The Body Final | Coagulation | White Blood Cell

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I. INTRODUCTION Today, about 2.5 billion (2/5 of the world population) are at risk from dengue, and 50 million are infected worldwide annually, with a mortality rate ranging from 1 percent to 2.5 percent, for those who receive treatment, according to WHO statistics. For those without treatment, the death rate could be 20 percent (one in 5) or higher. In the Philippines there are many diseases illness arising because of environmental changes that may be caused by human activities and geographical conditions. It is considered as one of the tropical country and so disease can spread throughout the country. One example of these is disease is what we called Dengue Fever Dengue Fever is caused by one of the four closely related, but antigenically distinct, virus serotypes Dengue type 1, Dengue type 2, Dengue type 3, and Dengue type 4 of the genus Flavivirus and Chikungunya virus. Infection with one of these serotype provides immunity to only that serotype of life, to a person living in a Dengue-endemic area can have more than one Dengue infection during their lifetime. Dengue fever through the four different Dengue serotypes are maintained in the cycle which involves humans and Aedes aegypti or Aedes albopictus mosquito through the transmission of the viruses to humans by the bite of an infected mosquito. The mosquito becomes infected with the Dengue virus when it bites a person who has Dengue and after a week it can transmit the virus while biting a healthy person. Dengue cannot be transmitted or directly spread from person to person. Aedes aegypti is the most common aedes specie which is a domestic, day-biting mosquito that prefers to feed on humans. Here in the Philippines, the Department of Health reports that the incidence of dengue fever doubled in metro Manila during the first quarter of 2011. The Philippines have been a dengue fever hotspot for several years, but the latest statistics are alarming: 4,399 cases in 2011 versus 1,984 in 2010. This outbreak comes despite the distribution of over 700,000 mosquito trap kits in recent months. The Department of Health cited Manila’s Barangay San Miguel in Pasig City and Barangay Hen. T. de Leon in Valenzuela as particularly high risk areas. Mortality rates for DHF are usually less than 1% but can be as high as 5% if the disease. The Philippines Department of health is not treated in a timely manner has declared a dengue outbreak in Bantanes which is in North Central Luzon. The Red Cross is asking for blood donations. Those that are most ill sometimes require blood transfusions. Most do not need this but it can be a matter of life or death for some. This patient has caught my attention and has given the opportunity to study his case. The objective of this study is to help us understand the disease process of Dengue Fever and to orient myself for appropriate nursing interventions that I could offer to the patient. This approach enables me to exercise my duties as a student nurse which is to render care. I was given the chance to improve the quality of care I can offer and to pursue my chosen profession as a future nurse. I humble myself to present my studied case and submit myself for further corrections to widen the scope of my knowledge and understanding.

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II.GENERAL DATA PATIENT’S PROFILE

NAME AGE SEX HEIGHT WEIGHT ADDRESS Cebu CITIZENSHIP DATE OF BIRTH PLACE OF BIRTH RELIGION OCCUPATION MARITAL STATUS DATE OF ADMISSION TIME OF ADMISSION ROOM NO FINAL DIAGNOSIS ADMITTING PHYSICIAN

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R. A. G. 8 years old Male 130 cm 38.2 kg Umapad Mandaue, City Cebu / Tagbawan, Tabuelan

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Filipino September 06, 2002 Cebu City Roman Catholic None Married August 23, 2011 4:42 pm GP 4 Dengue Fever Dr. De La Calzada, Jo Janette Ressureccion Chong Hua Hospital

ADMITTING INSTITUTION:

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III. HEALTH ASSESSMENT A. HEALTH HISTORY A1. BIOLOGICAL DATA

NAME AGE SEX HEIGHT WEIGHT ADDRESS Tabuelan Cebu CITIZENSHIP DATE OF BIRTH PLACE OF BIRTH RELIGION OCCUPATION MARITAL STATUS DATE OF ADMISSION TIME OF ADMISSION ROOM NO FINAL DIAGNOSIS ADMITTING PHYSICIAN

: : : : : :

R. A. G. 8 years old Male 130 cm 38.2 kg Umapad Mandaue, City Cebu / Tagbawan,

: : : : : : : : : : :

Filipino September 06, 2002 Cebu City Roman Catholic None Married August 23, 2011 4:42 pm GP 4 Dengue Fever Dr. De La Calzada, Jo Janette Ressureccion Chong Hua Hospital

ADMITTING INSTITUTION:

4 PAST HEALTH HISTORY Patient had previous hospitalization at Vicente Sotto at year 2003 due to pneumonia and at year 2005 admitted at Chong Hua Hospital to Urinary Tract Infection and was discharged and improved. Pale.4 A. A.2 REASONS FOR SEEKING CONSULTATION Patient had high on and off fever and cough. weakness and chills noted. One of the patients uncle on the mother side died due to heart disease. A. dry and cracked lips.5 FAMILY HISTORY (Refer to Pediatric Assessment for Genogram) Based on our short interaction with the patient’s mother we found out that the patient’s grandfather on the father side died due to old age whiles his grandmother is asthmatic .On the mother side of the patient. With skin rashes noted. . Patient has decreased appetite and had a dry non-productive cough. A. The father of the patient is well and his sister is asthmatic.3 CURRENT HEALTH STATUS Patient’s health status is under treatment because of cough and high on and off fever with the evidenced of warm to touch. Two of the patients siblings are well and the other one is allergy to seafoods. his grandparents is both hypertensive so as the patient’s mother.

In school. When he was hospitalized he was restricted to eat chocolates or any choco colored foods. There are also presence of dental carries. . he had completed all his immunization except hep B vaccine. he joined activities like academic competitions. Health Perception-Health Management Pattern The patient's mother perceives the health of his son as a state of excellence because they give much importance and value on the health of their family. And following therapeutic regimen per doctors ordered. Elimination Pattern There were no problems or complaints with urinating. However. According to his mother. A. and its transparency is clear. and semisolid in characteristics. But during the year of 2005 he was diagnosed with urinary tract infection and was improved. G. Activity-Exercise Pattern The patient usually play with his neighbor such as running and sometimes biking after taking his nap in the afternoon and that is what his mother considered as his exercise. He was able to had bowel movement every day. But his not allowed to play much and do strenuous activities because the patient is asthmatic. 2. And he had no problem with the frequency of his bowel. brown colored stool. dancing competition. Every time the patient will have cough and colds they immediately seek for the health care professionals..6 GORDONS FUNCTIONAL HEALTH PATTERN Data for R. According to his mother she always gave him vitamin supplements (Celine and Clusivol) everyday. 3. It is light yellow in color. organized according to: 1. Often. Usually upon waking up he immediately go to our computer and played with it. He was able to void 5 – 6 times during our 8 hours shift. His mother always prepares milk every morning. and boys scouts. Nutritional/Metabolic Pattern Patient loves eating pork and apple every after meals. Patient also had poor appetite due to illnesses felt. in this time there’s a disturbances in his daily activities. His favorite food to eat during lunch and dinner is ―Linatang Baboy‖. experienced constipation during elimination.5 A. No assistive devices used when hospitalized. 4.

During hospitalization the patient cannot sleep well due to the blood extraction for CBC monitoring. No deficits of any sensory perception. 11. He uses 1 pillow and doesn’t have any problems when sleeping. Sleep-Rest Patterns According to the patient’s mother.They also taught the patient to be courteous to the elderly . He can able to read and write.6 5. . Coping-Stress Management Tolerance According to the patient’s mother the patient usually go to his room and wants to talked to his father in abroad when scolded. Role-Relationship Pattern Since the patient is still eight years old his only role is as a son and a student . Sexuality/Reproductive Not applicable 10. 9.They offer mass most of the times . Self-perception Pattern N/A 8. responsive and coherent.The patient prays before he sleeps and prays every morning after he wakes up. 6.In simple things his parents will let him decide on what things he prefer. Cognitive-Perceptual Pattern Patient was able to ambulate. Value/Belief The patient’s parents said that ever since the patient was still young they already taught the patient how to pray . 7. the patient usually sleeps at 8pm and wakes up at 6:30 am during school days and about 11 am during weekends.

