Bulacan State University

City Of Malolos, Bulacan

College Of Nursing

A case study of an 20 years old woman

With Systemic viral infection

Submitted by:
PUNZALAN, Dan Louie S.
BSN 3A-Group 1

Submitted to:
Mylene Fajardo, RN
Clinical Instructor
TABLE OF CONTENTS
I. INTRODUCTION
II. OBJECTIVES
III. SIGNIFICANCE OF THE STUDY
IV. PATIENTS PROFILE
V. NURSING HEALTH HISTORY
VI. GROWTH AND DEVELOPMENT
VII. PHYSICAL ASSESSMENT
VIII. REVIEW OF SYSTEMS
IX. ACTIVITIES OF DAILY LIVING
X. PATHOPHYSIOLOGY
XI. NURSING CARE PLAN
XII. DRUG STUDY
XIII. DISCHARGE PLANNING
XIV. BIBLIOGRAPHY
I. INTRODUCTION

II. OBJECTIVES

General Objectives:
The purpose of this case study is to enhance the knowledge of nursing student who will have encountered this kind of case and to educate
the patient regarding her condition and the interventions needed. This aims is to develop the awareness of health care providers about this particular kind of case.

Specific Objectives:
• To assess for the possible signs and symptoms of SVI
• To assess for the possible complications to the patient
• To review the anatomy and physiology of the related system
• To know the pathophysiology of SVI
• To list the possible factors that may contribute to the occurrence of SVI
To provide health teaching to the patient

III. SIGNIFICANCE OF THE STUDY

This study of Dengue Hemorrhagic Fever intends to provide and share information to:

A. Allow nursing student to help them picture out and foresee client having this systemic viral infection and to guide them how to apply client-centered nursing
management for the said client.
B. For Significant others- to impart knowledge and information about viral infection and the possible management to be apply for the said condition.

IV. PATIENTS PROFILE

A. BIOGRAPHIC DATA
 NAME: Ms. M.C
ADDRESS: Pulilan Bulacan
AGE: 20
BIRTHDAY: October 18, 1987
SEX: Female
RACE: Filipino
MARITAL STATUS: Single
EDUCATIONAL ATTAINMENT: High School Graduate
OCCUPATION: N/A
RELIGIOUS ORIENTATION: Roman Catholic
FINAL DIAGNOSIS: Systemic Viral Infection

B. CHIEF COMPLAINT

“nagsuka at nagtae”, as verbalized by the mother.

V. NURSING HEALTH HISTORY

A. PRESENT HISTORY
The client was admitted in the hospital last August 21, 2009 around 6:30 am because of Acute Gastroenteritis. The client experienced frequent
vomiting, has a watery stool and cried most of the time.

B. PAST HISTORY
The client had a past history of measles, common colds, fever and cough. He had completed immunization like BCG,DPT, OPV, except Hepa B.
C. FAMILY HISTORY
The client grandparents in both side is still alive. His mother had first family and she conceived 8 children. One died because of hyperthermia in the
age of 9 months. The mother of the client first lived-in-partner died because of liver cirrhosis at the age of 66.The father of the client is only 22 years old.

VI. GROWTH AND DEVELOPMENT

YOUNG ADULTHOOD (20 to 30 yrs old)

This time are highly individualized. A person is defined as an adult when he or she is physically and psychologically mature, ready to assume adult responsibility
and be self sufficient. After rapid growth and development during adolescence, the adult completes physical growth and develops internal and external controls and values
acceptable to society. There are no specific measurements of maturity each person an individual and wide range of normal values and behaviors are considered healthy.
My client is physically and psychologically matured. She is ready to assume responsibilities and she is self sufficient. Her physical growth is complete.

PSYCHOLOGICAL DEVELOPMENT

According to Eric Erikson’s theory, the young adults, in the intimacy-versus-isolation stage, needs to complete tasks are not accomplished, the young adult becomes
isolated and self-absorb.
With regards to my client, she is in the intimacy rather than isolation stage because she has a task to complete to achieve independence to her parents like finishing
her study.

