I. INTRODUCTION Idiopathic thrombocytopenic purpura (ITP) is a blood disorder of unknown cause characterized by an abnormal decrease in the number of platelets in the blood. Platelets are cells in the blood that help stop bleeding. People who have ITP often have purple bruises (purpura) that appear on the skin or on the mucous membranes. The bruises mean that bleeding has occurred in small blood vessels under the skin. A person who has ITP may also have bleeding that result in tiny red or purple dots on the skin. These pinpoint-sized dots are called petechiae and it may look like a rash. Idiopathic thrombocytopenic purpura, also known as immune thrombocytopenic purpura is classified as an autoimmune disease. In an autoimmune disease the body forms antibodies that destroy its own blood platelets. Platelets are marked as foreign by the immune system and eliminated in the spleen, or sometimes the liver. There are three types of ITP: acute (temporary or short-term), chronic (long-lasting), and recurrent (intermittent). Acute ITP generally lasts less than 6 months. It mainly occurs in children, both boys and girls, and is the most common type of ITP. Acute ITP often occurs after an infection caused by a bacteria or a virus. Chronic ITP is long-lasting (6 months or longer) and mostly affects adults. However, some teenagers and children can get this type of ITP. Chronic ITP affects women 2 to 3 times more often than men. Treatment depends on how severe the bleeding symptoms are and the platelet count. In mild cases, treatment may not be needed. Recurrent ITP was characterized by intermittent episodes of thrombocytopenia followed by periods of recovery, unrelated to therapeutic intervention. It is a rare, mild, self-limited type of ITP, although intracranial hemorrhage 1
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I. INTRODUCTION
Idiopathic thrombocytopenic purpura (ITP) is a blood disorder of unknown cause characterized
by an abnormal decrease in the number of platelets in the blood. Platelets are cells in the blood that help
stop bleeding. People who have ITP often have purple bruises (purpura) that appear on the skin or on the
mucous membranes. The bruises mean that bleeding has occurred in small blood vessels under the skin. A
person who has ITP may also have bleeding that result in tiny red or purple dots on the skin. These
pinpoint-sized dots are called petechiae and it may look like a rash. Idiopathic thrombocytopenic purpura,
also known as immune thrombocytopenic purpura is classified as an autoimmune disease. In an
autoimmune disease the body forms antibodies that destroy its own blood platelets. Platelets are marked
as foreign by the immune system and eliminated in the spleen, or sometimes the liver.
There are three types of ITP: acute (temporary or short-term), chronic (long-lasting), and
recurrent (intermittent). Acute ITP generally lasts less than 6 months. It mainly occurs in children, both
boys and girls, and is the most common type of ITP. Acute ITP often occurs after an infection caused by a
bacteria or a virus. Chronic ITP is long-lasting (6 months or longer) and mostly affects adults. However,
some teenagers and children can get this type of ITP. Chronic ITP affects women 2 to 3 times more often
than men. Treatment depends on how severe the bleeding symptoms are and the platelet count. In mild
cases, treatment may not be needed. Recurrent ITP was characterized by intermittent episodes of
thrombocytopenia followed by periods of recovery, unrelated to therapeutic intervention. It is a rare, mild,
self-limited type of ITP, although intracranial hemorrhage may occur in a profoundly thrombocytopenic
child. Recurrence may occur close or far apart to a previous isolated thrombocytopenia episode.
This study is a case of a 2-month old baby boy, admitted at Pediatric unit of Manila Adventist
Medical Center due to fever, petechial rashes, and purpura on his trunk and extremities. The patient has
been diagnosed with Idiopathic Thrombocytopenic Purpura (ITP). The scope of this study encloses the
admission date, November 27, 2009 until his discharged date on December 10, 2009. The study includes
the maternal history, birth and past medical history of the patient. The disease process will provide the
students the knowledge on how the disease acquired and progresses. The laboratory exam and diagnostic
procedures use to diagnose ITP is also included as well as medication and health teaching given. The
purpose of this study is to let the students understand and have the knowledge on how to deal with clients
with idiopathic thrombocytopenic purpura.
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II. DEMOGRAHIC DATA
This is a case of a 2-month old baby boy born on September 23, 2009 via normal spontaneous
delivery with assisted midwife at their home in Makati City. In the course of this study, the patient was
named as Barney to protect his identity. Barney and his parents are currently residing at 319 Duhat Street,
Comembo Makati City. His father is a born-again Christian while his mother is a Seventh-day Adventist
believer. Both of his parents are a Filipino citizen and finished secondary education. Barney’s mother is a
plain housewife while his father is a tricycle driver. In this study the informants are his parents.
Barney was admitted at Pediatric Unit of Manila Adventist Medical Center on November 27,
2009 with an initial diagnosis of Idiopathic Thrombocytopenic Purpura vs. Evans Syndrome. He was
discharged on December 10, 2009 with the final diagnosis of Idiopathic Thrombocytopenic Purpura.
III. CHIEF COMPLAINT
Fever and generalized petechial rahes (face, trunk, and extremities):
“Ang init ng katawan niya at ang dami niyang pasa at rashes” (“His body is hot and have lots of
bruises and rashes”), as verbalized by the patient’s mother.
IV. HISTORY OF PRESENT ILLNESS
Barney was apparently well until four (4) days prior to admission (PTA) when he was noted to
have undocumented fever and petechial rashes on his face and buccal mucosa. His mother gave him
antipyretic (Calpol) which provided a temporary relief.
Three (3) days PTA, rashes had already spread on his extremities. His fever had gradually
decreased but the rashes remained all over his body and extremities.
Morning PTA, the persistence of the condition prompted the parents to consult at a nearby
hospital wherein a decreased hemoglobin, hematocrit, erythrocytes, segmenters and eosinophils were
noted. On the other hand, he had increased amounts of lymphocytes and monocytes. There were
generalized petechial rashes and ecchymoses on the trunk and extremities noted. They were advised
admission but due to room unavailability, they were referred and transferred to Manila Adventist Medical
Center and were subsequently admitted.
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V. PAST MEDICAL HISTORY
Prior to diagnosis of having Idiopathic thrombocytopenic purpura, Barney did not have any
serious illness since birth. He is completely immunized with BCG, OPV, 1st dose of DPT, 1st and 2nd
dose of Hepatitis B vaccine. He has not undergone any operations, no recorded injury and no known
allergies to any food or drug.
