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ZOILO ZERNA KHAZMERA AMPAO ASNIM AMER JOSEPH CALLET LESLEE EMATA SHEENA CLAIRE GENTALLAN JUNAIMA D. MACKNO BSN-4D
I. II. III. IV. V. Case Presentation Objectives Introduction Definition of Terms Vital Information Assessment a. b. c d.. e. VI. VII. VIII. Nursing History Genogram Gordon’s Assessment of Functional Health Patterns Physical Assessment and Review of System Diagnostic Test
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Normal Anatomy & Physiology Risk Factors and Pathophysiology (CONCEPT MAP) Nursing Management a. b. c. Nursing Care Plans Health Education Plan Discharge Plan
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IX. X. 3 |Page
Medical Management Prognosis
treatment. OBJECTIVES Within 1 hour and a half of case presentation: Presenters will be: • • • • • • Able to discuss the disease process (Dengue Hemorrhagic Fever): the causes.XI. Bibliography 59 I. Able to provide health teachings to the patient’s family about certain interventions in the maintenance of health care. Able to discuss how and why certain diagnostic tests are done for the condition. management. effects. Able to determine and discuss briefly the grades of DHF Able to determine why certain management and medications are given and provided for the condition. 4 |Page . Students or audience will be able to: • • Learn the underlying causes of the Dengue Hemorrhagic Fever Know the manifestations of patient having Dengue Hemorrhagic Fever. and possible preventions. Able to develop plan of care for the client with Dengue Hemorrhagic Fever.
Dengue fever is a disease caused by a family of viruses that are transmitted by mosquitoes.2. to a person living in a Dengue-endemic area can have more than one Dengue infection during their lifetime. it cannot be transmitted or directly spread from person to person. are now at risk from dengue and estimates that there may be 50 million cases of dengue infection worldwide every year. rash.• • • Recognize the cause and risk factors of Dengue Hemorrhagic Fever. and red palms and soles. was first recognized in the 1950s during the dengue epidemics in the Philippines and Thailand. All persons are susceptible and both sexes are equally affected.5 billion people. a potentially lethal complication. Dengue serotypes are transmitted by AedesAegypti through bite. Dengue hemorrhagic fever (DHF). exhaustion. Dengue Fever is caused by one of the four distinct virus serotypes Dengue type 1. Epidemic usually occurs during rainy seasons (June-November) peak months are September-October. fever. It is an acute illness of sudden onset that usually follows a benign course with symptoms such as headache. severe muscle and joint pain. Other signs of dengue fever include bleeding gums. It also has grading and staging from grade 1-4 based on severity and condition. and rash. moderate and severe depending on symptoms manifested. Enumerate nursing interventions appropriate for the diagnosis II.3 and 4 of the Genus Flavivirus and Chikungunya Virus. Dengue may also be transmitted via infected blood products. severe pain behind the eyes. Dengue Fever is sporadic throughout the year. Infection with one of this serotype provides immunity to only that serotype of life. INTRODUCTION Dengue fever and dengue hemorrhagic fever are acute febrile diseases. swollen glands (lymphadenopathy). Identify at least 6 nursing diagnosis out from the assessment data gathered. Dengue is classified as mild. It becomes infected with the Dengue Virus when it bites a person who has Dengue and after incubation period of 6-10 days transmits the virus to healthy person. The presence (the "dengue triad") of fever. The WHO says 2. and headache (and other pains) is particularly characteristic of dengue. Clinical manifestation of Dengue Fever 5 |Page .
Vectors 6 |Page . Slaves in the West Indies who contracted dengue were said to have dandy fever because of their postures and gait. fever. or constant conditions. and in severe cases. Symptoms include headache. dengue shock syndrome. weak pulse. vomiting. It is a more severe form of the viral illness. Dengue hemorrhagic fever is a specific syndrome that tends to affect children under 10 years of age. clammy extremities (the trunk is often warm). nausea.• • • Severe type are frank type flushing. Pneumonia is common. followed by sudden drop of temperature. The patient has increased vascular permeability and abnormal homeostasis (homeostasis is the maintenance of equilibrium. in a biological system) that can lead to hypovolemia (abnormal decrease in blood volume) and hypotension (drop in blood pressure). cool. Dengue can affect anyone but tends to be more severe in people with compromised immune systems. bleeding in the nose or gums. For moderate type high fever and spontaneous bleeding are present. and evidence of hemorrhage in the body. Petechiae (small red or purple splotches or blisters under the skin). For mild slight fever. black stools. severe hemorrhage. This form of dengue fever can be life-threatening and can progress to the most severe form of the illness. with or without petechial hemorrhage are evident. including "breakbone" or "dandy fever. cough. an attack of dengue produces immunity for a lifetime to that particular serotype to which the patient was exposed. hence the name breakbone fever. rash. and inflammation of the heart (myocarditis) may be present." Victims of dengue often have contortions due to the intense joint and muscle pain. result in hypovolemic shock (Shock due to a decrease in blood volume) often complicated by severe internal bleeding. shock and terminating in recovery or death. sudden high fever. it is possible to get dengue fever multiple times. Dengue goes by other names. and blueness around the mouth (circumoral cyanosis). The mainstay of treatment is timely supportive therapy to tackle circulatory shock dueto hemoconcentration and bleeding. However. There are respiratory and intestinal symptoms with sore throat. DHF starts abruptly with high continuous fever and headache. or easy bruising are all possible signs of hemorrhage. and abdominal pain. Because it is caused by one of four serotypes of virus. Shock occurs two to six days after the start of symptoms with sudden collapse.
an invasive.Aedesaegypti Dengue viruses are mainly transmitted by the bite of infected Aedesaegypti mosquitoes. Aedesalbopictus Another important mosquito vector of dengue is Aedesalbopictus. domestic species with tropical and subtropical worldwide distribution that originated in Africa. which is also an invasive species originally from Asia. Transmission The Aedesaegypti mosquito is the primary vector of dengue. The virus is transmitted to humans through the bites of infected 7 |Page .
The Aedesaegypti mosquito lives in urban habitats and breeds mostly in man-made containers. The virus is contracted from the bite of a striped Aedesaegypti mosquito that has previously bitten an infected person.albopictus is highly adaptive and therefore can survive in cooler temperate regions of Europe. Daybiting Low-flying Live in stagnant water In urban area The virus is not contagious and cannot be spread directly from person to person. Aedesalbopictus. Stages of Dengue Hemorrhagic Fever 8 |Page . After virus incubation for 4–10 days. maximum 12) via Aedes mosquitoes after their first symptoms appear. 3. Ae. lucky bamboo). Unlike other mosquitoes Ae. 4. its peak biting periods are early in the morning and in the evening before dusk. Patients who are already infected with the dengue virus can transmit the infection (for 4–5 days. hibernation.female mosquitoes.aegypti bites multiple people during each feeding period.aegypti is a daytime feeder. has spread to North America and Europe largely due to the international trade in used tyres (a breeding habitat) and other goods (e.g. Characteristics of an Aedesaegypti mosquito: 1. Female Ae. There must be a person-to-mosquito-to-another-person pathway. plastic bags. and cans year-round. One mosquito bite can cause the disease. serving as a source of the virus for uninfected mosquitoes. a secondary dengue vector in Asia. Its spread is due to its tolerance to temperatures below freezing. Infected humans are the main carriers and multipliers of the virus. The mosquito flourishes during rainy seasons but can breed in water-filled flower pots. 2. and ability to shelter in microhabitats. an infected mosquito is capable of transmitting the virus for the rest of its life.
Almost all patients with DHF have had previous experience with at least one of the four serotypes of dengue viruses. These antibodies bind to the surface proteins but do not inactivate the virus. Dengue starts with chills. the incubation period ranges from three to 15 (usually five to eight) days before the signs and symptoms of dengue appear in stages. with relatively low heart rate (bradycardia) and low blood pressure (hypotension). followed by a rapid drop in body temperature (defervescence) with profuse sweating. A characteristic rash appears along with the fever and spreads from the extremities to cover the entire body except the face. A second rapid rise in temperature follows.g: vomiting of blood). pain upon moving the eyes. The four serotypes of dengue virus that have 60-80% homology to each other. Antibodies are produced to combat the sub type previously encountered. disseminated intravascular coagulation is present. However. e. In addition to the plasma leakage. causing the symptoms to be much more serious. Upon infection. Fever and other signs of dengue last for two to four days. which the virus proceeds to infect because it has not been inactivated. which is the result of generalized vasculitis. The eyes become reddened. Dengue shock syndrome (DSS) results from leakage of plasma into the extravascular compartment. the immune response produced specific antibodies to that subtype's surface proteins that prevent the virus from binding to macrophage cells (the target cell that dengue viruses infect) and gaining entry.• • • • Grade I: fever + Herman's sign (flushes and redness of skin with lighter color at the center of the rash) Grade II: Grade I symptoms + bleeding (epistaxis or nosebleeding. the virus will activate the immune system to attack it as if it was the first subtype. if another subtype of dengue virus infects the same individual. gingival bleeding. Painful aching in the legs and joints occurs during the first hours of illness. Grade III: Grade II + Circulatory Collapse (hypotension. and low backache. Rapid and poor volume pulse. cold extremities. Infection with one dengue serotype provides lifelong homologous immunity but limited heterologous immunity. The temperature rises quickly as high as 104 F (40 C). Characteristics of DHF After being bitten by a mosquito carrying the virus. The body also 9 |Page . A flushing or pale pink rash comes over the face and then disappears. and melena or dark stool. cold clammy skin and weak pulse) Grade IV: Grade III + Shock. hypotension. and restlessness occur. headache. Dengue shock syndrome is usually a progression of dengue haemorrhagic fever and is often fatal. This precedes a period with normal temperature and a sense of well-being that lasts about a day. The glands (lymph nodes) in the neck and groin are often swollen. The immune response attracts numerous macrophages. hematemesis or upper gastrointestinal bleeding. The hypothesis that heterotypic antibodies from a previous dengue virus infection promote increased viral replication within mononuclear leukocytes by antibody-dependent enhancement. The palms and soles may be bright red and swollen.
are now at risk from dengue and estimates that there may be 50 million cases of dengue infection worldwide every year. the mortality rate rises to 20%.5% mortality rate. as in a "blue baby" who has a heart malformation that permits blood that is not fully oxygenated to enter the arterial circulation. causing abdominal pain. All persons are susceptible and both sexes are equally affected. which results in hemorrhagic fever and fluid loss from the blood vessels The mortality (death) rate with DHF is significant. However. Dengue Fever is sporadic throughout the year.5 billion people. With proper treatment. the lips may show cyanosis.releases cytokines that cause the endothelial tissue to become permeable. Cyanosis can be evident at birth. without proper treatment. For example. 10 | P a g e . Most deaths occur in children. Epidemic usually occurs during rainy seasons (June-November) peak months are September-October. Cyanosis can also appear at any time later in life. III. Dengue shock syndrome: A syndrome due to the dengue virus that tends to affect children under 10. the World Health Organization estimates a 2. DEFINITION OF TERMS Cyanosis: A bluish color of the skin and the mucous membranes due to insufficient oxygen in the blood. Infants under a year of age are especially at risk of dying from DHF The WHO says 2.
