1

I. INTRODUCTION Today, about 2.5 billion (2/5 of the world population) are at risk from dengue, and 50 million are infected worldwide annually, with a mortality rate ranging from 1 percent to 2.5 percent, for those who receive treatment, according to WHO statistics. For those without treatment, the death rate could be 20 percent (one in 5) or higher. In the Philippines there are many diseases illness arising because of environmental changes that may be caused by human activities and geographical conditions. It is considered as one of the tropical country and so disease can spread throughout the country. One example of these is disease is what we called Dengue Fever 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 these 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. Here in the Philippines, the Department of Health reports that the incidence of dengue fever doubled in metro Manila during the first quarter of 2011. The Philippines have been a dengue fever hotspot for several years, but the latest statistics are alarming: 4,399 cases in 2011 versus 1,984 in 2010. This outbreak comes despite the distribution of over 700,000 mosquito trap kits in recent months. The Department of Health cited Manilas Barangay San Miguel in Pasig City and Barangay Hen. T. de Leon in Valenzuela as particularly high risk areas. Mortality rates for DHF are usually less than 1% but can be as high as 5% if the disease. The Philippines Department of health is not treated in a timely manner has declared a dengue outbreak in Bantanes which is in North Central Luzon. The Red Cross is asking for blood donations. Those that are most ill sometimes require blood transfusions. Most do not need this but it can be a matter of life or death for some. This patient has caught my attention and has given the opportunity to study his case. The objective of this study is to help us understand the disease process of Dengue Fever and to orient myself for appropriate nursing interventions that I could offer to the patient. This approach enables me to exercise my duties as a student nurse which is to render care. I was given the chance to improve the quality of care I can offer and to pursue my chosen profession as a future nurse. I humble myself to present my studied case and submit myself for further corrections to widen the scope of my knowledge and understanding.

II.GENERAL DATA PATIENTS PROFILE

NAME AGE SEX HEIGHT WEIGHT ADDRESS Cebu CITIZENSHIP DATE OF BIRTH PLACE OF BIRTH RELIGION OCCUPATION MARITAL STATUS DATE OF ADMISSION TIME OF ADMISSION ROOM NO FINAL DIAGNOSIS ADMITTING PHYSICIAN

: : : : : :

R. A. G. 8 years old Male 130 cm 38.2 kg Umapad Mandaue, City Cebu / Tagbawan, Tabuelan

: : : : : : : : : : :

Filipino September 06, 2002 Cebu City Roman Catholic None Married August 23, 2011 4:42 pm GP 4 Dengue Fever Dr. De La Calzada, Jo Janette Ressureccion Chong Hua Hospital

ADMITTING INSTITUTION:

III. HEALTH ASSESSMENT A. HEALTH HISTORY A1. BIOLOGICAL DATA

NAME AGE SEX HEIGHT WEIGHT ADDRESS Tabuelan Cebu CITIZENSHIP DATE OF BIRTH PLACE OF BIRTH RELIGION OCCUPATION MARITAL STATUS DATE OF ADMISSION TIME OF ADMISSION ROOM NO FINAL DIAGNOSIS ADMITTING PHYSICIAN

: : : : : :

R. A. G. 8 years old Male 130 cm 38.2 kg Umapad Mandaue, City Cebu / Tagbawan,

: : : : : : : : : : :

Filipino September 06, 2002 Cebu City Roman Catholic None Married August 23, 2011 4:42 pm GP 4 Dengue Fever Dr. De La Calzada, Jo Janette Ressureccion Chong Hua Hospital

ADMITTING INSTITUTION:

A.2 REASONS FOR SEEKING CONSULTATION Patient had high on and off fever and cough.

A.3 CURRENT HEALTH STATUS Patients health status is under treatment because of cough and high on and off fever with the evidenced of warm to touch, dry and cracked lips. Pale, weakness and chills noted. Patient has decreased appetite and had a dry non-productive cough. With skin rashes noted.

A.4 PAST HEALTH HISTORY Patient had previous hospitalization at Vicente Sotto at year 2003 due to pneumonia and at year 2005 admitted at Chong Hua Hospital to Urinary Tract Infection and was discharged and improved.

A.5 FAMILY HISTORY (Refer to Pediatric Assessment for Genogram) Based on our short interaction with the patients mother we found out that the patients grandfather on the father side died due to old age whiles his grandmother is asthmatic .On the mother side of the patient, his grandparents is both hypertensive so as the patients mother. One of the patients uncle on the mother side died due to heart disease. The father of the patient is well and his sister is asthmatic. Two of the patients siblings are well and the other one is allergy to seafoods.

A.6 GORDONS FUNCTIONAL HEALTH PATTERN Data for R. A. G., organized according to: 1. Health Perception-Health Management Pattern The patient's mother perceives the health of his son as a state of excellence because they give much importance and value on the health of their family. Every time the patient will have cough and colds they immediately seek for the health care professionals. And following therapeutic regimen per doctors ordered. However, in this time theres a disturbances in his daily activities. According to his mother, he had completed all his immunization except hep B vaccine. 2. Nutritional/Metabolic Pattern Patient loves eating pork and apple every after meals. His favorite food to eat during lunch and dinner is Linatang Baboy. His mother always prepares milk every morning. According to his mother she always gave him vitamin supplements (Celine and Clusivol) everyday. When he was hospitalized he was restricted to eat chocolates or any choco colored foods. Patient also had poor appetite due to illnesses felt. There are also presence of dental carries. 3. Elimination Pattern There were no problems or complaints with urinating. He was able to void 5 6 times during our 8 hours shift. It is light yellow in color, and its transparency is clear. No assistive devices used when hospitalized. But during the year of 2005 he was diagnosed with urinary tract infection and was improved. He was able to had bowel movement every day. Often, experienced constipation during elimination. And he had no problem with the frequency of his bowel, brown colored stool, and semisolid in characteristics. 4. Activity-Exercise Pattern The patient usually play with his neighbor such as running and sometimes biking after taking his nap in the afternoon and that is what his mother considered as his exercise. Usually upon waking up he immediately go to our computer and played with it. In school, he joined activities like academic competitions, dancing competition, and boys scouts. But his not allowed to play much and do strenuous activities because the patient is asthmatic.

5. Sleep-Rest Patterns According to the patients mother, the patient usually sleeps at 8pm and wakes up at 6:30 am during school days and about 11 am during weekends. He uses 1 pillow and doesnt have any problems when sleeping. During hospitalization the patient cannot sleep well due to the blood extraction for CBC monitoring. 6. Cognitive-Perceptual Pattern Patient was able to ambulate, responsive and coherent. No deficits of any sensory perception. He can able to read and write. 7. Self-perception Pattern N/A 8. Role-Relationship Pattern Since the patient is still eight years old his only role is as a son and a student .In simple things his parents will let him decide on what things he prefer. 9. Sexuality/Reproductive Not applicable 10. Coping-Stress Management Tolerance According to the patients mother the patient usually go to his room and wants to talked to his father in abroad when scolded. 11. Value/Belief The patients parents said that ever since the patient was still young they already taught the patient how to pray .They offer mass most of the times .They also taught the patient to be courteous to the elderly .The patient prays before he sleeps and prays every morning after he wakes up.

7
PEDIATRIC ASSESSMENT ( 1 month to 12 years )

Name of Patient: R. A. G. I.

Date of Birth: September 16, 2002

Sex: Male

PRENATAL HISTORY ( of mother ) Obstetric Score G 4 Regular Irregular Obstetrician Nurse Hospital Clinic None Fever GDM Asthma UTI TB Allergy Hyperemesis T 4 P 0 A 0 L 4 M 0 None Hilot RHU Home Rash Heart Disease Hepatitis PIH

Maternal Age 38 years old Prenatal Check-up: Done By: Place: Maternal Illness:

Medication ( mother ) Iron supplements and vitamins for pregnant women

II.

