I.

INTRODUCTION "Health is not valued till sickness comes." - Dr. Thomas Fuller . Most of the people today are not conscious about their health. They eat what they want do what they want. They dont think much of their health. But when time comes that they feel different in their body, they would realize that the abused their body so much. According to World Health Organization (WHO), health as a state of complete physical, mental and social wellness, not merely the absence of disease or infirmity. Which means people in a state of emotional, physical, environmental and social well-being can fulfill their responsibilities and function effectively. Absence of these elements would entail risk for having unhealthy lifestyle. Environment greatly affects persons health. Like in the community there are many vectors that carries disease. These vectors are from unsanitary environment and could carry diseases are dysentery from house flies, leptospirosis from rats and dengue fever from mosquitoes. Dengue Fever or Dengue Hemorrhagic fever is the most common disease that a person could get from unsanitary environment, especially in the Philippines where in Dengue is found in tropical and sub-tropical climate. Dengue fever is an acute febrile disease caused by infection with one of the serotypes of dengue virus which is transmitted by mosquito genus Aedes. It refers to benign form of disease with systemic symptoms, fever and often rash associated with pain behind the eyes, the joints and bones. Dengue Hemorrhagic Fever (DHF) is severe, sometimes fatal manifestation of dengue virus infection characterized by a bleeding diathesis and hypovolemic shock. Headache, fever, exhaustion, severe joint and muscle pain, swollen glands (lymphadenopathy), and rash. The presence (the "dengue triad") of fever, rash, and headache (and other pains) is particularly characteristic of dengue. The incidence of dengue has grown dramatically around the world in recent decades. Some 2.5 billion people two fifths of the world's population are now at risk from dengue. WHO currently estimates there may be 50 million dengue infections worldwide every year.In 2007 alone, there were more than 890 000 reported cases of dengue in the Americas, of which 26 000 cases were DHF. The disease is now endemic in more than 100 countries in Africa, the Americas, the Eastern Mediterranean, South-east Asia and the Western Pacific. South-east Asia and the Western Pacific are the most seriously affected. Before 1970 only nine countries 1

had experienced DHF epidemics, a number that had increased more than four-fold by 1995. Not only is the number of cases increasing as the disease is spreading to new areas, but explosive outbreaks are occurring. In 2007, Venezuela reported over 80 000 cases, including more than 6 000 cases of DHF. (Reference: www.who.int/mediacentre/factsheets/fs117/en/index.html) As of July 10, 2010, dengue epidemic has already been declared in Davao del Sur which was placed under the state of calamity effective July 7 due to the widespread outbreak of the disease.At least 14 deaths have been reported in the province.Davao del Sur was placed under the state of calamity on July 7 during the inaugural SangguniangPanlalawigan (SP) session after cases of the dreadful dengue hemorrhagic fever (DHF) reached 600 cases, already considered an alarming level by the Provincial Health of Office of Davao del Sur. The Provincial Health Office also reported that Digos City is the hardest hit among other areas of Davao del Sur with dengue cases to have reached 352. The municipality of Bansalan ranked second with 95 cases and Sta.Cruz with 57 cases, the rest of the victims are spread out in the various municipalities of the province, Anion said. In the Eastern Visayas, local health officials reported 37 deaths out of the 3,862 dengue cases from January to July this year. In the Cordillera region, health officials reported 539 cases for the first half of the year, a sharp increase from the 317 fever reported in the same period last year. Ifugao and Mountain Province registered unusual increases in the number of individuals with dengue fever.For the first six months of this year, Ifugao recorded 187 dengue fever cases compared to the 25 cases during the same period last year while Mountain Province had over 100 cases this year compared to the 32 cases last year. Aside from the three local governments, Apayao reported increase in dengue cases from 5 cases last year to 64 for the first semester of this year. In Baguio City, dengue fever cases rose to over 100 cases during the first six months compared to the only 44 cases last year. In the Autonomous Region in Muslim Mindanao (ARMM), a total of 365 persons have been afflicted with dengue for the past six months. ARMM Health Secretary KadilSinolinding said at least six dengue-related deaths three in May, one in March, and two in June have been listed in Sulu where 183 cases of the killer disease have been previously reported. The other Muslim Mindanao areas which submitted dengue cases during the first semester of 2010, Sinolindingsaid, are Maguindanao which registered 89 incidents; Lanao del Sur, 60; and TawiTawi, 33. In General Santos City, Dr. Jacinto Makilang, city health officer, said they already recorded at least 231 positive dengue cases from the citys 26 barangays since January and with one confirmed fatality so far.(Reference: www.mb.com.ph/articles/266225/denguespreading-5597-cases-reported) 2

A. Current trends about the disease condition ScienceDaily (May 10, 2010) Some of the human immune system's defenses against the virus that causes dengue fever actually help the virus to infect more cells, according to new research published May 6 in the journal Science. The researchers behind this study have identified a set of antibodies, produced by the human immune system to fight off the dengue virus, that they believe scientists should avoid including in any new vaccine to prevent dengue fever. The new research shows that these precursor membrane protein (prM) antibodies do not do a very effective job of neutralizing the virus. Moreover, these antibodies actually help the virus to infect more cells. The study suggests that when a person who has already been infected with one strain of dengue virus encounters a different strain of dengue virus, the prM antibodies awakened during the first infection spring into action again. However, rather than protecting the body from the second infection, these prM antibodies help the virus to establish itself. This activity of the prM antibodies could explain why a second infection with a different strain of the virus can cause more harm than the first infection. The researchers believe that if a dengue virus vaccine contained prM antibodies, this could cause similar problems. B. Reasons for choosing Dengue Hemorrhagic Fever as a case study One of the formidable parts in doing a case study is choosing what case is to present. The Student Nurse decided to choose Mosquee as her patient, first and foremost because of the initial contact that the students have already established a harmonious relationship with the patient and her significant others. The student have established the trust and cooperation easily and that made them trouble-free to ask certain questions regarding the patients health condition and to collect information needed in the case study. Most importantly the student nurse decided to choose DHF as a case study because of the initiative and interest of knowing how this disease is developed by an individual. Case studies can help the student nurse to learn the pathophysiology, and the predisposing and precipitating factors that contribute to its onset. New trends regarding the diagnosis and treatment will also provide the student nurse with additional knowledge. 3

C. Objectives: Student Centered: Short Term: Within the course of the case study, the student nurse shall have: Established rapport with their patient Assessed the patients physical, mental, social, intellectual, emotional, and spiritual needs; Identified factors affecting her health; Identified the apparent signs and symptoms of the clientele in relation to Dengue Hemorrhagic Fever; Performed comprehensive assessment to the clientele cephalocaudally using the methods, inspection, and auscultation as well as obtained the personal and pertinent family health- illness history of the clientele and relate it to the present disease condition; Assumed responsibility of making nursing diagnoses and contribute to the total plan of care; and Demonstrated ability in making use of therapeutic communication skills. Long Term: After the completion of the case study, the student nurse shall have: Discussed Dengue Hemorrhagic Fever. Be able to state the non- modifiable and modifiable risk factors shown in the pathophysiology and synthesis of the disease that had contributed to the development of the disease condition; Understood the patients condition by discussing the rationale behind the occurrence of each factor affecting her health; Explained and specified various treatment modalities and their significance in managing the disease condition based on concrete knowledge to be able to meet the clienteles needs and modified the clients environment to minimize injuries; Encouraged patient to cooperate and comply with the patients treatment; Patient Centered Objectives: 4

Short Term : Within the course of the hospitalization, the patient/patients SO shall have: Established a good trusting relationship with the student nurses; Verbalized her feelings about her condition; Participated in the comprehensive assessment needed for data collection; Showed cooperation and understanding of her/the patients condition by being able to enumerate information and/or health teachings given; Acquired knowledge at their level of understanding and information about the present disease condition and determined factors which contribute to this condition with the use of therapeutic communication; Known the essence of strict compliance with the treatment regimen; Recognized the importance of seeking medical check- up on a regular basis; and Expressed understanding of the dos and donts regarding the disease condition. Long Term : After the course of treatment, the patient/patients SO shall have:

Adhered and maintained good health practices, modified lifestyle and health behaviors
for the achievement of recovery and reestablishment of optimal health condition by cooperating or participating in the treatment plan;

Complied with the treatment regimen; Enumerated and identified factors brought about by her present condition and/or
hospitalization; and

Demonstrated an improvement of her condition.

