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Paroxysmal Nocturrnal
Hemoglobinuria
PNH
Nursingcasestudy.blogspot.com
INTRODUCTION
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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
cells or neutrophils during their prolonged remission, but a few PNH-affected
lymphocytes were detectable in 3 of 4 patients tested.
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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 group’s 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
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
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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 disease—Paroxysmal
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
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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
patient’s 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
b. Anatomy and Physiology
c. Pathophysiology book base and client centered
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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 client’s 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. Client’s 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
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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 o’clock 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 the radio and watch the television as one of his past time and is also his
way to rest and relaxed. The client’s food preferences were mostly pork,
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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 o’clock in the evening. He doesn’t use mosquito nets when sleeping
because he said that it bothers him when he always urinates at night. He
added that he doesn’t 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 doesn’t 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 doesn’t
say/speak bad words.
2. Family History of Health and Illness
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FATHER SIDE MOTHER SIDE
? ? ? ?
Old Old Old Old
5 6 6 3 7 3 6 3 2
A&W A&W A&W A&W A&W suicide A&W A&W A&W
3 3 3 3 LEGEND
A&W A&W PNH A&W
Male
Female
Deceased Male
Deceased Female
Married
Children
Patient
Alive & Well
Paroxysmal Nocturnal
A&W Hemoglubinuria
PNH
3. History of Past Illness
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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 doesn’t 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 doesn’t 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
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relieve it and takes paracetamol if it is accompanied by fever. He also stated that
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 who’s 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 doesn’t 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.
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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 D’Amico and
Barbarito)
Analysis
The patient’s 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 client’s 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.
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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 patient’s 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)
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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 one’s limitations. (Fundamentals Of
Nursing, Kozier, pg 173.) Normal coping pattern or emotions stability could
include acceptance of the problem, adjustment to it, expressing of self-
perception 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
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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. He’s 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
ADL’s due to easy fatigability. Blood transfusion is his way of regaining
his strength.
V. Body Temperature
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The client’s general skin is warm to touch during the interview. The
following table indicates the client’s body temperature.
Date and Temperature (0C) Analysis
hours
2/11/09 8 am 36.5 0C Normal
10 am 36.7 0C Normal
1:30 pm 36.8 0C Normal
3:00 pm 37.1 0C Normal
2/12/09 8 am 37.8 0C Abnormal
12 noon 38 0C Abnormal
2 pm 38.3 0C Abnormal
3:30 pm 38.4 0C Abnormal
4:30 pm 38 0C Abnormal
6 pm 37.8 0C Abnormal
10 pm 37.3 0C Normal
2/13/09 8 am 37.2 0C Normal
10 am 37.4 0C Normal
2 pm 37.5 0C Normal
5 pm 38.9 0C Abnormal
6 pm 38.7 0C Abnormal
8 pm 38.5 0C Abnormal
10 pm 37.9 0C Abnormal
2/14/09 6 am 38 0C Abnormal
8 am 37.8 0C Abnormal
10 am 37 0C Normal
2 pm 37 0C Normal
6 pm 37.2 0C Normal
2/15/09 6 am 38.2 0C Abnormal
6 pm 36.5 0C Abnormal
2/16/09 8 am 36.9 0C Normal
10 am 36.7 0C Normal
12 noon 37.2 0C Normal
1:30 pm 37.2 0C Normal
4 pm 37.2 0C Normal
10 pm 38.9 0C Abnormal
2/17/09 4 pm 38.5 0C Abnormal
10 pm 38.2 0C Abnormal
2/18/09 6 am 37.2 0C Normal
2 pm 38.8 0C Abnormal
5 pm 37.2 0C Normal
2/18/09 4 pm 37.3 0C Normal
10 pm 38.1 0C Abnormal
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Norms
A healthy person's body temperature fluctuates between 97°F
(36.1°C) and 100°F (37.8°C), with the average being 98.6°F (37°C). 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 (body’s temperature control center) which can
trigger the body’s 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 T-
lymphocytes 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 client’s 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.
