Foundation University

College of Nursing
Dumaguete City

A Case Study
on
Dengue Fever

In partial fulfillment of the requirements

in
Nursing Care Management (NCM) 103

Submitted to:
Mrs. Socorro Paquita Palarpalar, RN

Submitted by:
Carreon, Chezka Mae
Kremoi, Mercy
Palalon, Francis Adrian
Talamera, Suzmita Faith
Velez, Ivory

August 13, 2016

Date

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 ACKNOWLEDGEMENT

A journey of a thousand miles begins with a single step

A prominent quote that will inspire us is that a single step makes us the person we want to be in the near future. These words will put in our
mind that life begins with a single step to achieve your dreams in life and this is related in the making of this paper. Perhaps, hardship is part of
learning but without the help of various people we could never come up a clinical paper just as this.

To start with, we would like to extend our greetings of gratitude to God, Our most Heavenly Father who is forgiving and has given us this
opportunity and chance as student nurses to study. The superior owner of what we call life, who is the protector of mankind and who gave us
strength to continue our journey.
To our most supportive, loving guardian and parents, who never gave up on us. Their love which no one in this world could ever compete.
Their financial support and care that inspires us to continue our journey and to strive hard on our studies.
To our beloved school Foundation University, College of Nursing for giving us the opportunity as students to develop our skills, enhance our
knowledge and promote positive attitude and values to this field.
For our dear Clinical Instructor, Mrs. Socorro Paquita Palarpalar, RN, MAN for helping us in correcting our mistakes and teaches us what it is
to be in our field. Thank you.
And lastly, for the patients significant others, for trusting us in sharing their thoughts & private informations and the cooperation that theyve
bestowed upon us. And to each and every one who helped realize this study into completion, may it be direct or indirect, no matter how minimal, the
gratitude and pleasure for this achievement of this task is ours to share.

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I. TABLE OF CONTENTS

MISSION, VISION & LIFE PURPOSE . 4

CENTRAL OBJECTIVES/SPECIFIC OBJECTIVES . 5
INTRODUCTION .... 6
DEMOGRPHIC PROFILE .... 7
DEVELOPMENTAL TASKS .... 8
ANATOMY & PHYSIOLOGY .. 10
REVIEW OF RELATED LITERATURE . 14
MEDICAL MANAGEMENT . 15
PATHOPHYSIOLOGY . 19
TREATMENT MODALITIES ... 22
DRUG STUDY .. 24
NURSING MANAGEMENT . 31
GENOGRAM .. 33
PHYSICAL ASSESSMENT FNDINGS .. 35
NURSING THEORIES .. 38
GORDONS FUNCTIONAL HEALTH PATTERN ..... 42
SUMMARY OF NURSING DIAGNOSIS . 48
NURSING CARE PLAN . 49
ANNOTATED READINGS 54
CONCLUSION 60
BIBLIOGRAPHY . 61
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II. FOUNDATION UNIVERSITY MISSION, VISION & LIFE PURPOSE

Mission

To enhance and promote a climate of excellence relevant to the challenges of the times, where individuals are committed to the pursuit of new

knowledge and life-long learning in service of society.

Vision

To be a dynamic, progressive school that cultivates effective learning, generates creative ideas, responds to societal needs and offers equal

opportunity for all.

Life Purpose

To educate and develop individuals to become productive, creative, useful and responsible citizens of society.

Core Values

Excellence

Commitment

Integrity

Service

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III. CENTRAL OBJECTIVE

This case study aims to identify and determine the general health problems and needs of the patient with an admitting diagnosis of dengue
fever. This presentation also intends to help patient promote health and medical understanding of such condition through the application of nursing
skills. This paper is also intended to provide a better understanding of the disease process based on the patients health history and as a reference
for future nursing students.

Specific Objectives
At the end of 1 hour and 30 minutes, the learners will be able to:
obtain the needed information of the client base on its demographic data completely but not surpassing the patients privacy;
identify the physical assessment accurately;
comprehensively understand the anatomy and physiology of systems involve in the disease condition;
trace the pathophysiology of the involve disease condition comprehensively;
identify both medical and nursing intervention, satisfactorily;
identify the different medical intervention and their rationale;
comprehend the nursing theory applicable to care of the patient;
determine the three priority nursing diagnoses comprehensively;
formulate a nursing care plan towards the care of the client critically; and
evaluate the case presentation by asking relevant questions.

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IV. INTRODUCTION

Dengue fever is a mosquito-borne tropical disease caused by the dengue virus. Symptoms typically begin three to fourteen days after

infection. This may include a high fever, headache, vomiting, muscle and joint pains, and a characteristic skin rash. Recovery generally takes less

than two to seven days.In a small proportion of cases, the disease develops into the life-threatening dengue hemorrhagic fever, resulting in bleeding,

low levels of blood platelets and blood plasma leakage, or into dengue shock syndrome, where dangerously low blood pressure occurs.

Dengue is transmitted by the bite of a mosquito infected with one of the four dengue virus serotypes. It is a febrile illness that affects infants,

young children and adults with symptoms appearing 3-14 days after the infective bite.

It is spread by several species of mosquito of the Aedes type, principally A. aegypti. The virus has five different types; infection with one type

usually gives lifelong immunity to that type, but only short-term immunity to the others. Subsequent infection with a different type increases the risk of

severe complications. A number of tests are available to confirm the diagnosis including detecting antibodies to the virus or its RNA.

Dengue is not transmitted directly from person-to-person and symptoms range from mild fever, to incapacitating high fever, with severe

headache, pain behind the eyes, muscle and joint pain, and rash. There is no vaccine or any specific medicine to treat dengue. People who have

dengue fever should rest, drink plenty of fluids and reduce the fever using paracetamol or see a doctor.

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V. DEMOGRAPHIC PROFILE

Name: P. K. B. Gender: Male

Address: Masaplod Sur, Dauin, Negros Oriental Birth Date: December 20 2008 Age: 7y/o 7mos

Religion: Roman Catholic Nationality: Filipino

Responsible Person: Mary Ann Partosa Relationship: Mother

Date of Admission: 8-7-16 Time: 7:27pm

Atttending Physician: Ontal, Benjamin Jr. MD

Chief Complaint: Three days PTA, patient experienced onset fever and experienced persisted stools, watery and vomited twice.

History of Present Illness: No previous admission but had experienced mild cough and colds given paracetamol. Received complete immunization.
Three days PTA, patient experienced onset fever and was given Paracetamol. Two days PTA, based on checkup no platelet. Condition fever
persisted stools, watery LBM and vomited twice.

Final Diagnosis:

General Impression: Received patient sitting on bed with D5LR I L at right metacarpal vein regulated at 22 gtts/min. Patient is well groomed,
oriented with the place, time, date and responsed comprehensively.

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VI. DEVELOPMENTAL TASKS

Erik Eriksons Theory of Psychosocial Development

Industry vs Inferiority

Children are at the stage (aged 5 to 12 yrs) where they will be learning to read and write, to do sums, to do things on their own. Teachers
begin to take an important role in the childs life as they teach the child specific skills. It is at this stage that the childs peer group will gain greater
significance and will become a major source of the childs self-esteem. The child now feels the need to win approval by demonstrating specific
competencies that are valued by society, and begin to develop a sense of pride in their accomplishments. If children are encouraged and reinforced
for their initiative, they begin to feel industrious and feel confident in their ability to achieve goals. If this initiative is not encouraged, if it is restricted by
parents or teachers, then the child begins to feel inferior, doubting his own abilities and therefore may not reach his or her potential. Id the child
cannot develop the specific skill they feel society is demanding then they may develop a sense of inferiority. Some failure may be necessary so that
the child can develop some modesty. Yet again, a balance between competence and modesty is necessary. Success in this stage will lead to the
virtue of competence.

Correlation:
The developmental task of patient has been met. The patient was able to learn and accomplish those skills including reading, writing and
telling time. He also get to form moral values, recognize cultural and individual differences and are able to manage most of their personal need and
grooming with minimal assistance.

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 Sigmund Freud Theory of Psychosexual Development

Latency (5 or 6 to puberty)

During this stage, sexual instincts subside, and children begin to further develop the superego or conscience. Children begin to behave in
morally acceptable ways and adopt the values of their parents and other important adults.

