INTRODUCTION

As a part of my Advance Nursing practice requirement I was posted in medical ICU

in Holy Cross Hospital, I came across the patient Mr. Shankar with the diagnosis of type 2
DM, Severe anemia, thrombocytopenia. To know more about the disease condition severe
anemia in detail and was taken him as my patient case study.

IDENTIFICATION DATA

Name - Mr. Shankar

Age - 70yrs

Sex -male

Education - uneducated

Address - Simli, Balarampur, CG

Ward - medical ICU

Bed No: -14

IP NO: - 125132

Date of admission - 23-4-15

Diagnosis - DM2, severe anemia, thrombocytopenia

Treating doctor -DR. Pushpa

A. SHORT MEDICAL HISTORY

 Chief complaints
Mr Shankar has the complaints of:
 Fever since 15 days
 Body ache since 15 days
 Decreased appetite since 10 days
 Disorientation since 3 days
 History of present illness

Mr. Shankar 70 yrs male patient came to the hospital on 23/4/15 with history fever since 15
days, body ache since 15 days decreased appetite since 10 days disorientation since 3 days.
He had the history of DM2 and has taken to the OPD and after all the examination like
history taking , physical examination, laboratory investigation; he is taken to medical ICU for
the emergency care. And diagnosed as DM2, severe anemia, thrombocytopenia.

Past medical history

Occasionally he had cough and cold, weakness and fatigue and he used to have the treatment
from government hospital Balarampur
 Present medical history
At present he is conscious mild disoriented. Has moderate pain in left leg and swelling, he
is confined to bed due to the weakness and unable to do his activities
 Past surgical history
Mr. Shankar has no any surgical history.
 Present surgical history
Mr. Shankar has no any surgical history.
B. SHORT PERSONAL HISTORY
 Family history
Mr Shankar belongs to a join family consist of 12 members. His father is the head of the
family. The family consists of his mother, father, his family, two brothers and their family.
They have no any hereditary disease.
 Family tree

Mr Jayashri Mrs. Phanpaty

Mr. Shankar Mrs. Sambavathi Mr. Ramsum Mrs.Rajmati mr.Arvind Mrs.

Jymanti

Mr.Rambilal Mrs. Rajmani Ms. Rejani Mr. Santosh

 Key

- Male

- Female

- patient

S.N NAME OF RELATIONS SEX AGE EDUCATION OCCUPATION REMARKS

O. THE HIP WITH
FAMILY THE H
MEMBERS PATIENT
1. Mr.Jayashri Father M 95yrs illiterate Farmer Unhealthy

2. Mrs.Phanpat Mother F 65yrs illiterate House wife Unhealthy

y
3. Mr. Shankar Patient M 70yrs illiterate merceri Unhealthy

4. Mrs. Wife F 55yrs illetrate House wife Healthy

Sambavathi
5. Mr Rambilal son M 26 yrs 8th standard Farmer Healthy

6. Mr Rajmani Daughter in F 22 yrs 8th standard Housewife Healthy

law
7. Mr. brother M 62 yrs 2ndstandard Farmer Healthy
RamSuminde
r
8. Mrs. Rajmati Sister in law F 50yrs illiterate House wife Healthy

9. Ms. Rejani Niece F 22yrs 10th standard Student Healthy

10.Mr.Aravind Brother M 58yrs 8th standard Farmer Healthy

11.Mrs.Jaymanti Sister-in-law F 50yrs illiterate Housewife Healthy

12.Mr.Santosh Nephew M 20yrs 11th standard Student Healthy

 Socio economic status

Mr. Shankar belongs to low class family. Mr.JayaShri his father is the head of the family.
He and his father, brothers, son are the bread earners, they are farmers and mr. Shankar is a
mercer and he earns 500 per day and altogether the monthly income is 3000RS.
They are living peacefully and having good relationship with each other.
  Nutritional status

Mr.Ram has a thin body built. He is a non vegetarian and takes meals 3 times a day. He
has no allergy towards any food items. He takes rice, dal, chappati, leafy vegetables, chicken
etc.

 Physical environment
Ventilation: Mr.Shankar’s house is a kacha house. It has good ventilation.
Lighting: they have electricity
Refuse of disposal: no drainage system. The drainage system directly goes to paddy field.
Toilet and facility: no toilet facilities are present. They practice open field defecation.
Water supply: water supply is from well. But they are not using boiled water for drinking.
 Health habits
Mr.Shankar has the habits of smoking, alcohol intake and tobacco consumption.
 Special interest
He likes farming. And during free times he used to do it.
 Psychological History
He looks sad because of illness.

PHYSICAL EXAMINATION
A. General appearance

A. General appearance

Patient is conscious and mild disoriented. He looks thin body built and also anxious and
tired. His gait is not normal and immobile due to weakness.

B. Height & weight

Height -160cm

Weight -56 kg

C. Vital signs

Parameters Normal values Patient value. REMARKS

Temperature 98.4* F 98.6* F Normal

Pulse 72-80/mt 80/mt Normal

Respiration 16-20 /mt 20/mt Normal

Blood pressure 120/80mmHg 150/100mmHg Increased

 D. Integumentary system

Inspection

Mr. Shankar is fair in complexion. No infections and breakdown of skin is found. His skin
is in normal texture. IV cannula is present on the left hand.

Palpation

Skin is warm to touch and dry. Skin texture is normal. Skin turgur is normal

E. Head

Inspection

Scalp looks clean, has no dandruff and pediculosis.

Palpation

Has no lesions found.

C. Eyes & Vision

Inspection

Eye brows and eye lashes are in symmetry. Has no abnormal discharge from the eyes, pupils
are reacting to light normally. Have no complaints of vision related to near and far objects.

Palpation

Nothing abnormal found.

D. Ear & Hearing

Inspection

Both ears are in symmetrical. No abnormal discharge from the ear. Ear wax is present in both
ears. He has no problem of hearing.

Palpation

No tenderness or swelling present

E. Mouth & Pharynx

Inspection

Oral hygiene is maintained, Lips are dry and dark in colour. No swelling or inflammation on
the gums. Tongue is in mid line and moist. Gag reflex is present. Infection in the pharynx is
absent. Redness in the pharynx is absent.
Palpation

No masses or ulceration present

F. Neck

Inspection

Range of motion is normal; the chin can touch the chest wall. No enlarged thyroid gland is
present or distension of vein present.

Palpation

No enlargement or masses can be palpated.

C. Lymph nodes

Inspection

There are no enlarged lymph nodes.

Palpation

No enlarged lymph nodes are palpable.

D. Axilla

Inspection

Hairs are present.

Palpation

No masses or lymph nodes are palpated

E. Respiratory system

Inspection

Mrs. Ram has shallow respiratory pattern. Respiratory rate is 24/mt. The thorax is normally
symmetric.

