Nurse`s Work

I am a staff nurse work at government sector at hematology department. My service as a staff nurse almost 4 years. This is my semester 2 assignment which is to write a case study for my patient. I choose a patient with diagnosis of aplastic anemia as my case study for this semester.

Aplastic anemia is a one type of blood disorder. The body's bone marrow in which the soft tissue in the center of bones doesn't make enough blood cells. (Bennington-Castro, 2015) . Our blood is composed of three types of blood cells in a liquid called blood plasma which is red blood cells, white blood cells and platelet. Red blood cells help to carry fresh oxygen to the body's cells and take carbon dioxide away from cells (and to the lungs to be exhaled).While the function of white blood cells is help to fight infections and foreign invaders. Platelets are disk-shaped cell fragments which help to form blood clots to stop bleeding. These blood cells have their own lifep and die naturally, to be replaced by new blood cells formed in bone marrow.

Without this replacement process, health issues involving the heart and lungs, bleeding, and infection can develop. As a nurse, we should be very careful when taking care of patient with aplastic anemia. The purpose of this paper is to examine an aplastic anemia patient with respect to review of subjective and objective data, determination of nursing diagnosis, formation of outcomes with interventions, evaluation of the outcomes that can be identified based on the patient's scenario. This paper will further discuss about the main risk problem that patient will be develop and the nursing intervention for the problem developed. (Knott, 2014)

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In his article:

• Epidemiology?
• The annual incidence of aplastic anemia is about two cases per million population.?
• Aplastic anemia is 2-3 times more common in Asia than in the West.?
• Acquired aplastic anemia most commonly presents between the ages of 15 years and 25 years but there is a second smaller peak in incidence after age 60 years.?

Certain histocompatibility locus specificities, especially HLA DR2, are associated with an underlying predisposition to acquired aplastic anemia.Nursing assessmentSubjective dataMr. X is 57 years old gentleman, came from one of the island at Malaysia, was admitted from casualty into ward on 17/11/17 with complained of mild dizziness, gum bleeding the day before admitted but he stated that it resolve after brushing teeth. He denies any chest pain, palpitations, orthopnea, cough, fever, or chills.

According to the Mr. X he has been diagnose as aplastic anemia since February 2016 from the BMAT result on Feb 2016. Patient also stated that he have known case of hypertension since 2012. According to the patient again he have previous admission on 17/5/17 till 10/6/17 for UGIB secondary to thrombocytopenia. On 20/7/17, he was admitted due to low platelet count and bleeding at gum. He was again hospitalized on 9/9/17 due to lot platelet count. Patient denies consume of alcohol and smoking. He claims that he has no family history of malignancy and bleeding disorder.

According to the patient, he is allergy to the antibiotic penicillin which will make his body develop rashes and itchiness with mild short of breath but no known of food allergy. Currently patient claims that he staying with his wife and son.Objective dataPatient is alert, awake and oriented to self, place, and time. Full Glasgow coma scale noted (15/15). Upon physical examination, noticed scattered petechiae (pinpoint hemorrhages from arterioles or venules) at the buccal mucosa and over bilateral upper limb and lower limb.

Vital sign taken during the admission (17/11/17)

Blood pressure: 110/60mmHg

Pulse rate: 100/min

Respiratory rate: 20/min

Underarm temperature: 37 degree Celsius

Blood oxygen saturation (Spo2): 99% on room air

Pain score: 1

Weight: 70kg

Height: 162cm

Body mass index (BMI): 26

Diagnostic lab taken during the admission (17/11/17).

TEST RESULT Unit NORMAL RANGEHemoglobin (HGB) 7.8 g/dl 13.0-17.0Hematocrit (HCT) 22.4 % 40.0-50.0Platelet 4 10^3/uL 150-410White Cell Count (WCC) 1.3 10^3/uL 4.00-10.00Clinical progressReviewed by doctor in the ward, plan for 4 unit platelet transfusion and 1 pint packed cell transfusion, watch out for bleeding tendency and was started medication iv tranexamic acid 1g TDS and mouthwash tranexamic acid 10mls TDS. On the 19/11/17, 4 unit platelet transfusion done and no reaction noted during the transfusion. No sign and symptom of bleeding noted.

Nursing Diagnosis

The main nursing problem concern for this patient is risk of bleeding related to low platelet count follow by risk of fall related to dizziness. This paper will focus on risk of bleeding related to low platelet count based on the data collected. The nursing care plan will include intervention that is mostly to provide health education for the patient, bleeding precaution and bleeding reduction as well.Nursing Plan and InterventionFirstly, nurse should assess sign and symptom of bleeding. Assessment of skin and mucous membrane for sign and symptom of petechial, brushing, hematoma formation, oozing of blood is important because patient with low platelet count might experience bleeding into tissue. For my patient, I assess that he has scattered petechial (pinpoint hemorrhages from arterioles or venules) at the buccal mucosa and over bilateral upper limb and lower limb on the day of his admission.

