BULACAN STATE UNIVERSITY COLLEGE OF NURSING City of Malolos

A CASE OF PATIENT WITH DENGUE FEVER SYNDROME

SUBMITED BY: Caidoy, Honey Angel V. BSN-3D Group 2

SUBMITTED TO: Rosel Calderon, RN

NURSING HEALTH HISTORY A.BIOGRAPHIC DATA NAME: Patient NR AGE: 15 y/o GENDER: Female ADDRESS: Sto. Nio, Calumpit, Bulacan MARITAL STATUS: Child OCCUPATION: Student RELIGION: Roman Catholic BIRTHDAY: May 4, 1996 BIRTHPLACE: Sto. Nio, Calumpit, Bulacan EDUCATIONAL ATTAINMENT: 3rd year high school POSITION IN THE FAMILY: 3rd child of the family HEALTH CARE FINANCING: Primary Source DATE OF ADMISSION: September 7, 2011 TIME OF ADMISSION: 2:00 pm INITIAL DIAGNOSIS: Dengue Fever Syndrome

B.CHIEF COMPLAINT and REASON FOR VISIT

The patient was admitted to the hospital with the chief complaint of vomiting and with 5 days intermittent fever.

C.HISTORY OF PRESENT ILLNESS

On September 11, 2011 patient NR, a 15 year old girl who was admitted with positive vomit, headache, abdominal fever and 5 days intermittent fever. She was given immediate management, few hours prior to arrival in the hospital of the clients fever and painful headache. Client says that when shes in their home she just take paracetamol for her headache.

D.HISTORY OF PAST ILLNESS

The patient does not confine in the hospital since she was a child. The patient has complete vaccination. . She doesnt have any allergies to drugs, food, and environmental factor such as dust and smoke. When he has a cold, cough or fever, she doesnt take any medicine, she just takes a rest to make herself relieve.

E.FAMILY HEALTH ILLNESS HISTORY (GENOGRAM) Clients grandmother on both father and mother side dont have any type of inherited disease, as well as the health of her aunties and uncles.

LEGEND:

MATERNAL

- MALE DECEASED - FEMALE

? UR AGE UR- UNRECALLED ( ) - CAUSE OF LM

PATERNAL

PM LM

DEATH

ER

? A/W

60 A/W

? UR

? A/W

CD

RB

JR

RM

AR

NR

NR

UR MR

46 A/W

? UR

42 A/W

38 A/W

50 A/W

? A/W

? UR

? UR

41 A/W

? ( HYDROCE PHALUS)

38 A/W

JR

NR

N R

JR

19 A/W

16 A/W

15 DENDUE

10 A/W

F.FUNCTIONAL HEALTH PATTERN (GORDON) PATTERN A .HEALTH PERCEPTION AND HEALTH MANAGEMENT PRIOR TO HOSPITALIZATION According to patient when she was in the house, she always stays in the bed and she loses her appetite because of her illness. She eats, but a small amount only. She thinks that her disease is caused by the change in environment. She doesnt take any kind of vitamins. When shes not feeling well, she just takes a rest. SEPT. 5 SEPT. 6 SEPT. 7 (prior to 2:00 pm) 1 bowl (250ml) of porridge glass (120ml) of water LUNCH DINNER 5 pcs. of quail eggs 500ml of mineral water DURING HOSPITALIZATION During hospitalization, my patient stated that she feels well while shes in the hospital. She takes her medicine, paracetamol 250 mg/ 5mL as prescribed by the doctor. She also said that she has s cough.

B. NUTRITIONAL METABOLIC PATTERN

SEPT. 7 BREAKFAST -

SEPT. 8 1 cup (160g) of noodles 500ml of mineral water -

BREAKFAST cup (80g) of plain rice 1 bowl (250ml) of noodles glass (120 ml) of water LUNCH 1 glass (240 ml) of milk

1 pc. Of pandesal bottle (250ml) of Gatorade

1 pc. Of pandesal glass (120ml) of water

2 pcs. of bread glass (120ml) of water

The patient drinks more amount of water than the previous day, ranges 2-5 glasses of water. She doesnt lose her appetite. She can eat anything except foe dark colored foods, because it is the doctors order.