PSYCHOSEXUAL DEVELOPMENT

The adolescent and young adults are on Freud’s genital stage. The libido reemerges in a mature, adult form and the individual is capable of full sexual function.
There is a sense of self and others, extending to the other adults and peers of the opposite gender. Creativity and pleasure are found in love and in work.
My client does not have partner at this moment because she said that she is busy on her study and she does not have enough time to entertain suitors.

COGNITIVE DEVELOPMENT

Young adult are creative in thought, objective and realistic and are less self-centered. There is enhanced through educational and life experiences. Piaget believes
that cognitive structures are complete during the formal operations period from roughly 11 to 15 years. Egocentrism continues to decline, however, according to Piaget,
these characteristics do not involve a change in the structure of thought, only a change in its content and stability.
My client being a young adult knows what is right and wrong. She also knows the importance of adapting to the rule of society. And for her, loyalty to the other
people especially to her parent is important. She also has her own belief and definition of what morality is . For her, morality is having a good moral conduct and/ or
attitude.

SPIRITUAL DEVELOPMENT
 Young adult can think in the abstract might question belief and practices that no longer serve to stabilized their identity or purpose. The individuating – reflective
period in the adult (defines by Fowlers) bring discovery of the meaning of values as they relate to the achievement of social purposes and the acceptance of the value
systems of others. Often, young adults as well as adolescent are temporary abandon traditional practices.
She respects and accepts the value system of other people as what she wants other people to do unto her. She is not very conscious about spiritual matters. She is not
able to attend mass regularly every Sunday and she is not able to participate is some religious practices.

VII. PHYSICAL ASSESSMENT

NAME: M.C
AGE: 20
 BODY PART ASSESSD TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS
A. GENERAL
APPEARANCE
1. Body Built Inspection and observation Proportionate, varies Proportionate, varies normal
with lifestyle with lifestyle
2. Posture and gait, standing Inspection and observation Relaxed, erect posture, Uncoordinated movements Decreased muscle tone.
Sitting and walking Coordinated movement

3. Gait Inspection Coordinated movements N/A

4. Overall hygiene and Inspection and observation Clean and neat Slightly Clean and neat Cant able to satisfy needs, in the
grooming hospital
5. Obvious signs of health or Inspection and observation Healthy appearance Unhealthy appearance Presence of illness
illness
B. VITAL SIGN
1. Temperature Inspection 36.5 - 37.5 ۫c 39.5 ۫c Due to fever
2. RR Inspection 12-20 CPM 24 cpm Due to hypotension,
3. PR Inspection 60-100 BPM 102 bpm normal
4. BP Auscultation 120/80 mmHg 100/70 mmHg
C. MENTAL STATUS
1. level of consciousness Inspection Responsive; responds to question She answer my question clearly normal
clearly and appropriately
2. orientation Inspection Cooperative She cooperate well normal
3.emotional status Inspection Appropriate to the situation Appropriate to the situation normal
4. language and Inspection understandable She has Low voice and cannot be Because of her illness
communication easily understood

D. SKIN AND NAILS

1.presence of edema, Inspection No edema, warm temperature Warm to touch Due to fever
temperature
2. examine the expose part Inspection and Palpation Convex curvature, Smooth texture, Convex curvature, Smooth texture, normal
VIII. REVIEW OF SYSTEM

CARDIOVASCULAR SYSTEM Because of the loss of blood or bleeding in dengue the patients heart compensate to this by increasing
the cardiac output to supply all the needed in organs in the body and this cause tachycardia.
RESPIRATORY SYSTEM Because of the increase cardiac output cause by bleeding the patient respiration also increase to supply
enough oxygen to the body organs and cells.
* tachypnea
ENDOCRINE SYSTEM Because of bleeding there is low rate of erythrocyte that are circulating that contains oxygen. In this
case a hormone called erythropoietin is being produced for the formation of erythrocyte
and also there is decreased platelet and leukocytes, so there is increased colony stimulating factors
thrombopoietin and interleukins released that is inside the bone (bone marrow) that helps in production
of platelets.

