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DMMA College of Southern Philippines

College of Nursing

In Partial Fulfillment of the Requirements in Related Learning



Submitted to:
Jameson Wils D. Ong I
Clinical Instructor

Submitted by:

Roy Baconga
Adel Lyde Bernales
Michelle Flores
Wella Orbigoso
Prettylyn Vallescas


Group 1


Objective of the Study--------------------------------------------------------------
Patient’s Profile-----------------------------------------------------------------------
Family Background------------------------------------------------------------------
Genogram ------------------------------------------------------------------------------
Physical Assessment---------------------------------------------------------------
Anatomy and Physiology----------------------------------------------------------
Laboratory Results-------------------------------------------------------------------
Definition of Terms-------------------------------------------------------------------
Nursing Care Plan--------------------------------------------------------------------
Drug Study------------------------------------------------------------------------------
Health Teaching------------------------------------------------------------------------

We will not be able to finish this case presentation without the help of those
people who sincerely gave their support to us. We would like to thank all the people
who generously gave their time, ideas and resources for the success of this

To the family of our chosen patient, for their time, and full participation.

To all our clinical instructors who gave us freedom and the challenge to discover
on our own what life would need in this kind of profession.

To Mr. Jameson Wils D. Ong, I for supervising us in our duty in Medical Mission
Group Hospital in Tagum City.

To the staff of Medical Mission Group Hospital who supported us and make us
feel warmth.

To our few Group mates whose heart, mind and soul is certain to make this
Case Presentation on Severe Anemia be informative and possible.

To all our classmates and friends, who generously share their knowledge to us,
whose friendship, inspiration, and support.

And finally, to GOD Almighty the GREAT PHYSICIAN and the AUTHOR OF LIFE
from whom wisdom comes. We thank HIM for the guidance and strength.

If you’re like most people who beat up on the snooze button each morning, an earlier
bedtime is the way to end your energy crisis. But if no amount of rest helps, it may not be
sleep that your body is craving. You may have a form of anemia. If you have anemia, people
may say you have tired blood. That's because anemia — a condition in which there aren't
enough healthy red blood cells to carry adequate oxygen to your tissues — can make you feel
tired. Anemia saps your energy by depriving your cells of oxygen. This happens when your
blood has too few red blood cells or too little hemoglobin that transports oxygen through the
bloodstream. Without oxygen, no living cell can survive. Without a specialized system of
oxygen transport to cells, no complex multi-cellular organism which carry oxygen to and
carbon dioxide away from the thirty trillion cells of the human body are basic requirements for
health and itself.

Anemia is a common blood disorder. Women and people Anemia is a common blood
disorder. Women and people with chronic diseases are at increased risk of the with chronic
diseases are at increased risk of the condition. Some people learn that their hemoglobin is
condition. Some people learn that their hemoglobin is low, which indicates anemia, when they
go to donate low, which indicates anemia, when they go to donate blood. Low hemoglobin
may be a temporary problem blood. Low hemoglobin may be a temporary problem remedied
by eating more iron-rich foods or taking a remedied by eating more iron-rich foods or taking a
multivitamin containing iron. However, it may also be a multivitamin containing iron. However,
it may also be a warning sign of blood loss in your body that may be warning sign of blood
loss in your body that may be causing you to be deficient in iron. If you're told that you
causing you to be deficient in iron. If you're told that you can't donate blood because of low
hemoglobin, ask your can't donate blood because of low hemoglobin, ask your doctor if you
should be concerned. If you suspect you doctor if you should be concerned. If you suspect
you have anemia, see your doctor. Anemia can be a sign of have anemia, see your doctor.
Anemia can be a sign of serious illnesses. Treatments for anemia range from serious
illnesses. Treatments for anemia range from taking supplements to undergoing medical
procedures taking supplements to undergoing medical procedures and even just eating
healthy varied diet.
There are many forms of anemia, each with its own cause. Anemia can be
temporary or long term, and it can range from mild to severe. See your doctor if you're
feeling fatigued for unexplained reasons, especially if you're at risk of anemia. Some
anemias, such as iron deficiency anemia, are common. But don't assume that if you're
tired, you must be anemic. Fatigue has many causes besides anemia. Anemia can be a
symptom of many different serious problems, including cancer. Anemia is a great
problem globally and worse in developing countries, but it is by no means absent in
industrialized nations and millions of Filipinos suffer from anemia, which is serious
and is usually caused by blood loss from an injury or hemorrhage and the demands of
pregnancy. Approximately 43.9% Filipinos pregnant women are estimated to develop
anemia, while many are unreported. Anemia can occur during pregnancy due to low
levels of iron and folic acid (folate) and changes in the blood. During the first 6 months
of pregnancy, the fluid portion of a woman’s blood (the plasma) increases faster than
the number of red blood cells. This dilutes the blood and can lead to anemia.

