Complete Blood Count Hemoglobin Hematocrit

Normal Values M= 13-18% F=12-16% M= 40-54 F=36-57 13.4% 42

Result

Indication Increase = indication of polycythemia decrease = indication of anemia A hematocrit of over 60% may result in spontaneous blood clotting A hematocrit of less than 15% can result in cardiac failure Increase = indication of Allergy, Inflammation, Infection Neutrophils Elevated with bacterial infection and low indicates an increased risk of infection. Lymphocytes Elevated in viral infections and low with diseases such as hepatitis, lymphoma, or AIDS. Eosinophils Elevated with allergies or infections with parasites. Monocytes Elevated in blood diseases, certain infections or auto-imune diseases. Basophils Elevated in blood diseases. Elevated in dehydration, high altitude and CVD and low in anemia, hemorrhages, cancers, fluid overload in pregnancy. Increased segmenters indicates viral infection Elevated in viral infections and low with diseases such as hepatitis, lymphoma, or AIDS. A rising ESR can mean an increase in inflammation or a poor response to a therapy; a decreasing ESR can mean a good response.

WBC

5000-1000 cum

4600

RBC Segmenters Lymphocytes

4.6 million/cum 55-65 25-35

4.6 million 65 32

Sedimentation rate

M= 0-15 F=0-20

75

Urinalysis Color Transparency S.P Gravity yellow Slightly hazy 1.030

Result

Indication

Specific gravity over 1.035 is either contaminated, contains very high levels of glucose Specific gravity less 1.022 after a 12 hour period without food or water, renal concentrating ability is impaired and the patient either has generalized renal impairment or nephrogenic diabetes insipidus

Sugar Pus ASOT Amurates Mucus Threads Bacteria

Negative 1-2/ hpf Negative Few Occasional Moderate more than 100,000/ml of one organism reflects significant bacteriuria.

Functional Health Pattern Health Perception/Health Management

Pattern Describes Client's perceived pattern of health and wellbeing and how health is managed. Pattern of food and fluid consumption relative to metabolic need and pattern; indicators of local nutrient supply. Patterns of excretory function(bowel, bladder, and skin Patterns of exercise, activity, leisure, and recreation. Sensory-perceptual and cognitive patterns. Patterns of sleep, rest, and relaxation. Client's self-concept pattern and perceptions of self. Client's pattern of role engagements and relationships. Patterns of satisfaction and dissatisfaction with sexuality pattern; reproductive pattern. General coping pattern and effective of the pattern in terms of stress tolerance Patterns of values, beliefs (including spiritual), and goals that guide clients choices or decisions.

Patients Answer Sees herself as a healthy individual and her hospitalization is only due to allergic reaction from exposure of pesticides She has a good appetite prefers vegetable and chicken seldom eat rice Voids maximum of 8 times a day and bowel movement of atleast once a morning. Most of her leisure time is spend in malling, shopping or watching movies. Does not have patterns of exercise. No problems in hearing and vision. Her learning style is both when listening and writing. Sleeps atleast 6-8 hours Sees herself as a happy go lucky and godfearing individual. Patient is in a relationship with her childhood friend and describes her relationship with him as one of the best thing about her life. Patient is not sexually active. Menarche: Grade 4 Have regular menstruation ever since Does not have infertility concerns. Handle her stress through being with friends and shopping. Believes in God. Prays before sleeping and put God in the center of every relationship she is handling.

Nutritional-Metabolic

Elimination Activity - Exercise Cognitive-Perceptual Sleep-Rest Self-Perception/Self Concept Role-Relationship

Sexuality-Reproductive

Coping / Stress Tolerance Value Belief

Patient X was admitted to the hospital with th chief complaint of rashes and fever, One day prior to admission patient wasa given Claritin (antihistamine) to control the inflammation/hypersensitivity reaction and infused D5LR to support in maintaining fluid and electrolytes balance in the body. Two to Three days prior to admission patient started to have febrile episodes and sore throat. Patient was given paracetamol to aid in increase of temperature and was advised for hypoallergenic diet to avoid increase of hypersensitivity reaction. Four days prior to admission patient was referred to a dermatologist and is allowed to discharge the following day with final diagnosis of hypersensitivity vasculitis.

