LEARNING OBJECTIVE

Gain more knowledge about anatomy and physiology of the blood system. State the definition of aplastic anemia. State the etiology and contributing factor of aplastic anemia. Explain the pathophysiology of aplastic anemia. State the clinical manifestation of aplastic anemia. State the diagnostic investigation for aplastic anemia. List the complication of aplastic anemia. Identify the treatment for aplastic anemia. Demonstrate the nursing care for patient with aplastic anemia. Appreciate the importance of Health Education in the prevention of recurrence to the patient and family member.

PATIENT’S BACKGROUND
Name : Miss L MRN : 190xxx I/C No. : 861213 – xx - xxxx Age : 20 years old Sex : Female Race : Chinese Religion : Buddhist Occupation : Student Citizen : Malaysian Marital Status : Single Language Spoken : English, Mandarin

On Admission
Date / Time of admission : 29 may 2007 @ 2000 h Consultant : Dr. D Mode of admission : Wheel chair

Reason for admission : Pt complain of palpitation, shortness of breath during exertion, lethargic, headache, easy bruising and sweating at night. Medical history : Nil Surgical history : Nil Family medical history : Aplastic anemia Current medication : Nil Allergies : Unknown

Vital sign Temperature : 36.5 º c Pulse : 110bpm Blood pressure : 120 / 76 mmHg Respiration : 24/min Weight : 55 kg Level of Consciousness : Conscious Mental status : Orientated Emotional status : Anxious

Activities of Daily Living of Miss L Breathing
 Miss

L has shortness of breath during exertion.  Miss L does not smoke. Eating and drinking  Miss L does not have any problem with eating and drinking.  Miss L does not have any allergic reaction. Elimination - Bowel  Miss L pass motion regularly everyday and no taking any medication for bowel movement.

Elimination - Bladder  Miss L does not have any problem in passing urine  Miss L does not get up at night to pass urine. Sleeping  Miss L sleeping pattern was normal, able to sleep well.  She does not require any medication to sleep. Mobility  Miss L was ambulating. Personal hygiene  Miss L can carry out her personal hygiene by herself.

Safe environment  Side rail raise up. Speech  Miss L can speak well (normal). Vision  Miss L wearing spectacles. Hearing  Miss L does not have any hearing problem. Spiritual support  Miss L does not require any spiritual support.

Petechia , Bruising

 Blood

is a highly specialized circulating tissue consisting of several types of cells suspended in a fluid medium known as plasma.  Blood is made of a liquid plasma which has red and white blood cells in it.  Make up about 7% of body weight (about 5.6 litres in a 70kg man)  blood is circulated around the lungs and body by the pumping action of the heart.  It provides one of the means of communication between the cells of different parts of the body and the external environment

BLOOD

It carries:
1.

Functions

2.

3. 4. 5. 6.

oxygen from the lungs to the tissue and carbon dioxide from the tissue to the lungs for excretion. nutrients from the alimentary tract to the tissue and cells waste to the excretory organs, principally the kidneys. hormones secreted by endocrine glands to their target glands and tissue. heat produced in active tissue to other less active tissue. protective substances, e.g. antibodies, to areas of infection. clotting factors that coagulate blood, minimizing its loss from ruptured blood vessels.

Blood Cells

Blood composed of a straw-colored transparent fluid, plasma, in which different types of cells are suspended. Plasma constitutes about 55% and cells about 45% of blood volume.

Composition of blood

Blood component – RBC, WBC, Platelet and Plasma

Plasma

1. 2.

Plasma is a pale yellow mixture of water, proteins and salts. One of the functions of plasma is to act as a carrier for blood cells, nutrients, enzymes and hormones. Constituents of plasma are water (90 to 92%) and dissolved substances, including: Plasma protein Inorganic salt (mineral salt)

3. 4. 5. 6. 

Nutrients Organic waste product Hormones Gases Responsible to creating the osmotic pressure of blood (normally 25mmHg) which keep plasma fluid within circulation.

Red Blood Cell

Red Blood Cell
 Red

cells are disc-shaped cells containing hemoglobin, which enables the cells to pick up and deliver oxygen to all parts of the body.  Red blood cell has a life span of about 4 months (120 days).  Each day, the body produces new red blood cells to replace those that die or are lost from the body.

White Blood Cell

White Blood Cell
 White

cells are the body's primary defense against infection.  They can move out of the blood stream and reach tissues being invaded.  White blood cells called granulocytes (neutrophil, eosinophil, basophil) and lymphocytes travel along the walls of blood vessels.  They fight germs such as bacteria and viruses and may also attempt to destroy cells that have become infected or have changed into cancer cells.

Platelet

Platelet
 Platelets

(also called thrombocytes) are tiny oval-shaped cells made in the bone marrow. They help in the clotting process and control bleding.  Platelets survive only about 9 days in the bloodstream and are constantly being replaced by new cells.  They form clusters to plug small holes in blood vessels and assist in the clotting process.