Palpation

There is no tenderness and chest movement is symmetric.

Percussion

No dullness sound is present and no other complaints

Auscultation

Vesicular, broncho vesicular and tubular sounds are heard in a normal manner. No any
abnormal sounds heard

F. Cardiovascular system
Inspection
Chest wall is normal in shape; Blood pressure is 150/100mmHg.
Auscultation
S1 and S2 are audible, auscultated from 3rd left inter space, close to the sternum. No any
abnormal sound heard. Heart rate is normal and of 80 beats/mt.
Peripheral circulation
Inspection
The skin colour, hair of extremities is normal,
Palpation
Peripheral pulses and temperature are normal except in left lower extremities
G. Gastro intestinal system
Inspection
The abdomen is flat and no other abnormalities present.
Auscultation
Bowel sounds are present. 30 b.s. /mt and no other abnormalities are present.
Percussion
On percussion resonce sounds are obtained
Palpation
No tenderness or masses are present. On deep palpation no any abnormalities are seen.

H. Musculoskeletal system
Inspection
Upper and lower extremities are symmetrical in size, no muscle mass are present.
Have mild pain during the time of examination in lower extremities.
Palpation
There are no abnormalities in other extremities and no any bony deformity is present.
I. Central nervous system

He is having abnormal mental status, the sensory, motor cerebellar functions are normal.
Memories and reasoning abilities are good. There are no abnormalities in reflexes except in
left lower extremity. No special complaints are present.

J. Genitourinary system

Lesions and scars are absent. Has got less urine output. Urie output is 100 ml at 10 am
 MEDICATIONS
Trade name Generic Dose Route Frequ- Action
Name ency

Inj.peptaz 2.25 I.V. Tds Antibiotic

Piperacilin gm Bactericidal
+
tazobactu
m
Inj. Tramadol Tramadol 100 I.M sos Opoid analgesic
hydrochlori mg
de
Inj. Pantop Pantrapazo 40 I.V. BD Proton pump
le mg inhibitor
Inj Amikacin Amikacin 500 IV 12 Antibacterial
sulphate mg Hourly
Inj Falcigo Artesunate 120 IM BD Anti protozoal
mg
Inj PCM Paracetam 300 IV 12 Anti pyretic
ol infusion mg Hourly
Iv NS with Noradrenal 200 IV 5- Vasodilator
Noradrenalin in mg 15ml/hr
Iv DNS with Inj Atrapid 60 IV 24 Insulin
Atrapid units hourly supplement
Tab mactor 10m PO HS
g
Trade Generic Dose Route Frequency Mechanism of Side Nursing responsiblity
name name action effects
Peptaz Piperacili 2.25 IV Tds Administration CNS:  Assess for
n+ of drug Headach infection
tazobactu e,  Obtain specimens
m It binds the cell GI:nause for culture and
wall of micro a,vomitin sensitivity
organism g,rashes,  Dilute Montaz in
GU: 10 ml of distilled
Destroys the cell hematuri water. Do not use
wall of micro a,pain, preparations
organism DERM: contain benzyl
Action : allergic alcohol for
antibiotic reaction neonates.
Administer slowly
over3-5 mt
Mactor 10 Po HS Administration CNS:  Obtain dietary
mg of drug dizziness history, especially
CV: with regard to fat
Inhibit 3- chest consumption
hydroxy-3- pain  Administer
methylglutaryl- GI: extended realease
coenzymeA abdomin tablet at bed
reductase al time.extended
cramps, release tablet
Catalyses the constipat shldnot crush
synthesis of ion break or chew.
cholestrol DERM:r  Instruct the patient
Action :lipid ashes to take as directed
lowering agents and not skip the
medicines.

Amikacin Amikacin 500 IV BD Administration CNS:Ata  Assess for

sulphate mg of drug xia, infection
Headach  Obtain specimens
Inhibits the e for culture and
protein synthesis ENT: sensitivity
in bacteria at ototoxicit  Monitor cranial
level of 30S y, nerve function
ribosome GU:neph  Ke4ep patient well
rotoxicit hydrated
Bactericidal y,
action MUSCU
Action : LOSKEL
bactericidal ETAL:
muscle
weakness
GI:
,nausea,v
omiting,r
ashes

Inj Tramadol 100 IM SOS Administration CNS:dro  Assess type,

Tramadol H mg of drug wsiness, location, and
ydrochlor dizziness intensity of pain
ide Binds to mu- , before and after
opoid receptors Headach administration
e  Assess bowel
Inhibts reuptake confusio function routenly
of serotonin and n,  Explain the
norepinephrine DERM:p therapeutic effect
in the CNS ruritis, of medicinr before
rashes administration to
reduction of , enhance the effect.
 pain GI:nause
action :opoid a,vomitin
analgesic g,
Inj Pantop Pantrapaz 40m IV BD Administer drug CNS:Hea  Assess for
ole g dache ,dr epigastric pain and
Inhibits the owsiness frank, or occult
effect of proton , blood in the stool,
pump receptor dizziness emisis or gastric
Action:proton , aspirate
pump receptor confusio  Doses should be
n administered at
GI:,naus bed time for
ea,vomiti prolonged effect
ng,
Inj PCM Acetamin 300 IV SOS Administer the ENDOC  Assess overall
ophen mg drug RINE: health status and
Hepatic alcohol usage
Inhibits the failure, before
synthesis of hepatic administering
prostaglandins toxicity, acetaminophen
that may serve GU:renal  Assess
as mediators of failure, fever:note the
pain and fever in HEMAT: presence of
the CNS leukopen associated
ia signs
Anti  If overdose occur
pyresis,analgesi acetylcysteine is
a the anti dote.
Action:antipyreti
c
Inj falcigo Artesunat 120 IV OD Administration CNS:Hea  Assess for
e mg of drug dache infection
GI:,naus  Obtain specimens
It binds the cell ea,vomiti for culture and
wall of micro ng, sensitivity
organism DERM:r  Dilute Montaz in
ashes, 10 ml of distilled
Destroys the cell allergic water. Do not use
wall of micro reaction preparations
organism GU:hem contain benzyl
Action : aturia,pai alcohol for
antiprotozoal n, neonates.
(anti malarial) Administer slowly
over3-5 mt

Inj Atrapid 60 IV Q12hrly Atrapid is a ENDO:H  Observe the

Atrapid units insulin ypoglyce patientrs for signs
with supplementwhic mia. and symptoms of
DNS h helps in DERM:s hypoglycaemic
lowering blood kin agents
 sugar bruisatio  Patient stabilized
n, on a diabetic
hypersen regimen who are
sitivity exposed to stress,
fever,trauma,infect
ion or surgerymay
require sliding
scale insulin
 Explain the patient
that medications
control
hyperglycemia but
doesnot cures
diabetics. Therapy
is long term.

