ARMED FORCES MEDICAL SERVICES SCHOOL

Military Health Assistant Program

Advanced Clinical Practicum

A CASE STUDY ON

Hemolytic Anemia
______________________________________

Submitted by: Malik Khalfan Mohammed Al Kharusi

Group: MND9
Date of Submission: 22/12/2024
Turnitin Paper ID (Ref. ID) 2557401747

Submitted to: Ms. Miad Juma AL-Hasani

Nurse Instructor
 ARMED FORCES MEDICAL SERVICES SCHOOL
Military Health Assistant Program
Adult Health Nursing

CASE STUDY FORM

Name of the Student: Malik Al-Kharusi ID No: D2-135841 Ward: Green

1. Client Demographic Data (1 mark)

Name of patient: mr.Elyas ALbaluchi ID No.: 01000225745

Age: 15 years Gender: male

Occupation: _________________________________

Medical Diagnosis: hemolytic anemia

Surgery (Proposed / Done) with Date: non

Name of surgery:__________________ postoperative day________________

2. History of Present Illness (1 mark)

The patient is a 15-year-old male who presented to the Local Health Center (LHC) with complaints of increased pallor, dysuria, and
constipation. The patient's father noted that the patient appeared more pale than usual the previous day, prompting a visit to the
LHC. Upon evaluation, the patient's hemoglobin level was found to be 7.0 g/dL, indicating significant anemia.
The patient has been experiencing dysuria for the past 2 days, characterized by a burning sensation during urination. Additionally,
the patient reports constipation over the past 2 days, with infrequent bowel movements and difficulty passing stool. There is no
history of fever, weight loss, or night sweats.
After visiting the LHC, the patient came to the Accident and Emergency (A&E) department for further evaluation and management.
The patient denies any recent travel, exposure to sick contacts, or changes in diet. There is no history of similar symptoms in the
past. The patient's medical history is otherwise unremarkable, with no known chronic illnesses or previous hospitalizations.

3. Past Medical History (1 mark)

The patient is a 15-year-old male with a history of spastic quadriparesis, for which he has been following up with Pediatrics. He also
has a history of Iron Deficiency Anemia (IDA), managed by the Ministry of Health (MOH).

 1/5/2024: The patient was admitted with a fever and found to have low hemoglobin levels. He was transfused with one unit
of blood and diagnosed with mixed autoimmune hemolytic anemia.
 6/6/2024: The patient was admitted with a hemoglobin level of 5.1 g/dL, CRP <0.6, WBC 11, ANC 5, LDH 504, and bilirubin
35. He was started on IVIG at 0.4 mg/kg, received a blood transfusion, and was discharged on prednisolone. His hemoglobin
level at discharge was 7.8 g/dL.
 August 2024: The patient was admitted again with fever and a drop in hemoglobin levels.
 5/11/2024: The patient was recently seen in the Hematology Outpatient Department (OPD) by Dr. Khalid Alhasmi.
Prednisolone was stopped, and a review was planned. In case of any relapse, the patient will be started on Rituximab.
4. Personal and Social History (1 mark)

The patient is a 15-year-old boy with a history of spastic quadriparesis and mixed autoimmune hemolytic anemia. He is bedridden
and requires assistance with daily activities. His father, Nabil, is his primary caregiver and is actively involved in his care. The
patient has no known allergies and has been following up with Pediatrics and Hematology departments for his condition

5. Family History (1 mark)

No family history

6. Menstrual history

n/a

7. Obstetric history

n/a

(* If the patient is a female, then 0.5 mark will be assigned each to Personal, Family, Menstrual, and Obstetric History)

8. GENERAL CONDITION (1 mark)

 General Appearance (specify):

Patient is alert and oriented but appears visibly uncomfortable. His skin is notably pallid, and he has dark circles under his eyes.
The patient is cooperative during the examination. There are no signs of acute distress, but he appears weak and slightly lethargic.
His overall hygiene is good, and there are no visible signs of trauma or injury. The patient exhibits spastic quadriparesis, consistent
with his cerebral palsy diagnosis.
________________________________________________________________________________________________________

9. VITAL SIGNS: (1 mark)

BP:147/65 Pulse:160 bpm Respiration: 23 breath/min Temp: 38.4 C Height: 118 cm Weight: 20kg BMI: 14.3

10. PHYSICAL ASESSMENT (8 marks)

* = Abnormal finding √ = Normal finding N/A = Not applicable

NEUROLOGICAL * √ N/A COMMENTS

Speech √ Patient is non-verbal but responds to simple questions by nodding.