Serotype: The kind of microorganism as characterized by serologic typing (testing for recognizable antigens on the surface of the microorganism). The Latin immunis means free. Known also as dengue hemorrhagic fever (DHFEndemic: Present in a community at all times but in relatively low frequency. Immunity can be innate (for example. Petechiae: Pinpoint flat round red spots under the skin surface caused by intradermal hemorrhage (bleeding into the skin). Incubation period: In medicine. Myalgia: Pain in a muscle. and necrosis (death) of cells in the kidney and liver. There are many specific causes of various types of myalgia. exempt. For example. Examples include epidemic myalgia and polymyalgia rheumatica. the viral infection causes a high fever. or from a more serious illness. Yellow fever: An acute systemic (bodywide) illness caused by a virus called a Flavivirus. Something that is endemic is typically restricted or peculiar to a locality or region." Abdominal pain: A condition which is characterized by the sensation of pain that is located in the abdomen. Immunity: The condition of being immune.hemorrhage (bleeding) and circulatory collapse (shock).Hence. The damage done to the liver from the virus results in severe jaundice which yellows the skin. Myalgia means muscle pain. or pain in multiple muscles. the incubation period of chickenpox is 14-16 days. Dengue fever: An acute viral disease characterized by fever. such as a virus infection. rash and myalgia and caused by a flavivirus which is transmitted by mosquitoes. a rash is referred to as an exanthem. Myalgia can be a result of a mild conditions. Myalgia can be temporary or chronic. the time from the moment of exposure to an infectious agent until signs and symptoms of the disease appear. humans are innately immune to canine distemper) or conferred by a previous infection or immunization. Petechiae are red because they contain red blood that has leaked from the capillaries into the skin. Medically. bleeding into the skin. In severe cases. Immune: Protected against infection. Dengue hemorrhagic fever: Severe complication of dengue 11 | P a g e . Rash: Breaking out (eruption) of the skin. Petechiae are quite tiny (less than 3 millimeters in diameter) and do not blanch when pressed upon. the "yellow" in "yellow fever.
e. bleeding) Viral diseases: Any disease that is caused by a virus 12 | P a g e .Viral Hemorrhagic Fevers: Viral infections causing hemorrhagic fever (i.
skin warm to touch.100.2005 Cultural Group:Iliganon Primary Language: Cebuano Religion: Roman Catholic Highest Educational Attainment: still in Grade 1 Occupation: student Usual Health Care Provider: Physician Reason for Health Contact: For further management Date of Confinement: February 10. Canoy – M. lying on bed. place and people. oriented to time. VITAL INFORMATION Name: Little K! Room Number: 242 . playful. Day 2: 30% .7 Age: 6 y/o Gender: Female Civil Status: single Date of Birth: March 15. coherent. good skin turgor. with patent IVF of D5NSS 1L @ 10 ugtts/min hooked at right metacarpal vein infusing well. well groomed. conscious. Dr.1 C. CRT<3sec.Dy Chu Tee Final Diagnosis: Dengue Hemorrhagic Fever Grade-3 Description of Patient: Day 1: Awake. PR. dress appropriate to her age. not in respiratory distress. strong peripheral pulses.D.IV. with non-productive cough. BP – 90/60 mmHg.Riza (Pediatrician) (Cardio-peditrician) F. RR – 36. afebrile T-36.2012 3:30 am Source of History:Chart = 13 | P a g e SO = 70% Attending Physician:Dr.
abdominal pain 8/10 associated with 3 episodes of vomiting. skin warm to touch.Awake lying on bed. V. conscious.7 C. PR-90. LBM – yellow. CRT <3secs.9. sweating temporarily relieved by paracetamol 14 | P a g e .0 – 39. ASSESSMENT A. with patent IVF of D5IMB 500 cc @ 40ugtts/min hooked at right metacarpal vein infusing well. RR. History of Present Illness: 2 weeks PTA patient started fever of 38. dress appropriate to her age. good skin turgor. NURSING HISTORY Chief Complaints/Reason for Visit: SO verbalized that her daughter was complaints of on and off fever T-39.30. well groomed. place and people. oriented to time. afebrile T-35. coherent.8 C associated with chills. non-mucoid. playful. not in respiratory distress. BP – 100/70 mmHg.
9 thus seek for consultation at City Heath and advised for U/A which result to infection. 15 | P a g e . and Pyrazinamide and the mother can’t recall the dosage of the medications. Last 2007 she had undergone minor operation – Left anterior foot about 4 stitches at Gregorio T. Last September 2005 after fiesta Little K! hospitalized at Mercy hospital at 7 months old due to fever and diarrhea and it was diagnosed of amoeba. Given with cotrimazole of 5ml TID. body malaise. thus prompted for admission at MSH. History of Past Illnesses: Little K! had a measles when she was 2 y/o and did not seek any consultation for it was subsides after a weeks. 6 hours PTA patient manifested 3 episodes of vomiting. 2 days PTA fever started again T-39. Last 2008 she had diagnosed primary complex by Dr. abdominal pain of 8/10. After being treated she had a regular check-up for further assessment and later part she had no regular check-up. medications and the doctor who handle her can’t recalled by the SO. Mariano and was treated 6 months therapy of Rifampacin.syrup of 5ml every 4 hours. On the next day she took a bath knowing that she was relief. pale lips and pale conjunctiva. Iosiniazide. loss bowel movement. Lluch Memorial Hospital due to playing bottles of coke during birthday of her twin sister.
16 | P a g e . Health center and she had an allergy to egg.Little K! had completed immunizations at Brgy. She had taken vitamins Ceeline but not compliant.
GENOGRAM PATERNAL MATERNAL 42 41 y/o y/o 17 | P a g e .B.
Patient had allergy to egg. LBM. GORDON’S ASSESSMENT Health Perception/ health management Pattern Reason for admission: Patient was admitted due to complaints of fever T-39. she ate 3 meals a day with occasional snacks in between meals. Patient did not complaints of problem upon chewing and swallowing foods. abdominal pain associated of 3 episodes of vomiting. McDonalds. She occasionally goes to some local fast foods like.6 y/o Legend: Female Male Patient RA 13 y/o heart attack DM Deceased DHF alive SO can’t remember C. She had tooth decay upper and . Chowking 18 | P a g e After diagnose DHF G3 and during hospitalization Nutritional/metabolic pattern She had poor appetite upon admission and prescribed Diet For Age. She occasionally had snacks in between meals such us apples and orange.9. Few years Before diagnosed DHF G3 Nutritional/metabolic pattern Patient had a good appetite. Her mother verbalized that patient understanding of the purpose of her admission to the hospital and the treatment received at the hospital means that she will be able to be treated with her illness. She likes to eat fried chicken and junk foods. Jollibee.
lower teeth. a brown. She took a nap for at least 19 | P a g e .ibig. During weekends she played along with her neighbor. She had tooth decay upper and lower teeth.6:00am and primetime of ikawangpag.During those years she drinks 6-8 glasses of water every day and often intake of softdrinks. She does not had any problem upon on her bowel movement. Her urination pattern is normal and is measured depending how much IVF intake and Patient had a regular BM pattern and she usually defecates fluid she drinks. She had rashes upon admission but does not everyday describing the stool as a normal. She usually takes a nap if bored for at least 1 hour and 30 minutes. 8:00pm – 9:00pm is her usual time to retire. She sometimes Sleep/rest Pattern had nightmares and sometimes wake up in the middle of the Patient’s usual time of arising is 5:30 am -6am preparing night.together with her mother and twin sisters. She has a vitamin intake of Ceeline but not compliant to it. At school she always play with her classmates and after school she also play with her twin Sleep/rest Pattern sisters and do her homework. And sometimes go outside for walking and sitting in chair watching people walk in and out in the hospital and also Exercise and Activity Pattern watching staff nurses at the station. She loves to watch TV especially the Patient’s usual time of arising is 5:00 . She also had a normal urination pattern and measured the amount of urine output depending on how much fluid intake she had. Patient did not complaint of any skin Exercise and Activity Pattern problem and neither experienced excessive sweating and During her admission all she can do is to play cellphone at her abnormal body odor. firmed stool. Patient did not have complaints for problems in chewing and swallowing foods. She usually sleeps by around Cognitive/perceptual Pattern 9:00pm after doing her homework. firmed experiences excessive sweating and abnormal body odor. stool. Patient’s typical day before started 5:30 am for school and during weekends around 9am. Elimination pattern Patient had experienced diarrhea prior to admission described as yellow non mucoid and during hospitalization she defecates Elimination pattern twice since admission-brown. She instructed to increase fluid intake. bed. for school during weekdays.
