Megaloblastic Anemia: A Case Study

INTRODUCTION

Everyone knows that we can't live without blood. Without blood, our organs couldn't get the oxygen and nutrients they need to survive, we couldn't keep warm or cool off, we couldn't fight infections, and we couldn't get rid of our own waste products. Without enough blood, we'd weaken and die. There are diseases and conditions involving the blood. The most common is anemia. An anemia is a condition in which the number of red blood cells (RBC) or the amount of hemoglobin (the protein in red blood cells that carries oxygen throughout the body) is below normal. Megaloblastic Anemia (MGA), also known as Pernicious Anemia, is a rare blood disorder characterized by the presence of large, structurally and visually abnormal, immature red blood cells (megaloblasts). Decreased numbers and immaturity of white blood cells (leukocytes) and blood platelets (thrombocytes) may also occur. Megaloblastic Anemias are usually caused by a deficiency or defective absorption of either vitamin B12 (cobalamin) or folic acid. As a result, they are also known as the vitamin deficiency anemias. In most cases, the fundamental flaws leading to the several forms of MGA caused by vitamin deficiencies are present at the time of birth and exist as a result of a genetic defect. In addition, certain immunosuppressive drugs may also cause Megaloblastic Anemia. As student nurses, we must be aware of the signs and symptoms of the disease so we could be more effective in doing our duties.

OBJECTIVES GENERAL:

To improve our skills, knowledge and attitude necessary to care for our patients with megaloblastic anemia. SPECIFIC: 1. To understand the disease process, its etiology, signs

and

symptoms,

pathophysiology

and

diagnostic

procedures, 2. To

discuss

and

describe

interventions

for

health

promotion, prevention and treatment of patients with megaloblastic anemia. 3. To

develop a teaching program that will educate

patients especially those who are susceptible to anemia by reiterating the importance of good and healthy nutrition. 4. To

assist patients in overcoming the anxiety and

depression brought about by the condition. 5. To

promote awareness to individuals by imparting

knowledge so they could learn and understand more about megaloblastic anemia. Biographic data: Name: Mr. X Address: Caloocan City Age: 40 years old Sex: Male Marital Status: married Religion: Roman Catholic Health Care financing: United Healthcare Usual Source of Medical Care: Health personnel Chief Complaints: Weakness Medical Diagnosis: Megaloblastic Anemia Doctor: Dr. Romeo Rivera

History of present illness: According to the patient, he was first diagnosed with Megaloblastic anemia last June of 2006 when he was hospitalized for 3 days at the Martinez Memorial Hospital. He was admitted with chief complain of body weakness. He received blood transfusion when hematology laboratory results revealed decreased blood count. From then on, he needed blood transfusion every time his blood count would fall below normal. He was again hospitalized recently in the same institution. According to him, his appetite was decreased and had difficulty walking which is a common manifestation of anemia because of weak muscles. He was also pale and noticeably irritable. The laboratory results showed an alarming decrease in blood components. His hemoglobin count was 8.2 g/dl as compared to normal adult male range of 14 - 18 g/dl; hematocrit of 25% compared to normal adult male range 40 - 54% and RBC count of 2.5 mill/mcl, normal adult male range 4.2 - 5.6 mill/mcl. Past history

According to Mr. X, he had measles when he was young, aside from the usual fever and cough. He doesn’t remember having immunizations although his mother has told him before that he completed his immunization vaccines when he was young, He is not allergic to drugs, animals, insects, food or other agents. Accidents and Injuries:

No accidents and injuries. Family History Illness:

Hypertension and diabetes on his mother side. Lifestyle and Personal Habits

Mr. X is a non-smoker but was a heavy drinker. When he was hospitalized two years ago, he stopped drinking under his physician’s advice. He doesn’t drink coffee or tea. He drinks soda once in awhile. He only takes drugs prescribed to him by his physician. Social data:

Mr. X has a good relationship with regards to his family and relatives. He loves to travel. Before he was diagnosed with megaloblastic anemia, they would go to his hometown province and spend a few days there. Summer was his children’s favorite time of the year because they would often go out of town. But because of his condition, his lifestyle was changed. He tires easily aside from the fact that blood transfusion and hospital bills affect his family’s financial status. Diet:

Mr. X eats 3-4 times a day. He prefers to eats fish and vegetables but would sometimes eat meat also. Sleep/Rest Pattern:

According to him, he has ample time to rest although sometimes, because of stress brought about by his condition, he has difficulty falling asleep. Ethnic affiliation:

Mr. X grew up in the province and is a believer of nuno sa punso, dwarfs and other superstitious beliefs He also believes in herb or quack doctors and faith healers. Educational History:

Mr. X is a high school graduate from Mindoro. Occupational History:

Mr. X has a small business painting cars. It is enough to make both ends meet for him, his wife and 3 children. He earns roughly about P30,000 - P40,000 every month. But since he was diagnosed with anemia, he works less and naturally earns less. His wife helps him by being a retail person for Avon and Saralee among others. Economic Status:

Having a medical insurance helps him pay his medical bills. His family helps too in whatever way they can. Psychological Data:

What troubles Mr. X most is his family’s financial concern. He doesn’t want to see his family suffer because of his condition. He wants to see his 3 children to grow up and be professionals some day. GORDON’S FUNCTIONAL HEALTH PATTERNS PATTERN OF HEALTH PERCEPTION AND HEALTH MANAGEMENT

Mr. X is very particular about his and his family’s health. He believes in the saying that health is wealth. When he started feeling weak and had difficulty breathing after doing some light activities, he went to see his doctor right away. No one in his family was ever hospitalized so it is a bit difficult for him to accept the fact that he, supposedly the head and pillar of the family is sick. At first, he had no clue about what his condition is. But as time goes by, he learns a lot from his doctors and his nurses. NUTRITIONAL – METABOLIC PATTERN Height

:

5’7”

TIME FRAME Before illness During illness Weight as of Feb. 1, 2007

WEIGHT 136 lbs 122 lbs 122 lbs

BMI 20.64 18.66 18.66

INTERPRETATION Normal Normal Normal

Basis of Interpretation:    

BMI BMI BMI BMI

of of of of

< 18.5 is classified as underweight 18.5 to 24.9 is classified as normal 25 to 29.9 is classified as overweight 30 to 39.9 is classified as obesity

*BODY MASS INDEX (BMI) = weight (kg) / height (m⅔)

Although Mr. X lost 14 lbs from the time prior to his illness up to the present, his body weight is still within the normal range based on his BMI. DIETARY PATTERN MEALS Breakfast

Lunch Snacks Dinner

BEFORE ILLNESS AMOUNT FOODS/DRINKS 2-3 cups Rice 3-5 pieces Boiled/scrambled eggs 2 glasses water 2-3 cups Rice 1 serving Pork/fish/vegetables 2 glasses water 1-2 pieces Sandwich 1-2 glasses Cola drinks 2 cups 1 serving 2 glasses

Favorite Foods

Rice Fish/vegetables water

PRESENT AMOUNT FOODS/DRINKS 1 cup Rice 1 serving Fish/vegetables 1 glass Juice 1 glass Water 1 cup Rice 1 serving Pork/fish/vegetables 2 glasses water 1 serving Pancit canton/ 2 glasses sopas water 1 cup Rice 1 serving Fish/ vegetables 2 glasses water

Vitamins

: Dishes like pinakbet, sinigang na baboy or bangus, Vegetables like eggplant, ampalaya, and cabbage. Fruits like mango, apple and orange. : Folic Acid

VISIT TO FAST FOOD RESTAURANTS

:

2-3 x a week

Allergies to Foods

:

(Jollibee, McDonalds, KFC) None

PATTERN OF ELIMINATION Bowel Elimination Frequency Character of stool Problem Encountered