II. NURSING PROCESS II.A ASSESSMENT 1. PERSONAL DATA

This is the case of Patient Mosquee, 13 years old, female and a natural-born Filipino and affiliated to Roman Catholic Church. She is the eldest among 3 siblings. She lives at Mexico, Pampanga. She was born on January 6, 2000 at a government hospital in Magalang. She was admitted last June 23, 2011 at around 9:48 pm with an admitting diagnosis Dengue Hemorrhagic Fever with warning signs in a certain government Hospital in San Fernando, Pampanga. The patient was not discharge during the days of nurse-patient interaction. Mosquees parents were the informant of the personal data obtained. 2. PERTINENT FAMILY HISTORY Mosquee is the eldest among the 3 children of Father Toph and Mother Remy and they are 5 in the family. She has 2 siblings named Chris and topher. Mother Remys pregnancies are all in normal spontaneous delivery from Mosquee to topher without any complications. During her pregnancy, she only seeks medical check-ups when she is already in her 2nd trimester of pregnancy specifically on the 5th month. first trimester for all of her 3 children. According to Father Toph, He and his wife are working for the family. He works as a vendor in Apu and earns only at around 4,500 php a month. While Mother Remy is a sales lady also in Apu and earns 2,000 php for every 4 Fridays of the month. Mosquee's family is classified as poor, since their income were not sufficient to meet the familys needs. Their expenses include their food, electric and water bill. They live in a small house that is made of both concrete and wood surrounded by a farm and has many tall grasses. The family has sewer outside their house which according to Father Toph it is not properly cleaned. Her family does not believe in superstitious beliefs but her family makes use of herbal medicines as alternative sources such to treat common illnesses like cough and colds. They use Bawang for toothache and hypertension, boiled Bayabas leaves for stomachache and cleaning wounds and some other herbs. They also attend to manghihilot and herbularios but would not hesitate to seek consultation from hospitals if the situation calls for it In mother Remys attitude towards pregnancy, she has sedentary lifestyle and she told that she had experienced vomiting on the

GENOGRAM PATERNAL MATERNAL

HPN HPN

x x
x x

LEGEND: Female

Male Pt. Moskee - Deceased - anemia

disease

Asthma
- No known

- DM

-Heart Attack

Hypertension

DHF

- Old Age

-CVA

EXPLANATION OF THE GENOGRAM: Pt. Mosquee, who is diagnosed to have Dengue Hemorrhagic fever, is the Eldest in a family with two siblings. Her two brothers have no known diseases. Her mother also has no known diseases as well as her Father. Pt. Mosquees father is the eldest among five children. Her fathers second to the last sibling has anemia and the rest have no known disease. With Pt. Mosquees maternal side, her mother is the 6th child among the 8 children in their family. All of the siblings of Mosquees mother have no known disease. Mosquees grandfather on paternal side has hypertension and his 3rd and 5th siblings too; while her grandmother on paternal side and her 2nd, 3rd and 5th siblings have no known disease and her eldest brother is deceased with no known diease. Mosquees grandfather on maternal side was diagnosed with DM and his 2nd 3rd 4th and 6th siblings are deceased. The 6th sibling died because of asthma. On the other hand, Mosquees grandmother on maternal side and her siblings have no known disease condition. All of great grandparents of Mosquee are deceased due to old age.

3. PERSONAL HISTORY During the pregnancy of Mother Remy to Mosquee, she was in a sedentary lifestyle and seldom eats nutritious foods. According to Mother Remy, she doesnt have any complication during her labor and when giving birth to Mosquee. Mother Remy gave birth to Mosquee via Normal Spontaneous Delivery and in normal AOG of 9 months. Mother Remy also told that when Mosquee was born she had a normal weight and height but she doent rember the xact weight of her child that time. Mosquee was born on January 6, 1997 in a hospital in Magalang.

Mosquee loves to eat chocolates and other junk foods especially sodas and she seldom eats vegetables and fruits. This signifies that she doesnt have enough nutrients in the body that can lower her immune system. Growth and development Erik Erikson (Psychosocial Development)

Identity vs. Role Confusion (13 to 18 y/o) Children of this age their significant person is the peer group. The development of who they are and going becomes a central focus for this stage. They continue to redefine their selfconcepts and the roles they can play, with certainty. According to Erikson, modern culture tends to make identity development more challenging. Adolescents who cannot develop a sense of who they are and what they are can experience role diffusion and an inability to solve core conflicts. As rapid physical changes occur, adolescents must reintegrate previous trust in their body, themselves and how they appear to others. Jean Piagets theory of cognitive development Formal operational Stage (11-15 y/o) In the stage of formal operations , develops abstract reasoning. Abstract reasoning includes inductive or deductive reasoning, the ability to connect separate events and the ability to understand later consequences. In formal thought, the adolescents thinks beyond the present and forms theories about everything, delighting especially in considerations of that which is not. The adolescent hypothesizes relationship as casual and analyzes them for effects. Manifestations of formal operational thought in adolescence include idealism which is envisioning a perfect world, Egocentrism which is preoccupation with ones own power of thought. Sigmund Freuds Psychosexual development Genital Stage (12-20 y/o) In this stage, adolescents focus on the genitals as the erogenous role and engage in masturbation and sexual relations with others. During this period of renewed sexual drive, adolescents experience conflict between their own needs for sexual satisfaction and societys expectations for control of sexual expression. Core concerns of adolescents include body image development and acceptance by the opposite sex. 4. HISTORY OF PAST ILLNESS

Pt. Mosquee had no previous hospitalization. According to her, she had not been hospitalized before due to major illness. Her parents said that simple fever, cough and colds are 9

easily cured by using over-the-counter drugs, and these drugs are effective and herbal meds, no further interventions to be done.

5. HISTORY OF PRESENT ILLNESS Pt. Mosquee was admitted at a secondary hospital in City of San Fernando last June 23, 2011 at 9:48 in the evening due to the complaint of on and off fever of 38.5 C. She was attended at the Emergency department and had taken a clinical history and physical assessment. She was transferred at the Pediatric Ward for further evaluation of the complaint. Upon reviewing the chart, it revealed that Pt. Mosquee 1 week prior to admission she experienced on and off fever. No consultation was made and no medication was taken until 5 days prior to admission she had a persistence of signs and symptoms and consults her to the nearest hospital in Mexico. 2 days prior to admission, persistence of signs and symptoms still exists. Pt. Mosquee decided to have a consultation in a hospital in San Fernando where she had laboratory tests and there she was advised to be admitted in the hospital due to decrease in platelet count. she was then admitted with a diagnosis of DHF with warning signs

6. PHYSICAL EXAMINATION Upon Admission (06-23-11) BP 110/70 mmHg PR 89bpm Temp. 38.5 C General: (-) wt lose/gain Skin: (+)petechial rash HEENT: (-) discharge Respiratory: (-) dyspnea Cardio: (-) orthopnea (-) PWB 10

GI: (-) constipation , (-) LBM Nervous: (-) impact in Sensorium Lymph Nodes: (-) clad Chest: Lungs: SCE, CBS Cardio: AP, NRRR Abdo: Flat, Soft, Non-tender Musculo Skeletal: Full range of motion Neuro: Intact nervous fxn.

First Nurse Patient Interaction (June 27, 2011) T: 36.1C, P: 82bpm, R: 21cpm, BP: 110/70 mmHg. General Appearance: Conscious and coherent, appears weak but can perform activities such as sitting and ambulating with the help of SO Skin: she has dark complexion; skin is warm; with good skin turgor,with minimal rashes on lower extremities. Hair: Evenly distributed; thick black hair; no infestations found; with no patches of hair loss, with no presence of dandruff. Nails: Short, dirty fingernails; normal curvature; smooth texture; intact epidermis; normal capillary refill (2 secs.) Skull and Face: Rounded; smooth; symmetrical. Eyes: Pupils are equally round and reactive to light and accommodation; black color of the eyes, no discharges, can move eyes in all direction, normal visual acuity, and color perception. Ears: Has symmetrical ears; no discharges; no nodules and lesions noted; no inflammation or deformities noted and has a good sense of hearing.

11

Nose: Has a symmetrical nares and no discharges; does not have nasal septum deviation; lesions or tenderness noted. Has a good sense of smelling. Lips, teeth and Throat: Lips are pale in color, teeth are slight yellow in color with dental carries; gums are pinkish in color and no bleeding, tonsils are not inflamed; dry mouth. Neck: Has no palpable lymph nodes, no swelling and tenderness noted. Neck is symmetrical in size and shape. Chest/Lungs: chest contour is symmetrical, spine is straight, no lumps, no masses, no Tender areas, with clear breath sounds Heart: Has normal heart rate and rhythm, no abnormal sounds heard upon auscultation. Abdomen: Has no lesions or scars noted at the abdomen; symmetrical. Upper and Lower Extremities: Symmetrical in shape, size and color; no edema

First Nurse Patient Interaction (June 28, 2011) T: 36.1C, P: 85bpm, R: 22cpm, BP: 110/80mmHg. General Appearance: Conscious and coherent, appears weak but can perform activities such as sitting and ambulating with the help of SO Skin: she has dark complexion; skin is warm; with good skin turgor,with minimal rashes on lower extremities. Hair: Evenly distributed; thick black hair; no infestations found; with no patches of hair loss, with no presence of dandruff. Nails: Short, clean fingernails; normal curvature; smooth texture; intact epidermis; normal capillary refill (2 secs.) Skull and Face: Rounded; smooth; symmetrical. Eyes: Pupils are equally round and reactive to light and accommodation; black color of the eyes, no discharges, can move eyes in all direction, normal visual acuity, and color perception.

