MALAWI COLLEGE OF HEALTH SCIENCES

PROGRAMME: DIPLOMA IN REIGISTERED NURSING

COURSE:

clinical

Assignment:

case study

Presented by:

ibrahim chiposyo

Presented to:
Hospital:

Queen Elizabeth central

Hospital

Ward name:

3B

Patient name:
Case study period:

27th to 29th April 2016

Ward in charge: .
Signature: .

Acknowledgement
I thank God for giving me the opportunity to study at Malawi
College of health sciences and for giving me the strength,
knowledge and wisdom to conduct the case study.
Many thanks goes to the clinical instructors and the qualified
nurses in the ward who were supervising me during the period I
was conducting the case study.
I would also like to acknowledge the patient on whom the case
study was done and the guardian who provided me with the
opportunity to conduct the case study and without their help it
would have been impossible.
My friends and my fellow students who provided me with
technical support and information I also thank them for their
assistance.
Lastly I dedicate this case study to my father who encouraged me
to peruse a course in health sciences and who provides me with
financial and emotional support.

TABLE OF CONTENTS
Acknowledgment..
Introduction...
Admission process..1
Health history.2-

5
Review
of
.6-7

systems..

Head
to
examination...8-12
List of
.13

nursing

toe

diagnoses..

Care plan..
Documentation using soapier format.
14-24
Nurses progress notes record ..
.25-26
Discharge plan. 28
Basic
fact...........................................................................
...................29-36
Medical
.37-43
3

management.

Medical investigations and Laboratory investigation

43-45
Personal
46

impression

References .47
Admission process
Orientation
Patient and guardians have been oriented to the ward in terms of the
physical place
The toilets and bath rooms
The nursing station where they would come and ask for immediate
and emergency help
The places to places where they would get wheel chairs gloves
and toilet papers
Nursing care

Bed making done

Vital signs checked on admission
Patient registered in the new patients admission book
Doctors orders carried out
(The admission process was done by night duty nurses but I had to ask and clarify points
that were not clear to the patient and showed her physical place )

PATIENTS HEALTH HISTORY

DEMOGRAPHIC DATA
Name:
Age: 46 years old
Sex: male
Address:
Next of kin:
Religion:
Marital status: Married
Rationale:
Demographic data is important to nurses in the following ways
Name is for easy identification of the client, to address him by name not by the
condition he is suffering from. Age helps us to address the client accordingly with
respect in accordance to age and for health talk and counseling appropriate to the
age. The address help in follow up care and helps nurses to identify the
demographic area that may have effect on the health of the patient e.g. if one may
be prone to malaria or choler. Religion is important to understand the beliefs and
values the patient uphold in order not to violet their religious rights and to know
factors that may have negative effect on health such us restrictions on certain
foods and therapy.

PAST MEDICAL AND SURGICAL HISTORY

In the year 2008 Mr. Mtira was diagnosed of HIV and was started on
antiretroviral treatment in 2009.
Has a history of tuberculosis. Was diagnosed of pulmonary TB in 2009. He started
and completed the course of treatment in the same year. It was cured and had
negative tuberculosis smear
Has no history of diabetes mellitus, hypertension or asthma.
5

Has a history of using chines herbs and other local remedies for what they
thought they cleanse the body and increases blood volume in the body, this was
following the recurrences of illnesses since 2009. The herbs which the wife Mrs.
Rose Mtira remembered were beetroots and chines herb tea.
Has no history of surgical operation
Rationale:
Past medical history helps nurses understand the disease progression and the
medication the patient had been using, it helps nurses have a clue on how the
patient was adhering to medication. Past medical history is also important in that it
enables nurses to determine if the current problem is a result of the past
undertreated medical problem.
HISTORY OF ALLERGIS
Has no history of allergies to medications and latex
Rationale:
History of allergies will help nurse prevent health risks such us anaphylaxis and
legal penalties

PERSONAL AND SOCIAL HISTORY

Hes married with four children, says wife and children well. Works as a banker at
national bank of Malawi.
He denies history of intoxication saying he does not drink alcohol nor smoke
tobacco or use any kind of illicit drugs and substances.
They live in an iron sheet roofed house
Rationale:
Personal and social history is where we learn about the patients life style including
health behaviors and personal choices. It enables practitioners to determine the
risk factors the patient is exposed to which might have impact on the clients
health

SEXUAL AND REPRODUCTIVE HISTORY

6

Patient denies history of sexually transmitted infections, but says he had multiple
sexual partners during the time when his wife went to college and he believes that
it is during that time that he contracted HIV
Rationale:
This help nurses assess other health problems that might be a result of sexual and
reproductive health such us sexually transmitted infections e.g. syphilis

NUTRITIONAL HISTORY
The patient says he manages to eat three to four times a day, with food comprising
of Nsima and meat or fish and vegetables for lunch or supper and tea with bread in
the morning. He says the use tap water for domestic purposes.
Rationale:
Nutritional history is important as it helps nurses to identify whether the illness is
a result of malnutrition

FAMILY HISTORY
Has family history of hypertension. His sister is the one who is hypertensive. Has
no family history of diabetes, epilepsy and cancer
Rationale:
Helps to distinguish if the current condition is a result of family genes inherited
from parents and siblings. Helps also to inquire more and encourage other family
members to go for checkup for early detection and treatment.

HISTORY OF PRESENTING COMPLAINT

The guardian Mrs. Mtira said for the past three months the patient has been
experiencing numbness and pain of the lower extremities, general body weakness
and was experiencing shortness of breath even at rest. She said he sometimes
reported dizziness and could fell to the ground in the bathroom due to loss of
balance and weakness.

They went to Mlambe private hospital in February where he was diagnosed of

having anaemia and was transfused single pack of whole blood but the condition did
not improve.