1 Definition Aplastic Anemia
s t

A severe form of anemia, resistant to therapy, in which the bone marrow fails to produce new blood cells (see pancytopenia). There are several causes, including a reaction to toxic drugs.
Dictionary of Nursing Malaysian edition

2nd Definition Aplastic Anemia
In aplastic anemia, the bone marrow fails to produce all 3 types of blood cells, leading to pancytopenia. Normal bone marrow is replaced by fat.
Medical surgical nursing Priscilla Lemone and Karen Burke Third edition

3 definition Aplastic Anemia
rd

Aplastic anemia is a disease of the bone marrow. The bone marrow stops making enough red blood cells, white blood cells and platelets for the body. Any blood cells the marrow does make are normal, but there are not enough of them.

https://www.aplastic/disease_information/education

Statistic of Aplastic Anemia at Puteri Specialist Hospital in year 2004, 2005, 2006 and 2007
3 Chi l d ( 0- 10 years ol d) Young adul t (15- 30 years ol d) El derl y (above 60 years ol d) 2004 2005 2006 2007 Year

2 N ber of um pati ent 1

0

Risk Factor
Treatment with high-dose radiation or chemotherapy for cancer Exposure to toxic chemicals Use of prescription drugs — such as chloramphenicol (Chloromycetin) used to treat bacterial infections and gold compounds used to treat rheumatoid arthritis Use of inhalants — such as paint thinner, gasoline, nail polish remover, glues and lighter fluid Certain blood diseases, autoimmune disorders and serious infections Pregnancy, rarely

Etiology
1. 2. 3.

Congenital or inherited e.g. Fanconi anemia Idiopathic or unknown e.g. Idiopathic aplastic anemia Exposure to radiation or chemotherapeutic drugs. Stem cell damage and suppress bone marrow function caused by exposure to the radiation and chemotherapy.

4.

5.

6.

Autoimmune disease body's immune system is reacting against itself and attacks the bone marrow thus stops it from making enough blood cells. Certain chemical substances and drugs E.g. benzene, inorganic arsenic, nitrogen mustard, airplane glue, antibiotic (chloramphenicol, penhylbutazone), anticonvulsant and some insecticides. Viral infection Such as hepatitis C and HIV disease

PATHOPHYSIOLOGY
Congenital or inherited (mother – Aplastic anemia)

Cause basic structure of bone marrow become abnormal (hypoplasia) Cause Pluripotent stem cells (hemotopoietic cells) greatly decreased in number or absent These hematopoietic cells are replaced by large quantities of fat.

Affect the precursor for erythroid (erythrocyte), megakaryocyte (platelet) and granulocytic (white blood dells) cell lines Precursors become severely limited in ability to proliferate and differentiate in appropriate cell line Inadequate blood cell formation by bone marrow Anemia, leucopenia and thrombocytopenia (pancytopenia)

Clinical Manifestation
Fatigue Shortness of breath with exertion. Low numbers of red blood cells can cause a person to feel tired or weak, be short of breath and look pale. Rapid heart rate Pale skin Frequent or prolonged infections. Low numbers of white blood cells can lead to frequent or severe infections.

Unexplained or easy bruising. Low numbers of platelets can lead to easy bleeding or bruising and tiny red spots under the skin (petechiae), or bleeding that is hard to stop.

Nose bleeds and bleeding gums Prolonged bleeding from cuts Skin rash Dizziness Headache

Complication
Shock Hypotension or coronary and pulmonary insufficiency. Heart Failure.

Investigation done for Miss L  29th May 2007 - Hematology, Diabetes mellitus screen

30th May2007  Hematology  Bone marrow aspiration and biopsy  Antinuclear Antibodies (ANA)  Peripheral blood film comment  Diabetes mellitus screen  Renal function and bone metabolism screen  Lipid profile  Liver function test  Thyroid function test  Venereal disease screen (VDRL)  Hepatitis B screen  Urine FEME 31st May 2007 - Hematology (platelet count)

Bone Marrow Aspiration and Biopsy

Bone Marrow Aspiration and Biopsy 

Bone marrow examination is used in the diagnosis of a number of conditions, including leukemia, multiple myeloma, anemia and pancytopenia.  bone marrow aspiration: test in which a sample of bone marrow cells is removed with a needle and examined under a microscope.  bone marrow biopsy: procedure in which a small piece of bone marrow tissue is removed with a needle; sample is processed by softening the bone and examining thin slices of the softened bone under a microscope.

Bone Marrow Aspiration

DATE DONE: 29, 30, 31 May 2007

Haematology
Result 29/5 **5.5 **20 **12 **3.8

Haematology Reference range 11.5 - 16.0 g/dL Red cell count 4.0 - 5.2 1012/L Haematocrit 36 - 46 % (PCV) Platelet count 150 - 450 10³/uL White blood 4.3 - 10.5 cell count 10³/uL Hemoglobin

Result 30/5 **7.7 **2.8 **26 **46 **3.6

Result 31/5 **28 -

White Blood Cell Differential Count
Reference Range Neutrophil Lymphocyte Eosinophil Monocyte Basophil 40 - 75 % 20 - 45 % 0-6% 0-6% 0-2% Result 29/5/07 46.0 **46.0 1.0 5.0 2.0 Result 30/5/07 60.3 34.4 0.1 5.0 0.2

Biochemistry
DATE DONE: 29/05/07 Result unit Reference range -- Diabetes mellitus screen -** glucose 7.1 mmol/L 3.9- 6.1 mmol/L Reference range : random blood sugar : < 7.8 mmol/L (<140 mg/dl)

Antinuclear Antibodies (ANA)
DATE DONE: 30 / 05 / 07

IMMUNOLOGY SPECIMEN: SERUM Anti - nuclear Antibody titre: < 80 (RR < 80) COMMENT: Antinuclear activity not detected. HAEMATOLOGY SPECIMEN: WHOLE BLOOD SI Units Conventional Units FILM: There is a moderate anemia. The red cells show moderate anisocytosis with poikilocytosis, several elliptocytes, several target cells and several tear drop cells. There is a moderate thrombocytopenia. The white cells appear normal. Large platelet forms present.