12

Ears: Has symmetrical ears; no discharges; no nodules and lesions noted; no inflammation or deformities noted and has a good sense of hearing. Nose: Has a symmetrical nares and no discharges; does not have nasal septum deviation; lesions or tenderness noted. Has a good sense of smelling. Lips, teeth and Throat: Lips are pale in color, teeth are slight yellow in color with dental carries; gums are pinkish in color and no bleeding, tonsils are not inflamed; with moist mucous membrane. Neck: Has no palpable lymph nodes, no swelling and tenderness noted. Neck is symmetrical in size and shape. Chest/Lungs: chest contour is symmetrical, spine is straight, no lumps, no masses, no Tender areas, with clear breath sounds Heart: Has normal heart rate and rhythm , no abnormal sounds heard upon auscultation. Abdomen: has no lesions or scars at the abdomen; symmetrical in shape. Upper and Lower Extremities: Symmetrical in size shape and color. No edema

13

7. Diagnostic/ Laboratory Procedures Complete Blood Count Date ordered; Diagnostic/ Laboratory Procedures Date performed; Date result in Indications and Purposes 1st Hemoglobin DO: 06-23-11; DP: 06-23-11 8 P.M. DO: 06-24-11; DP: 06-24-11 4 A.M. The hemoglobin test measures the amount of hemoglobin in blood and is the 12 P.M. a good blood's to 131 14 indication of ability 126 g/L 142 g/L 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Female: 115-155 g/L The is result within Results Normal Values (Based from the hospital) Analysis and interpretat ion of Results

normal range. This indicates improveme nt in terms of blood carry oxygen throughout the to

carry oxygen 8 P.M. throughout the body. DO: 06-25-11; DP: 06-25-11 4 A.M.

g/L 127 g/L

the There

body. are

sufficient blood cells to oxygenate the 131 g/L There adequate oxygenatio n of tissues body. is

DO: 06-26-11; DP: 06-26-11

4 A.M.

128 g/L

12 P.M.

130 g/L

8 P.M.

132 g/L 15

136 8 A.M. g/L

DO: 06-27-11; DP: 06-27-11 8 A.M. 117 g/L 123 g/L

12 P.M.

8 P.M. 118 g/L

Date ordered; 16

Diagnostic/ Laboratory Procedures

Date performed; Date result in Indications and Purposes 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Results

Normal Values (Based from the hospital)

Analysis and interpretat ion of Results

Hematocrit

DO: 06-23-11; DP: 06-23-11 8 A.M.

Often used in place of RBC count, it is a measure of the volume .43

Female: 0.38-0.48

The result is within normal range. Same with hemoglobi n, as RBC contain them; this as

DO: 06-24-11; DP: 06-24-11

of RBC in whole blood expressed as a

4 A.M. 12 P.M.

percentage.

.40 .37

indicates that blood to there cell is sufficient

8 P.M.

.38

oxygenate the body. is There 17

adequate DO: 06-25-11; DP: 06-25-11 4 A.M. .37 DO: 06-26-11; DP: 06-26-11 oxygenatio n tissues. This indicates absence of dehydratio n. 4 A.M. .36 12 P.M. .38 8 P.M. .39 8 A.M. DO: 06-27-11; DP: 06-27-11 .38 of

18

8 A.M. .30 12 P.M. .33 8 P.M. .35

Date ordered; Diagnostic/ Laboratory Procedures Date performed; Indications and 19 Results Normal Values (Based Analysis and interpretati

Date result in

Purposes

from the hospital) 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 150-400 x 10 /L 131 x 109/ L
9

on of Results

Platelet

DO: 06-23-11; DP: 06-23-11 8 A.M.

> To determine the circulating platelet in the blood. Platelets or

All are

results below

the normal range. This results the bone marrow and eventually destroys 112 x 109/ L 89 x 109/ L the platelet precursors which cytes. are megakaryo as virus

attacks the

DO: 06-24-11; DP: 06-24-11 4 A.M.

thrombocyte s for are the responsible formation of blood clots.

12 P.M.

8 P.M.

68 20

x 109/ L

DO: 06-25-11; DP: 06-25-11 4 A.M. 76 x 109/ L

DO: 06-26-11; DP: 06-26-11 4 A.M. 109 x 109/ L 12 P.M. 97 x 109/L

21

8 P.M.

100 x 109/ L

8 A.M.

72 x 109/ L

DO: 06-27-11; DP: 06-27-11 8 A.M. 80 x 109/ L 12 P.M. 22 64

x 109/ L 8 P.M. 108 x 109/L

Date ordered; Diagnostic/ Laboratory Procedures Date performed; Date result in Indications and Purposes 1st 2nd 3rd 4th 5th 6th 7th 8th 9th Results Normal Values (Based from the hospital) Analysis and interpretation of Results

23

WBC

DO: 06-23-11; DP: 06-23-11 8 A.M.

White blood cells protect the body against infection. If an infection develops, white blood cells attack and destroy the bacteria, virus, or 1.6 x 109/ L

5-10x109/L

The range.

result

is This bone and

below the normal indicate marrow suppression this occur as the virus attacks the bone marrow 3.8 x 109/ L

DO: 06-27-11; DP: 06-27-11 8 A.M.

other organism causing it.

Date ordered; Diagnostic/ Laboratory Procedures Date performed; Date result in Indications and Purposes 1st
9

Normal Results Values (Based from the hospital) 2nd 3rd 4th 5th 6th 7th 8th 9th

Analysis and interpretation of Results

24

Neutrophils

DO: 06-23-11; DP: 06-23-11 8 A.M.

It

plays

an

.20-.35

The range

result

is

important role in the bodys immune response. and They other that .37 produce antibodies

above the normal which indicate presence of viral infection.

DO: 06-27-11; DP: 06-27-11 8 A.M.

chemicals destroy

microorganisms and regulate the immune system. It increases infections. in chronic and viral .45

Date Diagnostic/ Laboratory Procedures ordered; Date performed; Date result in 1st Lymphocytes DO: 06-23-11; It is the most 25 2nd 3rd 4th 5th 6th 7th 8th 9th 0.45-0.65 Result is within Indications and Purposes Results Normal Values (Based from the hospital) Analysis and interpretation of Results

DP: 06-23-11 8 A.M. DO: 06-27-11; DP: 06-27-11 8 A.M.

numerous circulating WBCs .63 and they respond more rapidly to the inflammatory and tissue injury sites than other types of WBCs. 3.5

normal which absence

range indicates of

bacterial infection.

26

NURSING RESPONSIBILITIES: Complete Blood Count 1. Before (book-based) done. Inform the patient that there is no fasting needed. Advice the patient not to pull his when he feels sensation while Disinfect or cleanse the site where the needle will be pricked. Advise the patient to follow the proper procedures as to be Check doctors order. Explain the procedure (at the level of understanding of the

patient), how he would feel during the test and why it is necessary to be

inserting the needle to the site.

verbalized by the medical technologist. 2. During (book-based) tube. List on the laboratory slip any drug that may affect test results Provide comfort measures to the patient. Assess patient condition while the test/ procedure are being done. Assist the patient during procedure Collect approximately 5 to 7 ml of venous blood in a lavender top-

3.

After (book-based) Apply pressure dressing to the venipuncture site. Observed the site for any bleeding

Attached laboratory results to the patients chart. Explain to the patient the result of the test and inform him of the normal values.

27

28

Coagulation Test Date ordered; Date performed; Date result in DO: 06-23-11 DR: 06-23-11 Indications or Purpose Partial thromboplastin time prothrombin and time Results

Diagnostic/ Laboratory Procedures Coagulation Test PT Prothrombin Time

Normal Values (Based from the hospital) 14.8 seconds 11.4-15.8 sec

Analysis and Interpretation of Results Result is within

normal limits

are often done at the same time to check for bleeding problems.

PTT Partial thromboplastin time

DO: 06-23-11 DR: 06-23-11

Measures other clotting factors. The partial thromboplastin time (PTT) test is a blood test that is done to investigate bleeding disorders

38.4 seconds

23.8-35.8 sec

*above the normal level with a Increased bleeding levels in a person disorder indicate a clotting factor may be missing or defective.

29

NURSING RESPONSIBILITIES: Coagulation test: 1. Before (book-based) 2. Explain to the patient the procedure and purpose Check if the patient is taking any medications that may influence

the test results During (book-based) Assess patient condition while the test/ procedure is being done. Assist the patient during procedure Clean the needle site with alcohol Watch out for signs of bleeding Provide comfort measures to the patient.

3.

After (book-based) Advised patient to watch for bleeding gums, bruising easily, and

duty

other signs of clotting problems. and report it immediately to the nurse on Put pressure to the site and then a bandage.