G. A. 2002 Birth Rank Place of Delivery √ Hospital Attendant Midwife Gestation √ Full term Mode of Delivery √ NSVD Presenting Part √ Cephalic Medications √ Eye Prophylaxis III. POST-NATAL HISTORY √ Breastmilk √ None Sepsis Milk Formula Respiratory Seizure Mixed Cyanosis Jaundice Feeding: Medical Problems: . Date of Birth: September 16. I. 2002 Sex: Male PRENATAL HISTORY ( of mother ) Obstetric Score G 4 √ Regular Irregular √ Obstetrician Nurse √ Hospital Clinic √ None Fever GDM Asthma UTI TB Allergy Hyperemesis T 4 P 0 A 0 L 4 M 0 None √ Hilot √ RHU Home Rash Heart Disease √ Hepatitis PIH Maternal Age 38 years old Prenatal Check-up: Done By: Place: Maternal Illness: Medication ( mother ) Iron supplements and vitamins for pregnant women II. B Date of Birth September 06. NATAL HISTORY 5/5 Apgar Score 9.7 PEDIATRIC ASSESSMENT ( 1 month to 12 years ) Name of Patient: R.10 Home Lying –in Hilot Others Preterm Post term Forceps C/S(indication) Face Breech Transverse √ Vitamin K Hep.

FEEDING HISTORY √ 6 months Breastfeed Breastfeed √ Milk Formula Mixed Milk Formula Mixed Type Cereals or Blinded Vegetables Allergies When started Duration Since his 6 months 0 – 6 months 6 – 12 months Age semisolid started Food Preference: Food Dislikes Vitamin Supplements: Type Vitamin C Amount VI. IMMUNIZATION 1st dose √ √ √ √ √ No 2nd dose √ √ √ Yes 3rd dose √ √ √ at: √ Center 1st booster √ Private 2nd booster Both None BCG DPT OPV Hib Hep B Pneumoccocal Rotavirus Flu Varicella AMV MMR Others: Typhoid Hep. PAST MEDICAL / SURGICAL HISTORY Unremarkable √ Remarkable If Remarkable : Date Diagnosis Intervention Hospitalization ( including operation ) Date 2003 2005 Hospital VSMMC CHONG HUA HOSPITAL Diagnosis Pneumonia Urinary Tract Infection .8 IV.A Meningoccocal HPV √ √ V.

FAMILY HISTORY No significance FH √ HPN disease √ Blood Disorder Allergy TB Seizure Others : . c. GROWTH AND DEVELOPMENT Sat alone First raised head Rolled over Pulled up Walked with help Walked alone Talked Urinary Incontinence: Day Control of feces Comparison of development with that of other siblings School Grade Quality of work Night IX. e. Kidney Disease Cancer Stroke Mental Disorder Diabetes √ √ Significance FH Asthma √ Heart .9 VII. f. BEHAVIORAL HISTORY Does the child manifest behavior like thumb sucking Masturbation Temper Tantrums Negativism Does the child have sleep disturbances? √ Yes Phobias Pica ( ingestion of substances other than foods ) Abnormal Bowel Habits ( stool holding ) Bedwetting √ No b. a. . VIII. d.

FAMILY HISTORY ( insert the Genogram ) MOTHER’S SIDE MOTHER’S SIDE FATHER’S SIDE HPN HPN OLD AGE AST M HEART DISEASE HPN WELL WELL WELL AST WELL ALLERGY WELL DENGUE FEEVER LEGENDS: M = Deceased female due to hypertension and old age =Living Female with hypertension =Deceased male due to hypertension =Living Male with allergy ==Living male with asthma =Living female with asthma =Deceased male due to heart disease =Living male well =Living female well =Points to the patient .10 X.

Roman Catholic was admitted due to on and off fever and cough. EYES: Have the child’s eyes ever been crossed-eyed? Any foreign body? Any infection? EARS / NOSE AND THROAT √ Frequent Colds Sore throat Sneezing Stuffy nose Discharges Post-natal drip √ Mouth breathing Snoring Otitis Media Hearing Problem TEETH: Age of eruption of deciduous teeth Age of eruption of permanent teeth CARDIORESPIRATORY: Dyspnea Chest pain √ Cough Sputum Wheeze Expectoration Cyanosis √ Edema Syncope Tachycardia GASTROINTESTINAL: Vomiting Diarrhea Constipation √ Abdominal pain / discomfort Jaundice Type of stool GENITIURINARY: Enuresis Dysuria Frequency √ Polyurea Pyuria Hematuria Vaginal discharges Abnormal penis / testes Character of stream (urine) Bladder control NEUROMUSCULAR: √ Headache √ Nervousness Dizziness √ Tingling sentation Convulsions Spasm Ataxia Muscle or joint pains Postural Deformities Exercise tolerance ENDOCRINE Disturbance of growth Excessive fluid intake Polyphagia Goiter GENERAL Unusual weight loss Fatigue Temperature sensitivity Color brown C. male. Cebu / Tigbawan. G. F. . E. I. J. SKIN: Texture rough and slightly dry B. 8 years old. 3 days prior to admission. X. With a temperature of (39. CHIEF COMPLAINTS ( History of Present Illness ) Mr. Tabuelan Cebu. H. REVIEW OF SYSTEMS A. from Umapad Mandaue City. D. patient had onset of fever and cough. I.decreased appetite with the presence of skin rashes.11 X.2⁰c) and associated with non-productive cough.

with PNSS 1L at 190 – 195 cc/hr.2 kg HT. HEAD / EARS / NECK / THROAT HEAD Circumference: . Patient has slightly rounded body with no tenderness and pain felt. Patient is pale. VITAL SIGNS BP 120/80mmHg HR 131 bpm RR 20 cpm TEMP. person oriented. GENERAL OBSERVATION Receive patient lying on bed. with dry and cracked lips. SKIN: Color: Texture : Turgor: Lesions: √ √ √ √ Normal Cyanotic Normal Dry Good Poor None Rashes Punctured wound Pale Icteric Oily Burns Scars Flushed Ashen Abrasions Decubitus Lacerations 4. Date of Birth: September 06. With skin rashes noted. 2002 1. Patient is warm to touch. awake. A. With birth rank 5/5. G. Patient has decreased appetite.cm (up to 2 years and if significant ) Irregular Seborrhea Scales Lice FONTANELS: Anterior: Posterior: √ √ Close Close Open Open Flat Flat Sunken Sunken Bulging Bulging .nonproductive cough. 2. 130 cm 2. had onset of fever associated with dry . 39. SHAPE: SCALP: √ √ Round Normal Ovoid Pustule . at left arm.2⁰c WT. place. weak and chills noted. conscious.12 PEDIATRIC PHYSICAL EXAMINATION Name of Patient: R. 32. coherent with time.

aid R √ L √ R √ L √ √ √ 7. EYES Eyelids Laceration Inflamed Mass Puffy Drooping Sclerae Normal Icteric Red Discharges √ √ R √ L √ Eyeballs Normal Sunken Bulging Pupils Reactive Unreactive Equal Unequal Vision Normal Blurred Contact Lens With correctional glasses R √ L √ Comments: 6.13 5. EARS Pinna Normal Anomalies Symmetrical Tympanic Membrane Intact Perforated Discharge Mastoid Tenderness Swelling Comments: R √ L √ External Canal No Problem Discharge Pain Hearing Normal Deaf With hearing . NOSE / NECK / THYROID Nares No problem Nasal flaring Discharge Epistaxis Turbinates Normal Inflamed / Congested √ √ R √ L √ .

