47358424 case study in dengue compile
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DENGUE PERPETUAL HELP COLLEGE OF MANILA SECTION A4A1NOVEMBER 17, 2010 4
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INTRODUCTION
Dengue hemorrhagic fever is a severe, potentially deadly infection spread by certain species of
mosquitoes (Aedes aegypti). Globally, 2.5 billion people live in areas where dengue viruses can be
transmitted. In the Philippines, Hemorrhagic fever was first reported in 1953. In 1958, it became a notifiable
disease in the country and was later reclassified as Dengue hemorrhagic fever.
Dengue is a primary disease in the tropical and subtropical region. It is caused by one of four
different but related viruses. It is spread by the bite of mosquitoes, most commonly the mosquito Aedes
aegypti.
It is characterized by increased vascular permeability, hypovolemia and abnormal blood clotting me
chanisms. WHO case definition for DHF: 1) fever or history of recent fever, 2) thrombocytopenia (platelet co
unt equal to or less than 100 x 10 /cu mm),
3) hemorrhagic manifestations such as petechiae or overt bleeding phenomena, and
4) evidence of plasma leakage due to increase vascular permeability.
Illness is biphasic; it begins abruptly with fever, and in children, with mild upper
respiratory complaints often anorexia, facial flush and mild GI disturbances. Coincident with defervescence
and decreasing platelet count, the patient’s condition suddenly worsens, with marked weakness, severe res
tlessness, facial pallor and often diaphoresis, severe abdominal pain and circumoral cyanosis. GI hemorrha
ge is an ominous prognostic sign that usually follows a prolonged period of shock.
Dengue occurrence is sporadic throughout the year. Epidemic usually occurs during the rainy seas
ons June November. Peak months are September and October. It occurs wherever vector mosquito exists.
Currently vector control is the available method for the dengue and DHF prevention and control but
research on dengue vaccines for public health use is in process.
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DENGUE PERPETUAL HELP COLLEGE OF MANILA SECTION A4A1NOVEMBER 17, 2010 4
OBJECTIVES
General objectives
This case presentation aims to identify and determine the general health problems and
needs of the patient with a final diagnosis of dengue hemorrhagic fever with warning signs. This will further
expand our knowledge on this particular disease. We may be able to extend to our client a holistic
approach of care and services that would somehow contribute to the improvement of the client's current
status. It also aims to develop in us, student nurses the proper nursing care needed in order to provide an
effective nursing management in a hospital set-up until the client is ready for discharge.
Specific objectives
PATIENT BASED:
a. Educate the client for somehow that will contribute to the progress of his condition.
b. Promote an environment conducive for optimal health.
c. Emphasize the importance of maintaining a balance diet.
NURSE CENTERED:
Collects related facts regarding the clients personal data and family illness, past and present
medical history and to examine client thoroughly in order to come up with an accurate physical
assessment.
To review the Anatomy and Physiology and to understand better pathophysiology of the problem,
for us to know the risk factors of this case.
To know the drug properties as well as the diagnostic procedure in order to know the effects of the
drug to be administered. And also to be able to select the appropriate nursing intervention.
To enhance our knowledge about proper nursing management as well as its rationale that we take
into great considerations.
To help motivating the patient to continue the health care provided by health workers.
PATIENT‘S PROFILE
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DENGUE PERPETUAL HELP COLLEGE OF MANILA SECTION A4A1NOVEMBER 17, 2010 4
DEMOGRAPHIC HISTORY:
Patient’s Name: Boy XX
Age: 9 years old
Gender: Male
Address: Tanauan, Batangas
Educational Attainment: Elementary Level (Out of School)
Religion: Catholic
Nationality: Filipino
Dialect: Tagalog
Date of Admission: November 8, 2010
Chief Complaint: High Grade Fever
Admitting Diagnosis: Dengue with Warning Signs
Principal Diagnosis: Dengue
Admitting Hospital: San Lazaro Hospital
HEALTH HISTORY:
History of Present Illness
Early in the morning (Nov. 7, 2010), the child played outside their house and returned home at
lunch time. The afternoon on that day, the eldest brother noticed something strange and different and as
quoted by the eldest brother “nanghihina na siya noong dumating ng bahay, nanibago kami kasi malikot
siya. Hinawakan ko siya, napansin ko mainit ang katawan nya at para bang na dengue sya!” Afraid that
this is fatal,the brother immediately rushed the child on the hospital. They traveled from Batangas to Manila
( cannot afford Batangas hospital) he was admitted to San Lazaro Hospital (Nov.8, 2010) Patient X initial
temperature was 38degrees Celsius with petechial rash during tourniquet test. He was diagnosed Dengue
fever with warning sign. They got a sample blood from the patient and ordered an IVF and was referred to
Pavillion 4-Extension of Pediatric Ward.
Past Medical and Surgical History
No previous hospital confinement. The usual colds, minor cough and slight fever that a normal
child gets at his age. The treatment is usually rest, hot soup, and sometimes over the counter drugs.
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The patient was fully immunized child
Vaccine Minimum Age at 1st
dose
No. of doses Age received Interpretation and
analysis
BCG Birth or anytime
after birth
1 After birth BCG was given at
earliest possible
age to protect the
possibility of TB
meningitis and
other TB infectious
in which infants are
prone.
DPT 6 weeks 3 1 month and 2
weeks
An early start of
DPT reduces the
chance of severe
pertussis
OPV 6 weeks 3 1 month and 2
weeks
The extent of
protection against
polio is increase
the earlier the OPV
is given
Hep B At birth 3 At birth An early start of
Hep B reduces the
chance of the child
to be infected and
become a carrier.
This vaccine also
prevents liver
cirrhosis and liver
cancer.
Measles 9 months 1 9 months This vaccine
prevents death,
4SAN LAZARO HOSPITAL
DENGUE PERPETUAL HELP COLLEGE OF MANILA SECTION A4A1NOVEMBER 17, 2010 4
malnutrition,
pneumonia and
diarrhea.
Family Health History
(+) Heart Disease
(+) Hypertension
(-) Diabetes
(-) Asthma
Social Health History
The patient has 7 siblings, a deceased father and a jobless mother. The eldest sister is the only working
individual in the family and she is the breadwinner. They lived in a small upcoming city in Batangas. The
family belongs to the lower bracket of the society. As for the patient lifestyle, as soon as he wakes he is out
of the house. He comes home before dawn. The patient is undernourished , out of school all because of
financial difficulties .
They are loved by their neighbors and the patient has lots of friends his age
5SAN LAZARO HOSPITAL
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PERSON’S REVIEW OF SYSTEM
PERSON’S REVIEW OF
SYSTEM
PRIOR TO
HOSPITALIZATION
DURING
HOSPITALIZATION
INTERPRETATION AND ANALYSIS
1.) PSYCHOLOGICAL
Self Perception-Self-
Concept Pattern
Role Relationship Pattern
As a child, he was not
giving priority to his own
health; he just wants to
play with his friends.
According to the child, he
feels weak after playing
which is not usually happen
to him. His brother rushed
him to San Lazaro Hospital
even though it was far from
Batangas.
He has a happy family with
During hospitalization, the
patient was under
observation. The relatives
noticed that the child is
sometimes unresponsive
and sad. He said that he
missed her mother who was
not there for him because
her mother was 9 months
pregnant.
