Professional Documents
Culture Documents
College of
Nursing
A Case Study on
Dengue Hemorrhagic Fever
Submitted to
Professor Kathlyn Elizabeth Santiago
Submitted by
Johnson Baingan
Catherine Calimlim
Janice Pola Congzon
Ma. Theresa Dimaculangan
Dean Fornea
Erlyn Regondon
Ronaldo Zamora
September 2008
ACKNOWLEDGMENT
First of all, we would like to thank the Almighty God for the enlightenment
and strength He has bestowed on us in doing this case study.
We would like to acknowledge the following people:
To Ms. Kathleen Elizabeth Santiago for being one of our mentors;
To Mr. Edgar Clariz, for allowing us to review the medical records of our
patient; and
To our group, for the effort and a job well done!
TABLE OF CONTENTS
I
II
III
IV
V
VI
VII
VIII
IX
X
XI
XII
XIII
INTRODUCTION..................................................................1
OBJECTIVE........................................................................4
ANATOMY AND PHYSIOLOGY................................................5
DENGUE AND DENGUE HEMORRHAGIC FEVER......................10
PATHOPHYSIOLOGY...........................................................16
COMPREHENSIVE HEALTH HISTORY.....................................27
PHYSICAL ASSESSMENT....................................................29
DIAGNOSTICS AND LABORATORY EXAMS.............................32
MEDICAL MANAGEMENT.....................................................42
COURSE IN THE WARD 44
DRUG ANALYSIS...............................................................46
NURSING CARE PLAN........................................................49
HEALTH TEACHING............................................................58
I. INTRODUCTION
Dengue infection is one of the most common mosquito borne viral diseases of
public health significance. It has been identified as a clinical entity since
1780. Dengue is found in tropical and sub-tropical regions around the world,
predominantly in urban and semi-urban areas.
most
Asian
countries
and
has
become
leading
cause
of
Patient X temperature was closely monitored during his 6 day stay in the
hospital. His first 3 days was a period of high-fever, a classic symptom of
Dengue Fever in its Febrile stage. On his first day, the patient had a
convulsive state due to his elevated fever. Frequent tepid sponge bath were
given to him, two to four times in an eight hour shift, in conjunction with his
anti-pyretic drug medication to relieve him from his discomfort brought by
his high temperature. Anti-biotics was also part of his medication to treat his
tonsilopharyngitis. Within his first three day stay, patient is irritable most of
time, restless and crying. Patient X seldom ate the foods served to him. On
his fourth day, a significant drop in his temperature was noted, as low as
36.8 oC which is a sign that the patient is entering into the toxic stage of
Dengue Fever. This state of defervescence, is a period where the number of
patients platelet is at its lowest. It is at this time where his attending
physician
platelet count below 20,000 /L which would place the patient a candidate for
hemorrhagic bleeding.
After the significant drop of the clients temperature, Patient X temperature
were elevated again for eight hours, a normal phenomenon for a DHF patient
before entering into the convalescent stage. His fifth day up to his seventh
day stay in the pediatric ward was a period of recuperation. Patient Xs
Attending Physician noted the appearance of Hermans rash on his sixth day,
which is an indication that the patient is fully recovering since a rash after
the period of toxic stage is common to a patient suffering from DHF.
The patient was discharged on the seventh day with a resolving Dengue
Hemorrhagic Fever as his final diagnosis.
DENGUE HEMORRHAGIC FEVER
Asian
and
Latin
American
IMCI
adaptations.
Most
of
these
of
dengue.
The
Guidelines
for
Treatment
of
Dengue
II.
OBJECTIVES
General objective
This case study aims to identify and determine the general health problems
and needs of the patient with an admitting diagnosis of dengue hemorrhagic
fever. This presentation also intends to help patient promote health and
medical understanding of such condition through the application of nursing
skills. This paper is also intended to provide a better understanding of the
disease process based on the patients health history and as a reference for
future nursing students.
Specific Objectives
cellular
component
of
blood
(red
blood
cells
or
These
cellular
neutrophils (mature form of a WBC), and 175 billion platelets each day.
When the body needs more blood cells, as in infection (when WBCs are
needed to fight the invading pathogen) or in bleeding (when more RBCs are
required), the marrow increases its production of the cells required. Thus,
under normal conditions, the marrow responds to increased demand and
releases adequate numbers of cells into the circulation.
The volume of blood in humans is approximately 7% to 10% of the normal
body weight and amounts to 5 to 6 L. Circulating through the vascular
system and serving as a link between body organs, the blood carries oxygen
absorbed from the lungs and nutrients absorbed from the gastrointestinal
tract to the body cells for cellular metabolism. Blood also carries waste
products produced by cellular metabolism to the lungs, skin, liver, and
kidneys, where they are transformed and eliminated from the body. Blood
also carries hormones, antibodies, and other substances to their sites of
action or use.
Blood is made up of plasma (fluid component) and formed elements (cellular
component). Plasma consists of about 90% water and 10% solutes
(electrolytes, albumin, globulins, and clotting factors). The formed elements
include erythrocytes (red blood cells
[RBCs]),
leukocytes
(white
blood
leak
Excessive
in
the
blood
clotting
is
vessels.
equally
this, the body has a fibrinolytic mechanism that eventually dissolves clots
(thrombi) formed within blood vessels. The balance between these two
systems, clot (thrombus) formation and clot (thrombus) dissolution or
fibrinolysis, is called hemostasis.
