CS - Dengue Fever

Dengue Fever
RLE IV-Case Study

Jovel P. Gangcuangco BSN IV-4 | Group XIII November 12, 2010
I. Introduction
Dengue fever, also known as breakbone fever,is an acute febrile disease which a major public health concern particularly in tropical and subtropical countries. It is caused by four closely related virus serotypes of the genus Flavivirus, family Flaviviridae. Dengue hemorrhagic fever (DHF), which is a potentially lethal
complication of DF, was first recognized in the 1950s during dengue epidemics in the Philippines and Thailand. Today DHF affects most Asian countries and has become a leading cause of hospitalization and death among children in the region. Its geographical distribution has greatlyexpanded and the number of cases has dramatically increasedduring the past three decades. Two and a half billion peoplein more than one hundred countries are at risk of infection,with an estimated 50 million infections per year.According to the current statistics of the Department of Health (DOH) in Central Visayas, it showed that dengue cases in city surged by 51 percent to 546 cases and six deaths from January 1 to July 10 this year from only 362 cases and 10 deaths in the same period in 2009. Dengue is transmitted to humans by the Aedesaegypti or more rarely the Aedesalbopictus mosquito, which feed during the day. Symptoms range from a mild fever, to incapacitating high fever, with severe headache, pain behind the eyes, muscle and joint pain, and rash. It appears 314 days after the infective bite. There are no specific antiviral medicines for dengue. It is important to maintain hydration. Use of acetylsalicylic acid (e.g. aspirin) and non-steroidal anti-inflammatory drugs (e.g. Ibuprofen) is not recommended. In a small proportion of cases, the virus causes increased vascular permeability that leads to a bleeding diathesis or disseminated intravascular coagulation (DIC) known as dengue hemorrhagic fever (DHF). Secondary infection by a different dengue
virus serotype has been confirmed as an important risk factor for the development of DHF. Furthermore, diffuse capillary leakage of plasma is responsible for the hemoconcentration. In the presence of hemoconcentration and thrombocytopenia, the patient is considered to be seized by dengue hemorrhagic fever and classified according to the following World Health Organization classifications: 1. Grade I thrombocytopenia + hemoconcentration; Absence of
spontaneous bleeding 2. Grade II thrombocytopenia + hemoconcentration; Presence of
spontaneous bleeding 3. Grade III thrombocytopenia + hemoconcentration; Hemodynamic
instability: filiform pulse, narrowing of the pulse pressure (< 20 mmHg), cold extremities, mental confusion 4. Grade IV thrombocytopenia + hemoconcentration; Declared shock,
patient pulseless and with arterial blood pressure = 0 mmHg (dengue shock syndrome - DSS)
The researcher has chosen to present dengue fever for the case study in order to have in-depth knowledge regarding the disease condition and for the fact that it is prevalent on this season. From this case study, it would enable the formulation of plans for nursing care appropriate for the patient that would entail better progression towards healing and would also enhance the skills of the student-nurses as they would be equipped with knowledge in order to address similar situations in the future.
II. Nursing Assessment Personal History AedeeFlavier is male Filipino citizen and Roman Catholic in religion. He is 5 years old and was born on September 16, 2005. He and his family currently reside at PulongSantol, Porac Pampanga.
He has a nuclear type of family. He lives with his parents together with his two siblings. The total floor area of their house measures 464 m2. It has three bedrooms, one dirty and clean kitchen, one living room and four bathrooms. Lighting is adequate during the day and during the night. Their household trash is being disposed regularly at the community dumpsite.
Aedees father works as a sales representative and earns Php 20,000 monthly. His mother works as a call center agent in Clark and earns approximately Php 20,000 monthly, not including allowances and bonuses. Their monthly expenses consist of their monthly grocery of Php 10,000-13,000; annual tuition fee of Php 30,000; annual school allowance of Php 15,000; monthly electric bill of Php 1,600; monthly water bill of Php 400-600; and service fee of Php 1,500 per month.
The familys main source of food is the wet market in their area while their source of drinking water comes from the local water refilling station. The mother stores leftover food in the refrigerator together with the other fresh products coming from the market.
In times of illness, the family first consults a herbolario for consultation and goes to the hospital if the problem is not relieved for a couple of days. They also do self-
medication such as cough & cold medications or antibiotics coming from their doctor depending on their illness.
Schematic Diagram Father Side Mother Side
Grandfather Grandmother ( - ) (??)
Grandfather (OO)
Grandmother (GG)
Father
Mother
D
(WL)
AedeeFlavier Family Health-Illness History The figure shows that on the paternal side, his grandfather is deceased due to heart attack while his grandmother currently has Parkinsons disease. His father and his siblings however do not have any known disease or medical condition. On the maternal side, his grandfather has poor eyesight while his grandmother is suffering from goiter. His mother and her siblings do not have any known disease or medical condition as well.
History of Past Illness According to Aedees mother, he suffered from frequent cough and colds when he was around one to three years old. During those times, she gave him cough and cold medications prescribed by their pediatrician, Dr. Torres. When he was two years old, he was diagnosed with bronchopneumonia, on which he was given antibiotics. He also suffered from measles when he was three years old.
History of Present Illness Three days prior to confinement, Aedees mother reported of him having fever, abdominal pain and headache. She also said that her son was abnormally sleepy, has no appetite and has not defecated. On that same day, she brought her son to the herbolario and was told that Aedee was nakatuwaan by the unknown.Two days prior to confinement, Aedee had episodes of vomiting. On October 30, 2010, few hours PTC, he was noted to be suffering from the same manifestations. Upon assessment, he was diagnosed to have Dengue Fever.
Physical Examination October 30, 2010 (Upon admission, lifted from the chart) Vital Signs: Temp= 37C PR= 120 bpm RR= 32 cpm -HEENT: pale conjunctiva, anicteric sclera, (-) CIAD, (-) NOD, nasal flaring -Chest: symmetrical chest Expansion, clear breath sounds, (-) retractions -Heart: adynamic Precordium. regular rate and rhythm, (-) murmurs -Abdomen: soft, non-tender
-Extremities: (-) edema, normoflexion, full & equal pulse
October 31, 2010 (lifted from the chart) Vital Signs: Temp= 39 C PR= 106bpm RR= 28cpm BP= 100/60 mmHg General Appearance: With good posture, normal built, asleep.
Hair He has short straight, black evenly distributed strands. No presence of dandruff and lice noted.
Skull and Face He has normocephalic skull with frontal, parietal, temporal and occipital prominences and with smooth skull contour. There is absence of nodules and masses upon palpation. There is no abnormal elevation or depression on the face. Face is symmetrical in shape with palpebral fissures that are equal in size.
Eyes Eyebrows are symmetrically aligned with hair evenly distributed. Skin is intact and there is an equal movement of eyebrows. Eyelashes are also evenly distributed and curled slightly outward. Skin is intact and with no discolorations Bulbar conjunctiva is reddened without presence of lesions and nodules. 6
Pale palpebral conjunctiva. No edema or tearing at lacrimal sac and nasolacrimal duct upon inspection and palpation.
Pupils are dark brown in color, equal in size, approximately 3 mm in diameter, round, with smooth border and irises are flat and round.
Ears Auricles are aligned with the outer canthus of the eyes and with color same as the facial skin. Auricles are mobile, firm and not tender upon palpation. Pinna recoils after it is folded. No discharges were noted
Nose No deviations have been observed in the shape, size and color of the external nose. Thus, it is symmetric and straight. No discharges were noted With nasal flaring
Lips and Teeth Outer lips are symmetrical, chapped lips Inner lips and buccal mucosa are uniform in color, dry oral mucosa
Thorax and Lungs Posterior: There is symmetrical chest expansion. Anterior:There are rhythmic respirations, symmetrical chest movement.
