PERSONAL DATA

NAME: Ala AGE: 21 y/o GENDER: Female CIVIL STATUS: Single ADDRESS: Salinas, Bambang, Nueva Vizcaya BIRTHDAY: July 26, 1990 BIRTH PLACE: Bambang, Nueva Vizvaya NATIONALITY: Filipino FATHER: EO MOTHER: OD RELIGION: Espiritista LANGUAGE: Tagalog & Iloco ADMITTING DATE: September 9, 2011 ADMITTING TIME: 12:35 pm CHIEF COMPLAINTS: Fever, vomiting, nausea, body malaise, abdominal pain for 2 days ADMITTING DIAGNOSIS: Dengue Fever PRINCIPAL DIAGNOSIS: Dengue Fever WARD: Medical ATTENDING PHYSICIAN: Dr. H. Manaois DATE OF DISCHARGE: September 11, 2011 TIME OF DISCHARGE: 11:45 am

HISTORY OF PRESENT ILLNESS

Two days prior to admission, the patient experienced fever, vomiting, nausea, body malaise, & abdominal pain which prompted her mother to bring her to the hospital for management and treatment. In the ER, initial vital signs were taken as follow: T: 38oC & BP: 90/50 mmHg. She was examined by Dr. Hazel Manaois with orders made and carried out. After physical assessment, complete blood count with platelet count & urinalysis, she was diagnosed with Dengue fever, thus was requested for admission and hooked with PLRS 1L; 500cc fast drip @ left hand. The patient was prescribed with Paracetamol 300mg/ml IVP q4 o for fever. And requested for TPR monitoring every shift. She was then transferred to Medical ward via wheelchair after consent for hospitalization was signed by the mother.

HISTORY OF PAST ILLNESS

According to the mother, the patient has been suffering from asthma since birth triggered by dusts & pollution. Immunizations were completed like BCG, DPT, OPV & Measles vaccine. In the past, they always sought for consultation to Dr. Padre when attacked by asthma and prescribed with Salbutamol neb for management. She was never hospitalized due to asthma during her childhood years since her parents provided her with their own

nebulizer at home. But on August 5-8, 2008, at the age of 18, she was hospitalized in NVPH of Bambang, Nueva Vizcaya due to asthma. In many instances, the patient was reported to experience symptoms of anemia other than asthma and advised to take Ferrous SO4 & Multivitamins for remedy. Other than his hospitalization, the patient didnt undergo any kind of surgery.

Laboratory Examinations
Urinalysis
TEST
Color Character WBC/HPF RBC/HPF Specific Gravity A. urates/PO4 pH

Date: September 9, 2011 RESULT

Yellow Slight cloudy 1.3 0.2 1.020 + 6

NORMAL VALUES
Yellow amber Clear 0-5/hpf 0-5/hpf 1.010-1.025 rare 4.6-8.0

IMPRESSION
Normal Suggests presence of sediments Normal Normal Normal Normal

Jehova L. Olpindo, RMT, RN Medical Technologist

Michelle Claire R. Maniquis Pathologist Date: September 9, 2011

Hematology TEST Hemoglobin Hematocrit RBC Platelet WBC MCH MCV MCHC RESULT 13.7 g/dl 40.3 L 4.72 10^12L 16310^9L 12.5 10^9L 29.1 pg 85.4 fl 0.33 g/dl

NORMAL VALUES M: 13.5-17.0 F: 12-16 M: 40-54 F: 36-54 M: 4.70-6.90 F: 4.20-5.40 150-450 5.0-10.0 27-31 80-96 0.32-0.36

IMPRESSION Normal Normal Normal Normal - infection Normal Normal Normal

Nicano III M. Caoile, RMT Medical Technologist

Michelle Claire R. Maniquis Pathologist Date: September 10, 2011

Hematology TEST Hemoglobin RESULT 13.5 g/dl

NORMAL VALUES M: 13.5-17.0 F: 12-16

IMPRESSION Normal

TEST Hematocrit RBC Platelet WBC MCH MCV MCHC

RESULT 39.0 L 4.61 10^12L 115 10^9L 1.9 10^9L 29.3 pg 84.6 fl 0.33 g/dl

NORMAL VALUES M: 40-54 F: 36-54 M: 4.70-6.90 F: 4.20-5.40 150-450 5.0-10.0 27-31 80-96 0.32-0.36

IMPRESSION Normal Normal - bleeding - anemia Normal Normal Normal

Mariannty V. Castillo, RMT Medical Technologist

Michelle Claire R. Maniquis Pathologist

Hematology TEST Hemoglobin Hematocrit RBC Platelet WBC MCH MCV MCHC RESULT 13.8 g/dl 40.8 L 4.80 10^12L 154 10^9L 7.4 10^9L 29.3 pg 85.0 fl 0.4 g/dl