Any difficulty swallowing √ No difficulty swallowing observed.

Pain √ No pain reported or observed.

Numbness or paresthesia √ No numbness or paresthesia reported.

Pupils √ Pupils are equal and reactive to light.

Muscle strength of * Spastic quadriparesis noted, with significant muscle weakness in all
extremities extremities.

Glasgow coma scale score √ Patient is alert with a GCS score of 15.

Sleep/wake pattern √ Normal sleep/wake pattern observed.

OTHER: √ N/A
Respiratory

RESPIRATORY * √ N/A COMMENTS

Respiratory rate/rhythm/effort √ Normal respiratory rate and rhythm.

Breath sounds √ Clear breath sounds.

Chest expansion √ Symmetrical chest expansion.

Cough/secretions √ No cough or secretions observed.

O2 therapy (liter flow, delivery method) √ N/A

Chest tubes (location, drainage, suction/water seal, air leak) √ N/A

OTHER: √ N/A

Cardiovascular

CARDIOVASCULAR * √ N/A COMMENTS

Heart rhythm * Tachycardic (Pulse: 160 bpm).

Apical pulse/rhythm √ Normal apical pulse.

Heart tones √ Normal S1 S2.

Chest pain/intermittent √ N/A

Claudication √ N/A

Radial pulses * Weak radial pulses.

Pedal pulses * Weak pedal pulses.

Posterior tibial pulses * Weak posterior tibial pulses.

Capillary refill √ Normal capillary refill.

Skin turgor √ Normal skin turgor.

Edema √ No lower limb edema.

Nail clubbing √ N/A

JVD √ N/A

OTHER: √ N/A

SYSTEM * √ N/A COMMENTS

INTRAVENOUS ACCESS
IV site (note type, location, appearance, & IVFs √ RT hand and leg IVC in situ, site appears clean with no
including type and rate) signs of infection. IV fluids administered as per chart.
OTHER: √ N/A
GASTROINTESTINAL
Diet * Poor oral intake with nausea and more fatigue.
Supplements (vitamins, commercial i.e. ensure) √ N/A
Gastric tube (NGT specify type) √ N/A
Suction (low or high, continuous or intermittent), √ N/A
and amount of drainage
Tube feeding (specify type and rate) √ N/A
Nausea and vomiting √ No vomiting observed.
Abdominal contour, consistency tenderness √ Normal abdominal contour, no tenderness.
Bowel sounds √ Normal bowel sounds.
Last bowel movement (specify date, color, √ N/A
consistency, amount)
Ostomy/urinary diversion (specify type, describe √ N/A
drainage and stoma/site appearance)
OTHER: √ N/A
URINARY
Urinary output √ Normal urinary output.
Urine color, odor, appearance √ Clear urine, no abnormal odor.
Urinary drainage tubes (type, size, and date √ N/A
inserted)
Voiding pattern and ease √ Normal voiding pattern.
Dialysis (specify type) √ N/A
Dialysis access (specify type, if AV fistula or graft √ N/A
note presence of bruit/thrill)
OTHER: √ N/A
MUSCULOSKELETAL
Activity (note prescribed level, level of assistance * Bed-bound with contracture in upper and lower limbs.
and patient tolerance)
Bed mobility * Limited bed mobility due to spastic quadriparesis.
Gait √ N/A
Joint mobility * Limited joint mobility due to spastic quadriparesis.
Orthopedic drains (note type, describe √ N/A
amount/odor of drainage/color)
Orthopedic devices (splints, etc) √ N/A
OTHER: √ N/A