Shortening Thyroid a.Tender Sternocleidomastoid a.Inability to support head Lymph Nodes a.Swelling b.Swelling b.Not appreciated Comments: √ √ 8.Toticollis c. MOUTH / THROAT Lips: √ Teeth: Temporary Complete No problem Discoloration Gums: √ Tongue: √ Mucosa: √ Normal Bleeding Tonsils: √ Smell: √ Voice: Hoarseness Type of cry Comments: Stridor Grunting Type of speech Normal Foul Not assessed Normal Inflamed Exudates Thrush Discharge Ulcers Pink Coated Furrows Strawberry red Normal Inflamed Number √ √ Permanent Incomplete Braces Notching No teeth Caries Mottling Malocclusion / malalignment Pink Thin Red Pale Downturning Cyanotic Fissures √ Dry Moist Cleft Swelling .14 Neck a.Enlarged g.Nodules e.Contour c.Tenderness f.Normal b.Size b.Opistothonus d.Bruits d.

GASTROINTESTINAL Abdomen: Inspection: Percussion: Palpation: Tenderness: Bowel Sounds: Rectal Exam: Comments: √ √ √ √ Flat Scaphoid Distended Tympanitic Dull Fluid Wave Normal Splenomegaly Mass Hepatomegaly Liver edge Location Direct Normal Hyperactive Hypoactive Globular . RESPIRATORY THORAX Upper Airway: √ Normal Stridor Hoarseness Drooping of Secretions Chest / Upper Trunk: √ Normal Scars Expansion: √ Retractions: Lungs: √ Kyphosis Abrasions Equal Absent Scoliosis Rash Unequal Present Mass Normal Resonant Clear breath sounds Ronchi Normal for age Assymetrical Tenderness Tympanic Rales Wheeze √ Crepitations Dullness Flatness Breast: Symmetrical Lumps / masses Comments: 10.15 9. CARDIOVASCULAR Apical impulse: Pulses: Heart Sound: Rate: Location 4th Strong √ Normal √ Regular √ Normal >2 √ Precordial Bulging Weak Murmurs Tachycardia Heaves Irregular Regular Splitting Irregular Bradycardia Capillary Refill time: Comments: 11.

agitated. infant moves spontaneously or purposefully Localizes pain. Pediatric Glasgow Scale (Teasdale & bennel) Eye Opening Opens eyes spontaneously Opens eyes response to speech Opens eyes in response to painful stimuli Does not open eyes Verbal Response Smiles. moaning Incomprehensible. Oriented to sound. follow. NEUROLOGIC A. cries No verbal response Motor Response Obeys. consolable crying. oriented. consolable crying. Infant withdraws from touch Infant withdraws from pain. persistently irritable. inappropriate actions Inappropriate.16 12. follow odject. GENITOURINARY √ Genitals: MALES: Circumcised: Tanner Staging: √ Yes No Tanner Score: Normal √ Normal Mass Discharges Tenderness (location) Anomaly 13. inconsistently consolable Score 4 3 2 1 5 4 3 2 1 6 5 4 3 √ √ √ . restless. vocal sound. interacts Confused. interact Abnormal flexion to pain in infants (decorticated response).

inconsolable. IV. Trochlear.12 months = 11 (E4 V3 M4) 5 years = 14 (E4 V5 M5)  1 – 2 years = 12 (E4 V4 M4)  2 – 5 years = 13 (E4 V4 M5)  15 B. X (Glossopharyngeal) Gag reflex: CN XI (Spinal Accessory) Shrug shoulder: CN XII (Hypoglossal) Tongue at rest: Not Able Deviated Deviated Not done R R L L . irritable. CRANIAL NERVES: CN I (Olfactory) CN II (Optic) √ √ Intact Intact Anosmia Blindness Hyperosmia Scotoma Not Done Dislopia CN III. restless No motor response Aggregate Score (Normal)  0 – 6 months = 9 (E4 V2 M3) 2 1  6 . Abducens) PUPILS: √ Reactive Non-reactive EOM: √ Full ROM Palsy CN V (Trigeminal) Corneal Reflex CN VII (Facial) √ Trismus Present √ √ √ √ √ √ √ √ √ Paresthesia Absent Symmetric Intact Strong Normal Normal Present Able to Swallow Able Midline Midline √ Equal Ptosis Intact Right Assymetric Absent Weak Deafness Disequilibrium Absent Not done Non-equal Left Facial Symmetry: Tongue (sensory): Facial Muscle: CN VIII (Vestibulo-cochlear) Hearing: Balance: CN IX. XI (Oculomotor. MENTAL STATUS: √ Awake Stupurous Disoriented √ Conscious Coma √ Drowsy Oriented C.17 crying Extension to pain (decerebrate response).

hyperactive +3 – Brisker than average +2 – Average. MOTOR R 5 5 5 5 5 5 L 5 5 5 5 5 5 Manual Scoring 5 – Normal 4 – Can raise against slight resistance 3 – Can raise against gravity 2 – Gross movements but not against gravity 1 – Flicker of movements 0 – No movements Upper Extremity Proximal Distal Lower Extremity Proximal Distal 14. CEREBELLAR: FTNT: APST: Well-coordinated Well-coordinated Ataxia Romberg’s: Positive √ √ Not coordinated Not coordinated Nystagmus Negative Not done Not done Not done E. normal +1 – Somewhat diminished 0 – No response < (+) Babinski > (+)Babinski . REFLEXES Deep Tendon Reflexes +4 – Very brisk.18 D. SENSORY: Light touch Pain Temperature √ √ √ Intact Intact Intact Absent Absent Absent Not done Not done Not done F.

19 Meningeal Signs: Primitive Reflex: √ None NA Nuchal Rigidity Kernig’s Brudzinki’s Present Moro Rooting Sucking Grasp Absent √ √ Tonic Neck Babinski Ankle Clonus Present Absent √ √ 15. MUSCULOSKELETAL √ Normal Fractures Deformities Tenderness Swelling Comments: .

Blood is a type of connective tissue. ANATOMY AND PHYSIOLOGY BLOOD Blood is considered the essence of life because the uncontrolled loss of it can result to death.20 IV. The cells and cell fragments are formed elements and the liquid is plasma. Blood makes about 8% of total weight of the body. nutrients. and hormones >involve in regulation of homeostasis and the maintenance of PH. waste products. Functions of Blood: >transports gases. and electrolyte levels >protects against diseases and blood loss . fluid balance. body temperature. consisting of cells and cell fragments surrounded by a liquid matrix which circulates through the heart and blood vessels.

ions. Fibrinogen Produced by liver. lipids and fat-soluble vitamins. Albumins Smallest and most numerous plasma proteins.21 PLASMA Plasma is a pale yellow fluid that accounts for over half of the total blood volume. intestines. Normally. water intake through the GIT closely matches water loss through the kidneys. Alpha and beta globulins transport iron. produced by liver. and immune tissues as spleen. . kidneys. It consists of 92% water and 8% suspended or dissolved substances such as proteins. nutrients. Function as transport proteins for several steroid hormones and for fatty acids. absorbs. lungs. which helps maintain water balance between blood and tissues and regulates blood volume. Proteins (7.5%) Liquid portion of blood. GIT and skin. endocrine glands. transports and releases heat. BLOOD COMPONENTS SUBSTANCE IN BLOOD PLASMA Constituent Description Water (91. Antibodies help attack viruses and bacteria. Acts as solvent and suspending medium for components of blood. The suspended and dissolved substances come from the liver. waste products. Play essential role in blood clotting. which develop from B lymphocytes. and regulatory substances. Plasma volume remains relatively constant.0%) Exert colloid osmotic pressure. gases. Globulins Produced by liver and by plasma cells.

and strong oxidants. Natural killer cells attack a wide variety of infectious microbes and certain spontaneously arising tumor cells.000 Most live for a few hours to a few days Neutrophils Eosinophils Basophils Lymphocytes 43% .4 million/µL (F) WBC 4. without a nucleus. defensis. Phagocytosis. . cancer cells and transplanted tissue cells. and destroy certain parasitic worms. biconcave disks.500 – cells/µL Characteristics 7-8µm diameter. large cytoplasmic granules appear deep blue-purple 20% . large lymphocytes are 10 – 14µm in diameter. live for about 120 days 11. hydrogen chloride. large red-orange granules fill the cytoplasm 0% .6 – 6. the larger the cell. Combat pathogens and other substances that enter the body. nucleus has 2-5 lobes connected by thin strands of chromatin. such as superoxide anion. T cells attach invading viruses. cytoplasm form a rim around the nucleus that looks sky blue. the more cytoplasm is visible Function Hemoglobin within RBCs transports most of the oxygen and part of the carbon dioxide in the blood.73% of all 10 – 12µm WBCs diameter.2 million/µL (M) 4.1% of all 8 – 10µm WBCs diameter. which secrete antibodies. nucleus has 2 lobs. Mediate immune responses. Liberate heparin.40% of all Small lymphocytes WBCs are 6 – 9µm in diameter. phagocytize antigen-antibody complexes. nucleus has 2-3 lobes. pale lilac granules 0% . histamine and serotonin in allergic reactions that intensify the overall inflammatory response. B cells develop into plasma cells. nucleus is round or slightly indented.22 FORMED ELEMENTS IN BLOOD Name Number RBC 4. including antigen-antibody reactions.2 – 5. cytoplasm has fine.4% of all 10 – 12µm WBCs diameter. Destruction of bacteria with lysozyme. and hypochlorite anion Combat the effects of histamine in allergic reactions.