When he was in the
It is not usual to child to confine him in the
hospital because all he wants to do is to play with
his friends so her emotional and psychological
status was disturbed.
Self-concept involves all perceptions. A positive
self-concept is essential to person’s mental and
physical health. Individuals with positive self-
concept are better able to cope up in problems
and resist psychological and physical illnesses.
Harold Shryock, MD (Modern Medical Guide)
Having a family beside him makes him stronger.
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Sexuality and Reproductive
Pattern
7 siblings, his father died
last June2010 and her
mother was pregnant. He
was contented to their life
but when his father died
because of heart attack,
their life changed. Before,
his father was the one
supporting their family
needs.
In Tanauan, Batangas they
are near to the hospital but
because it was too
expensive they traveled to
Manila and confined the
chills to San Lazaro
Hospital.
The child was unaware to
his reproductive and
sexuality pattern. He was
hospital, his brother and
relatives supported him
emotionally and financially.
They are the one beside
him everyday. The family
can buy medications and
IVF appropriate for the
patient’s treatment.
There are no changes to his
sexuality and reproductive
pattern.
Because family is the one responsible in the
child’s care.
Based on the Erikson’s theory of psychosocial
development “states that all families have certain
tasks and survival and continuity and specific
tasks related to the sequential stage of
development throughout the life of the family”.
Taylor, Lilis and Le Mone ( Fundamentals of
Nursing 5th Edition pg 30)
Sexuality is the degree to which a person exhibits
and experiences maleness or femaleness in
physically, emotionally and mentally. Sexuality is
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Cognitive Perceptual
Pattern
not yet circumcised
because of young age.
The child has no problem in
hearing and vision. He has
a good communication
skills and awareness.
The child verbalized that
“masakit ang tiyan ko,” with
pain scale of 6/10. There
are no management done
yet except for diversional
activities for the client. The
aunt said that the child
behavior was changed.
defined not only by a person’s genitalia but also
the attitudes and feelings about it.
Harold Shryock, MD (Modern Medical Guide)
Cognitive- Concrete operations (ages 7 to 11).
As physical experience accumulates,
accomodation is increased. The child begins to
think abstractly and conceptualize, creating
logical structures that explain his or her physical
experiences.
Barbara Kozier (Fundamentals of Nursing)
Psychosocial Stage 4 - Industry vs. Inferiority-
Through social interactions, children begin to
develop a sense of pride in their accomplishments
and abilities.
Psychosexual-During the phallic stage, the
primary focus of the libido is on the genitals.
Children also discover the differences between
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Coping Stress Tolerance
Pattern
Value Belief Pattern
He has a good
developmental stage.
Pyschosoial development-
the client is in stage of
Industry vs. Inferiority. He
can compete to his
playmates.
Pyshosexual- he is in
phallic stage where he
knows male and female.
Cognitive- Concrete
Operations
Major life changes in his
life- when his father died
last june 2010.
He is a Roman Catholic, he
attended mass every
Sundays.
When he was in the
hospital, the child become
quiet.
His became inferior
because of his disease. He
doesn’t want to
communicate and interact.
During hospitalization, he
does not pray.
males and females.
Barbara Kozier (Fundamentals of Nursing)
Stress is a condition in which person responds to
changes in the normal balanced state. It can
affect physically, emotionally, socially and
spiritually.
Barbara Kozier (Fundamentals of Nursing pg
1013-1014)
Spiritual beliefs and practices are associated with
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all aspects of person’s life, including health and
illness.
Carol Taylor (Fundamentals of Nursing 5th edition
pg 977)
2.) ELIMINATION Bowel Elimination: once a
day at night
Urinary Elimination: 3-4
times a day every morning,
afternoon and evening.
He doesn’t feel any
discomfort during urination
and defecation.
Bowel Elimination: not yet
defecating duting our shift
Urinary Elimination: 3times
during 7-3 shift.
He doesn’t feel any
discomfort during urination
and defecation. And his
urine color is clear.
The amount of urine expelled from the bladder
depends on how much fluid has been taken into
the body and how much of this has been
eliminated. Same as in stool expulsion, this
depends on how much food and kind of food you
eat.
Harold Shryock, MD (Modern Medical Guide pg
199 and 244)
3.)REST AND ACTIVITY
Activity- Exercise Pattern He was a playful child so it
was his daily activity. Since
he was stop to his study,
he just help her mother to
household chores, he knew
how to clean their house.
During hospitalization, the
patient usually lying in bed.
He walks only when going
to the bathroom. And he sits
on his bed when he will eat
meals and take his
Because of his disease his activity was limited.
And he preferred to sleep than to interact with his
relative.
Exercise plays a major role in health
maintenance. It boasts body strength as well as
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Sleep-Rest Pattern
In terms of:
Feeding- he can eat on his
own.
Hygiene- he can take a
bath without assistance of
others, can wear and
remove clothing.
Toileting- he can recognize
urging in defecating and
urinating.
The child sleeps early in
the evening from 7pm to
5am. He woke up early to
play with his friends. He
does not take any
supportive aids to sleep.
medications. The doctor
ordered him to have an
enough bed rest to avoid
fatigue. But in terms of:
Feeding- his brother assist
him.
Hygiene- he cannot take a
bath, so only wiping his
body.
Toileting- no changes.
During hospitalization, the
child is always sleeping.
mind ability. It promotes a feeling of zest and well
being and provides greater vigor for the day’s
activities.
Harold Shryock, MD (Modern Medical Guide pg
45)
Because of the symptoms he experienced, he
preferred to sleep so that he will feel comfortable.
Sleep in some way restores the body’s normal
level of activity and balance. Sleep can also be a
form of comfort and relaxation.
Barbara Kozier (Fundamentals of Nursing pg
1115-1124)
4.) SAFE ENVIRONMENT He does not have any
allergic reactions to food
and medications. He has a
There were no changes.
According to his brother,
According to Maslow’s Hierarchy of Needs-
Security needs are important for survival, but they
are not as demanding as the physiological needs.
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good skin turgor.
Sometimes he has many
wounds because of
playing. They live in city
like town.
“hindi naming alam kung
saan siya nakagat ng
lamok, kasi kung saan-saan
siya pumupunta.”
Examples of security needs include a desire for
safe neighborhoods and shelter from the
environment.
Barbara Kozier (Fundamentals of Nursing)
5.) OXYGENATION He doesn’t have any
problem in oxygenation, he
does not experience
dyspnea while walking.
During hospitalization, his
nails are pale. But he doe
not use his accessory
muscles while breathing.
Respiration includes ventilation and breathing
which is the movement of air into and out of the
lungs.
Essentials of Anatomy and Physiology 6th Edition
(pg. 417)
6.) NUTRITION He has a good appetite in
all kinds of foods. Her
mother and sister was the
one preparing their foods.
According to the brother of
the patient, “kinakain niya
lahat ng pagkain kasi kung
ano lang ang nakahain sa
bahay, kahit na gulay at
isda.” . And he was not
taking vitamins
When he was in the
hospital, the doctor ordered
a ‘diet as tolerated except
dark colored foods’. He
recalled his past 24 hours
foods:
Breakfast –Pandesal
Lunch – 1 cup rice with
a piece of fried fish and
It is very important to a person to eat nutritious
foods because it is one of the factors that will
affect the health. The ideal state of health comes
partly from sufficient protein and carbohydrates in
the diet, adequate supply of minerals and
vitamins to be well nourished person.