SYSTEM * √ N/ COMMENTS
A
INTRAVENOUS ACCESS
IV site (note type, location, appearance, & IVFs √ RT hand and leg IVC in situ, site appears clean with no
including type and rate) signs of infection. IV fluids administered as per chart.
OTHER: √ N/A
GASTROINTESTINAL
Diet * Poor oral intake with nausea and more fatigue.
Supplements (vitamins, commercial i.e. ensure) √ N/A
Gastric tube (NGT specify type) √ N/A
Suction (low or high, continuous or intermittent), √ N/A
and amount of drainage
Tube feeding (specify type and rate) √ N/A
Nausea and vomiting √ No vomiting observed.
Abdominal contour, consistency tenderness √ Normal abdominal contour, no tenderness.
Bowel sounds √ Normal bowel sounds.
Last bowel movement (specify date, color, √ N/A
consistency, amount)
Ostomy/urinary diversion (specify type, describe √ N/A
drainage and stoma/site appearance)
OTHER: √ N/A
URINARY
Urinary output √ Normal urinary output.
Urine color, odor, appearance √ Clear urine, no abnormal odor.
Urinary drainage tubes (type, size, and date √ N/A
inserted)
Voiding pattern and ease √ Normal voiding pattern.
Dialysis (specify type) √ N/A
Dialysis access (specify type, if AV fistula or graft √ N/A
note presence of bruit/thrill)
OTHER: √ N/A
MUSCULOSKELETAL
Activity (note prescribed level, level of assistance * Bed-bound with contracture in upper and lower limbs.
and patient tolerance)
Bed mobility * Limited bed mobility due to spastic quadriparesis.
Gait √ N/A
Joint mobility * Limited joint mobility due to spastic quadriparesis.
Orthopedic drains (note type, describe √ N/A
amount/odor of drainage/color)
Orthopedic devices (splints, etc) √ N/A
OTHER: √ N/A
SKIN & HAIR, EYE, ENT
Surgical incisions (describe) √ N/A
Wound (describe) √ N/A
Oral cavity √ Clear
Skin color and temperature * Pallid and dehydrated
Hair √ Hair is thin and brittle, likely due to nutritional deficiencies.
Nails √ Nails are pale and brittle, indicating possible anemia.
Eyes √ Eyes are clear, no signs of jaundice or infection.
Ears √ Ears are normal, no signs of infection or discharge.
Nose √ Nose is clear, no signs of congestion or discharge.
Neck √ Neck is supple, no lymphadenopathy or masses.
OTHER: √ N/A
IMMUNOLOGICAL/ENDOCRINE/REPRODUCTIVE
Allergies √ None
Body temperature * 38.4°C
Isolation type (note type and reason) √ N/A
Menstruation (note LMP, any abnormalities) √ N/A
Breasts √ N/A
Testes √ Normal
OTHER: √ N/A
PSYCHOSOCIAL
General appearance and grooming √ Good hygiene
Behavior √ Cooperative
Support system (any visitors/calls/etc) √ Father, Nabil, is the primary caregiver
Learning needs (note any identified needs, √ N/A
barriers, patient preferences, etc)
SAFETY
ID band on √ N/A
Allergy band on √ N/A
Call bell within reach √ N/A
Suction setup at bedside √ N/A
Ambubag/mask at bedside/available √ N/A
Top side rails up √ N/A
Bed in lowest position √ N/A
11. INVESTIGATIONS: Results Of Lab Tests (relevant findings only) ( 3 marks)

SI. NO NAME OF INVESTIGATION RESULT NORMAL RANGE SIGNIFICANCE OF RESULT

1 Hemoglobin 7.2 12-16 g/dL Indicates anemia

2 CRP 4.7 <0.6 mg/dL Indicates inflammation

3 LDH (Lactate Dehydrogenase) 568 140-280 U/L Indicates hemolysis

12. MEDICATIONS - At least 2 Drugs (3 marks)
Drug Dosage Nursing Actions /
S.
Name & Frequency& Indications Contra Indications Side Effects Responsibilities
No
Classification Route
1.