After the initial clotting factors are activated. When a blood vessel is severely damaged. A clot is a network of threadlike protein fibers called fibrin. death can occur. the clotting factors are activated to produce a clot. Prothrombin is converted to its active form called thrombin. fibrin. Prothrombin activator acts on an inactive clotting factor called prothrombin. If large amounts of blood are lost. . Form platelet plug in hemostasis.000 2 – 4µm diameter cells/µL cell fragments that live for 7 – 10 days.23 Monocytes platelets 2% . Following injury however. A series of reactions results in which each clotting factor activates the next clotting factor in the series until the clotting factor prothrombin activator is formed. Small amounts of blood from the body can be tolerated but new blood must be produced to replace the loss blood. the contact of inactive clotting factors with exposed connective tissue can result in their activation.8% of all 12 – 20µm WBCs diameter. The formation of a blood clot depends on a number of proteins found within plasma called clotting factors. nucleus is kidneyshaped or horseshoe shaped. they in turn activate other clotting factors. This is a complex process involving chemical reactions. Thrombin converts the inactive clotting factor fibrinogen into its active form. BLOOD CLOTTING Platelet plugs alone are not sufficient to close large tears or cults in blood vessels. blood can leak into other tissues and interfere with the normal tissue function or blood can be lost from the body. which traps blood cells. Normally the clotting factors are inactive and do not cause clotting. Chemicals released from injured tissues can also cause activation of clotting factors. but it can be summarized in 3 main stages. blood clotting or coagulation results in the formation of a clot. contain many vesicles but no nucleus Phagocytosis (after transforming into fixed or wandering macrophages). cytoplasm is bluegray and has foamy appearance 150. platelets and fluids. PREVENTING BLOOD LOSS When a blood vessel is damaged. the chemical reactions can be stated in two ways: just as with platelets. releases chemicals that promote vascular spasm and blood clotting.000 – 450. The fibrin threads form a network which traps blood cells and platelets and forms the clots.

or tissue plasminogen activator released from surrounding tissues. which is plasma without its clotting factors. is squeezed out of the clot during clot retraction. CLOT RETRACTION AND DISSOLUTION After a clot has formed. the stimulation for activating clotting factors is very strong. it begins to condense into a denser compact structure by a process known as clot retraction.24 CONTROL OF CLOT FORMATION Without control. which is called plasmin. stimulate the conversion of plasminogen to plasmin. helping the stop of the flow of blood. Normally there are enough anticoagulants in the blood to prevent clot formation. The clot is dissolved by a process called fibrinolysis. the blood contains several anticoagulants which prevent clotting factors from forming clots. Consolidation of the clot pulls the edges of the damaged vessels together. The damaged vessel is repaired by the movement of fibroblasts into damaged wound divide and fill in the torn area. So many clotting factors are activated that the anticoagulants no longer can prevent a clot from forming. Thrombin and other clotting factors activated during clot formation. Serum. reducing the probability of infection and enhancing healing. An inactive plasma protein called plasminogen is converted to its active form. however. To prevent unwanted clotting. Over a period of a few days the plasmin slowly breaks down the fibrin. . At the injury site. clotting would spread from the point of its initiation throughout the entire circulatory system.

25 V. bite host (developed pre-existing antibody) ↓ Extrinsic incubation viral replication of 8-12 days ↓ Some host bitten by new heterologous vector which has the virus (risk for DHF) ↓ Recognizes infection and forms antigen-antibody complex ↓ Bound and internalized by immuno-globulin receptors ↓ Virus has not been neutralized ↓ Viruses replicates inside the macrophages → Develops infection → (Antibody dependent ↓ viscosity of blood Enhancement) ↓ ↓ platelet→ rash ↓ Leukocytes and macrophages . CONCEPTUAL FRAMEWORK OF DENGUE FEVER PATHOPHYSIOLOGY Reservoir ↓ Mosquito (Aeges Aegypti) → Mosquito remains affected for 15-65 days ↓ First.

26      Fever (5-7 days) Chills Facial flushing Headache Nausea and vomiting ↓ ↓ vascular permeability → Bleeding Alteration of GI ↓ ↓ motility Hypovolemia Melena occur ↓ Shock (DengueShockSyndrome) ↓ Lead to Hepatomegaly ↓ DEATH     .

an infected mosquito is capable. with or without petichial hemorrhage but epidemiologically related to typical cases usually discovered in the course of invest or typical cases GRADING THE SEVERITY OF DENGUE FEVER: Grade 1: >fever >non-specific constitutional symptoms such as anorexia. After virus incubation of 8-10 days. shock and terminating in recovery or death 2. during probing and blood feeding of transmitting the virus to susceptible individuals for the rest of its life.27 VI. Infected female mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs) transmission. Moderate >with high fever but less hemorrhage. frank type >flushing. The virus circulates in the blood of infected humans for two to seven days. no shock present 3. vomiting and abdominal pain >absence of spontaneous bleeding >positive tourniquet test Grade 2: >signs and symptoms of Grade 1: plus >presence of spontaneous bleeding: mucocutaneous. sudden high fever. gastrointestinal . followed by sudden drop of temperature. THEORETICAL FRAMEWORK OF THE PATHOPHYSIOLOGY OF DENGUE FEVER Dengue viruses are transmitted to humans through the infective bites of female Aedes mosquito. severe hemorrhage. Dengue cannot be transmitted through person to person mode. Aedes mosquito may have acquired the virus when they fed on an individual during this period. Mosquitoes generally acquire virus while feeding on the blood of an infected person. Humans are the main amplifying host of the virus. CLASSIFICATION: 1. at approximately the same time as they have fever. Mild >with slight fever. Severe.

pulse less and arterial blood Pressure = 1 mmhg (Dengue Syndrome/DS) SUSCEPTABILITY. RESISTANCE. narrowing of pulse pressure to 20 mmhg or less. declared shock. AND OCCURRENCE: >all persons are susceptible >both sexes are equally affected >age groups predominantly affected are the pre-school age and school age >adults and infants are not exempted >peak age affected: 5-9 years old .28 Grade 3: >signs and symptoms of Grade 2 with more severe bleeding: plus >evidence of circulatory failure: cold. cold extremities. mental confusion Grade 4: >signs and symptoms of Grade 3. clammy skin. massive bleeding. weak to compressible pulses. irritability.

29 VII.03 negative negative negative Reference Range negative negative negative up to 2 negative negative negative negative * Unit mg/dL mg/dL mg/dL mg/dL wbc/µL mg/dL mg/dL mg/dL . CLINICAL MANAGEMENT A.035 - Unit Chemical Characteristics Protein Glucose Ketone Urobilinogen Leukocytes Blood Bilirubin Nitrite Ascorbic Acid Result negative negative negative normal negative 0.0 1. 2011 06:35:49 Fully Automated Routine Urinalysis Uncentrifuged Specimen Physical Characteristics Color Transparency pH Specific Gravity Results Yellow Clear 6. MEDICAL MANAGEMENT A.015 Reference Range 5–6 1.1 LABORATORY AND DIAGNOSTIC EXAMINATION URINALYSIS REPORT Date and Time Requested: August 23.003 – 1.2011 06:30:09 Date and Time Performed: August 23.

