Case Study

CASE PRESENTATION OF

Iron Deficiency Anemia

INTRODUCTION Ms. Y is a 24 year old female residing at San Miguel, Tarlac City. Ms. Y’s family

has a heredo familiar disease which is diabetes. She had undergone some test, & they discovered that she is most likely to have diabetes. But then, she claimed to have taken some medications to avoid having diabetes. She also claimed to have a of polymenorrhia history which is the main reason for consulting her attending physician for several occasion & finally sought admission for diagnosis.

Anemia is a condition in which the hemoglobin content of the blood is below normal limits. It may be hereditary, congenital or acquired. Basically, anemia result from a defect in the production of hemoglobin & it’s carries the red blood cell. The most common cause is a deficiency in iron, an element necessary for the formation of hemoglobin. Symptoms vary with the severity & cause of the anemia but may include fatigue, weakness, pallor, headache & anorexia. Treatment also depends on the cause & severity & may include an iron-rich diet, iron supplement, blood transfusion & the correction or elimination of any pathological conditions causing the anemia.

Final diagnosis Iron Deficiency Anemia.

OBJECTIVES

Establish rapport and gain the trust and cooperation of the patient and immediate family members, perform and obtain thorough and complete physical assessment using the assessment techniques following the cephalocaudal approach, obtain complete medical, socio-cultural, and family history related to the patient’s current health condition. Analyze and prioritize problems based from the gathered pertinent data to come up with the correct nursing diagnosis and plan appropriate nursing care. Provide health teaching to modify behavior and to incorporate learning.

NURSING PROCESSNursing Health History A

Demographic DataPatient: Ms. Y

Date: August 1,2009 Ward: Female Surgical Ward Bed: E. #246

Age: 24 y/o Sex: F Religion: Catholic

I. Chief CompliantPallor

II. History Of Present Illness

Patient has chronic history of pallor not relieved by ferrous sulfate & recormion, advised Blood Transfusion prior to admission

III. Past Medical History (include dates and complications, if any)

A. Pediatric and Adult IllnessMumps: Pertussis: HPN:Measles: Rheumatic: Heart Disease:Chicken Pox: Pneumonia: Hepatitis:Rubella: Tuberculosis: Others:

B. Immunizations/TestBCG: HEPA B: For Pneumonia:DPT: Measles: Others:OPV: For Flu:

C. Hospitalizations Ms. Y has been hospitalize two times 1st – April 2, 2008

Pregnancy uterine 7 months delivered by CS to an alive baby girl. Hydropz fetalis bilateral ovarian cyst wedge resection of both ovaries.

• 2nd – August 1, 2009 Iron Deficiency Anemia

D. InjuriesNo history of injuries

E. TransfusionsMs. Y had Blood Transfusion with the current hospitalization.

G. Obstetrics/Gynecologic History

G=1 T=0 P=1 A=0 L=0 M=0

Last April 5,2008 Ms. Y had undergone surgical operation because of pregnancy uterine 7 months delivered by CS to an alive baby Girl. Hydropzfetalis, Bilateral Ovarian Cyst Wedge resection of both ovaries G1P1.

H. MedicationsThe patient take Hemostan prior to menstruation and ferrous sulfate as Iron Supplement

I. AllergiesThe patient had history of hypersensitivity reaction to a cosmetic preparation

IV. FAMILY HISTORY

Age List: Parents, Spouse, Children Health Status or cause of

death

Disease Present in the family

L D

Mr. N CL Hypertension

Mrs. S C L Hypertension

Mr. C C L

Ms. C C L

Ms. Y L

V. Social And Personal History

Birth Place: Tarlac Birth Date: Feb. 5, 1985

Education: College Graduate Ethnic Background: Tagalog, Ilocano, Kapampangan

Age And Sexes of Children (if any): None

Client’s position in the family: Second Child/middle child

ResidenceHome Environment: Their house is made of concrete structure and located along the highway and

it surrounded by tree.

