case presentation group 8 . edited

8/6/2019 Case Presentation Group 8 . Edited

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Microscopicpolyangiitis (MPA) is a

systemic pauci-immune

necrotizing vasculitisthat affects mainly

small vessels.


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Facts:

MPA is a rare type of

autoimmune disease.

Incidence rate is

approximately 1:100,000 with

the slight predominance inmen.


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The average age onset is

50 years, and is very rare

in children.

The most common

antineutrophil cytoplasmic

autoantibodies (ANCA)-associated small vessel

vasculitis


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What is ANCA?

Antineutrophil cytoplasmic

autoantibodies are antibodies

directed against the bodys

neutrophils and monocytes.

Two types of these

autoantibodies are identified

that are present in patients

with this disease.


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P-ANCA(perinuclear staining)

-70% of patients with

MPA.

C-ANCA

(cytoplasmic

staining) -30% of the

cases.


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Clients name: D.B.

14-year old, Female

Filipino, RomanCatholic

3rd year High Schoolstudent


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She had an active high

school social life withno history of sexual.

activity or drug abuse.

She was born and is

residing at Las PinasCity with her mother

and her sister.


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Patient DB had skin

asthma when she wasfive years old and was

ruled out before she

reached twelve.

No other past illnesses

were cited.

Immunization status:

complete immunization


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General Appearance

Upon assessment, the patient isweak looking but with no signs

of cardio-respiratory distress.

Admission Vital Signs

BP: 130/80 mmHg PR: 80 bpm

RR: 20cpm Temp: 36.5 C


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Withedematous

facial feature

and

periorbital

edema.


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With presence ofdandruff and

falling of hair

uponobservation.


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The patient

reported episodeof red spots

before her eyes

prior to her

admission to San

Juan De Dios

Hospital.

With pale

conjunctiva.


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Lips appeared

dry and scaly.


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Skin

Dry and slightly

pale.

With presence

of ecchymosis in

both arms.


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NAILS

With visible

splinter

hemorrhage

.


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NECK

With right

Intrajugularcatheter

access.


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Cardiovascular

Hypertensive.

Noted of taking anti-

hypertensive drugs.

Upon assessment,

the patients blood

pressure: 130/80

mmHg.


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With

ecchymosis onboth arms.

Visible striae

noted on

upper andlower limbs.


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(+) bipedal edema

upon assessment.

Upon palpation there

is no complain of painand discomfort.


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Breast/Axilla

with striae in both side

of the axilla.

Genitals

Appeared to be

edematous.


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HEMATOLOGY09-March-2011

Results

12-March-2011

Results

13-March-2011

Results

PT patient

PT control

PT INR

PT activity

APTT

APTT control

10 - 14 sec.

11 - 14 sec.

0 - 1.4

70 - 130%

25 - 39

25 - 39

14.1 sec.

12.5 sec.

1.16

83%

High 54.6

34.6

13.3 sec.

12.5 sec.

1.08 sec.

91%

34.6

10.6 sec.

12.5 sec.

0.81 sec.

130%

27.3

34.6

HEMATOLOGY Normal Range

09-March-2011

Results

12-March-2011

Results

13-March-2011

Results

PT patient 10 - 14 sec. 14.1 sec. 13.3 sec. 10.6 sec.

PT control 11 - 14 sec. 12.5 sec. 12.5 sec. 12.5 sec.

PT INR 0 - 1.4 sec. 1.16 sec. 1.08 sec. 0.81 sec.

PT activity 70 - 130% 83% 91% 130%

APTT 25 - 39High 54.6

27.3

APTT

control 25 - 39 34.6 34.6 34.6


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HEMATOLOGYNORMAL

RANGE

11-March-2011

Results

12-March-2011

Results

16-March-2011

Results

Leukocytes

5.0 - 10.0 x

109/L High 11.95 High 10.10 High 11.10

Erythrocytes 4.6 - 6.2 x1012/L

Low 2.80 Low 3.22 Low 3.95

Hemoglobin 12 - 17 g/dL Low 9.1 g/dL Low 8.9 g/dL 12.8 g/dL

Hematocrit37 - 47 %

Low 27.39% Low 27% 37.7%


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Thrombocytes 150 450 x109/L

160 x 109/L 175 x 109/L Low 146 x

109/L

Neutrophils 50 70 % High 84.3% High 78.1%

Lymphocytes 20 40 % Low 9.3% Low 10% Low 12%

Monocytes0 7 %

4.9% 5.9% High 8.4%


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Eosinophils 0 5 % 1% 1%

Basophils 0 1 % 0.5% 0.5%

Granulocyte 0 1 % High 83.5%


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CLINICAL

CHEMISTRY

NORMAL

RANGE

12-March-2011

Results

15-March-2011

Results

Blood Urea

Nitrogen 7 17 mg/dL High 95 High 69

Creatinine 0.52 1.04

mg/dLHigh 4.2 High 2.25


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UrinalysisMarch 11, 2011

PHYSICAL CHEMICAL

Color: YELLOWAlbumin: +++

Sugar: TRACE

Reaction: 7.5

Transparency: SLIGHTLY TURBID

Quantity: 25 mL

Specific Gravity: 1.010


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Manifestation from the book Actual ManifestationCONSTITUTIONAL SYMPTOMS