LAB INVESTIGATIONS
PARAMETERS NORMAL VALUE PATIENTS IMPRESSION
VALUE
HEMATOLOGY
Hb 12-15 gm% 7.5g/dl Decreased
Mp - Not seen
Blood group - B+ve
BIOCHEMISTRY
RBS 80-100mg/dl 130 mg/dl Normal
S creatine 1.2mg/dl Normal
ELECTROLYTES
Sodium 135-155meq/l 133 meq/l Normal
Potassium 3.5-5meq/l 2.2meq/l Normal
Chloride 98-108 meq/l 108meq/l Normal
LIPID PROFILE
TGL 200 mg/dL 236mg/dl Increased
HDL 40-50 mg/dL 15 mg/dl Decreased
LDL <130 mg/dL 24mg/dl Decreased
VLDL 47mg/dl

PERIPHERAL SMEAR COMMENT

 Microcytic hypochromic anemia, lecopenia,thrombocytopenia,pantocytopenia

DIAGNOSIS

SEVERE ANEMIA

INTRODUCTION
 Anemia is a medical condition in which the red blood cell count or haemoglobin is
less than normal. For men, anemia is typically defined as haemoglobin level of less than 13.5
gram/100ml and in women as haemoglobin of less than 12.0gm/100ml. Anemia is caused by
either a decrease in production of red blood cells or haemoglobin, or an increase in loss or
destruction of red blood cells. Some patients with anemia has no symptoms. Others may feel
tired, easily fatigued, appear pale, a feeling of heart racing, short of breath, and/or worsening
of heart problems. Anemia ccan be detected by a simple blood test called a Complete blood
cell count (CBC). The treatment of the anemia varies greatly and very much depends on the
particular cause.

DEFINITION
Anemia or anaemia is usually defined as a decrease in the amount of red blood cells (RBCs)
or haemoglobin in the blood. It can also be defined as a lowered ability of the blood to
carry oxygen

RISK FACTORS OF ANEMIA

According to book Seen in patient
 Anemia is a common condition. It occurs Thorough history has collected and history
in all age, racial, and ethnic groups. Both reveals that he’s not having any hereditary
men and women can have anemia. disease but he is diagnosed as diabetes.
However, women of childbearing age are
at high risk for the condition because
blood loss from menustraton
 Anemia can develop during pregnancy
-
due to low levels of iron and folic acid
and changes in blood. During the first 6
months of pregnancy, the fluid portion of
womans blood (the plasma) increases
faster than the number of red blood cells.
This dilutes the blood can lead to anemia
 During the first year of life, some babies -
are at risk for anemia because of iron
deficiency. At risk infants include those
who are born too early and infants who
are fed breast milk only or formula that
isn’t fortified with iron. These infants can
develop iron deficiency by 6 monthof
age. -
Major factors that arises the risk of
anemia are:
 A diet that is low in iron, vitamins,or -
minerals
 Blood loss from surgery or an injury
 Long-term or serious illnesses, such as
kidney disease, cancer, diabetes,
rheumatoid arthritis, HIV/AIDS,
 inflammatory bowel disease (including
Crohn’s disease), liver disease, heart -
failure, and thyroid disease
 Long term infections
 A family history of inherited anemia,
such as sickle cell anemia or thalassemia.
TYPES OF ANEMIA
According to book Seen in patient
The common types of anemia are: Mr. Shankar is having the anemia which
causes the ability of body to produce RBC
and also the less iron supplement is also a
 Iron-deficiency anemia is the most
cause.
common type of anemia. It happens when
there is not having enough iron in the
body. Iron deficiency is usually due to
blood loss but may occasionally be due to
poor absorption of iron. Pregnancy and
childbirth consume a great deal of iron
and thus can result in pregnancy-related
anemia. People who have had gastric
bypass surgery for weight loss or other
reasons may also be iron deficient due to
poor absorption.
 Vitamin-deficiency anemia may result
from low levels of vitamin B12 or folate
(folic acid), usually due to poor dietary
intake. Pernicious anemia is a condition
in which vitamin B12 cannot be absorbed
in the gastrointestinal tract.
 Anemia and Pregnancy 
 Aplastic anemia   is a rare form of
anemia that occurs when the body stops
making enough red blood cells. Common
causes include viral infections, exposure
to toxic chemicals, drugs, and
autoimmune diseases. Idiopathic aplastic
anemia is the term used when the reason
for low red blood cell production is not
known.
 Hemolytic anemia   occurs when red
blood cells are broken up in the
bloodstream or in the spleen. Hemolytic
 anemia may be due to mechanical causes
(leaky heart valves or aneurysms),
infections, autoimmune disorders, or
congenital abnormalities in the red blood
cell. Inherited abnormalities may affect
the hemoglobin or the red blood cell
structure or function. Examples of
inherited hemolytic anemias include
some types of thalassemia and low levels
of enzymes such as glucose-6 phosphate
dehydrogenase deficiency. The treatment
will depend on the cause.
 Sickle cell anemia is an inherited
hemolytic anemia in which the
hemoglobin protein is abnormal, causing
the red blood cells to be rigid and clog
the circulation because they are unable to
flow through small blood vessels.
 Anemia caused by other diseases   -
Some diseases can affect the body's
ability to make red blood cells. For
example, some patients with kidney
disease develop anemia because the
kidneys are not making enough of
the hormone erythropoietin to signal the
bone marrow to make new or more red
blood cells. Chemotherapy used to treat
various cancers often impairs the body's
ability to make new red blood cells, and
anemia often results from this treatment.

CAUSES OF ANEMIA
According to book Seen in patient
 Broadly, causes of anemia may be The main cause of the anemia is the impaired
production of RBC related to endocrine
 classified as impaired red blood cell disorders like diabetes mellitus 2. And it also
results in the complication of
(RBC) production, increased RBC thrombocytopenia.
destruction (hemolytic anemias), blood
loss and fluid overload (hypervolemia).
Several of these may interplay to cause
anemia eventually. Indeed, the most
common cause of anemia is blood loss,
but this usually does not cause any lasting
symptoms unless a relatively impaired
RBC production develops, in turn most
commonly by iron deficiency. (See Iron
deficiency anemia)
 Impaired production

Disturbance of proliferation and

differentiation of stem cells

 Pure red cell aplasia

 Aplastic anemia affects all kinds of blood
cells. Fanconi anemia is a hereditary
disorder or defect featuring aplastic
anemia and various other abnormalities.
 Anemia of renal failure by
insufficient erythropoietin production
 Anemia of endocrine disorders

Disturbance of proliferation and

maturation of erythroblasts

 Pernicious anemia is a form

of megaloblastic anemia due to vitamin
B12 deficiency dependent on impaired
absorption of vitamin B12. Lack of dietary
B12 causes non-pernicious megaloblastic
anemia
 Anemia of folic acid deficiency, as with
vitamin B12, causes megaloblastic anemia
 Anemia of prematurity, by diminished
erythropoietin response to declining
hematocrit levels, combined with blood
loss from laboratory testing, generally
occurs in premature infants at two to six
weeks of age.
  Iron deficiency anemia, resulting in
deficient heme synthesis
 Thalassemias, causing deficient globin
synthesis
 Congenital dyserythropoietic anemias,
causing ineffective erythropoiesis
 Anemia of renal failure (also causing
stem cell dysfunction)
Other mechanisms of impaired RBC
production
 Myelophthisic anemia or myelophthisis is
a severe type of anemia resulting from the
replacement of bone marrow by other
materials, such as malignant tumors or
granulomas.
 Myelodysplastic syndrome
 anemia of chronic inflammation
 Increased destruction
Anemias of increased red blood cell
destruction are generally classified
as hemolytic anemias. These are generally
featuring jaundice and elevated lactate
dehydrogenase levels.

