The document is a case presentation on blood dyscrasia submitted by nursing students to their clinical instructor at Silliman University. It outlines the objectives of the case study, patient background, and intended learning outcomes for peers regarding pediatric care. The presentation aims to enhance knowledge, skills, and attitudes towards patient care for individuals experiencing blood abnormalities.

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BLOODBLOOD DyscrasiaDyscrasia
1

2. Submitted to:Submitted to:
Ms. Dawn Janice A. Tiempo, RN, BsnMs. Dawn Janice A. Tiempo, RN, Bsn
Submitted by:Submitted by:
Kristine Marie G. BuquiranKristine Marie G. Buquiran
Ivan Jason M. DeLos SantosIvan Jason M. DeLos Santos
Submitted on:Submitted on:
March 6, 2008March 6, 2008
Application letter
C o l l e g e o f N u r s i n g
S i l l i m a n U n i v e r s i t y
D u m a g u e t e C i t y
N e g r o s O r i e n t a l
M a r c h 5 , 2 0 0 8
M s . D a w n J a n i c e A . T i e m p o , R N , B S N
C l i n i c a l I n s t r u c t o r
C o l l e g e o f N u r s i n g
2

3. S i l l i m a n U n i v e r s i t y
D e a r M a ’ a m :
G o o d D a y ! ! !
W e , K r i s t i n e M a r i e G . B u q u i r a n a n d I v a n J a s o n M . D e L o s S a n t o s , l e v e l I I I s t u d e n t s o f S U C N a r e h o p i n g
f o r y o u r a p p r o v a l f o r a c a s e s t u d y a b o u t o u r c l i e n t , J o h n C a r l o M a h i n a y A u s t i n o w h o i s 1 2 d a y s o l d , a r e s i d e n t
o f B a r a n g a y K a l u y - a h a n B a i s , N e g r o s O r i e n t a l w h o h a s a d m i t t e d a t N O P H l a s t F e b r u a r y 2 , 2 0 0 8 a n d w a s
d i a g n o s e d w i t h B l o o d D y s c r a s i a .
W e w o u l d l i k e t o t a k e t h i s o p p o r t u n i t y t o p r e s e n t t h i s c a s e b e c a u s e w e b e l i e v e t h a t s h a r i n g o u r
e x p e r i e n c e s t o o u r c l a s s m a t e s a n d a l s o t o o t h e r s w h o w a n t t o k n o w a n d l e a r n a b o u t t h i s c a s e . T h i s a i d s u s i n
o u r l e a r n i n g a n d f u r t h e r e n h a n c e s n o t o n l y o u r k n o w l e d g e a n d s k i l l s b u t a t t i t u d e a s w e l l .
T h a n k y o u f o r y o u r k i n d c o n s i d e r a t i o n .
R e s p e c t f u l l y y o u r s ,
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
K r i s t i n e M a r i e G . B u q u i r a n I v a n J a s o n M . D e L o s S a n t o s
Table of Contents
C o v e r p a g e 1
L e t t e r 2
T a b l e o f c o n t e n t s 3
V i s i o n / m i s s i o n o f S i l l i m a n U n i v e r s i t y 4
3

4. O b j e c t i v e s o f t h e C a s e P r e s e n t a t i o n 5 - 6
I n t r o d u c t i o n 7
D e m o g r a p h i c D a t a 8 - 9
G e n o g r a m 1 0
P h y s i c a l a s s e s s m e n t 1 1 - 1 9
G r o w t h a n d d e v e l o p m e n t 2 0 - 2 2
O v e r v i e w o f m e d i c a l d i a g n o s i s 2 3 - 2 4
A n a t o m y a n d p h y s i o l o g y 2 5 - 3 5
P a t h o p y h s i o l o g y 3 6 - 3 7
M e d i c a t i o n s 3 8 - 3 9
F u n c t i o n a l h e a l t h p a t t e r n 4 0 - 4 6
N u r s i n g C a r e p l a n 4 7 - 5 0
S u m m a r y o f n u r s i n g d i a g n o s i s 5 1
S y N T H E S I S 5 2
A c k n o w l e d g e m e n t 5 3
B i b l i o g r a p h y 5 4
A n n o t a t e d r e a d i n g s 5 5 - 6 0
4

5. COLLEGE OF NURSING
Silliman University
Dumaguete City
VISION/ MISSION STATEMENT
VISION:
As a leading Christian institution of learning in Asia, Silliman University is committed to total human development for societal and
environmental well-being.
MISSION:
In this regard, the University
• Provides opportunities for all members of the academic community to seek the truth, justice, and love.
• Pursues excellence in every dimension of inquiry, learning, and teaching.
5

6. • Instills in all members of the university community including all its integral units an enlightened social consciousness, a profound sense of
involvement, and a genuine compassion for every person.
• Enhances national development and unity by making its life and programs relevant to the total environment.
P l a c e m e n t : N C M 1 0 2 , L e v e l I I I
T i m e a l l o t m e n t : 1 h o u r
T o p i c : B l o o d D ys c r a s i a
T o p i c D e s c r i p t i o n : T h i s 1 h o u r c a s e p r e s e n t a t i o n d e a l s w i t h t h e c a r e o f p a t i e n t s w i t h b l o o d a b n o r m a l i t i e s u n d e r
P e d i a t r i c W a r d . T h i s s t u d y i n c l u d e s t h e g r o w t h a n d d e v e l o p m e n t o f t h e p a t i e n t , a n a t o m y a n d
p h ys i o l o g y o f t h e s ys t e m s i n v o l v e , p a t h o p h ys i o l o g y, t h e p r o f i l e o f t h e p a t i e n t , f u n c t i o n a l
h e a l t h p a t t e r n , p h ys i c a l a s s e s s m e n t , n u r s i n g c a r e p l a n s , l a b o r a t o r y a n d d i a g n o s t i c t e s t a n d
m e d i c a t i o n s .
C e n t r a l O b j e c t i v e s : A t t h e e n d o f o u r 1 h o u r c a s e p r e s e n t a t i o n , t h e l e a r n e r s s h a l l a c q u i r e k n o w l e d g e o n c o n c e p t s
r e l a t e d t o p a t i e n t s w i t h b l o o d d ys c r a s i a , d e v e l o p s k i l l s a n d m a n i f e s t d e s i r a b l e a t t i t u d e s i n
p r o v i d i n g c a r e t o p a t i e n t s , f a m i l y a n d s i g n i f i c a n t o t h e r s .
S p e c i f i c O b j e c t i v e s : W e , t h e p r e s e n t e r s o f t h i s c a s e s t u d y h a v e t h e f o l l o w i n g o b j e c t i v e s :
1 . E x p l a i n t h e g r o w t h a n d d e v e l o p m e n t o f t h e c h i l d
6

7. 2 . D i s c u s s t h e a n a t o m y a n d p h ys i o l o g y o f t h e o r g a n s i n v o l v e d i n c a r i n g p a t i e n t s w i t h b l o o d
d ys c r a s i a
3 . E n h a n c e o u r k n o w l e d g e o n t h e d i f f e r e n t c o n c e p t s r e l a t e d t o t h e c a r e o f p a t i e n t s w i t h
b l o o d d ys c r a s i a
4 . A c q u i r e m o r e r e a d i n g s a n d s o u r c e s f o r a d d e d i n f o r m a t i o n a n d a s a n e n h a n c e m e n t f o r
o u r s e l v e s a n d o t h e r s
5 . F o r m u l a t e c o m p r e h e n s i v e n u r s i n g c a r e p l a n s b a s e d o n t h e i d e n t i f i e d n u r s i n g p r o b l e m i n
r e l a t i o n t o c h i l d a n d f a m i l y
6 . C r i t i c a l l y a n a l yz e t h e n e e d f o r t a k i n g m e d i c a t i o n s w i t h r e g a r d s t o t h e c h i l d ’ s c o n d i t i o n
7 . M a n i f e s t p o s i t i v e a t t i t u d e s w h e n c a r i n g f o r a c h i l d e x p e r i e n c i n g i l l n e s s / d i s o r d e r s d u r i n g
h o s p i t a l i z a t i o n
A t t h e e n d o f t h e c a s e p r e s e n t a t i o n , o u r f e l l o w l e a r n e r s s h a l l :
1 . D e f i n e t h e i m p o r t a n t t e r m s u s e d i n t h e p r e s e n t a t i o n u s i n g t h e i r o w n w o r d s
2 . F o r m u l a t e n u r s i n g d i a g n o s i s w i t h t h e g i v e n c u e s a n d e v i d e n c e s f o r a c h i l d e x p e r i e n c i n g
i l l n e s s / d i s o r d e r s d u r i n g h o s p i t a l i z a t i o n
3 . I d e n t i f y a l t e r n a t i v e t h e r a p i e s t h a t c a n b e u s e d t o p r o m o t e t h e c o m f o r t o f t h e c h i l d d u r i n g
h o s p i t a l i z a t i o n
4 . V e r b a l i z e d u n d e r s t a n d i n g o f t h e p a r e n t s a n d t h e c h i l d
7

8. INTRODUCTION
T h e j o yo u s f e e l i n g o f h a v i n g a b a b y i s a n i r r e p l a c e a b l e m o m e n t o f o u r l i v e s . T h e
t i m e w e f i r s t s e e , f e e l a n d c u d d l e t h e m m a k e s o u r h e a r t g r o w f o n d e r . S o m e t i m e s , w e a r e
t o o o v e r w h e l m e d o f i t t h a t w e t e n d t o f o r g e t o u r b a s i c r e s p o n s i b i l i t i e s f o r o u r b a b y. W e
c a n n o t d e n y s o m e f a c t s o f l i f e t h a t t h e r e a r e a l o t o f c o n t r i b u t i n g f a c t o r s w h i c h h i n d e r s
8

9. t o o u r c a r e . D e s p i t e t h e s e t h i n g s , w e s t i l l d o a n yt h i n g t h a t w e c a n , i n o r d e r f o r t h e e n t i r e f a m i l y t o m a i n t a i n a n
o p t i m u m l e v e l o f w e l l n e s s . T h r o u g h l i f e ’ s c h a l l e n g e s , w e i n s t i l h o p e a n d c a r e n o m a t t e r w h a t i t t a k e s . A w o n d e r f u l
s a c r i f i c e i s a n u n e x p l a i n a b l e d e e d i n w h i c h i t i s t h e r e a s o n t h a t a c l u s t e r o f p e o p l e c a n b e c a l l e d a f a m i l y .
U n c o n d i t i o n a l l o v e b i n d s u s t o o n e p a t h a n d e n s u r e s u s o f a b l i s s f u l l i f e .
I n o u r r o t a t i o n , w e a r e f a c e d w i t h a c h a l l e n g e i n w h i c h , w e a r e o u g h t t o t a k e c a r e o f a p a t i e n t t h a t n e e d s m u c h
o f o u r c a r e . A 1 2 d a y o l d b a b y n a m e d , J o h n C a r l o M . A g u s t i n o , w h o l i v e s a t K a l o y - a h a n , B a i s , N e g r o s O r i e n t a l , a n d
h a s b e e n d i a g n o s e d t o h a v e b l o o d d ys c r a s i a . W e w o u l d l i k e t o s h a r e o u r e x p e r i e n c e a n d k n o w l e d g e r e g a r d i n g B a b y
J o h n ’ s c o n d i t i o n . I n t h i s c a s e b o o k , w e h o p e t h a t y o u w i l l u n d e r s t a n d a n d g a i n k n o w l e d g e t o w a r d s t a k i n g c a r e o f a
n e w b o r n w i t h b l o o d d ys c r a s i a . W e a r e s o g r a t e f u l t o b e g i v e n t h e c h a n c e o f s h a r i n g a c o m p l e x h e a l t h c o n d i t i o n , i n
w h i c h w e l e a r n e d a l o t f r o m i t a n d h o p e y o u w i l l l e a r n a l s o a s m u c h a s w e h a v e p e r c e i v e d i t . T o d a y , w e h o p e t h a t y o u
w i l l f o c u s y o u r a t t e n t i o n t o t h e c a s e p r e s e n t e d a n d o p e n y o u r m i n d s f o r a n o t h e r c h a p t e r o f l e a r n i n g . A m i l e s t o n e o f
e x p e r t i s e t o a d i a g n o s i s a n d a c o m p a s s i o n a t e h e a r t t o e x t e n d q u a l i t y c a r e , w h e n e v e r w e r e f a c e d w i t h a s t r e s s f u l
s i t u a t i o n .
N a m e : J o h n C a r l o M a h i n a y A g u s t i n o A g e : 1 2 d a ys o l d C i v i l S t a t u s : N e w b o r n
S e x : M a l e R e l i g i o n : C a t h o l i c N a t i o n a l i t y : F i l i p i n o
A d d r e s s : B a r a n g a y K a l u y- a h a n , B a i s N e g . O r C a s e n o . :
B i r t h d a t e : A p r i l 2 0 , 2 0 0 7 T i m e a n d D a t e o f A d m i s s i o n : F e b r u a r y 2 , 2 0 0 8 @ 1 2 : 4 0 p m
M o t h e r : V i c t o r i a A g u s t i n o O c c u p a t i o n : H o u s e w i f e
F a t h e r : R a n d y A g u s t i n o O c c u p a t i o n : F a r m e r
D o c t o r i n c h a r g e : D r . A l f e c h e
9
Demographic Data