A). Birth History:
According to Barney's mother, during her pregnancy, she had a hard time working at the
computer shop. She always feels restless and over fatigued after the day’s work. The mother noted that
she had urinary tract infection during her 6th month of pregnancy to Barney, thus she took Amoxicillin,
three times a day for 7 days.
Natal History
Barney was delivered via normal spontaneous delivery at home with assisted midwife. No NBS
and APGAR scoring done according to his mother. He had a birth weight of 4.1 kg. (9 lbs.), with no
fetomaternal complications noted.
Postnatal History
Barney was in a good condition at birth. There were no complications noted during the first 28
days of his life. He was breastfed by his mother.
B). Growth and Development History:
Barney grow rapidly both in size and his ability to perform tasks. He can regard with social smile
directly at people, making cooing sounds, can locate a sound in front of him, but not one behind,
differentiates cry; cries to seek attention and kicks and waves his arms when he is excited. He can turns
from side to back and shows eye coordination to light and objects.
Barney can recognize familiar face, enjoys sucking- puts hand in mouth, anticipate being feed
when in feeding position and becomes more aware and interested in environment.
C). Childhood Illnesses:
Barney did not have any serious illnesses. He just had experienced fever sometimes.
D). Immunizations/Vaccination History:
Barney was completely immunized with BCG, OPV, 1st dose of DPT and two doses of Hepatitis
Sensorimotor intelligence is practical intelligence, because words and symbols for thinking and
problem solving are not yet available at this early age. Primary Circular Reaction refer to activities related
to a child’s own body and shows that repetition of behaviors occurs.
Barney usually put his thumb to his mouth and enjoys the sensation of sucking it. He smiles
whenever he hears his parent’s voice and when his name was called. He cries as a response to pain.
Fowler’s Developmental Theory
In this stage, infant centers on relationship with primary caregiver. Barney centers his relationship
to his mother. He usually cries when his mother is not around that is why they always bond together.
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IX. GORDON’S ASSESSMENT
Health-Perception/Health Management Pattern
Before Barney was admitted, his mother usually brought him to the nearest health center for his
vaccination. His mother gives him vitamins and he is breastfed. When Barney had fever, they gave him
antipyretic (Calpol) which provided a relief. Four days before Barney was admitted, his mother noticed
petechial rashes all over his body and thought it was just a common rash. When the fever had gradually
decreased but the rashes all over his body remained, they got worried and brought him to the nearest
hospital.
Upon hospitalization Barney had been diagnosed with ITP. His parents did not know where and how
their son acquired his disease. His mother believes that this hospitalization will help his son to recover.
Nutritional/Metabolic Pattern
Barney was born a healthy baby boy with a birth weight of 4.1 kg (9 lbs.). The normal weight
gain for 0-4 months is 170 grams (.37 lbs) per week. Before he was admitted, his appetite was very good.
He usually fed every 2-3 hours within 5-10 minutes. He is taking Tiki-tiki vitamins.
During his hospitalization, his appetite was slightly reduced and his admitting weight was
decreased from 5.8 kg to 5.6 kg which is still within the normal range. Barney was not allowed to take
any vitamins during the course of his hospitalization.
Elimination Pattern
Before Barney was admitted, he had 2-3 bowel movement everyday with yellow color, not foul in
odor, formed, and moderate in amount.
During his hospitalization, his bowel movement has not changed. His stool has the same
characteristics as before. He has no problem in urination as evidenced by normal urinalysis results.
Activity/Exercise Pattern
Before Barney was admitted he usually played with peek-a-boo and rattles with his mother. He
enjoys listening to her voice and in return he smiles and laughs. Barney cries whenever he feels hungry
and when his diaper was soaked with urine and stool. He takes a bath everyday.
During his hospitalization, he still smiles and laughs whenever his mother played with him but
most of the time he cries.
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Sleep/Rest Pattern
Normally baby’s average sleeping rate is 15-16 hours. Barney sleeps mostly at night and will stay
awake much longer during the day and takes 2-3 naps a day according to his mother.
During his hospitalization, his sleeping pattern had been disturbed because of routine vital signs
taking and whenever he undergoes laboratory and diagnostic procedures.
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X. PHYSICAL ASSESSMENT
PhysicalAssessment
November 27, 2009(Admission Day)
November 29, 2009(Initial Visit)
a. General Appearance: Admitted this 2 month old baby boy with fever and petechial rashes on face, trunk, and extremities, awake, alert, not in cardiorespiratory distress.
Assessed this 2 month old baby boy admitted on 10/27/09, afebrile, still with generalized petechial rashes and ecchymoses, asleep, on supine position with IVF of #4 D5IMB 500cc x 24 cc/hr on left hand, patent and infusing well.
b. Vital Signs: BP – 100/90 mmHgT – 39.3 C
HR – 137 beats/minRR – 40 breaths/min
Wt – 5.8 kg. (12.8 lbs.)
