Nursing case presentation Nursing case presentation

On On
BLOOD BLOOD Dyscrasia Dyscrasia
Submi t t ed t o: Submi t t ed t o:
Ms. Dawn J ani ce A. Ti empo, N, Bsn Ms. Dawn J ani ce A. Ti empo, N, Bsn
Submi t t ed by: Submi t t ed by:
!r i st i ne Mar i e ". Bu#ui r an !r i st i ne Mar i e ". Bu#ui r an
$ %an J ason M. DeLos Sant os $ %an J ason M. DeLos Sant os
Submi t t ed on: Submi t t ed on:
Marc& ', ())* Marc& ', ())*
+
Application letter
Col l ege of Nur si ng
Si l l i man Uni ver si t y
Dumaguet e Ci t y
Negr os Or i ent al
Mar ch 5, 200
Ms! Da"n # ani ce A! $i empo, %N, &SN
Cl i ni cal ' nst r uct or
Col l ege of Nur si ng
Si l l i man Uni ver si t y
Dear Ma( am)
*oo+ Day, , ,
-e, .r i st i ne Mar i e *! &u/ui r an an+ ' van # ason M! De 0os Sant os, l evel ' ' ' st u+ent s of
SUCN ar e hopi ng f or your appr oval f or a case st u+y a1out our cl i ent , # ohn Car l o Mahi nay
Aust i no "ho i s 22 +ays ol +, a r esi +ent of &ar angay .al uy3 ahan &ai s, Negr os Or i ent al "ho
has a+mi t t e+ at NO45 l ast 6e1r uar y 2, 200 an+ "as +i agnose+ "i t h &l oo+ Dyscr asi a!
-e "oul + l i 7e t o t a7e t hi s oppor t uni t y t o pr esent t hi s case 1ecause "e 1el i eve t hat
shar i ng our e8per i ences t o our cl assmat es an+ al so t o ot her s "ho "ant t o 7no" an+ l ear n
a1out t hi s case! $hi s ai +s us i n our l ear ni ng an+ f ur t her enhances not onl y our 7no"l e+ge
an+ s7i l l s 1ut at t i t u+e as "el l !
$han7 you f or your 7i n+ consi +er at i on!
%espect f ul l y your s,
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9
(
.r i st i ne Mar i e *! &u/ui r an ' van # ason M! De 0os Sant os
Tab,e o- .ontents
.o%er page +
Let t er (
Tab, e o- c ont ent s /
0i s i on1 mi s s i on o- Si , , i man 2ni %er s i t y 3
Ob4 ec t i %es o- t &e .as e 5r es ent at i on 67 '
$ nt r oduc t i on 8
Demogr ap&i c Dat a *7 9
"enogr am +)
5&ys i c a, as s es s ment ++7 +9
"r owt & and de%e, opment ()7 ((
O%er %i ew o- medi c a, di agnos i s (/7 (3
Anat omy and p&ys i o, ogy (67 /6
5at &opy&s i o, ogy /'7 /8
Medi c at i ons /*7 /9
:unc t i ona, &ea, t & pat t er n 3)7 3'
Nur s i ng .ar e p, an 387 6)
Summar y o- nur s i ng di agnos i s 6+
SyNT;<S$ S 6(
Ac =now, edgement 6/
Bi b, i ogr ap&y 63
Annot at ed r eadi ngs 667 ')
/
CO00:*: O6 NU%S'N*
Silliman University
Dumaguete City
;' S' ON< M' SS' ON S$A$:M:N$
0$S$ON:
As a ,eading .&ristian institution o- ,earning in Asia, Si,,iman 2ni%ersity is committed to tota, &uman de%e,opment -or societa,
and en%ironmenta, we,,7being.
M$SS$ON:
$n t&is regard, t&e 2ni%ersity
5ro%ides opportunities -or a,, members o- t&e academic community to see= t&e trut&, 4ustice, and ,o%e.
5ursues e>ce,,ence in e%ery dimension o- in#uiry, ,earning, and teac&ing.
$nsti,,s in a,, members o- t&e uni%ersity community inc,uding a,, its integra, units an en,ig&tened socia, consciousness, a
pro-ound sense o- in%o,%ement, and a genuine compassion -or e%ery person.
<n&ances nationa, de%e,opment and unity by ma=ing its ,i-e and programs re,e%ant to t&e tota, en%ironment.
3
4l acement ) N.M +)(, Le%e, $ $ $
$i me al l ot ment ) + &our
$opi c) B, ood Dys c r as i a
$opi c Descr i pt i on) T&i s + &our c as e pr es ent at i on dea, s wi t & t &e car e o- pat i ent s wi t & b, ood
abnor ma, i t i es under 5edi at r i c ?ar d. T&i s s t udy i nc , udes t &e gr owt & and
de%e, opment o- t &e pat i ent , anat omy and p&ys i o, ogy o- t &e s ys t ems i n%o, %e,
pat &op&ys i o, ogy, t &e pr o@ , e o- t &e pat i ent , - unc t i ona, &ea, t & pat t er n, p&ys i c a,
as s es s ment , nur s i ng car e p, ans , , abor at or y and di agnos t i c t es t and medi c at i ons .
Cent r al O1= ect i ves) At t &e end o- our + &our cas e pr es ent at i on, t &e , ear ner s s &a, , ac #ui r e
=now, edge on c onc ept s r e, at ed t o pat i ent s wi t & b, ood dys c r as i a, de%e, op s =i , , s
and mani - es t des i r ab, e at t i t udes i n pr o%i di ng car e t o pat i ent s , - ami , y and
s i gni @ c ant ot &er s .
Speci > c O1= ect i ves) ?e, t &e pr es ent er s o- t &i s c as e s t udy &a%e t &e - o, , owi ng ob4 ec t i %es :
+. <>p, ai n t &e gr owt & and de%e, opment o- t &e c &i , d
(. Di s c us s t &e anat omy and p&ys i o, ogy o- t &e or gans i n%o, %ed i n c ar i ng
pat i ent s wi t & b, ood dys c r as i a
/. <n&anc e our =now, edge on t &e di A er ent c onc ept s r e, at ed t o t &e car e o-
pat i ent s wi t & b, ood dys c r as i a
3. Ac #ui r e mor e r eadi ngs and s our c es - or added i n- or mat i on and as an
en&anc ement - or our s e, %es and ot &er s
6. :or mu, at e c ompr e&ens i %e nur s i ng c ar e p, ans bas ed on t &e i dent i @ ed nur s i ng
pr ob, em i n r e, at i on t o c &i , d and - ami , y
'. .r i t i c a, , y ana, yB e t &e need - or t a=i ng medi c at i ons wi t & r egar ds t o t &e
c &i , dC s c ondi t i on
8. Mani - es t pos i t i %e at t i t udes w&en car i ng - or a c &i , d e>per i enc i ng
i , , nes s 1 di s or der s dur i ng &os pi t a, i B at i on
6
At t &e end o- t &e cas e pr es ent at i on, our - e, , ow , ear ner s s &a, , :
+. De@ ne t &e i mpor t ant t er ms us ed i n t &e pr es ent at i on us i ng t &ei r own wor ds
(. :or mu, at e nur s i ng di agnos i s wi t & t &e gi %en c ues and e%i denc es - or a c &i , d
e>per i enc i ng i , , nes s 1 di s or der s dur i ng &os pi t a, i B at i on
/. $ dent i - y a, t er nat i %e t &er api es t &at c an be us ed t o pr omot e t &e c om- or t o- t &e
c &i , d dur i ng &os pi t a, i B at i on
3. 0er ba, i B ed under s t andi ng o- t &e par ent s and t &e c &i , d
'
$NTOD2.T$ON
T&e 4 oy ous - ee, i ng o- &a% i ng a baby i s an i r r ep, ac eab, e moment o- our , i % es . T&e t i me we @ r s t
s ee, - ee, and c udd, e t &em ma=es our &ear t gr ow - onder. Somet i mes , we ar e t oo o% er w&e, med o- i t
t &at we t end t o - or get our bas i c r es pons i bi , i t i es - or our baby. ?e c annot deny s ome - ac t s o- , i - e t &at
t &er e ar e a , ot o- c ont r i but i ng - ac t or s w&i c & &i nder s t o our c ar e. Des pi t e
t &es e t &i ngs , we s t i , , do any t &i ng t &at we c an, i n or der - or t &e ent i r e
- ami , y t o mai nt ai n an opt i mum , e%e, o- we, , nes s . T&r oug& , i - eC s c &a, , enges ,
we i ns t i , &ope and c ar e no mat t er w&at i t t a=es . A wonder - u, s ac r i @ c e i s an
une> p, ai nab, e deed i n w&i c & i t i s t &e r eas on t &at a c , us t er o- peop, e c an be
c a, , ed a - ami , y. 2nc ondi t i ona, , o% e bi nds us t o one pat & and ens ur es us o- a
b, i s s - u, , i - e.
$ n our r ot at i on, we ar e - ac ed wi t & a c &a, , enge i n w&i c &, we ar e oug&t
t o t a=e c ar e o- a pat i ent t &at needs muc & o- our c ar e. A +( day o, d baby
named, J o&n .ar , o M. Agus t i no, w&o , i % es at !a, oy7 a&an, Bai s , Negr os
Or i ent a, , and &as been di agnos ed t o &a% e b, ood dy s c r as i a. ?e wou, d , i =e t o
s &ar e our e> per i enc e and = now, edge r egar di ng Baby J o&nC s c ondi t i on. $ n t &i s c as e boo= , we &ope
t &at y ou wi , , under s t and and gai n = now, edge t owar ds t a= i ng c ar e o- a newbor n wi t & b, ood dy s c r as i a.
?e ar e s o gr at e- u, t o be gi %en t &e c &anc e o- s &ar i ng a c omp, e> &ea, t & c ondi t i on, i n w&i c & we
, ear ned a , ot - r om i t and &ope y ou wi , , , ear n a, s o as muc & as we &a% e per c ei % ed i t . Today , we &ope
t &at y ou wi , , - oc us y our at t ent i on t o t &e c as e pr es ent ed and open y our mi nds - or anot &er c &apt er o-
8
, ear ni ng. A mi , es t one o- e> per t i s e t o a di agnos i s and a c ompas s i onat e &ear t t o e> t end #ua, i t y c ar e,
w&ene% er wer e - ac ed wi t & a s t r es s - u, s i t uat i on.
Name) J o&n .ar , o Ma&i nay Agus t i no Age) +( days o, d Ci vi l St at us) Newbor n
Se8) Ma, e %el i gi on) .at &o, i c Nat i onal i t y) :i , i pi no
A++r ess) Bar angay !a, uy7 a&an, Bai s Neg. Or Case no! )
&i r t h +at e) Apr i , (), ())8 $i me an+ Dat e of A+mi ssi on) :ebr uar y (, ())* D +(: 3) pm
Mot her ) 0i c t or i a Agus t i no Occupat i on) ;ous ewi - e
6at her ) andy Agus t i no Occupat i on: :ar mer
Doct or i n char ge) Dr. A, - ec &e
Chi ef Compl ai nt s : Not ed s udden ons et o- pr o- us e b, eedi ng i n t &e umbi , i c a, c or d
5i st or y of 4r esent ' l l ness)
Two days pr i or t o admi s s i on, i t C s mot &er not ed s udden ons et o- pr o- us e b, eedi ng i n t &e
umbi , i c a, c or d.
*ener al ' mpr essi on of t he cl i ent )
ec ei %ed i n s upi ne pos i t i on, r es t , es s and pa, e wi t & D6. / Na., 6))c c D r i g&t met acar pa, %ei n
r egu, at ed D +3 m, 1 &r.
5ast Medica, ;istory:
Client is 12 days old and he belongs to the infancy period. As verbalized by mother, client is in good health in the past days.
Client has not hospitalized since home delivery and is not allergic to food, drugs and plants. Client is not also prone to accident
since family is always at his side and takes good care of him always. Wounds easily heal and does not bleed profusely. As
verbalized by mother, client has not yet immunized since delivery.
*
Demographic Data
C5' 0D5OOD ' MMUN' ?A$' ON)
;ACC'N:
M' N' MUM
A*: A$
6' %S$
DOS:
NUM&:
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NON<
O50 ' wee=s / NON<
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NON<
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M<ASL<
S
9 mont &s
o, d
+
NON<
6amily 5istory
ami l y and r el at i ves ar e i n good heal t h. As ver bal i z ed by mot her , t hey don! t have any her edo"
f ami l i al di s eas es . #hey do not s moke nor dr i nk al c ohol i c bever ages ar ound c hi l dr en.
4sychosoci al 5i st or y
As %er ba, i B ed by mot &er , t &ey &a%e good r e, at i ons &i p wi t & t &e e>t ended - ami , y. T&ey , i %e
nor ma, , y as w&at t &ey &ad w&en t &ey &a%e t &ei r @ r s t c &i , d. ., i ent i s a good s on. Mot &er a, s o
%er ba, i B ed t &at t &ei r - ami , y i s r e, i gi ous and a, ways go t o c &ur c & e%er y Sunday. ., i ent i s s t r ong,
&ea, t &y and &appy. T&ey ne%er b, ame "od and - ami , y - or e%er y pr ob, em t &ey enc ount er ed.
9
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45@S'CA0 ASS:SSM:N$
5;ES$ .AL <FAM$ NAT$ ON:
*ener al Sur vey)
S t a t e o f Awa r e n e s s : Al e r t a n d c o h e r e n t
Ob v i o u s S i g ns o f Di s t r e s s : n o s i g n s o f d i s t r e s s n o t e d
Ga i t : Co o r di n a t e d
Po s t u r e : Go o d p o s t u r e
Bo d y Mo v e me n t s : c a n n o t ma i n t a i n a g o o d e y e c o n t a c t d u r i n g t h e c o n v e r s a t i o n
Hy g i e n e : Ap p e a r s c l e a n b u t b o d y o d o r n o t e d
S p e e c h : L e a r n s t o s p e a k ma ma a n d p a p a
Mo o d : Al wa y s c r y i n g
;i t al Si gns)
emp e r a t u r e : 3 7 . 4 C a ! i l l a
Pu ! s e "a t e " # $ % b p m& r e g u l a r ' s t r on g
"e s p i r a t o r y "a t e : ( ) c p m& r e g u l a r& s i l e n t a n d e f f o r t l e s s
