I.

INTRODUCTION Our client Mr. JM 8 years old, living in Norzagaray, Bulacan, was diagnosed with DHF II (Dengue Hemorrhagic Fever stage 2). His primary complaints are abdominal pain, headache and fever. He is a grade three student and studying at FVR elementary school. His parents are Mrs. A 33 years old and Mr. M 42 years old. Our patient was born in Korean because his parents are working on that country. Dengue Fever is caused by one of the four closely related, but antigenically distinct, virus serotypes Dengue type 1, Dengue type 2, Dengue type 3, and Dengue type 4 of the genus Flavivirus and Chikungunya virus. Infection with one of this serotype provides immunity to only that serotype of life, to a person living in a Dengue-endemic area can have more than one Dengue infection during their lifetime. Dengue fever through the four different Dengue serotypes are maintained in the cycle which involves humans and Aedes aegypti or Aedes albopictus mosquito through the transmission of the viruses to humans by the bite of an infected mosquito. The mosquito becomes infected with the Dengue virus when it bites a person who has Dengue and after a week it can transmit the virus while biting a healthy person. Dengue cannot be transmitted or directly spread from person to person. Aedes aegypti is the most common aedes specie which is a domestic, day-biting mosquito that prefers to feed on humans. .The biggest increase of Dengue cases in the country was seen in Metro Manila, where there was an almost 200 percent increase. According to government figures 15,061 cases of the disease in the Philippines were reported in the first six months of the year. The increase in the number of dengue cases may be attributed to the constantly changing climate brought by global warming as well as congestion in urban areas. Deaths due to dengue rose to 172 compared with 115 for the first half of 2007. Metro Manila had the highest number of cases, an increase of 191 percent over the same period in 2007.World Health Organization officials earlier this year warned climate change was increasing the incidence of dengue fever and other infectious diseases in the country. There is no known cure or vaccine for dengue fever, which is transmitted by the white-spotted mosquito. The Philippines Department of Health (DOH) today reported that a total of 2,332 dengue cases has been admitted to sentinel hospitals nationwide from January 1 to May 15 this year. There were sixteen deaths recorded. Partial reports from the DOH National Epidemiology Center (NEC) indicate a 58% decrease in the number of cases this year compared with the same period last year. The NEC report also revealed that the regions with the highest number of cases were the National Capital region

(732 cases), Region 3 (307), Region 5 (268), and Region 7 (231). The ages of cases ranged from 1 month to 75 years old, with forty-six percent (535) of the cases belonging to the 1-9 years age group.

OBJECTIVES: Knowledge Objectives: To acquire knowledge about DHF. To know the effects of DHF to our patient and the right intervention specified for him. To know the essentiality of the case that would assist us student-nurses to build a holistic knowledge, skills and attitude approach to learning .

Skill Objective: 1. Identify the risk factors that occur in the disease and make a pathophysiology about the disease. 2. Formulate significant diagnosis that is related to Nursing Care Plan and make a nursing care plan. 3. Identify the medications administered to the client and the drugs indication, contraindication, side effects, and nurses responsibility.

Attitude Objective: 1. 2. 3. To build trust and rapport to the patient. To gain cooperation and trust from the patient. To gain trust and cooperation from the relatives of the patient.

II.

NURSING ASSESSMENT

A. PERSONAL DATA NAME: Mr. JM AGE: 8 years old SEX: Male ADDRESS: Friendship Village Resour, Norzagaray Bulacan MARITAL STATUS: Single BIRTHDATE: February 16, 2002 NATIONALITY: Filipino BIRTHPLACE: Korea EDUCATIONAL ATTAINMENT: Grade 3 student POSITION IN THE FAMILY: Son RELIGION: Roman Catholic HEALTH CARE FINANACING AND USUAL SOURCES OF MEDICAL CARE: Mother DATE ADMISSION: September 6, 2010 TIME: 1:20 pm B. CHIEF COMPLAINT Mr. JM was admitted to Bulacan Medical Center with a chief complaint of abdominal pain and headache. C. HISTORY OF THE PRESENT ILLNESS The client experienced having abdominal pain every time his stomach is full. He was just lying on bed when the abdominal pain started. He was brought by his mother to Roquero hospital because of having fever, abdominal pain and headache and after 2 days he was transferred to BMC because his family observes having no improvement on their sons situation. He was given Ampicillin and Augmentin at the Roquero hospital. He was given Ranitidine at the BMC hospital for treatment of the abdominal pain. D. HISTORY OF THE PAST ILLNESS The client doesnt have any allergies and havent encountered any accident or injuries. He has completed his immunization according to his aunt. It was his second hospitalization because he was just transferred to BMC. He just had taken Paracetamol every time he experience having fever and headache. 3

E. FAMILY HEALTH ILLNESS HISTORY GENOGRAM HM 84 Y/O HPN EM 73 Y/O YC 89 Y/O KC 76 Y/O

OM 47 Y/O

KM 44 Y/O

MM 42 Y/O

AM 33 Y/O

AC 30 Y/O

MALE FEMALE PATIENT DECEASED ASTHMA Arthritis

HPN Hypertension JM 8 Y/O

The client is the only child of Mr. M.M and Mrs. A.M. He was born in Korea where his parents are working; when he was around 26 days old thats the time he was brought here in the Philippines. It was the first incidence of having Dengue in their family. His grandfather has arthritis and hypertension while his grandmother has asthma and the rest of the families are healthy.