Heart No lift or heave has been noted at pericardium area. Skin No abrasions and edema have been noted. Skin temperature in uniform; warm to touch, flushed skin He has a good skin turgor which turned back (<3 seconds) to previous state when pinched. Extremities Peripheral pulses are in full pulsations. Limbs are not tender and no edema is present at extremities. 7
Fingernails Nail bed capillaries blanched when pressed but quickly turned (<3 sec.) in their usual color when pressure was released.
November 1, 2010 (lifted from the chart) Vital Signs: Temp= 36.3 C PR= 80bpm RR= 24cpm BP= 90/60 mmHg General Appearance: With good posture, normal built, asleep
Eyes Eyebrows are symmetrically aligned with hair evenly distributed. Skin is intact and there is an equal movement of eyebrows. 8
Eyelashes are also evenly distributed and curled slightly outward. Skin is intact and with no discolorations Bulbar conjunctiva is reddened without presence of lesions and nodules. Pinkish palpebral conjunctiva. No edema or tearing at lacrimal sac and nasolacrimal duct upon inspection and palpation.
Pupils are dark brown in color, equal in size, approximately 3 mm in diameter, round, with smooth border and irises are flat and round.
Ears Auricles are aligned with the outer canthus of the eyes and with color same as the facial skin. Auricles are mobile, firm and not tender upon palpation. Pinna recoils after it is folded. No discharges were noted
Nose No deviations have been observed in the shape, size and color of the external nose. Thus, it is symmetric and straight. No discharges were noted
Heart No lift or heave has been noted at pericardium area. Skin No abrasions and edema have been noted. Skin temperature in uniform; warm to touch, He has a good skin turgor which turned back (<3 seconds) to previous state when pinched.
Extremities Peripheral pulses are in full pulsations. Limbs are not tender and no edema is present at extremities.
November 2, 2010 (lifted from the chart) Vital Signs: Temp= 36.3 C PR= 90 bpm RR= 23cpm BP= 90/60 mmHg General Appearance: With good posture, normal built, coherent to time, place and person, conscious
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Eyes Eyebrows are symmetrically aligned with hair evenly distributed. Skin is intact and there is an equal movement of eyebrows. Eyelashes are also evenly distributed and curled slightly outward. Skin is intact and with no discolorations Bulbar conjunctiva is reddened without presence of lesions and nodules. Pinkish palpebral conjunctiva. No edema or tearing at lacrimal sac and nasolacrimal duct upon inspection and palpation. Pupils are dark brown in color, equal in size, approximately 3 mm in diameter, round, with smooth border and irises are flat and round. Ears Auricles are aligned with the outer canthus of the eyes and with color same as the facial skin. Auricles are mobile, firm and not tender upon palpation. Pinna recoils after it is folded. No discharges were noted
Heart No lift or heave has been noted at pericardium area. Skin No abrasions and edema have been noted. Skin temperature in uniform; warm to touch, 11
He has a good skin turgor which turned back (<3 seconds) to previous state when pinched.
Extremities Peripheral pulses are in full pulsations. Limbs are not tender and no edema is present at extremities.
November 3, 2010 (1st NPI) Vital Signs: Temp= 36 C PR= 96bpm RR= 26cpm BP= 90/50 mmHg General Appearance: With good posture, normal built, coherent to time, place and person, conscious
Skull and Face He has normocephalic skull with frontal, parietal, temporal and occipital prominences and with smooth skull contour. There is absence of nodules and masses upon palpation. There is no abnormal elevation or depression on the face.
12
Face is symmetrical in shape with palpebral fissures that are equal in size.
Heart No lift or heave has been noted at pericardium area.
13
Skin No abrasions and edema have been noted. Skin temperature in uniform; warm to touch, He has a good skin turgor which turned back (<3 seconds) to previous state when pinched. Extremities Peripheral pulses are in full pulsations. Limbs are not tender and no edema is present at extremities.
November 4, 2010 (lifted from the chart) Vital Signs: Temp= 36.8 C PR= 100bpm RR= 24cpm BP= 90/60 mmHg General Appearance: With good posture, normal built, coherent to time, place and person, conscious
Skull and Face
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He has normocephalic skull with frontal, parietal, temporal and occipital prominences and with smooth skull contour.
There is absence of nodules and masses upon palpation. There is no abnormal elevation or depression on the face. Face is symmetrical in shape with palpebral fissures that are equal in size.
Thorax and Lungs
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Posterior: There is symmetrical chest expansion. Anterior:There are rhythmic respirations, symmetrical chest movement.
Heart No lift or heave has been noted at pericardium area. Skin No abrasions and edema have been noted. Skin temperature in uniform; warm to touch, He has a good skin turgor which turned back (<3 seconds) to previous state when pinched. Extremities Peripheral pulses are in full pulsations. Limbs are not tender and no edema is present at extremities.
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DIAGNOSTIC AND LABORATORY PROCEDURES DIAGNOSTIC/ LABORATORY PROCEDURES Complete Blood Count DATE ORDERED DATE RESULTS INDICATIONS OR PURPOSES ANALYSIS AND RESULTS NORMAL VALUES INTERPRETATION OF RESULTS
Hemoglobin
DO: 10-30-10 DR: 10-30-10
This test evaluates blood loss erythropoietic ability,
127
110-160 g/L
The
results
show
that normal levels of 143 Hgb which
DO: 10-31-10 DR: 10-31-10
anemia & response to therapy. Hemoglobin is an important
ensures adequate oxygenation of
tissues in the body 131
DO: 10-31-10 DR: 11-01-10
component of RBC that carries oxygen to the tissue.
DO: 11-01-10 DR: 11-02-10
122
17
DO: 11-02-10 DR: 11-03-10
130
DO: 11-03-10 DR: 11-04-10 Hematocrit DO: 10-30-10 DR: 10-30-10 This blood blood DO: 10-31-10 DR: 10-31-10 therapy balance. screens DO: 10-31-10 DR: 11-01-10 Hematocrit measure is test loss, evaluates anemia,
127
0.43
0.31-0.43%
The results indicate that there is normal concentration of
replacement & It fluid also RBC. a of 0.38 0.41
RBC in the blood
concentration of RBC DO: 11-01-10 DR: 11-02-10 within volume the blood 0.37
DO: 11-02-10 DR: 11-03-10
0.38
DO: 11-03-10 DR: 11-04-10
0.37
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White Cells
Blood
DO: 10-30-10 DR: 10-30-10
WBCs protect against
functions the
to body
2.12
5-15x109/L
The decreased levels of WBCs indicateimpairment
invading 4.5
DO: 10-31-10 DR: 10-31-10
microorganisms and to remove from dead cells
in the immune system which exposes the patient
tissues
through 2.96
DO: 10-31-10 DR: 11-01-10
phagocytosis.
in possible bacterial or viral infections.
DO: 11-01-10 DR: 11-02-10 DO: 11-02-10 DR: 11-03-10
4.2
5.02
The results are normal which indicate
DO: 11-03-10 DR: 11-04-10
5.72
improvement in the bodys immune system
Neutrophils
DO: 10-31-10 DR: 11-01-10
Helpful in localizing the infection and in immobilizing the
0.17
0.25-0.43
The elevated results indicate that there is failure in
DO: 11-02-10 DR: 11-03-10
pathogens until the WBC arrives.
0.13
the immune system from localizing and
19
DO: 11-03-10 DR: 11-04-10 DO: 10-30-10 DR: 10-30-10
0.15
controlling the spread of infection.
0.40
The normal levels of neutrophils indicate that the
DO: 10-31-10 DR: 10-31-10
0.44
bodys immune system is adequate to localize and
DO: 11-02-10 DR: 11-03-10 Lymphocytes DO: 10-30-10 DR: 10-30-10 Produces antibodies and other chemicals responsible for DO: 10-31-10 DR: 10-31-10 destroying microorganisms; contributes to allergic DO: 11-01-10 DR: 11-02-10 reactions, graft rejection, tumor control, and regulation DO: 11-03-10 DR: 11-04-10 DO: 10-31-10 of the immune system.
0.64
control infection.
0.60
0.20-0.65
The normal level of lymphocytes indicates that there
0.46
are adequate antibodies to eliminate infection.
0.64
0.72
Elevated
20
DR: 11-01-10
lymphocyte levels indicate presence
DO: 11-02-10 DR: 11-03-10
0.75
of infection and the body tries to compensate
Monocytes
DO: 10-31-10 DR: 10-31-10
Monocytes ingest nonbacterial foreign substances, usually
0.07
0.00-0.05
Elevation of monocyte level indicates presence
DO: 10-31-10 DR: 11-01-10
during chronic infection.
0.10
of viral infection
DO: 11-02-10 DR: 11-03-10
0.09
DO: 11-03-10 DR: 11-04-10 DO: 11-01-10 DR: 11-02-10
0.09
0.01
The level of monocyte is within the normal range indicates that the body has been able to suppress
