“NEVER LET ME DOWN”

A CASE PRESENTATION ON

IRON DEFICIENCY ANEMIAJENNIE ROSE V. ANONUEVO, BSN, RN

DEPARTMENT OF OB-GYNEDR. AHMAD ABANAMY HOSPITAL

JANUARY 2013

1. DEMOGRAPHIC DATA

Case number: 190***Age: 30 Years OldSex: FemaleDiagnosis: G4 P2 A1, 37 1/7 wks AOG, Iron

Deficiency Anemia

2. PHYSICAL ASSESSMENT

I. GENERAL APPERANCE:

Well groomCooperativeWeak looking

II. SKINPaleWarm to touchDry course noted in elbows and

kneesNo edema Hair is generally black, well

distributed over the scalpNo infestation notedNo clubbing but upon blanch test of

fingernails shows sluggish capillary refill ≥ 3 secs.

III. HEAD - NECK

Facial symmetry No scalp tendernessNo lesion nor masses notedIris are black, pupils equal, round, reactive to

light and accommodationWhite clear sclera notedConjunctiva are palePatient’s pinna is the same color as her facial

skin, smooth and aligned with the eye levelAble to hear sound clearly as claimedNo pain, inflammation or drainages notedShe has both patent and equal nostrilsNo nasal flaring, congestion or drainages noted

Lips and mucous membranes are pale

Tongue is centrally positioned, uvula is in the midline

Lingual tonsils noted at the posterior portion of the tongue

Have good oral hygiene, no presence of bad smell.

Jugular vein not distendedNo swollen lymph nodes palpatedWith good ROM.

IV. THORAX:

Symmetrical chest wall upon movement and breathing on room air

Breath sound equalRespiratory rate range = 18-24 cpm

V. CARDIOVASCULAR:

Absence of chest painPeripheral pulse noted. BP range (eg. 130-110/80-60), pulse rate range (95-135 bpm), O2 saturation range (94-98%)

VI. GENITOURINARY:

Positive gross watery vaginal discharges

No active bleeding notedNo discharges or foul smelling odor

Able to void freely to adequate clear urine

No sensation of pain during urination.

VII. GASTROINTESTINAL:

Abdomen is soft, with mild to moderate uterine contraction at time of assessment

No abdominal tenderness(+) bowel sound

VIII. MUSCULOSKELETAL:

No physical deformities, contractors nor paralysis noted

With active range of movementJoints can move freely without resistance or pain.

IX. NEUROLOGIC:

Awake, alert and oriented to time, place and person.

Understand written and spoken language and responds appropriately

Able to follow commands and instructions.

3. PATIENT HISTORY

I. PAST MEDICAL HISTORY

(+) History of Anemia as claimed

(+) History of Abortion(-) Surgical history

II. PRESENT MEDICAL HISTORY

Patient 190*** is a referral patient from Security Forces Hospital with chief complaint of labor pain and watery vaginal discharges since 10:00 pm (1-12-12).

She is G4P2A1 37 1/7 wks AOG, with Iron Deficiency Anemia.

LMP: 16-3-12

EDC: 22-12-12

P/V done : 3 cm dilated cervix, 50% effaced, station -3, cephalic in presentation

(+) adherent membrane, watery vaginal leaking noted, (+) Amnicator

Not able to tolerate intake of iron due to vomiting.

No allergies to food or drugs.

No relevant family medical history.

ANEMIA

4. TOPIC PRESENTATIONANEMIAAnemia is a medical condition in which the red blood cell count or hemoglobin is less than normal

PREVALENCE RATE

25% world’s population

56% developing countries(pregnant)

18% industrialized countries(pregnant)

CRITERIA:

<12 g/dL in nonpregnant women

<10 g/dL during pregnancy or the puerperium.

ANEMIA IN PREGNANCY

IRON DEFICIENCY ANEMIA (IDA) in PREGNANCY

Is defined as decreased total iron body

content.