Intrinsic (intracorpuscular)
abnormalities cause premature
destruction. All of these,
except paroxysmal nocturnal
hemoglobinuria, are hereditary genetic
disorders.

 Hereditary spherocytosis is a hereditary

defect that results in defects in the RBC
cell membrane, causing the erythrocytes
to be sequestered and destroyed by
thespleen.
 Hereditary elliptocytosis is another defect
in membrane skeleton proteins.
 Abetalipoproteinemia, causing defects in
membrane lipids
 Enzyme deficiencies

o Pyruvate
 kinase and hexokinase deficiencies, causi
ng defect glycolysis
o Glucose-6-phosphate dehydrogenase
deficiency and glutathione
synthetase deficiency causing
increased oxidative stress

 Hemoglobinopathies

o Sickle cell anemia

o Hemoglobinopathies causing unstable
hemoglobins
o Paroxysmal nocturnal hemoglobinuria

 Extrinsic (extracorpuscular)
abnormalities

Antibody-mediated

 Warm autoimmune hemolytic anemia is

caused by autoimmune attack against red
blood cells, primarily by IgG. It is the
most common of
the autoimmune hemolyticdiseases. It can
be idiopathic, that is, without any known
cause, drug-associated or secondary to
another disease such as systemic lupus
erythematosus, or a malignancy, such
as chronic lymphocytic leukemia.
 Cold agglutinin hemolytic anemia is
primarily mediated by IgM. It can be
idiopathic or result from an underlying
condition.
 Rh disease, one of the causes
of hemolytic disease of the newborn
 Transfusion reaction to blood
transfusions
 Mechanical trauma to red cells

 Microangiopathic hemolytic anemias,

including thrombotic thrombocytopenic
purpura and disseminated intravascular
coagulation
 Infections, including malaria
 Heart surgery
 Haemodialysis
 Blood loss

 Anemia of prematurity from frequent

blood sampling for laboratory testing,
combined with insufficient RBC
production
 Traumaor surgery, causing acute blood
loss
 Gastrointestinal tract lesions, causing
either acute bleeds (e.g. variceal
lesions, peptic ulcers or chronic blood
loss (e.g. angiodysplasia)
 Gynecologic disturbances, also generally
causing chronic blood loss
 From menstruation, mostly among young
women or older women who
have fibroids
 Infection by intestinal nematodes feeding
on blood, such as hookworms and the
whipworm Trichuris trichiura.
 Fluid overload
Fluid overload (hypervolemia) causes
decreased hemoglobin concentration and
apparent anemia:

 General causes of hypervolemia include

excessive sodium or fluid intake, sodium
or water retention and fluid shift into the
intravascular space.
Anemia of pregnancy is induced by blood
volume expansion experienced in pregnancy

PATHOPHYSIOLOGY
The Role of Red Blood Cells in Anemia

Red blood cells carry hemoglobin, an iron-rich protein that attaches to oxygen in the lungs
and carries it to tissues throughout the body. Anemia occurs when do not have enough red
blood cells or when our red blood cells do not function properly. It is diagnosed when a blood
 test shows a hemoglobin value of less than 13.5 gm/dl in a man or less than 12.0 gm/dl in a
woman. Normal values for children vary with age.

Increased oxygen extraction of anemic blood by the tissue produces increased concentration
of deoxyhemoglobin in the RBC.

Vasoconstriction of blood vessels nonvital areas allows more blood flow into critical
areas.

Total body red cells mass is decreased in aneamia

Blood volume is increased and increased plasma volume

The heart can respond to tissue hypoxia by

Decreased blood viscosity ( thin blood flow more freely than thick blood)

Anaemia must be developed (severe)

CLINICAL MANIFESTATION OF ANEMIA

According to book Seen in patient
 Mr Shankar has weakness,
 Anemia goes undetected in many people, and
or fatigue,general malaise,
symptoms can be minor or vague. The signs and Headache,cold hands or
symptoms can be related to the underlying cause or feet, mild disorientation
the anemia itself. dyspnea  . on examination
 weakness, or fatigue, pallor is present
 general malaise,
 Sometimes poor concentration.
 dyspnea (shortness of breath) on exertion.
 In very severe anemia: The body may compensate for the
lack of oxygen-carrying capability of the blood by
increasing cardiac output. The patient may have
symptoms related to this,
 Such as palpitations, angina (if pre-existing heart
disease is present), intermittent claudication of the
legs, and symptoms of heart failure.), but this is not a
reliable sign.
  pallor (pale skin, lining mucosa, conjunctiva and nai
l bedsspecific causes of anemia, e.g., koilonychia (in
iron deficiency), 

 Pounding or "whooshing" in your ears

 Headache
 Cold hands or feet

 jaundice (when anemia results from abnormal break

down of red blood cells — in hemolytic anemia),
 bone deformities (found in thalassemia major)
or legulcers (seen in sickle-cell disease).
 hyperdynamic circulation: tachycardia (a fast heart
rate),bounding pulse, flow murmurs,
and cardiac ventricular hypertrophy (enlargement).
 Heart failure. 
 Chronic anemia may result in behavioral
disturbances in children as a direct result of impaired
neurological development in infants, and reduced
scholastic performance in children of school age.
  Restless legs syndrome is more common in those
with iron-deficiency anemia

ASSESSMENT AND DIAGNOSTIC EVALUATION

According to book
Assessment
 Complete health history
 Physical examination
Diagnostic evaluation
 Anemia is typically diagnosed on
a complete blood count.
 Apart from reporting the number of red
blood cells and the hemoglobin level,
theautomatic counters also measure the
Done in patient
 Thourough history has collected and
it reveals that he is not having any
hereditary diseases bt diagnosed with
diabetes mellitus
 Physical examination reveals that he
has the clinical manifestations of
weakness, or fatigue,general malaise,
Headache,cold hands or feet, mild
disorientation dyspnea ,pallor is
present
 size of the red blood cells by flow  From laboratory examination CBC
cytometry, which is an important tool in has done and it shows that Mr.
distinguishing between the causes of Shankar has Hb =7.5gm/dl
anemia.  Ps comment says that microcytic
 Examination of a stained blood hypochromic RBC with mild degree
smear using a microscope can also be of anispoiklocytosis target.
helpful, and it is sometimes a necessity in Panocytopenia
regions of the world where automated
analysis is less accessible.
 In modern counters, four parameters
(RBC count, hemoglobin
concentration, MCV and RDW) are
measured, allowing others
(hematocrit, MCH and MCHC) to be
calculated, and compared to values
adjusted for age and sex. Some counters
estimate hematocrit from direct
measurements.