Bone Marrow Aspiration
DATE DONE: 30 / 05 / 07

 Cellularity

: No fragments. Peripheral blood.  Erythropoiesis: Not evaluable.  Leucopoiesis : Not evaluable. A few blast cells.  Megakaryocytes: None seen.  Plasma cells : Not increased.  M / E ratio : Not evaluable.  Foreign cells : Not present.  Iron store : Not evaluable.

Trephine Biopsy
DATE DONE: 30 / 05 / 07

GROSS Tiny fragment 0.8 x 0.2 cm. Decalcified and processed in toto. MICROSCOPY The marrow is markedly fatty with scattered tiny islands of myeloid cells. No megakaryocyte is seen. INTERPRETATION Can be compatible with aplastic anemia, if clinically relevant.

Peripheral Blood Film Comment
DATE DONE: 30th May 2007  Red

cells show hypochromic and normocytic picture.  White blood cells appear leucopenia.  Platelet are inadequate.

Biochemistry
DATE DONE: 30/05/07

Result unit

Reference range

-- Diabetes mellitus screen -glucose 5.4 mmol/L 3.9- 6.1 mmol/L Reference range : random blood sugar : < 7.8 mmol/L (<140 mg/dl)

LIPID PROFILE
DATE DONE: 30/05/07 Result Unit (mmol/L) 4.7mmol/L 0.7mmol/L 1.00mmol/L 3.4mmol/L 4.7mmol/L Reference Range (mmol/L) <5.2mmol/L <2.28mmol/L >1.42mmol/L <3.4mmol/L Up to 4.0mmol/L

Total cholesterol Triglycerides ** HDL cholesterol **LDL cholesterol ** chol / HDL chol

LIVER FUNCTION TEST
DATE DONE: 30/05/07 (abnormal result)

Result Unit Reference range ** indirect bilirubin 21.5umol/L < 20.5 umol/L

BLOOD TRANSFUSION. Dr. D ordered to transfuse 2 pint of pack cells and 2 pint of platelet to Miss L.

Treatment

Medication of Miss L
Medication Group Route orally orally Dosage 1 tab 1 tab Frequency BD TDS PRN Iberet Folic Antianemics Transamin Calamine Lotion Haemostatics

Topical typical Apply thin antihistamines, layer at skin protective affected area

Stat Medication
Medication Group Lasix Route Dosa Date on frequen ge cy Diuretic IV 40 30/05/ Stat mg 07 antihista IV mine 1 30/05/ Stat amp 07

Piriton

        

Iberet Folic Group : Antianemic Date On : 29 / 05 / 07 Date Off : 31 / 05 / 07 Dosage : 1 tablet (BD) Route : orally Indication : prevention and treatment of Fedeficiency anemia and prevention of folate deficiency. Contraindication : patient with pernicious anemia and hypersensitivity to folic acid. Adverse reaction : likelihood of gastric intolerance to iron. Allergic sensitization.

      

Transamin Group : Haemostatic, antiplasminic agent Date On : 29 / 05 / 07 Date Off : 31 / 05 / 07 Dosage : 1 tab (TDS) Route : orally Indication : hemorrhagic tendency considered to involve systemic hyperfibrinolysis (leukemia, aplastic anemia, purpura, etc) and abnormal bleeding during or after operation. Allergic and inflammatory symptom. Adverse reaction : GI disturbance, itching or skin rash occur rarely. Anorexia, nausea and vomiting, diarrhea, heart burn. Drowsiness and headache rarely.

      

Calamine Lotion Group : Topical antihistamine, skin protectives Date On : 29 / 05 / 07 Date Off : 31 / 05 /07 Route : typical Dosage : apply to affected parts Indication : for relief of dermatitis and prickly heat discomfort and treatment of pruritis, urticaria, sunburn, and other minor skin irritations. Adverse reaction : hypersensitivity reaction may occur occasionally.

Nursing Care Plan for Miss L Pre operation
1. 2.

Alteration in breathing pattern: shortness of breath related to low hemoglobin level (anemia). Alteration in emotional status: anxiety related to lack of knowledge regarding to procedure and treatment that will carry out.

3. 4.

High risk of bleeding related to low platelet count (thrombocytopenia). High risk of infection related to low white blood cell count (leucopenia).

Post operation 5. Alteration in comfort: pain related to post procedure incision site (bone marrow aspiration).

6.

7.

Potential bleeding related to post procedure incision site (bone marrow aspiration). Potential infection related to post procedure incision site (bone marrow aspiration).