CHIEF COMPLAINT
Patient was brought to Queen Elizabeth central hospital following deteriorating in
health status prior to admission at Mlambe Private Hospital with history of patient
having difficulties in eating, severe general body weakness, dizziness, vomiting
mostly whenever he took his ART drugs

Review of systems
Heard
Experiences dizziness when standing and when walking
Experiences occupational headaches

Ears
Experiences no unusual discharge, no earache, hears properly
Experiences no tinnitus
Has no vertigo and loss of balance

Eyes
He says he has no visual problems
He says he experiences No unusual discharge from the eyes
No photophobia

Nose
Has no discharge, no difficulty breathing through the nose
Says he is able to smell properly
Says he has no sores in the nose

Mouth
Says he has no sores in mouth, his teeth are blackish coz of drinks he takes
Has no dentures
Says has no problem swallowing

Neck
He says he has no swollen glands
Experiences no neck stiffness
9

Chest
He says he is having cough now and then but not productive
He has shortness of breath on exertion
Has no chest pains
Has heart palpitation

Extremities
(Hands and legs)
He says he has started feeling loss of strength
He says he does not experience stiffness in joints nor pain

Gastrointestinal tract (GIT)

He is having frequent diarrhea and vomiting
He is experiencing loss of appetite and at times heart burns
Passes flatus

Genital urinary tract

He says he does not have painful urinating
But says he is experiencing frequent urge to urinate

10

HEAD TO TOE PHYSICAL EXAMINATION

Name: Henry Mtira
Vital signs
-Blood pressure: 98/56

- respiratory rate: 18 breath/minute

-Purse rate: 108

-temperature 38c

-Body weight: 54kg

Head
On inspection: no lice, hair is evenly distributed, has no wounds and big
Scars, head size is proportional to his age and body Size, face is
symmetrical and no signs of facial palsy.
On palpation: there is no skull swelling, no contusion, and no masses or
edema. No any areas of tenderness or deformity.

Ears
On inspection: ears are symmetrical, all are in line with eyes, there is
little wax in the ears, no lesions and growth and there is no discharge.
No infection/inflammation of the external ear canal
On palpation: there are small palpable hard masses in the ear lobes, no
swelling and tenderness of the mastoid bones
NOTE: No hearing test done

Eyes
On inspection: Eyes are symmetrical to each other, there is no
discharge and growths, pale conjunctiva
11

 NOTE: no visual acuity test perfumed

Nose
On inspection: normal Size and shape. There is no discharge and
bleeding, no lesions and no growth/polyps, there are no foreign bodies.
On palpation: the sinuses are uninflamed, there tip is soft not
inflamed

Note: no smell test was conducted.

Mouth and Throat
On inspection: the lips looks dry, have sores on the right Conner of the
mouth, teeth are colored black, tongue looks whitish with some
patches, palate is pink with scattered whitish patches, there is no
bleeding and the gums are not swollen. The tonsils are not inflamed,
there is no bad breath coming from mouth. On the throat are small
sores probably fungal infection. Normal voice but delayed speech.
Chin

On inspection: There are no cuts Knicks and no infection to the chin.

Equal symmetry and well distributed beards.

Neck
On inspection: there is no enlarged thyroid gland i.e. no goiter, the
normal alignment. The Adams apple is protruding, no distended veins,
nor varicose veins, patient is able to hold his head and no scars present
On palpation: there are no masses, no enlarged lymph nodes and
tonsils. There is no neck stiffness.

12

 Chest examination
On inspection: there are no scars nor lesion on the skin. Normal chest
expansion, and no use of accessory muscles, no chest tightness and in
drawings. Left and right chest sides are symmetrical normal shape.
On palpation: there are no lamps on the chest, vocal vibrations (tactile
fremitus) are felt but from a distance, apex beet of the heart is felt.
On percussion: no dull sounds and no hyper-resonate sounds (its hard for
me to distinguish, I admit)

On auscultation: vesicular breath sounds i.e. no wheezing and gurgling

or crackles heard. Normal air entry
On auscultation of the heart: regular heart beet sound, no murmurs

Assessment of the abdomen

On inspection: there are no scars, lesions, or rashes. Abdomen is flat,
no distension and no visible veins.

On auscultation: peristaltic bowel sounds present

On percussion: normal dull sounds heard over the abdomen
On palpation: abdomen is soft and non-tender, there is no rebound and
guarding no masses noted
NOTE: abdominal girth not measure, we didnt have tape measure

13

 Muscle skeletal system

Back
On inspections: there no scars, both sides of the back are
symmetrical, no abnormal bending of the spine and whole back noted
(scoliosis) and kyphosis
On palpation: there is no sacral edema, no tenderness

Upper extremities
On inspection: there are no lesions, wounds and no infection of the
skin. Normal arm alignment, equal length, bluish fingernails, finger
clubbing present, reduced capillary refill hard to notice,
On palpation: extremities are warm to touch, poor skin turgor, no
edema, tenderness and swelling

Lower extremities
On inspection: there are scars on both legs, there are no wounds, legs
are symmetrical and in normal alignment and length.
On palpation: legs feel warm to touch, there is no edema, tenderness
or swelling, there is no stiffness in the joints. No signs of internal
bleeding

Examination of genital-urinary system

On inspection: hygiene is moderate. There are no hernias, no enlarged

or swollen testicles. There is a small bulging/ protruding growth like
structure size of tip small finger in between scrotum and anus.
14

On palpation: there are no masses in the scrotum, no enlarged inguinal

lymph nodes
NOTE: rectal exam was not done

15

NURSING DIAGNOSES
1. Activity intolerance related to ineffective tissue perfusion body weakness
and fatigue secondary to anaemia evidenced by patient failing to eat by
himself and walk alone to the toilet.

