1
Index
S.no Contents Page number
1 Introduction 2
2 Learning objectives 3
3 Time plan 4
3 Patient profile 5
4 History of the patient 8
5 Growth and development 11
6 Physical examination 12
7 Systemic examination 14
8 Nutritional assessment 15
9 Drug file 16
10 Definition, incidence, classification 17
11 Etiology 18
12 Pathophysiology 19
13 Clinical manifestations 20
14 Assessment and diagnostic findings 22
15 Medical management 24
16 Nursing management 26
17 Complications 27
18 Nursing diagnosis 28
19 Nursing process 29
20 Health education 34
21 Conclusion 36
22 Bibliography 37
2
INTRODUCTION
The word Thalassemia is derived from the Greek word “Thalassa” means the
great sea. The disease was first described by Cooley in 1925. It was first noticed
in patients originating from the littoral countries of the Mediterranean Sea. At
present the disease has been found in several countries all over the world. There
are millions of people as carriers of Thalassemia given and every year
thousands of thalassemic children are born in our country.
Thalassemia is a group of hereditary haemolytic anaemia characterised by
reduction in the size of haemoglobin. It produces hypo chromic microcytic
anaemia due to defective haemoglobin of RBC, haemolysis and ineffective
Erythropoiesis. Thalassemia can be considered as haemolytic and hypo
proliferative anaemia related to abnormal haemoglobin
3
OBJECTIVES
1. To develop attitude and skills by providing comprehensive nursing care
2. To promote good self-esteem and confidence
3. To learn and provide health education to child’s family members
4. To promote interpersonal relationship with the child and parents
5. To reduce further complications
6. To gain experience of effective planning
7. To study the disease process in practical
8. To explain the mother regarding knowledge about the disease condition and
the treatment modalities.
4
TIME PLAN
Date Time Activities performed
10-10-12 7.30 am to
12 noon
Greeted the staff and family members
Self introduction to the staff and family members
Established the rapport
History collected about the child
Comprehensive assessment performed
11-10-12 7.30 am to
12 noon
Greeted the staff and mother
Provided comfortable bed and position
Assessed the child’s diagnostic evaluations
Provided tepid sponging
Administered the medications
12-10-12 7.30 am to
12 noon
Greeted the staff and family members
Provided comfortable bed and position to child
Administered the medications
Health education was given regarding fluid intake to
mother
Provided psychological support
15-10-12 7.30 am to
12 noon
Greeted the staff and mother
Provided comfortable bed and position to child
Administered the medications
Health education was given regarding prevention of
complications
Psychological support was given to the family
members and child
16-10-12 7.30 am to
12 noon
Greeted the staff and family members
Provided comfortable bed and position
Administered the medications
Health education was given regarding prevention of
disease and proper follow up care
Thanked the child and mother as well as the staff
5
PATIENT PROFILE
Name of the child :
Chronological age : 2 years
Sex : female
Developmental age : Toddler
Religion : Hindu
Ward : 9th floor
Unit :
IP number :
Permanent address :
Date of admission : 5-10-12
Diagnosis : Thalassemia
Informant : mother, father, case sheet, doctors
Date of care study started : 10-10-12
Date of care study finished : 16-10-12
Reason for hospitalisation
Child admitted for poor feeding, pallor, fatigue, and fever and reduced Hb
levels for one week.
6
Present medical history
Child admitted with the complaints of fever on & off high grade intermittently.
H/O pallor, fatigue, decrease level of Hb%, poor feeding and there is no history
of jaundice and melena.
Past medical history
Last year child had been admitted on 20-08-11 in the thiruvallur GH hospital for
fever recurrent respiratory infection, weight loss, lethargy, poor intake of feed
for one month, antibiotics were given. Blood test done for all investigations,
reports will be all blood cell counts are decreased and erythroid study shows
hyper cellular and eryhtroid hyperplasia, treated with blood transfusion every
month.
