Idiopathic Thrombocytopenic Purpura

1
I. INTRODUCTION

Idiopathic thrombocytopenic purpura (ITP) is a blood disorder of unknown cause characterized
by an abnormal decrease in the number of platelets in the blood. Platelets are cells in the blood that help
stop bleeding. People who have ITP often have purple bruises (purpura) that appear on the skin or on the
mucous membranes. The bruises mean that bleeding has occurred in small blood vessels under the skin. A
person who has ITP may also have bleeding that result in tiny red or purple dots on the skin. These
pinpoint-sized dots are called petechiae and it may look like a rash. Idiopathic thrombocytopenic purpura,
also known as immune thrombocytopenic purpura is classified as an autoimmune disease. In an
autoimmune disease the body forms antibodies that destroy its own blood platelets. Platelets are marked
as foreign by the immune system and eliminated in the spleen, or sometimes the liver.
There are three types of ITP: acute (temporary or short-term), chronic (long-lasting), and
recurrent (intermittent). Acute ITP generally lasts less than 6 months. It mainly occurs in children, both
boys and girls, and is the most common type of ITP. Acute ITP often occurs after an infection caused by a
bacteria or a virus. Chronic ITP is long-lasting (6 months or longer) and mostly affects adults. However,
some teenagers and children can get this type of ITP. Chronic ITP affects women 2 to 3 times more often
than men. Treatment depends on how severe the bleeding symptoms are and the platelet count. In mild
cases, treatment may not be needed. Recurrent ITP was characterized by intermittent episodes of
thrombocytopenia followed by periods of recovery, unrelated to therapeutic intervention. It is a rare, mild,
self-limited type of ITP, although intracranial hemorrhage may occur in a profoundly thrombocytopenic
child. Recurrence may occur close or far apart to a previous isolated thrombocytopenia episode.
This study is a case of a 2-month old baby boy, admitted at Pediatric unit of Manila Adventist
Medical Center due to fever, petechial rashes, and purpura on his trunk and extremities. The patient has
been diagnosed with Idiopathic Thrombocytopenic Purpura (ITP). The scope of this study encloses the
admission date, November 27, 2009 until his discharged date on December 10, 2009. The study includes
the maternal history, birth and past medical history of the patient. The disease process will provide the
students the knowledge on how the disease acquired and progresses. The laboratory exam and diagnostic
procedures use to diagnose ITP is also included as well as medication and health teaching given. The
purpose of this study is to let the students understand and have the knowledge on how to deal with clients
with idiopathic thrombocytopenic purpura.

2

II. DEMOGRAHIC DATA

This is a case of a 2-month old baby boy born on September 23, 2009 via normal spontaneous
delivery with assisted midwife at their home in Makati City. In the course of this study, the patient was
named as Barney to protect his identity. Barney and his parents are currently residing at 319 Duhat Street,
Comembo Makati City. His father is a born-again Christian while his mother is a Seventh-day Adventist
believer. Both of his parents are a Filipino citizen and finished secondary education. Barneys mother is a
plain housewife while his father is a tricycle driver. In this study the informants are his parents.
Barney was admitted at Pediatric Unit of Manila Adventist Medical Center on November 27,
2009 with an initial diagnosis of Idiopathic Thrombocytopenic Purpura vs. Evans Syndrome. He was
discharged on December 10, 2009 with the final diagnosis of Idiopathic Thrombocytopenic Purpura.

III. CHIEF COMPLAINT
Fever and generalized petechial rahes (face, trunk, and extremities):
Ang init ng katawan niya at ang dami niyang pasa at rashes (His body is hot and have lots of
bruises and rashes), as verbalized by the patients mother.

IV. HISTORY OF PRESENT ILLNESS

Barney was apparently well until four (4) days prior to admission (PTA) when he was noted to
have undocumented fever and petechial rashes on his face and buccal mucosa. His mother gave him
antipyretic (Calpol) which provided a temporary relief.
Three (3) days PTA, rashes had already spread on his extremities. His fever had gradually
decreased but the rashes remained all over his body and extremities.
Morning PTA, the persistence of the condition prompted the parents to consult at a nearby
hospital wherein a decreased hemoglobin, hematocrit, erythrocytes, segmenters and eosinophils were
noted. On the other hand, he had increased amounts of lymphocytes and monocytes. There were
generalized petechial rashes and ecchymoses on the trunk and extremities noted. They were advised
admission but due to room unavailability, they were referred and transferred to Manila Adventist Medical
Center and were subsequently admitted.

3

V. PAST MEDICAL HISTORY

Prior to diagnosis of having Idiopathic thrombocytopenic purpura, Barney did not have any
serious illness since birth. He is completely immunized with BCG, OPV, 1st dose of DPT, 1st and 2nd
dose of Hepatitis B vaccine. He has not undergone any operations, no recorded injury and no known
allergies to any food or drug.

A). Birth History:
According to Barney's mother, during her pregnancy, she had a hard time working at the
computer shop. She always feels restless and over fatigued after the days work. The mother noted that
she had urinary tract infection during her 6
th
month of pregnancy to Barney, thus she took Amoxicillin,
three times a day for 7 days.
Natal History
Barney was delivered via normal spontaneous delivery at home with assisted midwife. No NBS
and APGAR scoring done according to his mother. He had a birth weight of 4.1 kg. (9 lbs.), with no
fetomaternal complications noted.
Postnatal History
Barney was in a good condition at birth. There were no complications noted during the first 28
days of his life. He was breastfed by his mother.

B). Growth and Development History:
Barney grow rapidly both in size and his ability to perform tasks. He can regard with social smile
directly at people, making cooing sounds, can locate a sound in front of him, but not one behind,
differentiates cry; cries to seek attention and kicks and waves his arms when he is excited. He can turns
from side to back and shows eye coordination to light and objects.
Barney can recognize familiar face, enjoys sucking- puts hand in mouth, anticipate being feed
when in feeding position and becomes more aware and interested in environment.

C). Childhood Illnesses:
Barney did not have any serious illnesses. He just had experienced fever sometimes.

D). Immunizations/Vaccination History:
Barney was completely immunized with BCG, OPV, 1st dose of DPT and two doses of Hepatitis
B vaccine.
4

E). Operations, Injuries, Hospitalizations, Allergies:
Barney did not undergo any operations, no injuries recorded, and no known allergies to any food
and drug.

5

49
HPN

VI. FAMILY MEDICAL HISTORY WITH GENOGRAM

Most of the family members of Barney are well and in good condition aside from his grandfathers
who have hypertension and his mother who has asthma. Recent studies have found a high number of ITP
patients with a positive family history indicating the likely existence of a genetic susceptibility for ITP.
The genogram shows that there is no known history of ITP or any hematologic disorder within his family.

64
HPN

28
Well

27
Well

19
Well

23
Well

16
Well

13
Well

9
Well

40
Well

2 mos.

ITP
62
Well

39
Well

34
Well

30
Well

49
Well

24
Well

19
Well

14
Well

11
Well

21
Asthma

LEGEND:

= Male
= Female
= Patient
6

VII. PERSONAL, SOCIAL, ENVIRONMENTAL HISTORY

Barney is the only child who lives with his parents and 10 other household members in a small
two bedroom house. His father is the breadwinner of their family and provides all the needs of his wife
and son.

VIII. DEVELOPMENTAL TASKS

Freuds Psychoanalytical Theory: Oral Phase
In this stage, infants are so interested in oral stimulation or pleasure during this time. According
to this theory, infants suck for enjoyment or relief of tension, as well as for nourishment.
Barney usually sucks his hands and sucks milk from his mothers breast which he enjoys and
gives nourishment to him.

Eriksons Psychosocial Theory: Trust vs. Mistrust
Infants whose needs are met when those needs arise, whose discomforts are quickly removed,
who are cuddled, played with and talked to, come to view the world as a safe place and people as helpful
and dependable. However, when their care is inconsistent, inadequate, or rejecting, it fosters a basic
mistrust.
Barney depends on his mother to meet his needs. When he cries, he was comforted by his mother
and was subsequently breastfed and his mother is always there to provide his needed care.

Piagets Cognitive Development: Sensorimotor ( Primary Circular Reaction)
Sensorimotor intelligence is practical intelligence, because words and symbols for thinking and
problem solving are not yet available at this early age. Primary Circular Reaction refer to activities related
to a childs own body and shows that repetition of behaviors occurs.
Barney usually put his thumb to his mouth and enjoys the sensation of sucking it. He smiles
whenever he hears his parents voice and when his name was called. He cries as a response to pain.

Fowlers Developmental Theory
In this stage, infant centers on relationship with primary caregiver. Barney centers his relationship
to his mother. He usually cries when his mother is not around that is why they always bond together.

7

IX. GORDONS ASSESSMENT

Health-Perception/Health Management Pattern
Before Barney was admitted, his mother usually brought him to the nearest health center for his
vaccination. His mother gives him vitamins and he is breastfed. When Barney had fever, they gave him
antipyretic (Calpol) which provided a relief. Four days before Barney was admitted, his mother noticed
petechial rashes all over his body and thought it was just a common rash. When the fever had gradually
decreased but the rashes all over his body remained, they got worried and brought him to the nearest
hospital.
Upon hospitalization Barney had been diagnosed with ITP. His parents did not know where and how
their son acquired his disease. His mother believes that this hospitalization will help his son to recover.

Nutritional/Metabolic Pattern
Barney was born a healthy baby boy with a birth weight of 4.1 kg (9 lbs.). The normal weight
gain for 0-4 months is 170 grams (.37 lbs) per week. Before he was admitted, his appetite was very good.
He usually fed every 2-3 hours within 5-10 minutes. He is taking Tiki-tiki vitamins.
During his hospitalization, his appetite was slightly reduced and his admitting weight was
decreased from 5.8 kg to 5.6 kg which is still within the normal range. Barney was not allowed to take
any vitamins during the course of his hospitalization.

Elimination Pattern
Before Barney was admitted, he had 2-3 bowel movement everyday with yellow color, not foul in
odor, formed, and moderate in amount.
During his hospitalization, his bowel movement has not changed. His stool has the same
characteristics as before. He has no problem in urination as evidenced by normal urinalysis results.

Activity/Exercise Pattern
Before Barney was admitted he usually played with peek-a-boo and rattles with his mother. He
enjoys listening to her voice and in return he smiles and laughs. Barney cries whenever he feels hungry
and when his diaper was soaked with urine and stool. He takes a bath everyday.
During his hospitalization, he still smiles and laughs whenever his mother played with him but
most of the time he cries.

8

Sleep/Rest Pattern
Normally babys average sleeping rate is 15-16 hours. Barney sleeps mostly at night and will stay
awake much longer during the day and takes 2-3 naps a day according to his mother.
During his hospitalization, his sleeping pattern had been disturbed because of routine vital signs
taking and whenever he undergoes laboratory and diagnostic procedures.

9

X. PHYSICAL ASSESSMENT

Physical
Assessment

November 27, 2009
(Admission Day)

November 29, 2009
(Initial Visit)

a. General Appearance:

Admitted this 2 month old baby boy
with fever and petechial rashes on
face, trunk, and extremities, awake,
alert, not in cardiorespiratory distress.

Assessed this 2 month old baby boy
admitted on 10/27/09, afebrile, still
with generalized petechial rashes and
ecchymoses, asleep, on supine
position with IVF of #4 D5IMB
500cc x 24 cc/hr on left hand, patent
and infusing well.

b. Vital Signs:

BP 100/90 mmHg
T 39.3 C
HR 137 beats/min
RR 40 breaths/min
Wt 5.8 kg. (12.8 lbs.)

BP 100/70 mmHg
T 36. 1 C
HR 119 beats/min
RR 30 breaths/min
Wt 5.6 kg. (12.3 lbs)

c. Skin:

Warm, pale, good skin turgor, with
generalized petechial rashes on face,
trunk and extremities

Pale, good skin turgor, still with
generalized petechial rashes on face,
trunk and extremities

d. Head and Neck:

Normocephalic, flat fontanels, no
lesions, no clad

Normocephalic, flat fontanels
(anterior fontanel /open), no lesions,
no clad
Head Circumference: 41 cm

e. Eyes:

Pupil reactive to light, pale palpebral
conjunctiva

Pupil reactive to light, pale palpebral
conjunctiva, presence of conjunctival
hemorrhage on left eye

f. Ears:

Intact tympanic membrane, no
discharge

Intact tympanic membrane, no
discharge

g. Nose:

Symmetrical, no deformity, no skin
lesions, no swelling, no discharge

Symmetrical, no deformity, no skin
lesions, no swelling, no discharge
10

h. Mouth and Throat:

Presence of petechial rashes on buccal
mucosa and tongue midline

Presence of petechial rashes on buccal
mucosa and tongue midline

i. Breasts:

No lumps, no discharge

No lumps, no discharge

j. Chest/Lungs:

Symmetrical chest expansion, no
retractions, clear breath sounds

Symmetrical chest expansion, no
retractions, clear breath sounds
Chest Circumference: 44 cm

k. Heart:

Dynamic precordium, normal rate,
regular rhythm, no murmurs

Dynamic precordium, normal rate,
regular rhythm, no murmurs

l. Abdomen:

Globular, soft, normoactive bowel
sound

Globular, soft, normoactive bowel
sound
Abdominal circumference: 43.5 cm

m. Back

Presence of petechiae and
ecchymoses, no back deformities

Presence of petechiae and
ecchymoses, no back deformities,
diaper rash on the buttocks

n. Extremities:

Full and equal pulse, presence of
petechiae and ecchymoses on upper
and lower extremities

Full and equal pulse, presence of
petechiae and ecchymoses on upper
and lower extremities

o. Genitalia:

Grossly normal, no hernia, no
discharge

Grossly normal, no hernia, no
discharge

p. Rectal:

No hemorrhoids

No hemorrhoids

q. Neurologic
Assessment:

Not assessed

Calm, active reflexes ( sucking,
rooting, moro, palmar, tonic neck, and
babinski reflex )

11

X1. REVIEW OF SYSTEMS

Systems

November 27, 2009
(Admission Day)

November 29, 2009
(Initial Visit)

a. Skin:

() rashes
(-) lumps
(-) itching
(-) dryness
() pallor
() petechiae and purpura on
extremities and trunk

