Objectives

Topic description: This topic deals on the discussion of aplastic anemia. It covers an overview of this type of anemia,
the anatomy and physiology of the hematologic system, analysis of our client’s clinical manifestations, physical assessment
findings, client’s growth and development, the pathophysiology of our client’s condition, and the nursing diagnoses with their
corresponding interventions and outcomes of care.

Central Objective: At the end of the presentation, the listeners will gain knowledge, develop skills and cultivate
positive attitudes in caring for patients with aplastic anemia.

Specific Objectives: At the end of this case presentation, the listeners shall:

• State the formed elements of blood and its corresponding functions

• Identify the expected developmental tasks and roles of patients in the school-age and early adolescent years
• Explain the predisposing factors of aplastic anemia
• Detect signs and symptoms of aplastic anemia
• Trace the pathophysiology correctly
• Review nursing principles and concepts learned during the lecture classes.
• Apply the nursing concepts in the care of the client.
• Recognize interventions appropriate in taking care of patients with aplastic anemia

• Evaluate the effectiveness of the nursing interventions done in taking care of patients with aplastic anemia

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 A variety of blood cells course through the bloodstream — red blood cells, white blood cells and platelets. All are important to the
health of many people. Red blood cells carry oxygen, white blood cells fight infection, and platelets help the blood to clot. In aplastic
anemia, the body stops producing enough new blood cells. This means a person is fatigued and at higher risk of infections and
uncontrolled bleeding. A rare and serious condition, aplastic anemia can develop at any age. Aplastic anemia’s symptoms result from a
shortage of one or more types of blood cells and it can occur suddenly or develop slowly over weeks or months. The illness may be brief, or
it may become chronic. Treatment for aplastic anemia may include medications, blood transfusions or a bone marrow transplant. Once
considered nearly always fatal, aplastic anemia has a much better prognosis today, thanks to advances in treatment.

Unfortunately, there's no prevention for most cases of aplastic anemia. However, avoiding exposure to insecticides, herbicides,
organic solvents, paint removers and other toxic chemicals may lower the risk of the disease. This is especially important if a person
already had aplastic anemia that was caused by toxic chemicals. Exposure to the same compound a second time may cause the condition
to return.

However, in our patient’s case, he needs a compatible donor for his blood type which is A+. He needed blood transfusions so as to
improve circulation and to bring back the normal functioning of his hematologic system.. Because of financial constraints, they were not
able to secure all the required number of blood bags to be transfused so they have to remain in the hospital. Our patient’s history is very
vague for us to trace the pathophysiology of his condition. We really dig deep within just to know the past illnesses, medications, and daily
activities, and even the heredofamilial diseases that he could acquire from his parents. Unluckily, we found no exact evidence or proof for
the existence of his condition.

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 As nurses, we have to educate our client regarding the importance of self care to prevent complications. We must teach him to avoid
excessive exercise because his condition can cause fatigue and shortness of breath. Next, avoiding contact sports because of the risk of
bleeding and observe practices to avoid infections such as washing hands. Since aplastic anemia is a very serious condition that could lead
to another problem if not treated, prompt intervention is necessary to prevent its further complications. Medical management and
supportive therapy is necessary to improve the prognosis of the condition.

DEMOGRAPHIC DATA
Name: Pajunar, Jerome P. Nationality: Filipino Sex: male
Age: 13 years and 1 month old Address: Canaway, Siaton, Negros Oriental Birth place: Siaton, Negros Oriental
Birth date: March 14, 1995 Religion: Roman Catholic Room No#: reverse isolation room
Father’s Name: Uldarico Pajunar Mother’s Name: Vicenta Pahayat Pajunar Height: 148 cm
Year level: incoming grade 4 student Admitted on: April 16, 2008 at 3:10 pm Weight: 27 kgs
Doctor-in-charge: Dr. Gutierrez

History of present illness:

1 week prior to admission, body malaise was noted followed by pallor on the extremities. Episodes of fainting were experienced while in
school. Experienced nose bleeds and gum bleeds 10 days PTA. Factors that have aggravated his condition were his constant work in the
household and late sleeping during the night because of discos. Consulted to Dr. Uy and was referred to NOPH for blood transfusion.

Chief Complaints: pallor, fainting, and body malaise noted 1 week PTA, with epistaxis and gum bleeding 10 days PTA

Health history:

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• Medication: Paracetamol, Neozep, Medicol, and antitussives
• Allergies: no known allergies
• Smoke, Alcohol & drugs: haven’t tried smoking, drinking alcohol or intake of drugs
• Family illness: no heredofamilial disease
• Immunizations: completed all immunization doses except for MMR
• Childhood illnesses: measles, mumps and chicken pox
• Injuries: knee injury due to vehicular accident when he was 10 y.o.
• Accidents: vehicular accident when he was 10 y.o.
• Hospitalization: has been admitted to the hospital last 1st week of March due to pallor on the extremities, lips and muscle weakness

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 Rehino
Pajunar Kelly
Legend: 66 yrs old Ayoma Juana
X – died Right hand Feliciano
Died Partalan
□ – male got burned Pahayat
because of 63 yrs old
○ – female ulcer 68 yrs old
Purple - patient

Victoria
Any Has been
43 yrs old Jennifer
Marsing admitted
Carpenter and 25 yrs old
38 yrs old because of
farmer Farmer using depo
provera

Uldarico Romeo Pahayat

41 yrs old Vicenta
Housewife, “kulutason,”
Elsi Igok Farmer and
farmer “hulubakon”
44 yrs old carpenter
37 yrs old 43 yrs old
farmer

Jerome Jenivie Jessa

Jenny Marie Jemar 13 yrs old Iris Je-anne
12 yrs old 2 months
19 yrs old 7 yrs old 4 yrs old
15 yrs old Incoming Grade Grade 5 old 5
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 Growth and Development of a school age transition to
adolescence
Normal growth and development
Biological Development:
• Rapidly, accelerating growth
• Body proportion is slimmer look with longer legs, and a low center of
gravity. These proportions make climbing, bicycle riding, and other
activities easier.
• Double their strength and physical capabilities.
• Loose tooth stage or primary teeth are lost and ugly duckling stage where
permanent teeth starts to grow, 28 sets of teeth
• Fewer stomach upsets, increase stomach capacity, bladder capacity
increases, heart and respiratory rates steadily decrease and blood pressure
increases
• Secondary sex characteristics have appeared: weight increases, pubic hair
Manifested by the client
• Has grown fast as the mother verbalized and that he is even taller than his
older brother Jemar and has a height of 14 8 cm
• Looks slim, with long lower extremities. Likes to climb trees and bicycle
riding, and usually does it after school to play with other playmates at
home.
• At this time, he is weak and can not do household chore and play
intensively because he easily gets tired and dizzy
• No tooth was lost but most of the right and left molar teeth are decayed
and mostly experience toothache
• Eat small amount of food and sometimes vomits the food. Urinates 6 to 7
times per day. Heart rate is 102 beats per min, respiratory rate is 28 cpm
and blood pressure is 120/70 mmHg
• Weight has slightly increased due to poor intake of food. Fine strands of
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 starts to appear, sebaceous gland secretion increases, and respiration hair start to appear in the pubic area, increased in sebaceous gland
increases secretion, respiration increased due to lack of O2 supply in the body parts
because of low RBC count

Psychosocial Development:
Identity vs Role Confusion (Erikson)
• Right now changes in his body are still on the run so he is still trying to
• Accepting their changed body image accept the changes in his body

• He wants to be a doctor someday to help the sick people like him right
now and to help his family in their finances
• Establishing a value system or what kind of person they want to be
• Right now, for him, he is sick and he needs treatment to be cured. He
considers his past experiences that triggered him to be like what he is
• Develop a stable, coherent picture of oneself right now and he wants to be cured so that he could help his family and
continue schooling.

• Sometimes asks his parents about right doings and changes his bad
• Learn from others what it is they ought to keep doing and what it is they attitude if reprimanded by parents.
want to change
Cognitive Development:
Concrete operational Thought (Piaget)
• Reasons about why they lack financial resources and tries to convince his
• Able to reason through any problem that they can actually visualize mother about the solution of going to the governor to ask for help for the
finances in the hospital

• Able to project his self to others situations, like for example, being in the
• Decentering, Accommodation, Conservation, class inclusion shoes of his parents. He really did understand why it is not easy for them
to provide all the daily needs for their family. He was also able to adapt
to the happenings to fit what is perceived and understand that there are
some reasons why people do things and knows to identify changes and

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 able to differentiate it

• Explores newfound ability for limited abstract thought • When he was at home, he is observant of his uncle making furniture so he
tries to apply it and was able to complete the task even not that good.

Formal Operational Thinking (Piaget)

• Able to think in abstract terms, thinks about possibilities through

hypotheses • Sometimes judges immediately when he cannot understand or not able to
perceive it correctly and do not think of possibilities
• Using a future-time perspective
• Thinks about his family and said that he want to finish studying to
support his family
Moral Development:
Preconventional Reasoning (Kohlberg)

• Able to judge and act by intentions rather than consequences. Rules and
judgments become less absolute and authoritarian and begin to be more
on needs and desires of others.
• Take into account a different point of view to make judgment
• Able to do things which he wants to do but is still a little afraid if does
something wrong because of the punishment that his parents would do to
him. Use of judgment is appropriate and thinks of others rather than
himself as he verbalized that “I felt sad because now that I’m here in the
hospital, my parents expenses are increasing each day. I really wanted to
go home to have no problem at all.”

• He does not do judgment directly, listens or observe the opposite side

before he judges, in cases of friendship conflict.
Conventional Reasoning

• Absolute moral guidelines are seen to emanate from authorities such as

parents or teachers. • He abides by the parent’s rules and learned to work or live with the rules
of the parent and his family by doing household chores before playing

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Spiritual Development:
• They picture God as human
• View illness or injury as a punishment for a real or imagined misdeed.
• Differentiate natural and supernatural
• Their petitions to their God in prayers tend to be very tangible and is less
concerned when prayers are less answered
Language Development:
• Able to apply minimum-distance principle (ability to think about
language and to comment on its properties)
• Provide directive that others can correctly interpret without visual data
• Able to think about quality of their own and other’s speech and to
evaluate and clarify messages
Social Development:
• Seeks peer affiliations to counter instability generated by rapid change
• Upsurge of close, idealized friendships with members of the same sex
outside
• Believes in God and that He would heal his disease and prays to him
fervently in order to be heard
• Doesn’t view that his condition a punishment but views but it as a trial
that he needs to overcome and is very positive that the God he believes in
would heal him
• Can differentiate between facts and fiction stories and able to identify
fiction movies. “I believe in God even he if I haven’t seen him” as he
verbalized
• Because of lack of money to supply the medication and support persons
to help in the finances, he puts his trust to God and offers his life to him
as he verbalized
• Able to appreciate jokes and riddles and easily laugh at double meaning
words
• Can provide direction properly when he was asked about how far was the
place where her father worked
• Asks about words of double meaning to elaborate more and sometimes
laugh at his mistakes as he mispronounces words and correct it or ask for
correction
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 • No major conflict over parental control • Talks to peers and to mother about the changes in his body

• Most of his friends are boys and he would hang out with them after
school and loves to go to disco with them