30

Liver Function Tests Date Diagnostic/ Laboratory Procedures ordered; Date performed; Date result in Ordered: Indications or Purpose Results

Normal Values (Based from the hospital) ALT 33.6 10-39 IU/L The within limits. result is Analysis and Interpretation of Results

Liver function tests

(LFTs or LFs), which 6-23-11 include liver enzymes, are groups of clinical biochemistry laboratory 6-23-11 blood assays designed to give information about the state of a patient's liver. Most liver diseases cause only mild symptoms initially, but it is vital that these diseases be detected early. This testing is Result:

> Alanine transaminase (ALT), also called Serum Glutamic Pyruvate Transaminase (SGPT) or Alanine aminotransferase cells). (ALAT) is an enzyme present in hepatocytes (liver When a cell is damaged, it leaks this enzyme into the blood, where it is measured. Elevations are often measured in multiples of the upper limit of normal (ULN).

normal

31

performed a medical technologist on patient's obtained by phlebotomy. or plasma sample

by a serum

AST 124.4 10-40 IU/L

The

result

is

>Aspartate transaminase (AST) also called Serum Glutamic Oxaloacetic (SGOT) or aminotransferase another enzyme Transaminase aspartate (ASAT) is

abnormal. It is raised in acute liver but damage, is also

present in red blood cells, and cardiac and skeletal muscle and is therefore not specific to the liver. This results due to the insult of the virus liver. to the

similar to ALT in that it is associated with liver parenchymal cells. It is raised in acute liver damage, but is also present in red blood cells, and cardiac and skeletal muscle and is therefore not specific to the liver. The ratio of AST to ALT is sometimes useful in
[3]

differentiating of liver

between damage.[2]

causes

Elevated AST levels are not

specific for liver damage, and AST has also been used as a cardiac marker.

32

NURSING RESPONSIBILITIES: 1. Before (book-based) Confirm the patients identity using two patient identifiers according to facility policy

Explain to the patient that ALT/AST is used to assess heart and Advise the patient that he/she may feel slight discomfort from the Inform the patient that the test usually requires 3 venipuncture for Inform the patient that he/she doesnt need to restrict food and Notify the laboratory practitioner about any medications the patient

liver function and that it requires a blood sample. tourniquet and needle puncture. AST fluids is taking that may affect test results. 2. During (book-based) Perform a venipuncture and collect the sample in a 4 mL tube Apply direct pressure to the venipuncture site until bleeding stops.

without additives

3. After (book-based) If hematoma develops at the venipuncture site, apply direct Instruct the patient that he/she may return medications

pressure. discontinued before the test as ordered.

33

Urinalysis Date ordered; Diagnostic/ Laboratory Procedures Urinalysis > Is an array of tests performed on urine and one Result: of the most 06-24-11 common methods of medical diagnosis A part of a urinalysis can be performed by using the color test urine results changes. can ALBUMIN 34 Positive 1 Negative dipsticks in which can be read as Urinalysis TRANSPARENCY Slightly turbid Normal urine The is clear result is Date performed; Date result in Ordered: 06-23-11

Normal Indications or Purpose Results Values (Based from the hospital) Color Dark yellow Pale (straw) yellow color

Analysis and Interpretation of Results is urinary crystals),

yellow Result the casts,

to abnormal. Any of sediments (cells, or bacteria make urine dark yellow in color.

normal.

Result reveal that diseases have gone in (proteinuria) produce tract infection chronic disease. Glucose negative Negative The result

is urine can

abnormal. Protein

unnoticed because they do not striking signs or symptoms.

indicate a urinary infection or kidney (UTI), a kidney

is

normal. .

1.030 SPECIFIC GRAVITY

1.002-1.040

The within range

result

is

normal

PUS CELL

4-6 wbc/ HPF 35

0-5 wbc/hpf

Result abnormal.

is

Numerous count indicate inflammation RBC 1-3/ HPF 0-2/ HPF or infection (pyuria)

Result abnormal. indicates

is This

inflammation and bleeding in the urinary tract.

36

NURSING RESPONSIBILITIES:

1. Before (book-based) Confirm the patients identity using two patient identifiers Explain that this analysis helps to diagnose renal or urinary tract Inform the patient that he/she doesnt need to restrict food and Notify the laboratory and practitioner of drugs that patient is taking according to facility policy. disease and to evaluate overall body function fluids for the test. that may affect laboratory results. 2. During (book-based) Collect a random urine specimen of at least 15 mL. Obtain a firstStrain the specimen to catch the calculi or calculus fragments if Carefully pour the urine through an unfolded 4 x 4 gauze pad or

voided morning specimen if possible. the patient is evaluated foe renal colic. a fine mesh sieve placed over the specimen container. 3. After (book-based) Inform the patient that he/she may resume to his/her usual diet

and medications.

37

Diagnostic / Laboratory Procedures

Date ordered; Date performed; Date result in DO: 06-23-11; DP: 06-23-11 Indications or Purpose - It is used to detect microscopic blood in the stool -to detect the presence of ova and parasites -to detect the presence of bacteria and viruses. Results No ova or parasites seen. Occult blood is negative Normal Values) No parasites and ova present in the fecal. No blood must see in the blood. Analysis and Interpretation of Results This indicates absence of bleeding.

Fecalysis with occult Blood

38

NURSING RESPONSIBILITIES: 1. Before (book-based) Explain the purpose of the procedure to the patient. For 72 hours prior to collecting samples, patients should avoid red meats, NSAIDs (including aspirin), antacids, steroids, iron supplements, and vitamin C. Give a specimen container for the stool sample. 2. During (book-based) Instruct the patient to catch a moderate amount of stool and put the sample into the specimen container. 3. After: After the test is performed by the patient and has given the specimen, inform the patient if there were any presence of parasitic infection regarding the findings.

39

III. Anatomy and Physiology

Human Circulatory System The human circulatory system functions to transport blood and oxygen from the lungs to the various tissues of the body. The heart pumps the blood throughout the body. The lymphatic system is an extension of the human circulatory system that includes cell-mediated and antibody-mediated immune systems. The components of the human circulatory system include the heart, blood, red and white blood cells, platelets, and the lymphatic system.

Heart The human heart is about the size of a clenched fist. It contains four chambers: two atria and two ventricles. Oxygen-poor blood enters the right atrium through a major vein called the vena cava. The blood passes through the tricuspid valve into the right ventricle. Next, the blood is pumped through the pulmonary artery to the lungs for gas exchange. Oxygen-rich blood returns to the left atrium via the pulmonary vein. The oxygen-rich blood flows through the bicuspid (mitral) valve into the left ventricle, from which it is pumped through a major artery, the aorta. Two valves called semilunar valves are found in the pulmonary artery and aorta. The ventricles contract about 70 times per minute, which represents a person's pulse rate. Blood pressure, in contrast, is the pressure exerted against the walls of the arteries. Blood pressure is measured by noting the height to which a column of mercury can be pushed by the blood pressing against the arterial walls. A normal blood pressure is a height of 120 millimeters 40

of mercury during heart contraction ( systole), and a height of 80 millimeters of mercury during heart relaxation ( diastole). Normal blood pressure is usually expressed as 120 over 80. Coronary arteries supply the heart muscle with blood. The heart is controlled by nerves that originate on the right side in the upper region of the atrium at the sinoatrial node. This node is called the pacemaker. It generates nerve impulses that spread to the atrioventricular node where the impulses are amplified and spread to other regions of the heart by nerves called Purkinje fibers. Blood Blood is the medium of transport in the body. The fluid portion of the blood, the plasma, is a straw-colored liquid composed primarily of water. All the important nutrients, the hormones, and the clotting proteins as well as the waste products are transported in the plasma. Red blood cells and white blood cells are also suspended in the plasma. Plasma from which the clotting proteins have been removed is serum. Red blood cells Red blood cells are erythrocytes. These are disk-shaped cells produced in the bone marrow. Red blood cells have no nucleus, and their cytoplasm is filled with hemoglobin. Hemoglobin is a red-pigmented protein that binds loosely to oxygen atoms and carbon dioxide molecules. It is the mechanism of transport of these substances. (Much carbon dioxide is also transported as bicarbonate ions.) Hemoglobin also binds to carbon monoxide. Unfortunately, this binding is irreversible, so it often leads to carbon-monoxide poisoning. A red blood cell circulates for about 120 days and is then destroyed in the spleen, an organ located near the stomach and composed primarily of lymph node tissue. When the red blood cell is destroyed, its iron component is preserved for reuse in the liver. The remainder of the hemoglobin converts to bilirubin. This amber substance is the chief pigment in human bile, which is produced in the liver. Red blood cells commonly have immune-stimulating polysaccharides called antigens on the surface of their cells. Individuals having the A antigen have blood type A (as well as anti-B antibodies); individuals having the B antigen have blood type B (as well as anti-A antibodies); 41

individuals having the A and B antigens have blood type AB (but no anti-A or anti-B antibodies); and individuals having no antigens have blood type O (as well as anti-A and anti-B antibodies). White blood cells White blood cells are referred to as leukocytes. They are generally larger than red blood cells and have clearly defined nuclei. They are also produced in the bone marrow and have various functions in the body. Certain white blood cells called lymphocytes are essential components of the immune system. Other cells called neutrophils and monocytes function primarily as phagocytes; that is, they attack and engulf invading microorganisms. About 30 percent of the white blood cells are lymphocytes, about 60 percent are neutrophils, and about 8 percent are monocytes. The remaining white blood cells are eosinophils and basophils. Their functions are uncertain; however, basophils are believed to function in allergic responses. Platelets Platelets are small disk-shaped blood fragments produced in the bone marrow. They lack nuclei and are much smaller than erythrocytes. Also known technically as thrombocytes, they serve as the starting material for blood clotting. The platelets adhere to damaged blood vessel walls, and thromboplastin is liberated from the injured tissue. Thromboplastin, in turn, activates other clotting factors in the blood. Along with calcium ions and other factors, thromboplastin converts the blood protein prothrombin into thrombin. Thrombin then catalyzes the conversion of its blood protein fibrinogen into a protein called fibrin, which forms a patchwork mesh at the injury site. As blood cells are trapped in the mesh, a blood clot forms.