NATAL HISTORY 5/5 Apgar Score 9,10 Home Lying in Hilot Others Preterm Post term Forceps C/S(indication) Face Breech Transverse Vitamin K Hep. B

Date of Birth September 06, 2002 Birth Rank Place of Delivery Hospital Attendant Midwife Gestation Full term Mode of Delivery NSVD Presenting Part Cephalic Medications Eye Prophylaxis

III.

POST-NATAL HISTORY Breastmilk None Sepsis Milk Formula Respiratory Seizure Mixed Cyanosis Jaundice

Feeding: Medical Problems:

IV.

IMMUNIZATION 1st dose

No 2nd dose

Yes 3rd dose

at:

Center 1st booster

Private 2nd booster

Both None

BCG DPT OPV Hib Hep B Pneumoccocal Rotavirus Flu Varicella AMV MMR Others: Typhoid Hep.A Meningoccocal HPV

V.

FEEDING HISTORY 6 months Breastfeed Breastfeed Milk Formula Mixed Milk Formula Mixed Type Cereals or Blinded Vegetables Allergies When started Duration Since his 6 months

0 6 months 6 12 months Age semisolid started Food Preference: Food Dislikes Vitamin Supplements:

Type Vitamin C Amount

VI.

PAST MEDICAL / SURGICAL HISTORY Unremarkable Remarkable

If Remarkable : Date Diagnosis Intervention

Hospitalization ( including operation ) Date 2003 2005 Hospital VSMMC CHONG HUA HOSPITAL Diagnosis Pneumonia Urinary Tract Infection

9
VII. FAMILY HISTORY No significance FH HPN disease Blood Disorder Allergy TB Seizure Others : . Kidney Disease Cancer Stroke Mental Disorder Diabetes Significance FH Asthma Heart

VIII.

GROWTH AND DEVELOPMENT Sat alone

First raised head Rolled over Pulled up Walked with help Walked alone Talked Urinary Incontinence: Day Control of feces Comparison of development with that of other siblings School Grade Quality of work

Night

IX. a.

BEHAVIORAL HISTORY Does the child manifest behavior like thumb sucking Masturbation Temper Tantrums Negativism Does the child have sleep disturbances? Yes Phobias Pica ( ingestion of substances other than foods ) Abnormal Bowel Habits ( stool holding ) Bedwetting

No

b. c. d. e. f.

10
X.FAMILY HISTORY ( insert the Genogram )

MOTHERS SIDE MOTHERS SIDE

FATHERS SIDE

HPN

HPN

OLD AGE

AST

M
HEART DISEASE HPN WELL WELL WELL AST

WELL

ALLERGY

WELL

DENGUE FEEVER

LEGENDS:

M
= Deceased female due to hypertension and old age =Living Female with hypertension

=Deceased male due to hypertension

=Living Male with allergy

==Living male with asthma

=Living female with asthma

=Deceased male due to heart disease

=Living male well

=Living female well

=Points to the patient

11
X. REVIEW OF SYSTEMS

A. SKIN: Texture rough and slightly dry B. EYES: Have the childs eyes ever been crossed-eyed? Any foreign body? Any infection? EARS / NOSE AND THROAT Frequent Colds Sore throat Sneezing Stuffy nose Discharges Post-natal drip Mouth breathing Snoring Otitis Media Hearing Problem TEETH: Age of eruption of deciduous teeth Age of eruption of permanent teeth CARDIORESPIRATORY: Dyspnea Chest pain Cough Sputum Wheeze Expectoration Cyanosis Edema Syncope Tachycardia GASTROINTESTINAL: Vomiting Diarrhea Constipation Abdominal pain / discomfort Jaundice Type of stool GENITIURINARY: Enuresis Dysuria Frequency Polyurea Pyuria Hematuria Vaginal discharges Abnormal penis / testes Character of stream (urine) Bladder control NEUROMUSCULAR: Headache Nervousness Dizziness Tingling sentation Convulsions Spasm Ataxia Muscle or joint pains Postural Deformities Exercise tolerance ENDOCRINE Disturbance of growth Excessive fluid intake Polyphagia Goiter GENERAL Unusual weight loss Fatigue Temperature sensitivity Color brown

C.

D.

E.

F.

G.

H.

I.

J.

I.

CHIEF COMPLAINTS ( History of Present Illness )

Mr. X, 8 years old, male, from Umapad Mandaue City, Cebu / Tigbawan, Tabuelan Cebu, Roman Catholic was admitted due to on and off fever and cough. 3 days prior to admission, patient had onset of fever and cough. With a temperature of (39.2c) and associated with non-productive cough,decreased appetite with the presence of skin rashes.

12

PEDIATRIC PHYSICAL EXAMINATION

Name of Patient: R. A. G.

Date of Birth: September 06, 2002

1.

VITAL SIGNS BP 120/80mmHg HR 131 bpm RR 20 cpm TEMP. 39.2c WT. 32.2 kg HT. 130 cm

2. GENERAL OBSERVATION Receive patient lying on bed, awake, conscious, coherent with time, place, person oriented; with PNSS 1L at 190 195 cc/hr. at left arm. Patient is warm to touch, with dry and cracked lips. Patient is pale, weak and chills noted. Patient has slightly rounded body with no tenderness and pain felt. Patient has decreased appetite, had onset of fever associated with dry ,nonproductive cough. With skin rashes noted. With birth rank 5/5.

2.

SKIN: Color: Texture : Turgor: Lesions: Normal Cyanotic Normal Dry Good Poor None Rashes Punctured wound Pale Icteric Oily Burns Scars Flushed Ashen

Abrasions Decubitus

Lacerations

4. HEAD / EARS / NECK / THROAT HEAD Circumference: . SHAPE: SCALP: Round Normal Ovoid Pustule .cm (up to 2 years and if significant ) Irregular Seborrhea

Scales

Lice

FONTANELS: Anterior: Posterior:

Close Close

Open Open

Flat Flat

Sunken Sunken

Bulging Bulging

13
5. EYES Eyelids Laceration Inflamed Mass Puffy Drooping Sclerae Normal Icteric Red Discharges R L Eyeballs Normal Sunken Bulging Pupils Reactive Unreactive Equal Unequal Vision Normal Blurred Contact Lens With correctional glasses R L

Comments:

6. EARS Pinna Normal Anomalies Symmetrical Tympanic Membrane Intact Perforated Discharge Mastoid Tenderness Swelling Comments: R L External Canal No Problem Discharge Pain Hearing Normal Deaf With hearing - aid R L

7. NOSE / NECK / THYROID Nares No problem Nasal flaring Discharge Epistaxis Turbinates Normal Inflamed / Congested R L

14
Neck a.Normal b.Toticollis c.Opistothonus d.Inability to support head Lymph Nodes a.Swelling b.Tender Sternocleidomastoid a.Swelling b.Shortening Thyroid a.Size b.Contour c.Bruits d.Nodules e.Tenderness f.Enlarged g.Not appreciated Comments:

8. MOUTH / THROAT Lips: Teeth: Temporary Complete No problem Discoloration Gums: Tongue: Mucosa: Normal Bleeding Tonsils: Smell: Voice: Hoarseness Type of cry Comments: Stridor Grunting Type of speech Normal Foul Not assessed Normal Inflamed Exudates Thrush Discharge Ulcers Pink Coated Furrows Strawberry red Normal Inflamed Number Permanent Incomplete Braces Notching No teeth Caries Mottling Malocclusion / malalignment Pink Thin Red Pale Downturning Cyanotic Fissures Dry Moist Cleft Swelling

15
9. RESPIRATORY THORAX Upper Airway: Normal

Stridor

Hoarseness

Drooping of Secretions

Chest / Upper Trunk: Normal Scars Expansion: Retractions: Lungs:

Kyphosis Abrasions Equal Absent

Scoliosis Rash Unequal Present

Mass

Normal Resonant Clear breath sounds Ronchi Normal for age Assymetrical

Tenderness Tympanic Rales Wheeze

Crepitations Dullness

Flatness

Breast: Symmetrical Lumps / masses

Comments:

10. CARDIOVASCULAR Apical impulse: Pulses: Heart Sound: Rate: Location 4th Strong Normal Regular Normal >2 Precordial Bulging Weak Murmurs Tachycardia Heaves Irregular

Regular Splitting Irregular Bradycardia

Capillary Refill time: Comments:

11. GASTROINTESTINAL Abdomen: Inspection: Percussion: Palpation: Tenderness: Bowel Sounds: Rectal Exam: Comments: Flat Scaphoid Distended Tympanitic Dull Fluid Wave Normal Splenomegaly Mass Hepatomegaly Liver edge Location Direct Normal Hyperactive Hypoactive Globular

16

12. GENITOURINARY Genitals: MALES: Circumcised: Tanner Staging: Yes No Tanner Score: Normal Normal Mass Discharges Tenderness (location) Anomaly

13. NEUROLOGIC A. Pediatric Glasgow Scale (Teasdale & bennel) Eye Opening Opens eyes spontaneously Opens eyes response to speech Opens eyes in response to painful stimuli Does not open eyes Verbal Response Smiles, Oriented to sound, follow odject, interacts Confused, consolable crying, inappropriate actions Inappropriate, persistently irritable, vocal sound, moaning Incomprehensible, restless, agitated, cries No verbal response Motor Response Obeys, infant moves spontaneously or purposefully Localizes pain, oriented, follow. Infant withdraws from touch Infant withdraws from pain, consolable crying, interact Abnormal flexion to pain in infants (decorticated response), inconsistently consolable Score 4 3 2 1 5 4 3 2 1 6 5 4 3

17
crying Extension to pain (decerebrate response), inconsolable, irritable, restless No motor response Aggregate Score (Normal) 0 6 months = 9 (E4 V2 M3)

2 1 6 - 12 months = 11 (E4 V3 M4) 5 years = 14 (E4 V5 M5)

1 2 years = 12 (E4 V4 M4)

2 5 years = 13 (E4 V4 M5)

15

B. MENTAL STATUS: Awake Stupurous Disoriented

Conscious Coma

Drowsy Oriented

C. CRANIAL NERVES: CN I (Olfactory) CN II (Optic) Intact Intact Anosmia Blindness Hyperosmia Scotoma Not Done Dislopia

CN III, IV, XI (Oculomotor, Trochlear, Abducens) PUPILS: Reactive Non-reactive EOM: Full ROM Palsy CN V (Trigeminal) Corneal Reflex CN VII (Facial) Trismus Present Paresthesia Absent Symmetric Intact Strong Normal Normal Present Able to Swallow Able Midline Midline

Equal Ptosis Intact Right Assymetric Absent Weak Deafness Disequilibrium Absent Not done

Non-equal

Left

Facial Symmetry: Tongue (sensory): Facial Muscle:

CN VIII (Vestibulo-cochlear) Hearing: Balance: CN IX, X (Glossopharyngeal) Gag reflex: CN XI (Spinal Accessory) Shrug shoulder: CN XII (Hypoglossal) Tongue at rest:

Not Able Deviated Deviated

Not done R R L L

18

D. CEREBELLAR: FTNT: APST: Well-coordinated Well-coordinated Ataxia Rombergs: Positive Not coordinated Not coordinated Nystagmus Negative Not done Not done Not done

E. SENSORY: Light touch Pain Temperature Intact Intact Intact Absent Absent Absent Not done Not done Not done

F.

MOTOR R 5 5 5 5 5 5 L 5 5 5 5 5 5 Manual Scoring 5 Normal 4 Can raise against slight resistance 3 Can raise against gravity 2 Gross movements but not against gravity 1 Flicker of movements 0 No movements

Upper Extremity Proximal Distal Lower Extremity Proximal Distal

14. REFLEXES Deep Tendon Reflexes +4 Very brisk, hyperactive +3 Brisker than average +2 Average; normal +1 Somewhat diminished 0 No response

< (+) Babinski > (+)Babinski

19

Meningeal Signs: Primitive Reflex:

None NA

Nuchal

Rigidity

Kernigs

Brudzinkis

Present Moro Rooting Sucking Grasp

Absent Tonic Neck Babinski Ankle Clonus

Present

Absent

15. MUSCULOSKELETAL Normal Fractures Deformities Tenderness Swelling

Comments:

20

IV. ANATOMY AND PHYSIOLOGY

BLOOD Blood is considered the essence of life because the uncontrolled loss of it can result to death. Blood is a type of connective tissue, consisting of cells and cell fragments surrounded by a liquid matrix which circulates through the heart and blood vessels. The cells and cell fragments are formed elements and the liquid is plasma. Blood makes about 8% of total weight of the body. Functions of Blood: >transports gases, nutrients, waste products, and hormones >involve in regulation of homeostasis and the maintenance of PH, body temperature, fluid balance, and electrolyte levels >protects against diseases and blood loss

21

PLASMA Plasma is a pale yellow fluid that accounts for over half of the total blood volume. It consists of 92% water and 8% suspended or dissolved substances such as proteins, ions, nutrients, gases, waste products, and regulatory substances. Plasma volume remains relatively constant. Normally, water intake through the GIT closely matches water loss through the kidneys, lungs, GIT and skin. The suspended and dissolved substances come from the liver, kidneys, intestines, endocrine glands, and immune tissues as spleen.

BLOOD COMPONENTS

SUBSTANCE IN BLOOD PLASMA Constituent Description Water (91.5%) Liquid portion of blood. Acts as solvent and suspending medium for components of blood; absorbs, transports and releases heat. Proteins (7.0%) Exert colloid osmotic pressure, which helps maintain water balance between blood and tissues and regulates blood volume. Albumins Smallest and most numerous plasma proteins; produced by liver. Function as transport proteins for several steroid hormones and for fatty acids. Globulins Produced by liver and by plasma cells, which develop from B lymphocytes. Antibodies help attack viruses and bacteria. Alpha and beta globulins transport iron, lipids and fat-soluble vitamins. Fibrinogen Produced by liver. Play essential role in blood clotting.

22

FORMED ELEMENTS IN BLOOD Name Number RBC 4.6 6.2 million/L (M) 4.2 5.4 million/L (F) WBC 4,500 cells/L

Characteristics 7-8m diameter; biconcave disks, without a nucleus; live for about 120 days 11,000 Most live for a few hours to a few days

Neutrophils

Eosinophils

Basophils

Lymphocytes

43% - 73% of all 10 12m WBCs diameter; nucleus has 2-5 lobes connected by thin strands of chromatin; cytoplasm has fine, pale lilac granules 0% - 4% of all 10 12m WBCs diameter; nucleus has 2-3 lobes; large red-orange granules fill the cytoplasm 0% - 1% of all 8 10m WBCs diameter; nucleus has 2 lobs; large cytoplasmic granules appear deep blue-purple 20% - 40% of all Small lymphocytes WBCs are 6 9m in diameter; large lymphocytes are 10 14m in diameter; nucleus is round or slightly indented; cytoplasm form a rim around the nucleus that looks sky blue; the larger the cell, the more cytoplasm is visible

Function Hemoglobin within RBCs transports most of the oxygen and part of the carbon dioxide in the blood. Combat pathogens and other substances that enter the body. Phagocytosis. Destruction of bacteria with lysozyme, defensis, and strong oxidants, such as superoxide anion, hydrogen chloride, and hypochlorite anion Combat the effects of histamine in allergic reactions, phagocytize antigen-antibody complexes, and destroy certain parasitic worms. Liberate heparin, histamine and serotonin in allergic reactions that intensify the overall inflammatory response. Mediate immune responses, including antigen-antibody reactions. B cells develop into plasma cells, which secrete antibodies. T cells attach invading viruses, cancer cells and transplanted tissue cells. Natural killer cells attack a wide variety of infectious microbes and certain spontaneously arising tumor cells.

