I.

INTRODUCTION
A.) OVERVIEW OF THE STUDY
Dengue Fever is found mostly during and shortly after the rainy season in tropical
and subtropical areas like Philippines. Dengue and Dengue Hemorrhagic fever (DHF)
are caused by one of four closely related, but antigenically distinct, virus serotypes
(DEN-1, DEN-2, DEN-3, and DEN-4), of the genus Flavivirus. Dengue is primarily an
urban disease of the tropics, and the viruses that cause it are maintained in a cycle that
involves humans and Aedes Aegypti, a domestic, day-biting mosquito that prefers to
fees on humans. Infection with a dengue virus serotype can produce a spectrum of
clinical illness, ranging from a nonspecific viral syndrome to severe and fatal
hemorrhagic disease. (Gubler, D. and Clark G., National Center for Infectious Disease)

Source: Department of Health Philippines Disease Surveillance Report Morbidity Week 36 ,figure 1 page 1

Here is a graphical report from the latest Department of Health Dengue

Surveillance. This graph shows comparison of cases by month of 2010 to 2011. In
2010, cases have been reported for the entire year with increased incidence in months
of July to September. (DOH, 2011)
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. The global strategy for dengue /DHF prevention and control developed by
WHO and the regional strategy formulation in the Americas, South-East Asia and the
Western Pacific during the 1990s have facilitated identification of the main priorities:
strengthening epidemiological surveillance through the implementation of DengueNet;
accelerated training and the adoption of WHO standard clinical management guidelines
for DHF; promoting behavioral change at individual, household and community levels to
improve prevention and control; and accelerating research on vaccine development,
host-pathogen interactions, and development of tools/interventions by including dengue
in the disease portfolio of TDR (UNDP/World Bank/WHO Special Programme for
Research and Training in Tropical Diseases) and IVR (WHO Initiative for Vaccine
Research). (WHO)
1

B.1) GENERAL OBJECTIVE:

This case presentation aims to identify and determine the general health
problems and needs of the patient with an admitting diagnosis of Dengue Hemorrhagic
Fever, Type 1. This presentation also intends to help patient promote health and
medical understanding of such condition through the application of the nursing skills.

B.2) SPECIFIC OBJECTIVES:

The student nurses aim to achieve the following objectives:
1. Present a thorough discussion of assessment, diagnosis, planning, intervention,
and health teachings of the patient.
2. Provide thorough discussion of Dengue Hemorrhagic Fever, its definition,
pathophysiology, signs and symptoms, laboratory findings, medical management,
nursing management, and health teachings.
3. Apply the learned concepts and theories of the disease.
4. Formulate Nursing Care Plans for the different problems identified.
5. Explain the outcome of the rendered nursing interventions.

C.) SCOPE AND LIMITATION

The limitation of this case study focused only to the patient who has been
diagnosed with Dengue Hemorrhagic Fever with Hypovolemic shock. This case study
encompasses the concepts of Dengue pathology. The data presented in this case was
primarily obtained from student nurse-patient interaction as well as with the significant
other who partly served as informant and is based on the patients chart. The student
nurse was able to render care to the patient during the 16 hours of duty on July 2-3,
2012.

II. HEALTH HISTORY

A.) PATIENTS PROFILE
Name: JMR
2

Sex: Female
Age: 6 years old
Address: Opol, Cagayan de Oro City
Religion: Roman Catholic
Birthday: 07- 16- 2005
Civil Status: child
Nationality: Filipino
Educational Attainment: Preschooler
Date of Admission: June 25, 2012
Time: 5:20 pm
Birthplace: Opol, Cagayan de Oro City
Allergy: No Known Food-Drug Allergy
Height: 112 cm
Weight: 18.5 kg
Mother: Mrs. DR
Occupation: housewife
Income: none
Father: Mr. OR
Occupation: Factory Worker
Income: P5,000-10,000/mo.
Vital signs upon admission:
T: 36.60C
PR: 116 bpm
RR: 17 cpm
BP: 100/70 mmHg

B.) PROBLEM ORIENTED NURSING RECORD

Chief Complaint and History of Present Illness:

A case of patient J.M.R., 6 years old, child, was admitted at Cagayan de Oro
Medical Center on June 25, 2012 at 5:20 pm with a chief complaint of abdominal pain,
fever and low blood pressure.
4 days prior to admission, onset of fever for 2 days; 2 days prior to admission,
headache. Admitted at Polymedic General Hospital with initial WBC=3500, Hct=36.6,
Platelet count=215,000, initial BP= 90/60 mmhg,HR=120bpm, IVF= D5LR 1L at 60
cc/hr, Right hand consequently with decrease BP of frequent abdominal pain since the
prior day.
Patient started with venolem moderate side drip 200 cc then regulated at 25 cc/hr
fastdrip with Dopamine 2 amp at 22 cc/hr. Transferred ,thus, for ICU admission.
Types of Previous Illness/ Pregnancy/
Date