F. FUNCTIONAL HEALTH PATTERN A. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN The clients health has been better. Prior to hospitalization he has no colds but if it happens their first aid is to drink herbal medicines and if it doesnt work they will seek for a doctors consultation. They think that the illness is caused by the poor sanitation of the place where they stayed at Tondo, Manila and when they went to Norzagaray, Bulacan thats when the symptoms started. He was rushed to the hospital after experiencing abdominal pain, headache and high fever. B. NUTRITIONAL AND METABOLIC PATTERN The client loves to eat fried chicken and he always eats fruits every breakfast and drinks milk twice a day. He also has a good appetite prior to hospitalization, while during hospitalization he has poor appetite because of the feeling of weakness and he doesnt like the food. During his hospitalization, he is restricted by his doctor to eat dark colored foods. He doesnt have any skin problems or any dental problems. C. ELIMINATION PATTERN The client urinates 4x a day during his hospitalization with a yellowish color about 100 ml per voiding. He defecate once a day everyday with a formed color brown stool. URINE STOOL AMOUNT 100 ml FREQUENCY 4 times a day Once a day COLOR Yellow Brown ODOR Pungent Foul

D. ACTIVITY-EXERCISE PATTERN Mr. JM has sufficient energy for completing his desired activities, like during playing and doing activities at school. During his spare time he would play outdoor activities with his neighbors. 0-Feeding 0-Dressing IV- Home maintenance 0-Bathing 0-Grooming II-Shopping 0-Toileting 0-General Mobility 0-Bed Mobility IV-Cooking

Level 0- full self care Level I- requires use of equipment or device Level II- requires assistance or supervision from another person Level III- requires assistance or supervision from another person or device Level IV- is dependent and does not participate E. SLEEP-REST PATTERN The client has a regular sleeping pattern because of having 10 hrs. of sleep starting from 8pm-5am. He has a continuous sleep and often takes nap in the afternoon after school. He doesnt have any problem falling asleep. F. COGNITIVE PERCEPTUAL PATTERN The client has no difficulty in hearing and on vision. He learned through school and family. Prior to hospitalization, he experienced abdominal pain and headache and he took Paracetamol to lessen the pain that he is experiencing, G. SELF-PERCEPTION AND SELF-CONCEPT PATTERN He felt good about himself. Since the illness started he missed some of his classes in school. He felt angry every time he wouldnt get what he wanted and being tearful every time he was forced to do something he wouldnt like to do. H. ROLE-RELATIONSHIP PATTERN He belongs to an extended family. Every time they have a problem they will just communicate with each other to solve the issue. His parents are really affected with his hospitalization because they are not here to take care of him. His relatives were the one taking good care of him while he in the hospital. I. SEXUALITY-REPRODUCTIVE PATTERN Not applicable J. COPING STRESS TOLERANCE PATTERN He had no big problem in his life, sometimes he experience having fight with his playmates but still they where able to solve it by themselves.

K. VALUE-BELIEF PATTERN The client is a catholic and they believe in God. For their family it is really important to have a connection to God. It really helps every time they are facing a problem and during his stay in the hospital his family is praying for his wellness. G. GROWTH AND DEVELOPMENT PSYCHOSOCIAL STAGE School Age Industry vs. Inferiority Latency (Genital Stage) Concrete Operations Phase Conventional (Interpersonal Concordance Orientation Stage) At Conventional level, person is concerned with maintaining expectations and rules of the family, group, nation, or society. A sense of guilt has developed and affects behavior. The person values conformity, loyalty, and active maintenance of social order and control. Conformity means good behavior or what pleases or helps another and is approved Societal focus. In interpersonal concordance orientation he decisions and behavior are based on concerns about others reaction; the person wants others approval or a reward. PSYCHOSEXUAL COGNITIVE MORAL

DEFINITION

At this stage, the children begin to create and develop a sense of competence and perseverance. They are motivated by activities that provide a sense of worth. They concentrate on mastering skills that will help the, function in the adult world. Although children of this age work hard to succeed, they are always faced with the possibility of failure, which can lead to a sense of inferiority. If children have been successful in previous stages, they are motivated to be industrious and to cooperate with others toward a common goal

The stage begins around the time that children enter into school and become more concerned with peer relationships, hobbies, and other interests. The latent period is a time of exploration in which the sexual energy is still present, but it is directed into other areas such as intellectual pursuits and social interactions. This stage is important in the development of social and communication skills and self-confidence.

Cognitive development refers to the manner in which people learn to think, reason, and use language. It involves a persons intelligence, perceptual ability, and ability to process information. At concrete operations phase it solves concrete problems. The child begins to understand relationships such as size. They understand right and left. The child has cognizant of viewpoints. In this stage (characterized by 7 types of conservation: number, length, liquid, mass, weight, area, volume), intelligence is demonstrated through logical and systematic manipulation of

symbols related to concrete objects. Operational thinking develops (mental actions that are reversible). Egocentric thought diminishes. ANALYSIS Our client has reached this stage. He is a grade 3 student; through social interactions to his classmates and friends he developed a sense of pride in his accomplishments and abilities. According to our patient, he is always encouraged and commended by his parents and teachers when he did something good. By encouraging and commending a child, our client developed a feeling of competence and belief in his skills. He also stated, that his parents always letting him to do what he wants to do but within the scope of his age. Mr. JM developed a strong sexual interest in his opposite sex like his friends. According to him, during his earlier age (around 5 to 7 years old) he was solely focus on his individual needs and interests in the welfare of others. He also stated that he is always socialized to his friends and classmates during their spare time in school. Our client thinks logically about concrete events, but has difficulty understanding abstracts or hypothetical concepts. He also understands the awareness that actions can be reversed because he is able to reverse the order of relationships between categories. Our client stated that his parents always calling him as a good-boy because according to him he is always following the saying and rules of his parents.

III.

ANATOMY AND PHYSIOLOGY Circulatory System

THE SYSTEMIC CIRCULATION Major arteries (in bright red) and veins (dark red) of the system Blood from the aorta passes into a branching system of arteries that lead to all parts of the body. It then flows into a system of capillaries where its exchange functions take place. Function only: to supply materials to and remove materials from the capillaries. Blood from the capillaries flows into venules which are drained by veins. BLOOD Blood is a liquid tissue. Suspended in the watery plasma are seven types of cells and cell fragments. red blood cells (RBCs) or erythrocytes platelets or thrombocytes kinds of white blood cells (WBCs) or leukocytes Three kinds of granulocytes neutrophils 10 Veins draining the upper portion of the body lead to the superior vena cava. Veins draining the lower part of the body lead to the inferior vena cava. Both empty into the right atrium.

eosinophils basophils

Two kinds of leukocytes without granules in their cytoplasm lymphocytes monocytes

FUNCTIONS OF THE BLOOD Blood performs two major functions: transport through the body of oxygen and carbon dioxide food molecules (glucose, lipids, amino acids) ions (e.g., Na+, Ca2+, HCO3) wastes (e.g., urea) hormones heat Defense of the body against infections and other foreign materials. All the WBCs participate in these defenses

11

All the various types of blood cells Are produced in the bone marrow (some 1011 of them each day in an adult human!). Arise from a single type of cell called a multipotent stem cell.

