CASE PRESENTATION

DENGUE HEMORRHAGIC FEVER

WITH
SEVERE WARNING SIGNS

PREPARED BY:GROUP 1
ARNOLD CABALLERO
EDNAH CAYETANO
PRECIOUS CALLADO
MARKEY GUTIERREZ
JUDY MAURRERA
JHOLLIE TICMAN
 CHAPTER 1
 DIAGNOSIS
 Dengue Hemorrhagic Fever with severe
warning signs.

 HISTORY OF PRESENT ILLNESS:

 3 days prior to confinement
 patient was suffering moderate grade of fever
(38.8ºc) not relieved by 6mL paracetamol
syrup 250mg/ml and TSB.
 2 days prior to confinement they consulted a
physician.
 The diagnosis was UTI and they were
prescribed an antibiotic 6mL CEFUROXIME
250mg/5mL TID and 6mL PARACETAMOL
SYRUP 250mg/ml every 4 hours

 On the day of confinement

 At ER the patient complained epigastric pain
while patient passes 3x black watery stool(as
verbalized of patient's mother) and High grade
fever of 39.7ºC . (+) result of Dengue NS1
and was encouraged to be confine at
 Hospital for close monitoring.
 PAST MEDICAL HISTORY
 The patient was no history of confinement
and she completed her immunization,
however she still acquired common
childhood illnesses such as; measles,
chicken pox but in minimal manifestation
and shortened prognosis.
 No known Allergies.
 HISTORY OF FAMILIAL DISEASE

 LEGEND
 MALE
 FEMALE
 NO HEREDITARY DISEASE AS FAR AS
 PATIENT'S MOTHER CAN RECALL.
 PHYSICAL ASSESSMENT

MEASUREMENT (September 11, 2015)

 VITAL SIGNS
TIME TEMP PR/CR RR BP O2 SAT.
8AM 36.70C 61 bpm 37 cpm 90/70 88
12PM 36.40C 67 bpm 40 cpm 100/80 99

 WEIGHT: 30 Kgs.
 HEIGHT: 4ft.
 GENERAL APPEARANCE
 The child is conscious but looks weak,
restless, irritable and with poor appetite.
Difficulty of breathing was prominent as nasal
flaring and use of accessory muscle is noted.
Her body weight and height are appropriate
for her age. She has a fair skin complexion,
dry, and extremeties are cold to touch. Her
fingernails and toenails are intact and well-
trimmed. Dress appropriately on the condition
of her room. Upon examination, the child is
connected to oxygen inhalation at 2 Lpm via
nasal cannula, with foley catheter connected
to urine bag and with veroclysis gauge 24 at
both feet.
 Body Part Normal Findings Actual Findings Interpretation
Examined /Analysis

SKULL
Size, shape Normo- The child’s skull
and cephalic: is rounded; Normal
symmetry rounded, symmetrical with
smooth skull frontal, parietal
contour and occipital
prominence's.
Smooth skull
contour
Nodules, Non tender, Upon palpation, Normal
depressions no nodules, there is no any
and no masses tenderness,
tenderness and no masses and
depression depressions
note
 Body Part Normal Findings Actual Findings Interpretation
Examined /Analysis

HAIR Scalp is The child’s Normal

AND whiter than hair color is
SCALP the facial black with thin
skin, strands. Her
odorless, hair is evenly
absence of distributed.
dandruff and No lesions
lesion and dandruffs
black in color, presence.
evenly Scalp is
distributed, whiter than
thick hair, the facial
silky and skin.
resilient,
absence of
infestations
Body Part Examined Normal Findings Actual Findings Interpretation
/Analysis

NAIL AND
SKIN
Color of skin, Skin varies Child’s skin Normal
skin integrity, from light to color is light
texture, deep brown; brown Abnormal
lesions, Dryness of
mobility and Skin is Skin is dry the skin
turgor smooth and Rashes suggests poor
even pinpoint at nutrition,
lower skin excessive
extremeties bathing or an
(+) itchiness endocrine
disorder.
Body Part Normal Findings Actual Findings Interpretation
Examined /Analysis
Pruritus is one
manifestation of
dengue
Veroclysis at Typically as a result
Left and right of accumulation of
hand is swollen. fluid.
Hematoma at Injury or trauma to
both hands and blood vessels. This
feet can happen as a
result of any
damage to blood
vessels that can
disrupt the integrity
of the blood vessel
wall.
Color of nail The child’s Normal
is pink, clean, fingernails and
and shape is toenails are
 Body Part Normal Findings Actual Findings Interpretation
Examined /Analysis

Capillary refill Pink tone Pink tone does Abnormal

Prolonged capillary
returns not return refill time may be a
immediately to immediately to sign of shock and
blanched blanched can also indicate
dehydration and
nailbeds (< 2 nailbeds (< 4 decreased
seconds) seconds) peripheral perfusion.