2. altered tissue perfusion related to inadequate blood volume and reduced

hemoglobin-hematocrit levels secondary to severe anaemia evidenced by
hypoxia-reduced capillary refill and finger clubbing and hemoglobin levels of
2.9mg/dl
3. Altered nutrition, less than body requirements, related to inadequate intake
of food due to loss of appetite, vomiting and diarrhea evidenced by patients
verbal report of weight loss and vomiting every time he eats
4. Altered thermoregulation hyperthermia related to sepsis evidenced by body
temperature reading of 38.4c
5. Hypovolemia-Fluid and electrolyte imbalance related to fluid loss due to
vomiting, diarrhea and inadequate intake evidenced by poor skin turgor, rapid
thread pulse rate of 108 beats per minute and dark concentrated urine.
6. Decreased cardiac output- hypotension related to reduced circulatory blood
volume and loss of fluids evidenced by low blood pressure of 84/56mmHg
7. Knowledge deficit regarding condition, prognosis, treatment and treatment
related to lack of exposure and unfamiliarity with hospital protocols
evidenced by asking so many questions
8. Ineffective copping mechanism-Anxiety related to delay in blood transfusion
evidenced by patient asking questions of when he is to be transfused
9. Risk for injury related to loss of balance and dizziness

16

DOCUMENTATION USING SOAPIE FORMAT

Date; 27th April, 2016
Time; 08:12am
Subjective data
Patient says he is feeling week
He vomited early in the morning
He says he doesnt have for food
Objective data
Vital signs:
Body temperature: 37.5 c
Blood pressure: 74/41
Respiration rate: 16 breath/minute
Purse rate: 108 beats per minute
Patient looks dehydrated i.e. he has poor skin turgor, has dry mucous membranes,
has sunken eyes and a rapid thread purse rate.
He is wasted and
Has slow capillary refill
Has bluish fingers and fingers which are clubbing (spooning)
Assessment
1. Ineffective tissue perfusion related to reduced circulatory blood volume
evidenced by low hemoglobin levels of 2.9 mg/dl

Plan
Take blood sample for blood grouping and cross match
Administer intravenous fluids normal saline bolus
Put patient on complete bed rest
Administer whole blood if available

17

Intervention
@ 8:15 normal saline bolus administered
@8:20 patients bed raised to semi-fowler position
@8:25 blood sample for blood grouping for cross match collected and sent to
the lab
Assessment
2. Hypovolemia (fluid and electrolyte imbalance) related to vomiting and
inadequate fluid intake evidenced by dehydration status, low blood pressure
and verbal report of vomiting

Plan
Administer intravenous fluids ringers lactate and alternate with normal
saline.
Ask patient to and give patient oral fluids
give patient food that is appetizing and tolerated by him
monitor vital signs especially purse rate and blood pressure
Interventions
@ 8:45 intravenous fluids ringers lactate administered to run for 8 hours at
42 drops per minute as maintenance.
@ 10:00 patient given fruit juice
@ 10:30 urinal provided
@12:00 vital signs checked
Body temperature: 36.4c, blood pressure 94/ 58, purse rate 106
beats per minute
Assessment
3. Decreased cardiac output related to hypovolemia evidenced by blood
pressure of 74/41
Plan
Administer intravenous fluid
Put patient in semi fowler position
Administer whole blood
Interventions
The intervention are for decreased cardiac output are those as on
hypovolemia

Assessment

18

4. Nutrition imbalance less than body requirement related to loss of appetite

and vomiting evidenced by wasting and verbal report of weight loss
Plan
Assess for random blood sugar
Give appetizing and nutritious food
Administer parenteral feeding. 5 dextrose if patient is not tolerating oral
food as maintenance
Interventions
@12:30 patient given Nsima with chicken but vomited
@ 2:00 pm guardian fed patient yoghurt

EVALUATION
@ 4:00 pm
Blood pressure has improved to 93/53
Patient still has cyanosis
Body temperature has reduced to 36.6 from 37.5
Whole blood for transfusion not available at the blood bank

19

DOCUMENTATION USING SOAPIE

Date: 27th April 2016
Time: 5:10 pm
Subjective data
Patient compliance of dizziness and in ability to balance when trying to walk and
when siting in upright position.
He says he feels shortness of breath walking going to the bathroom.
He says he ate a little porridge because he is having nausea and that food is
tasting sour in his mouth
He complains of feeling week
Objective data
Patient is looking week
He is awake
He is able to drink with help.
Vital signs: blood pressure 88/52,
Purse rate: 110 beats/minute
Body Temperature of 35.6
Respiratory rate of 16 breaths/minute
Assessment
1. Activity intolerance related to general body weakness and fatigue secondary
to low oxygen perfusion to tissues evidenced by patient complaining of
dizziness, loss of energy and failing to hold cup to feed himself.
Plan
Help patient meet activities of daily living such us feeding
Provide bed pan and urinal for voiding
Give small frequent energy and nutritious food that patient tolerate.

20

Intervention
@ 5:28 pm urinal (1 liter bottle) provided to patient
@ 6:00 pm patient given medication
@ 6:30 patient fed with the aid of the guardian

21

DOCUMENTATION USING SOAPIE FORMAT

Date: 28/04/2016
Time: 8:00
Subjective data
He says he is not feeling well
Patient is complaining why he is not being transfused
He complains of stomachache and heart burns mostly when he has just taken his
ART drugs
He says the drugs makes him have nausea and vomiting
The guardian says he had fever during early morning hours, she also says the
patient was complaining of body pains.
The guardian says the patient she fed him porridge but he did not vomit.

Objective data
Patient looking week, restless
He has soiled the bed
Cannula which was inserted yesterday has been removed
Vital signs: body temperature 38c
Blood pressure 81/42
Purse rate 106
Respiration rate 18 breaths per minute.

