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CENTRO ESCOLAR UNIVERSITY

MAKATI

COLLEGE OF NURSING

(Dengue Hemorrhagic Fever)

Submitted by:

Carlos, Donna F.
BSN-4F

Submitted to:

Mrs. Macalalad

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CHAPTER 1

A. NURSING HEALTH HISTORY

1. Personal Data

Client A.D. who is 4 years old, male, a Filipino citizen and a Roman Catholic
resides at Buli, Muntinlupa City. He was born on March 1, 2006. He was
admitted last August 2, 2010, 1:30 am.

2. Chief Complaint

“Nilalagnat, inuubo at sipon ang anak ko, limang araw na tapos nagdugo pa
yung ilong ng tatlong beses kaya naming dinala na sa hospital, nagsuka din
siya ng plema ng isang beses.” as verbalized by the client’s parents.

3. History of Present Illness

According to Client A.D.’s parents, 2 weeks ago, client’s mother experienced


cough and colds but easily cured through drinking paracetamol, after 1 week,
client’s older brother experienced fever with cough and colds too and was
relieved by paracetamol. Five days prior to client’s admission, he experienced
high grade fever with dry cough and colds. 3 hours prior to client’s admission,
he experienced nosebleeding for three times that lead to client’s hospital
admission. Client has no food and medications allergies.

4. Past Medical Illness

According to client’s father, this was the first time his child was hospitalized
since birth.

5. Family Health History

Legend: - asthma

Client has no hereditary diseases except for Asthma from his mother side. His
older brother had asthma since birth but didn’t last until today.

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6. Social History

Client A.D. is studying in a nursery school and usually spends his time with
his older brother playing inside their house. They usually go outside to play
around 5-7pm. He likes to watch cartoons. According to the father, they don’t
have a lot of mosquitoes on their community and they don’t have any cases of
dengue.

7. Developmental Theories

• Psychosocial Theory (Erik Erikson)

Initiative vs. Guilt (Preschool, 4 to 6 years)

Main Question: “Am I good or am I bad?”


Virtue: Purpose

Initiative adds to autonomy the quality of undertaking, planning and


attacking a task for the sake of being active and on the move. The child is
learning to master the world around him, learning basic skills and principles of
physics. Things fall down, not up. Round things roll. He learns how to zip and
tie, count and speak with ease. At this stage, the child wants to begin and
complete his own actions for a purpose. Guilt is a confusing new emotion. He
may feel guilty over things that logically should not cause guilt. He may feel
guilt when his initiative does not produce desired results.
Preschoolers are increasingly able to accomplish tasks on their own,
and with this growing independence comes many choices about activities to
be pursued. Sometimes children take on projects they can readily accomplish,
but at other times they undertake projects that are beyond their capabilities or
that interfere with other people’s plans and activities. If parents and preschool
teachers encourage and support children’s efforts, while also helping them
make realistic and appropriate choices, children develop initiative-
independence in planning and undertaking activities. But if, instead, adults
discourage the pursuit of independent activities or dismiss them as silly and
bothersome, children develop guilt about their needs and desires.
The client achieved this stage through the help of his parents and as of
now, he’s in a nursery school and this helps him to have initiative towards the
environment. His parents allows him to choose over things like on what food
he will eat in a day.

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Psychosexual Theory (Sigmund Freud)

Phallic Stage (Preschool, 4 to 6 years)

Boys experience the Oedipus Complex while girls experience the Electra
conflict, which is a process through which they learn to identify with the same
gender parent by acting as much like that parent as possible.
Boys suffer a castration anxiety, where the son believes his father knows
about his desire for his mother and hence fears his father will castrate him. He thus
represses his desire and defensively identifies with his father.
Girls suffer a penis envy, where the daughter is initially attached to her
mother, but then a shift of attachment occurs when she realizes she lacks a penis.
She desires her father whom she sees as a means to obtain a penis substitute (a
child). She then represses her desire for her father and incorporates the values of
her mother and accepts her inherent ‘inferiority’ in society.
The client is male and doesn’t possess castration anxiety because he doesn’t
fear his father.