5&ys i c a, As s es s ment by Body Sys t em:
A. S=i n:
.o, or : pa, e i n c o, or a, , o%er t &e body
G H 0er ni > .as eos a
G H Lanugo
<dema: G H ar ound eyes G H - ace G H , egs
G H dur s a o- &ands G H - eet
G H s c r ot um or , abi a
G H Ac r oc yanos i s
G H .ut i s mar mor at a
G H Mi , i a
+(
G H Mi , ar i a or s udami na
G H <r yt &ema t o>i c um
G H ;ar , e#ui n s i gn
G H Mongo, i an Spot s
G H Te, angi ec t at i c ne%i G I s t or = bi t es J H
B. ;ead:
:ont ane, :
G H Ant er i or
G H 5os t er i or
G H Bu, gi ng - ont ane, s becaus e o- c r yi ng
G H Mo, di ng
G H ound
G H .aput s uc c edaneum
G H .ep&a, &emat oma
.. <yes :
.o, or : B, ac =
G H Abs enc e o- t ear s G H Symmet r i c a,
G H .or nea, r eK e> i n r es pons e t o t ouc &
G H 5upi , , ar y r eK e> i n r es pons e t o , i g&t
G H B, i n= r eK e> i n r es pons e t o , i g&t or t ouc &
G H udi ment ar y @ >at i on on ob4 ec t s
G H Abi , i t y t o - o, , ow t o mi d, i ne
G H Sub4 unc t i ona, G Sc , er a, H &emor r &ages
G H <pi c ant &a, - o, ds G Or i ent a, i n- ant s H
D. <ar s :
5os i t i on: G H Top o- pi nna on &or i B ont a, , i ne wi t & out er c ant &us o- eye
G H S&ape: we, , 7 - or med
G H Symmet r i c a,
G H St ar t , e r eK e> e, i c i t ed by a , oud, s udden noi s e
G H 5i nna K e>i b, e G H .ar t i , age pr es ent
G H $ r r egu, ar s &ape or s i B e
G H S=i n t ags
<. Nos e:
+/
G H Loc at i on at mi d, i ne
G H 5at ent G H Br eat &es eas i , y wi t & mout & c , os ed
G H :, at t ened G H Li t t , e nas a, br i dge
G H Br ui s ed
G H Di s c &ar ges G s pec i - yH
:. Mout & and T&r oat
G H 0i gor ous gag r eK e>
G H Abs ent or mi ni ma, s a, i %at i on
G H $ nt ac t , &i g&7 ar c &ed pa, at e
G H 2%u, a i n mi d, i ne
G H :r enu, um o- t ongue
G H :r enum o- upper , i p
G H Tongue not pr ot r udi ng
G H Suc =i ng r eK e> L s t r ong and c oor di nat ed
G H oot i ng r eK e> G H Swa, , owi ng eK e>
G H <>t r us i on r eK e>
G H Nat a, t eet &
G H <i ps t ei n pear , s
G H ., e- t , i p G H ., e- t pa, at e
G H 5r o- us e s a, i %at i on or dr oo, i ng
G H .andi das i s G t &r us &H
G H Abnor ma, c r y G c &ar ac t er i B eH
". Nec=:
G H S&or t , t &i c =, us ua, , y s ur r ounded by s =i n - o, ds
G H Mo%es - r ee, y - r om s i de t o s i de
G H Toni c 7 nec = r eK e>
G H Tor t i c o, , i s G H ?ebbi ng
G H Mas s es G H Di s t ended %ei ns
;. .&es t :
S&ape: G H A, mos t c i r c u, ar G ant epos t er i or and , at er a, di amet er s e#ua, H
G H Symmet r i c a, mo%ement s wi t & r es pi r at i on
G H S, i g&t s t er na, r et r ac t i ons e%i dent dur i ng i ns pi r at i on
G H Fi p&oi d pr oc es s e%i dent
+3
G H Br eas t en, ar gement
G H es pi r at i ons abdomi na,
G H Abnor ma, c &es t mo%ement s wi t & r es pi r at i ons G des c r i beH
G H Abnor ma, s &ape G des c r i beH
G H Super numer ar y o- ni pp, es
G H Sec r et i on o- Iwi t c & mi , =J
G H As ymmet r i c c &es t e>pans i on
$ . Lungs :
Br eat & s ounds : Abs enc e o- br eat & s ounds s uc & as r a, es , w&eeB i ng and c r ac =, es .
at e: Nor ma,
Dept &: Nor ma,
G H Abnor ma, br eat & s ounds G des c r i beH
J . Abdomen:
S&ape: G H ounded G .y, i ndr i c H and pr omi nent
G H Ot &er s : Des c r i be
G H .or d s t ump dr y, not - ou, s me, , i ng G H 2mbi , i c a, &er ni a
G H Bi , at er a, - emor a, pu, s es G H ?&ar t onC s 4 e, , y
G H Di as t as i s r ec t i
!. "eni t a, i a:
G H Labi a and c , i t or i s edemat ous
Labi aC s appear , ar ge
G H 2r et &r a, meat us be&i nd c , i t or i s
G H Muc o, d di s c &ar ges bet ween , abi a
G H 2r i nat i on wi t &i n (3 &our s
G H 5s uedomens t r uat i on
G H ;ymena, t ag
Ma, e "eni t a, i a:
G H 2r et &r a, openi ng at t i p o- g, ans peni s
G H Abnor ma, ur et &r a, openi ng G des c r i beH
G H Tes t es pa, pab, e i n eac & s c r ot um
G H Sc r ot um us ua, , y , ar ge, edemat ous , pendu, ous , G H c o%er ed wi t & r ugae
G H 5i gment ed
G H Smegma
+6
G H 2r i nat es wi t &i n (3 &our s
G H Ti g&t pr epuc eM i nabi , i t y t o r et r ac t pr epuc e
G H <r ec t i on or pr i api s m
G H Tes t es pa, pab, e i n i ngui na, cana,
G H Sc r ot um s ma, ,
L. Bac =:
G H Spi ne s t r ai g&t
G H Spi ne i nt ac t , no openi ngs , mas s es , or pr omi nent c ur %es
G H Tr un= i nc ur %at i on r eK e>
G H S&ou, der s , s c apu, ae, i , i ac c r es t s ar e on s ame p, ane wi t & ot &er
M. ec t um:
G H 5at ent ana, openi ng G t emper at ur e can be t a=en r ec t a, , y or &as pas s ed out mec oni umH
G H 5as s age o- mec oni um wi t &i n 3* &our s
G H De, ayed
G H Ana, r eK e>
G H 5r es enc e o- @ s s ur es or b, eedi ng
N. <>t r emi t i es :
G H Ten @ nger s and t oes
G H :u, , r ange o- mot i on
G H Nai , beds pi n=, wi t & t r ans i ent c yanos i s a- t er bi r t &
G H .r eas es i n ant er i or t wo7 t &i r ds o- s o, e
G H So, e us ua, , y K at
G H <#ua, mus c , e t one bi , at er a, , y, es pec i a, , y r es i s t ant t o oppos i ng K e>i on
G H <#ua, bi , at er a, peda, pu, s es
Obs er %e - or : G Des c r i beH
G H "r os s abnor ma, i t i es , G i . e. , , i mi t at i on o- mo%ement s , - r ac t ur es , par a, ys i s H
G H Di s , oc at ed &i ps
G H ?ebbed di gi t s
G Syndac t y, yH or e>t r a di gi t s
G 5o, ydac t y, yH
G H Si B e and s &ape o- &ands and - eet
G H Abs ent OM G H 2ne#ua, mus c , e t one or OM
G H ?i de gap bet ween @ r s t and s ec ond t oes
+'
G H As ymmet r y o- e>t r emi t i es
G H Abs enc e o- di s t a, par t o- e>t r emi t y G ;emi H M
G H ;ands and - eet at t ac &ed c , os e t o t r un=
G H So, e c o%er ed wi t & c r eas es
G H Tr ans %er s e pa, mar G Si mi anH c r eas e
G H Abnor ma, c o, or o- nai , beds
Neur o, ogi c a, eK e>es :
5r es ent Abs ent S, uggi s & ;yper ac t i %e
+. oot i ng
(. Suc =i ng
/. Swa, , owi ng
3. <>t r us i on
6. B, i n=i ng1 .or nea, eK e>
'. 5upi , , ar y r eK e>
8. Tr un= $ nc ubat i on
*. 5a, mar "r as p
9. 5, ant ar "r as p
+). Mor o
++. Toni c 7 Nec=
+(. Danc e or St ep
+/. 5, ac i ng
$ NT<"2M<NTAE SEST<M
' ! 5eal t h 5i st or y
+8
*o t h e r v e r b a l i + e d t h a t t h e b a b y h a d n o t t a k e n a b a t h s i n c e d e l i v e r y o r f o r # , d a y s a l r e a d y . Cl i e n t i s
we l l - g r oo me d . Cl i e n t i s n o t a l l e r gi c t o f o o d s & d r u g s a n d p l a n t s . .er b a l i + e d b y mo t h e r& wo u n d e a s i l y h e a l s
a n d d o e s n o t b l e e d p r of u s e l y f o r t h e f i r s t # % d a y s . Cl i e n t h a d n o t u n d e r go n e a n y s u r ge r y i n v o l v i n g t h e
i n t e g u me n t .
' ' ! 4hysi cal :8ami nat i on
A! S7i n
/ h e c o l o r i s p a l e a n d t h e s a me wi t h t h e s u r r ou n d i n g s k i n . / h e r e i s n o p e r s p i r a t i o n n o t e d a t t h e f o r e h e a d &
n e c k a n d a ! i l l a r y a r e a s . 0 k i n i s c o l d t o t o u c h a n d t e mp e r a t u r e e 1 u a l b i l a t e r a l l y . 2 t i s s mo o t h a n d l o v e l y t o
t o u c h . 0 k i n t u r go r i s g o o d & i t l i f t s e a s i l y a n d s n a p s b a c k i mme d i a t e l y t o i t s n o r ma l p o s i t i o n . / h e r e a r e n o
b i r t h ma r k s o r f r e c k l e s p r e s e n t . / h e r e i s n o i n f l a mma t i o n s i n c e t h e r e i s a b s e n c e o f r a s h e s a n d l e s i o n s . / h e r e i s
n o e d e ma n o t e d o n t h e i n t e g u me n t .
&! Nai l s
3a i l s a r e s h o r t a n d c l e a n . 3a i l s a r e u n i f o r m i n t h i c k n e s s . 3a i l b e d s a r e p i n k i s h i n c o l o r wi t h t r a n s l u c e n t
wh i t e t i p s . 2 t i s we l l r ou n d e d wi t h a c o n v e ! c u r v e a b o u t # ( % 4 . L a n u l a i s c o l o r e d wh i t e . Ca p i l l a r y r e f i l l i s ,
s e c o n d s . / h e r e a r e n o l e s i o n s a n d i n f l a mma t i o n n o t e d .
C! 5ai r
5a i r i s c o l o r e d b l a c k a n d s o f t wi t h t h i n s t r a n d s . 5a i r i s e v e n l y d i s t r i b u t e d a n d i s a p p r op r i a t e f o r t h e f a c e .
/ h e r e i s a b s e n c e o f n i t s & d a n d r u f f s a n d s c a l i n e s s . 5a i r i s a l s o s mo o t h a n d p l i a n t .
ABDOM<N
+*
'! 5ealth 5istory
*o t h e r v e r b a l i + e d t h a t s h e b r e a s t f e d s t h e b a b y 6v e r y t i me h e c r i e s wi t h # - , o u n c e s o f mi l k . Cl i e n t s u c k s
we l l . Cl i e n t h a s n e v e r e ! p e r i e n c e d a n y o p e r a t i o n s u r ge r y i n v o l v i n g t h e a b d o me n . 0 h e wa s d i a g n o s e d f o r
b l o o d d y s c r a s i a s wi t h p r of u s e b l e e d i n g a t t h e c o r d s t u mp . 7el l o w wa t e r y s t o o l s a r e p a s s e d a t l e a s t o n c e o r
t wi c e a d a y . Co r d s t u mp wa s n o t c l e a n e d s i n c e d e l i v e r y p r i o r t o a d mi s s i o n .
''! 4hysical :8amination
A! 'nspection
Ab d o me n h a s 4 1 u a d r a n t s " r i g h t u p p e r 1 u a d r a n t & l e f t u p p e r 1 u a d r a n t & l e f t l o we r 1 u a d r a n t a n d r i g h t l o we r
1 u a d r a n t . 2 t a l s o c o mp r i s e s o f 8 r e g i o n s " r i g h t a n d l e f t h y p o c h o n d r i a c r e g i o n & u mb i l i c a l r e g i o n & r i g h t a n d l e f t
l u mb a r r e g i o n & h y p o g a s t r i c r e g i o n a n d r i g h t a n d l e f t i l i a c r e g i o n . Ab d o me n h a s f l a wl e s s s k i n a n d h a s t h e s a me
c o l o r wi t h t h e s u r r ou n d i n g s k i n . 2 t i s s mo o t h a n d s y mme t r i c a l . Co n t o u r o f t h e a b d o me n i s s l i g h t l y r ou n d e d a n d
d i s t e n d e d . / h e r e i s n o s p l e e n o r l i v e r e n l a r ge me n t n o t e d . 9e r i s t a l s i s a n d p u l s a t i o n s a r e n o t v i s i b l e . :mb i l i c u s
i s s l i g h t l y p r ot r u d i n g s l i g h t l y mo i s t wi t h l e s i o n . 2 t wa s c l e a n e d a n d d r e s s e d u p o n a d mi s s i o n . / h e r e a r e n o
s c a r s & s t r i a e & r a s h e s a n d r a s h e s n o t e d d u r i n g e ! a mi n a t i o n .
&! Auscultation
;o we l s o u n d s a r e a u d i b l e i n 4 1 u a d r a n t s . / h e r e a r e # $ - # ) b o we l s o u n d s h e a r d f o r o n e mi n u t e i n <L =.
C! 0i ght pal pat i on
Ab d o me n i s r e l a ! e d a n d h a s n o e n l a r ge d o r ga n s . 3o ma s s e s a n d t e n d e r n e s s n o t e d i n t h e a b d o me n d u r i n g
p a l p a t i o n o f t h e a b d o me n .
D! Deep pal pat i on
L i v e r p a l p a t i o n n o t d o n e d u e t o p a i n i n t h e a b d o me n a s v e r b a l i + e d b y mo t h e r a n d t h e c l i e n t i s a l s o c r y i n g
wh e n e v e r 2 t o u c h h i s a b d o me n a n d i n t e g u me n t . >u r i n g p a l p a t i o n & b l a d d e r i s n o t d i s t e n d e d a n d p a s s e d y e l l o w
s o f t s t o o l s t o g e t h e r wi t h y e l l o w c o l o r e d u r i n e .
:! 4er cussi on