• Follows rules made or implemented by the parents but sometimes violate

them but talks to parents about it and settles it

Functional Health Patterns

Usual Function Patterns Initial Appraisal Ongoing Appraisal

I. Health – Perception – Health – Management pattern

A. Parent’s Report: • Pallor noted all over his body

• Generally feels weak and tired, with
• Was delivered via NSVD • Lips were pale and dry. exertional breathing noted.
• General health status since birth is below satisfactory. • Scars noted on lower and upper • Pallor noted all over hid body.
Experienced infections such as colds, cough, and fever, at extremities due to scabies when he was
least 3 times a year. Experienced absences from school due • Lips were cracked, dry and very pale.
2 years old.
to fever. • Difficulty in following doctors orders
• During infections, OTC drugs such as paracetamol, • Difficulty in following doctors orders
for treatment because of financial
antitussives, medicol, and neozep are usually taken. for treatment because of financial
problems
problems and lack of blood donor
• Has completed all doses of immunizations except for MMR. • Medications:
• Medications:
• Has been hospitalized once due to frequent fainting and o prednisone 10g/tab 1 tab tid
o prednisone 10g/tab 1 tab tid
bleeding from gums and nose. PO
PO
• Preventive health practices include washing the utensils o Kremil S 1 tab tid
o Kremil S 1 tab tid
with soap and water. Usually change cloths daily. o paracetamol 3-5g/tab 1 tab q6h
o paracetamol 3-5g/tab 1 tab
• The father smokes but not around the child. o ampicillin 500g IVTT q6h
q6h
• A scar is present at the left knee due to vehicular accident o folic acid 5 mg/tab od

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 experienced at age 10. o tranexamic acid 150mg IVTT
• Sharp objects and medicines at home are kept out of q8h
children’s reach. o phytomenadione 1 ampule
IVTT stat
B. Parent (self): parents/family’s general health status o o
• Laboratory Values
• Family’s general health status has been good o Hemoglobin – 3.4 g%
o Hematocrit – 9.3 vol%
• The child’s hospitalization was the first ever crisis the o WBC – 3,400/cumm
family has encountered regarding health. o Neutrophil – 12 %
o Lymphocyte – 79 %
o Monocyte – 6 %
o Eosinophil – 3 %
o Platelet – 22,000/cumm
• Vital Signs:
o temp  37.9 0C
o pulse 111 bpm, regular,
bounding
o respi  28 cpm, with use of
accessory muscles
o BP  120/70 mmHg
II. Nutritional – Metabolic Pattern
A. Parent’s report:
• Food consumption became less. He
vomited after eating.
• Client has good appetite.
• D5.3 NaCl running at 41 gtts/min
• No feeding discomforts.
infusing well
• No supplements.
• Needs little assistance in eating like
• Can eat by himself without need for assistance.
o ampicillin 500g IVTT q6h
o folic acid 5 mg/tab od
o tranexamic acid 150mg IVTT
q8h
phytomenadione 1 ampule
IVTT stat
• Laboratory Values:
o Hemoglobin – 7.9 g%
o Hematocrit – 20.9 vol%
o Platelet – 10,000/cumm
• Vital Signs:
o temp  38.2 0C
o pulse  121 bpm, regular,
bounding
o respi  31 cpm, with use of
accessory muscles
o BP  124/72 mmHg
• Food consumption became even less.
He has the tendency to refuse eating.
• D5.3 NaCl running at 41 gtts/min
infusing well
• Needs assistance in feeding. Mother
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• Doesn’t like eating vegetables handing of utensils has to feed him while he is lying on
• No known food allergies. • As verbalized by the mother, client has bed.
• 24-hour intake of nutrients: improved in terms of consumption of • 24-hour intake of nutrients:
vegetables
o breakfast  1 cup rice and dried fish • Doctor ordered a diet avoiding dark- o Breakfast  only half a glass
o lunch  1 cup rice and “tinolang isda” colored foods of milk
o snacks  2 pcs bread and a cup of coffee • 24-hour intake of nutrients: o Lunch  2 tbsp of rice and
o dinner  1 cup rice and fried fish fish tinola
o Breakfast  1 cup “lugaw” o Dinner  5 tbsp lugaw
and a glass of milk
o Lunch  ½ cup rice and 1
slice beef
o Dinner  4 tbsp. rice, fried
• Birth weight = 2,800g fish, “malunggay”
• Weight taken last Feb. = 32 kgs • Weight: 27 kgs
• Height: 148 cm
• Scabies on lower extremities started to appear when teeth • Weight upon admission: 28 kgs • Skin was very pale and dry. Lips were
started erupting around 8 months of age and lasted until 2 and cracked and dry as well
½ years old. • Pallor noted on skin; scars due to
scabies evident on lower extremities
III. Elimination Pattern

A. Parent’s report:
• He gets to defecate once a day, usually in the morning
• Stool is light brown, soft and formed and moderate in amount
• No discomfort felt during bowel elimination
• Urination is 6-7 times in a day
• Urine is light yellow, clear and in considerable amounts
• Experience of perspiration in doing numerous activities such
as making a chair or playing with younger siblings
• Defecated twice of soft, formed and
dark brown stool.
• No discomfort felt upon defecation
• Urination is between 5-6 times for the
day
• Urine is light yellow, clear and in small
amounts
• He was not perspiring. Slight body odor
• Was not able to move bowel for that
day
• Urinated 4 times and no discomfort
upon doing so
• Urine was yellow, clear and in
moderate amount
• He was perspiring heavily in the head,
face and neck

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IV. Activity – Exercise Pattern
A. Parent’s report:
• He takes a bath once a day in a water pump near their house,
together with other siblings
• During classes, he takes a bath early in the morning, around
5:30 am
• Uses bathing soap (Zest)
• During school days, he wears his school uniform. When at
home, usually wears sando and shorts
• At home, time is mostly spent looking over and playing with
younger siblings. He also likes making small wooden chairs
as his type of play. He helps in taking care of their animals
like their cow, pig and chicken
• He easily gets tired. He can’t tolerate activities like running,
as he usually catches his breath with this activity
• Client is said to be a strong child. He doesn’t fear the dark.
He would even walk alone at night to look for his father. He
also wants doing things and solving problems on his own as
much as possible, and only asks for help when he can no
longer manage it by himself.
• He needs no assistance in bathing, feeding, toileting, dressing
and grooming.
V. Sleep – Rest Pattern
A. Parent’s report
noted probably because of failure to • Slight body odor still noted
take a bath
• Has not taken a bath
• He refused to be wiped with wet cloth
• Was not able to have a complete bath
on his body
since admission
• The mother would wipe his whole body • He only stayed lying on bed. He can’t
with wet cloth every other day tolerate sitting even for just a little
while. He was too weak to do so
• He would either lie on his bed or sit on
• He avoided any interaction and
the side
covered his face with his arms. He
• He played with her younger sister when
even refused when pulse rate was to be
it came to visit
taken, thinking that he would be asked
• The mother sees his child as still to stand up.
strong. He once told his mother that he
• Looked very frail and weak and was
wants to get well right away so he can
having fever.
finish his studies so he could help his
• Cannot eat by himself without being
family in their financial problem.
fed. He used a bedpan for urination
• Needs little assistance in eating but he
because he can’t tolerate going to the
can walk his way to the bathroom
bathroom anymore
• Respi rate  28 cpm, with use of
• Respi rate  31 cpm
accessory muscles
• Pulse rate  121 bpm
• Pulse rate  111 bpm, regular,
bounding
• His total hours of sleep during the night • There was a change in the usual
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• During classes, the child sees to it that he gets enough rest.
He would sleep at 8pm and wakes up at 5am, having about 9 were 6 hours only. sleeping pattern of the child. He didn’t
hours of sleep. • He wakes up during the night to urinate get enough rest during the night. He
• But on Fridays, he usually stays late until 12mn as he would • He didn’t appear to be well-rested was able to sleep well already in the
go with his aunts to a disco in their barangay. He would wake • His eyeballs were slightly sunken morning.
up 7am the next day, getting only 7hrs of sleep.
• They haven’t observed him having nightmares, nor did the • Not well-rested as evidenced by
child tell them he has experienced so. sunken eye balls
• The other members would usually sleep more or less the
same time with the patient, except during Fridays that they
are able to sleep earlier.

VI. Cognitive Perceptual Pattern

A. Parent’s report:

• Is very responsive to questions

• Responds when asked and easily obeys when a command is • Is not so responsive and is experiencing • Responds but very brief and doesn’t
given, doesn’t likes noise, is fascinated with things in which fatigue want to interact with us nor his parents
he has newly seen and loves to manipulate objects • Responds briefly when asked but because he just wants to rest
• Has a low voice and can speak fluently and can form sometime doesn’t response when being • Sometimes doesn’t listens when being
different sentences talked because he want to rest, gets talked and gets easily irritated with
• Has a long attention span and loves to play and walk around irritated when noise is present noise
• No problem about his vision, can hear clearly, and can feel • Usually vocalized 3 to 4 words when
the objects being touched asked due to fatigue and doesn’t • Still is experiencing fatigue and
elaborate more on the word he is saying muscle weakness
• Can tell his name, address, and even his cell number
• No pain present but is experiencing
muscle weakness and doesn’t want to
do something because of the feeling of
fatigue
VII. Self Perception – Self Concept Pattern

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 A. Parents report:
• Mother verbalized that he usually is happy and has a good
mood and interacts with his brothers and sister with a smile
on his face and doesn’t easily gets angry
B. Child’s report:
• Doesn’t easily gets irritated and always smile but gets angry
when exposed to an environment which is very noisy
• Have many friends and most of his aunts like him because he
is very responsible
• He is good most of the time and loves to play and do house
hold chores
• Doesn’t want to be alone but sometimes feels lonely when he
is the only one left in the house
VIII. Role/ Relationship Pattern
A. Parent’s Report:
• Most of the time, he is with his younger sibling and attending
to them when parents are working
• He usually disciplines his younger siblings if they have done
something wrong and he usually help his father to look for
money for financial problems
• Still smiles when were around but most
of the time feels sad thinking of his
condition
• Is very afraid of needles that he
collapsed during his first and second
blood transfusion seeing the needle
inserted in his arm
• Very irritable especially when disturbed
while resting
• Still has many friends and this friends
of his want to visit him to the hospital
but is not permitted
• Establishes eye contact when being
talked and answers the questions being
asked but briefly
• Stands up sometimes in a slouch
posture and is feeling weak
• Cannot attend to his youngest sibling
because of his condition right now
• Cannot interact with his younger
sibling because they are just left at
home with her grandmother and he is
• Usually stay in bed and always wants
to rest and the smile on his face was
gone because he has a fever so he feels
so weak
• Still is afraid of needles and had
collapsed again for the third time
during his blood transfusion
• Always thinking about his condition
and feels sad thinking he cannot play
and do his favorite stuffs
• Doesn’t wants to stand up and is
always lying down
• Misses his siblings because he haven’t
seen them foe quite a while
• He is not allowed to roam around and
interact with other patients because of
his condition
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• Mostly interacts with his youngest sibling and is the one
attending to her and usually plays with her
• Sometimes feels sad when left alone in the house but can
manage to be separated to parents
• He is dependent on his parents in terms of basic needs and
learns how to deal with household chores and problems at
school
• Usually after doing household chores in the morning, he
plays with his friends and every after school, he plays with
them and stays home at night
• Mother and father don’t have a problem in disciplining him.
Sometimes if violated the rules, he is reprimanded and
remains quiet
• Easily adjust to school activities
hear in the hospital • Due to muscle weakness and fatigue,
• Doesn’t want to be left alone in the he usually keeps on lying in bed and
hospital wants to rest
• He is very dependent to his parents • Unable to play anymore
because of his condition
• Cannot play most of the time because
of muscle weakness
• Relationship with his parents is more
strengthen because now is that time that
he really needs our help as verbalized
by his mother

B. Parent:

• Parents try to supervise the child in things that he do and is

satisfied with every achievement that their child has done

• Relationship with the child is good and parents trust him

when left alone in the house because parents go to work from
7 am in the morning until 5 pm in the afternoon
• Sexuality Reproductive Pattern

