DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION

COLLEGE OF NURSING
TACLOBAN CITY

CASE STUDY
ON

POLYCYTHEMIA VERA
PRESENTED TO:
FACULTY OF THE COLLEGE OF NURSING

PRESENTED BY:
LAYLE LAURA V. ABAIGAR
SHIE LOU O. ABELIDO
JANESSA MARIE C. ABELLA
SHERLAIN R. AVILA
SHAIRA MAY Y. BALAGA
DEO G. BALIOS
LUISA MARIE A. BAUTISTA
GINENA B. BELARMINO
NICOLE EVAN B. BELLO
JOHN JOSHUA CINCO
ARIES MATHHEW J. JOLBITADO

CLINICAL GROUP E
BATCH RUBY

AUGUST 8, 2022
GENERAL OBJECTIVE
After presentation and discussion of the case, the students’ knowledge of the
specific disease process of Polycythemia Vera will be enhanced and further understood
through comprehensive, detailed, and accurate History Taking, Gordon’s Typology of 11
Functional Health Patterns, presentation of Physical Examination and ROS results,
interpretation of Laboratory Test results and other specific tests done, explanation of the
pathophysiology through a schematic diagram, and the different treatment modalities
given to the patient.
SPECIFIC OBJECTIVES
• To accurately present the patient’s biographical profile along with a comprehensive
nursing health history
• To present the patient’s responses to each of the given basis of Gordon’s Typology
of 11 Functional Health Patterns
• To present both normal and abnormal findings of the Physical Assessment done
to the patient
• To interpret the different laboratory tests and results and other specific tests done
to the patient
• To discuss the related anatomy and physiology of Polycythemia Vera
• To explain the pathophysiology of the disease using a schematic diagram
• To identify, prioritize and implement nursing interventions for the patient
• To evaluate the patient’s response to treatment and interventions given
• To determine and discuss the prognosis and recommendations for the patient
• To identify and implement a proper discharge plan for the patient

INTRODUCTION TO THE DISEASE PROCESS

DEFINITION
Polycythemia refers to an increased volume of RBCs. It is a term used when the
hematocrit is elevated (to more than 55% in males, more than 50% in females).
Dehydration (decreased volume of plasma) can cause an elevated hematocrit, but not
typically to the level to be considered polycythemia. Polycythemia is classified as either
primary or secondary.
Polycythemia Vera, or primary polycythemia, is a proliferative disorder in which
the myeloid stem cells seem to have escaped normal control mechanisms. The bone
marrow is hypercellular, and the RBC, WBC, and platelet counts in the peripheral blood
are elevated. However, the RBC elevation is predominant; the hematocrit can exceed
60%. This phase can last for an extended period (10 years or longer). The spleen resumes
its embryonic function of hematopoiesis and enlarges. Over time, the bone marrow may
become fibrotic, with a resultant inability to produce as many cells (“burnt out” or spent
phase). The disease evolves into myeloid metaplasia with myelofibrosis or AML in a
significant proportion of patients; this form of AML is usually refractory to standard
treatments.
Secondary Polycythemia Vera is caused by excessive production of
erythropoietin. This may occur in response to a reduced amount of oxygen, which acts
as a hypoxic stimulus, as in cigarette smoking, chronic obstructive pulmonary disease, or
cyanotic heart disease, or in nonpathologic conditions such as high altitude. It can also
result from certain hemoglobinopathies in which the hemoglobin has an abnormally high
affinity for oxygen. Secondary polycythemia can also occur from neoplasms (eg, renal
cell carcinoma) that stimulate erythropoietin production.
CLINICAL MANIFESTATIONS
Patients typically have a ruddy complexion and splenomegaly (enlarged spleen).
The symptoms result from the increased blood volume (headache, dizziness, tinnitus,
fatigue, paresthesias, and blurred vision) or from increased blood viscosity (angina,
claudication, dyspnea, and thrombophlebitis), particularly if the patient has
atherosclerotic blood vessels. Another common and bothersome problem is generalized
pruritus, which may be caused by histamine release due to the increased number of
basophils. Erythromelalgia, a burning sensation in the fingers and toes, may be reported
and is only partially relieved by cooling.
ASSESSMENT AND DIAGNOSTIC FINDINGS
Diagnosis is made by finding an elevated RBC mass (a nuclear medicine
procedure), a normal oxygen saturation level, and an enlarged spleen. Other factors
useful in establishing the diagnosis include elevated WBC and platelet counts. The
erythropoietin level is not as low as would be expected with an elevated hematocrit; it is
normal or only slightly low. Causes of secondary erythrocytosis should not be present.
COMPLICATIONS
Patients with polycythemia vera are at increased risk for thromboses resulting in a
CVA (brain attack, stroke) or heart attack (MI); thrombotic complications are the most
frequent cause of death. Bleeding is also a complication, possibly due to the fact that the
platelets (often very large) are somewhat dysfunctional. The bleeding can be significant
and can occur in the form of nosebleeds, ulcers, and frank gastrointestinal bleeding.
MEDICAL MANAGEMENT
The objective of management is to reduce the high blood cell mass.
• Phlebotomy is an important part of therapy and can be performed repeatedly to
keep the hematocrit within normal range. This is achieved by removing enough
 blood (initially 500 mL once or twice weekly) to deplete the patient’s iron stores,
thereby rendering the patient iron deficient and consequently unable to continue
to manufacture RBCs excessively
• Patients need to be instructed to avoid iron supplements, including those within
multivitamin supplements
• If the patient has an elevated uric acid concentration, allopurinol is used to prevent
gouty attacks
• If the patient develops ischemic symptoms, dipyridamole is sometimes used
• Radioactive phosphorus or chemotherapeutic agents (eg, hydroxyurea) can be
used to suppress marrow function, but they may increase the risk for leukemia.
Patients receiving hydroxyurea appear to have a lower incidence of thrombotic
complications; this may result from a more controlled platelet count
• Low-dose aspirin is frequently used in patients with cardiovascular disease, but
even this dose is often avoided in patients with prior bleeding, especially bleeding
from the gastrointestinal tract. Aspirin is also useful in diminishing pain associated
with erythromelalgia.
• Anagrelide inhibits platelet aggregation and can also be useful in controlling the
thrombocytosis associated with polycythemia vera
• Medical management of secondary polycythemia may not be necessary; when it
is, it involves treating the primary problem. If the cause cannot be corrected (eg,
by treating the renal cell carcinoma or improving pulmonary function), therapeutic
phlebotomy may be necessary in symptomatic patients to reduce blood viscosity
and volume
NURSING MANAGEMENT
The nurse’s role is primarily that of educator. Risk factors for thrombotic
complications should be assessed, and patients should be instructed regarding the signs
and symptoms of thrombosis. Patients with a history of bleeding are usually advised to
avoid aspirin and aspirin-containing medications, because these medications alter platelet
function. Minimizing alcohol intake should also be emphasized to further diminish any risk
for bleeding. For pruritus, the nurse may recommend bathing in tepid or cool water, along
with applications of cocoa butter–based lotions and bath products.
 COMPREHENSIVE NURSING HEALTH
HISTORY
I. PATIENT’S DEMOGRAPHIC PROFILE

Patient’s Name: Patient F.N.M.

Sex: Male
Birthdate: August 16, 1952
Age: 69
Birthplace: Dagami, Leyte
Permanent Address: Brgy. 93 (Bagacay), Tacloban City, Leyte
Nationality: Filipino
Religion: Roman Catholic
Highest Educational Attainment: 1st Year College
Occupation: None
Marital Status: Married
Healthcare Financing: PhilHealth
Source of Medical Care: EVMC Hospital
Diagnosis: Ischemic Heart Disease not in failure; Polycythemia Vera;
S/P CVD Infarct
Chief Complaint: Chest pain
Time and Date of Admission: July 24, 2022; 5:50 PM

II. NURSING HEALTH HISTORY

A. HISTORY OF PRESENT ILLNESS

Patient reported to have severe diaphoresis, flushed skin and

dizziness way back February 2018, where-in they consulted a Doctor in
the OPD in Makati Medical Center, patient verbalizes that he had an
MRI, small clots were seen, so they were referred to a Hematologist.
He was prescribed Aspirin for 30 days. When he completed the
prescribed medications, weeks after, the patient had a stroke, and his
left part of the body was affected, except for his face. In the same year,
he was diagnosed with Polycythemia Vera, he came in and out of the
hospital until now for check-ups, laboratories and for his sessions in
Physical therapy.
 Before admission, patient reported that he had chest pain and
dizziness when he was inside of their house, so he requested to go
outside with her wife to breathe some fresh air, but then he was still
feeling the same, and severe diaphoresis and flushed skin follows,
these prompted them to go to the nearby hospital, which is the EVMC.

His vital signs upon admission were:

Temperature – 36.9°C
Pulse Rate – 150 bpm
Respiratory Rate – 20 cpm
Blood Pressure – 110/80 mmHg
Oxygen Saturation – 91%

Client’s Responses using COLSDPA:

C – Squeezing and tightness sensation. “Naabat ako bagat nahuot it

akon dughan,” as verbalized by the client.
O – 2018
L – Chest
D – Pain does not go away
S – Patient rated pain as 8 out of 10 using the Pain Rating Scale.
“Nakakatuok ako danay han kaul-ol na ak inaabat,” as verbalized.
P – Pain is decreased when patient is given with pharmacological
interventions; pain worsen when in a congested area
A – Dizziness, flushed skin and severe diaphoresis.

B. PAST MEDICAL HISTORY

Patient F.N.M has no problems at birth and cannot recall any

childhood illnesses. Patient was fully immunized when he was young,
but could not recall them. He had an accident when he was in Grade 4,
specifically 1965, he had a fall from riding on one of the rides in the
Carnival. No surgeries nor allergies were noted.

Patient had maintenance drugs of Clopidogrel and Hydroxyurea,

he reported that his Hematologist does not allow him to stop or hold his
medications because his blood will thicken eventually. No other
maintenance drug.

C. FAMILY HISTORY
 Hypertension in his maternal side was noted, her mother died
due to a heart disease, and liver disease is also present in their history.
His father is still alive and is currently 90 years old, he reported that his
father does not have any serious conditions that may lead to fatality.
No other herodofamilial diseases were noted.

D. LIFESTYLE AND HEALTH PRACTICES

a. ACTIVITY
Patient F.N.M has PT sessions in EVMC every Tuesday and
Wednesday on his left-side of the body. Everyday his form of
exercise is walking with assistance. He has lost weight after
being sick and being hospitalized. His weight in the past
years was 60 kg while his current weight is 53 kg. He is 5
feet and 5 inches tall, so his BMI is 19. 4 which is a normal
weight.
b. FOOD
Patient F.N.M’s partner prepares his meals. He eats three
times a day with snacks in between. He prefers to eat fatty
foods like crispy pata, and other foods high in cholesterol,
rather than eating fish or vegetables. Patient reported to only
eat bangus if he will eat fish, and he only consumes
vegetables if his wife really pushes him to consume healthy
foods. He does not take any vitamins or supplements.
c. SELF
Patient F.N.M is a funny person, he usually makes jokes
every time he talks to someone. He reported that sharing his
life experiences also made him feel happy, sharing his life
lessons is his way of helping people. His social activities for
fun and relaxation include watching television. One of his
stressors in life is his illness, but he always prays. Before
cigarette smoking was his unhealthy coping strategies. He
smokes 1 pack of cigarettes per day. Each pack consists of
20 pieces of cigarette stick. Patient started smoking when he
was only 18 years old. He has not been smoking since he
had a stroke.
d. RESIDENCY
The patient’s environment is free from pollution. But
according to him, there is a presence of vectors such as
 mosquitos in their neighborhood. The area where their house
is located is not congested. The structure of their house is
enough to accommodate their family.

e. OCCUPATION
Patient F.N.M was unable to finish college. He worked
abroad for 6 years, he is a certified mechanic, and the
patient reported that he was satisfied with his work. He feels
that he is able to meet the needs of his family. Currently he is
not working due to his condition.

E. PSYCHOSOCIAL HISTORY

Patient F.N.M. is in the stage of “Generativity vs Stagnation”

according to Erik Erikson’s Psychoanalytic Stages of Development.
The important events in this stage are work and parenthood. And
adults would contemplate, “will I provide something of value?” In this
stage, adults need to create or nurture things that will outlast them,
often by having children or creating a positive change that benefits
other people. Success leads to feelings of usefulness and
accomplishment, while failure results in shallow involvement of the
world.

In the patient’s case, he has 5 children which comprises 3 girls

and 2 boys, and they all now have a job. He accepts his role as a
husband and a father, despite his condition, being supportive is one of
his ways of taking care of his children, even though 3 of them are
working in Manila.

In 2020, the patient and his family decided to stay in Tacloban

City to get the treatments that he needs. He derives pleasure from
selected activities like watching movies. There were no changes in his
cognition.
 III. GORDON’S TYPOLOGY OF 11 FUNCTIONAL HEALTH
PATTERNS

HEALTH PATTERN BEFORE THE COURSE OF DURING THE COURSE

ILLNESS OF ILLNESS
1. Health Perception – Patient N.S.J. reports a general Patient define his health
Health health of 9/10 (10 – best, 1 – as. “Okay la,” as
Management worst) from 5 years ago. verbalized.
Pattern
He reports to have a healthy Patient N.S.J. reports a
well-being overall. He was able to general health of 6/10 (10
perform well on ADLs. – best, 1 – worst) now.
And is hopeful to have a
8/10 general health in the
next few years.

Patient is glad that his

2. Nutritional – TYPICAL FOOD INTAKE
Metabolic Pattern Patient F.N.M’s partner prepares
his meals. He eats three times a
day with snacks in between. He
prefers to eat fatty foods like crispy
pata, and other foods high in
cholesterol than eating fish or
vegetables. Patient reported to
only eat bangus if he eats fish, and
he only consumes vegetables if his
wife really pushes him to consume
healthy foods. He does not take
any vitamins or supplements.
family is really supportive
and stayed despite his
condition and
inconvenience. He
perceived that his family
is making sure that his
condition is controlled,
and nothing will trigger.
TYPICAL FOOD INTAKE
Patient F.N.M is now
ordered to consume Low
Salt, Low Fat *(LSLF)
diet.
He reports to have no
difficulty eating foods
provided by the hospital.
However, the patient
needs assistance from
SO in order to eat his
meals.

He does not take any vitamins or
supplements. He is really picky
with food, he does not like strong
smells, in which he reported that it
contributed to his decreased
appetite.
His food choices are the
same as the foods he
had consumed before the
course of his illness.

