Nursing diagnoses in a patient with Hemolytic Anemia due to poor FUNCTIONING OF THE BIOLOGIC MITRAL VALVE, ACCORDING TO CALLISTA ROY'S ADAPTATION THEORY AND THE NANDA'S TAXONOMY II

NURSING DIAGNOSES IN A PATIENT WITH HEMOLYTIC ANEMIA DUE TO
POOR FUNCTIONING OF THE BIOLOGIC MITRAL VALVE, ACCORDING TO
CALLISTA ROY’S ADAPTATION THEORY AND THE NANDA’S TAXONOMY
II
Eduarda Ribeiro dos Santos, RN, MSc

Introduction Hemolytic anemia due to poor functioning of the biologic mitral
valve happens when the spinal cord is not capable to compensate for, by
increasing production, the premature destruction of the blood red cells. It is
characterized by a massive or a very rapid destruction of the blood red cells by
hemolysis. This destruction or hemolysis can be due to the blood red cells’
excessive frailty (thalasemia) or to hyperactivity of the reticular-endothelial
system (mainly the spleen). Thus, in hemolytic anemia the erytrocites have a
short life. The spinal cord generally compensates for it by partially producing
new blood red cells three times faster than the normal rate, or beyond the
normal rate. This is an atypical disease because it shows a variety of signs and
symptoms which manifest differently in each patient. Thus, we can find very
critically ill patients, and patients with a benign evolution, that is, they do not
show complicated symtoms of the disease. The poor functioning of the patient’s
prothesis evolves to hemolysis due to trauma to erytrocites; they can undergo
hemolysis by fragmentation when exposed to excessive mechanic stress in the
intravascular medium, or along their extracorporel circulation.. Abnormal
wearing forces show up during erytrocites’passage through proteic cardiac
valves, injured natural valves or vascular shunts. Actually, chronic intravascular
hemolysis due to abnormal function of cardiac valves or valve protheses is
relatively rare. Generally, its occurrence points to the presence of a
dysfunctional valve due to major wearing stresses related to systemic
pressures. This kind of intravascular hemolysis is more often caused by
dysfunctional aortic valves, although the occurrence of similar syndromes has
also been noticed in the presence of a mitral valve pathology. Nurses have to
refer to more useful theories or models for the given situation. A nursing
diagnosis is a clinical judgement of the individual’s, the family’s or the
community’s responses to actual or potential (risk) health problems, and to vital
processes which make the foundation to select the nursing interventions to

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achieve the outcomes the nurse is committed to. The nursing process is a
problem-solution approach to meet the nursing needs and the individual’s
healthcare needs. The nursing process elements used in Roy’s Theory include:
behavior investigation; stimulus investigation; nursing diagnosis; aims setting;
intervention, and evaluation. The stimuli are the feeding data, divided into focal
stimuli (immediately faced by the individual, thus causing a major degree
change); context stimuli (internal or external stimuli, negative or positive stimuli
about the situation), and trace stimuli (internal and external features not clarified
yet). These three kinds of stimuli are then combined, and they set an
adjustment level for the individual. (coping mechanism), which is always
changing. The responses are the moments this individual leaves the system,
and they represent the person’s behavior. They can become a feedback either
for the individual and the environment. The responses can be adaptive (they
promote the individual’s integrity) and ineffective (they do not achieve the aims
of survival, growth, reproduction and mastery). In this particular case, the blood
red cells’ lysis was the focal stimulus, due to a dysfunctional valvar prothesis,
with the consequent decrease of hemoglobins and hematocrits. The context
stimuli were a decreased tissue oxygenation, a probable trace stimulus, and
tabagism. The ineffective reactions were pruritus, dyspnea, fatigue, coluria,
jaundice, dry skin, renal failure, hepatomegaly, extremity cyanosis. Objectives:
To identify the major nursing diagnoses for this patient with hemolytic anemia,
due to poor functioning of the biologic mitral valve, in a large Public General
Hospital of the Grande São Paulo, based on the Taxonomy II, of the North
American Nursing Diagnosis Association (NANDA), and on Roy’s adaptation
theory. Methodology: Data were collected from August to October 2006 along
the investigation, having Calista Roy’s theory as its basis. A careful physical
assessment and a survey of the case-related nursing diagnoses were carried
out. We report the case of CVO, 44 years old, female, married, two children,
elementary school level, catholic, Brazilian, from São Paulo City - SP. She was
admitted for treatment with a medical diagnosis of Hemolytic Anemia caused by
a poor functioning of the biologic mitral valve. She underwent an implant of a
mitral valve prothesis (swine pericardial biologic valve) 14 years ago (mitral
valve sthenosis), and a 20-year-old tabagism (a packet/day); she has not
smoked for 1 year. She lives in an apartment in an urban area with sanitation,

