COLEGIO DE SAN JUAN DE LETRAN – CALAMBA

School of Nursing
Calamba City, Laguna

DENGUE HEMORRHAGIC FEVER: A

CASE STUDY

Submitted by:
BIÑAS, MAYET O.
BONIFACIO, CYRIL S.
BUGUIS, JOHARA A.
BURGOS, MYRILL L.
CAASI, HECTOR ANTHONY A.
CABALFIN, APRIL RHOSE E.
CALDERON, APRIL EVISON A.
CALUPIG, LOURINE A.
CAMO, RACHEL ANNE D.
CANICON, HAZELLE G.
CAPIO, RENE C.
CAPURIHAN, CRIZZA JOY T.
CARIÑO, JENNIFER
CARMONA, MARICEL M.
4BSN1/GROUP III
Introduction

Background of the Study

Dengue hemorrhagic fever is an acute febrile diseases found in tropics.It is a

complication of Dengue fever with hemorrhages. It is characterized by abnormal
vascular permeability, hypovolemia and abnormal blood clotting mechanism.

The Dengue virus type 1,2,3,4, along with other arboviruse which are chikungunya, O’
nyong-nyong, west nile and flavi virus are classified as the causative agents. The vector
 responsible for the transmission of the virus is the domestic, day- biting mosquito
known as the Aedes aegypti.The vector responsible for the transmission of the virus is
the domestic, day-biting mosquito known as the Aedes aegypti.

Rationale for choosing the case

The researchers decided to choose this case because they wanted to acquire more
knowledge about Dengue Hemorrhagic Fever II. They wanted to use the knowledge
they have acquired in promoting awareness to the people especially the underprivileged
that they should seek for medical care in order to prevent the development and
progression of Dengue Hemorrhagic Fever. The researchers also wanted to focus on
preventive measures.

Significance of the Study

This study will help the nursing profession by providing information about the proper
management and care for patients who have Dengue Hemorrhagic Fever. It will also
educate the people, especially those who have Dengue Hemorrhagic Fever and
vulnerable individuals to seek medical care in order to prevent dengue Hemorrhagic
Fever. It will increase awareness about the importance of having a healthy lifestyle.

This study will elaborate the interrelatedness of lifestyle habits and developing Dengue
Hemorrhagic Fever.

Scope and Limitation of the Study

This study is focused on the nursing aspect of care to those patients who had, currently
have and are at risk for Dengue Hemorrhagic Fever. This study will only be used in the
nursing profession. The researcher will only be focused their attention on the
medications, diagnostics, care plan, pathophysiology and discharge planning. This study
is not limited to patients who have Dengue Hemorrhagic Fever only, but it is also for all
the people who are interested in the disease. We are more focused on the primary
prevention through health education because primary prevention is the true prevention.
Patient’s PROFILE
Biographic Data:
Name: Patient XL Case No: 05-992216
Age/Sex: 9/Female Civil status: Child
Birthdate: December 22, 2000 Religion: Roman Catholic
Birthplace: Makati Medical Center
Occupation: grade three student
Present address: Parian, Calamba City, Laguna
Date of Admission: July 18, 2009
Attending Physician: Dr. Moran, LBDH
Admitting Diagnosis: DHF II
Chief complaint: abdominal pain; episodes of vomiting
HISTORY OF PRESENT ILLNESS
The patient is a 9 year-old female, a grade three student who was diagnosed with Dengue
Hemorrhagic Fever II.
Five days prior to admission the client suffers from having a high fever with a temperature of
39. 4 degrees celcius, Paracetamol was given for relief. After three days the fever subsides and
abdominal pain and vomiting of brownish colored vomitus takes place. Due to persistence of the said
signs and symptoms, the patient seek consultation and hence admitted at Los Baños Doctors’ Hospital
Medical Center with Dr. Moran as her attending physician.
Upon admission the child has experienced gum bleeding with presence of petechiae over the
face and lower extremities accompanied by loss of appetite. Hematology examination shows low
platelet count with a value of 100 mm3.
During the interview session she has a fever and experiences no gum bleeding at all. Her
abdominal pain becomes intermittent.
PAST MEDICAL HISTORY
According to the patient’s mother, she experienced having urinary tract infection when she was
five years old. The patient only experiences having common cough and colds occasionally. She also
experiences fever before and it was relieved by over the counter drugs and rest. Their family does not
seek consultation for regular health check up. She has not been hospitalized and only seeks consultation
to their Baranggay Health Center whenever any health problem arises. She did not receive an
immunization vaccine for measles. She also denies having allergies to food and drugs. She says that she
is allergic to dust and particles.

