Revised 2019

Mindanao State University

COLLEGE OF HEALTH SCIENCES
Marawi City

Name of Student: Risha Ethel G. Berondo Clinical Instructor: Norhidayah Aragasi

Area of Assignment: Date Submitted: March 5, 2022

NURSING ASSESSMENT I

PATIENT’S PROFILE

Name: Patient X Address: Tiguma, Pagadian City, Zamboanga Del Sur Age: 27 years old

Sex: Female Religion: Roman Catholic Civil Status: Married Occupation: Teacher

HABITS

Frequency Amount Period/Duration

1. Tobacco None None None

2. Alcohol None None None
3. OTC-drugs/ non-prescription drugs (Paracetamol) As needed 300 mg As needed

A. CHIEF COMPLAINTS:
A 27-year-old pregnant woman, gravida 2 para 1, presented with hypertension with high blood pressure level that ranges from 140/100 to 150/110 for 2 days
already.

B. HISTORY OF PRESENT ILLNESS (HPI) {onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and vocational
responsibilities, affected diagnoses}.
A case of 27-year-old pregnant patient, G2 P1 from Tiguma, Pagadian City, Zamboanga Del Sur was admitted at APMC last March 2, 2022 at 11:34 AM. The patient
experienced 2 days with high levels of blood pressure prior to admission.

The patient undergone a Hematology test hours prior to admission having a 167.00 platelet count, 1.56 WBC, 14.10 hemoglobin, and 11.00 monocytes was then
advised for admission. On the day of admission, the patient experienced headache with a pain score of 7/10 and an intermittent fever. The fever and headache are alleviated
when lying of bed and taking Paracetamol as needed. “Bigla nalang ang taas nang lagnat niya, tapos baba rin maya-maya” as verbalized by the SO. “Sumasakit ulo ko at wala
akong lakas” as verbalized by the patient.
C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications, habits, birth
and developmental history, nutrition- for pedia)

3 years prior to admission, the patient experienced sprain on right Tarsal but was not advised for admission. The patient has never undergone any procedure, and
major illness prior to admission. The patient has no known allergies, he was immunized with BCG, #3 DPT, #3 OPV, #3 Hepa B, and #2 measles. The patient was taking
Paracetamol as needed to alleviate headache and to lower down fever. The patient has no known habits of Tobacco, Alcohol and other OTC drug aside from
Paracetamol. The patient was delivered with NSVD.
Deceased father
FAMILY HISTORY WITH GENOGRAM Mother

Sister Acquired Diseases: Heredo- familial Diseases:

55 Hypercholesterolemia X Diabetes X
Brother
Kidney Disease X Heart Diseases X
Patient Tuberculosis X Hypertension X
Alcoholism X Cancer X
Drug Addiction X Asthma X
Hepatitis A X Epilepsy X
33 29 28 23 19 17 13 12
B X Mental Illness X
Smoker
C X Rheuma/Arthritis X
Deafness @ right ear
Others (pls. specify) X Others (pls. specify) Deafness (older sister)

D. PATIENT’S PERCEPTION OF:

1. Present Illness

“Sumasakit ang katawan ko” as verbalized by the patient.

2. Hospital Environment

“Gusto ko nang umuwi” as verbalized by the patient.

E. SUMMARY OF INTERACTION

Patient was responsive, cooperative, and able to answer well the questions and the patient is very polite. The interaction with the patient was productive with the
help of the SO for some information that the patient was unable to answer.
 Physical Examination