Values and beliefs Pattern Even Little K! is just a child and just a 6 yr old. There's is congested and therefore risk for fire hazard. their location is prone of pollution and therefore not conducive for healthy living. This kind of no problem with spirituality of the family. Their neighborhood together with her family goes to church every sunday. Patient able to tell the difference of smell and taste. has nightmares and not suffered from insomnia. She can also distinguish objects through touch. She can also distinguish objects through touch. Values and Belief Pattern Environmental/ Hazards Even Little K! is just a child and just a 6 yr old. Patient’s house is near dump site area. MMDST (METRO MANILA DEVELOPMENTAL SCREENING TEST) - Screening is the presumptive identification of an unrecognized disease or defect by the application of tests. inflammation or any disorders involving the eyes.30 minutes to 1 hour during afternoon after school. She also didn’t experience hearing problems or any discomforts and Cognitive/perceptual Pattern abnormal discharges. environment. she said that she believed in God and has a fear for Him. She also didn’t experience hearing temperature. together with her family goes to church every sunday. changes in body and environmental disorders involving the eyes. Screening test sort out 20 | P a g e . can easily feel pain. She. She usually During admission still she didn’t experience blurring. problems or any discomforts and abnormal discharges. pain. able to tell the difference of smell and taste. pain. She. especially she She didn’t experience blurring. she said that she believed in God and has a fear for Him. inflammation or any is afraid of injections. Patient can easily feel pain. changes in body and environmental temperature. There's no problem with spirituality of the family.
thus developing a sense of industry. 2005 Age Physical and motor Mental Adaptive Personal-social 21 | P a g e . Parents are no longer the complete authorities they once were. although they are still important. This is also very social stage of development and if experience unresolved feelings of inadequacy and inferiority among peers. walk and jump. fine motor. is capable of learning. and gross motor behavior. can have serious problems in terms of competence and self-esteem. Inferiority. As the world expands a bit.apparently well person who probably have the problem from those who probably do not. It is an early detection model that applies to the detection of developmental disabilities in children aged six and half year old and younger. creating and accomplishing numerous new skills and knowledge. One such screening test is the metro manila development screening test (MMDST). follow direction and to speak. During this stage. our most significant relationship is with the school and neighborhood. often called latency. SCHOOL AGE AND DEVELOPMENT According to Erik Erikson Developmental stages . clinically usefull tool used in the early detection of children with serious developmental delays developed by Dr. *Birthday: March 15. Little K! belong to Industry vs. William. Language – indicate the child’s ability to hear. Fine motor – tasks which indicate the child’s ability to see and to use the his hands to pick up objects and draw. Phoebe D. Gross motor – task which indicates the child’s ability to sit. Personal-social – tasks which indicate the child’s ability to get along with people and to take care of himself. The MMDST is a simple. adaptive language. If evaluates four aspects of a child’s development: personal-social.
lying on bed. no deformities noted in the face. interact well. head is symmetric.PEROS Day 1 General Survey: awake. folds and paste paper toys Takes bath without supervision. conversant. both upper and lower extremities are symmetric. cooperative.6 years old - Central mandibular incisors erupt Losses first tooth Active age. cuts. appearance appropriate to age. performs bedtime activity alone Giggles a lot Tries out own abilities - Can share and cooperate better Has a great need for children of own age Often engage in rough play Often jealous of younger sisters Does what adults are seen doing May have occasional temper tantrums Has own way of doing things - - - - - D. with patent IVF of D5NSS 1L @ 40cc/hr hooked at right metacarpal vein. constant acitvity Often returns to finger feeding - Knows whether it is morning or afternoon Defines common objects such as fork and chairs in terms of their use Knows right and left hands Says which is pretty and which is ugly of a series of drawing of faces Attends first grade - At play. not in slump 22 | P a g e .
birthmarks and edema. trachea in midline No problem identified Problem Identified No problem Identified Neck “dili man sakitilihok”as verbalized by the pt.7inches. no epistaxis noted -mucosa and gingival pink. arm circumference.. warm.Nose e.Head and face b. height. no signs of distress. Areas Assessed Integumentary System Subjective Findings “ok namansiya run nawalanamaniyangmg a rashes sapanit” as verbalized by the S. nares patent. no lesions Neck supple w/ full ROM. no palpable lymph nodes. brownish in color. good skin turgor. no lesion or redness noted -pinna no mass. .Oral cavity “dili man sakitakongngipon” as verbalized by the pt. no lesions. hair normally distributed.posture. no dandruffs noted. symmetric. scaling. no lump and masses noted.nose no deformities. no clubbing of nails or discolorations. afebrile . tongue in midline. no rashes noted. no bleeding of gums -loose upper front teeth. palpable carotid pulse. No problem identified 23 | P a g e . HEENT a. multiple dark spots on most upper teeth. no lesions. no lice noted.O Objective Findings Skin uniformly. dry. lesions. discharge or tenderness. no lesions and lumps noted. long black hair.20kg.Eyes c. white sclera. -pupil equally reactive to light and accommodation. Face symmetric. no facial drooling noted. Normocephalic.117cm. no vein distention. no tenderness. pinkish conjunctivae. intact. nail beds pink in color and firm w/ prompt capillary refill CRT< 2 sec. weight.
RR-23-30bpm Chest X-ray result reveals: As compared to previous chest film dated 2-11-2012. there is significant decrease in the right pleaural fluid. Equal chest expansion. formed. brownish stool No problem identified “karun pa nibalikganaiyangpagkaon” as verbalized by the SO. not in respiratory distress. no masses or tenderness. non tender. discharges or lesion. Oral intake=350 IV=230 BM once moderate in amount. 10clicks/quadrants.Respiratory System “walanamansiyagiubo run” as verbalized by the SO. Risk for imbalance Nutrition: less than body requirement Genitourinary/Reproducti ve System 24 | P a g e “dili man sakitpag mu ihiko “ as verbalized Urinated 3x with dark yellowish color of urine. no lymphadenopathy Normoactive bowel sound. no abdominal pain as claimed Abdominal girth-22 inch. now small in volume and subpulmonic in location w/ inter-fissural seepage Risk for Impaired Gas Exchange Risk for infection Cardiovascular System “dili man sakitakongdughan” as verbalized by the pt. No problem identified . no retraction. soft. wheezes. no foul odor. Risk for decrease cardiac Output Breast and Axilla Gastrointestinal System and the abdomen No complaints made Symmetric. no cough noted. irregular heartbeat noted BP:100/70 PR-80-87 CRT> 2 sec. apical impulse at 5th ICS in the left MCL. lesions noted. no crackles . round . no mass . No murmurs.
oriented to time .by the pt. gusto nakomoulisabalay” Full ROM. no deformities noted Conversant.7-36. intact cranial nerves Developmental Stage: -Can count numbers -defines common objects -Obeys triple commands in succession -Knows left and right -Attends first grade -able to solve simple arithmetic -able to spell simple words T-35. muscle grade 5/5 in both upper and lower extremities.39 Platelet count=36 Risk for bleeding 25 | P a g e .place and person. no limitation of movement. no body weakness noted as claimed.3 0C No problem Identified Neurologic System No problem identified Lymphatic/Hematologic System “ la namangahubagiyanglu say” as verbalized by the SO No lymhpadenopathy Hematocrit=0. “grade one namanko. negative of hematuria Total output=390 cc Musculoskeletal System “dlili man luyaakongpamati run” as verbalized by the pt.
nail beds pink in color and firm w/ prompt capillary refill CRT< 2 sec. multiple dark spots on most upper teeth. brownish in color. no lesions and lumps noted.Eyes c.Oral cavity No complaints made Normocephalic. conversant. no lesion or redness noted -pinna no mass.Head and face b. dry. no lesions Neck supple w/ full ROM. HEENT a. no lice noted. lying on bed. no epistaxis noted -mucosa and gingival pink. no lump and masses noted. no rashes noted. no deformities noted in the face. symmetric. weight. no lesions.117cm. warm. no dandruffs noted. arm circumference. no facial drooling noted. Face symmetric. discharge or tenderness. cooperative.Day 2 General Survey: awake. birthmarks and edema. white sclera.20kg. no signs of distress. with patent IVF D5IMB@ 40cc/hr hooked at right metacarpal vein. no lesions. height.Nose e. no palpable No problem identified lymph nodes. head is symmetric. -pupil equally reactive to light and accommodation. hair normally distributed. . good skin turgor. scaling. long black hair. interact well. nares patent. intact.7inches. both upper and lower extremities are symmetric. lesions. Areas Assessed Integumentary System Subjective Findings No complaints made Objective Findings Skin uniformly. not in slump posture. appearance appropriate to age. afebrile . pinkish conjunctivae. no No problem identified Problem Identified No problem Identified Neck No complaints made 26 | P a g e .nose no deformities. no clubbing of nails or discolorations. no bleeding of gums -loose upper front teeth. tongue in midline.
RR-23-30bpm Chest X-ray result reveals: As compared to previous chest film dated 2-11-2012. not in respiratory distress. lesions noted. no mass . wheezes. no abdominal pain as claimed Abdominal girth-22 inch. trachea in midline Respiratory System No complaints made Equal chest expansion. no masses or tenderness. no cough noted. palpable carotid pulse. Oral intake=1400 IV=960cc 27 | P a g e No problem Identified Risk for decrease cardiac Output Risk for impaired Gas exchange “naniwangnasiyakarun. discharges or lesion. no crackles . non tender. No murmurs. 10-12clicks/quadrants. no retraction.perokusognanasiy anakaon run” as verbalized by the SO. apical impulse at 5th ICS in the left MCL. irregular heartbeat noted BP:100/70 PR-82-87 CRT> 2 sec. soft. no lymphadenopathy Normoactive bowel sound. Breast and Axilla Gastrointestinal System and the abdomen No complaints made Symmetric. round . there is significant decrease in the right pleaural fluid. imbalance Nutrition: less than body requirement . now small in volume and subpulmonic in location w/ inter-fissural seepage Cardiovascular System “dili man sakitakongdughan” as verbalized by the pt.tenderness. no vein distention.
DIAGNOSTIC TEST Diagnostic test/date 28 | P a g e Normal values Result Interpretation Significance Nursing . formed.BM once moderate in amount.5-36. negative of hematuria Total output=1000cc Musculoskeletal System No complaints of body weakness Full ROM. Urinated 6x with yellowish color of urine.place and person. muscle grade 5/5 in both upper and lower extremities. no deformities noted Conversant. no foul odor. intact cranial nerves Developmental Stage: -Can count numbers -defines common objects -Obeys triple commands in succession -Knows left and right -Attends first grade -able to solve simple arithmetic -able to spell simple words T-35.6 0C Lymphatic/Hematologic System No complaints made No lymhpadenopathy Hematocrit=0. no body weakness noted as claimed. oriented to time . no limitation of movement. brownish stool Genitourinary/Reproducti ve System “daghanrasiyaugnaihi run” as verbalized by the pt.39 Platelet count=129 Risk for bleeding No problem Identified No problem identified Neurologic System No complaints made No problem identified E.
responsibilities 29 | P a g e .