Nursing Care Plan 1
Alteration in breathing pattern: shortness of breath related to low hemoglobin level (anemia). Date: 29th May 2007 Time: 2000 hour Supporting data:  Patient complain of shortness of breath on and off during last 1 week.  Patient looks pale and tired.  Patient’s blood result show Hb is low (5.5g/dL)  Miss L’s vital sign: tarchycardia (110bpm), tarchypnea (24/min)

Expected outcome: Short term: Patient’s shortness of breath will be reduced within 1 hour after nursing intervention carried out Long term: Patient’s shortness of breath will be reduced and able to maintain a normal breathing pattern during hospitalization.
Nursing Intervention: 1. Assess patient’s breathing pattern such as respiration rate, rhythm, depth, cynosis and use of accessory muscle. Rational: to determine patient’s breathing pattern and plan a proper nursing care. Implementation: I assess patient’ breathing pattern, patient looks tired and short of breath.

2. Monitor patient’s vital sign such as respiration rate, pulse, blood pressure, and oxygen saturation 6 hourly. Rational: to act as baseline and comparison data and to detect any abnormality such as tachypnea and low oxygen saturation indicate shortness of breath. Implementation: I check my patient’s vital sign 6 hourly and do documentation in the observation chart. Her vital sign results are: Temperature: 36.5 º c Respiration: 24/min Pulse: 110bpm Blood pressure: 120/76 mmHg: Oxygen saturation: 97%

3. Position patient in semi fowler’s or fowler’s position. Rational: To promote better lung expansion and improve breathing pattern by increasing the lung capacity. This position also promotes comfort. Implementation: I put miss L in semi fowler’s position because she prefer in that position. 4. Administer oxygen 3L/min via nasal prong PRN as ordered by doctor. Rational: to increase oxygen concentration in the blood and reduce cardiac workload. Implementation: I administer oxygen 3L/min via nasal prong for my patient when she is in shortness of breath.

5.

Obtain patient’s blood for investigation such as FBC. Rational: low hemoglobin level may indicate dyspnea. Implementation: I assist SRN to take miss L’s blood for laboratory investigation as ordered by doctor and send to lab. The result show miss L’s Hb level is low, 5.5g/dL and 7.7g/dL. 6. Teach patient how to do Deep Breathing Exercise (DBE) in the correct method. Rational: to increase lung capacity and promote gas exchange thus improve breathing pattern and relax muscle. Implementation: I taught her to breathe in through the nose until the end and hold the breath as long as she can, then breathe out through the mouth (purse lips).

7. Advise patient to rest in bed and reduce physical activities. Rational: decreasing activity may reduce oxygen demand thus reduce oxygen consumption. Implementation: I advise miss L to rest and try to reduce physical activity as much as possible. 8. Provide a conducive environment for patient such as quiet and comfortable environment. Rational: to allow patient to has a good and enough rest. Implementation: I switch off the light for patient to sleep.

Administer medication: antianemic as prescribed by doctor. E.g. iberet folic. Rational: to replace iron store needed for red blood cells development. Implementation: I served medication as prescribed to miss L follow 5R with SRN supervise me.
9.

10. Inform doctor if patient’s condition still not improving. Rational: for further treatment and prompt action can be taken to avoid condition worsen. Implementation: I did not inform SRN and doctor because miss L’s breathing pattern able to maintain normal after nursing intervention carried out.

Evaluation: Date: 29th May 2007 Time: 2100 hour Evaluation: Miss L was able to breath normally after nursing intervention carried out. Supporting data:  Miss L no complains of shortness of breath.  Miss L oxygen saturation is 100%  Miss L respiration rate is 20/min

Date: 30th May 2007 Time: 1700 hour Re-evaluation: Miss L was able to maintain normal breathing pattern. Supporting data:  Miss L no complains of shortness of breath.  Miss L oxygen saturation is 100%  Miss L no needs use of oxygen nasal prong to maintain breathing pattern.  Miss L respiration rate is 18/min

Date: 31st May 2007 Time: 1000 hour Re-evaluation: Miss L was able to maintain normal breathing pattern. Supporting data:  Miss L no complains of shortness of breath.  Miss L oxygen saturation is 100%  Miss L no needs use of oxygen nasal prong to maintain breathing pattern.

Alteration in emotional status: anxiety related to lack of knowledge regarding to procedure and treatment that will carry out. Date: 29th May 2007 Time: 2000 hour Supporting data:  Miss L verbalized she is anxious about the procedure.  Miss L facial expression looks anxious and worried.  Miss L ask a lot of question about the procedure.

Nursing Care Plan 2

Expected outcome: Short term: Patient will verbalize anxiety had reduced and feel more confident regarding to the procedure after nursing intervention carried out. Long term: Patient will verbalize anxiety had reduced and feels more relax and calm during hospitalization. Nursing Intervention: 1. Assess patient’s level of anxiety and understanding regarding to the disease and procedure that will carry out for her such as bone marrow aspiration. Rational: to determine the level of anxiety and understanding of patient and plan a proper nursing intervention. Implementation: I assess her level of understanding about her disease and procedure that will carry out to her by asking some question on it. She is not so understand about bone marrow aspiration and quite anxious on it.

2.

Reinforce doctor’s explaination about her disease and procedure that will carry out to her with simple words and avoid medical jargon. Rational: to increase level of understanding of patient and ensure patient understand with the simple words of explaination. Implementation: I followed doctor ward round and re-explain doctor’s explaination with simple words to miss L without using any medical term. 3. Encourage patient to ask question about her disease and any doubt regarding to her condition. Rational: asking question on her doubt can make her more understand about her disease and condition. Implementation: I encourage her to ask question whenever she doesn’t understand and don’t be afraid to ask question. I told her that she can ask doctor while doctor is doing ward round.