Name: Patient X Date: October 26, 2019

Chief Complaint upon Initial Assessment: Body weakness and headache Height: 155 cm
Chief Complaint upon Final Assessment: Irregular defecation Weight: 41 kg
Initial Vital Signs: Temp: 37.5°c RR: 30cpm PR: 80bpm O2Sat:97% BP: 90/70mmHg Pain Score: 7/10 BMI: 17.08 kg/m2
 Initial Assessment
Received lying on bed in a right lateral position with IVF #4 D5LR, 1000ml with
1000ml fluid remaining, regulated at 30gtts/min, hooked at right metacarpal vein,
infusing well. The patient wears a red shirt and green malong. The patient has frizzy
hair. The patient is conscious and alert. Drowsiness, body weakness, disinterest in
GENERAL surroundings and tiredness was noted. Skin is cool to touch.
H: head is normocephalic, has a smooth contour, symmetrical to facial features and
absence of masses and lumps upon palpation. Hair is frizzy, dry and absence of lice.
E: eyebrows are black. Eyelashes are evenly distributed, whitish sclera, absence of
edema and discharges.
E: ears are symmetrical and proportional to outer canthus of the eyes. No tenderness
HEENT and lesions and discharges. No problem with hearing acuity.
N: no deformities, tenderness or swelling. Located at midline portion of the face. No
masses, discharges and nasal flaring.
T. trachea is in the midline. Absence of swelling or masses and enlargement.
Skin is cool to touch, and dryness noted. Hair is frizzy and dry and brownish color.
Nails are not trimmed and both finger nails and toe nails are not properly hygiene.
No rashes was observed during the assessment. No presence of edema. The patient
INTEGUMENTARY reported of skin rashes 1 day prior to admission. Skin turgor of <1second.
Final Assessment (Last Day)
Patient received sitting on bed with IVF #5 D5NSS, 1000ml with 650ml fluid
remaining, regulated at 30gtts/min, hooked at right metacarpal vein, infusing
well. The patient wears a blue shirt and green malong. The patient has soft hair.
The patient is conscious and alert. The patient is in an active and hyper mood.
H: head is normocephalic, has a smooth contour, symmetrical to facial features
and absence of masses and lumps upon palpation. Hair is frizzy, dry and absence
of lice.
E: eyebrows are black. Eyelashes are evenly distributed, whitish sclera, absence of
edema and discharges.
E: ears are symmetrical and proportional to outer canthus of the eyes. No
tenderness and lesions and discharges. No problem with hearing acuity.
N: no deformities, tenderness or swelling. Located at midline portion of the face.
No masses, discharges and nasal flaring.
T. trachea is in the midline. Absence of swelling or masses and enlargement.
Skin is warm to touch, and dryness noted. Hair is smooth and dry and brownish
color. Nails are trimmed and both finger nails and toe nails are not properly
hygiene. No rashes was observed during the assessment. No presence of edema.
The patient shows a blooming look. Skin turgor of <1second.
 Respiratory rate of the patient is 30cpm, SPO 2 of 97% via room air. No difficulty of
breathing and no difficulty of swallowing. No deformities on the chest and equal
chest expansion. No oxygen therapy is used. No history of respiratory problems
RESPIRATORY except common colds in cold weather.
Patient’s pulse rate is 80bpm, with blood pressure of 90/70mmHg. All the
peripheral pulses are palpable. No edema noted. Nail bed are pale with capillary
refill of <2seconds. Patient is not cyanotic. The patient has no cardiovascular
CARDIOVASCULAR disorders.
Patient’s lips are dry and slightly pale, oral mucosa is slightly moist and pinkish.
Teeth are slightly yellowish in color. No dental dentures noted, and tongue
DIGESTIVE appears white. Patient reported of 1 bowel output on 1 st day of admission around
3pm and 2nd bowel output on 2nd day of admission around 1pm with an intact stool
and dark in color characteristics.
Patient reported of 4 times urination within 24hrs with a characteristics of
yellowish in color.
EXCRETORY
Patient is able to move upper and lower extremities; patient can stand and walk
with assistance. Patient is able to maintain flexion extension on upper and lower
extremities. Body weakness was noted.
MUSCULOSKELETAL
The patient is coherent, conscious and oriented to time, date, place and person. All
senses are functioning well, sensitive to heat, cold and pressure. Able to hear and
communicate well.
NERVOUS
Respiratory rate of the patient is 27cpm, SPO 2 of 98% via room air. No difficulty of
breathing and no difficulty of swallowing. No deformities on the chest and equal
chest expansion. No oxygen therapy is used. No history of respiratory problems
except common colds in cold weather.
Patient’s pulse rate is 90bpm, with blood pressure of 100/60mmHg. All the
peripheral pulses are palpable. No edema noted. Nail bed are pale with capillary
refill of <2seconds. Patient is not cyanotic. The patient has no cardiovascular
disorders.
Patient’s lips are moist, reddish In color, oral mucosa is moist and pinkish. Teeth
are slightly yellowish in color. No dental dentures are noted and tongue appears
reddish. Patient reported of not defecating after his second defecation on second
day of admission. Has higher appetite.
Patient reported of 2 times urination with the characteristics of orange-like in
color.
Patient is able to move upper and lower extremities; patient can stand and walk
without assistance. Patient is able to maintain flexion extension on upper and
lower extremities. Shows active and hyper mood.
The patient is coherent, conscious and oriented to time, date, place and person.
All senses are functioning well, sensitive to heat, cold and pressure. Able to hear
and communicate well.
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Hydralazine(Apresoline) Direct-acting peripheral Moderate to severe Hypersensitivity CNS:  Monitor BP and