Fever & myalgiaNo

Malaise, fatigue Yes

Weight loss No (weight gain due to generalizededema)


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Manifestation from the book Actual Manifestation

Skin manifestations

SplinterHemorrhage

Yes

Skin rash, palpable

purpura, skin ulcerationsNecrosis and

gangrene/Necrotizing nodules

No

Pulmonary Manifestation

Hemoptysis, Dysnea, cough,

pulmonary rales,respiratoryory distress

No


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Hypertension Yes

Signs of cardiac failure,

myocardial infarction No

Gastrointestinal Involvement

GI bleeding, melena Yes

Bowel

ischemia/perforation/pancrea

titis

No

Cardiovascular


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Nervous System Manifestation

Seizures/ /brain swelling Yes

tingling sensation No

Renal Involvement

Uremia, generalized edema,

proteinuria, red blood cells in the

urine

Yes


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CAUSE:

IdiopathicPredisposing Factor

Gender/Sex: Men

Autoimmune Infection Malignancy Drug Therapy

Triggers production on p-ANCA

(antineutrophil cytoplasmic

antibodies)

Large antibodies bind to

neutrophil

Activate immune complexes

Deposits in small vessel walls

Increase Vascular permeability

Release of vasoactive amines and mast cells

Neutrophil

Releases

toxins

Causes a

release of

lytic

enzyme

FromWBC


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Endothelial Injury

INFLAMMATION

Of small blood vessels

Damage

peripheralnerves Nerve

InfarctionNerves are

deprived of

nutrients

Damage to vessels

of glumeruli

Impairs renal function:

PROTEINURIAHEMATURIA

FATIGUE

SWELLINGOF LEGS

EDEMA

ANEMIA

UREMIA

Constitution

al

Symptoms:

FEVER

WEIGHT

LOSS

MALAISE

Skin Lesions:

PALPABLE

PURPURA

NECROSIS

GANGRENE

Cardiovascular

Signs/symptoms

HYPERTENSION

CHEST PAINCARDIAC

FAILURE


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DRUG NAME

CYCLOPHOSPHAMIDE

50mg/tab 1 tab POODCLASSIFICATION

Antineoplastic or cytotoxic

DRUG ACT

IO

NCyclophosphamide first is converted by the liver into

two chemicals, acrolein and phosphoramide.

Acrolein and phosphoramide are the active

compounds, and they slow the growth of cancer cellsby interfering with the actions of deoxyribonucleic

acid (DNA) within the cancerous cells. It is, therefore,

referred to as a cytotoxic drug.


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Indication

Treatment of vasculitis

DRUG OF CHOICE for the treatment of MPA.

Cyclophosphamide has a significant

ability to suppress the immune system.

Thus, the medicine is very effective in thetreatment of immunologicallymediated

diseases, including some forms of vasculitis.

i C id i


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Nursing Consideration

1. Check for allergic history2. Periodically check renal function because the drug

is toxic for the kidneys

3. Teach patient to drink plenty of fluids because thisdrug can damage kidneys and bladder

4. The drug is immunosuppressive, monitor patientfor signs of infection

5. Causes depletion of number of blood cells, monitor

patients blood test

DRUG NAME


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DRUG NAME

PREDNISONE30mg 1 tab, 2 tabs post breakfast

CLASSIFICATION:

Corticosteroid (Glucocorticoid)

DRUG ACTIONSuppresses the immune system and

inflammation. This synthetic corticosteroid

mimic the action of cortisol (hydrocortisone),the naturally-occurring corticosteroid

produced in the body by the adrenal glands.


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IndicationDRUG OF CHOICE for treatment of vasculitis in combination

with cyclophosphamide.


1. Check and record BP during dose stabilization

period at least 2 times daily. Report an

ascending pattern.2. Be alert to possibility of masked infection and delayed

healing.3. Obtain fasting blood glucose, serum electrolytes, and

routine laboratory studies at regular intervals during

long-term steroid therapy.


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4. Be alert to signs of hypocalcemia.

5. Monitor bone density.

6. Be aware that long-term

corticosteroid therapy is notimmediately interrupted. Tapering is

done.


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DRUG NAME

METHYLPREDNISOLONE1g in 50mL D5W IV infusion

Single orderCLASSIFICATION:

Corticosteroid

(Glucocorticoid)

DRUG ACTIONMethylprednisolone is a synthetic (man-made)

corticosteroid. It mimics the action of cortisol

(hydrocortisone), the naturally-occurringcorticosteroid produced in the body by the adrenal

glands. Corticosteroids block inflammation and are

used in a wide variety of inflammatory diseases.