25-0.65 0.04 Normal An increased count of lymphocytes can occur in conditions such as influenza & mononucleosis.7 Increased High hct&hgb indicates polycythemia or hemoconcentration caused by blood loss & dehydration.35 0.50-0.10 0 Normal Monocytes 0.2/10/12 CBC & Platelet count RBC Hematocrit 4-6 x 10 12/L 0. Lymphocytes 0. myocardial infarction.50 Increased STABS 0.03-0.0 Increased WBC 5-10 X 10 9/L 12. Explain the procedure to the patient.47 8.46 Decreased An increased WBC count commonly signals infection.37 – 0. Segmenters 0. 30 | P a g e . Explain to the patient that he may experience a slight discomfort from the tourniquet and the needle puncture.05-0. Hemoglobin 110 – 180 g/L 183.55 Increased Increased A high RBC count may indicate absolute or relative polycythemia.07 0. Apply direct pressure to the venipuncture site until the bleeding stops.06 0.
blood clots normally. infectious disorders. iron deficiency anemia. that the test requires a blood sample.50 Increased Platelet count 140-450 x 10 9/L 80 Decreased High hct indicatespolycythemia or hemoconcentration caused by blood loss & dehydration.01 0 Normal Platelet count 150 140-450 x 10 9/L Increased Diagnostic test/date Normal values Result Interpretation Significance Nursing responsibilities 2/11/12 Hematocrit& Platelet count Hematocrit 0. Explain who will perform the venipuncture 31 | P a g e .03 0 Normal An increased count of platelet can result from hemorrhage.47 0.37-0. that the platelet count test determines whether the pt. such Explain to the pt.Eosinophils 0.37-0. Basophils 0.46 Normal A decreased count can result from aplastic or hypoplastic bone marrow disease.47 0. Tell the pt. 2/11/12 Hematocrit 0.01-0.
32 | P a g e .47 2/12/12 Hematocrit 140-450 x 10 9/L 39 Platelet count 0. and when. increased platelet destruction caused by drugs or immune disorders.46 46 Normal Decreased as leukemia.37-0. or disseminated infection. disseminated intravascular coagulation. that she need not restrict food and fluids. mechanical injury to platelets.39 50 Normal Decreased Decreased 0. that he may feel slight discomfort from the tourniquet and needle puncture.47 140-450 x 10 9/L Platelet count 0. pooling of platelets in an enlarged spleen.47 2/13/12 Hematocrit Platelet count 140-450 x 10 9/L 0.Platelet count 140-450 x 10 9/L 55 Decreased 2/11/12 Hematocrit 0. ineffective thrombopoiesis caused by folic acid or vitamin B12 deficiency. Inform the pt. Explain to the pt.37 Normal 0.37-0.37-0.
Diagnostic test/date Normal values Result Interpretation Significance Nursing responsibilities 33 | P a g e .
that he may feel slight discomfort from the tourniquet and needle puncture. that she need not restrict food and fluids.46 Normal 140-450 x 10 9/L Platelet count 46 Decreased Explain to the pt. blood clots normally.50 Increased Platelet count 140-450 x 10 9/L 80 Decreased High hct indicatespolycythemia or hemoconcentration caused by blood loss & dehydration.37-0.37-0.47 0. 2/12/12 34 | P a g e . ineffective thrombopoiesis caused by folic acid or vitamin B12 deficiency. that the test requires a blood sample. Explain who will perform the venipuncture and when.47 0. or disseminated infection.46 Normal A decreased count can result from aplastic or hypoplastic bone marrow disease. Tell the pt. Explain to the pt. increased platelet destruction caused by drugs or immune disorders. 2/11/12 Hematocrit 0.47 0. pooling of platelets in an enlarged spleen. such as leukemia. Inform the pt.2/11/12 Hematocrit& Platelet count Hematocrit 0.37-0. that the platelet count test determines whether the pt. disseminated Platelet count 140-450 x 10 9/L 55 Decreased 2/11/12 Hematocrit 0.
right hemidiaphragm was partially obscured. mechanical injury to platelets.37 Normal Platelet count 140-450 x 10 9/L 39 Decreased intravascular coagulation. heart is normal in size and orientation. trachea is at the midline.37-0. moderate in amount. bony thorax is normal Impression: Right Pleural Effusion. 35 | P a g e .2012 Chest AP PORT Result: • • • • • Veil The The The The –like haziness seen at the right lung with large ribbon-like homogenous density at the periphery.47 0.39 Normal Platelet count 140-450 x 10 9/L 50 Decreased February 11.47 0. 2/13/12 Hematocrit 0.Hematocrit 0.37-0.
The right costophrenic sulcus and hemidiaphragm are obscured. Heart and great vessels are not unusual.4 seconds Control: 12.2012 Chest AP Port Result: • • • • • • As compared to previous chest film dated 2-11-12. Hazy pneumonic infiltrates seen in both inner to mid lung zones with right midline and lower lobes atelectasis. No other significant interval chest findings.5 seconds Activity: 61.0 seconds Control: 29.February 13. now small in volume and subpulmonic in location with inter-fissural seepage.5 second 36 | P a g e . The left costophrenic sulcus and hemidiaphragm are intact. 2/10/12 PROTIME (PROTHROMBIN TIME) Patient: 20.88 APTT (Activated Partial Thromboplastin Time) Patient : 48.3% INR: 1. there is significant decrease in the right pleural fluid.
blood vessels. Found in ribs. and acid-base balance. and thrombocytes. lymph nodes. and thymus gland). ANATOMY AND PHYSIOLOGY The Hematologic System The structures of the hematologic or hematopoietic system include the blood. specific types of cells. red and yellow 1. collectively one of the largest organs of the body (4%-5% of total body weight) 2. myeloid. Red (functioning) marrow 1. occupies interior of spongy bones and center of long bones. 37 | P a g e . production site of erythroid. The major function of blood is to carry necessary materials (oxygen. Contained inside all bones. Primary function is hematopoiesis (the formation of blood cells) 3. Two kinds of bone marrow. and thrombocytic components of blood. The hematologic system also plays an important role in hormone transport. liver. Bone Marrow 1. and blood-forming organs (bone marrow. found in long bones. does not contribute to hematopoiesis 4. fluid-electrolyte balance. other flat bones 2. All blood cells start as stem cells in the bone marrow.VI. Carries out hematopoiesis. Yellow marrow: red marrow that has changed to fat. nutrients) to cells and to remove carbon dioxide and metabolic waste products. temperature regulation. the inflammatory and immune responses. leukocytes. spleen. vertebral column. collectively referred to as formed elements of blood or blood components: erythrocytes. one source of lymphocytes and macrophages 2. these mature into the different.
Distribution 1. Majority of formed elements is erythrocytes. Fibrinogen. plasminogen 1. Beta: role in transport of iron and copper 3. yellow in color because of pigments 2. middle layer of leukocytes and platelets. 840 ml venous 2. prothrombin.Blood 1. 2150 ml venous Plasma 1. fibrinogen. Albumin: largest of plasma proteins. 3. involved in regulation of intravascular plasma volume and maintenance of osmotic pressure 2. Centrifugation of blood results in separation into top layer of plasma. serum globulins. 1300 ml in pulmonary circulation 1. Gamma: role in immune response. bilirubin 2. beta. and bottom layer of erythrocytes. 400 ml arterial 2. prothrombin. Consists of serum (liquid portion of plasma) and fibrinogen 3. lipids. gamma 1. 550 ml arterial 2. Liquid part of blood. function of antibodies 3. volume of leukocytes and platelets is negligible. Hematocrit 1. Serum globulins: alpha. 60 ml capillary 3. Composed of plasma (55%) and cellular components (45%) 2. 3. 3000 ml in systemic circulation 1. Alpha: role in transport of steroids. Contains plasma proteins such as albumin. Reflects portion of blood composed of red blood cells 2. plasminogen (see Coagulation) Cellular Components 38 | P a g e . 300 ml capillary 3.
1. Iron. Mature cells removed chiefly by liver and spleen 4. pyridoxine (vitamin B6). Granulocytes: eosinophils. Immature RBCs destroyed in either bone marrow or other reticuloendothelial organs (blood. and other factors required for erythropoiesis 1. Bioconcave disc shape. Premature destruction: may be caused by RBC membrane abnormalities. Iron: freed from Hgb during bilirubin formation. Erythropoietin stimulates differentiation. and neutrophils 1. transported to bone marrow via transferrin and reclaimed for new Hgb production 6. Hemolysis (destruction) 1. Eosinophils: involved in phagocytosis and allergic reactions 2. mature into erythrocytes 2. Erythrocytes 1. extrinsic physical factors (such as the enzyme defects found in G6PD) 7. Normal blood contains 12-18 g Hgb/100 ml blood. liver. Average life span 120 days 2. basophils. Leukocytes: granulocytes and mononuclear cells: involved in protection from bacteria and other foreign substances 1. and lymph nodes) 3. excreted in bile 5. Production 1. liver. which function in hemostasis. leukocytes (white blood cells [WBCs]). no nucleus. Two portions: iron carried on heme portion. spleen. higher (14-18 g) in men than in women (12-14 g) 4. Bilirubin: byproduct of Hgb released when RBCs destroyed. lungs. connective tissue. vitamin B12. which are responsible for oxygen transport. folic acid. Cell membrane is highly diffusible to O2 and CO2 3. Normal age RBCs may be destroyed by gross damage as in trauma or extravascular hemolysis (in spleen. released as reticulocytes (immature cells). which play a major role in defense against microorganisms. second portion is protein 2. produced by kidneys and stimulated by hypoxia 3. Basophils: involved in prevention of clotting in microcirculation and allergic reactions 39 | P a g e . chiefly sacs of hemoglobin 2. Start in bone marrow as stem cells. RBCs are responsible for oxygen transport via hemoglobin (Hgb) 1. Hgb abnormalities. bone marrow) 1.Cellular components or formed elements of blood are erythrocytes (red blood cells [RBCs]). and thrombocytes (platelets).