BP – 100/70 mmHgT – 36. 1 C
HR – 119 beats/minRR – 30 breaths/min
Wt – 5.6 kg. (12.3 lbs)
c. Skin: Warm, pale, good skin turgor, with generalized petechial rashes on face, trunk and extremities
Pale, good skin turgor, still with generalized petechial rashes on face, trunk and extremities
d. Head and Neck:Normocephalic, flat fontanels, no lesions, no clad
Normocephalic, flat fontanels (anterior fontanel /open), no lesions, no cladHead Circumference: 41 cm
e. Eyes:
Pupil reactive to light, pale palpebral conjunctiva
Pupil reactive to light, pale palpebral conjunctiva, presence of conjunctival hemorrhage on left eye
f. Ears: Intact tympanic membrane, no discharge
Intact tympanic membrane, no discharge
g. Nose: Symmetrical, no deformity, no skin lesions, no swelling, no discharge
Symmetrical, no deformity, no skin lesions, no swelling, no discharge
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h. Mouth and Throat: Presence of petechial rashes on buccal mucosa and tongue midline
Presence of petechial rashes on buccal mucosa and tongue midline
i. Breasts: No lumps, no discharge No lumps, no discharge
j. Chest/Lungs: Symmetrical chest expansion, no retractions, clear breath sounds
Symmetrical chest expansion, no retractions, clear breath soundsChest Circumference: 44 cm
k. Heart: Dynamic precordium, normal rate, regular rhythm, no murmurs
Dynamic precordium, normal rate, regular rhythm, no murmurs
l. Abdomen: Globular, soft, normoactive bowel sound
Globular, soft, normoactive bowel soundAbdominal circumference: 43.5 cm
m. Back Presence of petechiae and ecchymoses, no back deformities
Presence of petechiae and ecchymoses, no back deformities, diaper rash on the buttocks
n. Extremities: Full and equal pulse, presence of petechiae and ecchymoses on upper and lower extremities
Full and equal pulse, presence of petechiae and ecchymoses on upper and lower extremities
o. Genitalia: Grossly normal, no hernia, no discharge
Grossly normal, no hernia, no discharge
p. Rectal: No hemorrhoids No hemorrhoids
q. Neurologic Assessment:
Not assessed Calm, active reflexes ( sucking, rooting, moro, palmar, tonic neck, and babinski reflex )
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X1. REVIEW OF SYSTEMS
Systems November 27, 2009(Admission Day)
November 29, 2009(Initial Visit)
a. Skin: () rashes (-) lumps(-) itching(-) dryness() pallor() petechiae and purpura on extremities and trunk
() rashes (-) lumps(-) itching(-) dryness() pallor() petechiae and purpura on extremities and trunk
b. Head: (-) headache(-) head injury
(-) headache(-) head injury
c. Eyes: (-) pain(-) redness(-) double vision(-) glaucoma(-) cataracts
White blood cells exist in variable numbers and types but make up a very small part of blood's
volume--normally only about 1% in healthy people. White blood cells are the largest of the blood cells
but also the fewest. There are 5,000 to 10,000 white blood cells per micro liter. There are several different
types of white cells but all are related to immunity and fighting infection. Leukocytes are not limited to
blood. They occur elsewhere in the body as well, most notably in the spleen, liver, and lymph glands.
Most are produced in our bone marrow from the same kind of stem cells that produce red blood cells.
Others are produced in the thymus gland, which is at the base of the neck. Some white cells (called
lymphocytes) are the first responders for our immune system. They seek out, identify, and bind to alien
protein on bacteria, viruses, and fungi so that they can be removed. Other white cells (called granulocytes
and macrophages) then arrive to surround and destroy the alien cells. They also have the function of
getting rid of dead or dying blood cells as well as foreign matter such as dust and asbestos. Red cells
remain viable for only about 4 months before they are removed from the blood and their components
recycled in the spleen. Individual white cells usually only last 18-36 hours before they also are removed,
though some types live as much as a year.
C. Platelets (Thrombocytes)
Platelets are only about 20% of the diameter of red blood cells, the most numerous cell of the
blood. The normal platelet count is 150,000-450,000 per microliter of blood, but since platelets are so
small, they make up just a tiny function of the blood volume. The principal function of platelets is to
prevent bleeding. Platelets are produced in the bone marrow, the same as the red blood cells and most of
the white blood cells. They are produced from very large bone marrow cells called megakaryocytes. As
megakaryocytes develop into giant cells, they undergo a process of fragmentation that results in the
release of over 1,000 platelets per megakaryocytes. The dominant hormone controlling megakaryocytes
development is thrombopoietin.
Platelets are not only the smallest blood cell, they are the lightest. Therefore they are pushed out
from the center of flowing blood to the wall of the blood vessel. There they roll along the surface of the
vessel wall, which is lined by cells called endothelium. The endothelium is a very special surface, like
Teflon, that prevents anything from sticking to it. However when there is injury or cut, and the
endothelial layer is broken, the tough fibers that surround a blood vessel are exposed to the liquid flowing
blood. It is the platelets react first to injury. The tough fibers surrounding the vessel wall, like an envelop,
attract platelets like a magnet, stimulate the shape change, and platelets the lump onto these fibers,
providing the initial seal to prevent bleeding, the leak of red blood cells and plasma through the vessel
injury.
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Platelets are vital for normal blood clotting. Produced in the bone marrow, they circulate in the
blood until they are needed. When there is an injury to a blood vessel, platelets adhere to the injury site
(with the help of von Willebrand factor, which acts as the “glue”), aggregate with other platelets, release
compounds that stimulate further aggregation, and form a loose platelet plug in a process called
hemostasis.
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XVI. PATHOPHYSIOLOGY
A. Pathophysiology Diagram
Etiology: Idiopathic Predisposing factors:-Common in children less than 2-4 y.o.-Previous exposure to bacterial infection during prenatal period. (UTI of mother)-Recent live/attenuated vaccines
Risk factors:-Age (common in children and young adults)-Gender (common in women)
Inflammatory response of the body
Fever-T-39.3°C
Body weaknessDec. 1, 2009
Stimulates immune system
Dominance of pro-inflammatory cytokines & T-cell repertoire
Idiopathic thrombocytopenic purpura (ITP), also called immune thrombocytopenic purpura, is a
blood-clotting disorder that can lead to easy or excessive bruising and bleeding. ITP results from
unusually low levels of platelets, the cells that help the blood clot. ITP is a common manifestation of
autoimmune disease in children. The syndrome maybe preceded by bacterial/viral infection.
In the patient’s case previous infection of the mother and recent live/ attenuated vaccines
triggered him to acquire the disease. The dominance of pro-inflammatory cytokines and T cell repertoire
causing the body to develop fever and cough as an inflammatory response of body against infection that
persist in patient creating a permissive environment for the emergence of previously suppressed auto
antibodies that will triggers the immune system to have an abnormal autoimmune reaction where in the
antibodies produced bind with viral antigen and cross react with platelet causing the platelet membrane
proteins become antigenic and stimulate the immune system to produce auto antibodies and cytotoxic
cells. These auto antibodies are against platelet glycoprotein GPIIb-IIIa or GP1b-IX that attributed to the
ability of these auto antibodies to coat circulating platelets. Instead of only phagocytosing the viral
antigen by splenic macrophages what happens is, it also phagocytosed the antibody coated platelet
because the body cannot distinguished self from non self. Cytotoxic cells damage megakaryocyte
production of new platelets causing the platelets to survive only a few hours instead of normal which is 7-
10 days that result in destruction of platelets because of cytotoxic T cells and splenic macrophages that
result in decrease platelets count.