/ymp a n y s o u n d s a r e h e a r d i n t h e 4 1 u a d r a n t s b u t d u l l s o me wh a t i n t h e l i v e r a r e a .
"<N$ TO7 2$ NAE SEST<M
+9
' ! 5eal t h 5i st or y
*o t h e r v e r b a l i + e d & c l i e n t c o u l d c o n s u me 3 - 4 d i a p e r s l i n e n s a d a y o r wh e n e v e r t h e b a b y ?s d i a p e r l i n e n i s
we t . Cl i e n t c a n p a s s s t o o l s o r d e f e c a t e s o n c e a d a y wi t h s o f t a n d y e l l o w s t o o l wi t h t h e e s t i ma t e d a mo u n t o f
, % % g r a ms wi t h o u t d i f f i c u l t y. Cl i e n t i s a l s o a b l e t o u r i n a t e wi t h y e l l o w c o l o r e d u r i n e wi t h t h e e s t i ma t e d
a mo u n t o f , 4 % ml wi t h o u t d i f f i c u l t y. Cl i e n t h a d n o t u n d e r go n e o p e r a t i o n s u r ge r y i n v o l v i n g g e n i t o u r i n a r y
s y s t e m. Cl i e n t d i d n ? t e ! p e r i e n c e a n y u r i n a r y t r a c t i n f e c t i o n a s v e r b a l i + e d b y mo t h e r.
' ' ! 4hysi cal :8ami nat i on
A! 4eni s
2 t i s s ma l l a n d h a s n o s i g n s o f s we l l i n g & s k i n l e s i o n s & i n f l a mma t i o n & o r o t h e r i r r e g u l a r i t i e s . / h e u r e t h r a l
me a t u s i s l o c a t e d a t t h e c e n t e r a n d t i p o f t h e g l a n s .
&! Scr ot um
2 t i s l a r ge i n r e l a t i o n t o t h e r e s t o f t h e g e n i t a l i a a n d h a n g s f r e e l y f r om t h e p e r i n e u m b e h i n d t h e p e n i s a n d
t h e l e f t s c r ot u m h a n g s l o we r t h a n t h e r i g h t . / h e s k i n i s l o o s e a n d s l i g h t l y wr i n k e d . 9r e s e n c e o f p h y mo s i s a n d
n o t c i r c u mc i s e d .
C! *r oi n
Co l o r o f t h e s k i n i s t h e s a me a s t h e s u r r ou n d i n g a r e a . Ab s e n c e o f s k i n l e s i o n s & s c a r s a n d n o d e s a r e n o t
p a l p a b l e .
D! %ect al
$l ut eal f ol ds ar e s ymmet r i c al and % r m. Abs enc e of r as hes , l es i ons and s c ar s . Anus i s
pr es ent bet ween t he gl ut eal f ol ds .
"O?T; AND D<0<LO5M<NT O: $N:AN.E
()
aA &i ol ogi c Devel opment
"r owt & L - as t es t at 67 ' doub, e bi r t & wei g&t
One year i t i s t r i p, ed.
Taper s oA i n (nd year G wi , , gai n 67 ' , bs . H
/r d year L 37 6 , bs .
;ei g&t L +)7 +( I by +s t yr. N /) i nc &es t a, ,
(nd year L up t o 6 I
( yr s . L / - t .
"r owt & oc c ur s i n s pur t s .
;ead bec omes pr opor t i onat e, y s ma, , er unt i , - u, , adu, t &ei g&t i s r eac &ed.
Bec omes , eaner
"enes di c t at e &ei g&t , bui , t but i nt er ac t s wi t & en%i r onment G Nut r i t i on, , i %i ng
en%i r onment - r eedom - r om di s eas es H
1A 4sychosoci al Devel opment
Tr us t %s . Mi s t r us t G bi r t & t o + year H
Tr us t i s t &e - or emos t i mpor t ant at t r i but e t o be de%e, oped - or a &ea, t &y per s ona, i t y.
Tr us t e>i s t s on, y i n r e, at i on t o s omet &i ng or s omeone.
es u, t s t o - ai t & and opt i mi s m.
5r i mar y Nar c i s s i s m i s at i t s &ei g&t .
T&e ne>t s oc i a, moda, i t y i n%o, %es a mode o- r eac &i ng out t o ot &er s t &r oug& gr as pi ng.
Dur i ng t &e s ec ond s t age t &e mor e ac t i %e and aggr es s i %e moda, i t y o- bi t i ng oc c ur s .
cA Cogni t i ve Devel opment
Sens or i mot or G bi r t &7 ( year s H
"o%er ned by s ens at i ons i n w&i c & s i mp, e , ear ni ng t a=es p, ac e.
(+
.&i , dr en pr ogr es s - r om r eK e> ac t i %i t y t &oug& s i mp, e, r epet i t i %e be&a%i or s t o
i mi t at i %e be&a%i or.
5r ob, em s o, %i ng i s t r i a, and er r or. T&ey di s p, ay a &i g& , e%e, o- c ur i os i t y,
e>per i ment at i on and en4 oyment .
T&r ee .r uc i a, <%ent s t a=e p, ac e dur i ng t &i s s t age:
Separ at i on 7 T&ey begi n t o de%e, op a s ens e o- s e, - as t &ey ar e ab, e t o di A er ent i at e
t &ems e, %es - r om t &e en%i r onment .
Ob4 ec t per manenc e 7 T&ey bec ome awar e t &at ob4 ec t s &a%e per manenc e L meani ng
t &e ob4 ec t s e>i s t e%en i - i t i s no , onger %i s i b, e.
Symbo, s or Ment a, epr es ent at i on L T&e us e o- s ymbo, s a, , ows t &e i n- ant t o t &i n= o-
an ob4 ec t or s i t uat i on wi t &out ac t ua, , y e>per i enc i ng i t .
St ages o- Sens or i mot or 5&as e
2s e o- r eK e>es L at bi r t & t &e i n- ant C s i ndi %i dua, i t y and t emper ament ar e e>pr es s ed
t &r oug& t &e p&ys i o, ogi c r eK e>es o- s uc =i ng, r oot i ng, gr as pi ng, and c r yi ng.
5r i mar y .i r c u, ar eac t i on L mar =s t &e begi nni ng o- t &e r ep, ac ement o- r eK e>i %e
be&a%i or wi t & %o, unt ar y ac t s . Ac t i %i t i es s uc & as s uc =i ng or gr as pi ng bec ome
de, i ber at e ac t s t &at e, i c i t c er t ai n r es pons es . T&e begi nni ng o- ac c ommodat i on i s
e%i dent .
Sec ondar y .i r c u, ar eac t i on L i n t &i s s t age t &e pr i mar y c i r c u, ar r eac t i ons ar e
r epeat ed and pr o, onged - or t &e r es pons e t &at r es u, t s . "r as pi ng and &o, di ng now
bec ome s &a=i ng, bangi ng, and pu, , i ng.
.oor di nat i on o- Sec ondar y Sc &emas and t &ei r App, i c at i on t o new s i t uat i ons L t &i s
s t age i s , ar ge, y t r ans i t i ona, . T&ey begi n t o di s c o%er t &at &i di ng an ob4 ec t does not
mean t &at i t i s gone but t &at r emo%i ng an obs t ac , e wi , , r e%ea, t &e ob4 ec t
+A Mor al Devel opment
T&e i n- ant per i od i s a pr e7 r e, i gi ous s t age.
$ t i s i mpor t ant t o pr ai s e an i n- ant - or doi ng w&at &e or s &e &as been as =ed t o do.
((
T&e de%e, opment o- t r us t i s i mpor t ant i n mor a, de%e, opment bec aus e i n- ant s w&o
de%e, op a s ound s ens e o- t r us t c an bet t er de%e, op a s pi r i t ua, or i ent at i on i n - ut ur e
year s or be bound by a mor a, c ons c i enc e.
eA Soci al Devel opment
At t ac &ment t o t &e par ent i s i nc r eas i ng, y e%i dent dur i ng t &e s ec ond &a, - o- t &e @ r s t
year.
5, ay i s a ma4 or s oc i a, i B i ng agent t &at pr o%i des s t i mu, at i on needed t o , ear n - r om and
i nt er ac t wi t & t &e en%i r onment .
eac t i %e at t ac &ment di s or der L i s a ps yc &o, ogi c and de%e, opment a, pr ob, em t &at
s t ems - r om ma, adapt i %e or abs ent at t ac &ment bet ween t &e i n- ant and t &e par ent and
may per s i s t i nt o c &i , d&ood e%en adu, t &ood.
Separ at i on an>i et y L t &e i n- ant begi ns t o &a%e s ome awar enes s o- s e, - and mot &er as
s epar at e bei ngs . T&er e- or e s epar at i on an>i et y de%e, ops and i s mani - es t ed t &r oug&
pr edi c t ab, e s e#uenc e o- be&a%i or s .
St r anger :ear L bec ome pr omi nent and ar e r e, at ed t o i n- ant s C abi , i t y t o di s c r i mi nat e
bet ween - ami , i ar and non7 - ami , i ar peop, e.
Type o- p, ay i s s o, i t ar y
O%<r0i<w O- B,OoD DyScaSiA
(/
;emo, yti c di sease o- t&e Newborn
T&e mos t c ommon caus e o- &emo, yt i c anemi a i n newbor ns i s
a, , i mmune di s eas e G ;DNH . ;DN can oc c ur on, y i - ant i gens on
- et a, er yt &r oc yt es di A er - r om ant i gens on mat er na,
er yt &r oc yt es . Mat er na, 7 - et a, i nc ompat i bi , i t y e>i s t s i - mot &er and
- et us di A er i n ABO b, ood t ype or i - t &e - et us i s &7 pos i t i %e and
t &e mot &er i s &7 negat i %e. Some mi nor b, ood ant i gens a, s o may
be i n%o, %ed.
ABO i nc ompat i bi , i t y oc c ur s i n about ()O7 (6P o- a, ,
pr egnanc i es , but on, y + i n +) c as es o- ABO r es u, t s i n ;DN. &
i nc ompat i bi , i t y oc c ur s i n - ewer t &an +)O o- pr egnanc i es and
r ar e, y caus es ;DN i n t &e @ r s t i nc ompat i b, e - et us . <%en a- t er
@ %e or mor e pr egnanc i es , on, y 6O o- women &a%e babi es wi t &
&emo, yt i c di s eas e. 2s ua, , y er yt &r oc yt es - r om t &e @ r s t
i nc ompat i b, e - et us caus e t &e mot &er C s i mmune s ys t em t o
pr oduc e ant i bodi es t &at aA ec t t &e - et us es o- s ubs e#uent
i nc ompat i b, e pr egnanc i es . On, y one i n t &r ee cas es o- ;DN i s
c aus ed by & i nc ompat i bi , i t y and mos t cas es ar e c aus ed by ABO i nc ompat i bi , i t y.
.L$ N$ .AL mani - est at i ons
Neonat es wi t & mi , d ;DN may appear &ea, t &y or s , i g&t , y pa, e, wi t &
s , i g&t en, ar gement o- t &e , i %er or s p, een. 5r onounc ed pa, , or ,
s p, enomega, y and &epat omega, y i ndi c at e s e%er e anemi a w&i c &
pr edi s pos es t &e neonat e t o c ar di o%as c u, ar - ai , ur e and s &oc =. Li - e7
t &r eat eni ng & i nc ompat i bi , i t y i s r ar e t oday, , ar ge, y becaus e o- t &e
r out i ne us e o- & i mmunog, obu, i n
Bec aus e t &e mat er na, ant i bodi es r emai n i n t &e neonat eC s
c i r c u, at or y s ys t em a- t er bi r t &, er yt &r oc yt e des t r uc t i on c an c ont i nue.
(3
T&i s caus es &yper bi , i r ubi nemi a and i c t er us neonat or um G neonat a, 4 aundi c eH s &or t , y a- t er bi r t &.
?i t &out r ep, ac ement t r ans - us i ons , i n w&i c & t &e c &i , d r ec ei %es & L negat i %e er yt &r oc yt es , t &e
bi , i r ubi n i s depos i t ed i n t &e br ai n, a c ondi t i on t er med =er ni c t er us . !er ni c t er us pr oduc es cer ebr a,
damage and us ua, , y caus es deat & G i c t er us gr a%i s neonat or umH . $ n- ant s w&o do not di e may &a%e
ment a, r et ar dat i on, c er ebr a, pa, s y or &i g& - r e#uenc y dea- nes s .
<%a, uat i on and t reat ment
out i ne e%a, uat i on o- - et us es at r i s = - or ;DN i nc , udes t &e .oombs t es t . T&e i ndi r ec t .oombs
t es t meas ur es ant i body i n t &e mot &er C s c i r c u, at i on and i ndi c at es w&et &er t &e - et us i s at r i s = - or
;DN. T&e di r ec t .oombs t es t meas ur es ant i body a, r eady bound t o t &e s ur - ac es o- - et a,
er yt &r oc yt es and i s us ed pr i mar i , y c on@ r m t &e di agnos i s o- ant i body medi at ed ;DN. ?i t & a pr i or
&i s t or y o- - et a, &emo, yt i c di s eas e, di agnos t i c t es t s ar e done t o det er mi ne r i s = wi t & t &e c ur r ent
pr egnanc y. T&es e t es t s i nc , ude mat er na, ant i body t i t er s , - et a, b, ood s amp, i ng, amni ot i c K ui d
s pec t r op&ot omet r y and u, t r as ound - et a, as s es s ment .
T&e =ey t o t r eat ment o- ;DN r es u, t i ng - r om & i nc ompat i bi , i t y , i es i n pr e%ent i on
G i mmunopr op&y, a>i s H . One o- t &e s uc c es s s t or i es o- i mmuno, ogy &as been t &e r es u, t s obt ai ned wi t &
& i mmune g, obu, i n G &o"AMH , a pr epar at i on o- ant i body agai ns t & ant i gen D. $ - an &7 negat i %e
woman i s gi %en & i mmune gobu, i n wi t &i n 8( &our s o- e>pos ur e t o &7 pos i t i %e er yt &r oc yt es , s &e
wi , , not pr oduc e ant i body agai ns t t &e D ant i gen and t &e ne>t &7 pos i t i %e baby s &e c onc ei %es wi , ,
be pr ot ec t ed.
$ - ant i geni c i nc ompat i bi , i t y o- t &e mot &er C s er yt &r oc yt es i s not di s c o%er ed i n t i me t o
admi ni s t er pr op&y, ac t i c i mmune g, obu, i n G &o"AMH and a c &i , d i s bor n wi t & ;DN, t r eat ment