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the infection. Eosinophils DO: 10-31-10 DR: 10-31-10 Eosinophils are one of the components of the immune system DO: 10-31-10 DR: 11-01-10 responsible for eradicating parasites. 0.01 0.03 The normal levels of eosinophils indicate absence of parasitism inside the body.
DO: 11-02-10 DR: 11-03-10
0.03
DO: 11-03-10 DR: 11-04-10 Platelets DO: 10-31-10 DR: 10-31-10 Platelets (thrombocytes) are the smallest type of blood DO: 10-31-10 DR: 11-01-10 cell. They in are blood When occurs. If
0.03
96
150-400x109/L
The decreased levels of platelet indicate that the
80
body has insufficient clotting factors making the
important clotting.
DO: 11-01-10 DR: 11-02-10
bleeding
83
patient prone to bleeding.
there are too many platelets, there is a 74
DO: 11-02-10
chance of a blood
22
DR: 11-03-10
clot forming in a blood vessel. Also it may also
DO: 11-03-10 DR: 11-04-10
evaluate the risk of having tendency internally externally. bleeding both and
109
23
Nursing Responsibilities Prior: Assess the patients knowledge about the test. Explain the patient that the test is used to detect an inflammation, infection, and anemia. Tell the patient that a blood sample will be taken. Explain who will perform the venipuncture and when. Explain to the patient that she may feel slight discomfort from the needle puncture and the tourniquet. Inform the patient that she should avoid strenuous exercise for 24 hours before the test. If the patient is being treated for an infection, advise her that this test will be repeated to monitor his progress. Notify the laboratory and physician of medications the patient is taking that may affect test results; they may need to be restricted. During: Adhere to standard precaution. Remove the needle after drawing blood sample, and apply a pressure dressing over the puncture site Promptly transport the specimen to the laboratory for processing and analysis Post: Observe venipuncture site for bleeding or hematoma formation. If a hematoma develops at the venipuncture site, apply warm soaks. If the hematoma is large, monitor pulses distal to the venipuncture site. Ensure subdermal bleeding has stopped before removing pressure. Reinforce information given by the patients health care provider regarding further testing, treatment, or referral to other health care provider.
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DIAGNOSTIC AND LABORATORY PROCEDURES Urinalysis
DATE ORDERED DATE RESULTS DO: 10-30-10 DR: 10-30-10
INDICATIONS OR PURPOSES
RESULTS
NORMAL VALUES Yellow, Clear
ANALYSIS AND INTERPRETATION OF RESULTS Urine ranges from pale yellow to amber because of the pigment urochrome (production of bilirubin metabolism). This indicates balanced water content and other urine elements
Urinalysis is part of Color:Yellow routine diagnostic and screening evaluations. It can reveal a significant amount of preliminary information about the kidneys and other metabolic processes. Urinalysis includes remarks as to the color, appearance and odor, pH, and presence of proteins, glucose, ketones, and blood and leukocyte esterase. In addition, the urine is examined microscopically for RBCs WBCs, casts, crystals and bacteria this procedure was done to our pt. to check test if there is pH: 7 any complication/ingestion. On her kidney or if her kidneys functioning Specific well. gravity:1.005
4.5-8
Acidic urine is associated with pyrexia or acidosis.
1.010-1.030
This indicates
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Albumin:trace none
lesser concentration of solutes in the urine
This indicates normal permeability of the nephrons. Glucose:none
none RBC: 1-2 Glycosuria usually indicates DM.
0-2 hpf Epithelial cells: rare This normal level of RBCs in the blood
rare/none These plugs of high molecular weight mucoprotein form in the renal tubules and collecting ducts by agglutination of protein cells.
26
27
Nursing Responsibilities: Prior: Confirm the patients identity using two patient identifiers according to facility policy Explain that this analysis helps to diagnose renal or urinary tract disease and to evaluate overall body function Inform the patient that he doesnt need to restrict food and fluids for the test Notify the laboratory and practitioner of drugs the patients is taking that may affect laboratory results During: Instruct SO to clean patients genital area before voiding. Provide a clean container for urine sample. Provide privacy. Collect a random urine specimen of at least 15 mL. obtain a first-voided morning specimen if possible Strain the specimen to catch calculi or calculus fragments if the patient is being evaluated for renal colic. After: Label specimen properly. Send specimen to laboratory as soon as possible. Inform patient when the results of the test are available. Record time and date of performed procedures.
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DIAGNOSTIC AND LABORATORY PROCEDURES Prothrombin Time
DATE ORDERED DATE RESULTS DO: 10-31-10 DR: 11-01-10
INDICATIONS OR PURPOSES PT measures the time required for a fibrin clot to form in a citrated plasma sample after the addition of calcium ions and tissue thromboplastin.
RESULTS 11.9 sec.
NORMAL VALUES 10-14 sec.
ANALYSIS AND INTERPRETATION OF RESULTS It shows that the patient has a normal PT time which means the body is capable of preventing further hemorrhage in case there is a break in the blood vessels. It shows that the patient has decreased clothing factors that maylead to hemorrhage in case there is a break in the blood vessels.
DO: 11-01-10 DR: 11-02-10
12.3 sec.
Activated Partial Thromboplastin Test
DO: 10-31-10 DR: 11-01-10
DO: 11-01-10 DR: 11-02-10
APTT is used to evaluate all the clotting factors of the intrinsic pathway, except platelets, by measuring the time required for formation of a fibrin clot after calcium and phospholipid emulsion is added to a plasma sample. An activator, such as kaolin, is used to shorten clotting time.
47.5 sec.
31.8-43.68 sec.
44.2 sec
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Nursing Responsibilities: Prior: Confirm the patients identity before starting the procedure Explain the procedure to be done to the patient Advise the patient that a blood sample will be taken. Explain that he may feel slight discomfort from the needle puncture and the tourniquet Inform the patient that he doesnt need to restrict food and fluids for the test During: Perform the venipuncture, and collect the sample in a 7 mL tube with sodium citrate added. Completely fill the collection tube, invert it gently several times, and send it one ice to the laboratory. After: Ensure subdermal bleeding has stopped before removing pressure. If hematoma develops at the venipuncture site, apply direct pressure. If the hematoma is large, monitor pulses distal to the venipuncture site
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DIAGNOSTIC AND LABORATORY PROCEDURES Fecal Analysis
DATE ORDERED DATE RESULTS DO: 11-02-10 DR: 11--03-10
INDICATIONS OR PURPOSES It assists in diagnosing disorders associated with GI bleeding or drug leads therapy to that
RESULTS COLOR: brown
NORMAL VALUES COLOR: Brown
ANALYSIS AND INTERPRETATION OF RESULTS The brown color of the feces is due to the bile pigment which is considered normal It indicates normal water reabsorption and motility in the large intestine
bleeding, of
diagnosis
Consistency: formed
Consistency: Solid and formed
pseudomembranous enterocolitis after use of broad spectrum antibiotic therapy, RBC: negative RBC: Negative
assist in the diagnosis of suspected
It indicates that the patient is not suffering from bleeding.
inflammatory bowel disease, altered digestion, intestinal infestation, indicated Detect protein Detect parasitic as by
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diarrhea of unknown cause.
Nursing Responsibilities: Prior: Inform the patient that the test is used to assist in the diagnosis of intestinal disorders or assess for any bleeding Obtain a history of the patients complaints, including a list of known allergens Instruct the patient to follow a normal diet for several days before the test During: Instruct the patient to cooperate fully and follow directions Instruct client to collect stool specimen in a half pint waterproof container with a tight fitting lid; if the patient is not ambulatory, collect it in a clean, dry bedpan. Collect specimen from the first, middle, last portion of the stool. Promptly transport the specimen to the laboratory for processing and analysis. After: Instruct the patient to resume his usual medications as ordered.
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III. Anatomy and Physiology 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 five kinds of white blood cells (WBCs) or leukocytes
o
y y y
Three kinds of granulocytes

