Escarez, Zarah Jane F. BSN-3D I. D19 Clients Profile Demographic Data Name: Ms. M.A.A.

. Date of Birth: May 3, 1981 Age: 30 Sex: Female Occupation: House helper Educational Attainment: High school undergraduate Date of Admission: August 21, 2011 Chief Complaint: Fever that lasted for 4 days Health History History of Present Illness

II.

4 days PTA, the client started to feel generalized body pain with chills but no medications were taken and no consultations were done. 3 days PTA, the clients symptoms persisted and were associated with intermittent fever with temperature ranging from 37.9-38.5C. This time the client took Paracetamol 500 mg and Ibuprofen (Alaxan) which provided temporary relief. The patient felt no abdominal pain, no loss of appetite and no dysuria. Still, no consult was done by the patient. 1 day PTA, the symptoms persisted and the patient decided to have a consultation. CBC and Chest X-ray were done. CBC revealed Hgb-131, Hct- 41, WBC-5.3, Platelet-145. X-ray revealed normal chest and negative lung opacity. The patient was advised for admission but refused. Instead, she was prescribed with Cefuroxime 500 mg, Ambroxol 30 mg/ 5 ml, Paracetamol 500 mg. On the day of admission, CBC revealed: Hgb-139, Hct- 140, Platelet-82. Past Health History

The client reported of having hyperthyroidism way back in 2009. She maintained Cenbinagole 5 mg TID and stopped taking it on July 2011 when the thyroid test revealed normal findings. Aside from this, the patient is having productive cough for a month already. The patient has no previous surgery or admission. Also, no known allergies were reported by the patient. Over-the-counter medications used by the patient include Paracetamol and Ibuprofen which were taken orally during occurrence of certain conditions such as fever and body pain. As soon as the patient is relieved, she would stop taking these.

Family History

HTN

Thyroid problem

Social History

The client is now living in her employers house as a house helper. They have good living condition at home and her employer is nice to her. She has been working for the employers family for years already and has not got any problem with them. And she receives enough salary and shes said that shes contented with it. Her youngest sister is with her while all their other siblings stay in their province, Bukidnon, Mindanao. So the only social support she got is her youngest sisters company. The patient verbalized that they often quarrel because her sister is somewhat irresponsible.

III.

Gordons Functional Health Pattern A. Health Perception-Health Management Pattern S: The patient verbalized, Hindi naman ako sakitin, for four years ngayon lang ulit ako nagsakit e. The patient also said that she doesnt smoke nor drink alcohol and eat healthy foods at home. O: The patient is alert and oriented with time, place and person. She also looked neat and well-groomed. Her hair is neatly combed and tied up. Her skin is smooth and moist. Her nails are trimmed. The facial expressions she manifested are appropriate to what shes saying. Vital signs were as follows: BP: 100/70, RR: 22 cpm, PR: 62 bpm, Temp: 36C. Nursing Diagnosis: Risk for injury r/t abnormal blood profile B. Nutrition-Metabolic Pattern S: The patient verbalized, Tatlong beses isang araw naman kami kumain at naguulam din ako ng gulay saka kumakain ng prutas paminsan-minsan. She also said that she doesnt skip any meal and drink about 6-8 glasses of water in a day. O:The clients skin is moist and smooth without any lesions. No rash was observed. Her mucous membranes are moist and pink in color. Her nailbeds are pink in color and no clubbing was noted. Her weight (54 kg) is appropriate for her height (51). The patients diet prescribed by physician was diet as tolerated by avoid dark-colored foods. Though, patient manifests low platelet count which may bring about bleeding leading to fluid volume deficit. Nursing Diagnosis: Risk for fluid volume deficit r/t possible bleeding and altered clotting processes C. Elimination Pattern S: The patient verbalized, Mga dalawang beses sa isang araw ako dumumi tas ihi naman madami e, mga apat o lima siguro. O: No distention of abdomen was noted and with normal bowel sounds. Rectal exam was not performed. Nursing Diagnosis: Readiness for enhanced elimination

D. Activity-Exercise Pattern S: The patient verbalized that, Naglilinis lang ako lagi ng bahay saka nag-aalaga ng mga bata. Hindi na rin ako masyadong napapagod kasi sanay na at nagpapahinga rin naman. Nag-eexercise pa nga ako araw araw e. O: The patient has normal range of motion, normal gait and balance, with muscle strength of 4/5. Proper posture was also observed. But the patient didnt want to stay in bed. Frequent shift of position from lying to sitting position was observed. No cyanosis was noted. Nursing Diagnosis: Deficient diversional activity r/t environmental lack of diversional activity as evidenced by observed statement of boredom, yawning and body language E. Sexuality Reproductive Pattern S: The patient verbalized, Regular naman ang menstruation ko, mga 3-4 days lang sya. She said that she doesnt have a boyfriend at the moment. Sexual activities was not asked. O: Examination of the genitalia was not done.