c ons i s t s o- e>c &ange t r ans - us i ons i n w&i c & t &e neonat eC s b, ood i s r ep, ac ed wi t & new &7 pos t i %e
b, ood t &at i s not c ont ami nat ed wi t & ant i 7 & ant i bodi es . 5&ot ot &er apy a, s o i s us ed t o r educ e t &e
t o>i c eA ec t s o- unc on4 ugat ed bi , i r ubi n.
ANATOME AND 5;ES$OLO"E
(6
Organs o- t&e &emato,ogic Systems
;eMostasi s
Norma, &emostasis is a process t&at repairs %ascu,ar brea=s to reduce b,ood ,oss -rom b,ood %esse,s w&i,e maintaining t&e
Kow o- b,ood t&roug& t&e %ascu,ar system. ;emostasis occurs in / stages.
+. 0asoconstriction o- b,ood %esse,s
(. :ormation o- p,ate,et p,ug
/. .oagu,ation or -ormation o- a @brin c,ot.
Once t&e @brin c,ot &as ser%ed its purpose, -urt&er c,ot -ormation is ba,anced by anticoagu,ation and by @brino,ysis Gc,ot
disso,utionH.
T&e -ormation o- a @brin c,ot can resu,t -rom acti%ation o- one o- / pat&ways: intrinsic or e>trinsic. T&e e>trinsic pat&way is
initiated w&en tissue in4ury occurs outside t&e %esse,s suc& as burn. T&e intrinsic pat&way in%o,%es t&e b,ood itse,- or damage to
t&e b,ood %esse,s. B,ood in norma, %esse,s t&at is stagnant -or a ,ong period o- time can -orm c,ots.
$n some cases, -ormation o- a @brin c,ot is unnecessary because &emostasis occurs at an ear,y stage. Temporary c,ots are
sometimes insuQcient.
BLOOD
B,ood, %ita, Kuid -ound in &umans and ot&er anima,s t&at pro%ides important nouris&ment to a,, body organs and tissues and
carries away waste materia,s. Sometimes re-erred to as It&e ri%er o- ,i-e,J b,ood is pumped -rom t&e &eart t&roug& a networ= o-
b,ood %esse,s co,,ecti%e,y =nown as t&e circu,atory system. T&e ce,,u,ar component o- b,ood consists o- t&ree primary ce,, types:
:rythrocytes B%&CA, 0eu7ocytes B-&CA, an+ throm1ocytes BplateletsA. T&ese ce,,u,ar components o- b,ood norma,,y ma=e
up 3)O736O o- t&e b,ood %o,ume. Because most b,ood ce,,s &a%e a s&ort ,i-e span, t&e need -or t&e body to rep,enis& its supp,y o-
ce,,s is continuous and t&is process is termed 5ematopoiesis!
('
An adu,t &uman &as about 6 to ' ,iters G+ to ( ga,H o-
b,ood, w&ic& is roug&,y 8O to +)O o- tota, body weig&t. $n-ants
and c&i,dren &a%e comparab,y ,ower %o,umes o- b,ood, roug&,y
proportionate to t&eir sma,,er siBe. T&e %o,ume o- b,ood in an
indi%idua, Kuctuates. During de&ydration, -or e>amp,e w&i,e
running a marat&on, b,ood %o,ume decreases. B,ood %o,ume
increases in circumstances suc& as pregnancy, w&en t&e
mot&erCs b,ood needs to carry e>tra o>ygen and nutrients to t&e
baby. .ircu,ating t&roug& t&e %ascu,ar system and ser%ing as a
,in= between body organs, b,ood carries o>ygen absorbed -rom
t&e ,ungs and nutrients absorbed -rom t&e gastrointestina, tract
to t&e body ce,,s -or ce,,u,ar metabo,ism. B,ood a,so carries
&ormones, antibodies, and ot&er substances to t&eir sites o-
action or use. $n addition, b,ood carries waste products
produced by ce,,u,ar metabo,ism to t&e ,ungs, s=in, ,i%er, and
=idneys, w&ere t&ey a re trans-ormed and e,iminated -rom t&e
body.
B,ood is Kuid, t&ere-ore, t&e danger a,ways e>ists t&at trauma can ,ead to ,oss o- b,ood
-rom t&e %ascu,ar system. To pre%ent t&is, an intricate c,otting mec&anism is acti%ated w&en necessary to sea, any ,ea= in t&e
b,ood %esse,s. <>cessi%e c,otting is e#ua,,y dangerous, because it can obstruct b,ood Kow to %ita, tissues. To pre%ent &is, t&e body
&as a @brino,ytic mec&ansism t&at e%entua,,y disso,%e c,ots Gt&rombiH -ormed wit&in b,ood %esse,s. T&e ba,ance between t&ese two
systems, c,ot -ormation and c,ot disso,ution or @brino,ysis is ca,,ed 5emostasis!
:2N.T$ONS O: T;< BLOOD
B,ood per-orms many important -unctions wit&in t&e body inc,uding:
Supp,y o- o>ygen to tissues Gbound to &emog,obin w&ic& is carried in red ce,,sH
Supp,y o- nutrients suc& as g,ucose, amino acids and -atty acids Gdisso,%ed in t&e b,ood or bound to
p,asma proteinsH
emo%a, o- waste suc& as carbon dio>ide, urea and ,actic acid
$mmuno,ogica, -unctions, inc,uding circu,ation o- w&ite ce,,s, and detection o- -oreign materia,
by antibodies
.oagu,ation, w&ic& is one part o- t&e bodyRs se,-7repair mec&anism
(8
Messenger -unctions, inc,uding t&e transport o- &ormones and t&e signa,ing o- tissue damage
egu,ation o- body p; Gt&e norma, p; o- b,ood is in t&e range o- 8./6 7 8.36H
egu,ation o- core body temperature
;ydrau,ic -unctions
BON< MAO?
T&e bone mar r ow i s t &e s i t e o- &emat opoi es i s or b, ood c e, ,
- or mat i on. A, , s =e, et a, bones ar e i n%o, %ed i n c &i , dr en, but as
c &i , dr en age, mar r ow ac t i %i t y dec r eas es . Mar r ow ac t i %i t y i s us ua, , y
, i mi t ed t o t &e pe, %i s , r i bs , %er t ebr ae, and s t er num i n adu, t s .
Mar r ow i s one o- t &e , ar ges t or gans o- t &e body ma=i ng up 3O7
6O o- t ot a, body wei g&t . $ t c ons i s t s o- i s , and o- ce, , u, ar
c omponent s G r ed mar r owH s epar at ed by - at G ye, , ow mar r owH . As t &e
adu, t ages , t &e pr opor t i on o- ac t i %e mar r ow i s gr adua, , y r ep, ac ed
by - at , &owe%er i n &ea, t &y per s on, t &e - at can agai n r ep, ac ed by
ac t i %e mar r ow w&en mor e b, ood c e, , pr oduc t i on i s r e#ui r ed.
T&e mar r ow i s &i g&, y %as c u, ar. ?i t &i n i t ar e pr i mi t i %e c e, , s
ca, , ed st em cel l s! T&e s t em c e, , s &a%e t &e abi , i t y t o s e, -7
r ep, i c at e, t &er eby ens ur i ng a c ont i nuous s upp, y o- s t em c e, , s c an
begi n a pr oc es s o- +i C er ent i at i on i nt o ei t &er myel oi + or
l ymphoi + st em cel l s! T&es e s t em ce, , s c ommi t t ed t o pr oduc e s pec i @ c t ypes o- b, ood ce, , s .
Lymp&oi d s t em c e, , s pr oduc e ei t &er T or B , ymp&oc yt es . Mye, oi d s t em c e, , s di A er ent i at e i nt o t &r ee
br oad c e, , t ypes : er yt &r oc yt es , , eu=oc yt es and p, at e, et s . T&us , wi t & t &e e>c ept i on o- , ymp&oc yt es ,
a, , b, ood c e, , s ar e der i %ed - r om mye, oi d s t em ce, , s . A de- ec t i n a mye, oi d s t em c e, , c an caus e
pr ob, ems wi t & er yt &r oc yt e, , eu=oc yt e, and p, at e, et pr oduc t i on. Many c omp, e> mec &ani s ms ar e
i n%o, %ed i n &emat opoi es i s , o- t en at t &e mo, ec u, ar , e%e, .
(*
BLOOD .<LLS
<r yt &r oc yt es G ed B, ood .e, , s H
T&e norma, eryt&rocyte is a biconca%e dis= t&at resemb,es a so-t ba,,
compressed between ( @ngers. $t &as a diameter o- about * um and is so Ke>ib,e t&at
it can pass easi,y t&roug& capi,,aries t&at may be as sma,, as (.* um in diameter.
<ryt&rocytes or ed b,ood ce,,s ma=e up a,most 36 percent o- t&e b,ood %o,ume. T&eir
primary -unction is to carry o>ygen -rom t&e ,ungs to e%ery ce,, in t&e body. ed b,ood
ce,,s are composed predominant,y o- a protein and iron compound, ca,,ed
5emoglo1in t&at captures o>ygen mo,ecu,es as t&e b,ood mo%es t&roug& t&e ,ungs,
gi%ing b,ood its red co,or. As b,ood passes t&roug& body tissues, &emog,obin t&en
re,eases t&e o>ygen to ce,,s t&roug&out t&e body. ed b,ood ce,,s are so pac=ed wit&
&emog,obin t&at t&ey ,ac= many components, inc,uding a nuc,eus, -ound in ot&er
ce,,s. ;emog,obin a,so ta=es up and re,eases nitric o>ide, w&ic& p,ays an important
ro,e in regu,ating b,ood pressure.
T&e membrane, or outer ,ayer, o- t&e red b,ood ce,, is Ke>ib,e, ,i=e a soap
bubb,e, and is ab,e to bend in many directions wit&out brea=ing. T&is is important
because t&e red b,ood ce,,s must be ab,e to pass t&roug& t&e tiniest b,ood %esse,s, t&e
capi,,aries, to de,i%er o>ygen w&ere%er it is needed. T&e capi,,aries are so narrow t&at
t&e red b,ood ce,,s, norma,,y s&aped ,i=e a
dis= wit& a conca%e top and bottom, must
bend and twist to maneu%er sing,e @,e t&roug& t&em.
T&e ,i-e span o- t&e B.s is bout +)67+() days. As eryt&rocytes age, t&ey become
increasing,y -ragi,e and e%entua,,y rupture.
;2MAN <E;O.ET<S
(9
T&e diameter o- a typica, &uman eryt&rocyte dis= is 'L* Sm, muc& sma,,er t&an most ot&er &uman ce,,s. A typica,
eryt&rocyte contains about (8) mi,,ion &emog,obin mo,ecu,es, wit& eac& carrying -our &eme groups.
Adu,t &umans &a%e roug&,y (L/ T +)
+/
red b,ood ce,,s at any gi%en time Gwomen &a%e about 3 to 6 mi,,ion eryt&rocytes per
micro,iter Gcubic mi,,imeterH o- b,ood and men about 6 to ' mi,,ionM peop,e ,i%ing at &ig& a,titudes wit& ,ow o>ygen tension wi,, &a%e
moreH. ed b,ood ce,,s are t&us muc& more common t&an t&e ot&er b,ood partic,es: T&ere are about 3,)))L++,))) w&ite b,ood
ce,,s and about +6),)))L3)),))) p,ate,ets in eac& micro,iter o- &uman b,ood.
T&e red b,ood ce,,s o- an a%erage adu,t &uman ma,e store co,,ecti%e,y about (.6 grams o- iron, representing about '6O o- t&e tota,
iron contained in t&e body.
U8VU*V
GSee ;uman iron metabo,ism.H
L$:< .E.L<
T&e process by w&ic& red b,ood ce,,s are produced is ca,,ed erythropoiesis.
<ryt&rocytes are continuous,y being produced in t&e red bone marrow o- ,arge
bones, at a rate o- about ( mi,,ion per second. G$n t&e embryo, t&e ,i%er is t&e main
site o- red b,ood ce,, production.H T&e production can be stimu,ated by t&e
&ormone eryt&ropoietin G<5OH, synt&esiBed by t&e =idneyM w&ic& is used -or doping
in sports. Just be-ore and a-ter ,ea%ing t&e bone marrow, t&ey are =nown as
reticu,ocytes w&ic& comprise about +O o- circu,ating red b,ood ce,,s.
<ryt&rocytes de%e,op -rom committed stem ce,,s t&roug& reticu,ocytes to mature
eryt&rocytes in about 8 days and ,i%e a tota, o- about +() days.
T&e aging eryt&rocyte undergoes c&anges in its p,asma membrane, ma=ing it
susceptib,e to recognition by p&agocytes and subse#uent p&agocytosis in t&e
sp,een, ,i%er and bone marrow. Muc& o- t&e important brea=down products are
recircu,ated in t&e body. T&e &eme constituent o- &emog,obin is bro=en down into
:e
/W
and bi,i%erdin. T&e bi,i%erdin is reduced to bi,irubin, w&ic& is re,eased into t&e
p,asma and recircu,ated to t&e ,i%er bound to a,bumin. T&e iron is re,eased into t&e
p,asma to be recircu,ated by a carrier protein ca,,ed trans-errin. A,most a,,
eryt&rocytes are remo%ed in t&is manner -rom t&e circu,ation be-ore t&ey are o,d
enoug& to &emo,yBe. ;emo,yBed &emog,obin is bound to a protein in p,asma ca,,ed
&aptog,obin w&ic& is not e>creted by t&e =idney.
L<2!O.ET<S G ?&i t e b, ood .e, , sH
/)
-hite 1loo+ cells or leu7ocytes are ce,,s o- t&e immune system de-ending t&e body against bot& in-ectious disease and
-oreign materia,s. Se%era, diAerent and di%erse types o- ,eu=ocytes e>ist but t&ey
are a,, produced and deri%ed -rom a mu,tipotent ce,, in t&e bone marrow =nown as a
&ematopoietic stem ce,,. Leu=ocytes are -ound t&roug&out t&e body, inc,uding t&e
b,ood and ,ymp&atic system.
T&e number o- ,eu=ocytes in t&e b,ood is o-ten an indicator o- disease. T&ere
are norma,,y between 3T.6 L ++ T1cumm w&ite b,ood ce,,s in a ,iter o- b,ood,
ma=ing up appro>imate,y +O o- b,ood in a &ea,t&y adu,t. $n conditions suc& as
,eu=emia, t&e number o- ,eu=ocytes is &ig&er t&an norma, and in ,eu=openia, t&is
number is muc& ,ower. T&e p&ysica, properties o- ,eu=ocytes, suc& as %o,ume,