IX. ACTIVITIES OF DAILY LIVING

FUNCTIONAL HEALTH PATTERN PRIOR TO HOSPITALIZATION DURING HOSPITALIZATION

• Health Perception and Health
management Pattern
• Nutritional and Metabolic Pattern
• Elimination Pattern
• Activity intolerance pattern
The client brought to the hospital due to frequent
vomiting and watery stool and cried most of the time.
The client has poor appetite because of illness felt for
continuously vomiting.diarrhea.
The client elimination pattern is abnormal. He urinates
frequently He defecate soft browned stool once a day.
The client has insufficient energy for not completing
his desired activities.
Because the client was still a child the mother was
informed and educated about the disease her son
encountered.
The client experienced weight loss because of her poor
appetite and he don’t like to be hospitalized.
The client output was high because of frequent
urination and he has a watery stool.
he can’t perform all activities alone.
 Dressing-level 1
Dressing-level 0 Bathing- level 2
Bathing- level 0 Grooming- level 2
Grooming- level 0 Toileting- level 2
Toileting- level 0 Cooking-level 1
Cooking-level 0 Bed mobility- level 2
Bed mobility- level 0 General mobility- level 2
General mobility- level 0
Home maintenance- level 0
• Sleep-Rest pattern Before he was admitted to the hospital, the client sleeps The client sleeping pattern was interrupted due to
normally from 10 pm to 5 am with no discomfort, no headache, hot environment and frequent urination.
medication used.
• Cognitive and perceptual pattern The does not have vision difficulties and any changes
in recent memory and has no hearing difficulties.

• Self perception and self concept pattern

• The client was irritable most of the time. He doesn’t want to be hospitalized because of being infant not being harm by any medication or procedure done
to him .

• Role relationship pattern

The client family . She lives with her mother and father and she maintains a good relationship between her brothers. They handle
problems by means of conversation and they try to find ways to solve it together.

• Sexuality-reproductive pattern

The client first menstrual period is when she is in the first year high school and menstrual problem
 • Coping stress tolerance pattern

Her way to relief stress is to relax, watch TV shows and listening to music

• Value pattern

The client is catholic although she rarely attend mass, she believes that her faith to god helps her when difficulties arise and made her
to be strong to surpass the problem she encountered.

XI. NARURSING CARE PLAN

Assessment Diagnosis Background Planning Implementation Rationale Evaluation

Knowledge

S: “Mainit ang Hyperthermia After 2 hours of 1) Apply Tepid 1) To reduce After 2 hours of
pakirmdam ko” as Nursing Intervention Sponge bath patient’s Nursing Intervention
verbalized by the the client’s temperature the patient’s
client temperature will be 2) Increase fluid 2) To prevent temperature was
reduce from 39.5 C to intake dehydration reduce from 39.5 C to
O: Increased body 37.2 C 3) Provide high 3) To meet 37.2 C
temperature- 39.5 C calorie diet increased
metabolic
Warm to touch 4) Maintain bed needs
rest 4) To reduce
Flush skin metabolic
5) Administer demands
medications as 5) To reduce
ordered(antipyr temperature
etics)

Assessment Diagnosis Background Planning Implementation Rationale Evaluation

Knowledge
S: “Ihi ako ng ihi” as Fluid Volume Deficit After 3 hours of !) Increase fluid intake 1) To replace the fluid Goal met:
verbalizes by the related to Active fluid Nursing Intervention loss After 3 hours of
client volume loss The client will 2) Administer IV 2) To replace fluid nursing interventions
maintain fluid volume fluids loss the client maintain
O: Frequent urination at a functional level as indicated fluid volume at
Dry mucous evidence by stable 3) To see if the function level
membrane vital signs and moist 3) Monitor Input and interventions are evidence by stable
Decrease skin mucous membrane Output effective vital signs and moist
turgor 4) mucous membrane
Increased pulse 4) Provide oral care
rate
102 bpm 5) Administer
antidiuretics as
ordered
 Assessment Diagnosis Background Planning Implementation Rationale Evaluation
Knowledge