No further psychosexual development takes place during this stage (latent means hidden). The libido is dormant. Freud thought that most
sexual impulses are repressed during the latent stage and sexual energy can be sublimated (re: defense mechanisms) towards school work, hobbies
and friendships. Much of the child's energy is channeled into developing new skills and acquiring new knowledge and play becomes largely confined
to other children of the same gender.

Correlation:

The developmental task of the patient has been met. The patient was able to adapt to reality and begins the process of his stage. The child
has evolved from a baby with primitive drives to a reasonable human being with complex feelings, like shame, guilt and disgust.

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VII. ANATOMY AND PHYSIOLOGY

HEMATOLOGIC SYSTEM

The hematologic system consists of the blood and the sites where blood is produced, including the bone marrow and the reticuloendothelial
system (RES). Blood is a specialized organ that differs from other organs in that it exists in a fluid state. Blood iscomposed of plasma and various
types of cells. Plasma is the fluid portion of blood; it contains various proteins, such as albumin, globulin, fibrinogen, and other factors necessary for
clotting, as well as electrolytes, waste products, and nutrients. About 55% of blood volume is plasma.

BLOOD
The cellular component of blood consists of three primary cell types : RBCs (red blood cells or
erythrocytes), WBCs (white blood cells or leukocytes), and platelets (thrombocytes). These cellular
components of blood normally make up 40% to 45% of the blood volume. Because most blood cells have
a short life span, the need for the body to replenish its supply of cells is continuous; this process is termed
hematopoiesis. The primary site for hematopoiesis is the bone marrow. During embryonic development
and in other conditions, the liver and spleen may also be involved. Under normal conditions, the adult
bone marrow produces about 175 billion RBCs, 70 billion neutrophils (mature form of a WBC), and 175
billion platelets each day. When the body needs more blood cells, as in infection (when WBCs are needed
to fight the invading pathogen) or in bleeding (when more RBCs are required), the marrow increases its
production of the cells required. Thus, under normal conditions, the marrow responds to increased
demand and releases adequate numbers of cells into the circulation.

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 The volume of blood in humans is approximately 7% to 10% of the normal body weight and amounts to 5 to 6 L. Circulating through the
vascular system and serving as a link between body organs, the blood carries oxygen absorbed from the lungs and nutrients absorbed from the
gastrointestinal tract to the body cells for cellular metabolism. Blood also carries waste products produced by cellular metabolism to the lungs, skin,
liver, and kidneys, where they are transformed and eliminated from the body. Blood also carries hormones, antibodies, and other substances to their
sites of action or use.
Blood is made up of plasma (fluid component) and formed elements (cellular component). Plasma consists of about 90% water and 10% solutes
(electrolytes, albumin, globulins, and clotting factors). The formed elements include erythrocytes (red blood cells [RBCs]), leukocytes (white blood
cells [WBCs]), and platelets (PLTs).
To function, blood must remain in its normally fluid state. Because blood is fluid, the danger always exists that trauma can lead to loss of blood
from the vascular system. To prevent this, an intricate clotting mechanism is activated when necessary to seal any leak in the blood vessels.
Excessive clotting is equally dangerous, because it can obstruct blood flow to vital tissues. To prevent this, the body has a fibrinolytic mechanism that
eventually dissolves clots (thrombi) formed within blood vessels. The balance between these two systems, clot (thrombus) formation and clot
(thrombus) dissolution or fibrinolysis, is called hemostasis.

BONE MARROW

The bone marrow is the site of hematopoiesis, or blood cell formation. In a child all skeletal
bones are involved, but as the child ages marrow activity decreases. By adulthood, marrow activity is
usually limited to the pelvis, ribs, vertebrae, and sternum. Marrow is one of the largest organs of the
body, making up 4% to 5% of total body weight. It consists of islands of cellular components (red
marrow) separated by fat (yellow marrow). As the adult ages, the proportion of active marrow is
gradually replaced by fat; however, in the healthy person, the fat can again be replaced by active

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marrow when more blood cell production is required. In adults with disease that causes marrow destruction, fibrosis, or scarring, the liver and spleen
can also resume production of blood cells by a process known as extramedullary hematopoiesis. The marrow is highly vascular. Within it are
primitive cells called stem cells. The stem cells have the ability to self-replicate, thereby ensuring a continuous supply of stem cells throughout the life
cycle. When stimulated to do so, stem cells can begin a process of differentiation into either myeloid or lymphoid stem cells. These stem cells are
committed to produce specific types of blood cells. Lymphoid stem cells produce either T or B lymphocytes.Myeloid stem cells differentiate into three
broad cell types: RBCs,WBCs, and platelets. Thus, with the exception of lymphocytes, all blood cells are derived from the myeloid stem cell. A defect
in the myeloid stem cell can cause problems not only with WBC production but also with RBC and platelet production. The entire process of
hematopoiesis is highly complex.

PLATELETS (THROMBOCYTES)

Platelets, or thrombocytes, are not actually cells. Rather, they are granular fragments of giant cells in the
bone marrow called megakaryocytes. Platelet production in the marrow is regulated in part by the hormone
thrombopoietin, which stimulates the production and differentiation of megakaryocytes from the myeloid stem cell.
Platelets play an essential role in the control of bleeding. They circulate freely in the blood in an inactive state,
where they nurture the endothelium of the blood vessels, maintaining the integrity of the vessel. When vascular
injury does occur, platelets collect at the site and are activated. They adhere to the site of injury and to each other,
forming a platelet plug that temporarily stops bleeding. Substances released from platelet granules activate
coagulation factors in the blood plasma and initiate the formation of a stable clot composed of fibrin, a filamentous protein. Platelets have a normal
life span of 7 to 10 days.

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PLASMA AND PLASMA PROTEINS

After cellular elements are removed from blood, the remaining liquid portion is called plasma. More than 90% of plasma is water. The
remainder consists primarily of plasma proteins, clotting factors (particularly fibrinogen), and small amounts of other substances such as nutrients,
enzymes, waste products, and gases. If plasma is allowed to clot, the remaining fluid is called serum. Serum has essentially the same composition
as plasma, except that fibrinogen and several clotting factors have been removed in the clotting process. Plasma proteins consist primarily of albumin
and globulins. The globulins can be separated into three main fractionsalpha, beta, and gammaeach of which consists of distinct proteins that
have different functions. Important proteins in the alpha and beta fractions are the transport globulins and the clotting factors that are made in the
liver. The transport globulins carry various substances in bound form around the circulation. For example, thyroid-binding globulin carries thyroxin,
and transferrin carries iron. The clotting factors, including fibrinogen, remain in an inactive form in the blood plasma until activated by the clotting
cascade. The gamma globulin fraction refers to the immunoglobulins, or antibodies. These proteins are produced by the well-differentiated
lymphocytes and plasma cells. The actual fractionation of the globulins can be seen on a specific laboratory test (serum protein electrophoresis).
Albumin is particularly important for the maintenance of fluid balance within the vascular system. Capillary walls are impermeable to albumin, so its
presence in the plasma creates an osmotic force that keeps fluid within the vascular space. Albumin, which is produced by the liver, has the capacity
to bind to several substances that are transported in plasma (eg, certain medications, bilirubin, some hormones). People with poor hepatic function
may have low concentrations of albumin, with a resultant decrease in osmotic pressure and the development of edema.

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VIII. REVIEW OF RELATED LITERATURE

Dengue is the most important arthropod-borne viral disease of public health significance. Compared to nine reporting countries in the 1950s,
today the geographic distribution includes more than 100 countries worldwide. Many of these had not reported dengue for 20 or more years and
several have no known history of the disease. The World Health Organization (WHO) estimates that more than 2.5 billion people are at risk of
dengue infection. Most will have asymptomatic infections. The disease manifestations range from an influenza-like disease known as dengue fever
(DF) to a severe, sometimes fatal disease characterised by haemorrhage and shock, known as dengue hemorrhagic fever/dengue shock syndrome
(DHF/DSS), which is on the increase. Dengue fever and dengue haemorrhagic fever/dengue shock syndrome are caused by the four viral serotypes
transmitted from viraemic to susceptible humans mainly by bites of Aedes aegypti and Aedes albopictus mosquito species. Recovery from infection
by one serotype provides lifelong immunity against that serotype but confers only partial and transient protection against subsequent infection by the
other three. First recognised in the 1950s, it has become a leading cause of child mortality in several Asian and South American countries.