neutrophils eosinophils basophils
Two kinds of leukocytes without granules in their cytoplasm

lymphocytes monocytes
Blood performs two major functions: transport through the body of

o o o o o o y
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.
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The Formation of Blood Cells All the various types of blood cells
y y
are produced in the bone marrow Arise from a single type of cell called a hematopoietic stem cell an "adult" multipotent stem cell.
These stem cells

y y
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;
y y
express a cell-surface protein designated CD34; produce, by mitosis, two kinds of progeny:
o
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.
Which path is taken is regulated by The need for more of that type of blood cell which is, in turn, controlled by appropriate cytokines and/or hormones. Example:
y
Interleukin-7 (IL-7) is the major cytokine in stimulating bone marrow stem cells to start down the path leading to the various lymphocytes (mostly B cells and T cells).
34
Erythropoietin (EPO), produced by the kidneys, enhances the production of red blood cells (RBCs).
Thrombopoietin (TPO), assisted by Interleukin-11 (IL-11), stimulates the production of megakaryocytes. Their fragmentation produces platelets.
Granulocyte-macrophage colony-stimulating factor (GM-CSF), as its name suggests, sends cells down the path leading to both those cell types. In due course, one path or the other is taken.
o
Under the influence of granulocyte colony-stimulating factor (GCSF), they differentiate into neutrophils.
Further stimulated by interleukin-5 (IL-5) they develop into eosinophils.
Interleukin-3 (IL-3) participates in the differentiation of most of the white blood cells but plays a particularly prominent role in the formation of basophils (responsible for some allergies).
Stimulated by macrophage colony-stimulating factor (M-CSF) the granulocyte/macrophage progenitor cells differentiate into monocytes, macrophages, and dendritic cells (DCs).
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RED BLOOD CELLS (Erythrocytes) The most numerous type in the blood. Women average about 4.8 million of these cells per cubic millimeter (mm3; which is the same as a microliter [l]) of blood.
y y
Men average about 5.4 x 106 per l. These values can vary over quite a range depending on such factors as health and altitude.
RBC precursors mature in the bone marrow closely attached to a macrophage. They manufacture hemoglobin until it accounts for some 90% of the dry weight of the cell.
y
The nucleus is squeezed out of the cell and is ingested by the macrophage.
No-longer-needed proteins are expelled from the cell in vesicles called exosomes.
Thus RBCs are terminally differentiated; that is, they can never divide. They live about 120 days and then are ingested by phagocytic cells in the liver and spleen. Most of the iron in their hemoglobin is reclaimed for reuse. The remainder of the heme portion of the molecule is degraded into bile pigments and excreted by the liver. Some 3 million RBCs die and are scavenged by the liver each second. Red blood cells are responsible for the transport of oxygen and carbon dioxide. Oxygen Transport In adult humans the hemoglobin (Hb) molecule
36
consists of four polypeptides:

o o
two alpha ( ) chains of 141 amino acids and two beta ( ) chains of 146 amino acids
y y y
Each of these is attached the prosthetic groupheme. There is one atom of iron at the center of each heme. One molecule of oxygen can bind to each heme.
The reaction is reversible. Under the conditions of lower temperature, higher pH, and increased oxygen pressure in the capillaries of the lungs, the reaction proceeds to the right. The purple-red deoxygenated hemoglobin of the venous blood becomes the bright-red oxyhemoglobin of the arterial blood.
y
Under the conditions of higher temperature, lower pH, and lower oxygen pressure in the tissues, the reverse reaction is promoted and oxyhemoglobin gives up its oxygen.
Carbon Dioxide Transport Carbon dioxide (CO2) combines with water forming carbonic acid, which dissociates into a hydrogen ion (H+) and a bicarbonate ions: CO2 + H2O H2CO3 H+ + HCO3
95% of the CO2 generated in the tissues is carried in the red blood cells:
y
It probably enters (and leaves) the cell by diffusing through transmembrane channels in the plasma membrane. (One of the proteins that forms the channel is the D antigen that is the most important factor in the Rh system of blood groups.)
Once inside, about one-half of the CO2 is directly bound to hemoglobin (at a site different from the one that binds oxygen).
The rest is converted following the equation above by the enzyme carbonic anhydrase into
o
bicarbonate ions that diffuse back out into the plasma and 37
hydrogen ions (H+) that bind to the protein portion of the hemoglobin (thus having no effect on pH).
Only about 5% of the CO2 generated in the tissues dissolves directly in the plasma. (A good thing, too: if all the CO2 we make were carried this way, the pH of the blood would drop from its normal 7.4 to an instantly-fatal 4.5!) When the red cells reach the lungs, these reactions are reversed and CO2 is released to the air of the alveoli.
White Blood Cells (Leukocytes) are much less numerous than red (the ratio between the two is around 1:700),
y y
have nuclei, participate in protecting the body from infection,
consist
of
lymphocytes with relatively
and clear
monocytes
cytoplasm, and three types of granulocytes, whose cytoplasm is filled with granules. Lymphocytes There are several kinds of lymphocytes (although they all look alike under the microscope), each with different functions to perform . The most common types of lymphocytes are
38
y y
B lymphocytes ("B cells"). These are responsible for making antibodies. T lymphocytes ("T cells"). There are several subsets of these:
o
inflammatory T cells that recruit macrophages and neutrophils to the site of infection or other tissue damage
cytotoxic T lymphocytes (CTLs) that kill virus-infected and, perhaps, tumor cells
helper T cells that enhance the production of antibodies by B cells
Although bone marrow is the ultimate source of lymphocytes, the lymphocytes that will become T cells migrate from the bone marrow to the thymus [View] where they mature. Both B cells and T cells also take up residence in lymph nodes, the spleen and other tissues where they encounter antigens; continue to divide by mitosis; mature into fully functional cells.
y y y
Monocytes Monocytes leave the blood and become macrophages and dendritic cells. Macrophages are large, phagocytic cells that engulf foreign material (antigens) that enter the body dead and dying cells of the body.
y y
Neutrophils - are the most abundant of the WBCs. Neutrophils squeeze through the capillary walls and into infected tissue where they kill the invaders (e.g., bacteria) and then engulf the remnants by phagocytosis. This is a never-ending task, even in healthy people: Our throat, nasal passages, and colon harbor vast numbers of bacteria. Most of these are commensals, and do us no harm. But that is because neutrophils keep them in check.
39
However, heavy doses of radiation chemotherapy and many other forms of stress
y y y
can reduce the numbers of neutrophils so that formerly harmless bacteria begin to proliferate. The resulting opportunistic infection can be life-threatening. Eosinophils The number of eosinophils in the blood is normally quite low (0450/l). However, their numbers increase sharply in certain diseases, especially infections by parasitic worms. Eosinophils are cytotoxic, releasing the contents of their granules on the invader. Basophils The number of basophils also increases during infection. Basophils leave the blood and accumulate at the site of infection or other inflammation. There they discharge the contents of their granules, releasing a variety of mediators such as:
y y y
histamine serotonin prostaglandins and leukotrienes
which increase the blood flow to the area and in other ways add to the inflammatory process. The mediators released by basophils also play an important part in some allergic responses such as hay fever and ananaphylactic response to insect stings.
y y
40
Platelets Platelets are cell fragments produced from megakaryocytes. Blood normally contains 150,000350,000 per microliter (l) or cubic millimeter (mm3). This number is normally maintained by a homeostatic mechanism. If this value should drop much below 50,000/l, there is a danger of uncontrolled bleeding because of the essential role that platelets have in blood clotting. Some causes: certain drugs and herbal remedies; Autoimmunity. (negative-feedback)
y y
When blood vessels are cut or damaged, the loss of blood from the system must be stopped before shock and possible death occur. This is accomplished by solidification of the blood, a process called coagulation or clotting. A blood clot consists of Aplug of platelets enmeshed in a network of insoluble fibrin molecules.
41
IV. The Patients Illness

Precipitating factors
A. Schematic Diagram (Book- based)

y
Poor environmental Sanitation (presence of stagnant water, uncovered water container, junked tires and bottles)
Predisposing factors y Age, Sex- both are affected

y
Poor practices to protect self against mosquitoes
Mosquito bite (AedesAegypti)
Dengue Virus enters the body, carried by circulation and multiplies
Immune response by the body (Defense mechanism of the body to foreign bodies) 42
FEVER
Cytokine and Prostaglandin release
Joint inflammation
Immune adherence to platelets produced by G3b
capillary/ vascular permeability
JOINT PAIN
thrombocytopenia
Extravasation of fluid y
Oral mucosa
Nasal mucosa
Bone marrow
tissue perfusion GUM BLEEDING
EPISTAXIS
Liver damage
GIT
Maturational arrest of megakaryocyt es
Altered liver y function
GIT bleeding, erosion, and ulcerations
Gastric stasis 43
LOW WBC
PETECHIAE
hepatomegaly
COAGULATIO N DEFECT Abd. Pain
MELENA VOMITING
BLEEDING
DEATH
SHOCK
hypotension
blood volume
LOW BP
hgb and hct
44
Precipitating factors
B. Schematic Diagram (Client- centered)