Occurs when iron deficiency is severe

enough to diminish erythropoiesis and

cause the development of anemia.

Most common form of anemia among

pregnant women.

IMPORTANCE OF IRON IN PREGNANCY

OXYGENATIONNUTRITION

DEVELOPMENTBRAIN DEVELOPMENTIMMUNE FUNCTION

5. ANATOMY AND PHYSIOLOGY

6. ETIOLOGY OF IDANutritional/ dietary deficiencies

Inadequate intake of iron supplement

Inability to absorb iron

Blood loss

7. SIGNS AND SYMPTOMSFeel weak and tire out more easily.

Look very pale. Feel short of breath. Weakness or fatigueDizziness. Develop palpitations (feeling of heart racing) on exertion.

Have headaches.Have trouble concentrating. Irritability. Craving substances that are not food (pica). In particular, a craving for ice can be a sign of iron deficiency anemia.

Cracked lips.Smooth, sore tongue.

Muscle pain during exercise.Trouble swallowing.Hair lossMalaise (general sense of feeling unwell)

Worsening of heart problemsBrittle fingernails and toenails.

PATHOPHYSIOLOGYFEMALE

POOR DIETARY INTAKE

(-) IRON TABLET

(+) HX OF ABORTIO

N

(+) HX OF ANEMIA

MENSTRATION

PREGNANT

SUPPLY OF IRON SUPPLEMENT

(+) HX OF BLOOD LOSS

IRON LOSS

IRON DEMAND

INABILITY TO COMPENSATE THE DEMAND AND SUPPLY NEEDS OF

IRON

(+) HX OF IRON LOSS

INABILITY TO COMPENSATE THE DEMAND AND SUPPLY NEEDS OF

IRON

USAGE OF IRON IN THE BONE MARROW

HGB SYNTHESIS IS IMPAIRED

MICROCYTIC HYPOCHROMIC ERYTHROCYTES

OXYGEN AND ENERGY

DELIVERY

Change in lab values in iron deficiency anemia

Change Parameter

Decrease HGB, hct, MCV

Increase RDW

HEMATOLOGY EXAMINATION REPORT

CBC (1-12-2012 @1406H)CODE RESULTS NORMAL VALUE SIGNIFIC

ANCE

WBC 7.02 [10$ 3/ uL] 3.98-10.04 N

RBC 3.40 [10$ 6/ uL] 3.95-51.7 ↓

HGB 6.0g/dl 11.2-15.7 ↓

HCT 22.4% 34.1-44.9 ↓

MCV 67.9 fL 79.4-94.8 ↓

MCH 18.2pg 25.6-32.2 ↓

MCHC 26.8g/dl 32.2-35.5 ↓

RDW-CV 22.4% 11.7-14.4 ↑

RDW-SD 51.9fL 36.4-46.3 ↑

PLT 280 [10$ 3/ uL] 182-369 N

OXYGEN AND ENERGY DELIVERY

SIGNS AND SYMPTOMS• PALE SKIN / PALE LOOKING

• PALE CONJUNCTIVA• WEAKNESS/ FATIGUE

• DIZZINESS• SHORTNESS OF BREATH ON

EXERTION• PALPITATION ON EXERTION

TREATMENT

• REST• POSITIONING

• O2 SUPPORT(PRN)

• BLOOD TRANSFUSION

POST NSVD

HEMATOLOGY EXAMINATION REPORT

CODE RESULTS N. VALUE SIGNIFICANCEWBC 10.64 3.98-10.04 NRBC 3.50 [10$ 6/ UL] 3.95-51.7 ↓HGB 7.8g/dl 11.2-15.7 ↓HCT 29.2% 34.1-44.9 ↓MCV 71.6 fL 79.4-94.8 ↓MCH 20.8pg 25.6-32.2 ↓