Monitor blood pressure, blood

Autoimmune Weight gain, sugar levels, and signs of infec
Prednisolone (Cortico 1 mg/kg daily, Active infection,
Hemolytic hypertension,
steroid) oral hypersensitivity tion
anemia hyperglycemia
Mayo Clinic. (2024).

2.

Monitor for allergic reactions, v

ital signs, and infusion site
IVIG (Immunoglobulin 0.4 mg/kg daily, Autoimmune he Hypersensitivity to I Headache, fever, chill
) IV molytic anemia VIG s (National Institutes of Healt
h). (2024).

3.
Monitor for side effects, ensure
proper hydration, and educate
patients on medication
45 mg twice dail Hypersensitivity to Nausea, vomiting, hea
Tamiflu (Antiviral) Influenza adherence
y, oral oseltamivir dache
(Centers for Disease Contr
ol and Prevention.) (2024).
13. Medical Diagnosis

A. Definition of Disease Condition / Medical Diagnosis (1 mark)

Autoimmune hemolytic anemia (AIHA) is a condition where the immune system mistakenly attacks and destroys
red blood cells, leading to anemia. This results in a decrease in the number of red blood cells, causing
symptoms such as fatigue, pallor, shortness of breath, and jaundice. AIHA can be classified into two main types:
warm antibody hemolytic anemia and cold antibody hemolytic anemia, depending on the temperature at which
the antibodies react with red blood cells (Mayo Clinic, 2024).

A. ETIOLOGY OF THE DISEASE (2 marks)

S. ACCORDING TO TEXTBOOK IN YOUR PATIENT
NO

1 Autoimmune disorder Mixed autoimmune hemolytic anemia

2 Infections, medications, or other autoimmune History of spastic quadriparesis and previous episodes of hemolytic
diseases anemia

3 Genetic predisposition No known genetic predisposition in the patient

4 Environmental factors No significant environmental factors identified in the patient

B. CLINICAL MANIFESTATIONS (2 marks)

S. ACCORDING TO TEXTBOOK IN YOUR PATIENT
NO
1 Autoimmune disorder Mixed autoimmune hemolytic anemia (Mayo Clinic, 2024)
2 Infections, medications, or other autoimmune History of spastic quadriparesis and previous episodes of hemolytic anemia (Mayo
diseases Clinic, 2024)
3 Genetic predisposition No known genetic predisposition in the patient (Mayo Clinic, 2024)
4 Environmental factors No significant environmental factors identified in the patient (Mayo Clinic, 2024)
 C. PATHOPHYSIOLOGY OF THE DISEASE CONDITION (2 marks)

Autoimmune hemolytic anemia (AIHA) occurs when the immune system produces antibodies that mistakenly target and destroy red
blood cells. These autoantibodies bind to red blood cells, marking them for destruction. The destruction can occur in the spleen
(extravascular hemolysis) or within blood vessels (intravascular hemolysis). This leads to a decrease in red blood cells, causing
anemia, jaundice, and other symptoms. The body tries to compensate by increasing red blood cell production in the bone marrow, but
it may not be sufficient to counteract the rapid destruction (Mayo Clinic, 2024).
 D. MANAGEMENT (5 marks)
*Include management according to text books and management related to your patient.
S. N
ACCORDING TO TEXTBOOK IN YOUR PATIENT
O
Prednisolone 1 mg/kg
1 Corticosteroids (e.g., Prednisolone) to reduce immune response (Mayo Clinic, 2024)
daily, oral
Immunosuppressive therapy (e.g., Rituximab) to suppress immune system (Mayo Cl
2 Not administered
inic, 2024)
Intravenous Immunoglobulin (IVIG) to decrease immune attack on red blood cells (N IVIG 0.4 mg/kg daily, I
3
ational Institutes of Health, 2024) V
Blood transfusions to increase red blood cell count in severe cases (Mayo Clinic, 20
4 Not required
24)
5 Plasmapheresis to remove antibodies from the blood (Mayo Clinic, 2024) Not performed