conducti%ity, and granu,arity, may c&ange due to acti%ation, t&e presence o-
immature ce,,s, or t&e presence o- ma,ignant ,eu=ocytes in ,eu=emia.
Types o- Leu=ocyt es
T&ere are se%era, diAerent types o- w&ite b,ood ce,,s. One primary tec&ni#ue to c,assi-y t&em is to ,oo= -or t&e presence o-
granu,es, w&ic& a,,ows t&e diAerentiation o- ce,,s into t&e categories granu,ocytes and agranu,ocytes:
*ranulocytes Bpolymorphonuclear leucocytesA) ,eu=ocytes c&aracteriBed by t&e presence o- diAerent,y staining
granu,es in t&eir cytop,asm o- t&e ce,,. T&ese granu,es are membrane7bound enBymes w&ic& primari,y act in t&e digestion o-
endocytosed partic,es. T&ere are t&ree types o- granu,ocytes: neutrop&i,s, basop&i,s, and eosinop&i,s, w&ic& are named
according to t&eir staining properties.
Agranulocytes Bmononuclear leucocytesA) ,eu=ocytes c&aracteriBed by t&e apparent absence o- granu,es in t&eir
cytop,asm. A,t&oug& t&e name imp,ies a ,ac= o- granu,es t&ese ce,,s do contain non7speci@c aBurop&i,ic granu,es, w&ic& are
,ysosomes. T&e ce,,s inc,ude ,ymp&ocytes, monocytes, and macrop&ages.
/+
O0<0$ <? O: TABL<
$ype
Mi cr oscop
i c
Appear an
ce
Car t oo
n
Appr o8!
D
i n
a+ul t s
E F G
S e e a l s o )
& l o o + v a l u e s
Di amet
er B HmA
E F G
Mai n t ar get s
E 2 G
Nucl eus
E
2 G
*r anul es
E
2 G
0i f et i me
E
F G
Neut r ophi
l
3)7 86O +)7 +(
bac t er i a
- ungi
mu, t i 7
, obed
@ ne,
- ai nt , y
pi n=
' &our s 7
- ew days
G days i n
s p, een
and ot &er
t i s s ueH
<os i nop&i , +7 'O +)7 +(
par as i t es
i n a, , er gi c
r eac t i ons
bi 7 , obed
- u, , o-
pi n=7
or ange
G w&en
s t ai nedH
*7 +( days
Bas op&i , X+O 97 +)
i n a, , er gi c
r eac t i ons
bi 7 or t r i 7
, obed
, ar ge b, ue Y
/(
Lymp&oc yt
e
()7 36O 87 *
B c e, , s : %ar i ous
pat &ogens
T c e, , s :
o .D3W
G &e, per H :
i nt r ac e, , u, a
r bac t er i a.
o .D*W
c yt ot o>i c T
c e, , s :
%i r us 7
i n- ec t ed
and t umor
c e, , s .
o Z[ T c e, , s :
Nat ur a, =i , , er
c e, , s : %i r us 7
i n- ec t ed and
t umor c e, , s .
deep, y
s t ai ni ng,
ec c ent r i c
on, y N!7
c e, , s
U 3 V
wee=s t o
year s
Monoc yt e (7 'O
+37 +8 %ar i ous
=i dney
s &aped
none
mont &s 7
year s
Mac r op&ag
e
N1 A days
Neut r ophi l
Neutrop&i,s dea, wit& de-ense against bacteria, or -unga, in-ection and ot&er %ery sma,, inKammatory processes and are
usua,,y @rst responders to microbia, in-ectionM t&eir acti%ity and deat& in ,arge numbers -orms pus. T&ey are a,so =nown as
po,ymorp&onuc,ear ,eu=ocytes and microp&ages. T&e term microp&age arises due to t&e ce,,sR acti%e in%o,%ement in p&agocytosis.
//
T&ey &a%e a mu,ti7,obed nuc,eus w&ic& may appear ,i=e mu,tip,e nuc,ei, &ence t&e name po,ymorp&onuc,ear ,eu=ocyte. T&e
cytop,asm may ,oo= transparent because o- @ne granu,es t&at are -aint,y pin= in co,or. Neutrop&i,s are %ery acti%e in
p&agocytosing bacteria and are present in ,arge amount in t&e pus o- wounds. 2n-ortunate,y, t&ese ce,,s are not ab,e to renew
t&eir ,ysosomes used in digesting microbes and die a-ter &a%ing p&agocytosed a -ew pat&ogens 7 e>p,aining w&y t&ey are -ound
primari,y in t&e pus, not in tissue.
:osi nophi l
<osinop&i,s primari,y dea, wit& parasitic in-ections and an increase in t&em may indicate suc&. <osinop&i,s are a,so t&e
predominant inKammatory ce,,s in a,,ergic reactions. T&e most important causes o- eosinop&i,ia inc,ude a,,ergies suc& as ast&ma,
&ay -e%er, and &i%esM and a,so parasitic in-ections. "enera,,y t&eir nuc,eus is bi7,obed. T&e cytop,asm is -u,, o- granu,es w&ic&
assume a c&aracteristic pin=7orange co,or wit& eosin stain.
&asophi l
Basop&i,s are c&ieKy responsib,e -or a,,ergic and antigen response by re,easing t&e c&emica, &istamine causing
inKammation. T&e nuc,eus is bi7 or tri7,obed, but it is &ard to see because o- t&e number o- coarse granu,es w&ic& &ide it. T&ey are
c&aracteriBed by t&eir ,arge b,ue granu,es.
0ymphocyt e
Lymp&ocytes are muc& more common in t&e ,ymp&atic system. Lymp&ocytes are distinguis&ed by &a%ing a deep,y staining
nuc,eus w&ic& may be eccentric in ,ocation, and a re,ati%e,y sma,, amount o- cytop,asm. T&e b,ood &as t&ree types o- ,ymp&ocytes:
B ce,,s: B ce,,s ma=e antibodies t&at bind to pat&ogens to enab,e t&eir destruction. GB ce,,s not on,y ma=e antibodies t&at
bind to pat&ogens, but a-ter an attac=, some B ce,,s wi,, retain t&e abi,ity to produce an antibody to ser%e as a RmemoryR
system.H
T ce,,s:
o .D3W G&e,perH T ce,,s co7ordinate t&e immune response and are important in t&e de-ense against intrace,,u,ar bacteria.
o .D*W cytoto>ic T ce,,s are ab,e to =i,, %irus7in-ected and tumor ce,,s.
o T ce,,s possess an a,ternati%e T ce,, receptor as opposed to .D3W and .D*W \ T ce,,s and s&are c&aracteristics o-
&e,per T ce,,s, cytoto>ic T ce,,s and natura, =i,,er ce,,s.
/3
o Natura, =i,,er ce,,s: Natura, =i,,er ce,,s are ab,e to =i,, ce,,s o- t&e body w&ic& are disp,aying a signa, to =i,, t&em, as t&ey
&a%e been in-ected by a %irus or &a%e become cancerous.
Monocyt e
Monocytes s&are t&e ]%acuum c,eaner] Gp&agocytosisH -unction o- neutrop&i,s, but are muc& ,onger ,i%ed as t&ey &a%e an
additiona, ro,e: t&ey present pieces o- pat&ogens to T ce,,s so t&at t&e pat&ogens may be recogniBed again and =i,,ed, or so t&at an
antibody response may be mounted. Monocytes e%entua,,y ,ea%e t&e b,oodstream to become tissue macrop&ages w&ic& remo%e
dead ce,, debris as we,, as attac=ing microorganisms. Neit&er o- t&ese can be dea,t wit& eAecti%e,y by t&e neutrop&i,s. 2n,i=e
neutrop&i,s, monocytes are ab,e to rep,ace t&eir ,ysosoma, contents and are t&oug&t to &a%e a muc& ,onger acti%e ,i-e. T&ey &a%e
t&e =idney s&aped nuc,eus and typica,,y agranu,ated. T&ey a,so possess abundant cytop,asm.
Macr ophage
Monocytes are ab,e to diAerentiate into t&e dedicated p&agocytosing macrop&age ce,, a-ter migrating -rom t&e b,oodstream
into tissues.
:unctions o- Leu=ocytes
0eu7ocytes protect t&e body -rom in%asion by bacteria and ot&er -oreign entities. T&e ma4or
-unction o- neutrophils is p&agocytosis. Neutrop&i,s arri%e at a gi%en site wit&in + &our a-ter t&e
onset o- an inKammatory reaction and initiate p&agocytosis, but t&ey are s&ort7,i%ed. An inKu> o-
monocytes -o,,ows. T&ese ce,,s continue t&eir p&agocytic acti%ities -or ,ong periods as
macrop&ages. T&is process constitutes a second ,ine o- de-ense -or t&e body against inKammation
and in-ection. Macrophages a,so digest senescent b,ood ce,,s, suc& as eryt&rocytes, primari,y
wit&in t&e sp,een.
T&e primary -unction o- lymphocytes is to produce substances t&at aid in attac=ing -oreign
materia,. One group o- ,ymp&ocytes GT ,ymp&ocytesH =i,,s -oreign ce,,s direct,y or re,eases a %ariety
o- ,ymp&o=ines, substances t&at en&ances t&e acti%ity o- p&agocytic ce,,s. T ,ymp&ocytes are
responsib,e -or de,ayed a,,ergic reactions, re4ection o- -oreign tissue and destruction o- tumor ce,,s.
T&e process is =nown cellular immunity. T&e ot&er group o- ,ymp&ocytes GB ,ymp&ocytesH is capab,e o- diAerentiating into
/6
p,asma ce,,s. 5,asma ce,,s produce antibodies ca,,ed immunog,obu,in G$gH, w&ic& are protein mo,ecu,es t&at destroy -oreign
materia, by se%era, mec&anisms. T&is process is =nown as &umora, immunity.
:osinophils an+ 1asophils -unction in &ypersensiti%ity reactions. :osinophils are important in t&e p&agocytosis o-
parasites. &asophils produce and store &istamine as we,, as ot&er substances in%o,%ed in &ypersensiti%ity reactions. T&e re,ease
o- t&ese substances pro%o=es a,,ergic reactions.
5,ate,ets GT&rombocytesH
4latelets or throm1ocytes are not tec&nica,,y ce,,s rat&er t&ey are
granu,ar -ragments o- giant ce,,s in t&e bone maroow ca,,ed
mega=aryocytes. 5,ate,et production in t&e bone marrow is regu,ated in
part by t&e &ormone t&rombopoeitin w&ic& stimu,ates t&e production and
diAerentiation o- mega=aryocytes -rom t&e mye,oid stem ce,,.
5,ate,ets p,ay an essentia, ro,e in t&e contro, o- b,eeding. T&ey
circu,ate -ree,y in t&e b,ood in an inacti%e state w&ere t&ey nurture t&e
endot&e,ium o- t&e b,ood %esse,s maintaining t&e integrity o- t&e %esse,.
?&en %ascu,ar in4ury occurs, p,ate,ets co,,ect at t&e site and are acti%ated.
T&ey ad&ere to t&e site o- in4ury and to eac& ot&er, -orming a p,ate,et p,ug t&at temporari,y stops b,eeding.
Substances re,eased -rom p,ate,et granu,es acti%ate coagu,ation -actors in t&e b,ood p,asma and initiate
t&e -ormation o- a stab,e c,ot composed o- @brin, a @,amentous protein. 5,ate,ets &a%e a norma, ,i-e span o-
87+) days.
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b, eedi ng es pec i a, , y dent a, pr ob, ems .
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ac t i %i t y. ?i t & s t r ong aQ ni t y - or t &e @ %e , ys i ne7 bi ndi ng s i t es o- p, as mi nogen, t r ane>ami c ac i d
c ompet i t i %e, y i n&i bi t s t &e ac t i %at i on o- p, as mi nogen t o p, as mi n, r es u, t i ng i n i n&i bi t i on o-
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ami noc apr oi c ac i d, w&i c & pos s es s es s i mi , ar mec &ani s ms o- ac t i on.
Si +e :C ect s) ;eadac &e G s e%er e and s uddenH M , os s o- c oor di nat i on G s uddenH M pai ns i n c &es t ,
gr oi n, or , egs , es pec i a, , y t &e c a, %es M s &or t nes s o- br eat & G s uddenH M s , ur r ed s peec & G s uddenH M
%i s i on c &anges G s uddenH M wea=nes s or numbnes s i n ar m or , eg
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Cont r ai n+i cat i ons) 5at i ent s wi t & a &i s t or y or r i s = o- t &r ombos i s . .aut i on s &ou, d be us ed i n
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Nur si ng Consi +er at i ons)
Moni t or ad%er s e eA ec t s .
Moni t or c omp, et e b, ood c ount .
Moni t or %i t a, s i gns es pec i a, , y b, ood pr es s ur e.
3)
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f l o o r wi t h Amu s k i t i r oB
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5a s n o d i f f i c u l t y i n
Cl i e n t i s p a l e & r e s t l e s s & l y i n g i n
s u p i n e p o s i t i o n wi t h >$ . 3 3a Cl $ % %
c c a t r i g h t me t a c a r p a l v e i n C # 4
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a s v e r b a l i + e d b y mo t h e r
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<e 1 u e s t s $ % c c HD; o f c l i e n t ?s
b l o o d t y p e a f t e r p r op e r c r os s -
ma t c h i n g
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c o n d i t i o n
9r e s e n c e o f >$ . 3 3a Cl $ % % c c a t
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Cl i e n t i s s t i l l p a l e & r e s t l e s s &
l y i n g i n s u p i n e p o s i t i o n wi t h
>$ . 3 3a Cl $ % % c c a t r i g h t
me t a c a r p a l v e i n C # 4 ml h r
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Co r d i s c l e a n e d a n d d r e s s e d
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d e l i v e r y u n t i l n o w a s v e r b a l i + e d
b y mo t h e r
