Nursing Process

“Dengue Fever Syndrome”

A Case Study
Presented to
The Faculty of the College of Nursing
MANILA DOCTORS COLLEGE
Macapagal Blvd., Pasay City

In Partial Fulfillment
Of the Requirement for the Degree
BACHELOR OF SCIENCE IN NURSING

Submitted by:
Krystal Jade D. Heruela
BSN III-A5
RLE Group I7

Submitted to:
Mrs. Vivian Camano
Clinical Instructor

Date:
August 24, 2010

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I. Assessment

A. General Data

Patient’s Initials: GCAS Sex: Female

Address: Navotas City
Age: 28 years old Civil status: Single
# of Days in this Hospital: 6 days Occupation: Teacher
Date of Birth: February 8, 1982 Place of Birth: Manila
Date of Admission: August 12, 2010 Order of Admission:
ambulatory
Informant: GCAS (patient) Date of History:

B. Chief Complaints

The client experience 4 days of high fever, 39.5°C, accompanied by

dizziness and lower back pain.

C. History of present illness

4 days prior to confinement, client has fever (38°C), chills, and

headache, she take Paracetamol in AM, and the fever continues until PM,
flank pain bilateral with a scale of 10/10, non- radiating, but doesn’t consult
the doctor.

2 days, prior to confinement, client has body malaise and persistent of

fever and other symptoms that prompts her to seek consultation; she was
diagnosed with Urinary Tract Infection she was given Paracetamol one tab,
but vomited after taking the said medication. The client was not yet
admitted, but ordered to come back if symptoms still continue.

1 day prior to confinement, the client was still experiencing symptoms

that evoke her to go back to the hospital. Complete Blood Count was taken,
that shows that her platelet count is low, hence admission.

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D. Past History

1. Childhood Illness: none

2. Adult Illness: Dengue and Urinary Tract Infection.
3. Immunization: Patient was fully immunized. Had hepatitis booster
6 months ago.
4. Previous Hospitalization: none
5. Operations: none
6. Injuries: None.
7. Medications Taken Prior to Confinement: No medications were
given to client. But she was taking vitamin C.
8. Allergies: The client was allergic to all kinds of analgesic.

E. Gordon’s Eleven Functional Health Patterns

1. Health Perception- Health Management Pattern

The client has a positive perception in life. The client said that she
never absent herself whenever she have flu, she only take Paracetamol to
cure her. The client believes that exercising and eating right kinds of food
is important in keeping her healthy, but she was unable to do so, when
she have spare time, she spend it going to mall, watching television. The
client started smoking when she was 2nd year college until now, she
smokes 5 sticks of cigarettes a week. She said that she do breast self
examination, whenever she feels something wrong with her breast. The
client doesn’t have any regular check up, but she said that if she felt
something wrong, she immediately consult her doctor, her last check up
was last year, chest x-ray was made. No accidents in the past.
During confinement, client knows why she was admitted she knows
that she would be well soon. She is checking her facebook to see the
greetings of her friends to make her feels better. The client said that she
is now feeling better, she said that she’ll try to change her lifestyle, when
she go home.

2. Nutritional- Metabolic Pattern

Before the client was admitted, she prefer eating food that comes
with soup, she enjoys eating when it’s her mother who cooks the food for
her. She typically eats three times a day aside from this was eating snacks

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at 4o’clock. The client is more of water drinker; she consumes more than
8 glasses a day, than other beverages but she still drinking some. She
said that she was in to C2 ice tea drink 1 month before confinement that
triggers her urinary tract infection. She said that she have a good appetite
especially when she likes the food served, the client was taking Vitamin C.
The client is wearing braces since December, 2009, but doesn’t affected/
disturb her eating pattern. Client doesn’t have any skin lesions, dryness or
poor healing of wound prior to confinement.
During hospitalization, client has a diet as tolerates, high fiber, no
dark colored foods and hypoallergenic diet. She likes the food served but
she still asks her mom to cook food for her, because the foods ordered
was dry and she likes foods with soup for her to swallow it easier. During 4
days of confinement the client have intravenous line of plain NSS, but
discontinued august 16, 2010. The still drinks water more than 8 glassless
a day. The client was positive with Hermann’s rashes.