There is altered blood clotting due to decrease number of platelets and not due to absence of
clotting factors. Thus, delayed wound healing is present that results to hemorrhage. On the other hand
when blood vessels have been damaged leakage in blood vessels is also manifested that results in local
hemorrhage. There are three things that can happen if there is hemorrhage. First, it will result to decrease
in blood volume and because of it dehydration can occur and narrow pulse pressure will be evident.
Second, a decrease in number of RBC and hemoglobin causes decrease in oxygen supply to the body;
leading to body weakness and pale skin color as manifested by the patient. Third, petechial rashes and
purpura on the face, trunk, extremities, buccal mucosa, tongue midline and left eye will be visible because
of ruptured blood vessel. On Barney’s CT scan result there is a small focus of hemorrhage seen on the left
side of his vermis. This finding may result to permanent loss of brain function and probably death.
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VII. NURSING CARE PLAN
Problem Prioritization
1. Acute pain
2. Risk for further bleeding
3. Fever
4. Risk for infection
5. Body weakness
6. Lack of knowledge
7. Disabled family coping
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NURSING PROBLEM with
CUES
NURSING DIAGNOSIS with RATIONALE (with
reference)
(SMART) GOALS/ OBJECTIVES
NURSING INTERVENTIONS
RATIONALE FOR INTERVENTIONS
EXPECTEDOUTCOMES
EVALUATION
1. Acute painDate: Nov. 30,2009
Subjective:
“Iyak siya ng iyak dahil kakatapos niya pa lang ng bone marrow aspiration”, as verbalized by the mother.
Objective:
• moaning • vigorous cry• T – 36.5 ˚C• ↑ HR-62 bpm• ↑ RR-165 bpm• BP 100/70mmhg• Restlessness• Irritability
Acute pain related to actual tissue damage.
Rationale:An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; pain may be sudden or slow onset, vary in intensity from mild to severe, and be constant or recurring; duration of pain is less than 6 months; and period of pain has an anticipated or predictable end. (Parks and Taylor’s Nursing Diagnosis Reference Manual 7th edition; p. 508)
Short term goal:
Within 30 minutes to 1 hour of nursing interventions, the patient will show signs of relief from pain and discomfort as evidence by having a good cry, not irritable, and by being calm. Long term goal:
After 2-3 days of nursing interventions, patient will be free from pain discomfort as evidenced by continually being calm and not irritable.
1. Assessed child’s physical symptoms and behavioral cues such as moaning and crying.
2. Repositioned the client and gave other comfort measures.
3. Applied heat or cold as appropriate to the pain site.
1. Young child lacks verbal skills to describe variation in pain sensation. Observations of non-verbal behavior provide alternative means to assess pain in a child. (Nursing Diagnosis Reference Manual 7th ed. p.509)
2. Non pharmacologic techniques decrease the pain and may enhance the effectiveness of analgesics if given by reducing muscle tension.(Nursing Diagnosis Reference Manual 7th ed. p.509)
3. Applying heat relaxes the muscles and decreases pain. Applying cold results in vasoconstriction reducing inflammatory response and reducing pain.(Nursing Diagnosis Reference Manual 7th ed.
1. Child will demonstrate improve comfort through less cry, smiling, playful behavior, good appetite (breastfeed) and responsive behavior.
Short term goal:Goal not met. The patient is still in pain and discomfort.
Long term goal:Goal met. The patient was free of pain and discomfort.
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4. Helped the child obtained an interrupted rest periods.
5. Anticipated and checked the patient from time to time for onset of pain.
6. Administered pain medication as ordered, Paracetamol (Calpol) 0.6ml drops
7. Provided non-pharmacologic treatment such as giving bonding or encouraging touch therapy of the mother for the infant and providing classical music.
p.509)
4. Adequate rests promotes the child’s well being and enhances the effectiveness of pain medication.(Nursing Diagnosis Reference Manual 7th ed. p.509)
7. Touch is the most intimate and meaningful of nonverbal techniques that could also be therapeutic. It lessens pain and diverts the child’s feelings when he is aware that the primary caregiver (mother) is present. The type of children to which children prefer to listen often conveys and soothes their mood.
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8. Provided a variety of stimulating toys and divertional activities and play for the infant such as playing a “peek-a-boo” and rattles.
(Pillitteri, Adele; MCHNursing; p.998)
8. It is an additional, yet important and creative interventions that can divert the child’s attention, promote a sense of well-being, and make the child more invigorated. It can also enhance and develop the child’s neurologic system and reflex activities as well.(Pillitteri, Adele; MCHNursing; p. 1054)
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NURSING PROBLEM with
CUES
NURSING DIAGNOSIS with RATIONALE
(with reference)
(SMART) GOALS/ OBJECTIVES
NURSING INTERVENTIONS
RATIONALE FOR INTERVENTIONS
EXPECTEDOUTCOMES
EVALUATION
2. Risk for Further Bleeding
Date: Nov. 29, 2009
Subjective:
“Ang dami niyang pasa at rashes” as verbalized by the patient’s mother.
Objective:
Petechial Rashes and ecchymoses on body and extremities
High Risk for Injury: Bleeding related to decreased platelet count
Rationale:
Platelets play an important role in clotting and bleeding. In people with a low platelet count, bleeding is more likely to occur, even after a slight injury. Low platelet count may result in spontaneous bleeding.(Merck Manual, 2009, Sec. 3, chapter 49)
Short term goal:
Within the shift, patient’s risk for further bleeding is reduced as evidenced by vital signs within normal range, absence of narrowed pulse pressure and decreased signs of bleeding (bruises/ petechiae, epistaxis, bleeding gums, abdominal pain, hematemesis, hematuria, melena).