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The client’s blood pressure and pulse rate are noted in the following
table:
Date and hours Blood pressure
(mmHg) Analysis
2/11/09 8 am 90/60 Abnormal
10 am 100/80 Abnormal
1:30 pm 100/60 Abnormal
3:00 pm 100/70 Abnormal
2/12/09 8 am 100/60 Abnormal
12 noon 100/60 Abnormal
2 pm 100/60 Abnormal
3:30 pm 110/60 Abnormal
4:30 pm 100/70 Abnormal
6 pm 110/70 Abnormal
10 pm 100/60 Abnormal
2/13/09 8 am 100/70 Abnormal
10 am 110/80 abnormal
2 pm 100/60 Abnormal
5 pm 130/90 abnormal
6 pm 120/70 normal
8 pm 110/70 abnormal
10 pm 90/60 Abnormal
2/14/09 6 am 90/70 Abnormal
8 am 100/70 Abnormal
10 am 100/70 Abnormal
2 pm 110/70 Abnormal
6 pm 110/70 Abnormal
2/15/09 6 am 110/70 Abnormal
6 pm 110/70 Abnormal
2/16/09 8 am 90/60 Abnormal
10 am 100/70 Abnormal
12 noon 100/70 Abnormal
1:30 pm 100/70 Abnormal
4 pm 120/70 Abnormal
10 pm 110/70 Abnormal
2/17/09 4 pm 120/80 Abnormal
10 pm 110/70 Abnormal
2/18/09 6 am 100/60 Abnormal
2/18/09 4 120/80 normal
pm
10 pm 130/90 abnormal
Date and hours Pulse rate
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(beats per min) Analysis
2/11/09 8 am 89 Normal
10 am 86 Normal
1:30 pm 87 Normal
3:00 pm 88 Normal
2/12/09 8 am 95 Normal
12 noon 96 Normal
2 pm 98 Normal
3:30 pm 106 Abnormal
4:30 pm 100 Normal
6 pm 94 Normal
10 pm 96 Normal
2/13/09 8 am 94 Normal
10 am 86 Normal
2 pm 105 *Abnormal
5 pm 102 Abnormal
6 pm 92 Normal
8 pm 91 Normal
10 pm 99 Normal
2/14/09 6 am 94 Normal
8 am 98 Normal
10 am 99 Normal
2 pm 98 Normal
6 pm 87 Normal
2/15/09 6 am 87 Normal
6 pm 90 Normal
2/16/09 8 am 88 Normal
10 am 88 Normal
12 noon 87 Normal
1:30 pm 86 Normal
4 pm 88 Normal
10 pm 86 Normal
2/17/09 4 pm 88 Normal
10 pm 85 Normal
2/18/09 6 am 88 Normal
2/18/09 4 pm 106 Abnormal
10 pm 86 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
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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
Client’s 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 patient’s respiratory rate throughout the hospital confinement:
DATE AND TIME RATE INTERPRETATION
2-11-09 22 Abnormal
8AM 25 Abnormal
10AM 22 Abnormal
1:30PM 23 Abnormal
3-11PM 21 abnormal
02-12-09 21 Abnormal
8AM 26 Abnormal
12PM 25 Abnormal
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2PM 33 *Abnormal
3:30PM 25 Abnormal
6PM 28 Abnormal
10PM 28 Abnormal
2-13-09 6 am 26 Abnormal
8AM 35 Abnormal
10AM 26 Abnormal
2PM 24 Abnormal
(3-11PM) 5PM 26 Abnormal
6PM 29 Abnormal
8PM 31 Abnormal
10PM 29 abnormal
2-14-09(11-7AM) 25 Abnormal
8AM 23 Abnormal
10AM 22 Abnormal
2PM 19 normal
3-11PM 20 normal
02-15-09(11-7AM) 20 normal
3-11PM 20 normal
2-16-09 (8AM) 30 Abnormal
10AM 25 Abnormal
12PM 27 Abnormal
1:30PM 25 Abnormal
4PM 26 Abnormal
10PM 30 Abnormal
2-17-09(4PM) 30 Abnormal
10PM 28 Abnormal
2-18-09(11-7AM) 26 Abnormal
7AM 25 Abnormal
10AM 24 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
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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 body’s demands.
VIII. State of Physical Rest and Comfort
Mr. X usually wakes 6 o’clock 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 DVD’s 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
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23.
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 sleep-
wake 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 don’t use any contraceptive method. The client doesn’t 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.
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24.
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,
client’s 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 5’7”. 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 doesn’t eat vegetables, he only eat meat. He doesn’t have
difficulty of eating because he has a good set of teeth. He drinks an
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25.
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 person’s 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
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26.
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 client’s 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 client’s 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
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27.
Client doesn’t 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. Client’s 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 pale-
red 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
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28.
moist, smooth and free from lesions. Gums should be pale-red stippled
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). Adult’s 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
Client’s 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 don’t 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. X’s 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
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29.
was also evident on both his fingernails and toenails. They appeared
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 patient’s 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 dark-
skinned 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.