TYPICAL FLUID INTAKE TYPICAL FLUID INTAKE

Patient drinks 5 glasses of water a Patient drinks 6-7 glasses
day. He does not like drinking milk of water a day.
or coffee.
 HEALTH PATTERN BEFORE THE COURSE OF DURING THE COURSE
ILLNESS OF ILLNESS
Patient’s weight
Patient has a weight of 60 kg. decreased from 60 kg to
53 kg. Weight loss was
noted.
3. Elimination Pattern BOWEL ELIMINATION PATTERN BOWEL ELIMINATION
Patient F.N.M. reported to have no PATTERN
difficulty in defecating. His bowel Patient F.N.M. reported to
elimination occurs once a day with have difficulty in
a yellow to brown stool that has a defecating. His bowel
soft to firm consistency. The color elimination occurs only
of his stool depends on the food he once or twice a week and
is eating. has a hard consistency.
The color of his stool
URINARY ELIMINATION depends on the food he
Patient has no difficulty in is eating.
urinating. He reports to be
urinating 5-6 times a day with an URINARY ELIMINATION
estimate of 1000 L of urine per Patient has a slight
day. His urine is yellowish in color
difficulty in going to the
and is clear in transparency. commode because he
needs assistance from
PERSPIRATION his SO. He does not
Patient easily perspires, and his report any difficulty in
perspiration increases whenever urinating. He reports to
he performs a physical activity. be urinating 8 times a day
with an estimate of 1500
ml of urine per day. His
urine is sometimes yellow
to dark yellow in color.
Patient’s urine remains
clear and transparent.

4. Activity – Exercise Patient has sufficient energy for
Pattern desired or required activities. His
form of exercises were walking,
stretching, and doing household
chores was also his way of
exercising.
5. Sleep – Rest Pattern Patient F.N.M. is generally rested
and is ready for activity after sleep.
He sleeps for about 8 hours a day.
PERSPIRATION
Patient sometimes have
severe diaphoresis if not
given with interventions.
Patient F.N.M has PT
sessions in EVMC every
Tuesday and Wednesday
on his left-side of the
body. Everyday his form
of exercise is walking
with assistance. He has
lost weight after being
sick and being
hospitalized. His weight
in the past years was 60
kg while his current
weight is 53 kg. He is 5
feet and 5 inches tall, so
his BMI is 19. 4 which is
a normal weight.
Patient F.N.M. does not
have a continuous sleep.
He claims to sleep
 HEALTH PATTERN BEFORE THE COURSE OF DURING THE COURSE
ILLNESS OF ILLNESS
He sleeps around 10 PM and around 8 or 9 PM but
wakes up at 5 AM to do his wakes up upon 12 AM,
exercises. from then he will be
awake until 4 AM in the
He easily falls asleep; but he can morning, and then he will
be easily awakened. sleep again until 7AM.
This cycle just continues
throughout the day.
6. Cognitive – Patient has no difficulty in hearing Patient has difficulty in
Perceptual Pattern and vision. His memory and hearing, especially on his
concentration are at its optimum right ear. He does not
level. He easily makes important have hearing aids, so
decisions. people around him
communicate with a loud
voice for them to have a
conversation. There is no
difficulty in his vision. His
memory and
concentration are intact.
Now, he is having
difficulty making
important decisions.

Sometimes, patient make

7. Self-Perception and Patient F.N.M is a funny person, he
Self-Concept usually makes jokes every time he
Pattern talks to someone. He reported that
sharing his life experiences also
made him feel happy, sharing his
life lessons is his way of helping
people. His social activities for fun
and relaxation include watching
television. Cigarette smoking was
his unhealthy coping strategy. He
smokes 1 pack of cigarettes per
day. Each pack consists of 20
pieces of cigarette stick. Patient
started smoking when he was only
18 years old.
jokes in conversations to
lighten up the mood.
One of his stressors in
life is his illness. He feels
that he is unable to
perform his duties as a
father and a partner.
He does engage in
unhealthy coping
strategies anymore,
which is cigarette smoke.
He has not been smoking
since he had a stroke.
 HEALTH PATTERN BEFORE THE COURSE OF DURING THE COURSE
ILLNESS OF ILLNESS
8. Roles – ROLE TO OTHERS ROLE TO OTHERS
Relationships Patient F.N.M. lives with his family. He accepts his role as a
Pattern He accepts his role as a husband, husband, and a father.
and a father. He reported that He accepts his role as a
sharing his life experiences also husband and a father,
made him feel happy, sharing his despite his condition,
life lessons is his way of helping being supportive is one of
people. his ways of taking care of
his children, even though
3 of them are working in
Manila.

ROLE OF OTHERS ROLE OF OTHERS

Whenever he has a problem, he Patient talks to his wife
consults his partner and asks for most regarding his
advice. Patient has a lot of friends illness. “Naluoy hira ha
in their neighborhood. akon,” as verbalized.

At present, his children

support his financial
needs, especially now
that they are in the
hospital.

9. Sexuality – Patient has not been

Reproductive Patient F.N.M. and his partner sexually active during the
Pattern were sexually active. He reports to course of his illness.
have a satisfying sexual
relationship. No problems
regarding intercourse or
reproduction reported. Patient and
his partner do not engage in any
family planning methods.
10. Coping – Stress Cigarette smoking was his The biggest change in
Tolerance Pattern unhealthy coping strategy. He patient F.N.M’s life is the
smokes 1 pack of cigarettes per illness that he is facing.
day. Each pack consists of 20 Due to his condition, he
pieces of cigarette stick. He shares does not engage in
his problem with his wife to cope. unhealthy coping
strategies anymore. He
still shares his problems
and concerns to his wife
to cope.
11. Values – Beliefs Patient F.N.M. does not easily get Patient F.N.M. still
Pattern what he wants in life. However, he attends mass every
perseveres to provide the needs of Sunday, not unless
his family. hospitalized. He prays to
Patient is a Roman Catholic. He God to heal him.
goes to church every Sunday with He feels that his religion
his family. Patient prays before and spirituality are often
sleeping and before eating a meal. helpful whenever he is
He believes in Jesus Christ and confronted with a
thinks that his religion is important problem.
in his life.
 I. PHYSICAL EXAMINATION

CATEGORY FINDINGS

Vital Signs ● Blood Pressure – 110/80 mmHg

● Pulse Rate – 132 beats/min, reg
● Respiratory Rate – 27 breaths/min
● Temperature – 36.6°C
General Appearance ● Well-developed, appearing stated age
● Hair normal texture and distribution
● No nail changes
Head, Eyes, Ears, Nose, ● Head is symmetric, round, erect, and in midline and
Throat appropriately related to body size (normocephalic). No
lesions are visible.
● The head is normally hard and smooth, without lesions.
● Facial wrinkles are prominent
● No visual problems
● Difficulty hearing both of his ear, but worst on his right ear
● Dental problems noted such as dental carries and has
missing tooth
Neck ● Neck is symmetric, with head centered and without bulging
masses
● The thyroid cartilage, cricoid cartilage moves upward
symmetrically as the client swallows
● Trachea is in the midline
● There is no swelling or enlargement and no tenderness
Chest and Lungs ● No abnormal curvature of spine.
● No nipple deformity or discharge.
● Axillary lymph nodes not enlarged.
● Chest pain
● SCE
● Crackles (Right mid-basal)
● RR- 27 breaths/min.
Cardiovascular ● PR- 132 beats/min.
● No extra sounds or murmurs
Abdomen ● No abnormal tympany.
● Superficial and deep palpation without organomegaly or
masses; no direct or rebound tenderness, rigidity, or
guarding.
Genitourinary ● Penis without lesions.
● No urethral discharge.
● Testes normal size without masses or tenderness.
● No scrotal masses.
Rectal ● Difficulty defecating
● No external lesions
● Good sphincter tone
● No tenderness or masses
Musculoskeletal ● Body weakness present
 CATEGORY FINDINGS

● Paralyzed left side of the body

● No edema were noted
● Does not able to turn from side to side
Extremities/Skin ● Skin warm is warm and dry.
● No abnormal pigmentation, bleeding, rash, or other lesions.
● Paralyzed left upper and lower extremities.
● No ulcers noted
Neurological ● Alert, oriented to time, place, person, and situation
● Recent and remote memory intact
● Good insight and cognitive function
● No aphasia, dysarthria, or hoarseness

II. REVIEW OF SYSTEMS

Skin, hair, and nails:

● No report of problems with skin, hair, or nails
Head and neck:
● Denies headaches, swelling, stiffness of neck, difficulty swallowing,
sore throat, enlarged lymph nodes.
Eyes:
● Denies visual problems. Denies eye infections, redness, excessive
tearing, halos around lights, blurring, loss of side vision, moving black
spots/ specks in visual fields, flashing lights, double vision, and eye
pain
Ears:
● Difficulty hearing both of his ears, but worst on his right ear, no hearing
aids noted.
Mouth, throat, nose, and sinuses:
● Client reports missing upper and lower molars.
● Denies bleeding of gums or other dental problems, sore throats, mouth
lesions, hoarseness, rhinorrhea, nasal obstruction, frequent colds,
sneezing or itching of eyes, ears, nose, or throat, nose bleeds, nor
snoring.
Thorax and lungs:
● Difficulty of breathing noted, no orthopnea, hemoptysis, respiratory
infections.
● Reports unproductive cough in morning upon waking.
Heart and neck vessels:
● Latest blood pressure was 110/80
● Chest pain noted
Peripheral vascular:
● No edema on both feet, inability to move left lower extremity.
Abdomen:
● Denies difficulty swallowing, nausea, vomiting, gas, jaundice
Musculoskeletal:
● Paralyzed left side of the body
● Reports body weakness.
● Reports inability to perform activities of daily living (ADLs)
Neurologic:
● Denies feelings of anger or suicidal thoughts.
● Denies concussions, headaches, difficulty speaking, memory
problems, strange thoughts and/or actions.
● Reports lack of coordination

Male genitalia:
● Denies sexual problems; sexually transmitted infections (STIs);
dribbling or incontinence.
● Denies lesions, urethral discharge, masses, or tenderness
● Denies hernia
Anus, rectum, and prostate:
● Reports having once or twice a week of bowel movement.
PRIORITY SIGNS AND SYMPTOMS FOCUSED ON PATIENT

1. Chest Pain
The National Library of Medicine for the study of Chest Pain
and Discomfort defined chest pain as “Pain, pressure, tightness, or
other discomfort originating in or radiating to the chest”.
Polycythemia vera can be fatal if not diagnosed and treated. It can
cause blood clots resulting in a heart attack, stroke, or pulmonary
embolism. Chest pain is caused when your heart muscle doesn't
get enough oxygen-rich blood.

2. Difficulty Breathing
A person who is having difficulty breathing feels short of
breath, has trouble inhaling or exhaling, or feels as though they
cannot get enough oxygen. Breathing difficulty is another sign of
chest pain that could be serious. Polycythemia vera causes your
body to produce too many red blood cells. Extra blood cells
increase your likelihood of bleeding, bruising and clotting. They
thicken your blood and slow your circulation, which means your
blood carries less oxygen to your body's tissues and organs than
they need. Polycythemia vera causes your body to produce too
many red blood cells. Extra blood cells increase your likelihood of
bleeding, bruising and clotting. They thicken your blood and slow
your circulation, which means your blood carries less oxygen to
your body's tissues and organs than they need.

3. Increased WBC
In polycythemia vera there’s an increase in red blood cell
production. It typically begins with a mutation in a single
hematopoietic stem cell, which gives rise to red blood cells, white
blood cells, and platelets. People with cancer are likely to have
compromised immune systems, which makes them prone to
infection.
 BLOOD CHEMISTRY RESULT
LABORATORY RESULT
AND 7/28/2022 07/30/2022 REFERENCE
DIAGNOSTIC RANGE CLINICAL SIGNIFICANCE
TEST
(PARAMETERS)
Creatinine - 136.60 60 – 115 umol/L Creatinine levels often rise and could
H indicate a problem with the kidneys, as
these organs get rid of waste products
from the body to keep the blood clean. If
the heart is pumping blood weakly, then
the kidneys will have reduced blood flow
to the kidneys. Creatinine is a waste
product usually secreted by the kidneys, if
raised, this suggests impairment.
FBS 4.57 - 4.1 – 6.6 NORMAL
mmol/L
HDL Ratio 4.56 - NORMAL
Total Cholesterol 4.10 - 3.6 – 5.7 NORMAL
mmol/L
Triglycerides 1.90 - 0.45 – 2.26 NORMAL
mmol/L
HDL Cholesterol 0.90 - 0.78 – 1.94 NORMAL
mmol/L
LDL Cholesterol 2.82 - - NORMAL
VLDL 0.38 - - NORMAL

HEMATOLOGY RESULT
COMPLETE BLOOD COUNT
LABORATORY RESULT
AND
DIAGNOSTIC
7/24/2022 7/27/2022 7/29/2022 7/30/2022 REFERENCE CLINICAL
TEST RANGE SIGNIFICANCE
(PARAMETERS)
Hemoglobin 158 148 137 - 140 – 170 g/L Slightly Decreased
L
Hematocrit 0.47 0.46 0.43 - 0.42 – 0.52 NORMAL
L/L
RBC 4.39 4.03 3.76 - 4.7 – 6.1 Polycythemia vera may
L L L x10^12/L eventually “burn out” so
that scar tissue replaces
the marrow. This may
also be referred to as the
“spent phase” of
polycythemia vera. When
this occurs, the marrow
can no longer produce
blood cells resulting in
low levels of healthy,
functioning red blood
cells.
WBC 36.47 33.40 27.24 - 4.8 – 10.8 The symptoms of
H H H x10^9/L polycythemia vera occur
because of abnormalities
affecting the formation of
blood cells that result in
an overproduction of
white blood cells.
Neutrophils 0.92 - 0.87 - 0.43 – 0.65 The rise in neutrophils
H H after stroke occurs as a
result of enhanced
production, increased
release from the bone
marrow and spleen, and
possibly from a reduction
in neutrophil apoptosis.
Lymphocytes 0.04 - 0.07 0.20 – 0.45 Lymphocytopenia, also
L L referred to as
lymphopenia, occurs
when the lymphocyte
count in the bloodstream
is lower than normal.
Severe or chronic low
counts can indicate a
possible infection or other
significant illness.
Monocytes 0.04 - 0.05 0.05 – 0.12 Having low levels of
L monocytes may mean the
body is more susceptible
to infection.
Eosinophils 0.00 - 0.00 0.01 – 0.03 Slightly Decreased
L
Basophil 0.01 - 0.01 0 – 0.01 NORMAL
MCV 107.70 114 114 80 – 94 fL A high mean corpuscular
H H H volume (MCV) in a blood
test indicates that red
blood cells are larger than
average. The presence of
large blood cells is
referred to as
macrocytosis.
MCH 36.0 37 36 27 – 31 pg High MCH are
H H H commonly a sign of
macrocytic anemia. This
condition occurs when
the blood cells are too
big.
MCHC 334 320 319 320 – 360 g/L Slightly Decreased
L
Platelet 349 337 354 150 – 400 NORMAL
x10^9/L
Blood Type - - - “A” NORMAL
RH - - - POSITIV NORMAL
E
 HEMATOLOGY RESULT
COAGULATION RESULT
LABORATORY REFERENCE CLINICAL SIGNIFICANCE
AND 7/28/2022 7/29/22 VALUES
DIAGNOSTIC /UNIT
TEST
(PARAMETERS)
PT CONTROL 11.6 10.70 sec NORMAL

PT 12.30 11.90 seconds 9.4 – 12.5 NORMAL

% Activity 96.00 100.00 % NORMAL

INR 1.03 1.00 INR NORMAL

APTT Control 28.8 29.10 seconds seconds NORMAL

APTT 34.20 39.60 25.1 – 36.5 Polycythemia vera is a type of

H chronic leukemia (blood cancer)
that causes the bone marrow to
produce too many red blood
cells. A prolonged aPTT usually
means that clotting is taking
longer to occur than expected. It
takes the blood more time to
form a blood clot and therefore
there is a prolonged bleeding
time.