Absence of both antigens results in type O blood.3. Blood-typing systems are based on the many possible antigens. 4. Antigens of system are labelled A and B. 2. 1. mature neutrophils: polymorphonuclear leukocytes 2. but the most important are the antigens of the ABO and Rh blood groups because they are most likely to be involved in transfusion reactions. Monocytes: involved in long-term phagocytosis. Thrombocytes (platelets) 1. produced by bone marrow: give rise to histiocytes (Kupffer cells of liver). which determine the different blood groups. produced primarily in lymph tissue (B cells) and thymus (T cells) (see also Immune Response) 1. aggregation. Lymphocytes: immune cells. 2. play a role in immune response 1. produce substances against foreign cells. Mononuclear cells: monocytes and lymphocytes: large nucleated cells 1. immature neutrophils: band cells (bacterial infection usually produces increased numbers of band cells) 1. and plug formation Release substances involved in coagulation Blood Groups 1. largest leukocyte 2. ABO typing 1. and heparin 4. serotonin. Eosinophils and basophils are reservoirs of histamine. Erythrocytes carry antigens. and other components of reticuloendothelial system 1. 40 | P a g e . Fragments of megakaryocytes formed in bone marrow Production regulated by thrombopoietin Essential factor in coagulation via adhesion. Neutrophils: involved in short-term phagocytosis 1. macrophages. 3. 2.
and XI activated 2. transfusion with mismatched or incompatible blood results in a transfusion reaction (Table 4. Thrombin acts on fibrinogen. Antibodies are automatically formed against the ABO antigens not on person's own RBCs. but in a subsequent pregnancy with an Rhpositive baby.Presence of both antigens is type AB. Blood Coagulation Conversion of fluid blood into a solid clot to reduce blood loss when blood vessels are ruptured. Factor XII initiates as contact made between damaged vessel and plasma protein 2. Platelet factor 3 (PF3) and calcium react with factors X and V. released from injured vessels ("extrinsic" to vessel) 2. Prothrombin converted to thrombin via thromboplastin. Factors VIII. 5. Factor VII activated 1. Systems that initiate clotting 1. 1. antibody formation starts and a second exposure to Rh antigen will trigger a transfusion reaction. forming soluble fibrin. 41 | P a g e . Important for Rh-negative woman carrying Rh-positive baby. Identifies presence or absence of Rh antigen (Rh positive or Rh negative). 6.17). insoluble fibrin clot. clot dissolves as tissue repairs. first pregnancy not affected. Intrinsic system: initiated by contact activation following endothelial injury ("intrinsic" to vessel itself) 1. the universal donor. 4. Anti-Rh antibodies not automatically formed in Rh-negative person. 3. mother's antibodies attack baby's RBCs ( in Unit 6). 3. Initiated by tissue thromboplastins. Rh typing 1. 4. Presence of either A or B results in type A and type B respectively. Extrinsic system 1. 2. Soluble fibrin polymerized by factor XIII to produce a stable. Common pathway: activated by either intrinsic or extrinsic pathways 1. 2. Clot resolution: takes place via fibrinolytic system by plasmin and proteolytic enzymes. Nearly half the population is type O. 2. but if Rh-positive blood is given. 1. IX. 3.
2. and antigens 4. and finally to the splenic vein to the liver. behind and to the left of the stomach. 3. phagocytic activity and iron storage. Important hematopoietic site in fetus. removes misshapen erythrocytes. and macrophages 2. Vascular. the veins. composed of RBCs. produces lymphocytes and sequesters lymphocytes. lies beneath the diaphragm. then passes into splenic venules that are lined with phagocytic cells. Also involved in antibody production by plasma cells and iron metabolism (iron released from Hgb portion of destroyed erythrocytes returned to bone marrow) 8. Contains two types of pulp 1. blood comes via the splenic artery to the pulp for cleansing. White pulp: scattered throughout the red pulp. In the adult. composed of a fibrous tissue capsule surrounding a network of fiber 3. The network of blood vessels that flow through the body is so extensive that blood flows within close 42 | P a g e . bean shaped. Circulation is achieved by a continuous one-way movement of blood throughout the body. Red pulp: located between the fibrous strands. unwanted parts of erythrocytes 7. This system is made up of the heart. Liver 1. Important in phagocytosis. macrophages. functions of the spleen can be taken over by the reticuloendothelial system. Involved in bile production (via erythrocyte destruction and bilirubin production) and erythropoiesis (during fetal life and when bone marrow production is insufficient). WBCs. the arteries.Spleen 1. postnatally produces lymphocytes and monocytes 6. 5. and the capillaries. Largest lymphatic organ: functions as blood filtration system and reservoir 2. 1%-2% of red cell mass or 200 ml blood/minute stored in spleen. The Circulatory System The Circulatory System is designed to deliver oxygen and nutrients to all parts of the body and pick up waste materials and toxins for elimination. Kupffer cells of liver have reticuloendothelial function as histiocytes. synthesis of antithrombins. Liver also involved in synthesis of clotting factors.
Blood Vessels Blood vessels are broken down into three groups: the arteries which carry blood out of the heart to the capillaries.proximity to almost every cell. It functions by recognizing viruses and bacteria and converting that information into hormones that activate the immune process. The Immune System The immune system is part of our general body defenses against disease. The left ventricle. where the body responds only to certain agents and no others as well as nonspecific. where the body works to defend 43 | P a g e . The right ventricle which pumps the oxygen-poor blood from the right atrium to the lungs.poor blood from the veins. Blood Pressure Blood pressure is the force exerted by the blood against the walls of the blood vessels. the veins which transport oxygen-poor blood back to the heart. The output or direct pumping of the heart and the resistance to blood flow in the vessels determines blood pressure. The left atrium which receives the now oxygen-rich blood that is returning from the lungs. which is a chamber which receives oxygen. The heart is located between the lungs. The heart is broken down into four chambers including: • • • • The right atrium. Heart The heart is a muscular pump that propels blood throughout the body. Blood pressure = blood flow x resistance. slightly to the left of center in the chest. Resistance is determined by blood viscosity and by friction between the blood and the wall of the blood vessel. which pumps the oxygenated blood through the arteries to the rest of the body. This response can be both specific. This process occurs about 72 times per minute. and the capillaries which transfer oxygen and other nutrients into the cells and removes carbon dioxide and other metabolic waste from these body tissues. every day of our lives.
Phagocytosis . even though we may be exposed to them on a number of occasions. There are 5 types (isotypes) of antibodies: IgA: protects mucosal surfaces. Natural Killer Cells . Chemical Barriers . Once inside cells. During cellular metabolism. Immunity is the ability of an individual to resist or overcome the effects of a particular disease or other harmful agent. B-cells: Develop in the bone marrow and become antibody-producing plasma cells. with one being immune to one disease and not necessarily another. Bind antigens to surfacebound antibodies. The immune system has been broken down into a number of different "lines of defenses". which is due to inherited factors.are able to distinguish cells with an abnormal cellular membrane such as tumor cells or cells infected with a virus and kill them on contact. pathogens are harder to detect. Fever .boosts the immune system by stimulating phagocytes. both in the cells and surrounding them. Acquired immunity develops during one's lifetime as they encounter various harmful agents and successfully fight them off. or acquired. If the inflammation is due to pathogens. waste 44 | P a g e . Cellular Immunity: T cells kill infected cells in the cell-mediated response. IgE: involved in allergy. Cell-mediated immunity recognizes and kills the body’s own infected cells.Antibodies: Antibodies are soluble proteins that are bound to the surface of cells. IgG: majority of antibody-based immunity and IgM: key to B-Cell immunity.tears.itself any harmful agent that enters the body. the inflammation is referred to as an infection. Immunity. starting simply with mechanical barriers and then becoming more and more complex. Acquired immunity is easily seen in the case that we only get the chicken pox once as a child. they include: • • • • • • • • • Mechanical barriers .are the first line of defense against harmful agents. Mechanical barriers include the skin. Immunity can be either inborn. as well as unbound in the circulation.is the body's effort to get rid of anything that irritates it. however. The Lymph System All body tissues live in a liquid environment.is the ability of certain white blood cells to take in and destroy waste and foreign materials. IgD: B-Cell antigen receptor. perspiration and saliva work to wash away harmful invaders while digestive juices and enzymes destroy bacteria and other toxins from ingested substances. is a selective process. differentiate into T-helper cells or T-cytotoxic cells. T-cells: Develop in the thymus. Inflammation . increasing metabolism and decreasing the ability of certain organisms to multiply. mucus membranes that line passageways that enter the body.
the lymph system does not have a heart to propel lymph (tissue fluids that have entered the lymphatic system) through the system. Major groupings of lymph nodes can be found in the neck (cervical nodes). The spleen also harbors phagocytes. The function of the lymph system is to remove excess tissue fluids that do not return through the circulatory system. in the armpits (axillary nodes). 45 | P a g e . The spleen also serves as a reservoir of blood in cases of emergency. It is located in the upper left quadrant of the abdominal cavity and is protected by the ribs. in and around the intestines (mesenteric nodes) and in the groin area (Inguinal nodes). the lymph system is responsible for absorbing protein form this fluid and returning it to the blood. In addition. where the muscles compress the lymphatic vessels and drive the lymph forward. the appendix is rich in lymph tissues. The appendix is located at the end of the cecum. whose function it is to filter the lymph. trapping and destroying bacteria and other foreign particles. which promotes the growth of lymphocytes and lymphoid tissue throughout the body. The movement of lymph is based upon either the volume of fluid within the lymph vessel or by mechanical means. can be found a series of lymph nodes. One function of the spleen is to filter out old red blood cells. Throughout the lymph system. once thought of as a useless organ. which is part of the large intestine. Spleen The spleen is an organ that contains lymphoid tissue and is designed to filter blood. i. The thymus secretes the hormone thymosin. but tend to be grouped together. In addition to the elimination provided for by the circulatory system. through movement of the skeletal muscles. including carbon dioxide and other substances are routed back through the blood stream to be eliminated. are actually masses of lymphoid tissue that are designed to filter tissue fluids. Thymus The thymus gland is the site in which T-lymphocytes develop and mature before birth and is most active prior to puberty. Tonsils The tonsils. a second pathway for the removal of tissue fluids from the body is achieved though the lymph system. Like the circulatory system.e. the lymphatic system is made up of a series of capillaries and lymphatic vessels. Unlike the circulatory system. which engulf bacteria and other foreign particles. Lymph nodes can be found throughout the body.products. Vermiform appendix Although the function of the vermiform appendix is unknown. near the trachea and bronchial tubes (tracheobronchial nodes).