PO: Hypertension- 10 mg arteriolar vasodilator. hypertension (with a Dizziness pulse frequently
Classification: 4 times daily initially. diuretic). Some products contain Drowsiness during initial dose
Antihypertensive/ After 2-4 days may tartrazine and should be Headache adjustment and
Peripheral Vasodilator increase to 25 mg 4 Unlabeled Use/s: avoided in patients with periodically
times daily (up to 300 HF unresponsive to known intolerance. CV: during theraphy.
mg/day). Once Therapeutic effects: conventional therapy with Tachycardia  Monitor
maintenance dose Lowering of BP in digoxin and diuretics. Angina frequency of
hypertensive patients and Arrythmias prescription refills
isestablished, twice daily
decreased afterload in Edema to determine
dosing may be used. HF-
patients with HF. Orthostatic adherence.
25-37.5 mg 4 times daily;
Hypotension  Do not confuse
may be up to 300 GI: hydralazinr with
 mg/day in 3-4 divided Diarrhea hydroxyzine
doses. Nausea  IM or IV route
Vomiting should be used
IM IV: Hypertension 5-40 Derm: only when drug
mg repeated as needed. Rash cannot be gven
Eclampsia- 5mg every 15- MS: orally.
20 min; if no response Arthralgias  Emphasize the
after a total of 20 mg, Arthritis importance of
Neuro: continuing tot ake
consider an alternative
this medication,
agent.
Peripheral Neuropathy even if feeling
well.
Misc:  Encourage the
patient to comply
Drug-induced lupus with additional
syndrome. preventions.
 Caution patient to
avoid sudden
changes in
position to
minimize
orthostatic
hypertension.

Monitor BP anf pulse

Nifedipine Inhibits calcium transport
into myocardial and
Classification: vascular smooth muscle
Therapeutic cells, resulting in inhibition
Antianginal of excitation-contraction
Antihypertensives coupling and subsequent
contraction.
Pharmacologic:
Calcium Channel Blockers Therapeutic Effects:
Systemic vasodilation,
resulting in decreased BP.
Coronary vasodilation,
resulting in decreased
CNS:
before theraphy during
Management of: Hypersensitivity; Sick Dizziness, abnormal
Hypertension (extended- Sinus syndrome; 2nd or 3rd dreams, anxiety,
release only), Angina Degree AV block (unless consfuison, jitterness,
pectoris, Vasospastic an artificial pacemaker is nervousness, psychiatric
(Prinzmetal’s) angina. in place); Systolic BP<90 disturbances, weakness,
mmHg; Coadministration drowsiness and Headache.
Unlabeled Use: with grapefruit juice,
Prevention of migraine rifampin, rifabutin, EENT:
Headache. Management phenobarbital, Blurred vision, disturbed
of HF or cardiomyopathy. carbamazepine or St. equilibrium, epistaxis and
John’s wort. syncope.
Resp:
frequency and severity of Cough, dyspnea, shortness
attacks of angina. of breath

CV:
Bradycardia, Arrythmias,
Peripheral Edema,
Syncope, Tachycardia and
Hypotension.

GI:
Liver enzymes, anorexia,
constipation, diarrhea, dry
mouth, Nausea, vomiting

GU: dysuria, nocturia,

polyuria, sexual
dysfunction, urinary
frequency.