Severe form of
plasma leakage
 Body Part Normal Findings Actual Findings Interpretation
Examined /Analysis
FACE .

color of the
skin, symmetry, Uniform color, The child’s face Normal
texture, palpebral is round; color
shape/contour fissures equal of skin is even
and facial on size, and smooth.
movements symmetrical The facial
nasolabial movements are
folds, smooth, symmetric.
rounded and
symmetrical
facial features
 Body Part Normal Findings Actual Findings Interpretation
Examined /Analysis

EYES

Eyeballs, Iris Eyes blink Her eyes blink Normal

and Pupil involuntarily at involuntarily at
the same time. the same time.
Eyeballs are Her eyeballs
symmetrically are
aligned. Pupil symmetrically
is dark brown aligned. Her
or black. Iris pupil is dark
and pupil are brown. Her iris
round and the and pupil is
pupil is equal in round and the
size with a pupil is equal in
diameter of 2-3 size with a
mm. diameter of 2-3
mm.
 Body Part Normal Findings Actual Findings Interpretation
Examined /Analysis

EAR
Color, position and Color same as facial Both ears have the Normal
symmetry of auricles skin, symmetrical, same color with the
ang aligned with facial skin,
outer canthus of eye symmetrical and
aligned with the outer
canthus of the eye.
There are no
Small amount of presence of any odor,
Cerumen, skin cerumen, no skin pus, blood and lesion
lesions, pus and lesions, pus and but there is a little Normal
blood in the external blood amount of cerumen in
ear canal her ears.
 Body Part Normal Findings Actual Findings Interpretation
Examined. /Analysis

NOSE
Shape, size, Symmetric and The child’s Normal
color and flaring straight, no nose is
or discharges discharges or symmetrical,
from of external flaring and uniform in color
nose uniform color and discharge
Abnormal
Nasal Flaring is Nasal flaring is
noted. a sign of
difficulty of
breathing
THROAT and Dry lips may
ORAL CAVITY
indicate mouth
Color, moisture, The child’s lips
texture and lesions of Uniform pink breathing or
appear dry,
the lips and buccal color, soft, DHN.
mucosa symmetric in
smooth, contour
symmetry of
contour
 Body Part Normal Findings Actual Findings Interpretation
Examined /Analysis

Inspect the Complete With complete Dental carries

teeth and gums Clean, white set of teeth, suggest poor
for condition, teeth with no with dental oral hygiene.
number , color, dental carries carries on
presence of lower molars
dental caries,
odor and
texture of gums
Inspect tonsils Uniform pink Tonsillo- Is usually the
and oropharynx color, soft, pharyngeal result of a viral
for color, size, smooth, congestion. infection, such
discharges and symmetrical as common
gag reflex with no signs of cold; Irritants
infection. including
 Body Part Normal Findings Actual Findings Interpretation
Examined /Analysis

smoke, dust,
fumes, very hot
foods and
drinks,
abrasions,
tooth and gum
infections can
also cause
throat
congestion

NECK
Neck muscles for No swellings, no No swellings, no
swelling or masses, Normal
masses, coordinated masses, coordinated
head movement and head movement and head movement and
muscle strength equal muscle equal muscle
strength strength
 Body Part Normal Findings Actual Findings Interpretation
Examined /Analysis

BREAST and
AXILLAE
Masses, No masses, No masses, Normal
tenderness, tenderness, tenderness,
discharge from discharge discharge
nipples
PULMONARY

Temperature and
integrity of skin, Skin intact, Chest Normal
areas of tenderness, uniform expansion is
bulges, abnormal
movements and temperature, symmetrical.
chest excursion no masses, No retractions.
chest excursion Skin is intact,
is full and uniform in
symmetrical temperature
and no
masses.
 Body Part Normal Findings Actual Findings Interpretation
Examined /Analysis

Difficulty of Excessive
breathing is accumulation of
noted fluid – Pleural
effusion.