Delivery
Fever, cough and colds

2012
January, 2012

Heredofamilial disease:
Diabetes

Medication Name

Dose/ Frequency

Time of last dose

Paracetamol (Biogesic)
Cefalexin syrup

250 mg q6hrs

2 tbsp. q8hrs

2012
2012

Admitting Diagnosis: Dengue Hemorrhagic Fever with Hypovolemic Shock

Final Diagnosis: Acute Respiratory Failure secondary to Dengue Hemorrhagic fever
Grade IV, dengue shock syndrome, pleural effusion, myocarditis, pneumonia, sepsis
Attending Physician: Dra. Agnes Sanchez & Dr. Raypon Akut

III. DEVELOPMENTAL DATA

Pertaining to our patient Johanna Mae B. Ramilo, female, a 6 years of age and
has qualified the following developmental task by the famous theorists namely:
A. Sigmund Freuds Psychosexual Theory
The first genital stage goes from 4 to 6 years. Children begin to become more aware
of their genital organs and may touch them a bit more and even masturbate. They may
receive shame from their parents if caught touching themselves, which can cause
4

shame in adulthood. The Electra complex is shown by little girls and stems from envy
that they do not have a penis, while their father does. They eventually learn to identify
with their mother. Someone who gets fixated in the phallic stage ends up being overly
vain, reckless and self-assured as an adult.

B. Erik Eriksons Stages of Psychosocial Development

Patient Johanna Mae belongs to the Industry vs inferiority in Erik Eriksons. Here
the child learns to master the more formal skills of life: (1) relating with peers according
to rules (2) progressing from free play to play that may be elaborately structured by
rules and may demand formal teamworkand (3) mastering social studies, reading,
arithmetic. Homework is a necessity, and the need for self-discipline increases yearly.
The child who has successive and successful resolutions of earlier psychosocial crisis,
is trusting, autonomous, and full of initiative will learn easily enough to be industrious.
However, the mistrusting child will doubt the future. The shame and guilt-filled child
will experience defeat and inferiority.
C. Jean Piagets Cognitive Developmental Theory
The stage two, Pre-operational Stage that occurs from 2-7 years of age. The
mental representation of the sensorimotor stage provides a smooth transition to
semiotic functioning in the pre-operational stage. This essentially means that a child can
use one object to represent another (symbolically). For example, a child swinging their
arms in a circular motion might represent the wheels on a train, or sticking their arms
out and running might symbolize the movement of an airplane. This shows the
relationships children can form between language, actions and objects at this stage. A
major characteristic of this stage is egocentrism: perception of the world in relation to
oneself only. Children struggle to perceive situations from another point of view or
perspective. Another feature of this stage is conservation. Children struggle to
understand the difference in quantity and measurements in different situations. For
example, suppose a child is shown a short, fat beaker full of water. When that water is
transferred entirely to a tall, thin beaker we would know the level of water is identical
only the beaker has changed. However, a child in this stage will conclude there is more
water in the tall beaker, just because the level of water looks higher. Children in this
stage also lack the required cognition to apply reversibility to situations; they cannot
imagine objects or numbers reversed to their previous form.

D. Robert Havighursts Personality Development Theory

In this stage the patient is learning physical skills necessary for ordinary games.
Learning to get along with age mates. Building wholesome attitudes toward oneself as a
growing organism. Learning on appropriate masculine or feminine social role.
Developing

concepts

necessary

for

conscience, morality and a scale of values.

everyday

living.

Developing

Achieving personal independence.

Developing attitudes toward social groups and institutions.

E. Lawrence Kohlbergs Moral Developmental theory
Preconventional: Emphasis on avoiding punishments and getting rewards.
Stage 1
Might makes right (punishment and obedience orientation).
At this stage the most important value is obedience to authority in
Stage 2

order to avoid punishment.

Look out for number one - "Self-needs" (instrumental and relativist
orientation).Each person tries to take care of his or her own needs.
The reason to be nice to other people is so they will be nice to you.
In other words, you scratch my back and I'll scratch yours.

III. MEDICAL MANAGEMENT

A.)DIAGNOSTIC RESULTS:
1.) Platelet Count
Normal Value: 150-400 x10^9/L
June 25, 2012
June 26, 2012
June 27, 2012
June 28, 2012

64 x10^9/L
46 x10^9/L
48 x10^9/L
55 x10^9/L
6

June 29, 2012

June 30, 2012
July 1, 2012
July 2, 2012

50 x10^9/L
54 x10^9/L
50 x10^9/L
51 x10^9/L

IMPLICATION:
>Low platelet count in dengue fever may result in spontaneous bleeding or may
cause delay in the normal process of clotting. Also signifies patient is positive with the
said illness.

2.) ECG
-RESULT:
Diffuse T wave inversions; saddle-shaped ST-segment elevations (myocarditis)
-IMPLICATION:
Myocarditis refers to an underlying process that causes inflammation and injury
of the heart

B.) DRUG STUDY

Generic
Name of
Ordered
Drug
Merone
m

Brand
Name

Date
Ordered

Classificati
on

Dose/
Frequenc
y/Route

Merre
m

6-27-12

Antibiotic

750mg
IV
Drip q8

Mechanism
of Action

Inhibits
bacterial
wall
synthesis.