After been transfused 4 unit of platelet on 19/11/17 no more petechial noted at patient buccal mucosa while the petechial on the bilateral upper limb and lower limb is reducing. Beside this, monitor patient's vital sign is important especially blood pressure and heart rate to look for orthostatic hypotension. Tachycardia and hypotension are initial compensatory mechanisms always can noted with bleeding (Wayne, 2016). Marc Hemeryck, a Medical advisor General Practitioner ; Geriatrics also state that hemorrhaging from internal and external can cause low blood pressure, so the heart needs to boost its output by pumping faster, thus this form of tachycardia is a necessary means for the body to compensate for the lower blood flow. ("What are possible causes of tachycardia and hypotension?" n.d.) This is supported by "a major injury or internal bleeding can quickly deplete an individual's body of blood and cause low blood pressure" (Saljoughian, 2014) which can support my statement.

During the whole admission, 4 hourly vital sign was monitored and no abnormal reading noticed. Stool and urine should be inspect as well to look for any melena stool or hematuria. Melena stool may be a sign of bleeding from upper gastrointestinal (Ansari, 2016). Whereas hematuria may indicate bleeding somewhere along the urinary tract (Mandal, 2014). Mr. x have a normal bowel open, no melena stool noted and normal urine output with amber color urine noted. Lab result such as hematocrit and hemoglobin can be monitor because when bleeding is not visible, decrease of hematocrit and hemoglobin can be an early sign of bleeding (Gil Wayne, 2016).

During admission, Mr. X hemoglobin level noted is 7.8, after being transfused of 1 pint packed cell hemoglobin increase to 9.0.Health care personnel should avoid intravenous or subcutaneous injection or rectal procedure such as enema and rectal temperature as possible as this can stimulate bleeding to patient and to reduce unnecessary bleeding ("Risk for Bleeding | Bleeding | Platelet", 2012).  [Should have been cited as www.scribd.com/doc/97160447 (2012)] H If subcutaneous or intravenous procedure are needed for the patient, apply pressure to the puncture site. No subcutaneous procedure one to Mr. X but only intravenous procedure (set intravenous line) applied since medication IV Tranexamic acid was ordered by doctor. Whereas, body temperature was taken on underarm for Mr. X and no rectal temperature taken.

Maintaining safe environment for patient such as raise side rail for confuse or restless patient, make sure floor is dry and have enough light can prevent patient from fall or injury. Mr. X is located at bed 12 which have adequate lighting and the floor at the ward always dry including the toilet. Medication adherence can help to reduce the risk of bleeding. Nurses should monitor patient to take his/her medication in the ward. I always make sure my patient to take his medication on time. Sometimes patient will request to take meal or to take bath before taking his medication and I will monitor again if the patient already take the prescribed medication.

Heath education play an important role in our nursing. "It is a much better idea to avoid bleeding rather than having it and then trying to deal with it" (Naik, n.d.). For this case, nurses can educate patient about precautionary measures to prevent tissue trauma or disruption of the normal clotting mechanisms. In the Nurses lab risk for bleeding, by giving information to patient regarding precaution measures can decrease the risk for bleeding (Wayne, 2016). To maintain an oral hygiene, patient can use a soft-bristled toothbrush and nonabrasive toothpaste and avoid the use of toothpicks and dental floss. Mouthwash tranexamic acid are prescribed to Mr. X and he was advice to buy a soft-bristled toothbrush to use. Patient follow the advice given.

Educate to the patient and family members about signs of bleeding such as petechial that need to be reported to a health care provider are vital as the health care provider can take early action and treatment for the patient which can reduce the complication from blood loss. Mr. X always been remind by staff nurses to inform if he notice any brushing in the body of gum bleeding while brush teeth. Educate to patient the important need to use water-soluble lubricants during sexual intercourse as lubricants are used to reduce friction and tissue trauma that increase the risk for bleeding. Mr. also being teach to use lubricants.

Teach the patient about measures to reduce constipation such as increased fluid intake and dietary fiber. Hard and dry feces may cause trauma to the mucous membranes of the colon and rectum. Increasing fluid intake and dietary fiber soften the fecal mass for easier defecation. I advised my patient to take more vegetables and fluid intake to get easier defecation and Mr. x total fluid intake was around 1.5 litter per day. Educate patient not do heavy lifting, contact sports, or strenuous exercise as it may increase the bleeding tendency. Mr. X was always being advised not to do heavy lifting or strenuous exercise and he understand about that. Patient's daily activity at home include washing clothes and cooking. Patient should be informed to wear proper fitting shoes all the time both in and out doors to avoid cuts on their feet ("Learn about Managing Your Chemotherapy", 2016). Mr. X are told to wear proper shoes and I noticed that patient always wear slippers instead of wearing shoes.

Educate the patient and family members about limiting the use of herbal remedies that can increased risk for bleeding like dongquai, feverfew, ginger, ginkgo biloba, and chamomile). Most herbal preparations interfere with platelet aggregation through inhibition of serotonin release from the platelet. Other herbs increase the effect of antiplatelet and anticoagulant medications, thus increasing the risk for bleeding.