Anemia affects many body systems. It can also lead to many complications. This
is the goal of health care providers, to prevent any occurrence of complications.
Ultimately, it is hoped that with timely intervention to control this complication of
anemia, improved patient outcomes on in terms of morbidity and mortality will be

General Objectives:

To have a better understanding on the effects and possible complicationsof severe

anemia. To obtain essential data from the health history of our patient that is useful to further
understand the disease and we could come up with the most effective nursing interventions.
This also aims to help the researchers, readers, students and nursing enthusiast to further
understand and know the right information regarding this case. And lastly, to systematically
evaluate the effect of disease management programs for patients with severe on processes
and outcomes of care.

Specific Objectives:

- Find a challenging case for the case study.

- Establish good rapport to the patient and his significant others in order to gain trust
and cooperation.
- Gather patient family health history that is fundamental for the onset of her illness.
- Illustrate the anatomy and physiology related to the client’s conditions
- Illustrate the pathophysiology of the client’s condition.
- Study and analyze the orders given by the physician.
- Define the diagnostic test undergone by the pt. and its implication.
- Classify prescribed drugs given by the pt. as the basis of his recovery.
- To formulate the nursing care plan to identify the present and possible problem of
the patient.
- Do health teachings with regards to his conditions.

Name: Rafael Mirafuentes Cudera

Sex: Male

Age: 78 years old

Address: P – 3B Manggayon, Compostela Valley Province

Birthday: October 24, 1931

Birthplace: Cebunga Cebu

Nationality: Filipino

Religion: Roman Catholic

Civil Status: Widow


Admission Date: December 29 , 2009

Admission Time: 6:32 PM

Chief Complaint: Pallor , Dizziness

Admitting Diagnosis:Anemia severe prob and to Ureterolithiasis ; R/O DM

Hospital: Medical Mission Group of Hospital

Ward and Room: Station W – B 38

Attending Physician:Felipe Balingit III G.M.D


Patients Health History

Patient's health history is the first part and one of the most sinificant aspects in case
studies. It is a systematic collection of subjective and objective data, ordering and a step by
step process inculcating detailed information in determining client's history, health status,
functional status and copping pattern. These vital information provide a conceptual baseline
data utilized in developing nursing diagnosis, subsequent plans for individualized care and for
the nursing process application as a whole.


A. History of Present Illness

Month PTA, admitted at a local hospital due to pallor and was discharged improving.
Week PTA, positive pallor accompanied with on and off dizziness persistence to admission.

B. Past Health Problem/Status

According to him it was the 1st time to be hospitalized of his disease, He also has no
known allergy of kind. He never had a serious illness like this before to be brought to the
hospital. He said that he experience cough, colds, fever, stomachache and headache also
diarrhea on the past. He used to smoking and drinking when he was 15 years old but he quit
at the age of 60.

C. Family History Illness

As claimed by patient during the interview, there is a family history of asthma on father
side. It includes his grandfather and his 1 sister and 1 brother. His grandfather died because
of aging. While his grandmother died of malaria.