Specific
Indication

Contraindication

Infection of

Hypersensit
ivity.

the
abdomen

ANST(-)

Potassiu
m
Chloride

Kalium
Durule

6-27-12

Potassium
Suppleme
nt

2tabs
q6/
NGT

Side
Effects/
Toxic
Effects
N/V,
Headache,
Diarrhea,
Rash,
Thrombophlebitis

Replace
potassium and
maintain
potassium
level.

Nursing
Precaution

>assess for
any allergy
to
penicillin or
cephalosporins.
>assess for
any brain
disorder.
>assess for

Treatment
of
potassium

Hyperkalem N/V,aria,
severe renal rhythmia,

depletion

impairment;

diarrhea,

symptoms

untreated
Addisons
disease;
severe
tissue
trauma

abdominal
pain, restlessness,
paresthe-

of hypokalemia
>monitor
pulse,blood

sia

pressure
and ECG

signs and

periodically.

Generic
Name of
Ordered
Drug
Tazobacta
m
sodium

Brand
Name

Tazocin

Date
Ordere
d

Classificati
on

6-25-12 antibiotic

Dose/
Frequenc
y/Route
1gm IV
q6
ANST(-)

Mechanism of
Action

Inhibits betalactamase, an
enzyme that
can
destroy
penicillins.
Death of
susceptible organism/
bacteria.

Specific
Indication

Infection

Contraindication

hypersensiti
vity
to
penicillins,
cephalospori
ns,
or
tazobactam

Side Effects/
Toxic Effects

Nursing
Precaution

Diarrhea,
constipation,
nausea,
vomiting,

>assess for

dyspepsia,

specimen
for
culture and

stool
changes,
abdominal
pain,
headache,
insomnia

infection
>obtain

sensitivity
>observe
for
signs and
symptoms
of
anaphylaxis

Generic
Brand
Name of
Name
Famotidine Pepcid
Ordered
Drug
Midazola
Versed
m

Date
Classificati
Dose/
Ordere
on
Frequency
6-25-12 Histamine
18mg
d
/
H2
IVTT
Route
receptor
q12
6-25-12 Sedative/
5mg/5ml

Mechanism
Specific
ContraSide
Nursing
of Action
Indication
indication
Effects/
Precaution
Inhibits the
Prevention
hypersensiti Dizziness,
>note for
Toxic
action
of
vity
headany
Effects
of histamine at ulcer
ache,
epigastric or
Acts at many Used to
Hypersensitiv Headache, >assess level
constipaity,
of
antagonist,
the H2
tion,
abdominal
hypnotic
6 amps
levels of the produce
comatose,
Excess
sedation and
receptor
drowsiness
pain
sedaAnti-ulcer plus
site located
and prank or
(benzodiaz 20cc D5W CNS to
sedation
pregnancy,
tion, agita- level of
prieproduce
marily in
occult blood
pam)
generalized
shock,
tion,
consciousness
gastric
lactation
blurred
parietal cells,
in the stool,
CNS
vision,
throughout.
thereby
emesis or
depression,
inhibiting
short
term
laryngo>monitor
BP,
gastric
acid
gastric
PR
aspirate
sedation
spasm,
and
RR
consecretion.
respiratory tinously.
depression
,
cardiac
arrest.
Dobutami Dobutr 6-25-12 Sympatho- 250
Stimulate
Short-term hypersensitiv Tachycardi >monitor BP,
ne
ex
mg/20ml
beta1
ity
a,
HR,
mimetic
plus 30cc
adrenergic
manageme to bisulfiles;
hpn, preECG,
nt
pulmonary
D5W at
receptors
of heart
Idiopathic hy- mature
capillary
Generic Name
Brand
Date
Classification
Dose/
Mechanism
Specific
Contraindicatio
Side Effects/
Nursing
1cc/
with
wedge
of Ordered
Name
Ordered
of Action failure
Indication pertropic
n
Toxic Effects
Precaution
hr. Frequency/
relatively
ventricular
pressure
Drug
Route
subminor effect
aortic
contractio
10
stenosis
ns,
or heart rate
headache
or peripheral
blood
vessels

Furosemide

Lasix

06-26-12

Loop Diuretic

40mg q8hrs

Inhibits the

Treatment

Hypersensitivity;

Metabolic

>monitor fluid

IVTT

reabsorption

for edema

cross-sensitivity

alkalosis,

status

of sodium &

with thiazides &

hypovolemia,

>Monitor BP &

chloride from

sulphonamides

dehydration,

PR before and

the loop of

may exist;

Hyponatremia,

during

Henle &

pregnancy or

Hypokalemia,

administration

distal renal

lactation

hypochloremia,

>asses for

hypomagnesemia

allergy to

tubule

sulphonamides
Norepinephrine
Bitartrate

Levophed

06-25-12

Vasopressor

4mg/4ml 4

Stimulates

Treatment of

Vascular,

Headache;

>monitor BP

drops 84cc

Alpha-

shock

mesenteric or

anxiety,

every 2-3

D5W @

adrenergic

peripheral

dizziness,

mins. Until

1.5cc/hr

receptors

thrombosis;

weakness,

stabilized &

located

pregnancy;

dyspnea,

every 5mins.

mainly in

hypoxia;

decreased urine

There after

blood

hypotension 2 hrs

output,

>ECG should

vessels

to hypovolemia

hypeerglycemia

be monitored

causing

continuously

constriction

>monitor urine

of both

output & notify

capacitance

physician if it

& resistance

decreases to <

vessels
11

30ml/hr.

