CASE PRESENTATION

OF
Iron Deficiency Anemia
 INTRODUCTION
Ms. Y is a 24 year old female residing at San Miguel, Tarlac City. Ms. Y’s family has a
heredo familiar disease which is diabetes. She had undergone some test, & they discovered
that she is most likely to have diabetes. But then, she claimed to have taken some medications
to avoid having diabetes. She also claimed to have a of polymenorrhia history which is the
main reason for consulting her attending physician for several occasion & finally sought
admission for diagnosis.
Anemia is a condition in which the hemoglobin content of the blood is below normal
limits. It may be hereditary, congenital or acquired. Basically, anemia result from a defect in
the production of hemoglobin & it’s carries the red blood cell. The most common cause is a
deficiency in iron, an element necessary for the formation of hemoglobin. Symptoms vary
with the severity & cause of the anemia but may include fatigue, weakness, pallor, headache
& anorexia. Treatment also depends on the cause & severity & may include an iron-rich diet,
iron supplement, blood transfusion & the correction or elimination of any pathological
conditions causing the anemia.

Final diagnosis Iron Deficiency Anemia.

 OBJECTIVES

Establish rapport and gain the trust and cooperation of the patient
and immediate family members, perform and obtain thorough and
complete physical assessment using the assessment techniques following
the cephalocaudal approach, obtain complete medical, socio-cultural, and
family history related to the patient’s current health condition. Analyze
and prioritize problems based from the gathered pertinent data to come
up with the correct nursing diagnosis and plan appropriate nursing care.
Provide health teaching to modify behavior and to incorporate learning.
 NURSING PROCESS
Nursing Health History A
Demographic Data
Patient: Ms. Y
Date: August 1,2009 Ward: Female Surgical Ward Bed: E. #246
Age: 24 y/o Sex: F Religion: Catholic

I. Chief Compliant
Pallor

II. History Of Present Illness

Patient has chronic history of pallor not relieved by ferrous sulfate & recormion, advised
Blood Transfusion prior to admission
 III. Past Medical History (include dates and complications, if any)

A. Pediatric and Adult Illness

Mumps: Pertussis: HPN:
Measles: Rheumatic: Heart Disease:
Chicken Pox: Pneumonia: Hepatitis:
Rubella: Tuberculosis: Others:

B. Immunizations/Test
BCG: HEPA B: For Pneumonia:
DPT: Measles: Others:
OPV: For Flu:
C. Hospitalizations
 Ms. Y has been hospitalize two times
 1st – April 2, 2008
Pregnancy uterine 7 months delivered by CS to an alive baby girl. Hydropz fetalis bilateral ovarian cyst wedge
resection of both ovaries.
• 2nd – August 1, 2009
Iron Deficiency Anemia
D. Injuries
No history of injuries
E. Transfusions
Ms. Y had Blood Transfusion with the current hospitalization.
G. Obstetrics/Gynecologic History
G=1 T=0 P=1 A=0 L=0 M=0
Last April 5,2008 Ms. Y had undergone surgical operation because of pregnancy uterine 7 months
delivered by CS to an alive baby Girl. Hydropzfetalis, Bilateral Ovarian Cyst Wedge resection of both
ovaries G1P1.

H. Medications
The patient take Hemostan prior to menstruation and ferrous sulfate as Iron Supplement

I. Allergies
The patient had history of hypersensitivity reaction to a cosmetic preparation
 IV. FAMILY HISTORY

Age List: Disease Present in the family

Parents, Spouse, Children Health Status or cause of
L D
death

Mr. N C
L Hypertension

Mrs. S C L Hypertension

Mr. C C L

Ms. C C L

Ms. Y L
 V. Social And Personal History

Birth Place: Tarlac Birth Date: Feb. 5, 1985

Education: College Graduate Ethnic Background: Tagalog, Ilocano, Kapampangan

Age And Sexes of Children (if any): None

Client’s position in the family: Second Child/middle child

Residence
Home Environment: Their house is made of concrete structure and located along the highway and
it surrounded by tree.

Occupation:
Nature of present occupation: She is a trainee in a telecom company.

Financial Support System: Ms. Y is sustented by her brother who is an engineer.