A. Parent’s Report:

• The child uses boy’s stuff and wears boy’s clothes and hangs • He is shy to answer questions when • He is still shy when asked
out with his peer boys. asked about his reproductive system about his reproductive system
• He tries to answer some of the questions about sexuality
appropriately based on his learning but tries to avoid or
doesn’t answer the question if he doesn’t have knowledge on

16
 it

B. Parent:

• Has no problems about their sexual life and has no history

of illness about it
X. Coping Stress Tolerance Pattern

A. Parent’s Report:

• If faced with problems, he usually tries to fix it on his own
but as soon as his patience ran out, he seeks help to his
mother
• If angry, he usually stays in a corner and doesn’t want to
talk or play
• He is optimistic that he will be cured • Usually gets irritated easily because
with his disease right now of fatigue so he just keeps quiet and
stays in bed and sleep

B. Parent:
• His parent, aunts and uncle is taking
• Mostly when problems arise, they talk together with his turn in taking care of him in the • Is continuously looking for blood for
husband and mother so look for solutions hospital and looking for blood donors transfusion and needs 4 packs of
• Sometimes ask for help to their parents and to there siblings • His mother is the one who is with her blood and is trying to look for
specially when dealing with financial and emotional mostly in the hospital and his father financial support for the blood and
problems visits him during weekend medications
• Due to many children, they cannot attend to each one’s • Financial support for hospitalization
needs was taken care by the governor

XI. Value – Belief Pattern

A. Parent

• Verbalized that he wants to finish his studies and help his • Mother verbalized that his child wants • Still hopes that God will cure his
family about the finances to get well and go back to his normal disease

17
 • Puts on “kinias sa saging” when wound is present
• Believes that scabies of his son was triggered by the routine and even tried to convince her
eruption of his teeth at the age of 8 months to 1 yr and a half to look for donor
• Prays to God fervently so that he would
be healed of his disease right now

• Mother requested us to offer some

prayers for his child

Physical Assessment
PAST MEDICAL HISTORY
Had experienced cough and colds and was intervened by taking OTC medications such as medicol and neozep. Had experienced
measles, mumps, and chicken pox while he was still 5-7 years old. Received complete doses of immunizations except for MMR. Has no
heredofamilial diseases such as diabetes, hypertension, tuberculosis and others.

18
REVIEW OF SYSTEMS:

General: Last February, he weighed 32 kgs; upon admission, his weight was 28 kgs; at present, he only weighs 27 kgs. Feels weak and tired
and has fever.
Skin: skin color is pale and yellowish. It is dry and scars are present due to scabies. Small unexplained bruises noted in the left upper arm. No
lumps, and sores noted.
HEENT: had not experienced head injury. Eye bags are slightly sunken. Had not experienced infection or any pain in the ears. Had experienced
colds, during early years of life. Has a complete set of teeth and dental caries been noted at the left and right molars. Had no canker sores but
had experienced bleeding from gums and lips. Was not able to go to the dentist.
Neck: no lumps, no pain, and no stiffness noted
Breasts: absence of pain
Respiratory: rate and depth are increased and use of accessory muscles was noted upon inhalation.
Cardiovascular: negative heart murmurs; chest pain and discomfort.
Gastointestinal: loss of appetite and vomiting was noted. Passage of soft, and formed brownish stools at least once in two days.
Urinary: urinates 7x a day when already admitted, but usually urinates 5-6x a day.
Genital: no foul odor, and no abnormal discharges noted.
Musculoskeletal: no presence of redness and swelling. Weakness and fatigue is noted.
Neurologic: had experienced episodes of fainting, and experienced convulsions once while he was still 1 year old. Had not experienced
seizures or any other involuntary movement.
Hematologic: had experienced anemia and bleeding from nose and gums
Endocrine: had experienced excessive sweating before and during admission.

PHYSICAL ASSESSMENT FINDINGS

19
I. General Survey
Client is awake, coherent, lying in bed. IVF present at Left metacarpal vein running at 41 gtts/min, infusing well. Weakness and fatigue
was noted.

Vital signs:
T = 37.9 0C ht = 148 cm
P = 111 bpm, regular, bounding wt = 27 kgs
R = 28 cpm, silent, use of accessory muscles BP = 120/70 mmHg

II. HEENT (head, eyes, ears, nose and throat)

Health History: to assess for presence of discoloration such as paleness, jaundice and bleeding, it is important to asses the eyes, ears,
nose, and throat. Our client never experienced head injury or any other deviations of the head. No experiences of memory loss but
experienced episodes of fainting and convulsions. No experiences of sore eyes, or eye pain. Had no experiences of ear infection and
any pain in the ears. Had experienced tonsillitis at age 6 years old.

Head
His head is symmetric and round. It is normally hard, without lumps or tenderness palpated. Hair is black, thick, with no lice present
and is evenly distributed all throughout his head.

Eyes
His eyelashes are evenly distributed and curved outward along the lid margin. Skin on both eyelids has no presence of redness,
swelling or lesions. Conjuctiva is pale, and moist. Sclera is white. Cornea is transparent, smooth and no opacities. Iris and cornea is
round flat and evenly colored. Pupils are normally equal in size. The eyes constrict as light is shone unto it. Has normal direct and

20
consensual pupillary response. Eyes turn inward when focusing on a near object. Was able to follow the 6 direction-gaze without
moving his head accordingly. The client can read at 14 inches what the normal eye can read at 14 inches.

Ears
Her ears are equal in size. Auricle is aligned with the outer canthus of each eye. Skin in the ears is pale just like the color of entire
body, smooth with no lesions, lumps, or nodules. Presence of cerumen on both ears. The client was able to hear and repeat the words
that were instructed to him during the auditory acuity. Verbalized cleaning of his ears is done once a week if cotton buds are
available. No inappropriate discharges noted coming out from the ears.

Nose
The color is pale with brown pigmentation, smooth, symmetric with no tenderness. Septum is red and swollen because of presence of
oxygen inhalation. Nose bleeding was noted and was wiped by mother. Frontal and maxillary sinuses are non-tender to palpation.

Mouth
Has complete set of teeth with presence of dental caries in the left and right molars. Frequent complaints of tooth ache especially
when the mouth was inspected. Gums are pale, dry, with no ulcerations present. Lips are cracked, dry, and bleeding was noted after
he brushed his teeth. Tongue is dry and is pale just like his gums.

Pharynx
No lumps and tenderness palpated in the pharynx. No bulging of lymph noted.

Neck
Neck is symmetrical without bulging masses. The adam’s apple moves up symmetrically as the client swallows. Upon palpation of the
thyroid, the lobes are smooth, firm, and nontender. Nodes have no swelling or enlargement and no tenderness.

21
III. Integumentary System

Health History
To check for presence of dehydration, dryness, and discoloration, thus, assessing the skin and its parts are important aspect in
determining deviations of its structures. Patient’s skin is brown in color with fair complexion before the occurrence of his condition. Had
experienced cuts or breaks in the skin as evidenced by presence of scars. Scars were also present in the posterior extremities due to
scabies and vehicular accident. Had experienced skin itching and redness at the lower extremities due to insect bite. Presence of
macules (moles) in the lower left posterior leg. Had experienced bruises as reported. Had undergone chicken pox, mumps, and measles
as reported by mother but had not experienced any skin allergies. Has presence of skin dryness and is febrile PTA. Has no history of hair
loss. Hair is shiny and thick and is equally distributed throughout the head. Had not experienced nail injury and nails are cut and
cleaned by himself every 2 weeks.

Skin
The skin is pale and yellowish in color and is distributed throughout the body. Presence of slight pain and redness at injection site and at
blood transfusion site. Skin is dry and is warm to touch because of his high temperature. Skin is slightly rough due to presence of
abrasions and scars. The skin does not lift up easily upon pinching and returns to place slowly. Presence of macules (moles) in the lower
left posterior leg. Scars from chicken pox were present all over the body in distributed manner.

Nails
The fingernails are not so short with minimal dirt underneath it. Nail beds are pale and capillary refill is absent. It is in 160 degrees
angle and is concave in shape. The toenails are pale and yellowish in color with minimal dirt underneath it. No abnormal pigmentation
noted in the toe nails. Has still delayed capillary refill.

22
 Hair
Hair is thick and coarse, black and dry, and is equally distributed all throughout the head. No dandruffs or scaliness noted in the hair. No
alopecia noted in any part of the head. Uses shampoo or soap every other day upon washing the hair. Had not used any hair treatment
formulas or any hair wax. Usually cuts his hair every 2 months.

IV. Respiratory System (Anterior and Posterior Chest)

Health History
As diagnosed to have aplastic anemia wherein oxygenation may be impaired, the respiratory system should be assessed to check for
presence of deviations from normal. Patient has no family history of lung cancer, tuberculosis, and any other respiratory conditions. Had
experienced cough and colds during the past year. Mother usually gives OTC drugs such as paracetamol, medicol, neozep for fever,
cough, and colds. Had not experienced hemoptysis or coughing out of blood streaked sputum. Respiratory rate before admission was
regular, silent and effortless. Had no experiences of difficulty in breathing as reported. Patient had no history of any allergy to dust or
other foreign organisms present in the air.

Inspection
Anterior thorax is symmetric with not so good expansion. Use accessory muscle is noted upon inhalation. There is no abnormal
retraction of the interspaces. No deformities in the chest noted. Respiration is deep, silent, with use of accessory muscle. Respiration
rate is 28 cpm. Posterior chest wall is symmetric in both sides and there are no abnormal retractions noted in the interspaces.

Palpation
In the anterior chest, there are no tender areas palpated as evidenced by absence of facial grimacing and crying. There are no bruises,
lesions, masses present in the chest. Posterior chest is warm to touch. No tender or painful areas palpated as evidenced by absence of

23
 crying. No bruises, lesions, or masses present in the posterior chest. Chest expansion is deep and symmetrical as evidenced by equal
movement of thumbs placed on the back. Upon assessing the tactile fremitus, equal vibrations are heard in the anterior and posterior
chest.

Percussion
Resonant sounds are heard in the areas around the lung fields. Diaphragm was percussed and dull sounds were heard. There are no any
other abnormal percussion notes heard in the anterior and posterior chest.

Auscultation
Breath sounds are louder in the lower posterior lung fields and also is loud in the upper anterior lung fields compared to other part of
the chest. There are no silent gaps present between sounds. Respiratory rate is 28 cycles per minute, and is deep with use of accessory
muscles. Vesicular and bronchovesicular sounds are heard over most of both lungs and 1st and 2nd ICS and also between the scapula.

THE BLOOD
The primary roles of blood in general are to integrate body functions and to meet the needs of specific tissues. This is accomplished through
transportation, regulation, and protection mechanisms. Blood transports oxygen, nutrients, waste products, and hormones from one place to another. Regulation is
accomplished through buffers in the blood, plasma proteins, and heat transport, such as muscle-generated temperature. The protection function of the blood includes
antibodies and phagocytes to protect against disease as well as factors that participate in hemostasis.

24
 Blood consists of a clear yellow fluid called plasma, in which cells and many other
substances are suspended. Proteins are the major solutes in plasma and consist primarily of
albumins, globulins, and fibrinogen. The composition of plasma is similar to that of interstitial fluid,
except that it has a much higher protein concentration which maintains the intravascular volume by
the exertion of colloid osmotic pressure. In addition to holding water in the intravascular spaces,
plasma proteins bind such substances as lipids and such metals as iron, contribute to blood viscosity,
and participate in the coagulation of blood. They are also important in regulating acid-base balance.
The blood volume is the sum of volumes of plasma and formed elements of blood in the
vascular system. Although numerous factors affect blood volume, it remains relatively stable in the
healthy person. Several compensatory mechanisms contribute
to this stability; for example, decreased RBC volume is
followed by increased plasma volume, thereby returning total
blood volume to its normal level. In this situation, the total
blood volume may be normal, but the ratio of plasma to cells
is altered.