Before illness Once a day Brownish, solid None

Present Once a day Brownish, solid None

Urinary Elimination Frequency Character of urine Problems Encountered

Before illness 8 -10 x a day Aromatic, pale yellow None

Present 8 -10 x a day Aromatic, pale yellow None

PATTERN OF ACTIVITY AND EXERCISE  Typical activity for the day prior to admission Time 6:00 – 7:00 AM 7:00 – 8:00 AM 8:00 – 11:00 AM 11:00-11:30 AM 11:30 – 12:00 NN 12:00 – 1:30 AM 1:30 – 5:00 PM 5:00-6::00 PM 6:00 – 7:00PM 7:00 - 8:00 PM 8:00 – 11:00PM 11:00 PM

Activity > Wakes up > prepare and eat breakfast > Work > Rest > Eat lunch > rest and sleep > Work > Socialize with neighbors and friends > Helps prepare dinner > Eat dinner with family > Watch TV/Read > Bed time

COGNITIVE – PERCEPTION PATTERN

We see no problem about the way he communicates. He could comprehend easily and could recall past as well as recent events in his life. He talks with sense and explains things logically. PATTERN OF SELF PERCEPTION AND SELF CONCEPT

Mr. X has a positive outlook about life in general. He doesn’t take it against himself or against anybody for what

happened to him. He is very optimistic that he would be better. In fact he is willing to undergo any medical interventions to alleviate his sufferings and to prolong his life. He has his family’s support and that is what’s giving him strength to battle towards recovery. ROLE RELATIONSHIP PATTERN

Mr. X married his childhood sweetheart. He lives with wife and 3 children, 2 boys and 1 girl, all of them are going in a nearby public school. He is close with all of his kids because he sees to it that he spends quality time with them even though he tires easily. His wife is very supportive with what he is going through. SEXUALITY PATTERN

According to Mr. X, although the quantity is lessened, he and his wife still enjoy sex even after having 3 children and being married for almost 15 years. His wife is “malambing” and thoughtful. She never misses to let him feel how much she loves him and how much they need him. He admitted that his family is not a perfect one but he and his wife made it a point to iron things out before it gets worse.

PATTERN OF COPING AND STRESS TOLERANCE

Mr. X views his problem more as a trial than an obstacle. Even though it affected his work, it did not dampen his spirit and trust in the Lord. According to him, it made him a better person. Now he realized the value of what he has. The only thing that stresses him out is about his family’s finances. But as of now, they could still manage. They still could eat 3-4 meals a day and he can still send his children to school despite the hospital bills. Before his diagnosis, he copes stress by drinking and playing basketball with his sons. Now, he feels relax when he watches the television or listens to the radio. He plans on doing some gardening too because according to one of his friends, gardening is one of the best way to relieve stress. PATTERN OF VALUES AND BELIEFS

He believes in God and that God won’t give him problems he could not bear. When he is not in the hospital, they go and hear mass as a family. He also has strong ties with his mother and siblings. They don’t see each other as much as they used to but because of the technology that we have now, the communication lines remain open. In spite of his condition, he still provides for his family because that is what his own father instilled in his mind when he was growing up. The man should be the head and the pillar of the family. According to him, to be able to be called a man, one has to provide, support and defend his family.

PHYSICAL ASSESMENT

I.

GENERAL APPEARANCE a. Body Build

: Medium Frame

b. Height and weight

: 5’7”; 122 lbs

c. Posture

: erect and straight body posture

d. Hygiene and grooming

: clean and neat

e. Body breath and odor

: none

f. Appearance

: appears weak

g. Mental status: clear and intact memory both recent

and remote,

oriented to person, time and place h. Attitude

: cooperative

i.

Mood and affect

: appropriate to situation

j.

Organization of speech

: understandable, moderate pace

k. Relevance and organization: has logical sequence and sense of reality of thought II.

III.