Breath sounds Vesicular and There is Crackles

broncho- presence of indicate
vesicular crackles when excessive fluid
sounds auscultated in the airways.

CARDIO-
VASCULAR
Aortic, pulmonic, No visible pulsations, Weak distal pulse, thready pulse occurs
tricuspid, motral and No lift and no heaves bradycardia because the blood is
epigastric area for Symmetrical pulse
pulsations volumes, full
pulsations
 Body Part Normal Findings Actual Findings Interpretation
Examined /Analysis

being shunted
away from the
peripheral
vasculature to
maintain
perfusion of
vital organs
(brain, heart,
lungs)

GASTRO-
INTESTINAL
Skin integrity Uniform skin, Normal
Uniform skin, unblemished skin
unblemished skin
Increased As more
Shape of the Flat or rounded Abdominal girth
abdomen
Body Part Examined Normal Findings Actual Findings Interpretation
/Analysis
Sept 10 - 25 cm fluid
Sept 11 – 26.5 cm
accumulates,
increased
abdominal girth
and size are
commonly seen.
Detect areas of Non tender, Soft to touch; Amino acid
tenderness and relaxed Abdominal Pain metablosim
muscle guarding abdomen with increases which
smooth causes
consistent abdominal pain.
tension It can also be a
manifestation in
dengue.
GENITO-
URINARY
Uniform, Uniform skin, Normal
Skin Integrity
unblemished unblemished
skin skin
 Body Part Normal Findings Actual Findings Interpretation
Examined /Analysis
Urine output – Voiding freely, No urine output As the body
amount, color, clear, with for 5 hours begins to shunt
consistency atleast 30cc/hr 9/11 – with foley
blood to the
UO catheter heart, lung, and
connected to brain, it
urine bag. decreases blood
flow to the
kidneys causing
poor renal
perfusion and
decreased
Urinary output.
Stool - amount, Soft, brown with 3x watery stool, Can be a sign of
color, regular bowel black in color as internal
character, elimation pattern verbalized by bleeding;
consistency mother upon
admission
 Body Part Normal Findings Actual Findings Interpretation
Examined /Analysis
manifestation of
dengue
hemorrhagic
fever
UPPER AND No deformities, Cool to touch This is also the
normal contour, extremeties.
LOWER symmetrical and non result of blood
EXTREMITIES tender shunting; blood
is shunted away
From the skin
leading too poor
perfusion and
cool, clammy
extremities.
LABORATORY PROCEDURES
 Date : September 7, 2015
EXAM NORMAL ACTUAL SIGNIFICANCE
VALUES FINDINGS
CBC Hgb 120-160 126 Normal
Hct .37-.47 .38 Normal
RBC 4.2 – 5.4 4.2 Normal
WBC 5.0 -10.0 6.5 Normal
PC 150-400 288 Normal
Segmenters .40 - .60 .75 Increased due
to infections, it
attacks and kill
infections
Lymphocytes .20 - .40 .22 Normal
Eosinophils .01 - .06 .03 Normal
Urinalysis Normal Findings Actual Findings Analysis
Color Normal urine is a transparent Yellow Normal
solution from colorless to amber
but is usually a pale yellow
Transparency The turbidity of the urine sample Slightly cloudy Normal
varies from clear, slightly cloudy,
cloudy and opaque. Normally,
fresh urine is slightly cloudy.
Specific Gravity Normal urine density or values 1.010 Normal
vary between 1.003- 1.035
Protein (-) (-) Normal
Sugar (-) (-) Normal
Pus cells 3-5 hpf
RBC 30-35 hpf
Epithelial Rare rare Possible
contamination of
specimen

Mucus threads Rare few

Bacteria Rare few
 Date : September 8, 2015
EXAM NORMAL ACTUAL SIGNIFICANCE
VALUES FINDINGS

CBC Hgb 120-160 131 Normal

Hct .37-.47 .40 Normal
RBC 4.2 – 5.4 4.3 Normal
WBC 5.0 -10.0 2.5 Decrease due to
inadequate inflammatory
response defense to
suppress infection and
anti-body mediated
immunity takes place.
PC 150-400 198 Normal
Differential Segmenters .40 - .60 .74 Increased due to
count infections, it attacks and
kill infections
Lymphocytes .20 - .40 .26 Normal
Eosinophils .01 - .06 -
 DENGUE NS1
Examination Dengue NS1 SIGNIFICANCE
Specimen Blood
Dengue NS1: Positive (+) Dengue NS1 an antigen
tests (NS1 stands for
nonstructural protein 1), full
name is Platella Dengue
NS1 Ag assay, is a test for
dengue. It allows rapid
detection on the first day of
fever, before antibodies
appear some 5 or more
days later.

