A CASE STUDY ON ANEMIA

OF CHRONIC DISEASE |1

A CASE STUDY ON ANEMIA OF CHRONIC DISEASE

JAYSON G. BENIS

MARY ROSE S. DAMILO

HARIET P. DEPAYSO

KYRA S. DOKEY

VIA GRACE V. GUERRERO

KREANJEL LEI B. GUINTO

BLITZ O. KILONGAN

ELDRICK B. PILANDO

NICOLEEN M. SIBAYAN

AULYN B. TANACIO

HANNAH LHYNE O. TAYAB

KRISTA DEE D. WAGAWAG

BENGUET STATE UNIVERSITY

LA TRINIDAD, BENGUET

BACHELOR OF SCIENCE IN NURSING

NOVEMBER 2017
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TABLE OF CONTENTS

Title Page………………………………………………………………………………….1

Table of Contents…………………………………………………………………….……2

Acknowledgements……………………………………………………………….……….3

General Profile…………………………………………………………………………….4

Chief Complaint………………………………………………………………..….4

Prinicipal Diagnosis……………………………………………………………….4

History of Present Illness………………………………………………………….5

Past Medical History…………………………………………………………...….5

Social and Environmental History…………………………………...…………....5

Family History…………………………………………………………………….5

Physical Examination……..……………………………………………………………….6

Diagnostic and Laboratory Procedure…………………………………………………….9

Case Study……………………………….…….………………………………………...28

Medical Diagnosis……..………………………………………………………...28

Pathophysiology……………………………………………………………….....30

Treatment…………………………………………………………………….......31

Discharge Plan…………………………………………………………………………...37

Conclusions and Recommendations……………………………………………...……...38

Nursing Care Plan…………………………………………...…………………………...39

References……………………………………………………...………………………...44
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ACKNOWLEDGEMENTS

We, the Group F Level III nurse learners, would like to express our gratitude to
all the people who have seen us through this case study; to all those who provided
support, talked things over, read and offered comments and remarks in editing this case
study.

This case study wouldn’t be possible without the aid of the following:

To Mr.Dominador Abad Jr., for his long and unending patience to guide us in our
duty.

To Mrs.Ervina Luisa D. Campus, for her support and comments in editing this
case study.

To our parent and guardians who have always been supportive all throughout the
start of the duty until the end.

Lastly, to God, for giving us the strength and wisdom in realizing and fulfilling
our duties in the clinical area.
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GENERAL PROFILE

A. Personal Profile:
Name: Lourdes
Age: 28
Sex: Female
Marital Status: Single
Occupation: Call center agent
Address: Cuenca, Pugo, La Union
Educational Attainment: High School Graduate
Nationality: Filipino
Religious Affiliation: Roman Catholic
Date of Birth: December 17, 1988
Place of Birth: Pugo, La Union

B. Chief Complaint

Patient Lourdes, a 28 year old female, was brought by her sibling for consultation
at the hospital on September 9, 2017 due to complaint of body weakness.

C. Admitting Diagnosis

Anemia of Chronic Disease probably secondary to:

1) Blood dyscrasia
2) Chronic Gastrointestinal blood loss
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D. History of Present Illness

3 week prior to admission, the patient complained of dizziness without
associated easy fatigability, loss of consciousness, and chest pain. She also noted
of epigastric pain with burning sensations that is relieved by food intake. No
weight loss was noted. No consultation was done prior to admission. Few hours
prior to admission, the patient complained of dizziness which is not tolerable,
easy fatigability and pallor. She decided to seek consultation at the hospital, and
was admitted.

E. Past Medical History

The patient was hospitalized in January 2017 at Nigeria respectively due
to Malaria and Typhoid Fever. She was given the following medications:
Combisunate, Artesunate, and Azithromycin.

F. Social and Environmental History

Patient Lourdes, a 28 year old female, is a high school graduate of Cuenca
National High School. Their house is located at Cuenca, Pugo, La Union. The
patient lives with her family. To augment her family’s salary, she worked as a call
center agent in Nigeria for two years. While she was in Nigeria, she stayed at an
apartment with a friend. She described Nigeria as similar to the Philippines except
that Nigeria was a place with stagnant waters all around.

G. Family History
Patient Lourdes is the first of the three siblings and according to her, one
of her siblings was diagnosed with Dengue. She is not aware of any food and
medicine allergies. She mentioned that both her parents are diagnosed with
hypertension, and that her grandfather died of a liver disease.
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REVIEW OF SYSTEMS

Physical examination is a routine procedure that follows a methodological head to

toe format. This is done systematically using the technique of inspection, palpation,
percussion and auscultation with the use of materials and instruments such as penlight,
thermometer, stethoscope, sphygmomanometer, and also the senses. The group made
every effort to recognize and respect the patient’s feelings as wells as to provide comfort
measures and follow appropriate safety measures.

A. General Survey

Patient is a 28 year old female, stands 5’1 feet, with a weight of 60

kilograms. Upon observation, patient is oriented, speaks clearly, and not
confused. She also shows no signs of distress and readily responds to questions
asked. Initial vital signs taken on upon assessment are as follows:

BP: 110/90 mmHg PR: 113 bpm RR: 20 cpm

T: 37.3degrees Celsius SP02: 93%

A. HEENT (Head, Eyes, Nose, Throat)

Head

Head is round in shape. Hair is long, thin and evenly distributed. Scalp is
lighter in color than complexion, no scars, lice, or dandruff noted. No patches
were seen.

Eyes

Eyes are bilaterally equal, round in shape, dark brown in color, none
protruding, anicteric sclera, with palpebral conjunctiva and equal palpebral
fissure. Pupils constrict as seen using a penlight when diverted to light and dilates
when gazes afar. She can see clearly without use of corrective devices such as eye
glasses. Visible puffiness of the eye was noted.