Family history
No history of consanguineous marriage, no family history of communicable
diseases.
55years 50years
27years 25years 24 years
2 years
Key notes
-
-Male
-Female
- Sick child
7
Socioeconomic history
Type of the family : joint family
Bread winner : father
Occupation : painter
Family income : Rs.5000/ month
Care giver of the child : mother
Housing condition : own home
Method of sewage disposal : closed system
Water sources : well water and corporation
Animal in the house : no pet animals
No Intake of alcohol, smoking and drug abuse by parents and tolerance in the
family.
Birth history
a. Antenatal history
Booked : Thiruvallur GH hospital
Immunized : TT given
Obstetrical history: G1, p1, L1, obstetrical history Normal.
Medications : no history of medication other than FST, calcium.
Consanguinity : no
H/O Infections : no h/o infections like TORCH, STD, AIDS, and Hep-B.
Rh incompatibility : not present.
b. Intranatal history
Period of gestation : 40 weeks
Mode and place of delivery : Normal delivery in thiruvallur GH
Birth weight of the child : 2.5kg
First cry after birth time : cried 2 minutes after birth
8
c. Post natal history
History of critical care : no
Prelacteal fluids : no
Time of initiation of breast feed : after one hour of birth
Feeding difficulties : no
Immunization schedule
S.no Age Name of the
vaccine
Dose Route Preventable
disease
Adverse
reactions
1 At birth BCG
Oral polio (zero)
0.05ml
2 drops
Intra
dermal
oral
Primary complex
Poliomyelitis
2 1 ½
month
DPT , hepatitis
hip vaccine
Polio 1st
0.5ml
2drops
IM
Oral
Diphtheria,
pertusis, tetanus,
Hep-B, Hip
poliomyelitis
3 2 ½
month
Pentavalent
Polio-2nd
0.5ml
2 drops
IM
Oral
Diphtheria,
pertusis, tetanus,
Hep-B, Hip
poliomyelitis
4 3 ½
month
Pentavalent
Polio 3rd
0.5ml
2drops
IM
Oral
Diphtheria,
pertusis, tetanus,
Hep-B, Hip
poliomyelitis
5 9month Measles 0.5ml S/C Measles
6 1 year MMR 0.5ml Intra
dermal
Mumps, measles,
rubella.
9
Growth and development of the child
Growth monitoring done during immunization and hospitalization
Mile stone achievement
Social smile : 6 weeks
Head control : 3 months
Reaches an object and holds it : 5 to 6 months
Sitting with support : 6 months
Sitting without support : 8 months
Standing with support : 9 months
Feeding self with spoon : 11 months
Running : 18 months
Climbing stairs : 20-24 months.
Gross motor development: The major motor skill during the toddler year is the
development of locomotion between 2-3 years of age refinement of the upright,
biped position is evident in improved co ordination and equilibrium. At age 2
years, toddlers can walk up and down stairs and by age 2 ½ years they can using
both feet.
Fine motor development: It is demonstrated increasingly skillful manual
dexterity. By 2 years of age toddler use their hands to built towers and by the 3
years of age they draw circles and paper.
Developmental theories
Psychosocial development (Erickson’s theory)
Autonomy Vs. shame and doubt: The developmental task of toddler hood is
acquiring a sense of autonomy while overcoming a sense of doubt and shame.
The toddler has the newly gained modality of holding on and letting go. To hold
on and let go is evident with use of the hands, mouth, eyes and eventually the
sphincters when toilet training is began. Child is able to control their bodies.
10
Psychosexual development (Sigmund Freud’s theory)
Anal stage: interest during the second year of life centers in the anal region as
sphincter muscles develop and children are able to withhold or expel fecal
material at will.
At this stage the climate surrounding toilet training can have lasting effects on
children’s personalities.
