Criteria:

Introduction and Objectives Personal Data and Health History Development Data Definition of Diagnosis Physical Assessment Anatomy and Physiology Pathophysiology Drug Study Diagnostic Exam Surgical-Medical Management Discharge Plan Promptness References Format

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RATIONALE
Life nowadays is full of surprises. There are days that man feels happy, and there are also days that man feels sad. Life isnt perfect for all we know, however man still preserve to survive surpasses that life has brought about. Challenges are parts of mans life. Without this, life isnt challenging and worth living for. As part of being a man who lives his life the way he wanted to be, man experiences difficulties. Losing a job, having no money to spend and having no food to eat are the major difficulties that man can encounter in his life. Above all these difficulties, physical problems such as getting sick is also a challenge to man. If man gets sick, he is unable to perform his duties and responsibilities. Hepatitis B is a potentially life-threatening liver infection caused by the hepatitis B virus. It is a major global health problem and the most serious type of viral hepatitis. It can cause chronic liver disease and puts people at high risk of death from cirrhosis of the liver and liver cancer. Hemolytic anemia is the destruction of red blood cells due to several factors. In this rotation, we are assigned in St. Lukes Ward of San Pedro Hospital to be able to have an assessment on patients with Fluids and Electrolytes. During our exposure, the group had difficulties of finding patients having diseases related to fluids and electrolytes. Due to the limited time, the group decided to look for other patient to be the subject of our case study with the approval of our clinical instructor. Thats why, the group finally decided to choose Mr. N.A., 45 years old as the subject of this case study. He has been diagnosed of having Hepatitis B infection and Hemolytic Anemia. With his condition, the group perceives it as an interesting topic for the case study. We have recognized that with the clients present condition, we are able to make use of our learnings in our NCM concepts specifically on how we can deal with the needs of his condition. The clients condition is challenging because it motivates us to find suitable interventions that should be rendered in order to achieve optimal health.

Based on research, according to the World Health Organization, statistical reports on Hepatitis B infection worldwide is about 2 billion people. In the Philippines, there are about 480,000 people affected in an 86 million population estimated used with
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this condition. On Hemolytic anemia, according to curereaserch.com, statistics show that there are approximately 1 in 80,000 cases to 2.6 per 100,000 people are affected worldwide. In the Philippines there are about 1,100 people affected in an 86 million population estimated used with this condition.

For the nursing profession, there are constant changes in the approaches to every disease. Many are still exploring improved ways to care for our patients and to attend to their needs. In view of this pursuit, this study will provide supplementary awareness to elevate the steadfastness of this vocation and to comprehend the ongoing mission of giving true service to the sick. Furthermore, the nursing education will be served as this study is a clear view of how the hospital setting operates with regard to providing total care. This will convey the actual situation in medical institutions to be integrated in the theories that are being taught to the students. This will be a source of illustrating real-life situations for nurses. Lastly, for the nursing practice, this case study will not just be of help to us but most of all to the succeeding student nurses who are still a long way at becoming skillful and equipped nurses, for there should be a balance between what we know and what we are capable to do in order to have a harmonious delivery of care, there should be a continuous and equivalent struggle to yearn for both greater knowledge and better skills.

OBJECTIVES
General Objective: Generally, we, the BSN 3A Group 2 subgroup 1, students aim to the impart to the reader, students and professional nurses, a thorough and further understanding of the diseases, Hepatitis B infection and Hemolytic anemia through learning its disease process and managements and specifically aim to: Specific Objective: The group specifically aims to: Select an interested and cooperative patient in the area of exposure as subject for the case study; establish a trusting relationship with the client and her significant others; use different therapeutic communication skills for better gathering of data; organize systematically all essential information and observations that would serve as a baseline data; come up with an introduction that would give the reader a better overview of our clients case; identify the studys contribution in the field of nursing research, nursing education, and nursing practice. formulate a specific, measurable, attainable, realistic and time bounded objective that will serve as a guide for the accomplishment of our case study. present a sensible personal data with corresponding information which will show his relationships to his family and relatives; present a concrete summary of both the past and present health history; provide a reliable definition of the patients complete diagnosis. identify the clients developmental stage and compare the tasks attained by the client and expected task to be achieved; conduct a cephalocaudal physical assessment;

present the anatomy and physiology of the system involved in the disease process present the pathophysiology of the disease including the predisposing and precipitating factors applicable to our patient. present the actual and possible diagnostic exams, that are relevant to the condition of the client; discuss the different drugs taken by the patient together with its indications, side effects, nursing responsibilities etc.; discuss the therapeutic and medical managements done including the possible ones present five prioritized nursing care plans intended for the well being of the patient discuss a discharge plan including health teachings following the METHOD approach provide a prognosis of the clients condition basing on the factors that are present; and enumerate the references and resources used in the completion of this case study.