The following herbs can increase the bleeding tendency to a low platelet patients (Peters, n.d.):

• GINGER- Ginger is for gastric, distress, migraines and headaches but it can interfere with platelet function.
• GINSENG- Use to treat colic, infections, aging, and stress. It can increase bleeding, and have side effects of nausea, headaches, and blood pressure changes.
• GINKO- Used to treat Alzheimer's and other memory disorders but it also been associated with excess perioperative bleeding.
• GARLIC- Garlic has been used as a medicine for centuries. It has been advocated for high blood pressure, fungal infections, heart attack and cancer. Consumption of garlic in high doses resulting in bleeding, nausea and vomiting as well as low blood sugar.Besides from herbal remedies, patient with high risk of bleeding should be very careful about their daily diet. Some food can lead to increase bleeding tendency.

The Platelet Disorder Support Association (PDSA) states that the most common offenders for low platelet patients are foods that contain quinine (tonic water, bitter lemon, bitter melon), aspartame (diet soda, sugar-free and low-fat candy and cakes) or alcohol such as beer, wine, hard liquor ("Eating for Health", n.d.). (Stein, 2017) Says "Leafy green vegetables and dairy product can help to reduce the risk of bleeding" in which this can support my statement. Leafy green vegetables are the best sources of vitamin K. The Platelet Disorder Support Association also recommends foods like leafy green vegetables rich in vitamin K which is important for blood clotting and platelet creation.

Chairman Tan, registered dietitian at Seventeen Nutrition Consultants advises: "Green leafy vegetables such as broccoli, spinach, kale, Chinese vegetables like choi sum and kai lan are rich with antioxidants and rich in vitamins and minerals which are believed to reduce inflammation and help increase platelet count. (South China Morning Post, 2018) Dairy products such as milk can help your blood clot because of their calcium. Calcium is an essential mineral at seven different points in the coagulation cascade that results in blood clotting when you've cut yourself, The Platelet Disorder Support Association recommends following an anti-inflammatory or macrobiotic diet to increase platelet counts. This diet focuses on whole grains, beans and vegetables and reduces animal foods.

Sesame oil has properties that can increase the platelet levels. Two tablespoons of a natural sesame oil when taken orally twice a day, and even rubbing some externally on lymph node areas can help to increase platelet counts over a period of several weeks (SINGLETON, 2017). I have told MR. X to consume more leafy green vegetables and drink more milk at home and I strongly remind him not to take herbs as it might increase the bleeding tendency and he claimed that he didn't take any herbs from others.EvaluationPatient being discharge on 20/11/17 with prescribed medication. Patient manage to get well and reduce bleeding tendency by adhere to the medication prescribed. Thus from here, nurses play an importance role in ensure patient is adherence to their medication to prevent bleeding for deteriorate. Beside for adherence to the medication, patient supposed to be advice to strictly follow the date given by doctor for their To Come Again (TCA) appointment to have regular blood checkup as this can detect early sign of bleeding.

During the admission, patient not receive any injury like fall because the environment provided is safe for the patient. Patient aware that he cannot do any hard activities that might cause bleeding. This case study can managed to meet the desired goal.ConclusionAlthough aplastic anemia is consider incurable but the prevention of bleeding form aplastic anemia can reduce a lot of complication that can threat one's life. Hence patient must be instruct clearly about the adherence to the medication prescribed. Diet also play a vital role in reducing the bleeding tendency hence must be strictly implemented. Continuous of blood checkup must be strictly follow.

Thus it is important to the nurses to provide a good heath education to the patient to increase patient awareness regarding the prevention of the bleeding that will take patient's life. Prevention is better can cure. We may never understand illnesses such as cancer. In fact, we may never cure it. But an ounce of prevention is worth more than a million pounds of cure. (Agus, n.d.). In writing of this case study, I feel happy that this writing meet the desired outcome. No further bleeding noted for my patient and no further deterioration condition developed. I have learnt many things after writing this case study and I hope that I can use it to others patient as well to increase their health and living. I have learn what intervention I should do while patient in the ward and what education I can give to patient when he discharge.

I manage to know what diet are recommended to the patient and what diet are not recommended to the patient. I feel glad to write this case study because I able to use this knowledge from what I have learnt not only to teach my patient but also to share the knowledge among my colleagues to improve our nursing care. In future, to improve the nursing care and practice, nurses might can put a sign over the patient's bed as a reminder of bleeding precaution. This will make all the health care provider be more alert when handling to the patient. Besides that, those patient with high risk of bleeding can wear a bracelet as a sign of bleeding precaution to others as well.

Environment also take a vital role in patient's safety. Nurses can advise patient and patient's family to create a safety environment such as put a holder in the bathroom as the floor wet and might easily fall down and not only focuses on the dry floor and adequate lighting. Creating a group of patient will high risk of bleeding can be consider as well. Nurses can gather them all and provide a health education to the patient. This can increase their awareness of the bleeding precaution.

At the same time they can communicate and share their experience to reduce the risk of bleeding. I hope this will improve our nursing care and practice with a patient with high risk of bleeding tendency. Together we work to improve our patient's well-being and our nursing care practice as a professional nurse.

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