Patients name: patient x Age: 22Y5M3D Gender: female Civil status: Single Nationality: Filipino Religion: Catholic Occupation: Flight Attendant Source of income: Job Rank in the family: third child Inclusive date of admission: March 1, 2, 3, 2012 Admitting time and date: March1 2012, 10:09 pm Discharge: March 4 2012 Initial diagnosis: Hypersensitivity Reaction Final diagnosis: neonatal sepsis hyperbilirubinemia sec to abo incompatibility Attending physician: Hypersensitivity Vasculitis

Historian: Patient X

Chief complaint: Rashes and Fever

Present Health Status:

Patient X was admitted to the hospital with th chief complaint of rashes and fever, One day prior to admission patient wasa given Claritin (antihistamine) to control the inflammation/hypersensitivity reaction and infused D5LR to support in maintaining fluid and electrolytes balance in the body. Two to Three days prior to admission patient started to have febrile episodes and sore throat. Patient was given paracetamol to aid in increase of temperature and was advised for hypoallergenic diet to avoid increase of hypersensitivity reaction.
Past Health History: Patient X has history of asthma and is allergic to dustmites and chocolates. General Health: BP: 120/80mmHg CR: 85bpm T: 36 C RR: 20cpm

Childhood Illness: Asthma Immunizations: Complete

Major Illness/Hospitalization: Hypokalemia Allergies: Ingestants : Dust mites and chocolates Habits: Caffeine: Once a week Family Health History: HPN Mother Eldest Son Father

Intimacy versus isolation is the sixth stage of Erik Erikson's theory of psychosocial development. This stage takes place during young adulthood between the ages of approximately 19 and 40. During this period of time, the major conflict centers on forming intimate, loving relationships with other people. While psychosocial theory is often presented as a series of neatly defined, sequential steps, it is important to remember that each stage contributes to the next. For example, Erikson believed that having a fully formed sense of self (established during the identity versus confusion stage) is essential to being able to form intimate relationships. Studies have demonstrated that those with a poor sense of self tend to have less committed relationships and are more likely to suffer emotional isolation, loneliness, and depression. Erikson believed it was vital that people develop close, committed relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation. Patient X does not experience isolation and she has really good skills in getting along with others. She is also in an intimate relationship with her long time boyfriend.

The prognosis for individuals with vasculitis varies depending on the severity of the disorder. Mild cases of vasculitis are generally not life-threatening, while severe cases (involving major organ systems) may be permanently disabling or fatal. The majority of cases are short-lived; in one paper around 60% of patients had symptoms resolving in less than 3 months.The outlook will depend on the underlying cause. If none is found and only skin and joints are affected, the prognosis is good, although recurrence is not uncommon. Paraesthesia, fever, and absence of painful lesions have been found to be risk factors for systemic involvement. Cryoglobulins, arthralgia, and normal temperature are risk factors for chronic cutaneous disease. Where the vasculitis presents on a background of Wegener's granulomatosis, polyarteritis nodosa, Churg-Strauss syndrome, or severe necrotising vasculitis, it can be fatal. Steroids and immune modulators may be life-saving.

Blood Vessels
The central opening of a blood vessel, the lumen, is surrounded by a wall consisting of three layers:

The tunica intima is the inner layer facing the blood. It is composed of an innermost layer of endothelium (simple squamous epithelium) surrounded by variable amounts of connective tissues. The tunica media, the middle layer, is composed of smooth muscle with variable amounts of elastic fibers. The tunica adventitia, the outer layer, is composed of connective tissue.

The cardiovascular system consists of three kinds of blood vessels that form a closed system of passageways:

Arteries carry blood away from the heart. The three kinds of arteries are categorized by size and function:

Elastic arteries (conducting arteries) are the largest arteries and include the aorta and other nearby branches. The tunica media of elastic arteries contains a large amount of elastic connective tissue, which enables the artery to expand as blood enters the lumen from the contracting heart. During relaxation of the heart, the elastic wall of the artery recoils to its original position, forcing blood forward and smoothing the jerky discharge of blood from the heart. Muscular arteries (conducting arteries) branch from elastic arteries and distribute blood to the various body regions. Abundant smooth muscle in the thick tunica media allows these arteries to regulate blood flow byvasoconstriction (narrowing of the lumen) or vasodilation (widening of the lumen). Most named arteries of the body are muscular arteries.

