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Objectives

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General Objectives:

At the end of the case presentation, the participants will be able to acquire the necessary knowledge, skills and attitude in delivering compassionate and competent nursing care for patients diagnosed with
Specific Objectives:

At the end of this case presentation, the participant will be able to: 2. Define and familiarize severe anemia. 3. Know the different drugs and their actions and perform necessary nursing responsibilities for each drug. 4. Discuss the etiology, anatomy and physiology of the blood. 5. Trace the pathophysiology of severe anemia and identify clinical manifestations and risk factors of the said disease. 6. Identify the medical and surgical management appropriate for the disease.
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Introduction

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If you’re like most people who beat up on the snooze button each morning, an earlier bedtime is the way to end your energy crisis. But if no amount of rest helps, it may not be sleep that your body is craving. You may have a form of anemia. If you have anemia, people may say you have tired blood. That's because anemia — a condition in which there aren't enough healthy red blood cells to carry adequate oxygen to your tissues — can make you feel tired. Anemia saps your energy by depriving your cells of oxygen. This happens when your blood has too few red blood cells or too little hemoglobin that transports oxygen through the bloodstream. Without oxygen, no living cell can survive. Without a specialized system of oxygen transport to cells, no complex multi-cellular organism which carry oxygen to and carbon dioxide away from the thirty trillion cells of the human body are basic requirements for health and itself.

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Anemia is a common blood disorder. Women and people with chronic diseases are at increased risk of the condition. Some people learn that their hemoglobin is low, which indicates anemia, when they go to donate blood. Low hemoglobin may be a temporary problem remedied by eating more iron-rich foods or taking a multivitamin containing iron. However, it may also be a warning sign of blood loss in your body that may be causing you to be deficient in iron. If you're told that you can't donate blood because of low hemoglobin, ask your doctor if you should be concerned. If you suspect you have anemia, see your doctor. Anemia can be a sign of serious illnesses. Treatments for anemia range from taking supplements to undergoing medical procedures and even just eating healthy varied diet.

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There are many forms of anemia, each with its own cause. Anemia can be temporary or long term, and it can range from mild to severe. See your doctor if you're feeling fatigued for unexplained reasons, especially if you're at risk of anemia. Some anemias, such as iron deficiency anemia, are common. But don't assume that if you're tired, you must be anemic. Fatigue has many causes besides anemia. Anemia can be a symptom of many different serious problems, including cancer. Anemia is a great problem globally and worse in developing countries, but it is by no means absent in industrialized nations and millions of Filipinos suffer from anemia, which is serious and is usually caused by blood loss from an injury or hemorrhage and the demands of pregnancy. Approximately 43.9% Filipinos pregnant women are estimated to develop anemia, while many are unreported. Anemia can occur during pregnancy due to low levels of iron and folic acid (folate) and changes in the blood. During the first 6 months of pregnancy, the fluid portion of a woman’s blood (the plasma) increases faster than the number of red blood cells. This dilutes the blood and can lead to anemia.
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Anemia affects many body systems. It can also lead to many complications. This is the goal of health care providers, to prevent any occurrence of complications. Ultimately, it is hoped that with timely intervention to control this complication of anemia, improved patient outcomes on in terms of morbidity and mortality will be achieved. As future nurses, we could help our patients by having a deep understanding of the disease, that we may learn the proper interventions for anemia patients. In this way, we could render quality health care for them. By having a wide understanding of the disease, we could impart teachings on how we could prevent anemia. It is our responsibility to render information and impart health teachings to improve the conditions of our patients to the best of our abilities. One of the characteristics that we should have is to be informative and only through a keen study of disease such as this way will help us to gain all the information we need to learn. May this case study served its purpose through the help of our Lord, Jesus Christ.
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Vital Information

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Name: Y.C. Age: 35 Sex: FEMALE Civil Status: MARRIED Religion: ROMAN CATHOLIC Nationality: FILIPINO Date of Birth: JUNE 27, 1973 Place of birth: GUIMARAS Provincial Address: LINAMPONGAN, PONTEVEDRA CAPIZ Date and time admitted: NOVEMBER 27, 2008; 1:55 AM Ward: OUR LADY OF LOURDES WARD (FEMALE MEDICAL Chief Complaint: DYSPNEA Diet: DIET AS TOLERATED (DAT) Admitting Diagnosis: SEVERE ANEMIA 2° VAGINAL

WARD)

BLEEDING FRAGMENTS

2°RETAINED PLACENTAL

Attending Physician: DR. M.B., DR. N.C. AND DR. R.B.
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G E N O G R A M
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E.G.

J.G.

A.F.

R.F

C.G. 67y.o.

M.G. 57y.o.

Y.C. 35y.o. Sever e Anem ia
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Nursing History

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A. History of Present Illness

2 weeks prior to admission, patient was noted to have generalized edema, allegedly consulted with local medical doctor and given unrecalled medications. And a week of continuous usage of medications her edema diminished so they stop the medications and didn’t seek for further medical advices. 6 days pta, patient delivered a baby via NSVD at home with a midwife’s assistance. She had a minimal vaginal bleeding and can only consume 1 pad of maternal napkin per day. A day before admission, she experienced difficulty in breathing at around 1 in the morning and that’s when they decided to bring her to St. Anthony College Hospital.

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B. Past Health Problem/Status

According to her it was her 1st time to be hospitalized even thought she had given birth 3 times and had a miscarriage. She also has no known allergy of any kind. She never had a serious illness like this before to be brought to the hospital. She said that she had occasional influenza, dysmenorrheal, stomachache and headache but worse than those, none.
C. Family History Illness

Y.C. is the only child of her parents. And both sides have no known serious illness. The most common cause of death among their family is old age.

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C. Family History Illness

Her records state that she had been pregnant 4 times and delivered 3 times (G4P3). 3 of the 4 were full term, one miscarriage and with 3 living children (3013). All her full term children were delivered via Normal Spontaneous Vaginal Delivery (NSVD) at home assisted by midwife. She had a prenatal check for her latest pregnancy to the local medical doctor and was given unrecalled medications for edema. Patterns of Functioning Breathing Patterns – Her usual RR ranges from 20 to 24 breaths per minute and she has a normal and calm manner of breathing. Circulation Patterns – Her usual BP is equal to 110/80 mm Hg accompanied by her AR that ranges from 70 to 75 beats per minute and PR of 65- 70 beats per minute.
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Brief Social, Cultural and Religious Background a. Educational Background – She is a high school graduate. b. Occupation – None, she’s a plain housewife and a full time mother. c. Religious Practices – She is a solid Roman Catholic who hears mass every Sunday and on special days like fiesta, Christmas and her birthday. She also prays rosary when she finds time. d. Economic Status – They are a member of the middle Class.

