis was anemia with myelodysplastic syndrome. 2days PTC, when patient
hat CBC, Hgb and Hct were decreased. Due to this patient consulted and admitted for BT

GENERAL APPEARANCE
• Weak in appearance
• Dry and messy hair
• Dirty Nails
• No body odor
• No breath odor
• Dry skin
DEFINITION OF THE DISEASE
Anemia is a condition that develops when your blood lacks enough healthy red blood
cells. These cells are the main transporters of oxygen to organs. If red blood cells are also
deficient in hemoglobin, then your body isn't getting enough iron. Symptoms of anemia -- like
fatigue -- occur because organs aren't getting enough oxygen.
• Certain forms of anemia are hereditary and infants may be affected from the time
of birth.
• Women in the childbearing years are particularly susceptible to a form of anemia
called iron-deficiency anemia because of the blood loss from menstruation and the
increased blood supply demands during pregnancy.
• Seniors also may have a greater risk of developing anemia because of poor diet
and other medical conditions.

ETIOLOGY OF THE DISEASE

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 any of the following:

• 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

SIGNS & SYMPTOMS

• Weakness
• Dizziness
• Difficulty standing
• Unconsciousness
• Low blood pressure
• Rapid breathing
• Breathing difficulty
• Rapid pulse
• Pallor
 ANATOMY AND PHYSIOOGY

Blood
whole blood has two components: (1) blood plasma, a watery liquid matrix that
contains dissolved substances, and (2) formed elements, which are cells and cell fragments.
Blood is about 45% formed elements and 55% plasma. Normally more than 99% of the formed
elements are red-colored red blood cells. Pale colorless white blood cells and platelets occupy
less than 1% of total blood volume.

SUBSTANCES IN BLOOD PLASMA

constituents description
Water (91.5%) Liquid portion of blood. Act as solvent and
suspending medium of components of blood;
absorbs, transports and releases heat.
Proteins (7.0%) Exert colloid osmotic pressure, which helps
maintain water balance between blood and
tissues and regulates blood volume.
albumins Smallest and most numerous plasma
proteins; produced by liver. Function as
transport proteins for several steoid
hormones fatty acids
globulins Produced by liver and plasma cells, which
develop from B lymphocytes. Antibodies help
attack viruses and bacteria. Alpha and beta
globulins transport iron, lipids and fat soluble
vitamins.
fibrinogen Produced by liver. Plays essential role ion
blood.
 FORMED ELEMENTS IN BLOOD

Name number characteristics functions

Red blood cells 4.8 million/µL (F) 7-8µm diameter; Hemoglobin within
5.4 million/µL (M) biconcave disc, RBCs transport most
without a nucleus; of the oxygen and
live for about 120 part of the carbon
days. dioxide in the blood.
White blood cells 5000-10,000/µL Most live for a few Combat pathogens
hours to a few days. and other foreign
substances that
enter the body
neutrophils 60-70%/µL 10-12µm diameter; Phagocytes,
nucleus has 2-5 destruction of
lobes connected by bacteria with
thin strands of lysozyme, defensis,
chromatin; and strong oxidants,
cytoplasm has very such as super oxide
fine, pale lilac anion, hydrogen
granules. peroxide, and
hypochlorite anion
eosinophils 2-4% of all WBCs 10-12µm diameter; Combat the effects of
nucleus has 2-3 histamine in allergic
lobes; large red- reactions,
oranged granules fill phagocytize antigen-
the cytoplasm antibody complexes,
and destroy certain
parasitic worms.
basophils 0.5-1% of all WBCs 8-10µm diameter; Liberate heparin,
nucleus has 2 lobes; histamine and
large cytplosmic serotonin in allergic
granules appear reaction that
deep blue-purple. intensify the overall
inflammatory
responce
name number characteristics functions
lymphocytes 20-25% of all WBCs Small lymphocytes Mediate immune
are 6-9µm in responses, including
diameter; large antigen-antibody
lymphocytes are 10- reaction, B cells
14µm in diameter; develop into plasma
nucleus is round or cells, which
slightly indented; Secrete antibodies. T
cytoplasm forms a cells attach invading
rim around the viruses, cancer cells
nucleus that looks and transplanted
sky blue; the larger tissue cells. Natural
the cell, the more killer cells attack a
cytoplasm is visible. wide variety of
infectious microbes
and certain
spontaneously
arising tumor cells.
monocytes 3-8% of all WBCs 12-20µm in Phagocytes (after
diameter; nucleus is transforming into
kidney shaped or fixed or wandering
horseshoe shaped; macrophages).
cytoplasm is blue-
gray and has foamy
appearance
platelets 150,000- 400,000µL 2-4µm in diameter Form platelet plug in
cell fragments that hemostasis; release
live for 5-9 days; chemicals that
contain many promote vascular
vesicles but no spasm and blood
nucleus. clotting.
HEMATOLOGY 1
HEMATOLOGY RESULT NORMAL VALUES
HEMOGLOBIN MASS 77 125-160
CONCENTRATION
ERYTHROCYTE VOLUME FRACTI0N 0.25 0.038-0.50

LEUKOCYTE NUMERICAL 5.4 4.5-11

CONCENTRATION
LEUKOCYTE TYPE NUMERICAL
FRACTION

METAMOLOCYTE 0
STAB 0-0.01
NEUTROPHIL 0.71 0.40-0.60
EOSINOPHIL 0.02 0.01-0.06
BASOPHIL 0-0.01
LYMPHOCYTE 0.024 0.20-0.40
MONOCYTE 0.03 0.02-0.08
THROMBOCYTE NUMERICAL 252 150-400
CONCENTRATION
CREATININE 51 53-115