Ears

Ears are clean, approximately of the same size and shape, symmetrical and
aligned to the eyes. No ear wax or discharge noted upon inspection. Patient can
normally hear using the Weber and Rinne test.
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Nose

Nose is found midline of the face, clean, with bilaterally equal nosetrils.
No discharge noted. The nasal mucosa is pinkish in color upon inspection. No
tenderness noted upon palpation of the paranasal sinuses.

Neck and Throat

Patient does not experience sore throat and difficulty in swallowing. She
also does not have hoarseness or speech difficulties and no lumps or masses were
observed. Oral mucosa and gingival are pink in color, moist, and no
inflammations nor lesions noted. Lymph noted. Patient is able to freely move her
neck back and forth, left and right.

B. Respiratory System

There is a full symmetrical expansion of the chest and the thumbs separate 2-3
cm during deep inspiration when assessing for the respiratory excursion.
Respiratory rate is within the range of 19-20 cycles per minute. Patient shows no
signs of orthopnea or shortness of breath. No reports of pain during inhalation and
exhalation. No crackles, wheezing or ronchi were noted. The patient manifested
quiet, rhythmic and effortless respirations.

C. Cardiovascular System

Patient does not experience chest pain nor palpitations. The average cardiac
rate of the patient is 100 beats per minute. The average blood pressure is 110/90
mmHg. Audible heart sound was auscultated. Point of maximum impulse was
heard between the 4th and 5th intercostal spaces. There were no visible pulsations
on the aortic and pulmonic areas. No heaves was noted.

D. Gastrointestinal System

The abdomen is not distended. Patient has episodes of vomiting with a

decreased appetite. Peristaltic sounds were present. 16-19 bowel sound per minute
was noted on the quadrants of the abdomen. No tenderness noted. Patient
defecates every other day.
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E. Genito-urinary System

Patient is able to void urine with a dark yellow, cloudy in character, and
moderate in amounts. No pain noted upon voiding. No lesions, discharges, nor
swelling noted. No bladder distension was felt upon palpation. There is a normal
hair distribution around the pubic area, with no presence of body lice.

F. Musculo-skeletal System

Fingers and toes are complete, symmetrical with no deformities. Patient’s

upper and lower extremities can be moved through active ROM. No difficulty in
ambulating and no redness, swelling and stiffness were observed. Muscles were
equal in size in both sides of the body. No edema on both extremities and crepitus
noted on joints.

G. Integumentary System

The patient’s skin is uniform in color, unblemished, with no presence of

any foul order. No presence of pallor and pale nail beds upon inspection, and
capillary refill took 2-3 seconds upon blanching. Normal turgor was noted. Nails
are short, clean, convex in shape and smooth in texture.

H. Mental Status Examination

Patient is alert, conscious, coherent and responsive to questions. Patient

speaks in a soft to moderate voice. She is able to follow simple instructions. She
doesn’t experience any strange thoughts, voices and visions. No difficulty in
recalling memory observed. She is oriented to the time, place, and people she is
interacting with. Reflexes such as blinking and deep tendon reflex were present.
The patient can properly hear; smell; read; follow a penlight in all directions;
move eyeballs down and laterally; identify location of touch on face; identify
blunt, light, and sharp sensations; move different parts of the face; move the
tongue from side to side and up to down; swallow; and move both upper and
lower extremities through active ROM.
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DIAGNOSTIC AND LABORATORY PROCEDURES

To obtain further data regarding the patient’s condition she was subjected to
different diagnostic and laboratory procedures where in blood and urine specimens were
obtained from the patient for analysis.

PROCEDURE DESCRIPTION RESULT

July 17, 2017 The ECG is graphic Sinus Tachycardia
ECG representation of the
electrical currents of the
heart.
Table 1.1 Electrocardiograph

Sinus tachycardia should be considered a physiological reflex rather than a true

dysrhythmia but it is an importance sign for which the etiology must be sought. Fever,
hypovolemia, and anemia all appropriately increase heart rate to at least maintain or
increase cardiac output.
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PROCEDURE DESCRIPTION RESULT REFERENCE

RANGE
September 4, 2017 This is a test that Hemoglobin: 85 Hemoglobin:
Complete Blood identifies the total M: 136-180 g/L
Count number of white and F: 126-160 g/L
red blood cells and Hematocrit: 0.25 Hematocrit:
platelets, and M: 0.04-0.54
measures F: 0.37-0.47
haemoglobin and RBC Count: 2.7 RBC Count:
hematocrit. M: 4.4-6.3 10^12 /L
F: 4.0-5.1 10 ^9/L
WBC Count: 4.4 WBC Count: 5.0-
10.0x/L
Neutrophils: 0.42 Neutrophils: 0.50-
Lymphocytes: 0.43 0.70
Monocytes: 0.13 Lymphocytes: 0.20-
Eosinophils: 0.02 0.40
Monocytes: 0.0-
Platelet Count: 154 0.07
ABO:B Eosinophils: 0.0-
Rh: Positive 0.05
Basophils: 0.0-0.01
Platelet Count: 150-
400x10/
Table 1.2 Complete Blood Count

The result of the CBC shows low haemoglobin with 85 g/L indicate anaemia,
recent hemmorhage, or fluid retention, causing hemodilutionand low haematocrit
suggests anaemia, hemodilution or massive blood loss. It shows also in the result with
low RBC that may indicate anaemia, fluid overload, or haemorrhage beyond 24 hours.
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Low RBC values are caused by many factors such as: haemorrhage ( as in
gastrointestinal bleeding or trauma and it shows in the diagnosis of the patient with
chronic GI blood loss), hemolysis (as in glucose-6-phosphatedehydrogenase (G6PD)
deficiency, spherocytosis, or secondary splenomegaly, in the result of the ultrasound of
the patient shows mild splenomegaly), dietary deficiency(as of iron or vitamin B12)
and others. CBC shows decreased total of WBC (leukopenia) occurs in many forms of
bone marrow failure.