D. Brief Social, Cultural and Religious Background

a. Educational Background
- He is a high school graduate.
b. Occupation
- farmer, and they have farm
c. Religious Practices
- He is a solid Roman Catholic who hears mass every Sunday and on special days like
fiesta, Christmas and his birthday.
d. Economic Status
-His not able to estimate his earnings.


Patient received lying on bed in a semi-fowler’s position, awake. Conscious and

responsive with foley catheter attached to urobag with bloody color urine. He is Rafael
Mirafuentes Cudera, 78 years old and he lives in P – 3B Manggayon, Compostela Valley
Province and was admitted to Medical Mission Group Hospital and Health Services
Coopertive of Tagum.


Afebrile with temperature of 36.6°C, a blood pressure of 100/80mmHg,a cardiac rate of

72bpm and a respiration of 21cpm.


Upon assessment, the patient’s skin is pale with poor skin turgor, no presence of
lesions and edema. Afebrile, with temperature of 36.6°C.


Eye brows-hair is evenly distributed, symmetrically aligned with equal movement,

equally distributed eye lashes, no presence of discharges on the eyelids; pupils are equal in
size and black in color. Pt. can react to light and respond to visual stimulus.

V. MOUTH (teeth, tongue, and lips)

With dentures, pink gum, moist and firm texture; tongue in central position, pink in color
with no lesions noted and dry lips.


Speak in soft tone voice with unclear speech.


Normacephalic and symmetrical with frontal, temporal, parietal, and occipital

prominence; no lesions noted upon inspection; with grey hair with no presence of dandruff.


Neck moves freely without any discomfort, no visible distended veins and no lesions


Equal chest expansion with normal respiration of 21cpm.


Normal blood pressure at 100/80mmHg with regular rhythm at 72bpm with full


Eliminates regularly; defecated at least one times with no difficulty in bowel movement;
with soft formed stool and brownish in color.


Urinated with bloody colored urine , output; 200cc/ 2hours.


Conscious able to cooperate with the task given; oriented with time, place, and person;
able to answer upon questioning.

− is a specialized body fluid that delivers necessary substances to the body cells
− such as nutrients and oxygen and transport waste products away from those
same cells.

− are the most abundant of the blood cells and they contain the oxygen- carrying
protein, hemoglobin that function in the transport of oxygen.
− Also called as erythrocytes.
− Constitute only 1 % of the total blood volume, they serve various roles in
immunity and inflammation. They include the granulocytes, the lymphocytes and
the monocytes.
− Also called as leukocytes.

− Are small cell fragments that are involved in the blood clotting.
− Also called as thrombocytes.

Hemoglobin (HGB) 01/03/2010- 05:55 PM

Normal Values
Hemoglobin, massc : 3.3 g/dl M 13.5 – 18.0 g/dl

Hemoglobin (HGB) 01/03/2010 – 07:32 AM

Hemoglobin, massc: 4.5 g/dl M 13.5 – 18.0 g/dl

CREATININE TEST 01/02/2010 9:04 AM

Concentration: 109.9 umol/l

Result: Normal
Reference: 80.0-115.0

OCCULT BLOOD 01/02/2010

Specimen: stool
Results: negative


Color: dark brown

HEMOGLOBIN (HGB) 01/02/2010

Hemoglobin, massc 3.9 g/dl M 13.5-18.0 g/dl

HEMOGLOBIN (HGB) 01/01/2010 5:37 PM

Hemoglobin, massc 4.2 g/dl M 13.5-18.0 g/dl


Clotting Time (CT) – 3 mins. 15 secs. 2-6 mins

Bleeding Time (BT) – 1 min. 15 secs. 1-3 mins.

