Introduction Anasarca is an accumulation of serous fluid in various tissues and cavities of the body.

It is different form edema in which it is defined as accumulation of fluid in the intercellular space of subcutaneous tissue or in body cavities. Here also is the difference between anasarca and edema --- Anasarca is different from slight swelling or edema that occurs mostly in the feet. In anasarca, the person looks like bloating and when the person is pinched, the skin will not go back to its normal condition right away. Anasarca refers to a diffuse generalized edema of multiple organ systems due to effusion of fluid into the extracellular space. Anasarca is very common in patients with kidney failure and heart failure because there is a loss of protein in the urine and the kidney cannot function well as a result water and other toxins are retained in the body while with heart failure there is a poor cardiac function so there is lesser blood volume that is pumped by the heart to be delivered in the other parts of the body. As a result, the kidney will be alarmed that there is a decreased blood volume in the body. To compensate for that problem, the kidney will retain salt and water thus, edema happens. Usually anasarca indicates severe illness and may often be seen in the serious condition. It is usually caused by cirrhosis of the liver or renal failure and increases over a short period of time. (http://symptomscausestreatment.com, 4 Feb 2012, Web.) Here are some symptoms of anasarca: vomiting, cramps, shortness of breath, weakness in body, swelling of the ankle and feet, anemia, unable to sleep at night, stretched out skin, burnished skin, loss of appetite, changes in blood pressure and insomnia. There are also some precautions to be followed in person who is suffering from anasarca and these are avoid chocolates, alcohol drink, exercise regularly, avoid water pills and salt, eat high fiber diet, take protein food like egg, broiled white fish, cottage cheese which can help to reduce edema but some of this precautions may be disregard by the attending physician. Patient who is suffering from anasarca may have an underlying cause of hypoproteinemia. This condition refers to a disorder characterized by a decrease in the amount of protein in the blood to an abnormally low level accompanied by edema, nausea, vomiting, diarrhea, and abdominal pain. It may be caused by an inadequate dietary supply of protein, by intestinal lymphangiectasia, or by renal failure. One common cause of hypoproteinemia is the kidney failure where in damaged kidneys start leaking proteins into the urine, causing proteinuria. This happens because of the plasma protein that causes the fluid to be pulled back into the capillary's from the tissue spaces. This is also called the capillary colloidal osmotic pressure or the pressure needed to pull back the fluid back into the vascular space. So plasma proteins act as regulators in keeping the capillary pressure in harmony. When there is a decrease in plasma proteins, this pressure is decreased and fluid starts to build up in the tissue spaces. Plasma proteins are derived from the liver. The liver cannot synthesize these plasma proteins without certain amino acids which can only be achieved by dietary intake. With malabsorbtion, there is insufficient intake of these amino acids and it results in Edema.

There is also a relation between anasarca and pleural effusion. First, pleural effusion is an abnormal collection of fluid in the pleural space resulting from excess fluid production or decreased absorption. Too much fluid impairs the ability of the lung to expand and move. According to some article, pleural effusion is an indicator of an underlying disease process that may be rule out as pulmonary or non-pulmonary in origin and may be acute or chronic. Since a pleural effusion is a manifestation of another illness, the risk factors are those of the underlying disease. It is nice to know that pleural effusions are usually seen in adults and less commonly in children. There are possible symptoms that can be seen in patient who have pleural effusion and these are shortness of breath which is the most common symptom of a pleural effusion. It happens when the effusion grows larger with more fluid, the harder it is for the lung to expand and the more difficult it is for the patient to breathe, Chest pain occurs because the pleural lining of the lung is irritated. According to study, the pain is usually described as pleuritic which define as a sharp pain, worsening with a deep breath. As the pleural effusion increases in size, the pain may increase. These two symptoms are the primarily seen in patient with pleural effusion. Objectives

a) General Objectives: During the course of the study, the patient and specific others shall have acquired knowledge on the risk factors that have contributed to anasarca, severe anemia, hypoproteinemia and peural effusion with its signs and symptoms and its therapeutic management. To gain understanding and show compliance on the treatment and management rendered by the health care team to and to be aware for its several effects that can potentially happen over again.

b) Specific Objectives: To make a trusting, cooperative and supporting relationship between the nurse researchers and the other members of the health care team to become united. To gain knowledge on the definition of anasarca, severe anemia, hypoproteinemia and peural effusion, its signs and symptoms, underlying causes, how it affect each disease and its relation to one another and lastly, medical and nursing care management. To give and received the best possible medical and nursing care that can help the individual to have a feeling of security, comfort and good development of the condition.

To demonstrate and promote compliance on each treatment and management. To demonstrate independence or self-care and home management upon discharge.

I.