VII.RISK FACTORS AND PATHOPHYSIOLOGY (CONCEPTMAP) 46 | P a g e .
NURSING MANAGEMENT A.VIII.onlymyhealth.com/cause-lowplatelet-count-in-dengue-fever-) Cues Subjective: 47 | P a g e Objectives STO: Nursing Interventions Independent: Rationale Evaluation . When vascular endothelial cell that are infected with dengue virus gets combined with platelets they tend to destroy platelets. NCP NURSING CARE PLANS Problem Identified: decrease platelet count Nursing Diagnosis: Risk for bleeding r/t altered clotting factor 20 DHF Cause Analysis(w/ reference):Blood platelets also known as thrombocytes play an important role in your body.( http://www. This is one of the major causes of low platelet count in dengue fever. These cell fragments are natural source of growth and play basic role in process of hemostasis (preventing bleeding from damaged blood vessel) as well.
LTO: Met. free from clutter 9. 8. to avoid sharp object. of nursing intervention and health teaching the pt. Result-36 -brownish color stool -BP 100/80 -PR-87 Within 2 hrs. Assessed for signs and symptoms of G. STO: 1. To avoid and preventing from tripping from bed to the floor.“La ramangadugoiyangilong. w/ transfer. will be able gain information about the diseases process and its potential problem. Observed for the presence of petechiae. NURSING CARE PLANS Problem Identified: weight loss Nursing Diagnosis: Imbalanced Nutrition: less than body requirements r/t increased metabolic demand and decrease oral intake 20 Dengue Hemorrhagic Fever Stage 3 Cause Analysis(w/ reference):There is an alteration in nutrient requirements that results from illness . 11.I tract is the most usual source of bleeding of its mucosal fagility. 9. Sub acute disseminated intravascular coagulation may develop secondary to altered clotting factors.Keep bed in low position at aleast 300 8. Emphasize the importance of safety measures. The G.every 2 hrs. 1. since there is an increase need for calories. 7. LTO: Within 2 days of nursing care the pt. bleeding from one or more sites. To promote individual safety. 2.1251) Cues Objectives Nursing Interventions Rationale Evaluation 48 | P a g e . To reduce risk factor for injury. 2. Prolongs coagulation potentiating risk for hemorrhage.pt was able to enumerate and keep in mind the ways that reduces risk for bleeding as evidenced by verbalization of 4 or 5 ways to reduce risk for bleeding.I bleeding. 4.Keep the pts. brown rapudang color saiyang tae” as verbalized by the S. 3. 3.Observe color and consistency of stool or vomitous. 6. ambulation 10. safety. This is the primary preventive measure to ensure pts.O Objective: -Plalete lab. Met.Assist pt. ecchymosis.pt was able to verbalized understanding on the disease process and enumerates potential problems. an increase in pulse w/ decreased blood pressure can indicate loss of circulating blood volume.p. and decrease food intake . Checked pt. Check for secretions. To avoid injury or skin breakdown.Monitor pulse. Change may indicate cerebral perfusion secondary to hypovolemia. will be able to demonstrate behaviors and ways that reduces risk for bleeding. BP 4.(Fundamentals of Nursing by Tallor and Lilis 5th ed. 7.Recommend avoidance of aspirin containing products 11. This promotes education and increases the awareness of clients condition. 6. Instructed the pt. 10. hypoxemia 5.Noted changes in of mentation and level of conciousnes 5.
Although nutritious intake is important. Discussed eating habits and food preferences. Provide food without comment. sleep and rest cycle. Timing of medical doses. 4. 2. arguing over food is counter-productive. Note the characteristic of stool. Determined the child’s current nutritional status using age-appropriate measurement. 6. LTO: Met. Provided information regarding on the individual nutritional needs and ways to make these needs within financial constraints. Elicited information from the child/parents of the child regarding typical daily food intake. Provides information about digestion/ bowel fxn and may affect choice/timing of feeding.significant weight loss (25kg to 20 kg) . Baseline information to determine adequacy of intake. of emphasizing the importance of food intake the pt. and provides comparative baseline. can affect nutritional intake. Emphasized the importance of well-balanced. Dietary beliefs. strength. and body build. interactions with certain foods 49 | P a g e .O’ cooperation.6 . Reviewed drug regimen.walanasiyaykaonkanonsukadna admit nasiya” as verbalized by the S.Subjective: “karun pa gyudnibalikganaiyangkaon. STO: 1. Identifies what child’s eat in a typical day. 7. nutritious intake. Avoid arguing over food intake.observable loss of appetite STO: Within 2hrs. 7.O Objective: -normally BMI: 14. Provides opportunity for identifying teaching needs and providing healthy snacks. 5. cultural/religious desires/influences and dietary choices. side effects. the pt. 2. 3.O about the progression of the pt. activity level.pt. was able to increased oral intake.arm circumference: 6 inches . was able to achieved adequate nutrition as evidenced by increased wt. LTO: Within 2 days of independent nursing intervention and w/ the pt. 4. Met. determining food and beverages normally consumed. will be able to achieve adequate nutrition as evidenced by progression of wt. Knowledge of child’s specific likes and dislikes maybe helpful in meeting nutritional needs during the time when appetite is suppress or child has no interest in food. Usual ethnic food choices can improve a child’s intake when appetite is poor. and potential interactions with other medications/ OTC drugs/ herbs. will be able to increase adequate diet for age.pt. and sodas child eats/drinks. Discussed what type of candy parents. gain and verbalization of S. Auscultated bowel sound. snacks. Determined psychologic. Identifies individual nutritional needs. such a vegetarianism.’s condition 5.’s and S. others sweets. including wt. 6. Providing age-appropriate guidelines to children as well as to parents/care provider may help them in making healthy choices. gain Independent: 1. 3.
10. 8. special dietary needs. 9.8. 10. Clarified family/caregiver access to/ use f resources such as food stamp. Established a nutritional plan that meets individual needs. incorporating specific food restrictions. Maybe necessary to improve child’s intake and availability of food to meet nutritional needs. Collaborative: 9. NURSING CARE PLANS 50 | P a g e . Indicators of nutritional health and effects of nutrients and organ fxn. can alter the effects of medication/digestion/ absorption of nutrients. . Referred to dietitian/ nutritional team. budget counseling and other appropriate assistance program. Reviewed lab results. Corrects/control underlying contributing factors.
. chest XRAY Rationale 1. S3 is usually assoc. although myocarditis may be a contributory factor. Auscultated heart sounds. Review ECG. ventricular stiffening. com. 9.γ. and neural input is important in the early phases of fever . interleukin-8 (IL-8). Their levels likely correlate with specific clinical manifestations and illness severity . cola as indicated. Nursing Interventions Independent: 1. IL-10. and developing complications. are substantially increased during dengue infection. coffee. 2. 2002. Irregularities suggest dysrrhythmias which may require further evaluation and monitoring. Administer supplemental oxygen as indicated. Evaluated the quality and equality of pulses as indicated.. but may also noted with the mitrial insufficiency and left ventricular overload that accompany severe infarction. presence of murmur/rubs. Monitored heart rate and rhythm. Noted response to activity and promote rest appropriately.pt. Note development of S3/S4. S4 may assoc in myocardial ischemia.87bpm ECG reveals: prob. Provided small/easily digested meals. Dengue: an update.pubmed. 3. 5. will be able to achieved normal hemodynamic stability as evidenced by decrease frequency/absence of dysrrhythmias 51 | P a g e . 4.100/80mmHG CRT <2secs Objectives STO: Within 8h of nursing intervention pt. Kouri G. Have emergency equipment/medication available. Monitored BP. Limit caffeine intake eg. LTO: Unmet. and pulmonary or systemic hypertension.pt was able to maintained normal vital signs. 5. and IL-12. Acute reversible hypokinesia and reduction in left ventricular ejection fraction was also reported by . Over exertion increase oxygen consumption/demand and can Evaluation STO: Met. Decrease cardiac output in diminished. exhibits irregular heart beat LTO: Within 2 days of giving nursing interventions and collaborative mgt. pt. ) Cues Subjective: no verbal cues Objective: Presence of abnormal heart sound HR. An echocardiographic showed depressed myocardial contractility and suboptimal heart rate response in some patients with dengue hemorrhagic fever. 4. hypoperfusion of the myocardium and vagal stimulation. interferon. LVH BP. The relationship of cytokines to relative bradycardia is unknown. 6. activity. including tumor necrosis factor.2:33–42www.Lancet Infect Dis. with heart failure. weak/thread pulses. Heart rate and rhythm respond to meds. Fever production in response to exogenous pyrogens is believed to be mediated mostly by cytokine prostaglandin pathways.. chocolate. 8. Concentrations of cytokines. Documented dysrrhythmias. 2. Collaborative: 7.Problem Identified: Irregular heart beat Nursing Diagnosis: Risk for decrease cardiac output r/t altered myocardial contractility and rhythm secondary to DHF Cause Analysis(w/ reference):Dengue fever may adversely affect cardiac function. Further studies could consider the relative importance of immune and neural mechanisms and also any direct cardiac pathology in the etiology of dengue-associated relative bradycardia. will be able to maintain normal vital signs. 3. (Guzman MG. Hypotension may occur r/t ventricular dysfxn. Murmurs indicate disturbances of normal blood flow. The underlying mechanisms were postulated to be immune in origin.
extension of infarct. 7. Caffeine is a direct cardiac stimulant that can increase heart rate. Chest Xray may reflect pulmonary edema r/t ventricular dysfxn. Sudden coronary occlusion. The release of endotoxins by the microbes can lodge in the brain. affecting the respiratory center in medulla resulting to altered oxygen supply. Provide information regarding status of ventricular fxn/electrolyte balance and effects of drug therapies. 8. 6. Large meal may increase myocardial workload and may cause vagal stimulation. Refer to cardiologist compromise myocardial fxn. 10. Increases amount of oxygen available for myocardial uptake reducing cellular dysrhythmias 9. and unrelenting pain are situations that may precipitate cardiac arrest. 10.result. 52 | P a g e . requiring immediate life-threatening therapies. lethal dysrhythmias. For further management and evaluation. Disruption of mechanical defenses and ciliary motility leads to colonization of lungs and subsequent infection. NURSING CARE PLANS Problem Identified: Plueral effusion Nursing Diagnosis: Risk for impaired gas exchange r/t pleural effusion 20 DHF Cause Analysis(w/ reference):Impaired gas exchange is a state in which there is excess or deficit oxygenation and carbon dioxide elimination. Inflamed and fluid-filled alveolar sacs cannot exchange oxygen and carbon dioxide effectively. The compensatory mechanism of lungs is to lose effectiveness of its defense mechanisms and allow organisms to penetrate the sterile lower respiratory tract where inflammation develops.