FAMILY HISTORY

The patient has a family history of hypertension. Her mother and father are both hypertensive.
Her eldest sister is 23 years old, alive and healthy. Followed by a 21 year old male, 20 year old female,
15 year old female which are alive and healthy also and the last is the patient, the youngest.

Activities of Daily Living

Gordon’s Functional Before During Hospitalization

Health Patterns

Health Perception and
Health Management
Pattern
The patient sees her pattern She believes that wellness
of health as normal as she will be attained if doctor’s
suffered from no serious orders are to be strictly
illnesses before. She manages followed.
her health by following her
mother’s instructions such as
sleeping early and eating
foods on regular basis. She
also follows proper personal
hygiene for her to become
healthy.

Nutritional and Metabolic The patient usually eats The patient is forbidden to eat
Pattern vegetables because they have dark-colored foods,
many of it planted in their carbonated drinks and junk
backyard. She said that her foods.
favorite food is junk foods
especially chips and salty
foods. She is also fond of
 eating sweets such as
chocolates and candies. She
usually drinks up to 6 glasses
of water a day including
other beverages. She is not
taking any vitamin
supplements.

Elimination Her elimination pattern has During her confinement, she

somehow deviated from her now urinates 5 times a day
usual urine and stool and defecates 3 times a day.
elimination. Before her According to her the variation
confinement, she usually from her elimination pattern
urinates for 7 times a day and is due to change in appetite
defecates at least 2 times per and setting.
day.

Rest and Activity A typical day to her would be She plays board games with
waking up at around 6:00 am her other siblings during
to attend her school. She goes confinement. She usually
home at 4:00 in the wakes up at 8 o’clock in the
afternoon. She does her home morning, takes nap after
works before eating dinner. lunch and goes to sleep at 10
She goes to sleep at 9:00 p.m. o’clock in the evening.
During her spare time, she
plays hide and seek,
patintero and piko with her
classmates.

Sleep-Rest Pattern The client doesn’t have any She usually wakes up at 8
difficulty in sleeping pattern. o’clock in the morning, takes
She sleeps at around 8 in the nap after lunch and goes to
evening and wake up early. sleep at 10 o’clock in the
She doesn’t have the habit of evening.
sleeping at daytime. She
usually drinks Milk before
she goes to Sleep and she
usually sleeps at about 10
hours daily.

Cognitive-Perceptual The patient is able to read Patient’s mother brings with

Pattern and write. She is currently in them her books to refresh her
grade three in elementary of the missed lessons in
education and portrays a school.
sharp memory when asked
about past experiences and
significant others. She also
has good eyesight and has a
 normal functioning for her
senses and perception.

Self-Perception and Self She views herself as a She has good body posture
Concept Pattern student. A student who needs and was able to maintain eye
to fulfill her dreams through contact upon interview.
studying hard. She also stated
that she is a jolly, smart and
caring individual.

Role-Relationships Pattern She is the youngest among Relationship with the family
her siblings. She helps the members is intact, it is
other family members by evidenced by their presence
doing and following little during their youngest
tasks whenever they ask her sibling’s confinement. They
to do so. The patient has a play board games, and give
good family relationship. She their youngest sibling
states that she is happy with pasalubong like fruits.
them and they care and love
her so much.