HEALTH HISTORY

A. Demographic (Biographical) Data

Clients Name or Initial: Patient A Gender (Sex) : Female Age, Birthdate and Birthplace: 21 years old, July 15, 1991, Albay Marital (Civil) Status: Single Nationality: Filipino Religion: Roman Catholic Address and Telephone Number: Brgy. Alima Bacoor, Cavite Educational Background: College Graduate Occupation: Travel Agent Usual Source of Medical Care: Baranggay Health Center, Private Clinic Admission Date: 01/26/2013 Time Admitted: 8:50 pm Attending Physician: Dr. Rizalina C. Bunyi OB-GYNE, FPOGS Final Diagnosis: Anasarca secondary to severe anemia, hypoproteinemia, pleural efusin R&L lung S/P preterm delivery Jan. 04, 2013

B. Source and Reliability of Information

The patient itself seems reliable. The patients father, Mr. Cula who seems also reliable. Patients chart, staff nurses and the family is also a source for information.

C. Reason for Seeking Care

(+) chest pain - According to the patient, she felt pain on her chest every time she breath. Patient A added also that she is not comfortable when she feels any pain. Upon asking the severity of pain she is experiencing she answered 4 with a pain scale of 1-3 mild | 4-6 moderate | 7-10 severe. (+) difficulty of breathing

Patient experience difficulty in breathing in which it aids to increase the pain in her chest. The patient verbalized lalo akong nahihirapan huminga kasi may nararamdaman akong sakit sa dibdib ko. (+) generalized edema - The patient is experiencing edema since Jan. 04, 2013. According to her, she first notices her edema on her both feet until it ascends to her upper extremeties.

D. History of Present Illness Patient A, a 21 years old single woman was been admitted at St. Dominic Medical Center last January 26, 2013 with chief complaints of chest pain, difficulty in breathing and generalized edema. January 4, 2013 patient went to a preterm delivery and unfortunately it is still birth. According to the patient, it was her first baby and expecting to be delivered alive. Patient doesnt look that she has a hard time coping with the lost of her supposed to be first baby. There is no evidence of postpartum depression symptoms that is visible to the patient. 2 weeks PTA, patient noted edematous legs ascending to the trunk and upper extremities ascending to face. Patient also had cough for only 3 days which is productive. According to her, she doesnt take any medication instead she increases her fluid intake. Few days PTA, patient had difficulty of breathing and chest pain hence consults in St. Dominic Medical Center leading to subsequent admission.

E. Past Medical History The patient had an episode of asthma attack during her childhood years. The first attack was experienced when she was 6 years old. And according to her, she always had cough and colds during that time. In addition, she was been hospitalized because of her asthma but as the time goes by and she gets older she notices that she doesnt experienced it anymore. And according to patient A, that was the first time she was admitted to a hospital and that was when she was 6 years old. She remembers that last asthma attack that she experienced when she was already 15 years old. Patient A also suffered from having a chicken pox at age of 10. At first she experienced fever accompanied by headache and after 2 days she noticed a red spots on her skin. Afterwards, she consulted a general physician and it was been confirmed that she has chicken pox. Patient A added that when she was 18 years old was been hospitalized because of urinary tract infection. Patient added that she was been confined only for 3 days. And the last hospitalization was only this year January 04, 2013, due to preterm delivery. Patient doesnt acquire any accidents when she was a child up to the present but she got only mild injuries when she was a child like scratch from falling at stair. And according to her, the mild injury that she would never forget was when she fell down in her own bike during her 6th year of age. And as of now, patient doesnt remember any other injuries that she acquired.

Patient A menarche at age of 11. After 1 year of menarche patient experience dysmenorrhea, irritable and sometimes she experience blackout. Patients usual cycle of menstruation is irregular. According to her, she always experience a skip of one month in her LMP. Each period usually last for 3 5 days and the blood flow is normal. She usually consumed 3 soaked pads during day time and 1 soaked adult pampers at night. Patients LMP (last menstrual period) July 08, 2013. OB SCORE: G1P0, T0P0A1L0. Patient stated that she is not using any family planning method.
Immunization: BCG: // at birth / / school entrance DPT: // 1st dose // 2nd dose // 3rd dose OPV: // 1st dose // 2nd dose // 3rd dose TT: // 1st dose / / 2nd dose / / 3rd dose / / 4th dose / / 5th dose Hepa B vaccine: // 1st dose // 2nd dose // 3rd dose Allergies: Foods (chicken) F. Family History

The patient is the young among sibling. Next to her is a 23 year old male who is healthy according to patients point of view. Patients brother doesnt have any family yet and stays with them. He doesnt acquire any inherited illness from her father and mothers inherited health conditions. Her mothers side has a history of hypertension. In fact, her grandmother died from hypertension. Patients mother is the young among her 2 siblings. On her father side, there is a history of heart illnesses in which her grandfather died from stroke. His father has 2 siblings and he was the youngest. According to the patient, she doesnt remember any alleviated health conditions on the side of his father.

LEGEND:

Male

Female

Patient

Deceased

Died from stroke

Hypertensive

Alive & Well

Heart attack

Alive & Well

Alive & Well

Alive & Well

Alive & Well

Alive & Well Alive & Well 5 years old Menopause baby Alive and Well

23 y/o Alive & Well

G. Socio-Economic

21 y/o Diagnosis: Anasarca secondary to severe anemia, hypopreteinemia, leural efusin s/p preterm delivery Jan. 04, 2013

FAMILY MEMBER Patient itself

OCCUPATION SOURCE OF INCOME Travel agent

MONTHLY INCOME Php 8,000

The patient worked at travel agency located at Quirino wherein she works for 7 months.