PROCEDURE DESCRIPTION RESULT REFERENCE

RANGE
September 6, 2017 This is the study of Hemoglobin massc. Male: 120-170 g/L
Hematology blood and blood- 79 g/L Female: 110-150
forming tissues. Leukocyte g/L
numc.4.1 x 109/L
Table 1.3 Hematology

The result of the test shows low haemoglobin mass concentration may determine
the presence of anemia, which is functionally defined as insufficient Red blood cell
(RBC) mass to adequately deliver oxygen to peripheral tissues.

PROCEDURE DESCRIPTION RESULT

September 6, 2017 The anatomic and The lung fields are clear
X-Ray appearance of the lungs. with normal vascular
shadows.
The heart, great vessels and
diaphragm are
unremarkable.
Bony ribs are intact.
Table 1.4 Chest X-Ray

Appearance of the lungs and heart.

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PROCEDURE DESCRIPTION RESULT REFERENCE

RANGE
September 6, 2017 This measures the PT 11.3 seconds PT=9.5-12 sec
Prothrombin Time extrinsic pathway (10-15 seconds)
activity and is used
to monitor the level
of anticoagulation.
Table 1.5 Prothrombin time

PROCEDURE DESCRIPTION RESULT REFERENCE

RANGE
September 6, 2017 Thyroid hormone TSH 6.14 ( 20-54 TSH: 6.14
Thyroid Test tests are blood tests y/o: 0.4-4.2 FT4: 1.7
that check how well ulU/mL)
the thyroid gland is
working.
Table 1.6 Thyroid Test
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PROCEDURE DESCRIPTION RESULT REFERENCE

RANGE
September 7, The test used to look Neutrophils = 66% Neutrophils=55%-
2017 for abnormalities in 70%
Peripheral the blood. Lymphocytes=22% Lymphocytes=20%-
Blood Smear Specifically, it 40%
provides information Monocytes=5% Monocytes=2-8%
on the number and Eosinophils=5%
shape of thecells. Bands=1% Eosinophils=1-4%
Metamyelocytes=1%
Table 1.7 Peripheral Blood Smear
Peripheral blood smears show red blood cells with mild hypochromia and moderate
anisopoikilocytosis (microcytes +++; ovalocytes +). The white blood cell count is
adequate in number for age group in the range of 4-6 x 109/L with the predominance of
neutrophils. The platelet count is adequate in number in the range of 160-190 x 109/L.

PROCEDURE DESCRIPTION RESULT REFERENCE

RANGE
September 7, 2017 A laboratory test that Reticulocyte count: 0.5-1.5%
Erythrocyte measures the rate of 0.70%
Sedimentation Rate/ settling of red blood
Reticulocyte Count cells; elevation is
indicative of
inflammation; also
called the sed rate.
Table 1.8 Erythrocyte Sedimentation Rate/ Reticulocyte Count
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PROCEDURE DESCRIPTION RESULT

September 7, 2017 Imaging method using Impression:
Ultrasound high-frequency sound 1. Mild Splenomegaly
waves to diagnose whether 2. Sonographically
masses are solid or fluid normal liver,
filled. gallbladder, pancreas,
kidneys and urinary
bladder.

Table 1.9 Ultrasound

The spleen enlarges as it performs its normal functions. Because the major function of the
spleen are inclearance of microorganisms and particulate antigens from the blood
stream,synthesis of immunoglobulin G (IgG), properdin (an essential component of the
alternate pathway of complement activation), and tuftsin (an immunostimulatory
tetrapeptide),removal of abnormal red blood cells (RBCs) and extramedullary
hematopoiesis in certain diseases.

PROCEDURE DESCRIPTION RESULT

September 7, 2017 The study of parasites, their Occult Blood:
Parasitology hosts, and the relationship LUMIQUICK (Result:
between them. Positive)

Table 1.10 Parasitology

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PROCEDURE DESCRIPTION RESULT REFERENCE

RANGE
September 7, 2017 The hemoglobin A1c HgbA1C: 4.3 (4.5 HgbA1C: 4.5-6.5%
HgbA1C test tells you your -6.5%)
average level
of bloodsugarover the
past 2 to 3
months. Further, this
test measures how
much glucose is
bound to the
Hemoglobin.
Table 1.11 Hemoglobin A1c Test

PROCEDURE DESCRIPTION RESULT

September 7, 2017 Antibody tests are done to find NEGATIVE
Coomb’s Test (Antibody certain antibodies that attack
Tests) red blood cells. Antibodies are
proteins made by the immune
system. Normally, antibodies
bind to foreign substances, such
as bacteria and viruses, and
cause them to be destroyed.
Table 1.12 Coomb’s test
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PROCEDURE DESCRIPTION RESULT

09/07/17 23:40 Urinalysis is a set of Physical Examination:
Urinalysis screening test that can Dark Yellow, Turbid
detect some common Chemical Examination
diseases. It may be used or Specific gravity:1.010
help diagnose condition pH: 6.0
such as a urinary tract Leukocyte Esterase:
infection, kidney disorders, Positive 2
liver problems, diabetes or Nitrates: Negative
other metabolic conditions. Protein: Negative
Microscopic Examination
Pus cells: 10-15/hpf
Red Blood Cells: 0-2/hpf
Yeast Cells: None
Bacteria: Few
Epithelial Cells: Moderate
Mucus threads: Few
Amorphous Materials: Few
Table 1.13 Urinalysis
Urinalysis shows low pH indicates a high protein diet – produces turbidity, and
formation of oxalate, cysteine, leusine, tyrosine, amorphous urate, and uric acid crystal.
Turbid indicates that urine may contain red or white blood cells, bacteria, fat or chyle,
and may reflect renal infection. Fixed specific gravity, in which values remain 1.010
regardless of fluid intake, occurs in chronic glomerulonephritis with severe renal damage.
Bacteria, yeast cells and parasites in urinary sediment reflect genitourinary tract infection
or contamination of external genitalia.
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PROCEDURE DESCRIPTION RESULT