3 12.2-11.0 130-400 Unit 10^3/µL 10^3µL g/dL 10^3/µL 10^/ µL Blood Indices MCV MCH MCHC RDW PDW MPV Results 79.30 Microscopic Findings RBC WBC Bacteria IMPLICATION: Results 3 1 1 Reference Range 1-16 1-8 * Unit /µL /µL /µL The urinalysis result was specific gravity of urine.1 14.8 Reference Range 80-94 27.2 16.0 33.57-6.8 4.0↓ 26.3↓ 33. 2011 07:50:09 Complete Blood Count WBC RBC Hemoglobin Hematocrit Platelet Results 5.0-37.0 11-16 9.60 5.0-14.1 Unit Fl Pg g/dL % % fL .2 110↓ Reference Range 4.47 14.8-10. 2011 07:40:03 Date and Time Performed: August 23.0-52.0 42. No marked decrease or increase in the HEMATOLOGY Date and Time Requested: August 23.8↑ 8. normal.0-18.0 7.4 43.0-31.

0 0.0 0.16-1. 2011 08:55:10 Dengue NS1 Antigen NS1 Antigen Ig M Antibody Ig G Antibody IMPLICATION: Results positive negative negative There was a positive NS1 indicating that the patient is confirm that he has a Dengue Fever.0↑ 10. SEROLOGY TEST Date and Time Requested: August 24.00 0.04 Reference Range 40-74 19-48 3.0-0.20 0.9-5.5 Reference Range 1.2 0.31 Relative Differential Count Neutrophil% Lymphocyte % Monocyte % Eosinophil% Basophil% Absolute Differential Count Neutrophils (#) Lymphocytes (#) Monocyte (#) Eosinophils (#) Basophils (#) IMPLICATIONS: Results 80.9-8.4-9. 2011 08:45:29 Date and Time Performed: August 24.56↓ 0.31 0. .0-1.1↓ 5.6 0.5 3.7 Results 4.2 % % % % % Unit Unit 10^3/µL 10^3/µL 10^3/µL 10^3/µL 10^3/µL There was a decrease in platelet because the virus creates antibodies that will kill the own antibodies of the body that will fight for foreign bodies leading to bleeding.0-7.0 0.8 0.47 0.0-0.

The patient should have about two tablespoons of this juice every day. Vital Signs are being monitored every hour to check for any deviations or unusualities. is a test panel requested by a doctor or other medical professional that gives information about the cells in a patient's blood.    . It helps in digestion. Give porridge and baked toasts. Some useful pointers to keep in mind when preparing a meal for someone suffering from dengue are:  Give the patient fresh orange juice frequently. The tea should be herbal made with ginger. before antibodies appear some 5 or more days later.    A. cardamom. is a test for dengue made by Bio-Rad Laboratories and Pasteur Institute.32 A. increases urinary output.3 MEDICATIONS (Refer to APPENDIX D) A. full name is Platelia Dengue NS1 Ag assay. Because these foods can alter the color of the stools and can lead to a misinterpretation of internal bleeding.Increased fluid intake. This is a very good home remedy for the treatment of dengue fever. introduced in 2006. It allows rapid detection on the first day of fever.is an array of tests performed on urine and one of the most common methods of medical diagnosis. crush them and squeeze them to extract the juice. Patient’s urine output was also monitored hourly and collected thru a container for she cannot go to the comfort room by himself.NS1 antigen test . and promotes antibodies for faster recover. SEROLOGY TEST (Dengue NS1 Antigen) .4 DIET o The food you should give to a dengue patient should be such that it can be easily digested. and other such fever-reducing herbs. CBC . Avoid choco colored foods like: chocolates or any dark colored foods.also known as full blood count (FBC) or full blood exam (FBE) or blood panel. Orange juice is packed with energy and vitamins. Biscuits with tea can also be given.2 TREATMENT AND PROCEDURES  Patient underwent Tepid Sponge Bath to reduce the body temperature in to normal range. URINALYSIS . Take two fresh papaya leaves.

NURSING MANAGEMENT B. I also conclude that every individual is highly susceptible to this disease if and when they will not take such precautionary measures (e. and other resources. dengue fever can be a source of significant morbidity and mortality if not recognized early. . Our body will not develop immunity even the person already experienced the diseased because there are different types of dengue.33 B.g. I have ascertained that this disease is increasing the incidence within the country.2 DISCHARGE PLAN (Refer to APPENDIX C) XII. CONCLUSION After obtaining all the data from the patient. Such definite differentiation is especially important in countries with adequate sanitation measures. CONCLUSIONS AND RECOMMENDATIONS A.1 NURSING CARE PLAN (Refer to APPENDIX B) B. book references. make sure that the environment is free from stagnant waters were the mosquito lives which will not lead it to complication. left stagnant water outside the house were the Aedes can live ). Most forms respond appropriately to medical therapy. The only thing we have to do is to clean the environment. where the predominant organism identified from morphologic blood examination will be Aedes Aegypti.

accompanied by research and consistent readings . This study accentuates the worth and meaning of the hypothesis in giving best possible care. With respect to myself recommendation. and to engage in this kind of study is one way of reaching for that objective. It will help develop an in-depth knowledge on a particular case. mainly because we have only a few health workers available who are willing and able to do that mission of spreading the necessary information.34 B. RECOMMENDATIONS It is common knowledge that only a few of these information about optimal care have reached all throughout the country. IMPLICATIONS OF THE STUDY TO: A. especially those non-affiliated ones. NURSING EDUCATION Development of nursing profession is an essential goal of nursing education. X. That information would not even reach the outskirts of the different communities. I would make every effort to continue this pursuit in order to broaden my knowledge base. Nursing education is not only confined and restricted within the four walls of the classroom but goes beyond. This only shows that nurse’s are not just doctor’s collaborators but also bearers of vital information. whether it is in hospitals. and a broad and sound knowledge base that will contribute to the competency of a nurse. and to be an efficient nurse in the future to be able to muddle through with the ever mounting role of the nurse. educators and epitome of classic example individuals. a community and like settings. I recommend to the student nurse as one of the heralds of health facts and data to disseminate to individuals about the importance of always practicing a healthy life with regards to the food that we eat and the source of water that we drink.

It is when you know that this study is geared towards the optimal care for clients who have this particular case. and proven care is a requisite without any exceptions. . reflective and questioning and within this mind. Moreover. NURSING RESEARCH Research is very imperative for all those health workers involved in rendering optimum care to patients. C. NURSING PRACTICE Nurses need to have good objective skills. constructive data on the provision of care for individuals who have Dengue Fever. the trends in nursing are ever changing constantly. With this endeavor. and one of the ways of keeping track to these necessary information is to read persistently and do research. which is turn contributed to our efficacy. students and patients may acquire sufficient insight on taking care of themselves to the optimum level.35 B. because employment of most selected. Doing a case study contributed much to nursing education as it widens our knowledge base and apply them to appropriate situations. It will not only be beneficial for the patients but also for the health care workers as well as so far as scientific based care is concerned. This study serves as a reference guide as it provides well-searched. they need to be purposeful. precise. Knowledge that is gained through practice is shared to inspire and sustain needed changes. evidence based nursing should always maintain a balance between research on a clinical subject and information that has been gained from the patient.