DATA BASE
BIOGRAPHICAL DATA Name: N.A. Gender: Male Age: 45 years old Birth date: October 22, 1964 Place of Birth: Mati City Nationality: Filipino Address: SIR, Davao City Religion: Islam Educational level: College Graduate Occupation: Fish vendor No. of dependents: 0 Marital Status: Married

CLINICAL DATA Chief Complaint: Weakness & Hgb Date of admission: August 18, 2010 @ 4:50 am Admitting diagnosis: Hep. B infection, Hemolytic anemia Ward: St. Lukes Ward Attending Physician: Dr. Maguinsay Date of Discharge: August 25, 2010 Final Diagnosis: Hep. B infection, Hemolytic anemia

Family History An in depth family health history is crucial to the identification of persons at risk for genetic diseases. For this reason, we have traced the family history of our client, Mr. N.A. including up to three generations of his family. Our client, Mr. N.A. is from the clan of W, maternal side, and A ,fathers side. On the paternal side, Mr. T.A., his grandfather is hypertensive. Mrs. I.A., his grandmother is also hypertensive. In their union, they had five children. The eldest was Mr. I.A., 72 years old which was known to be hypertensive and is deceased. Next to him is the father of our client, Mr. M.A., 70 years old, who is hypertensive and asthmatic. Then next to the father of our client is Mrs. H. A., 69 years old, has a breast cancer and is deceased. Next is his brother Mr. J. A., 68 years old, who is hypertensive and is deceased. Lastly, the youngest among them is Mrs. T. A., 65 years old, who is hypertensive and is deceased. Mr. P. W., who is hypertensive, and Mrs. S. W., our clients grandparents in the maternal side having seven children. The eldest among them is Mr. A. W., who is hypertensive and deceased, followed by Mr. P. W. who is deceased; next to him is Mr. H. W., who is hypertensive and deceased. Next to him is Mr. O. W., 74 years old who is deceased. Mrs. S. W., 73 years of age, the mother of our client, is hypertensive. Mr. J. W., 71 years old, who is hypertensive and deceased. Lastly, the youngest is Mrs. S. W., 68 years old. Mr. M. A. and Mrs. S.W. have seven children. Mr. C. A., 55 years old, eldest among the seven children, Mrs. F. A., 53 years old, the second child, Mr. R. A, 48 years old, Mrs. L. A., 47 years old and Mr. B. W., 43 years old.

Past Health History Our client was born full term via normal spontaneous delivery on October 22, 1964 at Mati. He had complete immunization of 1 BCG, 3 DPT, 3 OPV, 1 measles, and 3 hepatitis vaccinations when he was a child. During his childhood tears, he didnt have mumps, chicken pox or dengue but only cough, fever and colds. He doesnt have any serious problems when he was still a child. He has allergy to food such as eggs, pineapples, and seafoods. He always include vegetables in every meal since he was a child. He doesnt drink alcohol and he doesnt smoke. He doesnt have any vices. Last 1992, he was diagnosed to have Hemolytic Anemia and Hepatitis B infection. Our patient has not undergone any surgery before. Last February 2010, he had a fungal infection at his lower extremities and went to Davao for consultation. He went to Davao Medical Center to have his feet checked-up and was prescribed with Proconazole and Dalacin C but the medicines were not effective. There was a nun who advised him to boil Guava leaves and use the water to soak it to his feet. Then 1 week after, his feet was improving. He was suppose to meet his Doctor at March 28 but he was confident that his feet was getting better so he decided not to go to the Doctor.

History of Present Illness Last 1992, he was admitted due to difficulty of breathing and dizziness. He was diagnosed to have Hemolytic Anemia and Hepatitis B infection. With this, he was transfused with blood. Then, this year, January 2010, he was admitted in SPH due to edema in both lower extremities and right ventricular hypertrophy. He stayed in the hospital for 25 days, the medication that he could remember was Furosemide. He had undergone HBV DNA test, a diagnostic test to confirm if Hepatitis B virus is active or not active, at Davao Doc and the result was sent to Manila to be examined. He was prescribed and was given Godex. At February, he was again admitted to San Pedro Hospital due to decrease in albumin. His lower feet became edematous. He was advised to include 3 egg whites per day. After 3 days, he was complaining of pruritus which indicated an allergic reaction. At April, he was again admitted in San Pedro Hospital at St. Catherines Ward due to decrease hemoglobin then he was transfused with 4 units packed RBC. At August, he went to San Pedro Hospital for check-up to confirm if his body can tolerate fasting. Results revealed that he had decreased Hemoglobin thus he was scheduled for blood transfusion that's why he was admitted.