September 8, 2017 A blood typing is a method Crossmatched Blood- 3
Crossmatching to tell what type of blood phases
and to identify genetic Major Crossmatch:
disorders. It is also done to Compatible
test if you have a substance Minor Crossmacth:
called Rh factors on the Compatible
surface of the red blood Fully screened Blood
cells.
Table1.14 Crossmatching
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PROCEDURE DESCRIPTION RESULT REFERENCE

RANGE
September 8, 2017 This is a test that Hemoglobin: 70 Hemoglobin: 120-
Complete Blood evaluates the cell 160g/L
Count that circulates in the Hematocrit: 0.22 Hematocrit: 0.37-
blood. 0.47L/L
WBC Count: 4.46 WBC Count: 5.0-
Neutrophils: 0.62 10.0
Neutrophils: 0.50-
0.70%
Lymphocytes: 0.24 Lymphocytes: 0.20-
0.40%
Monocytes: 0.08 Monocytes: 0.0-
0.10%
Eosinophils: 0.06 Eosinophils: 0.0-
0.07%
Basophils: 0.00 Basophils: 0.0-
0.01%
RBC count: 2.42 RBC count: 4.04-
5.58 10^12/L
Platelet count: 155 Platelet count: 150-
400 10^9/L
RBC Indices RBC Indices
MCV: 90.91 MCV: 80-100 fL
MCH: 28.93 MCH: 27-31 pg
MCHC: 318.20 MCHC: 310-360
RDW-CV: 19.20 g/L
RDW-SH: 56.30 RDW-CV: 11-16%
RDW-SH: 35-56fL
Table1.15 Complete Blood Count
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The result of the CBC shows low haemoglobin with 85 g/L which may indicate
anaemia, recent hemmorhage, or fluid retention, causing hemodilution and low
haematocrit suggests anaemia, hemodilution or massive blood loss. It shows also in the
result with low RBC that may indicate anaemia, fluid overload, or haemorrhage beyond
24 hours. Low RBC values are caused by many factors such as: haemorrhage ( as in
gastrointestinal bleeding or trauma and it shows in the diagnosis of the patient with
chronic GI blood loss), hemolysis (as in glucose-6-phosphatedehydrogenase (G6PD)
deficiency, spherocytosis, or secondary splenomegaly, in the result of the ultrasound of
the patient shows mild splenomegaly), dietary deficiency(as of iron or vitamin B12)
and others. CBC shows decreased total of WBC (leukopenia) occurs in many forms of
bone marrow failure. In the RBC Indices increase in RDW-CV and RDW-SH may
indicate greater variation in size of the cell.

PROCEDURE DESCRIPTION RESULT REFERENCE

RANGE
September 9, 2017 This is a test that Hemoglobin: 85 Hemoglobin: 120-
Complete Blood evaluates the cell 160g/L
Count that circulates in the Hematocrit: 0.26 Hematocrit: 0.37-
blood. 0.47L/L
WBC Count: 4.79 WBC Count: 5.0-
Neutrophils: 0.63 10.0
Neutrophils: 0.50-
Lymphocytes: 0.30 0.70%
Lymphocytes: 0.20-
Monocytes: 0.02 0.40%
Monocytes: 0.0-
Eosinophils: 0.02 0.10%

Basophils: 0.00 Eosinophils: 0.0-

Immature Cells: 0.07%
0.02
Reactive Basophils: 0.0-
Lymphocytes: 0.01 0.01%
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RBC count: 2.95 RBC count: 4.04-

5.58 10^12/L
Platelet count: 122 Platelet count: 150-
400 10^9/L
RBC Indices RBC Indices
MCV: 87.80 MCV: 80-100 fL
MCH: 28.80 MCH: 27-31 pg
MCHC: 328.00 MCHC: 310-360
RDW-CV: 17.90 g/L
RDW-SH: 51.40 RDW-CV: 11-16%
RDW-SH: 35-56fL
Table 1.16 Complete Blood Count
The result of the CBC shows low haemoglobin with 85 g/L indicate anaemia, recent
hemmorhage, or fluid retention, causing hemodilution and low haematocrit suggests
anaemia, hemodilution or massive blood loss. It shows also in the result with low RBC
that may indicate anaemia, fluid overload, or haemorrhage beyond 24 hours. Low RBC
values are caused by many factors such as: haemorrhage ( as in gastrointestinal
bleeding or trauma and it shows in the diagnosis of the patient with chronic GI blood
loss), hemolysis (as in glucose-6-phosphatedehydrogenase (G6PD) deficiency,
spherocytosis, or secondary splenomegaly, in the result of the ultrasound of the patient
shows mild splenomegaly), dietary deficiency(as of iron or vitamin B12) and others.
CBC shows decreased total of WBC (leukopenia) occurs in many forms of bone marrow
failure. With low platelet count indicate (thromobocytopenia) can result from aplastic or
hypoplastic bone marrow; infiltrative bone marrow disease, such as carcinoma;
leukaemia, or disseminated infection; megakaryocytic hypoplasia; ineffective
thrombopoiesis due to folic acid or vitamin B12 deficiency; pooling of platelets in an
enlarged spleen; increased platelet destruction due to drugs or immune disorders;
disseminated intravascular coagulation; Bernard-soulier syndrome or mechanical injury
to platelets.
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PROCEDURE DESCRIPTION RESULT