23

Monocytes

platelets

2% - 8% of all 12 20m WBCs diameter; nucleus is kidneyshaped or horseshoe shaped; cytoplasm is bluegray and has foamy appearance 150,000 450,000 2 4m diameter cells/L cell fragments that live for 7 10 days; contain many vesicles but no nucleus

Phagocytosis (after transforming into fixed or wandering macrophages).

Form platelet plug in hemostasis; releases chemicals that promote vascular spasm and blood clotting.

PREVENTING BLOOD LOSS When a blood vessel is damaged, blood can leak into other tissues and interfere with the normal tissue function or blood can be lost from the body. Small amounts of blood from the body can be tolerated but new blood must be produced to replace the loss blood. If large amounts of blood are lost, death can occur.

BLOOD CLOTTING Platelet plugs alone are not sufficient to close large tears or cults in blood vessels. When a blood vessel is severely damaged, blood clotting or coagulation results in the formation of a clot. A clot is a network of threadlike protein fibers called fibrin, which traps blood cells, platelets and fluids. The formation of a blood clot depends on a number of proteins found within plasma called clotting factors. Normally the clotting factors are inactive and do not cause clotting. Following injury however, the clotting factors are activated to produce a clot. This is a complex process involving chemical reactions, but it can be summarized in 3 main stages; the chemical reactions can be stated in two ways: just as with platelets, the contact of inactive clotting factors with exposed connective tissue can result in their activation. Chemicals released from injured tissues can also cause activation of clotting factors. After the initial clotting factors are activated, they in turn activate other clotting factors. A series of reactions results in which each clotting factor activates the next clotting factor in the series until the clotting factor prothrombin activator is formed. Prothrombin activator acts on an inactive clotting factor called prothrombin. Prothrombin is converted to its active form called thrombin. Thrombin converts the inactive clotting factor fibrinogen into its active form, fibrin. The fibrin threads form a network which traps blood cells and platelets and forms the clots.

24

CONTROL OF CLOT FORMATION Without control, clotting would spread from the point of its initiation throughout the entire circulatory system. To prevent unwanted clotting, the blood contains several anticoagulants which prevent clotting factors from forming clots. Normally there are enough anticoagulants in the blood to prevent clot formation. At the injury site, however, the stimulation for activating clotting factors is very strong. So many clotting factors are activated that the anticoagulants no longer can prevent a clot from forming.

CLOT RETRACTION AND DISSOLUTION After a clot has formed, it begins to condense into a denser compact structure by a process known as clot retraction. Serum, which is plasma without its clotting factors, is squeezed out of the clot during clot retraction. Consolidation of the clot pulls the edges of the damaged vessels together, helping the stop of the flow of blood, reducing the probability of infection and enhancing healing. The damaged vessel is repaired by the movement of fibroblasts into damaged wound divide and fill in the torn area. The clot is dissolved by a process called fibrinolysis. An inactive plasma protein called plasminogen is converted to its active form, which is called plasmin. Thrombin and other clotting factors activated during clot formation, or tissue plasminogen activator released from surrounding tissues, stimulate the conversion of plasminogen to plasmin. Over a period of a few days the plasmin slowly breaks down the fibrin.

25

V. CONCEPTUAL FRAMEWORK OF DENGUE FEVER

PATHOPHYSIOLOGY

Reservoir Mosquito (Aeges Aegypti) Mosquito remains affected for 15-65 days First, bite host (developed pre-existing antibody) Extrinsic incubation viral replication of 8-12 days Some host bitten by new heterologous vector which has the virus (risk for DHF) Recognizes infection and forms antigen-antibody complex Bound and internalized by immuno-globulin receptors Virus has not been neutralized Viruses replicates inside the macrophages Develops infection (Antibody dependent viscosity of blood Enhancement) platelet rash Leukocytes and macrophages

26

Fever (5-7 days) Chills Facial flushing Headache Nausea and vomiting vascular permeability Bleeding Alteration of GI motility Hypovolemia Melena occur Shock (DengueShockSyndrome) Lead to Hepatomegaly DEATH

27

VI. THEORETICAL FRAMEWORK OF THE PATHOPHYSIOLOGY OF DENGUE FEVER

Dengue viruses are transmitted to humans through the infective bites of female Aedes mosquito. Mosquitoes generally acquire virus while feeding on the blood of an infected person. After virus incubation of 8-10 days, an infected mosquito is capable, during probing and blood feeding of transmitting the virus to susceptible individuals for the rest of its life. Infected female mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs) transmission. Humans are the main amplifying host of the virus. The virus circulates in the blood of infected humans for two to seven days, at approximately the same time as they have fever. Aedes mosquito may have acquired the virus when they fed on an individual during this period. Dengue cannot be transmitted through person to person mode.

CLASSIFICATION: 1. Severe, frank type >flushing, sudden high fever, severe hemorrhage, followed by sudden drop of temperature, shock and terminating in recovery or death 2. Moderate >with high fever but less hemorrhage, no shock present 3. Mild >with slight fever, with or without petichial hemorrhage but epidemiologically related to typical cases usually discovered in the course of invest or typical cases

GRADING THE SEVERITY OF DENGUE FEVER:

Grade 1: >fever >non-specific constitutional symptoms such as anorexia, vomiting and abdominal pain >absence of spontaneous bleeding >positive tourniquet test

Grade 2: >signs and symptoms of Grade 1: plus >presence of spontaneous bleeding: mucocutaneous, gastrointestinal

28

Grade 3: >signs and symptoms of Grade 2 with more severe bleeding: plus >evidence of circulatory failure: cold, clammy skin, irritability, weak to compressible pulses, narrowing of pulse pressure to 20 mmhg or less, cold extremities, mental confusion

Grade 4: >signs and symptoms of Grade 3, declared shock, massive bleeding, pulse less and arterial blood Pressure = 1 mmhg (Dengue Syndrome/DS)

SUSCEPTABILITY, RESISTANCE, AND OCCURRENCE: >all persons are susceptible >both sexes are equally affected >age groups predominantly affected are the pre-school age and school age >adults and infants are not exempted >peak age affected: 5-9 years old

29

VII. CLINICAL MANAGEMENT A. MEDICAL MANAGEMENT

A.1 LABORATORY AND DIAGNOSTIC EXAMINATION

URINALYSIS REPORT

Date and Time Requested: August 23,2011 06:30:09 Date and Time Performed: August 23, 2011 06:35:49

Fully Automated Routine Urinalysis Uncentrifuged Specimen

Physical Characteristics Color Transparency pH Specific Gravity

Results Yellow Clear 6.0 1.015

Reference Range 56 1.003 1.035 -

Unit

Chemical Characteristics Protein Glucose Ketone Urobilinogen Leukocytes Blood Bilirubin Nitrite Ascorbic Acid

Result negative negative negative normal negative 0.03 negative negative negative

Reference Range negative negative negative up to 2 negative negative negative negative *

Unit mg/dL mg/dL mg/dL mg/dL wbc/L mg/dL mg/dL mg/dL

30

Microscopic Findings RBC WBC Bacteria IMPLICATION:

Results 3 1 1

Reference Range 1-16 1-8 *

Unit /L /L /L

The urinalysis result was specific gravity of urine.

normal. No marked decrease or increase in the

HEMATOLOGY

Date and Time Requested: August 23, 2011 07:40:03 Date and Time Performed: August 23, 2011 07:50:09