S: “Masaki tang tiyan Acute pain related to After 2 hours of 1) assess pain 1) to know where After 2 hours of
ko” as verbalized by injuring Nursing Intervention location, the pain is Nursing Intervention
the client agent(biological) The client’s pain will duration and occurring and The patient’s pain was
be reduce from 8/10 frequency its reduce from 8/10 to
O: (+) facial grimace to 5/10 in the pain characteristics 5/10 on the pain scale
scale 2) Monitor Vital 2) Usually altered
Guarding the sings when acute
affected part pain is present
3) Provide 3) To provide
Pain scale: comfort non-
8/10 measures pharmacologic
al treatment
4) Encourage
adequate rest 4) To prevent
fatigue
5) Administer
analgesic or 5) To meet pain
antacids as control goals
ordered

XII. DRUG STUDY

Drug name Indication Contraindication Dosage and route Adverse effect Nursing responsibilities

Omeprazole >to prevent duodenal >patients hypersensitive to the 20mg/2ml Headache - Dosage adjustment may
ulcer drug Intravenous be necessary in Asian
Classification: Every 8 hours patients and patients with
Anti-ulcer >use cautiously with patient hepatic impairment.
with hypokalemia and - drug is labile in gastric
Action: respiratory acidosis acid
Inhibits the activity of acid - Gastrin level rises in most
pump and binds to patients during the first 2
hydrogen potassium at the weeks of therapy.
surface of gastric parietal
cells

Drug name Indication Contraindication Dosage and route Adverse effect Nursing responsibilities

Esomeprazole >to prevent duodenal >patient hypersensitive to the 20mg/2ml Headache - give drug at least q hour
 ulcer drug Intravenous every 8 before meals.
Classification: hours - antacids can be used while
Anti-ulcer >reduce the risk of >use cautiously to pregnant taking the drug, unless
gastric ulcer in patient and lactating women otherwise directed by
Action: receiving continous prescriber
Proton pump inhibitor that NSAIDs - monitor patient for rash or
reduces gastric secretions Therapy sign and symptoms of
and decrease gastric hypersensitivity
acidity - Long term therapy with
omeprazole, a drug similar
to esomeprazole, may cause
atrophic gastritis

Drug name Indication Contraindication Dosage and route Side Effect/ Nursing Responsibilities
Adverse effect
Paracetamol For mild pain and fever >patients hypersensitive to 500mg P.O. q 4 Headache >tell parents to consult
drug Hemolytic anemia prescriber before giving
Classification: Jaundice drug.
Antipyretic >use cautiously in patient Rash
with long term alcohol use urticaria >advice patient that drug is
Action: only for short-term use and
Relieve fever through to consult prescriber
central action in the
hhypothalamic heat
regulatin center

XIII. DISCHARGE PLANNING

 DATE & OBJECTIVES LEARNING CONTENTS STRATEGIES TARGET RESOURCES EVALUATION EXPECTED
VENUE OUTCOME

Health teaching After an hour of health
will be held at teaching the client will be
the Medical able:
ward. 1. Demonstrate the proper
cleaning of the
environment
2. Verbalize plan to
eliminate health and safety
hazards.
3. Demonstrate
appropriate, effective use
of resources.
The following are the
contents of the teaching:
1. Use mosquito netting
around your bed.
2. Limit the amount the
exposed skin by wearing
pants and long-sleeved
shirts. Cover up as much as
you can, even wearing
socks and boots.
3. Be sure to remove all
standing water that makes
perfect breeding grounds
for the mosquito.
4. Apply mosquito repellant
- lecture The target of - Internet The following The client was able to
discussion this teaching - - time and questions will be do following after an
- learning plan is Ms. M.C effort of the ask to the patient: hour:
interaction student 1. What will you 1. Demonstrate the
- demonstration apply on the skin proper cleaning of the
to prevent environment
mosquito bites? 2. Verbalize plan to
2. what will you eliminate health and
place around your safety hazards.
bed to prevent 3. Demonstrate
mosquito bites? appropriate, effective
3. what will you use of resources.
remove to prevent
the breeding of the
mosquitoes.

XIV. BIBLIOGRAPHY
Brunner and Suddarth’s Eleventh Edition Textbook of Medical-Surgical Nursing Volume 2

Marieb Elaine, (2007) Essential of Anatomy and Physiology

Carol Taylor, 5th edition Fundamentals of Nursing., The Art and Science of Nursing Care