They owned a house located at Bacoor, Cavite wherein they lived for almost 10 years since they left their province. Patient rent a bed space near her work place in which she spends her 5 days there and return to Cavite after her work. They have enough resources to support their daily needs and expenses. Patient A doesnt smoke and drinks alcohol. She added that she is not fun of going out to a night party or clubbing with her friends. But she added that if there is an occasion she can attend to that without no limitations even though if it is a night party.

H. Developmental History Erick Ericksons Psychosocial Development Theory - Stage: Intimacy vs. Isolation (Young Adulthood, 20-35 years old)

The patient starts family at an early age with no other issues except being pregnant in an early age but unfortunately she was been left by her partner after knowing that she is pregnant. She is very contented and feels secured with her family but still finding someone who can be her partner in life, the one who will love her strength and weakness and will never leave her during the ups and downs of her life. Patient is well committed to her life now. She expresses her unconditional love to her family and a wholehearted care. But still in this stage, patient continuously develop herself in expressing emotions to each family members. Patient is also building a God-centered and trusting relationship to her family that can help them to increase their faith which can aid them out in times of trouble. Patient has a tight relationship with her family and she is making a point that she will value what she had now. Even though patient experienced failure in her relationship, she still focuses her feelings and emotions to her family.

Patient still communicates with her friends from grade school up to college. She is still bonded with them even they have now their own families and priorities in life. They continue to develop and boost there feelings of friendship to one another. Even if they already have their own families their still have physical and emotional connection, support, love, comfort and trust to each other. I. Review of Systems

System

General

Integumentary

Head

Eyes

Ears

Nose & Sinuses

1. Regional Examination January 29, 2013 Actual Findings The current weight of the patient is 75 kg (165 lbs) and stands 5 tall. Based on the BMI categories she is said to be obese . BP: 140/90 mmHg PR: 95 bpm RR: 20 cpm T: 36.5oC (afebrile) Wt: 75 kg (165 lbs) Nails are cleaned, flat, smooth and firm with slightly curve. There is 160 degree angle between the nail base and the skin. It is hard and basically immobile. Nail plate is firmly attached to nailbed with capillary refill less than 3 seconds. Black is the natural hair color of the patient and hair strands are equally distributed with smooth in texture, firm and elastic. No hair loss is noted. The scalp is clean and dry without visible dandruff. Skin is intact with no redness noted. It is even and rough to touch with stretch marks and healed scars but without lesions seen. Dry skin is noted upon assessment. No birthmark was found on the patients skin. Skin surface is cool to touch. When skin pinches it doesnt returns immediately to its original position and doesnt rebound easily when pressure is released. The patients head is symmetric and round. It is held upright and still in midline of the spinal column. There is no lesion visible, no mass was been palpated and no evidence of head injury seen in patients head upon assessment. As of this time, patient doesnt experience headache or any disturbances in her head. Face is symmetric and round. There is visible edematous noted all over the patients face. There are no signs of deformities. No changes of vision manifested by the patient. It is 20/20 vision which signifies a normal distant visual acuity and can read prints at 12 inches without any difficulty. Patient doesnt use eyeglasses but she sometimes put contact lenses on her eyes for accessory purpose only. The eye movement is smooth and symmetric throughout the 6 directions from up, down, left, right, oblique left and oblique right. Upper and lower eyelids were able to meet together and close easily. Eyes are located in a proper placed and in line with each other. Pupils are easily reacted to light upon examination. Upon further assessment, there was no presence of swelling and redness on patients both eye. The ears are bilaterally equal in size and both auricles are also same in size with no deformities observed and aligned in the corner of each eye. Ears are line parallel to one another. Auricles skin is smooth without any presence of lesions, lumps or nodules. Ear lobes are attached to the skin. According to the patient, cerumen is yellow in color, soft and moist with no evidences of any other discharge like pus. And there is no evidence that patient has problem with her sense or hearing. Patient doesnt expose to any environmental noise. Patients nostrils are not deformed and have both equal in size and shape. It is moist with no presence of inflammation and abnormal discharge was been noted upon observation. There is no discoloration noted on the patients external nose. Its color is same with the complexion on the patients face. Nasal structure is smooth and symmetric without any tenderness felt upon palpation. Patient can breathe normally, sniff with each nostrils and a thoracic breather. No obstruction seen during observation

J. Functional Assessment

Health Perception and Health Management

Patient is not happy with his current health because she feels something wrongs. According to the patient before this condition happen she can perform her duties well in the family and outside the house like going to work. Patient doesnt have any activities that will improve her health only eating fruits and vegetables in substitute with rice but patient added that she usually exercise every morning for 60 minutes. She takes multivitamins daily as life time supplements prescribe by her doctor. Patient is very lenient in following doctors prescription and order. Patient A has knowledge about links between lifestyle choice and health. She was very conscious about her health in fact, she loves to eat different kinds of fresh fruits and vegetables and can really manage her life style choice that cannot affect her health status. The patient doesnt have any problems with regards on financing her health care because she her mother was the one who is supporting her hospital needs. Patient is aware with the current trends of medicine and the medication she is currently taking and its function in her body. She also has knowledge about her families medical problem in each side (mother and father).

