I.

BIOGRAPHIC DATA

Name: Patient X
Address: Km. 2 Indanan, Sulu
Gender: Female
Status: Single
Date of Birth: February 5, 1986
Birth place: Km. 2 Indanan, Sulu
Age: 20
Weight: 41 kg
Height: 5’ 1’’
Date of Admission: August 7, 2009 @ 4:50AM
Date of Discharge: August 9, 2009 @ 11:30 AM
Admitting Diagnosis:
To consider Aplastic Anemia; To consider Dysfunctional Uterine Bleeding
Final diagnosis: Aplastic anemia

II. NURSING HISTORY

a. PAST HEALTH HISTORY

Before the patient was admitted on the hospital, she was admitted
previously due to pneumonia. The patient was also experiencing simple
cough and colds. She had irregular menstrual cycles and episodes. Last
June 2009, the patient was experiencing dizziness associated with
decrease on level of consciousness episodes, associated with on and off
chest tightness and prolonged menstruation. Her menstruation last for 10
days, and she consumes 10 napkin a day with profuse vaginal bleeding.

b. HISTORY OF PRESENT ILLNESS

Last July 19, 2009 the patient started to have her menstruation, she
still consumes from 10 or more napkins daily. She describes it as heavy
flow and it lasted on July 25, 2009. But last August 6, 2009, she
experienced menses again, with same amount and condition. During her

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 menstruation, she was experiencing dizziness, as well as her level of
consciousness was affected. Her mother decided to go to the Hospital for
consultation. The patient condition upon arrival on the hospital was
ambulatory, pale in appearance, conscious and coherent. After the
assessment of the ROD to the patient, the admitting diagnosis was: To
consider Aplastic anemia; to consider Dysfunctional uterine bleeding. And
the patient was then referred to hematologist for the treatment.
Upon Admission, the Attending Physician assessed her and
ordered to be on a Reverse Isolation, and immediately asked to secure
Blood for immediate Blood transfusion since the platelet of the patient was
very low. The AP ordered to transfuse 5 unites of Platelet as soon as the
blood will be available. The patient was scheduled then for Bone Marrow
Aspiration on August 8, 2009. The patient was hooked to PNSS 1L to be
regulated at KVO. The Attending Physician prescribed medications and
ordered laboratory test like CBC, Platelet and for urinalysis. The patient
started to receive treatments and undergone BMA procedure.
On August 9, 2009, the patient was scheduled for discharge. Home
Medication was instructed to the patient.

c. FAMILY HISTORY
The patient has no history of any hereditary conditions, no known
allergy on foods or any drugs.

III. PATTERNS OF FUNCTIONING

a. PSYCHOLOGICAL HEALTH

i. Copping Patterns
Patient tries to cope up with her situation. The patient is anxious
with the procedure that she will undergone. She also expresses concern
about her friends. She tries to be as normal like her friends.

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ii. Interaction Patterns
She doesn’t have any problems relationship with any members of
her family. She’s close with her mother, experiences the proper care and
treatment from all of the members of the family. She’s the eldest among
the her brother’s and sisters. She has 2 sisters younger than the patient.

iii. Cognitive Patterns

No sensory deficits. She’s oriented with the time, place and person.
She’s responsive but fatigue. She responds appropriately to verbal and
physical stimuli. Her perception on her disease that it was just normal, at
first she thought a heavy flow of menstruation can be normal in any ways.
She thought that to experienced heavy menses meant that it would
cleanse her more. That’s why she didn’t pay attention with her menstrual
cycle.

iv. Self concept

She expresses concern with her disease as well as the expenses
that it may cost while she admitted. She was disturbed with her illness
especially when her menstruation occurs. She’s very disturbed of her
illness. Since she’s consuming 10 napkins daily. She felt uncomfortable,
especially if she’s on school. She’s also well groomed.

v. Emotional concept
She was so emotional while she was still admitted on the hospital,
because she feels so weak. Pale in appearance, and she continues to
experience heavy flow of menses.

vi. Family coping patterns

Good relationship with the parents. In fact, the mother insisted to
have her consulted to the doctor .

