CASE ANALYSIS

Unique Colleen S. De la Rosa

I. GENERAL DATA
Name: Enarciso, Alexander Lupiba
Address: Dagat-Dagatan, Caloocan City
Aged: 17 y/o
Birthday: June 20, 2000
Birthplace: Manila
Nationality: Filipino
Religion: Catholic
Date of Admission: July 02, 2017
Chief complaint: On and off fever, rashes and diarrhea
Admitting physician: Janet C. Perez, M.D.
Admitting diagnosis: Dengue with warning sign
II. BACKGROUND OF THE STUDY
DENGUE is an illness caused by a virus that is spread
through mosquito bites. Symptoms include fever, headache,
nausea, vomiting, rash, and pain in the eyes, joints, and
muscles.
III. HISTORY OF PRESENT ILLNESS
Patient with persisting symptom, patient decided to
sought consult at a hospital and UA and CBC were
requested which revealed dengue fever. It was then sent
home and advised to comeback for another laboratory. Few
hours PTA, patient was then advised to transfer to this
institution for proper management because of the
appearance of rash.

PAST MEDICAL: not pertinent medical hx. Patient is a

senior high school. Patient is a non-smoker and non
alcoholic beverage drinker.
IV. PHYSICAL EXAMINATION
Appearance: not in cardio respiratory distress.
Skin: warm to touch, good capillary refill
HEENT: Pink palpebral conjunctiva
Chest: Normal breath sounds, no retraction
Abdomen: no tenderness on light palpitation
Extremities: No gross deformity
V. LABORATORY
Result Normal Range Interpretation

WBC 2.63 4.8 10.8 bone marrow suppression is a

trademarks of dengue virus infection
in patients. The etiology remains
unclear but some research state data
that support the view that
intravenous infection of nonhuman
primate with DENV leads to direct
infection of the BM, which is likely to
Platelet 64.00 150 400
Count be a contributing factor for transient
cell suppression in the peripheral
blood characteristic of acute DENV
infection that leads to decreased
production of WBC and platelet of
the patient

Lymphocyte 51.90 19 48 Lymphocytosis happened to the

patient to dissipate fever.
VI. MEDICATIONS
Name of drug Action Indication Interpretation
Oresol Oresol may act as Oresol is oral Oresol was given to
an irritant to gastric rehydration my patient to
vagal receptors, and solution use to replace fluid
recruit efferent correct dehydration because my patient
parasympathetic caused by diarrhea experienced
reflexes that causes or correct fluid diarrhea and has a
glandular exocytosis imbalance in risk for fluid volume
of a less viscous dengue. deficit.
mucus mixture.
VII. NURSING CARE PROCESS
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: Impaired skin After the shift Emphasize To maintain Goal was met.
Ang dami ko integrity r/t the patient will importance good The patient
paring rashes at be able to of adequate general
makati. as
infection as was able to
demonstrate nutritional good health
verbalized by evidenced by behaviors/techn and fluid and skin
demonstrate
the patient. rashes iques to prevent intake. turgor. behaviors/
skin Suggest use To decrease technique to
Objective Data: breakdown. of ice, irritable prevent skin
- Rashes noted colloidal itching. breakdown.
on both arms, bath and To reduce
back and neck lotions. risk of
- With dry skin Recommend dermal
turgor keeping injury when
- Frequent nails short. serve itching
scratching Limit/Avoid is present.
- Disruption of use of Moisture
skin surface plastic potentiates
- WBC: 2.63 materials; skin
- Lymphocyte: Remove breakdown.
51.90 wet/wrinkle To prevent
d linens skin
promptly. irritation.
Instruct the
patient not
to use tight
clothing.