Dexamethasone

Nalbuphine
HCL

Dexasone

Nubain

06-30-12

06-25-12

glucocorticoid

4.5mg

Suppresses

Management

Active untreated

Depression,

>monitor

q6hrs IVTT

inflammation

of cerebral

infectious;

euphoria,

intake & output

and the

edema &

bisulphate,

hypertension,

ratios & daily

normal

septic shock

paraben or

nausea,

weight

immune

alcoholic

anorexia,

>assess for

response.

hypersensitivity

decreased wound

changes in

Has

healing, petechia,

LOC

numerous

ecchymosis,

intense

fragility, adrenal

metabolic

suppression,

effects

muscle wasting

Opoids

2mg q12hrs

Alters the

analgesic

IVTT

Hypersensitivity

Sedation,

>assess type,

perception of

to nalbuphine or

headache,

location &

the response

bisulfites ; opiod

dizziness,

intensity of

to painful

dependent

vertigo, nausea,

pain

stimuli, white

patients

vomiting, dry

>assess vital

pproducing

mouth, sweating,

signs before

generalized

clammy feeling

and

CNS
12

For pain

periodically

Depression
Clarithromycin

Phenobarbital

klaricid

solfoton

06-29-12

06-24-12

Antibiotic

anticonvulsants

250/5mg

Inhibits

3ml BID

Infection

Hypersensitivity

Headache,

>monitor vital

protein

to clarithromycin,

diarrhea, nausea,

signs

synthesis

erythromycin, or

abnormal taste,

>Obtain

thereby

other macrolide

dyspepsia,

specimen for

preventing

anti-infectives

leukopenia

culture an

their growth

sensitivity prior

and

to initiating

multiplication

therapy.

30mg/tab 1

Produces all

Febrile

Hypersensitivity

Hangover ,

>monitor

1/2 tab BID

levels of

seizures

comatose

drowsiness, N/V,

respiratory

NGT

CNS

patients or those

constipation,

rate, pulse,

depression;

with pre-existing

lethargy

and BP

inhibits

CNS depression;

frequently

transmission

uncontrolled

>seizure:

in the

severe pain

assess

nervous

location,

system and

duration, and

raises the

characteristics

seizure

of seizure

threshold

activity.

13

V. ANATOMY
ANATOMY AND PHYSIOLOGY OF THE BONE MARROW AND THE SPLEEN
Bone marrow is the flexible tissue found in the interior of bones. In humans, red
blood cells are produced in the heads of long bones, in a process known as
hematopoesis. On average, bone marrow constitutes 4% of the total body mass of
humans; in an adult weighing 65 kilograms (140 lb), bone marrow accounts for
approximately 2.6 kilograms (5.7 lb). The hematopoietic compartment of bone marrow
produces approximately 500 billion blood cells per day, which use the bone marrow
vasculature as a conduit to the body's systemic circulation.Bone marrow is also a key
component of the lymphatic system, producing the lymphocytes that support the body's
immune system.
The two types of bone marrow are medulla ossium rubra (red marrow), which
consists mainly of hematopoietic tissue, and medulla ossium flava (yellow marrow),
which is mainly made up of fat cells. Red blood cells, platelets and most white blood
cells arise in red marrow. Both types of bone marrow contain numerous blood vessels
and capillaries. At birth, all bone marrow is red. With age, more and more of it is
converted to the yellow type; only around half of adult bone marrow is red. Red marrow
is found mainly in the flat bones, such as the pelvis, sternum, cranium, ribs, vertebrae
and scapulae, and in the cancellous ("spongy") material at the epiphyseal ends of long
bones such as the femur and humerus. Yellow marrow is found in the medullary cavity,
the hollow interior of the middle portion of long bones. In cases of severe blood loss, the
body can convert yellow marrow back to red marrow to increase blood cell production.
The spleen is an organ found in virtually all vertebrate animals. Similar in
structure to a large lymph node, the spleen acts primarily as a blood filter. As such, it is
a non-vital organ, with a healthy life possible after removal. The spleen plays important
roles in regard to red blood cells (also referred to as erythrocytes) and the immune
system. In humans, it is located in the left upper quadrant of the abdomen. It removes
old red blood cells and holds a reserve of blood in case of hemorrhagic shock while also
recycling iron. As a part of the mononuclear phagocyte system, it metabolizes
hemoglobin removed from senescent erythrocytes. The globin portion of hemoglobin is
degraded to its constitutive amino acids, and the heme portion is metabolized to
bilirubin, which is subsequently shuttled to the liver for removal. It synthesizes
antibodies in its white pulp and removes antibody-coated bacteria along with antibodycoated blood cells by way of blood and lymph node circulation. The spleen is brownish.

14

A study published in 2009 using mice showed it has been found to contain in its reserve
half of the body's monocytes within the red pulp.
These monocytes, upon moving to injured tissue (such as the heart), turn into
dendritic cells and macrophages while promoting tissue healing. It is one of the centers
of activity of the reticuloendothelial system and can be considered analogous to a large
lymph node, as its absence leads to a predisposition toward certain infections.