Occupation:Nature of present occupation: She is a trainee in a telecom company.

Financial Support System: Ms. Y is sustented by her brother who is an engineer.

Habits: Texting, Watching T.V. & Surfing the internet

Physical Activity/Exercise, if any: She considered walking as her form of exercise.

Brief Description of average day: She woke up at 5:00AM to cook her food then she prepare her things, at 9AM she go to work until 10PM.

General Description

Weight Loss: Anorexia:

Height Sweats: Weakness:

Skin:

Itch: Bruising:

Rash: Bleeding:

Lesions:

Eyes:

Pain: Itch: Vision Loss:

Diplopia: Blurring: Excessive Tearing:

Glassess/Contact Lenses:

Ears:

Earaches: Discharge: Tinnitus: Hearing Loss:

Nose:

Obstruction: Epistaxis: Discharges:

Throat and Mouth:

Sore Throats: Bleeding Gums: Toothaches: Decay:

Neck:

Swelling: Dysphagia: Hoarseness:

Chest:

Cough: Sputum: Hemoptysis:

Wheeze: Pain on Respiration: Dyspnea: Rest/Exertion

Breast: Lumps: Pain: Bleeding: Discharge:

VI. Review of System

Fatigue

Color Change: Slightly Pallor

CVS:Chest Pain: Palpation: Dyspnea on exertion edema:PND: Orthopnea: Others:

GIT:Food Tolerance: Heartburn: Nausea: Excessinve Gas: Vomiting: Pain: Bloating: Constipation: Change in BM: Melena:

GU:Dysuria Nocturia Retention Polyuria DribblingHematuria: Flank PainMale: Penile Discharge Lesion Testicular Pains:Others:Female: Menarche 10 y/o LMP: July 6, 2009 Cycle: Others:

Extremities:Joint Pains: Claudication:Edema: Stiffness: Deformities:

Neuro:Headaches: Memory loss Fainting:Numbness tingling: Paralysis: Paresis: Seizures: Others:

Mental Health Status:Anxiety Depression: Insomnia: Sexual Problems: Fears:

Varicose Veins:

Dizziness:

NURSING HEALTH HISTORY BA. General Description of Client

Ms. Y appears pale & weak, but despite of that she was able to cooperate with us.

B. Health Perception – Health Management Pattern

Ms. Y stated that health is really essential for every one of us & then, she added that she was hoping that she could still achieve the optimum or excellent state of health.

Ms. Y said that whenever she feels bad or if there’s a presence of signs & symptoms of any illness or diseases, she urgently seeks for help to medical personnel. It’s because she know that they are the people where we could entrusted our health & well-being. And not by means of any faith healers.

C. Nutritional – Metabolic Pattern

Ms. Y said that she’s not fond of eating green leafy vegetables & also she was not taking vitamins such as those vitamins that rich in iron.

D. Elimination Pattern

Ms. Y said that she was voiding 3-4 times daily & she has a normal bowel habits, & it was about 1-2 times a day.

E. Activity – Exercise Pattern

She has a sedentary lifestyle, texting, surfing the internet & watching T.V are among her daily habits, then she was walking every morning as her daily exercise.

F. Sleep – Rest Pattern

She said that she do not have adequate sleep/rest, that she was stay up late at night & she always had her sleep with in 5 hours most of the time.

G. Cognitive – Perceptual Patter

She was able to follow any direction & answer promptly if what is being asked.

H. Self Perception – Self Concept PatternShe handled her problems systematically with the help of her mother. Her mother is a nurse, so whenever she is ill, she always promptly asked her mother about it.

I. Role – Relationship Patter

Menstrual History:

Age of Menarche: 10 yrs. Old

She verbalized that her menstrual cycle was only 26 days lasted for 7 days and she was not using any

contraceptives.

She was the second daughter & also she was the middle child of their family she consider her self as a good daughter to her

parents. She added that they were have a good & intact relationship within their family.