() rashes
(-) lumps
(-) itching
(-) dryness
() pallor
() petechiae and purpura on
extremities and trunk

b. Head:

(-) headache
(-) head injury

(-) headache
(-) head injury

c. Eyes:

(-) pain
(-) redness
(-) double vision
(-) glaucoma
(-) cataracts

(-) pain
() conjunctival hemorrhage
(-) double vision
(-) glaucoma
(-) cataracts

d. Ears:

(-) hearing loss
(-) tinnitus
(-) discharge

(-) hearing loss
(-) tinnitus
(-) discharge

e. Nose and Sinuses:

(-) frequent colds
(-) nasal stuffiness
(-) nose bleeds

(-) frequent colds
(-) nasal stuffiness
(-) nose bleeds

f. Mouth and Throat:

() lesions on gums
(-) sore throat
(-) hoarseness

() lesions on gums with buccal
petechial rashes
(-) sore throat
(-) hoarseness

g. Neck

(-) goiter

(-) goiter

h. Breasts:

(-) lumps

(-) lumps

12

(-) pain
(-) nipple discharge

(-) pain
(-) nipple discharge

i. Respiratory:

(-) cough
(-) sputum
(-) hemoptysis

(-) cough
(-) sputum
(-) hemoptysis

j. Cardiac:

(-) heart problem
(-) hypertension
(-) pain

(-) heart problem
(-) hypertension
(-) pain

k. GIT:

(-) hematemesis
(-) food intolerance
(-) vomiting
(-) melena
(-) hemorrhoids

(-) hematemesis
(-) food intolerance
(-) vomiting
(-) melena
(-) hemorrhoids

l. Urinary:

(-) nocturia
(-) dysuria
(-) hematuria

(-) nocturia
(-) dysuria
(-) hematuria

m. Genital:

(-) discharges
(-) hernias

(-) discharges
(-) hernias
(+) diaper rash

n. Musculoskeletal:

(-) joint pains
(-) weakness
(-) limitation of movement
(-) paralysis

(-) joint pains
(-) weakness
(-) limitation of movement
(-) paralysis

o. Peripheral Vascular:

(-) cramps
(-) thrombophlebitis

(-) cramps
(-) thrombophlebitis

p. Neurological:

(-) seizures
(-) numbness

(-) seizures
(-) numbness
(+) reflexes ( sucking, rooting,
moro, palmar grasp, tonic neck,
babinski )

13

q. Psychiatric:

(-) tension

(-) tension

r. Hematologic:

(-) anemias
() easy bruising or bleeding
(-) past transfusions

(-) anemias
() easy bruising or bleeding
(+) past transfusions ( 3 PRBC/
2 Platelet concentrate on
admission day, Nov. 27, 2009)

14

XII. COURSE IN THE WARD
Date and Time Doctors Order

Nursing Observations and
Evaluation

27 November 2009

2:18am

-Please admit patient to room of
choice under the service of Dr.
Duldulao

-Further assessment to follow

-Diet for age

-V/S q4

Diagnostic
-CBC with Platelet Count,
Coombs Test, Blood Typing,
Blood CS

-Reticulocyte Count, Peripheral
Blood Smear, PT, PTT

-Urinalysis

Therapeutic #1
-D5IMB 500cc x 24cc/hr

-Admitted to room 407-2

-Breastfed by the mother
Wt 5.8 kg. (12.8 lbs.)

BP 100/90 mmHg
T 39.3 C
HR 137 beats/min
RR 40 breaths/min

CBC:
RBC - 1.55
Hgb - 48
Hct - 0.13
WBC - 20.74
Lymphocyte - 0.44
Segmenters - 0.38
Platelet - 6
Coombs Direct (-)
Coombs Indirect (-)
Blood Type: A+

Reticulocyte Count - 5.3%
PT - 13.8
PTT Control - 28
Patient - 33

Sp Gr: 1.015
pH: 6
Glucose (-)
Protein (-)
WBC: 0-1
RBC: 0-1

-D5IMB hooked @ 6:30am &
regulated @desired rate

15

6:30am

12:30pm

-Inform Dr. Duldulao

-Refer to Dr. Naranjo for
hematologic evaluation

-Ampicillin 150mg IV q6

-Amikacin 30mg IV q8

-Save serum for possible
crossmatching

-Inform Dr. Naranjo

-For SGPT, TB, B1, B2, reverse
blood typing

-Neuro vital signs q2

-Blood transfusion regimen
(slow connection) once properly
secured, typed, and
crossmatched to be given as ff:

> 1
st
aliquot: 35cc x 4hrs
- 4hrs rest
> 2
nd
- 4hrs rest
>3
rd

-Please clarify / verify result of
blood type including
autoconnial, major, and minor
cross matching

-Secure consent.

-Transfuse PRBC properly
typed and crossmatched
(autoconnial, major, and minor
crossmatching) as follow:

>1
st
degree: BT #1- 35cc to run
for 4hrs then rest for 4hrs
>2
nd
for 4hrs then rest for 4hrs

-Dr. Duldulao informed

-Referred Dr. Naranjo

-Antibiotic drug

-Used to treat bacterial infection

-Saved blood transfusion

-Dr. Naranjo informed

SGPT - 37u/L
TB - 26.6umol/L
B1 - 17.3umol/L
B2 - 9.3umol/L

-Eyes: 2mm reacting briskly

-Checked and verified doctors
order
-Secured right indication for
patient
-Physical assessment done

-Blood properly typed and
crossmatched
Blood type: A+

-Consent secured

CBC: Indications for BT
RBC - 1.55
Hgb - 48
Hct - 0.13

-PRBC 35cc transfused and
consumed
consumed
16

12:40pm

4:42pm

7:20pm

>3
rd
for 4hrs, 4hrs rest

>BT #4&5
-Transfuse 2 units of platelet
concentrate, type specific a fast
drip and may be given in PRBC,
transfused

-V/S monitoring to q15 for 1
st

hour then q20 on the 2
nd
hour
then hourly when on transfuse

-Inform PROD once blood
provided accordingly

-IV TF > #2 D5IMB 500cc x
24cc/hr

-May give Paracetamol
100mg/ml drops, 0.6ml now

consumed.

APC: Indication for BT
Platelet-6
-2 units of platelet concentrate
transfused and consumed.

q15
T 37.7
HR -160
RR -36
BP -100/70

q30
T -38.6
HR -156
RR -35
BP -100/70

-Informed accordingly.

-D5IMB hooked @ 4:42pm &
regulated @ desired rate

-Antipyretic drug given
T - 38.6C

28 November 2009

7:30am

7:45am

9:00am

-Rounds with Dr. Duldulao

-For bed bath daily by nurse-in-
charge

-Watch out for urine output and
for occurence of hematuria for
PROD ASAP

-Update Dr. Naranjo

-Repeat CBC with platelet
count, reticulocyte count 6hrs
post 3
rd
PRBC

-Bed bath done

UO 300cc
-Watched out for melena,
hematuria or hematochesia

-Dr. Naranjo updated

CBC:
RBC - 3.91
Hgb - 116
Hct - 0.32
WBC - 9.00
Lymphocytes - 0.62
17

9:35am

10:45am

3:45pm

5:08pm

6:35pm

-For Na+, K+, Ca++, Cl at 9am

-Strict I&O monitoring

-For monitoring of vital signs to
q2hrs; include neuro vital signs

-Suggest STAT cranial UTZ to
R/O intracranial bleed (
sleeping time)

-Watch out for occurrence of
seizure

-May give Paracetamol
100mg/ml, 0.6ml now then
q4hrs PRN

-For STAT cranial ultrasound
today

-For cranial CT scan without
contact instead of cranial UTZ

-Schedule CT scan (without
contact) at Mediscan at 8:30am
tomorrow (November 29, 2009)

-Patient may go out on pass

-IVF TF: #3 D5IMB 500cc x 24
cc/hr

Segmenters - 0.23
Eosinophils - 0.07
Stabs - 0.04
Platelet - 7
Reticulocyte Count - 2.5

Na+: 137
K+: 3.9
Ca++: 2.25
Cl: 104

-I&O strictly monitored

T -36.6
HR -136
RR -41
BP -100/70
Neuro V/S 2mm RB

-No seizures noted

-Antipyretic drug given
T - 37.8C

-Cranial UTZ done @ Fe Del
Mundo Hospital

-Procedure done
Impression:
-Small focus of hemorrhage,
left vermis
-Mild fronto-temporal lobe
atrophy
-#3 D5IMB hooked @ 6:35pm
regulated @ desired rate

18

29 November 2009
(1
st
DUTY DAY)
6:50am

-Please give Diphenhydramine
6mg IV 15-30mins before the
procedure

- IVF TF: #4 D5IMB 500cc x
24 cc/hr

-Apply zinc oxide, on diaper
rashes TID

-For Bone Marrow Aspiration
tomorrow am at Fe del Mundo
Hospital

-Secure consent for BMA

-Secure needs for the procedure
Sterile gloves #2
Betadine #1
Alcohol #1
Cotton applicator
Sterile gauze (2 pads)
Syringe (10cc) #4
Lidocaine #2
Slides #10

-Show next stool to PROD

-Set abdominal circumference
now then OD, record with
separate sheet

-Antihistamine drug given for
relief of allergy condition

-#4 D5IMB hooked @ 7:00am
& regulated @ desired rate

-Emollients & skin protective
used to prevent diaper rash

-Secured consent

-Needs secured for the
procedure

Stool:
C- yellow
O-non foul
C-formed solid
A-small

-AC: 43.5cm

30 November 2009

7:00am

-May go out on pass today for
BMA at Fe del Mundo Hospital
at 10am

-For private conduction with
Pedia resident

-Bone Marrow Aspiration done
at Fe del Mundo Hospital

19

10:40am

12:00nn

10:50pm

-Shift IVF to heplock, without
on-pass

-Administered
Diphenhydramine (Benadryl)
6mg IV.

-S/P BMA right tibial

-Apply direct pressure

- Administer Paracetamol
(Calpol) 0.6ml drops.

-Inform Dr. Duldulao of Dr.
Naranjos suggestions.

-Start Hydrocortisone 10mg IV
q8

-For repeat CBC with platelet
count if with significant
bleeding

-Refer to PROD, if with bloody
stools

-Please have / get official CT
scan result at Mediscan

-IVF shifted to heplock

-Administered prior to BMA for
sedation

Results:
-Cellular marrow with noted
increase in megakaryocyte.
There is also abundant
erythrocyte in different stage of
maturation with binucleation.

-Granulocytes intact. There is a
predominance of lymphocytes
but do not appear premature.

-Symptoms: reactive marrow
consistent with immune
mediated ITP

-Direct pressure applied

-Paracetamol administered for
relief to mild to moderate pain.

V/S:
T-36.5C
PR-165 bpm
RR-62brpm
BP-100/70 mmHg

-Dr. Duldulao informed o Dr.
Naranjos suggestion

-Glucocorticosteroid drug
given for immunosuppresive
effect of antibodies
Platelet-7

-CBC not repeated

-Referred to PROD

Impression:
-Small focus of hemorrhage,
20

left vermis
-Mild fronto-temporal lobe
atrophy

01 December 2009

1:10am

cc/hr

-#5D5IMB hooked @ 1:10am

02 December 2009

1:50am

8:45am

6:05pm

cc/hr

-Update Dr. Naranjo

-Suggestions:
-Repeat CBC with platelet count
tomorrow at 5am to include
reticulocyte count

cc/hr



CBC:
RBC - 3.30
Hgb - 96
Hct - 0.28
WBC - 4.70
Lymphocytes - 0.78
Segmenters - 0.17
Platelet - 10
RC - 4.6


03 December 2009

4:35am

8:15am


-For change whole IV set

-For repeat CBC with platelet
count to include reticulocyte
count tomorrow (December 03,
2009) at 5am

-Update Dr. Naranjo

-Continue Hydrocortisone as

-Changed whole IV set

CBC:
RBC - 3.30
Hgb - 96
Hct - 0.28
WBC - 4.70
Lymphocytes - 0.78
Segmenters - 0.17
Platelet - 10
RC - 4.6


-Hydrocortisone continued
21

8:30am
previously ordered while patient
is admitted

cc/hr

Platelet-10


04 December 2009

6:00am

12:15nn

cc/hr

-D/C Amikacin

-D/C Ampicillin after 12nn dose
today


-Amikacin discontinued

-Ampicillin discontinued

05 December 2009

7:30am

1:00pm

9:05pm

9:10pm

-Update Dr. Yuson

-Repeat CBC with platelet count
today at 8am

-IVF TF: #10 D5IMB 500cc x
24 cc/hr

-Rounds with Dr. Yuson

-Suggest: To complete
antibiotics for 10-14 days

-Discontinue Hydrocortisone
(1) If vaccine-related usually
recovers spontaneously
(2) Age of patient

-Close follow-up of 3-4 days
with CBC with platelet count
and peripheral blood smear

-Update Dr. Duldulao

-Dr. Yuson updated

CBC:
RBC- 3.70
Hgb- 110
Hct- 0.32
WBC- 7.80
Lymphocytes- 0.69
Segmenters- 0.20
Platelet- 10

& regulated @desired rate

-Antibiotics completed

-Hydrocortisone discontinued

-Updated Dr. Duldulao

22

-Please start Amoxicillin
100mg/ml 0.7ml TID x 7 days

-Hold temporarily
Hydrocortisone as per Dr.
Yusons opinion

-Strict I&O, please indicate
what kind of fluid taken, if
breast feeding, please note
length of feeding

-CBC with platelet count after 3
days, please set aside peripheral
blood smear

-If IV out, may not re-intact IVF

-Antibiotic drug given for skin
infection

I breastfeed 6 times per shift
(10-15mins)
O- 200 cc + 1 BM

-IVF not re-inserted

06 December 2009

4:05am

10:50am

9:00pm


-Please observe closely for new
petechial appearance and other
bleeding

-Repeat CBC, platelet on
December 08, 2009

- Neuro vital signs to q4

-Rounds with Dr. Yuson

-Repeat CBC, platelet tomorrow
(December 07, 2009) instead of
December 08, 2009

-Observed closely for new
petechial appearance and other
bleeding

-No CBC done

-Neuro V/S: 2.5 reacting briskly

CBC:
RBC - 3.96
Hgb - 118
Hct - 0.34
WBC - 7.40
Lymphocytes - 0.76
Segmenters - 0.20
Platelet - 19
Monocytes - 0.08