Arterioles are small, nearly microscopic blood vessels that branch from muscular arteries. Most arterioles have all three tunics present in their walls, with considerable smooth muscle in the tunica media. The smallest

arterioles consist of endothelium surrounded by a single layer of smooth muscle. Arterioles regulate the flow of blood into capillaries by vasoconstriction and vasodilation.

Capillaries are microscopic blood vessels with extremely thin walls. Only the tunica intima is present in these walls, and some walls consist exclusively of a single layer of endothelium. Capillaries penetrate most body tissues with dense interweaving networks called capillary beds. The thin walls of capillaries allow the diffusion of oxygen and nutrients out of the capillaries, while allowing carbon dioxide and wastes into the capillaries. Below is a list of the different types of capillaries:

Metarterioles (precapillaries) are the blood vessels between arterioles and venules. Although metarterioles pass through capillary beds with capillaries, they are not true capillaries because metarterioles, like arterioles, have smooth muscle present in the tunica media. The smooth muscle of a metarteriole allows it to act as a shunt to regulate blood flow into the true capillaries that branch from it. The thoroughfare channel, the tail end of the metarteriole that connects to the venule, lacks smooth muscle.

True capillaries form the bulk of the capillary bed. They branch away from a metarteriole at its arteriole end and return to merge with the metarteriole at its venule end (thoroughfare channel). Some true capillaries connect directly from an arteriole to a metarteriole or venule. Although the walls of true capillaries lack muscle fibers, they possess a ring of smooth muscle called a precapillary sphincter where they emerge from the metarteriole. The precapillary sphincter regulates blood flow through the capillary. There are three types of true capillaries:

Continuous capillaries have continuous, unbroken walls consisting of cells that are connected by tight junctions. Most capillaries are of this type. Fenestrated capillaries have continuous walls between endothelial cells, but the cells have numerous pores (fenestrations) that increase their permeability. These capillaries are found in the kidneys, lining the small intestine, and in other areas where a high transfer rate of substances into or out of the capillary is required.

Sinusoidal capillaries (sinusoids) have large gaps between endothelial cells that permit the passage of blood cells. These capillaries are found in the bone marrow, spleen, and liver.

Veins carry blood toward the heart. The three kinds of veins are listed here in the sequence they occur regarding the flow of blood back to the heart:

Postcapillary venules, the smallest veins, form when capillaries merge as they exit a capillary bed. Much like capillaries, they are very porous, but with scattered smooth muscle fibers in the tunica media. Venules form when postcapillary venules join. Although the walls of larger venules contain all three layers, they are still porous enough to allow white blood cells to pass.

Hypersensitivity vasculitis (leukocytoclastic vasculitis) is a histopathologic term commonly used to denote a small vessel vasculitis. Many possible causes exist for hypersensitivity vasculitis, but a cause is not found in as many as 50% of patients. Hypersensitivity vasculitis (a form of small vessel vasculitis) may manifest clinically as cutaneous disease only or it may manifest as skin disease with involvement of other organs. The internal organs most commonly affected in hypersensitivity vasculitis are the joints, gastrointestinal tract, and the kidneys. The prognosis for hypersensitivity vasculitis is good when no internal involvement is clinically present. Hypersensitivity vasculitis may be acute and self-limited or chronic. Definition This is a disorder of the skin caused by small vessel vasculitis. It is part of the spectrum of vasculitides. Pathogenesis

The disorder can be acute or chronic and may also affect internal organs. The kidneys, gastrointestinal tract and joints may also be affected. The pathology is probably mediated by immune complexes.1