Harold Shryock, MD (Modern Medical Guide pg
46)
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supplements. The patient
he can able to swallow and
chew foods.
veggies.
Dinner- 1 cup of rice
and fried fish.
He has a fair appetite.
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PHYSICAL ASSESSMENT
DATE OF ASSESSMENT: November 9,, 2010 11:00am
General Survey:
Client was conscious and coherent, lying in bed with an IV line regulated to 80 gtts per min. hooked at the right side of his arm. His hair is
well-groomed and no body odor being noted during assessment. Patient was cooperative and responds to questions appropriately. He exhibits
moderate lower tone of voice but enough to understand during conversation assisted by his elder brother and he has a proper thought association
and has a sense of reality.
Vital Signs:
Vital signs Normal Actual Findings Interpretation/Analysis
Blood pressure 100/60 100/80 On the disease process any condition affects the cardiac output, blood
volume, blood viscosity has direct effect on the bold pressure. The
patient was not in distress during the assessment
(Kozier, B. (2004). Fundamentals of Nursing p. 510).
Temperature 36.5-37.5 37.8 Febrile due to increase of inflammation as evidenced by an increase in
the number of WBC from the normal value of 4.8 - 10.8 to 2.33.
Inflammation is a local, nonspecific defensive response of the tissues to
an injurious or infectious agent. It is an adaptive mechanism that
destroys or dilutes the injurious agent, prevents further spread of the
injury, and promotes the repair of damaged tissue.
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(Kozier, B. (2004). Fundamentals of Nursing p. 634)
Pulse rate 55-90 102 The pulse rate increases as a response to the lowered blood pressure
that results from peripheral vasodilation associated with elevated body
temperature and because of the increase metabolic rate.
(Kozier, B. . Fundamentals of Nursing, 7th edition p. 496).
Respiratory rate 12-25 26 Several factors influence the respiratory rate. Those that increase the
rate include increases in metabolism, stress (readies the body for fight
or flight), increased environmental temperature, and lowered oxygen
concentration at increased altitudes.
In the case of our patient it is increased because of stress and
increased environmental temperature.
(Kozier, B. (2004). Fundamentals of Nursing p. 506).
Skin
PARTS METHOD NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION / ANALYSIS
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Skin Inspection
Observation
Palpation
Skin color varies from light to deep
brown; from ruddy pink to light pink,
from yellow overtimes to olive.
Generally uniform except in areas
exposed to sun; areas of lighter
pigmentation (palms, lips nail beds) in
dark skin people. Moisture in the skin
folds and the axillae (varies with
environmental temperature, and
activity).
No edema, abrasions, lesion.
Temperature is uniform and w/in
normal range
Dark brown with excessive moisture
in the upper extremities and
petechial rashes.
Generally uniform except in areas
exposed to sun; areas of lighter
pigmentation (palms, lips nail beds)
in dark skin people.
No edema, abrasions, lesion.
Temperature is not w/in the normal
range, the skin is moist and warm to
touch.
Excessive moisture indicates
hyperthermia as evidenced
by an increase in the body
temperature from the normal
range of 35.5-37.5 to 37.8.
While petechial rashes
indicates the Herman’s sign,
the pathognomonic sign of
dengue.
The skin is warm to touch
because of the localized
hyperthermia due to
inflammation as evidenced
by an increase in the WBC
count
( Fundamentals of Nursing
by Kozier, pp.535,540,1071)
Nails Inspection Convex curvature; angle of nail plate
about 160o
- with smooth texture
- color is highly vascular& pink in light
Convex, smooth in texture, color is
pinkish and is highly vascular.
Blanch test: Prompt return of usual
Normal findings accdg. To Kozier
page 543’
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skinned clients; dark skinned clients
may have brown or black
pigmentation in longitudinal streaks
with intact epidermis on tissue
surroundings
- blanch test- prompt return of pink or
usual color 3-5 sec. Kozier, 2008
color (after 3 sec.)
Head
PARTS METHOD NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION / ANALYSIS
Hair Inspection
Palpation
Evenly distributed hair over
the scalp with thickness,
variable amount of body
hair. No infection or
infestation.
Hair is evenly distributed to
different parts of the body and it
is thick. No infection or
infestation noted.
The mother of the patient attend to his
need during hospitalization, it results to
good hygiene, the condition of the patient
limits his activities but despite of that
relatives are there for him to assist his
needs.
(Fundamental of Nursing by Kozier,
p541)
Scalp Inspection
Palpation
White, clean, free from
masses, lumps scars, lice,
nits, dandruff, and lesions
no area of tenderness
White, clean, free from masses,
lumps scars, lice, nits, dandruff,
and lesions no area of
tenderness
Skull Inspection
Palpation
Rounded( normocephalic &
symmetrical, with frontal,
Round (normocephalic), smooth
skull contour.
Normal findings according to
Kozier page 544.
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parietal, occipital,
prominences)
smooth, uniform, absence
of modules or masses
Smooth, absence of nodules or
masses.
Eyes
PARTS METHOD NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION / ANALYSIS
Eyebrows Inspection Symmetrically aligned.
Equally distributed, curled
slightly outward
Hair is evenly distributed skin
intact and aligned.
Symmetrically aligned and
equal movement.
Normal findings.
With age, eyebrows become bristly and
coarse.
(Kozier, B. Fundamentals of Nursing, 7th
edition, p. 548).
Eyelashes Inspection Equally distributed, Curled
slightly outward
Eyelashes are equally
distributed, it is thick and is
curled outward.
Normal findings.
Eyelashes should be curled outward to
sweep foreign particles away from the eyes.
Eyelids Inspection The skin is intact, no
discharge and no
discoloration. The lids
close symmetrically blinks
involuntary and with
bilateral blinking.
Lids closes symmetrically,
bilateral blinking and no
visible sclera above corneas,
and upper and lower borders
of cornea are slightly
covered when lids are open.
Normal findings according to Kozier page
548.
Sclera and
Conjunctiva
Inspection Shiny, smooth & pink or
red in color
Both sclerae are shiny and
smooth.
Extremely red color of both conjunctivae
indicates inflammation as evidenced by the
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Palpebral conjunctivae are
extremely red.
body temperature of 37.8 and an increase
in the WBC count. .
(Kozier, B. Fundamentals of Nursing, 7th
edition, p.548).
Cornea Inspection transparent, shiny &
smooth, details of the iris
are visible
Transparent shiny and
smooth.
Normal findings
(Kozier, B. Fundamentals of Nursing 7th
edition, p. 550).
Pupils and iris Inspection Black in color, equal in
size, normally 3-7 mm in
diameter, sound- smooth
border iris flat & sound.
Pupils constrict when
looking at near object and
dilate when looking at far
objects.
Iris brown in color, equal in
size and round in shape. Iris
is flat and round. Pupil
diameter is 4mm.
Patient’s pupils constrict
when looking at near objects
and dilate when looking at
far objects.
Normal findings.
Pupils equally reactive to light and
accommodates symmetrically.
(Kozier, B. Fundamentals of Nursing, 7th
edition, p. 550).
Extraocular
muscle tests
Inspection Both eyes coordinated,
move in unison with
parallel alignment.