Formed Elements
The formed elements of the blood include three
principal components: red blood cells, white blood cells, and
platelets. Although RBCs and WBCs are whole cells,
platelets are cell fragments. Unlike RBCs and platelets,

25
which have just a few roles, WBCs have a number of specialized functions. The percentage of total blood volume occupied by RBCs is called the hematocrit. A
significant drop in hematocrit indicates anemia, a lower-than-normal number of RBCs

Formation of Blood Cells

Although some lymphocyte has a lifetime measured in years, most formed elements of the blood are continually dying and being replaced within hours,
days, or weeks. Negative feedback systems regulate the number of RBCs and platelets in the circulation, and their numbers normally remain steady. The abundance
of different types of WBCs, however, varies in response to challenges by invading pathogens and other foreign antigens.
The process by which formed elements of blood develop is called hematopoiesis. Before
birth, hematopoiesis first occurs in the yolk sac of an embryo and later in the liver, spleen, thymus,
and lymph nodes of a fetus. In the last three months before birth, red bone marrow becomes the
primary site of hematopoiesis and continues as the main source of blood cells after birth and
throughout life.
Red bone marrow is highly vascularized connective tissue located in the microscopic
spaces between trabeculae of spongy bone tissue. It is present chiefly in bones of the axial skeleton,
pectoral and pelvic girdles, and the proximal epiphyses of the humerus and femur. About 0.05-0.1%
of red bone marrow cells are derived from mesenchymal cells called pluripotent stem cells, which
has the capacity to develop into several different types of cells.
Pluripotent stem cells produce two further types of stem cells, called myeloid stem cells
and lymphoid stem cells. Myeloid stem cells begin their development in red bone marrow and give
rise to red blood cells, platelets, monocytes, neutrophils, eosinophils, and basophils. Lymphoid stem
cells begin their development in red bone marrow but complete it in lymphatic tissues and give rise
to lymphocytes.

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 During hematopoiesis, the myeloid stem cells differentiate into progenitor cells which are also known as colony-forming units (CFUs). After the CFU
designation is an abbreviation that designates the mature elements in blood that they will produce: CFU-E ultimately produces erythrocytes (RBCs), CFU-Meg
produces megakaryocytes, the source of platelets, and CFU-GM ultimately produces granulocytes (speciafically neutrophils) and monocytes.
Several hormones are called hemopoietic growth factors regulate the differentiation and prolifieration of particular progenitor cells. Erythropoeitin or EPO
increases the number of red blood cell precursors. The main producers of EPO are cells in the kidneys that lie between the kidney tubules. Thrombopoietin or TPO
is a hormone produced by the liver that stimulates the formation of platelets from megakaryocytes.
Cytokines, which are small glycoproteins, are produced by the red bone marrow cells, leukocytes,
macrophages, fibroblasts, and endothelial cells. Cytokines stimulate proliferation of progenitor cells in red
bone marrow and regulate the activities of cells involved in nonspecific defenses (ie, phagocytes) and
immune responses (such as B cells and T cells). Two important families of cytokines that stimulate white
blood cell formation are colony-stimulating factor (CSFs) and interleukins.

RED BLOOD CELLS

Red blood cells or erythrocytes contain the oxygen-carrying protein hemoglobin, which is a
pigment that gives whole blood its red color. To maintain normal numbers of RBCs, new mature cells must
enter the circulation at the astonishing rate of at least 2 million per second, a pace that balances the equally high
rate of RBC destruction.

RBC Anatomy
RBCs are biconcave discs with a diameter of 7-8 micrometer. Their plasma membrane is both strong
and flexible, which allows them to deform without rupturing as they squeeze through marrow capillaries. RBCs
lack a nucleus and other organelles and can neither reproduce nor carry on extensive metabolic activities. The

27
cytosol of RBCs contain hemoglobin molecules, which were synthesized before loss of the nucleus during RBC production and which constitute about 33% of the
cell’s weight.

RBC Physiology
Red Blood cells are highly specialized for their oxygen transport function. Their internal space is always available for oxygen transport because of the
absence of nucleus. Moreover, RBCs lack mitochondria and generate ATP anaerobicallly. Hence, they do not use up any of the oxygen they transport. Each RBC
contains about 280 million hemoglobin molecules and each can carry up to four oxygen molecules.
A hemoglobin molecule consists of a protein called globin, composed of four polypeptide chains plus four nonprotein pigments called hemes. The oxygen
picked up in the lungs is transported bound to the iron of the heme group. As blood flows through tissue capillaries, the iron-oxygen reaction reverses. Hemoglobin
releases oxygen, which diffuses first into the interstitial fluid and then into cells. Hemoglobin also transports about 13% of the total carbon dioxide and blood
flowing through tissue capillaries picks up carbon dioxide. As blood flows through the lungs, the carbon dioxide is released from hemoglobin and then exhaled.
Hemoglobin also plays an important role in the regulation of blood flow and blood pressure. The gaseous hormone nitric acid, which is produced by the endothelial
cells that line blood vessels, binds to hemoglobin. Under some circumstances, hemoglobin releases nitric oxide and causes vasodilation which will then improves
blood flow and enhances oxygen delivery to cells near the site of nitric acid release.
Red Blood cells have an average life span of 105-120 days because of the wear and tear their plasma membranes undergo as they squeeze through blood
capillaries. Without a nucleus and other organelles, RBCs cannot synthesize new components to
replace damaged ones. The plasma membrane becomes more fragile with age, and the cells are
more likely to burst especially as they squeeze through narrow channels in the spleen.

Erythropoiesis: Production of RBCs

The production of RBCs starts in the red bone marrow with a precursor cell called a
proerythroblast in a process called Erythropoiedis. The proeyhthroblast divides severeal times,

28
producing cells that begin to synthesize hemoglobin. Loss of nucleus causes the center of the cell to indents, producing a distinctive biconcave shape. Normally,
eythropoiesis and red blood cell destruction proceed at roughly the same pace. If the oxygen-carrying capacity of the blood falls because eythropoiesis is not
keeping up with RBC destruction, a negative feedback system steps up RBC production. The controlled condition is the amount of oxygen delivered to body tissues.
Cellular oxygen deficiency, called hypoxia, may occur if too little oxygen enters the blood. Whatever the cause, hypoxia stimulates the kidneys to step up the
release of erythropoietin. This hormone circulates through the blood to the red bone marrow, where it speeds the development of proeryhtroblasts into reticulocytes.
When the number of circulating RBC increases, more oxygen can be delivered to body tissues.

WHITE BLOOD CELLS

WBCs or leukocytes, unlike RBCs, have nucleus and do not contain hemoglobin. They are classified as either granular or agranular, depending on
whether they contain conspicuous chemical-filled cytoplasmic vesicles (originally called granules)
that are made visible by staining. Granular leukocytes include neutrophils, eosinophils, and
basophils; agranular leukocytes include lymphocytes and monocytes. Monocytes and granular
leukocytes develop from a myeloid stem cell. In contrast, lymhocytes develop fro a lymphoid stem
cell.
The skin and mucous membranes of the body are continuously exposed to microbes
and their toxins. Some of these microbes can invade deeper tissues to cause disease. Once the
pathogens enter the body, the general function of the WBCs is to combat them by phagocytosis or
immune responses. To accomplish these tasks, many WBCs leave to bloodstreamand collect at
points of pathogen invasion or inflammation. Once the granulocytes and monocytes leave the
bloodstream to fight injury or infection, they never return to it. Lymphocytes, on the other hand,
continually recirculate – from blood to interstitial spaces of tissues to lymphatic fluid and back to
blood.

29
 Among WBCs, neutrophils respond most quickly to tissue destruction by bacteria. After engulfing a pathogen during phagocytosis, a neutrophil
unleashes several chemicals to destroy the pathogen. These chemicals include the enzyme lysozyme, which destroys certain bacteria, and strong oxidants, which is
similar to household bleach. Neutrophils also contain defensins, proteins that exhibit a broad range of antibiotic activity against bacteria and fungi.
Monocytes take longer to reach a site of infection than do neutrophils, but they arrive in larger numbers and destroy more microbes. Upon arrival, they
enlarge and differentiate into wandering macrophages, with clean up cellular debris and microbes by phagocytosis after an infection.
Eosinophils leave the capillaries and enter tissue fluid. They are believed to release enzymes that combat the effects of histamine and other mediators of
inflammation in allergic reactions. Eosinophils also phocytize antigen-antibody complexes and are effective against certain parasititc worms. A high eosinophil
count indicates an allergic reaction or a parasitic infection.
At sites of inflammation, basophils leave capillaries, enter tissues, and liberate heparin,
histamine, and serotonin. These substances intensify the inflammatory reaction and are involved in
hypersensitivity reactions.
Lymphocytes are the major soldiers in immune system battles. There are three main
types of lyphocytes which are the B cells, T cells, and natural killer cells. An increase in the number
of circulating WBCs usually indicates infection or inflammation.

PLATELETS
Under the influence of the hormone thrombopoetin, myeloid stem cells develop into
megakaryocyte-colony-forming cells that, in turn, develop into precursor cells called
megakaryoblasts. Megakayoblasts transform into megakaryocytes, huge cells that splinter into
2000-3000 fragments. Each fragment, enclosed by a piece of the plasma membrane, is a platelet
(thrombocyte). Platelets break off from the megakaryocytes in red bone marrow and then enter the
blood circulation. Platelets, like RBCs, are disc-shape and have no nucleus. These cells help stop

30
blood loss from damaged blood vessels by forming a platelet plug. Their granules also contain chemicals that, once released, promote blood clotting. Platelets have
a short life span, normally just 5 to 9 days. Aged and dead platelets are removed by fixed macrophages in the spleen and liver.

Aplastic Anemia describes a primary condition of bone marrow stem cells that results in a reduction of all three hematopoietic cell lines (red cells, white
cells, and platelets) with fatty replacement of the bone marrow. It is a disease in which a person has peripheral blood pancytopenia and hypocellular bone marrow.

Etiology
The incidence of aplastic anemia is low, affecting approximately 4 of every 1 million
persons. Though its cause is poorly understood and about half of the cases are of unknown cause,
there are still various etiologic classifications for aplastic anemia. The two major classifications for
the etiology are: congenital or acquired. The congenital aplastic anemia is caused by chromosomal
alterations and accounts for approximately 30% of all cases. On the other hand, acquired aplastic
anemia results from exposure to ionizing radiation, chemical agents (e.g. benzene, insecticides,
arsenic, alcohol), viral and bacterial infections (e.g. hepatitis, parvovirus, biliary tuberculosis, and
prescribed medications (e.g antimicrobial agents such as chloramphenicol, anticonvulsants, and anti-
inflammatory drugs).

Clinical Manifestations

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 The onset of aplastic anemia may be insidious, or it may strike with suddenness and great
severity. It can occur at any age. Clinically, the patient may have symptoms caused by suppression of any or all bone marrow elements. The initial presenting
symptoms include weakness, fatigability, and pallor. Petechiae and ecchymoses often are present on the skin, and there may be bleeding from the nose, gums,

vagina, of gastrointestinal tract because of decreased platelet levels (thrombocytopenia). The decrease number of neutrophils (neutropenia) is an indicative of
susceptibitlity to infection and may be febrile.