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30.
Client is at risk for infection with regards to the venipuncture he
had.
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31.
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 .092 L/L .370-.510 Below normal range:
percentage of red can be a sign of the
blood cells in 100 presence of
ml of whole blood. hemorrhage,
Determines if the anemia,
client is hydrated or hyperthyroidism,
dehydrated. dietary deficiency
and pregnancy.
RBC used to evaluate .90 T/L 4.2-6.3 Below normal range.
MCV the size, weight Decreased RBC
MCHC and hemoglobin result in lysis of RBC
MCH concentration of due to lack of decay
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32.
RBC’s. Oxygen accelerating
factor(CD55 and
transportation is its CD59) on RBC.
major function.
WBC - determines the 8.1 G/L 4.1-10.9 Within normal range.
Lymphocytes number of 0.225 0.6-4.1 low lymphocytes
circulating WBC’s indicates decrease
in the blood. It activity of the bone
monitors the marrow
presence of
infection in the
body.
Platelet - platelets are the 168 G/L 140-440 Within normal range
first line of
protection against
bleeding.
Blood typing “A”
RH Factor +
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:
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33.
the total amount of In response to
6:57 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 .87 L/L . .370-.510 Below normal range:
percentage of red can be a sign of the
blood cells in 100 presence of
ml of whole blood. hemorrhage, anemia,
Determines if the hyperthyroidism,
client is hydrated or dietary deficiency
dehydrated. and pregnancy
RBC used to evaluate 1.01 T/L 4.2-6.3 Below normal range.
MCV the size, weight Decreased RBC
MCHC and hemoglobin result in lysis of RBC
MCH concentration of due to lack of decay
RBC’s. Oxygen accelerating
factor(CD55 and
transportation is its CD59) on RBC.
major function.
WBC - determines the 6.9 G/L 4.1-10.9 Within normal range
lymphocytes number of 1.2 0.6-4.1
circulating WBC’s
in the blood. It
monitors the
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34.
presence of
infection in the
body.
Platelet - platelets are the 141 G/L 140-440 Within normal range
first line of
protection against
bleeding.
Blood typing “A”
RH Factor +
MCV - average volume 85.7 FL 80-97 Within normal range
of individual RBC’s
MCH - calculated 35.6 pg 26-32 above normal range.
average weight of Due to macrocytic
hemoglobin per anemia.
RBC
MHCH - average 414 g/l 310-360 above normal range.
concentration or Due to macrocytic
percentage of anemia.
hemoglobin per
RBC
DIFFERENTIAL COUNTS:
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35.
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 .097 L/L .370-.510 Below normal range:
percentage of red can be a sign of the
blood cells in 100 presence of
ml of whole blood. hemorrhage,
Determines if the anemia,
client is hydrated or hyperthyroidism,
dehydrated. dietary deficiency
and pregnancy
RBC used to evaluate . 1.14 T/L 4.2-6.3 Below normal range.
MCV the size, weight Decreased RBC
MCHC and hemoglobin result in lysis of RBC
MCH concentration of due to lack of decay
RBC’s. Oxygen accelerating
factor(CD55 and
transportation is its CD59) on RBC.
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36.
major function.
WBC - determines the 5.4 G/L 4.1-10.9 Within normal range
lymphocytes number of 1.4 0.6-4.1
circulating WBC’s
in the blood. It
monitors the
presence of
infection in the
body.
Platelet - platelets are the 127 G/L 140-440 Low platelet
first line of indicates decrease
protection against activity of the bone
bleeding. marrow
Blood typing “A”
RH Factor +
MCV - average volume 85.5 FL 80-97 Within normal range.
of individual RBC’s
Below normal range.
MCH - calculated 39.5 pg 26-32 Due to macrocytic
average weight of anemia.
hemoglobin per
RBC
464 g/l 310-360 Above normal
MHCH - average range.
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37.
concentration or Due to macrocytic
percentage of anemia.
hemoglobin per
RBC
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 .152 L/L .370-.510 Below normal range:
percentage of red can be a sign of the
blood cells in 100 presence of
ml of whole blood. hemorrhage,
Determines if the anemia,
client is hydrated or hyperthyroidism,
dehydrated. dietary deficiency
and pregnancy
RBC used to evaluate 1.80T/L 4.2-6.3 Below normal range.
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38.