Date: September 11, 2011

NORMAL VALUES M: 13.5-17.0 F: 12-16 M: 40-54 F: 36-54 M: 4.70-6.90 F: 4.20-5.40 150-450 5.0-10.0 27-31 80-96 0.32-0.36

IMPRESSION Normal Normal Normal Normal Normal Normal Normal - intravascular hemolysis

Gina Ramos-Jalimao, RMT Medical Technologist

Michelle Claire R. Maniquis Pathologist

DRUG NAMEACTIONINDICATIONCONTRAINDICATIONSNSG. CONSIDERATIONSGENERIC

NAME:

Acetaminophen BRAND NAME: Paracetamol CLASSIFICATION: T: antipyretic, analgesic DOCTORS ORDER: Paracetamol 300mg/ml IVP q4 for fever DATE STARTED: 09/09/11 DATE DISCONTINUED: 09/10/11It reduces fever by direct action on hypothalamus with consequent peripheral vasodilation, sweating, and dissipation of heat.FeverHypersensitivity

Monitor and be alert for early signs of hepatotoxicity. Do not administer other medications containing Paracetamol without medical advice; overdosing can cause liver damage and other toxic effects.ADVERSE/SIDE EFFECTSCNS: dizziness DRUG NAMEACTIONINDICATIONCONTRAINDICATIONSNSG. CONSIDERATIONSGENERIC NAME: Ascorbic acid GI: hepatotoxicity CLASSIFICATION: T: vitamin P: water soluble vitamin DOCTORS ORDER: Ascorbic acid 500mg OD DATE STARTED: 09/10/11 DATE DISCONTINUED: 09/11/11Stimulates collagen formation and tissue repair; involved in oxidationreduction reactions.To prevent vitamin C deficiency in patient with poor nutritional habits or increased requirements Severe febrile statesHypersensitivityAdvise bed rest in episodes of dizziness and faintness to prevent injury. Patient Teaching: Inform patient that urine will turn yellow. Inform patient that Vitamin C is readily available in citrus fruits.ADVERSE/SIDE EFFECTSCNS: faintness, dizziness GI: diarrhea, nausea, vomiting GU: acid urine

DRUG STUDY

DRUG NAMEACTIONINDICATIONCONTRAINDICATIONSNSG. CONSIDERATIONSGENERIC

NAME:

Ranitidne CLASSIFICATION: T: anti-ulcer P: H2-blocker DOCTORS ORDER: Ranitidine 1amp IV q8 DATE STARTED: 09/11/11 DATE DISCONTINUED: 09/11/11Inhibits the action of H2-receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion.Healing and prevention of ulcer. Decreased symptoms of gastroesophageal reflux. Decreased secretion of gastric acid. Treatment of heartburn, acid indigestion and sour stomach.HypersensitivityAssess vital signs. Assess for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. Inform patient that the drug may cause drowsiness or dizziness.
DRUG NAMEACTIONINDICATIONCONTRAINDICATIONSNSG. CONSIDERATIONSGENERIC ADVERSE/SIDE EFFECTSCNS: confusion

NAME:

Metoclopramide

CV: arrhythmias CLASSIFICATION: T: anti-emetic Hemat: agranulocytosis, aplastic anemia

DOCTORS ORDER: Metoclopramide 1amp IV prn for vomiting DATE STARTED: 09/11/11 DATE DISCONTINUED: 09/11/11Stimulate motility of upper GI, increases lower esophageal sphincter tone, and blocks dopamine receptors at the chemoreceptor trigger zone. This speeds up the rate at which the stomach empties into the intestines.To prevent or reduce nausea and vomitingHypersensitivityMonitor bowel sounds. Tell patient to avoid activities that require alertness for 2hours after doses Urge patient to report persistent or serious adverse reactions promptlyADVERSE/SIDE EFFECTSGI: bowel disorders, diarrhea, nausea GU: incontinence, urinary frequency

DRUG NAMEACTIONINDICATIONCONTRAINDICATIONSNSG. CONSIDERATIONSGENERIC

NAME:

Tranexamic Acid CLASSIFICATION: T: antifibrinolytic

DOCTORS ORDER: Tranexamic Acid 1amp IV q8 DATE STARTED: 09/11/11 DATE DISCONTINUED: 09/12/11Competitively inhibits the activation of plasminogen to plasmin, a molecule responsible for the degradation of fibrin. Fibrin is the basic framework for the formation of a blood clot in hemostasis. It has roughly 8 times the antifibrinolytic activity.Excessive G.I motility and hypertonia irritable bowel syndromeHypersensitivityAssess vital signs. Monitor for manifestations of hypersensitivity and report appearance. Monitor signs and symptoms and report immediately. Advise the patient not to take this medication if allergic to tranexamic acid, or if he/she has color blind, history of bleeding. ADVERSE/SIDE EFFECTSCNS: dizziness, drowsiness CV: tachycardia GI: nausea and vomiting