These stem cells are very rare (only about one in 10,000 bone marrow cells); are attached (probably by adherens junctions) to osteoblasts lining the inner surface of bone cavities; produce, by mitosis, two kinds of progeny: More stem cells (A mouse that has had all its blood stem cells killed by a lethal dose of radiation can be saved by the injection of a single

living stem cell!). Cells that begin to differentiate along the paths leading to the various kinds of blood cells.

12

IV.

THE PATIENT AND HIS ILLNESS A. PATHOPHYSIOLOGY (Schematic Diagram)

Non Modifiable Factors; -age

Modifiable Factors; -environment (sanitation)

Bite of aedes mosquito Dengue flavi virus mix in the blood circulation Immune system recognizes the viral invasion; triggers immune response

WBC

13

Macrophages will release pyrogens that would stimulate the thalamus to body temp.

Megakaryocytes desentigrate as core body temp. continue to rise which would result to platelet count.

Platelet count would now decrease the clothing capability hemorrhage

Hemorrhage in the micro circulation of the gums (that could cause bleeding gums)

14

PHYSICAL ASSESSMENT Name: Mr. JM Birthday: February 16, 2002 Age: 8 y/o Date of Assessment: Sept. 08, 2010 Weight: 27 kg. Height: 411 Parts to be Examined 1. GENERAL SURVEY Body built, height & weight in relation to clients age, lifestyle and health Clients posture and gait, standing, sitting and walking Clients overall hygiene and grooming Body and breath odor Technique Inspection Vital signs: Temperature: 38.4C Pulse rate: 90 bpm Respiratory rate: 35 cpm Blood pressure: 100/70mmHg BMI: 12.0 Normal Findings Proportionate, varies with lifestyle Relaxed, erect posture; coordinated movement Clean, neat No body odor or minor body odor relative to work or exercise; no breath odor Actual Findings He has a proportionate body built which is appropriate with his lifestyle He is slightly unrelaxed and has minimal movements He dresses cleanly, neatly and appropriately. He has no body & breath odor. Interpretation Normal Deviation from Normal due to discomfort and illness. Normal Normal

Inspection

Inspection Inspection

15

Clinical Measurements Height Weight

Underweight = <18.5 Inspection Normal weight = 18.524.9 Overweight = 25-29.9 Obesity = BMI of 30 or greater Inches 411 27 kg. BMI =12.0

The client is underweight based on the result of BMI.

Vital Signs Temperature Pulse rate Respiratory Rate Blood Pressure BEHAVIOR Signs of distress, in posture or facial expression Signs of health or illness Clients attitude Clients affect/mood; appropriateness of clients response Quantity of speech, quality

Inspection Palpation Inspection Auscultation and Palpation Inspection Inspection Inspection Inspection Inspection

36.5-37.5 C 60-100bpm 12-21cpm 120/80mmhg

38.4 C 90bpm 35cpm 100/70mmhg

Temperature are elevated due to increased WBC

No distress noted Healthy appearance Cooperative, able to follow instructions Appropriate to situation Understandable, moderate pace; clear tone and inflection;

On stress He has an unhealthy appearance He is very cooperative and able to follow my instructions He responds appropriately He speech is slightly understandable,clear and has association of

Deviation from Normal due to hospitalization. Deviation from Normal due to illness. Normal Normal Normal

16

Relevance and organization of thoughts 2. INTEGUMENTARY A. SKIN Color and uniformity of color

Inspection

exhibit thought association Logical sequence; makes sense; has sense of reality

thoughts He has relevance of thoughts that makes sense and has a sense of reality Normal

Inspection

Presence of edema Presence of lesion according to location, distribution, color, configuration, size, shape, type or structure Skin moisture

Inspection Inspection

Varies from light to deep brown; ruddy pink to light pink; from yellow overtones to olive Generally uniform except in areas exposed to the sun; areas of lighter pigmentation in darkskinned people No edema Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions Moisture in skin folds and axillae (varies with environmental temperature and humidity and activity) Uniform; within

Pale in color, Herman signs are present

Deviation from Normal d/t decreased tissue perfusion & peripheral vasoconstriction.

He has edema on the IV site He has no lesion; no abrasions or other lesions

Deviation from normal d/t IV infusion Normal Deviation from Normal d/t uncomfortable environment. Deviation from

Inspection

He has warm and silky skin moisture. His skin temperature

Skin temperature

Palpation

17

normal range Skin turgor B. NAILS Fingernails shape, curvature and angle Fingernail and toenail texture Fingernail and toenail bed color Palpation Skin springs back to previous state; has a good skin turgor Convex curvature; angle of nail plate about 160 No visible lines and cracks Smooth texture Highly vascular and pink in light-skinned people; dark-skinned may have brown or black pigmentation in longitudinal streaks Intact epidermis Blanch test of capillary refill Palpation Prompt return of pink or usual color; Delayed 1-2 sec

is warm With redness when pinched His nail has a convex curvature approximately 160 He has a smooth nails without any damages Pallor

normal due to increase body temperature Deviation from Normal d/t blood circulation Normal Normal Deviation from Normal d/t poor arterial circulation.

Inspection Palpation Inspection

Tissues surrounding nails

Inspection

He has an intact epidermis with no hangnails There is a prompt return of blood resulting to the usual color, delayed for 4 sec. His skull is rounded and has a smooth skull contour He has no nodules and masses

Normal Deviation from Normal d/t poor arterial circulation.