DEVELOPMENTAL DATA
Eric Eriksons Psychosocial Development theory Erik Erikson is a psychoanalyst who postulated eight stages of development in the life cycle and has termed them the eight stages of man. The seventh stage of human development, generativity versus stagnation, is in the middle adulthood. Generativity results in the sense of productivity and care for other people in his environment. On the other hand, stagnation results in lack of interest and commitment. In this stage, the main question is Will I produce something of real value? During this stage, the person will be able to assist his/her children in their teenage life to become responsible adults, establish stable career and is able to participate in community activities. Failure of accomplishing these tasks may lead to stagnation. We have observed that our patient is more in favor in generativity than stagnation. Our patient may not have children but he verbalized that he wanted to have children but his wife was not able to carry her pregnancy to term. As for his work, he works as a fish vendor. His salary can sustain their needs for his family but at times he has just enough for their needs and is not able to send money to support his parents. He does not engage in community activities because gets easily tired but he mentioned that he engaged in community activities before back in Mati. He was the president of a youth organization during his college years.

Robert Havighursts Developmental task theory Havighurst believes that certain developmental tasks arise at each age level; the nature of these tasks varies from person to person. According to Havighurst, developmental task is the one that arises at or about a certain period in the life of the individual, successful achievement of which leads to his happiness and to success with later tasks, while failure leads to unhappiness in the individual, disapproval by the society and difficulty with the later tasks.

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Our patient belongs to the middle adulthood. Under this stage, the patient will encounter the following tasks: Assisting teenage children to become responsible and happy adults The patient has no child because his wife had difficulty carrying her pregnancy to full term or until the fetus has reached the age of viability.

Achieving adult social and civic responsibilities Upon interview, the patient told us that he does not engage in any social or civic activities. But before he was the president of a youth organization in their school and he engaged in some activities when he was still residing in Mati.

Reaching and maintaining satisfactory performance in ones occupation career The client is working very hard to provide for his family. His salary can sustain the needs for his family and he also shared that there were times that he is having problems financially but it does not affect their life because they can still find ways to cope with the problem.

Developing adult leisure time activities The patient stays home whenever he is not working. He said that he likes to rest during his free time because he is easily tired. Sometimes, he goes to mall to buy things for their house and buy things they want.

Relating oneself to ones spouse as a person During interview, we have noticed that he and his wife are very close and sweet to each other. We asked them if they have problems and they have told us that as usual they have also encounter problems like other people but they make sure that these problems will not go overboard. They make sure that the problem will be resolved before they go to sleep.

To accept and adjust to the physiological changes of middle age

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He have mentioned that he does not have impairment in the eyes and he experiences only changes in his body because of his anemia and hepatitis. He is already used to the symptoms of the diseases.

Adjusting to aging parents He is providing financial aid to his parents in Mati. He sends them money whenever they have extra money. He also mentioned that sometimes he is not able to send them money because of financial constraints.

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PHYSICAL ASSESSMENT

On August 19, 2010, at 5:30 pm a comprehensive physical assessment was conducted to our client N.A., a 45 year old male, who was admitted last August 16, 2010 9:05 PM in St. Luke ward with the chief complaint of weakness.

I. General Survey During our assessment, we received our patient lying on his bed. He was awake, coherent, and responsive to stimuli and was oriented to the time, person and place. He has a mesomorphic body built. He has a body weight of 52.5 kg and a height of 161cm. (1.6 m) these yielded to a body mass index of (20.25 kg/m) Upon assessment, the patient appears to be relaxed and cooperative. He has O 2 inhalation at 1-2 LPM. He has an IVF of PNSS 1 L at 50 cc/ infusing well at his left metacarpal vein. Overall, the patient is looking well and he is not on any form of respiratory distress.

II. Vital Signs Upon the assessment, the patients vital signs are as follows:

Vital Signs

Actual

Normal Values

Clinical Significance

Temperature(axillary) Cardiac Rate Pulse Rate Respiratory Rate Blood Pressure

35.6C 65 bpm 62bpm 22cycles 120/60

35.5-37.5 C 70-80 bpm 70-80 bpm 16- 24 cycles 110/70-130/90

Normal Normal Normal Normal Normal

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III. Skin General skin color is brown. Skin is generally uniform in color except in areas exposed to sun and areas with lighter pigmentation such as the lips. Pallor noted on his palms and nails. Jaundice also noted on his stomach. His skin is smooth in texture, warm and dry to touch. Good skin turgor is observed characterized with skin springing back to previous state less than 2 seconds. No lesions, edema and ulceration noted upon assessing the patient. Scars noted on his both lower extremities.

IV. Head Head is normocephalic. Fontanels are closed. Upon palpation there are no signs of enlargement or any mass noted. Through inspection, scalp is clean and free from dandruff. Lice, wounds, scars and lesions are not noted. His hair is short, black in color and straight, fine and evenly distributed. The facial movements are all coordinated. Muscle strength of jaw is normal.