DINNER

cup (80g) of plain rice 1 scrambled egg glass (120 ml) of water

1 cup (160g) of rice 1 scrambled egg 1 glass (240ml) of water

The patient drinks 1-2 glasses of water. She thinks that even though she loses her appetite, she still gains weight. Her skin is dry. She has one tooth with dental carries. She can eat anything. If she has a wound, it heals fast. C. ELIMINATION PATTERN URINE SEPT. 5 SEPT. 6 SEPT. 7 (prior to 2:00 pm) URINE FREQUENCY AMOUNT CHARACTER Cloudy ,aromatic odor ISTICS Cloudy ,aromatic odor Cloudy ,aromatic odor SEPT. 7 1 SEPT. 8 1

FREQUENCY AMOUNT CHARACTER ISTICS

The patient still urinates 1-2 times a day. But for her, she tries to drink a lot because it is the doctors and nurses advised.

The patient urinates 1-2 times only because she doesnt drink lots of water. She said that she doesnt like the taste of the water. STOOL SEPT. 5 SEPT. 6 SEPT. 7

(prior to 2:00 pm ) FREQUENCY AMOUNT CHARACTE RISTICS Formed, brown in color, pungent odor Formed, brown in color, pungent odor 1 1

STOOL FREQUENCY AMOUNT CHARACTER ISTICS

SEPT. 7 O

SEPT. 8 1

Formed, brown in color, pungent odor

Her bowel movement was still normal. She doesnt find any difficulty in defecating.

Her bowel movement is normal, ranges 1-2 times daily. The client perspires normally depends on her activity

D. ACTIVITY EXERCISE PATTERN

The patient is able to do anything, but she doesnt do any household chores whenever she doesnt have a class. She always lies on bed and keep on texting the whole day. She doesnt have any form of exercises. _0_ Feeding _0_ Bathing _0_ Toileting _0_ Bed Mobility _0_ Dressing _0_ Grooming _0_ General mobility _0_ Cooking _0_ Home maintenance _0_ Shopping

The client always stays in bed. She doesnt take any exercises too. If she has a spare time, she just takes a sleep for a while. _0_ Feeding _0_ Bathing _0_ Toileting _0_ Bed Mobility _0_ Grooming _0_ General mobility _0_ Cooking _0_ Dressing

Level 0 Full self-care Level I - Requires use of equipment/ device Level II Requires assistance or supervision from another person Level III Requires assistance or supervision from another person or device Level IV Is dependent and does not participate

Level 0 Full self-care Level I - Requires use of equipment/ device Level II Requires assistance or supervision from another person Level III Requires assistance or supervision from another person or device Level IV Is dependent and does not participate

E. SLEEP-REST PATTERN SEPT. 5 Time of sleep 9 pm Time of 6am waking up Nap 3:00pm -4:00pm Total no. of 9 hours hours SEPT. 6 9pm 6am 2:00pm 3:00pm 9 hours SEPT. 7 (prior to 2:00 pm) 9pm 6am 9hours Due to her illness and new environment patient experienced sleep disturbances and short period of sleep. Sometimes she wakes up in the middle of the night, and then shes not able to sleep again. She stays in bed most of the time and does texting to divert her boredom. She always takes a rest, but if she is turning to her side, she feels something painful on her stomach. She just ignores it and doesnt report to the health provider. When I asked her to rate the pain from 10 as the highest and the most painful up to 1 as the lowest and less painful, she says it is 4/10. My patient says that shes weak. That she can get illnesses every time. But on her stay in the hospital, she feels comfortable because her naughty siblings were not there to make fun of her. If shes irritated because of her brother whos with her, she just tolerates and takes e rest to ignore her irritation. SEPT. 7 Time of sleep Time of waking up Nap Total no. of hours SEPT. 8 10pm 4am 6hours