Patient is pale. Patient has slightly rounded body with no tenderness and pain felt. With skin rashes noted. Cebu / Tigbawan. : GP4 PHYSICIAN : Dr. 3 days PTA. . G. at left arm. Patient has decreased appetite. conscious. Upon Physical Assessment. patient had onset of on and off fever and cough. place. With birth rank 5/5. A. AGE : 8 years old IMPRESSION : On and Off Fever and Cough DIAGNOSIS : Dengue Fever CLINICAL PORTRAIT I. decreased appetite with the presence of skin rashes. Tabuelan Cebu. male. ASSSESSMENT Receive patient lying on bed.36 NURSING CARE PLAN PATIENT : R. NO. coherent with time.nonproductive cough. With a temperature of ( 39. Patient’s VITAL SIGNS were as follows: Temperature : 38.2⁰c ) and associated with dry non – productive cough. CHIEF COMPLAINT On and off fever and cough. HISTORY OF PRESENT ILLNESS Mr. Patient is warm to touch. cough. De La Calzada NURSE’S SIGNATURE: PERTINENT DATA I. weak and chills noted. II. person oriented. Roamn Catholic was admitted due to fever (on and off fever ). with PNSS 1L at 190 – 195 cc/hr. awake. HOSP. had onset of fever associated with dry .3⁰c Pulse Rate : 64 bpm Respiratory Rate: 44 cpm Blood Pressure : 120/80 mmHg II.8 years old. : 080022480504 ROOM NO. . A. R. from Umapad Madue City. G. with dry and cracked lips.

2011 06:30:09 Date and Time Performed: August 23. RAW PROBLEM III. Risk for fall Patient had previous hospitalization at Vicente Sotto at year 2003 due to pneumonia and at year 2005 admitted at Chong Hua Hospital to Urinary Tract Infection and was discharged and improved. Ineffective airway clearance d. Hyperthermia b.2⁰c Pulse Rate : 131 bpm Respiratory Rate: 20 cpm Blood Pressure : 120/60 mmHg V. VITAL SIGNS TAKING UPON ADMISSSION Temperature : 39. Risk for bleeding c. PAST MEDICAL HISTORY a. Risk for fluid volume imbalance e. LABORATORY FINDINGS URINALYSIS REPORT Date and Time Requested: August 23.37 III. 2011 06:35:49 . IV.

035 - Unit Result negative negative negative normal negative 0.38 Fully Automated Routine Urinalysis Uncentrifuged Specimen Physical Characteristics Color Transparency pH Specific Gravity Chemical Characteristics Protein Glucose Ketone Urobilinogen Leukocytes Blood Bilirubin Nitrite Ascorbic Acid Results Yellow Clear 6.0 1.015 Reference Range 5–6 1.003 – 1.03 negative negative negative Reference Range Negative Negative Negative up to 2 Negative Negative Negative Negative * Unit mg/dL mg/dL mg/dL mg/dL wbc/µL mg/dL mg/dL mg/dL Microscopic Results Reference Unit Findings Range RBC 3 1-16 /µL WBC 1 1-8 /µL Bacteria 1 * /µL IMPLICATION: The urinalysis result was normal. . No marked decrease or increase in the specific gravity of urine.

39

HEMATOLOGY

Date and Time Requested: August 23, 2011 07:40:03 Date and Time Performed: August 23, 2011 07:50:09

Complete Blood Count WBC RBC Hemoglobin Hematocrit Platelet Blood Indices MCV MCH MCHC RDW PDW MPV Relative Differential Count Neutrophil% Lymphocyte % Monocyte % Eosinophil% Basophil%

Results 5.60 5.47 14.4 43.2 415↑ Results 79.0↓ 26.3↓ 33.3 12.2 16.8↑ 8.8 Results 80.0↑ 10.1↓ 5.5 3.6 0.7

Reference Range 4.8-10.8 4.57-6.1 14.0-18.0 42.0-52.0 130-400 Reference Range 80-94 27.0-31.0 33.0-37.0 11-16 9.0-14.0 7.2-11.1 Reference Range 40-74 19-48 3.4-9.0 0.0-7.0 0.0-1.5

Unit 10^3/µL 10^3µL g/dL 10^3/µL 10^/ µL Unit Fl Pg g/dL % % fL Unit

% % % % %

40

Absolute Differential Count Neutrophils (#) Lymphocytes (#) Monocyte (#) Eosinophils (#) Basophils (#) IMPLICATION: There was

Results

Reference Range 1.9-8.0 0.9-5.2 0.16-1.00 0.0-0.8 0.0-0.2

Unit

4.47 0.56↓ 0.31 0.20 0.04

10^3/µL 10^3/µL 10^3/µL 10^3/µL 10^3/µL

a increase in platelet because the virus creates antibodies that will kill the own antibodies of the body that will fight for foreign bodies leading to bleeding.

SEROLOGY TEST

Date and Time Requested: August 24, 2011 08:45:29 Date and Time Performed: August 24, 2011 08:55:10

Dengue NS1 Antigen Results NS1 Antigen Positive Ig M Antibody Negative Ig G Antibody Negative IMPLICATION: There was a positive NS1 indicating that the patient is confirm that he has a Dengue Fever.

41

CUES/ EVIDENCES

NURSING DIAGNOSIS

SCIENTIFIC BASIS

GOALS AND OUTCOME CRITERIA

NURSING ACTIONS AND NURSING ORDERS Perform nursing care and procedures to demonstrate temperature within normal range. INDEPENDENT:  Perform tepid Sponge Bath to the patient.  Maintain bed rest.

RATIONALE OF NURSING ORDERS

EVALUATION

SUBJECTIVE: ―Naghilanat na pud lagi ni siya dai oi. Nawala naman unta ni unya ni balik naman pud. Ganina 37⁰c ra ta karon ni 38⁰c na.‖ ―Ana man ang Doctor dai pagpermiro na basin dili dengue ky iya permirong platelet 130 man daw mao g.obserbahan lang usa siya, niya pag.untro niyang kuha sa dugo para test if dengue ba daw siya kay ni positive man.Mao ni karon sige pa taas iya hilanat.‖ As verbalized by the mother of the patient.

Hyperthermia related to infection secondary to dengue fever

Elevated body temperature (hyperthermia) is common with infection and raised the patient’s metabolic rate and oxygen consumption. Fever is one of the Body’s normal mechanism for fighting infection. Therefore, elevated tempareatures may not be treated unless they reach dangerous levels (more than 40⁰c [140⁰f] or unless the patient is uncomfortable. ( Brunner and

After 8 hours of varied nursing intervention, patient will be able to: 1. Maintain core temperature within normal range 2. Demonstrate behavior to monitor and promote normothermia.

GOAL WAS MET: Patient’s temperature decreases from 38.3⁰c to 37.8⁰c  To promote normothermia or to promote core cooling.  To reduce metabolic demands / oxygen consumption.  To prevent dehydration.

Specifically patient will: a. Initiates ways to promote normothermia. b. Demonstrate ways or appropriate intervention that

 Instruct the significant others to increase fluid intake of the patient.  Monitor use of hypothermia blanket and wrap the extremities

 To allow minimize shivering.

 Monitor temperature of the patient.42 ― Na.a pa jud siya ubo karon dai‖ as verbalized by the mother Suddarth’s MS. c. © 2010 p.  Monitor patients status or vital signs following the order of the physician.  Pallor noted  Headache is present/felt  Chills noted  Skin rashes noted will decreased temperature.  To maintain electrolyte and fluid balance of the body. 331) OBJECTIVE:  Weakness noted.  Paracetamol will decrease the temperature from high to low. .  Dry and cracked lips  Warm to touch. DEPENDENT:  Administer paracetamol as ordered by the physician.  To follow an intravenous fluid as ordered by the doctor. with bath towels.  To provide appropriate care and needed for the patient. Establish motivation or behavior that will promote normal body temperature. 10th ed.  To know if the patient temperature is increasing or decreasing.

7th edition.  Administer antipyretics with physicians ordered.  Used to reduce temperature. (NCP guidelines. Doenges.3⁰c PR : 64 bpm RR : 44 cpm BP : 120/80 mmHg COLLABORATIVE:  Provide highcalorie diet.43 VITAL SIGNS: Temp. tube feeding or parenteral nutrition.  To meet increase metabolic demands.: 38.2006) .