10. C h i e f C o m p l a i n t s : N o t e d s u d d e n o n s e t o f p r o f u s e b l e e d i n g i n t h e u m b i l i c a l c o r d
H i s t o r y o f P r e s e n t I l l n e s s :
T w o d a ys p r i o r t o a d m i s s i o n , i t ’ s m o t h e r n o t e d s u d d e n o n s e t o f p r o f u s e b l e e d i n g i n t h e u m b i l i c a l c o r d .
G e n e r a l I m p r e s s i o n o f t h e c l i e n t :
R e c e i v e d i n s u p i n e p o s i t i o n , r e s t l e s s a n d p a l e w i t h D 5 . 3 N a C l 5 0 0 c c @ r i g h t m e t a c a r p a l v e i n r e g u l a t e d @ 1 4
m l / h r .
Past Medical History:
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.
C H I L D H O O D I M M U N I Z A T I O N :
VACCINE
M I N I M U M
A G E A T
F I R S T
D O S E
N U M B E R
O F
D O S E S
R E M A R K S
B C G 1 w e e k o l d 1 NONE
O P V 6 w e e k s 3 N O N E
H E P A T I T I S
B
6 w e e k s 3
NONE
D P T 6 w e e k s 3 N O N E
M E A S L E S
9 m o n t h s
o l d
1
N O N E
1 0

11. Family History
F a m i l y a n d r e l a t i v e s a r e i n g o o d h e a l t h . A s v e r b a l i z e d b y m o t h e r , t h e y d o n ’ t h a v e a n y h e r e d o - f a m i l i a l
d i s e a s e s . T h e y d o n o t s m o k e n o r d r i n k a l c o h o l i c b e v e r a g e s a r o u n d c h i l d r e n .
P s y c h o s o c i a l H i s t o r y
A s v e r b a l i z e d b y m o t h e r , t h e y h a v e g o o d r e l a t i o n s h i p w i t h t h e e x t e n d e d f a m i l y. T h e y l i v e n o r m a l l y a s w h a t
t h e y h a d w h e n t h e y h a v e t h e i r f i r s t c h i l d . C l i e n t i s a g o o d s o n . M o t h e r a l s o v e r b a l i z e d t h a t t h e i r f a m i l y i s r e l i g i o u s
a n d a l w a ys g o t o c h u r c h e v e r y S u n d a y. C l i e n t i s s t r o n g , h e a l t h y a n d h a p p y. T h e y n e v e r b l a m e G o d a n d f a m i l y f o r
e v e r y p r o b l e m t h e y e n c o u n t e r e d .
1 1

12. 1 2
L i l i a
V i c t o r i
a
N e s t o r
L i n d a
M a h i n a y
R o b e r t
M a h i n a y
A n t o n i o
A g u s t i n o M a r i t e s
A g u s t i n o
N a t h
y
S u n n y
J u l y
M a r
g i e
F e m
a
I m e
l d a
J e m
a
L a n i
J o c
e l y n
R h e
a
M a e
J o h n
C a r l
o
A r i e l
A r m e l
R a n d y
J e r r y
D a n n y
S a m e o n
GENOGRAMGENOGRAM

13. PHYSICAL ASSESSMENT
PHYSICAL EXAMINATION:
G e n e r a l S u r v e y :
S t a t e o f A w a r e n e s s : A l e r t a n d c o h e r e n t
O b v i o u s S i g n s o f D i 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
G a i t : C o o r d i n a t e d
P o s t u r e : G o o d p o s t u r e
B o d y M o v e m e n t s : c a n n o t m a 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
H y g i e n e : A p 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 m a m a a n d p a p a
M o o d : A l w a y s c r y i n g
V i t a l S i g n s :
T e m p e r a t u r e : 3 7 . 4 ° C / a x i l l a
P u l s e R a t e : 1 5 0 b p m , r e g u l a r & s t r o n g
R e s p i r a t o r y R a t e : 6 8 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
P h ys i c a l A s s e s s m e n t b y B o d y S ys t e m :
A . S k i n :
C o l o r : p a l e i n c o l o r a l l o v e r t h e b o d y
( ) V e r n i x C a s e o s a
( ) L a n u g o
E d e m a : ( ) a r o u n d e ye s ( ) f a c e ( ) l e g s
( ) d u r s a o f h a n d s ( ) f e e t
( ) s c r o t u m o r l a b i a
( ) A c r o c ya n o s i s
( ) C u t i s m a r m o r a t a
( ) M i l i a
( ) M i l a r i a o r s u d a m i n a
1 3

14. ( ) E r yt h e m a t o x i c u m
( ) H a r l e q u i n s i g n
( ) M o n g o l i a n S p o t s
( ) T e l a n g i e c t a t i c n e v i ( “ s t o r k b i t e s ” )
B . H e a d :
F o n t a n e l :
( ) A n t e r i o r
( ) P o s t e r i o r
( ) B u l g i n g f o n t a n e l s b e c a u s e o f c r yi n g
( ) M o l d i n g
( ) R o u n d
( ) C a p u t s u c c e d a n e u m
( ) C e p h a l h e m a t o m a
C . E ye s :
C o l o r : B l a c k
( ) A b s e n c e o f t e a r s ( ) S ym m e t r i c a l
( ) C o r n e a l r e f l e x i n r e s p o n s e t o t o u c h
( ) P u p i l l a r y r e f l e x i n r e s p o n s e t o l i g h t
( ) B l i n k r e f l e x i n r e s p o n s e t o l i g h t o r t o u c h
( ) R u d i m e n t a r y f i x a t i o n o n o b j e c t s
( ) A b i l i t y t o f o l l o w t o m i d l i n e
( ) S u b j u n c t i o n a l ( S c l e r a l ) h e m o r r h a g e s
( ) E p i c a n t h a l f o l d s ( O r i e n t a l i n f a n t s )
D . E a r s :
P o s i t i o n : ( ) T o p o f p i n n a o n h o r i z o n t a l l i n e w i t h o u t e r c a n t h u s o f e ye
( ) S h a p e : w e l l - f o r m e d
( ) S ym m e t r i c a l
( ) S t a r t l e r e f l e x e l i c i t e d b y a l o u d , s u d d e n n o i s e
( ) P i n n a f l e x i b l e ( ) C a r t i l a g e p r e s e n t
( ) I r r e g u l a r s h a p e o r s i z e
( ) S k i n t a g s
E . N o s e :
( ) L o c a t i o n a t m i d l i n e
1 4

15. ( ) P a t e n t ( ) B r e a t h e s e a s i l y w i t h m o u t h c l o s e d
( ) F l a t t e n e d ( ) L i t t l e n a s a l b r i d g e
( ) B r u i s e d
( ) D i s c h a r g e s ( s p e c i f y)
F . M o u t h a n d T h r o a t
( ) V i g o r o u s g a g r e f l e x
( ) A b s e n t o r m i n i m a l s a l i v a t i o n
( ) I n t a c t , h i g h - a r c h e d p a l a t e
( ) U v u l a i n m i d l i n e
( ) F r e n u l u m o f t o n g u e
( ) F r e n u m o f u p p e r l i p
( ) T o n g u e n o t p r o t r u d i n g
( ) S u c k i n g r e f l e x – s t r o n g a n d c o o r d i n a t e d
( ) R o o t i n g r e f l e x ( ) S w a l l o w i n g R e f l e x
( ) E x t r u s i o n r e f l e x
( ) N a t a l t e e t h
( ) E i p s t e i n p e a r l s
( ) C l e f t l i p ( ) C l e f t p a l a t e
( ) P r o f u s e s a l i v a t i o n o r d r o o l i n g
( ) C a n d i d a s i s ( t h r u s h )
( ) A b n o r m a l c r y ( c h a r a c t e r i z e )
G . N e c k :
( ) S h o r t , t h i c k , u s u a l l y s u r r o u n d e d b y s k i n f o l d s
( ) M o v e s f r e e l y f r o m s i d e t o s i d e
( ) T o n i c - n e c k r e f l e x
( ) T o r t i c o l l i s ( ) W e b b i n g
( ) M a s s e s ( ) D i s t e n d e d v e i n s
H . C h e s t :
S h a p e : ( ) A l m o s t c i r c u l a r ( a n t e p o s t e r i o r a n d l a t e r a l d i a m e t e r s e q u a l )
( ) S ym m e t r i c a l m o v e m e n t s w i t h r e s p i r a t i o n
( ) S l i g h t s t e r n a l r e t r a c t i o n s e v i d e n t d u r i n g i n s p i r a t i o n
( ) X i p h o i d p r o c e s s e v i d e n t
( ) B r e a s t e n l a r g e m e n t
1 5

16. ( ) R e s p i r a t i o n s a b d o m i n a l
( ) A b n o r m a l c h e s t m o v e m e n t s w i t h r e s p i r a t i o n s ( d e s c r i b e )
( ) A b n o r m a l s h a p e ( d e s c r i b e )
( ) S u p e r n u m e r a r y o f n i p p l e s
( ) S e c r e t i o n o f “ w i t c h m i l k ”
( ) A s ym m e t r i c c h e s t e x p a n s i o n
I . L u n g s :
B r e a t h s o u n d s : A b s e n c e o f b r e a t h s o u n d s s u c h a s r a l e s , w h e e z i n g a n d c r a c k l e s .
R a t e : N o r m a l
D e p t h : N o r m a l
( ) A b n o r m a l b r e a t h s o u n d s ( d e s c r i b e )
J . A b d o m e n :
S h a p e : ( ) R o u n d e d ( C yl i n d r i c ) a n d p r o m i n e n t
( ) O t h e r s : D e s c r i b e
( ) C o r d s t u m p d r y, n o t f o u l s m e l l i n g ( ) U m b i l i c a l h e r n i a
( ) B i l a t e r a l f e m o r a l p u l s e s ( ) W h a r t o n ’ s j e l l y
( ) D i a s t a s i s r e c t i
K . G e n i t a l i a :
( ) L a b i a a n d c l i t o r i s e d e m a t o u s
L a b i a ’ s a p p e a r l a r g e
( ) U r e t h r a l m e a t u s b e h i n d c l i t o r i s
( ) M u c o l d d i s c h a r g e s b e t w e e n l a b i a
( ) U r i n a t i o n w i t h i n 2 4 h o u r s
( ) P s u e d o m e n s t r u a t i o n
( ) H ym e n a l t a g
M a l e G e n i t a l i a :
( ) U r e t h r a l o p e n i n g a t t i p o f g l a n s p e n i s
( ) A b n o r m a l u r e t h r a l o p e n i n g ( d e s c r i b e )
( ) T e s t e s p a l p a b l e i n e a c h s c r o t u m
( ) S c r o t u m u s u a l l y l a r g e , e d e m a t o u s , p e n d u l o u s , ( ) c o v e r e d w i t h r u g a e
( ) P i g m e n t e d
( ) S m e g m a
( ) U r i n a t e s w i t h i n 2 4 h o u r s
1 6

17. ( ) T i g h t p r e p u c e ; i n a b i l i t y t o r e t r a c t p r e p u c e
( ) E r e c t i o n o r p r i a p i s m
( ) T e s t e s p a l p a b l e i n i n g u i n a l c a n a l
( ) S c r o t u m s m a l l
L . B a c k :
( ) S p i n e s t r a i g h t
( ) S p i n e i n t a c t , n o o p e n i n g s , m a s s e s , o r p r o m i n e n t c u r v e s
( ) T r u n k i n c u r v a t i o n r e f l e x
( ) S h o u l d e r s , s c a p u l a e , i l i a c c r e s t s a r e o n s a m e p l a n e w i t h o t h e r
M . R e c t u m :
( ) P a t e n t a n a l o p e n i n g ( t e m p e r a t u r e c a n b e t a k e n r e c t a l l y o r h a s p a s s e d o u t m e c o n i u m )
( ) P a s s a g e o f m e c o n i u m w i t h i n 4 8 h o u r s
( ) D e l a ye d
( ) A n a l r e f l e x
( ) P r e s e n c e o f f i s s u r e s o r b l e e d i n g
N . E x t r e m i t i e s :
( ) T e n f i n g e r s a n d t o e s
( ) F u l l r a n g e o f m o t i o n
( ) N a i l b e d s p i n k , w i t h t r a n s i e n t c ya n o s i s a f t e r b i r t h
( ) C r e a s e s i n a n t e r i o r t w o - t h i r d s o f s o l e
( ) S o l e u s u a l l y f l a t
( ) E q u a l m u s c l e t o n e b i l a t e r a l l y, e s p e c i a l l y r e s i s t a n t t o o p p o s i n g f l e x i o n
( ) E q u a l b i l a t e r a l p e d a l p u l s e s
O b s e r v e f o r : ( D e s c r i b e )
( ) G r o s s a b n o r m a l i t i e s , ( i . e . , l i m i t a t i o n o f m o v e m e n t s , f r a c t u r e s , p a r a l ys i s )
( ) D i s l o c a t e d h i p s
( ) W e b b e d d i g i t s
( S yn d a c t yl y) o r e x t r a d i g i t s
( P o l yd a c t yl y)
( ) S i z e a n d s h a p e o f h a n d s a n d f e e t
( ) A b s e n t R O M ( ) U n e q u a l m u s c l e t o n e o r R O M
( ) W i d e g a p b e t w e e n f i r s t a n d s e c o n d t o e s
( ) A s ym m e t r y o f e x t r e m i t i e s
1 7

18. ( ) A b s e n c e o f d i s t a l p a r t o f e x t r e m i t y ( H e m i ) ;
( ) H a n d s a n d f e e t a t t a c h e d c l o s e t o t r u n k
( ) S o l e c o v e r e d w i t h c r e a s e s
( ) T r a n s v e r s e p a l m a r ( S i m i a n ) c r e a s e
( ) A b n o r m a l c o l o r o f n a i l b e d s
N e u r o l o g i c a l R e f l e x e s :
P r e s e n t A b s e n t S l u g g i s h H yp e r a c t i v e
1 . R o o t i n g
2 . S u c k i n g
3 . S w a l l o w i n g
4 . E x t r u s i o n
5 . B l i n k i n g / C o r n e a l R e f l e x
6 . P u p i l l a r y r e f l e x
7 . T r u n k I n c u b a t i o n
8 . P a l m a r G r a s p
9 . P l a n t a r G r a s p
1 0 . M o r o
1 1 . T o n i c - N e c k
1 2 . D a n c e o r S t e p
1 3 . P l a c i n g
INTEGUMENTARY SYSTEM
I . H e a l t h H i s t o r y
1 8