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Clinical nt assessme assessment

C li n i ca l

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1. Vital Signs (Upon Admission) T: 36.3 ° C AR: 110 beats per minute BP: 160/100 mm Hg RR: 30 breaths per minute 2. Height: 5’ 3” Weight: 65 kg (121 pounds)

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3. Assessment (Cephalocaudal)
A. General Appearance
-appears to be pale, weak and restless; in a semifowler’s position.

B. Skin, Hair and Nails

-with brown complexion, dry skin and poor skin turgor ; with black hair, adequate in amount but sticky in texture and there are presence of dandruff in the scalp; nails are untrimmed and dirty.

C. Face and Lymphatics

-has a clean face and no palpable mass noted.

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D. Eyes, Ears, Nose, Mouth and Throat -PERRLA, no discharges noted. -no discharge noted, hearing acuity is good and ears are well cleaned. -no discharge noted nor signs of rashes. E. Neck and Upper Extremities -no palpable mass; carotid pulse is palpable; without lesions. -has difficulty in moving the right arm and positive pain because of an IV cutdown (right radial artery site); no lesions.

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F. Chest, Breast and Axilla

-no tenderness and pain in chest; there is no . -no palpable mass and discharges noted in the breasts. -no mass noted and no enlargement of lymph nodes in the axilla.

G. Respiratory System

-normal respiratory sound is heard during auscultation.

H. Cardiovascular System

-normal heart rhythm; no complain of chest pain.

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I. Gastrointestinal System

-no complaint of stomachache was made; was not able to defecate for 5 days.

J. Genito – urinary System
-with offensive odor.

K. Musculoskeletal System

-positive weakness but to prefer to walk around and sit; has a limited ROM.

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4. General Appraisal: a. Speech -can talk loudly and clearly. b. Language -can fluently speak Hiligaynon and a little of Tagalog. c. Hearing -she can hear clearly and can comprehend well. d. Mental Status -conscious and coherent. e. Emotional Status -anxious about her condition, how are they going to pay her hospital bills and stated that she misses her children so much.
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Textbook discussion

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Definition

of anemia

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Anatomy and
physiology

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Signs and symptoms

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pathophysiology

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Diagnostic examination

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Chemistry

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Hematology

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X-ray
X-ray Request: Chest AP (Sitting) 11-27-08 Findings: The upper lobe vascular markings are prominent Haziness noted in the right lung base The trachea is at midline The cardiac shadow is enlarged with CTR of 0.63 There is bulging of the left pulmonary artery conus The right pulmonary artery is also prominent There is straightening of the cardiac waist line The left hemi diaphragm and costophrenic sulcus are poorly evaluated in this study The rest of the visualized soft and osseous structures are unremarkable Impression: Pulmonary Congestion Right Basal Pneumonia Cardiomegaly with Multichamber Enlargement Prominent Pulmonary Arteries

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X-ray
X-ray Request: Abdomen Supine & Upright 11-27-08 Findings: A segment of the bowel loop in the left hemi abdomen is prominent There is no evidence of differential air fluid level The renal and psoas shadows are partially visualize due to overlying bowel loops The rest of the visualize soft and osseous structures are unremarkable Impression: Segmental Ileus

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Ultrasound
Findings: Kidneys: The Right kidney measure approximately Coronal=90.1x42.5x47.8mm (LWT) with a cortical thickness of 13.7mm Both kidneys exhibit slightly hyperreflective parenchymal echopattern The central echo complex of both kidneys are not s eparated There is no lithiasis in both kidneys There is minimal perirenal fluid at the superior pole of the right kidney measuring 8.4mL in thickness Urinary Bladder: The urinary bladder is partially filled. There is a foley catheter balloon within the urinary bladder. There is no intraluminal lithiasis.

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Ultrasound
Pelvis: The antevertid uterus measures 132x80.4mm (LxAP) The borders are defined Heterogenous structures is noted within the uterine cavity measuring 78.4x22.2 to 28mm (LxAP) The cervix measures 29.9mm There is fluid in the posterior Culde sac approximately 39.6mL The adrexae are obscuired by the bowel loops The anterior abdominal wall appears thickened and edematous There is no fluid in the Monson’s Pouch

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Ultrasound Impression: Slightly hyperreflective renal parenchyma, both kidneys suggestive of bilateral diffuse renal parenchymal disease S/P foley catheter insertion Thick anterior abdominal wall, this could be subcutaneous edema Enlarged anteverted uterus with hetetogenous structure within the uterine c a v i t y. T h i s c o u l d b e r e t a i n e d p l a c e n t a tissue Minimal fluid in the posterior culdesac Minimal perirenal fluid, right kidney

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Ultrasound
Findings: Liver: 11-28-08

The liver is not enlarged The boarders are well-detained The intra hepatic ducts are not dilated The parenchyma have homogenous echopattern with increased parenchymal echogenicity The common duct measures 3mm The portal vein measures 3.8mm The hepatic vein measure 12.0 to 13.0mm (N=4 to 5mm) There is no fluid in the Monson’s Pouch Gallbladder: The Gallbladder is normal in size measuring approximately 61.0x38.3x28.9mm (LWH) with a volume of 35.4mL It has smooth walls The Gallbladder walls has a thickness of approximately 3.6 to 5.3mm No intraluminal echoes seen

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Ultrasound

Impression: Fatty liver with hepatic congestion Thick gallbladder walls could be due to: Cholecystitis Hypoalbuminemia Hepatitis