Lymphatic system The lymphatic system is an extension of the circulatory system consisting of a fluid known as lymph, capillaries called 42

lymphatic vessels, and structures called lymph nodes. Lymph is a watery fluid derived from plasma that has seeped out of the blood system capillaries and mingled with the cells. Rather than returning to the heart through the blood veins, this lymph enters a series of one-way lymphatic vessels that return the fluid to the circulatory system. Along the way, the ducts pass through hundreds of tiny, capsulelike bodies called lymph nodes. Located in the neck, armpits, and groin, the lymph nodes contain cells that filter the lymph and phagocytize foreign particles. The spleen is composed primarily of lymph node tissue. Lying close to the stomach, the spleen is also the site where red blood cells are destroyed. The spleen serves as a reserve blood supply for the body. The lymph nodes are also the primary sites of the white blood cells called lymphocytes. The body has two kinds of lymphocytes: B-lymphocytes and T-lymphocytes. Both

of these cells can be stimulated by microorganisms or other foreign materials called antigens in the blood. Antigens are picked up by phagocytes and lymph and delivered to the lymph nodes. Here, the lymphocytes are stimulated through a process called the immune response. Certain antigens, primarily those of fungi and protozoa, stimulate the T-lymphocytes. After stimulation, these lymphocytes leave the lymph nodes, enter the circulation, and proceed to the site where the antigens of microorganisms were detected. The T-lymphocytes interact with the microorganisms cell to cell and destroy them. This process is called cell-mediated immunity. B-lymphocytes are stimulated primarily by bacteria, viruses, and dissolved materials. On stimulation, the B-lymphocytes revert to large antibody-producing cells called plasma cells. The plasma cells synthesize proteins called antibodies, which are released into the circulation. The antibodies flow to the antigen site and destroy the microorganisms by chemically reacting with them in a highly specific manner. The reaction encourages phagocytosis, neutralizes many microbial toxins, eliminates the ability of microorganisms to move, and causes them to bind together in large masses. This process is called antibody-mediated immunity. After the microorganisms have been removed, the antibodies remain in the bloodstream and provide lifelong protection to the body. Thus, the body becomes immune to specific disease microorganisms. 43

Non-Modifiable Age Sex Heredity Race

Bite from infected female Aedes Aegypti mosquito

Modifiable Environmental conditions (open spaces with water pots, and plants) Aedes Aegypti Socio-economic status Season

Blood enters the blood stream Initial replication occurs at the site of infection and local lympathic tissue Viremia occurs until 4TH TO 5TH day after onset of symptoms

Initial febrile phase

VIREMIA
Increase vascular permeability

Increase capillary fragility Bleeding Hemorrhagic manifestatio ns Epistaxis Gum bleeding Hemateme sis

Fever (39 40 C) Flushed palms / soles IV. PATHOPHYSIOLOGY

Fluid shifting

Edema Abdominal a. Schematic diagram Pain

Ascites

hemoconcentrat Hypovolemi a.1 Schematic diagram (Book Centered) ion c shock Damage to megakaryocytes Thrombocytope nia Bleedin g DIC 44

Maculopapular ras and petechial rash Hermans sign

Hypovolemic Shock

Non-Modifiable None

Bite from infected female Aedes Aegypti mosquito

Blood enters the blood stream Initial replication occurs at the site of infection and local lympathic tissue Viremia occurs until 4TH TO 5TH day after onset of symptoms

Modifiable Environmental conditions (farm, sewer near the house) Aedes Aegypti Socio-economic status Season

Initial febrile phase

VIREMIA

Increase capillary fragility Maculopapu lar rash and Petechial rash (06-2311)

Fever (38.5) 06-23-11

Thrombocytopenia Damage to 6-23-11 Platelet = megakayocytes a.2 Schematic diagram (patient centered) 131 6-24 -11 Platelet = 112, 89, 68 6-25-11 Platelet = 76 6-26-11 Platelet = 76, 109, 97, 100, 72 6-27-11 Platelet= 80, 64,108 45 *Plt ct. are obtained q8

b. Synthesis of the disease b.1 Definition of the disease Dengue fever or dengue hemorrhagic fever (DHF) are acute febrile diseases, found in the tropics, with a geographical spread similar to malaria. Caused by one of four closely related virus serotypes of the genus Flavivirus, family Flaviviridae, each serotype is sufficiently different 46

Damage to Thrombocytope

that there is no cross-protection and epidemics caused by multiple serotypes (hyperendemicity) can occur. Dengue is transmitted to humans by the Aedes aegypti (rarely Aedes albopictus) mosquito. This mosquito tends to bite just after dawn and just before sunset. Incubation Period The incubation period is three to fourteen days; commonly seven to ten days. Period of Communicability Patients usually infective from mosquito from the day before the febrile period to the end of it The mosquito becomes infective from day 8 to 12 after the blood meal and remains infective all throughout life. Sources of infection Infected persons the virus is present in the blood of patients during the acute phase in the blood of patients during the acute phase of the disease and will become a reservoir of virus, sucked by mosquitoes which may then transmit the disease. Standing water any stagnant wateralong the household and premises are usual breeding sites of these mosquitoes. Pathogenesis and Pathology 1. Infectious virus is deposited in the skin by the vector and initial replication occurs at the site of infectionand in the local lympathic tissues 2. Within a few days , viremia occurs lasting until the 4th and 5th day after onset of the symptoms 3. Evidence indicates that macrophages are the principal site of infection 4. At the site of replication rash , non-specific changes are noted which include endothelial swelling, perivascular edema and extravasation of blood 5. There is marked increase in vascular permeability, hypotension, hemoconcentration, thrombocytopenia, with increased platelet agglunability and or moderate disseminated intravascular coagulation 6. The most serious pathophysiology abnormality is hypovolemic shock endothelium and loss of plasma from intravascular space. 47

Complications GI bleeding Concomitant gastrointestinal disorder (peptic ulcer) Metabolic acidosis Hyperkalemia Myocarditis Dengue Encephalopathy is manifested by increasing restlessness, apprehension or anxiety, disturbed sensorium, convulsions, spacity and hyporeflexia b.2. Predisposing and precipitating Factors Predisposing factors Age more predominantly children, less 15 years of age Sex common in females than males Heredity - Infants in mother having antibodies to dengue serotype, immunity to one dengue virus serotype may enhance response to the secondary infection Race - Common in Caucasian, dengue virus generally causes a benign syndrome, DF and severe syndrome DF/DSS in Southeast Asia. Precipitating factors Environmental conditions (open spaces with water pots, and plants) - Clear stagnant water is their breeding site. Aedes Aegypti it is the carrier of four type of virus Socio-economic status Due to their financial instability, people may find hard to improve their environment Season during rainy seasons, female mosquitoes lay their eggs

b.3. Signs and Symptoms High fever, Body weakness, headache,nausea, vomiting, and abdominal pain In acute DHF, the patients initially develop an abrupt onset high fever with malaise, headache, nausea,

48

vomiting, myalgia and sometimes abdominal pain due to bodys innate immune response from the virus Hemorrhagic Phenomena such as easy bruising, bleeding at the venipuncture site, gum bleeding In DHF, abnormal hemostasis due to vasculopathy, thrombocytopenia and coagulopathy may lead to various hemorrhagic manifestation Positive Torniquet Test positive tourniquet test indicating increased capillary fragility is found in the early febrile stage. It may direct effect of dengue virus as it appears in the first few days of illness during the viremic phase Petechial Rash- Due to low value of thrombocytes, client experiences this phenomenon Phases of Illness 1. Initial Febrile Phase lasting from two to three days a. fever (39-40 C) accompanies by headache b. febrile convulsions may appear c. palms and soles are usually flushed d. positive tourniquet test e. anorexia, myalgia and vomiting f. maculopapular rash maybe present that usually starts in the distal portion of the extremities, the skin appears purple with blanched areas with varies sizes, the Hermans sign known as pathognomonic to the disease g. generalized or abdominal pain h. hemorrhagic manifestation like positive tourniquet test, purpura, epistaxis and gum bleeding may be present 2. Circulatory Phase a. there is fall of temperature accompanied by profound circulatory changes usually on the 3rd to 5th day b. patient becomes restless, with cool clammy skin c. cyanosis is present d. profound thrombocytopenia accompanies the onset of shock e. bleeding diathesis may become more severe with GIT hemorrhage f. shock may occur due to loss of plasma from the intravascular spaces and hemoconcentration with markedly elevated hematocrit is present 49

g. Pulse is rapid, weak, pulse pressure becomes narrow and blood pressure may drop to an unobtainable level h. Untreated shock may result to comma, metabolic acidosis and death may occur with two days i. With effective therapy, recovery may follow in two to three days