RETICULOCYTE COUNT (12/30/2009 – 04:21 PM)

Result: 1.9%
Normal: Adult 1-2
Infant 4-8
Normal Values

PLATELET COUNT( 12/30/2009 – 04:22 PM)

Thrombocytes, numc : 281 x10 3/uL M 134-377


Creatinine 131.0 M 80-115 umol/ L

F 53-97 umol/L

Uric Acid 393.6 M 210-420 umol/L

F 150-350 umol/L

Triglyceride 0.4 0.9 – 1.6 mmol/L


Color: bloody red

Transparency: cloudy
Albumin: ++++
Reaction: Negative
Sp. Gravity: 1.020
Pus cells: 3-5


Hemoglobin, massc: 3.0 g/dl M 11.3-15.7 g/dl

Leucocytes, numc: 5.3 x 10 3/ul M 2.6-8.8
Segmenters : 0.59
Stab: 0.05 – 0.02 – 0.06
Lymphocytes: 0.32 0.20- 0.35
Monocytes: 0.03 0.02- 0.06
Eusophils: 0.01 0.01- 0.03
Packed Cell volume (hct): 10.5 M 32.6- 47.5


Left kidney measures 8.4x4.3x1.4 cm

Right kidney measures 8.5x4.8x16 cm

There is no significant disparity in the sizes, shapes and locations of both kidneys. No evident
mass calculus, or any abnormality in the scans obtained.

Both ureters were not visualized.

The urinary bladder is distended. Attached to the lower left lateral wall and floor is an
irregularly – shaped complex structure, measuring 6.8x5.1x5.6 cm (LWT)

The prostate gland is slightly enlarged, measuring 33.5x38.5x28.1 mm (LWT), weighing 19

grams. No focal lesions were seen.


1.) Normal kidneys ultrasonically

2.) Urinary bladder mass
3.) Prostate gland enlargement, Grade 1

Symptoms Actual Scientific Basis Clinical Significance

is a reduced amount of
oxyhemoglobin in skin or
mucous membrane, a pale
color which can be caused is not usually clinically
by illness, emotional shock significant unless it is
Pallor √
or stress, avoiding accompanied by a general
excessive exposure to pallor (pale lips, tongue,
sunlight, anemia or palms, mouth and other
genetics. regions with mucous
a range of afflictions,
varying from a general
state of lethargy to a is considered a symptom
Fatigue √
specific work-induced because it is reported by the
burning sensation within patient instead of being
one's muscles. observed by others.
Is a symptom of a number
of different conditions of
the head. Headache is
Headache x caused by a disturbance
of the pain-sensitive
structures in the head.

is a debilitating symptom It is a common symptom of

that is the experience of numerous medical disorders,
unpleasant or particularly those involving
uncomfortable respiratory the cardiovascular and
Dyspnea x sensations. respiratory systems;
dyspnea on exertion is the
most common presenting
complaint for people with
respiratory impairment.

Granulocytes - are a category of white blood cells characterised by the presence of

granules in their cytoplasm.They are also calledpolymorphonuclear leukocytes (PMN or PML)
because of the varying shapes of the nucleus, which is usually lobed into three segments. In
common parlance, the term polymorphonuclear leukocyte often refers specifically to
neutrophil granulocytes,the most abundant of the granulocytes.

Lymphocytes - is a type of white blood cell in the vertebrate immune system. Functionally
distinct subsets of lymphocytes correlate with their appearance. Most, but not all large
granular lymphocytes are more commonly known as the natural killer cells (NK cells). The
small lymphocytes are the T cells and B cells. Lymphocytes play an integral role in the body's

Monocytes - is a type of white blood cell, part of the human body's immune system.
Monocytes have two main functions in the immune system: (1) replenish resident
macrophages and dendritic cells under normal states, and (2) in response to inflammation
signals, monocytes can move quickly (approx. 8-12 hours) to sites of infection in the tissues
and divide/differentiate into macrophages and dendritic cells to elicit an immune response.

Reticulocytes - are immature red blood cells, typically composing about 1% of the red
cells in the human body. Reticulocytes develop and mature in the red bone marrow and
then circulate for about a day in the blood stream before developing into mature red
blood cells.

