INTRODUCTION

Paroxysmal nocturnal hemoglobinuria (PNH) sometimes referred to as

Marchiafava Micheli syndrome is a descriptive term for the clinical
manifestation of red cell breakdown with release of hemoglobin into the urine that
is manifested most prominently by dark-colored urine in the morning. The term
"nocturnal" refers to the belief that hemolysis is triggered by acidosis during sleep
and activates complement to hemolyze an unprotected and abnormal red cell
membrane. However, this observation later was disproved. Hemolysis is shown
to occur throughout the day and is not actually paroxysmal, but the urine
concentrated overnight produces the dramatic change in color. PNH is now
known to be a consequence of nonmalignant clonal expansion of one or several
hematopoietic stem cells that are deficient in GPI-anchor protein (GPI-AP)
acquired through a somatic mutation of PIG-A.
Paroxysmal nocturnal hemoglobinuria is a rare disease which affects 1 out
of 5 million people. It has been suggested that, PNH may be more frequent in
Southeast Asia and in the Far East. Men and women are affected equally, and no
familial tendencies exist.
PNH may occur at any age from children (10%) as young as 2 years to
adults as old as 83 years, but it frequently is found among young adults with a
median age at the time of diagnosis was 42 years (range, 16-75 year old). In
childhood through adolescence, patients presented with more of the primary
features of aplastic anemia than the normal adult population. Other
complications, such as infections and thrombosis, occurred with equal frequency
in all age groups.
The disease process is insidious and has a chronic course, with a median
survival of about 10.3 years. Twenty-two of the 80 patients (28%) survived for 25
years. Of the 35 patients who survived for 10 years or more, 12 had spontaneous
clinical recovery at which time no PNH-affected cells were found among the red
1

cells or neutrophils during their prolonged remission, but a few PNH-affected

lymphocytes were detectable in 3 of 4 patients tested.
Laboratory diagnosis can include specialized test, such as sucrose
hemolysis test, ham acid hemolysis test and fluorescent-activated cell analysis.
Treatment is mainly supportive, consisting of transfusion therapy, anticoagulation
therapy, antibiotic therapy, corticosteroids therapy and supplement therapy which
includes folic acid and iron. HSCT may be curative. Stress and strenuous
activities are contraindicated to the client. A change and adjustment in lifestyle is
encouraged for the client to be able to function in his fullest potential, minimize
the effects of the disease and somehow live a normal life.
On March 16, 2007, the U.S. Food and Drug Administration (FDA)
approved Soliris (eculizumab) for the treatment of PNH. This medicine works by
blocking part of the immune system. It should help decrease the number of blood
transfusions needed and the number of episodes of blood in the urine.
During the year 2008 to 2009, only one case of PNH is recorded at the
Tarlac Provincial Hospital. (TPH medical record).
Reason for choosing such case for presentation
Paroxysmal Nocturnal Hemoglubinuria is a rare disease which really
captures the groups interest among the other cases of the confined patients. It
gave a thrill for all of us since we do not have any idea about it and find it very
challenging.
The researchers are eager to study about the disease due to lack of
information, facts and studies. It is a new exploration. Our curiosity towards the
condition of our patient gave us a lot of questions just like how does the disease
affects an individual in different aspects; physically, emotionally, and socially and
somehow to help this client to promote and restore client wellness by providing
2

their needs and knowing the nursing responsibilities when caring the client. It is
an opportunity for us to study this disease to equip the group with knowledge and
skills to be able to manage future clients with the same disease in providing a
quality nursing care.
Importance of the case study
This case study is made for different purposes whereas it connects the
past, present and something to do in the future time. It is intended to educate,
inform and change untoward behaviors regarding the diseaseParoxysmal
Nocturnal Hemoglubinuria.
This case study will help the client to recover faster and maintain holistic
sense of wellness through applied effective management of the problem
experience by the client and it can also lessen the functional burden of the client
by understanding the treatment process and able to cope and adapt in the
present condition and also the client will be able to know the importance of taking
care of own self.
On the side of the group this case study can help each member to gain
new information about the disease and its etiology, pathophysiology, clinical
manifestations as well as the standard medical and nursing management so that
we may apply this newly-acquire knowledge to our client as well as similar
situations in the future. The group will learn new clinical skills as well as sharpen
our current clinical skills required in the management of the client with
paroxysmal nocturnal hemoglubinuria. Through this study the group members
will develop a sense of unselfish love and empathy in rendering nursing care to
the client so that the group may be able to serve future clients with a higher level
of holistic understanding as well as individual care.

On the side of the College of Nursing this study can be a documented

guide for the students it can be a source of facts and knowledge not only for the
students within the college but open to all students who are interested on
studying about the disease.
On the side of nursing profession, this study will serve as a symbol of
importance of the nursing profession and the field of education on dealing with
client with paroxysmal nocturnal hemoglubinuria.
Objectives (nurse centered)
General Objectives
The case study aimed to represent a comprehensive study of the chosen
patients condition called paroxysmal nocturnal hemoglubinuria and to know
systematically the disease and its medical and nursing management and
responsibilities while taking care of the client.
Specific objectives
This study aims to:
1. Assess properly to determine the contributing factors regarding to the
clients disease and identify any present abnormalities:
a. Personal Data
b. Family history of health and illness
c. History of past illness
d. History of present illness
e. 13 areas of assessment
2.

Gather the needed data that can help to understand how and why the

disease occurs
a. Diagnostic and Laboratory Procedures
4

b. Anatomy and Physiology

c. Pathophysiology book base and client centered
3.

Develop an individualized plan considering client characteristics or the

situation and setting a specific, measurable, attainable, realistic and time

bounded plan that reflect the onset, date of problem identified
a. Planning (nursing care plan)
4.

Provide an appropriate interventions for every problems encountered

and monitor the clients response to treatment and therapies through means
of physical assessment and communication with the client
a. Medical management
b. Surgical management
c. Nursing management
5.

Judge the effectiveness of chosen interventions, nursing care, and the

quality of care provided

a. Clients daily program in the hospital
6.

Describe the general condition of the client upon discharge and know

the take home medications, exercise, treatment for the client, provide health
teachings and inform client for OPD follow-ups
a. Discharge Planning
7.

Broaden the knowledge of each member through further research

about the latest news articles and journals regarding to the client disease
a. Related literature

II. Nursing Process

A. Assessment
1. Personal Data
a. Demographic Data
Name: Mr. X
Address: Victoria Tarlac
Age: 33 year old
Nationality: Filipino
Civil Status: Married
Occupation: Tricycle driver
Religion: Born Again Christian
Health Care Financing: Parents
Date Admitted: February 10, 2009
Admitting Diagnosis: Paroxysmal Nocturnal
Hemoglubinuria
Final Diagnosis: Paroxysmal Nocturnal Hemoglubinuria
b. Environmental Status
The client is currently residing at Victoria, Tarlac for about 10 years now.
He lives with his family in a house made up of wood and concrete with
cemented floor, located at a rice farm. Their forms of transportation are
through tricycles, jeepneys, or just merely by walking. Garbage is disposed
properly through segregation which is then collected by the garbage collector
in their place. Their water source comes from a water pump. Their area is not
congested according to the patient. He is aware about his neighbors, but not
much aware of the health source in their community.
c. Lifestyle
The client wakes up each morning around 8 - 10 oclock and starts the day
with a cup of coffee. After breakfast and rest, the client cleans the house and
their backyard. After cleaning the house, Mr. X always finds time to listen to
6

the radio and watch the television as one of his past time and is also his way
to rest and relaxed. The clients food preferences were mostly pork, poultry
products and seldom eat vegetables. According to him, he only eats
vegetables once a month. He said that even if their viand is vegetable, he
insist her mother to cook other food, specifically meat or he sets aside the
vegetables and only eats the meat. At noon, the client tends to sleep for about
4 hours per day. The client verbalized that he early goes to sleep at around 8
oclock in the evening. He doesnt use mosquito nets when sleeping because
he said that it bothers him when he always urinates at night. He added that
he doesnt use any slippers inside their house but wears them outside. They
used to put their left over foods in a basket. Meal time was the time where the
family bonds and the time they get to know what happens within the whole
day. The client also verbalized that he doesnt have any vices.
d. Social
The client stated that he knows to speak and is able to understand
Ilocano, Tagalog, and English. He verbalized that he use to attend to the
Roman Catholic and Aglipayan Church but he claimed that he is a Born Again
Christian. According to him, he is not a member of any organizations.
e. Psychologic
According to the client, financial problems and his disease are his primary
stressors. He said that praying is his way to cope up with his problems; he
believes that when he prays everything will be alright. The client speaks in a
casual way during the interview and he said that he doesnt say/speak bad
words.

2. Family History of Health and Illness

7

FATHER SIDE

?
Old
age

MOTHER SIDE

Old
age

5
0

A&W
3

7
A&W

A&W

3
1

A&W

6
6

A&W
3

3
PNH

Old
age

Old
age

7
0

5
A&W

A&W

suicide

3
3

6
0
A&W

3
0

2
8

A&W

A&W

LEGEND

A&W

Male
Female
Deceased Male
Deceased Female
Married
Children
Patient
Alive & Well
Paroxysmal Nocturnal
Hemoglubinuria

A&W
PNH

3. History of Past Illness

8

According to the client, he first experienced to have the signs and

symptoms of PNH when he was at the age of 29. He said that he used to urinate
frequently at night with a tea colored urine; without pain when urinating, and
urinates a large amount of urine but he doesnt know the exact volume of urine
being excreted. He assumed and told himself that it was just normal and he did
not tell it to his parents. Few days later, the other family members noticed that he
is already pale in appearance, but he told them that it was just normal. The client
just ignored his condition. Days passed by, he said that he always felt headache,
abdominal pain, difficulty of breathing, fever and weakness. To relieve his
headache and fever, he said that he took Medicol or Alaxan and Biogesic. Until
one day, he felt severe weakness and fell to the ground while sweeping their
backyard. Because of the said incident, his family has decided to bring him to the
hospital in their place in manila. He was sent to Philippine General Hospital. He
had experienced to have blood transfusion (washed RBC) for several times
there. The doctor prescribed him to take Ferrous Sulfate. According to the client,
he continued to take Ferrous Sulfate as a supplement. He was admitted to many
different hospitals because of his condition, he was hospitalized for about 4 times
for the past 4 years. First, he was admitted at PGH and the others are in Tarlac
Provincial Hospital. He also said that he does not go to the hospital for follow-up
check-ups.
According to him, he had chicken pox when he was in grade 4. He said
that he had all the immunizations. According to him, he experience to have cough
and colds only twice a year. He doesnt have any allergies. According to him, he
did not have any other severe diseases in the past except his current condition.
4. History of Present Illness
Five days prior to admission the client stated that he experienced
shortness of breath, pallor for five days and generalized body weakness.
According to the patient, when he is experiencing headache he takes a rest to
relieve it and takes paracetamol if it is accompanied by fever. He also stated that
9

the symptoms happen on a sudden onset. When he felt that he cannot handle
the severe body weakness and his parents noticed that he is very pale, his
parents have decided to take him to the hospital immediately. He was confined to
Tarlac Provincial Hospital on February 10 with an admitting diagnosis of
paroxysmal nocturnal hemoglobinuria.
5. Physical Examination
13 Areas of Assessment
I. Social Status
Mr. X is a 33 year old man whos currently residing at Victoria Tarlac
together with his family. He is a jeepney driver for about two years now but
due to his current condition, he cannot be able to continue his work. He
was married one year ago and not yet bless with any children. He
described his family as having a close ties wherein he believed that
whatever problems and chaos that the family will encounter is can be
solved by helping each other and through prayers. Financial aspect is
sometimes the problem that the family undergone. But he verbalized that
his salary is just enough to sustain their daily needs. He interacts with
different people to their place and doesnt have misunderstanding getting
along with them.
Despite his current condition, he still manages to interact with other
patient and health workers during his confinement in the hospital. His wife
is the one who stays and guide with him. The family perceived his
condition as alerting and felt nervous about it. He is not a member or
joined to any organizations in their place. The client is a Born Again
Christian and regularly attends services. He believed that life is very
important. In times of difficulties, he seldom goes and talked with his
cousin, who is a Pastor and also his good friend to get some advice.