4.

Display professionalism and caring behavior when approach to patient and family about the diagnostic text. Rational: To make the patient feels more comfortable and gain trust from him to make him feels less anxious. Implementation: I approach patient with professionalism and caring behaviour such as call her by name and inform her softly about all the diagnostic test and the nursing care. 5. Always provide clear explanation before carry out any procedure such as pre, during and post procedure expectation and care. Rational: to ensure patient is clear with the procedure and get co-operation from patient. Implementation: before start any procedure, I explain about the procedure and its purpose.

Provide some additional information or reading material about patient’s disease such as article from health magazine, internet research. Rational: to allow patient understand about her disease deeper. Implementation: I gave my internet research about aplastic anemia for her to read it in her laptop.
6.

7. Inform patient about her investigation result such as blood test result. Rational: allow patient to know more detail about her condition and reduce her doubt. Implementation: I always informed the laboratory test to her and make a copy for her to keep.

Encourage patient’s family member to spend more time with patient. Rational: family member’s companion may able to allay patient’s anxiety. Implementation: I advise miss L’s family member to stay with her. I ask her sister to accompany her while doing bone marrow aspiration.
8.

9. Inform doctor if patient needs further explanation. Rational: for further treatment and information to the patient. Implementation: I did not inform doctor because miss L look more calm and confident after nursing intervention given.

Evaluation: Date: 29th May 2007 Time: 2100 hour Evaluation: Patient verbalized worried about tomorrow procedure (bone marrow aspiration). Supporting data: Miss L looks worried and anxious. Miss L verbalized she is scare.

Date: 30th May 2007 Time: 0900 hours Re-evaluation: Patient looks more relax and verbalized anxious is lesser after nursing intervention carried out. Supporting data: Miss L looks more relax and confident Miss L verbalized she is less anxious compare to yesterday. Date: 31st May 2007 Time: 0800 hour Re-evaluation: Patient looks more cheerful and smiling after all procedure had carried out. Supporting data: Miss L is smiling when see us Miss L looks more cheerful.

Nursing Care Plan 3
High risk of bleeding related to low platelet count (thrombocytopenia). Date: 29th May 2007 Time: 2000 hour Supporting data:  Miss L’s platelet count is low (12 10³/uL).  Miss L has unexplained bruising.  Miss L has petechia.

Expected outcome: Short term: Patient’s sign and symptom of bleeding will be reduce within 24 hours after nursing intervention carried out Long term: Patient’s risk of bleeding will be reduced during hospitalization. Nursing intervention: 1. Assess patient’s sign and symptom of bleeding such as unexplained bruising, petechia, cold and clammy skin, pale, cynosis, decreased BP. Rational: for early detection and plan an appropriate nursing intervention. Implementation: I assess for sign and symptom of bleeding during physical examination.

2.

Monitor patient’s vital sign such as blood pressure, pulse, respiration and temperature. Rational: decrease in BP and rapid pulse rate may indicate bleeding. Implementation: I check miss L’s vital sign 6 hourly and do documentation. Her vital sign are: Pulse: 110bpm, Blood pressure: 120/76 mmHg. 3. Obtain patient’s blood for laboratory investigation as ordered by doctor such as full blood count and group and cross match. Rational: to monitor patient’s blood count especially platelet. Low platelet count may indicate high tendency of bleeding. Blood for group and cross match is done as preparation for blood transfusion. Implementation: I assist SRN to obtain blood for lab investigation and send the specimen to the lab.

4. Advise patient to rest in bed and avoid vigorous activity such as brush teeth with softly and carefully. Rational: to decrease tendency of bleeding. Implementation: I advise miss L to rest in bed and avoid any activity that will cause bleeding. I advise miss L to brush teeth softly and explain to her the reason. 5. Ensure no anticoagulant medication is served to patient such as aspirin and warfarin. Rational: anticoagulation drugs may increase tendency of bleeding. Implementation: SRN write in the nursing report and pass over to other shift to ensure other SRN are alert. I assist SRN to serve medication and ensure medications are not anticoagulant drug.

Prepare blood transfusion as ordered by doctor. Rational: To replace a deficiency of specific blood components. E.g. pack cell and platelet. Implementation: I prepared the blood transfusion and transfuse the pack cell and platelet for miss L under supervision of SRN.
6.

7. Administer medication antianemics as prescribed by doctor. E.g. Iberet folic 1 tablet BD Rational: to replace iron store needed for red blood cells development. Implementation: I serve medication haemostatic Iberet folic 1 tablet BD as prescribed by Dr. D under supervision of SRN.

8. Inform doctor if any sign and symptom of bleeding is detected. Rational: for further treatment and prompt action can be taken. Implementation: I informed doctor patient has petechia and bruising at the leg. Evaluation: Date: 29th May 2007 Time: 2100 hour Evaluation: Miss L has show sign and symptom of bleeding such as unexplained bruising and petechia. Supporting data:  Miss L verbalized has unexplained bruising.  During physical examination, petechia is detected.

Date: 30th May 2007 Time: 0900 hour Re-evaluation: Miss L’s sign and symptom had reduced after nursing intervention carried out. Supporting data:  Miss L’s bruising had decreased  Miss L’s petechia is reduced. Date: 31st May 2007 Time: 0900 hour Re-evaluation: Miss L’s sign and symptom had reduced during hospitalization. Supporting data:  Miss L’s bruising had decreased  Miss L’s petechia is reduced.