J. Sexuality – Reproductive Pattern

She got pregnant before, then she had undergone surgical operation because of pregnancy uterine premature delivered by CS

to an alive baby girl. Hydropsfetalis, bilateral ovarian cyst wedge her section of both ovaries. Unfortunately her baby died.

K. Coping – Stress Tolerance Pattern

She said that whenever she was down & depressed, her family was the one that who could support & help her to cope up with

her situation. She divert her attention on surfing the internet.

L. Value – Belief Pattern

She is Roman Catholic & she has a strong faith in God. She was attending mass every Sunday, regarding health management

she believed that the medical personnel are the people who are among that we should entrusted our health and well being &

not by means of any means of faith healers.

Physical ExaminationGeneral Survey:

Height: 5’5 Weight: 72 kg Body Make Up: Medium

Skin color: Clear complexion Turgor: none Bruises: None

State of Hydration: None

Eyes:Sclera: Bulbar conjunctiva is clear with tiny vessel visible

Pupils:

Respiratory: In Distress No Distress

Vital Signs:

HR: 78 /minute Temperature: 36.5 Degree Celsius

BP Supine R/L arm: 90/60mmHg Capillary Refill:

RR: 20

Body Position/Alignment

Fowlers: Semi-Fowlers: Others:

Alignment: Appropriate Inappropriate

Mental Acuity:

Coherent Appropriate responsive Others:

Disoriented Incoherent Inappropriate responsive

Sensory/Motor Restrictions:

Amputation Deformity Paresis Paralysis Others:

Gait Hearing Disorder Speech Fracture

Emotional Status:

Euphoric Depressed Apprehensive

Angry/Hostile Others:

Medically Imposed Restrictions:

CBR without BRP: OOB chair: Restricted Ambulation:

Easy Breathing:

Supine

Oriented:

BR with BRP:

Other Health Related Patterns:

Fatigue: Restlessness: Weakness: Insominia: Coughing:

Dyspnea: Dizziness: Pain: Others:

Environment:

Room Temperature: Inadequate

Lighting: Inadequate

Safety:

Violations of medical asepsis:

Violations of safety measures:

Activities of Daily Living:

Can performFeeding Brushing teeth Bath Transferring

Dressing combing

Adequate

Adequate

PATHOPHYSIOLOGY

Inadequate sleep pattern, inadequate iron intake. Inadequate intake of foods

rich in iron

Fatigability, waxy pallor, polymenorrhea, sores in the corners of the mouth.

Prior to Hospitalization

Complete Blood Count (CBC), Urine Analysis

RBC, HGB, Platelet, MCV, MCH & MCHC decrease to its normal

level

Lead to low hemoglobin and hematocrit, decrease iron stores and low serem iron and

ferritin. The RBC decreased in number

Iron-Deficiency

PLANNING Nursing Care Plan

Cues Diagnosis Scientific Explanation

Planning Nursing Intervention

Rationale Evaluation

Subjective:Ok naman ako medyo maputla lang ako ngayon at di pa ganun

kalakas.

Objective:Pale

Dry LipsBP: 90/60

CBC:

RBC: 2.5 HGB: 10.5 MCV: 67.2 MCH: 20.6 McHc: 30.6

Activity intolerance related to

inadequeate blood

component

Inability of red bone marrow to

produced red blood cells

Decreased O2

carrying capacity of body

Inadequate

supply of O2 in the Body

Activity

intolerance(Body

Weakness)

After 2 hours of nursing

intervention the patient BP will increase from

90/60 to 110/80.

Monitor V/S, watch for the

changes in blood pressure.

Note skin pallor & cyanosis

Adjust activities, reduced intensity

level or discontinue

activities that cause desired physiologic

changes.

Plan care with rest periods

between activities.