10

Norms
Social support is involved in mitigating the human stressful
response and associated illness. It meets a fundamental human need or
social ties, making life less stressful, thus indirectly contributing to good
health outcomes. Social responsibilities include forming new friendships
and assuming some community activities.

Social functioning of an

individual is to form relationships with others. Social support is a

perception that one has an emotional and tangible resource to fall on
when needed; perceived social support is being followed by the family to
express the love of the family, financial aspect is one of the normal
constraints in the family. (Nursing fundamentals by Daniels; an
introduction to health and physical assessment in nursing by DAmico and
Barbarito)
Analysis
The patients social status can be described as normal; he has
support system (the family) which he can turn to when facing difficult
periods particularly upon encountering emotional or coping crisis and has
a strong foundation of emotional stability. The clients spiritual relationship
with God is very strong and he has a strong faith with Him. He also has
closed family ties and interacts well with others. He also communicates
with his fellowmen thus, he gain many friends.
II. Mental Status

Physical Appearance and Behavior

During the interview, Mr. X wears a shorts and shirt which are
appropriate for his age and for the weather. We have observed that he
was not properly groomed, have untrimmed nails on both fingers and toes
and with uncombed hair. He looks pale and weak.

11

Mr. X facial expressions were appropriate for his feeling and mood
of conversation he was able to established good eye contact. When asked
to walk, he exhibits an erect posture, a smooth gait and symmetrical body
movements. He is cooperative throughout the interview and answered all
questions asked.

Level of Consciousness and Orientation

The client was conscious, coherent and responsive during the

interview. He was oriented with the time, place where he is and recognizes
the persons who are with him.

Intellectual Function

Mr. X is a graduate of 2 year Sea Man course. His ability to read

and write matched his educational level. He was able to understand every
question that was asked from him and he was able to respond to them
appropriately. He was able to remember past experiences during younger
years and recall family history.

Speech

Mr. X can speak Ilocano and Tagalog. He was able to speak

spontaneously with coherent speech. He was able to express himself.
Norms
The patient should appear relaxed with appropriate amount of
concern for the assessment. He should exhibit erect posture, a smooth
gait and symmetrical body movements with regards to posture and
movements. The patient should be clean and well-groomed and should
wear appropriate clothing for age, weather, and socio-economic status.
Facial expression should be appropriate to the content of the conversation
and should be symmetrical. The speech should have an effortless flow.
The patients ability to read and write should match his educational level.
He should be aware of self and the environment and should be able to
respond appropriately to questions being asked. (Health Assessment and
Physical Examination 2nd Ed, Estes pp.656-663)
12

Analysis
Based on the norms given, there were no major deviations from
normal on the mental status of the patient. However, the patient has poor
personal hygiene such as not properly groomed, untrimmed nails,
uncombed hair which are associated by prolonged confinement in the
hospital.
III. Emotional Status
During the interview, Mr. X told us that pagkakasakit ay swerte
swerte lang. He considered that having a disease is just a bad luck
(malas). It was noted that he has a positive coping and acceptance of his
health condition. He has a strong faith in God that he considered prayers
as his source of strength.
Likewise, his relationship with his family is harmonious and conflicts
are easily resolved. During his stay in the hospital, his family is always
there beside him to support and serve whatever he needs. Aside from this,
he also added that he usually talked to their pastor which is his cousin,
who is also his friend to asked for advice. He is also fond of watching
television during his free time. This is also his means of entertainment and
a sort of relieving stressful events in his life.
Norms
Emotional wellness is the ability to manage stress and to express
emotions appropriately. It involves the ability to recognize, accept and
express feelings, and to accept ones limitations. (Fundamentals Of
Nursing, Kozier, pg 173.) Normal coping pattern or emotions stability could
include acceptance of the problem, adjustment to it, expressing of selfperception and self-control of emotions, probable temporary use of
defense mechanism and support system (Fundamentals of Nursing by
Kozier). Carrying out emotional feelings through words and facial
13

expressions are normal signs of present physical condition (Nursing

Fundamentals by Daniels)
Analysis
The emotional state of the patient is well established. He does not
show any emotional feeling and weaknesses while in the hospital despite
having a health condition. The patient manifest acceptance with regards
to his health condition and keep on being strong and enjoying life he had
now and he spontaneously felt support from his family and friends. He is
also capable of controlling his emotions.
IV. Motor Stability
Prior to BT the patient experienced severe body weakness and he
was mostly confined on bed due to easy fatigability. After BT the patient
regains his strength. Hes able to ambulate without assistance but still
cannot tolerate too much activity. The patient is able to transfer from bed
to chair and vice versa.
NORMS:
Motor stability is the ability to move freely, easily, rhythmically, and
purposefully in the environment. People must move to protect themselves
from trauma and to meet their basic needs. It is vital to independence; a
fully immobilized person is vulnerable and dependent as an infant.
(Fundamentals of Nsg. by Kozier)
Analysis
The patient was not able to tolerate too much activity and perform
ADLs due to easy fatigability. Blood transfusion is his way of regaining
his strength.
V. Body Temperature
14

The clients general skin is warm to touch during the interview. The
following table indicates the clients body temperature.
Date and
hours
2/11/09 8 am
10 am
1:30 pm
3:00 pm
2/12/09 8 am
12 noon
2 pm
3:30 pm
4:30 pm
6 pm
10 pm
2/13/09 8 am
10 am
2 pm
5 pm
6 pm
8 pm
10 pm
2/14/09 6 am
8 am
10 am
2 pm
6 pm
2/15/09 6 am
6 pm
2/16/09 8 am
10 am
12 noon
1:30 pm
4 pm
10 pm
2/17/09 4 pm
10 pm
2/18/09 6 am
2 pm
5 pm
2/18/09 4 pm
10 pm

Temperature (0C)

Analysis

36.5 0C
36.7 0C
36.8 0C
37.1 0C
37.8 0C
38 0C
38.3 0C
38.4 0C
38 0C
37.8 0C
37.3 0C
37.2 0C
37.4 0C
37.5 0C
38.9 0C
38.7 0C
38.5 0C
37.9 0C
38 0C
37.8 0C
37 0C
37 0C
37.2 0C
38.2 0C
36.5 0C
36.9 0C
36.7 0C
37.2 0C
37.2 0C
37.2 0C
38.9 0C
38.5 0C
38.2 0C
37.2 0C
38.8 0C
37.2 0C
37.3 0C
38.1 0C

Normal
Normal
Normal
Normal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Normal
Normal
Normal
Normal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Normal
Normal
Normal
Abnormal
Abnormal
Normal
Normal
Normal
Normal
Normal
Abnormal
Abnormal
Abnormal
Normal
Abnormal
Normal
Normal
Abnormal
15

Norms
A healthy person's body temperature fluctuates between 97F
(36.1C) and 100F (37.8C), with the average being 98.6F (37C). The
body maintains stability within this range by balancing the heat produced
by the metabolism with the heat lost to the environment. Core body
temperature was established by the temperature of blood perfusing the
area of the hypothalamus (bodys temperature control center) which can
trigger the bodys physiological response to temperature. (Health
assessment and physical examination 3rd edition by Mary Ellen Zator
Estes)
Fever may suggest infections, and bleeding. A fever occurs when
the thermostat resets at a higher temperature, primarily in response to an
infection. To reach the higher temperature, the body moves blood to the
warmer interior, increases the metabolic rate, and induces shivering.
(www.fpnotebook.com/Hemeonc/Hemolysis/PrxysmlNctrnlHmglbnr.htm)
Analysis
During the stay in the hospital, client was experienced fever almost
all the time. His fever is a response to what is happening to his body. Due
to his condition, because of inability of protein to bind into the cell
membrane whereas lacking of these complimentary protein act on the Tlymphocytes of the cell which are primary responsible for the immune
response. These complimentary proteins cannot bind on the cell, infection
may possibly occur which is the primary cause f fever in the client.
VI. Circulatory Status
The clients general skin color is pale in appearance including his
conjunctiva, lips, tongue, gums, palms and nails. His peripheral pulses are
regular but apical pulse was very visible. No abnormal heart sound noted.
Capillary refill is at the speed of 5 seconds for both fingers and toes.

16

The clients blood pressure and pulse rate are noted in the following
table:
Date and hours
2/11/09 8 am
10 am
1:30 pm
3:00 pm
2/12/09 8 am
12 noon
2 pm
3:30 pm
4:30 pm
6 pm
10 pm
2/13/09 8 am
10 am
2 pm
5 pm
6 pm
8 pm
10 pm
2/14/09 6 am
8 am
10 am
2 pm
6 pm
2/15/09 6 am
6 pm
2/16/09 8 am
10 am
12 noon
1:30 pm
4 pm
10 pm
2/17/09 4 pm
10 pm
2/18/09 6 am
2/18/09 4

Blood pressure
(mmHg)
90/60
100/80
100/60
100/70
100/60
100/60
100/60
110/60
100/70
110/70
100/60
100/70
110/80
100/60
130/90
120/70
110/70
90/60
90/70
100/70
100/70
110/70
110/70
110/70
110/70
90/60
100/70
100/70
100/70
120/70
110/70
120/80
110/70
100/60
120/80

pm
10 pm

130/90

Date and hours

Pulse rate

Analysis
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
abnormal
Abnormal
abnormal
normal
abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
normal
abnormal

17

2/11/09 8 am
10 am
1:30 pm
3:00 pm
2/12/09 8 am
12 noon
2 pm
3:30 pm
4:30 pm
6 pm
10 pm
2/13/09 8 am
10 am
2 pm
5 pm
6 pm
8 pm
10 pm
2/14/09 6 am
8 am
10 am
2 pm
6 pm
2/15/09 6 am
6 pm
2/16/09 8 am
10 am
12 noon
1:30 pm
4 pm
10 pm
2/17/09 4 pm
10 pm
2/18/09 6 am
2/18/09 4 pm
10 pm

(beats per min)

89
86
87
88
95
96
98
106
100
94
96
94
86
105
102
92
91
99
94
98
99
98
87
87
90
88
88
87
86
88
86
88
85
88
106
86

Analysis
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Abnormal
Normal
Normal
Normal
Normal
Normal
*Abnormal
Abnormal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Abnormal
Normal

Norms
In a healthy young adult, the pressure at the highest of the pulse
(systolic pressure) is approximately 120 mmHg, and the pressure at the
lowest point of the pulse (diastolic pressure) is approximately 80 mmHg.
The normal pulse rate of a healthy young adult is 60-100 beats per
18

minute. Normal capillary refill is at the speed of 2-3 seconds. Lips,

conjunctiva, gums, nail beds and palms are should be pinkish in colour.
(Fundamentals of Nursing by Barbara Kozier, et al.)
Analysis
Clients blood pressure rates were mostly abnormal compared on
the normal values. Pulse rates were somehow normal but it can also
exceed to normal values. The client pale appearance including his
conjunctiva, lips, tongue, gums, palms and nails may be an indicative of
poor circulation of blood in the body. Because red blood cells are
immaturely breaking down or hemolysis happens with this condition, blood
does not carry enough RBCs which are responsible for the red coloration
of the body surfaces.
VII. Respiratory Status
Mr. X was admitted with a chief complaint of difficulty of breathing,
weakness and pallor. Upon admission, O2 inhalation therapy was given
with a rate of 1-2 lpm. Nail clubbing was present on both hands and feet
nails. Breathing pattern is effortless and use of accessory muscles was
noted during the interview. He has a regular breathing pattern. No
abnormal breath sounds heard. Resonant sound is heard during
percussion. The thorax is slightly elliptical in shape. The ratio of the AP
diameter to the transverse diameter is approximately 1:2.
The patients respiratory rate throughout the hospital confinement:
DATE AND TIME
2-11-09
8AM
10AM
1:30PM
3-11PM
02-12-09
8AM
12PM