MANAGEMENT
Treatments for anemia depend on cause and severity. Vitamin supplements given orally (folic
acid or vitamin B12) or intramuscularly (vitamin B12) will replace specific deficiencies.
GOALS:

 Increase the amount of oxygen that blood can cary.this is done by raising the red blood
cell count and/or haemoglobin level
 Treat the underlying cause of anemia.
MEDICAL MANAGEMENT
According to book Done in patient
The physician is ordered for blood
Oral iron transfusion of 2 unit of blood and
other symptomatic treatments like
 Nutritional iron deficiency is common in antibiotic therapy, fluid therapy etc
developing nations. An estimated two-thirds of to manage the symptoms. Bt Mr.
children and of women of childbearing age in most Shankar has not transfused the
developing nations are estimated to suffer from iron blood due to lack of money.
deficiency; one-third of them have the more severe
form of the disorder, anemia. Iron deficiency from
nutritional causes is rare in men and
postmenopausal women. The diagnosis of iron
deficiency mandates a search for potential sources
of loss, such as gastrointestinal bleeding from
ulcers or colon cancer. Mild to moderate iron-
 deficiency anemia is treated by oral iron
supplementation with ferrous sulfate, ferrous
fumarate, or ferrous gluconate. When taking iron
supplements, stomach upset and/or darkening of the
feces are commonly experienced. The stomach
upset can be alleviated by taking the iron with food;
however, this decreases the amount of iron
absorbed.Vitamin C aids in the body's ability to
absorb iron, so taking oral iron supplements with
orange juice is of benefit.
 In anemias of chronic disease, associated with
chemotherapy, or associated with renal disease,
some clinicians
prescribe recombinant erythropoietin or epoetin
alfa, to stimulate RBC production, although since
there is also concurrent iron deficiency and
inflammation present, parenteral iron is advised to
be taken concurrently.
Injectable iron
 In cases where oral iron has either proven
ineffective, would be too slow (for example, pre-
operatively) or where absorption is impeded (for
example in cases of inflammation),parenteral
iron can be used. The body can absorb up to 6 mg
iron daily from the gastrointestinal tract. In many
cases the patient has a deficit of over 1,000 mg of
iron which would require several months to replace.
This can be given concurrently
with erythropoietin to ensure sufficient iron for
increased rates of erythropoiesis.
Blood transfusions
 Blood transfusions in those without symptoms are
not recommended until the hemoglobin is below 60
to 80 g/L (6 to 8 g/dL). In those with coronary
artery disease who are not actively bleeding
transfusions are only recommended when the
hemoglobin is below 70 to 80g/L (7 to 8
g/dL). Transfusing earlier does not improve
survival.
 Transfusions otherwise should only be undertaken
in cases of cardiovascular instability.
 Erythropoiesis-stimulating agent
 The motive for the administration of
an erythropoiesis-stimulating agent (ESA) is to
maintain hemoglobin at the lowest level that both
minimizes transfusions and meets the individual
persons needs. They should not be used for mild or
moderate anemia. They are not recommended in
people with chronic kidney disease unless
hemoglobin levels are less than 10 g/dL or they
have symptoms of anemia. Their use should be
along with parenteral iron.
Hyperbaric oxygen
 Treatment of exceptional blood loss (anemia) is
recognized as an indication for hyperbaric
oxygen (HBO) by the Undersea and Hyperbaric
Medical Society. The use of HBO is indicated
when oxygen delivery to tissue is not sufficient in
patients who cannot be
given bloodtransfusions for medical or religious rea
son. HBO may be used for medical reasons when
threat of blood product incompatibility or concern
for transmissible disease are factors. The beliefs of
some religions (ex: Jehovah's Witnesses) may
require they use the HBO method. A 2005 review
of the use of HBO in severe anemia found all
publications reported positive results.

NURSING MANAGEMENT
Nursing diagnosis

1) Ineffective airway clearance dyspnoea related to disease condition characterizes by deep

breathing and sweating of the patient
2) Acute pain all over the body related to disease condition characterized by the facial
expression of the patient
3) Activity intolerance related to weakness and fatigue characterized by inability to do
activities
4) Impaired thermoregulation, hyperpyrexia related to infection characterized high
temperature shown by the patient
5) Impaired nutritional pattern anorexia related disease condition characterized by the
avoidance of food.
6) Fluid volume deficit related to inadequate fluid intake characterized by less I/O charting
7) Impaired sleeping pattern, insomnia related to pain, characterized by the drowsy eyes of
the patient
8) Fear and anxiety related to disease condition characterized by the uncooperativeness of
patient
9) Risk for decebitus ulcer related to the confinement and less movement characterized by
the colour changes in the sacral region
10) Knowledge deficit related to disease condition and management characterized by the
doubts of patient and relatives.

Short term goal

1) The patient will be relieving from dyspnoea as evidenced by the increased saturation rate.
2) The patient will be relieved from pain as evidenced by the verbalisation
3) The patient will be able to do his activities as evidenced by the participation of patient in
activities
4) The patient will be relieved from hyperpyrexia as evidenced by the reduced temperature
shown by the thermometer
5) The patient will have good nutritional pattern as evidenced by the improving health of
patient
6) The patient will have normal fluid maintenance as evidenced by the reading in I/O chart
7) The patient will have good sleeping pattern as evidenced by the reduced weakness of
patient
8) The patient will be relieved from anxiety as evidenced by the cooperation of patient
9) The patient will be protected from the risk of decibitus ulcer as evidenced by the reduced
symptoms
10) The patient and relatives will have adequate knowledge regarding disease condition and
its management characterised by the verbalisation