Within normal findings. Normal findings.
(Kozier, B. (2004). Fundamentals of Nursing
p. 554).
Visual Acuity Inspection Able to read newsprint
with 20/20 vision on
snellen chart.
The patient can read
writings that was given to
him for visualization .
Normal findings.
(Kozier, B. Fundamentals of Nursing, 7th
edition, p. 552).
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Ears
PARTS METHOD NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION / ANALYSIS
Auricles Inspection
Palpate
The color is same as facial
skin, symmetrical, the
auricles aligned with outer
cantus of the eye.
Mobile, firm and not
tender, pinna recoils after
it is folded.
The color is same as facial
skin, symmetrical, the
auricles aligned with outer
cantus of the eye.
Mobile, firm and not tender,
pinna recoils after it is
folded.
Normal Findings
Kozier, B Fundamentals of Nursing 7th
edition, p. 556
Ear Canal Inspection Distal third contains hair
follicles and glands. Dry
cerumen, grayish-tan color
or sticky, wet cerumen in
various shades of brown.
Distal third contains hair
follicles and glands. Dry
cerumen, grayish-tan color
or sticky, wet cerumen in
various shades of brown.
Normal Findings
Kozier, B. Fundamentals of Nursing, 7th
edition, p. 556
Hearing Acuity Inspection Normal voice tones
audible. Sound is heard in
both ears or localized at
the center of the head
(Weber Negative).
Air conducted hearing is
greater than bone
conducted hearing
(positive Rinne)
Normal voice tones audible.
Sound is heard in both ears
or localized at the center of
the head.
Normal Findings
according to Kozier page 558
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Nose
PARTS METHOD NORMAL FINDINGS ACTUAL FINDINGS ANALYSIS
Nose Inspection Symmetric and straight
No discharge in flaring
Uniform in color
Not tender, no lesion
Symmetric in shape. No
discharge or flaring, uniform
in color. (-) tenderness and
lesions.
Patient can breathe normally through nose
and no discharges. He can also identify
common odors like alcohol.
Normal findings according to Kozier page
560-561
Facial Sinuses Palpation No tenderness No tenderness noted. Normal findings according to Kozier page
560-561
Septum Inspection Air moves freely as the
client breathes through the
nares. Nasal septum intact
& in midline
Nasal septum intact and in
midline.
Normal findings according to Kozier page
560-561
Mouth
PARTS METHOD NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION / ANALYSIS
Lips Inspection
Palpation
Uniform pink color
Soft, moist, smooth
texture
Symmetry of contour
Ability to purse lips
Uniform pink color
Soft, moist, smooth texture
Symmetry of contour
Ability to purse lips
Normal findings accdg. to Kozier, p.563
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Buccal mucosa Inspection Uniform pink color
Soft, moist, smooth
texture
Uniform pink color
Soft, moist, smooth in texture.
Normal findings accdg. to Kozier, p.563
Gums Inspection Pink gums, moist, firm
texture to gums.
Pinkish gums, no retraction,
moist and firm.
Gums are pinkish in color.
Normal findings
(Fundamentals of Nursing by Kozier, p564)
Tongue Inspection
Palpation
Central position
Pink color, moist,
slightly rough; then,
whitish coating
Smooth; lateral margins;
no lesions
Raised papillae
Moves freely, no
tenderness
Smooth tongue base
with prominent veins.
Central position, pink in color,
moist, moves freely, no
lesions, tenderness and
nodules.
Normal
(Fundamentals of Nursing by Kozier, p564)
Teeth Inspection 24 pediatric teeth
smooth, white, shiny
tooth enamel
pink gums moist.
Missing tooth, with 22
smooth, yellow, shiny tooth
enamel
pink gums moist.
Normal Findings
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(Fundamentals of Nursing by Kozier, p602)
Uvula Inspection Soft, moist, smooth
texture Pink and
smooth.
Soft, moist, smooth texture
Pink and smooth.
Normal Findings
(Fundamentals of Nursing by Kozier, p602)
Tonsils Inspection No discharge. Tonsils of
normal size.
Pink and smooth
posterior wall.
No discharge. Tonsils of
normal size.
Pink and smooth posterior
wall.
Normal Findings
(Fundamentals of Nursing by Kozier, p602)
Neck
PARTS METHOD NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION / ANALYSIS
Neck Inspection
Palpation
Proportional to size of
the head, symmetrical
and straight. Freely
movable without
difficulty.
No palpable lumps or
tenderness
The trachea is in the
Central placement in
midline of neck, spaces
are equal on both sides.
Muscles equal in size, head
centered, coordinated
smooth movement, head
was flexed, hyperextend,
laterally flexes, laterally
rotates, no noted palpable
lymph nodes, trachea in
central placement in midline
of neck spaces are equal on
both sides, thyroid gland
moves with deglutition.
Patient has unlimited ROM.
There are no palpable lymph nodes. Head
can easily flex and rotates. Trachea is in the
central placement and no indication of
possible neck tumor nor thyroid enlargement
Muscles in the neck like sternocleidomastoid
and trapezius draw the head to the side and
elevate the chin and elevate the shoulders to
shrug them.
The trachea, thyroid gland, anterior cervical
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nodes and carotid artery lie within the anterior
triangle.
(Fundamentals of nursing by Kozier p566)
Upper extremities
PARTS METHOD NORM AL FINDINGS ACTUAL FINDINGS INTERPRETATION / ANALYSIS
Shoulders Inspection
Palpable
Able to tolerate wide
range of motion. No
difficulty upon bending
and stretching. . No
lesions, no scars and no
deformity.
Able to do ROM. Normal Findings
Arms and
forearms
Inspection
Palpable
Able to tolerate wide
range of motion. No
difficulty upon bending
and stretching. No
lesions, no scars and no
deformity.
Able to do ROM exercises
without difficulty in doing.
Have some scars but no
deformity.
Both arms have equal strength, patient can
move arms against gravity and against full
resistance.
(Fundamentals of Nursing by Kozier p1068)
Elbows Inspection
Palpable
Able to tolerate wide
range of motion. No
difficulty upon bending
and stretching. . No
Able to do ROM exercises
without difficulty in doing.
Normal findings according to Kozier page
1061
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lesions, no scars and no
deformity.
Wrist Inspection
Palpable
Able to tolerate wide
range of motion. No
difficulty upon bending
and stretching. . No
lesions, no scars and no
deformity.
Able to do ROM exercises
without difficulty in doing.
Normal findings according to Kozier page
1061
Hands and
Fingers
Inspection
Palpable
Able to tolerate wide
range of motion. No
difficulty upon bending
and stretching. . No
lesions, no scars and no
deformity.
Able to do ROM exercises
without difficulty in doing in
the left hand.
With the presence of IV line
in the right hand it makes
difficult to move.
Normal findings according to Kozier page
1061
Thorax
PARTS METHOD NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION / ANALYSIS
Chest size and
shape
Inspection Anteroposterior to
transverse chest is
symmetrical.
Anteroposterior to transverse
chest symmetrical.
Normal
(Fundamentals of nursing by Kozier p573)
Breath sounds Auscultation Bronchovesicular
breathe sound.
Patient has a clear,
bronchovesicular breath
Normal.
(Fundamentals of nursing by Kozier p573)
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sound.