GOAL WAS MET: The client was able to demonstrate behaviors that reduce the risk for bleeding. with severe headache. Check for secretions.  The G. ecchymosis. This infectious disease is manifested by a sudden onset of fever. INDEPENDENT:  Assess for signs and symptoms of G.44 CUES/ EVIDENCES NURSING DIAGNOSIS SCIENTIFIC BASIS GOALS AND OUTCOME CRITERIA NURSING ACTIONS AND NURSING ORDERS Perform nursing care and procedures to demonstrate behaviors that reduce the risk for bleeding. There may also be gastritis and some times bleeding. .  Observe for presence of petechiae. RATIONALE OF NURSING ORDERS EVALUATION Injury. patient will be able to: 1. Observe color and consistency of stools or vomitus. bleeding from one more sites.I bleeding. risk for hemorrhage related to altered clotting factor.Verbalize the sign and symptoms of bleeding. muscle and joint pains (myalgias and arthralgias— severe pain gives it the name breakbone fever or bonecrusher disease) and rashes and usually appears first on the lower limbs and the chest. 2.Understand what are the possible sign and symptoms of bleeding.  Sub-acute disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors.Demonstrate behaviors that reduce the risk for bleeding. Specifically patient will: a. After 8 hours of varied nursing intervention.I tract (esophagus and rectum) is the most usual source of bleeding of its mucosal fragility.

and forceful nose blowing.  Rectal and esophageal vessels are most vulnerable to rupture.45 ( Brunner and Suddarth’s MS. Blood pressure. avoiding straining for stool.  Monitor pulse.  An increase in pulse with decreased Blood pressure can indicate loss of circulating blood volume. . © 2010 ) b. hypoxemia. Establish motivation or behavior that will prevent the bleeding. c. Demonstrate ways or appropriate techniques in stopping the bleeding.  Note changes in mentation and level of consciousness  Avoid rectal temperature.  Changes may indicate cerebral perfusion secondary to hypovolemia. DEPENDENT:  Encourage use of soft toothbrush.  In the presence of clotting factor disturbances. 10th ed. minimal trauma can cause mucosal bleeding. be gentle with GI tube insertions.

 Minimizes damage to tissues. COLLABORATIVE:  Monitor Hb and Hct and clotting factors. reducing risk for bleeding and hematoma. Apply pressure to venipuncture sites for longer than usual. potentiating risk of hemorrhage.12th ed. active bleeding.  Indicators of anemia. or impending complications. (Brunner and Suddarth’s.46  Use small needles for injections.) .  Recommend avoidance of aspirin containing products.  Prolongs coagulation. MSN.

bronchioles) is produced by specialized airway epithelial cells (goblet cells) and submucosal glands. Demonstrate effective exercise when coughing and lungs are clear during auscultation.  Note chest movement. b.. RATIONALE OF NURSING ORDERS EVALUATION Ineffective airway clearance related to increase production of bronchial secretions secondary to fluid shifthing.  Crackles indicate accumulation of secretions Specifically patient will: a. Demonstrate the intervention that reduces the secretions. and allergens. used of accessory muscles during respiration.  Auscultate breath sounds. Sustain respiratory rate within norm al range. 2. Nasal mucus is produced by the nasal mucosa. noted areas with presence of . Small particles such as dust. may occur in response to ineffective ventilation. patient will be able to: 1. GOAL WAS MET: At the end of the shift the client was able to breathe properly without using his accessory muscles. as well as infectious agents such as After 8 hours of varied nursing intervention. particulate pollutants. Display decreasing amount of secretions. and mucal tissues lining the airways (trachea. bronchus. Achieve and improve the airway clearance.  Provides a basis for evaluating adequate ventilation. INDEPENDENT:  Assess the respiratory rate.47 CUES/ EVIDENCES NURSING DIAGNOSIS SCIENTIFIC BASIS GOALS AND OUTCOME CRITERIA NURSING ACTIONS AND NURSING ORDERS Perform nursing care and procedures to achieve the clear airways in breathing.  Used of accessory muscles of respiration.

DEPENDENT:  Administer medications as indicated: bronchodilators  To stimulate the sections that helps the patients breath properly. damaged of airway mucusa. Initiate ways that will clear the patency of breathing.  Maintained patient on moderate high back rest  Positioning helps maximize lung expansion. This event along with the continual movement of the respiratory mucus layer toward the oropharynx.48 bacteria are caught in the viscous nasal or airway mucus and prevented from entering the system. c. and inability to clear the airway. helps prevent foreign objects from entering the lungs during breathing.  Expectorations may be different when secretions are very thick. .  Suction as per physicians order.  Documented respiratory secretions: character and amount of sputum. Increased mucus production in the respiratory tract is a symptom of many common illnesses. such as the common adventitious sounds.  To reduce hazards of hypoxia.

but increased quantities can impede comfortable breathing and must be cleared by blowing the nose or expectorating phlegm from the throat. COLLABORATIVE:  .  Some institution the nurses collaborate with the respiratory therapist in giving nebulizres to the patient.Administer nebulizer to the patient done by the respiratory therapist. and impaired cilia action. asthma.49 cold and influenza. . Hypersecretion of mucus can occur in inflammatory respiratory diseases such as respiratory allergies.The presence of mucus in the nose and throat is normal. and chronic bronchitis.

50 DISCHARGE PLAN Patient’s Name: R. how. adverse effects of the medication. A. De La Calzada PATIENT’S OUTCOME CRITERIA As soon as the patient is discharged from the hospital. PLANNING  Plan for scheduled visits as ordered by the physician.: GP4 Physician: Dr. B. He and her significant others will be able to: NURSING ORDER A. Age: 8 years old Impression/Diagnosis: Dengue Fever Nurse’s Name & Signature: Hospital No. IMPLEMENTATION MEDICATION  Comply the medication completely and the timing of the medication. Take vitamin supplements as ordered by the physician. ASSESSMENT  Assess for the temperature of the patient. what to take the medications.  Advice the significant others to remind the patient for the set schedule for visiting the clinic.  Inform the patient. significant others on when.: 080022480504 Room No. significant others about the side effects. C.  Advice the significant other to monitor the temperature and if it will reach >40⁰c refer to the physician.  Make a plan of schedule when the patient and the physician is available.  Instruct the patient.  Encourage the patient to follow the schedule ordered by the physician for the next visit. . G.

 Encourage the patient to have adequate rest and sleep. OUT – PATIENT REFERRALS  Refer also to other facilities and physicians. TREATMENT  Administration of medication should follow the proper schedule and should be prescribed by the physician. whole wheat bread. DIET  Plan for a good meal of a lactating women. EXERCISES / ENVIRONMENT  Provide the patient room that is not to cold or to warm for the patient. HEALTH TEACHINGS  Encourage the patient to practice proper hygiene and handwashing. peanut butter.  Advice the significant others to always be reminded of the medication and the dose.  Advice the significant others to turn off the air condition if there room is air conditioned.  Inform the significant others of the signs and symptoms of the disease persist return immediately to the Physician. pasta.  Encourage the patient to increase electrolyte and fluid intake.  Advice the significant others to follow the referrals for the continuity of care. . the proper  Advice the patient and the significant others to rest and sleep uninterrupted of sufficient duration. chocolate nuts spread. Never miss a dose. such as cereals.  Instruct the patient to increase fluid intake.  Demonstrate to the patient techniques on handwashing.51  Explain to the patient the significant of the medication and its purpose.  Instruct the significant others to prepare high calorie foods for the patient.  Instruct the mother about the vitamins correct dosage and it should be given once daily.