V. Eyes His eyebrows are aligned. Eyelashes are evenly distributed and both are fine and black in color and curled outward. Eyelids have equal movement; without any discharges noted and closes symmetrically. His eyebrows are symmetrically aligned with equal movement. Upon inspection his conjunctiva is pallor. Skins of the eyelids were intact; discharges, discolorations and lesions are not observed. Edema, tenderness and excessive tearing are not noted over lacrimal gland, lacrimal sac and nasolacrimal duct upon palpation. He has an icteric sclera. Pupils are equally round and briskly reactive to light and accommodation with pupil constriction of 2mm on both eyes. Movements of the eyes are coordinated and uniform. He can see objects in periphery and can read a text in 3 feet away with a font size of 14.

VI. Ears The upper of the pinna are normoset, symmetrical and in line with the outer canthus of eyes. Auricles have the same color as the facial skin, symmetrical in position, firm and not tender. The pinna recoiled after it was folded.
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No presence of lesions, swelling or odorous discharges noted on both ears. Minimal cerumen is noted in the external canal. He can clearly hear spoken words. Patients gross hearing is symmetrical on both ears. He could hear normal voice tones and could hear whispered voices within 2 feet.

VII. Nose Nasolabial fold is symmetrical. Nasal septum is at the midline. Presence of tenderness and lesions, are not noted. Nostrils are symmetrical in shape and size. External nares are both patent and there are no discharges noted. External nares are symmetrical to each other. Frontal and maxillary sinuses are not tender.

VIII. Mouth and teeth Lips are symmetrical and pale to brown in color. There are no lesions, discharges, and ulcerations noted. Teeth are yellowish in color. At present he has 27 teeth with dental carries noted. He was using 4 teeth denture as replacement for mastication at upper teeth. Gums are pale in color and firm. The tongue is located midline. Palates are pale and normally concave with no lesions. Uvula is in the midline with a pallor mucosa. Tonsils are not inflamed. Gag reflex was noted. His speech is spontaneous.

IX. Neck The neck is symmetrical without any deformities, lesions or tenderness noted. The patient is able to move his neck from side to side then up and down without any pain or discomfort while flexing. The trachea is in midline. Lymph nodes are not palpable upon palpation. Upon swallowing the thyroid gland is not palpable. The carotid artery on the neck area has full pulsation with moderate force. Jugular veins are not distended.

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X. Chest and Lungs Patient has full and symmetric chest expansion. Upon palpation, there are no lesions, masses, deformities, and tenderness noted. There are no bulges or retraction on the intercostals upon respiration. When vocal (tactile) fremitus was assessed, the result indicated symmetrical sensation on both hands. There are clear breath sounds on both lung fields upon auscultation with respiratory rate of 22 cycles per minute. No tenderness, masses, and retractions on the chest were noted.

XI. Breast and Axillae Upon inspection of the breast, there were no unusualties noted such as tenderness or presence of lesions. His areola is brown in color .Upon assessment on his axillae, presence of hair is evident. There are no palpable lymph nodes noted.

XII. Heart Upon assessment there is no bulging or thrusting of the pericardium. The point of maximum impulse could be heard on the 5th intercostal space with regular heart beats and strong pulsations. Extra sounds such as S3 and S4 are not heard upon auscultation. Apical pulse is regular with the heart rate is 65 beats per minute. There are no masses noted.

XIII. Abdomen Jaundice noted on his abdomen. Bowel sounds is normoactive with 11 sounds per minute. Upon palpation, there is minimal tenderness noted. Umbilicus is centrally located, clean without any discharges and signs of inflammation noted. There are no masses or any other forms of unusualities noted. Upon percussion a tympanic sound was elicited. Bladder is not palpable. Ascites also was not noted.

XIV. Genito-Urinary As verbalized by the client, pubic hair is evenly distributed with dark color. There are no lesions, parasitic infection, enlargement and tenderness noted. Scrotum is symmetrical. Hernia and other unusualities are not noted.
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XV. Back and Extremities Skin color is darker than the skin in the chest. Spine is vertically aligned without any deformities. Both upper and lower extremities are symmetrical. It is warm to touch without any lesions. Upper and lower extremities have good range of motion. Toenails and fingernails are convex in shape, short and well trimmed with capillary refill time of greater than 2 seconds. Nail beds are pale in color. There was no edema noted on both upper and lower extremities. Scars noted on both lower extremities. There is no tenderness and swelling noted in the back and in the extremities. Radial pulse and posterior tibial pulse are equal.

XVII. Cranial Nerve Assessment CRANIAL NERVE I. Olfactory ASSESSMENT The patient is asked to sniff different kinds of aromas and asked to identify it. RESULT The client is able to identify aromatic substances such as alcohol, mango and orange. II. Optic This is done by testing the vision and visual fields with an eye chart or by having the patient read a few statements from an article or by testing the point at which the subject first sees an object moving into the visual field. III. Oculomotor Assess the six ocular movement, movement of the sphincter of pupil, movement of ciliary muscles of lens and pupil reaction. The patient is able to move his eye on six different directions. His pupil is reactive to light and the pupils are brisk; with pupil size of 2mm.
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The client is able to read a text with the font of 14 and with a distance of 3 feet. Also, he is able to see a moving object at a distance of 5 meters away.