Moral developmental theory (Kohlberg’s theory)
Pre conventional level: This is punishment and obedience orientation, culturally
oriented to the labels of good/bad and right/wrong, child integrates these in
terms of the physical or pleasurable consequences of their action.
Spiritual development (Fowler’s theory)
Intuitive-projective: toddlerhood is primarily a time of imitating the behavior of
the others child initiative the religious gestures and behaviors of others without
comprehending and meaning or significance to the activities.
Intellectual development (Piaget’s theory)
Pre operational phase- pre conceptual phase: At approximately 2 years of age
the child enters the pre conceptual phase, cognitive development, which lasts
until about 4 years child learning column, shapes, sizes and dentures.
Language and speech development:
Gestures precede or accompany each of the language mile stone up to 30
months of age (putting phone to ear, pointing). After sufficient language
development gestures phase out and the pace of word learning increases child
starts beginning to ask questions and speaks about 900 words.
Parallel play:
Children play in one place individually. Short attention on play enjoyment of
play and change on play are present.
Sensory development
Vision - Normal
Hearing - Normal
Touch - Normal
Taste - Normal
Smell - Normal
11
PHYSICAL EXAMINATION
1. General appearance : moderate body built
2. Behaviour : alert
3. Head
Size : Normal
Symmetry : symmetrical
Fontanells : closed
4. Face
Symmetry : symmetry
Eye set : Normal
Other findings : no
5. Eye
Eyelids : Normal
Eye lashes : Normal
Lacrimal gland : Normal
Pupils : reactive to light
Colour activity : Normal
Colour vision : Normal
6. Ear
Symmetry : Normal symmetry
Alignment : Normal
Hearing activity : Normal
7. Nose
Shape : symmetry
Discharge : Normal discharge
Air entry : bilateral air entry Normal
12
Patency of nose : patent
Mucus : present
8. Mouth
Lips : moist, soft, smooth
Tongue : pale, dry, mobility
9. Throat
Frenulum : Normal
Tonsils : Normal
Adenoids : Normal
Palate : intact and drone shaped
Dentition : canines (cuspids) +
, total number of teeth- 16
10. Neck
Length : Normal
Symmetry : Normal
Movement : Normal
Parotid gland : Normal
Tracheal position : Normal
Thyroid position : Normal
Lynphnodes : enlargement of lymphnodes +
11. Skin
Soft and smooth, skin turgor is Normal.
13
SYSTEMIC EXAMINATION
Central nervous system
General appearance : Normal
Behaviour : restless and crying
Stage of consciousness : conscious
Motor function : Normal
Muscular mass : Normal shape and contour
Muscle tone : Normal and adequate
Muscle strength : Normal
Involuntary movements : not present.
Respiratory system
Shape : circular & Normal
Size : Normal
Movement : bilateral symmetrical and co-ordinaly with breathing
Breathing pattern : Normal vesicular breath sounds
Frenitus : not present
Cough expectorant : not present
Use of respiratory muscles : no
Abnormality of breathing : no
Oxygen saturation : 100%
Axillary area : no obvious nodes
Cardio vascular system
Pulse rate : 106/minute
Blood pressure : 90/60 mmhg
Cardiac sounds : S1, S2 heard, no murmur present
14
Gastrointestinal system
Contour : Normal
Distension : not present
Visible peristalsis : not seen
Umbilicus : Normal
Organomegally : not present
Mass : not present
Bowel movement : Normal
Bowel elimination : Normal elimination pattern
Genitourinary system
Genetalia : Normal, no vulval oedema
Elimination : Normal urinary elimination
Musculo skeletal system
Spine : Normal curvature
Extremities : no genetic abnormalities
Range of motion : Normal in both extremities.
