Case Study Sample (Anemia)

32 Pages·2016·0.5 MB·English

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CASE STUDY ON ANEMIA

Date care started : 18.8.15

Date care ended : 28.8.15

Name of the student : Mr…………………

Submitted to : Mr. Manish Sharma

Submitted on : 12/09/2015

I. Introduction:
Anemia is a major problem which is facing by most of the pregnant women in India. This
problem has to be detected in its early stage and to be treated to prevent any complications to
mother as well as to baby. During our clinical posting in JK loan hospital, I got a chance to give
nursing care to a patient with severe anemia with IUGR.

II. Nursing history and assessment:

Head to toe examination

Skin: Not clean & healthy. Well hydrated.
Nails: Not Clean. Pale in colour. Capillary refill time > 3 sec.
Head: Symmetrical shape, hairs are soft. Scalp is clean and healthy. No dandruff.
Face: clean. Cholasma present.
Eyes: clear. Severely pale. Normal vision.
Ears: clean, no discharge, hearing normal.
Nose: clean, no discharge. No sepal deviations.
Mouth: pink in color. No ulcerations, dental caries, normal movement of tongue and pharynx.
Neck: normal movement. No rigidity.
Chest: symmetrical shape.
Lungs: bilaterally clear.
Heart: Soft systolic soft murmer heard.
Breast: soft and secretary. Colostrum present.
Abdomen: Linea nigra and striae gravidarum are present.
Abdominal girth is 75 cm. Size of uterus is small for the gestational age.
Fundal height: 31cm, 32 weeks.
Genitalia: clean and healthy, no leaking per vaginally.
Upper extremity: normal range of motion.
Lower extremity: normal range of motion. Edema present.

General Appearance

General condition of the patient is good. Having weakness.

Patient Profile:
Name of the patient : Mrs. Sudha w/o Mr. Sudhir
Hospital number :
Age : 30years
Sex : Female
Date & Time of Admission : 18.8.15
Diagnosis : G P A L with 38WKS with severe anemia
4 1 2 1
Date of surgery (if any) : No
Informant : Husband
Chief complaints:
History:
SOCIO-ECONOMIC & CULTURAL DATA

 Housing: My patient Mrs. Sudha lives in a rented house of single room set. There is no
adequate ventilation.
 Occupation & monthly income: Mrs. Sudha is a house wife, but her husband is a driver
working in a private firm. Their monthly income comes about Rs.5000/-
 Literacy: My patient Mrs. is illiterate. Her husband has studied till 10th class.
 Social life & recreational facilities: They are maintaining good communication with
their neighbours and others. There are no such recreational facilities in their home as well
as they are not interested in recreations.
 Religion: my patient belongs to Hindu religion. There are so many restrictions in their
house during pregnancy due to some religious beliefs.
 Health habits: she is maintaining health habits like washing the hands before and after
eating, preparing food, toileting etc.
 Dietary regime: She is an egg vegetarian. She used to take food only two times in a day.
Early morning she had tea/ milk. No extra things are added into their diet during
pregnancy also.
Breakfast/ Brunch: Milk/Tea + roti + Sabji
Dinner: rice + roti + dal + sabji

 Attitude towards present pregnancy by:
SELF: she had a positive attitude towards pregnancy. Her elder child is 4 yrs old and she
is eagerly waiting for her coming child. Though she is more anxious towards her present
pregnancy but she is not maintaining no more extra concerning towards her health in
pregnancy.
OTHERS: she is living along with her husband. Her in laws are not alive. Only she is
having distant relatives in their husband side. They used to come and visit her very rarely.
But her parents and sisters used to come and visit her during her pregnancy and they all
have a positive attitude to pregnancy.
 Cultural data: In their culture during pregnancy they are not allowed to go out alone.
After delivery also they have to remain inside the house for 7 days and after that only
they will come outside and face the other people. After delivery they have to eat only hot
foods and hot boiled water for 2 months.
 Position of mother in the family & society: She is living in a nuclear family along with
her husband. In her house she had a good position.
HISTORIES

 Personal history:
She is egg-vegetarian, no addictions and not allergic to any medicines and foods.
 Family history: there is no significant family history in her family like Diabetes,
hypertension, cardiac diseases etc.
 Past history of mother: There is no significant history of medical and surgical illness in
my patient.
 Menstrual history: Menarche at the age of 13 yrs. She had regular 3-4/28 day cycle.
Having Normal blood flow.
 Marital history: she is married since 6 yrs. She is having a good marital relationship
with her husband.