Half the world's population lives in countries endemic for dengue, underscoring the urgency to find solutions for dengue control. The
consequence of simple DF is loss of workdays for communities dependent on wage labour. The consequence of severe illness is high mortality rates,
since tertiary level care required for DHF/DSS management is beyond the reach of most of the persons at risk.

Dengue infection can cause a spectrum of illness ranging from mild, undifferentiated fever to illness up to 7 days' duration with high fever,
severe headache, retro-orbital pain, arthralgia and rash, but rarely causing death. Dengue Haemorrhagic Fever (DHF), a deadly complication,
includes haemorrhagic tendencies, thrombocytopenia and plasma leakage. Dengue Shock Syndrome (DSS) includes all the above criteria plus
circulatory failure, hypotension for age and low pulse pressure. DHF and DSS are potentially deadly but patients with early diagnosis and appropriate
therapy can recover with no sequelae. Case management for DF is symptomatic and supportive. DHF requires continuous monitoring of vital signs
and urine output. DSS is a medical emergency that requires intensive care unit hospitalisation

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XI. MEDICAL MANAGEMENT

A. Laboratory Exams

Hematology Result

Laboratory Exams Result Normal Values Correlation/Implication

1. CBC

Hematocrit 25.7 32-37% Decreased amount indicate blood

loss, anemia, renal failure and
leukemia. Increased level of
dehydration, polycythemia.Within
normal value. Means no indicative
of possible infection. Increased
WBC indicates presence of
infection, inflammation, stress,
tissue necrosis, trauma, and
leukocytosis.
Hemoglobin is predominantly
Hgb 13.6 g/dl 12-14 mg/dL
composed of protein and iron and
it capture oxygen as it passes
through the lungs. Increased level
of hemoglobin in dehydration,
polycythemia, congestive heart
failure, chronic pulmonary
diseases. Decrease level
indicates anemia, blood loss and
renal failure.

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 WBC 1.1 T/cumm 4.5 11 T/cumm Decreased lymphocyte
(leukopenia) level can indicate
Neutrophil 42% 40-75 diseases that affect the immune
system
Eosinophil 0-6% 0-6

Monocyte 7% 0-10

Platelet 49 T/cumm 150-400 T/cumm Low platelet count can cause

bleeding and may also accumulate
to few complications.

The Complete Blood Count is a screening test, used to diagnose and manage numerous diseases. Test results shows very low platelet count
and WBC. Lymphocytes are responsible for immune responses. An elevation is present in cases of viral infection, leukemia, cancer of the bone
marrow, or radiation therapy while a decreased lymphocyte (leukopenia) level can indicate diseases that affect the immune system. A significant
decrease in lymphocyte value indicates low immune response.

Hematocrit values are indicators of ratio of RBC in relation to blood volume. This is best compared with Hemoglobin value since the two
values are indicative of RBC present in the blood. The oxygen-combining ability of the blood is in direct proportion to the hemoglobin concentration,
rather than the numbers of red blood cells, because some cells contain more hemoglobin than others. Hemoglobin also serves as an important pH
buffer in the extracellular fluid. Hemoglobin determination is used to screen for anemia, to identify the severity of anemia, and to assist in evaluating
the patient's response to anemia therapy. While a patient with a platelet count of less than 20,000 is at high risk for spontaneous bleeding.

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 Urinalysis Result

Physical Appearance

Test Result Normal

Color Light Yellow Yellow

Transparency Clear Clear

Reaction PH 8.0 4.6 - 8.0

Specific Gravity 1.015 1.010 1.035

Glucose Negative Absent

Protein Negative Absent

Microscopic Exam

Test Result Normal

Pus Cell 1-2/hpf Absent

RBC 0-1/hpf 0-5/hpf

Epithelial Cells Rare

Protein Negative Absent

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 Urinalysis can disclose evidence of diseases, even some that have not caused significant signs and symptoms. The color of urine is normally
yellow, but if it is reddish, this is indicative of presence of blood in the urine. Urine transparency should be clear. Urine specific gravity measures the
concentration of particles in the urine. Increased urine specific gravity may indicate dehydration, glycosuria and heart failure. Decreased urine
specific gravity may indicate excessive fluid intake and pyelonephritis. Urine normally contains no glucose and abnormal results may indicate
excessive diabetes mellitus, renal glycosuria and increase Intra-Cranial Pressure. Protein is normally not found the urine, specifically albumin. The
most common cause of protein in the urine is glomerular damage from renal disease, renal distress, cardiac failure and febrile condition. Presence of
pus cells can mean there is kidney disease or an infection of the kidney, bladder or urinary tubes. The presence of abnormal numbers of white cells
in the urine is referred to as pyuria. Normally there is no hemoglobin or RBC in the urine. RBC in the urine may be due to many causes including
kidney damage, tumors eroding the urinary tract, stones, UTI and bleeding disorders.

The Appearance of urine, which is slightly turbid indicates infection. This is even supported by the presence of pus in the urine. Presence of
protein indicates a renal distress. The increased specific gravity signifies dehydration and glycosuria, supported by presence of glucose in the urine.
Any measurement below 1.007 to 1.010 indicates hydration and any measurement above it indicates relative dehydration. Urine having a specific
gravity over 1.035 is either contaminated, contains very high levels of glucose, or the patient may have recently received high density radiopaque
dyes intravenously for radiographic studies or low molecular weight dextran solutions. Amorphous urates are observed in acidic urines and
amorphous phosphates are found in alkaline urine. The amorphous urates seen in urine specimens are of little clinical value.

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B. Pathophysiology

Precipitating
Environmental conditions (open spaces with water
Predisposing pots, and plants)
Geographical area tropical islands in the Immunocompromised
Pacific (Philippines) and Asia Mosquito carrying dengue virus
Soldier
Sweaty skin

Aedes aegypti (dengue virus carrier): 8-12 days of

viral replication on mosquitos salivary glands

Bite from mosquito (Portal of Entry in the Skin) Redness & itchiness in the area

Allowing dengue virus to be inoculated towards the

circulation/blood (Incubation Period: 3-14 days)

Virus disseminated rapidly into the blood and Diagnostic:

stimulates WBCs including B lymphocytes that Hematology :
produces and secretes immunoglobulins (antibodies), Increased WBC:
and monocytes/macrophges, neutrophils 12,900/cumm
(5,000- 10,000/cumm)
Diagnostic: Increased Lymphocytes: 49%
Hematology : (20-40%)
Decreased Antibodies attach to the viral antigens, and
Monocytes: 4%(8- then monocytes/macrophages will perform
14%) phagocytosis through Fc receptor (FcR)
Decreased within the cells and dengue virus replicates
Neutrophils: in the cells of monocytes/macrophages Page | 19
49%(50-70%)
 Entry to the Entry to the bone
spleen, and liver marrow

Recognition of dengue viral antigen on

infected monocyte by cytotoxic T cells

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

Signs/ symptoms:
Febrile: 38.6C
Diaphoresis, warm skin, Dengue Fever
flushed; headache of 3/10 pain
scale; whitish spots; body
weakness

Virus ultimately targets liver and spleen Cellular direct destruction and infection of
parenchymal cells where infection red bone marrow precursor cells as well as
produces apoptosis/cell death immunological shortened platelet survival
causing platelet lyses

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Diagnostic:
Ultrasound: Diagnostic:
minimal hepatospleno Hematology :
megaly Decreased Platelet:
Blood Chemistry: 68,000/cumm
SGOT: 558.0 U/L(Up
Hepatosplenomegaly (150,000-400,000)
Thrombocytopenia
to 46)
SGPT:433.3 U/L(Up to Signs/ symptoms:
40) Red sclera in both
Signs/ symptoms: Dengue Hemorrhagic Fever eyes
Protein: 5.2g/dL (6.6- >Abdominal pain with
8.7) Petechiae
5/10 pain scale as
Albumin:2.3g/dL (3.5- verbalized.
5.5) Increase number and size of the pores
in the capillaries which leads to a Signs/ symptoms:
+1 Bipedal edema;
leakage of fluid from the blood to the
weak bounding
interstitial fluid (capillary leakage) of pulse of 79bpm
the different organs and skin
Signs/ symptoms:
Profuse non-productive
cough with white sputum
with blood spots noted; Signs/ symptoms:
shallow & rapid respirations Abdominal distention with
Pleural effusion Ascites
of 35cpm; crackles/rales abdominal girth of 93cm
(36.6 inches); hypoactive
bowel sounds of 2/min

Diagnostic:
Ultrasound: Diagnostic:
Conclusion: Ultrasound:
Minimal bilateral pleural Conclusion:
effusion. Recovery Complications: Moderate ascites
Intense bleeding
Pulmonary Edema
Shock
Very low blood pressure
Liver cirrhosis
Death
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C. Treatment Modalities

TREATMENT RATIONALE
1)Secure consent of admission > This helps secure permission for patient treatment.