VITAL SIGNS
Temperature : 99.70F
Pulse : 110/minute
Respiration : 32/minute
Blood pressure : 90/60mmHg
15
ANTHROPOMETRIC MEASUREMENT
Height : 100 cm
Weight : 11kg
Head circumference : 48cm
Chest circumference : 44cm
Mid arm circumference : 15cm
Dentition : first molar
Canines (cuspids), total number of teeth - 16
NUTRITIONAL ASSESSMENT
Nutritional status = Actual Weight of the Child X100
Expected Weight of the Child
= 11 X 100 = 84.6%
13
Nutritional status = normal
Daily fluid requirement= 70ml/kg/day i.e. = 70X11= 770ml/day
Protein requirement :
Protein =2gm/day/kg
Child is 11 kg weight
So protein requirement = 2X11=22gms/day
16
DRUG FILE
Name of the drug Dose Route &
frequency
Action Side effects Nurse’s
responsibilities
Inj. Cefatoxime
sodium
250mg IV & bd It is a Cephalosporin acts
by Inhibiting cell wall
synthesis and assembly of
cell components leading to
bacterial death
Nausea,
Vomiting
Liver and renal
toxicity
Check for
anaphylaxis
T.vitamin B complex 0ral & bd To treat all condition of
body building
Rare
complications
-
T.vitamin-C 100mg oral & bd Prevention of scurvy and
similar condition
Rare
complications
-
17
THALASSEMIA DISEASE CONDITION
Definition
The word Thalassemia is derived from the Greek word “Thalassa” means the
great sea. Thalassemia is a group of hereditary haemolytic anaemia
characterised by reduction in the size of haemoglobin. It produces hypo chromic
microcytic anaemia due to defective haemoglobin of RBC, haemolysis and
ineffective Erythropoiesis.
Incidence
It is estimated that nearly 6000-8000 thalassemic children are born every year in
India, hence over the 1, 00,000 Thalassemia in the country the disease is more
common among Sindhi, Punjabi and gujratis.
Classification
There are 3 types of Thalassemia
1. Thalassemia major
2. Thalassemia intermedia
3. Thalassemia minor
a. Thalassemia major
It is a severe form of the illness and associated with homozygous state. In this
condition, Thalassemic genes are inherited from both parents and synthesis of
beta chain is markedly reduced. Erythropoises becomes ineffective leading to
haemolysis and anaemia. Anaemia stimulated production of erythropoietin
resulting more ineffective erythropoises, expansion of medullary cavity of
different bones occurs. Extra medullary haemopoises lead to hepatomegally. It
is associated with absent of beta chain synthesis.
b. Thalassemia intermedia
It is a state of chronic haemolytic anaemia caused by deficient alpha or beta
chain synthesis. It is also a homozygous form. The clinical manifestation of this
is mainly intercurrent illness with exaggeration of anaemia and persistent
jaundice. These patients will have liver dysfunction, osteoporosis, mild
hepatomegally and chronic anaemia.
18
c. Thalassemia minor
It is a mild form of the illness produced by heterozygosisity of either alpha or
beta chain. Its clinical manifestations are mild anaemia, mild jaundice and
abdominal pain. This condition is usually diagnosed during the family study of
a child having thalassemia major. The prognosis of this condition is excellent.
Severity of thalassemia:
Three groups
a. Type of mutation affecting beta chain synthesis
b. Presence of alpha chain mutation
c. Effect of gamma chain synthesis
ETIOLOGY
1. Alpha chain synthesis is reduced due to gene deletion
2. Beta chain thalassemia is usually caused by point mutation
3. Delta – beta thalassemia is due to suppression of both beta and delta chain
synthesis
4. Absent or defective synthesis of Hb%
5. Decreased life span of RBC
6. Presence of haemoglobin can insoluble iron form
19
PATHOPHYSIOLOGY
Due to causes
↓
Partial or complete deficiency in the synthesis of beta chain of Hb molecules
↓
Defective Hb formation
↓
Hb becomes molecules unstable
↓
Damage RBCs
↓
Severe anaemia {β-thalassemia}
20
CLINICAL MANIFESTATIONS
S.no Book picture Patient picture
1 Haemoglobin Decreased
2 Pallor Present
3 Recurrent infection present
4 Depressed nasal bridge Present
5 Enlargement of lymph Absent
6 Exposure of malformed teeth Absent
7 Poor feeding Present
8 Irregular fever Present
Other systems: bone deformities in the face, fatigue, growth failure, shortness
of breath, yellowish skin.