Derm:
Flushing, Dermatitis,
erythema, Rash,
multiforme

Endo:
Gynecomastia,
hyperglycemia

Hemat: anemia,
leukopenia,thrombocytop
enia

Metab: weight gain

MS:
Joint stiffness, muscle
cramps

Neuro:
Paresthesia, tremor

Name: Patient X
Admitting Chief Complaint: Fever x 2 days, headache
Impression/Diagnosis Dengue Severe
Date/Time of Admission 10/24/19 @ 4:31pm
Diet: DAT, avoid dark colored foods
Type of Operation (if any): none
NORMAL PATTERN
1.ACTIVITIES- REST
a. Activities
b. Rest
c. Sleeping pattern
2.NUTRITIONAL- METABOLIC
a. Typical intake(food, fluid)
b. Diet
c. Diet restrictions
d. Weight
e. Medications/supplement
food
3. ELIMINATION
BEFORE HOSPITALIZATION
The patient was an active person
according to the SO. He plays
basketball, do house chores and
play computer games. He has a
sleeping pattern of 7pm to 5am.
According to the SO, he really likes
to do house chores. He is a very
helpful son and brother.
The patient has no diet restrictions.
Does not eat 3 times a day. Drinks
more than 4 full glass of water each
day. Patient cannot remember of his
weight. Patient’s not taking any
vitamins but takes some OTC drugs
like Paracetamol when needed.
Frequent urination color is amber
and transparent. Usually urinates 4
NURSING ASSESSMENT II
INITIAL
The patient shows body weakness,
tiredness and drowsiness. He spends
most of the time on bed. He usually
sleeps more than his usual sleeping
pattern. He is asleep most of the
time during stay in the hospital.
The patient is DAT and should avoid
dark colored foods. He takes more
than 3 full glass of water. Does not
usually eats. Has low appetite.
Patient’s weight if 41kg. the patient
is prescribed to take Omeprazole
40mg and Paracetamol 500mg
Patient reported of 2 times urination
during the day of assessment with
Age: 13 years old Sex: Male
Inclusive Dates of Care 10/26 to 27/2019
Allergies None
CLINICAL APPRAISAL
DAY 1 DAY 2
The patient shows active and hyper
mood. He spends most of the time
on bed. Usually sleeps more than his
usual sleeping pattern. Patient
reported of slept at 7pm last night
and wake up at 7am this morning.
The patient is DAT and should avoid
dark colored foods. He takes more
than 4 full glass of water. Has
higher appetite and eats a lot. He
reported he ate rice, apple, and
oranges. Patient’s weight if 41kg.
the patient is prescribed to take
Omeprazole 40mg and Paracetamol
500mg
Patient reported of 2 times urination
during the day of assessment with
 a. Urine (frequency, color, times a day.
transparency)
Usually defecates once every 2 days,
b. Bowel (frequency, color, with a characteristic of brown in
consistency) color and intact stool form.
4. EGO INTEGRITY Patient is happy and contented to
life. Prays regularly. He is supported
a. Perception of self by his family and is cheerful, active
and happy.
b. Coping Mechanism
c. Support System
d. Mood/Affect
5. NEURO-SENSORY Patient has no history of any mental
illness or disorders. The patient is
a. Mental state conscious, coherent and oriented to
time, date, place and persons.
b. Condition of five senses:
(sight, hearing, smell, taste, The patient’s 5 senses are intact.
Patient responds when he is being
touch) asked, able to smell and taste food.
an amber and transparent
characteristics. Also reported of
twice to defecate while admitted in
the hospital with a brown in color
and intact stool form
characteristics.
The patient shows tiredness, body
weakness and wants to go home
immediately. His family is his
primary source of strength.
Patient has no history of any mental
illness or disorders. The patient is
conscious, coherent and oriented to
time, date, place and persons.
The patient’s 5 senses are intact.
Patient responds when he is being
asked, able to smell and taste food.
an orange-like in color. Also
reported of not defecating since his
second defecation while in hospital
admission.
The patient shows more active and
hyper mood. His family is his
primary source of strength.
Patient has no history of any mental
illness or disorders. The patient is
conscious, coherent and oriented to
time, date, place and persons.
The patient’s 5 senses are intact.
Patient responds when he is being
asked, able to smell and taste food.
6. OXYGENATION T: not taken T: 37.5°c T: 35.6°c

a. Vital signs P: not taken P: 80bpm P: 90bpm

Temperature R: not taken R: 30cpm R: 27cpm

Respiratory rate BP: not taken BP: 90/70mmHg BP: 100/60mmHg

Heart rate SPO2: not taken SPO2: 97% via room air SPO2: 98%

Blood pressure

b. Lung sounds Lung sounds were not taken. No Lung sounds were not taken. No Lung sounds were not taken. No
history of respiratory problems. history of respiratory problems. history of respiratory problems.
c. History of Respiratory

Problems

The patient was experiencing The patient was experiencing Experiences headache with a pain
7. PAIN-COMFORT headache started 4days prior to headache started 4days prior to score of 3/10.
admission with a pain score of 7/10. admission with a pain score of 7/10.
a. Pain (location, onset,
Experienced skin rash 1 day prior to Experienced skin rash 1 day prior to
character, intensity,
admission. admission.
duration,
associated symptoms,
aggravation)
Alleviated when lying on bed and Alleviated when lying on bed and Alleviated when lying on bed and
taking Paracetamol. taking Paracetamol. taking Paracetamol.
b. Comfort
measures/Alleviation
Paracetamol drug is taken as need. Omeprazole 40mg ad Paracetamol Omeprazole 40mg ad Paracetamol
500mg was prescribed for the 500mg was prescribed for the
c. Medications
patient to take. patient to take.
8. HYGIENE AND ACTIVITIES
OF DAILY LIVING
9. SEXUALITY
a. female (menarche, menstrual
cycle, civil status, number of
children, reproductive status)
b. male (circumcision, civil
status, number of children)
Patient takes a bath regularly and
does household chores, plays
basketball and computer games.
The patient age 13 years old was
circumcised at age 12. With civil
status of child.
LABORATORY AND DIAGNOSTIC PROCEDURES
Patient cannot take a bath as usual
routine process. Not trimmed both
finger and toes nails are noted. The
SO performs TSB to the patient. The
patient cannot do usual ADLs and
shows tiredness, drowsiness and
body weakness.
The patient age 13 years old was
circumcised at age 12. With civil
status of child.
The patient was given TSB by his SO.
Trimmed nails but not properly
hygiene. Cannot do usual ADLs.
Shows active and hyper mood.
The patient age 13 years old was
circumcised at age 12. With civil
status of child.
 DATE NAME OF THE PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION

10/24/2019 Routine Chemistry:

SGOT 59.00 M: u to 37 U/L Higher amounts of AST may indicate liver
damage.
Sodium 132.20 135-155mmol/dl Low sodium level indicates Hyponatremia
10/24/2019 Hematology:
WBC 1.56 5.0 – 10.0x109/L low WBC may indicate viral Infection
Hematocrit 0.40 M: 0.40 – 0.50 Decrease Hct an indication of blood loss
Platelet count 167.00 140 – 340x109/L Low in PC an indication of risk of bleeding.
Monocytes 11.00 1 – 5% High level of monocytes may indicate the
presence of chronic infection
10/24/2019 Hematology:
WBC 1.23 5.0 – 10.0x109/L low WBC may indicate viral Infection
Platelet count 166.00 140 – 340x109/L Low in PC an indication of risk of bleeding.
Neutrophils 49.00 50 – 70% Absence of neutrophils makes a person
vulnerable to infection
Monocytes 17.00 1 – 5% High level of monocytes may indicate the
presence of chronic infection
10/25/2019 Hematology:
WBC 1.41 5.0 – 10.0x109/L low WBC may indicate viral Infection
Hematocrit 0.38 M: 0.40 – 0.50 Decrease Hct an indication of blood loss
Hemoglobin 13.10 M: 14.0 – 18.0 gm/L Decrease Hb an indication of low oxygenation
Platelet count 141.00 140 – 340x109/L Low in PC an indication of risk of bleeding.
Lymphocytes 32.00 20 – 40% High or lymphocytes may indicate bacterial
infection or autoimmune disorder, respectively
Monocytes 16.00 1 – 5% High level of monocytes may indicate the
presence of chronic infection.
10/26/2019 Hematology:
WBC 1.41 5.0 – 10.0x109/L low WBC may indicate viral Infection
Hematocrit 0.39 M: 0.40 – 0.50 Decrease Hct an indication of blood loss
Hemoglobin 13.50 M: 14.0 – 18.0 gm/L Decrease Hb an indication of low oxygenation
Platelet count 81.00 140 – 340x109/L Low in PC an indication of risk of bleeding.
 Neutrophils 40.00 50 – 70% Absence of neutrophils makes a person
vulnerable to infection
Lymphocytes 50.00 20 – 40% High or lymphocytes may indicate bacterial
infection or autoimmune disorder, respectively
Monocytes 10.00 1 – 5% High level of monocytes may indicate the
presence of chronic infection
10/27/2019 Hematology:
WBC 1.38 5.0 – 10.0x109/L low WBC may indicate viral Infection
Hematocrit 0.38 M: 0.40 – 0.50 Decrease Hct an indication of blood loss
Hemoglobin 12.90 M: 14.0 – 18.0 gm/L Decrease Hb an indication of low oxygenation
Platelet count 35.00 140 – 340x109/L Low in PC an indication of risk of bleeding.
Neutrophils 21.00 50 – 70% Absence of neutrophils makes a person
vulnerable to infection
Lymphocytes 59.00 20 – 40% High or lymphocytes may indicate bacterial
infection or autoimmune disorder, respectively
Monocytes 20.00 1 – 5% High level of monocytes may indicate the
presence of chronic infection

SUMMARY OF INTRAVENOUS FLUID

DATE/TIME STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE NUMBER OF HOURS DATE/TIME CONSUMED
10/24/19 4:31pm #1 PLR 1L FD 1hr 10/24/19 5:30pm
10/24/19 5:30pm 410cc/hr 2.43hrs 10/24/19 6:30pm
10/24/19 6:30pm 72 gtts/m 2 hrs 10/24/19 8:00 pm
10/24/19 8:40pm #2 PLR 1L 72 gtts/m 13.53hrs, 24secs 10/25/19 9:00am
10/25/19 9:00am 40 gtts/m 6hrs 10/25/19 2:40pm
10/25/19 8:50 pm #3 D5LR 1L 40 gtts/m 5 hrs 10/26/19 1:30 am
10/26/19 1:30 am #4 D5LR 1L 30 gtts/m 30mins 10/26/19 2:00 am
10/26/19 2:00 am #5 D5NSS 1L 30 gtts/m 8 hrs 10/27/19 11: pm