Approximately, my patient sleeps from 9pm-6am. She sleeps easily and doesnt find any difficulty. Her sleep is normal and do not find any interruption. She also takes a nap in the afternoon from 3pm-4pm. F. COGNITIVE-PERCEPTUAL PATTERN The client is able to hear and read clearly and normally because of her age and shes still young. She stated that doctors and nurses order were easy to follow especially if theres an example. Because of her illness, she always had a headache. She just take a rest to divert the pain and to feel relax. My patient says that when shes outside the house, she is well. But when she arrives home she becomes unwell because of her siblings. Her things were always used by her siblings without her permission, thats why she is irritated and becomes angry with them. And always make a fight with them.

G. SELF-PERCEPTIONANG SELFCONCEPT PATTERN

H. ROLE-RELATIONSHIP PATTERN

My patient lives with her father and mother and with her 3 brothers. They belong to a nuclear type of family. They lived on their own house. Their common problems are about financial matters. Her father was a construction worker and her mother is a housewife. Sometimes their school allowances were not enough thats why her parents seek help from their relatives through borrowing money. She said that they were naughty, that they were the one who blocked the canal thats why she got dengue fever. My patient got her first menstrual period when she was 10 years old. According to her it ranges up to 6 days and it is regular. She doesnt experience dysmenorrhea. When she has a problem, she always talks to her mother. She is open about her own problems as always. She doesnt like being disturbed by her family. She likes to be on herself. She says that shes not open to God, she doesnt pray sometimes and she doesnt go to church every mass. But she knows that God could help her anytime.

While shes on the hospital she feels sad especially when shes alone and her brother is not around. Her family were also sad because of her illness.

I.SEXUALITY REPRODUCTIVE PATTERN J. COPING-STRESS TOLERANCE K.VALUE-BELIEF PATTERN

My patient has her menstrual period now. And it is her second day. My client says that by now she has a problem, and it is sensitive. It is her best friends secret as well as her too. She always prays to God. She says that by doing this, God will remove her illness so that she can go home.

PATHOPHYSIOLOGY OF DENGUE FEVER SYNDROME: Breeding sites

Female aedes

Salivary gland

Monocyte, lymphocyte, endothelial cell

Histamine

Antibodies

Mast cell

Increased gastric juices

Gastrointestinal irritation

Abdominal pain

Dehydration

Decreased platelets

Decreased Hematocrit

Decreased coagulation factor

Dengue virus

WBC

Trigger hypothalamus

Increased body Temperature

Dengue Fever PHYSICAL ASSESSMENT NAME: Patient NR DATE: September 8, 2011

AGE: 15 y/o V/S: T: 37.5 C RR: 29 cpm PARTS TO BE ASSESSED GENERAL APPEARANCE Signs of distress in posture or facial expression Obvious signs of health or illness SKIN Skin lesions Inspect Inspect PR: 71 bpm BP: 90/60 mmHg TECHNIQUES

GENDER: Female WEIGTH: 50 kg

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

INTERPRETATION

No distress noted

There were signs of distress NOT NORMAL noted on clients posture and/ Pale, weak in appearance NOT NORMAL

Due to lack of sleep

Inspect

Healthy appearance

Due to lack of sleep and illness

Freckles, some birthmarks, some flat and raised nevi; no

With scars on her left upper NOT NORMAL arm, due to BCG

Rashes due to dengue

NOSE Presence of redness, swelling, growths and discharge of nares using the flashlight Inspect Mucosa pink, clear, watery discharges, no lesions. With discharges NOT NORMAL Due to colds

LABORATORY:

September 7, 2011 HEMOGLOBIN HEMATOCRIT PLATELET COUNT

FINDINGS: Normal Value: Female: Male: Child:

121g/L

0.39

107, 000

120-180g/L 140-180 g/L 140-280 g/L

0.38 o.47 0.40-0.54 0.44-0.64

Adult: Child:

140-440x10cumm 250-470x10cumm

a.IV FLUIDS MEDICAL MANAGEMENT DATE ORDERED CLASSIFICATION INDICATION CLIENT RESPONSE NURSING RESPONSIBILITIES

D5LR 1000cc Regulated at 83 gtts/ min

September 7 ,2011

Hypertonic- Non pyrogenic, parenteral fluid, electrolyte and nutrient replenisher.