Complete Blood Count WBC RBC Hemoglobin Hematocrit Platelet

Results 5.60 5.47 14.4 43.2 110

Reference Range 4.8-10.8 4.57-6.1 14.0-18.0 42.0-52.0 130-400

Unit 10^3/L 10^3L g/dL 10^3/L 10^/ L

Blood Indices MCV MCH MCHC RDW PDW MPV

Results 79.0 26.3 33.3 12.2 16.8 8.8

Reference Range 80-94 27.0-31.0 33.0-37.0 11-16 9.0-14.0 7.2-11.1

Unit Fl Pg g/dL % % fL

31

Relative Differential Count Neutrophil% Lymphocyte % Monocyte % Eosinophil% Basophil% Absolute Differential Count Neutrophils (#) Lymphocytes (#) Monocyte (#) Eosinophils (#) Basophils (#) IMPLICATIONS:

Results 80.0 10.1 5.5 3.6 0.7 Results 4.47 0.56 0.31 0.20 0.04

Reference Range 40-74 19-48 3.4-9.0 0.0-7.0 0.0-1.5 Reference Range 1.9-8.0 0.9-5.2 0.16-1.00 0.0-0.8 0.0-0.2 % % % % %

Unit

Unit 10^3/L 10^3/L 10^3/L 10^3/L 10^3/L

There was a decrease in platelet because the virus creates antibodies that will kill the own antibodies of the body that will fight for foreign bodies leading to bleeding.

SEROLOGY TEST

Date and Time Requested: August 24, 2011 08:45:29 Date and Time Performed: August 24, 2011 08:55:10

Dengue NS1 Antigen NS1 Antigen Ig M Antibody Ig G Antibody IMPLICATION:

Results positive negative negative

There was a positive NS1 indicating that the patient is confirm that he has a Dengue Fever.

32

A.2 TREATMENT AND PROCEDURES Patient underwent Tepid Sponge Bath to reduce the body temperature in to normal range. Vital Signs are being monitored every hour to check for any deviations or unusualities. Patients urine output was also monitored hourly and collected thru a container for she cannot go to the comfort room by himself. CBC - also known as full blood count (FBC) or full blood exam (FBE) or blood panel, is a test panel requested by a doctor or other medical professional that gives information about the cells in a patient's blood. URINALYSIS - is an array of tests performed on urine and one of the most common methods of medical diagnosis. SEROLOGY TEST (Dengue NS1 Antigen) - NS1 antigen test , full name is Platelia Dengue NS1 Ag assay, is a test for dengue made by Bio-Rad Laboratories and Pasteur Institute, introduced in 2006. It allows rapid detection on the first day of fever, before antibodies appear some 5 or more days later.

A.3 MEDICATIONS (Refer to APPENDIX D)

A.4 DIET o The food you should give to a dengue patient should be such that it can be easily digested. Some useful pointers to keep in mind when preparing a meal for someone suffering from dengue are: Give the patient fresh orange juice frequently. Orange juice is packed with energy and vitamins. It helps in digestion, increases urinary output, and promotes antibodies for faster recover. Take two fresh papaya leaves, crush them and squeeze them to extract the juice. The patient should have about two tablespoons of this juice every day. This is a very good home remedy for the treatment of dengue fever. Give porridge and baked toasts. Biscuits with tea can also be given. The tea should be herbal made with ginger, cardamom, and other such fever-reducing herbs. Avoid choco colored foods like: chocolates or any dark colored foods. Because these foods can alter the color of the stools and can lead to a misinterpretation of internal bleeding.Increased fluid intake.

33

B. NURSING MANAGEMENT

B.1 NURSING CARE PLAN (Refer to APPENDIX B)

B.2 DISCHARGE PLAN (Refer to APPENDIX C)

XII. CONCLUSIONS AND RECOMMENDATIONS

A. CONCLUSION After obtaining all the data from the patient, book references, and other resources, I have ascertained that this disease is increasing the incidence within the country, dengue fever can be a source of significant morbidity and mortality if not recognized early. Most forms respond appropriately to medical therapy. Such definite differentiation is especially important in countries with adequate sanitation measures, where the predominant organism identified from morphologic blood examination will be Aedes Aegypti. I also conclude that every individual is highly susceptible to this disease if and when they will not take such precautionary measures (e.g. left stagnant water outside the house were the Aedes can live ). Our body will not develop immunity even the person already experienced the diseased because there are different types of dengue. The only thing we have to do is to clean the environment, make sure that the environment is free from stagnant waters were the mosquito lives which will not lead it to complication.

34

B. RECOMMENDATIONS It is common knowledge that only a few of these information about optimal care have reached all throughout the country, mainly because we have only a few health workers available who are willing and able to do that mission of spreading the necessary information. That information would not even reach the outskirts of the different communities, especially those non-affiliated ones. I recommend to the student nurse as one of the heralds of health facts and data to disseminate to individuals about the importance of always practicing a healthy life with regards to the food that we eat and the source of water that we drink. With respect to myself recommendation, I would make every effort to continue this pursuit in order to broaden my knowledge base, and to be an efficient nurse in the future to be able to muddle through with the ever mounting role of the nurse.

X. IMPLICATIONS OF THE STUDY TO:

A. NURSING EDUCATION Development of nursing profession is an essential goal of nursing education, and to engage in this kind of study is one way of reaching for that objective. It will help develop an in-depth knowledge on a particular case, and a broad and sound knowledge base that will contribute to the competency of a nurse. This study accentuates the worth and meaning of the hypothesis in giving best possible care. This only shows that nurses are not just doctors collaborators but also bearers of vital information, educators and epitome of classic example individuals. Nursing education is not only confined and restricted within the four walls of the classroom but goes beyond, whether it is in hospitals, a community and like settings, accompanied by research and consistent readings

35

B. NURSING PRACTICE Nurses need to have good objective skills, they need to be purposeful, reflective and questioning and within this mind, evidence based nursing should always maintain a balance between research on a clinical subject and information that has been gained from the patient. Knowledge that is gained through practice is shared to inspire and sustain needed changes. It is when you know that this study is geared towards the optimal care for clients who have this particular case. Doing a case study contributed much to nursing education as it widens our knowledge base and apply them to appropriate situations, which is turn contributed to our efficacy.

C. NURSING RESEARCH Research is very imperative for all those health workers involved in rendering optimum care to patients. It will not only be beneficial for the patients but also for the health care workers as well as so far as scientific based care is concerned, because employment of most selected, precise, and proven care is a requisite without any exceptions. Moreover, the trends in nursing are ever changing constantly, and one of the ways of keeping track to these necessary information is to read persistently and do research. This study serves as a reference guide as it provides well-searched, constructive data on the provision of care for individuals who have Dengue Fever. With this endeavor, students and patients may acquire sufficient insight on taking care of themselves to the optimum level.

36

NURSING CARE PLAN

PATIENT : R. A. G. AGE : 8 years old IMPRESSION : On and Off Fever and Cough DIAGNOSIS : Dengue Fever CLINICAL PORTRAIT I. ASSSESSMENT Receive patient lying on bed, awake, conscious, coherent with time, place, person oriented; with PNSS 1L at 190 195 cc/hr. at left arm. Patient is warm to touch, with dry and cracked lips. Patient is pale, weak and chills noted. Patient has slightly rounded body with no tenderness and pain felt. Patient has decreased appetite, had onset of fever associated with dry ,nonproductive cough. With skin rashes noted. With birth rank 5/5.

HOSP. NO. : 080022480504 ROOM NO. : GP4 PHYSICIAN : Dr. De La Calzada NURSES SIGNATURE: PERTINENT DATA I. HISTORY OF PRESENT ILLNESS Mr. R. A. G. ,8 years old, male, from Umapad Madue City, Cebu / Tigbawan, Tabuelan Cebu, Roamn Catholic was admitted due to fever (on and off fever ), cough. 3 days PTA, patient had onset of on and off fever and cough. With a temperature of ( 39.2c ) and associated with dry non productive cough, decreased appetite with the presence of skin rashes.

