APLASTIC ANEMIA

SUBMITTED BY: JE NAW AND APRILLE ANNE C. SAGMIT

SUBMITTED TO: MS. EULIMELLA BAEZ, RN, MAN
DATE SUBMITTED: OCTOBER 23, 2015

I.

INTRODUCTION
Aplastic anemia is a rare, non-contagious and often life-threatening disorder
that results from the unexplained failure of the bone marrow to produce red blood
cells, white blood cells and platelets. A decrease in the production of blood cells
means that patients are more susceptible to bleeding, fatigue and infections. (Bare
and Smeltzer, 2004)
Aplastic anemia is thought to be more common in Asia than in the West.
The incidence was accurately determined to be 4 cases per million populations in
Bangkok, but may be closer to 6 cases per million populations in the rural areas of
Thailand and as high as 14 cases per million populations in Japan, based on
prospective studies. This increased incidence may be related to environmental factors,
such as increased exposure to toxic chemicals, rather than to genetic factors because
this increase is not observed in people of Asian ancestry who are presently living in
the United States.
In the Philippines, a descriptive study of 47 male and 23 female patients
with aplastic anemia referred during the period January 1979 - December 1981 was
undertaken at the Philippine General Hospital. Insecticides, which were either
organophosphates or organochlorines, were implicated in 21 patients. The probable
causes of the onset of this disease are due to intoxication of harmful chemicals.
Aplastic anemia is caused by a failure of the bone marrow, leading to
insufficient production of peripheral blood element. The marrow failure is due to
primary defects in, or damage to the stem cell or marrow microenvironment. The
disorder is characterized by a severely hypoplastic (underdeveloped) fatty marrow that
is devoid of all three hematopoietic cell lines (erythroid, myeloid, and megakaryocytic).
As such, this has a very strong relationship to our concept fluids and electrolytes.
Hypovolemia, as one of the complications of aplastic anemia, is a fluid volume
disturbance when the loss of extracellular fluid volume exceed the fluid intake. Occurs
when water and electrolytes are lost in the same proportions as they exist in normal
body fluids, so that the ratio of serum electrolyte to water remains the same.

II.

OBJECTIVES
General Objective:
1. To fully understand the underlying disease process of aplastic anemia.
Specific Objectives:
1. To learn about the major etiologies of aplastic anemia.
2. To determine the previous and present clinical history of the patient.
3. To perform physical assessment with special attention on the systems
focus.
4. To show the laboratory examination results with the corresponding
normal values, actual result from the patient, and it interpretation.
5. To understand the anatomy and physiology of the blood and blood
formation and its pathology during aplastic anemia.
6. To trace and understand the pathophysiology of aplastic anemia.
7. To learn the basic principle of nursing management of aplastic anemia.
8. To use the nursing process to identify nursing problems from the client
and provide the appropriate nursing care plan.
9. To understand the pharmacological management set on the client and
provide nursing interventions.
10. To identify the discharge plan for the patients rehabilitation to conduct
an evaluation of the clients condition from admission to present.

III. PATIENTS PROFILE

Personal Data

Patients Name

: Patient Z

Age

: 73 years old 8 months 9 days

Gender

: Female

Address

: 325 Dalisay St. Bacood, Sta. Mesa, Manila

Educational Attainment : College Graduate

Civil Status

: Separated

Birthday

: March 04, 1942

Birthplace

: Sorsogon, Bicol

Religion

: Catholic

Nationality

: Filipino

Occupation

: Self-employed

Medical Data

Chief Complaint

: Dyspnea, Pallor and Fatigue

Admitting Diagnosis

: T/c Severe Anemia

Final Diagnosis

: Aplastic Anemia

Time and Date Admitted : 11:13 AM/September 13, 2015

4

Attending Physicians

: Dra. Ma. Angelina Mirasol and Dr. Nable Semilla

Chief Complaint:

Biglang nanikip ang dibdib ko, medyo nahirapan ako huminga at bigla
akong nahilo.