21
DIAGNOSTIC EVALUATION
History collection
A physical examination may reveal a swollen spleen
Blood samples will be taken and sent to laboratory for examination
Red blood cells will appear and abnormally shaped when blood are under a
microscope
A complete blood count
A test called haemoglobin electrophoresis shows the presence of an
abnormal form of haemoglobin
Haemoglobin values are reduced, MCV, MCH, MCHC values are low.
Reticulocyte count increased or may below
RBCs in peripheral smear shows hypochromia, anisocytes, poikilocytosis,
microcytosis, nucleated RBCs and target cells
Bone marrow study shows hyper cellular and erythroid hyperplasia.
Osmotic fragility test shows decreased fragility
Sr.Bilirubin level is moderately elevated
Sr.iron level is high
Platelet count is usually Normal or increased
Radiological findings
- Bone marrow hyperplasia
- Skull bones show hair on end appearance due to vertical trabecular or
striation from widening of the diploic space and atrophy of the outer surface of
the skull.
22
DIAGNOSTIC INVESTIGATIONS
Name of the
investigation
Normal value Patient’s value Remark
Hemoglobin 8gm 14gms Abnormal;
Bleeding
time
2-7 minutes
2 minutes
Normal
Clotting time 5-8 minutes 4 minutes Normal
Total count 6000-11,000
cells/mm3
6,200 cells/mm3
Normal
Differential
count
P-58%
L-40%
E-2%
P-64%
L-37%
E-4%`
Normal
Total RBC
count
2.5 million cells/mm3
2.0 million cells mm
Abnormal
Blood urea 20-40mg/dl 22mgs/dl Normal
Blood sugar 70-1`0mgl/dl 100mg/dl Normal
Serum
creatinine
0.8-1.2mg/dl 0.8mg/dl Normal
23
MANAGEMENT
Repeated blood transfusions
It is given at regular interval to maintain the haemoglobin level at least 10 to 11
gm/dl. Interval and amount of blood transfusions depends upon the level of
haemoglobin. A child usually 10-15ml/kg every 2 to 3 weeks washed. Packed
RBCs are transfused, special precaution to be taken during transfusion to
prevent complications. Transfusion related infections can be prevented specific
protection with immunizing agents. Neocyte transfusions with new RBCs
having longer life span can also be given though it is not being used at present.
Iron chelation therapy
Iron chelating agent desferrioxamine is recommended to prevent complications
repeated blood transfusion, i.e. hemosiderosis and hemochromotosis. It is given
as continuous subcutaneous infusion in the dose of 25 to 50mg/day over a
period of 8 hours to 12 hours.
Special micro infusion pump is used. Usually this therapy is given at night and
5 to 6 hours night per week. It is given after 10-15th maintained between 1000-
2000ng/ml.
Vitamin-C 100mg/day is given concurrently to enhance the iron excretion.
Overdose of this chelating agent may result in growth retardation, visual
problems and hearing toxicity.
Intravenous desferrioxamine therapy is indicated in patients with poor
compliance and large iron induced cardiac disease. It is far more expensive than
Sc therapy. Oral iron chelating agent defereprone (DFP) is now available with
less toxicity. The dose is 75 to 100 mg/kg/day in 2 to 3 divided doses. The
common side effects are joint pain, nausea, abdominal pain.
24
Folic acid supplements
Folic acids supplementations are recommended where as iron therapy and
dietary iron should be avoided in prevent more iron deposition.