Patient doesnt have any idea how she got that illness. According to patient A, she doesnt eat any foods that are bad for her health. In fact, she verbalized Masusustansyang pagkain nga ang aking kinakain at ako pa mismo ang nagluluto. Bihira lang ako bumili ng lutong ulam o kumain sa fast foods. Kaya nagtataka ako kung bakit ganito yung kalusugan ko. Patient doesnt take actions by herself to alleviate her health instead she decided to consult at St. Dominic Medical Center.

Nutritional and Metabolic Pattern

Patient A regularly eats meal 3 times a day with 2 snacks (occasionally). She doesnt follow any diet that she knows but she maintains her normal weight. In fact, she eats whenever she is hungry. The common food intake of the patient is fruits and vegetables but when it comes to pork and beef she only eats that occasionally and patient has an allergy to poultry products most especially chicken. According to her, she loves fruits and vegetables. Patients favorite fruits are banana, mango and

grapes. She can live in a day without eating rice. Patient doesnt eat rice but during morning she does. Patient verbalized, Sa umaga ako kumakahin ng rice para may lakas ako sa buong araw. Heavy breakfast lagi ang hinahanda ko kasi mas healthy iyon. Patient drinks water more than 8 glasses a day. According to her, she is not into soda but pineapple juice is her choice with regards to beverages. Patient is on diet as tolerated ordered by her doctor. Water is the only beverages taken last 24hr.

The patient skin condition is dry and rough with no rash and redness is seen but it is cool to touch. It is still intact with presence of massive edema. There are no skins problems observed and noted during physical examination. The hair is not dry, smooth to touch, firm and elastic. Nails are firm, clean and the nailplate is firmly attached to the nailbed. Body temperature is normal (36.5oC). Patient weight and height is not proportional to one another. According to BMI categories, patient is said to be obese.

Elimination Pattern

Patient A has a regular bowel and bladder movement. According to her, she defecates twice a day, one at early morning and the other before bedtime. Patient doesnt have any problem with regards to defecation. Patient stated, Hindi ako nahihirapang dumumi. Basta kapag nakaramdam ako ng tawag ng kalikasan pumupunta na kaagad ako sa banyo maghihintay ng saglit at lalabas na. Saglit lang ako sa banyo kapag dumumi hindi katulad ng iba na madami pang seremonya ang gingawa. According to the patient upon palpation, she doesnt palpated any palpable mass in her anus and its surrounding areas. She also added that she doesnt have any hemorrhoids.

Patient urinates normally without any hesitance and pain during urination but there is a problem on her urine out, it is insufficient to compensate her daily fluid intake. She added that she only urinates 3 times a day and its characteristic is light yellow in color. She doesnt see any crystals or blood in her urine. There are no disturbances and changes noted by the patient itself. Patient skin is dry and clammy without any implication of dehydration. No diseases are present in patients digestive and urinary system. It is functioning well base on the assessment.

Self-perception and Self-concept Pattern

The patient perceives herself as an individual created by GOD with his own image and likeness. According to her, those people who always replica herself and get envy will never succeed because every one is unique. Patients description about her physical appearance is medium in height but not proportion in weight. She thinks that her body is too big for her height. Patient A added that sometimes she feels not good with herself because she is chubby. She is also frustrated with her body and she really wants to become sexy like Anne Curtis. Patient is thankful to God because she has this asset with no deformities and hindrances that can affect her life. And in fact, she has the capacity to do and performs whatever she wants to do. The patient doesnt have any regrets with her appearance and she is happy and enjoying it. She is comfortable and contented for whatever she had in her body from head down to foot. Patient verbalized, Kahit ano pa ang itsura ko hinding-hindi ako magsusubok magparetoke kahit naniniwala ako na lahat ng nilika ng Diyos ay magaganda. Their no noticeable problem with patient;s image that can affect her capabilities. There are some negative feelings were been felt by the patient with her appearance but still she is satisfied with that. She repeated that she is happy and contented for what God has given her.

There are some changes felt by the patient during the time the illness arises. Patient feels that her body is too bloated because of massive edema. Patient verbalized Mataba na nga ako tapos buong katawan ko pa manas kaya hindi na ako komportable sa itsura ko. But patient pushes her dedication to compensate her bad thoughts by merely getting adequate exercise and thinking how to become healthy and fit.