Posterior Palpation
Percussion
Full and symmetric chest
expansion. Fremitus
tactile most clearly at the
apex of the lungs
Quiet, rhythmic and
effortless respiration.
Vesicular and
bronchovesicular breath
sound.
Notes resonate, except
over scapula, the lowest
point of resonance is at
the diaphragm.
Vocal nor tactile fremitus,
Bronchovesicular breathe
sound.
Notes resonate, except over
scapula, the lowest point of
resonance is at the
diaphragm
Normal findings according to Kozier page
578-579
Anterior Inspection
Palpation
Quiet, rhythmic and
effortless respiration.
Full and symmetric chest
expansion. Same as
posterior vocal fremitus,
fremitus is normally
decreased over heart
Quiet rhythmic and effortless.
Full and symmetric chest
expansion.
Normal findings according to Kozier page
578-579
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Percussion
and breast tissue.
Notes resonate down to
the 6th rib at the level of
the diaphragm but are
flat over areas of heavy
muscle and bone, dull on
areas the heart and the
liver, and tympanic over
the underlying stomach.
Breast
PARTS METHOD NORNAL FINDINGS ACTUAL FINDINGS ANALYSIS
Breast Inspection
Palpation
No masses and lumps No masses and lumps Normal findings
(Kozier, 2008)
Areola Inspection
Palpation
Dark in color in contrast
to surrounding skin. No
masses, lumps and
lesions.
Dark in color in contrast to
surrounding skin. No masses,
lumps and lesions.
Normal Findings
(Kozier, 2008)
Nipples Inspection
Palpation
Size is proportional. No
discharged or
secretions.
Size is proportional. Normal findings.
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(Kozier, 2008)
Abdomen
PARTS METHOD NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION / ANALYSIS
Skin integrity Inspection Unblemished skin, uniform in color. Unblemished skin,
uniform in color
Normal findings Kozier page 592-
598
Contour and
symmetry
Inspection Flat, rounded.
Symmetric contour.
Flat, symmetric contour. Normal findings Kozier page 592-
598
Movement Inspection Symmetric movements caused by
respiration.
Symmetric movement
caused by respiration, no
visible vascular pattern.
Normal findings Kozier page 592-
598
Bowel sounds Auscultation Audible bowel sounds Audible bowel sounds Normal findings Kozier page 592-
598
Umbilicus Inspection Clean Clean Normal findings Kozier page 592-
598
Bladder Palpation Not palpable Not palpable Normal findings Kozier page 592-
598
Liver Palpation May not be palpable.
Border feels smooth
No enlargement. Not
palpable
Normal findings Kozier page 592-
598
Genitalia
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Patient refuses to be assessed but according to the patient he was not circumcise yet.
Lower Extremities
PARTS METHOD NORMAL
FINDINGS
ACTUAL FINDINGS INTERPRETATION / ANALYSIS
Hip Inspection Able to perform wide
range of motion. No
masses, scars and
deformity.
Able to perform minimal range of motion
exercise no masses and deformities.
Normal findings
(Fundamentals of Nursing by
Kozier p1068)
Leg Inspection
Palpation
Able to perform wide
range of motion. No
masses, scars and
deformity.
Able to perform wide range of motion.
Has flakes and scars but has no deformity.
Normal findings
(Fundamentals of Nursing by
Kozier pg. 495)
Knee Inspection
Palpation
Able to perform wide
range of motion. No
masses, scars and
deformity.
Able to perform wide range of motion.
No masses and deformity but have some round
and oval shape of scars of about 1cm in size.
Normal findings
(Fundamentals of Nursing by
Kozier (2004) p. 497)
Foot and toes Inspection
Palpation
Able to perform wide
range of motion. No
masses, scars and
deformity.
Comfortable to perform wide range of motion.
No masses and deformity .
Normal
(Fundamentals of Nursing by
Kozier,(2004) p.496)
Peripheral Palpation Symmetric full Symmetric full pulsation Normal findings
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pulse pulsation (by Kozier, (2004) p496)
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. ANATOMY AND PHYSIOLOGY
Blood Basics
Blood is a collection of specialized cells
suspended in straw-colored liquid called plasma.
Blood delivers oxygen and nutrients in the body
cells, collect waste, distribute hormones, spread
heat around the body to control the temperature
and play part in fighting infection and healing
injuries.
Blood forms about one-twelfth of the body
weighing of an adult, amounting to about 11 pints
(5 liters) in volume. Roughly 50-55 percent of the
blood is plasma, the liquid only-portion in which
cellular components are distributed. Plasma is 90% containing dissolve substances such as glucose(blood
sugar), hormones, enzymes, and also waste products such as urea and lactic acid.
Plasma also contains proteins such as
albumins, fibrinogen(important clotting factor) and
globular proteins or globulins help transport lipids,
which are fatty substance such as cholesterol.
Gamma globulins are mostly disease-fighting
substances that are known as antibodies. The
remaining 45-50% of blood is made up of 3 types
of specialized cells. Red cells or erythrocytes carry
oxygen; various white cells known as leukocytes
are part of defense system and cellular fragment
(platelets or thrombocytes) involved in the process
of clotting.
Two types of blood vessels carry blood throughout our bodies:
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1. Arteries carry oxygenated blood (blood that has received oxygen from the lungs) from the heart to
the rest of the body.
2. Blood then travels through veins back to the heart and lungs, where it receives more oxygen.
As the heart beats, you can feel blood traveling through the body at pulse points — like the neck and the
wrist — where large, blood-filled arteries run close to the surface of the skin.
The blood that flows through this network of veins and arteries is whole blood, which contains three types
of blood cells:
1. red blood cells (RBCs)
2. white blood cells (WBCs)
3. platelets
In babies and young kids, blood cells are made within the bone marrow (the soft tissue inside of bones) of
many bones throughout the body. But, as kids get older, blood cells are made mostly in the bone marrow of
the vertebrae (the bones of the spine), ribs, pelvis, skull, sternum (the breastbone), and parts of the
humerus (the upper arm bone) and femur (the thigh bone).
The cells travel through the circulatory system suspended in a yellowish fluid called plasma, which is 90%
water and contains nutrients, proteins, hormones, and waste products. Whole blood is a mixture of blood
cells and plasma.
Red Blood Cells
Red blood cells (also called erythrocytes) are shaped like slightly indented, flattened disks. RBCs contain
the iron-rich protein hemoglobin. Blood gets its bright red color when hemoglobin picks up oxygen in the
lungs. As the blood travels through the body, the hemoglobin releases oxygen to the tissues.
The body contains more RBCs than any other type of cell, and each has a life span of about 4 months.
Each day, the body produces new RBCs to replace those that die or are lost from the body.
White Blood Cells
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White blood cells (also called leukocytes) are a key part of the body's system for defending itself against
infection. They can move in and out of the bloodstream to reach affected tissues. Blood contains far fewer
WBCs than red blood cells, although the body can increase WBC production to fight infection. There are
several types of WBCs, and their life spans vary from a few days to months. New cells are constantly being
formed in the bone marrow.
Several different parts of blood are involved in fighting infection. White blood cells called granulocytes and
lymphocytes travel along the walls of blood vessels. They fight germs such as bacteria and viruses and
may also attempt to destroy cells that have become infected or have changed into cancer cells.