08 December 2009

8:00am

-Follow-up of Dr. Yuson on
December 10, 2009 at Fe del
Mundo Medical Center 9am-
12nn

-Dr. Yuson followed-up

23

-With repeat CBC, PC,
Reticulocyte count before
follow-up

-No CBC, PC, Reticulocyte
count done before follow-up

09 December 2009

8:05am

10:55am


Home Meds:

-Amoxicillin 100mg/ml, 0.7ml
TID for 5 days

-Follow-up on December 14at
OPD 10am-12pm

-Please provide baby book c/o
IOD, provide APs cellphone
number


-May go out on pass tomorrow
with intern to Fe del Mundo,
Banawe, for follow-up with Dr.
Yuson

-Home medications for infant
instructed to parents

-Baby book provided
-APs cellphone number given

10 December 2009

2:00pm

-May go home as previously
ordered

-Home Meds: Amoxicillin
100mg/ml drops, 0.7ml TID x 2
days more

-Follow-up with AP at OPD,
every Thursday 10am-12nn with
repeat platelet count (weekly
follow-up)

-Discharged with improved
condition

CBC:
RBC - 3.93
Hgb - 116
Hct - 0.34
WBC - 6.70
Lymphocytes - 0.75
Segmenters - 0.17
Platelet - 20

24

XIII. LABORATORY RESULTS/DIAGNOSTIC PROCEDURES

Biosave Medical and Diagnostic Center
(1) Complete Blood Count Test with Actual Platelet Count
Date: 26 November 2009

Hematology
Test Normal Value Units Results
Hemoglobin
Male: 14-17
Female: 12-14
gms % 6.7
Hematocrit
Male: 42-52
Female: 37-47
vol % 0.20
Leukocytes 5-10 x 10
9
/L 5.0
Erythrocytes
Male: 5-6
Female: 4.5-5.5
x 10
12
/L 2.38

Differential Count Result
Segmenters 0.55-0.65 0.27
Lymphocytes 0.21-0.30 0.64
Monocytes 0.04-0.06 0.08
Eosinophils 0.02-0.04 0.01

Platelet Count
Test Normal Value Units Results
Platelet Count 150-450 x 10
9
/L 68

The 2-month old patient was referred to MAMC because of generalized petechiae and because of
his initial laboratory results from Biosave Medical and Diagnostic Center (complete blood count test with
actual platelet count) which revealed decreased amounts of hemoglobin, hematocrit, erythrocytes,
segmenters and eosinophils. On the other hand, he has increased amounts of lymphocytes and monocytes.
There was no bleeding, yet there was obvious ecchymoses on the trunk and extremities. The parents of
the patient were advised to admit their son in the institution if sepsis work up and if there are possible
blood or platelet disorders to have further management and care of continuous manifestations of the
clients hematologic disorder (Black; Medical-Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).
25

Manila Adventist Medical Center
(2) Hematology Test
Complete Blood Count Test with Reticulocyte and Actual Platelet Count
Dates: 10 December 2009 27 November 2009
10 December 2009 / 5:00AM
28 November 2009 / 11:49PM
27 November 2009 / 7:29AM

Test Name:
Hematology
Reference
Range
Unit
Results with Dates
10 December
5:00AM
07 December
5:17AM
05 December
9:21AM
03 December
5:02AM
28 November
11:49PM
27 November
7:29AM

Reticulocyte Count

0.4-2.1

%

3.3

4.6

2.5

5.3

CBC with Platelet
Red Cell Count 4.00-6.00 10^12/L 3.93 3.96 3.70 3.30 3.91 1.55
Hematocrit 0.37-0.47 L/L 0.34 0.34 0.32 0.28 0.32 0.13
Hemoglobin 110-160 g/L 116 118 110 96 116 48
White Cell Count 5.00-10.00 10^9/L 6.70 7.40 7.80 4.70 9.00 20.74

26

Differential Count
Lymphocytes 0.25-0.35 0.75 0.76 0.69 0.78 0.62 0.44
Monocytes 0.03-0.07 0.07 0.08 0.05 0.04 0.04 0.07
Eosinophils 0.01-0.03 0.01 0.01 0.03 0.01 0.07 0.03
Basophils 0-0.01 0.00
Segmenters 0.50-0.65 0.17 0.15 0.20 0.17 0.23 0.38
Stabs 0.05-0.10 0.01 0.04 0.02
Atypical Cells 0.02 0.06

Morphology
Hypochromasia ++
Anisocytosis Micro+

Platelet Count

140-450

10^3/uL

20

19

10

10

7

6

Red Blood Cell Indices
MCV 75.0-86.0 fL 85.8 85.9 86.2 84.8 82.9 85.2
MCH 24.0-30.0 pg 29.5 29.8 29.7 29.1 29.7 31.0
MCHC 31.0-35.0 g/dL 34.4 34.7 34.5 34.3 35.8 36.4
27

Purpose and Interpretation of Results:
Diagnosis of a blood disorder depends primarily on laboratory analysis. Although dozens of
specific tests are used to diagnose individual disorders, all cases generally call for a (1) complete blood
count (CBC) to determine the number of leukocytes and erythrocytes; (2) a total differential count to
indicate the relative percentages of the different leukocytes; (3) coagulation studies such as prothrombin
time (PT) or partial thromboplastin time (PTT) and bleeding time; (4) a bone marrow aspiration and
biopsy to determine both the cellularity of the bone marrow and the morphology of the cells present; and
(5) a peripheral blood smear ( a study of the morphology of blood cells to help differentiate various
anemias and blood dyscrasias). The results of laboratory tests also guide therapy (Black; Medical-Surgical
Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

RETICULOCYTE COUNT
A reflection of RBC production, the reticulocyte count measures the responsiveness of the bone
marrow to a diminished number of circulating erythrocytes. Specifically, this test measures the number of
reticulocytes released from the bone marrow into the blood. Based from the patients laboratory results,
he has a continuous increase in his reticulocyte count. The latest result is 3.3%. An increase in the
reticulocyte count indicates an increase in erythrocyte production, probably due to excessive RBC
destruction (e.g., hemolytic anemia) or loss (e.g., hemorrhage). A decrease in the reticulocyte count may
indicate bone marrow failure or pernicious anemia. In addition, it is employed to evaluate the
effectiveness of therapy for pernicious anemia and bone marrow failure. Although the patient has a
continuous increase of his reticulocyte count, the amount of his red blood cells is continually decreasing.
Referring to the patients bone marrow aspiration (BMA) results, there is cellular marrow with noted
increase in megakaryocyte. There are also abundant erythrocytes in a different stage of maturation with
binucleation. His body may be producing high amounts of erythrocytes as compensation for excessive
RBC loss due to insufficient amounts of platelet and clotting factors, which makes the client prone to
injuries and bleeding (Black; Medical-Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

COMPLETE BLOOD COUNT (CBC) TEST
The CBC includes the red blood cell (RBC) count, hemoglobin, hematocrit, red cell indices,
white blood cell (WBC) count with or without differential, and platelet count. CBC is done to determine
general health status and to screen for a variety of disorders such as anemia and infection. It provides
important information about the kinds and number of cells in the blood, especially red blood cells, white
blood cells, and platelets (Black; Medical-Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

28

Red Blood Cell Count
The RBC count measures the number of RBCs per cubic millimeter (mm
3
) of blood. These
values are useful in verifying findings from other hematologic tests used to diagnose anemia (RBC) and
polycythemia (RBC). Normal values vary with age and sex. Our patient is an infant boy. Infants have
not yet fully developed a strong immune system at their age. Their blood production will not be good
enough, especially when a disorder or disease attacks their health, particularly disorders that affect the
hematologic system. The incidence of ITP in children is 85% of who are under 8 years of age wherein the
disease is self-limiting. Based on the patients laboratory results, he has a continuous decrease of his red
blood cells from his admission day up to his succeeding hospital days. The latest result is 3.93 x 10^12/L.
Red blood cell count or RBC production is decreased by anemia, fluid overload, recent hemorrhage, and
leukemia. Referring to the CT scan of the head, there is a small focus of hemorrhage on the left vermis,
which could be the main cause of the patients decreasing RBC amount and reduced hematologic values
as well. The patient is anemic due to insufficient amounts of his red blood cells. Thus, the patients
hematologic system is not able to provide enough oxygen to tissues. As a tendency, there is lack of energy
in the patients activities (Black; Medical-Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

Hematocrit
Often used in place of the RBC count, hematocrit measures the percent volume of RBCs in whole
blood. This test is useful in the diagnosis of anemia, polycythemia, and abnormal hydration states. The
hematocrit value is roughly three times the hemoglobin concentration. Normal values also vary with age
and sex. Based on the patients laboratory results, there is a continuous decrease of his hematocrit level
except for his 8
th
hospital day (December 05) which revealed a normal result. The latest result is 0.34L/L.
Hematocrit level is decreased by hemodilution (fluid overload), anemia, and acute massive blood loss.
The amount of his red blood cells is low, making the hemoglobin and hematocrit levels decreased as well.
Thus, the blood is also less viscous in nature because of decreased RBC production (Black; Medical-
Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

Hemoglobin
The hemoglobin determination evaluates the hemoglobin content of erythrocytes by measuring
the number of grams of hemoglobin/100 ml of blood. This measurement helps indicate anemias and
polycythemia in clients. Normal hemoglobin levels vary with age and sex. Based on the patients
laboratory results, he has decreased amounts of his hemoglobin level only on two separate days, upon his
admission (November 27) and on his 6
th
hospital day (December 03). The latest result is 116g/L.
Hemoglobin level is decreased by hemodilution, anemia, and recent hemorrhage. The patient had a recent
29

hemorrhage as referred to in his head CT scan. The amount of his red blood cells is abnormally low,
making the hemoglobin and hematocrit levels decreased eventually. Decreased levels of hemoglobin
content evaluate poor iron status and oxygen carrying capacity of erythrocytes in the patients
hematologic system, making the patient weak and not playful at times. The patient is also possible to have
difficulty of breathing and respiratory distress because of instances of having a decrease in his
hemoglobin level, indicating insufficient oxygen circulating in the body for proper functioning of systems
(Black; Medical-Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

White Blood Cell Count
The WBC count measures the number of WBCs in a cubic millimeter (mm
3
) of blood. It helps
detect infection of inflammation and is useful in monitoring a clients response to chemotherapy or
radiation therapy. Based on the clients laboratory results, he has an increased amount of white blood cells
during his initial laboratory test upon admission (November 27). White blood cell count or WBC
production is increased by infection, leukemia, and tissue necrosis. The patient is having an infection due
to his recent hemorrhage and due to other factors. Normal production of erythocytes in the bone marrow
depends on genetically normal precursor cells, functioning bone marrow, and an adequate intake of iron,
vitamin B12, and folic acid. If any of these factors is missing, erythrocytes may be fragile, misshapen,
abnormally large or small, deficient in hemoglobin, or too few in numbers. As a reaction for this, his
WBCs tend to increase in number as a compensatory mechanism to fight against infection. On the other
hand, the patient has a decreased amount of white blood cells only on his 6
th
hospital day (December 03),
with regards to his laboratory results. White blood cell count or WBC production is decreased by bone
marrow depression. The latest result is 6.70 x 10^9/L. If the bone marrow is depressed, it cannot produce
sufficient amounts of leukocytes to fight against infection. It will only produce immature cells that would
enable foreign cells to invade the immune system, making the patient eventually susceptible to infection
and blood disorders (Black; Medical-Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

WHITE BLOOD CELL DIFFERENTIAL
This test determines the proportion of the five types of WBCs in a sample of 100 WBCs. To
figure the actual (absolute) number of a specific cell, multiply the percentage of the cell by the total WBC
count. The differential helps in evaluating the bodys capacity to resist and overcome infection and in
detecting and identifying leukemias (Black; Medical-Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

30

Lymphocytes
Lymphocytes form the integral part of the immune system. Based on the patients laboratory
results, he has a continuous increase of his lymphocytes from his admission day (November 27) up to his
succeeding hospital days. The latest result is 0.75. The amount of lymphocytes is increased by viral
infections (infectious mononucleosis, pertussis, and tuberculosis), lymphocytic leukemia, and chronic
bacterial infections. An elevated number of lymphocytes occur in response to infection and usually
directed proportional to the degree of bacterial or viral invasion (Black; Medical-Surgical Nursing; 4
th
ed.;
1993; Pp. 1328-1332).

Monocytes
Monocytes are phagocytic cells that constitute the reticulo-endothelial system and are responsible
for removing all foreign particulate material that enters the body. Based on the patients laboratory
results, he has a very minimal increase in amount of monocytes by 0.01 only on his 10
th
hospital day
(December 07). The latest result is 0.07. Monocytes are increased by infections (tuberculosis, malaria,
Rocky Mountain spotted fever), collagen vascular diseases, and monocytic leukemia. The patient had a
recent viral infection (Black; Medical-Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

Eosinophils
Eosinophils are essential to protect against parasitic infections and to modulate IgE mediated
allergic responses. Based on the patients laboratory results, the patient has a low amount of eosinophils
when he was referred to MAMC. However, on his 1
st
hospital day (November 28), he has an increased
amount of eosinophils. The latest result is 0.01. Eosinophils are decreased by stress response and
Cushings syndrome. On the other hand, they are increased by allergic reactions, parasitic infestations,
skin diseases, neoplasms, and pernicious anemia. The patient is having several blood transfusions which
make him possibly allergic to it thats why he only had BT upon his admission. In addition, the patient is
developing purpura and ecchymoses thats why the amount of his eosinophils is increased, being a
response to the allergic reactions from infection (Black; Medical-Surgical Nursing; 4
th
ed.; 1993; Pp.
1328-1332).