SUMMARY OF MEDICATION

DATE MEDICATIONS- dosage, frequency, route Remarks

10/24/19 Paracetamol 500 mg tab, 1 tab q4h PRN T≥37.8°c Well administered, been given on the exact

time indicated

10/24/19 Omeprazole 40 mg IVTT, OD Well administered, been given on the exact

time indicated

10/25/19 Omeprazole 40 mg IVTT, OD Well administered, been given on the exact

time indicated

10/26/19 Omeprazole 40 mg IVTT, OD Well administered, been given on the exact

time indicated
 ANATOMY AND PHYSIOLOGY
Physiology of Circulation
Key Points
 The pulmonary circulatory system circulates deoxygenated blood from the heart to the lungs via the pulmonary artery and returns it to the heart via the pulmonary vein.
 The systemic circulatory system circulates oxygenated blood from the heart around the body into the tissues before it is returned to the heart.
 The arteries divide into thin vessels called arterioles, which in turn divide into smaller capillaries that form a network between the cells of the body. The capillaries then join up again to
make veins that return the blood to the heart.
 The flow of blood along arteries, arterioles and capillaries is not constant but can be controlled depending upon the body’s requirements.
 Vascular resistance generated by the blood vessels must be overcome by blood pressure generated in the heart to allow blood to flow through the circulatory system.
Key Terms
 Vasodilation: The opening of a blood vessel.
 Flow: The movement of blood around the body, closely controlled by alterations in resistance
and pressure.
 Vasoconstriction: The closing or tightening of a blood vessel.
 Resistance: The resistance which must be overcome by pressure to maintain blood flow
throughout the body.
 Pressure: The force which overcomes resistance to maintain blood flow throughout the body.

The circulatory system is the continuous system of tubes through which the blood is pumped
around the body. It supplies the tissues with their nutritional requirements and removes waste
products. The pulmonary circulatory system circulates deoxygenated blood from the heart to the lungs
via the pulmonary artery and returns it to the heart via the pulmonary vein. The systemic circulatory
system circulates oxygenated blood from the heart around the body into the tissues before returning
deoxygenated blood to the heart.

Three key factors influence blood circulation.

 Resistance

Resistance to flow must be overcome to push blood through the circulatory system. If resistance increases, either pressure must increase to maintain flow, or flow rate must
reduce to maintain pressure. Numerous factors can alter resistance, but the three most important are vessel length, vessel radius, and blood viscosity. With increasing length,
increasing viscosity, and decreasing radius, resistance is increased. The arterioles and capillary networks are the main regions of the circulatory system that generate resistance, due the small
caliber of their lumen. Arterioles in particular are able to rapidly alter resistance by altering their radius through vasodilation or vasoconstriction. The resistance offered by peripheral circulation
is known as systemic vascular resistance (SVR), while the resistance offered by the vasculature of the lungs is known as pulmonary vascular resistance (PVR).
  Blood Pressure

Blood pressure is the pressure that blood exerts on the wall of the blood vessels. The pressure originates in the contraction of the heart, which forces blood out of the heart and into the
blood vessels. If flow is impaired through increased resistance then blood pressure must increase, so blood pressure is often used as a test for circulatory health. Blood pressure can be
modulated through altering cardiac activity, vasoconstriction, or vasodilation.

 Blood Flow

Flow is the movement of the blood around the circulatory system. A relatively constant flow is required by the body’s tissues, so pressure and resistance are altered to
maintain this consistency. A too-high flow can damage blood vessels and tissue, while flow that’s too low means tissues served by the blood vessel may not receive enough oxygen to function.

 Lymphatic System

A major function of the lymphatic system is to drain body fluids and return them to the
bloodstream. Blood pressure causes leakage of fluid from the capillaries, resulting in the accumulation
of fluid in the interstitial space—that is, spaces between individual cells in the tissues. In humans, 20 liters of
plasma is released into the interstitial space of the tissues each day due to capillary filtration. Once this filtrate
is out of the bloodstream and in the tissue spaces, it is referred to as interstitial fluid. Of this, 17 liters is
reabsorbed directly by the blood vessels. But what happens to the remaining three liters? This is where the
lymphatic system comes into play. It drains the excess fluid and empties it back into the bloodstream
via a series of vessels, trunks, and ducts. Lymph is the term used to describe interstitial fluid once it has
entered the lymphatic system. When the lymphatic system is damaged in some way, such as by being blocked
by cancer cells or destroyed by injury, protein-rich interstitial fluid accumulates (sometimes “backs up”
from the lymph vessels) in the tissue spaces. This inappropriate accumulation of fluid referred to as
lymphedema may lead to serious medical consequences. As the vertebrate immune system evolved, the
network of lymphatic vessels became convenient avenues for transporting the cells of the immune system.
Additionally, the transport of dietary lipids and fat-soluble vitamins absorbed in the gut uses this system. Cells
of the immune system not only use lymphatic vessels to make their way from interstitial spaces back
into the circulation, but they also use lymph nodes as major staging areas for the development of critical
immune responses. A lymph node is one of the small, bean-shaped organs located throughout the lymphatic
system.
 PATHOPHYSIOLOGY