2) V/S q 4h > For baseline data and maintain normal v/s and detect any changes.

3) Start PNSS 1L at 20 gtts/min >To provide client with adequate nutrition, fluid and electrolytes.
D5NSS 1L at 50cc/hr x3

4) Laboratory exams:
CBC > A complete blood count determines other complications like anemia or
leukemia and also to monitor clients condition

Blood typing > This essential for blood transfusion or donating blood. Not all blood
types are compatible so its important to know your blood group.

U/A > To assess if there is infection, and to check if there are unusual
particles present in the urine

5) DAT (Diet as tolerated) >Indicates that the GI tract is tolerating food and is ready for
advancement to the next stage.

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6) Meds: >To relieve pain and also reduce fever.
-Paracetamol 250mg/5mL q 4h for >38C - To relieve fever

- Ranitidine 22mg IVTT q 8h -Inhibits cell wall synthesis; promoting osmotic instability

- Ampicillin 500mg IVTT q 6h ANST - Given to treat bacterial infection

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D. Drug Study

Drug Order: Paracetamol 250/5mL every 4 hours for more than 38 C

Generic Name: Paracetamol

Brand Name: Calpol

Classification: Analgesics

Mechanism of Action:

Decreases fever by a hypothalamic effect leading to sweating and vasodilation

Inhibits pyrogen effect on the hypothalamic-heat-regulating centers
Inhibits CNS prostaglandin synthesis with minimal effects on peripheral prostaglandin synthesis
Does not cause ulceration of the GI tract and causes no anticoagulant action.

Contraindication:

Contraindicated in patients hypersensitive to drug.

Use cautiously in patients with long term alcohol use because therapeutic doses cause hepatotoxicity in these patients.
Hematologic: hemolytic anemia, neutropenia, leukopenia, pancytopenia.
Hepatic: Jaundice
Metabolic: hypoglycemia
Skin: rash, urticaria.
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Side effects:

Minimal GI upset Leukopenia

Methemoglobinemia Urticaria
Hemolytic Anemia CNS Stimulation
Neutropenia Hypoglycemic Coma
Thrombocytopenia Jaundice
Pancytopenia Drowsiness

Adverse Drug Reaction:

Stimulation Hemolytic Anemia

Drowsiness Rash
Nausea Cyanosis
Vomiting Jaundice
Abdominal Pain Convulsion
Hepatotoxicity Coma
Hepatic Seizure Death

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Nursing Responsibilities:

Use liquid form for children and patients who have difficulty swallowing.
In children, dont exceed five doses in 24 hours.
Advise patient that drug is only for short term use and to consult the physician if giving to children for longer than 5 days or adults 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.

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Drug Order: Ranitidine 22mg IVTT every 8 hours

Generic Name: Zantac

Classification: Histamine (H2) Antagonist

Mechanism of Action:

Histamine is a naturally-occurring chemical that stimulates cells in the stomach (parietal cells) to produce acid. H2-blockers inhibit the action of
histamine on the cells, thus reducing the production of acid by the stomach.

Contraindication:

Contraindicated for the following conditions; liver problems, kidney disease, stomach cancer and porphyria.

Side effects:

constipation insomnia
diarrhea muscle pain
fatigue nausea
headache vomiting

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Adverse Drug Reaction:

Headache, dizziness. Rarely hepatitis, thrombocytopenia, leukopenia, hypersensitivity, confusion, gynecomastia, impotence, somnolence,
vertigo, hallucinations.
Potentially Fatal: Anaphylaxis, hypersensitivity reactions.

Nursing Responsibilities:
Monitor serum AST, ALT levels.
Assess mental status of the patient before giving the drug.
Teach patient that smoking decreases effectiveness of the medication.
Advise patient that he should not take the medicine within 1 hour of magnesium- or aluminum-containing antacids.
Advise patient to report any signs of headache.
Teach patient that transient burning/pruritus may occur with IV administration.

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Drug Order: Ampicillin 500mg IVTT every 6 hours After Negative Skin Test (ANST)

Generic Name: Ampicillin

Brand Name: Ampilin
Classification: Antibiotic, Penicillin

Mechanism of Action: Bactericidal action against sensitive organisms; inhibits synthesis of bacterial cell wall, causing cell death.

Contraindication:

Contraindicated in patients hypersensitive to drug or other penicillins.

Side effects:

Body as a whole - Severe allergic reactions such as rash, headache, fever and hives.
Gastrointestinal - Nausea, soreness of the tongue, inflammation in the mouth, oral candidiasis, vomiting, enterocolitis, pseudomembranous
colitis and diarrhea.
Hypersensitivity - Anaphylactic shock, redness of skin, skin inflammation, hives and inflammation of blood vessels.
Liver - Jaundice, moderate elevation of SGOT and liver inflammation.
Blood - Anemia and blood disorder.
Miscellaneous - Tooth discoloration.

Adverse Drug Reaction:

CNS: Lethargy, hallucinations, seizures

Page | 29
 CV: CHF
GI: Glossitis, stomatitis, gastritis, sore mouth, furry tongue, black hairy tongue, nausea, vomiting, diarrhea, abdominal pain, bloody diarrhea,
enterocolitis, pseudomembranous colitis, nonspecific hepatitis
GU: Nephritis
Hematologic: Anemia, thrombocytopenia, leukopenia, neutropenia, prolonged bleeding time
Hypersensitivity: Rash, fever, wheezing, anaphylaxis
Local: Pain, phlebitis, thrombosis at injection site (parenteral)
Other: Superinfectionsoral and rectal moniliasis, vaginitis

Nursing Responsibilities:
Use cautiously in patients with other drug allergies because of possible cross sensitivity
Before giving drug, ask patient about allergic reactions to penicillin. However a negative history of penicillin allergy is no guarantee against a
future allergic reaction
Obtain specimen for culture and sensitivity test before giving first dose. Therapy may begin pending results.
Decrease dosage in patients with impaired renal function
Dont use IM route in children
Monitor liver function test results during therapy
If large doses are given superinfection may occur

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X. NURSING MANAGEMENT

A. NURSING HISTORY

1. Chief Complaint

Three days PTA, patient experienced onset fever and experienced persisted stools, watery and vomited twice.

2. General Impression

Received patient sitting on bed with D5LR I L at right metacarpal vein regulated at 22 gtts/min. Patient is well groomed, oriented with the
place, time, date and responsed comprehensively.

3. HPI
No previous admission but had experienced mild cough and colds given paracetamol. Received complete immunization. Three days PTA,
patient experienced onset fever and was given Paracetamol. Two days PTA, based on checkup no platelet. Condition fever persisted stools, watery
LBM and vomited twice.

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4. Past Health History
P. K. B. is a school-age boy, admitted into the hospital around 7:20 pm together with his mother. He is born healthy, under normal
spontaneous vaginal delivery without any body-marks or observable congenital birth defects.

He has completed his immunization program for the following vaccines: BCG, DPT, OPV, MEASLES and HEPA-B. Patient ,being the second
to the youngest of his siblings, stays with her mother most of time at home.

This is his first time to contact a serious illness since his birth. Most of the time he frequently catch common colds and slight to moderate fever
but not of a high grade fever. The night prior to his admission to the hospital, patient is feverish and it worsens in the few hours of the morning.