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Urinalysis

11-27-08

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Urinalysis

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ABG

11-27-08; 08:40 AM

Interpretation: Respiratory Alkalosis with Partial Compensation

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ABG

11-27-08; 09:30 PM

Interpretation: Respiratory Alkalosis with Partial Compensation

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Cross-Matching

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Blood Transfusion

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Medical management

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Anemia may be sign of a curable GI cancer or of uterine fibroid tumors. Stool specimen should be tested for occult blood. People 50 yeas of age o older should have periodic colonoscopy, endoscopy, or x-ay examination of the GI tract to detect ulcerations, gastritis, polyps, or cancer. Several oral preparations—ferrous sulfate, ferrous gluconate, ferrous fumarate—are available for treating iron deficiency anemia. The hemoglobin level may increase in only few weeks, and the anemia can be corrected in a few months. Iron store replenishment takes much longer, so it is important that the patient continue iron for as long as 612 months. Vitamin C facilitates the absorption of iron. In some cases, oral iron is poorly absorbed or poorly tolerated, or iron supplementation is needed in large amounts. In these situations, IV o intramuscular (IM) administration of iron dextran may be needed. Before parenteral administration of a full dose, a small test dose should be administered parenterally to avoid the risk of prophylaxis with either IV or IM injections. Emergency medications should be close at hand. If no signs of allergic reaction have occurred after 30 minutes, the remaining dose of ion may be administered. Several doses are required to replenish the patient’s iron stores.

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Pharmacologic

therapy

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Documentation of the etiology of anemia is essential in the selection of therapy. All microcytic anemias are not caused by iron deficiency; some are iron-overloading disorders. Similarly, all megaloblastic anemias are not associated with either vitamin B-12 deficiency or folic acid deficiency. Hereditary hemolytic disorders do not improve with corticosteroid therapy.

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Nutritional therapy

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Iron deficiency anemia is prevalent in geographic locations where little meat is in the diet. Many of these locations have sufficient dietary inorganic iron to equal the iron content in persons residing in countries in which meat is eaten. However, heme iron is more efficiently absorbed than inorganic food iron. A strict vegetarian diet requires iron and vitamin B-12 supplementation. Folic acid deficiency occurs among people who consume few leafy vegetables. Coexistence of iron and folic acid deficiency is common among Third World nations.

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Surgical management

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Surgery is useful to control bleeding in patients who are anemic. Most commonly, bleeding is from the gastrointestinal tract, the uterus, or the bladder. Patients should be hemodynamically stable before and during surgery. A blood transfusion may be needed. Splenectomy is useful in the treatment of autoimmune hemolytic anemias and in certain hereditary hemolytic disorders (ie, hereditary spherocytosis and elliptocytosis, certain unstable Hb disorders, pyruvic kinase deficiency). Improvement in survival rates has been reported in patients with aplastic anemia, but splenectomy is not the preferential therapy. Leg ulcers have shown improvement in some patients with thalassemia. Prior to splenectomy, patients should be immunized with polyvalent pneumococcal vaccine. Preferably, this should be administered more than 1 week prior to surgery.

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Bone marrow and stem cell transplantation have been used in patients with leukemia, lymphoma, Hodgkin disease, multiple myeloma, myelofibrosis, and aplastic disease. Survival rates improved, and hematologic abnormalities were corrected. Allogeneic bone marrow transplantation successfully corrected phenotypic expression of sickle cell disease and thalassemia and provided enhanced survival in patients who survive transplantation.

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Dilation and evacuation (also sometimes called dilation and extraction) literally refers to the dilation of the cervix and surgical evacuation of the contents of the uterus. It is a method of abortion as well as a therapeutic procedure used after miscarriage to prevent infection by ensuring that the uterus is fully evacuated. It is commonly referred to as a D&E. The first step in a D&E is to dilate the cervix. This is often begun about a day before the surgical procedure. Enlarging the opening of the cervix enables surgical instruments such as a curette or forceps to be inserted into the uterus. The second step is to remove the fetus. Either a local anesthetic or general anesthesia is given to the woman. Forceps are inserted into the uterus through the vagina and used to separate the fetus into pieces, which are removed one at a time. Lastly, vacuum aspiration is used to ensure no fetal tissue remains in the uterus (such tissue can cause serious infections in the woman). The pieces are also examined to ensure that the entire fetus was removed.
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Va c u u m A s p i r a t i o n . T h e c l i n i c i a n m a y f i r s t u s e a local anesthetic to numb the cervix. Then, the clinician may use instruments called "dilators" to open the cervix, or sometimes medically induce d i l a t i o n w i t h d r u g s . F i n a l l y, a s t e r i l e c a n n u l a i s inserted into the uterus and attached via tubing to the pump. The pump creates a vacuum which empties uterine contents. After a procedure for abortion or miscarriage treatment, the tissue removed from the uterus is examined for completeness. Expected contents include the embryo or fetus as w ell as the decidua, chorionic villi, amniotic fluid, amniotic membrane and other tissue. Post-treatment care includes brief observation in a recovery area and a follow -up appointment a p p r o x i m a t e l y t w o w e e k s l a t e r.

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prevention

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Many types of anemia can't be prevented. However, you can help avoid iron deficiency anemia and vitamin deficiency anemias by eating a healthy, varied diet that includes foods rich in iron, folate and vitamin B-12. The best sources of iron are beef and other meats. Other foods rich in iron include beans, lentils, iron-fortified cereals, dark green leafy vegetables, dried fruit, nuts and seeds. Folate, and its synthetic form, folic acid, can be found in citrus juices and fruits, dark green leafy vegetables, legumes and fortified breakfast cereals. Vitamin B-12 is plentiful in meat and dairy products. Foods containing vitamin C, such as citrus fruits, help increase iron absorption. Eating plenty of iron-containing foods is particularly important for people who have high iron requirements, such as children — iron is needed during growth spurts — and pregnant and menstruating women. Adequate iron intake is also crucial for infants, strict vegetarians and long-distance runners. Doctors may prescribe iron supplements or multivitamins containing iron for people with high iron requirements. But iron supplements are appropriate only when you need more iron than a balanced diet can provide. Don't assume that if you're tired that you simply need to take iron supplements. Overloading your body with iron can be dangerous.
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Concept map

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8. Ineffective health maintenance related to deficient knowledge regarding nutrition in pregnancy. •Doesn’t know proper foods to eat. •Doesn’t take supplements. •Doesn’t take precautions for her baby and herself. 7. Self Care Deficit related to decreased strength. •Sticky hair, (+) dandruff •Untrimmed and dirty nails •(+) Body odor 6. Constipation related to decreased fluid intake and daily activity. •Limit to 1.5 L/day •Wasn’t able to defecate for 5 days. •(+) paleness and weakness •Often sitting