Brief Description of the Disease

Dengue (a.k.a. "break-bone" or "dandy fever") is a mosquito-borne infection which in recent years has become a major public health concern. It is a benign acute febrile syndrome occurring in tropical regions. The virus causes increased vascular permeability that leads to a bleeding diathesis or DIC known as Dengue Hemorrhagic Fever. ETIOLOGY

Dengue Virus Types 1,2,3,4 (Flavivirus) Chikungunya Virus (Arbovirus)

MODE OF TRANSMISSION

Vector/Mosquito bite (Aedes aegypti)

PREDISPOSING FACTORS

Stagnant water Wet season Urban Communities

INCUBATION PERIOD

Uncertain. Probably 6 to 7 days

MANIFESTATIONS

Fever Abrupt onset, rising to 39.5-41.4C Accompanied by frontal or retro-orbital headache Lasts 1-7 days, then defervesces for 1-2 days Biphasic, recurring with second rash but not as high Rash Initial rash transient, generalized, macular, and blanching; occurs in first 1-2 days of
fever

Second rash occurring within 1-2 days of defervescence, lasting 1-5 day Second rash morbilliform, maculopapular, sparing palms and soles Occasionally desquamates Bone Pain Absent in DHS/DSS After onset of fever

Increases in severity Not associated with fractures May last several weeks Most common in legs, joints, and lumbar spine Miscellaneous Symptoms Nausea and vomiting Cutaneous hyperesthesia Taste aberrations Anorexia Abdominal pain

CLASSIFICATION According to Severity:

Grade I fever accompanied by non-specific constitutional symptoms, the only

hemorrhagic manifestation is a positive Tourniquet test.

Grade II the additional manifestation to those of Grade I is spontaneous bleeding

skin and/or other hemorrhages.

Grade III Circulatory failure manifested by rapid and weak pulse, narrowing pulse
pressure or hypotension, with the presence of cold clammy skin and restlessness.

Grade IV profound shock with undetectable blood pressure and shock.

STAGES

Febrile or Invasive Stage (First 4 days). Starts abruptly as high fever, abdominal pain
and headache; later flushing may be accompanied by vomiting, conjunctival infection, epistaxis.

Toxic or Hemorrhagic Stage (4th-7th days). Lowering of temperature, severe abdominal

pain, vomiting and frequent bleeding from GIT in the form of hematemesis and melena. Unstable BP, narrow pulse pressure and shock. Death may occur. Tourniquet test which may be positive on 3rd day may become negative due to low or vasomotor collapse.

Convalescent or Recovery Stage (7th-10th days). Generalized flushing with intervening

areas of blanching appetite regained and blood pressure already stable. COMPLICATIONS

Brain damage from prolonged shock or intracranial pressure/hemorrhage Myocarditis Encephalopathy Liver Failure

PREVALENCE

All persons are susceptible. Both sexes are equally affected. Age groups predominantly
affected are the preschool age and school age. Adults and infants are not exempted. Peak age affected is 5-9 years.

Sporadic throughout the year. Epidemic usually occurs during the rainy seasons JuneNovember. Peak months are September and October.

Occurs wherever vector mosquito exists. Susceptibility is universal. Acquired immunity

may be temporary but usually permanent. DIAGNOSIS

Tourniquet Test (Rumpel Leads Test). Inflate the blood pressure cuff on the upper arm to
a point midway between the systolic and diastolic pressure for 5 minutes. Release the cuff and make an imaginary 2.5 cm square or 1 inch square just below the cuff, at the antecubital fossa. Count the number of Petechiae inside the box. A test is positive when 20 or more Petechiae per 2.5 cm square or 1 inch square are observed.

Laboratory Studies Isolation of virus in serum and detection of IgM and IgG by ELISA antibody capture,
monoclonal antibody, or hemoagglutination.

Complete Blood Count

> Hemoconcentration (HCT increased 20%) > Thrombocytopenia (platelet count <100 x 109/L > Leukopenia

Chemistry Panel
> Electrolyte Imbalances > Acidemia > Elevated BUN

Liver Function Tests

> Elevated transaminase > Hypoproteinemia

Guaiac Test for occult blood in stool DIC Panel, as indicated Imaging Studies
Chest X-Ray > Bronchopneumonia > Pleural Effusion

Head CT Scan without Contrast > For altered level o consciousness > Intracranial bleeding > Cerebral edema

NURSING MANAGEMENT

Isolation of patient is recommended

 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 is recommended. Avoid unnecessary movement.
If transfusion is given, support the patient during therapy. Observe for signs of deterioration (shock) such as low pulse, cold clammy perspiration, prostration.

For shock, prevention is the best treatment. Dorsal recumbent position facilitates
circulation.