RATE
22
25
22
23
21
21
26
25

INTERPRETATION
Abnormal
Abnormal
Abnormal
Abnormal
abnormal
Abnormal
Abnormal
Abnormal
19

2PM
3:30PM
6PM
10PM
2-13-09 6 am
8AM
10AM
2PM
(3-11PM) 5PM
6PM
8PM
10PM
2-14-09(11-7AM)
8AM
10AM
2PM
3-11PM
02-15-09(11-7AM)
3-11PM
2-16-09 (8AM)
10AM
12PM
1:30PM
4PM
10PM
2-17-09(4PM)
10PM
2-18-09(11-7AM)
7AM
10AM

33
25
28
28
26
35
26
24
26
29
31
29
25
23
22
19
20
20
20
30
25
27
25
26
30
30
28
26
25
24

*Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
abnormal
Abnormal
Abnormal
Abnormal
normal
normal
normal
normal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal

Norms
Normal RR is 14-20 cycles per minute. Normal respirations are
regular and even in rhythm. Depth of inspiration is unexaggerated and
effortless. Accessory muscle should not be used. Normal lung tissues
produce resonant sound during percussion. Adventitious sounds should
be absent.
The normal thorax is slightly elliptical in shape and the ratio of AP
diameter to the transverse diameter is approximately 1:2 to 5:7. In other
20

words, the normal adult is wider from side to side then front to back.
( Health Assessment and PE, Estes pg. 451-470)
Analysis
The patient has RR greater than 20 cpm, which means that he is
tachypneic. Tachypneic is frequently present in hypermetabolic and
hypoxic state. By increasing the RR, the body is trying to supply additional
oxygen to meet the bodys demands.
VIII. State of Physical Rest and Comfort
Mr. X usually wakes 6 oclock in the morning and starts the day with
a cup of coffee and continues to exercise by doing house hold chores. The
client verbalized that he sometimes feels dizzy and difficulty of breathing
while doing house chores. He can work as a driver and perform activities
of daily living with full self care without the help of others. During vacant
time, he usually watches television as a form of relaxation plays basketball
or just mingle around and talked to some friends. On a daily basis, he
sleeps for about 7 to 8 hours at night and takes a 4 hours nap in the
afternoon while resting from work. Mosquitoes from their house
sometimes interrupt him but most of the time his rest and sleeping time
was not interrupted. He sometimes watches DVDs to catch his sleep. The
client usually feels hungry every time he woke up in the morning.
During his stay in the hospital, he was mostly confined on bed
wherein he cannot perform daily activities like eating, taking a bath,
voiding, and getting dress and requires assistance from others. He
verbalized to feel fatigue and shortness of breath even when doing light
activities. He usually sleeps for about 4 hours with some interruptions from
others patients and health workers that provide cares and procedures
every now and then. His sleep was also interfered whenever he feels the
urge to void for about 10 times in a night. He appears lethargic, restless
and irritable, weak in appearance and yawns frequently. The environment
21

in the hospital is not conducive and is also one factor that the client cannot
rest enough. The hospital room is not well ventilated, warm in temperature
and the weather is also hot making the client uneasy.
Norms
The sleep wake cycle is very important to young adults. They
usually have an active lifestyle, and are thought to require 7 to 8 hours of
sleep each night but may do well on less. Maintaining a regular sleepwake rhythm is more important than the number of hours actually slept.
Sleep exerts physiologic effects on both the nervous system and
other body structures. Sleep in one way restores normal levels of activity
and normal balance among parts of the nervous system. It is also
necessary for protein synthesis, which also allows repair processes to
occur. (Kozier et. al., Fundamentals of Nursing 7th edition)
Analysis
Client experienced no complete sleep hours and irregular sleep
pattern. Compared with the normal values, client has an inadequate
amount of sleep which made him to become emotionally irritable, have
poor concentration, and experiencing difficulty in making decisions. The
client manifest discomfort from environmental temperature and lack of
ventilation which also affects his sleep and comfort.
IX. Reproductive Status
Mr. X was circumcised when he was 12 years old. He verbalized
that they dont use any contraceptive method. The client doesnt have any
children yet. No abnormal findings were noted like tenderness,
enlargement, or nodular growth on his penis and scrotum as stated by the
client. He verbalized that he is experiencing erectile dysfunction since the
time that he felt his illness which making their marriage sexual lie and
function to be impaired.
22

Norms
Penile erection is managed by two different mechanisms. The first
one is the reflex erection, which is achieved by directly touching the penile
shaft. The second is the psychogenic erection, which is achieved by erotic
or emotional stimuli. The former uses the peripheral nerves and the lower
parts of the spinal cord, whereas the latter uses the limbic system of the
brain. In both conditions, an intact neural system is required for a
successful and complete erection. Stimulation of penile shaft by the
nervous system leads to the secretion of nitric oxide (NO), which causes
the relaxation of smooth muscles of corpora cavernosa (the main erectile
tissue of penis), and subsequently penile erection. Additionally, adequate
levels of testosterone (produced by the testes) and an intact pituitary
gland are required for the development of a healthy erectile system.
Analysis:
As can be understood from the mechanisms of a normal erection,
clients impotence was develop due to hormonal deficiency, which is
disorder of the neural system, and lack of adequate penile blood supply or
psychological problems. Restriction of blood flow was arising from
impaired endothelial function which makes the client impotence. This
problem makes the client to be emotionally worried thus he feels that he
cannot perform his role as a husband to his wife and he cannot render his
worth in achieving their sexual satisfaction.
X. Nutritional Status
Mr. X weighs 58kg with a height of 57. His computed body mass
index is 20.67. Prior to admission, the patient usually eats pork and does
not eat vegetables. Upon admission, he eats food served by the hospital.
But he still doesnt eat vegetables, he only eat meat. He doesnt have
difficulty of eating because he has a good set of teeth. He drinks an
23

average of 8-10 glasses of water a day. The patient stated that he have
lost his appetite that resulted to loss of weight from 68kg to 58kg.
BMI= weight in kg
m2
= 58 kgs.
(1.675 m)2
= 58 kgs.
2.805625
BMI = 20.67
Norms
Nutrition is the sum of all the interactions between an organism and
the food it consumes. Nutrients are organic are organic and inorganic
substances found in foods and are required for body functioning. People
require the essential nutrients in food for the growth and maintenance of
all body tissues and the normal functioning of all body processes.
Several approaches attempt to approximate water needs for the
average healthy adult living in a temperate climate. The Institute of
Medicine advises that man consume roughly 3 liters (about 13 cups) of
total beverages a day and women consume 2-2 liters (about 9 cups) of
total beverages a day.
Many health professionals consider the BMI to be a more reliable
indicator of changes in body fat stores and whether a persons weight
appropriate to height and may provide useful instrument of malnutrition. A
BMI with a result of 16 is considered as malnourished; BMI of 16-19 is
undernourished. BMI of 20-25 is normal. BMI; of 26-30 is over weight; BMI
of 31-40 is moderately obese to severely obese and greater than 40 is
morbidly obese (Kozier)
Analysis
24

The patient knows the right food to eat but he is not fond of eating
vegetable. He meets the daily water requirement. Due to his condition he
demonstrated loss of appetite and he loss weight of about 10 kilograms.
Despite the clients condition his BMI is within normal range.
XI. Elimination Status
Client used to urinate frequently (5- times in day and -10 times in
night) with different volume which is most prominent in night time wherein
his urine becomes more tea like color in appearance without foul smell.
Defecates 1 to 2 times per day with brownish color stool. Patient
verbalized that she has no difficulty in voiding and defecating.
Norms
Normal urine output for an individual is 1200 to 1500 ml for 24hrs.
With color clarity of straw, amber transparent, faint aromatic odor and no
presence of blood. (Fundamentals of Nursing by Kozier)
Medications can have an impact on the clients elimination health
and pattern. Diuretic increase urine production. Anti depressants,
antihypertensive and some antihistamines and OTC cold medications may
lead to urinary retention. (Nursing Fundamentals by Daniels)

Analysis
Tea colored urine present to the client is a manifestation of his
condition where in there is an immature breakdown of RBCs in the body
which is eventually accumulates in the urine that makes it color tea like.
Urine is more concentrated during night time because body is at rest and
does not require a lot of movement unlike in daytime.
XII. Sensory Status

25

Client doesnt wear any reading aid, his pupils size are 4mm equal.
He has an intact visual acquity, sclera is anecteric and cardinal fields of
gaze are intact, in assessing corneal light reflex the reflected light seen
symmetrically in the center of each cornea, conjunctiva is pale and moist.
Reaction to light on both eyes is brisk. With uniform reaction to
accommodation. Mr. X has the ability to respond to light touch, superficial
pain and temperature. His sense of smell is normal and he can distinguish
foul and fresh odor. Clients both nostrils are patent, no evident swelling of
the frontal and maxillary sinuses and excessive mucus discharges. With
regards to the auditory perception, Mr. X can hear spoken words w/ a 2
feet distance away from the client. Lips are pale and dry, gums are palered in color, no bleeding and swelling noted. Buccal mucosa is pale in
color, smooth and moist, no lesions and halitosis noted. Tongue is also
pale in color, moist and rough, able to perform normal tongue movements,
asked client to move tongue side to side up and down. Client can
differentiate food according to taste, gag reflex present. Tonsils are graded
1+, uvula located on the midline (Normal, no signs of inflammation).
Norms
The client should be able to perceive light touch, superficial pain,
and temperature accurately and perceive the location of stimulus. During
assessment of auditory perception the client should be able to hear
spoken words from a distance of 2ft. Nostril should be patent, there should
be no evidence of swelling around the nose and eyes and lastly the client
should distinguish and identify the odors w/ each nostril. Breath should
smell fresh; lips and membranes should be pink and moist w/ no evidence
of lesions and inflammations. Tongue should be in the midline of the
mouth; the dorsum of the tongue must be pink, moist and rough (from the
taste buds) and must be w/o lesions. It should move freely and the
strength of the tongue is symmetrically strong, buccal mucosa should be
moist, smooth and free from lesions. Gums should be pale-red stippled
26

surface on light skinned people. Gum margins should be defined, no

presence of swelling and bleeding. Normal tonsilar size is graded 1+ or
2+, no swelling and exudates present, uvula in on the midline. Corneal
light reflex (light reflex) should be symmetrically in the center of each
cornea. Both eyes should move smoothly and symmetrically in each of the
six fields of gaze conjunctiva must appear pinkish and moist. (Health
assessment and physical examination 3rd edition by Mary Ellen Zator
Estes). Adults pain perception and behavior exhibited when experiencing
pain may be gender-based behaviors or by own interpretation of pain that
she/he is feeling. (Fundamentals of Nursing by Kozeir)
Analysis
Clients pale appearance of the skin and mucous membranes
(conjunctiva and mucosa) may indicate signs of anemia or perfuse
bleeding.(Medical Surgical Nursing 11th Edition by Brunner and Suddarths)
Due to his condition, he dont have enough blood supply wherein his
hemoglobin level is below normal (39 g/l compared to 120-10 normal) thus
making the client appearance to be pale. Hematocrit level (0.17) from a
normal 0.37-0.47 value is also very low. Other than that, client does not
show any significant deviations from the normal values and thus,
considerately shows no sensory impairment.
XIII. . Skin Appendages
Mr. Xs skin was pale all over the body but most apparently on the
face, mouth, lips, and conjunctiva. It is dry with minimize perspiration,
rough and warm to touch. It has no lesions and it is non tender. It returns
to its original state rapidly when the skin is pinched and released. Scalp
was pale white and there were no signs of infestation or lesions. No
dandruff found. His hair is equally distributed, rough and black in color. He
has untrimmed fingernails and toenails which pale in color and clubbing
was also evident on both his fingernails and toenails. They appeared
27

convex and wide and angle of the nail base was greater than 160 0. Nail
surface was smooth and its thickness was uniform throughout. The
venipuncture site was located on his left cephalic vein.
Norms
Normally, the skin is a uniform whitish pink or brown color,
depending on patients race. No skin lesions should be present. It should
be dry with minimize perspiration. Moisture on the skin will vary from one
body area to another with perspiration normally present on the hands,
axilla, face, and in between the skin folds. Skin surface temperature be
warm and equal bilaterally. Hands and feet may be slightly cooler than the
rest of the body. Skin surfaces should be non tender. It should normally
feel smooth, even and firm except where there is significant hair growth. A
certain amount of roughness can be normal. When the skin is pinched, it
should return to its original contour when released. The scalp should be
pale white to pink in light-skinned individuals and light brown in darkskinned individuals. There should be no sign of infestations or lesions.
Seborrhea may be present. Hair may feel thin, straight, course, thick or
curly. It should be shinny and resilient when traction is applied. Normally,
the nails have a pink cast in light skinned individuals and are brown in
dark skinned individuals. The nail surface should be smooth and slightly
rounded or flat. Its thickness should be uniform throughout, with no
splintering or brittle edges. The angle of the nail base should be
approximately 1600.
Analysis
Mr. X skin was pale which is due to low hemoglobin. Untrimmed toe
nails and fingernails indicate self care deficit and clubbing of the nails
result from long-standing hypoxia. Mr. X also has poor peripheral
circulation which is indicated by slow capillary refill.