• Cognitive Development (Jean Piaget

The Symbolic Function Substage

Occurs between about the ages of 2 and 7. The child is able to formulate
designs of objects that are not present. Other examples of mental abilities are
language and pretend play. Although there is an advancement in progress, there are
still limitations such as egocentrism and animism. Egocentrism occurs when a
child is unable to distinguish between their own perspective and that of another
person’s. Children tend to pick their own view of what they see rather than the actual
view shown to others. An example is an experiment performed by Piaget and Barbel
Inhelder. Three views of a mountain are shown and the child is asked what a
traveling doll would see at the various angles; the child picks their own view
compared to the actual view of the doll. Animism is the belief that inanimate objects
are capable of actions and have lifelike qualities. An example is a child believing that
the sidewalk was mad and made them fall down.

B. PHYSICAL ASSESSMENT

I. General Appearance

Client has a small frame body built and has an upright posture. He has a
smooth rhythmic gait and appropriately dressed. He has no body odor and
no physical deformities. His vital signs are as follows: T: 37.8 ° C; BP:
110/80; RR: 36cpm; PR: 110bpm.

II. Skin

Client has a fair complexion and has warm temperature. His skin is moist
and has a smooth texture. Skin turgor is elastic and mobile. There were no
lesions found except for some scars on his left leg.

III. Head and Face

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The skull is proportionate to body size. The scalp is non-tender and the
hair condition is evenly distributed and fine. The face and facial
movements are symmetrical to each other.
IV. Nose

The nose has a normal racial tone and nasal septum is intact and in
midline. Mucosa is pink and both patent. Client has nasal flaring, nasal
cavity is moist and sinuses are tender.

V. Mouth

Lips are pink and symmetrical. Mucosa is pink and has no lesions. Tongue
is in midline, pink in color with whitish coating and is slightly rough.
Tongue move freely. He has pink gums.

VI. Pharynx

The uvula is in midline, mucosa is pink. Tonsils are inflamed and gag
reflex is present.

VII. Neck

The neck muscles are equal in size and the lymph nodes are palpable.
Trachea is in midline. Thyroid gland is not palpable.

VIII. Chest and Lungs

The client has a regular breathing pattern and uses accessory muscles
(sternocleidomastoid). Lung expansion are symmetrical with AP to lateral
ratio of 1:2.

IX. Abdomen

Client has muscle guarding and feels pain when coughing. He has a
smooth, round abdomen.

C. DIAGNOSTIC PROCEDURE

• Complete Blood Count (Aug. 2, 2010)

A complete blood count is a test requested by a doctor or other medical


professional that gives information about the cells in a patient’s blood.

Indication: the test was ordered to the client in order to assess his platelet
count, WBC count, hydration status and to check other blood components.

Hgb – 111 g/L (125-160g/L)


Hct – 0.33% (0.38-0.50%)
Platelet – 198 10 ^9/L (150-350 10 ^9/L)

Nursing Responsibilities:

1. Check the physician’s order.


2. Check the patient’s identity to prevent errors.
3. Pressure is applied to the puncture site for several minutes using a cotton
ball.

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• Urinalysis (Aug. 2, 2010)

The urinalysis is used as a screening and/or diagnostic tool because it can


help detect substances or cellular material in the urine associated with different
metabolic and kidney disorders. It is ordered widely and routinely to detect any
abnormalities that require follow up. Often, substances such as protein or glucose
will begin to appear in the urine before patients are aware that they may have a
problem. It is used to detect urinary tract infections (UTI) and other disorders of the
urinary tract. In patients with acute or chronic conditions, such as kidney disease,
the urinalysis may be ordered at intervals as a rapid method to help monitor organ
function, status, and response to treatment.

Indication: A routine urinalysis may be done when you are admitted to the hospital. It
may also be part of a wellness exam, a new pregnancy evaluation, or a work-up for
a planned surgery. A urinalysis will most likely be performed when you see your
health care provider complaining of symptoms of a UTI or other urinary system
problem such as kidney disease. Some signs and symptoms may include:
• abdominal pain
• back pain
• painful or frequent urination
• blood in the urine
This test can also be useful when monitoring certain conditions over time.

Color: Yellow
Appearance: turbid
Ph: 6.5
specific gravity: 1. 015
protein: trace
sugar (-)
PUS cells: 20-30 hpf
RBC: 3-6/hpf
Epithelial cells: few
Bacteria: moderate
A. urates: moderate

D. ANATOMY AND PHYSIOLOGY

Circulatoy System

The circulatory system is an organ system that passes nutrients (such as amino
acids and electrolytes), gases, hormones, blood cells, etc. to and from cells in the
body to help fight diseases and help stabilize body temperature and Ph to
maintain homeostasis.