Long term goal:
Within 2-3 days of nursing interventions, patient will maintain reduced risk of further bleeding as evidence by normal platelet count and absence of any signs of bleeding (bruises/petechiae)
1. Assessed and monitored vital signs.
2. Assessed for any signs of bleeding.
3. Monitored platelet count.
4. Avoided IV /SC injections and rectal procedures (such as enemas and rectal temperature taking) as necessary.
5. Placed sign over patient’s bed as reminder of bleeding precautions.
1. Increased heart rate and orthostatic changes accompany bleeding. (NCP. 3rd ed., Schroeder & Jones, 1994, p 389)
2. Bleeding may be obvious (bruises/ petechiae epistaxis, bleeding gums, abdominal pain, hematemesis, melena, hematuria). (NCP. 3rd ed., Schroeder & Jones, 1994, p 389, 422)
3. Spontaneous bleeding can occur at platelet count <50,000/mm3
4. Can stimulate bleeding; to reduce unnecessary trauma. (NCP. 3rd ed., Mc McCarthy & Schroeder, 1994, p 383, 423)
5. To apply pressure after venipunctures and prevent unnecessary trauma. (NCP. 3rd ed.,
1. Patient will reduce risk of bleeding.
2. Patient will be free from any injury.
Short term goal:
Goal partially met. After 8 hours shift, patient still at risk for bleeding but eventually reduced as evidenced by vital signs within normal range, absence of narrowed pulse pressure and diminished signs of bleeding (epistaxis, hematemesis, hematuria, melena)
7. Transfused platelets concentrate as prescribed.
8. Administered Hydrocortisone as ordered.
Puzas, 1994, p 425)
6. To prevent falls/ injury.(NCP. 3rd ed., Schroeder, 1994, p 422)
7. To restore platelets level. (NCP. 3rd ed., Schroeder & Jones, 1994, p 389)
8. Inhibition of prostaglandin formation by hydrocortisone enhances hemostasis by allowing vasoconstriction to be maintained.( Blajchman et al, 1979 p 63)
RR– 34 bpm
Long term goal:
Goal partially met. After 3 days of nursing interventions, patient maintained reduced risk for bleeding as evidenced by diminished signs of bleeding (bruises/petechiae).
Fever is considered one of the body's immune mechanisms to attempt a neutralization of a perceived threat inside the body. Temperature is ultimately regulated in the hypothalamus. When the set point is raised, the body increases its temperature through both active generations of heat and retaining heat and vasoconstriction both reduces heat loss through the skin and causes the person increases temperature. (NCP 7th Edition; Doenges; pp 775)
Short term goal:
After 2 hours of nursing interventions the patient’s body temperature will decrease from 39.3°C to 37.5°C.
Long term goal:
After 2-3days of nursing interventions the patient’s body temperature will be stable within normal range.
1. Monitored client temperature (degree and pattern), note shaking chills/ profuse diaphoresis.
2. Monitored environmental temperature; limited/added bed linens as indicated.
3. Provided tepid sponge baths, avoid use of alcohol
4. Administered Calpol as indicated.
5. Provide blankets.
1. Temperature of 38.9-41°C suggests acute infection due to disease process.
2. Room temperature and number of blanket should be altered to maintain near-normal body temperature.
3. May help to reduce fever. Alcohol can cause chills and elevates body temperature and can also dry the skin.
4. Use to reduce fever by its central action on the hypothalamus.
5. Use to reduce fever, usually higher than 104-105F and is a helpful aid to prevent chills.
Patient will demonstrate normal temperature of 37.5°C.
Short term goal:
Goal met. After 2 hours of nursing interventions, patient’s body temperature decreased as evidenced by normal body temperature of 37.5°C and absence of any complications.
Long term goal:
Goal met.After 2-3 days of nursing interventions, patient’s body temperature remained stable.
“Ang daming test na ginagawa sa kanya, ang daming beses nyang kinunan ng dugo”as verbalized by the patient’s mother.
Objective:
the patient is staying in the hospital
presence of IVF puncture sites
Undergoing invasive procedure like blood transfusion.
broken skin/impaired skin integrity because of needle insertion from the IVF
Risk for infection may be related to presence of IVF, undergoing invasive procedure and being immune-compromised.
Rationale:
Broken skin because of presence of IVF and undergoing invasive procedures like blood transfusion and bone marrow aspiration may cause infection because of impaired skin integrity. (Luxner, Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed., 2005, p.50)
Short term goal:
After 30 minutes of nursing interventions the significant others will be able to perform appropriate hand washing.
Long term goal:Within the hospital days the client’s IV site will be clean and dry, without redness, edema, drainage or odor.
1. Assessed temperature every 4 hours.
2. Assessed IV site for edema, infiltration, redness, and warmth every 4 hour.
3. Washed hands before and after providing care for patient. Teach family of the child to wash hands frequently.
4. Changed IV site and tubing every 24 to 72 hours according to protocol.
1. Temperature above 37.5˚ or increase WBC may indicate development of infection. (Luxner, Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed., 2005, p.50)
2. Indicates phlebitis or dislodgement of infusion catheter for administration of fluids and IV medications. (Luxner, Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed., 2005, p.50)
3. Hand washing prevents the spread of microorganisms that may cause infection.(Luxner, Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed., 2005, p.51)
4. Prevents bacterial growth and prolonged irritation to vein. (Luxner, Karla, Delmar’s Pediatric Nursing Care
1. After the interventions the significant others will demonstrate proper hand washing procedures.
2. After the interventions the client’s IV site will be clean and dry, without redness, edema, drainage or odor.
Short term goal:
Goal met. After 30 minutes of nursing interventions the significant others was able to demonstrate proper hand washing.
Long term goal:
Goal met. During the patient’s hospital days the client’s IV site has been clean and dry, without redness, edema, drainage or odor.
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5. Administered Amikacin and Amoxicillin as ordered by physician.
Plan, 3rd ed., 2005, p.51)
5. Prevents irritation to vein and phlebitis as the drug action; for prophylaxis.(Luxner, Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed., 2005, p.53)
NURSING PROBLEM with
NURSING DIAGNOSIS with RATIONALE (with
(SMART) GOALS/ OBJECTIVES
NURSING INTERVENTIONS
RATIONALE FOR INTERVENTIONS
EXPECTEDOUTCOMES
EVALUATION
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CUES reference)
5. Body WeaknessDate: Dec. 01, 2009
Subjective:
“Hindi masyadong ngumingiti sa amin si baby kapag nilalambing namin siya. Parang nananamlay siya,” as verbalized by the patient’s mother.