Nursing Care Plan 4
High risk of infection related to low white blood cell count (leucopenia). Date: 29th May 2007 Time: 2000 hour Supporting data:  Miss L’s WBC count is low (3.8 10³/uL) Expected outcome: Short term: Patient will not show any sign and symptom of infection and reduced in risk after nursing intervention carried out. Long term: Patient will not show any sign and symptom of infection during hospitalization.

Nursing intervention: 1. Assess for sign and symptom of infection such as elevated body temperature, sore throat, and itchiness. Rational: act as baseline data and plan an appropriate nursing care plan. Implementation: I assess for any sign and symptom of infection during physical examination. Miss L does not have any sign and symptom of infection. 2. Monitor patient’s vital sign 6 hourly such as temperature, blood pressure, pulse and respiration. Rational: elevated in temperature may indicate body in response with infection. Implementation: I check miss L’s vital sign 6 hourly and do documentation in observation chart. Her vital sign are: Temperature: 36.5 º c, Pulse: 110bpm, Blood pressure: 120/76 mmHg.

3. Serve patient with high protein and vitamin diet such fish, egg, soya and fruits. Rational: to increase body immune system, this may reduce risk of infection. Implementation: I order and serve high protein diet to miss L and encourage her to eat a lot of fruits. 4. Advise patient to maintain personal hygiene such as wash hand before and after do any activity. Rational: good personal hygiene can decrease risk of migration of microorganism and infection. Implementation: I advise miss L to maintain a good personal hygiene and teach her proper method of hand washing.

5. Advise patient’s family member to limit visitor especially who is sick. Rational: to avoid patient expose to infection. Implementation: I advise miss L’s family member to limit visitor and explain to them the reason. 6. Teach patient to recognize sign and symptom of infection and inform SRN or doctor immediately if detected. Rational: for early detection so that prompt action can be taken to avoid complication develop. Implementation: I teach her to recognize the sign and symptom of infection such as elevated body temperature, redness, itchiness, sore throat and so on.

Inform doctor if sign and symptom of infection is detected. Rational: for further treatment and prompt action can be taken. Implementation: I did not inform doctor or SRN because patient doesn’t show any sign and symptom of infection.
7.

Evaluation: Date: 29th May 2007 Time: 2100 hour Evaluation: Patient does not show any sign and symptom of infection. Supporting data:  Miss L body temperature: 36.5 º c

Date: 30th May 2007 Time: 0900 hour Re-evaluation: Miss L does not show any sign and symptom of infection. Supporting data:  Miss L body temperature: 36 º c Date: 31st May 2007 Time: 0900 hour Re-evaluation: Patient does not show any sign and symptom of infection after nursing intervention carried out and during hospitalization. Supporting data:  Miss L body temperature: 36.3 º c  Miss L’s general condition stable  Miss L discharge without any antibiotic medication.

Alteration in comfort: pain related to post procedure puncture site (bone marrow aspiration). Date: 30th May 2007 Time: 1000 hour Supporting data:  Miss L complains of pain at incision site.  Miss L had done bone marrow aspiration. Expected outcome: Short term: Patient will verbalize pain had reduced within 24 hours after nursing intervention carry out. Long term: Patient will verbalize pain had reduced and free from pain during hospitalization.

Nursing Care Plan 5

Nursing intervention: 1. Assess patient’s level of pain by using pain scale 0-10 and characteristic of pain such as severity, location, duration and type. Rational: to determine characteristic of pain and plan a proper nursing intervention. Implementation: I assess miss L’s characteristic of pain by asking her question and use pain scale. Her pain scale is 2 (mild). 2. Monitor patient’s vital sign hourly until stable and continue with 6 hourly. Rational: to act as baseline and comparison data. Increase in blood pressure and pulse may indicate pain. Implementation: I check miss L’s vital sign hourly until stable and continue with 6 hourly and do documentation. Her vital sign are:

Respiration: 20/min, Pulse: 80bpm, Blood pressure: 110/70 mmHg. 3. Advise patient to complete rest in bed and put patient in supine position for 6 hours. Rational: to give pressure on the incision site and prevent bleeding. Reduce in movement may reduce pain. Implementation: I put miss L in supine position and ask her to complete rest in bed for 6 hour post procedure. 4. Teach patient the correct method of deep breathing exercise (DBE). Rational: DBE can relax muscle and improve breathing pattern. Implementation: I taught her to inhale through the nose until the end and hold the breath as long as she can, then exhale through the mouth (purse lips).

5. Provide divertional therapy such as switch on the television, newspaper, encourage patient to chat with other patient. Rational: to divert patient’s mind from thinking of the pain. Implementation: I switch on the television for miss L to watch. 6. Inform doctor if pain still persist or worsen. Rational: for further treatment and prompt action can be taken. Implementation: I did not inform doctor or SRN because patient verbalized pain had reduced.