14. NURSING CARE PLAN - at least 2 Nursing Diagnoses - 1 actual / 1 potential or 2 actual (10 marks)
 Assessment Nursing Evaluation
Goal of Care Nursing Interventions Rationale
Data Diagnosis
Hemoglobin: Short-term 1. Administer prescribed 1. To increase red
7.2 g/dL, goal: medications to manage blood cell count and
Improve anemia. improve oxygen
elevated CRP: oxygenation
delivery
4.7 mg/dL, and reduce 2. Monitor oxygen
Inadequate fatigue within saturation levels and 2. To ensure Patient
elevated LDH: oxygenation 1 week. provide supplemental adequate demonstrates
568 U/L, related to oxygen if needed.
oxygenation improved
decreased
fatigue, pallor, red blood cell 3. Encourage rest oxygenation,
3. To prevent
shortness of count as periods and energy reduced
conservation techniques. overexertion and
breath evidenced by Long-term fatigue, stable
low goal: manage energy
hemoglobin
hemoglobin Maintain 4. Monitor hemoglobin levels
levels,and
levels and stable levels and other relevant
lab results. 4. To assess the adherence to
fatigue hemoglobin
levels and effectiveness of the treatment
improve 5. Educate the patient treatment and plan
overall and family about the monitor progress
activity importance of medication
tolerance adherence and nutrition. 5. To ensure the
within 6 patient understands
months. their treatment plan
and its importance
Assessment Nursing Evaluation
Goal of Care Nursing Interventions Rationale
Data Diagnosis
Nutritional Short-term 1. Provide small, frequent,
 deficiencies goal: Achieve high-calorie meals
related to poor adequate
oral intake and nutritional 2. Administer antiemetics as 1. To ensure adequate
Poor oral intake, nausea as intake and prescribed caloric intake without ov
evidenced by improve energy erwhelming the patient
nausea, fatigue, anemia levels within 1 3. Monitor weight and
and low body week. nutritional intake Patient demonstr
fatigue, weight 20kg ates improved nut
Long-term 4. Collaborate with a dietitian 2. To reduce nausea an ritional intake, wei
anemia goal: Maintain to develop a personalized d improve appetite ght stabilization, i
(Hemoglobin: 7.2 stable weight nutrition plan ncreased energy l
g/dL), and improve evels, and adhere
overall 5. Educate the patient and
3. To assess nutritional nce to the nutritio
elevated CRP nutritional family about the importance
(4.7 mg/dL), status within 2 of nutrition and ways to status and effectivenes n plan.
months. manage nausea s of interventions
elevated LDH
(568 U/L)

4. To provide expert gui

low body weight dance on nutritional nee
20 kg ds and preferences

5. To empower the pati

ent and family to make i
nformed decisions abou
t nutrition
15. DISCHARGE PLAN (3 marks)
 Continue taking prescribed medications as directed by your healthcare provider. Monitor any side effects
:Medications and report them to your doctor.

Ensure a safe and comfortable home environment. Remove any hazards that could cause falls or injuries.
Environment
Arrange for necessary medical equipment and supplies.
Follow the treatment plan provided by your healthcare team. This may include medications, physical
Treatment
therapy, and other interventions as needed.
Educate the patient and family about the importance of medication adherence, nutrition, and managing
Health symptoms. Provide information on recognizing signs of infection, allergic reactions, and other potential
:Education
complications. Offer psychological support and resources for coping with the diagnosis and treatment.
Schedule follow-up appointments with your hematologist and primary care physician to monitor your
Out-patient condition and overall health. Ensure regular visits to manage any new symptoms and adjust treatment as
:follow-up
necessary.
Follow a high-calorie, nutrient-rich diet to address nutritional deficiencies. Small, frequent meals are
:Diet
recommended. Consult with a dietitian for a personalized nutrition plan.