Sexuality-Reproductive Patient denies having

Pattern secondary characteristics like
pubic hair and axillary hair.
But she confirms that her
breasts are becoming bigger
than usual.

Coping-Stress Pattern As a child she also deals with Her status now of being sick
some of stressful events is one of the greatest stressor
everyday. When she was in for the client and she was
school her teacher helps her
able to cope up because of the
with
help of the significant others
her study and school works.
She manages her problems
with the help of the
significant others.

Values-Belief Pattern The client is a catholic and

she usually goes to church
every Sunday with her
family. She state that being
 polite to them and
Following elderly them is an
important value for her. She
uses “po” and “opo” when
talking to her elder siblings.

V. Physical Assessment

BP: 100/90 mmhg

PR: 78 bpm

Temperature: 38.6 degrees celcius

RR: 18 bpm

Area Assessed Method Used Normal Actual Findings Rationale

Findings

SKIN

Color and Inspection Light to deep General flushing, Indicative of

pigmentation brown rashes bleeding

Inspection No lesions, but Normal

Lesions No lesions, scars presence of scars
or inflammation
Inspection Smooth Normal
Texture
Inspection Dry Due to imbalance
Smooth
Moisture fluid in the body
Moist
Inspection Warm Normal
Temperature
Warm

Pale
Imbalance
NAILS Inspection between
hemoiglobin and
Nail bed color Pink Convex
hematocrit results
Inspection No inflammation
Normal
of the skin
Shape Inspection Convex
around the nail Normal
Lesions Palpation No inflammation
Firm Normal
of
Normal capillary
the skin around
Palpation refill less than 2
the nail Normal
sec.
Thickness
(less than 2secs)
Capillary refill
Firm

HEAD

Size Inspection Proportion to the Proportion to the Normal

body body

and the skull is and the skull is

rounded
rounded and
smooth and smooth

Symmetrical Symmetrical
Symmetry Inspection Normal

HAIR
Black
Color Inspection Normal
Straight and
Texture Inspection smooth Normal
Black
Other findings Inspection No nits/lice Normal
Curly hair,
present
straight
 No nits/lice
present

SCALP

Distribution of Inspection Evenly Normal

hair distributed
Inspection Normal
Lesions Evenly No inflammation,
distributed lumps or masses

No inflammation,
FACE
Inspection Due to fever
lumps or masses Pinkish
Skin color
Inspection Normal
Symmetric facial
Texture
Inspection Normal
Light to deep Symmetric facial
Facial movement
brown
movement
Smooth

Symmetric facial

movement
EYES
Inspection
External structure
Inspection Normal
Pink conjunctiva
Eyebrows
Inspection Normal
Evenly
Eyelashes
Inspection distributed Normal
Eyelids
Evenly Evenly
distributed distributed

Evenly
distributed,

Evenly
EARS distributed,
Inspection Due to fever
curved outward
Color
Inspection Normal
Symmetry Pinkish
 Symmetric at the
level of the eyes
Inspection Normal
corner
Shape and size

Same as facial
No discharges
color
and
Symmetrical at
inflammation
the
NOSE Inspection Normal
level of the eyes
Color Inspection Normal
corner
Shape Same with facial Normal
Symmetric to
color
Inspection head
Symmetric
Discharges No discharges
and No discharges

inflammation

MOUTH Inspection Normal

Lips Inspection Due to fever and

Same with facial Pink decrease fluid in
Moisture color the body
Dry
Symmetric Normal
TONGUE Inspection

Position No discharges
Central position
Normal
Inspection
Normal
Color Inspection
Normal
Dull red
Texture Inspection Pink Normal
Smooth
Mobility Inspection Moist
Can move freely
Lesions
 No lesions or

inflammation

Positioned at the

NECK Inspection center can move Normal

Position Inspection freely Normal

Symmetry Inspection Dull red Head centered Normal

Range of Palpation Smooth Symmetrical Normal

movements
Can move freely Smooth
movements
No lesions or
without
inflammation
discomfort