IV. Trochlear

Tested in similarity with cranial nerve III, in this test patient is tested to move his eyeball downward and laterally.

He is able to move his eyes downward and laterally, by following the finger.

V. Trigeminal

This is done by testing the sensations of pain, touch, pressure and temperature. Motor branch is tested by asking the client to open mouth against resistance and move jaw from side to side.

The patient is able to distinguish if it is dull or sharp by the use of the cap of the ballpen and the feeling of coldness of an ice cold mineral water bottle. Corneal sensation and blinking are present. Also, he is able to open his mouth evenly against resistance.

VI. Abducens

Tested in similarity with cranial nerve III for the ability to move each eye laterally. Assess direction of gaze.

Patient can move his eyes laterally.

VII. Facial

Client is asked to close eyes, smile, purse lips and frown.

He is able to close his eyes and demonstrate many facial expressions such as smiling, frowning and pursing of lips.

VIII. Vestibulocochlear

Whispering words to the client and asking him to follow saying the word after you..

The client can reiterate the words that were whispered to his ears. The words Wednesday and Kadayawan were uttered by the patient

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after asked to repeat what was heard. IX. Glossopharyngeal Gag and swallowing reflexes are checked by asking the client to speak and cough. Gag reflex is present. A tongue depressor was placed on the posterior portion of the tongue and he started to act like he wants to vomit. X. Vagus It is tested in similarity with cranial nerve IX, since they both serve as muscles of the throat. XI. Accessory Sternocleidomastoid and trapezius muscles are checked for strength by asking him to turn his head side to side and shrug shoulders against resistance. XII. Hypoglossal He is able to turn his head side to side without any difficulty. He can shrug his shoulders against resistance without any pain felt. Gag reflex is present and he is able to swallow food without difficulty.

Patient was asked to stick out He is able to stick his his tongue and move his tongue in different directions tongue out and he is able to move it in different directions.

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DEFINITION OF DIAGNOS
Hemolytic Anemia, results from increased RBC destruction occurring in response to trauma, malarial infection, exposure to certain chemical or drugs, and autoimmune reactions. All increase rate of RBC destruction by causing membrane lysis (breakage). In immunohemolytic anemia, immune system products attack a persons own RBCs for unknown reasons. (Ignatavicius, 2010)

Hemolytic anemia, are characterized by the premature destruction of RBCs. RBCs may be destroyed because the cell itself is improperly formed (intrinsic) or because it has been damaged by an outside source (acquired). Intrinsic causes include defects in the cell membrane or hemoglobin structure and function, and inherited enzyme deficiencies. External causes of hemolytic anemia include drugs, bacterial and other toxins, and trauma. (Burke, 2007)

Hemolytic anemia, premature destruction of erythrocytes results in liberation of hemoglobin from the erythrocytes into the plasma. The increase erythrocytes destruction leads to tissue hypoxia, which in turn stimulates erythropoietin production. This increased production is reflected in an increased reticulocyte count as the bone marrow responds to the loss of erythrocytes. The released hemoglobin is converted in large part to bilirubin; therefore, the bilirubin concentration rised. Hemolysis can result from an abnormality within the erythrocyte itself (e.g. sickle cell anemia, glucose-6phosphate dehydrogenase [G-6-PD] deficiency) or within the plasma, or from direct injury to erythrocyte within the circulation. (Smeltzer, 2008)

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Hemolytic anemia, is anemia due to hemolysis, the abnormal breakdown of red blood cells (RBCs) either in the blood vessels (intravascular hemolysis) or elsewhere in the body (extravascular). It has numerous possible causes, ranging from relatively harmless to life-threatening. The general classification of hemolytic anemia is either inherited or acquired. (http://en.wikipedia.org/wiki/Hemolytic_anemia)

Hemolytic anemia is a rare form of anemia in which red blood cells (also called erythrocytes) do not live as long as healthy cells; they are destroyed and removed from the bloodstream prematurely. Healthy red blood cells usually live about 120 days in the bloodstream before the body removes them. In hemolytic anemia, the body breaks down and removes red blood cells faster than it can replace them. The breakdown of red blood cells is called hemolysis. The hemolysis can occur in the bloodstream or in an organ called the spleen. The bone marrow increases production of red blood cells to replace the hemolyzed blood cells, but it can't produce them fast enough to meet the body's needs. (http://wiki.medpedia.com/Hemolytic_Anemia)

Hepatitis B, is transmitted primarily through blood (percutaneous and permucosal routes). HBV can be found in blood, saliva, semen, and vaginal secretions and can be transmitted through mucous membranes and breaks in the skin. HBV has a long incubation period. It replicates in the liver and remains in the serum for relatively long periods, allowing transmission of the virus. (Smeltzer, 2008)