September 9, 2017 A blood typing is a method Crossmatched Blood- 3
Crossmatching to tell what type of blood phases
and to identify genetic Major Crossmatch:
disorders. It is also done to Compatible
test if you have a substance Minor Crossmacth:
called Rh factors on the Compatible
surface of the red blood Fully screened Blood
cells.
Table 1.17 Crossmatching
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PROCEDURE DESCRIPTION RESULT VERBAL

INTERPRETATION
September 10, 2017 This is a test that Hemoglobin: 113 Hemoglobin: 120-
Complete Blood evaluates the cell 160g/L
Count that circulates in the Hematocrit: 0.35 Hematocrit: 0.37-
blood. 0.47L/L
WBC Count: 4.56 WBC Count: 5.0-10.0
Neutrophils: 0.50-
Neutrophils: 0.64 0.70%
Lymphocytes: 0.20-
Lymphocytes: 0.27 0.40%
Monocytes: 0.0-
Monocytes: 0.07 0.10%
Eosinophils: 0.0-
Eosinophils: 0.00 0.07%
Basophils: 0.0-0.01%
Basophils: 0.00
Immature Cells:
0.01
Reactive RBC count: 4.04-5.58
Lymphocytes: 0.01 10^12/L
RBC count: 3.91 Platelet count: 150-
400 10^9/L
Platelet count: 132 RBC Indices
MCV: 80-100 fL
RBC Indices MCH: 27-31 pg
MCV: 89.50 MCHC: 310-360 g/L
MCH: 28.90 RDW-CV: 11-16%
MCHC: 323.00 RDW-SH: 35-56fL
RDW-CV: 18.20
RDW-SH: 53.90
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Table 1.18 Complete Blood Count

The result of the CBC shows low haemoglobin with 85 g/L indicate anaemia, recent
hemmorhage, or fluid retention, causing hemodilution and low haematocrit suggests
anaemia, hemodilution or massive blood loss. It shows also in the result with low RBC
that may indicate anaemia, fluid overload, or haemorrhage beyond 24 hours. Low RBC
values are caused by many factors such as: haemorrhage ( as in gastrointestinal
bleeding or trauma and it shows in the diagnosis of the patient with chronic GI blood
loss), hemolysis (as in glucose-6-phosphatedehydrogenase (G6PD) deficiency,
spherocytosis, or secondary splenomegaly, in the result of the ultrasound of the patient
shows mild splenomegaly), dietary deficiency(as of iron or vitamin B12) and others.
CBC shows decreased total of WBC (leukopenia) occurs in many forms of bone marrow
failure. With low platelet count indicate (thromobocytopenia) can result from aplastic or
hypoplastic bone marrow; infiltrative bone marrow disease, such as carcinoma;
leukaemia, or disseminated infection; megakaryocytic hypoplasia; ineffective
thrombopoiesis due to folic acid or vitamin B12 deficiency; pooling of platelets in an
enlarged spleen; increased platelet destruction due to drugs or immune disorders;
disseminated intravascular coagulation; Bernard-soulier syndrome; or mechanical injury
to platelets. In the RBC Indices increase in RDW-CV may indicate greater variation in
size of the cell.
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PROCEDURE DESCRIPTION RESULT

September 10, 2017 Urinalysis is a set of Physical Examination:
Urinalysis screening test that can detect Dark Yellow, Slightly Turbid
some common diseases. It
Chemical Examination
may be used or help diagnose
condition such as a urinary Specific gravity: 1.010
tract infection, kidney pH: 6.0
disorders, liverproblems, Leukocyte Esterase: Trace
diabetes or other metabolic
Nitrates: Negative
conditions.
Protein: Negative

Microscopic Examination

Pus cells: 2-4/hpf

Red Blood Cells: 4-6/hpf

Yeast Cells: None

Bacteria: Few

Epithelial Cells: Many

Mucus threads: None

Amorphous Materials: Few

Table 1.19 Urinalysis
Urinalysis shows low pH indicates a high protein diet – produces turbidity, and formation
of oxalate, cysteine, leusine, tyrosine, amorphous urate, and uric acid crystal. Urine
shows slightly turbid, turbid indicates that urine may contain red or white blood cells,
bacteria, fat or chyle, and may reflect renal infection.Fixed specific gravity, in which
values remain 1.010 regardless of fluid intake, occurs in chronic glomerulonephritis with
severe renal damage. Bacteria, yeast cells and parasites in urinary sediment reflect
genitourinary tract infection or contamination of external genitalia.

.
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PROCEDURE DESCRIPTION RESULT REFERENCE

RANGE
September 11, 2017 Routine chemistry LDH 592 U/L (R- LDH: 81-234
Routine Chemistry test is a blood test 81-234)
that measures the
level of several
substances in blood,
and to assess the
general health status
of the client.
Table 1.20 Routine Chemistry
High levels of LDH indicate some form of tissue damage. High levels of more
than one isoenzyme may indicate more than one cause of tissue damage.
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PROCEDURE DESCRIPTION RESULT REFERENCE