Supportive management
Supportive management is important to manage associated problems and treat
complications (like CCF, Hepatic failure), vaccination with hepatitis-B to be
given prevents transfusion related infection along with other routine
immunization. Emotional support is very essential to the parents and child.
Basic supportive nursing care is very important to prevent various
complications.
Bone marrow transplantation
Bone marrow transplantation is a effective treatment modality with potential of
curing thalassemia. Defective stem cells are replaced by Normal stem cells. It is
extremely expensive and possible in only very selective cases.
Splenectomy
Splenectomy is indicated when the child need very frequent blood transfusions
and develop hypertension or big spleen causing discomfort.
New approaches:
Now approaches in the management of thalassemia are gene therapy and gene
manipulation. In gene therapy insertion of Normal gene is done in the stem cells
to correct underlying defects. It is done in two approaches i.e. somatic and
transgenic. In gene manipulation, excess of alpha chain is decreased by
increasing the gamma chains.
25
NURSING MANAGEMENT
1. Assessment of child condition to prevent complications that can be done as
hospital based or community based.
2. Preparation for repeated hospitalization for treatment of the disease and its
complications
3. Arrangement of necessary diagnostic measures
4. Administration of blood transfusion and iron chelating agent with
appropriate precautions for specific therapy.
5. Provisioning of the supportive care with rest comfort nutrition diet
restrictions of iron containing food. Vitamin supplementation, immunization,
hygiene care and other symptomatic care.
6. Prevention of infection by aseptic techniques and promotion of general
cleanliness
7. Pre operative and post operative care during splenectomy with necessary
health education after the surgery
8. Information regarding treatment plan, prognosis and complications to be
given to parent and family members with appropriate explanation.
9. Emotional support to the parents and family for effective coping about the
stress of the illness.
10. Teaching the parent about importance of follow up, blood transfusion,
investigation, sign of complication, dietary and available treatment facilities.
11. Referral and necessary guidance for available support and community
facilities
26
Preventive measures
Antenatal screening in the first trimester of pregnancy by amniocentesis or
chronic callous sampling or fetoscopy help to detect thalassemia in fetal life,
genetic counselling in that respect is very important preventive measures which
guide the parent to decide whether to continue pregnancy with thalassemic fetus
or to terminate the pregnancy (by MTP) of affected foetus.
Carriers can be detected by simple blood examination or by identification of
thalassemic gene. Creation of awareness among public regarding detection of
thalassemia gene before marriage and marital counselling are also very
important preventive aspect.
Prognosis
Prognosis of thalassemia major is poor. Severe anaemia and early onset of
manifestations have poorer prognosis. Presence of complications also results in
poor out come.
Patients with thalassemia may continue their life up to 5 to 6 decade.
Thalassemia minor may lead a Normal life.
27
Complications
1. Congestive cardiac failure
2. Hepatic failure
3. Aplastic crisis
4. Intercurrent infection
5. Gall stone
6. Growth retardation
7. Delayed puberty
8. Hemosiderosis
9. Hemochromatosis
10. Transfusion related infection
11. Complication related to iron chelation therapy
12. Endocrinopathies
13. Skeletal complication
14. Multi organ dysfunction (MOD)
28
NURSING DIAGNOSIS
Impaired tissue perfusion related to reduced haemoglobin.
Imbalanced nutrition less than body requirement related to poor feeding
Risk for infection related to reduced haemoglobin level and low nutritional
status.
Chronic pain related to skeletal changes.
Ineffective family coping related to poor prognosis.
Knowledge deficit regarding child care in long term chronic illness with
haemolytic anaemia.
29
NURSING PROCESS-I
Assessment Nursing diagnosis Plan of action Implementation Rationale Evaluation
Subjective data:
mother says that her
child has difficulty in
breathing, restless,
crying, fatigue
Objective data: child
has dyspnea and
tachypnea and restless,
fatigue
Diagnosis: Impaired
tissue perfusion related
to reduced
haemoglobin.