22

Assessment
1. Self-care deficit (bowel elimination) related to general body weakness
evidenced by soiling of the bed with fecal matter.
Plan

Do bed bath
Do bed making
Tell patient to ask for bed pan when he want to empty bowels

Interventions
@ 8:05 boiled water for bed bath
@8:14 prepared patient for bed bath
@ 8:16 bed bathed patient and changed his clothes with the aid of the
guardian
@8:45 bed making done
Assessment
Hypovolemia (Fluid and electrolyte imbalance) related to vomiting and loss of fluids
through sweating evidenced by verbal report of vomiting and low blood pressure of
81/42
Plan
insert cannula
administer intravenous fluids
monitor for signs of fluid overload
encourage oral fluid intake
Interventions
@ 9:02 cannula inserted and commenced intravenous fluid ringers lactate to
run for six hours at 84 drops per minute.
@ around 10:00 am guardian report she gave him milk half a cup

23

Assessment
2. ineffective thermoregulation hyperthermia related to antigen antibody
reaction evidenced by body temperature reading of 38c
Plan

Reduce extra-linen
Open nearby windows
Fun the room
Provide cold oral fluids

Interventions

@ 9:15 extra linen removed

Windows and fun are already open and working
@ 10:30 patient given cold maheu.

Assessment
3. Reduced cardiac output related to reduced circulatory volume secondary to
anemia and loss of fluids through vomiting evidenced by low blood pressure
of 81/42.
Plan
administer intravenous fluids
monitor for signs of fluid overload
encourage oral fluid intake
Interventions
@ 9:02 commenced intravenous fluid ringers lactate to run for six hours at
84 drops per minute.
@ 11:45 495ml blood transfusion commenced to run for 4 hours at 83 drops
per minute

EVALUATION

24

25

@ 12:00 checked vital signs for the first 15 minutes of blood transfusion.
Blood pressure is 106/60
@13:00 body temperature reduced to 37.6c

DOCUMENTATION USING SOAPIE FORMAT

Date: 29/04/2016
Time: 8:00
Subjective data
Guardian complains of diarrhea, saying the patient had passed watery stools about
3 times during the night.
She also says, he vomited yellowish vomitus which was thick equivalent to the
porridge he had ate during the same night.
He has not eaten this morning because he has no appetite and has nausea.
Patient complains of sore throat and painful swallowing.
Objective data

Vital signs: blood pressure-88/44 mmHg

Purse rate- 104 beats/minute
0xygen saturation -98
Body Temperature -38.4c
Respiratory Rate- 18 breath/minute

Patient is looking weak

Slow in verbal response
Random blood sugar (RBS) 105 mg/dl

Assessment
1. Altered thermoregulation related to antigen-antibody reaction evidenced bt
bod temperature of 38.4c
Plan
Remove extra linen
Open nearby windows
Fun the room

26

Interventions

@8:17 extra linen removed

Windows and fun are already open and fun is already working

Assessment
2. Nutrition imbalance less than body requirement related to loss of appetite,
vomiting and sore throat as evidenced by patient looking wasted and weak.
Plan

Administer ant-emetic drug

Give food that is soft, tolerated and most liked by patient.

Interventions
Antiemetic promethazine 25mg administer intramuscularly
@ 8:30 patient fed one spoon of soya porridge, he wanted to vomit and is
given Maheu
Assessment
3. Decreased cardiac output related to reduced circulatory volume secondary
to anaemia and fluid loss through vomiting and diarrhea evidenced by low
blood pressure of 88/44
Plan

Administer intravenous fluids normal saline 1000 ml bolus then 2000 ml in 24

hours as maintenance plus 500 ml of 5% dextrose.

Monitor signs of fluid excess
Monitor blood pressure every 4 hours
Chase for blood transfusion

Interventions
@: 9:00 administered intravenous fluids bolus
@ 10:13 administered ringers lactate to run as maintenance
EVALUATION
body temperature reduced to 38c but is still high
Heart rate has reduced from 106- 97
27

NURSES CARE and PROGRESS RECORD

DATE: 27/04/2016
@ 7:50 Bed making done
Vital signs checked @ 8:00 am
Patient history obtained from guardian swell us patient
@ Patient taken to the toilet for bowel elimination but patient is so week
Blood samples for blood grouping and cross matching, urea, electrolytes and
creatinine, blood culture collected
@ 2:00 patient given his medication

DATE: 28/04/2016
Vital signs checked
Bed making done
Provided bed pan
Bed bathing with the aid of the patient and Patients clothes changed
Inserted a pink cannula
@11:30 went to collect blood for transfusion
Pre- transfusion vital signs checked
Blood transfusion commenced
Vital signs checked for the first 15 minutes
Blood transfusion complete, no signs of reaction such us chills, vomiting and skin
rush noted.
@4:30 sputum sample bottles for sputum collection given and instruction given
@ 6 pm medication administered
Patient fed rice with fish with the aid of guardian @ 7:00

28

DATE: 29/04/2016
Bed making done
Vital signs checked
Intravenous fluids commenced administered
Provided bed pan for bowel and urinary elimination
Have done physical exam on my patient with the aid and directions from my
instructor
@ 2pm medication administered
Went to check out for blood if available for transfusion but none
@ Around 3 patient given maheu by guardian

29

Patients condition has not improved he is still looking weak have pallor eyes
and continues having diarrhea and vomiting

DICHARGE PLAN
DISCHARGE INSTRUCTIONS:
Inform patients of the etiology of their anemia, the significance of
their medical condition, and the therapeutic options available for
treatment.
Educate patient on transfusions, about the symptoms that herald the
need for transfusion. Likewise, they should be aware of the potential
complications of transfusion.
Medicines:
Iron supplements will help replace iron in your body. Take iron on
an empty stomach. It is absorbed better when your stomach is
empty. Vitamin C also helps your body absorb iron. Take iron with
a vitamin C supplement or a glass of orange juice. Do not eat or
drink any dairy products within 2 hours after you take iron. Take
iron with a small amount of food if it upsets your stomach.
Take your medicine as directed.
Contact your primary healthcare provider if you think your
medicine is not helping or if you have side effects. Tell him if you
are allergic to any medicine. Keep a list of the medicines,
vitamins, and herbs you take. Include the amounts, and when and
why you take them. Bring the list or the pill bottles to follow-up
visits. Carry your medicine list with you in case of an emergency.