19. M o t h e r v e r b a l i z 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 1 2 d a y s a l r e a d y . C l i e n t i s
w e l l - g r o o m e d . C l i e n t i s n o t a l l e r g i c t o f o o d s , d r u g s a n d p l a n t s . V e r b a l i z e d b y m o t h e r , w o 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 o f u s e l y f o r t h e f i r s t 1 0 d a y s . C l i e n t h a d n o t u n d e r g o n e a n y s u r g e r y i n v o l v i n g t h e
i n t e g u m e n t .
I I . P h y s i c a l E x a m i n a t i o n
A . S k i n
T h e c o l o r i s p a l e a n d t h e s a m e w i t h t h e s u r r o u n d i n g s k i n . T 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 x i l l a r y a r e a s . S k i n i s c o l d t o t o u c h a n d t e m p e r a t u r e e q u a l b i l a t e r a l l y . I t i s s m o o t h a n d l o v e l y t o
t o u c h . S k i n t u r g o 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 m m e d i a t e l y t o i t s n o r m a l p o s i t i o n . T h e r e a r e n o
b i r t h m a r k s o r f r e c k l e s p r e s e n t . T h e r e i s n o i n f l a m m a 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 . T h e r e i s
n o e d e m a n o t e d o n t h e i n t e g u m e n t .
B . N a i l s
N a i l s a r e s h o r t a n d c l e a n . N a i l s a r e u n i f o r m i n t h i c k n e s s . N a i l b e d s a r e p i n k i s h i n c o l o r w i t h t r a n s l u c e n t
w h i t e t i p s . I t i s w e l l r o u n d e d w i t h a c o n v e x c u r v e a b o u t 1 6 0 ° . L a n u l a i s c o l o r e d w h i t e . C a p i l l a r y r e f i l l i s 2
s e c o n d s . T h e r e a r e n o l e s i o n s a n d i n f l a m m a t i o n n o t e d .
C . H a i r
H a i r i s c o l o r e d b l a c k a n d s o f t w i t h t h i n s t r a n d s . H a 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 o p r i a t e f o r t h e f a c e .
T 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 . H a i r i s a l s o s m o o t h a n d p l i a n t .
ABDOMEN
1 9

20. I. Health History
M o t h e r v e r b a l i z 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 E v e r y t i m e h e c r i e s w i t h 1 - 2 o u n c e s o f m i l k . C l i e n t s u c k s
w e l l . C l i e n t h a s n e v e r e x p e r i e n c e d a n y o p e r a t i o n / s u r g e r y i n v o l v i n g t h e a b d o m e n . S h e w a 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 w i t h p r o f u s e b l e e d i n g a t t h e c o r d s t u m p . Y e l l o w w a 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 w i c e a d a y . C o r d s t u m p w a 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 m i s s i o n .
II. Physical Examination
A. Inspection
A b d o m e n h a s 4 q u a d r a n t s : r i g h t u p p e r q u a d r a n t , l e f t u p p e r q u a d r a n t , l e f t l o w e r q u a d r a n t a n d r i g h t l o w e r
q u a d r a n t . I t a l s o c o m p r i s e s o f 9 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 m b 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 m b 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 . A b d o m e n h a s f l a w l e s s s k i n a n d h a s t h e s a m e
c o l o r w i t h t h e s u r r o u n d i n g s k i n . I t i s s m o o t h a n d s y m m e t r i c a l . C o n t o u r o f t h e a b d o m e n i s s l i g h t l y r o u n d e d a n d
d i s t e n d e d . T 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 g e m e n t n o t e d . P e 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 . U m b i l i c u s
i s s l i g h t l y p r o t r u d i n g s l i g h t l y m o i s t w i t h l e s i o n . I t w a s c l e a n e d a n d d r e s s e d u p o n a d m i s s i o n . T 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 x a m i n a t i o n .
B. Auscultation
B o w e l s o u n d s a r e a u d i b l e i n 4 q u a d r a n t s . T h e r e a r e 1 5 - 1 8 b o w e l s o u n d s h e a r d f o r o n e m i n u t e i n R L Q .
C . L i g h t p a l p a t i o n
A b d o m e n i s r e l a x e d a n d h a s n o e n l a r g e d o r g a n s . N o m a 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 m e 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 m e n .
D . D e e p p a l p a t i o n
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 m e n a s v e r b a l i z e d b y m o 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
w h e n e v e r I t o u c h h i s a b d o m e n a n d i n t e g u m e n t . D 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 w i t h y e l l o w c o l o r e d u r i n e .
E . P e r c u s s i o n
T y m p a n y s o u n d s a r e h e a r d i n t h e 4 q u a d r a n t s b u t d u l l s o m e w h a t i n t h e l i v e r a r e a .
GENITO-URINARY SYSTEM
2 0

21. I . H e a l t h H i s t o r y
M o t h e r v e r b a l i z e d , c l i e n t c o u l d c o n s u m e 3 - 4 d i a p e r s / l i n e n s a d a y o r w h 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
w e t . C l 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 w i t h s o f t a n d y e l l o w s t o o l w i t h t h e e s t i m a t e d a m o u n t o f
2 0 0 g r a m s w i t h o u t d i f f i c u l t y . C l i e n t i s a l s o a b l e t o u r i n a t e w i t h y e l l o w c o l o r e d u r i n e w i t h t h e e s t i m a t e d
a m o u n t o f 2 4 0 m l w i t h o u t d i f f i c u l t y . C l i e n t h a d n o t u n d e r g o n e o p e r a t i o n / s u r g e 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 . C l i e n t d i d n ’ t e x 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 z e d b y m o t h e r .
I I . P h y s i c a l E x a m i n a t i o n
A . P e n i s
I t i s s m a l l a n d h a s n o s i g n s o f s w e l l i n g , s k i n l e s i o n s , i n f l a m m a 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 . T h e u r e t h r a l
m e 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 .
B . S c r o t u m
I t i s l a r g e 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 o m 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 o t u m h a n g s l o w e r t h a n t h e r i g h t . 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 w r i n k e d . P r e s e n c e o f p h y m o s i s a n d
n o t c i r c u m c i s e d .
C . G r o i n
C o l o r o f t h e s k i n i s t h e s a m e a s t h e s u r r o u n d i n g a r e a . A b 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 . R e c t a l
G l u t e a l f o l d s a r e s y m m e t r i c a l a n d f i r m . A b s e n c e o f r a s h e s , l e s i o n s a n d s c a r s . A n u s i s p r e s e n t b e t w e e n t h e
g l u t e a l f o l d s .
GROWTH AND DEVELOPMENT OF INFANCY
2 1

22. a ) B i o l o g i c D e v e l o p m e n t
• G r o w t h – f a s t e s t a t 5 - 6 d o u b l e b i r t h w e i g h t
• O n e ye a r i t i s t r i p l e d .
• T a p e r s o f f i n 2 n d ye a r ( w i l l g a i n 5 - 6 l b s . )
• 3 r d ye a r – 4 - 5 l b s .
• H e i g h t – 1 0 - 1 2 “ b y 1 s t yr . = 3 0 i n c h e s t a l l
• 2 n d ye a r – u p t o 5 “
• 2 yr s . – 3 f t .
• G r o w t h o c c u r s i n s p u r t s .
• H e a d b e c o m e s p r o p o r t i o n a t e l y s m a l l e r u n t i l f u l l a d u l t h e i g h t i s r e a c h e d .
• B e c o m e s l e a n e r
• G e n e s d i c t a t e h e i g h t , b u i l t b u t i n t e r a c t s w i t h e n v i r o n m e n t ( N u t r i t i o n , l i v i n g e n v i r o n m e n t f r e e d o m
f r o m d i s e a s e s )
b ) P s y c h o s o c i a l D e v e l o p m e n t
• T r u s t v s . M i s t r u s t ( b i r t h t o 1 ye a r )
• T r u s t i s t h e f o r e m o s t i m p o r t a n t a t t r i b u t e t o b e d e v e l o p e d f o r a h e a l t h y p e r s o n a l i t y.
• T r u s t e x i s t s o n l y i n r e l a t i o n t o s o m e t h i n g o r s o m e o n e .
• R e s u l t s t o f a i t h a n d o p t i m i s m .
• P r i m a r y N a r c i s s i s m i s a t i t s h e i g h t .
• T h e n e x t s o c i a l m o d a l i t y i n v o l v e s a m o d e o f r e a c h i n g o u t t o o t h e r s t h r o u g h g r a s p i n g .
• D u r i n g t h e s e c o n d s t a g e t h e m o r e a c t i v e a n d a g g r e s s i v e m o d a l i t y o f b i t i n g o c c u r s .
c ) C o g n i t i v e D e v e l o p m e n t
• S e n s o r i m o t o r ( b i r t h - 2 ye a r s )
• G o v e r n e d b y s e n s a t i o n s i n w h i c h s i m p l e l e a r n i n g t a k e s p l a c e .
• C h i l d r e n p r o g r e s s f r o m r e f l e x a c t i v i t y t h o u g h s i m p l e , r e p e t i t i v e b e h a v i o r s t o i m i t a t i v e b e h a v i o r .
2 2

23. • P r o b l e m s o l v i n g i s t r i a l a n d e r r o r . T h e y d i s p l a y a h i g h l e v e l o f c u r i o s i t y, e x p e r i m e n t a t i o n a n d
e n j o ym e n t .
 T h r e e C r u c i a l E v e n t s t a k e p l a c e d u r i n g t h i s s t a g e :
• S e p a r a t i o n - T h e y b e g i n t o d e v e l o p a s e n s e o f s e l f a s t h e y a r e a b l e t o d i f f e r e n t i a t e t h e m s e l v e s f r o m
t h e e n v i r o n m e n t .
• O b j e c t p e r m a n e n c e - T h e y b e c o m e a w a r e t h a t o b j e c t s h a v e p e r m a n e n c e – m e a n i n g t h e o b j e c t s e x i s t
e v e n i f i t i s n o l o n g e r v i s i b l e .
• S ym b o l s o r M e n t a l R e p r e s e n t a t i o n – T h e u s e o f s ym b o l s a l l o w s t h e i n f a n t t o t h i n k o f a n o b j e c t o r
s i t u a t i o n w i t h o u t a c t u a l l y e x p e r i e n c i n g i t .
 S t a g e s o f S e n s o r i m o t o r P h a s e
• U s e o f r e f l e x e s – a t b i r t h t h e i n f a n t ’ s i n d i v i d u a l i t y a n d t e m p e r a m e n t a r e e x p r e s s e d t h r o u g h t h e
p h ys i o l o g i c r e f l e x e s o f s u c k i n g , r o o t i n g , g r a s p i n g , a n d c r yi n g .
• P r i m a r y C i r c u l a r R e a c t i o n – m a r k s t h e b e g i n n i n g o f t h e r e p l a c e m e n t o f r e f l e x i v e b e h a v i o r w i t h
v o l u n t a r y a c t s . A c t i v i t i e s s u c h a s s u c k i n g o r g r a s p i n g b e c o m e d e l i b e r a t e a c t s t h a t e l i c i t c e r t a i n
r e s p o n s e s . T h e b e g i n n i n g o f a c c o m m o d a t i o n i s e v i d e n t .
• S e c o n d a r y C i r c u l a r R e a c t i o n – i n t h i s s t a g e t h e p r i m a r y c i r c u l a r r e a c t i o n s a r e r e p e a t e d a n d
p r o l o n g e d f o r t h e r e s p o n s e t h a t r e s u l t s . G r a s p i n g a n d h o l d i n g n o w b e c o m e s h a k i n g , b a n g i n g , a n d
p u l l i n g .
• C o o r d i n a t i o n o f S e c o n d a r y S c h e m a s a n d t h e i r A p p l i c a t i o n t o n e w s i t u a t i o n s – t h i s s t a g e i s l a r g e l y
t r a n s i t i o n a l . T h e y b e g i n t o d i s c o v e r t h a t h i d i n g a n o b j e c t d o e s n o t m e a n t h a t i t i s g o n e b u t t h a t
r e m o v i n g a n o b s t a c l e w i l l r e v e a l t h e o b j e c t
d ) M o r a l D e v e l o p m e n t
• T h e i n f a n t p e r i o d i s a p r e - r e l i g i o u s s t a g e .
• I t i s i m p o r t a n t t o p r a i s e a n i n f a n t f o r d o i n g w h a t h e o r s h e h a s b e e n a s k e d t o d o .
• T h e d e v e l o p m e n t o f t r u s t i s i m p o r t a n t i n m o r a l d e v e l o p m e n t b e c a u s e i n f a n t s w h o d e v e l o p a s o u n d
s e n s e o f t r u s t c a n b e t t e r d e v e l o p a s p i r i t u a l o r i e n t a t i o n i n f u t u r e ye a r s o r b e b o u n d b y a m o r a l
c o n s c i e n c e .
e ) S o c i a l D e v e l o p m e n t
2 3