History of Present Illness

According to Patient Z, there were times that she experienced easy fatigability,
slight difficulty of breathing every time shes doing her usual activity. She continuously
takes supplementation for proper compliance. She was scheduled for a check-up last
August 7, 2015 at Our Lady of Lourdes Hospital and revealed that her laboratory result
was abnormal.

Past Health History

The patient was born March 4, 1942. Patient Z was completely immunized. She
underwent Bone Marrow Aspiration last August 7, 2015 at Our Lady of Lourdes
Hospital. No history of allergies of any kind. She was prescribed by her physician with
Epoetin 5,000 IU once a week (every Tuesday), Amlodipine for her maintenance, Folic
Acid, Vitamin B1, B6, B12 and Dimezine.

Personal/Social History
Patient Z is the eldest in their family. Her mother is still alive but her father left
them when she was 17 years old due to familial reasons and never heard from him
again. She has 3 brothers and 2 sisters who are all married and settled. She has 2 sons
and a daughter, who are all married and settled. She was married for quite a long time
but they got separated due to lack of understanding and trust for each other. She
doesnt usually drink liquors. Shes very active in terms of exercise because before she
owned a gym near her place. Now, she only attends Zumba and yoga classes every
5

Monday, Wednesday, Friday and Sunday morning at their street court, a project by their
Barangay Chairman. At her leisure time, she always spends her afternoon in her salon
which is 2 blocks away from her house and mingles with her kumares and some
neighbors.

Environmental History (Living/Neighborhood/Circumstances)

Patient Z is living with her 2 sons and her daughter including their own family.
They live in a house which she and his ex-husband bought many years ago. Their
house is within a subdivision kind of type where limited vehicles pass by. She also said
that their house is made of cement and wood which is enough for her family to live in.
According to her, cockroaches, flies and mosquitoes are present at their house. They
also own some appliances like television, radio, electric fan, personal computer and air
conditioner. They have an electric and water connection. They live in a place where
houses are a little bit close but not closer to each other. She also owned a salon 2
blocks away from her house. She also said that their environment is peaceful and quiet.

Family History
There are no recalled histories of any diseases in the family. She grew up close
to her mother side but not to her fathers side. She cannot recall any disease in both of
her parents side.

IV.

GENOGRAM

Maternal Side

Paternal Side

Legends:

Girl
Boy

PATIENT Z

Maternal Side:

Paternal Side:

Grandmother (deceased)

Grandmother (deceased)

Grandfather (deceased)

Grandfather (deceased)

Mother of the patient

V.

Father of patient

GORDONS FUNCTIONAL HEALTH PATTERNS

1. Health Perception/Management Pattern

BEFORE HOSPITALIZATION

She perceived health as being

able to work, fulfill her
responsibilities as a good
mother and good provider. She
believes that health is a very
important weapon to live a
long and peaceful life.

DURING
HOSPITALIZATION
Still have the same
perception of what health
is. However, patient Z
realized that its difficult to
be sick because of the
physical and financial
constraints. Patient Z
during hospitalization is
conscious, calm and
normal. Though there is
an obvious sign of
weakness and pallor.

ANALYSIS AND
INTERPRETATION
Many people define and describe
health as: Being free from
symptoms of disease and pain as
much as possible, being able to be
active and to do what they want or
must, and being good in spirits
most of the time. (Kozier.
Fundamentals of Nursing, 8th ed.)
With her being in a weakened
state, she can no longer fulfill her
role as a mother as long as her
illness continue. Her health is
impaired and thus cannot enjoy
her usual routine.

2. Nutritional/Metabolic Pattern

BEFORE HOSPITALIZATION

Patient has no known food

DURING
HOSPITALIZATION

ANALYSIS AND
INTERPRETATION

The patients diet is full Health status greatly affects ones

8

allergies and eats foods such as

green leafy vegetables and
fruits. She doesnt like much
fatty foods. She eats 3 full meals
a day: breakfast, lunch,
sometimes a snack in the
afternoon and dinner. She
doesnt drink alcohol and drinks
8 to 10 glasses of water every
day. She also doesnt like too
much sweet/salty foods and
crackers. She perceived that
eating crackers and sweet/salty
foods will only lead to kidney
malfunction and diabetes which
for her is a fact.

low purine. She drinks

water
8
to
10
glasses/day with an IV
fluid of PNSS 1L infusing
well at KVO rate. The
patient loss weight 1lb.

eating habits and nutritional status.