MCHC 29.1g/dl 32.2-35.5 ↓RDW-CV 24.1% 11.7-14.4 ↑RDW-SD 60.3fL 36.4-46.3 ↑

PLT 238 182-369 N

BLOOD TRANSFUSION OF 2 UNIT PRBC

1ST POST BT: HGB 7.3 g/dl2nd POST BT: HGB 8.3 g/dl

Delivered NSVD to alive Baby boy 2.99 kg

PATIENT WAS DISCHARGE 24 HRS POST DELIVERY STILL WITH LOW RBC AND HGB CONCLUDING OF STILL (+) FOR ANEMIA, HOME MEDICATION FERROUS SULFATE BID WAS PRESCRIBE, FOR FOLLOW –UP AFTER 4 WKS TO SFH.SHE WAS DISCHARGE IN GOOD CONDITION.

8. INTERVENTIONDietary Improvement- advises iron-rich diet.

Compliance to prescribe ante natal supplement such as ferrous tablet.

Undergo laboratory examination like routine CBC during prenatal check-up.

Emphasize the need for follow-up checkup.

9. TREATMENT1. Oral supplements of iron

(Ferrous Sulphate)

2. Parenteral Iron

3. Blood Transfusion

4. Identify and treat the underlying cause.

9. COMPLICATIONDiminishes work performance.

Heart problems. Worsen the pulmonary status of patients with chronic pulmonary disease.

Severe anemia with maternal Hgb ≤ 6 g/ dl may result to prematurity, spontaneous abortion, low birth weight and fetal death.

Increased risk of postpartum depression; with poor results in mental and psychomotor performance of offspring.

Increases susceptibility to infections.

10. PRIORITIZATION OF NURSING PROBLEM

1. Activity intolerance due to insufficient physiological and psychological energy to endure or complete required and desired daily activities as related to imbalance between oxygen supply and demand.

2. Imbalance nutrition less than body requirement related to lack of appetite and increasing needs of growing fetus.

.3. Fatigue related to lack of energy in the body.

 

4.Impaired social interaction related to ineffective quality to social exchange.

5. Risk for infection related to decreasing immune system.

11. NURSING CARE PLANASSESSMENT

CUES/ EVIDENCEA. SUBJECTIVE:“I easily get tired even I’m just walking or doing

simple task, I also experience shortness of breath and palpitation on exertion.”

B. OBJECTIVE:Cardiac rate: 125bpmRespiratory rate: 24cpm

ASSESSMENT

2. NURSING DIAGNOSIS

Activity intolerance due to insufficient physiologic and psychological energy to endure or complete required or desired daily activities as related to imbalance between oxygen supply and demand.

PLANNING

GOALS AND DESIRED OUTCOME

Within 6-12 hours of nursing intervention the patient will be able to do or maintains activity level with capabilities as evidenced by:

80-120 heart rate16-20 respiratory rate,Reduction of fatigue as claimed by the

patient.

IMPLEMENTATIONINDEPENDENT

NURSING INTERVENTION

RATIONALE FOR INTERVENTION

Do assess the activity tolerance and fatigue level of the patent during activities.

To provide us with idea / input on what kind of activity can the patient do or tolerate.

Encourage adequate rest periods especially before meals and other ADL.

Rest between activities provides time for energy conservation and recovery.

IMPLEMENTATIONINDEPENDENT

NURSING INTERVENTION

RATIONALE FOR INTERVENTION

Anticipates needs e.g place telephone and tissue within reach.

Help conserve energy.

Assist with ADL however avoid doing for the patient what she can do for self.

Assisting helps conserve energy at the same time enhances patient’s activity tolerance and self esteem.

Do prioritize nursing care/ procedure.

Increase tolerance to activities.

IMPLEMENTATIONINDEPENDENT

NURSING INTERVENTION

RATIONALE FOR INTERVENTION

Teach and encourage deep breathing exercises and do proper position such as placing in high fowler’s or semi fowler’s position, or any position of comfort.