Hemoglobin - is the iron-containing oxygen-transport metalloprotein in the red blood cells

of vertebrates and the tissues of some invertebrates.

Nursing Diagnosis: Risk for infection related to decreased hemoglobin production.

Date Cues Objectives Needs Nursing Rationale Evaluatio

Intervention n
01/05/10 Within 8 Health 1.)Stress 1.) To reduce/ Goal met
hour span perception proper hand correct existing as
of care - Health hygiene by all risk factor. evidence
patient will Managem caregivers by:
demonstra ent between patient
te no sign Pattern therapies/clien was able
of ts. 2.) To limit to
infection exposures, thus demonstr
such as 2.) Monitor reduce cross- ate no
increase client's contamination. sign of
in body visitors/ infection
temperatu caregivers for such ass
re. respiratory 3.) At high risk increase
illness. Offer for nosocomial/ in body
mask and healthcare temperat
tissues to associated ure.
client/visitors infections.
who are
coughing/ 4.) To prevent
sneezing. pneumonia.

3.) Instruct in
daily mouth 5.)To avoid
care. bladder
4.)Monitor/ urinary stasis.
assist with
use of 6.) To promote
adjuncts. wellness.

adequate 7.) Premature
hydration, discontinuation
stand/ sit to of treatment
void, and when client
catheterize, if begins to feel
necessary well may result in
return of infection
6.) Review and potential
individual drug resistant
nutritional strains.
appropriate 8.) Inappropriate
exercise use can lead to
program and development of
need for rest. drug-resistant
7.) Emphasize secondary
necessity of infections.
antivirals/antib 9.) To increase
iotics, as awareness of
directed. and prevention
of communicable
8.) Discuss diseases.
importance of
not taking 10.) To reduce
antibiotic/ incidence/
using “leftover transmission of
drugs” unless global infections.
instructed by

9.) Provide
involve in
and national

10.) Discuss
with client
engaged in
travel and
refer for
Nursing Diagnosis: Impaired physical mobility related to decrease muscle strength

Date Cues Objectives Needs Nursing Rationale Evaluation

01/05/10 S: After Activity 1.) Note 1.) That may Goal
8hour Exercise situations restrict partially met
“ Kapuyan span of Pattern such as movement as
ko care surgery, verbalized
maglakaw patient will fractures, 2.) To note any by pt. “ dili
-lakaw ug able to amputation, incongruencies na ko
magtindog participate tubing with reports of maglisod ug
-tindog”, in the ( catheter) abilities. lihok dili
as desired parehas sa
verbalized activities 2.) Observe 3.) Feeling of una na
by the pt. without movement frustrations, kapuyan ko.”
complaint when client is powerlessness
of unaware of may impede
tiredness. observation attainment of
O: goals.
3.) Note
- body emotional/ 4.) For position
weakness behavioral changes/
responses to transfers.
- slowed problems of
movement immobility. 5.) To maintain
position of
-gait 4.) Instruct in function and
changes use of side reduce risk of
rails, overhead pressure
trapeze, roller ulcers.
6.)To permit
5.) Support maximal effort/
affected body involvement in
parts/joints activity
using pillow air
mattress. 7.) To reduce
6.) Administer
medications 8.) Limits
prior to activity fatigue,
as needed for maximizing
pain relief. participation

7.) Schedule 9.) Promotes

activities with well-being and
adequate rest maximizes
periods during energy
the day. production.

8.) Identify 10.) Enhances

energy self- concept
concerning and sense of
techniques for independence.

9.) Encourage
intake of

participation in
self care,

Generic Name: Furosemide

Brand Name: Lasix
Classification: Diuretics

Mechanism of Action: A potent loop diuretic that inhibits sodium and chloride reabsorption at
the proximal and distal tubules and the ascending loop of Henle.