Disease process can disrupt
metabolism and caloric needs of a
middle-aged adult. Alterations in
the clients diet are often needed to
treat a disease process, to
increase or decrease weight, or to
allow an organ to rest and promote
healing. (Kozier. Fundamentals of
Nursing, 8th ed.)
Her current diet is same as from
her normal diet which involves a lot
of green leafy vegetables and
fruits.
.

3. Elimination Pattern

BEFORE HOSPITALIZATION

Patient reported that she voids

and defecates regularly. She
passes out stool twice a day;
she said her stool is usually
formed and brown in color.
Patient did not have any
difficulty urinating or defecating.

DURING
HOSPITALIZATION
Patient verbalized that
she still passes out stool
once or twice a day and
is formed and still brown
in color.

ANALYSIS AND
INTERPRETATION
The healthy body maintains a
balance between the amount of
fluid ingested and the amount of
fluid eliminated. The excretory
function of the kidney diminishes
with age, but usually not
significantly below normal levels
unless a disease process
intervenes. The frequency of
defecation is highly individual, the
amount also varies from person to
person. Many older people believe
that regularity means a bowel
movement everyday. (Kozier.
Fundamentals of Nursing, 8th ed.)
Her current urine output indicates
on how her body is suffering from
9

the disease. An altered elimination

pattern is very detrimental to any
person.

4. Activity/Exercise Pattern

BEFORE HOSPITALIZATION

HOSPITALIZATION

ANALYSIS AND
INTERPRETATION

Patient is physically active. She

said that she attends zumba and
yoga at their community
regularly every Monday,
Wednesday, Friday and Sunday.
She also said that sometimes
she plays badminton. Most of
her leisure time she spends it
inside her salon cleaning, dying
hair, nail polishing and doing
make-ups which she thinks lead
her to her condition today. She
also said that she noticed that
she easily gets tired when shes
moving a lot but she didnt mind
it.

Patient was advised not

to
perform
any
strenuous activity and
rest.

People often define their health

and physical fitness by their
activity because mental well-being
and the effectiveness of body
functioning depend largely on
their mobility status. People with
mobility impairments may feel
helpless and burdensome to
others. (Kozier. Fundamentals of
Nursing, 8th ed.)
Her condition has severely
impaired her daily activities and
even the most simple of those
tasks are important. It is difficult to
adjust into another
activity/exercise pattern just to
accommodate her limited abilities
in performing activities.

5. Sleep/ Rest Pattern

BEFORE HOSPITALIZATION

DURING
HOSPITALIZATION

Patient verbalized she sleeps at During

ANALYSIS AND
INTERPRETATION

hospitalization, People require sleep in order to

10

around 9 to 10pm after watching

telenovelas. The late time she
sleeps is 11pm. She also takes
a nap in the afternoon after
lunch. She said that she never
experienced sleeping late at
night. 11pm is the maximum
time she can handle.

patient verbalized that

she sleeps at night
properly. There were
times when she was not
able to sleep/rest aside
from
her
condition,
another factor is the
visitation of the nurses
who takes her vital
signs, medicines, etc.

cope with daily stresses, to

prevent fatigue, to conserve
energy, to restore the mind and
body, and to enjoy life more fully.
Illness that causes pain, physical
distress personal problems and
stress can result in sleep
problems. (Kozier. Fundamentals
of Nursing, 8th ed.)
Sleep deprivation being present
means that her pattern was
disrupted. Her current condition
causes pain and thus due to it she
cannot sleep very well.

6. Cognitive/ Conceptual Pattern

BEFORE HOSPITALIZATION

Patient did not experience any

sensory deficits, she did not use
hearing aid, or eye glasses.
She speaks Tagalog and English

DURING
HOSPITALIZATION
Patient speaks Filipino.
She did not have any
difficulty reading, writing
and
communicating.
Answered
every
question correctly and
was able to recall some
information
about
herself. Patient is also
oriented to person, time
and place.