URINE ANALYSIS RESULT

LABORATORY AND RESULT REFERENCE CLINICAL SIGNIFICANCE
DIAGNOSTIC TEST RANGE
(PARAMETERS) 7/27/2022 07/28/2022

Physical Exam
Color Yellow Yellow NORMAL
Clarity Clear Slightly turbid NORMAL
pH 5.5 5.5 NORMAL
Sp. Gravity 1.018 1.018 NORMAL
Glucose Negative Negative < trace NORMAL
Creatinine 300 300 10 – 300 mg/dl NORMAL
Ascorbic Acid - Negative <+ NORMAL
Chemical Exam

Leukocyte Negative + < trace Positive leukocytes indicate that

the immune system is trying to
fight off a bacterial infection.
Blood + +++ < trace Profuse hemorrhage into the
bladder in polycythemia vera
seems to have been a rare
occurrence. Polycythemia with
mild hematuria, evidently renal,
which quickly clears up.
Nitrite Negative Negative < trace NORMAL
Protein Negative +++ < trace High levels of protein in urine
over a period of time may be the
first sign that kidney disease or
another condition has damaged
the filters in the kidneys.
Urobilinogen Normal Normal < trace NORMAL
Ketone Negative Negative < trace NORMAL
Bilirubin Negative + < trace Bilirubin is also a product of
breakdown of red blood cells,
and a positive (+) reading may
be related to disorders of red
blood cells.
Albumin 150 150 10 – 150 mg/dl NORMAL
Microscopic Exam:

Pus Cells 17.42 18.33 0 – 17 /uL Presence of pus cells in urine

defined as pyuria is an important
accompaniment of bacteriuria
which may be asymptomatic or
can indicate underlying urinary
tract infection.
Squamous Epithelial 8.25 2.75 0 – 17 /uL NORMAL
Cells
Non-Squamous - 0.92 NORMAL
Epithelial Cells
Bacteria - 1.83 0 – 278 /uL NORMAL

Amorphous - 335.48 NORMAL

Mucus Threads - 3.67 < moderate NORMAL

Hyaline Casts - 10.74 NORMAL

SPECIAL HEMATOLOGY RESULT

LABORATORY AND RESULT CLINICAL SIGNIFICANCE
DIAGNOSTIC TEST 7/28/2022
(PARAMETERS)

COMPLETE BLOOD
COUNT
Hemoglobin 148 g/L NORMAL
Hematocrit 0.46 NORMAL
RBC Count 4.03 x 10^12/L NORMAL
White Blood Cell Count 33.40x10^9/L NORMAL
Platelet count 377x10^9/L NORMAL
Mean corpuscular Volume 114 fl NORMAL
Mean Corpuscular 37 pg NORMAL
Hemoglobin
Mean Corpuscular 332 NORMAL
Hemoglobin concentration
DIFFERENTIAL COUNT
Stab 0.03 NORMAL
Segmenters 0.94 NORMAL
Lymphocytes 0.03 NORMAL
 CHEMISTRY RESULT FORM
DETERMINATION REFERENCE VALUES RESULT CLINICAL SIGNIFICANCE
07/26/2021
Magnesium 0.66 – 1.07 1.01 NORMAL
Phosphorus 0.81 – 1.49 mmol/L 1.10 NORMAL
Ionized Calcium 1.1 – 1.3 mmol/L 1.07 Low serum calcium levels were
L found to be related to large
hematoma volumes in
intracerebral hemorrhagic
patients and hemorrhagic
transformation in ischemic
stroke patients after
thrombolysis.

PERIPHERAL SMEAR RESULT

LABORATORY AND RESULT CLINICAL SIGNIFICANCE
DIAGNOSTIC TEST 7/28/2022
(PARAMETERS)

Red Blood Cells Mild hypochromic, Anisocytosis is the medical term for red blood cells
moderate (RBCs) that are unequal in size. Normally, a person's
anisocytosis with RBCs should all be roughly the same size. Anisocytosis
moderate macrocytes is usually caused by another medical condition called
anemia.
White Blood Cells Leukocytosis with Fundamentally, a CVD infarct triggers a systemic
predominance of response to a necrotic insult characterized by
neutrophils; no leukocytosis and acute-phase protein synthesis. In this
abnormal cells setting, elevated WBC count plays a central role in the
reparative process that takes place to replace the
necrotic tissue for collagen.
Platelet Adequate with rare Giant platelet disorders, also known as
giant platelets macrothrombocytopenia, are rare disorders featuring
abnormally large platelets, thrombocytopenia and a
tendency to bleeding. Giant platelets cannot stick
adequately to an injured blood vessel walls, resulting in
abnormal bleeding when injured.
 BASIC METABOLIC PANEL TEST
DETERMINATION REFERENCE VALUES RESULT CLINICAL SIGNIFICANCE
07/25/2022
Creatinine 60-115 umol/L 255.96 Elevated creatinine level
H signifies impaired kidney
function or kidney disease. As
the kidneys become impaired for
any reason, the creatinine level
in the blood will rise due to poor
clearance of creatinine by the
kidneys. Abnormally high levels
of creatinine thus warn of
possible malfunction or failure
of the kidneys.
Sodium 135-148 mmol/L 141.8 NORMAL
Potassium 3.5-5.3 mmol/L 5.34 Slightly Elevated
Chloride 98-107 mmol/L 104.7 NORMAL
Blood Urea Nitrogen 2.9-9.3 mmol/L 11.00 The blood urea nitrogen test,
H which is also called a serum
BUN test, measures how much
of the waste product is found in
the blood. If the levels are off the
normal range, this could mean
that the kidneys may not be
working properly.
 ANATOMY AND PHYSIOLOGY OF THE AFFECTED SYSTEM

HEMATOLOGICAL SYSTEM
Hematology is the science of blood and blood forming tissues. It includes both
cellular and non‐cellular blood components. The hematopoietic system consists of organs
and tissues, primarily the bone marrow, spleen, tonsils, and lymph nodes, involved in the
production of blood.
The hematological system consists of the blood and bone marrow. Blood delivers
oxygen and nutrients to all tissues, removes wastes, and transports gases, blood cells,
immune cells, antibodies and hormones throughout the body.
Blood is composed of two elements:
• A liquid component known as plasma
• The solid components, which are mainly erythrocytes, leukocytes, and
thrombocytes
The solid components of blood are formed by hematopoiesis, which is the continuous,
regulated formation of blood cells.
There are three primary functions of hematopoiesis:
1. Oxygen delivery
2. Hemostasis
3. Host defense
Hematopoiesis, the formation of blood cells, occur in the bone marrow. The degree
and location of bone marrow activity varies depending on the age and health status of
the patient.
Within the bone marrow, there is a pluripotent stem cell. This stem cell is the “Mother
Cell” or the originator of all blood cells. It has the ability to self-renew and create
progenitor stem cell lines. They are naturally limited in number.
Erythrocytes
• Erythrocytes, or red blood cells (RBCs), originate from a stem cell
• Vitamin B12, folic acid, iron, and copper are essential in the formation of
erythrocytes
• Erythropoietin is a hormone released by the kidneys in response to hypoxemia,
which stimulates the bone marrow to produce red blood cells
• Typically, red blood cells live approximately 120 days. When the red blood cells
become old and damaged, the liver, spleen, and bone marrow cleanse them from
the blood
 • Increases or decreases in the red blood cell count indicate an abnormality
Reticulocytes
• When released from the bone marrow, red blood cells are slightly immature and
are known as reticulocytes
• Reticulocytes mature into red blood cells within a few days
• The number of reticulocytes in the blood indicates the amount of bone marrow
activity
Hemoglobin
Hemoglobin is a laboratory value used to evaluate the oxygen-carrying capacity of
the blood
Hematocrit
Hematocrit is a measure of the total percentage of blood volume that is composed
of red blood cells. It is also known as the packed cell volume (PCV). Low levels of
hematocrit may indicate anemia, blood loss or a disease process such as cancer. High
levels of hematocrit may be due to dehydration or blood disorders.
Mean Corpuscular Volume
The mean corpuscular volume (MCV) is the average volume of red cells in a
specimen. MCV is elevated or decreased in relation to the average red cell size. Low MCV
indicates small average RBC size, normal MCV indicates normal average RBC size, and
high MCV indicates large average RBC size.
Mean Corpuscular Hemoglobin
The mean corpuscular hemoglobin, or MCH, is the content or weight of hemoglobin
of the average red cell. MCH demonstrates the hemoglobin mass in red cells.
Erythrocyte Sedimentation Rate
The erythrocyte sedimentation rate (ESR) is the rate at which red blood cells settle
out when anticoagulated whole blood is allowed to stand. The ESR is affected by the
concentrations of immunoglobulins and acute phase proteins. The ESR is a sensitive, but
nonspecific, indicator of inflammation and tissue damage.
Iron
Iron is necessary for the formation of hemoglobin, an essential part of the red
blood cell. Iron is absorbed from the small intestine into the blood and binds with a
protein called transferrin. Transferrin transports iron to the bone marrow, where it is used
to make hemoglobin.
Platelets
Platelets are small, colorless cells that have a lifespan of seven to ten days.
Platelets perform three major roles: decreasing the luminal size of damaged vessels to
decrease blood loss, forming blockages in injured vessels to decrease blood loss, and
providing support accelerate blood coagulation through molecules on the surface of the
platelets.
CARDIOVASCULAR SYSTEM
The cardiovascular system is designed to deliver oxygen and nutrients to all parts
of the body and pick up waste materials and toxins for elimination. This system is made
up of the heart, the veins, the arteries and the capillaries.
Heart
The heart is the major organ of the cardiovascular system. Blood goes from the
heart to the lungs to get oxygen then pumps oxygenated blood through arteries to the
rest of the body.
Coronary Artery
Coronary arteries are part of the heart and they supply blood to the heart muscle.
Like all other tissues in the body, the heart muscle needs oxygen-rich blood to function.
Also, oxygen-depleted blood must be carried away. The coronary arteries wrap around
the outside of the heart. Small branches dive into the heart muscle to bring it blood.
There are 2 main coronary arteries, the left main and right coronary arteries.
Capillaries
Where exchange occurs between the blood and the tissue fluid. Capillaries have
thinner walls than do arteries. Blood flows through them more slowly, and there are far
more of them than of any other blood vessel type.
Veins
Carry blood toward the heart; usually, the blood is oxygen-poor. Compared to
arteries, the walls of veins are thinner and contain elastic tissue and fewer smooth
muscles.
Layers of Blood Vessel Walls
1. Tunica intima – or innermost layer, consists of an endothelium composed of
simple squamous epithelial cells, a basement membrane, and a small amount of
connective tissue
2. Tunica media – or middle layer, consist of smooth muscle cells arrange circularly
around the blood vessel
 3. Tunica adventitia – is composed of dense connective tissue adjacent to the
tunica media
CEREBROVASCULAR SYSTEM
• The cerebrovascular system comprises the vessels that transport blood to and from
the brain. The brain’s arterial supply is provided by a pair of internal carotid arteries
and a pair of vertebral arteries, the latter of which unite to form the basilar artery
• The internal carotid arteries, the anterior cerebral arteries, and the posterior
cerebral arteries anastomose through the anterior and posterior communicating
arteries to form the circle of Willis, a vascular circuit surrounding the optic chiasm
and pituitary stalk
• The circle of Willis equalizes the blood flow between the cerebral hemispheres and
provides anastomotic circulation, connecting the anterior and posterior cerebral
circulations and, thereby, permitting continued perfusion of the brain in the event
of carotid occlusion.
• The cerebral hemispheres are drained by superficial cerebral veins and deep
cerebral veins, which drain into the dural venous sinuses
• Brain perfusion is regulated by the partial pressure of carbon dioxide. The
interruption of perfusion due to occlusion or hemorrhage of the cerebral vessels
results in a stroke, which manifests with focal neurologic deficits in the body parts
controlled by the affected brain territory
RESPIRATORY SYSTEM
In addition to respiration, the respiratory system performs the following functions:
• Regulation of blood pH
• Voice production
• Olfaction
• Innate immunity
PARTS OF THE RESPIRATORY SYSTEM
• Mouth & nose: Openings that pull air from outside your body into your respiratory
system
• Sinuses: Hollow areas between the bones in your head that help regulate the
temperature and humidity of the air you inhale
• Pharynx: Tube that delivers air from your mouth and nose to the trachea
• Trachea: Passage connecting your throat and lungs
• Bronchial Tubes: Tubes at the bottom of your windpipe that connect into each
lung
 • Lungs: Two organs that remove oxygen from the air and pass it into your blood.
From your lungs, your bloodstream delivers oxygen to all your organs and other
tissues.
• Diaphragm: Muscle that helps your lungs pull in air and push it out
• Alveoli: Tiny air sacs in the lungs where the exchange of oxygen and carbon
dioxide takes place
• Bronchioles: Small branches of the bronchial tubes that lead to the alveoli
• Capillaries: Blood vessels in the alveoli walls that move oxygen and carbon
dioxide
• Pleura: Thin sacs that surround each lung lobe and separate your lungs from the
chest wall

ABNORMAL ANATOMY AND PHYSIOLOGY (POLYCYTHEMIA VERA)

HEMATOLOGICAL SYSTEM
• Polycythemia Vera causes an overproduction of different types of blood cells,
including red blood cells, white blood cells, and platelets, which can lead to
increased blood viscosity, or thickness.
CARDIOVASCULAR SYSTEM

• Myocardial infarction (MI) is the formal term for what is commonly referred to as
a heart attack. It normally results from a lack of blood flow (ischemia) and oxygen
(hypoxia) to a region of the heart, resulting in death of the cardiac muscle cells.
In secondary to polycythemia vera, increased formation of red blood cells leads to
increased blood viscosity which also increases incidental thrombus formation,
leading to occlusion of blood vessels and marked tissue and organ ischemia and
ultimately, infarction.
CEREBROVASCULAR SYSTEM
• Polycythemia Vera can also cause blood clots due to high viscosity which will lead
to stroke where there is a disruption of cerebral blood flow.
RESPIRATORY SYSTEM
• Due to increased blood viscosity, individuals develop polycythemia as a result of
chronic lung diseases like emphysema. This leads to decrease oxygen from poor
lung function which will also lead to overproduction of red blood cells to carry more
oxygen to the body tissues.
 MODIFIABLE FACTORS POLYCYTHEMIA VERA NON-MODIFIABLE FACTORS LEGEND
• CIGARETTE SMOKING • GENDER (MALE) MODIFIABLE/NONMODIFIABLE FAC-
• ALCOHOL CONSUMPTION • ADVANCED AGE (69 YEARS OLD) TORS NOT MANIFESTED BY THE PA-
• HYPERTENSION TIENT
• OVERWEIGHT MODIFIABLE/NONMODIFIABLE MANI-
• PULMONARY DISEASE FESTED BY THE PATIENT