Certain types of WBCs produce antibodies, special proteins that recognize foreign materials and help the
body destroy or neutralize them. The white cell count (the number of cells in a given amount of blood) in
someone with an infection often is higher than usual because more WBCs are being produced or are
entering the bloodstream to battle the infection.
After the body has been challenged by some infections, lymphocytes "remember" how to make the specific
antibodies that will quickly attack the same germ if it enters the body again.
Platelets
Platelets (also called thrombocytes) are tiny oval-shaped cells made in the bone marrow. They help in the
clotting process. When a blood vessel breaks, platelets gather in the area and help seal off the leak.
Platelets survive only about 9 days in the bloodstream and are constantly being replaced by new cells.
Important proteins called clotting factors are critical to the clotting process. Although platelets alone can
plug small blood vessel leaks and temporarily stop or slow bleeding, the action of clotting factors is needed
to produce a strong, stable clot.
Platelets and clotting factors work together to form solid lumps to seal leaks, wounds, cuts, and scratches
and to prevent bleeding inside and on the surfaces of our bodies. The process of clotting is like a puzzle
with interlocking parts. When the last part is in place, the clot happens — but if even one piece is missing,
the final pieces can't come together.
When large blood vessels are severed (or cut), the body may not be able to repair itself through clotting
alone. In these cases, dressings or stitches are used to help control bleeding.
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Nutrients in the Blood
Blood contains other important substances, such as nutrients from food that has been processed by the
digestive system. Blood also carries hormones released by the endocrine glands and carries them to the
body parts that need them.
Blood is essential for good health because the body depends on a steady supply of fuel and oxygen to
reach its billions of cells. Even the heart couldn't survive without blood flowing through the vessels that
bring nourishment to its muscular walls.
Blood also carries carbon dioxide and other waste materials to the lungs, kidneys, and digestive system to
be removed from the body.
Blood cells and some of the special proteins blood contains can be replaced or supplemented by giving a
person blood from someone else via a transfusion. In addition to receiving whole-blood transfusions,
people can also receive transfusions of a particular component of blood, such as platelets, RBCs, or a
clotting factor. When someone donates blood, the whole blood can be separated into its different parts to
be used in this way.
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BOOK BASED PATHOPHYSIOLOGY:
35SAN LAZARO HOSPITAL
MODIFIABLE
Environmental conditions
NON MODIFIABLE
GeographicalRainy season
Age
Dengue virus circulates in the blood
Dengue virus is inoculated into humans within 3-14 days
Aedes aegypti acquires virus from a host
The virus is transferred into the susceptible host via bite of the
mosquito
8-12 days of viral replication on mosquito’s salivary glands
Virus disseminate rapidly into the blood
Itchiness/ redness in the area
Stimulates leukocytes especially B lymphocytes
Production and secretion of Ig’s & monocytes/
macrophages, neutrophils
Leukocytosis
DENGUE PERPETUAL HELP COLLEGE OF MANILA SECTION A4A1NOVEMBER 17, 2010 4
36SAN LAZARO HOSPITAL
Stimulates leukocytes and pyrogen release
Release of cytokines w/c consists of vasoactive agents such as IL, TNF, UK,
platelet activating factors
Recognition of dengue viral antigen on infected monocyte by cytotoxic T
cells
Monocytes/macrophages perform phagocytosis through Fc receptor
within the cells. Dengue virus replicates in the cells of monocytes/
macrophages
Antibodies bind to the viral antigens
Direct cellular destruction & infection of bone marrow & immunological
shortened platelet survival
Fever DiaphoresisWarm flushed skinMalaiseHeadache
Thrombocytopenia
Causes depressed platelet synthesis
Leukopenia
DENGUE PERPETUAL HELP COLLEGE OF MANILA SECTION A4A1NOVEMBER 17, 2010 4
CLIENT BASED PATHOPHYSIOLOGY
37SAN LAZARO HOSPITAL
MODIFIABLE
Environmental conditions
NON MODIFIABLE
GeographicalRainy season
Age
Dengue virus circulates in the blood
Dengue virus is inoculated into humans within 3-14 days
Aedes aegypti acquires virus from a host
The virus is transferred into the susceptible host via bite of the
mosquito
8-12 days of viral replication on mosquitos salivary glands
Virus disseminate rapidly into the blood
Itchiness/ redness in the area
Stimulates leukocytes especially B lymphocytes
Production and secretion of Ig’s & monocytes/
macrophages, neutrophils
Leukocytosis
Pleural effusion Edema
Capillary permeability
Dengue hemorrhagic fever
EpistaxisGum bleedingMelenaHematocheziaHematuria Abdominal pain
DENGUE PERPETUAL HELP COLLEGE OF MANILA SECTION A4A1NOVEMBER 17, 2010 4
38SAN LAZARO HOSPITAL
Stimulates leukocytes and pyrogen release
Release of cytokines w/c consists of vasoactive agents such as IL, TNF, UK,
platelet activating factors
Recognition of dengue viral antigen on infected monocyte by cytotoxic T
cells
Monocytes/macrophages perform phagocytosis through Fc receptor
within the cells. Dengue virus replicates in the cells of monocytes/
macrophages
Antibodies bind to the viral antigens
Direct cellular destruction & infection of bone marrow & immunological
shortened platelet survival
Fever DiaphoresisWarm flushed skin
Thrombocytopenia
Causes depressed platelet synthesis
DENGUE PERPETUAL HELP COLLEGE OF MANILA SECTION A4A1NOVEMBER 17, 2010 4
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Dengue hemorrhagic fever
Abdominal painMelena
Leukopenia
DENGUE PERPETUAL HELP COLLEGE OF MANILA SECTION A4A1NOVEMBER 17, 2010 4
LABORATORY REPORTS
Diagnostic Procedures
HEMATOLOGY
Hematology is the branch of internal medicine, physiology, pathology, clinical laboratory work, and pediatrics that is concerned with the
study of blood, the blood-forming organs, and blood diseases.
Name: Indepenso, Ryan Patient I.D. 020238
Age: 9 Sex: Male Hospital Number: 0134623
COMPONENTS RESULT Unit Normal Interpretation and Analysis
WBC 2.33 10^9/L 4.8-10.8 Virus attacks WBC and this is a normal finding In a patient with
dengue.
RBC 4.79 10^9/L 4.7-6.1 Normal
Hemoglobin 13.04 g/L 13-17 Normal
Hematocrit 40.78 % 40-52 Normal
MCV 85.15 Hq 87-98 Mean corpuscular volume (MCV) is a measurement of the average size
of your RBCs. When the MCV is decreased, your RBCs are smaller
than normal (microcytic) as is seen in iron deficiency
MCH 27.23 Pq 28-33 Mean corpuscular hemoglobin (MCH) is a calculation of the average
amount of oxygen-carrying hemoglobin inside a red blood cell.
Macrocytic RBCs are large so tend to have a higher MCH, while
microcytic red cells would have a lower value.
MCHC 31.98 g/L 33-36 Decreased MCHC values (hypochromia) are seen in conditions where
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the hemoglobin is abnormally diluted inside the red cells, such as in iron
deficiency anemia and in thalassemia.