ANALYSIS AND
INTERPRETATION
The aged adults cognitive and
intellectual abilities change very
little. Cognitive process includes
reaction time, memory,
perception, learning. Problem
solving and creativity. (Kozier.
Fundamentals of Nursing, 8th ed.)
The condition disables her ability
to properly recognize and
comprehend and verbal or nonverbal cues. Concentration is still
intact and she can still
communicate properly among
persons.

11

7. Self-Perception Pattern

BEFORE HOSPITALIZATION

Patient verbalized that she felt

good about herself before the
hospitalization because she was
able to work and fulfill his
responsibilities.
She
also
reported that she is patient
about things and makes it a
point to resolve all matters that
annoys her. She does not have
any negative feelings about
herself or people around her.
She has a positive outlook in his
life because he felt fulfilled.

DURING
HOSPITALIZATION

ANALYSIS AND
INTERPRETATION

Patient verbalized that

during
hospitalization
and during treatment,
she felt like losing hope
because
she
thinks
shes going to die. She
felt bad about herself
because
of
the
limitations
that
she
experience.
However,
the support of the family
is one of the reason why
she is she still happy.

A positive self- concept is

essential to a persons mental and
physical health. Self- concept also
extends to the choices people
make and perceptions they have
about their health. People
respond to stressors such as
illness and alterations in function
related to aging in variety of ways.
Individuals with poor self-concept
may express feelings of
worthlessness, self-dislike or even
self-hatred. They may feel sad, or
hopeless, and may state they lack
energy to perform even the
simplest of tasks. (Kozier.
Fundamentals of Nursing, 8th ed.)

DURING
HOSPITALIZATION

ANALYSIS AND

8. Role/Relationship Pattern

BEFORE HOSPITALIZATION

Patient lives with her 2 sons and

her daughter including their
families. Patient also said that
she has good relationship with
her friends, neighbors and
family.

During
hospitalization,
the family of the patient
stays with her in the
hospital.
Her relative
visits her and is taking
care of her. She felt
grateful
by
their
presence even though

INTERPRETATION
Throughout life, people undergo
numerous role changes. Each
person usually has several roles.
Failure to master a role creates
frustrations and feelings of
inadequacy, often with
consequent lowered self-esteem.
(Kozier. Fundamentals of
12

her situation is odd.

Nursing, 8th ed.)

9. Sexuality/Reproductive Pattern

BEFORE HOSPITALIZATION

Patient is separated with her

husband. They have 2 sons and
a daughter who also have their
family of their own. After, they
got separated; she said she
doesnt
have
any
sexual
partners anymore. She quote,
One husband is enough and
three children. Ayoko ng sakit sa
ulo! and then she laughed.

DURING
HOSPITALIZATION
During
her
hospitalization, nothing
changed with her sexual
life. It remained the
same.

ANALYSIS AND
INTERPRETATION
Regardless of gender, age, race,
socioeconomic status, religious
beliefs, physical and mental
health, or other demographic
factors, people express their
sexuality in a variety of ways
throughout their lives. Sexual
health is the integration of the
somatic, emotional, intellectual
and social aspects of sexual
being, in ways that are positively
enriching and that enhance
personality, communication and
love. (Kozier. Fundamentals of
Nursing, 8th ed.)

10. Coping/Stress Tolerance Pattern

BEFORE HOSPITALIZATION

When faced with problems, she

talks to the person involved to
resolve it in a peaceful manner.
She prays to God whenever she
felt like everythings falling apart.
She also said that she doesnt

DURING
HOSPITALIZATION
During hospitalization, it
is very obvious that the
patient just sleeps and
pray
whenever
she
experiences
and
encounters
unwanted
situation and lately she

ANALYSIS AND
INTERPRETATION
Coping strategies vary among
individuals and are often related
to the individual\s perception of
the stressful event. A persons
coping strategies often change
with a reappraisal of a situation. If
13

hold grudges from other people. doesnt

I forgive them right away. stress.
Forgiving them relieves me from
any stress that may come in the
future

encounter the duration of the stressors is

extended beyond the coping
powers of the individual, that
person becomes exhausted and
may develop increased
susceptibility to health problems.
(Kozier. Fundamentals of
Nursing, 8th ed.)