Calibre and size of the vessels predominantly involved strongly influence the clinical features of the different forms of vasculitis and therefore are one major criterion for classification. Distinctions must also be made between IgG/IgM- and IgAassociated vasculitides and newer classifications exist to do so.2 Aetiology No cause is found in a third to half of all cases.3 Many drugs have been reported to cause the condition: o The most common are antibiotics, especially amoxicillin.4 o Non-steroidal anti-inflammatory drugs (NSAIDs) and diuretics are also frequently implicated. Upper respiratory tract infections, especially with beta haemolytic streptococci, can cause the condition. As it does not present until after the illness, it is often impossible to know if it was the illness or the antibiotic that caused it. Severe bacterial infection, especially bacterial endocarditis. Food and food additives have been implicated. Hepatitis C has been implicated, especially when there iscryoglobulinaemia. Collagen diseases; these have been implicated and, if so, it tends to suggest a more severe course to the disease. It probably represents 10 to 15% of cases.5 Inflammatory bowel disease has been implicated.

Malignancy probably accounts for around 1% of cases.6 Hairy cell leukaemia and Wegener's granulomatosis are the most common. Polyarteritis nodosa and Churg-Strauss syndrome have also been implicated. Epidemiology The disease is in many ways similar to Henoch-Schnlein purpura. Much of the literature comes from Spain where research has showed that the annual incidence is around 3 per 100,000 for hypersensitivity vasculitis and just under 1.5 per 100,000 for Henoch-Schnlein purpura.7 Most studies have found the number of men and women affected to be roughly equal. The condition does occur in children, but is often labelled as Henoch-Schnlein purpura, as the latter is more common in children. The opposite is true in adults.8 Presentation History The patient may complain of itching, burning or pain but often the lesions are asymptomatic. The most common complaint is of the rash - purpura.
o

o o

Ask about possible associated symptoms such as fever, arthralgia, myalgia, abdominal pain or diarrhoea. There may be blood in the stool, chronic cough, haemoptysis, paraesthesia, weakness, or haematuria. Look at past medical history including possible intravenous drug use, hepatitis, transfusion, and travel. Ask about inflammatory bowel disease including Crohn's diseaseand ulcerative colitis along with collagen vascular disorders, particularly rheumatoid arthritis, systemic lupus erythematosis, orSjgren's syndrome. It may be helpful to mark the lesions by circling them with a marker such as a ball point pen and asking the patient to note how long they last. Livedo reticularis (pink-blue mottled, 'net-like' pattern) is rare but suggests small-vessel vasculitis. It occurs with occlusive or inflammatory disease of small-sized vessels. Nodular lesions may also appear. Ulceration suggests involvement of larger vessels but it can occur with very intense purpura.

At the end of case presentation, the participants should be able to:

To determine the causes and related outcomes of early onset of vasculitis to determine the incidence of vasculitis. Describe the physiologic changes that may occur on the patient Formulate nursing diagnoses related to physiologic transition of the patient. Plan nursing care related to the needs of the patient. Evaluate outcome criteria for the achievement and effectiveness of care.

Assessment Subjective: may mga rashes ako sa kamay tapos meron din konti sa paa.as verbalized by the patient. Objective: Presence of rashes on the palms and soles

Diagnosis

Planning Long Term:

Intervention Independent Vital signs monitored and recorded. Instructed proper hygiene and self-care as well in her surroundings.

Rationale

Evaluation

Impaired skin integrity related to inflammation of blood vessels secondary to vasculitis as manifested by rashes on the palms and soles.

After rendering of nursing intervention the patient will regain normal skin integrity.

Changes in vital signs may indicate infection. Proper hygiene will prevent infection andcomplic ation.A clean environment occurrence of any disease. Vitamin C promoteswo und healing and diuretics decreasesre nal vascular resistance and may increase renal bloodflow

After rendering of nursing intervention the patient will regain normal skin integrity.

Dependent Administered prescribed meds such as ascorbic acid and cefuroxime.