Co mp l i a n t o f me d i c a l r e g i me n
*2 @ n o t mo n i t o r e d
0 t i l l r e 1 u e s t i n g $ % c c HD; o f
c l i e n t ?s b l o o d t y p e a f t e r p r op e r
c r os s - ma t c h i n g
;r e a s t f e e d wi t h a mo u n t o f ,
o u n c e s
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9r e s e n c e o f >$ . 3 3a Cl $ % % c c
a t r i g h t me t a c a r p a l v e i n C # 4
u b j e c t i v e
F a t h e r
v e r b a l i z e d ,
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a k o n g b a t a .
Ob j e c t i v e
P a t i e n t i s p a l e
d u e t o p r o f u s e d
b l o o d l o s s o n
t h e c o r d s t u mp .
!" # . $ % &
P '!( ) * b p m
''!+ , c p m
F o r b l o o d
t r a n s f u s i o n .
-o p a s t h e a l t h
h i s t o r y.
. k i n r e t u r n s
b a c k a f t e r
p i n c h i n g i n t h e
a b d o mi n a l a r e a .
. k i n i s d r y P /.
0ei g h t ! " . " k g
&! u i d v o ! u me
d e f i c i t r e ! a t e d t o
b ! e e d i n g a t t h e
c o r d s t ump &
0i t h i n my c a r e ,
t h e p a t i e n t 1i l l
ma i n t a i n a d e 2 u a t e
f l u i d b a l a n c e a s
e v i d e n c e d b y3
. t a b l e v i t a l
s i g n s .
4o i s t mu c o u s
me mb r a n e s .
52 u a l i n t a k e a n d
o u t p u t .
6i f f e r e n c e
s h o u l d n o t b e
g r e a t e r t h a n ( * *
ml .
. k i n e a s i l y
r e t u r n s b a c k
a f t e r p i n c h i n g .
&a p i l l a r y r e f i l l
1i t h i n ( 7 "
s e c o n d s .
. p e c i f i c g r a v i t y
o f u r i n e i s ( . * ( *
t o ( . * 8 ) .
4a i n t a i n
a c c u r a t e i n t a k e
a n d o u t p u t .
4o n i t o r 1e i g h t
d a i l y.
-o t e u r i n e
c h a r a c t e r i s t i c s
a n d s p e c i f i c
g r a v i t y.
4o n i t o r v i t a l
s i g n s .
9b s e r v e f o r
f e v e r c h a n g e s
i n t h e l e v e l o f
c o n s c i o u s , p o o r
s k i n t u r g o r ,
d r yn e s s o f s k i n
a n d mu c o u s
me mb r a n e s .
4o n i t o r
l a b o r a t o r y
r e s u l t s
e s p e c i a l l y
c o mp l e t e b l o o d
c o u n t .
/s s i s t
1h e n e v e r t h e r e
i s : ;F
i n s t i l l a t i o n .
ea c h p a r e n t s
t o s e c u r e b l o o d
a s s o o n a s
P a t i e n t ma y
i n c r e a s e f l u i d
i n t a k e t o p r e v e n t
d e h yd r a t i o n .
<i d n e ys c a n l o s e
i t s a b i l i t y t o
c o n c e n t r a t e u r i n e ,
r e s u l t i n g i n
e = c e s s i v e l o s s o f
d i l u t e u r i n e a n d
f i = a t i o n o f s p e c i f i c
g r a v i t y.
'e d u c t i o n o f
c i r c u l a t i n g b l o o d
v o l u me ma y o c c u r
f r o m i n c r e a s e d
f l u i d l o s s , r e s u l t i n g
i n h yp o t e n s i o n a n d
t a c h yc a r d i a .
. ymp t o ms
r e f l e c t i v e o f
d e h yd r a t i o n a n d
h e mo c o n c e n t r a t i o n
1i t h c o n s e 2 u e n t
v a s o o c c l u s i v e
s t a t e .
5l e v a t i o n ma y
i n d i c a t e
h e mo c o n c e n t r a t i o n .
6e p l e t i o n s
n e c e s s i t a t e
r e p l a c e me n t .
0i t h i n my c a r e ,
t h e o b > e c t i v e s
1e r e me t a s
e v i d e n c e d b y3
P a t i e n t h a d
s t a b l e v i t a l
s i g n s .
?a d mo i s t
mu c o u s
me mb r a n e s .
?a d e 2 u a l
i n t a k e a n d
o u t p u t .
6i f f e r e n c e
1a s 1i t h i n
( * * c c .
. k i n e a s i l y
r e t u r n s b a c k
a f t e r
p i n c h i n g .
&a p i l l a r y
r e f i l l 1a s 8
s e c o n d s .
?a d ( . * ( )
s p e c i f i c
g r a v i t y o f
u r i n e .
33
b l o o d t yp e
r e s u l t i s g i v e n .
ea c h p a r e n t s
t o h yd r a t e
p a t i e n t
e s p e c i a l l y
b r e a s t f e e d i n g .
P r o mo t e s a f e t y o f
p r o c e d u r e .
Cu e s / Ev i d e n c e s Nu r s i n g
Di a g n o s i s
Ob j e c t i v e s I n t e r v e n t i o n s Ra t i o n a l e Ev a l u a t i o n
36
u b j e c t i v e
F a t h e r
v e r b a l i z e d ,
Li h o k a n
k a a yo a n g
k a mo t s a
a k o n g b a t a .
4a h a d l o k k o
ma t a n d o g a n g
d a g u m s a
s u l o d .
Ob j e c t i v e
P r e s e n c e o f
: ;F 6) -a &l
* . " ) * * c c @
'i g h t
me t a c a r p a l
v e i n r e g u l a t e d
@ ( $ ml A h r .
: ; s i t e 3 : n t a c t ,
n o e r yt h e ma
a n d
i n f l a mma t i o n .
! " # . $ % &
P '! ( ) * b p m
''! + , c p m
-o l a b o r a t o r y
r e s u l t s ye t .
"i s ' f o r
i n f e c t i o n
r e ! a t e d t o
p r e s e n c e o f
( % ! i n e )
r i g h t
me t a c a r p a !
v e i n &
0i t h i n my c a r e ,
c l i e n t s h a l l b e
f r e e f r o m
i n f e c t i o n a t t h e
: ; s i t e a s
e v i d e n c e d b y3
. t a b l e v i t a l
s i g n s .
6e mo n s t r a t e
c l e a n i n s e r t i o n
s i t e , f r e e o f
d r a i n a g e ,
e r yt h e ma a n d
e d e ma .
La b o r a t o r y
r e s u l t s a r e
s t a b l e
e s p e c i a l l y
0B& c o u n t .
C $ . ) 7 ((
A c u mmD
. t r e s s p r o p e r
h a n d 1a s h i n g b y
s t u d e n t n u r s e a n d
p a r e n t s a s 1e l l
1h i l e t a k i n g c a r e
o f t h e b a b y.
4a i n t a i n s t e r i l e
t e c h n i 2 u e f o r
i n v a s i v e
p r o c e d u r e s .
P r o v i d e r o u t i n e
s i t e c a r e .
/s s e s s v i t a l s i g n s
e s p e c i a l l y
t e mp e r a t u r e p e r
p r o t o c o l .
/s s e s s i n s e r t i o n
s i t e f o r i n t a c t n e s s
o f s k i n , e r yt h e ma
a n d t e n d e r n e s s .
/s e p t i c a l l y a s s i s t
d o c t o r o r n u r s e i n
p a r e n t e r a l
a d mi n i s t r a t i o n .
-o t i f y c l i n i c a l
i n s t r u c t o r f o r
s i g n s o f
i n f e c t i o n .
'e d u c e s r i s k o f
c r o s s 7
c o n t a mi n a t i o n .
P r e v e n t s e n t r y o f
b a c t e r i a , r e d u c i n g
r i s k f o r
n o s o c o mi a l
i n f e c t i o n s .
/ r i s e i n
t e mp e r a t u r e o r
p u l s e ma y
i n d i c a t e i n f e c t i o n .
o p r e v e n t t i s s u e
t r a u ma a n d
p o t e n t i a l e n t r y o f
o r g a n i s ms i n t o
s k i n .
P r e v e n t
c o n t a mi n a t i o n a n d
i r r i t a t i o n 1h i c h
i n d i c a t e i n f e c t i o n .
P r o mo t e s s t e r i l i t y
o f p r o c e d u r e a n d
p r o mo t e
i mme d i a t e c a r e t o
i n f e c t i o n i f
p r e s e n t .
0i t h i n my c a r e ,
o b > e c t i v e s 1e r e
p a r t i a l l y me t a s
e v i d e n c e d b y3
P a t i e n t h a d
s t a b l e v i t a l
s i g n s .
: ; s i t e 1a s
c l e a n , f r e e o f
d r a i n a g e ,
e r yt h e ma , a n d
e d e ma .
La b o r a t o r y
r e s u l t s a r e n o t
ye t r e l e a s e d
a n d mo n i t o r e d .
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m e
o n
u b j e c t i v e
F a t h e r
v e r b a l i z e d ,
Li h o k a n k a a yo
a k o n g b a t a s a mu t
n a g a ma t a .
?a d l o k k o
ma t a n d o g a n g
t u b o s a i ya n g
i l o n g p a r a
o = yg e n .
Ob j e c t i v e
P r e s e n c e o f
o = yg e n v i a n a s a l
c a n n u l a @ 'i g h t
n a r e s , r e g u l a t e d
@ ( l i t e r A mi n
! " # . $ % &
P '! ( ) * b p m
''! + , c p m
&a n n u l a s t i c k s
t o t h e s k i n o f
t h e 'i g h t n a r e s .
P r e s e n c e o f
f r i c t i o n u p o n
mo v i n g .
&a n n u l a i s
mo v e d 1h e n e v e r
t h e b a b y mo v e s .
6r y s k i n a n d
p a l e .
"i s ' f o r a ! t e r e d
s ' i n i n t e g r i t y
r e ! a t e d t o
p r e s e n c e o f
o * y g e n v i a
n a s a ! c a n n u ! a &
0i t h i n my c a r e ,
c l i e n t 1i l l b e f r e e
f r o m s k i n
i n t e g r i t y
a l t e r a t i o n a s
e v i d e n c e d b y3
. t a b l e v i t a l
s i g n s
F r e e o f
c o mp l i c a t i o n s
a s s o c i a t e d 1i t h
o = yg e n s u p p o r t .
F r e e o f
e n v i r o n me n t a l
h a z a r d s .
Eo o d h yd r a t i o n
a s e v i d e n c e d
1i t h mo i s t
mu c o u s
me mb r a n e s .
/s s e s s p l a c e me n t
o f t h e c a n n u l a a n d
i t s s u r r o u n d i n g
s k i n .
P r o p e r n a s a l c a r e
s h o u l d b e d o n e .
4a i n t a i n
o c c l u s i v e d r e s s i n g
o n c a t h e t e r
i n s e r t i o n s i t e i f t o
b e r e mo v e d .
/s s i s t i n
r e p l a c e me n t a n d
i n s e r t i o n o f
c a n n u l a i f n e e d e d .
ea c h p a r e n t s t o
c l e a n t h e c a n n u l a
i n s e r t i o n s i t e
1h e n e v e r
s e c r e t i o n s a r e
n o t e d .
ea c h p a r e n t s t o
r e p o r t a n y
c o mp l i c a t i o n s a t
t h e s i t e o f
i n s e r t i o n .
Lo o s e c a n u l a
p r o mo t e s
f r i c t i o n t h u s
i n > u r i n g s k i n
s u r f a c e s .
h i s i s t o
p r e v e n t i n > u r y
a n d i n f e c t i o n
t o t h e
s u r r o u n d i n g
s k i n o f t h e
n a s a l c a n n u l a
i n s e r t i o n .
h i s i s t o
p r e v e n t
c a t h e t e r s k i n
t r a c t .
/s s e s s f o r a i r
e mb o l i s m i n
t h e s k i n t r a c t .
o ma i n t a i n a
s a f e
p r o c e d u r e .
o p r e v e n t
f u r t h e r
c o mp l i c a t i o n s
.
0i t h i n my c a r e ,
o b > e c t i v e s 1e r e
me t a s e v i d e n c e d
b y3
P a t i e n t h a d
s t a b l e v i t a l
s i g n s .
?a d mo i s t
mu c o u s
me mb r a n e s .
F r e e f r o m
e n v i r o n me n t a l
h a z a r d s 1h i c h
ma y h i n d e r t o
t h e s a f e t y o f
t h e t h e r a p y.
F r e e o f
c o mp l i c a t i o n s
a s s o c i a t e d 1i t h
o = yg e n s u p p o r t .
38
&! u i d v o ! ume d e f i c i t r e ! a t e d t o b ! e e d i n g a t t h e c o r d s t ump &
"i s ' f o r i n f e c t i o n r e ! a t e d t o p r e s e n c e o f ( % ! i n e ) r i g h t me t a c a r p a ! v e i n &
"i s ' f o r a ! t e r e d s ' i n i n t e g r i t y r e ! a t e d t o p r e s e n c e o f o * y g e n v i a n a s a ! c a nn u ! a &
+n o w! e d g e d e f i c i t r e ! a t e d t o p a r e n t , s u n d e r s t a n d i n g a b o u t b ! o o d d y s c r a s i a .
&a t i g u e r e ! a t e d t o c o mp e ns a t o r y me c h a n i s m f o r o * y g e n i n t h e b o d y .
( n e f f e c t i v e f a mi ! y c o p i n g r e ! a t e d t o f i n a n c i a ! p r o b ! e ms .
"i s ' f o r p e r i p h e r a ! v a s c u ! a r d y s f u n c t i o n r e ! a t e d t o h y p e r d y n a mi c c i r c u ! a t i o n o f f ! u i d s .
3*
SENT;<S$S
A, , o- us wer e s o &appy t &at we &a%e r eac &ed t &i s s emes t er , e%en t &oug& we wer e - ac ed wi t &
di A er ent c &a, , enges and , ot s o- &ar ds &i ps i n our , i - e, but t &r oug& a, , o- t &at , we wer e ab, e t o c ope
up and , ear n - r om i t .
At t &e begi nni ng o- t &i s r ot at i on G 5edi at r i c ot at i onH , we a, r eady =now w&at we wer e goi ng
t &r oug&. Dea, i ng wi t & i n- ant s and c &i , dr en i s not eas y es pec i a, , y i - pat i ent s ar e young G be, ongi ng
t o t &e i n- ant per i odH , pat i ent s t &at ar e di Q c u, t t o &and, e, pat i ent s t &at ar e s c ar ed o- nur s es or
s &y.
T&i s e>per i enc e i s s o c &a, , engi ng - or us s t udent nur s es and nur s es i n t &e - ut ur e. ?e nur s es mus t
be pr epar ed and be K e>i b, e i n dea, i ng wi t & pedi at r i c pat i ent s or anyone w&om we enc ount er