Basophils
Basophils form the integral part of hypersensitivity reactions. Based on the patients laboratory
results, the amount of his basophils are normal, 0.00. It is usually decreased by corticosteroids, allergic
reactions, and acute infections. Decline is unlikely to be detected because normal count is within zero to
31

minimal range. However, they are increased by leukemia, some hemolytic anemias, and polycythemia
vera (Black; Medical-Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

Segmenters, Stabs, and Atypical Cells
Based on the patients laboratory results, the patient has a continuous decrease in his segmenters
just like his RBCs. The latest result is 0.17.
Based on the patients laboratory results, the patient has a continuous decrease in his stabs just
like his RBCs. The latest result is 0.01. Early in the response to infection, immature forms of neutrophils
will be seen. These are called stab or band cells. The presence of these immature cells is called a shift to
the left and can be the earliest sign of a WBC response, even before the WBC becomes elevated. There
is also a presence of atypical cells. The latest result is 0.02 (Black; Medical-Surgical Nursing; 4
th
ed.;
1993; Pp. 1328-1332).

MORPHOLOGY / PERIPHERAL BLOOD SMEAR
A peripheral blood smear is an examination of the peripheral blood to determine variations and
abnormalities in erythocytes, leukocytes, and platelets. Cells of normal size and shape are termed
normocytes. Cells of normal color are called normochromic. Abnormalities of erythrocyte size, shape,
and color usually indicate some form of anemia. The patient has positive hypochromasia and anisocytosis
based on his laboratory results. There is a presence of those abnormal cells in the blood. Hypochromic
cells appear pale because of abnormally low hemoglobin content particularly due to the patients anemic
condition. Anisocytes vary from normal in size characterized by any of the anemias also (Black; Medical-
Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

ACTUAL PLATELET COUNT (APC) TEST
The platelet count measures the number of circulating platelets in venous or arterial blood and
evaluates thrombocyte (platelet) production, which has a role in blood clotting. The count is valuable in
assessing the severity of thrombocytopenia (abnormally low platelet count), which could result in
spontaneous bleeding. Based on the patients laboratory results, the patient has a continually low level of
his platelet count. On the other hand, his platelet count is gradually increasing but does not reach the
normal range. The latest result is 20 x 10^3/uL. Low platelet count results in prolonged bleeding time and
impaired clot retraction. Platelet count is usually decreased by Idiopathic Thrombocytopenia Purpura
(ITP), viral infection, AIDS, hemolytic disorders, chemotherapeutic drugs or radiation, hypersplenism or
splenomegaly, infiltrative bone marrow disease, and disseminated intravascular coagulation. The client is
diagnosed to have ITP. The client is prone to have bleeding disorders and is at risk for injuries. He is at
32

risk for easy bruising (bleeding in the skin that causes a characteristic skin rash called pinpoint red spots
or petechial rash), gum bleeding (bleeding in the mouth) or nosebleed, and internal bleeding. As
manifested on the patients hospital days, he had rashes, purpura, and ecchymoses which imply poor
platelet function because of insufficient amount of the essential blood component (Black; Medical-
Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

RED BLOOD CELL INDICES
RBC indices measure erythrocyte size and hemoglobin content. These values derive from the
RBC count and hemoglobin level. The three RBC indices mean corpuscular volume (MCV), mean
corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) are helpful
in assessing the various anemias (Black; Medical-Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

Mean Corpuscular Volume (MCV)
It measures the average size or volume of individual erythocytes. Based on the patients
laboratory results, he had a minimal increase in amount of MCV by 0.20 on his 8
th
hospital day
(December 05). It means that there are abnormally large (i.e., macrocytic) cells. The latest result is
85.8fL. MCV is increased by pernicious anemia, macrocytic anemia, folic acid or vitamin B12 deficiency
anemias. The patient is anemic due to RBC loss (Black; Medical-Surgical Nursing; 4
th
ed.; 1993; Pp.
1328-1332).

Mean Corpuscular Hemoglobin (MCH)
It measures hemoglobin content within erythrocyte of average size. Based on the patients
laboratory results, the client has normal amounts of MCH on his succeeding hospital days except for his
admission day (November 27). He had an increased amount of MCH that day. It indicates that macrocytic
cells with abnormally large volume of hemoglobin are present in the blood. There is also hemoglobin
deficiency (hypochromic cells). The latest result is 29.5pg. MCH is increased by macrocytic anemia
th
ed.; 1993; Pp. 1328-1332).

Mean Corpuscular Hemoglobin Concentration (MCHC)
It measures average hemoglobin concentration within 100 ml of packed red cells. Based on the
patients laboratory results, he had increased amounts of MCHC for his first two days in the hospital
(November 27 and 28). However, he had normal amounts of it for the following days. MCHC remains
normal when MCHC > 32 because cells are oversized (i.e., fewer cells can be packed together within
100ml. The latest result is 34.4g/dL. MCHC is increased by spherocytosis. A spherocyte is an abnormal
33

spheric red cell that contains more than the normal amount of hemoglobin, which could be the reason for
insufficient hemoglobin in the RBCs because they are not evenly distributed (Black; Medical-Surgical
Nursing; 4
th
ed.; 1993; Pp. 1328-1332).
34
(3) Clinical Chemistry Test (Ca, Na, K, Cl)
Date: 28 November 2009 / 11:05AM

Test Name:
Clinical Chemistry
Result Unit Reference Range
Calcium 2.25 mmol/L 2.10-2.55
Sodium 137 mmol/L 137-145
Potassium 3.9 mmol/L 3.6-5.0
Chloride 104 mmol/L 98-107

The test is helpful in assessing hydration and deficiencies of elements, which serve as major
electrolytes of the body and which are the major cations and anions within cells. It is followed carefully in
patients with uremia and in those with steroid therapy such as for our client, because one of the major
treatments for ITP is steroid therapy. Based on the patients laboratory results, he has normal and
sufficient amounts of calcium, sodium, potassium, and chloride in the intracellular and extracellular
compartments in the fluid and blood system of the body (Black; Medical-Surgical Nursing; 4
th
ed.; 1993;
Pp. 1328-1332).

(4) Clinical Chemistry Test (SGPT, Bilirubin)

Test Name:
Clinical Chemistry
SGPT (ALT) 37.0 U/L 9.0-52.0
Bilirubin T/D
Total Bilirubin 26.6 umol/L 17-180
Indirect Bilirubin (Bu)
[Unconjugated]
17.3 umol/L 10.0-180.0
Direct Bilirubin (Bc)
[Conjugated]
9.3 umol/L 0-10

35
Alanine aminotransferase (ALT), formerly SGPT, assess functions of the liver, heart, kidney, and
muscle cells and if there are damages to those organs. Elevations of this test accompany acute
hepatocellular alteration.
Serum bilirubin measures direct and indirect levels together. Direct bilirubin is increased with
impaired biliary excretion, causing conjugated fraction to accumulate in plasma. Indirect bilirubin is
increased with excessive erythrocyte hemolysis.
Based on the patients laboratory results, he has normal amounts of SGPT and serum bilirubin.
Thus, it indicates that his hepatic, biliary tract, and exocrine pancreatic system including the liver, heart,
kidney, and other organs are properly functioning (Black; Medical-Surgical Nursing; 4
th
ed.; 1993; Pp.
1328-1332).

(5) Coagulation Test (PTT, PT)

Test Name:
Coagulation
PTT
Control 28.0 Sec 23.7-42.5
Patient 33.0 Sec
PT
Patient 13.8 Sec 10.8-13.8
Activity 79.8 %
INR 1.12

Laboratory studies provide the most crucial evidence for pinpointing the type and cause of a
bleeding disorder. Initially, four basic laboratory tests are performed to discern whether the bleeding
problem is due to a vascular, coagulation, or platelet defect. These tests include bleeding time, PT,
platelet count, and PTT. Ninety-nine percent of all bleeding disorders are diagnosed by the PT and PTT.
Partial thromboplastin time (PTT) is a complex method for testing normalcy of intrinsic
coagulation process. It is employed to identify deficiencies of coagulation factors, prothrombin, and
36
fibrinogen. It also monitors heparin therapy. Prolongation of time indicates coagulation disorder due to
deficiency of a coagulation factor. It is not a diagnostic for platelet disorders.
Prothrombin time (Pro time / PT) determines activity and interaction of factors V, VII, X,
prothrombin, and fibrinogen. It is also used to determine dosages of oral anticoagulant drugs.
Prolongation of time indicates person receiving anticoagulants; abnormally low fibrinogen concentration;
deficiencies of factors II, V, VII, and X; presence of circulating anticoagulants as seen in lupus
erythematosus; and impaired prothrombin activity.
Based on the patients diagnostic test results, he has normal results with regards to PTT and PT
test, which indicates normal intrinsic coagulation process of clotting factors. He has no deficiencies with
fibrinogen concentration (Black; Medical-Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

(6) Coombs Test

Test Name: Results Normal Values
Coombs Direct Negative Negative
Coombs Indirect Negative Negative

Direct antiglobulin test (Coombs test) is used to detect certain antigen-antibody reactions
between serum antibodies and RBC antigens, differentiate between various forms of hemolytic anemia,
determine unusual blood types, and test for hemolytic diseases in newborns. The direct antiglobulin test
examines erythrocytes for the presence of antibodies (agglutinins) that damage erythrocytes without
causing clumping or hemolysis. It is used to crossmatch blood for blood transfusions, test umbilical cord
for erythroblastosis fetalis, and diagnose acquired hemolytic anemia.
The indirect antiglobulin test identifies antibodies to erythrocyte antigens in the serum of clients
who have a greater than normal chance of developing transfusion reactions. Both tests are agglutination
procedures that use a suspension of RBCs.
Based on the patients diagnostic test results, he has negative results for both direct and indirect
Coombs test which indicate normal results. There is no presence of agglutinins that damage the RBCs
th
ed.; 1993; Pp. 1328-1332).

37
(7) Group and RH Type Test

Test Name: Result
Group and RH Type A positive

This test is essential in order to determine the patients blood type that would properly crossmatch
and fit in the blood transfusion procedures. Blood transfusion is needed because of lack of blood
components and in order to give and maintain an enough supply of oxygen in the patients body system.
The patient has a blood type of A+, which has anti-B antibodies (Black; Medical-Surgical Nursing; 4
th

ed.; 1993; Pp. 1328-1332).

(8) Routine Culture and Sensitivity Test
Growth: No growth
Organism(s) Isolated: No organism isolated

This test is used to assess for the presence and growth of abnormal organisms or whether there is
isolation of organisms (Black; Medical-Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

(9) Urine Analysis

Macroscopic
Color:
Transparency:
Volume:

Chemical
Specific Gravity:
Result
Light Yellow
Clear
60 mL
Result
1.010
7.0
Negative
Microscopic
White Blood Cells:
Red Blood Cells:
Epithelial Squamous:
Epithelial Round:
Amorphous Sediment:
Crystals:
Casts:
Result
0-2/HPF
0-1/HPF
Occasional
None
None
None
None
38
pH Reaction:
Glucose:
Ketone:
Blood Occult:
Protein:
Nitrite:
Leucocyte Esterase:
Negative
Negative
Negative
Negative
Negative
Mucus:
Bacteria:
Negative
Occasional

Urine analysis (urinalysis) is a physical, microscopic, or chemical examination of urine. The
specimen is physically examined for color, turbidity, and specific gravity. Then it is spun in a centrifuge
to allow collection of a small amount of sediment, which is examined microscopically for blood cells,
casts, crystals, pus, and bacteria. Chemical analysis may be performed to measure the pH and to identify
and measure the levels of ketones, sugar, protein, blood components, and many other substances. Based
on the patients laboratory results, the color of his urine is light yellow, which is a very healthy sign,
which indicates that there is no presence of kidney or urinary disorders in the patient. There is no blood
occult present in the urine, which indicates that there is no internal, or intestinal bleeding that takes place
in the patients digestive system. His renal system is functioning well (Black; Medical-Surgical Nursing;
4
th
ed.; 1993; Pp. 1328-1332).

(10) CT Scan of the Head

Plain axial CT images were obtained.
A small focus of hemorrhage is seen on the left side of the vermis.
No extra axial hematoma.
Ventricle is normal in size.
No midline shift demonstrated.
No abnormal calcification seen.
Peripheral sulci in the frontal and temporal lobes are accentuated.
There is beginning closure of both occipital sutures.

39
Impression:
Small focus of hemorrhage, left vermis.
Mild fronto-temporal lobe atrophy

Purpose and Interpretation of Result:
The cranial CT scan is essential to assess and determine any deformities or damages in the
skeletal system of the patients head. Based on the diagnostic procedure done with the patient, the result
reveals a small focus of hemorrhage in the left vermis and mild fronto-temporal lobe atrophy which
contributes a lot to the decreasing blood component values of the patient for a couple of days (Black;
Medical-Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

(11) Blood Transfusion

Blood
Transfusion #

Volume of Blood
Desired
Remarks
BT 1 35cc
Transfuse PRBC properly typed and crossmatched (autoconnial, major and minor
crossmatching)
1
st
aliquot: 35cc to run for 4hours then rest for 4hours
BT 2 45cc
crossmatching)
2
nd
aliquot: 45cc to run for 4hours then rest for 4hours
BT 3 55cc
crossmatching)
3
rd
aliquot: 55cc to run for 4hours
BT 4 2units
Transfuse 2units of platelet concentrate, type specific as fast drip and may be given
in between PRBC transfusion.
BT 5 2units
Transfuse 2units of platelet concentrate, type specific as fast drip and may be given
in between PRBC transfusion.

Purpose:
Blood transfusion is the administration of whole blood or a component, such as packed red
cells, to replace blood lost through trauma, surgery, or disease. Blood for transfusion is obtained from a
healthy donor or donors whose ABO blood group and antigenic subgroups match those of the recipient
and who have an adequate hemoglobin level.
40
This procedure is really essential and necessary for our patient because of the continuous
decrease in amounts of several blood components, particularly the red blood cells and hemoglobin which
are generally responsible for maintaining the iron status and oxygenation that would circulate in the
bloodstream; and platelets that are mainly responsible for the clotting action in response to bleeding and
inflammation (Black; Medical-Surgical Nursing; 4
th
ed.; 1993; Pp. 1328-1332).

41
XIV. NURSING OR DIAGNOSTIC PROCEDURES WITH NURSING RESPOSIBILITIES

1. CT Scan - is a method of taking an image of the brain. CT stands for computed tomography, a
procedure that produces a clear, two-dimensional image of the brain that shows abnormalities such as
brain tumors, blood clots, strokes, or damage due to head injury. A CT scan can help identify the cause of
Alzheimer's-like symptoms either by finding an abnormality or by ruling out certain conditions.