II. Upon Physical Assessment, Patients VITAL SIGNS were as follows: Temperature : 38.3c Pulse Rate : 64 bpm Respiratory Rate: 44 cpm Blood Pressure : 120/80 mmHg

II. CHIEF COMPLAINT On and off fever and cough.

37

III. RAW PROBLEM III. PAST MEDICAL HISTORY a. Hyperthermia b. Risk for bleeding c. Ineffective airway clearance d. Risk for fluid volume imbalance e. Risk for fall Patient had previous hospitalization at Vicente Sotto at year 2003 due to pneumonia and at year 2005 admitted at Chong Hua Hospital to Urinary Tract Infection and was discharged and improved.

IV. VITAL SIGNS TAKING UPON ADMISSSION Temperature : 39.2c Pulse Rate : 131 bpm Respiratory Rate: 20 cpm Blood Pressure : 120/60 mmHg

V. LABORATORY FINDINGS

URINALYSIS REPORT

Date and Time Requested: August 23,2011 06:30:09 Date and Time Performed: August 23, 2011 06:35:49

38

Fully Automated Routine Urinalysis Uncentrifuged Specimen

Physical Characteristics Color Transparency pH Specific Gravity Chemical Characteristics Protein Glucose Ketone Urobilinogen Leukocytes Blood Bilirubin Nitrite Ascorbic Acid

Results Yellow Clear 6.0 1.015

Reference Range 56 1.003 1.035 -

Unit

Result negative negative negative normal negative 0.03 negative negative negative

Reference Range Negative Negative Negative up to 2 Negative Negative Negative Negative *

Unit mg/dL mg/dL mg/dL mg/dL wbc/L mg/dL mg/dL mg/dL

Microscopic Results Reference Unit Findings Range RBC 3 1-16 /L WBC 1 1-8 /L Bacteria 1 * /L IMPLICATION: The urinalysis result was normal. No marked decrease or increase in the specific gravity of urine.

39

HEMATOLOGY

Date and Time Requested: August 23, 2011 07:40:03 Date and Time Performed: August 23, 2011 07:50:09

Complete Blood Count WBC RBC Hemoglobin Hematocrit Platelet Blood Indices MCV MCH MCHC RDW PDW MPV Relative Differential Count Neutrophil% Lymphocyte % Monocyte % Eosinophil% Basophil%

Results 5.60 5.47 14.4 43.2 415 Results 79.0 26.3 33.3 12.2 16.8 8.8 Results 80.0 10.1 5.5 3.6 0.7

Reference Range 4.8-10.8 4.57-6.1 14.0-18.0 42.0-52.0 130-400 Reference Range 80-94 27.0-31.0 33.0-37.0 11-16 9.0-14.0 7.2-11.1 Reference Range 40-74 19-48 3.4-9.0 0.0-7.0 0.0-1.5

Unit 10^3/L 10^3L g/dL 10^3/L 10^/ L Unit Fl Pg g/dL % % fL Unit

% % % % %

40

Absolute Differential Count Neutrophils (#) Lymphocytes (#) Monocyte (#) Eosinophils (#) Basophils (#) IMPLICATION: There was

Results

Reference Range 1.9-8.0 0.9-5.2 0.16-1.00 0.0-0.8 0.0-0.2

Unit

4.47 0.56 0.31 0.20 0.04

10^3/L 10^3/L 10^3/L 10^3/L 10^3/L

a increase in platelet because the virus creates antibodies that will kill the own antibodies of the body that will fight for foreign bodies leading to bleeding.

SEROLOGY TEST

Date and Time Requested: August 24, 2011 08:45:29 Date and Time Performed: August 24, 2011 08:55:10

Dengue NS1 Antigen Results NS1 Antigen Positive Ig M Antibody Negative Ig G Antibody Negative IMPLICATION: There was a positive NS1 indicating that the patient is confirm that he has a Dengue Fever.

41

CUES/ EVIDENCES

NURSING DIAGNOSIS

SCIENTIFIC BASIS

GOALS AND OUTCOME CRITERIA

NURSING ACTIONS AND NURSING ORDERS Perform nursing care and procedures to demonstrate temperature within normal range. INDEPENDENT: Perform tepid Sponge Bath to the patient. Maintain bed rest.

RATIONALE OF NURSING ORDERS

EVALUATION

SUBJECTIVE: Naghilanat na pud lagi ni siya dai oi. Nawala naman unta ni unya ni balik naman pud. Ganina 37c ra ta karon ni 38c na. Ana man ang Doctor dai pagpermiro na basin dili dengue ky iya permirong platelet 130 man daw mao g.obserbahan lang usa siya, niya pag.untro niyang kuha sa dugo para test if dengue ba daw siya kay ni positive man.Mao ni karon sige pa taas iya hilanat. As verbalized by the mother of the patient.

Hyperthermia related to infection secondary to dengue fever

Elevated body temperature (hyperthermia) is common with infection and raised the patients metabolic rate and oxygen consumption. Fever is one of the Bodys normal mechanism for fighting infection. Therefore, elevated tempareatures may not be treated unless they reach dangerous levels (more than 40c [140f] or unless the patient is uncomfortable. ( Brunner and

After 8 hours of varied nursing intervention, patient will be able to: 1. Maintain core temperature within normal range 2. Demonstrate behavior to monitor and promote normothermia.

GOAL WAS MET: Patients temperature decreases from 38.3c to 37.8c To promote normothermia or to promote core cooling. To reduce metabolic demands / oxygen consumption. To prevent dehydration.

Specifically patient will: a. Initiates ways to promote normothermia. b. Demonstrate ways or appropriate intervention that

Instruct the significant others to increase fluid intake of the patient. Monitor use of hypothermia blanket and wrap the extremities

To allow minimize shivering.

42

Na.a pa jud siya ubo karon dai as verbalized by the mother

Suddarths MS, 10th ed. 2010 p. 331)

OBJECTIVE: Weakness noted. Dry and cracked lips Warm to touch. Pallor noted Headache is present/felt Chills noted Skin rashes noted

will decreased temperature. c. Establish motivation or behavior that will promote normal body temperature.

with bath towels. Monitor temperature of the patient. To know if the patient temperature is increasing or decreasing.

DEPENDENT: Administer paracetamol as ordered by the physician. Paracetamol will decrease the temperature from high to low. To provide appropriate care and needed for the patient. To maintain electrolyte and fluid balance of the body.

Monitor patients status or vital signs following the order of the physician. To follow an intravenous fluid as ordered by the doctor.

43

VITAL SIGNS: Temp.: 38.3c PR : 64 bpm RR : 44 cpm BP : 120/80 mmHg

COLLABORATIVE: Provide highcalorie diet, tube feeding or parenteral nutrition. Administer antipyretics with physicians ordered. To meet increase metabolic demands. Used to reduce temperature.

(NCP guidelines, Doenges,7th edition,2006)

44

CUES/ EVIDENCES

NURSING DIAGNOSIS

SCIENTIFIC BASIS

GOALS AND OUTCOME CRITERIA

NURSING ACTIONS AND NURSING ORDERS Perform nursing care and procedures to demonstrate behaviors that reduce the risk for bleeding.

RATIONALE OF NURSING ORDERS

EVALUATION

Injury, risk for hemorrhage related to altered clotting factor.

This infectious disease is manifested by a sudden onset of fever, with severe headache, muscle and joint pains (myalgias and arthralgias severe pain gives it the name breakbone fever or bonecrusher disease) and rashes and usually appears first on the lower limbs and the chest. There may also be gastritis and some times bleeding.