Eat iron-rich and protein-rich foods:

30

This includes nuts, meat, dark leafy green vegetables, and beans. Limit
caffeine. You may also need to limit milk to 2 cups a day. You may need
to meet with a dietitian to create the right food plan for you.
Drink liquids as directed:
Advices patient to increase fluid intake. Liquids will help prevent
constipation.
Follow up with your health facility as directed:
You may need to return regularly to have your iron checked. Write
down your questions so you remember to ask them during your visits.
Contact your nearest heath care facility if:
You have heartburn, constipation, or diarrhea.
You have nausea or are vomiting.
You are dizzy or very tired.
You have questions or concerns about your condition or care.
Seek care immediately if:
You have trouble swallowing because of the pain in your mouth and
throat.
You have shortness of breath, even when you rest.
You have blood in your bowel movement or vomit.
You are too dizzy to stand up
(http://www.drugs.com/cg/iron-deficiency-anemia-discharge-care.html)

31

ANAEMIA
Anemia is a clinical condition in which total number of red blood cells or the
quantity of hemoglobin in blood circulation has declined than the normal level so
that oxygen carrying capacity of hemoglobin is decreased and the amount of
oxygen delivered to body tissues is diminished.
Anemia is not a specific disease state but a sign of an underlying disorder. It is by
far the most common hematologic condition. (Brunner and Suddarths Textbook of MedicalSurgical Nursing 12th edition Volume 1)

CAUSES and CLASSIFICATION OF ANEMIA

1) Acute or chronic blood loss
2) Insufficient production of red blood cells because of the absence of
essential factors or bone marrow dysfunction
3) Increased destruction of red blood cells

ANAEMIA DUE TO BLOOD LOSS

The etiology behind this type of anemia is the loss of blood through trauma as in
accidents involving damage to the blood vessels, loss of blood through child birth,
or through administration of drugs that result in coagulopathy such us heparin.
Chronic blood loss can occur as a result of unrecognized blood loss with
unsuspected gastro-intestinal malignancy, a slowly bleeding peptic ulcer, or
hemorrhoids that bleed without the patients awareness.
When blood loss is continuous and moderate the bone marrow may be able to keep
up with losses by increasing its production of red blood cells if enough protein and
iron are supplied in the diet. However if chronic blood loss goes unnoticed the bone
marrow fails to cope up with the pace of blood loss and signs of anaemia appear.
Signs and symptoms of anemia secondary to blood loss are
Hypovolemia
Shock
Weakness
Irritability
32

Tachycardia
Tachypnea
Hypotension
Cool clammy skin
Stupor

ANAEMIA DUE TO REDUCED RED BLOOD CELL PRODUCTION

In this type of anemia, bone marrow cannot produce adequate numbers of
erythrocytes. Decreased erythrocyte production is reflected by an inappropriately
normal or low reticulocyte count. Inadequate production of erythrocytes may
result from bone marrow damage due to medications e.g. prolonged use of
chloramphenicol or exposure to chemicals such us benzene or from a lack of
factors necessary for production of erythrocyte e.g. iron, vitamin B12, folic acid,
and erythropoietin
IRON DEFICIENCY ANAEMIA
Iron deficiency anaemia occurs 20% in adult women, 50% in pregnant women and
3% adult males also 30% in pre-school children.
A normal diet provide about 10 to 20 mg of iron per day. Only approximately 10%
of ingested iron is absorbed. The daily iron requirement is 0.5 to 1.0 mg for men
and post-menopausal women and 2,5mg/day for pregnant and menstruating women.
Iron deficiency can result from

Inadequate dietary supply,

Impaired absorption from the intestines,
Increased bodily requirement of iron during periods of rapid bodily growth,

pregnancy and menstruation.

Loss of iron through hemorrhage.

Anaemia as a result of iron deficiency will cause the formation of microcytichypochromic blood cells. (PHIPSLONGWOODS Shafers medical-surgical nursing
seventh edition)

33

Clinical manifestations of iron deficiency anaemia

Laboratory diagnostics shows

Decreased red blood cell count

Decreased hemoglobin levels (Hgb)
Microcytic-hypochromic blood cells.
Reduced hematocrit (Hct)
Decreased iron stores in bone and liver.

PENICIOUS ANAEMIA
Pernicious anaemia was first discovered by Thomas Addison in London in 1849. In
this disease a substance called intrinsic factor normally produced by the parietal
cells of the stomach is lacking. The intrinsic factor is responsible for the
absorption of vitamin B12 that is normally found in food. Without vitamin B 12 red
blood cells becomes abnormal thus they may be very large (macrocytic) and assume
peculiar shapes and sizes (anisocytosis).
Pernicious anaemia usually occurs in age groups of older than 40 years. Patients
who have partial or complete gastrostomy need are at greater risk of developing
pernicious anaemia and requires vitamin B12 supplement throughout their life time
CLINICAL MANIFESTATION OF PENICIOUS ANAEMIA
Signs and symptoms of pernicious anaemia develop slowly.