Platelet 90 10^9/L 150-400 Destroys the body’s capacity to produce new platelets
RDW 13.09 % 11.4-19.0 Normal
Neutrophil 60.3 % 40-70 Normal
Lymphocytes 32.3 % 19-48 Normal
Eosinophil 0.7 % 2-8 Refer to Wbc
Monocytes 5.5 % 3-9 Normal
Basophils 1.2 % 0-2 Normal
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DRUG STUDY:
Drug Name Dosage,
Frequency,
Route
Action Indication Adverse Effect Contraindication Nursing Responsibilties
Generic:
Omeprazole
Brand:
Losec†‡, Prilosec,
Zegerid
Pharmacologic
Class: proton
pump inhibitor
Pregnancy
Category: C
Dosage: 20 mg
Frequency: OD
Route: IV
Inhibits activity of
acid (proton)
pump and binds
to hydrogen-
potassium
adenosine
triphosphatase at
secretory surface
of gastric parietal
cells to block
formation of
gastric acid.
GERD,
pathologic
hypersecretory
conditions,
duodenal ulcer,
helicobcter
pylori infection,
frequent
heartburn
CNS: headache,
dizziness,
asthenia.
GI: diarrhea,
abdominal pain,
nausea, vomiting,
constipation,
flatulence.
Musculoskeletal:
back pain.
Respiratory:
cough, upper
respiratory tract
infection.
Skin: rash.
Contraindicate in
patients with
hypersensitivity
with the drug.
Dosage adjustments
may be necessary in
Asians and patients with
hepatic impairment.
Drug increases its
own bioavailability with
repeated doses. Drug is
unstable in gastric acid;
less drug is lost to
hydrolysis because drug
increases gastric pH.
Caution patient to
avoid hazardous
activities if he gets dizzy.
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Drug Name Dosage,
Frequency,
Route
Action Indication Adverse Effect Contraindication Nursing Responsibilties
Generic Name:
Acetaminophen
Brand Name:
Paracetamol
Classification:
Paraminophenol
derivative
Pregnany
Category:
B
Dosage:250 g
Fraquency:
Q4, prn
Route:
Per Orem
Thought to
produce
analgesia by
blocking pain
impulses by
inhibiting
synthesis of
prostagalandin in
the CNS or of
other substances
that sensitize
pain receptors to
stimulation. The
drug may relieve
fever through
central action in
To relieve mild
to
moderate pain
due
to things such
as
headache,
muscle
and joint pain,
backache and
period pains. It
is
also used to
bring
down a high
temperature.
Hematologic:haem
olytic anmia,
leukopeia,
neutropenia
Hepatic: Jaundice
Metabolic:
Hyperglycema
Skin: rash,
urticaria
Hypersensitivity
to
acetaminophen.
Assessment & Drug
Effects
Monitor for S&S of:
hepatotoxicity, even
with moderate
acetaminophen doses,
especially in
individuals with poor
nutrition.
Patient & Family Education
Do not take other
medications (e.g., cold
preparations)
containing
acetaminophen
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the hypothalamic
heat-regulating
center.
For
this reason,
paracetamol
can be
given to children
after
vaccinations
to prevent post-
immunisation
pyrexia (high
temperature).
Paracetamol is
often included in
cough, cold and
flu
remedies
without medical
advice; overdosing
and chronic use can
cause liver damage
and other toxic
effects.
Tell patients to consult
prescriber before giving
drug to children younger
than 2.
Do not use for fever
persisting longer than
3 days, fever over 39.5°
C (103° F), or
recurrent fever unless
directed by prescriber.
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URSING CARE PLAN
1. Hyperthermia
CUESNURSING
DIAGNOSISINFERENCE
EXPECTED
OUTCOMESINTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE:
“Mainit po ang
pakiramdam ko.”
OBJECTIVE:
-Flushed skin
-Warm to touch
Vital signs taken
as follows:
T: 37.7˚C
PR: 102 bpm
RR: 26 cpm
BP: 100/80 mmHg
Hyperthermia
related to illness
as evidenced by
temperature of
37.7˚C
Exogenous
pyrogens (Dengue
virus)
Host cells
Endogenous
pyrogens
Hypothalamus
change in set
point
Fever (increase in
core temperature
to new set point)
After 30 minutes
of nursing
interventions, the
temperature of the
client will be
lowered to at least
37.5˚C or within
normal range of
37˚C
INDEPENDENT:
-provide tepid sponge
bath
-promote surface
cooling by means of
undressing
-provide cool
environment
-instruct client to
minimize movement
or maintain bed rest
-promotes heat
loss by
evaporation and
conduction
-promotes heat
loss by means
of radiation and
conduction
-promotes heat
loss by means
of convection
-to reduce
metabolic
demands of
After 30 minutes
of nursing
interventions, the
goal was not met
as evidenced by
the increase in
temperature of the
client rose to
37.8˚C.
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-discuss importance of
adequate oral fluid
intake particularly to
the parents
DEPENDENT:
-administer IV fluids
as ordered
-to prevent
dehydration
-to prevent
dehydration
2. ACUTE PAIN
Cues Nursing Inference Expected Nursing Rationale Evaluation
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diagnosis outcome interventions
Subjective:
I have severe
abdominal pain
Objectives:
Exhibited facial
grimace upon
body movement
Pain scale of 8/10
Vital signs taken
as follows:
Temp: 37.8 c
PR: 102 bpm
RR: 26 cpm
BP: 100/80mmHg
Acute pain related
to upper GI
bleeding
secondary to
dengue
hemorrhagic fever
Bite of infected
mosquito
Virus entered into
the blood
Virus attacks the
blood
Plasma leakage
Bleeding
Short term:
After one hour of
nursing
intervention, the
patient will:
~ Verbalize
gradual relief or
reduction of pain
Long term:
After two days of
nursing
intervention, the
patient will:
~ Verbalize
adequate relief of
pain or ability to
cope with
incompletely
relieved pain.
Independent
1.Assess pain
characteristics and
Severity
2. Encourage
verbalization of
feelings of pain
3. Provide comfort
measures and
encourage relative
to perform touch
therapy
4. Encourage and
assist to do deep
breathing exercise
1.To identify extent
of pain
2. Pain is
subjective and can
only be
experienced and
expressed by the
patient
3. To provide a
non pharmacologic
pain management
4 For relaxation
and can contribute
to pain relief
Short term:
After one hour of
nursing intervention,
the patient was able to:
~ Verbalize gradual
relief or reduction of
pain as evidenced by
absent of facial grimace
upon body movement.
Goal was met
Long term:
After two days of
nursing intervention,
the patient was able to:
~ Verbalize adequate
relief of pain as
evidenced by pain
scale of 4/10
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pain ~ Demonstrate
non pharmacologic
ways to lessen
pain
5. Teach the
client and
significant
others about
non
pharmacologic
ways to lesson
pain
6. Notify physician
if regimen is
inadequate
Collaborative:
1. Administer
medications as
prescribed.
2. Assist with
laboratory and
diagnostic studies
as indicated.
5. To maximize
their opportunities
for self control
over
manifestations of
pain
6. To meet pain
control goal.
.
1.To relief or
maintain
acceptable level of
pain
2. To determine
changes
indications of
healing or
~ Demonstrate non
pharmacologic ways to
lessen pain
Goal was met.