Long term goal

1) Patient will get early discharge

2) Patient will not have any complications

NUTRITIONAL MANAGEMENT
According to book Done in paient
Low levels of vitamins or iron in the body Health education is given regarding the
can cause some types of anemia. These low nutritional management and advised to take
levels might be the result of a poor diet or iron rich food.
certain diseases or conditions.
To raise the vitamins or iron level, change the
diet or take vitamin or iron supplements.
Common vitamin supplements are vitamin
B12 and folic acid. Vitamin C sometimes is
given to help the body to absorb iron.
Iron: Body needs iron to make
haemoglobin.
Body can more easily absorb iron from
meats than from vegetables or other
foods.
Spinach and other dark green leafy
vegetables
Tofu
Peas ;lentils: white, red, and banked
beans;soyabeans and chicken peas
Dried fruits’ such as prunes, raisins, and
apricots
Prune juice
Iron fortified cereals and breads
Vitamin B12: low levels of
vitaminB12 can lead to pernicious
anemia. This type of anemia often is
treated with vita in B12 supplements.
Breakfast cereals with added vitamin B12
Meats such as beef, liver, poultry, and
fish
Foods fortified with vitamin B12, such as
soy-based beverages and vegetarian
burgers.
Folic acid: folic acid is a form of
vitamin B that’s found in foods. Body
needs folic acid to make and maintain
new cells. Folic acid also is very
important for pregnant women. It
helps them avoid anemia and
promotes healthy growth of the fetus.
Bread, pasta, and rice with added folic
acid
Spinach and other dark green leafy
vegetables
Black –eyed peas and dried beans
Beef liver
Eggs
Bananas, oranges, orange juice, and some
other fruits and juices.
Vitamin C: vitamin C helps the body
absorb iron. Good sources of vitamin C
are vegetables and fruits, especially citrus
 fruits. Citrus fruits include oranges,
grapefruits, tangerines, and similar fruits.
Fresh and frozen fruits, vegetables, and
juices usually have more vitamin C than
canned ones.
Fruits rich in vitamin C include kiwi fruit,
strawberries, grape (if no
contraindications) and cantaloupes.
Vegetables rich in vitamin C include
boroccoli, peppers, Brussels sprouts,
tomatoes, cabbage, potatoes, and leafy
green vegetables like turnip greens and
spinach.
COMPLICATIONS OF ANEMIA
According to book Seen in patient
 At present Mr. Shankar had the
 Arrhythmias weakness and body pain no other
 Heart failure complications are present.
 Multi system disorder
 It weakens the people who have
cancer or HIV/AIDS

PREVENTION OF ANEMIA
According to book
 It may be able to prevent repeat episodes
of some types of anemia, especially those
caused by lack of iron or vitamins
 Treating anemias underlying cause may
prevent the condition
Done in patient
 For preventing the complication of
anemia the treatment of diabetes mellitus
is taking place as well as other
complimentary treatment is taking place.
 And also health education is given to the
family members about how to prevent
the anemia.

HEALTH EDUCATION
ANEMIA

Definition

Aneamia is a deficiency in the number of erythrocytes ,the quantity of hemoglobin, and the volume of
packed, it is a prevalent condition with many diverse causes such as blood loss , impaired production
of erythrocytes, or increased destruction of erythrocytes.

Types of anaemia:-
1) Anaemia caused by decreased erythrocyte production.
2) Anaemia caused by blood loss.
3) Anaemia caused by increased erythrocyte.

Causes of anaemia

1) Decreased erythrocyte
Production.
2) Decreased hemoglobin
Synthesis.
 Iron deficiency,
 Thalassemia (decreased globin synthesis).
 Sideroblastic aneamia
(decreased porphyrin),
3) Defective DNA synthesis
 Cobalamin
3) Folic acid deficiency

- Decreased number of erythrocyte precursor,

- Aplastic anaemia
- Anaemia of mylo proliferative disease, and mylodysplasia,
- Chronic disease or disorders.
- Chemotherapy
- Blood loss
- Trauma
- Blood vessel rupture
- Gastritis
- Menstrual flow
Clinical manifestations

Easy fatigue and loss of energy.

Unusually rapid heart beat,
Shortness of breath and headache,’
Difficulty concentrating
Dizziness
Pale skin
Leg cramp
Insomnia, hypoxia
RBC production is stimulated and the marrow becomes packed with immature
Erthroid precursors that die.
Diagnostic evaluations
 Collection of complete health history reveals the cause of anaemia.
 Physical examination: careful local examination explains the type of anaemia and helps in
emergency management.
 X-ray and other imaging studies to determine integrity of anaemia
 Blood studies (CBC, Electrolytes) with blood loss and extensive muscle damage- may
show decrease haemoglobin level and hematocrit.
Management

 Treatment of anemia is the focus of continued research. However, aside from the equally
important aggressive management of symptoms and complications, there are currently few
primary treatment modalities for sickle cell diseases.
 PBSCT: May cure sickle cell anemia but is available to only a small subset of affected
patients because of either the lack of a compatible donor or because severe organ damage
that may be already present in the patient .
 Pharmacologic therapy: Hydroxyurea, a chemotherapy agent, has been shown to be
effective in increasing fetal hemoglobin (ie, hemoglobin F) levels in patients with sickle cell
anemia; arginine may be useful in managing pulmonary hypertension and acute chest
syndrome
 Transfusion therapy: Has been shown to be highly effective in several situations.
 Fluid restriction may be beneficial. Corticosteroids may be useful.
 Folic acid is administered daily for increased marrow requirement.
 Supportive care involves pain management (aspirin or NSAIDs, morphine, and patient
controlled analgesia), oral or IV hydration, physical and occupational therapy, physiotherapy,
cognitive and behavioral intervention, and support groups.

Nutritional management
Healthy diet is preferred. Food high rich protein, vitamin and calcium makes the healthy, its
helps in wound healing and protein diet helps in degeneration of new cells and tissues

Complications

 Severe fatigue. 
 Heart problems.
  Death. 

DIABETES MELITUS

Definition

The commonest form of diabetes, caused by a deficiency of the pancreatic hormone insulin,
which results in a failure to metabolize sugars and starch. Sugars accumulate in the blood and
urine, and the by-products of alternative fat metabolism disturb the acid–base balance of the
blood, causing a risk of convulsions and coma.