-Treatment for persons needing extra calories who cannot tolerate fluid overload. - Treatment of shock.

The patient responded well with no signs of irritation and overdose reaction.

> Do not administer unless solution is clear and container is undamaged. > Caution must be exercised in the administration of parenteral fluids, especially those containing sodium ions to patients receiving corticosteroids or corticotrophin. >Solution containing acetate should be used with caution as excess administration may result in metabolic alkalosis. >Solution containing dextrose should be used with caution in patients with known subclinical or overt diabetes mellitus. > Discard unused portion. > In very low birth weight infants, excessive or rapid administration of dextrose injection may result in increased serum osmolality and possible intracerebral hemorrhage.

b.DRUGS GENERIC/BRAND NAME PARACETAMOL ACTION INDICATIONS CONTRAINDICATION Hypersensitivity; intolerance to tartrazine, alcohol, table sugar. Anemia, cardiac $ pulmonary disease. Hepatic or severe renal disease ADVERSE EFFECT NURSING RESPONSIBILITY

BIOGESIC

Decrease fever by Relief of mild to moderate inhibiting the effects of pain. pyrogens on the hypothalamic heat Treatment of fever regulating centers and by a hypothalamic action leading to sweating and vasodilation.

Simulation, drowsiness, PRIOR Assess patients fever or nausea, vomiting, pain, location, intensity, abdominal pain, duration, temperature, hepatotoxicity, hepatic diaphoresis. seizure (overdose), renal DURING failure (high, prolonged Assess allergic reactions: doses), leukopenia, rash urticarial neutropenia, hemolytic Assess hepatotoxicity. anemia,(long term Check I&O use),allergic skin reactions Assess for chronic positioning & GI disturbance. AFTER Teach patient to recognize sign of chronic overdose: bleeding. Bruising, malaise, fever, sore throat. Inform patient that urine may become dark brown as a result of phenacetin (metabolite of acetaminophen). Tell patient to notify prescriber for pain or fever lasting for more than 3 days Transient and reversible changes in liver function PRIOR

RANITIDINE

Inhibits histamine at H2 receptor site in the

Gastro esophageal disease in pathological hyper

Severe renal impairment.

gastric parietal cells, which inhibits gastric acid secretion.

secretory conditions.

test. Reversible hepatitis (hepatocellular, hepato canalicular or mixed) with or without jaundice. Skin rash.

Assess with cautions in presence of renal/hepatic impairment.

DURING Assess allergic reactions: rash urticarial Assess hepatotoxicity

AFTER Do not take any new medication during therapy without consulting physician Follow diet ass physician recommend

NURSING CARE PLAN ASSESSMENT SUBJECTIVE: Nahihirapan akong matulog, as verbalized by the client NURSING DIAGNOSIS Sleep deprivation related to uncomfortable sleep environment as manifested by presence of eye bags and malaise PLANNING LONG TERM GOAL: After 8 of nursing intervention, my patient will be able to achieve optional INTERVENTION INDEPENDENT: Determine clients usual sleep pattern and expectations. Provides comparative baseline. RATIONALE EVALUATION LONG TERM GOAL: Goal met. After 8 of nursing intervention, my patient was able to achieved

amount of sleep. OBJECTIVES: Restlessness Irritability Inability to concentrate Sunken eyeballs Yawning Fatigue SHORT TERM GOAL: 1to identify individually appropriate interventions to promote sleep. 1to verbalize understanding to sleep disorder. 2to adjust lifestyle to accommodate chronobiological rhythms. 2to report improvement in sleep/rest pattern.