Symmetric and at

midline position

UPPER AND
Inspection Head centered Normal
LOWER
Inspection Symmetrical Normal
EXTREMITIES
Inspection Smooth Due to fever and
Size
movements disease condition
Inspection
Symmetry Equal size
without Normal
Skin color discomfort Symmetrical
Due to
Lesions Symmetric and at Pinkish with
disease
rashes on both
midline position
extremities

No lesions,

deformities or

inflammation
 Equal size

Symmetrical

Light to deep
brown

No lesions,

deformities or

inflammation

THEORETICAL FRAMEWORK
Florence Nightingale's core nursing theory has an environmental focus: It was her belief that the
environment is an alterable medium that can be used to improve the conditions of Nature and
encourage healing. Ventilation, clean air, clean water, control of noise, provision for light, and
Adequate waste management are just a some of the elements She believed could be Monitored and
improved when necessary.
Nightingale’s theory addresses the prevention of occurrences of Dengue Hemorrhagic Fever. In
facilitating proper environmental sanitation we can achieve a surroundings with no presence of any
vector that cause its transmission as they can no longer exist if the environment is not suited for their
survival hence decreasing the morbidity rate of Dengue in our country. We should be
knowledgeable on how to keep our surroundings free from any breeding sites that could serve as a
reservoir for the mosquito. As a nurse we should teach our clients how to do proper water storage and
environmental sanitation so as to prevent disease occurrence and recurrence
 ANATOMY AND PHYSIOLOGY

Blood- a connective tissue

composed of a liquid

extracellular matrix called

blood plasma that dissolves

and suspends various cells and

cell fragments.

1 - HYPERLINK "http://www.psbc.org/education/hematology/blood/blood.htm" Formed elements:

Red blood cells (or erythrocytes)

White blood cells (or leucocytes)

Platelets (or thrombocytes)

2 - HYPERLINK "http://www.psbc.org/education/hematology/blood/plasma.htm" Plasma = water +

dissolved solutes

Characteristics of Blood

bright red

dark red/purplish

much more dense than pure water

pH range from 7.35 to 7.45

slightly warmer than body temperature

typical volume in an adult is 5 liters

8% of body weight

Major Functions of Blood

Distribution & Transport

Regulation (maintenance of homeostasis)

Protection

Formed Elements

RBC

biconcave disk shape

a hemoglobin carrier

anucleate

No mitochondria

120 lifespan

erythropoietin is the hormone that stimulates RBC production

WBC or Leukocytes

protection from microbes, parasites, toxins, cancer

1% of blood volume; 4-11,000 per cubic mm blood

amoeboid motion

chemotaxis

leukocytosis

leukopoiesis

Colony stimulating Factors and interleukins-stimulates white blood cell formation

Platelets

formed in the bone marrow from cells called megakaryocytes

very small, 2-4 microns in diameter

approximately 250-500,000 per cubic millimeter

essential for clotting of damaged vasculature

Thrombopoietin stimulates the production

Platelet Plug Formation

PATHOPHYSIOLOGY
Precipitating Factors: Predisposing
Factors:
Presence of drainage nearby Age
Not using mosquito nets, repellants
Live plants at home

Aedes Aegypti
↓
Virus goes into circulation
↓
Dengue Virus Type II
↓
IgG adheres to the platelet
↓
thrombocytopenia
↓
increased potential for hemorrhage
↓
stimulates intense inflammatory response
↓
petechial rash, high fever, headache,vomiting, abdominal pain, (+) torniquet test