Objective:
(+) Irritability (+) Restlessness Discomfort (+) Pallor on skin
Activity intolerance r/t generalized weakness and low oxygen supply in the body 2° to decreased RBC and decreased hemoglobin.
Rationale:
RBC is responsible for the delivery of oxygen to our body. Decreased levels caused decreased supply of oxygen to different parts of the body which eventually leads to fatigue.Intolerance in activity may affect the client physiologically and psychologically, and may not complete required or desired daily activities. (Geisller-Murr;2005:389)
Short term goal:
After 8 hours of nursing interventions, the patient will be able to tolerate activity as evidenced by interaction with parents such as responding through smiling and being able to tolerate feeding.
Long term goal:
After 3 days of nursing interventions, the patient will be able to continually experience comfort as evidenced by being interactive most of the time with people and responding positively through smiling and moving spontaneously.
1. Assessed functional ability/extent of impairment initially and on a regular basis.
2. Evaluated action of irritability and fatigue of the patient from parents.
3. Provided quiet environment and uninterrupted rest periods. Encouraged parents to have rest periods for the child before feeding.
4. Instructed parents and assisted in changing position at least every 2 hours (supine/side lying).
5. Set goals with parents/significant others for play or activities of the baby (solitary) such as making cooing sounds, providing objects with sounds (colored rattles), colored mobiles, etc.
1. Identifies strengths/deficiencies and may provide information regarding recovery to the parents. (Doenges;2006:232)
2. Effects of anemia may be cumulative, necessitating assistance. (Doenges;2006:232)
3. Restores energy needed for activity, cellular regeneration, and tissue healing. (Doenges;2006:232)
4. Reduces risk of tissue ischemia/injury. (Doenges;2006:233)
5. Promotes a sense of expectation of progress/improvement, including enhancement of the infant’s immune system and development of his reflexes such as grasping reflex. (Doenges;2006:233)
1. Patient will be able to demonstrate measurable increase in activity tolerance.
2. Patient show absence of body weakness.
Short term goal:
Goal partially met. Patient was able to demonstrate measurable increase in activity through being responsive to others but still maintained low levels of CBC results, making the patient less energetic.
Long term goal:
Goal partially met. Patient was able to participate in play activity as evidenced by smiling and energetic movements whenever
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feeding/ decreased sucking during feeding
6. Recommended breastfeeding for the baby.
7. Monitored CBC (laboratory results) especially RBC and platelet.
8. Transfused PRBC and platelet concentrate as prescribed.
9. Provided supplemental fluids such as IVF#5 (D5IMB 500cc x 24cc/hr)
6. Breastfeed milk is more nutritious for infants. It has certain antibodies that give more protection to the baby against diseases. (Doenges;2006:233)
7. Decreased levels indicate actual problems and may pose possible complications. (Doenges;2006:233)
8. It is essential to replace blood lost through disease. This would enable the body’s system to replace RBCs and hemoglobin which are responsible for maintaining the iron status and oxygenation of the body and the platelets that are responsible for clotting action in response to inflammation and bleeding. (Doenges;2006:233)
9. To avoid dehydration and exhaustion.(Doenges;2006:233)
parents and nurses make cooing sounds or provide colorful mobiles and objects with sounds.
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NURSING PROBLEM with
CUES
NURSING DIAGNOSIS with RATIONALE (with
reference)
(SMART) GOALS/ OBJECTIVES
NURSING INTERVENTIONS
RATIONALE FOR INTERVENTIONS
EXPECTEDOUTCOMES
EVALUATION
6. Lack of Knowledge
Date: Nov.27, 2009
Subjective:
“ hindi ko alam kung bakit nagkaganito ang anak ko” as verbalized by the patient’s mother.
Objective:
Questions/ request for information, verbalization of problem
Statement of misconception
Knowledge Deficit related to unfamiliarity with disease
Rationale:
There is a presence of knowledge deficit due to some unfamiliar information that causes some confusion to the client that needs to be discussed. (http://www.scribd.com)
Short term goal:
After 1 hour of nursing intervention the mother of the patient will verbalize accurate information about diagnosis, prognosis, and potential complications of the disease.
Long term goal:
After 2 days of nursing intervention the mother of the patient will initiate necessary lifestyle changes for her baby and correctly perform necessary procedures and explain reasons for the actions.
1. Reviewed with SO understanding of specific diagnosis, treatment alternatives, and future expectations.
2. Provided anticipatory guidance with SO regarding treatment protocol.
3. Reviewed with SO the importance of maintaining optimal nutritional status.
5. Advised patient’s mother concerning skin and hair care: e.g., avoid chlorinated water; avoid exposure to strong wind
1. Validates current level of understanding, identifies learning needs, and provides knowledge
2. Patient’s mother has the right to know (be informed) and participate in decision tree. Accurate and concise information helps dispel fears and anxiety.
3. Facilitates recovery
4. Early recognition of problems promotes early intervention, minimizing complications that may impair oral intake and provide avenue for systemic infection.
5. Prevents skin irritation.
1. The patient will verbalize accurate information about diagnosis, prognosis, and potential complications.
2. The patient will initiate necessary lifestyle changes for her baby and correctly perform necessary procedure and explain reasons for the actions.
Short term goal:
Goal met. The patient’s mother identified information about diagnosis and potential complications.
Long term goal:
The patient’s mother initiated necessary lifestyle changes for her baby and correctly performs necessary procedures and explains reasons for the actions.
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and extreme heat or cold.
6. Reviewed purpose and preparations for diagnostic studies.
7. Stated objectives clearly in learner’s term.
8. Provided written information/guidelines for the patient’s mother to refer to as necessary
9. Avoided all injections and rectal temperature.
10. Be alerted for sulfa- containing medication.
6. Anxiety/fear of the unknown increases stress level, Knowledge of what to expect can diminish anxiety.
7. To meet learner’s need.
8. Reinforces learning process.
9. To avoid stimulation of bleeding.
10. It can alter platelet function.
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NURSING PROBLEM with
CUES
NURSING DIAGNOSIS with RATIONALE (with
reference)
(SMART) GOALS/ OBJECTIVES
NURSING INTERVENTIONS
RATIONALE FOR INTERVENTIONS
EXPECTEDOUTCOMES
EVALUATION
7. Disabled Family Coping
Subjective: “Hindi naming matanggap mag-asawa na ganito ang nangyari sa anak namin.” as verbalized by the patient’s mother.