3. HEAD A. SKULL Size, shape and symmetry Presence of nodules, masses and depressions

Inspection Palpation

Rounded (normocephalic); smooth skull contour Smooth, uniform consistency; absence

Normal Normal

18

of nodules and masses B. SCALP Color and appearance Areas of tenderness C. HAIR Evenness of growth, thickness and thinness Texture, oiliness over the scalp Color D. FACE Facial features, symmetry of facial movements 4. EYES Inspect the eyes for edemas and hallowness A. EYEBROWS Evenness of distribution and direction of curl Inspection Palpation Inspection Palpation Inspection Inspection Usually white but it also depends on darkskinned people No tenderness Evenly distributed thick hair Smooth texture; no oiliness Black Symmetrical facial features and movements No edema No edema Normal His scalp is white and has a smooth surface There are no areas of tenderness He has a thick hair and it is evenly distributed He has a smooth scalp and oily and brittle hair. Black with short hair. He has asymmetrical facial features which has asymmetrical movements Normal Normal Normal Deviation from normal due to hospitalization. Normal Deviation from Normal d/t illness and hospitalization.

Inspection

Inspection

Hair evenly distributed and the curl is outward

He has an evenly distributed hair in her eyebrow and they are aligned with equal movement His eyelashes are equally distributed and curled outward

Normal

B. EYELASHES Evenness of distribution and direction of curl

Inspection

Equally distributed; curls slightly outward

Normal

19

C. EYELIDS Surface characteristics, position in relation to the cornea, ability to blink and frequency of blinking

Inspection

Skin intact; no discharge or discoloration; Lids closed symmetrically approximately 15-20 involuntary blinks per minute Transparent capillaries sometimes evident Shiny, smooth and pink or red Sclera appears white Transparent, shiny and smooth; the details of iris are visible Rounded shape which are the same in each eye; color varies depending on the race and the color is evenly distributed Black in color, equal

He has a smooth eyelids with no discharge; lids closed symmetrically and has 15-20 blinks per minute His Bulbar Conjunctiva is transparent and has some visible small capillaries He has shiny, smooth and reddish palpebral conjunctiva He has white sclera He has a transparent, shiny and smooth cornea He has a dark brown iris which is uniform and they are both rounded

Normal

D. CONJUNCTIVA Bulbar Conjunctiva for color, texture and presence of lesions

Inspection

Normal

Palpebral Conjunctiva for color, texture and presence of lesions E. SCLERA Color and clarity F. CORNEA Clarity and texture

Inspection

Deviation from Normal d/t blood circulation. Normal Normal

Inspection Inspection

G. IRIS Shape and color

Inspection

Normal

H. PUPILS Color, shape and symmetry of size

Inspection

His pupils are black,

Normal 20

in size and smooth border I. VISUAL ACUITY Near Vision Distant Vision Inspection Inspection Able to read newsprints When looking straight ahead, client can see objects in the periphery Illuminated pupils constricts Pupils also constricts when looking at near objects, dilate when looking at far objects and converge when near object is moved toward the nose No edema, tenderness or tearing Both eyes coordinated, move in unison, with parallel alignment When looking straight ahead, client can see

equal in size and has smooth borders He has been able to read newsprints with the use of eye glasses N/A (no equipment) Normal N/A

J. PUPILS Inspection Light reaction and accommodation His pupils constrict when light passes and it also converge when near object is moved toward his nose

Normal

5. LACRIMAL GLAND / SAC & NASOLACRIMAL DUCT Lacrimal Gland A. EXTRAOCULAR MUSCLES Alignment and coordination

Inspection and palpation Inspection

There are no edema, tenderness and tearing noted from the client His both eyes are coordinated, move in unison with parallel alignment He can see objects in the periphery

Normal

Normal

B. VISUAL FIELD Peripheral visual fields

Inspection

Normal

21

objects in the periphery 6. EARS A. AURICLES Color, symmetry of size and position Inspection Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye about 10 vertical Mobile, firm and not tender; pinna recoils after being folded Dry cerumen, grayish-tan color, sticky or wet cerumen in various shades of brown Normal voice tones audible Able to hear ticking sound in both ears Sound is heard at both ears or at the center (Webers negative) Air conduction is greater than the bone conduction (Rinne Positive) His ears skin color is same as the surrounding skin and both are symmetrical; the auricles are aligned in the outer canthus of each eye His auricles are mobile, firm and not tender; his pinna recoils when folded He had no visible cerumen, has a grayish color Normal

Texture, elasticity and areas of tenderness B. EXTERNAL EAR CANAL Cerumen, skin lesions, pus and blood

Palpation

Normal

Inspection

Normal

C. HEARING ACUITY TESTS Clients response to normal voice tone Watch tick test Webers test Rinne test

Inspection Inspection Inspection Inspection

His voice tones is audible He can hear ticking sound in both ears He heard at both ears or at the center (Webers negative) Air conduction is greater than the bone conduction (Rinne Positive)

Normal Normal Normal Normal

22

7. NOSE Deviations in shape, size or color and flaring or discharge Nasal cavities for presence of redness, swelling, growths and discharge Nasal septum between the nasal chambers Patency of both nasal cavities Tenderness, masses and displacement of bones and cartilage SINUSES Tenderness 8. MOUTH A. LIPS Symmetry of contour, color and texture

Inspection

Inspection Inspection Inspection Palpation

Symmetric and straight; no discharge or flaring; uniform color Mucosa pink; clear watery discharge; no lesions Nasal septum intact and in midline Air moves freely as the client breathes through the nares Not tender

His nose are uniform in color same as with the surrounding skin; there are no discharge and flaring He has a clear watery discharge and has no apparent lesions His nasal septum is in the middle He usually breathes freely through his nares There are no tenderness, masses or displacement of bones and cartilage His sinuses are not tender He has a pale in color lips, slightly dry and smooth; it has symmetry of contour and has the ability to purse his lips He has a moist, soft, glistening and elastic texture of his buccal mucosa

Normal

Normal Normal Normal Normal

Palpation

Not tender

Normal

Inspection

Uniform pink color, soft, moist, smooth texture, symmetry of contour, ability to purse lips Moist, smooth, soft, glistening and elastic texture

Deviation from Normal d/t illness.