11. Value/Belief Pattern

BEFORE HOSPITALIZATION

She felt contented with her life.

She is a Roman Catholic and
goes to church every Sunday
and visits Quiapo church on a
Friday.

DURING
HOSPITALIZATION
Because of the patients
condition, the chaplain of
the hospital does his
rounds and thats the
only time, the patient
receives holy sacrament.
Plus the holy mass that
was being played all
over the hospital rooms.

ANALYSIS AND
INTERPRETATION
Spiritual health as defined by the
Nursing Outcomes Classification
progect (Moorhead, Johnson, &
Maas, 2004 p.519), is the
Connectedness with self, others,
higher power, all life, nature and
the universe that transcends and
empowers the self. (Kozier.
Fundamentals of Nursing, 8th ed.)

After the diagnosis of her disease,

patient now has a stronger and
deeper relationship with God.

14

VI. Physical Assessment

General Appearance
Patient was received awake, responsive and coherent, with ongoing blood
transfusion and with IVF infusing well PNSS1L x KVO with a side drip of 2 nd unit packed
RBC via leukofilter at the left metacarpal vein. Patient has a mesomorphic type of body
built and weighs 82 kilograms and with a height of 52 ft. The patient was certainly
oriented to time, place and persons. Hygiene and cleanliness are maintained.

Vital Signs
T 36.9o C
P 80 bpm
R 21 bpm
BP 140/80 mmHg

Head
Head was normocephalic and had a smooth skull contour. Hair was smooth, and
evenly distributed. The hair was black in color and silky. The scalp was clean. No
swelling or tenderness noted upon palpation.

Ears
Both ears were symmetrical; auricle aligned with outer canthus of the eye. The
color of the outer ear was homogenous with that of the skin color. The external pinna
was firm, and non-tender. No discharges, tenderness, masses, or swelling were noted
upon inspection and palpation.

Eyes
Both eyes were symmetrical. Eyelashes equally distributed, curled slightly
outward. Pupil size in 3mm in diameter for both eyes. Reaction to light was brisk. There
15

was a uniform reaction to accommodation. The pupil was black in color with pinkish
conjunctiva. Lids closed symmetrically, skin intact, no discharges and no discoloration.
Blinking reflex was functional. No ulceration or lesions noted on the area. There were
obvious signs of darkened eyebags.

Nose
The external was symmetrical. Nasal mucosa was intact and pinkish in color and
was free of purulent discharges. No nasal flaring noted.

Mouth and Throat

The lips were dry and light pink in color. The gums were pinkish in color. Her
teeth were still intact, with orthodontic braces and complete set of teeth. Uvula was at
the middle. Mucosa was pinkish. Tonsils were uninflamed. No further abnormalities
noted.

Neck
The neck was symmetrical and was proportion to head and shoulder. The thyroid
were smooth as palpated. She was able to turn her head in upward, sideward and
downward position with movement. The carotid artery has mild pulsation. No sign of
lesion or tenderness noted.

Chest and Lungs

Size , shape and symmetry were normal, chest movement is bilateral equal,
respiratory rate is normal, dyspnea, cough, hemoptysis, cyanosis were absent, resonant
sound found all over the lungs are and no any dull sound on percussion, wheezing,
crept sounds were absent, normal breathing sound is present on auscultation and no
any abnormality found.

Abdomen
The abdomen was soft, globular and non-tympanitic. Upon palpation, the right
lower quadrant is still painful and still covered with sterile gauze. Bowel sounds were
still monitored.

16

Lower/Upper Extremities
Both upper and lower extremities were normal. No signs of lesions, deformity and
tenderness. Skin is uniform with the skin color of the body.

Cardiovascular System
Patients blood pressure was monitored every hour when she was under our
care. Blood pressure ranges from 140/80 mmHg to 160/80 mmHg. Her pulse from
80bpm to 85bpm. Capillary refill within 3-5 sec.