Classification according to severity (Halstead & Nimmanitya) Grade 1 There is fever accompanied with non-specific constitutional symptoms and the only hemorrhagic manifestation is positive tourniquet test. Grade 2 Allsigns of Grade 1 plus spontaneous bleeding from the nose, gums, GIT are present Grade 3 There is presence of circulatory failure as manifested by weak pulse , narrow pulse pressure, hypotension, cold clammy skin and restlessness Grade 4 There is profound shock, undetectable blood pressure and pulse

50

V. PLANNING (NURSING CARE PLAN) NCP # 1: Decrease cardiac output Assessment Subjective: Objective: - Weakness - Irritability Restlessness - VS taken as: > T: 36.1 C >P: 82 bpm >R: 21 cpm >BP: 110/70 mmHg Nursing Diagnosis Decrease cardiac output r/t hemorrhage Scientific Explanation Increased cardiac output that injures the endothelial cells of the arteries and the action of prostaglandins. Vasoconstriction occurs and blood pressure increases. It is the result from a decreased effective circulating volume of water, plasma, or whole blood and it is the most common type of shock for adults and children. External, sudden blood loss resulting from penetrating trauma and severe GI bleeding are common causes of shock. A significant loss of greater than 30% of circulating volume results to decrease ion venous Objectives Short-Term: After 3-4 hrs of NI, the patient will maintain BP within normal limits AEB warm, dry skin; regular cardiac rhythm; clear lung sounds; and strong bilateral, equal peripheral pulses Interventions >established rapport Rationale >To gain the trust and confidence of the client > to note any abnormality Expected Outcome Short term: the patient shall have maintained BP within normal limits AEB warm, dry skin; regular cardiac rhythm; clear lung sounds; and strong bilateral, equal peripheral pulses

>Monitor and record VS

>Note Risk factors for the occurrence of disease condition

>Detect deviations and identify need for prompt interventions

Long-term: After 4 days of NI, the patient will not manifest any s/sx related to decreased cardiac output > Monitored blood pressure every 4hours. > To know the base line of BP

Long-term: the patient shall have not manifested any s/sx related to decreased cardiac output.

> Instructed to have enough 51

> Sodium

return, in turn diminishes cardiac output and decreases perfusion to the vital organs causes

rest on semi fowlers position.

tends to be excreted at a faster rate

> Instructed to eatlow fat and low saltdiet.

> To reduce edema that may activate renin angiotensinaldosterone system.

> Administered antihypertensive drug as ordered

> To control the BP and to avoid other complication

52

NCP # 2:Ineffective Tissue Perfusion Assessment Nursing Diagnosis Subjective: Objective: Decreased WBC Decreased platelet Decreased HgB Decreased capillary refill time Dysrhythmias Altered LOC Fever Ineffective tissue perfusion related to decreased HgB concentration in the blood secondary to DHF 1 Scientific Explanation A mosquito which carries the dengue virus is called Aedes aegypti. The said mosquito comes in contact with a person and bites the person. The dengue virus will flow through the blood stream and destroys blood components. Patients with dengue often has decreased WBC, platelet &haemoglobin count. Hemoglobin count is used to measure oxygen carrying capacity of the blood. Hemoglobin Short Term: After 4 hours of NI, the pt will demonstrate behaviors to improve circulation. Long Term: After 4 days of NI, the pt will demonstrate increased perfusion as appropriate Objectives Nursing Interventions Monitor Vital Signs Assess patients condition To obtain baseline data To assess contributing factors Rationale Expected Outcome Short term: The pt shall have demonstrated behaviours to improve circulation Long term: For comparison with current findings To identify alterations from normal To identify / determine adequate perfusion To determine presence of thrombus formation To determine 53 The pt shall have demonstrated increased perfusion as appropriate

Note customary baseline data

Determine presence of dysrhythmias Perform blanch test

Check for Homans sign

carries oxygen. Therefore, if there is decreased haemoglobin, there is also decreased oxygen that reaches the different tissues of the body.

Note presence of bleeding

risk of anemia

Elevate HOB

To promote circulation

Encourage quiet & restful atmosphere

To promote comfort & decrease tissue O2 demand To decrease cardiac workload

Instruct to avoid tiring activities

Encourage light ambulation

To enhance venous return

Encourage use of relaxation techniques

To decrease tension and anxiety level

Administer medications 54

To treat underlying cause

NCP # 3:Risk for injury Assessment Nursing Diagnosis Subjective: Objectives: Weakness and irritability. Restlessness Low platelet count Risk for injury r/t abnormal blood profile AEB decreased platelet count. Scientific Explanation This infectious disease is manifested by sudden onset of fever with severe headache muscle and joint pain severe pain gives the name breakbone fever or bone crusher and rashes and usually appears first on the lower limbs and chest there may also be gastritis and sometimes bleeding. Short term: After 4 hrs of NI, the pt. will demonstrate technique of behavior lifestyle changes to risk factor to protect self. Long term: After 2-3 days of nursing interventions the patient together with the SO will correct hazardous situations to prevent injury. Objectives Nursing Interventions >established rapport >To gain the trust and confidence of the client >Detect deviations and identify need for prompt interventions >Establish a baseline data Rationale Expected Outcome Short term: After 4 hrs of NI, the pt. shall demonstrate technique of behavior lifestyle changes to risk factor to protect self. Long term: After 2-3 days of nursing interventions the patient together with the SO shallcorrect hazardous situations to prevent injury.

>Monitor and record VS

>Note Risk factors for the occurrence of disease condition >Assess for signs and symptoms of G.I bleeding. Check for secretions. >Observe color and consistency of stools or vomitus.

>The G.I tract (esophagus and rectum) is the most usual source of

>bleeding of its mucosal fragility.

55

>Observe for presence of petechiae, ecchymosis, bleeding from one more sites.

>Sub-acute disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors. >Rectal and esophageal vessels are most vulnerable to rupture. >In the presence of clotting factor disturbances, minimal trauma can cause mucosal bleeding.

>Monitor pulse, Blood pressure.

>Note changes in mentation and level of consciousness. avoid rectal temperature, be gentle with GI tube insertions. >Encourage use of soft toothbrush, avoiding straining for stool, and forceful nose blowing. >Use small 56

>Minimizes damage to tissues, reducing risk for bleeding and hematoma.

>Prolongs

needles for injections. Apply pressure to venipuncture sites for longer than usual. >Recommend avoidance of aspirin containing products. >Monitor Hb and Hct and clotting factors

coagulation, potentiating risk of hemorrhage.

>Indicators of anemia, active bleeding, or impending complications >Changes may indicate cerebral perfusion secondary to hypovolemia, hypoxemia.

NCP # 4: Hyperthermia 57

Assessment Subjective: Objective: pt may manifest the following: > Temp of 38.5 > Flushed skin > Skin warm to touch > Chills > Increased RR > Tachycardia > Convulsions > Sweating

Nursing Diagnosis Hyperthermia

Scientific Explanation When a person comes in contact with a mosquito, Aedesaegypti, the dengue virus flows through the blood stream. As the compensatory mechanism of the body, it will raise its temperature to allow the immune system to work better and to deteriorate the condition of the invaders thus causing hyperthermia.

Objectives Short Term: After 4 hours of NI, pts temperature will decrease from 39.8 to 37. Long Term: After 3 days of NI, the pt will identify underlying factors & importance of treatment as well as s/sx requiring further evaluation or intervention

Nursing Interventions Establish Rapport Monitor Vital Signs Assess neurologic response, note LOC & orientation, reaction to stimuli, papillary reactions & presence of seizures

Rationale To gain pts trust To obtain baseline data To evaluate effects & extent of hyperthermia

Expected Outcome Short Term: pts temperature shall havel decreased from 39.8 to 37. Long Term: the pt shall have identifed underlying factors & importance of treatment as well as s/sx requiring further evaluation or intervention

Note presence / absence of sweating

To monitor heat & fluid loss

Wrap extremities with bath towels Provide TSB q 15 minutes

To minimize shivering To reduce body temperature

58

Apply local ice packs in axilla

To reduce body temperature in areas of high blood flow

Instruct client to have bed rest

To reduce metabolic demands / oxygen consumption

Instruct client to increase OFI

To prevent dehydration

Administer replacement fluids

To support circulating blood volume and tissue perfusion

Administer antipyretics Reassess 59

To restore normal body temperature To determine

temperature q 15 minutes

effectiveness of interventions

NCP # 5: Ineffective Protection Assessment Subjective: Nursing Diagnosis Ineffective Scientific Explanation Objectives Nursing Interventions >established Rationale >To gain the Expected Outcome Short- term:

Dengue fever is an Short- term: 60

Objective: Weakness and irritability. Restlessness Low platelet count

protection r/t abnormal blood profile AEB decreased platelet count.

acute febrile disease caused by infection with one of the serotypes of dengue virus which is transmitted by mosquito genus Aedes. characterized by a bleeding diathesis and hypovolemic shock. Headache, fever, exhaustion, severe joint and muscle pain, swollen glands (lymphadenopathy), and rash. The presence (the "dengue triad") of fever, rash, and headache (and other pains) is particularly characteristic of dengue. Due to decrease in platelet count the patient have a decrease in protection and may be easily injured.