Fatigue is the most common sign, but comes in so slow that patients seldom
remembers its beginning
Anaerobia and symptoms of poor digestion yet little weight loss.
Laboratory test of gastric content reveals an absence of (achlorhydria) free
hydrochloric acid in the stomach, because of lack of functioning parietal
cells.
Pernicious anaemia disturbs the nervous system and patients shows signs of
irritability and depression and psychosis which id easily reversible with

correction of anaemia.
Dyspnea and heart palpitation

Tingling, burning and feeling of numbness in the lower extremities as the

disease attacks the nervous system.
34

FOLIC ACID DEFICIENCY ANAEMIA

Folic acid is stored as compounds referred to as folates. Folate stores in the body
are quickly depleted when the dietary intake of folate is deficient (within 4
months). Folate is found in green vegetables and liver. Folate deficiency occurs in
people who rarely eat uncooked vegetables. Alcohol increases folic acid
requirements. Folic acid requirements are also increased in patients with chronic
hemolytic anemia and in women who are pregnant, because the need for
erythrocyte production is increased in these conditions. Some patients with
malabsorptive diseases of the small bowel, such as sprue, may not absorb folic acid
normally. Infants who are exclusively fed milk diet are also at great risk of
developing folic acid deficiency anaemia. (Brunner and Suddarths Textbook of MedicalSurgical Nursing 12th edition Volume I)

APLASTIC ANAEMIA
Aplastic anaemia is characterized by aplasia, depression or cessation of activity of
all blood producing elements. There is a decrease in white blood cell production
(leukopenia) a decrease in platelets ( thrombocytopenia ) and a decrease in red
blood cells ( PHIPPSLONGWOODS SHAFFERS MEDICAL-SURGICAL NURSING)
The cause of aplastic anaemia are somewhat uncertain. In many instances no
etiological factors can be identified. Damage to the bone marrow stem cells,
damage to the microenvironment within the marrow, and replacement of the
marrow with fat are some of the explainable hypothesis in the cause of aplastic
anaemia. The precise etiology is unknown, but it is suggested that the bodys T cells
mediate an inappropriate attack against the bone marrow ( Young, Calado & Scheinberg,
2006)

resulting in bone marrow aplasia (i.e. markedly reduced hematopoiesis).

Therefore, in addition to severe anemia, significant neutropenia and
thrombocytopenia (i.e. a deficiency of platelets) also occur.
Aplastic anaemia may also be a result of treatment with anti-neoplastic drugs and
immunosuppressive drugs. It may also follow exposure to chloramphenicol,
sulfonamides, phenylbutazone and anti-convulsnants such as mephenytoin, DDT and

35

other insecticides. Disseminated tuberculosis may also produce symptoms similar to

aplastic anaemia.

Signs and symptoms of aplastic anaemia

Signs and symptoms of aplastic anaemia may appear suddenly but they usually
develop gradually over a period of weeks and months, they include

Pallor
Weakness
Dyspnea
Anaerobia
Headache
Fever
Bleeding from mucous membranes often noticed in the nose and mouth.

Anaemia due to destruction of red blood cells

THALASSEMIA
The thalassemias are a group of hereditary anemias characterized by hypochromic
(an abnormal decrease in the hemoglobin content of erythrocytes) extreme
microcytosis (smaller-than-normal erythrocytes) and destruction of blood elements
(hemolysis), and variable degrees of anemia.

PATHOPHYSIOLOGY OF ANAEMIA
All blood cells are produced in a process called hematopoiesis in the bone marrow.
The major raw material essentials for this process are proteins, vitamin B12, folic
acid, and iron.
Vitamin B12 and folic acid are essential for normal DNA synthesis and
hematopoiesis. In deficiency of either of this red blood cells cannot produce DNA
for normal nuclear maturation. (Lippincotts review medical surgical nursing)

36

In iron deficiency anaemia, when body stores for iron decreases there is reduced
red blood cell mass resulting in decreased hemoglobin concentration and decreased
oxygen carrying capacity of blood

Pathophysiology of anemia differs according to its etiology. Acute or chronic red

blood cell loss, inadequate production of red blood cells in the bone marrow, or an
increased hemolysis can produce anemia (Gaspard, 2005; Hodges et al., 2007)

When anemia develops because of hemorrhage, the reduction in red blood cell
numbers causes a decrease in blood volume and the cardiovascular (CV) system
becomes hypovolemic. Anemia becomes evident when the maximum level of
hemodilution occurs, usually within 3 days after the acute blood loss. . Hemodilution
occurs in response to decreased blood volume when fluid moves from the
interstitium into the intravascular space to expand the plasma volume. The
decrease in blood viscosity from the lower number of red blood cells, along with
increased intravascular fluid, causes the blood to flow faster through the CV
system and the flow becomes more turbulent. This process causes pressure on the
ventricles, the heart dilates, and heart valve dysfunction develops (Metivier,
Marchais, Guerin, Pannier, & London, 2000).
Hypoxia contributes to the changes in the CV and respiratory systems in anemia by
causing the blood vessels to dilate and the heart to contract more forcefully,
which further increases the demand for oxygen. Tissue hypoxia causes the rate
and depth of breathing to increase. Hemoglobin, the oxygen-carrying protein in the
red blood cells (RBCs), releases that oxygen to the tissues more rapidly. When
anemia becomes severe, the body directs blood to the vital organs, such as the
heart and the brain, and renal blood flow decreases. Decreased renal blood flow in
turn causes an activation of the renin-angiotensin system response, leading to salt
and water retention. This process increases blood volume to improve kidney
function without changing tissue hypoxia in other organs (Gaspad, 2005; Metivier
et al., 2000).
Bone marrow failure due to leukemia as a result of exposure to chemicals, drugs
and radiation also causes reduction in red blood cell mass which consequently
reduces hemoglobin and oxygen carrying capacity.
37

Infections, hyperactive spleen and infections such as disseminated tuberculosis

result in hemolysis of red blood cells leading into jaundice, pallor, fatigue and
diminished exercise tolerance.
The pathophysiology of hemolytic anemia involves the destruction of erythrocytes
and the subsequent acceleration of erythropoiesis. Hemolytic anemia may be
inherited or acquired. The inherited form occurs from cellular abnormalities in the
membrane or the enzymes that influence the production of hemoglobin. Acquired
hemolytic anemia occurs as a result of infection, chemical agents, and abnormal
immune response. Hemolytic anemia produces hemolysis within the blood vessels or
lymphoid tissue that filters blood. Immunohemolytic anemias are caused by
extravascular hemolysis and associated with autoimmune mechanisms or drug
reactions (Hodges et al., 2007; Mansen & McCance, 2006).