Hepatitis B, is usually transmitted by blood transfusion or contaminated needles, but also may be spread by sexual contact and from an infected mother to her fetus. Carriers cant transmit HBV while having no symptoms of the disease. The risk of liver cancer is signicant in clients infected with Hepatitis B. (Burke, 2007)

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Hepatitis B virus, is not transmitted like HAV. It is a double-shelled particle containing DNA composed of a core antigen (HBcAg), a surface antigen (HBsAg), and another antigen found within the core (HBeAg) that circulates in the blood. HBV may be spread through these common modes of transmission: Unprotected sexual intercourse with an infected partner Sharing needles Accidental needle sticks or injuries from sharp instruments Blood transfusions Hemodialysis Maternal-fetal route

The clinical course of HBV may be varied. Symptoms usually occur within 25- 180 days of exposure and include: Anorexia, nausea and vomiting Fever Fatigue Right upper quadrant pain Dark urine with light stool Joint pain Jaundice

(Ignatavicius, 2010) The hepatitis B virus is a DNA virus, meaning that its genetic material is made up of deoxyribonucleic acids. It belongs to a family of viruses known as Hepadnaviridae. The virus is primarily found in the liver but is also present in the blood and certain body fluids. Hepatitis B virus consists of a core particle (central portion) and a surrounding envelope (outer coat). The core is made up of DNA and the core antigen (HBcAg). The envelope contains the surface antigen (HBsAg). These antigens are present in the blood and are markers that are used in the diagnosis and evaluation of patients with suspected viral hepatitis. (http://www.medicinenet.com/hepatitis_b/article.htm)
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Hepatitis B is caused by infection with the hepatitis B virus (HBV). This infection has 2 phases: acute and chronic.

Acute (new, short-term) hepatitis B occurs shortly after exposure to the virus. A small number of people develop a very severe, life-threatening form of acute hepatitis called fulminant hepatitis.

Chronic (ongoing, long-term) hepatitis B is an infection with HBV that lasts longer than 6 months. Once the infection becomes chronic, it may never go away completely.

(http://www.emedicinehealth.com/hepatitis_b/article_em.htm)

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ANATOMY AND PHYSIOLOGY

Blood Blood is heavier, thicker and more viscous than water. It flows more slowly than water, at least in part because of its viscosity. The adhesive quality of blood, or its stickiness, may be appreciated by touching it. The temperature of the blood is about 38C, which is slightly higher than normal body temperature, and has a slightly alkaline pH or about 7.40. blood constitutes about 8% of the total body weight. The blood volume is 5-6 liters in an average-sized adult female. Several hormonal negative feedback systems ensure that blood volume and osmotic pressure remain relatively constant. Especially important are those involving aldosterone, antidiuretic hormone, and atrial natriuretic peptide, which regulate how much water is excreted in the urine. Blood is a liquid connective tissue that has three general functions: transporation, regulation and protection. Transportation. Blood transports oxygen from the lungs to the cells of the body and carbon dioxide from the cells to the lungs. It also carries nutrients from the gastrointestinal tract to body cells, heat and waste products away from cells and hormones from endocrine glands to other body cells. Regulation. Blood helps regulate pH through buffers/ it also adjusts body temperature through the head-absorbing and coolant properties of its water content and its variable rate of flow through the skin, where excess heat can be lost from blood to the environment. Blood osmotic pressure also influences the water content of cells, principally through dissolved irons and proteins. Protection. The clotting mechanism protects against blood loss, and certain phagocytic white blood cells and plasma proteins.

The whole blood is composed of two portions: (1) blood plasma, a watery liquid that contains dissolved substances, and (2) formed elements, which are cells and cell fragments. On average, more than 99% of the formed elements are red colored erythrocytes, also called red blood cells. The percentage of the total blood volume occupied bu RBCs normally is about 45% and plasma accounts for the remaining 55%.
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Pale, white-colored leukocytes, or white blood cells, and platelets represent less than 1% of the total blood volume. They form a very thin layer, called the buffy coat, between the packed RBCs and plasma.

Blood Plasma When the formed elements are removed from blood, a straw-colored liquid called plasma is left. Plasma is about 91 % water and 8% solutes, most of which by weight (7%) are proteins. These proteins play a role in maintaining proper blood osmotic pressure, which is an important factor in exchange of fluid across capillary walls. Most plasma proteins are synthesized by hepatocytes, including the albumins, most globulins and fibrinogen. Plasma and other lymphatic tissues, produce gamma globulins, one of the more important types of globulins. These plasma proteins are also called antibodies or immunoglobulins because they are produced during certain immune responses. Foreign invaders such as bacteria and viruses stimulate production of millions of different antibodies. An antibody binds to the foreign substance, called antigen, that provoked its production. Besides proteins, other solutes in plasma include electrolytes; nutrients; regulatory substances such as enzymes acid, creatinine, ammonia and bilirubin.