Activities Tolerance Exercise Pattern

The patient usually performs morning exercise at their compound. According to patient A, almost every day she tries to perform morning exercise for about 60 minutes of combine running and walking. Patient spends most of her time during Saturdays and Sundays with her family. During Saturdays, they eat breakfast, lunch and dinner together. They spend all the time of Saturdays together. They would go to mall, buy some stuff for each other, watch movies and anything else that will boost their bond with each other. During Sundays, they all go to church to hear Gods message. After Sunday service, patient with her family will eat lunch

together in their own house. Patient added that if ever her off in work falls on weekdays she stills try make things and activities that will bond their family more. She always utilized all of her time with her family.

Patient regularly took a bath and sometimes she bathe 3 times a day most the days during summer season. Patient is very hygienic and making a point that every time she went to toilet she has her own tissue or wipes. Upon assessment, patient is well groomed. Patient A can perform her task well without any problem in her body and perceived ability for full self care.

Sleep Rest Pattern

The patient pattern of sleep is somewhat good because can be able to sleep whatever time she wants. And during day time, she spends a lot of time to her job but sometimes if there is no client and no pending paper works she tries to take a nap for a while so that she gain back some of her energy. As far as now, patient seems that she doesnt suffer from any sleeping disorder. The sleep-wake up cycle of the patient is waking early in the morning to for morning exercise and usually sleeps early at night. Patient doesnt have any factors that distract her sleeping pattern. And she added that there are no environmental factors that trigger the patients pattern of sleep. Most of the time upon waking, patient is satisfied in her sleep and she looks well relaxed and rested.

During the time that the patient was been hospitalized, she shared that she is not comfortable staying in the hospital thats why every time she woke up in the morning she looks lethargic. Patient A verbalized, Maaga akong nakakatulog at maayos naman din akong gumising kaya lang nanlalambot ako pag-gigising ko. Siguro dahil ito sa nararamdaman ko. According to patient A, if she has a time to sleep in the afternoon or anytime during the day, she maximized it to sleep so that at least half of her energy will restore.

Cognitive Perception Pattern

According to the patient, when it comes to vision and other sensory organ it is functioning well without any procedure done since she was been born and doesnt experience any problem with her sensory modes. Patients vision is 20/20 and categories as normal. According to her, she can read writings even though it is written in font 12. She can also see things clearly even if it is 12 inches far from her and can differentiate one object to another. Patient can hears words clearly and can answer question correctly during the interview. She can differentiate sounds and repeat sentences that was been whispered softly in her ears. Patient A is very aware when it comes to touch. She was very sensitive to it. She can easily feels something like if you dump the cotton slowly and softly on her skin. She can differentiate hot, warm and cold from the other. Patients both palms can grasp and hold things for a period of time without any presence of shaking or tingling. But according to patient A, sometimes if the object is too big she has a hard time to hold it because of swelling in her both hands. It is also not numb because patient can feel the pain when I gently pinch her palms. Patient A can distinguish different kinds of taste (sweet, sour, salty and bitter) from one another without any doubled thoughts. Upon assessment, patient doesnt have any problem in regards to sense of taste. Patient can smell different scent of perfumes, fruit and etc. She can also tell the difference between each scent. There is no possible problem in patient sensory of smell because she can identify immediately the difference with each other.

During the interview, patient can express her feelings and thoughts clearly and logically. Base on the ways the patient answers the questions, she can be automatically judge of acquiring a highly educated person. Patient is a college graduate She seems that she doesnt have any problem with his mental and sensory function. Patient identifies pain as a tolerable feeling because according to her she had a wide pain threshold. As she can tolerate the pain she wouldnt take any medicine except if it is prescribe by her doctor. Currently, she pain is suffering from mild pain due to her condition.

Role Relationship Pattern

The patient is the young in the family. She only has one sibling. Next to her is a 23 year old male who is healthy according to patients point of view. Patient still has a father and mother who are doing all the roles. According to patient, she doesnt have any new significant roles in her life but she added that before she had a preterm delivery she is expecting for a big changes of role in her life and this is to become a good

mother but unfortunately it doesnt happen because the outcome was still birth. Now, she still performing my role as a good daughter to my parents and sibling. Being the youngest and the girl in the family she was assigned in many task in household chores. Patient doesnt have any regret or bad feeling with my role and in fact, she is satisfy and enjoying her role in the family. Patient A was also helping their family in financing their daily need. Even though her mother was the one who gives everything still patient wants to help.

The patients relationship to her family is very close, tight, God and family centered. They both expressing their love from one another and continuously gaining enough affection from them. Patient doesnt have any significant relationship at this moment instead she focuses on her own relationship with her family.