Page | 32
 5. Family History with Genogram

58y/o 49y/o 58y/o 52y/o

21y/o 22y/o 28y/o 30y/o 33y/o 36y/o 42y/o 23y/o 24y/o 25y/o 24y/o
37y/o
Hemorrhoi
HPN DM HPN
d

1y/o 7y/o 10y/o 12y/o

Patient

- Female

- Male

- Deceased

Page | 33
6. Psychosocial History

Patient socializes with children around the neighborhood usually within his age group, engaging in play activities. Patient always interacts with
his friends at school. He is not yet engaged in any political activities.

7. Environmental History

Patient lives in Barangay Masaplod Sur, Dauin. Their house is one-storey made up of concrete and wood with a rooftop made of steel. They
are located along the highway with random types of trees growing nearby (i.e., acasia, germilina & mango tree) and is also located near a canal.
House is surrounded with taro(gabi) plants. Neighborhood is good and peaceful with friendly neighbors.

8. Spiritual History

Patient was baptized as Roman Catholic the same with his siblings and parents. But patient still havent fully understand the true meaning and
purpose of God. Family seldom goes to church on Sunday.

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B. PHYSCAL ASSESSMENT FINDINGS

CATEGORY FINDINGS

General Appearance The patient is well groomed and oriented to the time and place
Temperature: 40.5
Vital Signs Respiration: 30 cpm
Pulse Rate: 110
Blood Pressure: 90/40
Good skin turgor
Pale lips
Skin Good capillary refill
Rash present in the right foot
Nails are not too long with dirt inside
Skin is warm and smooth to touch
Has good capillary refill
Hair is black
Dry hair
Short hair
Hair No evidence of alopecia
Hair in the head is evenly distributed
No dandruffs
No nits or head lice
Absence of lesions, deformities and lumps on the scalp

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CATEGORY FINDINGS

Nails Nails are round

Absence of clubbing
Eyebrows and eye lashes are evenly distributed
Eyes are black in color
Eyes Sclera is white
Pupils are black in color and equal in size
No lesions or discharges in conjunctiva and is pink in color
Same color as facial skin
Ears Symmetrical auricle aligned with outer canthus of eyes
Able to hear sound in both ears
No discharges
Nose Symmetrical and straight alignment
Uniform in color
No tenderness and lesions
Dry lips
Lips Teeth are intact
No inflammation in uvula and tonsil and tongue is in central position

Uniform in color
Neck No lumps/masses
No pain in swallowing

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 CATEGORY FINDINGS

No retractions when breathing

No use of accessory muscle use when breathing
Chest Symmetrical chest movement

Heart/Cardiovascular Normal cardiac rate, symmetrical peripheral pulse noted.

Soft non tender abdomen
Abdomen Uniform in color, skin intact, soft, no tenderness

Mental Status Conscious and oriented

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C. NURSING THEORIES

Self-care Deficit Theory

by Dorothea Orem

Nursing is as art through which the practitioner of nursing gives specialized assistance to persons with disabilities which makes more than ordinary
assistance necessary to meet needs for self-care. The nurse also intelligently participates in the medical care the individual receives from the
physician.

Humans are defined as men, women, and children cared for either singly or as social units, and are the material object of nurses and others who
provide direct care.

Environment has physical, chemical and biological features. It includes the family, culture and community.

Health is being structurally and functionally whole or sound. Also, health is a state that encompasses both the health of individuals and of groups,
and human health is the ability to reflect on ones self, to symbolize experience, and to communicate with others.

According to her, the central idea of the theory of self-care deficit is that the requirements of persons for nursing are associated with the subjectivity
of mature and maturing persons to health-related or health care-related action limitations. These limitations render them completely or partially
unable to know existent and emerging requisites for regulatory care for themselves or their dependents. They also limit the ability to engage in the
continuing performance of care measures to control or in some way manage factors that are regulatory of their own or their dependents.

Page | 38
Correlation: During admission, our client is not able to do his daily activities by himself. He is fully dependent on his parents or either the nurses. So
our patients usual routines were altered and cannot render an independent self-care. Our nursing goal is to assist him regain back his strength and
capability of taking care of self through quality nursing care.

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 Environmental Theory

by Florence Nightingale

What nursing has to do is to put the patient in the best condition for nature to act upon him (Nightingale, 1859/1992)

Nightingale stated that nursing ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and
administration of diet all at the least expense of vital power to the patient.

She reflected the art of nursing in her statement that, the art of nursing, as now practiced , seems to be expressly constituted to unmake what God
had made disease to be, viz., a reparative process.

Human beings are not defined by Nightingale specifically. They are defined in relationship to their environment and the impact of the environment
upon them.

The physical environment is stressed by Nightingale in her writing. Nightingales writings reflect a community health model in which all that surrounds
human beings is considered in relation to their state of health.

Nightingale (1859/1992) did not define health specifically. She stated, We know nothing of health, the positive of which pathology is the negative,
except from the observation and experience. Given her definition that of the art of nursing is to unmake what God had made disease, then the goal
of all nursing activities should be client health.

Page | 40
She believed that nursing should provide care to the healthy as well as the ill and discussed health promotion as an activity in which nurses should
engage.

Correlation: In general, our goal is to manipulate the environment to compensate for our patients response to it. We are challenged to be creative
and effective in manipulating our patients surroundings conducive to health which promotes faster healing.

Page | 41
D. GORDONS FUNCTIONAL HEALTH PATTERN

USUAL INITIAL

I. HEALTH-PERCEPTION HEALTH-MANAGEMENT PATTERN

- patients usual health is good - patient experiences mild abdominal pain in pain scale of 4/10

- patient eats meat, chicken, and vegetables so as drinking juice and

- eats nutritious foods and water to improve health energy drink

- patient was not able to monitor weight before and during hospitalization
- complete immunizations
- no previous hospitalizations

- no previous hospitalizations - patient sought for admission due to fever for 3 days

- patient was able to follow the prescribed medications ordered

- does not anticipate problems caring for himself
- Meds:
Paracetamol 250/5mL every 4 hours for more
than 38C
Ranitidine 22mg IVTT every 8 hours
Ampicillin 500mg IVTT every 6 hours ANST

- Labs:
WBC 2.9 (L) MCHC 35.0
HGB 14.2 PLT 49 (L)
HCT 40.5

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II. NUTRITIONAL-METABOLIC PATTERN

- patient usually eat vegetables, fried chicken and hotdog either in

breakfast, lunch, or dinner - patient ate bangus fish, egg with rice for breakfast

-patient eats a lot of rice about 2 cups - drinks about 500mL of water

- did not experience indigestion, nausea or vomiting
- no food restrictions or allergies
- patients not taking any food supplements
- no problems in ability to eat
- also consumes 1-2 bottles of Gatorade energy drink and 500mL orange
juice
- patient is often times feels full
- does not experience indigestion, nausea, vomiting or sore throat
- no food allergies or any restrictions

- patient was not able to monitor weight for the last 6 months

- no problems in ability to eat

III. ELIMINATION PATTERN

Bladder
- no problems or complaints with the usual pattern of urinating
- no problems or complaints in urinating
- usually urinates 4-5 times a day
- usually urinates 6 times a day with whitish color
- no assistive devices used
- no assistive devices used
Bowel
- usually moves bowel during night time with brownish in color and
not watery - moves bowel in any time of the day

Page | 43
- no assistive devices used
- moved bowel this morning yellowish color

Skin - no assistive devices used

- patients skin condition:
> light-brown
> warm to touch - patients skin condition:
> normal skin turgor > light-brown
> absence of any edemas or lesions > warm temperature
> normal skin turgor
> absence f edemas or lesions
IV. ACTIVITY-EXERCISE PATTERN

- patient is a Grade 2 student and goes to school on weekdays

- patient cannot perform much activities due to hospitalization
- plays usually outside of house with friends
- no limitations in ability to ambulate, dress, toileting or bathing
- no limitations in ability to ambulate, dress, toileting, or bathing self
- no complaints in dyspnea or fatigue
- no complaints in dyspnea or fatigue