IgG Positive (+) Had a previous Infection

IgM Positive (+) Current infection

 Dengue fever testing is used to determine whether
a person with symptoms and recent potential
exposure to dengue has been infected. The
infection is difficult to diagnose without laboratory
tests because symptoms may initially resemble
other diseases, such as malaria.
 Antibody tests—these tests are primarily used to
help diagnose a current or recent infection. They
detect two different classes of antibodies
produced by the body in response to a dengue
fever infection, IgG and IgM.
  IgM antibodies are produced first and tests for
these are most effective when performed at
least 7-10 days after exposure.
 IgG antibodies are produced more slowly in
response to an infection. Typically, the level
rises with an acute infection, stabilizes, and
then persists long-term.
 Molecular testing (polymerase chain
reaction, PCR)—this type of test detects the
genetic material of the dengue virus in blood
up to 5 days after symptom onset (fever).
Hematology Normal Values 09/10/15 09/11/15
Report
AM PM AM PM
HGB 123-153 145 152 152 160
HCT .36-.44 .40 .42 .42 .44
RBC 4.70-5.40 5.27 5.60 5.59 5.86
MCH 23-29 27.5 27.5 27.2 27.3
MCHC 31-35 36.3 36.5 36.5 36.2
MCV 76.0-89.0 75.7 75.4 74.6 75.4
WBC 4.40-11.0 2.4 6.3 5.9 6.5
PC 150-450 62 52 40 38
NEUTROPHILS 50-70 57 35 36 45
LYMPHOCYTES 20-40 41 61 59 48
MONOCYTES 0-7 2 3 4 7
EOSINOPHILS 0-5 0 1 1 0
BASOPHILS 0 0 0 0 0
 Hematology Normal Values 09/12/15 09/13/15 09/14/15 09/15/15 09/20/15
Report

HGB 123-153 130 127 127 124 121

HCT .36-.44 .36 .33 .33 .34 .35
RBC 4.70-5.40 4.73 4.44 4.63 4.53 4.32
MCH 23-29 27.5 27.5 27.4 27.4 27.8
MCHC 31-35 36.6 36.5 36.7 36.5 36.2
MCV 76.0-89.0 75.1 75.2 74.7 75.1 75.5
WBC 4.40-11.0 7.8 6.3 5.7 6.4 5.5
PC 150-450 66 82 134 160 333
NEUTROPHILS 50-70 46 59 64 64 31
LYMPHOCYTES 20-40 46 36 32 32 61
MONOCYTES 0-7 8 4 3 3 5
EOSINOPHILS 0-5 0 1 1 1 3
BASOPHILS 0 0 0 0 0 0
 PT, APTT
Protime NORMAL VALUES 09/10/2015 09/12/2015

Patient Value 11.0-14.0 20.4 secs 18.3 secs

Ctrl Value 11.9-16.1 13.3 secs 13.3 secs

% Activity 70-100% 38.0% 46.10%

APTT
Patient Value 28.0-38.0 58.5 secs 45.2 secs
Ctrl Value 27.0-37.0 31.85 secs 35.2 secs
 SGPT/ALT, SGOT/AST
CLINICAL NORMAL VALUES ACTUAL INTERPRETATION
CHEMISTRY FINDINGS
SGPT/ALT 10.0-35.0 60.98(H)

SGOT/AST 10.0-35.0 48.33(H)

 The precise levels of these enzymes do not

correlate well with the extent of liver damage
or the prognosis. Thus, the exact levels of AST
(SGOT) and ALT (SGPT) cannot be used to
determine the degree of liver disease or
predict the future. For example, patients with
acute viral hepatitis may develop very high
AST and ALT levels (sometimes in the
thousands of units/liter range).
PHYSIOLOGY OF RELATED BODY
SYSTEM
CIRCULATORY SYSTEM
 The circulatory system in humans is
a network of blood vessels through which the
heart pumps the blood and keeps the blood in
circulation.
 The cardiovascular system consists of
the heart, blood and the blood vessels
in the form of arteries and veins.
 There are two categories of blood
vessels arteries and veins.
  The arteries carry the oxygenated
blood from the heart to the rest of
the body where it distributes the
oxygen and nutrients.
 The lymphatic system consists of the
lymph vessels, lymphatic nodes and
lymph.
 Filters blood and localize infection.
 ARTERIES

 Arteries form part of the circulatory system.