BONE MARROW
The bone marrow is the site of hematopoiesis, or blood cell formation. In a
child all skeletal bones are involved, but as the child ages marrow activity
decreases. By adulthood, marrow activity is usually limited to the pelvis, ribs,
vertebrae, and sternum. Marrow is one of the largest organs of the body,
making up 4% to 5% of total body weight. It consists of islands of cellular
components (red marrow) separated by fat (yellow marrow). As the adult
ages, the proportion of active marrow is gradually replaced by fat; however,
in the healthy person, the fat can again be replaced by active marrow when
more blood cell production is required. In
adults with disease that causes marrow destruction, fibrosis, or scarring, the
liver and spleen can also resume production of blood cells by a process
known as extramedullary hematopoiesis. The marrow is highly vascular.
Within it are primitive cells called stem cells. The stem cells have the ability
to self-replicate, thereby ensuring a continuous supply of stem cells
throughout the life cycle. When stimulated to do so, stem cells can begin a
process of differentiation into either myeloid or lymphoid stem cells. These
stem cells are committed to produce specific types of blood cells. Lymphoid
stem cells produce either T or B lymphocytes.Myeloid stem cells differentiate
into three broad cell types: RBCs,WBCs, and platelets. Thus, with the
exception of lymphocytes, all blood cells are derived from the myeloid stem
cell. A defect in the myeloid stem cell can cause problems not only with WBC
production but also with RBC and platelet production. The entire process of
hematopoiesis is highly complex.
PLATELETS (THROMBOCYTES)
Platelets, or thrombocytes, are not actually cells. Rather, they are granular
fragments of giant cells in the bone marrow called megakaryocytes. Platelet
production
in
the
marrow
is
regulated
in
part
by
the
hormone
an inactive form in the blood plasma until activated by the clotting cascade.
The gamma globulin fraction refers to the immunoglobulins, or antibodies.
These proteins are produced by the well-differentiated lymphocytes and
plasma cells. The actual fractionation of the globulins can be seen on a
specific
laboratory
test
(serum
protein
electrophoresis).
Albumin
is
fifths of the world's population (2.5billion) lives in areas potentially at risk for
dengue. Because travelers to endemic areas are also at risk, healthcare
providers should have an understanding of the spectrum of infection, how to
diagnose it, and what the appropriate treatment is.
Dengue infection is caused by any of four dengue virus serotypes. The clinical
manifestations range from asymptomatic infection to undifferentiated fever,
dengue fever and dengue hemorrhagic fever (DHF). DHF is characterized by
sustained high fever for 27 days; bleeding diathesis such as positive
tourniquet test, petechiae, epistaxis and hematemesis; thrombocytopenia
with platelet counts
less than
and
ascites.
Bleeding
diathesis
is
caused
by
vasculopathy,
There are four distinct, but closely related, viruses that cause dengue.
Recovery from infection by one provides lifelong immunity against that
serotype but confers only partial and transient protection against subsequent
infection by the other three. There is good evidence that sequential infection
increases the risk of more serious disease resulting in DHF.
Prevalence
The global prevalence of dengue has grown dramatically in recent decades.
The disease is now endemic in more than 100 countries in Africa, the
Americas, the Eastern Mediterranean, South-east Asia and the Western
Pacific. South-east Asia and the Western Pacific are most seriously affected.
Before 1970 only nine countries had experienced DHF epidemics, a number
that had increased more than four-fold by 1995.
Some 2500 million people -- two fifths of the world's population -- are now at
risk from dengue. WHO currently estimates there may be 50 million cases of
dengue infection worldwide every year.
In 2001 alone, there were more than 609 000 reported cases of dengue in
the Americas, of which 15 000 cases were DHF. This is greater than double
the number of dengue cases which were recorded in the same region in
1995.
Not only is the number of cases increasing as the disease is spreading to new
areas, but explosive outbreaks are occurring. In 2001, Brazil reported over
390 000 cases including more than 670 cases of DHF.
Some other statistics:
During epidemics of dengue, attack rates among susceptible are often 40 -50%, but may reach 80 -- 90%.
An estimated 500 000 cases of DHF require hospitalization each year, of
whom a very large proportion are children. At least 2.5% of cases die,
although case fatality could be twice as high.
Without proper treatment, DHF case fatality rates can exceed 20%. With
modern intensive supportive therapy, such rates can be reduced to less than
1%.
The spread of dengue is attributed to expanding geographic distribution of
the four dengue viruses and of their mosquito vectors, the most important of
which is the predominantly urban species Aedes aegypti. A rapid rise in urban
populations is bringing ever greater numbers of people into contact with this
vector, especially in areas that are favorable for mosquito breeding, e.g.
where household water storage is common and where solid waste disposal
services are inadequate.
Clinical Presentation
Dengue fever is a severe, flu-like illness that affects infants, young children
and adults, but seldom causes death.
The clinical features of dengue fever vary according to the age of the patient.
Infants and young children may have a non-specific febrile illness with rash.
Older children and adults may have either a mild febrile syndrome or the
classical incapacitating disease with abrupt onset and high fever, severe
headache, pain behind the eyes, muscle and joint pains, and rash.