y
Poor environmental Sanitation (presence of stagnant water, uncovered water container, junked tires and bottles)
Predisposing factors y Age, Sex- both are affected
Mosquito bite (AedesAegypti)
Dengue Virus enters the body, carried by circulation and multiplies
Immune response by the body (Defense mechanism of the body to foreign bodies) 45
FEVER (10-31-10)
Cytokine and Prostaglandin release
Immune adherence to platelets produced by G3b
capillary/ vascular permeability
Thrombocytopenia (10-30-10)
Extravasation of fluid y
GIT
Bone marrow
tissue perfusion
Gastric stasis
hepatomegaly
ABD. PAIN (10-27-10) VOMITING (10-28-10) COAGULATION DEFECT (11-01-10)
Liver damage
Maturational arrest of megakaryocyt es
Altered liver function
LOW WBC (10-30-10)
46
C. Synthesis of the Disease
Dengue is a mosquito borne infection which in recent years, become a major international concern. Dengue is found in tropical and sub-tropical regions. It is an acute febrile disease cause by serotypes of dengue virus which is transmitted by mosquito genus Aedes. Dengue Hemorrhagic fever is severe, sometimes fatal manifestation of dengue virus that contains single strands of RNA characterized by bleeding, diasthesis and hypovolemic shock.
Mode of transmission is by bite of mosquito, principally the AedesAegypti(a day biting mosquito which appears two hours after sunrise and two hours before sunset). They breed at stagnant water. The incubation period is 3-14 days; commonly 7-10 days.
Infectious virus is deposited in the skin by vector and initial replication occurs at the site of infection and local lymphatic tissue. Within few days, viremia occurs and evidence indicates that macrophages are the principal site for replication. At the site of petichial rash, non-specific changes are noted which include endothelial swelling, edema and extravasation of blood. There is marked increased in vascular permeability, hypotension, hemoconcentration, thrombocytopenia, with an increase platelet agglutinability and moderate DIC. Then most serious side effect or abnormality is hypovolemic shock which could lead to death.
Non Modifiable Risk Factor y Age- dengue fever may occur at any age, but it is common among children usually ages 0- 15 years old. y y Sex- both sexes can be affected. Season- it is more frequent during rainy season.
47
Modifiable Risk Factor y Environment/Housing Condition- usually mosquitos breed in a messy, dirty environment, in a open drainage, and left stagnant water. y y y Location- more prevalent in urban areas Occupation- those who are working near the forest, or those mountain climbers. Immune System- usually dengue virus easily attacks those with low or weak immune system.
Signs and symptoms with rationale y Fever due to profound circulatory changes. Due to affectation of thermoregulatory system that may include headache, retro orbital pain, body aches, nausea and vomiting. Fever is usually 39-40 degree Celsius and again accompanied with fever. It is also the normal response of the body towards an invading microorganism (dengue virus). y Malaise- because of the condition, the body tends to utilize more energy to meet the increase metabolic need thus using the reserve or stored energy resulting in weakness. y y Anorexia- related to malaise Nausea and vomiting- probably due to irritation of the medulla oblongata which is the vomiting center of the brain. y Petechiae most common hemorrhagic manifestation due to rupture of small blood vessels in the skin and may be due to plasma leakage and increase vascular permeability. Maybe also due to decrease circulating platelet and increase capillary fragility. y Hemoconcentration due to elevated hematocrit level brought about by increase vascular permeability and leakage of plasma content. y Thrombocytopenia due to plasma leakage and increase vascular permeability. Also maybe due from profuse bleeding. Blood vessels adhere to platelet surface, which then damages it. Platelet become injured and removes by
reticuloendothelial cells of spleen. Platelet destruction is greater than platelet production hence reducing thrombocytes.
48
V. The Patient and His Care
A. Medical Management A. IVF Medical Management/ Treatment D5 0.3 NaCl x 1617gtts/min Date Ordered Date Performed Date Changed(D/C) Date Ordered: October 30, 2010 Date Started: October 30, 2010 Date Interrupted: October 31, 2010 General Description Indication(s) or Purposes Clients response to the treatment
hypotonic has
solution Purpose of hypotonic The patient responded greater solution is to give up its well to the IV infusion. water content to a No signs of over or were is as by good normal and
that
concentration of free
water molecules that dehydrated cell so it hydration are found inside the cell rather than on its surrounding. can return to isotonic dehydration equilibrium noted.
Hydration
maintained evidenced
D5 0.3 Nacl x 1617gtts/min
Date Ordered: November 1, 2010 Date Started: November 2, 2010
skin
turgor, refill, oral
capillary moist
mucous
membranes.
A hypertonic solution For hydration purpose, No that has higher
allergic
reaction
it is a routine electrolyte was noted. Hydration is
49
osmolarity D5 LRS x 17-18 gtts/min Date Ordered: October 31, 2010 Date Started: October 31, 2010
than
the maintenance
solution; maintained by
as good normal and
serum. It pulls fluid and serves as a route of evidenced electrolytes intracellular interstitial from the administration for IV skin turgor,
and medicines and used to capillary increase the amount of moist circulating volume bleeding. in
refill, oral
mucous Blood
Date Changed: November 1, 2010
compartments into the intravascular compartment.
blood membranes. cases
of volume is maintained; shock is prevented AEB normal VS especially with
D5 LRS x 14 gtts/min
Date Ordered: November 1, 2010 Date Started: November 1, 2010
Blood
pressure
normal pulse pressure.
50
B. Drugs
Name of Drugs
Paracetamol (TEMPRA FORTE)
Date ordered Date taken/given Date changed/ D/C Date Ordered: October 30, 2010 Date Given: October 31, 2010
Route Dosage and frequency of administration 250 mg/ 5ml, 4ml q4
General Action, Functional classification, mechanism of action
Indication(s) or Purposes
Clients response to the medication w/ actual side effect
Antipyretics, analgesics
non-opioid
Anti-pyretic and analgesic
There is a decrease in the patients body temperature.
Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS. Have no significant antiinflammatory properties or GI toxicity.
NURSING RESPONSIBILITIES: Prior: y y y y Get the temperature of the client Assess fever; note for presence of associated sign. Assess type, location, and intensity of pain. Make sure that the 10 rights are applied.
Check the patency of the IV tube.
During: y After: y y Provide opportunities for rest. Maintain a quiet environment. Slow IV push when the client complains of pain.
51
Name of Drugs
Ranitidine (ZANTAC)
Date ordered Date taken/given Date changed/ D/C Date Ordered: October 31, 2010 Date Given: November 1, 2010 Date Changed: November 2, 2010
Route Dosage and frequency of administration 20 mg SIVP, q8
Histamine2 antagonist
20 mg, SIVP, q12
Competitively inhibits action of histamine at the H2 receptors of the parietal cells of the stomach, inhibiting basal gastric secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonist, gastrin and pentagastrin
Ranitidine is given since the patient vomited, and also was under NPO status, to decrease gastric acid secretion
No side effects where noted. The patient
did not experienced abdominal pain that may be brought by gastric acid secretions, increased by the NPO status of the client.
52
NURSING RESPONSIBILITIES: Prior y y y y y y y Assess: Allergy to ranitidine, impaired renal or hepatic function. Check the doctors order. Check the drug label, contents, and appearance. Check the right dosage, route and time of administration. Use aseptic technique. Identify correct patient. Inform patients SO of the drug and its purpose and action.
During y y Check patency of IV Administer slow IV push
After y y Monitor the patients reaction to the drug. Inform client to report severe headache, muscle and joint pain
53
Name of Drugs
Oracare
Date ordered Date taken/given Date changed/ D/C Date Ordered: October 31, 2010 Date Given: October 31, 2010
Route Dosage and frequency of administration 10ml, TID
Eliminates bacteria & odor-causing volatile sulfur compounds in the mouth.
client didn't Oracare is used, The since the patient develop mouth sores manifested dry r/t to having dry mouth mouth.
NURSING RESPONSIBILITIES: Prior y y y y Check the doctors order Check the drug label, contents, and appearance. Check the right dosage, route and time of administration. Identify correct patient.
Instruct the patient not to swallow the mouthwash after gargling
After y Document procedure in the chart
During y Instruct the patient to gargle mouthwash for 60 sec.
54
Name of Drugs
Miconazole (DAKTARIN)
Date ordered Date taken/given Date changed/ D/C Date Ordered: November 1, 2010
Route Dosage and frequency of administration TID
Anti-Fungal
Prophylaxis
for The patient did not signs of
infection; also since develop Altersfungal cell membrane permeability, the patient
was mouth infection
observed to have dry lips
Date Given: November 1, 2010
causing cell death; also may alter fungal cell DNA and RNA metabolism or cause accumulation of toxins peroxides intracellularly
55
NURSING RESPONSIBILITIES: Prior y y y y y Check the doctors order. Check the drug label, contents, and appearance. Check the right dosage, route and time of administration. Identify correct patient. Inform patients SO of the drug and its purpose and action.
During y y Use hygiene measures to prevent reinfection Apply lotion to areas that is affected
After y y Monitor the patients reaction to the drug. Inform client that he may experience burning, stinging sensation.
56
Name of Drugs
Date ordered Date taken/given Date changed/ D/C
Route Dosage and frequency of administration
BISACODYL (Dulcolax)
Date Ordered: November 3, 2010
Pedia Supp.
Laxative
Bisacodyl acts mainly in the large intestine by
Bisacodyl is a laxative that stimulates bowel movements. It is used to treat constipation
The patient was able to defacate after the administration of the supp.
Date Given: November 3, 2010 NURSING RESPONSIBILITIES: Prior: y y Prepare for pedia supp. as ordered.
increasng its motility to effect bowel evacuation. y y Hold in the suppository for a 15 to 20 minutes. Inform the SO, that the suppository will melt quickly once inserted and you should feel little or no discomfort while holding it in. After: y Do not let client to immediately go to the bathroom right after insertion of suppository.
Give drug after each unformed stool. Keep track of amount given to avoid exceeding
recommended dose During: y Lie on the patient on his side and gently insert the suppository pointed end first.
57
Name of Drugs
Hydroxyzine (ITERAX)
Date ordered Date taken/given Date changed/ D/C Date Ordered: November 3, 2010
Route Dosage and frequency of administration PO, 5 ml, TID
Anti-Emetic, Anti histamine
Prevents stimulation of vagus nerve therefore preventing vomiting
The patient did not experience episodes of vomiting
Actions may be due to Date Given: November 3, 2010 suppression of subcortical areas of the CNS.
NURSING RESPONSIBILITIES: Prior y y y Check the doctors order. Check the drug label, contents, and appearance. Check the right dosage, route and time of
Inform patients SO of the drug and its purpose and action.
During y Administer the drug as instructed
After y Monitor patients reaction to the drug
administration. y Identify correct patient.
58
C. DIET Type of Diet Date Ordered Date Started Date Changed General Description Indications Specific foods taken Clients response/reaction to the diet
Nothing Per Orem ( NPO )
Date Ordered: October 31, 2010 Date Given: November 1, 2010 Date Changed: November 2, 2010
Nothing
per NPO is indicated While the patient Vomiting
is
Orem; a medical for clients who are is on NPO diet he prevented. instruction meaning withhold vomiting to prevent oral vomiting to did not eat any further foods.
foods and fluids tendencies. from a patient for various reasons.
Nursing Responsibilities: Prior y y y Check physicians order Inform the patients SO about the type of diet. Explain the purpose of the diet ordered the consequences of not following such diet and how it
will be implemented. During y y Monitor if the patient complies with the given diet. Monitor intake and output.
After y Document response of the patient.
59
Type of Diet
Date Ordered Date Started Date Changed
General Description
Indications
Specific foods taken
Clients response/reaction to the diet
DAT except dark colored foods
Date Ordered: November 2, 2010
The patient can Indicated to bring Rice, take anything by back patients milk,
Crackers, The bread, verbalized
patient hunger
mouth as long as normal diet and orange juice, Date Started: November 2, 2010 foods taken can to absorb
but complied with the diet.
be tolerated by nutrients that he the except patient needs. Dark
dark colored foods are contraindicated because it may mask the possible presence bleeding of
colored foods
NURSING RESPONSIBILITIES: Prior y Encourage the patient to eat smaller food portions more often- five to six small meals daily instead of three larger ones or small meals combined with high protein or complex carbohydrates snacks throughout the day. y y y Monitor the client and assess for signs of weakness. Include the patient in deciding on the menu which follows the dietary prescription. Explain the purpose of the dietary recommendation to her current condition. 60
During y y y Be sure that the patient is taking or eating foods he can tolerate. Assess patients condition and how he responded on the foods he is taking. Give lots of fruits and vegetables.
After y y y Encourage the patient to have a regular eating habit. Assess patient for signs of allergy, contentment and other factors after eating. Assess patients satisfaction on the food he ate.
61
B. Nursing Care Plans Problem # 1: Hyperthermia