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complications and
to identify
precipitating
factors
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DIAGNOSTIC EXAMINATIONS
Tourniquet Test
It is a test to determine the vascular resistance and platelet function. It an ancillary test but not considered as a confirmatory test.
Place the cuff of a sphygmomanometer around the arm in the usual manner and inflate to a pressure halfway between systolic and diastolic levels. Maintain compression for five minutes and wait two minutes or more before observation. Describe an area 1-square inch on the volar surface of the forearm 1-1/2 inches distal from the antecubital fossa. Count the petechiae within this prescribed area. A positive tourniquet test is > 20 petechiae.
Total White Blood Cells Count
In case of dengue, this test will reveal leukopenia. The presence of leukocytosis and neutrophilia excludes the possibility of dengue and bacterial infections (leptospirosis, meningoencephalitis, septicemy, pielonephritis etc.) must be considered.
Thrombocytopenia (< 100.000 /mm3)
Total platelets count must be obtained in every patient with symptoms suggestive of dengue for three or more days of presentation. Leptospirosis, measles, rubella, meningococcemia and septicemy may also course with thrombocytopenia.
Hematocrit (micro-hematocrit)
According to the definition of DHF, it is necessary that there is a presence of hemoconcentration (hematocrit elevated by > 20%); when it’s not possible to know the previous value of hematocrit, we must regard as significantly elevated the results > 45%.
Bleeding Parameters
Bleeding Time = 1-3 minutes Clotting Time = 3-5 minutes
Prothrombin Time = 12-15 seconds
Activated Partial Thromboplastin Time = 30-40 seconds
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MEDICAL MANAGEMENT
Supportive and symptomatic treatment should be provided.
For fever, give paracetamol for muscle pains. For headache, give analgesic. Do not give aspirin.
Rapid replacement of body fluid is the most important treatment.
Includes intensive monitoring and follow-up.
Give ORESOL to replace fluid as in moderate dehydration at 75ml.kg in 4-6 hours or up to 2-3L in
adults. Continue ORS intake until patient’s condition improves.
IVF (PLR)
Intravenous fluid therapy is recommended when danger signs are present, especially during
defervescence. Crystalloids (D5LRS or D5NSS or PLRS or PNSS) can be given at 5-15
ml/kg/hour, with periodic adjustment according to patient's subsequent response. The vital signs
and urine output are important parameters to monitor response to IVF therapy. When the patient is
in shock, IVF must be given at a faster rate and bigger volume, the 20/20 rule, that is, 20ml/kg in
20-30 minutes. After adequately replacing the fluid losses, maintenance IVF therapy should be
instituted. D5LRS or D5IMB if < 2 yrs old may be used and should be given at 3 ml/kg/hr up to 2-3
liters per day in adults. Patients usually require IVF therapy for 24-48 hours
H2-antagonists – anti-ulcer (proton pump, antacids)
Plasma Expanders –Dextran
Blood Transfusion:
1. Platelet Concentration
2. PRBC
3. Fresh Whole Blood
4. Fresh Frozen Plasma
5. Cryoprecipitate
Monitor platelet count and hematocrit level
Baseline platelet count should be available at any stage of dengue hemorrhagic fever. Serial
determinations may be required during the defervescence stage to anticipate the onset of shock or
to detect occult bleeding. After recovery with fluid replacement, platelet count and hematocrit may
be repeated just before discharge.
NURSING MANAGEMENT
Provide a comfortable, dim and quiet room for rest.
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Advise to increase oral fluid intake.
Watch out for bleeding manifestations.
For hemorrhage – keep the patient at rest during bleeding episodes. For nose bleeding, maintain
an elevated position of trunk and promote vasoconstriction in nasal mucosa membrane through an
ice bag over the forehead. For melena, ice bag over the abdomen. Avoid unnecessary movement.
Observe signs of shock such as low pulse, cold clammy perspiration, prostration. Dorsal
recumbent position facilitates circulation.
Diet – DAT EDCF and drinks.
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DISCHARGE PLANNING (METHODS)
M – Instruct the patient’s mother the importance of compliance to medicines to achieve appropriate
therapeutic effects. Take Paracetamol for fever, if the patient’s temperature is 38 degrees Celsius and
above and Vitamin C to increase immune system.
E – Tell the patient that he may have to decrease his activities and may not be allowed to do any hard
exercises for faster recovery.
T – Emphasized the proper treatment if the signs and symptoms of DHF reoccur. Proper TSB (Tepid
sponge bath) if there is a fever, increasing the fluid intake except for colored drinks and seek the
professional health team.
H – Advice the patient’s mother to guide and follow the balance diet and to have adequate rest and sleep
of his son. Instructed the patient’s mother to provide insect repellants (natural or synthetic) for him and
emphasized the environmental cleanliness is a must. Advise patient to seek medical help if the sign and
symptoms
occur:
Shortness of breath ▪Symptoms of underlying disorders (wheezing, coughing)
Swelling of the feet or ankles ▪ Intolerance
Chest discomfort
- For some complications of DHF
O – Instructed patient to have follow-up checked-up @ OPD 2 weeks
after discharge from the hospital.
D - Suggest the patient to eat healthy foods from all of the 5 food
groups: fruits, vegetables, breads, dairy products, meat and fish.
Eating healthy foods may help her feel better and have more energy.
She may be told to eat foods that are low in fat and salt.
S - Advise patient to always pray to our lord and never lose hope in
any obstacle that we may encounter.
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DENGUE PERPETUAL HELP COLLEGE OF MANILA SECTION A4A1NOVEMBER 17, 2010 4
EVALUATION
We met the objective we post at the beginning of this case study. We gained knowledge
about the related factor hinged in Communicable Disease like Dengue, through our clients we are able to
apply the nursing intervention needed for their situation. With this, as our fundamental foundation, we can
provide the expected care management and health teaching for our clients with this kind of condition. In
addition to this the case study, it also identify and determine the general problems and needs of the patient
with Dengue. The proper evaluation concerning the nursing management of client has also been aptly
accomplished. This presentation was able to help the patient promote health, prevention of disease and
medical understanding of such condition through the application of nursing skills.
RECOMMENDATION
The absence of danger signs allows the treatment of dengue hemorrhagic fever at home. Hospitalized
patients may be sent home if they have remained afebrile for at least 72 hours or if the danger signs have
resolved. However Primary prevention of dengue mainly resides in mosquito control. We can eliminate
vector by changing water and scrubbing sides of lower vases once a week, destroying the breeding places
of mosquito by cleaning surroundings, having a proper disposal of rubber tires, empty bottles and cans and
cleaning all stagnant water and water containers and make sure to cover these. The Department of Health
has a new program called the 4S: (a) Search and destroy (b) Self-protection measure (c) Seek early
consultation (d)Say yes to defogging during an outbreak.
For the Nursing student who will be assigned to San Lazaro wherein they will encounter
communicable diseases such as Dengue can gain knowledge by reading this case study we prepared. This
case presentation is an appropriate tool that will meet the current information needs of individuals, and
guide to promote health. They must be first equipped with the proper basic knowledge about the Anatomy
and Physiology of the system involved in this case. This case presentation also recommended to nursing
students who have patients with Dengue to use this presentation as an instrument or a source of
background knowledge about the said problem.
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DENGUE PERPETUAL HELP COLLEGE OF MANILA SECTION A4A1NOVEMBER 17, 2010 4
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