LABORATORY RESULT
Date: July 18, 2009
9:15
Fecalysis Report

Result Normal Findings Analysis

Color Yellow Yellow Normal

Consistency Semi-formed Semi-formed Normal

Blood: Negative
Remarks: No ova/intestinal parasite seen

Drug Study
Generic/Brand Classification Indication Contraindicati Side effects Nursing
Name (r/t present on (r/t present Intervention
illness) (r/t present illness) (r/t present
illness) illness)
Ranitidine Histamine H-2 Prevent gastric Impaired renal Nausea Obtain CBC;
receptor damage from or hepatic Vomiting assess for
blocking drug NSAIDS. function Abdominal infections,
pain renal or liver
Fatigue disease.
Dizziness
Malaise Report any
evidence of
yellow
discoloration
of skin and
eyes, or
diarrhea.

Maintain
adequate
 hydration.

Advise patient
to report any
confusion or
disorientation.

COURSE IN THE WARD

Date Doctor’s Order Nursing Assessment and

Function

July 18, 2009 Admit to ROC Platelet counts and

2:33 pm Secure consent hematocrits should be
BP: 90/80 TPR q shift
monitored repeatedly to
Temp: 38.60C DAT except dark colored
review the progress of
foods
patients.
Diagnostic TestCBC, platelet
in AM Oral and PRN medication is
IVF D5LRS 1L X 6 hrs @ 40 given to the patient at the
gtts/min right time to promote health
Ranitidine 1 amp IV q 8hrs and maintain wellness.
Paracetamol 1 amp IV q 6hrs
Intake and output is
Monitor Temp and BP q1hr
monitored to check if the
I&O hs and record
Refer patient’s fluid status is within
normal.

July 19, 2009

8:15
BP: 100/80
Temp: 38.00C

Continue meds
TF: D5LRS 1L X 6hrs @ 40gtts/min
BP and Temp q 2hrs
HCT am
If the hematocrit levels fall dangerously then a blood transfusion should be considered. If the
hematocrit values rise the patient should be given fluids intravenously and the fluids carefully
monitored to ensure that the patient does not get excess fluids. A rise of more than 20 % as compared
to previous levels may be an indication for IV fluids. The doctor should decide based on best judgment
of patient's condition.

Continuation of medications to prevent diseases and maintain wellness.

LABORATORY RESULT

Date: July 18, 2009

9:15
Urinalysis Report

Result Normal Findings Analysis

Color Yellow Yellow amber Normal

Transparency Clear Clear to sl. Turbid Normal

pH 6.5 4.5-8 Normal

Sp.gravity 1.020 1.005-1.030 Normal

 Sugar Negative Negative Normal

Protein Negative Negative Normal

Squamous epithelial Occasional Few Normal

cell
0-2 Few Normal
RBC
0-2 Few Normal
Pus Cells
Occasional Few Normal
Amorph.
Urates/Phosphates

LABORATORY RESULT

Date: July 18, 2009

Hematology Report

Result Normal Findings Analysis

White blood cell 12 x 10^g/L 5-10 x 10^g/L Increased due to

presence of infection

Hemoglobin 10.2 g/dL F: 13.0-18.0 g/dL Decreased due to

bleeding or
hemorrhage
Hematocrit 31 % 39-54 %
Decreased due to
bleeding or
Segmenters 0.73 0.60-0.70 hemorrhage

Increased due to high

Lymphocytes 0.27 0.20-0.30 glucose level in the
blood
Platelet count 100 x 10^g/dL 150-450 x 10^g/L
Normal

Due to presence of
bleeding
Date: July 19, 2009, AM

Hematology Report

Result Normal Findings Analysis

White Blood Cells 11.9 x 10^g/L 5-10 x 10^g/L Increased due to

presence of infection

Hemoglobin 8.5 g/dL F: 13.0-18.0 g/dL Decreased due to

bleeding or
hemorrhage
Hematocrit 29 % 39-54 %
Decreased due to
bleeding or
Segmenters 0.65 0.60-0.70 hemorrhage