After 8 hours of varied nursing intervention, patient will be able to:

1.Demonstrate behaviors that reduce the risk for bleeding. 2.Understand what are the possible sign and symptoms of bleeding.

INDEPENDENT: Assess for signs and symptoms of G.I bleeding. Check for secretions. Observe color and consistency of stools or vomitus. Observe for presence of petechiae, ecchymosis, bleeding from one more sites. The G.I tract (esophagus and rectum) is the most usual source of bleeding of its mucosal fragility. Sub-acute disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors.

GOAL WAS MET: The client was able to demonstrate behaviors that reduce the risk for bleeding.

Specifically patient will:

a.Verbalize the sign and symptoms of bleeding.

45

( Brunner and Suddarths MS, 10th ed. 2010 ) b. Demonstrate ways or appropriate techniques in stopping the bleeding. c. Establish motivation or behavior that will prevent the bleeding.

Monitor pulse, Blood pressure.

An increase in pulse with decreased Blood pressure can indicate loss of circulating blood volume. Changes may indicate cerebral perfusion secondary to hypovolemia, hypoxemia. Rectal and esophageal vessels are most vulnerable to rupture.

Note changes in mentation and level of consciousness

Avoid rectal temperature, be gentle with GI tube insertions.

DEPENDENT: Encourage use of soft toothbrush, avoiding straining for stool, and forceful nose blowing. In the presence of clotting factor disturbances, minimal trauma can cause mucosal bleeding.

46

Use small needles for injections. Apply pressure to venipuncture sites for longer than usual. Recommend avoidance of aspirin containing products.

Minimizes damage to tissues, reducing risk for bleeding and hematoma.

Prolongs coagulation, potentiating risk of hemorrhage.

COLLABORATIVE: Monitor Hb and Hct and clotting factors. Indicators of anemia, active bleeding, or impending complications. (Brunner and Suddarths, MSN,12th ed.)

47

CUES/ EVIDENCES

NURSING DIAGNOSIS

SCIENTIFIC BASIS

GOALS AND OUTCOME CRITERIA

NURSING ACTIONS AND NURSING ORDERS Perform nursing care and procedures to achieve the clear airways in breathing..

RATIONALE OF NURSING ORDERS

EVALUATION

Ineffective airway clearance related to increase production of bronchial secretions secondary to fluid shifthing.

Nasal mucus is produced by the nasal mucosa, and mucal tissues lining the airways (trachea, bronchus, bronchioles) is produced by specialized airway epithelial cells (goblet cells) and submucosal glands. Small particles such as dust, particulate pollutants, and allergens, as well as infectious agents such as

After 8 hours of varied nursing intervention, patient will be able to: 1. Achieve and improve the airway clearance. 2. Demonstrate the intervention that reduces the secretions.

GOAL WAS MET: At the end of the shift the client was able to breathe properly without using his accessory muscles. Demonstrate effective exercise when coughing and lungs are clear during auscultation.

INDEPENDENT: Assess the respiratory rate. Provides a basis for evaluating adequate ventilation. Used of accessory muscles of respiration, may occur in response to ineffective ventilation. Crackles indicate accumulation of secretions

Specifically patient will: a. Sustain respiratory rate within norm al range. b. Display decreasing amount of secretions.

Note chest movement; used of accessory muscles during respiration.

Auscultate breath sounds; noted areas with presence of

48

bacteria are caught in the viscous nasal or airway mucus and prevented from entering the system. This event along with the continual movement of the respiratory mucus layer toward the oropharynx, helps prevent foreign objects from entering the lungs during breathing. Increased mucus production in the respiratory tract is a symptom of many common illnesses, such as the common

adventitious sounds. c. Initiate ways that will clear the patency of breathing.

and inability to clear the airway. Expectorations may be different when secretions are very thick.

Documented respiratory secretions: character and amount of sputum.

Maintained patient on moderate high back rest

Positioning helps maximize lung expansion.

DEPENDENT: Administer medications as indicated: bronchodilators To stimulate the sections that helps the patients breath properly.

Suction as per physicians order.

To reduce hazards of hypoxia, damaged of airway mucusa,

49

cold and influenza. Hypersecretion of mucus can occur in inflammatory respiratory diseases such as respiratory allergies, asthma, and chronic bronchitis.The presence of mucus in the nose and throat is normal, but increased quantities can impede comfortable breathing and must be cleared by blowing the nose or expectorating phlegm from the throat.

and impaired cilia action.

COLLABORATIVE: .Administer nebulizer to the patient done by the respiratory therapist. Some institution the nurses collaborate with the respiratory therapist in giving nebulizres to the patient.

50

DISCHARGE PLAN

Patients Name: R. A. G. Age: 8 years old Impression/Diagnosis: Dengue Fever Nurses Name & Signature:

Hospital No.: 080022480504 Room No.: GP4 Physician: Dr. De La Calzada

PATIENTS OUTCOME CRITERIA

As soon as the patient is discharged from the hospital. He and her significant others will be able to:

NURSING ORDER

A. ASSESSMENT Assess for the temperature of the patient.

Advice the significant other to monitor the temperature and if it will reach >40c refer to the physician.

B. PLANNING Plan for scheduled visits as ordered by the physician.

Encourage the patient to follow the schedule ordered by the physician for the next visit. Make a plan of schedule when the patient and the physician is available. Advice the significant others to remind the patient for the set schedule for visiting the clinic.

C. IMPLEMENTATION

MEDICATION Comply the medication completely and the timing of the medication. Take vitamin supplements as ordered by the physician.

Instruct the patient, significant others on when, how, what to take the medications. Inform the patient, significant others about the side effects, adverse effects of the medication.

51 Explain to the patient the significant of the medication and its purpose. Instruct the mother about the vitamins correct dosage and it should be given once daily.

EXERCISES / ENVIRONMENT Provide the patient room that is not to cold or to warm for the patient.

Advice the significant others to turn off the air condition if there room is air conditioned.

TREATMENT Administration of medication should follow the proper schedule and should be prescribed by the physician.

Advice the significant others to always be reminded of the medication and the dose. Never miss a dose.

HEALTH TEACHINGS Encourage the patient to practice proper hygiene and handwashing. Encourage the patient to have adequate rest and sleep. Encourage the patient to increase electrolyte and fluid intake.

Demonstrate to the patient techniques on handwashing.

the

proper

Advice the patient and the significant others to rest and sleep uninterrupted of sufficient duration. Instruct the patient to increase fluid intake.

OUT PATIENT REFERRALS Refer also to other facilities and physicians.

Advice the significant others to follow the referrals for the continuity of care. Inform the significant others of the signs and symptoms of the disease persist return immediately to the Physician.

DIET Plan for a good meal of a lactating women.

Instruct the significant others to prepare high calorie foods for the patient, such as cereals, pasta, whole wheat bread, peanut butter, chocolate nuts spread.

52

SPIRITUAL Have a positive outlook in life.

Encourage the patient to seek for spiritual guidance. Encourage to be motivated.

D. EVALUATION Understand the treatment and regimen as well as planned actions.

Encourage the patient and the significant others to ask questions that they do not know or understand. Explain again to the patient the different plans and interventions, if not clearly understood.

53

UNIVERSITY OF CEBU COLLEGE OF NURSING DRUG STUDY Patient: R. A. G. Impression/Diagnosis: Dengue Fever Allergy to: Sea foods Generic/Brand Name & Classification Generic: Paracetamol Dose, Strength & Formulation Age: 8 years old Hospital No.: 080022480504 Room No.: GP4 Attending Physician(s): Dr. De La Calzada

Indication/Mecha nism of Drug Action Indications: Temporary relief of pain and discomfort of headache, fever, cold or flu

Adverse/Side Effects Drug Interaction Acute poisoning, Anorexia, nausea and vomiting, dizziness, lethargy. Diaphoresis, chills, epigastric or abdominal pain, diarrhea, onset of hepatotoxicity

Nursing Responsibilities Before Perform a baseline assessment.