Provide as a baseline data

To prevent over exertion

To reduce

fatigue

After the end of nursing

intervention the patient blood

pressure increased from 90/60 to 110/80

Cues Diagnosis Scientific Explanation

Planning Nursing Intervention

Rationale Evaluation

Subjective:Eto for discharge na daw ako, Sabi ng OB ko at hind na din ako ganun kaputla. Objective:Good ConditionV/S – normal

Readiness for enhance comfort related to therapeutic regimen

The patient is now ready for to go home for therapeutic regimen

After 1 hour of health teaching the patient will have knowledge on how to develop her lifestyle

Verify clients level of knowledge/ understanding of therapeutic regimen and note specific goals Identify steps necessary to reach desired health Goads. Accept patient evaluation of own strengths/limitations while working together to improve abilities.

Provides opportunity to assure accuracy & completeness of knowledge base for future learning Understanding the process enhance commitment & the like hood of achieving the goals Promote sense of self-esteem & confidence to continue efforts

After the end of the health teaching the patient have the knowledge on how to develop her lifestyle

Drug study Drug Name Classification dosage Action Indication Contraindicati

onSide-effect Adverse

reactionNursing

responsibilities

Iberet Vitamins &/or Minerals

500mg tab od Iberet used in the treatment

of anemia.

Prevention & treatment of nutritional

anemia; supplement for

physical & mental

abilities; & for maintenance of optimum

health.

Patients w/ thalassemia, sideroblastic anemia, hemochromatosis & hemosiderosis. Repeated blood transfusion or parenteral Fe therapy, intestinal diverticula or intestinal obstruction. Liver disease or active peptic ulcer, arterial hemorrhaging or severe hypotension.

Black stool discoloration.

Allergic reactions, GI effects, hepatic dysfunction w/ abnormal liver function tests, hyperbilirubinemia, deterioration of acne form vulgaris or eruption of acne form exanthema, bright yellow urine discoloration, flushing, peripheral sensory neuropathies, stone formation, crystalluria, oxalosis.

-The nurse Should

administer this drug to the

patient with an empty

stomach (Best taken between meals. May be taken w/ meals

to reduce GI discomfort.).

-Instruct the patient to

report signs of adverse reaction

Drug Name Classification dosage Action Indication Contraindication

Side-effect Adverse reaction

Nursing responsibilities

antamin Antihistamines &

Antiallergics

1cc, IM 30 min. prior to

BT.

Compete with histamine for #1 receptor

site on effect or cells;

decreases allergic

response by blocking histamine

Allergy, allergic rhinitis,

bronchial asthma,

vasomotor rhinitis,

dermatoses of allergic

etiology, urticaria, drug sensitization,

serum sickness,

anaphylactic shock, insect

bites.

Lower resp tract disease. Newborn or premature

infants.

Open- & closed-angle glaucoma. Prostatic

enlargement. Avoid

operating vehicles or machinery.

Hypersensitivity, CV

diseases, cardiac

arrhythmias, HTN,

hyperthyroidism,

pheochromocytoma, diabetes.

Sedation, lassitude, elation or

depression, irritability, paranoid

psychosis, delusion,

hallucination. Muscular weakness,

incoordination. GIT

disturbances. Headache, tinnitus.

Difficulty in micturition. CV effects.

-Check for BT before giving

this drug.

-Keep this

product, as

well as

syringes and

needles, out of

the reach of

children and

away from

pets. Do not

reuse needles,

syringes, or

other

materials.

Drug Name Classification dosage Action Indication Contraindication

Side-effect Adverse reaction

Nursing responsibilities

Hemostan Haemostatics 1 tab In the first to third day of menstruation.

Inhibits breakdown of fibrin clots. It acts primarily by blocking the binding of plasminogen & plasmin to fibrin; direct inhibition of plasmin occurs only to a limited degree.

Menorrhagia/menometrorrhagia.

Not advisable to use for prolonged periods in patients

predisposed to thrombosis.

Not recommended

for prophylaxis

during pregnancy &

before delivery.