28

Client is at risk for infection with regards to the venipuncture he

had.

29

6. Diagnostic and Laboratory Procedures

DIFFERENTIAL COUNTS:
Hematology- This diagnostic test is a tool that provides information about the hematologic system of the patient.
Diagnostic/
Date ordered
Indications or
Normal
Analysis and
Laboratory
and date
purposes
Results
values
Interpretation of
procedure
results
data
February
Hemoglobin
10,2009
- is a measure of
31 g/l
120-180
Below normal range:
the total amount of
In response to
8:23 am
hemoglobin in the
decrease RBC,
blood. It carries
hemoglobin also
oxygen to the cells
decrease
from the lungs and
carbon
dioxide
away from the cells
to the lungs
Hematocrit

measure
the
percentage of red
blood cells in 100
ml of whole blood.
Determines if the
client is hydrated or
dehydrated.

.092 L/L

.370-.510

Below normal range:

can be a sign of the
presence
of
hemorrhage,
anemia,
hyperthyroidism,
dietary
deficiency
and pregnancy.

RBC
MCV
MCHC
MCH

used to evaluate
the size, weight
and
hemoglobin
concentration
of

.90 T/L

4.2-6.3

Below normal range.

Decreased
RBC
result in lysis of RBC
due to lack of decay

30

RBCs. Oxygen

accelerating
factor(CD55
and
CD59) on RBC.

transportation is its
major function.
WBC
Lymphocytes

- determines the
number
of
circulating WBCs
in the blood. It
monitors
the
presence
of
infection in the
body.

8.1 G/L
0.225

4.1-10.9
0.6-4.1

Within normal range.

low lymphocytes
indicates decrease
activity of the bone
marrow

Platelet

- platelets are the

first
line
of
protection against
bleeding.

168 G/L

140-440

Within normal range

Blood typing
RH Factor

A
+

DIFFERENTIAL COUNTS:
Hematology- This diagnostic test is a tool that provides information about the hematologic system of the patient.
Diagnostic/
Date ordered
Indications or
Normal
Analysis and
Laboratory
and date
purposes
Results
values
Interpretation of
procedure
results
data
February
Hemoglobin
13,2009
- is a measure of
36 g/l
120-180
Below normal range:

31

6:57 am

the total amount of

hemoglobin in the
blood. It carries
oxygen to the cells
from the lungs and
carbon
dioxide
away from the cells
to the lungs

In response to
decrease RBC,
hemoglobin also
decrease
.

Hematocrit

measure
the .87 L/L
percentage of red
blood cells in 100
ml of whole blood.
Determines if the
client is hydrated or
dehydrated.

. .370-.510

Below normal range:

can be a sign of the
presence
of
hemorrhage, anemia,
hyperthyroidism,
dietary
deficiency
and pregnancy

RBC
MCV
MCHC
MCH

used to evaluate 1.01 T/L

the size, weight
and
hemoglobin
concentration
of
RBCs. Oxygen

4.2-6.3

Below normal range.

Decreased
RBC
result in lysis of RBC
due to lack of decay
accelerating
factor(CD55
and
CD59) on RBC.

4.1-10.9
0.6-4.1

Within normal range

transportation is its
major function.
WBC
lymphocytes

- determines the 6.9 G/L

number
of 1.2
circulating WBCs
in the blood. It
monitors
the

32

presence
infection
body.
Platelet

in

of
the

- platelets are the

first
line
of
protection against
bleeding.

Blood typing

141 G/L

140-440

Within normal range

RH Factor

MCV

- average volume
of individual RBCs

85.7 FL

80-97

Within normal range

MCH

calculated
average weight of
hemoglobin
per
RBC

35.6 pg

26-32

above normal range.

Due to macrocytic
anemia.

MHCH

average
concentration
or
percentage
of
hemoglobin
per
RBC

414 g/l

310-360

above normal range.

Due to macrocytic
anemia.

DIFFERENTIAL COUNTS:
33

Hematology- This diagnostic test is a tool that provides information about the hematologic system of the patient.
Diagnostic/
Date ordered
Indications or
Normal
Analysis and
Laboratory
and date
purposes
Results
values
Interpretation of
procedure
results
data
Feb. 14, 2009
Hemoglobin
- is a measure of
45 g/l
120-180
Below normal range:
7:05 am
the total amount of
In response to
hemoglobin in the
decrease RBC,
blood. It carries
hemoglobin also
oxygen to the cells
decrease
from the lungs and
carbon
dioxide
away from the cells
to the lungs
Hematocrit

measure
the
percentage of red
blood cells in 100
ml of whole blood.
Determines if the
client is hydrated or
dehydrated.

.097 L/L

.370-.510

Below normal range:

can be a sign of the
presence
of
hemorrhage,
anemia,
hyperthyroidism,
dietary
deficiency
and pregnancy

RBC
MCV
MCHC
MCH

used to evaluate
the size, weight
and
hemoglobin
concentration
of
RBCs. Oxygen

. 1.14 T/L

4.2-6.3

Below normal range.

Decreased
RBC
result in lysis of RBC
due to lack of decay
accelerating
factor(CD55
and
CD59) on RBC.

transportation is its

34

major function.
WBC
lymphocytes

- determines the
number
of
circulating WBCs
in the blood. It
monitors
the
presence
of
infection in the
body.

5.4 G/L
1.4

4.1-10.9
0.6-4.1

Within normal range

Platelet

- platelets are the

first
line
of
protection against
bleeding.

127 G/L

140-440

Low platelet
indicates decrease
activity of the bone
marrow

Blood typing

RH Factor
MCV
MCH

MHCH

+
- average volume
of individual RBCs
calculated
average weight of
hemoglobin
per
RBC
-

average

85.5 FL

80-97

Within normal range.

39.5 pg

26-32

Below normal range.

Due to macrocytic
anemia.

464 g/l

310-360

Above
range.

normal

35

concentration
percentage
hemoglobin
RBC

or
of
per

Due to macrocytic
anemia.

DIFFERENTIAL COUNTS:
Hematology- This diagnostic test is a tool that provides information about the hematologic system of the patient.
Diagnostic/
Date ordered
Indications or
Normal
Analysis and
Laboratory
and date
purposes
Results
values
Interpretation of
procedure
results
data
Feb. 16, 2009
Hemoglobin
- is a measure of
58 g/l
120-180
Below normal
2:00 pm
the total amount of
range: In response
hemoglobin in the
to decrease RBC,
blood. It carries
hemoglobin also
oxygen to the cells
decrease
from the lungs and
carbon
dioxide
away from the cells
to the lungs
Hematocrit

measure
the
percentage of red
blood cells in 100
ml of whole blood.
Determines if the
client is hydrated or
dehydrated.

.152 L/L

.370-.510

Below normal range:

can be a sign of the
presence
of
hemorrhage,
anemia,
hyperthyroidism,
dietary
deficiency
and pregnancy

RBC

used

1.80T/L

4.2-6.3

Below normal range.

to

evaluate

36

MCV
MCHC
MCH

the size, weight

and
hemoglobin
concentration
of
RBCs. Oxygen

Decreased
RBC
result in lysis of RBC
due to lack of decay
accelerating
factor(CD55
and
CD59) on RBC.

transportation is its
major function.
WBC
Lymphocytes

- determines the
number
of
circulating WBCs
in the blood. It
monitors
the
presence
of
infection in the
body.

4.5 G/L
1.2

4.1-10.9
0.6-4.1

Within normal range

Platelet

- platelets are the

first
line
of
protection against
bleeding.

104 G/L

140-440

Low platelet
indicates decrease
activity of the bone
marrow

Blood typing

RH Factor

MCV

- average volume
of individual RBCs

84.4FL

80-97

Within normal range

MCH

32.2 pg

26-32

Above

calculated

normal
37

average weight of
hemoglobin
per
RBC
MHCH

average
concentration
or
percentage
of
hemoglobin
per
RBC

range.
Due to macrocytic
anemia.
382 g/l

310-360

Above
normal
range.
Due to macrocytic
anemia.

Nursing responsibilities:
Before
prepare the client
instruct client and family about requirements or restrictions(when and what to eat and drink, how long to fast)
explain to the client on how the procedure is done and why is it necessary
During
assist the client
use standard precautions and sterile technique as appropriate
use the correct procedure for obtaining the specimen
provide client comfort, privacy and safety
ensure correct labeling, storage and transportation of specimen
After
nursing care of the client and follow-up activities and observations
compare previous and current test results
Blood Chemistry

Date

Purpose

Result

Normal values

Analysis

38

BUN

02-13-09

Creatinine

To asses for
electrolyte
imbalance.

18.71

2.9-8.2 mmol/L

353.6

53-106mmol/L

Elevated BUN and

creatinine level
indicates decreased
kidney perfusion.

Nursing Responsibilities
Before
Explain the test procedure and the importance of the test.
During
Adhere to understand the precaution.
Apply pressure to the venipuncture site.
Explain that some bruising discomfort and swelling may appear at the site and that warm, moist compress can
alleviate this. Monitor for signs of infection.
After
Label the container and send to the laboratory.
Do hand washing after the test.

39

VII. Anatomy and Physiology

ERYTHROPOIESIS

Erythropoiesis is the development of mature red blood cells

(erythrocytes). Like all blood cells, erythroid cells begin as pluripotential stem
cells. The first cell that is recognizable as specifically leading down the red
cell pathway is the proerythroblast . As development progresses, the nucleus
becomes somewhat smaller and the cytoplasm becomes more basophilic,
due to the presence of ribosomes. In this stage the cell is called a basophilic
erythroblast . The cell will continue to become smaller throughout
development. As the cell begins to produce hemoglobin, the cytoplasm
attracts both basic and eosin stains, and is called a polychromatophilic
erythroblast . The cytoplasm eventually becomes more eosinophilic, and the
cell is called an orthochromatic erythroblast . This orthochromatic erythroblast
will then extrude its nucleus and enter the circulation as a reticulocyte .
Reticulocytes are so named because these cells contain reticular networks of
polyribosomes. As reticulocytes loose their polyribosomes they become
mature red blood cells.( www.som.tulane.edu)
40

Erythrocytes: (a) seen from surface; (b) in profile, forming rouleaux; (c)
rendered spherical by water; (d) rendered crenate by salt. (c) and (d) do not
normally occur in the body.
RED BLOOD CELL, OR ERYTHROCYTE, is a hemoglobin-containing
blood cell in vertebrates that transports oxygen and some carbon dioxide to
and from tissues. Erythrocytes are formed in the red bone marrow and
afterward are found in the blood. They are the most common type of blood
cell and the vertebrate body's principal means of delivering oxygen from the
lungs or gills to body tissues via the blood (Dean 2005).
Erythrocytes consist mainly of hemoglobin, a complex molecule
containing heme groups whose iron atoms temporarily link to oxygen
molecules in the lungs or gills and release them throughout the body.
Oxygen can easily diffuse through the red blood cell's cell membrane.
Hemoglobin also carries some of the waste product carbon dioxide back from
the tissues. The color of erythrocytes is due to the heme group of
hemoglobin.
The blood plasma alone is straw-colored, but the red blood cells
change color depending on the state of the hemoglobin: when combined with
oxygen the resulting oxyhemoglobin is scarlet, and when oxygen has been

41

released the resulting deoxyhemoglobin is darker, appearing bluish through

the vessel wall and skin.
Erythrocytes develop from committed stem cells through
reticulocytes to mature erythrocytes in about seven days and live a
total of about 120 days.
he heme constituent of hemoglobin are broken down into Fe 3+ and biliverdin.
The biliverdin is reduced to bilirubin, which is released into the plasma and
recirculated to the liver bound to albumin. The iron is released into the plasma
to be recirculated by a carrier protein called transferrin. Almost all
erythrocytes are removed in this manner from the circulation before they are
old enough to hemolyze. Hemolyzed hemoglobin is bound to a protein in
plasma

called

haptoglobin

which

is

not

excreted

by

the

kidney.