Normal
Lymphocytes 0.35 0.20-0.30

Platelet Count 110 x 10^g/dL 150-450 x 10^g/L Increased due to viral

infection

Due to presence of
bleeding

Date: July 19, 2009, PM

Hematology Report

Result Normal Findings Analysis

White Blood Cells 10 x 10^g/L 5-10 x 10^g/L Normal

 Hemoglobin 9.5 g/dL F: 13.0-18.0 g/dL Decreased due to
bleeding or
hemorrhage
Hematocrit 29 % 39-54 %
Decreased due to
bleeding or
Segmenters 0.68 0.60-0.70 hemorrhage

Lymphocytes 0.32 0.20-0.30 Normal

Platelet Count 113 x 10^g/dL 150-450 x 10^g/L Increased due to viral

infection

Due to presence of
bleeding

Date: July 20, 2009, AM

Hematology Report

Result Normal Findings Analysis

White Blood Cells 9.8 x 10^g/L 5-10 x 10^g/L Normal

Hemoglobin 9.7 g/dL F: 13.0-18.0 g/dL Decreased due to

bleeding or
hemorrhage
Hematocrit 29 % 39-54 %
Decreased due to
bleeding or
Segmenters 0.69 0.60-0.70 hemorrhage

Lymphocytes 0.36 0.20-0.30 Normal

Platelet Count 126 x 10^g/dL 150-450 x 10^g/L Increased due to viral

infection

Due to presence of
bleeding
Date: July 20, 2009, PM

Hematology Report

Result Normal Findings Analysis

White Blood Cells 9.8 x 10^g/L 5-10 x 10^g/L Normal

Hemoglobin 10.3 g/dL F: 13.0-18.0 g/dL Decreased due to

bleeding or
hemorrhage
Hematocrit 31 % 39-54 %
Decreased due to
bleeding or
hemorrhage
Segmenters 0.57 0.60-0.70

Decreased due to low

Lymphocytes 0.43 0.20-0.30 glucose level in the
blood
Platelet Count 133 x 10^g/dL 150-450 x 10^g/L
Increased due to viral
infection

Due to presence of
bleeding

Date: July 21, 2009, AM

Hematology Report

Result Normal Findings Analysis

 White Blood Cells 8 x 10^g/L 5-10 x 10^g/L Normal

Hemoglobin 10 g/dL F: 13.0-18.0 g/dL Decreased due to

bleeding or
hemorrhage
Hematocrit 30 % 39-54 %
Decreased due to
bleeding or
Segmenters 0.68 0.60-0.70 hemorrhage

Normal
Lymphocytes 0.32 0.20-0.30

Increased due to viral

Platelet Count 85 x 10^g/dL 150-450 x 10^g/L infection

Due to presence of
bleeding

Date: July 21, 2009, PM

Hematology Report

Result Normal Findings Analysis

White Blood Cells 10 x 10^g/L 5-10 x 10^g/L Normal

Hemoglobin 11.4 g/dL F: 13.0-18.0 g/dL Decreased due to

bleeding or
hemorrhage
Hematocrit 35 % 39-54 %
Decreased due to
bleeding or
Segmenters 0.53 0.60-0.70 hemorrhage

Decreased due to low

Lymphocytes 0.47 0.20-0.30 glucose level in the
 blood

Platelet Count 101 x 10^g/dL 150-450 x 10^g/L Increased due to viral

infection

Due to presence of
bleeding

DISCHARGE TEACHING
Medication
Remind to take the prescribed medicine, having a written reminder of the correct medication, time to
take, and the right frequency of the medicine on the way home to establish assurance of medication
compliance.
Don’t give aspirin and NSAID’s, they increase the risk of bleeding. Any medicines that decrease
platelet count should be avoided.
Exercise
Instruct to avoid excessive activities that may result to stress.
Just advised to perform range of motions and repetitive body movements for promotion of optimum
health.
Remind about the need for health promotion activities such as reading, watching T.V, etc.
Treatment
Bed rest is advisable during the re-occurrence of fever phase.
Instruct to drink plenty of water or fluids that are available at home and eat nutritious diet.
Advised to look for re-occurrence of danger signs and symptoms and report immediately.