The
three
stages
of
clinical
presentation
are
named
febrile, toxic
by
high
fever,
hemorrhagic
phenomena--often
with
bleeding
or
thrombocytopenia.
Further
evaluation
in
large
such
as
petechiae,
epistaxis
and
hematemesis;
grade
III,
circulatory failure manifested by a rapid and weak pulse with narrowing pulse
pressure ( less than 20 mmHg) or hypotension, with the presence of cold
clammy skin and restlessness; and grade IV, profound shock in which pulse
and blood pressure are not detectable.
V.
PATHOPYSIOLOGY
Etiologic agent
Dengue viruses type 1, 2, 3, & 4
Alternative Names
Hemorrhagic dengue; Dengue shock syndrome; Philippine hemorrhagic
fever; Thai hemorrhagic fever; Singapore hemorrhagic fever
Definition/Transmission
Dengue hemorrhagic fever is a severe, potentially deadly infection bite by
certain mosquitoes (Aedes aegypti ). Day biting female mosquito that breeds
in the household or standing clean water.
Dengue viruses are transmitted to humans through the bites of infective
female Aedes mosquitoes. Mosquitoes generally acquire the virus while
feeding on the blood of an infected person. After virus incubation for 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, but the role of this in sustaining
transmission of virus to humans has not yet been delineated.
Humans are the main amplifying host of the virus, although studies have
shown that in some parts of the world monkeys may become infected and
perhaps serve as a source of virus for uninfected mosquitoes. The virus
circulates in the blood of infected humans for two to seven days, at
approximately the same time as they have fever; Aedes mosquitoes may
acquire the virus when they feed on an individual during this period.
Incubation Period
Uncertain, Probably 6 days to one week.
Period of Communicability
Unknown. Presumed to be on the first week of illness when virus is still
present in the blood.
Susceptibility, Resistance and Occurence
All persons are susceptible. Both sexes are equally affected. Age groups
predominantly affected are the preschool and school age. Adults and infants
are not exempted. Peak age affected 5-9 years of age.
Occurrence is sporadic throughout the year. Epidemic usually occur during
the rainy season as June November. Peak months are September and
October.
Susceptibility is universal. Acquired immunity may be temporary but usually
permanent.
Causes
Four different dengue viruses have been shown to cause dengue hemorrhagic
fever. This condition occurs when a person catches a different dengue virus
after being infected by another type sometime before. Prior immunity to a
different dengue virus type plays an important role in this severe disease.
Worldwide, more than 100 million cases of dengue fever occur every year. A
small number of these develop into dengue hemorrhagic fever. Most
infections in the United States are brought in from other countries. It is
possible for a traveler who has returned to the United States to pass the
infection to someone who has not traveled.
Risk factors for dengue hemorrhagic fever include having antibodies to
dengue virus from prior infection and being younger than 12, female, or
Caucasian.
Pathogenesis
The pathogenesis of DHF is poorly understood. DHF caused by primary or
secondary dengue infection is due to the occurrence of abnormal immune
response involving production of cytokines or chemokines, activation of Tlymphocytes and disturbance of the hemostatic system.
phenomenon
known
as
original
antigenic
sin,
and
is
undergoing
programmed cell death. Many denguespecific T-cells are of low affinity for the
infected virus and show higher affinity for other, probably previously
encountered serotypes. Profound T-cell activation and death during acute
dengue infection may suppress or delay viral elimination, leading to the
higher viral loads and increased immunopathology found in patients with DHF
Symptoms
Early symptoms of dengue hemorrhagic fever are similar to those of dengue
fever, but after several days the patient becomes irritable, restless, and
sweaty. These symptoms are followed by a shock-like state.
Bleeding may appear as pinpoint spots of blood on the skin (petechiae) and
larger patches of blood under the skin (ecchymoses). Bleeding may occur
from minor injuries. Shock may cause death. If the patient survives, recovery
begins after a one-day crisis period.
Early symptoms include the following:
Fever
Malaise
Headache
Decreased appetite
Muscle aches
Vomiting
Joint aches
Shock-like state
Sweaty (diaphoretic)
Petechiae
Ecchymosis
Generalized rash
The severity of DHF is categorized into four grades: grade I, without overt
bleeding but positive for tourniquet test; grade II, with clinical bleeding
diathesis
such
as
petechiae,
epistaxis
and
hematemesis;
grade
III,
circulatory failure manifested by a rapid and weak pulse with narrowing pulse
pressure ( less than 20 mmHg) or hypotension, with the presence of cold
clammy skin and restlessness; and grade IV, profound shock in which pulse
and blood pressure are not detectable.
Category I
Category II
Category III
Category IV
History or
presence of
fever 2-7
days duration,
with a (+)
tourniquet
test or
presence of
skin flushing
or petechial
rash
Category I plus
Presence of one or more
Danger Signs (especially
defervescence)
Restlessness
Changes in sensorium
Cold, clammy skin
Sudden onset of
abdominal pain
Difficulty of breathing
Circumoral cyanosis
Seizures
Spontaneous bleeding
(gum bleeding,
epistaxis, rashes,
petechiae)
Category II plus
Circulatory failure
Cold clammy skin
Weak thready
pulse
Narrow pulse
pressure ( less
than 20mm/Hg)
Hypotension
Restlessness
Category III
plus profound
shock with
undetectable
pulse and
blood
pressure
hypoproteinemia/hypoalbuminemia,
pleural
effusion,
ascites, threatened shock and profound shock. The rising hematocrit may not
be evidenced because of either severe bleeding or early intravenous fluid
replacement.