(newworldencyclopedia.org)
The G6PD(Glucose-6-dehydrogenase) gene provides instructions for
making an enzyme called glucose-6-phosphate dehydrogenase. This
enzyme, which is active in virtually all types of cells, is involved in the normal
processing of carbohydrates. It plays a critical role in red blood cells, which
carry oxygen from the lungs to tissues throughout the body. This enzyme
helps protect red blood cells from damage and premature destruction.
glucose-6-phosphate dehydrogenase deficiency disrupt the normal
structure and function of the enzyme or reduce the amount of the enzyme in
cells.
Without enough functional glucose-6-phosphate dehydrogenase, red blood
cells are unable to protect themselves from the damaging effects of reactive
oxygen species. The damaged cells are likely to rupture and break down
prematurely (undergo hemolysis). Factors such as infections, certain drugs,
and ingesting fava beans can increase the levels of reactive oxygen species,
causing red blood cells to undergo hemolysis faster than the body can
replace them. This loss of red blood cells causes the signs and symptoms of
hemolytic anemia, which is a characteristic feature of glucose-6-phosphate
dehydrogenase deficiency.( /ghr.nlm.nih.gov)
42

LYMPHOCYTE is a type of white blood cell (leukocyte) in the

vertebrate immune system. The two main types of lymphocytes are T cells
and B cells, which function in the adaptive immune system. Other
lymphocyte-like cells are commonly known as natural killer cells, or NK cells,
and are part of the innate immune system. The NK cells are sometimes
labeled "large granular lymphocytes," while the T cells and B cells are labeled
as "small lymphocytes."
Types of lymphocytes
A stained lymphocyte surrounded by red blood cells viewed using a
light microscope.
The two main categories of lymphocytes are the B lymphocytes (B
cells) and T lymphocytes (T cell), both of which are involved in the adaptive
immune system (Alberts 1989). B cells specifically are involved in the humoral
immune system and produce antibodies, while T cells are involved in the cellmediated immune system and destroy virus-infected cells and regulate the
activities of other white blood cells (Alberts 1989). In essence, the function of
T cells and B cells is to recognize specific non-self antigens, during a
process known as antigen presentation. Once they have identified an invader,

43

the cells generate specific responses that are tailored to maximally eliminate
specific pathogens, or pathogen infected cells.
B cells respond to pathogens by producing large quantities of
antibodies that then neutralize foreign objects like bacteria and viruses. In
response to pathogens, some T cells, called "helper T cells," produce
cytokines that direct the immune response while other T cells, called
"cytotoxic T cells," produce toxic granules that induce the death of pathogen
infected cells.
The adaptive immune system, also called the "acquired immune
system" and "specific immune system," is a response of the body whereby
animals that survive an initial infection by a pathogen are generally immune to
further illness caused by that same pathogen. The adaptive immune system
is based on dedicated lymphocytes.
The basis of specific immunity lies in the capacity of immune cells to
distinguish between proteins produced by the body's own cells ("self" antigen
those of the original organism), and proteins produced by invaders or cells
under control of a virus ("non-self" antigenor what is not recognized as the
original organism).

44

Although the complement system has traditionally been considered part

of the innate immune system, research in recent decades has revealed that
complement is able to activate cells involved in both the adaptive and innate
immune response. Complement triggers and modulates a variety of immune
activities and acts as a linker between the two branches of the immune
response. In addition, the complement system maintains cell homeostasis by
eliminating cellular debris and immune complexes. (www.nature.com)
The complement system distinguishes "self" from "non-self" via a
range of specialized cell-surface and soluble proteins. These homologous
proteins belong to a family called the "regulators of complement activation
(RCA)" or "complement control proteins (CCP)". The complement system is
an enzyme cascade that helps defend against infection. Many complement
proteins occur in serum as inactive enzyme precursors (zymogens); others
reside on cell surfaces. The complement system bridges innate and acquired
immunity by Augmenting antibody (Ab) responses and immunologic memory,
Lysing foreign cells, Clearing immune complexes and apoptotic cells.
Complement components have many biologic functions (eg, stimulation of
chemotaxis, triggering of mast cell degranulation independent of IgE).
(www.merck.com)
Members of this family are:

complement receptor 1 (CR1 or CD35)

membrane cofactor protein (MCP or CD46)

C4b-binding protein (C4BP).

decay-accelerating factor (DAF or CD55)

factor H (fH)
The complement system is an enzyme cascade that helps defend

against infection. Many complement proteins occur in serum as inactive

enzyme precursors (zymogens); others reside on cell surfaces. The
45

complement system bridges innate and acquired immunity by Augmenting

antibody (Ab) responses and immunologic memory, Lysing foreign cells,
Clearing

immune

complexes

and

apoptotic

cells.

Complement

components have many biologic functions (eg, stimulation of chemotaxis,

triggering of mast cell degranulation independent of IgE). (wikipedia.org)
In addition, membrane components (decay-accelerating factor, CD55 and
CD59, and membrane inhibitor of C8 and C9 insertion) are important
regulating proteins. The complement cascade is a dual-edged sword, causing
protection against bacterial and viral invasion by promoting phagocytosis and
inflammation. Pathologically, complement can cause sub-stantial damage to
blood vessels (vasculitis), kidney basement membrane and attached
endothelial and epithelial cells.( questdiagnostics.com)

46

8. Pathophysiology

47

B. PLANNING
Nursing Priorities Based on Maslows Hiearchy of Needs:
A. Enhance tissue perfusion
1. Ineffective Tissue perfusion: Peripheral r/t decreased hemoglobin concentration in blood
B. Provide nutritional/fluid needs
2. Imbalanced nutrition: less than body requirements r/t decrease intake of essential nutrients
C. Prevent complications brought about by disease
3. Activity Intolerance r/t imbalance between oxygen supply delivery and demand
4. Self-care deficit: Bathing/Hygiene r/t weakness and tiredness
5. Disturbed sleep pattern r/t excessive stimulation from environment
6. Anxiety r/t change in health status and role function
7. Risk for Infection r/t inadequate seco0.ndary defenses (decreased hemoglobin)
D. Provide information about disease process, prognosis and treatment regimen
8. Deficient knowledge (PNH) r/t lack of exposure

48

Nursing Care Plans

(Date Identified)
Assessment
S
> fatigue and shortness of breath
when doing light physical activities
like eating, urinating in bed pan,
oral and body hygiene and
changing clothes
> general body weakness
O
> requires SOs assistance when
accomplishing ADLs
> pale conjunctiva, oral and nasal
mucosa and integument
> carpal and tarsal clubbing
> hair growth on fingers and toes
absent
> capillary refill of 5 seconds in
fingernails, 4-5 seconds in toenails
> Tachycardia = 105 bpm
> Tachypnea = 33 cpm
> Hgb value = 36 g/l
> Hct values = 0.17
Nsg Dx
IneffectiveTissue Perfusion:
peripheral r/t decreased Hgb
concentration in blood

Planning

Intervention

After 6
hours of
nursng
intervention,
the client will
display an
increase in
peripheral
tissue
perfusion.

1. Independent
a. Assist client to semifowlers position
R: To promote maximum lung expansion to
increase oxygenation and tissue perfusion.
b. Assist client to do deep breathing exercises
R: Helps regulate rate of breathing and anxiety to
conserve pt.s energy.
c. Provide and quiet environment and provide
comfort measures.
c.1 Change linens regularly.
c.2 Instruct SOs to minimize talking with the pt.
c.3 Provide back massage as needed.
c.4 Assist pt. in doing guided imagery and
visualization relaxation techniques
R: Helps promote rest and relaxation which
conserves pt.s energy and decreases the bodys
demand for oxygen.
2. Collaborative
a. Assist in obtaining specimen for laboratory
studies (Hb/Hct, RBC count, ABG)
R: Identifies deficiencies in RBC composition and
monitors the pts status in terms of oxygenation
and perfusion. Also serves as a parameter for
clients progress in achieving activity tolerance.

Expected
Outcome
The pt. will
display an
increase in
peripheral tissue
perfusion as
manifested by:
a. improvement
in capillary refill
b. good
peripheral
pulses
c. normal heart
rate and
respiratory rate
d. verbalization
of improvement
in level of
energy
e. improvement
in disposition
f.improvement of
Hgb/Hct values

49

SE:
PNH is a condition in which there
is a continuous autoimmune
destruction of RBCs. A significant
decrease in the total number of
circulating RBCs would lead to
inadequate amount of oxygen
perfused to the tissues of the body.
Poor perfusion at the peripherals
would cause clubbing, prolonged
capillary refill time, pale nailbeds,
weak pulses and fatigue.
Compensatory mechanisms like
tachycardia and tachypnea help
increase tissue perfusion which is
also evident in the pt.

b. Provide supplemental oxygen as indicated.

R: Maximizing oxygen-carrying capacity of RBCs
to transport to tissues of the body.
c. Administer packed RBC blood transfusion as
indicated.
R: Increases the number of oxygen-carrying cells
to correct inadequate tissue perfusion.

50

Assessment
S:
> fatigue and shortness of breath
when doing light physical activities
like eating, urinating in bed pan,
oral and body hygiene and
changing clothes
> frequently naps during daytime (12 hours)
O:
> confined to bed most of the time
> pt. depends on assistance of SO
in accomplishing ADLs like eating,
urinating in bed pan, oral and body
hygiene and changing clothes
> appears generally weak
> fingernails and conjunctiva pale
> tachycardia = 103 bpm
> tachypnea = 33 cpm
> low HB= 36 g/l
> low HCT= 0.17
Dx:
Activity intolerance [Level III] r/t
imbalance between oxygen supply
and demand
SE:
PNH is a condition in which the
RBC count is decreased because of
continuous hemolysis. Pale

Planning
After 1 hour of
daily nursing
intervention,
client will display
a gradual
progressive
tolerance of
physical activity
w/o report of
chest pain upon
exertion

Intervention
1. Independent:
a. Limit activities and decrease
external stimulus.
R: Limitation decreases oxygen
demand and decreasing stimulus
promotes relaxation and decreases
anxiety which can also increase
oxygen demand.
b. Assist patient to gradually
increase activity level. Start from
simple ADLs like combing hair,
brushing teeth and eating. Progress
to mild activity like active-assistive
ROMs and then ambulating with
assistance.
R: Gradual increase in activity level
ensures that the pt.s heart is not
overworked and the complications of
prolonged immobility will be
prevented.

Expected Outcome
After appropriate nursing
intervention, pt. will
display a gradual
increase in activity
tolerance as manifested
by:
a. increase in capacity to
do ADLs
b. absence of chest pain
and SOB while doing
daily activities
c. improvement of skin
and nail color, peripheral
pulses and capillary refill
which indications good
circulation
d. increase in
independence

c. Record and document pt.s VS

before, during and after activities
and correlate with presence or
absence of SOB.
R: Provides a baseline trend to
monitor pt.s tolerance on the
activity. Also provides a source for
evaluation for the clients progress to
increase his activity tolerance.