A. Indications for procedure
The doctor may recommend a CT scan to help pinpoint the location of an infection or blood clot and
detect internal injuries and internal bleeding or intracranial hemorrhage.

B. Procedure with Nursing Responsibilities
Preparing a patient for a CT scan depends on which part of the body is being scanned. The patient
may be asked to remove his clothing and wear a hospital gown. He will need to remove any metal objects,
such as jewelry, that might interfere with image results. Some CT scans require the patient to drink a
contrast liquid before the scan or have contrast injected into a vein in his arm during the scan. A contrast
medium blocks X-rays and appears white on images, which can help emphasize blood vessels, bowel or
other structures. If a test involves a contrast medium, the doctor may ask the patient to fast for a few hours
before the test. Depending on the part of the body being scanned, the doctor may ask the patient to take
laxatives, enemas or suppositories, or temporarily modify his diet. If an infant or toddler is having the CT
scan, the doctor may give the child a sedative to keep him or her calm and still. Movement blurs the
images and may lead to incorrect results. Ask the doctor how best to prepare a child. The parent may be
allowed to stay with his or her child during the test. If so, he or she may be asked to wear a lead apron to
shield him or her from X-ray exposure.

C. Risks and Complications
CT scan risks are similar to those of conventional X-rays. During the CT scan, the patient is briefly
exposed to radiation. Although rare, the contrast medium involved in a CT scan poses a slight risk of
allergic reaction. Most reactions are mild and result in hives or itchiness. For people with asthma who
become allergic to the contrast medium, the reaction can be an asthma attack. In rare instances, an allergic
reaction can be serious and potentially life-threatening including swelling in patients throat or other areas
of his body. If the patient experience hives, itchiness or swelling in his throat during or after his CT exam,
immediately inform the technologist or doctor. If the patient had a reaction to a contrast medium in the
past, and need a diagnostic test that may require a contrast medium again, inform the doctor. Be sure to let
42
the doctor know if the patient has kidney problems, since contrast material that's injected into a vein is
removed from the body by the kidneys and could potentially cause further damage to the kidneys.

2. Bone Marrow Aspiration (BMA) - the removal of a small amount of bone marrow (usually from the
hip) through a needle. The needle is placed through the top layer of bone and a liquid sample containing
bone marrow cells is obtained through the needle by aspirating (sucking) it into a syringe. The suction
causes pain for a few moments.
A bone marrow is done to look for the cause of problems with red blood cells, white blood cells,
or platelets in people who have conditions such as thrombocytopenia, anemia, or an abnormal white blood
cell count.
Before the test, parents should know that their child will most probably cry, and that restraints
may be used. To provide comfort, and help their child through this procedure, parents are commonly
asked to be present during the procedure. Crying is a normal infant response to an unfamiliar
environment, strangers, restraints, and separation from the parent. Infants cry more for these reasons than
because they hurt. An infant will be restrained by hand or with devices because they have not yet
developed the physical control, coordination, and ability to follow commands as adults have. The
restraints used thus aim to ensure the infant's safety. After the needle is removed, the biopsy site is
covered with a clean, dry pressure bandage. The patient must remain lying down and is observed for
bleeding for one hour. The patient's pulse, breathing, blood pressure, and temperature are monitored until
they return to normal. The biopsy site should be kept covered and dry for several hours.
Bone marrow exams don't usually pose a big risk. Complications are rare, and those that do occur
are often mild. They include excessive bleeding, particularly in people with a low platelet count,
Infection, especially in people with weakened immune systems, breaking of needles within the bone,
which may cause infection or bleeding, long-lasting discomfort at the biopsy site, and complications
related to sedation, such as an allergic reaction, nausea or irregular heartbeats.

43
3. Blood Transfusion - is the process of transferring blood or blood-based products from one person into
the circulatory system of another. Blood transfusions can be life-saving in some situations, such as
massive blood loss due to trauma, or can be used to replace blood lost during surgery. Blood transfusions
may also be used to treat a severe anemia or thrombocytopenia caused by a blood disease.

Blood transfusions are done to replace blood lost during surgery or due to a serious injury. A
transfusion also may be done if the body can't make blood properly because of an illness.

Check if the patients blood has been typed and cross-matched. Verify that patient or significant
others (SO) have signed a written consent form. Instruct the patient or SO about signs and symptoms of
transfusion reaction (itching, hives, swelling, shortness of breath, fever, chills). Take patients
temperature, pulse, respiration, and blood pressure to establish baseline for comparing vital signs during
transfusion. Double check the labels with another nurse or physician to make sure that the ABO group
and Rh type agree with the compatibility record. Check the number and type on the donor blood label and
on the patients chart are correct. Check the patients identification by asking the patients name or SO
and checking the identification wristband. Check the blood for gas bubbles and any unusual color or
cloudiness (gas bubbles may indicate bacterial growth and abnormal color or cloudiness may be a sign of
hemolysis). Make sure PRBC transfusion is initiated within 30 minutes after removal of the PRBC from
the blood bank refrigerator. Be alert for signs of adverse reactions.

The risks of blood transfusions include transfusion reactions (immune-related reactions), non-immune
reactions, and infections. Immune-related reactions occur when your immune system attacks components
of the blood being transfused or when the blood causes an allergic reaction. Most transfusion reactions
occur because of errors made in matching the recipient's blood to the blood transfused. These
administrative errors may occur because of mislabeled blood samples or misread labels. Much effort is
made to prevent these errors; they occur about once in every 14,000 transfusions.

Even receiving the
correct blood type sometimes results in a mild transfusion reaction. These reactions may be mild or
severe. Most mild reactions are not life-threatening when treated quickly. Even mild reactions, though,
can be frightening. Severe transfusion reactions can be life-threatening. Mild allergic reactions may
involve itching, hives, wheezing, and fever. Severe reactions that involve anaphylactic shock can be life-
threatening.
44
Fluid overload is a common type of non-immune reaction. Fluid overload can occur when you
receive too much fluid through transfusions, especially if you have not experienced blood loss before the
transfusion. Fluid overload may require treatment with medicines to increase urine output (diuretics) to
rid your body of the excess fluid. Very rarely, a person can develop iron overload after having many
repeated blood transfusions. This condition, sometimes called acquired hemochromatosis, is often treated
with medicine. Too much iron can have an effect on many organs in the body.
The transmission of viral infections, such as hepatitis B or C or HIV, through blood transfusions
has become very rare because of the safeguards enforced by the U.S. Food and Drug Administration
(FDA) on the collection, testing, storage, and use of blood. The risk of infection from a blood transfusion
is higher in less developed countries, where such testing may not happen and paid donors are used. It is
possible for blood, especially platelets, to become contaminated with bacteria during or after donation.
Transfusion with blood that has bacteria can result in a systemic bacterial infection. Because of the
precautions taken in drawing and handling donated blood, this risk is small. There is a greater risk for
bacterial infection from transfusions with platelets. Unlike most other blood components, platelets are
stored at room temperature. If any bacteria are present, they will grow and cause an infection when the
platelets are used for transfusion.

45
XV. NORMAL PHYSIOLOGY

The Immune System
The immune system is composed of many interdependent cell types that collectively protect the
body from bacterial, parasitic, fungal, viral infections and from the growth of tumor cells. Many of these
cell types have specialized functions. The cells of the immune system can engulf bacteria, kill parasites or
tumor cells, or kill viral-infected cells. Often, these cells depend on the T helper subset for activation
signals in the form of secretions formally known as cytokines, lymphokines, or more specifically
interleukins.
The organs of the immune system include the lymphatic vessels, lymph nodes, tonsils, thymus,
Peyer's patch, and spleen. Each of these organs either produces the cells that participate in the immune
response or serves as a site for immune function. Lymphocytes, a type of white blood cell, are
concentrated in the lymph nodes, which are masses of tissue that act as filters for blood at various places
throughout the body-most notably the neck, under the arms, and in the groin. As the lymph (white blood
cells plus plasma) filters through the lymph nodes, foreign cells are detected and overpowered.
The tonsils, located at the back of the throat and under the tongue, contain large numbers of
lymphocytes and filter out potentially harmful bacteria that might enter the body via the nose and mouth.
Peyer's patches, scattered throughout the small intestine and appendix, are lymphatic tissues that perform
this same function in the digestive system. The thymus gland, located within the upper chest region, is
another site of lymphocyte production, though it is most active during childhood. The thymus gland
continues to grow until puberty, protecting a child through the critical years of early development, but in
adulthood it shrinks almost to the point of vanishing.
Marrow, the soft tissue at the core of bones, is a key producer both of lymphocytes and of another
component of blood, the hemoglobin-containing red blood cells. Because of its critical role in the immune
system, it is a very serious decision to allow marrow to be extracted (itself an extremely serious operation,
of course) for use in a cancer treatment, as described in Noninfectious Diseases. The spleen, in addition to
containing lymphatic tissue and producing lymphocytes, acts as a reservoir for blood and destroys worn-
out red blood cells.
The functioning of the immune system also calls into play a wide array of substances, most
notably antibodies and the two significant varieties of lymphocyte: B cells and T cells. Antibodies, the
most well known of the three, are proteins in the human immune system that help fight foreign invaders.
B cells (B lymphocytes) are a type of white blood cell that gives rise to antibodies, whereas T cells (T
lymphocytes), are a type of white blood cell that plays an important role in the immune response. T cells
are a key component in the cell-mediated response, the specific immune response that utilizes T cells to
46
neutralize cells that have been infected with viruses and certain bacteria. There are three types of T cells:
cytotoxic, helper, and suppressor T cells. Cytotoxic T cells destroy virus-infected cells in the cell-
mediated immune response, whereas helper T cells play a part in activating both the antibody and the cell-
mediated immune responses. Suppressor T cells deactivate T cells and B cells when needed, and thus
prevent the immune response from becoming too intense.

The Blood
The primary function of blood is to supply oxygen and nutrients as well as constitutional
elements to tissues and to remove waste products. Blood also enables hormones and other substances to
be transported between tissues and organs. Problems with blood composition or circulation can lead to
downstream tissue malfunction. Blood is also involved in maintaining homeostasis by acting as a medium
for transferring heat to the skin and by acting as a buffer system for bodily pH.
The blood is circulated through the lungs and body by the pumping action of the heart. The right
ventricle pressurizes the blood to send it through the capillaries of the lungs, while the left ventricle
repressurizes the blood to send it throughout the body. Pressure is essentially lost in the capillaries, hence
gravity and especially the actions of skeletal muscles are needed to return the blood to the heart.
Normally, 7-8% of human body weight is from blood. In adults, this amounts to 4-5 quarts of
blood. This essential fluid carries out the critical functions of transporting oxygen and nutrients to our
cells and getting rid of carbon dioxide, ammonia, and other waste products. In addition, it plays a vital
role in our immune system and in maintaining a relatively constant body temperature.

Blood Components

A. Red blood cells (Erythrocytes)
Red blood cells are relatively large microscopic cells without nuclei. Red cells normally make up
40-50% of the total blood volume. They transport oxygen from the lungs to all of the living tissues of the
body and carry away carbon dioxide. The red cells are produced continuously in the bone marrow from
stem cells at a rate of about 2-3 million cells per second. Hemoglobin is the gas transporting protein
molecule that makes up 95% of a red cell. Each red cell has about 270,000,000 iron-rich hemoglobin
molecules. People who are anemic generally have a deficiency in red cells. The red color of blood is
primarily due to oxygenated red cells. Human fetal hemoglobin molecules differ from those produced by
adults in the number of amino acid chains. Fetal hemoglobin has three chains, while adults produce only
two. As a consequence, fetal hemoglobin molecules attract and transport relatively more oxygen to the
cells of the body.
47
B. White blood cells (Leukocytes)
White blood cells exist in variable numbers and types but make up a very small part of blood's
volume--normally only about 1% in healthy people. White blood cells are the largest of the blood cells
but also the fewest. There are 5,000 to 10,000 white blood cells per micro liter. There are several different
types of white cells but all are related to immunity and fighting infection. Leukocytes are not limited to
blood. They occur elsewhere in the body as well, most notably in the spleen, liver, and lymph glands.
Most are produced in our bone marrow from the same kind of stem cells that produce red blood cells.
Others are produced in the thymus gland, which is at the base of the neck. Some white cells (called
lymphocytes) are the first responders for our immune system. They seek out, identify, and bind to alien
protein on bacteria, viruses, and fungi so that they can be removed. Other white cells (called granulocytes
and macrophages) then arrive to surround and destroy the alien cells. They also have the function of
getting rid of dead or dying blood cells as well as foreign matter such as dust and asbestos. Red cells
remain viable for only about 4 months before they are removed from the blood and their components
recycled in the spleen. Individual white cells usually only last 18-36 hours before they also are removed,
though some types live as much as a year.

C. Platelets (Thrombocytes)
Platelets are only about 20% of the diameter of red blood cells, the most numerous cell of the
blood. The normal platelet count is 150,000-450,000 per microliter of blood, but since platelets are so
small, they make up just a tiny function of the blood volume. The principal function of platelets is to
prevent bleeding. Platelets are produced in the bone marrow, the same as the red blood cells and most of
the white blood cells. They are produced from very large bone marrow cells called megakaryocytes. As
megakaryocytes develop into giant cells, they undergo a process of fragmentation that results in the
release of over 1,000 platelets per megakaryocytes. The dominant hormone controlling megakaryocytes
development is thrombopoietin.
Platelets are not only the smallest blood cell, they are the lightest. Therefore they are pushed out
from the center of flowing blood to the wall of the blood vessel. There they roll along the surface of the
vessel wall, which is lined by cells called endothelium. The endothelium is a very special surface, like
Teflon, that prevents anything from sticking to it. However when there is injury or cut, and the endothelial
layer is broken, the tough fibers that surround a blood vessel are exposed to the liquid flowing blood. It is
the platelets react first to injury. The tough fibers surrounding the vessel wall, like an envelop, attract
platelets like a magnet, stimulate the shape change, and platelets the lump onto these fibers, providing the
initial seal to prevent bleeding, the leak of red blood cells and plasma through the vessel injury.
48
Platelets are vital for normal blood clotting. Produced in the bone marrow, they circulate in the
blood until they are needed. When there is an injury to a blood vessel, platelets adhere to the injury site
(with the help of von Willebrand factor, which acts as the glue), aggregate with other platelets, release
compounds that stimulate further aggregation, and form a loose platelet plug in a process called
hemostasis.