Diet low fat, low-fiber, non-irritating, non-carbonated. Noodle-soup may be given. For anxiety of patient and family explain thoroughly the nature, the discomforts and
limitations of activity associated with the diagnostic procedures. Encourage participation of family in patient care. Create a comfortable position for the patient.

For fever cooling measures through sponges. Administer prescribed drugs; encourage
fluid intake unless contraindicated. PREVENTION

The infected individual, contacts and environment. Recognition of the disease Isolation of the patient (screening or sleeping under the mosquito net) Health education Control measures.
Eliminate vector by: > Changing water and scrubbing the sides of lower vases once a week. > Destroy breeding places of mosquito by cleaning surroundings, proper disposal of rubber tires, empty bottles or cans.

Avoid too many hanging clothes inside the house. Residual spraying with insecticides.

Pathophysiology

ETIOLOGY: Dengue Virus Types 1,2,3,4 (Flavivirus) Chikungunya Virus (Arbovirus)

PREDISPOSING FACTORS: Stagnant water Wet season Urban Communities

Bite of an aedes aegypti mosquito carrying a virus Virus goes into the circulation Viral entry to a permissive host cell Viral replication and proliferation Release of exotoxins and endotoxins Antigen-Antibody Complex

C1, C4, C2, C3 Activation C3b Immune adherence to platelet Platelet injury Thrombocytopenia Vascular permeability Extravasation of fluids Bleeding >Petechiae Hypovolemia >Ecchymose s CO >Gingival bleeding >Hematuria Hypotension >Epistaxis >GI bleeding Shock Blood GI irritation Functions of Blood Hematemesis Dehydration Stimulation of nerve endings Pain Activation of Kallikrein-Kinin System Release of kinins C3a, C5a anaphylatoxins

Activation of macrophages Secretion of endogenous pyrogenic cytokines Hypothalamic set point Fever Diaphoresis

Histamine release

ANATOMY AND PHYSIOLOGY

Dehydration >Hemoconcentration >Hypoproteinemia >Weakness >Fatigue >Tachypnea >UO >Weak, rapid pulse Tissue perfusion >Dizziness >Capillary refill time Hypoxia Anaerobic metabolism Lactic acid formation

Acidosis

Blood is pumped by the heart through blood vessels, which extend throughout the body. Blood helps to maintain homeostasis in several ways:

1. Transport of gases, nutrients, and waste products. Oxygen enters the blood in the

2.

3. 4. 5. 6. 7.

lungs and is carried to the cells. Carbon dioxide, produced by the cells, is carried in the blood to the lungs, from which it is expelled. Ingested nutrients, ions, and water are transported by the blood from the digestive tract to the cells, and the waste products of the cells are transported to the kidneys for elimination. Transport of processed molecules. Many substances are produced in one part of the body and transported in the blood to another part, where they are modified. For example, the precursor to Vitamin D is produced in the skin and transported by the blood to the liver and then to the kidneys for processing into active Vitamin D. Transport of regulatory molecules. Many of the hormones and enzymes that regulate body processes are carried from one part of the body to another part within the blood. Regulation of pH and osmosis. Buffers which help keep the bloods pH within its normal limits of 7.35-7.45 are found in the blood. The osmotic composition of blood is also critical for maintaining normal fluid and ion balance. Maintenance of body temperature. Blood is involved with body temperature regulation because warm blood is transported from the interior to the surface of the body where heat is released from the blood. Protection against foreign substances. Cells and chemicals of the blood constitute an important part of the immune system, protecting against foreign substances such as microorganisms and toxins. Clot formation. Blood clotting provides protection against excessive blood loss when blood vessels are damaged. When tissues are damaged, the blood clot that forms is also the first step in tissue repair and the restoration of normal function.

Physical Characteristics Blood is sticky opaque fluid with a characteristic metallic taste. Depending on the amount of oxygen it is carrying, the color of blood varies from scarlet (oxygen-rich) to a dull red (oxygen-poor). Blood is heavier than water and about five times thicker, or more viscous, largely because of its formed elements. Blood is highly alkaline, with a pH between 7.35-7.45. its temperature (38C or 100.4F) is always slightly higher than body temperature. Blood accounts for approximately 8% of body weight, and its volume in healthy males is 5 to 6 liters, or approximately 6 quarts

Composition of Blood Blood is a connective tissue consisting of plasma and formed elements.