51

fingernails and conjunctiva as well

as low Hb/Hct indicates an
abnormally low RBC count.
An increase in physical activity will
cause the cells to increase their
demand for oxygen to meet the
increased metabolic state.
However, the amount of oxygen
supplied by the RBC is decreased
because of the decrease in the
number of circulating RBCs.
Therefore, fatigue is evident even in
doing light physical activities and
the bodys compensatory
mechanism in response to
decreased oxygenation at the tissue
level is to increase the heart rate
and respiratory rate.

d. Instruct pt. to avoid activities

which increase abdominal pressure.
(e.g. straining during defecation)
R: It can cause bradycardia which
would decrease tissue perfusion to
all tissues including the myocardial
tissues.

52

Assessment
S:
> Frequent daytime naps (12 hours)
> Feels that he lacks energy
and is always tired
> Has difficulty in falling
asleep at night
O:
> less than age-normed
total sleep time (7-8 hours)
> lethargic
> irritable and restless
> yawns frequently
> weak in appearance
> Frequent conversations
from SO
> Interruption of rest and
sleep due to therapeutic
and monitoring activities of
health care workers in
hospital
Dx:
Disturbed sleep pattern r/t
excessive stimulation from
environment
SE:
Excessive environmental

Planning
After 8 hours
of nursing
intervention
the client will
report an
improvement
in sleep/rest
pattern.

Intervention
Independent:
a. Explain the necessity for therapeutic and
monitoring procedures while the client is
hospitalized.
R: Pt. is more apt to be tolerant of
disturbances by staff if he understands the
reasons and importance of care.
b. Restrict the intake of foods and fluids rich
in caffeine
R: Increases pt.s wakefulness and delay
falling asleep.
c. Support continuation of usual bedtime
rituals.
R: Promotes relaxation and readiness for
sleep.

Expected Outcome
After appropriate nursing
intervention, client will report
an improvement in
sleep/rest pattern as
manifested by:
a. verbalization of increase
in energy and physical
activity
b. reduction or absence of
yawning, irritability and
restlessness
c. increase in total time of
continuous, uninterrupted
night time sleep

d. Increase interaction time between pt. and

SOs/staff during day and reduce physical and
mental activities late in the day and at night.
Minimize unnecessary disturbances during
hours of sleep at night.
R: Planned activities during daytime and
reduction of stimulation during night time
promotes continuous, uninterrupted sleep.
e. Provide comfort measure
e.1 provide evening snack if available
e.2 hygiene (bed bath and oral care)
53

stimulus causes a disruption

in the normal sleep-wake
cycle of the pt. Disturbance
in sleep esp. night time
reduces the length of REM
sleep. Insufficient REM
sleep causes the pt. to feel
fatigue and lack of energy.
The pt. also manifests
frequent yawning and
irritability. The body
compensates for the
insufficiency by taking
daytime naps which is also
evident in the pt.

e.3 massage and back rub

e.4 provide clean and comfortable bed
e.5 assist pt. to wear comfortable clothes
R: Promotes drowsiness, aid in relaxation
and falling asleep.
f. Reduce fluid intake in the evening and
advice client to urinate/defecate before
sleeping if necessary.
R: Decreases the need to get up and go to
bathroom during night time and prevents
interruption of REM sleep.

54

Assessment
S
> Hindi ako mahilig kumain
ng prutas at gulay.
> reports difficulty in eating
d/t weakness, requires
assistance from SO when
eating
O
> Eats only the meat and
rice of the meal served by
the hospital
> Lost 10 kg. since Feb.
14,2009
> weak and pale in
appearance
Dx:
Imbalanced nutrition: less
than body requirements r/t
decrease intake of essential
nutrients
SE:
In PNH, the red blood
cells are broken down
accompanied by the release
of hemoglobin into the urine
which contributes to the low
hemoglobin level that is
circulating within the body.

Planning
After 8
hours of
proper
nursing
interventions,
the client will
maintain an
adequate
nutritional
status

Intervention
> Monitor percentage of meals and snacks
client consumes. Report a pattern of
inadequate intake.
- an awareness of the amount of
foods/fluids the client consumes alerts the
nurse to deficits in nutritional intake.
Reporting an inadequate intake allows for
prompt intervention.
> Perform or assist with anthropometric
measurements such as skinfold thickness,
mid-upper arm circumference (MAC), and
mid-upper arm muscle circumference
(MAMC) if indicated. Report measurements
lower than normal.
- anthropometric measurements such as
skinfold thickness, MAC, MAMC provide
information about the amount of muscle
mass, body fat, and protein reserves the
client has. These assessments assist in
evaluating the clients nutritional status.

Expected Outcome
After hours of proper
nursing interventions, the
client will be albe to
maintain an adequate
nutritional status as
evidenced by:
a. identification of
nutritional requirements
b. consume adequate
nourishment

> Implement measures to improve oral

intake:
a. perform actions to relieve gastrointestinal
distention if present- distention of the
gastrointestinal tract(especially the stomach
and duodenum) can result in stimulation of
the satiety center and subsequent inhibition
of the feeding center in the hypothalamus.
This effect, along with discomfort that occurs

55

Iron, folic acid and Vit.B12

are essential for hemoglobin
synthesis and
erythropoiesis. All of these
elements are derived from
the diet. Inadequate intake
of these essential nutrients
can further aggravate the
decrease in hemoglobin
concentration in the
circulation. The symptoms
associated with a decrease
hemoglobin level can in turn
interfere with maintaining
adequate nutrition.

with distention, decreases appetite.

b. increase activity as allowed and
tolerated- activity usually promotes a general
feeling of well-being, which can result in
improved appetite.
c. maintain a clean environment and a
relaxed, pleasant atmosphere- noxious
sights and odors can inhibit the feeding
center of the hypothalamus. Maintaining a
clean environment helps prevent this from
occurring. In addition, maintaining a relaxed,
pleasant atmosphere can help reduce stress
and promote a feeling of well-being, which
tends to improve appetite and oral intake.
c. encourage a rest period before meals if
indicated- the physical activity of eating
requires some expenditure of energy. Fatigue
can reduce the clients desire and ability to
eat.
d. provide oral hygiene before meals- oral
hygiene freshens the mouth by moistening
the oral mucous membrane and removing
unpleasant tastes. This can improve the
taste of foods/fluids, which helps stimulate
appetite and increase oral intake.
e. serve foods/fluids that are appealing to
the client and adhere to personal and cultural
preferences whenever possible- these foods
most likely stimulate appetite and promote
interest in eating.
f. serve frequent, small meals rather than
large ones if client is weak, fatigues easily,

56

and/or has a poor appetite- providing small

rather than large meals can enable a client
who is weak or fatigues easily to finish a
meal.
g. if client is experiencing dyspnea, place
him in a high Fowlers position and provide
supplemental oxygen therapy during meals if
indicated- because a person cannot swallow
and breath at the same time, relief of
dyspnea increases the likelihood of
maintaining a good oral intake. In addition,
relieving dyspneadecreases the clients
anxiety about and preoccupation with
breathing efforts and increases the ability to
focus on eating and drinking.
h. perform actions to compensate for taste
alterations- enhancing the taste of
foods/fluids and providing nutritious
alternatives to those that taste unpleasant to
the client help to stimulate appetite and
improve oral intake.
i. limit fluid intake with meals unless the fluid
has a high nutritional value- when the
stomach becomes distented, its volume
receptors stimulate the satiety center in the
hypothalamus and the client reduces his oral
intake. Drinking fluids with meals distends
the stomach and may cause satiety before
an adequate amount of food is consumed.
> Ensure that meals are well balanced and
high in essential nutrients.

57

- in order to meet his nutritional needs

a. instruct client to avoid or limit intake of
alcoholic beverages- it interferes with the
utilization of essential nutrients needed by
the body
b. instruct client to increase intake of iron,
folic acid and Vit.B12 rich foods such as liver,
leafy green vegetables and legumes- iron,
folic acid and Vit.B12 are essential for
hemoglobin synthesis and erythropoiesis
c. advise client to increase intake of foods
ric in Vit.C- it is known that Vit.C enhances
iron absorption within the body
> administer vitamins and minerals if ordered
- needed to maintain metabolic functioning

Assessment
S:
> reports fatigue
O:
> mostly confined in bed
> requires assistance from
SO in accomplishing selfcare hygiene activities
> weak and pale in
appearance
> with foul body odor
> limited movements

Planning
After 6 hours
of
appropriate
nursing
interventions,
the client will
be able to:
a. bathe
with
assistance of
caregiver or

Intervention
> Develop a bathing care plan based on the
clients own history of bathing practices that
addresses skin needs, self-care needs, client
response to bathing, and equipment needs.
- bathing is a healing rite and should be
comforting experience that concentrtes on
the clients needs, rather than being a
routinely scheduled task

Expected Outcome
After 6 hours of appropriate
nursing interventions, the
client will be able to:
a. bathe with assistance of
caregiver or significant
others as needed and
b. remain free of body odor
and maintain intact skin

> Plan activities to prevent fatigue during

bathing; seat with feet supported.
- energy conservation increases activity

58

significant
Dx:
others as
Self-care
deficit: needed and
b. remain
Bathing/Hygiene
r/t
free of body
weakness and tiredness
odor and
maintain
SE:
intact skin
PNH is charaterized by
RBC destruction with
release of hemoglobin into
the urine. Hemoglobin is the
oxygen carrying compound
in the blood that carries
oxygen to the cells of the
body. As the hemoglobin
concentration is depleted,
the oxygen supply within the
cells is also decreased
which in turn is associated
to the easy fatigability of an
individual and causes
decrease tolerance to
ADLs.

tolerance and promotes self-care

> Provide pain relief measures: ice packs,
heat and analgesics 45 minutes before
bathing.
- pain relief promotes participation in selfcare and preserves dignity
> Teach use of adaptive bathing equipment
such as long-handled brushes, washcloth
mitt, shower chair, etc.
- adaptive devices extend the clients reach,
increase speed and safety, and decrease
exertion and reduce caregiver burden
> provide privacy: have only one caregiver
providing bathing assistance, encourage a
traffic-free area and postprivacy signs.
- the client perceives less privacy if more
than one caregiver participates or if bathing
takes place in a central bathing area in a
high-traffic location that allows staff to enter
freely during care
> Keep the client warmly covered.
- some clients may experience evaporative
cooling during and after bathing, which
produces an unpleasant cold sensation
> Use tepid water when bathing.
- hot water promotes skin dryness

59

C. Medical Management

60

Blood
transfusion of
PRBC

1st unit
02-12-09, 9:45pm hooked 1st unit
of PRBC with serial # of 09-0490
after typing
1:45am consumed
2nd unit
02-13-09, 7:45 am hooked 2nd
unit of PRBC with serial # of 090489 after typing
11:00am consumed
3rd unit
02-14-09, 1:45pm hooked 3rd unit
of PRBC with serial # of 2007859232 after typing
5:40pm consumed
4th unit
02-16-09, 7:30am hooked 4th unit
of PRBC with serial # of 2007858859 after typing.
11:30am consumed
5th unit
02-17-09, 3:00am hooked 5th unit
of PRBC with serial # of 2007859171 after typing.
6:30am consumed
6th unit
02-18-09, 5:20am hooked 6th unit
of PRBC with serial # of 2007859061 after typing

A blood
transfusion is a
relatively simple
medical
procedure that
doctors use to
make up for
loss of blood
or any part of
the blood, such
as red blood
cells or
platelets. The
whole
procedure
usually takes
about 2 to 4
hours,
depending on
how much
blood is
needed.