VI. PATHOPHYSIOLOGY OF DHF

CAUSE:
AEDES EGYPTI MOSQUITO

Virus Disseminated
rapidly into the blood
and stimulates WBC
including B lymphocytes
that produce and secrete
antibodies and
monocytes and
neutrophils

15

DENGUE FEVER

DENGUE HEMORRHAGIC
FEVER

Complications
Intense Bleeding
Pulmonary edema
Shock
Hypotension

VII. NURSING ASSESSMENT

16

A.)NURSING SYSTEM REVIEW CHART

NAME of PATIENT: Baby JMR
Pulse: 116bpm RR: 17cpm

Date: July 2-3, 2012

Temp: 36.60C
Height: 112cm

Nasal
flaring

Shortness
of breath

EENT:
[ ] Impaired Vision [ ] Blind [ ] Pain [ ] Reddened
Productive
[ ] Drainage [ ] Gums [ ] Hard of Hearing
cough
[ ] Deaf [ ] Burning [ ] Edema [ ] Lesion
[ ] Teeth [x] No Problem
[ ] Assess Eyes, Ears Nose, and Throat for Abnormalities.
RESPIRATORY SYSTEM:
[ ] Asymmetric [ ] Tachypnea
[ ] Apnea
[ ] Rales
[x] Cough
[ ] Barrel Chest [ ] Bradypnea
[ ] Shallow
[ ] Rhonchi [x] Sputum
[ ] Diminished
[x] Dyspnea [ ] Orthopnea [ ] Labored
[x] Wheezing
[ ] Pain
[ ] Cyanotic [ ] No Problem
[ ] Assess Resp. Rate, Rhythm, Depth, Pattern,
Breath Sounds and Comfort.
CARDIO VASCULAR:
[ ] Arrhythmia [X] Tachycardia [ ] Numbness
[ ] Diminished Pulses [ ] Edema
[ ] Fatigue [ ] Irregular
[ ] Bradycardia [ ] Murmur [ ] Tingling [ ] Absent Pulses
[ ] Pain [ ] No Problem
[ ] Assess Heart Sounds, Rate, Rhythm, Pulse,
Blood Pressure, Circulation, Fluid Retention, and Comfort.
GASTRO - INTESTINAL TRACT:
[ ] Obese
[ ] Distention [ ] Mass [x] Dysphagia
[ ] Rigidly
[ ] Pain [ ] No Problem
[x] Assess Abdomen, Bowel Habits, Swallowing,
Bowel Sounds and Comfort.
GENITO - URINARY AND GYNE:
[ ] Pain
[ ] Urine Color
[ ] Vaginal Bleeding
[ ] Hematuria [ ] Discharge [ ] Nocturia
[x] No Problem
[x]Assess Urine Frequency, Control, Color,
Odor, Comfort, Gyne-Bleeding and Discharge.

D5IMB 500cc @10cc/hr

@400cc
D5IMB 500cc @10cc/hr

NEURO:
[ ] Paralysis [ ] Stuporus [ ] Unsteady [ ] Seizures
[x] Lethargic [ ] Comatose [ ] Vertigo [ ] Tremors
[ ] Confused [ ] Vision [ ] Grip
[ ] No Problem
[x] Assess Motor Function, Sensation, LOC, Strength,
Grip, Gait, Coordination, Orientation and Speech.

Area: ICU
Weight: 18.5 kgs.
With 02 inhalation
@2LPM via nasal
cannula
With
nasogastric
tube
Dry lips,
ulcer
With ET to MV:
Fi02=30% TV=120
RR=10 PEEp=5
ecchymosis
With
cardiac
monitor
SD#1
Levophed drip
@1.5cc/hr/I.P
Update:
decreased
levophed drip
to 1.4cc/hr
then decrease
SD#2
midazolam
drip (5mg/5ml
midazolam+
30cc D5W) @
0.5cc/hr/IP
Update:
With FBC
attached to
urobag
Levophed drip
(2amps in
17cc D5) @0.4
cc then
decrease by
0.1cc every 4
hours until 0.1
headache

- dry skin
- weakness

MUSCULOSKELETAL and SKIN:

[ ] Appliance [ ] Stiffness [ ] Itching [ ] Petechiae
[ ] Hot [ ] Drainage [ ] Prosthesis [ ] Swelling
[ ] Lesion [ ] Poor Turgor [ ] Cool [ ] Deformity
[ ] Wound [ ] Rash [ ] Skin Color [ ] Flushed
[ ] Atrophy [ ] Pain [ ] Ecchymosis [ ] Diaphoretic
[ ] Moist
[x] No Problem
[x] Assess Mobility, Motion, Gait, Alignment,
Joint Function, Skin Color, Texture, Turgor, and Integrity.