 Encourage the patient and the significant others to ask questions that they do not know or understand. if not clearly understood.52 SPIRITUAL  Have a positive outlook in life. . D.  Encourage the patient to seek for spiritual guidance.  Explain again to the patient the different plans and interventions.  Encourage to be motivated. EVALUATION  Understand the treatment and regimen as well as planned actions.

nausea and vomiting. (Jones & Bartlett 10th ed. Impression/Diagnosis: Dengue Fever Allergy to: Sea foods Generic/Brand Name & Classification Generic: Paracetamol Dose.53 UNIVERSITY OF CEBU COLLEGE OF NURSING DRUG STUDY Patient: R. dizziness. onset of hepatotoxicity Nursing Responsibilities Before  Perform a baseline assessment. lethargy. De La Calzada Indication/Mecha nism of Drug Action Indications: Temporary relief of pain and discomfort of headache. A. Rationale Client Teaching  Monitor for I/O and vital signs on the patient  Report promptly for any side effects  Avoid form overdose  Do not give with pain more than 3days. Ordered: 500mg/tab 1 tab every 4hours fro temp. (Jones & Bartlett 10th ed. chills.: GP4 Attending Physician(s): Dr.. perhaps by action on peripheral  Assess if patients has any drug allergies. Anorexia. cold or flu Adverse/Side Effects Drug Interaction Acute poisoning. diarrhea. Diaphoresis..621)  To establish proper precautionary measures.1hour Duration: 4hours  To monitor the condition of the patient.621 Mechanism of Action: Produces analgesia by unknown mechanism. Strength & Formulation Age: 8 years old Hospital No.: 080022480504 Room No. . epigastric or abdominal pain.>38ºC Brand: Timing: Tylenol PRN Classification: Analgesic nonopoid and antipyretics Duration: Peak Levels: 2hours Onset: 30 mins. G. fever.p.p.

Reduce fever by direct action on hypothalamus.regulating center with consequent peripheral vasodilation.p. During  Do not overdose the medication  Monitor for any side effects  Monitor for any signs of liver dysfunction Monitor for the urine output  For it can cause liver damage  To know for any signs of hypersensitivity  To monitor for hepatotoxicity and to monitor for renal failure After  Assess regularly patient for signs of increasing temperature  To prevent complications and to provide appropriate intervention. acetaminophen has little effect of platelet aggregation does not affect bleeding time and generally produces no gastric bleeding. sweating and dissipation of heat unlike aspirin.. (Jones & Bartlett 10th ed. heat.621) .54 Other forms: Tablets Syrup nervous system.

(Jones and  If symptoms Bartlett 10th persist more Ed) than 1 week. malaise. recur or are accompanied by a persistent headache.  To have a fever change good baseline in secretions . Short-term (up to 7 days) treatment of all grades of erosive esophagitis.V. switch to PO lansoprazole formulations. Nursing Responsibilities Before  Check the V/S of the patient Rationale Client Teaching Ordered: Give 5 mg by P. De La Calzada Indication/Mecha nism of Drug Action Indications: I. agitation.: GP4 Attending Physician(s): Dr. Impression/Diagnosis: Dengue Fever Allergy to: Sea foods Generic/Brand Name & Classification Generic: Salbutamol Guaifenesin Dose.55 UNIVERSITY OF CEBU COLLEGE OF NURSING DRUG STUDY Patient: R. dizziness. N&V diarrhea. A.D Duration: Classification Expectorant Other forms: Granules: Drug is gastric acid pump inhibitor in that it blocks the final 7 days Mechanism of Action: During  Be alert for adverse  Take only as directed and  To examine do not exceed the prescribed characteristics dose. dry mouth CNS: Headache. Adverse/Side Effects Drug Interaction Adverse Reactions: Most Common: Diarrhea. tablets with in relation to full glass of the medication water. given. Take of the sputum. constipation. rash GI: Constipation. bezoar.O Timing: Brand: Ventolin 3x a day / T. abdominal pain.anxiety. N&V.I. amnesia .: 080022480504 Room No. Then. G. headache. Strength & Formulation Age: 8 years old Hospital No.

(Jones and Bartlett 10th Ed. GU: Abnormal menses.) or lack of response  Report any evidence of increased bruising After  Assess patient’s and family’s knowledg e of drug therapy. apathy CV: Angina.) . dysuria. 100mg/pack Oral liquid: 100mg/5mL Tablets: 200mg. gynecomastia. electrolytes.56 50mg/packet.  To be able to know the possible effects of the drugs.K+)ATPase system located at the secretory surface of the parietal cells in the stomach. 400mg Syrup: 100mg/5mL step of acid production.  Monitor CBC. dysmenorrhea. Suppresses gastric of acid secrection by inhibition of the (H+. and side effects or signs and symptoms of the medication. reactions and drug interactions. Hypotension. renal and LFT’s data in assessment findings.  To assess clients condition. triglycerides. breastenlargement s.hypertensi on. ( Jones and Bartlett 10th Ed.

malaise.V: Prevent paclitaxel hypersensitivity. G. abdominal pain. Nursing Responsibilities Before  List reasons for therapy.57 UNIVERSITY OF CEBU COLLEGE OF NURSING DRUG STUDY Patient: R.)  To assess clients condition and fot the baby in the womb  Take as directed with or immediately following meals. onset. Strength & Formulation Age: 8 years old Hospital No.5-3hrs Classification: Histamine H2. dizziness or drowsiness may occur  Determine of pregnant . N&V diarrhea. Receptor blocking Other forms: Capsules: 150mg. De La Calzada Indication/Mecha nism of Drug Action Indications: I. diarrhea. CNS: Headache. dizziness. abdominal pain. reduce the incidence of GI hemorrhage associated with stress-related ulcers Adverse/Side Effects Drug Interaction Adverse Reactions: Most Common: Headache. 300mg Mechanism of Action: Competitively inhibits gastric acid secretion by blocking the GI: Constipation. A. vertigo. Impression/Diagnosis: Dengue Fever Allergy to: Sea foods Generic/Brand Name & Classification Generic: Ranitidine HCL Dose. (Jones and Bartlett 10th Ed.: GP4 Attending Physician(s): Dr.  Do not drive or operate machinery until drug effects are realized. triggers.: 080022480504 Room No. duration. CV:  To indicate baseline data and monitor drug’s effectiveness. insomnia. characteristics of S&S Rationale Client Teaching Ordered: Give 25 mg IV push Timing: Brand: Ulcin Every 8 hrs Duration: 2.

renal. LFTs.)  Skin test using allergens may elicit false negative results. Assess for infection  To avoid further complications. Premature ventricular beats following rapid I. (Jones and Bartlett 10th Ed. B12 . and beverages that contain caffeine  Do not smoke. stop drug 24-72 hr prior to testing  To check if the client is allergic to the drug or not.V use (Jones and Bartlett 10th Ed. 300mg effects of histamine on histamine H2 receptors. tachycardia. (Jones and Bartlett 10th Ed. aspririncontaning products. Both daytime and nocturnal basal gastric acid secretion. as well as food-and pentagastrinstimulated gastric acid are inhibited.)  Be alert for adverse reactions and drug  To establish proper precautionary measures and management for possible adverse effects of the drug . Bradycardia.)  Avoid alcohol. interference with healing and drugs’ During  Monitor CBC.58 Injection: 1mg/mL Oral Solution: 15mg/mL Syrup: 15mg/mL Tablets: 150mg.

 To check the effectively of the drugs.59 After  Monitor / check the vital signs of the patient.) . (Jones and Bartlett 10th Ed.

: GP4 Age: 8 years old Status: Child TYPE OF SOLUTION Plain Normal Saline Solution CLASSIFICATION Isotonic CONTENT MECHANISM OF ACTION An isotonic that expands the extra cellular fluid (ECF) volume. diabetic ketoacidosis.60 IVF STUDY Patient’s Name: R. resuscitative efforts. b. d. . G.2010) Doctor: Dr. Hypercalcemia And mild Sodium deficit. used in hypovolemic states. A. Room / Bed no. Signs of infiltration / sluggish flow. c. Used in blood transfusions. Sign of phlebitis / infection. Dwell time of catheter and replacement. hyponatremia. shock. Each 100mL contains 900 mg of Sodium Chloride For replacement or maintenance of fliud and electrolytes. Condition of catheter dressing. (Brunner and Suddarth. burn victims. 2011 Hospital no: 080022480504 Diet: No choco colored food INDICATIONS CONTRAIN DICATIONS None HOW SUPPLIED 1000 mL DOSE 65 – 70 cc/hr NURSING RESPOSIBILIT Y  Monitor patient closely for: a. De La Calzada Date of Admission: August 28.

 Change the IVF solution if needed and prescribed . medication and volume.61  Check the level of IVF.  Correct solution.  Check the correct flow rte of the IVF.

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