Habits: Texting, Watching T.V. & Surfing the internet

Physical Activity/Exercise, if any: She considered walking as her form of exercise.

Brief Description of average day: She woke up at 5:00AM to cook her food then she prepare her things, at
9AM she go to work until 10PM.
 VI. Review of System
General Description
Weight Loss: Fatigue Anorexia:
Height Sweats: Weakness:
Skin:
Itch: Bruising:
Rash: Bleeding:
Lesions: Color Change: Slightly
Pallor
Eyes:
Pain: Itch: Vision Loss:
Diplopia: Blurring: Excessive Tearing:
Glassess/Contact Lenses:
Ears:
Earaches: Discharge: Tinnitus: Hearing Loss:
Nose:
Obstruction: Epistaxis: Discharges:
Throat and Mouth:
Sore Throats: Bleeding Gums: Toothaches: Decay:
Neck:
Swelling: Dysphagia: Hoarseness:

Chest:
Cough: Sputum: Hemoptysis:
Wheeze: Pain on Respiration: Dyspnea: Rest/Exertion
Breast: Lumps: Pain: Bleeding: Discharge:
CVS:
Chest Pain: Palpation: Dyspnea on exertion edema:
PND: Orthopnea: Others:
GIT:
Food Tolerance: Heartburn: Nausea: Excessinve Gas:
Vomiting: Pain: Bloating:
Constipation: Change in BM: Melena:
GU:
Dysuria Nocturia Retention Polyuria Dribbling
Hematuria: Flank Pain
Male: Penile Discharge Lesion Testicular Pains: Others:
Female: Menarche 10 y/o LMP: July 6, 2009 Cycle: Others:
Extremities:
Joint Pains: Varicose Claudication:
Veins:
Edema: Stiffness: Deformities:
Neuro:
Headaches: Memory loss Fainting:
Numbness tingling: Dizziness: Paralysis: Paresis:
Seizures: Others:
Mental Health Status:
Anxiety Depression: Insomnia:
Sexual Problems: Fears:
 NURSING HEALTH HISTORY B
A. General Description of Client
Ms. Y appears pale & weak, but despite of that she was able to cooperate with us.
B. Health Perception – Health Management Pattern
Ms. Y stated that health is really essential for every one of us & then, she added that she was hoping that she could still
achieve the optimum or excellent state of health.
Ms. Y said that whenever she feels bad or if there’s a presence of signs & symptoms of any illness or diseases, she urgently seeks
for help to medical personnel. It’s because she know that they are the people where we could entrusted our health & well-
being. And not by means of any faith healers.
C. Nutritional – Metabolic Pattern
Ms. Y said that she’s not fond of eating green leafy vegetables & also she was not taking vitamins such as those vitamins that
rich in iron.
D. Elimination Pattern
Ms. Y said that she was voiding 3-4 times daily & she has a normal bowel habits, & it was about 1-2 times a day.
E. Activity – Exercise Pattern
She has a sedentary lifestyle, texting, surfing the internet & watching T.V are among her daily habits, then she was walking every
morning as her daily exercise.
F. Sleep – Rest Pattern
She said that she do not have adequate sleep/rest, that she was stay up late at night & she always had her sleep with in 5 hours
most of the time.
G. Cognitive – Perceptual Patter
She was able to follow any direction & answer promptly if what is being asked.
H. Self Perception – Self Concept Pattern
She handled her problems systematically with the help of her mother. Her mother is a nurse, so whenever she is ill, she
always promptly asked her mother about it.
I. Role – Relationship Patter
Menstrual History:
Age of Menarche: 10 yrs. Old
She verbalized that her menstrual cycle was only 26 days lasted for 7 days and she was not using any
contraceptives.
She was the second daughter & also she was the middle child of their family she consider her self as a good daughter to her
parents. She added that they were have a good & intact relationship within their family.
J. Sexuality – Reproductive Pattern
She got pregnant before, then she had undergone surgical operation because of pregnancy uterine premature delivered by CS
to an alive baby girl. Hydropsfetalis, bilateral ovarian cyst wedge her section of both ovaries. Unfortunately her baby died.
K. Coping – Stress Tolerance Pattern
She said that whenever she was down & depressed, her family was the one that who could support & help her to cope up with
her situation. She divert her attention on surfing the internet.
L. Value – Belief Pattern
She is Roman Catholic & she has a strong faith in God. She was attending mass every Sunday, regarding health management
she believed that the medical personnel are the people who are among that we should entrusted our health and well being &
not by means of any means of faith healers.
 Physical Examination
General Survey:
Height: 5’5 Weight: 72 kg Body Make Up: Medium
Skin color: Clear complexion Turgor: none Bruises: None
State of Hydration: None
Eyes:Sclera: Bulbar conjunctiva is clear with tiny vessel visible
Pupils:
Respiratory: Easy Breathing: In Distress No Distress
Vital Signs:
HR: 78 /minute Temperature: 36.5 Degree Celsius
BP Supine R/L arm: 90/60mmHg Capillary Refill:
RR: 20
Body Position/Alignment
Supine Fowlers: Semi-Fowlers: Others:
Alignment: Appropriate Inappropriate
Mental Acuity:
Oriented: Coherent Appropriate responsive Others:
Disoriented Incoherent Inappropriate responsive
Sensory/Motor Restrictions:
Amputation Deformity Paresis Paralysis Others:
Gait Hearing Disorder Speech Fracture
Emotional Status:
EuphoricDepressed Apprehensive
Angry/Hostile Others:
Medically Imposed Restrictions:
CBR without BRP: BR with BRP: OOB chair: Restricted Ambulation:
Other Health Related Patterns:
Fatigue: Restlessness: Weakness: Insominia: Coughing:
Dyspnea: Dizziness: Pain: Others:
Environment:
Room Temperature: Adequate Inadequate
Lighting: Adequate Inadequate
Safety:
Violations of medical asepsis:
Violations of safety measures:
Activities of Daily Living:
Can perform
Feeding Brushing teeth Bath Transferring
Dressing combing
 PATHOPHYSIOLOGY
Inadequate sleep pattern, inadequate
iron intake. Inadequate intake of foods
rich in iron