3. Elimination Pattern

Prior to the admission, the client doesn’t have any difficulty when
defecating, she eliminates everyday, and characteristic is formed,
brownish in color and moderate amount. But, she have difficulty in
urinating, because she have urinary tract infection before, especially the
last part, because burning sensation was felt, her urine was dark yellow in
color because of the supplement she is taking but aside from this she
doesn’t have any concerns. The client doesn’t have excessive perspiration
or body odor.
Presently, the bowel movement of the client is changed, she now
defecates every other day, but when she is urinating she doesn’t anymore
feels the burning sensation. She have an output of estimated 1150 cc a
day.

4. Activity- Exercise Pattern

Before the admission, she said that she has an active lifestyle. She
goes to her work and does other activities with sufficient energy. The
client doesn’t have a regular exercise that she can do because of her
work, she consider walking from home to her work as her exercise. As a
teacher of special kids, she should have enough energy to take care of
them, she said that she also do the exercise that the kids do every
morning, she said “at least may exercise pa ako everyday”. When she has
spare time, she usually just spends it at the mall, at home watching

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 television, having movie marathon. The client could eat, groom, and go to
bathroom, dress, cook and shop by herself.
Presently, the client could still eat, groom, and go to bathroom,
dress, cook and shop by herself, but her mother assist her in taking foods
and drinks for her. She said that when she go home she would try to allot
time for exercising, because she believe that it would help her to have a
healthy living. Muscles are firm and can do things on her own. Hand grip
is good because she is holding stuffs like cellular phone and comb without
dropping it. She has a good gait and posture.

5. Sleep- Rest Pattern

Before being hospitalized, she said that she could sleep without any
difficulty, but whenever she is stress she cannot sleep on time. when she
could sleep on time it is usually 10 in the evening and wakes up 6 in the
morning, but when she have insomnia she sleeps at 4 am. When she will
not go to work she sleeps around 11 pm to 12 midnight and wakes up 8-9
in the morning. She said that she prefer sleeping in a room with people to
divert her mind in thinking about problems and stress. Client doesn’t
experience nightmares that help her to have a continuous, this helps to
have her a relax the next day.
During the admission, the client still have a usual sleeping pattern,
she sleeps at 10 in the evening and wakes up 7 in the morning. The client
sleeps every afternoon. She doesn’t snore and sleeps with two pillow, and
another to cover her eyes. She has enough energy for the day.

6. Cognitive-Perception Pattern

Prior to admission, she already have a problem with her vision, she
wears glasses with a grade of 100(left) and 50(right). The client doesn’t
have any hearing difficulties, she could respond according to what is
asked. When problems occur she said that she is calm and thinks of ways
how to solve it. The biggest problem she encountered was when she
decided to change work from private school to public; the reason was that
benefits from public school are better than private school. The client
speaks English and tagalog, she is now studying sign languages for deaf
people and those who cannot speak, every Saturday.
The client answers question directly and knows what is happening,
she conscious and coherent. The client responds to the questions I ask
her. The client doesn’t wear her glasses; she said that she only uses it
when watching television, reading and other activities. She could make

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 decision on her own, she could still remember the things outside the
hospital and in the past.

7. Self-Perception Self-Concept Pattern

The client said that most of the time she was relaxed. The things that
make her angry was when people pressure her, she say a particular person,
the principal, that make her angry, because the principal always pressure
them of the papers need to pass to her, not only the principal but also the
students that are naughty, noisy and those who always ask question to her.
She said that it’s normal for the kids to be like that, but she was just being
angry when it was accompanied by headaches and problems. The thing that
make her happy was when there is things that she accomplished and when
she done particular things on time. most of the time, the thing that affects
her mood was when there is changed about herself, and her health.
Presently, while interviewing the client, she was relaxed and not
nervous, she was smiling and happy. She was assertive and answering
question that are related to the question. The client remains optimistic and
full of hope that she will be well soon.