1. Impaired gas exchange related to altered oxygen carrying- capacity of the blood. •(+) DOB •AR: 110 beats/min •RR: 30 breaths/min •BP: 160/100 mmHg •Easily irritated •(+) paleness and weakness • RBC = 2.10 • Hgb = 60 • Hct = 0.18 • O2 Sat. = 50.1%

5. Hyperthermia related to invasion of pathogens. •T = 38.9°C •Flush skin and warm to touch • Neutrophils = 86.0 • Lymphocytes = 14.0 •CXR = Right Basal Pneumonia •Ux = Bacteria = Many

2. Imbalanced nutrition less than body requirements related to inability to absorb nutrients. •(+) paleness and weakness • RBC = 2.10 • Hgb = 60 • Hct = 0.18 • Urea = 10.99 • Albumin = 21.8 • Direct HDL = 0.33 • LDL = 1.29 • Potassium = 3.01 3. Activity intolerance related to imbalance between oxygen supply and demand. •AR: 110 beats/min •RR: 30 breaths/min •BP: 160/100 mmHg •Limited ROM •(+) paleness and weakness • RBC = 2.10 • Hgb = 60 • Hct = 0.18 • O2 Sat. = 50.1% 4. Infection related to inadequate secondary defenses. •T = 38.9 • RBC = 2.10 • Hgb = 60 • Hct = 0.18 • WBC = 15.6 • Neutrophils = 86.0 • Lymphocytes = 14.0 •CXR = Right Basal Pneumonia •Ux = Bacteria = Many
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Nursing management

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Preventive education is important, because anemia is common in menstruating and pregnant women. Food sources high in iron include organ meats (beef or calf’s liver, chicken liver), other meats, beans (black, pinto, and garbanzo), leafy green vegetables, raisins, and molasses. Taking iron-rich foods with a source of Vitamin C enhances the absorption of iron. Nutritional counseling can be provided for those whose usual diet is adequate. Patients with a history of eating fad diets or strict vegetarian diets are counseled that such diets often contain inadequate amount of absorbed iron. Encourage the patient to continue iron therapy as long as it is prescribed, although the patient may no longer feel fatigued. Iron is best absorbed in empty stomach, the patient is instructed to take the supplement an hour before meals. Iron supplements are usually given in oral forms, typically as ferrous sulfate. Most patients can use the less expensive, more standard forms of ferrous sulfate. Tablets with enteric coating may be poorly absorbed and should be avoided. Many patients have difficulty tolerating ion supplements because of GI side effects (primarily constipation, but also camping, nausea, and vomiting). Some iron formulations are design to limit nausea and gastritis. Specific patient teaching aids can assist patients with the use of ion supplements.

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If taking iron in an empty stomach causes gastric distress, the patient may need to take it with meals. However, doing so diminishes iron absorption by as much as 50%, thus prolonging the time required to replenish ion stores. Antacids or dairy products should not be taken with iron, because they greatly diminish its absorption. Polysaccharide iron complex forms that have less GI toxicity are also available, but they are more expensive. Liquid forms of iron that cause less GI distress are available. However, they can stain the teeth; the patient should be instructed to take his medication through a straw, to rinse the mouth wit water, and to practice good oral hygiene.

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D r ug study

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Drug: Methergin Dosage: 1 amp IM Pharmacologic class: Exogenous hormone Therapeutic class: Lactation stimulant, Oxytocic Mechanism of Action Chemical effect: Causes potent and selective stimulation of uterine and mammary gland smooth muscle. Therapeutic effect: Induces labor and milk ejection and r educes postpartum bleeding. Indications: -To induce or stimulate labor. -To reduce postpartum bleeding after expulsion of placenta. -Uterine hemorrhage -Incomplete or inevitable abortion.
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Contrainidications: -Pregnancy; first and second stage of labor and before crowning of the head -Severe hypertension -Preeclampsia and eclampsia -Occlusive vascular disease -Sepsis Adverse Recations: CNS: Dizziness, headache, seizures, .hallucinations, CVA with IV use. CV: Hypertension, transient chest pain, palpitations, hypotension, thrombophlebitis.
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EENT: Tinnitus, nasal congestion. GI: nausea, vomiting, diarrhea, foul taste. GU: Hematuria Musculoskeletal: leg cramps Resp: Dyspnea Skin: Diaphoresis

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Nursing Responsibilties: -Monitor and record blood pressure, pulse rate and uterine response; report in sudden change in vital signs, frequent periods of uterine relaxation, and character and amount of vaginal bleeding. -Monitor contractions, which may begin immediately. -Contractions may continue for up to 3 hours or more after I.M. use. -Monitor fluid intake and output. -Antidiuretic effect may lead to fluid overload, seizures, and coma.

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Drug: Iberet Folic Dosage: 1 tab bid (8 am-6 pm) Pharmacologic class: Oral Iron supplement Therapeutic class: Hematinic Mechanism of Action Chemical effect: Provides elemental iron, an essential

component in formation of hemoglobin. Therapeutic effect: Relieves iron deficiency.
Indications:

Treatment and prevention of iron deficiency and concomitant folic acid deficiency with associated deficient intake or increase need for vitamin Bcomplex.

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Contraindications: -Thalassemia -Sideroblastic anemia -Hemochromatosis -hemosedirosis Adverse effects: GI: Anorexia, black stools, constipation, diarrhea, epigastric pain, nausea, vomiting. Nursing Responsibilities: -Obtain baseline assessment of patient’s iron deficiency before starting therapy. -Evaluate hemoglobin level, hematocrit, and reticulocyte count during therapy.
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Drug: Kalium Durule Dosage: 1 tab tid p.c. (8am-12nn-6pm) Pharmacologic class: Potassium supplement Therapeutic class: Minerals, Vitamins Mechanism of Action Chemical effect: Aids in transmitting nerve impulses,

contracting cardiac and skeletal muscle, and maintaining intracellular tonicity, cellular metabolism, acid-base balance, and normal renal function. Therapeutic effect: Replaces and maintains potassium level.
Indications: -Hypokalemia. -As prophylaxis during treatment with diuretics.