GI disorders, nausea, vomiting, anorexia, headache may appear, impaired renal insufficiency, hypotension when IV inj is too rapid.

-Instruct the patient that May be taken with or without food.-Instruct the patient to report signs of adverse reaction

Patient: Ms. Y

Physician: Dr. M J L

Age: 24

Sex: Female

Date & Time: 8/1/2009

Routine Blood Count [RV]

WBC 7.7 4-10

RBC 2.5 (M) 4.5 – 5.5; (F) 3.8 – 4.8

HGB 10.5 (M) 13.0 – 17.0; (F) 12.0 – 15.0

HCT 40.2 (M) 40 – 50; (F) 36 - 46

MCV 67.2 83 – 99 FL

MCH 20.6 27.0 – 32.0 PG

MCHC 30.6 31.5 – 34.5 G/DL

Platelet 139 150 - 400

MPV 8.6 6.5 – 11.0 um3

Lymphocytes % 19.4 20 – 40

MXO % 8.3 2 – 10

Neutrophiles % 72.3 40 – 80

Lymphocytes # 1.5 1 – 3

MXO # 0.6 0.2 – 1

Neutrophiles # 5.6 2.5

LABORATORY RESULT

Patient: Ms. YPhysician: Dr. M J LAge: 24Sex: FemaleDate & Time: 8/2/2009

Routine Blood Count [RV]

WBC 7.7 4-10

RBC 5.98 (M) 4.5 – 5.5; (F) 3.8 – 4.8

HGB 12.3 (M) 13.0 – 17.0; (F) 12.0 – 15.0

HCT 40.2 (M) 40 – 50; (F) 36 - 46

MCV 83.5 83 – 99 FL

MCH 28.1 27.0 – 32.0 PG

MCHC 32.2 31.5 – 34.5 G/DL

Platelet 409 150 - 400

MPV 8.6 6.5 – 11.0 um3

Lymphocytes % 28.3 20 – 40

MXO % 8.3 2 – 10

Neutrophiles % 72.3 40 – 80

Lymphocytes # 1.5 1 – 3

MXO # 0.6 0.2 – 1

Neutrophiles # 5.6 2.5

METHODMedication: Iberet 500mg daily once a day for 1 week Antamin 1cc IM 0 min prior to BR Hemostan 500mg capsule 3 times a day on her 1st 3 days of menstruation Iron Follic as iron supplement

Exercise: Relaxation Technique

Treatment: Take medicine such as multivitamins to restore energy & ferrous sulfate as iron supplement

Health Teaching: Advise patient to increase dietary intake of iron such as meat, green leafy vegetable.

OPD: The patient will be back for follow up check-up on August 8, 2009 around 10:30AM at

CLDH San Vicente.

Diet as Tolerated: Instruct the patient to eat nutritious foods rich in iron, meat & green leafy vegetables

Social Activity: Encourage to socialize with friends and significant to others.

PHYSICAL EXAMINATION FINDINGS

PHYSICAL EXAMINATION

Observed the client over all

Mental Status

BODY PARTS METHOD USED ACTUAL FINDINGS NORMAL FINDINGS

Hygiene and grooming Inspection Tidy Clean and neat

Note for body odor Inspection No body odor No body odor

Note obvious signs of health

illness

Inspection Slightly Weak Healthy appearance


Assess the client’s altitude Inspection Cooperative Cooperative

Listen for quantity & quality

of speech

Inspection Understandable moderate

pace

Understandable moderate

pace

Skin


Color Inspection Brown skinLight to deep brown; from pink to light pink; from yellow overtones to olive

Lesion Inspection Absence of lesions No abrasions and/or lesions

Moisture Inspection/palpation Moisture in skin folds & axillae Moisture in skin folds and axillae

Temperature Palpation Normal or within normal range Uniform, within normal range

Turgor Palpation Normal skin turgor When pinched, skin returns to

previous state

Hair


Distribution Inspection/Palpation Evenly distributed hair Evenly distributed hair