RANGE
September 13, 2017 This is a test that Hemoglobin: 81 Hemoglobin: 120-
Complete Blood evaluates the cell 160g/L
Count that circulates in the Hematocrit: 0.26 Hematocrit: 0.37-
blood. 0.47L/L
WBC Count: 3.83 WBC Count: 5.0-
10.0
Neutrophils: 0.65 Neutrophils: 0.50-
0.70%
Lymphocytes: 0.24 Lymphocytes: 0.20-
0.40%
Monocytes: 0.10 Monocytes: 0.0-
0.10%
Eosinophils: 0.01 Eosinophils: 0.0-
0.07%
Basophils: 0.00 Basophils: 0.0-
0.01%
RBC count: 2.88 RBC count: 4.04-
5.58 10^12/L
Platelet count: 125 Platelet count: 150-
400 10^9/L
RBC Indices RBC Indices
MCV: 88.90 MCV: 80-100 fL
MCH: 28.10 MCH: 27-31 pg
MCHC: 316.00 MCHC: 310-360
RDW-CV: 19.00 g/L
RDW-SH: 59.40 RDW-CV: 11-16%
RDW-SH: 35-56fL
Table 1.21 Complete Blood Count
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The result of the CBC shows low hemoglobin with 85 g/L indicate anaemia,
recent hemmorhage, or fluid retention, causing hemodilution and low haematocrit
suggests anaemia, hemodilution or massive blood loss. It shows also in the result with
low RBC that may indicate anaemia, fluid overload, or haemorrhage beyond 24 hours.
Low RBC values are caused by many factors such as: haemorrhage ( as in
gastrointestinal bleeding or trauma and it shows in the diagnosis of the patient with
chronic GI blood loss), hemolysis (as in glucose-6-phosphatedehydrogenase (G6PD)
deficiency, spherocytosis, or secondary splenomegaly, in the result of the ultrasound of
the patient shows mild splenomegaly), dietary deficiency(as of iron or vitamin B12)
and others. CBC shows decreased total of WBC (leukopenia) occurs in manyforms of
bone marrow failure. With low platelet count indicate (thromobocytopenia) can result
from aplastic or hypoplastic bone marrow; infiltrative bone marrow disease, such as
carcinoma; leukaemia, or disseminated infection; megakaryocytic hypoplasia; ineffective
thrombopoiesis due to folic acid or vitamin B12 deficiency; pooling of platelets in an
enlarged spleen; increased platelet destruction due to drugs or immune disorders;
disseminated intravascular coagulation; Bernard-soulier syndrome; or mechanical injury
to platelets.
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CASE STUDY

This section discusses the medical diagnosis that includes the description of the
patient’s case, and the pathophysiology which reviews the conditions typically observed
during a disease state and processes or mechanisms within an organism, and treatments
administered to address the conditions

Medical Diagnosis

Anemia of Chronic Disease probably secondary to blood dyscrsia and chronic G.I
bleeding

Anemia of Chronic Disease

Anemia of chronic disease is immune driven; cytokines and cells of the

reticuloendothelial system induce changes in iron homeostasis, the proliferation of
erythroid progenitor cells, and the production of erythropoietin, and the life span of red
cells, all of which contribute to the pathogenesis of anemia. Bleeding episodes, vitamin
deficiencies, hypersplenism, renal dysfunction, and chemotherapeutic interventions
themselves can also aggravate anemia.

A hallmark of anemia of chronic disease is the development of disturbances of

iron homeostasis, with increased uptake and retention of iron within cells of the
reticuloendothelial system.

Signs & Symptoms

Anemia of chronic disease varies in severity from one person to another. In most
cases, anemia is usually mild or moderate. Affected individuals may develop a variety of
symptoms such as fatigue, paleness of the skin (pallor), lightheadedness, shortness of
breath, a fast heartbeat, irritability, chest pain and additional findings. These symptoms
may occur in any individual who has a comparable degree of anemia. In most cases, the
symptoms associated with the underlying disease usually take precedent over the mild or
moderate anemia symptoms.

Precipitating Factors
Malaria

The major mechanisms are those of red cell destruction and decreased red cell
production. Potential causes of haemolysis include loss of infected cells by rupture or
phagocytosis, removal of uninfected cells due to antibody sensitization or other
physicochemical membrane changes, and increased reticuloendothelial activity,
particularly in organs such as the spleen.

Diet
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Iron is required for the production of red blood cells, a process known as
haematopoiesis.Without enough iron in the body the production of red blood cells is
decreased than the normal production.

Predisposing Factors

1. Gastrointestinal Bleeding

Losing blood is losing red blood cells, which contain the substance
hemoglobin that carries life-giving oxygen. A deficiency of hemoglobin leads to a
lack of sufficient oxygen to the organs and other tissues.

2. Blood Dyscrasia

Blood Dyscrasias is a condition which occurs when one part of the blood is
not present in the normal supply and it is usually referred to as a blood disorder. This
condition may occur when different constituents of blood like white blood or red
blood cells and platelets are either high or too low in counts. The condition of blood
dyscrasias mainly occurs when there is an abnormal function of blood and its
components.

The precipitating and predisposing factors will activate the reticuloendothelial

system.Reticuloendothelial system a network of cells and tissues found throughout th
e body, especially in the blood, generalconnective tissue, spleen, liver, lungs, bone ma
rrow, and lymph nodes.

These cells are concerned withblood cell formation and destruction, storageof
fatty materials, and metabolism of iron and pigment, and they play a role in inflamma
tion and immunity. There may be slightly shortened RBC survival, thought to be due
to release of inflammatory cytokines,.Erythropoiesis is impaired because of decreases
in both erythropoietin (EPO) production and marrow responsiveness to EPO.Iron
metabolism is altered due to an increase in hepcidin, which inhibits iron absorption
and recycling, leading to iron sequestration. Due to change of erythropoietin
production, the number of matured red blood cells that carries oxygen which
circulates in the body is decreased, thus alters the oxygen supply to the different
organs of the body results to poor tissue perfusion. Consequently, the following
manifestations were observed; mild splenomegaly, chest pain, dizziness, and pallor.
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ANEMIA OF CHRONIC DISEASE

Predisposing factors: Precipitating factors:

Bone Marrow
 Hx of Malaria  GI bleeding
Suspension
 Diet  Blood Dyscrasia

Activation of the
reticuloendothelial Cytokines triggers changes in intracellular iron
system metabloism

Reduced effect of serum erythropoietein

Reduced tissue perfusion

Mild splenomegaly, chest pain, dizinnes, pallor

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Treatment

This section shows the treatment given to patient Lourdes. This includes the
drugs, intravenous fluids, and blood transfusion with the description, purpose and nursing
intervention of each treatment given.