24. • A t t a c h m e n t t o t h e p a r e n t i s i n c r e a s i n g l y e v i d e n t d u r i n g t h e s e c o n d h a l f o f t h e f i r s t ye a r .
• P l a y i s a m a j o r s o c i a l i z i n g a g e n t t h a t p r o v i d e s s t i m u l a t i o n n e e d e d t o l e a r n f r o m a n d i n t e r a c t w i t h t h e
e n v i r o n m e n t .
• R e a c t i v e a t t a c h m e n t d i s o r d e r – i s a p s yc h o l o g i c a n d d e v e l o p m e n t a l p r o b l e m t h a t s t e m s f r o m
m a l a d a p t i v e o r a b s e n t a t t a c h m e n t b e t w e e n t h e i n f a n t a n d t h e p a r e n t a n d m a y p e r s i s t i n t o c h i l d h o o d
e v e n a d u l t h o o d .
• S e p a r a t i o n a n x i e t y – t h e i n f a n t b e g i n s t o h a v e s o m e a w a r e n e s s o f s e l f a n d m o t h e r a s s e p a r a t e b e i n g s .
T h e r e f o r e s e p a r a t i o n a n x i e t y d e v e l o p s a n d i s m a n i f e s t e d t h r o u g h p r e d i c t a b l e s e q u e n c e o f b e h a v i o r s .
• S t r a n g e r F e a r – b e c o m e p r o m i n e n t a n d a r e r e l a t e d t o i n f a n t s ’ a b i l i t y t o d i s c r i m i n a t e b e t w e e n
f a m i l i a r a n d n o n - f a m i l i a r p e o p l e .
• T yp e o f p l a y i s s o l i t a r y
OvErViEw Of BlOoD DyScRaSiA
Hemolytic disease of the Newborn
T h e m o s t c o m m o n c a u s e o f h e m o l yt i c a n e m i a i n n e w b o r n s i s a l l
i m m u n e d i s e a s e ( H D N ) . H D N c a n o c c u r o n l y i f a n t i g e n s o n f e t a l
e r yt h r o c yt e s d i f f e r f r o m a n t i g e n s o n m a t e r n a l e r yt h r o c yt e s . M a t e r n a l - f e t a l
2 4

25. i n c o m p a t i b i l i t y e x i s t s i f m o t h e r a n d f e t u s d i f f e r i n A B O b l o o d t yp e o r i f t h e f e t u s i s R h - p o s i t i v e a n d t h e m o t h e r i s
R h - n e g a t i v e . S o m e m i n o r b l o o d a n t i g e n s a l s o m a y b e i n v o l v e d .
A B O i n c o m p a t i b i l i t y o c c u r s i n a b o u t 2 0 % - 2 5 & o f a l l p r e g n a n c i e s , b u t o n l y 1 i n 1 0 c a s e s o f A B O r e s u l t s i n
H D N . R h i n c o m p a t i b i l i t y o c c u r s i n f e w e r t h a n 1 0 % o f p r e g n a n c i e s a n d r a r e l y c a u s e s H D N i n t h e f i r s t i n c o m p a t i b l e
f e t u s . E v e n a f t e r f i v e o r m o r e p r e g n a n c i e s , o n l y 5 % o f w o m e n h a v e b a b i e s w i t h h e m o l yt i c d i s e a s e . U s u a l l y
e r yt h r o c yt e s f r o m t h e f i r s t i n c o m p a t i b l e f e t u s c a u s e t h e m o t h e r ’ s i m m u n e s ys t e m t o p r o d u c e a n t i b o d i e s t h a t a f f e c t
t h e f e t u s e s o f s u b s e q u e n t i n c o m p a t i b l e p r e g n a n c i e s . O n l y o n e i n t h r e e c a s e s o f H D N i s c a u s e d b y R h i n c o m p a t i b i l i t y
a n d m o s t c a s e s a r e c a u s e d b y A B O i n c o m p a t i b i l i t y.
CLINICAL manifestations
N e o n a t e s w i t h m i l d H D N m a y a p p e a r h e a l t h y o r s l i g h t l y p a l e , w i t h s l i g h t e n l a r g e m e n t o f t h e l i v e r o r s p l e e n .
P r o n o u n c e d p a l l o r , s p l e n o m e g a l y a n d h e p a t o m e g a l y i n d i c a t e s e v e r e a n e m i a w h i c h p r e d i s p o s e s t h e n e o n a t e t o
c a r d i o v a s c u l a r f a i l u r e a n d s h o c k . L i f e - t h r e a t e n i n g R h i n c o m p a t i b i l i t y i s r a r e
t o d a y, l a r g e l y b e c a u s e o f t h e r o u t i n e u s e o f R h i m m u n o g l o b u l i n
B e c a u s e t h e m a t e r n a l a n t i b o d i e s r e m a i n i n t h e n e o n a t e ’ s c i r c u l a t o r y s ys t e m
a f t e r b i r t h , e r yt h r o c yt e d e s t r u c t i o n c a n c o n t i n u e . T h i s c a u s e s h yp e r b i l i r u b i n e m i a
a n d i c t e r u s n e o n a t o r u m ( n e o n a t a l j a u n d i c e ) s h o r t l y a f t e r b i r t h . W i t h o u t
r e p l a c e m e n t t r a n s f u s i o n s , i n w h i c h t h e c h i l d r e c e i v e s R h – n e g a t i v e e r yt h r o c yt e s ,
t h e b i l i r u b i n i s d e p o s i t e d i n t h e b r a i n , a c o n d i t i o n t e r m e d k e r n i c t e r u s .
K e r n i c t e r u s p r o d u c e s c e r e b r a l d a m a g e a n d u s u a l l y c a u s e s d e a t h ( i c t e r u s g r a v i s
n e o n a t o r u m ) . I n f a n t s w h o d o n o t d i e m a y h a v e m e n t a l r e t a r d a t i o n , c e r e b r a l p a l s y
o r h i g h f r e q u e n c y d e a f n e s s .
Evaluation and treatment
R o u t i n e e v a l u a t i o n o f f e t u s e s a t r i s k f o r H D N i n c l u d e s t h e C o o m b s t e s t . T h e
i n d i r e c t C o o m b s t e s t m e a s u r e s a n t i b o d y i n t h e m o t h e r ’ s c i r c u l a t i o n a n d i n d i c a t e s
w h e t h e r t h e f e t u s i s a t r i s k f o r H D N . T h e d i r e c t C o o m b s t e s t m e a s u r e s a n t i b o d y
a l r e a d y b o u n d t o t h e s u r f a c e s o f f e t a l e r yt h r o c yt e s a n d i s u s e d p r i m a r i l y c o n f i r m
t h e d i a g n o s i s o f a n t i b o d y m e d i a t e d H D N . W i t h a p r i o r h i s t o r y o f f e t a l h e m o l yt i c
2 5

26. d i s e a s e , d i a g n o s t i c t e s t s a r e d o n e t o d e t e r m i n e r i s k w i t h t h e c u r r e n t p r e g n a n c y. T h e s e t e s t s i n c l u d e m a t e r n a l
a n t i b o d y t i t e r s , f e t a l b l o o d s a m p l i n g , a m n i o t i c f l u i d s p e c t r o p h o t o m e t r y a n d u l t r a s o u n d f e t a l a s s e s s m e n t .
T h e k e y t o t r e a t m e n t o f H D N r e s u l t i n g f r o m R h i n c o m p a t i b i l i t y l i e s i n p r e v e n t i o n ( i m m u n o p r o p h yl a x i s ) . O n e o f
t h e s u c c e s s s t o r i e s o f i m m u n o l o g y h a s b e e n t h e r e s u l t s o b t a i n e d w i t h R h i m m u n e g l o b u l i n ( R h o G A M ) , a p r e p a r a t i o n
o f a n t i b o d y a g a i n s t R h a n t i g e n D . I f a n R h - n e g a t i v e w o m a n i s g i v e n R h i m m u n e g o b u l i n w i t h i n 7 2 h o u r s o f e x p o s u r e
t o R h - p o s i t i v e e r yt h r o c yt e s , s h e w i l l n o t p r o d u c e a n t i b o d y a g a i n s t t h e D a n t i g e n a n d t h e n e x t R h - p o s i t i v e b a b y s h e
c o n c e i v e s w i l l b e p r o t e c t e d .
I f a n t i g e n i c i n c o m p a t i b i l i t y o f t h e m o t h e r ’ s e r yt h r o c yt e s i s n o t d i s c o v e r e d i n t i m e t o a d m i n i s t e r p r o p h yl a c t i c
i m m u n e g l o b u l i n ( R h o G A M ) a n d a c h i l d i s b o r n w i t h H D N , t r e a t m e n t c o n s i s t s o f e x c h a n g e t r a n s f u s i o n s i n w h i c h t h e
n e o n a t e ’ s b l o o d i s r e p l a c e d w i t h n e w R h - p o s t i v e b l o o d t h a t i s n o t c o n t a m i n a t e d w i t h a n t i - R h a n t i b o d i e s .
P h o t o t h e r a p y a l s o i s u s e d t o r e d u c e t h e t o x i c e f f e c t s o f u n c o n j u g a t e d b i l i r u b i n .
ANATOMY AND PHYSIOLOGY
Organs of the hematologic Systems
HeMostasis
Normal hemostasis is a process that repairs vascular breaks to reduce blood loss from blood vessels while maintaining the flow of blood through the vascular
system. Hemostasis occurs in 3 stages.
1. Vasoconstriction of blood vessels
2. Formation of platelet plug
3. Coagulation or formation of a fibrin clot.
Once the fibrin clot has served its purpose, further clot formation is balanced by anticoagulation and by fibrinolysis (clot dissolution).
The formation of a fibrin clot can result from activation of one of 3 pathways: intrinsic or extrinsic. The extrinsic pathway is initiated when tissue injury
occurs outside the vessels such as burn. The intrinsic pathway involves the blood itself or damage to the blood vessels. Blood in normal vessels that is stagnant for a
long period of time can form clots.
2 6

27. In some cases, formation of a fibrin clot is unnecessary because hemostasis occurs at an early stage. Temporary clots are sometimes insufficient.
BLOOD
Blood, vital fluid found in humans and other animals that provides important nourishment to all body organs and tissues and carries away waste materials.
Sometimes referred to as “the river of life,” blood is pumped from the heart through a network of blood vessels collectively known as the circulatory system. The
cellular component of blood consists of three primary cell types: Erythrocytes (RBC), Leukocytes (WBC), and thrombocytes (platelets). These cellular
components of blood normally make up 40%-45% of the blood volume. Because most blood cells have a short life span, the need for the body to replenish its supply
of cells is continuous and this process is termed Hematopoiesis.
An adult human has about 5 to 6 liters (1 to 2 gal) of blood, which is roughly 7% to 10% of total body weight. Infants and children have comparably lower
volumes of blood, roughly proportionate to their smaller size. The volume of
blood in an individual fluctuates. During dehydration, for example while
running a marathon, blood volume decreases. Blood volume increases in
circumstances such as pregnancy, when the mother’s blood needs to carry extra
oxygen and nutrients to the baby. Circulating through the vascular system and
serving as a link between body organs, blood carries oxygen absorbed from the
lungs and nutrients absorbed from the gastrointestinal tract to the body cells for
cellular metabolism. Blood also carries hormones, antibodies, and other
substances to their sites of action or use. In addition, blood carries waste
products produced by cellular metabolism to the lungs, skin, liver, and kidneys,
where they a re transformed and eliminated from the body.
Blood is fluid, therefore, the danger always exists that trauma can
lead to loss of blood from the vascular system. To prevent this, an intricate
clotting mechanism is activated when necessary to seal any leak in the blood
vessels. Excessive clotting is equally dangerous, because it can obstruct
blood flow to vital tissues. To prevent his, the body has a fibrinolytic
mechansism that eventually dissolve clots (thrombi) formed within blood vessels. The
balance between these two systems, clot formation and clot dissolution or fibrinolysis
is called Hemostasis.
FUNCTIONS OF THE BLOOD
2 7

28. Blood performs many important functions within the body including:
• Supply of oxygen to tissues (bound to hemoglobin which is carried in red cells)
• Supply of nutrients such as glucose, amino acids and fatty acids (dissolved in the blood or bound to plasma proteins)
• Removal of waste such as carbon dioxide, urea and lactic acid
• Immunological functions, including circulation of white cells, and detection of foreign material by antibodies
• Coagulation, which is one part of the body's self-repair mechanism
• Messenger functions, including the transport of hormones and the signaling of tissue damage
• Regulation of body pH (the normal pH of blood is in the range of 7.35 - 7.45)
• Regulation of core body temperature
• Hydraulic functions
BONE MARROW
T h e b o n e m a r r o w i s t h e s i t e o f h e m a t o p o i e s i s o r b l o o d c e l l f o r m a t i o n . A l l
s k e l e t a l b o n e s a r e i n v o l v e d i n c h i l d r e n , b u t a s c h i l d r e n a g e , m a r r o w a c t i v i t y
d e c r e a s e s . M a r r o w a c t i v i t y i s u s u a l l y l i m i t e d t o t h e p e l v i s , r i b s , v e r t e b r a e , a n d
s t e r n u m i n a d u l t s .
M a r r o w i s o n e o f t h e l a r g e s t o r g a n s o f t h e b o d y m a k i n g u p 4 % - 5 % o f
t o t a l b o d y w e i g h t . I t c o n s i s t s o f i s l a n d o f c e l l u l a r c o m p o n e n t s ( r e d m a r r o w )
s e p a r a t e d b y f a t ( ye l l o w m a r r o w ) . A s t h e a d u l t a g e s , t h e p r o p o r t i o n o f a c t i v e
m a r r o w i s g r a d u a l l y r e p l a c e d b y f a t , h o w e v e r i n h e a l t h y p e r s o n , t h e f a t c a n
a g a i n r e p l a c e d b y a c t i v e m a r r o w w h e n m o r e b l o o d c e l l p r o d u c t i o n i s r e q u i r e d .
T h e m a r r o w i s h i g h l y v a s c u l a r . W i t h i n i t a r e p r i m i t i v e c e l l s c a l l e d s t e m
c e l l s . T h e s t e m c e l l s h a v e t h e a b i l i t y t o s e l f - r e p l i c a t e , t h e r e b y e n s u r i n g a
c o n t i n u o u s s u p p l y o f s t e m c e l l s c a n b e g i n a p r o c e s s o f d i f f e r e n t i a t i o n i n t o
e i t h e r m y e l o i d o r l y m p h o i d s t e m c e l l s . T h e s e s t e m c e l l s c o m m i t t e d t o p r o d u c e
s p e c i f i c t yp e s o f b l o o d c e l l s . L ym p h o i d s t e m c e l l s p r o d u c e e i t h e r T o r B
l ym p h o c yt e s . M ye l o i d s t e m c e l l s d i f f e r e n t i a t e i n t o t h r e e b r o a d c e l l t yp e s : e r yt h r o c yt e s , l e u k o c yt e s a n d p l a t e l e t s .
T h u s , w i t h t h e e x c e p t i o n o f l ym p h o c yt e s , a l l b l o o d c e l l s a r e d e r i v e d f r o m m ye l o i d s t e m c e l l s . A d e f e c t i n a m ye l o i d
s t e m c e l l c a n c a u s e p r o b l e m s w i t h e r yt h r o c yt e , l e u k o c yt e , a n d p l a t e l e t p r o d u c t i o n . M a n y c o m p l e x m e c h a n i s m s a r e
i n v o l v e d i n h e m a t o p o i e s i s , o f t e n a t t h e m o l e c u l a r l e v e l .
2 8