Assessment Nursing Diagnosis Hyperthermia Scientific Explanation Hyperthermia is a systematic inflammatory response that occurs when bacterial infection cant be localized or destroyed. In this case, the presence of infectious subs. In the blood causing to an inflammatory response. Chemical mediators such as pyrogens are released which acts upon the thermoregulatory center of the brain, which would lead to an increase in core temperature. Objectives Nursing Interventions >Establish rapport >Monitor and record vital signs >provide AM/PM care >Provide TSB >Encourage to oral fluid intake >Health teachings such as proper hand washing, proper food handling and preparation >Encourage to take of food rich in Vit. C >Keep pt.s back Rationale Outcome
S> O> The patient manifested the following: > in the body temp. above normal range >Skin is warm to touch. >Flushed skin (10-31-10)
Short term: After 3 hrs. of NI, the pt.s temp. will decrease to its normal range
>To gain trust and cooperation >To assess pt.s condition > provide comfort >To pts temp.
Short term: After 3 hrs. of NI, the pt.s temp. shall decrease to its normal range Long term: After 3 days of NI, the pt. shall maintain core temperature within normal range.
Long term: After 3 days of NI, the pt. will maintain core temperature within normal range
>To prevent dehydration >For hygiene maintenance and prevent pathogen for infections
>To pt.s resistance >To prevent worsening of pt.s
62
dry >Encourage pt to loosen clothing
condition >To loosen heat properly by evaporation >To provide comfort
>Provide proper ventilation
>Instruct pt. to follow doctors advice >Encourage/ provide opportunities to rest >Regulate IVF as ordered
>For better recovery
>To lessen fatigue
>To maintain hydration
63
Problem #2: Imbalanced nutrition less than body requirement r/t to inability to ingest 2 to vomiting
Assessment S:> O:>patient manifested: >Episodes of vomiting >Generalized weakness Nursing Diagnosis Imbalanced nutrition less than body requirement r/t inability to ingest 2 to vomiting Scientific Explanation Through a bite of an infected mosquito, there could be virus replication on the body that causes the release of certain toxins. These toxins stimulate the release of prostaglandin leading to manifestation of Pt. may manifest: >Increase sudden weight loss >Sore buccal cavity >Pale conjunctiva signs and symptoms of DHF such as fever, epigastric pain and joint pain. Fever causes the patient to Long Term: Objectives Short term: After 4 hours of nursing interventions, patient or significant others will verbalize understanding of the bodys energy needs. >Assess weight, age, >to evaluate degree of nutritional deficit. >to help the significant others establish a nutritional plan. >Assess patients condition >to indentify patients needs and for plan of intervention. Long Term: The patient shall have increased in weight and maintain nutrition status. Nursing interventions >monitor and record vital signs >to have baseline data Rationale Expected Outcome Short term: The patient or significant others shall have verbalized understanding of the bodys energy needs.
experience increase rate in After 3 weeks of NI, body built and metabolism which further lead to wasting of nutrients. Fever also because loss of appetite which contributes to intake of nutrients to meet the bodys metabolic needs. the patient will increase in weight and maintain nutrition status. activities. >Instruct the patients significant to follow diet regimen.
64
>Emphasize importance of nutritious and well balanced in take.
>to promote wellness
>Provide comfort measures especially during meals
>To promote relaxation and stimulate patients appetite
>Encourage adequate rest period especially before eating
> to further increase strength
> encourage use of techniques to reduce stress
>to promote relaxation and stimulate patients
65
appetite.
Problem # 3: Risk for injury r/t decrease platelet count 2 to DHF