Diagnostic Studies
The diagnosis is confirmed by laboratory studies. Because all marrow elements are affected, hemoglobin, WBC,
and platelet values are often decreased in aplastic anemia. The reticulocyte count and the bleeding time is prolonged. Bone
marrow biopsy, aspiration, and pathologic examination may be done for any anemic state. However, the findings are
especially important in aplastic anemia because the marrow is hypocellular, with increased yellow marrow (fat content), a
finding sometimes referred to as “dry tap”.

Management
Management of aplastic anemia is based on identifying and removing the causative agent (when possible) and providing supportive care until
pancytopenia reverses.
The prognosis of aplastic anemia is poor (approximately 75% fatal). However, advances to medical management, including
bone marrow transplantation and immunosuppressive therapy with antithymocyte globulin (ATG) and cyclosporine, have improved
outcomes significantly, producing remission in 50% of patients. ATG, a purified gamma globulin solution, is obtained from horses or
rabbits immunized with human T lymphocytes. Side effects during the infusion are common and may include fever and chills. The

32
sudden onset of a rash or bronchospasm may herald anaphylaxis and requires prompt management. Serum sickness, as evidenced by fever, rash, arthralgias, and
pruritus, may develop in some patients and may take weeks to resolve. Immunosuppressants prevent

the patient’s lymphocytes from destroying the stem cells. If relapse occurs (ie, the patient becomes pancytopenic again), reinstitution of the same immunologic
agents may induce another remission.
It is presumed that the lymphocytes of patients with aplastic anemia destroy the stem cells and consequently impair the production of erythrocytes,
leukocytes, platelets. Despite its severity the aplastic anemia can be treated in most people. Those who are younger than 60 years, who are otherwise healthy, and
who have compatible donor can be cured of the disease by bone marrow transplant or peripheral blood stem cell transplant.
Supportive therapy plays a major role in the managemtent of aplastic anemia. Any offending agent is discontinued. The patient is supported with
transfusions of packed RBCs and platelets as necessary. Death is usually caused by hemorrhage or infection.
Nursing management include assessment for signs of infection and bleeding since patients with aplastic anemia are vulnerable to problems related to
erythrocyte, leukocyte, and platelet deficiencies. Specific interventions are delineated in the sections on neutropenia and thrombocytopenia.

Pathophysiology
Normally, your bone marrow supplies the right numbers of blood cells to keep you healthy. Aplastic anemia develops when damage occurs to your bone
marrow, slowing or shutting down the production of new blood cells — a serious problem. Factors that can temporarily or permanently injure bone marrow include:

• High-dose radiation and chemotherapy treatments. While these cancer-fighting therapies kill cancer cells, they can also damage healthy cells, including
stem cells in bone marrow. Secondary aplastic anemia can be a temporary side effect of these treatments.
• Exposure to toxic chemicals. Exposure to toxic chemicals, such as some used in pesticides and insecticides, may cause secondary aplastic anemia.
Exposure to benzene — an ingredient in gasoline — also has been linked to secondary aplastic anemia.
• Use of certain drugs. Some medications, such as those used to treat rheumatoid arthritis and some antibiotics, can cause secondary aplastic anemia.

33
 • Autoimmune disorders. An autoimmune disorder, such as lupus, in which your immune system begins attacking healthy cells, may involve stem cells in
the bone marrow.
• A viral infection. Viral infections that affect bone marrow may play a role in the development of aplastic anemia in some people.
• Unknown factors. In about half of cases, doctors aren't able to identify the cause of aplastic anemia. This is called idiopathic aplastic anemia.

In aplastic anemia, the bone marrow is described in medical terms as aplastic or hypoplastic — meaning that it's empty, or contains very few blood cells. In
line with these risk factor, as a whole, they attack the healthy cells of the bone marrow causing alterations in its normal functioning. There are two theories that
could support this assumption: (1) seed or stem-cell – deficiency theory, and (2) the microenvironmental deficiency theory.

The seed or stem-cell – deficiency theory proposes that, a common stem cell population is irreversibly altered, rendering it incapable of proliferation and
differentiation. An intrinsic derangement of hemopoietic proliferation capacity that is essentially compatible with life has to be considered a premalignant condition.
This primarily diseased tissue can be destroyed by immune mechanisms in an attempt to achieve self-cure Failure of the immune mechanisms can lead to absence of
bone marrow cytokines and colony-stimulating factors present in the red bone marrow. On the other hand, the microenvironmental deficiency theory proposes that
the stem cell environment (i.e. the marrow) is altered so as to inhibit differentiation of stem cells to precursor cells thereby inhibiting erythopoiesis. These two
theories can now lead to decreased production of RBCs, WBCs, and platelets, because of the alterations in hematopoiesis. Signs and symptoms may be manifested
before diagnosis was made. In decreased RBC production, tissue hypoxia can occur as a result of decreased oxygen-carrying capacity of the blood. Tissue hypoxia
creates additional demands and effects on the pulmonary and hematologic systems. The rate and depth of breathing increases in an effort to increase oxygen
availability and is accompanied by an increase in the release of oxygen from hemoglobin. All of these may cause an individual to experience shortness of breath and
a rapid, pounding heart beat, dizziness, and fatigue. The skin, mucous membranes, lips, nail beds, and conjunctiva become pale because of reduced hemoglobin
concentration and tissue hypoxia may lead to delayed wound healing and loss of skin elasticity. On the other hand, decreased oxygen supply to the gastrointestinal
tract often produces abdominal pain, nausea, vomiting, and loss of appetite.

34
 Compensatory mechanisms may either be present in response to meet the normal oxygen demands of the body. For example, during hypoxemia, wherein
there is a reduced oxygen level in the blood, may lead to cardiovascular dysfunction by causing dilation of arterioles, capillaries, and venules, thus increasing flow
through them. Increased peripheral blood flow and venous return further contributes to an increase in heart rate and stroke volume. These identified compensatory
mechanisms may lead to heart failure. Another compensatory mechanism when the anemia is severe or acute in onset is peripheral blood vessel constriction,
diverting blood flow to essential vital organs. Decreased blood flow detected by the kidneys activates the rennin-angiotensin response , causing salt and water
retention in an attempt to increase blood volume. Prompt intervention is necessary and palliation of associated symptoms. Therapies include transfusion,
administration of supplemental vitamins or iron, medications to prevent complications.

Etiology

Acquired
Congenital
Idiopathic

Drugs: Radiation: Viral or bacterial Toxic agents:

• Antibiotics • Chemotherapeutic infection: • Benzene
(Chloramphenicol) agents • Hep non- A/B • Insecticides
• Antiinflammatory • Mononucleosis or • Paint thinner
(Phenylbutazone) Epstein-Barr Virus • Lacquers
• Anticonvulsant • Mumps, Measles
(Phenytoin)
Autoimmune
Strong affinity to Bone marrow disease:
bone marrow toxicity • SLE

35
 Attacking healthy cells in the bone
marrow causing alteration in the
function of the bone marrow

Mngt:
Bone marrow biopsy,/transplant,
Stem-cell deficiency theory: Microenvironmental immunosuppressive therapy
proposes that a common stem deficiency theory:
cell population is irreversibly proposes that the stem
altered, rendering it incapable cell environment (ie, the
of proliferation and marrow) is altered so as
differentiation to inhibit erythropoeisis

Absence of bone marrow cytokines

(precursor to cell differentiation) and
colony-stimulating factors

Altered differentiation of
blood vessels. Myeloid stem
cells and lymphoid stem cells
cannot differentiate to
precursor cells.

Altered hematopoeisis

36
 Management:
• CBC Monitoring

Decreased RBCs, Decreased clotting Decreased neutrophils (neutropenia)

decreased hemoglobin factors (platelets):
(anemic condition) Thrombocytopenia

Decreased oxygen- Bleeding and Weak immune responses

carrying capacity of hemorrhagic
the blood tendencies
(hypoxemia)
Inability to defend the body against
invading pathogens
folic acid Petechiae, ecchymosis,
epistaxis, bleeding from
Mngt: gums and from GIT paracetamol and ampicillin
infection
Blood
transfusions

tranexamic acid, phytomenadione

Tissue hypoxia

37
Decreased Respiratory: Impaired wound CNS: dizziness, Weakness and GI: abdominal pain,
hemoglobin Increase rate and healing and loss fainting, lethargy increased fatigue nausea, vomiting,
concentration depth of of elasticity loss of appetite
respiration,
“exertional
dyspnea”
Kremil-S

O2
Pale mucous inhalation
membranes, lips,
nail beds, and Compensatory mechanisms
conjunctiva

Peripheral blood vessel constriction, Dilation of arterioles, capillaries,

diverting blood flow to essential vital venules, thus increasing blood flow
organs through them

Increase peripheral blood flow and

Decreased blood flow detected by venous return, further contributes to
the kidneys and activates the renin- an increase in heart rate
angiotensin response

vasoconstriction Heart failure Legend:

management and treatment
red – clinical manifestations the
client
green – medical management
applied to patient
38
violet – 3 types of aplastic anemia
 Water and salt retention

Decreased urine output

Blood transfusions
People with severe aplastic anemia usually need blood transfusions.

• Platelet transfusions reduce the risk of life-threatening bleeding caused by very low numbers
of platelets.
• Red blood cell transfusions reduce problems with being very tired and short of breath.

Transfusions are an important treatment to manage the symptoms of aplastic anemia. For
patients with severe aplastic anemia, doctors try to give as few transfusions as possible to:

• Limit the amount of iron that builds up in the body from red blood cell transfusions. Large
amounts of iron in the body cause organ damage. Patients who need many red blood cell
transfusions may receive additional treatment to remove iron from the body. Iron-chelating
should be instituted if iron overload occurs. Became iron chelating therapy became
available, this complication was a leading cause of death.

39
 • Reduce risks the immune system will develop antibodies (immune cells) that attack transfused platelets.
• Prepare for the possibility of a transplant. For patients treated with transplant, having many transfusions increases
transplant risks.

In addition, it is common to treat the blood with radiation and to filter the white blood cells out of the blood before it is given in a
transfusion. These steps help reduce the risks of an immune system reaction against transfused platelets and risks of a potential
transplant, as well as risks of other possible complications.

If there is any chance a patient may receive a transplant, the doctor will avoid giving the patient blood donated by a family
member. If that family member is later found to be a suitable donor for a transplant, the patient's immune system may react
against the transplant.

Infection prevention

People with severe aplastic anemia are at risk for life-threatening infections. Even a common infection like a cold could become
serious. To help prevent infection, people with severe aplastic anemia need to
protect themselves from germs. Steps to take may include avoiding crowds and
sick people.

Fungal infections are a major. Clients should be treated with a broad-based

antibiotic with gram-negative and staphylococcal coverage. For clients with
febrile neutropenia, antipseudomonal therapy should be initiated. Antifungal
agents should be considered for those with persistent fever.

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Bone Marrow Biopsy

In a bone marrow biopsy, cells are collected through a hollow needle inserted into the outer edge of a hipbone, scapula, or from
the patella which contains marrow is removed with a special needle. The marrow sample is examined with a microscope for the
presence of abnormal cells.

Bone Marrow Transplantation (BMT)

For many patients with severe or very severe aplastic
anemia, a bone ma rrow transplant is the preferred
standard treatment. A transplant replaces the abnormal
cells in the bone marrow with healthy blood-forming cells
from a family member or unrelated donor.
The donor for a transplant must closely match the
patient's tissue type. The best donor is usually a matched
sibling. Unrelated donors are only used if
immunosuppressive therapy is unsuccessful.

