Author(s): Andina Setyawati*, Abraham Heumasse, Andi Humaerah A Azimah and Ernik Jumain Drajayati
Assessment: A 30-year-old woman with severe hemolytic anemia arrived at the ER with a critically low hemoglobin level of 2.1 g/dL, leading to an immediate packed red blood cell transfusion. After stabilization, she was moved to the ICU due to her deteriorating condition. The assessment covered respiratory health, cardiovascular markers, fluid/nutrition balance, physical exam, and X-ray results. Importantly, her Glasgow Coma Scale score showed altered consciousness.
Diagnosis: Based on the comprehensive assessment, a range of nursing diagnoses were formulated according to the North American Nursing Diagnosis Association (NANDA) 2021-2023. These included Impaired Gas Exchange due to low Hb levels, Risk for Bleeding stemming from decreased red blood cell (RBC) count, Risk for Infection owing to compromised immunity, Activity Intolerance due to severe anemia, and Anxiety prompted by critical illness and unfamiliar surroundings.
Planning: The care plan targeted interventions for each nursing diagnosis. To address Impaired Gas Exchange, we closely monitored respiration and adjusted ventilator settings. For Risk of Bleeding, we took bleeding precautions, handling gently and tracking coagulation. To prevent Infection, we prioritized aseptic methods and temperature checks. For Activity Intolerance, we used Activity Therapy and gradual progression. To ease Anxiety, we applied techniques to reduce psychological stress.
Discussion: This case stressed the urgency of interventions for severe hemolytic anemia. The patient's critical state led to immediate PRC transfusion and ICU transfer. Cardiovascular and oxygen-carrying interplay showed in physiological signs. Nursing diagnoses and care planning revealed holistic care needs. Altered GCS and lab values steered interventions, urging interdisciplinary teamwork. Radiography showed heart response to chronic anemia. The discussion emphasized precise assessment, diagnoses, and planning for intricate conditions like severe hemolytic anemia
Hemolytic anemia, a condition characterized by the accelerated destruction of red blood cells, presents a complex clinical scenario that demands thorough investigation and effective management [1]. This case report contributes to the growing body of knowledge in the field of hematology by presenting a comprehensive analysis of a critical case involving a 30-year-old female with hemolytic anemia.
Hemolytic anemia can arise from a myriad of underlying factors, including inherited genetic mutations, immune-mediated responses, or exposure to various environmental triggers [2]. The resulting reduction in red blood cell count and hemoglobin levels can lead to severe tissue hypoxia 1, necessitating prompt and targeted interventions. This report provides a detailed exploration of the patient's clinical journey, encompassing initial presentation, diagnostic evaluations, treatment modalities, and subsequent response to therapeutic measures.
Nurses play a pivotal role in the holistic care of patients with hemolytic anemia, from the moment of admission to the point of recovery. Their close interaction with patients allows them to monitor vital signs, administer medications, and assess treatment responses [3]. This report not only outlines the patient's medical journey but also highlights the indispensable contributions of nursing professionals in administering transfusions, monitoring for adverse events, and ensuring patient comfort. By synergizing medical interventions with vigilant nursing care, this case exemplifies the collaborative approach necessary for successful patient management in complex hematological cases. Therefore, the study aimed to provide a comprehensive perspective that acknowledges the interdependence of medical and nursing disciplines.
A 30-year-old female presented to the Emergency Department (ED) with a confirmed diagnosis of hemolytic anemia. On arrival, her hemoglobin (Hb) level was critically low at 2.1 g/dL. She received an immediate transfusion of 1 unit of packed red blood cells (PRC) in the ED. Subsequently, she was transferred to the Intensive Care Unit (ICU) due to her deteriorating condition. Her Glasgow Coma Scale (GCS) score was E2M2Vx upon ICU admission. After four days of treatment, her Hb level improved to 6.1 g/dL. Her white blood cell count (WBC) measured 12.3 mmol/l, and her red blood cell count (RBC) was 2.02 mmol/l. Urea level stood at 98, and creatinine at 0.80.
The patient was placed on a ventilator using SIMV-PC mode. Ventilator settings included a tidal volume (TV) of 380, a minimum ventilation rate (MvT) of 14, PEEP set at 5, FiO2 at 30%, and respiratory rate (f) at 8. Oxygen saturation (SpO2) was 97%. Arterial blood gas analysis indicated a pH of 7.60, pCO2 of 24, and HCO3 of 24. The patient's respiratory rate (R) was 26 breaths per minute, suggesting continued vigilance in assessing ventilator support.