VITAL SIGNS a. Temperature

: 36.6’ C

b. Pulse Rate

: 75 bpm

c. Respiration Rate

: 18 bpm

d. Blood Pressure

: 110/70 mmHg

INTEGUMENT A. Skin a. Color complexion

: fair complexion

b. Skin moisture

: dry, slightly wrinkled, dry lips

c. Skin temperature

: normal

d. Skin turgor

: slightly poor skin turgor

B. Nails a. Fingernail plate shape : convex b. Texture

: smooth

c. Bed color

: pink

d. Capillary refill

: pink in color returns after 5 secs. - Intact epidermis around the nail

IV.

HEAD A. Hair a. Color

: black

b. Distribution

: evenly distributed

c. Texture and oiliness

: silky, fine and oily - Thin strands of hair

B. Scalp - Absence of drandruff - No lesions, masses, deformities, swelling and tenderness. C. Skull - Normocephalic - Smooth, uniform consistency; absence of nodules or masses D. Face - symmetrical facial features and movements E. Eyes and Vision a. Eyebrows : eyebrows are black, evenly distributed and symmetrically aligned b. Eyelashes c. Eyelids

: equally distributed, slightly curled outward

: skin is intact, lids close symmetrically

d. Bulbar conjunctiva

: transparent, capillaries are not

evident, sclera appears yellowish e. Palpebral conjunctiva: shiny, smooth, and slightly yellowish f. Lacrimal gland : no edema, or tenderness over the gland g. Pupils

: black in color, iris appears yellowish

h. Visual acuity

: decreased visual acuity, difficulty in

reading prints in near vision (farsighted 65 degree) i. Visual field

: decreased peripheral vision

j. Consensual reaction to light and accommodation: normal constriction of pupil upon the presence of light ( PERRLA) F. Ears and hearing

a. Auricles

: symmetrical, skin color is same with facial

skin, aligned with outer canthus of the eye; movable, firm and tender, recoils back after it is folded b. External ear canal : with scant amount of cerumen and few cilia c. Gross hearing acuity test: able to hear normal voice and able to hear whisper voice within 6 inches (15. 24 cm) V.

NECK

: No area of tenderness -No masses found -Range of motion is done actively within normal limits and pain free

VI.

CHEST a. Anterior chest

: intact skin with uniform color, -no area of tenderness, -no

mass

is

found

with

visible

bone

prominence -Symmetrical chest expansion b. Posterior Chest : fair complexion - smooth skin - no evidence of enlargement - no area of tenderness - no mass is found VII.

UPPER EXTREMITIES a. Shoulder

: range of motion on right shoulder is actively done within normal limits and pain free. - Left shoulder’s range of motion are done in active assistive with restricted motions due to IV line

b. Elbows

: range of motion on left elbow is actively done within normal limits and pain free.

-Right elbow’s range of motion is done actively with normal limits and pain free. c. Wrist and hands : range of motion of right wrist and fingers are actively done within normal limit and pain free. - Left wrist and fingers are not movable due to inserted IV line. d. Muscles

: No tenderness found

VIII. ABDOMEN

:

soft

abdomen,

no

masses

and

areas

of

evidence

of

tenderness -Uniform

in

color

with

no

enlargement of liver and spleen. -Umbilicus is in the normal position between the xiphoid process and symphysis pubis with Normal Abdomen Bowel Sound (NABS) IX.

LOWER

EXTREMITIES

:

fair

complexion,

smooth

skin,

symmetrical\muscles, intact skin, warm to touch with good muscle tone -Range of motion on joints is done within normal limits and pain free. -Toe nails: with good capillary refill upon blanch tests (<5 secs), convex, pinkish nail beds with intact skin around the nails.