PRBC is indicated
for :to increase the
bloods ability to
transport oxygen
and carbon
dioxide

No allergic
reaction occurred

9am consumed
61

62

Nursing Responsibilities
Before :
Obtain blood from the blood bank, just before starting the transfusion.
Do not store the blood in the net on the nursing unit because lack of temperature control may damage the blood.
Prepare G- 18-20 IV needle or catheter for administering blood transfusion.
Use saline to prime the set and flush the needle before blood transfusion.
Double-check labels on the bags of blood that are about to be given to ensure the units are intended for that
recipient,
During:
Stay with the patient 15- 30 minutes for allergic reaction
The health care practitioner gives the blood to the recipient slowly, generally over 2 to 4 hours for each unit of
blood.
After:
Assess for allergic reaction
After that, a nurse checks on the recipient periodically and must stop the transfusion if an adverse reaction occurs.

MEDICAL
MANAGEMENT
/TREATMENT
PNSS

DATE
ORDERED:

GENERAL DESCRIPTION

Feb. 10, 2009 Plain normal saline

solution is a solution of

INDICATION OR
PURPOSE

Plain normal saline

solution (PNSS) is

CLIENTS
CLIENTS INITIAL
INITIAL
RESPONSE TO
REACTION TO
TREATMENT
TREATMENT
Well hydrated

Normal

63

Feb. 11, 2009 0.9% w/v of NaCl, about 300 used frequently in
mOsm/L. Physiological
intravenous drips (IVs)
Feb. 12, 2009 saline is 9g NaCl dissolved for patients who cannot
in 1 liter water. The mass of take fluids orally and
Feb. 13, 2009 1 milliliter of normal saline is have developed severe
1.009 grams. The molecular dehydration. Normal
Feb. 14, 2009 weight of sodium chloride is saline is typically the
approximately 58 g/mole, so first fluid used when
Feb. 15, 2009 58g NaCl is 1 mole. Since dehydration is severe
saline contains 9 grams
enough to threaten the
Feb. 16, 2009 NaCl, the concentration is adequacy of blood
9g/L divided by 58g/mole
circulation and is the
Feb. 17, 2009 =0.154
safest fluid to give
mole/L. Since NaCl
quickly in large
Feb. 18, 2009 dissociates into two ions volumes. It is also the
sodium and chloride 1
only solution
molar NaCl is 2 osmolar. It compatible with blood
contains 154 mEq/L of Na+ .
and Cl. It has a slightly
higher degree of osmolality
(i.e. more solute per liter)
compared to blood .

MEDICAL
MANAGEMENT
/TREATMENT
Oxygen
inhalation

DATE
ORDERED/PERFORMED/CHANGED
Date ordered:
02-10-09

1-2 lpm via

nasal cannula

Date discontinued:
02-11-09

GENERAL
DESCRIPTION

INDICATION OR
PURPOSE

Administration
of oxygen and
monitoring of its
effectiveness

To relieve difficulty
in breathing

CLIENTS INITIAL
RESPONSE TO
TREATMENT
difficulty in
breathing was
relieve

64

NURSING RESPONSIBILITIES
BEFORE
ASSESS
-Skin and mucous membrane. Note color whether there is cyanosis
-breathing patterns
-chest movements
-chest wall configuration
-lung sounds
DURING
-explain to the client the procedure
-wash hands and observe appropriate infection control
-provide client privacy
-set up the oxygen equipment and the humidifier
-turn on the oxygen: check if the oxygen is flowing freely, there should be no kinks and bubbles
-apply the appropriate oxygen delivery device
AFTER
-assess the clients vital sign, color, ease of respirations and provide support while the client is to the
adjusting of to the device
-assess the client in 15-30 minutes, depending on the clients condition and regularly thereafter
-assess the client regularly for sign of hypoxia, tachycardia, confusion, dyspnea, and restless
-check the liter flow and the level of water in humidifier in 30 minutes and whenever providing care to the
client
-make sure that safety precautions are followed
-document findings in the clients record

65

Name of Drug

Date ordered/, Route of Admin.

General Action,
Date taken/given,
& Dosage &
Mechanism of Action
Date changed
Frequency of
Admin.

Indications/
Purposes

Clients response to
Medicine with actual
Side Effect

66

Generic:
02-12-09
Acetaminophen
Brand:
Paracetamol

IVP, 300mg now Acetaminophen belongs Acetaminophen is Decrease in the clients

P.O 500mg after 4 to a class of drugs called used for the relief temperature noted.
hrs
analgesics (pain
of fever as well as
relievers) and
aches and pains
antipyretics (fever
associated with
reducers). The exact
many conditions.
mechanism of action of
acetaminophen is not
known.
Acetaminophen relieves
pain by elevating the
pain threshold, that is, by
requiring a greater
amount of pain to
develop before a person
feels it. It reduces fever
through its action on the
heat-regulating center of
the brain.

Nursing Responsibility:
Take this medication as directed.
Do not take more acetaminophen than recommended.
Do not use for more than 10 days without consulting your doctor.
This medication is not to be given to children under 3 years of age without your doctor's approval.

67

Ascorbic Acid
(water-soluble
vitamin)

Date
ordered:
Feb 12,
2009

Oral; 500mg once a

day

Vitamin
Stimulates
collagen
formation and
tissue repair
Involved in
oxidationreduction
reactions
throughout body
Raises vitamin C
level in the body

Recommended daily Able to tolerate. No

adverse reaction
allowance
Frank and subclinical noted
scurvy
Extensive burns
Delayed fracture or
wound healing
Postoperative wound
healing
Severe febrile or
chronic disease states
Prevention of vitamin
C deficiency in patients
with poor nutritional
habits or increased
requirements

Nursing Responsibilities:
Prior:
Explain the purpose of taking the medication and any side effects associated with the medication use
Assess patents condition before starting therapy
During
Monitor for adverse reactions and drug interactions
Administer the medication with the right dosage, route, and frequency.
If adverse GI reactions occur, monitor patients hydration
Stress proper nutritional habits to prevent recurrence of deficiency
Advise patient with vitamin C deficiency to decrease or stop smoking
After
Document all information after administration of the drug
Observe patient for any reactions.

68

NAMES
OF
DRUGS
(GENERIC
AND
BRAND
NAME)

DATE ORDERED/ ROUTE OF

DATE
ADMIN. &
TAKEN/GIVEN, DOSAGE &
DATE
FREQUENCY
CHANGED/D/C OF ADMIN.

Calcium
02-16-09
Gluconate

IVP 10 cc

GEN. ACTION, MECH. INDICATIONS/S

OF ACTION
PURPOSE/S

CLIENTS
RESPONSE TO MED.
W/ ACTUAL S/E

Replaces and maintains - Treatment of hypocalcemia calcium

in those conditions requiring
prompt increases in plasma
calcium
for
- Emergency cardio tonic
effect
- For blood transfusion

Nursing Responsibilities:
Assess patients calcium level before and ate therapy.
If hypercalcemia occurs, stop the drug and notify the physician.
Instruct patient to avoid foods containing Oxalic Acid, Phytic Acid, and Phosphorus because interactions may interfere
with calcium absorption.
After injection, make sure that the patient remains at recumbent position for 15 minutes.
Precipitate will form if the drug is given IV with sodium Bicarbonate or other alkaline drug. Use an in-line filter.

69

NAMES
OF
DRUGS
(GENERIC
AND
BRAND
NAME)

DATE ORDERED/ ROUTE OF

DATE
ADMIN. &
TAKEN/GIVEN, DOSAGE &
DATE
REQUENCY
CHANGED/D/C OF ADMIN.

Ferous
Sulate

02-12-09

GEN. ACTION, MECH.

OF ACTION

INDICATIONS/S
PURPOSE/S

Oral, 1 cap OD Provides elemental iron - iron deficiency

and essential component
in formation of
hemoglobin.

CLIENTS
RESPONSE TO MED.
W/ ACTUAL S/E

- able to tolerate the

medication.
- client experience
constipation

Nursing Responsibilities:
- Assess the patients iron deficiency before starting the therapy.
- Give tablets with juice or water.
- To avoid staining of teeth, give suspension with straw and place drops at the back of the throat.
- Dont crash or allow the patient to chew extended release forms.
- Give the drug in between meals, but if GI upset continues, give the patient foods except eggs, milk products, coffee, and
tea, which may impair absorption.
- Inform the patient that there will be discoloration in the stool.
- Encourage the patient to at fiber rich foods, such as string beans and pineapple juice.

70

NAMES
OF
DRUGS
(GENERIC
AND
BRAND
NAME)

DATE ORDERED/ ROUTE OF

DATE
ADMIN. &
TAKEN/GIVEN, DOSAGE &
DATE
REQUENCY
CHANGED/D/C OF ADMIN.

Folic Acid

02-16-09

GEN. ACTION, MECH.

OF ACTION

INDICATIONS/S
PURPOSE/S

CLIENTS
RESPONSE TO MED.
W/ ACTUAL S/E

Oral, 1 cap OD Stimulates normal

- Folic Acid is effective in the - able to tolerate the
erythropoiesis and
treatment of megaloblastic medication.
nucleoprotein synthesis. anemias due to a deficiency - no adverse reactions
of Folic Acid (as may be
noted.
seen in tropical or
nontropical sprue) and in
anemias of nutritional origin,
pregnancy, infancy, or
childhood.

Nursing Responsibilities:
- Assess Folic Acid deficiency before starting the therapy.
- Make sure that the patient is getting properly balanced diet.
- Tell patient to report hypersensitivity reactions like difficulty of breathing.
- Instruct the patient to avoid drinking and eating foods with alcohol because it increases folic acid requirements.
- Give vitamin B12 with this therapy if needed.

71

Type of Diet

Date Ordered

General description

Indication/
Purpose

Specific foods
taken

Diet as Tolerated

02-10-09

Patient can eat

whatever food he can
tolerate w/o specific
restrictions.

Ordered when Rice, vegetables,

the patients
meat
appetite, ability
to eat and
tolerance for
food is regained.

Clients Response
Client understands
the need to be in the
DAT diet. He is able
to tolerate the diet

Nursing Responsibilities:
> make sure that the client takes in a well balanced diet.

72

Blood
Chemistry

Date

Purpose

Purpose

BUN
Creatinine

02-13-09

BUN is made To asses for

up of urea,
electrolyte
which is an end imbalance.
product of the
metabolism of
protein by the
live
CREATININE is
end product of
muscle
metabolism.

Result

Normal values

Analysis

18.71
353-6

2.9-8.2 mmol/L
53-106mmol/L

Elevated BUN and

creatinine level
indicates decreased
kidney perfusion.

Nursing Responsibilities
Before
Explain the test procedure and the importance of the test.
During
Adhere to understand the precaution.
Apply pressure to the venipuncture site.
Explain that some bruising discomfort and swelling may appear at the site and that warm, moist compress can alleviate
this. Monitor for signs of infection.
After
Label the container and send to the laboratory.
Do hand washing after the test.

73

1. Nursing management (SOAPIE/R)

S
> fatigue and
shortness of
breath when
doing light
physical
activities like
eating,
urinating in bed
pan, oral and
body hygiene
and changing
clothes
> frequently
naps during
daytime for 1-2
hours

O
> confined to
bed most of the
time
> pt. depends
on assistance of
SO in
accomplishing
ADLs like
eating, urinating
in bed pan, oral
and body
hygiene and
changing
clothes
> appears
generally weak
> fingernails
and conjunctiva
pale
> tachycardia =
103 bpm
> tachypnea =
33 cpm
> low HB= 36 g/l
> low HCT=
0.17

A
Activity
intolerance
[Level III] r/t
imbalance
between
oxygen supply
and demand

P
After 1 hour
of daily
nursing
intervention,
client will
display a
gradual
progressive
tolerance of
physical
activity w/o
report of
chest pain
upon
exertion

I
1. Independent:
a. Limited activities and decrease
external stimulus.