They carry blood that is oxygenated after it
has been pumped from the heart. Arteries also
aid the heart in pumping blood. Arteries carry
oxygenated blood away from the heart to the
tissues, except for pulmonary arteries, which
carry blood to the lungs for oxygenation.
(Usually veins carry deoxygenated blood to
the heart but the pulmonary veins carry
oxygenated blood)
 There are two unique arteries. The pulmonary
artery carries blood from the heart to
the lungs, where it receives oxygen. It is
unique because the blood in it is not
"oxygenated", as it has not yet passed through
the lungs.
 VEINS

 In general, veins function to return

deoxygenated blood to the heart, and are
essentially tubes that collapse when their
lumens are not filled with blood. The thick
outermost layer of a vein is made of
connective tissue, called tunica adventitia or
tunica externa. There is a middle layer band of
smooth muscle called tunica media, which are,
in general, thin, as veins do not function
primarily in a contractile manner.
 The interior is lined with endothelial cells
called tunica intima. The precise location of
veins varies much more from person to person
than that of arteries. Veins often display a lot
of anatomical variation compared with arteries
within a species and between species.
 Blood
 Blood is made of specialized cells
suspended in a liquid substance called
plasma.
 The specialized cells include red blood cells
(erythrocyte) white blood cells (leukocyte)
and platelets (thrombocyte).
 Erythrocytes
 Red blood cells, or erythrocytes make
up the majority of all blood cells
 They are produced by the red bone
marrow at a rate of about 2 million cells
per second
 An equal number of worn out RBCs are
destroyed by the spleen and liver
 These cells liver for about 120 days
and are confined to the bloodstream
 A key component of erythrocytes is
haemoglobin
 Primarily responsible for transporting
oxygen and carbon dioxide
 Hematocrit – the % if RBCs in relation
to the total blood volume
 Leukocytes
 White blood cells or leukocytes protect
the body against invaders such as
bacteria, viruses, parasites, toxins and
tumors.
 Unlike erythrocytes, leukocytes can
leave the capillaries to do their work.
 Leukocytes are grouped into two
categories, bases on their physical
 and chemical characteristics.
 Granulocytes – these contains membrane
bound cytoplasmic granules that can be
stained for observation.
 Neutrophils – phagocytes that destroy
bacteria and some fungi
 Eosinophils – phagocytise antigen-antibody
complexes; increased in allergic conditions
 Basophils – combat allergic reactions
 Agranulocytes – these contain a spherical
nucleus but no cytoplasmic granule
 Lymphocytes – found mostly in lymph
tissues
 T lymphocytes – attack virus infected cells
and tumors
 B lymphocytes – produces antibodies
 Monocytes – also effective against viruses
and certain bacterial parasites
 Thrombocytes
 Blood platelets or thrombocytes are the
smallest elements in the plasma
 They prevent blood loss from small vessels
by clumping together to begin the clotting
process at the site of an injury
 Normal platelet count is 250,000 to 500,000
/mm3
 Plasma
 The straw – colored liquid that remains
when the cells are removed from the
blood.
 Plasma makes up about 55% of total
blood volume
 About 90% of plasma is made up of
water
 Serum is the fluid portion of the blood that
remains when clotting factors such as
fibrinogen are removed.
 When the blood is drawn for testing,
various tubes are used. Some of these
tubes contain anticoagulants, while
others allow the blood to clot leaving
the serum behind for testing.
CHAIN OF INFECTION
PATHOPHYSIOLOGY
 BITE OF AEDES AEGYPTI
(INJECTION OF DENGUE VIRUS)
PRUITUS

VIRUS PENERATIONTHROUGH
SKIN
VIRUS (ALTERTED 1st LAYER OF
PROLIFERATIO DEFENSE)
N
DENGUE INFECTS AND (+/-) IgG
REPLICATE (+) IgM
TOXINS INSIDE THE LANGERHANS CELLS
TARGETED (+) dengue
ANDATTACHED NS1
TO BLOODVESSEL
AND WEAKENS DETECTION OF RELEASE
ANTIGEN OF
ANTIBODIES
DAMAGE INCREASED LIVER
TISSUE/ ENZYME
BLOOD VESSEL 2 ALT, AST, SGPT
NEUTROPHILS AND
WHITE BLOODCELL
PLASMA LEAKAGE AMINO ACID
METABOLISM
INCREASES
 RELEASE OF
ABDOMINAL PAIN
PYROGENS