8. Roles-Relationship Pattern

‘S’ family

HAS EAS
(Mother) (Father)

IAS VAS CAS PAS

(Brother) (Sister) (Client) (Sister)

The client has a good relationship with her family. She is close to them,
she share her problems to her sister, PAS, and sometimes to her mother, but
still she said that she doesn’t say all her secret to her mother. Even thou she
have an adopted sister, VAS, she still have good relationship with her. she
describe her home as small but a happy.

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 The family felt sad of what happened to the client but still they stay
optimistic and hopeful that she gets well. Base on my observation she has a
good interaction with her parent, despite of her age, she still respect them by
saying “PO”.

9. Sexuality – Reproductive Pattern

The client was not yet married, but she has her boyfriend. She said
that they are in good terms; she said that her boyfriends make her happy
despite of her condition and that he was always by her side. They have
communication via face book and cellular phone.

10. Coping Stress Tolerance pattern

The client doesn’t face any problems now except for her hospitalization
but when problems and stress occurs to the patient, she immediately talks to
God for guidance. Her family also helps her if problems were encountered.
Most of the time, the client was successful of what she does, because she
thinks first of what she would do to achieve it. She doesn’t take any
medications to calm her down when she was stress or tensed, she said that
only God and her family could help her out.
Now that she was hospitalized, she get strength from her friends,
partner and family and of course with God. She said that whatever problems
occur she would remain calm because she knows that it would help her to
think more of what to do and to lessen stress.

11. Values Belief Pattern

Clients’ religion was Methodist. She believes that whenever problems

occur there is someone who will help her to solve it. The client always pray,
she said that when problems occur she go straight to God and tell Him her
problems, she said that, friends and other people could help her, but
sometimes, there are those who will make you feel more bad, and she also
believes that God has a reason for experiencing problems in life.
Presently, her primary plan was get back to normal so that she would
return to her work and help her family. She still continues in praying to God
so that she could go home and she and her family would be blessed.

F. Family Assessment

Name Relation Age Sex Occupation Educational

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 Attainment
EAS Father 66 Male Jeep operator College graduate
HAS Mother 55 Female Teacher College graduate
IAS Brother 44 Male Office worker College graduate
VAS Sister 32 Female Office Worker College graduate
PAS Sister 30 Female Teacher College graduate

G. Heredo
1. Maternal: none
2. Paternal: Allergy

H. Developmental History

Theory/ Age Task

Patient Description
Theorist

Psychosocial 28 years Intimacy VS The client is more on intimacy. She

theory old Isolation has her work, she is a teacher for
Eric Erikson special students, and she is satisfied
of what she is doing. She has her
boyfriend that is always there for
her. She knows that she have a role
of being a good daughter to her
parents and good partner.
Now that she was confined, she was
not able to do her work, but still
believes that she will be well soon,
and can teach again her students.

Psychosexual 28 years Genital stage The client has her partner but not
theory old yet married. Doesn’t yet perform
Sigmund Freud sexual intercourse.

Cognitive 28 years Formal The client could solve problems and

theory old operational decide on what to do when this
Jean Piaget phase occurs. She asks help from her
parents and friends. She knows that
what she know is the best, but still
she respect the decisions of others
The client have vision disturbance
but is wearing glasses with grade of
100 (left) and 50 (right), but uses

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 only her glasses when she is
reading, watching television and
other things. The client still
remembers things in the past.

Moral theory 28 years Level III- Post- The client abides from law and rules
Lawrence old Conventional and also orders. When the client was
Kohlberg Level ordered to pass the papers that
were asked by there principal she
would spend time to do the work.
When rules are made and she knows
that it is not right, she act according
to what she knows is right.

Spiritual theory 28 years Synthetic- The client is very spiritual person,

James Fowler old Conventional she gives time to pray, and believes
stage that God is always there for her nad
guiding her. she believe that it is
better to share problems to God
because God could really help her.
she said that people around us could
help us in our problems but only God
can guide her.