This system may be seen strictly as a blood distribution network, but some consider
the circulatory system as composed of the cardiovascular system, which distributes
blood,[1] and the lymphatic system,[2] which distributes lymph. While humans, as well
as other vertebrates, have a closed cardiovascular system (meaning that the blood
never leaves the network of arteries, veins and capillaries),
some invertebrate groups have an open cardiovascular system. The most primitive

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animal phyla lack circulatory systems. The lymphatic system, on the other hand, is
an open system.

Two types of fluids move through the circulatory system: blood and lymph. The
blood, heart, and blood vessels form the cardiovascular system. The lymph, lymph
nodes, and lymph vessels form the lymphatic system. The cardiovascular system
and the lymphatic system collectively make up the circulatory system.

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E. PATHOPHYSIOLOGY (Dengue Hemorrhagic Fever)

Inoculation of Flaviviridae/Arboviridae
|
Initial replication occurs at the site of inoculation and local lymphatic tissue
|
Viremia (up to 5th day) Prodromal Symptoms
(Presence of Pyrogen) Lead to fever
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Macrophages (Principal site of replication)
Destruction of virus on
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Dec. and destruction of platelet, wbc
|
Leads to vasculopathy
|
Fluid shifting of ICF to ECF
|
Inc. capillary fragility (Herman’s sign – Pathognomonic)
|
Possible leads to bleeding (Abdominal Pain, Melena or hematochezia, gum
bleeding/ epistaxis and hemorrhagic shock, hypovolemic shock in severe form)

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CHAPTER 2

. PRIORITIZED NURSING DIAGNOSES

Nursing Dx Rationale Score


Ineffective Airway According to ABC, 1
Clearance r/t mucus airway is the highest
secretions prioritized nursing
diagnosis.
Acute abdominal Pain r/t Pain is subjective, 2
frequent cough therefore is the second
highest prioritized
problem.
Altered Body Body temperature 3
temperature (37.8°C) elevated above normal
r/t inflammatory process range.

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B. Nursing Care Plans

CUES NURSING DX SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION


EXPLANATION
Subjective: Ineffective Normally the lungs STG: Independent: Goal was
“Inuubo at may Airway are free from 1. Elevate head of >To take advantage achieved.
sipon pa din ang Clearance r/t secretions. But with After 8 hours of bed/change of gravity
anak ko.” as mucus bronchopneumonia nursing position every 2 decreasing After 8 hours of
verbalized by the secretions , bacteria are interventions, the hours and PRN. pressure on the nursing
client’s mother. invading the lung client will diaphragm and interventions, the
parenchyma thus, expectorate enhancing drainage client was able to
producing secretions readily. of ventilation to expectorate
Objective: inflammatory different lung secretions readily.
process. And LTG: segments.
 crackles (+) this response leads >To maximize
 ineffective to filling of the After 3 days of 2. Encourage effort. After 3 days of
cough alveolar sacs with nursing deep breathing nursing
 RR: 36cpm exudates leading to interventions, the and coughing interventions, the
 Difficulty consolidation. client will maintain exercises. >Hydration can client was able to
vocalizing Due to airway patency. 3. Increase fluid help liquefy viscous maintain airway
 Transparent consolidation, the intake to at least secretions and patency.
mucus airway is narrowed 2000mL/day within improve secretion
secretions thus wheezes is cardiac tolerance. clearance.
being heard, DOB
 Nasal
insome cases >To prevent
flaring
orthopnea is vomiting with
 orthopnea
observed. 4. Discourage use aspiration into
of oil-based lungs.
products around
nose.

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Dependent: >To improve cough
when pain is
1. Administer inhibiting effort.
analgesics as
prescribed by the
doctor.

Collaborative:

1. Assist with use >Various


of respiratory therapies/modalities
devices and may be required to
treatments. acquire/maintain
adequate airways,
improve respiratory
function and gas
exchange.

