Case Study #1
Brief Client History:
45 yo female chemistry assistant working on a project with insecticides for 2
months. Fainted at her desk and fell out of the chair to the floor.
Subjective data per husband:
Fatigue x 2 weeks, SOB on exertion
Objective data:
Slightly confused, large hematoma L shoulder & L hip, pale skin & oral mucous
membranes. BP 90/50 (LOW), pulse 116 (tachycardia), resp 24 (tachypnea), temp
101.4 (HIGH), Breath sounds decreased in both bases.
Lab Work:
WBC
Plt.ct
3.1 (L)
80,000 (L)
RBC
H&H
2.9 (L)
8.4 (L)/28 (L)
MCV‐82 (Normal) normocytic
MCHC – 35 (Normal) normochromic
Physician Orders:
Bedrest with BRP with assistance
Reg diet with 1 can ensure 3 x day in between meals
I&O
O2 @ 2L per NC
IV – D51/2NS @ 100cc/hr
Stool for guiac x3
T&C 2u WB
UA
Coagulation studies
CXR
Xray L hip & L shoulder
Bone marrow biopsy
Major Diagnosis: Aplastic Anemia
Secondary Diagnosis: Pancytopenia (low RBC, WBC, platelets)
Describe the patho: RBC’s made by the bone marrow will be associated with
impaired cellular regulation. In this patients case it is caused by Insecticides
2. List the nursing diagnoses: Impaired tissue perfusion, fatigue, activity intolerance,
risk for bleeding, acute confusion, risk for injury, ineffective breathing pattern risk
for falls.
3. Explain the reason for each Dr. order:
• Bedrest with BRP with assistance—so the client will not fall due to fatigue and she
already fainted.
• Reg diet with 1 can ensure 3 x day in between meals—so that she can recover with the
correct nutrition needed
• I&O – to make sure kidneys are working efficiently
• O2 @ 2L per NC – client is having on exertion
• IV – D51/2NS @ 100cc/hr – to keep fluid + electrolytes balanced
• Stool for guiac x3 – check stool for blood
• T&C 2u WB – (whole blood) to increase o2 carrying abilities
• UA – check for blood or infection
• Coagulation studies – to establish baseline of bleeding and coagulation times
• CXR – check lungs for infection
• Xray L hip & L shoulder – injury from falling
• Bone marrow biopsy—to tell us if bone marrow is damaged or low and see what is
wrong
4. What complications are likely to delay improvement and why?
Infection due to WBC being low, low o2 getting thru body since her RBC are low, risk of
bleeding since her platelets are low.
5. List the treatment choices including meds
Erythropoietin (increase RBC production), filgrastim (increase WBC’s) blood transfusion
Possible splenectomy
6. Describe the client after 2 weeks of improvement. Include physical assessment and
lab data.
The client will have more energy and all symptoms should have improved.
RBC, WBC, Platelets and H+H should all be normal now.
Case Study #2
71 year old female, slightly overweight.
Felt “bad” for a month. Couldn’t get OOB today and called her son. He brought
her to ER. Client too weak to talk, son is poor historian, no previous records.
Client presents in the ER with: Severe weakness and fatigue. SOB, dizziness,
confusion, anorexia. Denies pain, nausea, vomiting.
Brief Assessment:
Skin dry with poor turgor, no petechiae. Resp 28 (tachypnea), rapid & shallow.
Breath sounds clear. BP 94/54 (LOW). Pulse 125 (tachycardia), weak & thread,
regular. Slow capillary refill. Tongue beefy red.
Lab Work:
WBC 8.0 (L)
RBC 3.0 (L)
Hgb 7.4 (L)
Hct 28 (L)
MCV 69 (L) microcytic
MCHC 27 (L) hypochromic
Physician Orders:
Admit for anemia:
O2 per NC at 2L
VS q4h
IV‐D51/2NS @ 75cc/hr
Bedrest
NPO
Foley to cavity drainage
T&C 4 u PRBCs
CXR
EKG
Chem profile
Ask son to bring in all home meds.
Case manager to assess home situation.
What disease/conditions will need to be ruled out as the cause of the anemia?
thalassemia, and chronic blood loss
2. What meds might you expect the doctor to order? Why?
Iron supplements to help raise H+H patient could possibly need an iron transfusion
to raise iron faster.
3. List the nursing diagnoses for the client.
Activity intolerance, risk for bleeding, risk for injury, ineffective breathing pattern,
decreased cardiac output, acute confusion, risk for falls, fatigue, risk for injury,
imbalanced nutrition, overweight, impaired standing, ineffective peripheral tissue
perfusion, impaired walking.
4. Describe the client after 3‐4 days of improvement. Include the physical assessment
and lab work.
Increased energy, no SOB, normal b/p
H+H should be increasing, cap refill should be <3 sec, skin should not be as dry, client
should be A+O, and have an appetite
5. List the expected outcomes for this client.
Patient should start to feel better. If she is taking oral iron supplements it could take 612 months for her iron to be normal. But everything should start to improve with
continued treatment
6. What complications are likely to occur and why?
Reaction to iron infusion, blood loss or injury from being weak. Constipation
7. Suggest discharge orders, include meds.
Continue iron supplements if taking orally, follow up why HCP for repeat labs and
continued care. Call in rx to a pharmacy, teach client about iron rich foods.
Case Study #3
Mr. C 73 yo male with bowel obstruction, exp. Lap. Removal of adhesions and 6
inches of colon. 2 days post‐op, he spikes a temp of 102.4(high) and treatment
begins for sepsis.