I. Physical Examination

Date: August 17,2010

Time: 1200H
Height : 162 cm
Actual Weight: 56kg

Vital Signs
Temp: 37.0 ºC
PR: 75 beats per minute
RR: 19 breaths per minute
BP: 100/60 mmHg

Regional Examination
A. Skin:
• (+) Hermann’s rash

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 • Superficial blood vessel are seen both in hands and feet
• Warm to touch
• Skin turgor springs back to normal state
B. Nails:
• Transparent, well-rounded and convex
• Fingernails are clean
• Intact epidermis
• colorless
• Smooth fingernails
• Firmly attached to nail bed
• Capillary refill= 2 seconds
C. Head and Face:
• Normocephalic and positioned on the midline
• Proportion to gross body structure
• Facial expressions are symmetrical
• Absence of deformities, lumps or masses
• Absence of tenderness
D. Eyes:
• Eyes are parallel to each other
• Eyebrows are greyish and symmetrical
• Eyelashes are evenly distributed and curved outward
• Blinking is symmetrical
• Able to see things in the periphery
• Visual acuity: 100/50
E. Ears:

• Bean shaped
• At the level of outer canthus of the eyes
• Absence of discharges and lesions
• Firm and smooth
F. Nose:
• Nose is same color as skin
• Nasal mucosa is pinkish and moist
• Patent nares
• Absence of masses and tenderness
G. Mouth and Pharynx:
• Lips are pale and dry
• Oral mucosa is pinkish and dry

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H. Neck:
• Symmetric
• Proportion to gross body structure
I. Spine
• Located at the midline
• Absence of tenderness, masses or lumps
J. Breast:
• Breasts are symmetric
K. Abdomen:
• Abdomen is round and symmetric
• The color is the same as neighboring skin
• Absence of scars and lesions
• Soft
• Absence of masses
L. Extremities
Arms:
• Symmetrical
• Absence of swelling and venous enlargement
Legs:
• Symmetrical
• Absence of swelling and venous enlargement

M. Genital and Rectum and Anus

Not performed.
N. Neurologic Exam:
Appearance and Behavior:
• Awake and alert
• Understand questions and responds appropriately
• Able to walk around
• Looks relaxed
• Dressed appropriately, has good hygiene
• Has appropriate facial expression

II. Personal/Social History

1. Vices: the patient smokes 5 sticks a day since when she was 2nd year
college.
2. Lifestyle: patient has an active lifestyle.
3. Rank in the family: she was the 3rd child.
4. Travel: Singapore and Malaysia last January 2010.

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 5. Educational Attainment: college graduate.
6. Usual day like: Every weekdays, in the morning, the client wakes up
eat breakfast, go to work until 2 o’ clock of the afternoon then go
home, do her lesson plan, watch television, then sleep. Every Saturday
she goes to her school, where she studies sign language for deaf and
people who can’t speak. While every Sunday, she stays at home with
her family, watch DVD’s and other activities.

III. Environmental History

The client said that they have good environment in their place.
Their home has an adequate space and has good ventilation. She said
that it is peaceful and quiet. They don’t have problem with water and
electrical supply. It is clean and the garbage are collected every
morning at there house, and they don’t have problem with flies and
mosquitoes. The client makes sure that her things are in order, and
she likes a snug environment.
The client said that she doesn’t got her illness from there home
because it is neat and properly cleaned. She thinks that she got this
from other place.

IV. OB-Gyne History

Menarche: 2nd year high school; 14 years old

When: every month; regular menstruation
Amount and Characteristics: she consumes 4 pads a day and have
her menstruation fo 4 days, but spots are visible until the 10th day.
Duration: 4-10 days Symptoms: dysmenorrhea is felt on the 1st and
2nd day.