PETECHAI
E/ MELENA FEVER
RASHES

PLATELET REPAIRS
2 DAMAGE BLOOD VESSEL

THROMBOCYTOPENI
A
 NURSING CARE PLAN

 DIAGNOSIS
 Elevated body temperature related to
infection as evidence by body
temperature of 38.7ºc
 NURSING CARE PLAN

 ASSESSMENT
 SUBJECTIVE
 “Mainit ang anak , mukhang mataas ang
lagnat niya” as verbalized by the mother.
 OBJECTIVE
 Patient is warm to touch
 Flushed skin
 Body malaise
 (+) Chills
 Body temperature : 38.7ºc
 NURSING CARE PLAN

 PLANNING
 After 30 minutes of nursing intervention,
patient will be able to decrease body
temperature from 38.7ºc to 37.5ºc
 After 8 hours of nursing intervention, patient
will be able to:
 maintain a normal body temperature
 NURSING CARE PLAN

 INTERVENTION
 Independent:
 Instructed mother to do tepid sponge bath,
Advice no to use alcohol
 Provided Droplight over cold extremities
 Loosen clothing
 Advised patient to increase oral fluid intake
 Adjusted room temperature
 Provided comfortable environment to promote
rest
 Monitored body temperature
 NURSING CARE PLAN

 COLLABORATIVE
 ADMINISTERED ANTI-PYRETIC
MEDICATION AS ORDERED
 MAINTAIN IV FLUID AS ORDERED
 NURSING CARE PLAN

 EVALUATION
 Patient was able to decrease body
temperature to 37.1 ºc and maintain normal
body temperature for 8 hours
 NURSING CARE PLAN

 DIAGNOSIS
 Impaired gas exchange related to ventilation
perfusion imbalance secondary to
hypovolemic shock as evidenced by O²
saturation of 88%
 NURSING CARE PLAN
 ASSESSMENT
 SUBJECTIVE
 “Nahihirapan ang anak ko na huminga
parang hingal na hingal siya” as verbalized
by the mother.
 OBJECTIVE
 Respiratory rate 40BPM
 (+) Nasal Flaring
 Use of accessory muscles
 O² Saturation:88%
 (+) Crackles
 Chest x-ray result :Bibasal pneumonia
 NURSING CARE PLAN

 PLANNING
 After 30 minutes of nursing intervention,
patient will be able to increase O² saturation
from 88% to 94% and decrease respiratory
rate from 40bpm to 20bpm.
 After 8 hours of nursing intervention, patient
will be able to:
 maintain a normal O² saturation
 respiratory rate

NURSING
INDEPENDENT
CARE PLAN
 Maintained patient on high back rest
 Loosened clothing
 Advised patient to limit activities like
bathroom privileges
 Advised patient to perform deep breathing
exercise
 Encourage pursed lip technique
 Advised patient to change position by turning
every 2 hours
 Provided comfortable environment to
promote rest
 Monitored respiratory rate and O² saturation
 NURSING CARE PLAN
 COLLABORATIVE
 Provided O² inhalation 1-2 liters per minute
via nasal cannula as ordered by the
physician
 Instructed patient to perform blow bottle to
facilitate expansion of lungs as ordered by
the physician
 EVALUATION
 Patient was able to decrease respiratory rate
to 21bpm and O² saturation of 96% and
maintain normal respiratory rate and O²
saturation
 NURSING CARE PLAN

 DIAGNOSIS
 Imbalanced Nutrition: Less than body
requirements related to decreased appetite
 ASSESSMENT
 Subjective:
 “wala akong gana kumain” as
verbalized by the patient
 NURSING CARE PLAN

 OBJECTIVE
 Diaphoresis
 Dry skin
 Poor skin turgor
 Capillary refill test >4 seconds
 Concentrated urine(Yellow)
 NURSING CARE PLAN