16. Evidence-based Practice (2 marks) * Attach the related article (not later than 5 years from publication)
 A. Summary of literature findings
Title: Mechanism of Actions, Efficacy, and Long-term Use of Steroids in Autoimmune Hemolytic Anemia (AIHA)"

The purpose of the study is to investigate the long-term use, effectiveness, and mechanism of action of steroids, specifically
prednisolone, in the management of autoimmune hemolytic anemia (AIHA).

Population: One hundred patients with AIHA, including both adult and pediatric patients, who were receiving prednisolone
treatment were included in the study.

Method: Prednisolone was administered to patients as the initial treatment for warm AIHA (wAIHA). The study tracked any possible
negative effects of long-term steroid use and assessed the therapeutic effectiveness of steroids over the first two to three weeks of
delivery. Additionally, the study evaluated how steroids affected the hypothalamic-pituitary-adrenal axis (HPAA), blood glucose
metabolism, and bone health.

Results:

• Efficacy: Within the first two to three weeks of therapy, steroids demonstrated superior therapeutic results. After stopping steroids,
a comparatively small percentage of patients continued to be in remission.
• Mechanism of Action: In order to stop hemolysis, steroids inhibit the generation of autoantibodies and reduce the expression of
Fcγ receptors on monocytes.

• Long-term Use: Steroid use over an extended period of time may have an impact on blood glucose metabolism, bone health, and
HPAA. For long-term use in the treatment of AIHA, steroids having a linear pharmacokinetic profile—like prednisolone or
methylprednisolone—and reducing doses after 2-4 weeks of dosing are deemed safe.

The study comes to the conclusion that because steroids can inhibit the development of autoantibodies and stop hemolysis, they
should continue to be the first line of treatment for AIHA. To control any potential negative effects, long-term steroid use
necessitates close observation.
B. How it is related to your patient
This study is directly related to my patient, who is diagnosed with autoimmune hemolytic anemia (AIHA). The findings
support the use of Prednisolone as a first-line treatment for AIHA, which aligns with my patient's treatment plan. The
study provides evidence that Prednisolone is effective in suppressing autoantibody production and preventing
hemolysis, which are critical aspects of managing AIHA. Additionally, the study highlights the importance of
monitoring for potential side effects of long-term steroid use, which is relevant for ensuring my patient's safety and
well-being during treatment.

C. Compare literature finding with real practice

In real practice, my patient's management of autoimmune hemolytic anemia (AIHA) aligns with the study findings.
Prednisolone is used as a first-line treatment, effectively suppressing autoantibody production and preventing
hemolysis. The study emphasizes monitoring for potential side effects of long-term steroid use, such as effects on
bone health, blood glucose metabolism, and the hypothalamic-pituitary-adrenal axis (HPAA). My patient's treatment
plan includes regular monitoring for these side effects, ensuring safe and effective care.

D. Implication in practice

Implementing evidence-based practice ensures my patient receives effective and up-to-date care. The study supports
using Prednisolone as a first-line treatment for AIHA and emphasizes monitoring for side effects of long-term steroid
use. This approach helps achieve better patient outcomes and optimizes healthcare resources.
17. REFERENCES including Grammar, cover-page and legibility (2 marks) * Use APA or Harvard format

 Mayo Clinic. (2024). Prednisolone. Retrieved from https://www.mayoclinic.org/drugs-supplements/prednisolone-oral-route/description/drg-

20075247

 National Institutes of Health. (2024). Intravenous Immunoglobulin (IVIG). Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK513295/

 Centers for Disease Control and Prevention. (2024). Tamiflu (Oseltamivir). Retrieved from https://www.cdc.gov/flu/treatment/tamiflu.htm

 Mayo Clinic. (2024). Autoimmune Hemolytic Anemia. Retrieved from https://www.mayoclinic.org/diseases-conditions/autoimmune-

hemolytic-anemia/symptoms-causes/syc-20355609
 Yulistiani, Y., Dwiyatna, S., & Utomo, F. N. (2023). Mechanism of Actions, efficacy, and long-term use of steroids in autoimmune

hemolytic anemia (AIHA). Molecular and Cellular Biomedical Sciences, 7(3), 109. https://doi.org/10.21705/mcbs.v7i3.345