Figure 1 The composition of blood

Plasma Plasma is a pale yellow fluid that consists of about 91% water; 7% proteins; and 2% other substances, such as ions, nutrients, gases, and waste products. Plasma proteins are the most abundant solutes in plasma. Except for antibodies and protein-based hormones, most plasma proteins are made by the liver. Plasma proteins include albumin, globulin, and fibrinogen. Albumin makes up 58% of the plasma proteins. Although osmotic pressure of blood results primarily from sodium chloride, albumin makes an important contribution. The water balance between blood and tissues is determined by the movement of water into and out of the blood by osmosis. Globulins account for 38% of the plasma proteins. Some globulins, such as antibodies and complement, are part of the immune system. Other globulins and albumin function as transport molecules because they bind to molecules such as hormones and carry them in the blood through out the body. Fibrinogen constitutes 4% of plasma proteins and is responsible for the formation of blood clots. Formed Elements

Erythrocytes

Erythrocytes, or red blood cells (RBCs), function primarily to ferry oxygen in blood to all cells of the body. RBCs differ from other blood cells because they are anucleate; that is, they lack a nucleus. They also contain very few organelles. Mature RBCs circulating in the blood are literally sacs of hemoglobin molecules. Hemoglobin, an iron-containing protein, transports the bulk of the oxygen that is carried in the blood. Moreover, because erythrocytes lack mitochondria and make ATP by anaerobic mechanisms, they do not use up any of the oxygen they are transporting, making them very efficient oxygen transporters. Erythrocytes are small cells shaped like a biconcave disks flattened disks with depressed centers. Because of their thin centers, they look like miniature doughnuts when viewed with a microscope. Their small size and peculiar shape provide a large surface area relative to their volume, making them ideally suited for gas exchange. The primary functions of red blood cells are to transport oxygen from the lungs to the various tissues of the body and to assist in the transport of carbon dioxide from the tissues to the lungs. Oxygen transport is accomplished by hemoglobin which consists of four protein chains and four heme groups. Each protein, called a globin, is bound to one heme, a red-pigmented molecule. Each heme contains one iron atom, which is necessary for the normal function of hemoglobin. When hemoglobin is exposed to oxygen, one oxygen molecule binds to the iron atom of each heme. Hemoglobin that is bound to oxygen is a darker red in color. Hemoglobin is responsible for 98.5% of the oxygen transported in the blood. Because iron is necessary for oxygen transport, it is not surprising that two-thirds of the bodys iron is founding hemoglobin. Small amount of iron are required in the diet to replace the small amounts lost in the urine and feces. Women need the dietary iron than men do because women lose iron as a result of menstruation.

Function

Life History of Red Blood Cells

Red blood cells live for about 120 days in males and 110 days in females. Under normal conditions, about 2.5 million red blood cells are destroyed every second. Fortunately, new RBCs produced rapidly as old red blood cells are destroyed. Stem cells form proerythroblasts, which give rise to RBCs. Red blood cells are the final cells produced from a series of cell divisions. The process of cell division requires the B vitamins folate and B12, which are necessary for DNA synthesis. Iron is required for the production of hemoglobin. Consequently, lack of folate, vitamin B12, or iron can interfere with normal red blood cell production. Red blood cells are stimulated by low blood oxygen levels. Typical causes of low blood oxygen are decreased or defective hemoglobin, disease of the lungs, high altitude, inability of the cardiovascular system to deliver blood to tissues, and increased tissue demand for oxygen. Low blood oxygen levels increase red blood cell production by increasing the formation of the glycoprotein erythropoietin. Erythropoietin stimulates red bone marrow

to produce more red blood cells. Thus, when oxygen levels in the blood decrease, the production of erythropoietin increases, which increase red blood cell production. The increased number of red blood cells increases the ability of the blood to transport oxygen. This mechanism returns blood oxygen levels to normal and maintains homeostasis by increasing the delivery of oxygen to tissues. Conversely, if blood oxygen levels increase, less erythropoietin is released and red blood cell production decreases. Old, abnormal, or damaged red blood cells are removed from the blood by macrophages located in the spleen and liver. Within the macrophage the globin part of the molecule is broken down into amino acids that are reused to produce other proteins. The iron released from heme is transported in the blood to the red bone marrow and is used to produce new hemoglobin. Only small amounts of iron are required in the daily diet because the iron is recycled. The heme molecules are reconverted to bilirubin, a yellow pigment molecule. Bilirubin normally is taken up by the liver and released into the small intestine as part of the bile.