V. SLEEP-REST PATTERN

- patient usually sleeps around 7PM to 5AM - sleeps 7PM to 5AM during hospitalization

- 9-10 hours of sleep at night - no difficulties in falling or remaining asleep

- no sleeping aids used or any medications or foods - no sleeping aids used

- no difficulties in sleeping

Page | 44
VI. COGNITIVE-PERCEPTION PATTERN

- no deficits in sensor perception (hearing, sight, or touch)

- does not wear eyeglasses or any hearing aids
- no complaints of vertigo or insensitivity to superficial pain or
cold/heat
- no deficits in sensor perception (hearing, sight, or touch)
- does not wear eyeglasses or any hearing aids
- no complaints of vertigo or insensitivity to superficial pain or cold/heat

- patients able to read and write - patients able to read and write

VII. SELF-PERCEPTION PATTERN

- patients parents is concerned of their childs health

- patients parents is concerned of their childs health
- describes himself as a good boy and disciplined
- describes himself as a good boy and disciplined

- being ill made him feel differently because of him lying all day and the
environment in the hospital
VIII. ROLE-RELATIONSHIP PATTERN

Communication
- patient speaks Cebuano - patient speaks Cebuano clearly and relevant

- speech is clear and relevant - able to express self verbally

- able to express self verbally

Page | 45
Relationships
- patients parents speaks Cebuano and English and also clear and
relevant - stays at the hospital with parents for now

- patient lives with his parents and siblings - turns to parents or sibling in times of need

- turns to parents or siblings in times of need - no difficulties with relatives and in-laws

- no difficulties with relatives and in-laws - no signs of any type of abuse (physical, verbal, substance)

- no signs of any type of abuse (physical, verbal, substance)

IX. SEXUALITY-SEXUAL PATTERN

- patient does not yet anticipate a change in his sexual relations

- patient does not yet anticipate a change in his sexual relations
- no knowledge yet of sexual functioning
- no knowledge yet of sexual functioning

X. COPING-STRESS MANAGEMENT PATTERN

- patients parents are usually the one who makes decisions

- patients parents are usually the one who makes decisions
- no loss in life for the past year
- no loss in life for the past year
- patient likes about himself is that his good, honest, and obeys his
parents - patient likes about himself is that his good, honest, and obeys his parents

- does not have anything to change in his life - does not have anything to change in his life

Page | 46
- when patient is under stress or any problems he seeks help from
his patients - when patient is under stress or any problems he seeks help from his
patients

XI. VALUE-BELIEF PATTERN

- patient is Roman Catholic

- patient is Roman Catholic
- patients family finds source of strength and meaning from God
- patients family finds source of strength and meaning from God
- verbalizes that God is very important to their family
- verbalizes that God is very important to their family
- seldom goes to church in Sunday
- seldom goes to church in Sunday
- patients values or moral beliefs were not challenged
- patients values or moral beliefs were not challenged
- no religious practices or rituals were observed
- no religious practices or rituals were observed

Page | 47
E. SUMMARY OF NURSING DIAGNOSES

One of the signs and symptoms of Dengue is fever. Fever is an important part of the bodys defense against infection. Many infants and

children develop high fever with mild viral illness, and improper care would lead to dehydration and brain damage, in severe cases. With these

reasons, we selected Hyperthermia related to inflammatory response from viral infection as evidenced by: fatigue; skin warm to touch; chills;

sweating and with the following vital signs: temperature is 38C ; pulse rate is 90 bpm; respiratory rate is 22 cpm and blood pressure is 130/ 90mmHg

and following laboratory results: WBC is 1.4 T/cumm; platelet is 7.6 T/cumm and hemoglobin of 14.2 g/dL , as our first nursing diagnosis. Another

signs and symptoms for dengue fever is dehydration. The second nursing diagnosis selected is Risk for deficient fluid volume related to vomiting

and decrease fluid intake as manifested by: fatigue; dry skin; poor appetite with the following abnormal vital signs: temperature is 38C; pulse rate is

90 bpm; respiratory rate is 22 cpm and blood pressure is 130/ 90mmHg. We included dehydration because if not corrected it may result to damage

of vital organs. Lastly, we selected Pain related to inflammatory process secondary presence of viral infection, because the patient complains of

abdominal pain since the first day of admission. Pain was rated 6 in a scale of 0 to 10.

Page | 48
 Nursing Care Plan

ASSESSMENT NURSING DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective: Risk for deficient fluid After 4 days of nursing Independent: At the end of 4 days
Gasuka siya ug volume related to intervention, nursing intervention, the
mga ika-duha vomiting and the patient will manifest: -Monitor vital signs -Vital sign help identify objectives have been met
guro ug decrease fluid intake every 3 hours / more fluctuations in as evidenced by:
panalagsa ra siya due as manifested often. intravascular fluid.
muinom ug tubig, by: fatigue; dry skin; -Maintain fluid volume at a -Maintained fluid volume
as verbalized by poor appetite with functional level as - Indications adequacy at a functional level as
the patient. the following evidenced by individually -Observation of of peripheral circulation. evidenced by individually
abnormal vital signs: adequate urinary output capillary refill. adequate urinary output
Objective: T= 38C with normal specific with normal specific
Fatigue P= 90 bpm gravity, stable vital signs, - Indications adequacy gravity, stable vital signs,
Dry skin R= 22 cpm moist mucous - Observation of of peripheral circulation. moist mucous
Poor BP= 130/ 90mmHg membranes, good skin capillary refill. membranes, good skin
appetite turgor and prompt turgor and prompt
v/s: capillary refill (less than 3 - Decrease in urine capillary refill (less than 3
T= 38C sec). -Observation of intake output concentrated sec).
P= 90 bpm and output. Note the suspected dehydration.
R= 22 cpm -Vital signs within normal color of urine / -Vital signs within normal
BP= 130/ limits. concentration. limits.
90mmHg - To consume body T= 36.8C
- Suggest increase fluid fluids orally P=110 bpm
-Demonstrate behaviors or intake 1500-2000 ml / R= 18 cpm
lifestyle changes to day (as tolerated). BP= 120/80mmHg
prevent development of -It can increase the
fluid volume deficit. Collaborative: amount of body fluid, to
- Intravenous fluid prevent shock -Demonstrated behaviors
administration. hypovolemic. or lifestyle changes to
prevent development of
fluid volume deficit.

Page | 49
 ASSESSMENT NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: Hyperthermia related After 4 days of nursing Independent: At the end of 4 days
Init kayo hikapon to inflammatory intervention, nursing intervention, the
ang iyang ulo, as response from viral the patient will -Monitor BP and invasive -Central hypertension or objectives have been
verbalized by the infection as manifest: hemodynamic parameters peripheral/postural partially met as
SO. evidenced by: if available (e.g., mean hypotension can occur. evidenced by:
fatigue; skin warm to -Vital signs within arterial pressure- MAP,
touch; chills; normal range CVP, PAP,PCWP) -Vital signs within normal
sweating and vital range as evidenced by:
signs of: - Free of complications -Monitor respirations -Hyperventilation may T= 36.8C
Objective: T= 38C such as irreversible initially be present, but P=110 bpm
Fatigue P= 90 bpm brain and neurological ventilator effort may R= 18 cpm
Skin warm R= 22 cpm damage, acute renal eventually be impaired BP= 120/80mmHg and
to touch BP= 130/ 90mmHg; failure. by seizures, lab results of:
Chills and laboratory hypermetabolic state
Sweating results of: (shock and acidosis). WBC=1.4 T/cumm
WBC= -Monitor heart rate and Plt=49 T/cumm
v/s: Platelet= rhythm -Dysrhythmias and Hmg: 14.2 g/dL
T= 38C Hemoglobin= ECG changes are
P= 90 bpm common due to -Be free of complications
R= 22 cpm electrolyte imbalance, such as irreversible brain
dehydration, specific and neurological
BP= 130/
action of damage, acute renal
90mmHg
catecholamines, and failure.
Laboratory results:
direct effects of
WBC= 1480
hyperthermia on blood
t/cumm
-Note presence / absence and cardiac tissue.
Plt=76000 t/cumm
Hmg: 14.2 g/dL of sweating
-To monitor heat & fluid
-Provide TSB q 15 minutes loss