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Contraindications: Renal insufficiency Hyperkalemia Untreated Addison’s disease Stricture of the esophagus Heart/ kidney disease Pregnancy and lactation Adverse effects: CNS: Flaccid paralysis, listlessness, mental confusion, paresthesia of limbs, weakness or heaviness of legs.   CV: Arrhythmias, cardiac arrest, ECG changes,
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CV: Arrhythmias, cardiac arrest, ECG changes, heart block. GI: Abdominal pain, diarrhea, hemorrhage, nausea, obstruction, perforation, ulcerations, vomiting. Nursing Responsibilities: -Monitor ECG, renal function, fluid intake and output, and potassium, creatinine, and BUN levels.

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Drug: Pen G. Na Dosage: 1 million “u” IV Q6h ANST (8-2) Pharmacologic class: Natural penicillin Therapeutic class: Rapid-acting antibiotic Mechanism of Action Chemical effect: Inhibits cell wall synthesis during

microorganism multiplication. Therapeutic effect: Kills susceptible bacteria.
Indications:

-Moderate to severe systemic infections. -To prevent post streptococcal rheumatic fever and glomeruloneprhitis -Bacterial endocarditis. -Mild cases of streptococcal pharyngitis and skin structure infections.
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Contraindications: -Hypersensitivity to penicillins. Adverse effects: CNS: Neuropathy, seizures   CV: Thrombophlebitis   Hematologic: hemolytic anemia, leucopenia, thrombocytopenia   Musculoskeletal: Arthralgia   Other: Hypersensitivity reactions, overgrowth of nonsusceptible organisms, pain at injection site, vein irritation.
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Nursing Responsibilities: -Before giving drug, ask patient about allergic reactions to penicillin. -Obtain specimen for culture and sensitivity tests before giving first dose. Therapy may begin pending results. -Observe patient closely. With large doses and prolonged therapy, bacterial or fugal superinfection may occur, especially in elderly, debilitated, or immunosuppressed patients. -Assess renal, cardiac and vascular condition with physical exams and laboratory testing. -Assess risk of fluid overload or electrolyte

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Drug: Moriamin Forte Dosage: 1 cap OD Pharmacologic class: Folic Acid Derivatives Therapeutic class: Vitamin Mechanism of Action Chemical effect: Stimulates normal erythropoiesis and

neucloprotein synthesis. Therapeutic effect: Nutritional supplement.
Indications:

-To maintain health megaloblastic or macrocytic anemia caused by folic acid or other nutritional deficiency, hepatic disease, alcoholism, intestinal obstruction, excessive hemolysis. -Nutritional supplement -To test folic acid deficiency in patients with megaloblastic anemia without masking pernicious anemia.
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Contraindications: Contraindicated in patients with vitamin B12 deficiency or undiagnosed anemia Adverse effects: CNS: General malaise   GI: Anorexia, bitter taste, flatulence, nausea.   Respiratory: Bronchospasm,   Other: Allergic reactions

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Nursing Responsibilities: - Assess patient’s folic acid deficiency before starting therapy -Evaluate CBC and assess patient’s physical status throughout therapy.

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Drug: Aldazide Dosage: 1 tab bid Pharmacologic class: Mineralocorticoid Receptor Antagonist Therapeutic class: Potassium-sparing diuretic Mechanism of Action Chemical effect: Antagonizes aldosterone in distal tubule Therapeutic effect: Promotes water and sodium excretion and hinders potassium excretion, lowers blood pressure, and helps to diagnose primary hyperaldosteronism.
Indications: -Essential hypertension, edema, CHF, liver cirrhosis, nephrotic syndrome, idiopathic edema. -Management of edema, antihypertensive, diagnosis of primary hyperaldosteronism, treatment of diuretic- induced hypokalemia

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Contraindications: -Acute renal insufficiency -Significant renal impairment -Anuria -hyperkalemia Adverse effects: CNS: Headache, drowsiness, lethargy, confusion, ataxia GI: Diarrhea, gastric bleeding, ulceration, cramping, gastritis, vomiting GU: Impotence, menstrual disturbances
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Hematologic: Agranulocytosis Metabolic: Hyperkalemia, hypernatremia, mild acidosis, dehydration Skin: Urticaria, hirsutism, maculopapular eruptions, erythematous rash Other: Drug fever, gynecomastasia, breast soreness. Nursing Responsibilities: Monitor electrolyte levels, fluid intake and output, weight, and blood pressure.
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Drug: Tarka Dosage: 1 tab OD Pharmacologic class: Calcium channel blocker Therapeutic class: Antianginal, antiarrhythmic,

antihypertensive

Mechanism of Action Chemical effect: Not clearly defined; inhibits calcium ion

influx across cardiac and smooth muscle cells, thus decreasing myocardial contractility and oxygen demand. Drug also dilates coronary arteries and arterioles. Therapeutic effect: Relieves angina, lowers blood pressure, and restores normal sinus rhythm.
Indications:

Essential Hypertension
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Contraindications: Cardiogenic shock, 2nd and 3rd degree AV block and sick sinus syndrome except in patients with a functioning artificial pace maker, atrial fibrillation/ flutter. History of angioedema associated with administration of an ACE inhibitor, pregnancy, lactation. Adverse effects: CNS: Asthenia, dizziness, headache   CV: AV block, bradycardia, heart failure, peripheral edema, transient hypotension, ventricular fibrillation, ventricular asystole
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GI: constipation, nausea   Resp: Pulmonary edema   Skin: Rash Nursing Responsibilities: -Monitor blood pressure at start of therapy and during dosage adjustments

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Drug: Paracetamol Dosage: 300 mg IVTT q 4hrs. PRN T<37.8°C Pharmacologic class: Para-aminophenol Derivatives Therapeutic class: Nonopioid Analgesic, Antipyretic Mechanism of Action Chemical effect: May produce analgesic effect by

blocking pain impulses by inhibiting prostaglandin or pain receptor sene-sitizers. May relieve fever by acting hypothalamic heat- regulating center. Therapeutic effect: Relives pain or fever
Indications:

-Fever

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Contraindications: -Previous hypersensitivity products containing alcohol, aspartame, saccharine sugar, or tartrazine, should be avoided in patients who have hypersensitivity or intolerance to this compounds Adverse effects: GI: Hepatic failure, hepatoxicity (overdose)   GU: Renal failure (high doses/ chronic use)   Skin: Rash, urticaria
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Nursing Responsibilities: -Assess fever and note for the presence of associated signs, such as diaphoresis, tachycardia and malaise -Check and monitor patient’s temperature before and after giving the medication -Tell patient to report any adverse reaction that may occur -Before giving the medication intravenously, check first the patency of the IV site -Observe patient during administration of the drug

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Drug: Zinnat Dosage: 500 mg 1 tab BID Pharmacologic class: Second- generation Cephalosporin Therapeutic class: Antibiotic Mechanism of Action Chemical effect: Bind to bacterial cell wall membrane, causing cell death Therapeutic effect: Bactericidal action Indications: -Lower & upper resp tract infections, Genito- Urinary Tract infections, gonorrhea including acute uncomplicated gonococcal urethritis & cervicitis.