I di ti


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Indication

For treating inflammatory conditions (vacultitis).


1. Watch for allergic reactions

2. Check the electrolyte and glucose reports

for early indications of electrolyte imbalanceor hyperglycemia

3. Keep accurate records of intake and output,

daily weights, vital signs4. Ask patients about any signs of infection

(sore throat, fever, malaise, nausea and

vomiting)

Oth D


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FUROSEMIDE 60mg 1 1/2tab q8 hrs

Loop diuretics Treatment ofedema

CLONIDINE 150mg /tab

1 tab BID

Central acting alpha

adrenergic

antihypertensivedrug

Hypertension

AMLODIPINE

10mg/tab

OD

Calcium Channel

Blocker

Hypertension

Used to prevent

angina

TELMISARTAN

40mg/tab 1

tab OD

Angiotensin II

receptor

antagonist

Hypertension

Other Dugs

NAME OF DRUG DOSAGE/FREQUENCY

CLASSIFICATION INDICATION

NAMEOF DRUG DOSAGE/FREQUENCY CLASSIFICATION INDICATION


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ENALAPRIL

(renital)

10mg /tab,

1/2 tab OD

Angiotensin

converting

enzyme (ACE)inhibitors.

Hypertension

CITICOLINE

500mg 1 cap, 1

capOD

ODCentral nervous

system stimulantPatient is noted to have

hypertensive

encepalopathy

CALCITRIOL1 tab 0.25mg

ODSynthetic

Vitamin D

Use to treat and

prevent low levels of

calcium in the bloodof patients with

damaged kidneys or

with patients in

hemodialysis

NAMEOF DRUG / CLASSIFICATION INDICATION

NAMEOF DRUG DOSAGE/FREQUENCY CLASSIFICATION INDICATION


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CALCIUM

CARBONATE1 tab 500mg

TID

Mineral electrolyte

replacement

supplements

Hyperphosphataemia in

chronic renal failure

FERROUS

SULFATE

325mg 1 tab post

lunch, 2 tabs

post dinner

Iron preparationUsed to treat and prevent

iron deficiency anemia

COTRIMOXAZOLE800mg /100mg

tab/tablet forte,

1 tab (every

Sunday, Tuesday

and Thursday)

Sulfamethoxazol

e and

trimethoprim

Prophylaxis for

infection

OMEPRAZOLE40 mg IV OD

Proton pump

inhibitor

Short-term

treatment of

active, benign

gastric ulcer

CLASSIFICATION INDICATION


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Problem/ SignificantI t ti E l ti


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NotationsInterventions Evaluation

Objective Data:

broken skin,traumatized tissue

Problem/ Significant


Objective Data:

broken skin,traumatizedtissue

presence of right

intrajugular

catheter access

needle pricks onthe arms from

invasive

procedures

Intrajugular access

cleaned and dressed

aseptically

Proper use of PPE

for staff and visitors

Problem/ SignificantI t ti E l ti


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Sterile technique

for all invasive

procedure. Suggested to place

in protective

isolation.

Maintained ortaught asepsis for

dressing changes

and wound care.



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Immunosupressionrelated to

immunosuppressive

drugs

Cyclophosphamide

Prednisone

Proper handhygiene by all care

givers

Offer mask or

tissue to

client/visitors who

are

coughing,sneezing

to limit exposure

Follows medication

regimen

No noted signs of

infection (feveror pus on lesions)


Maintained IV flow rate


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Objective Data:y Hematemesis

(fresh blood,

scanty amount)

y Melena

(semi-formed,

moderate in

amountTarry stool)

y Auscultate BP,calculate

pulse pressure every 4

hours

y O

bserve for color of allexcretion to evaluate

for bleeding

Have a written record

of fluid intake, urine

output and daily weight.

Maintained IV flow rate

No bleeding

episodes noted


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Objective Data:

y Blood Pressure: 150/90

mmHg

y

Generalized edema

y Pitting edema

grade 2

y Facial edema

Monitoring of vital signs q1

especially blood pressure

y Record an accurate intake and

output

Administer medication

as prescribed ( Diuretics,

antihypertensive)

Protected edematous

skin from injury

Fluid restriction of 1L

per day as ordered

Blood pressure :

110/70 mmHg

Patient still

edematous

Cautious in eatingand drinking



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Objective Data:

(+) Weakness(+) Fatigue

(+) Muscle

weakness

(+) Fatigue whenmoving

Assessed level of

activity intoleranceand degree of fatigue

Encouraged

alternating periods ofrest and ambulation

Encouraged and

assisted with gradualincreasing of periods

of exercises

Patient reported

no signs of

decrease in fatigue

and body malaise

Still requires full

assistance inmoving

Exhibited

increased interestin activities and

event

Problem/ Significanti l i


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Turned side to side

every 2 hours

Health teachings about

the importance of

ambulation

ROM exercises done

Collaborated withphysical therapist for

treatment plans and

interventions

Increases exercises

within physical

limits


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case presentation group 8 . edited

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