49

XVI. PATHOPHYSIOLOGY

A. Pathophysiology Diagram

Etiology: Idiopathic Predisposing factors:
-Common in children less than 2-4 y.o.
-Previous exposure to bacterial infection
during prenatal period. (UTI of mother)
-Recent live/attenuated vaccines
Risk factors:
-Age (common in children
and young adults)
-Gender (common in women)

Inflammatory response of the body
Fever-T-39.3C
Nov. 27, 2009
Body weakness
Dec. 1, 2009

Stimulates immune system
Dominance of pro-inflammatory
cytokines & T-cell repertoire
Abnormal autoimmune reaction
(Auto-immunity)
Production of anti-bodies
Nov. 27, 2009 Dec. 5,2009
Paracetamol (Calpol) Amoxicillin
Ampicillin (Omnipen) (Amoxil)
Amikacin (Amikin)
React with platelet
membrane
Platelet become
antigenic
Anti-bodies bind with viral
or bacterial antigen
Phagocytosed by splenic
macrophages
Destruction of platelets
Production of antibodies
against glycoprotein
IgG coated the platelets
Lab Results:
White Cell Count:
Nov. 27, 2009 20.74 x10
9
/L
Nov. 28, 2009 9.00 x10
9
/L
Dec. 3, 2009 4.70 x10
9
/L
Dec. 5, 2009 7.80 x10
9
/L
Dec. 7, 2009 7.40 x10
9
/L
Dec. 10, 2009 6.70 x10
9
/L
Nov.30, 2009
Hydrocortisone
(Cortef)
Legend:
- Manifestation
- Lab results
- Medications
- Diagnostic
procedures
50

platelet count
Blood Transfusion:
Nov. 27, 2009
BT 1-35 cc PRBC
BT 2-45cc PRBC
BT 3-55cc PRBC
BT 4-2 units platelet concentrate
BT 5-2 units platelet concentrate

Bone Marrow Aspiration
Nov. 30, 2009

Lab Results:
Platelet count:
(Reference range 140-450 x 10
3
/UL)
Nov. 27, 2009 6 x 10
3
/UL
Nov. 28, 2009 7 x 10
3
/UL
Dec. 3, 2009 10 x 10
3
/UL
Dec. 5, 2009 10 x 10
3
/UL
Dec. 7, 2009 19 x 10
3
/UL
Dec. 10, 2009 20 x 10
3
/UL

number of cytotoxic cells
Nov.29, 2009
Diphenhydramine
(Benadryl)
Pain
Nov.30, 2009

Demand in number of platelets
Workload for Megakaryocytes to
produce new platelets
Damaged megakaryocyte
platelet lifespan
51

Altered clotting Delayed wound healing
If blood vessel has been damaged
Leak in blood vessel
Lab Results:
Coagulation Test:
PTT
(Reference range 23.7-42.5 sec)
control-28.0 sec
patient-33.0 sec

PT
(Reference range 10.8-13.8 sec)
patient- 13.8 sec
activity-70.8 %
INR-1.12

*The coagulation test is normal.
There is altered blood clotting due to
decreased number of platelets and
not due to absence of clotting
factors.
Local hemorrhage
52

Physical Assessment:
Nov. 27, 2009
-petechial rashes on face, trunk, extremeties,
buccal mucosa, tongue midline & left eye
Nov. 29, 2009
-purpura on face, extremeties & trunk

Blood volume
Dehydration
Narrow pulse
pressure 100/90 bpm
number of RBC
number of Hgb
Pale skin color
Nov.27, 2009

When there is intracranial hemorrhage
Hemorrhagic shock
Possible complication:
DEATH
Permanent loss of brain
function
CT-Scan of the Head:
Nov. 29, 2009
A small focus of
hemorrhage is seen on
the left side of vermis.

Lab Results:
Date: Hgb Hct
(110-160 g/L) (0.37-0.47
L/L)
Nov. 27, 2009 48 0.13
Nov. 28, 2009 116 0.32
Dec. 3, 2009 96 0.28
Dec. 5, 2009 110 0.32
Dec. 7, 2009 118 0.34
Dec. 10, 2009 116 0.34

Oxygen supply
Body weakness
Dec. 1, 2009

53
B. Pathophysiology Narrative
Idiopathic thrombocytopenic purpura (ITP), also called immune thrombocytopenic purpura, is a
blood-clotting disorder that can lead to easy or excessive bruising and bleeding. ITP results from
unusually low levels of platelets, the cells that help the blood clot. ITP is a common manifestation

of
autoimmune disease in children. The syndrome maybe preceded by bacterial/viral infection.
In the patients case previous infection of the mother and recent live/ attenuated vaccines
triggered him to acquire the disease. The dominance of pro-inflammatory cytokines and T cell repertoire

causing the body to develop fever and cough as an inflammatory response of body against infection that
persist in patient creating a permissive environment

for the emergence of previously suppressed auto
antibodies that will triggers the immune system to have an abnormal autoimmune reaction where in the
antibodies produced bind with viral antigen and cross react with platelet causing the platelet membrane
proteins become antigenic and stimulate the immune system to produce auto antibodies and cytotoxic
cells. These auto antibodies are against platelet glycoprotein GPIIb-IIIa or GP1b-IX that attributed to the
ability of these auto antibodies to coat circulating platelets. Instead of only phagocytosing the viral
antigen by splenic macrophages what happens is, it also phagocytosed the antibody coated platelet
because the body cannot distinguished self from non self. Cytotoxic cells damage megakaryocyte
production of new platelets causing the platelets to survive only a few hours instead of normal which is 7-
10 days that result in destruction of platelets because of cytotoxic T cells and splenic macrophages that
result in decrease platelets count.
There is altered blood clotting due to decrease number of platelets and not due to absence of
clotting factors. Thus, delayed wound healing is present that results to hemorrhage. On the other hand
when blood vessels have been damaged leakage in blood vessels is also manifested that results in local
hemorrhage. There are three things that can happen if there is hemorrhage. First, it will result to decrease
in blood volume and because of it dehydration can occur and narrow pulse pressure will be evident.
Second, a decrease in number of RBC and hemoglobin causes decrease in oxygen supply to the body;
leading to body weakness and pale skin color as manifested by the patient. Third, petechial rashes and
purpura on the face, trunk, extremities, buccal mucosa, tongue midline and left eye will be visible because
of ruptured blood vessel. On Barneys CT scan result there is a small focus of hemorrhage seen on the left
side of his vermis. This finding may result to permanent loss of brain function and probably death.

54
VII. NURSING CARE PLAN

Problem Prioritization
1. Acute pain
2. Risk for further bleeding
3. Fever
4. Risk for infection
5. Body weakness
6. Lack of knowledge
7. Disabled family coping

55

NURSING
PROBLEM with
CUES

NURSING DIAGNOSIS
with RATIONALE (with
reference)

(SMART) GOALS/
OBJECTIVES

NURSING
INTERVENTIONS

RATIONALE FOR
INTERVENTIONS

EXPECTED
OUTCOMES

EVALUATION

1. Acute pain
Date: Nov. 30,2009

Subjective:

Iyak siya ng iyak
dahil kakatapos niya
pa lang ng bone
marrow aspiration,
as verbalized by the
mother.

Objective:

moaning
vigorous cry
T 36.5 C
HR-62 bpm
RR-165 bpm
BP 100/70mmhg
Restlessness
Irritability

Acute pain related to
actual tissue damage.

Rationale:
An unpleasant sensory
and emotional
experience arising from
actual or potential tissue
damage or described in
terms of such damage;
pain may be sudden or
slow onset, vary in
intensity from mild to
severe, and be constant
or recurring; duration of
pain is less than 6
months; and period of
pain has an anticipated
or predictable end.
(Parks and Taylors
Nursing Diagnosis
Reference Manual 7
th

edition; p. 508)

Short term goal:

Within 30 minutes to
1 hour of nursing
interventions, the
patient will show
signs of relief from
pain and discomfort
as evidence by
having a good cry,
not irritable, and by
being calm.

Long term goal:

After 2-3 days of
nursing interventions,
patient will be free
from pain discomfort
as evidenced by
continually being
calm and not irritable.

1. Assessed childs
physical symptoms and
behavioral cues such as
moaning and crying.

2. Repositioned the client
and gave other comfort
measures.

3. Applied heat or cold as
appropriate to the pain
site.

1. Young child lacks
verbal skills to describe
variation in pain
sensation. Observations
of non-verbal behavior
provide alternative
means to assess pain in a
child.
(Nursing Diagnosis
Reference Manual 7
th
ed.
p.509)

2. Non pharmacologic
techniques decrease the
pain and may enhance
the effectiveness of
analgesics if given by
reducing muscle tension.
(Nursing Diagnosis
Reference Manual 7
th
ed.
p.509)

3. Applying heat relaxes
the muscles and
decreases pain. Applying
cold results in
vasoconstriction
reducing inflammatory
response and reducing
pain.(Nursing Diagnosis
Reference Manual 7
th
ed.

1. Child will
demonstrate
improve comfort
through less cry,
smiling, playful
behavior, good
appetite
(breastfeed) and
responsive
behavior.

Short term
goal:
Goal not met.
The patient is
still in pain and
discomfort.

Long term
goal:
Goal met. The
patient was
free of pain
and discomfort.

56

4. Helped the child
obtained an interrupted
rest periods.

5. Anticipated and
checked the patient from
time to time for onset of
pain.

6. Administered pain
medication as ordered,
Paracetamol (Calpol)
0.6ml drops

7. Provided non-
pharmacologic treatment
such as giving bonding or
encouraging touch
therapy of the mother for
the infant and providing
classical music.

p.509)

4. Adequate rests
promotes the childs well
being and enhances the
effectiveness of pain
medication.(Nursing
Diagnosis Reference
Manual 7
th
ed. p.509)

5. Careful pain
management can
improve relief.
(Nursing Diagnosis
Reference Manual 7
th
ed.
p.509)

6. Relief of mild to
moderate pain. (MIMS)

7. Touch is the most
intimate and meaningful
of nonverbal techniques
that could also be
therapeutic. It lessens
pain and diverts the
childs feelings when he
is aware that the primary
caregiver (mother) is
present. The type of
children to which
children prefer to listen
often conveys and
soothes their
57

8. Provided a variety of
stimulating toys and
divertional activities and
play for the infant such as
playing a peek-a-boo
and rattles.
mood.(Pillitteri, Adele;
MCHNursing; p.998)

8. It is an additional, yet
important and creative
interventions that can
divert the childs
attention, promote a
sense of well-being, and
make the child more
invigorated. It can also
enhance and develop the
childs neurologic system
and reflex activities as
well.(Pillitteri, Adele;
MCHNursing; p. 1054)

58

NURSING
PROBLEM with
CUES

NURSING DIAGNOSIS
with RATIONALE
(with reference)

(SMART) GOALS/
OBJECTIVES

NURSING
INTERVENTIONS

RATIONALE FOR
INTERVENTIONS

EXPECTED
OUTCOMES

EVALUATION

2. Risk for Further
Bleeding
Date: Nov. 29, 2009

Subjective:

Ang dami niyang
pasa at rashes as
verbalized by the
patients mother.

Objective:

Petechial Rashes
and ecchymoses
on body and
extremities
Hematology:
(Nov. 28, 2009)
-Platelet: 6 10
3
/UL
-Hgb: 116
-Hct: 0.32
V/S as follows:
(Nov. 29, 2009)
-T: 36.1C
-HR: 119 bpm
-RR: 30 bpm
-BP: 100/70mmHg

High Risk for Injury:
Bleeding related to
decreased platelet count

Rationale:

Platelets play an
important role in
clotting and bleeding.
In people with a low
platelet count, bleeding
is more likely to occur,
even after a slight
injury. Low platelet
count may result in
spontaneous bleeding.
(Merck Manual, 2009,
Sec. 3, chapter 49)

Short term goal:

Within the shift,
patients risk for
further bleeding is
reduced as evidenced
by vital signs within
normal range, absence
of narrowed pulse
pressure and decreased
signs of bleeding
(bruises/ petechiae,
epistaxis, bleeding
gums, abdominal pain,
hematemesis,
hematuria, melena).

Long term goal:

Within 2-3 days of
patient will maintain
reduced risk of further
bleeding as evidence
by normal platelet
count and absence of
any signs of bleeding
(bruises/petechiae)

1. Assessed and
monitored vital signs.

2. Assessed for any signs
of bleeding.

3. Monitored platelet
count.

4. Avoided IV /SC
injections and rectal
procedures (such as
enemas and rectal
temperature taking) as
necessary.

5. Placed sign over
patients bed as reminder
of bleeding precautions.

1. Increased heart rate
and orthostatic changes
accompany bleeding.
(NCP. 3
rd
ed., Schroeder
& Jones, 1994, p 389)

2. Bleeding may be
obvious (bruises/
petechiae epistaxis,
bleeding gums,
abdominal pain,
hematemesis, melena,
hematuria). (NCP. 3
rd
ed.,
Schroeder & Jones, 1994,
p 389, 422)

3. Spontaneous bleeding
can occur at platelet
count <50,000/mm3

4. Can stimulate
bleeding; to reduce
unnecessary trauma.
(NCP. 3
rd
ed., Mc
McCarthy & Schroeder,
1994, p 383, 423)

5. To apply pressure after
venipunctures and
prevent unnecessary
trauma. (NCP. 3
rd
ed.,

1. Patient will
reduce risk of
bleeding.

2. Patient will be
free from any
injury.

Short term
goal:

Goal partially
met. After 8
hours shift,
patient still at
risk for
bleeding but
eventually
reduced as
evidenced by
vital signs
within normal
range, absence
of narrowed
pulse pressure
and diminished
signs of
bleeding
(epistaxis,
hematemesis,
hematuria,
melena)

Nov. 29, 2009
V/S as follows:
BP 90/60
mmHg
T 36. 2C
HR 122 bpm
59

6. Maintained safe
environment for patient.

7. Transfused platelets
concentrate as prescribed.

8. Administered
Hydrocortisone as
ordered.

Puzas, 1994, p 425)

6. To prevent falls/
injury.(NCP. 3
rd
ed.,
Schroeder, 1994, p 422)

7. To restore platelets
level. (NCP. 3
rd
ed.,
Schroeder & Jones, 1994,
p 389)

8. Inhibition of
prostaglandin formation
by hydrocortisone
enhances hemostasis by
allowing vasoconstriction
to be maintained.(
Blajchman et al, 1979 p
63)
RR 34 bpm

Long term
goal:

Goal partially
met. After 3
days of nursing
interventions,
patient
maintained
reduced risk for
bleeding as
evidenced by
diminished
signs of
bleeding
(bruises/petechi
ae).