DRUG DESCRIPTION AND NURSING INTERVENTION

PURPOSE
FeSO4 + FA 1 tab BID This medication is used to 1. Caution partient to make
Date and time ordered: prevent or treat iron position changes slowly to
September 7, 2017 deficiency; used in anemia due minimize orthostatic
7:00PM to blood loss during hypotension.
menstruation, infections, 2. Take ferrous sulfate and
surgery, delivery, intoxications folic acid.
or other causes of anemia. 3. Avoid taking antacids or
antibiotic.
4. Use this medication exactly
as directed.
5. Do not use it in larger
amounts
Table1. Ferrous Sulphate + Folic Acid

The patient Lourdes had blood extraction and subjected for complete blood
count. The result shows 2.95/L compared to the normal values of (4.04-5.48 10^12/L)
that signifies a decrease in red blood cells thus given ferrous sulphate plus folic
acid.Ferrous sulfate and folic acid is used to treat iron deficiency anemia. This
medication is necessary for the formation and function of red blood cells and helps
thebody to produce and maintain new cells, and also helps prevent changes to DNA that
may lead to cancer.
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DRUG DESCRIPTION AND NURSING

PURPOSE
Omeprazole 40g/cap OD Omeprazole is a proton
a.c. breakfast pump inhibitor (PPI). It
Date and Time Ordered: works by decreasing the
September 7, 2017 amount of acid produced by
the stomach. This drug is
used to treat certain
conditions where there is
too much acid in the
stomach. It is used to treat
gastric and duodenal ulcers,
erosive esophagitis, and
gastroesophageal reflux
disease (GERD). In
addition, omeprazole is
used in combination with
antibiotics (eg, amoxicillin,
clarithromycin) to treat
ulcers associated with
infection caused by the H.
pylori bacteria (germ).
INTERVENTION
1.Assess patient routinely
for epigastric or abdominal
pain and frank or occult
blood in the stool, emesis,
or gastric aspirate.
2.Capsule should be
swallowed whole; do not
crush.
3.Advise patient to:
a.Report onset of black,
tarry stools; diarrhea;
abdominal pain; or
persistent headache to
health care professional
promptly.
b.Report any changes
in urinary elimination such
as pain or discomfort
associated with urination, or
blood in urine.

4. Monitor urinalysis for

hematuria and proteinuria.
Table 2. Omeprazole

Prior to admission, patient Lourdes had symptoms of epigastic pain, with burning
sensation and relived through food intake. This are manifestations of gastric ulcer.
Further tests are done which includes occult blood with a positive result. Complete blood
count is also done which indicated a decrease red blood cells, hematocrit and
hemoglobin.

Patients admitted to the hospital with GI bleeding are typically treated with a
proton pump inhibitor (PPI). This will be started empirically on an intravenous (IV) PPI
(eg, omeprazole 40 mg IV twice daily). It can be started at presentation and continued
until confirmation of the cause of bleeding. ( Coll 2010)
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Drug Description and Purpose
Ampicillin-Sulbactan 1.5g This drug is given for the
IV q6○ x 7 days treatment of infections due
Date and Time Ordered: to susceptible organisms in
September 7, 2017 skin and skin structures,
7:00PM intraabdominal infections,
and gynecologic infections.
Sulbactan makes the
ampicillin more effective by
inhibiting beta-lactamases
Table 3. Ampicillin-Sulbactam
Nursing Interventions
1.Determine previous
hypersensitivity reactions to
penicillins, cephalosporins,
and other allergens prior to
therapy.
2. Lab tests: Baseline C&S
tests prior to initiation of
therapy; start drug pending
results.
3.Report promptly
unexplained bleeding (e.g.,
epistaxis, purpura,
ecchymoses).
4.Monitor patient carefully
during the first 30 min after
initiation of IV therapy for
signs of hypersensitivity and
anaphylactoid reaction.
Serious anaphylactoid
reactions require immediate
use of emergency drugs and
airway management.
5.Observe for and report
symptoms of
superinfections (see
Appendix F). Withhold drug
and notify physician.
6.Monitor I&O ratio and
pattern. Report dysuria,
urine retention, and
hematuria.
7.Report chills, wheezing,
pruritus (itching),
respiratory distress, or
palpitations to physician
immediately
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Most Stomach ulcers are almost always caused byan infection with the bacterium
Helicobacter pylori ( Johnson 2017). This is treated through the use of antibiotics for
seven days. In this case ampicillin-sulbactam is used.

Drug Description and Purpose Nursing Interventions

Paracetamol 500mg tab q4○ This drug used to treat
prn for fever many conditions such
Date and Time Ordered: as headache, muscle aches,
September 9, 2017-10-25 arthritis, backache,
3:30PM toothaches, colds,
and fevers. It relieves pain
in mild arthritis but has no
effect on the underlying
inflammation and swelling
of the joint.
Table 4. Paracetamol
1. Advise patient to take
medication exactly as
directed.
2. Advise patient to
report if discomfort
or fever is not
relieved by routine
doses of this drug or
of fever is greater
than 39.5○C (103○F)
or lasts longer than 3
days.
3. Administer with a
full glass of water.

Patient had an eleveted temperature of 38 degree celcius few hours after

admission. Thus, paracetamol was given. Paracetamol (acetaminophen) is a pain reliever
and a fever reducer. This is used to treat many conditions such as headache, muscle
aches, backache, colds, and fevers.