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Contraindications: -Hypersensitivity to cephalosporins. -Hypersensitivity to penicillins. -Pseudomembranous colitis. -Diabetics & phenylketonurics. Adverse effects: CNS: Seizures (high doses)   GI: pseudomembranous colitis, nausea, vomiting, cramps   Skin: Rashes, urticaria
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Nursing Responsibilities: -Assess patient for infection at beginning and after therapy. -Before initiating therapy, obtain a history to determine previous use and reactions to penicillins or cephalosporins -Obtain specimens for culture and sensitivity before I nitiating therapy

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Drug: Furosemide Dosage: (Lasix) 20 mg STAT Pharmacologic class: Loop Diuretic Therapeutic class: Anti-hypertension Mechanism of Action Chemical effect: Inhibits sodium and chloride reabsorption at proximal and distal tubules and ascending loop of henle. Therapeutic effect: Promotes water and sodium excretion Indications: -Acute Pulmonary Edema -Heart failure and chronic renal impairment -Hypertension -Hypercalcemia
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Contraindications: -Contraindicated in patients hypersensitive to drug or any of its components and in dose with anuria -Use cautiously in patients with hepatic cirrhosis -Patients with allergy to sulfonamide may also be allergic to furosemide Adverse effects: CNS: Dizziness, fever, headache, paresthesia, restlessness, vertigo and weakness CV: Orthostatic hypotension, thrombophlebitis
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EENT Blurred or yellow vision, transient deafness GI Abdominal discomfort, anorexia, constipation, diarrhea, pancreatitis, vomiting GU Azothemia, frequent urination, nocturia, olyguria, polyuria Hematologic Agranulocytosis, anemia, aplastic anemia, leucopenia, thrombocytopenia Hepatic hepatic dysfunction
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Metabolic Asymptomatic hyperurecemia: fluid and electrolyte imbalances, including dilutional hyponatremia, hypocalcemia, hypomagnecemia Nursing Responsibilities: -Monitor weight, peripheral edema, breath sounds, blood pressure, fluid intake and output, and electrolyte, glucose, BUN, and Carbon dioxide level -Monitor uric acid level, especially if patient has history of gout -Be alert for adverse reactions and drug

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Drug: Metronidazole Dosage: 500 mg, 1 tab, q 8° 8am-4pm-12mn Pharmacologic class: Nitroimidazole Therapeutic class: Antibacterial, Antiprotozoal, Amebicide Mechanism of Action Chemical effect: Direct acting trichomonacide and amebicide that works at both intestinal and extraintestinal sites Therapeutic effect: Hinders growth of selected organisms, including most anaerobic bacteria and protozoa Indications: -Amebic hepatic abscess -Intestinal amebiasis
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-Trichomoniasis

-Refractory trichomoniasis -Bacterial infections caused by anaerobic microoragnisms -To prevent postoperative infections in contaminated or potentially contaminated colorectal surgery -Inflammatory papules and pustules of acne rosacea -Pelvic inflammatory disease -Bacterial vaginosis -Active crohn’s disease -Helicobacter pylori with peptic ulcer disease

Contraindications: -Contraindicated in patients hypersensitive to drug and other nitroimidazole derivatives -Use cautiously in patients receiving hepatotoxic drugs and in patients with history of blood discrasia or CNS disorder, retinal or visual field changes, hepatic disease, or alcoholism
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Adverse Effects: CNS Ataxia, confusion, depression, drowsiness, fatigue, fever, headache, incoordination, insomnia, irritability, neuropathy, paresthesia of limbs, psychic stimulation, restlessness, seizures, sensory neuropathy, vertigo and weakness CV Edema, flattened T-wave, flushing, thrombophlebitis EENT Eye tearing

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GI Abdominal cramping, anorexia, constipation, diarrhea, dry mouth, metallic taste, nausea, proctitis, stomatitis and vomiting GU Cystitis, darkened urine, dry vagina and vulva, dyspareunia, dysuria, incontinence, polyuria, pyuria, sense of pelvic pressure Hematologic -neutropenia, thrombocytopenia, transient leukopenia

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Nursing Responsibilities: -Assess patient’s infection before therapy and regularly thereafter to monitor drug effectiveness -Watch carefully for edema -IV infusion may caused thrombophlebitis at site; observe closely -Assess skin or severity, areas of rosacia before and after therapy, and any local adverse reactions

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Drug: Dulcolax Dosage: 1 suppository per rectum Pharmacologic class: Diphenylmethane Derivative Therapeutic class: Stimulant Laxative Mechanism of Action Chemical effect: Increases peristalsis, probably by acting directly on smooth muscle of intestine. May irritate musculature, stimulate colonic intramural plexus, and promote fluid accumulation in colon and small intestine. Therapeutic effect: Relieves constipation. Indications: -Chronic constipation; preparation for childbirth, surgery, or rectal or bowel examination
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Contraindications: -Contraindicated in patients hypersensitive to drug or other penicillins and in dose with a history of amoxicillin-related cholestatic jaundice or hepatic dysfunction. -Use cautiously in patients with other drug allergies, especially to cephalosporin, and those with mononucleusis or hepatic impairment Adverse effects: CNS Agitation, anxiety, behavioral changes, confusion, dizziness, insomnia GI Abdominal pain, black “hairy” tongue, diarrhea, enterocolitis, gastritis, glossitis, indigestion, nausea, stomatitis and vomiting
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GU Vaginal candidiasis, vaginitis Hematologic Agranulocytosis, anemia, eosinphilia, leucopenia, thrombocytopenia, thrombocytopenic purpura Nursing Responsibilities: -Before therapy begins, assess patient’s infection, ask about past allergic reactions to penicillins, and obtain specimen for culture and sensitivity test. -Be alert for adverse reactions and drug interactions. -Monitor hydration status if adverse GI
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Contraindications: -Contraindicated in patients hypersensitive to drug and in dose with rectal bleeding, gastroenteritis, intestinal obstruction, or symptoms of appendicitis or acute surgical abdomen, such as abdominal pain, nausea or vomiting