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 b. SOCIO-CULTURAL PATTERNS

i. Cultural patterns/significant relationships

She is a Muslim; that knows how to speak Tusug. They just don’t
eat pork.

ii. Recreation patterns

Loves to surf the net especially facebook. She Also loves to watch
television, and a fanatic of Twilight.

iii. Environment (hospital) Interpretation and analysis

During her stay, a Reverse Isolation was ordered by the AP. The
patient doesn’t have any idea what was really the concern of it. She
thought that she has this rare disease, or a complicated or an infectious
disease that others might also have. The Family members were given an
explanation how a reverse isolation must be, and the importance of
complying it. So the patients wears mask.

iv. Spiritual patterns

Strong belief on Allah, Kur-an seen on the bed.

IV. ADL
ADL Before During Interpretation/Analysis
Hospitalization Hospitalization
Nutrition Fund of eating junk Diet as tolerated To regain nutrition since
foods; the patient is weak due
Doesn’t eat too much to excessive blood loss
of vegetables, Loves to
eat sea foods
Elimination Normal BM a day; and Normal BM; profuse Normal elimination
UO vaginal bleeding pattern; Profused
vaginal bleeding due to
decrease in platelet
count
Exercise Sedentary lifestyleWeak, pale in Weak due to blood loss
appearance
Hygiene Bathing daily Sponge bathing Normal
Sleep and 5 – 8 hours of sleep a 6-8 hrs of sleep in a Normal
Rest day; day
Don’t take siestas

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 V. Physical Assessment
General Norms Actual Finding Interpretation/
Appearance Analysis
Posture/Gait Good posture Relaxed; correct body Normal
allignment
Skin Color Varies from light to Palor, eryhthema Anemia; heavy flow of
deep brown menstruation (10
napkins a day)
Personal Well groomed Clean and neat Normal
Hygiene/Grooming
Verbal Behavior Quantity/quality of Understandable; Normal
speech is in Exhibits thought
moderate pace association
Weight 41 kg Normal for age
Height 5’1 Normal for age

Body Part Norms Actual Finding Interpretation/Analysis

Hair Shiny; neither dry nor Brown in color; shiny Normal
oily and long
Face Rounded(normocepha Round shaped; Normal
lic); smooth skull symmetric facial
contour features; symmetric
facial movements
Eyebrows Hair evenly Hair evenly distributed Normal
distributed; skin intact
Eyelashes Equally distributed, Equally distributed Normal
curled slightly outward
Eyelids Skin intact; no No discharge; no Normal
discharge; no discoloration
discoloration
Conjunctiva Transparent; Pale Anemia; heavy flow of
capillaries sometime menstruation (10
evident; napkins a day); platelet
decrease
Sclera White Pale Anemia; heavy flow of
menstruation (10
napkins a day); platelet
decrease
Eye Both eyes Both eyes are Normal
Movement coordinated; move in coordinated
unison, with parallel
alignment
Ears Color same as facial Same as facial skin Normal
skin color
Ear Canal Distal third contains Ear cerumen dry Normal
hair follicles and

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 glands
Hearing Normal voice tones Normal voice tones; Normal
Acuity audible able to repeat
nonconsecutive
numbers
Nose Symmetric and Symmetric; no Normal
straight; no discharge discharges; uniform
or flaring; Uniform color
color
Mouth (lips) Uniform pink color; Pink in colot; soft moist Normal
Symmetry of contour; smooth
Soft, moist, smooth
texture
Gums Pink gums; Easily bleeds Anemia; decrease
platelet count
Tongue Central position; pink Pink in color; no lesions Normal
in color; moves freely;
no tenderness mucosa
intact with no lesion and
discoloration. Freely and
symmetrical mobile.
Neck Muscle equal in size; Head centers, Normal
head centered; coordinated movement
Neck ROM Coordinated, smooth Coordinated; no Normal
movements with no difficulty on moving the
discomfort nexk
Thorax/lungs Chest symmetric Normal thorax structures. Normal
Heart No pulsations No pulsation Normal
Abdomen Unblemished skin; Uniform color, no Normal
uniform color; lesions, audible bowel
Symmetric contour; sounds.
Audible bowel sounds;

Upper Norms Actual Finding Interpretation/

extremities Analysis
Arms Symmetrical; no Symmetrical,; good range Normal
redness or swelling, non of motion
tender without nodules.
Palms & Symmetrical, no Symmetrical, normal Normal
Dorsal swelling and structures.
Surface deformities.
Nails Convex curvature; Normal Structures; Normal
smooth texture; highly convex curvatures
vascular