29. BLOOD CELLS
E r y t h r o c y t e s ( R e d B l o o d C e l l s )
The normal erythrocyte is a biconcave disk that resembles a soft ball compressed between 2 fingers.
It has a diameter of about 8 um and is so flexible that it can pass easily through capillaries that may be as
small as 2.8 um in diameter. Erythrocytes or Red blood cells make up almost 45 percent of the blood
volume. Their primary function is to carry oxygen from the lungs to every cell in the body. Red blood cells
are composed predominantly of a protein and iron compound, called Hemoglobin that captures oxygen
molecules as the blood moves through the lungs, giving blood its red color. As blood passes through body
tissues, hemoglobin then releases the oxygen to cells throughout the body. Red blood cells are so packed
with hemoglobin that they lack many components, including a nucleus, found in other cells. Hemoglobin
also takes up and releases nitric oxide, which plays an important role in regulating blood pressure.
The membrane, or outer layer, of the red blood cell is flexible, like a soap bubble, and is able to bend
in many directions without breaking. This is important because the red blood cells must be able to pass
through the tiniest blood vessels, the capillaries, to deliver oxygen wherever it is needed. The capillaries are
so narrow that the red blood cells, normally shaped like a disk with a concave top and bottom, must bend
and twist to maneuver single file through them.
The life span of the RBCs is bout 105-120 days. As
erythrocytes age, they become increasingly fragile and
eventually rupture.
HUMAN ERYHROCYTES
The diameter of a typical human erythrocyte disk is 6–8 µm, much smaller than most other human cells. A
typical erythrocyte contains about 270 million hemoglobin molecules, with each carrying four heme groups.
Adult humans have roughly 2–3 × 1013
red blood cells at any given time (women have about 4 to 5 million
erythrocytes per microliter (cubic millimeter) of blood and men about 5 to 6 million; people living at high altitudes
2 9

30. with low oxygen tension will have more). Red blood cells are thus much more common than the other blood particles: There are about 4,000–11,000 white blood
cells and about 150,000–400,000 platelets in each microliter of human blood.
The red blood cells of an average adult human male store collectively about 2.5 grams of iron, representing about 65% of the total iron contained in the body.[7][8]
(See Human iron metabolism.)
LIFE CYCLE
The process by which red blood cells are produced is called erythropoiesis. Erythrocytes are
continuously being produced in the red bone marrow of large bones, at a rate of about 2 million per
second. (In the embryo, the liver is the main site of red blood cell production.) The production can be
stimulated by the hormone erythropoietin (EPO), synthesized by the kidney; which is used for doping in
sports. Just before and after leaving the bone marrow, they are known as reticulocytes which comprise
about 1% of circulating red blood cells.
Erythrocytes develop from committed stem cells through reticulocytes to mature erythrocytes in about 7
days and live a total of about 120 days.
The aging erythrocyte undergoes changes in its plasma membrane, making it susceptible to recognition
by phagocytes and subsequent phagocytosis in the spleen, liver and bone marrow. Much of the important
breakdown products are recirculated in the body. The heme constituent of hemoglobin is broken down
into Fe3+
and biliverdin. The biliverdin is reduced to bilirubin, which is released into the plasma and
recirculated to the liver bound to albumin. The iron is released into the plasma to be recirculated by a
carrier protein called transferrin. Almost all erythrocytes are removed in this manner from the circulation
before they are old enough to hemolyze. Hemolyzed hemoglobin is bound to a protein in plasma called
haptoglobin which is not excreted by the kidney.
LEUKOCYTES (White blood Cells)
White blood cells or leukocytes are cells of the immune system defending the body against both infectious disease and foreign materials. Several different
and diverse types of leukocytes exist but they are all produced and derived from a multipotent cell in the bone marrow known as a hematopoietic stem cell.
Leukocytes are found throughout the body, including the blood and lymphatic system.
3 0

31. The number of leukocytes in the blood is often an indicator of disease. There are normally
between 4×.5 – 11 T/cumm white blood cells in a liter of blood, making up approximately 1% of blood in
a healthy adult. In conditions such as leukemia, the number of leukocytes is higher than normal and in
leukopenia, this number is much lower. The physical properties of leukocytes, such as volume,
conductivity, and granularity, may change due to activation, the presence of immature cells, or the
presence of malignant leukocytes in leukemia.
Types of Leukocytes
There are several different types of white blood cells. One primary technique to classify them is to look for the presence of granules, which allows the
differentiation of cells into the categories granulocytes and agranulocytes:
• Granulocytes (polymorphonuclear leucocytes): leukocytes characterized by the presence of differently staining granules in their cytoplasm of the cell.
These granules are membrane-bound enzymes which primarily act in the digestion of endocytosed particles. There are three types of granulocytes:
neutrophils, basophils, and eosinophils, which are named according to their staining properties.
• Agranulocytes (mononuclear leucocytes): leukocytes characterized by the apparent absence of granules in their cytoplasm. Although the name implies a
lack of granules these cells do contain non-specific azurophilic granules, which are lysosomes. The cells include lymphocytes, monocytes, and macrophages.
OVERVIEW OF TABLE
T y p e
M i c r o s c o p i c
A p p e a r a n c e
C a r t o o n
A p p r o x . %
i n a d u l t s [ 3 ]
S e e a l s o :
D i a m e t e r
( μ m ) [ 3 ] M a i n t a r g e t s [ 1 ]
N u c l e u s [ 1 ]
G r a n u l e s [ 1 ]
L i f e t i m e [ 3 ]
3 1

32. B l o o d v a l u e s
N e u t r o p h i l 4 0 - 7 5 % 1 0 - 1 2
• b a c t e r i a
• f u n g i
m u l t i -
l o b e d
f i n e , f a i n t l y
p i n k
6 h o u r s - f e w
d a ys
( d a ys i n
s p l e e n a n d
o t h e r
t i s s u e )
E o s i n o p h i l 1 - 6 % 1 0 - 1 2
• p a r a s i t e s
• i n a l l e r g i c
r e a c t i o n s
b i - l o b e d
f u l l o f p i n k -
o r a n g e
( w h e n
s t a i n e d )
8 - 1 2 d a ys
B a s o p h i l < 1 % 9 - 1 0
• i n a l l e r g i c
r e a c t i o n s
b i - o r t r i -
l o b e d
l a r g e b l u e ?
L ym p h o c yt e 2 0 - 4 5 % 7 - 8
• B c e l l s : v a r i o u s
p a t h o g e n s
• T c e l l s :
o C D 4 +
( h e l p e r ) :
i n t r a c e l l u l a r
b a c t e r i a .
o C D 8 +
c yt o t o x i c T
c e l l s : v i r u s -
i n f e c t e d a n d
t u m o r c e l l s .
o γ δ T c e l l s :
• N a t u r a l k i l l e r c e l l s :
v i r u s - i n f e c t e d a n d
t u m o r c e l l s .
d e e p l y
s t a i n i n g ,
e c c e n t r i c
o n l y N K -
c e l l s [ 4 ]
w e e k s t o
ye a r s
3 2

33. M o n o c yt e 2 - 6 %
1 4 - 1 7 v a r i o u s
k i d n e y
s h a p e d
n o n e
m o n t h s -
ye a r s
M a c r o p h a g e N / A d a ys
N e u t r o p h i l
Neutrophils deal with defense against bacterial or fungal infection and other very small inflammatory processes and are usually first responders to microbial
infection; their activity and death in large numbers forms pus. They are also known as polymorphonuclear leukocytes and microphages. The term microphage arises
due to the cells' active involvement in phagocytosis. They have a multi-lobed nucleus which may appear like multiple nuclei, hence the name polymorphonuclear
leukocyte. The cytoplasm may look transparent because of fine granules that are faintly pink in color. Neutrophils are very active in phagocytosing bacteria and are
present in large amount in the pus of wounds. Unfortunately, these cells are not able to renew their lysosomes used in digesting microbes and die after having
phagocytosed a few pathogens - explaining why they are found primarily in the pus, not in tissue.
E o s i n o p h i l
Eosinophils primarily deal with parasitic infections and an increase in them may indicate such. Eosinophils are also the predominant inflammatory cells in
allergic reactions. The most important causes of eosinophilia include allergies such as asthma, hay fever, and hives; and also parasitic infections. Generally their
nucleus is bi-lobed. The cytoplasm is full of granules which assume a characteristic pink-orange color with eosin stain.
B a s o p h i l
Basophils are chiefly responsible for allergic and antigen response by releasing the chemical histamine causing inflammation. The nucleus is bi- or tri-lobed,
but it is hard to see because of the number of coarse granules which hide it. They are characterized by their large blue granules.
L y m p h o c y t e
Lymphocytes are much more common in the lymphatic system. Lymphocytes are distinguished by having a deeply staining nucleus which may be eccentric in
location, and a relatively small amount of cytoplasm. The blood has three types of lymphocytes:
3 3

34. • B cells: B cells make antibodies that bind to pathogens to enable their destruction. (B cells not only make antibodies that bind to pathogens, but after an
attack, some B cells will retain the ability to produce an antibody to serve as a 'memory' system.)
• T cells:
o CD4+ (helper) T cells co-ordinate the immune response and are important in the defense against intracellular bacteria.
o CD8+ cytotoxic T cells are able to kill virus-infected and tumor cells.
o T cells possess an alternative T cell receptor as opposed to CD4+ and CD8+ αβ T cells and share characteristics of helper T cells, cytotoxic T cells
and natural killer cells.
o Natural killer cells: Natural killer cells are able to kill cells of the body which are displaying a signal to kill them, as they have been infected by a
virus or have become cancerous.
M o n o c y t e
Monocytes share the "vacuum cleaner" (phagocytosis) function of neutrophils, but are much longer lived as they have an additional role: they present pieces
of pathogens to T cells so that the pathogens may be recognized again and killed, or so that an antibody response may be mounted. Monocytes eventually leave the
bloodstream to become tissue macrophages which remove dead cell debris as well as attacking microorganisms. Neither of these can be dealt with effectively by the
neutrophils. Unlike neutrophils, monocytes are able to replace their lysosomal contents and are thought to have a much longer active life. They have the kidney
shaped nucleus and typically agranulated. They also possess abundant cytoplasm.
M a c r o p h a g e
Monocytes are able to differentiate into the dedicated phagocytosing macrophage cell after migrating from the bloodstream into tissues.
Functions of Leukocytes
Leukocytes protect the body from invasion by bacteria and other foreign entities. The major function of neutrophils
is phagocytosis. Neutrophils arrive at a given site within 1 hour after the onset of an inflammatory reaction and initiate
phagocytosis, but they are short-lived. An influx of monocytes follows. These cells continue their phagocytic activities for
long periods as macrophages. This process constitutes a second line of defense for the body against inflammation and
infection. Macrophages also digest senescent blood cells, such as erythrocytes, primarily within the spleen.
The primary function of lymphocytes is to produce substances that aid in attacking foreign material. One group of
lymphocytes (T lymphocytes) kills foreign cells directly or releases a variety of lymphokines, substances that enhances the
activity of phagocytic cells. T lymphocytes are responsible for delayed allergic reactions, rejection of foreign tissue and
destruction of tumor cells. The process is known cellular immunity. The other group of lymphocytes (B lymphocytes) is
3 4

35. capable of differentiating into plasma cells. Plasma cells produce antibodies called immunoglobulin (Ig), which are protein molecules that destroy foreign material
by several mechanisms. This process is known as humoral immunity.
Eosinophils and basophils function in hypersensitivity reactions. Eosinophils are important in the phagocytosis of parasites. Basophils produce and store
histamine as well as other substances involved in hypersensitivity reactions. The release of these substances provokes allergic reactions.
Platelets (Thrombocytes)
Platelets or thrombocytes are not technically cells rather they are granular fragments
of giant cells in the bone maroow called megakaryocytes. Platelet production in the bone
marrow is regulated in part by the hormone thrombopoeitin which stimulates the production
and differentiation of megakaryocytes from the myeloid stem cell.
Platelets play an essential role in the control of bleeding. They circulate freely in the
blood in an inactive state where they nurture the endothelium of the blood vessels maintaining
the integrity of the vessel. When vascular injury occurs, platelets collect at the site and are
activated. They adhere to the site of injury and to each other, forming a platelet plug that
temporarily stops bleeding. Substances released from platelet granules activate coagulation
factors in the blood plasma and initiate the formation of a stable clot composed of fibrin, a filamentous protein. Platelets have a
normal life span of 7-10 days.
3 5