• CONSUMPTION OF HIGH-FAT FOODS DISEASE PROCESS

JAK KINASE 2 GENE MUTATION

SIGNS & SYMPTOMS NOT MANIFEST-
ED BY THE PATIENT
SIGNS & SYMPTOMS MANIFESTED BY
EXPRESSION OF ALTERED GENE PRODUCT
THE PATIENT
ABNORMAL LABORATORY RESULTS
HEMATOPOIETIC CYTOKINE-INDEPENDENT
COMPLICATIONS
SIGNALLING ACTIVITY

OVERPRODUCTION BY BONE MARROW

ABNORMAL HEMATOPOIESIS

PROLIFERATION OF MYELOID STEM CELLS

EXCESSIVE PRODUCTION OF DEFECTIVE BLOOD CELLS

↑ MAST CELLS EXTREME HYPERCELLULARITY SHORTER BLOOD CELL LIFESPAN

↑ MYELOBLAST ↑ PROERYTHROBLAST ↑ MEGAKARYOBLAST
OF PERIPHERAL BLOOD

↑ GRANULOCYTE ↑ MEGAKARYOCYTE
ABNORMAL HISTAMINE ↑ ERYTHROCYTE RAPID TURNOVER OF BLOOD CELLS BREAKDOWN
↑ BLOOD VISCOSITY CIRCULATING BLOOD CELLS
RELEASE
↑ LEUKOCYTE ↑ THROMBOCYTE
↑ HGB—158 G/L
CROWD IN THE BONE MARROW
↑ MCV—114 FL
↑ MCH—36 PG
↑ PERIPHERAL SLOWER BLOOD ↑ AMOUNT OF CELL
↑ WBC—27.24X10^9/ RESISTANCE FLOW SCAR TISSUE FORMS
DEBRIS
↑ PLT—349X10^9/L
IMPAIRED
CLOTTING
DISTENDED SUPER-
IMPAIRED OXYGEN- CAPACITY FICIAL NERVES SPENT PHASE OCCURS
↑ NEUTROPHIL ↑ EOSINOPHIL ↑ BASOPHIL
CARRYING CAPACITY ↑ URIC ACID HYPERKALEMIA

BLEEDING CBC RESULT:

FACIAL
PRURITUS ↓ HEMOGLOBIN—137 G/L
FLUSHING ↑ BLOOD GOUT ↑ POTASSIUM— ↓ RBC—3.76X10612/L
↑ SUSCEPTIBILITY TO INFECTION VASCULAR STASIS 5.34 MMOL/L
↑ APTT—39.60 SECONDS PRESSURE ↓ LYMPHOCYTE—0.07
↓ EOSINOPHIL—0.00
↓ MCHC—319 G/L
THROMBOSIS

↑ NEUTROPHILS - 0.87 O2 SATURATION—91% ↓ OXYGEN ↑ OCCLUSION OF BLOOD

UPON ADMISSION PERFUSION VESSELS

↓ CEREBRAL BLOOD FLOW ISCHEMIC HEART KIDNEY DAMAGE EXTREMITIES:

DISEASE • NUMBNESS
• BURNING PAIN

BLOOD CHEMISTRY RESULT:

CHEST PAIN ↑ CREATININE—136.60UMOL/L
CEREBROVASCULAR BLURRED VISION HEARING PROBLEM
↑ BUN—11.00 MMOL/L
DISEASE INFARCT
URINALYSIS RESULT:
SLIGHTLY TURBID
• HEADACHE + LEUKOCYTE
• DIZZINESS +++ BLOOD
+++ PROTEIN
• WEAKNESS
+ BILIRUBIN
↑ PUSS CELLS—18.33/UL
↑ RED CELLS—94.41U/L
 NARRATIVE

Polycythemia vera (PV) is a chronic, progressive myeloproliferative neoplasm

(MPN). It causes the bone marrow to make too many red blood cells so the blood is too
thick. Modifiable factors that are present in the case of the patient include cigarette
smoking, alcohol consumption, hypertension, pulmonary disease, and consumption of
high-fat foods. Non-Modifiable factors include gender and advanced age. Polycythemia
vera occurs more often in men than in women. There is increased susceptibility to gene
mutation for people who are at an advanced age. It is most likely to get polycythemia vera
after age 60, but it can start at any age. It is often caused by smoking, and drinking too
much alcohol. Smoking increases the number of erythrocytes and values of hematocrit
therefore tissue hypoxia caused by increased creation of carboxy hemoglobin leads to an
increased secretion of erythropoietin, thus increasing erythropoiesis. Alcohol acts as a
diuretic, increasing urination and contributing to dehydration. Myeloproliferative
neoplasms are caused by an overproduction of different types of blood cells, including
red blood cells, white blood cells, and platelets, which can lead to increased blood
viscosity, or thickness. Individuals can also develop polycythemia as a consequence of
chronic lung diseases like emphysema. For this case, the patient has subcutaneous
emphysema therefore, It decreases oxygen from poor lung function and triggers
overproduction of red blood cells to carry more oxygen to the body tissues. It is also
important to avoid consuming too much high-fat foods because they can increase your
risk of blood clots and inflammation.

In polycythemia vera there’s an increase in red blood cell production. It typically

begins with a mutation in a single hematopoietic stem cell, which gives rise to red blood
cells, white blood cells, and platelets. In 90 percent of the affected individuals there is a
mutation of the Janus Kinase 2 or JAK2 gene. Normally, the kidneys produce
erythropoietin which is a hormone that binds to receptors on the hematopoietic stem cells
and activates JAK2 gene. When that happens, it causes the cell to divide and thus
produce more blood cells. However, when there’s a mutation, it keeps the JAK2 gene
activated, and these cells are able to divide even in the absence of erythropoietin so this
causes an alteration in gene product because of the altered gene product, this causes
the hematopoietic to be independent in signaling activity. The mutated cells proliferate,
and rapidly become the predominant hematopoietic cells in the bone marrow where it
overproduces. The overproduction by the bone marrow leads to abnormal hematopoiesis.
Normal cellular functioning will be altered such as transcription and translation process.
Due to mutation, the cell’s error detection and correction mechanism is dysfunctional
causing production of more mutated cells of myeloid stem cells. This causes uncontrolled
cell cycle and cell division due to dysfunction in regulatory mechanisms where the product
is defective blood cells
.
In polycythemia vera, the manifestations are related to an increase in the red cell
count, hemoglobin level, and hematocrit. Secondary polycythemia results from a
physiologic increase in the level of erythropoietin, commonly as a compensatory response
to hypoxia. The resultant release of erythropoietin by the kidney causes the increased
formation of red blood cells in the bone marrow. The greatest concern associated with
the polycythemia is increased blood viscosity; namely, an increase in incidental thrombus
formation, leading to occlusion of blood vessels of virtually all sizes, and marked tissue
and organ ischaemia and, ultimately, infarction. It also interferes with cardiac output and
blood flow. Hypertension is common, and there may be complaints of headache and
some difficulty with hearing and vision because of decreased cerebral blood flow.
Polycythemia vera can also cause blood clots resulting in stroke. Stroke results in
disruption of cerebral blood flow with subsequent tissue damage. Venous stasis gives
rise to a plethoric appearance or dusky redness—even cyanosis—particularly of the lips,
fingernails, and mucous membranes. Because of the increased concentration of blood
cells, the person may experience itching and pain in the fingers or toes, and the
hypermetabolism may induce night sweats and weight loss. Thromboembolism occurs
in 15% to 60% of persons with polycythemia vera. Hemorrhage, due to platelet
abnormalities, occurs in 15% to 35% of cases and is also an important cause of death.
Abnormally high levels of uric acid can also cause kidney stones. Gout is associated with
polycythemia vera occurring due to the high turnover of red blood cells, which results in
higher-than-normal uric acid production. Marked increase in platelet count
(thrombocytosis) was the first identified cause of pseudohyperkalemia. It is due to
increased in vitro release of potassium from activated platelets during the process of
clotting and is therefore only a problem if serum is used to measure potassium.
 DRUG NAME MECHANISM OF INDICATION CONTRAINDICATION ADVERSE NURSING RESPONSIBILITIES
ACTION EFFECTS

N. ACETYLCYSTEINE Acetylcysteine Adjuvant therapy in Hypersensitivity to CNS: Dizziness, BEFORE:

probably acts by patients with acetylcysteine; patients at drowsiness.  Right patient.
Classifications: disrupting disulfide abnormal, viscid, or risk of gastric hemorrhage.  Right dosage
SKIN AND MUCOUS linkages of inspissated mucous GI: Nausea,  Right route
MEMBRANE AGENT; mucoproteins in secretions in acute Special Precautions vomiting,  Check 12 Rights to Drug Administration
MUCOLYTIC; purulent and and chronic stomatitis, 1. Assess the patient’s medication history
ANTIDOTE nonpurulent bronchopulmonary - Patients with asthma, hepatotoxicity because acetylcysteine inhalation solution
secretions. diseases, and in - older adults, (urticaria). may interact with other medications, vitamins,
Dosage: pulmonary - severe hepatic disease,
or herbs you may be taking. An interaction is
600 mg 1 tab complications of cystic - esophageal varices, Respiratory:
- peptic ulcer disease; Bronchospasm, when a substance changes the way a drug
Therapeutic fibrosis and surgery,
Route: - debilitated patients with rhinorrhea, burning works. This can be harmful or prevent the
Effects: tracheostomy, and
PO atelectasis. Also used severe respiratory sensation in upper drug from working well.
Acetylcysteine
in diagnostic bronchial insufficiency, respiratory 2. Assess for allergies because acetylcysteine
lowers viscosity and
Frequency: studies and as an passages, can cause a severe allergic reaction.
facilitates the
OD HS antidote for acute Drug Interaction: epistaxis. Symptoms can include:
removal of - trouble breathing
acetaminophen Acetylcysteine has no
secretions. - swelling of your throat or tongue
poisoning. known serious
interactions with other
drugs. Moderate DURING:
interactions of 1. Verify patient’s identity
acetylcysteine include: 2.
activated charcoal 3. During IV infusion, carefully monitor for
fluid overload and signs of hyponatremia
(i.e., changes in mental status).
4. Monitor for S&S of aspiration of excess
secretions, and for bronchospasm
(unpredictable); withhold drug and notify
physician immediately if either occurs
5. Volume of bronchial secretions may
increase after administration; if cough
response is inadequate, consider
maintaining airway by mechanical suction
if necessary; if airway block arises
because of foreign body or local
accumulation, clear by endotracheal
aspiration, with or without bronchoscopy.
6. Monitor asthmatic patients closely.
AFTER:

1. Lab tests: Monitor ABGs, pulmonary

functions and pulse oximetry as indicated.
2. Have suction apparatus immediately
available. Increased volume of respiratory
tract fluid may be liberated; suction or
endotracheal aspiration may be necessary
to establish and maintain an open airway.
Older adults and debilitated patients are
particularly at risk.
3. Educate that nausea and vomiting may
occur, particularly when face mask is
used, due to unpleasant odor of drug and
excess volume of liquefied bronchial
secretions to avoid anxiety.
4. Advise to report difficulty with clearing the
airway or any other respiratory distress.
5. Advise to report nausea, as an antiemetic
may be indicated.
6. Note: Unpleasant odor of inhaled drug
becomes less noticeable with continued
use.
 DRUG NAME MECHANISM OF INDICATION CONTRAINDICATION ADVERSE EFFECTS NURSING RESPONSIBILITIES
ACTION

ISOSORBIDE Organic nitrate with Isordil (isosorbide Body as a Whole: BEFORE:

DINITRATE pharmacologic actions dinitrate) Titradose Hypersensitivity to nitrates Hypersensitivity  Right patient.
similar to those of tablets are indicated or nitrites; severe anemia; reaction, paradoxical  Right dosage
Classifications: nitroglycerin. Relaxes for the prevention of head trauma; increased increase in anginal  Right route
CARDIOVASCULAR vascular smooth angina pectoris due to intracranial pressure. Safe pain,  Check 12 Rights to Drug
AGENT; NITRATE muscle with resulting use during pregnancy methemoglobinemia Administration
coronaryartery
VASODILATOR vasodilation. Dilation of (category C) or lactation is (overdose).
disease. The onset of
peripheral blood not established 1. Do not confuse with isosorbide, an
Dosage: vessels tends to cause action of immediate- CNS: Headache, oral osmotic diuretic.
5 mg 1 tab peripheral pooling of release oral isosorbide Caution Use: dizziness, weakness,
blood, decreased dinitrate is not lightheadedness, DURING:
Route: venous return to heart, sufficiently rapid for Glaucoma, hypotension, restlessness. 1. Verify patient’s identity
SUBLINGUAL and decreased left this product to be hyperthyroidism. 2. Give regular oral forms on an empty
ventricular end-diastolic useful in aborting an CV: Palpitation, stomach (1 h a.c. or 2 h p.c.). If
Frequency: pressure, with acute anginal episode. Drug Interaction: postural hypotension, patient complains of vascular
PRN consequent reduction tachycardia. headache, however, it may be taken
in myocardial oxygen Drugs to treat erectile with meals.
consumption. dysfunction-ED or GI: Nausea, vomiting. 3. Advise patient not to eat, drink, talk,
pulmonary hypertension or smoke while sublingual tablet is
(such as sildenafil, Skin: Flushing, pallor, under tongue.
Therapeutic Effects: tadalafil), certain drugs to perspiration, rash, 4. Instruct patient to place sublingual
Has an antianginal treat migraine headaches exfoliative dermatitis. tablet under tongue at first sign of
effect by causing (ergot alkaloids such as an anginal attack. If pain is not
vasodilation of the ergotamine) Some products relieved, repeat dose at 5–10 min
coronary arteries have ingredients that could intervals to a maximum of 3 doses.
worsen your heart failure. If pain continues, notify physician or
go to nearest hospital emergency
room.
5. Chewable tablet must be thoroughly
chewed before swallowing.
6. Do not crush sustained release
form. It must be swallowed whole.
7. Have patient sit when taking rapid-
acting forms of isosorbide dinitrate
(sublingual and chewable tablets)
because of the possibility of
faintness.
8. Store in tightly closed container in a
cool, dry place. Do not expose to
 extremes of temperature.