Riskfactors
 Family history of diabetes
 Obesity(ie,≥20% over desired body weight or BMI ≥27 kg/m2)
 Race/ ethinicity(eg. AfricanAmericans, Hispanic Americans, Asian Americans, Pacafic
Islanders
 Age ≥45years
 Previously identified impaired fasting glucose or impaired glucose tolerance
 Hypertension(≥140/90mmhg)
 HDL cholesterol level ≤35 mg/dl(0.90mmol/l) and/or triglyceride level ≥
250mg/dl(2.8mmol/L)
 History of gestational diabetes or delivery of babies over 9 Ib
Causes
 Age >30 years

 Lifestyle:A number of lifestyle factors are known to be important to the development

of type 2 diabetes, including:
obesity and overweight (defined by a body mass index of greater than 25)
lack of physical activity,
Poor diet,
 stress, and 
urbanization.
 Dietary factors also influence the risk of developing type 2 diabetes.
Consumption of sugar-sweetened drinks in excess is associated with an increased risk.
The type of fats in the diet are also important, with saturated fats and trans fatty
acids increasing the risk, and polyunsaturated and monounsaturated fat decreasing the
risk.
Eating lots of white rice appears to also play a role in increasing risk.]
 A lack of exercise is believed to cause 7% of cases.
Persistent organic pollutants may also play a role.
 Genetics-Most cases of diabetes involve many genes, with each being a small
contributor to an increased probability of becoming a type 2 diabetic.
 If one identical twin has diabetes, the chance of the other developing diabetes within his
lifetime is greater than 90%, while the rate for nonidentical siblings is 25–
50%. (The TCF7L2 allele)
There are a number of rare cases of diabetes that arise due to an abnormality in a single
gene (known as monogenic forms of diabetes or "other specific types of diabetes"). 
 Medical conditions- There are a number of medications and other health problems
that can predispose to diabetes.
Some of the medications include: glucocorticoids, thiazides, beta blockers,atypical
antipsychotics, and statins.
 Those who have previously had gestational diabetes are at a higher risk of developing
type 2 diabetes. 
Other health problems that are associated include: acromegaly, Cushing's
syndrome, hyperthyroidism, pheochromocytoma, and certain cancers such
as glucagonomas. Testosterone deficiency is also associated with type 2
Clinical manifestation

 Polydipsia (Increased thirst)

 Polyphagia (Increased hunger (especially after eating)
 Dry mouth
 Polyuria (Frequent urination)
 Unexplained weight loss (even though you are eating and feel hungry)
 Fatigue (weak, tired feeling)
 Blurred vision
 Headaches
 Loss of consciousness (rare)
 Recurrent infections, including thrush infections

Diagnostic evaluation

 History
 Symptoms related to the diagnosis of diabetes
 Symptoms of hyperglycemia
 Symptoms of hypoglycaemia{frequency,timing, severity, resolution}
 Results of blood glucose monitoring
 Status, symptoms, and management of chronic complications of diabetes: eye, kidney,
nerve, genitourinary, sexual, bladder, and gastrointestinal, cardiac, peripheral
vascular;foot complicationsassociated with Diabetes
 Adherence to/ ability to follow prescribed pharmacologic treatment (insulin or oral
antidiabetic agents)
 Use of tobacco, alcohol, and prescribed and over the counter drugs
 Life style, cultural, psychosocial, and economic factors that may affects diabetes
treatment
 Effects of diabetes or its complications on functional status (eg. Mobility, vision)
 Physical examination
 Blood pressure (sitting and standing to detect ortostatic changes)
 Body mass index
 Fundoscopic examination and visual acuity
 Foot examination (lesions, signs of infection, pulses)
 Skin examination (lesions and insulin injection sites)
 Neurologic examination- vibratory and sensory examination using monofilament Deep
tendon reflexes
 Oral examination
 Laboratory examination
  HgbA1c(A1C)
 Fasting lipid profile
 Test for microalbuminuria
 Serum creatine level
 Urinalysis
 Electrocardiogram
Management

 Blood sugar control — The goal of treatment in type 2 diabetes is to keep blood sugar
levels at normal or near-normal levels. Careful control of blood sugars can help prevent
the long-term effects of poorly controlled blood sugar (diabetic complications of the eye,
kidney, and cardiovascular system).
 Home blood sugar testing — In people with type 2 diabetes, home blood sugar testing
might be recommended, especially in those who take oral diabetes medicines or insulin
shots. Home blood sugar testing is not usually necessary for people who are diet-
controlled. A normal fasting blood sugar is less than 100 mg/dL (5.6 mmol/L).
 A1C testing — Blood sugar control can also be estimated with a blood test called
glycated hemoglobin, or A1C. The A1C blood test measures your average blood sugar
level during the past two to three months. The goal A1C for most people with type 2
diabetes is 7 percent or less, which corresponds to an average blood sugar of
150 mg/dL (8.3 mmol/L) 
 Cardiovascular risk control — The most common long-term complication of type 2
diabetes is cardiovascular (heart) disease, which can lead to heart attack, chest pain,
stroke, and even death. People with type 2 diabetes have twice the risk of heart disease as
those without diabetes.

Substantially lower your risk of cardiovascular disease by:

●Quitting smoking
●Managing high blood pressure and high cholesterol with diet, exercise, and medicines
●Taking a low-dose aspirin (81 mg) every day, if indicate

 DIET AND EXERCISE IN TYPE 2 DIABETES

Changes in diet can improve many aspects of type 2 diabetes, including weight, blood
pressure, and body's ability to produce and respond to insulin. Regular exercise can help
control type 2 diabetes, even if do not lose weight. Exercise improves blood sugar control
because it improves how your body responds to insulin.

Complication
 Heart and blood vessel disease. .
  Nerve damage (neuropathyKidney damage (nephropathy). .
 Eye damage. 
 Foot damage.  Hearing impairment.  Skin conditions. Diabetes may leave you more
susceptible to skin problems, including bacterial and fungal infections.
 Alzheimer's disease. 

Prevention
 Keep tight control of your blood sugar. This reduces the risk of most complications.
 Lower your risk of heart-related complications by:Taking a daily aspirin.Aggressively
managing other risk factors for atherosclerosis, such as:High blood pressureHigh
cholesterol and triglyceridesCigarette smokingObesity
 Visit an eye doctor and a foot specialist every year to reduce eye and foot complications.
THROMBOCYTOPENIA
Definition

Thrombocytopenia and thrombopenia refer to a disorder in which there is a relative decrease

of thrombocytes, commonly known as platelets, present in the blood

Causes
 Dehydration, Vitamin B12 or folic acid deficiency
 Leukemia or myelodysplastic syndrome or aplastic anemia
 Decreased production of thrombopoietin by the liver in liver failure
 Sepsis, systemic viral or bacterial infection
 Dengue fever
 Hereditary syndromes
 Congenital amegakaryocytic thrombocytopenia
 Thrombocytopenia absent radius syndrome
 Fanconi anemia
 Bernard-Soulier syndrome, (associated with large platelets)
 May-Hegglin anomaly,
 Grey platelet syndrome
 Alport syndrome
 Wiskott–Aldrich syndrome
Clinical manifestations

 Thrombocytopenia usually has no symptoms and is picked up on a routine of full blood

count (or complete blood count).
 Some individuals with thrombocytopenia may experience external bleeding such
as nosebleeds, and/or bleeding gums.
 Some women may have heavier or longer periods or breakthrough bleeding. Bruising,
particularly purpura in the forearms, may be caused by spontaneous bleeding under the
skin. Petechia (pinpoint bleeds in the skin and mucous membranes), may occur on feet
and legs.
 .Painless, round and pinpoint (1 to 3 mm in diameter) petechiae usually appear and fade,
and sometimes group to form ecchymoses. Larger than petechiae, ecchymoses are purple,
 blue or yellow-green areas of skin that vary in size and shape. They can occur anywhere
on the body.
 disease may also complain of malaise, fatigue and general weakness (with or without
accompanying blood loss).
 Inspection typically reveals evidence of bleeding (petechiae or ecchymoses), along with
slow, continuous bleeding from any injuries or wounds. Adults may have large, blood-
filled bullae in the mouth. 
Management
Treatment is guided by the cause and disease severity. The main concept in treating
thrombocytopenia is to eliminate the underlying problem, whether that means discontinuing
suspected drugs that cause thrombocytopenia, or treating underlying sepsis. Diagnosis and
treatment of serious thrombocytopenia is usually directed by
ahematologist.Corticosteroids may be used to increase platelet production. Lithium
carbonate or folate may also be used to stimulate the bone marrow production of platelets.