36. 3 6

37. T I S S U E H Y P O X I A
3 7
PATHOPHYSIOLOGYPATHOPHYSIOLOGY
E t i o l o g i c A g e n t
( E r yh t r o p o i e s i s )
( B l o o d l o s s )
( D e s t r u c t i o n )
R e d b l o o d c e l l s h e m o g l o b i n
( A n e m i c c o n d i t i o n )
O x yg e n - c a r r yi n g c a p a c i t y
( H yp o x e m i a )
I s c h e m i a
L i v e r
( F a t t y c h a n g e s ;
f a t t y c h a n g e s c a n
a l s o o c c u r i n h e a r t
a n d k i d n e y)
W e a k n e s s ,
f a t i g u e
P a l l o r
( s k i n / m u c o u s
m e m b r a n e )
R e s p i r a t o r y
( R e s p i r a t o r y
r a t e , d e p t h ,
e x e r t i o n a l
d ys p n e a ” )
C N S
( D i z z i n e s s ,
f a i n t i n g ,
l e t h a r g y
C l a u d i c a t i o n
( M u s c l e )

38. 3 8
O x y g e n
d e m a n d s f o r
w o r k o f
h e a r t
C a r d i o v a s c u l a r
S t i m u l a t e s b o n e
m a r r o w ( s i z e a n d
m a s s )
C a p i l l a r y
D i l a t i o n
H e a r t
( a n g i n a )
C o m p e n s a t o r y
M e c h a n i s m s
E r yt h r o p o i e t i n
H e a r t
r a t e
S V
R e n a l
D P G i n
c e l l s
R e n i n -
a l d o s t e r o n e
r e s p o n s e
S a l t a n d H 2 0
r e t e n t i o n
E x t r a c e l l u l a r
f l u i d
B P
H yp e r d yn a m i c
c i r c u l a t i o n
H i g h o u t p u t / S V
c a r d i a c f a i l u r e
E x t r a c e l l u l a r
f l u i d
C a r d i a c
M u r m u r s R e l e a s e o f
o x yg e n f r o m
h e m o g l o b i n i n
t i s s u e s
p u l s e
BP

39. MEDICATIONS
o Tranexami c Acid 125mg q 8 H IVTT
G e n e r i c N a m e : T r a n e x a m i c A c i d
C l a s s i f i c a t i o n : A n t i f i b r i n o l yt i c A g e n t s
I n d i c a t i o n s : g i v e n t o p a t i e n t s w i t h s e v e r e b l e e d i n g a n d b l o o d p r o b l e m s . A l s o g i v e n t o o r a l b l e e d i n g e s p e c i a l l y
d e n t a l p r o b l e m s .
M e c h a n i s m o f A c t i o n : A s yn t h e t i c d e r i v a t i v e o f t h e a m i n o a c i d l ys i n e w i t h a n t i f i b r i n o l yt i c a c t i v i t y. W i t h s t r o n g
a f f i n i t y f o r t h e f i v e l ys i n e - b i n d i n g s i t e s o f p l a s m i n o g e n , t r a n e x a m i c a c i d c o m p e t i t i v e l y i n h i b i t s t h e a c t i v a t i o n o f
p l a s m i n o g e n t o p l a s m i n , r e s u l t i n g i n i n h i b i t i o n o f f i b r i n o l ys i s ; a t h i g h e r c o n c e n t r a t i o n s , t h i s a g e n t
n o n c o m p e t i t i v e l y i n h i b i t s p l a s m i n . T h i s a g e n t h a s a l o n g e r h a l f - l i f e , i s a p p r o x i m a t e l y t e n t i m e s m o r e p o t e n t , a n d
i s l e s s t o x i c t h a n a m i n o c a p r o i c a c i d , w h i c h p o s s e s s e s s i m i l a r m e c h a n i s m s o f a c t i o n .
S i d e E f f e c t s : H e a d a c h e ( s e v e r e a n d s u d d e n ) ; l o s s o f c o o r d i n a t i o n ( s u d d e n ) ; p a i n s i n c h e s t , g r o i n , o r l e g s ,
e s p e c i a l l y t h e c a l v e s ; s h o r t n e s s o f b r e a t h ( s u d d e n ) ; s l u r r e d s p e e c h ( s u d d e n ) ; v i s i o n c h a n g e s ( s u d d e n ) ; w e a k n e s s
o r n u m b n e s s i n a r m o r l e g
D o s a g e : 1 2 5 m g T I D
C o n t r a i n d i c a t i o n s : P a t i e n t s w i t h a h i s t o r y o r r i s k o f t h r o m b o s i s . C a u t i o n s h o u l d b e u s e d i n p a t i e n t s w i t h r e n a l
i n s u f f i c i e n c y s i n c e t h e d r u g i s e l i m i n a t e d b y g l o m e r u l a r f i l t r a t i o n .
N u r s i n g C o n s i d e r a t i o n s :
 M o n i t o r a d v e r s e e f f e c t s .
 M o n i t o r c o m p l e t e b l o o d c o u n t .
 M o n i t o r v i t a l s i g n s e s p e c i a l l y b l o o d p r e s s u r e .
3 9

40. O VITAMIN K 4MG IVTT OD
G E N E R I C N A M E : P h yt o n a d i o n e
B R A N D N A M E : A q u a m e p h yt o n / H e m a K
C L A S S I F I C A T I O N : V i t . K
I N D I C A T I O N : t o p r e v e n t h e m o r r h a g i c d i s e a s e o f n e w b o r n
MECHANISM OF ACTION: Used for prophylaxis and treatment of hemorrhagic disease in the newborn. It is necessary component for the production of certain
coagulation factors
S I D E E F F E C T S / A D V E R S E R E A C T I O N S : P a i n a n d e d e m a m a y o c c u r a t i n j e c t i o n s i t e . P o s s i b l e a l l e r g i c r e a c t i o n s u c h
a s r a s h e s m a y o c c u r
D O S A G E : 0 . 5 - 1 . 0 m g I M o n e t i m e i m m e d i a t e l y a f t e r b i r t h
C O N T R A I N D I C A T I O N S : C o n t r a i n d i c a t e d i n p a t i e n t s h yp e r s e n s i t i v e t o d r u g
NURSING CONSIDDERATIONS:
• E x p l a i n p u r p o s e o f d r u g
• T e l l p a t i e n t t o a v o i d h a z a r d o u s a c t i v i t i e s i f d i z z i n e s s o c c u r s
• I n f o r m p a t i e n t t h a t d r u g i s f a t s o l u b l e ; a d v i s e h e r t o t a k e d r u g o n l y a s p r e s c r i b e d t o a v o i d a c c u m u l a t i o n
• C h e c k b r a n d n a m e l a b e l s f o r a d m i n i s t r a t i o n r o u t e r e s t r i c t i o n s
4 0

41. 4 1

42. 4 2
F U N C T I O N A L P A T T E R N I N I T I A L A P P R A I S A L 2 / 2 / 0 8 O N G O I N G A P P R A I S A L 2 / 3 / 0 8
1 . H e a l t h P e r c e p t i o n –
H e a l t h M a n a g e m e n t
P a t t e r n
• G e n e r a l H e a l t h f o r t h e p a s t
1 0 d a y s h a s b e e n g o o d .
• H e a l t h d u r i n g
p r e g n a n c y / l a b o r / d e l i v e r y
h a s b e e n g o o d a n d h a s n o
c o m p l i c a t i o n u p o n d e l i v e r y
a t h o m e .
• M o t h e r v e r b a l i z e d h a d
r e g u l a r p r e n a t a l v i s i t s
• P a r e n t s a r e w e l l g r o o m e d
• P a r e n t s u s e s O T C d r u g s i f
n e c e s s a r y
• 2 n d
a n d y o u n g e s t c h i l d
• N o i m m u n i z a t i o n s s i n c e
d e l i v e r y
• S o u g h t a d m i s s i o n u p o n
b l e e d i n g o f c o r d s t u m p w a s
n o t e d
• P a r e n t s d o e s n o t s m o k e n o r
d r i n k a l c o h o l i c b e v e r a g e s
a r o u n d c h i l d r e n
• B a b y s l e e p s o n t h e w o o d e n
f l o o r w i t h “ m u s k i t i r o ”
• C o m p l i a n t o f a l l o r d e r s
g i v e n b y t h e d o c t o r s a n d
n u r s e s
• C h a n g e s c l o t h e s w h e n b a b y
i s w e t
2 . N u t r i t i o n a l – M e t a b o l i c
P a t t e r n
• C l i e n t h a d f r e q u e n t
b r e a s t f e e d i n g
• S u c k s w e l l
• G o o d a p p e t i t e
• S h e g a i n e d w e i g h t
• H a s n o d i f f i c u l t y i n
• C l 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 w i t h D 5 . 3 N a C l 5 0 0
c c a t r i g h t m e t a c a r p a l v e i n @ 1 4
m l / h r
• C o r d s t u m p i s s l i g h t l y w e t
• W e i g h t – 3 . 3 k g
• V i t a l S i g n s :
o PR = 120-140 bpm
o RR = 26-28 cpm.
o T = 36.5˚C-37.4˚C
• Medications:
o V i t a m i n k 4 m g O D
o T r a n e x a m i c A c i d 1 2 5 m g q 8 H
I V T T
o O 2 i n h a l a t i o n 1 L / m i n v i a n a s a l
c a n n u l a
• N P O
• C o r d i s c l e a n e d a n d d r e s s e d u p o n
a d m i s s i o n
• C l i e n t i s n o t b a t h e d s i n c e d e l i v e r y
a s v e r b a l i z e d b y m o t h e r
• C o m p l i a n t o f m e d i c a l r e g i m e n
• M I O n o t m o n i t o r e d
• R e q u e s t s 5 0 c c F WB 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 o p e r c r o s s -
m a t c h i n g
• C l i e n t i s n o t b r e a s t f e d d u e t o
c o n d i t i o n
• P r e s e n c e o f D 5 . 3 N a C l 5 0 0 c c a t
r i g h t m e t a c a r p a l v e i n @ 1 4 m l / h r
• C l 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 w i t h
D 5 . 3 N a C l 5 0 0 c c a t r i g h t
m e t a c a r p a l v e i n @ 1 4 m l / h r
• C o r d s t u m p i s s l i g h t l y w e t
• We i g h t – 3 . 3 k g
• V i t a l S i g n s :
o PR = 120-144 bpm
o RR = 24-28 cpm.
o T = 36.5˚C-37.6˚C
• Laboratory Examination
o Blood typing – A +
o Rh type – Rh +
• Medications:
o V i t a m i n k 4 m g O D
o T r a n e x a m i c A c i d 1 2 5 m g q 8
H I V T T
o O 2 i n h a l a t i o n 1 L / m i n v i a
n a s a l c a n n u l a
• N P O
• C o r d i s c l e a n e d a n d d r e s s e d
• C l i e n t i s n o t b a t h e d s i n c e
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 z e d
b y m o t h e r
• C o m p l i a n t o f m e d i c a l r e g i m e n
• M I O n o t m o n i t o r e d
• S t i l l r e q u e s t i n g 5 0 c c F W B 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 o p e r
c r o s s - m a t c h i n g
• B r e a s t f e e d w i t h a m o u n t o f 2
o u n c e s
• S u c k s w e l l
• P r e s e n c e o f D 5 . 3 N a C l 5 0 0 c c

43. C u e s / E v i d e n c e s N u r s i n g
D i a g n o s i s
O b j e c t i v e s I n t e r v e n t i o n s R a t i o n a l e E v a l u a t i o n
4 3

44. S 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 ,
“ L u s p a d k a a yo
a k o n g b a t a . ”
O b 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 m p .
• T = 3 7 . 4 ˚ C
• P R = 1 5 0 b p m
• R R = 6 8 c p m
• F o r b l o o d
t r a n s f u s i o n .
• N o p a s t h e a l t h
h i s t o r y.
• S 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 m i n a l a r e a .
• S k i n i s d r y P T A .
• W e i g h t = 3 . 3 k g
F l u i d v o l u m e
d e f i c i t r e l a t e d t o
b l e e d i n g a t t h e
c o r d s t u m p .
W i t h i n m y c a r e ,
t h e p a t i e n t w i l l
m a i n t a i n a d e q 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 y:
• S t a b l e v i t a l
s i g n s .
• M o i s t m u c o u s
m e m b r a n e s .
• E q u a l i n t a k e a n d
o u t p u t .
D i 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 1 0 0
m l .
• S 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 .
• C a p i l l a r y r e f i l l
w i t h i n 1 - 3
s e c o n d s .
• S p e c i f i c g r a v i t y
o f u r i n e i s 1 . 0 1 0
t o 1 . 0 2 5 .
 M a 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 .
 M o n i t o r w e i g h t
d a i l y.
 N 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.
 M o n i t o r v i t a l
s i g n s .
 O b 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 m u c o u s
m e m b r a n e s .
 M o 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 m p l e t e b l o o d
c o u n t .
 A s s i s t
w h e n e v e r t h e r e
i s I V F
i n s t i l l a t i o n .
 T e a 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 m a 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 .
 K 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 x 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 x a t i o n o f s p e c i f i c
g r a v i t y.
 R 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 m e m a 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 .
 S ym p t o m s
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 m o c o n c e n t r a t i o n
w i t h c o n s e q u e n t
v a s o o c c l u s i v e
s t a t e .
 E l e v a t i o n m a y
i n d i c a t e
h e m o c o n c e n t r a t i o n .
D e 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 m e n t .
W i t h i n m y c a r e ,
t h e o b j e c t i v e s
w e r e m e t a s
e v i d e n c e d b y:
 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 .
 H a d m o i s t
m u c o u s
m e m b r a n e s .
 H a d e q u a l
i n t a k e a n d
o u t p u t .
D i f f e r e n c e
w a s w i t h i n
1 0 0 c c .
 S 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 .
 C a p i l l a r y
r e f i l l w a s 2
s e c o n d s .
 H a d 1 . 0 1 5
s p e c i f i c
g r a v i t y o f
u r i n e .
4 4