To gain pt. was free cyanosis and -O2 98% ineffective ventilation. Elevated head of the pt. now small in LTO: volume and subpulmonic in location -w/ inter-fissural Within 2 days of seepage effective nursing intervention and -RR =30 collaborative management the -CRT< 2 sec. 7.Cues Objectives Nursing Interventions Independent: Rationale Evaluation STO: PARTIALLY METPt. Note for presence of cyanosis 7. Administered prescribed medications as ordered: Furosemide 10mg IVTT 1. pt. 1. Provided health teaching on how to alleviate pt’s condition 9. To promote optimum chest expansion 8. To note for etiology precipitating factors that can lead to impaired gas exchange. For the pharmacological management of the patient’s condition LTO: MET Pt. film dated 2-11-2012. depth and rhythm 3. will be able to stabilized normal As compared to previous chest RR from 30 to 20bpm. 6. To assess inadequate systemic oxygenation or hypoxemia. there is significant decrease in the right pleaural fluid. Provided supplemental oxygen at lowest concentration indicated by laboratory results and client symptoms/ situation 10. was free from cyanosis and ineffective ventilation./SO’s trust and cooperation. note areas of decreased/adventitious breath sounds as well as fremitus 5. Monitored respiratory rate. To determine pt’s oxygenation status 10. Auscultated breath sounds. Established rapport.O providing nursing care and Objective: collaborative management the -Chest X-ray : pt.’s RR-23 Subjective: STO: “La ramanpudbiyanasiyanangluspad” Within 8 hrs.To obtain baseline data 2. Encouraged frequent position changes and deep-breathing exercises 8. of as verbalized by the S.Monitor and record vital signs 2. To correct/ improve existing deficiencies 9. Assessed pt’s general condition 4. 11. To enhance lung expansion 6. Reviewed laboratory result. To empower SO and pt 11. To assess for rapid or shallow respiration that occur because of hypoxemia and stress 3. 4. To evaluate degree of compromise 5. NURSING CARE PLANS 53 | P a g e .
Problem Identified: pleural effusion Nursing Diagnosis: Risk for Infection r/t fluid accumulation in the pleural cavity 20 DHF Cause Analysis: The primary symptoms of DHF consist of plasma leakage and bleeding, which are potentially lethal, as plasma leakage is caused by an increase of capillary permeability, often resulting in hemoconcentration, pleural effusions and ascites; and bleeding, caused by capillary fragility and thrombocytopenia (a marked decrease of platelets) may result in bleeding incidents into the skin (petechial skin hemorrhages), or even life-threatening bleeding into the gastrointestinal tract. ( http://www.medicinemd.com/Med_articles/Dengue_fever_en.html) CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
STO: Within 3-4 hours of giving effective nursing interventions and health teachings to the pt/SO, pt will be identify different interventions to prevent or reduce the risk of infection
Independent: 1. Reviewed pathology of the condition- risk for infection, and possible dissemination of infection through bronchi to adjacent tissues or via bloodstream and lymphatic systemand potential spread of infection via airborne during coughing, sneezing, spitting, talking, laughing and singing. 2. Identified others for potential carrier, such as household members, playmates, and friends. 3. Reviewed proper disposal of tissue and good hand-washing. request return demonstration. 4. Monitored temperature as indicated. 5. Encouraged selection and ingestion of well-balanced meals. Provide frequent small “snacks” in place for large meals as appropriate. 6. Assessed SO/patients knowledge and ability to maintain opportunistic infection prophylactic regimen. 7. Washed hands before and after all care contacts. Instruct pt./SO to wash 1. Helps client to realize and accept the necessity in adhering to medication regimen to prevent infection and it’s complications. 2. Other family member or friends of the client who has a current infection (any other form), must require a course prevention of requiring infections. 3. Behaviors necessary to prevent occurrence of infection. 4. Febrile reactions are indicators of presence of infection. 5. Presence of anorexia or preexisting malnutrition lowers resistance to infection and impairs healing process. Small snacks may enhance overall intake. 6. Multiple medication regimen is difficult to maintain over a long period of time. Patient may adjust medication regimen based on side effects experienced, contributing to inadequate prophylaxis, active disease, and resistance. 7. Reduces the risk of acquiring
STO: MET Pt./S.O was able to identify different interventions to prevent or reduce the risk of infection.
No verbal cues
Chest X-ray : As compared to previous chest film dated 2-112012, there is significant decrease in the right pleaural fluid, now small in volume and subpulmonic in location -w/ inter-fissural seepage -RR =30 -CRT< 2 sec. 54 | P a g e
LTO: Within 1-2 days of giving effective nursing interventions and health teachings to the pt/SO, pt will be able to demonstrate techniques and initiate lifestyle changes to promote
LTO: The pt/S.O. was able to demonstrate techniques and initiate lifestyle changes to promote safe environment and was free from signs of
-O2 98% -T.35.6 0C
hands as indicated. 8. Provided a clean, well-ventilated environment. 9. Assessed respiratory rate/ depth; note dry spasmodic cough on inspiration, presence of sputum and presence of wheezes or ronchi. Collaborative:
infection and cross-contamination. 8. Reduces the number of pathogens presented to the immune system and reduces possibility of pt. contracting nosocomial infection. 9. Respiratory congestion/ distress may indicate developing Pleural Effusion. 10. Shifts in the differential and changes in WBC count indicate infectious process. 11. Bacteriacidal
10. Monitored lab studies, e.g., CB, CX-ray 11. Administered medication as indicated : CEFUROXIME Reference: : Nursing Diagnosis Handbook by: Judith M. Wilkinson
NURSING CARE PLANS
Problem Identified: less knowledge Nursing Diagnosis: Deficient Knowledge related to potential risks of Dengue Hemorrhagic Fever Cause Analysis: Dengue vector control requires effective participation of the local community.Although education campaigns have increased people’s awareness of dengue, it remains unclear to what extent this knowledge is put into practice, and to what extent this practice actually reduces mosquito populations,public has less knowledge about dengue hemorrhagic fever, a fatal complication, than dengue fever. ( http://www.ajtmh.org/content/74/4/692.) CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Independent: 1. Ba aware of and deal with anxiety of client and family. 2. Provided activity role for the client/SO in 1. Anxiety can interfere with ability to hear and assimilate information. 2. Learning is enhanced when persons STO:
Patient/S.O may 55 | P a g e
Within 3-4 hours of giving
verbalize statements of concerns and questions regarding the condition.
Objectives: • Statements of concerns and questions • Inaccurate follow-through of instructions • Frequent asking questions regarding the disease.
health teachings regarding present condition, the patient/mother will be able to verbalize understanding of own condition/disease process, prognosis and potential complications.
Within 1-2 days of giving health teachings to the patient/mother, she will be able to identify/initiate necessary practices/lifestyle changes to for dengue-free environment
the learning process. 3. Provided written and verbal information as indicated. Include articles of books, internet sites, special TV programs related to client/family needs and encourage reading and discussing what they learn. 4. Paced learning activity to individual needs. 5. Reviewed condition and prognosis/ future expectations. 6. Discussed relationship of drug use to current situation. 7. Educated about the different practices to eradicate/lessen mosquitoes carrying dengue virus. 8. Discussed potential for re-occurrence of the disease if bitten again with mosquitoe carrying dengue virus with another strand of DNA 9. Informed client/S.O alternative ways on treating/minimizing complications of DHF 10. Discussed variety of helpful organizations and community programs that are available for assistance/referral.
are actively involved. 3. Helps client/SO make informed choices about future and can be a useful addition to other therapeutic approaches. 4. Assist in planning for long-range changes necessary for maintaining sobriety/dengue-free status. 5. Facilitates learning because information is more readily assimilated when timing is considered. 6. Provides knowledge base from which client can make informed choices. 7. Often client has misinterpretation of real reason for admission to the medical setting. 8. Information will help client understand possible re-occurrence of such condition. 9. Even though cure may have passed, client maybe at risk of developing the same condition. 10. Long-term support is necessary to maintain optimal recovery. Community programs maybe helpful on eradicating/minimizing mosquitoes carrying dengue virus.
MET The S.Owas able to verbalized understanding the condition and disease process of the pt.
LTO: MET The S.O was able to identify/initiate necessary practices/lifestyle changes to for dengue-free environment.
Reference: : Nursing Diagnosis Handbook by: Judith M. Wilkinso
56 | P a g e
and low-fat dairy foods Educate the SO about the importance of proper hygiene of the patient from head to toe. Eating more fruits. Materials Needed: 1) Visual aids 2) Pamphlets/ fact sheets GENERAL HEALTH TEACHING SPECIFIC HEALTH TEACHING Medication • • Diet Advice client and SO to take the medication at regular basis. route . and special consideration of each medications. HEALTH EDUCATION PLAN Objectives: 1) Within 1 hour of health teachings. vegetables. dosage .B. 3) Within 1 hour of health teachings. the client and SO will verbalize the importance of proper hygiene in maintaining good health. the client and SO will verbalize understanding about the goals of treatment. 2) Within 1 hour of health teachings. the client and SO will verbalize understanding of therapeutic needs of the pt’s condition. Proper Hygiene • • • Drinking extra glasses of water a day and eating less salt. 57 | P a g e . Teach the patient and SO the time .adverse effect.