Values Belief Pattern

The patient had learned the values and beliefs that were been introduce to her by her mother were all important during her childhood years and until now she is conveying it. Most of the values that the patient learned from her parents are still present and she used to act upon it. Manners are well taught according to her because patient believes that if you have good manners it simply signifies that your parents mold you in a very nice manner. According to the patient, spiritual beliefs is one of her guide in life most especially when it comes to lifestyle choice and decision making. Patient verbalized, Naniniwala ako sa kakayanan ng ating Panginoon na siya ang gagabay sa aming pamilya. At higit sa lahat alam ko na hindi kami pababayaan ng Panginoon dahil malakas ang pananampalataya naming sa kanya. The patient doesnt put any trust on what we called Albularyo when it comes to health, because she knows that they dont have the capabilities to cure disease. Her perspective to health is already modern in which only doctor with the guidance of God is the one can cure and everything that happens in our life is Gods perfect choice and plan for our family. K. Personal / Social History Patient is the youngest in the family. She is an intelligent, bright and down to earth person. She is friendly and nice person and in fact, during her elementary up to college days she had plenty of real friends but according to her she only consider 4 best friends of hers. The patient doesnt want people who are stabber, back fighter, liar, social climber and

boastful. She also doesnt want a person who always talks about nonsense topic instead she wants interesting and knowledgeable subject. Patient usually works out every morning and she is having fun every time she performs it. There is no sports was been played by the patient. The patient usually prefers to have a healthy life style but still she is trying to achieve it most especially in performing exercise. She doesnt have fan of any sports but she loves watching movies with her friends while eating pop corn and have some pep talk as well. Patient also loves to eat in a buffet which only cost not that much. According to patient A, whenever she was stress she was into singing and cooking. All of the bad vibes were lessen if she does it including listening to radio and playing music. She spends some of her money buying stuff for their house and for herself, and family. She doesnt feel anything about how much money she spends for a one day in buying some stuff. Patient loves and like going to different destination but there was a hindrance with her finances. L. Environmental History Patient is currently residing at Bacoor, Cavite. Their own house was been surrounded by plenty of neighbors. Patient added that there are lots of trees in there area and it looks refreshing. According to the patient, her place was peaceful and safe but sometimes it is noisy because of some occasions like birthdays, wedding reception, fiestas and etc but most of the time it is a quiet place. The place has security that roams around especially at midnight care of the baranggay counsel. There are streetlights and warning device posted in some accident prone areas. Drainage is well maintained and clean without any bad odor. The streets are cleaned and maintained by the street kipper and only some homeowners who still really do burning of trash. M. OB-GYNE History Patient A menarche at age of 11. After 1 year of menarche patient experience dysmenorrhea, irritable and sometimes she experience blackout. Patients usual cycle of menstruation is irregular. According to her, she always experience a skip of one month in her LMP. Each period usually last for 3 5 days and the blood flow is normal. She usually consumed 3 soaked pads during day time and 1 soaked adult pampers at night. Patients LMP (last menstrual period) July 08, 2013. OB SCORE: G1P0, T0P0A1L0. Patient stated that she is not using any family planning method.

II. Laboratory Studies and Diagnostics HEMATOLOGY

Examination Hemoglobin

Results 106

Reference 125-160

Value g/L

Significance Decrease in adequate tissue oxygenation

Hematocrit

0.32

0.38-0.50

Decreased impaired erythropoeisis. Decreased numbers are seen in disorders involving in impaired erythropoeisis excessive blood cell destruction (ex: hemolytic anemia) and blood loss and in chronic inflammatory diseases.

RBC Unit WBC Unit

4.25 4.25

5-15

10^g/L 10^g/L

Neutrophile Eosiphile Basophile Lymphocyte Monocyte Reticulocyte Platelet Count Blood Typing Bleeding Time Clotting Time MVC MCH MCHC MPV

0.54 0.00 0.00 0.38 0.08 0.00 386

5-10 0.40-0.60 0.01-0.06 0.00-0.01 0.20-0.40 0.02-0.08 4.5-5.5 150-350 2-4 7-15 86-100 26-31 310-370 9.13

% % % % % 10^4/L

Increase Infection ( Bacterial, Viral, Malignancies)

75 24.9 331 9.60

Mins Mins fL PG g/L f/l

I. Pathophysiology

Fluid in the body exists within cells (intracellular fluid), within the tissue space between cells (interstitial fluid), within the blood vessels (blood) or lymphatic vessels (lymph or lymphatic fluid). This fluid is not just water but there are also cells, nutrients, electrolytes and waste products existing with water in these areas. Two forces are responsible for maintaining the fluid in specific areas or pulling and pushing fluid into other areas. These forces are known as hydrostatic pressure and osmotic pressure. Hydrostatic pressure is the force that pushes fluid from an area of high pressure to low pressure. Osmotic pressure is the force that draws fluid from an area of low electrolyte concentration to one of a higher electrolyte concentration. Fluids within our blood vessels are at a higher pressure than the fluid in the tissue spaces. This is due to the pumping heart that pushes the blood with force within the vessels. Blood does not just ooze out of the vessels unless the vessel wall becomes permeable and allows it to exit. Fluid within the tissue spaces also have a hydrostatic force but this is usually smaller than the pressure within the vessels so very little fluid flow from the tissues spaces into the vessel due to hydrostatic pressure. Usually fluid from the tissue spaces enters the blood vessel due to a difference in osmotic pressure. Fluid is pushed away from an area of high hydrostatic pressure but is pulled into an area of high osmotic pressure. Therefore the blood vessels which have a higher hydrostatic and a higher osmotic pressure will push out some fluid into the tissue spaces and draw other fluids from the tissue spaces. This allows for the exchange of nutrients, gases and wastes. The lymphatic system also plays an essential part here as the interstitial fluid is pulled from the tissue spaces into the lymphatic vessels which then empties into the blood vessels. II. Concept Mapping