Drug Description and Purpose Nursing Interventions

PRBC 250 mL x 4-6○ Packed red blood cells are 1. Monitor for any signs
Date and Time Ordered: typically given in situations of anaphylactic
September 7, 2017 where the patient has either reactions.
4PM lost a large amount of blood 2. Monitor VS.
or has anemia that is
causing notable symptoms.
Table 5. Packed RedBlood Cells

In thediagnostic procedure done specifically complete blood count (CBC) display

that the count of red blood cells is2.95/Lcomparedtothenormalvaluesof(4.04-
5.4810^12/L), Hematocrit of0.22 (0.37-0.47L/L), Hemoglobin of 70g/L ( 120-160
g/L)thatshowsadecreaseinthe three values.This signifies the need for blood transfusion.

According to (KleinHG,SpahnDR,CarsonJL 2007) Red blood cell transfusions are

used to treat hemorrhage and to improve oxygen delivery to tissues. Indications for
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transfusion include symptomatic anemia (causing shortness of breath, dizziness,

congestive heart failure, and decreased exercise tolerance) and a decrease in the normal
valuesof blood components.

Drug Description and Purpose Nursing Interventions

PNSS 1L X 16○ Normal Saline is a
Date and Time Ordered: sterile, nonpyrogenic
September 7, 2017 solution for fluid and
4PM electrolyte
replenishment;
contains no
antimicrobial agents.
Table 6. Plain Normal Saline Solution
1. Frequently assess the
patient's response to I.V.
therapy, monitoring for
signs and symptoms of
hypervolemia, such as
hypertension, bounding
pulse, pulmonary crackles,
dyspnea/shortness of breath,
peripheral edema, jugular
venous distention (JVD),
and extra heart sounds.
2. Monitor intake and
output.
3. Elevate the head of bed at
35 to 45 degrees, unless
contraindicated. If edema is
present, elevate the patient's
legs. Note if the edema is
pitting or nonpitting and
grade pitting edema.
4. Monitor for signs and
symptoms of continued
hypovolemia, including
urine output of less than 0.5
mL/kg/hour, poor skin
turgor, tachycardia, weak,
thready pulse, and
hypotension.
5. Educate patients and their
families about signs and
symptoms of volume
overload and dehydration,
and instruct patients to
notify their nurse if they
have trouble breathing or
notice any swelling.
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Plain Normal Saline Solution is an IsotonicIntravenous fluid used for hydration,

irrigation during surgery, diluent of medication and used with blood transfusions. Also
this is given to the patients suffering from salt and water deprivation.
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DISCHARGE PLAN

Discharge planning is a process that aims to improve the coordination of services

after discharge from hospital by considering the patient’s needs in the community. It
seeks to bridge the gap between hospital and the place to which the patient is discharged,
reduce length of stay in hospital, and minimize unplanned readmission to hospital.

CRITERIA HEALTH TEACHINGS

Activity and Rest Encouraged to avoid extraneous activities

to manage fatigability, prioritize your
activities and establish balance between
activity and rest. Make sure that you have
times for relaxation and work during the
day.

Encouraged to have adequate sleep to help

recharged your system and body.

Diet and Nutrition Continue taking your iron supplements

until your following visit.
It is important to eat a well-balanced, diet
and drink plenty of fluids. Drink two quarts
of fluid per day. Also, to increase intake of
foods rich in iron and folic acid and to
include foods high in vitamin C at the same
meal to increase iron absorption.

Due to the health teaching, we have done to Patient Manzano, we observed that
some of the activities were performed. Student nurses have provided nurture and support
needed to facilitate the adaption of health teaching behaviors. This kind of help assures
that the educational gains achieved by the mother will be maximized by a long and
healthy life.

We conclude that the health education like diet and nutrition, adequate rest period
and avoiding extraneous activity will produce a significant improvement to the patient.
Finally, we recommend the different approaches used in health education to be an
effective strategy for the improvement of others competence in managing their health
condition.
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CONCLUSION AND RECOMMENDATION

Conclusion
After assessing the patient’s condition, activities, interventions done and
outcomes we have come to a conclusion that anemia is a life-threatening condition that
needs an immediate treatment. Anemia is further broadly subcategorized acute and
chronic. It is group with three categories: decreases red blood cell production, increased
RBC destruction and blood loss. If not treated it may cause complication like hypoxia,
cardiomegaly, liver and renal disease, and rheumatic disease are such examples of
complications that may lead to death.

Recommendation
Furthermore, the researchers recommend that the healthcare provider (HCP)be
aware and inform that gastritis, gastric or duodenal ulcer liver or renal disease,
hypothyroidism, sickle cell anemia, iron deficiency and history of previous anemia or
blood transfusion are such complication that increases the risk of having anemia. It is
highly recommended to the patient to follow the discharge plan given such as promote
healthy diet such as food rich in Iron, to attend checkups, to continue medications as
prescribed by the physician.
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Nursing Care Plans

A. List of problems as prioritized

1. Ineffective Tissue Perfusion related to decreased hemoglobin
2. Activity Intolerance related to imbalance between oxygen supply and demand
3. Risk for infection related to decreased hemoglobin
4. Risk for Bleeding related to decreased platelet count

5. Risk for deficient fluid volume related to vomiting and inadequate fluid intake
as evidence by dry lips

B. Nursing Care plans (Refer to pages 40-44)

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References:
Guenter Weiss, M. a. (2005) Anemia of Chronic Disease . The New England Journal of
Medicine, 1011.
National Organization for Rare Disorders(2009) Anemia of Chronic Disease
Judith Hopfer Deglin, a. H. (2009). Davis's Drug Guide for Nurses. Philadelphia, PA:
iGroup Press Co., Ltd.
Klein HG, Spahn DR, Carson JL. Red blood cell transfusion in clinical practice. Lancet.
2007;370(9585):415–426

McFarland, M. B., & Grant, M. M. (2009). Nursing Implications Of Laboratory Tests.

Chicago: Educational Publishing House.