s omeday. ?e s &ou, d ne%er s ur r ender t o any obs t ac , es 1 pr ob, ems weC %e been t &r oug& i n our , i %es
and s &ou, d ne%er s t op as =i ng - or gui danc e t o our e%er , o%i ng "OD.
5edi at r i c ot at i on i s - un and c &a, , engi ng. ?e di dnC t - ee, any e>&aus t i on dur i ng our dut y.
A, t &oug& we wer e bombar ded by &umongous pi , e o- paper wor = but we wer e ab, e t o c ope and
s ur %i %e - r om i t . Ne%er t &e, es s , t &an=s t o our ., i ni c a, $ ns t r uc t or - or bei ng pat i ent and , o%i ng.
Our cas e i s t &e mos t i nt er es t i ng o- a, , , s i nc e i t dea, s wi t & b, ood. $ t i s t &e mos t c &a, , engi ng
and i t &e, ps our mi nd wor = t o =now and , ear n w&at c aus es t &es e di s eas es t o c &i , dr en and adu, t s .
!nowi ng t &e s pec i @ c a, t er at i ons i n t &e body, we s &ar pened our as s es s ment s =i , , s and &ad a =een
mi nd. Doi ng t &e appr opr i at e nur s i ng i nt er %ent i ons pr o%ed us t &at we ar e c apab, e o- &and, i ng t &i s
=i nd o- c as e and t &at we ar e opt t o gi %e t &e bes t c ar e. Dea, i ng wi t & b, ood i s %er y c r uc i a,
es pec i a, , y wi t & t &e pr es enc e o- b, ood abnor ma, i t i es . ?e s &ou, d pr e%ent our s e, %es - r om
c ont ami nat i on. T&at i s t &e r eas on be&i nd e>er c i s i ng our nur s i ng s =i , , s . ?e ar e s o gr at e- u, t &at we
ar e gi %en t &i s t ype o- cas e and our pat i ent t oget &er wi t & &i s par ent s c ooper at ed t o our car e. ?e
ar e &appy t &at t &ey per mi t t ed us t o pr es ent t &ei r s ons cas e - or t &e bene@ t o- , ear ni ng upon
as s ur anc e o- c on@ dent i a, i t y. $ t &as been a 4 our ney t &r oug& , i - e.
39
?e, !r i s t i ne and $ %an, t &i r d year nur s i ng s t udent s o- Si , , i man 2ni %er s i t y ar e &onor ed t o &a%e gi %en
s uc & oppor t uni t y i n s t udyi ng and pr es ent i ng t &i s c as e. T&i s cas e s t udy &e, ped us br oaden our
=now, edge, en&anc i ng our s =i , , s and i mpr o%ed our at t i t udes . T&i s s t udy a, s o mo, ded us t o be a
bet t er s t udent s and nur s es i n t &e - ut ur e. $ t a, s o &e, ped us r ea, i B e &ow gr at e- u, we ar e t o be i n
t &i s wor , d and &ow we s &ou, d be t &an=- u, t o "od and - ami , y w&o &a%e s ac r i @ c ed e%er yt &i ng - or us .
T&r oug& t &i s e>per i enc e, we wou, d a, s o , i =e t o t &an= t &e - o, , owi ng peop, e bec aus e wi t &out
t &em t &i s wou, d not be made pos s i b, e. :i r s t , we wou, d , i =e t o t &an= "od - or gi %i ng us t &i s s pec i a,
, i - e t &at we wer e ab, e t o r eac & t &i s s t age and - or t &e gui danc e t &r oug& our 4 our ney i n , i - eM Sec ond,
- or our - ami , i es - or bei ng %er y s uppor t i %e and under s t andi ngM T&i r d, our be, o%ed .. $ Ms . Dawn
J ani c e A. Ti empo - or t eac &i ng us t &e good ways and mo, ded us as a bet t er per s onM :our t &, - or t &e
NO5; 5edi at r i c s t aA s - or a, , owi ng us t o be e>pos ed i n t &i s r ot at i onM :i - t &, wou, d be our c , as s mat es
w&os e a, ways t &er e - or us t &r oug& t &i c = and t &i nM And , as t , y, wou, d be our pat i ent J o&n .ar , o
Ma&i nay Agus t i no and &er - ami , y w&o ga%e - u, , y t &ei r par t i c i pat i on and c ooper at i on. T&an= you.
6)
B$ BL$ O"A5;E
B, ac =, J oyc e P ;aw=s , J ane ;. G ())6H . Medi c a, 7 s ur gi c a, nur s i ng: c , i ni c a, management - or
pos i t i %e out c omes . 8
t &
ed. St Loui s , Mi s s our i , 2SA: <, s e%i er $ nc .
Deg, i n, J udi t & ;. G ())6H . Da%i s C s Dr ug "ui de :or Nur s es 9
t &
ed. 5&i , ade, p&i a: ?. B. Saunder s ,
.ompany
Doenges , Mar i , ynn <. G ())3H . Nur s eC s 5oc =et "ui de . 9
t &
ed. .opyr i g&t by :. A Da%i s .ompany
<nc ar t a <nc yc , opedi a 5r emi um Sui t e. G ())8H
"or r i e, T. M. et . a, . :oundat i ons o- mat er na, newbor n nur s i ng . 5&i , ade, p&i a: ?. B. Saunder s ,
.ompany
;oc =enber r y, M. J . G ())6H . Wong! s &s s ent i al s of 'edi at r i c (ur s i ng . G 8
t &
edH . <, %es i er : Mos by
Mar i eb, <. ())). &s s ent i al s of )uman Anat omy * 'hys i ol ogy G 't & <d. H 5ear s on <duc at i on As i a
5t e. Lt d
Mc .anc e, !. P ;uet &er , S. G +993H . 'at hophys i ol ogy . (
n d
ed. 2. S. A. : Mos by7 Eear Boo=, $ nc .
Mos byC s poc =et di c t i onar y o- medi c i ne, nur s i ng and a, , i ed &ea, t & G 3
t &
d. H . G ())(H .
O, ds , Sa, , y et . a, . G +99*H Mat er na, 7 newbor n nur s i ng . G 6
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5i , , i t er i , Ade, e. G +999H . Mat er na, and Newbor n &ea, t &c ar e . (
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ed. Li ppi nc ot t : 5&i , ade, p&i a
?ong, Donna L. G +999H . Whal ey and Wong! s nur s i ng car e of i nf ant s and c hi l dr en . '
t &
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Mi s s our i , 2SA: Mos by, $ nc .
6+
AT$.L< <AD$N"S
Anemi a treatment may 1e a +ou1l e3 e+ge+ s"or+
!er i St edman M. D. F03 # an3 200
<r yt &ropoi et i nR s eA ect s on b, ood7 %esse, growt & may bene@ t or &ar m pat i ent s wi t &
under , yi ng ret i nopat &y or cancer.
<ryt&ropoietin &as so -ar been =nown to doctors as a &ormone t&at boosts red7b,ood7ce,, production. Now, a
mouse study ,ed by Lois Smit&, MD, 5&D, an op&t&a,mo,ogist at .&i,drenRs ;ospita, Boston, s&ows it a,so =eeps
b,ood %esse,s a,i%e and growing in t&e eye. T&e @ndings not on,y add a new -unction to t&e &ormone, but a,so
gi%e doctors a reason to pause be-ore prescribing it to patients wit& diseases aAected by abnorma, b,ood7%esse,
growt&, suc& as retinopat&y and cancer.
T&e study, pub,is&ed in t&e :ebruary issue o- t&e Journa, o- .,inica, $n%estigation , a,so -ound t&at w&et&er t&e
&ormone is a ris= or bene@t depends on t&e timing o- administration.
Smit& and @rst aut&or Jing .&en, 5&D, wor=ed in mice wit& retinopat&y, an eye disease t&at begins w&en
&ea,t&y b,ood %esse,s nouris&ing t&e retina die. Numerous %esse,s t&en grow in, but t&ey are de-ormed.
2,timate,y, t&e de-ormed %esse,s may pu,, t&e retina oA t&e bac= o- t&e eye, causing b,indness. T&e researc&ers
measured eryt&ropoietin produced in t&e retina as t&e disease progressed. 5roduction was / to +) times be,ow
norma, during ear,y7stage retinopat&y, w&en &ea,t&y b,ood %esse,s died, and +( to // times abo%e norma,
during ,ate7stage retinopat&y, w&en de-ormed b,ood %esse,s grew into t&e retina. T&e researc&ers conc,uded
t&at eryt&ropoietin &e,ps b,ood %esse,s sur%i%e and grow in t&e retina, wit& eAects t&at may be &ea,t&y or
&arm-u,.
6(
Ne>t, t&e team e>amined w&et&er gi%ing eryt&ropoietin cou,d treat retinopat&y. T&ey in4ected eryt&ropoietin
into t&e b,oodstream eit&er ear,y, as t&e mice ,ost &ea,t&y b,ood %esse,s, or ,ater, w&en de-ormed b,ood %esse,s
began to in%ade77t&en compared t&em wit& untreated mice.
Boosting eryt&ropoietin ear,y s,owed t&e disease. T&e mice ,ost &a,- as many &ea,t&y b,ood %esse,s, causing
about /) percent -ewer de-ormed %esse,s to grow in. aising eryt&ropoietin ,e%e,s ,ater, w&en de-ormed b,ood
%esse,s were present, appeared to acce,erate t&e disease77s,ig&t,y more de-ormed b,ood %esse,s grew in.
$- simi,ar eAects are -ound in &umans, and its use is proper,y timed, t&en gi%ing eryt&ropoietin ear,y cou,d s,ow
,oss o- &ea,t&y b,ood %esse,s in retinopat&y, says Smit&. ]ig&t now, t&ere is %ery ,itt,e out t&ere to treat b,ood
%esse, ,oss in patients wit& retinopat&y. ;owe%er, -urt&er studies on t&e restoration o- norma, ,e%e,s o-
eryt&ropoietin are needed to trans,ate t&ese resu,ts to patients.]
$n ot&er diseases, ,i=e cancer, in w&ic& doctors need to s,ow b,ood %esse, growt&, t&e &ormone cou,d be
b,oc=ed, a,t&oug& c,inica, tria,s wou,d need to con@rm t&is idea, s&e adds.
But gi%en at t&e wrong time, eryt&ropoietin may ma=e b,ood %esse,s grow in an un&ea,t&y way, says Smit&. :or
e>amp,e, because it boosts red b,ood ce,,s, eryt&ropoietin is o-ten prescribed to premature babies and diabetic
adu,ts -or anemia. Some o- t&ese patients a,so &a%e retinopat&y. "i%ing t&e &ormone at t&e wrong time mig&t
&e,p anemia, but worsen t&e eye disease.
]?eRre not saying, RdonRt do it.R ?eRre saying, Rt&in= about it,R] says Smit&. ]5&ysicians s&ou,d ,oo= at t&e state o-
t&e eye be-ore gi%ing eryt&ropoietin to patients wit& retinopat&y. T&ey s&ou,d consider not gi%ing it to patients
wit& -u,,7b,own retinopat&y, in w&ic& abnorma, %esse,s are present, because our wor= suggests it may
acce,erate t&e disease. ;owe%er, i- a patient is ear,y on in t&e disease, t&en our wor= suggests eryt&ropoietin
may be bene@cia,.]
6/
.ancer patients, w&o o-ten ta=e eryt&ropoietin -or anemia, -ace a simi,ar potentia, ris=, says Smit&. ]Since
eryt&ropoietin &as t&e potentia, to ma=e b,ood %esse,s in tumors grow, it cou,d ma=e tumors worse, a,t&oug& a
c,inica, tria, is re#uired to =now i- t&is is true in &umans.]
O%era,,, Smit& says &er mouse studies are a reason -or doctors to t&in= and researc&ers to in%estigate, not -or
patients to panic.
Anemi a occur s w&en t &ere i s a s&ort age o- red b, ood ce, , s or w&en t &e red b, ood
ce, , s are not correct , y - ormed. $ n di a, ysi s uni t s, anemi a i s usua, , y measured by
t &e hematocri t b, ood t est , w&i c& repor t s t &e percent age o- t &e b, ood t &at i s
compr i sed o- red b, ood ce, , s. Norma, , y, a &emat ocr i t i s - rom /8O t o 38O - or
women and - rom 3(O t o 6(O - or men. ?i t &out i nt er %ent i ons, a di a, ysi s pat i ent R s
&emat ocr i t usua, , y st abi , i Bes bet ween ()7 (6O. At t &i s , e%e, , most pat i ent s t i re
easi , y and - ee, dr ai ned o- energy. Se%er a, st at i st i ca, ana, yses &a%e s&own t &at
di a, ysi s pat i ent s &a%e si gn@ cant , y more comp, i cat i ons, &ospi t a, i Bat i ons, and a
&i g&er mor t a, i t y r at e w&en t &ei r &emat ocr i t i s be, ow /)O G appro>i mat e, yH .
?i t & most pat i ent s now rout i ne, y recei %i ng <5O dur i ng t &ei r di a, ysi s t reat ment s,
&emat ocr i t s are rout i ne, y i n t &e r ange o- /)7 /'O. T&e N!:7 DO^$ recommended
t arget &emat ocr i t r ange - or di a, ysi s pat i ent s current , y i s //O t o /'O. Most
63
i nsur ance compani es and Medi care wi , , not rei mbur se t &e di a, ysi s - aci , i t i es - or
<5O i n4 ect i ons w&en t &e pat i ent R s &emat ocr i t i s abo%e a cer t ai n number G /'O
appro>i mat e, yH .
T&e product i on o- &ea, t &y b, ood ce, , s i s a, so dependent on t &e body &a%i ng
enoug& i ron, %i t ami n B+(, - o, i c aci d and ot &er subst ances. $ - a pat i ent does not
respond t o <5O t &er apy, t &e most , i =e, y cause i s a de@ ci ency o- i ron. :or t &i s
reason, most di a, ysi s cent er s rout i ne, y moni t or i ron , e%e, s i n t &e b, ood.
%:C:N$ AD;ANC:S 'N $5: $%:A$M:N$ O6 &0OOD D@SC%AS'AS 'N C5'0D%:N
M$LA 5$<.< M.D., $. DA0$DSO;N M.D., <D$T; 5OTT< M.D., ?$LL$AM J. S.OTT M.D., and JAM<S B. SNO? M.D.
SAM$EA A__A^, M.D.
Chairman 'ierce+ $ wis& to emp&asiBe t&at your participation