- Warm to
touch
- restless

LEGEND:
= FIRST DAY
= SECOND DAY
callus

B.) NURSING ASSESSMENT II

17

SUBJECTIVE
COMMUNICATION
Comments: no
[ ] hearing loss
[ ] visual changes verbal cues
[X]denied

OXYGENATION:
[x]dyspnea
[ ]smoking history
none
[x] cough
[x]sputum
[ ]denied
CIRCULATION:
[ ]chest pain
[ ] leg pain
[ ] numbness of
extremities
[X] denied

Comments: no
subjective cues

OBJECTIVE
[ ] glasses
[ ]languages
[ ] contact lens
[ ] hearing aide
R
L
Pupil size: 3mm
[ ] speech difficulties
Reaction: Pupil Equally Round Reactive to
Light and Accommodation
Resp. [ ]regular [x]irregular
Describe: bronchovesicular breath sounds
heard over lungs; RR; 25cpm
R:symmetrical to Left lung upon expansion
L:symmetrical to Right lung upon expansion

Comments: no
subjective cues

NUTRITION:
Diet: 1.100 cal in 1400cc vol. in 6 feedings
(CHO=700, CHON=150, FATS=550)
[]N[]V
Comments: no
Character:
subjective cues
[ ] recent change in
Weight and appetite
[x] swallowing difficulty
[ ]denied
ELIMINATION:
Usual bowel pattern
[ ] urinary frequency
Once a day
3 times a day
[]constipation
[ ]urgency
Remedies:
[ ]dysuria
None
[ ] hematuria
Date of last BM
[ ] incontinence
06-30-12
[ ]polyuria
[ ] diarrhea character
[x] foley in place
None
[ ] denied
MGT. OF HEALTH & ILLNESS:
[ ] alcohol
[x]denied
(Amount, frequency): no subjective cues
[ ] SBE: none
Last Pap smear: none
LMP: none

Heart rhythm [X] regular [ ] irregular

Ankle Edema: non-pitting edema
Carotid Radial Dorsal Pedis Femoral
R
+2
+2
+1
+2
+2
L
+2
+2
+2
+2
+2
Comments: all pulses are palpable
*if applicable: not applicable
[ ]dentures
Upper
Lower

Full
[ ]
[ ]

[X]none
partial
[ ]
[ ]

Comments: Patient
bowel sounds is
normoactie with 25
bowel sounds
heard upon
auscultation.

with patient
[ ]
[ ]

Bowel sounds:
normoactive
Abdominal Distention
Present [ ] yes [X] No
Urine* (color,
Consistency, odor)
Yellowish, aromatic
*if foley balloon catheter
Is in place none
Briefly, describe the patients ability to follow
treatments (diet, meds, etc.) for chronic
health problems (if present).
N/A

18

SKIN INTEGRITY:
[x] Dry
Comments: no
[ ] Itching
[ ] other
subjective cues
[ ] denied

ACTIVITY/SAFETY:
[ ] convulsion
Comments: no
[ ] dizziness
subjective cues
[ ] limited motion
of joints
[x] ambulate
[x] bathe self
[ ] other
[ ] denied

[X] dry
[ ]cold
[ ] pale
[ ] flushed [X]warm
[ ] moist [ ]cyanotic
*rashes, ulcers, decubitus (describe size,
location, drainage) mouth ulcers noted;
callus noted at both foot
[ ] LOC and Orientation: Patient is conscious
but drowsy.
[ ] Gait [ ] walker [ ] care [] others
[X] steady [ ] unsteady
Sensory and motor losses in face or
extremities: No sensory and motor losses in
face or extremities noted
[ ] ROM limitations: limitation range of
motion to move because of the IV site, ET &
NGT

COMFORT/SLEEP/AWAKE:
[ ] pain
(location) frequency Comments: no
subjective cues
remedies)
[ ] nocturia
[ ] sleep difficulties
[X] denied
COPING:
Occupation: child
Members of household: 5 members
Most supportive person: parents

[ ] facial grimace
[ ] guarding
[ ] other signs of pain: none
[ ] side rail release form signed (60 + years)
N/A

Observed non-verbal behavior: none

Person (Phone Number): denied

19

VIII. NURSING MANAGEMENT

A.) IDEAL NURSING MANAGEMENT
CUES
Subjective:
No subjective cues
Objectives:
Dyspnea/shortness of

breath
Restlessness
Lethargy
Hypoxia
Weakness

NURSING

OBJECTIVE

INTERVENTIONS

DIAGNOSIS
S
Impaired gas At the end of Independent:
1. Monitor vital signs &
exchange
8 hours duty,
cardiac rhythm.
related
to the
patient
2. Evaluate
vital
imbalance
will
capacity by using
ventilation
demonstrate
pulse oximeter to
perfusion
improve
determine
oxygenation.
secondary to ventilation &
3. Elevate head of the
hypovolemic
adequate
bed.
shock.
oxygenation
of tissues.

RATIONALE

EVALUATION

1. For prompt intervention if At the end of 8

vital signs is without normal hours duty,
range.
patient was
2. To
assess
respiratory able to
insufficiency.
demonstrate
improved
ventilation &
3. To promote
expansion.

proper

lung

4. Provide
adequate
intake & output.
5. Encourage
position
changes
every
2
hours.
Dependent:
6. Administer Midazolam
5mg/ml 6amps + 20cc
D5W as prescribed.
20

adequate
oxygenation of
tissues.