-Apply local ice packs in -To reduce body

axilla temperature

Page | 50
-Instruct client to have bed
rest
-Instruct client to increase
of fluid intake
Collaborative:
-Administer replacement
fluids
-Administer antipyretics,
orally or rectally(e.g.,
ibuprofen,
acetaminophen), as
ordered.
-To reduce body
temperature in areas of
high blood flow
-To reduce metabolic
demands / oxygen
consumption
-To prevent dehydration
-To support circulating
blood volume and tissue
perfusion
-To restore normal body
temperature
Page | 51
 ASSESSMENT NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Acute pain related to After 4 days of nursing Independent: After 4 days of nursing
Sakit akong inflammatory process interventions the patient -Note or investigate -To rule out worsening of interventions the goal
tiyan, as secondary to will be able feel changes from previous underlying was met. The patient
verbalized by the presence of viral lessening of pain as report of pain. condition/development was able to feel
patient infection manifested by: of complications. lessening of pain as
manifested by:
-Verbalization of -Body language or
lessening of pain scale -Note nonverbal cues, nonverbal cues may be -Lessening of pain
Objective: from 6/10 to 4/10. such as restlessness, both physiological and scale from 9/10 to
- pain, 6 out of 10 reluctance to move, psychological and may 5/10
pain scale -Absence of facial abdominal guarding, be used in conjunction
-slight facial grimace& guarding withdrawal and with verbal cues to -Absence of facial
grimace behavior. depression. determine extent and grimace& guarding
-Guarding and severity of the problem. behavior
holding of -Absence of
abdomen restlessness -These may point -Less irritability
- Fatigue -Review factors that precipitating or
-CBC result of: -Demonstrate ways on aggravate or alleviate aggravating factors or -Demonstrated deep-
WBC - how to lessen pain pain. identify developing breathing technique
1.1T/cumm through a non- complications.
pharmacological way. -Utilized music
-Maintain a quiet & non- -To provide an therapy to refocus
stimulating environment. environment that is attention
conducive for resting &
relaxation.

-Provide comfort -To promote a non-

measures such as back pharmacological way of
rub & deepbreathing pain management. The
gate control theory of
pain proposes that

Page | 52
 stimulation of fibers
transmit non-painful
sensations can block or
decrease the
transmission of pain
-Instruct the patient to impulses.
report immediately any
improvement / -Only the client
exacerbations in pain can judge the level
experience. and distress of pain;
pain management
should be a
teamapproach that
includes theclient.

Dependent:
-Administer Paracetamol -Paracetamol are
as ordered by the doctor. thought to decrease pain
by inhibiting
cyclooxygenase, the
enzyme involved in the
production of
prostaglandin.

Page | 53
XI. ANNOTATED READINGS

Severe Dengue Virus Infection in Pediatric Travelers Visiting Friends and Relatives after Travel to the Caribbean

Nivedita Krishnan, MurliPurswani, and Stefan Hagmann*

Abstract
Dengue represents the most common global arboviral infection, and one of the most frequent causes of systemic febrile illness in travelers returning
from tropical regions. In local populations, severe dengue morbidity occurs predominantly in infants and children, and travel-associated severe
dengue infections have been hitherto mostly described in adults.Increasing global migration has contributed to the growing proportion of children
traveling to tropical and subtropical regions with risk of exposure to dengue virus infection.This report analyzes the travel, clinical, and laboratory
characteristics of eight children with dengue including, three with severe dengue infection after return from a trip to the Caribbean.

Bronx-Lebanon Hospital Center is among the largest primary health care providers in the Bronx. Dengue cases were identified by searching the
electronic hospital chart system with dengue-specific International Classification of Diseases9 codes for children (< 18 years of age) who were
cared for at one of the institution's pediatric outpatient clinics, emergency department, or inpatient unit during May 1, 2007December 31, 2010.

During the study period, serologic analysis was performed at Focus Diagnostics (Cypress, CA) by using a dengue virus IgM capture enzyme-linked
immunosorbent assay and a dengue virus IgG indirect enzyme-linked immunosorbent assay, and results of both assays were expressed as an index
value.World Health Organization (WHO) criteria were used to diagnose dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS): DHF
was defined as an acute febrile illness accompanied by hemorrhagic manifestations, platelet count less than 100,000/mm 3, and evidence of plasma
leakage; and DSS was established when the DHF criteria were fulfilled in addition to hypotension for age.Charts of children with dengue virus
infection diagnosed during the study period were retrospectively reviewed for data abstraction. The study was approved by the institution's
institutional review board.

Page | 54
During the study period, we identified eight children with the diagnosis of a probable acute dengue virus infection according to the WHO, and
supported by a single positive IgM and/or IgG antibody test result. All cases were in children visiting friends and relatives (pediatric visiting friends
and relatives [VFR] travelers) in the Dominican Republic (88%) or Puerto Rico (12%). Identified cases were mostly in females (63%) and in U.S. born
(75%), who had a median age of 13.6 years (range = 0.317.6 years). The median travel duration was 32 days (range = 10 days4.3 years), two
(25%) persons had previously traveled to the same destination, and the median time to seeking treatment since return was 6 days (range = 111
days).

All travelers sought treatment because of an acute febrile illness. Associated clinical features in decreasing frequency were gastrointestinal
complaints (63%), myalgia (50%), petechial rash (38%), signs of dehydration (25%), and headache (13%). One child had sought treatment initially
with a febrile seizure. Significant laboratory findings included leukopenia (63%), thrombocytopenia (75%), elevation of serum alanine
aminotransferase level (38%), low serum albumin level (38%), and increased hematocrit (25%). Evaluations by sonogram showed ascites (50%),
pleural effusion (38%), gallbladder thickening (38%), and heterogeneous liver parenchyma (25%).

Three cases (38%) were deemed complicated; two fulfilled the WHO case definition for DHF and one for DSS. Two of the three persons with
DHF/DSS cases had profound leukopenia, thrombocytopenia, and an increased hematocrit, even at first encounter. Only persons with DHF/DSS had
elevation of alanine aminotranferase levels. Median leukocyte nadir (cells/mm 3) and platelet nadir (cells/mm 3) for DHF/DSS and uncomplicated
dengue fever (DF) cases was 3.7 versus 3.0 and 18 versus 76, respectively. Serologic analysis suggested a primary immune response in the infant
with DSS and a secondary immune response in the two teenagers with DHF.

Sonographic (ascites, pleural effusion) and laboratory evidence (hypoalbuminemia) of plasma leakage were more pronounced in, but not limited to,
the DHF/DSS cases. Evidence of intraperitoneal inflammation (gallbladder thickening and heterogeneous liver parenchyma) was exclusively seen in
the DHF/DSS cases. All persons with DHF/DSS responded well to fluid resuscitation and recovered fully without further complications.

This study highlights that pediatric health care providers in communities with large proportions originally from dengue-endemic regions need to be
prepared to diagnose dengue and recognize warning signs for severe disease. The Bronx is one of the ethnically most diverse counties in the United

Page | 55
States, and most of its immigrant/migrant population maintain close ties to the Dominican Republic, Puerto Rico, and other Caribbean
islands.Although data on pediatric travel activity is sparse, this study suggests that pediatric VFR travelers in the Bronx tend to travel repeatedly
(25%, probably underreported) and for extended durations (30 days) (63%). The incidence of dengue in the Caribbean has been expanding, 7 and
one-fourth of travel-related dengue infections in the United States are imported from the Caribbean.Thus, pediatric VFR travelers to the Caribbean
may be at significant risk for dengue virus infection. They are possibly more likely to be exposed at locations that do not benefit from vector control
activities as much as resort areas that are typically visited by pediatric tourist travelers. However, previous research has not found VFR travelers
overall to have an increased risk for dengue, contrary to other travel-related infectious diseases such as malaria when compared with tourist
travelers.Further research assessing the incidence of dengue specifically in pediatric travelers is warranted.