After 3-4 hrs of rapport NI, the pt will be free from injury Long-term: After 4 days of >Monitor and NI, the patient record VS will modify environment to enhance safety. >Note Risk factors for the occurrence of disease condition >Assess for signs and symptoms of G.I bleeding. Check for secretions. >Observe color and consistency of stools or vomitus. >Observe for presence of petechiae, ecchymosis, bleeding from one 61

trust and confidence of the client >Detect deviations and identify need for prompt interventions >Establish a baseline data

pt shall have been free from injury Long-term: the patient shall have modified environment to enhance safety

>The G.I tract (esophagus and rectum) is the most usual source of

>bleeding of its mucosal fragility. >Sub-acute disseminated intravascular coagulation (DIC) may develop secondary to

more sites.

altered clotting factors. >Rectal and esophageal vessels are most vulnerable to rupture. >In the presence of clotting factor disturbances, minimal trauma can cause mucosal bleeding.

>Monitor pulse, Blood pressure.

>Note changes in mentation and level of consciousness. avoid rectal temperature, be gentle with GI tube insertions.

>Encourage use of soft toothbrush, avoiding straining for stool, and forceful nose blowing. >Use small needles for injections. Apply pressure to venipuncture 62

>Minimizes damage to tissues, reducing risk for bleeding and hematoma.

>Prolongs coagulation, potentiating risk of hemorrhage.

sites for longer than usual. >Recommend avoidance of aspirin containing products. >Monitor Hb and Hct and clotting factors >Indicators of anemia, active bleeding, or impending complications >Changes may indicate cerebral perfusion secondary to hypovolemia, hypoxemia.

63

VI. IMPLEMENTATION

1. MEDICAL MANAGEMENT a. IVF Date ordered (DO), date Medical Management performed (DP), date changed or D/C IVF D5 Lactated Ringers Solution 1000 ml DO: 06-23-11 DP: 06-23-11 To rehydrate the patient Also serve as a route for IV medications When administered intravenously, these solutions provide sources of water and electrolytes. Their electrolyte content resembles that of the principal ionic constituents of normal plasma and the solutions therefore are suitable for parenteral replacement of extracellular losses of fluid 64 Clients response to treatment without any actual allergic reactions. Client was rehydrated AEB increased BP Indications/purpose General description Clients response to treatment

and electrolytes, with or without carbohydrate calories. NURSING RESPONSIBILITIES. 1. Before (book-based) Check for the doctors order Explain to the patient the procedure to be done and why it is Assemble equipment and supply Observe the 10 rights in administering medication. Be sure that Provide the client privacy Wash hands

necessary to be given Do proper assessment

the medication you will incorporate to the IVF is the right one 2. During (book-based) Check for the doctors order Explain to the patient the procedure to be done and why it is Assemble equipment and supply Observe the 10 rights in administering medication. Be sure that Provide the client privacy Wash hands necessary to be given Do proper assessment

the medication you will incorporate to the IVF is the right one

3. After (book-based) Press the site where the needle was inserted and secure it with micropore Check the site of the hand where the needle is inserted if bulging is not visible. If so, reinsertion is to be under taken.

65

 Advice the patient to avoid scratching the site and less movement of the hand were the needle was inserted. Instruct patient or significant others to inform the nurse on duty if bulging on the site is visible and if there is back flow of blood or IVF is not infusing well. Always check if the IVF is infusing well and intact. Monitor the patients skin integrity. b. Drugs Date ordered, Generic name and brand name General action date Indication or purpose performed, date changed or D/C Analgesic, Antipyretic Relief of mild to moderate pain; treatment of Brand Aeknil Route: IV Dosage:300 mg Frequency: PRN for fever > 37.8 NURSING RESPONSIBILITIES: 1. Before (book-based) Check the doctors order Introduce yourself and explain the procedure Prepare the necessary materials Read the label of medication before administering it. Check the expiration date of each medication. 66 Name: fever. DO: 06-23-11 The decrease temperature. Clients response to the medication with actual side effects had a in

Generic Name: Paracetamol

 Know the right patient

2. During (book-based) Administer as indicated in the doctors order. Administer medication cautiously and slowly. If IVF clean the insertion point with cotton balls. Gradually inject the drug in to the port. Observed aseptic technique. 3. After (book-based) Advise patient report any signs of reaction. Wash hands after administration of medication. Observe clients reaction. Document time and date the medication is administered.

Date ordered, Generic name and brand name date performed, date changed or D/C Generic Name: omeprazole Brand Name: Prilosec Date ordered: 06-23-11 Date Performed: 06-23-11 to 06-27-11 Date Discontinue: 06-27-11 40mg IV OD Antisecretory Drug Proton inhibitor Gastric suppresses gastric specific 67 acid secretion by a Pump Indication or purpose General action

Clients response to the medication with actual side The effects clients has

gastric secretions been reduced

aeb absence of acid GIT bleeding and

pump inhibitor; abdominal pain

inhibition of the hydrogenpotassium ATPase enzyme system at the secretory surface of the gastric parietal cells, blocks the final NURSING RESPONSIBILITIES: 1. Before (book-based) Check doctors order. Verify the Client. Wash hands before handling the medication. Assess patient V/S prior to administration. Prepare the medication as needed. 2. During (book-based) Administer as indicated in the doctors order. Administer medication cautiously and slowly. If IVF clean the insertion point with cotton balls. Gradually inject the drug in to the port. Observed aseptic technique. Take the drug with food. Swallow the capsule do not chew it. Administer antacid if needed. 3. After (book-based) Advise patient report any signs of reaction. Wash hands after administration of medication. 68 step of acid production.

 Observe clients reaction. Document time and date the medication is administered. c. DIET TYPE OF DIET DATE ORDERED, DATE STARTED, DATE CHANGED GENERAL DESCRIPTION INDICATIONS OR PURPOSES SPECIFIC FOODS TAKEN CLIENTS RESPONSE AND/OR REACTION TO DIET

1.DAT EDCF once fully awake

06-23-11 to 06-27-11

A prescribed treatment for patients where in you can eat the foods that are light in color in

For it not to mask presence of bleeding

Light colored foods

With the super vision of SO the patient had followed the required food ordered.

moderation NURSING RESPONSIBILITIES: 1. Before (book-based) Introduce self and verify clients identity Explain the purpose and benefits of DAT EDCF Explain the reason for compliance for DAT EDCF 2. During (book-based) Identify what kinds of soft diet is provided Explain to the significant others the reason including the health precaution for the diet given Assess clients reaction Monitor if the patient complies with the diet given 69

 Monitor intake and output 3. After (book-based) Document findings in the client record Encourage clients SO when possible to participate in complying with diet Assess clients reaction

70

2. SURGICAL MANAGEMENT No surgical management ordered by the physician during the hospital stay. 3. NURSING MANAGEMENT (Actual SOPIER) 06-27-11 S>O O> received patient sitting on bed conscious and coherent with an ongoing IVF of 1L D5 LRS x 55-58 gtts/min at 490cc infusing well at the left hand, with good skin turgor, skin warm to touch, afebrile, no epigastric pain, (-) sign of bleeding in stool and gums, with platelet count of 108 with vs taken as follows: T: 36.1C, P: 82bpm, R: 21cpm, BP: 110/70mmhg. A> Risk for injury r/t abnormal blood profile AEB decreased platelet count. P> After 4 hrs of NI, the pt. will demonstrate technique of behavior lifestyle changes to risk factor to protect self. I>established rapport >assessed level of consciousness and cognitive level >provided safe environment >observed for bleeding of gums, ecchymosis, petechiae >encouraged intake of food rich in vit. C like oranges to boost the immune system >monitored VS >provided comfort measures such as stretching linens >encouraged to increased fluid intake >advised not to eat foods that are hard >advised the patient not to eat dark colored foods. >encouraged the patient to use soft bristle tooth brush. >instructed the patient to avoid pointed objects to avoid injury. 71

E>goal met AEB the pt. demonstrated technique of behavior lifestyle changes to risk factor to protect self. 06-28-11 S>O O> received patient sitting on bed conscious and coherent with an ongoing IVF of 1L D5 LRS x 55-58 gtts/min at 600cc infusing well at the left hand, with good skin turgor, skin warm to touch, afebrile, no epigastric pain, (-) sign of bleeding in stool and gums, with vs taken as follows: T: 36.1C, P: 85bpm, R: 22cpm, BP: 110/80mmhg. B> Inefective protection r/t abnormal blood profile AEB decreased platelet count. P> After 4 hrs of NI, the pt. will demonstrate technique of behavior lifestyle changes to risk factor to protect self. I>established rapport >assessed level of consciousness and cognitive level >provided safe environment >observed for bleeding of gums, ecchymosis, petechiae >encouraged intake of food rich in vit. C like oranges to boost the immune system >regulated IVF >monitored VS >provided comfort measures such as stretching linens >encouraged to increased fluid intake >advised not to eat foods that are hard >advised the patient not to eat dark colored foods. >encouraged the patient to use soft bristle tooth brush. >instructed the patient to avoid pointed objects to avoid injury. 72

> advised to use mosquito repellant lotion > instructed to use mosquito nets to avoid the pt. from mosquito bites. >monitored platelet count as ordered >instructed not to take medicines that can make the person bleed such as aspirin and NSAIDs E>goal met AEB the pt. demonstrated technique of behavior lifestyle changes to risk factor to protect self.