Hygiene
Encourage to continue the routinely hygienic care of the patient
Out-Patient Follow-Up Care
Instruct the family members to have a check-up or to consult physician once a while to monitor
patient’s condition and for detection of recurrences and other complications that may arise on to
it.
Diet

Instruct the family members to give the client protein rich foods such as meat, fish, eggs and
 nuts, vitamin K rich foods such as green leafy vegetables, vit C rich foods(guava and tomatoes
and other citrus fruits), carbohydrates rich food (breads and rice)

Long Term Objectives:

To promote holistic wellness through rendering quality nursing care and health education.

Short Term Objectives:

For Hyperthermia:

1.Within 2 hours of nursing care, the patient temperature will decrease from 38.6°C to 37-37.5°C

For Abdominal Pain:

2. Within 2-4 hours of nursing care the patient will be able to reduced pain felt from 7/10 to 5/10.

For Moderate Dehydration:

3. Within 8 hours of nursing care client will be able to minimize occurrence of fluid deficit as
evidenced by normal skin turgor

NURSING CARE PLAN

ASSESSM NURSING BACKGR PLANNIN INTERVE RATIONA EVALUAT

ENT DIAGNOSI OUND G NTION LE ION
S KNOWLE
DGE
Subjective: Elevated Entry of Within 2 Independen Within 2
“Taas baba body pathogens in hours of t: hours of
po yung temperature the systemic nursing To promote nursing care,
lagnat ko,” related to circulation care, the Rendered surface the patient
as inflammator patient tepid sponge cooling temperature
verbalized y response temperature bath will
by the as evidenced Regulation will To replace decrease
patient. by Temp= of toxins in decrease Encouraged fluid loss from 38.6°C
Objective: 38.6, the body from 38.6°C to increase due to body to 37.4°C,
Skin flushed and to 37- fluid intake heat skin is cool
war warm to 37.5°C and flushing
m to touch skin. Release of Heat is loss is absent.
touc pyrogens Promoted by
h surface evaporation
Flus cooling, and
hed Stimulation loosen conduction
skin of clothing,
Tem hypothalam and cool
perat us environment To
ure: reduce
38.6 metabolic
°C Increase or Encouraged demands
alteration of to have
Dry thermoregul adequate
lips ation bed rest
note
d To decrease
WB Increase in temperature
C= body Dependent:
12,0 temperature To support
00 as Administere circulating
seen d volume and
in Paracetamol tissue
labor as ordered perfusion
atory
resul Administere
t d IVF as
ordered

ASSESSM NURSING BACKGR PLANNIN INTERVE RATIONA EVALUAT

ENT DIAGNOSI OUND G NTION LE ION
 S KNOWLE
DGE
Subjective: Acute pain Entry of Within 2-4 Independen After 2-4
“Masakit po related to pathogens in hours of t: hours of
yung tyan inflammator the systemic nursing care To nursing care
ko,” as y response circulation the patient Monitored determine the patient
verbalized as evidenced will be able vital signs alteration was able to
by the by to reduced reduced pain
patient. verbalizatio Regulation pain felt Helps in felt from
n of patient of toxins in from 7/10 to Instructed relieving 7/10 to 5/10.
Objective: of “masakit the body 5/10. deep pain
po yung breathing
ĉ tyan ko”, exercise To divert
pain pain scale of Release of attention of
scale 7/10, anti- Encouraged patient from
of grimace and inflammator to have pain
7/10 irritability. y mediators diversional
grim activites like Helps
ace watching reduce pain
note Vascular t.v. felt
d response
irrita
ble Placed For
weak Increased patient on relaxation
ness capillary comfortable and to
note permeability position prevent
d stress
Characteris
tic: Hyperemia Encouraged To provide
stabbing, Cellular to have comfort
shooting exudation adequate
pain bed rest