B. BUCCAL MUCOSA Color, moisture, texture and presence of lesions

Inspection

Normal

23

C. TEETH Color, number, condition and presence of dentures D. GUMS Color and condition E. TONGUE/ FLOOR OF MOUTH Color and texture of the mouth and frenulum

Inspection

Pre-schooler teeth; smooth, white and shiny tooth enamel Pink gums; moist and firm texture to gums; no retractions Central position; Pink color, moist, slightly rough; thin whitish coating, lateral margins; no lesions; raised papillae Moves freely; no tenderness; smooth tongue base with prominent veins Smooth with no palpable nodules Light pink, smooth, soft palate Lighter pink hard palate, more irregular Positioned in midline of soft palate Pink and smooth posterior walls Pink and smooth; no discharge; of normal

He has a shiny tooth enamel without any dental problems His gums are pinkish to reddish in color His tongue is in the center, pink in color, it is moist, slightly rough without lesions; it has a thin whitish coating and lateral margins His tongue moves freely with weak tenderness It has no nodules He has pale in color and smooth soft palate while pale and irregular hard palate The uvula is in the middle He has a smooth and pinker posterior walls His tonsils are pink and smooth without

Normal Deviation from normal due to bleeding

Inspection

Inspection

Normal

Position, color and texture, movement and base of tongue Presence of nodules, lumps or excoriated areas F. PALATES AND UVULA Color, shape, texture, and presence of bony preminences Position of uvula and mobility while examining the palates. G. OROPHARYNX AND TONSILS Color and texture Size of tonsils, color and discharge

Inspection and palpation Palpation Inspection

Normal Normal Deviation from Normal d/t decrease blood circulation Normal Normal Normal

Inspection Inspection Inspection

24

size Presence of Gag reflex 9. NECK A. LYMPH NODES Lymph Nodes and tenderness B. TRACHEA Placement Inspection Gag reflex is present

discharge and of normal size He has a positive gag/cough reflex His nodes are not palpable His trachea is in the middle with equal spaces on both sides It is not visible His thyroid glands rise when swallowing; it is smooth and painless

Normal

Inspection and palpation Inspection and palpation

Not palpable Central placement in midline of neck; spaces are equal in both sides Not visible on inspection Glands ascends during swallowing; painless, centrally located and smooth Chest symmetric; anteroposterior to transverse diameter in ratio of 1:2 Spine vertically aligned Skin intact; uniform temperature Full and symmetric

Normal Normal

C. THYROID GLAND Symmetry and visible masses Smoothness, enlargement and nodules 10. THORAX A. POSTERIOR Shape, symmetry, compare the diameter of anteroposterior to transverse diameter Spinal alignment Temperature, tenderness and masses Respiratory excursion

Inspection Palpation

Normal Normal

Inspection

Inspection Palpation Inspection and

His chest are symmetric; anteroposterior to transverse has a diameter ratio of 1:2 His spine is vertically aligned His skin is intact and has uniform warm temperature He has a full and

Normal

Normal Normal Normal 25

palpation

Vocal fremitus

Palpation

Percuss the thorax

Percussion

Auscultate the thorax B. ANTERIOR Breathing patterns Temperature, tenderness and masses Respiratory excursion

Auscultation

expansion; as the client breathes, thumbs usually separates 3-5cm Bilateral symmetry of vocal fremitus; it is heard mostly at the apex of lungs Percussion notes resonance except over scapula Lowest point of resonance is at the diaphragm Vesicular and bronchovesicular sounds Quiet, rhythmic and effortless respiration Skin intact; uniform temperature Full and symmetric expansion; as the client breathes, thumbs usually separates 3-5cm Bilateral symmetry of vocal fremitus; it is heard mostly at the apex of lungs

symmetric expansion and as she breathes, thumbs usually separate for 3-5 cm. He has a bilateral symmetry of vocal fremitus; it is heard clearly at the apex His percussion notes resonance sound except over the scapula and the lowest resonance heard is at the diaphragm There are vesicular and bronchovesicular sounds heard He has a quiet, rhythmic and effortless respiration His skin is intact and has uniform warm temperature He has a full and symmetric expansion and as he breathes, thumbs usually separate for 3-5 cm. He has a bilateral symmetry of vocal fremitus; it is heard clearly at the apex

Normal

Normal

Normal

Inspection Palpation Inspection and palpation

Normal Normal Normal

Vocal fremitus

Palpation

Normal

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Percuss the anterios thorax

Percussion

Auscultate the trachea Auscultate the thorax 11. CARDIOVASCULAR Aortic and pulmonic areas Tricuspid area Apical area

Auscultation Auscultation

Percussion notes resonance except over ribs Lowest point of resonance is at the diaphragm Bronchial or tubular breath sounds Vesicular and bronchovesicular sounds No pulsation No pulsation; no lift or heave Some pulsations visible; no lift or heave Aortic pulsations S1-usually heard at all sites but louder at the apical area S2-usually heard at all sites but louder at the base of heart Symmetric pulse volumes; full pulsations

His percussion notes resonance sound except over the ribs and the lowest resonance heard is at the diaphragm There are bronchial or tubular sounds heard There are vesicular and bronchovesicular sounds heard No pulsations felt No pulsations or lift and heave There are some pulsations felt but there are no lift or heave There are aortic pulsations There are heart sounds heard in all sites

Normal

Normal Normal

Inspection and palpation Inspection and palpation Inspection and palpation Inspection and palpation Auscultation

Normal Normal Normal

Epigastric area Auscultate aortic, pulmonic, apical, tricuspid and epigastric area

Normal Normal

12. CAROTID ARTERIES Palpate with extreme caution

Palpation

His carotid artery has a full symmetric pulse volumes and pulsations

Normal

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Auscultate the carotid arteries 13. JUGULAR VEINS Presence of veins 14. ABDOMEN Skin integrity Abdominal contour Enlarged liver or spleen Symmetry of contour Abdominal movements Vascular patterns Bowel sounds, vascular sounds and peritoneal friction rubs

Auscultation Inspection Inspection Inspection Inspection Inspection Inspection Inspection Auscultation

No sounds heard Veins not visible Unblemished skin, uniform color Flat, rounded or scaphoid No evidence of enlarged liver and spleen Symmetric contour Symmetric movements caused by respiration No visible vascular patterns Audible bowel sounds usually occur every 520seconds; absence of arterial bruits and friction rub Tympany over stomach and gasfilled bowels; dullness over the liver and spleen or full bladder No tenderness, relaxed abdomen with smooth, consistent