Objective:
Significant others display negative emotion towards baby’s condition
Family attempts supportive behaviors with less than satisfactory result.
Disabled family coping related to significant others unexpressed feelings of guilt, anxiety, despair and failure to deal adequately with underlying condition.
Rationale:
Family members are the source of strength and behavior of family member that disables their capabilities to address tasks essential to either person’s adaptation to the health challenge.(http://www.scribd.com)
Short term goal:
After 8 hours of nursing intervention, the SO will be able to understand and express feelings to expectations openly and honestly as appropriately within the family members.
Long term goal:
After 2 days of nursing intervention, the SO will be able to participate positively regarding patient care.
1. Noted the factors that may be stressful for the family like financial difficulty and lack of support group.
2. Assisted family to identify coping skills being used and how these skills are/are not helping them deal with situation.
3. Determined readiness of family members to be involved with care of patient.
4. Active-listen concerns: noted both over concern/ lack of concern, which may interfere with ability to resolve situation.
5. Acknowledged difficulty of the situation for the family, like reduce blaming or guilt.
6. Involved SO in the plan of care, provide instruction.
7. Refrained negative expression into positive one.
1. To assess causative factors and provide opportunity for appropriate referrals as much as possible. (Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed. 2005,p.50)
2. To promote wellness. (Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed. 2005,p.50)
3. To assess causative factor and underlying the willingness of the SO. (Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed. 2005,p.50)
4. To provide assistance to enable family to deal. (Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed. 2005,p.50)
5. To promote positive environment. (Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed. 2005,p.50)
6. To promote wellness. (Karla, Delmar’s Pediatric Nursing Care Plan, 3rd ed. 2005,p.50)
7. It helps to accept the situation easily and it will strengthen their faith towards the condition(Karla, Delmar’s
1. SO will be able to express feelings and expectations openly and honestly as appropriately
2. SO will be able to participate accordingly in care of patient within limits of family’s abilities and patient’s needs.
Short term goal:Goal met:After 8 hours of nursing intervention the SO has an open attitude and honest to expressed their feelings regarding baby’s condition and at the end of two-day duty they participated accordingly in caring the patient within the limits of patient’s needs.
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XVIII. MEDICATIONS/TREATMENT
A. GENERIC NAME(BRAND NAME)
B. GENERALCLASSIFICATION
OF DRUGS
A. INDICATIONTO PATIENT
B. OTHERINDICATIONS
C. DOSAGE
DRUG ACTION
A. SIDE EFFECTS
B. PRECAUTIONSAND SPECIAL
CONSIDERATION
(A) Amikacin (Amikin)
(B)Aminoglycoside Antibiotic
(A) Used to treat bacterial infection.
(B) Serious infection caused by the sensitive strains of pseudomonas aeroginosa, e. coli, klebsiella or staphylococcus.Uncomplicated UTI caused by organisms not susceptible to less toxic drugs.
(C) 30 mg IV q8
Binds to bacterial ribosomal subunit to cause misreading of the genetic code w/c leads to inaccurate peptide sequence of protein synthesis and bacteria death.
(A) Musculoskeletal: arthralgiarespiratory: apnea
(B) Contraindicated in patients with hypersensitivity to drug or other aminoglycosides. Use cautiously in patient with impaired renal function or neuromuscular disorder.
(A) Ampicillin (Omnipen)
(B) Beta-lactam Antibiotic
(A) Used to treat bacterial infection.
(B) Uncomplicated gonorrhea, GI infection or UTI’s
(C) 150 mg IV q6
Interferes with cell wall synthesis of susceptible organisms preventing bacterial multiplication, it also renders the cell wall osmotically unstable and burst due to osmotic pressure. Deactivated by beta- lactamase, an enzyme produced by resistant bacteria.
(B) Contraindicated in patients with hypersensitivity to drug or other penicillin.*Before giving drugs assist patient about allergic reaction to penicillin.
(A) Hydrocortisone (Cortef)
(B)Glucocorticosteroid
(A) Used for immunosuppressive effect. Treatment of autoimmune disease/ hematologic disorder (idiophatic
Glucocorticosteroids with anti inflammatory effects because of its ability to inhibit prostaglandin of
(A) CNS: vertigo, insomniaCV: heart failureGI: pancreatitis, nausea and vomiting
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thrombocytopenic purpura).
(B) Severe inflammation, adrenal insufficiency
(C) 10 mg IV q8
macrophages, leukocytes and fibroblast at sites of inflammation, phagocytosis and lysosomal enzyme release. It can also cause and reveals of increased capillary permeability.
(B) Contraindicated in patients with hypersensitivity to drug or its ingredients in those with systemic fungal infection. Determine whether the patient is sensitive to other corticosteroid.
(A) Diphenhydramine (Benadryl)
(B) Antihistamine
A) For the symptomatic relief of allergic condition including angio-edema, rhinitis and conjunctivitis and pruritic skin.
(B) Treatment of nausea and vomiting, particularly in the prevention and treatment of motion sickness.
(C) 6 mg IV
Acts on blood vessel, GI, respiratory system by antagonizing the effects of histamine for GI receptor site; decreases allergic response by blocking histamine; causes increased heart rate, vasodilation, and secretion, significant CNS depressant and anticholinergic properties.
(B) May cause drowsiness and dulling of mental alertness. It has been associated with clinical exacerbation of porphyria and is considered unsafe in porphyric patients.
(A) Paracetamol (Calpol)
(B) Antipyeretic
(A) Treatment of fever
(B) Relief of mild to moderate pain
(C) 0.6 ml drops 3x-4x/day
Decreases fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilation. Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not have anti inflammatory action because of its minimal effect on peripheral prostaglandin synthesis.
(B) The possibility of superinfections with mycotic or bacterial pathogens should be kept in mind during therapy. If superinfections occur, amoxicillin should be discontinued and appropriate therapy instituted. Because of incompletely developed renal function in neonates and young infants, the elimination of amoxicillin may be delayed. Dosing of AMOXIL should be modified in pediatric patients 12 weeks or younger (≤ 3 months).