45. b l o o d t yp e
r e s u l t i s g i v e n .
 T e a 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 m o t e s a f e t y o f
p r o c e d u r e .
C u e s / E v i d e n c e s N u r s i n g
D i a g n o s i s
O b j e c t i v e s I n t e r v e n t i o n s R a t i o n a l e E v a l u a t i o n
4 5
L i l i a
V i c t o r
i a
N e s
t o r
L i n
d a
M a
h i n
a y
R o b
e r t
M a h
i n a y
A n t o n
i o
A g u s t
i n o
M a r i t e s
A g u s t i n o
N a t h y
S u
n n
y
J
u
l y
M
a
r
g
i e
F
e
m a
I
m
e
l
d a
J
e
m a
L
a
n i
J
o
c
e
l
y n
R
h
e
a
M
a e
J o
h
n
C
a r
l o
A
r i
e l
A r
m
e l
R a
n d y
J e
r r y
D a
n n
y
S a
m e
o n

46. S 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 ,
“ L i h o k a n
k a a yo a n g
k a m o t s a
a k o n g b a t a .
M a h a d l o k k o
m a t a n d o g a n g
d a g u m s a
s u l o d . ”
O b j e c t i v e
• P r e s e n c e o f
I V F D 5 N a C l
0 . 3 5 0 0 c c @
R i g h t
m e t a c a r p a l
v e i n r e g u l a t e d
@ 1 4 m l / h r .
• I V s i t e : I n t a c t ,
n o e r yt h e m a
a n d
i n f l a m m a t i o n .
• T = 3 7 . 4 ˚ C
• P R = 1 5 0 b p m
• R R = 6 8 c p m
• N o l a b o r a t o r y
r e s u l t s ye t .
R i s k f o r
i n f e c t i o n
r e l a t e d t o
p r e s e n c e o f
I V l i n e @
r i g h t
m e t a c a r p a l
v e i n .
W i t h i n m y 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
I V s i t e a s
e v i d e n c e d b y:
• S t a b l e v i t a l
s i g n s .
• D e m o 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 m a a n d
e d e m a .
• L a 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
W B C c o u n t .
( 4 . 5 - 1 1
T / c u m m )
 S t r e s s p r o p e r
h a n d w a 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 w e l l
w h i l e t a k i n g c a r e
o f t h e b a b y.
 M a i n t a i n s t e r i l e
t e c h n i q 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 .
 A 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 m p e r a t u r e p e r
p r o t o c o l .
 A 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 m a
a n d t e n d e r n e s s .
 A 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 m i n i s t r a t i o n .
 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 .
 R e d u c e s r i s k o f
c r o s s -
c o n t a m i 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 m i a l
i n f e c t i o n s .
 A r i s e i n
t e m p e r a t u r e o r
p u l s e m a y
i n d i c a t e i n f e c t i o n .
 T o p r e v e n t t i s s u e
t r a u m a 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 m s i n t o
s k i n .
 P r e v e n t
c o n t a m i n a t i o n a n d
i r r i t a t i o n w h i c h
i n d i c a t e i n f e c t i o n .
 P r o m o 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 m o t e
i m m e 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 .
W i t h i n m y c a r e ,
o b j e c t i v e s w e r e
p a r t i a l l y m e t a s
e v i d e n c e d b y:
 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 .
 I V s i t e w a 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 m a , a n d
e d e m a .
 L a 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 m o n i t o r e d .
4 6

47. 4 7
C u e s / E v i d e n c e s N u r s i n g
D i a g n o s i s
O b j e c t i v e s I n t e r v e n t i o n s R a t i o n a l e E v a l u a t i o n
S 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 ,
“ L i h o k a n k a a yo
a k o n g b a t a s a m u t
n a g a m a t a .
H a d l o k k o
m a 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 x yg e n . ”
O b j e c t i v e
• P r e s e n c e o f
o x yg e n v i a n a s a l
c a n n u l a @ R i g h t
n a r e s , r e g u l a t e d
@ 1 l i t e r / m i n
• T = 3 7 . 4 ˚ C
• P R = 1 5 0 b p m
• R R = 6 8 c p m
• C 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 R 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
m o v i n g .
• C a n n u l a i s
m o v e d w h e n e v e r
t h e b a b y m o v e s .
• D r y s k i n a n d
p a l e .
R i s k f o r a l t e r e d
s k i n i n t e g r i t y
r e l a t e d t o
p r e s e n c e o f
o x y g e n v i a
n a s a l c a n n u l a .
W i t h i n m y c a r e ,
c l i e n t w i 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 y:
• S t a b l e v i t a l
s i g n s
• F r e e o f
c o m p l i c a t i o n s
a s s o c i a t e d w i t h
o x yg e n s u p p o r t .
• F r e e o f
e n v i r o n m e n t a l
h a z a r d s .
• G o o d h yd r a t i o n
a s e v i d e n c e d
w i t h m o i s t
m u c o u s
m e m b r a n e s .
 A s s e s s p l a c e m e 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 .
 M a 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 m o v e d .
 A s s i s t i n
r e p l a c e m e 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 .
 T e a 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
w h e n e v e r
s e c r e t i o n s a r e
n o t e d .
 T e a c h p a r e n t s t o
r e p o r t a n y
c o m p 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 .
 L o o s e c a n u l a
p r o m o t e s
f r i c t i o n t h u s
i n j u r i n g s k i n
s u r f a c e s .
 T h i s i s t o
p r e v e n t i n j 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 .
 T 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 .
 A s s e s s f o r a i r
e m b o l i s m i n
t h e s k i n t r a c t .
 T o m a i n t a i n a
s a f e
p r o c e d u r e .
 T o p r e v e n t
f u r t h e r
c o m p l i c a t i o n s
.
W i t h i n m y c a r e ,
o b j e c t i v e s w e r e
m e t a s e v i d e n c e d
b y:
 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 .
 H a d m o i s t
m u c o u s
m e m b r a n e s .
 F r e e f r o m
e n v i r o n m e n t a l
h a z a r d s w h i c h
m a 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 m p l i c a t i o n s
a s s o c i a t e d w i t h
o x yg e n s u p p o r t .

48. • F l u i d v o l u m e d e f i c i t r e l a t e d t o b l e e d i n g a t t h e c o r d s t u m p .
• R i s k f o r i n f e c t i o n r e l a t e d t o p r e s e n c e o f I V l i n e @ r i g h t m e t a c a r p a l v e i n .
• R i s k f o r a l t e r e d s k i n i n t e g r i t y r e l a t e d t o p r e s e n c e o f o x y g e n v i a n a s a l c a n n u l a .
• K n o w l e d g e d e f i c i t r e l 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 l o o d d y s c r a s i a .
• F a t i g u e r e l a t e d t o c o m p e n s a t o r y m e c h a n i s m f o r o x y g e n i n t h e b o d y .
• I n e f f e c t i v e f a m i l y c o p i n g r e l a t e d t o f i n a n c i a l p r o b l e m s .
• R i s k f o r p e r i p h e r a l v a s c u l a r d y s f u n c t i o n r e l a t e d t o h y p e r d y n a m i c c i r c u l a t i o n o f f l u i d s .
4 8

49. SYNTHESIS
A l l o f u s w e r e s o h a p p y t h a t w e h a v e r e a c h e d t h i s s e m e s t e r , e v e n t h o u g h w e w e r e f a c e d w i t h d i f f e r e n t
c h a l l e n g e s a n d l o t s o f h a r d s h i p s i n o u r l i f e , b u t t h r o u g h a l l o f t h a t , w e w e r e a b l e t o c o p e u p a n d l e a r n f r o m i t .
A t t h e b e g i n n i n g o f t h i s r o t a t i o n ( P e d i a t r i c R o t a t i o n ) , w e a l r e a d y k n o w w h a t w e w e r e g o i n g t h r o u g h . D e a l i n g
w i t h i n f a n t s a n d c h i l d r e n i s n o t e a s y e s p e c i a l l y i f p a t i e n t s a r e yo u n g ( b e l o n g i n g t o t h e i n f a n t p e r i o d ) , p a t i e n t s t h a t
a r e d i f f i c u l t t o h a n d l e , p a t i e n t s t h a t a r e s c a r e d o f n u r s e s o r s h y.
T h i s e x p e r i e n c e i s s o c h a l l e n g i n g f o r u s s t u d e n t n u r s e s a n d n u r s e s i n t h e f u t u r e . W e n u r s e s m u s t b e p r e p a r e d a n d b e
f l e x i b l e i n d e a l i n g w i t h p e d i a t r i c p a t i e n t s o r a n yo n e w h o m w e e n c o u n t e r s o m e d a y. W e s h o u l d n e v e r s u r r e n d e r t o a n y
o b s t a c l e s / p r o b l e m s w e ’ v e b e e n t h r o u g h i n o u r l i v e s a n d s h o u l d n e v e r s t o p a s k i n g f o r g u i d a n c e t o o u r e v e r l o v i n g
G O D .
P e d i a t r i c R o t a t i o n i s f u n a n d c h a l l e n g i n g . W e d i d n ’ t f e e l a n y e x h a u s t i o n d u r i n g o u r d u t y. A l t h o u g h w e w e r e
b o m b a r d e d b y h u m o n g o u s p i l e o f p a p e r w o r k b u t w e w e r e a b l e t o c o p e a n d s u r v i v e f r o m i t . N e v e r t h e l e s s , t h a n k s t o
o u r C l i n i c a l I n s t r u c t o r f o r b e i n g p a t i e n t a n d l o v i n g .
O u r c a s e i s t h e m o s t i n t e r e s t i n g o f a l l , s i n c e i t d e a l s w i t h b l o o d . I t i s t h e m o s t c h a l l e n g i n g a n d i t h e l p s o u r
m i n d w o r k t o k n o w a n d l e a r n w h a t c a u s e s t h e s e d i s e a s e s t o c h i l d r e n a n d a d u l t s . K n o w i n g t h e s p e c i f i c a l t e r a t i o n s i n
t h e b o d y, w e s h a r p e n e d o u r a s s e s s m e n t s k i l l s a n d h a d a k e e n m i n d . D o i n g t h e a p p r o p r i a t e n u r s i n g i n t e r v e n t i o n s
p r o v e d u s t h a t w e a r e c a p a b l e o f h a n d l i n g t h i s k i n d o f c a s e a n d t h a t w e a r e o p t t o g i v e t h e b e s t c a r e . D e a l i n g w i t h
b l o o d i s v e r y c r u c i a l e s p e c i a l l y w i t h t h e p r e s e n c e o f b l o o d a b n o r m a l i t i e s . W e s h o u l d p r e v e n t o u r s e l v e s f r o m
c o n t a m i n a t i o n . T h a t i s t h e r e a s o n b e h i n d e x e r c i s i n g o u r n u r s i n g s k i l l s . W e a r e s o g r a t e f u l t h a t w e a r e g i v e n t h i s t yp e
o f c a s e a n d o u r p a t i e n t t o g e t h e r w i t h h i s p a r e n t s c o o p e r a t e d t o o u r c a r e . W e a r e h a p p y t h a t t h e y p e r m i t t e d u s t o
p r e s e n t t h e i r s o n s c a s e f o r t h e b e n e f i t o f l e a r n i n g u p o n a s s u r a n c e o f c o n f i d e n t i a l i t y. I t h a s b e e n a j o u r n e y t h r o u g h
l i f e .
4 9