AFTER:

1. Monitor effectiveness of drug in

relieving angina.
2. Note: Headaches tend to decrease
in intensity and frequency with
continued therapy but may require
administration of analgesic and
reduction in dosage.
3. Note: Chronic administration of
large doses may produce tolerance
and thus decrease effectiveness of
nitrate preparations.
 DRUG NAME MECHANISM OF INDICATION CONTRAINDICATION ADVERSE EFFECTS NURSING RESPONSIBILITIES
ACTION

CARVEDILOL Adrenergic receptor Management of Patients with class IV Body as a Whole: BEFORE:
blocking agent that essential decompensated cardiac Increased sweating,  Right patient.
Classifications: combines selective hypertension, CHF, in failure, bronchial asthma, or fatigue, chest pain,  Right dosage
AUTONOMIC alpha activity and conjunction with other related bronchospastic pain, arthralgia.  Right route
NERVOUS SYSTEM nonselective beta- heart failure conditions (e.g., chronic  Check 12 Rights to Drug
AGENT; ALPHA- AND bronchitis and emphysema), Administration
adrenergic blocking medications, left CV: Bradycardia,
BETA-ADRENERGIC second- and third-degree
actions. Both activities ventricular dysfunction hypotension, syncope,
ANTAGONIST; AV block, cardiogenic shock 1. Monitor BP and pulse frequently
ANTIHYPERTENSIVE contribute to blood post MI.. or severe bradycardia; hypertension, AV during dose adjustment period and
pressure reduction. pregnancy (category C), block, angina. periodically during therapy.
Dosage: Peripheral lactation. GI: Diarrhea, nausea, 2. Assess for orthostatic hypotension
6.25 mg vasodilatation and, abdominal pain, when assisting patient up from
therefore, decreased Caution Use: vomiting. supine position. If heart rate
Route: peripheral resistance Respiratory: decreases below 55 beats/min,
PO results from alpha1- - Patients on MAOI Sinusitis, bronchitis. decrease dose.
blocking activity of agents, diabetes, Hematologic: 3. Monitor intake and output ratios and
Frequency: Coreg. It is 3–5 times hypoglycemia; patients Thrombocytopenia, daily weight.
BID more potent than at high risk for Metabolic: 4. Assess patient routinely for
labetalol in lowering anaphylactic reaction, Hyperglycemia, weight evidence of fluid overload
blood pressure. peripheral vascular increase, gout. CNS: (peripheral edema, dyspnea,
disease, hepatic rales/crackles, fatigue, weight gain,
Dizziness, headache,
impairment. Safety and jugular venous distention). Patients
Therapeutic Effects paresthesias.
efficacy in patients <18 y may experience worsening of
of age have not been symptoms during initiation of
An effective established. therapy for Heart failure.
antihypertensive agent
5. Hypertension: Check frequency of
reducing BP to Drug Interaction: refills to determine adherence.
normotensive range
and useful in  Antidepressants, such Lab Test Considerations:
managing some as fluoxetine,
angina, dysrhythmias, paroxetine, St John’s May cause ↑ BUN, serum lipoprotein,
and CHF by Wort, and monoamine potassium, triglyceride, and uric acid levels.
decreasing myocardial oxidase inhibitors
oxygen demand and
 Antifungals, such as May cause ↑ ANA titers.
lowering cardiac work
fluconazole May cause ↑ in blood glucose levels.
load..
 Antihistamines, such as
diphenhydramine DURING:
 Bupropion, which may 1. Verify patient’s identity
be used for the 2. Do not confuse carvedilol with
 treatment of depression captopril.
and as a stop-smoking 3. Discontinuation of concurrent
aid clonidine should be gradual, with
 Antimalaria agents, such carvedilol discontinued first over 1–
as hydroxychloroquine 2 wk with limitation of physical
 Fingolimod, which may activity; then, after several days,
be used for the discontinue clonidine.
treatment of multiple 4. For PO: Take apical pulse before
sclerosis administering. If <50 bpm or if
 HIV medications such as arrhythmia occurs, withhold
ritonavir or delavirdine medication and notify health care
 Indigestion and professional.
heartburn medications, 5. Administer with food to minimize
such as cimetidine and orthostatic hypotension.
ranitidine 6. Administer extended-release
 Some medications used capsules in the morning. Swallow
to treat mental illness, whole; do not crush or chew.
such as haloperidol or Extended-release capsules may be
thioridazine opened and sprinkled on cold
 Some heart applesauce and taken immediately;
medications, such as do not store mixture.
amiodarone, clonidine,
digoxin, diltiazem, AFTER:
propafenone, quinidine,
and verapamil 1. Monitor for therapeutic
 Other medications effectiveness which is indicated by
including celecoxib, lessening of S&S of CHF and
hydralazine, and improved BP control.
rifampicin 2. Lab tests: Monitor liver function
 NSAIDs, such as tests periodically; at first sign of
diclofenac, ibuprofen, hepatic toxicity (see Appendix F)
and indomethacin, may stop drug and notify physician.
decrease the blood 3. Monitor for worsening of symptoms
pressure-lowering in patients with PVD.
capabilities of carvedilol. 4. Monitor digoxin levels with
concurrent use; plasma digoxin
concentration may increase.
5. Patient and Family Education:
 Do not abruptly discontinue
taking this drug.
 May experience dizziness or
faintness, as a risk of
 orthostatic hypotension.
 Do not engage in hazardous
activities while experiencing
dizziness.
 If you have diabetes, the
drug may increase effects of
hypoglycemic drugs and
mask S&S of hypoglycemia.
 DRUG NAME MECHANISM OF ACTION
TRIMETAZIDINE Trimetazidine inhibits β-
oxidation of fatty acids by
Classifications: FATTY blocking long-chain 3-
ACID OXIDATION ketoacyl-CoA thiolase, with
INHIBITOR the effect of enhancing
glucose oxidation, resulting
Dosage: in more efficient production
35 mg 1 tab of ATP with less oxygen
demand. It prevents a
Route: decrease in intracellular
PO ATP levels by preserving
energy metabolism in cells
Frequency: exposed to ischaemia or
BID hypoxia, thus ensuring the
proper functioning of ionic
pumps and transmembrane
Na-K flow without changing
haemodynamic parameters.
DRUG NAME MECHANISM OF ACTION
INDICATION CONTRAINDICATION ADVERSE EFFECTS NURSING RESPONSIBILITIES
Indicated for the Parkinson's disease, Significant: New- Before:
symptomatic parkinsonian symptoms, restless onset or worsening of  Right patient.
treatment of stable leg syndrome, tremors, and other parkinsonian  Right dosage
angina pectoris in related movement disorders. symptoms (e.g.  Right route
patients Severe renal impairment (CrCl akinesia, hypertonia,  Check 12 Rights to Drug
inadequately <30 mL/min). tremor). Administration
controlled or 1. Assess location, duration
intolerant to first Precaution: Cardiac: Rarely, and intensity of anginal pain
line therapies. palpitations, 2. Monitor BP and PR before
. Patient predisposed to closed- extrasystoles, and after administering the
angle glaucoma (when using tachycardia. drug
modified-release tab). Not
indicated as a treatment for Gastrointestinal: During:
angina attacks, as initial Nausea, vomiting,
treatment for unstable angina or abdominal pain,  Verify patient’s identity
MI, nor in the pre-hospital phase diarrhoea, dyspepsia.  Instruct to avoid strenuous
or during the 1st days of or hazardous activities
hospitalisation. Mild to moderate General and requiring alertness to
renal impairment. Elderly administration site prevent risks of falls and
(particularly >75 years old). conditions: Asthenia. injury
Drug Interaction: Nervous system: After:
Headache, dizziness.
Metoclopramide  Document administration of
Skin and drug
subcutaneous tissue:  Instruct patient to report
Rash, urticaria, immediately for any adverse
pruritus. reactions
 Monitor vital signs especially
Vascular: Rarely, cardiac changes
arterial hypotension,
orthostatic
hypotension, flushing.
INDICATION CONTRAINDICATION ADVERSE EFFECTS NURSING RESPONSIBILITIES
 HYDROXYREA The precise mechanism of Palliative treatment Myelosuppression and CNS: Rare: Headache, Before:
action is unknown. However, of metastatic hypersensitivity to the drug. dizziness,  Right patient.
Classifications: various studies support the melanoma, chronic hallucinations,  Right dosage
ANTINEOPLASTIC; hypothesis that hydroxyurea myelocytic Precaution: convulsions.  Right route
ANTIMETABOLITE causes an immediate leukemia; recurrent  Check 12 Rights to Drug
inhibition of DNA synthesis metastatic, or Recent use of other cytotoxic GI: Stomatitis, Administration
Dosage: by acting as a ribonucleotide inoperable ovarian drugs or irradiation; renal anorexia, nausea,
50 g 1 tab reductase inhibitor, without cancer. Also used dysfunction; older adults; history vomiting, diarrhea, 1. Explain therapeutic value of
interfering with the synthesis as adjunct to x-ray of gout. constipation. drug
Route: of ribonucleic acid or of therapy for 2. Assess allergy to the drug
PO protein. treatment of Drug Interaction: Hematologic: Bone 3. Caution patient of the
advanced primary marrow suppression different side effects
Frequency: squamous cell Hydroxyurea has no known mild (leukopenia, anemia, 4. Assess vital signs.
OD HS Therapeutic Effects (epidermoid) interactions with other drugs. thrombocytopenia), 5. Proper preparation of the
Cytotoxic effect limited to carcinoma of head megaloblastic drug
tissues with high rates of cell (excluding lip), erythropoiesis.
proliferation. No cross neck, lungs.. During:
resistance with other Skin: Maculopapular
antineoplastics has been rash, facial erythema,  Verify patient’s identity
postirradiation  Administer with food to
demonstrated.
erythema. prevent GI upset
 Administer drug at right
Urogenital: Renal time, route, and dosage
tubular dysfunction,  Advise to swallow the tablet
elevated BUN, serum, whole
creatinine levels,  Monitor vital signs
hyperuricemia.  Open, mix with water, and
give immediately when
Body as a Whole: patient has difficulty
Fever, chills, malaise. swallowing capsule.
 Store in tightly covered
container at 15°–30° C
(59°–86° F) unless
otherwise directed.

After:

1. Lab tests: Determine status

of kidney, liver, and bone
marrow function before and
periodically during therapy;
 monitor hemoglobin, WBC,
platelet counts at least once
weekly.
2. Interrupt therapy if WBC
drops to 2500/mm3 (million
cubic meter) or platelets to
100,000/mm3 (million cubic
meter)
3. Monitor I&O. Advise patients
with high serum uric acid
levels to drink at least 10–12
240 mL (8 oz) glasses of
fluid daily to prevent uric
acid nephropathy.
4. Note: Patients with marked
renal dysfunction may
rapidly develop visual and
auditory hallucinations and
hematologic toxicity.
5. Advise patient to guard
against infection (frequent
hand washing, etc.), and to
avoid crowds and contact
with persons with
contagious diseases.
6. Advise patient that rashes
and other skin reactions
(itching, hair loss, redness,
warmth) are likely. Severe
or unexpected skin
reactions should be reported
to the physician.
7. Advise patient about the
likelihood of GI reactions
such as diarrhea, nausea,
vomiting, constipation, loss
of appetite, and
inflammation in/around the
mouth. Instruct patient to
report severe or prolonged
GI problems, or signs of
drug-induced hepatitis,
 including abdominal pain,
severe nausea and
vomiting, yellow skin or
eyes, skin rashes, and
muscle/joint pain.
8. Advise patient that flu-like
symptoms (fever, chills,
body aches) are likely, and
to report severe or
prolonged symptoms.
9. Instruct patient to report any
urinary problems, including
difficult or painful urination.
 DRUG NAME GENERAL SPECIFIC INDICATION CONTRAINDICATION ADVERSE NURSING RESPONSIBILITIES
ACTION ACTION EFFECTS

Inhibits binding of Clopidogrel is an  Recent  Hypersensitivity to drug  CNS: depression,

CLOPIDOGREL enzyme adenosine irreversible inhibitor myocardial  Active pathologic dizziness, fatigue, Assessment & Drug Effects:
phosphate (ADP) to of the platelet P2Y12 infarction bleeding headache CV: chest  Review history of seizure disorder
Generic name (intensity, frequency, duration, level
its platelet receptor adenosine (MI) or pain, hypertension
of consciousness).
and subsequent diphosphate receptor. stroke or PRECAUTIONS: EENT: epistaxis,
Use cautiously in:  Initiate safety measures, quiet dark
75 mg/1 tab ADP-mediated Inhibition of this established rhinitis GI: diarrhea, environment. CBC, platelet count
 thrombotic abdominal pain,
activation of a receptor prevents the peripheral should be performed before and 2
Dose thrombocytopenic
glycoprotein downstream arterial dyspepsia, gastritis, wks after therapy begins, then 2 wks
purpura
complex. activation of the disease GI bleeding following maintenance dose.
 increased risk of bleeding
Inhibits platelet glycoprotein IIb/IIIa  concomitant use of drugs Hematologic:  Obtain baseline hepatic function
aggregation. receptor complex, that inhibit CYP2C19 bleeding, tests.
ORAL
which leads to (such as esomeprazole, neutropenia,
reduced platelet thrombotic Drug administration:
Route omeprazole)
aggregation.  concomitant use of thrombocytopenic Verify patient’s identity

Clopidogrel is an aspirin in patients with purpura
1 tab OD inactive prodrug that recent transient ischemic  Metabolic:  Administer the right drug with the
requires enzymatic attack or cerebrovascular hypercholesterolemia right dose at the right time
Frequency accident , gout
activation via a
variety of CYP  premature discontinuation  Musculoskeletal:  State importance and purpose of the
of drug joint pain, back pain drug to the patient
enzymes, including
ANTIPLATELET  pregnant or breastfeeding  Respiratory: cough,
the CYP2C19 and patients  Monitor hemoglobin and
Classification CYP3A4 enzymes, dyspnea, bronchitis,
upper respiratory hematocrit periodically.
through a two-step
process of tract infection,  Monitor platelet count for evidence
bioactivation. Genetic bronchospasm
of thrombocytopenia.
polymorphisms to  Skin: pruritus, rash,
these enzymes can angioedema  Assess BUN, serum creatinine,
influence response to  Other: bilirubin, AST, ALT, WBC, Hgb,
therapy. The most hypersensitivity Hct, signs/symptoms of hepatic
commonly discussed reactions,
insufficiency during therapy.
genetic anaphylactic
polymorphism related reactions  Monitor patient for unusual
to clopidogrel is that bleeding or bruising; drug
of one or both alleles significantly increases risk of
of the CYP2C19 bleeding.
enzyme. Patients with
any loss of function After:
allele will not  Do
 It may take longer to stop bleeding
effectively
during drug therapy.
metabolize
 Report any unusual bleeding.
clopidogrel, leading  Inform physicians, dentists if
to the inability to clopidogrel is being taken, esp.
inhibit platelet before surgery is scheduled or before
activity. taking any new drug
DRUG NAME GENERAL SPECIFIC INDICATION CONTRAINDICATION ADVERSE NURSING RESPONSIBILITIES
ACTION ACTION EFFECTS