SIGNS AND SYMPTOMS OF ANAEMIA

Integumentary system
Pale, jaundice eyes
Pale skin and mucous membranes
Poor skin turgor typical dehydration status
Brittle, spoon-shaped nails
Anorexia

Cardiovascular system
Tachypnea
Tachycardia
Postural hypertension
Widened pulse pressure
Ankle edema

Neurologic System
Confusion
Impaired judgment
38

Irritability

Musculoskeletal System
Ataxia
Unsteady gait
Paralysis

(Adamson, J.W., & Longo, D.L. (2001). Hematologic alterations. In E. Braumwald, A.S. Fauci, D.L)

MEDICAL MANAGEMENT OF ANAEMIA

Medical management of severe anaemia and all other forms of anaemia
depend on the underlying cause and severity of the symptoms and
clinical manifestation of the anemic patient.
In adults:
If Hemoglobin count is less than 5g/dl and
If hemoglobin is less than 8g/dl and there are clinical complications
Transfuse 1 unit of whole blood or packed red cells suspension
this will raise hemoglobin level by 1-1.5g/dl Give 100-200mg
elemental oral iron with a meal
Administer ferrous compound orally 170mg daily with food
Continue treatment for 6 months.
Prophylaxis ferrous sulfate 65mg and elemental iron 65mg orally
For pernicious and anaemia caused by deficiency in folate and vitamin
B12
Start folic acid and vitamin B12
take blood samples for RBS, folate and vitamin B12 to test for
levels before starting treatment
monitor serum potassium levels and replace if necessary
39

 give folic acid 5mg daily until Hb returns to normal, vitaminB12

intramuscularly 1 mg once daily for 7 days
(Malawi-Standard-Treatment-Guidelines-Essential-Medicines-List-2015)
MEDICAL MANAGEMENT FOR HENRY MTIRA
MEDICAL DIAGNOSIS:
Severe anaemia secondary to (a) sepsis
(B) AIDS disease
MANAGEMENT
Cefuroxime 500mg 12 hourly for 10 days
Indications
Cefuroxime is used to treat certain infections caused by
bacteria, such as bronchitis; gonorrhea; Lyme disease; and
infections of the ears, throat, sinuses, urinary tract, and skin.
Contraindications
Do NOT use cefuroxime if:
You are allergic to any ingredient in cefuroxime or to any other
cephalosporin (e.g. cephalexin) (http://www.drugs.com/cdi/cefuroxime.html)
Mode of action
Cefuroxime is in a class of medications called cephalosporin
antibiotics. It works by stopping the growth of bacteria.
(https://www.nlm.nih.gov/medlineplus/druginfo/meds/a601206.html)

40

Side effects
upset stomach
vomiting
diarrhea
stomach pain
severe skin rash

itching
hives
difficulty breathing or swallowing
wheezing
diaper rash
painful sores in the mouth or throat
vaginal itching and discharge

Why giving cefuroxime to Mr. Henry Mtira

He was prescribed cefuroxime for the treatment of the sepsis
Cefuroxime was used instead of ceftriaxone which was not
available at the hospital at that time
Paracetamol 1g 8 hourly
Mode of action
It has analgesic and antipyretic properties. It suppresses
prostaglandin production. Inhibition of prostaglandin synthesis in brain
explains the antipyretic activity of paracetamol and includes the
blocking effects of both the peripheral (COX inhibition), and central
(COX), serotonergic descending neuronal pathway thereby reducing
pain sensation (Acta Poloniae Pharmaceutica Drug Research, Vol. 71 No. 1 pp. 1123, 2014)
Indication
Paracetamol is used to treat many conditions such as headache,
muscle aches, arthritis, backache, toothaches, colds, and fevers.
It relieves pain in mild arthritis but has no effect on the
underlying inflammation and swelling of the joint.
Is the drug of choice in patients that cannot be treated with nonsteroidal anti-inflammatory drugs (NSAID), such as people with
bronchial asthma, peptic ulcer disease, hemophilia, salicylatesensitized people
41

Contraindication
alcoholic liver disease (cirrhosis)
Allergic to acetaminophen or Paracetamol
Paracetamol side effects
Hives
Difficulty breathing
Swelling of your face, lips, tongue, or throat.
Serious side effects:
low fever with nausea, stomach pain, and loss of appetite;
dark urine, clay-colored stools; or
Jaundice (yellowing of the skin or eyes).

Rationale for administering Paracetamol to Mr. Mtira

It was administered to reduce fever and pain
FERROUS SULFATE 200mg orally 8 hourly
Ferrous Sulfate tablets belong to a group of medicines called iron
supplements. (Ferrous sulfate leaflet-Actavis, Barnstaple, EX32 8NS, UK )
Mode of action
These medicines work by replacing body iron. Iron is a mineral that the
body needs to produce red blood cells.
Indications
Ferrous Sulfate tablets are used for the prevention and treatment of
iron-deficiency anaemia.
Contraindications
Do not administer Ferrous Sulfate tablets if:
Patients are allergic (hypersensitive) to dried ferrous sulfate or any of the
other ingredients in Ferrous Sulfate
42

are receiving repeated blood transfusions

are receiving iron intravenously
have a disorder in which there is excessive absorption and storage of iron
such as hemochromatosis

NOTE:
Ferrous Sulfate tablets should not be taken within one hour before
or two hours after eating or drinking the following products: tea,
coffee, milk, eggs and whole grains. These products can reduce the
absorption of iron. Meat and products containing vitamin C can
increase the absorption of iron
Fluconazole 200mg orally once daily
It is a member of the triazole anti-fungal agents

Mode of action
It inhibits fungus sterol synthesis

Indications for fluconazole

Fluconazole is indicated for the treatment of:
Cryptococci meningitis and as maintenance therapy for Cryptococci disease
in AIDs patients
Systemic candidiasis

Oral pharyngeal and esophageal candidiasis

Prevention of fungal infections in patients with malignancy who are
predisposed to such infections as a result of cytotoxic radiotherapy.