Leukocytes Leukocytes, or white blood cells, are the only complete cells in the blood; that is, they contain nuclei and the usual organelles. On average, there are 4000 to 11,000 WBCs per cubic millimeter. Leukocutes form a protective, movable army that helps defend the body against damage by bacteria, viruses, parasites, and tumor cells. WBCs are able to slip into and out of the blood vessels a process called diapedesis. The circulatory system is imply their means of transportation to areas of the body where their services are needed for inflammatory or immune responses. In addition, WBCs can locate areas of tissue damage and infection in the body by responding to certain chemicals that diffuse from the damaged cells. This capability is called positive chemotaxis. Once they have caught the scent, the WBCs move through the tissue spaces by ameboid motion. By following the diffusion gradient, they pinpoint areas of tissue damage and rally round in large numbers to destroy foreign substances or dead cells. Whenever WBCs mobilize for action, the body speeds up their production, and as many as twice the normal number of WBCs may appear in the blood within a few hours. A total WBC count of above 11,000 cells/mm3 is referred as leukocytosis. Leukocytosis generally indicates that a bacterial or viral infection is stewing in the body. The opposite condition, leukopenia, is an abnormally low WBC count. It is caused by certain drugs such as corticosteroids and anticancer agents. White Blood cells are classified into two major groups, depending on whether or not they contain visible contain visible granules in their cytoplasm. Granulocytes are granule-containing WBCs. They have lobed nuclei, which typically consist of several rounded nuclear areas connected by thin strands of nuclear material. The granules in their cytoplasm stain specifically with Wrights stain. The granulocytes include the neutrophils, eosinophils and basophils. Neutrophils have a multilobed nucleus and very fine granules that respond to both acid and basic stains. Consequently, the cytoplasm as a whole stains pink. Neutrophils are avid phagocytes at sites of acute infection. Eosinophils have a blue-red nucleus that resembles an old-fashioned telephone receiver and sport large brick-red cytoplasmic granules. Their number increases rapidly during allergic reactions and infections by parasitic worms. Basophils, the rarest of the WBCs, contain histamine-containing granules that stain dark blue. Histamine is an inflammatory chemical that makes blood vessel leaky and attracts other WBCs to the inflammatory site.

The second group, agranulocytes, lack visible cytoplasmic granules. Their nuclei are closer to the norm-that is, they are spherical, oval, or kidney-shaped. The agranulocytes include lymphocytes and monocytes. Lymphocytes have a large dark purple nucleus that occupies most of the cell volume. Only slightly larger than RBCs, lymphocytes tend to take up residence in lymphatic tissues where they play an important role in the immune response. Monocytes are the largest of the WBCs. Except for their more abundant cytoplasm and in dependent nucleus, they resemble large lymphocytes. When they migrate into the tissues, they change into macrophages with huge appetites. Macrophages are important in fighting chronic infections.

Platelets

Platelets, or thrombocytes, are minute fragments of cells, each containing a small cytoplasm surrounded by a cell membrane. They are produced in the red bone marrow from megakaryotes. Small fragments of these cells break off and enter the blood as platelets, which play an important role in preventing blood loss. This prevention is accomplished in two ways: (1) the formation of platelet plugs, which small holes in small vessels, and (2) the formation of clots, which help seal off larger wounds in the vessels.

Hematopoiesis (Blood Cell Formation)

Blood cell formation, or hematopoiesis, occurs in the red bone marrow, or myeloid tissue. In adults, this tissue is found chiefly in the flat bones of the skull and pelvis, the ribs, sternum, and proximal epiphyses of the humerus and femur. Each type of blood cell is produced in different numbers in response to changing body needs and different stimuli. After they mature, they are discharged into the blood vessels surrounding the area. All the formed elements arise from a common type of stem cell, the hemocytoblast, which resides in the red bone marrow. Their development differs, however, and once a cell is committed to a specific blood pathway it cannot change. The hemocytoblast forms two types of descendants the lymphoid stem cell, which produces lymphocytes, and the myeloid stem cell, which can produce all other classes of formed elements. Because they are anucleate, RBCs are unable to synthesize proteins, grow or divide. As they age, RBCs become more rigid and begin to fragment, or fall apart, in 100 to 120 days. Their remains are eliminated by phagocytes in the spleen, liver, and other body tissues. Lost cells are replaced more or less continuously by the division of hemocytoblasts in the red bone marrow. The developing RBCs divide many times and then begin synthesizing huge amounts of hemoglobin. Suddenly, when enough hemoglobin has been accumulated, the nucleus and most organelles are ejected and the cell collapses inward. The result is the young RBC, called a reticulocyte because it is still contains some rough endoplasmic reticulum. The reticulocytes enter the bloodstream to begin their task of transporting oxygen. Within 2 days of release, they have ejected the remaining ER and have become fully functional erythrocytes. The entire development process from hemocytoblast to mature RBC takes 3 to 5 days. The rate of erythrocyte production is controlled by a hormone called erythropoietin. Normally a small amount of erythropoietin circulates in the blood at all times, and red blood cells are formed at a fairly constant rate. Although the liver produces some, the kidneys play the major role in producing this hormone. When blood levels of oxygen begin to decline for any reason, the kidneys step up their release of erythropoietin. Erythropoietin targets the bone marrow, prodding it into higher gear to turn out more RBCs. An over abundance of erythrocytes, or an excessive amount of oxygen in the bloodstream, depresses erythropoietin release and red blood cell production. An important point to remember is that it is not the relative number of RBCs in the blood that controls RBC production. Control is based on their ability to transport enough oxygen to meet the bodys demands. Like erythrocyte production, the formation of leukocytes and platelets is stimulated by hormones. These colony stimulating factors (CSFs) and interleukins not only prompt red bone marrow to turn out leukocytes, but also enhance the ability of mature leukocytes to protect the body. Apparently, they are released in response to specific chemical signals in the environment such as inflammatory chemicals. Additionally, exposure to certain bacteria or their toxins stimulates macrophages and lymphocytes (and other cell types) to release CSFs and interleukins, which marshal an army of WBCs to ward off the attack. The production of platelets is accelerated by the hormone thrombopoeitin, but little is known about the regulation of platelet formation.