Dengue Fever

Ideal Actual

Rash
 MEDICAL MANAGEMENT

Ideal Actual

There is no specific medicine to treat dengue infection.  Please admit the patient
 Secure consent to care
 Oral rehydration therapy. Oral rehydration therapy is recommended for patients
 DAT, avoid dark colored foods
with moderate dehydration caused by high fever and vomiting.
 IVF: PLR 1L, fast drip 410cc now then refer for reassessment after fast drip
 IV fluids. IVF administration is indicated for patients with dehydration.
 Laboratory to be done:
 Blood transfusion and blood products. Patients with internal or gastrointestinal
CBC with platelet count
bleeding may require transfusion, and patients with coagulopathy may require fresh
Urinalysis
frozen plasma.
Blood typing
 Oral fluids. Increase in oral fluids is also helpful.
BUN
 Avoid aspirins. Aspirin can thin the blood. Warn patients to avoid aspirins and other
SGPT
NSAIDs as they increase the risk for hemorrhage.
Albumin
Drugs need to administer: Na, K
Creatinine
 Paracetamol (Acetaminophen) SGOT
CXR – APL
Recommended:
 Medication to be administer:
 PO (Children 1-12yr): 10-15mg/kg/dose q 4-6hr as needed (not to exceed 5
Omeprazole 40 mg IVTT, OD
doses/24hr).
Paracetamol 500 mg tab, 1 tab q4h PRN T≥37.8°c

 TPR q4h
 BP q hourly, SBP ≤ 80mmHg
 Refer for any active bleeding, weak pulse, narrow pulses, persistent abdominal pain,
vomiting, dyspnea
 After fast drip reassessment: PLR;1L, 410cc for 1hr then refer to reassessment due
5:30pm
 PLR;1L @ 72gtts/min for 2hrs then refer to reassessment after 2hrs due 7:30pm
 Regulate IVF rate to 40gtts/min
 IVFTF with D5LR;1L at 40gtts/min
 For dengue due test
  IVTF with D5LR;1L at 30gtts
 IVTF with D5NSS;1L at 30gtts
 continue TSB for fever
 continue medication
 IVTF with D5LR;1L at 30gtts
 IVTF with D5NSS;1L at 30gtts

NURSING MANAGEMENT

Ideal Actual
 Evaluation of the patient’s heart rate, temperature, and blood pressure.  Monitor V/S every 2 hrs

 Evaluation of capillary refill, skin color and pulse pressure.  Monitor Capillary Refill and skin color

 Assessment of evidence of bleeding in the skin and other sites.  Monitor of I/O.

 Assessment of increased capillary permeability.  Water therapy (drink more than 6 glasses of water each day)

 Measurement and assessment of the urine output.  TSB if high fever noted.

 Use cold sponging to keep temperature.  Administer Paracetamol and Omeprazole at given time

 Fluid replacement and establish 24hrs fluid replacement needs.  Regulate IVF as indicated.

 Monitor trauma prevention.  Bed rest is advisable during acute phase.

 Platelet and FFP transfusion when needed.  Monitoring pain. Note client report of pain in specific areas whether pain is

 Tourniquet test increasing, diffused, localized.

 Monitor signs of further bleeding.

SURGICAL MANAGEMENT
No surgical procedures undergone
 DISCHARGE PLAN

NAME Patient X DATE OF DISCHARGE: ____________________

CONDITION UPON DISCHARGE ___________ Nature: Home per request ( ) Discharge against medical advice ( )

- Administration of acetaminophen if temp increases

1. MEDICATIONS

- Perform activities of daily living (ADL’s) as tolerated to recover from muscle stiffness due to a long period time of being
2. EXERCISE bedridden.
- Provide enough time for rest (complete bed rest)

- Increase intake of fluids

3. DIET - Increase intake of leafy vegetables and foods rich in protein.
- Avoid eating unhealthy foods such as junk foods to lessen the effect of UTI.

Explain the 4P’S strategy on how to prevent Dengue Infection (MAG 4P’s TANO!)
4. HEALTH TEACHING - PANGILOBAAN SO MGA KAPAKAY MBALAYAN O MGA RUNGIT
- PSULOT SA MATAS AGO PANGAPPLAY SA MGA ANTI-MOSQUITO A LOTION ODI NA HAPLAS
- PIKICONSULTA SA DOKTOR AMAY KO 2 DN KA GAWII SO MAYAW ODI NA MYALAY RON SO MGA TANDA A DENGUE
FEVER.
- PSUPORTA SA “FOGGING/SPRAYING” (KAPAGABUL) IGIRA A ADN A OUTBREAK.)
 - Observe carefully of the signs and symptoms if second infection occurs.
5. SCHEDULE FOR THE NEXT VISIT - Follow-up check-up if happens that an intermittent fever occurs again