 Obstetrical history:
G1: spontaneous abortion at 2 1/2 month 5 yrs back. D & C done.
G2: full term normal vaginal delivery at home. Baby girl 4 yrs old. Active and healthy.
G3: Spontaneous abortion at 3 months 3 years back. D & C done in private clinic.
G4: present pregnancy.
 History of present condition
Trimester I: uneventful, had normal minor ailments of pregnancy.
Trimester II: had stomach pain in 5th month, shown to nearby clinic where she has given
some medicines and Inj. TT was also taken. Advised for blood test and other
investigations but it was not done by them.
Trimester III: weakness started, breathlessness, tiredness etc. When it becomes severe she
was again shown to nearby clinic where she was advised to do the USG and it was done
shows oligohydramnios with low birth weight baby. On 18.05.14 breathlessness was
increased and she came to Ummaid hospital and gets admitted there.
Mile stones& New born reflexes
PHYSICAL EXAMINATION

 Skin - warm and pink
 Respiration - regular
 Cyanosis - acrocynosis
 Oedema - negative
 Fotannel (A/P) - palpable
 Sutures - palpable
 Moulding - present
 Head and neck - normal
 Eyes - well-formed
 ENT - bilateral pinna formed, no pre-auricular tags formed
 Thorax - symmetrical
 Abdomen - normal
 External genitalia - labia majora and minora seen
 Congenital anomalies - TOF ruled out, no Anal atresia- baby passed meconium
 Reflexes - present
 Grasp - good
 Respiration - normal, 40/mt
 CVS - S S normal
1 2
 GIT - normal

V. MEDICAL PLAN OF TREATMENT (MEDICAL & SURGICAL)
INVESTIGATION DONE:
INVESTIGATION VALUE NORMAL VALUE INFERENCE
INPATIENT
27.03.15
Maternal blood group B+ve
5.08.15 Single live fetus,
USG vertex presentation,
placenta is fundo
posterior grade II,
FHS- 156/min. &
regular, expected
foetal weight= 2.9 kg.
18.8.15
Haemoglobin 3.7gm% 12-16 gm % Abnormal
Urine – albumin Nil Nil Normal
Urine – sugar Nil Nil Normal
TLC 9400mm3 6000-11000mm3 Normal
DLC P=68%, L=26%, P=40-75%, L=30-50% ,
M=02%, N=04% M=1-10%, E=01-3%
Platelet count 2,30000mm3 150000-450000mm3 Normal
10-40mg/dl
Blood urea 26 mg/dl Normal
20.8.15
Urine routine & Pus cells & RBCs – Within normal
microscopy nil limits
Epithelial cells- 2-3
Nil
Urine albumin Nil
Urine sugar
22.8.15
Haemoglobin 6.9gm% 12-16gm% Less
TLC 7900mm3 6000- 11000mm3 Normal
DLC P=68%, L=26, P=40-75%, L=30-50% ,
M=02, E=04 M=1-10%, E=01-3% Normal
Platelet count 2,20000mm3 150000-450000mm3 Normal
Blood urea 28 10-40mg/dl Normal
Serum creatinine 0.4
S. Bilirubin(total) 0.5
SGOT 36
SGPT 35
Alkaline phosphatase
841

25.8.15
Haemoglobin 7.7gm% 12-16gm% Less
TLC 6400mm3 6000- 11000mm3 Normal
DLC P=65%, L=29%, M= P=40-75%, L=30-50%L, & E are
01%, E=05% M=1-10%, E=01-3% abnormal
Platelet count 197000mm3 150000-450000mm3 Normal
Colour Doppler USG Placenta anterior
grade III. Liquor less.
AFI=3. Single live
fetus in cephalic
position. Expected
fetal weight=
1549gm. Both uterine
arteries are normal in
flow velocity.