Evaluation: Date: 30th May 2007 Time: 1400 hour Evaluation: Miss L verbalized pain had reduced after nursing intervention carried out. Supporting data:  Miss L verbalized pain had reduced.  Miss L’s vital sign show normal. BP: 100/65mmHg, PR: 70bpm

Date: 31st May 2007 Time: 0800 hour Re-evaluation: Miss L verbalized pain had reduced and able to tolerate with the pain. Supporting data:  Miss L verbalized able to tolerate with the pain.  Miss L general condition is stable.  Miss L vital sign is normal. BP: 110/70mmHg, PR: 85bpm

Nursing Care Plan 6
Potential bleeding related to post procedure puncture site (bone marrow aspiration). Date: 30th May 2007 Time: 1000 hour Supporting data:  Patient had done bone marrow aspiration.  Patient diagnosed as aplastic anemia. Expected outcome: Short term: Patient will not show any sign and symptom of bleeding during 1st 24 hours after nursing intervention carried out. Long term: Patient will not show any sign and symptom of bleeding during hospitalization.

Nursing intervention: 1. Assess patient’s general condition such as clammy skin, cynosis, pale, tired and low blood pressure. Rational: to act as baseline data and plan an appropriate nursing intervention. Implementation: I assess miss L’s general condition and her condition was stable. 2. Monitor patient’s vital sign hourly until stable and continue with 6 hourly. Rational: decrease in blood pressure and pulse may indicate bleeding. Implementation: I check miss L’s vital sign hourly for 6 hour and continue with 6 hourly. I do documentation in the observation chart. Blood pressure: 110/70mmHg, Pulse: 80bpm

3. Observer patient’s dressing site for sign and symptom of bleeding such as fresh blood stain. Rational: to detect sign and symptom of bleeding and prompt action can be taken. Fresh blood stain may indicate bleeding. Implementation: I observe miss L’s dressing site for any blood stain during hourly observation. 4. Position patient in supine position for at least 6 hours. Rational: to apply pressure at incision site to reduce risk of bleeding. Implementation: I position miss L in supine position for at least 6 hours to reduce risk of bleeding.

5. Advise patient to complete rest in bed for at least 6 hours. Rational: reduce in movement or mobilization may minimize risk of bleeding. Implementation: I advise miss L to complete rest in bed and give the call bell to her to call nurse if need help. 6. Ensure no anticoagulant medication is served to patient such as aspirin and warfarin. Rational: anticoagulation drugs may increase tendency of bleeding. Implementation: SRN write in the nursing report and pass over to other shift to ensure other SRN are alert. I assist SRN to serve medication and ensure medications are not anticoagulant drug.

7. Obtain patient’s blood for laboratory investigation as ordered by doctor such as full blood count. Rational: to monitor patient’s blood count. Low blood count may indicate bleeding. Implementation: I assist SRN to obtain blood for lab investigation and send the specimen to the lab. 8. Administer medication antianemics as prescribed by doctor. E.g. Iberet folic 1 tablet BD Rational: to replace iron store needed for red blood cells development. Implementation: I serve medication haemostatic Iberet folic 1 tablet BD as prescribed by Dr. D under supervision of SRN.

Administer medication Haemostatics as prescribed by doctor. E.g. Transamin 1 tablet TDS. Rational: To reduce the tendency of bleeding and prevent hemorrhage. Implementation: I administered medication Transamin to miss L under supervise by staff nurse.
9.

10. Inform doctor if sign and symptom of bleeding is detected. Rational: for further treatment and prompt action can be taken. Implementation: I did not inform doctor or SRN because sign and symptom of bleeding not detected.

Evaluation: Date: 30th May 2007 Time: 1100 hour Evaluation: Patient did not develop sign and symptom of bleeding after nursing intervention carried out. Supporting data:  Miss L’s dressing site does not show fresh blood stain.  Miss L’s vital sign is stable: BP: 100/60mmHg, PR: 80bpm.  Miss L general condition is stable.

Date: 30th May 2007 Time: 1200 hour Re-evaluation: Patient did not develop sign and symptom of bleeding after nursing intervention carried out. Supporting data:  Miss L’s dressing site does not show fresh blood stain.  Miss L’s vital sign is stable: BP: 100/65mmHg, PR: 70bpm.  Miss L general condition is stable.

Date: 30th May 2007 Time: 1400 hour Re-evaluation: Patient did not develop sign and symptom of bleeding after nursing intervention carried out. Supporting data:  Miss L’s dressing site does not show fresh blood stain.  Miss L’s vital sign is stable: BP: 110/65mmHg, PR: 65bpm.  Miss L general condition is stable.

Date: 31st May 2007 Time: 0800 hour Re-evaluation: Patient did not develop sign and symptom of bleeding after nursing intervention carried out and during hospitalization. Supporting data:  Miss L’s dressing site does not show fresh blood stain.  Miss L’s vital sign is stable: BP: 110/70mmHg, PR: 85bpm.  Miss L general condition is stable.  Miss L’s dressing had removed.  Miss L can be discharge.

Nursing Care Plan 7
Potential infection related to post procedure puncture site (bone marrow aspiration). Date: 30th May 2007 Time: 1000 hour Supporting data:  Patient had done bone marrow aspiration.  Patient diagnosed as aplastic anemia. Expected outcome: Short term: Patient will not show any sign and symptom of infection during 1st 24 hours after nursing intervention carried out. Long term: Patient will not show any sign and symptom of infection during hospitalization.