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 VI. Laboratory
Date Procedure Norms Result Interpretation/Analysis
CBC, Platelet
Hemoglobin 120-160 g / L 120 Normal
Hematocrit 0.36 – 0.48 0.36 Normal
WBC 5.0 – 10.0 X10 3.8 Low-Viral infection; bone
8-7-09 g/L marrow depression
Lymphocyte 0.20 - 0.40 0.67 Viral Infection
Monocytes 0.01 – 0.06 0.10 Infection
Segmenters 0.50 – 0.70 0.65 Normal
Platelet 150-350X10g/L 130 Aplastic anemia;
URINALYSIS
Color yellow Yellow Normal
Transparency clear Hazy Pus Cells
Specific Gravity 1.005-1.030 1,020 Normal
Pus Cells Negative 2 – 5 / hpf UTI
RBC Negative TNTC Inflammation of kidney,
ureters, bladders
Epithelia 4-5 Few Infection
8-8-09 Bacteria Moderate
Protein Negative (+) Nephrosis,
glumerulonephritis , SLE
Sugar Negative Negative Normal
Reaction 4.5-8 6.0 Normal
Amorphous Few Few Normal
Urates
CBC, Platelet
Hemoglobin 120 – 160 g/L 103 Dehydration/excessive
blood loss
Hematocrit 0.36 – 0.48 0.31 Dehydration/excessive
blood loss
WBC 5.0 – 10.0 2.8 Low-Viral infection;; bone
X10g/L marrow depression/
inability of the stem cell to
reproduce blood
components
Lymphocyte 0.20 – 0.40 0.48 Viral Infection / inability of
the stem cell to reproduce
blood components
Monocytes 0.01 – 0.06 0.02 Normal
Segmenters 0.50 – 0.70 0.52 Normal
Eosinophils 0.01 – 0.05 0.01 Normal
Platelet 150-350X10g/L 160 Normal

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 VII. TREATMENT

a. IV Fluid
PNSS 1 L infused and regulated at KVO.
b. Procedure
Bone Marrow Aspiration (BMA) performed on August 8, 20099. It
started at 9:20 and ended at 9:35. Aseptic technique done, the AP used
2% Liddocaine over Left posterior, Iliac Crest. Then a core pressure
dressing done. This is the only Diagnostic procedure to diagnosed aplastic
anemia. BMA is the most common procedure for obtaining a bone marrow
sample. A small amount of bone marrow is removed during a bone
marrow aspiration. The procedure is uncomfortable, but can be tolerated
by both children and adults. The marrow can be studied to determine the
cause of anemia, the presence of leukemia or other malignancy, or the
presence of some "storage diseases" in which abnormal metabolic
products are stored in certain bone marrow cells.
c. Blood transfusion
5 units of platelet concentrate were transfused because of low platelet
count. This mat cause bleeding to the patient once BT will not be performed.
d. Medications

Drug Indication Contra- Side Effects Nursing

indication Responsibilities
Generic: Antihemmorhagi Hypersensit problems with Instruct patient to
Tranexamic c ive to the vision (including watch symptoms
Acid Antifibrinolytic drug and its color vision); of side effects.
drug sudden numbness
Classificatio component or weakness, Instruct patient to
n:
s especially on one let her
Antifibrinolytic
side of the body; accompany
Dosage/ sudden headache, when going on
Frequency: confusion, the bathroom.
500mg; TID problems with
for 7 days vision, speech, or
balance;
sudden chest pain
or trouble
breathing;

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 pain or swelling in
one or both legs;
or
urinating less than
usual or not at all.

Generic: Immuno- Hypersensit Euphoria; Instruct patient to

Prednisone suppression ive to insomnia; heart take it with full
drugs, and failure; stomach
Classificatio in those pancreatitis; Teach patient s/s
n:
receiving adrenal of adrenal
Corticosteroid
s
immunosup insufficiency insufficiency
pressive (fatigue, muscle
Dosage/ doses weakness, joint
Frequency: together pain, fever,
20 mg; BID with live anorexia)
(taken with virus
full stomach) vaccines
Generic: Frequent heart Hypersensit Headace, Tell patient to
Omeprazole burn; Block ive to drug abdominal pain, swallow
formation of back pain, rash tablets/capsules
Classificatio gastric acid whole and not to
n:
open,
Anti Ulcer
crush/chew
Dosage/ Instruct aeg to
Frequency: take drug 30 min
20 mg/ OD before meal
Generic: inhibition of first Hypersensit high blood Tell patient to
Cyclosporine phase of T-cell ive to drug, pressure, hirsutism avoid crowd
(Neoral) cultivates with T- (unusual growth of places (immune
lymphocyte hair), kidney system
Classificatio
(which normally damage, decreases);
n:
Immunusupre
stimulate excessive growth Maintain good
ssant antibody of the gums, and personal hygiene
production) tremor.
Dosage/
Frequency:
3 capsules ;
BID
Maintenance
for 6 months