 PLANNING
 After 30 minutes of nursing intervention,
patient will be able to tolerate food intake
 After 8 hours of nursing intervention, patient
will be able to restore normal fluid volume as
evidenced by:
 Good skin turgor
 Urine specific gravity within normal
range
 Decrease perspiration
 NURSING CARE PLAN
 INTERVENTION
 INDEPENDENT
 Monitored vital signs
 Reviewed the history of nutrition, including
food preferences
 Observed and record the patient's food
intake
 Measured body weight daily
 Advised patient to eat small frequent feeding
 Advised patient to increase oral fluid intake
 Avoid foods that stimulate and gassy.
 NURSING CARE PLAN

 COLLABORATIVE
Administered IV fluids as ordered by


the physician
 Administer anti-pyretics and antacids
as ordered by the physician
 EVALUATION
 Patient was able to tolerate food intake and
maintain good skin turgor, urine specific
gravity and decreased perspiration
 NURSING CARE PLAN
 DIAGNOSIS
 Acute pain related to pathological disease
process secondary to dengue as evidenced
by pain scale of 9/1
0

 ASSESSMENT
 Subjective:
 “Ang sakit ng tyan ko, kung I rarate ko
9 out of 10 ang pain niya” as verbalized
by the patient.
 OBJECTIVE
 Facial grimace
 Abdominal girth 34 inches
 NURSING CARE PLAN

 PLANNING
 After 30 minutes of nursing intervention,
patient will be to able to decrease pain scale
from 9/10 to 4/10
 After 8 hours of nursing intervention, patient
will be relieved from pain
 NURSING CARE PLAN
 INTERVENTION
 Independent:
 Monitor vital signs
 Assessed abdominal girth
 Advised patient to perform deep breathing
exercise
 Provided comfortable environment to promote
rest
 Encourage patient to do diversion activities
 NURSING CARE PLAN

 Collaborative:
Pain medications given as ordered by


physician
 EVALUATION
 Patient was relieved or tolerate the pain with
a pain scale of 2/10
 NURSING CARE PLAN

 DIAGNOSIS
 Deficient Fluid Volume related to
hypovolemia as evidenced by no urine
output for 5 hours
 ASSESSMENT
 Subjective
 “Hindi pa ako umiihi kaninang umaga
pa ang huling naihi ako ” as verbalized
by the patient
 NURSING CARE PLAN

 OBJECTIVE
 Patient is cold to touch
 No urine output for 5 hours
 Body malaise
 Pallor skin
 Blood pressure of 90/60mmHg
 Weak thread pulse
 Capillary refill test: more than 4 seconds
 Abdominal girth 34 inches
 NURSING CARE PLAN

 PLANNING
 After 30 minutes of nursing intervention,
patient will be able to excrete urine output at
least 30ml/ hour
 After 8 hours of nursing intervention, patient
will be able to
 maintain normal urine output
 NURSING CARE PLAN
 INTERVENTION
 Independent:
 Assessed patients Level of consciousness
 Check for patent airway and adequate
circulation.
 Monitored vital signs, intake and output hourly
 Adjusted room temperature
 Monitored patient’s abdominal girth
 Position patient flat on bed with the feet lifted
about 12 inches to increase circulation
 Watch out for profuse bleeding
 Advise patient to use soft bristled tooth
 brush
 NURSING CARE PLAN