Fatigability, waxy pallor, polymenorrhea,

sores in the corners of the mouth.

Prior to Hospitalization

Complete Blood Count (CBC), Urine

Analysis

RBC, HGB, Platelet, MCV, MCH

& MCHC decrease to its normal
level

Lead to low hemoglobin and hematocrit,

decrease iron stores and low serem iron and
ferritin. The RBC decreased in number

Iron-Deficiency
 PLANNING
Nursing Care Plan
Cues Diagnosis Scientific Planning Nursing Rationale Evaluation
Explanation Intervention

Subjective: Activity Inability of red After 2 hours of Monitor V/S, Provide as a After the end of
Ok naman ako intolerance bone marrow to nursing watch for the baseline data nursing
medyo maputla related to produced red intervention the changes in blood intervention the
lang ako ngayon inadequeate blood cells patient BP will pressure. patient blood
at di pa ganun blood   increase from   pressure
kalakas. component Decreased O2 90/60 to 110/80. increased from
  carrying capacity Note skin pallor 90/60 to 110/80
Objective: of body & cyanosis
Pale    
Dry Lips Inadequate
BP: 90/60 supply of O2 in Adjust activities,
  the Body reduced intensity To prevent over
CBC:   level or exertion
RBC: 2.5 Activity discontinue  
HGB: 10.5 intolerance activities that  
MCV: 67.2 (Body cause desired  
MCH: 20.6 Weakness) physiologic  
McHc: 30.6 changes.  
 
Plan care with  
rest periods To reduce
between fatigue
activities.
Cues Diagnosis Scientific Planning Nursing Rationale Evaluation
Explanation Intervention