 Suppresses  Chemically  Hypertension Contraindications:  CNS: dizziness,

ENALAPRIL renin- fatigue, headache, Assessment & Drug Effects:
enalapril is (S)-1-
angiotensin-  Hypersensitivity to drug insomnia,
Generic name [N-[1-  Check doctor’s order
aldosterone or other ACE inhibitors drowsiness, vertigo,
system (prevents (ethoxycarbonyl)-  Angioedema asthenia, paresthesia,  Assess nutritional status, dietary
conversion of 3-phenylpropyl]-l-  Pregnancy ataxia, confusion,
5 mg 1/2 tab history.
angiotensin I to alanyl]-l-proline. depression,
Dose PRECAUTIONS:  To prevent mucous membrane and
angiotensin II, a The active form of nervousness,
 Use cautiously in: renal or
potent cerebrovascular teeth staining with liquid
enalapril is hepatic impairment,
vasoconstrictor; hypovolemia, accident preparation, use dropper or straw
enalaprilat. It
may inhibit hyponatremia, aortic  CV: orthostatic and allow solution to drop on back
ORAL inhibits
angiotensin II at stenosis, hypertrophic hypotension, of tongue.
Route local vascular, angiotensin- cardiomyopathy, palpitations, angina
renal sites). converting enzyme cerebrovascular or cardiac pectoris, tachycardia, Drug administration:
Decreases plasma (ACE), thereby insufficiency peripheral edema,
 concurrent diuretic use  Verify patient’s identity
OD angiotensin II, reducing the level arrhythmias, cardiac
increases plasma  elderly patients arrest  Administer the right drug with the
Frequency of angiotensin-II.  breastfeeding patients
renin activity,  EENT: sinusitis right dose at the right time
This action causes  children.  GI: nausea,
decreases
aldosterone a decrease in total vomiting,  State importance and purpose of the
ANGIOTENSIN- secretion. peripheral constipation, drug to the patient
CONVERTING dyspepsia, abdominal
resistance without
ENZYME (ACE) pain, dry mouth,  In patient with renal insufficiency
INHIBITOR an increase in
pancreatitis or renal artery stenosis, monitor for
cardiac oxygen
Classification  GU: proteinuria, worsening renal function.
demand. There is a urinary tract
decrease in infection, erectile  After initial dose, observe patient
aldosterone and an dysfunction, closely for at least 2 hours until
increase in serum decreased libido, blood pressure has stabilized. Then
renin levels. oliguria continue to observe for additional
 Hematologic: hour.
agranulocytosis,bone
marrow depression  Monitor vital signs, fluid intake and
 Hepatic: hepatitis output, and daily weight.
Metabolic:
 Supervise patient during
hyponatremia,
ambulation until effects of drug are
hyperkalemia
 Respiratory: cough, known.
upper respiratory
tract infection,  Monitor liver function tests, BUN,
asthma, bronchitis, and creatinine and electrolyte
dyspnea, eosinophilic levels.
pneumonitis
 Skin: rash, alopecia, After:
photosensitivity,  Inform patient that drug’s full effect
diaphoresis,
may not occur for several weeks.
exfoliative
dermatitis,  Advise patient to report persistent
angioedema, dry cough with nasal congestion.
erythema multiforme
 Other: altered taste,  Tell patient to immediately report
fever, increased swelling of face, eye area, tongue,
appetite, lips, hands, or feet; rash, hives, or
anaphylactoid severe itching; unexplained fever;
reactions unusual tiredness; yellowing of skin
or eyes; abdominal pain; or easy
bruising.

 Instruct patient to move slowly

when sitting up or standing, to
avoid dizziness or light-headedness
from sudden blood pressure
decrease.
DRUG NAME GENERAL SPECIFIC INDICATION CONTRAINDICATION ADVERSE NURSING RESPONSIBILITIES
ACTION ACTION EFFECTS

Inhibits HMG-CoA Atorvastatin  Adjunct to Contraindications:  CNS: amnesia,

ATORVASTATIN reductase, which competitively inhibits diet for  Hypersensitivity to drug abnormal dreams, Assessment & Drug Effects:
catalyzes first step in 3-hydroxy-3- controlling or its components emotional lability,
Generic name 
cholesterol synthesis; methylglutaryl- LDL, total  Active hepatic disease or headache,
this action reduces coenzyme A (HMG- cholesterol, unexplained, persistent hyperactivity, poor Drug administration:
concentrations of CoA) reductase. By apo- serum transaminase coordination,
80 mg/tab elevations
serum cholesterol preventing the lipoprotein B, malaise, paresthesia,  Verify patient’s identity
Dose  Pregnancy or
and low-density conversion of HMG- and peripheral Administer the right drug with the
breastfeeding 
lipoproteins (LDLs), CoA to mevalonate, triglyceride neuropathy,
right dose at the right time
linked to increased statin medications levels and to Cautions: drowsiness, syncope,
risk of coronary decrease cholesterol increase HDL Use cautiously in: weakness  State importance and purpose of the
ORAL
artery disease production in the liver. levels in  hypotension, uncontrolled  CV: orthostatic drug to the patient
Route (CAD). Also Atorvastatin also patients with seizures, myopathy, hypotension,
moderately increases increases the number primary alcoholism ● severe palpitations,  Monitor patient for signs and
concentration of of LDL receptors on hypercholeste metabolic, endocrine, or phlebitis, symptoms of allergic response.
OD HS high-density the surface of hepatic rolemia and electrolyte disorders vasodilation,
 concurrent use of arrhythmias  Evaluate for muscle weakness (a
lipoproteins (HDLs), cells. mixed
Frequency cyclosporine, HIV  EENT: amblyopia, symptom of myositis and possibly
associated with dyslipidemia;
decreased risk of primary protease inhibitors altered refraction, rhabdomyolysis).
tipranavir or lopinavir glaucoma, eye
CAD dysbetalipopr Be aware that reduction in dosage
HMG-COA plus ritonavir, hepatitis C hemorrhage, dry

oteinemia in protease inhibitor
REDUCTASE eyes, hearing loss, and periodic monitoring of creatine
patients telaprevir, HMGCoA
INHIBITOR; LIPID- tinnitus, epistaxis, kinase level may be considered for
LOWERING AGENT unresponsive reductase inhibitor
to diet alone; sinusitis, pharyngitis patients taking drugs that may
gemfibrozil (avoid use)
Classification adjunct to diet  concurrent use of  GI: nausea, increase atorvastatin level.
to reduce colchicine, fibric acid vomiting, diarrhea,
constipation,  Monitor liver function test results
elevated products, lipid-modifying
doses (1 g/day or more) abdominal cramps, and blood lipid levels.
triglyceride
levels of niacin, clarithromycin abdominal or biliary After:
and itraconazole (with pain, colitis,
atorvastatin dose above indigestion,  Tell patient he may take drug with
20 mg), or grapefruit dyspepsia, flatulence, or without food.
juice (more than 1.2 stomach ulcers,
L/day) gastroenteritis,  Advise patient to immediately
melena, tenesmus, report allergic response, irregular
glossitis, mouth heart beats, unusual bruising or
sores, dry mouth,
 dysphagia, bleeding, unusual tiredness,
esophagitis, yellowing of skin or eyes, or muscle
pancreatitis,rectal weakness.
hemorrhage
 GU: hematuria,  Caution patient to avoid driving and
nocturia, dysuria, other hazardous activities until he
urinary frequency or knows how drug affects
urgency, urinary concentration, alertness, and vision.
retention, cystitis,
nephritis, renal  Inform patient taking hormonal
calculi, abnormal contraceptives that drug increases
ejaculation, estrogen levels. Instruct her to tell
decreased libido, all prescribers she’s taking drug.
erectile dysfunction,
epididymitis  Tell men that drug may cause
 Hematologic: erectile dysfunction and abnormal
anemia, ejaculation. Encourage them to
thrombocytopenia discuss these issues with prescriber.
 Hepatic: jaundice,
hepatic failure,  Tell patient he’ll undergo regular
hepatitis Metabolic: blood testing during therapy.
hyperglycemia,
hypoglycemia  As appropriate, review all other
 Musculoskeletal: significant and life-threatening
bursitis, joint pain, adverse reactions and interactions,
back pain, leg especially those related to the drugs,
cramps, gout, muscle tests, foods, and herbs mentioned
pain or aches, above.
myositis, myasthenia
gravis, neck rigidity,  Document and record
torticollis,
rhabdomyolysis
Respiratory:
dyspnea, pneumonia,
bronchitis Skin:
alopecia, acne,
contact dermatitis,
eczema, dry skin,
pruritus, rash,
 urticaria, skin ulcers,
seborrhea,
photosensitivity,
diaphoresis, toxic
epidermal necrolysis
 Other: taste loss,
gingival bleeding,
fever, facial
paralysis, facial or
generalized edema,
flulike symptoms,
infection, appetite
changes, weight
gain,allergic
reaction, Stevens-
Johnson syndrome.
DRUG NAME GENERAL SPECIFIC INDICATION CONTRAINDICATION ADVERSE NURSING RESPONSIBILITIES
ACTION ACTION EFFECTS

 Reduces gastric  Gastroesopha Contraindications:  CNS: dizziness,

OMEPRAZOLE Omeprazole is a proton BEFORE
acid secretion and geal reflux  Hypersensitivity to drug headache, asthenia
pump inhibitor. It or its components
Generic name increases gastric inhibits the parietal cell disease  GI: nausea, Baseline Assessment
mucus and Cautions: vomiting, diarrhea,
H+ / K+ ATP pump, the Use cautiously in:
bicarbonate final step of acid constipation,  Right Assessment
production,  hepatic disease abdominal pain
40 gm production. In turn,  hypomagnesemia
creating Metabolic:  Right Drug/Medication
omeprazole suppresses  concurrent use of

Dose protective coating gastric basal and hypomagnesemia
clopidogrel (avoid use).  Right Client/Patient
on gastric mucosa stimulates acid  Musculoskeletal:
and easing secretion. The back pain; fractures DURING
discomfort from inhibitory effects of of hip, wrist, spine
IV omeprazole occur Intervention/Evaluation
excess gastric (with long-term daily
Route acid rapidly within 1 hour of use)
administration, with the  Right Approach
 Respiratory: cough,
maximum effect Right Route
upper respiratory 
occurring in 2 hours.
OD tract infection
The inhibitory effects  Right Frequency/Time
last for approximately  Skin:rash
Frequency
72 hours after  Right Principle of Care
administration,
followed by a return to  Assess vital signs.
PROTON PUMP baseline activity in 3 to
INHIBITOR  Check for abdominal pain, emesis,
5 days. With daily use
Classification of the medication, the diarrhea, or constipation.
effects will plateau at
 Evaluate fluid intake and output.
four days.
Omeprazole is  Watch for elevated liver function
extensively test results (rare).
metabolized by the
hepatic cytochrome  Monitor magnesium level before
P450 enzyme system, starting drug and periodically
mainly via CYP2C19 thereafter in patients expected to be
and CYP3A4 isozymes. on long-term treatment or who take
Urinary excretion is a proton pump inhibitors with other
primary route of
drugs such as digoxin or drugs that
excretion of omeprazole
metabolites. Omeprazol may cause hypomagnesemia.
e has a short half-life of
a half-hour to an hour in
healthy subjects and
about three hours half-
life for patients with AFTER
hepatic impairment.
Patient/Family Teaching
However, the
pharmacological effect  Right Education
of omeprazole lasts
much longer as the drug  Do not chew/crush sublingual,
preferentially extended-release, sustained-release
concentrates in parietal
forms
cells where it forms a
covalent linkage with  Tell patient to take 30 to 60 minutes
H+/K+ ATPase, which before a meal, preferably in
it irreversibly inhibits.
morning.

 Instruct patient to swallow capsules

or tablets whole and not to chew or
crush them. If he can’t swallow
capsule, tell him he may open it,
carefully sprinkle and mix entire
contents into 1 tbsp of cool
applesauce, and swallow
immediately with glass of water.

 Instruct patient on how to use

delayed-release oral suspension:
Empty contents of a 2.5-mg packet
of powder into a container with 5
ml of water or 10-mg packet of
powder into a container with 15 ml
of water; don’t use other liquids or
foods. Stir and allow drug to
thicken for 2 to 3 minutes. Stir well
and drink within 30 minutes. If any
drug remains after drinking, add
more water to container, stir, and
drink immediately.

 Inform patient taking OTC

delayedrelease tablets for heartburn
that full effect may take 1 to 4 days.
 Advise him not to take tablets for
more than 14 days without
consulting health care professional.

 Caution patient to avoid driving and

other hazardous activities until he
knows how drug affects
concentration and alertness.

 As appropriate, review all other

significant adverse reactions and
interactions, especially those related
to the drugs and tests mentioned
above.

 Right Evaluation

 Right Documentation
DRUG NAME GENERAL SPECIFIC INDICATION CONTRAINDICATION ADVERSE NURSING RESPONSIBILITIES
ACTION ACTION EFFECTS

 Interferes with  Ceftriaxone  Infections of Contraindications:  CNS: headache,

CEFTRIAXONE bacterial cell-wall works respiratory  Hypersensitivity to drug confusion, BEFORE
synthesis and by inhibiting the system, or its components hemiparesis,
Generic name Baseline Assessment
division by mucopeptide bones, joints,  Hyperbilirubinemic lethargy, paresthesia,
binding to cell synthesis in the and skin neonates, esp. premature syncope, seizures  Right Assessment
wall, causing cell bacterial cell  Septicemia infants, should not be  CV: hypotension,
2 gm treated with ceftriaxone
to die. Active wall. The beta-  Treatment of palpitations, chest  Right Drug/Medication
Dose (can displace bilirubin
against gram- lactam moiety of susceptible pain, vasodilation Right Client/Patient
from its binding to serum 
negative and ceftriaxone binds infections due albumin, causing bilirubin EENT: hearing loss
gram-positive to to gram- encephalopathy).  GI: nausea,  Question for history of allergies,
bacteria, with carboxypeptidases negative  Ceftriaxone must not be vomiting, diarrhea, particularly cephalosporins,
IV
expanded activity , endopeptidases, aerobic coadministered with abdominal cramps, penicillins.
Route against gram- and organisms, calciumcontaining IV oral candidiasis,
negative bacteria. transpeptidases in some solutions, including pseudomembranous DURING
Exhibits minimal the bacterial continuous calcium- colitis,pancreatitis,Cl
containing infusion such Intervention/Evaluation
OD immunosuppressa cytoplasmic ostridium difficile–
nt activity. membrane. These as parenteral nutrition, in associated diarrhea  Right Approach
Frequency neonates due to the risk of  GU: vaginal
enzymes are
involved in cell- precipitation of candidiasis  Right Route
ceftriaxone-calcium salt. Hematologic:
wall synthesis and Right Frequency/Time
THIRD GENERATION Cautions: lymphocytosis,

cell division. Use cautiously in:
CEPHALOSPORIN; eosinophilia,
 hypersensitivity to  Right Principle of Care
ANTI-INFECTIVE bleeding tendency,
cephalosporins or
Classification hemolytic anemia,  Monitor for extreme confusion,
penicillins, allergies
 renal impairment, hepatic hypoprothrombinemi tonic-clonic seizures, and mild
disease, gallbladder a, neutropenia, hemiparesis when giving high
disease, phenylketonuria thrombocytopenia, doses.
 history of GI disease, agranulocytosis,
diarrhea following bone marrow  Monitor coagulation studies.
antibiotic therapy gram- depression
 Assess CBC and kidney and liver
positive organisms  Hepatic: jaundice,
including respiratory hepatomegaly function test results.
tract, GU tract, skin and  Musculoskeletal:  Monitor for signs and symptoms of
skin structure, bone and arthralgia
joint, intra-abdominal, superinfection and other serious
Respiratory: dyspnea
pelvic inflammatory adverse reactions.
Skin: urticaria,
disease (PID), biliary
maculopapular or  Be aware that cross-sensitivity to
tract/urinary tract
infections, bacterial erythematous rash penicillins and cephalosporins may
septicemia, meningitis,  Other: chills, fever, occur.
perioperative prophylaxis, superinfection, pain
acute bacterial otitis at I.M. injection site,  Assess oral cavity for white patches
media anaphylaxis, serum on mucous membranes, tongue
sickness (thrush).