Determine interventions client has tried in the past. Instruct client and/or bed partner to keep a sleep-wake log. Promote adequate physical exercise activity during day.

Helps identify appropriate options. Document symptoms and identify factors that are interfering with sleep. Enhances expenditure of energy/ release of tension so that client feels ready for sleep/ rest. They impair ability to sleep at night.

optimal amount of sleep.

SHORT TERM GOAL: Goal met. Identified individually appropriated interventions to promote sleep. Goal met. Verbalized understanding to sleep disorder. Goal met. Adjusted lifestyle to accommodate chronobiological rhythms. Goal met. Reported improvement in sleep/rest pattern.

Suggest abstaining from daytime naps.

DEPENDENT:

Administer sedatives/ other sleep medications, when indicated, noting clients response.

Reduce need for re dosing during prime sleep hours.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: Pakiramdam ko sakitin ako, as verbalized by the client.

Situational low self-esteem related to loss of health status and development changes like adolescence

LONG TERM GOAL: After 8 of nursing intervention, my patient will be able to express positive self-appraisal.

INDEPENDENT: Assess degree of threat/perception of client in regard to crisis. Some people view a major situation as manageable, while another person may be overly concerned about a minor problem. May provide client with support or reinforce negative self-evaluation.

LONG TERM GOAL: Goal met. After 8 of nursing intervention, my patient was able to expressed positive selfappraisal.

OBJECTIVE: Self-negating verbalization Indecisive behavior Facial grimace Irritation SHORT TERM GOAL: 2 to verbalize understanding of individual factors that precipitated current situation. 2to identify feelings and underlying dynamics for negative perception of self. 2to demonstrate behaviors to restore positive esteem. 2to participate in treatment regimen/activities to correct factors that precipitated crisis. Verify clients concept of self in relation to cultural/religious ideals. Identify previous adaptions to ill ness/disruptive events in life. Encourage expression of feelings, anxieties. Assist client to problem solve situation, developing plan of action and

SHORT TERM GOAL: Goal met. Verbalized understanding of individual factors that precipitated current situation.

Goal met. Identified May be predictive of feelings and underlying current outcome. dynamics for negative perception of self. Facilities grieving loss. Enhances commitment to plan, optimizing outcomes. Goal met. Demonstrated behaviors to restore positive esteem. Goal met. Participated in treatment regimen/activities to correct factors that precipitated crisis.

setting goals to achieved desired outcome. Encourage client to set long-range goals for achieving necessary lifestyle changes. Support view that this is an ongoing process.

DISCHARGE PLANNING Medication: Intake of appropriate vitamin supplement and diuretics to increase protection mechanism of the immune system and decreases renal vascular resistance and may increase renal blood flow, respectively. Exercise: The use of non-pharmacotherapy such as drinking plenty of water will promote increase plasma in blood to increase immunity and proper hygiene and promotion of cleanliness at home and work area. Treatment: Management of such condition would be through hydration and doing control measures to eliminate vector by promoting cleanliness in the environment through proper disposal of rubber tires, changing of water of lower vases once a week, destruction of breeding places of mosquito and residual spraying with insecticides. Hygiene: Advise to follow proper body hygiene and to maintain cleanliness on surroundings. This would prevent additional cases of Dengue Hemorrhagic Fever. Out Patient:

Any odd signs such as fever, petechiae, recurrence of fever, etc. must be immediately reported to the physician. Diet: Instruct to eat foods that are low fat, low fiber, non-irritating and non-carbonated. Health Teaching: Discussed the possible source of infection of the disease. Educated the family/patient on how to eliminate those vectors. Never stocked water in a container without cover. Gallon, container and tires must have proper way of disposal. Use insecticides at home to kill or reduce mosquito. Encourage the family of the patient to clean the surroundings to destroy the breeding places of mosquito.