Dec. 3, 2009
Hematology:
Platelet = 10 x
10
3
/UL
Hgb- 0.28
Hct- 0.96

60

NURSING
PROBLEM with
CUES

NURSING DIAGNOSIS
reference)

(SMART) GOALS/
OBJECTIVES

NURSING
INTERVENTIONS

RATIONALE FOR
INTERVENTIONS

EXPECTED
OUTCOMES

EVALUATION

3. Fever
Date: Nov. 27, 2009

Subjective:

"Nilalagnat siya" as
verbalized by the
patients mother.

Objective:

Skin is warm to
touch, flushed
skin
V/S as follows:
-T: 39.3C
-HR: 137 bpm
-RR: 40 bpm
-BP:100/90mmHg
Hematology:
-WBC: 20.74
-Platelet: 6 10
3
/UL

Hyperthermia related to
inflammatory response

Rationale:

Fever is considered one
of the body's immune
mechanisms to attempt a
neutralization of a
perceived threat inside
the body. Temperature
is ultimately regulated in
the hypothalamus. When
the set point is raised,
the body increases its
temperature through
both active generations
of heat and retaining
heat and
vasoconstriction both
reduces heat loss
through the skin and
causes the person
increases temperature.
(NCP 7
th
Edition;
Doenges; pp 775)

Short term goal:

After 2 hours of
nursing interventions
the patients body
temperature will
decrease from 39.3C
to 37.5C.

Long term goal:

After 2-3days of
the patients body
temperature will be
stable within normal
range.

1. Monitored client
temperature (degree and
pattern), note shaking
chills/ profuse
diaphoresis.

2. Monitored
environmental
temperature;
limited/added bed linens
as indicated.

3. Provided tepid sponge
baths, avoid use of
alcohol

4. Administered Calpol as
indicated.

5. Provide blankets.

1. Temperature of 38.9-
41C suggests acute
infection due to disease
process.

2. Room temperature and
number of blanket should
be altered to maintain
near-normal body
temperature.

3. May help to reduce
fever. Alcohol can cause
chills and elevates body
temperature and can also
dry the skin.

4. Use to reduce fever by
its central action on the
hypothalamus.

5. Use to reduce fever,
usually higher than 104-
105F and is a helpful aid
to prevent chills.

Patient will
demonstrate
normal
temperature of
37.5C.

Short term
goal:

Goal met.
After 2 hours
of nursing
interventions,
patients body
temperature
decreased as
evidenced by
normal body
temperature of
37.5C and
absence of any
complications.

Long term
goal:

Goal met.
After 2-3 days
of nursing
interventions,
patients body
temperature
remained
stable.

61

NURSING
PROBLEM with
CUES

NURSING DIAGNOSIS
reference)

(SMART) GOALS/
OBJECTIVES

NURSING
INTERVENTIONS

RATIONALE FOR
INTERVENTIONS

EXPECTED
OUTCOMES

EVALUATION

4. Risk for I nfection
Date: Nov. 27, 2009

Subjective:

Ang daming test na
ginagawa sa kanya,
ang daming beses
nyang kinunan ng
dugoas verbalized
by the patients
mother.

Objective:

the patient is
staying in the
hospital
presence of IVF
puncture sites
Undergoing
invasive
procedure like
blood
transfusion.
broken
skin/impaired
skin integrity
because of needle
insertion from the
IVF

Risk for infection may
be related to presence of
IVF, undergoing
invasive procedure and
being immune-
compromised.

Rationale:

Broken skin because of
presence of IVF and
undergoing invasive
procedures like blood
transfusion and bone
marrow aspiration may
cause infection because
of impaired skin
integrity.
(Luxner, Karla,
Delmars Pediatric
Nursing Care Plan, 3
rd

ed., 2005, p.50)

Short term goal:

After 30 minutes of
the significant others
will be able to
perform appropriate
hand washing.

Long term goal:
Within the hospital
days the clients IV
site will be clean and
dry, without redness,
edema, drainage or
odor.

1. Assessed temperature
every 4 hours.

2. Assessed IV site for
edema, infiltration,
redness, and warmth
every 4 hour.

3. Washed hands before
and after providing care
for patient. Teach family
of the child to wash hands
frequently.

4. Changed IV site and
tubing every 24 to 72
hours according to
protocol.

1. Temperature above
37.5 or increase WBC
may indicate
development of
infection.
(Luxner, Karla, Delmars
Pediatric Nursing Care
Plan, 3
rd
ed., 2005, p.50)

2. Indicates phlebitis or
dislodgement of infusion
catheter for
administration of fluids
and IV medications.
Plan, 3
rd
ed., 2005, p.50)

3. Hand washing
prevents the spread of
microorganisms that may
cause infection.
Plan, 3
rd
ed., 2005, p.51)

4. Prevents bacterial
growth and prolonged
irritation to vein.

1. After the
interventions the
significant others
will demonstrate
proper hand
washing
procedures.

2. After the
interventions the
clients IV site
will be clean and
dry, without
redness, edema,
drainage or odor.

Short term
goal:

Goal met.
After 30
minutes of
nursing
interventions
the significant
others was able
to demonstrate
proper hand
washing.

Long term
goal:

Goal met.
During the
patients
hospital days
the clients IV
site has been
clean and dry,
without
redness,
edema,
drainage or
odor.

62

5. Administered Amikacin
and Amoxicillin as
ordered by physician.

Plan, 3
rd
ed., 2005, p.51)

5. Prevents irritation to
vein and phlebitis as the
drug action; for
prophylaxis.
Plan, 3
rd
ed., 2005, p.53)

63

NURSING
PROBLEM with
CUES

NURSING DIAGNOSIS
reference)

(SMART) GOALS/
OBJECTIVES

NURSING
INTERVENTIONS

RATIONALE FOR
INTERVENTIONS

EXPECTED
OUTCOMES

EVALUATION

5. Body Weakness
Date: Dec. 01, 2009

Subjective:

Hindi masyadong
ngumingiti sa amin si
baby kapag
nilalambing namin
siya. Parang
nananamlay siya, as
verbalized by the
patients mother.

Objective:

(+) Irritability
(+) Restlessness
Discomfort
(+) Pallor on skin
and mucous
membrane
V/S as follows:
-T-39.3C
-PR: 137 bpm
-RR: 40bpm
-BP: 100/90mmHg
Hematology:
-RBC: 1.55
-Hgb: 48
-Hct: 0.13

Activity intolerance r/t
generalized weakness
and low oxygen supply
in the body 2 to
decreased RBC and
decreased hemoglobin.

Rationale:

RBC is responsible for
the delivery of oxygen
to our body. Decreased
levels caused decreased
supply of oxygen to
different parts of the
body which eventually
leads to fatigue.
Intolerance in activity
may affect the client
physiologically and
psychologically, and
may not complete
required or desired daily
activities. (Geisller-
Murr;2005:389)

Short term goal:

After 8 hours of
the patient will be
able to tolerate
activity as evidenced
by interaction with
parents such as
responding through
smiling and being
able to tolerate
feeding.

Long term goal:

After 3 days of
the patient will be
able to continually
experience comfort as
evidenced by being
interactive most of
the time with people
and responding
positively through
smiling and moving
spontaneously.

1. Assessed functional
ability/extent of
impairment initially and
on a regular basis.

2. Evaluated action of
irritability and fatigue of
the patient from parents.

3. Provided quiet
environment and
uninterrupted rest periods.
Encouraged parents to
have rest periods for the
child before feeding.

4. Instructed parents and
assisted in changing
position at least every 2
hours (supine/side lying).

5. Set goals with
parents/significant others
for play or activities of the
baby (solitary) such as
making cooing sounds,
providing objects with
sounds (colored rattles),
colored mobiles, etc.

1. Identifies
strengths/deficiencies
and may provide
information regarding
recovery to the parents.
(Doenges;2006:232)

2. Effects of anemia may
be cumulative,
necessitating assistance.
(Doenges;2006:232)

3. Restores energy
needed for activity,
cellular regeneration, and
tissue healing.
(Doenges;2006:232)

4. Reduces risk of tissue
ischemia/injury.
(Doenges;2006:233)

5. Promotes a sense of
expectation of
progress/improvement,
including enhancement
of the infants immune
system and development
of his reflexes such as
grasping reflex.

1. Patient will be
able to
demonstrate
measurable
increase in activity
tolerance.

2. Patient show
absence of body
weakness.

Short term
goal:

Goal partially
met.
Patient was
able to
demonstrate
measurable
increase in
activity
through being
responsive to
others but still
maintained low
levels of CBC
results, making
the patient less
energetic.

Long term
goal:

Goal partially
met.
Patient was
able to
participate in
play activity as
evidenced by
smiling and
energetic
64
-WBC: 20.74
-Lympho: 0.44
Minimal in
feeding/
decreased
sucking during
feeding

6. Recommended
breastfeeding for the
baby.

7. Monitored CBC
(laboratory results)
especially RBC and
platelet.

8. Transfused PRBC and
platelet concentrate as
prescribed.

9. Provided supplemental
fluids such as IVF#5
(D5IMB 500cc x 24cc/hr)

(Doenges;2006:233)

6. Breastfeed milk is
more nutritious for
infants. It has certain
antibodies that give more
protection to the baby
against diseases.
(Doenges;2006:233)

7. Decreased levels
indicate actual problems
and may pose possible
complications.
(Doenges;2006:233)

8. It is essential to
replace blood lost
through disease. This
would enable the bodys
system to replace RBCs
and hemoglobin which
are responsible for
maintaining the iron
status and oxygenation of
the body and the platelets
that are responsible for
clotting action in
response to inflammation
and bleeding.
(Doenges;2006:233)

9. To avoid dehydration
and exhaustion.
(Doenges;2006:233)
movements
whenever
parents and
nurses make
cooing sounds
or provide
colorful
mobiles and
objects with
sounds.

65

NURSING
PROBLEM with
CUES

NURSING DIAGNOSIS
reference)

(SMART) GOALS/
OBJECTIVES

NURSING
INTERVENTIONS

RATIONALE FOR
INTERVENTIONS

EXPECTED
OUTCOMES

EVALUATION

6. Lack of
Knowledge
Date: Nov.27, 2009

Subjective:

hindi ko alam kung
bakit nagkaganito
ang anak ko as
verbalized by the
patients mother.

Objective:

Questions/
request for
information,
verbalization of
problem
Statement of
misconception

Knowledge Deficit
related to unfamiliarity
with disease

Rationale:

There is a presence of
knowledge deficit due to
some unfamiliar
information that causes
some confusion to the
client that needs to be
discussed.
(http://www.scribd.com)

Short term goal:

After 1 hour of
nursing intervention
the mother of the
patient will verbalize
accurate information
about diagnosis,
prognosis, and
potential
complications of the
disease.

Long term goal:

After 2 days of
nursing intervention
the mother of the
patient will initiate
necessary lifestyle
changes for her baby
and correctly perform
necessary procedures
and explain reasons
for the actions.

1. Reviewed with SO
understanding of specific
diagnosis, treatment
alternatives, and future
expectations.

2. Provided anticipatory
guidance with SO
regarding treatment
protocol.

3. Reviewed with SO the
importance of maintaining
optimal nutritional status.

4. Assessed oral mucous
membranes routinely,
noting erythema,
ulceration.

5. Advised patients
mother concerning skin
and hair care: e.g., avoid
chlorinated water; avoid

1. Validates current level
of understanding,
identifies learning needs,
and provides knowledge

2. Patients mother has
the right to know (be
informed) and participate
in decision tree. Accurate
and concise information
helps dispel fears and
anxiety.

3. Facilitates recovery

4. Early recognition of
problems promotes early
intervention, minimizing
complications that may
impair oral intake and
provide avenue for
systemic infection.

5. Prevents skin
irritation.

1. The patient will
verbalize accurate
information about
diagnosis,
prognosis, and
potential
complications.

2. The patient will
initiate necessary
lifestyle changes
for her baby and
correctly perform
necessary
procedure and
explain reasons for
the actions.

Short term
goal:

Goal met. The
patients
mother
identified
information
about diagnosis
and potential
complications.

Long term
goal:

The patients
mother
initiated
necessary
lifestyle
changes for her
baby and
correctly
performs
necessary
procedures and
explains
reasons for the
actions.

66

exposure to strong wind
and extreme heat or cold.

6. Reviewed purpose and
preparations for
diagnostic studies.

7. Stated objectives
clearly in learners term.

8. Provided written
information/guidelines for
the patients mother to
refer to as necessary

9. Avoided all injections
and rectal temperature.

10. Be alerted for sulfa-
containing medication.

6. Anxiety/fear of the
unknown increases stress
level, Knowledge of
what to expect can
diminish anxiety.

7. To meet learners
need.

8. Reinforces learning
process.

9. To avoid stimulation
of bleeding.

10. It can alter platelet
function.

67

NURSING
PROBLEM with
CUES

NURSING DIAGNOSIS
reference)

(SMART) GOALS/
OBJECTIVES

NURSING
INTERVENTIONS

RATIONALE FOR
INTERVENTIONS

EXPECTED
OUTCOMES

EVALUATION

7. Disabled Family
Coping

Subjective:
Hindi naming
matanggap mag-
asawa na ganito ang
nangyari sa anak
namin. as verbalized
by the patients
mother.

Objective:

Significant others
display negative
emotion towards
babys condition

Family attempts
supportive
behaviors with
less than
satisfactory
result.