73

VII. EVALUATION 1. Clients Daily Progress Chart DAYS ADMISSION 06-23-11 NURSING PROBLEMS 1. Decreased Cardiac Output 2. Ineffective Tissue Perfusion 3. Risk for Injury 4. Hyperthermia * * * * * * * * NPI * * * * 06-24-11 06-25-11 06-26-11 06-27-11 06-28-11 Not discharged at the period of

DISCHARGE

VITAL SIGNS 74

Body Temperature (oC)

38.5 C

37.1 C

36.5 C

36.8 C

36.1 C

36.1 C

Pulse Rate (bpm) Respiratory Rate (cpm) Blood Pressure (mmHg)

89 bpm 18 cpm 110/70mmH g

92 bpm 20 cpm 90/60 mmHg

73 bpm 18 cpm 90/60 mmHg

78 bpm 18 cpm 90/60 mmHg

82 bpm 21 cpm 110/70 mmHg

85 bpm 22 cpm Not discharged at the period of NPI 110/80 mmHg

DISCHARGE

Diagnostic Procedures Hematology (CBC): Hemoglobin (115-155g/L) 131 g/L 127 g/L 130g/L 132 g/L 136 g/L .43 .40 .37 75 .37 .36 .38 .30 .33 123 g/L 118 g/L 144 g/L 133 g/L 131 g/L 128 g/L 117 g/L

Hematocrit (.40-.52)

.38

.39 .38

.35

Platelet Count (150-400 x109/L)

131 x 109 /L

112 x 109 /L 89 x 109 /L 68 x 109 /L

76 x 109 /L

109 x 109 /L 97 x 109 /L 100 x 109 /L 72 x 109 /L

80 x 109 /L 64 x 109 /L 108 x 109 /L

WBC (5-10x 109/L)

1.6

3.8

Neutrophils (0.20-0.35) .37 .45

.63 Lymphocytes (0.45-0.65) 76

3.5

Liver Function Test SGPT SGOT

33.6 IU/L 124.4 IU/L

Coagulation Test PT PTT

14.8 sec 38.4 sec

COLOR : Urinalysis Dark yellow SLIGHTLY TURBID ALBUMIN (+1) GLUCOSE: 77

(-) GRAVITY : 1.030 PUS CELLS : 4-6 wbc/HPF RBC: 1-3/ HPF FA w/ occult blood No ova or parasites seen. Occult blood is negative Medical Management IVF: Not GE D5LRS * * * * * * DISCHAR

78

Drugs: Paracetamol Omeprazole * period of NPI * * * * * discharged at the

Diet: DAT EDCF

79

2. Discharge Planning a. General condition of client upon discharge The client was diagnosed last June 2011. Health teachings concerning clients condition and diet or proper nutrition were emphasized. The following are the health teachings given to diet through his SO with the home management and maintenance. b. METHOD S= O = Received pt. on bed, conscious and coherent with with an ongoing IVF of D5 LRS with 1 x 55-58gtts/min at 600cc infusing well at the left hand, with good skin turgor, skin warm to touch, afebrile, no epigastricd pain, (-) sign of bleeding in stool and gums. A = For home maintenance and management P= after 4 hours of NI, pt. will verbalize and demonstrate understanding of the health teachings given. I= M>Instructed pt. to strictly comply with home medications which includes:

- Multivitamins 500mg OD E> Avoid activity that may precipitate the occurrence weakness avoid active play for 1 week. T> Instructed SO to strictly comply with the medication/ treatment regimen. H> Provided health teachings for the improvement and maintenance of health such as: -Encouraged the pt. to have adequate rest periods. -Instructed SO to provide comfort and safety measures. -Instructed pts SO to provide adequate and balance nutrition and promote proper chewing of food. - Instructed the pt. to clean their surrounding and to avoid stagnant water. O> Instructed pts SO to come back after 1 week for check up. D> instructed to avoid dark colored fluids. 80

E= Goal met, AEB pts SO verbalization of understanding on the health teachings given. VIII. Conclusions and Recommendations The study conducted to the patient for me is difficult because it is my first time to do the whole case study on my own. I thank the parents of my patient for without them this study would not be possible. It has been a great deal of effort, time and exhaustive interactions wherein i realized the relative implication of the study for future endeavors or researches. I find that through clinical duties, I encounter numerous cases that which I am unaware off. In the span of time that I engage myself in the attempt to understand such disease conditions, I sincerely devout my maximal effort to comprehend and internalize this condition for it certainly applies for most of the women in our society. For this, I take pride on this accomplishments, progress and learning attributed to the study. Dengue Hemorrhagic Fever is very common illnesses today as I handle this patient Ive learned a lot about this disease on how to prevent it and the process to get this type of illness. Also the patho- physiology of DHF and its complication to the patient. It is recommended that DHF should be included in the Health Policy. DHF must be included in the list of Essential Health Care Services, so that local health posts can provide clinical services and advice to the children suffering from DHF. Health workers should be provided with orientation and training on both preventive and curative aspects of DHF. In the medium term, the government should allocate a budget and prepare a strategy for providing treatment services in district or regional hospitals for children with DHF. The government and concerned civil society organizations should work with the mass media to raise awareness on DHF issues, through radio, TV, print media. More sustained and explicit messages are necessary to draw attention to this. The government should allocate tasks for different sectors, such as curative service providers, social service sectors, human resource development and media for effective delivery of services. There should be a forum to exchange information and build synergy amongst the concerned stakeholders. 81

The government should look for funds from donors to support specific work on DHF and related problems.

Awareness children.

on the prevalence and causes of DHF is important, targeting different

groups, such as adolescents in and out of schools, delinquents, and DHF - affected

The above target groups need to be aware of both the social and medical causes of DHF

A mass campaign for reducing the prevalence of DHF should be undertaken at the level that has been undertaken for HIV/ AIDS.

82

IX. SOCIOGRAM 06-27-11

At my duty in the hospital, I established meaningful relationship with my patient on my case study. I introduced myself and stated my purpose of getting my patient as my case study. I performed physical assessment and interview to get the necessary information needed for the study. Through this nurse-patient interaction, I gained their trust and I was able to perform assessment and taught some interventions about the disease effectively

06-28-11 83

On the 2nd day of Nursing Assessment and interaction, the student nurse had the second assessment to determine changes from previous day that the student handled the patient. After assessing I provided interventions to keep the patient on her most comfortable way. During the shift , I also gave health teachings such as modifying the environment by cleaning it to avoid mosquitoes from accumulating on stagnant waters, I also told the patients SO to eat healthy foods and increase vit. C intake to boost immune system

84

X. Bibliography BOOKS 1. Brunner & Suddarths Textbook of Medical-surgical Nursing Eleventh edition (volume 1& 2). Suzanne C. Smeltzer, Brenda C. Bare, Janice L. Hinkle, Kerry H. Cheever 2. 3. Daviss drug guide for nurses Tenth edition, Judith Hopfer Deglin, April hazard vallerand Joyce M. Black, J. H. (2008). Medical-Surgical Nursing: Clinical Management for Positive Outcomes. Winsland House I: Elsevier. 4. Nursing Care Plan, Guidelines for individualizing patient care 7th edition. Marily E. Doenges, Mary Frances Moorhouse, Alice C. Murrr 5. Nurses Pocket Guide 9th Edition. Marily E. Doenges, Mary Frances Moorhouse, Alice C. Murrr 6 Brunner & Suddarths Handbook of Laboratory and Diagnostic Tests. Internet http://www.cliffsnotes.com/WileyCDA/CliffsReviewTopic/Human-CirculatorySystem.topicArticleId-8741,articleId-8711.html www.mb.com.ph/articles/266225/dengue-spreading-5597-cases-reported www.who.int/mediacentre/factsheets/fs117/en/index.html http://www.sciencedaily.com/releases/2010/05/100506141603.htm

85