Goal: To improve the
tissue perfusion
Assess the vital
signs
Vital signs are monitored
and recorded.
Temperature: 98.40F
Pulse: 120/minute
Respiration: 36/minute
To know the base
line data
Mother
verbalised that
her child has
reduced
dyspnea, and
breaths better. Provide clean and
comfortable
environment
Provided clean and
comfortable environment
as well as comfortable
bed
To provide relief
from discomfort
Provide nasal
oxygen
Provided nasal oxygen To increase the O2
level in blood
Provide
nutritional
advices
High calorie diet is
advised
To provide energy
and to reduce
fatigue
Reassess the
child’s condition
Vital signs are monitored
and recorded again
Temperature: 98.40F
Pulse: 120/minute
Respiration: 36/minute
To know the effect
our intervention for
further plan.
30
NURSING PROCESS -II
Assessment Nursing diagnosis Plan of action Implementation Rationale Evaluation
Subjective data:
The mother says that
the child is not taking
feeds properly
Objective data:
The child looks tired
and lethargy
Diagnosis: Imbalanced
nutrition less than body
requirement related to
poor feeding.
Goal: to improve the
nutritional status
Assess the
general condition
of the child
Assessed the general
condition of the child
To know about
base line data
The child
looks active
and she is able
to drink small
feed
Provide small
frequent feeds
Provided small frequent
feeds and the child after
feeding
To improve the
nutritional status
Explain disease
condition
Explained the disease
condition to the mother
To remove anxiety
Provide
comfortable bed
and position
Provided comfortable bed
and position
To promote good
sleep
31
NURSING PROCESS-III
Assessment Nursing diagnosis Plan of action Implementation Rationale Evaluation
Subjective data:
child’s mother says
that she is very
anxious and worried
about the child’s
condition
Objective data:
The mother looks very
dull and anxious
Diagnosis: Fear &
Anxiety related to
disease condition and
management and
outcome.
Goal: to alleviate the
parents anxiety
Explain the
parents about the
condition of the
child
Explained the parents
about the condition of the
child
To remove anxiety Mother’s
anxiety and
fear removed
Explain about the
nutrition to be
given
Explained about the
nutrition to be given with
diet plan.
To improve the
child’s health
Teach about
follow up care
Taught about follow up
care
For the future
management
32
NURSING PROCESS-IV
Assessment Nursing diagnosis Plan of action Implementation Rationale Evaluation
Subjective data:
Mother says that the
infant is warm to touch
Objective data:
The child looks febrile
Diagnosis: Risk for
infection related to
reduced haemoglobin
level and nutritional
deficiency
Goal: to prevent
infection
Assess the vital
signs
Vital signs are monitored
T-99.40F
P- 120/m
R-36/minute
To know the base
line data
Maintained
body
Temperature
in Normal
way Teach hand
washing and
hygiene
Educated the mother
about hand washing and
hygiene of the body
To avoid infection
Provide clean and
comfortable
environment
Provided clean and
comfortable environment
as well as comfortable
bed
To minimize the
chance of infection
Administer
antibiotics
Administered antibiotics
as per prescription
To prevent
infection
Reassess the vital
signs
Vital signs are monitored
and recorded again.
Temperature: 99.40F
Pulse: 120/minute
Respiration: 36/minute
To know the effect
of our intervention
and plan for further
actions.
33
NURSING PROCESS-V
Assessment Nursing diagnosis Plan of action Implementation Rationale Evaluation
Subjective data:
mother says that she is
not having adequate
knowledge about the
management of her
child’s condition
Objective data: mother
looks confused and
asking many question
about her child’s
condition
Diagnosis:
Knowledge deficit
of mother regarding
child care in long
term chronic illness
with haemolytic
anaemia.