CUES NURSING DX SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION


EXPLANATION
Subjective: Acute chest Pain Pulmonary chest STG: Independent: Goal was
“Masakit ang r/t frequent pain is 1. Provide comfort >To promote achieved.
dibdib niya kaka- cough usually due to After 30 minutes measures, quiet nonpharmacological
ubo.” as pleuritis or of nursing environment and pain management. After 30 minutes of
verbalized by the inflammation of interventions, calm activities. nursing
client’s mother. the client’s pain scale 2. Encourage use >To distract interventions, the
membranes that will be minimize of relaxation attention and client’s pain scale
line the from 5 to 2/10. techniques, such reduce tension. was minimized
Objective: chest cavity. as focused from 5 to 2/10.
Pleuritic LTG: breathing,
Pain scale of 5/10 chest pain is imaging,
10-highest score characterized by After 1 day of CDs/tapes. After 1 day of

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1-lowest score sharp, nursing 3. Use puppets to >To enhance nursing
>guarding well localized pain interventions, the demonstrate understanding and interventions, the
behavior that is client will procedure for reduce level of client was able to
>irritability made worse on demonstrate use child. anxiety/fear. demonstrate use
>distraction breathing of relaxation skills 4. Suggest parent >To comfort child. of relaxation skills
behavior and coughing or and diversional be present during and diversional
sneezing. activities. procedures. activities.

Dependent:
1. Administer >To maintain
analgesics as “acceptable” level of
prescribed by the pain.
doctor.

CUES NURSING DX SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION


EXPLANATION
Subjective: Altered Body ENTRY OF STG: Independent: Goal was
“Limang araw temperature PATHOGENS IN THE 1. Promote >Heat loss by achieved.
nang may lagnat (37.8°C) SYSTEMIC After 30 surface cooling by radiation and
ang anak ko.” as r/t inflammatory CIRCULATION minutes of means of conduction. After 30 minutes
verbalized by the process | nursing undressing. of nursing
client’s mother. REGULATION OF interventions, 2. Promote cool >Heat loss by interventions, the
TOXINS IN THE the client’s environment convection client’s
BODY temperature and/or fans. temperature was
Objective: | will be 3. Apply tepid >Heat loss by decreased to
RELEASE OF decreased to sponge bath evaporation and 37.5°C.
>T: 37.8°C PYROGEN 37.5°C. conduction.
>flushed skin; | 4. Wrap >To minimize
warm to touch STIMULATION OF LTG: extremities with shivering. After 1 day of
>tachypnea THE bath towels. nursing
>restlessness HYPOTHALAMUS After 1 day of interventions, the
| nursing 5. Provide >To offset client was able to

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INCREASE OR interventions, supplemental increased oxygen maintain core
ALTERATION OF the client will oxygen. demands and temperature
THERMOREGULATION maintain core consumption. within normal
| temperature Dependent: range.
INCREASE IN BODY within normal
TEMPERATURE range. 1. Administer >To decrease temp.
| antipyretics as within normal
Altered Body prescribed by the range.
temperature physician.
2. Administer >To support
replacement fluids circulating volume
and electrolytes. and tissue
perfusion.
Collaborative:

1. Assist with >To promote rapid


internal cooling core cooling.
methods to treat
malignant fever.

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CHAPTER 3

A. MEDICAL MANAGEMENT

1. Drug Study

DRUG CLASSIFICATION/ DOSE, ROUTE MECHANISM OF CONTRAINDICATION SIDE EFFECTS NURSING


INDICATION & ACTION RESPONSIBILITIES
FREQUENCY
Generic Name: Bronchodilator neb T nebule q Stimulates beta-2 >Hypersensitivity >headache 1. Assess vital signs
salbutamol 8° receptors of >Thyrotoxicosis >nausea 2. Assess for allergy.
>Relief of bronchioles by >Lactation. >vomiting 3. Dilute 5 mg/mL
Brand Name: bronchospasm in increasing levels >dizziness solution/2.5 mL
Activent bronchial asthma, of cAMP which 0.9% NaCl for
Cletal chronic bronchitis, relaxes smooth inhalation other
Airomir emphysema and muscles to solution do not
other reversible, produce require dilution for
obstructive bronchodilatation. nebulizer O2 flow or
pulmonary compressed air 6-10
diseases. L/min
4.Teach patient to
use inhaler; to avoid
getting aerosol in
eyes or blurring may
result
5. Instruct patient to
limit caffeine
products such as
chocolate, coffee,
tea and cola.