 Monitor daily pattern of bowel

activity, stool consistency. Mild GI
effects may be tolerable (increasing
severity may indicate onset of
antibiotic-associated colitis).

 Monitor I&O, renal function tests

for nephrotoxicity, CBC.

 Be alert for superinfection: fever,

vomiting, diarrhea, anal/ genital
pruritus, oral mucosal changes
(ulceration, pain, erythema).

AFTER

Patient/Family Teaching

 Instruct patient to report persistent

diarrhea, bruising, or bleeding.

 Caution patient not to use herbs

unless prescriber approves.

 As appropriate, review all other

significant and life-threatening
adverse reactions and interactions,
especially those related to the drugs,
tests, and herbs mentioned above.
DRUG NAME GENERAL SPECIFIC INDICATION CONTRAINDICATION ADVERSE NURSING RESPONSIBILITIES
ACTION ACTION EFFECTS

 Bactericidal and  Azithromycin  Treatment of Contraindications:  CNS: dizziness,

AZITHROMYCIN bacteriostatic; binds to the 23S susceptible  Hypersensitivity to drug, drowsiness, fatigue, BEFORE
inhibits protein portion of the 50S infections due erythromycin, or other headache, vertigo
Generic name Baseline Assessment
synthesis after bacterial to Chlamydia macrolide antiinfectives  CV: chest pain,
binding with 50S ribosomal subunit. pneumoniae, palpitations EENT:  Right Assessment
500 mg 1 tab ribosomal subunit It inhibits C. eye irritation (with
Cautions: ophthalmic use)  Right Drug/Medication
of susceptible bacterial protein trachomatis,
Dose Use cautiously in:
organisms. synthesis by H. influenzae,  GI: nausea, diarrhea, Right Client/Patient
 severe hepatic 
Demonstrates preventing the Legionella, impairment, severe renal abdominal pain,
crossresistance to transit of M. insufficiency, prolonged cholestatic jaundice, DURING
erythromycin- aminoacyl-tRNA catarrhalis, QT interval. dyspepsia, flatulence,
ORAL Intervention/Evaluation
resistant gram- and the growing Mycoplasma melena,
Route positive strains protein through pneumoniae, pseudomembranous  Right Approach
and resistance to the ribosome. N. colitis GU: nephritis,
most strains of Compared to gonorrhoeae, vaginitis, candidiasis  Right Route
OD Enterococcus erythromycin, S. aureus., S.  Metabolic:
hyperglycemia,  Right Frequency/Time
faecalis and azithromycin is pneumoniae,
Frequency hyperkalemia Skin:
methicillin- less prone to S. pyogenes,  Right Principle of Care
resistant disassociation including photosensitivity,
Staphylococcus from the gram- mild to rashes, angioedema  Monitor temperature, white blood
MACROLIDE; aureus. negative moderate  Other: overgrowth of cell count, and culture and
ANTIBIOTIC nonsusceptible
ribosome, infections of sensitivity results.
Classification conferring its upper organisms (with
greater efficacy respiratory prolonged use)  Assess for signs and symptoms of
against gram- tract infection.
negative (pharyngitis,  Monitor patients at risk for cardiac
pathogens. Like tonsillitis),
arrhythmia.
other macrolides lower
and protein- respiratory AFTER
synthesis tract (acute
inhibitors, bacterial Patient/Family Teaching
azithromycin exacerbations
 Tell patient he may take tablets
primarily acts as a , COPD,
with or without food.
bacteriostatic pneumonia),
agent, meaning it uncomplicate  Advise patient to take suspension 1
inhibits bacterial d skin and hour before or 2 hours after meals.
growth rather than skin-structure
directly killing infections,  Remind patient to complete entire
organisms. Howe sexually course of therapy as ordered, even
ver, especially at transmitted after symptoms improve.
higher doses, diseases
azithromycin has (nongonococc  Advise patient not to wear contact
been shown to al urethritis, lenses if signs or symptoms of
have a cervicitis due bacterial conjunctivitis exist.
bactericidal effect to Chlamydia
against certain trachomatis),  As appropriate, review all other
bacteria such as chancroid. significant and life-threatening
streptococci Prevents adverse reactions and interactions,
and H. influenzae. disseminated especially those related to the drugs,
Mycobacteriu foods, and behaviors mentioned
m avium above.
complex
(MAC).
Treatment of
mycoplasma
pneumonia,
communityac
quired
pneumonia,
pelvic
inflammatory
disease (PID).
Prevention/tre
atment of
MAC in pts
with
advanced
HIV
infection.
 NURSING CARE PLAN
NURSING SCIENTIFIC
CUES OBJECTIVES IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS RATIONALE

SUBJECTIVE: Acute Pain related to Myocardial ischemia After 1 hour of INDEPENDENT: INDEPENDENT: After 1 hour of
myocardial ischemia reperfusion injury nursing interventions nursing interventions
“Naabat ako danay 1. Assess pain level 1. Provides
as evidenced by contributes to the patient will be the patient was able
na nasakit iton akon through information upon
reports of chest pain. adverse able to: to:
dughan” as observation which valid
cardiovascular
verbalized by the ● Report (verbal pain assessments ● Report
outcomes after
patient. decreased expressions of and treatment decreased
myocardial ischemia.
pain using pain, facial effectiveness can pain using
Primarily, no blood
pain rating grimace), utilizing be based. pain rating
flow to the heart
OBJECTIVE: scale, from 8 pain scale scale, from 8
causes an imbalance
to 4/10 assessment such to 4/10
● VS: between oxygen
● Manifest as FLACC, and by ● Manifest
demand and supply,
- BP: 110/80 decreased obtaining relevant decreased
named ischemia
irritability. pain information irritability.
- HR: 132 bpm resulting in damage
● Absence of from parents ● Absence of
- RR: 27 cpm or dysfunction of the
facial grimace about child’s facial grimace
cardiac tissue.
● PRS: 8/10 expression of
pain.
2. These nonverbal Goals met
● Irritable
2. Observe for cues may indicate
● Facial grimace anxiety, irritability, the presence or
crying, degree of pain
restlessness, and being
sleep experienced.
disturbances.
3. Heart rate usually
3. Monitor vital signs. increases with
acute pain,
although a
bradycardia
response can
 occur in a
severely diseased
heart. BP may be
elevated slightly
with incisional
discomfort but
may be
decreased or
unstable if chest
pain is severe or
myocardial
damage is
occurring.

4. Identify and 4. Pillows or blanket

promote position rolls are useful in
of comfort, using supporting
adjuncts as extremities,
necessary. maintaining body
alignment, and
splinting incisions
to reduce muscle
tension and
promote comfort.

5. Provide comfort 5. May promote

measures, such relaxation,
as back rubs and redirect attention,
position changes, and reduce
assist with self- analgesic dosage
care activities, and needs or
encourage frequency
diversional
activities, as
indicated.
6. May promote 6. Rest and sleep
 relaxation, redirect are vital for
attention, and cardiac healing
reduce analgesic (balance between
dosage needs or oxygen demand
frequency and consumption)
and can enhance
coping with stress
and discomfort.

7. Identify and 7. Relaxation

encourage use of techniques aid in
behaviors such as management of
guided imagery, stress, promote
distractions, sense of well-
visualizations, and being, may
deep breathing. reduce analgesic
needs, and
promote healing.
 CUES NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS RATIONALE

SUBJECTIVE: Ineffective Breathing Polycythemia is a STO: INDEPENDENT INDEPENDENT “Mas maupay na it

Pattern Related to blood condition in akon paghinga yana
“Nagkukuri ako pag- Decreased Oxygen which the bone After 6 hours of 1. Establish 1. So that the kaysa kakulop,” as
hinga, kun gin Perfusion Secondary marrow makes nursing intervention, therapeutic patient will be verbalized.
tatanggal it akon to Polycythemia Vera excess blood cells, the patient will be able nurse-client comfortable in
oxygen” as verbalized primarily red blood to: relationship, sharing his/her GOALS PARTIALLY
by the patient. cells, but also conveying an feelings MET as evidenced by
● Establish a attitude of
platelets and white normal/effective client being able to
blood cells. caring and 2. Provides establish a
respiratory pattern, developing a opportunities
OBJECTIVE: as evidenced by: normal/effective
Secondary sense of trust for listening to respiratory pattern, as
polycythemia is - RR: 12 – 20 2. Visit client concerns and
● VS (Upon cpm evidenced by:
admission) caused by excessive frequently and questions.
- O2 sat of above - RR: 25 cpm
o HR: 150 bpm production of acknowledge 3. To promote
96% - O2 sat of 98%
o RR: 27 cpm erythropoietin. This the individual optimal healing
may occur in - (-) use of - (-) use of
o O2 sat: 91% as someone and adaptation
response to a accessory accessory
who is 4. To assist in
● Use of accessory hypoxic stimulus, as muscles muscles
worthwhile creating an
muscle upon in certain ● Verbalize ease of 3. Assist in accurate
breathing hemoglobinopathies breathing correcting diagnosis and
in which the underlying monitor
● O2 @ 3 LPM via hemoglobin has an After 3 days nursing problems effectiveness
nasal cannula abnormally high interventions, the 4. Assess the of medical
affinity for oxygen. patient will be able to: patient’s vital treatment.
Also, in secondary signs and 5. Promotes
polycythemia, long- ● Carry out ADLs characteristics maximal
term oxygen with assistance of respirations inspiration;
deprivation, such as and breathing at least every enhances lung
from chronic pattern remains 4 hours. expansion and
smoking causes normal 5. Maintain a ventilation.
increased production position of
of red blood cells comfort,
and resultant blood usually with 6. Assists patient
thickening. This form the head of to deal with the
of polycythemia bed elevated. physiological
often resolves once Encourage effects of
the cause of oxygen patient to sit hypoxia, which
deprivation is up as much as may be
addressed. possible. manifested as
6. Maintain a anxiety or fear.
calm attitude, 7. This method
assisting the relaxes
patient to “take muscles and
control” by increases the
using slower patient’s
and deeper oxygen level.
respirations. 8. Extra activity
can worsen
7. Encourage shortness of
diaphragmatic breath. Ensure
breathing for the patient
patients with rests between
chronic strenuous
disease activities.
8. Encourage
frequent rest
periods and DEPENDENT
teach the 1. To improve
patient to pace oxygenation in
activity. the body.
2. Medications
will fasten the
DEPENDENT recovery of the
patient.
1. Administer O2
therapy as
prescribed – 3
LPM via face COLLABORATIVE
mask. 1. To assess the
2. Administer patient’s condition
and monitor
 medications effectiveness of
as prescribed. treatment.

COLLABORATIVE
1. Monitor
laboratory exams
such as CBC, etc.
 NURSING SCIENTIFIC
CUES OBJECTIVES IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS RATIONALE

SUBJECTIVE: Impaired physical During a stroke, After 1 month of INDEPENDENT: INDEPENDENT: After 1 month of
mobility related to certain parts of your nursing interventions nursing interventions
“Dire ko makiwa 1. Assess and Check 1. Understanding
left-sided body brain do not get the patient will be the patient was able
maupay akon wala for functional level the particular
weakness as enough oxygen, able to: to:
na parte akon lawas of mobility. level, guides the
evidenced by Inability causing the cells to
kay maluya agi han  Increase ROM design of best  Increased ROM
to purposefully move die. If these parts are
stroke” as verbalized  Maintain or possible  Maintained or
within the physical associated with body
by the patient. increase strength management increased
environment. strength and
and function of plan. strength and
movement, damaging
them can cause affected or function of
OBJECTIVE: hemiparesis. compensatory 2. Assess the safety 2. Environmental affected or
body part. of the factors that can compensatory
● Limited range of Hemiparesis is a
 Demonstrate environment. further control body part.
motion common after-effect
techniques and and limit one’s  Demonstrated
of stroke that causes
behaviors that ability to ambulate techniques and
● Left-sided body weakness on one
enable harmlessly. behaviors that
weakness side of the body. This
one-sided weakness resumption of enable
● Perform ADLs with can limit your ADLs with limited resumption of
3. Assess the 3. This assessment
assistance. movement and affect assistance. ADLs with limited
strength to provides data on
all basic activities, assistance.
perform ROM to extent of any
such as dressing, all joints. physical problems Goals met
eating, and walking.
and guide’s
therapy. Testing
by a physical
therapist may be
needed.

4. Reduces risk of
4. Change positions tissue ischemia
at least every 2 and injury.
hours (supine, Affected side has
side lying) and poorer circulation
possibly more and reduced
often if placed on sensation and is
affected side. more predisposed
to skin breakdown
and pressure
ulcers.

5. Adds to gaining
5. Assist patient for enhanced sense
muscle exercises of balance and
as able or when strengthens
allowed out of compensatory
bed; execute body parts.
abdominal-
tightening
exercises and
knee bends; hop
on foot; stand on
toes.
6. These measures
6. Present a safe promote a safe,
environment: bed secure
rails up, bed in a environment and
down position, may reduce risk
important items for falls.
close by.
7. Exercise
7. Execute passive enhances
or active assistive increased venous
ROM exercises to return, prevents
all extremities. stiffness, and
maintains muscle
 strength and
stamina. It also
avoids
contracture
deformation,
which can build
up quickly and
could hinder
prosthesis usage.