Bleeding tendency
The bleeding diathesis is caused by vasculopathy, thrombocytopenia, platelet
dysfunction and coagulopathy.
Vasculopathy
A positive tourniquet test indicating the increased capillary fragility is found
in the early febrile stage. It may be a direct effect of dengue virus as it
appears in the first few days of illness during the viremic phase.
Thrombocytopenia and platelet dysfunction.
Patients with DHF usually have platelet counts less than 100 x 10 9/L.
Thrombocytopenia
is
most
prominent
during
the
toxic
stage.
The
the
number
of
platelets
is
rapidly
increased
in
the
convalescent stage and reaches the normal level within 710 days after the
defervescence.
Platelet dysfunction as evidenced by the absence of adenosine diphosphate
(ADP) release was initially demonstrated in patients with DHF during the
convalescent stage. The subsequent study during the febrile and early
antithrombin
degradation
and
product
or
antiplasmin,
have
D-dimer
slightly
is
been
demonstrated.
elevated.
Low
Fibrin
levels
of
Shock
Encephalopathy
Seizures
Liver damage
Diagnostic Procedure
Red throat
Swollen glands
Rash
Enlarged
Red eyes
(hepatomegaly)
Hematocrit
Platelet count
Electrolytes
Coagulation studies
Liver enzymes
liver
Release cuff and make an imaginary 1square inch just below the cuff,
Serum
studies
from
samples
taken
during
acute
illness
and
Medical Management
Management Protocol in DHF by Dept. of Health (strategies)
Health education/Advocacy
Surveillance
Training
Medical Treatment
Assist
in
the
trendelenburg
management
position.
of
Dorsal
shock.
Dorsal
recumbent
recumbent
position
to
facilitates
circulation.
Diet:
Low fat, low fiber, non irritating, non carbonated, non acidic
food. Noodle soup may be given. No dark colored foods, which can
be mistaken as melena for a dark colored stool.
Outlook (Prognosis)
With early and aggressive care, most patients recover from dengue
hemorrhagic fever. However, half of untreated patients who go into shock do
not survive
Patient History
Patient X is a toddler, admitted into the hospital around 5:00 am carried by
his mother.
He is born healthy, under normal spontaneous vaginal delivery without any
body-marks or observable congenital birth defects. He has completed his
immunization program for the following vaccines: BCG, DPT, OPV, MEASLES
and HEPA-B.
Patient X being the youngest of three 3 siblings, stays with her mother most
of time at home. This is his first time to contact a serious illness since his
birth. Most of the time he frequently catch common colds and slight to
moderate fever but not of a high grade fever. The night prior to his admission
to the hospital, patient X is feverish and it worsens in the wee hours of the
morning. Patient is irritable, crying and has vomited for about three times.
FINDINGS
The patient looks weak and with eyebags.
Temperature: 40.5
Respiration: 30 cpm
Pulse Rate: 110
Blood Pressure: 90/40
Skin
Hair
Head/skull
Eyes
Ears
Nose
Lips
Neck
Thorax/Lung
Mental Status
Respiratory
(-) Hoarseness
(-) Persistent cough
(-) Blood in spit
(-) Shortness of breath
Cardiovascular
(-) Chest pain traveling down left arm
(-) Palpitations
Genitourinary
(-) Painful urination
Endocrine
(-) Chronic fatigue
(-) Weight loss recent
(-) Bruise easily
(-) Cold extremities
(-) Tremors (shaking of hands)
(-) Convulsions
(+) Muscle weakness
Neurological
(-) Numbness
(-) Tingling sensations
(-) Moodiness
(+) Headaches
(-) Nervousness
Musculoskeletal
(-) Neck pain
(-) Joint pain
(-) Low back pain
(-) Foot pain
(-) Stiff joints
Skin
(-) Petechiae rashes
(-) Hives
HEMATOLOGY RESULT
Day 1
Hemoglobin-13.6 M:(13.0-18.0 Cms%)
F:(12.0-18.0 Cms%)
F: (3.8-5.8x10 L)
C:(11.7-13-0 Cms%)
C: (4.0-5.2x10 L)
WBC---4.7---(4.5-10X10 L)
F:(0.37-0.47 Vol%)
C:(0.32-0.42 Vol%)
Differential Count:
Segmenters-----0.80 (0.50-0.70)
Blood Type O+
Lymphocytes---0.20 (0.20-0.40)
Bleeding Time----(1-4mins)
Eosinophils------------(0.01-0.05)
Clotting Time-----(2-5mins)
Basophils---------------(
-0.01
Monocytes--------------(
-0.03)
E.S.R
M:(0.10mm/hr)
F: (0.20mm/hr)
_________________________________
(Commanding Officer)
_________________________________
(Comanding Officer)
______________________
(Medical Technologist)
______________________
(Medical Technologist)
The Complete Blood Count is a screening test, used to diagnose and manage
numerous diseases. Test results shows normal value for Lymphocytes.