Onset: Sw
“pasumpon elling Provided
g-sumpong therapeutic
po” touch
Pai Helps in
Location: n relieving
no exact pain
location
“basta sa
buong tyan
po masakit”

Duration:
2-3 minutes Dependent:
 Administere
Exacerbatio d Ranitidine
n: as ordered.
Gets worse
when
pressure is
applied in
the stomach

Radiation:
Radiates in
whole
abdomen

Relief:
“Kapag
iniipit ko
po”
Associated
signs and
symptoms:
Bod
y
weak
ness,
fever

ASSESSM NURSING BACKGR PLANNIN INTERVE RATIONA EVALUAT

ENT DIAGNOSI OUND G NTION LE ION
S KNOWLE
DGE
Subjective: Independen
“Tatlong Fluid Insufficient Within 8 t: After 8
beses po Volume fluid intake, hours of Ensure hours of
akong Deficit fluid loss nursing care Monitored accurate nursing car
nagsuka related to from client will Intake and picture of the client
simula frequent loss vomiting be able to Output fluid status was able
kanina,” as of fluid in minimize minimize
verbalized the occurrence occurrence
by the gastrointesti Imbalanced of fluid To prevent of deficit as
patient. nal tract as in fluid deficit as irritation in evidenced
evidenced volume evidenced Withhold stomach. by normal
Objective: by frequent by normal foods and skin turgor
3 vomiting. skin turgor. fluids for and
episo Decreased about 3 To verbalization
des volume in hours. determine if of patient
of intravascula the stomach “hindi na po
vomi r can already ako
ting compartmen Instructed to tolerate nagsuka.”
wate t sip small fluids
ry amounts of Intake
and fluids after (parenteral):
smal Moderate three hours To relieve 960mL
l in dehydration fasting. hunger due
amo to the Urine
unt fasting Output:
decr Instructed to done. 900mL
ease give
d crackers and
skin toasted
turgo bread. Prevents
r fluctuation
dry, in fluid
pale Dependent: levels
lips
weak Provided
ness supplementa
note l fluids as
d indicated.
(e.g., IV
fluids)
Leukocytes, or white cells, are responsible for the defense of the organism.

Round nucleus, produces antibodies, contributes to allergic reactions,tumor control, regulation of the immune
system

Nucleus with 2-4 lobes connected by thin filaments;

Phagocytizes microorganisms and other substances

Red blood cells are responsible for providing oxygen to tissues and partly for recovering carbon dioxide
produced as waste.

Platelets are important in preventing blood loss, releases chemicals for blood clotting

Nucleus with indistinct lobes; releases histamine, which promotes inflammation

The plasma is a slightly alkaline fluid, with a typical yellowish color

Nucleus often bilobed; releases chemicals that reduce inflammation; attacks certain worm parasites

Eosinophils attack parasites and phagocyte antigen-antibody complexes

Neutrophils are very active in phagocyting bacteria and are present in large amount in the pus of wounds.
Unfortunately, these cells are not able to renew the lysosomes used in digesting microbes and dead after having
phagocyted a few of them
Basophil secrete anti-coagulant and vasodilatory substances as histamines and serotonin. Even if they have a
phagocytory capability, their main function is secreting substances which mediate the hypersensitivity reaction.

The main function of platelets, or thrombocytes, is to stop the loss of blood from wounds (hematostasis).

Monocytes are the precursors of macrophages. They are larger blood cells, which after attaining maturity in the bone
marrow, enter the blood circulation where they stay for 24-36 hours.

1st child

23 yrs. old female

5th child

9 yrs old female (patient)

4th child

15yrs. old female

3rd child

20 yrs. old female

2nd child

21yrs. old male

Father

46 yrs. old w/ hypertension

 Mother

48 yrs. old w/ hypertension