Nursing Diagnosis Risk for injury r/t decrease platelet count 2 to DHF Expected Outcome >to obtain Short term: The patient shall have remained >Assess level of consciousness and cognitive level >assist in determining patients ability to protect self and comply Long Term: After 1 day of nursing interventions, the patient will demonstrate behavior, and >Provide safe environment (pad, >Minimizes injury to occur with required self protective actions Long Term: The patient shall have demonstrated techniques behavior, lifestyle changes to risk factors and protect self. > Replace sharp > Avoids cuts free from injury
Assessment S:> O:>patient manifested the following which put his at risk for injury: >Low platelet count of 83 >Abnormal blood profile
Scientific Explanation Risk of Injury as a result of environmental conditions interacting with the individuals adaptive and defensive resources. It is also because of the infection of DHF I Virus that destroys the platelets which place the patient at risk of bleeding. When the blood vessels are cut or damage, the loss of blood from the system must be
Objectives Short term: After 4 hours of nursing interventions, patient will remain free from injury.
Nursing interventions >monitor and record vital signs
Rationale
Patient may manifest: >Sensory dysfunction >Broken Skin
stop before shock and possible death may occur. This is accompanied by solidification of the blood, a process called
protect self from side rails, prevent falls) injury
66
>Malnutrition
coagulation or clotting. If the value should stop below normal,(150,000 450,000 g/dl), there is a danger of uncontrolled bleeding because of the essential role that platelets have in blood clotting.
object(razor/knife) with safer items
and bleeding
> Observe for each stool color, consistency and amount
>Permits detection of bleeding in GI tract
>Be alert for symptoms of anxiety epigastric fullness, weakness and restlessness
>May indicate early sign of bleeding and shock
>Observe for hemorrhagic manifestation, ecchymosis, epistaxis, Petechiae, and bleeding gums
>Indicate altered clotting mechanism
> Provide soft toothbrush, instruct patient to avoid use
> Prevents trauma to oral mucous while
67
of toothpick
promoting good oral hygiene
>Encourage intake of foods with high content of Vit. C
> Promotes healing
> Provide comfort measures, such as stretching bed linens
> To promote relaxation and alleviate anxiety
>Demonstrate and encourage use of techniques to reduce risk for injury like providing assistance during ambulation.
>To reduce risk for injury.
>determine the need for safety ambulation devices > to assist client and reduce
68
individual risk factors and promote safety
> Avoid SC, IM route of injection as possible
> Minimizes tendency of trauma or bleeding
Problem # 4: Risk for altered tissue perfusion

Nursing Diagnosis Risk for altered tissue perfusion Scientific Objectives Explanation Due to the replication of dengue virus in the body, there could be stimulation of production of kinine causing increase vascular permeability leading to capillary Short term: After 4 hours of nursing interventions the SO will verbalize understanding on behaviors that will improve patients tissue perfusion. >assess for possible causative factors related to temporarily impaired arterial blood flow >early detection of cause facilitates prompt, effective treatment Nursing interventions >Monitor and record vital signs Rationale Expected Outcome >to have baseline data Short term: The SO shall have verbalized understanding of behaviors that will improve patients tissue perfusion.
Assessment S> O> patient manifested: >appears pale and weak >flushed palms and soles > capillary refill of 1 second
69
damage. Thus will cause internal bleeding. Long Term: After 3 days of nursing interventions, the patient will maintain normal tissue perfusion AEB Hgb on normal level
>Monitor quality of all pulse
>loss of peripheral pulses must be reported or treated immediately Long Term: The patient shall have maintained normal tissue
>maintain optimal cardiac output
>to increase cellular oxygen supply
perfusion AEB Hgb on normal level
>review laboratory values and note customary baseline data
>to evaluate the importance of nursing interventions given and provide comparison by current findings
70
Problem # 5: Fatigue
Nursing diagnosis Fatigue Scientific Objectives Explanation Being in a disease O>patient manifested: >listlessness >drowsiness >weakness condition can alter an individuals capacity for physical and mental work at Patient may manifest: >disinterest in surroundings >decreased performance usual level since the body itself is not in its normal level of functioning because of the increase demands for compensation. Increase demands would actually make the body Long term: After 3 days of nursing interventions the patient shall perform activities of daily living and participate in desired >limit exposure to temperature and humidity >to prevent negatively impact energy level Short term: After 4 hours of nursing interventions the SO shall identify basis of patients fatigue an individual areas of control. >instruct sitting instead of standing during daily care/other activities; taking short rest breaks during activities; asking for assistance Long term: After 3 days of nursing interventions the patient shall have performed activities of daily living and participate in desired activities >to conserve energy >encourage to have adequate rest and sleep >to minimize exertion and energy loss Nursing interventions >monitor and record vital signs > to obtain a baseline data Expected Outcome Short term: After 4 hours of nursing interventions the patient shall have identified basis of fatigue an individual areas of control.
Assessment S>
Rationale
71
exhausted.
activities at level of ability.
extremes
at level of ability.
>provide comfort measures such as use of electric fan
>to promote relaxation
>provide safety measures such as securing pillows on the bedside
>to prevent the patient from falling
>assist in activities of daily living
>to lessen energy utilization
>encourage having a well balanced following DAT except dark
>to suffice nutrients needed for metabolic needs
72
colored foods diet.
>regulate intravenous fluid as ordered.
>for proper infusion of intravenous fluid in the body
73
C. ACTUAL SOAPIERs
November 3, 2010 (6-2 shift) General Appearance: Received lying on bed, conscious & coherent with an ongoing IVF #3 of D5 0.3 NaCl 500cc x 14gtts/min infusing well on the left hand @ 80cc level. Afebrile, appears weak, with dry oral mucosa, chapped lips, platelet count of 83. V/S are taken and recorded as follows: T= 36, PR=96, RR=20, BP=90/50 Problem# 1: Risk for injury S>
O>With dry oral mucosa, chapped lips, platelet count of 83

A>Risk for injury P>After 4 hours of nursing interventions, the patient will remain free from injury I>Assessed general condition >Monitored & recorded V/S Monitored for signs of bleeding >AM care rendered >Assisted in changing position >Provided comfort & safety measures >Reinforced diet prescribed >Due meds given as ordered >Advised to use soft bristled toothbrush >Encourage to increase intake of foods rich in Vit. C E>Goal met AEB patient remained free from injury
74
Problem #2: Risk for impaired tissue integrity S>

A>Risk for impaired skin integrity P>After four hours of nursing interventions, the patients skins will remain intact I>Assessed general condition >Monitored & recorded V/S Monitored for signs of bleeding >AM care rendered >Assisted in changing position >Provided comfort & safety measures >Reinforced diet prescribed >Instructed not to give hot/irritating food to the patient >Instructed to increase fluid intake as tolerated >Instructed to gargle frequently >Due meds given as ordered >Advised to use soft bristled toothbrush >Encourage to increase intake of foods rich in Vit. C E>Goal met AEB patients skin remained intact
75
November 4, 2010 (6-2 shift) General Appearance: Received lying on bed, asleep with an ongoing IVF # 6 of D5 0.3 NaCl 500cc x 14gtts/min infusing well on the right hand @ 250 cc level. Afebrile, with dry oral mucosa, chapped lips, platelet count of 109, (-) dyspnea & absence of cyanosis. V/S are taken and recorded as follows: T= 36, PR=102, RR=24, BP=90/60 Problem# 1: Risk for injury S>

A>Risk for injury P>After 4 hours of nursing interventions, the patient will remain free from injury I>Assessed general condition >Monitored & recorded V/S Monitored for signs of bleeding >AM care rendered >Assisted in changing position >Provided comfort & safety measures >Reinforced diet prescribed >Due meds given as ordered >Advised to use soft bristled toothbrush >Encourage to increase intake of foods rich in Vit. C E>Goal met AEB patient remained free from injury
76
Problem #2: Risk for impaired tissue integrity S>