Adverse effects:
GI Abdominal cramps, burning sensation in rectum (with suppositories), diarrhea (with high doses), laxative dependents (with long-term or excessive use), nausea, protein-losing enteropathy (with excessive use), vomiting

Metabolic Alkalosis, fluid and electrolyte imbalance, hypokalemia Musculoskeletal Muscle weakness ( with excessive use), tetany
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Nursing Responsibilities: -Obtain history of bowel disorder, GI status, fluid intake, nutritional status, exercise habits, and normal patterns of elimination -Monitor effectiveness by checking frequency and characteristics of stools -Be alert for adverse reactions and drug interactions -Auscultate bowel sounds at least once per shift

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Drug: Oxytocin Dosage: 20 “u” incorporate to PNSS 1L Pharmacologic class: Exogenous Hormone Therapeutic class: Lactation Stimulant, Oxytocic Mechanism of Action Chemical effect: Causes potent and selective stimulation of uterine and mammary gland smooth muscle. Therapeutic effect: Induces labor and milk ejection and reduces postpartum bleeding Indications: To induce or stimulate labor To reduce postpartum bleeding after expulsion of placenta Incomplete or inevitable abortion Oxytocin challenge test to assess fetal distress in high-risk pregnancies greater than 31 weeks gestation

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Contraindications: Contraindicated in patients hypersensitive to drug or any of its components. Also contraindicated in cephalopelvic disproportion or delivery that requires conversion, as in transverse lie; in fetal distress when delivery is not imminent; in prematurity; in other obstetric emergencies; and in severe toxemia, hypertonic uterine patterns, total placenta previa, or vasa previa

Adverse effects: Maternal CNS Coma form water intoxication, seizures, subarachnoid hemorrhage from hypertension CV Arrhythmias; hypertension; increased hear rate, systemic venous return, and cardiac output
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GI Nausea and vomiting GU Abruptio placentae, increased uterine motility, impaired uterine blood flow, pelvic hematoma, tetanic uterine contractions, uterine rupture Hematologic Afibrinogenemia (may be related to postpartum bleeding) Fetal CV Bradycardia, PVCs, tachycardia Hematologic Hyperbilirubilinemia Respiratory -anoxia, asphysia
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Nursing Responsibilities: -Assess patient’s condition before starting therapy and regularly thereafter -Monitor and record uterine contractions, heart rate, BP, intrauterine pressure, fetal heart rate, and blood loss every 15 minutes. -Be alert for adverse reactions and drug interactions -Monitor fluid intake and output. Antidiuretic effect may lead to fluid overload, seizures, and coma

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Drug: Sodium bicarbonate Dosage: 1 amp. slow IV STAT Pharmacologic class: Alkalanizer Therapeutic class: Ion Buffer, Oral Antacid
Mechanism of Action Chemical effect: Restores body’s buffering capacity and neutralizes excess acid. Therapeutic effect: Restores normal acid-base balance and relieves acid indigestion.

Indications: -Adjunct to advanced cardiovascular life support during cardiopulmonary resuscitation -Severe metabolic acidosis -Less urgent metabolic acidosis -Urine alkalization Antacid
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Contraindications: -Contraindicated in patients with metabolic or respiratory alkalosis; patients who are losing chlorides from vomiting or continuous GI suction; patients taking diuretics known to produce hypochloremic alkalosis; and patients with hypocalcemia in which alkalosis may produce tetani, hypertension, seizures, or heart failure. Oral Sodium bicarbonate is contraindicated in patients with acute ingestion of strong mineral acids. -Use cautiously in patients hypertension, heart failure or other edematous or sodium-retaining conditions or renal insufficiency.

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Adverse effects: GI Belching, flatulence, gastric distention Metabolic Hypernatremia, hyperosmolarity (with overdose), hypokalemia, metabolic alkalosis Other: Irritation and pain at injection site

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Nursing Responsibilities: -Assess patients condition before starting therapy and regularly thereafter to monitor drug’s effectiveness -To avoid risk of alkalosis, obtain blood pH, PaO2, PaCO2, and electrolyte level -If Sodium bicarbonate is being used to produce alkaline urine, monitor urine pH (should be greater than 7) q 4 to 6° -Be alert for adverse reactions and drug interactions

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Drug: Lanoxin Dosage: 0.25 mg, 1 tab, OD 8am Pharmacologic class: Cardiac Glycoside Therapeutic class: Anti-arrhythmic, Inotropic Mechanism of Action Chemical effect: Inhibits sodium-potassium-activated adenosine triphosphatase, thereby promoting movement of calcium form extracellular to intracellular cytoplasm and strengthening myocardial contraction Therapeutic effect: Strengthens myocardial contractions and slows conduction thru SA and Av nodes. Indications: -Heart failure -Paroxysmal supraventricular tachycardia -Atrial fibrillation -Flutter

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Contraindications: -Contraindicated in patients hypersensitive to drug or any of its components and in dose with digoxininduced toxicity, ventricular fibriltion, or ventricular tachycardia unless caused by heart failure -Use cautiously in patients with acute MI, incomplete AV block, sinus bradycardia, PVCs, chronic constrictive pericarditis, hypertrophic cardiomyopathy, renal insufficiency, severe pulmonary disease, or hypothyroidism.

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Adverse effects: CNS Agitation, dizziness, fatigue, generalized muscle weakness, hallucinations, headache, malaise, paresthesia, stupor and vertigo CV Arrhythmias, heart failure, hypotension EENT Blurred vision, diplopia, light flashes, photo phobia, yellow-green halos around visual images GI Anorexia, diarrhea, nausea and vomiting

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Nursing Responsibilities: -Monitor potassium level carefully. -Monitor effectiveness by taking apical pulse for 1 full minute before giving a dose. -Evaluate ECG, and regularly assess patient’s cardiopulmonary condition for signs of improvement. -Look for adverse reactions and drug interactions.