A transplant can offer the best chance for a cure of

aplastic anemia, but it is not an option for all patients. A
transplant may be a good option for patients who have a
suitable donor or and are healthy enough to tolerate a

41
transplant. Children and young adults tend to do better than older patients, but advances in transplant have enabled older
patients to undergo a transplant successfully.

Transplants for aplastic anemia can have serious risks. However, doctors have developed treatment methods to address many of
these risks and transplant outcomes have improved in the last decade.

One risk that is greater for patients with aplastic anemia than for many other diseases is graft rejection or graft failure (when the
transplanted cells do not grow and make blood cells for the body). Having many transfusions increases the risk of graft rejection
because the patient's immune system may develop antibodies that can react against the transplanted cells. Today, doctors give
aplastic anemia patients as few transfusions as possible. The transfused blood is also commonly treated with radiation and filtered
to remove the white blood cells. These practices have improved transplant outcomes.

Another serious risk of transplant for patients with aplastic anemia is graft-versus-host disease (GVHD). This is a common
transplant complication that can range from mild to severe. For patients who receive a transplant to treat leukemia or another
cancer, GVHD may be associated with a beneficial graft-versus-leukemia effect. However, there is no benefit to GVHD for patients
with aplastic anemia. Advances in the treatment of GVHD have reduced this risk, but doctors continue to search for better
treatments.

Immunosuppressive therapy
Immunosuppressive therapy is one of two standard treatments that have the potential to offer a person with severe aplastic
anemia a longer life. The other treatment, a transplant, is often recommended as the first treatment for children and young adults
with a suitable sibling donor. Immunosuppressive therapy is often recommended as the first treatment for patients who:

42
 • Are older than age 60
• Are unable to tolerate a transplant because of other health problems or older age.
• Do not have a suitable donor for transplant.
• Will be treated with transplant, but are waiting for a suitable donor to be found.
• Choose immunosuppressive therapy after weighing the potential risks and benefits of all options.

Combination therapy is used and usually includes cyclosporine (Neoral, Sandimmune), ATG (antithymocyte globulin), ALG
(antilymphocyte globulin), cyclosporine A, and methylprednisolone, with or without cytokine support. Because a central venous
catheter is required for immunosuppressive therapy, clients should be carefully monitored for the development of infection.

The immune system is made up of organs and cells that work together to protect the body from infection and disease. The immune system uses white blood cells to
fight infections. The white blood cells mark and attack cells that they do not recognize as belonging in the body. Immunosuppressive therapy uses drugs that
suppress (weaken) the immune system. This treatment is based on the widely accepted theory that aplastic anemia is a result of the immune system attacking the
bone marrow. Immunosuppressive therapy weakens the immune system's response and allows the marrow to make more blood cells. For many people,
immunosuppressive therapy raises blood counts to normal or near normal levels and leads to long-term survival.

Growth factors
Growth factors are drugs that help the body make more blood cells. A person with aplastic anemia may be given growth factors to
try to reduce the need for red blood cell transfusions. However, in many cases of aplastic anemia, the marrow does not respond to
growth factors.

43
Growth factors may also be given after treatment with immunosuppressive therapy or transplant. In this case, growth factors often
are effective. They can help speed up new blood cell production, reducing a person's need for transfusions and reducing infection
risks.

Diet Adjustments

For clients who are neutropenic or are on immunosuppressive therapy, foods that are likely to harbor bacteria, fungi, or mold (ex. raw meat, dairy products, certain
fruits and vegetables) should be avoided.

Laboratory Exams

Laboratory Exam Results Normal Values Implication

4-16-08 4-22-08

Hemoglobin 3.4 7.9 13-16 g% Hemoglobin (Hgb or Hb) is the

protein molecule in red blood cells
that carries oxygen as blood
circulates throughout the body.
Hemoglobin gives blood its red
color. The hemoglobin test measures
the amount of hemoglobin in a
patient’s blood and gives a good
indication of a blood cell’s ability to
transport oxygen.
Hematocrit 9.3 20.9 42-50 g% Hematocrit (Hct) refers to the
percentage of blood consisting of red
blood cells. Hematocrit (meaning “to

44
 separate blood”) is an indicator of
both the number and the size of red
blood cells.
WBC 3,400 5-10T/cumm WBC is commonly used to indicate
the presence of an infection such as
appendicitis, a blood disease such as
leukemia or to monitor the body’s
response to cancer treatment.
Neutrophil Seg 12 55-60% The absolute neutrophil count (ANC)
indicates whether white blood cells
are being produced normally.

Lymphocyte 79 20-35% Lymphocytes react with antigen and

generate diverse antibodies that
protect the host against infection.
The patient’s increased results
indicate the presence of infection.
Monocyte 6 1-6% Monocytes help in phagocytosis. His
result is within normal limits.
Eosinophil 3 1-4% It’s function is for phagocytosis,
antibody-mediated defense against
parasites, allergic reactions and
recovery phase infection. His result
is within normal limits.
Platelet Count 22,000 10,000 150-400T/cumm This test counts the number of
platelets within a specific amount
(usually a cubic millimeter) of blood.
Platelets are the smallest type of
blood cell and play a major role in
blood clotting. Too few platelets can
lead to uncontrolled bleeding.
Bloodtyping A+ Blood typing is a means of
determining the presence of ABO

45
 antibodies as well as the Rh factor.
The test was requested by the
physician not only to detect the blood
type of the client but also to detect
the blood of perspective donors.

Pharmacology
Generic Name: prednisone
Brand Name: Novo-prednisone
Drug Class: Corticosteroid, Glucocorticoid
Action: enters target cells and binds to intracellular corticosteroid receptors, initiating many complex reactions that are
responsible for its anti-inflammatory and immunosuppressive effects.
Indications:
• hematologic disorder: thrombocytopenia purpura and erythroblastopenia
• hypercalcemia associated with cancer
• replacement therapy in adrenal cortical in sufficiency
Contraindications:
• contraindicated with infection, specially tuberculosis, fungal infections, amebiasis, vaccinia and varicella, and antibiotic
resistant infections; lactation

46
 • use cautiously with kidney or liver disease, hypertension, seizure disorders, diabetes mellitus, pregnancy
Adverse effects:
• vertigo, headache, paresthesia, insomnia, seizure, cataracts, hypotension, shock, hypertension and CHF fluid retention, Na+
and fluid retention, hypocalcemia, hypokalemia, irregular menses, increase blood sugar, abdominal distention, nausea and
vomiting, muscle weakness, immunosuppression impaired wound healing
Nursing Responsibilities:
• do not stop intake of the drug without consulting health care provider
• avoid exposure to infection
• teach patient to report unusual weight gain, swelling of extremities, muscle weakness, black or tarry stool, fever, or any
other infections
• Increase dosage as ordered when patient is subjected to stress.

Generic Name: ampicillin

Brand Name: Ampicin, novo-ampicillin
Drug class: Antibiotic, Penicillin
Action: bacterial action against sensitive organisms; inhibits synthesis of bacterial cell wall, causing cell death.
Indication:
• Treatment of infection caused by strains of Shigella, Salmonella, E. coli, H. influenza, P. mirabibis, N. gonorrhoeae,
enterococci, gram negative organisms,
• Meningitis caused by Neisseria meningitides
Contraindications:

47
 • Contraindicated with allergies to penicillins, cephalosporins, or other allergies.
• Use cautiously with renal failure and lactation
Adverse effect:
• Seizure, nausea and vomiting, diarrhea, abdominal pain, nephritis, anemia, thrombocytopenia, leucopenia, neutropenia,
prolonged bleeding time, rash, fever, wheezing, anaphylaxis, phlebitis, thrombosis at injection site, and superinfection like
oral and rectal moniliasis, vaginismus
Nursing Responsibilities:
• Check IV site carefully for signs of thrombosis or drug reaction
• Do not give IM injection on the same site; atrophy can occur. Monitor injection site.
• Administer oral drug in an empty stomach, 1 hour before or 2 hours after meals with full glass of water, do not give with fruit
juice or soft drink
• Report pain or discomfort at sites, unusual bleeding or bruising, mouth sores, rash, hives, fever, itching, severe diarrhea,
difficulty breathing.
• Do not use for self treatment without prescription of a physician

Generic Name: folic acid (folate)

Brand Name: Folvite
Drug Class: folic acid, vitamin supplement
Action: required for nucleoprotein synthesis and maintenance of normal erythropoiesis.
Indication: treatment of megaloblastic anemias due to sprue, nutritional deficiency, pregnancy, infancy, and childhood
Contraindications:

48
 • Contraindicated with allergy to folic acid preparations, pernicious, normocyctic anemia.
• Use cautiously during lactation
Nursing Responsibility:
• Administer orally if at all possible. With severe GI malabsorption or severe disease, give IM, IV, or subcutaneously
• Test using schilling test and serum vitamin B12 levels due to rule out pernicious anemia. It masks the signs of pernicious
anemia while the neurologic deterioration continues.
• Tell patient to report rash, difficulty breathing, pain or discomfort at injection site.

Generic name: tranexamic acid (cyklokapron)

Brand Name: Hemostan
Drug Class: Hemostatics
Action:
Is a competitive inhibitor of plasminogen activation and may directly interfere with the action of plasmin at high
concentrations. Thrombin time is prolonged, but the drug has no effect on platelet aggregation or coagulation time.
Indications
:
• Antihemorrhagic & antifibrinolytic for effective hemostasis in various surgical & clinical cases, in traumatic injuries, post-
tooth extraction & other dental procedures.
• prevention of heavy bleeding such as heavy periods, nose bleeds
• Prevention of bleeding during tooth extraction in hemophiliacs (people who lack a clotting factor) Hereditary angioneurotic
edema (excess fluid around the body)
Adverse Reaction:

49
 • GI disorders, nausea, vomiting, anorexia, headache may appear, impaired renal insufficiency, hypotension when IV infusion
is too rapid.
• Diarrhea, giddiness, visual abnormalities

Nursing responsibilities:
• Close mentoring for signs of clot formation such as chest pain, change in color, temp., or pain in the extremities, dyspnea,
abdominal pain, changes in neurological signs or changes in peripheral pulse.
• If bleeding continues to be severe, emergency treatment may be instituted while aminocaproic acid is being given. Fresh
whole blood or fibrinogen may be infused to provide clotting factors
• Not advisable to use for prolonged periods in patients predisposed to thrombosis.
• May be taken with or without food.
• Before taking tranexamic acid make sure the doctor or pharmacist knows:
 If you are pregnant, trying for a baby or breast-feeding.
 If you have a history of thromboembolic disease (where a blood clot forms and travels in the bloodstream).
 If you have kidney problems.
 If you suffer from undiagnosed irregular menstrual bleeding.