Goal: To improve
the knowledge level
of the mother about
the management of
Thalassemia
Assess the
knowledge level of
the mother
Knowledge level of the
mother is assessed by
asking questions about
her child’s condition
To know the base
line data
Mother
verbalised that
she has gained
good
knowledge
and assured to
do practice in
child care.
Explain about the
condition and the
procedure that are
planned to be done
for her child
A clear detail is given
regarding the disease
condition. &Details about
the investigations and
treatments available has
been explained to the
mother clearly
To make her
confident and to
improve her
knowledge
Provide health
education about diet
High protein & nutritious
diet is advised iron rich
diet are advised to avoid
To improve her
knowledge level
Provide
psychological
support
Psychological support
was given by speaking
about positive things
about the prognosis of t
her child
To make her
confident on her
child
Reassess the
mother’s knowledge
Mother’s knowledge is
reassessed again
To know the effect
our intervention
34
HEALTH EDUCATION
Prevention efforts
1. Pre marital screening to make sure that couple is not carriers.
2. Provision of counselling and health education for the thalassemia families
and the public.
3. Provision of prenatal testing for thalassemia.
4. Reduction of marriage between relations.
Transfusion therapy
Transfusion therapy should begin once a diagnosis of thalassemia major is
confirmed.
1. Laboratory test (e.g. haematological molecular or Hb% electrophoresis and
other laboratory test such as high pressure liquid chromatography.
2. Genetic analysis to identify the nature of alpha and beta thalassemia
mutation as well as the pressure of the Xmm /restriction enzyme site- an
indicator that can help predict the severity of the disease and identify the
treatment regimen most appropriate to each patient.
Folic acid supplementation
Folic acid supplementation is recommended where as iron therapy and dietary
iron should be avoided to prevent more iron deposition.
Iron chelation therapy
Iron chelating agent desferrioxamine (desferal) is recommended to prevent
complication of repeated blood transfusions, i.e. hemosiderosis and
hemochromatosis. It is given as continuous subcutaneous infusion in the dose of
25 to 50 mg/kg/day over a period of 12 hours.
Oral iron chelating agent desferene (DFP) is now available with less toxicity.
The dose of 75 to 100mg/kg/day in 2 to 3 divided dose. The common side
effects are joint pain, nausea, vomiting, and pain abdomen.
35
Supportive management
Supportive management is important to manage associated problems and to
treat complications.
Vaccination with hepatitis-B is to be given to prevent transfusion related
infection along with other routine immunization.
Emotional support
Emotional support is very essential to the parents and child. Basic supportive
nursing care is very important to prevent various complications.
Emotional support to the parents and family for effective coping about the stress
of the illness
36
CONCLUSION
From this care study I gained knowledge about the care of the child with
thalassemia. I got an opportunity to provide a complete care to give health
education to the parents. I would like to thank my madam for giving this
opportunity and for her valuable guidance to me to widen my knowledge.
37
BIBLIOGRAPHY 1. Nelson (1986), “Text Book Of Pediatrics”, prism books pvt.ltd.15
th
edition, page number: 1513-1515.
2. Parul datta, “Pediatric Nursing” (2009), 2nd
edition published by jaybee
brothers, New Delhi, page number: 253-256.
3. Ross and Wilson (2004), “Anatomy and Physiology”, 19th
edition
published by Churchill and Livingstone, page number: 365.
4. Wong’s (2009), “Essential Of Pediatric Nursing,8th
edition, published
by Mosby publisher, page number: 517-519.
5. Brunner and suddarth, “ Text Book Of Medical Surgical Nursing”, 12th
edition, published by wolters kluwer, page no:976-980
6. Joyce M. black, “ Medical And Surgical Nursing”, 5th edition,
published by W.B Saunders company, page no: 1211-1216
7. Lippincott, “ Manual Nursing Practice” 9th edition, published by
wolters kluwer page no: 558-562
8. Ross and Wilson, “Anatomy And Physiology”, 4th
edition, published by
wolters kluwer page no: 212-216