A>Risk for impaired skin integrity P>After four hours of nursing interventions, the patients skins will remain intact I>Assessed general condition >Monitored & recorded V/S Monitored for signs of bleeding >AM care rendered >Assisted in changing position >Provided comfort & safety measures >Reinforced diet prescribed >Instructed not to give hot/irritating food to the patient >Instructed to increase fluid intake as tolerated >Instructed to gargle frequently >Due meds given as ordered >Advised to use soft bristled toothbrush >Encourage to increase intake of foods rich in Vit. C E>Goal met AEB patients skin remained intact
77
VI. Clients Daily Progress in the Hospital 1. Clients Daily Progress Chart
ADMISSION 10-30-10
Day 2 10-31-10
Day 3 11-01-10
Day 4 11-02-10
Day 5 11-03-10 (1st NPI)
Day 5 11-04-10 (1st NPI)
NURSING PROBLEMS
1. Hyperthermia
2. Imbalanced Nutrition: Less than body requirements 3. Risk for injury 4. Risk for altered tse. perfusion 5. Fatigue
VITAL SIGNS
T P R BP
37 120 34 -
39 106 28 100/60
36.3 80 24 110/60
36.3 90 23 90/60
36 96 26 90/50
36.8 100 24 90/60
78
LABORATORY PROCEDURES o CBC y y y y y y y y Hemoglobin Hematocrit WBC Neutrophils Lymphocytes Monocytes Eosinophils Platelets 127 0.43 4.5 0.40 0.60 143 0.41 2.12 0.44 0.46 0.07 0.03 96 131 0.38 2.96 0.17 0.72 0.10 0.01 80 122 0.37 4.2 0.64 0.35 0.01 83 130 0.38 5.02 0.13 0.75 0.09 0.03 74 127 0.37 5.72 0.15 0.73 0.09 0.03 109
o URINALYSIS Color PH Specific Gravity Albumin Sugar Epithelial Cells RBC yellow 7.0 1.005 trace none rare 1-2
o Prothrombin Time
11.9 sec
12.3 sec
79
o APTT o Fecal Analysis Color Consistency RBC MEDICAL MANAGEMENT o IVF D5 0.3 NaCl DRUGS
Paracetamol 250 mg/5 ml, 4 ml PO q4
47.5
44.2
Brown Formed Negative
Ranitidine 20mg IV q8/q12 Oracare 10 ml TID Daktarin Ointment TID Dulcolax Iterax 5 ml PO Diet NPO DAT except dark colored foods
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2. Discharge Planning a. General condition of client upon discharge He appears well than the time he was admitted and able to do his activity of daily living. No sign of weakness. There is absence of signs and symptoms of his previous disease according to what is expected.
b.
METHOD
Home Management and Maintenance Medication: y Instructed patients significant others to give the following medications to the patient: Nutroplex 1 tsp OD Ceelin 5 ml 2x a day Exercise: y y y Encouraged ambulation within limits of individuals ability. Instructed patient to do moderate activity Encouraged patients significant others to assist patient in activity of daily living
Treatment: y Emphasized to patients significant others the importance of strict compliance to treatment regimen Health teaching: y y Instructed patients significant others to have adequate rest period Instructed patients significant others to observe for any signs of bleeding and refer to HCP y Instructed patients significant others to drink at least 8 glasses of water daily
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Out patient department: y Diet: y y Encouraged the patient to eat nutritious foods for her faster recovery. Informed the patient that dark colored foods are no longer prohibited. Instructed patient to come back the next Monday for a follow up check.
VII. Conclusion and Recommendations It is inevitable to experience illness. And once under this state, not a single person can say that he/she is not the least bit afraid. That is why it is important to as much as possible; prevent illness from afflicting our bodies in the first place. This is what the student-nurse has learned from this case study. Dengue Fever, are one of the many diseases that originate from poor sanitation. By being lax regarding maintaining cleanliness in the environment, new breeding sites sprout for rodents or mosquitoes that may cause different disease condition. This is where the essentiality of health education is presented. Patient education is an important preventive aspect of the disease and is basically one of the primary roles of nurses. Additionally, acquiring a disease is not only the burden of the patient, but also the burden of his/her family and significant others. What the patient feels is also being felt by his significant others. As student nurses, handling such cases feeds the group with learning. Being exposed in the hospital broadens their horizons in the different kinds of diseases and their management as well as how to give or deliver proper care to the patient. This study is in response to the essential provision of helpful information to the authorized facilitator of care and, as well, to the concerned public in which, in some cases, knowledge deficit is an issue. After accomplishing the study, the following recommendations were formulated by the group: 82
To all patients who were diagnosed with Dengue Fever now is the time for them to have an idea about the curative procedure suitable for their condition and what are the different preventive measures that they could practice in order to prevent its occurrence.
To the student nurses - This study provides additional knowledge and awareness regarding the disease. This could be shared to the public by the student nurses through propagation of rightful health teachings.
To the registered nurses learning never stops when you are a nurse. Understanding the said case and having knowledge on it can really strengthen their care given and rendered to each patient who is unaware of what course of action he is to utilize.
To the whole medical team - This study can enhance the level of awareness to each member of the medical team and it will bring out the best possible solutions to help patients who are unaware about the possible procedure that may be taken into consideration in order to correct the abnormality present.
To the Department of Health the Department of Health must conduct seminars, symposia, lectures, and conferences, tackling more about the case, preventive measure, risk factors, etc., so that the medical field, and as well as the whole community at large will be fully aware of the disease condition.
To the whole country at large - This study reaches all people around the country, primarily to increase their awareness on how to prevent the occurrence of such disease condition.
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VIII. Sociogram
Legend: It represents the Student Nurses who helped AedeeFlavier towards improvement of his condition. This refers to the final assessment and evaluation done by the student nurse.
It represents AedeeFlavier adhering to the said health teachings and medication regimen in order to regain his healthier state.
This refers to the health teachings given by the student nurse to the patient
This refers to the health teachings given by the student nurse to the patient to help him improve his health.
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IX. Bibliography Book Source y y y y y Daviss Comprehensive Handbook of Laboratory and Diagnostics Tests Lippincott Williams & Wilkins Professional Guide to Diseases 9th Edition Ray A. Hargrove-Huttel Medical-Surgical Nursing 4th Edition Brunner &Suddarths Handbook of Laboratory and Diagnostic Tests Joyce Black Medical Surgical Nursing Clinical Management for Positive Outcomes, 8th edition y Lippincotts Nursing Drug Guide 2010
Internet Source y y y http://www.medicinenet.com/dengue_fever/article.htm http://www.cdc.gov/ncidod/dvbid/dengue/ http://www.medindia.net/news/Dengue-Cases-Up-in-the-PhilippinesOfficial-30397-1.htm y http://www.who.int
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Dengue Fever

RLE IV-Case Study

spontaneous bleeding 2. Grade II thrombocytopenia + hemoconcentration; Presence of

spontaneous bleeding 3. Grade III thrombocytopenia + hemoconcentration; Hemodynamic

Schematic Diagram Father Side Mother Side

Grandfather Grandmother ( - ) (??)

-Extremities: (-) edema, normoflexion, full & equal pulse

Heart No lift or heave has been noted at pericardium area.

Skull and Face

Thorax and Lungs

DO: 10-30-10 DR: 10-30-10

This test evaluates blood loss erythropoietic ability,

that normal levels of 143 Hgb which

DO: 10-31-10 DR: 10-31-10

anemia & response to therapy. Hemoglobin is an important

ensures adequate oxygenation of

tissues in the body 131

DO: 10-31-10 DR: 11-01-10

component of RBC that carries oxygen to the tissue.

DO: 11-01-10 DR: 11-02-10

DO: 11-02-10 DR: 11-03-10

The results indicate that there is normal concentration of

replacement & It fluid also RBC. a of 0.38 0.41

RBC in the blood

DO: 11-02-10 DR: 11-03-10

DO: 11-03-10 DR: 11-04-10

DO: 10-30-10 DR: 10-30-10

WBCs protect against

The decreased levels of WBCs indicateimpairment

DO: 10-31-10 DR: 10-31-10

microorganisms and to remove from dead cells

in the immune system which exposes the patient

DO: 10-31-10 DR: 11-01-10

in possible bacterial or viral infections.

DO: 11-01-10 DR: 11-02-10 DO: 11-02-10 DR: 11-03-10

The results are normal which indicate

DO: 11-03-10 DR: 11-04-10

improvement in the bodys immune system

DO: 10-31-10 DR: 11-01-10

Helpful in localizing the infection and in immobilizing the

The elevated results indicate that there is failure in

DO: 11-02-10 DR: 11-03-10

pathogens until the WBC arrives.

the immune system from localizing and

DO: 11-03-10 DR: 11-04-10 DO: 10-30-10 DR: 10-30-10

controlling the spread of infection.

The normal levels of neutrophils indicate that the

DO: 10-31-10 DR: 10-31-10

bodys immune system is adequate to localize and

The normal level of lymphocytes indicates that there

are adequate antibodies to eliminate infection.

lymphocyte levels indicate presence

DO: 11-02-10 DR: 11-03-10

of infection and the body tries to compensate

DO: 10-31-10 DR: 10-31-10

Monocytes ingest nonbacterial foreign substances, usually

Elevation of monocyte level indicates presence

DO: 10-31-10 DR: 11-01-10

during chronic infection.

DO: 11-02-10 DR: 11-03-10

DO: 11-03-10 DR: 11-04-10 DO: 11-01-10 DR: 11-02-10

DO: 11-02-10 DR: 11-03-10

The decreased levels of platelet indicate that the