The patient exhibited sinus tachycardia with a heart rate of 125 beats per minute, and a regular rhythm was observed on the EKG. Blood pressure was recorded as 128/92 mmHg. These vital signs indicate potential cardiovascular stress and the body's compensatory response to anemia.
A urinary catheter was in place, registering an output of 530 ml over 7 hours. The patient received parenteral nutrition through intravenous fluid (IVFD) consisting of 5% dextrose at a rate of 47 ml/hour. Intravenous fentanyl was administered at a rate of 30 mcg/hour.
The patient was unable to perform self-care activities and required complete assistance. Her abdomen was observed to be flat, and bowel sounds were noted to occur 5-6 times per minute. The patient's inability to perform self-care underscores her critical condition and the need for comprehensive care.
A chest X-ray (PA view, with insufficient inspiration) revealed an enlarged heart, aorta, and pulmonary dilation within normal limits. These findings could be linked to chronic anemia and the heart's compensatory response to maintain oxygen supply.
The provided nursing diagnoses shed light on the multifaceted impact of anemia on the patient's health and well-being. Based on the information provided in the case, here are some nursing diagnoses according to North American Nursing Diagnosis Association (NANDA) 2021-2023 (see Table 1):
|
Diagnose |
Evidence |
|
Impaired Gas Exchange related to decreased hemoglobin levels |
Low hemoglobin (Hb) levels, increased respiratory rate (R), |
|
Risk for Bleeding related to decreased red blood cell |
Low Hb levels, elevated white blood cell (WBC) count, and the need for blood transfusion |
|
Risk for Infection related to compromised immune response and invasive interventions |
Elevated WBC count, immunosuppression due to anemia, |
|
Activity Intolerance related to severe anemia, decreased oxygen-carrying capacity, and muscle weakness |
The need for complete assistance in self-care activities and limited mobility. |
|
Anxiety related to critical illness, unfamiliar ICU environment, and invasive interventions |
Altered level of consciousness (Glasgow Coma Scale score of E2M2Vx), |
These nursing diagnoses underscore the comprehensive nature of anemia's effects on the patient's health, encompassing physiological challenges in oxygenation and clotting, increased susceptibility to infections, physical limitations, psychological distress, and potential skin integrity issues.
The provided table (Table 2) outlines the nursing interventions and corresponding desired outcomes for the identified nursing problems in the case.
|
Problem |
Intervention |
Outcome |
|
Impaired Gas Exchange |
Respiratory Monitoring 1. Monitor respiratory rate, depth, pattern, and effort. 2. Assess breath sounds for adventitious sounds or changes. 3. Observe for signs of respiratory distress (use of accessory muscles, nasal flaring). 4. Maintain proper ventilator settings and monitor alarms. 5. Administer supplemental oxygen as prescribed. |
Respiratory Status: 1. Maintain oxygen saturation (SpO2) ≥ 94%. 2. Demonstrate arterial blood gas values within normal range 3. Exhibit normal respiratory rate and pattern. 4. Clear breath sounds and absence of adventitious sounds. |
|
Risk for Bleeding |
Bleeding Precautions 1. Monitor laboratory values including platelet count and coagulation parameters. 2. Use a soft toothbrush, avoid sharp objects, and encourage gentle handling during care. 3. Educate patient about risk factors and measures to prevent bleeding. 4. Administer blood products as prescribed. |
Bleeding Control Outcomes: 1. Exhibit no signs of active bleeding or hematoma formation. 2. Maintain stable vital signs. 3. Demonstrate normal coagulation parameters. 4. Participate in measures to prevent bleeding. |
|
Risk for Infection |
Infection Control 1. Perform hand hygiene before and after patient contact. 2. Use aseptic techniques during invasive procedures. 3. Monitor temperature and signs of infection (fever, increased WBC count). 4. Maintain sterile dressing changes for invasive lines. 5. Administer prescribed antibiotics as ordered. |
Infection Control Outcomes: 1. Maintain normal body temperature. 2. Demonstrate absence of signs of infection (fever, chills). 3. Exhibit white blood cell count within normal range. 4. Achieve negative blood and urine cultures if applicable. |
|
Activity Intolerance |
Activity Therapy 1. Collaborate with physical therapy for gradual activity progression. 2. Encourage frequent position changes to prevent pressure ulcers. 3. Assess patient's response to activity and modify as needed. 4. Monitor vital signs before, during, and after activity. |
Physical Mobility Outcomes: 1. Participate in activities of daily living with minimal assistance. 2. Exhibit stable vital signs during and after activity. 3. Maintain skin integrity and absence of pressure ulcers. |
|
Anxiety |
Anxiety Reduction 1. Provide emotional support and establish rapport. 2. Offer information about procedures, treatment, and care plan. 3. Implement relaxation techniques (deep breathing, guided imagery). 4. Promote a calm and reassuring environment. |
Anxiety Level Outcomes: 1. Express reduced feelings of anxiety. 2. Demonstrate understanding of the condition and treatment plan. 3. Participate in relaxation techniques to manage anxiety. 4. Report improved emotional well- being. |
The case of the 30-year-old female with hemolytic anemia sheds light on the challenges associated with managing a critically ill patient. The discussion revolves around the patient's initial presentation, assessment findings, and subsequent nursing diagnoses derived from the presented data.