Contraindications

It should not be used in patients with known hypersensitivity to the drug or

medications related to the azole compound
Lactating mothers as it is found in breast milk in similar concentration as in
serum plasma
in pregnancy it may increase the risk of miscarriage

Adverse side effects associated with fluconazole

rash, headache, dizziness, nausea, vomiting, abdominal pain, diarrhea
elevated liver enzymes
43

 anorexia, fatigue, constipation,

Rationale for administering fluconazole to Mr. Mtira
The patient is HIV reactive and is having AIDs so fluconazole is
indicated for prophylaxis of Cryptococci meningitis infections.
Patient has oral pharyngeal thrush likely candidiasis.
Albendazole 400mg orally start
It is a broad spectrum an anti-parasitic drugs against parasites of the worm
family (helminthic) found in the intestines

Mode of action

It interferes with the reproduction and survival of helminthes (intestinal

worms) by inhibiting the formation of microtubules from tubulins thus
impairing glucose uptake, depletion of glycogen stores and consequently
death of the worms.

Indications
For the treatment of Parasitic worm infection
Contraindications
The drug is contra indicate to patients with known hypersensitivity and
patients with kidney failure
Low blood count due to bone marrow failure

Side

effects associated with albendazole

Liver problems
Stomach pains
Nausea
Headache
Dizziness
Increased intracranial pressure
Meningeal signs.
Acute kidney failure

Rationale for administering Albendazole

It was given on suspicion that he might have worms causing
anaemia, diarrhea and wasting.

44

TRIPPLE THERAPY
1. Omeprazole 40mg orally once daily for 14 days
2. Amoxicillin 1g orally twice daily for 14 days
3. Metronidazole 500mg twice daily orally for 14 days
Triple therapy Is a combination of two antibiotics and one anti secretory
agent omeprazole aimed at treating peptic ulcers .
Mode of actions

Omeprazole- They suppress the secretion Hydrochloric acid into the

lumen of GIT from parietal cells
Amoxicillin and metronidazole- Antibiotics will eradicate the bacteria

Rationale for administering triple therapy

Patient was complaining of heart burns and stomach pains
and the differential diagnosis for that was stomach ulcer

Blood transfusion
INDICATION FOR BLOOD TRANSFUSION
Severe anaemia
If Hemoglobin count is less than 5g/dl and

If hemoglobin is less than 8g/dl and there are clinical complications (MalawiStandard-Treatment-Guidelines-Essential-Medicines-List-2015 section 1.2.2 page 6 )

CONTRAINDICATIONS

Do not transfuse in Megaloblastic anaemia (MCV110)

Vitamin B12 deficiency anaemia

Adverse reactions associated with blood transfusion

Severe pain at site of transfusion or back pain, loin or chest pain.
45

 Urticaria
Rise in temperature by 1c above base line temperature
Shortness of breath
Wheezing
Hemologlobinuria
Anxiety
Pruritus
Tachycardia
Palpitation fever
Itchy rash
Chills (Malawi-Standard-Treatment-Guidelines-Essential-Medicines-List-2015 section 1.6.1
page13

Treatment for transfusion reactions

For Hypersensitivity: slow infusion

Administer promethazine 25mg intramuscularly or chlorpheniramine 4mg
orally

For severe reactions- stop transfusion and refer to physician .

46

LABORATORY INVESTIGATIONS
1. Full blood count (FBC)
The Complete Blood Count identifies the total number of white and red blood cells
and platelets, and measures hemoglobin and hematocrit .

(Brunner and Suddarths Textbook

of Medical-Surgical Nursing 12th edition Volume I)

VALUES FOR MY PATIENT

(For the values on complete blood count for patient refer to copy in the file)

test

qualification

White blood count

low
low
low (due to anaemia)

Red blood cell count RBC

Hemoglobin
Hematocrit (HCT)
47

Low

Neutrophils
Mean capsule hemoglobin (MCH)
Mean capsule hemoglobin concentration (MCHC)
Platelet count
Mean capsule volume (MCV)

Low
low
Normal
normal
low

Rationale for complete blood count

Hematocrit represents the percentage of red blood cells found in 100 mL of

whole blood
The red blood cells count reflect hemoglobin, which transports oxygen to
the cells. Low hemoglobin and hematocrit levels have serious consequences
White blood cell WBC counts are monitored in immune-compromised
patients, including patients with heart transplants or in situations (WBC)
where there is concern for infection just as my patients differential
diagnosis of sepsis.

Test
Urea
creatinine

UREA AND CREATININE

Normal range
Patients level
10-50mg/dl
34mg/dl
0.6-1.8mg/dl
1.2mg/dl

qualification
Normal range
Normal range

Rationale:

Creatinine is a metabolic waste generated by muscle metabolism to produce.

Kidneys are responsible for maintaining normal levels of serum creatinine. A
rise in serum creatinine signifies kidney disease or kidney failure.
Therefor serum creatinine is checked to assess kidney functioning.

SPUTUM FOR AAFB AND GENE-EXPERT

Acid fast bacilli-AAFB
This is a test for tuberculosis
The patient had negative tuberculosis smear in his sputum
Rationale:
Patient was being investigated for tuberculosis since he had the infection in 2009
and was being suspected that it had relapsed

CEREBRAL SPINAL FLUID FOR MENINGITIS

Results:
48

 negative for Cryptococci

the fluid was clear
Impression:
Patient has no meningitis

Rationale:
It was done to rule out meningitis as differential diagnosis for sepsis

49