E
Pt. displayed
gradual increase
in activity
tolerance as
b. Assisted patient to gradually
manifested by:
increase activity level. Started
a. increase in
from simple ADLs like combing
physical activity
hair, brushing teeth and eating.
tolerance from
Progressed to mild activity like
complete
active-assistive ROMs and then
dependence in
ambulating with assistance.
doing ADLs to
accomplishment
c. Recorded and documented
of simple tasks
pt.s VS before, during and after
like feeding,
activities and correlate with
urinating and
presence or absence of SOB.
defecating with
assistance
d. Instructed pt. to avoid activities b. absence of
which increase abdominal
SOB while doing
pressure. (e.g. straining during
daily activities
defecation)
c. improvement
of skin and nail
color,
d. decreased
capillary refill
time from 5
seconds to 4
seconds
d. increase in

74

independence
while doing tasks

S
> fatigue and
shortness of
breath when
doing light
physical
activities like
eating,
urinating in bed
pan, oral and
body hygiene
and changing
clothes
> general body
weakness
> shortness of
breath when
doing physical
activities like
standing up to
urinate and
changing
positions

O
> requires SOs
assistance
when
accomplishing
ADLs
> pale
conjunctiva, oral
and nasal
mucosa and
integument
> carpal and
tarsal clubbing
> hair growth on
fingers and toes
absent
> capillary refill
of 5 seconds in
fingernails, 4-5
seconds in
toenails
> tachycardia =
103 bpm
> tachypnea =

A
IneffectiveTiss
ue Perfusion:
Periperal r/t
decreased Hb
concentration
in blood

P
After 6
hours of
nursng
intervention,
the client will
display an
increase in
peripheral
tissue
perfusion.

I
1. Independent
a. Assisted client to semifowlers
position
b. Assisted client to do deep
breathing exercises
c. Provided and quiet
environment and provide comfort
measures.
c.1 Changed linens regularly.
c.2 Instructed SOs to minimize
talking with the pt.
c.3 Provided back massage as
needed.
c.4 Assisted pt. in doing guided
imagery and visualization
relaxation techniques

E
The pt. showed
improvement in
peripheral tissue
perfusion as
manifested by:
a. improvement
in capillary refill
(from 5 seconds
to 4 seconds)
b. verbalization of
improvement in
level of energy
c. improvement
in disposition
d. improvement
in skin color
e.improvement of
Hgb/Hct values

2. Collaborative
a. Assisted in obtaining specimen
for laboratory studies (Hb/Hct,
RBC count, ABG)

75

33 cpm
> low HB= 36 g/l
> low HCT=
0.17

b. Provided supplemental oxygen

as indicated.
c. Administered packed RBC
blood transfusion as indicated.

S
> Frequent
daytime naps
for 1-2 hours
> Feels that he
lacks energy
and is always
tired
> Has difficulty
in falling asleep
at night

O
> less than agenormed total for
7-8 hours night
time sleep
> lethargic
> irritable and
restless
> yawns
frequently
> weak in
appearance
> Frequent
conversations
from SO
> Interruption of
rest and sleep
due to
therapeutic and
monitoring
activities of

A
Disturbed
sleep pattern
r/t excessive
stimulation
from
environment

P
After 8 hours
of nursing
intervention
the client will
report an
improvement
in sleep/rest
pattern.

I
1. Independent:
a. Explained the necessity for
therapeutic and monitoring
procedures while the client is
hospitalized.
b. Restricted the intake of foods
and fluids rich in caffeine
c. Supported continuation of
usual bedtime rituals.
d. Increased interaction time
between pt. and SOs/staff during
day and reduce physical and
mental activities late in the day
and at night. Minimize
unnecessary disturbances during
hours of sleep at night.

E
Pt. reported an
improvement in
sleep/rest pattern
as manifested by:
a. verbalization of
increase in
energy
b. reduction of
yawning,
irritability and
restlessness
c. increase in
total time of
continuous,
uninterrupted
night time sleep
(from 4 hours to
7 hours)

76

health care
workers in
hospital

e. Provided comfort measures

e.1 provide evening snack if
available
e.2 hygiene (bed bath and oral
care)
e.3 provided massage and
back rub
e.4 provided clean and
comfortable bed
e.5 assisted pt. to wear
comfortable clothes
f. Reduced fluid intake in the
evening and advice client to
urinate/defecate before sleeping
if necessary.

S
> Hindi ako
mahilig kumain
ng prutas at
gulay.
> reports
difficulty in
eating d/t
weakness,
requires
assistance from
SO when
eating

O
> Eats only the
meat and rice of
the meal served
by the hospital
> Lost 10 kg.
since Feb.14,
2009
> weak and pale
in appearance

A
Imbalanced
nutrition: less
than body
requirements
r/t decrease in
appetite

P
After 8
hours of
proper
nursing
interventions
, the client
will maintain
an adequate
nutritional
status

I
> Monitor percentage of meals
and snacks client consumes.
Report a pattern of inadequate
intake.
> Performed or assisted with
anthropometric measurements
such as skinfold thickness, midupper arm circumference (MAC),
and mid-upper arm muscle
circumference (MAMC) if
indicated. Reported

E
After 8 hours of
proper nursing
interventions, the
client was able to
maintain an
adequate
nutritional status
as evidenced by:
a. identification
of nutritional
requirements

77

measurements lower than

normal.

b. consume
adequate
nourishment

> Implemented measures to

improve oral intake:
a. performed actions to relieve
gastrointestinal distention if
present
b. increased activity as allowed
and tolerated
c. maintained a clean
environment and a relaxed,
pleasant atmosphere
c. encouraged a rest period
before meals if indicated
d. provided oral hygiene before
meals
e. served foods/fluids that are
f. served frequent, small meals
rather than large ones if client is
weak, fatigues easily, and/or has
a poor appetite
g. if client is experiencing
dyspnea, placed him in a high
Fowlers position and provided
supplemental oxygen therapy
during meals if indicated
h. performed actions to
compensate for taste alterations
i. limited fluid intake with meals
unless the fluid has a high

78

nutritional value
> Ensured that meals are well
balanced and high in essential
nutrients such as foods rich in
iron. Offer dietary supplements if
indicated.
> administered vitamins and
minerals if ordered

S
> reports
fatigue

O
> mostly
confined in bed
> requires
assistance from
SO in

A
Self-care
deficit:
Bathing/Hygie

P
After 6 hours
of
appropriate
nursing
interventions

I
> Developed a bathing care plan
based on the clients own history
of bathing practices that
addresses skin needs, self-care
needs, client response to

E
After 6 hours of
appropriate
nursing
interventions, the
client was able

79

accomplishing
ne
r/t , the client
bathing, and equipment needs.
self-care
will be able
weakness and
hygiene
to:
> Planned activities to prevent
activities
tiredness
fatigue during bathing; seat with
> weak and pale
a. bathe
feet supported.
in appearance
with
> with foul body
assistance of
odor
caregiver or > Provided pain relief measures:
> limited
significant
ice packs, heat and analgesics
movements
others as
45 minutes before bathing.
needed and
b. remain
> Teached use of adaptive
free of body bathing equipment such as longodor and
handled brushes, washcloth mitt,
maintain
shower chair, etc.
intact skin
> provided privacy: have only
one caregiver providing bathing
assistance, encourage a trafficfree area and postprivacy signs.

to:
a. bathe with
assistance of
caregiver or
significant others
as needed and
b. remained free
of body odor and
maintain intact
skin

> Kept the client warmly covered.

> Used tepid water when
bathing.

B. EVALUATION
Patients daily program in the hospital.

80

Daily Program

02-13-09

Nursing Problems
1. Ineffective Tissue perfusion: Peripheral r/t
decreased hemoglobin concentration in blood

2. Activity Intolerance r/t imbalance between oxygen

supply delivery and demand

3. Disturbed sleep pattern r/t excessive stimulation

from environment

4. Imbalanced nutrition: less than body

requirements r/t decreased intake of essential
nutrients

02-14-09

02-15-09

02-16-09

02-17-09

02-18-09

RR: 23
PR: 87
BP:
100/70
T: 37.8
Hgb: 45
g/L
Hct:
0.097 L/L
RBC:
1.14 T/L
MCH:
39.5 pg

RR:25
PR: 87
BP:
100/70
T: 38.2

RR:30
PR: 88
BP:
100/70
T: 36.7
Hgb: 58
g/L
Hct:
0.152 L/L
RBC:
1.80T/L
MCH:
32.2 pg

RR: 30
PR: 88
BP:
110/70
T: 38.2

RR: 26
PR: 106
BP:
100/60
T: 38.8

5. Self-care deficit: Bathing/Hygiene r/t weakness

and tiredness
Vital signs

Diagnostic & Lab. Procedures

RR:35
PR: 94
BP:
110/80
T: 37.2
Hgb: 36
g/L
Hct: 0.87
L/L
RBC:
1.01 T/L
MCH:
35.6 pg

81

MHCH:
414 g/L

MHCH:
464 g/L

MHCH:
382 g/L

BUN: 2.98.2
mmol/L
Crea: 53106
mmol/L
Medical and Surgical Mgt.

Drugs
1. Ascorbic Acid
2. Calcium Gluconate
3. Fe SO4
4. Folic Acid
Diet

IVF:
PNSS @
30-31
gtts/min

IVF:
PNSS @
30-31
gtts/min

IVF:
PNSS @
30-31
gtts/min

BT: 1 u
PRBC

BT: 1 u
PRBC

DAT

DAT

DAT

IVF:
PNSS @
30-31
gtts/min

IVF:
PNSS @
30-31
gtts/min

IVF:
PNSS @
30-31
gtts/min

BT: 1 u
PRBC

BT: 1 u
PRBC

BT: 1 u
PRBC

DAT

DAT

DAT

82

83

METHOD
MEDICATIONS prescribed are as follows:
B-Complex

250 mg/cap OD

Vitamin C

500 mg tab/ OD

Ferrous Sulfate

1 cap OD

EXERCISE
-

the client was instructed by the physician to avoid strenuous activities,

wherein heavy exercise is also prohibited.

TREATMENT/TEST
-

the client was instructed to have a Hgb/Hct test a week after being
discharged.

HEALTH TEACHINGS
-

Encouraged not to hold the urge to urinate.

Encouraged the client to have a proper hygiene and do hand washing

properly before and after eating.

Taught the client some of the stress-coping strategies such as seeking

help from others, expressing his feelings assertively, to think positive
and always seek God for help.

Encouraged to take rest if he feels weak.

Instructed the family members of the patient to give emotional support.

Discussed the basic disease process of the condition of the patient to

his family embers.

Encouraged the client to stay away from the other people with illness
such as cough and colds, because he is immunosuppressed.

84

OPD/FOLLOW-UP CHECK-UPS
-

The client was instructed to have a follow-up check-up to the OPD

section of TPH after a week.

DIET
-

Instructed the client to eat foods rich in Iron, Vitamin C, Vitamin Bcomplex, Fiber and Protein.
Foods rich in Iron:
Liver
Deep green colored vegetables
Internal Organs
Milk
Foods rich in Vit. C
Citrus fruits like guavas and mangoes, and areavailable to the
season
Foods rich in B-complex, Fiber and Protein
Green leafy vegetables
Fruits
Meat
Fish

85

IV. RECOMMENDATION
The group recommends that the patient should have to do the following:

Encouraged not to hold the urge to urinate to prevent the occurence of

urinary tract retention and infection.

Encouraged the client to have a proper hygiene and to practice hand

washing before and after eating.

Taught the client some of the stress-coping strategies such as seeking

help from others, expressing his feelings assertively, to think positive
and always seek God for help.

Encouraged to take rest if he feels weak, to prevent the injury.

Instructed the family members of the patient to give emotional support,

to elevate self-esteem and sense of belongingness.

Discussed the basic disease process of the condition of the patient to

his family members for them to know what to do.

Encouraged the client to stay away from the other people with illness
such as cough and colds, because he is immunosuppressed.

V. BIBLIOGRAPHY
o Fundamentals of Nursing by Kozier et al.
o Fundamentals of Nursing by Daniels et al.
o Physical Assessment by Estes et al.
o Medical Surgical Nursing by Suddarth and Brunner et al.
o http://www.answers.com/topic/erectile-dysfunction#Pathophysiology
o http://www.answers.com/fever
o http://www.mayoclinic.com/health/water/NU00283

86

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