(A) Zinc Oxide (Diaparene)
(B) Emollients & skin protectives
(A) Used to treat or prevent diaper rash.
(B) Used to treat or prevent minor skin irritations (e.g., burns, cuts, poison ivy).
(C) Topical TID
It works by providing a skin barrier to prevent and help heal skin irritation.
(A) This medication is generally well tolerated when used as directed. There are no reports of any side effects due to the use of this medication. However, if you experience any unusual effects while using this medication, notify your doctor.
(B) Tell your doctor your medical history, especially of: other skin infections/problems,
allergies (especially drug allergies). Before using this medication, tell your doctor if you are pregnant. It is not known if this medication passes into breast milk. Consult your doctor before breast-feeding.
Proper nutrition and a healthy Immune system of the body are the key measures that can be
applied to prevent the spread of bacterial or viral infection in the body.
Medications
Barney is required to take amoxicillin (antibiotic) and prophylaxis from bacterial infection and to
skin rashes. Prevention of bacterial growth is necessarily to prevent the progress of the disease.
Exercise
Encourage the significant others to continuously try to make their child fit and interact
appropriately through body movements and vocalization but do not stress them too much to prevent any
problems that can occur within stressful activities.
Therapy/Treatment
Acute idiopathic thrombocytopenic purpura may be allowed to run its course without
intervention. Alternatively, it may be treated with glucocorticoids or immunoglobulin. Treatment with
platelet transfusion has met with limited success.
Health Teaching
It is important to instruct the parents to adhere to medications and the most commonly used
antiplatelets are aspirin, heparin, abciximad (reopro) as well as food such as grape skin extract, soy sauce
and to have a follow up check up to prevent developing any complications. Breastfeeding is very
important; it reduces the chances of infection and increases the immunity of the baby. Maintaining
cleanliness in the surrounding and proper hygiene can also be very beneficial because it promotes safety
and can help in boosting body’s defense and immune system and it is also an opportunity for the parents
to monitor and really give their best care for their baby. Informing the parents of the risk associated with
the disease and ensured that they understand the need to return the patient to the hospital if bleeding
occurs. Correct information and awareness of the disease can help in avoiding more complications that
may arise in the future.
Out Patient follow-up
Regular consultation to the physician is necessary to monitor the progress of the disease and
prevent any complications from developing.
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Diet
The required diet for Barney is breastmilk which is best for him since he is just 2 months old.
Spiritual
Prayer and trusting the divine power is a healthy tip that a health care provider can give to their
patients. This will guide them spiritually and develop their faith in the almighty God that their baby will
recover and have a normal life in the future.
XX. CONCLUSION AND RECOMMENDATION
Idiopathic thrombocytopenic Purpura (ITP) is the condition of having a low platelet count of no
known cause. As most causes appear to be related to antibodies against platelets, we conclude that the
probable cause that triggered the onset of the ITP of Barney was the previous exposure to bacterial
infection during prenatal period of the mother which alters the immune response of Barney and recent
live/attenuated bacterial vaccines he received before he was admitted.
Having a child with an ITP may be a life-changing disease not only for the patient but also to his
family. We recommend the parents of a child with ITP must learn about their child’s health and condition
in order for them to manage the disease properly and appropriately in case the disease comes back again.
They must find the best hematologist available and work with them to decide which care plan is suitable
for their child. Treatment should be individualized and focused on bleeding symptoms and prevention of
treatment toxicity.
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XXI. ACKNOWLEDGEMENT
We students of Manila Adventist College Block J from section C want to express our deep sense
of gratitude to all the individuals who have given their heart whelming full support in making this case
study possible.
To our Dear Almighty God for giving us wisdom, knowledge, strength, and patience to keep us
standing and for the hope that keep us believing that this case study would be possible and more
interesting.
We also wanted to thank our family who inspired, encouraged and fully supported us for every
trials that comes our way. To our parents and guardians for their unending financial and emotional
support and understanding, thank you for being our inspiration.
To our blockmates who willingly help us gathered and provided the necessary data and
information needed for this case study.
To Mr. Oemer Rey Daquila for the encouragement, guidance and support from the initial to the
final level of this case study enabled us to develop an understanding of the subject.
To our clinical instructors and all medical staff of Pediatric Unit of Manila Adventist Medical
Center who sincerely devoted their time and service in making of this case study.
Again, we thank you all from the bottom of our heart.
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XXII. BIBLIOGRAPHY
Books:
Black, J. M., & Jacobs, E. M. (1993). Medical-Surgical Nursing: A Psychophysiologic Approach. 4 th ed. Hematologic Disorders (Pp. 1328-1332). USA: W. B. Saunders Company.
Kozier et al. “Fundamentals of Nursing” 8th Edition, Copyright 2007 by Pearson Education South Asia pte.Ltd
Lippincott Williams and Wilkins, “Nurses Quick Check: Diagnostic Tests, Copyright 2006 by Wolters Kluwer Company.
Marilyn E. Doenges, “Nursing Care Plans”, 4 th Edition, Copyright 1997 by F.A. Davis Company, Philadelphia, Pennsylvania.
Pilliteri, Adele “Maternal and Child Health Nursing: Care of the Child Bearing and Child Rearing Family”, 5th Edition. Copyright 2007 by Adele Pilitteri.
Sparks Shiela et al. “Nursing Diagnosis Reference Manual” 7th Edition, Copyright 2008 by Wolters Kluwer Company.
Taylor et al. “Fundamentals of Nursing”, 5th Edition, Copyright 2005 by Lippincott Williams and Wilkins
“PPD’s Nursing Drug Guide: For Nursing Students and Professional Nurses”, 2nd Edition, Copyright 2008 by Malan Press, Inc.
Internet Websites:
http://www.mayoclinic.com/health/ct-scan/MY00309. Mayo Clinic.com. Mayo Clinic Staff. January 12, 2008. Mayo Foundation for Medical Education and Research.
http://www.webmd.com/a-to-z-guides/blood-transfusion-risks-of-blood-transfusion. WebMD Better information. Better Health. December 27, 2007. Risk of Blood Transfusion. Healthwise Inc.
http://en.wikipedia.org/wiki/Blood_transfusion. Wikepedia the free encyclopedia