CUES
Subjective:
“sumasakit ang ulo ko” as
verbalized by the patient.
Objective:
7 AM, Received patient lying
on bed, conscious, coherent
and alert, #4D5LR; 1L with
1000ml fluid level left;
hooked @ right arm, infusing
well. G20.
- restlessness noted
- teary-eyed noted
- low appetite
- pain score of 7/10
With initial vital signs:
T – 37.5 °C
P – 80 bpm
RR – 30 cpm
BP – 90/70mmHg
SPO2 – 97% via room air
NURSING DIAGNOSIS
Acute pain related to disease
state as evidenced by pain
score of 7/10
NURSING CARE PLAN
OBJECTIVES
Within 8 hours of nursing
care, the patient will be able
to report pain is relieved or
controlled.
INTERVENTIONS RATIONALE EVALUATION
 Monitor vital signs every  To have baseline data After 8 hours of nursing
2 hours care, the patient was able to
 Monitor and regulate IVF  For continuity of care report pain is relieved or
regularly controlled.
 To provide comfort
 Perform morning bed
side care.
 To assess causative factors
 Determine and
document causing pain
 Evaluate pain  To evaluate client response
characteristics and to pain
intensity
 Encourage adequate rest  To promote wellness
periods
 Provide  To explore methods for
nonpharmaological pain alleviation of pain
management:
- Divertional activities
 Identification of causative
- comfort measures factors
 Assist with medical work  For further treatment
up
 Refer to primary care  For continuity of care
provider
 Administer analgesics  For continuity of care
 Administer other  For continuity of care
alleviation of pain drugs

CUES
Objective:
7 AM, Received patient lying
on bed, conscious, coherent
and alert, #4D5LR; 1L with
1000 fluid level left; hooked
@ right arm, infusing well.
G20.
- WBC: 1.14
- Hematocrit: 0.39
- Hemoglobin: 13.50
- headache with pain score of
7/10
- pallor noted
- pale nail beds noted
With initial vital signs:
T: 35.4°c
P: 90bpm
R: 27cpm
BP: 100/60mmHg
SPO2: 98% viia room air
NURSING DIAGNOSIS
Risk for infection related to
disease state as evidenced by
1.14 WBC, 0.39 hematocrit
and 13.50 Hemoglobin.
NURSING CARE PLAN
OBJECTIVES
Within 8 hours of nursing
care, the patient will be able
to verbalize understanding of
individual risk factors.
INTERVENTIONS
 Monitor vital signs every
2 hours
 Monitor and regulate IVF
regularly
 Perform morning bed
side care.
 Promote healthy foods
 Practice and emphasize
constant and proper
hygiene
 Perform or instruct in
daily mouth care.
 Promote hydration
 provide information of
proper hygiene routine
regimen
 provide pharmaceutical
measures
 refer to care providers
RATIONALE EVALUATION
 To have baseline data After 8 hours of nursing care,
the patient was able to
 For continuity of care verbalize understanding of
individual risk factors.
 To provide comfort
 For strong immunity
 To reduce existing risk
factors
 To reduce existing risk
factors
 To promote wellness
 To promote wellness
 For continuity of care
 For continuity of care

CUES
Subjective:
“pababa ng pababa yung
platelet ko sabi ng doktor” as
verbalized by the patient.
Objective:
7 AM, Received patient lying
on bed, conscious, coherent
and alert, #5D5NSS; 1L @
650ml fluid level left; hooked
@ right arm, infusing well.
G20.
- platelet count: 35.00
- WBC: 1.38
- Neutrophils: 21.00
- lymphocytes: 59.00
- monocytes: 20.00
- with initial vital signs:
T: 35.4°c
P: 90bpm
R: 27cpm
BP: 100/60mmHg
SPO2: 98% via room air
NURSING DIAGNOSIS
Risk for bleeding related to
low platelet count as
evidenced by 35.00 platelet
count as of 10/27/19
NURSING CARE PLAN
OBJECTIVES
Within 8hrs of nursing care,
the patient will be free of
signs of active bleeding.
INTERVENTIONS RATIONALE EVALUATION
 Monitor vital signs  For base line data After 8hrs of nursing care, the
 Regulate IVF  For continuity of care patient was free of signs of
 Provide bed side care  To provide comfort active bleeding.
 Assess client risk, noting  To identify contributing
possible medical risk factors
diagnosis or disease
processes that may lead
to bleeding
 Evaluate the client’s  To identify contributing
medication regimen risk factors
 Restrict activity that may  To prevent bleeding
cause bleeding
 Protect the client from  To prevent bleeding
trauma such as falls
 Use soft toothbrush for  To prevent bleeding
oral care
 Be prepare to administer  To prevent bleeding
hemostatic agent if
necessary
 Monitor hematology  To assess risk factors
laboratory results
 Provide dietary measures  To promote wellness
 Administer  To promote wellness
pharmaceutical
measures