Adverse Reaction:
CNS: Vertigo, headache, dizziness, paresthesia, weakness, restlessness, fever
CV: orthostatic hypotension, thrombophlebitis with I.V administration
EENT: transient deafness, blurred or yellowed vision
GI: abdominal discomfort and pain, diarrhea, anorexia, nausea, vomiting, constipation,
GU: nocturia, polyuria, frequent urination, oliguria
Hematologic: agranulocytes, leucopenia, anemia
Hepatic: hepatic dysfunction
Musculoskeletal: muscle spasm
Skin: dermatitis, purpura

Contraindications and Cautions:

• Contraindicated in patients hypersensitivity to drug and in those with anuria.
• Use cautiously in patient with hepatic cirrhosis and in those allergic to sulfonamides.
Use during pregnancy only if potential benefits to mother clearly outweigh risks to

Nursing Considerations
• Monitor weight, blood pressure, and pulse rate routinely with long term use and during
rapid diuresis. Use can lead to profound water and electrolyte depletion.
• Monitor uric acid level, especially in patients with a history of gout.
• Don’t confuse furosemide with torsemide or Lasix with Lonox.
Patient Teaching
• Advise patient to take drug with food to prevent GI upset, and to take drug in morning
to prevent need to urinate at night.
• Inform patient of possible need for potassium or magnesium supplements.
• Tell patient to check with prescriber or pharmacist before taking OTC drugs.
• Teach patient to avoid direct sunlight and to use protective clothing and a sunblock
because of risk of photosensitivity reactions.
Generic Name: Mebendazole
Brand Name: Vermox
Classification: Anthelmmintic

Mechanism of Action: Irreversibly blocks glucose uptake by susceptible helminths, depleting

glycogen stores needed for survival and reproduction of the helminths, causing death

Adverse Reaction:
GI: Transient abdominal pain, diarrhea
Other: Fever

Contraindications and Cautions:

• Contraindicated with allergy to mebendazole, pregnancy ( embryotoxic and

teratogenic; avoid use, especially during first trimester)
• Use cautiously with lactation

Patient Teaching
• Chew or swallow whole or crushed and mixed with food.
• Pinworms are easily transmitted; all family members should be treated for complete
• Use strict handwashing and hygiene measures. Launder undergarments, bed linens,
and nightclothes daily. Disinfect toilet facilities daily and bathroom floors periodically.
• You may experience these side effects: Nausea, abdominal pain, diarrhea (eat
frequent small meals)
• Report fever, return of symptoms, severe diarrhea.

After the case study the researchers were able to:

- Discuss the total overview of Anemia

- Gather patient family health history that is fundamental for the onset of her illness.

- Discuss the anatomy and physiology related to the client’s conditions

- Discuss the pathophysiology of the client’s condition.

- Discuss the diagnostic test undergone by the pt. and its implication.

- Classify prescribed drugs given by the pt. as the basis of his recovery.

- Formulate the nursing care plan to identify the present and possible problem of the


- Do health teachings with regards to his conditions.

Exercise and Activity:

Emphasize the need to maintain regular exercise and activities; to maintain muscle
strength and motility, to help activities; to help prevent bone demineralization, to decrease
protein breakdown and to promote good circulation of the body system. However, avoid
contact sports, crowds, and persons system. Passive exercise like breathing can also help
the patient to feel calm and comfortable.

Home Teaching:

Teach the patient/folks the importance of monitoring the progress and compliance with
the treatment regimen.

Patient needs ongoing education and reinforcement on the multiple dietary requirement
she needs.

Patient needs health promotion activities and health screening. Emphasize to the
patient the importance of having regular check-up to know her present condition.

Out patient Follow-up Out

After discharged, patient may go to clinic for follow-up check-up after a week. As part of
this follow-up care, she should receive blood test to check for the level of her RBC and Hgb.

Encourage intake of high biologic value protein foods such as eggs, dairy products and
meats (causes positive nitrogen balance needed for growth and healing).

Encourage high calorie and high iron containing foods like liver, red meat, seafood,
poultry, eggs, beans and peas, dark green leafy vegetables — such as spinach — and
raisins, nuts, and seeds.