Rationale

Client Teaching Monitor for I/O and vital signs on the patient Report promptly for any side effects Avoid form overdose Do not give with pain more than 3days.

Ordered: 500mg/tab 1 tab every 4hours fro temp.>38C

Brand: Timing: Tylenol PRN Classification: Analgesic nonopoid and antipyretics Duration: Peak Levels: 2hours Onset: 30 mins.1hour Duration: 4hours

To monitor the condition of the patient. (Jones & Bartlett 10th ed.,p.621) To establish proper precautionary measures. (Jones & Bartlett 10th ed.,p.621

Mechanism of Action: Produces analgesia by unknown mechanism, perhaps by action on peripheral

Assess if patients has any drug allergies.

54

Other forms: Tablets Syrup

nervous system. Reduce fever by direct action on hypothalamus, heat- regulating center with consequent peripheral vasodilation, sweating and dissipation of heat unlike aspirin, acetaminophen has little effect of platelet aggregation does not affect bleeding time and generally produces no gastric bleeding.

During Do not overdose the medication Monitor for any side effects Monitor for any signs of liver dysfunction Monitor for the urine output

For it can cause liver damage To know for any signs of hypersensitivity To monitor for hepatotoxicity and to monitor for renal failure

After

Assess regularly patient for signs of increasing temperature

To prevent complications and to provide appropriate intervention. (Jones & Bartlett 10th ed.,p.621)

55

UNIVERSITY OF CEBU COLLEGE OF NURSING DRUG STUDY Patient: R. A. G. Impression/Diagnosis: Dengue Fever Allergy to: Sea foods Generic/Brand Name & Classification Generic: Salbutamol Guaifenesin Dose, Strength & Formulation Age: 8 years old Hospital No.: 080022480504 Room No.: GP4 Attending Physician(s): Dr. De La Calzada

Indication/Mecha nism of Drug Action Indications: I.V. Short-term (up to 7 days) treatment of all grades of erosive esophagitis. Then, switch to PO lansoprazole formulations.

Adverse/Side Effects Drug Interaction Adverse Reactions: Most Common: Diarrhea, headache, N&V, constipation, rash GI: Constipation, N&V diarrhea, abdominal pain, bezoar, dry mouth CNS: Headache, dizziness, malaise, agitation, amnesia ,anxiety,

Nursing Responsibilities Before Check the V/S of the patient

Rationale

Client Teaching

Ordered: Give 5 mg by P.O Timing:

Brand: Ventolin

3x a day / T.I.D

Duration: Classification Expectorant Other forms: Granules: Drug is gastric acid pump inhibitor in that it blocks the final 7 days Mechanism of Action:

During Be alert for adverse

Take only as directed and To examine do not exceed the prescribed characteristics dose. Take of the sputum, tablets with in relation to full glass of the medication water. given. (Jones and If symptoms Bartlett 10th persist more Ed) than 1 week, recur or are accompanied by a persistent headache, To have a fever change good baseline in secretions

56

50mg/packet, 100mg/pack Oral liquid: 100mg/5mL Tablets: 200mg; 400mg Syrup: 100mg/5mL

step of acid production. Suppresses gastric of acid secrection by inhibition of the (H+,K+)ATPase system located at the secretory surface of the parietal cells in the stomach.

apathy

CV: Angina,hypertensi on, Hypotension, GU: Abnormal menses, breastenlargement s, dysuria, dysmenorrhea, gynecomastia.

reactions and drug interactions. Monitor CBC, electrolytes, triglycerides, renal and LFTs

data in assessment findings. To assess clients condition, and side effects or signs and symptoms of the medication. ( Jones and Bartlett 10th Ed.)

or lack of response Report any evidence of increased bruising

After Assess patients and familys knowledg e of drug therapy. To be able to know the possible effects of the drugs. (Jones and Bartlett 10th Ed.)

57

UNIVERSITY OF CEBU COLLEGE OF NURSING DRUG STUDY Patient: R. A. G. Impression/Diagnosis: Dengue Fever Allergy to: Sea foods Generic/Brand Name & Classification Generic: Ranitidine HCL Dose, Strength & Formulation Age: 8 years old Hospital No.: 080022480504 Room No.: GP4 Attending Physician(s): Dr. De La Calzada

Indication/Mecha nism of Drug Action Indications: I.V: Prevent paclitaxel hypersensitivity; reduce the incidence of GI hemorrhage associated with stress-related ulcers

Adverse/Side Effects Drug Interaction Adverse Reactions: Most Common: Headache, diarrhea, abdominal pain.

Nursing Responsibilities Before List reasons for therapy, onset, duration, triggers, characteristics of S&S

Rationale

Client Teaching

Ordered: Give 25 mg IV push Timing:

Brand: Ulcin

Every 8 hrs

Duration: 2.5-3hrs Classification: Histamine H2, Receptor blocking Other forms: Capsules: 150mg, 300mg

Mechanism of Action: Competitively inhibits gastric acid secretion by blocking the

GI: Constipation, N&V diarrhea, abdominal pain, CNS: Headache, dizziness, malaise, insomnia, vertigo, CV:

To indicate baseline data and monitor drugs effectiveness. (Jones and Bartlett 10th Ed.) To assess clients condition and fot the baby in the womb

Take as directed with or immediately following meals. Do not drive or operate machinery until drug effects are realized; dizziness or drowsiness may occur

Determine of pregnant

58

Injection: 1mg/mL Oral Solution: 15mg/mL Syrup: 15mg/mL Tablets: 150mg, 300mg

effects of histamine on histamine H2 receptors. Both daytime and nocturnal basal gastric acid secretion, as well as food-and pentagastrinstimulated gastric acid are inhibited.

Bradycardia, tachycardia, Premature ventricular beats following rapid I.V use

(Jones and Bartlett 10th Ed.) Skin test using allergens may elicit false negative results; stop drug 24-72 hr prior to testing To check if the client is allergic to the drug or not. (Jones and Bartlett 10th Ed.)

Avoid alcohol, aspririncontaning products, and beverages that contain caffeine Do not smoke; interference with healing and drugs

During Monitor CBC, B12 ,renal, LFTs, Assess for infection To avoid further complications. (Jones and Bartlett 10th Ed.)

Be alert for adverse reactions and drug

To establish proper precautionary measures and management for possible adverse effects of the drug

59

After Monitor / check the vital signs of the patient. To check the effectively of the drugs. (Jones and Bartlett 10th Ed.)

60

IVF STUDY

Patients Name: R. A. G. Room / Bed no.: GP4 Age: 8 years old Status: Child TYPE OF SOLUTION Plain Normal Saline Solution CLASSIFICATION Isotonic CONTENT MECHANISM OF ACTION An isotonic that expands the extra cellular fluid (ECF) volume, used in hypovolemic states, resuscitative efforts, shock, diabetic ketoacidosis, Hypercalcemia And mild Sodium deficit. (Brunner and Suddarth,2010)

Doctor: Dr. De La Calzada Date of Admission: August 28, 2011 Hospital no: 080022480504 Diet: No choco colored food INDICATIONS CONTRAIN DICATIONS None HOW SUPPLIED 1000 mL DOSE 65 70 cc/hr NURSING RESPOSIBILIT Y Monitor patient closely for: a. Signs of infiltration / sluggish flow. b. Sign of phlebitis / infection. c. Dwell time of catheter and replacement. d. Condition of catheter dressing.

Each 100mL contains 900 mg of Sodium Chloride

For replacement or maintenance of fliud and electrolytes. Used in blood transfusions, hyponatremia, burn victims.

61

Check the level of IVF.

Correct solution, medication and volume. Check the correct flow rte of the IVF. Change the IVF solution if needed and prescribed