Assessment Subjective: medyo nahihirapan akong maglakad at tumapak gawa ng mga rashes ko sa paa .as verbalized by the patient. Objective: Presence of rashes on the palms and soles

Diagnosis

Planning Long Term:

Intervention

Rationale

Evaluation

Independent
Assisted withnor mal range of motion exercises andfunction of lowerextremity .Encouragedprog ressive activities according to level of fatigue Necessary to regainnormal mobility of legto speed recovery. Increase patientsuse of affected leg After rendering of nursing intervention the patient demonstrated and verbalized exercises of the lower extremities and was able to perform activities of daily living with minimal assistance

Impaired physical mobility of the lower extremities related to inflammation of blood vessels as manifested by discomfort when walking, presence of rashes on the soles of the feet

After rendering of nursing intervention the patient demonstrate and verbalizes exercises of the lower extremities and will be able to perform activities of daily living with minimal assistance

Assessment Subjective: Nagpapalpitate ako kanina saka napansin kong ang putla ko.as verbalized by the patient. Objective: Presence of rashes on the palms and soles Pallor

Diagnosis

Planning Long Term:

Intervention Independent: Maintain optimal cardiac output Assist with diagnostic testing as indicated

Rationale

Evaluation

Ineffective tissue perfusion related to vasospasm secondary to vasculitis as evidenced by pallor, rashes and hyperemia.

After rendering of nursing intervention the patient will maintain optimal tissue perfusion to vital organs, as evidenced by strong peripheral pulses, normal ABGs, and absence of chest pain.

This ensures adequate perfusion of vital organs. Support may be required to facilitate peripheral circulation Doppler flow studies or angiograms may be required for accurate diagnosis

After rendering of nursing intervention the patient maintains optimal tissue perfusion to vital organs, as evidenced by strong peripheral pulses, normal ABGs, and absence of chest pain.

Physical Assessment
General observation a.General Appearance and behavior

Conscious and coherent

With paleness of skin on the extremities. Skin warm to touch

b.Body Movement: The patient is able to flex her upper and lower extremities well. d. Manner of Dressing: The patient is dressed well and properly according to hospital protocol.

e.Affect and Mood: The patient appears to be cheerful and approachable. f. Nutrition: The patient is supported by dextrose and due to her hypersensitivity reaction she was given and advised to have hypoaalergenic foods or diet. g. Elimination: The patient was able to void a maximum of 8 times a day and bowel movement atleast once every morning. h.Rest and Sleep: The patient sleeps for 6-8 hours a day.

Vital Signs: Blood Pressure:120 mmHg Cardiac Rate: 85 bpm Respiratory Rate: 20 cpm Temperature: 36 C

Head: Hair Evenly distributed , no patches of hair loss, thick resilient hair, no presence of sores,lice,nits and not flaking. Skull and Face Normocephalic and symmetric, with frontal,parietal, and occipital prominence. Absence of nodules or masses Symmetrical facial features and symmetric nasolabial folds. Symmetric facial movements Eyes Hair of the eyebrows evenly distributed, eyebrows symmetrically aligned, with equal movement. Eyelashes equally distributed and slightly curled outward. Eyelids: no discharge, discoloration and lids closes symmetrically. No visible sclera above corneas and upper and lower borders of cornea are slightly covered. No edema and tearing on the lacrimal sac. Pupils constricts when looking at near object and dilates when looking at far object.

Both eyes coordinated , with parallel alignment.

Ears: Color same as facial skin. Symmetrical, firm and not tender. Able to hear normal voice tones. Nose: Symmetric, straight and uniform color. No discharge and nasal flaring Mouth: Uniform pink color Tongue and lips can move freely Neck: Muscles are equal in size and head centered. Patient can turn to sides. Absence of palpable lymph nodes.

Upper Extremeties: Skin: Warm to touch Presence of rashes on palms and soles. Nails: Convex curvature and smooth in texture. Blanch Test: Prompt return of the usual color of the nails.

Joint range of motion: Patient was able to do range of motions on both the upper and lower extremities although she is uncomfortable in walking due to rashes on her soles

Chest: Chest is symmetric and spine is vertically aligned Skin intact and with uniform temperature, No tenderness and no masses.

Breasts: No tenderness, masses, nodules or nipple discharge. Genitalia: With regular menstruation Does not bleed between periods. Absence of warts and lesions Absence of bleeding. Do not have any history of Sexually acquired diseases. Lower Extremities: Gait and balance: patient is able to walk but with discomfort due to rashes on soles. Neurological: Glasgow Coma Scale Score: 15

Case Presentation (Vasculitis)

Submitted by: Sarina D. Maraa 2NRS-1 Group4b Submitted to: Ms. Girlie Mannphy Atienza Lacambra