MCV the size, weight Decreased RBC
MCHC and hemoglobin result in lysis of RBC
MCH concentration of due to lack of decay
RBC’s. Oxygen accelerating
factor(CD55 and
transportation is its CD59) on RBC.
major function.
WBC - determines the 4.5 G/L 4.1-10.9 Within normal range
Lymphocytes number of 1.2 0.6-4.1
circulating WBC’s
in the blood. It
monitors the
presence of
infection in the
body.
Platelet - platelets are the 104 G/L 140-440 Low platelet
first line of indicates decrease
protection against activity of the bone
bleeding. marrow
Blood typing “A”
RH Factor +
MCV - average volume 84.4FL 80-97 Within normal range
of individual RBC’s
MCH - calculated 32.2 pg 26-32 Above normal
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39.
average weight of range.
hemoglobin per Due to macrocytic
RBC anemia.
Above normal
MHCH - average 382 g/l 310-360 range.
concentration or Due to macrocytic
percentage of anemia.
hemoglobin per
RBC
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
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40.
BUN 02-13-09 To asses for 18.71 2.9-8.2 mmol/L Elevated BUN and
electrolyte creatinine level
imbalance. indicates decreased
Creatinine 353.6 53-106mmol/L 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.
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41.
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)
41

42.
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
42

43.
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 Fe3+ 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)
43

44.
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 cell-
mediated 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,
44

45.
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" antigen—or what is not recognized as the
original organism).
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46.
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
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47.
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)
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8. Pathophysiology
48

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50.
B. PLANNING
Nursing Priorities Based on Maslow’s 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
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51.
Nursing Care Plans
(Date Identified)
Assessment Planning Intervention Expected
Outcome
S After 6 1. Independent The pt. will
> fatigue and shortness of breath hours of a. Assist client to semifowler’s position display an
when doing light physical activities nursng R: To promote maximum lung expansion to increase in
like eating, urinating in bed pan, intervention, increase oxygenation and tissue perfusion. peripheral tissue
oral and body hygiene and the client will perfusion as
changing clothes display an b. Assist client to do deep breathing exercises manifested by:
> general body weakness increase in R: Helps regulate rate of breathing and anxiety to a. improvement
peripheral conserve pt.’s energy. in capillary refill
O tissue b. good
> requires SO’s assistance when perfusion. c. Provide and quiet environment and provide peripheral
accomplishing ADLs comfort measures. pulses
> pale conjunctiva, oral and nasal c.1 Change linens regularly. c. normal heart
mucosa and integument c.2 Instruct SOs to minimize talking with the pt. rate and
> carpal and tarsal clubbing c.3 Provide back massage as needed. respiratory rate
> hair growth on fingers and toes c.4 Assist pt. in doing guided imagery and d. verbalization
absent visualization relaxation techniques of improvement
> capillary refill of 5 seconds in R: Helps promote rest and relaxation which in level of
fingernails, 4-5 seconds in toenails conserves pt.’s energy and decreases the body’s energy
> Tachycardia = 105 bpm demand for oxygen. e. improvement
> Tachypnea = 33 cpm in disposition
> Hgb value = 36 g/l 2. Collaborative f.improvement of
> Hct values = 0.17 a. Assist in obtaining specimen for laboratory Hgb/Hct values
studies (Hb/Hct, RBC count, ABG)
Nsg Dx R: Identifies deficiencies in RBC composition and
IneffectiveTissue Perfusion: monitors the pt’s status in terms of oxygenation
peripheral r/t decreased Hgb and perfusion. Also serves as a parameter for
concentration in blood client’s progress in achieving activity tolerance.
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52.
SE: b. Provide supplemental oxygen as indicated.
PNH is a condition in which there R: Maximizing oxygen-carrying capacity of RBCs
is a continuous autoimmune to transport to tissues of the body.
destruction of RBCs. A significant
decrease in the total number of c. Administer packed RBC blood transfusion as
circulating RBCs would lead to indicated.
inadequate amount of oxygen R: Increases the number of oxygen-carrying cells
perfused to the tissues of the body. to correct inadequate tissue perfusion.
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.
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53.