PROGNOSIS

27/4/15, Monday day -1

This is the first day of my clinical presentation, I have visited Mr, Shankar I wished him he
was looking very weak. I have given complete bed bath and back care, mouth care and
changed the position into left lateral for some time and made him to lie in supine position.
Arranged the patient unit clean and tidy. Checked the vital signs, his blood pressure was high
up to 90/80 mmHg. Assisted him to take the breakfast by giving good position. Then I’ve
given the entire medical regimen. I’ve informed all my care to MICU in charge, reported and
recorded all care and condition of the patient. After the rounds Dr. Pushpa advised for the
combination of insulin and norarenalin therapy. After the basic care the wellbeing of the
patient is improved after the administration of analgesic he reduced his pain and was resting,
general condition looks poor

Parameters Normal value Patients value

Temperature 98.20f 98.80f
Pulse 72 /mt 80 /mt
Respiration 18 /mt 20 /mt
Blood pressure 120/80 mmHg 90/80 mmHg
Pain - Severe pain
Urine output 900-1000ml 650ml

28/4/15 Tuesday day-2

Today, I went and wish the patient. Mr. Shankar also wished me. I have assisted him in
taking bath and given back care, taken the vitals and recorded. He has 101.4 0f advised him to
drink adequate water. He has not taken the food and passed motion. He has moderate pain,
administered all the medications. Today I’ve collected the history and done the physical
examination. I’ve recorded all the care, medications which I’ve given and the condition of the
patient and informed it into the ward in charge.Mr. Shankar is improving his status, resting at
present general condition looks weak.

Parameters Normal value Patients value

Temperature 98.20f 101.40f
Pulse 72 /mt 80 /mt
Respiration 18 /mt 20 /mt
Blood pressure 120/80 mmHg 90/80 mmHg
Urineoutput 900-1000ml 700ml

29/4/15 WEDNESDAY DAY-3

As same today also I went and wished the patient. He was looking good. I have given assisted
bed bath and back care .I‘ve done the bed making and patient unit tidy. He has taken food and
passed motion. I’ve carried out all the medications. I have given health education regarding
anaemia its causes, clinical manifestation and management as well as, he understood the topic
and he cleared his doubts. He has moderate pain and fatigue and weakness. Vitals checked
and recorded. General condition looks poor. Resting at present. Informed the condition to
ward in charge.

Parameters Normal value Patients value

Temperature 98.20f 98.80f
Pulse 72 bts/mt 80 bts/mt
Respiration 18 brths/mt 20 brths/mt
Blood pressure 120/80 mmHg 80/40 mmHg
Pain - Moderate pain
Urine output 900-1000ml 650ml

30/4/15 THURSDAY day-4

Today is my fourth day of case presentation as usual i went and wished my patient he wished
me back. His condition becomes more weak, because of the difficulty in the arrangement of
blood by family members and doctor also diagnosed him as thrombocytopenia. and advised
for referral. I went and checked vitals. BP was feeble. I’ve given all the injections. His
condition is poor recorded and reported all the condition and care to the ward in charge.

Parameters Normal value Patients value

Temperature 98.20f 98.60f
Pulse 72 /mt 80 /mt
Respiration 18 /mt 20 /mt
Blood pressure 120/80 mmHg 80/40 mmHg
Pain - Severe pain
Urine output 900-1000ml 900ml
1/5/15 FRIDAY day-5

As usual I went and wished him he was so weak and family members are taking the patient
for higer treatment as by the advice of doctor. The patient got referral. I have checked the
vitals BP were feeble. I have done all the chart work for referral and prepared the patient. He
got the referral with inj. Noradrenalin in NS as a treatment.

Parameters Normal value Patients value

Temperature 98.20f 98.20f
Pulse 72 bts/mt 80 bts/mt
Respiration 18 brths/mt 20 brths/mt
Blood pressure 120/80 mmHg 80/40 mmHg
Pain - Severe pain
Urine output 900-1000ml 900ml

Summary
Anemia or anaemia is usually defined as a decrease in the amount of red blood
cells (RBCs) orhemoglobin in the blood. It can also be defined as a lowered ability of the
blood to carry oxygen. When anemia comes on slowly the symptoms are often vague and
may include: feeling tired, weakness, shortness of breath or a poor ability to exercise. Anemia
that comes on quickly often has greater symptoms which may include: confusion, feeling like
one is going to pass out, and increased thirst. There needs to be significant anemia before a
person becomes noticeably pale. There may be additional symptoms depending on the
underlying cause.

There are three main types of anemia, that due to blood loss, that due to decreased red
blood cell production, and that due to increased red blood cell breakdown. The treatment for
anemia depends on what causes it.

Mr. Shankar is having DM2 and severe anemia occurs as its complication. As from
my case study I estimate that he is having the severe anemia which is caused by the
inadequate RBC production as a result he has less platetlet count and also diagnosed as
thrombocytopenia.

Conclusion

Garitude is the feeling of humbleness. Iam great full to Sr.Caroline Principal of Holy
Cross College of Nursing and Sr. Philomina Toppo for giving the opportunity and posting in
medical ICU . Bouquets’ of gratitude to Ms. Nancy for her supervision and guidance in all
over my study also remembering Ms. Stephy ,clinical instructor for the supervision and Sr.
Bincy ICU incharge for the support . Also remembering Mr. Shankar and his relatives for all
the cooperation. At last but not least thankful to almighty for all the blessings.

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Prespectives, 7thedition, 2003, Mosby Publications,Pp812-828

HOLY CROSS COLLEGE OF NURSING

CASE STUDY
 ON

MR. SHANKAR WITH

ANEMIA

SUBMITTED TO: SUBMITTED BY:

MS. SNEHA NANCY SRUTHY JOSEPH

LECTURER MSC NURSING FIRST YEAR

STUDENT
MEDICAL SURGICAL NURSING
DEPT. MEDICAL SURGICAL NURSING
DEPT.