Hemostasis
Hemostasis involves three major phases, which occur in rapid sequence; platelet plug formation, vascular spasms, and coagulation or blood clotting. Blood loss at the site is permanently prevented when fibrous tissue grows into the clot and seals the hole in the blood vessel. Basically, hemostasis occurs as follows:

1. Platelet plug forms. Platelets are repelled by an intact endothelium, but when it is
broken so that the underlying collagen fibers are exposed, the platelets become sticky and cling to the damaged site. Anchored platelets release chemicals that attract more platelets to the site and as more and more platelets pile up, a small mass called a platelet plug or whit thrombus is formed. 2. Vascular spasms occur. The anchored platelets also release serotonin which causes that blood vessel to go into spasms. The spasms narrow the blood vessels at that point, decreasing blood loss until clotting can occur. (Other factors causing vessel spasms include direct injury to the smooth muscle cells and stimulation of local pain receptors.)

3. Coagulation events occur. a. At the same time, the injured tissues are releasing thromboplastin, a factor

that plays an important role in clotting. b. PF3, a phospholipid that coats the surfaces of the platelets, interacts with thromboplastin, other blood protein clotting factors and calcium ions to form an activator that triggers that clotting cascade. c. This prothrombin activator converts prothrombin present in the plasma, to thrombin, an enzyme. d. Thrombin then joins soluble fibrinogen proteins into long hairlike molecules of insoluble fibrin, which forms a meshwork that traps the RBCs and forms the basis of the clot. Within the hour, the clot begins to retract, squeezing the serum from the mass and pulling the ruptured edges of the blood vessel closer together.

Blood Groups

PSYCHOSOCIALPATHOPHYSIOLOGICAL BASISPRIMARY CAREGIVERS:

The patients mother who is always supportive during times of difficulties and attends to her needs. COPING MECHANISM: Problem focused specifically fight response

RELIGION: Espiritista; the family seldom go to mass on Sundays according to the mother due to her hectic schedule PRIMARY LANGUAGE: Iloco & Tagalog PRIMARY SOURCE OF HEALTH CARE: Barangay Health Centers FINANCIAL RESOURCES RELATED TO ILLNESS: From the salary and the savings of the family

3rd year college, taking up food technology GENERAL APPEARANCE: PSYCHOMOTOR Able to do ADLs PHYSICAL PHYSIOLOGICAL

PERSON Assessmentskin turgor, weight normal with height(50kg=52), well Nourishment/Hydration: Good
developed firm muscles Color/Quality of skin: with maculo-papular rashes over skin of lower extremities VITAL SIGNS T: 36oC HR: 88 bpm RR: 22 cpm BP: 100/70 mmHg ORIENTATION: Oriented SPEECH: Comprehensible NONVERBAL BEHAVIOR: Facial Expression: grimace Posture: Normal; balanced The significant other provides comfort and security to the patient

LOC: Normal;oriented to time, place, event

The patient verbalizes her needs and complaints when in pain The patient copes with the stress through finding ways to solve problem

platelet count

ELIMINATIONPATHOPHYSIOLOGICAL BASISSTOOL:
Frequency: once a day Pattern: no regular pattern Due to Consistency and shape: well-formed pain Amount: moderate Color: yellow to brown URINE: Quantity:per voiding within 8hrs-24hrs; 1200-1300 mL: Normal Pattern: 4-7 times a day Color: yellow-amber Clarity: clear ABDOMEN Globular Bowel sounds: LLQ: 1 gurgles per min. LUQ: 1 gurgles per min. RLQ: 1 gurgles per min. RUQ: 2 gurgles per min.REST AND ACTIVITY LEVEL: Ambulatory

ACTIVITYPATHOPHYSIOLOGICAL BASISCURRENT

ADLs: Able to do grooming, feeding, toileting without assistance from the SO SLEEP: Bedtime: 9:00pm Usual waking time: 5:00am-6:00am Duration: 7-8 hours Quality: deep sleep The patient usually becomes irritated during sleep disturbances BODY FRAME: Mesomorph POSTURE: Normal posture;without slouching GAIT: Coordinated movements COORDINATION: Good coordination without purposeless rapid motions BALANCE: Without bending toward the sides; able to stand and rise from bed MUSCLE: Tone: normal Movement: without involuntary movements MOTOR FUNCTION: Gross: abel to flex and extend extremities Fine: can grasp items RANGE OF MOTION: Legs: equal movements Arms: pronation and supination of arms can extend, flex, abduct and adduct minimally