Provide respiratory support and offers comfort for the patient.

Encourage verbalization of feelings regarding limitations.

Provide emotional support enhances patient’s self esteem.

Include family and significant others in patients health plans.

Provides empowerment to family members and significant others.

IMPLEMENTATIONDEPENDENT

NURSING INTERVENTION

RATIONALE FOR INTERVENTION

Made referral to DOD if with complaints of palpitation and shortness of breath.

Adequate medical interventions can be provided.

Administer O2 support and medications if/ as ordered.

Provide O2 support @ 2-3 Lpm as ordered during complaint of shortness of breath.

Administer blood transfusion as order.

To help correct anemia before the patient deliver and in preparation for blood loss during deliver.

IMPLEMENTATIONCOLLABORATIVE

NURSING INTERVENTION

RATIONALE FOR INTERVENTION

Collaborate to other department such as Laboratory, Respiratory therapist, Pharmacy , Dietician, etc. when needed for patient’s care and management.

•To provide the necessary services needed to improve the patient’s care and management.

EVALUATION

After 6-12 hours of nursing interventions the goals were met as evidence by:

90bpm heart rate18cpm respiratory rateReduction of fatigue as claimed by the patient.

13. NURSING HEALTH TEACHINGPromote an adequate intake of iron-rich

foods (iron fortified formula and cereals, liver, egg yolk, and organ meats

Encourage to include in the meal fruits juice or/ and Vitamin C especially when taking iron supplement to enhance absorption.

Instruct to take iron supplement with 1 hour before meal.

Consume milk, cheese and other dairy products as a between-meal snack rather than at mealtime.

Advised patients with moderately severe iron deficiency anemia and significant cardiopulmonary disease should limit their activities until the anemia is corrected with iron therapy.

Emphasize the need for follow-up checkup, this is to ensure that there is an adequate response to iron therapy and that iron therapy is continued until after correction of the anemia to replenish body iron stores.

Emphasize to family members or care givers proper administration of oral iron supplements.

Explain the potential adverse effects of iron which includes nausea and vomiting, diarrhea or constipation or black stools and tooth discoloration.

Provide adequate rest periods in between activities.

Instruct care givers to keep iron supplements out of reach of children since it is toxic when overdosed.

14. CONCLUSIONIron is a mineral that is essential to life, deviation from normal which means having low or excess iron will never be good for us. Our body is so wonderful that it has its own way on how to balance things as it should be.

Having this case discussion on Iron deficiency anemia, we can conclude that it is easy to prevent having IDA. Food around us helps us gain the needed iron for our everyday use. Although it may be hard to detect if we have IDA especially when it is mild, we should always remember that prevention is still better than cure, which means that we should be more vigilant and compliant to the recommended treatments, teachings and recommendations for us.

Early detection and prevention is also the key words for this case. A simple Ferrous Tablet recommended by our physicians can helps us recover from IDA, but we should also think that it is a case to case base; it may vary in severity and cause. Same with its treatment it may also have different approach.

As a nurse it is our main responsibility to give health teachings to our patients and her family on how to prevent IDA especially in pregnancy. Giving them enough information will help them feel empower and have control on the things which they can prevent. Through this we can establish rapport with them, which can help us deliver more quality nursing care.

15. BIBLIOGRAPHY1. Sherwood, Lauralee (2006).

Fundamentals of physiology: a human perspective (Third ed.).

Florence, KY: Cengage Learning. pp. 768. ISBN 0-534-46697-4.

http://books.google.com/?id=GoMD0tpYgBkC.

2. Stephen J. McPhee. Current mediccal diagnosis and treatment

2009 page 429

3. Handout; Iron Deficiency Anemia-National Anemia Action Action

Council

4. “Iron Deficiency Anemia” Mayo clinic. Marsh 4,2011

5. Review of numbers of Infection.

6. catea.gatech.edu

THANK YOU