4. Provide/promote mobilization
of secretions

5. Promote optimal lung/chest

expansion and drainage of
secretions.
6. Acts at many levels of CNS

to produce generalized CNS

depression causing sedation

CUES
Subjective:
No subjective
cues
Objectives:
Bronchial

secretions
Dyspnea
Nasal flaring
Restlessness
Weakness
RR: 25 cpm
Shortness of

breath
Productive
cough

NURSING

OBJECTIVES

INTERVENTIONS

RATIONALE

DIAGNOSIS
Ineffective
airway At the end of 8 Independent:
1. Elevate the head of the
clearance related to hours duty, the
bed above plane.
presence
of patient will be
bronchial

able to maintain

secretions.

airway patency.

2. Suction secretions
needed.

as

3. Change position every 2

hours and as necessary.

4. Ensure
that
the
endotracheal tube to
mechanical ventilator is in
place.
5. Feed per patent NGT
with
strict
aspiration
precaution.

21

EVALUATION

1. To open airway, in At the end of 8

at-rest
or hours duty,
compromised
patient was able
individual.
to maintain
2. To clear
airway
airway patency.
when secretions are
blocking the airway.
3. To
enhance
drainage
of/ventilation
to
different
lung
segments.
4. To maintain airway
patency.

5. To
aspiration,
maintain
patency.

prevent
thus
airway

CUES
Subjective:
No subjective
cues
Objectives:
Dyspnea
Tachypnea RR:

NURSING

OBJECTIVES

INTERVENTIONS

DIAGNOSIS
Ineffective breathing At the end of 8 hours Independent:
1. evaluate cough
pattern
related
to duty, the patient will be
for
the
weak
respiratory able
to
breathe
presence
of
muscles
normally on his own as
secretions
2.
note for any
evidence by negative
pain
or
respiratory distress.
discomfort.
3. Suction airway
as needed.

25 cpm
Use of
accessory
muscle to breath
Nasal flaring
Restlessness
weeakness

4. Elevate
the
head of the bed
30
degrees
above plain.
Dependent:
5. Administere
oxygen
as
ordered by the
physician.

22

RATIONALE

EVALUATION

At the end of 8 hours

1. This
might
duty, the patient was
indicate possible
able
to
breathe
obstruction.
normally as evidence
2. This may restrict by negative respiratory
respiratory effort
distress.
3. To
clear
secretions.
4. To
promote
physiological
and
psychological
ease of maximal
inspiration.
5. For
management of
underlying
pulmonary
condition.

B.) ACTUAL NURSING MANAGEMENT

First day
S
O

No subjective cue
Dyspnea

SOB
Restlessness
Lethargy
Hypoxia decreased capillary : 2 seconds
O2 saturation : 93 per cent

Impaired gas exchange related to ventilation perfusion

imbalance.
Long term: at the end of eight hours nursing interventions,
the patient will be able to maintain adequate ventilation and
adequate oxygenation of tissues.
Short term: at the end of thirty minutes nursing
interventions, the patient will be able to improve ventilation
and adequate oxygenation of tissues.

I
Monitored vital signs and cardiac rhythm.
Evaluated vital capacity by using pulse oximeter to
determine oxygenation.
Elevated head of the bed 30 degrees above plane.
Turned to sides every 2 hours or as needed.
Administered oxygen at 2 liters per minute via nasal
cannula.
E
At the end of thirty minutes nursing interventions, the
patient was able to demonstrate improved ventilation and
adequate oxygenation, thus goal met.

S
No subjective cue

23

Dyspnea
Tachycardia: RR-25cpm
Restlessness
Weakness
Use of accessory muscle to breath
Nasal flaring

Ineffective breathing pattern related inadequate exchange

of air secondary to weak respiratory muscles.

P
Long term: at the end of eight hours nursing interventions,
the patient will have normal breathing patterns as evidence
by normal rate and rhythm of respirations.
Short term: at the end of thirty minutes nursing
interventions, the patient will be able to have normal rate
and rhythm of respirations.
I
Evaluated cough for the presence of secretions.
Noted for any pain and discomfort (location,intensity and
severity).
Elevated head of the bed 30 degrees.
Suctioned as needed.
Administered oxygen at 2 liters per minute via nasal
cannula.

E
At the end of eight hours nursing interventions, the patient
was able to maintain normal respiratory patterns, thus goal
met.

24

S
No subjective cue
O

Bronchial secretions
Dyspnea
SOB
RR-25cpm
Restlessness
Weakness
Nasal flaring

Ineffective airway clearance related to presence of

bronchial secretions.

P
Long term: at the end of eight hours nursing interventions,
the patient will be able to maintain airway patency.
Short term: at the end of thirty minutes nursing
interventions, the patient will be able to maintain airway
patency.
I
Evaluated cough for the presence of secretions.
Noted for any pain and discomfort (location, intensity and
severity).
Elevated head of the bed 30 degrees.
Suctioned as needed.
Ensured that the endotracheal tube is in place.

E
At the end of eight hours nursing interventions, the patient
was able to maintain patent airway, thus goal met.

Second day
S
No subjective cue
25

Increased pulse rate

Decreased venous filling
Hypotension
Decreased skin turgor
Restlessness
Weakness
Dry mucous membrane

Deficient Fluid Volume related to active fluid volume loss.