Subjective: Readiness for The patient is After 1 hour of Verify clients Provides After the end of
Eto for enhance comfort now ready for to health teaching level of opportunity to the health
discharge na related to go home for the patient will knowledge/ assure accuracy teaching the
daw ako, Sabi therapeutic therapeutic have knowledge understanding of & completeness patient have the
ng OB ko at regimen regimen on how to therapeutic of knowledge knowledge on
hind na din ako develop her regimen and base for future how to develop
ganun kaputla. lifestyle note specific learning her lifestyle
  goals  
Objective:   Understanding
Good Condition Identify steps the process
V/S – normal necessary to enhance
reach desired commitment &
health Goads. the like hood of
  achieving the
Accept patient goals
evaluation of  
own Promote sense
strengths/limitat of self-esteem &
ions while confidence to
working continue efforts
together to
improve
abilities.
 Drug study
Drug Name Classification dosage Action Indication Contraindicati Side-effect Adverse Nursing
on reaction responsibilities
Iberet Vitamins &/or 500mg tab od Iberet used in Prevention & Patients w/ Black stool Allergic -The nurse
Minerals the treatment treatment of thalassemia, discoloration. reactions, GI Should
  of anemia. nutritional sideroblastic effects, hepatic administer this
anemia; anemia, dysfunction w/ drug to the
supplement for hemochromato abnormal liver patient with
physical & sis & function tests, an empty
mental hemosiderosis. hyperbilirubin stomach (Best
abilities; & for taken between
Repeated emia,
maintenance meals. May be
blood deterioration
of optimum taken w/ meals
transfusion or of acne form
health. to reduce GI
parenteral Fe vulgaris or
discomfort.).
therapy, eruption of
intestinal acne form -Instruct the
diverticula or exanthema, patient to
intestinal bright yellow report signs of
obstruction. urine adverse
Liver disease discoloration, reaction
or active flushing,
peptic ulcer, peripheral
arterial sensory
hemorrhaging neuropathies,
or severe stone
hypotension. formation,
crystalluria,
oxalosis.
Drug Name Classification dosage Action Indication Contraindicati Side-effect Adverse Nursing
on reaction responsibilities
antamin Antihistamines 1cc, IM 30 Compete with Allergy, Lower resp Open- & Sedation, -Check for BT
& min. prior to histamine for allergic tract disease. closed-angle lassitude, before giving
Antiallergics BT. #1 receptor rhinitis, Newborn or glaucoma. elation or this drug.
site on effect bronchial premature Prostatic depression, -Keep this
or cells; asthma, infants. enlargement. irritability,
product, as
decreases vasomotor Avoid paranoid
rhinitis, operating psychosis, well as
allergic
dermatoses of vehicles or delusion, syringes and
response by
allergic machinery. hallucination. needles, out of
blocking
etiology, Hypersensitivi Muscular the reach of
histamine
urticaria, drug ty, CV weakness,
children and
sensitization, diseases, incoordination.
serum cardiac GIT away from
sickness, arrhythmias, disturbances. pets. Do not
anaphylactic HTN, Headache, reuse needles,
shock, insect hyperthyroidis tinnitus. syringes, or
bites. m, Difficulty in
other
pheochromocy micturition.
toma, diabetes. CV effects. materials.
 Drug Name Classification dosage Action Indication Contraindicati Side-effect Adverse Nursing
on reaction responsibilities
Hemostan Haemostatics 1 tab In the Inhibits Menorrhagia/ Not advisable GI disorders, -Instruct the
first to third breakdown of menometrorrh to use for nausea, patient that
day of fibrin clots. It agia. prolonged vomiting, May be taken
menstruation. acts primarily periods in anorexia, with or
by blocking patients headache may without food.
the binding of predisposed to appear, -Instruct the
plasminogen thrombosis. impaired renal patient to
Not
& plasmin to insufficiency, report signs of
recommended
fibrin; direct hypotension adverse
for
inhibition of when IV inj is reaction
prophylaxis
plasmin occurs too rapid.
during
only to a pregnancy &
limited degree. before
delivery.
LABORATORY RESULT Routine Blood Count [RV]

WBC 7.7 4-10

Patient: Ms. Y
Physician: Dr. M J L RBC 2.5 (M) 4.5 – 5.5; (F) 3.8 – 4.8
Age: 24
Sex: Female HGB 10.5 (M) 13.0 – 17.0; (F) 12.0 – 15.0