REVIEW OF SYSTEMS: 1. Hematopoietic system: a. Hemoglobin b. Hematocrit c. RBC d. WBC 2. Genito-Urinary System

Normal Value 14 - 18 g/dl 40 - 54% 4.2 - 5.6 mill/mcl 3.8 - 10.8 thous/mcl

Result 8.2 25 2.5 5.1

Interpretation Decreased Decresed Decreased Normal

-

Urinates 8-10 times per day, having a characteristic of aromatic pale yellow with no burning sensation.

3. Respiratory System: Normal 12-20 bpm

Respiratory rate

Result 18 bpm(normal)

4. Cardiovascular system: Normal 60-100 bpm 120/180 mmHg

Pulse rate Blood pressure

Result 75 bpm( normal ) 110/70( normal )

5. Integumentary System: Normal 37.5

Temperature

Result 36.6( normal)

6. Digestive System: - No constipation, no diarrhea and no allergies found. - Eliminates once a day (am), having a characteristic of brownish solid and doesn’t experience any pain sensation. 7. Reproductive System: - No. of child: 3 - Reproductive organs are well-functioning. No inflammations found. However, having such condition lessened the number of times that they make love.

LABORATORIES Date Taken: Feb. 1, 2008 Hospital: Martinez Memorial Hospital Hematology Report Hemoglobin

Normal Values 14 - 18 g/dl

Results 8.2

Interpretation Decreased. In case of megaloblastic anemia are abnormally large cells predominate, thicker as well as larger

Hematocrit

40 - 54%

25

RBC

4.2 - 5.6 mill/mcl

2.5

WBC Platelet Neutrophil Lymphocyte Eosinophil Monocyte Basophil

3.8 - 10.8 thous/mcl 150 - 450 0.500 – 0.700 0.200 – 0.500 0 – 0.060 0.020 – 0.090 0 – 0.20

5.1 245 0.692 0.328 0.022 0.021 0.002

Blood type

: A

Rh

: (+)

in diameter than normal RBC it appear supersaturated with hemoglobin. The RBC count is reduced more than proportionately as compared with hemoglobin Decreased. Indicated by a reduced volume of packed red cells followed by RBC counts and hemoglobin. Blood smear examination found evidences of macrocytes and nucleated red cells. Decreased. Disturbed red cell formation Normal Normal Normal Normal Normal Normal Normal

ANATOMY AND PHYSIOLOGY

The

The production of red blood cells is referred to as erythropoiesis. Mature red blood cells develop from haemocytoblasts. This development takes about 7 days and involves three to four mitotic cell divisions, so that each stem cell gives rise to 8 or 16 cells. The various cell types in erythrocyte development are characterised by the gradual appearance of haemoglobin and disappearance of ribonucleic acid (RNA) in the cell the progressive degeneration of the cell's nucleus which is eventually extruded from the cell the gradual loss of cytoplasmic organelles, for example mitochondria a gradual reduction in cell size The young red cell is called a retlculocyte because of a network of ribonucleic acid (reticulum) present in its cytoplasm. As the red cell matures the reticulum disappears. Between 2 and 6% of a new-born baby's circulating red cells are reticulocytes, but this reduces to less than 2% in the healthy adult. However, the reticulocyte count increases considerably in conditions in which rapid erythropoiesis occurs, for example following haemorrhage or acute haemolysis of red cells. A reticulocyte normally takes about 4 days to mature into an erythrocyte. In health, erythropoiesis is regulated so that the number of circulating erythrocytes is maintained within a narrow range. Normally, a little less than l% of the body's total red blood cells are produced per day and these replace an equivalent number that have reached the end of their life span. However that still represents a huge 200,000,000,000 cells Erythropoiesis is stimulated by hypoxia (lack of oxygen). However, oxygen lack does not act directly on the haemopoietic tissues but instead stimulates the production of a hormone, erythropoietin. This hormone then stimulates haemopoietic tissues to produce red cells. Erythropoietin is a glycoprotein. It is inactivated by the liver and excreted in the urine. It is now established that erythropoietin is formed within the kidney by the action of a renal erythropoietic factor erythrogenin on plasma protein, erythropoietinogen. Erythrogenin is present in the juxtaglomerular cells of the kidneys and is released into the blood in response to hypoxia in the renal arterial blood supply. Various other factors can affect the rate of erythropoiesis by influencing erythropoietin production. Thyroid hormones, thyroid-stimulating hormone, adrenal cortical steroids, adrenocorticotrophic hormone, and human growth hormone (HGH) all promote erythropoietin formation and so enhance red blood cell formation (erythropoiesis). In thyroid deficiency and anterior pituitary deficiency, anaemia may occur due to reduced erythropoiesis.