Red Blood Cells More than 99% of the formed elements in blood are red blood cells. They contain the oxygen-carrying protein hemoglobin, which is a pigment that gives whole blood its red color. A healthy adult male has about 5.4 million red blood cells per cubic millimeter of blood. To maintain normal quantities of RBC, new mature cells must enter the circulation at the astonishing rate of at least 2 million per second. This pace balances the equally high rate of RBC destruction. Under the microscope, RBCs appear as biconcave discs. Mature RBCs have a simple structure. They lack a nucleus and other organelles and can neither reproduce nor carry on extensive metabolic activities. The plasma membrane encloses hemoglobin, which was synthesized before loss of the nucleus and which constitutes about 33%of the cell weight, dissolved in the cytosol.
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RBC Physiology As blood passes through the lungs, hemoglobin inside RBCs combines with oxygen to form oxyhemoglobin. A hemoglobin molecule consists of a protein called globin, composed of four polypeptide chains, plus four nonprotein pigments called hemes. Each heme is associated with one polypeptide chain and contains an iron ion that combine reversibly with one oxygen molecule. The oxygen is transported in this state to other tissues of the body. In the tissues, the iron-oxygen reaction reverses. Hemoglobin releases oxygen, which diffuses into the interstitial fluid and from there into cells. Hemoglobin also transports about 23% of the total carbon dioxide, a waste product of metabolism. Blood flowing through tissue capillaries picks up carbon dioxide, some of which combines with amino acids in the globin portion of hemoglobin to form carbaminohemoglobin. This complex is transported to the lungs, where the carbon dioxide is released and then exhaled.

White Blood Cells Unlike RBC, WBCs have a nucleus and do not contain hemoglobin. Two major groups of WBC are granular leukocytes and agranular leukocytes. Granular leukocytes develop from myeloblasts. They have conspicuous granules in the cytoplasm that can be seen under a light microscope. The three types are eosinophils, basophils and neutrophils. Agranular leukocytes do not have cytoplasmic granules that can be seen under a light microscope, owing to their small size and poor staining qualities. The two kinds of agranular leukocytes are lymphocytes and monocytes.

Platelets Besides the immature cell types that develop into erythrocytes and leukocytes, hemopoietic stem cells also differentiate into megakaryoblasts. Under the influence of a hormone known as thrombopoietin, megakaryoblasts transform into

metamegakaryocytes, huge cells that splinter piece of the cell membrane, is a platelet. Platelets break off from the metamegakaryocytes in red bone marrow and then enter the blood circulation. They are disc-shaped and exhibit many granules but no nucleus. Platelets help stop blood loss from damaged blood vessels by forming a platelet plug.
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Their granules also contain chemicals that upon release promote blood clotting. Platelets have a short life span, normally just 5-9 days.

Blood Flow through the Pulmonary and Systemic Circulations The right atrium receives deoxygenated blood from various parts of the body. From the right atrium, blood flows into the right ventricle, which pumps into the pulmonary trunk. The pulmonary trunk divides into a right and left pulmonary artery, each of which carries blood to one lung. As blood flows through pulmonary capillaries, it loses CO2 and takes on O2. This blood, called oxygenated blood, returns to the heart via the pulmonary veins that empty into the left atrium. The blood then passes into the left ventricle which pumps the blood into the ascending aorta. Branches of the arch of the aorta and descending aorta deliver blood to systemic arteries, which lead into systemic capillaries. In the systemic capillaries, blood loses O2 and gains CO2. This blood, called deoxygenated blood, returns to the right side of the heart through the superior vena cava and inferior vena cava.

RBC Life Cycle Red blood cells live only about 120 days because of the wear and tear inflicted on their plasma membranes as they squeeze through blood capillaries. Without a nucleus and other organelles, RBCs cannot synthesize new components to replace damaged ones. The plasma membranes thus become more fragile with age and the cells more likely to burst, especially as they squeeze through narrow channels in the spleen. Worn-out RBCs are removed from circulation and destroyed by fixed phagocytic macrophages in the spleen and live and the breakdown products are recycled as follows: Macrophages in the spleen, liver, or red bone marrow phagocytize worn-out RBCs The globin and heme portion of hemoglobin are split apart Globin is broken down into amino acids, which can be Reused to synthesize other proteins Iron removed from the heme portion
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Associates with a plasma protein called transferring, which transports iron in the blood-stream In muscle fibers, liver cells and macrophages of the spleen and liver, iron detaches from transferring and attachs to iron-storage proteins called ferritin and heosiderin.