Date & Time: 8/1/2009

HCT 40.2 (M) 40 – 50; (F) 36 - 46

MCV 67.2 83 – 99 FL

MCH 20.6 27.0 – 32.0 PG

MCHC 30.6 31.5 – 34.5 G/DL

Platelet 139 150 - 400

MPV 8.6 6.5 – 11.0 um3

Lymphocytes % 19.4 20 – 40

MXO % 8.3 2 – 10

Neutrophiles % 72.3 40 – 80

Lymphocytes # 1.5 1–3

MXO # 0.6 0.2 – 1

Neutrophiles # 5.6 2.5

Patient: Ms. Y
Routine Blood Count [RV]
Physician: Dr. M J L
Age: 24
WBC 7.7 4-10
Sex: Female
Date & Time: 8/2/2009
RBC 5.98 (M) 4.5 – 5.5; (F) 3.8 – 4.8

HGB 12.3 (M) 13.0 – 17.0; (F) 12.0 – 15.0

HCT 40.2 (M) 40 – 50; (F) 36 - 46

MCV 83.5 83 – 99 FL

MCH 28.1 27.0 – 32.0 PG

MCHC 32.2 31.5 – 34.5 G/DL

Platelet 409 150 - 400

MPV 8.6 6.5 – 11.0 um3

Lymphocytes % 28.3 20 – 40

MXO % 8.3 2 – 10

Neutrophiles % 72.3 40 – 80

Lymphocytes # 1.5 1–3

MXO # 0.6 0.2 – 1

Neutrophiles # 5.6 2.5

 METHOD
Medication:
 Iberet 500mg daily once a day for 1 week
 Antamin 1cc IM 0 min prior to BR
 Hemostan 500mg capsule 3 times a day on her 1 st 3 days of menstruation
 Iron Follic as iron supplement
 
Exercise:
 Relaxation Technique
Treatment:
 Take medicine such as multivitamins to restore energy & ferrous sulfate as iron supplement
Health Teaching:
 Advise patient to increase dietary intake of iron such as meat, green leafy vegetable.
OPD:
 The patient will be back for follow up check-up on August 8, 2009 around 10:30AM at
CLDH San Vicente.
Diet as Tolerated:
 Instruct the patient to eat nutritious foods rich in iron, meat & green leafy vegetables
Social Activity:
 Encourage to socialize with friends and significant to others.
 PHYSICAL EXAMINATION FINDINGS

PHYSICAL EXAMINATION
Observed the client over all

BODY PARTS METHOD USED ACTUAL FINDINGS NORMAL FINDINGS

Hygiene and grooming Inspection Tidy Clean and neat

Note for body odor Inspection No body odor No body odor

Note obvious signs of health Inspection Slightly Weak Healthy appearance

illness

Mental Status

BODY PARTS METHOD USED ACTUAL FINDINGS NORMAL FINDINGS

Assess the client’s altitude Inspection Cooperative Cooperative

Listen for quantity & quality Inspection Understandable moderate Understandable moderate

of speech pace pace

 Skin

BODY PARTS METHOD USED ACTUAL FINDINGS NORMAL FINDINGS

Light to deep brown; from

Color Inspection Brown skin
pink to light pink; from
yellow overtones to olive

Lesion Inspection Absence of lesions No abrasions and/or lesions

Moisture Inspection/palpation Moisture in skin folds & axillae Moisture in skin folds and axillae

Temperature Palpation Normal or within normal range Uniform, within normal range

Turgor Palpation Normal skin turgor When pinched, skin returns to

previous state

Hair

BODY PARTS METHOD USED ACTUAL FINDINGS NORMAL FINDINGS

Distribution Inspection/Palpation Evenly distributed hair Evenly distributed hair

Texture Inspection/Palpation Smooth, thin Smooth, thin

Lice Inspection/Palpation Absent Absent of capitis, pubis &

corporis

Color Inspection Black hair Depends upon the age and race
 Nails

BODY PARTS METHOD USED ACTUAL FINDINGS NORMAL FINDINGS

Curvature & Angle Inspection Convex curvature Convex shape, about 160 degress

Bed color Inspection Pale in color Highly vascular & pink

Capillary refill Palpation Normal Prompt return of usual

Head

BODY PARTS METHOD USED ACTUAL FINDINGS NORMAL FINDINGS

Skull size, shape & symmetry Inspection/Palpation Round shape, normal size Rounded, smooth skull contour