Medications:
S.N Name of the Pharmacol Action Side-effects Nursing
o drug ogical responsibilities
name
1 Tab. Ampicillin Broad-spectrum Rash, bone Assess I& O, report
Ampicillin anti-infectant marrow haematuria, bowel
500mg suppression, patterns before
nausea, vomiting, treatment,
diarrhoea, respiratory rate, and
vaginitis, allergies.
glomerulonephriti
s, lethargy, coma
convulsions.
2 Tab. Rantac Ranitidine Histamine (H ) headache, Assess allergy to
2
150 mg hydrochlori antagonist constipation, ranitidine, impaired
de diarrhoea, nausea, renal or hepatic
vomiting, function, CBC, liver
abdominal pain, and renal function
local burning or tests, orientation,
itching at IV site affect etc. Monitor
leukopenia, for side effects.
granulucytopenia,
thrombocytopenia
, pancytopenia
3 Tab. Ferrous Ferrous Haematinic Nausea, Assess HB level
sulphate sulphate constipation, before and after
200mg epigastric pain, treatment.
black and tarry Observe for signs of
red stools, toxicity—nausea,
temporarily vomiting, diarrhoea,
discoloured tooth, haematemesis, pallor,
enamel and eyes cyanosis, shock.
Increase water intake
if constipation
occurs.
4 Tab. Voveran Diclofenac Analgesic and Nausea, anorexia, Assess blood count,
sodium anti pyretic vomiting, LFT and uric acid,
dysrhymias, evaluate therapeutic
dysuria, responses.
bronchospasm.
5 Tab. Alendronate Calcium Rash, oedema of Assess for history of
Osteocalcin sodium regulator— feet, headache, allergy.
500mg increases flushing, tetany, Observe for side-
absorption of chills, weakness, effects.
calcium in dieresis, nausea, Assess BUN,
bones. diarrhoea, creatinine, uric acid,
vomiting, chloride, electrolytes
anorexia,
abdominal pain,
salty taste,
swelling and
tingling of hands.

Surgery: NO
VI. DESCRIPTION OF THE DISEASE:

DETAILS OF CONDITION

ANAEMIA IN PREGNANCY

It is the commonest disorder that may occur in pregnancy. According to the standard laid
down by the WHO, anaemia in pregnancy is present when the haemoglobin concentration in the
peripheral blood is 11gm% or less. During pregnancy plasma volume expands resulting in
haemoglobin dilution. For this reason, haemoglobin level below 10gm% at any time in
pregnancy is considered anaemia.

INCIDENCE

The incidence of anaemia in pregnancy ranges widely from 40-80% in the tropics
compared to 10-20% in the developed countries. Anaemia is responsible for 20% of maternal
death in the third world countries.
CAUSES OF PREVALANCE OF ANAEMIA
Iron deficiency anaemia is very much prevalent in the tropics particularly amongst
women of child bearing age, specially in the under privileged sector. The main causes are
Faulty dietetic habit: high phosphate and phytic acid help in formation of insoluble iron
phosphate and phytates in the gut, thereby reducing the absorption of iron.
Faulty absorption mechanism: because of high prevalence of intestinal infestation, there is
intestinal hurry which reduces the iron absorption. Hypochlorhydria, often associated with
malnutrition also hinders absorption.
Iron loss: more iron is lost through sweat. Repeated pregnancies at short intervals along with a
prolonged period of lactation puts a serious strain on the iron store.Excessive blood loss during
menstruation which is left untreated and uncared for. Hook worm infestation with consequent
blood depletion. Chronic malaria, chronic blood loss due to bleeding piles and dysentery.

CLASSIFICATION

 Physiological anaemia of pregnancy
 Pathological anaemia
1. Deficiency anaemia – iron deficiency, folic acid deficiency, vitamin B12
deficiency, protein deficiency.
2. Haemorrhagic- acute ( following bleeding in early months or APH), chronic(
hook worm infestation, bleeding piles etc.)
3. Hereditary- thalassemia, sickle cell haemoglobinopathies, hereditary
haemolyticanaemia, other haemoglobinopathies.
4. Bone marrow insufficiency
5. Anaemia of infection- malaria, tuberculosis
6. Chronic disease (renal) or neoplasm.