Key Problem #1 Ineffective breathing pattern related to decrease lung expansion (accumulation of air and liquid)

Key Problem #2 Ineffective tissue perfusion related to vasoconstriction of blood volume

Key Demographic Data: Clients initial: Patient A Age: 21 y/o Gender: Female Assessment of Patient: Chest pain, Shortness of breathing, Massive edema Key Assessments: BP: 140/ 90 mmHg RR: 20 cpm PR: 95 bpm Temp: 36.5 0C

Key Problem #3 High risk damage to skin integrity related to circulatory and neurologic changes III. Problem List

Key Problem #4 Fluid volume excess related to water retention secondary to decreased renal perfusion and cardiac output

ACTUAL or active

Problem No.

Problem

Remarks

1.

Ineffective breathing pattern related to decrease lung expansion (accumulation of air and liquid)

Patient will indicate normal and effective breathing pattern within her normal range. Patient blood pressure decreased from 140/90 to 120/80 after a 4 hour nursing intervention.

2.

Ineffective tissue perfusion related to vasoconstriction of blood volume

3.

High risk damage to skin integrity related to circulatory and neurologic changes

Patient maintain and improve ambulation with performs normal daily activities.

4.

Fluid volume excess related to water retention secondary to decreased renal perfusion and cardiac output

Patient demonstrates stabilized fluid volume with balanced intake and output.

5.

Activity intolerance related to imbalance between oxygen supply and demand

Patient achieved measurable increase in activity tolerance, evidenced of reduced fatigue and weakness.

IV. Nursing Care Plan

a. Ineffective breathing pattern related to decrease lung expansion (accumulation of air and liquid)

Assessment
S: Nahihirapan pa din akong huminga kahit na may nakalagay na oxygen sa ilong ko pero kumpara ngayon mas medyo nakakahinga ako ng maayos kesa dati na walang oxygen as verbalized by the patient. O: Received patient lying on bed with on going D5LR, 1L to run for 8 hours, IV is intact and on oxygen therapy. Conscious and coherent Ambulatory Cool to touch (+) dry lips and skin (+) skin pallor (+) massive edema grade: ++++ (+) facial grimace (+) guarding behaviour BP: 140/ 90 PR: 95 bpm RR: 20 cpm Temp: 36.5 0C

Diagnosis
Ineffective breathing pattern related to decrease lung expansion (accumulation of air and liquid)

Planning
After 4 hour of nursing interventions, the patient will establish a normal and effective breathing pattern within her normal range.

Intervention
Independent: Identify etiology or precipitating factors. Monitor vital signs. Assess lung sounds, respiratory rate and effort and the use of accessory muscles. Evaluate respiratory function, noting rapid or shallow respirations, dyspnea and changes in vital signs. Observe skin and mucous membranes for signs of cyanosis. Encourage adequate rest and limit activities within clients level of tolerance. Promote a calm and restful environment. Dependent: Administer supplemental oxygen as ordered by the physician.

Evaluation
GOAL MET. Within 4 hour of nursing care, the patient stated Maginhawa na ang pakiramdam ko ngayon hindi katulad nung nakaraan araw. At mas maayos na din ang aking paghinga. In addition, the patient participated in treatment regimen. Vital signs are within normal range.

Administer medications as prescribed by the physician.

V. Medical Surgical Management

a. Pharmacotherapeutic b. GN (BN) Classification Stock Ferrous Sulfate (Iberet Active) Classification: Iron preparation Indication (Client Specific) Dosage & Frequency Indication: Prevention and treatment for iron deficiency anemia and dietary supplement for iron. Nursing Responsibilities includes Health Teaching and Implications 1. Contraindicated in clients with hemolytic anemia, peptic ulcer and ulcerative colitis. 2. Administer with food to prevent

Mechanism Of Action Ferrous sulfate facilitates O2 transport via haemoglobin. It is used as iron source as it replaces iron found in

Side Effect Adverse Reaction GI irritation abdominal pain cramps nausea and vomiting constipation

Dosage & Frequency: Adult: Treatment: 400600 mg daily in divided doses. Prevention: 200 mg daily. Child: Treatment: <6 yr or <22 kg: Not recommended. 6-12 yr: >22 kg: 200 mg daily; >44 kg: 200 mg bid >66 kg: 200 mg tid

hemoglobin, myoglobin and other enzymes. Onset: Oral: 3-10 days. Absorption: Duodenum and upper jejunum: 10% absorption after oral admin in persons with normal serum iron stores; 20-30% absorption in those with inadequate iron stores. Excretion: Via urine, sweat, sloughing of the intestinal mucosa and menstruation. These medications block the transport of calcium into the smooth muscle cells lining the coronary arteries and other arteries of the body. Since calcium is important in muscle contraction, blocking calcium transport relaxes artery muscles and dilates coronary arteries and other arteries of the body. By relaxing coronary arteries, amlodipine is useful in preventing chest pain (angina) resulting from coronary artery

diarrhea dark stool discoloration of urine heartburn

GI upset. Inform clients of side effects like nausea and vomiting, diarrhea, constipation, epigastric pain and refer to attending nurse upon occurrence for management. 4. Monitor adverse reaction. 3.