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Drug: Atrovent Dosage: 1 neb q6° 4am-10am-4pm-10pm Pharmacologic class: Anticholinergic Therapeutic class: Bronchodilators Mechanism of Action Chemical effect: Inhibit vagally mediated reflexes by antagonizing acetylcholine. Therapeutic effect: bronchospasms and symptoms of seasonal allergic rhinitis. Indications: To prevent or threat bronchospasm in patients with reversible obstructive airway disease

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Contraindications - To patients with cardiovascular disorders (including coronary insufficiency and hypertension) -Patients with Hypertyroidism or DM and those who are unusually responsive to adrenergies. Adverse effects CNS Tremor, nervousness, dizziness, insomnia, headache, hyperactivity, weakness, CNS stimulation, malaise. CV Tachycardia, palpitation, hypertension. EENT Dry and irritated nose and throat with inhaled form, nasal congestion, epistaxis, hoarseness.
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GI Heartburn, nausea, anorexia, altered taste, increased appetite. Metabolic- hypokalemia.

Musculuskeletal Muscle cramps. Respiratory Bronchospasm, cough, wheezing, dyspnea, bronchitis, increase sputum Nursing Responsibilities: - Monitor closely for signs and symptoms for toxicity. - Warn patient about risk of paradoxical bronchospasm and to stop drug immediately after it occurs. - Teach patient to perform oral inhalation correctly.
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medimap

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Risk Factors •Poor diet •Intestinal disorders. •Menstruation. •Pregnancy •Chronic conditions •Family history Medical Management Ferrous sulfate, ferrous gluconate, ferrous fumarate are often prescribed in treating iron deficiency anemia. Vitamin C is recommended also because it helps in facilitating in the absorption of iron. Pathophysiology Delivery placental fragments has been retained in the uterus preventing contraction of the uterus dilatation of the blood vessels in the uterus heavy bleeding (PPH) decreasing RBC, Hgb and Hct Severe Anemia
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Anemia is a condition in which your blood has a lower than normal number of red blood cells. This condition also can occur if your red blood cells don’t contain enough

Signs and Symptoms • Weakness • Pale skin • A fast or irregular heartbeat • Shortness of breath • Chest pain • Dizziness • Cognitive problems • Numbness or coldness in your extremities • Headache Nursing Management Preventive education is important, because anemia is common in menstruating and pregnant women. Nutritional counseling can be provided for those whose usual diet is adequate. Patients with a history of eating fad diets or strict vegetarian diets are counseled that such diets often contain inadequate amount of absorbed iron.
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Complication • Heart problems • Problems during pregnancy • Growth problems
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Nursing Care plan

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Discharge planning

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Medication: Proper compliance with the medication prescribed to the patient will limit the progression of her condition. MoriamenForte 1 cap OD – Vitamin Iberet Folic Acid 1 tab BID pc – Hematinic Aldazide 1 tab OD – Potassium- sparing Diuretic Kalium Durule 1 tab BID x 3 days (to consume 6 tabs only) – Minerals, Vitamins Exercise and Activity: Emphasize the need to maintain regular exercise and activities; to maintain muscle strength and motility, to help prevent bone demineralization, to decrease protein breakdown and to promote good circulation of the body system. However, avoid contact sports, crowds, and persons with respiratory infections. Passive exercise like breathing can also help the patient to feel calm and comfortable.
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Treatment: Iron Deficiency Anemia can cause death if severe and prolonged, early detection of it is very important. After the cause of her vaginal bleeding was removed through surgery all she needs for treatment is to comply with her medications. But in cases where iron deficiency anemia persists blood transfusions can help replacing iron and hemoglobin quickly.

Home Teaching: Teach the patient/folks the importance of monitoring the progress and compliance with the treatment regimen. Patient needs ongoing education and reinforcement on the multiple dietary requirement she needs. Patient needs health promotion activities and health screening. Emphasize to the patient the importance of having regular check-up to know her present condition.
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Out patient Follow-up After discharged, patient may go to clinic for follow-up check-up after a week. As part of this follow-up care, she should receive blood test to check for the level of her RBC and Hgb. Diet: Encourage intake of high biologic value protein foods such as eggs, dairy products and meats (causes positive nitrogen balance needed for growth and healing). Encourage high calorie and high iron containing foods like liver, red meat, seafood, poultry, eggs, beans and peas, dark green leafy vegetables — such as spinach — and raisins, nuts, and seeds.
ØEncourage the patient to adhere to fluid restrictions. Suggest that she suck on ice chips or hard candies to relieve thirst.
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Sexuality and Spirituality Sexual intercourse is not advisable as it may be may have a complication on the condition of the patient. Encourage a closer relationship with God through praying and attending any religious activity that we have.

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evaluation

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acknowledgements

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We w i l l n o t b e a b l e t o f i n i s h t h i s c a s e presentation without the help of those people who sincerely gave their support to u s. We w ou ld like t o th an k a ll t h e peo ple who generously gave their time, ideas and resources for the success of this presentation. THANKS……… To t h e f a m i l y o f o u r c h o s e n p a t i e n t , e s p e c i a l l y t o Y. C . , f o r t h e i r t i m e , a n d f u l l participation.

To a l l o u r c l i n i c a l i n s t r u c t o r s w h o gave us freedom and the challenge to discover on our own what life would need in this kind of profession. To M s . M a u r e e n N . P a t r i c i o , o u r beloved adviser in the clinical area, to Mrs. Katherine C. Bengan, Mrs. Pearl 138 J o y A . D e g o m a PRESENTATION: “SEVEREs . F l o r a M ay R . a n d M ANEMIA” 12/18/08 A CASE

To Dr. Nora B. Cambas for sharing her time and expertise as our Guest Speaker in today’s event. To the staff of St. Anthony College Hospital who supported us and make us feel warmth. To our dean, Sr. Edith Bagayaua, D.C. and to our clinical coordinator, Mrs. Suzette Vela for making this event possible. To our dearest class adviser, Mrs. Stella Cordenillo, who never cease to remind us the importance of studying. To our few Group mates whose heart, mind and soul is certain to make this Case Presentation on Severe Anemia be informative and possible. To all our classmates and friends, who generously share their knowledge to us, whose 139 friendship, inspiration, “SEVERE ANEMIA” and support we 12/18/08 A CASE PRESENTATION:

And finally, to

GOD Almighty, the GREAT PHYSICIAN and the AUTHOR OF LIFE, from whom wisdom comes. We thank HIM for
guidance and strength.

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Thank You!
**God bless us all**

-Group 1

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