As noted by others, fever and nonspecific gastrointestinal complaints predominated as presenting signs in pediatric travelers with dengue, therefore
constituting a diagnostic challenge.Our study shows that a simple complete blood count and sonogram may enable an early presumptive diagnosis of
dengue because leukopenia, thrombocytopenia, and sonographic evidence of plasma leakage could be found on presentation in most cases. Severe
dengue (DHF/DSS) was heralded by especially profound thrombocytopenia, evidence of hepatic/intraperitoneal inflammation, and
hemoconcentration that was only noted in the DHF cases.

Our relatively high proportion of severe cases caused by DHF/DSS (38%) contrasts with a recent report on dengue morbidity in adult travelers, in
which 11% had severe clinical manifestations, and only 0.9% had DHF. 3This retrospective study precluded our ability to identify mild dengue cases,
potentially leading to an overestimation of the relative burden with severe morbidity. However, the high proportion of cases with a platelet count less
than 50,000/mm 3 (63%), and the presence of plasma leakage (63%) is similar to what has been described in case series in endemic pediatric
populations.Likewise, according to a new simplified dengue case classification, which divides dengue (with or without warning signs) and severe
dengue, 63% of the cases would have been deemed as severe (case 3) or requiring close observation because of the presence of warning signs
(cases 1, 2, 6, and 7).In this novel system, severe dengue requires clinically significant plasma leakage leading to shock or respiratory distress
because of fluid accumulation, or severe bleeding or severe organ involvement, and so-called warning signs in non-severe dengue cases include

Page | 56
abdominal pain/tenderness, persistent vomiting, clinical fluid accumulation, mucosal bleed, lethargy/restlessness, liver enlargement (> 2 cm), or
increase in hematocrit with rapid decrease in platelet count.

Studies of children in disease-endemic regions lend support to the leading but not uncontested antibody-dependent enhancement theory that
secondary infections with a heterotypic dengue virus serotype constitute a significant risk factor for severe morbidity. Likewise, pediatric VFR
travelers with frequent recurrent travel may be prone to be exposed to dengue repeatedly over time. Thus, it is no surprise that in this study at least
38% of all cases, and both DHF cases had a serologic profile suggestive of a secondary dengue virus infection. The DSS case in the 8-month-old
infant with a primary dengue virus infection may also be consistent with the epidemiology of dengue in children in disease-endemic communities
where a peak of severe dengue morbidity has been observed in infants 49 months of age in the context of a primary dengue virus infection. 2 It has
been hypothesized that at this age the concentration of transplacentally acquired maternal dengue antibodies in the infant's circulation may decrease
from protective to enhancing levels.However, recent research could not find an association between maternal antibodies and development of severe
dengue in infants, thereby challenging the antibody-dependent enhancement theory. Dengue genotypes and individual host factors may have a
greater impact on the development of severe morbidity than previously appreciated .

Reaction

Pediatric VFR travelers with frequent and prolonged travel to dengue-endemic regions may adopt a risk profile for dengue morbidity that is
similar to that of children residing in dengue-endemic countries. High index of suspicion for dengue in febrile children returning from dengue-endemic
regions will enable timely diagnosis and successful management of a potentially fatal condition. Identification of children with travel plans may
represent an important opportunity for pre-travel advice. Currently, the preventive efforts need to focus primarily on mosquito-preventive measures
and on education of caregivers to seek prompt medical care in case of a febrile illness.

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Dengue Fever Prevention

By Vincent Chen, N.D.

Dengue fever is caused by a bite from an infected Aedes mosquito. This species of mosquito has black and white stripes on its legs and body.
It bites during daylight hours. Its preferred breeding waters are clean, stagnant waters in shady areas.

Dengue fever ( DF ), dengue hemorrhagic fever ( DHF ) and Dengue Shock Syndrome ( DSS ) are caused by viruses DEN-1, DEN-2 and
DEN-3. DHF is contracted when the victim is infected with a second or even third strain of virus after the initial infection of a strain of dengue virus.
This is because being infected with one strain of dengue virus does not render you immune to the other strains ( or serotypes ).

If your housing area is dengue-prone, you may need four different dengue immunizations. The most common dengue is dengue fever.

You need to see your physician immediately if you show clinical signs of dengue. The symptoms include fever, bad headaches, muscle and
joint pains, skin rashes and overall weakness in the body. DHF has further complications of cough, vomiting and stomach pains. DSS is detected
with symptoms like cold, sweaty palms, nose or gum bleeds, excretion of blood, vomiting and stomach pains.

Dengue is a fatal disease and deserves immediate medical treatment. Intravenous fluids ( IV ) are used to treat the electrolyte imbalances and
dehydration. Depending on the patient's condition, blood transfusion may be ordered by the doctor. Dengue needs hospitalization and intensive
care. Recovery is possible. In contrast, untreated victims have only a 50 % chance of survival.

To cope with dengue, prevention of being bitten by aAedes mosquito or any other infected mosquito is better than curing the disease. Guard
against collection of stagnant water within the house. Flower vases, plant plates, receptacles, rainwater and gully traps within bathrooms invite
breeding. For water receptacles, change the water daily.

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 Outside the house, watch out for holes, accumulation of leaves, exposed rubbish and stagnant gully traps. These are sources of stagnant
water for mosquito breeding.

There are sprays and insecticides to kill mosquitoes and larvae. These are cheap preventive measures as compared to the high costs of
hospitalization and danger to human lives.

Reaction:

Prevention of dengue fever is a great thing to do to reduce the number of cases involve in dengue fever. Its not just benefit to those who are at
high risk or who are prone to dengue such those who have less immune system that could fight back the virus, or those that live in far flange area.
We all know that the most susceptible host for this kind of disease are children. How could we protect our child if we ourselves cannot prevent the
occurrence of such epidemiology. Now, its better to take precaution than do nothing at all.

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XII. CONLUSION

This case study has made us better as nursing students. We have gained plenty of information on our case, dengue. Upon making this case
study, we must say we had a strong teamwork relied on each other just to make sure we came up with the best output. We gave it all, our time,
resources and above all, our efforts to see all this as a success.

All this wouldnt be possible without God on our side he alone has been our main source of strength and He gave us the energy to push it
through despite all and overcame it. If we just made this for the sake of requirement then we must say we couldnt have gotten to this point of us
writing our conclusion.

This disease process dengue, made us aware of the need to be self-cautious about the health of the people around us and especially our
own health, that if we experience any abnormalities, we ought to immediately seek for the doctors attention. Early detection or having regular check-
ups would mean less invasive interventions and less detrimental to ones overall well-being.

Staff nurses of government hospitals are required by law to assist student nurses on their learning. We would like to extend our gratitude to
the Pediatric ward nurses and staffs who gladly helped us in times of need and guidance during our clinical exposure in the area. They have been a
good example of what we have been taught n our NCM103 class.

We highly appreciate the efforts and time put in by our clinical instructor, Mrs. Socorro Paquita Palarpalar who cared for our future as soon-to-
be professional nurses. She advised us accordingly and assisted us throughout the rotation. We thank God for her good heart and efforts towards
making us better nurses. May God bless her, because if we not for her, we couldnt have made it!

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XIII. BIBLIOGRAPHY

Books Source:

Black, J.M. & Hawks, J.H.(2004). Medical-Surgical Nursing. 7th Edition. Philippines: Elsevier (Singapore) PTE LYD.
Kozier, B., et. al.,(2004). Fundamentals of Nursing, Concepts, Process and Practice, 7th Edition. New Jersey: Pearson Education Inc.
Potter, P.A. & Perry, A.G.(2004) Fundamentals of Nursing. Philippines: Elsevier (Singapore) PTE LYD.
Porth, C.M.(2002). Pathophysiology: Concepts of Altered Health States. 6th Edition. Philadelphia: Lippincott Williams & Wilkins.
Harrison, T.R., et. al. Principles of Internal Medicine. 5th Edition. The Blackiston Division; McGraw Hill Book Company.
Torney, A. M., et. al.(2002). Nursing Theorists and their Work. 5th Edition. Mosby, Inc.

Internet Source:

Retrieved at 8/11/16, 6:45PM. http://www.who.int/topics/dengue/en/

Retrieved at 8/11/16, 7:00PM. http://www.mayoclinic.org/diseases-conditions/dengue-fever/basics/definition/con-20032868
Retrieved at 8/12/16, 9:50PM. http://nurseslabs.com/category/drug-study/

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