Eosiniphils Basophils and Monocytes values were not included in the
laboratory result, a marked increased in WBC indicates a positive infection.
Neutrophils/Segmenters are elevated, suggestive of Bacterial infection.
Lymphocytes are responsible for immune responses. An elevation is present
in cases of viral infection, leukemia, cancer of the bone marrow, or radiation
therapy while a decreased lymphocyte level can indicate diseases that affect
the immune system.
HEMATOLOGY RESULT
Day 4
Hemoglobin-14.3 M:(13.0-18.0 Cms%)
RBC 5 M: (4.5-6.5x10 L)
F:(12.0-18.0 Cms%)
F: (3.8-5.8x10 L)
C:(11.7-13-0 Cms%)
C: (4.0-5.2x10 L)
WBC---8.2---(4.5-10X10 L)
F:(0.37-0.47 Vol%)
C:(0.32-0.42 Vol%)
Differential Count:
Segmenters-----0.36 (0.50-0.70)
Blood Type O+
Lymphocytes---0.64 (0.20-0.40)
Bleeding Time----(1-4mins)
Eosinophils------------(0.01-0.05)
Clotting Time-----(2-5mins)
Basophils---------------( -0.01)
E.S.R
Monocytes--------------( -0.03)
M:(0.10mm/hr)
F: (0.20mm/hr)
_________________________________
(Commanding Officer)
_________________________________
(Comanding Officer)
______________________
(Medical Technologist)
______________________
(Medical Technologist)
URINALYSIS RESULT
Day 1
Physical Appearance
Test
Result
Normal
Color
Yellow
Yellow
Transparency
Slightly hazy
Clear
Reaction PH
6.0
4.6 - 8.0
Specific Gravity
1.030
1.010 1.035
Sugar
Negative
Absent
Protein
Negative
Absent
Microscopic
Test
Result
Normal
Pus Cell
0-3
Absent
RBC
0-1
0-5
Epithelial Cells
Occasional
Protein
Negative
Crystal
Amorphous urates
Positive
Amorphous Phosphate
Blank
Absent
Urinalysis can disclose evidence of diseases, even some that have not caused
significant signs and symptoms. The color of urine is normally yellow, but if it
is reddish, this is indicative of presence of blood in the urine. Urine
transparency
should
be
clear.
Urine
specific
gravity
measures
the
Presence of protein
below
1.007
to
1.010
indicates
hydration
and
any
phosphates are found in alkaline urine. The amorphous urates seen in urine
specimens are of little clinical value.
FECALYSIS
Day 3
Color: Yellow
Consistency: Soft
Fecalysis result is normal, no dark colored bowel that would indicate GI bleeding.
TYPHIDOT
Day 3
Test Result:
IgG : Positive
IgM
: Negative
Interpretation of typhidot test should be based on the result of IgM. A positive IgM is
indicative of typoid fever. Typhidot test can be used as a valid tool in the diagnosis of
typhoid fever among Filipinos but whenever feasible, confirmation with blood cultures is
strongly encouraged especially with the appearance of drug resistant strains in the
community. A valid conclusion can be made from a single sample based on results of
IgM titer. Typhidot offers the advantage of speed, simplicity and early diagnosis.
Day 1
Day 3
13.6
0.41
4.7
4.7
0.80
0.20
138
Day 4
14.3
0.43
5
8.2
0.36
0.64
190
Yellow
Slightly Hazy
Normal Values
13.0 - 18.0 Cms%
0.40 - 0.54 Vol%
4.5 - 6.5x10 L
4.5 - 5.2x10 L
0.50 - 0.70
0.20 - 0.40
150 - 350
Yellow
Clear
4.6 - 8.0
1.010 - 1.035
Absent
Absent
6.0
1.03
Negative
Negative
0-3
0-1
Occasional
Negative
Absent
0-5
Absent
Positive
Blank
Yellow
Soft
Positive
Negative
TPR SHEET
Hours
Temperature
8H
12H
4H
8H
12H
4H
40.5
39.8
37.5
38.0
38.8
37.2
Day 1
Pulse
Rate
110
105
102
108
108
114
Hours
Temperature
Day 2
Pulse Rate
8H
12H
4H
8H
12H
4H
37.6
39.2
39.3
37.5
37.8
38.1
102
102
122
100
106
108
Hours
Temperature
8H
12H
4H
8H
12H
4H
38.3
37.8
38.1
37.1
37.8
38.8
Day 3
Pulse
Rate
110
114
116
110
112
116
Respiratory
Rate
Blood
Pressure
30
37
35
40
30
32
Respiratory
Rate
Blood
Pressure
24
18
24
27
25
27
Respiratory
Rate
28
27
26
27
28
29
Blood
Pressure
90/40
Day 4
Hours
8H
12H
4H
8H
12H
4H
Temperature
38.2
38.2
36.8
39.4
38.3
37.2
Pulse Rate
118
118
118
126
114
94
Respiratory
Rate
40
35
37
40
34
37
Blood
Pressure
Day 5
Hours
8H
12H
4H
8H
12H
4H
Hours