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and she works with sales, thus being standing most of the day. Physical activity
is not part of her life; she enjoys traveling and magazine reading. For breakfast
she has coffee and milk with bread; for lunch she has rice and black beans,
meat and vegetables; she has some fruit in the afternoon, and soup for dinner.
Urinary and bowel eliminations are normal, as well as her menses. Sexually
active. Good social interaction and religion beliefs (catholic); she has heatlh
insurance and needs help only for a few daily activities. She is optimistic about
the treatment. She has faced problems with her body image and avoided
looking herself in the mirror; she has resisted to shower, nail and hair care. She
was awake and conscious during physical assessment, and stated that has
awakened many times a night in the hospital and took naps along the day.
Light-reacting pupils, ambulatory, pale ++++/4+, presence of jaundice +++/4+,
dry oral mucosa membrane and skin, with generalized pruritus, dry and brittle
hair, normal skull. She reported pondered weight loss (10 kg along 3 months).
She showed decreased visual acuity (Nearsightedness and Astigmatism),
although she does not wear contact lenses; bilateral exophthalmia; epistaxis for
4 days; oral cavity with missing teeth, and presence of cavities. No
abnormalities in the neck; normal chest, and symetrical breasts. Pulmonary
auscultation revealed bilateral MV+ w/ RA; she keeps herself in environment
air. Arrhythmic heart, with the presence of systolic murmurs, and unchanged
precordial. Geniturinary system with no anatomical changes, with SVD with
hematuric output (2,000ml/day); she shows yellowish odorless exudate in the
urinary meatus. Flat and soft abdomen, hepatomegaly (4-5 cm of the back
fringe), RHA+. Upper extremities with peripheral puses; peripheral venous
device in MSE; pervious, and with no signs of infection; light extremity cyanosis;
decreased peripheral capilary perfusion. Lower extremities with peripheral
pulses and mobility. Arterial blood pressure: 140 x 80 mmHg at 180 x 80
mmHg. Pulses: 90 to 120 bpm. Temperature: 370C to 37.50C. Respiratory rate:
22 to 29 ipm. Weight: 47 kg. Height: 1.58 cm. Laboratory data: erytrocites (1.47
milh/mm³) signaling anemia related to cell destruction; decreased levels of
hemoglobin (4,4 g/dl), which signals anemia and hemolytical responses;
hematocrits at 12% also mean the presence of anemia; glycosis level of 125
mg/dl; increased creatinine level (3.7 mg/dl); urea of 123 mg/dl. She was given
two units of blood red cells packet (250 ml, O+ type) on admission. Prescribed

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medicines: hyposodic diet; Ringer’s lactate, with 125 mL/h of continuous
physiological solution by infusion pump; intravenous Manitol at 20% every 6
hours; oral Captopril 25 mg every 12 hours; sodic levotiroxin 100mg, 1 tablet
early before breakfast; 1 tablet early of oral 0.25 mg Digoxina; Paracetamol and
codeine phosphate 30 mg, 1 tablet orally, if necessary; 40 mg Omeprazol
intravenously every 6 hours. Results: The noticed responses allowed us to
divide the nursing diagnoses into four adaptive modes, resulting from the coping
mechanisms (regulatory and cognate). They included: physiological mode,
selfconcept mode, role function mode, and interdependent mode. In this
investigation, and mainly for this particular patient, the pertinent diagnoses were
the physiological mode and the selfconcept mode diagnoses. Physiological
Mode: oxygenation – Impaired Gas Exchange, characterized by dyspnea;
abnormal skin color (dark); tiredness after small efforts; fatigue; cyanosis,
related to impaired ventilation and perfusion. Ineffective Tissue Perfusion:
Renal, characterized by increased urea rates (123 mg/dl), and creatinine level
(3.7dL); altered blood pressure, and pruritus, related to hypervolemia,
mechanical decrease of the venous and arterial blood flux, and impaired oxygen
transportation through the alveolar-capillary membrane, due to decreased blood
hemoglobin concentration. Ineffective Tissue Perfusion: Peripheral,
characterized by cyanosis; pale skin; hair loss; dry skin; dry and brittle hair;
generalized pruritus; capillary refill longer than 3 seconds (arterial), related to
hypervolemia, impaired oxygen transportation through the capillary membrane,
decreased concentration of blood hemoblobin, mechanical decrease of the
venous and arterial blood flux. Ineffective Respiratory Pattern, characterized by
dyspnea under light efforts; use of respiratory accessory muscles; respiratory
rate of 29 ipm, related to fatigue, decreased hemoglobin, thus making gas
exchanges difficult, due to the medullar production of imature cells. Decreased
Cardiac Output, characterized by tachycardia; edema; cold skin; dyspnea;
fatigue; longer peripheral capillary perfusion; changes in skin color, related to
poor function of the mitral valve (altered preload), and altered cardiac rate (90
bpm). Physiological Mode: Nutrition – Nutrition, altered: less than body
requirements, characterized by reports of inappropriate food ingestion; pale
conjunctive and mucosa membranes; weight loss; excessive hair loss, related
to dehydration and appetite loss. Physiological Mode: Activity and Rest –Sleep

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Pattern Disturbance, characterized by many awakening episodes through the
night; decreased functional capacity; verbal complaints of difficulty to fall asleep,
and not feeling rested in the morning, related to anxiety and separation of
significant others Fatigue, characterized by increased rest needs; perceived
need of additional energy to perform daily activities; expressed constant and
oppressive lack of energy, related to decreased blood hemoglobin, and poor
nutrition. Activity Intolerance, characterized by fatigue; weakness; dyspnea by
effort; abnormal response of cardiac rate, and extremity cyanosis, related to bed
rest, unbalance between oxygen demand and supply, due to anemia.
Physiological Mode: Protection – Impaired Skin Integrity, characterized by
generalized pruritus; dry skin, and dehydration, related to jaundice, fatigue, with
physical immobility and altered circulation. Risk for Infection, related to invasive
procedures (change of the mitral valve); inappropriate secondary defenses
(decreased hemoglobins); inappropriate primary defenses (skin breakdown –
peripheral venous access – indwelling vesical catheter). Selfconcept Mode:
Disturbed Body Image, characterized by expressed feelings that reflect an
altered vision of own body regarding appearance; change or loss concern;
avoidance to look at a body part; avoidance to look at the mirror, related to
jaundice, exophthalmia, weight loss, and hair loss. Conclusions:: The
theoretical framework at the light of Callista Roy was significant for diagnoses
survey by emphasizing the psychosocial aspects and the nursing care, with a
holistic individualized and humane vision which improved the patient’s quality of
life.

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