SAFE ENVIRONMENTPATHOPHYSIOLOGICAL BASISALLERGIES:

Medication: none Food: none Environment: dusts & pullution EYES/VISION: Eye alignment and coordination Both eyes are coordinated Move in unison and with parallel alignment HEARING: Follows where the sound is coming from and responds verbally SKIN: Color: with maculo-papular rashes over skin of lower extremities Good skin turgor

TEMPERATURE: 36oC(AXILLA)

Triggers asthma attack

platelet count

OXYGENATIONPATHOPHYSIOLOGICAL BASISACTIVITY TOLERANCE:

Independent on performing ADLs HR: 88 bpm RR: 22 cpm AIRWAY CLEARANCE: Nose: intact and moist Mouth: lips are moist LUNG SOUNDS: Absence of abnormal breath sounds such as crackles, wheezes, stridors COLOR: Nail beds and lips: Pinkish Skin color: with maculo-papular rashes over skin of lower extremities CAPILLARY REFILL: Normal capillary refill (1-2sec) APICAL PULSE: 90 bpm RESPIRATION: RR: 22 cpm Depth: regular Rhythm: regular

NUTRITIONPATHOPHYSIOLOGICAL BASISDIET:
Diet as tolerated except dar-colored foods FLUID INTAKE: 8-12 glasses a day/1-2L per day INTRAVENOUS FLUIDS: D5 NSS 1L D5 LRS 1L MVT + Glucose ABILITY: Can feed self without assistance from the mother platelet count

To compensate the fluid demands of the body

Doctors OrderSeptember 9, 2011Laboratory:

CBC with Plt count Blood Typing

IVF: D5 LRS 1L FD 500cc then regulate @ 30gtts/min MVT + Glucose x 6o To ff: D5 NSS 1L @ 30 gtts/min

DIET: DAT except dark-colored foods Medications: Paracetamol 300mg/ml IVP q4 for fever Ascorbic acid 500mg OD Nursing Procedure: TPR q shift1st day of hospitalization: At around 12:35pm, a 21y/o female arrived at the ER with her mother, who was admitted with chief complaints of fever, vomiting, nausea, body malaise, abdominal pain for 2 days. Upon assessment, the patient was weak in appearance and skin is pale. Initial vital signs were taken: T: 38oC & BP: 90/50 mmHg. After taking the vital signs, Dr. Manaois examined her. The patient was requested for admission. Meds given were Paracetamol and Ascorbic acid. 500cc of D5 LRS IVF was administered to the patient in fast drip. After which, it was regulated to 30 gtts/min. The patient was then endorsed to the nurse on duty. At 12:45pm, she was transferred via wheelchair to the Medical ward with ongoing IVF of D5 LRS 1L regulated @ 30gtts/min. Nursing care was rendered and her meds were administered as ordered. At 4:30pm, above IVF was consumed and replaced with D5 NSS 1L @ 30 gtts/min.Doctors OrderSeptember 10, 2011Laboratory: CBC daily IVF: D5 NSS 1L @ 30 gtts/min MVT + Glucose x 6o D5 NSS 1L @ 20 gtts/min Medications: Cont. meds o RanitidineOrderSeptember 11, 2011Laboratory: Doctors 1amp IV q8 -----Nursing Procedure: Monitor v/s q shift2nd day of hospitalization: IVF: D5 NSS 1L @ 20 gtts/min At 12:30am, the patient was in bed, asleep & above IVF was consumed and replaced with MVT + Glucose x 6o, infusing well. Upon assessment and v/s taking, patient was afebrile with temperature of 37.2oC and negative complaint of abdominal pain. Her meds Medications: were given, needs attended and regular v/s monitoring were implemented. The patient Cont. meds was kept at rest. Nursing care was performed. Ranitidine 1amp IV q8o Metoclopramide 1amp IV prn for vomiting At 7:00am, above IVF was consumed and replaced with D5 NSS 1L @ 30 gtts/min, infusing Procedure: Nursing well. Nursing care was renderes and needs attended. Monitor v/s q shift At 4:30pm, above IVF was consumed and replaced with D5 NSS 1L @ 20 gtts/min, MGH: Ascorbic acid 500mg3nd day of hospitalization: infusing well. At 2:30am, the patient was in bed, asleep & above IVF was consumed and replaced with D5 NSS 1L @ 20 gtts/min, infusing well. Upon assessment and v/s taking, patient was

afebrile with temperature of 36oC and negative complaint of abdominal pain. She complained of vomiting. Her meds were given, needs attended and regular v/s monitoring were implemented. The patient was kept at rest. Nursing care was performed.