Amlodipine (Norvasc) Classification: Cardiovascular agent Calcium channel blocker Antihypertensive agent

Indication: In patients with severe coronary artery disease, amlodipine can increase the frequency and severity of angina or actually cause a heart attack on rare occasions. This phenomenon usually occurs when first starting amlodipine, or at the time of dosage increase. Excessive lowering of blood pressure during initiation of amlodipine treatment can occur, especially in patients already taking another blood pressure lowering medication. In rare

CV: 1. Monitor BP for Palpitations, therapeutic flushing effectiveness. BP tachycardia, reduction is greatest peripheral or facial after peak levels of edema, bradycardia, amlodipine are chest pain, syncope, achieved 69 h postural following oral doses. hypotension. 2. Monitor for S&S of dose-related CNS: peripheral or facial Light-headedness, edema fatigue, headache. 3. Monitor BP with postural GI: changes. Report Abdominal pain, postural hypotension. nausea, anorexia, 4. Monitor more constipation, frequently when dyspepsia, additional dysphagia, diarrhea, antihypertensives or flatulence, vomiting. diuretics are added. Urogenital:

instances, congestive heart failure has been associated with amlodipine, usually in patients already on a beta blocker. Dosage & Frequency: Hypertension Adult: PO 510 mg once daily Geriatric: start with 2.5 mg, adjust dose at intervals of not less than 2 wk Renal Impairment Start with 2.5 mg, adjust dose at intervals of not less than 2 wk

spasm. Relaxing the muscles lining the arteries of the rest of the body lowers the blood pressure, which reduces the burden on the heart as it pumps blood to the body. Reducing heart burden lessens the heart muscle's demand for oxygen, and further helps to prevent angina in patients with coronary artery disease.

Sexual dysfunction, frequency, nocturia. Respiratory: Dyspnea. Skin: Flushing, rash. other:Arthralgia, cramps, myalgia.

I. Discharge Health Teaching Advice patient to return upon occurrence of symptoms listed below: - Fever - Gain weight for no known reason - Urinate more than usual. - New or increased swelling in your legs or feet. - Breathing very fast, sweating, and feel confused. - Chest pain or trouble breathing that is getting worse. - Heart feels like it skips a beat or flutters. - Urinate very little or not at all. - Lips and nail beds are very white or blue. Instruct the patient to: - Limit your liquids as directed: Follow your primary healthcare provider or pulmonologist's directions about how much liquid

you should drink each day. Too much liquid can increase your risk for fluid buildup. - Rest as needed: Return to activities slowly, and do more each day. You may have trouble breathing when you are lying down. Use foam wedges or elevate the head of your bed. This may help you breathe easier while you are resting or sleeping. Use a device that will tilt your whole body, or bend your body at the waist. The device should not bend your body at the upper back or neck. - Eat a variety of healthy foods: Healthy foods include fruits, vegetables, whole-grain breads, low-fat dairy products, beans, lean meats, and fish. Healthy foods may decrease your symptoms and help you have more energy. Ask if you need to eat low-salt or low-fat foods. Offer anticipatory guidance relative to expected recovery, the need for rest and delay of another pregnancy until the client fully recovers.

I. On-going Appraisal The patient was admitted last January 26, 2012 with a chief complaint of chest pain, shortness of breath and massive edema. She was diagnosed with Anasarca secondary to severe anemia, hypoproteinemia, pleural efusin R&L lung S/P preterm delivery Jan. 04, 2013 . On the same day, she was been on observation for further assessment and diagnosis. The physician ordered to insert D5LR 1L with normal gtts/min and prescribed drugs to help her condition becomes better with the help of oxygen therapy. The patient was suffering from different illnesses with accompanying signs and symptoms of possible other diseases. As a student nurse, I gave her health teaching and advices with regards to her condition, I told her to use of and assist with non pharmacological approaches to pain management relaxation and breathing exercise. Promoting comfort and emotional support for the client is one of my primary objectives to relieve or reduce patients problem.

A CASE STUDY ABOUT Anasarca secondary to severe anemia, hypoproteinemia, pleural efusin R&L lung S/P preterm delivery Jan. 04, 2013

PRESENTED TO THE SCHOOL OF HEALTH SCIENCE PROFESSION

In Partial Fulfillment of the Requirement for Related Learning Experience Second Semester AY 2012 2013

Submitted By: Alyxzza U. Gandia BSN 2A, Group 2A

Submitted to: Mr. Paul John Carvajal RN Clinical Instructor

13 February 2013