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DRUG CLASSIFICATION/ DOSE, ROUTE MECHANISM OF CONTRAINDICATION SIDE EFFECTS NURSING
INDICATION & ACTION RESPONSIBILITIES
FREQUENCY
Generic Name: Analgesics, Muscle 250mg/5ml Decreases fever >hypersensitivity >drowsiness 1. Assess for allergy.
paracetamol Relaxants and 3ml q 4° PRN for by inhibiting the >intolerance to >nausea 2. Give with food or
Uricosurics + > 37.8°C effects of tartrazine. >vomiting milk to decrease
Brand Name: pyrogens on the gastric symptoms;
Aldep >Relief of mild-to- hypothalamic give 30 mins before
Alvedon moderate pain; heat regulating or 2 hours after
Biogesic treatment of fever. centers and by a meals; absorption
Calpol hypothalamic may be slowed.
Tempra action leading to 3. Advise patient to
sweating and avoid alcohol
vasodilatation. 4. Teach patient to
recognize signs of
chronic overdose.
5. Inform patient that
urine may become
dark brown as a
result of phenacetin.

DRUG CLASSIFICATION/ DOSE, ROUTE MECHANISM OF CONTRAINDICATION SIDE EFFECTS NURSING


INDICATION & ACTION RESPONSIBILITIES
FREQUENCY
Generic Name: Cephalosporin 520mg/Iv q 8° Cefuroxime >hypersensitivity >drowsiness 1. Determine history
cefuroxime antibiotic binds to one or >nausea of hypersensitivity
more of the >vomiting reactions to
Brand Name: >For the treatment penicillin- cephalosporins,
Ceftin of many different binding proteins penicillins, and
Zinacef types of bacterial (PBPs) which history of allergies,
Kefurox infections such as inhibits the final particularly to drugs,
bronchitis, before therapy is

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sinusitis, tonsillitis, transpeptidatio initiated.
ear infections, skin n step of 2. Inspect IM and IV
infections, peptidoglycan injection sites
gonorrhea, and synthesis in frequently for signs
urinary tract bacterial cell of phlebitis.
infections. wall, thus 3. Report onset of
inhibiting loose stools or
biosynthesis diarrhea. Although
and arresting pseudomembranous
cell wall colitis.
assembly 4. Monitor I&O rates
resulting in and pattern:
bacterial cell Especially important
death. in severely ill
patients receiving
high doses.
5. Report any
significant changes.

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2. Treatment

Symptomatic and supportive. IV: PLR 1L 46-47 ugtts/min is


indicated as a source of water and electrolytes or as an alkalinizing agent.
Salbutamol for bronchospasm, cefuroxime for infection and paracetamol for altered
body temperature. Complete blood count to determine blood components and
Urinalysis to determine if there’s infection.

3. Diet

Meat should be avoided. The orange juice helps with digestion,


increased urinary output, promotes antibodies for faster healing and recovery. It
gives energy and vitamins, over all a great source for fighting fevers.

4. Activity/Exercise

Complete bed rest.

Nursing Management

• Provide comfort measures, quiet environment and calm activities.


• Elevate head of bed/change position every 2 hours and PRN.
• Increase fluid intake to at least 2000mL/day within cardiac tolerance.
• Discourage use of oil-based products around nose.
• Encourage to continue vitamins.

CHAPTER 4

A. Narrative Evaluation

After 3 days of nursing interventions, the client was able to maintain


airway patency, the client’s pain scale was minimized from 5 to 2/10, and was
able to maintain core temperature within normal range.

B. Discharge Planning Instructions:

Medications

Continue paracetamol for fever > 37.8°C, ascorbic acid and vitazinc.

Exercise

Client may continue ADL as long as he can and doesn’t have fever.

Treatment

Continue monitoring client’s temperature.

Health Teachings

• Provide comfort measures, quiet environment and calm activities.


• Elevate head of bed/change position every 2 hours and PRN.
• Increase fluid intake to at least 2000mL/day within cardiac tolerance.
• Discourage use of oil-based products around nose.

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• Encourage to continue vitamins.

Out-Patient Department

Client may come back for check-up after 2 weeks after discharge.

Diet

Meat should be avoided. The orange juice helps with digestion, increased
urinary output, promotes antibodies for faster healing and recovery. It gives energy
and vitamins, over all a great source for fighting fevers. Porridge and baked toasts
(not fried) can be had for allaying hungers in the course of the day. Biscuits with tea
can be had. The tea must be herbal, with tulsi, ginger, cardamom and other
such fever-reducing herbs in it.

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