Nursing intervention: 1. Assess for any sign and symptom of infection such as redness, itchiness, elevated body temperature. Rational: for early detection and plan a proper nursing intervention. Implementation: I assess for sign and symptom of infection during hourly observation. Miss L does not show any sign and symptom of infection. 2. Monitor patient’s vital sign especially temperature for hourly until stable and continue with 6 hourly. Rational: elevated in body temperature may indicate body response to infection. Implementation: I check patient’s vital sign hourly for 6 hour and continue with 6 hourly. I do documentation in the observation chart. Vital sign: Temp: 37 º c

3. Observe patient’s dressing and puncture area. Rational: dressing show oozing may indicate infection occur. Implementation: I observe miss L’s dressing site for oozing. Miss L dressing is intact. 4. Provide patient high in protein and vitamin diet such as fish, egg, vegetable and fruits. Rational: high protein and vitamin diet may enhance healing process. Implementation: I ordered high in protein and vitamin diet for miss L and encourage her to eat more fruits.

5. Advise patient not to touch the puncture site unnecessary. Rational: to avoid microorganism transmit to the puncture site which may lead to infection. Implementation: I advise miss L not to touch her puncture site. 6. Advise patient not to apply any traditional medicine or powder to the puncture site. Rational: to reduce risk of infection. Implementation: I advise miss L not to apply any traditional medicine or powder at the puncture site and explain the reason to her.

7. Inform doctor if sign and symptom of infection is detected. Rational: for further treatment and prompt action can be taken. Implementation: I did not inform doctor or SRN because miss l does not develop any sign and symptom of infection. Evaluation: Date: 30th May 2007 Time: 1100 hour Evaluation: Patient does not show any sign and symptom of infection within 24 hours after nursing intervention carried out.

Supporting data:  Vital sign patient is normal: temperature: 36.8 º c  Miss L’s dressing does not show oozing. Date: 31st May 2007 Time: 1000 hour Re-evaluation: Miss L does not develop any sign and symptom of infection after nursing intervention is carried out and during hospitalization. Supporting data:  Temperature miss L was normal: 36 º c  Dr. D had seen miss L and remove her dressing.  Miss L can be discharge.

Health Education
Health education that will be given to Miss L is about how to detect sign and symptom of infection and bleeding. Diet Exercise Medication Follow up

Date of discharge: 31st May 2007 Miss L was discharge on 31st May 2007 after seen by Dr. D during his morning ward round. Before miss L discharge, I reinforce about the health education that I had given before regarding to her disease. It includes diet, type of exercise that she can do medication and follow up. When the bill was ready, I asked her to pay at billing department and then come back to the ward to take her TTA medication to continue her treatment at home. Her TTA drugs are:  Iberet Folic 1 tablet BD  Transamin 1 tablet TDS Appointment selected 1 week after discharge, that is on 7th June 2007 and the card is given.

FOLLOW UP
The day before follow up, I had called miss L to remind her that tomorrow, 7th June is her follow up day. Unfortunately, her sister answered the call and told me that she is admitted to Hospital at Skudai since 5th June 2007. She said that tomorrow she will be discharge and will try her best to come for follow up. On the day of follow up, Miss L did not show up. Her mother had called and said that she will continue treatment at Singapore.

My patient, Miss L, 20 years old Chinese girl was admitted to Puteri Specialist Hospital on 29th May with complain of shortness of breath, unexplained bruising at the leg, palpitation and headache. Miss L was seen by Dr. D and diagnosed as query pancytopenia to rule out aplastic anemia. During admission, her vital sign are temperature: 36.5 º c, pulse: 110 bpm, blood pressure: 120/76mmHg, respiration: 24/min. Miss L does not have any medical and surgical history. She had family medical history of Aplastic anemia (mother). Miss L does not have any allergic reaction.

Dr. D had ordered few blood test for Miss L. On the day of admission, Dr. D had ordered 2 pint of pack cell and 2 pint platelet. On the 30th May, Dr. D had done bone marrow aspiration. For Miss L’s treatment, Dr. D prescribed Transmin 1 tablet BD and Iberet Folic 1 tablet TDS for her. Dr. D discharges Miss L on 31st May 2007, her TTA are Transamin 1 tablet TDS and Iberet Folic 1 tablet BD. Her follow up is 7th June 2007. On the follow up day, Miss L does not show because she continue her treatment at Singapore.

        

Suzanne C.Smeltzer, Brenda Bare (2004) Brunner & Suddarth’s Textbook of MEDICAL-SURGICAL NURSING, 10th ed. United States, Lippincott Williams &Wilkins. Pg867-886 Lemone.P,Burke.K (2004)Medical-Surgical Nursing, 3rd ed.United States, Pearson Education. Pg941-943 Elizabeth A.Martin (2004) Dictionary of Nursing, Malaysian Edition, pg31 MIMS, Malaysia Index of Medical Specialites. Volume 33 Number 2 (2004) MIMS, 102nd Edition (2005), Malaysia.DIMS Linda Skidmore-Roth (2006) Mosby’s NURSING DRUG REFERENCE. http://www.emedicine.com/med/topic2971.htm http://www.ncbi.nlm.nih.gov-www.pubmed.gov http://MedlinePlus/Medical Encyclopedia/ Secondaryaplasticanemia_files.htm http://Wikipedia.htm

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer for students: Only $4.99/month.

Master Your Semester with a Special Offer from Scribd & The New York Times

Cancel anytime.