Disabled family coping
related to significant
others unexpressed
feelings of guilt,
anxiety, despair and
failure to deal
adequately with
underlying condition.

Rationale:

Family members are the
source of strength and
behavior of family
member that disables
their capabilities to
address tasks essential to
either persons
adaptation to the health
challenge.
(http://www.scribd.com)

Short term goal:

After 8 hours of
nursing intervention,
the SO will be able to
understand and
express feelings to
expectations openly
and honestly as
appropriately within
the family members.

Long term goal:

After 2 days of
nursing intervention,
the SO will be able to
participate positively
regarding patient
care.

1. Noted the factors that
may be stressful for the
family like financial
difficulty and lack of
support group.

2. Assisted family to
identify coping skills
being used and how these
skills are/are not helping
them deal with situation.

3. Determined readiness
of family members to be
involved with care of
patient.

4. Active-listen concerns:
noted both over concern/
lack of concern, which
may interfere with ability
to resolve situation.

5. Acknowledged
difficulty of the situation
for the family, like reduce
blaming or guilt.

1. To assess causative
factors and provide
opportunity for
appropriate referrals as
much as possible. (Karla,
Delmars Pediatric
rd

ed. 2005,p.50)

2. To promote wellness.
(Karla, Delmars
Plan, 3
rd
ed. 2005,p.50)

3. To assess causative
factor and underlying the
willingness of the SO.
(Karla, Delmars
Plan, 3
rd
ed. 2005,p.50)

4. To provide assistance
to enable family to deal.
(Karla, Delmars
Plan, 3
rd
ed. 2005,p.50)

5. To promote positive
environment. (Karla,
Delmars Pediatric
rd

1. SO will be able
to express feelings
and expectations
openly and
honestly as
appropriately

2. SO will be able
to participate
accordingly in care
of patient within
limits of familys
abilities and
patients needs.

Short term
goal:
Goal met:
After 8 hours
of nursing
intervention
the SO has an
open attitude
and honest to
expressed their
feelings
regarding
babys
condition and
at the end of
two-day duty
they
participated
accordingly in
caring the
patient within
the limits of
patients needs.

68

6. Involved SO in the plan
of care, provide
instruction.

7. Refrained negative
expression into positive
one.
ed. 2005,p.50)

6. To promote wellness.
(Karla, Delmars
Plan, 3
rd
ed. 2005,p.50)

7. It helps to accept the
situation easily and it
will strengthen their faith
towards the condition
(Karla, Delmars
Plan, 3
rd
ed. 2005,p.50)

69
XVIII. MEDICATIONS/TREATMENT

A. GENERIC NAME
(BRAND NAME)

B. GENERAL
CLASSIFICATION
OF DRUGS

A. INDICATION
TO PATIENT

B. OTHER
INDICATIONS

C. DOSAGE
DRUG ACTION
A. SIDE EFFECTS

B. PRECAUTIONS
AND SPECIAL
CONSIDERATION

(A) Amikacin
(Amikin)

(B)Aminoglycoside
Antibiotic

(A) Used to treat bacterial
infection.

(B) Serious infection
caused by the sensitive
strains of pseudomonas
aeroginosa, e. coli,
klebsiella or
staphylococcus.Uncompli
cated UTI caused by
organisms not susceptible
to less toxic drugs.

(C) 30 mg IV q8

Binds to bacterial
ribosomal subunit to
cause misreading of
the genetic code w/c
leads to inaccurate
peptide sequence of
protein synthesis and
bacteria death.

(A) Musculoskeletal:
arthralgia
respiratory: apnea

(B) Contraindicated in
patients with
hypersensitivity to drug or
other aminoglycosides.
Use cautiously in patient
with impaired renal
function or
neuromuscular disorder.

(A) Ampicillin
(Omnipen)

(B) Beta-lactam
Antibiotic

(A) Used to treat bacterial
infection.

(B) Uncomplicated
gonorrhea, GI infection or
UTIs

(C) 150 mg IV q6

Interferes with cell
wall synthesis of
susceptible organisms
preventing bacterial
multiplication, it also
renders the cell wall
osmotically unstable
and burst due to
osmotic pressure.
Deactivated by beta-
lactamase, an enzyme
produced by resistant
bacteria.

(A) CNS: seizure,
lethargy
G.I: diarrhea
GO: nephropathy
Hematology:
thrombocytopenia

patients with
other penicillin.
*Before giving drugs
assist patient about
allergic reaction to
penicillin.

(A) Hydrocortisone
(Cortef)

(B)Glucocorticosteroid

(A) Used for
immunosuppressive
effect. Treatment of
autoimmune disease/
hematologic disorder
(idiophatic

Glucocorticosteroids
with anti
inflammatory effects
because of its ability
to inhibit
prostaglandin of

(A) CNS: vertigo,
insomnia
CV: heart failure
GI: pancreatitis, nausea
and vomiting

70

thrombocytopenic
purpura).

(B) Severe inflammation,
adrenal insufficiency

(C) 10 mg IV q8

macrophages,
leukocytes and
fibroblast at sites of
inflammation,
phagocytosis and
lysosomal enzyme
release. It can also
cause and reveals of
increased capillary
permeability.

patients with
its ingredients in those
with systemic fungal
infection. Determine
whether the patient is
sensitive to other
corticosteroid.

(A) Diphenhydramine
(Benadryl)

(B) Antihistamine

A) For the symptomatic
relief of allergic condition
including angio-edema,
rhinitis and conjunctivitis
and pruritic skin.

(B) Treatment of nausea
and vomiting, particularly
in the prevention and
treatment of motion
sickness.

(C) 6 mg IV

Acts on blood vessel,
GI, respiratory system
by antagonizing the
effects of histamine
for GI receptor site;
decreases allergic
response by blocking
histamine; causes
increased heart rate,
vasodilation, and
secretion, significant
CNS depressant and
anticholinergic
properties.

(A) Orthostatic
hypotension; palpitations,
bradycardia, tachycardia,
reflex tachycardia, extra
systoles, sedation,
dizziness, disturbed
coordination.

(B) May cause drowsiness
and dulling of mental
alertness. It has been
associated with clinical
exacerbation of porphyria
and is considered unsafe
in porphyric patients.

(A) Paracetamol
(Calpol)

(B) Antipyeretic

(A) Treatment of fever

(B) Relief of mild to
moderate pain

(C) 0.6 ml drops 3x-
4x/day

Decreases fever by
inhibiting the effects
of pyrogens on the
hypothalamic heat
regulating centers and
by a hypothalamic
action leading to
sweating and
vasodilation. Relieves
pain by inhibiting
prostaglandin
synthesis at the CNS
but does not have anti
inflammatory action
because of its
minimal effect on
peripheral
prostaglandin
synthesis.

(A) Stimulation,
drowsiness, nausea,
vomiting, abdominal pain,
hepatotoxicity, hepatic
seizure (overdose), renal
failure, leucopenia,
neutropenia, hemolytic
anemia.

(B) Patients with impaired
kidney or liver function.
Patient with alcohol
dependence.

71

(A) Amoxicillin
(Amoxil)

(B) Penicillin/
Antibiotic

(A) Treatment of
infection of skin and skin
structure.

(B) Treatment of infection
of respiratory tract,
genitourinary tract, otitis
media, meningitis,
septicemia, sinusitis.

(C) 0.7 ml TID x 2 days

Prevents bacterial cell
wall synthesis during
replication.

(A) Dizziness, fatigue,
insomnia, reversible
hyperacidity, urticaria,
maculopapular to
expoliative, dermatitis,
vesicular eruptions, itchy
eyes, glossitis, stomatitis,
dry mouth or tongue,
abnormal taste sensation,
laryngospasm, laryngeal
edema, gastritis, anorexia.

(B) The possibility of
superinfections with
mycotic or bacterial
pathogens should be kept
in mind during therapy. If
superinfections occur,
amoxicillin should be
discontinued and
appropriate therapy
instituted. Because of
incompletely developed
renal function in neonates
and young infants, the
elimination of amoxicillin
may be delayed. Dosing
of AMOXIL should be
modified in pediatric
patients 12 weeks or
younger ( 3 months).

(A) Zinc Oxide
(Diaparene)

(B) Emollients & skin
protectives

(A) Used to treat or
prevent diaper rash.

(B) Used to treat or
prevent minor skin
irritations (e.g., burns,
cuts, poison ivy).

(C) Topical TID

It works by providing
a skin barrier to
prevent and help heal
skin irritation.

(A) This medication is
generally well tolerated
when used as directed.
There are no reports of
any side effects due to the
use of this medication.
However, if you
experience any unusual
effects while using this
medication, notify your
doctor.

(B) Tell your doctor your
medical history,
especially of: other skin
infections/problems,

72

allergies (especially drug
allergies). Before using
this medication, tell your
doctor if you are
pregnant. It is not known
if this medication passes
into breast milk. Consult
your doctor before breast-
feeding.

73
XIX. DISCHARGE PLANNING

Proper nutrition and a healthy Immune system of the body are the key measures that can be
applied to prevent the spread of bacterial or viral infection in the body.

Medications
Barney is required to take amoxicillin (antibiotic) and prophylaxis from bacterial infection and to
skin rashes. Prevention of bacterial growth is necessarily to prevent the progress of the disease.

Exercise
Encourage the significant others to continuously try to make their child fit and interact
appropriately through body movements and vocalization but do not stress them too much to prevent any
problems that can occur within stressful activities.

Therapy/Treatment
Acute idiopathic thrombocytopenic purpura may be allowed to run its course without
intervention. Alternatively, it may be treated with glucocorticoids or immunoglobulin. Treatment with
platelet transfusion has met with limited success.

Health Teaching
It is important to instruct the parents to adhere to medications and the most commonly used
antiplatelets are aspirin, heparin, abciximad (reopro) as well as food such as grape skin extract, soy sauce
and to have a follow up check up to prevent developing any complications. Breastfeeding is very
important; it reduces the chances of infection and increases the immunity of the baby. Maintaining
cleanliness in the surrounding and proper hygiene can also be very beneficial because it promotes safety
and can help in boosting bodys defense and immune system and it is also an opportunity for the parents
to monitor and really give their best care for their baby. Informing the parents of the risk associated with
the disease and ensured that they understand the need to return the patient to the hospital if bleeding
occurs. Correct information and awareness of the disease can help in avoiding more complications that
may arise in the future.

Out Patient follow-up
Regular consultation to the physician is necessary to monitor the progress of the disease and
prevent any complications from developing.
74
Diet
The required diet for Barney is breastmilk which is best for him since he is just 2 months old.

Spiritual
Prayer and trusting the divine power is a healthy tip that a health care provider can give to their
patients. This will guide them spiritually and develop their faith in the almighty God that their baby will
recover and have a normal life in the future.

XX. CONCLUSION AND RECOMMENDATION

Idiopathic thrombocytopenic Purpura (ITP) is the condition of having a low platelet count of no
known cause. As most causes appear to be related to antibodies against platelets, we conclude that the
probable cause that triggered the onset of the ITP of Barney was the previous exposure to bacterial
infection during prenatal period of the mother which alters the immune response of Barney and recent
live/attenuated bacterial vaccines he received before he was admitted.
Having a child with an ITP may be a life-changing disease not only for the patient but also to his
family. We recommend the parents of a child with ITP must learn about their childs health and condition
in order for them to manage the disease properly and appropriately in case the disease comes back again.
They must find the best hematologist available and work with them to decide which care plan is suitable
for their child. Treatment should be individualized and focused on bleeding symptoms and prevention of
treatment toxicity.

75
XXI. ACKNOWLEDGEMENT

We students of Manila Adventist College Block J from section C want to express our deep sense
of gratitude to all the individuals who have given their heart whelming full support in making this case
study possible.
To our Dear Almighty God for giving us wisdom, knowledge, strength, and patience to keep us
standing and for the hope that keep us believing that this case study would be possible and more
interesting.
We also wanted to thank our family who inspired, encouraged and fully supported us for every
trials that comes our way. To our parents and guardians for their unending financial and emotional
support and understanding, thank you for being our inspiration.
To our blockmates who willingly help us gathered and provided the necessary data and
information needed for this case study.
To Mr. Oemer Rey Daquila for the encouragement, guidance and support from the initial to the
final level of this case study enabled us to develop an understanding of the subject.
To our clinical instructors and all medical staff of Pediatric Unit of Manila Adventist Medical
Center who sincerely devoted their time and service in making of this case study.
Again, we thank you all from the bottom of our heart.

76
XXII. BIBLIOGRAPHY

Books:
Black, J. M., & Jacobs, E. M. (1993). Medical-Surgical Nursing: A Psychophysiologic Approach. 4
th
ed.
Hematologic Disorders (Pp. 1328-1332). USA: W. B. Saunders Company.
Kozier et al. Fundamentals of Nursing 8
th
Edition, Copyright 2007 by Pearson Education South Asia
pte.Ltd
Lippincott Williams and Wilkins, Nurses Quick Check: Diagnostic Tests, Copyright 2006 by Wolters
Kluwer Company.
Marilyn E. Doenges, Nursing Care Plans, 4
th
Edition, Copyright 1997 by F.A. Davis Company,
Philadelphia, Pennsylvania.
Pilliteri, Adele Maternal and Child Health Nursing: Care of the Child Bearing and Child Rearing
Family, 5
th
Edition. Copyright 2007 by Adele Pilitteri.
Sparks Shiela et al. Nursing Diagnosis Reference Manual 7
th
Edition, Copyright 2008 by Wolters
Kluwer Company.
Taylor et al. Fundamentals of Nursing, 5
th
Edition, Copyright 2005 by Lippincott Williams and Wilkins
PPDs Nursing Drug Guide: For Nursing Students and Professional Nurses, 2
nd
Edition, Copyright
2008 by Malan Press, Inc.

Internet Websites:
http://www.mayoclinic.com/health/ct-scan/MY00309. Mayo Clinic.com. Mayo Clinic Staff. January 12,
2008. Mayo Foundation for Medical Education and Research.
http://www.webmd.com/a-to-z-guides/blood-transfusion-risks-of-blood-transfusion. WebMD Better
information. Better Health. December 27, 2007. Risk of Blood Transfusion. Healthwise Inc.
http://en.wikipedia.org/wiki/Blood_transfusion. Wikepedia the free encyclopedia

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