 COLLABORATIVE
 Performed blood typing and cross matching
for blood products
 Inserted an indwelling urinary catheter as
order by physician
 Hemostatic and diuretic medications given as
ordered by the physician
 EVALUATION
 Patient was able to excrete normal urine
output 300ml within 8 hours
NURSING CARE PLAN
24 HOURS NURSES NOTES
DATE TIME FOCUS D=ATA, A=CTION R=ESPONSE
9/11/ Risk for Bleeding D > % Activity 38%.
2015
6AM
> (-) Abdominal pain.
A > Advised to use soft
bristled toothbrush.
>Encourage to limit
physical activity.
R > Acknowledged.
8AM For IV D > (+) pain (+) swelling on
insertion IV site.
A > Reinserted IV
aseptically.
R > Good flow.
9:30 Physician's D > Seen and examined by
AM Visit Dr. Tabar.
A > Assisted during
rounds.
DATE TIME FOCUS D=ATA, A=CTION R=ESPONSE
9/11/ A>with new orders made
2015
R > new orders made carried out
12:45 Physician's D > Seen and examined by
PM Visit Dr. Ruiz(Hematologist).
A > Assisted during rounds.
A>with new orders made
R > new orders made carried out
9:30 Shock D > (+) Cold clammy skin.
AM > (-) Urine output for 4 hours.
> BP 100/80.
> CRT greater than 3 seconds.
A > Reinserted another IV line.
>Dopamine drip started.
R > Good flow.
> BP 90/60.
> CRT greater than 3 secs.
> With urine output.
> Endorsed
DATE TIME FOCUS D=ATA, A=CTION R=ESPONSE
9/11/ 8PM CBC WITH D > Decreased APC = 38.
2015
PC A > Relayed to attending
physician.
>Inquired availability of platelet
concentrate; still for pick-up as per
lab.
ALTERED D > No urine output since 6:30 pm.
URINARY >Updated all attending physician.
ELIMINATION
9PM FFP D > With 3 units available.
Transfusion > Updated attending physician.
> Informed resident doctor on
duty to further assess the
patient for congestion.
R> Updated all attending
physician of patient’s
status and vital signs.
DATE TIME FOCUS D=ATA, A=CTION R=ESPONSE
9/11/ 11PM A > Hooked 2nd unit of FFP.
2015
>Monitored vital signs and
input
and output care of private
duty
nurse.
R> No BT reaction and updated
AP.
12AM Physician's visit D > Seen by attending physician.
A > with new orders made
R> Carried out order.
12:30 For Indwelling A > Secured consent; signed by
AM Foley Catheter patient’s mother.
Insertion >Insertion done by resident
doctor on duty.
R > with minimal OU.
FFP A > Referred to ROD for
TRANSFUSION reassessment.
DATE TIME FOCUS D=ATA, A=CTION R=ESPONSE
9/11/ 2:30 R > FFP transfusion completed.
2015
AM > Clear breath sounds on right
lung.
> (+) Crackles left lung.
> Stable vital signs.
3:00 PLATELET D > 2 units available.
AM TRANSFUSION A > Updated all attending
physician.
>Transfusion of platelets 2
units started.
4:30 FFP Transfusion A > Transfusion done.
AM >Informed resident doctor on
duty for reassessment.
> Congestion precaution
instituted during transfusion.
> Furosemide 3 mg
given TIV as ordered.
DATE TIME FOCUS D=ATA, A=CTION R=ESPONSE
> Reassessed by ROD
> Put on hold another dose of
Furosemide as advised by the
ROD.
5:20 Still for A > Updated attending physician
AM Cryoprecipitate of
Transfusion available blood component; 1
unit cryoprecipitate.
>Advised lab tech of urgency of
requested blood.
R >Stable vital signs.
>Endorsed
 TREATMENT MODALITIES

 Betadine swabs
 Expiratory water bottle
 02 support for 2Lpm
 Iv fluids support
24 HOURS NURSES NOTES
 DISCHARGE PLANNING
 M-EDICATION
 cefuroxime 500mg/tab 1tab every 8am and
8pm for 4 days.
 essentiale forte 1tab every 8am and 8pm as
food supplement/Vitamins.
 folart syrup 5mL ONCE a day as Vitamins.
 Advised relative to continue the prescribed
home medications to ensure optimum
recovery.
 Instruct relative not to give asprin or any
NSAID drugs for they increase risk for
bleeding.
 Cont.. DISCHARGE PLANNING

 E-XERCISE
 Instruct to avoid excessive activities that may
result to stress.
 Advise to perform range of motions and
repetitive body movements for promotion of
optimum
 Advise to do deep breathing exercises
 T-REATMENT
 Instruct to increase oral fluid intake
 Instruct to have complete bed rest
 Cont.. DISCHARGE PLANNING
 H-EALTH TEACHING
 hand hygiene
 proper hygiene
 Preventions
 Discuss the possible source of infection of
disease
 Educate family on how to eliminate vectors
 Never stock water in a container without
covers
 Gallon, drums or used tires should have a
proper way of disposal
 Use insecticides at home
 Encourage relative to clean surroundings to
destroy mosquito breeding sites.
 Cont.. DISCHARGE PLANNING
 O-UT PATIENT FOLLOW VISIT
 Follow up schedule September 25 (Fri)1-
3pm at CAHWCI MO5(Dr. TABAR)
 Follow up schedule on September 26 (Sat)
at Metro Doctors Parola Cainta Rizal 3pm
(Dr. Ruiz) to repeat CBC PC, SGPT bring
previous laboratory results.
 D-IET
 Diet for Age encouraged to eat nutritious
foods; green leafy vegetables and fruits
discourage junk foods as a snack
 Drink at least 8-10 glasses of water a day.