The patient's initial presentation with a critically low hemoglobin level of 2.1 g/dL indicated a severe state of hemolytic anemia. The prompt administration of a packed red blood cell transfusion highlighted the immediate need to address the life-threatening deficiency in oxygen-carrying capacity [4]. The subsequent transfer to the ICU underlined the seriousness of her deteriorating condition [5]. This sequence of events underscores the vital role of quick interventions in managing hemolytic anemia. The nursing diagnoses and planning of care revolve around optimizing gas exchange, preventing complications such as bleeding and infection, managing activity limitations, addressing anxiety, and maintaining skin integrity. These focused interventions are crucial for enhancing the patient's well-being and facilitating her recovery in the context of this complex hematological condition.
The patient's altered levels of consciousness, as indicated by the Glasgow Coma Scale (GCS) score of E2M2Vx upon ICU admission, added a layer of complexity to her condition, prompting the need for vigilant neurological monitoring. The significant improvement in her hemoglobin level to 6.1 g/dL within four days underlines the successful collaboration between medical and nursing interventions in addressing the deficit in oxygen- carrying capacity. The comprehensive range of laboratory values, including the white blood cell count (WBC), red blood cell count (RBC), urea, and creatinine, offers valuable insights into her physiological status and potential areas of concern [6]. These clinical parameters serve as crucial guides for tailoring nursing care, optimizing medical management, and ensuring a holistic approach to her treatment plan.
The nursing care plan focused extensively on assessing and maintaining the patient's respiratory status, a critical concern given her requirement for mechanical ventilation using SIMV- PC mode. Regular evaluation of ventilator settings and arterial blood gas analysis played a pivotal role in monitoring her oxygenation and ventilation adequacy [7]. Concurrently, her cardiovascular dynamics were vigilantly observed, as evidenced by the presence of sinus tachycardia and recorded blood pressure levels. These cardiovascular manifestations underlined the patient's physiological response to the anemia-induced oxygen-carrying deficit, highlighting the interconnectedness of her complex condition and the necessity for a comprehensive nursing care approach [8].
Fluid and nutrition management emerged as another critical facet of the nursing care plan, as indicated by the assessment of the patient's urinary catheter output and the administration of parenteral nutrition and fentanyl. Monitoring the patient's fluid balance and providing the necessary nutrients and pain management were integral to her overall well-being. A comprehensive physical assessment further accentuated the urgency of the situation, with the patient's limited capacity for self-care activities and her flat abdomen becoming pronounced markers of her debilitated condition. These factors collectively underscored the intricate care requirements of the patient, necessitating a holistic nursing approach that encompassed multiple dimensions of her health and well-being.
Radiographic findings, particularly the chest X-ray revealing an enlarged heart, offered insights into the patient's cardiac response to the chronic anemia [9]. The heart's enlargement can be interpreted as a compensatory mechanism to enhance oxygen delivery to the body's tissues in the face of reduced oxygen- carrying capacity. This aspect of the assessment added another layer of complexity to the nursing care plan, highlighting the interplay between the cardiovascular system and the patient's anemic state. It underscored the need for vigilant monitoring of the cardiac status and adjustments to the care plan to address potential cardiovascular implications. The integration of these findings into the nursing care plan exemplified the comprehensive and adaptive approach required to manage the intricate health challenges posed by severe hemolytic anemia. Thorough assessment and nursing diagnoses are essential for patient-centered care, addressing both physical and psychological aspects. This emphasizes a holistic approach for complex cases like severe hemolytic anemia, requiring interdisciplinary collaboration and vigilant nursing for optimal outcomes.
A 30-year-old female with hemolytic anemia highlights the urgency in managing critical cases. Swift actions like blood transfusion and ICU transfer are crucial for addressing oxygen deficits. Nursing diagnoses from the case show anemia's diverse impacts, leading to interventions for gas exchange, mobility, anxiety, and skin integrity. This case shows close medical-nursing collaboration, adapting care to changing indicators like Glasgow Coma Scale and lab values. Managing hematological conditions requires teamwork, emphasizing a cohesive approach for successful recovery.