Temperature
8H
12H
4H
8H
12H
4H
37.3
36.3
36.4
36.5
36.0
36.0
96
94
82
78
70
70
Day 6
Pulse
94
112
100
100
102
98
Respiratory Blood
Rate
Pressure
23
23
22
22
26
26
Rate
28
28
28
28
26
25
Blood
Pressure
90/50
90/60
90/60
90/60
IV FLOW SHEET
Date
Bot. Solution/
/Time
No. AMT/MEDS
IV SITE AMT
Date
INFUS /Time
AMOUNT SIG
ENDORSE
9/26
1
Started
0745H
D5 0.3% NaCl
ADDED/
RATE Right
500cc x
Hand
50mggts/min
500cc
ED
2330H
Started 30cc
D
9/26
2330H
D5IMB 500cc X
50mggts/min
Right
Hand
500cc
0945H
280cc
9/26
1000H
D5IMB 500cc X
50mggts/min
Right
Hand
500cc
9/27/06
180cc
9/28
1040H
D5IMB 500cc X
50mggts/min
Right
Hand
500cc
9/28
2300H
D5IMB 500cc X
50mggts/min
Right
Hand
500cc
9/29
2300H
D5IMB 500cc X
50mggts/min
Left
Hand
500cc
9/30
0815H
D5IMB 500cc X
50mggts/min
Left
Hand
500cc
10/01
0115H
D5IMB 500cc X
50mggts/min
Left
Hand
500cc
10/01
1605H
D5IMB 500cc X
50mggts/min
Left
Hand
500cc
10/01
1345H
10
D5IMB 500cc X
50mggts/min
Left
Hand
500cc
1040H
9/28/06
20cc
2300H
9/29/06
220cc
2300H
9/30/06
80cc
0815H
10/01/06 110cc
0115H
10/01/06
0135H
10/01/06
0345H
Day 1
Assessment
Patient (+)Tonsillopharyngitis
Clear Breath Sounds
VS:
RR = 30
PR = 110
T = 40.5
BP = 90/40
Physicians Order
DIAGNOSTICS
CBC
QPC - done
Urinalysis - done
Stool Examination
THERAPEAUTICS
Admit to Pediaward
Paracetamol 125mg/5ml
@ 10:15 am
@ 16:00 pm
For Bloodtyping
Physicians Order
Day 2
Continue Meds/IVF
Physicians Order
Day 3
Continue Meds/IVF
Physicians Order
Day 4
Continue Meds/IVF
Physicians Order
Day 5
Physicians Order
Day 6
MGH
Meds:
o
Diet as
At
1000H, patient had a febrile seizure with temperature 41.8 0C, Paracetamol
was given.
The
with the value of 0.36 which is below the normal value of 0.50-0.70. After
the significant drop of the clients temperature, Patient X temperature were
elevated again for eight hours, a normal phenomenon for a DHF patient
before entering into the convalescent stage. The patient had general rashes
with itchiness.
In day 5, the patient is afebrile and positive for Hermans sign.
In day 6, the patient is afebrile and still positive for Hermans sign.
Additional medication was ordered Ascorbic acid with dosage of 100mg/5mL
to be taken 1 tsp everyday. Diagnosis of Dengue Hemorrhagic Fever II was
resolved. The patient was discharged.
XI.
Drug Study
BRAND
NAME/GENERIC
PARACETAMOL
Acetaminophen
CLASSIFICATION
Antipyretic
ACTION
Thought to
produce analgesia
by blocking pain
impulses by
inhibiting
synthesis of
prostaglandin in
the CNS or of
other substances
that sensitize
pain receptors to
stimulation. The
drug may relieve
fever through
central action in
the hypothalamic
heat-regulating
center.
ROUTE&DOSAGE
Paracetamol
125mg/5ml PO
5ml q4 RTC
Paracetamol
300mg/amp
IV ampule IV
PRN
CONTRAINDICATIONS
NURSING INTERVENTION
- Contraindicated in
patients hypersensitive
to drug.
Use cautiously in
patients with long term
alcohol use because
therapeutic doses cause
hepatotoxicity in these
patients.
Hematologic:
hemolytic anemia,
neutropenia,
leukopenia,
pancytopenia.
Hepatic: Jaundice
Metabolic:
hypoglycemia
Skin: rash, urticaria.
BRAND
NAME/GENERIC
AMPICILIN
Ampicillin
CLASSIFICATION
Anti-infective
Antibiotic
(Penicillin
Family)
ACTION
ROUTE&DOSAGE
Ampicillin: 130
mg IV q8h ANST
Children age 1
and older
weighing less than
40kg (88lb):
300mg/kg daily IV
in individual doses
every 6 hours.
Dont exceed 4 g
daily .
CONTRAINDICATIONS
NURSING INTERVENTION
- Contraindicated in
patients
hypersensitive to
drug or other
penicillins
- Use cautiously in
patients with other drug
allergies because of
possible cross sensitivity
- Before giving drug, ask
patient about allergic
reactions to penicillin.
However a negative
history of penicillin
allergy is no guarantee
against a future allergic
reaction
- Obtain specimen for
culture and sensitivity
test before giving first
dose. Therapy may
begin pending results.