There are no sounds heard There are no visible veins He has unblemished skin, uniform color He has symmetric contour There are no evidence of enlarged liver and spleen He has a symmetric contour He has symmetric movements because of respiration There are no vascular patterns seen There are audible bowel sounds heard every 30 seconds but no arterial bruits and friction rub There is tymphany over stomach and gas filled bowels There is no tenderness, his abdomen is relaxed with smooth consistent

Normal Normal Normal Normal Normal Normal Normal Normal Normal

Percuss in each quadrants

Percussion

Normal

Light palpation of quadrants

Palpation

Normal

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tension 15. MUSCULOSKELETAL A. MUSCLES Size, comparison on one side to other side Contractures Fasciculation and tremors Muscle tonicity Muscle strength B. BONES Normal structure and deformities Edema and tenderness C. JOINTS Swelling Inspection Inspection Inspection Palpation Inspection and Palpation Inspection Palpation Equal size on both sides of the body No contractures No tremors Normally firm Smooth coordinated movements No deformities No tenderness or swelling No swelling

tension He has equal muscle size on both sides of the body He has no contractures He has no tremors He has firm muscles He has a weak and slight un-coordinated movements He has no deformities He has no edema, tenderness and swelling Positive swelling Normal Normal Normal Normal Deviation from Normal d/t illness. Normal Normal

Inspection

Deviation from Normal d/t uncomfortable environment. Normal

Tenderness, smoothness of movements, crepitation and nodules

Palpation

No swelling, tenderness, crepitation or nodules

There are no tenderness, swelling, crepitation or nodules;

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Joint range of motion

Inspection

Varies to some degree in accordinance with persons genetic makeup and degree of physical ability.

He has a good joint ROM.

Normal

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DIAGNOSTIC PROCEDURE/ LABORATORY

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Diagnostic Laboratory Procedure Complete Blood Count

Date Ordered Sept. 07, 2010

`Indication or Purpose The CBC provides valuable information about the blood and to some extent the bone marrow, which is the blood-forming tissue. The CBC is used for the following purposes: as a preoperative test to ensure both adequate oxygen carrying capacity and hemostasis to identify persons who may have an infection to diagnose anemia to identify acute and chronic illness, bleeding tendencies, and white blood cell disorders such as leukemia to monitor treatment for anemia and other blood diseases To determine the effects of chemotherapy and radiation therapy on blood cell production.

Result

Normal Values

Analysis and Interpretation of Result Analysis/Interpretation Abnormal/Decreased Abnormal/Elevated Normal Normal Abnormal/Decreased Abnormal/Decreased Abnormal/Decreased Normal Abnormal/Elevated Abnormal/Elevated Normal Normal Normal Abnormal/Decreased Abnormal/Elevated Abnormal/Decreased Normal Normal

Nursing Responsibilities Before: -Identify the patient -explain the procedure to the patient -Inform the patient that there are no foods, fluids, or medications restrictions, unless by medical directions. During: -Instruct the patient to cooperate fully and to follow directions during the laboratory procedures. After: -Secure the laboratory results of the patient.

Components WBC RBC HGB HCT PLT PCT MCV MCH MCHC RDW MPJ PDW %Lymphocytes #Lymphocytes %Monocytes #Monocytes %Granulocytes #Granulocytes

Actual Findings 2.2 L 109/L 6.20 H 1012/L 100 g/L 0.330 69 L 109/L 0.046 L 10-2/L 72 L fl 25.5 L pg 356 H g/L 16.7 H% 6.6 fl 10.1 % 39.3 % 0.8 L 109 L 13.3 H% 0.2 L 109L 47.4 % 1.2 L 109L

Normal Findings 3.5 10.0 3.80 5.80 110 165 0.350 0.500 150 390 0.100 0.500 80 97 26.5 33.5 315 350 10.0 15.0 6.5 11.0 10.0 18.0 17.0-48 1.2-3.2 4.0-10.0 0.3-0.8 43.0-76.0 1.2-6.8

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V.

THE PATIENT AND HIS CARE A. MEDICAL MANAGEMENT a. IVF, BLOOD TRANSFUSION, NEBULIZATION, TOTAL PARENTERAL NUTRITION, NGT, OXYGEN THERAPY ETC.

MEDICAL MANAGEMENT

DATE ORDERED, DATE RESULT IN

GENERAL DESCRIPTION

INDICATION/ PURPOSES

CLIENTS RESPONSE

NURSING RESPONSIBILITIES

D5 0.3 NaCl 500 cc @ 25 gtts/ min

September 6, 2010 Hypertonic Crystalloid Sterile, nonpyrogenic and contain no bacteriostatic or antimicrobial agents. It contains 77 mEq/L solution and 77 mEq/L chloride.

Hypertonic solution draws fluids from the ICF causing cells to shrink and ECF to expand. Given to patients with hyponatremias (Na deficits) with edema. IVF may also come in a form of nutrient solution, electrolyte solution, alkalyzing solution & acidifying solution.

The patient gets sufficient energy for the body and the brain to function well.

-Frequently check the IVF site for infiltration, dislodge and inflammation -Explain the purpose of the IVF to the patients family.

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Normal Saline Solution 250 cc as fast Drip

September 06, 2010

Solution of common salt in distilled water, of a strength of 0.9 per cent. It is called normal saline because the percentage of salt resembles that of the crystalloids in the blood plasma. Applied to a wound an isotonic causes no increase in the flow of lymph from the capillary blood vessels.

-Can be use to replace fluids in dehydration, go with blood transfusion, hyponatremia, and burn victims. It is isotonic. -to dilute medications and to clean wounds out and to clean wounds out and other things. -fast drip for low BP in dengue hemorrhagic fever patient.

The patient gets sufficient energy for the body and the brain to function well.