Polycythaemia (excess red blood cell production) is often a feature of Cushing's syndrome. However, very high doses of steroid hormones seem to inhibit erythropoiesis. Androgens (male hormones) stimulate and oestrogens (female hormones) depress the erythropoietic response. In addition to the effects of menstrual blood loss, this effect may explain why women tend to have a lower haemoglobin concentration and red cell count than men. Plasma levels of erythropoietin are raised in hypoxic conditions (low oxygen levels). This produces erythrocytosis (increase in the number of circulating erythrocytes) and the condition is known as secondary polycythaemia. A physiological secondary polycythaemia is present in the foetus (and residually in the new-born) and in people living at high altitude because of the relatively low partial pressure of oxygen in their environment. Secondary polycythaemia occurs as a result of tissue hypoxia in diseases such as chronic bronchitis, emphysema and congestive cardiovascular abnormalities associated with right-to-left shunting of blood through the heart, for example Fallot's tetralogy. Erythropoietin is also produced by a variety of tumours of both renal and other tissues. The oxygen carrying capacity of the blood is increased in polycythaemia but so is the thickness (viscosity)of the blood. The increased viscosity produces circulatory problems such as raised blood pressure. Ther is a condition known as primary polycythaemia (polycythaemia rubra vera), where there are increases in the numbers of all the blood cells, and plasma erythropoietin levels are normal. The cause of this condition is unknown. The underlying cause of secondary polycythaemia is treated with the aim of eliminating hypoxia. Venesection (blood letting) is sometimes employed to reduce red cell volume to normal levels. Frequently blood is removed, centrifuged to remove cells and the plasma returned to the patient (plasmapheresis). In anaemia there is a reduction in blood haemoglobin concentration due to a decrease in the number of circulating erythrocytes and/or in the amount of haemoglobin they contain. Anaemia occurs when the erythropoietic tissues cannot supply enough normal erythrocytes to the circulation. In anaemias due to abnormal red cell production, increased destruction and when demand exceeds capacity, plasma erythropoietin levels are increased. However, anaemia can also be caused by defective production of erythropoietin as, for example, in renal disease.

Gastritis Faulty Dietary Intake Dysfunctional Parietal Cell of the Stomach Lack of Intrinsic Factor (GLYCOPROTEIN) Malabsorption of Vitamin B12 Dysfunctional Binding of Transcobalamin II Vitamin B12 Deficiency Ineffective Erythropoiesis

Abnormal Erythroblast

Hypersegmented Neutrophils

Megaloblast Megaloblastic Anemia

Decreased Nutrients to Cells Abnormal Cell Metabolism Decreased production of energy Poor Skin Turgor

Decreased Oxygenation

RBC Count 2.5 (decreased) Hemoglobin 8.2 (deceased)

Tissue Hypoxia Body Weakness Weight Loss

Pallor 122 lbs

DRUG STUDY DRUG

ACTION

Generic Name: Antamin

•

Classification: Anti histamine / antiallergic

•

Dosage: 1 amp. IV prior to BT

•

Compet es with histamin e for Recepto r sites on effector cells Drug prevents but doesn’t reverse histamin e mediate d response .

INDICATION • •

CONTRA INDICATIO N Allergy • Lower respirato Prophylacti ry tract c drug for disease possible BT reaction

SIDE EFFECTS •

Drowsines s, hypnosis, gastro intestinal

ADVERSE REACTION •

DRUG INTERACTION

Depressio • n, • Irritability , hallucinat ion, muscular weakness , incoor dination, headache

No known drug-drug interaction.