Generic Name: aluminum magnesium

Brand Name: Kremil S
Drug Class: Antacids & Antiulcer

50
Action: reduces total acid load in gastrointestinal tract, elevates gastic pH to reduce pepsin activity, strengthens gastric mucosal
barrier, and increases esophageal sphincter tone.
Indication: acid indigestion
Contraindications:
• Patients with renal failure. Partial intestinal obstruction, appendicitis, fecal impaction, gastric outlet obstruction &
constipation. Phosphate depletion, low serum phosphate & osteomalacia.
Adverse Reaction:
• Mild constipation, diarrhea, increased urine pH, hypokalemia.
Nursing
responsibilities:
• Urge patient to notify prescriber about signs and symptoms of gastrointestinal bleeding, such as tarry stool, or coffee-ground
vomitus.
• Monitor magnesium level with mild renal impairment. Symptomatic hypermagnesemia usually occur in severe renal failure.
• Drug has a low sodium content and is good for patients with sodium restriction

Generic name: Phytomenadione (menadiol)

Brand name: Cycomin apm, Vitakay
Drug class: Haemostatics
Action:
Promotes hepatic synthesis of blood clotting factor II, VII, IX, and X; probably by functioning as an essential cofactor for
microsomal system that activate the precursors of clotting factors.
Indication

51
s
• Treatment of hemorrhage or threatened hemorrhage associated w/ a low blood level of prothrombin.
• Treatment for vit. K deficiency caused by antibacterial therapy

Adverse Drug Effects:

• Rarely, severe, shock-like reactions, phlebitis; flushing of the face, sweating, chest constriction on too rapid administration.
• Dizziness, nausea and vomiting, tachycardia, weak pulse, chills, fever, hypotension, dyspnea, anaphylaxis

Nursing Responsibilities:
• Assess and record baseline data. (V/S, weight, skincolor, Temp., lab exams)
• Before taking phytomenadione make sure the doctor or pharmacist knows:
 if you are pregnant, trying for a baby or breast-feeding
 if you have ever had an allergic reaction to this or any other medicine
 if you are taking any other medicines, including those available to buy without a prescription, herbal and
complementary medicines
• Take the medication exactly as directed by the doctor. Never take more than the prescribed dose.
• Monitor prothrombin time.

Generic Name: paracetamol

Brand Name: Tempra, Tylenol

Classification: antipyretic and analgesic

52
Action:

• Analgesic mechanism of action has not been completely established

• Elevates pain threshold by blocking Prostaglandin synthesis in the CNS
• Decreases elevated temperature by locking the action of endogenous pyrogens

Indications:

• relief of mild to moderate pain, dysmenorrhea

• Reduction of elevated temperature associated with colds, bacterial and viral infections

Contraindications:

• Glucose -6- phosphate dehydrogenase deficiency

• Cautious use in patients with kidney disease

Adverse reaction:

• Urticaria, hypoglycemia, CNS stimulation, cyanosis, hemophylactic anemia, leucopenia, kidney damage, psychological
changes
• Acute poisoning is characterized by chills, diarrhea, fever, skin eruptions, palpitations, depression, convulsion,
• Hepatotoxicity (5-8g/day)

Nursing responsibilities:

53
 • Administer with food or after meals, full glass of water
• Caution patients with excessive or prolonged use.
• Drug should be use cautiously in rheumatic conditions because of its non-antinflammatory effect.
• Teach patient to notify nurse or doctor if rashes, bleeding, and changes in voiding pattern occurs.

Cues & Evidences Nursing Diagnosis Objectives Interventions Rationale Evaluation

Subjective:
 Complained Impaired gas exchange Within our care, the Independent At the end of our care,
difficulty breathing related to decreased client will be able to • Monitor respiratory - Increased respiratory the client was able to
after going to the oxygen-carrying demonstrate improved rate, depth, and effort, rate, use of accessory demonstrate improved
comfort room capacity of the blood ventilation and adequate including use of muscles, nasal flaring, ventilation and adequate
 Complained oxygenation as accessory muscles, abdominal breathing, and oxygenation as
headache upon evidenced by: nasal flaring, and a look of panic in the evidenced by:
awakening abnormal breathing client’s eyes may be seen
• Vital sings within patterns. with hypoxia.
Objective: normal limits:  Not met. Respiratory
- The presence of rate (31cpm) and

54
 Respiratory rate: 31 o T= 36.5-37.5 oC • Auscultate breath crackles and wheezes pulse rate (121 bpm)
cpm, with use of o P=70-85 bpm, sounds every 1-2 may alert the nurse to still above normal
accessory muscles strong, and hours. airway obstruction, limits
regular which may lead to or
 Pulse rate of 121 o R= 16-20 cpm, exacerbate existing tissue  Not met. There was
bpm silent and hypoxia. still use of accessory
effortless muscles during
 Exertional breathing o BP=112/60 - Compensatory changes inhalation because of
noted mmHg • Monitor vital signs; in vital sings and difficulty breathing
note changes in development of
 Weak and lethargic • reduced cyanosis in cardiac rhythm. dysrhythmias reflect
the nail beds effects of hypoxia on
 Very pale skin color cardiovascular system.
• minimize the use of
- changes reflect  Not met. Presence of
 Pale and cracked, accessory muscles
• Observe for cyanosis diminished cyanosis in the nail
dry lips
particularly in the lips circulation/hypoxia beds was not reduced.
and nail beds; potentiating capillary
 Excessively • participation in
occlusion.
perspiring treatment regimen
- Promotes optimal chest  Not met. Was not able
such as breathing
• Assist in turning, expansion, mobilization to participate in deep
 Very poor capillary exercises and
coughing, and deep- of secretions, and breathing and
refill effective coughing,
breathing exercises. aeration of all lung coughing due to
within the level of his
fields; reduces risk of fatigability
 Lab results: ability
stasis of
o Hemoglo secretions/pneumonia.
bin – 3.4 g% • exert additional
o Hematocri movements in the - Protects from excessive
arms and legs  Not met. Not able to
t – 9.3 vol% fatigue and reduces
• Encourage patient to perform physical
 O2 inhalation 3- oxygen demands. The activities because of
alternate periods
4L/min hypoxic client has severe fatigability.
physical activity.
 Medications: Schedule rest periods limited reserves;
as indicated. inappropriate activity can

55
o Folic Acid increase hypoxia.

- Sufficient intake is  Not met. Fluid intake

• Promote adequate necessary to provide for is only 3 glasses for
fluid intake of 6-8 mobilization of that day.
glasses per day secretions.

Collaborative - Maximizes oxygen  Met. O2 inhalation of

• Administer transport to tissues. having 3-4 L/min
supplemental
humidified oxygen as
indicated.
- Increases number of  Not met. Only 4 out 8
• Administer packed oxygen-carrying cells. blood bags were
RBCs as indicated. administered because
- for effective outcomes of inability to secure
• Administer meds as of therapy it.
ordered:  Met. All medications
were administered as
ordered.
o prednisone
10g/tab 1 tab tid
PO
o Kremil S 1 tab tid
o paracetamol 3-
5g/tab 1 tab q6h
o ampicillin 500g
IVTT q6h
o folic acid 5
mg/tab od
o tranexamic acid
150mg IVTT q8h

56
 o phytomenadione
1 ampule IVTT
stat

Cues & Evidences Nursing Diagnosis Objectives Interventions Rationale Evaluation

Subjective: High risk for infection Within our care, the Independent At the end of our care,
related to inadequate client will remain free • Take vital signs every - Changes in vital signs the client was able to
 Complains of fatigue secondary defenses from signs and can indicate the onset of remain free from signs
4hours.
and weakness. symptoms of infection as bleeding or infection. and symptoms if
evidenced by: infection as evidenced
• Use appropriate hand - Improved adherence to by:
Objective: • free of any evidence hygiene. hand hygiene has been
of new bleeding shown to lessen
 Weakness noted outbreaks of infection in  Met. There was no
 Has non-productive • vital signs within health care facilities, to evidence of new

57
 cough for 2 days normal range: reduce transmission of bleeding noted.
antimicrobial-resistant
 Presence of IV fluid o T= 36.5-37.5 oC organisms.  Not met. Vital signs
at left metacarpal o P=70-85 bpm, were still above
strong, and • Limit and screen - It minimizes exposure normal:
vein running for 41 to infectious
regular visitors.  T  38.2 oC
microdrops/minute o R= 16-20 cpm, microorganisms.  P  121 bpm
silent and  R  31 cpm
 Has poor appetite - Laboratory studies give
effortless • Monitor the client’s  BP  124/72 mmHg
 Bleeding on the lips o BP=112/60 risk for bleeding; a good indication of the
mmHg evaluate results of seriousness of the
when he brushed his  Met. He also
clotting studies and bleeding disorder.
verbalized precautions
teeth • Observe ways to platelet counts. to take to prevent
prevent infection bleeding such as
 Lab results: • Have the client use a - This action helps
such as washing frequent hand
- WBC – 3,400/cumm hands very soft child’s prevent trauma to the
washing.
toothbrush. oral mucosa, which
- Neutrophil – 12 result in bleeding.
• Take necessary  Not met. Client was
- Lymphocyte – 79 % precautions to not able to secure a
prevent bleeding in Dependent new soft, bristled
- Monocyte – 6 % • Monitor for and - The immune system is
the lips and gums. toothbrush.
- Eosinophil – 3 % report signs of stimulated with the onset
infection (e.g., fever, of infection, which
• Minimize frequent  Not met. Visitors
chills, flushed skin, results in classic signs of
visitors which may often come and go.
drainage, edema, infection. Antibiotics
be a source of Strict reverse isolation
redness, abnormal lab must be given promptly
pathogens precautions were also
values and pain) in neutropenic clients
because a delay increases not met because of
• Observe strict morbidity and mortality. lack of knowledge of
reverse isolation the disease condition.
techniques by being
in a private room, • Administer  Met. All meds were
away from other medications as administered.
patients orederd:

58
 o prednisone -following required
10g/tab 1 tab tid treatment regimen is
PO essential to improve the
o Kremil S 1 tab tid prognosis of the
o paracetamol 3- condition
5g/tab 1 tab q6h
o ampicillin 500g
IVTT q6h
o folic acid 5
mg/tab od
o tranexamic acid
150mg IVTT q8h
o phytomenadione
1 ampule IVTT
stat
- Additional pressure is
• Give medications needed to stop bleeding
orally or sites of clients with
intravenously only; bleeding disorders.
avoid giving them
intramuscularly,
subcutaneously or
rectally. Apply
pressure for a longer
time than usual to
invasive sites.

59
 Cues & Evidences Nursing Diagnosis Objectives Interventions Rationale Evaluation

Subjective: Imbalanced nutrition: Within our care, the Independent At the end of our care,
less than body client will have • Determine or measure - Determining the child’s objectives were not met as
 Mother verbalized requirements related improved nutritional body weight can provide evidenced by:
the child’s body
that the child eats to weakness and poor status as evidenced by: weight baseline data for future
appetite comparisons to check on
very little only
• progressive weight the improvement of his  There was decrease in
 February of this year, gain or stable weight. nutritional status. weight. From 28 kgs,
weight decreased to 27
he weighed 32kgs - Monitors caloric intake
• Observe and record kgs.
patient’s food intake or insufficient quality of
• laboratory values food consumption.  Laboratory values
Objective:
within normal range. remained to be below
 Weakness • Provide - Mealtime usually is a normal.
companionship at time for social
noted interaction; often clients
• absence of signs of mealtime to  He had pale and dry
 Decrease tolerance malnutrition. encourage nutritional will eat more food if skin, looked frail and
intake. other people are present weak
for activity at mealtimes.
 Decreased • consumption of  He displayed poor
adequate • Consider six small - Eating small, frequent appetite. Ate only 2
consumption; intake nourishment. nutrient-dense meals meals reduces the tbsp of rice.
of only 2-4 tbsp of versus three larger sensation of fullness and
• Verbalization meals daily to reduce decreases the stimulus to  He was too weak to
rice the feeling of fullness. vomit.
appropriate of verbalize nutritional
 Weight upon nutritional requirements. He
requirements • Encourage mother to - Heme iron in meat, avoided any
admission: 28 kgs offer foods rich in fish, and poultry is interactions because he
iron, and vitamin absorbed more readily wants to rest.
 Weight during than nonheme iron in
B12, C and folic acid.
assessment: 27 kgs plants. Vitamin C
increases the solubility
of iron. Vitamin B12 and
folic acid are necessary
for erythropoiesis.