-monitor for urine output, which should be 100ml or more every 4hrs. -assess IV site carefully to avoid extravasations and tissue necrosis. -monitor renal function, urinary output, fluid balance and electrolytes level.

b. Drugs Generic/ Brand name Ranitidine Hydrochloride (Zantac, Gavilast, Aporanitidine.Ranitil Ulzan) Date ordered, date taken/Given, date changed, date discontinued September 6, 2010 Route of administration, dosage, frequency 250mg TIV q 8 General action, classification, mechanism of action Histamine-receptor antagonist Anti ulcer drug Reduces gastric secretion and increases gastric Indication/ purposes Treatment of active duodenal ulcer; maintenance therapy for duodenal ulcer patient after healing of acute Clients response Nursing responsibilities (Prior, during, after) Assess vital signs. Monitor CBC and liver function tests. Assess patient for epigastric or abdominal pain and 34

No signs of any adverse reaction.

mucus and bicarbonate production, creating a protective coating in gastric mucosa.

ulcer; treatment of gastro esophageal Reflux disease: short-term treatment of active, benign gastric ulcer; treatment of pathologic GI hypersecretory conditions (e.g., Zollinger-Ellison syndrome, systemic mastocytosis, and postoperative hypersecretion); heartburn.

frank or occult blood in the stool, emesis, or gastric aspirate. Inform patient that it may cause drowsiness or dizziness. Inform patient that increased fluid and fiber intake may minimize constipation. Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health care professional promptly.

c. Diet Type of diet Date started Date changed/D/C General description Indications/Purposes Specific Foods taken Client response to the diet

DAT except dark colored food

September 6, 2010

A human being pattern of Any food except dark colored eating. foods that he desires nutritious,

All nutritious food except dark colored

The patient obeys and maintained the

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It simply means "eat anything you want except dark colored foods.

if this will not lead to any complications and if the client needs further monitoring for lab test

foods such as chocolates, dinuguan, squid, etc.

instructed diet.

d. ACTIVITY/ EXERCISE TYPE OF EXERCISE DATE ORDERED/ DATE STARTED/ DATE DISCONTINUED GENERAL DESCRIPTION INDICATIONS/ PURPOSES CLIENTS RESPONSE TO ACTIVITY NURSING RESPONSIBILITIES

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Regular physical activity

September 6, 2010

important for maintaining physical fitness and can contribute positively to maintaining a healthy weight, building and maintaining healthy bone density, muscle strength, and joint mobility, promoting physiological wellbeing, reducing surgical risks, and strengthening the immune system.

-improve the range of motion of muscles and joints. - increasing cardiovascular endurance.

The patient can regain the strength he has lost in the days of his hospitalization

-explain to the patient the importance and benefits of having a regular exercise. -encouraged the relative or family to join in the activity. -give some exercises that the patient can do that cant cause him any stress.

NURSING CARE PLAN

CUES

NURSING DIAGNOSIS

SCIENTIFIC KNOWLEDGE

GOALS/ OBJECTIVES

NURSING

RATIONALE

EVALUATION/ EXPECTED 37

INTERVENTION Subjective: Nahihilo, nanghihina at sumasakit ang tiyan ko as verbalized by the patient. Ineffective Tissue Perfusion r/t Decreased hemoglobin concentration in blood AEB low hemoglobin concentration, pallor and dizziness, and muscle weakness. Typhoid Ileitis & DHF After 12 hours of 1. nursing intervention, 1. a.) Encourage 2. the client will be able patient to take to: iron supplements and 1. Demonstrate eat foods rich in different ways to iron. improve blood b.) Elevate head of oxygenation and bed to about 10 circulation. degrees. 2. Verbalize understanding of condition and importance of treatment regimen. 3. Demonstrate increased tissue perfusion. c.) Discourage strenuous activities. 2. a.) Provide health teaching regarding DHF and Typhoid Ilietis b.) Provide health teaching on drugs being taken. 3. a.) Monitor vital signs .

OUTCOME 1. a.)To help After 32 hours of elevate nursing intervention hemoglobin and the client was: hematocrit levels 1. Demonstrated different ways to b.) To promote improve blood circulation and oxygenation and venous drainage. circulation. c.)To avoid increased oxygen demand. 2. a.) To help client understand his health condition. b.)To maintain compliance to meds. 2. Verbalized understanding of condition and importance of treatment regimen. 3. Demonstrated increased tissue perfusion

Viral infection

Objective: Pallor Hemoglobin = 100 g/L Hematocrit = 0.330 L/L

Decreased CBC & platelet count

Definition: Decrease in oxygen resulting in the failure to nourish the tissues at the capillary level [Tissue perfusion problems can exist without decreased cardiac output; however there may be a relationship between cardiac output and tissue perfusion.]

Decreased level of hemoglobin and hematocrit

Decreased blood oxygenation

pallor, dizziness, muscle weakness

3. a.)Serve as basis for any alteration in system functions.

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Ineffective tissue perfusion Source: Nurses Pocket Guide Ninth Edition

b.) Encourage early ambulation when possible.

b.) Enhances venous return.

Collaborative: Administer medications as ordered Administer and regulate IVF as ordered Administer packed RBCs Monitor lab studies ( Hb,Hct, RBC count)

Help control/alleviate symptoms Maintain hydration and help wash away toxins Packed RBCs are adequate for stable patients with subacute/chronic bleeding to increase oxygen carrying capability. Aids in establishing blood replacement needs & monitoring effectiveness of

39

Source: Nurses Pocket Guide Ninth Edition

therapy. Source: Nurses Pocket Guide Ninth Edition

CUES

NURSING DIAGNOSIS

SCIENTIFIC KNOWLEDGE

GOALS/ OBJECTIVES

NURSING INTERVENTION

RATIONALE

EVALUATION/ EXPECTED OUTCOME

Infectious agents (pyrogens) Subjective: Mainit ang pakiramdam ko as verbalized by the patient. Objective: Flushed skin, warm to touch. Hyperthermia related to inflammatory response as manifested by body temperature of 38.6 degree Celsius, flushed and warm to touch skin. After 4 hrs. Of nursing interventions, the patient will maintain core temperature within normal range. Independent: Rendered tepid sponge bath Encouraged to increase fluid intake Promoted surface cooling, loosen clothing, and cool environment Encouraged to have adequate To promote cooling surface To replace fluid loss due to body heat Heat is loss by evaporation and conduction After 4 hrs. Of nursing interventions, the patient was able maintain core temperature within normal range. Goal met.