Upon release from a storage site or absorption from the gastrointestinal tract, iron attaches t o transferring It is then transported to bone marrow, where RBC precursors take it up through receptor-mediated endocytosis For use in production of new hemoglobin molecules Erythropoiesis in red bone marrow results in the production of red blood cells, which enter the circulation At the same time, the non-iron portion of heme is converted to biliverdin, a green pigment and then into Bilirubin, an orange pigment Bilirubin enters the blood and is transported to the liver Within the liver, bilirubin is secreted by liver cells into bile, which passes into the small intestine In the large intestine bacteria convert bilirubin into urobilinogen Some urobilinogen is absorbed back into the blood, converted to urobili, a yellow pigment, and excreted in urine Mose urobilinogen is eliminated in feces in form of a brown pigment called stercobilin, which gives feces their characteristic color.

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PATHOPHYSIOLOGY HEPATITIS B
Predisposing Sex Present Absent Significance It is the third most common cause of death from cancer in males and the seventh most common cause in females. Race The disease is more common in South-East asia and Africa. Age 19-39 year olds and in persons 40 years and older are more prone to be having a hepatitis B. hepatitis B is commonly transmitted by blood or sexual contact.

Precipitating Environment

Present

Absent

Significance Hepatitis B surface antigen also was found in swab samples of surfaces frequently touched or placed in the mouth. In the absence of classical exposure to infectious blood or blood products, these findings suggested that, in a crowded home environment, saliva and cutaneous exudates containing hepatitis B virus may play a role in the transmission of hepatitis B.

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Lifestyle

When patient is highly sexually active. The patient is high risk for acquiring hepatitis B. Hepatitis B is an infection of the liver that usually is transmitted in adults by sexual contact or sharing of contaminated drug needles.

History of BT

Hepatitis B is acquired when he blood products is not properly checked

Symptomatology

Signs and Symptoms Anorexia

Present

Absent

Rationale

Loss of appetite due to feeling of being nauseated.

Nausea Vomiting

There is increase pressure. Several organs failed to excrete waste in the body, as compensatory mechanism the body would try to excrete waste by vomiting,

Dehaydration

Due to excessive fluid loss cause by excessive vomiting.

Arthralgia

Severe pain in joint, without swelling or other sign of arthritis.

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Malaise

Feeling of being unwell due to presence of disease.

Fatigue

There is a problem in metabolism; the liver cant synthesize the glucose ingested by person. Thats why liver would convert protein into energy causing muscle wasting.

Low grade Fever

In incubation period. The patient is asymptomatic. When the t-cell detect foreign pathogen. The immune system would attack the pathogen as defence mechanism.

Urticaria

An itchy rash resulting from the release of histamine by mast cell.

Pruritus

Accumulation of bile salts in the pigment in the skin.

Hepatomegaly

Inflammatory process causes liver swelling that would lead to enlargement of liver.

Tender liver WBC

It is caused by liver inflammation. Inflammatory process occur, immune system will increase the WBC to fight the foreign pathogen.

Jaundice

It indicates excessively high levels of bile salts in the skin and mucous membrane.

Icteric sclera

There is a problem in synthesising of bilirubin, it will mix to the blood. Mucous membrane would be the first evident of having jaundice.
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Dark colored urine

There is a problem in reabsorption of urobilinogen to return to liver. When the urobilinogen exposed to air it will oxydixed and that would lead to dark color urine.

Steatorrhea

The liver has impaired function in metabolizing the fat. Causing fat malabsorption and it wil mixed to the feces of patient with hepatitis B.

RBC

When there is decreased Vit. K absorption in the body. When bleeding happens here would be problem in coagulation does causing anemia and decreased RBC.

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HEMOLYTIC ANEMIA
Predisposing Age Present Absent Significance It is common in adult(24-45 years of age) Gender It is more common in female than male. Family history It is also transmitted by genes

Precipitating Medication

Present

Absent

Significance Medications that can cause immune hemolysis include the following (see References for more complete lists):,Penicillin, Cephalothin,Ampicillin, Methicillin ,Quinine, Quinidine

Medical History

If the patient has the history haemolytic anemia. It will reoccur because it is not treated immediately.

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SYMPTOMATOLOGY
Signs and Symptoms Fever It is also serving as defence mechanism. That indicates that there is infection and for thermoregulation. Chills Chills are body's compensatory mechanism to increase body temperature thus helping to fight infection. Dyspnea Difficulty of breathing due to obstruction or it is common with the patient having cardiac problem. Hypotension Hypotension is a relative term because the blood pressure normally varies greatly with activity, age, medications, and underlying medical conditions. Hypoxia Tissue perfusion RR It is known as decreased oxygen in the tissue. This is due to decreased oxgen production in the tissue. This will served as compensatory mechanism of the body if the patient is suffering from hypoxia or decreased oxygen. Rapid Heartbeat This is also a compensatory mechanism for decreased blood volume to attain normal blood level. Present Absent Rationale

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Cold Clammy skin Cyanosis

This is due to fainting or decreased blood supply in the part of body. This will happen when the patient experiencing decreases oxygen in the body. The tissue begun to necrotize if cyanosis will still continue.

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