-decrease dosage in
patients with impaired
renal function
- Dont use IM route in
children
-Monitor liver function
test results during
therapy
- if large doses are given
superinfection may occur
BRAND
NAME/GENERIC
Ascorbic Acid
CLASSIFICATION
Vitamins and
Minerals
ACTION
Stimulates
collagen
formation and
tissue repair,
involved in
oxidationreduction
reactions
For extensive
burns, delayed
fracture or
wound healing,
severe febrile or
chronic disease
states
ROUTE&DOSAGE
Oral liquid
100mg/5ml - 5ml
OD
CONTRAINDICATIONS
NURSING INTERVENTION
Contraindicated in
patients with an
allergy to tartrazine
or sulfites. Large
doses are
contraindicated
during pregnancy
Assessment
SUBJECTIVE:
Kahapon pa siya
inaapoy ng lagnat,
as verbalized by the
patients mother.
OBJECTIVE:
Increase in body
temperature
above normal
range: 40.5 C
Profused
Sweating
Dry lips and
mucous
membrane
Flushed skin
Warm to touch
Nursing
Diagnosis
Hyperthermia
related to direct
effect of
circulating
endotoxins on the
hypothalamus,
altering
temperature
regulation.
Inference
Dengue Fever
Elevated WBCs
Release of
endotoxins, that
cause disruption of
hypothalamic set
point
Goal
After 8 hours of
nursing intervention,
the patient will
demonstrate a
temperature within
the normal range,
free of chills and
associated
complications.
Intervention
Inference
Goal
Goal is met,
after 8 hours of
nursing
intervention, the
patient achieved
a temperature
within the
normal range as
evidenced by a
decreased in
body
temperature
from 40.5 C to
37 C. Patient
was also free of
chills and
associated
complications.
Monitor patient
temperature (degree
and pattern) and note
shaking chills or
profused diaphoresis.
Temperature of
38.9 - 41.1 C
suggests acute
infectious
diseases process.
Fever pattern
may aid in
diagnosis.
Monitor
environmental
temperature; limit or
add bed linens as
indicated.
Room
temperature or
number of
blankets should
be alterd to
maintain near
normal
temperature.
Provide tepid
sponge baths; avoid
use of alcohol.
Administer
antipyretics like
acetylsalicylic acid
(aspirin) and
acetaminophen
(Tylenol).
Increase in body
temperature
Nursing
Diagnosis
Evaluation
Assessment
Rationale
Provide cooling
blanket.
Intervention
Rationale
Evaluation
Subjective:
Ayaw kumain ng anak
ko , as verbalized by
the patients mother.
Objective:
Decreased tolerance
for activity
Weakness
Weight upon
admission in
kilogram: 13
Imbalanced
Nutrition: less
than body
requirement
related to loss of
appetite
secondary to
dengue virus
Dengue Fever
Joint pain
Nausea,
vomiting
Anorexia
Decreased
appetite
After 3 days of
nursing
intervention,
patient will
demonstrate
stable weight and
will be free of
signs of
malnutrition.
Patient or mother
will demonstrate
behaviors or
lifestyle changes
to maintain
appropriate
weight.
Independent:
Assess causative/
contributing factor:
Assess client's
weight, age, strength,
activity/rest level, and so
forth
Assess nutritional
Encourage client to
choose food that are
appealing to increase
appetite
Dependent:
Establish a nutritional
plan that meets individual
needs:
Provides
comparative baseline
Identify
deficiencies, suggests
possible interventions
To monitor
caloric intake or
insufficient quality of
food consumption
Toddlers eat a
lot of food that are
appealing to their
taste
Foods such as
gas-forming, spicy,
too hot, too cold,
caffeinated
beverages can result
to epigastric pain
that will decrease
appetite leading to
weight loss
To enhance
intake
To implement
interdisciplinary team
management
Consult
dietitian/nutritional team
as indicated
Provide nutritious
food and diet modification
as indicated.
Small frequent
feeding with aspiration
precaution
Promote pleasant,
relaxing environment
Promote
adequate/timely fluid
intake
Weigh as often as
possible and PRN
To prevent
dehydration
To monitor
effectiveness of
efforts
Presence of
inflamed throat may
affect ability to
eat/lose of appetite
Assessment
Nursing
Diagnosis
Subjective:
Nanghihina at
nanglalambot sya.
Ni hindi nga nya
kaya umupo para
uminom ng gamot,
as
verbalized by the
patents
mother.
Activity intolerance
related to
generalized
weakness and
reduced energy
stores
Objective:
Decreased
tolerance for
activity
Greater need
for sleep and
rest
Weakness and
fatigue
Inference
Fever
Nausea and
vomiting
After 8 hours of
nursing
intervention, the
mother will report a
measurable
increase in activity
tolerance
Intervention
Assess patients
ability to perform
normal tasks
noting complaints
of weakness and
fatigue
Provide quiet
atmosphere,
uninterrupted rest
periods and
maintain bed rest.
Implement
energy-saving
techniques like
sitting, rather
than standing,
when
administering oral
medications or
when providing
tepid sponge
baths.
Anorexia
Rationale
Influences
choice of
intervention and
needed
assistance
Enhances rest
to lower bodys
oxygen
requirements
and reduces
strain on the
body
Maximizes
available energy
for other tasks.
Decreased
appetite
Reduced energy
stores
Muscle weakness
and fatigue
Goal
Evaluation
Assessment
Objective:
- Weakness and
irritability.
- Restlessness.