• Rest & Sleep • Cleaning the whole body with tap water every day Educate the SO and patient about the importance of complete bed rest Safety Precaution • • Psychological Support • • • Spiritual Support • Encouraged the relatives to pray over for the patient and do some reading about bible or God. Inform the family of the patient to monitor if there is any sudden change to the patient and report immediately. 58 | P a g e . Provide emotional and spiritual support to patient/families. Observe for symptoms of depression and intervene ASAP Assist family in providing emotional support Instruct the SO to monitor the client’s safety everyday to avoid injury from falls.
C. DISCHARGE PLAN (METHODS) 59 | P a g e .
Keep water container covered.g. It can lead to fatality if not treated immediately. Eliminate Vector by: • • • • Changing water and scrubbing sides of lower vases once a week Destroy breeding places of mosquito by cleaning surroundings Proper disposal of rubber tires.Avoid too many hanging clothes inside the house 3. non-carbonated Noodle soup may be given.5 ml Environment: 1. and organ meats) as allowed. non-irritating. 2.Medication: Vita syrup once a day 7. . Outpatient/Inpatient Referral: The SO instructed to: • • Diet: Diet for age: 60 • P a g e | Encourage intake of foods high in folic acid (e. low fiber. asparagus. • • Low fat. And refer to nearest hospital if she exhibit symptoms of sudden increase of fever and gradually lowering temp. severe abdominal pain and vomiting.Residual spraying with insecticides Treatments: • • Increase fluid intake CBR for 2 weeks Health Knowledge of the Disease: SO has been educated that DHF is an acute febrile diseases. cooked green leafy vegetables. Follow up ECG after 1week Follow up check-up after 1 week to Dr. empty bottles and cans.RizaCanoy for further assessment of the pt.
GENERIC NAME AND TRADE NAME MEDICAL MANAGEMENT CLASSIFICATI ON MECHANISM OF ACTION INDICATION DOSAGE/RO UTE/ FREQUENCY ADVERSE EFFECT NURSING RESPONSIBILITIES GENERIC NAME: CEFUROXIME Anti-infective Second generation cephalosporin TRADE NAME: Pharmacef Interferes with bacterial cell wall synthesis and division by binding to cell wall. hypertonia. abdominal pain. urinary or respiratory tract and septicaemia. review all other significant and life threatening 61 | P a g e . to report CNS changes. renal dysfunction. how to recognize signs and symptoms or superinfection.IX. Teach pt. As appropriate. vomiting. causing cell to die. diarrhea. bone. Instruct the SO to report these right away. with expanded activity against gram negative bacteria. aplastic anemia. vaginal candidiasis. 500mg q 8h IVTT CNS: headache. Advise pt. including those of skin. joints. to immediately report rash or bleeding tendency. haemorrhage Hepatic: hepatic • • • • Advise pt. Moderate to severe infections. acute renal failure Hematologic: haemolytic anemia. Exhibits minimal immunosuppressant activity. dyspepsia GU: hematuria. Active against gramnegative and grampositive bacteria. hyperactivity. seizures GI: nausea.
drug fever. especially those related drugs. GENERIC NAME AND TRADE NAME CLASSIFI CATION MECHANISM OF ACTION INDICATION DOSAGE/RO UTE/ FREQUENCY ADVERSE EFFECT NURSING RESPONSIBILITIE S 62 | P a g e . test. Other: allergic reaction. adverse reactions & interactions. anaphylaxis. superinfection. and foods.dysfunction. Metabolic: hyperglycemia Skin: toxic epidermal necrolysis.
prn for fever CNS: weakness.V. site. GENERIC NAME AND TRADE NAME CLASSIFICATIO N MECHANISM OF ACTION INDICATIO N DOSAGE/RO UTE/ FREQUENCY ADVERSE EFFECT NURSING RESPONSIBILITIES GENERIC NAME: PARACETAMOL 63 | P a g e Analgesic Anti-pyretic -Decreases fever by inhibiting the effects of pyrogens on the Relief of mild-tomoderate pain 250mg 5ml q 4h p. Monitor CBC liver function tests.o. Caution pt. burning or itching at I.duration. Hematologic: reversible granulocytopenia and thrombocytopenia Hepatic: hepatitis Skin: rash Other: pain at I. 20mg q 8hr IVTT CNS: Headache. constipation. abdominal discomfort or pain. injection site. fatigue. creating a protective coating on gastric mucosa. to avoid hazardous activities until she knows how drug affects concentration and alertness. nervousness. vomiting. to maintain healing of duodenal and gastric ulcers. agitation. anxiety GI: nausea.drowsiness. location. diarrhea. sedation. hypersensitivity reaction.temperature .GENERIC NAME: RANITIDINE Antiulcers H2 Receptors antagonis t TRADE NAME: Zantac Reduces gastric acid secretion and increases gastric mucus and bicarbonate production. intensity.M. Assess patient’s fever or pain:type of pain. • • • Assess vital signs. Active duodenal and gastric ulcers.
hepatic insufficiency GU: Hematuria. glycosuria.headache. drug mayhave to be discontinued -Assesss :rapid. -Administer with food or milk to weakness. seizures Dermatologic: pruritus. urticaria. tremor. nausea. clammy extremities report immediately to prescriber. if theseoccur. constipation. . crystaluria -Assess allergic reactions: rash. GENERIC NAME AND TRADE NAME CLASSIFICATIO N MECHANISM OF ACTION INDICATIO N DOSAGE/RO UTE/ FREQUENCY ADVERSE EFFECT NURSING RESPONSIBILITIES GENERIC NAME: FUROSEMIDE 64 | P a g e Loop Diuretic Inhibits the reabsorption of sodium and chloride For hypertension 10mg IVTT with BP CNS: dizziness. rash GI: Anorexia. urinary frequency. vertigo. prevent GI irritation. vomiting. paresthesias. renal colic.depression. weak pulse dyspnea:cold. urticaria.TRADE NAME: Napran hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilation -Relieves pain by inhibiting prostaglandins synthesis at the CNS but does not have antiinflammatory action because of its minimal effect on the peripheral prostaglandin synthesis -Temporary reduction of fever dizziness.
CV: Orthostatic thrombophlebitis. patients with DM after starting this drug. rash. oral and same clothing and record the gastric irritation. weight. hypotension. anemia. nocturia.TRADE NAME: Frusema from the ascending limb of the loop of Henle. GENERIC NAME AND TRADE NAME CLASSIFICATION MECHANISM OF ACTION INDICATIO N DOSAGE/ROU TE/ FREQUENCY ADVERSE EFFECT NURSING RESPONSIBILITIE S 65 | P a g e . -Reduce dosage if given with antihypertensive drugs. -Avoid IV used if oral use is possible. urinary -Blood glucose levels may bladder spasm. Dermatologic: photosensitivity. precaution headache. become temporarily elevated in Hematologic: leucopenia. GU: Polyuria. urticaria. -Weigh the client in regular basis. at the same time and I the GI: Nausea. leading to sodium rich dieresis. vomiting. constipation. thrombocytopenia. pruritus.
ECG changes. taper gradually. of extremities. gangrene of extremities (with high doses for prolonged periods or in occlusive vascular disease) • • • • Monitor blood pressure.site regularly for irritation. Avoid extravasatio n Monitor color& temp. myocardial contractility. urinary output and pulmonary artery wedge pressure during infusion. leading to vasodilation of renal and mesenteric arteries. hypotensio n 250ml @ 65cc/hr CNS: headache CV: palpitations. vasopressor Causes norepinephrine release (mainly on dopaminergic receptors). Shock. hyperglycemia Respiratory: dyspnea. blood flow. asthma attacks Skin: piloerection Other: irritation at injection site. arrhythmias EENT: mydriasis GI: nausea and vomiting Metabolic: azotemia. which increases the heart rate. hemodyna mic imbalance. tachycardia.V. 66 | P a g e . Also exerts inotropic effects on heart. vasoconstriction. Inspect I. and stroke volume. pulse.adrenergic TRADE NAME: Intropin Inotropic. Never stop infusion abruptly. Instead. angina. hypotension. because this may cause severe hypotension.GENERIC NAME: DOPAMINE Catecholamine .
Surgical Nursing: Concepts and Clinical Applications by Udan.Surgical Nursing by Smeltzer and Bare. 4thed Human anatomy and physiology by Marieb.2.2 Pathophysiology by Porth.Surgical Nursing by Black and Hawks. most patients recover from dengue hemorrhagic fever. 4th edition Diagnostic Tests “Nurse’s Quick Check” by Williams and Wilkins Nursing spectrum drug handbook 2008 by Patricia Dwyer Schull Nursing care plan by Doenges. 2nd edition Mosby’s Pocket Dictionary of Medicine. half of untreated patients who go into shock do not survive.BIBLIOGRAPHY BOOKS: • • • • • • • • • • • • Medical.Surgical Nursing by Ignatavicius and Workman.X. 5th edition vol. Our patient shows good prognosis. pp. 7th edition Physical Examination and Health Assessment by Jarvis. However. Nursing. 6th edition vol. 11th edition Medical. Introductory Medical Surgical Nursing by Timby and Smith.1 Medical. and Allied Health. PROGNOSIS With early and aggressive care.7th edition. XI. Moorhouse and Murr. SUPPLEMENTARY SOURCES: 67 | P a g e . 11th edition vol. 9th edition Medical.
com http://nursinglectures.askjeeves.dictionrary.• • • • • • • • http//emedicine.merck.google.html www.com www.com/mmpe/sec17/ch233c.com 68 | P a g e .html www.com/article/238798-overview http//www.com www.medscape.com/2009/01/post-operative-nursing.blogspot.com www.about.medindia.
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