Assessment Planning Intervention Expected Outcome
S: After 1 hour of 1. Independent: After appropriate nursing
> fatigue and shortness of breath daily nursing a. Limit activities and decrease intervention, pt. will
when doing light physical activities intervention, external stimulus. display a gradual
like eating, urinating in bed pan, client will display R: Limitation decreases oxygen increase in activity
oral and body hygiene and a gradual demand and decreasing stimulus tolerance as manifested
changing clothes progressive promotes relaxation and decreases by:
> frequently naps during daytime tolerance of anxiety which can also increase a. increase in capacity to
(1-2 hours) physical activity oxygen demand. do ADLs
w/o report of b. absence of chest pain
O: chest pain upon b. Assist patient to gradually and SOB while doing
> confined to bed most of the time exertion increase activity level. Start from daily activities
> pt. depends on assistance of SO simple ADLs like combing hair, c. improvement of skin
in accomplishing ADLs like eating, brushing teeth and eating. Progress and nail color, peripheral
urinating in bed pan, oral and body to mild activity like active-assistive pulses and capillary refill
hygiene and changing clothes ROMs and then ambulating with which indications good
> appears generally weak assistance. circulation
> fingernails and conjunctiva pale R: Gradual increase in activity level d. increase in
> tachycardia = 103 bpm ensures that the pt.’s heart is not independence
> tachypnea = 33 cpm overworked and the complications of
> low HB= 36 g/l prolonged immobility will be
> low HCT= 0.17 prevented.
Dx: c. Record and document pt.’s VS
Activity intolerance [Level III] r/t before, during and after activities
imbalance between oxygen supply and correlate with presence or
and demand absence of SOB.
R: Provides a baseline trend to
SE: monitor pt.’s tolerance on the
PNH is a condition in which the activity. Also provides a source for
RBC count is decreased because of evaluation for the client’s progress to
continuous hemolysis. Pale increase his activity tolerance.
fingernails and conjunctiva as well
as low Hb/Hct indicates an d. Instruct pt. to avoid activities
abnormally low RBC count. which increase abdominal pressure.
(e.g. straining during defecation)
An increase in physical activity will R: It can cause bradycardia which
cause the cells to increase their would decrease tissue perfusion to
demand for oxygen to meet the all tissues including the myocardial
increased metabolic state. tissues.
However, the amount of oxygen 53
supplied by the RBC is decreased
because of the decrease in the
number of circulating RBCs.

54.
Assessment Planning Intervention Expected Outcome
S: After 8 hours Independent: After appropriate nursing
> Frequent daytime naps of nursing a. Explain the necessity for therapeutic and intervention, client will report
(1-2 hours) intervention monitoring procedures while the client is an improvement in
> Feels that he lacks energy the client will hospitalized. sleep/rest pattern as
and is always tired report an R: Pt. is more apt to be tolerant of manifested by:
> Has difficulty in falling improvement disturbances by staff if he understands the a. verbalization of increase
asleep at night in sleep/rest reasons and importance of care. in energy and physical
pattern. activity
O: b. Restrict the intake of foods and fluids rich b. reduction or absence of
> less than age-normed in caffeine yawning, irritability and
total sleep time (7-8 hours) R: Increases pt.’s wakefulness and delay restlessness
> lethargic falling asleep. c. increase in total time of
> irritable and restless continuous, uninterrupted
> yawns frequently c. Support continuation of usual bedtime night time sleep
> weak in appearance rituals.
> Frequent conversations R: Promotes relaxation and readiness for
from SO sleep.
> Interruption of rest and
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55.
sleep due to therapeutic d. Increase interaction time between pt. and
and monitoring activities of SOs/staff during day and reduce physical and
health care workers in mental activities late in the day and at night.
hospital Minimize unnecessary disturbances during
hours of sleep at night.
Dx: R: Planned activities during daytime and
Disturbed sleep pattern r/t reduction of stimulation during night time
excessive stimulation from promotes continuous, uninterrupted sleep.
environment
e. Provide comfort measure
SE: e.1 provide evening snack if available
Excessive environmental e.2 hygiene (bed bath and oral care)
stimulus causes a disruption e.3 massage and back rub
in the normal sleep-wake e.4 provide clean and comfortable bed
cycle of the pt. Disturbance e.5 assist pt. to wear comfortable clothes
in sleep esp. night time R: Promotes drowsiness, aid in relaxation
reduces the length of REM and falling asleep.
sleep. Insufficient REM
sleep causes the pt. to feel f. Reduce fluid intake in the evening and
fatigue and lack of energy. advice client to urinate/defecate before
The pt. also manifests sleeping if necessary.
frequent yawning and R: Decreases the need to get up and go to
irritability. The body bathroom during night time and prevents
compensates for the interruption of REM sleep.
insufficiency by taking
daytime naps which is also
evident in the pt.
55