- Knowledge of the
• Do health teaching to
importance of
the child and to the 60
consuming adequate
significant other as to
nourishment can foster
the importance of
compliance.
 Cues & Evidences Nursing Diagnosis Objectives Interventions Rationale Evaluation

Subjective: Activity intolerance Within our care, the Independent At the end of our care,
related to low client will tolerate • Determine cause of - Determining the cause objectives were not met as
 Mother verbalized hemoglobin levels activity as evidenced by: of a disease can help evidenced by:
activity intolerance
that PTA, client and determine direct appropriate
• report of an increase whether cause is interventions.  Client remained in
can’t tolerate
in activity tolerance physical, lying in bed most of the
running even for just including ADLs. psychological, or time.
motivational
a short while; he
would usually catch • pulse, respirations • Asses the client daily - Inappropriate  Pulse, respirations, and
and blood pressure for appropriateness prolonged bed rest blood pressure
his breath orders may contribute to
within patient’s of activity and bed remained to be above
 Patient verbalized normal range. rest orders. activity intolerance. normal
that he would just lie - Heart rate and blood
• display of laboratory • When getting up the
down while student values (hemoglobin client, observe for pressure responses to  Laboratory results
and hematocrit) symptoms of orthostasis vary widely. remained to be below
nurse held his hand Vital signs changes by
within acceptable intolerance such as normal:
to count for the pulse range. nausea, pallor, themselves and should  Hgb  7.9 g%
dizziness, visual not define orthostatic  Hct  20.9 vol%
• normal skin color dimming, and intolerance.
 Platelet10T/cumm
Objective: and skin is warm and impaired
dry with activity consciousness, as  Skin was still very pale
 He usually lies on his
well as changes in
bed vital signs.
 Can’t tolerate sitting - Inactivity rapidly
• Perform range of
on top of bed for long motion exercises if contributes to muscle
the client if the client shortening and changes
 Needs to be fed and is unable to tolerate in periarticular and
prefers lying down activity. cartilaginous joint
structure. These`factors
while eating contribute to contracture
and limitation of motion.
 Can’t tolerate going
to the bathroom • Allow for rest - Rest periods decrease
periods before and oxygen consumption and
during urination; uses 61
after planned promote client comfort.
a bedpan instead exertion periods such
as meals, baths,
 List of Nursing Diagnoses

• Impaired gas exchange related to decreased oxygen-carrying

capacity of the blood
• Ineffective protection related to abnormal blood profiles secondary
to aplastic anemia
• Imbalanced nutrition: less than body requirements related to
weakness and poor appetite
• Activity intolerance related to low hemoglobin levels
• Ineffective tissue perfusion related to decreased hemoglobin
concentration in the blood
• Fatigue related to decreased oxygen supply to the body
• Disturbed body image related to severe pallor

62
 • Ineffective therapeutic regimen management related to economic
difficulties

Synthesis
The entire pediatric rotation was one of the most promising and most unforgettable experiences that we ever had. We had difficult y in
dealing with pediatric patients because they are afraid of medical health members because of their perception and anticipation that we will do
something harm to them. We were very grateful that we were rotated in Negros Oriental Provincial Hospital Pediatrics Ward because it is in
there that we deal with sick infants and children and some of them are less fortunate when talking about financial constraints. We have
encountered different childhood diseases and disorders and learn how to deal and care for them if situation persist. We had an amazing
experience that within 3 weeks of the rotation, we learned many things that would be a great help of our future career. We took this rotation
not as a challenge but a stepping stone to success because we know that we would undergo hardships and its topics are really difficult to
tackle. Perseverance and dedication to ones duty and work made us face every trial that we have encountered.
This rotation made us realize that we, people, especially children can acquire different diseases if there is no proper care, and safety
preventions because their immune system is not yet well developed. It is through proper prevention and control of illness that would help us in
minimizing transmission of diseases. These patients were a big help to us because without them, we could not practice our skills and

63
knowledge that we have learned in school. We conducted health teachings that would help our clients and families gain knowledge about the
proper prevention and safety methods in caring for their children. Despite the difficulties and the hardships that we had face during the
rotation, we still enjoyed this rotation and we’re very thankful that we extended our help to the pediatric patients and their families even in
our own little ways. Now that the rotation is almost over, we will miss the fun and the laughter that we have shared with our patients but the
knowledge and the learning that we have learned from them will always be in our minds and hearts.
We could still remember that when we had our first assessment of our patient, he smiled, was jolly, energetic, and optimistic that he
would get well with the help of the hospital staff and emotional support from his family. His condition served as an encouragement and a
challenge for us to do appropriate intervention and to do everything that we could to help him in his condition. We wish that he would recover
from his illness, able to surpass the trials that he is facing right now and is able to go back to his normal life as a kid with good health. We will
surely miss our client who was there to strengthen our knowledge and skills and made an impression out of our lives. We would also miss
other patients there and the staff nurses especially our clinical instructor who is with us in every step of the way. Thanks to this rotation, we
have developed the skill and the knowledge to be a more competitive burse in the days to come.

Articles
Katy's Story
Katelyn Rose Hubbell turned four years old on June 26th marrow is the soft spongy material inside your bones that is home
1997, and had a big party at her home in Fisher, Illinois. She was a to stem cells. Stem Cells are the little factories that produce the
happy, healthy little girl, until July 11, 1997 when she was three types of blood cells, that along with a liquid called plasma,
diagnosed with a life threatening bone marrow failure disease makes up your blood. In people with Aplastic Anemia, the workers
called Severe Aplastic Anemia. In case you didn't know, bone

64
in the "factory" go on strike. They do not produce enough blood
cells to keep the patient alive.
On June 17th of 1998, Katy underwent a second round of
immunosuppressive therapy, only this time with a much stronger
drug, Cytoxan. Cytoxan (a.k.a. Cyclophosphamide) is a
chemotherapy drug often used to treat cancer patients. It is a
powerful immunosuppressant, "wiping the slate clean" so to speak,
as it kills off peripheral blood cells in an attempt to stop Katy's t-
cells from attacking her stem cells. Nearly 10 months post her
Cytoxan therapy, it became clear that Katy was not responding.
Her blood counts were still slipping daily, she was still dependent
upon twice-monthly platelet transfusions, and required daily
Epogen and Neupogen injections to stimulate her red and white
blood cells. As a result, Katy's doctors planned a Bone Marrow
Transplant for Katy on May 7th, 1999, at Texas Children's Hospital
in Houston.
We are happy to report that Katy's bone marrow transplant
was a success, and her new marrow is working beautifully! We
thank God, and her hero bone marrow donor, Ernie, every day for
this miracle of new life. Katy still suffers some side effects from
the toxicity of the chemo/radiation therapy that she received
before her transplant. She suffered some permanent neurological
damage, which may take years to fully reveal itself. She is growth
hormone deficient, and requires nightly HGH injections in order to
grow and feel good. Radiation to her eyes has caused cataracts to
form which will eventually require surgery. Despite these new
challenges, Katy continues to amaze us, and every day with our
smiling little girl is a gift.
One year after her BMT, Katy Rose experienced some
unexpected complications. On May 20th, 2000 she had a terrible
nosebleed, and an emergency CBC showed that her platelets had
plummeted to only 14,000. We rushed back to Houston, and a bone
marrow biopsy confirmed that her graft was solid, but somehow
her platelets and red blood cells were being destroyed once they
entered her peripheral bloodstream. She was treated with high
dose steroids, and over a period of 6 weeks, her counts normalized,
and she was back on track to recovery from her transplant.
Reaction:
Katelyn, despite with her happy birthday party,
was diagnosed to have aplastic anemia which served
as a trial to her and her family as well.
Immunosuppressive therapy was implemented on
her care but despite the medication and the therapy,
after 10 months, it was not successful so she has to
undergo another therapy for her bone marrow to be
cured. Bone marrow transplantation was the next
option of the doctor attending her care. They found a
donor named Ernie and was thankful of him for the
bone marrow that he donated for Katelyn. After the
operation, another problem arises and that is the
toxicity of chemotherapy and developed a cataract
65
on her eyes due to radiation therapy. Despite these
complications, she still managed to smile and be
strong. They thought that she would get well after
sometime but another challenge came up and that is
nosebleeding because of very low platelet. It was
confirmed that the transplant was good but the RBC
was destroyed on the peripheral bloodsteam.
Steroids were introduced to treat the recent
IMMUNOSUPPRESSANT THERAPY OF PATIENTS
WITH APLASTIC ANEMIA
Survival and Mortality
Overall survival of all patients at 7 years post treatment was
55%. Patients younger than 50 years had better survival than
those older than 50 years. Patients with absolute neutrophil counts
of less than 200/µL at presentation had worse survival than those
with higher absolute neutrophil counts. Excess deaths in severely
neutropenic patients occurred mainly in the first few months after
diagnosis. There were 12 deaths in 48 patients with severe
neutropenia within 3 months of treatment compared with 3 deaths
in 74 patients without severe neutropenia. Sex, ethnicity, etiology,
and duration of disease were not correlated with survival. Post
treatment status was strongly associated with long-term prognosis,
as defined by response criteria (blood cell counts inconsistent with
severe aplastic anemia, transfusion-independence) or by blood cell
counts. For patients classified as responders at 3 months, actuarial
complication and after 6 weeks, she had recovered
and is recovering for her transplant.
Kate had undergone many treatment and
management of complications but despite these
trials, she still manages to be strong and never lose
hope that she will be cured because she subdues
herself to the treatment for her own.
survival at 5 years was 86% compared with 40% for non-
responders. For patients surviving to 3 months, the median platelet
and reticulocyte counts were each approximately 50_103/µL.
Survival of patients who had either or both counts above the
median value was 90% (64/71 alive) at 5 years compared with 42%
(12/34 alive) for patients with both counts below the median.
There were no deaths from disease more than 3 years after
treatment among patients classified as responders at 3 months.
For patients who responded qualitatively, quantitative counts were
still of prognostic importance. Survival for responders with more
robust blood cell count recovery was 91% at 5 years compared with
47% for responders with both counts below the median. Sixteen
patients (13%) died before their 3-month evaluation (mostly due to
fungal infection). Despite persistent thrombocytopenia, few
patients died of hemorrhage. Six patients died due to
complications following bone marrow transplant (immunosuppression
failed in these patients). A total of 7 patients who entered the
66
 study ultimately underwent bone marrow transplantation (all from
matched, unrelated donors): 4 were nonresponders and died due to
transplant complications; 3 were patients classified as responders
at 3 or 6 months who later evolved to myelodysplasia. Only 1
responder who relapsed with a new finding of monosomy 7 survived
after a matched unrelated transplant.
Reaction:
55% survive only survives after
immunosuppressive treatment and most of them are
under 5o yrs of age. Most of the survivors have
neutrophil count higher than 200/ul. Patients die with
severe neutrophil count or have Neutrogena during
the treatment. For those who respond positively to
the treatment for the first 3 months, they have
higher survival percentage. Most of the patients who
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• Black, J. & Jacob, E. (2005). Medical-surgical nursing. 7th ed. USA: W.B. Saunders Co.
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survived for the first three months of treatment has a
platelet of 50-103/uL. Most of the survivors of the
first three months of treatment survive after 3 years
post treatment. Despite the treatment, patient still
die because of hemorrhage due to
thrombocytopenia. Also, they day because of
immunosuppresion after bone marrow transplant.
Death is very evident with this disease but still
there are ways to prevent and control this aplastic
anemia. Despite the present or advanced treatment
of today they still cant develop a treatment for
aplastic anemia that could have a high percentage
for survival without any adverse side effects. Most of
the present treatments have side effects so some of
the patients instead of responding positively to
treatment, they become more ill and disease
becomes more complicated.
67
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