Laboratory Values:
Platelet count: 130/ L
Hct : 0.41%
Hgb: 13.6%
Nursing
Diagnosis
Risk for
injury/bleeding
related to
altered clotting
factor secondary
to the
coagulopathy
effect of dengue
virus
Inference
Dengue virus
Immune response
involving production
of cytokines and
chemokines
activation of Tlymphocytes
Goal
After 8 hours of
nursing
intervention, the
mother
of the client will
learn through
health teaching and
demonstration the
skills and practices
in preventing injury
to the patient that
will cause him to
bleed and to
identify the signs of
ongoing internal
bleeding
Intervention
Rationale
Evaluation
Independent:
- Assess for signs and
symptoms of G.I bleeding.
Check for
secretions. Observe color and
consistency
of stools or vomitus.
Goal is met
after 8 hours
of nursing
intervention,
the mother
of the client
learned
through health
teaching and
demonstration
the skills and
practices in
preventing
injury to the
patient that
will cause him
to bleed as
evidenced by
providing soft
toothbrush to
the client and
mother also
identified the
signs of
ongoing
internal
bleeding as
evidenced by
frequent
observation of
the patients
stool color
- Monitor pulse,
Blood pressure.
vasculopathy,
increase capillary
fragility
disturbance of
hemostatic system
Severe bleeding
- An increase in
pulse with decreased
Blood pressure can
indicate loss of
Circulating blood volume.
- Changes may
Indicate cerebral
Perfusion secondary to,
Hypoxemia
- Rectal and
Esophageal vessels are
most vulnerable
to rupture.
- In the presence
of clotting factor
disturbances,
minimal trauma can
cause mucosal bleeding.
- Minimizes damage to
tissues, reducing risk for
bleeding and
hematoma.
thrombocytopenia
and platelet
dysfunction
prolongation of PT
and PTT time
- Sub-acute disseminated
Intravascular coagulation
(DIC) may develop
secondary to altered
clotting factors.
- Recommend avoidance of
aspirin containing products.
- Prolongs coagulation,
potentiating risk of
hemorrhage.
Collaborative:
- Indicators of
anemia, active
bleeding, or
impending
complications.
Assessment
Nursing
Diagnosis
OBJECTIVE:
Rashes on chest
area
Mild scratching of
patient is observed
Inference
Dengue virus
infection
Immunoglobulin
antibodies
attached to the
surface of mast
cells bind with an
antigen
Goal
Intervention
Rationale
Evaluation
Hermans rash/sign
usually appears on the
upper and lower
extremities about 1cm
or less in size. Although
typically located in
extremities, unusual
manifestation of rash
may be generalized
classic rash. Itchiness
may be present at times
To prevent skin
excoriation and
secondary infection
caused by scratching
Independent:
After 8 hrs nursing
intervention the
patient will maintain
optimal skin integrity
as evidence by
absences of skin
breakdown
Immune response
system is
activated
Histamine and
chemoctactic
substance are
released
Histamine causes
permeability of
blood vessels
and peripheral
vasodilation
Encourage adequate
nutrition and hydration
Assessment
Nursing
Diagnosis
Inference
Goal
Intervention
Provide or advice
significant other to use
light clothing material
that is comfortable to the
client
To prevent sweating
and keep the skin dry.
Sweat can potentiate
skin irritation and
scratching
Moisture potentiates
skin breakdown. Dry,
crisp linen provides
comfort to the client
To provide maximum
relief from itchiness
Collaborative:
Administer antiitchiness as prescribe
Rationale
Evaluation
Nursing
Diagnosis
Assessment
Inference
Goal
Intervention
Rationale
Dengue virus
After an 8 hr of nursing
intervention, the clients
significant others will
verbalize understanding
of desired
preventive/precautionar
y skills in maintaining an
aseptic environment to
the client
-Insertion sites of
invasive lines, sutures,
and surgical incisions are
the most common site of
infection
Evaluation
Objective:
Length of Stay: 5
days (ongoing)
Admitted at Pediatric
Ward - sharing with
other sick clients in a
15 bed capacity room
Risk for
nosocomial
infection related
to prolonged
hospital stay
Prolonged
hospitalization
(ongoing 5 days)
Exposure to
pathogens
Risk for nosocomial
infection
-Proper handwashing
lessen the transmission
of pathogens
-Monitoring of visitor to
prevent exposure of client
-Completing the
medicated antibiotics will
treat the infection
Goal is met,
after an 8 hr of
nursing
intervention,
As evidenced
by the client
identifying/
practicing the
appropriate
behaviors and
skills in
maintaining an
aseptic
environment
favorable to
the client as
evidenced by
performing
frequent
handwashing
before and
after eating
and attending
to his child
References:
Suzanne C. Smeltzer Brenda G. Bare, Brunner & Suddarthss Textbook
of Medical Surgical Nursing, 10th Edition, 2004
Frances Prescilla L. Cuevas, RN MAN, Public Health Nursing in the
Philippines, 10th Edition 2007
Catherine Paradiso, Lippincots Review Series Pharmacology, 1998
Websites:
http://www.merck.com/mmpe/sec14/ch191/ch191b.html#sec14ch191-ch191b-2577
http://doh.gov.ph/
http://www.webmd.com/video/travel-dengue-fever