F. Sleep-Rest Pattern S: The patient verbalized, Yung tulog ko mga anim o pitong oras lagi. At nakakapagrelax lang naman ako kapag tapos na mga Gawain tapos manonood na lang kami ng TV. O: No bluish discolorations around the eyes. And the patient didnt appear restless. She was also able to pay attention to our conversation. Nursing Diagnosis: Readiness for enhanced sleep G. Sensory-Cognitive Pattern S: Wala naman akong problema sa senses ko, kahit sa paningin o kaya pandinig. The client reported absence of pain. O: The patient is able to see and hear clearly. Good communication and understanding was shown by the patient. And she was able to respond appropriately to what Im asking. Nursing Diagnosis: Readiness for enhanced comfort

H. Role-Relationship Pattern S: The patient verbalized, Hindi pa ako nag-aasawa kasi may panganay ako e pinapaaral ko pa yung mga kapatid ko. Dapat makapagtapos muna sila bago ako mag-asawa. She also mentioned that Okay naman ako sa amo ko. Mabait naman sila saka tama magpasweldo. O: The clients sister visited her and fair communication was observed between them. Nursing Diagnosis: Readiness for enhanced family processes I. Self-Perception-Self Concept Pattern S: The patient verbalized, Masaya naman ako kahit walang boyfriend. O: Patient appeared calm. Proper body posture and good eye contact was observed. Voice and speech pattern are normal. Thought processes are appropriate with the conversations. Nursing Diagnosis: Readiness for enhanced power J. Coping-Stress Tolerance S: The patient verbalized, Ay ang nakakapagpa-stress lang naman sa akin e yung mga bata. Makukulit kasi sila pero ngayon, pinapabayaan ko na lang. Maiinis ka lang kapag lalo mong pinansin e. O: No signs of stress were observed such as crying, wringing or clenched fists. Nursing Diagnosis: Readiness for enhanced coping K. Value-Belief Pattern S: Born Again Christian ako e nasanay na ako na laging nagdadasal. Kaya pag may mga problema, dasal lang kay Lord tapos okay naman. O: Reading of bible by the patient was observed. Nursing Diagnosis: Readiness for enhanced spiritual being IV. Anatomy and Physiology Platelet Production

Platelets are not actually cells, but cytoplasmic fragments of large cells known as megakaryocytopoiesis. The platelets themselves are incapable of mitotic division since they lack a nucleus and have no DNA. Contained within the platelets are cytoplasmic granules which can release biochemical mediators when stimulated by an injury to a blood vessel.[1] The disc-shaped platelets circulate in an inactive state as long as the endothelium lining of the blood vessels is intact and remain in circulation for about 10 days before being

removed from circulation by the spleen.[2] When the blood vessel is damaged, the blood is exposed to the subendothelial layer of the vessels. The platelets become spherical and extend pseudopods, which adhere to vessel walls and each other, and hemostasis is initiated in conjunction with coagulation factors.[2] These events lead to the formation of a fibrin plug that stops bleeding from the injured vessel.[3] The earliest blood cells develop from endothelial cells within the walls of the newly forming vessels of the cardiovascular system. These vessels begin forming within the walls of the yolk sac and allantois around the end of the third week of gestation. Blood formation begins in the embryo during the fifth week of gestation, occurring in various parts of the embryonic mesenchyme.[4] Platelets are first noted in the fetal circulation by the fifth to sixth week of gestation.[5] The transition to hepatic hematopoiesis may involve stem cell migration from the yolk sac to the liver.[6] Megakaryocytes can be found in the liver/spleen tissue by 10 weeks' gestation.[7] Megakaryocytes were recognized as the source for platelets in the early 1900s, almost 100 years after platelets were first described.[8] They make up 0.02 to 0.1% of the total nucleated bone marrow cells and are large in size.[9] Neonatal megakaryocytes are smaller than adult megakaryocytes, and their size increases with advancing gestational age.[10] The progenitors of megakaryocytes arise from pluripotent hematopoietic stem cells by a process that is not yet well understood. The burst forming unit-megakaryocyte (BFU-MK) is the earliest identifiable megakaryocyte progenitor. The later progenitor is the colony forming unitmegakaryocyte (CFU-BK). Both BFU-MK and CFU-MK can be quantified and have proliferative potential.[11] CFU-MK are more plentiful in the bone marrow; BFU-MK are more plentiful in circulating peripheral blood.[12] Interleukin 3 (IL-3) stimulates megakaryocytopoiesis progenitor cells. interleukin 6 (IL-6) and interleukin 11 (IL-11) act with IL-3 to stimulate CFUMK proliferation. Interleukin 1 (IL-1), IL-6, IL-11, and leukemia-inhibiting factors are active in the latter stages of megakaryocyte maturation.[13]Thrombopoietin (TPO), which stimulates all stages of megakaryocyte growth and development, was first described as a humoral regulator of platelet concentration in circulation by Kelemen and coworkers in 1958.[14] Almost 36 years later, in 1994, TPO was purified and cloned by five independent research groups.[15] TPO is thought to be the primary stimulant of megakaryocyte maturation.[11] At the end of the maturation process, each megakaryocyte divides into a few thousand platelets.