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 VIII. ANATOMY

The term hematopoiesis refers to the formation and development of the cells of the
blood. In humans, this process begins in the yolk sac in the first weeks of embryonic
development. By the third month of gestation, stem cells migrate to the fetal liver and
then to the spleen (between 3-7 months gestation these two organs play a major
hempatopoietic role). Next, the bone marrow becomes the major hematopoietic organ
and hematopoiesis ceases in the liver and spleen. Every functional specialized mature
blood cell is derived from a common stem cell. These stem cells are therefore
Pluripotent. It has been estimated that there is approximately 1 stem cell per 10 4 bone
marrow cells. These stem cells represent a self-renewing population of cells. Initial
differentiation of pluripotent stem cells will be along one of two major pathways
( lymphoid or myeloid). Stem cells then become progenitor cells for each type of
mature blood cell. These cells have lost the capacity for self-renewal and are committed
to a given cell lineage. T&B progenitors, and progenitor cells for erythrocytes,
neutrophils, eosinophils, basophils, monocytes, mast cells, and platelets.

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 IX. PATHOPHYSIOLOGY

Aplastic Anemia occurs as a result of reduced bone marrow function and

causes a drop in levels of all blood elements. The number of pluripotent stem
cells appears to decrease, and the blood forming cells are not formed to mature.
Typically, anemia refers to low red blood cell counts, but aplastic anemia patients
have lower counts of all three blood cell types: red blood cells, white blood cells,
and platelets, termed pancytopenia.
 Caused by a decrease in or damage in precursor cells in the bone marrow
and replacement of bone marrow with fats.

Bone Marrow [ common stem cell]

Stem cell(affected)

Production of blood components will be altered

X. PRIORITIZED NURSING PROBLEM

Date Nursing Cues Justification

Diagnosis
Fluid volume Subjective Cues: Profused vaginal
deficit related to The patient verbalized “Twice a bleeding may lead to
profuse vaginal month ako nagmemenstruate.” hypovolemic shock, and
August bleeding Objective Cues: have a higher risk to get
7, 2009 - Packs of Sanitary Napkin an infection.
seen on bedside table Health teaching given:
- Pale in appearance - Reverse Isolation
- Cold, Clammy skin to touch - Do’s and Don’t’s
High risk for Subjective Cues: Patient on Reverse
infection related No Subjective cues isolation has a low WBC
to profuse Objective Cues: count. High risk to get an
August vaginal - Patient uses mask infection. Especially the
8, 2009 bleeding - Strict handwashing by patient doesn’t have the
secondary to the health personnel capability yet to produce
decrease WBC and the relatives done blood cells.
- Avoiding many visitors

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Black M. Joice, Hawks Hokanson Jane.

Medical Surgical Nursing: Clinical
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Missouri. 2005.

Bullock, Barbara, and Reet Henze. Focus

on Pathophysiology. Lippincot Willaims &
Wilkins. 2000.

Castro-Malaspina, Hugo, and Richard J.

O'Reilly. "Aplastic Anemia and
Myelodysplastic Syndromes." In Harrison's Principles of Internal Medicine, ed.
Anthony S. Fauci, et al. New York: McGraw-Hill, 1997.

Daniels, Rick. Laboratory and Diagnostic Tests. Thomson, Delmar Learning.

Ashlan Oregon. 2003.

Kozier, Barbara, and Glenora Erb, et al. Fundamentals of Nursing. Pearson

Education. 5th Edition. 2002.

Phipps J Wilma, Sands K Judith. Medical Surgical Nursing: concepts & clinical
practice. 6th edition. Philadelphia. Mosby publications. 1996.

http://wrongdiagnosis.com/h/hoyeraal_hreidarsson_syndrome/book-diseases-
20a.htm

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http://www.nhlbi.nih.gov/health/dci/Diseases/aplastic/aplastic_signsandsymptoms.h
tml

http://www.drugs.com/mtm/tranexamic-acid.html

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