1 day later c/o HA, dizziness, weakness, increased abd. Pain, gums bled when
brushing teeth this AM.
Brief Assessment:
Abd distention, urine pink‐tinged, BP 128/84, pulse 112(tachycardia), resp
24,(tachypnea) temp 101.4. Slight oozing blood @ IV site and abd. incision
You Suspect: D.I.C.
Lab Work:
H&H
PT
PTT
10(L)/34(L)
20 sec (H)
60 sec (H)
Fibrinogen
Platelet CT
100 (200‐400) (L)
20,000 (L)
Fibrin degradation productions (FDP) 50 (less than 10) (H)
Physician Orders:
Bedrest
Portable CXR
T&C 4u WB
Give 2u FFP, 10 platelet packs, 1 u cryoprecipitate, 1 u WB
Bleeding continues – gauze on incision is saturated every 30 minutes.
New Order:
Transfer to ICU
Heparin 7500u IVP, then drip 1000u/hr
Repeat PTT & fibrinogen q4h and call to MD
Why is heparin ordered? Why is it controversial? How is it monitored?
Can be used to decrease micro clots from forming and using up clotting factors. Bc
heparin is used to thin blood and the patient is bleeding out but we are trying to
shock the body into doing what it should be doing and at this point you throw
everything you can at the patient bc it can’t get much worse.
Monitor labs and function.
2. Explain the purpose of each type of transfusion given.
• Platelets—increase platelets
• Fresh froze plasma—no rbc. No wbc, no platelets but helps with coagulation factor
deficiency
• Cryoprecipitate—man made plasma clotting factors (factor 13) help increase clotting
after trauma
3. What hemodynamic, extremity and skin problems are watched for? What S&S will
you assess for?
Regularly access vital signs and hemodynamic status
Manifestations of micro emboli so they can have cyanotic nail beds and pain.
Bleeding gums and bleeding or oozing of the incisions.
4. What GI & kidney problems are watched for? What S&S will you assess for?
Watching for any signs of organ failure, abdominal distention(pt has) olguria and
hematuria
5. What respiratory problems are watched for? What S&S will you assess for?
Respiratory distress
Cardiopulmonary arrest
Tachypnea, abnormal breathing, crackles
6. What neurological problems are watched for? What S&S will you assess for?
Hemorrhages or infarctions of the brain.
Decreased LOC, seizures, stoke symptoms, coma, decreased motor function, decreased
pupil activity
7. What will you explain to the family? What is happening? Why? What is the
prognosis? Be sure to use simple terminology.
The prognosis is not good, but we are doing everything we can to help your family
member. The client is experiencing a life-threatening condition in which the blood is
using up all the clotting factors in their body, meaning his blood is causing blood
clots in the small blood vessels and cutting off circulation to body and organs. This is
a complication of the sepsis which is the infection in his blood.
Case Study #4
21 yo single white male, non‐smoker, social drinker, works at Walmart.
Presents in the ER vomiting blood
Complains of:
Low back pain, abd pain
Fatigue, anorexia & sore mouth X 1 week
Brief Assessment:
Multiple bruising on extremities
Spleen enlarged and tender
Gingival lesions
Skin pale and hot, temp 101.6
Lab Work:
WBC 31.7 (h)
Hgb 10.1 (L)
Hct 29% (L)
Plt. Ct. 16,000 (L)
Physician Orders:
I&O
Bedrest
IV D51/2NS @ 100cc/hr
Bone marrow bx
T&C 3u WB
NGT to low gomco suction, irrigate with iced saline prn
Mycostatin oral swish & swallow 3cc q6h
Soft diet with 1 can Ensure 3xDay in between meals
Bone Marrow biopsy was + for acute lymphoblastic leukemia
Surgical placement of portacath.
List the nursing diagnosis for the client:
acute pain, risk for powerlessness, risk for spiritual distress, impaired tissue
perfusion, risk for imbalanced fluid volume, risk for injury, nausea, imbalanced
nutrition, impaired oral mucous membrane integrity, Risk for bleeding, risk for
decreased cardiac output, fatigue.
2. Explain the reason for each of the complaints and assessment data:
Abdominal pain: enlarged liver and spleen
Fatigue: anemia
Anorexia: n+V
Sore mouth: dehydration
Bruising: low platelets
Gingival lesions: low platelets
Skin pale: low H+H
Temp: poss. Infection, wbc are not functional
3. What are the teaching needs for this client and his family?
Leukemia is cancer of WBC or of cells that develop into WBC that are not functiona;l
they invade and destroy bone marrow and they can metastasize to liver, spleen, lymph
nodes, testes and brain. Teach client to monitor for evidence of infection. Hand hygiene
and to try to prevent injury.
4. Describe the process of bone marrow transplantation:
Bone marrow is destroyed or ablated using radiation or chemotherapy and later
replaced with healthy stem cells.
The body is able to resume normal production of blood cells they can use the clients
own cells that are collected before chemo or they can use a donor. Without transplant
client will likely die from infection or bleeding.
5. Describe the client after 3‐4 weeks of improvement. Include the physical assessment
data and lab work.
Should have more energy, more control over pain. Should have improvement in mouth
sores. Labs will vary and still need to be checked.
6. What complications are likely to delay improvement and why?
Infection or injury because risk for those are already high and their body does not
have the ability to fight off infection or help itself heal.