PHYSIOLOGICAL ANAEMIA

There is disproportionate increase in plasma volume, RBC volume and haemoglobin
mass during pregnancy. In addition there is marked demand of extra iron during pregnancy
specially in the second half. Even an adequate diet provide the extra demand of iron. As a result
there will be low serum iron, increased iron binding capacity, and increased rate of iron
absorption. Thus the fall in haemoglobin concentration during pregnancy is due to combined
effect of haemodilution and negative iron balance. The anaemia is normocytic and
normochromic in type.
Criteria for physiological anaemia: the lower limit of physiological anaemia during the second
half of pregnancy should fulfil the following haematological values.
a) Hb – 10gm%
b) RBC – 3.2 million/mm3
c) PCV – 30%
d) Peripheral smear showing normal morphology of the RBC with central pallor
PATHOLOGICAL ANAEMIA- IRON DEFICIENCY ANAEMIA
The women who has got sufficient iron reserve and is on a balanced diet, is unlikely to develop
anaemia during pregnancy inspite of an increased demand of iron. But if the iron reserve is
inadequate or absent, the factors which lead to the development of anaemia during pregnancy
are:
i. Increased demand of iron: an adequate balanced diet contains not more than 18-20 mg
of iron and assuming that the absorption rate is increased by two folds, the demand is
hardly fulfilled.
ii. Diminished intake of iron: apart from socio-economic factors, faulty dietetic habits, loss
of appetite and vomiting in pregnancy are responsible factors.
iii. Disturbed metabolism: pregnancy depresses the erythropoietic function of the bone
marrow. Presence of infection markedly interferes with the erythropoiesis. One should
not even ignore the presence of assymptomaticbacteriuria.
iv. Pre-pregnant health status: majority of the women in the tropics usually starts
pregnancy on a pre existinganaemic state or atleast with inadequate iron reserve. It is
the state of the stored iron which largely determines whether or not and how soon a
pregnant woman will become anaemic.
v. Excess demand: Multiple pregnancy, women with rapidly recurring pregnancy, the
demand of iron which accompanies the natural growth before the age of 21.
CLINICAL FEATURES
The clinical features depend more on the degree of anaemia.

Symptoms:

Features in book In patient
Lassitude & a feeling of exhaustion or weakness Present
Anorexia Present
Indigestion Absent
Palpitation Present
Dyspnoea Present
Giddiness Present
Swelling of legs Absent

Signs :

Features in book In patient
Pallor Present
Glossitis Absent
Stomatitis Absent
Oedema of the legs Absent
A soft systolic murmur Present
Crepitations may be heard at the base of the Present
lungs
INVESTIGATIONS

The patient having haemoglobin level 9gm% or less should be subjected to a full haematological
investigations to ascertain the type of anaemia, degree of anaemia, cause of anaemia.
Degree of anaemia: this requires haematological examinations which includes the estimation of
haemoglobin, total red cell count, determination of packed cell volume.
Haemoglobin level 8-10gm% ----Mild anaemia
7-8gm%-------moderate anaemia
Less than 7gm% ----severe anaemia

Type of anaemia:
 Peripheral blood smear: abundant presence of small pale
staining cells with variation in size and shape suggest
microcytic hypochromic anaemia. Reticulocyte count may be
slightly raised.
Fig.1
Type of anaemia
 Haematological indices: calculation of MCHC, MCV and MCH are based on the values
of Hb estimation, red cell count and PCV.
 Other blood values: serum iron is usually below 30µg/100ml., Total iron binding capacity
is elevated to beyond 400µg/100ml, percentage saturation is10% or less, serum ferritin
below 15µg/L, serum bilirubin is not raised.
A typical iron deficiency anaemia shows the following blood values. Haemoglobin- less than
10gm%, red blood cells –less than 4million/mm3, PCV- less than 30%, MCHC- less than 30%,
MCv- less than 75µm3 and MCH- less than 25pg.

Cause of anaemia
Appropriate investigations should be taken as per the history and clinical examination to find out
the cause of anaemia.
 Examination of stool: to detect helminthic infestation
 Urine examination; microscopic and culture examination should be done to rule out any
infections.
DIFFERENTIAL DIAGNOSIS
1. Infection
2. Nephritis
3. Pre eclampsia
4. Haemoglobinopathies
TREATMENT
PROPHYLACTIC