Long term: at the end of eight hours nursing interventions,

the patient will have adequate volume and electrolyte
balance as evidenced by urine output greater than 30 ml
per hour, normotensive BP, heart rate less than 100bpm
and normal skin turgor.
Short term: at the end of two hours nursing interventions,
the patient will be able to have urine output greater than 30
ml per hour, normotensive BP, heart rate less than 100bpm
and normal skin turgor.

Patients vital signs were monitored.

Intake and output was monitored.
Skin / mucous membranes were continually assessed for
dryness and turgor.
Patients position was frequently changed (given skin care

and bed was kept dry.

Parenteral fluids were administered as ordered.
At the end of eight hours nursing interventions, the patient
was able to maintain adequate volume and electrolyte
balance.

S
No subjective cue

26

Dyspnea
SOB
Restlessness
Lethargy
Hypoxia decreased capillary : 2 seconds
O2 saturation : 93 per cent

Impaired gas exchange related to ventilation perfusion

imbalance.
Long term: at the end of eight hours nursing interventions,
the patient will be able to maintain adequate ventilation and
adequate oxygenation of tissues.
Short term: at the end of thirty minutes nursing
interventions, the patient will be able to improve ventilation
and adequate oxygenation of tissues.

I
Monitored vital signs and cardiac rhythm.
Evaluated vital capacity by using pulse oximeter to
determine oxygenation.
Elevated head of the bed 30 degrees above plane.
Turned to sides every 2 hours or as needed.
Administered oxygen at 2 liters per minute via nasal
cannula.
E
At the end of thirty minutes nursing interventions, the
patient was able to demonstrate improved ventilation and
adequate oxygenation, thus goal met.

S
No subjective cue

27

Dyspnea
Tachycardia: RR-25cpm
Restlessness
Weakness
Use of accessory muscle to breath
Nasal flaring

Ineffective breathing pattern related inadequate exchange

of air secondary to weak respiratory muscles.

P
Long term: at the end of eight hours nursing interventions,
the patient will have normal breathing patterns as evidence
by normal rate and rhythm of respirations.
Short term: at the end of thirty minutes nursing
interventions, the patient will be able to have normal rate
and rhythm of respirations.
I
Evaluated cough for the presence of secretions.
Noted for any pain and discomfort (location,intensity and
severity).
Elevated head of the bed 30 degrees.
Suctioned as needed.
Administered oxygen at 2 liters per minute via nasal
cannula.

E
At the end of eight hours nursing interventions, the patient
was able to maintain normal respiratory patterns, thus goal
met.

IX. HEALTH TEACHINGS

MEDICATION
28

Encouraged and instructed to comply prescribed

medications such as;
Salbutamol 1 nebule q4- to loosen secretions
Clusivol syrup 5mL CD- for cough
Tempra Forte 5mL PRN- for fever

EXERCISE

Encouraged the patient and the significant others to have

daily exercises such as walking.

Encouraged and instructed to perform passive range of
motion exercises to promote proper blood circulation.

TREATMENT

Increased fluid intake as tolerated to prevent dehydration.

Instructed the significant others to avoid or eliminate
stagnant water in their home environment to eliminate or

minimize the presence of mosquitoes in the area.

Instructed the parents to let the patient wear long- sleeved
shirts, long pants, socks and shoes when going into a
mosquito-infested area.

OUT PATIENT

Instructed and encouraged to have follow-up check-up

one week after discharge or as per physicians order.

DIET

Instructed and encouraged to let the patient eat small

amount of her usual food.

Instructed to let the patient eat foods that is rich in iron

and protein.
Instructed and encouraged to eat foods rich in vitamin C
such as oranges.

X .REFERRAL AND FOLLOW-UP (DISCHARGE PLAN)

Since the family support system towards the patient is good, we encouraged the
family and relatives to continue their medical and emotional support to the patient
gearing towards the patients condition. They are encouraged to be sensitive to the
needs and care of the patient.
We also encourage the patient together with the significant others to visit
regularly at the nearest health center to their place to monitor her improvement from the
29

previous condition and maintain safety. We referred the patient back her current
attending physician if she needs further consultation with regards to her health status.

XI. EVALUATION AND IMPLICATION

After thorough assessment to the patient, the students were able to
identify problems and performed independent and collaborative nursing interventions
and were able to provide some health teachings that can alleviate the patients condition
such as the compliance of medications and how to handle its side effects; universal
precaution to prevent infection; prevention of complications; and enhanced nutrition.
This study had broadened the knowledge and skills of the students on the said
condition which is dengue hemorrhagic fever with hypovolemic shock. In the days to
come, the nurses would be more confident in attending patients with this case for they
already have the knowledge of the disease process.

XII. BIBLIOGRAPHY
1. )http://nursingcrib.com/case-study/dengue-fever-case-study/
2.) http://cmr.asm.org/content/11/3/480.short
3.) http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-relatedto-travel/dengue-fever-and-dengue-hemorrhagic-fever.htm]
4.) Dengue Fever & Dengue Hemorrhagic Fever - Chapter 3 - 2012 Yellow Book Travelers' Health - CDC wwwnc.cdc.gov
5.) http://www.who.int/csr/disease/dengue/en/

30