Masses & Depressions Palpation No deformities, no presence of Smooth, uniform consistency,

mass/lesions absence of nodule masses

Facial features Inspection Slightly symmetric Symmetric/Slightly symmetric

Facial movement Inspection Symmetric facial movement Symmetric

 Eyes
BODY PARTS METHOD USED ACTUAL FINDINGS NORMAL FINDINGS

Eyebrows Inspection Symmetric & aligned, hair evenly Hair evenly distributed, skin

distributed intact eyebrows symmetrically

aligned, equal movements

Eyelids surface & characteristics Inspection Pale Skin intact, no discharge, no

decolonization

Ears
BODY PARTS METHOD USED ACTUAL FINDINGS NORMAL FINDINGS

Hearing Percussion Sound is heard on both ears Sound is heard on both ears

Nose

BODY PARTS METHOD USED ACTUAL FINDINGS NORMAL FINDINGS

Shape, size Inspection Symmetric Symmetric and straight

Color Inspection Same as facial skin Same as facial skin

Flaring and discharge Inspection Each nostril is patent No Discharge or flaring

Texture Palpation Not tender No tenderness

 Mouth

BODY PARTS METHOD USED ACTUAL FINDINGS NORMAL FINDINGS

Lips Inspection Asymmetrical Asymmetry of contour

Color Inspection Pallor Uniform pink color, darker

Texture Palpation Soft, dry Soft, moist, smooth in texture

Tongue Inspection Moves freely Moves freely

Neck

BODY PARTS METHOD USED ACTUAL FINDINGS NORMAL FINDINGS

Muscle Palpation Muscle equal inside, head Muscle equal inside, head

centered centered

Movement Inspection Slightly weak movement Coordinated, smooth movement,

with no discomfort

Thorax
BODY PARTS METHOD USED ACTUAL FINDINGS NORMAL FINDINGS

Shape Inspection/Palpation Chest Symmetric Chest Symmetric

Breath sounds Auscultation Broncho-vesicular breath sounds Vesicular and bronchovesicular

breath sounds
 Abdomen

BODY PARTS METHOD USED ACTUAL FINDINGS NORMAL FINDINGS

Skin integrity Inspection With stretch marks & linea negra Umblemished skin, uniform in

where evident color

Contour and symmetry Inspection & Palpation Flat Abdoment Flat, rounded or scaphoid

Bowel sounds Auscultation Normal bowel sounds Normal bowel sounds

Texture Palpation No tenderness No tenderness

Musculoskeletal System
Muscle
BODY PARTS METHOD USED ACTUAL FINDINGS NORMAL FINDINGS

Size Inspection Equal on both sides of the body Equal on both sides of the body

Strength Inspection Equal on both sides Equal on both sides

Lower Extremities

BODY PARTS METHOD USED ACTUAL FINDINGS NORMAL FINDINGS

Legs, size, shape, and presence of Inspection No Presence of rashes, Symmetrical in size and shape

lesion symmetrical in size shape

 Vital Signs

Temperature Inspection 36.5° C 36.5° C – 37.5°C

Pulse Rate Palpation 78 beats/minute 60-100 beats/minute

Respiratory Rate Inspection 20 beats/minute 16-20 beats/minute

Blood Pressure Auscultation 90/60 mmHg 120/80 mmHg

 COURSE IN THE WARD DOCTOR’S ORDER

August 1, 2009
The patient was admitted to Dr. M J L. The patient was ordered to secure consent prior to blood transfusion & also the doctor
ordered complete blood count & urine analysis

August 2, 2009
The doctor ordered blood transfusion and CBC should be repeat 6 hours after blood transfusion and the doctor also ordered a
diet as tolerated.

August 3, 2009
The doctor ordered MGH if stable and IBERET 500mg once a day after dinner.
 Evaluation
Gain knowledge about the disease process, performed and obtained thorough and complete
physical assessment. Planned the appropriate nursing interventions to let the patient meet her
needs.

Recommendation

We advised patient to increase dietary intake of iron together with the advised Iron capsule
supplements. To have adequate sleep & to monitor the amount of blood loss during
menstruation by counting the sanitary napkin used in a day.
THANK YOU