Texture Inspection/Palpation Smooth, thin Smooth, thin

Lice Inspection/Palpation Absent Absent of capitis, pubis &

corporis

Color Inspection Black hair Depends upon the age and race

Nails


Curvature & Angle Inspection Convex curvature Convex shape, about 160 degress

Bed color Inspection Pale in color Highly vascular & pink

Capillary refill Palpation Normal Prompt return of usual

Head


Skull size, shape & symmetry Inspection/Palpation Round shape, normal size Rounded, smooth skull contour

Masses & Depressions Palpation No deformities, no presence of

mass/lesions

Smooth, uniform consistency,

absence of nodule masses

Facial features Inspection Slightly symmetric Symmetric/Slightly symmetric

Facial movement Inspection Symmetric facial movement Symmetric

Eyes


Eyebrows Inspection Symmetric & aligned, hair evenly

distributed

Hair evenly distributed, skin

intact eyebrows symmetrically

aligned, equal movements

Eyelids surface & characteristics Inspection Pale Skin intact, no discharge, no

decolonization

Ears


Hearing Percussion Sound is heard on both ears Sound is heard on both ears

Nose


Shape, size Inspection Symmetric Symmetric and straight

Color Inspection Same as facial skin Same as facial skin

Flaring and discharge Inspection Each nostril is patent No Discharge or flaring

Texture Palpation Not tender No tenderness

Mouth


Lips Inspection Asymmetrical Asymmetry of contour

Color Inspection Pallor Uniform pink color, darker

Texture Palpation Soft, dry Soft, moist, smooth in texture

Tongue Inspection Moves freely Moves freely

Neck


Muscle Palpation Muscle equal inside, head

centered

Muscle equal inside, head

centered

Movement Inspection Slightly weak movement Coordinated, smooth movement,

with no discomfort

Thorax


Shape Inspection/Palpation Chest Symmetric Chest Symmetric

Breath sounds Auscultation Broncho-vesicular breath sounds Vesicular and bronchovesicular

breath sounds

Abdomen


Skin integrity Inspection With stretch marks & linea negra

where evident

Umblemished skin, uniform in

color

Contour and symmetry Inspection & Palpation Flat Abdoment Flat, rounded or scaphoid

Bowel sounds Auscultation Normal bowel sounds Normal bowel sounds

Texture Palpation No tenderness No tenderness

Musculoskeletal SystemMuscle

Lower Extremities


Size Inspection Equal on both sides of the body Equal on both sides of the body

Strength Inspection Equal on both sides Equal on both sides


Legs, size, shape, and presence of

lesion

Inspection No Presence of rashes,

symmetrical in size shape

Symmetrical in size and shape

Vital Signs

Temperature Inspection 36.5° C 36.5° C – 37.5°C

Pulse Rate Palpation 78 beats/minute 60-100 beats/minute

Respiratory Rate Inspection 20 beats/minute 16-20 beats/minute

Blood Pressure Auscultation 90/60 mmHg 120/80 mmHg

COURSE IN THE WARD DOCTOR’S ORDER

August 1, 2009

The patient was admitted to Dr. M J L. The patient was ordered to secure consent prior to blood transfusion & also the doctor ordered complete blood count & urine analysis

August 2, 2009

The doctor ordered blood transfusion and CBC should be repeat 6 hours after blood transfusion and the doctor also ordered a diet as tolerated.

August 3, 2009

The doctor ordered MGH if stable and IBERET 500mg once a day after dinner.

Evaluation

Gain knowledge about the disease process, performed and obtained thorough and complete physical assessment. Planned the appropriate nursing interventions to let the patient meet her

needs.

Recommendation

We advised patient to increase dietary intake of iron together with the advised Iron capsule supplements. To have adequate sleep & to monitor the amount of blood loss during

menstruation by counting the sanitary napkin used in a day.

THANK YOU

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