NURSING RESPONSIBILITIES •

•

Warn the patient to avoid alcohol and hazardous activities that require alertness until CNS effects of drug. Observe for the 10 R’s of the drug

DRUG STUDY DRUG

ACTION

Generic Name: Aeknil

Unknown, thought to produce analgesic by blocking pain impulses

Classification : Non-oploid analgesic Dosage: 1 amp. IV PRN ANST(-)

INDICATION CONTRAINDICATION fever

Long term use in anemia

SIDE EFFECTS Skin rashes and other allergic reactions,G I disturbance

ADVERSE REACTION Hematologic anaphylaxis, tinnitis

DRUG INTERACTION No known drugdrug interaction

NURSING RESPONSIBILITIES -Warn the patient that high doses of long term use can cause liver damage. -Observe for the 10 R’s of the drug administration

DRUG STUDY DRUG

ACTION

INDICATION

CONTRA INDICATION

SIDE ADVERSE DRUG NURSING EFFECTS REACTION INTERACTION RESPONSIBILITIES

Generic Name: Folic Acid

-It is converted to tetrahydrofolic acid which is a Classification: cofactor in the Vitamin B biosynthesis of complex purines and thymidylates of Dosage: nucleic acid. OD -Synthetic folic acid is absorbed from the GI tract even if the client suffers from malabsorption syndrome.

Treatment of megalo-blastic anemia and nutritional deficiency

Use in aplastic, hormocytic or pernicious anemia.

Allergies, rashes, itching

Erythema, general malaise, abdominal distention, flatulence, bitter or bad taste

No known drugdrug interaction

-Take only as directed. Avoid alcohol. -Drug may discolor urine into a deep yellow. -Add dietary sources of folic acid which includes: green leafy vegetables, beans, milk, fortified breads and cereals -Observe for the 10 R’s of the drug administration

DRUG STUDY

DRUG

ACTION

Brand Name: Pred 20

-3 to 5 times as potent as cortisone or hydrocortisone

Generic Name: Prednisone Classificatio: Anti inflammatory Dosage: 1 tab TID

-May cause moderate fluid retention.

INDICATIO N Erythroblasto penia

CONTRA INDICATION Contraindicated with infections, especially TB, fungal infections, varicella.

SIDE ADVERSE EFFECT REACTION Weight Vertigo, gain, insomia, headache depression, cataracts, peptic ulcer

DRUG INTERACTION No known drugdrug interaction

NURSING CONSIDERATION -Take only as directed. Avoid alcohol. -Observe for the 10 R’s of drug administration -Report for any adverse reaction.

-Metabolized in the liver to prednisone, the active form

NURSING CARE PLAN

ASSESSMENT

NURSING DIAGNOSIS

RATIONALE

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

Subjective: “sa totoo lang di ko talaga alam kung ano ang leukemia” as verbalized by the patient.

Knowledge deficit related to lack of information resources as manifested by verbalization of situation reflecting ignorance.

Deficiency of cognitive information regarding the etiology as well as the signs and symptoms of the disease.

The patient will be able to attain right information and knowledge about the nature of illness within 2 hours.

-

Determine client’s ability to learn.

- To determine the cognitive ability of the patient.

-

Provide information relevant to the situation.

- To add new information relevant to the condition of the patient.

-

Use team and group teaching as appropriate

- So that the patient will be easily gain some relevant information because they can share information

Goal is met: After 2 hrs of nursing intervention, the patient gained correct information and knowledge regarding his condition.