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 V. Laboratory Result/ Findings

Urinalysis
Specimen: Urine
Date: August 12, 2010
Culture:
20000 colonies of staphylococcus per milliliter of urine.
Sensitive:
Group A sulfa/ trimethoprim
Resistant:
Penicillin, Ceprofloxcin, Cefocitin and Oxacillin.
Note:
Please correlate with the symptoms of the patient.

Specimen: Serum
Date: August 12, 2010

Salmonella:
Description Patient value Result
IgM 1.51 +
IgG 1.44 +

Normal:
Less than 0.900- negative
0.900+ 01.100- borderline- positive
More than 1.100- positive

Lumbosacral X-ray
Date: august 16, 2010

The vertebral bodies, pedicles, posterior elements and intervertebral

disc spaces are intact.
The normal lumber lordosis maintained. The vertebral line of weight
bearing falls anterior to the sacral promontory with a lumbosacral angle of
34°.
The visualized pelvic osseous structures and joint spaces are intact.

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Impression:
Signs of lumbosacral instability.

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 VI. Pathophysiology

A. Theoretical Based

Dengue Hemorrhagic
Fever

Precipitating Factor Predisposing Factor:

- Aedes aegypti - Age
mosquito - Sex
-Immunodeficiency

Bite of a virus carrying

mosquito

Mosquito injects fluid

into victim’s skin

Virus enters in the

host’s blood stream

Infects cells and

replicate in sufficient
amount

Platelet will Initiates immune

provide a shield system response
for the virus from
exposure and
binding to
Activation of memory Stimulates release of
neutralize pre-
T-cell response during cytokines
re-exposure
Macrophages or
monocytes Virus-antibody complex Cytokines destroy cell
engulfed the virus membrane and cell
having a platelet wall
Cytolysis
Complement activation
system
Coagulopathy (PT, PTT)
Fluid Thrombocytopenia
shifting Vasculopathy (plasma Vascular endothelian
ICF to ECF leakage) cell activation

High Fever, body weakness, headache, nausea &

vomiting, abdominal pain, petechial rash in areas
of the body, 15
 B. Client Based

Dengue Hemorrhagic
Fever
Modifiable Non-modifiable
Factors: Factors:
- - Age: 28 y/o
Immunodeficien - Sex: Female

Poor Environmental
Sanitation

Aedis Aegypti
Mosquito bites

Creates multiple Virus multiply in Increase phagocytic

lesions in the blood bloodstream activity

After 2-3 days

Excessive Paracetamol incubation, fever
consumption of given abdominal pain and
vomiting appears
Hematologic reports Scheduled BT
reveal that patient has For

Dengue Fever Syndrome

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X. Ongoing Appraisal

On august 16, 2010 the client was received patient awake on bed, with
an intravenous line # 10 PNSS to run for 8 hours. With a diet of DAT, no dark
colored foods, hypo allergenic and high fiber diet. For daily urinalysis and
complete blood count in morning. Monitor vital signs and input, output every
4 hours. Watch out for close pulse pressure as sign of bleeding. Due meds
were given.
On august 17, 2010, client intravenous line was discontinued as
ordered. The client has with the same diet. For urinalysis and complete blood
count taken at morning, 7 am. Due meds were given by 0800H and 1200H. At
0830, the client was seen by Dr. Montalban with orders carried out. At 1000H
Dr. Jauculan visited the client.
On August 18, 2010, the client was receives conscious and coherent.
Vital signs were taken and recorded. Due meds were given. May Go Home
were ordered by the physicians.

XI. Discharge Plan

Medications: Paracetamol 1tab for fever with temperature of 38.5°C.

Godex 1 cap, TID
Exercise: Avoid strenuous exercise.
Treatment: Increase fluid intake.
Apply warm compress to site of pain when occurs.
Health Education: Avoid strenuous activities.
Increase fluid intake
Maintain a clean environment
Practice good hygiene
OPD follow-up: consult the doctor when problem occurs again.
Diet: Diet as tolerated
Increase fluid intake
Eat balance meal daily.
Maintain high fiber and hypoallergenic diet.

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