in t&e discussion is cordia,,y in%ited. $t is t&e
desire o-

t&e 5rogram .ommittee t&at t&e ound Tab,e pro%ide an opportunity

-or a,, o- us to s&are our
e>perience. T&e specia,ists w&om

we &a%e in%ited to 4oin us and w&o are we,, =nown to us &a%e

=ind,y
indicated t&eir wi,,ingness to ta=e part in t&e discussion.

Dr. $. Da%idso&n is t&e attending &emato,ogist
at Mt. Sinai

;ospita,M Dr. <dit& 5otter is t&e pat&o,ogist at .&icago Lying7in

;ospita,. T&e sub4ect -or
discussion t&is morning wi,, be ,imited

to a discussion o- acute &emo,ytic anemia o- t&e newborn, or
eryt&rob,astosis -eta,is`&emato,ogic and pat&o,ogic aspects

o- t&e disease. A,, t&e &emo,ytic anemias
&a%e certain common

c&aracteristics. <ryt&rocytes are destroyed, anemia -o,,ows,

&epatic -unction is
disturbed by ano>ia, and -urt&er impaired

by t&e demand -or t&e e>cretion o- e>cessi%e #uantities o-
b,ood

pigment. Bi,irubinemia -o,,ows. T&e &ematopoietic centers compensate

-or b,ood destruction by
de,i%ery o- reticu,ated eryt&rocytes

or normob,asts to t&e b,ood and e>tramedu,,ary eryt&ropoiesis

may
resu,t. $n t&e acute &emo,ytic anemias t&is c&ain o- e%ents

is initiated by a p,asma -actor w&i,e t&e ce,,s
66
t&emse,%es are

norma,. T&e p,asma -actor may be G+H an antibodyM G(H a to>in

o- bacteria, or spiroc&eta,
originM G/H a c&emica,, or G3H a

&ormone. $n t&e c&ronic types o- &emo,ytic anemias t&ere is

o-ten a
-ami,ia, or racia, abnorma,ity o- t&e eryt&rocytes w&ic&

predisposes it to t&e &emo,ytic eAects o- a
p,asma -actor.

<>amp,es o- &emo,ytic anemia resu,ting -rom t&ese %arious causes

are seen in t&e
newborn. G+H <ryt&rob,astosis -eta,is or &emo,ytic

disease o- t&e newborn is due to t&e antigen antibody
reaction

caused by incompatibi,ity o- b,ood groups o- mot&er and babyM

G(H &emo,ytic anemia due to
bacteria, to>in may resu,t -rom

sepsis, bronc&opneumonia or congenita, ,uesM G/H in congenita,

&emo,ytic
icterus, t&e sp,enic or &ormona, -actor toget&er wit&

eryt&rocytes w&ic& are sp&eroids rat&er t&an discs
in t&e cause

o- t&e anemia.
5emolytic Uremic Syn+rome) An :merging 5ealth %is7
SAM$EA A__A^, M.D.
T&e c,assic triad o- -eatures -or &emo,ytic uremic syndrome consists o- microangiopat&ic &emo,ytic anemia,
t&rombocytopenia, and acute rena, -ai,ure.(+7(/ .&i,dren in-ected wit& <. co,i O+68:;8 are symptomaticM
in-ected adu,ts may be asymptomatic. T&e incubation period -or <. co,i O+68:;8 is usua,,y t&ree to -our daysM
&owe%er, t&e incubation a,so can range -rom 4ust one day to eig&t days.+/ Typica, &emo,ytic uremic syndrome
usua,,y de%e,ops a-ter a prodrome o- diarr&ea. .,inica, -eatures identi-ying patients at &ig& ris= -or &emo,ytic
uremic syndrome are %ague and may mimic common gastroenteritis, inc,uding b,oody diarr&ea occurring -rom
t&ree days to more t&an two wee=s be-ore &emo,ytic uremic syndrome is diagnosed.( Additiona, symptoms
inc,ude nonb,oody diarr&ea, abdomina, cramping, and nausea or %omiting. :e%er may be ,ow grade or e%en
absent. Ten percent o- cases are associated wit& recta, pro,apse wit& co,itis.(
;emo,ytic uremic syndrome cannot be diagnosed wit&out e%idence o- &emo,ytic anemia. ;emato,ogic @ndings
inc,ude destruction and -ragmentation o- eryt&rocytes t&at resu,t in microangiopat&ic &emo,ytic anemia. T&is
6'
de%e,ops in a,, patients wit&in a day or so o- contamination and may resu,t in respiratory and cardio%ascu,ar
compromise. Mean &emog,obin concentration o- ' g per dL G') g per LH is common and re#uires red b,ood ce,,
trans-usion.( Ninety7two percent o- patients wit& &emo,ytic uremic syndrome de%e,op t&rombocytopenia, w&ic&
resu,ts -rom entrapment o- p,ate,ets in t&e organs.( .,otting times are norma,, and petec&iae and purpura are
uncommon -eatures o- &emo,ytic uremic syndrome.(( 5,ate,et trans-usion is not recommended because it cou,d
e>acerbate t&e t&rombotic processM &owe%er, ris=s and bene@ts s&ou,d be considered w&en p,ate,et trans-usion
is indicated Ge.g., in%asi%e %ascu,ar procedure, acti%e b,eedH.
Acute rena, -ai,ure resu,ts w&en microt&rombi are deposited in =idney parenc&yma. T&is mani-ests in t&e -orm o-
&ypertension associated wit& o,iguria and anuria, w&ic& are ear,y signs o- acute rena, -ai,ure.
T&e centra, ner%ous system is anot&er organ system t&at cou,d become in%o,%ed. T&irty7t&ree percent o-
patients wit& &emo,ytic uremic syndrome e>perience neuro,ogic comp,aints suc& as irritabi,ity, seiBures, and
a,tered menta, status.
Typica, &emo,ytic uremic syndrome is a se,-7,imiting disease wit& spontaneous reco%ery, a,t&oug& c,ose
monitoring and treatment o- symptoms are essentia,. Because &emo,ytic uremic syndrome &as a wide spectrum
o- presentations, supporti%e t&erapy Ge.g., good nutrition, c,ose monitoring o- Kuid and e,ectro,yte statusH is
crucia, -or a good outcome. ecent studies indicate t&at t&e amount o- parentera, &ydration gi%en to a patient
be-ore t&e de%e,opment o- &emo,ytic uremic syndrome, especia,,y t&e amount o- sodium, is crucia, in
pre%enting anuria and, u,timate,y, dia,ysis.
68
Strict Kuid ba,ance monitoring is important in detecting ear,y rena, -ai,ure. $- -ai,ure de%e,ops, it s&ou,d be
&and,ed aggressi%e,y(3 by starting rena, rep,acement t&erapy Ge.g., peritonea, dia,ysis,
&emodia,ysisH.;ypertension is treated traditiona,,y wit& anti&ypertensi%es and diet.
Antibiotics and antimoti,ity agents are not recommended as treatments -or &emo,ytic uremic syndrome during
t&e diarr&ea, stage o- t&e disease. Studies o- antibiotic usage in c&i,dren wit& <. co,i O+68:;8 in-ections s&ow an
increased ris= o- comp,ications -rom &emo,ytic uremic syndrome.(6,(' One study reported t&at using antibiotics
to treat c&i,dren testing positi%e -or <. co,i O+68:;8 increased t&eir ris= o- de%e,oping &emo,ytic uremic
syndrome.(' Additiona,,y, some c&i,dren w&o were diagnosed wit& S&ige,,a dysenteriae type + and treated wit&
ampici,,in de%e,oped &emo,ytic uremic syndrome.(6
Seria, monitoring o- t&e &ematocrit and p,ate,et count is important. .urrent,y, p,ate,et trans-usion is
contro%ersia, because it can worsen t&e t&rombotic process.(8 ;owe%er, trans-usion o- red b,ood ce,,s may be
needed to aggressi%e,y correct anemia, w&ic& can deteriorate t&e patientRs condition and -urt&er comp,icate t&e
picture by causing respiratory and cardio%ascu,ar compromise.
Moda,ities suc& as p,asmap&eresis, antit&rombotic agents, steroids, and S&iga to>in7binding agents &a%e pro%ed
ineAecti%e and remain contro%ersia,.
6*