Monocytes

Pyrogenic cytokines

Anterior hypothalamus

Elevated thermoregulatory set point

To reduce metabolic

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 Restlessness V/S taken as follows: T: 38.6 C P: 78 R: 19 BP: 110/80

Increased Heat bed rest Dependent: conservation(Vasoconstriction/behaviour changes) Increased Heat production (involuntary muscular contractions) Administered Paracetamol as ordered Administered IVF as ordered

demands

To decrease temperature

F EVER

To support circulating volume and tissue perfusion

CUES Subjective: Palagi akong

NURSING DIAGNOSIS Diagnosis: Risk for deficient

SCIENTIFIC KNOWLEDGE Recognition of dengue viral antigen

PLANNING Short Term: After 1 hr. of nursing

NURSING INTERVENTION Independent: > Note possible conditions like

RATIONALE >These conditions may lead to fluid

EVALUATION Short term: Goal Met.

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nauuhaw, as verbalized by the patient Objective: > Decreased platelet count= 69L >Thirst >Weakness

fluid volume related to decreased blood volume secondary to altered platelet production Definition: The state in which an individual is at risk of experiencing vascular, cellular, or intracellular dehydration

on infected monocyte by cytotoxic cells Cellular direct destruction Infection of red bone marrow precursor cells Immunological platelet survival Platelet lyses Hemorrhage Increasing the risk for fluid volume deficit

interventions, the client will be able to demonstrate behaviors that reduce the risk of decreased fluid volume as manifested by: > > Increased oral Enumerate ways fluid intake. to prevent bleeding

fluid loss and limited intake. > Monitor I&O

deficits >To ensure accurate picture of fluid status >Water loss can directly affect the body system >The GI tract is the most usual source of bleeding of its mucosal fragility

> Monitor VS changes. > Assess the signs and symptoms of GI bleeding. Check for secretions. Observe color and consistency of stools or vomitus. > Observe for presence of petichiae, ecchymosis, bleeding from one more sites. > Encourage use of soft toothbrush. Avoid straining in stool, and forceful nose blowing.

After 1 hour of nursing interventions, the client was able to demonstrate behaviors that reduce the risk of decreased fluid volume. .> Increased oral fluid intake. > Enumerate ways to prevent bleeding

>Su-acute disseminated intravascular coagulation may develop seondary to altered clotting factor >Minimal trauma can cause mucosal bleeding

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> Monitor lab studies ( Hb,Hct, RBC count, platelet, PTT, APTT) > Encourage water for thirst instead of juices or soda.. > Promote intake of high-water content foods (e.g. popsicles, gelatin, eggnog, watermelon)

>Aids in establishing blood replacement needs & monitoring effectiveness of therapy. >Juices or soda are more concentrated and has lesser water content. >Adds water in the diet without overwhelming the client with bulk of drinking water.

Collaborative: > Provide/ assist in >To replenish fluid volume for severe giving dehydration supplemental fluids as indicated (e.g. parenteral, enteral)

VI.

DISHARGE PLANNING

METHODS MEDICATION: 43

Continue taking prescribe medication for the patient on exact dosage, time, and frequency making sure that the purpose of the medication is truly discussed by the health care provider. Instruct the patient to follow the instruction when administering meds. Advice the significant others not to leave the patient during meds. Advice the patient not to stop intake of prescribed meds, unless approved by the physician. Dont give aspirin and NSAIDs, they increase the risk of bleeding. Any medicines that decrease platelet count should be avoided.

EXERCISE: Instruct to avoid excessive activities that may result to stress. Just advised to perform range of motions and repetitive body movements for promotion of optimum health. Remind about the need for health promotion activities such as reading, watching T.V, etc. TREATMENT: Bed rest is advisable during the re-occurrence of fever phase. Instruct to drink plenty of water or fluids that are available at home and eat nutritious diet. Advised to look for re-occurrence of danger signs and symptoms and report immediately.

HYGIENE: Encourage to continue the routinely hygienic care of the patient

44

OPD: Instruct the family members to have a check-up or to consult physician once a while to monitor patients condition and for detection of recurrences and other complications that may arise on to it. DIET: Instruct the family members to give the client protein rich foods such as meat, fish, eggs and dairy products.

VII.

CONCLUSION As part of our requirement, we had learned so much in handling our client who DHF. We attained and follow certain standards and rules to promote

nurse patient interaction. With this case study, we gain knowledge that we can surely use in the future ahead. All we do to our client is the summary of what we have learned in lectures in school. We also share some information with our client like the main probable cause and the risk factors of having DHF. We do manage our time to give sufficient care to our beloved client. We believed that client is our work and we have the responsibility to attend to their needs and serve them as best as we can. We are able to provide health teaching about the proper health care to our client with DHF. We started having an interview by building trust to our client because at first, he wasnt like to share some information to us. But, as time goes by, we were able to let our client share some information that will be very useful in this case studies. VIII. BIBLIOGRAPHY Schull, Dwyer Patricia, Nursing Spectrum DRUG Handbook, The McGraw-Hill Companies, Inc. copyright 2008 Wilkinson, Judith M, and Nancy R. Ahern, Nursing Diagnosis Handbook 9th edition, Pearson Education South Asia Pte. Ltd copyright 2009

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Kozier, Barbara; Avory Berman; Glenora Erb and Shirlee Snyder, Fundamentals of Nursing 7th Edition, Pearson Education South Asia Pte. Ltd. Copyright 2004 Colbert, Bruce J; Jeff Ankney and Karen T. Lee, Principles of Anatomy & Physiology, an interactive journey, Pearson Education South Asia Pte. Ltd. Copyright 2007 Walker, Richard Guide to the HUMAN BODY, Octopus Publishing Group Ltd. Copyright 2003 Delaune, Sue E. and Patricia K. Ladner, Fundamentals of Nursing, Standards and practice, 3rd edition, Thomson learning Asia,Copyright 2006 Nursing 2006 Drug handbook 26th edition, Lippincott Williams and wilkins Deglin, Judith Hopper and April Hazard Vallerand, Daviss Drug Guide for Nurses, 9th edition Nurses Pocket Guide: Nursing diagnoses with interventions 4th edition Brunner & Suddarths, Medical and Surgical Nursing 10th edition, Lippincott Williams & Wilkins Copyright 1996

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