Musculoskeletal System
Muscle weakness is absent, joint pain or stiffness is absent, edema on joints or
ankles are absent and any other fracture or deformity is not found.

Skin/Skin Appendages
Patients skin was cold to touch with fair complexion; fingernails were trimmed
and tidy. Hair was distributed evenly no clubbing of fingers noted.

17

VI.

LABORATORY FINDINGS AND INTERPRETATION

COMPLETE BLOOD COUNT WITH PLATELET COUNT

Name: Patient Z
Age: 73 years 6 months and 9 days
Physician: Dr. Nable Semilla

Birthdate: 03/04/1942
Sex: Female

. DATE: 9/13/ 2015

HEMATOLOGY
TEST
Hemoglobin

REFRENCE
RANGE
120.00-150.00g/l

Hematocrit
0.37-0.451
Erythrocyte No.
4.00-5.00x (10)12/l
Conc.
Leukocyte No.
5.00-10.00x (10)9/L
Conc.
Leukocyte Differential
Segmenters
0.55-0.65
Lymphocytes
0.25-0.40

Monocytes
Platelet count
Red Cell indices
MCV
MCH
MCHC
RDW

RESULT
45.0

INTERPRETATION

0.13
1.32

Below Normal.
Indicates
Below Normal.
Below Normal.

3.3

Below Normal.

0.35
0.64

0.02-0.06
150.00-400.00x
(10)9/L

0.01
55.0

Below normal
Above normal.
Indicates presence
of infection and
the body fights
against it
Below Normal
Below Normal.

80.00-96.00fL
27.00-33.00pg
33.00-36.00g/dl
11.60- 14.60%

99.0
34.2
34.7
13.4

Above Normal
Above Normal
Normal
Normal

18

DATE: 09/13/2015
TEST
Total Protein
Albumin
SGPT (ALT)
Albumin/Globulin Ratio
Potassium
Globulin
Calcium (greater than
50 yrs. Old)
Creatinine

REFERENCE
RANGE
66.00-87.00 g/L
34.00-48.00 g/L
10.00-41.00 U/L
1.8:1-2.3:1
3.60- 5. 30 mmol/L
23.00-35.00 g/L
2.10-2.42 mmol/L

RESULT

INTERPRETATION

60.3
41.0
18.4
2.14:1
4.44
19.2
2.06

Below Normal
Normal
Normal
Above Normal
Normal
Below Normal
Below Normal

53.00-106.00
umol/L

50.0

Below Normal

Date: 08/06/2015
CHEST X-RAY REPORT

Name: Patient Z
Age: 73 years 5 months and 2 days
Physician: Dr. Nable Semilla

Birthdate: 03/04/1942
Sex: Female

Fibrohazed infiltrates are seen in both upper lungs.

Apico pleural thickening is noted in the right.
Heart is not enlarged.
Aortic knob is calcified.
Trachea is at the midline.
Right CP sulcus is blunted.
Left CP sulcus is intact.

IMPRESSION:

19

Findings suggestive of PTB, both upper lobes.

Atheromatous aorta.
Minimal pleural thickening, right.

VIII.

ANATOMY AND PHYSIOLOGY

IX.

PATHOPHYSIOLOGY

Predisposing Factors
-

Precipitating Factors:
Stress

Immunocomprom
ised

Genes
Age

Damage to the
microenvironment of the
marrow
Altered bone marrow
function
Reduced
hematopoiesis

Fatigue
Dizziness
Shortnes
s of
Breath
Pale Skin
Bruising
Oral

Anemi
a

Leukope
nia

Thrombocytop

20

APLASTIC

If treated:
-

Blood Transfusion
o Packed RBC
o Platelet Concentrate
o Transplantation (BMT)
o Peripheral Blood stem
cell
transplantation(PBSC

If NOT treated:
Pancytopenia
Relapse

RBC

Platelet

Hypoxem
ia

Hemorrha
ge

Hypoxia

Hypovole
mic

Anoxia

WBC
Localize
d
Infection
Systemi
c
Infection
Septic

X.
XI.

NURSING CARE PLAN

DISCHARGE PLAN

21