V.

Pathophysiology of Disease Condition

Precipitating Environmental conditions (open spaces with water pots, and plants) Immunocompromise Mosquito carrying dengue virus Sweaty Skin

Predisposing Geographical area tropical islands in the Pacific (Philippines)

Aedes Aegypti (dengue virus carrier): 8-12 days viral replication on mosquitos salivary glands Bite from mosquito (portal entry in the skin) Allowing the dengue virus to be inoculated in the circulation (incubation period: 3-14 days) Virus disseminated rapidly into the blood and stimulates WBCs including B lymphocytes that produces/secretes antibodies and monocytes, macrophages and neutrophils Antibodies attach to the viral antigen and monocytes/macrophages perform phagocytosis through Fc receptor within the cells and dengue replicates in the cells Redness/itchiness in the area

Entry to spleen

Recognition of dengue viral antigen on infected monocytes and macrophges

Entry to bone marrow

Release of cytokines which consist of vasoactive agents such as interleukins, tumor necrosis factor, urokinase, and platelet activating factors which stimulates WBCs and pyrogen release

Intake of analgesic, antipyretic

Early s/sx: fever, diaphoresis, warm flushed skin, headache, body weakness

Dengue

Cellular destruction and infection of red bone marrow precursor cells as well as immunological shortened platelet life span

Watch out for signs of bleeding: petechiae, easy bruising, epistaxis, bleeding gums, black stool; Bleeding precautions

Thrombocytopenia

Hematology: decreased platelet

Leads to dengue hemorrhagic fever

Leads to dengue hemorrhagic fever

Increase number and size of the pores in the capillaries which leads to leak of fluids from blood to interstitial spaces Administration of IV fluids, PLRS/PNSS

Decreased intravascular fluids

VI.

Laboratory Values Latest CBC revealed: Parameter Hgb Hct RBC MCHC MCH MCV RDW WBC Diff Count -Neutrophil -Stabs -Lymphocytes -Monocytes -Eosinophils -Basophils Platelet MPV Value 130 37 4.3 34 29.7 84 12 2.3 52 33 2 7 1 54 00 Reference 120-140 37-47 4-4.5 32-37 27.5-33.2 80-94 11-15 5-10 40-75 3-5 20-45 2-6 1-4 0-1 150-440 7.5-11.5

RBC Morphology VII. Medication Generic Name: Paracetamol Brand Name: Biogesic Dosage: Adults and children 5001000 mg orally every 4-6 hours Drug Analysis Mode of Action Antipyretic: reduces fever by acting directly on the hypothalamic heat-regulating center to cause vasodilation and sweating, which helps dissipate heat

Normochromic,Normocytic

Indication Symptomatic relief of pain and fever

Contraindication -Contraindicated in patients hypersensitive to drug -Use cautiously in patients with long term alcohol use because therapeutic doses cause hepatotoxicity in these patients.

Adverse Reaction -Hematologic: hemolytic anemia, neutropenia, leucopenia, pancytopenia. -Hepatic: Jaundice -Metabolic: Hypoglycemia -Skin: rash, urticaria.

Nursing Intervention Advise patient that drug is only for short term use and to consult the physician if giving to adult for longer than 10 days. Advise patient or caregiver that many over the counter products contain acetaminophen; be aware of this when calculating total daily dose. Warn patient that high doses or unsupervised long term use can cause liver damage.