NURSING CARE PLAN ASSESSMENT

NURSING DIAGNOSIS

RATIONALE

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

- 4 secs of nail blanch test - pallor - decreased count of hematocrit (25) - decreased count of hemoglobin(8.2) - decreased count of RBC(2.5)

Risk for ineffective tissue perfusion (peripheral) related to decreased Hgb concentration in the blood as manifested by decreased hemoglobin(8.2)

In case of megaloblastic anemia there is an abnormal production of enlarged but few RBC, the Hgb decreases thus lowering the oxygencarrying capacity of the blood that is at risk for failure to nourish the tissues at capillary level

The patient will be able to increase his RBC and Hgb concentrations within 4 hours.

-

Give blood transfusion as ordered by the physician.

-

Instruct the patient to limit his physical activities.

-

-

-

To replace the decreased count of RBC and Hgb.

-

Extreme activities consume a greater concentrati on of O2.

Encourage the patient to eat foods rich in Vit. B12, protein and Iron.

Instruct the patient to take folic acid and as prescribed by the doctor.

Vit.B12 is required for for healthy RBC; iron is important for the delivery of O2 to tissues and blood components; protein to build and repair tissues. - Folate is required for the nucleoprotein synthesis and maintainance of normal erythropoiesis

- After 4 hours of nursing intervention, the laboratory results showed an increase in the patient’s Hgb and RBC count.

NURSING CARE PLAN ASSESSMENT Subjective: “para akong nauupos na kandila.” As verbalized by the patient. Objectives: - Weakness -Dyspnea -Pallor -Decreased activity level

NURSING DIAGNOSIS

RATIONALE

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

Activity intolerance related to insufficient oxygen delivery to the body parts secondary to production of abnormally large RBC as evidenced by body weakness.

Any anemia in which there is a predominant number of megaloblasts, erythroblasts and relatively few normoblasts among the hyperplastic erythroid cells in the bone marrow characterized by numbness and tingling,weakness, a soar smooth tongue as well as dyspnea after slight exertion, faintness, pallor of the skin and mucuous membrane, anorexia, diarrhea, loss of weight .

Within 2 days of my duty, the patient will be able to demonstrate increase in strength and ability to perform activities without difficulty in breathing.

-Teach the client the preventive measures and the possible cause of his illness.

-To educate and help the client to have awareness regarding his illness.

Goal met: The patient was able to demonstrate increase in strength and was showed no signs of difficulty in breathing.

-Encourage the client to take a rest and follow medical advice. -Assist the client in his nutritional intake. -Encourage the client to practice self-care. -Assist in IV infusion.

-For faster recovery.

-For the client to know what food to avoid. -To promote wellness. -To prevent fluid and electrolyte imbalance

DISCHARGE PLAN MEDICATION: Folic Acid and Prednisone

EXERCISE:

• Perform passive ROM exercise like flexion, extention of the extremities. • Brisk walking every morning. TREATMENT: •

Blood transfusion if blood count falls below normal.

• Folic acid injection if available. HEALTH TEACHING:

• Encourage participation in recreation and regular exercise program • Provide appropriate level of environmental stimulation (e.i; music, TV/ radio, personal possessions and visitors) • Suggest use of sleep aid/ promote normal sleep/rest. OPD: Return to OPD for further check-up when there are changes

on physical strength. DIET:

• High fiber diet like vegetables and fruits. • Protein rich diet

• Folic and vitamin B12 rich foods such as : liver, dried beans, peas, wheat products, spinach, dark leafy vegetables, meat, eggs, milk SIGNS/SYMPTOMS:

Observe for signs and symptoms such as body weakness, poor skin turgor, pallor and weight loss.

Prognosis

The prognosis of the patient is expected to be good and will respond well to treatment usually within two months. Although anemia is considered incurable, regular Vit. B12 shots will alleviate

symptoms

and

reverse

the

complications.

Some

symptoms will disappear as soon as treatment begins. The client must be instructed about the medications he must take and reinforce all the medical advice given by the attending physician. Diet would play a vital part in his recovery, hence must be strictly implemented. Although he displayed willingness to get better, continuous monitoring of his blood components must be strictly observed.