50. W e , K r i s t i n e a n d I v a n , t h i r d ye a r n u r s i n g s t u d e n t s o f S i l l i m a n U n i v e r s i t y a r e h o n o r e d t o h a v e g i v e n s u c h o p p o r t u n i t y
i n s t u d yi n g a n d p r e s e n t i n g t h i s c a s e . T h i s c a s e s t u d y h e l p e d u s b r o a d e n o u r k n o w l e d g e , e n h a n c i n g o u r s k i l l s a n d
i m p r o v e d o u r a t t i t u d e s . T h i s s t u d y a l s o m o l d e d u s t o b e a b e t t e r s t u d e n t s a n d n u r s e s i n t h e f u t u r e . I t a l s o h e l p e d u s
r e a l i z e h o w g r a t e f u l w e a r e t o b e i n t h i s w o r l d a n d h o w w e s h o u l d b e t h a n k f u l t o G o d a n d f a m i l y w h o h a v e s a c r i f i c e d
e v e r yt h i n g f o r u s .
T h r o u g h t h i s e x p e r i e n c e , w e w o u l d a l s o l i k e t o t h a n k t h e f o l l o w i n g p e o p l e b e c a u s e w i t h o u t t h e m t h i s w o u l d n o t
b e m a d e p o s s i b l e . F i r s t , w e w o u l d l i k e t o t h a n k G o d f o r g i v i n g u s t h i s s p e c i a l l i f e t h a t w e w e r e a b l e t o r e a c h t h i s
s t a g e a n d f o r t h e g u i d a n c e t h r o u g h o u r j o u r n e y i n l i f e ; S e c o n d , f o r o u r f a m i l i e s f o r b e i n g v e r y s u p p o r t i v e a n d
u n d e r s t a n d i n g ; T h i r d , o u r b e l o v e d C . I M s . D a w n J a n i c e A . T i e m p o f o r t e a c h i n g u s t h e g o o d w a ys a n d m o l d e d u s a s a
b e t t e r p e r s o n ; F o u r t h , f o r t h e N O P H P e d i a t r i c s t a f f s f o r a l l o w i n g u s t o b e e x p o s e d i n t h i s r o t a t i o n ; F i f t h , w o u l d b e
o u r c l a s s m a t e s w h o s e a l w a ys t h e r e f o r u s t h r o u g h t h i c k a n d t h i n ; A n d l a s t l y, w o u l d b e o u r p a t i e n t J o h n C a r l o
M a h i n a y A g u s t i n o a n d h e r f a m i l y w h o g a v e f u l l y t h e i r p a r t i c i p a t i o n a n d c o o p e r a t i o n . T h a n k yo u .
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51. BIBLIOGRAPHY
• B l a c k , J o yc e & H a w k s , J a n e H . ( 2 0 0 5 ) . M e d i c a l - s u r g i c a l n u r s i n g : c l i n i c a l m a n a g e m e n t f o r p o s i t i v e o u t c o m e s .
7 t h
e d . S t L o u i s , M i s s o u r i , U S A : E l s e v i e r I n c .
• D e g l i n , J u d i t h H . ( 2 0 0 5 ) . D a v i s ’ s D r u g G u i d e F o r N u r s e s 9 t h
e d . P h i l a d e l p h i a : W . B . S a u n d e r s , C o m p a n y
• D o e n g e s , M a r i l yn n E . ( 2 0 0 4 ) . N u r s e ’ s P o c k e t G u i d e . 9 t h
e d . C o p yr i g h t b y F . A D a v i s C o m p a n y
• E n c a r t a E n c yc l o p e d i a P r e m i u m S u i t e . ( 2 0 0 7 )
• G o r r i e , T . M . e t . a l . F o u n d a t i o n s o f m a t e r n a l n e w b o r n n u r s i n g . P h i l a d e l p h i a : W . B . S a u n d e r s , C o m p a n y
• H o c k e n b e r r y, M . J . ( 2 0 0 5 ) . W o n g ’ s E s s e n t i a l s o f P e d i a t r i c N u r s i n g . ( 7 t h
e d ) . E l v e s i e r : M o s b y
• M a r i e b , E . 2 0 0 0 . E s s e n t i a l s o f H u m a n A n a t o m y & P h y s i o l o g y ( 6 t h E d . ) P e a r s o n E d u c a t i o n A s i a P t e . L t d
• M c C a n c e , K . & H u e t h e r , S . ( 1 9 9 4 ) . P a t h o p h y s i o l o g y . 2 n d
e d . U . S . A . : M o s b y- Y e a r B o o k , I n c .
• M o s b y’ s p o c k e t d i c t i o n a r y o f m e d i c i n e , n u r s i n g a n d a l l i e d h e a l t h ( 4 t h
d . ) . ( 2 0 0 2 ) .
• O l d s , S a l l y e t . a l . ( 1 9 9 8 ) M a t e r n a l - n e w b o r n n u r s i n g . ( 5 t h
e d ) . A d d i s o n - W e s l e y: N e w Y o r k .
• P i l l i t e r i , A d e l e . ( 1 9 9 9 ) . M a t e r n a l a n d N e w b o r n h e a l t h c a r e . 2 n d
e d . L i p p i n c o t t : P h i l a d e l p h i a
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52. • W o n g , D o n n a L . ( 1 9 9 9 ) . Wh a l e y a n d Wo n g ’ s n u r s i n g c a r e o f i n f a n t s a n d c h i l d r e n . 6 t h
e d . M i s s o u r i , U S A :
M o s b y, I n c .
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53. ARTICLE READINGS
Ane mia treat ment may be a double-edged sword
K e r i S t e d m a n M . D . 3 0 - J a n - 2 0 0 8
Erythropoietin's effects on blood-vessel growth may benefit or harm patients with underlying
retinopathy or cancer.
Erythropoietin has so far been known to doctors as a hormone that boosts red-blood-cell production. Now, a mouse study led by Lois Smith,
MD, PhD, an ophthalmologist at Children's Hospital Boston, shows it also keeps blood vessels alive and growing in the eye. The findings
not only add a new function to the hormone, but also give doctors a reason to pause before prescribing it to patients with diseases affected by
abnormal blood-vessel growth, such as retinopathy and cancer.
The study, published in the February issue of the Journal of Clinical Investigation , also found that whether the hormone is a risk or benefit
depends on the timing of administration.
Smith and first author Jing Chen, PhD, worked in mice with retinopathy, an eye disease that begins when healthy blood vessels nourishing
the retina die. Numerous vessels then grow in, but they are deformed. Ultimately, the deformed vessels may pull the retina off the back of
the eye, causing blindness. The researchers measured erythropoietin produced in the retina as the disease progressed. Production was 3 to 10
times below normal during early-stage retinopathy, when healthy blood vessels died, and 12 to 33 times above normal during late-stage
retinopathy, when deformed blood vessels grew into the retina. The researchers concluded that erythropoietin helps blood vessels survive
and grow in the retina, with effects that may be healthy or harmful.
Next, the team examined whether giving erythropoietin could treat retinopathy. They injected erythropoietin into the bloodstream either
early, as the mice lost healthy blood vessels, or later, when deformed blood vessels began to invade--then compared them with untreated
mice.
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54. Boosting erythropoietin early slowed the disease. The mice lost half as many healthy blood vessels, causing about 30 percent fewer
deformed vessels to grow in. Raising erythropoietin levels later, when deformed blood vessels were present, appeared to accelerate the
disease--slightly more deformed blood vessels grew in.
If similar effects are found in humans, and its use is properly timed, then giving erythropoietin early could slow loss of healthy blood vessels
in retinopathy, says Smith. "Right now, there is very little out there to treat blood vessel loss in patients with retinopathy. However, further
studies on the restoration of normal levels of erythropoietin are needed to translate these results to patients."
In other diseases, like cancer, in which doctors need to slow blood vessel growth, the hormone could be blocked, although clinical trials
would need to confirm this idea, she adds.
But given at the wrong time, erythropoietin may make blood vessels grow in an unhealthy way, says Smith. For example, because it boosts
red blood cells, erythropoietin is often prescribed to premature babies and diabetic adults for anemia. Some of these patients also have
retinopathy. Giving the hormone at the wrong time might help anemia, but worsen the eye disease.
"We're not saying, 'don't do it.' We're saying, 'think about it,'" says Smith. "Physicians should look at the state of the eye before giving
erythropoietin to patients with retinopathy. They should consider not giving it to patients with full-blown retinopathy, in which abnormal
vessels are present, because our work suggests it may accelerate the disease. However, if a patient is early on in the disease, then our work
suggests erythropoietin may be beneficial."
Cancer patients, who often take erythropoietin for anemia, face a similar potential risk, says Smith. "Since erythropoietin has the potential to
make blood vessels in tumors grow, it could make tumors worse, although a clinical trial is required to know if this is true in humans."
Overall, Smith says her mouse studies are a reason for doctors to think and researchers to investigate, not for patients to panic.
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55. Anemia occurs when there is a shortage of red blood cells or when the red blood cells are not
correctly formed. In dialysis units, anemia is usually measured by the hematocrit blood test,
which reports the percentage of the blood that is comprised of red blood cells. Normally, a
hematocrit is from 37% to 47% for women and from 42% to 52% for men. Without interventions,
a dialysis patient's hematocrit usually stabilizes between 20-25%. At this level, most patients
tire easily and feel drained of energy. Several statistical analyses have shown that dialysis
patients have signficantly more complications, hospitalizations, and a higher mortality rate when
their hematocrit is below 30% (approximately).
With most patients now routinely receiving EPO during their dialysis treatments, hematocrits are
routinely in the range of 30-36%. The NKF-DOQI recommended target hematocrit range for
dialysis patients currently is 33% to 36%. Most insurance companies and Medicare will not
reimburse the dialysis facilities for EPO injections when the patient's hematocrit is above a
certain number (36% approximately).
The production of healthy blood cells is also dependent on the body having enough iron, vitamin
B12, folic acid and other substances. If a patient does not respond to EPO therapy, the most
likely cause is a deficiency of iron. For this reason, most dialysis centers routinely monitor iron
levels in the blood.
RECENT ADVANCES IN THE TREATMENT OF BLOOD DYSCRASIAS IN CHILDREN
MILA PIERCE M.D., I. DAVIDSOHN M.D., EDITH POTTER M.D., WILLIAM J. SCOTT M.D., and JAMES B. SNOW M.D. SAMIYA
RAZZAQ, M.D.
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56. Chairman Pierce: I wish to emphasize that your participation in the discussion is cordially invited. It is the desire of the Program
Committee that the Round Table provide an opportunity for all of us to share our experience. The specialists whom we have invited
to join us and who are well known to us have kindly indicated their willingness to take part in the discussion. Dr. I. Davidsohn is the
attending hematologist at Mt. Sinai Hospital; Dr. Edith Potter is the pathologist at Chicago Lying-in Hospital. The subject for
discussion this morning will be limited to a discussion of acute hemolytic anemia of the newborn, or erythroblastosis fetalis—
hematologic and pathologic aspects of the disease. All the hemolytic anemias have certain common characteristics. Erythrocytes are
destroyed, anemia follows, hepatic function is disturbed by anoxia, and further impaired by the demand for the excretion of
excessive quantities of blood pigment. Bilirubinemia follows. The hematopoietic centers compensate for blood destruction by
delivery of reticulated erythrocytes or normoblasts to the blood and extramedullary erythropoiesis may result. In the acute
hemolytic anemias this chain of events is initiated by a plasma factor while the cells themselves are normal. The plasma factor may
be (1) an antibody; (2) a toxin of bacterial or spirochetal origin; (3) a chemical, or (4) a hormone. In the chronic types of hemolytic
anemias there is often a familial or racial abnormality of the erythrocytes which predisposes it to the hemolytic effects of a plasma
factor. Examples of hemolytic anemia resulting from these various causes are seen in the newborn. (1) Erythroblastosis fetalis or
hemolytic disease of the newborn is due to the antigen antibody reaction caused by incompatibility of blood groups of mother and
baby; (2) hemolytic anemia due to bacterial toxin may result from sepsis, bronchopneumonia or congenital lues; (3) in congenital
hemolytic icterus, the splenic or hormonal factor together with erythrocytes which are spheroids rather than discs in the cause of the
anemia.
Hemolytic Uremic Syndrome: An Emerging Health Risk
SAMIYA RAZZAQ, M.D.
The classic triad of features for hemolytic uremic syndrome consists of microangiopathic hemolytic anemia, thrombocytopenia, and acute
renal failure.21-23 Children infected with E. coli O157:H7 are symptomatic; infected adults may be asymptomatic. The incubation period
for E. coli O157:H7 is usually three to four days; however, the incubation also can range from just one day to eight days.13 Typical
hemolytic uremic syndrome usually develops after a prodrome of diarrhea. Clinical features identifying patients at high risk for hemolytic
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57. uremic syndrome are vague and may mimic common gastroenteritis, including bloody diarrhea occurring from three days to more than two
weeks before hemolytic uremic syndrome is diagnosed.2 Additional symptoms include nonbloody diarrhea, abdominal cramping, and nausea
or vomiting. Fever may be low grade or even absent. Ten percent of cases are associated with rectal prolapse with colitis.2
Hemolytic uremic syndrome cannot be diagnosed without evidence of hemolytic anemia. Hematologic findings include destruction and
fragmentation of erythrocytes that result in microangiopathic hemolytic anemia. This develops in all patients within a day or so of
contamination and may result in respiratory and cardiovascular compromise. Mean hemoglobin concentration of 6 g per dL (60 g per L) is
common and requires red blood cell transfusion.2 Ninety-two percent of patients with hemolytic uremic syndrome develop
thrombocytopenia, which results from entrapment of platelets in the organs.2 Clotting times are normal, and petechiae and purpura are
uncommon features of hemolytic uremic syndrome.22 Platelet transfusion is not recommended because it could exacerbate the thrombotic
process; however, risks and benefits should be considered when platelet transfusion is indicated (e.g., invasive vascular procedure, active
bleed).
Acute renal failure results when microthrombi are deposited in kidney parenchyma. This manifests in the form of hypertension associated
with oliguria and anuria, which are early signs of acute renal failure.
The central nervous system is another organ system that could become involved. Thirty-three percent of patients with hemolytic uremic
syndrome experience neurologic complaints such as irritability, seizures, and altered mental status.
Typical hemolytic uremic syndrome is a self-limiting disease with spontaneous recovery, although close monitoring and treatment of
symptoms are essential. Because hemolytic uremic syndrome has a wide spectrum of presentations, supportive therapy (e.g., good nutrition,
close monitoring of fluid and electrolyte status) is crucial for a good outcome. Recent studies indicate that the amount of parenteral hydration
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58. given to a patient before the development of hemolytic uremic syndrome, especially the amount of sodium, is crucial in preventing anuria
and, ultimately, dialysis.
Strict fluid balance monitoring is important in detecting early renal failure. If failure develops, it should be handled aggressively24 by
starting renal replacement therapy (e.g., peritoneal dialysis, hemodialysis).Hypertension is treated traditionally with antihypertensives and
diet.
Antibiotics and antimotility agents are not recommended as treatments for hemolytic uremic syndrome during the diarrheal stage of the
disease. Studies of antibiotic usage in children with E. coli O157:H7 infections show an increased risk of complications from hemolytic
uremic syndrome.25,26 One study reported that using antibiotics to treat children testing positive for E. coli O157:H7 increased their risk of
developing hemolytic uremic syndrome.26 Additionally, some children who were diagnosed with Shigella dysenteriae type 1 and treated
with ampicillin developed hemolytic uremic syndrome.25
Serial monitoring of the hematocrit and platelet count is important. Currently, platelet transfusion is controversial because it can worsen the
thrombotic process.27 However, transfusion of red blood cells may be needed to aggressively correct anemia, which can deteriorate the
patient's condition and further complicate the picture by causing respiratory and cardiovascular compromise.
Modalities such as plasmapheresis, antithrombotic agents, steroids, and Shiga toxin-binding agents have proved ineffective and remain
controversial.
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