8. Providing small,
8. Give explanation attainable goals
about progressive helps increase
activity to patient. self-confidence
and reduces
frustration.
COLLABORATIVE:
COLLABORATIVE: 1. Individualized
1. Consult with program can be
physical therapist developed to
regarding active, meet particular
resistive exercises needs and deal
and client with deficits in
ambulation. balance,
coordination, and
strength.
 NURSING SCIENTIFIC
CUES OBJECTIVES IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS RATIONALE

SUBJECTIVE: Ineffective cerebral Blood flow to the After 6 hours of INDEPENDENT: INDEPENDENT: After 6 hours of
tissue perfusion brain is called nursing interventions nursing interventions
“Danay nanlalabo tak 1. Assess the 1. The GCS
related to diminished cerebral perfusion the patient will be the patient was able
pagkita ngan dire na patient's state of evaluates
or interrupted blood pressure. Blood able to: to:
gud ako makabati consciousness changes in
flow as evidenced by pressure and
maupay” as  Maintain using the Glasgow awareness based  Maintained
changes in motor or intracranial pressure
verbalized by father. adequate Coma Scale on verbal, adequate
sensory responses affect the cerebral
cerebral tissue (GCS). sensorimotor, and cerebral tissue
perfusion pressure. If
perfusion pupillary reflexes. perfusion
the blood pressure is
OBJECTIVE:  Demonstrate Restlessness and  Demonstrated
low and/or the
stable vital signs anxiety are early stable vital signs
 VS (Upon intracranial pressure
 Display no further indicators of  Display no further
admission) is high, the blood flow
deterioration or cerebral hypoxia, deterioration or
- BP: 110/80 to the brain may be
recurrence of which progresses recurrence of
limited. This causes
- HR: 150 bpm deficits. to agitation, deficits.
decreased cerebral
- RR: 27 cpm  Maintain usual disorientation,  Maintained usual
perfusion pressure.
- O2: 91% motor or sensory lethargy, and motor or sensory
The brain needs
 Blurring of vision function. coma. function.
enough blood flowing
 Hearing problem through it to stay
2. Examine the 2. The
healthy. The brain
factors that comprehensive
can suffer damage Goals met
contribute to neurologic
when this cerebral
ineffective investigation will
perfusion is
cerebral perfusion aid in the
disrupted. As a result,
direction of
many neurological
therapy and the
conditions and
selection of
disabilities can
intervention
develop.
strategies.
3. Hypertension or
hypotension; 3. Fluctuations in
compare blood pressure may
 pressure (BP) occur because of
readings in both cerebral pressure
arms or injury in
vasomotor area of
the brain.
Hypertension or
hypotension may
have been a
precipitating
factor.
Hypotension may
follow stroke
because of
circulatory
collapse.
4. Evaluate pupils,
noting size, shape, 4. Pupil reactions
equality, and light are regulated by
reactivity. the oculomotor
(III) cranial nerve
and are useful in
determining
whether the
brainstem is
intact. Pupil size
and equality is
determined by
balance between
parasympathetic
and sympathetic
enervation
Response to light
reflects combined
function of the
optic (II) and
oculomotor (III)
 cranial nerves.
5. Position with head
5. Reduces arterial
slightly elevated
pressure by
and in neutral
promoting venous
position.
drainage and may
improve cerebral
circulation and
perfusion.

6. Keep an eye on 6. Variations in rate,

the patient's heart particularly
rate and rhythm bradycardia, can
and listen for occur due to brain
murmurs. injury.
Dysrhythmias and
murmurs may
indicate heart
illness and
precipitate CVA
(stroke after MI or
valve
dysfunction).
Atrial fibrillation
increases the
probability of
emboli
development.
 CUES NURSING SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS RATIONALE
Independent:
SUBJECTIVE Mild anxiety Anxiety can occur STO: 1. Assess client’s level 1. Anxiety may GOALS MET
related to without fear. Mild Within 1 hour of of anxiety result from the as evidenced by client
“danay dire na ako situational crisis Anxiety is necessary nursing intervention struggle of not appearing more
nangangaturog hin and stress for a person to the client will be able being able to relaxed and verbalized
maupay tak secondary to function and respond to: breathe properly. her anxiety in a more
kahadlok it pwede ischemic heart effectively to the - describe own manageable level.
matabo haakon disease not in environment and anxiety and 2. May be
tungod hini na akon failure, events. coping patterns. 2. Monitor physiological indicative of the
mga sakit” As polycythemia - demonstrate responses, such as degree of fear
verbalized by the vera and CVA improved tachypnea, client is
client. infarct Source: concentration and palpitations, experiencing —
Moyet’s Nursing Care accuracy of dizziness, headache, client may feel
OBJECTIVE Plans and thoughts. tingling sensations, out of control of
Documentation - Demonstrate and behavioral cues, the situation or
 Insomnia Edition 4, p37 ability to reassure such as restlessness, reach a state of
 Dark circles self. irritability, lack of eye panic. However,
under the eyes Vague uneasy feeling - Demonstrate contact, and symptoms may
 Restlessness of discomfort of dread some relaxation combativeness or also be related
 Inability to focus accompanied by an techniques such attack behavior. to physical
autonomic response as visualization, condition or
(the source of ten deep breathing 3. Encourage shock state.
non- specific or exercises, guided verbalization of
unknown to the imagery concerns. Assist 3. Establishes a
individual) a feeling of client in expressing therapeutic
apprehension caused Within 8 hours of feelings by active relationship.
by anticipation of nursing intervention listening. Assists client in
danger. It is an the client will be able dealing with
altering signal that to: feelings, and
warms of impending - appear relaxed provides
danger and enables and report anxiety opportunity to
the individual to take is reduced to a clarify
measures to deal with manageable level. 4. Use presence, touch misconceptions.
threat. (with permission),
verbalization, and 4. Being supportive
Source: demeanor to remind and
Nurses pocket guide patients that they are approachable
by M. Doenges not alone and to promotes
encourage communication.
expression or
clarification of needs,
concerns, unknowns,
and questions.

5. Provide a calm,
restful environment.

5. Removing client
from outside
stressors
promotes
6. Demonstrate and relaxation and
encourage relaxation may enhance
techniques such as coping skills.
visualization, deep-
breathing exercises, 6. Learning ways to
and guided imagery. relax can be
helpful in
7. Help client identify reducing fear
and initiate positive and anxiety.
coping behaviors
used successfully in
the past.

7. Successful
behaviors can
be fostered in
dealing with
current fear,
enhancing
client’s sense of
self-control and
providing
reassurance.
 CUES NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS RATIONALE

SUBJECTIVE: Readiness for Illness, along with STO: 1. Create an accepting, 1. Establishes rapport and “it Ginoo gud la
Enhanced feelings of anxiety, nonjudgmental the therapeutic talaga it permi aadi
“Gusto ko mas Spiritual Well- fear, grief, and After 6 hours of atmosphere. relationship, which para haaton ngan
mapalapit ako Being Related to despair can produce nursing promotes communication nakakabulig ngan
haaton Ginoo Desire of barriers to intervention, the and open expression. hatag hin kusog”
kay maaram Acquiring relationships in patient will be as verbalized.
ako na Hiya Strength through general and to the able to freely 2. The nature of spiritual
nala talaga it engage in 2. Observe and listen
Prayer relationship the empathetically to patient care may directly affect
makakabulig patient has with the spiritual the speed and quality of
ngan practices. communication. GOALS MET as
Divine. Research recovery and/or evidenced by
makakahatag shows that there is a redefining hope.
ha akon hin patient being able
connection between 3. Be physically present and 3. Attentive listening and to freely engage in
kusog,” as a patient’s beliefs After 3 days of actively listen to the physical presence can be
verbalized. spiritual practices
and their sense of nursing patient. spiritually nourishing. and was able to
well-being. Positive interventions, the express and
beliefs, comfort, and patient will be integrate meaning
able to express 4. Assess the patient for loss 4. Prayer improves clinical
strength gained from of meaning, purpose, and and purpose in life
religion, meditation, and integrate outcomes and provides a
hope in life. sense of spiritual well- and a sense of
and prayer can meaning and connectedness
contribute to well- purpose in life being.
5. Religious rites/rituals can with self and
being. It may even and a sense of 5. Allow the patient privacy others.
promote healing. connectedness and a quiet place for enhance meaning in life
Improving one’s with self and prayer. and promote a sense of
spiritual health may others. connectedness with a
not cure an illness, higher power
6. Assist the patient in any 6. Spirituality is associated
but it may help a
religious rites/rituals that with a sense of meaning
patient feel better.
she requests. and purpose in life and
hope.
7. Respecting the patient’s
7. Respect the patient’s
beliefs promotes trust and
beliefs.
connectedness.

8. Instruct the patient in the
use of meditation and
guided imagery.
9. Assist the patient in
identifying meaningful
experiences.
10. Monitor support systems.
Be aware of own belief
systems and accept
patient’s spirituality.
8. These activities are often
used to promote spiritual
well-being.
9. Meaningful experiences
promote spiritual well-
being.
10. To effectively help a client
with spiritual needs, an
understanding of one’s
own spiritual dimension is
essential.
 PROGNOSIS

Polycythemia vera (PV), the excessive production of erythrocytes, leukocytes, and

platelets, is caused by excessive activation of pluripotent stem cells in the bone marrow. It is a
chronic, life-shortening, pan-hyperplastic, malignant, neoplastic marrow disorder. The
inordinate mass production of these three cell lines results in (1) an increase in blood viscosity;
(2) an increase in the total blood volume, which may be twice or even three times greater than
normal; and (3) severe blood congestion of all tissues and organs.

A permanent cure for PV is currently unavailable, but remission of many years can be
achieved. The goals of care in PV are 2-fold: reduction of (1) blood volume and viscosity and
(2) myeloproliferative activity. These decreases are accomplished through phlebotomy,
administration of myelosuppressive agents, and radiation therapy. Emergency phlebotomy
can be used to normalize red cell mass as quickly as possible (removal of 500 to 2000 ml of
blood until the HCT reaches 45%). Clients with hematocrits of less than 70% may be bled
twice a week. Clients who are older or who have car diovascular compromise or
cerebrovascular complications should receive volume replacement with saline solution to
avoid postural hypotension. If platelet counts are elevated, a myelosuppressive agent should
be used in combination with aspirin (300 mg three times a day) to avoid thrombotic or
hemorrhagic complications. Women of childbearing age should be treated only with
phlebotomy. Once normal HcT levels are reached, subsequent phlebotomies should be carried
out as frequently (monthly) as necessary to maintain the HCT at about 45%. Iron deficiency
will likely result, but as it supervenes, RBC production will be retarded so that clients
managed by phlebotomy alone may require as few as two or three phlebotomies a year. The
myelosuppressive agent hydroxyurea is commonly used in clients older than 50 years of age.
Radioactive phosphorus, chlorambucil, busulfan (Myleran), and melphalan (Alkeran) have
also been tried but are not indicated for long-term use because of the increased incidence of
acute leukemia (17%) after 15 years. Radioactive phosphorus, however, may be used for
clients older than 80 years or for those with co-morbid conditions in which life expec tancy is
shorter than 5 to 10 years. Anagrelide may be used in younger clients (50 to 70 years) if
hydroxyurea is contra indicated. In young males, myelosuppressive therapy can lead to
aspermia; use of this treatment should be carefully evaluated for these clients. Hyperuricemia
is treated with allopurinol until remission is attained; acute gouty attacks are treated with
colchicine or other anti-inflammatory agents.

Untreated patients with PV have increased risk for bleeding complications after
surgery. Thus, if surgery is needed for any reason, treatment should be put in place to bring
the hematocrit to a normal concentration before surgery.Some PV patients have disease
progression despite treatment. After years of disease, their cells undergo further changes and
no longer overproduce red cells. For a time, the red cell count may stay near normal without
treatment or it may drop below normal, resulting in anemia. The spleen may become further
enlarged. The marrow may become fibrous or scarred, reducing its ability to make red cells
and platelets. This condition of the marrow is called “myelofibrosis” or more precisely, post-
polycythemia vera myelofibrosis. The platelet count may fall to low levels. Immature white
cells may be released from the marrow into the blood.PV can also transform into other blood
cancers such as acute leukemia or myelodysplastic syndromes, but this is a very uncommon
occurrence.
The likely outcome of a disease, called the “prognosis,” varies in patients with PV.
Each patient’s risk factors, which affect his or her prognosis, are evaluated individually. In
people with PV, median survival approaches or exceeds 20 years. Some people may survive
longer after diagnosis, perhaps achieving a near-normal life expectancy
 Recommendation:

Although PV is a chronic, incurable disease, it can be managed effectively for long periods of time.
Careful medical supervision and therapy are designed to reduce hematocrit and platelet concentrations
to normal or near-normal value, in order to control PV-related symptoms, decrease the risk for arterial
and venous thrombotic events and other complications, and avoid leukemic transformation.

Strategies for the prevention of thrombotic events are determined after considering the multiple factors
that can influence a patient's hypercoagulable state. Phlebotomy or cytoreduction are recommended
for Hgb and hematocrit control, and antiplatelet therapy is used to prevent arterial events. Most
patients take low-dose aspirin once daily, whereas those who are sensitive to aspirin are given
clopidogrel. Aggressive control of cardiovascular risk factors, including blood pressure, lipids, smoking,
weight, and physical fitness, is also relevant.

Arterial Events

Stroke and antiplatelet agents

- Current guidelines recommend clopidogrel, aspirin, or extended-release dipyridamole firstline,

but these agents have not been tested in patients with PV. For most patients, there is no
increased benefit associated with the use of clopidogrel combined with aspirin
- Assess other CV risk factors: diabetes mellitus, hypertension, cholesterol

Cardiac and antiplatelet agents

- Aspirin 150 to 325 mg daily may be combined with clopidogrel for 12 months
- Assess other CV risk factors: diabetes mellitus, hypertension, cholesterol

Venous Events

Deep vein thrombosis/pulmonary embolism

- Initial therapy with LMWH is recommended, but duration of therapy is unclear. Data are
available to guide decision-making regarding LMWH use, aspirin continuation, warfarin
transition, and use of oral anticoagulants

In all patients who have experienced arterial or venous thrombotic events, treatment with cytoreductive
agents is appropriate.

Diet Recommended

- •Eat antioxidant-rich foods, including fresh fruits and vegetables to add fiber to your body which
ultimately will help in controlling blood pressure.
- Avoid refined foods, such as white processed sugar, bread and junk food to control
inflammation as they may contain high-fat content and can increase chances of blood thickening.
- Avoid red meat completely and choose lean meats like chicken, cold-water fish (in moderation),
pulses and beans, nuts and seeds for protein. Protein is important for the repair of cells in our
bodies.
- Use healthy oils, such as cold-pressed coconut oil, sesame, mustard or groundnut oil or A2 ghee
for cooking food over any refined oils. This helps in controlling inflammation.
- Try to eliminate trans-fatty acids from your routine, these are mostly found in commercially
baked goods such as cookies, crackers, cakes, French fries, onion rings, doughnuts, processed
foods and margarine. They can make your blood flow sluggish and can increase the chances of
blood clots.
- Avoid caffeine, alcohol, and tobacco as they can keep the inflammation levels high and will not
help the body to heal.

Lifestyle Modifications

- Exercise. Moderate exercise, such as walking, can improve blood flow. This helps decrease risk
of blood clots. Leg and ankle stretches and exercises also can improve blood circulation.
- Avoid tobacco. Using tobacco can cause blood vessels to narrow, increasing the risk of heart
attack or stroke due to blood clots.
- Avoid low-oxygen environments. Living at high altitudes, skiing or climbing in mountains all
reduce the oxygen levels in the blood even further.
- Skin protection. To reduce itching, bathe in cool water, use a gentle cleanser and pat skin dry.
Adding starch, such as cornstarch, during bath might help. Avoid hot tubs, heated whirlpools,
and hot showers or baths. Try not to scratch, as it can damage your skin and increase the risk of
infection. Use lotion to keep your skin moist.
- Avoid extreme temperatures. Poor blood flow increases risk of injury from hot and cold
temperatures. In cold weather, advise to always wear warm clothing, particularly on hands and
feet. In hot weather, protect from the sun and drink plenty of liquids.
- Watch for sores. Poor circulation can make it difficult for sores to heal, particularly on the hands
and feet. Inspect feet regularly and report to physicians about any sores.